Reducing patient harm associated with clinical alarm systems is a national patient safety goal that is a multifaceted problem, requiring systematic and interdisciplinary coordinated solutions [1]. Collaborative partnerships between Health Care Organizations (HCO) and patient monitoring vendors can create a change management paradigm that meets this Joint Commission patient safety goal. In addition, this collaboration can also be used to further understand and improve upon the emotional pressure caregivers feel in alarm-rich environments, precipitating alarm fatigue [2].

Clinical consultants from a patient monitoring vendor and HCO agreed upon a Scope of Work to identify alarm management opportunities through 3 days of onsite observations. This included policy and procedure review, and analysis of alarm data. A validated Alarm Fatigue Survey (AFS) was electronically distributed to measure baseline alarm fatigue in staff [2]. Additionally, three sites encompassing four telemetry units, 1 NICU, and 1 ICU were in scope. Observations, baseline AFS data from 109 respondents, and alarm data were analyzed with opportunities categorized into people, process, and technology categories.

The team found that people and process opportunities were often interconnected:

Opportunities related to understanding alarm policies led to varying practices related to alarm response and alarm parameter adjustments.
Additional research is needed on SpO2 utilization in telemetry environments. Utilization criteria should be present in the policy.
Opportunities related to skin prep and electrode maintenance written into policy and procedure led to nuisance alarms and delayed interaction with technical alarms.

30 days of alarm data further validated the opportunities derived from onsite activities:

SpO2 low limit alarms were a top 3 alarm on all tele units.
Skin prep and electrode maintenance opportunities were validated. ECG leads-off reminder alarms accounted for 53% of one unit’s alarms; the initial ECG leads-off alarm accounted for 4.69%, suggesting alarm response opportunities.

Tailoring alarms to patient needs is supported as best practice; this practice reduces the occurrence of non-actionable alarms [3]. For example, autonomy to make a SpO2 low limit change by 1% could reduce low SpO2 alarms by 33% and 30% in two respective tele units. The same units would reduce HR alarms by 34% and 61% with a high HR limit change from 120 bpm to 130 bpm.

Technology recommendations included:

Guidance from a patient monitoring policy for patient profile usage with ECG or SpO2-only monitoring.
Aperiodic SpO2 mode in the monitoring system
An end user is allowed to pause alarms in the NICU to reduce SpO2 alarms during direct care.

An interdisciplinary team from an HCO and patient monitoring vendor can identify actionable alarm management opportunities through a people, process, and technology assessment framework.

References:

National Patient Safety Goals. The Joint Commission. 2021. URL: https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2021/npsg_chapter_hap_jan2021.pdf [accessed 2022-08-22]
Torabizadeh, C., Yousefinya, A., Zand, F., Rakhshan, M., & Fararooei, M. (2017). A nurses’ alarm fatigue questionnaire: development and psychometric properties. Journal of Clinical Monitoring and Computing, 31(6), 1305-1312.
Graham, K. C., & Cvach, M. (2010). Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms. American Journal of Critical Care, 19(1), 28-34.

Purpose: The pediatric complex care plan was created in the electronic medical record (EMR) to provide a centralized, concise location for the care team to document and easily access critical patient care planning information. The complex care plan is personalized for each patient and easily accessible at any time by the care team. Care instructions can be shared with patients and families through an after-visit summary that can be printed or viewed in the online patient portal.

Description: Care plans are an evidence-based strategy to improve communication and collaboration in the management of complex patients. Pediatric ambulatory care clinic nurses in our organization had difficulty locating critical care plan information for patients in the electronic medical record (EMR) related to nutrition, equipment, supplies, and therapies. Nurses documented care plan information in various locations within the EMR including in specialty notes that may or may not be viewable by other team members. Not having a standard easily accessible care plan created productivity challenges as nurses searched frequently for information and could potentially delay care.

In collaboration with informatics colleagues, a team of registered nurses, physicians, advanced practice registered nurses, case managers, and dieticians provided design input for a comprehensive complex care plan. The goal of the project was to increase the percent of pediatric complex care clinic patients with an updated care plan in the EMR to 80%.

Evaluation/outcome: The care plan was implemented in the pediatric complex care clinic in January 2020. By June 2020, approximately 70% of patients had a care plan present in their chart at the time of the visit. However, the number of patient care plans shared via the online patient portal was only 30%. Over the next 2 years, efforts focused on implementing the plan throughout our pediatric primary care and specialty clinics as well as spreading adoption to our inpatient areas to support patient care across the continuum.

Adoption of the pediatric complex care plan has grown, and today over 90% of complex patients have a care plan completed in the EMR. Next steps include further spread and adoption throughout surgical services and continued improvement of online portal access.

Purpose: The purpose of the fall risk screen documentation tool is to ensure standardized documentation of the patient’s fall risk and promote clinician knowledge of strategies to prevent future falls in the outpatient clinic setting.

Background/significance: Falls are known to be one of the leading causes of injuries among older adults, adults aged 65 and over. The academic medical center’s operational plan includes goals to decrease ambulatory care falls with injury. Historically, ambulatory care clinics utilized a fall risk screen within the electronic health record (EHR) that was originally developed for the inpatient setting. This screen did not fully capture the future risk of falls specifically for patients in the ambulatory care clinics. Additionally, the screen did not receive a formal review by the ambulatory care fall risk prevention committee. The ambulatory care fall policy was recently modified to increase the frequency of older adults' fall risk screening. With increased screenings, the clinical staff are more aware of the patient’s risk of falling. Once the ambulatory care fall policy was updated, the committee reviewed the available fall risk screens found in the EHR and discovered gaps in the existing fall risk screens. The CDC also provides the stopping elderly accidents, deaths, and injuries (STEADI) initiative resources to assist healthcare systems with mitigating and eliminating factors that lead to accidents, injuries, and death for older adults.

Description: With the assistance of the electronic medical record (EMR) team, a new fall risk screen was developed based on the current policy and vetted by the ambulatory care fall risk prevention committee. This new fall risk screen included screening questions from the STEADI algorithm for fall risk screening, assessment, and intervention among community-dwelling adults 65 years and older. By incorporating the CDC’s STEADI initiative tools and clinic-related fall prevention interventions, the new fall risk screening tool was created to be a more comprehensive tool that is better suited for encouraging fall risk prevention interventions in the outpatient setting. The tool provides physicians and advanced practice practitioners with appropriate documentation of the patient’s risk for falls.

Evaluation/outcome: With the new fall risk screen documentation tool available to clinic staff, users report an increased preference for the new fall risk screening tool when compared to the previous fall risk screening tool. The new tool continues to be promoted and socialized to non-hospital-based clinics through clinic in-services and presentations in ambulatory care practice committees. Although a new fall risk screen tool was created, the past fall risk screens remain available in the EHR. To improve the standardization of documentation tools, we plan to introduce the new screen to hospital-based clinics too. Also, the EMR team is currently developing a report to capture the utilization of the new fall risk screen. With this data, we can better understand how many patients are being screened and if there has been a reduction in falls in the outpatient setting.

Introduction: The military health system (MHS) is undergoing a modernization of its electronic health record (EHR) by implementing an integrated EHR called MHS-GENESIS, a $4 billion commercially procured EHR-based on Cerner’s Millennium platform. Most literature regarding EHR transitions focuses on a single health system such as a multi-hospital network, which pales in comparison to the size, scope, and pace of the MHS’ EHR implementation. Because of this, traditional and non-traditional leadership methods are required to successfully orchestrate an EHR transition. By the end of calendar year 2023, MHS-GENESIS will be implemented in over 850 medical and dental treatment facilities worldwide. This EHR transition impacts more than 9.5 million Department of Defense (DOD) beneficiaries and over 250,000 MHS end users by integrating and optimizing the technology to streamline access to health records.

Materials and methods: The authors surveyed available literature to identify the knowledge and information about key facets of EHR implementation and transition in healthcare systems overall. This review will explore published literature and provide a comprehensive comparison between the DOD’s implementation of MHS-GENESIS and the private sector/civilian healthcare organizations’ EHR implementations. MHS-GENESIS implementations do not have robust published literature; therefore, the authors sought the DOD subject matter experts to provide information and perspective about the unpublished data and information about the EHR transition.

Results: Each MHS GENESIS go-live event is an opportunity to disseminate best practices and lessons learned to improve future integrations in military and non-military healthcare organizations. However, published literature providing a comprehensive review on MHS-GENESIS roll out and post-implementation best practices is lacking. In addition, findings of studies citing MHS-GENESIS implementation are limited in scope and rigor. Due to the magnitude and the wide geographical spread of the EHR transition across the DOD, standardization and collaboration across the military services are key to a successful MHS-GENESIS implementation. A list of challenges and sustainable lessons learned from the MHS-GENESIS Go-live at one military treatment facility (MTF) are described to potentially aid other healthcare organizations in future and successful EHR implementations while also discussing how organizations can promote and encourage clinical transformation within a positive culture of change.

Conclusion: MHS-GENESIS continues to be phase implemented and currently in the Atlantic and European regions. At the forefront of clinical transformation, clinicians at all levels drive change management across healthcare organizations. Garnering best practices and lessons learned from the military’s larger-scale EHR transition provides a model for future successful EHR implementation for any healthcare system, regardless of size or entity, and leverages the influence leadership holds in the process.

Introduction: During the school learning process, students often need to inquire about relevant subject knowledge and school information-related resources and information. They may receive very little information due to the complexity of the inquiry process and often do not know from which department to inquire about information. Sometimes they may forget to ask the question and neglect some parts. Thanks to the vigorous development of technology, we can quickly obtain information. Knowing the chat robot also brings great advantages. I wanted to apply it to various problems of Hongguang freshmen. The difficulties that each freshman may encounter could be solved quickly, and at the same time, they could adapt to a new life as soon as possible, reducing the situations where administrative staff would answer the phone and provide help.

Method: Select the freshmen of the nursing department as the subjects, use the questionnaire mode to collect the general question direction needed, obtain relevant information through the department office of the nursing department and the school website, and build the information into the line chat robot.

Result: A total of 37 questionnaires were answered, and of the satisfaction scores provided on "school resources," "school map list," "graduation credits, " "scholarships," and "keywords" most were very satisfied and 91.6% were satisfied.

Conclusion: When dealing with the questionnaire, many people encouraged us. We included a navigation map so that students can get to know each building. The biggest problem in the process is the direction of data collection. After completing the questionnaire, the direction can be determined including if you want to cross the university. When it comes to details, it is necessary to cooperate with various departments, and at the same time, it must be managed by someone.

Barcode medication administration (BCMA) has been the standard practice in the inpatient and infusion environments for many years, but implementation in the ambulatory care and procedural realms has lagged due to a lack of realized value. With the challenges of a global pandemic, increased clinic volumes, clinic expansions, and staffing shortages, the vison to tackle such a large-scale project like BCMA seemed bleak. With the support of nursing leadership and unwavering determination- BCMA has now successfully been implemented in all pediatric and adult clinics and two newly acquired regional practices at Vanderbilt University Medical Center (VUMC). This presentation will share some of the challenges, triumphs, and lessons learned throughout the implementation process. Extensive workflow analysis occurred as areas were implemented to identify the roles that administered meds and adjust processes to incorporate the guiding principles of BCMA. Mid-implementation, the medical assistant role was expanded to include administration of vaccines (COVID and flu) to reduce burden on nursing staff. This added further complexity to the roll-out. Resources for managers to utilize, such as a hardware toolkit, BCMA end user toolkit, and BCMA leader toolkit were created to keep managers, nurses, and front desk staff in alignment. Virtual support structure of go-live was staggered by grouping similar areas (with input from operational leaders) and considering hardware readiness, medication administration practices (volume, high risk, high cost), and other constraints. Go live support consisted of both onsite support deployed to help high-volume or high-risk areas and virtual support using an open Teams line to field questions. These topics cover just a few of the important lessons learned during the implementation of BCMA in the ambulatory care setting at VUMC. Ambulatory care BCMA is a multifaceted project that requires cooperation from many departments and can improve administration safety, patient safety, and nurse satisfaction. This is an important innovation for the ambulatory care space that we recommend to other organizations.

With the shortage of blood supplies, management of blood products for patients, patient preference and religious beliefs, and patient care outcomes post-blood administration, an alternative source for treating patients requiring transfusion management transformed and improved patient care management with the implementation of a hospital transfusion-free anemia management program for hemoglobin 7.1-9 g/L at University Medical Center of El Paso. The development and implementation of a power plan within the EHR that managed patient care for inpatients as well as the development of an ambulatory care follow-up program guided clinical teams while improving patient care. The underlying purpose of this initiative focused on evaluating and discussing the outcome of the interdisciplinary approach enabling bedside nurses, physicians, pathologists, laboratory specialists, blood bank specialists, pharmacists, nursing informatics, information technology, and other essential healthcare teams to better understand evidence-based practice principles in the management of blood and improving patient care.

Variability in blood management guidelines to include nurse and physician understanding of the importance of utilizing the hospital transfusion-free anemia management program power plan was observed with the use of data from the EHR identifying a need to review criteria and focus on engagement with utilization of the power plan. An interdisciplinary subcommittee was formed composed of bedside nurses and administrators, residents and physicians, and nursing informatics to outline the principles and criteria outlined in the power plan and increase engagement with the utilization of the power plan and bring uniformity with treating patients with transfusion-free anemia criteria.

Strategy and implementation included the use of PDSA and the principles of Kolb's model of experiential learning. The combination of handouts, badge buddies, power point presentations at nursing leadership committee meetings, and physician medical staff process improvement meetings to include education specific to the use of the hospital transfusion-free anemia management program power plan improved the utilization of the power plan.

Results revealed significant positive changes with the utilization of the power plan. There was also improvement in the number of patients referred to the outpatient anemia management program upon discharge.

The transfusion-free anemia management program serves as a model to other healthcare organizations that would like to implement a transfusion-free management program with the use of an electronic power plan in the midst of blood shortages and complex treatment plans for patients requiring transfusions. It assists in enhancing the knowledge base and confidence of nurses and physicians interested in evidence based practice that improve patient care. The transfusion-free anemia management program went from 20% to 90% utilization and continues to grow.

Multidisciplinary rounds are used to address barriers to discharge, decrease length of stay, and decrease patients boarding in ED. Many units and facilities within our healthcare system are/were conducting multidisciplinary rounds, but there was no standardization to the process or the way the rounds were being documented. We created a team to work on standardizing the process and determining how to document that the multidisciplinary rounds occurred. This team consisted of nursing, social work, care coordination, and informatics. This team was charged with developing a toolkit to foster standardization, EHR documentation, and training. Initial work was to determine who should be conducting these rounds, when these rounds should be conducted, and where these rounds should be conducted. Once the who, when, and where were determined, the team began putting specific expectations of what the content of the multidisciplinary rounds needed to be. All of these things were laid out in an electronic toolkit for users. We also developed a multidisciplinary rounding list for each unit in our EHR with vital information to be seen and discussed in the rounds. We also created a way to have some documentation on key elements for the rounds in the EHR. We developed a metric dashboard to monitor compliance with multidisciplinary rounds. Lastly, we have created videos to use for training all employees to ensure standardization in conducting and documenting rounds. The poster will also show how that LOS was affected as well as increased compliance in conducting the rounds with key disciplines involved.