Sometimes it takes those on the front line to really bring change to a hospital, and critical care nurses at seven Washington hospitals have proven so with quality improvement projects that reduced communication-related medical errors by 80% and catheter infections by 92%.
The nurses participated in a leadership and innovation training program called the AACN Clinical Scene Investigator (CSI) Academy, sponsored by the American Association of Critical-Care Nurses (AACN). The 16-month programs are intended to train bedside nurses as clinician leaders and change agents by helping them develop and carry out quality improvement projects unique to their own facilities, says Marian Altman, RN, MS, CNS-BC, ANP, an AACN clinical practice specialist who works with the CSI program.
Hospitals are facing increasing demands for quality improvement from payers, patients, and family, she says, and finances are threatened due to decreased reimbursement and the move toward value-based purchasing. Nurses are underutilized in quality improvement at most hospitals, she says.
“Nurses are well positioned on the front line for any quality improvement initiative, but we don’t really get much training in quality improvement in school,” Altman says. “With some training and the right tools, they can drive quality improvement from ground up. A lot of initiatives fail because they were imposed from the top down.”
Each team determines what issue to address in their facilities, and two teams focused on catheter-associated urinary tract infections (CAUTIs), reporting reductions of 64% and 92%. (See the story later in this issue for more on one of the CAUTI projects.) Another team decreased communication-related medication errors by 80%, and one increased progressive mobility of patients in the neuroscience ICU by 11%. One hospital successfully addressed the average length of calls for its Rapid Response Team and another eliminated patient falls related to communication issues.
Improve communication
Improving communication between patients and care providers was selected by three teams, partly because of its effect on clinical outcomes, patient satisfaction scores, and reimbursement, Altman explains.
One of those teams was from the Regional Hospital for Respiratory and Complex Care (RHRCC) in Burien, WA, the only long-term acute care hospital to participate in CSI Academy to date. Nurses there decided to focus on bedside shift reports, explains Becky Madsen, RN, BSN. By improving the way nurses exchange information at change of shift, the team reduced falls and medication errors at the 26-bed facility providing ventilator weaning and complex medical care to high-acuity patients, and they are seeing better patient, family, and nurse satisfaction.
Named Can We Talk? The Bedside Report Project, the goal was to improve the change-of-shift report, which traditionally was given at the nurses’ station or in a hallway. This resulted in communication breakdowns between nurses at change of shift, with negative effects on patient safety, satisfaction, and outcomes, Madsen says.
“With bedside reports, we go in the patient’s room and do the report in front of them,” Madsen explains. “You can actually see if they’re safe, the settings on the ventilator, and lot of other important things with both nurses present and able to discuss anything. It also is good because patients and family can ask questions of the nurses, improving continuity of care.”
With studies showing that that bedside reports increase patient safety, have a positive effect on nursing and patient satisfaction, and enhance patient/family involvement in their care, the RHRCC team created a tool to help nurses give a thorough report at the bedside. The tool was developed using SBAR (Situation, Background, Assessment, Recommendations), the 5Ps (Patient, Plan, Purpose, Problems, Precautions) for Patient Handoffs SafetyFirst initiative, best current literature, nurses’ clinical expertise, and available resources in the EHR. The bedside reporting tool consists of four components: actions at the bedside, safety checks, patient information to be handed off to the next nurse, and location of patient information in the EHR. The bedside reporting tool is attached to every patient bedside computer for reference during the handoff.
“An attempt at implementing bedside reports had been tried a couple years earlier but failed,” Madsen explains. “That made this effort harder, because nurses said it had already been tried and failed, so they didn’t have much confidence. We had to show them that this time was different.”
Significant costly improvements
Nurses were educated regarding the new bedside reporting policy, with the team nurses explaining the benefits of bedside reporting, how to give a bedside report by using the tool, and strategies to overcome the barriers to bedside reporting. Nurses were expected to implement bedside reporting after attending an education session. Bi-weekly drawings are conducted to reward nurses who participate.
Halfway through the 16-month project, the hospital’s quality control nurse joined the team, assisting with identifying the right measures to assess progress and evaluating the fiscal savings. Madsen says it was an oversight not to have the quality control nurse involved from the beginning. The team measured patient and family satisfaction, nursing satisfaction, and medication errors. They also tracked falls as shift change is often a time of high fall risk, the result of the nurses being off the floor or away from the patient’s room discussing handoffs.
The results of project were significant, Madsen says. The number of falls related to handoff communication decreased by two falls in each quarter. Medicare estimates that each fall costs an average of $9,491, so that meant a savings of $18,982 per quarter. Projected potential annual savings from fall reduction are $75,928, she says.
Medication errors cost savings are expected to be $140,000 per year, for a total projected potential annual savings $215,928.
The participating nurses at Island Hospital, Anacortes, also selected bedside shift reports as the focus of their CSI project. Using the program’s structured process helped solidify acceptance of bedside shift reports as a best practice for patients at the 43-bed hospital, the nursing team reported. Handoff reports at the bedside allow patients to see their nurses working as a team to provide around-the-clock high-quality care, the hospital’s CSI team reported. The increased communication has led to greater continuity of care for our patients and improved how satisfied they are with the nursing care, they reported.
In addition to improving patient outcomes and raising patient satisfaction scores, the CSI Academy teams documented their initiatives’ fiscal impact, with an anticipated combined savings of nearly $570,000.
Nurses from six other states have participated in the academy. AACN says the academy helps front line nurses amplify their role as advocates for evidence-based clinical practice, frequently serving as resources for colleagues developing additional change initiatives. Their projects often take on a life of their own, expanding to other units and becoming the foundation for system-wide implementation efforts.
SOURCES
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Marian Altman, Clinical Practice Specialist, American Association of Critical-Care Nurses, Aliso Viejo, CA. Telephone: (949) 362-2000.
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Becky Madsen, RN, BSN, Regional Hospital for Respiratory and Complex Care, Burien, WA. Telephone: (206) 248-4604.
Research Shows EHRs Distract Clinicians
EHRs change clinician workflow and decrease the amount of time spent directly interacting with patients, according to a recent study in Laryngoscope, published by the American Laryngological, Rhinological and Otological Society.
Researchers from the Baylor College of Medicine studied how EHRs affect workflow and resident training, conducting a time motion study of eight residents in second and fourth post-graduate years. They found that, on clinic days, residents who used EHRs spent significantly less time on direct patient care and more on documenting into the EHR and reading results in the EHR. The EHR also resulted in more fragmented workflow. (An abstract of the study is available online at http://1.usa.gov/239WYa1.)
A recent RAND Health report, conducted at the request of the American Medical Association, says physicians’ views of EHRs are still mixed, with many saying they are good in theory but have “significantly worsened” their professional satisfaction. Top complaints were that EHRs required time-consuming data entry that could be better accomplished by clerks and scribes, were difficult to use, interfered with patient face-to-face interaction, lacked interoperability, and degraded clinical documentation. (The report is available online at http://bit.ly/1ceWQeQ.)
The Joint Commission (TJC) also is concerned about how EHRs affect quality of care and patient satisfaction. In a recent Sentinel Event Alert, TJC warned of how incorrect or miscommunicated information entered in EHRs might result in adverse events. TJC recommends an improved safety culture, process improvement, and leadership regarding EHR safety. In particular, the commission urges a “collective mindfulness focused on identifying, reporting, analyzing, and reducing health IT-related hazardous conditions, close calls or errors.” The full alert, with resources, is available online at http://bit.ly/1Ok0BEU.
The TJC warning came on the heels of a letter in which representatives from 27 medical societies, including the American Medical Association, the American College of Physicians, the American College of Surgeons, and several other major medical organizations, expressed worries about EHR safety to the National Coordinator for Health Information Technology at the Department of Health and Human Services. “Unfortunately, we believe the Meaningful Use (MU) certification requirements are contributing to EHR system problems, and we are worried about the downstream effects on patient safety,” they wrote. The full letter can be found online at http://bit.ly/183Z2ey.
