Level IV Neuro ICU Nurse Kim McDuffie

The heart of flu season has passed, making way for spring and the promise of warm weather, but not without making its mark in 2008. This tricky virus has a way of popping up unexpectedly and causing misery to even the healthiest of individuals. For this reason, vaccines are always encouraged, and at hospitals, there are firm regulations for this vaccine and others. One ICU nurse decided to take the lead on an initiative to make all units of North Fulton Regional Hospital compliant with these regulations and subsequently increase the quality of care in the process.

Kim McDuffie has been a nurse in the Neuro Trauma ICU of North Fulton Regional Hospital for nineteen years. In 2007 she, along with several others nurses, took on the challenge to participate in the nurse laddering program. This clinical advancement program for RNs takes
one year to complete and seeks to promote professional growth and recognition while improving patient care and job satisfaction and providing for skills advancement, leadership development and retention.

“These nurses become leaders on their units, both formally and informally,” says Rhonda Perkey, NFRH Operative Services Director. As Chairman of the Clinical Advancement Committee, Perkey believes strongly in this program’s ability to cultivate an environment where quality care is the number one priority. “Some of the projects completed through this program become hospital-wide initiatives, proving that these nurses really bring about change and become internal cheerleaders.” Kim McDuffie has become one of these cheerleaders.

As a Level IV Nurse (one who excels in her leadership role, holds a national certification, and consistently serves as a resource and mentor to staff), McDuffie has many requirements to fulfill to complete her program, some of which include: participation in a health-related community project, participation in a hospital committee, publication of an article in a newsletter, presentation of two different unit-based in services and one hospital-based in-service and successful completion of at least 24 accredited CEU’s of Continuing Education in addition to her normal requirements as a nurse. The biggest area of her time, however, has been dedicated to her Performance Improvement (PI) project. For her PI project, McDuffie chose to tackle the issue of compliance as it relates to the distribution of the flu and pneumonia vaccines to patients before they are discharged from the hospital.

Hospitals are required by JCAHO, the Joint Commissions on Accreditation of Hospital Organizations, to ask all patients about the flu and pneumonia vaccines. “Each nurse has a form to fill out that looks almost like a physician order for every patient,” McDuffie says. “Each
patient should get these vaccines prior to discharge if indicated.” What she found through looking through the charts was that some patients were not receiving the vaccines even when they should have been given. “When patients don’t get the vaccines, there should be a reason marked for why they weren’t given. This wasn’t the case on all the charts.”

McDuffie sites several reasons why this could occur, one of these being that the flu vaccine is not indicated year-round. Whatever the reason, McDuffie took the lead on randomly surveying charts on a monthly basis throughout the various units of the hospital. “I look at the charts until I find five that are compliant, so the fewer charts I have to look at the better,” she says. “One area of the hospital took this on as a unit project, and now a nurse randomly checks 30 charts each month. It’s a great way to provide accountability and remind nurses of this important policy.”

Since the start of her project, McDuffie has seen significant improvement as chart compliance has dramatically increased and other nurses and units are getting behind this initiative. She looks forward to taking her project to the next level in the coming year.

North Fulton Regional Hospital (NFRH) is a 202 bed acute-care hospital located on Highway 9, Alpharetta Highway, in Roswell. Opened in 1983, NFRH serves North Fulton and surrounding counties through its team of over 1000 employees, 400 staff physicians and 200 volunteers. NFRH is a state-designated Level II trauma center and provides a continuum of services through its centers and programs, including neurosciences, orthopedics, rehabilitation, surgical services, bariatric surgical weight loss, gastroenterology and oncology. The hospital is fully accredited and also is certified as a Primary Stroke Center by the Joint Commission on the Accreditation of Healthcare Organizations, the nation’s oldest and largest
hospital accreditation agency.

For more information about North Fulton Regional Hospital and any of its various programs and services, visit www.northfultonregional.com or call 770-751-2500.