In March of 2017 an informational flyer titled “Nexus: What is it?” was distributed across the Spectrum Health Delivery System. Nexus, described as “a sweeping initiative that will improve our processes and coordination of care”, was initially thought to be a new electronic health record (EHR). In reality Nexus is a way of changing how clinicians practice across the system. Epic, the EHR which would become the platform for documentation across the delivery system, was only one part of the Nexus initiative.
The guiding principles of one patient story, evidenced based practice, consistent exceptional experience, and respect for people became the foundation for the Nexus journey. As the journey evolved a variety of roles within nursing were integral as we embarked on visioning sessions, direction setting sessions, adoption sessions, walked through workflows and training and deployment. Clinical nurses, nurse educators, clinical nurse specialists, nursing informatics, nurse managers and nursing directors were all heavily engaged in transforming our care delivery model and leveraging a new EHR to revolutionize the care we provide to our patients and community.
Beginning with the visioning sessions, nursing was integral to the process of asking, “What if…?” What if we redesign the process of how a patient registers for surgery; what would that look like? What if we completely rethink how a same-day surgery patient moves through the system? What if we totally rework the medication cycle careflow, from ordering to administration; what efficiencies might we achieve? How would the patient benefit? This questioning attitude was the beginning of the Nexus journey and nursing was at the helm.
It was with an “anything is possible” mindset that nurses from many roles entered into interdisciplinary direction setting sessions in partnership with the Epic team. The basis of this work was examining careflow through a step-by-step analysis of each aspect of care delivery in our system. How would Epic impact these careflows? What efficiencies could Epic give us? This activity led to adoption sessions in which we reviewed what Epic had built and either adopted as is or modified.
Clinical Nurse Specialists (CNS) were key in articulating scope of practice for nurses and describing how nursing assessment standards, workflow routines and technology tools should come together to monitor patients for safety and alert the appropriate care providers in a timely manner.
The CNSs:
- Championed the vision for the patients’ health record – advocating for documentation in the patient EHR as a reflection of the patients care.
- Advocated for maximizing nursing scope of practice throughout the Nexus journey such as clarifying what nursing work could be completed without requiring a provider order.
- Reduced the documentation burden for nurses by revising policies and minimizing assessment documentation with a focus on documenting abnormal findings and clinical interventions.
- Participated in content and build validation of more than 300 order sets to ensure nursing and clinical program best practices remained evidence based – examples include disease specific order sets.
Nurse educators, CNSs, and nursing informatics from across the delivery system collaborated to identify changes in practices that would impact nursing most. These practices were categorized and used to identify supplemental education that the clinical nurse would need in addition to Nexus Epic Training.
Another collaborative effort between nurse educators and CNSs resulted in the development of educational offerings focusing on assessment and screening tools that were new to our health system. These included:
- ABCS – Fall Injury Risk Assessment (Used in conjunction with the Hester Davis Fall Risk Assessment)
- Aggression Screen
- Ask Suicide-Screening Questions (ASQ)
- Extravasation Scale
- Infiltration/Phlebitis Screen
- Oral Mucositis Screen
There were also educational offerings developed regarding changes in assessment and screening tools that were already in use, such as:
- Abuse Screen
- Audit C – previously the CAGE assessment
- Columbia Suicide Screen
- Hester Davis Fall Risk Assessment
- Influenza Vaccine
- LACE+ Readmission Risk
- Malnutrition Screen
- Modified Early Warning Score (MEWS)
- Modified Aldrete
- Pneumococcal Vaccine
- Sepsis
Nurse educators and nurse informaticists were involved in the review of the curricula for many roles including clinical nurses, nurse techs, and unit secretaries. Superusers, 435 nurses from SHGR including nursing informaticists, nurse educators, clinical nurses and CNSs helped teach hundreds of classes and also supported classes as the “guy-in-the-back” helping students who may have fallen behind and answering questions.
Training and education expanded beyond preparation for go-live to ongoing education for all new hire nurses throughout the Spectrum Health hospital group. Led by the nurse educators, a re-design of the new hire onboarding curriculum took shape as a nursing system and resulted in a change in the overall curriculum for nursing and standardization across the hospital group.
Student nurses were also impacted by the Nexus journey. Students are now required to attend and successfully pass Epic training prior to beginning their clinical rotation. Collaboration with schools of nursing was integral in ensuring this transition from the previous model.
Planning for cutover began 6 months prior to go live and required a partnership between informatics nurses, nurse managers and directors, operational leaders and IS analysts to coordinate the translation of data and orders for current patients who would be in the hospital during the transition from Cerner to Epic. Nursing informatics developed standard work for various phases of the cutover events, starting one week prior to go-live.
Nursing informatics along with clinical and operational nursing leaders participated in the cutover event held within the Plainfield Learning Center by facilitating, supporting and providing resources to clinical nurses and other individuals who participated. Nurses served as room captains (leads), runners, and subject matter experts as nursing peers from areas across the system participated in the actual cutover activity by entering a minimum data set and orders for every patient in the hospital census during go-live.
During Go Live nursing supported every area of the hospital in which nursing practice exists by answering questions, gathering information, and looking at trends. Nurses also attended application-specific team huddles as well as Top 10 at 10 daily meetings to prioritize concerns and communicate back to staff.
Spectrum Health Grand Rapids participated in Wave One Epic go-live in November 2017, with Wave 2 go-live in the Spectrum Health regional hospitals occurring in May 2018. Nexus, “a sweeping initiative that will improve our processes and coordination of care” was undoubtedly one of the greatest initiatives undertaken by the Spectrum Health delivery system. Nursing’s incredible level of interdisciplinary collaboration and the engagement across various areas of nursing expertise was integral in the success of the Nexus initiative.