Electronic Documentation in the ED Improves Patient Care
Paper charts are virtually a thing of the past in Crozer-Keystone Emergency Departments. The nursing staff at all four CKHS EDs have traded in their clipboards for computer “work stations on wheels,” or WOWs, as part of the new electronic documentation information system (EDIS) implemented last year. This state-of-the-art system is improving patient care by helping ED staff save time, improve accuracy and enhance patient safety.
The design and implementation process began in November 2006 with the formation of a Crozer-Keystone EDIS build team that includes two ED nurses from each hospital as well as representatives of Information Systems (see EDIS Build Team sidebar). The team met several times weekly for several months to identify needs and determine the features that the system should include. Springfield Hospital was the first to go live with it in April 2007, followed by Crozer in June, DCMH in October and Taylor in November, well ahead of the 2014 target date set by the federal government for healthcare institutions nationwide to convert all medical records to electronic documentation.
Now that the system has been fully operational for several months, ED nurses and their patients are reaping a wide range of benefits.
“Electronic documentation saves so much time in so many ways,” says Don Webb, RN, staff nurse in the Crozer ED and member of the EDIS build team. “When patients visit the ER, their history is stored in the system and can easily be recalled so they don’t have to repeat it again on subsequent visits.
“Physicians and nurses can view and access the system and work on the same patient charts at the same time,” notes Lee Cowley, RN, staff nurse in Taylor’s ED and EDIS build team member.
The system also includes pre-treatment guidelines for nurses to use with patients who present with certain symptoms, such as a febrile child or an adult with chest pain. “This enables the ED nurse to order lab work and X-rays before the physician arrives, another time saver,” says EDIS build team member Terri Hoffecker, RN, staff nurse in the ED at DCMH.
Test results come back in real time on the system. “We don’t have to wait for someone to bring the test results to the ED or send someone to get them,” says Cowley. “Test results are entered by the lab and become part of the patient’s electronic chart. And we immediately receive a prompt on the system’s patient tracking board when the lab results have been reported.”
Webb likes the system’s medication “quick list,” which enables him to easily access information about more than 100 of the most commonly prescribed medications rather than doing a multi-step search for each one. He also uses the system to create macros for standard nursing notes, such as the one he uses every time he starts an IV. “With macros, I can just push one button instead of typing the whole note every time,” he says.
Another time-saver is the fingerprint reader used by ED nurses to log on and off the system. “Since we log on and off every time we work on a different patient chart, this saves a lot of time,” relates Cowley. “It also provides an extra level of data security.”
These and other time-saving features improve patient care as well as patient flow through the ED, decreasing diversion times and reducing the time that patients spend in the ED waiting room, according to Jennifer Cummins, RN, clinical nurse educator in the DCMH ED and EDIS build team member.
Crozer-Keystone’s EDIS build team requested that many patient safety features be incorporated into the new electronic documentation system, including warnings about drug interactions and medication allergies. “These warnings pop up as soon as the physician enters a drug that may cause a problem for a particular patient, giving the doctor an opportunity to consider other options,” notes Webb.
“The documentation is customizable to the patient’s complaint,” adds Cowley. “Built-in cues help ED nurses to ensure that they’re hitting all the points of care for specific complaints such as lacerations, headache or chest pain.”
“Computerized physician order entry also enhances patient safety by improving accuracy and reducing the chance of medical errors due to illegible handwriting,” observes Cowley.
Patient Tracking and Reporting
The new system has comprehensive patient tracking capabilities that include patient placement, orders and order status, length of stay, and many quality indicators. Previously, only patient placement could be tracked. Built-in timers track the length of time that has passed since the patient signed into the ED and enable the ED staff to identify delays and the reasons for them.
A surveillance tool just added last month helps ED staff screen patients for catheter associated urinary tract infections when they are admitted so the origin of the infection can be accurately traced and documented.
The system also features powerful reporting tools for managing the ED more effectively. Reports include number and type of patients, number of patients assigned to each staff nurse, acuity by day, and nursing and physician productivity.
“The system enables us to constantly audit our documentation for thoroughness and accuracy,” says EDIS build team member Amy Meehan, ED nurse manager at Springfield Hospital. “It is definitely helping us to improve patient care.”
Future Enhancements Planned
The new system is still a work in progress as the EDIS team continues to meet monthly to assess performance and evaluate ideas for enhancement. Currently, the team is working to streamline the physician order process by creating an interface that will enable the new Picis system to “talk to” the Envision system used by CKHS hospital labs and X-ray departments. Currently, ED staff must print out physician orders and manually deliver them to those departments. The new interface will save time and improve accuracy.
Another enhancement to be implemented this year will enable ED documentation to automatically generate facility charges, “This will ensure that patient invoices accurately reflect all the care that was provided,” explains Meehan. “We invite and encourage the ED staffs to come to our EDIS team with other suggestions for improvements and enhancements.”
EDIS Build Team Members
- Bev Relyea, RN
- Don Webb, RN
- Jennifer Cummins, RN
- Terri Hoffecker, RN
- Amy Meehan, RN
- Mary Pat Towne, RN
- Lee Crowley, RN
- Pat Eckenrode, RN
- Elaine Foy
- Sandy Mitchell
- Patti Montella, RN
- Jeannine Wilk, RN
Spotlight on: Community Service
Ten years ago, Dottie Loving, RN, recognized that nurses could play an important role in the health of the community by serving local church congregations. After completing a health ministry training program, she proposed that Delaware County Memorial Hospital begin a parish nursing program.
“Through my own church, I could see that a lot of healthcare needs were not being met in the community,” says Loving, a 25-year veteran at DCMH. “It was important to me to keep people from falling through the cracks of the healthcare system, especially seniors who often have a hard time navigating it.”
DCMH approved her proposal and Loving was appointed coordinator of the grant-funded program, a position she still holds in addition to her primary role as clinical nurse leader of the SurgiCenter at DCMH. Under Loving’s leadership, the parish nursing program has grown to include 10 churches and 30 parish nurses in Delaware County. Most of the nurses volunteer their time to provide services that may include monthly blood pressure monitoring, annual health fairs, home visits to ailing parishioners, cooking for new mothers, and arranging presentations by Crozer-Keystone health professionals on topics such as smoking cessation and diabetes.
“We also provide one-on-one assistance to those who ask us,” says Loving, recalling the time she helped a senior parishioner at her own church. “The woman told me she had found a breast lump. She said, ‘I might call the doctor.’ I said, ‘You have until Tuesday to make an appointment. I’m going to call and make sure that you did.’” The lump was malignant, and later the women told Loving, “I don’t think I ever would have gone to the doctor if you hadn’t said that.” Loving also arranged for fellow parishioners to provide the women with transportation to and from the hospital throughout her cancer treatments.
“It’s rewarding to help people who otherwise might not get the help they need,” she says. Loving hopes the program will continue to expand to more churches, noting that a parish nurse program has now begun at Springfield Hospital.
Sally Spear, RN, knows firsthand the joy that people receive from their pets. An avid dog lover, she has owned Norwegian elkhounds for most of her life, so she fell quite naturally into the role of rescue coordinator for the Garden State Norwegian Elkhound Club 14 years ago. Since 1994, she has been helping to rescue displaced dogs and find new loving homes for them. “We save the lives of many dogs and enrich the lives of many new owners,” says Spear, a staff nurse in endoscopy and pain management at Springfield Hospital.
As a rescue coordinator, Spear screens potential adopters, conducts home visits, checks veterinary references and serves as the point of contact for local animal shelters. The Garden State club rescues about 40 Norwegian elkhounds in the tri-state area annually.
From 1998 through 2003, Spear also served as national coordinator for the Norwegian Elkhound Association of America (NEAA), which rescues more than 100 dogs each year. In that role, she coordinated rescues nationwide, acting as liaison between 17 regional rescue clubs. She facilitated adoptions by helping to organize transportation for the dogs between clubs via the national Canine Underground Railroad. Spear says that she drew on her years of experience with Springfield Hospital’s Nurse Practice Committee to develop adoption contracts and release forms which have become the national model for all Norwegian elkhound rescue groups.
Currently the owner of three Norwegian elkhounds, Spear has personally fostered 10 dogs until she could find them homes. While she is rewarded by saving the lives of many dogs, she also notes that the dogs may, in some cases, save human lives. She recalls one dog that was being fostered by a family in New Jersey. One night, a fire broke out in the basement of their home and the dog, “Tobey,” saved the family by barking incessantly until someone woke up and came downstairs to see what was wrong.
“It’s very rewarding to find a really good dog that’s been dumped in a shelter and give it a second chance,” reflects Spear, a 31-year veteran of Springfield Hospital. “It’s also great to help a bereaved family who has lost a dog by giving them a new one to love.”
“I’ve been fortunate in life because I’ve never been without food or shelter,” says Glenys Zigmont, RN, staff nurse on 3A at Taylor Hospital. “I believe that it’s our duty and obligation to give back to those who aren’t so fortunate.”
Give back, she has! As a member of the Chester City Team, Zigmont has adopted five families for Christmas for each of the past 10 years and, with the help of several friends, provided gifts for all of them. “Every kid deserves to have a nice Christmas, especially the little ones,” she says. “We want to make sure they wake up to something under the tree.”
Zigmont also gives back through the Loaves and Fishes food pantry located at a Prospect Park church. For the past five years, she has helped her husband, a local postal worker, to coordinate the postal service’s annual food drive, channeling the donations to the food pantry which feeds 500 to 700 families each month. “These are people who have lost their jobs or have other serious challenges in life,” says Zigmont, who also runs food drives for the pantry at Taylor.
This year, Zigmont also gave flu shots to the people served by Loaves and Fishes with flu vaccine donated by a pharmacist friend, Michael Amoruso, owner of Costa’s Pharmacy in Ridley Park. “Many people who come to the pantry don’t have health insurance and couldn’t afford to pay for a flu shot,” she observes.
Last year, Zigmont raised close to $1000 for the Leukemia and Lymphoma Society in honor of Amoruso’s granddaughter who has leukemia. She also participated in the Susan G. Komen Breast Cancer Walk for the seventh time, and regularly provided blood pressure checks for the senior women who exercise with her at a local fitness facility. “I just like helping people,” she says.
Best Practices: New Protocol Improves Glycemic Control
Crozer-Keystone Health System is participating in the VHA Transformation of the Intensive Care Unit (TICU) initiative. The goal of the TICU program is to achieve better clinical outcomes, fewer adverse events and greater patient satisfaction with ICU care through a series of interventions that achieve significantly better outcomes when implemented together rather than individually. One of these interventions is improving glycemic control.
Critically ill patients are more prone to develop hyperglycemia because the stress reaction of the illness makes them more insulin resistant, whether or not they were diabetic previously. Research has shown that hyperglycemia decreases the ability of white blood cells to fight infection, leaving the critically ill patient with decreased immunity and heightened vulnerability. Numerous studies have shown that improving glycemic control results in better outcomes for critically ill patients, including fewer blood transfusions, less renal failure, fewer days on ventilator and shorter stays. In March 2005, Crozer-Keystone set a goal of tightening glycemic control by maintaining 75 percent of ICU patients within the blood glucose range of 70 to 120. At that time, only 28 percent of ICU patients were within that range.
In 2005, multidisciplinary teams that included ICU nursing staff, clinical pharmacists, pulmonologists and endocrinologists at Crozer-Chester Medical Center and Delaware County Memorial Hospital developed a new insulin infusion protocol. By the fourth quarter of 2007, Crozer-Keystone was maintaining 75 percent of ICU patients within the blood glucose range of 70 to 120, more than 62 percent better than before the new protocol was implemented. In addition, on a daily basis, the majority of ICU patients on ventilators are now within the 70 to 120 blood glucose range over 65 percent of the time, more than 30 percent better than with the old protocol. The new protocol also cut the incidence of hypoglycemia nearly in half to 3 percent, well below the national average of more than 5 percent.
For the fourth quarter of 2007, Crozer-Chester Medical Center’s MICU, CVU and STU ranked among the top VHA hospitals nationally for glycemic control, placing third, fifth and sixth respectively in the nation. Crozer also ranked within the top tier of a group of 130 hospitals sharing results through their point-of-care testing lab vendor.
In addition, Crozer-Keystone Health System was chosen as the top performer for glycemic control for VHA East Coast and Pennsylvania.
The new protocol is now being used in all Crozer-Keystone hospitals.
The ICU nursing staff manages patients by monitoring their blood glucose with hourly finger stick tests. This enables the nursing staff to respond to blood glucose changes and adjust the continuous drip insulin dosage before the blood glucose gets too far out of control. In the past, patients were checked every four to six hours.
The nursing staff makes adjustments to the insulin dosage based on blood glucose changes, not just blood glucose value. The amount of insulin given depends on how much the blood glucose has gone up or down since the last hourly finger stick, as well as the blood glucose value.
The new protocol calls for nurses to use a column system chart with narrower ranges of blood glucose values in each column to determine the appropriate insulin dosage. For example, instead of using a blood glucose range from 80 to 120, that range has been broken down on the chart into two smaller ranges of 80 to 100 and 101 to 120. “We changed this because if you give the same insulin dose to a patient whose blood glucose, for instance, is 91 as you do to one whose reading is 119, the patient at 91 might get more than needed and the one at 119 might get less than needed,” explains Patricia LaPorta, RN, BSN, MS, CCRN, BC, critical care clinical nurse educator at DCMH. The same approach is used for hyperglycemic and hypoglycemic control.
The majority of antibiotics are now administered to patients in normal saline solution instead of dextrose. The nursing staff at DCMH met with clinical pharmacists to discuss concerns about the effects of antibiotics administered in dextrose. In a subsequent study conducting by the pharmacists, more than half the patients given antibiotics in the smallest possible volume of dextrose (50 cc) experienced out-of-control blood glucose levels. The switch to saline solution has contributed to the overall improvement in glycemic control.
The nursing staff initiated a change to variable depth lancets for hourly finger stick tests to reduce discomfort for the patients. “The staff was really concerned about causing the patients additional pain with such frequent finger sticks,” relates LaPorta. “Now they can use the smallest depth lancet needed to obtain the required blood supply.”
The clinical pharmacist rounds on ICU patients every day, evaluates their blood glucose values, determines their 24-hour average, then consults with the physicians or notes on the chart whether the patient should be on the insulin infusion protocol.
The ICU nursing staff continuously evaluates the protocol and recommends changes to the multidisciplinary team.
What are the 14 Forces of Magnetism?
In the next several issues, we will summarize each of the Forces. These are qualities that nurses find attractive in their place of employment.
Force 1: Quality of Nursing Leadership
Nurse leaders are knowledgeable and strong, take risks, and follow an articulated philosophy in the day-to-day operations of the nursing department. Nursing leaders also convey a strong sense of advocacy and support on behalf of the staff.
Force 2: Organizational Structure
Organizational structures generally should be flat, rather than tall, and unit-based decision-making prevails. There is strong nursing representation evident in the organizational committee structure. Executive level nursing leaders serve at the executive level of the organization, and the chief nursing officer (CNO) often reports directly to the CEO.
Force 3: Management Style
Hospital and nursing administrators use a participative management style, incorporating feedback from staff at all levels of the organization. Feedback is encouraged and valued. Nurses serving in leadership positions are visible, accessible and committed to communicating effectively with staff.
Remember, we are on the “Journey to Nursing Excellence.” If you have an amazing story that illustrates these qualities or you have a suggestion as to how we can better demonstrate these qualities, please e-mail them to firstname.lastname@example.org.
Nancy Politharos, RN, MSN (candidate)
Assistant Vice President for Patient Services Taylor Hospital
“Leadership is a sacrifice . . . it is love, it is fearlessness, and it is humility . . . . The role of the leader is to enhance, transform, coach, care, trust and cheerlead.” - Tom Peters and Nancy Austin
This quote, from the bestselling book Passion for Excellence, captures the essence of Janice Perry, RN, MBA. For 14 years, Janice has inspired her staff and colleagues at Taylor Hospital by, indeed, leading with love, fearlessness and humility. Her enthusiasm and energy for her profession invigorates everyone around her. Her expertise and ability to rally her colleagues to accomplish even the most challenging goals is legendary. She is the ultimate coach and cheerleader rolled into one capable and caring package.
Janice has been the champion of so many vital initiatives that are helping to advance our profession and improve patient care. Our patients and nursing staff are the beneficiaries of her work to establish the Nurse Practice Council, reduce catheter-associated urinary tract infections, develop an effective advance directive process and implement electronic nursing documentation, among many other contributions.
The finest tribute a nurse leader could ever hope to receive is the appreciation of those she has led. I’m certain that the following thoughts from Sue Mingis, R.N., are shared by all those who have had the privilege of knowing and working with Janice:
“Janice is a true transformational leader. She makes a continuous effort to motivate and rally her followers, constantly doing the rounds, listening, soothing and enthusing. She engages with us in a positive and collaborative manner that empowers us to draw on our inner resources. She creates trust among those she leads. We are always aware that she cares about us and wants us to individually succeed. She accepts that there are failures along the way, but chooses to celebrate the positives and successes. As her followers, we are also transformed in some way by the process.
“Janice has the ability to see the big picture. In the course of assisting her with the details needed to make her vision a reality, we often perceive that we were responsible for the positive changes, when in reality it was her force behind us. She always gives the kudos back to us, when she also deserves them. Janice had the vision to start the Nurse Practice Council and develop the role of the wound care nurse. In monthly meetings, she guided me gently in these ventures, listened to what I had to say and interjected where needed. Janice also allowed me to disagree with her, sometimes loudly. Knowing I had her trust, I was able to move forward. In this respect, I also learned a little how to be like her as a leader.
“Janice chooses her attitude and puts fun in our day. This is an attribute that used to drives me nuts, especially when I was stressed and hurried. But I have learned from Janice that it is important to have joy in our work.
“Janice has always believed in patient-centered care. She believes the authority, responsibility and accountability for the rendered nursing care lies with the nurse. She believes that managers have the responsibility to ensure that the staff has the tools they need to do their job. It is interesting that these are the attributes and qualities of a Magnet hospital; how fortunate that we have had the opportunity to work with a leader of this quality -- many years before we even spoke about Magnet!”
Personally, I have considered it a privilege to be a member of Janice’s team. She is a wonderful leader, teacher and mentor to whom we owe a debt of gratitude. I know you all join me in wishing her the very best as she moves into her new position as Assistant Vice President of Clinical Services at Taylor. As we continue the journey, the lessons that Janice has taught us will take us a long way toward “Nursing Excellence,” as well as our own personal goals.