Novant changes mindset for travel nurses, CMS action plan details recruitment efforts

On August 30, Novant released its action plan for addressing the “immediate risk” status with the Centers for Medicare and Medicaid Services. (PCD / Johanna F. Still).

NEW HANOVER COUNTY – Novant New Hanover Regional Medical Center is recruiting more contract workers, a recently released action plan shows, after many contracts were terminated earlier this year.

The report shows that over 120 travel nurses were hired between June 30 and July 22, with potentially more to come.

READ MORE: Fed Report Confirms Novant’s Understaffing, Nursing Details PCD Problem Extends Beyond ER

On August 30, Novant released its action plan for addressing the “immediate risk” status with the Centers for Medicare and Medicaid Services. The federal agency threatened to revoke NHRMC’s contract with Medicare for hospital conditions that caused or could cause serious injury, harm, damage or death to a patient.

NHRMC’s immediate danger status has since been lifted.

The CMS findings followed investigators’ observations from June 21 to June 29, about a month after Novant decided to reduce its reliance on travel nurses. Novant did not provide PCD with data on the number of travel nurse contracts. However, three nurses told PCD that the hospital relied heavily on travelers, staffing about 30% to 50% of its departments with them.

Novant created an action plan that addresses its security breaches by CMS. In many cases, NHRMC was cited for not adequately staffing its emergency department, and as nurses confirmed, other departments are also running understaffed.

Herein lies the crux of NHRMC’s problem: the lack of workers affects the hospital’s ability to perform effectively in every area. If a department is understaffed, it hurts the interconnected ecosystem of the hospital.

Novant’s action plan details its efforts to increase contract work.

In response to its dire situation — a 138:13 patient-to-nurse ratio in the ER on June 21 — Novant took steps to hire rapid-response travel nurses.

According to the report, NHRMC’s chief nursing executive — who is not named, although Amy Akers holds the position according to the hospital’s website — requested on June 29 the use of rapid response travelers, temporary nurses who fill emergency and critical positions. A contract with an agency — also unnamed — to provide crisis response personnel within 10 days was approved on July 5.

By July 11, 20 traveling nurses had arrived.

At an Aug. 24 Novant news conference outlining the action plan, Akers said Novant has been “aggressive” in its recruiting efforts. The report shows staff have attended five local recruitment events since June 28.

Novant also improved its contract labor incentives.

On June 24, a new travel agency was approved to help search for additional clinical nursing positions, including 18 specifically for the ER. Novant extended the contract to 26 weeks and 48 hours per week to attract candidates. Also, the travel nurse rate was increased “based on work area.”

The report says contract rates for ER nurses have increased twice in the past two months, while medical/surgical, labor and delivery and ICU rates have increased once, though the report did not detail how much. According to a spokesperson, Novant does not share salary figures.

As of June 30, the report says NHRMC had 116 active travel nurse contracts, another 25 traveler contracts, but was looking to recruit 182 more travelers.

Almost a month later, on July 22, NHRMC had won 46 active contracts and another seven traveler contracts. According to the report, another 70 contracts have been confirmed with future start dates planned.

However, the NHRMC sought to recruit 72 more travelers at the end of July.

As a Novant spokesperson previously told PCD, the hospital hopes to increase its contract employment to 315 positions. Novant has filled or applied for 291 positions, according to the report.

As for permanent staffing, on June 22, the chief nurse executive requested eight more ER nurses and 16 medical/surgical nurses — the two most understaffed departments, according to nurses’ testimony.

The report shows that 88 nursing graduates started work on July 11, with 31 scheduled to begin employment by the end of August. Between July 11 and 25, 10 care associates, three ED technicians, nine nursing assistants and seven physician assistants were hired.

Inadequate staffing was only one area of ​​improvement addressed in Novant’s action plan, even though understaffing affects every aspect of the hospital. The plan details corrections in other areas, including the hospital’s triage process, denial of care obligations, use of chemical restraints and other emergency department procedures.

The CMS report detailed many instances where the hospital’s ER triage process was not followed properly.

One victim of that absence, a 77-year-old woman coding in the ER’s waiting room, stayed in the lobby for five hours, her vitals not checked for four — a violation of the triage policy.

Novant’s plan involved re-educating nurses in the triage process, including what’s called the “ESI scale,” ranking patients based on the severity of symptoms. The triage policy clarification states that patients presenting with an ESI of 1 will be seen immediately and 2 will be directed to the waiting room and rechecked at least hourly. ESI Levels 3, 4 and 5 will be re-evaluated every four hours.

The new policy clarifies that vitals should be reviewed as needed, not every four hours. The last time the policy was approved was July 15, 2022.

The report says an emergency department coordinator will review at least 20 cases of people waiting more than four hours for vital signs to be checked. This process will occur until compliance is achieved for four consecutive weeks and then transition to a monthly review for three consecutive months until the issues are resolved.

To keep track of patient wait times, a charge nurse will oversee a tracking board that will show how many patients are in the waiting room. The board will help notify when a patient’s vitals should be reevaluated. Nurses and clinical team members will also be required to attend a muster before working a shift.

NHRMC was tasked with improving its data and reducing EMS turnaround times. The CMS report cited numerous instances of delays in EMS discharge, with trucks sometimes waiting for hours to get their patients into the building. Improvements there include dedicating a charge nurse to observe delays in the turnaround process between EMS and ER vehicles. Improvements will be reviewed monthly.

Hospital staff are also mandated to improve their responses to patients who refuse care. The CMS report found multiple instances where staff did not follow protocol when a patient left without being seen. The policy was reviewed and staff educated on its requirements.

Weekly audits of 30 patients who left without being seen or against medical advice began on July 22. Starting September 1, the sample size will be reduced to 60 charts per month and will continue for up to four consecutive months subject to compliance.

NHRMC also failed to properly document the use of chemical restraints, or sedation, in numerous cases of combat patients. A facility is permitted to use certain medications to sedate a patient who puts staff or other patients in physical danger, although this restriction must be documented.

Novant updated its policy on the use of chemical restraints. Staff must document every 15 minutes to the hour, every 30 minutes to the hour, or every hour to two hours, unless otherwise specified by the chemical restraint provider. A patient safety manager will complete a daily review of chemical restriction orders to monitor compliance. The policy took effect on July 24.

Data on the use of chemical restraints will be reported until compliance is achieved for three consecutive months, and will be reviewed quarterly thereafter.

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