How Do You Support Early Pregnancy Losses The Miscarriage ...

I N N O VAT I V E P R O G R A M S Proceedings of the 2013 AWHONN Convention

Women’s Health

How Do You Support Early Pregnancy Losses? The Miscarriage Management Training Initiative: Improving Care for Women Purpose for the Program arly pregnancy loss (EPL) is a common pregnancy complication. Historically, surgical dilation and curettage in the operating room setting has been the standard of care for EPL. Evolving knowledge and research have led to a paradigm shift in which three alternatives have been recognized as safe and effective treatment options. Reviews of the research have concluded that women’s preferences should be key determinants of management when one option is not medically superior to another. Miscarriage Management Training Initiative (MM-TI) is an evidence-based intervention designed to facilitate the womancentered approach to EPL by expanding the range of safe and effective options available, including the use of the manual vacuum aspirator (MVA), for office-based management. Designed as a systems change approach, this intervention stresses training a cross-section of primary care disciplines in hospital and clinical settings.

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Tara L. Cardinal, MN, RN, CNM, ARNP Miscarriage Management Training Initiative, Seattle, WA Carolyn A. Nance, BS, RN, ICCE, C-EFM, Miscarriage Management Training Initiative, Columbia, SC Blair G. Darney, PhD, MPH, Oregon Health & Sciences University, Portland, OR Deborah L. Vanderhei, BSW, Women’s Health Consulting, Edmonds, WA Loren Fields, MSN, NP-C, WHNP-BC, Planned Parenthood of Southern New England’s Meriden affiliate, Meriden, CT Mary E. Wallace, MSW, RN, Independent Consultant, Mercer Island, WA

Proposed Change Training registered, advance practice nurses, and allied healthcare staff to provide comprehensive care for EPL in an office-base setting has the potential to reduce costs, provide evidencebased and community standard services, and expand access, especially for underserved women. By practicing patient-centered care, it also has the potential to address the myriad of emotions women experience after EPL.

Implementation, Outcomes, and Evaluation The MM-TI was first implemented with physicians, nurses, and allied healthcare staff in family medicine residency programs in Washington State. Our primary outcome was self-reported practice of MVA after the training. The evaluation demonstrated a significant program effect (preintent and postintent to practice MVA, controlling for individual and site-level confounders). The evaluation also showed a significant correlation between clinical and administrative support staff knowledge of MVA and the physician intent to practice MVA. The MM-TI has now expanded to other states and broadened the scope to include obstetriciangynecologists, nurse managers, nurse–midwives, nurse practitioners, and allied healthcare staff. Our preliminary qualitative assessment with stakeholders in Washington State pointed to the importance of clarifying scope of practice for miscarriage management and for MVA usage in particular.

Implications for Nursing Practice Nurses play key roles in caring for women who experience EPL. These roles include providing direct services for EPL, education, counseling, systems management, training staff, assisting the healthcare provider, and providing patientcentered care.

Keywords miscarriage management spontaneous abortion early pregnancy loss patient-centered care

Poster Presentation

Third-Trimester HIV Testing: Caring for Georgia, One Family at a Time Tonia Russell, RN, Columbus Regional Medical Center, Columbus, GA Chris Cannon, RN, Columbus Regional Medical Center, Columbus, GA

Purpose for the Program ith the progress made in infectious disease prevention, a mother’s positive-HIV status does not mean her infant will have HIV as well. By testing mothers, initiating treatment before delivery, and educating families, prevention of in utero transmission is possible.

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Proposed Change To provide third-trimester HIV testing and antiviral administration to expectant mothers. Outcomes are positively affected by initiating early antiviral administration as a result of third-trimester HIV test results. Testing was offered to all women with the expectation of providing care before delivery.

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C 2013 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses

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Implementation, Outcomes, and Evaluation r Education from Southeast AIDS Training and Education Center was used for pretest counseling r Ongoing in-service was conducted, which provided updates on test form completion, submission, and patient education r Coordinated process between nursing staff, laboratory staff, and physicians ensured timely testing, results, and notifications to patients r Comprehensive test forms were collected, verified for accuracy, and submitted to the Department of Public Health before the established deadline The implementation of third-trimester HIV testing established new guidelines and processes for the conduction of HIV tests in the third trimester of

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pregnancy. Within 1 hour, the labor and delivery and triage nurses provided comprehensive pretest counseling and testing, relayed the test results to the physicians, and the physicians provided the patients with the test results. By conducting HIV testing upon admission, immediate antiviral treatment was initiated before delivery. Implications for Nursing Practice As an active participant to improve the health of the local community, Columbus Regional Medical Center provided third-trimester HIV testing to expectant mothers. Test results were made available within 1 hour. Antiviral treatment and linkage to care protocols were made available to each patient on a continual basis. Early detection provided greater opportunities for positive outcomes for both mother and infant.

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12047

Keywords Regional Perinatal Center third-trimester testing HIV obstetrics Georgia high-risk pregnancy

Women’s Health Poster Presentation

http://jognn.awhonn.org

Mahoney, K., Boyle, C. J., Gregory, S., and Flores-Icarangal, J.


Save the Perineum! A Protocol to Reduce Perineal Trauma

Childbearing

Carol A. Burke, MSN, RNC, APN, Northwestern Memorial Hospital, Chicago, IL Elizabeth Centanni, BSN, RNC, Northwestern Memorial Hospital, Chicago, IL Keywords perineal trauma third-degree and fourth-degree laceration labor down second stage management

Paper Presentation

Kathleen Mahoney, APN, Robert Wood Johnson University Hospital, Whitehouse Station, NJ Carla J. Boyle, BSN, RN-C, Robert Wood Johnson University Hospital, New Brunswick, NJ Suzanne Gregory, MS, RN, CCRN, APN, C, Robert Wood Johnson University Hospital, New Brunswick, NJ Joan Flores-Icarangal, RN, MSN, CCRN-BC, Robert Wood Johnson University Hospital, New Brunswick, NJ Keywords telemetry cardiac disease

Purpose for the Program erineal trauma, including a third-degree or fourth-degree laceration, is a serious adverse outcome of a vaginal delivery, which can lead to chronic pain, urinary or bowel disturbances, and sexual dysfunction. The third-degree and fourth-degree laceration rate at this large university hospital was noted to be in the high range based on the University Health System Consortium database. The Obstetric Quality and Safety Committee identified the rate of third-degree and fourth-degree lacerations and charged a multidisciplinary team composed of physicians, nurses, and nurse–midwives to investigate potential causes that could be addressed to make positive improvements on the issue.

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Proposed Change To implement a perineal safety bundle for management of the second stage of labor. There are practices with some evidence thought to decrease perineal trauma; however, the team was not confident that one particular change alone would affect the rate of third-degree and fourth-degree lacerations. Therefore, a bundle was created composed of the following: (a) “Labor down” for at least 1 hour or until the urge to push is felt (but no longer than 2 hours); (b) use of warm packs to the perineum applied every 30 minutes during the sec-

ond stage of labor; (c) change position every 15 to 20 minutes to help facilitate fetal descent and rotation; (d) foot position should rest on the bed or in foot rests instead of being held by the nurse or support person (avoidance of McRobert position except for the shoulder dystocia maneuver); and (e) avoidance of manual perineal stretching during the second stage of labor. Implementation, Outcomes, and Evaluation Nurses, physicians, and residents were educated about the bundle protocol. Physicians were given the option to opt-in or opt-out of the bundle. The protocol used during this 6-month time frame concluded in January 2013. Data on differences between use of the bundle versus nonuse will be compared with third-degree and fourth-degree laceration rates. Implications for Nursing Practice The implementation of evidence-based practice related to the second stage of labor is a process. Varied techniques of leg holding positions, perineal massage and manipulation, and passive management of the “labor down” phase have been thought to add to the perineal trauma and use of operative vaginal delivery techniques. Introduction of the bundle has provided direction to the nursing and medical staff in use of evidencebased practice.

Don’t Break Her Heart: Cardiac Telemetry for the Pregnant and Postpartum Patient Purpose for the Program hen pregnant or postpartum patients are in need of telemetry monitoring, they often are separated from their newborns, or require the use of two nurses to attend to them because the units for perinatal services do not have telemetry access. As more patients with preexisting diseases become pregnant, this situation will only become more frequent.

Implementation, Outcomes, and Evaluation Policy and procedures were developed based on a shared governance model of care. Outcomes have resulted in maintaining the postpartum mother–baby dyad and accomplishing remote telemetry for cardiac assessment.

Proposed Change This nurse-driven change involves the use of remote telemetry to monitor the obstetric patient. Communication standards and co-nursing man-

Implications for Nursing Practice This program allows for seamless maternal– newborn care. In addition, staff are engaged in collegial relationships and co-management situations that were not available to them in the past.

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agement plans were developed to enable this change.

Childbearing Paper Presentation

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A Hospital-Based, Healthy Pregnancy Promotion Program to Empower the Socially at Risk: The Healthy Beginnings Program Purpose for the Program he Healthy Beginnings Program provides education, support, counseling, and a link to community resources to socially high-risk pregnant women who will give birth at Saint Joseph Medical Center. The purpose is to encourage a healthy lifestyle for every mother, so she will give birth to a full-term, healthy newborn.

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Eligibility includes the following: Medicaid patient; limited finances; uninsured; single or without social support; teen; domestic violence; and drug/alcohol use. Proposed Change A registered nurse meets privately with the patient (four 1-hour visits) and encourages her to write goals and attend childbirth and breastfeeding classes. Participants also are offered incentives, such as free books, maternity clothes, infant clothes, a breast pump, food vouchers, and a car seat. The following are topics covered in the program: Maternal/fetal growth and development, preterm labor, urinary tract infection prevention, nutrition, benefits of breastfeeding, seat belt use, smoking and secondhand smoke, healthy relationships, sudden infant death prevention, shaken baby syndrome awareness, and infant care and car seat usage. Implementation, Outcomes, and Evaluation The Healthy Beginnings Program was established in 1996 and has enrolled between 100 patients

and 172 patients annually. The annual operating budget for the Healthy Beginnings Program is approximately $35,000 per year. The average cost per participant in 2012 was $203. Statistics, such as birth weight, birth length, number of neonatal intensive care days, gestational age, and hospital costs, are compiled and compared with those of infants whose mothers are not in the program, but who are similar demographically. The comparative outcomes show that enrolled women tend to have infants that are slightly larger and slightly longer than nonparticipants who come from a similar client base. The most remarkable facts are the number of days spent in the neonatal intensive care unit and the gestational age. Year after year, program participants have healthier infants that are closer to term than nonparticipants. In 2009, 8.8% of program participants gave birth to infants at 37 weeks of gestation or less. Comparatively, out of the women who qualified for the program but did not partake 15.2% gave birth to infants at 37 weeks of gestation or less.

Sandra Kapka, RN, BSN, IBCLC, St. Joseph Medical Center, Kansas City, MO Keywords socially at risk pregnancy education health promotion program


Implications for Nursing Practice Caring for the socially high-risk pregnant patient and her infant is an ongoing nursing challenge because of the short hospitalization period at delivery. By establishing a rapport with families prenatally, the transition of a healthy mother and newborn from the hospital to the home is much easier and often times seamless, which saves both nursing time and energy.

The Implementation of the Discharge Nurse on a Mother–Baby Unit: A Conduit to Increased Patient Satisfaction Purpose for the Program he discharge nurse (DN) position was presented to hospital administration in 2011 for permission to grant a trial as a strategy to improve patient satisfaction with the mother–baby unit (MBU) discharge process. We hoped to improve consistency of parent education before discharge and improve patient satisfaction with the process. We also felt this position would affect throughput between the labor and delivery unit and the MBU simply through facilitation of

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timely discharges. We projected an increase in our Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores as a result of this innovative program.

Nancy Longworth, BSN, RNC-NIC, White Plains Hospital, White Plains, NY Laurie Larraz, BSN, RNC-NIC, CLC, CCRN, White Plains Hospital, White Plains, NY

Proposed Change A DN would work five 8-hour shifts Monday Jane Ciaramella, MS, RNC-OB, through Friday. The DN would meet patients on C-EFM, IBCLC, White Plains their first day admitted to the MBU and begin their Hospital, White Plains, NY plan for discharge. Furthermore, the DN would review all prescriptions on the day of discharge,

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12051


I N N O VAT I V E P R O G R A M S

Ratto, C. M. and Huwe, V. Y.

Proceedings of the 2013 AWHONN Convention

Stacy Murphy, BSN, RN, White Plains Hospital, White Plains, NY Keywords discharge nurse patient satisfaction HCAHPS scores standardization nurse satisfaction


including the effects of medication and potential adverse effects, review and prepare necessary paperwork, review discharge instructions for the mom and infant, review all screening tests and results, and review follow-up appointments for the mom and infant. Patients discharged in the coming day or days would attend a daily parent education class taught by the DN. The final car seat check would also be executed by the DN. After the mom and infant were discharged, the DN would document the discharge and complete the process. Implementation, Outcomes, and Evaluation The position was trialed for 3 months and made permanent late spring 2012 after evaluation of outcomes were realized. Press Ganey as well as HCAHP scores validated an increase in patient

satisfaction with the discharge process and patient education class time. The hospital administration recognized the positive outcomes and is presently using this best practice on another unit. Implications for Nursing Practice This innovative program can be used on any unit struggling with discharge-related patient satisfaction scores. The efficiency gained as a result of this process can be extrapolated for admission as well, and an admission and discharge team can be used to generate improved satisfaction in addition to improved throughput between units. Standardization ensures that the education surrounding discharge of mothers and newborns is consistent from one patient to the next. Nurse satisfaction was improved from this process and left more time for the staff nurse to monitor, care for, and teach patients with less fragmentation.

Patients in the Antepartum Period: Our Most Important Patients Purpose for the Program o address the need for structured programs and consistent nursing care to improve the Valerie Yates Huwe, RNC-OB, experience of hospitalized patients in the anteparMS, CNS, UCSF Benioff tum period.

during their antepartum period and now have infants in the neonatal intensive care unit (NICU) to come to the tea party and share their own NICU experience.

Children’s Hospital, San Francisco, CA

Implementation, Outcomes, and Evaluation Implementation of the program relies on one person to be the administrator with the SPCA and the co-facilitator (along with one of our perinatal social workers) for the tea party. The bedside nurses can initiate other interventions. We have found that the interaction between mothers meeting at our tea party is enough of an introduction that they continue to contact one another either by phone, e-mail, or visiting one another’s room. Patient satisfaction is important to us and we are working on a method to conduct posthospitalization interviews to find out if patients were able to cope better with their hospitalization after our interventions.

Christine M. Ratto, MSN, RN, RNC-OB, UCSF, San Francisco, CA

Keywords antepartum patients stressor coping collaboration needs


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Proposed Change To initiate program interventions that affect the ability of a patient in the antepartum period to cope and feel less lonely in her prolonged hospitalization. Collaborate with the local American Society for the Prevention of Cruelty to Animals (SPCA) to bring in therapy dogs for weekly visits. Collaborate with the spiritual care department to provide opportunities individualized for each patient in the antepartum period: offer meditation; live music through a Music in Medicine program; the ability to work within each family’s faith to have a blessing or good health ritual for the unborn fetus; and weekly tea parties, which bring together patients for a facilitated chat about their hospitalized experience, how to fight the boredom of long days and nights in the hospital, and their hopes and fears for their yet-to-be-born infants. We also invite mothers who were patients


Implications for Nursing Practice Women experience loneliness, fear, anxiety, and boredom during bed rest and hospitalization. A nurse’s understanding of this experience is essential to provide adequate care and coping strategies for women at this time.

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Healthy Weight Gain in Pregnancy: A Clinicians Tool for Individualized, Patient-Focused Collaboration Purpose for the Program he purpose of this poster presentation is to share a tool developed by the Washington State Department of Health for prenatal clinicians to use to engage patients in developing goals and healthy behaviors, and provide individualized resources for healthy weight gain during pregnancy.

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Proposed Change Five obstetric (OB) practices were presented with the tool as a way to address healthy weight gain during the first prenatal (intake) exam. Previously, one of these practices did not formally address weight gain and the other four did not have a patient-based tool. The goal was to get each clinic to use the tool. Implementation, Outcomes, and Evaluation In a pilot, five OB practices throughout the Southwest Region of Washington State were presented with the “Healthy Weight Gain in Pregnancy” tool, along with a “Clinician’s Tool for Healthy Weight Gain in Pregnancy” to help clinicians with assessment, dialog, and monitoring. Represented were one urban, underserved OB access clinic; one urban family practice and residency practice; one urban OB practice; one suburban OB practice; and one rural OB practice. The clinician tools and patient tools were given to each practice (in laminated pad form) in three languages: English,

Spanish, and Russian. After 3 months, each practice was queried regarding whether healthcare providers were using the tool, the patient interaction and success in engagement, and plans to continue the use of the tool. Of the five practices, only the rural practice did not embrace the tool— probably because of significant changes in staff, healthcare providers, and management. All others incorporated the tool in their OB intake process. The OB access clinic used the tool in their Centering/Group visit program and the other practices used the tool as part of their OB intake interview. Most successful in embracing the tool was the suburban practice, which used the tool and resources within the tool to develop plans that were incorporated into their electronic medical record (EMR) and monitor weight gain based on the goals developed.

Susan B. Bishop, MN, RNC-OB, MultiCare Health System, Tacoma, WA Keywords gestational weight gain obesity in pregnancy pregnancy weight gain tool

Childbearing Poster Presentation

Implications for Nursing Practice The purpose of presenting this poster is genuinely to share this tool with others. Many healthcare providers are seeking a tool that will help engage patients and are eager to find something that has already been developed and can be used in their practices. This tool is a tangible, readily accessible way to involve patients and have them participate in healthy behaviors for healthy pregnancies and healthy birth outcomes.

You’re Trained, You’re Ready, Panic is Not in Your Vocabulary: When a Helicopter Becomes a Delivery Room Purpose for the Program aginal delivery in a helicopter is an unpredictable and uncommon emergency. A healthcare provider’s ability to react prudently in an unexpected situation is one of the most critical factors in creating a positive outcome in an obstetric emergency. This emergency delivery pilot program prepares the life flight team and maternal transport team to successfully manage together this rare and unpredictable obstetric emergency through simulated training experiences that pose no risk to mother and infant.

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Proposed Change To develop collaborative emergency delivery training between the life flight and maternal transport crews. The life flight helicopter air-medical

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transport system was established at OSF Saint Francis Medical Center in June 1984. A maternal transport team dedicated to the care and transport of high-risk pregnant women was established in 1986. These two teams have come together to transport mothers with perinatal complications, or those at risk of premature delivery to a hospital that can provide a higher level of care. The crew configuration for obstetric transports includes one obstetrically trained registered nurse and one primary life flight registered nurse or paramedic. This interprofessional pilot program will provide this training.

Mary Ann Liner, APN, OSF Saint Francis Medical Center at Peoria and Illinois State University Student Health Services at Normal, Peoria, IL Mary Wheeler, RNC, BS, OSF Saint Francis Medical Center, Peoria, IL Mildred Elaine Shafer, APN, MSHA, MS-PSL, OSF Saint Francis Medical Center, Peoria, IL Joshua Croland, MD, OSF Saint Francis Medical Center, Peoria, IL

Implementation, Outcomes, and Evaluation Michael, R. Leonardi, MD, A pretest of 30 questions to document the par- OSF Saint Francis Medical ticipants’ knowledge of emergency delivery was Center, Peoria, IL

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12054



Brown, J. P. and Zaya, C.


administered. The average number of correct responses was 18.8 for the life flight team and 24.7 for the maternal transport team. The reference Amy L. Vandel, RNC, BS, OSF population for this collaborative includes 21 life flight nurses, one paramedic, and 15 maternal Saint Francis Medical Center, Peoria, IL transport nurses. James Michael Palmer, RN, OSF Saint Francis Medical Center, Peoria, IL

Keywords emergency delivery training simulation


The didactic segment includes five e-learning modules. These modules review strategies for emergency vaginal delivery management, correct application of interventions to manage vaginal delivery complications, infant stabilization, and relevant team communication tools. Data will be collected for prelearning and postlearning comparison.

Completion of the emergency delivery e-learning will be a mandatory requirement before participation in a helicopter in situ simulation. Using a standardized patient and partial obstetric task trainer, the aim of the simulation component will be to analyze the crews’ performance using reallife emergency delivery scenarios, detect areas of deficiency, and initiate performance improvements that will transfer to applied clinical practice. Implications for Nursing Practice Evidence-based guidelines exist for safe vaginal delivery practices. The challenge is to ensure that these guidelines are applied to every patient every time, regardless of whether the delivery occurs inside a hospital or en route to a hospital.

Implementing an Antepartum Epilepsy Monitoring Unit Leslie Diane Spagnol, MSN, Purpose for the program RNC, Magee-Womens Hospital The purpose of the epilepsy monitoring unit is to of UPMC, Pittsburgh, PA

provide a safe environment for pregnant women

Joyce A. Thompson, MS, BSN, on teratogenic antiepileptic drugs (AEDs) and reRNC, Magee-Womens search the maternal–fetal effects while doing so. In Hospital, Pittsburgh, PA the United States, three to five of 1,000 births are Keywords epilepsy monitoring unit epilepsy in pregnancy


from women who have a form of epilepsy. Many of these women take class D AEDs during their pregnancies. When clinically advantageous, women who take class D AEDs are converted in a controlled environment to an AED with less adverse fetal effects. Proposed Change Research indicates that AED drug conversion is done best in a monitored environment. Continuous fetal monitoring provides invaluable clinical information on fetal status while the AED drug conversion is taking place.

Implementation, Outcomes, and Evaluation The clinical team has established a multidisciplinary group consisting of neurology, maternal–fetal medicine, nursing, and administrative leadership to build the physical environment; identify training needs; and form policies, procedures, and best practices. The epilepsy monitoring unit is newly developed and ongoing evaluation is taking place.

Implications for Nursing Practice Knowledge for the clinical team has been broadened to include epilepsy in pregnancy, seizure management, and adverse effects of AEDs. Successful outcomes have already been achieved in a safe environment, which provides a model for other healthcare facilities.

Designing Adult Code Simulations for Antepartum and Postpartum Nurses Purpose for the Program o improve the ability of nurses in the postpartum and antepartum units to respond in the Claire Zaya, MSN, RN, event of a maternal code. Even very experienced IBCLC, Brigham and Women’s nurses expressed that though they knew how to Hospital, Boston, MA perform cardiopulmonary resuscitation, the maternal code experience was overwhelming and they felt unprepared.

pital collaborated to propose a simulation-based learning experience for the registered nurse (RN) staff of these units. Simulation-based learning provides an opportunity to practice skills in a safe environment while helping the nurse develop critical thinking skills, promote effective communication, and work collaboratively with other members of the team.

Proposed Change The leadership of the antepartum and postpartum units and the nursing simulation faculty at the hos-

Implementation, Outcomes, and Evaluation Over a period of months, the program faculty (simulation staff, nurse educators, and staff nurses)

Judy P. Brown, MSN, RNC, Brigham and Women’s Hospital, Boston, MA

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created two maternal code simulations. The final program involved three stages: skills sessions, simulated code scenarios, and debriefings. During the skill sessions the staff reviewed skills, such as use of the defibrillator, contents of the code cart, medications used in a code, and communication techniques. The participants toured the simulation lab before the actual simulation to see how the room was set up and how the manikin worked. When it was time for each scenario, participants were given role cards to remind them of critical activities during a code. The primary nurse received a report on the mock patient and the simulation started. One half of the group participated in each simulation whereas the other half watched the scenario on a live feed in a conference room. Immediately after each scenario a debriefing session took place. Consistent themes during debriefing included discussions about the role of the

nurse in a code situation, effective communication in an emergency, and the value of effective team work. Without exception, results of the 196 written evaluations indicated that staff nurses felt more knowledgeable and confident about adult codes after the simulation. Implications for Nursing Practice Based on the overwhelming positive feedback of simulation-based learning, the program was offered again the following year to all RN staff. Anecdotally, many nurses in the second year of the simulation program commented that they also felt more confident in other emergencies in the units after having participated in the maternal code simulation the previous year. The current plan is to offer simulation-based learning experiences to all RNs in the antepartum and postpartum units annually.

Keywords simulation maternal code antepartum postpartum


Patient-Centered Care of the Pregnant Patient with Diabetes Who Uses an Insulin Pump during Labor and Delivery Purpose for the Program ontinuous subcutaneous insulin infusion (CSII) pump therapy is associated with better quality of life and in some studies better glucose control than standard multidose insulin injections. A person with diabetes who uses an insulin pump for blood glucose management considers the insulin pump as a lifeline. Disconnecting from the insulin pump raises concern and triggers unnecessary anxiety. Most of our patients were told to discontinue their pumps on admission to the labor and delivery unit. Sometimes a physician would write an order to allow a patient to continue using the pump, which was problematic because no supervision of insulin delivery or assessment of the patient’s ability to manage the pump was taking place by nursing staff or physicians. The obstetricians were not familiar with the intricacies of dose adjustments and the need for quick, abrupt changes in dosage during the postpartum period.

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Proposed Change To partner with the director of our Diabetes and Obesity Institute and initiate a pump pilot program with tools and guidelines unique to the obstetric setting. The most important component of this patient-centric journey was use of an insulin pump agreement. Because these patients make daily insulin dose adjustments independently, it was critical to empower both the pump-using patient and nurse to form a partnership concerning insulin dosage during hospitalization. The agreement addressed the following key points:

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Showing the nurse bolus doses, basal rates, and changes. Frequency of infusion set and infusion site changes. Reporting symptoms of hypoglycemia and pump problems. Situations when the pump may need to be discontinued.

Implementation, Outcomes, and Evaluation Standardized orders for insulin pump therapy management in the intrapartum and immediate postpartum periods were developed, along with a medication administration record that allowed for documentation of basal rates and boluses. All pump patients have an endocrine consult to assess ability to manage self-care and determine postpartum dosage changes. Mandatory education sessions for all nurses, midlevel healthcare providers, and physician staff were provided by our diabetes nurse clinicians. The sessions addressed technical aspects of CSII pump therapy and the patient’s emotional connection to the pump. The nurse clinicians were notified when a patient using an insulin pump was admitted and assisted nurses and healthcare providers with any process issues. Data collection and outcomes evaluation are ongoing with changes being made as relevant.

Margaret T. Celenza, MSN, RNC-OB, C-EFM, Winthrop University Hospital, Mineola, NY Mary Lynn Brassil, MS, RN, CES, C-EFM, Winthrop University Hospital, Mineola, NY Virginia Peragallo-Dittko, RN, BC-ADM, CDE, FAADE, Winthrop University Hospital, Mineola, NY Jane Wendel, RN, BS, CDE, Winthrop University Hospital, Mineola, NY Linda Zintl, RN, BSN, CDE, Winthrop University Hospital, Mineola, NY Keywords continuous subcutaneous insulin infusion pump type 1 diabetes in pregnancy insulin pump patient agreement patient-centered care


Implications for Nursing Practice Nursing has been essential in the formation of a multidisciplinary team that partnered with other disciplines to provide safe, effective, and patientcentered care.

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12057


Maloof-Bury, P. A. and Russell, E.


“You Scratch My Back, I’ll Scratch Yours”: Reciprocal Intraprofessional Collaboration for OB Simulation Kathryn R. Alden, EdD, MSN, Purpose for the Program RN, IBCLC, UNC Chapel Hill imulation is a widely used educational stratSchool of Nursing, Chapel Hill, egy that promotes critical thinking and clinNC

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ical decision-making skills. It often is integrated into nursing school curricula, but more recently is used by hospitals to train nursing staff. Though intraprofessional simulation is a “hot topic” in education, there is minimal evidence of collaboraJennifer Taylor Alderman, tive simulation efforts within a profession. This MSN, RNC-OB, CNL, UNC program demonstrates how nursing school facChapel Hill School of Nursing, ulty can collaborate with medical center nurses to Chapel Hill, NC provide enhanced simulation experiences through Keywords sharing pedagogic and clinical expertise and simulation resources. Lisbeth Coulombe, JD, BSN, RNC-OB, NE-BC, UNC Hospitals, UNC Health Care, Chapel Hill, NC

intraprofessional collaboration


Proposed Change In this intraprofessional collaborative endeavor, experienced practicing nurses from UNC Hospitals assisted faculty from the UNC School of Nursing to facilitate six simulation cases for over 100 students per semester for three semesters. In a reciprocal manner, faculty assisted these nurses and their nurse manager to run case scenarios for the nurses who were new to obstetrics.

Implementation, Outcomes, and Evaluation The UNC School of Nursing has a high-fidelity simulation learning lab, which includes birthing and newborn simulators. The labor and delivery unit’s nurse manager asked to use this lab to ensure that her staff had quality training in recognizing and responding to obstetric emergencies. After visiting the simulation learning lab and observing nursing students participate in simulations, the manager and several experienced nurses collaborated with faculty to enhance the content and flow of the simulation scenarios. The nurse manager arranged for equipment and supplies to be provided to the UNC School of Nursing so that the simulation setting was more realistic.

Implications for Nursing Practice Intraprofessional collaboration is a win–win situation for nurse educators and nursing staff. The sharing of resources and expertise provides opportunities for realistic, simulated learning experiences.

Implementing a Birth Kangaroo Care Policy in Labor and Delivery: Bringing Evidence-Based Practice to the Bedside Paris A. Maloof-Bury, ADN, RNC-OB, IBCLC, ICCE, Community Memorial Hospital, Ventura, CA Elizabeth Russell, MSN, RN, FNP, Community Memorial Hospital, Ventura, CA Keywords birth kangaroo care breastfeeding family-centered maternity care change theory


Purpose for the Program he birth of an infant is one of the most meaningful experiences in a woman’s life. Birth kangaroo care (BKC), early skin-to-skin contact between mother and infant from birth until first breastfeeding is accomplished, is recommended by the American Academy of Pediatrics and many other organizations. Research shows that BKC provides physiologic and emotional benefits for both mother and infant. Newborn thermoregulation and blood glucose stabilization are enhanced when infants are kept skin-to-skin with their mothers. They cry less and breastfeed easier. Mothers report more confidence, stronger attachment, and distraction from discomfort when they hold their infants immediately after birth. Yet, despite the evidence, most hospitals still practice routine separation of mothers and infants. How can a team of nurses create a policy and change the culture of childbirth in a community hospital?

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Proposed Change Making BKC part of the labor and delivery unit’s normal routine requires more than writing a policy. It requires using change theory and evidencebased research to bridge the gaps between “the way we’ve always done it” and family-centered maternity care. This community hospital wanted to make skin-to-skin contact between mothers and infants part of their normal routine for vaginal and cesarean births. Implementation, Outcomes, and Evaluation By using evidence-based research, a team of nurses wrote a policy that made BKC the standard of care for vaginal and cesarean births. Key issues addressed in the policy include management of the third stage of labor while the mother maintains skin-to-skin contact with her infant; caring for the newborn (vital signs, medications, glucose monitoring, and bathing); time management; and providing BKC while caring for a patient who

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has had a cesarean delivery. In addition to logistics, change theories were used to deal with the resistance to change in practice and culture within the institution. Lewin’s Change Theory and Roger’s Diffusion of Innovation Theory were used to bring staff and physicians on board. While the policy was being implemented, management supported staff by ensuring ratios allowed nurses the time they needed as they adjusted to the change. Breastfeeding rates went up initially from 59% to

75%. Maternal satisfaction was enhanced as indicated from the positive letters, surveys, and inperson feedback. Implications for Nursing Practice Cultural shift within the unit was facilitated with Lewin’s concepts of unfreezing, moving, and refreezing and Roger’s concepts of early adopters. Implementing BKC benefited the families served and staff were empowered by the process.

Making the Most of Bed Rest: Weekly Support Group and Education for Hospitalized Antepartum Patients Purpose for the Program sychological sequelae associated with pregnancy bed rest have been well documented with hospitalized women’s reactions being more pronounced. Women quickly develop feelings of separation and isolation from their normal routines and usual connections with others. As a result, anxiety, boredom, powerlessness, stress, dysphoria, and depression may complicate an already high-risk pregnancy. Perinatal nurses can provide support as well as pregnancy-related education to these women. At this community hospital, with a large high-risk obstetric population and more than 3,500 deliveries a year, a support group for patients in the antepartum period is being used for socialization, to lessen anxiety, improve mood, and provide patient education.

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Proposed Change To develop and initiate weekly support group sessions on an 18-bed antepartum unit that will address commonly identified concerns with evidence-based education and support. Furthermore, to also develop a tool to collect data that identifies successful group topics and patients’ moods before and after group participation. Implementation, Outcomes, and Evaluation The perinatal clinical nurse specialist (CNS) identifies patients in the antepartum period who are able to attend the group session, requests a physician’s order, and then invites patients to attend. A multidisciplinary team within perinatal services is used to provide education for each one-hour

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“Moms in Waiting” group session, where the CNS or the perinatal social worker also is present. A structured activity or discussion occurs for part of the hour, with time left specifically for socialization among the group members. At the end of group a short Likert scale survey is administered to each participant.

Lisa Sharpe, MSN, RN-BC, CNS, Henrico Doctors’ Hospital, Richmond, VA Mary Barbot, BSN, RN, Henrico Doctors’ Hospital, Richmond, VA

Keywords Survey results for the first eight months provide an antepartum support group socialization overwhelming positive response to the group ses- education

sion. Ninety-eight percent of the attendees state they looked forward to attending the group session and 98% note enhanced mood perception after attending the group session. Participants frequently dress and apply make-up before the group sessions and the conversations in the sessions flow easily. Popular session topics, chosen by participant suggestions, include breastfeeding, infant massage, guided imagery, and neonatal intensive care unit (NICU) preparation. The postgroup survey currently is being amended to include additional markers for improved mood.


Implications for Nursing Practice Survey documentation should promote development of support groups in other antepartum settings. Currently at this hospital, patients in the antepartum period, as well as mothers in the postpartum period whose infants are in the NICU, are screened with the Edinburgh Postnatal Depression Scale (EPDS). Because perinatal mood disorders have been shown to correlate with poor maternal and neonatal outcomes, long-term goals include evaluating EPDS scores and mood disorders related to group attendance.

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12060


Smart, CJ, Glass, C., Smith, B., and Wright, M. E.


Lights, Camera, Save Lives! Impact of Low Budget, Low Fidelity Simulation to the Bedside Nursing Practice Johanah M. Carrera, BSN, RN, UC Irvine Medical Center, Orange, CA Keywords simulation critical access rural facility low frequency high-risk rare events


Purpose for the Program vidence has shown how simulation is an effective modality of teaching especially for adult learners. In a perinatal unit, where the level of nurse experience ranges from 1 to 30 years, the focus should not only be to determine the nurses’ skills and readiness to respond during a crisis but also on the ability of the nurses to be great team players and practice effective communication. Simulation, even on a low budget, would still help nurses prepare for high-risk rare events with an ultimate goal of a healthy mother and infant.

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Proposed Change To improve patient outcomes through evidencebased practice following a standardized process in an obstetric (OB) emergency or neonatal complication after birth. The proposed changes included role-specific functions and responses, initiating the chain of communication, improving teamwork, redesigning unit practice, and regular multidisciplinary simulations. Implementation, Outcomes, and Evaluation The first step was to send out an online questionnaire regarding simulation and high-risk rare events to evaluate what the nurses’ current view of such topics and to see if they were willing to participate in a simulation. The next step was to

create a calendar of dates and times to make the nurses want to participate with simulations. The schedule was one scenario per shift. Lowfidelity simulators and/or volunteers were used to make the simulations more realistic. Debriefing, through the evaluation of the recorded event, took place after the simulations were completed. It was then decided by the OB advisory that debriefings should be done on all OB procedures that were completed in our unit. In addition, protocols were revised and updated. New protocols were incorporated in our electronic medical record that also prompts documentation. Implications for Nursing Practice Staff’s perception of simulation has changed from a negative outlook to a positive outlook. They are aware that the environment of a simulation is safe and mistakes are allowed so that during a real event staff may be prepared and ready. Staff readiness was improved by using simulation to define the process, educate, assess competency, and improve teamwork and communication. The use of simulation for ongoing team evaluation will continue to reinforce these skills so that if a complication does occur this multidisciplinary team will be prepared to ensure the most optimal outcome. We are on our journey toward excellence in our nursing practice.

Nurse-to-Nurse: Implementing a Perinatal Loss Resource Nurse Program Purpose for the Program o describe a perinatal loss resource nurse program. A transdisciplinary team was formed to assess the needs and develop a standard of Chi Glass, RN, BSN, Mission Hospital System, Asheville, NC compassionate care for families experiencing a perinatal loss. As a result, a perinatal loss resource Brenda Smith, BSN, RN, nurse program has been developed to sustain Mission Hospital System, the work of the team by offering nurse-to-nurse Asheville, NC support in working with families who have experiMary Ellen Wright, MSN, enced a perinatal loss. CJ Smart, MSN, RNC, CPN, Mission Hospital System, Asheville, NC

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ARPN, CPNP, Mission Hospital System, Asheville, NC Proposed Change

To create and implement a team of nurses who share a mission for providing consistent, highquality care to patients that experience a pregnancy loss. A resource nurse is a registered nurse who functions as both a resource and change agent in a specialty area of nursing practice under


the guidance and support of a resource program coordinator. Resource nurses disseminate information and collaborate with nurses, physicians, other healthcare providers, and patients and their families to facilitate quality care in a specialized area of practice. Implementation, Outcomes, and Evaluation In order for this program to be successful, support from administration was essential. Program description and goals were discussed in detail with the managers. Once approval was obtained, interested nurses from the women’s service line were recruited. After the applicants were selected, an agenda for training was distributed. The foundation for preparing the nurses for their new role was a 2-day didactic certification using the Resolve Through Sharing (RTS) program. Part of the

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responsibility for maintaining resource nurse status was to complete individual projects that enhanced direct care to the patients. The themes of the interventions and projects include photography program, palliative care services, emergency department grief cart, education offerings for peers, tracking and ordering of supplies, and mother-to-daughter nurse mentoring. Implications for Nursing Practice Nursing involvement in developing projects and protocols that enhance care of patients increases adherence, confidence, and accountability in the

care in which they provide. Studies have shown that the physical and mental health concerns of families who experience a perinatal loss include grieving, potential for depression, and the risk of experiencing feelings of loss with subsequent pregnancies. The development of training programs to acquire competency in management of perinatal bereavement are necessary to prevent complicated grief and health outcomes related to ineffective coping. Implementation of a perinatal loss resource nurse program is one way to ensure patients experience the best care during this devastating time.

Keywords perinatal loss training programs bereavement


Healing Hearts with Time and Talent Purpose for the Program urses working in the maternal–child specialty are most challenged by bereaved families because they are the most vulnerable and needy in our care. Appropriate intervention can promote healing. By changing the nurses’ professional role from protective to supportive, interventions can focus on assisting the bereaved families make meaning of their loss. The creation of a program that finds ways to link time and talent offered by community members can be a win–win situation that benefits both groups.

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Proposed Change To enlist the aid of community groups and individuals who wanted to volunteer but were in need of direction to provide for those in need. The bereavement council from one labor, delivery, and recovery unit, with about 200 pregnancy losses per year, found difficulty with maintaining supplies for patient memory boxes. This group of nurses recognized the need to discover new resources to help. Implementation, Outcomes, and Evaluation Over the past 5 years, members of the bereavement council have uncovered numerous resources for assisting bereaved families. A local DJ started a program that provided an opportunity for the radio station listeners to make blankets and hats. A retired labor and delivery nurse

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joined forces with fellow nurses to create handsmocked dresses. Teenagers who needed to earn community service hours, scout troops, and local churches took on projects, such as decorating memory boxes and painting wooden ornaments. Several local photographers joined a national organization that offers families a photo session with their infant at no cost.

Kim L. C. Petrella, RN, Christiana Care Health Services, Newark, DE Cheryl Swift, BS, RNC-OB, MSN, Christiana Care Health System, Newark, DE

Keywords bereavement stillbirth The result of our community outreach program has memory box been an increase in available items for the memory healing boxes, which gives nurses the opportunity to per- grieving

sonalize the contents of these boxes for our families. Regular feedback with volunteers, which is offered through e-mail and phone calls, indicates what works and what does not work to further personalize our care.


Implications for Nursing Practice A renewed commitment to excellence is evident as our nursing staff delivers interventions that provide meaning to the tragedy of death, create a positive memory, and facilitate healing for parents who take home only a memory box. Many who have volunteered have shared stories of their own previous perinatal loss and indicated that through the process of helping others they have also healed themselves. Passion has been ignited in those who have the opportunity to help supply memory box items, evidenced by the generosity of community members and the beauty of the work donated.

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12063



Rice, D. L.


Check One, Check Two, Check Three. Implementation of a Shoulder Dystocia Checklist in the Labor and Delivery Unit Purpose for the Program houlder dystocia is an obstetric emergency that requires teamwork, effective communication, and collaborative documentation. The labor Robin Lynn Driver, RN, C-EFM, BS, Mount Carmel and delivery (L&D) unit is an area of high liability. Health System, Westerville, OH The shoulder dystocia checklist was designed to assist staff with management and documentation and, thus, improve patient safety. Keywords Pamela A. Foley, BSN, RNC, C-EFM, Mount Carmel East Hospital, Columbus, OH

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shoulder dystocia checklist


Proposed Change To implement a shoulder dystocia checklist to improve standardized management and collaborative documentation and, thereby, improve maternal and neonatal outcomes. Implementation, Outcomes, and Evaluation The nurse manager, clinical educator, and a physician champion developed a checklist. It was introduced to the L&D nurses during designated days of education so that they would have the opportunity to test the process. Staff provided feedback and the checklist was revised according to their suggestions. The checklist was placed in every L&D room in a specific location next to the infant warmer. During a shoulder dystocia, staff called for help and the checklist was immediately implemented to provide a standardized approach to management and collaborative documentation.

The checklist was used as a worksheet and was not a permanent part of the medical record. Postdelivery, the team (i.e., L&D registered nurse [RN], obstetrician, certified nurse–midwife, and neonatal intensive care unit RN) used the checklist to collaboratively document staff arrival times, maneuvers, and patient response to maneuvers. The checklist was trialed with positive feedback. The nurses had a vested interest because they assisted with the revisions. The checklist has been adopted system wide. The medical record shows improved adherence to standardized management and documentation consistency during shoulder dystocia emergencies. In addition, nurses have reported increased confidence with their roles and responsibilities during this critical event. Implications for Nursing Practice Risk factors for shoulder dystocia may be present, but shoulder dystocia cannot be predicted or prevented. Therefore, it is imperative that shoulder dystocia training and simulation drills be a focus of ongoing education in the L&D unit. The shoulder dystocia checklist is a valuable tool used to guide management and collaborative documentation during this emergency situation.

Implementing a Monthly Interdisciplinary Team Meeting to Promote Optimal Outcomes for High-Risk Obstetric Patients and Their Newborns Debbie L. Rice, RN, BSN, Purpose for the Program University of Oklahoma Health oordination of care for high-risk obstetric paSciences Center, Oklahoma tients and their infants is vital to promoting City, OK

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Keywords coordination of care interdisciplinary team collaboration optimal outcomes


optimal outcomes. When an obstetric patient receives a diagnosis of some form of fetal anomaly, she begins to receive close follow-up care and supervision. The patient also needs to obtain additional information about the fetal diagnosis and have questions answered. Information can be provided by prenatal consults with a neonatologist or other pediatric specialists that will be involved with the infant’s care after delivery and by other personnel, such as nurses, social workers, and hospital chaplains. A coordinated plan of care promotes the exchange of information between physicians and all other healthcare professionals involved in care of the mother and infant.


Proposed Change To develop a comprehensive plan of care for both mother and infant. Under the direction of an obstetric geneticist at the Oklahoma University Medical Center, an interdisciplinary team was developed. All staff that might be involved with planning and coordination of care were invited to the initial meeting. A discussion was held to review the basic format of the proposed monthly meeting. All in attendance agreed to the model. Implementation, Outcomes, and Evaluation A spreadsheet was developed to enter each month’s new patients. The data in the spreadsheet included basic demographic information, expected date of delivery, parity, fetal diagnosis, maternal issues, and the suggested plan of care.

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At each monthly meeting, each patient that was new to the system was discussed and ultrasound images were provided for review. Furthermore, the upcoming planned deliveries for the month were also discussed. This provided time for the multidiscipline professionals to come together and review complex cases to plan for the most comprehensive care. The monthly meeting has now been in place for 3 years and continues to evolve. It has been very successful in providing a venue for multidisciplined healthcare professionals to be informed of

the patients and provide their input into the plan of care. Implications for Nursing Practice Nursing leadership for women’s services and the neonatal intensive care unit (NICU) attend the meetings. A weekly updated case list is used to inform of patient delivery plans and potential admissions to the NICU. This knowledge can be communicated to staff as needed and used in considering availability of beds, staffing needs, and needs for specialized staff availability for certain deliveries.

Implementing an Obstetric Triage Nurse Competency Program Purpose for the Program he need for a method to validate the competency of the U.C. Davis Medical Center’s labor and delivery (L&D) triage nurses was identified during a visit by the United States Department of Health and Human Services (DHHS). Deficiencies in Emergency Medical Treatment and Active Labor Act (EMTALA) compliance were noted in both the emergency room and the L&D triage unit, and there was no documentation of training specific to triage for the L&D nurses. Additionally, the unit lacked a consistent method of assigning acuity as patients presented for care. Our project involved the creation and implementation of both an obstetric (OB)-specific acuity system, and a program to establish and validate the competency of the nurses from the L&D triage unit.

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Proposed Change A multidisciplinary committee was established and tasked with the development of a comprehensive program for the orientation, training, and ongoing competency validation of the L&D triage nurses. The L&D managers of other area hospitals were queried about their triage nurse competency validation tools and methods, and many quickly responded. We worked with the emergency room staff to develop an OB acuity system compatible with the Emergency Severity Index (ESI), a program already in use by the emergency room. The basic education and training requirements for the L&D triage registered nurses (RN) were delineated and some audit tools were developed: a medical screening exam competency assessment tool and an annual chart audit form. A stan-

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dardized procedure for the medical screening examination, performed by the L&D triage nurse, in compliance with EMTALA regulations, was written and approved. A spreadsheet was developed to verify the current status of the training of each of the L&D triage nurses. Implementation, Outcomes, and Evaluation Core L&D RNs attended the emergency department’s ESI training and became the trainers for the L&D staff. A PowerPoint presentation was developed, courses were scheduled, and all L&D triage staff attended a 2-hour training session on the use of the newly developed “Emergency Severity Index for OB.” Using the aforementioned competency validation tool, a trainer then tested each RN in his or her competency of a medical screening examination.

Carolyn A. Cook, MSN, RN-C, UC Davis Medical Center, Sacramento, CA Mandy R. Williams, BSN, RN, UC Davis Medical Center, Sacramento, CA Helena Veerkamp, RN, WHNP, UC Davis Medical Center, Sacramento, CA Keywords obstetric triage acuity competency


An Intermediate Fetal Monitoring course of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) was scheduled. All OB triage nurses who had not previously attended were enrolled. The new, five-tiered OB ESI acuity system was put into practice. These changes have allowed us to more efficiently triage and care for OB patients and improve documentation of the competency of our OB triage nurses. Implications for Nursing Practice The education and ongoing competency evaluation of OB triage nurses should be well documented. A standardized medical screening examination procedure and OB acuity system will enable OB triage nurses to improve patient flow and outcomes.

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12066



Kemplin, K.


Shhh! It’s Quiet Time From 2 P.M. to 4 P.M.: Our Family is Bonding Beyond This Door Leah Romine, BSN, RNC-OB, PHN, Torrance Memorial Medical Center, Torrance, CA Donna Yukihiro, MN, RNC-OB, CLE, Torrance Memorial Medical Center, Torrance, CA

Purpose for the Program reating a quiet environment in the mother– baby unit can be challenging. Literature suggests that implementing quiet time (QT) can increase patient satisfaction and promote healing.

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Proposed Change To initiate a QT program that would provide famAnnmarie Hext, ADN, ilies and their new infants an uninterrupted peRNC-MNN, CLE, Torrance Memorial Medical Center, riod to rest, bond, and breastfeed. The scores Torrance, CA related to a quiet environment from the Hospital Leah Klein, ADN, RNC-MNN, Consumers Assessment of Health Providers and Systems (HCAHPS) and feedback from mothers Torrance Memorial Medical Center, Torrance, CA who were discharged confirmed the need to reMartha Ortiz, ADN, RN, CLE, duce interruptions. QT was conceived after the Mother/Baby Shared Decision Making Council reTorrance Memorial Medical viewed the literature and current practice and Center, Torrance, CA identified potential solutions. QT is a daily 2-hour Keywords period in which no one may enter the patient’s quiet time room unless requested by the patient. breastfeeding patient satisfaction


Implementation, Outcomes, and Evaluation The Iowa Model for evidence-based practice and Kaizen quality improvement techniques guided the project. The typical number and timing of interruptions per day were observed to determine when the least amount of traffic was entering and leaving patient rooms. It was identified that the best time for QT was between 2 p.m. and 4 p.m. Implementation involved collaboration and coordination with several departments, and education

about the benefits of QT and its effect on daily routines. Changes in work routines for several services were required to avoid interrupting patients during QT. Letters were sent to physicians to describe the program and purpose of the change. The maternal–child staff was educated and a date was set for implementation. QT signage was created and displayed. Flyers were given out during maternity tours and childbirth classes, and were also distributed to patients on admission. QT was also advertised on the facility’s web site and in monthly publications. During implementation, meetings continued to discuss and resolve issues and promote full adoption. Since starting QT, positive feedback was obtained from followup phone calls with patients who were discharged and no complaints about interruptions have been received. HCAHPS scores for “patients room always kept quiet” increased from 70% in the fourth quarter in 2011 to 78% in the second quarter in 2012. Though it is not possible to conclude that QT increased exclusive breastfeeding, it may contribute to the increase in rates from 33% in January 2012 to 63% in July 2012. Implications for Nursing Practice New mothers need time to rest, heal, and bond with their infants. Providing QT each day can contribute to improved patient satisfaction and increased rates of exclusive breastfeeding.

Meeting the Challenges of Perinatal Bereavement Support Through Collaboration and Innovation Kathy Kemplin, BSN, RN, EFM-C, RTS, St. Elizabeth Healthcare, Edgewood, KY Keywords perinatal loss bereavement collaboration


Purpose for the Program o better meet the needs of the patient and families who experience perinatal loss and those of the staff providing care.

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Proposed Change To improve and expand the perinatal bereavement program in response to staff, patients, and community feedback. Implementation, Outcomes, and Evaluation The perinatal bereavement committee was expanded to include staff from labor and delivery, neonatal intensive care unit, mother–baby unit, genetic counseling, pastoral care, and nursing leadership. The committee identified opportuni-


ties for improvement in staff education, and the need to increase and improve processes for the respectful and individualized care of patients and infants. The existing process for burial was cost prohibitive for many families and confusing to implement. In response to these concerns, contact was made with the hospital’s Foundation to identify financial resources to make this service accessible to all families who experience perinatal loss. We partnered with community resources, such as The Alexis Foundation, Linnemann Funeral Home, the HEARTS peer led support group and volunteers, to provide improved quality of care and tools. Tools include handmade blankets and hats, memory boxes individualized for gestational age, PresHand carriers for the respectful transport and

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handling of these infants, and brochures to assist patients and families in their journey through the grief process. Nursing management provided encouragement and financial support for the development and implementation of education for all nursing staff.

Education and quality tools empower nurses to give individualized and respectful care to patients and infants. As a Magnet hospital, St. Elizabeth Healthcare continually focuses on the importance of collaboration and innovation to improve patient care and the enhancement of professional growth and development of nurses.

Implications for Nursing Practice Collaboration within the healthcare system and the community affects the care we give our patients.

Helping New Mothers and Newborns Sleep: An Innovative Sleep Support Program Purpose for the Program he goal of the Sleep Support program is to improve newborn/infant and maternal sleep opportunities by using a personalized education approach focused on evidence-based behavioral and environmental sleep hygiene adjustments.

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Proposed Change Families frequently voice frustration with newborn and infant sleep patterns, often holding unrealistic expectations or lack of understanding of expected sleep patterns during the day and night. Typical resources used for seeking sleep pattern information include the pediatric visit, popular books, and the Internet. The Sleep Support consultation offers parents an opportunity to speak by phone with a trained sleep counselor for targeted education. Anticipatory guidance, a supportive sleep plan that is designed in conjunction with family desires, and follow-up are provided. Implementation, Outcomes, and Evaluation New parents who were self-selected participated in the Sleep Support option. Once the consult request was initiated, families completed a detailed intake form outlining their infant’s current sleep habits, patterns, routines, environmental factors, and any medical, clinical, or feeding issues. The intake form served as an initial screening tool: infants with snoring, sleep apnea, severe reflux, severe eczema, or other clinical factors that affect sleep were referred to the pediatrician for treatment or clearance.

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The phone-based 45-minute consultation included the mother/parents and consultant. Other family members or caregivers involved in the infant’s care were invited to participate. Information about the sleep environment, newborn/infant sleep and feeding patterns, sleep safety, and maternal sleep hygiene were reviewed. Appropriate suggestions were designed into a sleep plan in accordance with the mother’s/parents’ situation and reasonable goals. A 15-minute follow-up call occurred within 1 to 2 weeks.

Nancy Holtzman, BSN, RN, IBCLC, CPN, Isis Parenting, Inc., Needham, MA Keywords newborn sleep maternal sleep postpartum depression


Continuous evaluation found that 90% of the participants felt the consultation provided increased understanding of infant sleep, sleep safety, environmental and behavioral sleep approaches, and consequently, had improved sleep for infant and mother. Evaluation methods included feedback during follow-up calls, survey scores, requests for additional consultations, referrals of family, and numerous unsolicited e-mails. Parents most often stated that the individualized approach was key to the success of the intervention. Implications for Nursing Practice Infant and maternal sleep is highly personalized. When areas for adjustment or improvement are identified and effective education provided, sleep health can be improved. Nurses are able to use their unique skills to assess and educate a family struggling with newborn/infant sleep and suggest individualized environmental and behavioral adjustments to improve overall sleep health.

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12069



Brassil, M. L. and Celenza, M. T.


Accurate Assessment of Blood Loss Saves Lives! Joni Scholz, MS, BSN, RNC, Samaritan Health Services, Corvallis, OR Keywords accurate assessment collaboration teamwork protocols simulation resources


Purpose for the Program very obstetric department works to provide safe outcomes for mothers and infants. Some smaller, community hospitals may not have optimal resources available around the clock to handle an obstetric emergency, such as a maternal hemorrhage, that requires massive transfusion. Increasing situational awareness can make a significant difference in preventing a crisis.

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Proposed Change Collaboration within a multidisciplinary team that provides patient care can facilitate changes to improve staff preparedness. This is done by implementing protocols that identify patients at risk of hemorrhage and guidelines to improve teamwork and communication. The proposed change was to ask staff to estimate the blood loss of each patient by weighing all blood soaked items during the postpartum recovery period, use an effective communication tool, and document accurately on a standardized form.

Implementation, Outcomes, and Evaluation With the support of management, a patient care model was implemented to provide better coverage where needs were identified. Department protocols provided guidelines that promote evidence-based care. A rapid response protocol was implemented that emphasized early activation, collaborative team response, and effective communication. Documentation was enhanced by the electronic medical record. Obstetric emergency drills, using patient simulators, were used to practice methods for accurately assessing blood loss. Implications for Nursing Practice Using a systematic approach of quantifying blood loss by weight helped to identify the inaccuracies of estimations. Once the problem was identified, staff were able to implement methods to facilitate the proposed change by supplying scales in all the postpartum recovery rooms and create a postpartum hemorrhage cart for rapid access to supplies needed in emergent situations.

The Tetralogy: Hemorrhage, Hypertension, DVT, Infection. Implementation of a Perinatal Safety Net Mary Lynn Brassil, MS, RN, CES, C-EFM, Winthrop University Hospital, Mineola, NY Margaret T. Celenza, MSN, RNC-OB, C-EFM, Winthrop University Hospital, Mineola, NY Keywords obstetric emergency team team STEPPS


Purpose for the Program regnancy and childbirth may unexpectedly become obstetric emergencies. The Centers for Disease Control and Prevention, National Center for Health Statistics reported that the rate of perinatal mortality in the United States has increased since 2002. Hypertensive disorders or hypertensive emergencies are the most common medical complication of pregnancy and the second leading cause of maternal death in the United States. Pulmonary embolism remains a leading cause of death after hemorrhage in New York State. Advanced maternal age, obesity, cesarean delivery, and significant chronic disease contribute to postpartum infection.

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Proposed Change To initiate a realistic screening process to identify obstetric patients at risk of hemorrhage, hypertension, thromboembolic events, and infection after delivery; enhance nursing and medical staff education regarding evidence-based standards of care; establish specific triggers for responding to changes in maternal vital signs and condition, and triggers for the activation of emergency re-


sponse teams; and furthermore, to conduct multidisciplinary obstetric emergency drills.

Implementation, Outcomes, and Evaluation A Team STEPPS approach established a process to identify obstetric patients at risk of hemorrhage, hypertension, thromboembolic events, infection, and the tetralogy of Fallot. Individualized plan of care, medications, and home care referrals were driven by physician orders and nurse handoff communication. Multidisciplinary education included evidence-based standards of care, specific triggers for responding to changes in maternal vital signs and condition, and activation of emergency response teams. Preeclampsia, eclampsia, and magnesium sulfate education also was provided in the intensive care unit and emergency department. Obstetric emergency drills that emphasized team goals, knowledge, mutual support, situation monitoring, and Situation-Background-AssessmentRecommendation communication were conducted using video playback to assist with debriefing.

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The medical rapid response team (RRT) quickly recognized it was imperative to collaborate with the obstetrics department to meet the physiological needs of women who are pregnant and in the postpartum period. The code H team (Hemorrhage) and obstetric crisis team (OCT) were established.

something is not right, the OCT and RRT respond via one phone call to the emergency operator. When the changing needs of the patient are identified quickly and a revised plan of care is implemented, a transfer to the intensive care area is frequently avoided and mother–infant bonding can continue.

Implications for Nursing Practice For obstetric emergencies (i.e., hypertensive emergency, seizures, cardiac compromise, change in patient status) or when the nurse feels

A shared mental model is the foundation of this multidisciplinary perinatal safety initiative. Recognizing early deviations in the plan of care and escalation of patient care needs have fostered teamwork and provide an obstetric safety net.

Beyond the Bundles: Tachysystole Surveillance and Management during Oxytocin Administration Purpose for the Program iterature has shown that oxytocin, a potentially dangerous intrapartum drug for both mother and fetus, has been associated with as much as a 30% incidence of tachysystole during its administration. This risk has been partially alleviated by the use of the Institute of Healthcare Improvement’s bundle methodology for safe initiation of oxytocin for labor induction and augmentation. However, the surveillance, documentation, and management of the tachysystole bundle component, after initiation, has been harder to effectively capture and needs additional exploration.

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Proposed Change We began with a compliance rate of 25.9% in 2008 and improved to a compliance rate of 97.8% (p > .001) as a result of our current process and outcomes initiative: “all or none” oxytocin safety flow sheet bundles. As a result, a subsequent innovative approach to tachysystole management and documentation during oxytocin administration was instituted by using education of the bundle and reliability of the sciences. After a meticulous literature review and assurance of best practices, the oxytocin administration protocol and the tachysystole algorithm were revised, and healthcare provider education was revisited.

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Implementation, Outcomes, and Evaluation A mandatory standardized physician/nursing surveillance and systematic documentation process, which took place every 2 hours, was established with default goals, and hard stop implications should noncompliance occur. A change of culture over time was sought after for sustainability purposes. The overriding goals of both educational and bundle/reliability approaches included safer oxytocin initiation and administration, tachysystole detection and management, and improved neonatal outcomes. Since January 2012, compliance with the induction of the Beyond the Bundles methodology has been 91.3%, with documented or defined tachysystole occurring in only 10.83% of cases. By using tachysystole as the denominator, meaningful intervention was accomplished in 91.86% of cases and only 3.49% of neonates had adverse outcomes.

Melanie Martin, RN, BSN, St. Luke’s Hospital, Allentown, PA Jan Holder, RN, St. Luke’s Hospital, Allentown, PA Ella Rios, RN, St. Luke’s Hospital, Allentown, PA Keywords tachysystole Institute of Healthcare Improvement’s bundle documentation hard stop


Implications for Nursing Practice In summary, to further lower the rate of tachysystole-related adverse neonatal outcomes, the opportunity to further increase awareness and education for both physicians and nurses alike can be done by using an obligatory and comprehensive oxytocin safety flow sheet before and during oxytocin administration, along with a focused tachysystole management protocol. This will be a design worthy of consideration in reducing adverse effects from this high-risk medication.

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12072



Webber, E. and Cecil, J.


Who Wants to Play With Dolls? Implementing a Collaborative OB Simulation Program to Improve Patient Safety Purpose for the Program bstetric emergencies are low volume but extremely high risk with potentially devastating outcomes. The purpose of this program is to Janet Hooper, RNC, BSN, MA, provide a more structured approach to simulation LCCE, Inova Fairfax Hospital training in the obstetric department and improve Women’s Services, Falls patient safety through real time feedback. The moChurch, VA bile obstetric emergency simulator (MOES) proKeywords vides us the opportunity to simulate in the actual simulation location of the event compared with an offsite locaMOES tion. In addition, this program results in decreased communication patient safety events as well as enhanced teampatient safety work among nurses and physicians. Tracy Rickard, RNC-NIC, BSN, NNP, Inova Fairfax Hospital Women’s Services, Falls Church, VA


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Proposed Change All physicians and nurses participate in simulation training using the MOES system led by a team of physicians and nurses working collaboratively. The MOES system gives us the ability to transfer the training simulator to an actual patient room where simulation of specific obstetric emergencies can then be played out in a more realistic environment. This program brings the simulation directly to the bedside unannounced and unscheduled, which further enhances a realistic emergency environment. The program consists of case scenarios that specifically involve high-risk situations to include postpartum hemorrhage, um-

bilical cord prolapse, shoulder dystocia, and maternal code. Implementation, Outcomes, and Evaluation The MOES system includes a mannequin as well as a mobile electronic cart that houses a monitor that can be programed for real time viewing of maternal and fetal vital signs. Each participant completes an online education module before attending the course. Once in the course, each participant then participates in hands-on skills stations before the actual simulation event. Following the simulation, a debriefing takes place where the participants submit feedback through an audience response system. Outcomes include decreased adverse events and enhanced collaboration and teamwork based on the Safety Attitudes Questionnaire. Outcomes also include increased physician and nurse satisfaction. In addition, policy changes and additional training needs are identified during the simulation session. Results are communicated throughout the division. Implications for Nursing Practice The staff members who participate in the simulation program have demonstrated more effective communication and collaboration. The nurses have gained increased confidence in responding to unexpected emergencies related to maternal and fetal complications.

Implementing a Perinatal HIV Testing and Treatment Program Elaine Webber, DNP, Purpose for the Program PPCNP-BC, IBCLC, University erinatal transmission of HIV is the most comof Detroit Mercy, Detroit, MI Janice Cecil, BSN, RN, Botsford Hospital, Farmington Hills, MI Keywords perinatal HIV neonatal transmission


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mon route of HIV transmission in children. Infection can occur late in the pregnancy, during delivery, or through breastfeeding. Nearly one in four women who are infected with HIV are unaware of their HIV status. Many cases of perinatal HIV infection involve women who were not tested early enough in pregnancy or who did not receive prevention services. This presentation describes the development of a comprehensive HIV testing and treatment program for pregnant women in a community hospital.


Proposed Change Our maternal and child health department experienced a missed opportunity regarding an HIV-positive woman, an all too frequent event nationwide. The patient came to the hospital with incomplete laboratory test results. Subsequent tests for a high-risk patient were conducted after the infant showed signs of illness, which indicated a preliminary maternal positive-HIV test result. Despite the test result, notes indicate the infant breastfed during the postpartum period. This event exposed gaps in the department’s management of high-risk obstetric patients. A task force was convened to develop a comprehensive HIV management plan. Working with the Department of Community Health

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to ensure the plan incorporated state recommendations and statutory requirements, a new interdisciplinary plan was developed, which addressed areas of inadequate maternal assessment, poor data gathering and documentation, and delayed treatment options.

tation were between 75% and 90% compliance. To address areas of lower compliance, ongoing education regarding HIV testing, treatment, and documentation is currently included in the department’s mandatory education program for all staff and continued audits are ongoing.

Implementation, Outcomes, and Evaluation A new policy, HIV Testing and Treatment, was written to address the revision of documentation and legal consent issues regarding HIV testing. To reduce procedural errors, an algorithm, Hospital Responsibilities for HIV Testing and Treatment, was developed and all department personnel attended in-services on the algorithm. After the implementation of the policy, audits were conducted to evaluate compliance with the protocol. Initial review indicated 100% compliance with HIV documentation on the labor and delivery summary sheets. Other areas of documen-

Implications for Nursing Practice The Centers for Disease Control and Prevention (CDC) reports that 100 to 200 infants in the United States are infected with HIV annually. Given that the most common route of transmission in infants is through the mother, it is imperative that hospitals comply with state guidelines for testing and treatment of all pregnant women. Maternity nurses must be aware of the importance of early HIV status identification for all pregnant women and follow-up with appropriate care for mother and infant.

The Electronic Medical Record in Our L&D: Working Out the Kinks Purpose for the Program nnovative technology has resulted in the emergence of the electronic medical record (EMR) as the standard in healthcare documentation. Our labor and delivery (L&D) unit witnessed many positive changes since implementing an EMR. Patient information that may have a significant effect on our plan of care for a patient could have been omitted on the paper medical record. Healthcare professionals no longer struggle to interpret illegible entries. This improvement positively influences patient safety.

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The program used in our L&D unit, Stork, is a product of Epic. Many nurses, accustomed to reviewing a paper chart to ensure that all expected components of that record were present and complete, have encountered some challenges. In Stork, nurses navigated the chart in many different directions. This approach allowed for important sections of the chart to be overlooked. Documentation deficiencies that could easily be spotted before the use of EMR were easily overlooked in the electronic system. This EMR system made it challenging for the departing nurse to systematically inspect her documentation for flaws. Many hours were spent reviewing charts and discussing the challenges at unit meetings. Improvement was often fleeting, only to have the same defects arise again, which required more time educating and reminding staff via e-mails. Our nurses needed two things: (a) a list

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of required documentation and (b) a standardized Kathleen Gorman, BSN, order for gathering and recording the information. RNC-OB, C-EFM, The Christ Hospital, Cincinnati, OH

Proposed Change Keywords To implement a list of required documentation and checklist a standardized order for gathering and recording deficiencies electronic medical record the information. bedside report

Implementation, Outcomes, and Evaluation A report checklist was created. Report in our unit is given at the bedside to include the patient and family during this exchange of information, allow correction of information, and reinforce the plan of care in the minds of all present. During report, both incoming and outgoing nurses review all components of the Stork chart listed on the checklist. The nurse handing over care, aware of deficits in the record, can correct incomplete documentation in real time.


Implications for Nursing Practice The goal of this initiative is to standardize the order in which assessment data are reviewed during report and reveal opportunities to correct deficiencies. In addition, cost savings should occur as the hours spent reviewing charts, formulating action plans for improvement, and re-educating staff will be reduced. Daily reinforcement of the actions required by the registered nurse (RN) when caring for our patients (specifically monitoring and documenting a patient’s temperature every 2 hours after rupture of membranes) will improve safety.

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12075



Tyson, R. L.


Preterm Birth Prevention: Marrying Centering Pregnancy and Community Health Workers Amy McKeever, PhD, RN, Villanova University, Lafayette Hill, PA Keywords preterm birth centering pregnancy community health workers


Purpose for the program o test a new model of coordinated and enhanced services for pregnant women, beyond traditional prenatal services, to improve perinatal outcomes for high-risk low-income women on Medicaid. The goal is ultimately to reduce the risk of preterm births and improve health outcomes for infants in the first year of life. The innovative collaborative interdisciplinary program is designed to improve patient care and coordination, improve maternal and perinatal health outcomes, and ultimately, reduce healthcare costs by using a centering model of care. The proposed project has selected areas of high risk and high need that are served by different healthcare delivery systems where preterm birth statistics are alarming.

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Proposed Change To transform existing models of prenatal care to centering models of health for improved maternal and perinatal health outcomes and reduced healthcare costs. Implementation, Outcomes, and Evaluation Low-income pregnant women will be identified by their Medicaid provider and prenatal care provider. By using the components of Rising’s Centering Pregnancy Model, participating prenatal care Federally Qualified Health Centers (FQHCs) with advisory support from an academic setting will implement and support the Center-

ing Pregnancy group education model of enhanced prenatal care. Four FQHCs will participate in the transformation of a traditional medical model of prenatal care to a centering model of care; women who are pregnant will be enrolled in the centering program. All pregnant clients will be partnered with a culturally and linguistically appropriate trained community health worker that will serve as the client’s pregnancy peer mentor. Data will be extracted from the FQHCs and tracked for perinatal health outcomes, healthcare utilization and costs, care coordination, and birth outcomes. Implications for Nursing Practice Preterm birth is a critical public health problem in the United States. Preterm birth is a complex, multifactorial process that accounts for 12% of all live births and more than 500,000 premature births annually. One in eight infants born in the United States are premature. Infant prematurity is the leading cause of neonatal death in the United States and is responsible for 27% of infant deaths, or one million infant deaths annually. Prematurity is the leading cause of death among African American newborns as compared with non-Hispanic White newborns. The centering pregnancy model of care, primarily used in midwifery care centers has demonstrated reductions in preterm birth. The implications for improved maternal–child outcomes are vast.

Where’s the Lactation Consultant? Increasing Exclusive Breastfeeding Rates by Empowering L&D Nurses Rana L. Tyson, BSN, RNC-OB, Purpose for the Program Baylor University Medical reastfeeding is widely recognized as the Center, Dallas, TX Keywords exclusive breastfeeding lactation support Baby Friendly Joint Commission quality measurement labor and delivery


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ideal method of feeding infants. An objective of Healthy People 2010 was for 75% of infants to be exclusively breastfed upon hospital discharge. Currently, breastfeeding rates in the United States have not met this goal. Baylor University Medical Center (BUMC) implemented a program that focused on increasing exclusive breastfeeding rates (EBRs).

Proposed Change There has been a significant increase in BUMC’s EBR because of nurse and patient education, nurses’ hands-on assistance with breast-


feeding initiation, and the labor and delivery (L&D) nurses role as bedside breastfeeding advocates. Implementation, Outcomes, and Evaluation An International, Board Certified, Lactation Consultant (IBCLC) at BUMC championed a project that filled the gap in lactation support, which is given to patients throughout the Women’s and Children’s service line, by creating the crew. The crew consists of nurses that underwent training and were committed to serving their individual unit’s needs regarding breastfeeding. The L&D crew is addressing barriers to breastfeeding on our unit and is implementing changes to overcome

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these challenges. In particular, we re-purposed a patient breastfeeding education sheet used by the lactation department. By adding the breastfeeding education sheet to our electronic system, it prints with the chart and is readily accessible to staff. Also, crew members are assessing attitudes and comfort levels of L&D nurses regarding lactation support by using an online survey. Once survey results are analyzed, in-services and staff education will be implemented that focuses on topics such as hand expression of colostrum and spoon-feeding, skin-to-skin contact, breastfeeding in the operating room, use of breast pumps, and breast milk storage. Implementation of the crew in L&D has already made an impact on our EBR, increasing the rates from 41% to 72%.

Follow-up from the online surveys will hopefully further increase the EBR rate. Implications for Nursing Practice Increasing the EBR is a Baylor Healthcare System goal, prompted by Medicaid reimbursement policies, The Joint Commission quality measurement tools, and the Baby Friendly designation that BUMC is working to achieve. This innovative project will increase the EBR at our institution by empowering BUMC nurses to be champions of excellent care of women and newborns. By exclusively breastfeeding, our patients will take part in one of the most highly effective preventative measures a mother can take to protect the health of her infant and herself.

All Clear: Improving the Code Process Purpose for the Program he simulation facilitators at Baylor University Medical Center recognized the need to create best practice surrounding maternal codes; therefore, a new process for annual Mock Code was developed that used the concept of simulationbased learning.

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Proposed Change For the past 5 years our facility used simulationbased learning that focused on high-risk obstetric events; however, we still performed Mock Codes on the unit in a didactic type format with skills check-off. Following a maternal code on our unit, we incorporated simulation concepts with a hands-on approach, which focused on documentation, communication, full use of the defibrillator, and crash cart knowledge. Implementation, Outcomes, and Evaluation Because maternal codes are rare, staff were not comfortable with the different aspects of the defibrillator/automated external defibrillator (AED). In addition, staff were not accustomed to using the code documentation sheet. The Perinatal Simulation Team developed an anaphylactic syndrome of pregnancy or amniotic fluid embolism (AFE) scenario and recorded it. Using this video, we were able to debrief our entire staff regarding the processes they viewed. Initially, we made them serve as the documenter and record what they observed

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as the video played. We then had them discuss and compare documentation to gain an understanding of the importance of speaking up to ensure all necessary information is gathered during a code. Then we reviewed the tape again, this time debriefing the scenario and addressing teamwork, communication, and technical skills. Following this discussion, we ran a simulation scenario that mimicked what they just watched. They had to perform CPR, place the pads from the defibrillator/AED and deliver shock as advised, print the EKG strip from the defibrillator, change from AED mode to defibrillator mode, increase joules as requested, draw up code medications, retrieve any necessary equipment or supplies from the crash cart, prepare for a STAT bedside delivery, document the code events, and communicate appropriately to the medical team. Our training increased staff confidence, knowledge of the crash cart and defibrillator, and awareness of communication needs during the maternal code.

Kristin Scheffer, BSN, RNC-OB, C-EFM, Baylor University Medical Center, Dallas, TX Christine Renfro, BSN, RNC-OB, C-EFM, Baylor University Medical Center, Dallas, TX Keywords simulation maternal code safety anaphylactic syndrome of pregnancy competencies


Implications for Nursing Practice When applying the science of simulation by creating a unique learning experience, nurses’ confidence level, knowledge, and skills in recognizing the signs and symptoms of AFE can be improved. The use of simulation also improves the nurses’ ability to use the defibrillator, draw up code medications, serve as documenter, and effectively use closed-loop communication in a code situation.

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12078



Simpson, E. and Culp, S.


An Innovative Approach to Addressing Anemia in the Perinatal Patient John Lanier, MS, RN, NE-BC, Trinitas Regional Medical Center, Elizabeth, NJ Keywords prenatal anemia urban setting managing care


Purpose for the Program regnancy related anemia is a common occurrence in today’s healthcare environment. Many factors come into play, such as less than optimum nutritional intake, everyday demands on women, and self-care deficits. These factors are magnified in the urban setting where limited fiscal and human resources exist. Managing patient care through the continuum, from the prenatal period through the postpartum period, is essential to ensure optimum patient outcomes and efficient use of the limited resources available.

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Proposed Change Changing the process by which patients with prenatal anemia were managed was essential to improve outcomes and decrease the use of resources during the postpartum period. This urban hospital developed a process in which patients with downward trending hemoglobin (70%) were rooming-in with their mothers. There was concern on the part of the staff that the new mother–baby care delivery model would be blamed for the increased rate in falls. The hospital had also recently purchased new beds that may have been contributory to the increased rate in falls because the side rails were not as high when the head of the bed was elevated.

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Proposed Change To fully evaluate contributory factors related to infant falls in the mother–baby unit and develop safety strategies to reduce/eliminate infant falls by instituting a Newborn Safety Partnering Agreement for Parents. Implementation, Outcomes, and Evaluation An increased rate of infant falls in the mother–baby unit prompted review to identify potential contrib-

utory factors, which included exhaustion of the mother after delivery, bedside rail position, too many pillows, timing and type of pain medication, cultural issues, and unsafe parental behaviors. A query was sent out to the NY Organization of Nurse Executives list serve, which requested any infant fall prevention programs that were successful. The query and literature review yielded minimal results. An infant safety checklist was developed to include awareness for potential falls. Based on feedback, the checklist evolved into a Newborn Safety Partnering Agreement for Parents and fall debrief tool to be used after a fall to immediately identify contributing factors. The premise behind the partnering agreement was to increase parents’ awareness of the potential of an infant fall beyond traditional patient education. The tool is used to educate and ask parents to partner with staff to keep their infant safe. A pilot to evaluate effectiveness was conducted. Minor changes to the tool and implementation of the agreement in the delivery room before delivery proved successful. Since the implementation of the Newborn Safety Partnering Agreement for Parents there have been no infant falls to date. Implications for Nursing Practice Implementation of a Newborn Safety Partnering Agreement for Parents on the mother–baby unit raises awareness to prevent infant falls and injury.

Are You Ready for the Change? Embracing the Neonatal Resuscitation Program Guidelines of Simulation and Debrief Purpose for the Program hange is an inevitable, ongoing process in the healthcare profession. When significant Theresa Rollo, BSN, RNC-OB, practice changes occur, opportunities present for Christiana Care Health System, nursing leaders to champion innovative methods Newark, DE for overall performance improvement. The Neonatal Resuscitation Program (NRP) has offered a Keywords standardized approach to the teaching and pracperformance improvement innovative methods tice of neonatal resuscitation since 1987. This change program has more than 27,000 instructors who simulation train more than three million healthcare providers. debrief NRP guidelines were updated in 2010 through evidence-based practice that revealed a need for new teaching methods. Two labor and delivery Newborn Care nurses recognized the chance to revamp the way Poster Presentation NRP was taught within their level III tertiary facility. Cheryl Swift, BS, RNC-OB, MSN, Christiana Care Health System, Newark, DE

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Proposed Change Traditionally, NRP instructors have conducted classes through a lecture, video, testing format, followed by a megacode to practice skills. The current changes by the American Academy of Pediatrics to the NRP guidelines have brought about a new education methodology. Instructors need to shift their roles from teachers to facilitators; which requires new skills for successful education. Each instructor previously had his/her own style of teaching, emphasized different points of NRP, and held megacodes that did not always offer the most effective cognitive, technical, and behavioral skills necessary for newborn resuscitation. The proposed change includes standardizing two to three scenarios of infant resuscitation,

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practicing together as an instructor group, and learning how to be less of a teacher and more of a facilitator so that participants will assume more of the responsibility for their own learning.

mately optimize improvements in the acquisition of improved performance in neonatal resuscitation. Staff and participants will be surveyed regarding their experience in this updated learning format.

Implementation, Outcomes, and Evaluation Initially, three standardized resuscitation scenarios were created. Next, a workshop for all unit NRP instructors was scheduled. Instructors were able to practice together and learn how to become effective facilitators of education. Proposed outcomes include successfully bringing current NRP instructors together, establish momentum for change, refocus on the fundamentals of neonatal resuscitation, increase the challenge for participants by their biennial NRP experience, and ulti-

Implications for Nursing Practice The main goals for nurses are to create a consistent learning atmosphere, equally stimulating for all participants, led by a core group of instructors. The instructors use adult learning methods to optimize improved performance in neonatal resuscitation, which promotes safe, reliable practice. Finally, the program empowers program participants to champion excellence in the care of newborns.

Baby Steps: One Hospital’s Quest to Improve Its Breastfeeding Practices Purpose for the Program hough numerous research studies show the positive effect of the United Nations International Children’s Emergency Fund (UNICEF)/World Health Organization (WHO) Baby Friendly Hospital Initiative on breastfeeding rates, only 143 hospitals in the United States have undertaken the necessary steps to become Baby Friendly. In the current economic climate, some hospitals may be concerned about potential costs, including refusing free formula, and others may face cultural or institutional barriers to full implementation.

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In 2011, Huntsville Hospital for Women & Children began an initiative to improve its breastfeeding practices. Alabama has the fourth lowest breastfeeding rate in the nation, with less than 60% of infants ever having been breastfed. At Huntsville Hospital, about three-fourths of women intend to breastfeed (similar to the national rate). To support these mothers, hospital leaders decided to advance breastfeeding practices to be in line with the Baby Friendly Hospital Initiative and evidencebased practice. Proposed Change Using the Baby-Friendly steps as guidelines, a committee of interested staff and leaders from the postpartum unit planned and implemented a series of interventions focused on breastfeeding. Implementation, Outcomes, and Evaluation Staff members were first surveyed about breastfeeding knowledge and education ability. Survey data were used to create a mandatory full-day course for all unit nurses that focused on areas where staff needed further education.

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Additional steps undertaken by the unit included replacing the patient discharge bags that display the formula company with bags that contain the hospital logo, increasing lactation consultant hours on the unit, creation of a unit-specific breastfeeding booklet for staff, changing the infants’ intake/output sheet to include breastfeeding education for parents, and to not distribute pacifiers unless specifically requested by parents. Preliminary data indicated that the breastfeeding course objectives were met and patient satisfaction scores related to breastfeeding assistance were high. Despite the hospital’s initial successes, it still faces many challenges in its quest to implement all 10 steps of the Ten Steps to Successful Breastfeeding as outlined by the Baby Friendly Hospitals Initiative. In a state with traditionally low breastfeeding rates, barriers include getting families to room-in with infants, encouraging physicians’ infant assessments and other interventions to be performed in patient rooms, increasing funding for lactation consultants at night and on weekends, looking at ways for mothers who had a cesarean delivery to breastfeed their infants within 1 hour of delivery, and implementing breastfeeding support groups. Implications for Nursing Practice Increased staff knowledge, high patient satisfaction scores, and movement toward compliance with the Baby Friendly Hospital’s Ten Steps to Successful Breastfeeding are all positive signs of improved breastfeeding practices at Huntsville Hospital. Other hospitals that want to work toward Baby Friendly practices can learn from Huntsville’s successes and continued challenges in improving its breastfeeding policies and practices.

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12097

Cindy Gatlin, RN, Huntsville Hospital for Women and Children, Huntsville, AL Bonnie Rausch, RN, Huntsville Hospital for Women and Children, Huntsville, AL Rose Mary Ainsworth, RN, MSN, Huntsville Hospital for Women and Children, Huntsville, AL Linda Maetzold, RNC, MS, LCCE, Huntsville Hospital for Women and Children, Huntsville, AL Cathy Mog, RN, Huntsville Hospital for Women and Children, Huntsville, AL Shelley Summerlin-Long, RN, MPH, MSW, Huntsville Hospital for Women and Children, Huntsville, AL Keywords breastfeeding Baby Friendly patient education

Newborn Care Poster Presentation


Kreiner, E. J., Schroeder, T., and Hopkins, C.


Preventing a Broken Heart: Critical Screening for Congenital Heart Disease Marianne Allen, MN, RNC-OB, CNS, Pinnacle Health System, Harrisburg, PA Stacy Chubb, BSN, RNC-MNN, Pinnacle Health System, Harrisburg, PA

Purpose for the Program o develop an interdisciplinary program of universal screening for congenital cardiac heart disease (CCHD) based on the 2011 American Academy of Pediatrics recommendations for the 4,000 term and late-preterm infants cared for in our mother–baby unit.

Before implementation of this evidence-based practice change, only symptomatic newborns had screening and diagnostic evaluation. Through the CCHD screening program, all newborns receiving care in the mother–baby unit benefit from early screening to determine the risk of CCHD. Based on positive-pulse oximetry screening, infants at risk receive a predischarge diagnostic echocardiogram and evaluation by a pediatric cardiologist, with follow-up as indicated.

for positive-pulse oximetry screens; revised documentation forms to include CCHD screen/referrals; developed patient teaching guidelines and written education materials; and established the communication of the results to the newborn’s primary care provider. This collaborative initiative resulted in a change in the standard of practice to improve the outcomes and safety of newborns that may be at risk of morbidity and mortality due to unknown cardiac factors. Screening through pulse oximetry provides an inexpensive, noninvasive tool to identify newborns with structural heart defects, which usually are associated with hypoxia and physiologic changes in the newborn period that could have significant sequelae. Parents receive education about CCHD and the importance of postscreening follow-up with primary care providers or pediatric cardiology based on the results of the newborn CCHD screen.

Implementation, Outcomes, and Evaluation An interdisciplinary committee of physicians, nurses, and advanced practice nurses met to review the literature, evaluate current practice, and develop plans for implementation of CCHD risk identification and referral for diagnostic and cardiology follow-up. Implementation strategies included the following: developed a policy for newborn CCHD screening; revised preprinted order sets/protocols; developed procedure for pulse oximetry screening; completed physician education, nurse education, and competencies related to the screening program; obtained additional equipment; established the coordination of diagnostic echocardiogram and cardiology referrals

Implications for Nursing Practice The CCHD screening program is an example of interdisciplinary collaboration among nursing, medicine, and cardiology for universal identification, early diagnosis, and management of asymptomatic newborn cardiac pathology to prevent morbidity and mortality. Through assessment, pulse oximetry screening, and patient teaching, nurses are integral to the safety and wellbeing of newborns. This timely implementation of the 2011 American Academy of Pediatrics CCHD recommendations promotes the organization’s mission of patient safety and can be a model to others for establishing CCHD screening programs.

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Keywords critical congenital heart disease Proposed Change CCHD screening


Their Hearts in Our Hands: Implementation of Screening for Critical Congenital Heart Disease in a Level I Nursery Enid J. Kreiner, MSN, RNC-MNN, C-EFM, Hanover Hospital, Hanover, PA

Purpose for the Program he purpose of this presentation is to describe how we have been able to implement pulse oximetry screening for critical congenital heart diseases (CCHDs) in our level I nursery through the use of an evidence-based tool kit, which was developed by the Children’s National Medical Center (CNMC). Universal CCHD screening has been endorsed by the American Academy of Pediatrics, the United States Department of Health and Hu-

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man Services (HHS), the National Association of Neonatal Nurses (NANN), other prominent healthcare organizations, and grassroots efforts by families of children who have been affected by CCHD. Many infants who suffer from CCHD are asymptomatic and may experience developmental delays, sudden onset of symptoms, or even unexpected death. Pulse oximetry is a noninvasive screening tool, which has great potential to reduce both morbidity and mortality in the newborn

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population. Many states have passed legislation that requires that CCHD screening be offered by hospital nurseries, but it is not yet mandated in Pennsylvania. Though we are a small community hospital, it is our hope to be a leader in the promotion of good health in our community. Proposed Change All neonates born at Hanover Hospital will be screened for CCHD unless the procedure is declined by the family or the neonate is transferred to another facility. Staff are trained to perform screening according to guidelines described in the tool kit. Women giving birth at our facility and their families are informed of the CCHD screening in childbirth education classes, written educational materials, and through bedside teaching with our nursing and pediatric medical staff. Data gathered will be shared with CNMC pending approval of the director of Hospital Information Management.

Implementation, Outcomes, and Evaluation The staff was trained to use the equipment and educated on evidence that supports screening. Screening was implemented in March 2012. To date, of the 292 neonates that have been screened, one had a positive CHDD test result and was referred for outpatient follow-up.

Tiffany Schroeder, BSN, RN, Hanover Hospital, Hanover, PA Carol Hopkins, BSN, RN, RNC-OB, Hanover Hospital, Hanover, PA

Keywords newborn screening Implications for Nursing Practice critical congenital heart disease Neonates cared for at our facility are screened (CCHD) for CCHD using the most current guidelines. pulse oximetry

In response to initial misinterpretations, the electronic medical record has been modified to actively prompt the end user to rescreen, report, or conclude screening based on the data entered. It is hoped that through the collaboration to share our data with CNMC, our relationship may evolve and facilitate additional sharing of knowledge.


The Float Nurse: Promoting Safety and Support at Delivery and Beyond Purpose for the Program erinatal units are challenged with providing the nurse-to-patient ratios recommended by the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). For uncomplicated births, one nurse should be assigned to the mother and another to the newborn. Healthy mothers and infants belong together, and separating them can disrupt early mother and infant interactions and affect breastfeeding. Our goals to align with Healthy People 2020 and the Baby Friendly Hospital Initiative’s Ten Steps to Successful Breastfeeding motivated us to develop a program that would allow us to meet these goals.

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Proposed Change To promote early skin-to-skin contact between mother and newborn, eliminate or reduce separation of mothers from healthy stable infants, and promote early initiation of breastfeeding, we proposed to pilot a role for select nurses in our department called the float nurse. The float nurse acts as an advocate and liaison between the family, labor and delivery staff, mother–baby staff, and healthcare providers. The float nurse is present at uncomplicated vaginal deliveries and meets the AWHONN standard of being the nurse assigned to the newborn. She provides initial breastfeeding and newborn education as well as performs the initial physical assessment. The float nurse transitions the mother and infant together from the labor and delivery unit to the mother–baby unit.

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Implementation, Outcomes, and Evaluation A departmental task force consisting of leadership, clinical specialists, healthcare providers, and nurses met to develop the float nurse pilot. They obtained a baseline survey of current patient satisfaction, breastfeeding initiation rates, and quality of breastfeeding assistance. The department task force then determined the skill set required and identified potential float nurse participants. The 2-week pilot enlisted six registered nurses with 24-hour nurse coverage. The float nurse carried a cell phone and was contacted by the labor and delivery nurse when a birth was imminent. Despite a much higher than average birth rate during the pilot period, participating nurses were able to survey each participating mother. Preliminary survey results showed improved patient satisfaction, breastfeeding initiation rates, and quality of breastfeeding assistance. We proposed that positions be budgeted for FY 2013 to continue with this model of care.

Marianne D. Bittle, BSN, RNC-OB, Hospital of the University of Pennsylvania, Philadelphia, PA Laura Scalise, RNC-MNN, Hospital of the University of Pennsylvania, Philadelphia, PA Meghan Ziegler, BSN, RNC-MNN, Hospital of the University of Pennsylvania, Philadelphia, PA Bonnie Renner Ohnishi, BSN, RN, Hospital of the University of Pennsylvania, Philadelphia, PA Keywords skin-to-skin breastfeeding maternal infant attachment nurse–patient ratios

Newborn Care Poster Presentation Implications for Nursing Practice This model of practice has the advantage of meeting the AWHONN staffing recommendation as well as promoting early nursing interventions that promote maternal–infant attachment and breastfeeding success. It also has the potential to provide other avenues of practice for the obstetric and neonatal nurse.

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12100



Taub, M. and Shields, R. L.


Vital Human Milk: Implementing a Donor Milk Program Purpose for the Program reterm infants are at considerable risk of increased morbidity and mortality. They have a higher risk of learning disabilities, cerebral palsy, Eileen Magri, MSN, RN, sensory deficits, respiratory illnesses, and gasNE-BC, Winthrop University trointestinal illnesses. Providing mother’s own milk Hospital, Mineola, NY to the preterm infant has nutritional, gastrointestinal, immunological, developmental, and psychoMargaret Murphy, MS, NNP, RNC-NIC, NE-BC, Winthrop logical benefits. Breastfed preterm infants have University Hospital, Mineola, a lower rate of ear infections, respiratory infecNY tions, or infection-related events. They have lower rates of gastrointestinal infections, necrotizing enKeywords pasteurized human donor milk terocolitis, and mortality. Breastfed preterm infants expressed human milk are discharged earlier from the neonatal intensive Human Milk Banking of North care unit than formula-fed preterm infants. In this America vulnerable preterm infant population, the rate of lactation support mothers who provide their own milk is less than mothers who delivered healthy newborns. When a mother’s own milk is unavailable, the American Newborn Care Academy of Pediatrics recommends pasteurized Poster Presentation human donor milk. Karen Hylton-McGuire, MS, RNC-NIC, IBCLC, RLC, Winthrop University Hospital, Mineola, NY

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Proposed Change To provide premature infants with the access to pasteurized human donor milk when their mother’s own milk is unavailable. Implementation, Outcomes, and Evaluation The pasteurized donor milk program was instituted in conjunction with other lactation support inter-

ventions to increase the amount of mother’s own milk as the primary source of infant nutrition. New York State requires a tissue license for infants to receive pasteurized human donor milk. The tissue bank compliance officer was contacted and the application form C, viewing section 405.25 organ and tissue donation, was submitted. Policies and procedures were implemented according to the regulations. A Human Milk Banking Association of North America was identified as donor human milk bank. Informed consent is obtained from the parents. Frozen milk is shipped in dry ice. Upon arrival to the unit, the milk is inspected and placed in bins in the freezer. A donor milk utilization log with the patient’s identification, number of bottles and ounces, batch number of donor milk, and signature/print of the nurse removing the milk from the freezer is initiated when milk is removed from the freezer. This information is kept for 7 years. To date 27 infants have received pasteurized human donor milk. Implications for Nursing Practice Mothers of premature infants in the neonatal intensive care unit are encouraged and supported with lactation interventions to provide their infants with their own milk. When a mother’s own milk is unavailable pasteurized human donor milk is available.

Neonatal Resuscitation Plan: What’s New and How to Implement Guideline Changes Marybeth Taub, RN, BSN, Purpose for the Program Women and Infants Hospital of n 2010, the American Academy of Pediatrics Rhode Island, Providence, RI Robin L. Shields, RNC-OB, Women and Infants Hospital of Rhode Island, Providence, RI Keywords neonatal resuscitation pulse oximetry oxygen saturation prematurity newborn


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significantly changed the Neonatal Resuscitation Program (NRP) guidelines by incorporating emerging evidence of best practices for the delivery of oxygen to the neonatal population. Women and Infants Hospital (WIH) delivers more than 9,000 infants annually; the neonatal intensive care unit resuscitation team attends approximately 3,000 deliveries and performs supportive measures on approximately 900 infants.

Proposed Change Creating a comprehensive educational design would become paramount in successful dissemination of the impending practice changes.


Three objectives were identified: (a) negotiate a uniform local interpretation of key NRP recommendations in the context of institutional standard practices; (b) create an educational intervention to efficiently and effectively disseminate changes to more than 760 multispecialty staff; and (c) assess the adoption of new practices in clinical resuscitation events. Implementation, Outcomes, and Evaluation The use of educational video recordings has served this institution well. With the extensive vastness of varying units in contact with neonates, multiple scenarios would need to be explored. Staff members were recruited for the video productions. To assist in strengthening the information being

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supplied, an outlined PowerPoint presentation was created, which fostered continuity of instruction. A “train-the-trainer” model was developed to facilitate the needs of a large hospital-wide staff. A subcommittee of seven NRP instructors would act as the frontline educators of this instructional venture. Each department provided targeted champions who would be trained and tasked as “super-users.” Trainers introduced the material on January 9. By January 25, the targeted goal of disseminating the information among 80% of WIH staff was attained. A committed group trained 610 neonatal resuscitation providers within 16 days! Compliance data collection was initiated to assess the success of creating a culture change in neonatal practices.

Implications for Nursing Practice As children, we all had an opportunity to play the game of telephone; the premise being that one person share a piece of information with another and that piece of information is shared with another, and so forth. By the end of the communication, it is found that the final message in no way resembles the original message. It is with this concept in mind that many struggle when the task is disseminating information to large groups of employees. Feedback from this endeavor has been fruitful—corroborating data, reported by event observations, has spoken to retention and implementation of theory into practice and affirmation of a job well done.

Fast Track Initiation of a Congenital Heart Disease Screening Program Purpose for the Program ongenital heart disease (CHD) is a common newborn heart defect that is often asymptomatic. These newborns are discharged home as seemingly healthy newborns. CHD symptoms may develop days or weeks after discharge and a newborn may quickly decompensate, which results in devastating sequelae. A simple pulse oximetry reading performed 24 hours after birth may identify newborns in need of further cardiac evaluation.

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Proposed Change To develop and implement a pulse oximetry screening program for all newborns in a suburban hospital. Traditionally, a process such as this takes 6 months to a year to fully integrate into practice. Because of the seriousness of undiagnosed CHD and the potential Connecticut State mandate for CHD screening, the hospital’s department of pediatrics felt an urgent need to put this process into place. The proposed practice change would include all newborns in well nursery and the neonatal intensive care unit.

Implementation, Outcomes, and Evaluation Nursing management was charged with creating a program to educate families, screen newborns, and create an algorithm that would ensure 100% compliance. Additionally, the program would include physician notification, further evaluation, and follow-up when indicated.

Colleen A. Loyot, BSN, RNC-NIC, Danbury Hospital, Danbury, CT

Within 7 weeks from idea conception, the program was created, all staff educated, and competency was ensured. The results of this successful program were reported to the state legislature as part of the testimony supporting the Connecticut General Assembly Bill #56.

Keywords congenital heart disease pulse oximetry screening competency education

Implications for Nursing Practice Nursing can be effective in developing and implementing evidence-based practice in a rapid time frame to improve quality of care. This process can be duplicated in other hospitals and with other projects.

Cynthia A. Palmer, MSN, RN-BC, C-OB, C-EFM, CNL, Danbury Hospital, Danbury, CT


Overcoming Obstacles to Become a Baby Friendly Hospital Purpose for the Program chieving Baby Friendly designation is supported by the following: Healthy People’s 2020 objective to increase exclusive breastfeeding of mothers during the early postpartum period, the February 2012 American Academy of Pediatrics’ recommendation that mothers exclusively breastfeed their infants for the first 6 months after

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birth; and the Joint Commission’s perinatal core Liz Peters, BSN, Poudre Valley measure for exclusive breastfeeding while in the Hospital, Fort Collins, CO hospital. Keywords Baby Friendly initiatives obstacles education Proposed Change To implement Baby Friendly Initiatives and con- customer satisfaction

tinue to revise practices to meet updated guidelines to maintain Baby Friendly designation.

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12105


Delong, S., Jordan, L., Snider, D., Leist-Smith, M., Lipke, J., and Green, D.



Implementation, Outcomes, and Evaluation Baby Friendly components can be met with resistance from staff and physicians. Baby Friendly requires that staff reverse ideas, such as sending infants to the nursery so that mothers can sleep, offering supplementation of formula until lactation is established, using pacifiers to satisfy suckling, and keeping mothers and healthy infants apart during medical procedures. Becoming Baby Friendly often demands a change in practice toward family-centered care. The program teaches breastfeeding skills to mothers, supports skin-toskin contact after birth, promotes rooming-in as standard of care for healthy infants, and offers breastfeeding resources upon discharge. Myths and obstacles of Baby Friendly practice can present obstacles to implementation. The most common myths are that mothers will not have a choice in how to feed their infant, hospital cost will increase significantly, and the requirement of staff

education will be difficult to meet. Obstacles to meeting the Baby Friendly goals include supplying consistent information to parents and staff regarding breastfeeding, keeping moms and infants together with rooming-in as standard of care, and changing practice to meet skin-to-skin contact requirements. Customer satisfaction measured before and after implementation of Baby Friendly practices to the question “I learned how to feed my baby properly” demonstrated a significant increase. This same result is reflected in the perinatal care core measure of exclusive breastfeeding. Implications for Nursing Practice Many changes to current practice were implemented to meet the Baby Friendly Initiative guidelines. Though these were initially perceived as obstacles, they are now part of every day practice and have not only increased patient satisfaction, but have increased nursing satisfaction as well.

Got Code Pink? Neonatal Code Response Team Sarah Delong, BSN, RN, Purpose for the Program C-EFM, Mercy Health-Fairfield ffective communication and collaboration Hospital, Cincinnati, OH

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among the clinical team is essential to optimize perinatal patient safety during the delivery of emergent care to a neonatal patient. In more than 80% of perinatal deaths and injuries, Deborah Snider, MSN, communication concerns have been identified by RNC-OB, C-EFM, Mercy the Joint Commission on Accreditation of Health Health-Fairfield Hospital, Cincinnati, OH Care Organizations (JCAHO) as the most freMarie Leist-Smith, MSN, RNC, quent identified root cause. “Code Pink” was creC-EFM, Mercy Health Partners, ated to optimize outcomes and prevent failure to rescue. Cincinnati, OH Lora Jordan, PNP, RN, Mercy Health Partners, Fairfield, OH

Jennifer Lipke, BSN, RN, Mercy Health-Fairfield Hospital, Fairfield, OH

Proposed Change Based upon the recommendation from the Joint Commission and needs assessment of the periDonna Green, BSN, RN, natal staff, a Midwestern level II family-birth cenPhD(c), Mercy Health Partners, ter examined, developed, simulated, and then Fairfield, OH adapted an algorithm for the assignment of the Keywords procedural roles needed to provide care during a neonatal resuscitation neonatal emergency, titled “Code Pink.” simulation team training algorithm


Implementation, Outcomes, and Evaluation The implementation of the Code Pink algorithm identifies specific procedural roles for the entire unit during a neonatal emergency. Within the algorithm there is a telephone triage to ensure that the ancillary departments are notified. The Code Pink algorithm also includes a shift assignment of the following procedural roles: fetal monitor watcher, medications/crash cart, chest compressions, recorder, airway, and runner. These roles are fulfilled by registered nurses who have com-


pleted the Neonatal Resuscitation Program (NRP). The role of “runner” is assigned to perinatal patient care assistants who have completed NRP. To activate the Code Pink algorithm any staff member presses our staff emergency button, located in every room, which alerts every staff member’s wireless telephone with the room number. The algorithm is then followed and all staff know their assigned roles of the Code Pink team, and if necessary staff will telephone ancillary departments, including respiratory, special care nursery, neonatology, and anesthesia. The algorithm has been practiced and simulated numerous times, with each simulation focusing on interdisciplinary communication and role identification. Since the creation of the Code Pink algorithm/team there have been no role-based communication errors and no failure rescue events. Implications for Nursing Practice Adherence to the Code Pink algorithm provides for rapid intervention at the time of care when the patient, and other patients on the unit, need seamless and collaborative care. With the application of the Code Pink algorithm into nursing practice, patient care and staff communication of emergent roles and expectations are optimized. This organized, team-based care process has improved delivery of care through the creation of an algorithm and environment that is clearly focused on patient safety and communication among an entire staff during obstetric emergencies.

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Skin-to-Skin Cesarean Delivery Purpose for the Program kin-to-skin cesarean delivery is an innovative way to facilitate the involvement of the family during a cesarean delivery. Just by changing the routine to incorporate immediate skin-to-skin contact there is a potential enhancement of the bonding process for the family and the facilitation of breastfeeding.

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Proposed Change To establish a team involved in care during cesarean deliveries for the purpose of the development of a protocol, which includes family input, to institute skin-to-skin care immediately after cesarean deliveries. Implementation, Outcomes, and Evaluation The inclusion criteria for skin-to-skin contact candidates were foundational to the protocol development. The families included experienced nonemergent, elective, repeat cesarean deliveries, or cesarean deliveries performed because of a failure to progress/dilate or breech presentation. The infants were greater than 38 weeks of gestation and in no acute distress. Role responsibilities were developed for the neonatal registered nurse, certified registered nurse anesthetist/anesthesiologist, circulating registered nurse, delivering physician, scrub technician, the mother, and the mother’s support person. The protocol included a surgical

unit that was setup to allow the mother to select music, provided the use of dim lighting, provided extra sterile plastic cord clamp on field, and positioned warmed blankets and an infant cap near the head of the mother’s bed. The protocol of family education was to discuss with the mother and her support person one of the following three options: (a) observe the delivery from the moment of uterine incision up to the birth (not for breech deliveries); (b) immediate skin-to-skin contact if the infant is vigorous and stable; and (c) delayed skin-to-skin contact for infants with any situation that would lead to a delay transition. Key elements of skinto-skin contact after cesarean delivery were open communication with the operating room team and the family throughout the procedure; placing of the infant on the mother’s chest if infant is deemed stable; monitoring infant’s axillary temperature every 10 minutes; and perform measurements, medications, and footprints when the mother requests them to be done.

Diane Duffy, MSN, NNP, C, Park Ridge Health, Hendersonville, NC Christine Conrad, BSN, RNC-OB, Mission Hospital, Asheville, NC Keywords cesarean section kangaroo care skin-to-skin bonding


Implications for Nursing Practice Assuring the provision of family-centered care during a cesarean delivery that includes skin-to-skin contact may improve breastfeeding, bonding, and family satisfaction with the birth experience. Continued evaluation is ongoing on these outcome indicators.

Implementation of a Critical Congenital Heart Disease Pulse Oximetry Screening Program for Newborns Purpose for the Program n September 2011, the Secretary of the U.S. Department of Health and Human Services recommended that all U.S. hospitals be required to screen newborns for critical congenital heart disease (CCHD). Screening for CCHD with the use of pulse oximetry also has been endorsed by the American Academy of Pediatrics, the American College of Cardiology Foundation, and the American Heart Association. The purpose of this project was to examine the current research and recommendations supporting the use of pulse oximetry as a method of screening newborns for CCHD and to implement a newborn screening program supported by this evidence.

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Proposed Change To identify and address the implementation steps for initiating a neonatal CCHD pulse oximetry screening program. Implementation, Outcomes, and Evaluation A review of recent literature and evidence-based recommendations supported the need to make screening of every eligible newborn a standard of care in our facility. With the supporting evidence and recommendations in hand an interdisciplinary work group was established to implement a CCHD pulse oximetry screening program for newborns in our facility.

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12109

Mary Ann Salazar, MNSc, RNC-MNN, WHNP-BC, APN, UAMS, Medical Center, Little Rock, AR Keywords CCHD critical congenital heart disease pulse oximetry screen newborn pulse oximetry screen




Salazar, M. A.


Implementation steps identified included the following: (a) policy and procedure development; (b) screening tool and documentation plan; (c) equipment and supply needs; (d) staff training and education; (e) parent education materials; (f) physician notification; (g) community education; and (h) tracking results and follow-up. Work was initiated and by January 1, 2012 we developed a policy and procedure and a screening form. The physician documentation of screen results was setup in our electronic medical record and equipment was in place. The staff training was completed and educational materials produced. The physicians were notified of the screening procedure and screening for CCHD with pulse oximetry was initiated on all eligible newborns delivered or admitted to UAMS, Medical Center. Ongoing


review of the program by the work group continued to assess the need for program revisions as indicated. The policy and screening form were both revised after initial implementation to better address the screening of the ill infant. A plan to track all positive screening results has been initiated within our maternal/infant division to continue the assessment of our screening program, identify any false-positive results, and assess the medical follow-up of those infants identified with CCHD. Implications for Nursing Practice This project is an excellent example of taking current evidence and research and expanding it into evidence-based practice at the bedside and the necessity of interdisciplinary collaboration when introducing a new practice into a healthcare facility.

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Skin-to-Skin in the Operating Room—It Takes a Village Professional Issues Karen M. Brady, MAHSM, BSN, RNC-OB, C-EFM, St. Vincent’s Medical Center, Bridgeport, CT Denise Bulpitt, RN, BSN, IBCLC, St. Vincent’s Medical Center, Bridgeport, CT Caren Chiarelli, RN, BSN, St. Vincent’s Medical Center, Bridgeport, CT Linda Shepard, RN, St. Vincent’s Medical Center, Bridgeport, CT Keywords skin-to-skin contact cesarean delivery interdisciplinary teamwork

Paper Presentation

Purpose for the Program arly skin-to-skin contact between a mother and her infant has been studied and shown to improve outcomes for both mother and infant. As a hospital that received the Baby Friendly designation in April 2010, we are well aware of the benefits of skin-to-skin contact. During our journey to become Baby Friendly, the topic of skinto-skin contact was researched and discussed as we worked to develop a plan to implement skin-to-skin contact at birth. At the time of our site visit, we had successfully implemented skinto-skin contact immediately after birth for vaginal deliveries and in the recovery room for cesarean deliveries.

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Proposed Change As professionals, we are constantly evaluating our practices and looking for ways to improve. During our Baby Friendly journey, there was resistance to the idea of implementing skin-to-skin contact in the operating room (OR) from all disciplines. As time went on, we realized that implementing skin-to-skin contact in the OR was the next step in providing the optimal care for our mothers and infants. To do that, we would need support from all members of the interdisciplinary team.

Implementation, Outcomes, and Evaluation The first step began with a journal club article and discussion on implementing skin-to-skin contact in the OR. Barriers were identified and a plan to overcome them began. The following week, two staff nurses took it upon themselves to try skinto-skin contact in the OR to see how it could be done. From there, the topic became an agenda item for further discussion for both the OB service line meeting and the Perinatal Safety and Satisfaction Interdisciplinary Committee. Following that, a presentation was made at the anesthesia service line meeting to provide education and gain their support. We incorporated the topic of skin-to-skin contact into our prenatal breastfeeding classes and the nurses introduced it to the families on admission to the labor and delivery unit. Additionally, changes were made to our electronic medical record to provide documentation of skin-to-skin contact in the OR and allow us to track the data. Implications for Nursing Practice Change is difficult for any intervention you are looking to implement. By getting support from all stakeholders throughout the process, keeping everyone engaged, and taking it one step at a time, change is possible. As a result, we have implemented skin-to-skin contact in the OR.

Preparing the Next Generation of Front-Line Nursing Leaders: The Development of an Evidence-Based Charge Nurse Curriculum Katherine Cvach, RNC, MS, Mercy Medical Center, Centreville, MD Keywords charge nurse education charge nurse roles communication in nursing

Professional Issues Paper Presentation

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Purpose for the Program n January 2011, the Maternal–Child Health Division of Nursing at our hospital began preparations to move to a larger, more state-of-the-art facility. Assessment of nursing knowledge and nursing satisfaction was part of this preparation. It became clear from the results of a self-assessment of skills questionnaire that the nurses who were serving in the permanent charge role felt unsupported and unprepared to take on the added responsibilities that the move to the new hospital would demand. Knowing that prior methods of charge nurse education were not sufficient to meet the knowledge and competency expectations of the charge nurses, a search was performed to find evidence-based practices that supported leadership development.

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Proposed Change The charge nurses determined the learning method and setting. A year-long charge nurse workshop was developed and classes were presented on a monthly basis. All charge nurses were expected to complete all components of the new charge nurse curriculum and were given tools to facilitate the process. Implementation, Outcomes, and Evaluation The development of the topics for the curriculum came from the evidence that supports the core responsibilities for the charge nurse role. The 24 charge nurses were divided into four groups: (a) clinical/technical skills; (b) critical thinking skills; (c) organizational skills; and (d) human relations skills. Each group developed an extensive list of

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12111



Cvach, K. and Williamson, K. M.


component skills for their assigned category and shared their information at a summary phase during the initial meeting, which allowed for additions to the list and prioritization of the topics. This information was used to develop a charge nurse core competency checklist. The leadership team took the information provided by the charge nurses and developed the monthly educational programs, which were collaboratively presented by the experts of each topic, and built a resource guide for ongoing reference. In January 2012, after the program was completed, the charge nurses were asked to complete the self-assessment of skills questionnaire a sec-

ond time. A significant improvement was reported in all categories. Implications for Nursing Practice The successful implementation of this process has provided our institution with the basis for charge nurse education for all nursing divisions. Our nursing satisfaction results have improved among charge nurses. The results indicate that the nurses feel prepared to complete assigned duties, feel supported by nursing leadership, and have a sense of accomplishment regarding the last shift worked. This process can easily be implemented in any healthcare institution as a method of continuing education for the development of nursing leaders.

Implementing the Neonatal Assessment Nurse Role in the LDR: Improving Neonatal Outcomes While Supporting Family-Centered Care Purpose for the Program nowing the stabilization and bonding benefits of minimizing the separation of the mother– Karen Marie Williamson, BSN, baby dyad at delivery, a nurse-driven task force RNC, Maternal Child Health, integrated the role of a neonatal assessment nurse Mercy Medical Center, (NAN) into the care delivery process. The task Baltimore, MD force discovered that inconsistent care practices, anecdotally reported by the medical providers, Keywords neonatal assessment nurse affected the quality of neonatal care and maternewborn transitional care nal satisfaction. The purpose of this project was family-centered care to establish an innovative role designed to consistently provide transitional care at the mother’s bedside for eligible newborns. Without funding Professional Issues to hire additional nurses into this position, a core of nurses from all maternal child health units Paper Presentation group volunteered. Katherine Cvach, RNC, MS, Mercy Medical Center, Centreville, MD

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Proposed Change Introduction of the NAN, as a dedicated clinical assignment, would positively facilitate the transition of life from fetus to neonate, decrease mother– neonate separation, increase rate of skin-to-skin contact, improve nurses’ perspective of neonatal care, decrease neonatal intensive care unit admissions, and improve maternal satisfaction. The NAN provides transitional care at the mother’s bedside, thus changing the current practice of separating the infant from the mother to conveniently transfer the infant to where the work can be accomplished. Implementation, Outcomes, and Evaluation Hospital Institutional Review Board approval was obtained. Strategies for NAN success included detailed role description; patient care priorities;


expectations when the labor and delivery room (LDR) had no neonatal patients; and a decisive evaluation plan for those infants requiring nonintensive yet supportive care and monitoring. A comprehensive process of didactic education and clinical orientation was individualized based on the nurse’s expertise along the spectrum of neonatal care. Simulation scenarios served as teaching adjuncts and reinforced evidence-based practices. The enthusiasm of the NAN-identified nurses and creative staffing models developed by the maternal–child health units’ charge nurses ensured coverage for every shift, 7 days a week. The Caring Behaviors Inventory by Wu, Larrabee, and Putman (2006) was used before and after NAN to gain clinical nurses’ perspective about the care delivered to neonates who were less than 4 hours of age. This tool and survey, which focused on maternal perspective, were chosen because both aligned with the hospital’s choice of Watson Caring Theory, which is the framework that currently guides our nursing practice. Implications for Nursing Practice The NAN role in the LDR presents an extended benefit of having a dedicated nurse to provide neonatal care in situations when transition time requires pulse oximeter monitoring and/or additional poststabilization assessments. With no literature available on this topic, publication of the positive results of this implementation plan will help others adopt similar roles specific to their settings.

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Implementing a New Nurse-Sensitive Quality Metric: Initiation of Breastfeeding Within 60 Minutes of Birth Purpose for the Program he purpose of this presentation is to propose a feasible nurse-sensitive quality metric, entitled “Initiation of Breastfeeding Within 60 Minutes of Birth,” along with a toolkit for implementation.

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Proposed Change To develop and define quality measures that are sensitive to obstetric nursing care and can be replicated across institutions. Implementation, Outcomes, and Evaluation A team of seven Magnet-accredited hospitals collaborated to define the elements of quality obstetric nursing care. The team included perinatal nurses, nurse managers, informaticists, and report writers. A pilot project was established by The Christ Hospital and Summa Health System for the first proposed metric, entitled “Initiation of Breastfeeding Within 60 Minutes of Birth.” Development of documentation and reporting tools followed. Priorities for development included evidencebased, simple, and uniform documentation; efficient data collection methods; and reporting tools to track and drive improvements in quality of care. The documentation tool specifies exclusions to breastfeeding and then a presents a single question, “Breastfeeding,” with cascading documentation options based upon the staff entry of yes or no. Staff input was imperative so that the documentation integrated with normal workflow and allowed real-time access at the point of care. Standardized reporting tools were then developed for enterprise

and departmental information systems as well as Mary Stevie, MS, RN, The Christ Hospital, Taylor Mill, paper-based records. KY

Pilot work has resulted in the development of a toolkit for the proposed quality metric, “Initiation of Breastfeeding within 60 Minutes of Birth” and includes documentation and reporting tools, staff education modules, and result dissemination materials. Pilot hospitals have met monthly to evaluate the effectiveness of the toolkit’s implementation and replicability. Pilot hospitals have been tracking nurse adherence to the metric. Rates of initiation of breastfeeding within 60 minutes of birth based on standardized numerators and denominators are also being evaluated to establish short-term and long-term benchmark goals for quality improvement. The next steps for this project involve creating a data-sharing database and extending pilot work to include the two other quality measures proposed by the team of Magnet-accredited hospitals.

Tiffany Kenny, MSN, RN, Summa Health System, Akron City Campus, Akron, OH Keywords metrics toolkit data collection


Implications for Nursing Practice Labor and delivery nurses have a critical role to ensure that women initiate breastfeeding within 60 minutes of birth. Implementation of a toolkit to track and improve the initiation of breastfeeding has the potential to increase national breastfeeding success rates and improve maternal and neonatal outcomes. Improving rates of the initiation of breastfeeding can also positively affect the established national metric of exclusive breastfeeding.

Getting to the Heart of the Matter: Implementing a Critical Congenital Heart Disease (CCHD) Newborn Screening Program Across a Rural Health System Purpose for the Program ritical congenital heart disease (CCHD) occurs in approximately 8 of 1,000 births. With shorter hospitalization stays, newborns without cardiac anomaly identification before birth may appear healthy during their hospitalization. CCHD may not be identified until the newborn is at home and in distress. Early identification and intervention of CCHD promotes optimal outcome for newborns. A CCHD screening program was implemented for newborns in six obstetric/newborn

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units across a rural health system before the man- Marsha Rodgers, RNC-OB, MSN, Johnson City Medical dated legislative requirement. Center, Johnson City, TN

Proposed Change To facilitate intervention for those normal appearing newborns with undiagnosed heart defects after birth, a screening protocol before discharge should be implemented by nurses to identify CCHD in newborns who are 24 hours of age.

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12114

Lisa Smithgall, PhD, RNC, CPNP, NEA-BC, RNC-NIC, Geisinger Medical Center, Danville, PA



Walls, K. and Jerrell, J.


Implementation, Outcomes, and Evaluation Keywords newborn screening An interdisciplinary healthcare team consisting critical congenital heart disease of obstetric/newborn nursing leadership, clinical CCHD in-hospital program nurse specialist, respiratory therapy leadership, implementation


and neonatology and pediatric cardiology physicians collaborated to develop a specific protocol for CCHD newborn screening. Protocol development was initiated based on recommendations from the United States Secretary of Health and Human Services, the American Academy of Pediatrics, the American Heart Association, the introduction of state legislation for mandated CCHD screening by hospitals, and the evaluation of published evidence that identified the method for CCHD screening. Newborn nursing leadership developed the protocol and presented information for discussion and input to pediatric physicians across six healthcare facilities within the two state health system for adoption. Equipment was identified and acquired for each unit. Electronic health record modification assisted nursing team members to follow the protocol algorithm for accuracy. Nursing and respiratory therapy leadership

developed a competency assessment for nursing team members and the comprehensive newborn nursing education plan for implementation. Since implementation in October 2011, approximately 4,700 infants have been screened with one true positive case of CCHD identified and two instances of false positive results where CCHD was ruled out with further testing. The minimal cost of implementation related to supplies and the time spent performing the test (3–4 minutes of nursing time per infant) has resulted in a successful program in which early identification of CCHD improves the outcome for those infants at risk.

Implications for Nursing Practice The performance of CCHD screening by nurses facilitates the identification of CCHD in healthy appearing newborns with undiagnosed disease before ductal closure to promote timely intervention and optimal health outcomes. Nurses provide information and education to parents about the screening.

Happy Patients, Happy Nurses, Happy Doctors! How the Implementation of a Preadmission Process Prepares Patients for Their “Big Day” and Allows Nurses to Focus on Bedside Care Purpose for the Program et’s face it, today the “buzz word” is budget— save time and money anyway you can. In a “feast or famine” unit, it can be unclear as to how Janette Jerrell, RN, Parkwest Medical Center, Knoxville, TN that can be accomplished. Think outside the box! Is it possible to save time before a patient even Keywords gets admitted? By implementing a preadmission preadmission nurse process, the answer is “yes.” preadmission process Kimberly Walls, MSN, RN, RNC-OB, Covenant Health, Knoxville, TN

nursing bedside care increasing patient satisfaction


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Proposed Change This process starts with the physician. The physician should inform the patient at her 35- to 36week-of-gestation appointment that she will need to meet with the preadmission nurse. The patient is given the preadmission nurse’s business card and is instructed to call and make an appointment. The proposed change for this implementation is to establish who is going to serve in the role of preadmission nurse. Consistency is key to ensure that all patients receive the same information. Implementation, Outcomes, and Evaluation The patient meets with the staff from registration to obtain a prenumbered patient account. This inactive account will sit dormant in the hospital census until the patient’s full admission date of service. The patient is welcomed into a private


office where a full up-to-date medical history is obtained from the prenatal record and the patient. All maternal/fetal risks and complication to date are obtained, current medication regimen is updated, and a family medical history is completed. Consents for obstetric care and newborn care are obtained, advanced directives are discussed, and pediatrician information is obtained. After all consents have been discussed patient education begins (detailing what the patient should expect). After questions have been answered, the patient is offered a full tour of the unit, including the labor room, triage, and newborn nursery. This process has been shown to increase focused bedside care at admission for nursing staff by almost 50%, which reduces the traditional admission time from 45 to 60 minutes to nearly 15 to 30 minutes! This added time also benefits the physicians because their patient care will not be delayed by waiting for nursing admission tasks (e.g., starting an intravenous line or monitoring) or completion of the patient chart before scheduled patient care (e.g., induction or cesarean delivery).

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Implications for Nursing Practice Overall, quality patient care starts before the patient is even admitted. The success of implement-

ing a process that can show the patient we care about them and strive for excellence even before they are admitted is proven by an increase in patient satisfaction scores.

“Yes, U Can!” Professional Development Program Purpose for the Program s a Magnet-designated facility, we encourage our nurses to consider completing their baccalaureate degree, obtain a specialty certification, or return to school to obtain a masters or doctoral degree. Responses from these nurses often include: “I don’t even know where to start,” “I think I’m too old,” and “It’s too expensive. I can’t afford it.” The Institute of Medicine and experts such as Dr. Patricia Benner have long advocated the baccalaureate degree as the minimum education required for entry into nursing practice. Many existing nurses who completed a diploma or associate degree program are overwhelmed by the idea of returning to school.

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Proposed Change An innovative program was developed to offer counseling/referral for nurses interested in educational opportunities and professional growth. After the pilot this program was opened to nurses at all sites/locations within the St. Luke’s Healthcare System. Components of this program include a referral into the program, an initial questionnaire, preparation of materials, a confidential one-onone meeting with the participant, and a follow-up questionnaire. Overwhelming response has resulted in expanding and dividing the program into two groups. The first group includes those staff members who are

not clinical but desire a clinical career. The second group includes those staff members who are not clinical and do not want a clinical position but desire professional growth. This resulted in a significant increase in volume and an opportunity to partner with organizational development.

Teresa Stanfill, RNC-OB, MSN, St. Luke’s Health System, Boise, ID

Keywords certification baccalaureate completion advanced nursing degrees tuition reimbursement Implementation, Outcomes, and Evaluation IOM 2010 Before the program was piloted in the fall of 2009, healthcare reform

much care was given to the creation of forms, data tracking, and an electronic database of various nursing programs, which identify the admission process, prerequisites, application deadline, contact information, and costs associated with each program. Additional program information was prepared, including information on tuition reimbursement, certification prepayment, and scholarships offered by the healthcare system. The “Yes, You Can!” program has provided services to more than 280 participants in 3 years.


Implications for Nursing Practice Assisting interested and motivated nurses in navigating the process toward a specialty certification and/or furthering their education is of benefit to all. The individual nurse benefits personally and perhaps financially from furthering his/her education. The employer benefits from the added knowledge and new ways of thinking. The patients benefit from the nurses advanced education and their ability to integrate and synthesize.

All on Board? Changing the Culture of Couplet Care Purpose for the Program or many years traditional couplet care has separated mothers and newborns shortly after birth. Studies have shown the detrimental effects on mothers and newborns when care is given in separate locations.

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Proposed Change Before the implementation of couplet care, this organization separated mothers from their newborns when providing care during transition and at night in the nursery. Using the Iowa model of evidencebased practice to improve quality care, we developed evidence-based practice changes that

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were guided by nurses that questioned the rational (which was not supported by the literature) for continued separation of mothers and newborns. The planning phase included development of an interdepartmental team, literature review, survey of comparable facilities, and piloting models of couplet care. Implementation, Outcomes, and Evaluation In 2011, the implementation process began with interdepartmental and interdisciplinary meetings lead by the clinical nurse specialist and staff development instructors to identify barriers and assist with the change process. Discussion at unit

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12117

Stacy Chubb, BSN, RNC-MNN, Pinnacle Health System, Harrisburg, PA Marianne Allen, MN, RNC-OB, CNS, Pinnacle Health System, Harrisburg, PA Keywords couplet care skin-to-skin




Lombardo, C. A.


based committees provided staff input and feedback for the change. Education was provided for registered nurses, ancillary staff, and physicians. Verbal and written information also was provided to patients at childbirth classes and prenatal visits. Skin-to-skin contact began in the delivery room for all healthy term and late preterm newborns. After transfer to the maternity unit skin-to-skin contact was uninterrupted throughout the transition period. The journey to the standard of couplet and familycentered care has had many challenges and rewards. Changing the nursing culture to embrace this new practice has been challenging. Some staff nurses are resistant to change their delivery of care. The mother’s exhaustion often was sited as the reason for the newborn being returned to the nursery at night. Some staff members use

pacifiers to comfort newborns. Difficulty in maintaining sustained practice changes contribute to the challenges. Positive outcomes related to the nonseparation of new mothers and newborns focus on both patients and staff. Increased patient satisfaction scores, decreased neonatal intensive care unit admissions, reduced incidences of hypoglycemia, as well as positive feedback from families about their experience validate the success of our care model. Staff satisfaction and interdepartmental teamwork related to bedside report for new admissions have improved. Though there have been many successes and challenges along the way, our organization is committed to evolve a culture of best practice for couplet care. Implications for Nursing Practice The nursing culture shifted from traditional care to evidence-based care.

Nursing’s Role in Achieving Excellence in Care Delivery Across the Continuum of Health for New Mothers With Hypertension Cathy Ann Lombardo, MSN, FNP, RNC, Huntington Hospital, Huntington, NY Keywords hypertension pregnancy new mothers


Purpose for the Program he purpose of this innovative program was to prevent new mothers with hypertension from having to be readmitted to the hospital because of hypertension-related complications.

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Proposed Change In 2010, direct care nurses became disturbed with an increased trend of new mothers readmitted to the hospital within 30 days of discharge with complications associated with hypertension, such as severe headache, blurry vision, nausea, and vomiting. These nurses identified a need to educate patients facing the major healthcare challenge of hypertension and improve the gap between the care received in the hospital and the home. Hypertension is the most common medical problem encountered during pregnancy. It occurs in as many as 10% of first pregnancies and in 20% to 30% of women with a history of chronic hypertension. Hypertensive disorders may cause maternal and fetal morbidity and remains a leading cause of maternal mortality. Implementation, Outcomes, and Evaluation Within an interdisciplinary, Mother/Baby Collaborative Care Council, nurses led the development of an innovative, patient-friendly educational program for new mothers with hypertension. A hall-


mark of this evidence-based, patient safety initiative is close collaboration and care coordination between inpatient mother–baby registered nurses (RNs), case management RNs, and physicians. In addition, within 24 to 36 hours of discharge from the hospital, every new mother with hypertension is visited at home by a community health RN to assess blood pressure and adherence to such things as prescribed medications and diet. These nurses use patient-centered care to address the diverse needs of new mothers with hypertension. The setting for this innovative program is a 408bed, Magnet-designated community hospital in Long Island, New York. In 2010, there were 1,564 deliveries and 38 new mothers were readmitted for treatment of complications associated with hypertension. In 2011, there were 1,456 deliveries and only five new mothers were readmitted with hypertension. This represents an approximately 85% decrease in readmissions of new mothers with hypertension. Implications for Nursing Practice As patient care advocates, educators and care coordinators, direct care nurses can improve their own professional practice and achieve excellence in care delivery across the continuum for new mothers with special healthcare needs, such as hypertension.

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Implementation of AWHONN 2010 Guidelines for Professional Registered Nurse Staffing for Perinatal Units—The Journey of a Level III Maternal/Newborn Unit in a Community Hospital Setting Purpose for the Program ith a trial of staffing assignments, based on the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) 2010 staffing guidelines, the maternal–newborn unit of a midsized community hospital (with a level III obstetric center) desired to assess the effect of the trial on unit productivity. A trial staffing grid was developed based on published guidelines. The purpose of the trial was chiefly to assess the effect of the proposed changes on the overall unit productivity, which was based on hours per patient day.

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Proposed Change The previously followed staffing grid allowed for a 1:4 nurse to couplet patient assignment. During a 6-week trial period, nurses followed a 1:3 nurse to couplet patient assignment to assess the overall effect of the trial on total unit productivity and focus on time management related to individual nursing staff overtime. Unit productivity statistics were posted for staff at 2-week intervals during the initial 6-week trial.

patient volume. Significant reductions were noted with regard to overtime. Findings included marked improvements in patient satisfaction scores and nurse satisfaction with a 1:3 nurse to couplet assignment. Numerous nursing comments related favorably to improvements in patient care and patient education, and overall satisfaction with the care provided by nurses and the nursing role. Because of the positive effect noted during the 6-week trial, the trial was extended for additional weeks. Implications for Nursing Practice The application of AWHONN’s Guidelines for Professional Registered Nurse Staffing for Perinatal Units can be accomplished with overall improvement in individual nursing productivity and a moderate effect on unit productivity for the maternal–newborn unit. Both patient and nursing satisfaction are significantly improved with the implementation of a 1:3 nurse to couplet assignment for the postpartum mother and newborn. As follow-up to the trial, the maternal–newborn nursing unit is working toward fully adopting the 2010 AWHONN staffing guidelines.

Darla Baker, MS, RNC-OB, CNM, NEA-BC, Kettering Medical Center, Kettering, OH Emily Massengale Hunter, BSN, RNC-MNN, Kettering Medical Center, Kettering, OH Keywords staffing guidelines hours per patient day productivity budget patient satisfaction nurse satisfaction


Implementation, Outcomes, and Evaluation During the 6-week trial period, overall productivity was maintained within the established budget for

Raising a New Generation of Empowered Nurses in Maternal–Child Health Purpose for the Program o encourage undergraduate nursing students to think about nursing from a global perspective and explore the needs of underserved childbearing women. Furthermore, to introduce students to scholarly writing for professional presentations or publications.

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Proposed Change Typically, undergraduate nursing students who take courses for honors credit write a literature review or give a presentation to peers/clinical staff on a particular topic germane to the class. Though these exercises are valuable, they do not challenge the students to think about nursing from

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a global perspective, nor do they require them Karen Brandt, PhD, RN, to write at a professional level worthy of publica- Northern Illinois University, Downers Grove, IL tion/presentation. This program encouraged students to choose a Keywords nursing education topic related to the health care of underserved global maternity/child nursing childbearing women in the United States and across the globe. Each student chose a different topic and met with the instructor on a regular baProfessional Issues sis to complete a scholarly paper and an abstract that could be submitted to a professional nursing Paper Presentation organization. Implementation, Outcomes, and Evaluation Students who enrolled in a maternal–child nursing course decided on a project that would

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Tucker, J. A. and McCann, L. H.


enhance their understanding from a global perspective of the nursing implications for underserved childbearing populations. Students were asked to share resources and findings as they conducted literature reviews for their papers. The students wrote a 200-word abstract and the combined instructor–student effort resulted in the submission of the abstract for presentation at an international nursing conference. Students chose challenging topics. Some of these topics included nursing care of pregnant women, incarcerated women, health implications during pregnancy, delivery for immigrant woman with genital mutilation, nursing considerations for the families with surrogate pregnancies in the United

States and Europe, and care of homeless pregnant women in the United States and Europe. Students had never written an abstract before this class, but were successful with coaching. The abstract submitted by the instructor/student team to the international conference of Sigma Theta Tau was accepted as a poster presentation. Implications for Nursing Practice This program demonstrates that undergraduate nursing students are able to perform scholarly activities that add to nursing knowledge before the official start of their nursing careers. Early guidance and encouragement may lead to novice nurses who are eager to join and contribute to a global nursing community.

Collaborating for Family-Centered Care: Integrating Child Life Specialists in the Prenatal Setting Janet A. Tucker, MSN, RNC-OB, LeBonheur Children’s Hospital, Memphis, TN Lauren H. McCann, LMSW, CCLS, Le Bonheur Children’s Hospital, Memphis, TN Keywords psychosocial care family-centered care patient-centered care high-risk obstetrics


Purpose for the Program e Bonheur Fetal Center opened in September 2009 to provide comprehensive care for women who had received a prenatal diagnosis of a congenital anomaly. After a generic request for child life staff to supervise the children of expectant mothers during their mother’s ultrasound examinations, the child life team saw the need for more specialized psychosocial services for the expectant family. A certified child life specialist with prior experience in program development was assigned to the fetal center to assess the needs and initiate services.

and bereavement support when necessary. Success is totally reliant upon ongoing communication between all team members and the desire to always do what is best for that family in their unique situation.

Proposed Change To more closely examine the psychosocial care provided to this population and ways in which all the disciplines could be utilized to provide support as needed for each unique family.

Implications for Nursing Practice Though nurses and child life specialists have worked closely to develop the communication and collaboration needed to successfully meet the psychosocial care of these patients, all specialties can gain further understanding and respect for the need for psychosocial care in the medical treatment of any population. It should be encouraged to consider if all the disciplines within an institution are being used to their best potential in collaborative efforts to provide patient- and family-centered care. Though high-risk obstetrics is not a population found in every healthcare setting and child life specialists are not staffed in every institution, the lessons learned from collaboration and communication in patient- and family-centered care can be benefited by all healthcare providers.

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Implementation, Outcomes, and Evaluation We discuss collaboration that begins in the fetal center during obstetric visits, moves into labor and delivery at the nearby adult facility, and then follows with entry into the pediatric hospital. During this journey, families trust that all team members are working together to care for their child. To assist in the multiple transitions, child life specialists, in collaboration with nurses, aim to support the expectant family by providing preparation, emotional support, sibling preparation, parental coaching,


The literature reveals that a prenatal diagnosis results in anxiety, grief, and uncertainty for the entire family. Whether a prenatal diagnosis is relatively minor or a lethal anomaly, ongoing multidisciplinary collaboration allows for individualized care and best practice to be provided for this population. Case studies will illustrate this collaboration.

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Daily Leader Safety Brief: The Power of an Interdisciplinary Team Purpose for the Program he increasing acuity and complexity of obstetric patients underscores the importance of communication and well-functioning teams, as recommended by The Institute of Medicine (1999) as components of a culture of safety. When communication and teamwork are ineffective, the risk of maternal and fetal morbidity and mortality increases. Communication failures were identified by The Joint Commission as the root cause of nearly 80% of the sentinel events reviewed, and are a leading cause of preventable adverse events in healthcare settings. Effective team communication is equally important among interdisciplinary leaders at an organizational level, to ensure quality, patient safety, and seamless operations. Emerging as a best practice, conducting daily leader safety briefs may facilitate such communication.

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Proposed Change To provide an overview of the purpose and goals of conducting daily leader safety briefs. Implementation, Outcomes, and Evaluation The process that the leadership team used to begin conducting daily leader safety briefs in the Pavilion for Women at Texas Children’s Hospital

will be reviewed, and practical tips for implementing them at other obstetric facilities will be provided. This presentation is appropriate for all disciplines, all leaders, and the content may be applied to any healthcare setting.

Frances C. Kelly, MSN, RNC-OB, NEA-BC, CPHQ, Texas Children’s Hospital, Pavilion for Women, Houston, TX Keywords

Daily leader safety briefs provide a venue to iden- daily leader briefs tify and discuss quality, safety, and operational leadership team events or concerns that occurred during the previous 24 hours, and facilitate the identification of concerns or threats to patient safety that may oc- Professional Issues cur over the next 12 to 24 hours. To reinforce accountability, leaders are assigned to address and Paper Presentation resolve the identified threats and work together as a team to mitigate risks. Leaders report back the next day about how the issue was resolved or what action plan is in place to resolve and sustain the correction. Implications for Nursing Practice Daily leader safety briefs can help to maintain situational awareness; promote and model transparency; foster organizational trust; as well as improve interdisciplinary communication, collaboration, and cooperation. By being present together as a leadership team and talking with one another in a proactive manner, leaders can work more effectively together to avoid or resolve problems.

Championing Evidence-Based Interdisciplinary Plans of Care for the Neonate: Where Do You Begin? Purpose for the Program o describe the main strategies used by a multisite hospital system to develop and adopt interdisciplinary, evidence-based plans of care (IPOC) within an electronic health record (EHR) for the neonatal population.

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Proposed Change The EHR project vision at this organization was to provide a fully integrated, enterprise-wide, single-patient EHR based on current science that supports and enhances patient safety, patient experience, patient- and family-centered care, interdisciplinary practice and collaboration, and capacity/revenue management. The EHR project was to replace several of the computer systems/paper-based systems and move from a fragmented discipline-specific approach to an interdisciplinary model of care.

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Implementation, Outcomes, and Evaluation To fully realize this vision from beginning to adoption, a cultural transformation needed to occur and was defined in the Clinical Documentation Philosophy and Guiding Principles. These principles provided the foundation to support the project’s vision. The vigorous selection process for an EHR system and IPOC content that incorporated this philosophy was crucial.

Carol Lawrence, PhD, MS, BSN, RNC-OB, Lee Memorial Health System, Cape Coral, FL Sandra Blackington, RN, MSN, The Children’s Hospital of Southwest Florida, Fort Myers, FL Jana Hawley, RN, Lee Memorial Health System, Fort Myers, FL

A project management team with evidencepractice expertise was employed to collaborate with an interdisciplinary team of subject matter experts. The first step was to prioritize the needed IPOC content for all populations. This team then developed the general IPOC content. A second interdisciplinary team was assembled to develop content that was specific to the neonatal population. This team first identified the

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12123


Manelski, M. J., Wagner, S. P., and Norris-Grant, D. M.


Keywords plans of care neonatal electronic health record interdisciplinary evidence-based practice


need for gestationally based IPOCs (preterm, late preterm, and term newborn). Specialty content that addressed additional neonatal medical conditions and procedures was identified with an emphasis on prevention of nosocomial complications/infections, family-centered care, breastfeeding, and neurodevelopmental promotion. This was challenging, yet it was exciting to hear all of the disciplines speak to their own expertise about providing care for neonates. This team developed the IPOC content using a third-party content vendor of evidence-based IPOC templates and an online blogging technology to seek feedback from clinicians.

Innovative strategies were used to facilitate interdisciplinary use and adoption. Preparatory education and training strategies included online learning modules, lectures, simulation labs, access to practice learning environments, and real-time online information. Post go-live strategies included real-time updates on the organization’s Intranet to communicate system status/problems, daily hot topics, tip sheets, as well as end-user bedside support and chart audits. Implications for Nursing Practice A total of 187 IPOCs were developed over a 24month period of which 18 were neonatal-specific and 24 were neonatal/pediatric-specific.

Beginnings: An Educational Foundation for Perinatal Nurses Patricia D. Woods, BSN, Purpose for the Program RN-BC, RNC-MNN, LCCE, ith the 2006 opening of Winnie Palmer HosCLC, Orlando Health, Orlando, pital for Women and Babies (WPH), a large FL

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Keywords beginnings novice nurses AWHONN Perinatal and Education Program comprehensive program women and newborn

Professional Issues Poster Presentation

tertiary care hospital, an influx of graduate nurses were hired. To provide optimum patient care for this specialty population, it was identified that standardized education was needed.

Proposed Change Information received from hospital administration, clinical managers, and educators served as the basis for the new course, Beginnings, which started in January 2008. The format was developed to provide novice nurses with an allinclusive women and newborn educational experience. Course presentations utilized the 2008 Association of Women’s Health, Obstetric and Newborn Nurses (AWHONN) Perinatal and Education Program (POEP). Implementation, Outcomes, and Evaluation The course began as a 7-day class and soon evolved into a 2-week comprehensive program. Format and presentations blended didactics with

case studies, simulations, and clinical opportunities. Additionally, the focus on student guidance and support was emphasized. Requirements for successful course completion included daily assessments and a post test with a minimum score of 84%. The Beginnings class was recognized as “core” specialty-education in women and newborn care for novice nurses, as well as for all nurses entering all areas of women’s services at WPH. Course evaluations were overwhelmingly positive. After the fact, it was noted that the retention rate was greater than 90% for those that attended the Beginnings course from January 2008 through December 2011. Implications for Nursing Practice Development of the Beginnings class continues to serve as the foundation of nursing knowledge for the graduate nurse by incorporating the Nursing Professional Practice Model and Magnet components, which utilize evidence-based practice, provide standardization, and support nursing practice for optimum patient-first care.

The Pearls and Perils of Cross-Training: A Collaboration of Antepartum and Labor and Delivery Room Nurses Mary J. Manelski, BSN, RNC, Purpose for the Program Christiana Care Health System, cross-training program was designed to inBear, DE

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crease the skill level of antepartum nurses in

Shelli P. Wagner, BSN, RNC, preparation for the increase acuity of patients in Christiana Care Health System, the unit. Cross-training has been used by healthNewark, DE care facilities to support the fluctuating needs of

hospital units. Staff with similar skill sets have been successfully cross-trained with education


and clinical support. A cross-training program was implemented in our health system to increase the skill level of the nurses in the antepartum unit. The program was to be a means of strengthening ties with labor and delivery (L&D), while at the same time giving the antepartum nurse an opportunity to experience the L&D process. Linking these units with similar skills made cross-training easier

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because the nurses were already familiar with many of the protocols and devices. This poster presentation will display the benefits of crosstraining the antepartum and L&D staff, and illustrate challenges encountered. Proposed Change To provide opportunities for antepartum nurses to acquire new skills and enhance skills, knowledge, and abilities. Implementation, Outcomes, and Evaluation To implement cross-training to increase the skill level of nurses to accommodate the higher acuity level of patients in an antepartum unit. The nurses from the antepartum unit were paired with nurses from L&D for several shifts. New staff nurses were oriented in L&D for several weeks. Experienced nurses had a shorten rotation to the L&D unit. The L&D preceptors played an important professional and individual role toward achieving desired clinical outcomes. The nursing staff from L&D and the antepartum unit developed a bond of

respect after spending time together. The antepartum nurses gained a surge of knowledge, confidence, and professional growth during their crosstraining. Outcomes included acquisition of new skills and insights, increased morale, improved overall motivation and collaboration between the units, and improved confidence of staff. Implications for Nursing Practice Cross-trained nurses developed new skills, confidence in patient care delivery, and respect for each other. With more skilled and flexible nursing staff, patients receive optimal care. At the end of cross-training, nurses from the antepartum unit were given a survey to evaluate their crosstraining experience. Novice nurses learned new skills, experienced antepartum nurses expanded their knowledge base, and L&D nurses had the opportunity to take pride in their leadership capacity as preceptors. All participants involved in this cross-training program enriched their skills and strengthened the delivery of care in our women’s health units.

Donna M. Norris-Grant, BSN, RNC, Christiana Care Health System, Bear, DE Keywords cross-training morale preceptor staff development novice nurse antepartum


Integrating Evidence for Excellence in the Care of Women and Newborns: The Evidence-Based FellowS Program Purpose for the Program hough the importance of evidence-based practice (EBP) is readily acknowledged and ascribed to, studies show that a small percentage of nurses are incorporating research findings into practice. This presentation describes a pragmatic model implemented in a Magnet hospital, the EBP FellowS (Sharing Science) program, to facilitate the integration of evidence into practice. The EBP FellowS program is a 12-week offering of didactic and project development, with an additional 8 to 12 weeks of mentoring. Participants are selected based on a proposed question that has potential to improve patient care through the translation of evidence into practice. FellowS participate in didactic offerings, workshops, and coaching sessions that take them from question formulation through an evidence review and subsequent project development, implementation, evaluation, and dissemination. For this presentation, the aforementioned process will be illustrated by an EBP project undertaken by a team from the mother–baby unit.

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Proposed Change Based on evidence that nonseparation leads to improved attachment between mother and infant, emotional stability, protection against infection, and increased breastfeeding rates, this team is

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seeking to promote mother–infant attachment by allowing mothers and infants to remain together 24 hours per day. This would, hopefully, decrease or eliminate the need for a newborn nursery. Implementation, Outcomes, and Evaluation To implement this evidence-based project, the mother–baby team will establish a nonseparation model of care by educating the staff through staff meetings and group sessions. Questionnaires and surveys will be distributed to mothers to gather their perceptions of rooming-in. The nurses in the mother–baby unit also will receive surveys to determine reasons for separation of the mother and infant. Admission pamphlets will explain the nonseparation model before the mother/infant stay in the unit. Upon completion of this EBP performance improvement project, expected findings indicate an increase in patient satisfaction and comfort with infant care. The anticipated completion date of this study is October 2012.

Jennifer Anne King, BSN, RN, Lehigh Valley Health Network, Allentown, PA Krista Diane Thomas, BSN, RN, Lehigh Valley Health Network, Allentown, PA Keywords EBP nonseparation mother/baby attachment performance improvement


Implications for Nursing Practice The EBP FellowS program is a model that can be replicated in a wide variety of healthcare settings. More specifically, the EBP study to promote mother–infant attachment serves as an example of how evidence can be used to positively improve practice in the mother–baby unit.

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Olivere, R. M.


Setting Yourself and Your Patients Up for Success: Utilizing Scripting in the OB Setting Allison Reynolds, BSN, RNC-MNN, Baylor University Medical Center, Dallas, TX Keywords scripting best practice outcome customer service finance


Purpose for the Program very mother–baby unit must strive to provide excellent patient care, including excellent customer service. Unfortunately, patients can present with unrealistic expectations of hospitalization after giving birth to the infant. Nurses are challenged to deal with patient requests and demands, which may not be aligned with current best practices or be fiscally responsible (e.g., “I want my infant in the nursery so I can sleep,” “I’m going to breastfeed, but not until I get home,” or “I need two packs of wipes and another pack of diapers for my baby”). If not dealt with appropriately, patient satisfaction scores can suffer, mothers can be ill prepared to care for their infants at home, and/or finances can be negatively affected.

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Proposed Change To train nurses to educate and inform patients while utilizing scripting tools and customer service tips. Implementation, Outcomes, and Evaluation This first step included a review of patient satisfaction scores, core measures, and budget. A focus group was assembled to address each issue and propose scripting tools to address areas of concern. Scripts were written and shared with staff. Over time, the unit saw an increase in patient satisfaction scores and exclusive breastfeeding, and a significant reduction in supply cost. Implications for Nursing Practice When provided with scripting tools, nurses can provide excellent patient care and excellent customer service while maintaining budget.

Bringing the Patient to the Center: Implementing an Interdisciplinary Rounding Approach in the Labor and Delivery Setting Ryan M. Olivere, MSN, RNC-OB, The Hospital of the University of Pennsylvania, Philadelphia, PA Keywords interdisciplinary rounds performance improvement methodologies teamwork


Purpose for the Program o create an interdisciplinary approach to care in a busy labor and delivery unit that keeps the patient at the center of the care provided.

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Proposed Change To create a standardized approach to care in which staff from obstetrics, nursing, neonatology, and anesthesia have the opportunity to meet and discuss the plan of care for each patient in the labor and delivery unit at designated times during the day. In addition, the patient has the opportunity to meet the team who will care for her and her infant in the upcoming shift. Implementation, Outcomes, and Evaluation By using performance improvement methodologies, an interdisciplinary team was assembled to identify why previous attempts at an interdisciplinary approach to care in this setting was unsuccessful, to work with their respective disciplines to bring the voice of the patient to the table, and to identify what elements of care were identified as the most important to share with the team and receive from the team during the actual interdisci-


plinary rounds. The team chose a huddle format where the interdisciplinary team would assemble at least twice a day in the labor and delivery unit, walk room-to-room to discuss each patient, and devise a plan of care that the entire team was aware of. The outcomes identified an increased culture of safety in the labor and delivery unit. Two specific Agency for Healthcare Research and Quality (AHRQ) survey questions that highlight teamwork within the unit were distributed and transitions/handoffs are anticipated to be increased. The initial AHRQ survey was conducted approximately 1 year before the implementation of the interdisciplinary rounds. We will repeat the safety culture survey 6 months after implementation to see if there is an increase in the domains that have already been identified. Implications for Nursing Practice Successful implementation will allow the work of the nurse to be more streamlined, bring the voice of the patient to the discussion, and allow the nurse to fulfill her accountability of being the patient’s primary advocate.

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Implementing AWHONN’s Perinatal Staffing Guidelines: Curing the Staffing Blues and Transforming a Unit Purpose for the Program mprove patient outcomes, quality of care, and nurse satisfaction by following the updated staffing guidelines of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN).

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Proposed Change To transition to an all registered nurse (RN) staff while meeting staffing ratios in a defined time frame. Implementation, Outcomes, and Evaluation To meet AWHONN’s professional perinatal staffing guidelines released in 2010, leadership advocated for an all RN staff for the mother–infant unit. This skill mix change involved finding new roles for 11 licensed practical nurses (LPNs) employed both in the nursery and caring for mother– baby couplets. Leadership collaborated with the human resources department to identify various departments within Bon Secours seeking LPNs. Informational sessions were held so they could stay within the organization. Leadership advocated for increased hours per patient day in

the mother–infant unit so practice would com- Mary Otero, BSN, RN, NE-BC, ply with the recently updated AWHONN staffing Bon Secours St. Mary’s Hospital, Richmond, VA guidelines. Transformation in the mother–infant unit over the past year has taken place after the implementation of the AWHONN guidelines. This is evidenced by increased Gallup RN satisfaction scores from 4.55 in 2011 to 4.88 in 2012. Certifications have increased from three certified nurses to 22 certified nurses and quality of care has risen. Patient satisfaction scores have also steadily increased. Implications for Nursing Practice Before this change, the RN was responsible for the outcome of care for six to eight couplets if the RN was caring for his/her own assignment of patients and directing care for the LPN’s patients. Modification of our staffing guidelines decreased workload and individual responsibility, which allowed for unified teamwork. Now the RN has more time at the bedside and spends less time making daily and shift-to-shift staffing decisions.

Kirstin T. Mason, RNC-MNN, Bon Secours St. Mary’s Hospital, Richmond, VA Keywords transformation AWHONN perinatal staffing guidelines RN satisfaction employee engagement certification


Nulliparous, Term, Singleton, Vertex Cesarean, Oh My! Deciphering the Perinatal Core Measures Purpose for the Program n late 2009, the Joint Commission introduced the Perinatal Care Core Measure Set as a way for hospitals to use evidence-based practice to assess quality in perinatal care. By reviewing data collected and proposing changes to the current state of care, patient safety and quality are improved. Our Women’s and Children’s Services department started collecting data as a way to make staff aware of how we compare nationally and to identify areas that need improvement. Performance improvement (PI) was introduced to the staff.

Implementation, Outcomes, and Evaluation Data collection began in late 2011. A scheduling form for labor inductions and cesareans was developed to capture reasons for elective deliveries and cesareans and as a tracking mechanism for assistance with data collection. Triage data were used to collect antenatal steroid usage. Exclusive breastfeeding rates have also become very important in the hospital’s move toward Baby Friendly designation. A staff report card was developed to see how well each person was doing to support exclusive breastfeeding. Data collection for PI was introduced to staff in a nonthreatening, simplified way.

Jennifer A. Orlosky-Novack, MSN, RNC-OB, APN, Bayhealth Milford Memorial, Milford, DE

Proposed Change Data collection began using the Perinatal Core Measures as a guide. Those data were graphed, analyzed, and communicated to physicians and nurses. The goals were to decrease the rate of elective deliveries, give antenatal steroids as required, and decrease the cesarean delivery rate.

There is a greater awareness of elective inductions among staff nurses and physicians and a better understanding of the importance of PI data collection. A preterm labor order set was developed to help remind staff about ordering and administering antenatal steroids. The elective delivery rate is decreasing since putting the scheduling criteria in place. The exclusive breastfeeding rates are


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JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12130

Susan M. Kline, BSN, RNC-OB, Bayhealth Kent General, Dover, DE Keywords core measures elective deliveries cesarean deliveries antenatal steroids exclusive breastfeeding


Shields, N., Younker, T., Polis, N., and Saurman, C.


increasing as all staff compete to score 100% on their breastfeeding report card.

which change comes. More nurses are becoming involved in PI at the unit level.

Because we strive to have zero elective deliveries, there is still work to be done to continue to improve elective delivery rates. Educating the staff and community will help with exclusive breastfeeding rates. The core measures are a springboard from

Implications for Nursing Practice The use of the Joint Commission Perinatal Care Core Measures helped improve communication with the staff nurses and physicians. Staff nurses learned that PI does not have to be incomprehensible. PI helps nurses keep patients safe!

How Did You Get That Job? Exploring the Role of the Perinatal Clinical Research Nurse Robin Lynn Driver, RN, Purpose for the Program C-EFM, BS, Mount Carmel erinatal research is an emerging focus and Health System, Westerville, OH

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has become the topic of many recent discussions. A priority at our level III facility is to promote Keywords research and provide our patients with the opporperinatal clinical research nurse tunity to participate in various studies that may have a significant effect on their outcomes.


Proposed Change The addition of the perinatal research team was led by the system medical director for maternal– fetal medicine. Support from administration was imperative, as this position required a full-time nurse, office space, supplies, and staff education. In addition, there were added responsibilities for the maternal–fetal medicine specialist as the principle investigator. Implementation, Outcomes, and Evaluation A plan to implement the perinatal research team was developed. The team consists of a full-time perinatal clinical research nurse, several casual research nurses, and two perinatologists dedicated to the principle investigator role. Implementation required nurse/physician collaboration, as the perinatal clinical research nurse and physician principle investigators provided education to staff nurses, advanced practice nurses, obstetricians, and neonatologists regarding the various studies. Challenges included financial obligations related to salaries and supplies, office space, and

staff resistance related to changes and new protocols. The addition of the perinatal research team has been an excellent addition to our facility as we strive to move forward and provide best practices to our moms and infants. Since initiation, our facility has participated in seven different studies that involve hundreds of patients. Several studies are ongoing for data collection and two remain open for recruitment. Two articles have been published in professional journals and data analysis continues. Implications for Nursing Practice The role of the perinatal clinical research nurse provides an exciting opportunity for professional growth and development. The position is the perfect balance of patient interaction and data collection. Essential responsibilities include educating patients about various studies and obtaining informed consent, collaboration with the direct care nurses and physicians, data collection, and followup. Other duties include learning about new study procedures, Human Subject Protection policies, Institutional Review Board protocols and documentation, and good clinical practices. The benefits to both the patient and the research team are plentiful. The patient has the option to participate in studies that may improve outcomes for her and her infant and the research team has the opportunity to contribute to advances in perinatal care.

Raising the Bar for Patient Safety in Obstetric Care Nancy Shields, MSN, BSN, RNC-OB, Main Line Health, Paoli, PA Tracy Younker, MSN, BSN, RNC-OB, Main Line Health, Paoli, PA

Purpose for the Program mproving patient safety has become a major focus for healthcare organizations, especially in high-risk areas such as obstetrics. Teamwork and collaboration among the healthcare team are essential for improved outcomes for mothers and neonates, error prevention, and quality care. Clinical care in obstetrics is complex, and the healthcare team often deals with rapidly changing or

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ambiguous patient situations, time pressures, and decisions that have the potential for serious consequences. The healthcare team is made up of individual expert clinicians, but these clinicians are not necessarily experts in working together and communicating effectively. Thus, the purpose of this program is to take teams of expert clinicians in a healthcare system and turn them into expert (functioning) teams.

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Proposed Change Four obstetric units within a healthcare system proposed to take patient safety to a higher level with the goals of improving clinical quality and outcomes; keeping mothers, infants, and family members safe; and becoming more effective and efficient as a team. The strategy was to combine the best practices of team/crew training and the tools needed to develop a high-reliability culture into one patient safety program for obstetric care providers. Interdisciplinary classroom education was developed and included crew training concepts related to communication, teamwork, and collaboration; high-reliability culture error prevention tools; and simulation and experiential learning. Other tools, such as chain of communication, board rounds, preprocedure and postprocedure briefings, and contingency teams were discussed during the educational program but implemented one at a time to hardwire the changes.

Implementation, Outcomes, and Evaluation An interdisciplinary team was involved in the program planning and development and served as trainers. Teams of obstetricians, anesthesiologists, certified nurse anesthetists, midwives, neonatologists, neonatal nurse practitioners, registered nurses (RNs), obstetric technicians, and unit secretaries participated in the collaborative training experience. Qualitative and quantitative data were collected related to clinical outcomes as well as teamwork and collaboration. Implications for Nursing Practice Improvements have been identified in multiple areas, including quality, communication, and teamwork, and the use of tools to support communication (e.g., board rounds and briefings) has been sustained. A comprehensive program that addresses both the development of expert teams and the tools needed to shape a high-reliability culture provides the needed framework for delivering care in a safe, reliable, and accountable environment with engaged healthcare providers.

Nikki Polis, PhD, RN, Methodist LeBonheur Healthcare, Memphis, TN Christina Saurman, MSN, BSN, RNC-OB, Main Line Health, Paoli, PA Keywords team training patient safety communication high-reliability culture


Improving Obstetric Rapid Response Teams: Multidisciplinary Simulation Training Using the Plan-Do-Study-Act Cycle Purpose for the Program neffective teamwork and communication failures contribute to 70% of adverse obstetric events. Citing an increase in maternal mortality, the American College of Obstetricians and Gynecologists (ACOG) and the Joint Commission recommended creating obstetric rapid response teams. These recommendations include using drills to ensure competency during emergencies.

Proposed Change The purpose of this innovative program was to train the obstetric RRT in PDSA cycle use (through multidisciplinary simulation) to achieve the following three goals: (a) identify the most common errors during obstetric emergencies and reduce them by 50% in 1 year; (b) increase the number of rapid response calls by 50% in 1 year; and (c) decrease the time from the rapid response call to team response by 25% in 1 year.

Karen Smith, BSN, RNC-OB, York Hospital, York, PA

Our institution developed a rapid response team (RRT) of nurses, residents, attending physicians, and ancillary staff from the obstetrics, neonatology, and anesthesiology departments.

Implementation, Outcomes, and Evaluation Each multidisciplinary training session includes the following: RRT lectured in one obstetric emergency per session; videotaped live simulation in the unit, which is witnessed by the entire RRT; RRT divides into small groups and use PDSA method to discuss needed changes/process improvements; the entire RRT debriefs on simulation/small group simulation results; the debrief action plan is created based on group PDSA/simulation findings; PDSA changes are trailed clinically by teams during real calls; and successful changes are implemented and reviewed at the next training session.

Eileen Garavente, MD, York Hospital, York, PA

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We used the Plan-Do-Study-Act (PDSA) methodology to train RRT members to identify system and process barriers that impede effective emergency response. Changes, based on these observations, were trialed during live videotaped in situ simulations. If, after debriefing, the group deemed the changes worthwhile, an action plan to implement the change was created. Changes were incorporated into obstetric emergency protocols and reviewed at the next training session.

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JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12133

Jennifer Leash, BSN, RNC-OB, York Hospital, York, PA Tracy Cadawas, BSN, RNC-MNN, York Hospital, York, PA Jennifer Aguilar, MSN, RN-NIC, York Hospital, York, PA

Meredith McMullen, MD, York Hospital, York, PA Denita Boschulte, MD, York Hospital, York, PA Keywords rapid response PDSA obstetric emergency




Massaro, D. and Murphy, S.


Since implementation of the RRT, we have increased accessibility of equipment and supplies by 50% by creating RRT carts, increased accessibility to uterotonic medications by 50%, increased team response calls by 50%, successfully implemented two mass alert communication systems, and created and completed three group simulation.

Implications for Nursing Practice Multidisciplinary PDSA cycle training creates objective team building and problem solving. This gives healthcare providers ownership in change that directly affects clinical care. PDSA simulation training aids in improving staff emergency preparedness, identifying the most common obstetric emergency errors, and creating evidence-based protocols based on successful PDSA change implementation.

Blending Caring and Excellence: Translating Culture of Caring and Safety in Bedside Handoff Felicitas Cacal, BSN, Purpose for the Program RNC-Inpatient, Obstetrics, o determine whether the blending of culture of Northwest Community caring, bedside handoffs, and safety checks Hospital, Arlington Heights, IL

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will improve patient satisfaction, increase collabo-

Pauline Moy, BSN, Northwest ration among team members, and improve patient Community Hospital, Arlington safety in the labor and delivery unit. Heights, IL Keywords Proposed Change bedside handoffs A labor and delivery unit in a community hospital safety checks developed a new process for shift-to-shift reportchampions and culture of safety

ing that blends the culture of caring concept with bedside handoffs and safety checks.


Implementation, Outcomes, and Evaluation Change of shift report is the time when critical information relevant to patient care is communicated and exchanged between staff members. With the initiation of the culture of caring concept and the analysis of the last two quarters’ house-wide Press Ganey patient satisfaction scores, results revealed that improving patient satisfaction and safety must be the primary goals of the unit. A voluntary labor and delivery core team of nurses and physicians named Innovative Practice Team (INPT) was created. Expectations, goals, and evaluations were developed and probable challenges and barriers were recognized and identified. Information regarding the new initiative was communicated through e-mails before implementation. Physician and nurse champions piloted the initiative. This was followed by the go live phase. Structured bed-

side handoffs were implemented. Critical and private information were discussed in a brief report outside the patients’ rooms. Bedside handoffs took place in the patients’ rooms using the patient care board with patient friendly language. Key information, such as plan of care, was discussed with the patients, including significant events that occurred during the previous shift. Teach-back method was used, including pain medication and plan of care. Safety checks were performed on high-alert medications and equipment. Staff evaluations provided strong positive feedback in the areas of value of communication methods, increase in collaborative efforts among team members, and efficacy of safety checks. Leadership will continue to play an important role in sustainability through daily shift-to-shift rounding. Additional outcomes will continue to be assessed through house-wide quarterly Press Ganey patient satisfaction scores. Implications for Nursing Practice The methods used enhanced the majority of staff acceptance and the participation necessary to improve patient satisfaction and maintain culture of safety and caring while including patients in the plan of care. Patients witnessed collaborative effort among team members. Staff participation has been strong and continuous efforts to bring staff to compliance through unit leadership (daily rounding) has played a considerable role.

White Boards: An Innovative Tool for Patient-Centered Communication Danielle Massaro, BSN, RN, White Plains Hospital, White Plains, NY

Purpose for the Program n the fall of 2011, the Press Ganey patient satisfaction scores reflected that there were areas for improvement, specifically in communication between physicians and nurses, pain med-

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ication accessibility, and lactation education. This trend was noted throughout the hospital. Having the patients actively participate in their care has been cited as an important part of ensuring patient safety.

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Proposed Change The entire hospital ventured on the path of creating unit-specific whiteboards to address this issue. We had small plain whiteboards in every room for a few years. There was no standardized and consistent approach to what was written on the whiteboards. Staff in the mother–baby unit worked on several templates that were devised and shared with the staff. The whiteboards were divided into several sections, including information that was important to our patients. Implementation, Outcomes, and Evaluation In the early January 2012, new obstetric whiteboards were hung in each of the rooms. They are large, easy to read, colorful, and patient centered. The entire hospital staff received in-service training on the use of the whiteboards, how to help patients achieve their goals by using the whiteboards, and the expectation that whiteboards should be updated. At each shift, the oncoming nurse updates the whiteboard with new information, names, and goals that are created in conjunction with the patient. Managers round on all of the patients on a daily basis and audit the whiteboards

during that time. When whiteboards are being inconsistently filled out staff are addressed accordingly. The outcomes, using the Press Ganey and the Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) surveys, reflect that patients love the whiteboards and note improved communication. We are currently working on using magnets with pictures of the healthcare team so that the patient can identify a face along with a staff name. Implications for Nursing Practice Overall, because communication is related to patient safety, it has always been cited as an area that has opportunities for improvement. Patients do not always remember names of healthcare providers and uniforms do not help patients distinguish who is a nurse or nurse technician. Patients cannot remember telephone numbers, what time their pain medication is available again, and when they need to walk or pump their breasts. This patient-centered tool has been acclaimed as wonderful, by other health professionals visiting our hospital, by patients and their family members, and by members of the Perinatal Listserv.

Stacy Murphy, BSN, RN, White Plains Hospital, White Plains, NY Keywords whiteboards communication patient satisfaction


Shaping Up: Unit-to-Unit Handoffs with a Lean Six Sigma Work Out Purpose for the Program t is well documented that ineffective communication through handoffs can lead to gaps in patient safety. Sharp Mary Birch Hospital for Women & Newborns has approximately 8,500 annual deliveries. As a result of the rapid turnover of patients, number of daily admissions, and daily bed capacity limitations, unit-to-unit handoffs are frequent, fast-paced, and problem prone. The Employee Opinion Survey and Culture of Safety data indicated that there was room for improvement in unit-to-unit handoffs and teamwork across departments.

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Proposed Change Conducting a Lean Six Sigma Work Out that focused on unit-to-unit handoffs. A Work Out is a process designed to bring together the right stakeholders to develop solutions and actions. The Work Out group reviewed current practices, determined information that should be included in reports between units, and developed a standardized report checklist. The Work Out group also planned the next steps for implementing face-toface report.

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Implementation, Outcomes, and Evaluation After a trial of the standardized report checklist, input from staff was used to revise the checklist, which is now to be used for all unit-to-unit handoffs. When comparing the 2012 with the 2011 Culture of Safety Survey for the hospital, there were significant improvements in patient safety perception and teamwork within units. There was no change in the overall score for teamwork across units, though this score was already at the 75th percentile and there were notable improvements in individual departments. The hospital plans to implement faceto-face report in all hospital units starting with labor and delivery and maternal infant services. To minimize training costs to implement the new process and to improve retention of information, creative tools, such as animated video of good and bad handoffs, will be used.

Ellen Fleischman, RN, RD, MBA, MSN, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA Monika Lanciers, BSN, RN, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA Keywords handoffs six sigma patient safety culture of safety communication


Implications for Nursing Practice Lean Six Sigma tools provide an effective methodology for process improvement in hospitals. The Lean Six Sigma Work Out process can be used to standardize report between units and as a result lead to improvements in patient safety.

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12136



Reis, H. and Sinopoli, S. M.


Meaningful Use: Staff Led Design for a New Perinatal Electronic Health Record Elizabeth Remsburg-Bell, MSN, RN, Palomar Health, Poway, CA Vaneese Cook, RN, BSN, Palomar Health-Pomerado Hospital, Poway, CA Keywords meaningful use electronic health record balanced scorecard clinical documentation trend analysis


Purpose for the Program here is no greater current challenge for healthcare organizations than clinical information and documentation. It is through the gathering and strategic use of accessible information about the patient, care provided, and outcomes that we will be able to measure and improve efficacy of care.

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Proposed Change With the evolution and implementation of the electronic health record (EHR) in 2011, Palomar Health launched the process to support the health system documentation, trend analysis, and business practices in both low-risk and high-risk practice settings. The addition of the perinatal EHR documentation component was strategically planned for phase two of the implementation. This phase also included the retiring of a legacy system currently being used for documentation by the obstetrics service line at multiple locations. Implementation, Outcomes, and Evaluation This project blends documentation design and validation, continuing education, and ongoing performance improvement to achieve regulatory

compliance and goals. The perinatal EHR is intended to provide all members of the healthcare team with comprehensive, accurate, and timely patient information. Staff-led teams completed a design review of data collection, clinical, and registration forms, along with integration to surgical scheduling and documentation. In addition, key standardized reports were identified. These reports support statistical analysis of delivery data as well as department statistics. An aggressive timeline was set with postimplementation benefits identified and measured. Implications for Nursing Practice The project work correlates nicely with the establishment of a freestanding Women’s Hospital and alignment to standardize practice and policy as well as strengthen relationships within the health system. Staff and leaders from both sites were instrumental in the success of the project. The next phase of this project continues to focus on strategic alignment of policy and practice with the creation of custom reports and advanced data abstraction for benchmarking.

Collaboration and Simulation: Striving for Obstetric Excellence With the Emergency Department Hope Reis, MS, RNC-OB, Purpose for the Program ANP-BC, Northwest o coordinate the obstetric (OB) rapid reCommunity Hospital, Arlington sponse team with the emergency department Heights, IL

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trauma team of a busy community hospital. Atten-

Susan M. Sinopoli, BSN, dance by OB and emergency staff at an AssociRNC-MNN, Northwest ation of Women’s Health, Obstetric and Neonatal Community Hospital, Arlington Nurses (AWHONN) webinar, Perinatal Code ManHeights, IL Keywords obstetric rapid response team critical obstetric patient simulation


agement, sparked a lively dialogue from which evolved a plan for simulation. A policy on management of the OB patient for the emergency department worked well in most situations. The focus was to fine-tune the actual response times and process. How do we work together? Is it possible to deliver a newborn via emergency cesarean within the recommended 5 minutes after cardiac arrest? Because it could be applied to the emergency department, simulation often was used on the OB unit for staff training of critical situations.

Proposed Change When the OB team responds to the emergency department in critical situations, coordination of both


interdisciplinary teams is important for best patient outcomes and coordinated emergency response. Training most often occurs at department levels; this silo training can lead to challenges between the teams. Implementation, Outcomes, and Evaluation Coordinators first met to identify current process, team members, best practice, and purpose of the simulation. The multidisciplinary team participants identified included members from the emergency department, labor and delivery, neonatal intensive care unit, and other ancillary departments. The following education items were identified for presimulation review: communication, team purposes, roles, and equipment. A scenario was developed for the simulation that incorporated a pregnant female who had been in a motor vehicle accident and was experiencing cardiac arrest after admission to the emergency room. The debriefing after the simulations was used to identify elements that went well and

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opportunities for improvement. Initial notification of the teams worked well, as did management of patient care. Some opportunities identified were access and use of equipment, wayfinding, critical times, and communication. As a result of these findings, projects were assigned to specific team members to eliminate gaps. Subsequent simulations were planned to test these changes. Implications for Nursing Practice Two separate critical response teams working together bring differences in communication and processes that must be identified and understood by all participants to promote true interdis-

ciplinary/interspecialty coordination. Teams who normally function well in rapid response situations may react differently when taken out of familiar environments. The OB department staff was familiar with the process of unit simulations; however, the emergency department primarily used simulation for large, emergency management drills. Crew resource management processes were used for communication and identification of roles. Additional simulations are planned using additional patient situations that require support by the OB rapid response team (e.g., stroke).

Implementing Multidisciplinary Competency Simulation Drills in a Financially Challenged Public Safety Net Hospital Purpose for the Program atient safety is always a priority, and several needs were identified. We wanted to create new training to capture the staff’s attention and motivate them to incorporate changes in their practices. We chose to use simulation as our method of instruction. Because of the limited resources, we had to be creative to implement this endeavor. Inclusion of all disciplines was very important to increase the understanding of everyone’s role and improve communication.

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Sabrina Dryden, RN, BSN, Proposed Change The simulation included process changes and in- Wishard Health Services, Indianapolis, IN troduction of new equipment. Keywords

Implementation, Outcomes, and Evaluation simulation education The process is undergoing continuous evaluation. financially challenged public safety net hospital multidisciplinary Implications for Nursing Practice Overall, the staff expressed increased confidence in being prepared for these situations as well as improved communication with the medical staff. Professional

Issues Poster Presentation

You Can Do It! A Practical Approach to Building a Strong Perinatal Leadership Team Purpose for the Program astern Idaho Regional Medical Center (EIRMC) recognized the need to grow the charge nurse team and create a succession plan that allowed this rural, regional center to have a wealth of skilled nursing leaders who in the future could move into high-level management positions and ensure the future success of the hospital’s nursing staff. The purpose of this abstract is to break down the process that is used to convert a charge nurse team from ordinary leaders to extraordinary clinical supervisors. This process is made possible through a combination of focused education around key leadership values and the practical steps used to move the team forward.

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Proposed Change The development of the Perinatal Leadership Council at EIRMC started in June 2012 with a proposed change in the job description of the clini-

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cal supervisor. Previously, the job description and daily responsibilities of the clinical supervisor mirrored that of a charge nurse. The delineation of the role of a charge nurse versus a clinical supervisor was predominately by title only, and the clinical supervisor was on a different pay scale than a charge nurse. The role was implemented with the proposed change in the job description and clearer delineation of the role, including a BSN, certification in their specialty, crucial conversations training, and accountability beyond their scheduled shifts.

Dixie K. Weber, MS, RNC, Eastern Idaho Regional Medical Center (HCA), Idaho Falls, ID Keywords perinatal leadership development growth team


Implementation, Outcomes, and Evaluation Fourteen perinatal clinical supervisors are currently participating in the updated role. A selfassessment was the first tool used to identify the current status and health of each member of the team. This initial assessment consisted of questions that helped them recognize their strengths

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12140



Rust, C. L.


and weaknesses, as well as determine both personal and professional goals. By using the results of the questionnaire, a focused education plan was developed for each team member through a one-on-one coaching session with the nursing director. The education plan includes biweekly meetings as a team, quarterly hospital-wide leadership education, one-on-one coaching sessions, and individual safety-focused projects to assist with improving the outcomes of the department.

Implications for Nursing Practice Data will be analyzed in the spring of 2013 through questionnaires, focused interviews, and overall hospital ratings, including patient satisfaction scores, core measure data comparisons, and physician satisfaction scores. The team anticipates it will be able to clearly identify the course for developing leaders at the staff level who have the key skills required to manage the day-to-day activities of their department, support and promote peer development, and improve patient outcomes and experiences.

Implementing a Healthcare Worker Pertussis Immunization Program: Benefits and Barriers Christina L. Rust, MSN, RNC-OB, C-EFM, St. Elizabeth Healthcare, Edgewood, KY Keywords pertussis immunization healthcare worker health belief model


Purpose for the Program o create an education plan to empower healthcare workers to understand their susceptibility to pertussis and to receive the pertussis vaccination.

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Proposed Change To increase the number of pertussis immunized healthcare workers from approximately 20% to 90% at one healthcare facility. Implementation, Outcomes, and Evaluation By increasing the number of healthcare workers who have received the pertussis vaccination through a comprehensive healthcare worker pertussis immunization program, the likelihood that a newborn infant and mother would be exposed to pertussis from a healthcare worker would be greatly decreased. This would increase fortify the pertussis cocoon the healthcare facility attempts to establish around the newborn and his/her family. Pertussis immunization also would protect healthcare workers from exposure to pertussis from patients, family members, and visitors. Pertussis infection in newborns carries a significantly high morbidity and mortality rate because these infants are too young to have received their pertussis vaccination. A comparison of healthcare worker immunization rates before and after program implementation will


be calculated. A survey of healthcare workers will also be conducted using the Health Belief Model framework to determine their reasons for receiving the pertussis vaccination and the perceived barriers to pertussis immunization. These results will be used to modify the immunization plan to increase adherence. If the healthcare worker immunization rate does not reach the goal of 90% then a mandatory pertussis immunization policy may be implemented. Implications for Nursing Practice Pertussis is a completely preventable disease that can be almost completely eradicated through proper immunization. Currently most healthcare workers are not aware of their potential susceptibility to pertussis or that they could acquire pertussis from patients and individuals in the community in which they live. According to a study by Calagar et al. (2006), healthcare workers are at 1.6 times higher risk of acquiring pertussis than the general population. Increasing pertussis immunization rates for healthcare workers to 90% would protect the healthcare workers, newborns, the newborns’ mothers and family members, other patients and visitors, and the community from pertussis infection. The pertussis healthcare worker immunization plan also could benefit the employee and healthcare facility by decreasing potential employee absence due to pertussis illness.

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Discharge Timeliness for Mother Baby Couplets: A Six Sigma Project to Improve Throughput Purpose for the Program he purpose of the project was to improve the throughput and discharge timeliness of mother–baby couplets. The capacity on the mother–baby unit delayed care of the patients admitted to the labor and delivery unit for treatment and delivery. Six Sigma methodology application was enlisted to improve the care at discharge and provide a seamless discharge transition. Baseline measurements revealed that only 30% of mother– baby couplets was discharged by noon.

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Proposed Change The maternity throughput goals were to improve the rate of patients discharged by 12 p.m. from 31.5% to 50%, to have 75% of mother–baby couplets depart from the unit within 90 minutes of the last discharge, and to improve the skill level of the charge nurse to manage throughput. Implementation, Outcomes, and Evaluation An interdisciplinary team addressed processes. The methodology of Lean Six Sigma was applied. An improvement of 1.5% (30.5%) was noted. Areas that were stabilized through collaboration of the team were the services provided the day before discharge. Baseline data concluded that 69.1% of discharged patients left after 12 p.m., 55% of the deliveries occurred during the scheduled time frame, and low throughput. Lack of capacity to accommodate patients during periods of the day was identified. Stabilization of services before the day of discharge did not significantly improve throughput. The following processes on the day of discharge were not ad-

dressed: charge nurse ability, staff nurse ability, patient readiness for discharge, infant care, and physician discharge timeliness. The strategy for improvement included prepared designated charge nurses, a maternity discharge workflow indicator, and rapid cycle testing. The charge nurse ability was improved. The electronic discharge alert for mother and for infant was created. The maternity expected discharge list was completed each evening. Lactation consultation and documentation was developed within the electronic medical record. Phototherapy equipment consignment eliminated the wait for delivery and decreased readmissions for hyperbilirubinemia. The use of teletracking and transport aide expedited patients leaving the unit and maternity staff remained to care for other patients. Rapid cycle outcomes indicated that 47% of mother– baby couplets left the unit within rapid cycle three. The number of departures from the unit that took place within 90 minutes of the last discharge declined. Individual services and personal choice affected the data for couplet discharges. Average discharge time by 12 p.m. improved to 83%. A 12 p.m. discharge time has been normalized with correlation of consistency of application of processes.

Patricia Maurer, MSN, MBA, RNC-MNN, Pinnacle Health System, Harrisburg, PA Keywords throughput discharge timeliness patient satisfaction


Implications for Nursing Practice Improved staffing ratios enhanced the ability to promote discharge timeliness. Patient perception improved and documentation for lactation services improved quality of care. Newborn readmissions declined by 75%.

Overcoming Barriers to Implementing the International Code of Marketing of Breast Milk Substitutes—The Rosebud Experience Purpose for the Program n response to unethical marketing practices of infant artificial substances, such as formula, The World Health Organization (WHO) and the United Nations International Children’s Emergency Fund (UNICEF) drafted the International Code of Marketing of Breast Milk Substitutes (the code) in an effort to promote breastfeeding all around the world.

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Proposed Change The code was officially endorsed by WHO and UNICEF 1981 as an official stance against the unethical marketing and promotion of breast milk substitutes. However, within the United States, no formal legislation exists that requires compliance with the code, and violations of the code that inhibit breastfeeding initiation, duration, and exclusivity occur every day. Courageously, the staff and healthcare providers at the Rosebud PHS Indian Hospital (Rosebud) have taken a unique stand

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12143

Clifton J. Kenon, DNP, RN, IBCLC, The Indian Health Service, Aberdeen, SD Keywords code breastfeeding Baby Friendly hospital initiative

Professional Issues Poster Presentation http://jognn.awhonn.org


Young, R.


against unethical marketing practices within their facility and have overcome many barriers to implementing the code.

Implementation, Outcomes, and Evaluation Rosebud has been successful at implementing the code in its entirety to include exclusion of artificial substances and infant feeding materials as gifts, creating a commercial free patient education curriculum, and educating the entire hospital staff about their roles and responsibilities related to the promotion of breastfeeding and compliance with the code.

Implications for Nursing Practice This poster will highlight successful strategies used to overcome barriers of code implementation and create an environment where the promotion of breastfeeding is a priority. These strategies include removal of noncommercialized patient gift packs, acquisition of feeding supplies and artificial substances at fair market value, and education and motivation of staff members about code compliance. Through the implementation of this code, breastfeeding initiation and exclusivity rates have risen significantly at Rosebud. Therefore, the implementation of the code is an evidence-based paradigm for hospitals all over the world.

Perinatal Blood Pressure Measurement: A Critical Need for Accuracy. Implementation of an Evidence-Based Protocol Roselyn Young, MSN, RNC, Jersey Shore University Medical Center, Neptune, NJ Keywords hypertension pregnancy blood pressure protocol


Purpose for the Program ypertension in pregnancy is a leading cause of maternal and perinatal morbidity and mortality. Blood pressure measurement is the primary assessment in diagnosis and treatment planning for these high-risk patients. Inconsistent practices in technique can lead to inconsistent and inaccurate measurements. To improve safety and accuracy when providing nursing care, an evidencebased blood pressure measurement protocol was developed.

Implementation, Outcomes, and Evaluation A specific protocol was written based on the recommendations of the review team and all staff were informed of the new practice change. We then developed a computer-based learning program, which was required education for all staff and was completed before the change. All residents, faculty, and department chairs reviewed the recommendations at department meetings. The equipment was purchased and the biomedical team provided preventive maintenance for the equipment per standards.

Proposed Change The Hypertensive Obstetric Blood Pressure Measurement Evidence Review team was formed and included representation from nursing staff, nursing research, nursing education, and nursing management. A literature review was performed and a summary of recommendations was written for dissemination. These recommendations included positioning of the patient for measurement, use of auscultated manual blood pressures, cuff placement, sizes of cuffs, and use of the fifth Korotkoff sound. The recommendations also specified that manual measurements be used for any suspected or actual hypertensive patient on admission and discharge for accurate baseline measurements, and at any time a treatment change would be indicated based on blood pressure determinations or when clinical judgment suggested it.

A build of the documentation fields in the clinical information systems was completed and data for manual blood pressures, position of patient, time, and date were collected. Ongoing evaluations of the compliance data identified that improvement initiatives were still needed. Further improvement was implemented to highlight each patient needing a manual blood pressure assessment at morning team rounds each day and to reinforce staff education.

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Implications for Nursing Practice Inconsistent blood pressure measurement can lead to inaccurate assessments and lead to delays in or missed treatment for high-risk patients. Improving practices to follow evidence-based research and recommendations can improve safety and excellence of nursing care.

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The Art of Staffing in Labor and Delivery: A Tool to Quantify Staffing Demands Purpose for the Program n large and small labor and delivery (L&D) units nationwide staffing for patient needs can be overwhelming. Though those on the units know they are busy, there has been very little proof to relay to administration and leadership peers just how busy the unit can become or how quickly patient acuity fluctuates with little predictability. The WIDOC tool was developed as an L&D acuity tracking tool that quantifies the staffing pressure felt in all L&D units. Through use of this tool to track acuity (patient flow and adequacy of staffing) a platform is created for developing a common ground in communicating the needs of the unit to administration.

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Proposed Change Each L&D unit strives to not only provide safe and quality care to our patient population, but also provide exceptional delivery experiences for our growing families. We are challenged with finding ways to adequately staff for these events without having patients feel like nursing staff did not have adequate time to provide the needed care and desired experiences. The implementation of use of the WIDOC tool allows the L&D units to track patient acuity, patient flow, and adequacy of staffing. In addition, staff, fellow leaders and administration

need to receive education to understand the tool, Dara N. Lankford, BSN, RNC, what it measures, and what they can do to provide Baylor Health Care System, Rhome, TX support to the L&D unit in times of need. Keywords

Implementation, Outcomes, and Evaluation staffing The WIDOC tool was originally developed to sim- acuity ply track acuity on a busy L&D unit. After data safety collection using the first version and input from staff using the tool, it was expanded to include the element of patient flow to more accurately cap- Professional Issues ture the true state of the unit. We are currently in Poster Presentation the process of validating the tool and collecting data following the WIDOC tool revision. In early 2013, we will evaluate if all information needed to safely staff the unit is included in the WIDOC tool. Implications for Nursing Practice The WIDOC tool gives charge nurses a communication tool to help those outside of L&D understand the current state of the unit and helps leaders and administrators understand measures they can take to assist in turbulent environments. In addition, it gives the charge nurse a toll that can be used to predict what the unit acuity will look like at a specified time to be proactive in summoning help as needed. It also has proven useful in management of productivity.

Bedside Handoff: Enhancing the Patient Experience Purpose for the Program neffective communication has been cited by The Joint Commission as the root cause of most reported sentinel events. Patient handoff has been identified as a time when the risk of ineffective communication contributes to errors. When a report is given at the bedside, there is an opportunity to visualize the patient and include the patient and family in an exchange of information and planning of care. Bedside report has been shown to decrease lapses in reported information and, thus, increase patient safety and satisfaction. Improved nurse efficiency at shift change has been demonstrated while putting the woman, her infant, and support system at the center of communication.

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Proposed Change Shift report has traditionally taken place at the nurses’ station with little consistency in content or quality of the information exchanged. The proposed change moved the shift report to the bed-

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side, utilizing the electronic medical record and Jane Pierce, MSN, RNC-OB, incorporating the patient and her support system ACNS-BC, C-EFM, LNC, Upper Valley Medical Center, into the planning of her care. Troy, OH

Implementation, Outcomes, and Evaluation The first step was to research best practice regarding shift-to-shift report and various methods for implementation of such a change. From this research, a timeline was developed, which included staff and patient education, process development, utilization of tools in the electronic medical record and staff competencies before implementation. Nurse champions provided a key role by volunteering from each shift to act as leaders in bringing this change forward. A task force of nursing staff came together to identify challenges and potential solutions during each step of the development and implementation. All staff received a weekly e-mail before implementation, which enhanced their understanding of the positive effect of a shift report at the patient bedside and kept staff

JOGNN, 42, S1-S73; 2013. DOI: 10.1111/1552-6909.12147

Jenny Dietz, BSN, RNC-OB, Upper Valley Medical Center, Tipp City, OH Keywords bedside report handoff shift patient safety



Salas, T., Dalton, T., and Gettemeier, J. A.


informed of where we were in the process of changing report from the nurses’ station to the bedside. Staff acceptance and, therefore, participation in this process was greatly enhanced by education and buy-in before implementing bedside report. The nurse manager on our unit rounds on our patients daily and discusses bedside report as a part of their experience. To date, no negative issues re-

garding bedside report have been verbalized by patients. Implications for Nursing Practice Bedside reporting improves the patient experience by forming a partnership between the patient/family and their caregivers. In this poster presentation we will share our experience in planning and changing an integral part of our daily routing by moving report to the patient bedside.

Two Hospitals, Two Obstetric Units, One Common Vision for Education Trish Salas, BSN, RN, Progress Purpose for the Program West Healthcare Center, s the nursing profession continues to evolve, O’Fallon, MO

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evidence-based practice is crucial for caring for ongoing needs of obstetric patients. Community hospitals often are challenged with limited educational resources, yet have a strong desire Julie A. Gettemeier, MSN, RN, to deliver safe, quality care to the patients. In this project, two suburban community hospitals 7 miles Barnes-Jewish St. Peters Hospital, St. Peters, MO apart, with common organizational structure, similar volumes and practices came together with a Keywords plan to bridge the resource gap for education recommunity hospital garding women and infants. professional development Tamra Dalton, RN, Barnes-Jewish St. Peters Hospital, St. Peters, MO

collaboration education


Proposed Change To form an interdisciplinary committee to bring two obstetric departments from two community hospitals together for nursing education and professional development. Implementation, Outcomes, and Evaluation A committee with members from both hospitals including nursing management, clinical education, nursing staff, diabetes management, and lactation specialists was formed to work on this project. They completed a learning needs assessment and prioritized learning opportunities for staff. They developed the tools, content, policies, and procedures using evidence-based research and included expert staff from the nursing departments in developing programs. Education topics included maternal complications, such as uterine rupture, postpartum hemorrhage, peripartum and postpartum cardiomyopathy, managing second stage labor, pharmacology, breastfeeding ba-


sics, 39-week-of-gestation inductions, water birth, and diabetes management. The educational offerings were implemented using evidence-based practice to provide the support and foundation for the classes. The committee members worked collaboratively on the projects, promoting cohesive bonds between the departments while breaking down cultural barriers between the hospitals. The members united to strengthen the knowledge and expertise of bedside caregivers to provide safe and effective care for patients. As a result of this collaborative approach to education, the knowledge base of the nursing staff has increased because of the expertise and additional educational offerings provided to them. Implications for Nursing Practice The shared education program has laid the foundation for the collaboration of nursing resources between the two hospitals. Recently, the hospitals began sharing staff within the nursing departments to meet the demands of staffing and patient acuity. Collaborative learning as one unit has provided the nursing staff with the foundation and knowledge to comfortably move between the two hospitals. With the support of leadership and education, the committee continues to plan for additional future educational offerings. The commitment to the patients is represented through the dedication of two community hospitals and two departments, which creates an environment that supports the art and science of nursing care for their patients.

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Improving Safety Through Collaboration: The Interdisciplinary Perinatal Practice Committee Purpose for the Program linical care may not always be consistent with the latest evidence and scientific standards found in the peer-reviewed scientific literature, professional organization standards, and regulatory agencies. Risk reduction strategies in perinatal practice include adopting professional organization guidelines, standardizing evaluation and monitoring processes, and communicating identifiable pregnancy risks to members of the healthcare team. Communication issues have been identified as a leading cause of sentinel events. There was not an identifiable process to review the scientific literature, compare current practice to current scientific evidence, and recommend change based on the literature review.

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Proposed Change We needed an opportunity to collaborate with nursing, medical providers, risk management, and administration to look at our processes and practice throughout the continuum of maternal– newborn care. The concept of the Interdisciplinary Perinatal Practice Committee (IPPC) was identified and applied to our setting. Implementation, Outcomes, and Evaluation Discussions with key leaders in nursing, obstetrics, neonatology, and risk management were held to garner support of the idea. The perinatal advanced nurse clinician attended ob-gyn staff meetings to further promote the idea and to assist with the identification of healthcare providers

who would co-chair the IPPC with nursing. Infor- Jean Salera-Vieira, MS, mal nursing leaders and change agents were re- RNC-OB, C-EFM, Kent Hospital, Warwick, RI cruited to be part of the committee. Since its inception, the IPPC has met regularly. Topics are chosen based on staff input, policies, and procedures that are in need of being updated, and trends in evidence-based practice in the perinatal setting. The first topic, which took three meetings to review, was the use of oxytocin. Scientific, evidence-based articles and professional guidelines pertinent to the topic of discussion were sent to the committee members for review before each meeting. Medical education credits and nursing contact hours were obtained for each meeting. Each meeting has consisted of a lively, collaborative, and respectful discussion.

Keywords interdisciplinary perinatal committee perinatal safety collaboration


Nursing and medicine came together to look at the standards and evidence, compare current practice, and make changes to policies and procedures. New electronic medical record order sets were created based on the work of the IPPC. Order sets default to an increase of the rate of oxytocin every 30 minutes. Random audits of charts have shown that the healthcare providers are consistently using the new order sets. This indicates the success of the work of the IPPC. Implications for Nursing Practice Regularly scheduled meetings will ensure the continued work of the IPPC. This will serve to enhance patient safety as all disciplines involved are communicating using the same framework, collaborating, and integrating current science into practice.

New Year, New Way: Where Families Begin Purpose for the Program here Families Begin is a program being implemented in order for Women and Infants Hospital (WIH) to be certified Baby Friendly. In moving toward this designation WIH recognized that cultural changes needed to be made. Because the birth experience and postpartum approach to the care of all obstetric patients needed to be addressed, a three-part plan was developed.

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Proposed Change The initiative fell into the following three easily identifiable areas of change opportunities:

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Face-to-face reporting: All information regarding the patient and her newborn were to take place in the mother’s presence and in her room. This exchange would provide the mother with valuable information about her and her infant’s health. This process allows for improved patient safety by encouraging her to ask questions and correct misinformation. Skin-to-skin care: The mother and infant will maintain skin-to-skin contact throughout the transfer from the labor and delivery room (LDR) to the postpartum room. This initiative improves temperature stability, glucose control, pain relief, bonding, and breastfeeding success for the infant.

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Donnalee Segal, RN, BA, BSN, Women & Infants Hospital, Providence, RI Keywords Baby Friendly face-to-face reporting skin-to-skin rooming-in patient satisfaction breast feeding




Lundeen, S. and Padilla, M.


Rooming-in couplet care: Quality of care is enhanced when mothers, partners, and infants are not separated. This allows families to learn about their new infant while they become more experienced and comfortable with their infant’s cues.

Our patient satisfaction outcomes, measured by Press Ganey showed a slight improvement once our implementation began and the staff increased their level of competency with the new model. Increasing breastfeeding rates is also an initiative of this program and also showed a positive increase.

Implementation, Outcomes, and Evaluation To facilitate this change, weekly meetings were held with all staff on the mother–baby and LDR areas. Each nurse received re-education and training called “Off to the Best Start,” which focused on the three areas of change. Additional lactation education was provided and the staff began their transition to a new model of care.

Implications for Nursing Practice We are incredibly pleased with the enthusiasm of our staff and the ability of so many people to come together to plan, cross-train, and educate our staff and inform our patients. It was a monumental task, but as a leading maternity hospital in New England, it is important that we are on the cutting edge of care by incorporating best practice as our standard of care.

Mother–Baby Discharge Teaching Sharon L. Strek, MSN/Ed, RN, RNC-OB, Spectrum Health, Grand Rapids, MI Keywords patient education postpartum learning needs patient collaboration


Purpose for the Program ospital length of stay continues to decrease for new mother–baby couplets though the number of topics to learn continues to grow. Patients have not been involved in choosing what to learn during their hospital stay.

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Proposed Change The purpose of this project is to increase patient involvement in education and increase satisfaction with discharge teaching. During the first 4 days after delivery, patients present additional challenges in their readiness to learn. Self-care needs must be met before caring for an infant. Literature has demonstrated that patients did not always want to learn what nurses thought was the highest priority. Press Ganey surveys revealed dissatisfaction with discharge teaching. The Quality of Discharge Teaching Scale was used as a diagnostic tool to focus on specific areas for improvement.

Implementation, Outcomes, and Evaluation The New Parent Education Plan was developed to ask patients to identify their personal learning needs during the hospital stay. Nurses have been using the New Parent Education Plan to help the patient prepare for discharge. Improvement has been noted in Press Ganey discharge teaching scores. Patients have actively participated in identifying learning needs. Nurses have identified a need to document patient education on the same form that the patient uses to identify learning needs. The New Parent Education Plan and the education record have been incorporated into the appropriate care plans. The Quality of Discharge Teaching Scale has shown improvement in scores since the beginning of the project. Implications for Nursing Practice Patients want to identify and choose what they will learn, when they will learn it, and which family members should be present. Nurses need to ensure that patients have that opportunity.

Communication and Collaboration: Creating a Culture of Teamwork Through the Use of TeamSTEPPS Strategies Suzanne Lundeen, RNC, PhD, Purpose for the Program Harris Health System, Houston, o improve patient safety and satisfaction TX Maureen Padilla, DNP, RNC-OB, NEA-BC, Harris Health System, Houston, TX

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by implementing an evidence-based system to enhance communication and teamwork skills among healthcare professionals.

Proposed Change TeamSTEPPS is an innovative program that works to solidify collaboration among the healthcare team to achieve the best outcomes for patients.


A multidisciplinary group committed to changing the culture of the department attended the TeamSTEPPS master training course. The team identified communication as a recurring problem that threatened patient safety and satisfaction. The team then developed the departmentwide “snapshot” as an intervention to improve communication.

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Implementation, Outcomes, and Evaluation The women’s services department consists of high-risk labor and delivery (L&D), well-baby nursery, level II and level III neonatology units, mother– baby couplet unit, and perinatal special care unit. Direct patient care providers from the departmental units attended the TeamSTEPPS fundamentals 4-hour interactive workshop. This workshop provided hands-on learning experience of the TeamSTEPPS philosophy as well as an opportunity to practice the TeamSTEPPS behaviors.

have. Next, staff from the anesthesia department discuss the OR cases, epidurals infusing, problem epidurals, and anticipated high-risk cases. The staff from the neonatology department then has an opportunity to discuss any concerns. To close the snapshot, the OB faculty clearly states, “If any team member sees anything unsafe or not in the best interests of our patients, we expect you to speak up. If you are unable to get a timely or effective response, call me, OB faculty, .” Dr.

At 8 a.m. and 8 p.m. daily, the obstetric (OB) faculty member on duty conducts the interdisciplinary department-wide “snapshot.” The snapshot is a scripted report that begins with the OB faculty giving L&D staff the big picture report. Next, the L&D team lead nurse reports on inductions, surgeries, expected patients, antepartum unit census and concerns, OB triage status, and patients waiting for beds and staffing. The OR nurse discusses concerns about scheduled cases and the mother–baby team lead nurse reports census, discharges, and concerns. The nurse–midwife and family medicine resident report on admitted patients and bring to light any concerns they may

Improved communication has been evidenced by expediting safe mother–baby discharges during periods of increased census, improved operating room productivity, timely and effective neonatology consultations, and accessibility and accountability of the OB faculty member on duty.

Keywords TeamSTEPPS safety communication collaboration


Implications for Nursing Practice Effective collaboration and communication are essential elements of professional nursing. The department-wide snapshot encourages nurses to be actively involved in the multidisciplinary healthcare team and make valuable, evidence-based contributions to patient safety and satisfaction.

Perinatal High Reliability: Doing the Right Thing for Every Patient, Every Time Purpose for the Program igh-reliability organizations operate highly complex and hazardous systems, essentially without mistakes. Safety is the hallmark of a highreliability unit (HRU) and is understood to be the responsibility and duty of every team member. The purpose of this project is to implement the clinical and cultural changes required to establish our Women Infant Services units as HRUs.

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Proposed Change All clinicians have an obligation to speak up for safety. This project creates the environment and mechanisms that support team efforts to achieve safety. Activities are geared toward ensuring that quality issues are exposed to provide opportunities for prevention. Project activities include daily check-in meetings, increased leadership presence, implementing a process for timely and open review of safety incidents, and communicating findings and solutions to team members. Implementation, Outcomes, and Evaluation Daily check-in (DCI): DCI reviews the past 24 hours, looks ahead at the next 24 hours, and asks, “Are there any safety concerns?” The team includes charge nurses from the departments of

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labor and delivery, mother–baby (M/B), gynecology (GYN), antepartum, and neonatal intensive care unit; nurse management; physicians; social work; pharmacy; and anesthesiologists. In the first 10 weeks of DCI, 55 safety concerns were verbalized; 66% resolved the same day and 88% within 5 days.

Charmaine L. Kyle, MSN, RN, EFM-C, Spectrum Health, Grand Rapids, MI Erin Keenan Nulf, BSN, RN, Spectrum Health, Grand Rapids, MI Keywords

Rounding to influence: Obstetric leaders round high-reliability unit safety twice per month. Bedside nurses verbalize safety communication concerns and safety behaviors. STAR (stop, think, act, review) and ARCC (ask a question, make a request, voice a concern, and use the chain of Professional Issues command) behaviors are reinforced. Patient interviews give further opportunity to verbalize safety Poster Presentation concerns. High-Reliability Committee structure:

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High-Reliability Committee: Accountability and transparency of safety, quality, and patient satisfaction measures. Incident Report Committee (ISIS): Monthly meetings; bedside nurses review incident reports and make action plans.

Debrief/cause analysis: Critical safety events are brought forward within a week of occurrence. Participants assess the event from every angle look-

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Wilson, M., Engel, S., Case, S., Lisenbee, J., and Smith, L.


ing for opportunities to improve and make action plans. Safety newsletter: Monthly updates on action plans and safety concerns close the loop of communication. Evaluation: Fall 2012 safety culture survey.

Implications for Nursing Practice Within the safe culture of an HRU, the authority gradient is lessened and nurses experience decreased stress and increased respect for their contribution to the team. When unusual or unexpected events occur, nurses are empowered to improve bedside practice through the debriefing process and support from the team. Job satisfaction is increased on units where practice is based on evidence and professional standards.

Stress Buster: Introducing Quiet Time for Neonatal Nurses Sandra Tollinche, BSN, RN, Winthrop University Hospital, Mineola, NY Keywords stress reduction neonatal nurses meditation


Purpose for the Program uiet Time was developed in this level III neonatal intensive care unit (NICU) as a strategy to reduce stress among the staff. Due to the highly technical nature of this unit and the complexity of the patient population, staff experienced high levels of stress that was exhibited by poor morale, absenteeism, and poor interpersonal relationships in the work environment. To alleviate the effect that this highly stressful environment was having on staff, mindful meditation was introduced as a strategy. The purpose of mindful meditation is to allow the staff to be self-aware of escalating stress levels and provide techniques for stress reduction that are healing and restorative. This unique and innovative approach provided the outlet the staff needed.

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Proposed Change Reduce the stress levels of the NICU staff by using mindful meditation as a unique and innovative strategy and provide the opportunity for Quiet Time to accomplish stress reduction, enhance the bedside care (calm nurse, calm infant), and improve the way nurses handle stressful situations in the unit. Implementation, Outcomes, and Evaluation In 2009, NICU staff indicated that they were suffering from high-stress levels that were evidenced by poor morale, absenteeism, and poor interpersonal

relationships in the work environment. A program was developed to relieve stress among staff using a holistic approach. Personnel skilled in holistic strategies were identified. Staff members volunteered to spearhead the development of a program that came to be known as Quiet Time. Program leaders had varying degrees of experience and skill in meditation. One leader further developed the necessary skills by becoming a meditation specialist. Quiet Time was structured as 15-minute sessions, which were repeated immediately back-to-back to maximize staff attendance. During the session, lighting was dimmed and aromatherapy, guided imagery, and soft bell sounds were used. Techniques focused on abdominal breathing and respiration control. Progress was monitored by a series of questions about stress levels. Before the session, staff self-rate their stress level using a Likert scale. This was repeated at the end of the session to gauge the effect meditation had on the participant. Data collected since the inception of the program have shown on average, a 72% reduction in stress levels. Implications for Nursing Practice Quiet Time for neonatal nurses reduces the stress level of staff exhibited as poor morale, absenteeism, and poor interpersonal relationships in the work environment and, therefore, affects patient care.

Drug Shortage: A Transdisciplinary Team Approach to Injectable Vitamin K Shortage for Newborns Melissa Wilson, BSN, RN, CMSRN, Mission Hospital, Asheville, NC

Purpose for the Program he 2011 American Hospital Association survey found 100% of responding hospitals (N = 800) experienced a drug shortage in the past 6 months. The proposed presentation will present a model of care developed in response

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to a critical shortage of injectable vitamin K to newborns at a tertiary regional hospital. The implemented management strategy, developed by a transdisciplinary team, considered issues of safety, ethics, communication, collaboration, education, and evaluated published, evidence-based

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data on the use of alternative formulations of vitamin K. Proposed Change In an immediate response to a critical injectable vitamin K shortage at a children’s hospital, a transdisciplinary team was formed and an action plan developed, which currently serves as a response model for drug shortage management. Inclusion of the voice of patients was a cornerstone to addressing their needs during this drug shortage crisis. Implementation, Outcomes, and Evaluation The response included availability assessment of alternative drug formulations; development of evidence-based clinical guidelines; electronic point of care decision-making tools for physicians; education materials for patients/families; education materials for healthcare providers on management plans; ethical considerations for rationing of supplies; and communication strategies for all administrators, healthcare providers, and patients. The success of the program was linked to working with a local pharmacy to compound oral vitamin K for administration to the infants who met the criteria for that route of administration. Injectable vitamin

K was reserved for infants in the neonatal intensive Suzanne Engel, MS, Midwifery, RNC-OB/EFM, HTP, Mission care unit and high-risk infants. Hospital, Asheville, NC

Tools developed to support the model of drug shortage response include color coding system of drug supply for pharmacy and healthcare providers, process flow diagrams, published literature classification system, point of care decision templates, lists of ethical principles to consider, pharmacy policies guiding evaluation of alternative suppliers, and educational guides. As a result of the collaborative response to the injectable vitamin K shortage, 100% of the infants, whose parents consented to receive vitamin K, were given the correct oral dosage while in the hospital. Continued development and system-wide dissemination of the drug shortage response model is underway. Implications for Nursing Practice By proactively addressing the drug shortage, safety, evidence-based clinical practice, ethical decision making, efficiency, and cost have the potential to be affected. The response to drug shortages is best conducted with a proactive, rather than reactive, approach to have the necessary elements in place for an appropriate controlled response.

Sandy Case, RNC, NUS, MNC, Mission Hospital, Asheville, NC Joni Lisenbee, RN, BSN, IBCLC, Mission Hospital, Asheville, NC Linda Smith, RNC, MSN, IBCLC, Mission Hospital, Asheville, NC Keywords vitamin K shortage transdisciplinary team collaborative response


It’s a Crime to Risk Patient Safety Purpose for the Program atient safety was defined by the Institute of Medicine as “the freedom from accidental injury due to medical care or from medical error.” Creating a culture of safe patient care is leading the healthcare industry in terms of quality of care, medical reimbursement, patient outcomes, patient satisfaction, and nursing education. The purpose of this innovative education is to enhance the critical thinking skills of perinatal direct care nursing staff on patient safety hazards with the intent to decrease adverse patient outcomes. The Crime Scene Investigation (CSI) education program was implemented to improve an overall safe environment that reduces the rate of adverse obstetric safety events.

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Proposed Change Traditional nursing education includes self-study packets, written examinations, online learning modules, and didactic oral presentations. As nurses we routinely use psychomotor skills; however, traditional nursing education fails to address how we perform and critically think. A CSI room was created to have the direct care nurses physically identify safety hazards in an obstetrics’ patient room.

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Implementation, Outcomes, and Evaluation A patient’s room was simulated into a crime scene with a low fidelity mannequin and more than 35 patient safety hazards with various maternal education competencies, including invasive lines, wound care, sepsis, respiratory, blood administration, medication safety, and falls. Neonatal patient safety hazards included patient identification, safe sleep, and radiant warmer equipment. The nurses received information about the crime scene through a case study and then entered the room to investigate for patient safety hazards. The investigating enhanced critical thinking skills and awareness of patient safety hazards. Direct care nurses engaged in communication about the safety hazards and discussed process and flow in the patient’s room. Direct care nurses were able to identify areas of risk on the obstetric unit and implement ideas for process improvement.

Angelita Cook, BSN, RN, C-EFM, Mercy Health-Fairfield Hospital, Cincinnati, OH Marie Leist-Smith, MSN, RNC, C-EFM, Mercy Health Partners, Cincinnati, OH Keywords education professional development critical thinking simulation psychomotor skills


Implications for Nursing Practice The CSI project affected nursing care because it created a new type of learning environment that enhanced critical thinking skills and psychomotor skills. Minimal cost was associated with the

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Bradley, P. A. and Zion, J. K.


project as everything was preformed on the unit during the staff’s scheduled shift. This CSI education project is adaptable to any health professional education. Avoiding preventable injuries to mother

and neonates improves a patient’s outcomes and is on the forefront of staff education and awareness.

Innovation, Collaboration, and Systemness: Three Sisters Playing Nice in the Sandbox Kasondra Lynn Miller, RNC-OB, C-EFM, Bon Secours St. Mary’s Hospital, Richmond, VA Erin T. Robson, MSN/Ed, RNC-NIC, Bon Secours St. Francis Medical Center, Midlothian, VA Keywords patient safety teamwork simulation obstetric emergencies


Purpose for the Program atient safety is in the forefront of education in the healthcare profession. The promotion of open communication and teamwork using obstetric simulation is the purpose of an innovative program introduced to our healthcare system. A new simulation lab was constructed at the College of Nursing within the system. The sister facilities are located within a 30-mile radius and attempt to attract the same patient population.

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Proposed Change An obstetric simulation planning committee was formed to include educators from the three facilities within the healthcare system. The planning committee corresponded via e-mails and had monthly meetings to share patient safety goals and develop a comprehensive plan for incorporating simulation as an educational component for nurses working in obstetric units. Implementation, Outcomes, and Evaluation Through scheduled monthly meetings the committee shared numerous ideas to support a fiscally responsible implementation plan. The drills are designed to enhance the learning of the nurse by incorporating the use of psychomotor skills. The

nurse also will role-play and care for a woman through the stages of labor and delivery using the simulator. Responding appropriately to spontaneous obstetric emergencies, including shoulder dystocia and precipitous delivery, are the first areas covered during the implementation of simulation. Implications for Nursing Practice Meaningful implications for the simulation training include effective communication as an interdisciplinary team; safe collaborative care to the obstetric simulator in the antepartum, intrapartum, and postpartum periods; and incorporate the collaboration of facilities to increase competency in varying skill mixes. The labor and delivery staff nurses are required to participate in 4 hours of simulation training annually. The scheduling of nurses from three facilities will allow 16 nurses to participate in training per month. Learning modules on shoulder dystocia and precipitous delivery were constructed to optimize the learning experience for each nurse. The modules contain objectives for each simulation module, pertinent educational materials, and learning assessments. Confidence level scoring will be performed by the nurse to evaluate the effectiveness of the simulation.

Multidisciplinary Antepartum Model of Care to Improve Perinatal Outcomes Patricia A. Bradley, RN, MSN, Purpose for the Program WHNP-BC, North Kansas City he Maternal–Child Health Services MultidisHospital, North Kansas City, ciplinary Antepartum Team Project was deMO

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Janel K. Zion, RN, MSN, WHNP-BC, North Kansas City Hospital, North Kansas City, MO

veloped to identify evidence-based practice and guide nursing care with a model of approach that involves all disciplines of care, plus the patient and her family. The goal of the multidisciplinary antepartum team is to use all members of the healthcare team, to address needs of the patient, to potentially lengthen pregnancy, improve fetal wellbeing, decrease maternal adverse events, and reduce the need to admit infants to the neonatal intensive care unit.


Proposed Change To improve maternal/fetal outcomes through early identification and communication of maternal risk factors by developing a multidisciplinary individualized plan of care. This team will use evidencedbased nursing research to improve patient outcomes, decrease the emotional and physical stressors of a long-term hospitalization, and to positively affect the patient’s perception of the healthcare team. Implementation, Outcomes, and Evaluation The Maternal–Child Healthcare team identified the need for improved communication and

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collaboration for long-term hospitalized antepartum patients. A multidisciplinary team that included members from education, nursing, social services, research, and management convened to examine the need to improve antepartum care.

obstetrician, perinatologist, neonatologist, nursing team, social services, pastoral care, and unit educators is planned to continue the collaborative care model to achieve the best possible outcome for the patient and the infant.

As a result of the initial team planning, new nursing processes have been implemented. Specific changes include a daily huddle to discuss patient diagnoses, diagnostics, consultations, plan of care for the day, and the use of the antepartum SBAR tool to improve communication. The primary nurse reviews the daily plan of care with the team and the patient, and also solicits information from the patient to identify urgent needs, with specific attention to emotional and physical wellbeing. A weekly meeting that includes the patient’s

Implications for Nursing Practice The patient’s status is reviewed and evaluated daily by the nursing team at the daily huddle. The goals for the previous plan of care are reviewed, to be certain that goals were met or refined. Patient provides information to the nursing team daily to identify any needs that have yet to be addressed or resolved. The multidisciplinary team continues to meet, update, and communicate goals for the patient, until the patient gives birth or is discharged.

Keywords antepartum multidisciplinary team high-risk pregnancy evidence-based nursing care communication


The Use of the Clinical Resource Nurse to Solve the Eternal Dilemma of Financial Responsibility Versus Staffing Requirements Purpose for the Program his pilot quality improvement project provides data to support a creative option that involves the use of a clinical resource nurse to support units with high percentages of new-to-practice staff, and also improves nursing satisfaction, complies with new staffing guidelines set by a professional organization, and improves patient flow.

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Proposed Change A 2-week pilot project of the clinical resource nurse (CRN) was implemented on a labor and delivery floor in an academic medical center with 772 beds. This concept was tested for five main reasons: (a) increased acuity, (b) new staffing guidelines, (c) high percentages of new to practice staff, (d) high percentages of nurse turnover rates, and (e) low nurse satisfaction scores. To implement the pilot project, an extra registered nurse (RN) was assigned as the clinical resource nurse on every shift (excluding weekends) resulting in over budgeting (one extra RN was needed from 7 a.m. to 7 p.m. and from 7 p.m. to 7 a.m.) for a 2-week period. Implementation, Outcomes, and Evaluation A core group of nurses were selected to continue the role of CRN 24 hours per day, 7 days per week. A PowerPoint presentation was created as a resource for all staff, and education continued sur-

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rounding the daily responsibilities of this nurse by a clinical level IV nurse. During the trial period this role focused on the use of the CRN on the labor and delivery floor, but upon implementation the scope of this role was expanded to be a resource for the newly developed antepartum unit (APU). This requires the CRN to assess the APU every 4 hours and assist with admissions and overseeing the management of nursing care for patients.

Meghan Maloney, RN, BSN, Hospital of the University of Pennsylvania, Philadelphia, PA Alexandra Nelson, RN, MSN, Hospital of the University of Pennsylvania, Philadelphia, PA

Keywords resource staffing acuity A preimplementation and postimplementation sur- nursing satisfaction

vey was given to 32 nurses based on the Likert scale. Results showed increased perceived quality of care provided to patients and increased feelings of having the necessary resources for help when they need them. Furthermore, the results showed an increased perception of improved quality of patient care with 50% of respondents rating their care as excellent posttrial as opposed to only 16% pretrial. A decrease in incident reports was also noted.


Implications for Nursing Practice This pilot indicated that a CRN may be useful in areas with high rates of new-to-practice nurses. In the short period of time, nurses reported increased perceived quality of care along with resources needed for complex patients. Patient flow was improved as well as possible improved quality of care related to the decrease in incident reports filed.

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Harris, M. S.


Achieving Excellence: Collaborating with Families to Make a Difference in Care Margaret Sharon Harris, MSN, RN, NEA-BC, LeBonheur Childrens Hospital, Methodist LeBonheur Healthcare, Memphis, TN Keywords patient-centered care family-centered care family faculty tip sheets


Purpose for the Program ur less than optimal patient satisfaction scores and our desire to embrace patientand family-centered care principles required that we focus on our culture and adopt a true method of accountability to hold our staff to new standards of excellence. Our leadership team and the facility associates adopted Vision 2020, which outlined the strategic initiatives for our facility to help us become one of the top hospitals in the country.

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Proposed Change The very first bullet in Vision 2020 was to embrace the principles of patient- and family-centered care. Since the beginning of this implementation, we have grown our family partners group to more than 40 families and developed five family-led committees with staff liaisons that affect the culture of this facility and enable staff to reach specific goals and measure success. Implementation, Outcomes, and Evaluation The staff education committee of the family partner’s council developed a curriculum by which to train family faculty. The goal of this committee is to assist the staff in acquiring knowledge and competencies in patient- and family-centered principles, skills and attitudes. The principles are dignity and respect for the family; complete and unbiased


information sharing in ways that are affirming and useful; family participation in care planning and delivery to provide enhanced control and independence; and family collaboration with clinicians in policies, procedures, and staff education. Family faculty with their committee staff liaison attend staff meetings within the facility and share what each principle means to them with tangible examples where the principles were positively met and examples of where things could have gone better. The team also develops quarterly “tip sheets” written from the perspective of the families to reinforce the principles. In addition, this group works with other family members to learn to tell and share their stories as well. Implications for Nursing Practice Nurses play a key role in promoting patient- and family-centered care. When the family can be involved and the principles are followed, the facility goals can be more easily reached with measurable growth in the patient satisfaction scores. Evaluations of presentations reflect that staff acquire new strategies in dealing with families, which will affect their practice positively. The use of families to drive home the concept of true patient- and family-centered care has shown an increase in the facility patient satisfaction scores.

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