Informatics programs that allow med/surg nurses to cut down on documentation and increase patient safety at the touch of a button are becoming more essential in today’s fast-paced healthcare environment.
“Most all nurses use the electronic health record in their daily practice,” said Jill Arzouman, MSN, RN, ACNS-BC, CMSRN, president of the Academy of Medical-Surgical Nurses and clinical nurse specialist in surgical oncology at the University of Arizona Medical Center, Tucson. The university has computer stations inside each patient room for access to charting, she said, and some hospitals are investing in iPads to facilitate charting. Arzouman is a DNP candidate.
Med/surg nurses at New York’s Montefiore Health System in the Bronx use informatics throughout the day to document patients’ electronic medical records and provide direct care to patients, said Maureen Scanlan, MSN, RN-BC, vice president, nursing and patient care services and former director of informatics for the health system. “Electronic documentation has provided us the ability to track and trend patient outcomes data in a more efficient manner. We have the added benefit of decision support alerts to guide practice and documentation. We then can leverage information collected from the records to streamline workflows and improve patient safety.”
Patient safety comes first
According to a HealthIt.gov study “Benefits of EHRs,” (www.healthit.gov/providers-professionals/improved-diagnostics-patient-outcomes), having quick, up-to-date access to patients’ information can also reduce errors and support better patient outcomes by keeping a record of a patient’s medications or allergies, checking for problems whenever a new medication is prescribed and alerting the clinician to potential conflicts.
“The ability to clearly read a medication order printed from a computer is vastly different than trying to decipher a handwritten order,” said Arzouman.
In addition, staff can revisit patient information at any time.
“Many of the systems are very intuitive and allow the entire interdisciplinary team to document and communicate with precision and ease,” she said. “A medical/surgical nurse may be busy with another patient but she or he can go back and read documentation from the dietitian who may have visited the patient at the same time.“
A reduction in medication errors was the catalyst for a project using computerized EHRs at Abington (Penn.) Health. When staff realized that patients with heart failure were being readmitted largely because of incorrect medication lists upon discharge, Diane Humbrecht, MSN, RN-BC, chief nursing informatics officer, devised a plan to evaluate the accuracy of such lists.
Humbrecht, a DNP candidate who is also a chapter director for the American Nursing Informatics Association, has worked in both cardiac and home care during her career and said she had experienced heart failure patients going home with medication lists that were either incorrect or missing information.
“It was very frustrating for both the patient and the nurse who is trying to follow up,” she said.
As part of her DNP program, Humbrecht decided to focus on transitions of care for this vulnerable population to help correct their discharge medication instructions and reduce their risk for readmission.
“As I began researching, I saw medication errors on medication discharge lists were the main reasons patients were readmitted to the hospital,” she said.
Her findings were validated, she said, when the transition nurses who were involved in the postop discharge process informed her of problems with patients going home with incorrect medication lists. “Medication reconciliation and discharge instructions are done by the physician, but the nurses are the ones who review them and they were finding these errors after discharge,” she said.
Humbrecht implemented three changes to remedy the situation. The first step was to bring the pharmacists in on the front end. Pharmacists already performed patient rounding on units, but they were not involved in medication reconciliation at all, she said. The new protocol called for pharmacists to come in within 24 hours of a patient’s admittance to review the co-medications. The input from the pharmacists on the front end was crucial. “The pharmacists had to change about 80% of the lists,” Humbrecht said.
Next, upon discharge, the nurses perform a thorough review of the co-medications list that was corrected by the pharmacist. “If anything needed to be corrected, the nurse then called the physician to tell them they need to change a medication,” Humbrecht said. “Once that was done, it caused the physician to perform medication reconciliation again, automatically updating the entire medication list.”
The transition nurses were the final piece to the puzzle. Prior to the new protocol, upon calling the discharged patient and finding any errors, the nurse would make notations on paper. If the patient was readmitted, and the change was not transferred onto the patient’s EHR, the incorrect information was still in the system. Now, using the computerized medication list, any errors are updated immediately in the system.
The changes worked. Since implementation last fall, the transition nurses have found one error on the medication list of a discharged patient, Humbrecht said.
“We figured if we can get the home medication list correct on the front end by using the pharmacists and double-checked and changed as needed by the nurses on the back end, then the transition nurses should find less errors,” she said.
Innovative uses for informatics
Besides documentation and patient safety, med/surg nurses are using informatics to enhance patient care. “Our staff nurses provide expert advice when we are defining a new process for delivering patient care,” said Scanlan, who holds board certification in nursing informatics. “A recent implementation of a new lab system that changed the way specimens are collected was successful due to workflow and hardware recommendations from the frontline staff.”
Scanlan said staff nurses recently have contributed to revising the electronic skin assessment template as well.
“Although not a clear time saver,” she said, “it has significantly improved the ability to track, trend and communicate hospital-acquired pressure ulcers [and] has supported performance improvement efforts that are led by the nursing staff.”
Arzouman also noted innovative uses. “For a postoperative patient who needs to continue to ambulate and exercise while at home, a medical/surgical nurse can teach the patient how to track his activity using a smart phone app,” she said. “I have had the opportunity to trial an app on my smart phone that translates basic medical information into many different languages without needing to use a translator. For something simple like ‘Hi, my name is Jill and I will be the nurse coordinating your care today,’ it is a very helpful tool.”