Glossary
NK - New Knowledge, Innovation, and Improvements

NK8 Describe and Demonstrate Innovations in Nursing Practice

Jersey City Medical Center encourages nurses to utilize their expertise and nursing skills to generate new ideas and processes with the goal of improving quality of care and patient safety. Nurses at all levels use innovative methods to engage patients and family members, implement best practices, and impact the overall delivery of care. Many projects and initiatives implemented during the last two years at JCMC have been nurse inspired innovations. The two examples described are great exemplars demonstrating transformations in care developed using creative nursing ideas.

NK8-Table 1

Implementing an Early Warning Scoring System (EWSS) along with Team Building Sessions to increase the number of Rapid Response Calls

The JCMC Rapid Response Team (RRT) was established in 2006 with the goal of preventing deaths through early intervention of patients, employees, and visitors who are clinically deteriorating or develop sudden illness while on the premises. The Institute for Healthcare Improvement (IHI) recommends 25 calls per 1000 patient discharges. A review of the number of RRT Calls in 2010 revealed a need to increase the use of the rapid response team and ensure a reliable process for assessment and management of patients who are identified at risk for deterioration. As discussed in SE1EO, for the calendar year of 2010, RRT calls averaged 17 calls per 1000 discharges and non-critical care cardiopulmonary arrests averaged four per month. The RRT/ Code Blue Task force established the following goals for 2011:

  • Increase RRT calls to 25 call per 1000 patient discharges and decrease non critical care cardiopulmonary arrests (Please refer to SE1EO for more information regarding these goals)
  • Decrease failures to rescue and unplanned transfers to critical care by utilizing patient risk scores and alerts to develop an algorithm for response to deteriorating patients
  • Educate RRT members, Nursing Staff, Physicians, and Respiratory Therapists using Team STEPPS approach
  • Implement a culture of safety promoting “There is never a wrong reason to call the Rapid Response Team”

NK8-Table 2

A review of the literature by the Rapid Response/Code Blue Task Force revealed that failures to rescue often result from delays in identifying early signs and symptoms of deterioration, breakdown in communication between providers, and preventable delays in care. Therefore, emphasis was placed on implementation of an Early Warning Scoring System (EWSS) and team building strategies.

Failures To Rescue

Using criteria available in the literature and adopting a user friendly approach, Mabel LaForgia RN, MSN, CNL and Claudia Garzon-Rivera MSN, RN, CNL were innovative in developing a EWSS tool to meet the needs of the patients and nurses at JCMC. The EWSS is a color scoring graph that encompasses a range of normal vital signs to abnormal findings that alert the end user to reassess the patient or call for an RRT intervention. The premise of the EWSS is to detect early deterioration before the patient decompensates. The tool was color coded using the stop light approach to provide visual cues for the nursing staff. Symptoms for sepsis were also incorporated into the tool to assist with identification of patients at risk for severe sepsis and septic shock outside of the critical care units. Below is the Early Warning Scoring System.

NK8-Table 3

NK8-Table 4

Guidelines (Reference NK8-A) were developed by the Rapid Response Team Committee and a process was established for nursing staff to use the EWSS as a scoring method for early identification of patients at risk for deterioration. The following process was implemented by the nursing staff employed on all non critical care units:

  1. Nurses score patients every shift.
  1. Category values that fall in the “green” are given a score of zero and patients are continue to be assessed with the EWSS every shift and as needed.
  1. A score of one prompts an increase in the frequency of the EWS Scoring and patient assessment is completed at a minimum of every four hours or as indicated and the patient’s MD, NP, or PA is notified.
  1. A score of 2 or greater prompts activation of the RRT. If the RRT was not activated an explanation is documented in progress note.
  1. The EWSS score is documented in the patient medical record

Prior to house wide implementation of the EWSS tool. The tool was piloted on 6W medical/surgical nursing unit during a one month trial period. Staff feedback and suggestions were instrumental in establishing a meaningful process that worked for the nursing staff.

Team work and communication skills are essential to the success of the rapid response team because collaboration from all team members including the person who activated the team is necessary. Team building sessions were held using the TeamSTEPPS, an evidence based program developed by the Agency for Healthcare Research and Quality (AHRQ). The team building sessions included nurses from different specialties, medical residents, respiratory therapists, patient care techs, and unit clerks. During these sessions, attendees learned the core concepts of teamwork as they should be applied to the Rapid Response calls. In addition EWSS was introduced and applied to the scenarios. The sessions reinforced the idea that promoting “There is never a wrong reason to call the Rapid Response Team” and that the rapid response teams can be activated by any member of the patient care team including patients and family members. A booklet of supporting materials was developed by Nicole Sardinas MSN, RN with personalized information about JCMC rapid response team, policies, resources etc (Appendix NK8EO-A).

In June 2011, the role of the critical care charge RN’s, whose primary role is to respond to RRT calls was introduced. Having the consistent critical care RRT RN has facilitated the development of the RRT and has influenced a change in culture that empowers anyone to the RRT if the need arises. By using evidence-based practice, implanting the EWSS, providing on-going education, through improved collaboration, the rapid response process has improved. Rapid response calls have increased and cardiac arrests have successfully decreased. Below is a graphical description of the increase in rapid response calls from July 2010 through July 2012. For more data regarding cardiac arrests please refer to SE1EO

RRT calls per 1000 patient discharges

 

Implementation of Family Assistance & Support Team (FAST)

Jersey City Medical Center is a Level II Trauma Center, which provides full trauma services including pre-hospital response, emergency care, 24-hour surgical services and rehabilitation. Traumas are sudden and at times life threatening posing a challenge for patients and their family members

A press release described it best when it stated “When five police officers were shot in a gun battle…and a 51-year-old local man was struck and run over by a speeding pickup truck…and a pregnant mother hit her head when falling down a flight of stairs…and a drunken driver slammed into a car occupied by four teenagers, those injured were rushed to Jersey City Medical Center, the county’s only state-designated Trauma Center, where doctors and staff saved their lives” (www.libertyhealth.org)

Unfortunately, as nurses and physicians work hard to save these patient’s lives in the fast pace environment of the ED, the likelihood of staff nurses being available to provide family support to patient family members is low. The emergency and trauma nurses recognize the distress these family members experience when someone they care about is being treated for a potentially life threatening injury or illness. Jen Jones MSN, RN, CNL, Trauma Program Manager, identified this as an opportunity to implement a more patient centered family focused approach.

A review of the literature revealed that in April 2007, the New Jersey Division of Mental Health Services (DMHS) in affiliation with Morristown Medical Center Emergency and Trauma Department developed the Family Assistance and Support Team (FAST) pilot training program funded through a grant from the NJ Department of Health and Senior Services. Jen Jones collaborated with Meg Kallman, MSW, LCSW, ACSW from Morristown Memorial Hospital to bring this program to JCMC in 2011. The objectives (as seen in the FAST brochure Appendix NK8-B) include:

  • Improving and maintaining communication between families, patients and the emergency department (ED) medical team
  • Meet family at the entrance to the ED and remain with the family throughout their time or as long as deemed necessary
  • Facilitate family presence in the treatment room
  • Keep family apprised of patient’s condition and treatment as relayed by the medical team
  • Assure medical team that the family of the patient is being taken care of and the family will not interfere with treatment needs
  • Manage practical needs of family such as requests for clergy, phone calls, consideration such as child care, how to inform other family/friends and other basic needs that may arise
  • Assist in familiarizing family members with acute care units such as the ICU and CCU, as well as the surgical family waiting room

Non-healthcare personnel interested in becoming volunteer crisis counselors were interviewed, accepted into the program, and participated in twelve hour of didactic training before beginning shifts with trainers in the ED. A commitment to provide counseling services for one year was provided by each counselor. These volunteers are also part of the state wide roster to respond to emergency mass casualties if needed. They have been instrumental to patients and families at JCMC. They are available during peak hours to assist family members when sudden traumas and emergencies occur. They remain with family members when they are separated from their love ones and remain the liaisons between the family members and the medical team. They frequently make babysitting arrangements, call funeral homes, provide directions to other facilities if they are being transferred, and introduce the family members to nursing staff. This service has provided an alternative to family members and the nursing staff to ensure that JCMC’s patient care model patient centered family focused care remains a priority in the busy trauma center at JCMC.

A family member wrote “My family and I met you when my uncle passed away in the trauma ER after a bad fall in April.

We were so grateful to everyone in the ER that day. It was such a blessing that we could all be there when they took the tube out - remember it was a room full of women?!! Everyone was so nice to us and we really appreciated everything."