In This Issue:

EBP Council Update—Internship Program launched

SVMHS Nurses Attend National Magnet Conference

What's New

Partners in Care—Laboratory Services

Poster presented at California Hospital Association Disaster Planning Conference

Meet Our Nurses-Avilez

Presentations by SVMHS nurses

Improving hand hygiene—a commitment to patient safety

Nurses Making a Difference
Diane Martin, RNC, RN-SNIII, CLC

Diane Martin, RNC, RN-SNIIIDiane Martin, RNC, RN-SNIII, CLC is now in her 25th year at SVMHS and has worked the last 13 in Mother/Baby. She joined our Pediatrics Department as a new graduate of the Maureen Church Coburn School of Nursing at MPC. Certified in Maternal Newborn Nursing, the 2010 Nurse of the Year nominee earned her Staff Nurse III (SN III) in March of last year.

"I appreciate that SVMHS gives us opportunities to grow in our profession and advance in the organization," says Diane who serves on the Staff Nurse III Review Board. "The SN III process not only lets nurses move up the ladder, but it also acknowledges nurses for their individual contributions and accomplishments."

In addition to being a relief Charge Nurse on her unit, Diane serves on the Breastfeeding Task Force, Perinatal Unit Safety and Readiness Committee and co-chairs the Competency Committee. "It is a lot of responsibility running a unit for a shift, but I have a great support system," she says. "It's important for me to push myself out of my comfort zone while maintaining a healthy balance between my work, personal and family life."

"Every day I'm thankful for my family, my health and my job," Diane continues. "Nursing is a gift I can share with families as they bring a child into the world. I'm there to encourage and support growth through patient education. And we have a great multi-disciplinary team to help our patients and their families when something unfortunate and unexpected happens."

Diane and her husband of 23 years have two grown sons. In her leisure time, she enjoys spending time with her family, gardening, home improvement projects, hiking and walking her two dogs.

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Evidence Based Practice Council Update—Internship Program launched

The Evidence Based Practice Council (EBPC) introduced an Internship Program at the EBP Poster Expo in May. "It's designed to encourage more staff nurses to implement evidence based practice into their day-to-day work," says Nicosia Brake, BSN, RN, Pediatrics, and EBPC member who led development of the program. "We researched similar programs at other hospitals and also had contact with Massachusetts General Hospital about their program."

A number of nurses submitted an application outlining their project idea and/or reasons for wanting to join the EBPC. Two nurses—Deb Avilez, BSN, RN-SNIII, CPAN, PACU and Pam Yates, RN, CLC, Peds—were selected and will begin their internship in January. "They'll work with a mentor, someone who will guide them and show them the most effective ways to use research and evidence, bring a project forward and implement EBP changes," explains Nicosia. "Having a mentor for the first major EBP project makes it so much easier and rewarding." Following the internship, the nurses will be full-fledged members of the EBPC.

"We'll use feedback from the interns to make any necessary refinements to the program," Nicosia says. "The EBPC hopes to offer the internship program to more nurses in the future. The end goal is to make evidence based practice the norm at SVMHS."


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SVMHS Nurses Attend National Magnet Conference

Magnet Steering Committee members Michelle Savala, BSN, RN, CLC, AHN in Perinatal Services, Jeanne Hayashi, RN-SNIII, PACU, and Doreen Faiello-Burnett, RN, MHA, Administrative Supervisor attended this year's National Magnet Conference. Themed A Culture of Caring, it was held in Phoenix, October 12 to 15. Six thousand people, including 1,900 bedside nurses, from 15 countries attended. The majority of hospitals represented were either Magnet certified or on their journey to Magnet.

"Magnet certification benefits patient care, the practice of nursing and the organization as a whole," says Michelle. "Studies show that Magnet hospitals do better on patient care benchmarks and that nurses are following best practices. I'm proud that SVMHS is committed to achieving this important designation."

"A Culture of Caring highlighted that, while nursing is a scientific discipline with quality measures and processes, it is also about empathy and caring that can be quantified," explains Jeanne. "These attributes can be measured with data such as stopping the infection process, decreasing falls and preventing wounds. As nurses, we need to rely on science and best practices, but it's the caring and empathy that increase patient satisfaction and quality of care."

Participants also learned about "Forces of Evidence." After an application for Magnet has been submitted, surveyors complete an on-site visit. During this review, hospitals must demonstrate and show examples of having all the components of Magnet, such as Shared Governance and Transformational Leadership, in place.

While nursing leads and is responsible for meeting Magnet certification criteria, it takes the entire organization—from housekeepers, valets and support staff to administrators and clinicians. "It's essential to engage staff at all levels, and invite them to be part of the process and participate in solutions," Michelle says.

Today, only 5 percent of all U.S. hospitals have earned Magnet certification. "The Magnet brand says that a hospital excels at employing best processes and achieving quality outcomes," Jeanne says. "We're already meeting a lot of the criteria and are now tightening up processes and making sure we can validate our claims in preparing for the on-site visit."


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What's New

Melanie Cancio, BSN, RN-SNIII, OCN, CMSRN and Kimberly Brown, BSN, MSEd, RNSuccessful conversion to new IV tubing

In March, Wendy Ogden, MSN, RN, CCRN, PCCN, Clinical Nurse Educator, led a demonstration and evaluation by nurses, pharmacy and other staff to select a new vendor for IV tubing. "They brought clinical experience and professional knowledge to the process to ensure we made the best choice for our patients," says Wendy. As a result, Baxter tubing was selected and the conversion was completed in September. Baxter conducted on-site inservices for about 400 nurses and pharmacy staff September 12 to 15. Patient Care Champions (PCC) are now educating staff members not available during the inservice period. "Baxter also did a 60-minute inservice on all the things we would need to educate staff who missed the initial training," says Kimberly Brown, BSN, MSEd, RN in the Emergency Department and a PCC. "Patient safety comes first so we want to make sure that nurses know exactly how to flush, lock and bus cap as well as double check to ensure that it's tight." "I like the fact that there are 'clear links' so I can visually see if something's clogging the device rather than having to take it apart," adds Melanie Cancio, BSN, RN-SNIII, OCN, CMSRN. "And it's easier to reconstitute secondary piggy backs with the new tubing."

Kathy Finnigan, RN, MS, Clinical Nurse Specialist for Oncology

group photoKathy Finnigan, RN, MS, Clinical Nurse Specialist for Oncology (OCNS), graduated from the University of California, San Francisco in June 2010 with a masters of science, majoring in oncology and genomics. The content of the graduate program included advanced pathophysiology, pharmacology and physical assessment as well as specific course work and clinical experience in caring for patients with a past, current or potential cancer diagnosis. "I am now prepared to meet the specialized physiologic and psychological needs of patients throughout the continuum of cancer care," Kathy says. "This encompasses everything from risk identification, prevention, detection and diagnosis to treatment, rehabilitation, survivorship and end-of-life care." Kathy works to improve patient outcomes by advancing the practice of oncology nursing and influencing organizations and systems in which care is provided. "I draw on all available evidence to effect positive changes in the healthcare delivered to our patients," she says "Kathy has been a great addition to the oncology floor," says Nancy Voogd, RN. "She is our liaison with Los Palos Oncology, working on order sets for chemotherapy and outpatient orders. She is a great resource for the staff nurses."

Nurses in the Community: Labor of Love

SVMHS nurses Shawna Helmuth, RN-SNIII, BS, IBCLC, Luz Jimenez, BSN, RN, BA and Michelle Savala, BSN, RN, CLC, Women's and Children's Services; and NICU Unit Assistant Rosemary Rico staffed a table at the annual Labor of Love event at Sherwood Hall. Organized by Salinas Adult School, the September 2 event drew more than 570 people including 223 pregnant women, plus children, dads, grandparents, professionals and volunteers. Celebrate Birth, the theme of this year's event, featured educational classes and information booths providing information to pregnant women in Monterey County. "This is our 16th year participating in this event," says Shawna. "SVMHS donated a car seat for the raffle and we handed out breastfeeding and parenting information at our table. It really was a celebration of life."

Third Annual Staff Nurse III Celebration

Suzette Urquides, RN-SNIII, Cardiac Catheterization Lab"The Power of Focused Attention" was the theme of the 3rd annual All Staff Nurse III Celebration, held September 10. The event, hosted by the Staff Nurse III Review Board, showcased a variety of ongoing projects, activities and functions driven by Staff Nurse IIIs (SN III). "It was a great opportunity for nurses to network, share information and learn from one another," says Molly McCarty, BSN, RN-SNIII, Float Pool. Posters from the 2010 Evidence Based Poster Expo—sponsored by the Evidence Based Practice Council (EBPC)—highlighted the work being done by our bedside nurses. The SN III Review Board previewed the Role Based Track language to be included in edition 5 of the Staff Nurse III Application and Recertification Packet, effective this year.

Deb Denham, PhD, RN, the featured speaker, led discussions on personal and professional goal setting using SMART goal theories—Specific, Measurable, Attainable, Realistic and Timely. This goal setting approach applies to nurses at all levels and in all disciplines.

The next SN III celebration will be held in fall 2011 and will focus on nursing specialty certification opportunities.


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Partners in Care—Laboratory Services

Robin Reclusado, CLS, MT(ASCP), Kathy Finnigan, RN, MS and Kathryn Maurer, RN-SNIII Robin Reclusado, CLS, MT(ASCP), Clinical Laboratory Manager, formerly SVMHS Blood Bank Supervisor, compiled data that indicated that blood transfusion documentation needed improvement. "Nurses are on the front lines of patient care," says Robin. She invited Pat Valenzano, MSN, RN, Director of Women's/Children's Services and Sharon Roberts, RNC, MSN, CNS, Director of Education, who share oversight of compliance with National Patient Safety Goals (NPSG) to a meeting to discuss the issue. NPSG goal one focuses on patient identification—a related element is accuracy of identification of patients receiving a blood transfusion. "We identified areas where nurses needed more information and a more detailed process," adds Robin. "It's a win-win-win, for our patients, the lab and nursing."

As partners in care, Laboratory Services and Nursing collaborated to revise current documentation forms to assist the nurses in identifying when a patient was having a reaction to blood transfusions. "Robin showed us some of the challenges nurses were having recognizing when a reaction was occurring," Pat says.

The results of the group's efforts include the Issue Transfuse Card (ITC) and a new algorithm. The ITC allows compliance with the requirement of having two qualified practitioners confirm the patient's ID. The ITC also provides the location to enter vital signs and document other required components including any reactions. The algorithm provides clear information that will alert the nurse when it is required to call a physician. "It provides a very clear, step-by-stop process for identification and response to reactions," explains Sharon. "The algorithm is available on MEMNET so nurses can easily check it."

The new process follows College of American Pathology rules. Nurses and other staff who participate in the transfusion process were educated regarding the required competencies. Kathy Finnigan, RN, MS, Clinical Nurse Specialist for Oncology, developed an e-learning module that these individuals must repeat each year. "The Healthstream module was well done," says Kathryn Maurer, RN-SNIII. "The use of tables helps me to be clear on the appropriate action to be taken. Case studies that were included in the module provided additional clarity in ensuring that we're providing the best and safest care for our patients."

"The nurses were very receptive," says Robin. "Audits now show that we are completing the required components of this NPSG and providing consistent patient care as a direct result of this collaboration with nursing."


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Poster presented at California Hospital Association Disaster Planning Conference

Renee Comee, MSN, FNP, RNA Best Practice poster developed by Renee Comee, MSN, FNP, RN, Director of Ortho/Neuro/Spine (formerly Assistant Director of the Emergency Department) and chapter chair for SVMHS emergency management committee, was selected for display at the 2010 California Hospital Association Disaster Planning Conference held September 22 in Sacramento. The poster highlighted how SVMHS partnered with the Monterey Bay Area Chapter of the American Red Cross to create a low cost, yet very effective personal preparedness program.

"When a disaster happens, we really need to have all types of staff be available to either remain or return to work," says Renee. "This program teaches our employees how to put a personal disaster plan in place for their home and family. The theory is that if staff feel they have an effective way to ensure their family is taken care of, they are more likely to remain or return to work. It was an honor to present our program and to help make it a reality at SVMHS. Other hospitals are now looking into partnering with their local Red Cross chapters to develop similar programs."

Red Cross Emergency Services Manager, Lynda Maguet, trained fifteen SVMHS staff members, including Renee, to be facilitators for the Be Red Cross Ready program. These trainers are now training employees throughout the organization.

Renee was inspired to collaborate with our Education Department to develop the program following a presentation at the July 21 Nursing Grand Rounds, sponsored by the EBPC. Glen Woodbury, Director of the Naval Postgraduate School's Center for Homeland Defense and Security, spoke on Community, Organizational and Personal Preparedness.


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Meet Our Nurses


Deb Avilez, BSN, RN-SNIIIDeb Avilez, BSN, RN-SNIII, CPAN has 25 years of experience working in PACUs—20 of those at SVMHS. "It's rewarding to be there for surgery patients, providing care throughout the process," says Deb. She became a Staff Nurse III (SN III) in 1994 under the previous system. "My experience and talking to other nurses made me realize that the system didn't enable nurses to showcase their unique talents and interests," she says. Deb was instrumental in developing the SN III process in place today. The 2010 Nurse of the Year nominee is known and respected as an advocate for professional development.

She earned her BSN in 1978 from the State University of New York at Buffalo and has been a Certified Perianesthesia Nurse (CPAN) since1992. "Specialty certification gives me a better foundation for what I do every day and helps me stay on top of the latest evidence based practices through continuing education," Deb says. She is a member of PANAC, the Perianesthesia Nurses Association of California and ASPAN, the American Association of Perianesthesia Nurses, professional organizations that offer educational and networking opportunities for nurses.

Together, she and her husband have four grown children and one grandchild. She is active in her church, enjoys gardening and playing with her dog Dennis, a Basenji-Terrier mix.


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Presentations by SVMHS Nurses

At the UCSF School of Nursing & the Center for Nursing Research and Innovation 12th Annual Research Days held October 27 and 28, Vanessa Irwin, MSN, RN, CLC, Clinical Nurse Educator, Med/Surg and Pediatrics presented her poster entitled "Patient Care Champions: Staff Nurses Evaluation of the Effectiveness of Teaching Methodologies." Attended by more than 175 nurses and other professionals, the conference showcased nurse-led evidence based research projects and offered workshops to aid nurses in identifying, developing and implementing future projects within their organizations.

Lorraine Shields, RNC, MN, NNP, Clinical Nurse Specialist, NICU and Ashley Triplett RRT-NPS, Supervisor/Educator, presented the results of their work: "Improving Intubator Coverage in the NICU Through Simulation Training" during a poster session at the October Magic in Teaching Simulation Conference. Sponsored by the California Institute for Nursing and Health Care (CINHC), the conference was attended by more than 230 people. A wide variety of presentations and workshops focused on innovative teaching strategies in curriculum development and in the clinical setting. The CINHC is committed to optimizing the health of Californians through nursing excellence. They also presented their work during a poster session at the 12th Annual Research Days sponsored by the UCSF School of Nursing & the Center for Nursing Research & Innovation.


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Improving hand hygiene—a commitment to patient safety

Vanessa Lockard, BSN, RN-SNIII and Laurel Black, RN-SNIIIThe Hand Hygiene Operations Team, formed in June 2010, was tasked with addressing a drop in compliance with consistent hand washing. Their goal was to achieve and maintain a compliance rate of at least 90 percent. A house-wide Hand Hygiene project was initiated to increase patient awareness of the importance of hand hygiene and to encourage them to ask their caregivers and visitors if they have "cleaned their hands" (see video on MEMNET). Also, individual units and departments were asked to develop their own plans to improve hand hygiene. Here's what two units—the Emergency Department (ED), with the greatest amount of patient contact; and the Intensive Care Unit/Cardiac Care Unit (ICU/CCU), caring for the most critically ill patients—did to address and improve compliance on their units by more than 30 percent, surpassing the 90 percent goal.

Emergency Department
"Our numbers were low," says Vanessa Lockard, BSN, RN-SNIII, chair of EPIC (Emergency Department Performance Improvement Committee), the Emergency Department's Unit Practice Council, at the time, "so we decided to face the challenge head-on. First we tried 'glo soap' thinking that it would highlight germs left behind, but it was not successful." Then, Staff Nurse IIIs, AHNs and charge nurses decided to ask everyone (nurses, CNAs and registration clerks, for example) to document hand hygiene compliance whether it was their own or observed, for 2 weeks. "Armed with data, we took it a step further," says Vanessa, who led the efforts. "If a person didn't actually observe someone else washing their hands in the hall, they would ask if they washed in the patient's room. Our goal was to support each other, raise awareness when hand hygiene isn't being practiced and praise staff when they did comply. Now, we're asking paramedics, EMTs, volunteers, and non-ED physicians to wash their hands."

Intensive Care/Cardiac Care Unit
"When our director brought the unit's hand hygiene statistics and our infection rates to the Unit Practice Council, we realized we could make small changes that would greatly impact our patients," says Laurel Black, RN-SNIII, ICU/CCU, UPC chair. "We started by looking at what the NICU was doing since they had great numbers," she says. They then looked at the products they were using (soap and foam). Each shift, the charge nurse and another chosen staff member on the floor completed hand hygiene audits for 10 days. "We realized not only where our hand hygiene could improve, but that those improvements also applied to RTs, PT/OTs, x-ray technicians, physicians and other staff who care for our patients, as well as visitors," remembers Laurel. "We changed to a lotion gel and made it more accessible by placing it in and in front of each room in addition to more areas around the nursing station. We also required a 3-minute wash with a chlorhexidine scrub sponge at the start of each shift." UPC members are now in the process of educating the ICU/CCU staff and all ancillary departments and visitors in the new procedures. "The staff has been very welcoming of the change as they understand that it greatly improves outcomes for our patients," adds Laurel

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