Sharing the Learnings

IMPLEMENTED SAFE CARE PROJECTS AT HOSPITALS


Sharing the Learning…

PROJECTS (displayed in alphabetical order by project name)

PROJECTS (displayed in alphabetical order by facility name)

BOTHWELL REGIONAL HEALTH CENTER

Project Title: 2SW Stop CAUTI
Project Summary: We began the CUSP-CAUTI initiative in February 2010 in efforts to decrease our CAUTI infections. During presentations at the bi-monthly Infection Control meetings, we found that our rate for CAUTI was 15-20% for a specific medical unit. The committee members chose to make it a priority to reduce the numbers and improve patient safety. Our team identified strong individuals who would have a commitment to and a passion for reducing the rate. As evidence revealed and TJC supported our project "CUSP/STOP CAUTI" was born. Our original goal was to reduce the mean CAUTI rate on our medical unit by 2% over 18 months. Data was gathered and an increase in communication and awareness occurred between shifts and departments, critical thinking skills were enhanced and an education board was implemented.  Staff physicians viewed the "science of safety" video and nursing staff were required to have initial training and demonstrated yearly competencies on appropriate foley usage.  Since then, our entire facility is CAUTI aware. Our CAUTI rate for the medical unit has remained at ZERO for the past 6 consecutive months.  We are excited and proud to know we are helping make a difference through educations and implementation.

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GOLDEN VALLEY MEMORIAL HEALTHCARE

Project Title: Wipe Out CAUTI
Project Summary: Four years ago Golden Valley Memorial Hospital (GVMH) took on elimination of catheter-associated urinary tract infections (CAUTI) as their rate was as high as 4.9/1000 catheter days with a catheter prevalence rate that averaged between 25-30% organization-wide and up to 39% in the ICU. While their initial CAUTI improvement team made some progress, they were unable to achieve their goal of zero infections.  Determined to be successful as a member of the HRET-Hospital Engagement Network (HEN), GVMH realigned their team and joined the CUSP initiative to eliminate CAUTI's lead by the Center for Patient Safety.  What was different?  Front-line staff joined the improvement team; strict protocol aligned with APIC's Guide to Preventing Catheter-Associated Urinary Tract Infections and the CDC's Indications for Urinary Catheters was implemented; insertion competencies were verified for all staff who insert catheters; in-depth CAUTI Prevention education and training was provided to all patient care staff; a CAUTI Prevention Bundle was developed and implemented; departmental and organization results became transparent; along with a little fun.
Meet Fred and Fran Foley:  Fred and Fran Foley live at Golden Valley Memorial Hospital, moving from unit to unit as determined by the best CAUTI rate each month. They seem to hang out a lot on the medical floor who has had no CAUTIs for 702 days!  Senior leaders formally recognize staff and physicians for their excellent care resulting in no CAUTIs for the last 416 days across the entire hospital!  Kudos to Golden Valley Memorial Hospital!

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HANNIBAL REGIONAL HOSPITAL

Project Title: Daily Safety Huddle
Description: Daily safety huddles have been shown to be an effective tool in helping healthcare organizations develop a culture of safety, an essential characteristic of a High Reliability Organization.  Hannibal Regional Hospital's pursuit of high reliability status took a step forward when the first Daily Safety Huddle was held on March 3, 2014. Since then, Unit and Department Directors, along with members of Senior Leadership, have been meeting every Monday through Friday to identify and respond effectively to safety issues, both those that haves already occurred and those that can be confidently anticipated.

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MEMORIAL MEDICAL CENTER

Project Title: Exploring How Nurses Make Sense of the Safety Features of Smart Infusion Pump Technology
Project Summary: Smart infusion pump technology (SIPT) was designed to enhance IV medication safety but introduced new risks from nurse-initiated workarounds. Infusion pumps ranked second among the top ten technology hazards, yet few studies have directly examined nurses' experiences with SIPT.  A qualitative research study was designed to explain nurses' experiences with SIPT and their responses to workflow blocks, and conditions contributing to workarounds. Semi-structured interviews were conducted with key informants in one hospital. Data collection, sampling, and analysis followed grounded theory principles. The final sample included 28 nurses from 13 different units, a pharmacist, an education coordinator, and a nursing director. Data analysis resulted in the grounded theory of Nurse-Technology Interplay which explicates nurses' experiences with SIPT during care delivery: interacting with SIPT, making meaning and taking action in response to workflow blocks, and consequences with medication administration and impacts on nursing practice. Study findings expand the limited literature on nurses' perceptions of SIPT, suggested effects of training variations on nurse-level capabilities, knowledge about nurses' trust of SIPT, and generational differences. Use of nurse-initiated SIPT workarounds was confirmed and reflected nurses' sense-making and problem solving approaches in clinical context. Results highlight the importance of organizational scanning for potential points of technology failures and re-conceptualizing nurse-initiated workarounds as organizational issues rather than individual behavior issues. Study findings have implications for patient safety, including education and training, processes supporting SIPT, and learning from workarounds. Nurses can safely use SIPT when appropriate training occurs and when supporting structures and processes are robust.

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MERCY HOSPITAL ST. LOUIS

Project Title: Team Training and Safety Tools in Labor and Birth
Description: Mercy Hospital St. Louis Labor and Birth is a high risk perinatal center experiencing 8,500 births per year.  To improve perinatal patient safety and improve communication and teamwork, the entire multicisiplinary team (obstetricians, anesthesia providers, resident physicians, nurse leaders, staff nurses, OB scrub techs and support staff) underwent team training team.  From this group, a dedicated Hardwired Safety Tool team developed Labor and Birth specific hard-wired safety tools.  Implementation of the tools occurred over two years. The following safety tools were developed and still in use today: SBAR report and safety rounding tool which includes a postpartum hemorrhage risk assessment, Code White algorithm for mobilizing resources for emergent cesarean birth, cesarean birth checklist, Code White role lanyards for nurses, 3-3-3 debrief format and vaginal birth checklist. Members of the Hardwired Safety Tool team transitioned to the Perinatal Safety Committee which is still active today.  This team meets every two weeks and discusses safety concerns including near misses and good catches and effectiveness of safety tools. The Perinatal Safety Committee receives nominations for "Safety Champion of the Month/Week".  The team member's contribution to patient safety is discussed and their photo is displayed in a prominent space in the unit.  The team develops a "safety tip of the week" to redose an aspect of team training or emphasize a certain aspect of a hardwired safety tool.  As new co-workers and care providers join the team, they are required to attend Team Training to continue the safety education for the entire perinatal team.

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MERCY HOSPITALS ST. LOUIS AND WASHINGTON

Project Title: Teamwork Reveals Source of Burkholderia Cepacia Outbreak in 2 Hospitals
Project Summary: From September 19, 2011 through October 21, 2011, 16 hospitalized patients (6 in Mercy Hospital Washington and 10 in Mercy Hospital St. Louis) were found to be harboring Burkholderia Cepacia in their sputum.  A Critical Care Physician who works in both facilities was in Washington when the 2 cases were identified and notified St. Louis.  It was at this point that the shared investigation began.  A multidisciplinary committee was formed with representation from both facilities and daily teleconferences took place with representation from nursing, pharmacy, infection prevention, quality management, risk management, critical care, infectious disease, microbiology and administration. These daily teleconferences, as well as the investigation itself were led by an infectious disease physician who is the hospital epidemiologist for both facilities.  The 2 hospitals worked collaboratively daily to establish an updated line listing of all affected patients in an attempt to identify commonalities.  Through collaboration and use of best practice our 2 hospitals, though many miles apart, were able to minimize this impact of this outbreak to our patients while also minimizing the duration of the outbreak.  There is no greater goal in the work that we do than this.

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OZARKS MEDICAL CENTER

Project Title: CUSP-Stop CAUTI (PDF)
Project Summary: Frontline staff are critical to patient care and have the highest awareness of patient needs.  Implementation of Comprehensive Unit-based Safety Program (CUSP) teams have been foundational to increase our culture of safety at our organization. This specific project has shown the impact that CUSP teams have on reducing healthcare-acquired conditions.

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SSM HOSPITAL SYSTEM

Project Title: BERT (Behavioral Emergency Response Team)
Project Summary: At (facility) we have initiated a program called BERT: Behavioral Emergency Response Team.  BERT is a remarkable pilot program consisting of the collaboration of Behavioral Health, Nursing Operations and Security designed to reduce the risk of injury to patients, visitors and staff by proactively deploying artfully skilled experts in de-escalation techniques to patients experiencing a crisis. Previously, when a patient began to escalate, a Code Strong was overhead paged and all available employees responded to perform a physical intervention.  The addition of the BERT program encourages us to tailor our response to the level of escalation of the patient.  Because it is a smaller responding team, it is a more therapeutic approach and the team that responds is specially trained in CPI (Crisis Prevention Intervention), excelling at verbal de-escalation.  As a result of the program we have seen an improvement in the collaborative relationships of all departments involved as well as a reduction in the use of the traditional method of intervention which provides a safer environment for everyone involved.  We also have additional quantitative results that could benefit other organizations in their journey to address escalating patients in medical departments.

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SSM HEALTHCARE SYSTEM

Project Title: BOAT: Best Outcome Assessment Team
Project Summary: We would like to share this new innovative process/practice as we believe this to be best practice as identified by the joint commission team during our December 2012 survey. The Behavioral Health team was challenged by our Network Vice President, to develop and initiate a process/practice to address our growing challenges with safety on our units as we were experiencing an increase in patients that were refractory to treatment and were difficult to place post discharge.  The team identified 3 goals:  Improve safety on the unit, improve clinical outcomes on patients to refractory to treatment/unresponsive to therapy, and improve discharge dispositions and readmission rates on our most challenging patients.  Key members of the BH team collaborated to develop a process called BOAT: Best Outcome Assessment Team. The BOAT is an innovate process that leverages the strength of our professional teams (RN, SW, CM, PT, MD, AT/RT, Leadership) from across our 4 campuses and external partners to "collaborate" on our most difficult cases. The team, when activated, reviews cases and adjusts the care of patients who are challenging to treat and/or place following discharge.  We describe the BOAT as a fresh set of eyes to review cases and recommend adjustments to therapy or make additional recommendations for discharge.

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SSM HEALTHCARE SYSTEM

Project Title: A Healthcare System Approach to Tackling Clostridium-difficile
Project Summary: One of the greatest challenges for Infection Preventionists and hospital patient safety professional is managing and mitigating risks of Clostridium-difficile infections (CDI) in the healthcare setting.  CDI is the most common cause of infectious diarrhea with rates increasing three-fold since 2000.  In 2007, 14,000 deaths were linked to CDI.  This healthcare system reported a healthcare onset (HO) rate of 3.0 per 10,000 patient days in 2010, HO rate of 2.9 in 2011 and year to date (thru October 2012) aggregate rate of 1.9. We are on course of significantly reducing CDI.  Beginning in April of 2012, an intensive approach to environmental cleaning and rounding was began along with feedback to line leaders managing Environmental Services (EVS).  At the same time, a network wide antibiotic stewardship team began to review the data along with stewardship recommendations.  Checklists, feedback and education on EVS procedures occurred throughout this healthcare network. To drill down further, in October 2012, a three-pronged approach was implemented. A root cause tool was developed that incorporates metrics for environmental, transmission and antibiotic usage. EVS, Infection Prevention and Pharmacy will drill down each case to assess the management of each case.

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SSM ST. LOUIS NETWORK

Project Title: VTE Core Measure Process Improvement
Project Summary: SSM St. Louis began the journey to reduce hospital-acquired VTE through implementation of evidence-based care in 2013.  A network Core Measure Improvement Team used preliminary results to identify current performance and opportunities for improvement.  This muldisicplinary team identified process and electronic health record changes to be in compliant, educational materials for nurses, physicians and pharmacist, and concurrent oversignt processes.  The results show improvement in the network VTE composite score from 80% in January, 2013 to 98% in October, 2014; improvement in VTE discharge instructions from 25% in January, 2013 to 100% in October, 2014; and improvement in the unfractionated heparin measure from 82% in January, 2013 to 100% in October, 2014.  The multidisciplinary improvement team added members throughout the System and is the approach we use to improve other key improvement opportunities.

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ST. LUKE'S HOSPITAL

Project Title: One Chance to Get it Right
Project Summary:
INTRODUCTION:  With the increasing complexity and acuity of patients, strategies must be developed to help healthcare teams provide safe and effective care.  The use of high fidelity simulation has strong evidence in the literature that encourages hospitals to provide learning environments for their staff using multidisciplinary programs.
BACKGROUND:  One of the Institute of Medicine's (IOM) guiding principles in their report, To Err is Human: Building a Safer Health Care System (1999) is for health care organizations to develop a multidisciplinary program using simulation as a means to promote competency and clinical decision making skills (Hallenbeck, 2012). Simulation provides the novice and experienced professional with exposure to clinical situations in a controlled learning environment for complex clinical situations. The clinical educators at St. Luke's Hospital are utilizing simulation as a valid and reliable means of assessment. Simulated patient experiences are an integral part of the learning experience, enhancing feelings of professionalism and competence.
CONCLUSION:  The use of simulation creates a safe environment where participants are able to identify their clinical strengths as well as areas requiring further development.  Participants reported feeling more confident in the clinical environment following the simulation experience. In addition, they found the debriefing session to provide valuable feedback. Participants rated the scenarios as realistic with strong ability to incorporate what they learned in simulation into practice.
IMPLICATIONS:  Implications of our current findings show strong support of continued use of simulation to develop advanced critical thinking skills which will lead to improved patient care and positive clinical outcomes.

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ST. MARY'S HEALTH CENTER

Project Title: Reduction in Home Medication List Errors
Project Summary: Medication errors at transitions of care are exhibited repeatedly in literature to be one of the most frequent sources for errors; patient hospital admission represents one of those key sources.  National data indicates at least 40% of home medication orders have some type of error this approximation is even higher when taking into account drug omissions.  Our facility is no better or no worse than national data when it comes to home medication errors upon admission.  Regardless of benchmarking, a 40% error rate in any process that impacts patient safety should be and is unacceptable. This project was conducted using Continuous Quality Improvement (CQI) tools and methods.  Tools like process mapping and root cause analysis were applied to determine safety roadblocks of the home medication reconciliation process.  The team established there are three essential components that must be present to implement a successful and error-reduced medication reconciliation process: Process Ownership, Interview Accuracy and Home Medication List Responsibility.  The team developed a practice model, incorporating these components, that was pilot-tested and resulted in decreased home medication list errors and improved patient safety.

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TRUMAN MEDICAL CENTER

Project Title: Trauma Activation,Unidentified, and Mass Casualty Incident Patients
Project Summary: Our project stemmed from a mismatch transfusion event in August 2011. It was determined at the root cause analysis of this event that the 20+ year old process,used at the time for identifying trauma patients, did not meet patient safety standards of our institution. The project to explore alternatives was initiated by the Systems Director of Lab Operations and the Trauma Services Director. The project was a multidepartmental/multidisciplinary project that affected all service lines within the hospital system from ED,Medical Imaging to Environmental Services and Food Service. It was a truly collaborative effort from a large number of managers, directors,physicians and front line staff. Patient Safety was our number one goal of this project.

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TRUMAN MEDICAL CENTER

Project Title: Reduced Use of Behavioral Restraints (PDF)
Project Summary: Our project focused on reducing the use of behavioral restraints through the implementation of staff and patient debriefings and through use of alternative interventions.  Patients have the right to be free of restraints unless used to ensure the immediate safety of the patient, staff member or others.  The use of restraints has the potential to produce serious consequences to the patient such as physical or psychological harm, loss of dignity, violation of rights, and even death.  Many of our patients have histories of physical and trauma-inducing experiences and the use of restraints can increase that traumatic experience.  We believe restraint use can be reduced by understanding the vulnerabilities or "triggers" of these patients and utilizing known techniques that can de-escalate the patient.  This was not an easy project because there was a great amount of push-back from staff when implementing the staff debriefings after each behavioral restraint use.  However, over time, staff and physicians bought into the process.  Reducing restraint use is very doable but takes a huge about of commitment from staff and leadership.  Outcomes have proven the interventions work and provide better care and outcomes for our patients.

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UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF PHARMACY

Project Title:  Implementation of electronic health record (HER)-based medication management functionalities associated with decreased 30-day acute myocardial infarction (AMI) readmission rates.
Description:  Authors:  Mark E. Patterson, PH.D., M.P.H. and Stephen Andrews, PharmD. Candidate
(1):  UMKC School of Pharmacy Department of Pharmacy Practice and Administration
(2):  UMKC School of Pharmacy, PharmD Candidate.
INTRODUCTION:  Although providing medication reconciliation at admission and generating medication lists at discharge improves clinical outcomes by decreasing medication errors, less is known about how performing these activities within the context of electronic health record (EHR) systems impact readmission rates.
OBJECTIVE: To compare 30-day acute myocardial infarction (AMI) readmission rates between hospitals capable of providing EHR-based medication reconciliation at admission, EHR-generated medication lists at discharge, neither, or both.
METHODS:  This retrospective cohort study uses data from the American Hospital Association Health IT survey and Hospital Compare to measure associations between EHR-based medication management capabilities and hospital-level readmission rates.  Multivariable linear regressions estimated differences in 30-day AMI readmissions between hospitals implementing EHRs capable of performing medication reconciliation, generating medication lists, neither, or both, controlling for hospital-level covariates.
RESULTS:  Unadjusted readmission rates were lower (19.7%) in hospitals reporting capabilities of EHR-based medication reconciliation and medication list generation, compared to hospitals reporting neither capability (20.3%) (p<0.0001).  Compared to hospitals not capable of performing EHR-based medication reconciliation or medication discharge lists, those hospitals capable of both experienced on average 0.5% lower 30-day AMI readmission rates (B=-0.48; 95% CI-0.78 to -0.18).
CONCLUSTION:  The significant negative associations found between EHR-based medication management capability levels and 30-day readmission suggest that performing these activities within the context of electronic health record (EHR) systems reduces AMI readmissions.  Because the modest differences raise doubt about the clinical relevance of the findings, future studies need to continue investigating the causal nature of clinical relevance of these associations.

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