Learning packets help staff reduce falls, improve safety

Educating your staff is an ongoing challenge, but one hospital has found that patient safety packets with practical, goal-oriented information can be especially effective in helping reduce falls and other hazards.

JCAHO recently awarded its Eisenberg Award to the University of Pittsburgh Medical Center (UPMC) in McKeesport, PA, for development of personalized patient safety self-learning packets. JCAHO praised UPMC for creating tools that "demonstrated their effectiveness in creating an organization culture of patient safety that facilitates the resolution of problems associated with hospital-acquired infections and falls."

UPMC began working on the patient safety packets in 2002, says T. Michael White, MD, senior vice president for value and education at UPMC. The hospital built on previous work at the University of Pittsburgh that suggested instead of waiting until a patient was near death to call a code, it is better to call the code as soon as the patient becomes significantly unstable. The researchers called this "Condition C."

Codes go up, deaths go down

To encourage calling codes at Condition C, UPMC put a learning packet together and called it "Keeping Each Patient Safe (By Calling for Help Early)," White explains. "These are learning packets for our professionals. Once we had the educational material ready, we used them to teach each professional individually," he says. "We can do that in a room of 30 doctors, each with their own packet, and the attendings get continuing medical education credit for that."

Or the packets can be used to teach clinicians one at time. The nursing departments make use of the same packets. And the results of that first learning packet suggested that the method worked for getting across the new strategy on calling codes.

Prior to July 2002, UPMC had about six codes per month and about half of the patients survived. The packets were introduced in July and August, and suddenly the number of codes shot up to about 30 codes a month, with nearly all of them surviving. The data also showed that one unit of the hospital was not calling codes early, and a review of the records revealed that was the only unit that had been overlooked in the training program. That oversight was rectified.

Then doctors reported that physical therapy was calling too many of the early codes, so UPMC conducted a root-cause analysis and found that actually the department was not calling too many codes. The real problem was that patients going to physical therapy were having a difficult time enduring the ride down, the wait for a therapist, and finally the therapy itself. The codes were valid; the patients were just being pushed to the brink. "So we changed our policy so that we bring therapy to the patient so that it can be done at the bedside," he says.

More learning packets developed

The success of the Condition C packet led UPMC to develop others. There are now five learning packets now, each under the rubric of "Keeping Each Patient Safe . . . : By Calling for Help Early, By Preventing Hospital-Acquired Infections, From Falls and Confusion, With Standardized Admission Orders, and With Excellence in the Discharge Process."

Rich Kundravi, director of risk management and patient safety at UPMC, says the topics were selected through root-cause analyses and trends in data. The hospital’s patient safety committee drove the process, he says. "From a risk management perspective, some topics are always a concern, like patient falls," he says. "Historically, we had tried several fall reduction programs that we thought would be very helpful but when we looked back at our data we were consistently at the same fall rate. Our staff was making an effort to prevent falls, but when we studied the root causes, we found that patient confusion was something we could address within our organization."

As part of that learning packet, medication experts at UPMC studied the drugs that were most often the cause of delirium in patients and eliminated those from the formulary.

Studying the data specific to UPMC allowed the patient safety team to implement solutions that addressed what actually happening at their hospital, not just general solutions to general problems, he says.

White says the learning packet helped clinicians at UPMC develop a common language regarding falls, so that nurses more commonly alerted physicians that a patient was "confused," and both professionals knew that the word had particular meaning regarding the risk of falling. The number of patients diagnosed with delirium has increased, he says, because the culture encourages the diagnosis and treatment.

The learning packets are different from the typical inservice education materials, White says. (For examples of the packets and the overall UPMC patient safety effort, see this web site: http://mckeesport.upmc.com/keepingpatientssafe.htm.) The packets provide a primer on each topic and are written in a language that is easily understood by each of the target audiences: physicians, nurses, therapists, and other clinicians. The same packet is used for everyone.

"That was a key goal, providing the information in a way that they could easily digest and put to use," he says. "So many times, physicians go to a seminar and sit there for an hour, understand everything that is said, but when we go to take care of our patients our behavior is not changed. These packets lead to immediate change in behavior."

For instance, Kundravi says the patient safety committee determined that nurses at UPMC were assessing patients for falls but the physicians often were not aware that patients were at risk of falling. So the learning packets also provide a linkage between departments and different professionals by providing a common language and encouraging everyone to focus on the same priorities.

Each professional receives a packet to keep and can refer back to the resources inside. Kundravi says the packets also encourage a blame-free environment because they encourage staff to share information, with the goal of protecting the patient rather than punishing staff for oversights. White says staff have responded well to the learning packets. Participation is mandatory for nurses and the patient safety sessions are part of the nurses’ annual competency requirements. "Physicians have responded with enthusiasm, although it is not mandatory for them, and they report a positive change in the care of their patients," he says.