Update - Palomar Health

Transcription

Compassion
•
Integrity
•
Teamwork
•
Innovation and Creativity
•
Excellence
•
Stewardship
Nursing News Network
FALL 2007
CNE
Inside This Issue:
Update
1
CNE Update
inston Churchill could
have been referring to
the planned new hospital in
Escondido or the Pomerado
Hospital expansion when he
said in a speech in 1943 to
Britain’s House of Commons,
“We shape our buildings, and
afterwards our buildings shape
us.” As you know, our buildings
are shaping up to include such
staff-driven innovations as a
healing environment, an integrated
interventional platform for the
surgical suites, single occupancy,
same-handed rooms, and acuity-adaptable rooms with distributed nursing stations.
Schematic designs are in the 12- to 18-month approval process with the Office of
Statewide Health Planning and Development (OSHPD), so we are now turning our
attention to the colors, textures and design of the interior spaces.
2
Magnet Journey,
Notes from the Field
3
Relationship-Based Care
4
Magnet Champions
5
force Teams
6
EXPERT ADVISORY PANEL
6
PROFESSIONAL ENHANCEMENT
PROGRAM UPDATE
7
SURGICAL CARE
IMPROVEMENT PROJECT
8
CERNER OPTIMIZATION
8
IOWA MODEL OF
EVIDENCE-BASED PRACTICE
We are also beginning to work with the California Department of Health Services
(DHS) on necessary regulation changes for our acuity-adaptable care delivery
model. As it stands right now, the DHS only licenses rooms as general acute care,
intensive care, pediatrics, NICU, perinatal, and/or psychiatric. There is currently no
recognition or designation of a room wherein care can be provided to all acuities of
a patient population.
10
EVIDENCE-BASED
PRACTICE SERIES
10
ICU BEDS/ LSTAT
11
Save the Date
Therefore, this is truly ground-breaking work in the state of California. I had the
pleasure of presenting our acuity-adaptable care delivery model to key members
of the DHS in Sacramento on June 12 along with Dr. Rivera, Michael Covert,
Gerald Bracht, and Mike Shanahan. Our goal was to convince regulators
that acuity-adaptable care enhances patient safety, reduces medical errors,
and contributes to patient and care-giver satisfaction, and as such the State
should consider changing its regulations. While we were not completely
successful, the DHS did agree to entertain a proposal to pilot acuityadaptable care at Palomar Medical Center in preparation for the new
facility’s opening. I have drafted that proposal and it is on its way to
the DHS for consideration. More to follow later on this exciting topic!
Lorie Shoemaker, RN, MSN, CNAA-BC, Chief Nurse Executive
11
KYXY Care Award
12
Palomar Pomerado Health
Honors Top Nurses
14
Nurses in the News
17
NURSING INTRANET SITE
18
Collaborative Leadership
19
San Diego Fair Banner
Force1
19
nursing Grand Rounds
W
Magnet Journey,
Notes from the Field
I
want to introduce myself as I am new to PPH and have not had the I want to share with you one nurse’s story that speaks to the essence of
opportunity to meet everyone. I will update you on where we are what it means to be a nurse…
on the Magnet journey and share my experiences and observations.
The Forces of Magnetism provide standards that we must continually
I have been a home health nurse for 21 years. That is bordering on a long
assess and use to improve our processes for achieving quality in
time! I don’t do anything that is glamorous or that would make it into an
nursing and patient outcomes. At PPH we are committed to creating
episode of “ER” or “Grey’s Anatomy”. You can find me crawling around
a professional practice environment of leadership, education and
on the floor in a patient’s home, trying to do wound care to his leg, while
research while embracing the diversity of nursing throughout the
a dog nips at my feet, only to stand up and have cat hair all over me. I
system. We strive to develop relationships of trust, openness and
have crawled through a window, after climbing on patio furniture, to
reach a patient who is unable to get to the door. Other times you will
respect in an environment where decision-making and leadership are
find me lost, trying to find a patient’s home out on the reservation where
shared. To this end we have formed teams around each of the Forces
they do not have addresses. I have hiked up muddy dirt roads because
whose core members include a Nursing Executive Council Leader,
my car can’t make it up the steep grade. I have been to migrant worker
Advanced Practice Nurse and two Magnet Champions. These Force
camps in which my patient lives in a shack and the chickens get in my
Teams, as part of our Collaborative Leadership (CL) Structure, are
car. I have been in homes so filthy that I cannot find a place to sit down.
charged with deeply understanding the components and sources of
I am the queen of low-tech nursing…I wouldn’t know how to read an
evidence for their specific force and how this is expressed at PPH.
EKG strip, run all those machines at the hospital, or hand the right
The Force Teams are empowered to close any gaps that are identified.
instrument to the surgeon. But I know how to look, feel and listen closely
The Force Teams attended retreats held on June 8 and 29 where they
to what my patients tell me.
obtained the information and tools needed to begin the process of
understanding each Force and collecting the evidence to support
I am a fiercely proud home health nurse. Each and every day that I go to
our efforts towards Magnet Recognition. PPH Nursing Services is
work, I know in the depths of my soul that what I do for my patients is
in the documentation and evidence-gathering phase of the Magnet
important in so many ways. I do the little things, like holding a shaking
Journey, with our Magnet “books” being due at the American
hand as a patient learns to give his first insulin shot. I make sure my
Nurses Credentialing Center on April 1, 2008. A Magnet Project
patients don’t take Lanoxin and Digoxin, mistakenly thinking they are
Plan has been initiated and you can view our progress on-line in the
different medications. I kiss the face of an old person who hasn’t had a
Balanced Scorecard software that can be accessed on the intranet.
tender touch for such a long time. Sometimes I bring chicken soup or a
Each of the Force Teams will be working through the Summer and
birthday cupcake. I comfort, I teach, I talk about life and death. Oh, I
Fall to document the evidence with a due date of November. The
do the nurse-type stuff too…you know, like wound care, shots, assessments.
Magnet documentation books will then be circulated throughout the
But the true and honorable thing I do is care for people, regardless of the
organization for review and comment prior to submission. Key to
circumstances they live in. I laugh every day. My patients bring me such
our evidence are the stories about nurses and their patients that are
joy. They want to hear about my family, and I get to be a part of theirs,
the heart and soul of nursing at PPH. I encourage you to contact your
even if for a short period of time. Many times patients tell me that I must
Magnet Champion to share your stories or place your stories in the
really love my job - they see the joy in me. I tell them I often feel selfish
“Brag Big” boxes that your Magnet Champion has placed on your unit.
that I get to do what I do, and get paid for it!
I am inspired every day by the people and expressions of nursing that
surround us at PPH.
I don’t do anything fancy. But I know being a home health nurse has
meaning and purpose. I am so lucky.
Patrice Gadd, RN, Home Health Unit Practice Council Chair
I invite you to join us in envisioning, shaping, and manifesting a future
that reflects the deepest passions, beliefs, and values that come from
our roots in nursing – a future that is deliberately and consciously
formed on our Magnet journey.
Sincerely,
Brenda Fischer, RN, MSN, MBA, CPHQ
Magnet Program Manager
Ext. 5090
Magnet cell phone 760-802-8014
[email protected]
nursing news network
Force1
Relationship
Based Care
A
ll nursing models involve some method of
assessing a patient’s individual needs and
implementing appropriate patient care. An
essential portion of each nursing model includes
measurable goals so that the process can be
evaluated to provide better care for the patient
in the future. Nursing models are conceptual
models, constructed of theories and concepts.
They are used to help nurses assess, plan, and
implement patient care by providing a framework
within which to work. They also help nurses achieve
uniformity and seamless care.
A team of four nurses came together and did a literature
search on nursing models of care. After culling seven models
down to The Synergy for Clinical Excellence and RelationshipBased Care models, 1,200 ballots were sent out to PPH nurses in
all roles, departments, and specialties. Of those, 436 ballots were returned
for a 36% return rate, with 72% of votes for the Relationship-Based
Model of Care.
Relationship-Based Care is comprised of three crucial relationships:
care provider’s relationship with patients and families, care provider’s
relationship with self, and care provider’s relationship with colleagues.
The provider relationship is one in which the care provider consistently
maintains the patient and the family as his or her central focus. Compassion
and care are conveyed through touch, a kind act, through competent
clinical interventions, or through listening and seeking to understand
the other’s experience. Relationship-Based Care refers to a philosophical
foundation of the model and its operational framework. Healthcare is
provided through relationships. All care practices visibly demonstrate the
mission and values of the organization, including those of clinicians and
staff members from all disciplines, departments, and services.
Leadership, teamwork, professional nursing, care delivery, resources,
and outcomes are all elements of the model. Relationship-Based Care
promotes organizational health, clinical safety and quality, patient
and family satisfaction, physician and staff satisfaction, and effective
recruitment and retention.
Leaders know the vision, act with purpose, remove barriers, and
consistently hold patients, families, and staff as their highest priority.
Teamwork requires a group of diverse members from all disciplines
and departments to define and embrace a shared purpose and to work
together to fulfill that purpose. The patient care delivery system is
the infrastructure for organizing and providing care to patients and
families. The system determines the way in which the activities of
care are accomplished and is built upon the concepts and values of
professional nursing practice. Professional nursing exists to provide
compassionate care to individuals and their loved ones. Nursing
is a primary component in a complex, interdependent healthcare
delivery system. A resource-driven practice maximizes all available
resources: staff, time, equipment, systems, and budget. Achieving
quality outcomes requires planning, precision and perseverance. It
begins with defining specific, attainable and measurable outcomes.
The Relationship-Based Care model has been presented to the
Clinical Leadership Council, PMC Nursing Leadership, Pomerado
Nursing Leadership and Professional Practice Council. Posters are
being created for education days at PMC and Pomerado. Posters
have puzzle pieces with each model component delineated, and
one model component will be highlighted to be sent out to the
councils, along with the representative puzzle piece to be discussed
at council and staff meetings. Staff will be asked to discuss how
they implement each model component. Next steps will also be to
communicate the model to other departments, link the nursing model
with Magnet Forces, and differentiate the practice model from a care
delivery model.
Force5
Magnet Champions
PMC Clin Resource MgtVickie Austin
Villa Pomerado-Winnie Manglicmot
PMC T5-Luana Bashel
POM ICU/IMC-Kim Moore
PMC ED/Trauma-Christine Bauer
POM Birth Center-Cyn Brynjestad
PMC Home Health-Sharon Culotta
PMC Birth Center-Diane Foster
PMC Birth CenterStephanie Morahan
PMC ED/Trauma-Madelyn Goble
POM Med Surg-Karen Gordon
PMC IMC-Julee Graham
PMC Peds/NICU-Shamin Khalfan
PMC T7-Leah Koenig
PMC CCU-Pam Moehlenhof
POM Periop (OR, PACU, OP)-Mary Odgers
POM ED-Tonya Pearcey
WCC-Theresa Petersen
POM GPU-Denise Pocholski
POM Admin Supervisor-Dee Raley
ESC OR-Cathie Wulff
PMC CCU-Robin Russo
PMC Tele-Beth Salvador
ESC - PACU/Endo-Debbie Fitchett
PMC MHU-Tom Shearer
PPH Trauma Services-Tricia Reynaldo
PCCC-Shirley Livelo
Villa Pomerado-Josefa Macasieb
PMC PACU-Sara Watson
PMC OR-Jeannie Weeks
Magnet honorary Champions
Rehab-Devina Acharya
FANS/EVS-Jana Markley
Laboratory PMCBarbara Borgeson
Laboratory PMCKellee Smith-Harrison
Quality ManagementPat Correnti
Organizational Development-Ruth Szakaly
Performance ExcellenceCarrie Frederick
Finance-Melanie VanWinkle
Human ResourcesLorraine Gilbert
Respiratory Therapy-Staci Greene
Marketing-Tami Weigold
force teams
8. C onsultation & Resources
Denise Pocholski
Joyce Morrey
Stephanie Boyd
Susan Linback
Tom Shearer
1. Nursing Leadership
Bunny Krall
Kim Moore
Lorie Shoemaker
Madelyn Goble
2. Organizational Structure
Ann Moore
Dee Raley
Jackie Close
Theresa Petersen
9. Autonomy
Beverly Berg
Debbie Fitchett
Margaret Talley
Cathie Wulff
3. Management Style
Anne Wagner
Catherine Konyn
Robin Russo
Shirley Livelo
10. Community & HEALTH SYSTEM
Elissa Hamilton
Elllen McKissick
Sara Watson
Sharon Culotta
4. Personnel Policies & Programs
Debra Casey
Josefa Macasieb
Leah Koenig
Marilyn Bailey
5. Professional Models of Care
Tricia Reynaldo
Jeannie Weeks
Karen Gordon
Kim Dodson
Valerie Martinez
6. Quality of Care
Caroline Etland
Linda Urden
Pam Moehlenhof
Shamin Khalfan
7. Quality Improvement
Cyn Brynjestad
Debbie Barnes
Mary Oelman
Pat Correnti
Maria Sudak
11. Nurses as teachers
Barbara Mayer
Luana Bashel
Marilyn Dolatshahi
12. Image of Nursing
Diane Foster
Diane Key
Irma Moore
Mary Odgers
13. Interdisciplinary Relationships
Beth Salvador
Julee Graham
Kathleen Stacy
Sharon Andrews
14. Professional Development
Christine Bauer
Joanne Barnett
Kim Colonnelli
Pam Hoppie
Sharon Gautier
Tonya Pearcey
Expert
Professional
M
M
Advisory Panel
Enhancement Program Update
any staff at Palomar Pomerado Health are still thinking
about the challenges that were issued and the ideas that
were discussed when the Expert Advisory Panel convened in early
February. Lourdes Januszewicz, RN, BSN, CCRN, a member of
the Technology Champion Team and leader of a sub-group on
Communications, was invited to attend.
She was one of approximately 35-40 people, including CEO
Michael Covert, members of the Executive Management Team
and key stakeholders, who listened to Chief Information Officer
Steven Tanaka give a presentation on the direction and status of
the district’s technology efforts. The 15 invited experts, from a
variety of professional fields and diverse companies throughout
the country, heard Tanaka explain the district’s plans to upgrade
and expand information systems.
“It’s a powerful group that helps us focus on our issues and goals,”
explains Januszewicz. “The experts keep asking questions and
despite all you’ve put into an effort, they inspire you to think again.
Even though you’ve come so far, you realize you can take an idea
further still. It really is an amazing process. “By simply asking,
‘Have you thought of this?’ they can help us take an approach we
might never have considered,” said Januszewicz.
Januszewicz explains that the Communications sub-group is
a multidisciplinary team of representatives from nursing, OR,
IT, telecommunications, radiology, and security. The team was
formed to explore a new communications system for the Hospital
of the Future. “We’re in the infancy stages of exploring our
communication needs for the future,” says Januszewicz. “One
example is how we’ll be documenting patient information. We
don’t expect to be using the current ‘computer on wheels.’ We
believe it will be something more like a ‘point and click’ device, or
a palm pilot, or possibly a voice recognition system.”
ore than two hundred nurses at Palomar Pomerado Health
(PPH) have been reaping the benefits – monetary and
otherwise – of the Professional Enhancement Program (PEP) since
its inception in 2005. They are RNs who are dedicated to enhancing
their profession and who have contributed to improving patient
outcomes. For their extra efforts in 2006, 211 nurses throughout
the district received bonuses totaling more than $302,000.
How have they done this? According to Linda Urden, PPH’s
Executive Director, Nursing Quality, Education & Research, the
opportunities to earn “Bonus Points” in the voluntary program are
plentiful. Nurses can choose options from six different categories:
Clinical and Professional Expertise, Community Involvement,
Committees/Councils, Education, Professional Development
& Recognition, and Quality, Evidence-Based Practice Research.
“Many of our staff members have been providing extra services
within the district and various communities for years. They serve
as members of community groups, they teach a patient group or
skills lab for other nurses, some design patient education materials,
and others have their work published or earn their Master’s
Degree. They deserve recognition for all they do. PEP provides
that, with a financial bonus as well. The greater leadership a nurse
demonstrates, the more points she or he receives.”
The PEP model allocates 10, 20 or 30 points for the different
roles. For every point they earn, RNs are rewarded with $10.00.
A minimum of 70 points to a maximum of 300 points must be
earned between September 1st and August 31st.
Those who wish to take part in PEP should see their Directors/
Managers or PEP committee staff representative. The paperwork
is also available on Lucidoc. Type in “Title:PEP” on the home
page search field. Once a form is displayed, you can print it by
pressing Ctrl+P.
The Communications team is currently working on an immediate
problem of determining how to best replace call bells that are
failing at Palomar Medical Center. “We need to decide on
something that will help us today and take us into the future.
Our team is currently doing research on what’s available and what
might be available in the future. We may have call bells that
communicate directly to wireless phones, pagers or Vocera instead,”
Januszewicz indicated.
Forces5,13
Forces8,10,14
Surgical Care Improvement Project
I
n their constant effort to improve patient outcomes, nursing staff
at Palomar Pomerado Health (PPH) is currently participating
in a national initiative designed to reduce the number of surgical
complications and the costly and sometimes devastating ramifications.
The Surgical Care Improvement Project (SCIP) was initiated by the
Centers for Medicare and Medicaid Services (CMS) and the Centers
for Disease Control and Prevention in July 2006, after the success
of the Surgical Infection Prevention Project (SIP) that was launched
in 2005.
complications by 25% by 2010. In doing so, we expect to reduce
morbidity and mortality rates and consequently reduce the length of
stay for patients and the cost of care for them while providing the best
possible care.”
According to statistics published by the Journal of the American
Medical Association (JAMA) in 2003, post-operative complications
accounted for up to 22% of preventable deaths among patients.
Furthermore, the Journal reports, 18 types of medical injuries during
hospitalization accounted for 2.4 million additional hospital days,
Associate Chief Nursing Officer Mary Oelman heads the project with $9.3 billion in additional charges each year.
for the district while Nurse Epidemiologist Joyce Agorrilla, RN,
SCIP is focused on four broad areas where incidence and cost of
MA, CIC, is the facilitator. Agorrilla says there is good reason for
complications in surgery are high:
PPH’s participation. “The ultimate goal is to reduce post-operative
1
P revention of
Surgical Site Infections (SSI).
To combat SSIs, the program is adopting those measures that
proved effective in the SIP campaign that call for the correct
and timely use of antibiotics before, during and after surgery.
Additionally, SCIP measures blood glucose levels post-operatively
in all cardiac surgery patients and calls for the removal of hair
before surgery to be done with clippers rather than shavers.
The project also requires that the body temperature of patients
undergoing colorectal surgery is maintained at 98.6 degrees
immediately after surgery.
3
Prevention of
Adverse Cardiac Events.
SCIP calls for the use of Beta Blockers prior to surgery for patients
who have required them for angina, hypertension or arrhythmias.
Without their use, statistics show that as many as 30% of patients
undergoing vascular surgery will experience acute myocardial
infarction, sudden cardiac death, or pulmonary edema. Those
cardiac events are associated with a mortality rate of nearly 60%
per event.
2
Prevention of
Venous Thromboembolism.
National statistics show that without the use of prophylaxis, more
than 50% of major orthopedic operations are complicated by deep
vein thrombosis and up to 30% by pulmonary embolism. Data also
shows that prophylaxis are underused, despite evidence-based
guidelines showing it is effective in preventing complications.
4
Prevention of
Respiratory Complications.
CMS data show that ventilator-associated pneumonia occurs in
9 – 27% of all intubated patients and that up to 90% of pneumonia
cases in intensive care occur during mechanical ventilation.
Additionally, there’s an increased risk of stress ulcer disease and
gastrointestinal bleeding. SCIP calls for raising the elevation of
the head of the bed, administering prophylaxis for stress ulcer
disease, and using ventilator-weaning protocols.
PPH submitted the first quarter’s data for the project based on patients admitted for surgery from July to September 2006. As yet, there is no
feedback on results. Agorrilla says the staff expects additional measures and revisions of current ones as more evidence comes to light in the
project. “Meanwhile,” she says, “this important documentation will continue. We have everything to gain by adopting these guidelines and
participating in this worthwhile study.”
Forces6,7,8,13
cerner OPTIMIZATION
N
urses throughout the Palomar Pomerado Health (PPH) system will be relieved to know that their voices have been heard. Three work
groups, launched in February, are working full-time making improvements to the Cerner documentation system. The teams working on
the Cerner optimization project are the Emergency Department’s FirstNet, Perioperative Service’s SurgiNet and the Medical Surgical Team’s
CareNet. Each group has a Project Manager and front-line nursing staff who are reviewing work flow and documentation for their particular areas.
According to Chief Nurse Executive Lorie Shoemaker, “This is
definitely one of the most important initiatives we have going. We
can’t move forward with Computerized Physician Order Entry
(CPOE) or bar coding until we have optimized Cerner Phase One.”
Shoemaker states that nurses have had difficulty with the system
since it was introduced at PPH in 2004 and while changes have
been made to the system in the past, there has been no attempt as
comprehensive as the one underway.
Says Shoemaker, “We are serious about making this work. This
affects so many areas – from registration, to bedside, to billing – it
will all be addressed.”
Shoemaker explains that Rajiv Kapur, an outside consultant and
Cerner expert hired by the district, has done extensive research
into PPH’s system. He compiled information about problems or
difficulties with Cerner that he gathered in interviews with frontline nursing staff and handed 26 pages of pertinent data to the Net
groups for their review.
The information speaks to four issues:
1. Did we build our system incorrectly to begin with?
The groups are reviewing Kapur’s information line by line. Once
they determine what needs to be done, changes will be implemented.
Shoemaker expects the entire process will take approximately one
year. But she’s optimistic that when it’s over, nurses will be able to perform
their jobs more efficiently, ultimately providing safer patient care.
“We have allocated the talent and resources to turn the system around
and make it work for us. I’m confident that a year from now we will
have re-built screens, and nurses will have a system that functions the
way they do, not the other way around.”
The teams report to the Clinical Documentation Steering
Committee, which Shoemaker chairs. Once these crucial problems
are addressed, the Chief Nurse Executive says the district can look
forward to implementing more advanced uses of Cerner, including
having doctors input their own data into a patient’s computerized
medical record – without having to have a transcriber interpret their
hand-written orders. This use and bar-coding, where a patient’s
identification and medication will be more efficiently tracked, are
certain to bring about better outcomes for patients and improve the
working environment for nurses throughout the PPH system.
Forces6,7,8,10,13
2. Does our system have the capability to do what we want, and we
just don’t know it?
3. Does the system do what we need it to do, but
we just don’t like it?
4. Is the system not capable of doing what we want?
Iowa model
of evidence-based practice
W
hat do you do if you’re a nurse and you’re concerned that the
care you’re giving isn’t the best you can do for your patient?
What if you’re a manager and you recognize a need for a better way
of working with your staff or designing programs? How do you solve
these problems? How do you get things changed? Nursing leaders at
Palomar Pomerado Health (PPH) have the answer. You turn to the
Iowa Model of Evidence-Based Practice (EBP) to facilitate finding
and implementing changes in practice.
Most of PPH’s Clinical Nurse Specialists (CNS) have made a trek to
the University of Iowa in Iowa City, Iowa to immerse themselves in
the Iowa Model of EBP – a methodical and thorough approach to using
the best existing evidence to change clinical practice, the way patients
receive care, and the way managers implement their roles. In four intense
days, they absorb all that they can about this formula for implementing
change in the hospital setting and become the key people to take PPH
staff through the process. The model was first developed in the 1990s
and the district has been using it for more than a year as an organizing
framework for many clinical and systems initiatives.
“We’ve always known that collecting information was the best place to
start when we encountered problems in our setting,” says Linda Urden,
Executive Director, Nursing Quality, Education & Research. “In the
past we followed procedures that called for research of all literature on
the topic. Or, we’d call colleagues at other hospitals to see what they
were doing. But with the Iowa Model, we have a better roadmap of the
most effective steps to take, and what to do once we have the various
types of evidence. We know how to critique the
information and determine if it’s appropriate
for us. Now we know how to critically analyze
what is published, determine how to integrate
the findings into our practice, conduct a pilot
test and eventually adopt a new procedure or
create our own new one, and then implement
that change throughout our system.”
The model is major in its scope, applying to
every discipline throughout the district. The
EBP starts with the question of a practice or the
discovery of information that offers alternatives
to accepted practices. Then a team is formed,
with a project leader and major stakeholders,
to tackle the problem. Literature and research
are gathered. The information is graded and
critiqued. A pilot program is established, and its
effectiveness is evaluated.
Several CNSs have already applied the model in
some of PPH’s major district-wide initiatives:
Kate Stacy, RN, IMC, CNS, and her team were
concerned about back injuries in staff nurses.
They asked: “What can we do to decrease
staff’s back injuries?” A team was formed with
representatives across the district and they all
went to work gathering information on the topic.
They reviewed existing research, examined best
practices from across the nation and discussed
procedures and assistive equipment. Stacy
also attended Safe Patient Handling national
conferences and talked with experts in the area
of safe patient handling. The result: All of the
evidence was used to modify and/or create new
procedures, educate staff on the use of existing
equipment, and make recommendations that
will impact our new facility design.
Bunny Krall, RN, Medical-Surgical CNS,
launched a project to determine the best “handoff” procedures throughout the district that
would affect communication from caregiver
to caregiver throughout a patient’s stay. The
new procedure that is currently being pilottested at both Pomerado and Palomar Medical
Center ensures that whoever is taking over care
receives the patient’s key data and information
– whether it’s between nurses during change of
shifts, a transfer to a new unit, a brief trip to
radiology, or a transfer to skilled nursing.
Jackie Close, RN, Gerontology CNS, is leading the Falls Team – an interdisciplinary group across
the district with representatives who are dedicated to decreasing falls and falls with injuries.
Margaret Talley, RN, Wound Care CNS, leads a similar interdisciplinary cross-district team that
is passionate about skin care.
Through the efforts of these concerned staff leaders, PPH has been identified as a best
practice site, sharing our team approach in a book recently published by the American
Nurses Association. The Professional Enhancement Program (PEP) is another example of
an evidence-based program that has been implemented at PPH.
As PPH moves forward, Urden says, the EBP process will continue to be applied to a growing
number of areas – including those that aren’t interdisciplinary. With the Iowa Model in place,
staff can use the same consistent framework to resolve their problems and know they have made
a contribution toward changing their profession for the better.
Forces1,6,7,8,13,14
EVIDENCE BASED PRACTICE
SERIES
T
he titles range from Selecting an Evidence-Based Practice
(EBP) Topic, to Piloting Change, to Lessons Learned. These
are sessions found in the schedule for the 2007 EBP Series – 1½hour components taught each month by nursing leaders at Palomar
Pomerado Health (PPH) in an effort to provide caregivers a
framework for assessing and implementing clinical, managerial
and educational evidence into practice. The information is
applicable to all disciplines and the model that is being used
can be implemented across the district in all departments
and specialties.
“These sessions challenge us to ask why we’re doing what we’re doing,”
states Linda Urden, Executive Director of Nursing Education,
Quality & Research for PPH. “They encourage us to take a look at
the practices that benefit the patients, staff or the community most,
so that outcomes are improved.”
According to Urden, the series teaches staff how to find and examine
evidence in a given area, how to critique it, and how to implement
change for the new practice. “Today patients are admitted with more
medical conditions, more prescribed drugs for those conditions, and a
variety of newer devices. Patients are more complex – especially now
that they’re living longer. They have multiple problems complicating
each other and our caregivers need to know how to proceed. There is
ICU
Urden says the series provides information that’s valuable to everyone
in the district, not only to nurses. “We want the world to learn this.
Everyone in the district is invited to attend and managers are strongly
encouraged to do so. Managers need to be there to understand how
to evaluate the practices in place in their area of work. In doing so,
they can understand the best methods to manage and lead in this
very intense healthcare environment, they can help staff perform
their jobs more efficiently, and ultimately they can create a work culture
that is conducive to recruitment and retention of the best.”
Classes are taught by Urden, Bunny Krall, MSN, RN, CNS, and by other
Clinical Nurse Specialists (CNSs) who all have expertise with evidencebased practice and using the EBP model. They serve as mentors for
staff. Most of the CNSs have attended an EBP immersion course at the
University of Iowa that gives them a greater understanding of the EBP
model and the effect that change has on health care practices. “It takes
a lot of effort to implement change in a hospital setting,” says Krall.
“We’re teaching our staff a methodical and thorough way to do that. It
can’t take place in three meetings. It takes a great deal of time.”
The series runs through November, and those who attend receive
continuing education credit. Staff will have the opportunity to become
more involved and learn the EBP process in the EBP Nurse Fellow
Program that will begin in Fall, 2007 and expand over a year’s period
of time.
Anyone with questions can contact Urden at extension 4072. Those
who wish to attend the classes can register in Xpand.
Forces5,6,8,9,13,14
oxygen, fluid/drug infusion, blood analyzer, defibrillator, and patient
physiological monitoring. The latest model also includes a fully networkcapable onboard computer monitoring system. It actually begins triaging
while the patient simply lies there.”
BEDS/LSTAT
P
alomar Pomerado Health’s (PPH) Technology Champion
Team continues to research the potential use of state-of-the-art
equipment that could greatly change the way patients are cared for
in the future. An item of particular interest is a futuristic gurney
that does much more than transport patients. Staff got a glimpse of
the new equipment, called Life Support for Trauma and Transport
(LSTAT), at a Hospital of the Future Conference in 2005.
LSTAT was designed by Integrated Medical Systems, Inc. (IMS) for
the military, in an effort to move trauma care closer to the site of
an injury in the battlefield so that diagnostics and therapeutics can
occur throughout the evacuation and treatment process. Caregivers at
PPH realize that application of the technology can be just as effective
in reducing mortality and morbidity in the hospital setting as it is
in the battlefield. According to Lourdes Januszewicz, RN, BSN,
CCRN, “The gurney has the ability to monitor the vital signs of the
patient. Among other things, it offers a ventilator with on-board
10
also a lot of evidence related to managerial, leadership, and educational
practice that can be assessed for integration into practice.”
IMS gave a presentation on LSTAT to representatives from the ER,
EMT and Champion Teams again last year when the company was
invited to the site of the mock hospital rooms in Escondido. “We know
that technology exists and we’re interested in the possibility of having it
work for our needs,” says Januszewicz. “If it’s used in the ER or in an
ICU, we can provide early and continuous life support and sustainment
throughout the continuum of care, and when we transfer patients it can
be without equipment trailing behind them.”
For now, it’s just one of many ideas that the Champion Teams are
exploring for future use. As Januszewicz says, “We’re taking it one step at
a time, but it really is an incredible possibility.”
Forces6,8
APIC Association for Professionals in Infection Control &
Epidemiology, Inc. Inland Empire & San Diego Chapter Presents:
State of Surveillance:
Cultivating Your
IC Program
October 12, 2007
8 a.m. to 4 p.m.
Wilson Creek Winery and Vineyard
35960 Rancho California Road
Temecula, CA
For more information, please contact Joyce Agorrilla at 760.739.3396.
forces 8, 13
KYXY Care Award
Congratulations to Kim Moore, R.N., from the ICU at Pomerado
Hospital. Kim was recently awarded the KYXY Care Award
which is given monthly by KYXY and Azusa Pacific University
School of Nursing to a nurse in San Diego County. The award
honors individuals who have made a career of caring for others.
Nominations are made through the KYXY web site and the winners
receive a commemorative plaque and a $250 gift certificate to The
Catamaran Spa so that they can let someone else take care of them
for a day.
In June 2007, all CARE Award recipients were invited to a private
reception at The Catamaran Resort & Spa hosted by KYXY
and Azusa Pacific University School of Nursing. The 9 monthly
winners will be entered into a drawing for a Catamaran Resort &
Spa grand prize package that includes a two-night stay in a Bay
Side Suite, a “Day of Pamper” at the Spa and dinner for two in the
award-winning Atoll Restaurant overlooking Mission Bay.
Way to go, Kim
Kim Moore, R.N. (center) with Linda
Hansen-Kyle and John Burlison of
Azusa Pacific University
you deserve it!
11
palomar
pomerado health
honors top nurses
The nursing staff at Palomar Pomerado Health (PPH) is among
the finest in the business. Their commitment to excellence
and superior knowledge in nursing makes PPH and its
facilities the healthcare providers of choice for North Inland
San Diego County.
PPH is proud to honor Palomar Medical Center’s Brenda
Michalek, R.N., Critical Care Unit; Pomerado Hospital’s Lori
Carroll, R.N., Medical Surgical/Telemetry Unit; and Clinical
Outreach’s Linda Phillips, R.N., Escondido Surgery Center,
as the recipients of the 2007 Nurse of the Year Awards.
These nurses were nominated and selected by their peers
for demonstrating outstanding characteristics of teamwork
and compassion.
In addition, the following nurses were selected as the Nurse of
the Year winners for their respective departments:
12
Palomar Medical Center
Pomerado Hospital
Orleta Rodis, Intermediate Care Unit
Verna Bacuetes, Intensive Care/Intermediate Care
Alain Ombao, Orthopedics and Neurology
Estrellita Dilag, Emergency Department
JoDeanne Goeres, Oncology
Marilyn Clements, Operating Room
Luzviminda Nebreja, Cardiac Care Unit
Lori Carroll, Medical Surgical/Telemetry Unit
Brenda Michalek, Critical Care Unit
Gale Matthews, Outpatient Surgery
Mitra Khosroshahi, Outpatient Services/Endoscopy
Valerie Swarthout, Birth Center/NICU
Sandra DeWees, Emergency Department
June Alberti, Clinical Resource Management
Liza Congjuico, Acute Rehabilitation Unit
Tara Fletcher, Post Anesthesia Care Unit
Paula Roberts, Imaging Services
Clinical Outreach SERVICES
Marvilynn Helm, STAT Nurses
Melinda Kanter, Wound Care Center
Sara Watson, Post Anesthesia Care Unit
Abraham Tabula, Gero-Psychiatric Unit
Kathleen Xavier, Birth Center
Darrell Opperman, Mental Health Unit
Hope Trompeter-Guzman, Pediatrics/NICU
Linda Phillips, Escondido Surgery Center
Elizabeth Nazareno, Medical Surgical Unit
Margaret Womack, Home Health
Keri Holtz, Surgery
Rufina Mahon, Villa Pomerado
Victoria Austin, Clinical Resource Management
Jennifer Rodrigo, Palomar Continuing Care Center
PPH congratulates all of its exceptional nurses for their hard work, dedication and continued service to our
patients and their families. These individuals exemplify the mission of PPH – to heal, comfort and promote
health in the communities we serve.
13
nurses
in the news
Awards/Honors
Dennis-Rouse, Melissa, RN, BSN, CEN
CNS Scholar Emergency Services
Honor Society of Nursing-Zeta Mu Chapter
2007
Moore, Kim, RN
Pomerado Intensive Care Unit
CARE Award / KyXy and Azuza Pacific University
2007
Palomar Medical Center Tower 5
Leadership and Staff
Robert Wood Johnson Foundation / American Organization of Nurse Executives / Transforming Care at the
Bedside Study
2007
Palomar Medical Center Tower 6
Leadership and Staff
Sustained Achievement Award / Get With the Guidelines / Congestive Heart Failure / Acute Myocardial
Infarction / American Heart Association
September 2006
Dilag, Estrellita, RN, BSN
Pomerado Emergency Services
Pomerado Emergency Services Nurse of the Year / Hero, Salute to Nurses Del Mar Fair
2007
Urden, Linda, DNSc, RN, CNA-BC, FAAN
Executive Director of Nursing Quality, Education
and Research
Arthur Hughes Lifetime Achievement Award / University of San Diego
April 2007
Carroll, Lori, RN, Supervisor, Pomerado M/S
Certification in Medical Surgical Nursing / Academy of Medical Surgical Nursing / American Nurses Association
2007
Cid, Sandra, RN, BSN, Advanced Clinical RN
PMC Cardiac Care Unit
Progressive Care Certification PCCN
American Association of Critical Care Nurses
2006
Certified Emergency Nurse
Emergency Nurses Association
2007
Fornasdoro, Trifona, RN, BSN, Supervisor
T5 Ortho/Neuro
Ortho Nurse Certification (OCN)
National Association of Orthopaedic Nursing
2007
Hirsch, Susan, RN, BSN, Advanced Clinical RN
IMC/PMC
2007
Ingraham, Kathy, RN, BS, Supervisor
2006
Julian, Lisa, RN, Supervisor, Pomerado M/S
2007
Korytko, Shelly, RN, BSN, Day Supervisor
Clinical Outreach, PMC MHU
Certification in Psychiatric/Mental Health Nursing
American Nurses Association
December 2006
Krall, Bunny, RN, MSN, CNS, CMSRN
Pomerado M/S CNS
2007
Martinez, Valerie, RN
Nurse Manager, Pomerado M/S
2007
Medin, Julie, RN, BSN, Pomerado M/S
2007
Mirkovich, Becky, RN, CMSRN
Nursing Supervisor, PMC M/S
2007
Moore, Betty, RN, BSN
Pomerado M/S
2007
Morrey, Joyce, RN, MA, Program Manager
Clinical Outreach, PMC MHU
Certification in Psychiatric / Mental Health Nursing
American Nurses Association
December 2006
Naval, Leah, RN, BSN, Supervisor, Pomerado M/S
2007
Praxidio, Cindy, RN, BSN, Supervisor
2006
Rajec, Olga, RN, CMSRN, Clinical RN, PMC M/S
2007
Ryan, Christine, RN, BSN,
Escondido Surgery Center
Certified Ambulatory Peri Anesthesia (CAPA) Nurse / American Society of PeriAnesthesia Nurses
2006
Salvador, Beth, RN, BSN, Advanced Clinical RN
Certification in Critical Care Nursing (CCRN)
2006
Sherbo, Chikako, RN, Pomerado M/S
2007
Certifications
14
Certifications (continued)
Swain, Valerie, RN, OR Charge RN
Certified Nurse Operating Room, Association of Perioperative Registered Nurses (AORN)
Current
Wulff, Catherine, RN, BSN, CGRN
Endoscopy, Escondido Surgery Center
Certified Gastroenterology Registered Nurse (CGRN)
Current
Renaldo, Tricia, RN, MSN, Trauma Clinician
Trauma Nurse Core Curriculum (TNCC) Instructor
April 2007
Cronk, Bobbi, RN, CAPA
PACU Charge Nurse, Escondido Surgery Center
Certified Ambulatory PeriAnesthesia (CAPA) Nurse
American Society of PeriAnesthesia Nurses
Current since
1997
Smith, Denise, RN, Escondido Surgery Center
Corrective Makeup Camouflage Therapy
2007
Cresci, Alice, RN, Pomerado Emergency Services
Legal Nurse Consultant / UCSD
2003
Oelman, Mary, RN, BS, MS, MBA, CNAA-BC
Associate Chief Nursing Officer, Pomerado Hospital
CNAA-BC Certified in Nursing Administration Advanced
American Nurses Credentialing Center
October 2006
Proulx, Denise, RN, RN Supervisor, PCCC
Certification in Foot and Nail Care / Wound, Ostomy, and Continence Board
2007
PPH Board of Directors Quality Committee
2006
Brown, Jin, RN, BSN, Clinical RN, IMC/PMC
BSN, University of San Diego
Current
DiCintio, Frank, RN, BSN, MAS
Nursing Supervisor, PMC Cardiac Care Unit
Master’s, Leadership of Healthcare Organizations
University of California, San Diego
2007
Doubrava, Melanie, RN, BSN, Clinical RN, IMC/PMC
BSN, University of Phoenix
June 2007
Hasty, Karen, RN, BSN, Supervisor, PMC T5
2007
Hirsch, Susan, RN, BSN
Advanced Clinical RN, IMC/PMC
2007
Lopez, Dawn, RN, BSN, Administrative Supervisor
BSN, CSU Dominguez Hills
December 2006
Mitchell, Suzanne, RN, BSN
Advanced Clinical RN, IMC/PMC
June 2007
Nichols, Cheryl, RN, BSN, Escondido Surgery Center
BSN-San Diego State University
1985
Committee Appointments
Cid, Sandra, RN, BSN,
Advanced Clinical RN, PMC Cardiac Care Unit
Education
Renaldo, Tricia, RN, MSN, Trauma Clinician
MSN Nursing Education, CSU Dominguez Hills
May 2007
Wright, Michelle, RN, BSN, Clinical RN, IMC/PMC
June 2007
BSN, CSU Dominguez Hills
2002
Munson, Alivia, RN, BSN, BS
BSN, University of North Carolina, Chapel Hill
2002
Pierce, Jennifer, RN, PCCC
Completion of RN Program, National University
2007
Agorrilla, Joyce, RN, MA, CIC
Infection Control
4th term Treasurer for the California Association of Professionals in Infection Control and Epidemiology (APIC)
Coordinating Council
2007
Penner, Faye, RN, BHScN, CIC
Infection Control
Secretary, Association of Professionals in Infection Control and Epidemiology (APIC),
San Diego and Imperial Counties Chapter
2007
Phillips, Linda, RN
OR RN, Escondido Surgery Center
California Nurses Association
Negotiating Team
2007
Chair of Education
Southern California Society of Gastroenterology Nurses Association
Current
Pedersen, Sue, RN
Supervisor, Relief Administrative Supervisor
Chair, Pomerado Disaster Committee
Current
Ross, Steven, RN, Pomerado Emergency Services
pph Facilities and Grounds Board Committee
Current
Elected Office/Appointments
15
Elected Office/Appointments (continued)
Pearcey, Tonya, RN
Chair, Unit Practice Council
Chair, Patient and Staff Education Sub-Committee of the Professional Practice Council
Current
Executive Director of Nursing Quality,
Education and Research
California Institute for Nursing and Health Care,
Nursing Education Redesign for California Think Tank
Current
and Research
American Academy of Nurses, Health Care Quality Panel
Current
Pomerado M/S CNS
Secretary, Academy of Medical Surgical Nursing
San Diego Chapter
2007
Ritchie, Michelle, RN, BSN, Pomerado Emergency
Services, Advanced Clinical Nurse, Relief Charge
Nurse, Preceptor
“Transvenous Pacemakers” and
“Accessing Port a Cath’s”
Pomerado Emergency Services RN Skills Certification
Ongoing
Hoffman, Diane, RN
Clinical RN
“Go Red for Women”
Palomar Medical Center
2007
Ryan, Christine, RN, BSN
“Professional Enhancement Program at PPH”
Association of California Nurse Leaders, San Diego, CA
November 2006
and Research
Keynote Speaker
“The Evidence-Based Practice Imperative: Current and Future Challenges”
Conference: Mountains of Evidence: Learning Under the Midnight Sun
Anchorage, Alaska
June 2007
and Research
Keynote Speaker
“Leveraging Organizational Data for the Magnet Journey”
Conference: Failure to Rescue
Costa Mesa, California
May 2007
and Research
Keynote Speaker
“Leveraging CalNOC for the Magnet Journey”
Conference: CalNOC
Anaheim, California
November 2006
and Research
“Evidence-Based Practice: What’s In It For You”
Conference: AMSN
San Diego, California
May 2006
and Research
Keynote Speaker
“Leadership for the Future”
Conference: Philippine Nurses Association
San Diego, California
June 2006
and Research
Keynote Speaker
“Are You Ready for Your Close-Up: Validating Excellence”
Conference: Association of California Nurse Leaders Annual
Los Angeles, California
February 2006
CNS Scholar-PPH Emergency Services
2007
Ginter, Kathy, RN, pmc t5
Advanced Clinical RN
June 2006
Miller, Veronica, RN, Advanced Clinical RN, PMC T5
2007
Praxidio, Cindy, RN, BSN
Supervisor, PMC Cardiac Care Unit
Nursing Supervisor
2007
Reyes, Renante RN, BSN
Advance Clinical RN, PMC T5
2007
Salvador, Beth RN, BSN
2006
Scott, Carolyn, RN, Escondido Surgery Center
Diabetic Educator
2006
Cid, Sandra, RN, BSN
2006
Dilag, Estrellita, RN, BSN
Relief Charge Nurse
2007
Presentations
PromotionS
16
Publications
“Rules of Attraction”
Advances for Nurses
November 2006
“It’s Time to be Strategic”
Journal of Nursing Administration
36 (6); 285-287
2006
and Research
Guest Editor: Special Issue Devoted to Strategic Succession Management
Journal of Nursing Administration
36 (6)
2006
and Research
Chapter: Transforming Professional Work Environments
Book: Beyond Leading and Managing
Elsevier
2006
Pomerado M/S CNS
Quality Report Cards Inform Staff Nurses About Pressure Ulcer Rates and Document Success of Quality
Improvement Initiatives
NDNQI: Transforming Nursing Data into Quality Care: Profiles of Quality Improvement in US Healthcare
Facilities/ANA pp 105-115
2007
Moore, Ann, RN, MN, CWCN
System Program Director, Wound and
Hyperbaric Clinic
2007
Nichols, Cheryl, RN, BSN
Talley, Margaret, RN, CNS, CWCN
District Wound CNS
“Wrist Arthroscopy-Ambulatory Surgery Procedure”
AORN Journal
Vol 49 #3 pg.759-771
1989
2007
Southern California Society of Gastroenterology Nurses & Associates Newsletter
“Methemoglobinemia”
2006
“Dynamic Forces on the Cell Cycle Affecting Fibroblasts in Pressure Ulcers”
Wound Repair and Regeneration
Vol 9, Issue 1
2001
“Influence of Single and Sequential Cytoxine Therapy on the Cell Cycle of Pressure Ulcer Fibroblasts”
Journal of Applied Research
Vol 2, Number 1
2002
Every attempt has been made to maintain the accuracy of this list. For corrections or additions, notify Brenda Fischer at Ext. 5090 or [email protected]
NURSING
INTRANET SITE
G
ood news! Things are going to get a lot easier for you when it comes to gathering information about your
role as a nurse at PPH and about your profession in general. That’s because NURSING will soon occupy
its own space on the new and improved PPH Intranet…otherwise known as pph.net. The Nursing pages will
be equipped with valuable information, tools, resources and updates on just about every aspect of nursing
you can think of. From current classes offered for your advancement, to the latest accomplishment in the
Magnet journey – it will all be available at the touch of your fingers.
And if it’s not there, be sure to let us know and we’ll add it. It will be YOUR site and we know it will keep
you better connected to your fellow nurses and to the rest of the PPH staff as well.
Contact: Brenda Fischer, RN, MSN, MBA, CPHQ Ext. 5090, Magnet Program Manager
17
PPH NURSING
COLLABORATIVE LEADERSHIP
PMC Council
of Chairs
R-John Feucht
Unit Practice
Councils
APN Council
Professional
Practice
Council
C-Ginger McDonald
Co-Sue Phillips
F-Brenda Fischer
M-UPC Chairs
POM Council of
Innovation
C-Cathie Wulff
F-Linda Urden
PMC Nursing
Leadership
C-Sharon Andrews
R-Brenda Fischer
C: Chair
Co: Co-Chair
R: Representative
Practice
Technology
Education
C-Theresa Bologna
F-Caroline Etland
C-Breana Feistel
F-Lourdes Januszewicz
C-Tonya Pearcey
F-Barb Mayer
Nursing Executive
Council
(Magnet Steering and
Workgroup)
C-Brenda Fischer
M-Ginger McDonald,
Sue Phillips
F: Facilitator
M: Member
Communication and reporting is bi-directional and
accomplished via roles and responsibilities
Magnet
Force Teams
PCC Chair Ginger McDonald, R.N. and Lisa Hazard,
Trauma Services Administrative Assistant
18
Clinical
Leadership
C-Brenda Fischer
R-Vicki Sanchez
Quality
and Research
C-Caroline Etland,
M-Jackie Close,
M-Margaret Talley
POM Nursing
Leadership
C-Mary Oelman
R-Brenda Fischer
san diego fair
banner
Nursing Grand Rounds:
Promoting Excellence
in Nursing Practice
Purpose:
Nursing Grand Rounds provides
staff nurses with a forum to
share their clinical expertise
and best practice in nursing
within their practice setting.
Through case presentations
the bedside RN develops
his/her knowledge as well as the
knowledge of his or her peers in
caring for a particular patient
population.
Forum:
This is a one-hour staff presentation on clinical topic of interest to
nursing. Research best practice on given topic and present case.
Nursing grand rounds uses an interactive approach engaging those
in attendance to participate in case review.
Mentoring:
CNS/Educator mentor staff in literature search to gain the latest
best practice relating to topic presented, critique the case,
critically examining the care provided.
Staff develops skills and knowledge in performing literature
searches, critiquing case studies, applying best practice knowledge,
development of presentations as well as oral presentation skills
before a group of their peers.
Forces6,8,14
Estrellita Dilag, R.N., appears on a banner promoting
the San Diego Fair. She was recognized as a Hometown
Hero, the theme of this year’s fair.
19
NURSE
WEEK
2007
Nursing News Network
15255 Innovation Drive
San Diego, CA 92128
PPH Nursing Vision
Palomar Pomerado Health Nursing will be nationally
recognized for setting the standard of nursing service
excellence in practice, education, research and leadership.
Our Nurses are the Key
Nursing News Network Editorial Team
Brenda Fischer, RN, MSN, MBA, CPHQ, Magnet Program Manager, Ext. 5090
Lourdes Januszewicz, RN, BSN, CCRN, Nursing Strategic Initiatives Manager, Ext. 5091
Dionne Blaha, Executive Assistant to CNE, Ext. 5524
Tami Weigold, Manager, Marketing & Communications, Ext. 5508
Please contact the NNN Editorial Team for content submission
PRST STD
U.S. POSTAGE
PAID
SAN DIEGO, CA
PERMIT NO. 2838

Update - Palomar Health

Transcription

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