Abstracts of the 2014 AWHONN Annual Convention, June 14-18, 2014, Orlando, Florida.

I N N O VAT I V E P R O G R A M S Proceedings of the 2014 AWHONN Convention

You Are Not Alone: Addressing Perinatal Mood Disorders Women’s Health

Tonia Russell, RN, Columbus Regional Healthcare System, Cataula, GA

Purpose for the Program o dispel the stigma surrounding mental health complications and provide compassionate care to promote healthy pregnancies, happy mothers, and safe children. Women are experiencing greater degrees of anxiety and depression, earlier in pregnancy, which results in more women developing mood and major depressive disorders. Perinatal mood disorders are an evolving blend of emotional and mental uncertainty affecting women during pregnancy and through the postpartum period. Early diagnosis and treatment can prevent a multitude of intrapartum complications from preterm labor to suicidal ideations.

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Astrid S. Wightman, RNC, Columbus Regional Healthcare System, Columbus, GA Proposed Change

In response to changing patient needs, small adChris Cannon, MSN, Columbus justments in practice result in tremendous imRegional Medical Center, provement in the wellness of mothers and infants. Midland, GA

Conducting perinatal screening for mood disorders addresses this need.

Dawn Hurst, RNC, MS, Columbus Regional Healthcare Implementation, Outcomes, and Evaluation System, Zebulon, GA

A collaboration between antepartum, labor and delivery, postpartum, social work, health information systems, and maternal outreach units resulted in the Perinatal Mood Disorders Program. Upon admission to the antepartum or labor and delivery Natalie N. Heath, RN, unit, patients are asked questions from the choColumbus Regional Healthcare sen screening tool. A new Social Services Consult System, Columbus, GA tab and screening questions with corresponding weighted answers are part of the admission asLaTisha Walker, LMSW, Columbus Regional Healthcare System, Columbus, GA

Jamie Evans, RN, Columbus Regional Healthcare System, Columbus, GA

sessment. Any score that reflects the potential for mood disorders automatically alerts the admitting registered nurse (RN) to enter a maternal child social services or physician consult through the electronic order entry system. Further evaluation and appropriate referrals are then provided. Hospital policies reflect nomenclature changes and incorporate new processes. After discussions with the U.S. Department of Health and Human Services, which involved explaining the purpose of the program, the need for perinatal screening and educational materials, and the overall goal of the project, English and Spanish educational booklets were graciously provided each month at no charge. In addition, a Community Resource Guide to Mental Health was provided as a supplement for each patient. This supplement contains mental health providers, psychiatrists, psychologists, and support group/counseling resources in the region along with contact numbers. Trending data and reporting reflects the increase in number of consults and highlights the number of patients whose conditions would have remained unrecognized and undiagnosed. Implications for Nursing Practice By addressing perinatal mood disorders, women are assessed, screened, and treated as needed to ensure the health of the mother and newborn. Negative connotations with mental health issues can be eliminated with compassionate care that is focused on the well-being of the family.

Kelly Hunter, RN, Columbus Regional Healthcare System, Columbus, GA Jennifer Osborne, RNC-MNN, Columbus Regional Healthcare System, Midland, GA Keywords perinatal mood disorders postpartum depression postpartum psychosis

Poster Presentation

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2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses

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I N N O VAT I V E P R O G R A M Proceedings of the 2014 AWHONN Convention

Creating a Comanaged Obstetric/Intensive Care Unit Purpose for the Program he critically ill pregnant woman presents a complex challenge to physicians and nurses in obstetric and critical care specialties. Statistics suggest the overall estimate of obstetric patients in the United States who require critical care services is 1% to 3% annually. A multidisciplinary approach was taken to review the literature and create an environment where the complicated obstetric patient can receive comanaged care in a large, university hospital birth center. The key focus was to recognize complications of pregnancy and the effect of preexisting disease on pregnancy to care for the critically ill patient who has the potential to develop a life-threatening condition.

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Proposed Change The literature shows that most intensive care admissions for obstetric patients are secondary to obstetric complications (e.g., hypertensive disorders or hemorrhage) along with complications related to preexisting conditions (e.g., respiratory failure or diabetes) warranting a higher level of care. A proposal was developed using a comanaged approach of obstetric and critical care specialties to care for critically ill obstetric patients within a six-bed licensed intensive care unit (ICU) located in the birth center. Implementation, Outcomes, and Evaluation A multidisciplinary team consisting of obstetric and critical care nursing; maternal–fetal medicine and critical care physicians; anesthesia, respiratory, pharmacy, and infection control was es-

tablished to improve the assessment and management of the complicated obstetric patient. A change in culture and the need for additional education was identified within the birth center, and the facility recognized this unit as the place where the complicated obstetric patient would receive care.

Linda Dudas, RNC, MSN, CNL, Magee-Women’s Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA

Keywords maternal–fetal medicine critical care medicine To implement the proposal, OB Triggers were de- comanagement

veloped to guide staff in identifying patients who would be transferred to the obstetric (OB)/ICU beds. A core team of nursing staff was established to take ownership of the unit and receive additional education on pregnancy complications and the effect of preexisting disease on pregnancy. Since the initiation of this project, an increase in the daily census of complicated patients per day in the sixbed OB/ICU unit has been demonstrated through cumulative statistics based on diagnosis coding. An increase in the amount of comanagement opportunities also has been demonstrated based on the admitting physician and consults.

Women’s Health Poster Presentation

Implications for Nursing Practice The implementation of this project helped staff to recognize the importance of ongoing assessment of each patient by identifying complications of pregnancy that requires an increased level of care. In addition, the project has given all members of the health care team tools for recognizing the need for comanaged care and for implementing timely and well-coordinated interventions when faced with increasingly complicated patients at risk of life-threatening conditions.

Comadre Group Teaching in Nutrition Purpose for the Program he purpose of this evidence-based practice (EBP) project was to assess if a comadrelike group teaching approach would increase Hispanic women’s knowledge of nutrition. Small cultural support groups are unique to many Hispanic women because they rely on relatives and friends within their communities. The uniqueness of this population is their high regard for family and their close social network, which makes group teaching a potentially more effective approach for health promotion and wellness.

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Proposed Change To increase knowledge of nutrition and explore the potential for other areas for group teaching in women’s health.

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Implementation, Outcomes, and Evaluation Nine bilingual Hispanic women between 19 and 68 years of age participated in this project. After consent was obtained, participants were given a 10-item pretest intervention questionnaire (totaling 50 points) to assess their knowledge of nutrition. A total of four sessions on general nutrition were provided. Classes consisted of lectures, posters, handouts, and discussion. The same 10-item postintervention questionnaire (totaling 50 points) was given to assess the participants’ knowledge of nutrition and feedback on the comadre-like group teaching approach.

Lisa A. Gernon, MSN, Hunterdon Medical Center, Flemington, NJ Carolynn Kedzierski, MSN, RN, C-OB Hunterdon Medical Center, Flemington, NJ Keywords group teaching


Implications for Nursing Practice The results of this evidence-based transcultural nursing project underscored the importance of

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http://jognn.awhonn.org

Chichester, M., Whitworth, M. S., and Patel, N. R.


using a comadre-like group teaching approach to increase Hispanic women’s knowledge of nutrition. This method could be used in other areas of

nursing and health education to promote a healthy lifestyle.

Empowering Patients: Partnering in Pain Management Using Medication on Demand Lisa J. Hreniuk, RN, Penn State Purpose Milton S. Hershey Medical o provide high-quality and efficient nursing Center, Hershey, PA

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care in a safe environment using medication on demand (MOD). This is a device ordered by the Shelda M. Sheaffer, RNC, Penn physician, programmed and loaded with the narState Milton S. Hershey cotic analgesic by the registered nurse (RN), and Medical Center, Hershey, PA used on demand by the patient to facilitate postop Jana Sukeena, RNC, Penn State pain relief. The MOD device does not replace the nurse’s interaction with the patient. Frequent comMilton S. Hershey Medical munication about postoperative pain relief is still Center, Hershey, PA necessary and required. Wendy Tribioli, RNC, BSN, Penn State Milton S. Hershey Medical Center, Hershey, PA Keywords medication on demand


Proposed Change Striving to increase our patients’ satisfaction in pain management, we are implementing a new method of administering a narcotic analgesic to our postoperative cesarean patients. This method is a patient-controlled oral medication devise that allows the patient to take acetaminophenoxycodone every 2 hours as needed. This autonomy given to a patient to relieve pain increases her satisfaction in pain control during hospitalization. Implementation The hospital MOD pilot team conducted a literature review and sought assistance from the MOD device representative. Women’s Health Unit nurses reviewed an e-learning prior to attending a live training session with the MOD device and the representative. MOD brochures were available. During the pilot, weekly e-mail updates were

sent to the nurses on patient and RN feedback, questions, or issues. The nurses learned how to screen patients in labor and delivery for those who could safely use MOD and how to set up the device, teach the patient, and document in power chart. Outcomes and Evaluation Responses to date have been positive. Implications for Nursing Practice The nurse must screen the patient, and postoperative cesarean patients must be selected for MOD using the following criteria: the patient must be awake and alert and able to accept the device responsibilities; have no swallowing difficulties or trouble taking pills; have no history of drug abuse or drug seeking; and have no physical disability to prevent the device being used. The nurse must continue to assess the patient’s pain relief and document it. The nurse must document the remaining tablets in the kit at shift change and must continue to relieve the patient’s pain with nonmedication pain relief measures, such as splinting the incision and proper positioning. Security is a priority. The device IV pole clamp can only be loosened using a special locking wrench. The confirmation screen requires an RN to verify that the order is correctly entered and to give the patient a secure identification band to keep unauthorized users away from accessing the device.

The Role of the Office Nurse in Caring for Families Choosing Pregnancy Termination for Anomalies Melanie Chichester, BSN, RNC-OB, Christiana Care Health System, Newark, DE

Purpose for the Program hen severe or fatal anomalies are diagnosed during pregnancy, the decision to end a pregnancy is a difficult. Parents struggle with grief and guilt because of the stigma associated with this choice. Their regular obstetric provider may transfer their care, and they may feel abandoned and have fragmented follow-up support for the loss. The purpose of this program was to provide im-

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proved continuity of care and support for these families. Proposed Change When care is disrupted by a transfer of health care provider, the office-based nurse can do much to assist these parents through sensitive prenatal care, counseling and education, memorial planning, postpartum visits, referrals, and interconception care.

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Implementation, Outcomes, and Evaluation The office-based women’s health nurse identified the need for an improvement in care for these families during and after pregnancy. Care was changed beginning with intake because women or couples were arriving with poor comprehension of fetal diagnosis, prognosis, or options. More time was allocated to provide further education, and couples were encouraged to explore pregnancy interruption and effects of the decision on the family within their cultural and religious framework, which promoted a trusting relationship. The nurse also provided resources specifically associated with grief and assisted with determining options of memory items to affirm the existence and importance of the pregnancy. The office nurse now establishes contact with the hospital-based personnel to ensure communication of the patient’s arrival, pertinent history, plans for delivery, and plans regarding autopsy or burial arrangements. This alleviates some of the discom-

fort of a woman arriving in labor and provides time to consider options most appropriate. Postpartum care now includes time to review pathology reports and interconception planning with the same health care provider and assessment to identify need for long-term support. Patient comments confirm that couples feel supported throughout the process by knowing there is a single nurse who can address their concerns, communicate their plan, and follow up with them afterwards. Implications for Nursing Practice Having a dedicated nurse–physician team to coordinate patient care through difficult decisions is essential to help couples make a truly informed decision in a supportive environment, which entails arranging couples’ access to consultation before and subsequent to pregnancy termination, as well as coordinating care with the inpatient facility. Implications for research include the need for more studies that explore couples’ care during and after pregnancy termination.

Margaret S. Whitworth, RN, BSN, Christiana Care Health System, Newark, DE Nima R. Patel, MD, MS, Christiana Care Health System, Newark, DE Keywords collaborative care pregnancy termination perinatal loss


Nursing and Service-Learning Partnerships: Implementation of a Community Breast Cancer Awareness Outreach Purpose for the Program ervice learning is a method to connect nursing students to their community by assessment of an identified health need. The nursing students engaged community participants with health education material and formed mutually beneficial partnerships. This collaboration instills a sense of civic engagement because nursing students serve as advocates for health promotion within their communities.

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Proposed Change A community needs assessment was used to identify a high rate of breast cancer in the state and parish. The purpose of the service-learning project was to provide education to women of all ages on breast cancer awareness (BCA). A communitywide approach to reach all age groups was implemented. This community outreach proposal was enabled by a grant funded from the Northeast Louisiana Affiliate (NELA) of the Susan G. Komen foundation. The purpose of this grant was to provide funding of educational materials from the Komen foundation to enable nursing students to engage the community in a variety of settings that utilized service learning. Implementation, Outcomes, and Evaluation BCA educational materials that targeted women of all ages, race, and ethnicities were used. Nursing students engaged women in a variety of settings: the parish medical center allowed nursing students to participate in a BCA event, area S4

churches sponsored health and wellness fairs in which BCA booths were present, and communitybased awareness outreaches were planned to target adult women. For students enrolled in the Maternal Newborn Nursing course the servicelearning project was a clinical component that targeted nursing peers in the annual university campus health symposium, which emphasized the “know your normal” focus on self-awareness for young women. New mothers on the postpartum unit received BCA materials as part of nursing students’ clinical experiences. The largest outreach by students was the “Bulldogs Tackling Breast Cancer” football game. Nursing students hosted educational booths at each stadium entrance, and engaged the community with educational displays, BSE models, and distribution of the Komen educational materials. These activities attained success as service-learning endeavors, and met the overall objective: to improve the health of citizens of the community in which these nursing students live and will serve as registered nurses. Service-learning evaluations completed by students and agency partners positively validate this partnership success.

Tanya Sims, RNC-OB, MSN, Louisiana Tech University, Ruston, LA Keywords service learning breast cancer awareness community outreach


Implications for Nursing Practice Nursing students gain awareness of breast cancer, commit to make a positive health impact on the community, commit to a plan of action to implement health education for women, and engage the community through implementation of their service.

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352


Kinder, S. J. R., Cherepski, A., and Freeman, K.


Speaking With One Voice: A Strategy to Improve Communication on a Gynecology Unit A. Penn Ritter, BSN, RN-C, Inova Health System, Falls Church, VA Elizabeth Freund, MSN, RN-BC, Inova Health System, Falls Church, VA Keywords communication handoff gynecology


Purpose for the Program ecently, the gynecology unit experienced several dramatic changes. Our patients, particularly the gynecologic (GYN)-oncology patients voiced their concerns about the inconsistent and often conflicting information they receive. This was evident in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores received for communication and longer length of hospital stay. The purpose in creating the One Voice project was to improve communication between all disciplines and improve the patient experience.

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Proposed Change The proposed change by the One Voice initiative is to have every multidisciplinary team member give a consistent message to our GYN patients. The foundation for the initiative was the establishment of a unit-based Mission and Vision statement to refocus on what is important to the team and reestablish pride and a sense of belonging. Involving the patient is the second aspect of the program. Development of an interactive care path form for patients to review and track their recovery progress promotes independence and control of their care. The third component of the program is changing how the clinical technicians conduct shift report. By incorporating the clinical technicians into the bedside handoff with the nurse

and eventually with each other, communication is streamlined. Finally, the fourth component of the One Voice initiative is physician education on the care path and inclusion of the care team when physicians round. The expected outcome is increased multidisciplinary communication and patient safety. Implementation, Outcomes, and Evaluation Implementation of the One Voice initiative occurred over a 1-month period. Multidisciplinary focus groups made up of GYN physicians, nurses, and clinical technicians helped develop each component. Education sessions were held at shift huddles and staff meetings on the details of the One Voice program. The One Voice interactive care path tool was initiated on the GYN minimally invasive surgical patient population. The evaluation of the outcomes was very positive. Of the care paths returned from patients, 99% reported that the care path was helpful and that they were better prepared for discharge. Overall HCAHPS results exceeded the target goal for two consecutive months after implementation. Implications for Nursing Practice By a successful implementation of One Voice, nurses are able to efficiently improve care and enhance the safety of the GYN patient population through consistency in communication.

E-Learning in Obstetrics and HIV: Utilizing Online Interactive Scenarios to Replicate Critical Decision Making Moments Sarah J. Rhoads Kinder, PhD, Purpose for the Program DNP, APN, WHNP-BC, he Mississippi Delta region is one of the most RNC-OB, University of impoverished, medically underserved regions Arkansas for Medical Sciences, of the nation. This region’s health disparities in Little Rock, AR

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HIV/AIDS prevention, care, and outcomes reflect the need to offer greater support and education to rural health care providers who may only occasionally see patients who are infected with HIV/AIDS. It is often difficult to provide this education to these health care providers because their presence within their practice is imperative, and thus it is difficult to attend face-to-face con-


tinuing education. This dilemma necessitates the delivery of education materials online. By delivering this content through interactive online modules, the learner is presented with case-based scenarios that elicit increased engagement and comprehension. The interactive component encourages decision making rather than reading the content, and therefore makes the learning process more real. Case-based learning leads to better decision-making skills. Assessing knowledge based on step-by-step procedures closely simulates situations that the health care providers might

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find themselves in. Because these courses are offered online, they can be accessed anytime, practically anywhere. Proposed Change Providing online interactive scenarios to rural health care providers regarding HIV care for the pregnant female and neonate has the potential to increase knowledge and preparedness on the part of the health care provider. Implementation, Outcomes, and Evaluation The AIDS Telehealth Training Center, entitled HIV Health Education, Assessment, and Research in Telehealth (HIV HEART) was created with the intent of improving access to HIV/AIDS evidencebased, culturally appropriate continuing education and collegial support for rural health care providers who have limited experience with rural patients infected with HIV/AIDS. In an effort to focus on quality over quantity, instructional designers created interactive case-based scenarios

utilizing adult learning theory, which could be accessed through a customized learning management portal. These interactive modules go beyond the status quo of passive learning lectures, and require the learner to make critical decisions that affect the outcome of the patient featured in the online scenario. Knowledge competencies are shown through pretest and posttest assessment reports. The HIV team members will evaluate the findings and make changes as needed to educational methodologies and strategies for improving future online educational materials.

Adam Cherepski, Med, University of Arkansas for Medical Sciences, Little Rock, AR Keith Freeman, Med, University of Arkansas for Medical Sciences, Little Rock, AR

Keywords HIV AIDS distance education simulation Implications for Nursing Practice infectious disease Multidisciplinary education is essential when car- pregnancy

ing for complex patients. Nurses and nurse practitioners are essential to provide comprehensive care for these medically complicated women and neonates. These interactive modules are easily disseminated to health care providers regardless of their practice settings or specialties.


Looking to the Future of Compassionate Care: Implementation of a Holistic Perinatal Palliative Care Program Purpose for the Program his program provides family-centered holistic perinatal palliative care (PPC) during the perinatal period.

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Proposed Change Establishment of an effective interdepartmental, interprofessional palliative care team to support patients and their families throughout the perinatal continuum. Implementation, Outcomes, and Evaluation The current perinatal bereavement program was evaluated, and the literature on PPC was reviewed. A staff survey was performed to assess staff awareness, understanding, and comfort regarding PPC. A PPC planning team was created. After analysis of the findings, an interdepartmental strategy for PPC education, which included nurses, medical residents and attendings, and social workers, was developed. This team attended palliative care conferences and evaluated other PPC programs. A plan was developed for improving support for our patient population. This plan included didactic presentation with discussion and shadowing opportunities for all members of the health care team. An electronic PPC documentation tool was created to collect demographic, obstetric, and follow-up data on all perinatal be-

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reavement patients. Data were used to identify the need for PPC services. The PPC planning team networked with resources in the community, which allowed for coordination of care beyond the acute care setting. A relationship with community perinatal palliative care programs was developed, allowing for patient referrals, which lead to more comprehensive holistic perinatal support in the care of patients. The support of outside palliative care has provided an opportunity for increased patient advocacy, education in the community, and improved preadmission and postdischarge care. The program coordinator continues to promote awareness of palliative care at public events throughout Maryland. Staff and patients voiced increased satisfaction with the current palliative care program and the positive effect it has on our community.

Naomi R. Cross, ADN, RN, Johns Hopkins Hospital, Baltimore, MD Keywords perinatal palliative care fetal death perinatal loss


Implications for Nursing Practice The Johns Hopkins perinatal staff provides palliative care for approximately 100 families each year. This includes all patients who have a prenatal diagnosis of a fetal life limiting condition, unexpected fetal deaths, and missed abortions. Although the care of PPC patients is emotionally daunting, nursing staff have developed crucial palliative care skills obtained through PPC education. Nurses identify and have access to

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Proceedings of the 2014 AWHONN Convention

PPC support resources. Evidence-based coordination of services allows for nursing to provide holistic family-centered care. PPC skills and interprofessional support empower nurses to advocate


for their palliative care patients. Opportunities exist for continual evaluation, development, and research of the effect of services on patients and their families.

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We Can Save Her: Managing Postpartum Hemorrhage

Childbearing

Purpose for the Program ostpartum hemorrhage (PPH) is the leading cause of maternal death. Because the incidence of PPH remains high, nurses must be prepared to identify the signs and symptoms, recognize maternal compromise, and deal with hemorrhage promptly.

Allison Reynolds, BSN, RNC-MNN, Baylor University Medical Center, Dallas, TX

Proposed Change To incorporate protocols and training to better equip registered nurses (RNs) to manage PPH.

Laura Briggs, RN, Baylor University Medical Center, Dallas, TX

Implementation, Outcomes, and Evaluation The Women & Children’s Quality Committee drafted a nursing guideline that addressed the management of PPH based on the recommendations of the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). A three-drawer cart was purchased and stocked with supplies identified as essential by experienced nurses and physicians.

Keywords postpartum hemorrhage maternal morbidity maternal mortality

Poster Presentation

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The service-line pharmacist was consulted as to the best method to create and store an emergency medication box. The simulation coordinator drafted several PPH drills that incorporated the nursing guidelines and emergency cart. All staff RNs participated in annual simulation training, reviewed the PPH guideline, and completed a test regarding content. Although the incidence of PPH has not decreased on the postpartum unit, the incidence of transfers to labor and delivery following bleeding episodes has decreased. Nurses and physicians verbalized newly found efficiency when dealing with PPH. During emergency situations, many patients have commented how calm the staff are and how “everyone knew exactly what to do.” Implications for Nursing Practice By identifying PPH promptly and providing swift interventions, maternal morbidity and mortality can be greatly reduced.

Code Green: An Effective Approach to Respond to Obstetric Emergencies Outside of the Labor and Delivery Unit Purpose for the Program uring an emergency, a swift response by the health care team improves patient outcomes. This has been noted in most types of medical emergencies. Medical rapid response teams Jennifer M. Doak, AASN, RN, have existed in tertiary care centers for more than University Hospital Case 30 years and have been used more in the past Medical Center MacDonald Women’s Hospital, Cleveland, 10 to 15 years. Many hospitals began seeing imOH proved patient outcomes after forming rapid response teams. Lisa Kaloczi, DNP, CNM, WHNP-BC, University Hospitals Case Medical Manager, Cleveland, OH

Keywords obstetric emergency obstetric rapid response rapid response team

Childbearing Poster Presentation

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Proposed Change University Hospitals Case Medical Center (UHCMC) MacDonald Women’s Hospital (MWH) has applied this process to obstetric emergencies in the obstetric units and is also creating a plan to implement this throughout all of UHCMC on every type of inpatient unit. The Code Green procedure was developed to alert specified team members of obstetric emergencies. The plan was to empower nurses to call a Code Green at the start of an obstetric patient’s decline to access the correct medical team. Also, the goal was to decrease challenges of communication between different units and improve patient outcomes.

Implementation, Outcomes, and Evaluation Several quality cases within the MWH with delays in patient care were analyzed. It was noted that many of them involved challenges in communication between the different obstetric units. An interdisciplinary team was developed, including obstetricians, anesthesiologists, and nursing staff from all three obstetric units. The outcome was the initial Code Green response intended to be a systematic rapid response to patients who experience an obstetric emergency within the hospital. A plan was created for a team that consisted of the obstetric chief resident and a prespecified nurse who would respond directly to the patient’s location no matter where in the hospital that might be. Additional staff, including anesthesia, would be on standby. All hospital staff within MWH and the emergency department were educated using various methods before initiation. Within the Women’s Hospital, communication and timeliness of response to emergencies has improved. However, the education has been found to be limited in the emergency department, and the Code Green is not always used appropriately in this area. Reeducation is being planned. Later, the

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Miller, J. A. and Junes, A.


Code Green will be opened to the entire inpatient setting to include any obstetric patient admitted to UHCMC.

tients off of the labor and delivery unit and access the correct medical team. It improves interdisciplinary communication, which leads to improved patient outcomes.

Implications for Nursing Practice The new Code Green promotes empowerment of nurses to initiate rapid responses for obstetric pa-

Designing a Multidisciplinary Accreta Program Purpose for the Program he increase in the rate of cesarean delivery has led to an increase in placenta accreta, increta, and percreta, medical conditions that occur when an abnormal placenta implantation results in Carol J. Olson, MBA, BSN, massive bleeding and potential multiorgan failure. RN, Banner Good Samaritan The staff at one tertiary perinatal center developed Hospital, Phoenix, AZ a multidisciplinary program to proactively improve process, delivery methods, and clinical outcomes Christopher K. Huls, MD, using a comprehensive patient centric model that Obstetrix/Pediatrix Medical Group of Phoenix, Phoenix, AZ addresses the antepartum, intrapartum, and postpartum phases of care. Christina Tussey, MSN, CNS, RNC-OB, RNC-MNN, Banner Good Samaritan Hospital, Phoenix, AZ

Jordan Perlow, MD, Phoenix Perinatal Associate Leadership Board, Phoenix, AZ Keywords placenta accreta/increta/percreta multidisciplinary accreta program care of accreta patients


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Proposed Change Baseline data indicated these patients required extensive use of blood products and a postdelivery intensive care unit (ICU) admission. Recognizing that a comprehensive program encompassing the entire hospital stay was needed for this patient population, health care providers from the main operating room (OR), trauma, blood bank, interventional radiology, and the obstetric units were organized into four teams to address patient management for scheduled and emergent situations. Additional program components addressed development of quality indicators, financial review, and marketing efforts to obstetricians– gynecologists throughout the state and community education. Implementation, Outcomes, and Evaluation Our comprehensive program began in January 2012. This presentation covers identified patient and family needs during the antepartum, intra-

partum, and postpartum periods and addresses the following: the four different teams (i.e., antepartum care, OR, community outreach, and financial teams); plan of care checklist content; staff education; stat OR mock drills for emergent situations; marketing channels and materials for referring physicians; use of public relations resources to increase public education; creation of a data bank using identified outcome criteria; and program evaluation. Since implementation, we have seen an increase of 33% of percreta patients cared for at the facility. Clinical improvements in the care of accreta patients after program implementation have shown a reduced rate of postdelivery admission to the ICU and shorter postsurgical length of stay. Evaluation of more than 60 patients from 2009 to 2013 confirms our observations are consistent with the findings of other authors, including decreased blood loss and reduced blood transfusions. Positive personal accounts from patients reflect increased patient satisfaction of their continuum of care during prolonged hospital stay. Implications for Nursing Practice Nurses need to be aware of the high-risk complexity of these patients and have defined protocols to use in their care. Tertiary facility nursing leaders should work to create an organized multidisciplinary program at their facilities to care for the medical and nursing needs of this new high-risk population to achieve the best possible outcomes for the mother and infant.

A Progressive Format for Annual Interdisciplinary Education Featuring High-Risk Obstetric Simulation Jessica A. Miller, BSN, RNC, St. Cloud Hospital, Saint Cloud, MN

Purpose for the Program resent a format that promotes the effective planning and facilitation of multiple simulation topics in obstetric complications and teamwork training in a structured prescheduled session.

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Proposed Change Our unit is planning structured annual review of high-risk, low-frequency clinical events in labor and delivery, including shoulder dystocia and postpartum hemorrhage using this progressive

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format to optimize staff and facilitator time and supply and space resources. Implementation, Outcomes, and Evaluation After the identification of the topics to be presented, simulation scenarios were developed that allowed progressive development of the patient’s symptomatology. Staff were assigned and scheduled in small groups for these education days, which ensured that implementation was not dependent on unit workflows. This also ensured that all staff received an opportunity to participate. This results in efficient use of space, time, and resources because the stem of each scenario remains consistent and the participants all have firsthand knowledge of the preceding events. The scenarios built upon each other in situ, utilizing the same labor room and cesarean suite. Debriefing occurred after each scenario segment, which

allowed focused reflection and discussion to occur before the next topic. TeamSTEPPS principles of effective teamwork and communication were stressed along with review of clinical responses. The participants of our sessions completed evaluations and rated the sessions very highly in terms of organization, being able to implement the ideas and activities, and being a beneficial use of time: overall 4.96/5.0. Implications for Nursing Practice This model represents an efficient use of resources in the planning and execution of simulation training for staff and health care providers who practice in a high-risk clinical area. Regular practice of clinical and medical teamwork behaviors can improve responses and positively affect outcomes of women and infants in the labor and delivery setting.

Amy Junes, MSN, RNC, St. Cloud Hospital, Saint Cloud, MN Keywords simulation teamwork shoulder dystocia postpartum hemorrhage drill


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

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Proposed Change To develop and initiate weekly support group sessions on an 18-bed antepartum unit to address commonly identified concerns with evidencebased education and support. To develop a data collection tool identifying successful group topics and patient’s moods before and after group participation. Implementation, Outcomes, and Evaluation The perinatal clinical nurse specialist (CNS) identifies antepartum patients able to attend the group, requests a physician’s order, and then invites patients to attend. A multidisciplinary team within perinatal services is used to provide education

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for each 1-hour “Mom’s In Waiting” group session, where the CNS or the perinatal social worker is also present. A structured activity or discussion occurs for part of the hour, with time being specifically left for socialization among the group members. At the end of group session, a short Likert scale survey is administered to each participant.

Lisa Sharpe, MSN, RN-BC, CNS, Henrico Doctors’ Hospital, Richmond, VA Maria K. Conron, BSN, RN-MNN, Henrico Doctors’ Hospital, Richmond, VA Keywords

Survey results for the first 18 months provide an depression overwhelmingly positive response to the group by socialization attendees with 98% noting enhanced mood per- education ception after attending the group and 100% stating they looked forward to attending the group. Group participants frequently dress and apply Childbearing make-up before the sessions and the conversations in the sessions flow easily. Popular session Poster Presentation topics, chosen by participants’ suggestions, include breastfeeding, infant massage, guided imagery, and neonatal intensive care (NICU) preparation. The postgroup survey is currently being amended to include additional markers for improved mood. Implications for Nursing Practice Survey documentation should promote development of support groups in other antepartum settings. Currently at this hospital, antepartum patients as well as postpartum NICU mothers are screened with the Edinburgh Postnatal Depression Scale (EPDS). As perinatal mood disorders have been shown to correlate with poor maternal and neonatal outcomes, long-term goals include evaluating EPDS scores and mood disorders related to group attendance.

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Graham, S., Patterson, M., and Bush, E.


Do You See What I See? Using Telemedicine in Obstetrics to Improve Patient Safety Connie S. Garrison-Isler, MSN, Purpose for the Program RNC-LRN, NE-BC, Riverside elemedicine has gained momentum nationMethodist Hospital, Columbus, ally, especially in intensive care settings. Little OH

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Laura Gilbert, BSN, RNC, C-EFM, Riverside Methodist Hospital, Columbus, OH

information is available on remote fetal monitoring. The purpose of this project is to test the use of surveillance of the results of fetal heart tracing monitoring using the telemedicine concept. As a result, we will improve birth outcomes, improve patient safety, minimize medical and legal risks, and reduce preventable neonatal injuries or death.

Celia (Julie) Miller, BSN, MBA, C-EFM, Riverside Methodist Hospital, Columbus, OH Proposed Change Keywords patient safety electronic fetal monitoring telemedicine


Remote fetal monitoring, with an experienced labor and delivery (L&D) nurse, will serve as a second opinion for bedside clinicians. The use of telemedicine in the L&D setting also is useful when pregnant patients are admitted to other units, such as the intensive care unit (ICU). Implementation, Outcomes, and Evaluation The L&D department will serve as the pilot for the project. The pilot involves monitoring 20 L&D rooms and 7 triage rooms. E-Care Mobile Carts (cameras) will be used for the visual monitoring of high-risk patients. One L&D registered nurse (RN) will share space in the electronic ICU and be available 24 hours per day, 7 days per week. Before the pilot, data will be obtained on the following outcomes: infants with arterial cord blood pH ࣘ7.0 or pH 7.01 to 7.09 with base excess ࣙ–10.0 with

transfer to the NICU; unanticipated NICU admission; and 5-minute Apgar score ࣘ5. For Category III tracing, the following data will be obtained: time of onset to health care provider notification; time from notification to decision for cesarean delivery; time from decision to incision; obstetric TraceVue (OBTV) surveillance of all Category II fetal tracings; number of nursing interventions; and number of electronic L&D nurse interventions. Also, management of tachysystole, good catches, response to alerts, staff mentoring and coaching calls, calls to the electronic L&D, and differences in clinical interpretation will be recorded. After implementation of the pilot program, aggregate measures will be reviewed to determine success. A 6-month period is necessary to determine the potential effect on patient safety measures. Implications for Nursing Practice Through these constant, direct nursing observations and interventions there will be a positive effect in the number of good catches, significant safety events, and fetal outcomes. A supporting goal includes timely and appropriate management of Category III heart rate tracings. It is expected that a decrease from time of onset of this tracing to time of decision to incision will decrease. The pilot program also will be considered successful if either the preventable neonatal injuries or deaths decrease.

Transforming the Preoperative Process for Scheduled Cesarean Deliveries Using Patient- and Family-Centered Care Purpose for the Program n a high-risk maternal infant program at a large, academic medical center, patients admitted to the labor and delivery unit for scheduled cesarean deliveries frequently waited hours for delivery beMarie Patterson, MSN, RNC, cause of priority, high-risk transports coming into University of Arkansas for Medical Sciences, Little Rock, the hospital. Conversely, patients awaiting transport to the University of Arkansas for Medical SciAR ences (UAMS) often were declined or delayed beErin Bush, MAIOC, BSN, RN, cause of high census. With the institutional push University of Arkansas for toward patient- and family-centered care (PFCC), Medical Sciences, Little Rock, the staff was challenged to provide PFCC in light AR of sustained high census. Shannon Graham, MNSc, WHNP-BC, APN, University of Arkansas for Medical Sciences, Little Rock, AR

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Proposed Change Maternal-infant staff suggested admitting patients to the postpartum floor where they would reside after surgery instead of to the labor and delivery unit. Implementation, Outcomes, and Evaluation Patients are admitted to the postpartum unit by a preoperative nurse who starts the intravenous (IV) fluid, draws blood, performs the intake assessment, and notifies the physicians (anesthesiologist and obstetrician [OB]). Once the preoperative preparation is completed, the patient is passed to

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the postpartum nurse who cares for the family before and after delivery. When ready for surgery, the patient is transferred to the labor and delivery unit. After surgery, the mother recovers for 2 hours while the neonate is transitioned at her bedside. Then the mother and neonate return to the same room and nurse on the postpartum unit. From April 1 to July 1, 2013, 87 patients were routed using the new preoperative process. Continuity of nursing care for scheduled cesarean delivery patients increased PFCC, patient safety, and efficiency in the preoperative process for scheduled cesarean deliveries and emergent transports. Patients reported appreciating having a private area for the family to wait during the surgery and recovery.

Postpartum leadership has applied for Institutional Review Board (IRB) approval to formally evaluate this process. Currently, patients report high levels of satisfaction with this process as reported to unit leadership in daily rounds. Implications for Nursing Practice Reorganization of traditional care delivery methods could be useful to any facility that sees the need for change to better assist the patient and her family. Nursing has recognized the need for safety, but holistic nursing requires the recognition of the importance of other concepts, such as comfort and emotion, which can positively be affected by continuity of nursing care and a comfortable, familiar environment.

Keywords Patient- and family-centered care staffing efficiency cesarean delivery


Building Better Communication for Safer Patient Care Purpose for the Program he obstetric (OB) department at St. Luke’s University Hospital and Health Network (SLUHN) has struggled to provide education for staff members to integrate TeamSTEPPS and Perinatal Rapid Response Team (PERRT) initiatives.

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TeamSTEPPS was developed by the U.S. Department of Defense in collaboration with the Agency for Healthcare Research and Quality (AHRQ). An evidence-based program, TeamSTEPPS improves communication and teamwork skills among health care professionals by eliminating barriers to quality and safety through increased awareness. The PERRT initiative, developed by OB nurse and physician leaders, prevents and diverts emergent adverse OB outcomes by using subacute trigger identification through a time out and a teamdetermined action plan. Proposed Change The department was chosen as a pilot group for an e-learning program that integrated these concepts. To maintain and sustain the culture of safety in obstetrics, we incorporated My elearning/TeamSTEPPS PERRT into a competency training program that provided a cost-effective alternative to live classroom training and demonstrated ongoing favorable results in staff perceptions of safety. Implementation, Outcomes, and Evaluation In reviewing available curriculums, it was determined that AHRQ and TeamSTEPPS content ex-

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perts did not have an online curriculum to spread the teamwork concepts. A joint venture with the SLUHN instructional web designer and the OB department, an innovative and interactive e-learning module, was developed for the TeamSTEPPS curriculum. Online components were developed by nurse and physician leaders from the OB department and consisted of podcasts and PowerPoint presentations with voice over whereas the web designer provided the technology that achieved our team’s goals: an interactive, online educational module to provide training and elicit feedback from the participants related to the overall culture of safety and team training. Cost-effectiveness analysis showed preliminary savings of $8,500 in salaries for staff over a 2-year period. With an increase in teamwork and subacute trigger identification, a reduction of $79K in neonatal intensive care unit (NICU) clinical costs during a 3-year time frame was calculated by the finance department.

Melanie Martin, RN, BSN, CCE, St. Luke’s University Hospital and Health Network, Allentown, PA Keywords TeamSTEPPS perinatal rapid response culture of safety e-learning


Implications for Nursing Practice A culture of safety is an organizational priority. Teamwork, respect, communication, and open discussion of patient safety and quality of care issues support the PERRT and TeamSTEPPS concepts. Through e-learning, the SLUHN nurses will be able to sustain these concepts. While the elearning program provides consistency in education, it also eases the monitoring education compliance along with having significant cost savings for the network.

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Carmichael, A, and Matulionis, B.


Code Sepsis: Development of a Sepsis Protocol for the Obstetric Patient Kelli Bural, BSN, RNC-OB, C-EFM, Baylor University Medical Center, Dallas, TX Diana Rich, BSN, RNC-OB, C-EFM, Baylor University Medical Center, Dallas, TX Keywords sepsis screening tool protocol


Purpose for the Program n 2003, the Surviving Sepsis Campaign partnered with the Institute for Healthcare Improvement (IHI), which led to Surviving Sepsis Campaign Bundles for quality improvement techniques to treat sepsis and decrease mortality. Although great strides have been made in early recognition and intervention for sepsis in the general population, there has been little focus on the obstetric population and their unique considerations. The labor and delivery (L&D) nurses at Baylor University Medical Center (BUMC) identified an improvement opportunity in the area of promoting the health and safety of the obstetric patients. A screening tool, protocol, and sepsis bundle were developed and implemented for the obstetric population aiding in early detection and reducing sepsis mortality.

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Proposed Change A process was developed to facilitate early recognition and prompt intervention for sepsis in the obstetric patient. Implementation steps included establishing a screening tool and protocol for sepsis in L&D, incorporating a sepsis bundle, and educating and training all staff. Implementation, Outcomes, and Evaluation BUMC has implemented sepsis bundles in the emergency department and the intensive care units (ICUs); however, the staff at Women and Chil-

dren’s recognized that sepsis presentation in the obstetric population was unique and would require specific bundles. As frontline caregivers who perform initial assessments, the nurses in L&D are a critical part of the health care team responsible for early identification and timely intervention. Using the Iowa model, benchmarking, and a current literature review, a multidisciplinary team collaborated to establish a protocol and a sepsis screening tool specific to the obstetric patient. Preeducational and posteducational surveys were created to identify knowledge deficits surrounding sepsis, and educational in-services were presented to staff. Posteducational surveys showed improvements in early identification and recognition to promptly treat sepsis in the hospital setting. Implications for Nursing Practice In many cases, sepsis-related deaths and additional severe comorbidities are preventable through swift detection and treatment. The first 24 hours in sepsis treatment are critical because mortality increases with each passing hour sepsis goes unrecognized and untreated. Implementation of standardized sepsis education, initiation of a sepsis screening tool, and a sepsis protocol can improve the care provided to patients. Incorporating a standardized, multidisciplinary approach will ensure that patients receive the best care to promote optimal outcomes.

Implementing the Gentle C-Section: A Birth Experience More Like a Vaginal Delivery Amy Carmichael, BSN, RNC-OB, C-EFM, The Christ Hospital, Cincinnati, OH Barbara Matulionis, BFA, RNC-Low-Risk, Neonatal, Nursing, The Christ Hospital, Cincinnati, OH Keywords breastfeeding skin-to-skin cesarean


Purpose for the Program nhance the birth experience and improve breastfeeding within 1 hour of birth for cesarean delivery patients.

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Proposed Change Medically appropriate patients can now give birth through the Gentle Cesarean Section (C-section), which mimics a vaginal birth by allowing the mother to watch the birth and experience skinto-skin contact immediately after birth. Evidence shows that placing infants skin-to-skin with their mothers immediately after birth increases the success and lengthens the duration of breastfeeding, promotes bonding, and facilitates thermoregulation. Our facility implemented immediate skin-to-


skin into our practice for vaginal deliveries but realized a gap existed with cesarean deliveries. New ideas for clinical practice were sought from professional literature. Based on the evidence, we proposed to change our practice to provide immediate skin-to-skin contact after cesarean deliveries. Implementation, Outcomes, and Evaluation A multidisciplinary team, which included obstetric, anesthesia, nursery, and labor and delivery (L&D) personnel, was formed. A physiciannarrated YouTube video of a Gentle C-Section was shown and supporting literature was provided to the team. Agreement for the new innovative plan was reached. Logistical challenges,

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such as ensuring maintenance of a sterile field and creating enough physical space for staff, the anesthesiologist, and significant other, were identified. We also encountered staffing challenges because a nursery nurse would need to stay with the patient during the entire skin-toskin contact period. The first two pilot cases were videotaped, and feedback was obtained from the parents regarding their experiences. This helped us identify opportunities for improvement. The team collaborated, and educational materials were created for physicians, staff, and parents.

Implications for Nursing Practice This process took approximately 4 months from the initial presentation to the first scheduled Gentle C-Section. As of August 6, 2013, our facility performed five Gentle C-Sections. Of the five patients, 100% have initiated breastfeeding within the first hour of life: a recommendation put forth by the World Health Organization and one of our nurse-sensitive indicators in L&D. Parents have expressed increased satisfaction of their birth experiences. Going forward, a marketing campaign is in production to educate women throughout the community about this alternative birth experience.

The Obstetric Virtual Visit: It’s Your Pregnancy Journey, Why Not Do It Your Way? Purpose for the Program o describe the obstetric (OB) Virtual Visit model successfully developed and implemented at MultiCare Health System. This program gives women options for how they receive their OB prenatal care, allows flexibility with schedules, increases partner involvement, and provides convenient delivery of routine prenatal care. Additionally, the OB Virtual Visit improves adherence with prenatal care recommendations and provides positive pregnancy outcomes.

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Proposed Change Telemedicine is used to replace one-half of the traditional, in-person prenatal visits (virtual and traditional visits alternate). At each OB Virtual Visit, a complete fetal and maternal assessment is performed. Implementation, Outcomes, and Evaluation A multidisciplinary team met to discuss increasing patient options for OB care and seek opportunities to improve care and increase cost efficiency. The resultant program includes three options for prenatal care: traditional medical doctor (MD) visits; group visits alternating with MD visits; and

virtual visits alternating with MD visits. Since the program’s implementation in June 2012, the Virtual Visit program has become a very popular option for women from all backgrounds. Patients describe the program as empowering as they take more actives role in their care. They also report that the Virtual Visit helps them comply with recommended care schedules and provides flexibility in terms of hours and location. The Virtual Visit enables physicians to focus more of their time at the clinic on high-risk patients and to increase productivity.

Malinda Carlile, MN, WHNP, BC, RNC, OB, MultiCare System, Tacoma, WA Keywords telemedicine prenatal care patient-centered care pregnancy


Implications for Nursing Practice As prenatal care becomes more convenient and accessible, improvement can be made in women’s prenatal experience and pregnancy outcomes. Technology is being increasingly used in all aspects of life in today’s connected world; telemedicine is a natural progression of this upand-coming platform. The Virtual Visit empowers women, gives them options for how they receive their OB prenatal care, allows flexibility with schedules, increases partner involvement, and provides convenient delivery of routine prenatal care.

A Mother-Centered Approach to Skin-to-Skin in the Operating Room Purpose for the Program large body of evidence demonstrates that skin-to-skin (STS) contact at birth is beneficial to newborns. Newborns who experience STS at the time of vaginal birth have better temperature stability, higher rates of ex-

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clusive breastfeeding at discharge, and better glucose levels. Implementing early skin-toskin in the obstetric operating room (OOR) can be challenging. However, a growing body of research shows that STS decreases maternal perception of pain while in the OOR and

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352

Courtney Sundin, MSN, RNC-OB, Baylor All Saints Medical Center, Andrews Womens Hospital, Fort Worth, TX



Sincore, T. J. and Levine, L. C.


increases maternal satisfaction with the birthing Lauren Mazac, BSN, RNC-OB, experience. Baylor All Saints Medical Proposed Change Center-Andrew’s Womens Hospital, Fort Worth, TX At a large women’s hospital, with more than 5,000 Keywords maternal skin-to-skin cesarean pain satisfaction


deliveries annually, STS in the OOR on routine, repeat, scheduled cesarean deliveries was initiated. Implementation, Outcomes, and Evaluation Expected outcomes will be that the patient will report that her delivery experience was more meaningful and family-centered than she experienced previously and she will not need any additional pain medication other than the initial, routine combined spinal dose. Maternal satisfaction will be measured by a follow-up questionnaire, whereas

maternal pain control will be evaluated by reviewing the anesthesia record for any additional medications administered during the cesarean. Implications for Nursing Practice Nursing implications will include but are not limited to ensuring that the woman wants the infant placed on her skin immediately, ensuring that the involved staff proceeds with the woman’s request, and that proper equipment is used and placed in a manner that skin-to-skin contact is attainable. The ultimate goal of translating STS in the OOR on all qualifying cases is to decrease maternal pain perception and increase satisfaction with birth experience.

Keep Calm and Carry On: Reducing Elective Early-Term Deliveries Purpose for the Program elivery before 39-week gestation is associated with increased neonatal morbidity and mortality. Significant risks associated with earlyLinda C. Levine, MSN, RN, term delivery (defined as 37–38 6/7 weeks of RNC-MNN, Baptist Hospital of gestation) include respiratory distress, transient Miami, Miami, FL tachypnea of newborn, admission to the neonaKeywords tal intensive care unit (NICU), temperature instaearly-term delivery bility, hypoglycemia, feeding difficulties, and high elective delivery rates of hospital readmission. Elective delivery patient safety frequently is used to accommodate patient and physician convenience, with an increased risk that it may be performed earlier than is appropriate. Childbearing In an effort to reduce neonatal complications, the Poster Presentation March of Dimes and American College of Obstetricians and Gynecologists recommend that elective delivery should not occur before 39 weeks of gestation. A multidisciplinary team of professionals at Baptist Hospital of Miami collaborated to adopt the 39th week of gestation elective early-term delivery initiative, with voluntary data collection reported to Leapfrog Group.

early-term delivery rate was 30%. Educational programs were then presented to physicians and obstetric personnel that emphasized the importance of the initiative with the ultimate goal to decrease the incidence of elective early-term deliveries to the nationally proposed benchmark rate. Through implementation of educational programs for medical personnel and patient population, surveillance of elective delivery schedules, and enforcement of practice policies, including elimination of psychosocial indications for early delivery scheduling, the rate of elective early-term delivery steadily decreased from 30% to 5.1% during a period of 4 years. This decrease in early delivery rate occurred simultaneously with a decrease in associated NICU admissions from 14 cases in 2009 to 2 cases in 2013. These results demonstrate a necessity for multidisciplinary vigilance against needless early-term deliveries and shared responsibility for policy compliance to ensure optimal patient outcomes.

Proposed Change The staff at Baptist Hospital of Miami (BHM) proposed to evaluate their elective early-term delivery scheduling processes and implement changes aimed to decrease elective early-term delivery rate to a benchmark proposed by the Leapfrog Group.

Implications for Nursing Practice Improved adherence to The Joint Commission recommendations with reduction of early-term elective deliveries can be accomplished through initiatives that involve education, surveillance of elective delivery schedules, enforcement of practice policies, and ongoing outcome data collection and evaluation. Through the application of evidence-based practice, nurses are empowered to monitor elective deliveries with direct result to patient outcomes.

Tammy J. Sincore, BSN, RN, RNC-OB, Baptist Hospital of Miami, Miami, FL

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Implementation, Outcomes, and Evaluation The first step of the evaluation involved retrospective data collection that demonstrated the elective


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The High-Risk Postpartum Transitional Program: A Multidisciplinary Approach to Caring for Postpartum Woman With Hypertensive Disease Purpose for the Program reeclampsia complicates 5% to 8% of all pregnancies, is the second leading cause of maternal death in the United States, and a common cause of unplanned postpartum hospital readmissions. Women with perinatal hypertensive disease are also at increased risk of future cardiovascular disease. The High-Risk Postpartum Transitional Program targets postpartum women at risk of persistent hypertensive disease and includes women with the diagnoses of preeclampsia, eclampsia, hemolysis, elevated liver enzymes, and low platelet counts (HELLP), gestational hypertension, and chronic hypertension. The purpose and goal of the program is to standardize care for postpartum women with hypertensive disease, decrease postpartum morbidity, and decrease hospital readmissions related to hypertension.

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Proposed Change A multidisciplinary team developed a standardized clinical protocol that addressed surveillance, treatment, education, and follow-up across the continuum from identification through delivery and beyond discharge. Identified patients received education about their disease, future health implications, lifestyle modifications, and medication education if appropriate. Home care blood pressure (BP) and symptom monitoring was arranged, and an appointment was made for the patient to return within 2 weeks to the High-Risk Postpar-

tum Transitional Clinic. A follow-up phone call was Marianne D. Bittle, BSN, made before the appointment as reinforcement. RNC-OB, Hospital of the Implementation, Outcomes, and Evaluation Overall readmission rates for patients involved in the High-Risk Postpartum Transitional Program have decreased since it was initiated in the summer of 2012. Recently, we initiated follow-up telephone calls with the goal of bolstering the current clinic admittance rate of 45% to 60%. Our multidisciplinary Unit-Based Clinical Leadership is exploring additional strategies that will enable us to serve more women through partnerships with community outreach programs and additional home care agencies. Implications for Nursing Practice As primary coordinators of postpartum care, the nurses’ role is a critical factor in its development, implementation, and success. Postpartum clinical nurses educate these women about their disease and its effect on future health, and consult with other professional disciplines such as social work and the unit-based clinical pharmacist to provide additional resources. Unit-based clinical resource coordinator nurses arrange postdischarge home care nursing services for BP and symptom monitoring and women’s health nurse practitioners offer inpatient support and a mechanism for home care nurses to triage identified concerns and reinforce education. This program offers nursing research opportunities to study the effect of nursing interventions on postpartum morbidities, such as hypertensive disease.

University of Pennsylvania, Philadelphia, PA Laura Scalise, RNC-MNN, Hospital of the University of Pennsylvania, Philadelphia, PA Dana Green, RN, MSN, CRNP, Hospital of the University of Pennsylvania, Philadelphia, PA Sindhu Srinivas, MD, MSCE, Hospital of the University of Pennsylvania, Philadelphia, PA Adi Hirshberg, MD, Hospital of the University of Pennsylvania, Philadelphia, PA Suchitra Chandrasekaran, MD, Hospital of the University of Pennsylvania, Philadelphia, PA Keywords postpartum preeclampsia hypertension transitions programs


PREGNANT Rounding for Birth Center Shift Manager and Charge Nurse Purpose for the Program revention of maternal and infant sentinel events is a major focus in the labor and delivery setting. Rounding with purpose is a key risk reduction strategy.

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Proposed Change A rounding checklist was developed to guide the shift manager/charge nurse in Purposeful, Rounding, Expectations, Got your back, Notification of provider, Assessment (maternal and fetal), Nec-

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essary interventions, and Timely (PREGNANT) Stacey B. Tribbett, MSN, rounding, which is required for each shift and as RNC-OB, Centra, Lynchburg, VA needed. Debra D. Acors, BSN, RNC-OB, RN-BC, Centra, Implementation, Outcomes, and Evaluation The nurse manager and clinical educator chose Lynchburg, VA the word PREGNANT to use as an acronym to develop a PowerPoint presentation that described the elements of purposeful rounding in a labor and delivery setting. Salient points while rounding include but are not limited to scanning the room

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352



Pritham, U. A.


Keywords rounding charge nurse outcomes quality safety error reduction


for safety issues, ensuring the primary registered nurse (RN) is keeping the health care provider updated on maternal and fetal status, reviewing fetal and maternal surveillance, reviewing complications, seeking out detailed information from the primary nurse, ensuring that the primary nurse is sharing information with the shift manager/charge nurse, discouraging unsafe or unproductive behaviors, responding quickly to observed fetal decelerations and emergent situations, notifying the health care provider regarding changes in maternal and/or fetal status, assessing the maternal and fetal well-being, recognizing what necessary interventions are indicated, and taking action in a timely manner to result in positive outcomes. The checklist was introduced at mandatory staff meetings. Staff provided input and the checklist was revised before the implementation date. The measurement of perinatal adverse outcomes

includes maternal death, maternal admission to the intensive care unit (ICU), uterine rupture, and death of a neonate weighing >2,500 g. Also being evaluated is the shift manager/charge nurse compliance rate with rounding on their shift. The checklist is a way to ensure that the shift manager/charge nurse and staff nurse are communicating changes in patient status (maternal and fetal). Implications for Nursing Practice This rounding checklist was developed to ensure that the standards of care are being upheld in the care of every intrapartum patient in a labor and delivery setting. It is used as a template for enhancing communication between all patient care providers (RN, medical doctor [MD], certified nurse–midwife [CNM]). It serves as a risk reduction strategy for preventing maternal and infant sentinel events.

A Program for Pregnant Women Electing Inpatient Opioid Detoxification Ursula A. Pritham, PhD, WHNP-BC, FNP-BC, Georgia Southern University, Statesboro, GA Keywords opioid dependence in pregnancy neonatal abstinence syndrome opioid detoxification in pregnancy buprenorphine sobriety


Purpose for the Program o minimize fetal exposure to opioids to optimize brain development and to prevent neonatal abstinence syndrome (NAS). The purpose of this presentation is to provide an overview of an innovative program that allows pregnant women to voluntarily undergo in-patient opioid detoxification followed by outpatient therapy and support in lieu of opioid replacement therapy.

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Proposed Change To offer opioid-dependent pregnant women the opportunity for a sober delivery and a sober infant. Implementation, Outcomes, and Evaluation A private substance abuse treatment facility provides insured and private pay opioid-dependent pregnant women elective inpatient detoxification with tapered doses of buprenorphine and short courses of anxiolytics and other pharmacotherapies as needed. The average length of inpatient stay is 2 weeks with intensive outpatient counseling and support. Anecdotal reports indicate positive perinatal outcomes and clients reported satisfaction with care. Many of the women were able to achieve sobriety at the time of delivery and harbored less guilt about the potential for NAS. Implications for Nursing Practice Ethical issues surrounding potential risk of fetal loss and altered fetal development with opioid


detoxification warrant consideration. There are no standardized protocols for detoxification in pregnancy and the treatment is not endorsed by the American College of Obstetricians and Gynecologists (ACOG) or the American Academy of Pediatrics (AAP). Nurses will be at the forefront in the assessment and management of women undergoing inpatient detoxification. As a result of the current epidemic of opioid abuse in the Unites States there has been an increase in maternal opioid dependence and treatment with synthetic opioids, namely methadone or buprenorphine. Over one-half of the neonates with in utero exposure to regular maternal opioid use experience neonatal abstinence syndrome (NAS). Presently, it is estimated that one newborn is born with NAS every hour and these neonates stay in the hospital for an average of 16.4 days compared with 3.3 days for those without NAS. The increased length of stay and complications that infants with NAS experience, such as increased rates of prematurity, low birth weight, respiratory problems, and seizures, elevate health care expenditures. The need for an inexpensive and effective treatment for NAS is crucial but more importantly, a strategy to prevent NAS is preferable. Detoxification among a select group of opioid-dependent pregnant women to prevent NAS warrants consideration and further exploration.

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Grief Is a Process Some Call a Journey Purpose for the Program he purpose of a Perinatal/Child Loss Bereavement Program is to provide a system-wide standard of care that offers individualized, interdisciplinary, and holistic support to families experiencing the loss of a pregnancy, infant, or child.

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Proposed Change Develop a standardized process to identify families in the health care system that experience a perinatal loss or loss of a child and provide support, follow-up, and/or referrals to community resources. Most patients with a perinatal or child loss were seen in the emergency and perioperative departments. We realized this was a very large patient population that was not given appropriate resources as inpatients or much needed follow-up as outpatients. Implementation, Outcomes, and Evaluation A multidisciplinary committee was constructed to develop a perinatal/child loss bereavement program. After attending formal training, we developed processes and educated staff in the women and family, emergency, and perioperative departments; chaplains; counseling; and other support staff system-wide. We now also hold monthly multidisciplinary perinatal grand rounds to identify patient cases that may require increased services from the program. We had 438 staff that completed education for the program. As a result of our efforts, we have

received 225 referrals since the program began on September 1, 2012. Most of these referrals have been captured through the emergency departments and perioperative departments systemwide via the electronic health record system. Through development of a database, in conjunction with the electronic health record, we are able to track referrals and follow up with patients and families. Prenatal families with a terminal fetal diagnosis can now present in labor with a preconstructed collaborative care plan to help guide staff and family decisions.

Kelly A. Housel-Bernatow, BSN, RNC-MNN, CLC, University of Colorado Health-North, Fort Collins, CO

Pamela Muncaster-Ney, BSN, BA, RNC-NIC, University of Colorado Health-North, Fort Collins, CO

Keywords perinatal bereavement The fact that most of the bereavement referrals loss have originated from the emergency and periop- emergency department

erative departments proves that we were initially missing a large number of patients experiencing a perinatal or child loss. It validates the need for further follow-up assessment of those patients entering the health care system for short periods. Future goals are to continue to educate new, incoming staff, create a mainstream resource mailing process, and further collaborate with community resources.


Implications for Nursing Practice A standardized, multidisciplinary team approach should be used for these bereavement situations to best support families. Nurses should receive additional training so as to be sensitive to the emotional and individualized needs that may present.

A Unique Care Model for Pregnancies Complicated by a Fetal Anomaly: A Review of the First 5 Years Purpose for the Program dvances in the field of prenatal ultrasonography have allowed for the identification of neonates with anomalies that will require intervention at birth. This allows health care providers and families the ability to devise delivery plans to optimize neonatal outcomes. A unit was envisioned that eliminated the need for a mother and her critically ill newborn to be in separate facilities to receive the necessary medical attention and promote the establishment of the maternalinfant bond. In 2008, the Garbose Family special delivery unit (SDU) at The Children’s Hospital of Philadelphia was opened. This unit enabled mothers carrying fetuses with anomalies to receive prenatal care and give birth in the same facility where

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their neonates would receive immediate postnatal care. This innovative program review highlights the advantages and challenges identified in the first 5 years of operation. Proposed Change Patients are referred to the SDU for outpatient evaluation and fetal therapy and receive seamless outpatient and inpatient obstetric services. The belief was that this model of care would normalize the pregnancy and birth experience for women and their families. A dedicated staff of advanced practice and registered nurses from multiple specialties collaborate on a daily basis to coordinate the care of these families. Women also have access to a multitude of ancillary and psychosocial services.

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352

Tyra Jones, RNC-OB, MSN, CRNP, The Children’s Hospital of Philadelphia, Philadelphia, PA Susan S. Spinner, MSN, The Children’s Hospital of Philadelphia, Philadelphia, PA Susan R. Miesnik, RNC-OB, MSN, CRNP, The Children’s Hospital of Philadelphia, Philadelphia, PA



Tussey, C. and Sciuto, M.


Keywords fetal anomalies maternal-infant bonding special delivery unit


Implementation, Outcomes, and Evaluation To keep abreast of unit operations, processes, and patient needs, monthly multidisciplinary meetings are scheduled. With rapidly increasing patient referrals and volume, this structure facilitates ongoing, open communication. Each discipline, including nursing, is grounded in evidence-based practice. In this forum, conflicts, ideas, and gaps in services are addressed. For example, it was identified that our patients and their families needed additional behavioral health support to cope with the birth of a child with an anomaly. Resources were then al-

located to hire a full-time psychologist for the unit. Implications for Nursing Practice This care model as well as the knowledge and expertise we have gained during the past 5 years can serve as an example for other centers that provide care to women with pregnancies complicated by fetal anomalies. Nurses are at the forefront for the development and dissemination of maternal and neonatal care guidelines for this population. Nurses are central in providing holistic care and preventing the disruption of the maternal-infant bonding process.

Sugar Babies: High-Risk Obstetric Diabetes Resource Team to the Rescue Christina Tussey, MSN, CNS, RNC-OB, RNC-MNN, Banner Good Samaritan Hospital, Phoenix, AZ Mary Sciuto, RNC-MNN, MSN, Banner Good Samaritan Hospital, Phoenix, AZ Keywords diabetic resource team insulin management diabetic teaching


Purpose for the Program he average number of patients with diabetes in the hospital setting on any given day averages from 26% to 30% of the population. In a high-risk obstetric (OB) Level III tertiary medical center, there is a large population of pregnant patients with diabetes. A team of registered nurses was formed to strengthen the knowledge base of staff, support the care process, and provide safe, optimal care of the diabetic patient population in Women and Infant Services (WIS).

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Proposed Change After conducting a needs assessment in the department, team members of staff with a special interest in care of the female patient with diabetes was formed. Advanced education sessions were provided to the team members quarterly with primary focus on standardizing best practice in the women’s health and pregnant population. Members then chose education topics per year to train fellow staff and collaborated with the health care providers to ensure best outcomes for the patient population with diabetes and pregnancy. Implementation, Outcomes, and Evaluation A business plan was purposed to the WIS leadership and a charter was written to establish the OB diabetic resource team. Members were recruited from staff and quarterly meetings were scheduled. The results indicated that this team filled a need


for diabetes management support through providing increased staff coaching and patient education, ultimately improving staff knowledge and confidence in care of the patient with diabetes. Validation of increased staff knowledge and confidence was tracked with coaching and patient education sessions. The average number of staff coached per month by the Sugar-Babies team was 19 and the average number of patient education sessions per month was 13. Topics included treatment of patient with hypoglycemia, carbohydrate counting, proper use of insulin pumps, insulin timing, action, and administration. Before this program, there was no unit-specific diabetes education resource team available to staff. Continued successes are recognized daily by patients, staff, and physicians. Implications for Nursing Practice With the establishment of a unit-based diabetic resource team, all shifts are covered with a knowledgeable diabetic resource consultant. This has greatly affected night shift staff because they experience limited diabetic resources. With the increasing number of pregnant diabetic patients as well as increased use of insulin pumps and the different insulin regimens, the bedside nurse now has the tools to provide evidence-based practice when managing the challenges of providing care for these patients.

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Code Creta and Prevention of Massive Transfusion Purpose for the Program he increase in number of cesarean deliveries and other uterine surgeries has resulted in the increase in the incidence in accreta. Placenta accreta occurs when placenta implantation is abnormal. Placenta accreta is a serious complication of pregnancy that is associated with massive and potentially life-threatening hemorrhage. It is the primary cause of emergency hysterectomies.

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Proposed Change It is imperative that organizations are prepared to manage patients with accretas and/or massive blood loss. In response to the growing numbers of accretas, we developed a Code Creta protocol to minimize the risk to the mother and infant for patients with accretas, either known or unknown. Implementation, Outcomes, and Evaluation The protocol includes an algorithm to assist in necessary intervention based upon the severity of the accreta. It begins with early detection and diagnosis of suspected accreta. The physician consults with a gynecologic–oncologist to determine the extent and best course of action for the patient. The radiologist is consulted to determine if perioperative interventions are needed and an anesthesiologist is consulted to assist with the appropriate form of anesthesia. Nursing assists with early de-

tection and monitors the patient for changes in Jennifer Truax, MSN, RNC-OB, Inova Fairfax clinical status and coordination of care.

Hospital, Falls Church, VA

In addition to the surgical plan, the protocol includes a Code Hemorrhage protocol to assist with rapid turnaround times for blood testing and transfusion. As soon as a Code Hemorrhage is called, the blood bank assists with the rapid running of the blood specimen. A preestablished number of blood products are prepared and sent. A dedicated member of the OB team communicates with the blood bank during the code. The creation of the Code Creta policy has decreased the number of unexpected cesarean hysterectomies, unintended intensive care unit (ICU) admissions, and use of blood products. Our next phase of this protocol is to use simulators for an obstetrician–gynecologist to manage massive blood loss until a gynecologic–oncologist is available to assist with the surgery. We anticipate further reduction in massive blood loss and use of blood products with further training.

Janet Hooper, RNC, BSN, MA, LCCE, Inova Fairfax Hospital Women’s Services, Falls Church, VA Keywords accreta massive blood loss cesarean hysterectomy


Implications for Nursing Practice The standardized approach to high-risk situations assists in decreasing stress, poor communication, and negative patient outcomes. The Code Creta can be replicated in other organizations as a way to approach patients with accretas or massive blood loss.

A Collaborative Practice Initiative to Reduce the Rate of Cesarean Deliveries: The Vaginal Delivery Optimization Team Purpose for the Program reventing cesarean delivery is important for many reasons, largely because it is associated with many adverse outcomes, such as infection, increased length of hospital stay, and increased maternal morbidity. In an attempt to promote change and lower the cesarean delivery rate, The Joint Commission has adopted a new perinatal core measure set. This initiative will require the submission of cesarean delivery rates beginning in 2014.

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Proposed Change As a Magnet facility, we strive to improve quality outcomes, improve safety, and provide the newest evidence-based practice to our patients. The vaginal delivery optimization team was formed to focus

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on lowering the rate of cesarean delivery. This collaborative practice group, which consists of registered nurses, obstetricians, clinical educators, and nursing administration, decided to take on this initiative by optimizing the opportunity for every woman to have the best chance of a vaginal delivery. Implementation, Outcomes, and Evaluation There are many reasons why cesarean deliveries are performed; therefore, we chose to focus on factors that we could modify through collaborative practice changes. After careful data collection and review of clinical practice, we identified two factors that increased the likelihood of cesarean delivery: elective induction and lack of labor support. After a year-long participation with the

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352

Jessica Lennon, BSN, RNC-OB, C-EFM, Bon Secours St. Mary’s Hospital, Mechanicsville, VA Darla Seaver, ADN, RNC-OB, C-EFM, Bon Secours St. Mary’s Hospital, Chester, VA Keywords collaboration evidence-based practice low intervention optimize outcomes



Alles, C., Seyfert, K., and Gonzalez, A.


Institute for Healthcare Improvement (IHI) Perinatal Improvement Community, we successfully implemented no elective inductions before 39 weeks gestation. To improve support for our patients in labor, nursing administration supported the implementation of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) perinatal staffing guidelines and hired more nursing and support staff. A survey was conducted to determine the comfort level of the nursing staff with low-intervention nursing support. With the assistance of a respected childbirth educator and doula, mandatory education sessions provided staff with the most up-to-date evidence-based practice strategies for the man-

agement of latent, active, and second stage of labor. Implications for Nursing Practice Our nurses now enthusiastically embrace and are consistently implementing current evidencebased practices, such as active position changes that encourage fetal rotation, and descent and passive descent, and open glottis pushing, which decrease maternal exhaustion and improve fetal outcomes. With the incorporation of these measures, we have seen our primary cesarean delivery rate decrease from 25.1% in January 2012 to 18.3% in December 2012 for low-risk nulliparous women with term singleton vertex fetuses.

Improving Nurse to Patient Communication on Antepartum Special Care Cynthia Alles, BA, ASN, Purpose for the Program RNC-OB, Orlando pon review of recent patient satisfaction reHealth/Winnie Palmer Hospital, sults of a 35-bed antepartum unit, it was sugOrlando, FL

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gested by a bedside nurse and member of the Unit Nurse Practice Council that a formal written plan Karen Seyfert, BSN, RNC-OB, Orlando Health/Winnie Palmer of care may help improve communication between the nurse and patient. After a thorough search of Hospital, Orlando, FL the literature and discussion among other units within the organization, it was discovered that a Ashleigh Gonzalez, BSN, cardiac unit within the organization demonstrated RNC-OB, Orlando Health/Winnie Palmer Hospital, improvements in their nurse-to-patient communiOrlando, FL cation scores after initiating a pilot that provided each patient with a computer-generated plan of Keywords care for the day. plan of care nurse–patient communication


Proposed Change Information Services’ Clinical Informatics team and the Antepartum Unit Practice Council collaborated to develop a computerized plan of care that uses information automatically transferred from the electronic medical record. The computerized plan of care was then distributed to every patient each morning. During the Unit Nurse Practice Council meetings, shift huddles, and staff meetings, staff was educated on the implementation of the plan of care pilot, including its purpose and how to present it to the patient.


Implementation, Outcomes, and Evaluation To implement the change, we educated staff at huddles, staff meetings, Nurse Practice Council meetings, and through education boards; held separate education for secretaries on how to access and print plan of care; followed up on participation in the initiative; spoke with management and charge nurses to obtain feedback from patient rounding; and reeducated staff periodically to maintain momentum. Discharged patient satisfaction surveys were analyzed after the initiation of the written plan of care. The survey included questions related to the patient’s perception of effective communication. The results of the survey before and after the initiation of the pilot were compared. The feedback from nurses and patients was very positive. An increase in two scores directly related to nurse–patient communication was seen after the initiation of the computer-generated daily plan of care. Implications for Nursing Practice Involving patients in their care by reviewing a printed daily plan of care can make a huge difference in their knowledge, hospital experiences, and outcomes. The team felt that customizing the plan of care to the obstetric population could increase the patient’s understanding and adherence.

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Implementing the Modified Early Obstetric Warning Score (MEOWS) to Detect Early Signs of Clinical Deterioration and Decrease Maternal Mortality Purpose for the Program odified Early Warning Score (MEOWS) was introduced to obstetric units in the United Kingdom to decrease maternal mortality by improving early detection of clinical signs of deterioration in women who were developing critical illnesses. Early warning scores have been used successfully in other areas, such as acute medicine, however these scores are not transferrable to obstetric patients because of the normal physiological changes in pregnancy. The parameters of vital signs for the MEOWS chart accounts for this. The existing Joint Commission standards require hospitals to have a process for identifying early warning signs of deterioration and for staff to seek assistance if this occurs. A sentinel event alert concerning increasing rates of maternal mortality in the United States recommends that specific changes in maternal vital signs and clinical condition should trigger a predetermined response.

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Proposed Change To quantify vital signs to identify early signs of deterioration. Implementation, Outcomes, and Evaluation A tool has been designed for the obstetric population and used in the United Kingdom; maternal deaths are decreasing and evaluation is ongoing.

MEOWS is an innovative approach to care in the field of obstetrics. It is not currently widely used in North America; however, the United Kingdom is striving to make this the gold standard across all obstetric units. In a validation study, MEOWS had high sensitivity in predicting morbidity (89%) and reasonable specificity (79%) supporting its use for obstetric patients. The philosophy behind MEOWS reflects that the majority of validated obstetric emergency training courses, such as PROMPT, More OB, ALARM, and ALSO), encourage recognizing risk, implementing a coordinated approach to managing emergencies, open communication, and working within a multidisciplinary team.

Clare A. Cook, BSc, RN, RM, Sidra Medical and Research Center, Doha, Qatar Keywords maternal mortality Early Warning Score


MEOWS is now being incorporated into a stateof-the-art new facility in the state of Qatar, which encourages innovative practice, multidisciplinary work, and evidence-based practice. MEOWS can be paper-based or used as part of an electronic medical record and provides a standardized approach to the assessment of maternal well-being. It has been incorporated into the rapid response policy, which ensures clarity of staff roles and responsibilities. Implications for Nursing Practice Implementing MEOWS could provide a rich opportunity for nurses to develop research programs, standardize care, and coordinate responses to deteriorating conditions.

Creation of a Postpartum Roadmap and Whiteboard: A Family’s Step-By-Step Guide Toward Their Journey Home Purpose for the Program o manage expectations of the postpartum patient and her family regarding the hospital stay from admission to discharge through the use of he postpartum roadmap and whiteboard. Patient feedback indicated new families were uncertain of what to expect from caregivers and what was expected of them with regard to learning all of the postpartum and newborn skills needed for successful discharge.

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Proposed Change Rather than allowing patients to remain unsure about their care, an interdisciplinary team set out to create a tool (by going shift-to-shift to learn

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what tests, skills, and education would occur) that allows families to navigate to a successful discharge, beginning the moment they arrive on the postpartum unit. The postpartum roadmap and whiteboard guide the new family through everything that will occur during the postpartum stay. By explaining to the family what they can expect of the caregivers and what they in turn will be expected to learn and demonstrate, we have created an interactive tool that outlines every phase of the postpartum hospital stay.

Jonna L. Horgan, MSN, RN, RNC, Northwestern Memorial Hospital, Chicago, IL Michele Roe, MBA, RN, NE-BC, Northwestern Memorial Hospital, Chicago, IL Margaret Yocom-Piatt, MSN, RN, RNC, BFC, Northwestern Memorial Hospital, Chicago, IL

Implementation, Outcomes and Evaluation After reviewing input from nurses, physicians, patients (current and past through satisfaction

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Nichols, S. D., Furey, P. M., Palmer, J. P., and Birnholz, E. M.


Nicole Cohn, BSN, RNC-MNN, CBC, Northwestern Memorial Hospital, Chicago, IL Keywords roadmap postpartum plan of care whiteboard


surveys), marketing, and social work, two tools (one written roadmap and one whiteboard) were created that broke the postpartum experience and expectations for families into six phases: Admission, Getting to know your baby, Preparing to be a family at home, Complete all patient tests, You are ready to go home, and Discharge. All staff on the four mother–baby units were educated on how to communicate the roadmap and whiteboard upon the patient’s admission to the floor. Evaluation surveys were given to staff and patients to ensure satisfaction was obtained on both parts. The survey results showed staff appreciated patients having a written tool they could refer to after being educated on expectations during the post-

partum stay. Patients seemed to enjoy referring to the written tool as well as the visual ease of the whiteboard. The combination of both tests put patients at ease with concerns about expectations of their care. Overall, since implementing the tool in January 2013, there has been a 15.8% increase in very good response to the Press Ganey’s survey question on discharge preparedness. Implications for Nursing Practice The postpartum roadmap and whiteboard may be valued tools that allow nursing and patients to fully communicate all stages and expectations of postpartum care. Including patients in the plan of care is an innovative approach to nursing.

Lights, Camera, Hemorrhage: Using Creative Learning Strategies to Engage Nurses Shiree D. Nichols, MSN, RN, RNC-OB, Florida Hospital, Orlando, FL Patricia M. Furey, BSN, RN, RNC-OB, CCE, Florida Hospital, Orlando, FL Jillian P. Palmer, BSN, RN, Florida Hospital, Orlando, FL Elvia M. Birnholz, BSN, RN, RNC-OB, Florida Hospital, Orlando, FL Keywords postpartum hemorrhage skill stations simulation debriefing


Purpose for the Program ostpartum hemorrhage (PPH) is the number one killer of women in the postpartum period, despite the fact that the United States spends more on health care than any other country. The need for education on PPH identification and management in our department was recognized because a number of nurses who were new to the specialty were hired. Communication issues between the labor and delivery unit and the blood bank, as well as confusion in ordering blood products after the implementation of computerized provider order entry also were identified. A final issue was inconsistency in nurses’ ability to recognize and respond to PPH in a coordinated manner.

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Proposed Change To reduce mortality and morbidity due to PPH, the labor and delivery Nurse Practice Council (NPC) developed and presented two simulation scenarios. The first depicted common deficits in knowledge, skills, and communication leading to denial and delay, whereas the second demonstrated best practices. Implementation, Outcomes, and Evaluation The NPC developed two scenarios depicting PPH. Night shift chose a scenario showing denial of signs and symptoms of PPH, delay in management, and poor communication with physician, team members, and patient/family. Day shift chose a scenario demonstrating best practices. Each


group recruited actors and developed their script in collaboration with the educator, unit medical director, anesthetist, and the blood bank educator. The educator worked with the NPC to develop skill stations that reinforced the objectives: no denial, no delay, and consistent weighing of blood loss. Forty members of the department attended the presentation. Attendees were actively involved in debriefing after each scenario and participated in the skill stations. The research department provided breakfast and paid for the nurses to attend. Nurse interviews 3 months after the event indicated the following changes: increased use of the PPH cart, consistent weighing of blood loss, articulation of risk factors for PPH during shift huddles, and an increase in critical thinking. Most importantly, nurses had clear role expectations, which has improved teamwork during a PPH. Implications for Nursing Practice Engagement of direct care nurses in teaching each other is an effective method for changing practice to align with current recommendations for eliminating preventable deaths from PPH. Active learning, including simulation, with adequate debriefing provides education in a safe environment. The hospital has applied to participate in the Florida Perinatal Quality Collaborative’s quality improvement initiative for obstetric hemorrhage management to assist us in achieving this goal.

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Implementation of a Nitrous Oxide Program at a Small Community Hospital Purpose for the Program t is a part of the mission of Monadnock Community Hospital’s Birthing Center to allow patients as much autonomy as possible in their birthing experiences. We believe that providing patients with various pain management options and the education to empower them in their decision making is essential to obtaining satisfaction in their birth experiences. Monadnock Community Hospital is one of the few hospitals in the United States to launch minimally invasive, self-administered inhaled nitrous oxide for obstetric analgesia.

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Proposed Change As an option for pain management while in labor or during the immediate postpartum recovery period, nitrous oxide will be offered to all women who meet the eligibility criteria. Unlike other organizations that use nitrous oxide, Monadnock Community Hospital’s nitrous program will be nurse led rather than facilitated by the anesthesia department. Implementation, Outcomes, and Evaluation Monadnock Community Hospital is a critical access hospital with 25 inpatient beds. The obstetric (OB) unit has seven labor, delivery, recovery, and postpartum (LDRP) rooms. Coverage 24 hours per day, 7 days per week in-house for either an obstet-

ric or anesthesia provider is not available. The initiation of the nitrous program has made access to immediate pain relief a reality. A journal of the process from concept to implementation has helped to capture the successes and challenges of this project. Implications for Nursing Practice A long-time labor nurse described nitrous as “another quiver in the arrow” for helping women to manage their pain. Because of a national shortage, Monadnock Community Hospital has been unable to obtain Nubain, a popular intravenous (IV)/intramuscular (IM) analgesic medication for obstetrics, leaving many women who choose a pharmacological approach for pain management to choose between Stadol, a sedative medication, and epidural anesthesia. Nurses note that they experience frustration at the lack of better options.

Elizabeth Kester, RN, CLC, CCE, Monadnock Community Hospital, Peterborough, NH Keywords nitrous labor analgesia pain management option patient satisfaction


The nurse-led approach to the nitrous program at Monadnock enables nurses to provide safe and quick pain relief to patients, which was not available previously. Night nurses noted that they were hesitant to call the anesthesia provider in the middle of the night if there was a chance that the patient would deliver before the physician’s arrival. Nitrous helps bridge the gap of time that can seem endless while waiting for a health care provider to arrive.

“Don’t Rush Me . . . Go the Full 40” as a Public Health Strategy to Promote Spontaneous Labor and Normal Birth Purpose for the Program he “Don’t Rush Me . . . Go The Full 40” campaign of the Association of Women’s Health, Obstetric and Neonatal Nurses’ (AWHONN) seeks to increase the percentage of women who complete at least 40 weeks of pregnancy and wait for spontaneous labor and to improve the effectiveness of maternity care professionals in reducing elective inductions and cesarean births.

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Proposed Change Women and their infants benefit from an intricate cascade of endocrine events that leads up to and facilitates labor and vaginal birth when labor occurs spontaneously. The results are shorter hospital stays, lower infection rates, increased breastfeeding, and faster recoveries with fewer complications. However, the induction of labor

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rate has doubled in the United States in the past 20 years, and the cesarean rate has increased 50%. A significant number of labor inductions are not medically necessary. Leading experts say that the overuse of labor interventions is a public health problem that exposes women and infants to unnecessary risks in the perinatal period and long-term, and results in considerable and unnecessary health care costs. Overuse of inductions increases long- and short-term maternal and neonatal morbidity, including obstetric hemorrhage, neonatal intensive care unit (NICU) admissions, less breastfeeding, overuse of cesarean, and infection. Because of persistent prematurity, increasing labor interventions, and increasing perinatal morbidity and mortality, AWHONN launched “Don’t

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Catherine Ruhl, CNM, MS, AWHONN, Washington, DC Carolyn D. Cockey, MLS, AWHONN, Washington, DC Keywords normal birth cesarean elective induction spontaneous labor overuse perinatal morbidity and mortality




Renfro, C. and Scheffer, K.


Rush Me . . . Go the Full 40” in 2012 as a grassroots, public health campaign about the benefits of a full-term pregnancy and spontaneous labor. Implementation, Outcomes, and Evaluation The goals of “Go The Full 40” are aligned with AWHONN’s Nursing Care Quality Measures and complementary to efforts in progress at The Joint Commission, American Medical Association Physician Consortium for Performance Improvement, and the Centers for Medicaid and Medicare Services (CMS) to increase patient safety and quality of care. More than four states have implemented the campaign as a public health message, and CMS includes the campaign in its Strong Start

tools to help reduce early and elective births. We present the major components and outcomes to date regarding the campaign’s goals and objectives, including resources and toolkits, a 40 Reasons article, Spontaneous Labor Pledge, and the “Go The Full 40” Champions group. Implications for Nursing Practice We demonstrate how AWHONN’s “Go The Full 40” campaign promotes spontaneous labor to improve maternal and neonatal health by helping to reverse current trends in perinatal morbidity and mortality. This poster equips nurses to champion the campaign in their institutions and communities.

Holy Smoke: There’s a Fire in the Operating Room Christine Renfro, BSN, RNC-OB, C-EFM, Baylor University Medical Center, Dallas, TX Kristin Scheffer, BSN, RNC-OB, C-EFM, Baylor University Medical Center, Dallas, TX Keywords simulation OR fire safety education drills


Purpose for the Program ecently, the Association of Perioperative Nurses (AORN) and The Joint Commission (TJC) have stressed the importance of operating room (OR) fire safety. One of the many competencies labor and delivery (L&D) staff must possess includes OR-specific competencies. AORN stresses the importance of education and mock drills. A needs assessment of staff led the perinatal simulation facilitators to develop a scenario and drill that would allow all members of the perioperative team to experience an OR fire and the steps necessary to maintain a safe environment for patient and staff alike.

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Proposed Change For the past 6 years, our facility has used simulation-based learning that focuses on high-risk obstetric events; however, much of the education regarding fire safety was presented in a didactic format with little hands-on focus. Thus, the perinatal simulation team developed an OR fire simulation scenario to focus on immediate intervention, role assignment, effective communication, use of the fire extinguisher, and evacuation. Implementation, Outcomes, and Evaluation Because OR fires in L&D are rare, staff are not comfortable performing all the necessary steps that are needed to extinguish a fire, ensure pa-


tient and staff safety, and evacuate the OR. In L&D, the mother–infant dyad creates a unique situation and special consideration must be taken with a compromised infant who requires resuscitation. The simulation team developed an intense OR fire scenario, implemented and recorded it, and debriefed the participants immediately after. Focus was placed on the duties of the perioperative team, effective communication between the perioperative and the neonatal intensive care unit (NICU) teams, extinguishing the fire with a live fire extinguisher, evacuation of the patients, and vulnerability of infant abductions during fires. The perioperative and NICU teams admitted to having little awareness that an OR fire could occur, steps that must be taken during a fire to ensure safety to all, and use of a fire extinguisher. The teams also voiced how the training increased their awareness and gave them a better understanding of all steps that must be taken to ensure patient safety for the mother–infant dyad. Implications for Nursing Practice By creating an innovative scenario and a unique learning experience, the simulation team was able to increase the perioperative and neonatal teams’ confidence level surrounding a circumstance that while very possible is also very rare in our environment.

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Perinatal Education in a Community Setting Purpose for the Program o provide childbirth educators and nurses an innovative, community-based program that creates a positive learning environment and access to a network of interdisciplinary resources for pregnant women and their families. Providing patient education is essential for effective care, improving health, preventing disease, and positive outcomes for patients, families, and communities. Proposed Change Experts concur that prenatal education and care are essential to decreasing preterm births. Knowing the community before developing interventions for health care and services will help in articulating partnerships and culturally congruent care. Extensive literature confirms that many barriers exist to prevent pregnant women from creating healthy environments for their unborn infants: lack of transportation, age, literacy, socioeconomic factors, and racism. This program touches on these issues and provides the community with needed prenatal education at the point of care to improve the outcomes for pregnant women and their infants.

childbirth education program was presented to the obstetrician’s group and was approved. The physician provided a conference room and storage room for weekly classes. Collaborative relationships with lactation, social work, financial counselors, and translators were established. A plan of care, pretests and posttests, evaluation, and curriculum for four classes were developed (Understanding Birth I/II and Baby Basics I/II). The classes focused on topics such as benefits of breastfeeding, signs and symptoms of preterm labor, sudden infant death syndrome (SIDS), smoking cessation, and car seat safety. The office manager identified the day and times that most prenatal visits occurred. Childbirth educators were recruited to teach weekly classes from 10 a.m. to 12 p.m. and from 2 p.m. to 4 p.m. An incentive program was implemented for women who met three of the five criteria, attended all the classes, and gave birth at Mercy Health Fairfield. Outcome data show that most participants in the program were primiparous women younger than 25 years. Pretest and posttest data illustrated that education produced greater understanding of the information taught.

Implementation, Outcomes, and Evaluation An obstetrician’s office was designated as having a large number of pregnant women who were at risk for not receiving childbirth education. The

Implications for Nursing Practice Prenatal education for the vulnerable pregnant population before delivery helps support the education given by the perinatal nurse in the hospital.

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Wendy Chastain, MSN, RNC-CCE, C-EFM, Mercy Health Fairfield, Cincinnati, OH Jennifer Lipke, BSN, RN, Mercy Health-Fairfield Hospital, Fairfield, OH Keywords childbirth education collaborative interdisciplinary relationships incentives criteria


Perinatologists and Advanced Practice Nurses Collaborate to Provide High-Risk Prenatal Care in Rural Virginia Communities Purpose for the Program he specific intent was to assess the effect of a telemedicine-based high-risk prenatal clinic on maternal-child health outcomes for low-income women in rural communities.

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Proposed Change Adequate and early access to risk-appropriate prenatal care can reduce the incidence of adverse outcomes. Limited access disproportionately affects women of low socioeconomic status and with limited English proficiency in rural communities. Distance and costs associated with frequent travel and the limited number of perinatologists are barriers to high-risk care. Telemedicine can reduce barriers through collaboration of perinatologists and advanced practice nurses. Telemedicine has

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shown favorable results in a variety of clinical Sharon T. Veith, MSN, disciplines. Prenatal care is a relative newcomer University of Virginia, to the spectrum of health care provided via Charlottesville, VA telemedicine. Implementation, Outcomes, and Evaluation Collaborative high-risk obstetric (OB) telemedicine clinics were implemented in five rural locations between 2009 and 2013. Local clinics serving the targeted population were solicited as partners. Hands-on prenatal care and examinations at the local site were provided by nurse practitioners. Video telemedicine visits were in real time with the patient, local practitioner, and remote perinatologist. The telemedicine clinics served 374 patients. With Institutional Review Board (IRB) approval, charts were reviewed to compare patient

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352

Christian Chisholm, MD, University of Virginia, Charlottesville, VA Wendy Novicoff, PhD, University of Virginia, Charlottesville, VA Karen Rheuban, MD, Department of Telemedicine, Charlottesville, VA Wendy Cohn, PhD, University of Virginia, Charlottesville, VA



Fickley, S.K.


Keywords telemedicine collaborative care rural health care advanced practice nurse high-risk prenatal care


access measures and pregnancy outcomes before and after initiation of telemedicine. The comparison group consisted of 181 patients. Demographic, patient access, and pregnancy outcome data for women referred before and after the initiation of the telemedicine clinics were compared using two-sample t test and chi-square test. Women who received care before telemedicine had a higher rate of missing one or more prenatal visits compared with the telemedicine group (57.1% vs. 21.3%, p = .000). The overall missed visit rate decreased from 0.71% to 0.53% per patient (p = .086). There was no difference in the groups for gestational age at first visit (13.6 vs. 14.0 weeks of gestation). Deliveries after 37 weeks of gestation were similar (84% pretelemedicine vs.

83% telemedicine). The telemedicine group had a higher mean birth weight (3,226 vs. 3,137 g, p = not significant). There was no difference in the neonatal intensive care unit (NICU) admission rate (12.0% vs. 10.8%); mean NICU days were reduced in the telemedicine group (22.11– 13.42, p < .01). Aggregate saved patient travel was 162,126 miles in 3 years. Implications for Nursing Practice Collaborative care through telemedicine is an effective method for providing high-risk prenatal care to women who live in rural communities. When compared with traditional care, telemedicine is associated with improved access to care and similar rates of important outcomes.

Achieving Realism With Low-Tech Simulation Sharon K. Fickley, MSN, RNC-OB, C-EFM, CNL, Sentara Martha Jefferson Hospital, Charlottesville, VA Keywords simulation low fidelity postpartum hemorrhage


Purpose for the Program he use of simulation to increase team confidence and competence in responding to obstetric emergencies is well documented in the literature. However, limits on financial and human resources make the purchase and operation of high-fidelity simulators challenging in many organizations. Some literature indicates that setting appropriate goals for simulation and conducting effective debriefing sessions, rather than the use of high-fidelity simulators, are the most significant drivers of enhanced team performance associated with simulation.

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As a relatively new perinatal clinical educator, I recognized our staff’s need for simulation. One of my physician partners was convinced that highfidelity simulation was the only effective way to accomplish this learning modality. However, after attending a 1-day course on the programming and operation of this mannequin, I was daunted by the prospect of learning to use the equipment effectively. Because the male mannequin cannot simulate hemorrhage like an obstetric simulator can, I held doubts that the staff would not be distracted by the fact that our mannequin was male. Proposed Change Wanting to accomplish successful simulation with the means I had available, I worked with our simulation coordinator to develop appropriate goals for a low-fidelity postpartum hemorrhage simulation.


Implementation, Outcomes, and Evaluation I concocted nonstaining blood, developed a realistic scenario, used a colleague as a standardized patient, partnered with the blood bank to obtain expired blood for use during simulation, and garnered the support of two obstetricians to participate in the hemorrhage simulation. Simulator intravenous (IV) arms from the clinical skills laboratory were used during the simulation to allow staff to feel the pressure of having to start IVs in an emergency situation, and the postpartum hemorrhage cart was a key part of our simulation. The nursing shift manager, anesthesia, pharmacy, and the operating room staff were all included in the simulation to allow testing of the integrity of systems and processes. Staff completed a brief pretest before a briefing and then took an identical posttest after the debriefing. The average improvement in test scores was approximately 10 points. The staff and physicians who participated in the simulations were extremely satisfied with the event. Evaluations indicated improved knowledge and confidence as well as a genuine feeling that the event was real. Several staff members stated, “I felt scared.” Potential communication and process breakdowns were identified and have since been addressed. Implications for Nursing Practice With proper planning and execution, low-fidelity simulation can be an effective means of team training.

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Couplet Care: The Magic Within Purpose for the Program eeping mothers and newborns together in couplet care after delivery has many benefits. The purpose of this project was to enhance the delivery experience and provide excellent outcomes for the mother and newborn by incorporating evidence-based care.

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Proposed Change Before the implementation of couplet care, newborns were taken to the newborn nursery shortly after delivery where they remained for several hours. Many were then placed in the nursery at night so the mother could rest. Although labor and delivery nurses placed the newborn skin-to-skin with the mother immediately after birth and worked to facilitate breastfeeding, there was an interruption in the natural care process when transferring newborns to the nursery. The goal was transition from traditional nursery care to couplet care. Implementation, Outcomes, and Evaluation The beginning phase of this process included a literature review along with contacting comparable hospitals. Our women’s health team met to discuss the proposed process change and identify possible barriers and necessary resources. An algorithm was constructed to outline the process that guided newborn care from birth to the postpartum unit. While on the labor and delivery unit, a transition nurse from the nursery would care for the newborn and a labor and delivery nurse would care

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for the mother. This allowed the mother and newborn to remain together skin-to-skin while each received care from their specialty nurse. When the dyad is transferred to postpartum unit, couplet care and rooming-in are reinforced.

Alicia Brenneman, BSN, RNC, C-EFM, Grant Medical Center OhioHealth, Columbus, OH

Kimberly M. Price, BSN, RN, ANLC, IBCLC, Grant Medical A fact sheet and brochure were designed to ed- Center, Columbus, OH

ucate parents and visitors on the benefits of couplet care. All healthy newborns remain with their mothers throughout their stays to empower parents to guide their newborns’ care. The outcomes revealed that couplet care was very successful with only positive outcomes. A notable increase in patient satisfaction was evidenced by follow-up phone calls. Parents reported they felt more confident in caring for their newborns. Staff satisfaction and unit relationships improved. A considerable decrease in tachypneic and neonatal abstinence syndrome (NAS) admissions to the neonatal intensive care unit (NICU) was reported. Positive anecdotal reports from mothers have sparked our interest in further research.

Keywords couplet care skin-to-skin transition


Implications for Nursing Practice Nursing culture has transitioned from traditional care to evidence-based practice care. The change has enhanced interprofessional collaboration and communication, and nurses have been empowered to make changes that affect the care, satisfaction, and outcomes of their patients. There has been improved patient outcomes and satisfaction.

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352



Rodgers, E. et al.


A Multidiscipinary Approach to Improving Skin-to-Skin Contact Immediately After Birth Newborn Care

Donna M. Norris-Grant, BSN, RNC, Christiana Care Health System, Bear, DE Carol E. Jaggers, RN, BSB, IBCLC, PCE, Christiana Care Hospital, Elk Mills, MD Keywords breastfeeding skin-to-skin maternal-infant bonding teamwork Baby Friendly

Poster Presentation

Purpose for the Program o educate labor and delivery staff about the complex institutional changes necessary to increase skin-to-skin rates based on Baby Friendly criteria. Establishing a major practice change in a large labor and delivery unit with more than 6,000 births annually proved a difficult task for nursing staff alone. Meeting the goal of having 90% of healthy newborns to remain undisturbed for at least 1 hour after birth in direct skin-to-skin contact with the mother became a major challenge. Since 2009, nursing staff initiatives to improve skin-toskin contact in the labor and delivery unit had only limited success. A team made up of pediatricians, lactation specialists, and postpartum and labor and delivery staff was formed to take on the task of defining guidelines for skin-to-skin contact. As challenges and barriers were identified, input from anesthesia, administration, information services, clerical staff, hospital clinics, and community services became essential.

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Proposed Change To improve rates for skin-to-skin contact in the labor and delivery room and ultimately improve breastfeeding rates in the community. Implementation, Outcomes, and Evaluation Survey nursing staff for baseline of current skinto-skin practice. Identify barriers and team de-

velopment, including all departments associated and plans to remove barriers. Continue to monitor skin-to-skin rates and survey staff and patients. This presentation will highlight the paths traveled to achieve success, crediting teamwork on all levels to implement practice change. Nursing champions for skin-to-skin contact reached out to ancillary personnel in disciplines affecting newborn care. Barriers identified by staff survey, observation, and trial and error were addressed individually. Labor and delivery nursing staff took on the challenge of keeping mothers and infants together for 1 hour after birth, and with the dedication of all supporting departments they soon achieved success. Implications for Nursing Practice Success in improving skin-to-skin rates in labor and delivery depends on the cooperation and flexibility of every discipline involved in the care of mothers and newborns. Skin-to-skin contact rates increased dramatically in a relatively short period, and patients and nurses expressed satisfaction about these changes. The statistics collected indicate an impressive improvement in skin-to-skin contact rates. Patient and staff surveys support the growing satisfaction with the changes implemented. Involving all stakeholders helped to identify and address sustainability of our new practice.

Skin Rounds: A Standardized Approach to Pressure Injury Detection and Reporting in the Neonatal Intensive Care Unit Elizabeth Rodgers, BSN, RN, Nationwide Children’s Hospital, Columbus, OH

Purpose for the Program voiding skin injury is critical to optimizing outcomes in hospitalized patients. High rates of pressure injuries have been reported among paMarliese D. Nist, BSN, tients in pediatric and adult intensive care units RNC-NIC, Nationwide Children’s Hospital, Columbus, (ICUs), but less data on incidence or prevention are available for neonatal ICU patients. The aim of OH this quality improvement program is to standardize the skin care of patients in our neonatal intensive Renee Gardikes-Gingery, RN, BSN, Nationwide Children’s care unit (NICU).

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Hospital, Columbus, OH Edward Shepherd, MD, FAAP, Nationwide Children’s Hospital, Columbus, OH

Proposed Change An interdisciplinary team was formed in an acute care, Level IIIC, all referral NICU. This team is responsible for weekly rounds on patients to assess and document skin injuries, collect demo-


graphic information, provide education to bedside caregivers, and provide recommendations for skin care. Implementation, Outcomes, and Evaluation The team underwent standardized training over a 4-week period to detect and stage pressure injuries. Weekly skin rounds began in July 2011. Initial staff resistance to the change in routine was overcome by education via in-services and selfstudies on skin injury prevention; this led to a gradual shift in perception and skin rounds are now an accepted routine. There was also tremendous support from administration and nursing, respiratory, and medical leadership, which helped integrate skin rounds into the unit culture.

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Between July 2011 and August 2013, the skin injury team rounded on a median of 47 patients per week for 100 weeks, for a total of 4,672 patient assessments. The overall incidence of Stage II or greater pressure injuries was 2.79 injuries per 1,000 patient days. Stage II pressure injuries accounted for 64.5% of the injuries assessed. Stage III pressure injuries accounted for 2.8% of the injuries. Suspected deep tissue injuries accounted for 21.5% of the injuries. Injuries that could not be staged accounted for 3.7% of the injuries. Mucosal injuries accounted for 7.5% of the injuries. No Stage IV pressure injuries were detected. The greatest cause of pressure injuries was respiratory devices followed by immobility. The incidence of

pressure injuries after the formation of the unitbased skin team increased significantly (from a Brenda Ruth, BSN, RN, baseline of 0.49 injuries per 1,000 patient days), CWON, Nationwide Children’s which demonstrated an improved detection of in- Hospital, Columbus, OH juries with standardized skin rounds. Implications for Nursing Practice We have created the largest database of skin injury in the NICU by means of an interdisciplinary team focused on skin injury prevention, education, and regular skin assessments of all infants. This database provides a stable platform upon which to build and measure prevention strategies. This skin care approach could serve as a model for other institutions.

Leah Keller, BSN, RN, Nationwide Children’s Hospital, Columbus, OH Keywords pressure ulcer skin injury neonate

Newborn Care Poster Presentation

The For Ever Storybook Program Purpose for the Program aternal bonding is critical in the newborn period that has traditionally been entrusted to nurses. Nurses have met this challenge through a variety of interventions, including keeping newborns in close physical proximity to their mothers, helping mothers interpret the behavioral cues of their newborns, and creating a nurse–mother relationship that gives credibility to all other nursing interventions. Nurses continually search for ways to help mother fall in love with their newborns, which is critical beginning for a positive, life-long, secure mother–child attachment. The For Ever program facilitates bonding and promotes early literacy.

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Proposed Change The envisioned change of the For Ever program is improved maternal (and paternal) bonding and long-term appreciation of a book that has special meaning in the postpartum moment. Implementation, Outcomes, and Evaluation The nurse gives each mother a spiral-bound children’s book that has been especially designed for these tasks. The book’s story line reinforces the importance of a mother’s responsiveness to the cues of her newborn and the long-term effects of that responsiveness for the child: “When I’m sleeping

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you gaze at me. When I cry, you hold me close, and I feel safe. When I open my eyes and look at you, you look back. You touch my toes . . . .” Brightly colored drawings depict an infant who while growing into a young child searches for and unites with his/her mom. The For Ever book, written and illustrated by a nurse, is personalized with one page for writing the newborn’s birth information and another for attaching a family photo that can be taken by the nurse at the bedside with an instant camera added later. Evaluating the importance of this program requires an interim time of several months to understand how the book and its message have been used over time. We hypothesize that the personalizing features of the book will be an enticement for it to be read and valued, even in families where literacy is not a priority. Evaluation is planned for 6 months after hospital discharge via a phone call to the mother to answer a short list of questions about the use of and interest in the book.

Donna J. Karl, MS, APRN-BC, Children’s Hospital Boston, Boston, MA Keywords newborn maternal-child attachment maternal bonding


Implications for Nursing Practice The For Ever Program offers the nurse a tool to facilitate maternal bonding while enriching the postpartum experience and strengthening family literacy.

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352


Tootelian, P., Roamn, K., and Cruz, D.A.


Implementing the Best Fed Beginnings Collaborative for Baby Friendly Designation in a Large Urban Teaching Hospital Pam Gessling, MBA, BSN, NEA-BC, RNC-OB, C-EFM, Methodist Dallas Medical Center, Dallas, TX Keywords Baby Friendly breastfeeding


Purpose for the Program he purpose of the presentation is to describe the experience of a large-volume, urban, teaching hospital with the Best Fed Beginnings Collaborative in achieving Baby Friendly designation. Best Fed Beginnings is a National Initiative for Children’s Healthcare Quality (NICHQ) collaborative to promote breastfeeding education in hospitals. Our hospital is one of 90 hospitals chosen nationwide to participate in this collaborative as a pathway to Baby Friendly designation.

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Breastfeeding initiation rates, exclusivity rates, and sustainability for 1-year rates are all much lower in the United States than is desired by Healthy People or the American Academy of Pediatrics (AAP). Breastfeeding is recognized as the best choice for infant feeding. Healthy People 2020 goals include increasing the proportion of infants who are not breastfed at all and those exclusively breastfed at 3 months, 6 months, and 1 year. Proposed Change Our goal is to provide the hospital staff, physicians, and patients the education and support to allow for the greatest success rates for mothers breastfeeding their infants. Evidence shows the care provided in the hospital during and after birth directly affects the success rates for breastfeeding. We worked to change our delivery of care model to maintain the mother and infant to-

gether, support mother/family education, and provide family-centered care in our facility. Implementation, Outcomes, and Evaluation In 2011, our facility began to work toward becoming Baby Friendly by reviewing our current practices and determining the route to take. We evaluated our practices and decided to apply to the Best Fed Beginnings Initiative. Our challenges included traditional roles that were not focused on supporting breastfeeding success. We removed formula bags and pacifiers, initiated skin-to-skin contact time, and added a newborn admission nurse in the delivery suite. We discovered major hurdles regarding nurse/physician comfort levels, perceptions of what patients wanted, and what was best for the mother–infant dyad. Our multidisciplinary team, which includes obstetricians, pediatricians, nursing staff, leadership, and lactation consultants, has made great progress toward meeting our goal of completing a Baby Friendly survey by September 2014. Implications for Nursing Practice Our path toward Baby Friendly designation has improved patient satisfaction, nursing satisfaction, and empowered new mothers/families to make informed choices for the health of the infant and mother. We hope to have our Baby Friendly survey completed in the fall of 2014. This change has empowered nurses and physicians to work together toward a common goal.

Skin-To-Skin: Nurse Buy-In and Results on Exclusive Breastfeeding Patricia Tootelian, RNC, Purpose for the Program Inpatient, OB,Thomas Jefferson o discuss strategies used by a large urban University Hospital, teaching institution to initiate and optimize the Philadelphia, PA

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practice of skin-to-skin contact by the interdisci-

Karen Roman, RNC, Inpatient, plinary care team. OB,Thomas Jefferson University Hospital, Philadelphia, PA Proposed Change Deborah A. Cruz, MSN, CRNP, To implement a practice change that would increase the exclusive breastfeeding rate and overThomas Jefferson University Hospital, Philadelphia, PA all breastfeeding rate during the inpatient stay.


While staff were cognizant of the importance of skin-to-skin contact and the health benefits from exclusive breastfeeding, they still believed there would be issues with thermoregulation and glycemic control, even though this is not supported in the literature. Implementation, Outcomes, and Evaluation Through implementation of an extensive educational program for the staff, competency validation, and monitoring neonatal temperatures and

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glucose values, data demonstrated no issues of thermoregulation or glycemic control. In addition, the practice of skin-to skin contact as a standard of care for all stable, healthy newborns increased the exclusive breastfeeding rate approximately 16%.

Implications for Nursing Practice This positive effect on breastfeeding has created a positive impetus to move forward with Keywords the application to become a Baby Friendly skin-to-skin breastfeeding hospital.

exclusive breastfeeding thermoregulation hypoglycemia Baby Friendly


Establishing a Community Donor Human Milk Depot Purpose for the Program here is a critical shortage of donor human milk (DHM) in the United States. The American Academy of Pediatrics (APA) recommends that all preterm and compromised infants have their mothers’ breast milk, but when it is not available, pasteurized DHM is the next best nutrition. Pasteurized DHM offers healing properties for compromised infants and can prevent necrotizing enterocolitis (NEC), a life-threatening condition for significantly premature infants. The results are immediate health benefits, better long-term outcomes, and significantly reduced health care costs. Only DHM provided by a Human Milk Banking Association of North America (HMBANA) milk bank is safe for newborns in the neonatal intensive care unit (NICU). DHM depots can provide a valuable service to increase the collection of DHM and raise awareness of the need for milk donation. They provide an easy drop off location where women can bring their breast milk, which spares the donor from having to ship the milk to the milk bank for processing.

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Proposed Change If every hospital established a DHM depot, the supply of DHM would increase dramatically, which would reduce the shortage of this vital lifesaving

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nutrition. There are 12 HMBANA milk banks currently operating in the United States. Only 149 DHM depots are available to provide milk to the HMBANA milk banks. It is estimated that 9 million ounces of DHM are needed to meet the needs of NICUs nationwide. Implementation, Outcomes, and Evaluation In May of 2013, Florida Hospital in Orlando opened the Mother’s Milk Depot under the guidelines of HMBANA. The depot’s doors opened with relatively low overhead, maintained existing staff, and used existing space to house a deep freezer. In 4 months time, the Mother’s Milk Depot had collected and shipped nearly 10,000 ounces of DHM to the milk bank of Colorado from 13 donors. This was roughly the same quantity as the amount of processed DHM that the hospital had received over the past 8 months from the milk bank. Implications for Nursing Practice Having a hospital-based DHM depot allows nurses the opportunity to help raise awareness of the need for DHM, and they can offer their patients an easy drop off location for milk donation. Nurses can be instrumental in reducing the shortage of DHM, saving the lives of infants, and showing their communities that the health of women and children is a top priority.

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352

Colleen A. Andrew, BSN, RN, LCCE, Florida Hospital, Orlando, FL Stacie L. Gehring, RN, BSN, IBCLC, Florida Hospital, Orlando, FL Shiree D. Nichols, MSN, RN, RNC-OB, Florida Hospital, Orlando, FL Brigit Zamora, RN, BSN, CPAN, CAPA, Florida Hospital Orlando, Orlando, FL Keywords milk depot donor human milk milk bank




Giordano, J. et al.


A Breastfeeding Education Initiative for Registered Nurses Outside the Obstetric Unit: Emergency Department and Medical-Surgical Nurses Learn to be Baby-Friendly Angel Cook, MSN, RNC-OB, c-EFM, Mercy Health- West Hospital, Cincinnati, OH Robin L. Hirth, MEd, BS, IBCLC, Mercy Health- West Hospital, Cincinnati, OH Keywords RN education breastfeeding nonmaternity hospital units


Purpose for the Program he most recent statistics available from the Centers for Disease Control and Prevention indicate that 77% of mothers initiated breastfeeding in the year 2009 in the United States. In 2012, the American Academy of Pediatrics recommended breastfeeding for 1 year or longer as mutually desired by mother and infant. Consequently, we have increased the length of time when a breastfeeding woman may experience a hospitalization related or unrelated to her childbirth or lactation status. During hospital care, mothers may be needlessly instructed to pump and dump their breast milk due to lack of evidence-based practice. The purpose of the program was to close the education gap for registered nurses (RNs) who may care for a breastfeeding patient on a nonmaternity unit.

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The results of a needs assessment indicated that the most common medical needs of breastfeeding mothers receiving care in the emergency department and medical/surgical units of four Midwestern Mercy Health Hospitals included conditions unrelated to childbirth, such as injuries, gall bladder, asthma, and ear infections; conditions related to childbirth, such as postpartum hypertension, uterine infection, cesarean delivery incision complications, spinal headaches, deep vein thrombosis, pulmonary embolism, and postpartum hemor-

rhage; and conditions related to lactation, such as engorgement, plugged ducts, mastitis, abscess, and fungal infection. Our program had the added challenge of providing education in the midst of closing two hospitals to move to a new hospital, adding maternity services for the first time, and implementing Baby Friendly Hospital Initiative guidelines. Proposed Change To provide breastfeeding education to all RNs in the emergency department and medical/surgical units. Implementation, Outcomes, and Evaluation Implementation included providing a 60-minute PowerPoint lecture during 13 inservices over a 1-month period. The lecture introduced breastfeeding-related policy, equipment, medication safety, and resources. Outcomes and evaluation included short- and long-term data. Short-term data include evaluation collected immediately postlecture. Long-term data include the number and type of consultations that RNs who were caring for breastfeeding patients requested from lactation or obstetric providers. Implications for Nursing Practice Could your hospital benefit from a program targeted to meet these needs?

Cultivating Better Outcomes for Mothers and Newborns Through Integrated Best Practice Models Jennifer Giordano, RN, BSN, IBCLC, Catholic Health Services at St. Catherine of Siena Medical Center, Smithtown, NY Neila Hernandez, MSN, RN, WHNP-BC, Catholic Health Services at St. Catherine of Siena Medical Center, Smithtown, NY Mary Ann Gulutz, MS, RN-C, Catholic Health Services at St. Catherine of Siena Medical Center, Smithtown, NY

Purpose for the Program he purpose of the program was to improve mother and newborn outcomes on multiple key measures through the integration of multiple best practice models into a community hospital setting.

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Proposed Change The proposed change involved identification and cultivation of nurse-led teams to successfully deploy and manage the integration of these practice models into the existing culture and practice setting. Implementation involved a well-staged sequential 4-year roll-out of five integrated best practice models. The setting was Catholic Health Ser-


vices at St. Catherine of Siena Medical Center community hospital. Implementation, Outcomes, and Evaluation The outcomes of interest were measures of quality and perception of transition care during delivery, frequency counts of continuous skin-to-skin contact, frequency of rooming-in, quality and perception of nonseparation of mother and infant from delivery to discharge, and frequency of breastfeeding exclusivity. Formative and summative evaluation of the program’s structure and processes, and patient and staff outcomes were required to ensure continual attention to the effect of the implementation and subsequent revision of methods.

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Quantitative and qualitative outcomes of multiple sources were examined for triangulation of evidence to drive program success. We modified our model of practice from traditional postpartum/nursery care to a couplet care model promoting nonseparation of mother and infant from delivery to discharge. With these programmatic changes in our culture of care came staff resistance, which warranted education, support, and reward. Staff was provided with ongoing education, including didactic training, staff-driven cross-training, modeling of care, shared governance, competencies, and new evaluation tools to foster accountability. Policies were updated to support these changes. The maternity education line was increased from part-time to full-time and the lactation consultant staff line became an education position.

Implications for Nursing Practice We discovered that a major change in programmatic culture of care takes a great deal of education, time, and patience. Budgeting is also a consideration. It is better to make small changes that include staff for buy-in and to reward each victory. We identified the need to slow our change process by taking baby steps and implementing in phases. Collecting data and surveys are excellent tools to promote staff accountability and ensure that patients’ needs are being met. A dedicated transition nurse to initiate biological harmony and adjustment to parenthood promotes best care and practice. Finally, a team approach, which includes staff and management, is essential to support success.

Barbara Neuhaus, MSN, RN, WHNP, Catholic Health Services at St. Catherine of Siena Medical Center, Smithtown, NY Maura Anders, RN-C, Catholic Health Services at St. Catherine of Siena Medical Center, Smithtown, NY Kristin Thayer, RN-C, BSN, Catholic Health Services at St. Catherine of Siena Medical Center, Smithtown, NY Ann Robbins, RN-C, BSN, Catholic Health Services at St. Catherine of Siena Medical Center, Smithtown, NY Vicki B. Shulman, RN, BSN, CES, Catholic Health Services at St. Catherine of Siena Medical Center, Smithtown, NY Connie Kacinski, RN, Catholic Health Services at St. Catherine of Siena Medical Center, Smithtown, NY Denise Gebhart, RN, Catholic Health Services at St. Catherine of Siena Medical Center, Smithtown, NY Patricia Eckardt, PhD, BS, RN, Catholic Health Services at St. Catherine of Siena Medical Center, Smithtown, NY Keywords programmatic changes transition care skin-to-skin contact breastfeeding exclusivity nonseparation rooming-in


Baby It’s Cold Outside Purpose for the Program vidence shows that cold stress and hypothermia contribute to neonatal morbidity and mortality. Newborn infants are at risk of heat loss, and current practices after their birth contribute to cold stress and hypothermia. In traditional practice, the operating room temperatures are established at the comfort level of the operating room staff, who are clothed in layers of scrubs and sterile gowns.

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Infants who were transported to the mother–baby unit or the neonatal intensive care unit (NICU) were wrapped in blankets with no additional heat source. The initial bath was frequently performed within 30 minutes of birth. As part of our Perinatal Safety Team, we initiated a project team to look at our practices and outcomes and implement initiatives to decrease cold stress and hypothermia in our newborn population.

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352

Pamela G. Kennard, BSN, RNC, Lakeland Regional Medical Center, Lakeland, FL Shannon M. Hartwig, RNC, MSN, BSN, Lakeland Regional Medical Center, Lakeland, FL


Asher, S., Williams, K., and Richardson, R.


Keywords neonatal hypothermia cold stress


Proposed Change Strategies to reduce cold stress and hypothermia were examined and a plan was developed. Medical staff education, including recommendations from professional organizations and journals, was provided at obstetric and pediatric medical staff department meetings. Nursing education was provided via frequent presentations on all shifts in the labor and delivery unit, NICU, and the mother– baby unit. The team collaborated with the engineering department to set and control temperatures in the operating room and in the NICU. Thermal gel mattresses and polyethylene wrap were obtained and implemented. Infants were transported to the NICU via a prewarmed transporter. A skin-to-skin policy was developed and implemented. A policy was developed to include delaying of the first bath until the newborn’s temperature was within normal range for a minimum of two sets of vital signs (30 minutes apart) and no sooner than 1 to 2 hours of life.

Implementation, Outcomes, and Evaluation Before implementation of our program, our study revealed that 17% of infants were cold stressed and 3% were hypothermic. Following implementation, the average admission temperature was 36.9°C (36.2–37.6°C) at 30 minutes of life and 36.9°C (36.4–37.7°C) at 60 minutes of life. The number of cold-stressed newborns was reduced to 5% at 30 minutes of life, and 3% were cold stressed at 60 minutes. No infants were hypothermic.

Implications for Nursing practice Multidisciplinary team work and implementation of evidence-based strategies can be effective in reducing incidents of neonatal hypothermia and cold stress. Additional studies would be prudent to determine further initiatives to prevent hypothermia and associated morbidities in neonates.

Nondiscriminatory, Multidisciplinary Care for Neonatal Abstinence Syndrome Sheila Asher, RN, Mercy Health-Fairfield Hospital, Cincinnati, OH Kecia Williams, BSN, RN, Mercy Health-Fairfield Hospital, Cincinnati, OH Rela Richardson, RNC-MNN, Mercy Health-Fairfield Hospital, Cincinnati, OH Keywords nondiscriminatory care multidisciplinary collaboration neonatal abstinence syndrome maternal drug use Finnegan Scoring Tool


Purpose for the Program he State of Ohio has recommended that all labor and delivery hospitals drug test women in labor to better detect infants with neonatal abstinence syndrome (NAS). A multidisciplinary approach to caring for infants diagnosed with NAS is essential to optimizing outcomes. An innovative education session was developed for all disciplines to promote nondiscriminatory evidencebased care.

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Proposed Change Based upon the recommendations from the State of Ohio, needs assessment of the perinatal staff, and an increase in maternal drug and substance abuse in the Greater Cincinnati Area, a community-based Level II Family Birth Center examined and developed an innovative multidisciplinary education program about the plan of care for infants diagnosed with NAS that provided nondiscriminatory family-centered care and improved inter-rater reliability with the Finnegan Scoring Tool. Implementation, Outcomes, and Evaluation In response to the increase in maternal drug abuse, the NAS education program was implemented in collaboration with nurses, physicians,


social workers, pharmacists, and spiritual care. Together the team created a multidisciplinary education program that covered incidence and general discussion of NAS; identification of fetal, maternal, and neonatal effects of commonly abused perinatal drug exposure; the role of diversity and compassionate care in relation to perinatal drug exposure; social service involvement in relation to perinatal maternal drug abuse and NAS; types of drug-testing techniques, pharmacologic protocol, and treatment for NAS; nonpharmacologic treatment for newborns with NAS; and scoring the signs and symptoms of NAS using the Finnegan Scoring Tool. As a result, the NAS education program fostered interdisciplinary communication, identified standards of care, and promoted nondiscriminatory care. Implications for Nursing Practice With the application of the content covered in the NAS education program, nurses are able to facilitate nondiscriminatory family-centered care with an infant diagnosed with NAS. With the increase of NAS at the Level II facility, the education program improved delivery of care, enhanced multidisciplinary communication, and improved inter-rater reliability for the Finnegan Scoring Tool.

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Small Tests of Change Solve the Big Problem of Critically Low Temperatures at Birth Purpose for the Program o investigate the etiology of low newborn temperatures at birth. A critical aspect of newborn care is thermoregulation of the newborn environment to ensure safety and facilitate growth and optimal outcomes.

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Proposed Change In 2012, a clinical nurse specialist (CNS) and maternity center manager (CM) engaged nurses in a test of change approach to improve newborn thermoregulation based on observed, low, birth temperatures (LT). Organizational nursing professional practice model (PPM) provided structures and processes within the work environment to enable and ensure excellence in care delivery. Within the PPM, unit-based, nurse-led, and nurse-driven professional practice councils (PPC) sought care delivery innovations in a rapidly changing environment. An iterative approach of small tests of change was systematically used to evaluate outcomes and gain salience among nurses. Implementation, Outcomes, and Evaluation Baseline data for temperatures at birth, defined as within 30 minutes of delivery, were collected for all cesarean deliveries during a 2-week period in 2012. Newborns had LT (ࣘ36.1°C) at birth in 15% of cases. The first test of change was to standardize operating room (OR)-temperature monitoring during every cesarean delivery to ensure OR temperatures of 71 to 73°F. After 3 months of monitored compliance, newborn temperatures were reaudited. LT at birth after a cesarean deliv-

ery increased to 22%. Concurrently, temperatures of newborns who were delivered vaginally were collected to clarify whether the OR temperature was the problem. The rate of LT for newborns in this group was 6.2% at birth. Discussion with colleagues and internal/external consultants led the team to question whether disposable thermometers used with newborns might produce false low temperatures. A nurse measured newborn temperatures with disposable and nondisposable (calibrated by clinical engineering) thermometers over a 2-week period. There were numerous incidences of lower temperature readings using disposable thermometers. PPC members reviewed the thermometer discrepancies and subsequently eliminated all disposable thermometers. Data collected 4 months later did not reveal any cases of LT at birth for newborns who were delivered vaginally or by cesarean.

Kerista Hansell, MSN, RN, CNS-BC, C-EFM, IBCLC, Indiana University Health, Indianapolis, IN Betsy Bigler, MSN, BS, RNC-OB, Indiana University Health, Indianapolis, IN Keywords practice improvement newborn test of change


Implications for Nursing Practice Direct care nurses were engaged in the audit and feedback process and in discovery of each small test of change; this created a culture of inquiry and performance improvement. Removal of disposable thermometers from the units saved $1,500 annually, which allowed the unit to purchase calibrated thermometers for all patient rooms. There is also the potential for prevention of neonatal intensive care unit (NICU) admissions for unstable temperatures, which keeps the newborn and mother together. The next step is to reinforce standards for temperature frequency to regulate newborn temperatures during the transition.

Family-Centered Cesarean Birth Offers Appropriate Thermoregulation in Term Neonates Purpose for the Program vidence-based practice is a cornerstone of safe effective care. Evidence indicates skinto-skin contact is beneficial in terms of parent– child bonding, physiological regulation, stimulation of milk production, and neonate rooting. Exclusive breastfeeding is a best practice; its success increases when skin-to-skin contact is initiated within the first hour of life. Although this practice has been adopted in many delivery rooms, it is less frequently used in the operating room. We sought to implement early

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skin-to-skin contact for mothers after cesarean Lacey Burke, BSN, RN, Monroe Carell Jr. Children’s births. Proposed Change Practices following a cesarean birth included taking neonates to the nursery for assessment, medications, and bathing. Thus, neonates were separated from their mothers for an hour or more immediately postbirth. Often, neonates were not reunited with their mothers until they were in the recovery room or postpartum. To facilitate familycentered cesarean births, neonates stay in the operating room with their mothers while surgery

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352

Hospital at Vanderbilt, Nashville, TN

Anna W. Morad, MD, FAAP, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN



Henderson, C. J.


Keywords cesarean births skin-to-skin contact thermoregulation


is completed. The neonate is placed skin-to-skin with the mother or support person shortly after birth. If actively rooting, breastfeeding is initiated. Bathing is delayed, to allow adequate time for neonates to transition to extrauterine life. Implementation, Outcomes, and Evaluation To implement family-center cesarean births, a nurse was hired to initiate skin-to-skin contact in the operating room. Obstacles were encountered during implementation. Preterm neonates, those with life-threatening anomalies, and neonates born to mothers with infectious sexually transmitted diseases (STDs) were not candidates for family-centered cesarean births. Surgeons had to become comfortable with the window drape, where mothers could see into the surgical field as their neonates were delivered. Anesthesiologists had to become comfortable with sharing space at the head of the table so the nurse would have access to the infant. Stakeholders were offered an explanation of benefits of family-centered ce-

sarean birth, including improved patient satisfaction. After 1 month of discussion, the stakeholders were agreeable and eager to implement the changes. Safety was measured through rectal temperature obtained shortly after birth, before skin-to-skin contact, and immediately after skin-to-skin contact. Data from 47 neonates revealed none had starting temperatures less than normal, and 5 had starting temperatures higher than normal limits. Following skin-to-skin contact, temperatures were within normal limits. Following skin-to-skin contact, 2 remained stable, 3 had increased temperature, and 42 had decreased temperature. The average change in temperature from before to after skin-toskin contact was less than 1%. These data indicate that skin-to-skin contact is safe for neonates. Implications for Nursing practice Family-centered cesarean birth offers safe care that may enhance bonding and breastfeeding.

Circumcision 6 “S” Comfort Care Connie J. Henderson, BSN, Purpose for the Program RN, RNC-MNN, Bethesda t is well documented that infants experience North Hospital, Cincinnati, OH Keywords infant procedural pain pain management


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pain when undergoing circumcision. Infants’ nerve pathways are developed enough to allow them to feel pain but not mature enough to interpret noxious stimuli and react. Pain scales help caregivers infer what the infant may be experiencing but most still feel the newborn has some degree of discomfort. Efforts have been made to minimize the pain felt during circumcision by using injected or topical lidocaine anesthetic and allowing the infant to suck sucrose on a pacifier or gloved finger during the procedure. The amount of wait time from injection to circumcision many times is at the discretion of the physician. The purpose of this project was to develop a means to decrease the discomfort of circumcision. A review of the literature revealed additional interventions nurses could do to improve the care given to infants during the procedure.

Proposed Change It seems that combining several modalities of comfort, thus using the sensory saturation theory, is the best practice to address procedural pain in the term infant. Merging current care practices with a few additional measures found in the literature resulted in the Circumcision 6 “S” Comfort Care program. The six measures were each given a word that begins with the letter “s.” A poster was


displayed in the circumcision area as a visual reminder of the steps and the order of implementation for maximum benefit. Implementation, Outcomes, and Evaluation The six “S” measures include the following: (1) Swaddle, facilitated tucking promotes body selfregulation and assists in modulating physical response, (2) Shade, the infant’s cap is used to shade his/her eyes from bright light, (3) Sucrose produces analgesia through endogenous opioid and nonopioid pathways, (4) Sucking, synergistic effect with sucrose provides soothing, (5) Syringe, dorsal nerve penile block or ring block blunt behavioral and physiological pain response, and (6) Stop, a timer is set for 3 to 5 minutes wait time so all participants are aware of the elapsed time after a lidocaine injection. At the conclusion of the project, 58% of the circumcised infants displayed crying during the procedure, after, or both. This compares to 68% of the infants crying before initiating the program. The 30-minute postprocedure, mean Newborn Infant Pain Scale (NIPS) score went from 1.3 before the project to 0.85 after the project. Implications for Nursing Practice Now nurses who assist with circumcisions feel they play a pivotal role in consistently helping infants manage pain.

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Does Breastfeeding Education of Nurses Increase Exclusive Breastfeeding Rates in a Large Academic Medical Institution? Purpose for the Program o determine if increased breastfeeding education among 500 perinatal nursing staff using the Baby Friendly Health Initiative (BFHI) requirements is effective for increasing exclusive breastfeeding rates.

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Proposed Change A large academic women’s medical center that delivers 12,500 infants per year entered into the Baby Friendly Health Initiative in January 2011 and initiated breastfeeding nursing education in April 2013. This hospital is the largest hospital to date to enter the Baby Friendly pathway. Before entering into the BFHI, there were very few nursing breastfeeding education opportunities offered. Implementation, Outcomes, and Evaluation In April 2013, 20 hours of nursing breastfeeding education were initiated as mandated by the BFHI. A multidisciplinary team of advanced practice nurses, managers, lactation consultants, and education coordinators from the neonatal intensive care unit, labor and delivery unit, and mother– baby unit came together to plan for this initiative. The perinatal service line used a variety of methods to meet the 20-hour requirement of education needs. Fifteen of these hours involved a didactic portion of education. Programs chosen to meet the didactic requirements were one of the following: Certified Lactation Counselor course, Certi-

fied Breastfeeding Counselor course, The University of Virginia Breastfeeding Education course, or the Breastfeeding Advisor course. Five of the hours of training were required for hands-on skilled nursing breastfeeding education. The multidisciplinary team developed a breastfeeding educational skills workshop, electronic learning module, and a hands-on bedside learning opportunity to meet these requirements.

Gina Siggia, MSN, WHNP-BC, FNP-BC, C-EFM, Northwestern Memorial Hospital, Chicago, IL Susie Rosenberg, MS, CNS-BC, Northwestern Memorial Hospital, Chicago, IL Keywords

Following implementation of a comprehensive ed- Baby Friendly Health Initiative ucational program, the rates of initiation of exclu- nursing breastfeeding education sive breastfeeding have trended upward. Before exclusive breastfeeding nursing breastfeeding education from December 2012 to March 2013, the average exclusive breastfeeding rate was 38.55%. After completion of nurs- Newborn Care ing breastfeeding education, from April 2013 to Poster Presentation July 2013, the average exclusive breastfeeding rate was 53.5%. By providing a comprehensive breastfeeding education plan to perinatal nursing staff, we have demonstrated that the BFHI is a valid breastfeeding educational program and leads to increased exclusive breastfeeding rates. Implications for Nursing Practice A multidisciplinary team approach is an effective way to develop a plan to support breastfeeding nursing education based on the principles of the BFHI and effectively change breastfeeding culture and increase exclusive breastfeeding rates in a large academic medical setting.

Sustaining Baby Friendly Excellence With Innovative Strategies Purpose for the Program he process to obtain Baby Friendly status began in 2009, and designation was achieved in 2011. It was recognized that nursing practices could be challenged and improved beyond the Ten Steps. The traditional methods of education were becoming fiscally demanding and lacked a measurement for effectiveness. A review of the literature provided examples of practices that had been associated with improved exclusive breastfeeding rates. The literature did not provide us with a fiscally responsible and effective education mechanism. The measurement of success chosen to evaluate the proposed changes was The Joint

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Commission (TJC) Perinatal Core Measure (PC- Kim Rehling-Anthony, MSN, 05) and the quality improvement process provided RN, WHNP, IBCLC, C-EFM, University of Colorado by Baby Friendly. Health,Medical Center of the Rockies, Loveland, CO

Proposed Change The shared governance council reviewed the literature and voted to concentrate on two practice changes: immediate, uninterrupted skin-toskin contact after vaginal birth and delaying the bath for a minimum of 12 hours. Leadership also determined that education needed to be engaging. After evaluating options, a game show question and answer session was created that was easily completed at staff meetings.

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352

Keywords PC-05 Baby Friendly breastfeeding




Rehling-Anthony, K.


Implementation, Outcomes, and Evaluation A gap analysis was conducted with stakeholders to determine barriers to the proposed practice changes. Some barriers identified were the need to document birth weight immediately after birth, nursing assessments, administering medications at the warmer, bathing that was performed based on a nursing checklist, and a lack of patient knowledge. A variety of strategies was used to address each barrier. Preimplementation, the exclusive breastfeeding rate was 64%. The rate has steadily increased to 90% as compared with 78%, which was the top 10% in the TJC core measure hospitals in 2013. The second initiative of educating staff was implemented with the Baby Friendly quality improvement (QI) process. Staff was provided education

in a nontraditional game show fashion and then individually interviewed. The interview tool evaluated the staff knowledge of the Ten Steps as well as how the hospital integrated them into practice. A total of 80% of the staff were interviewed. One hundred percent of the interviewees were able to articulate appropriate answers to the entire tool. The results of patient rounding by leadership indicated that patients were receiving consistent messaging about breastfeeding. Implications for Nursing Practice Evaluating typical nursing practices may reveal opportunities to change work flow and processes to improve exclusive breastfeeding rates. Education can be completed by using a less-traditional modality and can be effective.

Implementing a Screening Program for Congenital Cardiac Defects in Newborns in a Community Hospital Setting Kathy LiVolsi, MHA, BSN, RNC, Stamford Hospital, Stamford, CT Donna S. Bowman, MSN, FNP-BC, RNC-OB, EFM-C, Stamford Hospital, Stamford, CT Keywords CCHD screening cardiac defects newborn screening


Purpose for the Program ongenital cardiac defects account for 24% of infant deaths due to birth defects. Approximately 4,800 infants born annually have one of seven critical congenital heart defects (CCHDs): hypoplastic left heart syndrome, pulmonary atresia, tetralogy of Fallot, total anomalous pulmonary venous return, transposition of the great arteries, tricuspid atresia, or truncus arteriosus. Infants born with one of these seven CCHDs are at high risk of death and disability if they are not diagnosed and treated in a timely manner. Pulse oximetry screening can be used to help detect infants who are asymptomatic before discharge from the newborn nursery.

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Proposed Change Although certain hospitals routinely screen all newborns using pulse oximetry screening, it is not currently mandated as part of newborn screenings in most states. As of January 1, 2013, the State of Connecticut requires that all babies be screened for CCHDs before discharge. Implementation, Outcomes, and Evaluation The nursing team presented the state mandate to our multiprofessional Perinatal Quality and Safety Committee and conducted an exhaustive literature review to ascertain necessary steps in developing and implementing a CCHD screening program. A CCHD screening policy was developed by nursing and approved by the nursing shared governance councils and physician leadership. Nurs-


ing leadership presented at the monthly business meetings for the obstetric and pediatric departments to educate them on the state mandate, the CCHD screening policy, parent education handouts, process flow for performing screenings, and documentation of screening results. Consensus was reached at the Pediatric Departmental Business Meeting for interventions related to a failed screening or a positive test result. Education and competency evaluation were completed with all nursing staff conducting the screenings and with staff caring for women in labor or postpartum patients so that the staff would have knowledge of the state mandate and screening process when caring for new parents. Screenings were conducted (beginning in December 2012) to work through process improvement issues before the mandatory implementation date. The documentation tool was tweaked and parents were notified of screening results by the nurse performing the screening. During the first month of implementation, a reconciliation process was done with nursing leadership before discharge to ensure there were no missed screenings. Closed chart audits were conducted monthly on every patient to ensure accurate testing. Eight months after the state mandate, 1,556 infants were screened of 1,556 eligible patients. Implications for Nursing Practice Nursing-led initiatives can be the driving force in the implementation of evidence-based practice.

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Designing an Innovative Nursing Care Delivery Model to Promote Continuity of Care Purpose for the Program o improve the continuity of care for the neonatal intensive care unit (NICU) patients and families by the development and implementation of a nursing care delivery model that addresses the complex NICU environment. Our aim was to demonstrate a 25% improvement in the continuity of care index (CCI) by the end of the summer 2012 pilot. The CCI is defined as the total number of nurses caring for an individual patient divided by length of stay (days) times two shifts per day. A decrease in CCI translates to improved consistency in nurse caregivers.

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Proposed Change The Safety Attitudes Questionnaire (SAQ) was used to assess nursing and medical staff attitudes toward interdisciplinary communication. Using data from the SAQ survey, our CCI taskforce developed a nursing model (team nursing) based on geographic pod microsystems so that a team of nurses would be responsible for staffing one pod. The staffing model was implemented in the summer of 2012 in one patient area (pod). The nursing team model emphasized consistency in patient assignments for nurses, nursing team huddles to enhance communication, and a daily goal sheet

to enhance nurse participation in interdisciplinary Carol Spruill, MSN, RN, CPHQ, NTMNC, Children’s team rounds. Implementation, Outcomes, and Evaluation First, we collected baseline data, including CCI and the prepilot nursing safety survey. Then, relevant literature was reviewed and analyzed and findings were shared with staff, physicians, and the leadership team. A volunteer team of nurses was recruited for the pilot. For our model, nursing staff was assigned as a team to one NICU pod. After a 6-month pilot period, postpilot CCI and safety survey results were collected. Results included a 30% increase in staff perception of communication and teamwork, a 13% decrease in the total number of RNs per infant per hospital stay, a 28% decrease in CCI in the pilot pod, and a 9% decrease in CCI in the nonpilot NICU pods.

Memorial Hermann Hospital, Houston, TX Ashley Heaton, RNC-NIC, Children’s Memorial Hermann Hospital, Houston, TX Keywords NICU continuity of care team nursing nursing care delivery model microsystem


Implications for Nursing Practice We used a validated culture survey to help us transform our culture and develop a patientcentric microsystem approach to care delivery. By creating a model of care that improves caregiver and family relationships and maximizes team collaboration, we expect that our care model will result in improved parent satisfaction and ultimately patient outcomes. In the future, we plan to measure those outcomes.

A Simple Change in Process Results in Significant Improvement in the Rate of First Feeding at Breast Purpose for the Program o increase the number of neonatal intensive care unit (NICU) newborns discharged on maternal breast milk (MBM). Pumping to establish and maintain a milk supply requires tremendous dedication. Many NICU mothers pump for weeks or even months before their infants are physically and developmentally ready to attempt oral feedings. In 2009 to 2011 at Winnie Palmer Hospital for Women & Babies, 85% of NICU mothers initiated breast pumping and were still supplying MBM for their infants on day 7 of life. However, by the newborns’ discharge, this rate fell to less than 40%. The NICU’s Breast is Best Committee implemented a First Feeding at Breast initiative as a nursing measure to improve rates of newborns who received MBM at discharge.

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Proposed Change As a department, the NICU prioritizes the first oral feeding to be a breast feeding for all NICU infants whose mothers desire to breastfeed. NICU policy states a nipple feeding can be a bottle nipple or a breast feeding. Individual nursing care practice ultimately determines route of initial oral feeding.

Cindy Nichols, BSN, RN, IBCLC, Orlando Health,Winnie Palmer Hospital for Women & Babies, Orlando, FL

Keywords NICU breast milk breastfeeding Implementation, Outcomes, and Evaluation discharge Mothers who were pumping were asked if they mother

would like for their infants’ first oral feeding to be a breast feeding. If the mother agreed (and most did), then a small sign was attached to the crib indicating the mother’s desire to breastfeed for her newborn’s first nipple feeding. This visual cue reminded the mother of her ultimate goal and encouraged staff to support her efforts.

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352




Nichols, C.


When this initiative began, the rate of first feeding at breast was zero and the portion of newborns who received MBM at discharge was approximately 40%. Within 6 months of implementation, the rate of first feed at breast was up to 92% and within this cohort, 92% were discharged on MBM. In contrast, during this same period, the rate of MBM at discharge for newborns whose first oral feeding was not a breast feed was 40% before the initiative and 36% after.


Implications for Nursing Practice This nurse-driven initiative essentially costs nothing other than interest and a willingness to alter individual practice routines. The collaboration between the nurse and mother regarding a first oral feeding also highlighted the mother’s expanding role in the daily care of her infant. The NICU experience by its very nature robs parents of so many facets of parenting, at least for a time. The First Feeding at Breast initiative returned one big first to the mother.

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Professional Issues

Raising the Bar for Nursing Excellence: Exploring an Innovative Approach to Labor and Delivery Charge Nurse Selection, Orientation, and Evaluation

Purpose for the Program harge nurses are frequently selected and placed into leadership positions without adequate educational preparation, which leaves them without the skills needed to function to their fullest potential. As a result, this organization set out to expand the current charge nurse selection, orientation, and evaluation processes, and to develop Sherri D. Strong, MSN, a more robust plan to meet the needs of the unit RN-BC, C-OB, C-EFM, Mount and organization. We felt this would allow us to Carmel Health System, reach the level of excellence expected of a tertiary Westerville, OH center and to tap into the abundant leadership poKeywords tential of the newly appointed charge nurses.

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charge nurse leadership orientation competency

Poster Presentation

Proposed Change On a daily basis, charge nurses provide the minute-to-minute leadership at the unit level and are typically selected based on their skill and knowledge or sometimes simply by default. We felt we could do better. The new selection process looks to those nurses with a desire to advance their level of leadership and includes a thorough application process to identify the key elements needed to succeed in the role. It includes a self-evaluation of leadership skills and two peer-reviews that ultimately play a key factor in the decision-making process. We developed a plan to provide early support in their orientation period and to continue to expand on those

skills over time. It included a thorough orientation packet of essential resources and the development of a charge nurse workshop that focused on leadership skills necessary to be an effective change agent on the unit. We also developed a competency assessment for ongoing evaluation that builds on previously learned skills and identifies areas of opportunities for professional growth in the role. Implementation, Outcomes, and Evaluation Historically, the selected nurse would shadow an experienced charge nurse for two to three shifts, which would complete their orientation to the role. We know through evidence in the literature that charge nurses need broader skills to influence organizational outcomes, foster teamwork, and promote nursing excellence. The new processes allow for building a better foundation of understanding of the new role, making the group of charge nurses more cohesive in their management styles, and creating a feeling of stability and support in the unit. Implications for Nursing Practice Through this new comprehensive program, the charge nurse role will be preserved, strengthened, and validated, which gives them the skills to become successful in their new positions.

Putting the Pieces Together: It Takes a Whole Village to Raise a Novice Nurse Jennifer P. Boyd, RNC, BSN, Baylor All Saints Hospital, Grandview, TX Keywords novice engagement accountability internship collaboration

Professional Issues Poster Presentation

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Purpose for the Program eing a part of the leadership team, I have discovered that our new nurses completed the internship program and learned the basic skills to care for patients in labor but did not always know why they were doing what they were doing. The new nurses were going through the motions but were not always seeing the big picture and putting all the pieces together. The more experienced staff and physicians were not working to help educate and engage our new nurses, nor were these staff and physicians always engaged or accountable for their own practice.

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Proposed Change When staff are provided the knowledge to care for their patients and are engaged and accountable, they provide safer patient care with less errors and an increased patient focus. Better collaboration between the nurses and physicians and an internship with qualified clinical coaches will allow them to take ownership of their practice and provide patient-centered care. This will give the nurses the desire to continue to learn and advance in their career.

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352


Lutwak, R., Conte, T. F., and Chapman, C.


Implementation, Outcomes, and Evaluation The process began by having the staff complete a short survey, including their perception of teamwork, engagement, accountability, education, patient focus and safety, and collaboration among the nurses and physicians. We then tallied the results, which yielded engagement, registered nurse (RN) to medical doctor (MD) collaboration, patient safety, and our education/internship with the lowest scores. We will now have teams work on these areas of focus to include physician attendance at staff meetings, classes for clinical coaches, policy education, weekly educational inservices, and much

more. At the end of our project, we will resurvey the staff to see if we made improvement in these areas. We also will track our staff reporting system to determine if we had decreased errors. Implications for Nursing Practice With today’s changing health care system, it will be imperative to provide nurses with the necessary education and support to provide safe patient care. By starting with your new graduates, the knowledge, engagement, and accountability of your staff will start to increase and in turn produce better patient outcomes.

Unlocking the Potential of AWHONN’s Perinatal Orientation and Education Program Roselle Lutwak, MS, RNC-OB, Purpose for the Program C-EFM, Orange Regional his program demonstrates the application of Medical Center, Middletown, adult learning principles and novice to exNY

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pert concepts in developing a strategic plan for the implementation of the Association of

Theresa Fay Conte, MSN, RNC, NE-BC, Orange Regional Women’s Health, Obstetric and Neonatal Nurses’ (AWHONN) Perinatal Orientation and Education Medical Center, Middletown, Program (POEP). The POEP is a significant finanNY Cynthia Chapman, MSN, RNC-OB, NE-BC, C-EFM, Orange Regional Medical Center, Middletown, NY Keywords orientation perinatal staff development team training shared mental model


cial investment and is so robust and flexible that it can potentially overwhelm even seasoned educators and administrators. Because we found little guidance or direction, we wish to share our planned strategy as a model that other POEP users might adapt to their unique facilities. Proposed Change To use the POEP as our primary staff development vehicle. Modules will supplement the current orientation program, which is short on didactic content and highly dependent on clinical preceptors. These preceptors and other experienced staff will use POEP modules to update their knowledge base, earn contact hours, and enhance their expertise as preceptors and mentors. We propose meeting the varied needs of learners at different levels through the use of multiple educational modalities. We also anticipate development of a shared mental model as our cross-trained nurses are exposed to the same standardized, evidencebased content. Implementation, Outcomes, and Evaluation After receiving and reviewing the POEP, our leadership team spent months purposefully develop-


ing a multifaceted implementation plan. We identified congruent and divergent learner needs, decided which groups should be prioritized for contact hours, and examined feasible, cost-effective teaching strategies preferred by adult learners. Our plan includes formal module presentations by content experts, online learning, self-study packets, and small study groups. Some POEP content will be assigned based on identified departmental learning needs, but most learners will exercise autonomy in choosing modules and learning modalities. POEP content also will be used by our shared governance council to guide policy development and educate staff about evidence-based practice changes. There is already excitement on the part of the staff who appreciate the investment made in their ongoing professional development. We plan to share the results of our implementation strategy by reporting attendance at live and virtual sessions, number of contact hours earned, certifications achieved or maintained, and participant feedback and recommendations.

Implications for Nursing Practice Leadership sees the POEP as a team training modality. As we work toward Magnet designation, we believe it will support nursing staff in implementing the standardized, evidence-based nursing care and will improve teamwork, communication, critical thinking, and optimal patient outcomes.

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Leveraging Technology to Help Manage Oxytocin/Tachysystole, Hyperbilirubinemia, and Postpartum Hemorrhage Purpose for the Program nnovative technologies are rapidly flooding many health care institutions in response to the government mandate for meaningful use of electronic health records (EHR). Technology that is introduced at the bedside must be innovative to improve quality, safety, and patient outcomes. Technology was leveraged to assist clinical management of oxytocin/tachysystole, hyperbilirubinemia, and postpartum hemorrhage. The challenge of managing these complex health issues was aided through the clinical decision support system (CDSS) to guide the care of patients who receive oxytocin, neonatal hyperbilirubinemia management, and postpartum hemorrhage risk assessment.

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Proposed Change Innovate and optimize the use of technology to assist clinicians in providing quality care to the obstetric and neonatal patient population. Implementation, Outcomes, and Evaluation Interdisciplinary collaboration was the key to success in the development and implementation of our CDSS. Members of the perinatal safety committee worked with clinical informaticians and information technology (IT) to present intuitive and critical information to clinicians. Managing a patient on oxytocin required standardized electronic orders with detailed information on titration and discontinuation. Creation of an electronic oxytocin checklist and reference link to the algorithm for managing tachysystole was a critical component

to ensure seamless access to the best practices. This work was recognized by The Joint Commission (TJC) and is being submitted to TJC leading practice library.

Krissy A. Quintana, MSN, BS, RN-BC, C-EFM, Lakeland Regional Medical Center, Lakeland, FL

Management of neonatal hyperbilirubin is complex. In response to the complexity, rules were created in the EHR based on best practices. The system automatically fires orders based on clinical documentation of major and minor risk factors. The system assists the clinician by providing that decision support.

Shannon M. Hartwig, RNC, MSN, BSN, Lakeland Regional Medical Center, Lakeland, FL

Keywords technology hyperbilirubinemia oxytocin tachysystole Early identification and treatment of postpartum postpartum hemorrhage

hemorrhage is critical. Leveraging technology to assist clinicians is also critical. Our CDSS identifies a baseline assessment of each patient admitted to the labor unit. The system continues to assess ongoing risk factors and identifies each patient as low risk, medium risk, or high risk for hemorrhage based on rules and nursing documentation. The nurse is notified when the CDSS identifies a patient who is at risk. Clinicians will employ a built-in blood loss calculator, which incorporates baseline dry weights of routine items and enables accurate estimation of blood loss and early detection of a patient with postpartum hemorrhage.


Implications for Nursing Practice Leveraging technology to assist clinicians must be a commitment by nursing. Nursing is complex and the tools that we have designed provide support for nurses and serve our obstetric and neonatal patient population.

System-Wide Skills Fair Among Three Hospitals in a Health System Purpose for the Program he obstetric and neonatal divisions of Bon Secours Richmond Health System consist of three hospitals in different community settings. Previously, each facility has validated yearly competencies in the individual obstetric and neonatal areas independent of each other. Standardized policies and procedures have not been shared across the facilities, though physicians have been shared among the facilities. The educators from the obstetric and neonatal areas believe in pro-

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moting systemness throughout the facilities and Erin T. Robson, MSN/Ed, moving away from the adage of that’s how we’ve RNC-NIC, Bon Secours St. Francis Medical Center, always done it at our hospital. Midlothian, VA

Proposed Change The system-wide skills fair will incorporate the methodologies of team training, knowledge expansion, professional communication techniques through simulation, and teach back opportunities. By promoting a system-wide level of education in the obstetric and neonatal areas, patients who

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352

Deanna Daniel, RNC-OB, BSN, C-EFM, Bon Secours Memorial Regional Medical Center, Mechanicsville, VA


Aguilera, S. M. and Rodriguez-Henderson, R.


Kasondra Lynn Miller, RNC-OB, C-EFM, Bon Secours St. Mary’s Hospital, Richmond, VA Keywords skill fair teach back competency assessment simulation


enter any hospital in the health system will benefit from the same level of expertise and knowledge from the nursing staff. Implementation, Outcomes, and Evaluation The concept of the system-wide skills fair was derived 18 months ago by the educators. To ensure success of the program, the educator group determined a slow introduction to simulation, and staff networking was prudent. The original skills assessment took place over an 8-month period. The labor and delivery unit nursing staff from the three facilities were included. Simulation training and skills validation took place 1 day per month in 4-hour sessions. Nursing staff from the units were introduced to each other and had the ability to discuss practice issues at each facility. Open discussion around the practice issues was en-

couraged and alliances were formed. Evaluations of the simulation education performed with the smaller groups were positive and the results indicated a request for different scenarios to be introduced. The system-wide skills fair will incorporate different simulation scenarios and an opportunity for teach back validation. Staff will be scheduled for the time spent at skills fair to promote the effectiveness of learning in smaller groups. Implications for Nursing Practice Nurse leaders from the different units in the three facilities will present best practices to the participants. Teach back opportunities will be performed on skills considered to be low volume and high risk in the obstetric and neonatal areas. The educator group feels that best practices should be promoted regardless of geographic location.

A New Role in Nursing: Unit-Based Manager of Patient Safety and Quality Susan M. Aguilera, MSN, ARNP-BC, Baptist Hospital of Miami, Miami, FL Rosie Rodriguez-Henderson, MSN, Baptist Hospital of Miami, Miami, FL Keywords patient safety process improvement patient outcomes


Purpose for the Program o introduce the role of Patient Safety and Quality Program Manager to the community. In today’s health care environment, quality care is at the forefront for health care professionals, regulatory agencies, accrediting bodies, patients, and families. This person in this new role assumes accountability for facilitating performance improvement and safety initiatives throughout designated areas using evidence-based practice, evaluation of core measures, and continuous accreditation readiness. Our simulation staff, clinical educators, and patient outcome facilitators (POFs) work together to achieve best outcomes. Our team is unit based.

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Proposed Change To implement the role of program manager in other institutions to improve their culture of safety and quality. Each program manager has a team that collaborates to improve processes and achieve best outcomes. The team consists of clinical educators and POFs for each specialty area. The team works together by combining individuals who can facilitate, educate, monitor, and assist with safety and quality initiatives in synergy. The clinical educators and POFs work together to educate staff on new and ongoing measures that affect patient outcomes and drive initiatives for their areas.


Currently three program managers are in place at our hospital. The areas that benefit from this type of specialty are pediatrics, obstetric/women’s services, critical care, pulmonary and step-down, and dialysis. This unique team works alongside the direct patient care health care to ensure daily compliance with clinical improvement initiatives. Implementation, Outcomes, and Evaluation The Safety and Performance Improvement team collaborates with the health care team, leadership, and key stakeholders to improve care. Together we work in synergy to collect, measure, and improve safety and quality indicators. We anticipate that with this close collaboration, we can continuously monitor for opportunities for improvement. Communicating any initiative to frontline staff is a challenge in many organizations. This unique team structure provides consistent access to individuals who focus on clinical improvements and can support the health care team directly at the individual unit level. Implications for Nursing Practice Improvement of patient safety and quality outcomes through continual process evaluation, evidence-based improvements, and measurement of outcomes.

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Parents Supporting Parents: Implementing a Peer Parent Program for Perinatal Loss Purpose for the Program he purpose of this poster presentation is to review and evaluate a peer parent program for perinatal bereavement based at a mid-sized hospital in the Midwest. Support following a pregnancy loss can be found in many different ways. Although peer support groups have been well documented over the past decade as an effective means of helping people get through difficult periods, peer support programs have been less formally utilized and evaluated.

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Proposed Change To provide an effective model from which other hospitals and support programs can develop peer support programs for patients who have experienced pregnancy loss and/or a neonatal demise. Focus groups (completed by peer parents) and brief program evaluation surveys (completed by the peer parents and the parents receiving support) were used to document participants’ perceptions of the program. Data analysis consisted of descriptive statistics and qualitative content analysis of demographic data and feedback received from the surveys and focus groups. Implementation, Outcomes, and Evaluation The program has been active since 2010. During this time, a total of 15 women and one man

have been trained as peer parents; 17 women have been assigned to peer parents. For the peer parents, the most rewarding aspect of being involved in the program was giving back by helping others with similar experiences; conversely, the most difficult part was related to logistics (e.g., handling unreciprocated contact). The parents who received support found it was helpful to talk with someone with a similar experience; however, others reported that it was difficult to accept support if they were not emotionally ready.

Implications for Nursing Practice Hospitals and organizations that support parents dealing with perinatal loss should consider including peer support programs. Although some organizations may develop such programs informally, we determined parents found benefit in a more formalized training to gain confidence in their therapeutic abilities and to further develop their own support and sense of community. As a whole, the parents providing support and those receiving support found the program to be helpful toward their healing. Such programs offer a much needed one-on-one approach to care that provides grieving parents with a normalizing experience.

Rosmarie Roose, RNC, MSN, Adventist Hinsdale Hospital, Hinsdale, IL Rachel M. Mirecki, PhD, Adventist Hinsdale Hospital, Hinsdale, IL Cathy Blanford, MEd, Adventist Hinsdale Hospital, Hinsdale, IL Keywords bereavement perinatal loss peer parent program


Striving to Attain High Reliability in Perinatal Services: Perinatal Safety SMART Lean Process Improvement Purpose for the Program his program addresses quality initiatives to decrease the incidence of birth trauma, enhance the culture of patient safety and teamwork, and standardize key clinical practices associated with risk of harm to mothers and infants by bringing evidence and best practice to the bedside.

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Proposed Change A strategic and purposeful focus on perinatal safety using a SMART Lean methodology with engagement from the perinatal team serves a critical role toward achieving high reliability in perinatal services at Lakeland Regional Medical Center (LRMC). The work of the Perinatal Safety Initiative is accomplished through multidisciplinary teams. All teams are supported by a dyad partnership, which includes an expert physician and opera-

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tional/clinical leader who are in turn supported by a sophisticated team including project management, performance improvement, informatics, industrial engineering, information technology, and risk management. The Perinatal Safety Working Team provides support to the Steering and Project Teams. The Perinatal Safety Steering Team meets monthly and is comprised of a group of clinical experts (nurse leaders and physicians who represent obstetric–gynecology, neonatology, and anesthesiology) as well as key members of the Executive Team. This team provides operational oversight and decision making, driving priorities, professional practice standards, strategy, and clinical expertise for the Initiative. The Project Teams are comprised of health care providers, nurses, and other LRMC team members as appropriate. Project Team work focuses on a specific

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352

Shannon M. Hartwig, RNC, MSN, BSN, Lakeland Regional Medical Center, Lakeland, FL Pamela D. Schwartz, D.O., OB/GYN, Watson Clinic,LLP,Lakeland Highlands, FL Keywords perinatal safety evidence-based practice high reliability




Daniel, L.


clinical opportunity and includes review of current evidence and professional practice standards, policy development, defining expectations and educational requirements, measuring progress, and providing feedback and recommendations to the Steering Team. Implementation, Outcomes, and Evaluation Outcomes measures are adverse outcome index (AOI), weighted adverse outcome score (WAOS), severity index (SI), neonatal mortality, and patient safety indication (PSI) #17: Birth Trauma; Joint Commission Measures: PC-01 Elective Delivery and PC-02 Cesarean Section, Agency for Healthcare Research & Quality (AHRQ) Survey on Patient Safety Culture, and Focus Studies for Bundle Compliance. Major accomplishments include a hard stop for early elective deliveries; a standardized schedule

and checklist for oxytocin administration focused on uterine and fetal response; implementation of Situation, Background, Assessment, Recommendation (SBAR), and twice-daily team briefings; an established chain of communication policy; TeamSTEPPS and simulation training; quarterly strip review; Advanced Practice Solutions (GNOSIS for electronic fetal monitoring); a newborn hyperbilirubinemia risk assessment and intervention; and an obstetric hemorrhage protocol. Implications for Nursing Practice The implications and key measures of success include the following: top leadership support; dyad partnership (medical doctor/nurse); SMART lean methodology; Steering Committee representation from key stakeholders; emphasis on evidencebased practice, standardization with technology, and operationalizing perinatal safety.

Reducing Cesarean Deliveries in Low-Risk, Nulliparous, Term, Singleton, Vertex Women Linda Daniel, MSN, RN, CPHQ, Christiana Care Health Services, Newark, DE Keywords PC-O2 perinatal quality measure RPI CQI low-risk cesarean NTSV


Purpose for the Program o reduce cesarean deliveries in nulliparous, term, singleton, vertex (NTSV) women by 10% during the next 18 months from 28.3% to 25.5%.

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Proposed Change To train a multidisciplinary team in rapid process improvement (RPI) techniques and promote the use of quality tools to plan, prioritize, and execute rapid cycle testing to empower team members to actively participate in successful quality initiatives. This lays the foundation to build a culture of continuous quality improvement. Implementation, Outcomes, and Evaluation Reducing cesarean rates in NTSV women is a perinatal quality measure endorsed by the National Quality Forum (NQF) and The Joint Commission (TJC). In 2014, TJC is mandating hospitals with more than 1,100 deliveries per year to report this quality indicator (PC-02). When we began this process, our cesarean rate in NTSV women was 28.3%. A multidisciplinary team convened to participate in a 90-day RPI program. The team established a goal to reduce cesareans in NTSV women by 10% (25.5%) during the next 12 to 18 months. By using tools provided in the RPI program, the team collected baseline data, mapped current and ideal flow processes, completed a cause and effect analysis (Fishbone diagram) and priority impact matrix to determine what initiatives to focus on first. Administrative support


was secured. Oxytocin order sets were standardized. A minimum Bishop score of greater than 8 was mandated to schedule an elective induction. Widespread educational efforts were set in motion, including a Grand Rounds presentation on Preventing the First Cesarean Delivery. Nurses were educated on calculating Bishop scores, order set changes, benefits of laboring down, and the importance of complying with existing guidelines. Ideas solicited from our Family Advisory council fostered community educational efforts that promoted the importance of completing the full 40 weeks of pregnancy. In July, 2013 (7 months into this initiative), our rate was 26.3%, which demonstrated a 7% reduction in the cesarean rate. Hospitalist and resident staff (early adopters) who embraced an evidencebased labor algorithm realized a 14.8% reduction in the cesarean rate (27% down to 23%), and NICU admissions for NTSV deliveries decreased 18% (17.1–13.9%) for our early adopters. It is critical to fully understand processes and collect complete baseline data to effectively target interventions for the greatest effect. Future efforts will focus on medically induced patients. Implications for Nursing Practice It is essential to involve frontline staff and set clear expectations to promote evidence-based practices. Valuable quality tools exist to guide and sustain quality improvement endeavors.

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Does the Use of Standardized Patients in Maternal-Newborn Simulation Increase Student Confidence Prior to Entering the Clinical Setting? Purpose for the Program o evaluate strategies in nursing education simulation when teaching Bachelor of Science in Nursing (BSN) students enrolled in a Care of the Childbearing Family course. The purpose of this pilot study was to determine if simulation using standardized patients (SPs) improved the students’ level of confidence in their assessment and communication skills before entering the maternal-newborn clinical setting. Proposed Change To evaluate the effect of standardized patients on student confidence. Our hypothesis was that the use of standardized patients for simulation would increase student confidence in the clinical setting.

postsimulation self-efficacy surveys adapted from Bandura to identify changes in confidence levels. An additional survey evaluated the students’ perception of the experience of working with the standardized patient. Face validity of both survey tools was established through collaboration with faculty content experts. Thirty nine of 48 students participated. Results indicated a statistically significant increase in students’ self-confidence in their abilities to assess the mother–infant couplet and educate the new mother. Most students strongly agreed that their experience with simulation and debriefing with the standardized patient improved their critical thinking skills and better prepared them to care for the newborn and postpartum woman.

Implementation, Outcomes, and Evaluation BSN nursing students who were participating in required simulations in a senior year childbearing family course were asked to voluntarily participate in the study. Simulation objectives were to complete a postpartum examination on the SP and a newborn assessment using a manikin. Students were asked to complete presimulation and

Implications for Nursing Practice This pilot study offers strong support for the use of standardized patients in preparation for maternalnewborn clinical practice. Further research is suggested to validate the tool with a larger sample size and to control for course sequencing issues (previous pediatric and critical care experience) and variance in the style of the standardized patients.

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Sarah J. Hampson, MSN, RN, Samuel Merritt University, Oakland, CA Susan Cantrell, MSN, RN, C-HROB, Samuel Merritt University, Oakland, CA Keywords maternal-newborn nursing simulation standardized patients postpartum newborn assessment nursing education


Working Nine to Five: An Innovative Scheduling Initiative Inspired by a Movie Purpose for the Program ob satisfaction in nursing has been linked to satisfaction with work schedule particularly in the younger generations of nurses. Our nursing unit had an increasing turnover rate and morale issues related to work schedules and the scheduling process itself. Research has demonstrated that self-scheduling is a potential approach to increasing job satisfaction especially in generationY members.

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Proposed Change Work shifts and call days were signed up based on a first-come, first-serve basis on designated days. These days were very stressful for most staff as many drove in from home on a day off and tensions were high as staff waited for their turn to sign up. Once a day’s allotted slots were full, no one else could sign up to work that day. Despite having specific guidelines to follow, shifts were

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left uncovered and staff were unhappy when their Sue Ellen Abney-Roberts, shifts were changed by leadership. A change in MSN, RNC, C-EFM, Georgia how staff were scheduled to work was imperative. Regents Health System, Augusta, GA

Implementation, Outcomes, and Evaluation Inspired by the flexible scheduling and job sharing in the movie 9 to 5 (starring Dolly Parton, Jane Fonda, and Lily Tomlin), one of our charge nurses came up with an idea for self-scheduling that involved scheduling partners similar to job sharing in the movie. The vision was that each nurse could set her schedule to allow for appointments and personal activities. There was a perceived need to provide a work–life balance that was not being met with the previous scheduling system. Staff were grouped into sets of scheduling partners with a total of 1.8 full-time equivalent/group. Staff were paired based on skill sets and ability to work with the mother–baby, antepartum, and labor and delivery units. One of the group members must be

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352

Paulalyn Boll, RNC, BSN, Georgia Regents Health System, Augusta, GA Keywords self-scheduling job satisfaction



Maxwell, S., Wellman, L. G., and Savage, T.


signed up to work in a 12-hour shift each day during the week. One of the 7 days is self-designated as a call shift. The leadership team then makes minor changes by incorporating approved vacations, classes, and the availability of pro re nata to work. Since April 2012 when this self-scheduling process was put in place, staff have been more satisfied with the scheduling process and no one

has resigned based on job dissatisfaction with scheduling. Completing the schedule is less time consuming and less stressful for the leadership team. Implications for Nursing Practice This is a viable alternative for scheduling that can be implemented in any area.

Small Changes Can Streamline the Handoff Process in a Staff-Driven Process Improvement Project Stephanie Landau, BSN-RN, Purpose for the Program C-NRP, C-EFM, CNII, here were inconsistencies with patient handYale-New Haven Hospital, New offs between the labor and birth unit and the Haven, CT

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maternity unit that contributed to dissatisfaction between units and potential patient care errors. A Lynn G. Wellman, MS, APRN, WHNP-BC, C-EFM, Yale-New review of the literature related to best practice for perinatal handoffs was presented to the Women’s Haven Hospital, New Haven, Services staff nurse cluster. CT Keywords handoffs communication SBAR transfer tool staff satisfaction


Proposed Change The Situation, Background, Assessment, Recommendation (SBAR) transfer template was revised to reflect a complete yet succinct comprehensive overview of the patient’s plan of care. Specifics were included regarding screens of the medical record to be reviewed within a given time frame. Although all staff members are TeamSTEPPS trained, barriers to the safe and seamless handoff were identified. Those barriers fell into one of our “3 Cs bucket”: collaboration, consistency, and communication. Audits were designed to identify the degree to which those inconsistencies existed, and input was solicited from both units for ways to improve the handoff transfers. The goals were to improve communication and teamwork among staff, improve patient satisfaction, and support our responsibility to Service Excellence. Implementation, Outcomes, and Evaluation The process improvement project was carried out over a period of 10 months with a total of 235 audit tools collected over three audit cycles. Staff

members were educated about the key points identified by the cluster following the initial audit cycle. The second audit cycle represented the process improvements following the implementation of the handoff strategies and the final audit cycle confirmed that these strategies were hardwired. These strategies included using the SBAR transfer tool, contact numbers for the transferring and the receiving nurse located in the patient’s medical record, timeliness of the initial and secondary call from the transferring nurse to the receiving nurse, involvement of the business associate in the transfer process, room readiness, direct handoff in the patient’s room, verification of the patient’s identification, specific screens reviewed during handoff, and verification of intravenous (IV) fluids and site. Implications for Nursing Practice Although all of the strategies were simplistic and revolved around communication and consistency, there was a marked improvement in the timeliness and direct communication between staff that contributed to a greater degree of satisfaction between units. This project exemplified that process improvement projects do not have to be complex to directly affect patient safety and staff satisfaction. This service line shared governance cluster that worked as a team to overcome challenges faced at handoff with measurable improvements.

Merging Two Robust Women’s Services in Alignment With a Comprehensive Nursing Strategic Business Plan Susan Maxwell, RN, MBA, NEA-BC, Yale-New Haven Hospital, New Haven, CT

Purpose for the Program n September 2012, Yale-New Haven Hospital (YNHH), a 1,000-bed tertiary care center, acquired the Hospital of St. Raphael’s, a 500-bed

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community hospital, creating the fourth largest hospital in the United States. Affiliated with the Yale School of Medicine and the Yale School of Nursing, YNHH is a provider of choice for the greater

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New Haven area. Women’s Services, which is comprised of inpatient and outpatient high- and low-risk obstetrics as well as gynecologic services, is provided at both campuses. The merger of two hospitals within a changing obstetric population trending toward outpatient antepartum care required a restructuring of services. Proposed Change The Women’s Services Leadership Team launched initiatives to merge the two campuses by using a strategic plan developed by hospital senior nursing leadership for all service lines. This plan provided a framework to operationalize process improvements and included four strategic dimensions with specific strategies: (1) Hardwiring the Common Purpose. Women’s services policies across the two campuses were revised by a multidisciplinary team to standardize practice; (2) Optimize Structured Operational Processes. An electronic medical record, barcoding, and fetal central surveillance systems were implemented at both campuses; (3) Expand Effectiveness as a High-Reliability Organization. A strategic decision was made to combine more than 100 inpatient staff from the labor and birth unit and antepartum unit to increase competence and allow for more efficient use of nursing services. A knowledge assessment was completed by nurses to individ-

ualize their education plans using the Association of Women’s Health, Obstetric Neonatal Nurses’ (AWHONN) Perinatal Orientation and Education Program. Nursing competencies and new hire orientation were also standardized. (4) Maximize Cost and Value Position. Improving the use of services was a consideration in the decision to consolidate antepartum and labor and birth units under one manager. The antepartum manager position was relocated to the growing outpatient area. To reduce duplication, services (such as maternal–fetal medicine [MFM], neonatal intensive care, and ambulatory services) were consolidated. To receive optimal reimbursement and improve the patient experience, a multidisciplinary team was formed to explore patient feedback and develop corrective initiatives. Implementation, Outcomes, and Evaluation Patient survey scores, results of nursing knowledge assessments, and budgetary trends were used to evaluate outcomes.

Lynn G. Wellman, MS, APRN, WHNP-BC, C-EFM, Yale-New Haven Hospital, New Haven, CT Tracey Savage, MS, BSN, RN, EFM-C, Yale New Haven Hospital, New Haven, RI Keywords strategic plan cross-training cost and value positioning


Implications for Nursing Practice Flexible models that allow for staff to practice across settings facilitate increased flexibility and expand nursing knowledge. This is an example of how nursing leaders are at the forefront of evolving trends in inpatient and ambulatory obstetric care and have a direct effect on care provision.

Engaging Community Health Care Providers in Genomic Research Purpose for the Program he purpose of this presentation/poster is to describe the process of working in partnership with the hospital, physicians, and their staff to recruit participants for perinatal and neonatal whole-genome research. We will share the challenges in placing the right clinical research staff in the office or unit, staff preparation and education, and the tools necessary to support our study.

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Proposed Change We made specific efforts to recruit subjects of diverse race, ethnicity, and socioeconomic status. To do this, we hired a multicultural staff of clinical research coordinators and associates to recruit subjects. We provided enrollment materials in English and Spanish as well as at averagereading and low-reading levels. We placed an emphasis on creating partnerships with hospital and community health care providers to be able to approach their patients for our studies.

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Implementation, Outcomes, and Evaluation Our Translational Medicine Institute enrolled more than 1,200 family trios from more than 70 countries in three whole-genome research studies. Recruitment for the preterm birth study required our team to join forces with multicultural health care providers from neonatology, obstetrics, perinatology, and a richly diverse nursing staff.

Lisa Z. Klein, DNP, CNS, RNC-OB, RNC-LRN, Inova Fairfax Hospital, Reston, VA Kathi C. Huddleston, PhD, RN, CNS, CCRC, Inova Fairfax Hospital, Burke, VA

Keywords research Enrollment for the longitudinal study occurs dur- perinatal ing the pregnancy, which requires our staff to ap- diversity proach patients in the prenatal care setting. We engagement

are currently recruiting from several large obstetric practices, including a safety-net community clinic.

Implications for Nursing Practice Knowing the community, the health care providers, and the staff at the offices and hospital will enhance the ability of nurse researchers to recruit participants in their studies.

JOGNN, 43, S1-S51; 2014. DOI: 10.1111/1552-6909.12352




Balestrieri-Martinez, B.


Implementing an Automated Data Collection Process for Reporting the Perinatal Care Core Measure Set Bernadette BalestrieriMartinez, MSN, RNC-OB, CNS, C-EFM, Sharp Chula Vista Medical Center, Chula Vista, CA Keywords core measures automation data collection electronic medical record


Purpose for the Program o standardize an automated data collection process for reporting the perinatal care core measure set in advance of The Joint Commission’s 2014 mandatory deadline. As part of a threehospital maternity service line, the demand of collecting data manually for core measure reporting was immense.

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Proposed Change Our proposed change took the form of a six-sigma workout that examined workflow in data collection at all three entities. An agreement on best practice standardized work became the template our team used to design the new process that would introduce automation for reporting. Implementation, Outcomes, and Evaluation Previous to this plan, only minimal automation was used during core measure reporting, and with a fully implemented electronic medical record (EMR) system having been used for years, it was our belief that we were not making full use of what was available. With the mandatory reporting requirements for 2014 looming, our team wanted to have our process hardwired before the end of 2013. The implementation process proved more challenging than originally thought. As our team designed the process from start to finish, we came


upon technical roadblocks within our database and documentation systems that needed to be addressed before further implementation. With the assistance of physicians, nurses, data analysts, informaticists, report writers, and researchers, our team began to design the outcome we envisioned. With the assistance of several products already in use for data collection, our evaluation began by comparing their accuracy to our new process. We found many discrepancies in our reports that forced our team to look at how we were inputting the data into our EMR. In our evaluation, we realized that in the future, we would need to design our clinical documentation to reflect specifically how the core measure question was asked and ensure the data output was in the required format for reporting. Implications for Nursing Practice The implications for nursing practice are vast. The mandatory requirement for core measure reporting has the potential to dictate how we will document in the future. Standards of care and core measure criteria must be written into physician orders and clinical documentation so that data reporting is accurate. Because of the immense data elements required, an automated process is the only viable solution for the future.

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ISOO Symposium, June 26-28, 2014, Miami, Florida.

Abstracts from the Environmental Mutagenesis and Genomics Society, 45th Annual Meeting, September 13–17, 2014, Orlando, Florida.

Abstracts of the 2014 NATA Annual Meeting & Clinical Symposia, June 26-28, 2014, Indianapolis, Indiana.

Abstracts from the 2014 research poster session at the american massage therapy association annual convention.

Abstracts of the British Society of Gastroenterology Annual General Meeting. June 16-19, 2014.

Abstracts of the ILTS 20(th) Annual International Congress, June 3-7, 2014, London, United Kingdom.

Abstracts of the 54th Annual Teratology Society Meeting, June 28-July 2, 2014, Bellevue, Washington.

Abstracts of the APOS 11th Annual Conference, 13-15 February 2014, Tampa, Florida.

Abstracts of the AAGBI GAT Annual Scientific Meeting, 11-13 June 2014, Newcastle, UK.

Best of the 2014 AUA Annual Meeting: Highlights From the 2014 American Urological Association Annual Meeting, May 16-21, 2014, Orlando, FL.

The College of Podiatry Annual Conference 2014: meeting abstracts.

Abstracts from the 2014 International Nitric Oxide Society Conference,June 16–20, 2014, Cleveland, Ohio.

Abstracts of the 38th Annual Congress of the Italian Urodynamic Society, 19-21 June, 2014, Milan, Italy.

Abstracts of the SAEM 2014 Annual Meeting, May 13-17, 2014, Dallas, Texas.

Abstracts of the 2014 SGI 61st Annual Scientific Meeting, March 26-29, 2014, Florence Italy.

Abstracts of the Thirteenth Annual UT- KBRIN Bioinformatics Summit 2014, April 11-13, 2014, Cadiz, Kentucky.

Abstracts of the SICB 2014 Annual Meeting, January 3−7, 2014, Austin, TX.

Abstracts of the British Psychosocial Oncology Society, 2014 Annual Conference, 27 - 28 February 2014, Preston, UK.

British Paediatric Neurology Association Abstracts of the 2014 Annual Meeting, 29-31 January 2014, Winchester, UK.

Abstracts of the 56th Annual Meeting of the American Headache Society, June 26-29, 2014, Los Angeles, CA.

SVM Annual Meeting - June 2014 La Jolla, California, USA.

Abstracts 2014.

Editor's perspectives--June 2014.

Abstracts from the 3rd World Congress on Vascular Access, WoCoVA 2014, 18-20 June 2014, Berlin, Germany.