Introduction

On July 19th, 2023, New York State (NYS) Governor Hochul signed the Non-Patient Specific Orders bill #A6030C- Paulin/S6886 Rivera into law. Previously, Registered Nurses (RNs) in NYS were permitted to perform Non-Patient Specific Orders for vaccinations, Tuberculin PPD testing, HIV/Hepatitis C testing, and emergency treatment of opioid overdose and anaphylaxis. This most recent bill specifies the ability for RNs to independently perform additional procedures: (1) electrocardiograms for  signs and symptoms of an acute cardiac syndrome, (2) point of care blood glucose for change in mental status /symptoms of hypoglycemia (3) pregnancy testing prior to imaging studies, operative procedures and/or use of anesthesia  that can harm pregnant individuals , and (4) performance of lab testing and intravenous lines for patients that meet severe sepsis and septic shock criteria. This legislation enables registered nurses in NYS to optimize and hasten patient care that may otherwise be delayed and aligns with the more autonomous nursing practices in much of the United States.

The Mount Sinai Health System (MSHS) swiftly moved the new law into clinical practice.  In late May 2024, the team implemented an RN Sepsis Order Set for patients with concern for sepsis identified during the Emergency Department (ED) Triage process. This work was spearheaded through the leadership of the Health System’s Sepsis Committee and System Nursing Education and Professional Practice, which consisted of Leadership, Nurses, Physicians, Informaticists, Pharmacists, and Process Improvement experts.

The MSHS is located in New York City and Nassau County, New York and is comprised of eight EDs. Six of the eight EDs were involved in this initiative, and collectively the six EDs have an annual visit volume of approximately 550,000 patients and range from large academic medical centers to community hospital settings. Four of the six EDs were awarded the prestigious Emergency Nurses Association (ENA) Lantern Award, two are part of American Nurses Credentialing Center (ANCC) Magnet designated hospitals, five are American College of Emergency Physicians (ACEP) Geriatric Bronze certified, and one Silver. Varying ED sites are 911 STEMI receiving, Thrombectomy capable, and two Level II trauma centers.

Engagement

To socialize, plan, and seek design input from the clinical ED RNs, several focus groups occurred via zoom with participation from all sites. The Focus group participants were comprised of ED Nurse Leaders, Educators, and Clinical Staff Nurses with experience ranging from 20 years to new graduates.

Focus group participants were given information on the new law and rallied at the notion of expanding their nursing practice. The groups discussed the current state of sepsis care and helped design new workflows that optimized communication of the nursing order from the triage RN to the provider and nursing teams assuming the patients care.  Proposed elements of the nursing order-set were reviewed, and the RNs advocated for additional labs to be included. Lastly, the group reviewed the build within our Electronic Health Record (EHR) which included nursing order triggers, workflow logic, redundancy prevention, and visual displays. Ultimately, the nurses in the focus groups approved and endorsed the final workflow for which they actively participated in designing.

Design

In the MSHS EDs, the pre-existing informatics infrastructure included a pop-up notification (Best Practice Advisory (BPA)) for triage nurses indicating when a patient had at least two vital signs meeting Systemic Inflammatory Response Syndrome (SIRS) criteria. This prior state alerted RNs that the patient was at risk of sepsis and prompted them to notify a provider to evaluate the patient and enter sepsis orders if appropriate.

Incorporation of the new RN Sepsis Order Set (RN SOS) (Figure 1.) into the EHR required careful reconciliation with the existing ED Provider Sepsis Order Set (Provider SOS) and selection of the subset of orders that were covered by the new law. This was done by an interdisciplinary team to ensure stakeholder buy-in, accuracy, and integration with existing workflows. Ultimately, the RN SOS was created and included peripheral intravenous line placement and the relevant lab tests and a link to the order set was embedded into the existing triage BPA to facilitate easy completion. Careful attention was made to maintain initial lactate orders could be performed via point-of-care testing devices. In addition, a pathway for close the loop communication to the primary provider was developed.

Early discussion during the planning phase indicated that RNs were particularly concerned about the possibility of duplicate orders being entered by providers, who would then cancel the tests ordered through the nursing standing orders. The concern was addressed by embedding design features that decreased the likelihood of order duplication. EHR logic was built such that when the RN SOS is activated, the corresponding orders were automatically unchecked from the Provider SOS. Text was added to the top of the Provider SOS to inform the ordering provider that this had occurred. A Nursing Practice Alert (figure 2.), Online Education Sepsis Module, and Provider tip sheet were developed. The new workflow and education tools were socialized with ED leadership prior to launch, to facilitate support and buy-in of the changes.

Sepsis Goals

The implementation of the RN SOS aligns with the MSHS Sepsis Program Goals; early identification and management of sepsis to reduce mortality, length of stay and readmissions; adherence to the MSHS Sepsis Care Pathway; and optimization of clinical workflows. In addition, team communication and team handoffs were created to support sepsis care.

Our primary goal of the RN SOS workflow is to empower RNs to work the top of their license and when appropriate, facilitate early drawing of labs to enhance clinical decision making and establish early IV access to quickly begin IV antibiotic and fluid administration in septic patients.

Results

Across the six hospitals, for June – August 2024, on average 30% of patients placed on the sepsis pathway by a provider in Triage, also had the RN SOS activated (N = 439).  Utilization is not the same at all our sites; hospitals that have a provider in triage tend to have lower utilization which is to be expected.  Additionally, ED configuration, in terms of where nurses and providers sit also appears to have an impact on utilization.

It has been important to leadership that that RNs feel empowered when implementing the sepsis and other Non-Patient Specific Orders.  At this time, utilization targets are not purposefully set. The RN SOS is a tool for RNs to work at the top of their license when clinically appropriate, which currently is challenging to measure. The RN SOS workflow facilitates RN and provider timely communication about potential or actual septic patients, which in of itself is a very important outcome. Over the coming months the continued impact of the RN SOS utilization on sepsis bundle compliance as well as outcome metrics will be assessed.

Future Implication on Nursing Order Legislation

With continued success in early detection of critical clinical conditions and reduction in delays in care delivery, the nursing professional community continues to support the expansion of Non-patient Specific Orders for the advancement of nursing practice and will continue to be advocated for within the NYS legislation process.

Authors