In answering the question “What is Nursing?” on the American Nurses Association website, it states: “21st Century nursing is the glue that holds a patient’s health care journey together. Across the entire patient experience, and wherever there is someone in need of care, nurses work tirelessly to identify and protect the needs of the individual.”
That description is clearly evident throughout the multitude of nursing roles and venues in the Department of Defense (DOD) and the Department of Veterans Affairs (VA). While nurses’ commitment to highly skilled and compassionate care never waivers, the techniques and technologies utilized to deliver that care are continuously evolving.
DOD Trauma Documentation Study: From Paper to Electronic
In one example of an evolving technology, trauma staff at Brooke Army Medical Center (BAMC) in San Antonio, Texas, have been conducting a performance improvement study since August 2018 using T6, an electronic trauma documentation application created by T6 Health Systems.
U.S. Air Force (USAF) Lt. Col. (Dr.) Valerie Sams, trauma critical care surgeon at BAMC and the T6 study lead, explained the reason for the study, based on her observations and experience during deployment to Afghanistan a few years ago.
Sams categorized the T6 as a nursing documentation tool, with the application extending “beyond documentation into things like clinical support, clinical practice guideline compliance, supply and logistics chain management, personnel management, coding and billing, and registry data capture,” she said.
Sams said that standard trauma documentation in the United States is still predominantly a paper process. The problem she noted while deployed, “with military health care being a continuum of care, from the point of injury through the Role 4, Role 5 level of care both in Germany and in the States, is that that paper documentation becomes very cumbersome in terms of data capture,” she said. “This is a process that follows people from the battlefield to wherever they’re going for their definitive care. A lot of the documentation was pretty poor, given the fog of war and difficult operational environments.”
Sams continued, “In order for us to make decisions about resources, practice guidelines, and casualty care, we really rely on accurate data.”
In an effort to improve data capture along the continuum of military trauma care, Sams worked with company representatives to explore an “electronic version of what we’ve been doing on paper for a very long time.” With improved efficiency and accuracy of data capture, she said, “combat casualty care is only going to get better.”
Sams categorized the T6 as a nursing documentation tool, with the application extending “beyond documentation into things like clinical support, clinical practice guideline compliance, supply and logistics chain management, personnel management, coding and billing, and registry data capture,” she said. While those T6 capabilities exist, this yearlong, off-line study focuses solely on the documentation aspect.
Because the trauma nursing community is passionate about ensuring accurate and complete documentation, Sams said, “finding an application that they can use and feel confident in was huge.” To evaluate the T6 application as a pilot at BAMC, nursing staff are documenting trauma care both electronically and with the paper method in a head-to-head comparison. Recently, the study has been extended to trauma care in Afghanistan, where Sams was again deployed.
In use, Sams said the T6 application is loaded on Apple Inc. iPads ® that are mounted to stands in the trauma bays, but are removeable for continuing documentation as patients are transported to other locations for diagnostic studies, such as X-rays. Large monitors also display the documentation in the trauma bay, including checklists, algorithms, warnings, and decisions, so everyone involved “can be on the same page with what is going on with that patient.”
“The systematic approach to the T6 design is ideal for the general nursing environment,” said USAF Capt. Seana L. Gerald-Ellsworth, NC, BSN, RN, CEN, emergency/trauma nurse at BAMC. “The wheel set-up allows for head-to-toe guided assessments. It is very user friendly when time allows for the structured flow the T6 provides. The system flags abnormal values in the vital signs flow sheet and also allows for trending of vital signs in a graph format, which adds a visual component to the long-term observation of the patient.”
Gerald-Ellsworth also identified challenges in implementing the T6 into their trauma practice. For example, she noted that it does not allow for easy navigation if a patient’s condition requires parts of the assessment to be done out of order, adding, “This also is partially attributed to the comfort or experience level of the nursing staff with the program. We have only been utilizing this system on a trial basis, which has been staffing dependent on how frequently we are able to use it in live trauma situations.”
Capt. Katie Barnack (left), an emergency room nurse, and Lt. Col. Valerie Sams, a trauma surgeon, both deployed with the 455th Expeditionary Medical Group, demonstrate the T6 Health System, which is in trial phase at the Craig Joint Theater Hospital at Bagram Airfield, Afghanistan, March 30, 2019. The T6 mobile device application is a high-resolution, digital documentation system that may be used to replace some paper records and streamline patient care processes.
Gerald-Ellsworth observed that T6 utilization “follows a very structured layout that requires flipping through multiple pages at times to obtain certain categories for documentation. In some sections, there are not adequate options available and minimal ability to free text; for example, lab tests or radiology exams can only be charted as ‘ordered/not ordered’ and ‘results.’ This is not useful in our trauma environment given that we need to chart the times the blood was obtained or not obtained. Also, there is not an option for ‘unable to obtain’ or ‘deferred’ in the vital sign categories, which creates difficulties when closing out the charts that require vital signs to be entered.”
However, she continued, “These may be [factors] that have potential to be tailored through the developers of the program to whom we have provided feedback when they have returned for follow-up visits.
“As with any change to standard practice, there are always difficulties with comfort and ease of implementation that can only be improved upon with familiarity with the program,” she concluded. “This is an ongoing process that we are trying to incorporate into our practice as staffing and availability allows.”
Acknowledging the challenges and discomfort inherent in a new process, USAF Maj. (Dr.) Remealle How, trauma surgeon at BAMC and who is also involved with the T6 study, added that the electronic documentation system benefits patients by improving continuity of care. “Whenever you transfer a patient from one location to another, you’re relying mainly on verbal sign-out and paper charts,” she said. “From a clinician standpoint, it’s helpful to have all that information available in one location versus trying to piece it together from what people are telling you, and then trying to look over a paper chart where you have to figure out everybody’s handwriting. I think it improves the process of caring for patients and getting the clear story from one location to another.”
Looking to the future, Sams said the study also investigates whether the system could be used at earlier roles of care, beginning with point of injury, air medical evacuation, and other pre-hospital environments.
VA Telehealth: Using Technology to Expand Access
In another example of broadening technology, the VA is recognized as a world leader in the development of telehealth services that are now mission critical to the future direction of VA health care, according to John Peters, M.G., VA deputy director for telehealth services. Goals of utilizing telehealth technologies include enhancing accessibility, capacity, and quality of VA health care for veterans, their families, and their caregivers anywhere in the country.
“VA’s history with telehealth goes back more than 50 years, when closed-circuit television was used to connect specialist providers at the University of Nebraska Medical Center in Omaha with veterans at three VA hospitals in Grand Island, Lincoln, and Omaha, Nebraska,” Peters noted. “Modern VA telehealth services, as integrated into VA’s national health care delivery, quality, and staff training systems, began almost 20 years ago. Today, VA telehealth services are available from more than 900 VA locations, and most recently to veterans at home or other non-VA locations. Last fiscal year, VA served more than 782,000 veterans in over 50 specialty areas of care through telehealth.”
VA telehealth services function in three overlapping categories: remote patient monitoring/home telehealth; asynchronous telehealth; and synchronous telehealth.
Remote patient monitoring/home telehealth applies care and case management principles to coordinate care using health informatics, chronic disease management, and technologies such as in-home mobile monitoring, messaging, and/or video technologies.
Asynchronous telehealth uses technologies to acquire and store clinical information – such as data, images, or sounds – that is later reviewed, assessed, and evaluated by a VA provider at another location.
Synchronous telehealth uses real-time interactive video conferencing, sometimes with supportive peripheral equipment, to assess, treat, and provide care to a veteran in a separate clinical location, increasingly at home or another non-VA location.
As with VA health care services delivered in person, nurses serve at all levels of VA telehealth services, making a significant and sustainable impact on the care of veterans, according to Rita Kobb, APRN-BC, telehealth training team lead.
Clinically, nurses utilize telehealth technologies along a continuum, from licensed practical nurses providing health coaching, to registered nurses serving as case managers, to nurse practitioners managing complex care for veterans in primary and specialty care.
Additionally, Kobb expanded, “VA registered nurses and advanced practice nurses have meaningful roles in research to shape telehealth practice; roles in education to ensure telehealth competency for VA staff; as well as roles in administration to provide vision and collaboration for enhancing veterans’ care through telehealth expansion and innovation. Nurses are involved in identifying patient outcomes and measures for telehealth services, establishing disease management standards and protocols, and developing tools to support staff performance.”
VA telehealth enhances the quality of care for veterans living in remote or rural areas who can access nationally recognized VA specialists in several specialty clinical areas such as post-traumatic stress disorder, bipolar disease, and genomics, for example.
VA telehealth services augment the in-person care veterans receive from their local VA, Peters explained, and offer many benefits. Veterans can utilize telehealth to access care that may not otherwise have been as easily accessible, due to factors such as travel time, distance, and cost; traffic; loss of work; daycare; inclement weather; or social stigma seeking care.
Veterans also benefit when VA uses telehealth to better match supply and demand. “VA can hire providers at larger, often urban and academic, VA medical centers to provide interim vacancy coverage at smaller, often rural, VA facilities where there is relatively less recruitment potential,” Peters noted. “VA telehealth enhances the quality of care for veterans living in remote or rural areas who can access nationally recognized VA specialists in several specialty clinical areas such as post-traumatic stress disorder, bipolar disease, and genomics, for example.”
Peters described several ways in which the VA plans to expand its use and definition of telehealth services, including: further development of its VA clinical telehealth resource hubs to provide mental health, primary care, and other core clinical providers’ services; strategic partnerships with public community centers and commercial retailers to establish telehealth access stations for veterans without video capability or internet at home; VA provider and veteran adoption of VA Video Connect, VA’s mobile app enabling “anywhere to anywhere” synchronous video telehealth; expansion of asynchronous telehealth services from the VA clinic to the veteran’s home and mobile device; and growth of VA’s remote patient monitoring/home telehealth and the use of artificial intelligence.
Nurses participate in a video conference at the VA Sierra Nevada Health Care System (VASNHCS) Medical Center. VASNHCS’ telehealth services include primary care, nutrition, mental health, women’s care, urology, wound care, and more.
VA Patient-Aligned Care Teams: Veteran-Focused Primary Care
Nurses also have a pivotal role in the Veterans Health Administration’s (VHA) Patient Aligned Care Team (PACT) model of care, a team-based approach launched in 2009 that built on previous team-based strategies for providing comprehensive primary care to veterans. VHA adopted and customized principles of the patient-centered medical home model that features patient-centered care, coordination of care, and access to care.
Individual PACTs consist of a primary care provider (PCP), registered nurse care manager (RNCM), clinical associate (CA), and administrative associate, explained Karey Johnson, DNP, RN, director of clinical learning, VHA Office of Primary Care. They are also supported by extended team members in the roles of clinical pharmacy specialist, registered dietitian, social worker, and integrated mental health partners. Each PACT cares for a dedicated group of patients and serves as the central point of coordinating and managing care for the assigned veterans. This includes not only providing primary care, but also coordinating with other services such as specialists and community organizations to provide comprehensive health care for veterans.
The original goal of the PACT model was two-fold. For the overall model, the goal was to address the anticipated primary care provider shortage combined with the increasing number and aging population of veterans by moving away from the “lone provider” model to one that was proactive, personalized, and “included a team that could share the workload for the panel of patients,” Johnson said.
For the individual PACTs, she continued, “the goal is to be responsible in a continuity-type relationship for a core group of patients, to develop relationships with those patients, to really understand who they are, what their story is, and then understand through their story and their life how we can help them achieve whatever they want for that life. And you can really only do that best through that relationship. Having a dedicated group of providers – including doctors, nurses, and extended providers who can develop that relationship – was key.”
Nurses function in a variety of roles within PACTs. For example, advanced practice nurses, such as certified nurse practitioners, can function as the team’s PCP.
The RNCM provides comprehensive and coordinated nursing care, collaborating with both VA and community services to meet the health promotion or disease prevention, acute, chronic, and long-term needs based on the veteran’s goals and plan of care, with a focus on self-management.
On a typical day, Johnson said, the RNCM provides overall coordination regarding that day’s patients, discussing patients’ needs with the PCP and other team members, and triaging veterans who present with acute needs. “Nurses have their own schedule grids,” she said, “so if patients need follow-up visits that are within the purview and scope of an RN, they’ll see patients for that follow-up care.”
Additionally, “they may have had alerts come in from a call center – if a veteran called in and needs something, they’ll check back with those veterans.
They’ll also look at the list of patients who’ve been discharged from the hospital or the emergency room,” she said, and, in all instances where possible, contact that patient within 72 hours of an inpatient discharge, ensuring their needs are met for their transition and their follow-up plan.
In addition to individual patient care, the RNCM role includes population-based management, “looking at different cohorts of patients with different risk levels and working to arrange with the provider the right services that are needed to address that cohort of patients,” Johnson said.
In the CA role, licensed practical or licensed vocational nurses work closely with the PCP to manage the clinic day and prepare for office visits by gathering veterans’ pertinent information such as vital signs, lab results, and completing basic preventive health questionnaires, and performing routine procedures such as immunizations and screenings as ordered by the PCP.
Future trends for the PACT model include increasing use of advancing technologies, including VA Video Connect, for web-based visits, said Johnson. For example, if a veteran has medication questions, “the nurse is able to say, ‘Why don’t you take your phone and show me your medicine cabinet, show me what you’re seeing,’ as opposed to that veteran having to deal with traffic and parking … Nurses are using this technology to have those visits with patients without requiring them to come into the hospital.”
Dr. Leonie Heyworth, VA’s national lead, synchronous telehealth, Office of Connected Care, echoed that point in describing how the technologies of telehealth intersect with the PACT care model. “Currently, VA is undergoing an expansion of video telehealth across PACT with the goal of 100 percent of PACT clinicians capable of offering a video visit by the end of fiscal year 2020,” she noted. “Integration of video visits across PACT using VA Video Connect gives veterans and their caregivers the opportunity to access their VA care from anywhere using any smartphone, tablet, or computer.” Other examples of video visits include interval blood pressure checks with nurses, post-hospital discharge visits, insulin management, and educational opportunities across all PACT services, particularly nutrition, clinical pharmacy, and primary care-integrated mental health services.
Heyworth added, “The flexibility of video care from any location enhances continuity of VA care by PACT for traveling veterans, reinforcing the PACTveteran relationship. Engaging veterans, their families, and caregivers through VA Video Connect visits has already demonstrated high veteran satisfaction, travel cost savings, and has the potential to increase access to timely primary care.”
Johnson emphasized that within the PACT roles and across the VA, nursing can make a big impact in veterans’ lives. She said, “Regardless of what type of nurse you are, there’s a place for you to be able to serve our veterans, and serve our country, essentially, through service to them.”