Transitioning Registered Nurses To a Higher Level of Care ... · That’s exactly what helped build...
Transcript of Transitioning Registered Nurses To a Higher Level of Care ... · That’s exactly what helped build...
Transitioning Registered Nurses
To a Higher Level of Care Utilizing the
Resource Nurse/Partners in Practice Model
FOR ICU/IMC/PCU
Contingency Planning for Surge Capacity during
a Disaster Event
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Updated: 6/25/2020
Resilience
At HCA Healthcare, we’re no strangers to threat. We deal with them daily.
Infectious diseases, natural disasters, unspeakable emergencies.
Some say that managing life-threatening situations is part of business as usual for an advanced
healthcare network like HCA Healthcare. And it’s true.
That’s exactly what helped build a sharp set of best practices and a robust network of response
teams, which helped us, HCA Healthcare, mobilize quickly and scale accordingly in times of
need.
As this latest threat evolves, HCA Healthcare is collaborating with federal and local health
agencies, providing timely and practical updates that will help contribute to accurate reporting
and consistent guidelines. While our immediate priority remains the well-being of our patients
and people, we know that sharing insights can impact care far beyond the communities we
serve.
In the face of a threat, we don’t panic, we prepare.
Introduction
Our everyday lives and the way HCA Healthcare provides care is drastically changing due to the
spread of COVID-19. We are faced with an unprecedented health crisis. The worldwide scale is
daunting, and the challenge to our infrastructure, standard processes of care and even
standards of care demands novel approaches. It is during these times that our colleagues have
shown their resilience and lead us through these difficult periods
Our goal is to support our nursing colleagues as we prepare for patient surges predominately in
our Critical Care Services. To support critical areas, we will need to reassign registered nurses
to various nursing departments to serve in a Resource Nurse/ Partners-in-Practice model.
To prepare for this surge in patients, HCA Healthcare Center for Clinical Advancement teams
have come together to provide information and education for you to serve in a Resource
Nurse/Partner-in-Practice role and support various nursing units that are facing challenges
related to resource gaps in patient care. In the Resource Nurse/Partner-in-Practice model, you
will be partnering with a primary nurse to care for a group of patients. You will be performing
general nursing functions in concert with the Primary Nurse, who will oversee care for all
patients in the assignment, manage complex aspects of care, and serve as a partner to the
team.
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This booklet is not all inclusive, but does provide additional information to help you build on
your current nursing knowledge and skills.
Let’s begin our journey.
Knowledge and Skills
We recognize that each Registered Nurse (RN) brings knowledge, experience and skills to the
clinical unit where you are assigned and you may already be very comfortable with some of the
knowledge and skills listed below. We have provided a list of knowledge and skills that you are
currently performing in your home nursing unit. Review the list below and initial the skills that
you can perform independently.
Medical-Surgical/Progressive Care Knowledge and Skills
Skills Initials Skills Initials
AED Assessment (General/Focused, I&O)
Pain Assessment/ Management Blood Administration
Central Line Management/ Dressing Change
CIWA/ COWS Management
CPAP Diabetes Management
Fall Prevention & Gait Belt Use Glucometer
Vital Signs VTE Prophylaxis
Indwelling Urinary Catheter Insertion
Indwelling Urinary Catheter Maintenance
IV Pump Med Administration (General)
PIV Insertion PPE Utilization
General Meditech Documentation
Line Draw Blood Sampling
Suction Set Up CHG Bathing
NG Tube Maintenance Respiratory Therapies (Nebs, MDI, IS, MDU, EZPAP, CPAP/BiPAP)
PCA Management Restraints
As you move into the critical care nursing areas, listed below are common knowledge and skills
that you will experience. Please review this list to acknowledge if you have any experience.
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ICU Knowledge & Skills
Topic Initials Topic Initials
CHG Bathing of the ICU patient Documentation (ICU Specific)
Non-Invasive Cardiac Monitoring
& CMI
Med Administration: Common Meds in
Critical Care (Independent), High-Risk
Meds & Titration (Cosign Only)
Oxygen Therapy (High Flow,
Optiflow, NRB)
Restraints
Respiratory Therapies (Nebs, MDI,
IS)
Blood Sampling (Line Draw &
Venipuncture)
Assisting with Procedures End Tidal CO2
Tube Feeding Pumps Prone Therapy Management,
positioning assistance only
NICOM (Basic knowledge only) COVID-19 Testing Specimen Collection
Fluid administration with or without IV pump
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Preparatory Learning
First, we want to introduce you a variety of e-learning modules in HealthStream to help you
better understand some of the terminology, equipment and various medical and nursing
interventions you may encounter. In order to access the majority of the content for your
preparatory learning, you will need to log in to HealthStream and enroll yourself. This will allow
you to access any modules that you need. See below for instructions for logging into
HealthStream from home.
HealthStream Modules
Obtaining a Blood Sample from a Central Venous Catheter in Adults- EBSCO
Limb Restraints in Adults- EBSCO
Prone Therapy Utilization- EBSCO
Aerosol Therapy—EBSCO
Metered Dose Inhaler Use in Adults—EBSCO
Restraint Review
Phlebotomy Blood Sampling—EBSCO
How to Access HealthStream Remotely
Access from Home through
www.stdavids-institute.com or healthstream.com/hca
When logging in to HealthStream, use your 3-4 ID for both the User ID and Password entries.
IMPORTANT! Your password is case sensitive, so if you can't log in with your 3-4 in CAPITALS,
try lower case password entries. Be sure to obtain prior authorization from your manager to
work on HealthStream assignments at home.
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Orientation
Introductions are crucial to team success. Each individual brings with them certain
competencies and skills. In the introduction, each member should discuss what skills they can
assist with throughout the shift. Lead nurses should discuss the care needs for patients within
the unit and how the work can divided up to ensure each patient receives the best care utilizing
everyone’s talents on the team. During the orientation phase, the lead nurse will review
environment of care, which will include the safety features of the unit.
Orientation time may be limited, but as time allows we will provide hands-on learning for
common skills, documentation and work routines. If we are not able to provide any hands-on
training, there are huddle cards, videos that you will be able to access on I-Mobile, on the
hospital Intranet site or provided on the nursing unit for you to review.
When you arrive on the assigned nursing unit, you will be introduced to the team and provided
with an introduction to the unit that will include a document that will provide the location of
the following:
Department/Nursing Orientation Introduction to Charge Nurse Medical Gas Shutoff Values
Introduction to your Resource Nurse/Partner-in-Practice
KRONOS Clock location
Location of Pyxis-Medication Room Location of Applicable Equipment
Location of Linen Room, Clean and Dirty Utility Rooms
Location of Nurses Lounge and/or Locker Room
Additional locations of other areas
Emergency Exits
Fire Station Pulls
Fire Extinguishers
Location of Code Blue Button
Provide description of other type Codes utilized, such as Code Pink
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This document below is what you should expect regarding conversations with the primary
nurses you will be supporting at the end of your shift.
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Meditech Education
The clinical education team has developed training on how to utilize and document in
Meditech. This education has been developed for the following scenarios:
Nurses in their current role that have not utilized Meditech
Nurses who utilize Meditech in their current role and will need to document in another
care area, i.e., Med-Surg Nurse documenting in ICU or Nurse documenting in the ED.
Listed below are the Meditech courses names that includes a short description and they are
located in HealthStream:
COVID-19 Medical-Surgical Meditech Resource Toolkit – this course will provide a
nurse that has basic experience with Meditech, how to document in adult inpatient
units, such as Med-Surg, Telemetry, and Critical Care
Meditech EBCD Critical Care Interventions (Screenshots) – this course will provide a
nurse that has experience with Meditech, but needs to understand the various types of
documentation that will need to be done in the Critical Care Area
There are full courses that are utilized during a nurse’s orientation to Meditech and these
include:
HWS HCA WBT Meditech BCMA – this is the full course to teach nurses for bedside
computerized medication administration.
HWS HCA WBT Meditech Nursing Documentation – this is the full course for teaching
nurses to document in Meditech utilizing Evidence Based Clinical Documentation.
Meditech Assistance Hotline
For Meditech assistance, please call us at 1-800-737-8661 x1333 or 954-514-1333 and select option
2 to contact an experienced Meditech instructor.
Hours:
Weekdays: 8 AM – 5 PM EST
Thank you,
Healthtrust Education Team
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Just In Time Resources
In the Resource Nurse/Partner-in-Practice model you are not going to have all the knowledge
and skills as you begin to support the primary nurses. That is ok! As a Registered Nurse you
understand that you need to ask questions. We want you to use the resources that you have
available. We have developed resources that includes information and guidance to help
provide excellent care.
Listed below are resources that are available to you, if you cannot locate one, please ask. We
are here to help you!
ONLINE REFERENCES
Resource Name Description Location
Atlas HCA corporate intranet-HCA initiatives
and documents SDH intranet>Atlas Connect
CE Direct Free access to continuing education and
certification review courses SDH intranet>Clinical Tools; internet
access available
Clinical Pharmacology Drug reference, including medication interactions, compatibility, etc.
SDH intranet>Medical Resources
EBSCO Clinical Research Clinical research database-to access
specific articles or journals
SDH intranet>Medical Resources; internet access available
E-Demand Repository for facility/SDH forms
(consents, specific patient instructions, etc.)
SDH intranet>Admin Tools
HealthStream
SDH/HCA Learning Management System- repository for most mandatory and
elective learning; HealthStream Competency Center: electronic orientation and annual
competency assessment for all staff, as well as annual evaluations;
HealthStream CE Center: free access to continuing education and certification
review courses
SDH intranet>Admin Tools; internet access available
Dynamic Health SDH procedure manual, includes
instructions, checklists and references SDH intranet>Medical Resources
Policytech Electronic file for SDH policies SDH intranet>Policies
Institute for Learning (IFL) Course Registration-for any course offered through the Institute For
Learning
SDH intranet>Institute for Learning; internet access available www.stdavids-
institute.com
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HUDDLE CARDS/QR Codes – You are likely to see huddle cards or posters throughout
the nursing unit and on some equipment. For additional information about a specific
topic or to better understand equipment, please scan the QR code on the document.
Many of these documents will include videos.
VIRTUAL PRECEPTOR – We are introducing Virtual Preceptor that is available through I-
Mobile. This will include numerous quick references on a number of topics. These tools
are designed for rapid review immediately prior to performing a task.
APPENDIX
The appendix will provide additional information that you will find helpful. Listed below are the
topics that are found in this section:
Reassigning nurses to other nursing units using the Donna Wright Model
Common Procedures in Critical Care
Common Medications given in Critical Care
Critical Care Intervention Screenshot Documentation in MediTech
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Reassignment of Nurses – Based on Donna Wright Model
When nurses are floated from one nursing unit to another, the issue of competency arises. We
ask quite frankly, does this nurse have the skills, knowledge and abilities to function in this
capacity? Experiencing a surge of patients can make it difficult to cross-train or put nurses
through a complete orientation. How can we facilitate a successful floating process? According
to Donna Wright, when asking nurses that float and those that receive float nurses, there are
three themes that consistently are heard and are actually competencies for the nurse that is
reassigned to another care area. These include:
Learning on the Fly
Marketing yourself in a positive way
Understanding crisis management options
Learning on the Fly
Learning on the fly competency has two parts. First, I need to know what I do not know, and be
able to speak up about it. The second essential aspect of learning on the fly includes:
I am not sure about this procedure….I am going to look it up.
I am going to ask someone how to do this.
I will use the resources that are available to guide my actions.
Obviously, this is not going to work for every procedure and task that we do, but many times
learning on the fly skill is used successfully. To demonstrate learning on the fly, imagine a nurse
is floated to a medical-surgical floor that provides dialysis. The nurse has never worked in
dialysis before and does not know how to properly provide dialysis. The charge nurse may ask
an experienced nurse to setup the dialysis and point out the basic things to watch for when
monitoring a patient on dialysis. The charge nurse can buddy up the inexperienced nurse with
another professional to ask further questions to support the patient’s care. The most important
thing is to propose ways to be useful while remaining open to learning new things.
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Marketing Yourself in a Positive Way
As a Registered Nurse you have lot of knowledge, skill and experience that you can bring to any
situation. Also as RNs, we need to market ourselves a little better and let those we are working
with understand what skills and experience that we can bring to the team. Sometimes we may
say, I was told to come here, I have never worked her before, I am not familiar or comfortable
with working in this area or specialty, and I do not know how to do any of those things.
When you are reassigned to another nursing unit, we recommend that you make these two
statements to the team or the charge nurse:
My name is ________ I am floating to your unit for this shift. I am here to help you out.
I have the following skills that I can offer to you today, and you can see how they may
fit into what is needed. I can do ___________, and so on.
When nurses have the ability to market themselves positively, the results and the shift
experiences are much better. The success of the shift and the reassignment experience do not
lie in the clinical skills, but instead in the “can-do” attitude the person brings.
Understanding Crisis Management Options
Most of the time when a nurse is reassigned to another area, that area is under stress,
stretched, or moving into crisis mode because they do not have enough staff to meet the
needs. They need help to function, so they reach out for support. The nurse being reassigned
can provide care and/or service assistance to help the team get the routine work done, but can
also offer something else: a fresh perspective or insight that he group may have trouble seeing.
Here is an example:
An Oncology/Med-Surg nurse was asked to float to the ICU. The nurse that is being
floated understands that she is not an ICU nurse. I would not want to take an
independent patient assignment because I do not have the ICU-specific competencies to
be successful. I know for certain that I can help this ICU team. I know that the ICU
practices the primary nursing delivery model. I can tell the charge nurse that I am here
to help out today. I suggest we use a Resource Nurse/Partner-in-Practice model. This is
where you pair me with a nurse from your staff. I can do the non-specific skills of care
and assessment, and the ICU nurse can focus on the ICU-specific items. We will work
together as a team and the patients will have safe care provided by skilled individuals.
By using the Resource Nurse/Partner-in-Practice delivery model we will have a better outcome
for the patients and the team. As the shift progresses, I may have time to learn new skills so I
can better support my partner. Eventually, I may want to transfer to the ICU/IMC/PCU based on
my experience.
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The skill of understanding crisis management options can work in any area, not just in nursing.
The team is able to change the normal workflow temporarily to match the crisis situation and
still produce the desired results.
This is an excerpt from Donna Wright’s, Competency Assessment Field Guide for
Implementation and Application, 2015, Creative Healthcare Management. Prior to COVID-19,
HCA Healthcare began to transition to the Donna Wright Competency Assessment Model. We
will resume the implementation later in 2020.
Common Procedures and Medications in the Intensive Care Setting
Common Procedures Requiring RN Assist in the ICU Procedure Supplies/Nursing/Personnel Common Medications
Intubation
Ensure suction is set up with a Yankauer
RT will assist
Airway Box from the Crash cart has most of the supplies
1. Move the bed away from the wall (better access for the provider intubating)
2. Get towels to roll (if time permits) 3. Remove the headboard on the bed (if
time permits) 4. May be asked to get the Glidescope (in
the supply room on wheels, it is a device with a light on to assist in a difficult intubation)
RSI Kit (override in the Pyxis) (Rapid Sequence Intubation)
It does NOT contain narcotics, will need to override those medications.
Be sure to get an order and document waste and medications given.
Central line insertion
Provider will need the Ultra- sound machine,
procedure cart if available on the unit with supplies
PPE (blue packets from supply room) are to be worn by everyone in the room
Chest x-ray will be taken before using the line to confirm placement and no signs of a pneumothorax
May need a pain/sedation medication depending on the situation
Chest tube insertion
Chest tube set up (Pleurovac or Atrium)
Procedure cart with supplies
Chest x-ray post procedure to evaluate tube placement
May need a pain/sedation medication depending on the situation
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Common Medications in Critical Care
Cardiovascular Class/Indication Tips Route
Furosemide (Lasix) Diuretic
Used in fluid overload states/Pulmonary edema, Heart failure
Monitor electrolytes
I & O for response of med
IVP: give slowly 10mg /minute
Metoprolol Beta Blocker
Anti-hypertensive
Anti-arrhythmia
Given for ↑BP or arrhythmias
Atrial fib with a Rapid ventricular response, SVT
Monitor for bradycardia
IVP: give slowly
Hydralazine Vasodilator
Anti-hypertensive
Given for ↑BP
Monitor BP
IVP: give slowly
Amiodarone Anti-arrhythmia
Used in atrial fib with a rapid ventricular response
IV bolus: 150mg in 50/100ml bag infuse over 10 minutes, then change to continuous infusion at 1mg/min for 6 hours, then decrease to 0.5mg/min Follow order set
Pain Meds
Fentanyl Opioid Has pain and sedative properties, monitor resp status if not vented
IVP: give slowly
Hydromorphone (Dilaudid)
Opioid Pain and sedative properties, monitor resp status if not vented Potent: 1mg Dilaudid = 7mg Morphine
IVP: give slowly
Ketamine Non- opioid pain control
IV continuous infusion Follow order set
Lidocaine
Non- opioid pain control
Monitor for signs of toxicity, numbness around mouth, slurred speech, restlessness, vertigo, GI symptoms
IV continuous infusion Follow order set
Ketorolac (Toradol)
NSAID Also used for pain
Avoid use in patients with renal dysfunction
IVP: give slowly
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Anti-Emetics
Ondansetron (Zofran)
Promethazine (Phenergan)
Anti-emetics Can potentiate effects of sedative and opioids
Avoid combination of Zofran and Promethazine can cause arrhythmias
Zofran: IVP slowly Promethazine: Dilute w 10 ml NS & IVP slowly
Critical Care Interventions Screen Shots on Meditech
This is a typical Critical Care Process Care menu screen that populates when you complete the Quick
Start on Admission for a patient.
Descriptions and charting were covered during the Meditech for Nursing Documentation Healthstream
module for inpatient charting requirements such as Admission Health History, Admission/Shift
Assessment, etc.
Screen shots of the most often charted care items are provided for reference.
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RASS/CAM ICU:
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Restraints:
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Critical Care Flowsheet:
If you have any questions or need further information please reach out to the St. David’s HealthCare Institute for Learning Team at 512-544-0100 or email SDHP.DL IFL Clinical
Education
Page 1 / Updated: 04/15/2020 / HCA Healthcare Center for Clinical Advancement
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Page 2 / Updated: 04/15/2020 / HCA Healthcare Center for Clinical Advancement
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