The Hawaiʻi Nurse

Official Newsletter of Hawaiʻi - American Nurses Association Quarterly publication distributed to approximately 9,400 RNs and LPNs in Hawaiʻi.

August 2020 | Vol. 1 No. 1 -ana.nursingnetwork.com American Nurses Association is Join Hawaiʻi-ANA ʻ & ANA Today! Back in Hawai i! Hawaiʻi - American Nurses Association Only $15 per month. (Hawai’i-ANA) is the newly established state nurses association, a constituent of American Nurses Association (ANA), representing all 13,000s RNs in the state. In 2008, as a result of Hawaiʻi Nurses’ Association (HNA) reforming itself as an independent collective bargaining organization Hawai’i lost its American Nurses Association (ANA) arm. Since 2008 a group of Hawai i nurse leaders ʻ Local publications, in-person networking, have been working tirelessly toward the re- mentoring, legislative events, annual establishment of a state nurses association. conventions and events After years of hard work the American Nurses Association Board of Directors voted to approve Visit hawaii-ana.nursingnetwork.com Hawaiʻi-ANA as the newest constituent state nurses association in December 2019. Hawaiʻi- Support nursing advocacy efforts, which to find out more or to join! ANA joined the 48 mainland U.S. states and help protect your job, your safety and two U.S. territories, Guam and the Virgin your rights as a nurse Islands, with state nurses associations. Over the beginning months of 2020, Hawaiʻi-ANA has been in the building phases by growing Save $125 on ANCC initial certification BECOME A and up to $150 on ANCC certification membership, completing virtual community renewal outreach, and planning our first annual Protect Yourself with members-only MEMBER TODAY! membership assembly. The year 2020 has been savings on ANA Personal Benefits challenging, uncertain, and often frustrating however this year has taught us and our community the value of nurses. It is only fitting that our global celebration for Year of the Nurse Stay current with a subscription to ANA’s peer-reviewed, award winning journal is partnered with a global pandemic to showcase American Nurse Today and other printed the extraordinary contributions of the nursing and electronic publications including: Links to Other Nursing The Online Journal of Issues in Nursing profession. and SmartBrief The state of Hawaiʻi has done an exceptional Organizations job at mitigating the spread of COVID-19. Our initial surge in March - April forced us to execute Hawai’i Board of Nursing strict social distancing, mask wearing, and work Advance your knowledge through ANA's extensive online Continuing Education Hawai’i Association of Professional Nurses from home procedures as our state leaders (CE) Library. Excel in your health care acknowledged the fragility of our healthcare career with the ANA Leadership Institute Hawaiʻi Nursesʻ Association-OPEIU Local 50 and ANA Mentorship Program system’s capacity. We de-escalated our curve Hawai’i State Center for Nursing then later began opening businesses and were Hawai’i Nurses Association adopting this new form of normal. However as comfort rose our second wave in July hit and Philippine Nurses Association of America we began questioning how will this impact our American Association of Nurse Leaders Hawaii healthcare system and most importantly our Go to Hawaii-ana.nursingnetwork.com for more health professionals’ safety. PPE shortages continue to be a widespread issue amongst healthcare facilities throughout Hawai’i islands which places our nurses and allied health American Nurses Association is Back in Hawaiʻi! professionals at risk. This is only one of many continued on page 3

Non-Profit Org. U.S. Postage Paid Princeton, MN Permit No. 14 current resident or INDEX

Meet Your Board of Directors .. . . 2-3 ANA-Hawai’i Membership...... 6 President’s Message...... 4 Lobbying, National & State Policy News. . 7 Central Oahu District Notes. . . . . 5 Student Nurses Page...... 7-10 Continuing Competency...... 5 Membership Application. . . . . 11 Page 2 • Hawai’i Nurse August, September, October 2020 Meet Your Board BOARD OF DIRECTORS

of Directors Executive Director/President Elect: Linda Beechinor, DNP, APRN Hawaiʻi - American Nurses Association Secretary: Poki’i Balaz, DNP, APRN President: Katie Kemp, RN-BC, BAN (Hawaiʻi-ANA) Secretary: Board of Directors Biographies Poki’i Balaz, DNP, APRN who is newly appointed to the Poki’i Balaz, DNP, APRN Secretary position on the Hawaiʻi-ANA Board of Directors. Can also be found via link: https://hawaii-ana. Dr. Balaz replaces Andrea Montgomery-Kylie who has Treasurer: Aggie Pigao Cadiz, BSN, RN nursingnetwork.com/page/93393-board-of-directors resigned her position to return to graduate school. Director: Robin Zachary, DNP, Ed.S, RN

Executive Director/President Elect: Treasurer: Aggie Pigao Cadiz, BSN, RN Director: Linda Beechinor, DNP, APRN Nancy Atmospere-Walch, CEO & CNO, DNP, MPH, Aggie Pigao Cadiz is a born MCHES, LNHA, CCHN, CMC, BSN, RN Linda Beechinor has and raised Hawaiʻi woman Director: Jailu V. Navarrete, RN been in Hawai i since 1984 who left for Seattle University ʻ Director: Joan Parker-Dias (previously from Canada). School of Nursing following While practicing as a graduation from the then St. Director: Marion Poirier, M.A., R.N. staff nurse, Linda earned Francis Convent School. Aggie a Masterʻs degree from practiced 18 years in Seattle UH Manoa and currently establishing two free clinics and PRODUCTION practices as a family nurse working with disenfranchised Publisher practitioner in independent populations. Arthur L. Davis Publishing Agency, Inc. practice with vulnerable Aggie’s first involvement populations in urban Aggie Pigao Cadiz in the American Nurses Editor and Publisher are not responsible nor liable for editorial or news content. Linda Beechinor : mostly homeless, Association (ANA) was as a mentally ill clients with member of the King County Hawai’i Nurse is published four times a year, February, May, complex health issues coincidental with their legal Nurses Association. Returning to Hawaiʻi in 1984, she August, and November, for the Hawai’i - American Nurses continued her involvement through the non-collective Association, a constituent member of the American Nurses difficulties. Association. Hawai’i Nurse provides a forum for members to Linda has been involved with American Nurses bargaining aspect of Hawaiʻi Nurses Association (HNA). express their opinions. Views expressed are the responsibility Association on their Board of Directors and in various Aggie served in various capacities in HNA among them of the authors and are not necessarily those of the members aspects of the enterprise such as the Credentialing district member and president, on the HNA Board of the Hawai’i-ANA. Center (ANCC). When Hawai'i previously had a of Directors including President of HNA. She has the Articles and letters for publication are welcomed by the state association with ANA, it was in tandem with distinction of being the first Executive Director of HNA editorial committee. Hawai’i-ANA Editorial Committee the union or collective bargaining organization, following the reorganization of HNA as a union yet reserves the right to accept or reject articles, advertisements, which separated from ANA 10 years ago and is now still within the body of ANA. Aggie has continued her editorials, and letters for the Hawai’i Nurse. The editorial known an "Hawai i Nurses Association / OPEIU Local involvement with the professional association as a committee reserves the right to edit articles, editorials, and ʻ letters. 50" (HNA). Linda was at various times president, founding member and current Treasurer of the newly executive director, treasurer, etc. of the original established Hawaiʻi-American Nurses Association. She Address editorial comments and inquiries to the following "HNA" and has continued efforts to re-establish looks forward to an increasing awareness of registered address: nurses in Hawai i and their involvement in Hawai i- 500 Lunalila Home Road, #27-E our professional nurses association with American ʻ ʻ Honolulu, HI 96825 Nurses Association (ANA) in Hawaiʻi. Now here she American Nurses Association in improving the health of [email protected] is as executive director and president-elect for the our community. initial Board of Directors, many of whom are founding No parts of this publication may be reproduced without permission. members of the re-established ANA state nurses Director: Robin Zachary, DNP, Ed.S, RN association in Hawaiʻi. It is a passion of hers that we Subscription to the print version of the Hawai’i Nurse is all involve ourselves in the politics of healthcare in In October 2017, Robin and included with membership to the Hawai’i - American Nurses her husband travelled to Hawai i Association/American Nurses Association. Complimentary order to fulfill our professional promise as nurses. ʻ electronic copies are sent to all Hawai’i nurses and posted to celebrate their thirtieth on the Hawai’i - American Nurses Association website at President: Katie Kemp, RN-BC, BAN wedding anniversary. Over the hawaii-ana.nursingnetwork.com. Address such requests course of fifteen days, they to the Hawai’i-ANA Office at the address above or email Katie Kemp is a Minnesota travelled from Long Beach, CA to [email protected]. Circulation 9,400. native who moved to Oahu Hawaiʻi and back. After returning For advertising rates and information, please contact Arthur L. in 2016 as a new graduate to Knoxville, a chain-reaction of Davis Publishing Agency, Inc., PO Box 216, Cedar Falls, Iowa RN. She has four years of events occurred. Robin updated 50613, (800) 626-4081, [email protected]. Hawai’i-ANA RN experience working in and posted a resume on Indeed© and the Arthur L. Davis Publishing Agency, Inc. reserve the right to reject any advertisement. Responsibility for errors in various levels of community job site and waited. In June 2017, Robin Zachary advertising is limited to corrections in the next issue or refund based nursing including Robin accepted a position with of price of advertisement. care home, assisted living, Kapiʻolani Community College and moved from Knoxville, Tennessee to Honolulu, Oahu. A Acceptance of advertising does not imply endorsement internal medicine clinic, or approval by the Hawai’i - American Nurses Association and now home health. As four thousand, four hundred, and fifteen-mile move! of products advertised, the advertisers, or the claims Lead RN/Case Manager Robin has been a member of American Nurses made. Rejection of an advertisement does not imply a Katie Kemp at Oahu Home Healthcare Association and Kentucky Nurses Association for several product offered for advertising is without merit, or that she cares for adult and years before moving to Hawaiʻi. After moving to Hawaiʻi, the manufacturer lacks integrity, or that this association Robin was disappointed that Hawai i did not have a state disapproves of the product or its use. Hawai’i-ANA and the geriatric patients throughout the island of Oahu. ʻ Arthur L. Davis Publishing Agency, Inc. shall not be held liable Katie's passions in nursing are wound care, patient nursing association. That all changed spring of 2019, for any consequences resulting from purchase or use of an education, and mentorship of nursing colleagues Robin became a part of the Hawaiʻi - American Nurses advertiser’s product. Articles appearing in this publication as well as empowering patients and colleagues to Association. Currently, Robin is on the Board of Directors express the opinions of the authors; they do not necessarily achieve the definition of wellness and success. for the association and is eager for more nurses to learn reflect views of the staff, board, or membership of Hawai’i- ANA or those of the national or local associations. As a founding member of Hawaiʻi - American about and join the Hawaiʻi - American Nurses Association! Nurses Association, and now President, Katie was inspired to be involved in her professional nursing Director: Nancy Atmospere-Walch, association in order to advocate for the reduction of CEO & CNO, DNP, MPH, MCHES, LNHA, CCHN, RNs working in unit clerk and CNAs roles in Hawaiʻi's CMC, BSN, RN hospital systems, and promote increase in RN new graduate/new to specialty residency programs. Dr. Walch is a Nurse Executive “passionate” about the Education is the foundation of nursing practice and provision of high-quality nursing care. She works in her investing in our local talent will promote better health own business, ADVANTAGE Health Care Provider, Inc., a outcomes for our Hawaiʻi community. local company that has a contract with the State of Hawaii to provide health care services and support to the Special August, September, October 2020 Hawai’i Nurse • Page 3 Meet Your Board of Directors

Population - the Intellectually forward to, and achieve in hope, and love that will influence their action and practice and Developmentally Disabled the course of serving. She in delivering quality, high performance nursing care to (I/DD) individuals in need of completed her BSN in Manila, individual patients, families, communities, and population “Home & Community Based Philippines in 1976, and MBA served. Let us move forward together as Hawaiʻi-ANA, for Health Care Services” on the in Honolulu, Hawaii in 2001. Together Each Achieve More. Islands of Oahu, Maui, and Her 44 years of being a nurse Kauai. www.advantagehealth. can be summed up into four Director: Joan Parker-Dias, MSN, APRN care categories of service training, Dr. Walch served on practice, and research: Joan Parker Dias, MSN, APRN is originally from Canada numerous boards such as the 1. Primary Healthcare and has worked in inpatient and outpatient behavioral Aloha Medical Mission, the In Urban and Rural health for 28 years. Nancy Jailu V. Navarrete Filipino Chamber of Commerce Communities. Atmospere-Walch of Hawaii as an Immediate 2. Women and Newborn Care Services Director: Marion Poirier, M.A., R.N. Past President, Hawaii Waiver 3. Leadership Effectiveness and Strategic Planning Provider Association, the Philippine Nurses Association 4. Spiritual Dimension in Caring. Marion Poirier, M.A., R.N. of America and the PNAAF Foundation, the Chaminade has been an executive director School of Nursing Advisory Board, and the State of The first ten years were learning/teaching years as of the then combined Hawaii Hawaii Small Business Regulatory Review Board. She is a she explored on how to deliver "Health Care For All." Nurses Assn. from 1979 to Founding Director and Trustee of The Belize Foundation, This brought her consultative knowledge and experience 1985. The American Nurses https://thebelizefoundation.org/. The Belize Foundation to disadvantaged communities in the Philippines, South Assn. and its then student is a non-profit (501c3) organization to promote human Korea, Midwest USA, and East Africa. She settled in nurses association began the and environmental development, conservation, and Honolulu, Hawaii and served roles as Staff/Charge Nurse/ journey in my home state of sustainability within the nation of Belize. Preceptor/New Grad Program educator, at a Women and Massachusetts. Most recently Dr. Walch, a Nurse Executive, has a Bachelor’s and Newborn facility where she also volunteers her time, I have focused on getting our Doctorate Degree in Nursing, Master’s degree in Public resources, and passion, speaking and advocating Nursing new organization in Hawaii Marion Poirier Health, a Licensed Nursing Home Administrator, a Certified as a career to high school seniors at two local H.S., and “together” with other Board Care Home Nurse, a Master Certified Health Education at Hawaii Convention Center during Health Occupation members and being active with Specialist, AHRQ Master TeamSTTEPS Trainer, DHS Services-Fair. She served as a Panel Member for the RN the ANA-PAC. Approved Registered Nurse Evaluator, and a Certified Case National Licensure Exam (NCLEX) in 2010. Her volunteer When my two sons got busy with school I got busy Manager. Dr. Walch manages her business fulltime while services extends with Aloha Medical Mission in 2014, and with my graduate degree in management/healthcare going for her doctorate and still found time to give back Foodbank food distribution, 2019. administration. That led me into a satisfying non-profit to numerous professional and community organizations. Jailu Navarrete who is also known as J.V. Navarrete for health and human services career. I’m currently retired Dr. Walch is a role model and mentor for other aspiring her research work, presented Leadership Effectiveness after 14 years at NAMI HAWAII. Nurse Executives. She is a member of Sigma Theta Tau and Strategic Planning Methods at conferences of Through all my work years and even now, government International, the Nursing Honor Society, and an inductee the International Council of Nurses, held in Japan, affairs has had my heart and soul. to the UH Manoa Nursing Alumni Hall of Fame. South Africa, and South Korea. She declares in her I look forward to spending time with all of you, both presentations, "All nurses are leaders, be it at the bedside socially and professionally. Director: Jailu V. Navarrete, RN or in a board room." She's a member of ACHE. May you and yours stay healthy and happy until we Jailu's caring would not be complete without the meet again. Jailu Navarrete is a visionary, where a vision is the Spiritual Dimension of Nursing/Healthcare. She co-founded preferred and expected outcome that inspire, to work the Hawaii Christian Nurses Fellowship. Nurses need faith,

American Nurses Association is Back in Hawai’i! for health insurance plans to cover the total costs of Hawaiʻi Registered Nurses now is the time to continued from page 1 contraception, and reversal of the policy in the ACA that join your state professional nurses association to prohibits discrimination against patients based on their demonstrate to the community the power of the nursing reasons why Hawaiʻi needed a professional state nurses gender or sexual orientation. voice. Join today at hawaii-ana.nursingnetwork.com! association. There needs to be one collective voice for Hawaiʻi-ANA is committed to active engagement in all Hawaiʻi nurses! dialogue, education, and advocacy to address these Hawaiʻi-ANA’s mission to to empower nurses to issues. We are the professional state nurses association advocate for the improvement of the healthcare system that can educate our legislators and community on the in the communities where we live and work. In the distressing effects of these rulings and advocate for past years Hawaiʻi-ANA’s’ leadership group provided prevention in the future. We also can use our voice to BECOME A written testimony for state legislative hearings regarding inform our community on the importance of wearing healthcare issues, APRN scope of practice, medical aid masks and other infection control strategies. We can MEMBER TODAY! in dying, dental coverage for medicaid recipients, and support our new nursing workforce as the inevitable more. At the national level, ANA has provided joint future of the baby boomer retirement approaches. We position statements with other healthcare organizations can provide continued education opportunities that regarding mask wearing, return to normal OSHA will assist our workforce to meet licensure renewal standards for healthcare professional work safety, and requirements. And most importantly we can increase testimony for legislative bills such as the DACA program, the representation of nurses in the media to promote the Supreme Court’s ruling to strike down the Patient the profession of nursing. Protection and Affordable Care Act’s (ACA) requirement One team committed to the best patient CARE for our community. Compassion Aloha Respect Excellence COME JOIN OUR TEAM OF DEDICATED TEAM OF NURSES AT

Equal Opportunity Employer / Disability / Vet TO VIEW OUR NURSING OPPORTUNITIES, PLEASE VISIT US AT www.queens.org/careers. Page 4 • Hawai’i Nurse August, September, October 2020 President’s Message

Katie Kemp, RN-BC, BAN when Hawaiʻi Nurses Association (ANA) moved to an from various health settings: Laura Reichhardt, independent collective bargaining group. Over the AGPCNP and Director of Hawaiʻi State Center Aloha Hawaiʻi Nurses! I next three years our group overcame challenges, for Nursing; Melody Kilcommons, MBA, BSN and am honored to write you in occasionally felt hopeless, but at the end were Director of Emergency and Trauma of Kapiʻolani our first quarterly newsletter rewarded with American Nurses Association (ANA) Medical Center; and Bradley Kuo, PMHNP, and as President of the newly approving our constituent state nurses association Founder of Wellness Partners a online mental established Hawaiʻi - American in December of 2019. health clinic. During the webinar we discussed the Nurses Association. My journey With January 2020 around the corner we felt use of telemedicine and nurses role, emerging with Hawaiʻi-ANA began in what is more fitting than to welcome Hawaiʻi-ANA nurse specialities and health professions, economic 2016 when I moved from and the Year of the Nurse and Midwife? Of course challenges of nursing during a pandemic, and Minnesota to Hawaiʻi as a 2020 had a different plan in mind and we fell recommendations to new graduates entering the new graduate RN and found into how do we advertise our new state nurses workforce. Our speakers had a common consensus Hawaiʻi to be without a state association in the middle of a pandemic when that nurses need more representation in policy and Katie Kemp nurses association. Coming social distancing has squandered all capabilities legislation to improve and strength our profession, from a union state with a strong union presence of hosting in-person events? Without choice we and support better outcomes for our patients; and state nurses association I was disheartened welcomed the new fad of virtual events via webinar! and new trends suggest more job opportunities in to learn there was no professional organization for As both a member of Hawaiʻi-ANA and Hawai’i community based nursing roles. Although the task me to belong to. Through networking connections I Young Healthcare Professionals (HYHP) I had the of running my first virtual webinar with a panel was able to connect with a group of nursing leaders opportunity to lead our first joint event titled “The presentation was daunting it demonstrated the in Hawai’i who had been working to re-establish Future of Nursing, The Future of Healthcare.” We resilience and quick adaptability of nurses. With one the state nurses association that was lost in 2008 had a panel of excellent Hawaiʻi nurse leaders virtual event under my belt I am looking forward to our first annual (virtual) membership assembly on September 12, 2020 where we will feature two CE presentations on “Compassion Fatigue” and “Health Disparities and Initiatives,” adopt our bylaws, and elect several officer positions. I invite you to connect with us on Facebook, Twitter, Instagram, our website, or via email! August, September, October 2020 Hawai’i Nurse • Page 5 Central Oahu District Notes

Your Central Oahu Hawai’i-ANA Coordinators In addition, our vision is that you get to know each District Formation at Jailu Navarrete, RN and Marion Poirier, M.A., R.N. other personally. Maybe some of you write, are musical, [email protected] or (808) 497-3443(m) or would enjoy future outings together. Because of the Central Oahu Covid 19 Virus, gatherings are on hold. We’re thinking Hi One and All! We appreciate your time and interest about virtual gatherings of our group on Zoom. Are you in our inclusion of a geographically local group of interested? Email below. Do you have guest speakers in members of Hawaiʻi-ANA and members of ANA-Only. mind? Until we meet, stay safe, and share your thoughts Our vision is to have members interact with nurses about the subject. working in different settings and sharing their expertise.

BE PROUD OF YOUR MEMBERSHIP IN YOUR STATE PROFESSIONAL ASSOCIATION. These are the Hawaiʻi- ANA members living in Central Oahu: Is your name here?

Carrie Alexander Ariel Aquino Teri Fonoti Alohalani Lindsey Christy Rios Pokii Balaz Jenny Greenlee Veronica Mitchell Edna Smith James Beasley Paul Hannigan Jailu Navarrete Corinne Suzuka Marion Poirier, M.A., R.N. Laura Blue Bobbie (Roberta) Holloway Nora Phillips Lani Untalan and Jailu Navarrete, RN Alice Chang Leilani Hosaka Cadiz Agnes Pigao Christina Villanueva Perie Danao Leeah Javier Marion F. Poirier Suzette Wright-Maximo GEOGRAPHICAL BACKGROUND Alison Diehl Teah Karamath Joselyn Ponce Kelly Yano Central Oahu is the region of Oahu situated between Karen Dureg Natalie Kitamura Rica Lorraine Rabanal Kristine Yearwood the Waianae Mountain Range and the Koolau Mountain Range. Central Oahu encompasses the communities of Pearl City, Mililani, Wahiawa, Ewa Beach, and Kapolei. Central Oahu is between 15-30 minutes from Honolulu. This region is where large medical centers such If your name is on this list, you are a member of ANA-Only, and you are not a member of your state as Pali Momi, Queens-West, and several urgent care, association. Want to join Hawaiʻi-ANA jointly with ANA? Just email Linda Beechinor at executivedirector@ specialty clinics, nursing care homes are located. hawaii-ana.org and say you “want to be a joint member of ANA and Hawaiʻi-ANA.” We will help you join us in our state nurses association (bonus: it is less $$!) The VISION for CENTRAL OAHU DISTRICT Linda Fukuhara Michelle Maxilom Liza Oasay As Hawaii-ANA will be divided into districts, Central Jennifer Abe Marcelina Gallardo Tammy McKee Chanel Paresa Oahu will be a major district where many nurses Kris Aceret Reveline Gorospe Mark Mendoza Ralf Ian Pasion live. Our vision is to gather nurses, actual or virtual, Cindy Arce Michele Hadano Mildred Mikuni Jennifer Pyun to inspire, interact, and influence one another while Rosemary Baugh Carissa Hamelin Haunani Miller Kristine Qureshi working at different settings. Through these gatherings, Tania Budyn Guillerma V. Helco Kristina Miller Liberty Rongcal there will be personal and professional sharing of Manuel Calupe Jr Eunice Hipolito Linda Mitchell Elsa Talavera common interests. Among those events and activities Marie Suzette Castillo Emma Holland Stephanie Miyasaki Linda Thorp could be sharing of expertise, inviting guest speakers, Michelle Chapman Carly Hu Andrea Montgomery-Kylie Janet Uyehara addressing issues and concerns, form study groups for Trang Christie Karen Kalanta Rachel Morrison Aimee Villarmia continuing education, meeting legislators representing Michelle Clayton Alison Kaneshiro Ku’uleikuponookealoha Susan Von Essen the community to partner in solving healthcare issues, Kilihune Demello-Kamaka Elaine J. Kawamoto Na’ahi’elua Jasmine Wagner cultural and sports events, music, arts, and the list can Belinda A. Dungca Ethel Koga Ramona Nakagawa Kimberly Webster go on. Members of the Hawaii-ANA will be engaged as Joanna Edwards Madelyn Locquiao Priscilla Navares Gary Yoshimoto event planners and leaders. The ripple effect of recruiting Eileen Factora Rowena Fuata Christine Loui Esther Njoroge John Yoza new members and developing new leaders will sustain Jennifer Zafrani organization growth.

WHERE DO WE BEGIN? Our current joint members, (listed here,) will be tapped, assessed on talents, skills, specialties, begin mentoring leaders, and then reach out to all nurses in the district. There'll be introductions about the brand- new Hawaii-ANA through marketing materials, social Continuing Competency media, group presentations, one-on-one. Joint members will be invited and encouraged to attend the Hawaii-ANA Membership Assembly in September 12, 2020 where joint members are eligible to vote. ANA Webinar Series Meeting Continuing Contact us! We want to hear from you. The future is open for possibilities. Availablie at https://hawaii-ana.nursingnetwork.com/ Competency Marion Poirier: [email protected] page/94845-nursing-courses-focused-on-covid-19 Jailu Navarrete: [email protected] Requirements for • COVID-19 in Non-Acute Care Settings: Hard- Learned Lessons from Two APRNs on the RN License Renewal Frontlines If you are ANA-Only • How You Can Have a Direct Impact on Reducing the Devastating Racial Disparities of COVID-19 RENEWAL REQUIREMENTS & FAQs You cannot register for Membership • How to Survive the Pandemic with An Unbroken https://cca.hawaii.gov/pvl/files/2019/02/1902- Assembly and receive the member Spirit: Actions to Take Right Now to Stay Strong NURSING-RENEWAL-REQUIREMENTS-AND-FAQS- registration discount, nor can you vote, and Focused final.pdf • Be Confident Protecting Yourself and Providing pass bylaws, elect officers, or run for office. the Best Care to Your Patients during this CONTINUING COMPETENCY GUIDANCE and COVID-19 Pandemic INFORMATION BOOKLET Switch to joint membership! • Ventilator Management: Essential Skills for Non- https://cca.hawaii.gov/pvl/files/2013/06/BON-CCG- ICU Nurses INFO -2017.pdf Email Linda Beechinor at • How to Respond to Ethical Challenges and Moral [email protected] Distress During the COVID-19 Pandemic • COVID-19 Self-Care Package for Nurses and state you “want to be a joint member • How to Survive the Pandemic with An Unbroken of ANA and Hawaiʻi-ANA.” Spirit: Actions to Take Right Now to Stay Strong and Focused Page 6 • Hawai’i Nurse August, September, October 2020 ANA-Hawai’i Membership

BE PROUD OF YOUR MEMBERSHIP IN YOUR STATE PROFESSIONAL ASSOCIATION. These are the Hawaiʻi-ANA members (other than central Oahu): Is your name here?“ Theresa Abraham Ruthie Clearwater Amelia Greenidge Katherine Kemp Liza Oasay Dawn Styner Soraya Acosta Denise Cohen Kathleen Hagan Daniel Kim Maureen O’Brien Keli Taylor John Aiwohi III Rachel Coolidge Rhoberta Haley Randi-Anne Lau Mary Frances Oneha Martina Taylorcampbell Veronica Alvarez Gerilyn Corpuz-Takemoto Marie Hammond Quanae Lill Susan Oppie Claudine Tomasa Blanca Badgett Abigail Daigle Jani Harada Tazialynn Lynam Valerie Parayno Alice Tse Linda Beechinor Phoebe Dahilig Kimberly Hayashi Sherlyne Gayle Mabalot Elizabeth Pavlik Alexis Uttecht Ali Bernhardt Haley Deforest Nyra Hebrio Mary Marshall Sarah Perkins May Joyce Vertido Francia Birulin Patti Dellaport Stephanie Higa Cheryl Menzsa Carol Petith-Zbiciak Erin Von Der Ahe Jeny Bissell Liza Dernehl Ruth Honda Soila Mirin Alexander Phelps Thyra Wilbur Pola Isabelle Bonete Cortez Fabia Ferna Idica Jaymilette Moken Marieliese Ramirez Jennifer Wold Darlene Bootier Lynne Faulkner Kathryn Inamine Molly Moore Dana Ramos Kamomilani Anduha Wong Lydia Brandes Janice Ferguson Barbara Insisiengmay Richard Moore Christina Ranan Victoria Yao Patricia Brooks Sara Flake Valerie Janikowski Doreen Nakamura Karol Richardson Robin Zachary Kathleen Burger Vanessa Galutira Monica Joiner Abbie Neves Anne Scharnhorst Lorena Zerwig Rachel Cabel Peter Gampon Laura Jambura Patricia W. Nishimoto Young Schoen Michelle Casteel Lena Gebelein Kathryn Jones Maria Noel Samantha Shackleford Jessics Caudill Gian Gizelle Grasparil Barbara Karodia Shellie Norman Dolores Soler Bergau

If your name is on this list, you are a member of ANA-Only, and you are not a member of your state association. Want to join Hawaiʻi-ANA jointly with ANA? Just email Linda at [email protected] and say you “want to be a joint member of ANA and Hawaiʻi-ANA.” We will help you join us in our state nurses association (bonus: it is less $$!)

Kathleen Acierto Dyanarra Alexa Ballesteros Natalyn Cayetano Trisha Devereaux Andrea Manaea Katharine Sawicki Susan Anderson Daniel Baston Clementina D. Ceria Corey Dillman Anella Mark Helena Sena Kristin Arrindell Nancy Bellatti Lolita Ching Helena Doherty-Gehrke Catherine Marquette Elizabeth Seymour Elizabeth L. Asahara Mary G. Boland Kristen Collat Glenda Dumayas Shaun Marsh Maureen Shannon Nancy Atmospera-Walch J. Kamailani A Boyd Francisco Conde Janina Espiritu Stephanie Marshall Raelene Shinchi Merita Sao Auelua Stacy Braddy Mae Kimberly Corpuz Janet Francisco George McElravy Sharon Skouge Ingabritt Backlund Susan Cabalce Bobbie-Jean Crivello Brendon Friedman Jason McGregor Sharlene Skripko Alfred Bagdon Sara Castro Katherine Davis Debbie Fujiyama Cherry Elaine Medina Amy Snyder Cathlyn Gabriel Mi Mende Lena Souza Jennifer O. Galicinao Wendy Meyers Donna Ashlynne Spencer Arthur Garza Miller Dorota Strugala Joseph Giovannoni Semico Miller Cari Suhr kauai Melanae Gimang oahu Shirley Morca Kanoe Tani Caroline Glover Susan Ohlson Jona Marie Taylor-Palalay maui Eden S. Goto Linda Pacyau Tracy Thornett Michelle Grandalen Grace Pakele Kathleen Tomasa lanai Cindy Griswold Jennie Pasalo-Dominno Kim Tomasa Trisha Guillermo Melanie C. Pekala Joyce Trompeta Jaime Hahn Katie Pimentel Lani Tsuneishi Frankie Hale Jennifer Pliska Jolly Anne Uclaray Kristina Halloran Julie A. Potter-Dunlop Patti Urso hawaii Linda M. Hamada Linda Price Janet Uyehara Cindy Hanscam Sandra Quipotla Coraleen Valdez Madeline Harris Sandi Rabaca Jody Webb REGISTERED NURSE Rose Hata Richard Ramirez Karen Wilhite Katie Hokama Madonna Reisert Aya Windham Actively participates in the delivery of patient care including vital signs, phlebotomy, Renee Hollison laboratory processing, injections, immunizations, medication administration and Sheri Richards Shelley A. Womack Beverly M. Hookano Gayle Rodrigues Marie Wong under the auspices of the physician, assists with medical procedures, emergency Paula Hulme care, and x-rays. Coordinates referrals and case management. Promotes patient Brian Rose Elena Woo Christine Inamine Mary Rovelstad Monina Yamashita independence by establishing patient care goals, teaching and counseling patients Therese Ingram and family members and reinforcing their understanding of disease, medications Feliciana Sales Valerie Yim Jillian Inouye Lindsay Sanchez Naomi Yoshimoto and self-care skills. Also assists with supply inventory, quality control and maintaining Kristen Ishikawa clinic wide regulatory program compliance. Donna Sandberg Leigh Ziegler Elishia Jackson Paula Sanders Mary Jang EDUCATION Avril Jenkins Graduation from an accredited School of Nursing. Current Hawaii state license Allan Johnson as a professional Registered Nurse required. Current CPR, ACLS and PALS Jennifer Johnson certification required. Reid Kaneko Lori Kaneshige If you are ANA-Only EXPERIENCE Martin Katz Leanne Kauwe You cannot register for Membership At least two years current experience as an RN. Experience/comfortable with Josette Kawana the use of electronic health records. Emergency room experience desirable. Assembly and receive the member Leanne Kihara Experience in a rural community-based health setting preferred. Cera Kim-Sunada registration discount, nor can you vote, Merritt Kott pass bylaws, elect officers, or run for office SKILLS/KNOWLEDGE Christine Kramer Commitment to team approach to the provision of health services. Knowledge Lydia Kumasaka Switch to joint membership! of principles and practices of nursing in a community-based agency. Ability Krystle-Ann Lazo to communicate warmth, trust and professionalism to patients and staff. Basic Edith Loh Email Linda Beechinor at computer skills particularly in the use of electronic health records. Demonstrated Alison Lovell organizational skills with the ability to complete work assignments on time with Joyce Lovell [email protected] and state minimal supervision. Rachael Lund you “want to be a joint member of ANA Macey Luo-Souza and Hawaiʻi-ANA.” FIND OUT MORE AT: HANAHEALTH.ORG Sidney Macaw August, September, October 2020 Hawai’i Nurse • Page 7 Lobbying, National & State Policy News National and State Policy/Lobbying

Lobbying and influencing health policy Nurse Staffing Regulation One of the purposes of Hawaiʻi-ANA is to “Build a network of empowered nurses to ANA has supported ALL Nurses in their Practice through a legislative model that inspire change and improve our healthcare system and community” empowers nurses to create staffing plans specific to each unit. Staffing levels that are oo In Hawaiʻi: Nurses were very active in the state legislature to advocate accountable and flexible for changes such as intensity of patient's needs, number of for our profession and the community in the past. We have lost our “one admissions, discharges and transfers during a shift, level of experience of nursing staff, strong voice of Hawaiʻi nurses” over the past decade, but we are back and lay out of the unit, availability of resources (ancillary staff, technology, etc.), There are active as Hawaiʻi-ANA, working with other stakeholder organizations. about 14 states that address hospital staffing in laws/regulations. oo In the nation: Our senators and congresspeople ask “where are Hawaiʻi’s Hawaiʻi-ANA has been working with ANA's Government Affairs by supporting a nurses?” Linda Beechinor, who is now Executive Director of Hawaiʻi-ANA, NATIONAL Staffing Bill. was the only nurse from Hawaiʻi at Lobby Day in years past in Washington HR 5052 that amends title XVII Social Security Act to provide for patient protection DC , to sit down and discuss bills of interest to nursing with , by establishing safe nurse staffing levels at certain Medicare providers, and for other , Mark Takai, , , and others. purposes. HR 5052 is co-sponsored by our own Hawaii Congresswoman Tulsi Gabbard. It is a well-structured amendment to Title XVIII of the Social Security Act. In addition to promoting safe quality patient care via safe nurse staffing the Bill includes enforcement and a money penalty clause for non-compliance PLUS a prohibition of discrimination Rep. Tulsi Gabbard Introduces and retaliation clause to protect patients and/or employees. Nurses in all fields will benefit should HR 5052 become law and so will their patients. Bill to Prevent Forced According to Hawaiʻi-ANA Executive Director, Linda Beechinor, APRN: "Nurses are seen by the public as a most trusted profession. It is our duty as a profession to advocate for the patient in our complex, user-unfriendly healthcare Furloughs for Nurses During system. As a member of the American Nurses Association I fully support this bill. Evidence in the professional literature supports these safe staffing requirements to Coronavirus Crisis prevent errors, readmissions to hospitals, and nurse burnout, among others. Poor outcomes of healthcare burden the taxpayer and the patient with preventable costs, Washington, DC—Today, Reps. Tulsi both financial and in quality and quantity of life." Gabbard (HI-02) and Rodney Davis (IL-13) introduced H.R.6809, the Nurse Workforce State Lobbying: Protection Act, which would prevent a We attended Opening Day at the 2020 Legislature, see Legislation page on our healthcare provider from laying off a website. significant portion of its nursing workforce We have offered testimony on various bills posted in the website too, https://hawaii- or significantly reducing their hours during ana.nursingnetwork.com/page/93916-legislative-testimony. The latest testimony was the coronavirus crisis as a condition for offered re: continuation of Federal Student Loan grants for healthcare professionals in receiving federal emergency relief funds. Hawaiʻi which was not taken up by the legislature in the special session following the gabbard.house.gov shutdown d/t Covid-19 pandemic. To get involved in lobbying activities and healthcare policy/ legislative initiatives, https://gabbard.house.gov/news/press-releases/ contact Linda Beechinor, Executive Director at [email protected]. rep-tulsi-gabbard-introduces-bill-prevent- forced-furloughs-nurses-during Student Nurses Page An Opportunity for Student Nurses to have a Voice in Hawaiʻi-ANA. Members of the National Student Nurses Association (NSNA) are eligible to sign- up as ANA Student Subscribers for free – a $10 value! If you are not a member of NSNA, you can still sign up as an ANA Student Subscriber for free by agreeing to receive membership information from NSNA anasubscribersignup.org or https://www.nursingworld.org/membership/student-nurses/. Also check out your Hawaii Student Nursesʻ Association at www.hisna.org

Reducing Hospitalized Length of Stay by Addressing Barriers to Discharge

Dana Malia Fuerte and Sara Mitre College of Health and Society, Hawai’i Pacific University Dana Malia Fuerte Biography Evidenced-Based Practice April 10, 2020 This month we are featuring the work of a student nurse who has contributed to the literature supporting the practice of nursing. Born in Introduction Honolulu, Hawaiʻi, Dana Malia Fuerte, BSN, RN recently graduated from Length of stay (LOS), defined as an inpatient’s duration of hospitalization in the Hawaiʻi Pacific University and found her journey to Hawaiʻi-American acute care setting, is affected by multiple factors, both medical and non-medical. Nurses’ Association as both a member and communication intern. Fuerte While LOS varies by the complexity of each patient, diagnosis and the standing worked alongside Sara Mitre, BSN, RN in an Evidenced-based Practice support of outpatient resources, the Organisation for Economic Cooperation and project titled "Reducing Hospitalized Length of Stay by Addressing Development reports the average length of stay (ALOS) in the is 6.1 days Barriers to Discharge,” which analyzes cost efficient methods for reducing (Health at a Glance, 2017). The anticipated discharge date for most patients can be an inpatient’s hospitalization in the acute care setting. By reducing an determined early in the admission process to alleviate any non-medical postponements inpatient’s length of stay, hospitals experience decreased workload in discharge if a multidisciplinary approach, case management, and client education demand, a reduction of costs and supplies, and ensure that patients are are effectively utilized at the earliest given opportunity. This paper addresses how receiving the best possible care from admission to discharge and beyond. acknowledging barriers to discharge prompts the reduction of patients’ LOS, which The literature research and review highly recommends integrating ultimately allows for a faster achievement of health outcomes, reduction of hospitalized the prioritization of discharge rounding through all members of the interdisciplinary team. Reducing Hospitalized Length of Stay by Addressing Barriers to Discharge continued on page 8 Page 8 • Hawai’i Nurse August, September, October 2020

Reducing Hospitalized Length of Stay by Addressing Barriers to This particular method of addressing likely and potential discharge patients first Discharge continued from page 7 allows for the most time between identification and actual discharge. In doing so, it allows all members of the team to be aware of the potential discharge and perform costs and supplies, more bed time, increased service capacity, and decreased hospital all tasks required prior to the discharge orders being placed, again reducing and workload demand, which are all desirable hospital goals nationwide. mitigating wait times. Additionally, this type of rounding proves to be exceptionally Our team developed the PICO question: In the acute care setting, how does beneficial for physicians because a barrier often cited by physicians is that they are acknowledging barriers to discharge impact acute care inpatients’ average length of either rounding on other patients or tending to their other patients’ healthcare needs stay? Our study analyzes facilitators and barriers to ultimately reducing hospitalized (Zoucha et al, 2018). ALOS and provides effective recommendations for implementation of practices into The prospective cross-sectional study of 1,584 patient evaluations based on the clinical setting, with a nodded acknowledgement to what is already respectfully physician and housestaff surveying from five academic hospitals conducted by Zoucha serviced in a general, Level 1 hospital, Queen’s Medical Center at Punchbowl (QMC) in et al. (2018) determined what the most likely barriers to discharge order writing were. Honolulu, Hawaiʻi. Each participating physician or staff member was given a survey three times a day— approximately 8:00am, 12:00pm, and 3:00pm. Each survey asked the participating Facilitators team members what the most common or likely barrier to ensuring timely discharge Facilitators are medically-related proponents that acknowledge barriers to for targeted patients was at that point. The results revealed different yet connected discharge, promoting a sooner anticipated discharge date for all inpatients by meeting causes to a delay in writing the discharge orders. In the morning survey, most healthcare outcomes in a timely manner and thus reducing ALOS. The analyzed practitioners attributed a delay on having not finished rounding on other patients. The facilitators of a multidisciplinary approach, case management, and client education noontime survey responses alluded to an inability to complete discharge paperwork through ERAS all evoke the six competencies derived from the Quality and Safety due to actively caring for other patients. Responses in the afternoon stated that most Education for Nurses (QSEN). Reducing ALOS through client education, especially physicians were currently in the process of doing the discharge paperwork and that in when integrated through the ERAS multimodal pathway, cannot be effective without and of itself was the delay. evidence-based practice, safety, and the incorporation of compassionate and coordinated patient-centered care with respect to multiple values and perspectives Case Managers of the patient’s own view of health and symptoms. Teamwork and collaboration Managed care through a case management approach advocates for early is unequivocally seen through all areas of the hospital, but are strongly evident discharge planning in an attempt to contain the expenses of hospitalized care. through a multidisciplinary approach and the coordination of the case management By utilizing a collaborative, multidisciplinary approach, case managers are able to team. Additionally, information and technology is utilized as an effective tool to track assess, coordinate, and facilitate the complexity of individualized patient needs. readmissions, frequent utilizers, and various inpatient needs. The collective data can Through prompt planning with initial assessments of all inpatients paired with the be utilized through a quality improvement approach of standards; in turn, facilitators care coordination for patient dispositions, medical equipment and community care improve health care services to all inpatients. resources, case management is an effective system to combat barriers to discharge— without exhausting available resources—and ultimately reduces both the number of Multidisciplinary Approach acute care visits and ALOS. If there is not effective unit cohesiveness and a multidisciplinary approach utilized to Case managers are a vital resource in all areas of the hospital, with their role treat patients, a barrier often encountered is ineffective communication, which results attaining most valuable in units with high admissions. A medical center’s emergency in a discharging postponement of patients who otherwise are prepared for discharge department (ED) is a commonly frequented area for super utilizers with clients (Ragavan, Svec, & Shieh, 2017). Proper and early communication by members of making visits to up to four or 20 visits per year. Up to 28% of utilizers are admitted as different healthcare disciplines can help mitigate an unnecessary delay of discharge. inpatients, ultimately contributing to recurrent increases in healthcare costs, resource Known as a multidisciplinary approach, this method allows for early integration of shortages, and overcrowding with lack of bed availability (Grover et al., 2018). While multiple components of a patients’ treatment team, reducing the wait times for the chief reasons for emergency visits and admissions are complex and varied, ancillary services. These services include but are not limited to physical therapy, inpatients that commonly visit and are admitted with a prolonged ALOS (average occupational therapy, speech therapy, and pharmacy. When a patient’s discharge length of stay) incur significant medical charges and testing as part of the acute status changes from a ‘definite’ or ‘possible’ discharge status, as many as 39% care assessment, evaluation, and treatment by ED physicians, nurses, and other of these cases are changed due to barriers associated with these ancillary services members of the interdisciplinary team. and receiving necessary recommendations or guidance regarding patient status and A comprehensive study conducted by Grover et al. (2018) verified the care (Zoucha et al, 2018). By integrating them early and as an equal partner in the true effectiveness of the case management team in a suburban hospital with discharge planning process, it could reduce or eliminate the wait times associated. approximately 56,000 ED visits per year. Population of the study included 158 adult Incorporation of the social work team at the earliest point of intervention patients, which comprised of clients with a high risk for readmission, concerning possible to begin working on the complex nature of psychosocial barriers—including ED use (as identified by an ED staff), and/or a high number of ED visits and homelessness, mental health issues, domestic violence, and substance abuse— helps admissions within a period of time. More important to note, this included frequent address potential barriers early to assist with barrier mitigation. Oftentimes, these utilizers who acquired 10 or more visits to the ED in 12 months, six or more in six psychosocial barriers are the only thing keeping the patient from being discharged months, or four or more visits in one month. The study immersed the Emergency to the next level of care, either to a previous living situation, foster home, or skilled Department Recurrent Visitor Program (EDRVP), a case management program that nursing facility (SNF) simply because care coordination could not be completed for addressed increasing visits to the ED, by identifying patient needs adequately, and these patients (Harrison, O’Malia, & Napier, 2019). While the complexity of certain was introduced at the onset of patient visitation to the ED. An additional, further situations warrants additional time, if these issues are identified at admission they aim of the study investigated the reasons for inpatient admissions with respect to should be addressed immediately. Because The Queen’s Health System (QHS) has various types of insurance. In the one year prior to patient-population enrollment implemented the CMS Accountable Health-Related Social Needs Screening Tool—a of EDRVP, the hospital acquired 1,686 ED visits with 159 inpatient admissions. simple survey used to identify five crucial areas of social needs—into their electronic However, after inclusion of the program paired alongside the case management health records (EHR) it makes it quick and effective to identify these patients upon team, the hospital received a significantly less amount of visits and readmissions: admission (Trinacty, et al, 2019). 855 ED visits and 97 inpatient admissions. ALOS for inpatients prior to EDRVP was A retrospective observational study of 93 patients’ electronic medical records 125 days as compared to post-intervention of ALOS as 83 days; the percentage (EMR) was conducted by Harrison et al. to determine the importance of developing a change is 33.45% (Grover et al., 2018). Additionally, the utilization of overusing model of care that incorporates early social work intervention to identify and combat hospital resources, such as CTs, ultrasounds, radiographs, and blood testing all psychosocial barriers (2019). The age range of patients’ EMRs referenced was 16 to statistically decreased in turn of about 49%. Majority of the inpatients (57%) had 97 years old. The study identified categories of barriers for these patients including Medicaid, a federal and state funded coverage for low income, which demonstrated homelessness, substance abuse/misuse, mental health issues, family conflict, domestic lower hospital reimbursements as compared to private health insurance programs. violence, financial stresses, and challenging behaviors. What researchers revealed Overall, the study demonstrated that case management simply reduced cost was that, typically, patient psychosocial barriers were not appropriately identified and metrics by simply limiting the number of people out of the ED, which has a major addressed until a point of crisis during their hospitalization. The crisis then initiated effect on admissions and the costs of testing on inpatients. the need for a social work consult and referral to be placed much later than upon From a hospital administration standpoint, it is proven that rotations from the admission, posing a potential for a delay in the discharge planning process. The research concluded that the prioritization of early social work intervention and inclusion in patient care could reduce unnecessary LOS by 33 days over a 12 month span by appropriately managing the barriers proactively rather than reactively (Harrison et al., 2019). The order in which members of the multidisciplinary team or interprofessional collaboration (IPC) conduct their rounds and assessments of the patients also impacts discharge planning and ultimately LOS. While rounds in general—whether nursing, physician, ancillary, or IPC rounds—are based on a system of prioritization, the priority framework varies based on the individual conducting the rounds. There are numerous methods of rounding utilized in hospitals; there is no universally used process, even among units within the same hospital. Convenience-based rounding, also called ‘room- by-room’, includes starting at one location and moving systematically down a hallway. Other methods include assessing patients based on the most recently admitted first or the patients who have been on the unit longest first. A more commonly used approach to rounding is rounding based on the patients’ condition (i.e. sickest patient first). Lastly, rounding on the premise of discharge eligibility is another rounding method— one that we will discuss further. August, September, October 2020 Hawai’i Nurse • Page 9 Barriers Barriers are components of care that hinder the discharge of a patient. There are several different barriers depending on the patient, their diagnosis/medical status, psychosocial factors, and/or medical staff assigned to the patient. Because there is no one cumulative list of barriers that impact patient LOS, it is important for each member of the multidisciplinary team to attempt to address potential or perceived barriers as soon as they arise. By identifying and overcoming barriers, patient outcomes are positively impacted as well as the hospital anticipated revenues.

Patient Disposition Patient disposition essentially means where the patient will be going upon discharge—whether that is a discharge to home, hospice, skilled nursing facility, or short-term rehabilitation. One specific type of patient disposition is one often encountered in the healthcare system, the “stranded” patient. This term is used for patients who have been medically cleared for discharge but remain in the hospital due to lack of appropriate availability at the next anticipated level of care (Harrison et al., 2019). Often, these patients will remain in a medical-surgical unit, step- down unit, or clinical decision unit (CDU) as they await placement in an available case management team are an effective, beneficial resource in reducing visits and post-acute care (PAC) facility. These patients are at an increased risk of infection, inpatient LOS, lowering institutional costs, and the reduction of over-utilization of functional decline, and overall negative patient outcomes (Kuluski, Im, & Mcgeown, healthcare resources allowing the interdisciplinary team to provide faster health 2017). Additionally this lack of disposition increases hospital and insurance costs, interventions and care to ED patients. This ideal can be applied to other facets decreases revenue, and decreases the bed availability for a unit (Zhao et al., 2018). in the acute care setting. By advocating for prompt discharges and reducing To examine discharge barriers, Zhao et al. (2018) conducted a retrospective visitations, facilities are incurring less testing costs and are acquiring available observational study of 172 patient charts from Stanford Hospital. Results from bedtime for new, acutely ill patients in need for more time-sensitive treatments. this study revealed that 93 of the total studied population were a postponed discharge due to ongoing medical problems. Of the remaining 79 patients, 56% Client Education Through ERAS were discharge delayed due to patient disposition unavailability. These 44 patients As health educators, nurses are knowledgeable in illness care, health education experienced average delays of 8.5 days for a PAC facility to have availability; and promotion, and disease prevention activities. Education facilitated by the multiple patients remained in the acute care setting for more than two months nursing staff empowers patient independence by building upon health knowledge following medical clearance. The 44 patients accounted for approximately 693 and preparedness for self-management and expectations through the entirety of excessive inpatient days. Overall, the study showed that the most common barrier treatment. This practice benefits both participants of the nurse-client relationship— to safe and effective discharge is having a PAC facility available for the number of as nurses are able to assess the degree of health capacity while simultaneously patients regarding the services. establishing rapport, patients become equally or more involved in their treatment and are likely to continue in beneficial health practices post-discharge (Siask et Homelessness al., 2019). More commonly, client education of medications and positive health Hawai i is undoubtedly a culturally, ethnically, and racially diverse community. actions as related to the complexity of care, are initiated by the nurse at the point ʻ The population also consists of people representing every socioeconomic class— of discharge. If client education is introduced at the earliest point of the nurse- one in particular requiring immediate attention within our state: the homeless. client relationship, ALOS is reduced due to the prevention of medical conditions and Because homelessness is a psychosocial barrier that warrants involvement of the comorbidities. The Enhanced Recovery After Surgery (ERAS) Program challenges social work team, case management team, and community resources, ensuring the compliance pathway by implementing client education as an early facilitator for these entities are effectively communicating with one another as well as the discharge planning. physician, nursing staff, and ancillary services is a major component of preventing The multimodal program ERAS launched in 2009, with the prioritization of prolonged discharges. By working as one unified force, it ensures that the client education and independence that centered on patients undergoing major discharge is the most thorough and appropriate for this specific subpopulation; not surgical procedures through the education of determinants to health during the only to remove the barrier to discharge, but also to potentially prevent a 30-day preoperative phase for expedited bodily healing after surgery (Greenshields & readmission (Lawall, Wu, Fan, Ashton, & Sentell, 2019). Mythen, 2020). Educational classes with the integration of evidenced-based theories While not all homeless people utilize medical services, this population accounts and interventions are utilized with a cosmic emphasis on optimizing various medical for a significant portion of annual emergency department visits. Homelessness, conditions as determined by the client’s medical and holistic needs. Common topics along with other social determinants such as poverty and limited social support, of ERAS include tobacco and alcohol cessation in addition to stress reduction comprise nearly 40% of all healthcare burdens (Trinacty et al., 2019). QMC is aware techniques, which includes but is not limited to deep rhythmic breathing and guided of the financial cost associated with caring for this population as between 2013 and imagery (Siask, et al, 2019). After surgery, ERAS protocol is subject to early client 2016, the hospital system had to absorb more than $40 million dollars of medical independence with the prevention and treatment of barriers or uncomfortable services for this demographic (Thornton, Koshiba, & Lee-Ibarra, 2017). symptomology—pain, nausea and vomiting. Health interventions include early Because these individuals are oftentimes unable to carry out safe and effective mobilization and early oral nutrition with the minimization of invasive tubes and drains post-discharge care, they remain in the hospital until it is safe for them to be as indicated by the patient’s readiness. Health facilities that utilize the ERAS pathway discharged to their previous living situation or until a PAC facility is willing to demonstrate a reduction in ALOS by optimizing allotted times for independence and accept them into their care. Because of the homelessness, many PAC facilities are education during the course of treatment as concluded by the Department of Health reluctant to take these patients as it puts a financial burden on the organization (Greenshields & Mythen, 2020). that likely will go unpaid. If these patients can be identified upon admission and The relationship of client education through ERAS and the reduction of ALOS was the multidisciplinary team can begin coordination for PAC placement or other analyzed through a preoperative education class with a group of inpatients at risk for community resources and alternative options, it could assist with decreasing this an extended length of hospitalized stay (Siask et al., 2019). The study analyzed how demographic’s LOS and assisting the hospital to avoid excessive cost absorption. early client education established inpatients’ psychological factors, such as feelings As “simple” as that task may seem, there are many factors that impact safe of control and empowerment with lack of pain, would affect positive patient health discharge planning for these individuals. Unfortunately, there are situations that behaviors post-procedure; and how this would in turn influence medical clearance many hospitals face related to the homeless population that no amount of timely and reduce LOS. A further aim investigated which groups of patients, in particular, and adequate discharge coordination can curtail. In instances such as this it takes would benefit most from early client education through the Risk Assessment a solid team, generally case management, to discuss with utilization management, and Predictor Tool (RAPT). At-risk patients were gathered based on the RAPT the best course of action for the patient and for the hospital. questionnaire, which ultimately assessed patient demographics and barriers to discharge. While all inpatients what standardized physiotherapy as initiated by the Recommendations and Implementation physical and occupational therapists, with surface-level education on protection, QMC respectively integrates a multitude of successful methods that attend rest, ice, compression, and elevation (PRICE), the preoperative educational class to inpatients’ barriers to discharge, reducing ALOS and facilitating the discharge was a call to reduce hospitalized anxiety by providing a detailed explanation of process. These methods incorporate EPIC Case Management Barriers to Discharge expectations during the course of treatment—protocols for induced-anesthesia, documentation, a multidisciplinary approach to patient wellbeing, and early exercises to start prior to operation, given pain control options in the post-operative intervention on behalf of the case management team and other ancillary services. phase on the acute care unit, and education on using durable medical equipment if Case managers work in tandem with social workers, social worker assistants, determined as a need at the point of discharge (Siask et al., 2019). ALOS was the physicians, and registered nurses to address inpatients’ barriers to discharge. An ultimate concluding factor between inpatients who attended an educational class initial assessment (IA) is performed on all inpatients within 48 hours of admission prior to arthroplasty and those who did not. Results of the retrospective study by the assigned case manager on the unit. Assessed and documented factors yielded a significant reduction in ALOS for the inclusion of a preoperative education include that of the inpatient: home address, health and medical insurance, session through an ERAS pathway from 3.1 days to 4.1 days. Additionally, early client support system, an accurate file of the primary care physician, current functional education is demonstrated to be most beneficial for patients at high-risk for ALOS, status and the status prior to admission, home health with any current durable with multiple barriers to discharge, averaging at a mean difference of 2.58 days less medical equipment, discharge transportation, medication, readmission to the QMC in the acute care setting. facility within thirty days, and the last visit to the primary care physician. From While the multimodal ERAS program is primarily focused on surgical patients, the this assessment, case managers are able to formulate a comprehensive health notion of integrating client education at the earliest point is significant to deduce. All members of the interdisciplinary team should and must educate clients at the earliest Reducing Hospitalized Length of Stay by Addressing point possible in addition to any given time in the relationship. Barriers to Discharge continued on page 10 Page 10 • Hawai’i Nurse August, September, October 2020 Reducing Hospitalized Length of Stay by Addressing best ways to decrease Barriers to Discharge continued from page 9 inpatient LOS, we have found that the QHS plan to address any anticipated discharge needs. has many evidence- Documented barriers to discharge at QMC include: based practices already behavioral, intravenous antibiotics, insurance, wound incorporated into the care, deconditioned, medications, isolation, durable system to benefit medical equipment, lab or radiology status, dialysis, the patients while social determinants, transportation upon discharge, decreasing costs and and/or unclear criteria for discharge. increasing revenue. While these are credible ways to decrease LOS Our recommendation while simultaneously reducing internal costs and would be implementing increasing service capacity, after a thorough review a standardized rounding of the evidence collected, our findings have led us to priority framework for suggest for a change in current practice. We highly members of the IPC recommend that QMC integrates the prioritization team. By prioritizing of discharge rounding through all members of the most likely discharges interdisciplinary team. Currently, members of the case first, it allows the management team prioritize their caseload based on team to determine what requirements still need on this journey in various ways. From faculty advising potential imminent discharge; we posit that utilizing to be met, establish an acceptable timeline for regarding how to approach this project to case this framework for other members of the IPC will those requirements, and discharge orders can be managers at Queen’s Medical Center who taught us help ensure timely discharges—decreasing cost to the written prior to members of the multidisciplinary everything we know about case management and the healthcare system, while simultaneously increasing team addressing other patients that are not pending importance of decreasing length of stay! beds available and hospital revenue. discharge. This would enable the team to have • Jennifer Nafarrete, MSN RN: Hawai’i Pacific more time to determine needs prior to discharge. In University Faculty Advisor Conclusion addressing these patients first, it decreases the LOS • Lise Choucair, EdD APRN FNP-BC: Queen’s Prolonged inpatient LOS with frequent readmission by making all members of the IPC aware of pending Medical Center Instructor, QHS Care is a top reason for healthcare expenditures, needs and helps practitioners determine a more Coordination representing a rising, complex group that ultimately effective timeline for writing discharge orders. • Mariesen Kirkham, BSN RN: Queen’s Medical overuses healthcare commodities, including the Center Case Manager indispensable resources of patient beds, hospital Acknowlegements • William Lee, BSN RN: Queen’s Medical Center services, and medical supplies. When researching We know that we could not have done this Case Manager practices that have been implemented successfully at evidence-based practice project without the help of other facilities and examining evidence regarding the multiple people. Thank you to all who have assisted us References Greenshields, N. & Mythen, M. (2020). Enhanced recovery after surgery. Current Anesthesiology Reports, 10(328) 49-22. doi: idm.oclc/org/10.1136/bmj.322.7284.473 Grover, C.A., Sughair, J., Stoopes, S., Guillen, F., Tellez, L., Wilson, T., Gaccione, C., & Close, R.J.H. (2018). Case management reduces length of stay, charges, and testing in emergency department frequent users. Western Journal of Emergency Medicine, 19(2): 238-245. doi: 10.5811/westjem.2017.9.34710 Harrison, G., O’Malia, A., & Napier, S. (2019). Addressing psychosocial barriers to hospital discharge: A social work led model of care. Australian Social Work, 72(3), 366– 374. doi: 10.1080/0312407x.2019.1593469 Health at a Glance 2017: Oecd Indicators. (2017). doi: https://doi.org/10.1787/health_glance-2017-64-en Health Care Use - Length of Hospital Stay - OECD Data. (n.d.). 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Journal of Rehabilitation Medicine,51: 788-796. doi: 10.2340/16501977-2602 Thornton, G., Koshiba, J., & Lee-Ibarra, J. (2017, September). Touchpoints of homelessness. Retrieved from https://humanservices.hawaii.gov/wp-content/ uploads/2018/02/Touchpoints-of-Homelessness-Report- Final.pdf Trinacty, C. M., LaWall, E., Ashton, M., Taira, D., Seto, T.B., & Sentell, T. (2019). Adding social determinants in the electronic health record in clinical care in hawai'i: supporting community-clinical linkages in patient care. Hawai'i Journal of Medicine & Public Health: A Journal of Asia Pacific Medicine & Public Health, 78(6 Suppl 1), 46–51. Zoucha, J., Hull, M., Keniston, A., Mastalerz, K., Quinn, R., Tsai, A., … Burden, M. (2018). Barriers to early hospital discharge: A cross-sectional study at five academic hospitals. Journal of Hospital Medicine, 13(12), 816–822. doi: 10.12788/jhm.3074 August, September, October 2020 Hawai’i Nurse • Page 11

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