Provide two examples, with supporting evidence, of an improvement in patient safety that resulted from clinical nurses' involvement in the evaluation of patient safety data at the unit level. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
Example 1 Improvement in Patient Safety: Reduction in Catheter Associated Urinary Tract Infections (CAUTI) on 3 East. Background/Problem FF Thompson Hospital's strategic plan for quality includes elimination of hospital acquired infections. The quality strategic aim for this goal sits within the patient harm category and action items for reducing patient harm are derived from review of data at both the unit level and at the organizational level at Patient Safety and Quality committee meetings. We use the National Database for Nursing Quality Indicators (NDNQI) to benchmark our data and review progress toward our goals. In addition we publish a weekly harm report to share our results with all associates, the executive team, medical staff and Board Members (Exhibit EP20EO.1). This transparency allows us to remain focused on reducing patient harm and improving patient safety. In December of 2013, it was identified that 3 East, a medical-surgical unit, had an increase in CAUTI's.
Exhibit EP20EO.1- Weekly Harm Report
One of the Joint Commission's National Patient Safety goals is to reduce the risk of health care associated infections. Catheter Associated UTIs (CAUTIS) account for 40% of all facility acquired infections according to the Institute for Healthcare Improvement (IHI). The risk of UTI is correlated with the length of time the catheter is in situ.
3 East is a medical surgical floor that specializes in the care of orthopedic patients. The nurses on the unit use data from NDNQI to identify trends and areas for improvement in patient safety. In the fall of 2012 the nurses recognized a significant increase in the rate of CAUTI's. The majority of these CAUTI's were in the surgical population. They came together as a team, utilizing the expertise of our Clinical Nurse Leader, Diana Ellison MS, RN, CNL and with the support of their Director, Elizabeth Alexander, MS, RN, CN-E, they developed a plan to reduce the number of CAUTI's. Goal Reduce CAUTI's to below the Magnet mean as measured by NDNQI. CAUTI's per 1000 patient days was used to demonstrate the improvement.
Description of Interventions
Clinical staff and Diana Ellision, MSN, RN, CNL, Clinical Nurse Leader, reviewed the cases of CAUTIs that were identified on 3 East to help create opportunities for improvement (Exhibit EP20EO.2). Using best practice for reducing risk of CAUTI utilizing information from the Center for Disease Control (CDC), Medscape, and Chicago Journal, hands-on skill sessions were created to help awareness of best practice around Foley care and removal. An annual training session regarding CAUTIs is mandatory for all nurses and new hires. Using Nursing Spectrum, our online educational platform, unit directors can identify who has completed their mandatory education (Exhibit EP20EO.3a). The Monthly Education Component (MEC) listed below, shows the required education regarding cathetered care and urinary incontinence, while incorporating the Synergy model of care (Exhibit EP20EO.3b).
Exhibit EP20EO.2
CAUTI's 2012-2013.pdf
Exhibit EP20EO.2 a and b
Exhibit EP20EO.3a 3 East Roster.JPG
Exhibit EP20EO.3b MEC layout.png
Following best practice, the nursing staff implemented a practice to use a new (not just clean) wash basin every day, and use a separate clean wash cloth for perineal care. In addition, perineal care was required prior to the genital preparation for any urinary catheter insertion. The Nursing Spectrum article and the GRN (Geriatric Resource Nurse) education via the NICHE (Nurses Improving Care for Healthsystem Elders) (Exhibit EP20EO.3b) reinforced the hands-on education, as well as the nurse-driven Foley catheter removal protocol (Exhibit EP20EO.4).
Exhibit EP20EO.3
Exhibit EP20EO.4
Exhibit EP20EO.4 Foley Catheter Removal Algorithim.png
Implemented visual management boards on the unit with number of days since last Catheter Associates UTI and tips to remind nurses and patient care technicians of the "best practices" for reducing infections (Exhibit EP20EO.5).
Exhibit EP20EO.5
The team developed laminated forms for "Reminders for Hygiene with Foley Catheter Care" for each room where a patient had a Foley catheter. In 2013, the nursing staff collaborated with the Nursing Informatics team, and added a reminder to the Foley catheter insertion order within the electronic medical record to collect a urine for culture and sensitivity testing upon insertion to rule out those patients that had an existing urinary tract infection prior to the insertion of the Foley catheter. Additionally, daily documentation of the Foley catheter was built into the focused daily assessment in the Electronic Medical Record. This documentation includes the criteria for Foley removal, and asks for a reason for the continuation of the Foley. (Exhibit EP20EO.6).
Exhibit EP20EO.6
Reviewed progress towards goal on a quarterly basis and re-educated, reinforced all steps after the noted increase in Q3 2013.
Participants Elizabeth Alexander, MS, RN, CN-E, Director of Medical Surgical Nursing, Patient Care Services Diana Ellison, MS, RN, CNL: Clinical Nurse Leader, Nursing Administration, Patient Care Services Vicki Erway, RN, CMSRN, float nurse, Department of Nursing Lisa Maier, RN, clinical nurse 3 East , Medical Surgical Nursing, Department of Nursing Adrian Hordon, MSN, RN, Clinical Nurse Educator and Magnet Program Director, Nursing Administration, Patient Care Services Cassandra Massa, BSN, RN, 3 East Medical Surgical Unit, Department of Nursing Kaitlyn Claeys, PCT, 3 East Medical Surgical Unit, Department of Nursing Lynette Ward, RN, Infection Control, Department of Infection Control and Emergency Preparedness, Administration Sarah Boyce, BSN, RN, CEN, Clinical Nurse, Emergency Department, Department of Nursing James Busch, Patient Care Tech, Emergency Department, Department of Nursing
Data
Outcomes The graph with data table above demonstrates the achievement of the goal set. Within the first quarter after implementation the raw number of CAUTI's reduced 75% from the baseline data in Q3 2012. With continued effort and reinforcement of the action plan we exceeded our original goal of outperforming the Magnet mean and eliminated CAUTI's. As the graph demonstrates we have sustained this for a total of 2 quarters.
Example Two: Improvement in Patient Safety due to process redesign in the Perioperative Services Department for "clinical" patients
Background/Problem The operating room (OR) nurses identified in November of 2012 that critical patient safety information (allergies, medications, vital signs and past medical history) was missing on a regular basis for a select group of patients coming to the OR. These patients were not being seen in pre-admission testing as they did not receive general anesthesia. Clinical (or clinic) patients are those patients that could be seen in a clinic setting for the procedure they need. There is no designated space for this at F. F. Thompson Hospital so patients are routinely admitted to the OR for these procedures. The OR nurses were responsible for their admission and discharge as well as maintaining the normal flow of the OR and turnover of rooms. Goals Accurate and complete documentation of vital signs, medications, allergies and past medical history for clinic patients. • Standardize surgical patient process for admission to the OR with ○ 100% proper booking of clinic cases by MD offices ○ 100% SCC registration as clinic patient • Capture the clinic patient profile in the Electronic Medical Record with ○ 100% clinic patients interviewed by PATC Clinical Nurse ○ 100% patient profiles completed, including current medications, medical history, allergies and vital signs • Assure compliant and consistent documentation of intra-operative times • Improve discharge of clinic patients from SCC ○ SCC Clinical Nurse captures patient discharge times Improve charge capture Description of interventions FF Thompson Hospital has a culture of safety and associate empowerment called "The Thompson Way". This program allows any associate to identify a problem and put together a Do It Group (DIG). A DIG was created in November 2012 to address this important patient safety issue. This interdisciplinary team included OR schedulers, Nurses from pre-admission testing, OR, Surgical Care and informatics. The first step during the DIG was to identify the current process. A flow diagram was developed to visually describe the current steps (Exhibit EP20EO.7).
Exhibit EP20EO.7 Admission Process for Clinic Patients 2012
At the second meeting the interdisciplinary team developed a new "ideal state" process (see exhibit EP20EO.8). In addition the team created a form to track "key" issues including: • Booking slips from the providers office • Completion of the patient profile by Pre-admission Testing nurses • Complete registration into Surgical Center • Evidence of "clinic" care plan being generate and used by the OR RN • Vital signs documented • Discharge instructions completed
Developed new process for admission (Exhibit EP20EO.8) Exhibit EP20EO.8
2013 New Admission Process of Clinic Patients
Having mapped out the new process the team presented the ideas to the key stakeholders: leadership , MD office staff, OR schedulers and nurses working in pre-admission testing, the surgical care center and the OR. All associates involved in the operationalization of the change received information and education with respect to their role in the smooth and safe transition of clinic patients using the new process. A new "bed type" was created within the Electronic Medical Record to ensure that patients were placed in the correct status prior to arrival. The new process was operationalized in January 2013 and the results were tracked from January through June 2013.
Participants:
DIG Chair, Catherine Habberfield RN, CNOR, Clinical Nurse, Operating Room, Perioperative Services, Department of Nursing DIG member, Vickii Bement, BSN, CNOR, Charge Nurse, Operating Room, Perioperative Services, Department of Nursing DIG member, Kathy Cooley, BSN, CNOR, Informatics Nurse, Operating Room , Perioperative Services, Department of Nursing DIG Member, Kim Hyde, LPN, OR Scheduler, Operating Room, Perioperative Services, Department of Nursing DIG Member, Tammy Jeffrey, RN, Clinical Nurse, Perioperative Services, Department of Nursing DIG Member, Kelly Hennessy, RN, Clinical Nurse, Pre-Admission Testing Center,Perioperative Services, Department of Nursing DIG Member, Louise McGuire, RN, Clinical Nurse, Surgical Care Center,Perioperative Services, Department of Nursing DIG Sponsor, Janet Kerr, Director of Performance Improvement, Finance Department
Data
Outcome The graph demonstrates that that the goal of 100% compliance with required data elements (vital signs, past medical history, home medications and allergies) was met from the second month of implementation of the new process. The new process is hardwired in the system and we have consistently achieved our goal of 100% compliance with required patient safety information in our electronic medical record. The results were shared with the organization during the "QTIPS" quality fair and this DIG was recognized during Associate Recognition month as the DIG of the Year for its contribution to patient safety in the OR.