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Pittsburgh, PA 15213

412-623-2345

https://www.upmc.com/locations/hospitals/presbyterian

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Letter from CNO…………………………………………………………………………………………………………………………………………… 1

About UPMC Presbyterian……………………………………………………………………………………………………………………………. 2

Nursing Strategic Plan……………………………………………………………………………………………………………………………………. 3

Magnet Journey Update…………………………………………………………………………………………………………………………………. 4

COVID-19 Caregivers…………………………………………………………………………………………………………………………………….. 5-6

How to Prevent COVID-19……………………………………………………………………………………………………………………………. 7

Linking Living Donors During COVID-19 Crisis…………………………………………………………………………………………… 8

Exemplary Professional Practice…………………………………………………………………………………………………... 9-10

Sustained Achievement of Bedside Shift Report Practices……………………………………………………………………. 9

Improved Compliance with Hourly Rounding………………………………………………………………………………………… 10

Structural Empowerment………………….………………………………………………………………………………………….. 11-21

Nursing Certifications……………………………………………………………………………………………………………………………….. 11

Nursing Degrees………………………………………………………………………………………………………………………………………… 12

Panel Presentations…………………………………………………………………………………………………………………………………… 13

Podium Presentations………………….……………………………………………………………………………………………………………. 13

Poster Presentations…………………………………………………………………………………………………………………………………. 13-14

Leadership Positions in Professional Organizations………………………………………………………………………………. 14

Cameos of Caring Recipients/Nominees………………………………………………………………………………………………... 15

Above and Beyond Recipients………………………………………………………………………………………………………………….. 16

ACES Recipients…………………………………………………………………………………………………………………………………………. 17

DAISY Award Recipients…………………………………………………………………………………………………………………………… 18

BEACON Award…………………………………………………………………………………………………………………………………………. 19

Motivating Kids to Move to a Healthy Lifestyle………………………………………………………………………………………. 20

Expanding our Shared Leadership to Procedural and Ambulatory Departments……………………………….. 21

New Knowledge and Innovation…………………………………………………………………………………………………... 22-24

Creating a Nurse-Focused Technology Checklist…………………………………………………………………………………… 22

Literature Leads to Change………………………………………………………………………………………………………………………. 23-24

Transformational Leadership……………………………………………………………………………………………………….. 25-27

Exemplary Practice Lead to Improved Patient Satisfaction…………………………………………………………………... 25

Improving the Patient Experience……………………………………………………………………………………………………………. 26

Patient Care Services Nursing Division Leaders…………………………………………………………………………………… 27

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LETTER FROM CHIEF NURSING OFFICER SANDY RADER DNP, MSA, RN, NEA-BC CHIEF OPERATING OFFICER, CHIEF NURSING OFFICER, VICE PRESIDENT PATIENT CARE SERVICES UPMC PRESBYTERIAN SHADYSIDE

This annual report is the perfect time capsule for the outstanding work we have accomplished at UPMC Presbyterian in the last year. 2020 has been a year like no other in our lifetime with the COVID-19 pandemic. We at UPMC Presbyterian played an integral role in the pandemic as we cared for our patients, participated in the trial for a vaccine for COVID-19, and helped keep the community informed of any developments of the disease. As “essential workers”, we were faced with many challenges and difficult decisions, yet we were able to lean in and stay focused on providing each of our patients the care they needed. The community outpouring of support was humbling and kept us motivated during this time.

We did not let this pandemic slow down our progress with the UPMC Experience. At the start of our UPMC Experience work in 2017 our Rate the Hospital percentile rank was at the 26th percentile. In less than three years, we have improved significantly — exceeding the 78th percentile rank as of July 2020! This success is made possible because of each of your contributions through our Shared Leadership structure. We had the Professional Practice and Development Council hardwire our Bedside Shift Report and our Quality and Safety Council lead the way with Hourly Rounding. When UPMC Presbyterian nurses identify an opportunity for improvement, we lead the way. The Evidence-based Research and Practice Council did just that when they identified an opportunity with patient falls which led them to develop TUMBLE. The Informatics and Technology Council saw a need for nurse-focused maintenance of technology and developed a maintenance checklist. The success of many of these projects is made possible through the support and guidance of our Transformational Leadership Council. This year we expanded our Shared Leadership structure with the addition of our Procedural Ambulatory Council. This council brings nurses together from the various ambulatory and procedural settings to share best practices and collaborate on initiatives. Our Clinicians and Charge Nurses implemented post discharge calls, giving us the opportunity to close the loop on the patients’ experience while they were with us. Lastly, our UPMC Experience work included the introduction of the HEARD model, which is used to de-escalate an individual who appears to be upset or dissatisfied. The HEARD Model is:

Hear them Out Empathize Apologize Resolve Decide

Our Magnet® Journey is well underway. We have been tracking Patient Satisfaction outcomes and Nurse Sensitive Indicator Outcomes. Our BSN and greater rate is currently at 70.1%, and our certification rate currently is at 30.5%. We took part for the first time in the Press Ganey Nurse Excellence Survey. The 2019 participation rate was an outstanding 87%! Presby will be participating in the Press Ganey Nurse Excellence Survey again in September, 2020. The results from the 2020 survey will further define our next steps on our Magnet Journey!

I would like to welcome Denise Abernethy, Senior Director, Emergency Services and Ruth Hall, Clinical Director, Cardiovascular Service line to our Nurse Executive team. I greatly appreciate each of you that serve on one of our Shared Leadership Councils and continue to lead the UPMC Experience work, and lean in during challenging times. Your commitment to our nursing profession inspires me as your Chief Nursing Officer. Let’s continue to celebrate our wins and I look forward to our bright vision ahead for UPMC Presbyterian.

Sandy Rader, DNP, MSA, RN, NEA-BC Chief Operating Officer, Chief Nursing Officer, Vice President Patient Care Services UPMC Presbyterian Shadyside

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The 4th Annual UPMC Presbyterian All Council Conference was held on September 13, 2019 at the

Herberman Conference Center located on the UPMC Shadyside campus. The objective for the

conference was to re-evaluate the nursing Mission, Vision and Values and Strategic Plan for 2020-2025.

The conference included a series of exercises to encourage contributions from the 175+ council

representatives in attendance. The contributions included words identified to consider incorporating into

the updated nursing Mission, Vision, and Values. The Steering Council, which is the overarching Shared

Leadership Council at UPMC Presbyterian, spent several meetings following the All Council Conference

examining the contributions and began formulating the recommendations for the Mission, Vision, and

Values. Then each council chair and co-chair would present the recommendations to each of their

councils and then the Steering Council modify and then approve the changes.

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NURSING STRATEGIC PLAN LAUREN CHRISTY, PhD, MSN, RN, NEA-BC MAGNET PROGRAM DIRECTOR, UPMC PRESBYTERIAN SHADYSIDE

Our strategic plan is our roadmap of where we are and where we want to go. The purpose of creating a strategic plan gives us a direction when making decisions and allocating resources in pursuit of our direction. This also ensure we are all working in the same direction, together to achieve common goals. At UPMC, our overall organization develops a strategic plan that cascades down to the business units, and then the various divisions. The overall UPMC strategic plan has four pillars:

Service People Quality Finance

UPMC Presbyterian nurses consistently strive for excellence. We encompass past successes with future endeavors in our strategic plan. We have cleared defined our pathway for 2020-2025. The nursing strategic plan was developed from our Shared Leadership representatives at our 2019 All Council Conference. That conference had over 150 attendees participating in various exercises to develop updates to our Mission, Vision, and Strategic Plan. After the conference, the responses to the exercises were collated and quickly themes began to be identified.

Patient Experience New Ideas/Innovations Staff Experience/Well-Being Nurses impact on the bottom line (finances)

This strategic plan will serve as our lantern/guiding light for nursing for the next five years. We may need to make revisions as needed, but this defines where we want our nursing practice in 2025. Thank you to those that participated in the 2019 All Council Conference this will forever be part of your legacy at UPMC Presbyterian.

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MAGNET® JOURNEY UPDATE LAUREN CHRISTY, PhD, MSN, RN, NEA-BC MAGNET PROGRAM DIRECTOR, UPMC PRESBYTERIAN SHADYSIDE

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COVID-19 CAREGIVERS MELANIE SMITH-FORTNEY, MSN, RN, NEA-BC DIRECTOR OF NURSING, UPMC PRESBYTERIAN

When I think back on the Pandemic of 2020, many things run through my mind. At the top of those various things is pride. I am so proud to lead such an amazing workforce of nurses and health care professionals through such a complex and very fluid situation. Collectively we have cried together, problem-solved together, and ultimately grew together all in a very short period.

The Pandemic of 2020 is commonly referred to as Coronavirus (SARS-CoV-2). The disease that is caused from the Coronavirus is referred to as COVID-19. This is a virus that causes respiratory infections in humans. Illnesses range from a common cold to a Severe Acute Respiratory Syndrome (SARS). To date, we believe this virus originated in Wuhan, China in late 2019. The virus quickly spread

around the globe with the state of Washington having the first positive tested patient on Feb. 25, and Pennsylvania had our first two presumptive positive patients by March 6.

Early on UPMC came to the forefront of providing our community with information and knowledge about Coronavirus as the information became available to us. We quickly started clinical trials for therapies and partnered with the University of Pittsburgh School of Medicine to work on a vaccine. From a nursing perspective, we launched a Command Center that operated 24/7 for 12 weeks, starting March 16 through June 8. Our Command Center was co-led by Heidi Karalagas and Jeannine DiNella with numerous others staffing the Command Center as needed. We needed to quickly identify which units were best suited to care for our COVID patients. The initial decision-making model included two factors. The first factor was the location of rooms that were already negative pressure or that could be made negative pressure by our

maintenance team, knowing we would need both critical care units and med-surg units. The second factor was we looked at the largest population that seemed to be coming in with COVID. Most of the patients were those needing medical management, rather than surgery. The units that cared for our COVID patients included: 6F/G, 9G, 7G, MICU, CTICU, and 8N.

UPMC Presbyterian was well prepared to care for COVID patients from the onset of presumptive positive patients as well as care for our employees. We maintained a stable supply of Personal Protective Equipment (PPE), we setup screeners at our open entrances to screen and take every person’s temperature that entered the building, and we strengthened our lines of communication with huddles, Microsoft Teams meetings, and regular townhalls to keep all staff informed of any

developments as well as answer the staff’s questions in real time from our Executive Management Group. We were able to provide PPE fit testing directly onsite and, in some cases, directly on the unit. We collaborated with our Maintenance Department to convert the necessary rooms to negative pressure.

UPMC quickly instituted the Pay Protection Program. The Pay Protection Program was created to provide certainty and financial protection for UPMC employees and their families throughout the early part of this crisis. Many of our staff were redeployed into various roles and continued to retain their current pay level. For some employees, when there may not have been any work available and those staff members were asked to stay idle at home, the employee was compensated their full wages for their scheduled hours through the close of the program on May 9.

Many of the units have expressed the level of stress and anxiety early during this pandemic. We all felt that level of uncertainty. We were all in this together and my leadership team were amazing by assisting the units as needed to answer questions, calm staff, and jump in where needed. We identified our first positive patient on 12N and instantly Laurie Rack and

Shauna Campbell transported the patient to 6F/G, and at that moment UPMC Presbyterian was now caring for our first pandemic patient. Once we confirmed all COVID positive patients did not require a critical care setting we began to open some of our med-surg floors to care for these patients. 9G was the first med-surg unit. To help prepare the staff on 9G we had them observe the care delivery on 6F/G for a couple of days prior to 9G caring for their first patient. Then the same process happened with 7G and then the MICU. 8N quickly turned from a Medicine unit to a COVID unit practically overnight. It was introduced at a staff meeting via Microsoft Teams then they had to move their current patient population out and then within a couple hours they were caring for six patients. The camaraderie

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between the units was truly humbling. Units were calling to check on and support one another as we learned more about the virus and how to treat it.

As each day passed, the confidence in staff increased tremendously, the levels of anxiety subsided, and the processes became more routine.

Nurses are very ingenious. We initially planned on using 2D for our COVID patients, but with the feedback of staff we quickly realized

that was not the right decision and moved those patients into the CTICU. The CTICU also used extension tubing for ECMO and Prisma outside of the room. In our MICU, since the patient room doors are glass, nurses were writing on the glass with dry erase markers to remind them when drips would need changed. The MICU identified a core team of nurses that would be responsible for caring for our COVID patients. They all purchased bright-colored Crocs shoes in order to be identifiable on the unit. 9G put Team Nursing into practice, where one nurse would stay in the room with the patient, while the other stayed in the hall as the runner. PCTs on 9G also served as observers for Donning and Doffing.

We did have to make some challenging decisions during this time. One of those decisions was no longer allowing visitors for our patients. We had to make this decision as COVID-19 is a novel virus, and there was so much we did not know initially. We were learning how to care for these patients as they initially came into the hospital until we knew more, we needed to eliminate all risk of exposure to others. The impact of not being permitted to physically see

loved ones was a strain on many patients and certainly on their families. We got creative, combining empathy, innovation, and collaboration to provide virtual visits and last rites via an iPad and FaceTime. A patient’s daughter made a playlist on YouTube of her dad’s favorite songs and we put a Computer on Wheels (COW) in his room to listen to the music. As we continued learning from the Coronavirus, we were able to clearly define infection prevention and PPE practices, which allowed us to evolve our stance of no visitors to implement an identified support person for each patient. This was different than our standard visitation, the Support Person is to be one consistent person who has a purpose in being at their loved one’s bedside and involved in their care plan. The Support Person’s main purpose is to

advocate for the patient, communicate with the care team, and be involved in the care of the patient up to and including the transition to home or another facility if needed. The Support Person helped our caregivers provide better rounding with our physicians, more hands-on assessments, and more direct communication related to the patient’s care.

The outpouring of support from our community was truly overwhelming. Health care professionals were an elite group of individuals identified as “essential workers”, during a time when everyone was told to shelter in place. We continued coming to work and providing world class care. We had various local and state government agencies, local businesses, and individuals donate to the hospital to honor the incredible care we were providing. These kind acts really helped keep morale high. Some of the highlights to honor our healthcare workers included:

Pennsylvania Air National Guard fly over Pittsburgh Public Safety hosted a parade for Healthcare workers on National Nurses Day Numerous meal donations, snack donations, etc. T-shirts purchased from the physicians.

While to date, this is still considered a volatile situation, we have learned so much and have much more to learn. We will continue to collaborate, innovate, and care for our patients. Thank you for your commitment to health care and for continuing to provide world class care to all of our patients.

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COVID-19 created many challenges for hospitals across the country. Hospitals were faced with many

difficult decisions to prioritize resources to care for COVID-19 patients. The result of the reallocation of

resources meant other services like non-lifesaving surgeries and transplants were forced to be postponed

or even cancelled in some situations. UPMC Presbyterian was not exempt from these challenges as many of

our elective procedures were postponed at the height of the COVID-19 pandemic. We were able to maintain

our Living Donor Liver Transplant Program during this time, and we were able to assist hospitals in our

neighboring states to care for their Liver Transplant patients.

In November 2018, George Rogers of Fresno, California discovered his liver was

failing and he would require a transplant. Like many transplant patients George

faced a series of setbacks toward his goals of receiving a healthy viable liver.

George’s nephew Casey supported George throughout his entire journey. Casey

along with his sister has researched Living Donor Liver Transplant programs at the

suggestion of a friend. The procedure involves replacing the patient’s liver with a

portion of a liver taken from a healthy patient and the organ in both patients will

eventually grow to normal size. Currently, only about 5% of transplants are done

from a living donor. George and Casey were scheduled for a transplant surgery in December 2019 at

University of California — San Francisco, however Casey’s blood was

not a match for George, and the surgery had to be cancelled. The next

stop on George’s journey took them to Weill Cornell Medical Center,

part of New York Presbyterian. Everything was scheduled for April 24,

2020, until the hospital was consumed with COVID-19 patients and they

were unable to proceed as planned.

A doctor at New York Presbyterian referred George to Dr. Humar at

UPMC Presbyterian. Another patient, by the name of Tim Corbin was at

the hospital also waiting for a liver. Tim’s relative Josiah Leach had been

tested as a match for Tim, but he too was not a match for his uncle.

Ultimately, UPMC Presbyterian brough the George and Corbin families

together. Casey was a match for Tim, and Josiah was a match for

George. In May 2020, four procedures were performed just eight days

apart. All are doing well.

LINKING LIVING DONORS DURING

COVID-19 CRISIS

INTERESTED IN BECOMING AN ORGAN DONOR?

FOR MORE INFORMATION PLEASE VISIT

ORGANDONOR.GOV

Decreased mortality rate of

5.8% in 2019 from our living donor program

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Bedside Shift Report (BSR) is, by definition, a bedside, change-of-shift hand-off between the off-going nurse and oncoming nurse. By ensuring this report is completed at the bedside, staff ensure the patient can participate in the delivery of their care. BSR has been shown to increase patient safety by decreasing preventable errors while promoting staff accountability and a sense of inclusion for patients previously left out of the process. UPMC Presbyterian’s Professional Practice and Development Council (PPDC) was tasked with establishing guidelines for BSR on the inpatient units and facilitating implementation in 2018. The goal is that patients/families will have a safe, quality dialogue with nursing at the bedside at each change of shift, enhancing their experience and in turn, the HCAHPS scores for BSR. The aim of the BSR initiative was to achieve a 5% increase in Top Box “Always” responses for the HCAHPS (inpatient) survey adopter questions for the question ‘at the change of shift, my off going nurse and oncoming nurse discussed my care at my bedside’ by Oct. 2018. An adopter question is an additional question added to the HCAHPS survey by the vendor, Press Ganey, upon the request of UPMC Presbyterian. The data is not publicly reported but provides the hospital with feedback from the patient’s perspective on how well we have implemented the evidence-based practice of BSR. Data was collected through the hospital’s monthly HCAHPS scores. The outcome measure is the score results associated with the HCAHPS adopter question above, which is correlated with patient satisfaction. In 2018, PPDC supported nurse autonomy with BSR and was able to increase the HCAHPS Adopter Question Top Box Scores by 26%, exceeding the initial goal of 5%.

In 2019 and 2020, PPDC noted that there was opportunity to continue hardwiring the evidence-based best practices of BSR. Unit Directors and Clinical Directors were tasked with completing BSR validations to ensure accountability and consistency. They coached staff to use key words at key times. Success was measured through the HCAHPS adopter question data. BSR “Always” top box responses showed an overall increase of 127% between April 1, 2017 – June 30, 2020, far exceeding the 5% expectation. Please see the graph below for BSR adopter question scores. The Executive Management Group (EMG) established a hospital-wide goal by the end of calendar year 2019 to reach 80% in top box scores for each unit and hospital-wide implementation of BSR. The scores did not meet the benchmark, thus posing an opportunity to continue to hardwire the behavior for 2021.

Since beginning the initiative, initial barriers continue to be a struggle. PPDC has worked with the transportation department to address concerns about getting the shuttle home at change of shift and was able to have the shuttle times adjusted. Additional concerns related to coordinating giving report with multiple nurses and staff comfort level discussing care with the patient were addressed at a unit level, allowing BSR to become a more natural feeling. The ratings on the HCAHPS survey have a significant impact on the hospital since they are a direct reflection of the patient’s perception of care. All members of the multidisciplinary team strive to ensure patients play a role in the excellent care they receive at UPMC Presbyterian. BSR is an evidence-based practice used to increase these scores and is a simple task that can make a big difference in HCAHPS scores and patient outcomes.

SUSTAINED ACHIEVEMENT OF BEDSIDE SHIFT REPORT PRACTICES PROFESSIONAL PRACTICE AND DEVELOPMENT COUNCIL LATASHA KAST MSN, RN, CCRN, CNL JESSICA SEGELEON BSN, RN, CEN KAYLA MAHAN MSN, RN, CCRN

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The Quality and Safety Council is a dynamic, multidisciplinary group that of focuses on improving and

maintaining Quality and Safety for our patients at UPMC Presbyterian. The council utilizes the nursing process to

determine new and pre-existing quality opportunities to impact nursing practice at UPMC Presbyterian.

This year extensive work is underway to improve compliance with Hourly Rounding on the inpatient units to

improve patient satisfaction and safety with a goal of pushing toward 100% compliance with the strategy.

We support Hourly Rounding through education of council members on the important touch points and key

words of Hourly Rounding as well as assist with data collection on the nursing units. Education regarding best

practice was done through presentation by the Huron Group Studer Coach, Lauren Charles, and local nurse

leaders. Role playing was incorporated to ensure members can observe and coach staff on proper hourly

rounding. The education also focused on the “why” behind the strategy with an emphasis on quality and safety

outcomes. The group also developed a tool for data collection on proficiency of rounding by staff. Quality and

Safety Council representatives perform audits of Hourly Rounding by staff, provided feedback and share findings

with the steering committee. The Quality and Safety Council also produced a video to show the right and the

wrong way to preform Hourly Rounding. The metrics the council continues to monitor are patient fall rates and

HCAHPS scores in addition to one on one observations to evaluate effect of its implementation.

Additional work of the council includes:

• Provide a forum for multi-disciplinary information sharing through communication and problem solving to

create valued partnerships.

• Education and data collection to support the implementation of hourly rounding on in-patient units.

• Address safety topics and concerns from bedside and frontline staff.

• Assisting with the Magnet® Journey.

• Supporting house-wide initiatives like the Annual Quality and Safety Awareness Week.

• Support professional growth and development.

The Quality and Safety council provides quarterly reports for our subcommittees of:

• Infection Prevention Committee

• Diabetes Committee

• Skin Committee

• Falls Committee - Support the hospital-wide Marie Wengryn I-Care Falls Prevention Program.

In the early part of 2020, the Quality and Safety Council embarked on the new normal challenges of COVID-19

along with the support of UPMC administration. We learned how to convene in new ways and are eager to get

stronger together as a council.

IMPROVED COMPLIANCE WITH HOURLY ROUNDING QUALITY AND SAFETY COUNCIL CAROL CISNEY MSN, RN, CPAN BETH CIARDI RN

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UPMC Presbyterian prides itself on the exemplary care given to patients and values the

excellence of the nursing staff providing this care. One way to acknowledge this excellence

is through encouraging our eligible clinical nurses to achieve a certification in their

specialty. By achieving certification, it demonstrates to patients, employers, and the public

that the nurse’s knowledge, skills, and abilities meet the rigorous national standards and

reflects a deep commitment to patient safety. Today, there are over 100 different nursing

specialty certification exams available. UPMC supports our nurses’ efforts and will

reimburse the nurse when he/she successfully completes the certification exam.

Certification is part of our professional development process and promotion with in the

My Nursing Career Ladder. Currently UPMC Presbyterian has a certification rate of 30.13%

NURSING CERTIFICATIONS AGAC-NP

Julie Clark

AGACNP-BC

James Byass-Rascoe

CARN

Kimberly Baker

CCMA

Kiera Young

CCRN

Cara Carano

Kristina Caraway

Catherine Davis

Duke Dyer

Kelly Dzialowski

Tara Horn

Kaylan Kerrigan

Kaitlyn Kozak

Tyler Schultz

Tara Zajac

CCRN-K

Courtney Nyoh

CCTN

Kyla Colcombe

Darlene Lovasik

Sarah Skubak

CEN

Amy Roth

Mallory Tokarski

Jessica Segeleon

CHRN

Cora Zohoranacky

CMSRN

Meredith Amour

Amanda Ball

Maureen Lijewski

Dane Romano

Mary Steele

CNL

Teresa Lucchetti

CNRN

Rena King

CPPS

Roberta Jones

CRRN

Michelle Eger

CSRN

Marianne Kinsey

NEA-BC

Ben Morrow

Carol Scholle

NE-BC

Staci Saunders

PCCN/CCRN

Lauren Lido

PCCN

April Heller

Katie Speranza

Sara Walsh

PHRN

John Leinhauser

RN-BC

Ashlee Wells

SCRN

Rena King

VA-BC

Amy Czerniak

Kimberly Hayes

Kathleen Mastroianni

Leslie Rodd

Melissa Williams

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UPMC Presbyterian also supports professional development through nurses obtain-

ing a higher degree of nursing. UPMC provides many resources and tools to support

our nurses pursuit of their higher education. Through the programs and benefits of-

fered as part of our Total Rewards program, nurses can advance their degree, with

features that include, tuition assistance benefits and tuition discounts through various

higher education institutions. These opportunities can broaden our nurses’

knowledge and skill set while also advancing the nurse through the My Nursing Career

Ladder. Currently, our nursing workforce with a minimum Bachelor’s of Science in

Nursing (BSN), through the Master’s degree and Doctorate level is 70.02%

BSN

California University

of Pennsylvania

Sarah Edwards Huggins

Amina Iskandarova

Kayla Smith

NURSING DEGREES BSN

Carlow University

Derik Hansen

Lauren Mazzant

Jacob Myers

Jordan Stacy

BSN

Chamberlain University

Nicole Dominick

Lauren Kenzig

Chatham University

Alexis Demchenko

BSN

Duquesne University

Kayla Green

Elizabeth Smialek

Indiana University

of Pennsylvania

Jessica Shaffer BSN

Ohio University

Taylor Codispot

Kelsey Decort

Caroline Fleming

Kristin Gates

Tanya Lopez

Matthew Martino

Sarah Miller

Kerstin Quinten

Jessica Steele

Courtney Teatino

Cynthia Zieger

BSN

Slippery Rock University

Angela Longo

South University

Lauren Lido

University of Pittsburgh

Courtney Miller

Waynesburg University

Madeline Quast

West Liberty University

Austin Raines

MSN

University of Pittsburgh

Paul Wheeler

Krystal Wojtaszek

Waynesburg University

OpeYemi Banjo

Wheeling Jesuit University

Regina Evans

Georgetown University

James Byass-Rascoe

Robert Morris University

Mallory Tokarski

MSN

Aspen University

Amber Flanigan

Becca Kolonay

Capella University

Lindsay Ball

Christina Fenyus

Carlow University

Diana Mangery

Weiwen Wang

Jennifer Demko

Melissa Eynon

Duquesne University

Alicia McChesney

Caitlin Chiado

DNP

University of Pittsburgh

Jessica Young

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UPMC Presbyterian encourages our nurses to consistently evaluate our current nursing practices. Through this evaluation we often discover opportunities to improve our practices that are beneficial to our patients as well as our nursing workforce. When the outcomes support the efforts of our new and innovative practices our nurses look to share our best practices with colleagues, locally, regionally, nationally, and even internationally. One way to share our best practices is by presenting at various conferences either as a panelist, podium, or poster presenter.

PANEL PRESENTATIONS Jay, E., Varadi, C., and Ambrose, H., panelists. Panel Discussion. PONL Annual Leadership Conference, 27 Sept. 2019, Shera-

ton Harrisburg Hershey Hotel, Harrisburg, PA.

PODIUM PRESENTATIONS Lovasik, D. (2019, September). Caution: You are administering hazardous drugs. Are you using safe handling practices? Academy of Medical-Surgical Nurses (AMSN) 28th Annual Convention. Chicago, Illinois. Lovasik, D. (2019, September). Are you Prepared to Care for your Next Admission: A Transplant Patient? Academy of Medical-Surgical Nurses (AMSN) 28th Annual Convention. Chicago, Illinois. Lovasik, D. (2019, November). NAFLD (Nonalcoholic Fatty Liver Disease) and NASH (Nonalcoholic Steatohepatitis): The Next Public Health Crisis. 2019 Transplant Nurses Symposium, International Transplant Nurses Society (ITNS). Orlando, Florida. Robles, L., Bertoty, J., Charley, D., Klein, J., Jones, R., (2020, June). Identifying the Knowledge Deficit related to Forensic (Prisoners in Police Custody) Patient Care and Mitigating the Gaps through Effective Communication Tool. J. Bertoty, 15th Annual St. Margaret Clinical Research Symposium. Pittsburgh, PA. Scholle, C. (2019, November). Living Donor Liver Transplantation: opportunities and challenges. 2019 Transplant Nurses Symposium, International Transplant Nurses Society (ITNS). Orlando, Florida. Svec, S., Hainly, J. (2020, June). Peripherally Infused Norepinephrine to Avoid Central Venous Catheter. J. Hainly, 15th Annual St. Margaret Clinical Research Symposium. Pittsburgh, PA.

Ambrose, H. Emergency Department and Express Care Partnership—Bringing the Right Care to the Patient, At the Right Time, In the Right Place. Poster presented at: Southwestern Pennsylvania Organization of Nurse Leaders: Celebrating 40 Years of Excellence in Nursing Leadership; August 2019; Farmington, PA. Ambrose, H. More than Just Numbers: Improving HCAHP Scores through Better Understanding and Communication. Poster presented at: Southwestern Pennsylvania Organization of Nurse Leaders: Celebrating 40 Years of Excellence in Nursing Leadership; August 2019; Farmington, PA. Ambrose, H. Utilizing Clinical Analytics to Develop and Implement a Hospital Readmission Program. Poster presented at: Southwestern Pennsylvania Organization of Nurse Leaders: Celebrating 40 Years of Excellence in Nursing Leadership; August 2019; Farmington, PA. Nyoh, C., Piper, L. Implementation of a Simulation-Based Training to Improve Staff Competence in Medical Emergencies. Poster presented at: 5th Annual Evidence-based Practice and Research Forum—Relationship-based Care; September 2019; Greensburg, PA. Christy, L., Dowds, V., Dellaera, R., Gaughan, K., Glaser, K., Rendine, A., Stine, C. Changing the Climate from Worst to Best: A Unit’s Voyage to Success. Poster presented at: Pennsylvania Organization of Nurse Leaders (PONL); September 2019; Harrisburg, PA. Cochenour, C., Yutzy, J., Scholle, C., Lovasik, D., IV Team Staff. Increasing Successful PICC Insertion at UPMC Presbyterian. Poster presented at: Southwestern Pennsylvania Organization of Nurse Leaders: Celebrating 40 Years of Excellence in Nursing Leadership; August 2019; Farmington, PA. Jay, E., Varadi, C., Ambrose, H. More than Just Numbers: Improving HCAHP Scores through Better Understanding and Communication. Poster presented at: Southwestern Pennsylvania Organization of Nurse Leaders: Celebrating 40 Years of Excellence in Nursing Leadership; August 2019; Farmington, PA.

POSTER PRESENTATIONS

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POSTER PRESENTATIONS

(CONTINUED)

Spiering, K. , Weisgerber, A. Next Level Champions: Creating an Expert RN Team for DCD Donors. Poster presented at: Southwestern Pennsylvania Organization of Nurse Leaders: Celebrating 40 Years of Excellence in Nursing Leadership; August 2019; Farmington, PA. Emmett, K. , Fox-Hawranko, L., Tamenne, C., Jaynes, D., Lovasik, D., Unit 11N. Connecting with Patients: Nurse Leader Rounds, Updating White Boards, and Bedside Shift Report. Poster presented at: 2019 Transplant Nurses Symposium, International Transplant Nurses Society (ITNS); September 2019; Orlando, Florida. Tamenne, C., Lovasik, D., Fox-Hawranko, L., Esper, S., Holder-Murray, J., Hache, J., Humar, A., Hughes, C., Tevar, A., Wijkstrom, M., Meister, K. 11N Unit. Enhanced Recovery After Surgery (ERAS) Protocols in Living Donors. Poster presented at: 2019 Transplant Nurses Symposium, International Transplant Nurses Society (ITNS); September 2019; Orlando, Florida. Henry, A., Como, M. Transplant-Focused Orientation: What Nursing School Didn’t Teach You. Poster presented at: 2019 Transplant Nurses Symposium, International Transplant Nurses Society (ITNS); September 2019; Orlando, Florida. Schrall, L., Doyle, G. Navigating a Director Road to Immunosuppression Compliance. Poster presented at: 2019 Transplant Nurses Symposium, International Transplant Nurses Society (ITNS); September 2019; Orlando, Florida. Ros, C., Mulkern, M. Educating and Managing Professional Nurses to Administer Chemotherapy on a Pulmonary Transplant Unit. Poster presented at: 2019 Transplant Nurses Symposium, International Transplant Nurses Society (ITNS); September 2019; Orlando, Florida. Marcone, M., Wilson, K. ABO and Organ Verification Processes Completed in the Operating Room Prior to Organ Transplantation. Poster presented at: 2019 Transplant Nurses Symposium, International Transplant Nurses Society (ITNS); September 2019; Orlando, Florida.

LEADERSHIP POSITIONS IN PROFESSIONAL ORGANIZATIONS

Cystic Fibrosis Foundation Southwestern Pennsylvania Lauren Christy, PhD, MSN, RN, NEA-BC, Magnet Program Director Board Member

Academy of Medical-Surgical Nurses (AMSN) Terri Morris, MSN, RN Secretary

Golden Triangle Chapter, International Transplant Nurses Society (GTC, ITNS) Arley Henry, MSN, RN, CCTN, Programmatic Nurse Specialist Board Member

Pennsylvania Emergency Nurses Association Tyler Babcock, MSN, MBA, RN, CEN, Unit Director President

Golden Triangle Chapter, International Transplant Nurses Society (GTC, ITNS) Karen Emmett, BSN, RN, CCTN, Clinical Transplant Coordinator Board Member

South Western Pennsylvania on Nurse Leaders (SWPONL) Shelley Watters, DNP, RN, NE-BC, Sr. Director Cultural Excellence Board Member, Membership Committee

Wound, Ostomy, and Continence Nurses Society (WOCN) Cecilia Zamarripa, MSN, RN, CWON, Clinician National Conference Planning Committee Ostomy Expert

University of Pittsburgh Alumni Association Board of Directors Maria Hamidi, MSN, RN, Programmatic Nurse Spe-cialist Director-at-Large

Professional organizations can be beneficial to all nurses since these organizations can close the loop between the clinical nursing practice and outside influences that impact nursing. Whether one has a passion for a particular organization or one wants to expand their knowledge for their specialty there are various professional organizations that UPMC Presbyterian nurses belong to locally, regionally, nationally, and even internationally. Participation in such organizations shows a true com-mitment to the nursing profession and the following nurses are actively leading various professional organizations in some capacity.

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UPMC Presbyterian in collaboration with UPMC offers many opportunities to honor the

outstanding contributions from our associates. Every year, during Nurses Week, UPMC

Presbyterian hosts a Cameos of Caring® ceremony. The Cameos of Caring offers 14 categories

to acknowledge the efforts of our nurses, patient care support members, and champions of

nursing. The Cameos of Caring ceremony also identifies the nominees that UPMC Presbyterian

will submit to the University of Pittsburgh for their regional annual Cameos of Caring® gala.

The Above and Beyond program acknowledges quarterly our associates who go out of their

way to provide service Above and Beyond the expectations of our patients, guests, and one

another. The Award for Commitment and Excellence in Service (ACES) honors staff

throughout the health system who exemplify UPMC’s five core values of Quality and Safety, Dignity and Respect, Caring and

Listening, Responsibility and Integrity, and Excellence and Innovation. Each year fewer than 1% of UPMC staff receive this honor.

The DAISY AwardTM is a national program that rewards and celebrates the extraordinary clinical skills and compassionate care

given by nurses every day. Each quarter we recognize individuals with a DAISY Award, and annually we recognize a team with the

Team DAISY Award during the Cameos of Caring ceremony.

2020 CAMEOS OF CARING RECIPIENTS/NOMINEES

Each year our Professional Practice and Development Council organizes our annual Cameos of Caring awards process. The

council will review the current awards to ensure they capture the current contributions from our organization, then they will

vet the 100+ nominations to identify the annual recipients.

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2020 ABOVE AND BEYOND RECIPIENTS

6F/G & Supporting Areas

Stefanie Benevenuto Emily Clark

Jonathan Crossett Kayla Hogsett

Jodi Juba Marcy Marchilena Karen McFadden

Mary McFarland Megan McMurray

Lydia Presper Brian Russell

Myron Rickens Curtis Neill

3F CCU

Ashley Ayers Laris Davenport Emily Gregerson Mark LeDonne Kimberly Page

Kimberly Simmons Kimberly Volpatti

MICU

Carla Baxter Sue Svec

Stacey Bednar

Sr. Professional Staff Nurse

PACU

Christopher Mathews

Advanced Patient Care Technician

10S

James Roth

Lead Respiratory Therapist

Respiratory Therapy

Mary Saltzman

Sr. Professional Staff Nurse

9N

Jessica Shastay

Nursing Assistant

9G

Alyson Spierling

Intake Coordinator

Liver Transplant

Carol Tamenne

Clinician

11N

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2019 ACES RECIPIENTS

Cory Clemens Lead PCT, 10D/G

Jennifer Kilpatrick Clinical Transplant

Coordinator I, Liver Transplant

Christopher Mathews Patient Care Technician,

Advanced, 10S

Hugh Smith Transporter,

Transportation Services

Mary Vash Clinician, 3E

Jane Yutzy Clinician, IV Therapy Team

https://upmchs.sharepoint.com/sites/infonet/UPMCExperience/Recognition/Pages/Above-and-Beyond.aspx

https://upmchs.sharepoint.com/sites/infonet/UPMCExperience/Recognition/ACES/Pages/default.aspx

DAISY Award https://upmchs.sharepoint.com/sites/infonet/UPMCExperience/Recognition/Pages/DAISY-Award.aspx

Monica Miles Professional Staff Nurse,

11N

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2019-2020 DAISY AWARD RECIPIENTS

The generosity of LHAS plus the vision of Sue Svec, DAISY coordinator, equals a lasting tribute to DAISY Award winners at UPMC Presbyterian.

On Monday June 22, 2020, a small gathering was convened on the UPMC Presbyterian and UPMC Montefiore bridge. The event featured the unveiling of a large-scale version of the hallmark Healer's Touch serpentine-stone sculptures that are hand-carved and presented to each DAISY Award winner. Sculpted by artists of the Shona Tribe in Zimbabwe, the statue honors the latest bunch of DAISYs to grow at UPMC Presbyterian.

The sculpture is on the UPMC Presbyterian side of the bridge. It is accompanied by a digital message board which displays the photos and names of past DAISY Award winners and a plaque describing the Healer's Touch sculpture, its origin, and significance.

Sue applied for a grant from the Ladies Hospital Aid Society to fund the project last year. She received the grant alongside a number of other project leaders in a courtyard ceremony.

"I am so thankful for the generosity of the LHAS in funding this lasting tribute to the excellent, compassionate

nurses we have here at UPMC Presbyterian,” said Sue.

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BEACON AWARD

The Cardiothoracic Intensive Care Unit (CTICU) has earned a first-time recognition at UPMC Presbyterian — an American Association of Critical-Care Nurses Beacon Award of Excellence.

The CTICU learned in late May that they had been selected as a 2020 Silver Beacon Award recipient following a rigorous application process.

The Beacon Award recognizes top hospital units that meet standards of excellence in recruitment and retention; education, training and mentoring; research and evidence-based practice; patient outcomes; leadership and organizational ethics; and creation of a healthy work environment.

Joni Minor, unit director, CTICU, has always thought that her team has done great things for their critically ill patients. As for when they decided to go for a Beacon Award, she shares, "When one of the senior nurses on our unit went to NTI [AACN's National Teaching Institute], she said that we should apply and I concurred."

Recognizing that there was no shortage of great work happening across the unit, thanks to the engaged team of patient care professionals on the CTICU, the unit assembled a team of five engaged and motivated staff members with Betsy George, programmatic nurse specialist, Office of Patient Experience, as their mentor, to pull everything together.

"With all of the outstanding work that occurs on the unit every day, thanks to our dedicated CTICU team, we really needed a few individuals to look at all we were doing and assemble it into the document," Join explains.

Over the course of six months, the team collected and compiled data to complete their application document, and on Jan. 6, , the team submitted the application.

"The AACN website was checked frequently for changes in the status of the application," Joni shared. "On May 21, I received an email saying 'Congratulations.' After jumping up and down in excitement, I sent a text to our group members."

Celebrations amid COVID-19 are tampered a bit given physical distancing and masking rules, but nothing can dull the excitement felt across the unit. The CTICU's Beacon Award is valid for three years before it is necessary to reapply.

To colleagues and others looking to apply for this prestigious award, Joni offers this advice: "Form a highly engaged team to collect the data and enter it into the document, and set a deadline for yourselves. That helps to keep all those who are involved engaged and productive."

Joni shared the great news on Yammer, which has allowed for the congratulations from across the system to roll in. Take a moment to share your congratulations to the CTICU team on this honor.

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UPMC Presbyterian proudly support community outreach as well as

promotes the initiatives identified in the Healthy People 2020 topics.

Healthy People is part of the Office of Disease and Health Promotion in the

U.S. Department of Health and Human Services. Heathy People identifies

our nation’s health improvement opportunities. Healthy People establishes

evidence-based national healthy objectives to monitor, motivate, and guide efforts to improve health across

America. One of the goals identified for 2020 was to improve health fitness, and quality of life through physical

activity. More than 80% of adults do not meet the guidelines for aerobic and muscle strengthening activities.

Likewise, 80% of adolescents do not do enough aerobic physical activity to meet the youth guidelines. Physical

activity in youth is particularly important because it improves bone health, improves cardiorespiratory and

muscular fitness, decreases levels of body fat, reduces depression symptoms, improves cognitive skills, and

improves one’s ability to concentrate and pay attention.

Kids of Steel is an organization that provides a free training program that

helps motivate kids and their families to get moving. The program is

available in over 180 schools throughout western Pennsylvania. The goal

established by the organization is for each participant to run a total of 26.2

miles over the length of time, with the final 1.2 mile run during the official “Kids of Steel Marathon”.

Teresa Lucchetti, Unit Director, 4G and Rapid Response team began volunteering as a coach at

the Kids of Steel organization in November 2019. Teresa advocated to UPMC Presbyterian to

support her team. Teresa contacted Lauren Christy, Magnet Program Director, UPMC

Presbyterian Shadyside for some assistance. After consideration, the Office of Patient

Experience department supported Kid of Steel with the purchase of one-hundred water

bottles. Teresa conducted two in-person practices for the children of Whitehall, Pennsylvania.

The practices focused on proper stretching, running form, endurance, and general physical

activity for the members. Due to the COVID-19 pandemic Teresa transitioned her team and

practices to virtual practices that included family involvement with various activities that were

recommended by the program. On May 2, 2020, the Kids of Steel Marathon hosted its virtual

marathon. Teresa’s Kids of Steel consisted of 25 children and 50 family members from the

Whitehall, Pennsylvania community. The event was a huge success, and each child will be

presented with a water bottle to ensure hydration while they complete healthy behaviors such

as running or walking.

Keep an eye out as this story will be highlighted in our Magnet® document as exemplar SE10a!

MOTIVATING KIDS TO MOVE TO A HEALTHY LIFESTYLE TERESA LUCCHETTI MSN, RN, CNL, CCRN UNIT DIRECTOR, 4G AND RAPID RESPONSE TEAM

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EXPANDING OUR SHARED LEADERSHIP TO PROCEDURAL AND AMBULATORY DEPARTMENTS PROCEDURAL AMBULATORY COUNCIL RACHEL RASMUSSEN BSN, RN RENEE KELLY DNP, MBA, RN

In September 2019, the Presbyterian Procedural Ambulatory Council (PAC) had its first official meeting

and became the Steering Council’s sixth council member.

The PAC was created as a shared leadership forum representing the ambulatory, procedural, hospital-

based clinic, and testing areas, to serve as the voice of the outpatient frontline staff. It strives to be a

multidisciplinary council, seeking to include a diverse group not limited to nurses, in which all staff are

empowered to participate. Our shared leadership model exists to facilitate continual cultural growth in

alignment with UPMC’s mission. Our members are looking forward to connecting departments in a

cohesive way in order to bridge the gap between inpatient and outpatient services.

Laura Gailey Moul, Vice President of Imaging, is the executive sponsor for the PAC. She shares

administrative updates monthly at meetings and provides ongoing support to the council and its

members. Tim Powell, Nancy Jones, and Jill Bertoty serve as PAC facilitators. The elected Chair is Renee

Kelly and elected Co-Chair is Rachel Rasmussen.

Since the PAC has been formed, we have been working closely with Lauren Christy, Magnet Program

Director, who has been very influential in guiding us through the Magnet journey and narrowing our

objectives. One of the Steering Council goals is to improve patient satisfaction HCAHPS scores and has

also been adopted as a goal of the PAC. Currently, we are focusing on Negate the Wait and have chosen

two baseline measurements related to the outpatient setting in which to concentrate our efforts. While

we are relatively new, we have had full agendas including multiple guest speakers from all areas of

UPMC brought in by member requests, and we look forward to sharing our progress in the future.

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CREATING A NURSE-FOCUSED TECHNOLOGY MATINENANCE CHECKLIST INFORMATICS AND TECHNOLOGY COUNCIL MICAH VINOVSKIS BSN, RN ALICIA CAHALL RN

The inclusion and integration of technology has been instrumental in the evolution of healthcare, allowing for increased patient safety and more efficient nursing workflows. Use of the electronic health record and processes such as barcode medication administration and medical device integration require daily use of such technologies for the bedside clinician. Not only is the upkeep of these devices necessary for general function and patient safety, but continued maintenance reduces cost and increases patient satisfaction by improving reliability and quality of services (Galan & Martinez Gomez, 2018).

We identified a need for nurse-focused maintenance of our technology. The bedside nurse has direct interaction with these devices at the point of care. While staff can identify and manage maintenance issues in real time, a conflict often exists between reporting issues and patient care responsibilities. Over the course of a 12-hour shift, a nurse may interact with technology that may be serviced by one of six different departments. We found that staff are often unaware of how, when, or with whom to resolve technical or performance issues they may experience. Our goal was to empower an individual or small group of auditors, to maintain accountability for the functionality of the technology on their units. Additionally, we sought to encourage self-reliance in resolving technological issues from the bedside.

While there is a robust hospital-wide maintenance system via clinical engineering, many of the devices that nurses interact with fall under the ownership of Information Technology (IT) and do not have a preventative maintenance (PM) timeline. The structure of the checklist is intended to promote regular performance verification of these items in order to avoid costly and dissatisfying device failures that may otherwise be unreported or unresolved (Sezdi, 2016). The creation of the checklist was hinged on three unique factors: Inventory and itemizing device units that do not have a preventative maintenance schedule with IT (or have a lengthy PM timeline); Identifying and describing the optimal operational status of these devices; and Naming the servicing department (IT, Clinical Engineering, Engineering and Maintenance, and others). In November 2019, Council Co-Chairs Micah Vinovskis, RN, BSN and Alicia Cahall, RN surveyed the Transplant Intensive Care Unit and the Cardiothoracic Intensive Care Unit via walk-through to pinpoint tools with which nurses frequently interact that tend to have a high rate of failure. The preliminary list of devices was then shared with the Informatics Council for review, and additions and deletions were made in December 2019 and January 2020 based on council consensus. The checklist however does provide opportunity to for each individual auditor to include service line specific devices. The final document was presented to the Transformational Leadership Council for consensus and approval in January 2020, and the project went live the following month. Following a ‘strategic maintenance training model’ (Sezdi, 2016), quick tip sheets and self-help guides for many of the included devices were uploaded to the Informatics Council SharePoint, to facilitate troubleshooting without necessitating a help-desk ticket or IT intervention.

The checklist, intended to be completed monthly, requires the auditor to create a full inventory of the listed devices to identify missing or excess units; ensure each device is functioning properly based on a short-list of standards, report any damaged or non-functioning items to the appropriate authority for restoration and to follow up upon resolution. Through these repeated interactions, auditors may become more self-reliant at resolving technological or hardware issues and assist and encourage this reliance amongst their professional peers.

Due to the unexpected challenges and demands imposed by the COVID-19 pandemic, we as a council diverted our focus toward accessibility of Telemedicine applications and education regarding COVID-19 eRecord changes. We look forward to evaluating the impact and efficacy of the technology rounding checklist in the near future by surveying nurse perception of technology performance post project initiation and surveying rounder/auditor confidence in independent troubleshooting.

Galan, M. H., & Martinez Gomez, E. A. (2018). A review of maintenance management models: Application for the clinic and hospital environment. International Journal of Engineering and Sciences (IJES), 7(9), 1-7. doi:10.9790/1813-0709040117

Sezdi, M. (2016). Two different maintenance strategies in the hospital environment: Preventive maintenance for older technology devices and predictive maintenance for newer high-tech devices. Journal of Healthcare Engineering, 2016, 1-16. doi:10.1155/2016/7267983

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LITERATURE LEADS TO CHANGE EVIDENCE-BASED PRACTICE AND RESEARCH COUNCIL MEGAN KONKOL BSN, RN, CCRN APRIL HELLER BSN, RN

The Evidenced Based Practice and Research (EBP&R) Council dedicates itself to the development of evidenced-based care through research initiatives. Primarily driven by subcommittees of council members, such initiatives lead to changes that result in improved outcomes for patients and families. Each subcommittee is guided by council leadership Megan Konkol and April Heller, who are themselves guided by Betsy George and Laurie Rack, to organize and disseminate their research findings across the UPMC Presbyterian/Montefiore campus. The EBP&R Council focuses on the Magnet® component of New Knowledge, Innovation, and Improvements. Falls:

Falls forever plague a hospital’s operation. An EBP subcommittee began investigating if patients, specifically after transferring out of an ICU, are at an increased fall risk. A review of internal data from January 2019 to July 2019 showed a total of 458 falls. 40% (n=182) of patients who fell spent time in the ICU setting at some point during their stay. Subsequently, 23% (n=41) of those patients fell within 48 hours of transfer from an ICU. A thorough literature search found a severe lack of published data investigating fall rates within this targeted time period.

In January 2020 the committee identified 6D, 8D, and 9G as units with the highest fall rates, with the NICU, CTICU, and TSICU. Nurses on each unit participated in a three-question survey to gain understanding of their perception of anticipating and preventing falls. From the survey responses and further literature review, council members identified six overarching attributes of high fall risk patients. They quickly developed the TUMBLE Tip Sheet to guide both nurse education and handoff.

The aim is to reduce the number of ICU-to-Floor falls within a 48-hour timeline by increasing and streamlining communicating between nursing staff. As nurses transfer, utilizing the TUMBLE Tip Sheet highlights individualized information related to patient’s fall risk level. At present the group continues to educate staff with the help of unit leadership and develop a post-intervention data collection plan. None of this could have been implemented without unit director buy-in.

T U M B L E

TRANSFER • What level of assistance do they need to sit on the side of the bed, stand, pivot, or walk?

• Do they use any assistance devices to stand or walk?

UNDERSTANDING • Will they reliably use the call bell if they need assistance?

• Is the patient aware of their fall risks?

MENTATION/MEDICATION

• Do they have an altered mental status, delirious?

• Are they on any medication that could affect their fall level (diuretics—frequently requiring the bath-room, anticoagulation, pain medication/benzos?

BEARING • Are they partially or fully bearing weight?

• What was their level of activity prior to their

hospitalization?

• Have they worked with PT/OT?

• What has been their highest level of mobility in the ICU?

LEVEL OF FALL RISK • What was their fall risk score?

• Have they had a previous fall, if so when?

• What implementations are needed to prevent falls—bed alar, fall band risk?

EDUCATION

• Use of call bell/location of call bell

• Recent removal of foley

• Personalized risk factors (age, meds, IV infusions, monitoring equipment, pain)

• Recommendations for floor nurse (bed alarm, Posey alarm, Telesitter/Sitter)

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Delirium:

At UPMC Presbyterian Hospital, non-ICU floors have no evidence-based tools for assessment and implementation of interventions for delirium. This leads to a delay in diagnosis and treatment of delirium, resulting in overall adverse outcomes and increased length of stay. An EBP&R sub-committee review of literature found appropriate interventions can prevent 30-40% of delirium cases. Only 4% of patients completely recover from delirium at time of discharge, while one-third of patients with delirium never return to their baseline. Needless to say, delirium remains a concern in the non-ICU setting.

The subcommittee made it their aim to reduce delirium in patients 65-years and older in the medical-surgical setting. Using the established Confusion Assessment Method (CAM) Tool the group developed a Delirium Tip Sheet to help better identify and prevent delirium in non-ICU floors. Even though pathogenesis, assessment, and specific treatment for delirium remain unclear, early detection, and prevention programs prove beneficial for elderly patients. In July 2020, the group set up unit-based education with nursing staff on three medical-surgical floors - 9N, 11S, 7F. In spite of COVID-19, the team persisted forward with implementation of their Delirium Tip Sheet and follow up education on each unit. The goal is to incorporate the tip sheet into nursing practice throughout UPMC Presbyterian/Montefiore and to systematically address and lower inpatient, non-ICU delirium rate.

Mentorship:

Retention and support of new staff remains a focus of UPMC Presbyterian/Montefiore. Multiple studies have shown improved staff satisfaction and nurse retention with implementation of a mentorship compared to baseline practices. One EBP&R sub-committee took it upon themselves to further review the literature on mentorship programs and develop such a program for UPMC Presbyterian. They modeled their program after UPMC Shadyside’s program. The UPMC Presbyterian Mentorship Program included new nurses with less than one year of experience who have completed standard preceptorship on their unit.

In October 2019, the program rolled out on 10D/G Pulmonary Step-down and 4D Cardiology. A group of experienced nurses volunteered to pair as a mentor with a newly hired or graduate nurse. Mentors agreed to guide, support, and foster their mentees. Mentees were encouraged to reach out to their mentors via text, email, phone, and in person. The program design fostered a meaningful relationship between the mentee and mentor, where the mentee would have a “critical friend” in their mentor. From this relationship, they could build a network of support and resources. In January 2020, the Emergency Department adapted the program to fit their specific needs and recruited a group of experienced nurses ranging from 18 months to 20 years of experience to act as mentors. The EBP&R members worked closely with each department to guide them through the program. Members of the program completed follow-up surveys at the beginning of 2020. COVID-19 interrupted the original planned timeline of survey collection. However, answers slowly came back. Survey answers will influence program revision and improvement. After revisions, the team plans to implement the program hospital-wide to address the need for staff retention and satisfaction.

DELIRIUM PREVENTION IS KEY:

HOB elevated Review invasive lines daily Early mobilization OOB in chair with meals Daily BM: avoid constipation Promote sleep-wake cycle (lab holiday) Fall risk assessment Know the patient’s home routine

Obtain sensory supports (i.e. glasses, hearing aids) and nutrition supports (i.e. dentures) Record % meals Encourage PO intake Encourage the family to stay Blinds up, lights on during the day and off and night Activity boxes Music therapy Oral Care Physical Therapy

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EXEMPLARY PRACTICES LEAD TO IMPROVED PATIENT SATISFACTION SHELLEY WATTERS, DNP, RN, NE-BC SR. DIRECTOR CUTLURAL EXCELLENCE, UPMC PRESBYTERIAN SHADYSIDE

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The Transformational Leadership Council’s mission is to earn the satisfaction of our patients, respect,

and trust from those that govern us, and the pride of our employees. We serve to be a resource for our staff,

patients, and patients’ families. We continually attract, develop, motivate, and retain a workforce within a

supportive environment. Our council representation is comprised of nursing leaders from inpatient,

ambulatory, procedural departments, as well as our Emergency Department.

In summer 2019, we collected nominations for new co-chairs for our council. We held elections in July

2019 and announced our new co-chairs in August 2019 with Ruth Hall representing Presbyterian and Megan

Como representing Montefiore. Ruth Hall was promoted in the late fall 2019, and Christine Ros assumed the co-

chair role for Presbyterian in December 2019. Our council utilizes tactics that are rooted in evidence and

identified as best practices in healthcare when an opportunity for change is needed. Our council, in conjunction

with the other shared leadership councils collaborate on various projects to ensure sustainability. In 2019 and

2020, along with the Professional Practice and Development Council and Quality and Safety Council, we

supported the education and implementation of Hourly Rounding.

Hourly rounding is a purposeful form of rounding that proactively addresses patients’ needs. The

leaders in this council were educated on hourly rounding. We then attended skills labs offered by Studer Coach

Lauren Charles. We took the information learned and formally educated our individual units’ staff. The leaders

were also tasked with assisting with creating with a type of log to keep track of hourly rounding. In our current

state, nurse leaders are validating the competency of hourly rounds performed by our staff, as well as

monitoring compliance by reviewing data completed on the hourly rounding logs.

Hourly rounding in conjunction with Bedside Shift Report have effectively helped improve

communication to our patients about their care needs and concerns. It allowed a streamlined platform for

patients and families to feel heard and involved in their care. Bedside shift report allows nurses to work

collaboratively with each other to address patient concerns proactively and to have better closed loop

communications. This ultimately improves the patient’s health and lowers readmission rates into the hospital.

Since starting bedside shift report and hourly rounding, UPMC Presbyterian has increased their nurse

communication domain in our HCAHPS scores from the 63% to the 81% from calendar year 2019 to calendar

year 2020. The nurse leaders help guide these practices and coach for continued success.

In the early part of 2020, this council was faced with unexpected new challenges related to COVID-19.

The council had to work to figure out how to connect without being physically together. This council has been

able to successfully hold productive large meetings virtually via Microsoft Teams. As this council works through

our “new normal”, we are excited and eager to see the future for UPMC Presbyterian.

IMPROVING THE PATIENT EXPERIENCE TRANSFORMATIONAL LEADERSHIP COUNCIL MEGAN COMO, MSN, RN, CCTN, UNIT DIRECTOR 5E/W CHRISTINE ROS, MSN, RN, UNIT DIRECTOR 10D/G

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PATIENT CARE SERVICES NURSING DIVISION

LEADERS

Heidi Karalagas Director, Patient Care Business Operations

Lauren Christy Magnet Program

Director

Jeannine DiNella Director, Organizational

Development and Nursing Education & Research

Michaele Kennedy Director, Patient Care

Services

Jennifer Manns Director, Clinical

Operational Informatics

Ruth Hall Clinical Director

Shauna Campbell Clinical Director

Ben Morrow Clinical Director

Laurie Rack Clinical Director

Carol Scholle Clinical Director

Shelley Watters Sr. Director,

Cultural Excellence

Lisa Donahue Sr. Director,

Patient Safety & Innovation

Denise Abernethy Sr. Director,

Emergency Services

Melanie Smith-Fortney

Director, Nursing

Sandra Rader Chief Operating Officer,

Chief Nursing Officer and Vice President,

Patient Care Services