Baystate case managers act as quality safety net

CMs ensure that quality checklist is followed

Case managers act as the safety net in making sure that patients receive appropriate evidence-based care interventions and ensuring safety protocols and preventive measures are in place at Baystate Medical Center in Springfield, MA.

Case managers participate in the interdisciplinary bedside rounds at the hospital and often are in charge of coordinating the team to ensure that appropriate interventions from the quality checklist are in place for every patient. The checklist acts as a prompt to prevent omissions in care and patient safety protocols, says Jan Fitzgerald, MS, RN, CPHQ, director, quality and medical management, division of health care quality.

"The case managers are the key to organizing these rounds and asking questions to ensure that all of the patients' needs are being met and that the protocols are being followed," Fitzgerald says.

Baystate Medical Center started its patient safety initiatives in 1992 and has tracked and worked to avoid hospital-acquired conditions long before the Centers for Medicare & Medicaid Services required hospitals to document conditions that were present on admission and announced that it no longer will pay for certain never events and hospital-acquired conditions, Fitzgerald adds.

"We have focused on two issues when it comes to hospital-acquired conditions — accurate, reliable documentation of pre-existing conditions and prevention of hospital-acquired conditions — to make sure that we provide the absolute best care to the patient and that the documentation in the medical record is appropriate and an accurate reflection of the patient and the hospitalization," she says.

Electronic prompts

The hospital quality department and health information management department have worked together to embed into the medical record electronic reminders to prompt the interdisciplinary team to ensure that patient safety/prevention measures and other recommended protocols are being followed.

For instance, the multidisciplinary teams have a checklist that calls attention to devices that can lead to infections such as urinary catheters and central lines.

"Every day, the checklist asks if the patient has a central line or a urinary catheter and if he or she still needs it. If not, the staff must determine and document the rationale as to why it needs to stay in," she says.

Case managers may be responsible for this documentation and, if it's time for the catheter to be removed, may prompt the physician to generate the orders.

The doctors must be the ones to make the decision to remove a catheter or a central line, but the nurses and case managers also must take responsibility, she adds.

"The doctor may not have rounded but the catheter is due to come out. The nurse or case manager should make sure the physician gives it his or her attention," she says.

If a patient is at risk for pressure ulcers, the daily flow sheet includes a series of questions that include: Is the bed plugged in? Is the pressure release mattress turned on? If the patient has compression boots, are they turned on?

"These electronic reminders prompt the team to check to make sure all of the interventions are in place," Fitzgerald says.

The electronic medical record also prompts the staff to assess patients for conditions that may be present on admission.

Upfront assessment

Every patient who comes to Baystate Medical Center receives a head-to-toe assessment for pressure ulcers by the nurse who enters the information in an online assessment form.

The physician also must conduct a skin assessment during the history and physical. The electronic medical record asks if there are broken areas in the skin. If the answer is yes, the doctor documents if it is a decubitus ulcer or another problem. If he or she doesn't know, the system automatically orders a wound consultation.

Each patient's skin is assessed every day.

"We want to make sure we have it right from the beginning and that we are doing what is right for the patient to prevent wounds and to treat those they have upon admission," Fitzgerald says.

The hospital has taken the approach that any patient admitted is at moderate risk for deep venous thrombosis (DVT) or pulmonary embolism, Fitzgerald says.

Each patient is assessed every day for both conditions and interventions are implemented according to the risk factor, she says.

The protocols for avoiding never events and hospital-acquired conditions are in the hospital's electronic system. They include the prevention bundles for ventilator-associated pneumonia, bloodstream infections, urinary catheter-related infections, DVT prophylaxis as well as the Surgical Care Improvement Project (SCIP) measures, acute myocardial infarction, and heart failure care.

When the doctor opens the chart to put in orders, if he or she hasn't ordered prophylaxis for DVT and pulmonary embolism, the record prompts the doctor for the order or to document that the patient is low risk and doesn't need it.

"We tried to put all of these things into the flow of work so people will automatically see that they are done," Fitzgerald says.

The postoperative orders for surgical procedures automatically include prophylaxis for DVT and pulmonary embolism.

"If the doctor doesn't want to order the prophylaxis, he or she has to uncheck the box and document why not," Fitzgerald says.

To ensure that all hospital-acquired conditions are accurately documented, the hospital's coding software includes built-in prompts for the hospital-acquired conditions.

Any time the software determines that a patient has one of the targeted conditions, the coders automatically stop and put the chart aside until a quality improvement nurse can complete a clinical review. The electronic system is set up so the coders can't close the chart until it is reviewed by a quality improvement nurse.

"A patient might come in with a pressure ulcer, but if the doctor doesn't clearly write that in the chart, it looks like it happened in the hospital. We review the chart and if it appears to have been present on admission, we have the physician review it and amend it if necessary. Our goal is to make sure that the data we report are accurate," Fitzgerald says.

Other quality initiatives include re-educating nurses on insertion and removal of catheters and central lines as part of their annual training and training for physicians who put in central lines.

"We're pushing to make sure that clinically we are doing the right thing and that best practices are being followed every time for every patient the first time," Fitzgerald says.

(For more information, contact: Jan Fitzgerald, MS, RN, CPHQ, director, quality and medical management, division of health care quality, Baystate Medical Center, e-mail: