Transcription:
Heart Centered as an APP

Tricia Williams (Host):  Welcome to the Advanced Practice Perspectives. I'm Tricia Williams.

Tobie O'Brien (Host): And I'm Tobie O'Brien. This is a podcast created by Advanced Practice Providers for Advanced Practice Providers. We will be highlighting our amazing APPs here at Children's Mercy and do some education along the way.

Host 1: We are so glad that you are joining us. So, sit back, tune in and let's get started.

Host 2: Happy Heart Awareness Month, everyone. We are so honored today to have Megan Jensen on the podcast with us. She is an inpatient APRN and also the APRN Manager in our Ward Family Heart Center. Welcome Megan.

Megan Jensen, MSN, CPNP- PC (Guest): Hi.

Host 1: Hi, Megan. We're so excited for you to join us today. Let's tell our listeners a little bit about who Megan Jensen is.

Megan Jensen, MSN, CPNP- PC (Guest): Yes, thank you for having me on and thank you guys for celebrating Heart Awareness Month. I got my start in Children's Mercy back in 2001. I went to undergraduate and graduated from the University of Louisville in Kentucky. Go Cardinals and moved to Kansas City after I graduated and started as a new nurse in the Pediatric Intensive Care Unit, with Tricia, because for everyone to know, Tricia was my first preceptor in the Pediatric ICU way back in 2001.

Host 1: Way back. That dates us a little bit, doesn't it?

Megan: It does date us quite a bit.

Host 1: We've known each other for 20 years. That's crazy.

Megan: That is very crazy. So, then I spent about eight years as a nurse in the ICU and went back to get my Master's in Nursing. And when I graduated, I took a job with Cardiac Surgery. At that point, Cardiac Surgery and Cardiology were two separate divisions. And about a year or two after I joined as a Nurse Practitioner with Cardiology, they moved or Cardiac Surgery, they moved to become the Heart Center. And that really improved collaboration between the two divisions.

At that point, my job changed. And then I started to rotate through different areas and all of the nurse practitioners in cardiology and cardiac surgery, now became one. And so, I rotated through cardiac surgery, general consult for cardiology on the floor, in the ICU and pre-admission testing and in the OR and it was a mixed bag. Then about 10 years ago, things changed and they decided that the APNs should pick their specialty area. And I settled on the floor, Cardiology, which is known as the Blue Team. And I've spent the last 10 years caring for our cardiac surgery patients on the acute care floor there on the blue team. And then a year and a half ago, I became the Inpatient Manager for the Inpatient Heart Center APRNs. And that's about 20 APNs that work in the ICU, the floor, and then our general cardiology consult. And then I did go back to continue my nursing degree. And just recently in December, graduated with my Doctorate of Nursing Practice from the University of Missouri.

Um, funny story, but my husband says he he's a big KU fan. So, when I graduated, he like refused to buy Mizzou gear for me, but.

Host 1: That's funny. I did not know you went back to get your doctorate. Congratulations. That's amazing.

Megan: Yes. Thank you. Yes, it was about three years of work. I'm glad it's done. But I learned a lot along the way. It's a Doctorate in Leadership, so not a Clinical Practice Doctorate, which was nice. I was able to take a little bit more classes that kind of focused on that aspect, which was good for my career growth.

Host 1: Fantastic. That's great. Yeah. I got my Master's Degree at the University of Missouri as well. So, my husband did not agree with buying tiger Mizzou gear either, but it has, it has a lot of our money.

Host 2: Well, I did undergrad and grad school at Mizzou. So Go Tigers,

Host 1: Go Tigers. Look at all of us.

Host 2: Yeah. So, Megan, now do you practice? Do you get to actually still do inpatient practice or are you just managing the APRNs?

Megan: Yeah. So, my role is supposed to be 25, 75%. So, 25 clinical and 75% administrative. And I will say, I probably settle in between there depending on staffing within the unit. So, I'm, I'm anywhere from 25%, but I am still heavily involved in the clinical aspect. Probably more so than I need to be.

Host 1: And you guys cover on the Blue Team, 24/7, correct. So, there are some night shifts involved and weekends holidays, all the things.

Megan: Correct. So, it's a 24/7 coverage, seven days a week, holidays, all of that. And we're the frontline providers working right along with the resident team. The role has really grown. I've been able to kind of help develop that role. And it's a great role, collaborative between the bedside nursing and the Blue Team and Cardiologists. And we've been heavily respected and valued I think in that position.

Host 1: Tell us a little bit more about that role and what that looks like on a day-to-day basis.

Megan: Yes. So, when we come in, we have two APNs that staff the Blue Team on a daily basis. One is kind of a counterpart to a resident. They're the frontline provider for a number of patients and write the notes, do all the care and follow up,. We also have a Heart Failure Service, so our Heart Failure Service is staffed strictly with our APNs and our Heart Failure Team. So, we're responsible for all of those patients and are the direct frontline provider there. And then our second APN, kinda like oversees the whole service line. And is the knowledge expert on all of the patients. They're able to provide that cardiology specific knowledge content. They're able to facilitate and collaborate between the different divisions within the Heart Center. So, between the Cardiologists, the Cardiac Surgeons, the Echos, communication with the ICU, and really be the continuity person that stays and knows these patients really well. They're also heavily involved in patient education and bedside nursing education. We've really seen an improvement in our outcomes since we placed the APN on that team and in that role.

Host 1: We are very outcome driven. So, I love, that terminology, improvement of our outcomes. What type of outcomes did you specifically look at? I know just from being a colleague of yours in the past, like you're very driven towards QI, so tell me, like what kind of outcomes and QI projects you built around it?

Megan: Yes. So QI, I'd laugh and say is like my love language. And so I love QI work and I think advanced practice nurses have a unique aspect to participate in QI work because they really bridge that gap from bedside to providers. And also with parents, as far as education and engagement goes and they pose that unique aspect to really lead and champion that work if you're developing or starting any quality improvement work.

So, we've done a lot of work with early discharges. We've reduced our early discharge time from discharging patients on an average of two o'clock in the afternoon to before 11 and 12, we usually average about 55 to 60% of our patients are discharged and that helps with throughput through the hospital.

So, it really helps to get patients who need surgeries to get into the hospital and admissions. We have worked on reducing codes outside of the ICU and high acuity transfers. So, any patient that maybe would go to the ICU and need really intensive ICU care within an hour or so, because those are kind of like missed patients, because if you only have an hour before a patient was going to be intubated in the ICU, you probably waited too long to transfer that patient.

So, we've really reduced the number of patients that are high acuity transfers. We've worked on debriefings in that area and started a whole debriefing for any child that does qualify for that. We have recently developed a Touch Program. So, I don't know if the community is familiar with our CHAMP Program, which is our Cardiac High-Acuity Program that monitors all of our really high, fragile patients during this high-risk interstage period between their first and second surgeries. They have a whole Tele-health app that they use, and we are starting to bridge that for other high-risk patients. And that program is now managed by all of our inpatient acute care APNs. We also, not just on the floor, but in the ICU, our APNa are involved, we're involved in another throughput project called the Fast Track Project, which is working on getting patients out of the ICU faster and out to the floor based on straightforward heart surgeries.

And then we're working on reducing VTEs. So, we have a, sort of have a high venous thrombus in our population since they have a lot of indwelling lines that stay in. And so, we're really looking at reducing those. Those are just a few, but yes.

Host 1: Just a few!

Host 2: Oh my goodness. You are busy. Sounds like such great work. The CHAMP Program you said that to the APRNs are involved with that. Can you tell me a little bit more about that app?

Megan: Yeah. So, we have two APNs that are housed just in CHAMP. And then there's two nurse coordinators. And the app allows the parents to submit videos via the app. And they also submit vital signs. Those are directly communicated in real time to the providers so that we have real-time physical assessments to these patients at home.

We also have ongoing tracking of their weight. And their vital signs, their oxygen, their heart rate, respiratory rate and those sorts of things. So, we can really keep a close eye on these patients. So, our single ventricle patients who go home between their first surgery as a neonate, and then usually around four to six months in that interstage period, what we call it, is a very high-risk period. Through research and experience we've found that's where we have a high incidence of mortality and implementing very close in-home monitoring has significantly reduce that mortality and has allowed us to keep a close eye and identify need for intervention in these patients sooner to get those areas addressed. And so, it is a collaboration between Cardiologists and Nurse Practitioners, but most of the monitoring and communication with the parents and families is all nurse led and APN led.

Host 2: Wow. I love that. It sounds very helpful and a nice way for families to be able to, be able to go home. And I feel like they didn't used to be able to always go home in between.

Megan: Exactly. exactly. This definitely allowed us to do that. And this program is now a national program. And so a bunch of other centers have partnered with Children's Mercy to implement this CHAMP app. And so not only is it affecting patients at Children's Mercy, but it's been able to impact care for patients across the country.

And I really think this is the future of medicine, right? COVID has really shown us how much Tele-health and all of this is impacting. I think we'll start to see this type of technology branch out to many other different types of chronic health diseases and issues that you can really build on what technology is potential to be.

Host 1: Yeah. I agree. I think, this app world that we're living in, it's life saving. That hands down the CHAMP app has saved lives. I know it has, I've read about it. I heard about it. I've talked with people about it and I would love to know a little bit more about the Heart Center. So, I know that the word Heart Center is a very big, robust thing that we have at Children's Mercy, that's available for our patients. But can you tell us a little bit more about how many Cardiologists, CV Surgeons and Nurse Practitioners and different little departments of it, just a quick rundown.

Megan: Yeah. We are a very large section. We have three Heart Surgeons. I'm not exactly sure how many Cardiologists, but we have 36 Advanced Practice Nurses and they function in basically every area of the Heart Center. So, there's a Nurse Practitioner in our Fetal Health Department, there's the inpatient setting. So both, like I said, in the General Cardiology role and in the NICU and the PICU, on the acute care floor, they are in our preadmission testing area and our OR, and our cath lab and EP, CHAMP and then we have also Heart Transplant and then others sub specialties, as far as like Pulmonary Hypertension may go and then just General Cardiology Clinics. So, we have a few that go into General Outpatient Cardiology Clinic.

Host 2: We certainly utilize the PAT Cardiology Nurse Practitioners often in the ENT clinic. We oftentimes are doing history and physicals and we'll hear murmurs. And then we sort of say, okay, we heard a murmur, but now what? And since we pretty much stay above the neck, when we identify a murmur, we typically just rely on you guys. I wonder though, we'd love to have some sort of little Pearl of Wisdom for our listeners. Could you help us who don't listen to hearts all the time with any little tips on when we do identify a heart murmur that perhaps hadn't been heard previously? So, we tell the parents, oh, has anyone said that they've had a heart murmur and when they say yes, I'm like, okay, cool. But when they say no, I say, okay. So, I typically send them to you, but any Pearls of Wisdom for us?

Megan: Yes, so when we think of innocent murmurs, we think of the seven or eight S's. And before I start, I do want to share a unique story. So, my son had tonsils taken out and went to ENT for pre-admission physical assessment and the ENT Nurse Practitioner exactly what you said. So, we noticed a murmur and referred us to Cardiology and he ended up having a congenital heart defect that needed to have surgery. At this point, I had been in Cardiac Surgery for two years and I had, you try not to listen to your child. I'd heard the murmur and wrote it off as an innocent murmur and come to find out it wasn't.

And so I was so indebted to that ENT Nurse Practitioner, who was able to diagnose this murmur in my child. I will say that he diagnosed with an ASD. Which is typically found about kindergarten age because the murmur increases and that's about how old he was. He was four years old at the time. So, it is characteristic of when ASD murmurs are heard and ASDs are diagnosed, but small world, right? We all benefit.

Host 2: For sure. And it reassures that we are doing the right thing when we hear something. If we can't identify, send them to you is maybe take away.

Megan: Yeah, exactly. No, but when you think of the seven S's, so you think of, so the first S is short, so innocent murmurs are short. They usually stay in systole. They are not holo systolic. So, you won't hear them across the whole heart times. They're single. So, they'll have normal S ones and S twos. They won't have a split or any type of jump. They are small. So, they don't ever usually radiate. So, they're best heard at the apex or the second and fourth intercostal space. They're soft. So, they're usually just a grade one or a two. You would never have a grade three or four or higher.

They're sweet. So, they're not harsh sounding. And then they usually only happen in sytole. So, if you ever hear a murmur in diastole that is usually a sign that there is going to be structural abnormality that goes around with that. And then the last one, this would be the seventh when is sensitive. So, you know, when you listen to a patient and they're lying down and you hear the murmur, and if you sit them up or they stand, the murmur goes away. That usually is a sign that it's an innocent murmur. The last eight S is usually symptoms. So, obviously if the patient's having failure to thrive, respiratory distress or anything like, that's more of an indication of a structural heart disease murmur.

Host 1: So helpful. I was taking notes.

Host 2: Yeah. Send me the notes, Tricia.

Megan: And that's when to refer, right? Cause that's really, all you have to do is know, should I refer this or should I not refer this.

Host 2: Very helpful. Thank you so much.

Host 1: Very helpful. So, I have a little note on here that we would love to know about the pediatric cardiology acute care collaborative. And I don't know if we've already touched base and just didn't give a name on it. Or if this is something we need to share more about.

Megan: So this is where my QI comes in. This is a national collaborative of a bunch of different institutions and it's focused strictly on the acute care floor. So, general floor cardiology, and it's a group of different institutions who are focusing on improving care for these cardiac patients in this environment.

There's similar institution that focuses just on critical care cardiology. So, that's called the PC-4 and this is the partner organization called PAC-3. And so it's a national database of data that we submit and put into to collect data so that we can really benchmark and look at how we're doing against other institutions. So, top institutions like Chop and Boston and Cincinnati, all submit data, and we're able to look and see how we compare to them so that we can know where and what areas we need to improve. They also are heavily focused on education and quality improvement. So, they've been working on a chest tube project that has been working on reducing the amount of time a chest tube is in place, which we all know a chest tube is a pain. And causes pain in patients postop, and it can also delay their postoperative course being in the hospital. And a lot of institutions have reduced that, reducing length of stay, reducing need for pain management, improving parent satisfaction. And so, that's the kind of work that they do. And I've been able to lucky enough to be heavily involved with this and work with the couple quality improvement projects through it. So, it's a great networking tool as well as just help to really focus on education and quality improvement work to improve outcomes.

Host 1: Plus, it's your love language, right? It's amazing work. I love it when you can do amazing work and have your love language, all tied up into one thing.

Host 2: Yes. Lots of data for you.

Megan: Lots of data.

Host 1: I did want to ask you about the Camp Systole. Will you tell us a little bit about camp systole and how long it's been in fruition and your involvement with it?

Megan: Yes. So Camp Systole is our camp for kids with heart disease. It actually has been around for a long time, but it took a little pause. There were some issues as far as sponsorship for it. And so we revived it in 2013 and this stemmed from my son having heart surgery and kind of my passion to get more involved with this community from a parent end and from a patient engagement end. And so we partner with Congenital Heart Disease Families Association, and they sponsor camp. It's your good old fashioned Heart Camp, summer camp for kids.

Many of our patients wouldn't be able to go to this experience, to be out doing camp things without it being medically supervised. And this is like another passion of mine. I mean, when I was encouraged to revive this, when my son went through heart surgery, I was like, oh yeah, I'll do a camp. It sounds fun. And then I realized camp involves the outdoors and hikes and ticks and all these kinds of things, which I wasn't quite fond of, but in the last, what seven years, I've become very fond of it. And it's truly one of those things where you like give back. The smiles on these faces of these kids, who they look forward their entire year to this experience and being able to see other children who have the same scars on them and have the same experiences.

It's just hugely rewarding. I would say that I probably, and all the volunteers get equally as much out of it as all of the campers do. We're very disappointed that we weren't able to do it during COVID and we're waiting to see what's going to happen this year to see kind of what support we can provide working with Children's Mercy and the CHD Families Association. Fingers crossed.

Host 1: Fingers crossed. Stupid COVID. Maybe you can do a virtual camp this year.

Megan: We did, but it just still doesn't get the same experience.

Host 2: Sure.

Host 1: No, it's not the same.

Host 2: You don't get the Sure I know

Host 1: I don't get the ticks. I did I volunteered back during the first part of it, like I think it was early 2000s. I volunteered. back in the old days and it was the big smiles on their faces and the fact that you're really gonna take me on a hike and let me swim and do all those things. And it was amazing. So, I knew back when I met you in the early 2000s, that you were destined for greatness, Megan, and you really, have just surpassed greatness. You're doing amazing work. And I hope that you know that. So good job.

Megan: Thank you. Thank you. Yeah, I look back on how much I've learned in those last twenty years. I can remember a couple of things I said to you thinking, oh my God, I went home that day thinking oh my God. I can't imagine what thinks of me.

Host 1: Back then I was really honest to a fault. Heck I'm honest to a fault now, but you would have known Megan, you would have known.

Host 2: I was going to say, I work with her now. She's pretty honest.

Megan: She is.

Host 2: No, we really appreciate you sharing more about the Heart Center and how many of you there are and what all you do. And all of the QI projects. It has been a really great conversation. Thank you so much for talking with us today.

Megan: Thank you. I hope I did my division justice and all the other APNs, speaking for them and what the great work they do. I know there's much more that I have not spoke about. And I really appreciate this time to, like you said, focus on Heart Awareness Month and what the Heart Center does as far as Advanced Practice Nurses.

Host 1: You highlighted well Megan, you represented well. I feel like you did, and you guys are doing amazing work.

Host 2: We like to end each episode with a question. And so if you could go back to 2009, when you were a brand new APRN in Cardiac Surgery, what advice would you give yourself, Megan?

Megan: Yeah. So, I think the biggest advice that I now focus to give new APNs and myself is that this medicine that we practice is gray, right? And as a new nurse practitioner, you want it to be black and white. And so, you can be very critical of your system and critical of others. And then it just can be also kind of hard to learn in that environment when you're, you see one person practice one way and another person practice another way, and you're trying to determine how you're going to practice. And so, I encourage all new APNs to keep that overarching. You're right when you're right and wrong when you're wrong. And we need to strive to be right and learn from when we're wrong. I think that's the biggest thing that I want. We're human. We practice medicine. And the most important gift that we can give to our patients is that we learn from that and that we don't let it happen again.

And we move forward and you understand that gray area and appreciate that gray area. Appreciate that I'm going to practice differently than you Tobie or Tricia. And that's not a bad thing. That's a wonderful thing that we're all able to provide different types of practice to our patients. That's also what benefits them immensely as far as when they are able to interact with different people throughout their continuum of their healthcare.

Host 2: I love it. I love that advice. It's so true because we are human, but the best thing for our patients is to move on and learn, keep going and move forward.

Host 1: That was good. That was really good and we all need that. I was like, yeah, I need that advice. That's great advice. Well, Megan, it has been an absolute true pleasure to speak with you today. Listeners, thanks for tuning in. Our next episode will feature Ashley Flynn. She is a Nurse Practitioner in Hematology Oncology Department. We'll be chatting with her about her amazing story and her passion for fertility preservation.

Host 2: If you have a topic that you would like to hear about, or you're interested in being a guest, please contact us. You can email me at tdobrien@cmh.edu or contact tricia@twilliams@cmh.edu. Once again, thanks so much for listening. Thank you to Megan and thank you all for listening to the Advanced Practice Perspectives podcast.