Improvements in technology and decreased cost of equipment have poised virtual reality to change the education of healthcare professionals and the clinical treatment of patients.
This article first appeared in the December 2016 issue of HealthLeaders magazine.
For most people, a quick trip to the gas station isn't a big deal. Gas is pumped and paid for, and sometimes coffee and a donut are purchased. But for someone with a history of alcohol abuse, a trip to the gas station can mean the difference between staying sober or not.
"You're going to go get gas one day, and guess what, there's going to be alcohol in the gas station," says Patrick B. McGrath, PhD, clinical psychologist and director of the Center for Anxiety and Obsessive Compulsive Disorders at AMITA Health Alexian Brothers Behavioral Health Hospital in Hoffman Estates, Illinois. "Or you're going to be with a buddy that needs to stop at a liquor store and pick up a bottle of wine for a party that night. Do you just want to stay in the car every time? Or can you learn that you can walk through that and handle triggers and cravings and not have to drink?"
McGrath's goal for his patients, who include those with phobias, PTSD, and drug and alcohol issues, is for them to be active participants in life rather than sitting on the sidelines. One tool, he says, that has the potential to help them achieve this is virtual reality—the use of computer technology to immerse users in an interactive, sensory-rich environment that simulates the real world.
McGrath has been using virtual reality technology in his clinical practice for about eight years. But because of the cost of equipment and the need for a powerful computer to provide a high-quality, realistic experience, virtual reality's use has not been widespread across the healthcare industry.
But that is about to change. Big players such as Facebook, Samsung, and Microsoft are getting in on virtual reality and creating more affordable and accessible devices that provide high-resolution graphics.
"Now we can use virtual reality for diagnosis, for treatment, and for teaching," says Alberto Odor, MD, adjunct professor for the Betty Irene Moore School of Nursing at the University of California, Davis, and for the UC Davis School of Medicine Health Informatics Program. "I think it's going to be coming beginning next year. It's going to be coming pretty quickly because the hardware and the software are now something we can afford."
The anatomy of accessibility
Virtual reality has been around for decades, but until now its use in healthcare was not practical. "The equipment needed was expensive and very difficult to use," Odor says.
The large virtual reality system McGrath uses ran in the $30,000–$40,000 range in 2008 and was paid for with grants from the Illinois Department of Veterans' Affairs. Now, however, the technology has started becoming more accessible and affordable.
"We can use virtual reality for diagnosis, for treatment, and for teaching. It's going to be coming pretty quickly because the hardware and the software are now something we can afford."
"A couple of years ago it became a reality because it's now possible to have high-quality virtual reality using one of the computers you use every day and equipment that is not more expensive than the price of a cell phone and a $100 viewer," Odor says.
One example is Gear VR, a wireless virtual reality headset created through a partnership between Samsung and the virtual reality company Oculus, which is owned by Facebook.
For a 360-degree virtual reality experience, users can snap their Samsung Galaxy phones into the device, which resembles a diving mask, and see the virtual world through the viewer.
With improvements in the technology's resolution, graphics, and price, Odor sees big potential for its use both in healthcare education and in the clinical realm.
In anticipation of its increased prevalence, Odor retooled his course, Virtual Reality, Simulation, and Robotics for the UC Davis 2016 fall semester, and his students will now be creating virtual reality applications during the course.
The technology can also help educate physicians and nurses, Odor says. He points to the work being done through a partnership between Case Western Reserve University and Cleveland Clinic.
In 2015, the Ohio-based institutions broke ground on their joint venture, the $515 million, 485,000-square-foot Health Education Campus, which is slated to open in 2019. The goal of the space is to promote interprofessional education and offer advanced technology.
For example, to learn about human anatomy, students can use Microsoft's HoloLens, a wearable holographic computer that resembles the visor on a motorcycle helmet and allows users to interact with high-definition 3-D holograms of the body and its systems.
This type of technology is called augmented reality—the use of computer technology to add elements like graphics or sound to a person's real environment—and Odor says it's still an excellent way to learn.
"It's going to be very useful and probably will allow medical schools to avoid the anatomy-of-cadaver labs," he says. "These might actually be much better than cadavers because cadavers lose their natural colors. The detail that you can have with the HoloLens is really interesting."
Clinical uses
Virtual reality also has applications in the clinical setting and can play a role in neurosurgery pain management, treatment of phobias, PTSD, and substance abuse.
Neurosurgeons at the University of California, Los Angeles, have used CT and MRI scans to create virtual reality representations of actual patients. This allows the surgeons to plan and practice a surgery before stepping into the operating room, thus improving precision, clinical outcomes, and surgical time.
At the University of Washington, burn patients who used medications and SnowWorld—a virtual reality application where users throw snowballs at penguins and woolly mammoths—reported feeling 35%–50% less pain during painful medical procedures compared to when medication alone was used.
"I'd say it's moving from research to actually being used clinically now," says McGrath, who has used virtual reality technology as a tool to provide exposure and response prevention (ERP) therapy for patients with anxiety, phobias, and PTSD. Through exposure, therapy patients expose themselves to the thoughts, feelings, objects and situations that cause anxiety. Response prevention helps them learn that they can make the choice not to engage in a specific behavior.
Over the past two years, he has been using ERP in pilot groups to treat drug and alcohol issues.
With the virtual reality system he is currently using, which requires a powerful computer to provide a high-quality virtual reality experience, McGrath can place patients in challenging settings. He can have them walk past the gas station beer cooler, go to a party and be offered a drink, or walk through a house that contains drug paraphernalia and, using a smell machine, wafts marijuana odors, and have them practice making choices.
"You can't talk people out of drinking. You can't talk people out of being anxious. You have to have the patient practice," he says.
There are also virtual reality scenarios for patients with phobias of spiders, elevators, or flying.
"The only way to have someone overcome a fear is to have somebody do the thing they're afraid of and learn that they can handle it," he says. "If you're afraid of an elevator, what do you eventually do? You need to get on an elevator."
McGrath has used virtual reality to treat military veterans with PTSD. In this simulation, he can place veterans in a virtual Humvee and have them experience a simulated blast through a rumble pad under their feet.
"Our first patient who did it, when I turned on just the night vision, he about had a panic attack the first time I met with him," he says. "By session 15, I blew off 20 minutes of straight bombs and grenades and noise and gunshots and explosions and he was able to take the goggles off and say, "OK, I'm good. It doesn't bother me anymore."
Virtual reality's bright future
McGrath estimates that over the past eight years, about 20 veterans have done intensive one-on-one therapy for PTSD, which includes the use of virtual reality, and he is hoping the numbers will increase in the future.
"It's been difficult getting the VA to give up patients," he says. "But now with the Veterans Choice Program, I'm hoping that we're going to have more veterans that are going to come through and decide that they want to try it." The Veterans Choice option allows veterans to go to non-VA facilities and still receive care under their veteran's benefits.
"The future's amazing with this. It's going to be the next wave of things that we'll be able to do, and I think in 20 years we'll look back on some of the therapies that we used to do and just kind of chuckle and think, 'Why did people do that?' "
And when AMITA Health Alexian Brothers Behavioral Health opens its new 48-bed residential treatment center in 2017, patients will have access to virtual reality treatment for anxiety and drug and alcohol abuse. McGrath says the plan is to train clinicians in the organization's group practice, residential practice, and intensive outpatient programs to use virtual reality as a treatment tool.
"Our big push in the next six to eight months is to incorporate virtual reality availability into all of our different programs."
McGrath says the affordable, high-quality, smartphone-based virtual reality applications will bring virtual reality therapy within reach for even more clinicians and more patients.
"You can do that for a couple hundred dollars," he says. "I don't think that's a huge investment for a therapist to have that in their office."
Perhaps someday, this type of treatment will be available beyond a physical office, says McGrath.
"There will even be the ability to start to do something like this over the phone in people's homes," he says.
For instance, a person who has not left his or her home for years because of agoraphobia—an anxiety disorder in which a person fears and avoids places and situations where they may panic or feel trapped—might be able to receive a phone and virtual reality headset and practice being outside.
"The future's amazing with this," says McGrath. "It's going to be the next wave of things that we'll be able to do, and I think in 20 years we'll look back on some of the therapies that we used to do and just kind of chuckle and think, 'Why did people do that?' "
Workplace safety and nurse surveillance capacity can boost quality ratings and lower pressure ulcer rates, Press Ganey analysis finds.
Workplace safety and nurse surveillance capacity are significantly associated with healthcare organizations' performance on nurse, patient, patient experience, and pay-for-performance outcomes, according to analysis by Press Ganey.
The analysis found that when compared to hospitals in the bottom quartile of perceived nursing workplace safety, hospitals in top quartile of perceived nursing workplace safety had:
A rate of RN-perceived missed care that is approximately 52% lower
RN job enjoyment that is 27% higher
A 22% higher CMS Overall Hospital Quality star rating
Average "likelihood to recommend" scores that are 3% higher
Christy Dempsey, RN, MSN, MBA, CNOR, CENP, FAAN, Chief Nursing Officer at Press Ganey, assessed the findings in relation to Maslow's hierarchy of needs, a concept familiar to most nurses. "Safety is at the bottom of the pyramid. The only thing more important is physiological needs," Dempsey says.
"As a nurse, if I don't perceive that my work environment is safe, then I'm not going to be able to continue up the pyramid to self-actualization—the 90th percentile—or any other improvement effort that you want me to do."
To assess the components of a safe work environment, researchers created an RN Safety Composite measure that included survey items related to safe patient handling and mobility practices, RN-to-RN interaction, appropriateness of patient care assignments, meal-break practices, and shift duration.
The analysis also found the work environment significantly influences nurse surveillance capacity—the degree to which nurses are able to observe, monitor, collect, interpret, and synthesize patient information to make informed decisions regarding their course of care.
Compared to hospitals in the bottom quartile of perceived nursing surveillance capacity, those in the top quartile had:
26% fewer hospital-acquired pressure ulcers
A 5% higher CMS Overall Hospital Quality star rating
3% higher average "likelihood to recommend" scores
13% lower rate of RN-perceived missed care
To measure nurse surveillance capacity, the researchers adapted a composite measure that included subscales of the Practice Environment Scale of the Nursing Work Index linked to surveillance capacity, according to the report.
"Staffing, resource adequacy, nurse manager ability and leadership, the percent of nurses with certification, and the nurses' participation in hospital affairs—those are the things that drive the ability to surveil your environment," Dempsey explains.
The surveillance composite also included RN characteristics such as education, clinical competence, and years of experience.
Of the two work environment components, workplace safety had a stronger influence on outcomes than perceived surveillance capacity.
"It was interesting that workplace safety was a more significant driver than the surveillance capacity," Dempsey says. "I think that goes back to the whole fundamental basic need that before you can move to anything else you have to feel safe."
One the many takeaways from the analysis, says Dempsey, is the need for frontline nurse managers to have the skills to create safe work environments that foster nurse surveillance capacity.
Nurse leaders need to be "making sure that frontline leadership has the resources and training that they need to actually make a difference in that role," she says. "Not just training on the budget and on scheduling but on coaching and leading and mentoring."
Attendees at the HealthLeaders Media 2016 Chief Nursing Officer Exchange shared their best peer-to-peer solutions to some of the biggest challenges facing the nursing profession.
More than two dozen top nurse executives from around the country gathered at the invitation-only HeathLeaders Media 2016 Chief Nursing Officer exchange from Nov. 2 to 4 at the Bacara Resort & Spa in Santa Barbara, CA, to discuss issues of concern to nurse leaders and to share viable solutions to these challenges including the nursing shortage.
"As I listened to our conference planning calls, it seemed like workforce, staffing, and scheduling issues just never go away," said Barbara R. Medvec, RN, MSA, MSN, NEA-BC, adjunct professor at the University of Michigan School of Nursing and executive at BRM Health Associates.
The Problem
One particular challenge nurse leaders are currently dealing with is difficulty finding experienced nurses to fill positions in specialty areas such as critical care.
During the event's popular Ideas Exchange breakfast, Medvec shared the specifics of an innovative specialty nursing orientation program that was put in place at a four hospital systems in Southeast Michigan.
Nurses in specialty units there were leaving for opportunities outside the organization or transitioning to advanced practice. Replacing them with equally experienced nurses had become a challenge. As during previous nursing shortages, one solution was to bring new nurses directly into critical care areas.
"The problem with that [was that] transition and turnover was very high, satisfaction was not there with our preceptors, and we certainly started to see an increase in preceptor burnout as well as our vacancy rates increasing," Medvec said.
"As soon as the discussions about sign-on bonuses and retention bonuses started, it was time to do some critical thinking."
The Solution
This led to the creation of the specialty immersion program—a detailed orientation into specialty areas using an academic/faculty model that provided in-depth specialty education, critical thinking simulations, and competency building experiences.
Participants had a 75-day immersion with the faculty and a 14-day unit-based orientation plus simulation and competency experiences. Education was based on existing curriculum from the American Association of Critical-Care Nurses and the Emergency Nurses Association and specialty certifications.
RNs with more than 12 months' experience could apply to the immersion program. They signed a transfer agreement to stay in the specialty area for 12 to 36 months depending on the specialty.
The Outcomes
Feedback from preceptors and unit staff members was positive.
"[Preceptors were feeling] like they had been orienting and orienting and orienting," Medvec says. "Some of their frustrations certainly had been the fact that sometimes they would orient and people wouldn't necessarily seem to fit."
Unit staff members were impressed with the critical thinking skills the nurses coming through the immersion program had developed.
"We've seen feedback from staff saying, 'Wow they're already critically thinking about what our issues are on this unit,' and 'It's like working with colleagues with many years of experience.'"
The staff who completed the immersion reported a decrease in fear about making a change into a specialty. They also felt they could contribute to the unit on their first day and their career transition was going to be positive.
The program has been in effect for 18 months and there has been a 30% decrease in orientation time because the new specialty nurses were coming to the units more prepared. There has been a 98% retention rate of nurses going through the immersion program.
A Boost for Both Internal, External Recruitment
"Internal for career transition and movement," Medvec says, "external recruitment primarily because our recruiters are bringing new nurses in knowing that if they have aspirations for any of these specialty areas they can make application to move into the immersion program within that first year or right after their first 12 months of their experience."
Medvec says the program is at minimum budget-neutral, but it is expected to save costs as a result of improved retention.
When Southwestern Vermont Medical Center deployed its nurses in new ways, it saw a big drop in hospital admissions and ED usage among at-risk patients.
The American Nurses Credentialing Center last month awarded the 2016 National Magnet Nurse of the Year Award in Structural Empowerment to Barbara Richardson, MS, RN-BC, CCRN, clinical nurse specialist in transitional care nursing at Southwestern Vermont Medical Center in Bennington.
She earned the distinction for her transitional care nursing work.
The medical center serves a rural region in portions of three states, and began actively using transitional care nursing about three years ago. Since then, there has been a 69% decrease in hospital admissions and 29% drop in emergency department visits among patients enrolled in the program.
The patient cohort is traditionally hospitalized patients connected with primary care practices, Richardson says. "However, it can also be patients or people who have not been hospitalized but who the primary care providers feel are at risk for hospitalization or at risk for failing their medical regimen."
The program, based on Mary Naylor's Transitional Care Model, was launched and led by Richardson and has grown in size from one clinical nurse specialist—Richardson—to one part-time and three full-time clinical nurse specialists as well as a social worker.
The program received a $200,000 innovation grant from the state of Vermont, which it used to add the part-time CNS as well as a health promotion advocate in the ED and some hours from a clinical pharmacist.
"When we first started, it was just transitional care nurses, and we quickly found that we had a community that was far more impoverished than we really recognized, and far less health-literate, with great social needs," Richardson says.
The program has a fluctuating patient load that is currently around 80 patients.
Richardson has the following advice for those who wish to build a successful transitional care nursing program:
1. Understand Your Community
When she was developing the program, Richardson considered a diagnosis-driven program model but realized that format would limit the reach of the program.
"We're a small community and we wouldn't be touching the numbers [of patients] we want to touch so we went a different direction," she says. "We'll see anyone with any diagnosis as long as they're a part of the primary care provider practices that we're associated with."
Transitional care nurses do not see patients who have a primary behavioral health issue or drug addiction because these patients' needs are different than those of other transitional care patients.
2. Connect with Community Resources
Strong community partnerships have played a role in the success of the program, and Richardson fostered connections with community care partners, visiting nurses, and local nursing homes early in the program's development.
"We actually started connecting with them before we started seeing patients so that we would get to know what was out there in our community," she says.
She also created relationships with community resources like Meals on Wheels, food pantries, the Vermont Council for Independent Living, and the state's Support and Services at Home program.
"Our goal is to help people learn to take care of themselves," she says. "To teach them how to take care of themselves and provide them with tips and tools to really manage their chronic diseases on their own so that they don't have to come to the hospital to have them managed."
3. Shift Your Resources
When it comes to manpower, Richardson recommends looking at using existing resources in new ways. "You don't have to hire all sorts of new FTEs for a program like this," she says.
"We shifted resources from inpatient to outpatient. The clinical nurse specialist is a traditionally inpatient role and we were all [in inpatient roles]. Our inpatient census was going down and I think that's common in rural American in small community hospitals."
The effectiveness of patient advisory councils varies. The director of a solutions-oriented patient advocacy at a suburban Chicago hospital offers tips on creating engaged and effective patient advisory groups.
But these groups can differ in effectiveness. Some are able to create meaningful solutions that influence organizational outcomes, while others get stuck in silos or see no action on their suggestions.
One organization that has had success with its patient advisory committee is Elmhurst (IL) Hospital. Since the creation of its advisory committee in 2009, the 259-bed suburban Chicago hospital has leveraged the group's feedback to design and build a new hospital campus, achieve Planetree designation, and continuously improve policies, procedures, and processes.
Joanne Muzzey, RN, MHA, director of patient advocacy and Planetree at Elmhurst, has overseen the group since its inception and has some advice on getting the best results from a patient advisory council.
1. Know Where to Find Members
Finding people who are willing to volunteer their time is not always easy, but organizations may already have a treasure trove of potential members among patients who have made complaints.
"When we started our council, we looked back at a database of patient complaints," Muzzey says. "We went back over a year's worth and selected about 20 or 30 that we knew would have some valuable feedback."
Suggestions from department managers can also be fruitful since they can identify patients who have frequent experiences on specific units.
By using those two lists, Muzzey and her colleagues were able to identify about 40 people to invite to an informational session on the advisory committee. After the presentation, 20 patients expressed interest in participating and filled out a brief application. By the time the inaugural meeting was held, there were about 13 patients ready to be active members.
Unlike some patient advisory committees that rotate members every two years, Elmhurst does not set a limit on how long a member can serve. Instead, members are replaced as slots become open through natural attrition.
"It was important to us to have the history of where we came from to recognize how we've really transformed over the years," Muzzey says.
2. Consider Member Demographics
One challenge in creating a patient advisory committee is assuring diversity of membership.
"You're going to end up with more females and that younger middle-age to Baby
Boomer-age group," Muzzey says about patient advisory councils in general.
She tries to look for patients who come from the different geographic areas the organization serves as well as those who represent the continuum of care.
"Outpatient vs. inpatient vs. ED so at least they're bringing that different perspective," she says.
3. Start with Tangible Projects
Projects with tangible outcomes can help promote engagement and enthusiasm, especially among a new advisory group. "Those very visual, hands-on pieces help," Muzzey says, "They can see that their feedback [has had an] effect."
Elmhurst's patient advisory council was integrally involved in designing the new hospital campus which opened in 2012.
"When we were building the new campus we were asking them for feedback on everything from furniture to room service menus to beds," Muzzey says.
The group even test drove potential critical care beds during a meeting. Even though the purchase put it slightly over budget, the organization purchased the beds because of the council's feedback.
4. Demonstrate Strong Leadership Support
"Just like everything, you have to have that senior leadership support," Muzzey says.
Muzzey reports directly to Elmhurst's CNO Pamela Dunley and provides monthly reports from the council. Dunley has also asked for council feedback prior to making decisions, such as whether it was OK to eliminate white boards in patient rooms at the new hospital campus.
The council members were adamant about keeping them, so sleek, glass models were installed at the new campus.
Muzzey also recommends including leaders such as managers and department directors as guests at meetings so they can share and receive feedback from the group.
As nursing organizations review the 2,400-page final rule, some are calling on CMS to clarify the implications for APRNs.
Sometimes called the "doc fix," the Medicare Access and CHIP Reauthorization Act (MACRA) will affect other healthcare providers as well, including advanced practice registered nurses, physician assistants, and physical therapists.
While many nursing organizations are still reviewing the 2,400-page final rule, several have issued comments.
The American Association of Nurse Anesthetists is in the process of reviewing the final rule, and looks forward to working with CMS to assure that certified registered nurse anesthetists have the opportunity to be competitive participants in this program, officials said.
The American Association of Nurse Practitioners officials noted the MACRA rule is approximately 2,400 pages long, and is still being reviewed by the association's Federal Government Affairs team. "We are unable to provide a comment at this time," the AANP stated.
The American Nurses Association submitted comments on the proposed rule in June. "While we continue reviewing the 2,398-page document, it appears that many of the concerns articulated in ANA's comment letter did not result in corresponding changes from the proposed to final regulation," the organization stated.
ANA raised issues related to restrictions on non-physician data input observed in some certified electronic health records, attribution of the services of advanced practice registered nurses billed "incident to," and restrictive APRN credentialing practices observed in many health plans and anticipated with respect to some Alternative Payment Model plans, the group stated.
"ANA looks forward to an ongoing … dialog with CMS regarding the concerns of APRNs enrolled as Part B providers as well as the important role registered nurses provide to Medicare beneficiaries as well all of patients these front line providers care for."
The American Organization of Nurse Executives did not issue a separate comment on the final rule but referred to The American Hospital Association's statement by Tom Nickels, executive vice president, government relations and public policy at AHA. AONE is a subsidiary of AHA.
"[The] final MACRA rule presents challenges and opportunities for hospitals and health systems, and the nearly 540,000 directly employed or contracted physicians with whom they partner to deliver quality care.
AHA is disappointed that CMS continues to narrowly define advanced APMs, which means less than 10% of clinicians will be rewarded for their care transformation efforts, but is encouraged that CMS is exploring a new option that would expand the available advanced APMs that qualify for incentives, Nickels wrote.
"We urge CMS to ensure that this option be available in 2017 and look forward to working with them so this new model achieves an appropriate balance between risk and reward."
The AHA lauded CMS for provided clinicians increased flexibility to meet MACRA's aggressive timelines and reporting requirements. Allowing clinicians in a variety of settings to "pick their pace" will enable them to more easily transition to the new program.
The final measures in the Advancing Care Information section are a welcome step back from the "overly aggressive" initial proposal, but the AHA is concerned that the lack of sociodemographic adjustment to the measures used in the MIPS will unfairly burden clinicians and hospitals caring for the poorest patients, Nickels wrote.
CMS has announced its intent to expand opportunities for clinicians to participate in advanced APMs by retrofitting existing models to qualify as advanced APMs. The organization also intends to use the CMS Innovation Center to create new models.
The U.S. Department of Health & Human Services encourages feedback on the final rule and will accept comments until December 17. Comments can be submitted through the e-Regulation website.
Take time, educate patients, and use assistive technology to curb injuries, says a nurse honored for reducing workplace injuries.
In a culture of drive-thru restaurants and text messages, it can be easy to forget that faster is not always better. But that's the message Roxanne Hupp, RN, occupational health coordinator at Mercy Regional Medical Center in Durango, CO, is trying to get across regarding safe patient handling.
"In my mind, if patients feel comfortable and safe and feel the staff is doing their best to take care of them, then time is less of an issue," she says.
In May, Hupp was recognized as a Nightingale Luminary by the Colorado Nurses Foundation for her work in reducing workplace injuries.
The 83-bed hospital has seen a downward trend in the number and severity of patient handling injuries. In 2012, there were 10 patient handling injuries—three of which were serious and resulted in a large number of lost, transferred, or restricted work days, says Hupp.
In 2013, the number of patient handling injuries dropped to six, with two that were considered serious. In 2014, there were six patient handling injuries, but none were considered serious.
Hupp has tackled patient-handling injuries in a number of ways, including equipment, education, and culture change. Here are some of her insights for handling patients safely:
Lift Equipment is Your Friend
In 2012, Hupp used a $45,000 grant from Catholic Health Initiatives to help purchase new lift equipment, including lateral transfer air mattress devices and bariatric-friendly lifts and commodes.
Mercy's ICU is a good example of how familiarity with and access to equipment can improve injury rates. Because of room size, all bariatric patients stay in the ICU. Bariatric equipment is housed on the unit and all staff members have been trained on how to use it.
"The ICU, despite the fact that it has our sickest and largest patients, has the lowest injury rate because they have good adjuncts, they know how to use them, and they're careful to do so," Hupp says.
Focus on Safety, Not Speed
Trying to be fast can compromise safety. Nurses first should think about the safest way to transfer patients or assist them up from the floor, and whether personnel or equipment may be available to assist with the move.
Safe patient handling does not take an extraordinary length of time, says Hupp. "In one of our annual trainings, I got down on the floor and people got the lift device, and the longest it ever took was four and a half minutes," she says.
"I said, 'How long is it going to take you to find six people to get that patient back to bed as opposed to getting one person and the lift?' I think that was the big eye-opener."
Involve Patients and Families
During the initial admission assessment, patients should be assessed for fall risk, and both patients and families should be instructed on the best way for patients to get out of bed safely.
"We have lots of good CNA and RN cooperation to assure that the patients are rounded on frequently and reminded not to get up by themselves," she says, "and every time a new lift device or transfer adjunct is used, the patients and family are instructed on what's going on."
Drug diversion and addiction among nurses is not uncommon, but it is often misunderstood. An expert shares insights to improve understanding.
Have you ever worked with a colleague who diverted drugs to feed an addiction?
Chances are you have, though you may not have known it, since drug diversion and addiction are often very secretive issues. Most estimates put nurses' drug and alcohol misuse at around 6% to 10%, or about one in 10 nurses.
This makes it highly likely that at some point in your career you'll encounter a colleague or staff member who is, or will, divert and misuse drugs.
Yet, diversion and addiction are still misunderstood, says Laura Wright, PhD, CRNA, associate professor in the Department of Acute, Chronic, and Continuing Care at The University of Alabama at Birmingham, School of Nursing.
"Addiction is a disease, it's not a moral defect," she says. "But, when I talk about addiction, I still get people asking me, 'Why would they ever do that? That's an awful thing. How could they do that to their children?'"
Here are five things Wright, who is a member of the American Association of Nurse Anesthetists Peer Assistance Advisors Committee, (AANA) wants nurses to know about drug diversion and addiction.
1. Addiction is a disease.
Wright describes addiction as a "disease of choice." What does this mean? I shared with her that I once had a colleague who, after going to a new employer, was caught diverting drugs.
When I worked with this nurse, they had sustained injuries from a car accident and had been prescribed prescription pain medication. Eventually, the nurse started mentioning that the medication wasn't helping with the physical pain anymore.
"Tolerance builds and they need more," Wright explains. "The brain has been rewired so that the drug becomes necessary for survival on a very unconscious level."
This rewiring interrupts their ability to make proper choices and, biologically, addicts become unable to "just say no."
2. Know the signs and behaviors of impairment.
There are often red flags that there is a problem with diversion and addiction well before the narcotics counts are "off."
A nurse may become forgetful, unpredictable, or lack concentration. He or she may have frequent illnesses, physical complaints, and elaborate excuses for things. They may pick-up extra on-call shifts, have a labile mood with unexplained anger and overreaction to criticism, or have an increase in unexplained tardiness or absenteeism.
"When it gets to the point, when nurses are diverting, where it's noticeable on audits and in the Pyxis, it's way out of control," Wright says of addiction.
3. Turning a blind-eye helps no one.
Colleagues who notice signs and behaviors of drug diversion and addiction are often hesitant to raise their concerns.
"The people who love them know that they're a great nurse, and they don't want to get them in trouble… because they're worried that they're going to be the one that causes somebody to lose their job," Wright says.
But inaction can lead to permanent harm and even death. Creating policies that incorporate rehabilitation and reentry into practice versus automatic termination could help peers feel more comfortable speaking up when they notice something is suspicious, she says.
4. Screen for the right drugs.
Some medications, such as fentanyl, may not be part of the panel on a standard drug screen.
Managers need to know what a typical drug panel entails and, if it is not included, have the drug suspected of being diverted added to the laboratory tests.
5. When confronting diversion, do not leave the person alone.
Nurses caught diverting drugs are at high risk for suicide, Wright says.
"They often have the means. They've got the drug, and now their whole life has just fallen apart," she says. "A lot of policies say, 'You're out of here, empty your locker,' and security escorts you to the door."
Rather than immediately severing ties with drug diverters, organizations should instead have policies that ensure the nurse is under direct watch until a family member can come to get them, or they can be taken someplace safe, such as a treatment center.
For more on drug diversion and addiction, join Laura Wright, PhD, CRNA, associate professor in the Department of Acute, Chronic, and Continuing Care at The University of Alabama at Birmingham, School of Nursing, and member of the Peer Advisors Committee at the American Association of Nurse Anesthetists for the HealthLeaders Media webcast, Addressing the Pitfalls of Employee Drug Diversion and Addiction, on October 13 from 1:00 to 2:00pm ET.
The Joint Commission has called for improvements in clinical alarm safety, but nurses can't do it on their own. They need the help of device manufacturers, hospital leaders, and quality and risk management specialists.
When was the last time you responded to the sound of a car alarm? The noise may have been irritating, but it probably didn't raise enough concern to warrant a call to the police.
"When car alarms first came out, we heard those and were like, 'Hey, someone's ripping that guy's car off!'" says Michele M. Pelter, RN, PhD, assistant professor at University of California, San Francisco School of Nursing and director of the ECG monitoring research lab in the school's department of physiological nursing.
"And then we realized, well no it isn't [being stolen]. Somebody bumped it, or it's the wind, or a motorcycle went past. And so we now ignore those."
But in healthcare, ignoring alarms can be dangerous or even deadly.
From 2009 to 2012, 98 alarm-related sentinel events, 80 of which resulted in death, were reported to The Joint Commission.
In 2014, the organization added clinical alarm safety to its list of national patient safety goals, and in January 2016, phase two of the goal's implementation was rolled out. Hospitals are now expected to create policies and procedures to improve clinical alarm safety.
'They Don't Hear It'
"The Joint Commission got involved because the alarms are getting turned down or silenced," Pelter says. "We think, too, that there is an assimilation [that occurs] and the noise just becomes background noise. The nurses just don't even acknowledge it. They don't hear it. It's nothing new to them."
Often called alarm fatigue, the issue around clinical alarm safety goes beyond clinicians just tuning-out alarms they are constantly hearing. In addition to not responding to alarms because they've become background noise, nurses will also ignore alarms they do hear because they are often false.
"If all morning it's been false and we take that risk of saying, 'The chances are it's going to be false,' we push the envelope," Pelter says.
Disabling or turning down the volume on alarms is not a solution.
"This term, 'alarm fatigue' is going to change over time as we understand what that really means. I think it's a complex concept that we're still trying to understand," says Pelter. "I think that a lot of institutions, they don't know what to do with it, it's such a new patient safety goal to measure."
Nurses Need Help
As the SON's representative on UCSF Medical Center's, Clinical Alarm Management (CALM) Committee Pelter has gained some insights into the complexities of clinical alarm safety.
Even though nurses are on the front lines trying to manage alarms, one group on its own cannot be expected to solve the problem on its own.
While it helps to identify a key person to coordinate the improvement process, hospital leaders, physicians, nurses, and members of the safety, quality, risk management, and the biomedical departments should all be involved because decreasing the number of alarms may require changing alarm parameters, which are often left on the manufacturer's default settings.
"You want to get all sides of what the risk of change to all these parameters is and what do we gain from it," she says.
It also pays to reach out to device manufacturers for support, since they may be able to provide data or reports to help an organization make informed decisions about parameter changes, Pelter says. They can also assist with the technical aspect of making a change across an organization as it can be difficult to adjust alarm parameters.
"The monitoring companies have made it pretty hard. There [are] many steps to it, and it can be confusing," Pelter says of changing parameters.
Monitoring companies also need to be a part of improving alarm safety including adjusting alarm algorithms based on feedback from their users or evidence-based practice.
"The monitoring companies don't just update their software like our cellphones do, and that is something that we really want to push [them] to do," she says. "Why can't we have updates that make alarms better?"
After a South Carolina health system introduced an electronic system for monitoring handwashing compliance among clinical staff, it saw MRSA rates plummet.
Discussions about handwashing irk me because there is no excuse for healthcare professionals to not wash their hands. It's simple, only takes 20 seconds, and we've all been educated about the dangers viruses and bacteria—especially the drug-resistant kinds—pose to our patients.
So can't we just wash our hands already?
But after talking with Connie Steed, MSN, RN, CIC, FAPIC, director of infection prevention at Greenville (SC) Health System, I realize applying Nike's concept of "Just Do It" to hand hygiene is too simplistic.
There's more to hand hygiene than just washing your hands. Duration and frequency of handwashing is also extremely important.
"It really shouldn't be rub in, rub out, or zap the dispenser when you go in and out," Steed says. At GHS, the hand hygiene policy is based on World Health Organization's Five Moments for Handwashing and it's monitored through both direct observation and an electronic, algorithm-based monitoring system.
WHO's Five Moments
Launched in 2009, WHO's Five Moments calls for healthcare workers to wash their hands:
1. Before patient contact
2. Before an aseptic task
3. After body fluid exposure risk
4. After patient contact
5. After contact with patient surroundings
"We chose [the] Five Moments [protocol] because we think it's more protective for the patient," Steed says.
But in order for it to be effective, healthcare workers need to correctly follow the protocol.
Traditionally, hand hygiene compliance has been monitored via direct observation where trained nurses visit nursing units and observe whether healthcare workers are washing their hands or not.
Steed points out that this misses a large portion of hand hygiene opportunities—those that take place in the patients' rooms. In addition, direct observation may not get the most accurate data because people often change their usual behavior when they know they are being observed, which skews compliance rates to appear higher than they actually are.
To verify that the algorithm for the electronic surveillance system was accurate, Steed and her counterparts got IRB approval to put video cameras some consenting patient's rooms to video tape their care. They then compared direct observation rates to the electronic compliance index which was verified through the video monitoring.
"The electronic monitoring system data was clearly statistically within appropriate confidence intervals of being more accurate than direct observations," Steed explains.
Electronic Monitoring Improves Compliance Rates
How does the electronic monitoring system work? On every nursing unit there is a chip inside each soap and gel dispenser. The chip communicates each dispenser activation to a web-based program which logs the activation.
To determine compliance rates, activation numbers are run through an algorithm that calculates the estimated number of activations that should occur if healthcare workers are following the 5 Moments protocol. The algorithm also takes into account the hourly patient census on every unit and the nurse-to-patient ratios for that census.
Unit managers have access to the data and can address compliance issues on their individual units.
"It's not Connie Steed didn't clean her hands five times today. It's all about what their team compliance rate is," she says.
"It's [nursing staff] influencing their fellow team members, the physicians, and the other professionals that come to their unit to increase their hand hygiene."
Use of this data for unit-based improvement seems to be working.
Results
A recent study co-authored by Steed, found a direct correlation between using data from the electronic hand hygiene compliance system to improved compliance with the WHO 5 moments and a reduction in hospital onset MRSA infections.
The study found that hand hygiene compliance rates increased by more than 25%, hospital onset MRSA rates decreased by 42%, and total costs of care avoided were about $434,000.
"Hand hygiene compliance is a cornerstone of infection prevention," Steed says. "Our goal was to find a more accurate picture of what the compliance [rate] was so that we could legitimately improve it so that we would reduce [infection] rates, improve patient safety, and, for that matter healthcare worker safety."