Healthcare facilities are employing RTLS (real-time locating system) for varied uses, one of which is asset management. It requires the attachment of a mobile tag which transmits wireless signals to track and manage the movement of assets in real time. RTLS was piloted at our 450-bed acute care hospital. It was initiated in collaboration with nursing, biomed, and IT to gather user feedback about this application in an acute care hospital.
At our facility, use of RTLS proved beneficial in locating tagged equipment. Initially, the application needed to be tweaked post implementation to reevaluate reference points to improve accuracy of locating the devices and to also avoid “floor hopping.”

Early in the pilot, it was recognized that a formal process was needed to request tagging of equipment for other types of assets. An intradisciplinary governance committee was formed to evaluate and create an approval process. It was co-led by nursing and hospital administration. Clinical nurses were engaged and encouraged to nominate new types of assets to be tagged, e.g., defibrillators, tele-health carts, ventilators, portable HEPA filters, and specialized infusion pumps.

The literature review shows that RTLS can save more than 90 minutes in locating devices and we experienced comparable results. Nursing staff were less frustrated as they no longer had to leave the unit searching for equipment. The impact was a reduction in capital equipment purchase and deployment since said equipment was easily locatable. Staff feedback during administrative rounds was that this was a valued pilot, it saved time, and they were ecstatic that their voices were heard.

Some of the hurdles of this pilot were the cost of the tracking tags, best method to secure the tags to equipment, tags that have fallen off equipment needed to be returned to our bio-med department, and transitioning staff from learning the software to using it to locate an asset.

In conclusion, RTLS was beneficial in appropriately utilizing our nursing resources and manpower to locate assets. This initiative demonstrated to our clinical nurses that their time is valued and caring for the patient at the bedside is our priority to deliver quality care. Additional safety features and merit included quick location of recalled equipment, location of devices requiring annual maintenance, equipment found quickly to prevent hoarding, and monitoring of inventory.

Patient safety is at risk when the nurse fails to follow the five rights of medication administration. Barcode medication administration (BCMA) has been proven to decrease medication administration errors by taking advantage of real-time administration documentation in the electronic health record (EHR). BCMA is a key safety process in the tertiary care setting that is closely measured and trended to safeguard medication administration. After years of meeting organization goal, compliance in the pediatric intensive care unit (PICU) decreased, causing nurse leaders to ask “why?”

Effective BCMA implementation requires a multidisciplinary approach with nursing, pharmacy, and information services department (ISD) to identify barriers and workflow issues. Physical aspects of barcode scanning, the scanners and labels, along with a hands-on approach to education are crucial. Nurse informaticists are key in bridging the gap to resolve issues and barriers and promote collaboration.

Data was recorded using a database management system that generated report from the EHR. A statistical process control chart (SPC) was used to plot monthly compliance using the total number of scanned medications divided by the total medications administered. January 2022 to July 2022 acted as the pre-intervention period. A mean was calculated using this time frame with baseline barcode scanning compliance at 90.8%. Aim goal was set to improve average monthly compliance in the PICU from 90.8% to 95% by August 2023. Subsequent monthly data points after the baseline time period were evaluated for statistical significance using SPC rules for shifts in the mean.

Interventions eliminated the shortage of workstation on wheels and unreliable scanners. Mobile EHR was utilized. Workflow analyses were completed to optimize the mobile EHR to improve functionality. In addition, mobile device setting updates were completed to eliminate frustration from end users when using the mobile application. Lastly, hands-on training was performed.
Next, the lack of ease and flexibility of the BCMA report was identified. The report included pages of PDF report that were difficult for nursing managers to trend and troubleshoot in real time. Nurses reported medications not scanning despite multiple attempts and reporting to pharmacy. Interactive dashboards were created to replace manual reports. The dashboards empowered nurse managers, nurses, pharmacy, and nursing informaticists to identify BCMA issues. The dashboards are user friendly, easy to trend, and comprehend. Managers are able to quickly see which users are not scanning while pharmacy can identify medications not scanning. Nurse informaticists utilize the dashboards to optimize medication administration documentation and workflows.

Scanning compliance in the PICU was 95.5% in August 2023. This is significant for a unit that administers thousands of critical and high-risk medications to pediatric patients. An improvement in average monthly barcode scanning compliance was demonstrated by a sustained centerline increase on the SPC chart. The success of this project is not the end, as interventions are being spread outside of PICU to sustain positive results towards patient safety. With interventions completed at a system level, collateral benefits increased scanning compliance not only in the PICU but in all inpatient areas, emergency, and respiratory therapy department.

Nurses are the largest users of electronic health record (EHR) systems in health care. Front-line nurses at our healthcare system expressed the need to remove unnecessary documentation and improve efficiency in Epic. Documentation burden in the EHR is defined as non-meaningful documentation elements and will increase over time if not identified and removed.

With the support of our chief nursing officer (CNO), the information technology (IT) healthcare system’s nursing documentation improvement (NDI) team comprised of analysts and informatics nurse specialists collaborated with bedside nurses on a quality improvement project to redesign flowsheet templates and streamline documentation. We were also given the task of creating meaningful KPIs for our various nursing documentation burden initiatives for our academic health system (AHS) leadership.

The electronic health record (EHR) vendor time data was used pre-/post-implementation to measure time in system and per activity. The NDI team manually analyzed the monthly workbooks to drilldown by campus, specialty, department, and nurse. Findings were presented at our monthly steering council meetings with the CNO and IT meetings to measure project success and to determine department(s)/nurse(s) for outreach. The EHR vendor time data provides meaningful information but may be challenging to quickly trend data and perform comparative analysis across several workbooks. The EHR executive summary report gave our CNO a high-level overview of how we compared to our peers, but it is not an interactive tool to further analyze and pivot metrics. The EHR vendor time data and executive summary also did not provide metrics on nursing tenure at our organization to measure nursing mastery overtime. Our steering council desired a shareable dashboard to quickly explore metrics and trends, and to easily compare hospital locations and departments that they oversee.

The NDI and IT reporting team partnered to develop an interactive dashboard that consolidates monthly time in system data for ease of access and use. The NDI and reporting team met weekly to strategize on dashboard layout and design. The NDI team created a metrics specification content tracker to discuss dashboard scope, key metrics and filters, and build timeline with the reporting team and IT leadership. Metrics identified are related to in-flight nurse well-being projects such as flowsheet efficiency and standard medication administration timing.

The dashboard provides aggregated enterprise data as well as hospital/department/nurse drilldown for each metric. Dashboard filters include direct patient care, day shift, shift duration, hospital, location, department, nurse, and nursing experience. We created a medication administration filter to use as a proxy to identify nurses who provide direct patient care. We leveraged human resources (HR) nursing experience metrics to explore nurse role and tenure over time and how that impacts time spent in the EHR. Time-stamp interventions or project go-lives can be marked on the linear trend graphs to track interventions. Metrics benchmarks also help us to initiate process improvements. Making data accessible and meaningful can help create better informed decisions on which projects to undertake as resources are finite.

Purpose: To improve clinician BCMA compliance, interdisciplinary communication, and digital experience using the mobile EHR

Background/significance:The growing demand for personalized, safer, and more efficient patient care at our radiation oncology (rad onc) locations has prompted us to optimize and streamline clinician workflows. Our objective is to elevate staff satisfaction and enhance patient safety. Through collaboration between nursing leadership at our rad onc locations and the medical center information technology (MCIT) department, we have identified areas for improvement where the functionalities and features of our mobile EHR can play a crucial role: communication. Outpatient settings, such as the rad onc, present unique challenges in fostering effective interprofessional communication, hindering the seamless collaboration crucial in providing high-quality patient care.

Medication administration compliance: Nurses encounter distinct challenges related to medication administration compliance that necessitate focused attention. Rad onc clinicians predominantly utilize workstations-on-wheels (WOWs) for essential tasks like data entry, medication administration, and secure messaging members of the patient’s treatment team. Unfortunately, the current WOWs fall short in meeting clinicians' requirements for portability and mobility. To tackle these challenges, a decision was made to implement our mobile EHR at our rad onc locations. Existing literature strongly supports the positive impact of mobile technology on interprofessional communication. Secure text messaging has been associated with enhanced and improved communication among clinicians. Furthermore, the use of mobile EHR during clinical work offers various benefits,aiding clinicians in their workflow.

Evaluation/outcome: A thorough analysis of the BCMA compliance report, evaluating the periods before, during, and after implementation, was conducted to determine the influence of the mobile EHR in enhancing compliance and adoption. Additionally, a pre- and post-implementation survey was distributed among the staff to evaluate their baseline and post-implementation perceptions of how the mobile EHR has impacted their workflow.

Conclusion:The implementation of the mobile HER stands as a transformative milestone, showcasing significant improvement in BCMA compliance, interdisciplinary communication, and overall digital experience. This success not only reflects the adaptability of our clinicians but also highlights the importance of embracing digital solutions to enhance efficiency, communication, and the overall healthcare journey.

The American Medical Informatics Association (AMIA) defines documentation burden as the stress resulting from excessive work required to document in the electronic health record (EHR). The information technology (IT) healthcare systems’ nursing documentation team partnered with documentation improvement committees comprised of front-line nurses and senior nursing leadership to determine perceived barriers to documentation in the EHR.

Purpose: This quality improvement project explored the perception of documentation challenges and burden related to the EHR among inpatient nurses practicing in an academic health system (AHS) and identified improvement strategies.

Methodology: This project used a convergent mixed method approach. Qualitative data was collected during five focus groups, guided by questions related to the EHR. Each session was recorded, transcribed, and anonymized. 20 nurses across the AHS participated. The transcripts were analyzed in aggregate by the project team. Thematic analysis was conducted. Themes and sub-themes were identified. Deidentified quantitative data was collected from the EHR vendor, including active time in the EHR, provided in aggregated monthly intervals. Time in each activity and activity type within the EHR were calculated for clinical nurses. The number of shifts worked in the monthly interval, relevant clinical data such as number medications administered, and notes written also were provided by the vendor. Clinical nurses were defined as nurses having at least one medication administration per shift.

Findings: 20 nurses participated in the focus groups from across the system. 42% were from the adult medical-surgical area. 70% were full-time employees, with 35% having between 3-5 years of experience. While there was representation from the pediatric and adult services, half of the participants were from the adult medical-surgical area. The major themes that emerged from the anonymized focus groups included empowerment, workflow opportunities, nuisances, and communication. The sub-themes identified were uninterrupted documentation time, non-meaningful documentation, consistency, redundancy, education and training opportunities, and flowsheet utilization. Focus group participants perceived their time spent in the EHR at approximately 40%. The vendor system time data showed that the average time spent in the EHR was 19% across the health system. This was less than half of the focus group’s perceived time spent in the system. Overall, participants were favorable regarding the focus group format.

Conclusion: Front-line nursing perspectives in workflow redesign is imperative in identifying interventions to promote adoption and EHR satisfaction. Nurses may not always recognize the need for documentation optimization nor understand the rationale for certain documentation in clinical practice and how it can reduce their perceived burden. We recommend continuing to build partnerships between IT and clinical leadership to inform nurses in a timely fashion of the clinical value of documentation updates occurring in the EHR. Future work will include determining the existence of duplicative documentation, identifying successful communication methods regarding upcoming enhancements, and considering focus group format to explore the EHR documentation needs of various specialties.

Kathleen Zavotsky discloses that she is the editor of a textbook published by Elsevier.

Purpose: This is a large urban safety-net hospital that contains a 20-bed level-3 designated NICU. There are roughly 3000 deliveries per year, with 250 neonates being admitted to the NICU. Workflow challenges were identified with breastmilk and formula feedings. This resulted in inconsistencies with order entry, milk preparation, and milk delivery. Studies show that 74.83% of feeding-related errors in the neonatal intensive care unit (NICU) have led to differing levels of harm to patients.

Description: Feeding neonates breastmilk can help support growth, immune system development, neurological development, and gastrointestinal absorption of fats and minerals. Additional calories by fortification and formula may be added to the breastmilk to promote rapid weight gain and maturity. For premature infants, neurodevelopmental outcomes are strongly linked to growth. Due to the complex needs of the neonatal population, it is imperative that their nutritional needs are met.
Utilizing lean six sigma principles, the work was initiated by performing a multidisciplinary Gemba walk. Next, the team mapped the process from order entry to milk delivery. It was identified that the area with the greatest opportunity was related to order translation. Due to the excess amount of nonessential information and lack of pertinent elements within the order, providers were forced to enter written instructions into a comment box. This led to inconsistency in order entry and incorrect milk preparation. The downstream impacts were delays in patient care and discharge to the home. The electronic health record (EHR) breastmilk and formula order revamps were initiated to replace the nonessential order questions with order questions pertinent to milk preparation and delivery. Leveraging the EHR, the new order was able to ensure clear, transparent, and consistent administration instructions. Additionally, the team created a printable patient list from the EHR which translated the order questions into a report. The list creates a separate column for each order question, allowing the milk technician to see all the selections the providers have chosen. The list is then used by the milk preparation technician to match the milk recipe to the order.

Evaluation/outcomes: From October 2022 to October 2023, an analysis was performed of the total number of breastmilk and formula orders. In a 1-year timeframe, the number of incorrectly prepared and delivered milk orders was reduced by 50%. The physicians, nursing staff, and milk technicians all reported increased satisfaction with the improved workflow and reduction of order reentry due to unclear instructions. It was also reported the reduction from 18 questions to the new order of 10 questions improved efficiency. The new order build ensures patients are provided with the correct nutrition and helps sustain a reduction in errors related to order clarity.

The clinical informatics (CI) department of a 23-hospital integrated health system played a vital role in planning, designing, and implementing an inpatient interactive patient care system (IPC) at its quaternary care teaching hospital to enhance patient engagement and involvement in their health care.

Purpose: The mission and goals of implementing the IPC system are to improve patient satisfaction, increase patient autonomy, engage the patient in their own health management and education, increase patient awareness of their care plan and team, initiate service requests, and provide patient access to a vast audio-visual library of health education to improve patient outcomes. The IPC technology increases accessibility, trust, satisfaction, and independence throughout a patient admission. The IPC system also offers facility details and daily schedule/goals for the day to keep the patient informed. The system provides meal ordering options, friends and family connectivity, and entertainment to enjoy during their admission.

Method: The IPC integrates with the hospital’s current electronic medical record (EMR), creating a seamless education experience tailored to the patient’s needs. Hundreds of patient education videos comprised of health issues management, surgical/non-invasive procedures, and wellness/relaxation methods were carefully chosen and vetted by clinical informatics and a contingency team of hospital clinicians. Partnering with the IPC vendor, educational videos were mapped to patient health conditions for auto-assignment and an EMR bi-directional interface was implemented to automate accurate documentation of patient education and decrease nursing documentation burden. Dietary department integration was implemented to create seamless meal ordering by patient without staff intervention. Environmental services department integration was implemented to create a direct line of communication to request room cleaning services and restocking of toiletries. Patient experience department integration was implemented to request to rate their admission experience and/or speak with a supervisor. Recognition surveys were integrated into the digital whiteboard to reward a staff member for their exceptional service. Clinical informatics developed effective training materials for clinicians and patients; vetted devices; and provided in-person training, demos, and support for all phases of production.

Result: Press Ganey survey score results continue to climb. Clinicians are supported by the new IPC system by decreasing clinician/administrative workload. Patients are utilizing the IPC to receive for education; learn their schedule and plan of care; visualize their care team; order their meals, provisions, and room services; utilize interpreter services; and enjoy entertainment. Staff and patient feedback have reported positive ease of use for devices provided.

Conclusion: Clinical informatics continues to partner with the hospital and vendor to optimize this innovative tool to develop initial and ongoing educational materials for clinicians, offering hands-on training and providing elbow-to-elbow support during all phases of go-live, with the ultimate goal of finalizing a system-wide implementation plan and process. Ongoing assessment of staff and patient feedback regarding the IPC technology continues to evolve and feedback is taken into actionable consideration to improve the staff and patient experience.

Over 15 years ago, there was a movement towards going electronic in all our clinical departments. We were transitioning from those who were brought up on paper charts with a Kardex to those who will not even be taught paper documentation. As our nursing informatics role was focused on everything EMR (electronic medical record) and go-lives, there was a gap in what our clinical users needed to be prepared for. Our organization looked at the gap of downtime education and preparedness and evolved our role to meet that gap.

Our informatics department, took on the initiative and developed our roles to address this downtime preparedness. Some of these methods included developing a nursing-specific business continuity plan (mentoring other clinical departments to develop their own business continuity plans), developing a downtime equipment check list embedded in the charge RN workflow to check weekly, rounding on the departments for preparedness, developing a mandatory downtime CBL (computer-based learning), developing tabletop drills, being a member of the emergency preparedness, and being at the table when new clinical build is being discussed so downtime in front of mind when preparing the area.

As with any process, there is still opportunity for this role to grow. There will come a time when the majority of the clinical staff will never have documented on paper and/or experienced an extended downtime. As we continue to educate our staff on the current downtime processes and reports, our informatics role will need to expand into education of clinical staff to document on paper, write orders, and take off those orders. In addition, every downtime will provide the opportunity to review lessons learned and continue to take our nursing informatics roles into a new space for providing support to our clinical users and patients.

The setting for the work that I currently support in downtime preparedness is 300 downtime computers over a 7-hospital system with 1497 beds and 2.3 million outpatient visits a year.

The increasing number of emerging technologies that healthcare organizations implement are enormous and have an impact on nursing practice. These technological solutions are designed with common themes around improving patient safety, addressing strategic KPIs (key performance indicators), and/or improving clinical workflow efficacies. What is not common is the initial involvement of the nurse informatics specialists (NIS). Kaye reported having early involvement of nursing during the selection process improves the usability and sustained adoption of emerging technologies (2017). This discussion will highlight harnessing the knowledge, skills, and power of the NIS as key clinical consultants and stakeholders at the onset of projects beyond the electronic health record (EHR). Explore the strategic role NIS possesses from a unique perspective of both clinical and technical knowledge to help evaluate new technologies.

When NIS are absent from the decision table, critical elements in a solutions’ success for adoption that impact nursing practice are potentially missed. Their understanding of the current clinical state in collaboration with bedside clinical staff is invaluable. NIS can help improve the very themes that emerging technologies are positioned to address by leading and fostering a culture of transformation. Authors have suggested that having nurses incorporated in the technology selection process can drive clinical staff’s perceptions and acceptance of emerging technologies. The Institute of Medicine’s report (2010) on the future of nursing states that allowing the nurses to practice to the full extent of their education and training will aid the profession to lead change and advance health care. A seat at the table representing the experience of the NIS is essential to achieve this goal.

We will describe some emerging technologies as opportunities to engage the NIS early in the planning process. Additionally, we will discuss the NIS use of lean principles and practical problem solving to critically examine current and future states of practice. Also, we will demonstrate eliminating waste to streamline workflows to improve patient and staff satisfaction with the use of technology. Data illustrates that bedside staff’s perceptions of emerging technologies must be easy to use and provide relevant data. The NIS has an intimate connection to clinical practice to guide decision making at an administrative level, which is vital to achieve project goals while managing expectations. NIS has comfort with the concept of going to the Gemba, identifying clinical bottlenecks that often impair organizations from moving to the next level of performance excellence and obtaining ROI with purchased technologies. We will also examine utilizing consulting skills to impact change management and project success.

Change is constant in today’s complex healthcare environments, yet no stranger to a day in the life of a NIS. They possess a greater appreciation for managing change due to the nature of EHR evolutions. Effective change management can be one of the most impactful elements that drive acceptance or adoption failure of new technologies. This discussion will explore two established change models at work within different organizations, illustrating the good, the bad, and the ugly.

Orlando Scott discloses that he is an employee of Philips Healthcare.

The communicating narrative concerns entered by RNs (CONCERN) multi-site study recently concluded at two medical centers in the Northeastern United States. CONCERN is an early warning system (EWS) that uses machine-learning prediction algorithms to analyze nurses’ documentation patterns to identify patients at low, medium, and high risk of clinical deterioration. The hourly CONCERN scores are displayed to nurses and prescribing providers in their electronic health record patient lists. The CONCERN EWS intervention was developed using the healthcare process modeling-expert signals framework to phenotype clinician behaviors and predict patients’ clinical trajectories. Clinical nurses’ feedback and engagement were solicited and incorporated regularly throughout the study.

The CONCERN intervention was implemented on 37 randomly selected acute care and ICU units. The trial was conducted between October 2020 and October 2022. Prior to study implementation, clinical nurses participated in user-centered design and simulation sessions to provide feedback on the CONCERN SmartApp, including the frequency and method of alerts, the design of the CONCERN interface, and how CONCERN could be incorporated in nurses’ workflows. During the implementation phase, clinical nurses served as unit champions, acting as resources for their peers and as a point of contact for the study team. Finally, post-implementation, clinical nurses participated in focus groups and interviews on optimizing and spreading CONCERN to additional study sites. They also provided comments and suggestions on CONCERN onboarding resources, which allowed the study team to refine and add resources for future implementations.

Based on nurses’ feedback during the design stage, CONCERN does not generate interruptive alerts. The visual indicator is green-yellow-red color convention corresponding to low-medium-high risk scores. During the CONCERN implementation, 1,996 nurses worked on the 37 intervention units at the two sites. using the unit Champion model helped to facilitate the onboarding education of the clinical staff, especially during night and weekend shifts. There were approximately 12,100 launches of the CONCERN Smart App by clinical end users during the study period. Finally, the feedback from the clinical staff regarding the education process and resources used during the original implementation informed the CONCERN implementation toolkit, which is being used for new implementations of CONCERN at two additional academic health systems. Incorporating clinical nurses’ feedback at every stage of the CONCERN intervention development and implementation was crucial to successfully adopting this novel EWS that uses nursing surveillance data to predict patients at risk for clinical deterioration.

This work is funded by the National Institute of Nursing Research (1R01NR016941-01) and the American Nurse Foundation (ANF) Reimaging Nursing Initiative.