Palliative Care: Achieving Comfort for those with Limited
Treatment Options
Moderator:Janet Hewson, RN, Western Medical Center Santa
AnaPresenters:Cynthia Jugo, RN; Georgi Collins, RN; Karina Kilian,
RN; Jackie Leopard, RN, Riverside Community HospitalBreakout
Session B:Doubling Donation OutcomesWhat a Difference a Year Can
Make1
Doubling Donation OutcomesWhat a Difference a Year Can Make:
Riverside Community HospitalModerator: Janet Hewson, RNDirector of
Trauma ServicesWestern Medical Center-Santa Ana
Moderator2
Doubling Donation OutcomesWhat a Difference a Year Can Make:
Riverside Community HospitalCynthia Jugo, BSN, CCRN, MBA, RN,
Director Surgical ICU/CVUGeorgi Collins, BSN, RN, Trauma Program
ManagerKarina Kilian, CEN, MICN, RN, ER Clinical ManagerJackie
Leopard, MSN/ED, CNOR, RN, Perioperative Clinical Educator
ModeratorCynthia Jugo, BSN, CCRN, MBA, RN Cynthia is currently
the Director of SICU/CVU. She comes to us today with over 35 years
of nursing experience, 26 of those years have been in critical care
units with the last 11 years in management. Cynthia currently
serves as the RCH Donor Council Chair.Georgi Collins, BSN, RNGeorgi
has been a RN for 14 years, focusing on Emergency, Trauma, and
Critical Care nursing. She was acting Trauma Systems Manager for
Inland Counties Emergency Medical Services Agency (07-08). Georgi
currently serves as the Trauma Program Manager at RCH. She has been
with the RCH Donor Council since its inception.Karina Kilian, CEN,
MICN, RNKarina has over 10 years experience in telemetry,
transplant, and emergency nursing. She currently serves as ED
Clinical Nurse Manager at RCH. Karina has personal experience with
donation and is an active Donor Council member.Jackie Leopard,
MSN/ED, CNOR, RNJackie has over 20 years nursing experience and is
the Perioperative Services Clinical Educational Specialist at RCH.
She is an active member of the Inland Empire AORN chapter, she
served as President and Vice President and was recently was
published in the AORN Association of periOperative Registered
Nurses Journal. She also is a proud member of the RCH Donor
Council. 3How to beBeing in action!
The answers are in the room
Report out on Question to Run-on: Scribe Spokesperson
All Teach / All Learn
Moderator4Question to Run-OnHow will you bridge the donation
process and your current practices to create a culture of
donation?
Moderator
5ObjectivesBy the end of this presentation, the attendee will be
able to:Learn the strategies needed to build an effective end of
life teamRecognize the positive impact of standardized order sets
for the management of catastrophic brain injury Recognize barriers
to donation embedded in current hospital culture
Moderator6Riverside Community HospitalFounded in 1901, Riverside
Community Hospital/RCH is a 373 licensed bed, acute care hospital
in the heart of the Inland Empire. RCH houses the largest Emergency
Room and Level II Trauma Center in the Inland Empire with 50 beds,
a Heli-stop and a 40 bed ICU.RCH is one of the Riverside Countys
STEMI receiving centers and is a fully accredited Chest Pain
Center.
Cynthia Jugo7Riverside Community HospitalCenters of Excellence
include:HeartCare InstituteUrology/GYN da Vinci ProgramCancer
Center Level II Neonatal Intensive Care Unit.Transplant Program,
Kidney and Pancreas Center since 19971 of 20 kidney centers; 1 of
16 kidney/pancreas centers in California
Cynthia Jugo8
Need for Team
Outcomes not meeting national standardsNeeded increased
visibility and availability of OneLegacy staffOpportunity to
improve communication between OneLegacy and ED, ICU, and OR
Cynthia JugoLate referrals , missed opportunities for organ
donation, RCH staff unsure of clinical triggers for organ
donation9Need for TeamRCH staff misunderstood the donation
processEducation on clinical triggers and consultation
timeliness
Cynthia JugoRCH staff was afraid to refer pts to OneLegacy
fearing that the staff would give-up on the pt and that the family
was not ready to talk about organ donation.
10Building the FoundationCustomized Donation Program at RCH
based on continuous staff feedbackModified clinical trigger card
languageReferral to consultationIn-serviced ICU, ED, and OR on the
donation process (clinical triggers and consultation timeliness)
Communication boards developed in ICU, ED and OR
Cynthia JugoModified clinical trigger card from referral to
consultation. Begin re-education of all critical care RN staff as
well as RTs, unit secretaries, social work, case mgmt, and chaplain
services.
11
Cynthia JugoChanged clinical trigger language from referral to
consultAdded RCH logo to show collaboration and support OneLegacy
suggested removing Glasgow Coma Scale 5 to allow for the evaluation
of additional pts for Donation after Cardiac Death. RCH felt that
the RNs needed Glasgow Coma Scale as a point of reference.
OneLegacy and I were rounding on SIC when I asked OneLegacy if
they received a consult for a pt that was going to be terminally
weaned. RN stated that the pt did not meet criteria because his
Glasgow Coma Scale was 7. Modified trigger card a second
time.12
Cynthia JugoResulted in increase in timely referrals and staff
understanding donation processConsult, evaluation of medical
suitability, approach process, recovery, after care support
services 13Creating the TeamIdentified champions in ED/Trauma, ICU,
RT, Social/Chaplain Services , OR and Marketing
Created Monthly Donor Council meetings
Mission: The Donor Council at RCH is a multi-disciplinary team
dedicated to improving the overall health of our community by
preserving the gift of life through organ, tissue, and eye
donation.
Georgi CollinsThe RCH Donor Council evaluated and updated all
organ and tissue donation policies.Since RCH is a Level II Trauma
Center many of the consults were beyond 1 hour of meeting the
clinical trigger due to the pt being in holding. Pt would be
admitted to ICU and consult could come several hours later. Began
educating ED/Trauma staff on the importance of making the timely
consult. RCH took ownership of the DDP/Donation Development Plan to
ensure that we were meeting standards. We reviewed the dashboard
data monthly and develop PI strategies as needed.14Building the
TeamProvided hospital badge access and laptops to OneLegacy
staffElectronic patient records access to OneLegacy staff
Building the TeamImplemented Adult Catastrophic Brain Injury
Support Guidelines and Physician ordersGood patient care is good
donor carePreventing secondary organ damage is crucialRCH CBIG 2011
08 NS4241 05 10 AdultCatasBrainInjury p1^FP P11.pdf
Georgi CollinsTrauma Surgeons requested that they be notified on
all pts that OneLegacy is consulting on. They began asking
questions about how to ensure they medically manage pts to preserve
and maximize the opportunity for organ donation. RCH does not have
a Palliative Care Team, we decided that if we are calling OneLegacy
we should ensure that social service and chaplaincy are also
involved.
Our order set is sometimes referred to as CBIG, Catastrophic
Brain Injury Guidelines, we choose to refer to this tool as a
Guideline and Physician Order to maintain the manner in which the
physicians are accustomed to at RCHfamiliar language.16Building the
TeamOn-going education with Trauma and Neuro Surgery
physiciansIn-serviced at New Employee
OrientationsRounds/Communication with champions and staff on every
consult
Georgi CollinsProvided education and donor outcome summaries
presented at Trauma Rounds and pre-shift ED huddlesProvided
education on the clinical triggers and the donation process to RNs
at EVERY new hire orientationOneLegacy sent email notifications on
ALL pending consults (timeliness status) and outcomes to key
hospital champions (Unit Director, Manager, Social services, and
chaplaincy)RCH hosted a flag raising ceremony attended and
supported by RCH staff, community members and the transplant
center.OneLegacy hosted an Appreciation Breakfast for staff. Donor
mom from another hospital came to shared her experience with
donation with staff. Flag and Flyer slides next17
Georgi CollinsRCH hosted a Flag Raising CeremonyDonate Life flag
flies daily in front of the hospital Photo of the Donate Life Flag
at RCH. The flag pole is located in our physician parking lot and
at the main hospital entrance.18Walking In-services
Georgi CollinsRCH staff appreciation breakfast with donor mom
ED, OR, and ICU units Walking In-servicebegin in ICU, to ED and
concluded in the OR.Staff began to think of donation as the right
thing to do.
19Case Study43 year old female head trauma; status post fall
from horse. Arrival time 1027 Day 1:Timely consult from ED; Consult
time 1039Patient was a Registered donor
Day 4:Consult closed by OneLegacy as Not Brain Dead
Day 8:Second consult made to OneLegacy Karina KilianDescribe the
front lines staffs feelingsConsult closed in SICPt declined
neurologically. Second consult made on day 8 from SIC as requested
by Dr Nagappan Trauma Medical Director20Gift of LifeDay
8:Catastrophic Brain order set/CBIG implemented
Day 9:Declared brain dead by 2 licensed physicians
Outcome:5 organs recovered/4 lives saved
Karina KillianED staff perceptions of donation slowly changing.
Staff became more accepting and engaged in the donation
processmaking consults for one another, etc. Donation slowly
becoming known as the gift of life, RNs began to understand their
critical role as the key to honoring pts last wishes and saving
lives through donation21Gift of LifeLiver/Left Kidney-55 Married,
with 3 children, was on the waiting list for 13 days. He works as a
branch manager at a pest control company. Lives in Ontario, CA, and
enjoys fishing and travel.
Double Lung-24 Single, no children, was on the waiting list for
22 days, lives in Las Vegas, NV.
Heart-68 Married, was on the waiting list for 9 days, lives in
California.
Right Kidney-62 Married with 2 children, 2 grandchildren, was on
the waiting list for 1, 191 days. Works in dental equipment repair
and enjoys reading, talk radio and cooking.
Karina KilianKarinas donation story22Outcomes
2008Pre-team2009Building2010Post-team2011
(YTD)HardwiredConsultations45115155186Eligible Deaths 881410Organ
Donors 35108Consent Not Recovered/CNR0310Timeliness Goal
100%54%86%97%98%Organs Transplanted per donorGoal
3.75%3.672.803.802.5Conversion rateGoal 75%35%63%71%80%Lives
saved11143820Karina KilianYTD data 9/30/11 Staff are now aware that
not every pt is going to be a donation. Our staff have seen many
GSWs to the head, traumas, strokes get better and walk out of the
hospital.Many consults Early consult by OneLegacy saves more lives.
Guidelines are in place so that pts are being managed to prevent
secondary injury to the organs,. Good patient care is good donor
careIn 2011 our first 4 (ECD) donors were older medical pts;
however were still able to recovery and 4 organs for research and 3
organs for transplant. One of the donors was a former kidney
recipient.23Tree of Life
Jackie LeopardRCH donor council decided to honor organ donors
and their families through the erection of a Tree of Life. Invited
donor families from 2007-2009 14 families consented to their loved
ones name to appear on the Tree of Life.
Our January 27th ceremony was attended by over 70 donor family
members and countless RCH employees from Administrators down.
Several RNs attended to support families throughout the
ceremony.
What have learned is that the Tree does much more than honor
donors & their families, it illustrates the support of donation
at RCH and the benefit of donation to families. Staff can whole
heartedly strive to support donation, knowing it is the right thing
to do and what families really want. 24Tree of Life
The Courage of OneCalled from this world by Gods hand, we mourn
the loss of a loved one. But a legacy was left behind; sight to a
blind man, a new heartbeat for one whose broken heart can beat no
more, breath for one who had drawn near to her last, a second
chance to live a life forsaken. A heros welcome awaits their
arrival, for a courageous act was their last. Giving their last
breath, the last beat of their heart, the very sight from their
eyes, to those who needed it most. A living legacy to fallen
heroes, who gave all they had to give, as God called them home, to
a heros welcome.
Jackie LeopardHere is a picture of our Tree of Life. This poem
was read aloud at our ceremony.25Bobby D. Collins
Jackie LeopardFamily members could not attend but wanted their
loved ones to be honored. Many RCH employees placed the leaves on
behalf of their loves ones. Here is a photo of placing Bobbys
leaf.Play thank you VM.26
Riverside: Hospital Honors Organ Donors
Rich Linton / Special to The Press-Enterprise A Tree of Life
memorial was recently unveiled at Riverside Community Hospital
honoring organ donors. A permanent marble monument will be added
later and erected in the entry hallway.
Jackie LeopardArticle from our local newspaper the Press
Enterprise; Janeens family was interviewed by the PE after the
ceremony. Janeen is heroher family is proud of their decision to
honor their precious daughter through the gift of life. 272011
InitiativesOneLegacy presents at monthly ED, ICU, RT and OR staff
meetings.
OneLegacy activities/updates are included in the hospital
newsletter.
OneLegacy participates in:General New Employee Orientation ICU
clinical practiceIntro to Trauma classesTrauma Rounds
Jackie LeopardCurrent initiatives includeCommunication remains
key to our success282011 InitiativesRCH ecampaign on the RCH
website
http://riversidecommunityhospital.com/service/transplant-services
Adult Brain Death examination forms RCH Determination of Brain
Death Exam Form Revise 6 10 2011 gc (2).docx
Identify Donation After Cardiac Death opportunities
Jackie Leopard weve already mentioned several of our
initiatives. We feel the Process hardwired in RCH policy but there
is still room for improvement. Here are a few of our current
initiatives to improve our process. RCH wants to confirm that ALL
pts are evaluated for donation opportunities.
29
Jackie LeopardOur brochure is given by our ICU RNs, social
workers, and physicians once the pt is declared. It is used to help
families understand what has occurred with their loved one and what
happens next. Donation is NOT discussed at this time. 30
Jackie Leopard:As we conclude, please understand that this
process is for the donor family to honor their loved ones through
the gift of life. A simple phone call COULD make a difference in
these family's lives. Familys want to honor their loved ones
through donation and you can be a part of the gift of life.
31Question to Run-OnHow will you bridge the donation process and
your current practices to create a culture of donation?
ModeratorThank you RCH, your hard-work and dedication in
honoring patient and family wishes is impressive. Lets revisit the
Question to run on32Transition to LunchLunch is from 12:10 1:10
In the Main Ballroom
Open seating
Bon Apptit!
33Moderator