“Distraction Free Practice in the Ambulatory Setting” by Ashley Renaud for OPENPediatrics

By Adem Lewis / in , , , , , , , , , , , , , , , , /

Hello and welcome to this
Nursing World Shared Practice Forum. My name is Sarah
Gibbons, and I’m the Senior Director for Clinical
Education, Informatics, Quality and Practice, and the Chief
Nursing Informatics Officer at Boston Children’s Hospital. Today I am very pleased to
introduce Ashley Renaud. Ashley is currently a
Professional Development Specialist for Quality
and Professional Practice. She has been a member of the
Boston Children’s community for 11 years, working
in various roles, focusing on quality improvement
for the majority of the time. She has a dedication to safety
and a passion for improving outcomes for patients. Getting involved in
the Red Zone initiative was a natural fit,
given her experience in implementing
multidisciplinary quality improvement initiatives
in previous roles. Ashley, welcome. Thank you so much for having me. It’s truly a pleasure. Tell us a little bit
about the Red Zone. What is it? Sure. Red Zone is a
distraction-free practice that occurs during high
alert activities that’s really aimed to mitigate risk
and decrease adverse events. So we truly try and utilize
it for small activities where you can get
easily distracted and make sure that
we’re providing safe care whenever possible. Red Zone is used for
preparing medications, administering
medications, but it also could be used for obtaining
heights and weights in an ambulatory setting. And what are the benefits
to patient safety that you see with this? So it really decreases
errors in events, but also it is a really great
tool for empowerment for staff to be able to
speak up for safety and really utilize our
guiding principles that we have for creating
a work environment with effective communication. So tell me more about the
history of the Red Zone and how it was implemented
at Boston Children’s. Sure. So back in 2010, the
cardiovascular intensive care unit had seen an increase
in the amount of medication administration errors
within their unit, and they tried to figure out
a way to, sort of, decrease those errors. And they thought bringing
in distraction-free practice would be a great place to start. So they, sort of,
were the pioneers at Children’s to take this, sort
of, evolution of this practice and bring it into their unit. And once they did that, they
saw about a 80% decrease in the amount of medication
events that they had. And so it really started
to show proof of concept, and they were actually
seeing decreases in the amount of errors that
were reaching the patient. So once that started
to take effect, they started to implement it
in other units as well based on how they developed
their process. And from there, it’s
caught on and it was implemented across the
rest of the inpatient areas up until 2016 where
it started to move towards the ambulatory areas and
other aspects of the hospital. So tell me more about how Boston
Children’s has used Red Zone. How is it best used? So it’s really dependent on
the area that you’re using it. In the inpatient areas,
medication preparation and administration really
seem to be the strongest benefit for
distraction-free practice, but also during
communication hand-offs was really a benefit to the
inpatient areas as well. As we started to move
into the ambulatory areas, heights and weights
was something that was a really big benefit. Because that occurs
almost multiple times for a large amount of patients,
and they were really starting to see some errors there. So we try and target based
on where the Red Zone is being implemented
and seeing what’s going to have the highest
impact and return on investment for the practice that
you’re utilizing it for. Tell me more about the
implementation in inpatient. I’m interested in that. So it was quite the robust
process that was in place. So one of the things is they
created an ambassador group on each of the floors, and
that really was, sort of, your super users, if you
want to call them that, for the implementation
on the areas. So they were the people that
were visible that really helped us to get the
implementation running in all the different areas. And they thought
about how it was going to be best
used and implemented across their particular unit. There was also a big push on
patient and family education. There was something included
in all the admission packets so it was made
aware that this is a practice that is implemented
on the inpatient area. And if they see the signage,
they know what to do. There was also a lot of
materials used to, sort of, alert people that they were
in the distraction-free zone. So we had floor decals
that we placed in areas that we wanted to create
distraction-free zones, such as our Pyxis machine
where you get and prepare medications. There was also actual
laminated signs that would go in areas as well,
such as the medication room. And then there was
also badges created. So if someone was standing in
an area that didn’t necessarily have a sign or a
decal, or you just wanted to really make
the point that you were in the zone, a badge you
could throw over your shoulder. So if someone tried to
approach it from behind, they would see that symbol and
know that you’re in the zone. Let’s stop here and
share with the viewers how Red Zone is currently
used in the inpatient setting at Boston Children’s Hospital. Good morning. Good morning. My name’s Jen. I’m going to be taking
care of Jackson today. How are you guys? We’re good. Good. I’m just going to take a few
minutes to double check some of her medications, so
I’ll be in the Red Zone in distraction-free time. But I’ll let you know
as soon as I’m done to answer any questions, OK? All right. Great. Jen, did she get her
Diuril last night? Oh. You know what? I’m just still in the
middle of checking some of her medications
in distraction free time. I’m happy to answer
that question as soon as I’m done, though, OK? Thank you. Thanks. Jen, did she pee
enough last night? You know what? I just don’t want to make
any mistakes with checking her medication, so just
for Jackson’s safety I need to focus on
distraction-free time for just a few minutes. Absolutely. Sorry. Thank you so much
for understanding. Great. Looks like all of
her drips look good. I’m also out of
distraction-free time, so I can answer any
of your questions. What were you asking about? Did she get her Diuril
dose last night? She did. She got her Diuril
about 8 o’clock, and she had a really
good response from it. And how much did she pee? She was negative about 140
overall, so that’s great. We’re really happy with how
much she’s making urine. Thank you very much. And why was having decals
in front of the Pyxis so important? Because that’s one of the
areas where you can really get distracted and have a huge
possibility for errors. So really, sort of, if someone
was approaching the Pyxis and you were
standing there, they could see that you were in
the zone based on the fact that you were standing
on this floor decal. And what’s happening at the
Pyxis that makes it so risky? Just your medication
preparation. So you’re getting medications
out for the patients, and you really need to
be able to concentrate to make sure, A, you’re
taking the medication out for the right patient. You’re taking out
the right dose. It’s the right time to be
taking out that medication. Really, looking at your
five rights to the patient. Let’s stop here and
share with the viewers how Red Zone is currently used
during medication preparation. Hi, Jen. How are you? I’m totally dying to see
you because I wanted to show you pictures from the weekend. They came out awesome. I would love to see them, Vicki. I’m just in the middle of
the Red Zone right now, getting some meds. Can I catch you at break? Yeah. Sounds good. Thanks. Thank you so much. Ashley, you mentioned hand-offs
as being an important place where Red Zone can be used. Tell me more about that. Why is it so important,
and how is it used? So hand-offs are really
a time where you’re getting critical information. If you’re the physician
or the nurse coming onto your oncoming shift, you’re
getting all the key pieces of information to be
able to safely take care of the patient. So it’s really a
time that you don’t want to be having a lot of
interruptions or distractions so that way the person
giving you the report doesn’t lose their
place and forget to tell you a really key
piece of information. But also so you
can really actively listen to what the
other person is saying. So a lot of times you’ll have
consulting services coming on, and they’re trying to
plan for their day. But it’s really important
that we give people the tools and the communications
to be able to say, “No. I’m in a distraction-free zone. This is really critical
to patient safety and for being high reliable. I want to make sure that I’m
getting the information that I need.” It seems like handoff might be
a really busy time on a unit. How does one maintain a Red Zone
in that type of environment? That’s a great question. So I think, sort of,
having the expectation up front, so communicating
when patients and families get admitted to the unit. Really saying from the get go
that we have this certain time during the day where we do
our handoff peer to peer, and this is a time that we
ask that there’s uninterrupted and distracted free practice. I know in some areas they
make an announcement when it’s time to do handoff so people– if maybe they didn’t
hear it during admission they’re getting it at
the time, saying this is our distraction-free practice. But really constantly
communicating so people understand
that this is really important for patient safety. Let’s stop here and
share with the viewers how Red Zone is currently
used during patient handoff. Baby boy Smith is
a three-month-old, three kilo patient who came
in on Monday for an ASD repair with Dr. Amani. He did very well
post-operatively– Hey, Jen. I just need to get
ready for rounds. Can you tell me how Baby
Boy Smith’s night was? We’re actually in the middle
of Red Zone for nursing report. Do you mind coming back
in just a few minutes? What’s Red Zone? The Red Zone allows for
distraction-free time for us to exchange important patient
information so we don’t forget anything if we’re interrupted. Oh, OK. Sorry for interrupting. I’ll come back when you’re done. Thank you so much. So as I was saying, he
did very well on Monday and is now ready for the floor. You mentioned the
ambassadors in the inpatient and the cheerleaders, as you
call them, in ambulatory. Why are those people so
important to the success of this? So I think ambassadors really
play an important role, because they’re the positive
reinforcers of this is an initiative that’s important. I think when you have people
that really buy into it and that can really get people
motivated to be involved, I think you have much
better sense of success. And they’re very aware of the
practices and the principles, and they can really help
educate and promote it across all the different shifts
and areas within their unit. Interesting. And how do units know how well
they’re doing with Red Zone? The previous group
had created dashboards that looked at medication
events over a period of time. So they were able to track
those medication events to see the trends and how
distraction-free practice was really affecting that. Interesting. Tell me more about ambulatory
and heights and weights. How does that become
a distraction zone? You tend to have the
families or the parents present while you’re doing a
height and weight on the child. And oftentimes
because we do things in kilos, which is
different from how they get their weight so
they’re used to seeing things in pounds. So oftentimes while you’re
providing the height and weight, the parents
are asking, “OK. So what’s that in pounds?” And so you’re easily– so they tend to interrupt and
ask you a lot of questions, or they’re trying to
figure out, you know, what’s my visit
going to look like? Where am I going to go to next? How long am I going to wait? So there’s all these
pressing questions. They have a body
in front of them, and they want to utilize
that body to try and get their information. And why are heights and weight
so important in pediatric care? Because a lot of our
medications are dosed off of height and weights. And we utilize it for all
sorts of different adjustments that we make. And so we look at nutritional
status based on their height and weights, medications that
we use to sedate patients in procedures. We also utilize it
just to dose whatever medications they’re on
chronically for their disease. So it can make a
really huge impact if you don’t document
that correctly or don’t obtain it correctly. We would now like to turn to
our audience and ask a question. In your response, please leave
your city and country location. The question is,
what distraction-free practices are using
in your institution, and where are you using them? We’ve talked a lot about
where it’s a good fit. So medication administration
and heights and weights. Tell me about places
where maybe Red Zone wouldn’t be a good fit. So if you’re going to be in a
procedure for two hours doing something, that is really not
the place where we’re trying to implement distraction-free– I mean, obviously you want
to pay attention and provide safe care. But that’s not really
the point of what we’re trying to accomplish. It’s these short activities
that you don’t really think about where distractions can
come into play that you want to really focus,
your five minutes that you need to perform
a task, and make sure that no one’s coming up to you
and trying to interrupt you during those times. You became involved in the
Red Zone Project in 2016. Tell me about how you
got started with it. Sure. So I actually started
my current role in 2016, and as soon as I came
on it was something I was really interested in. I knew about it
from previous roles, and it just seemed to be
a natural fit with what I had been working on previously. So I really sort
of jumped right in and wanted to take
this to spread it to the rest of the hospital,
because currently it had only been in the inpatient areas. And we saw a need for
the ambulatory areas to really utilize this practice
in a unique and different way than how the inpatient
areas were utilizing it. Tell me more about that. What did you do in ambulatory? There had been a few events
related to height and weights in the ambulatory area,
and we saw a need there that maybe this
practice could be utilized with clinical
assistance to be– who were obtaining a lot
of the height and weights to see if we could decrease
the amount of distractions. It, sort of, was
overwhelming at first because a lot of the
interactions are with families, and it’s, how do really bring
this practice into the family environment and really getting
them to understand the concept? But pretty soon we realized
that with a little bit of education, a little bit of
coaching clinical assistants on how to communicate that
they were in the Red Zone, that you could
really see an impact that it was going to be making. And what steps did you
take to operationalize Red Zone in ambulatory? I’m guessing it’s not the same
as it would be an inpatient. Yeah, it is a little
different, because it’s very multidisciplinary
because of the amount of different disciplines
that actually sit in the ambulatory clinics. And it’s not just nurses that
are utilizing this practice, so clinical assistants,
allergy techs, all sorts of different
people that are in the clinic are utilizing this. And plus, there’s
so much interaction between the administrative
staff with the clinical staff, and also the patient
experience representatives. There really had to be
a thoughtful approach to how we educate and really
look at this and what we do. So we tried to get
champions from all the different disciplines
to really build a team that could
help be the champions, or I like to call
the cheerleaders, the positive reinforcers,
and that this is a really important safety initiative. And we took that and tried
to do education and collect some information before
we actually went live to see and measure the success. Because a lot of the– previously the data
we would use would not apply for how we could
measure success in this area. Tell me more about working
with clinical assistants. You mentioned them
a couple of times. So this was an
interesting group, because it’s someone
that I don’t think was as familiar
with the practice as other clinicians
were in the institution. And one of the things that
we often find with them is their apprehension
with telling families, too, that they needed
not to be distracted. So we really spent a lot
of time working with them and giving them the toolkit to
have pocket responses that they could utilize with
families to help empower them to have
that conversation. But also with other
disciplines as well, because they may feel a
little bit like, you know, we’re trying to get
these patients out so I don’t want
to be able to tell the doctor that I
can’t have them talk to me at this moment in time. So giving them things
like, “Please give me X amount of minutes
to do this task.” Or “Do you have any
questions now for me, because I’m about
to do something that’s going to require me
to have uninterrupted time.” So giving them sort
of blanket statements that they could
utilize, I think, was a much more
successful toolkit to use. So they felt like they
had the right words to say that weren’t going to
be offensive or cause any issues with communication. So I’ve heard that you have
a fabulous education sheet for patients and families. Tell me about the
evolution of that material. When we started
working on this project and looked at the education
sheet that was currently in place for families,
it was very wordy. And given that we’re in
an ambulatory setting– you have a high volume of
international and non-English speaking patients– we needed something
that could be a tool that if we
didn’t have a chance to verbally with an interpreter
be able to educate them, there’d be something
that they could visually look at that would clue
them into what was going on and what we were doing. So we tried to really take words
and make them more pictures to alert them that this is going
to be a distraction-free zone. So I’ve heard that there’s
been some great success in the gastroenterology clinic. Tell me more about that. This clinic actually had
a really good showcase about some of the
culture changes that we wanted to
see with implementing this distraction-free practice. So part of our practice that
we have for implementation is we take a survey of the
distraction environment pre-implementation. And then six months
after implementing, we re-survey them to see if
the environment has changed. And the GI Clinic
really had some success in showing some small
incremental changes in their culture. So we asked, about
how often you get distracted or interrupted
during a patient interaction? And before we got started it
was really most of the time or always seemed to be
50% of their answers. But after six months
of implementation that number dropped about
15% of always or never. It really bucketed into
the sum at the time. So, I mean, it’s
not a huge change, but it’s enough
to show that we’re making small incremental
changes with the culture itself. But there’s also
one of the things that we asked is about being
interrupted by a colleague. Because this is
something we felt was really important
to understand of, how often are the
peers that you’re working with interrupting you? We didn’t know if it was mainly
the patients and the families, or is it really the colleagues? And before implementation
there was about 30% of staff that said they get
interrupted by a colleague 30% of the time. But six months afterwards we
dropped that number to 7%. And we even saw an increase
in the amount of never getting distracted by a colleague. So, and to further sort
of speak about that, we also asked, did you actually
ask them not to interrupt you? And before it was about
50% said they’d never asked them to not interrupt them. So it’s hard to look at the–
when someone’s interrupting you, if you’re not asking
them not to interrupt you, you’re going to continue
to see interruptions. But post implementation we
really saw a marked increase in the amount of always
or most of the time people asking their colleagues not
to interrupt them at all. So it’s been interesting. And afterwards, we also
asked about whether or not they’re being respected
when they asked them not to interrupt them. And that number increased
post-implementation. So small increments,
but definitely starting to see in a six month
period time, which I think is pretty exciting,
to see culture change. And we all know that takes
a long period of time. So small incremental changes
but we’re getting there. That’s really impressive. What do you attribute the
culture changes there to? I think they had great
buy-in from their physicians, and they had a really
good physician champion that partnered with
the other disciplines to really support this. I think there was a lot
of marketing, so to speak, and really getting the word out
there that this is important. But I also think it
was a lot of work with coaching the
clinical assistants on their communication and
what they’re utilizing it for. So I think that
helped extremely well. And the clinical assistant who
was working there at the time is one of the most charismatic
people you’ll ever meet, and I think that was
a huge factor as well. Because he really had a
great working relationship with the physicians,
and I think that was a huge aspect to
making this a success. What were some of the
challenges of implementation, and how did you overcome them? So I think one of the
biggest challenges is just the mere
volume of patients that are seen on a daily basis. They’re extremely busy
clinics, and you’re really trying to get them in
and out because that all plays into the patient
experience and the throughput. And I think that sometimes
creates a challenge with having people say, “No. Stop. I need to have
five minutes to be able to finish this task
in an uninterrupted time.” So I think that played
a big part in terms of, you know, really getting more
of a buy-in than we already did. But some of the
other challenges are in these– we’re a
teaching hospital, and we get a lot of
residents and fellows. And they’re not
consistently in the clinic so that creates a
challenge in terms of keeping the
momentum alive, keeping the education and
the consistency in terms of how we
communicate this. Because it’s not always the same
people that are in the clinic all the time. And also, too, speaking
of the physicians. The way that they
receive education is a little bit different
than the way nurses and other disciplines do. We’re able to easily learn
it online learning system to be able to give information. But a lot of times it’s
not always effective for physicians, so they
were educated a little bit differently. And I think that plays into
the challenges as well. We would like to turn again to
our colleagues around the world and ask another question. In your response, please leave
your city and country location. The question is, what
challenges have you encountered while utilizing
distraction-free practices, and how did you overcome them? I know you’ve been doing
this work for a while now and are starting to
think about innovation. Tell me more about that. It’s been really interesting. This is part of our high
reliability principles at Boston Children’s Hospital. It’s really utilized
distraction-free practice for patient safety. But it’s really been
fun to, sort of, think about this beyond
your typical ways that you think
about utilizing it. So we’ve been starting to work
with some areas on utilizing lights and having red lights
be an indicator of that we’re in the zone. Because we’re trying
to really think about, what are other practices beyond
just medication administration and heights and weights
and dressing changes that we can really bring
this practice to light? And I think one of the biggest
areas that we’re finding is when you’re in a patient
room in the inpatient area that can be a huge
distracting environment. You’re a clinical
person, you come in. The parents have a ton
of questions for you. And how do you create that
distraction-free environment within the room with the
patient so you can make sure that you’re providing safe care
in an effective and distracted free way? So we’re really starting
to think about other ways. So that’s some of
the things that we’re starting to do to really
expand Red Zone beyond just the typical areas that you
think you’d apply it to. Interesting. So how do the lights work? If you’ve ever had a night light
that you just, sort of, tap on, I mean, essentially
that’s what it is. You just tap it on. And we’re working with– we’re going to try and work
with the company a little bit to see if we can change the
technology, because right now if you tap it, it can
be multi different colors. We would like it just to
be red because that’s what we’re ultimately looking for. Because that’s
really the color that signifies that you’re in
distraction-free zone. But it’s a simple technology. You can hang it on a wall. You can magnet onto something. But you can also just
place it on a bedside. So it’s mobile,
which I think makes it really effective in
terms of how you utilize it. And with all the different
designs of the room, you can really take
it and utilize it any way you possibly can. This seems like an
initiative that you want to sustain for
a really long time. Because it’s a really
important safety initiative, how do you maintain the
excitement and the interest in it? I think constant communication
is really a big piece of it. It’s constantly getting
data back to them, constantly interfacing with them
and communicating with them. And it’s almost like you have
to reinvent yourself every so often to keep it alive
and keep it exciting. This is why I think I’m so
excited about the Red Zone light, because it sort of
gives a fresh perspective on something that’s
so important and such a huge safety initiative that it
brings it to a different light, you know, in some
way, shape, or form. So I think just
constantly really trying to innovate and think
of different ways that keeps people
excited about it, and keeps people in the forward
momentum of understanding that this is a really
important safety issue, and that we need to make
sure that we’re providing safe care for our patients. Ashley, thank you so much for
joining us today and sharing with us how Boston Children’s
has implemented the Red Zone. You’re so welcome. It was truly a pleasure.

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