(Examples include organizational quality councils, budget review committees, equipment selection committees, mortality and morbidity committees, pharmacy and therapy committees, blood utilization committees, safety committees, and bioethics committees) Provide two examples, with supporting evidence, of improvements resulting from the contributions of clinical nurses in inter-professional decision-making groups at the organizational level. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
Example One Background / Problem
A new team of Hospitalists came on board in the summer of 2013. The recently implemented electronic medical record (EMR) continued to provide complications and challenges across all disciplines. With the recent changes in physicians and onboarding of electronic documentation, Sarah Gallagher, BSN, CCRN Stroke Coordinator, began seeing significantly different charting and practices related to the care of stroke patients, and a decline in proper documentation from nurses and physicians alike. To meet New York State (NYS) stroke measures, very specific information must be documented on all stroke/transient ischemic attack (TIA) patients, by both physician and nursing staff. Sarah identified multiple items that were being missed on both stroke and TIA patients. She was unable to determine if this was due to the lack of symptoms being addressed or the lack of appropriate documentation within the new electronic system. Sarah took this information to the Stroke Committee, an inter-professional decision-making group focused on increasing stroke guideline compliance and improving patient outcomes. Goal Statement The goal was to improve our processes and meet the NYS measures related to Stroke/TIA patients. Improvement could be related to education on the stroke measures and/or education of the appropriate way to document meeting those measures. The Stroke Committee meets on the first Thursday of every month, and has representation across all disciplines within the hospital. Case studies were conducted during the Stroke Committee meetings, and the charge nurses helped identify areas of fallout to include documentation on discharge and specific stroke measures not being met (see meeting minutes below Exhibit SE1EO.1). The committee decides each month on the best plan of action to prevent similar instances from happening in the future.
Exhibit SE1EO.1 SE1EOa Stroke Committee meeting minutes 12-19-2013
SE1EOb Stroke Committee meeting minutes 4-3-2014
SE1EOc Stroke Committee meeting minutes 2-6-2014 Historically, stroke patients were abstracted and reviewed retrospectively. In order to demonstrate improvement in meeting the goal of improving stroke measures for stroke/TIA patients, Sarah Gallagher, BSN, CCRN, the Stroke Coordinator started reviewing stroke patient charts concurrently in October of 2013. Sarah looked at stroke patients that were currently in-house every morning and determined if appropriate measures were being met. If measures were not met, the Stroke Coordinator worked with the Charge Nurses on the Stroke Units and the individual providers to share the findings and discuss the appropriate measures and/or documentation of those measures. The Charge Nurses would communicate with the providers and nurses involved in the care of the patient to ensure that the measures were met. This information was taken back to the Stroke Committee to analyze findings. Additionally, overall trends/themes were identified and education was implemented with both nurses and physicians.
The changes implemented addressed multiple areas of opportunity:
Data Requirements
Participants:
Sarah Gallagher, BSN, RN, CCRN Stroke Coordinator/Quality Improvement RN/Emergency Department clinical nurse, Quality Wendy Mulholland, Diagnostic Services Director, Hospital Administration Vijay Bansal,MD, Emergency Physician, Director of Emergency Medicine, Hospital Administration Bruce Gage, Point of Care Coordinator, Laboratory Kelly Newton, RN, Clinical Nurse,Emergency Department, Department of Nursing Jessica Schojan, RN, Clinical Nurse/Charge Nurse, 3 West Medical Surgical Unit, Department of Nursing David Baum, MD, Senior Vice President of Medical Services/Emergency Physician, System Administration Joshua Kulp, BSN, RN, Director of Critical Care, Patient Care Services Hazel Robertshaw, PhD, RN, CENP, Chief Nursing Officer, Vice President of Patient Care Services, Hospital Administration Kimberly Ricigliano,SLP, Speech Pathologist, Rehabilitation Services Sarah Clayson, RN, BSN, MHA, Acting Nurse Leader Intensive Care Unit and Nursing Supervisor, Nursing Administration, Patient Care Services Clelia Negrini, MD, PhD, Director of Hospitalist Medicine Elizabeth Alexander, MSN, RN, CN-E, Director of Medical Surgical, Patient Care Services Antonio Russo, Clinical Coordinator CT Scan, Diagnostic Imaging Ragan Stevens, RN, SANE, Clinical Nurse/Charge Nurse, 3 West Medical Surgical Unit, Department of Nursing Barbara Lafler, Inpatient Physical Therapist, Rehabilitation Services Kiera Champlin-Kuhn, BSN, MS-HQS RN Director of Quality/Safety/Utilization and Clinical Documentation and Patient Safety Officer, Administration Hazel Wilcox, RN, Quality Improvement Coordinator, Quality Amber Fulmer, BSN, RN, Clinical Nurse/Charge Nurse, 3 West Outcome There was a rapid improvement in all concurrently reviewed Stroke Measures (early Antithrombotics, VTE prophylaxis, LDL/Statin, Rehabilitation Considered) for the month of October. All measures were 100% in October and all improved from the previous month. The previous month measures were prior to the implementation of concurrent review and education/feedback. After the first month of improvement and concurrent review, trends continued to remain 100% or at least improved from the baseline measurements., outscoring the CMS State and National Averages for Stroke documentation/implementation.
Example 2
Use Of Tranexamic Acid to Reduce Blood Transfusions
Background/Problem Total Joint Arthroplasty (TJA) is associated with a large amount of perioperative blood loss and high rates of blood transfusions. Blood loss during TJA can reach 1000-2000mls. Blood transfusions are costly and increase the risk of complications that negatively affect the outcome of TJA. These include longer lengths of stay, transfusion reactions, and infection. In May 2014 Stephanie Friel, RN, Orthopedic Service Line Coordinator attended the National Association of Orthopedic Nurses Annual Conference. The Orthopedic Service Line Coordinator is an interprofessional position at FF Thompson Hospital that provides support to the interdisciplinary orthopedic team as they seek to obtain the Joint Commission Gold Seal in Orthopedic Care. While at the conference she received information on the use of Tranexamic Acid (TXA) to reduce blood transfusions. TXA is a synthetic amino acid that prevents the binding of plasmin with fibrinogen and fibrin structures after clot formation by inhibiting activation of plasminogen to reduce blood loss and transfusions in patients undergoing TJA. Upon returning form the conference, Stephanie presented the TXA information to the Orthopedic Service Line Committee and discussed with Dr. Klein, Orthopedic Surgeon at FF Thompson Hospital, to begin using TXA. Dr. Klein and the Orthopedic Service Line Committee agreed to trial the use of TXA and Stephanie would track and trend results. Dr. Peck and Dr. Grimm, also Orthopedic Surgeons within FF Thompson Hospital, also agreed to trial TXA. Goal Statement Evaluate the effectiveness the administration of intravenous TXA has on the reduction of postoperative blood transfusions in the Total Joint Arthroplasty population. Concurrent and retrospective audits of the data were used for data collection. Participants
Stephanie Friel, RN, Orthopedic Service Line Coordinator, 3 East Clinical Nurse, Medical Surgical Nursing, Department of Nursing Dr. Bruce Klein, Orthopedic Surgeon, Private Attending, Canandaigua Orthopedics Dr. David Grimm, Orthopedic Surgeon, Private Attending, Canandaigua Orthopedics Dr. Brad Peck, Orthopedic Surgeon, Private Attending, Canandaigua Orthopedics Hazel Robertshaw, PhD, RN,CENP, Vice President of Patient Care Services/CNO, Hospital Administration Kurt Kozent, BSN, MHA, RN, Executive Vice President/COO, System Administration Elizabeth C. Alexander, MS, RN, CN-E, Director of Medical Surgical Nursing, Patient Care Services
In May of 2014 discussion was held at the Orthopedic Service Line meeting regarding blood transfusions and the potential to use TXA to reduce blood transfusions. Stephanie Friel and Dr. Klein discussed the pros and cons of TXA and the decisions was made to trial TXA for a period of 3-4 months beginning in June. Dr. Klein agreed to take it back to the other 3 orthopedic surgeons and see who else would like to be involved. Dr. Peck and Dr. Grimm agreed to the trial of TXA. The patients all receive a dose of IV preoperatively and some receive a dose postoperatively in the PACU as well. Hemoglobin and hematocrits are trended preoperatively and during the inpatient. This data is reviewed daily by the care team and based on subjective and objective data the decision to transfuse is made. Education regarding TXA was completed with perioperative services by the Pharmacy team and on 3 East a "read and sign" was completed. Data
Outcome Based on the data collected for a three month period of time after initiating TXA a substantial decrease in blood transfusions in the total joint arthroplasty population has not been realized. Improvement was noted in June and July, yet there appears to have been a significant change in August. Further data analysis will need to be completed based on these results. The Orthopedic Service Line will need to look at the number of TXA doses given (1 versus 2) and the patients' preoperative hemoglobin and hematocrit. Furthermore, justification for the blood transfusions must also be reviewed. The physicians will continue to use TXA at this point. Stephanie will continue collaborative efforts with the Orthopedic Service Line Committee and update them on a monthly basis. The findings from this inter-professional decision has the potential to reduce the number of blood transfusions for our patient population post orthopedic surgery. Additional data collection and analysis will take place.