Transitioning Registered Nurses

To a Higher Level of Care Utilizing the

Resource Nurse/Partners in Practice Model

FOR ED

Contingency Planning for Surge Capacity during

a Disaster Event

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Updated: 6/25/2020

Resilience

At HCA Healthcare, we’re no strangers to threat. We deal with them daily.

Infectious diseases, natural disasters, unspeakable emergencies.

Some say that managing life-threatening situations is part of business as usual for an advanced

healthcare network like HCA Healthcare. And it’s true.

That’s exactly what helped build a sharp set of best practices and a robust network of response

teams, which helped us, HCA Healthcare, mobilize quickly and scale accordingly in times of

need.

As this latest threat evolves, HCA Healthcare is collaborating with federal and local health

agencies, providing timely and practical updates that will help contribute to accurate reporting

and consistent guidelines. While our immediate priority remains the well-being of our patients

and people, we know that sharing insights can impact care far beyond the communities we

serve.

In the face of a threat, we don’t panic, we prepare.

Introduction

Our everyday lives and the way HCA Healthcare provides care is drastically changing due to the

spread of COVID-19. We are faced with an unprecedented health crisis. The worldwide scale is

daunting, and the challenge to our infrastructure, standard processes of care and even

standards of care demands novel approaches. It is during these times that our colleagues have

shown their resilience and lead us through these difficult periods

Our goal is to support our nursing colleagues as we prepare for patient surges predominately in

our Emergency Departments and Critical Care Services. To support these critical areas, we will

need to reassign registered nurses to various nursing departments to serve as a Resource

Nurse/Partner in Practice to help close resource gaps in patient care.

This booklet is not all-inclusive, but does provide additional information to help you build on

your current nursing knowledge and skills.

Let’s begin our journey.

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Knowledge and Skills

We recognize that each Registered Nurse (RN) brings knowledge, experience and skills to the

clinical unit that you are assigned and you may already be very comfortable with some of the

knowledge and skills listed below. We have provided a list of those knowledge and skills that

you are currently performing in your home nursing unit. Review the list below and initial the

skills that you can perform independently.

Medical-Surgical/Progressive Care Knowledge and Skills

Skills Initials Skills Initials

AED Assessment (General/Focused, I&O)

Pain Assessment/ Management Blood Administration

Central Line Management/ Dressing Change

CIWA/ COWS Management

CPAP Diabetes Management

Fall Prevention & Gait Belt Use Glucometer

Vital Signs VTE Prophylaxis

Indwelling Urinary Catheter Insertion

Indwelling Urinary Catheter Maintenance

IV Pump Med Administration (General)

PIV Insertion PPE Utilization

General Meditech Documentation

Restraints

Suction Set Up Respiratory Therapies (Nebs, MDI, IS,

MDU, EZPAP, CPAP/BiPAP)

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As you move into the emergency department nursing areas, listed below are common

knowledge and skills that you will experience in the emergency departments. Please review

this list to acknowledge if you have any experience by initialing next to the topics

Emergency Department Knowledge and Skills

Topic Initials Topic Initials

Restraints Monitor Set up/Alarm Management

Blood Glucose Monitoring Proficiency in Rhythm Interpretation

Assists with the insertion of central lines: setting up central venous access device equipment, Caring for central venous access device, explaining indication of use and sites, complications of CVAD’s, indications for post insertion x ray

CPAP/BiPAP-Noninvasive Ventilation (Basic Knowledge)

Basic Hemodynamic Monitoring & Arterial Lines (Basic Knowledge)

Respiratory Equipment (flow meter, tubing, Oxy-mask, nasal cannula, NRB Mask, O2 Cylinder, BVM, High-Flow Nasal Cannula.

Bladder Management/Insertion and removal on a male and female patient: Foley catheter, 3 way Foley catheter, Coude catheter

Blood Collection: Type & Cross Match, Central line, Arterial Line, Peripheral line, Blood Cultures, & Routine Blood work.

Blood Administration Suctioning: Orally, Nasopharyngeal, Tracheal, & in-line.

Mechanical Ventilation (Pt Care)

Care of the intubated & ventilated patient: indications for intubation, oxygenation, patient positioning, pain mgmt., & sedation.

Cardiac Respiratory Continuous Monitoring & 12 Lead EKG

Administer and monitor pharmacological agents related to the respiratory system: Bronchodilators, Steroids, Thrombolytic agents, Analgesics, Reversal agents, Sedatives, Neuromuscular blocking agents.

Chest Tubes and Drainage Systems

Med Administration: Common Meds in Emergency Care (Independent), High-Risk Meds & Titration (Cosign Only)

CHG Bathing of the ED Patient COVID-19 Testing Specimen Collection

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Conscious Moderate Sedation Fluid administration with or without IV Pump

DVT/PE Documentation (ED Specific)

Preparatory Learning

First, we want to introduce you a variety of e-learning modules in HealthStream to help you

better understand some of the terminology, equipment and various medical and nursing

interventions you may encounter. In order to access the majority of the content for your

preparatory learning, you will need to log in to HealthStream and enroll yourself. This will allow

you to access any modules that you need.

Health Stream Modules (Emergency Department)

Endotracheal Suctioning Using the Closed Suction Technique in Intubated Adults- EBSCO

Bilevel Positive Airway Pressure (BIPAP)- EBSCO

Continuous Positive Airway Pressure (CPAP) for Acute Respiratory Distress-EBSCO

Mechanical Ventilation in Adults-EBSCO

COVID-19 Response: Mechanical Ventilation Management-EBSCO

Endotracheal Suctioning Using the Closed Suction Technique in Intubated Adults- EBSCO

End Tidal Carbon Dioxide Monitoring in Intubated Patients-EBSCO

End Tidal Carbon Dioxide Monitoring in Non-Intubated Patients-EBSCO

Aerosol Therapy – EBSCO

Metered Dose Inhaler Use in Adults – EBSCO

Chest Tube Monitoring & Care-EBSCO

Oxygen Therapy Administration-EBSCO

Phlebotomy Blood Sampling- EBSCO

Central Venous Access Device Blood Sampling-EBSCO

Arterial Pressure Monitoring & Care-EBSCO

ECG Fundamentals & Basic Dysrhythmias: Part 1- A&P and ECG- 20-720240

Restraint Review

Basic Respiratory Care Nursing Skills-SDH

Advanced Respiratory Care for Nurses-SDH

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How to Access HealthStream Remotely

Access from Home through

www.stdavids-institute.com or healthstream.com/hca

When logging in to HealthStream, use your 3-4 ID for both the User ID and Password entries.

IMPORTANT! Your password is case sensitive, so if you can't log in with your 3-4 in CAPITALS,

try lower case password entries. Be sure to receive prior clearance from your manager for any

HealthStream education time you spend at home.

Orientation

Introductions are crucial to team success. Each individual brings with them certain

competencies and skills. In the introduction, each member should discuss what skills they can

assist with throughout the shift. Lead or Primary nurses should discuss the care needs for

patients within the unit and how the work can divided up to ensure each patient receives the

best care utilizing everyone’s talents on the team. During the orientation phase, the lead nurse

will review environment of care, which will include the safety features of the unit.

Orientation time may be limited, but as time allows we will provide hands-on learning for

common skills, documentation and work routines. If we are not able to provide any hands-on

training, there are huddle cards, videos that you will be able to access on I-Mobile, hospital

Intranet site or provided on the nursing unit for you to review.

When you arrive on the assigned nursing unit, you will be introduced to the team and provided

with an introduction to the unit that will include a document that will provide the location of

the following: (Next Page)

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This document below is what you should expect regarding conversations with the primary

nurses you will be supporting at the end of your shift.

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Below, you’ll see the huddle card created for the ED that will introduce you to the Partners in

Practice role

Meditech Education

For those nurses who have utilized Meditech and now will be documenting in another care area

(i.e., Med-Surg Nurse documenting in ICU or OR Nurse documenting in the ED), education has

been developed.

Listed below are the Meditech course names including a short description. The courses are

located in HealthStream:

COVID-19 - Resource RN to ED during Surge – Basic Meditech Documentation – this

course will provide a nurse that has experience with Meditech, but needs to understand

the various documentation that will need to be done in the Emergency Department

There are also full courses utilized during a nurse’s orientation to Meditech and these include:

HWS HCA WBT Meditech BCMA – this is the full course to teach nurses for bedside

computerized medication administration.

HWS HCA WBT Meditech Nursing Documentation – this is the full course for teaching

nurses to document in Meditech utilizing Evidence Based Clinical Documentation.

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Meditech Assistance Hotline

For Meditech assistance, please call us at 1-800-737-8661 x1333 or 954-514-1333 and select option

2 to contact an experienced Meditech instructor.

Hours:

Weekdays: 8 AM – 5 PM EST

Thank you,

Healthtrust Education Team

Meditech Huddle Card for ED

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Just In Time Resources

As a Registered Nurse you understand that you need to ask questions. We want you to use the

resources that you have available. We have developed resources that include information and

guidance to help provide excellent care. If you cannot locate one, please ask. We are here to

help you!

ONLINE REFERENCES

Resource Name Description Location

Atlas HCA corporate intranet-HCA initiatives

and documents SDH intranet>Atlas Connect

CE Direct Free access to continuing education and

certification review courses SDH intranet>Clinical Tools; internet

access available

Clinical Pharmacology Drug reference, including medication interactions, compatibility, etc.

SDH intranet>Medical Resources

EBSCO Clinical Research Clinical research database-to access

specific articles or journals

SDH intranet>Medical Resources; internet access available

E-Demand Repository for facility/SDH forms

(consents, specific patient instructions, etc.)

SDH intranet>Admin Tools

HealthStream

SDH/HCA Learning Management System- repository for most mandatory and

elective learning; HealthStream Competency Center: electronic orientation and annual

competency assessment for all staff, as well as annual evaluations;

HealthStream CE Center: free access to continuing education and certification

review courses

SDH intranet>Admin Tools; internet access available

Dynamic Health SDH procedure manual, includes

instructions, checklists and references SDH intranet>Medical Resources

Policytech Electronic file for SDH policies SDH intranet>Policies

Institute for Learning (IFL) Course Registration-for any course

offered through the IFL

SDH intranet>Institute for Learning; internet access available www.stdavids-

institute.com

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HUDDLE CARDS/QR Codes – You are likely to see huddle cards or posters throughout

the nursing unit and on some equipment. For additional information about a specific

topic or to better understand equipment please scan the QR code on the document.

Many of these documents will include videos.

VIRTUAL PRECEPTOR – We are introducing Virtual Preceptor that is available through I-

Mobile. This will include numerous quick references on a number of topics. These tools

are designed for rapid review immediately prior to performing a task.

APPENDIX

The appendix will provide additional information that you will find helpful. Listed below are the

topics that are found in this section:

Reassigning nurses to other nursing units using the Donna Wright Model

Common Procedures in ED

Common Medications given in ED

Reassignment of Nurses – Based on Donna Wright Model

When nurses are floated from one nursing unit to another, the issue of competency arises. We

ask quite frankly, does this nurse have the skills, knowledge and abilities to function in this

capacity? Experiencing a surge of patients can make it difficult to cross-train or put nurses

through a complete orientation. How can we facilitate a successful floating process? According

to Donna Wright, when asking nurses that float and those that receive float nurses, there are

three themes that consistently are heard and are actually competencies for the nurse that is

reassigned to another care area. These include:

Learning on the Fly

Marketing yourself in a positive way

Understanding crisis management options

Learning on the Fly

Learning on the fly competency has two parts. First, I need to know what I do not know, and be

able to speak up about it. The second essential aspect of learning on the fly includes:

I am not sure about this procedure….I am going to look it up.

I am going to ask someone how to do this.

I will use the resources that are available to guide my actions.

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Obviously, this is not going to work for every procedure and task that we do, but many times

learning on the fly skill is used successfully. To demonstrate learning on the fly, imagine a nurse

floats to a medical-surgical floor that provides dialysis. The nurse has never worked in dialysis

before and does not know how to properly provide dialysis. The charge nurse may ask an

experienced nurse to setup the dialysis and point out the basic things to watch for when

monitoring a patient on dialysis. The charge nurse can buddy up the inexperienced nurse with

another professional to ask further questions to support the patient’s care. The most important

thing is to propose ways to be useful while remaining open to learning new things.

Marketing Yourself in a Positive Way

As a Registered Nurse you have lot of knowledge, skill and experience that you can bring to any

situation. Also as RNs, we need to market ourselves a little better and let those we are working

with understand what skills and experience that we can bring to the team. Sometimes we may

say, I was told to come here, I have never worked her before, I am not familiar or comfortable

with working in this area or specialty, and I do not know how to do any of those things.

When you are reassigned to another nursing unit, we recommend that you make these two

statements to the team or the charge nurse:

My name is ________ I am floating to your unit for this shift, I am here to help you out.

I have the following skills that I can offer to you today, and you can see how they may

fit into what is needed. I can do ___________, and so on.

When nurses have the ability to market themselves positively, the results and the shift

experiences are much better. The success of the shift and the reassignment experience do not

lie in the clinical skills, but instead in the “can-do” attitude the person brings.

Understanding Crisis Management Options

Most of the time when a nurse is reassigned to another area, that area is under stress,

stretched, or moving into crisis mode because they do not have enough staff to meet the

needs. They need help to function, so they reach out for support. The nurse being reassigned

can provide care and/or service assistance to help the team get the routine work done, but can

also offer something else: a fresh perspective or insight that the group may have trouble

seeing.

By using the Primary Nurse model we will have a better outcome for the patients and the team.

As the shift progresses, I may have time to learn new skills so I can better support my partner.

Eventually, I may want to transfer to the ED based on my experience.

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The skill of understanding crisis management options can work in any area, not just in nursing.

The team is able to change the normal work-flow temporarily to match the crisis situation and

still produce the desired results.

This is an excerpt from Donna Wright’s, Competency Assessment Field Guide for

Implementation and Application, 2015, Creative Healthcare Management. Prior to COVID-19,

HCA Healthcare began to transition to the Donna Wright Competency Assessment Model. We

will resume the implementation later in 2020.

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Common Procedures and Medications in the Emergency Department

Setting

Common Procedures Requiring RN Assist in the ED Procedure Supplies/Nursing/Personnel Common Medications

Intubation

Ensure suction is set up with a Yankauer

RT will assist

Airway Box from the Crash cart has most of the supplies

1. Move the bed away from the wall (better access for the provider intubating)

2. Get towels to roll (if time permits) 3. Remove the headboard on the bed (if

time permits) 4. May be asked to get the Glidescope (in

the supply room on wheels, it is a device with a light on to assist in a difficult intubation)

RSI Kit (override in the Pyxis) (Rapid Sequence Intubation)

It does NOT contain narcotics, will need to override those medications.

Be sure to get an order and document waste and medications given.

Central line insertion

Provider will need the Ultra- sound machine,

Procedure cart if available on the unit with supplies

PPE (blue packets from supply room) are to be worn by everyone in the room

Chest x-ray will be taken before usinguse the line to confirm placement and no signs of a pneumothorax

May need a pain/sedation medication depending on the situation

Chest tube insertion

Chest tube set up (Pleurovac or Atrium)

Procedure cart with supplies

Chest x-ray post procedure to evaluate tube placement

May need a pain/sedation medication depending on the situation

Suturing/Wound Care

Suture Kit

Gauze

Saline for irrigation/cleansing as needed

Absorbent pads

Local anesthetic ordered and administered by physician for numbing area

Fracture Care/Splinting

Prior to splinting, ensure injured extremity is immobilized and may provide ice pack as needed

Primary nurse will assist with splinting or moderate sedation; may bring splint cart to procedure area

Pain medication or moderate sedation as ordered by physician

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Common Medications in ED

Cardiovascular Class/Indication Tips Route

Furosemide (Lasix) Diuretic

Used in fluid overload states/Pulmonary edema, Heart failure

Monitor electrolytes

I & O for response of med

IVP: give slowly 10mg /minute

Metoprolol Beta Blocker

Anti-hypertensive

Anti-arrhythmia

Given for ↑BP or arrhythmias

Atrial fib with a Rapid ventricular response, SVT

Monitor for bradycardia

IVP: give slowly

Hydralazine Vasodilator

Anti-hypertensive

Given for ↑BP

Monitor BP

IVP: give slowly

Amiodarone Anti-arrhythmia

Used in atrial fib with a rapid ventricular response

IV bolus: 150mg in 50/100ml bag infuse over 10 minutes, then change to continuous infusion at 1mg/min for 6 hours, then decrease to 0.5mg/min Follow order set

Pain Meds

Fentanyl Opioid Has pain and sedative properties, monitor resp status if not vented

IVP: give slowly

Hydromorphone (Dilaudid)

Opioid Pain and sedative properties, monitor resp status if not vented, monitor blood pressure Potent: 1mg Dilaudid = 7mg Morphine

IVP: give slowly

Morphine Opiod Pain and sedative properties, monitor resp status if not vented, monitor blood pressure

IVP: give slowly IM

Ketamine Non-opioid pain control

IV continuous infusion Follow order set

Lidocaine

Local anesthetic

Used as local anesthetic and administered by physician

Ketorolac (Toradol)

NSAID Also used for pain

Avoid use in patients with renal dysfunction

IVP: give slowly IM

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Sedation Class/Indication Tips Route

Lorazepam (Ativan)

Benzodiazepine Sedative properties, monitor resp status if not vented

Essential in patients with Alcohol Withdrawal Syndrome

Follow CIWA orders, the patient needs this med to avoid seizures during withdrawal.

DO NOT use CIWA scale if the patient is on a ventilator, use RASS when giving Lorazepam

Can be used in conjunction with Precedex, however the patient still needs a benzo during withdrawal

IVP: give slowly IV continuous infusion (follow order set with parameters ordered)

Midazolam (Versed)

Benzodiazepine Sedative properties, monitor resp status if not vented

Can be used PRN for sedation in a patient on a ventilator

Often used as a pre sedation medication for a procedure:

Example: intubation, chest tube insertion

IVP: give slowly unless used in a rapid intubation situation

Can be a continuous infusion

Dexmedetomidine (Precedex)

Alpha 2 adrenergic agonist

Sedative effect without respiratory effects.

Monitor heart rate: bradycardia is a frequent side effect

IV continuous infusion

Avoid abrupt discontinuation

Follow order set

Anti-Emetics

Ondansetron (Zofran)

Promethazine (Phenergan)

Anti-emetics Can potentiate effects of sedative and opioids

Avoid combination of Zofran and Promethazine can cause arrhythmias

Zofran: IVP slowly Promethazine: Dilute in 10 ml NS & IVP slowly

If you have any questions or need further information please reach out to the St. David’s HealthCare Institute for Learning Team at 512-544-0100 or email SDHP.DL IFL Clinical

Education

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