Cross training is key to cross-continuum success
Docs lead some educational sessions
Case management leaders at Holston Valley Medical Center knew that cross training staff was critical in successfully implementing new guidelines for surgical procedures, but were surprised to learn that physicians were willing to help in the educational process.
Cross-training efforts at the Kingsport, TN, hospital is how the surgical case management team is educating staff about using guidelines for its top 10 surgical procedures. The guidelines serve as case management tools and are formatted similar to critical paths. All 10 guidelines were implemented this June as part of a six-month pilot project. (See the related story on how Holston Valley developed its guidelines, p. 118.)
Having physicians involved in the cross-training efforts was "the exciting part" of the project, says Keltie Kerney, BSN, RN, A-CCC, MPH, director of the hospital's home care services. "The physicians upfront agreed that they would be a part of lectures and training for these nurses so that every single person would know how to do the procedures," she explains.
"One of the physicians lectured on wound care, skin care, dressing changes, and actually demonstrated how he wanted wet-to-dry dressings implemented. Another physician did a lecture on chest tubes, chest drainage, the anatomy and physiology of the need for chest tubes, and then management of chest tubes," notes Kerney.
Both acute and home care nurses were invited to the same session "so that we all heard the same thing," says Kerney. "The intent was to identify potential problematic areas and then to reduce the variations in practice by having physicians teach the actual classes. The nurses could rotate through the unit to be checked off by a nurse who had been doing this for some time. In addition, some of the surgical unit nurses came down to home health and rotated through home health and did some visits to see the other site -- or what happens when their patient goes home," she adds.
Developing the cross-training program began when the project's development team began its work two years ago. Case management directors from both the acute and home health departments first asked for volunteers who wanted to be a part of this project, explains Kerney.
"We were hopeful that we would get some of the most experienced nurses, and as it turned out, we truly have our most experienced nurses in home care, general surgery, cardiac surgery, and thoracic surgery, among other areas. We really had the cream of the crop of the nurses who volunteered to participate in this program," adds Kerney.
Once the participating nurses were identified, the first step in preparing the acute and home care case managers for surgical guideline implementation was to develop a skills checklist.
The skills checklist was developed through a collaboration between the home care case managers and the nurses on the A400 unit, the surgical unit. "The checklist includes all of the procedures that are specific to these patients," explains Kerney.
The three-page checklist includes 24 generic areas. Of those general areas, many are further divided into subcategories. For example, item number eight lists the Penrose drain, which is further divided into the "care of" and "removal" subcategories. Item number 16 -- the nasogastric tube -- is subcategorized into sump, corpak, and care. The "care" subcategory in item 16 is further broken down to include: insertion, general hygiene, irrigation, Gomco suction, Ohio suction, removal, Toomey syringe, and mouth and nasal care.
Corresponding to each item are three columns: discussed, demonstrated, and return demonstration. Once each area is successfully completed, the columns are checked accordingly.
Because the guidelines clearly state what is to occur during each phase of the patient's care -- from physician office visit to home care -- the case managers are kept abreast of what is happening with the patient.
The next cross training step was for the inpatient nurses to spend a few days in home care and the home care nurses to spend a few days on the surgical unit. "Our nurses rotated through the A400 inpatient unit until they were able to demonstrate competencies in all these procedures," says Kerney. "All of us had a very high level of confidence that everybody knew how to change the dressing, for example, the way the physician wanted it done."
Through this system, the inpatient nurses learned what was happening and being taught once the patients were discharged back home. Conversely, the home care nurses learned how inpatient nurses and case managers were coordinating a patient's care and what they were teaching the patient.
Follow-up inservices will be conducted as needed, explains Kerney. At this point, however, she says that the training with the physician-led sessions has been adequate. "If anything arises outside of what we've already done that still needs to be done, we'll immediately address that," she says.
"But based upon the 10 diagnoses, we feel we have addressed all of the needs right now. However, if we add a new procedure then we will provide some education through inservicing for that." *
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