The North Dakota Nurse - July 2022

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Page 16 The North Dakota Nurse July, August, September 2022 Progression of North Dakota POLST and Emergence of Honoring Choices® North Dakota Nancy E. Joyner, MS, CNS-BC, APRN, ACHPN® Karli Olson, DNP, APRN, FNP-C, CCRN Inception of POLST In 2003, Altru Health System staff from Grand Forks, Nancy Joyner, MS, CNS-BC, APRN, ACHPN® and Gayla Drengson, MS, LICSW, attended Physician Orders for Life Sustaining Treatment (POLST) session at a national conference and brought the information back to administration. At that time, Altru Health System was evaluating the change the code level status from numbers (e.g., 1,2,3) to nationally recognized wording (e.g., Full Code, Do Not Resuscitate (DNR), Do Not Intubate (DNI), and Allow Natural Death (AND) as well as promote engagement in serious illness conversations. By 2007, Altru Health System developed a workgroup of physicians, nurses, social workers, chaplains, and other disciplines to study and plan for the implementation of the POLST form. Both a POLST policy and form were developed and adapted through Altru Health System. Altru worked with first responders and paramedics in hopes of implementing POLST in the communities surrounding Grand Forks. The local long term care facilities also became involved. There was also interest, regarding the implementation of POLST, at the state level from the North Dakota Medical Association’s (NDMA) Ethics Committee at that time. In 2010, the North Dakota Medical Association’s House of Delegates adopted a resolution, urging North Dakota physicians and other healthcare professionals across all healthcare settings to consider POLST components in developing an initiative across the state. NDMA’s Ethics Committee reviewed the National Institutes of Health (NIH) support of POLST and analyzed studies published, regarding POLST, and concluded that engaging in POLST conversations have a significant advantage over traditional methods to communicate preferences about life-sustaining treatment. The Minnesota Medical Association Ethics Committee and Medical-Legal Affairs had also endorsed the POLST program in their state. In 2012, NDMA assigned the POLST project to the ND Healthcare Review in Minot (now formally known as Quality Health Associates of North Dakota). The project and workgroup were led by Quality Improvement Specialist, Sally May, BSN, RN. May invited interested parties throughout the state to explore a statewide POLST initiative as well as advance care planning. The ND advance care planning coalition grew from 10 to 40 members. By 2013, an initial POLST workgroup was formed. The original POLST form, created in 2007 at the Altru Health System, was updated to reflect the efforts and recommendations of the POLST workgroup. In 2017, the statewide ND POLST form and ND POLST program were established and went live on July 1, 2017. Lastly, in 2018, the ND POLST form was updated to meet the national standards. Commencement of Honoring Choices® North Dakota As the statewide POLST project was evolving, Sally May, BSN, RN presented a webinar in 2013 titled, Advance Care Planning: Beyond an Advance Medical Directive. North Dakota Advance Care Planning Initiative face-to-face meeting. By December of 2013, members of the North Dakota Advance Care Planning Initiative had drafted a vision, goal, and objectives for a prospective organization with a focus to create a statewide initiative to improve advance care planning across the state. In 2014, several interested individuals participated in the Minnesota Network of Hospice and Palliative Care. At the conference, individuals learned about Respecting Choices®, an evidence-based practice program that focuses on person-centered decision-making to ensure individuals’ preferences and wishes, regarding their medical decisions, are known and respected as well as Honoring Choices® Minnesota (HCM), which was a public health initiative to help individuals make informed decisions about their future medical care. HCM recently dissolved in 2021. At the time, HCM was creating a national network and with licensing through HCM/East Metro Medical Society Foundation, Honoring Choices® North Dakota (HCND) was formed. HCND created a steering committee and active workgroups, and by April of 2015, HCND was incorporated as a ND 501(c)3 nonprofit organization. The original vision of goal of HCND were as follows: Vision: To create a culture across ND where continuous (on-going) advance care planning is the standard of care, and every individual’s informed preferences for care are documented and upheld. Goal: To assist statewide community partners with the development and implementation of a comprehensive advance care planning program by December 2016 In 2016, the efforts and aspirations of the North Dakota Advance Care Planning Initiative Committee and HCND came to light. In September of 2016, HCND held its first conference, Striving for Success: Challenges and Opportunities for Advance Care Planning. In November 2016, First Steps® ACP (Advance Care Planning) instructors were trained and prepared to educate ACP facilitators across the state. Lastly, in December of 2016, HCND was awarded a $10,000 grant from Consensus Council of Bismarck through its Community Innovation Grant Program, offered in partnership with the Bush Foundation, to assist with the statewide ACP facilitator training. The National Healthcare Decisions Day event on April 16th was recognized, and events were planned annually. ND POLST awareness, education, and implementation had gone statewide. In 2017, the HCND website was created and has been hosted by Quality Health Associates of ND. The HCND Board of Directors revised the previous vision and goals and composed the following: VISION: The health care choices a person makes become the health care the person receives. GOAL: To assist communities to develop a successful advance care planning process. OBJECTIVES: 1: Promote advance care planning through community and professional outreach and education. 2: Promote standardization of advance care planning. 3: Establish base of financial support. In 2018, HCND held a second statewide presentation at a conference in Fargo titled, Improving Quality of Life—It Starts with Competent Caring Conversations. HCND continued offering the First Steps® ACP training opportunities. The HCND Board of Directors welcomed the first physician affiliate, Dr. Kristina Schlecht, MD, and Dr. Jonathon Berg, MD became the POLST medical director. Continuing medical education (CME) for POLST was endorsed nationally, and as previously mentioned, the statewide POLST policy went into effect. In 2019, HCND became affiliated with ND Palliative Care Taskforce and Center for Rural Health (CRH) with an emphasis on CRH’s Rural Community-Based Palliative Care program to promote all aspects of advance care planning (ACP) and POLST. With the support of CRH, HCND held educational POLST webinars throughout 2020 and 2021, which focus on increasing awareness and discuss key elements to implement the POLST process. The POLST webinars are available to multiple disciples, currently being offered, and are approved for 1.5 contact hours by the North Dakota Board of Nursing, North Dakota Board of Social Work Examiners, North Dakota Department of Health – EMS Division, and the Board of Chaplaincy Certification, Inc. In December 2021, HCND received a $10,000 grant from the North Dakota Comprehensive Cancer Control Program to create, educate, and certify individuals who were interested in becoming ACP Facilitators. The ACP Facilitator training course utilized resources from The Conversation Project and the Serious Illness Conversation Guide. In total, there were twentyseven individuals who completed the training, are newly designated ACP facilitators, and received four continuing education (CEs) credits through the North Dakota Board of Nursing. To promote HCND as well as the process of ACP and POLST, HCND began sending bimonthly newsletters to update communities, local health care organizations, and interested individuals with recent activities, upcoming educational offerings, and progress within HCND. As of March 2022, Honoring Choices® North Dakota became a 501(c)3 public charitable organization. To date, the organization is all volunteer, and HCND continues to pursue funding for hiring staff and program development. Currently, HCND’s Board of Directors is comprised of individuals across the state of North Dakota, who represent various organizations and professions, with a focus to promote advance care planning and POLST.
July, August, September 2022 The North Dakota Nurse Page 17 Throughout the next year, HCND has aspiring plans to promote ACP and POLST through community engagement (i.e., bimonthly newsletters, Facebook), professional education (i.e., POLST webinars), and expanding partnerships and affiliations. Advance care planning, or lack thereof, has recently been identified as a public health issue due to the aging population and the significant implications that ACP possesses, including enhanced, individualized care at the end-of-life, reduction in patient and family emotional stress as well as minimization of associated costs, which may be incurred by unwanted medical treatments. There are many components of ACP and POLST, but it all begins with a conversation. Call to Action: 1. Please partner with us, join our email list, and stay abreast of upcoming activities, educational offerings, and opportunities to promote advance care planning and POLST within your local community and organization. 2. Please do your part in promoting advance care planning and engaging in shared decision-making conversations, particularly with individuals who have a serious illness. 3. Please reach out if you, your colleagues, or your local health care organization are interested in learning more about how ACP and POLST and how Honoring Choices® North Dakota can assist with individual and community outreach interventions. The name “Honoring Choices North Dakota” is used under license from East Metro Medical Society Foundation. https://www.honoringchoicesnd.org/ Nurse License Protection Case Study: Administering medication without an order Nurses and License Protection Case Study with Risk Management Strategies, Presented by NSO A State Board of Nursing (SBON) complaint may be filed against a nurse by a patient, colleague, employer, and/or other regulatory agency, such as the Department of Health. Complaints are subsequently investigated by the SBON in order to ensure that licensed nurses are practicing safely, professionally, and ethically. SBON investigations can lead to outcomes ranging from no action against the nurse to revocation of the nurse’s license to practice. This case study involves a registered nurse (RN) who was working as the clinical director of a small, rural emergency care center. Summary The insured RN was employed as the clinical director of a small, rural emergency care center when they responded to a Code Blue, arriving just as the patient was being intubated. The patient was fighting the intubation, so a physician gave a verbal order for propofol. The RN asked the pharmacy technician to withdraw a 100-cc bottle of propofol from the medication dispensing machine and asked another nurse to administer the medication to the patient. Shortly after the other nurse began administering the propofol, the patient’s blood pressure dropped, so the nurse was ordered to stop the propofol infusion. The patient continued to decompensate and suffered respiratory collapse/arrest. Following some delay, the patient was eventually intubated, then emergently transferred to a higher acuity hospital for further treatment. The patient ultimately suffered anoxic encephalopathy while he was in respiratory arrest. A recorder was present documenting the Code, and, afterwards, another nurse transcribed the recorder’s notes into the patient’s healthcare information record. The recorder noted that it was the insured RN who advised the pharmacy technician to remove propofol from the medication dispensing machine and instructed a nurse to administer the medication. However, the recorder failed to note that the physician gave a verbal order for the propofol. The insured RN failed to review the notes that the recorder and nurse entered into the patient’s healthcare information record and failed to note this error. The physician who was present during the Code also failed to catch this error in the record. Approximately six months later, the patient’s family filed a lawsuit against the emergency care center. During a review of the Code record in response to the lawsuit, it was noted that, during the Code, the RN instructed another nurse to administer propofol. However, there wasn’t any indication in the record that a physician had ordered the medication. The emergency care center dismissed the RN from employment and reported the incident to the SBON. The SBON opened its own investigation into the RN’s conduct. Resolution While the insured RN denied ordering another nurse to administer propofol without a verbal order from the physician, the RN could not deny failing to ensure that the propofol administration was documented in the patient's healthcare information record. The RN entered into a stipulation agreement with the SBON, under which: • the RN’s multi-state licensure privileges were revoked; • the RN was required to complete coursework on nursing jurisprudence and ethics, medication administration, documentation, and professional accountability; and • the RN was required to work under direct supervision for one year and submit quarterly nursing performance evaluations to the SBON. The total incurred expenses to defend the insured RN in this case exceeded $16,600. Risk Control Recommendations • Know the parameters of your state’s nursing scope of practice act, and your facility’s policies and procedures, related to medication administration. • Only accept verbal drug orders from practitioners during emergencies or sterile procedures. Before carrying out a verbal order, repeat it back to the prescriber. During a Code Blue, be sure to communicate all procedures, medications, treatments to the recorder. • Review Code Blue records for completeness and process of care after each Code. Report any concerns and provide feedback through proper channels to ensure that any errors in the record or areas of improvement are identified and addressed. • Document simultaneously with medication administration, whenever possible, in order to prevent critical gaps or oversights. Disclaimers These are illustrations of actual claims that were managed by the CNA insurance companies. However, every claim arises out of its own unique set of facts which must be considered within the context of applicable state and federal laws and regulations, as well as the specific terms, conditions and exclusions of each insurance policy, their forms, and optional coverages. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. These statements do not constitute a risk management directive from CNA. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation, encompassing a review of relevant facts, laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information. This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. This information is provided for general informational purposes only and is not intended to provide individualized guidance. All descriptions, summaries or highlights of coverage are for general informational purposes only and do not amend, alter or modify the actual terms or conditions of any insurance policy. Coverage is governed only by the terms and conditions of the relevant policy. Any references to non-Aon, AIS, NSO, NSO websites are provided solely for convenience, and Aon, AIS, NSO and NSO disclaims any responsibility with respect to such websites. This information is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., NSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information. Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc., a licensed producer in all states (TX 13695); (AR 100106022); in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services, Inc.; in CA, Aon Affinity Insurance Services, Inc., (CA 0G94493), Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY, AIS Affinity Insurance Agency.
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