12/17/2015

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mayoweb/creatingthefuture

©2012 MFMER | 3226733-1

Driving Outcomes: Registered Nurses Performing Bone Marrow Biopsies Utilizing a Battery Operated Rotary Device

Jay Maningo-Salinas, PhD, RN, NE-BC, FACHEMayo Clinic Arizona

©2012 MFMER | 3226733-2

Objectives

• Identify understand drivers for change

• Identify steps taken to implement new procedure

• Describe metrics used to ensure quality

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©2012 MFMER | 3226733-3

Disclosure Statement

• Author and speaker have no financial or commercial interest in this content.

• Author and speaker have no financial or commercial interest in products discussed in the presentation.

©2012 MFMER | 3226733-4

Background

The Arizona State Board of Nursing – Scope of Practice Committee Advisory opinion:

“Based on national and local evidence, it is recognized that an RN who has satisfactorily completed an instructional program or supervised clinical practice in bone marrow aspiration and biopsy, can safely perform bone marrow biopsy and aspiration.”

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©2012 MFMER | 3226733-5

Overview of the Problem

• Performed in multiple areas in the organization and by various staff (nurses, physician, NP/PA, fellows, residents)

• Challenges• Conflicts in scheduling • Differences in paperwork among sites• Inconsistency in how the procedure is performed• Training and education of proceduralist• Quality of samples

©2012 MFMER | 3226733-6

Drivers for Change

• Team based model • Quality outcomes• Consistency of samples• Safety of nurses and patients• Nurses performing role at top of scope, education

and training• Free up provider calendar for new patients

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Timeline of the Journey

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February – June 2008

• Consolidation discussion initiated

• Two physicians (hematologist and pathologist) agreed to champion the project

• Interprofessional planning meetings every 2 weeks

• Physician champions communicated the process changes with key referring physicians and hospital administration leaders via email, division meeting, presentations and newsletters.

• RN team implemented June 2008 with manual procedure

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June – November 2008

• Team challenges encountered with manual method

• Explore alternative with the use of the driver

• Check with Arizona Board of Nursing

• Physician champions on board and committed to quality and safety

©2012 MFMER | 3226733-10

November 2008

• A subset of 10 Ambulatory Infusion Center nurses who had previously completed an instructional program and supervised practice were scheduled to attend a 1-day workshop

• Each nurse had to perform 10 supervised BMBX using the driver procedures over a span of 6 months until the trainer and the nurse were both comfortable of the operator’s ability

• Documentation of satisfactory completion and competency is maintained in the nurses file

• Two laboratory staff personnel were also invited to attend the workshop

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©2012 MFMER | 3226733-11

The Innovative Way of Delivering Care

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• All bone marrow biopsy procedures are performed by a subset of group of AIC RN staff who have undergone education and training.

• 2-3 nurses per day are scheduled to perform bone marrow biopsies (ambulatory & inpatient)

• One nurse performs the procedure and another RN provides analgesia and monitoring of the patient

• A lab technician is present to prepare the slides and transports samples to the lab.

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©2012 MFMER | 3226733-13

• Outpatient BMBXs are scheduled in the morning and inpatient are performed in the afternoon

• Anticipated start-up volume was between 5-6 biopsies per day. Current volume from 5-10 per day

• An audit tool was developed to aid in evaluating outcomes.

• Patients will are called at home 24-hours after procedure by the bone marrow procedure nurse for follow-up assessment.

©2012 MFMER | 3226733-14

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©2012 MFMER | 3226733-15

Metrics & Outcomes

©2012 MFMER | 3226733-16

BMBX Procedures 2008 - 2015

453

989

1172

1369

1451 1446

13371310

0

200

400

600

800

1000

1200

1400

1600

 CY 2008  CY 2009  CY 2010  CY 2011  CY 2012  CY 2013  CY 2014  YTD 2015

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©2012 MFMER | 3226733-17

273

237 243

277

319

289

334

362

396

337

306325

345 352

308322

288301 300 300

323

288278

0

50

100

150

200

250

300

350

400

450

1stQtr2010

2ndQtr2010

3rdQtr2010

4thQtr2010

1stQtr2011

2ndQtr2011

3rdQtr2011

4thQtr2011

1stQtr2012

2ndQtr2012

3rdQtr2012

4thQtr2012

1stQtr2013

2ndQtr2013

3rdQtr2013

4thQtr2013

1stQtr2014

2ndQtr2014

3rdQtr2014

4thQtr2014

1stQtr2015

2ndQtr2015

3rdQtr2015

Sedation Status

Sedated Non Sedated Total

©2012 MFMER | 3226733-18

0 1 0 0 2 1 0 0 0 0 0 1 1 2 1 0 0 0 4 7 3 0 3

62

3035

2837

44 42 3844

30 28 26

914

19 188

1621 17 20

616

162154 156

178170

183

201 200

215

200

184190

214 212

176

206197 198 196

211

228

201

186

81 81

65

89

127

71

104

142

164

131

114124

147157

147

123 119124

112106 109

121

108

0

50

100

150

200

250

1stQtr2010

2ndQtr2010

3rdQtr2010

4thQtr2010

1stQtr2011

2ndQtr2011

3rdQtr2011

4thQtr2011

1stQtr2012

2ndQtr2012

3rdQtr2012

4thQtr2012

1stQtr2013

2ndQtr2013

3rdQtr2013

4thQtr2013

1stQtr2014

2ndQtr2014

3rdQtr2014

4thQtr2014

1stQtr2015

2ndQtr2015

3rdQtr2015

How would you rate the instructions you recieved regarding the BMBX?

Poor Satisfactory Excellent Not Available

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©2012 MFMER | 3226733-19

291

256241

280

318

283

319

359

395

331

307321 320

369

323 330310

321312 314 321

304286

14 10 15 15 16 1629

11 1827

17 14 12 15 20 16 14 13 1827

3823 25

0 0 0 0 2 0 6 10 10 3 2 1

39

1 0 1 0 4 3 0 1 4 20

50

100

150

200

250

300

350

400

450

1stQtr2010

2ndQtr2010

3rdQtr2010

4thQtr2010

1stQtr2011

2ndQtr2011

3rdQtr2011

4thQtr2011

1stQtr2012

2ndQtr2012

3rdQtr2012

4thQtr2012

1stQtr2013

2ndQtr2013

3rdQtr2013

4thQtr2013

1stQtr2014

2ndQtr2014

3rdQtr2014

4thQtr2014

1stQtr2015

2ndQtr2015

3rdQtr2015

Pre Procedure Pain Score

Pain Score 0‐4 Pain Score 5‐10 Not Available

©2012 MFMER | 3226733-20

297

258240

274

318296

327350

386

335319

338 331

376

338 339317 324 322 331

343320

306

8 5 8 4 5 3 1 1 5 4 2 2 3 6 2 7 6 4 6 7 10 6 50 3 8 17 130

26 29 3222

5 1

37

3 3 1 1 9 5 3 7 5 20

50

100

150

200

250

300

350

400

450

1stQtr2010

2ndQtr2010

3rdQtr2010

4thQtr2010

1stQtr2011

2ndQtr2011

3rdQtr2011

4thQtr2011

1stQtr2012

2ndQtr2012

3rdQtr2012

4thQtr2012

1stQtr2013

2ndQtr2013

3rdQtr2013

4thQtr2013

1stQtr2014

2ndQtr2014

3rdQtr2014

4thQtr2014

1stQtr2015

2ndQtr2015

3rdQtr2015

Pain score prior to discharge

Pain Score 0‐4 Pain Score 5‐10 Not Available

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©2012 MFMER | 3226733-21

197

175 173

190 190

209

229237

252

223207 212

231221

193

227

202 203 203 205217

201194

27

10 15 1928

19 174

11 13 13 8 215 9 8 9 14 18

28 3022

13

81 8168

86

118

71

108

139

160

125

106121

138149

141

112 113121

112 108 113 108 106

0

50

100

150

200

250

300

1stQtr2010

2ndQtr2010

3rdQtr2010

4thQtr2010

1stQtr2011

2ndQtr2011

3rdQtr2011

4thQtr2011

1stQtr2012

2ndQtr2012

3rdQtr2012

4thQtr2012

1stQtr2013

2ndQtr2013

3rdQtr2013

4thQtr2013

1stQtr2014

2ndQtr2014

3rdQtr2014

4thQtr2014

1stQtr2015

2ndQtr2015

3rdQtr2015

Pain Score at 24 hour follow up

Pain Score 0‐4 Pain Score 5‐10 Not Available

©2012 MFMER | 3226733-22

0 1 0 1 5 0 0 3 0 3 0 0 0 0 2 2 0 0 2 0 0 0 0

305

265249

275

319298

331351

390

343322

340

370381

338 343320

337 331 338360

328311

0 0 719 12

123 26 33

154 1 1 4 3 2 4 1 0 3 0 3 2

0

50

100

150

200

250

300

350

400

450

1stQtr2010

2ndQtr2010

3rdQtr2010

4thQtr2010

1stQtr2011

2ndQtr2011

3rdQtr2011

4thQtr2011

1stQtr2012

2ndQtr2012

3rdQtr2012

4thQtr2012

1stQtr2013

2ndQtr2013

3rdQtr2013

4thQtr2013

1stQtr2014

2ndQtr2014

3rdQtr2014

4thQtr2014

1stQtr2015

2ndQtr2015

3rdQtr2015

Bleeding requiring dressing change prior to discharge

Yes No Not Available

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©2012 MFMER | 3226733-23

1 1 1 3 3 0 4 1 2 4 3 2 4 5 4 3 2 1 0 4 1 1 4

223

184 190207 214

229

349

248265

237221 222 230 231

196

235216 223 220

234

257

230211

81 8165

85

119

70

101

131

156

120102

117137

149 143

109 106 114 113100

1

100 98

0

50

100

150

200

250

300

350

400

1stQtr2010

2ndQtr2010

3rdQtr2010

4thQtr2010

1stQtr2011

2ndQtr2011

3rdQtr2011

4thQtr2011

1stQtr2012

2ndQtr2012

3rdQtr2012

4thQtr2012

1stQtr2013

2ndQtr2013

3rdQtr2013

4thQtr2013

1stQtr2014

2ndQtr2014

3rdQtr2014

4thQtr2014

1stQtr2015

2ndQtr2015

3rdQtr2015

Patients who developed issues requiring emergency care of physician follow up 24 hours post BMBX

Yes No Not Available

©2012 MFMER | 3226733-24

https://youtu.be/-snQBm_cuv8

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©2012 MFMER | 3226733-25

Questions ?