KentuckyOne Nurse Advancing Nursing Across KentuckyOne Health Summer 2016 Inside News At a Glance 2 Making a Difference Across KentuckyOne 3 Jewish Hospital and Sts. Mary & Elizabeth Hospital Slash Door-to-Needle Times for Acute Ischemic Stroke Treatment 4 Nursing Assessment of VTE Risk in Medical and Surgical Patients 5 Process Change Leads to Dramatic Quality Improvement 6 University of Louisville Hospital Trauma Resuscitation Nurse Pilot 7 S.M.A.R.T.: The Journey to ZERO CLABSI 8 Did You Know? Nurses Leading the Way for Patient Outcomes We Are One. Nursing Vision: KentuckyOne nurses are leaders distinguished by evidence-based practice, exquisite service to others, and safe, effective care. Nationally renowned for our innovative practice environment, our nurses will achieve the highest level of outcomes by partnering with patients, their families, other care providers and our communities.
Making a Difference Across KentuckyOne By Velinda Block, DNP, RN, NEA-BC, SVP, System Chief Nursing Officer At the beginning of April, we kicked off our Emergency Department Differentiator initiative across KentuckyOne. In the dictionary, the word differentiate means to make a distinction or to separate from others. We believe that we have a unique opportunity to separate ourselves from others and greatly improve the care we deliver by focusing on throughput in our emergency departments. In today s world of health care consumerism, patients expect fast and friendly service. There are many options for urgent/ emergent care that patients can choose; we want them to choose us! Saying that you want to be different does not make it happen you have to intentionally work for it to be so. We have been using a methodology called lean to drive this work. Lean is a customer-focused approach that enables one to Saint Joseph Hospital Emergency Department Improvement Team improve a process by eliminating waste. In addition, it engages all of the stakeholders in the design of the future state. As the executive leading this effort, I have been inspired to see teams in all of our sites come together around this common goal. While it is still early in our rollout, we are seeing amazing results that include improvement in our door-to-provider time, a reduction in the length of stay for patients, fewer people leaving our emergency departments prior to being seen, and improvement in the patient experience. All of this means better care. I encourage you to talk with your colleagues who work in the emergency department so that you can learn more about lean and how we are truly becoming different. Saint Joseph Mount Sterling Emergency Department Improvement Team Event Velinda J. Block, DNP, RN, NEA-BC 2
Jewish Hospital and Sts. Mary & Elizabeth Hospital Slash Door-to-Needle Times for Acute Ischemic Stroke Treatment By Amy Porter, BSN, RN, Stroke Program Coordinator, Jewish Hospital and Sts. Mary & Elizabeth Hospital The stroke teams at Jewish Hospital (JH) and Sts. Mary & Elizabeth Hospital (SMEH) have worked hard over the course of the last year to improve the care we give stroke patients. We recognized an opportunity in March of 2015 when The Joint Commission began requiring Primary Stroke Centers to achieve door-to-needle times of 60 minutes or less at least 50 percent of the time for patients treated with IV tpa. To address the challenge of meeting this metric, we formed a multidisciplinary subcommittee comprised of members from the stroke team, pharmacy, ED, imaging, lab and nursing leadership. We began by reviewing our tpa cases in real time, speaking with staff involved, and identifying processes that were hindering our ability to deliver timely treatment. We looked at current literature to ensure we were following the latest guidelines, and also investigated what other facilities across the country were doing to successfully meet this goal. We recognized the need to create a new policy to quickly triage and treat acute stroke patients, including those in the ED and those who may develop a stroke during their stay as an inpatient with us. We created step-bystep algorithms mapping out the exact process for each area specific to each individual facility, and educated staff about the changes. We conducted mock Code Stroke drills to practice and streamline our process. The new policy took effect in July at SMEH, and in October at JH. Since that time, both facilities have seen dramatic reductions in our door-to-needle times, correlating with better patient outcomes. After implementing the new Code Stroke policy, JH saw a 27% reduction in door- to- needle times, and SMEH saw a 17% reduction by the end of 2015. Year-to-date in 2016, both facilities have achieved door-to-needle times of less than 60 minutes for more than 75% of patients treated, and are treating about 50% in less than 45 minutes. We know that during a stroke, time is brain. So we are essentially saving brain cells, to the tune of 1.9 million brain cells for each minute that we shave off that treatment time. Door to tpa (Percent treated within 60 minutes) Door to tpa (Percent treated within 60 minutes) 140 120 100 80 60 40 20 0 SMEH 2016 YTD tpa Times 140 120 100 80 60 40 20 0 JH 2016 YTD tpa Times Minutes from Presentation Minutes from Presentation tpa Administrations SMEH Median DTN 2016 YTD = 49 min tpa Administrations JH Median DTN 2016 YTD = 44 min 3
Nursing Assessment of VTE Risk in Medical and Surgical Patients By: Faith Reynolds, MSN, RN, AOCNS, CRNI, Saint Joseph Hospital Venous thromboembolism (VTE) is one of the most common preventable causes of death in hospitalized patients. In order to prevent VTE and ensure that appropriate prophylaxis is ordered, it is recommended that hospitalized patients be assessed for VTE risk upon admission, and upon any change in level of care. At Saint Joseph Hospital (SJH), it is the nurse s responsibility to conduct a VTE risk assessment and to notify the physician if VTE prophylaxis has not been ordered within 24 hours of admission. Historically we have used the Caprini VTE risk assessment, a quantitative model displaying over 30 VTE risk factors with totaled point values to determine if the patient is low, moderate, high, or very high risk. Quantitative risk assessment models like this can be cumbersome for clinicians, and are not validated in all patient populations. UCSD model. The assigned nurse and the clinician reviewer assessed 50 medical and 50 surgical patients for VTE risk using both models, then did a comparative review. The Caprini model resulted in more variation of risk scores between reviewers. Patients also scored at higher risk for VTE a variable that could result in over-prophylaxis and increased bleeding risk. The UCSD model demonstrated better inter-observer agreement, and more Medical Patients Caprini Model 8% 2% patients were classified as moderate risk. Nurses also found the UCSD model to be a quicker way to determine patients VTE risk. As a result of this project and other evidence-based recommendations from our KentuckyOne team, the UCSD risk assessment is now available in Cerner for physicians to utilize when ordering VTE prophylaxis. This project shows that nurses have the power to influence quality improvement efforts. They lead the way in improving patient-centered outcomes within our health system! Medical Patients UCSD Model 4% Simplified, qualitative VTE risk assessment models are now recommended as best practice and endorsed by multiple health care quality improvement organizations. A widely used and validated example of this type of model is the University of California San Diego (UCSD) VTE Risk Assessment. This model identifies patients as low, moderate, or high risk for VTE based on simplified criteria. 90% High Risk Moderate Risk Low Risk Surgical Patients Caprini Model 4% 2% 96% Moderate Risk Low Risk Surgical Patients UCSD Model 6% As part of a KentuckyOne VTE quality improvement team s efforts, SJH conducted a small pilot project on the VTE risk assessment process that compared the Caprini model with the 94% 50% 44% High Risk Moderate Risk Low Risk High Risk Moderate Risk Low Risk 4
Process Change Leads to Dramatic Quality Improvement By: Cathy Wagner, LPN, Clinical Data Abstractor, Our Lady of Peace Cathy Wagner, LPN and Angela Hockman, BSN, RN The Joint Commission (TJC) sets guidelines and standards for Behavioral Health facilities which include a set of performance core measures for Hospital-Based Inpatient Psychiatric Services (HBIPS). At Our Lady of Peace (OLOP), these are the standards by which we measure our success. I realized from my years as a staff nurse in the behavioral health field that most nursing staff members have little knowledge about TJC psychiatric core measure standards. In July of 2015, we introduced HBIPS at our annual Safety Fair, providing information about the specifics of the core measures, including how the data is collected. We discussed how this process helps to provide our patients with a seamless plan of care as they transition from inpatient to outpatient status. We offered one-on-one education with each of our nurses and physicians, and are including this information in our new staff orientation groups as well. Over the past 18 months, we have seen measurable improvement in all of the core measures, as illustrated in the table below. HBIP Core Measures TJC Goal OLOP 2014 Data OLOP 2016 Data After moving from the position of staff nurse to quality abstractor at my facility, we quickly realized a need for process improvement in this area. Utilizing the SafetyFirst techniques of STAR and asking clarifying questions, we determined that the reason for our results did not lie solely with the individuals conducting the tasks, but also derived from our process/ system for completing these tasks. HBIP #1 - Admission Screening HBIP #4a - Multiple Antipsychotics at D/C HBIP #5a - D/C on multiple antipsychotics with appropriate justification 95% 11% or less 41% 99.5% 10.9% 18.2% 100% 3.96% 66.67% As a team, we started our process improvement by restructuring our discharge documentation process. Due to the nature of their illnesses, many of our patients have difficulty remembering details of their hospital stay, as well as the plan for their continued treatment. With that in mind, we revamped our discharge medication form. We now require our physicians to include a discharge diagnosis, a list of discharge medications and the indications for their use, the number of antipsychotic medications patients are discharged on, and appropriate justification for the use of multiple antipsychotics. The nursing staff then transcribes this information to the Continuing Care Plan, which is transmitted to the patient s next level-of-care provider, and also given to the patient at discharge. HBIP #6a - Post Continuing Care Plan has D/C dx and d/c meds with indication for use HBIP #7a - Continuing Care Plan sent to next provider within 5 days or less 93% 69% 94.96% 85% 61.6% 93.17% The numbers show that at Our Lady of Peace, we take pride in meeting TJC Standards, while providing our patients with the best quality of care available! Our goal is to continuously assess our systems and processes, and drill down for quality improvement, promoting safety and quality care each and every day! 5
University of Louisville Hospital Trauma Resuscitation Nurse Pilot By Kim Denzik, RN, BSN, Trauma Program Manager, University of Louisville Hospital The Trauma Center at University of Louisville Hospital (ULH) has a longstanding history of being the local, regional and national leader for trauma and burn care in Western Kentucky and Southern Indiana. Last year alone, our trauma center provided care for over 3,000 patients who needed the highly specialized services of our multidisciplinary trauma program. We are the region s only American College of Surgeons (ACS) Verified Level I Trauma Center for adults, and we are one of only two Level I adult trauma centers in the Commonwealth of Kentucky. Transformation of care is driven by evidence-based process changes that will benefit patient safety and outcomes while improving communication. Like many hospitals around the country, ULH must ensure the delivery of safe, quality care for these complex patients. This need led us to develop the Trauma Resuscitation Nurse (TRN) pilot program. The quality improvement project focused on: Improving communication/hand off between the ICU and ED staff. Appropriate triage to decrease ED length-of-stay for the highest acuity trauma patient. Safe and efficient handling of the traumatically injured patient. Supplementing ED staffing with TRN responding to trauma activations and assisting the ED with stabilization of patient. Assisting with the admission to the ICU. The TRN pilot was the inspiration of Carolyn Backes, RN, BSN, TCRN, of the Surgical Intensive Care Unit (8W). With the approval of Shari Kretzschmer, CNO, and the collaboration of the Trauma Program Manager, the TRN pilot process was put into action November of 2015 through February of 2016. With input from the ED charge nurses and staff, the role was modified to have the greatest impact throughout the pilot. The results were dramatic. ED length of stay decreased for patients who had both Level I and Level II trauma activations. The additional staffing allowed the ED nurses to focus their care on other patients, because the TRN traveled and assisted in patient stabilization. ICU staff had positive reactions due to the more detailed bedside report. With such encouraging results, this role has moved from pilot to permanent and a second position is being added in order to provide additional support for these very complex patients. Pilot Patient ED Length of Stay Pilot Patient ED Length of Stay ULH ED Times for TRN with compare group year 2014 Level 1: Pilot patients vs. Compare group year 2014 ULH ED Times for TRN with compare group year 2014 Level 2: Pilot patients vs. Compare group year 2014 160 140 120 100 80 60 40 20 0 145 400 350 300 250 200 150 100 50 0 361 103 226 279 64 161 6 5 21 Min ED min Avg ED min Median ED min 14 11 Min ED min Avg ED min Median ED min 2015 Trial 2014 Compare 2015 Trial 2014 Compare 6
S.M.A.R.T.: The Journey to ZERO CLABSI By: Sarah Bishop, MSN, APRN, CCNS, CIC, Director of Infection Prevention and Control, Jewish Hospital and University of Louisville Hospital A central line-associated bloodstream infection (CLABSI) is attributed to the placement or use of a central venous catheter. CLABSI results in thousands of deaths each year, and costs the U.S. health care system billions of dollars. CLABSI data are reported publicly, and can be viewed by consumers through sites such as Hospital Compare. These rates impact reimbursement, and are considered a Never Event by the Centers for Medicare & Medicaid Services (CMS). This health care-associated infection is considered preventable when evidence-based practice guidelines are implemented. After a review of CLABSI data from the 2015 calendar year, Jewish Hospital (JH) recognized an opportunity to improve practice-- and save lives. An innovative partnership between JH and BARD Medical produced the All Points Training Program, in which a designated IV Therapy Team member completed a full in-house assessment, including the audit of actual central line dressings (i.e., dressing clean, dry and intact; dressing dated; central line secured) and a review of staff knowledge around the care of the central line (i.e., proper procedure for central line dressing change; administration of intravenous medication). The team disseminated the results of this assessment to nursing leadership and direct care nurses. The power of this data and the identification of barriers to practice set the course for ZERO CLABSI and ignited the S.M.A.R.T. Campaign! S.M.A.R.T. is an acronym outlining an evidence-based strategy for achieving ZERO device-associated infections. S = Selection (use only evidence-based indication for device utilization) M = Maintenance (implement evidencebased device care bundles) A.R.T = And Remove Today (assess for device removal daily) The SMART- Getting to ZERO campaign kicked off with enthusiasm! First fifty super-users were recruited and re-trained in evidence-based practices related to the care and maintenance of the central venous catheter (CVC). These super-users disseminated the information to frontline staff, who then completed a return demonstration/skills check-off on CVC care and maintenance. Simultaneously, department managers and charge nurses implemented daily auditing of central line bundle elements while Infection Prevention provided detailed Performance Improvement (PI) review of all CLABSI cases for review and discussion at the department level. The result: In the first three months, we have achieved a 50% reduction in CLABSI rates, as compared to the three months before the intervention! The journey to ZERO is well underway with many great accomplishments yet to come! 7
Did You Know? Research, evidence-based practice and quality improvement projects are all ways to evaluate and improve patient care. The Institute of Medicine has recommended that by 2020, 90 percent of clinical decisions are to be supported by the best evidence. Are you confident that your practice is supported by the best evidence? Evidence-Based Practice (EBP) is a problem-solving approach to clinical decision-making that combines the best available evidence with the nurse s clinical experience and patient values. KentuckyOne Health has several evidence-based practice committees across the system. All nurses are invited to participate. Contact Pam Elzy, System Director of Clinical Education, for the committee nearest you, at PamelaElzy @CatholicHealth.net. Did You Know? One process our hospitals use to improve care is Common Cause Analysis (CCA). This process provides a retrospective review of an event, or a series of events, by the key stakeholders. As part of the CCA, there is an analysis of potential causes and an identification of factors which could have prevented the issue, including a review of systems and processes that may have been contributing factors. A corrective action plan is implemented, with findings and improvements reported to all stakeholders. As a nursing professional, when you identify issues, it s your responsibility to report them and assist in getting resolution to those issues. If you are aware of patient care issues, contact your Unit Manager or Quality Leader and ask for a Common Cause Analysis. It s a step in the right direction for continuous performance improvement, and might prevent a Safety Event from occurring. Did You Know? KentuckyOne Health has a department dedicated to performance excellence. This department employs a team of people who are certified in Lean Six Sigma. Lean Six Sigma is a program that uses a collaborating team to improve performance by evaluating and systematically removing processes or procedures that do not add value to what is being done. The Clinical and Process Excellence Program (CPE) analyzes the procedures of daily work in order to streamline processes by eliminating wasted time and effort. Michael Waterman, Division Director of Performance Excellence, explains that the goal of CPE is to create an environment where continuous improvement is part of everyone s role, and all voices can be heard. Nursing involvement provides critical value to this work including the ED Differentiator Project, improving scheduling and throughput in surgical services, and improving the discharge planning process. Did You Know? The Nursing Professional Development Program (NPDP) recognizes the importance of research, evidence-based practice and quality improvement initiatives to both the care of patients and the professional development of the RN. Participation in any of these activities can be used for points in this program, which offers the RN a financial incentive for pursuing professional development opportunities. Need more information on how to get started? Visit the nursing section of insidekentuckyonehealth. org and click on professional development, or contact NPDP Chairperson Jerri Mobley at fnur.jkp@flaget.com. KentuckyOne Nurse Editorial Board Velinda Block, DPN, RN, NEA-BC; Katrina Bates, BSN, RN; Pam Elzy, MHA, MSN, RN, RN-BC; Cinda Fluke, M.Ed., BSN, RN, NEA-BC; Patrick McCool, BSN, RN; Lisa McQuillen, MA; Marguerite L. Newton, BSN, RN, CCRN-K; and Tammy Sizemore, BSN, RN, CNML 8 KentuckyOne Nurse is a quarterly publication produced by the KentuckyOne Health clinical communications team. To contribute news articles or announcements, please contact KentuckyOneNurse@kentuckyonehealth.org or 502.560.8374.