November 2017 - Mind the Gap: A Collaborative Initiative to Address Potential Safety Risks in Intrahospital Patient Transitions
Objectives
- Describe potential safety risks associated with intrahospital patient transitions
- Describe a corporate initiative to address some of the potential safety risks
- Reflect on opportunities for continuous quality improvement in intrahospital patient transitions that exist in their own clinical area
Presenters
- Colleen McNamee, RN, MN, Corporate Nursing Education Manager
- Cecilia Santiago, RN, MN, CNCC(C), Nursing Practice Manager
References
- Kue R, Brown P, Ness C, Scheulen J. Adverse clinical events during intrahospital transport by a specialized team: a preliminary report. Am J Crit Care. 2011;20(2):153-61; quiz 162. doi: 10.4037/ajcc2011478.
- Eberhardt S. Improve handoff communication with SBAR. Nursing. 2014;44(11):17-20.
- Robertson ER, Morgan L, Bird S, Catchpole K, McCulloch P. Interventions employed to improve intrahospital handover: a systematic review. BMJ Qual Saf. 2014;23(7):600-7. doi: 10.1136/bmjqs-2013-002309.
- Ong MS, Coiera E. A systematic review of failures in handoff communication during intrahospital transfers. Jt Comm J Qual Patient Saf. 2011;37(6):274-84.
- Alamanou DG, Brokalaki H. Intrahospital transport policies: The contribution of the nurse. Health Sci J. 2014;8(1):166-78.
- Uhrenfeldt L, Aagaard H, Hall EO, Fegran L, Ludvigsen MS, Meyer G. A qualitative meta-synthesis of patients' experiences of intra- and inter-hospital transitions. J Adv Nurs. 2013;69(8):1678-90.
- Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170(11):1678-86.
- RNAO BPG on Care Transitions.
- Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. 2003;348(25):2526-34.
- CPPS Policy 2174
- CPPS Policy 2153
October 2017 - The emerging role of the Mental Health Emergency Services Area (MHESA) and the MHESA RN at St. Michael's Hospital
Objectives
- To learn about the new Mental Health Emergency Services Area in the Emergency Department (ED)
- To review the role of the Mental Health Liaison Nurse and collaborative care
- To discuss inter-professional collaboration, medical escalation, triage and flow processes between the MHESA and the ED
Presenters
- Stephanie Lucchese, RN, Psychiatric Emergency Services
- Dominic Gascon, RN, Operational Readiness Specialist, Planning/Development
References
- Crismani, C., Galletly, C. 'Walk-ins': developing a nursing role to manage unscheduled presentations to a community mental health clinic. Contemporary Nurse. 2011;39(1):12-19.
- McDonough, S., Wynaden, D., Finn, M., McGowan, S., Chapman, R., Hood, S. Emergency department mental health triage consultancy service: an evaluation of the first year of the service. Accident and Emergency Nursing. 2004;12:31-38. Order Through the Library
- Wand, T., D'Abrew, N., Acret, L., White, K. Evaluating a new model of nurse-led emergency department mental health care in Australia: perspectives of key informants. International Emergency Nursing. 2016;24:16-21. doi: 10.1016/j.ienj.2015.05.003 Order Through the Library
- Registered Nurses Association of Ontario. (2006). Crisis Intervention.
- SMH Library Mental Health & Addictions Service Research Guide
- PsychiatryOnline - Comprehensive online access to psychiatric textbooks, journals, and professional development tools.
September 2017 - Contact Tracing for Tuberculosis
Objectives
- Review pathogenesis, epidemiology and transmission of TB
- Discuss TB contact investigation process in hospital and the community
- Review strategies to prevent TB transmission in hospitals
Presenter
- Julie Seemangal MN, NP-Adult, TB Program, Division of Respirology
References
- Centres for Disease Control and Prevention (2005). Guidelines for the Preventing the Transmission for Mycobacterium tuberculosis in Health-Care Settings. MMWR 2005; 54(No RR-17).
- Uppal, N., Batt, J., Seemangal, J., McIntyre, S., Aliyev, N., Muller, M. (2014). Nosocomial tuberculosis exposures at a tertiary care hospital: A root cause analysis. American Journal of Infection Control 42(5), 511-16.
- Public Health Agency of Canada, The Lung Association, & the Canadian Thoracic Society: Canadian Tuberculosis Standards. 7th Edition. 2014.
- Menzies, D., Joshi, R., Pai, M. Risk of tuberculosis infection and disease associated with work in health care settings. Int J Tuberc Lung Dis. 2007(11), 593–605.
- Baussano, I., Nunn, P., Williams, B., Pivetta, E., Bugiani, M., Scano, F. Tuberculosis among health care workers. Emerg Infect Dis. 2011;17:488–494.
- Joshi, R., Reingold, A.L., Menzies, D., Pivetta, E., Bugiani, M., Scano, F. Tuberculosis among health care workers in low- and middle-income countries: a systematic review. PLoS Med. 2006;3:e494.
June 2017 - Every Patient Must Have a Destination: Transitioning Care Within the CVICU
Objectives
- Review the journey of CVICU long-stay patients using a quality improvement model
- Share supporting tools utilized to guide transition process from CVICU to alternative level of care
- Discuss future opportunities for the transitioning of long-stay patients
Presenters
- Sandra Ashtarieh, RN, CVICU
- Darren Day, RN, CVICU
- Margaret Ferraro, RN, CVICU
References
- Boutilier, S. (2007). Leaving critical care: facilitating a smooth transition, Dimensions of critical care nursing, 26(4), p. 137-42.
- Burns, S. M., et al. (2012). The relationship of 26 clinical factors to weaning outcome, American Journal of Critical Care, 21(1): 52-59.
- Critical Care Services Ontario (2013). Long-term mechanical ventilation: Toolkit for adult acute care providers, 1-70.
- Dumbović, V., et al. (2014). Understanding the psychological needs of long term weaning patients, Connect: The World of Critical Care Nursing 9(3): 63-64.
- Elliott, D., et al. (2014). Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting, Critical Care Medicine 42(12): 2518-2526.
- Ely, E., Meade, M., Haponik, E., Kollef, M., Cook, D., Guyatt, G., & Stoller, J. (2001). Mechanical ventilator weaning protocols driven by nonphysician health-care professionals: Evidence-based clinical practice guidelines, Chest 120, 454S-463S.
- MacIntyre, N. R. (2012). Chronic Critical Illness: The Growing Challenge to Health Care...49th Respiratory Care Journal Conference, “The Chronically Critically Ill Patient,” September 2011, Florida." Respiratory Care 57(6): 1021-1027.
- Weled, B., Adzhigirey, L., Hodgman, T., Brilli, R., Spevetz, A.; Kline, A., Montgomery, V., Puri, N., Tisherman, S., Vespa, P., Pronovost, P., Rainey, T., Patterson, A., & Wheeler, D. (2015). Critical care delivery: The importance of process of care and ICU structure to improved outcomes: An Update from the American College of Critical Care Medicine Task Force on Models of Critical Care, Critical Care Medicine, 43, 1520-1525.
- White, A. C. (2012). Long-Term Mechanical Ventilation: Management Strategies...49th Respiratory Care Journal Conference, “The Chronically Critically Ill Patient,” September 2011, Florida." Respiratory Care, 57(6): 889-899.
- Wise, P. M. and D. S. Wallace (2012). Direct sunlight and ventilator weaning outcomes, Holistic Nursing Practice, 26(6): 350-355.
May 2017 - Managing COPD
Presenters
- Katie Bowler
- Jonathan Hunchuk
- Carolene Garcia
- Newton Leong
References
- Canadian Thoracic Society. (2008). The Human and Economic Burden of COPD: A leading cause of hospital admission in Canada.
- Chronic Disease Network and Access Program. (2009). Nutritional Management of COPD: Guide for Health Professionals.
- College of Nurses of Ontario. (2002). Professional Standards.
- Global Initiative for Chronic Obstructive Lung Disease. (2017). 2017 Pocket Guide to COPD Diagnosis, Management and Prevention: A Guide for Healthcare Professionals . CreateSpace Independent Publishing Platform.
- GlaxoSmithKline group of companies. (2016). The COPD Assessment Test tool.
- National Advisory Committee on Immunization. (2013). Statement on the Use of Conjugate Pneumococcal Vaccine - 13 Valent in Adults (Pneu-C-13).
- O’Donnell, D. E., Hernandez, P., Kaplan, A., Aaron, S., Bourbeau, J., Marciniuk, D., … Voduc, N. (2008). Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease – 2008 update – highlights for primary care. Canadian Respiratory Journal : Journal of the Canadian Thoracic Society, 15(Suppl A), 1A–8A.
- Public Health Agency of Canada. (2007). Life and Breath: Respiratory Disease in Canada: COPD.
- Spitzer RL, Kroenke K, Williams JBW, Lowe B. (2006). A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097.
- The Lung Association (2008). My COPD Action Plan.
- World Health Organization. (2008). World Health Statistics 2008. Switzerland.
- Canadian Lung Asssociation. Variety of resources on COPD.
March 2017 - Quality Improvement in Hemodialysis: Introducing the Hemo Pause
Objectives
- Review the evidence for checklist implementation in patient care settings as a QI initiative
- Describe an approach to checklist implementation in the SMH Hemodialysis Unit (Hemo Pause)
- Discuss lessons learned and next steps for Hemo Pause use within the SMH Hemodialysis Unit
Presenters
- Alison Thomas, RN(EC), MN, CNeph(C), Nurse Practitioner, Hemodialysis
Multimedia
References
- Bray BD, Boyd J, Daly C et al. How safe is renal replacement therapy? A national study of mortality and adverse events contributing to the death of renal replacement therapy recipients. Nephrol Dial Transplant 2014; 29: 681–687.
- Renal Physicians Association: Health and safety survey to improve patient safety in end stage renal disease.
- Page A. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press, 2004.
- Pippias M, Tomson CR. Patient safety in chronic kidney disease: time for nephrologists to take action. Nephrol Dial Transplant 2014; 29: 473–475.
- Kliger AS. Maintaining safety in the dialysis facility. Clin J Am Soc Nephrol 2015; 10: 688–695.
- Ulrich B, Kear T. Patient safety culture in nephrology nurse practice settings: initial findings. Nephrol Nurs J 2014; 41: 459–475.
- Ulrich B, Kear T. Patient safety and patient safety culture: foundations of excellent health care delivery. Nephrol Nurs J 2014; 41: 447–456.
- Garrick R, Kliger A, Stefanchik B. Patient and facility safety in hemodialysis: opportunities and strategies to develop a culture of safety. Clin J Am Soc Nephrol 2012; 7: 680–688.
- Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf 2014; 23: 299–318.
- Jeffs L, Law MP, Straus S et al. Defining quality outcomes for complex-care patients transitioning across the continuum using a structured panel process. BMJ Qual Saf 2013; 22: 1014–1024.
- Bray BD, Metcalfe W. Improving patient safety in haemodialysis. Clin Kidney J 2015; 8: 262–264.
- Leape LL. The checklist conundrum. N Engl J Med 2014; 370: 1063–1064.
- Morello RT, Lowthian JA, Barker AL et al. Strategies for improving patient safety culture in hospitals: a systematic review. BMJ Qual Saf 2013; 22: 11–18.
- Urbach DR, Govindarajan A, Saskin R et al. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med 2014; 370: 1029–1038.
Web Resources
February 2017 - Care Transitions: Lessons Learned from the Trauma Neurosurgery Program
Presenters:
- Wendy Legacy
- Lory Wen-Ya Lee
Multimedia
References
- Care Transitions Program. (2017). Evidence and adoption.
- College of Nurses of Ontario. (2014). RN and RPN practice: The client, the nurse and the environment.
- Critical Care Services Ontario (2017). Neurosurgical Care.
- Health Quality Ontario. (2016). Measuring up 2016.
- Holly, C., & Poletick, E. B. (2014). A systematic review on the transfer of information during nurse transitions in care. Journal of clinical nursing, 23(17-18), 2387-2396.
- Li, J., Young, R., & Williams, M. V. (2014). Optimizing transitions of care to reduce rehospitalizations. Cleveland Clinic journal of medicine, 81(5), 312.
- Registered Nurses’ Association of Ontario. (2014). Care Transitions.
- Sheppard, S., McClaran, J., Phillips, C. O., Lannin, N.A., Clemson, L. M., McCluskey, A.,...Barras, S. L. (2010). Discharge planning from hospital to home. Cochrane Database of Systematic Reviews, 1, 1-51. Order through the Library
- St. Michael’s Hospital.( 2017). Excellence in quality.
- The Joint Commission (2006). The Joint Commission’s Annual Report on Quality and Safety. The Joint Commission, Washington, DC.
January 2017 - When Stroke Strikes, Minutes Matter
Presenters:
- Denise Ouellette, RN, MSN(c), CNN(C), CNS, Stroke Network
- Jacqueline Willems, RN, MN, Regional Stroke Program Manager
Multimedia
References
- Berkhemer, O. A., Fransen, P. S., Beumer, D., Van Den Berg, L. A., Lingsma, H. F., Yoo, A. J., ... & van Walderveen, M. A. (2015). A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med, 2015(372), 11-20.
- Goyal, M., Demchuk, A. M., Menon, B. K., Eesa, M., Rempel, J. L., Thornton, J., ... & Dowlatshahi, D. (2015). Randomized assessment of rapid endovascular treatment of ischemic stroke. New England Journal of Medicine, 372(11), 1019-1030.
- Heart and Stroke Foundation. (2014). Canadian Stroke Best Practice Recommendations.
- Saltman, A. P., Silver, F. L., Fang, J., Stamplecoski, M., & Kapral, M. K. (2015). Care and outcomes of patients with in-hospital stroke. JAMA neurology, 72(7), 749-755.
