Proper evaluation and documentation of skin-related wounds is crucial in the development of a comprehensive treatment plan. However, even with detailed written descriptors (i.e. color, tissue condition, and dimensions) a visual image can provide a more complete representation of the current state of the wound. The National Pressure Ulcer Advisory Panel (NPUAP) recommends using digital photography to more accurately capture wound dimensions as well as track wound progression over time. However, even the best photograph of a wound becomes inefficient if there isn’t a timely way to integrate the images into the patient’s medical record.
Digital cameras are the common form of media for wound photography, but the process to upload and attach the images to a patient’s medical record is often tedious and time-consuming, requiring the nurse to download the pictures from the camera, index the proper image to the proper patient, and then upload them to the patient’s EMR. Recent advances in mobile EMR applications have significantly reduced the time between photographing the wound and uploading the images to a patient’s EMR. This presentation describes an initiative to improve efficiency and streamline the workflow required to attach images to the EMR using available technology.
Tactics implemented by the presenting organization to enhance wound care include the use of a mobile EMR with a built-in camera to photograph the wound. Post-capture, the clinical nurse or wound care specialist can simultaneously review both the EMR flowsheet data and uploaded image to assess the wound quickly, therefore facilitating an accurate diagnosis and developing an expeditious treatment plan. Additionally, an integrated mobile EMR also allows for an image viewer to show multiple images of the same wound over various points in time without the need to open each image separately, thus eliminating non-value-added work for the clinician.
Qualitative staff evidence reports improved documentation processes and a reduction in the amount of time spent indexing images. Information gained during this presentation can be incorporated in the inpatient or ambulatory care setting, allowing clinicians to work with real-time information which may enhance communication amongst the care team by allowing the utilization of remote consultations between facilities and practitioners providing a comprehensive, systematic, and standardized approach to wound care management.
Background: One of the most common reasons for treatment failure in pediatrics is non-adherence.1 Asthma action plans are commonly used in practice and have shown positive outcomes while emerging evidence suggests action plans can be beneficial to other diseases.2 Other disease action plans (DAP) have the ability to increase caregiver confidence, encourage disease self-management, and improve treatment adherance.1,2
Purpose: To provide a clinical tool for clinicians to create generalized DAP templates for management of various diseases that can be individualized to patients and utilized by caregivers.
Learning outcomes include the importance of DAPs and a basis for and areas for improvement for implementation of DAPs.
Description: DAP is a custom-made solution consisting of two parts: a template for a plan and a customized plan for a patient based on the template. Each plan consists of zones, each with that specific qualifications and treatment actions. Templates for a disease are created and published by prescriber superusers from each clinical area. All templates also include a pharmacist approved medication profile that dynamically pulls disease relevant medications into the plan from the patient’s medication list. Only clinicians with prescriber privileges are allowed to publish templates and sign plans. Nurses may create a plan and propose it to the prescriber to sign. Signed plans include consents for self or school nurse administration of the plan/medications and are available as a finalized document, a pdf, and the discharge workflow.
For initial go-live, three clinical areas and four diseases were targeted: neurology – seizure, medicine – constipation and eczema, and allergy/immunology – anaphylaxis.
Outcome: Implementation of a tool allowing for action plans to be created for various diseases succeeded. One-month post-go-live, a total of 53 action plans have been created on patients. The majority (30) were created by nurses then signed by a prescriber. Current templates available for use are anaphylaxis, eczema, seizure, and constipation. The vast majority of signed plans are seizure action plans. Other templates currently in progress but not yet published are diabetes (age 6+), diabetes (age 6+) Spanish, and migraine.
Conclusion: Though some issues were faced, such as workflow ambiguity and timely response of pharmacists, overall, the project succeeded. Within the first weeks of implementation, workflow issues gained clarity as process norms were established. Areas for improvement include earlier engagement of the pharmacy team, increasing awareness of the tool to nurses, and technical support for non-English language characters. Though more widespread use of the plans over other diseases than seizure would have been beneficial, having additional disease templates already in progress is promising.
1. Waldecker A, Malpass A, King A, Ridd MJ. Written action plans for children with long-term conditions: A systematic review and synthesis of qualitative data. Health Expectations. 2017;21(3):585-596. doi:10.1111/hex.12643
2. Chisolm SS, Taylor SL, Balkrishnan R, Feldman SR. Written action plans: Potential for improving outcomes in children with atopic dermatitis. Journal of the American Academy of Dermatology. 2008;59(4):677-683. doi:10.1016/j.jaad.2008.04.025
Background: Smartphone technologies are increasingly used in the acute care setting to enhance interprofessional team-based care. However, evidence in the literature is scant and of low quality. There has been nothing to date using a realist lens. Realist reviews of literature are based on the theory-driven methodology of realist evaluation (Pawson & Tilley, 1997) that provide the heuristic context-mechanism-outcome (CMO) configuration to explain socially mediated complex interventions. Realist reviews use a variety of sources to aid in theory-building including peer-reviewed and gray literature. The results of realist reviews produce contingency CMOs of how, why, when, and for whom an intervention works.
Purpose: The aim of this realist review was two-fold. First, we sought to systematically deconstruct the existing evidence of smartphone technologies used by interprofessional teams to explain how they impact people, processes, and outcomes. Specifically, we sought to uncover, a) the changes in thinking, behavior, and attitude of team members who are exposed to smartphone technology (mechanisms), b) the anticipated and unanticipated outcomes resulting from those mechanisms, and c) the contextual factors that trigger or block those mechanisms. Second, our aim was to provide practical guidance for decision-makers, implementers, evaluators, and researchers.
Methods: We searched CINAHL, Medline, and PubMed from 2009 to March 2019. For gray literature, we used Google as the search engine. We appraised evidence for relevance and rigor according to realist standards. Inclusion criteria included articles of smartphone technologies used by interprofessional healthcare teams to communicate, collaborate, or coordinate patient care within hospital settings. Analysis was completed using retroductive logic. We operationalized our findings to make them relevant to nurse leaders and nurse informaticists.
Results: 21 reports from 2009 to 2019 were fully reviewed and categorized as qualitative (7), quantitative (7), multi-methods (4), and expert opinion (3). The evidence supported 7 CMO statements. The use of smartphone technologies results in positive outcomes (patient- and team-related) when the following mechanisms are triggered: feeling efficient, feeling a sense of urgency to act, learning and a sense of security. Smartphone technologies, in certain contexts, can also result in negative outcomes when users feel frustrated, misinterpret messages, feel inefficient, and feel disrupted or slighted by other team members. Contextual factors that influence whether a mechanism will be triggered or blocked include: a) having protocols in place for smartphone use,(b) the complexity of patient care, c) team members in disparate locations, d) voluntary smartphone usage or having multiple choices of communication modes, e) time-sensitive disease processes that have protocol-driven care, f) team members who are not involved in the entire case, and g) team members who are supervisors or coordinators of team-based care.
Conclusion: Smartphone technology results in different outcomes based on the responses and reasonings of team members and the contextual characteristics of team members, teams, and environment. The findings of this realist review are relevant to nurse informaticists and nurse leaders who are making decisions regarding smartphone technology purchases, implementations, and evaluations. The resulting CMOs offer a myriad of opportunities for scholarly research.
Suicide in the United States is becoming a public health crisis. According to the Centers for Disease Control and Prevention (CDC), the United States experienced a 28% increase in suicide between 2000 and 2015 (Stone et al., 2017). In a sentinel event alert published by the Joint Commission in 2016, suicide was identified as the 10th leading cause of death in the United States. Shockingly, “providers often do not detect the suicidal thoughts (also known as suicide ideation) of individuals (including children and adolescents) who eventually die by suicide, even though most of them receive health care services in the year prior to death” (Joint Commission, 2016). Further research into this increase has shown that within the first two weeks of discharge from an inpatient psychiatric stay, patients are most vulnerable to self-harm (Redding et al, 2017, Wise, 2014). As such, missed opportunities for healthcare providers to facilitate the transition of care to outpatient mental health treatment is the area that this project is targeting.
The project is designed to provide an evidence-based structure for these follow-up calls, standardizing the assessment questions, using a depression screening tool already embedded in the electronic medical record (EMR), as well as providing evidence-based interventions for staff to implement for those patients at the highest risk for self-harm. In addition to a telephone call note template that will provide for consistent data collection about barriers to care after discharge, the staff will administer the patient health questionnaire (PHQ-9), a depression screening tool currently embedded in the EMR, and administered upon discharge from the inpatient psychiatric units.
In closing, this project has the potential to strongly support the proposed post-discharge outreach program. This project, once implemented as part of the larger outreach program, will give the nurses guidance in their assessment of the patient’s needs during their transition from inpatient to the community. It will provide evidence-based interventions for patients found to be at high risk for self-directed violence. In addition, it will maximize the data collection functionality of the EMR, thus allowing for analysis to identify trends in barriers to care, which leadership can act upon. For example, if a patient attempts to fill a prescription that requires a prior authorization, this contact can allow staff to expedite this process, thereby removing the barrier to medication adherence. Using the data to solve the individual patient’s problem is useful, but adding in the ability to track barriers and outcomes will also demonstrate cost savings by reducing avoidable readmissions.
Purpose: This presentation aims to explore the impact of utilization of the health system application’s services to operational workflow, patient satisfaction, and cost-effectiveness.
Background/significance: There is pressure on the healthcare industry to improve quality of care and clinical outcomes while reducing hospital expenses. As the cost of healthcare increases, healthcare organizations (HCOs) are seeking to address unnecessary hospital encounters. The current healthcare model is unable to meet increasing demands. There is a need for a healthcare model that supports patients in managing their own health.
Patients value convenience as much as quality and cost. They want convenient and immediate access to their health information and healthcare services. Providers need a tool where they can see all clinical data for continuity of care and decision making.
The challenge relies on how HCOs empower patients to engage in their healthcare while providing a consistent workflow for providers.
Digital health technology solutions such as telehealth, mobile health applications (app), and patient portals are becoming industry standard tools and are rapidly improving. Combining these technologies into a single enterprise platform will vastly improve the patient digital experience and offer many additional benefits to healthcare stakeholders.
Our organization built a health app which delivers a singular digital experience by fully integrating the patient portal, electronic health record, virtual urgent care (VUC), telehealth, and other health services. This is a streamlined approach for both the patient and care team that is built to enhance provider workflow, patient-provider communication, improved data collection, continuity of care, and improved patient access to health information with emphasis on patient experience and the same high-quality care at a lower cost.
Method: An in-depth data analysis from health app dashboard was conducted to determine the total number of unique records and encounters involving digital communication, online scheduling, active app users, and other key metrics.
Result: Since the health app launched, numerous new features have been deployed and optimized using agile software development principles. A dashboard has been built to track utilization and performance. It measures user access, completion of business percentage, and key clinical outcomes.
A review of the database showed a total of 839,854 (September 2018–October 2019) active users. It shows a 200% increase in health app installations since January 2019. Since the addition of radiology scheduling feature, 37% of eligible patients scheduled their appointment and 15,702 viewed their imaging results within the app. Patients used the app to find a provider; a total of 180,412 encounters were recorded. Over 7,800 VUC encounters have been completed since the service launched in 2017. Patients used the app to communicate directly with their providers; a total of 2,896,619 messaging were recorded. Patients have expressed high satisfaction, highlighting the ease-of-use, convenience, and access to world-class medical care.
Conclusion: Fully integrated health apps can improve digital experience for both patients and providers. As a data-driven organization, it is important to track key performance indicators and key clinical outcomes to help identify opportunities for investment in new digital health tools to further improve healthcare services.
Purpose: The implementation of robotic process automation can assist ambulatory providers addressing preventative care opportunities at bedside during an office visit
Background: Inconsistency in education, training, core staffing, standardization of workflow, and chart preparation to support a value-based care model has created a need for robotic process automation at bedside. Robotic process automation has not been utilized to automate tasks at bedside. Robotic process automation can assist providers identifying patient populations that are eligible for breast cancer screening, colon cancer screening, hemoglobin A1C, tobacco cessation education, and pneumococcal vaccination by standardizing the orders, diagnoses, and documentation for clinicians to successfully address preventative care opportunities during the office visit.
Methods: This study was a retrospective pre/post analysis of clinicians in family medicine and internal medicine clinics addressing care gap opportunities for patients eligible for breast cancer screening, colon cancer screening, hemoglobin A1C, tobacco cessation education, and pneumococcal vaccination. Robotic process automation was leveraged along with EHR functionality to identify patient populations eligible for preventative care gap closure. Robotic process automation was configured to pend standardized orders, diagnoses, and discreet documentation for the ambulatory care provider 48 hours ahead of an office visit to address patient populations eligible for breast cancer screening, colon cancer screening, hemoglobin A1C, tobacco cessation education, and pneumococcal vaccination. Clinicians were measured from three different regions of CommonSpirit Health on designated care gap compliance before and after the implementation of robotic process automation.
Results: The mean percentage of patients who were eligible and received discreet tobacco cessation education prior to bot implementation was 3.38% and 60.01% after bot implementation. The mean percentage of patients who were eligible and received pneumococcal vaccination prior to the bot implementation was 9.47% and 38.03% after bot implementation. The mean percentage of patients who were eligible for breast cancer screening and had an order signed for mammography during an office visit prior to the bot implementation was 30.99% and 65.76% after bot implementation. The mean percentage of patients who were eligible for hemoglobin A1C testing and had an order signed for mammography prior to the bot implementation was 30.99% and 65.76% after bot implementation. The mean percentage of patients who were eligible colorectal cancer screening and had an order signed for colorectal cancer screening prior to the bot implementation was 27.12% and 70.08% after bot implementation. Data is currently being validated for a larger longitudinal sample size.
Conclusion: Robotic process automation can be utilized to standardize the orders, diagnoses, and discreet documentation for providers addressing preventative care opportunities at bedside during an office visit. The implementation of robotic process automation resulted in an increase in providers addressing preventative care gap during office visits.
Introduction: The cohort of nurses from the millennial generation is becoming the fastest-growing group rising into nursing leadership positions. The modern manager, however, is required to possess business or operational skills, a degree of clinical acumen, and a cadre of leadership skills to promote connection, resilience, and relationship building with staff or direct reports. Millennial managers, however, are often adept with the use of technology and using it to their advantage. The purpose of this poster is to discuss how two novice millennial managers designed, implemented, and successfully replicated the "report card" to collate and present key unit-based metrics, goals, and accountability tasks to facilitate real-time staff interfacing and engagement.
Impact: The report card required little resource of financial impact to create. Using existing time and attendance interfaces, quality data, and the electronic medical record, an electronic report is automatically generated that culls multiple data points into a single report card for easy tracking and trending and stimulating monthly conversations with staff. These conversations are two-fold: they provide a mechanism to recognize and praise high-performing staff and to make a deliberate event to counsel or address low-performing employees.
Outcomes: Both units exceeded all their unit specific goals during the year. Since managers remain engaged and connected to their employees on a regular basis, external turnover for both units remains low. Concomitantly, patient satisfaction scores for both units outperform both organization and national benchmarks.
Implications: Leadership engagement with staff is sustained using simple technology that is comfortable for the millennial leader. Staff are aware of unit-based and personal performance metrics, receive mentoring or strategies for improvement, and praise for jobs well done. Retention on the unit, and in the organization, remains high.
Application to other settings: This initiative was presented as a best practice throughout the organization, and is currently being adopted by other units. This tool can be customized to for any organization.
Lessons learned: Through staff feedback, the report cards have changed to include a focus on staff resiliency by promoting their personal goals, self-care, and patient connections in addition to the achievement of unit goals. Accountability becomes a positive interaction through effective consistent communication on a monthly basis, which fosters better relationships between staff, patients, and management.