Nursing Councils Report for July/August/September

Nursing Councils Report for July/August/September

Nursing Research Evidence-Based Practice Council
Chair: Cathaleen Ley, PhD, RN
Co-Chair: Cheryl Briggs, BSN, RN

Journal Club:

  • -July: Denise Matteson, BSN, RN and Terry Ridel, RN- Promoting Patient Safety with Perioperative Hand-off Communication
  • -August: Kristen Becker, BSN, MSN- Nursing Burnout and Intent to Leave Nursing

Evidence Based Practice Fair:

  • -The 2016 Evidence Based Practice Fair was held in conjunction with Professional Practice Day in the Doordan Center on October 28. Event participants had an opportunity to view posters, ask questions and discuss the initiatives with poster authors.
  • -The purpose of the Evidence-Based Practice Fair is to provide nurses with an opportunity to present and discuss recent Nursing research and quality improvement initiatives conducted at AAMC and to demonstrate how AAMC Nurses use research evidence to guide practice and promote positive outcomes for the patients and families we serve.

Bedside Scientist Awards – Fiscal Year 2017:

  • -Bedside Scientist Grants are awarded to clinical nurses and clinical support staff to conduct studies to improve the quality of patient care, specially to reduce patient harm. All grants are reviewed and approved by the Nursing Research and Evidence Based Practice Council  for scientific metric and feasibility. For questions regarding Bedside Scientist Grants please contact Cathaleen Ley at


Nursing Quality Council
Chair: Cathaleen Ley, PhD, RN
Co-Chair: Lauren Stylc, RN

  • Benchmark of Nurse Sensitive Indicators CY2016 Q2:
    • The majority of the inpatient units outperformed their NDNQI benchmark on falls with injury (10 of 12 units), hospital acquired pressure ulcers (HAPU) (10 of 12 units), central line associated blood stream infections (CLABSI) (8 of 11 units), and catheter  associated urinary tract infections (CAUTI) (6 of 10 units).
    • The majority of the ambulatory departments/units outperformed their NDNQI benchmark on total falls (15 out of 17 departments/units) and on injury falls (15 out of 17 departments/units).
    • AAMC exceeded the Core Measure national mean for PC-03 Antenatal Steroids (1 of 1 units) and PC-04 (Neonatal Hospital Associated BSI (1 of 1 units).
  • Catheter  Associated Urinary Tract Infections  (CAUTI):
    • CAUTI Champion classes have been completed.
    • BPA will be implemented for CAUTI documentation.
    • Condom Catheter trial will be conducted on CCU/IMU in October
  • Falls Committee
    • For the previous eight quarters (CY Q3 2014 to CY Q2 2016) AAMC has outperformed its NDNQI benchmark on injury falls per 1,000 patient days for all quarters.  In Calendar Q1 2016 (latest data available), the median hospital unadjusted score was 0.36 which falls between the 25th and 50th percentile of all comparison hospitals (N= 886 hospitals).
    • In an on-going effort to continue to strengthen our inpatient fall prevention program the following actions have been implemented this quarter:
  • Purchase of DE Royal Chair Sensor Pads and Chair Alarms for inpatient units, ED, and Infusion Center.  Fall alarms have been installed on the South Tower. A second pilot study will be conducted to specifically test connectivity between the alarms and the nurse call system this month. This study will be conducted on the NCU.
  • Review and approval of Inpatient Fall Policy which includes the following modifications: (1) requirement that patients be assessed at minimum every 12 hours (previous version stated every shift), (2)  inclusion of observing high fall risk patient while using urinal while sitting or standing and when on bedpan), and (3) requirement of those transporting high risk fall patients back to unit to notify RN when patient has returned to unit to ensure bed and  fall alarm are plugged back in.
  • Nursing Peer Review Committee: Case reviewed in July resulted in the revision of Emergency Transfer Request form and revising the transfusion policy to include documentation of transfusion.


Professional Nurse Council
Chair: Daniel Shields, RN
Co-Chair: Shahde Graham-Coker, MSN, RN
Initiatives: SNAC, Diversity/Advocacy, Community, COPE

  • PNC designed t-shirts to celebrate the two year anniversary of becoming magnet designated. PNC members were very active in helping with distributing the t-shirts at Nursing Grand Rounds on September 12.
  • Kelly Vogt, RN, AAMC’s most recent DAISY Award recipient was awarded on  August 25, 2016.  Many colleagues, family, friends and PNC members assembled to  pull off the surprise.
  • Over 200 backpacks and other items were gathered for Back-to-School from AAMC staff members in August.
  • PNC is advocating to help with unit readiness for the Joint Commission visit this year.
  • Julie Flinchum from the Pharmacy spoke to PNC members in regards to correcting Pyxis discrepancies as soon as possible.
  • Maulik Joshi provided a presentation on diversity and disparities. PNC members are to encouraged to remember to always provide culturally competent care.


Clinical Education Council
Chair:  Robin Colchagoff, MSN, RNC, CCE
Co-Chair: Mary Cohn, MSN, RN
Initiatives: Professional Development

  • Jamie Heinmiller discussed Wellbeing at AAMC and Wellbeing for educator group.
  • Review of the new clinical ladder criteria with recommendations for more starred items for levels 3 and 4.
  • Discussed and prepared staff education for the new LDA for the insulin pump; review of pain/POSS and range orders; new chair alarms education.
  • Professional Development Day was held on 10/28/16, about 90 staff attended.
  • Discussion and preparation for the Learning needs assessments for all nurses at AAMC.
  • Preparing for the October Educator Workshop to review and revamp nursing orientation at AAMC.


Interdisciplinary Informatics Council
Chair: Jennifer Dupre, MSN, RN
Co-Chair: Lindsey Alexander, BSN, RN

  • Starting October 4, the Activity Report defaults to open.
  • One-time med hold order went live October 4.
  • Remind staff to use Insulin Pump LDA for patients coming into the hospital with a home insulin pump in place.
  • Restraint documentation updates went live October 4.
  • Stop IV Meds  – Must stop on MAR in EPIC too.
  • Ability to more specifically identify LDA drains & chest tube with comment line went live October 11.
  • Worklist pilot occurring in the OBS Unit .
  • Clinicians must document how an allergy was assessed with the patient.
  • A new report search tool has been added to EPIC that can be used to find parts of the chart.
  • Informatics tip sheets can be found on the intranet, under Department → Informatics → Tip sheets.


Clinical Practice Council
Co-Chair: Denise Matteson, BSN, RN, CAPA

In preparation for Joint Commission the Clinical Practice Council has been meeting twice a month to review policies.  Clinical Practice Council has reviewed a total of 83 policies for the months of July, August, and September. CPC approved the following policies to move on to the Hospital Policy Review Committee (HPRC):

Pediatrics:  3YR review (1)

Nutrition: 3YR review (2)

Surgical Services:  3YR review (5)

Pharmacy:  3YR review (25)

IV Therapy:  3YR review (5)

Labor & Delivery:  3YR review (2)

Laboratory:  3YR review (2)

General Nursing:  3YR review (6)

Radiology Oncology: 3YR review (2)

Oncology:  3YR review (4)

Infection Control:  3YR review (2)

Critical Care:  3YR review (3)

NICU:  3YR review (3)

Clinical Education:  3YR review (1)

Women’s & Children 3YR review (5)

  • CPC retired the following policies: One General Nursing policy was retired during this time period.


Charge Nurse Council
Chair: Lisa Davis, RN
Co-Chair: Devra Cockerille, RN


  • The Charge Nurse Workshop planned for October 11 was discussed and encouraged Unit Charge Nurses to reach out if they have staff that would benefit from workshop.
  • Amanda Chipko discussed the PAIN/POSS document changes in EPIC with the group.
  • The volunteers were present and are going to assist units in Joint Commission prep.
  • Kathy Whittaker discussed interpretation services and the new badge without the green strip for in house interpreters. 24/7 coverage is coming soon for the hospital.
  • Barbara Jacobs discussed the unit changes, 3 south to open/HVU moving to 3 south. 5 North/central moving to 4 North. ICU will be 18 beds as well as IMU 18 beds.


  • The group discussed the title change and agreed on Clinical Supervisor.
  • Leadership changes were discussed by the group: Lil Banchero has been promoted to Senior Director of the Geriatric service line. Devra Cockerille has been promoted to ACE/FLEX Director.
  • Julie Flinchum spoke to the group about Pyxis discrepancies and a proposed list to choose to document discrepancies.
  • Michelle Lusby presented a SBAR regarding HP PACU returning to method of transporting monitored patients to the floors.
  • Lil Banchero discussed organizational changes in the ACP.
  • The group discussed a new alarm management system being looked at by a work group.
  • Barbara Jacobs discussed throughput initiatives and reorganization. Barbara also discussed bullying and the no tolerance policy.

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