e6 ASPAN NATIONAL CONFERENCE ABSTRACTS

developed SBAR-Q tool and “Team Care” minimized the loss of

patient data during transfer of care (P, 0.019).

Discussion/Implications for Practice: The use of “Team

Care” handoff process standardizes our handoff process for sur-

gical inpatients and has transformed handoffs to make patient

safety our priority.

SURVEY ON RN PERCEPTION OF ELECTRONICCHARTING USING THE EPIC COMPUTER SYSTEMTeam Leader: Tess Mazloomian, RN, MN, CCRN, CPAN, CAPA

Saddleback Memorial Medical Center. Laguna Hills, CA

Background Information:

� 2004 - all clinical staff training on principles of change,

leadership, Partnership Councils and basic computer

skills. Staff input on computer system to choose, solicited.

Staff participated in the design, build, validate phases of

program. IT personnel trained by Epic.

� 2006 - total system (all departments, entire hospital) Epic

“go live” with integration of physician order entry, nurs-

ing documentation, MAR and support staff documenta-

tion in the patients’ EHR (electronic health record).

Environmental redesign of all departments implemented

to accommodate desktops and rovers. 24 hour Helpline

for Epic and computer issues.

� RNs have used Epic for five years now

� Author is interested in looking into RNs’ perceptions re-

garding various aspects of electronic documentation

(see questionnaire)

Objectives: To determine

� If perceived level of computer skills correlates with per-

ceived ease of use of the EHR.

� RN acceptance and perception of the benefits of comput-

erized charting

� RN perception on whether computerized documentation

influences positive patient outcome

Implementation:

� Author developed survey questionnaire, distributed

housewide to RNs

� Duration - September 25 through October 15, 2011

� Author will tally results

� Results will be shared with SMMC Epic Documentation

Guidelines Committee for consideration of staff RN rec-

ommended changes

Successful Practice Identified:

� Acceptance of electronic charting and perceived ease of

use promotes efficiency in the utilization of Epic for doc-

umentation in the EHR.

Positive Outcomes Achieved:

� Epic program improvement to further benefit patients

and staff.

Implications for Perianesthesia Nurses:

� Enhanced staff satisfaction and improved patient care and

safety.

SUCCESSFUL IMPLEMENTATION OF SBARHANDOFF COMMUNICATION TOOLS IN THEPERIANESTHESIA/ PERIOPERATIVE SETTINGTeam Leader: Diane Roche, RN, CAPA

Aria Health Torresdale, Philadelphia, PA

Team Member: Sarah Carter, RN, CAPA

Background information: Sentinel event that involved an an-

esthesia provider and orderly bringing patient into the Operat-

ing Room prior to serum HCG result.

Objective: Provide safe patient care at all levels of patient hand-

off in the Peri Anesthesia/ Peri-Operative settings

Process: Piloted with SBAR handoff communication tool to be

used during “Pre Op huddle” involving pre-op RN, circulating

RN and anesthesia provider. Eventually led to SBAR handoff

communication tools at every level of care in the Peri Anesthe-

sia/ Peri Operative setting.

Statement of the successful practice: SBAR handoff commu-

nication tools will be utilized during all levels of patient handoff

in the Peri Anesthesia/ Peri Operative settings at Aria Health to

ensure safe delivery of care to all of our patients.

Implications for advancing the practice: Ensuring the safe

delivery of care for all patients in all procedural areas.

IMPROVING DOCUMENTATION IN THE PACU

Team Leader: Melissa Schmidt, RN, BSN, CPAN

Portland Veteran’s Hospital, Portland, OR

Jennifer Johnson, RN, BSN, MS, CPAN, Linda Kitchen, RN, BSN,

Dawn Jackson, RN, BSN, LaVonne Albertson, RN, BSN, CRGN

In October 2008, an initial review of nurses charting revealed

only 81.2% of charts were complete. We looked at our charting

template and charts monthly to determine how to improve

charting in the PACU. The information was collected by all staff

nurses in the form of chart reviews, all nurses are required to do

one chart review per month. ASPAN standards were used to de-

termine completeness of charts.

During FY 2009 the data collected were used to create a new

PACU flowsheet to save time, improve charting, improve pa-

tient care, meet ASPAN/JCAHO standards. This was accom-

plished by reviewing existing forms from other hospitals,

brainstormed as a unit, and used Survey Monkey to survey staff

for preferences. The new flowsheetwas rolled out in December

2009. Education was provided to staff prior to implementation,

support was available for the first week of implementation, and

individual feedback was provided to staff.

Chart Reviews resumed Feb 2010, chart reviews since imple-

mentation reveal a compliance of 94%. Feedback from the staff

nurses regarding the existing chart review tool was that it did

not mirror the new flowsheet, and updated chart review tool

was completed May 2010. Areas on charting weakness were

noted as patients receiving spinals and epidurals. After review

and education of nurses of specific weakness charting compli-

ance increased.

The final data indicated that education, involving the entire staff

in the project, and creation of a new flowsheet have improved

documentation in the PACU.