Palliative Care: Achieving Comfort for those with Limited Treatment Options

Moderator:Janet Hewson, RN, Western Medical Center Santa AnaPresenters:Cynthia Jugo, RN; Georgi Collins, RN; Karina Kilian, RN; Jackie Leopard, RN, Riverside Community HospitalBreakout Session B:Doubling Donation OutcomesWhat a Difference a Year Can Make1

Doubling Donation OutcomesWhat a Difference a Year Can Make: Riverside Community HospitalModerator: Janet Hewson, RNDirector of Trauma ServicesWestern Medical Center-Santa Ana

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Doubling Donation OutcomesWhat a Difference a Year Can Make: Riverside Community HospitalCynthia Jugo, BSN, CCRN, MBA, RN, Director Surgical ICU/CVUGeorgi Collins, BSN, RN, Trauma Program ManagerKarina Kilian, CEN, MICN, RN, ER Clinical ManagerJackie Leopard, MSN/ED, CNOR, RN, Perioperative Clinical Educator

ModeratorCynthia Jugo, BSN, CCRN, MBA, RN Cynthia is currently the Director of SICU/CVU. She comes to us today with over 35 years of nursing experience, 26 of those years have been in critical care units with the last 11 years in management. Cynthia currently serves as the RCH Donor Council Chair.Georgi Collins, BSN, RNGeorgi has been a RN for 14 years, focusing on Emergency, Trauma, and Critical Care nursing. She was acting Trauma Systems Manager for Inland Counties Emergency Medical Services Agency (07-08). Georgi currently serves as the Trauma Program Manager at RCH. She has been with the RCH Donor Council since its inception.Karina Kilian, CEN, MICN, RNKarina has over 10 years experience in telemetry, transplant, and emergency nursing. She currently serves as ED Clinical Nurse Manager at RCH. Karina has personal experience with donation and is an active Donor Council member.Jackie Leopard, MSN/ED, CNOR, RNJackie has over 20 years nursing experience and is the Perioperative Services Clinical Educational Specialist at RCH. She is an active member of the Inland Empire AORN chapter, she served as President and Vice President and was recently was published in the AORN Association of periOperative Registered Nurses Journal. She also is a proud member of the RCH Donor Council. 3How to beBeing in action!

The answers are in the room

Report out on Question to Run-on: Scribe Spokesperson

All Teach / All Learn

Moderator4Question to Run-OnHow will you bridge the donation process and your current practices to create a culture of donation?

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5ObjectivesBy the end of this presentation, the attendee will be able to:Learn the strategies needed to build an effective end of life teamRecognize the positive impact of standardized order sets for the management of catastrophic brain injury Recognize barriers to donation embedded in current hospital culture

Moderator6Riverside Community HospitalFounded in 1901, Riverside Community Hospital/RCH is a 373 licensed bed, acute care hospital in the heart of the Inland Empire. RCH houses the largest Emergency Room and Level II Trauma Center in the Inland Empire with 50 beds, a Heli-stop and a 40 bed ICU.RCH is one of the Riverside Countys STEMI receiving centers and is a fully accredited Chest Pain Center.

Cynthia Jugo7Riverside Community HospitalCenters of Excellence include:HeartCare InstituteUrology/GYN da Vinci ProgramCancer Center Level II Neonatal Intensive Care Unit.Transplant Program, Kidney and Pancreas Center since 19971 of 20 kidney centers; 1 of 16 kidney/pancreas centers in California

Cynthia Jugo8

Need for Team

Outcomes not meeting national standardsNeeded increased visibility and availability of OneLegacy staffOpportunity to improve communication between OneLegacy and ED, ICU, and OR

Cynthia JugoLate referrals , missed opportunities for organ donation, RCH staff unsure of clinical triggers for organ donation9Need for TeamRCH staff misunderstood the donation processEducation on clinical triggers and consultation timeliness

Cynthia JugoRCH staff was afraid to refer pts to OneLegacy fearing that the staff would give-up on the pt and that the family was not ready to talk about organ donation.

10Building the FoundationCustomized Donation Program at RCH based on continuous staff feedbackModified clinical trigger card languageReferral to consultationIn-serviced ICU, ED, and OR on the donation process (clinical triggers and consultation timeliness) Communication boards developed in ICU, ED and OR

Cynthia JugoModified clinical trigger card from referral to consultation. Begin re-education of all critical care RN staff as well as RTs, unit secretaries, social work, case mgmt, and chaplain services.

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Cynthia JugoChanged clinical trigger language from referral to consultAdded RCH logo to show collaboration and support OneLegacy suggested removing Glasgow Coma Scale 5 to allow for the evaluation of additional pts for Donation after Cardiac Death. RCH felt that the RNs needed Glasgow Coma Scale as a point of reference.

OneLegacy and I were rounding on SIC when I asked OneLegacy if they received a consult for a pt that was going to be terminally weaned. RN stated that the pt did not meet criteria because his Glasgow Coma Scale was 7. Modified trigger card a second time.12

Cynthia JugoResulted in increase in timely referrals and staff understanding donation processConsult, evaluation of medical suitability, approach process, recovery, after care support services 13Creating the TeamIdentified champions in ED/Trauma, ICU, RT, Social/Chaplain Services , OR and Marketing

Created Monthly Donor Council meetings

Mission: The Donor Council at RCH is a multi-disciplinary team dedicated to improving the overall health of our community by preserving the gift of life through organ, tissue, and eye donation.

Georgi CollinsThe RCH Donor Council evaluated and updated all organ and tissue donation policies.Since RCH is a Level II Trauma Center many of the consults were beyond 1 hour of meeting the clinical trigger due to the pt being in holding. Pt would be admitted to ICU and consult could come several hours later. Began educating ED/Trauma staff on the importance of making the timely consult. RCH took ownership of the DDP/Donation Development Plan to ensure that we were meeting standards. We reviewed the dashboard data monthly and develop PI strategies as needed.14Building the TeamProvided hospital badge access and laptops to OneLegacy staffElectronic patient records access to OneLegacy staff

Building the TeamImplemented Adult Catastrophic Brain Injury Support Guidelines and Physician ordersGood patient care is good donor carePreventing secondary organ damage is crucialRCH CBIG 2011 08 NS4241 05 10 AdultCatasBrainInjury p1^FP P11.pdf

Georgi CollinsTrauma Surgeons requested that they be notified on all pts that OneLegacy is consulting on. They began asking questions about how to ensure they medically manage pts to preserve and maximize the opportunity for organ donation. RCH does not have a Palliative Care Team, we decided that if we are calling OneLegacy we should ensure that social service and chaplaincy are also involved.

Our order set is sometimes referred to as CBIG, Catastrophic Brain Injury Guidelines, we choose to refer to this tool as a Guideline and Physician Order to maintain the manner in which the physicians are accustomed to at RCHfamiliar language.16Building the TeamOn-going education with Trauma and Neuro Surgery physiciansIn-serviced at New Employee OrientationsRounds/Communication with champions and staff on every consult

Georgi CollinsProvided education and donor outcome summaries presented at Trauma Rounds and pre-shift ED huddlesProvided education on the clinical triggers and the donation process to RNs at EVERY new hire orientationOneLegacy sent email notifications on ALL pending consults (timeliness status) and outcomes to key hospital champions (Unit Director, Manager, Social services, and chaplaincy)RCH hosted a flag raising ceremony attended and supported by RCH staff, community members and the transplant center.OneLegacy hosted an Appreciation Breakfast for staff. Donor mom from another hospital came to shared her experience with donation with staff. Flag and Flyer slides next17

Georgi CollinsRCH hosted a Flag Raising CeremonyDonate Life flag flies daily in front of the hospital Photo of the Donate Life Flag at RCH. The flag pole is located in our physician parking lot and at the main hospital entrance.18Walking In-services

Georgi CollinsRCH staff appreciation breakfast with donor mom ED, OR, and ICU units Walking In-servicebegin in ICU, to ED and concluded in the OR.Staff began to think of donation as the right thing to do.

19Case Study43 year old female head trauma; status post fall from horse. Arrival time 1027 Day 1:Timely consult from ED; Consult time 1039Patient was a Registered donor

Day 4:Consult closed by OneLegacy as Not Brain Dead

Day 8:Second consult made to OneLegacy Karina KilianDescribe the front lines staffs feelingsConsult closed in SICPt declined neurologically. Second consult made on day 8 from SIC as requested by Dr Nagappan Trauma Medical Director20Gift of LifeDay 8:Catastrophic Brain order set/CBIG implemented

Day 9:Declared brain dead by 2 licensed physicians

Outcome:5 organs recovered/4 lives saved

Karina KillianED staff perceptions of donation slowly changing. Staff became more accepting and engaged in the donation processmaking consults for one another, etc. Donation slowly becoming known as the gift of life, RNs began to understand their critical role as the key to honoring pts last wishes and saving lives through donation21Gift of LifeLiver/Left Kidney-55 Married, with 3 children, was on the waiting list for 13 days. He works as a branch manager at a pest control company. Lives in Ontario, CA, and enjoys fishing and travel.

Double Lung-24 Single, no children, was on the waiting list for 22 days, lives in Las Vegas, NV.

Heart-68 Married, was on the waiting list for 9 days, lives in California.

Right Kidney-62 Married with 2 children, 2 grandchildren, was on the waiting list for 1, 191 days. Works in dental equipment repair and enjoys reading, talk radio and cooking.

Karina KilianKarinas donation story22Outcomes 2008Pre-team2009Building2010Post-team2011 (YTD)HardwiredConsultations45115155186Eligible Deaths 881410Organ Donors 35108Consent Not Recovered/CNR0310Timeliness Goal 100%54%86%97%98%Organs Transplanted per donorGoal 3.75%3.672.803.802.5Conversion rateGoal 75%35%63%71%80%Lives saved11143820Karina KilianYTD data 9/30/11 Staff are now aware that not every pt is going to be a donation. Our staff have seen many GSWs to the head, traumas, strokes get better and walk out of the hospital.Many consults Early consult by OneLegacy saves more lives. Guidelines are in place so that pts are being managed to prevent secondary injury to the organs,. Good patient care is good donor careIn 2011 our first 4 (ECD) donors were older medical pts; however were still able to recovery and 4 organs for research and 3 organs for transplant. One of the donors was a former kidney recipient.23Tree of Life

Jackie LeopardRCH donor council decided to honor organ donors and their families through the erection of a Tree of Life. Invited donor families from 2007-2009 14 families consented to their loved ones name to appear on the Tree of Life.

Our January 27th ceremony was attended by over 70 donor family members and countless RCH employees from Administrators down. Several RNs attended to support families throughout the ceremony.

What have learned is that the Tree does much more than honor donors & their families, it illustrates the support of donation at RCH and the benefit of donation to families. Staff can whole heartedly strive to support donation, knowing it is the right thing to do and what families really want. 24Tree of Life

The Courage of OneCalled from this world by Gods hand, we mourn the loss of a loved one. But a legacy was left behind; sight to a blind man, a new heartbeat for one whose broken heart can beat no more, breath for one who had drawn near to her last, a second chance to live a life forsaken. A heros welcome awaits their arrival, for a courageous act was their last. Giving their last breath, the last beat of their heart, the very sight from their eyes, to those who needed it most. A living legacy to fallen heroes, who gave all they had to give, as God called them home, to a heros welcome.

Jackie LeopardHere is a picture of our Tree of Life. This poem was read aloud at our ceremony.25Bobby D. Collins

Jackie LeopardFamily members could not attend but wanted their loved ones to be honored. Many RCH employees placed the leaves on behalf of their loves ones. Here is a photo of placing Bobbys leaf.Play thank you VM.26

Riverside: Hospital Honors Organ Donors

Rich Linton / Special to The Press-Enterprise A Tree of Life memorial was recently unveiled at Riverside Community Hospital honoring organ donors. A permanent marble monument will be added later and erected in the entry hallway.

Jackie LeopardArticle from our local newspaper the Press Enterprise; Janeens family was interviewed by the PE after the ceremony. Janeen is heroher family is proud of their decision to honor their precious daughter through the gift of life. 272011 InitiativesOneLegacy presents at monthly ED, ICU, RT and OR staff meetings.

OneLegacy activities/updates are included in the hospital newsletter.

OneLegacy participates in:General New Employee Orientation ICU clinical practiceIntro to Trauma classesTrauma Rounds

Jackie LeopardCurrent initiatives includeCommunication remains key to our success282011 InitiativesRCH ecampaign on the RCH website http://riversidecommunityhospital.com/service/transplant-services

Adult Brain Death examination forms RCH Determination of Brain Death Exam Form Revise 6 10 2011 gc (2).docx

Identify Donation After Cardiac Death opportunities

Jackie Leopard weve already mentioned several of our initiatives. We feel the Process hardwired in RCH policy but there is still room for improvement. Here are a few of our current initiatives to improve our process. RCH wants to confirm that ALL pts are evaluated for donation opportunities.

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Jackie LeopardOur brochure is given by our ICU RNs, social workers, and physicians once the pt is declared. It is used to help families understand what has occurred with their loved one and what happens next. Donation is NOT discussed at this time. 30

Jackie Leopard:As we conclude, please understand that this process is for the donor family to honor their loved ones through the gift of life. A simple phone call COULD make a difference in these family's lives. Familys want to honor their loved ones through donation and you can be a part of the gift of life.

31Question to Run-OnHow will you bridge the donation process and your current practices to create a culture of donation?

ModeratorThank you RCH, your hard-work and dedication in honoring patient and family wishes is impressive. Lets revisit the Question to run on32Transition to LunchLunch is from 12:10 1:10

In the Main Ballroom

Open seating

Bon Apptit!

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