Rita Wilson, RN, MEd, MN January 16, 2013 N URSING O RDER S ETS : F AST T RACKING K NOWLEDGE T RANSLATION

2 Presenter Disclosure  Presenter: Rita Wilson  Relationships with commercial interests:  Nothing to disclose

3 Disclosure of Commercial Support  Potential for conflict(s) of interest:  Registered Nurses’ Association of Ontario benefits from the sale of a product that will be discussed in this program: Nursing Order Sets

4 Agenda  Challenges with traditional Knowledge Translation (KT) approaches  RNAO’s nursing order sets: Accelerating KT  Implementation options

5 Knowledge Translation (KT) KT is a “dynamic and iterative process that includes synthesis, dissemination … and …application of ethically sound knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system”. (CIHR, 2011)

6 Traditional KT Approaches  Traditional KT approaches:  Research findings published in journals  Presentation at conferences  Development and dissemination of practice guidelines  Departmental Bulletin Board

7 Challenges With Traditional KT Approaches

8  Nurses have few readily accessible evidenced-based resources at the point of care  Minimal standardization in nursing care provided to patients/clients  Patient safety jeopardized  Hinders nursing research  Invisibility of nursing care in the health record

9  Underlying need:  Find an effective way to deliver knowledge to the nurse when needed at the point-of-care. Challenges With Traditional KT Approaches  Huge gap between knowledge and practice in healthcare *  30-45% of patients do not receive care with proven effectiveness  20-25% of patients get care that is not needed or is potentially harmful

10 Environmental Scan: Assessing RNAO’s KT Effort  RNAO’s environmental scan (2011)  Inconsistent Best Practice Guideline (BPG) implementation  Main barriers to KT: Lack of resources (i.e. time, knowledge, human resources) High cost of adapting BPGs to practice setting context System limitations (i.e. outdated, limited functionality) Variability in interpretation  Request for tools to improve KT(e.g. nursing order sets)

11 Results: Technology-Enabled BPG Implementation & Evaluation

Nursing Order Sets A nursing order set is a group of evidence-based interventions that are specific to the domain of nursing. It is intended to standardize the care provided for a specific clinical condition (e.g. pressure ulcers). It is ordered independently by nurses (i.e. without MD signature).

13 Nursing Order Sets: Standardized & Evidence-Based  Clear, concise evidence- based nursing interventions aligned with the nursing process.  Linked to respective practice recommendations (PR#)  Highlights interventions with the strongest evidence  Links to associated documents/ decision support resources  Each nursing intervention formulated using standardized terminology

14 Standardized Terminology  Standardized terminology language:  International Classification for Nursing Practice (ICNP) Developed by ICN to describe nursing practice Endorsed by CNA  Systematized Nomenclature of Medicine Clinical Terms ® (SNOMED CT) Developed by pathologists expanded to include other disciplines Endorsed by Canada Health Infoway

15 Standardized Terminology: ICNP Pressure Ulcer Care Completed Decubitus Ulcer Care Completed Bed Sore Care Completed

16 Standardized Terminology  Standardized nursing data is essential in electronic systems  Improves data quality  Standardized internally and externally among health care organizations to facilitate:  Exchange of health information among clinicians  Comparative analysis by policy makers  Evaluation for quality improvement  Research for knowledge creation

Nursing Order Sets In Acute Care 17 Patient Flow Post Stroke Patient Admitted to Acute Care Hospital Nursing Assessment On Admission  Stage 1 Pressure Ulcer Assessment & Management of Stage 1-4 Pressure Ulcers Nursing Order Set Nursing Assessment Pre-Discharge  No Pressure Ulcer Patient Discharged to Long-Term Care TriggersOutcome

Nursing Order Sets In Primary/Community Care 18 Patient Flow Smoking Cessation Intervention Initial Clinic/Home Visit Screen for tobacco use in last 6 months  Smokes 2 Packs/Day Smoking Cessation Minimal Intervention Nursing Order Set (Duration: 1-3 Min ) Triggers Follow-Up Visit Smoking Cessation Intensive Intervention Nursing Order Set (Duration: 10+ Min) Assess for tobacco use in last 7 days  Quit Smoking Follow-Up Visit #6

19 Implementation Option#1 - TxConnect  Web-based clinical document library and content management system  Enables organizations to build and maintain their own customized library of nursing order sets.  Order sets can be printed and used as a paper-based tool.  Ideal for organizations with paper-based systems. Order Set Library Development Library RNAO Order Set Library RNAO Order Sets  Partnership with PatientOrderSets.com to disseminate nursing order sets.

20 Implementation Option#2 - EntryPoint  Web-based tool that allows clinicians to complete nursing order sets electronically on a PC or mobile device.  Can be customized to include patient demographics.  Can be printed and stored in the patient’s chart.  Ideal for organizations with ClinDoc but not CPOE

21 Provides real-time data analytics (e.g. frequency of ordering specific interventions or order set utilization) Implementation Option#2 - EntryPoint

22 Implementation Option#2 - EntryPoint Provides real-time data analytics to show ordering practices by clinician or by unit

23 Implementation Option#3 - Customized

24 Benefits of Nursing Order Sets 17  Facilitates technology-enabled BPG implementation  Evidence-informed decision-making at the point of care  Utilization of standardized nursing terminology.  Mechanism to embed evidence-based nursing assessments and interventions in clinical systems.  Link nursing sensitive outcomes to specific nursing interventions.  Provides data analytics to evaluate outcomes and inform practice.  Improves patient safety and quality of nursing care.  Beneficial to health care organizations across the spectrum of care

25 27 Available Nursing Order Sets Chronic Diseases  Risk Assessment and Prevention of Pressure Ulcers  Assessment and Management of Stage I to IV Pressure Ulcers  Ostomy Care and Management  Strategies to Support Self-Management in Chronic Conditions with Clients  Decision Support for Adults Living with Chronic Kidney Disease  Reducing Foot Complications for People with Diabetes  Assessment and Management of Foot Ulcers for People with Diabetes  Assessment and Management of Pain  Management of Hypertension  Stroke Assessment Women & Children  Breastfeeding Addictions & Mental Health  Smoking Cessation Elder Care  Prevention of Falls and Fall Injuries in the Older Adult  Screening for Delirium, Dementia & Depression in Older Adults General  Client-Centred Care 16

Rita Wilson, eHealth Program Manager Registered Nurses’ Association of Ontario For more information visit: Contact Information