C790 Task 1 Informatics E-Portfolio Example

Nursing Informatics E-Portfolio: The Informatics Nurse Specialist's Role in Moving Suicide Risk Screening From Paper to Structured Documentation at a Rural Hospital

Student Name

Leavitt School of Health, Western Governors University

C790: Foundations in Nursing Informatics, Task 1

Course Instructor

Month Day, Year

Nursing Informatics E-Portfolio: The Informatics Nurse Specialist's Role in Moving Suicide Risk Screening From Paper to Structured Documentation at a Rural Hospital

The Setting and the Informatics Problem

The setting is a composite 110-bed hospital that serves a rural county of about 60,000 people, with a 14-bed emergency department (ED), two medical-surgical floors and a small intensive care unit. The hospital screens ED patients who present with behavioral health complaints for suicide risk, as the accreditor's suicide prevention safety goal requires (The Joint Commission, 2019). In practice, the screening is done on a paper Columbia Suicide Severity Rating Scale (C-SSRS) screener that is scanned into the electronic health record (EHR) as an image after the visit. Nobody can search the answers, the risk level does not trigger any orders, and inpatient nurses cannot see an ED screen without opening a scanned document. Hospital leaders have decided to extend screening to every ED patient aged 12 and older and every inpatient admission, and to build the screener into the EHR as structured data linked to decision support. The chief nursing officer has asked the informatics nurse specialist (INS) to lead the clinical side of the work.

The Role of the Informatics Nurse Specialist

The profession's scope and standards document frames nursing informatics as the specialty that combines nursing knowledge with information science and analytics, so that what nurses record can move from raw data to sound judgment (American Nurses Association [ANA], 2015). In this project the INS works in four capacities.

As translator, the INS sits between nurses, the behavioral health team and EHR analysts, turning a clinical question, such as what a nurse should do when a patient answers yes to the question about a recent suicide attempt, into requirements an analyst can build. As designer, the INS decides with frontline nurses how the screener appears, where it sits in the admission workflow and which answers are required. As educator, the INS prepares nurses in the ED and on the floors, who have never used the tool electronically. As evaluator, the INS defines what the organization will measure after go-live: how many eligible patients are screened, how quickly high-risk patients receive safety precautions and whether the alerts help or annoy.

Stakeholders include ED and floor nurses, the ED medical director, the behavioral health liaison who performs follow-up assessments, EHR analysts, the patient safety officer, security staff who carry out one-to-one observation and patients themselves, whose privacy the design must protect.

Data, Information, Knowledge and Wisdom

The data-information-knowledge-wisdom framework describes how raw facts become the basis for sound action, and it has been used in nursing informatics to explain what informatics systems contribute at each level (Matney et al., 2011). It maps directly onto the screening project.

Data are the individual answers to the screener's questions, recorded as yes or no. Information is those answers organized and interpreted: a patient who answers yes to having had thoughts of killing themselves in the past month and yes to having started to work out how is at high risk by the screener's own scoring. Knowledge is the organization's protocol connecting that risk level to action, such as continuous observation, removal of hazardous items and a behavioral health evaluation before discharge. Wisdom is the nurse's judgment when the screen and the patient do not match, for example a patient who screens low but whose affect and history worry the nurse, or a patient who screens high because of a question misunderstood through an interpreter. A paper image stops at the data level. Structured documentation lets the system produce information automatically and prompt the knowledge the organization has agreed on, while leaving wisdom to the nurse.

Standardized Terminology and Interoperability

If screening answers are stored as free text or as one hospital's local codes, they cannot be compared across settings or shared with the community mental health center that receives referrals. The INS will ask the analysts to map the screener questions and the resulting risk level to Logical Observation Identifiers Names and Codes (LOINC), which assigns standard codes to questionnaires and their items, and to record nursing interventions using the organization's existing standardized nursing terminology. Standard coding also allows the hospital to report screening rates to its quality program without manual chart review.

The Systems Development Life Cycle for This Project

The project will follow the systems development life cycle (SDLC), which moves a system change through planning, analysis, design, building and testing, implementation, and maintenance and evaluation. In planning, the INS confirms scope, the extension of screening to all eligible patients, and secures a project sponsor. Analysis documents the current paper workflow and the future electronic one. Design specifies the screener form, the risk scoring and the orders each risk level suggests. Building and testing include scenario testing with nurses using realistic test patients. Implementation covers education, a go-live date and at-the-elbow support. Maintenance and evaluation track screening rates and alert responses and adjust the build. Later courses in the program take several of these phases in depth.

Evidence for the Change

Universal screening in EDs is feasible and finds patients who would otherwise be missed. In a multisite study of eight EDs, documented screening rose from 26% to 84% after universal screening was introduced and improved, and detection of suicidal ideation or behavior nearly doubled, from 2.9% to 5.7% (Boudreaux et al., 2016). The C-SSRS itself has shown good validity against other measures of suicidal ideation and behavior and high sensitivity and specificity for classifying suicidal behavior in adolescent and adult samples, including adults presenting to an ED (Posner et al., 2011). Neither finding helps patients if the result is trapped in a scanned image, which is why the informatics design matters.

Reflection on the Role

I came into this course picturing informatics as the people who repair computers. Mapping one project to the framework showed me that most of the INS's work is clinical and relational: deciding with nurses what the right action is, and then making the system make that action easier than the alternative. The part I expect to find hardest is evaluation, because a screening rate is easy to count but a missed patient is not. I will use the rest of the program to build that evaluation deliberately rather than leaving it to the end.

References

American Nurses Association. (2015). Nursing informatics: Scope and standards of practice (2nd ed.). American Nurses Association.

Boudreaux, E. D., Camargo, C. A., Arias, S. A., Sullivan, A. F., Allen, M. H., Goldstein, A. B., Manton, A. P., Espinola, J. A., & Miller, I. W. (2016). Improving suicide risk screening and detection in the emergency department. American Journal of Preventive Medicine, 50(4), 445-453. https://doi.org/10.1016/j.amepre.2015.09.029

Matney, S., Brewster, P. J., Sward, K. A., Cloyes, K. G., & Staggers, N. (2011). Philosophical approaches to the nursing informatics data-information-knowledge-wisdom framework. Advances in Nursing Science, 34(1), 6-18. https://doi.org/10.1097/ANS.0b013e3182071813

Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., Currier, G. W., Melvin, G. A., Greenhill, L., Shen, S., & Mann, J. J. (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266-1277. https://doi.org/10.1176/appi.ajp.2011.10111704

The Joint Commission. (2019). R3 report issue 18: National patient safety goal for suicide prevention. The Joint Commission.