healthcare workers, volunteers and...

Mandatory Seasonal Flu Shot Vaccination for

Healthcare Workers,

Volunteers and Students TABLE 1

Multidisciplinary Team Members• Ambulatory services: Michael Koller, Bridgid Steele, Cheryl White• Emergency Medicine: Chris Chaput, Katherine Martens • Human Resources: Vicky Piper• Infection Control: Jaime Belmares, Bridget Gaughan, Jorge Parada• IT: Roger Russel• Legal: Jill Koppell• Media Services: Anne Dillon• Nursing Administration: Paula Hindle, Carol Schleffendorf• Occupational Health: Sandra Brehm, Mary Capelli-Schellpfeffer• Pharmacy: Brian Hardy• Safety & Security: Jen Carlson• Stritch School of Medicine: Mike Lambesis

Project Aim Statement• 1984 - CDC recommends yearly flu shot for all health care workers

(HCW)• 2009 Infectious Disease Society of America recommends mandatory

flu vaccination for HCW• 2009 Nursing Magnet Forces align with vaccination

• Despite best efforts, LUHS flu HCW flu shot rate is 73% in 2008- 2009

Target

100% HCW, volunteer and student participation in mandatory influenza vaccination program

Solutions Implemented• HR policy includes flu shot as condition of employment• Widespread publicity in local media and throughout health system

(including “Safety Dance”video) • 3 ply consent form and portal based tracking system created to

measure compliance• HR implements exemption process• EMS coordinates mass vaccination drill Oct 15 & 16• Student affairs office coordinates medical school efforts• Nursing administration coordinates times and locations for vaccination

up to December 1 deadline

Analysis: Target achieved!100% participation 99.3% vaccinated

Next Steps• Utilize ID card swipe tracking system• Consider earlier deadline if vaccine supply permits• Encourage vaccination at large scale events• Avoid perceived resource competition between immunization delivery

to employees and patients• Align policies at Loyola and Gottlieb campuses • Incorporate messaging that includes compliance with immunization

policy into broader education emphasizing the holistic relationship between patients and employee safety actions

Team Membership Emergency Department Nursing Staff and Physicians

Bypassing the Bypass:Elimination of Emergency Department

and Hospital Bypass Time

TABLE 2

Goal

Develop and implement strategies to decrease Emergency Department and Hospital bypass time to zero hours immediately without compromising patient safety and quality care.

• February 2009 – commitment from hospital and ED to avoid bypass as tool to manage ED overcrowding

• March 2009 – instituted the use of an ED physician in triage with second triage nurse to expedite evaluations and work-ups during peak census (1pm-9pm)

• Reallocation of physician and nursing staff hours to accommodate expanded use of ED triage and Patient Care Annex (PCA)-previously Fast Track area

• Expanded ED triage from one to four rooms and Patient Care Annex from five to six treatment rooms

• Work-up of patients directly from waiting room and evaluation of higher acuity patients in PCA

Solutions Implemented

Num

ber o

f ED

Vis

itsED Volume

Confidential for Quality Improvement Purposes Only

2005

Q120

05Q2

2005

Q320

05Q4

2006

Q120

06Q2

2006

Q320

06Q4

2007

Q120

07Q2

2007

Q320

07Q4

2008

Q120

08Q2

2008

Q320

08Q4

2009

Q120

09Q2

2009

Q320

09Q4

2010

Q120

10Q2

2010

Q3

12000

12500

13000

13500

14000

14500

UCL = 14238.30

Mean = 12956.26

LCL = 11674.23

Bypa

ss H

ours

Confidential for Quality Improvement Purposes OnlyQuarter (FY)

2005

Q120

05Q2

2005

Q320

05Q4

2006

Q120

06Q2

2006

Q320

06Q4

2007

Q120

07Q2

2007

Q320

07Q4

2008

Q120

08Q2

2008

Q320

08Q4

2009

Q120

09Q2

2009

Q320

09Q4

2010

Q120

10Q2

2010

Q3

0

50

100

150

200

250

300

350

UCL = 242.62

Mean = 80.31

ED Bypass Hours per Quarter

Per

cent

age

of E

D p

atie

nts

LWBS

Confidential for Quality Improvement Purposes OnlyFY Quarter

2005

Q120

05Q2

2005

Q320

05Q4

2006

Q120

06Q2

2006

Q320

06Q4

2007

Q120

07Q2

2007

Q320

07Q4

2008

Q120

08Q2

2008

Q320

08Q4

2009

Q120

09Q2

2009

Q320

09Q4

2010

Q120

10Q2

2010

Q3

1

2

3

4

5

6

UCL = 6.62

Mean = 3.84

LCL = 1.07

Zero Bypass Instituted

Left Without Being Seen (LWBS)

Per

cent

age

LWBS

Emergency Department LWBS RateJune 2009 - Feb 2010

Confidential for Quality Improvement Purposes Only

6/28-7

/047/0

5-7/11

7/12-7

/187/1

9-7/25

7/26-8

/018/0

2-8/08

8/09-8

/158/1

6-8/22

8/23-8

/298/3

0-9/05

9/06-9

/129/1

3-9/19

9/20-9

/269/2

7-10/0

3

10/04

-10/10

10/11

-10/17

10/18

-10/24

10/25

-10/31

11/1-

11/07

11/8-

11/14

11/18

-11/21

11/22

-11/28

11/29

-12/05

12/06

-12/12

12/13

-12/19

12/20

-12/26

12/27

-1/02

1/03-1

/091/1

0-1/16

1/17-1

/231/2

4-1/30

1/31-2

/62/7

-2/13

2/14-2

/202/2

1-2/27

2/28-3

/63/7

-3/13

3/14-3

/203/2

1-3/27

0

1

2

3

4

5

6UCL = 6.24

Mean = 3.06

UCL = 3.55

LUMC Mean = 1.77

(since Nov 2009)

UHC Mean= 3.9%

Mean = 1.77

ED Volume and LWBS

0

20004000

6000

8000

1000012000

14000

16000

2005

Q120

05Q2

2005

Q320

05Q4

2006

Q120

06Q2

2006

Q320

06Q4

2007

Q120

07Q2

2007

Q320

07Q4

2008

Q120

08Q2

2008

Q320

08Q4

2009

Q120

09Q2

2009

Q320

09Q4

2010

Q120

10Q2

2010

Q3

ED V

olum

e

0

1

2

3

4

5

6

7

Perc

ent L

WB

S

Visits LWBS Percentage

Tim

e in

Min

utes

1/8/20

082/8

/2008

3/8/20

084/8

/2008

5/8/20

086/8

/2008

7/8/20

088/8

/2008

9/8/20

0810

/8/20

0811

/8/20

0812

/8/20

081/8

/2009

2/8/20

093/8

/2009

4/8/20

095/8

/2009

6/8/20

097/8

/2009

8/8/20

099/8

/2009

10/8/

2009

11/8/

2009

12/8/

2009

1/8/20

102/8

/2010

5

10

15

20UCL = 19.12

Mean = 11.04

LCL = 2.95

No Bypass 2/09

ED Time to Evaluate by Acuity Level 1(lowest level of care)

No Bypass 2/09

Tim

e in

Min

utes

1/8/20

082/8

/2008

3/8/20

084/8

/2008

5/8/20

086/8

/2008

7/8/20

088/8

/2008

9/8/20

0810

/8/20

0811

/8/20

0812

/8/20

081/8

/2009

2/8/20

093/8

/2009

4/8/20

095/8

/2009

6/8/20

097/8

/2009

8/8/20

099/8

/2009

10/8/

2009

11/8/

2009

12/8/

2009

1/8/20

102/8

/2010

10

12

14

16

18

20

UCL = 21.18

Mean = 15.54

LCL = 9.90

ED Time to Evaluate by Acuity Level 2 (Simple – lower level of care)

Tim

e in

Min

utes

1/8/20

082/8

/2008

3/8/20

084/8

/2008

5/8/20

086/8

/2008

7/8/20

088/8

/2008

9/8/20

0810

/8/20

0811

/8/20

0812

/8/20

081/8

/2009

2/8/20

093/8

/2009

4/8/20

095/8

/2009

6/8/20

097/8

/2009

8/8/20

099/8

/2009

10/8/

2009

11/8/

2009

12/8/

2009

1/8/20

102/8

/2010

16

18

20

22

24

26 UCL = 25.95

Mean = 20.42

LCL = 14.89

No Bypass 2/09

ED Time to Evaluate by Acuity Level 3 (Urgent)

Tim

e in

Min

utes

1/8/20

082/8

/2008

3/8/20

084/8

/2008

5/8/20

086/8

/2008

7/8/20

088/8

/2008

9/8/20

0810

/8/20

0811

/8/20

0812

/8/20

081/8

/2009

2/8/20

093/8

/2009

4/8/20

095/8

/2009

6/8/20

097/8

/2009

8/8/20

099/8

/2009

10/8/

2009

11/8/

2009

12/8/

2009

1/8/20

102/8

/2010

13

14

15

16

17

18

19

20

21

UCL = 20.37

Mean = 16.54

LCL = 12.71

No Bypass 2/09

ED Time to Evaluate by Acuity Level 4(Urgent-requiring higher level of care)

Tim

e in

Min

utes

1/8/20

082/8

/2008

3/8/20

084/8

/2008

5/8/20

086/8

/2008

7/8/20

088/8

/2008

9/8/20

0810

/8/20

0811

/8/20

0812

/8/20

081/8

/2009

2/8/20

093/8

/2009

4/8/20

095/8

/2009

6/8/20

097/8

/2009

8/8/20

099/8

/2009

10/8/

2009

11/8/

2009

12/8/

2009

1/8/20

102/8

/2010

8

10

12

14

16

18

20

22UCL = 21.52

Mean = 14.08

LCL = 6.63

No Bypass 2/09

ED Time to Evaluate by Acuity Level 5(Critical – highest level of care)

Analysis

• The ED has maintained ZERO Bypass since February 2009. In addition, despite an increase in ED volume, patients Left Without Being Seen (LWBS) has decreased below UHC average for academic medical centers.

• The time-to-evaluate for acuity levels 3-5 has shown a statistically significant decrease in minutes in the last several months.

Projected Gross Charges Resulting from Decreased LWBS Rate

• PROJECTED reduction of LWBS patients = 306 patients for FY10– FY09 = 1752 LWBS patients (actual)– FY10 = 1446 LWBS patients (projected based

on current trend and annualized rate of 3.96 pts/day)

• PROJECTED FY10 Gross Charges = $334,759*

* Based upon average charge per patient of $1093.98

Next Steps

• Continue to utilize the strategies implemented• Continue to monitor LWBS rate and identify and

implement solutions to further decrease rate• Work with Lean Team to optimize flow

Pediatric Assessment of Rapid Treatment Needs and the Emergency Response System

Department of PediatricsPediatric and Pediatric Critical Care

Kathleen Webster M.D.Jenny Wang MDDina Calamur MDCindi La Porte BSN, RN

TABLE 3

When your patient needs help, call on your

Pediatric Assessment of Rapid Treatment Needs and Emergency Response System

AIM STATEMENT•Reduce mortality of internal pediatric transfer patients below the overall pediatric ICU mortality rate of 1.7%.

GOAL•To provide multidisciplinary team assistance for an acutely ill or decompensating patient prior to an arrest state.

MAGNET• Force 7: Quality Improvement

http://www.childrenscentralcal.org/MagnetNursing/PublishingImages/Magnet-logo.gif

BACKGROUND Mortality Risk of Ward Patients

Transferred to ICU

• Michigan: Patients transferred from the ward to the ICU have a higher risk of mortality than pt admitted from the emergency room1

• Not statistically significant– Small numbers

• ? Target group for intervention

1Odetola PCCM 2008

Mor

talit

y of

Ped

iatri

c Pa

tient

s

Pediatr ic Mortality RateLoy ola University Health Sy stem

For quality improvement purposes only

W ard Tran sfersIC U P atien ts

20 03

20 05

20 07

2

3

4

5

6

7

Prior to “PARTNERS” implementation, patients admitted to ward or ICU prior to transfer to PICU experienced a mortality rate

as high as 7% exceeding the overall ICU mortality rate of 1.7%

Telemedicine Implemented

Target 1.7%


• Creation of PARTNERS: Pediatric Assessment of Rapid Treatment Needs and Emergency Response System

• Defined team members roles• Developed criteria for contacting rapid response team• In-service to all RN staff in PICU, IMC, and floor• In-service to respiratory therapists• In-service to intensivists• Weekly review of team calls and transfers • Feedback to staff regarding appropriateness of calls, missed

opportunities

Team Composition and Roles• Bedside Nurse

– Activates team– Keeps record

• Critical Care Nurse– Brings telemedicine cart– Initial assessment and

intervention– Updates family

• Respiratory Care Practitioner– Brings respiratory box– Provides airway/breathing

interventions• Intensivist

– Team leader– Updates primary team

PARTNERS: Phase 1 June 2008-December 2008

• Implemented June 2008– 12 evaluations

• Reason– Respiratory: 7– Neurological: 3– Cardiovascular: 2

• Change in management: 83%– Transferred to PICU: 75%– Intubation: 17%, NIV: 17%– Imaging: 8%– Urgent surgical intervention: 8%

PARTNERS: Phase 2 January-December 2009

• 6 change in management • Transferred to Peds ICU 9 • Stayed in Peds IMC 5• Transferred to Peds IMC 1

Mor

talit

y of

ped

iatri

c pa

tient

s

P ed ia tr ic M or ta lity RateLoy o la Un ive rsity Hea lth S y stem

Fo r q u a l i ty im p ro ve m e n t p u rp o s e s o n ly

W a rd T ran s fe rsIC U P a t ie n ts

20 03

20 04

20 05

20 06

20 07

20 08

20 09

0

1

2

3

4

5

6

7

Phase 2 of “PARTNERS” implementation outcomes: patients admitted to ward or ICU prior to transfer to PICU: a mortality rate of 0.0% which demonstrates a decrease below the overall ICU

mortality rate of 1.7% in 2009.

Telemedicine Implemented PARTNERS implemented

Target 1.7%

July2006June 2007

July2007June 2008

July 2008June 2009

July 2009March 2010

Percent of ward admits transferred to PICU

2.7 2.1 2.4 2.3

Actual mortality 2.4% 4.6% 0% 0%

Impact of Rapid Response TeamImpact of Rapid Response Team

In FY 09 there were no deaths of patients transferred from ward/IMC to PICU.

Predicted mortality (Pediatric Index of Mortality Score) for this time period is 9.1%

Validating our Conclusions

• Telemedicine facilitates intensivist led RRT.• Helps achieve goal of evaluation of high risk

patients quickly.• Increased evaluation of patients prior

to transfer. • Decrease in mortality rate for internal transfer

patients to 0%.

Next Steps• PARTNERS : Pediatric Rapid Response Team

will continue• Utilize the Epic document flow sheet to document when a

rapid response occurred• Develop a clarity report to monitor PARTNERS activity• Develop a tracking mechanism to monitor PARTNERS calls• Practice mock rapid responses and mock codes: identify

areas for improvement• Investigate outliers• Report to key stakeholders• Celebrate Successes

Reduction of Reduction of Calcium Bolus Infusions Calcium Bolus Infusions

in the Neonatal ICUin the Neonatal ICU

TABLE 4

Team MembershipTeam MembershipPamela Pamela NicoskiNicoski PharmDPharmDLawrence Bennett MD Lawrence Bennett MD

Barb Barb HeringHering RN RN Lisa Lisa FestleFestle RNRNMarc Weiss MDMarc Weiss MD

BackgroundBackground•• Identified inconsistent use of calcium Identified inconsistent use of calcium

bolus infusions to treat bolus infusions to treat hypocalcemia in neonatal patients.hypocalcemia in neonatal patients.

•• Inherent risks are associated with the Inherent risks are associated with the administration of intravenous administration of intravenous calcium (i.e. severe bradycardia, calcium (i.e. severe bradycardia, tissue necrosis).tissue necrosis).

Improve the utilization of calcium Improve the utilization of calcium bolus infusions in Neonatal ICU bolus infusions in Neonatal ICU patients by establishing and patients by establishing and adhering to guidelines for the adhering to guidelines for the treatment of hypocalcemia.treatment of hypocalcemia.

Project Aim StatementProject Aim Statement

Nursing Magnet ForcesNursing Magnet Forces

Forces 6: Quality of CareForces 6: Quality of CareForce 7: Quality ImprovementForce 7: Quality ImprovementForce 11: Nurses as Teachers Force 11: Nurses as Teachers Force 12: Image of NursingForce 12: Image of NursingForce 13: Interdisciplinary RelationshipsForce 13: Interdisciplinary Relationships

Phase 1Phase 1•• Evaluated 1 year data on IV calcium Evaluated 1 year data on IV calcium

orders. orders. –– June 2007June 2007––May 2008May 2008

•• Identified avoidable administration of Identified avoidable administration of calcium bolus infusions. calcium bolus infusions.

•• Created departmental guidelines for the Created departmental guidelines for the treatment of hypocalcemia:treatment of hypocalcemia:–– Increase calcium in continuous IV fluids / TPN Increase calcium in continuous IV fluids / TPN –– Calcium bolus infusions:Calcium bolus infusions:

•• Symptomatic (neuromuscular irritability, cardiac Symptomatic (neuromuscular irritability, cardiac effects) effects)

•• Asymptomatic (Ca: <0.85 Asymptomatic (Ca: <0.85 mmolmmol/L)/L)

•• Recommended laboratory values to Recommended laboratory values to help elucidate cause:help elucidate cause:–– Magnesium, Phosphorus, pHMagnesium, Phosphorus, pH

•• Determined how many calcium bolus Determined how many calcium bolus infusions may have been avoided with infusions may have been avoided with guidelines in place.guidelines in place.

•• NICU physicians and nurses inNICU physicians and nurses in-- serviced on new recommendations.serviced on new recommendations.–– Changes presented at Neonatal Division Changes presented at Neonatal Division

meeting, QA meeting and daily nursing meeting, QA meeting and daily nursing report. report.

–– ““NICU NewsflashNICU Newsflash”” ee--mailed to all NICU mailed to all NICU nurses.nurses.

–– Guidelines reinforced monthly during resident Guidelines reinforced monthly during resident neonatal TPN lecture.neonatal TPN lecture.

–– Guidelines added to LUMC Neonatal Guidelines added to LUMC Neonatal Resident Physician Manual .Resident Physician Manual .

Phase 2Phase 2

•• Reinforced that administration for Reinforced that administration for calcium bolus infusions should be calcium bolus infusions should be through a central line, if possible.through a central line, if possible.–– If no central line, nurses are instructed to verify If no central line, nurses are instructed to verify

with another nurse that the peripheral IV is with another nurse that the peripheral IV is patent. patent.

•• EPIC medication order pathway EPIC medication order pathway updated to include new updated to include new recommendations.recommendations.

* Given for low calcium.

*

Guidelines implemented

Number of Calcium Bolus Infusions*

ResultsResults

* Given for low calcium.

*

81% decrease

Number of Calcium Bolus Infusions*

One year Prior to Guideline Implementation

One year After Guideline Implementation

Calcium Bolus Infusions Given for Asymptomatic Hypocalcemia Relative to Ionized Calcium

<0.85 0.85 - 0.89 0.9 - 0.94 0.95 - 0.99 > 1

One year Prior to Guideline Implementation (n=170)

One year After Guideline Implementation (n=33)

11%

14%

25%27%

23%

53%

16%

13%

9%9%

AnalysisAnalysis•• Development of departmental Development of departmental

guidelines along with staff guidelines along with staff education improved judicious use of education improved judicious use of calcium bolus infusions in the calcium bolus infusions in the Neonatal ICU:Neonatal ICU:–– 81% reduction in the number of calcium 81% reduction in the number of calcium

bolus infusions given to patients in the bolus infusions given to patients in the NICU. NICU.

–– Avoided 137 calcium bolus infusions over a one Avoided 137 calcium bolus infusions over a one year period based on historical data.year period based on historical data.

–– Reduction of potential harm to our neonatal Reduction of potential harm to our neonatal patients (severe bradycardia, patients (severe bradycardia, extravasationextravasation risk).risk).

–– Cost savings to the Medical Center.Cost savings to the Medical Center.–– Room for improvement:Room for improvement:

•• Only 17/32 (53%) of calcium bolus infusions Only 17/32 (53%) of calcium bolus infusions administered for hypocalcemia (not documented as administered for hypocalcemia (not documented as symptomatic) met guideline criteriasymptomatic) met guideline criteria..

Next StepsNext Steps•• Increase compliance of current Increase compliance of current

guidelines, focusing on management guidelines, focusing on management of asymptomatic patientsof asymptomatic patients::–– Continue to reinforce guidelines to incoming Continue to reinforce guidelines to incoming

medical teams.medical teams.–– If calcium given for symptomatic If calcium given for symptomatic

hypocalcemia, reinforce need for comment hypocalcemia, reinforce need for comment in patient care note.in patient care note.

–– ReRe--evaluate in one year.evaluate in one year.

•• Positive results from these guidelines Positive results from these guidelines have prompted the goal of reviewing have prompted the goal of reviewing other electrolyte bolus infusions other electrolyte bolus infusions includingincluding::–– Potassium chloride Potassium chloride –– Sodium bicarbonateSodium bicarbonate

Team Membership

Oversight Team: Sharon Englert, Dr. John Gianopoulos, Mark Cerkvanik, Karen Pickney, Anne Porter, LuAnn Vis, Sandy Swanson, Barb Pudelek, Elaine Trulis, Maureen Davey

Multidisciplinary Change Team: Dr. Marc Weiss, Dr. Paula White, Pat Hester-Lund, Laurie Brennan, Carolanne Bartosiewicz, Linda Juretschke, Chris Besler, Julie Kramer, Rita Risatti, Dr. Ku-mie Kim, Dr. Renata Wilczek, Dr. John Gianopoulos, LuAnn Vis, Sandy Swanson, Barb Pudelek, Elaine Trulis, Maureen Davey

Teaming Up for Patient Safety: Implementation of a Team

Training Program

TABLE 5

Team STEPPS is an evidence-based team training system developed by the Department of Defense (DOD) in collaboration with the Agency for Healthcare Research and Quality (AHRQ)

Team training provides methods to empower all members of the healthcare team, creates a shared mental framework to organize communication, and provides a structured communication process

Background

• The purpose of Team Training is to reduce medical errors by teaching human-factors concepts to interdisciplinary teams of medical professionals

• This requires a culture change form a focus on individual performance to one that values team performance and encourages effective communication

• Team Training focuses on leadership, workload performance, situation monitoring, policy/regulations, mutual support, available resources, communication, and operating strategy

Aim

Improve patient safety and eliminate adverse events by implementing AHRQ Team STEPPS (Team Training) for the all team members in Labor & Delivery, Women’s Health and the NICU

• Developed a multidisciplinary change team

• September, 2009: Change team trained, planned for tool implantation for whole staff when training implemented

• Implemented Perinatal Briefs, unit huddles and NICU Evening Rounds from change team training

• Oct/Nov 2009: Introductory training completed for whole multidisciplinary team in 2 week burst of training (10-27-09 to 11-05-09)

• November 2009: Grand rounds with Team Training expert MD presented to broad Loyola Audience

• Change team evaluated training and planned next steps

• January 5, 2010: Change team implemented SBAR train- the trainer-education as second “dose” of team training


00.5

11.5

22.5

33.5

44.5

5

Mean Score

Key Principles Team Tools Apply Strategies

Measure

Team Training Evaluations (Range 0= Strongly disagree, 5=Strongly agree)

StaffMD

Evaluation Comments

•Identify change you plan to make:

•“Better handoffs and feedback”

•“Will use SBAR for communication/ use SBAR more frequently”

•“Daily multi-team meetings with NICU, L&D, and Women’s Health”

•“Be more assertive”

•“Implement debriefings and huddles”

•“This was better than I thought it would be!”

Percent of time Perinatal Briegs and NICU Evening Rounds are Occuring

0

20

40

60

80

100

120

Sept Oct Nov Dec Jan Feb

Perinatal Briefs NICU Evening Rounds

Adverse Outcome Indicator and Weighted AO Score

0

0.5

1

1.5

2

2.5

3

3.5

4

Q1, 2008 Q2, 2008 Q3, 2008 Q4, 2008 Q1, 2009 Q2, 2009

AOI/W

AO

S

Adverse Outcome Index Weighted AO score

Low risk OB to Gottlieb

Adverse Outcome Index (AOI): the # of deliveries with 1 or more of the perinatal adverse events as a proportion of total deliveries

Weighted AO Score (WAOS): the total weights of all the adverse events divided by the total number of deliveries

From the National Perinatal Information Center/Quality Analytic Services (NPIC/QAS) www.npic.org

These scores represent the Loyola experience pre-implementation of Team Training. One measure we will follow is whether these scores increase or decrease.

http://www.npic.org/

Perinatal Adverse Outcomes

•Maternal death

•Intrapartum and Neonatal Death

•Uterine Rupture

•Maternal Admission to ICU

•Birth Trauma

•Return to OR/L&D

•Admission to NICU

•APGAR 5 <7

•Blood Transfusions

•3rd and 4th degree perineal laceration

Analysis– Staff driven strategies- Briefs, huddles,

evening rounds- were implemented and continue to occur regularly

– The Change Team is actively engaged in determining next steps

– SBAR training was developed and implemented by Change Team as a second training initiative

– Consultant scheduled to return to coach Change Team and complete education for those on LOA during previous training sessions

Next Steps• Change Team to receive additional coaching education• Change Team to review “Magic Wand list” and prioritize plans for

future activities• Completion of team training for those who were unable to

participate• Regular new inservices related to AHRQ Team Training tools

implemented• AOI measures reviewed• Team behavior observation by external consultant during visit to

assess implementation progress

• Long term – observe incidents of significant adverse outcomes and dollars spent in malpractice settlements

Keep it in Neutral … Let’s Get Off to a Good Head Start

Preventing IVH in the Very Low Birth Weight Infant

The Outstanding NICU Nursing StaffLisa Festle, MSN, RNC-NIC, APRN/CNS & Barb Hering, MSN, RNC-NIC, APRN/CNS

NICU Education, Co-chairsMarianne Chybik, MSN, RNC-NIC, APN/CNS, NICU Case Manager

Elaine Trulis, BSN, NE-BC, Nurse ManagerMarc Weiss, MD, Director of Neonatology

TABLE 6

BackgroundCurrent rates of Intraventricular Hemorrhage (IVH)

range between 10 –

15%; for the very low birth weight (VLBW) infant, this risk is highest during the

first week of life.

The severity of IVH is classified Grade 1 – 4

Grades 3 & 4 are the most severe and associated with poor long term outcomes

Magnet Forces 5,6,7,8,9

Background

The negative impact of IVH on long term outcomes includes:

Impaired cognitive skills/learning disabilities

motor deficits, including fine or gross motor delay and cerebral palsy

sensory impairment, including hearing or vision loss

behavioral and psychological problems

Current evidence suggests that maintaining the head and body in neutral alignment may

prevent functional obstruction of cerebral venous drainage

prevent elevation of central venous pressure...and thus IVH

Aim Statement

1. Reduce the incidence of severe IVH in VLBW infants at LUMC to less than the national average (9.4%) as benchmarked against the Vermont Oxford Network (VON)

*VON - international collaborative group of NICU’s who report quality data

2. All infants < 32 weeks gestational age will be maintained in a neutral head position for the first week of life


For all infants <32 weeks gestational age during the first week of life:Only supine or side-lying positioning with the

head midline in a neutral position; when turning, do so slowly and make sure that the head and body are turned as a unitNo prone positioningElevate Head of Bed 30°No routine suctioningMinimal handlingMaintain normal body temperature

Results – All NICU PatientsIncidence of severe IVH (grades 3 & 4)

decreased from ~28% to ~17% in the NICU (VON benchmark)

Severe IVH (Grades 3 & 4)

2006 2007 2008 2009

VON 9.7% 9.3% 9.3% 9.3%

Loyola NICU

28% 25.7% 16.2% 17%

* LUMC is less than the national average for Grades 1 & 2 IVH

Results Inborn Infants with Severe IVH

* LUMC is less than the national average for Grade 1 & 2 IVH

25.0%23.9%

14.3%

16.5%

8.1% 8.0% 7.8% 7.8%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

2006 2007 2008 2009Year

Seve

re IV

H ra

tes

LUMCVON

Neutral Head Positioning initated

4/08

Analysis

Decreased incidence of severe IVH by almost 50% since instituting neutral midline head positioning

Potentially better long term developmental outcomes for VLBW infants in the NICU

Next Steps• Incorporating IVH prevention guidelines as part of a

multidisciplinary VLBW protocol• Develop a standard admission order set in EPIC

integrating best practices for care of the VLBW infant on admission and during the first weeks of life as these infants transition to extra-uterine life

• Focus on “the Golden Hour”…the first hour of life:consistent care beginning in the delivery room through admission to the NICU

• Neutral midline positioning• Hypothermia prevention• Minimal handling

• Incorporate guidelines into inter hospital transports and provide education to network hospitals

References• Bada H, et al. Frequent handling in the neonatal intensive care unit

and intraventricular hemorrhage. J of Pediatrics, July 1990; 117 (1): 126-131.

• Carteaux P, et al. Evaluation and development of potentially better practices for the prevention of brain hemorrhage and ischemia in the very low birth weight infants. Pediatrics, April 2003, 111 (4): e489- 496.

• Cowan F. Thoresen M. Changes in superior sagittal sinus blood velocities due to postural alterations and pressure on the head of the newborn infant. Pediatrics, 75 (6): 1038-1047.

• Emery J. Peabody J. Head position affects intracranial pressure in newborn infants. J of Pediatrics., 1983, 103 (6): 950-953.

• Kenner C. McFrath J. Developmental care of newborns and infants guide for health professionals. St. Louis: Elsevier; 2004: 309-311.

• McLendon D et al. Implementation of potentially better practices for the prevention of brain hemorrhage and ischemic brain injury in very low birth weight infants. Pediatrics, April 2003; 111 (4): e497-503.

PNEUMONIATeam Membership:

Mary Altier, MS, RNRose Lach, Administrative Director

Clinical Departments: Emergency Medical Services, General Medicine, Cardiac Services

Hospital Departments: 6 Northeast, 3NESW, 2 NE, Emergency Department, Medical Records, Quality & Resource Management, Center for Clinical Effectiveness

Confidential: For Quality Improvement Purposes Only

Force 6:Quality of CareForce 7: Quality ImprovementForce 9: Autonomy

TABLE 7

Room for Improvement

To increase the rates for those quality measures specific to the Pneumonia Core measure:

•

Antibiotic timing•

Appropriate Antibiotic Administered

•

Adult Smoking Cessation Counseling•

Blood Culture Collection

•

Pneumococcal Vaccination: > 65 years of age•

Influenza Vaccination: > 50 years of age


Goals

•

Initial antibiotics administered within 6 hours of arrival at hospital

•

Appropriate antibiotic administered

•

Blood cultures collected prior to initial antibiotic dose

•

Pneumococcal Vaccine administered to patients > 65 years old prior to discharge

•

Influenza Vaccine administered to patients > 50 years old prior to discharge

•

Smoking Cessation Counseling completed prior to discharge


Plan

•

System-wide influenza campaign Oct-Feb with posters placed in general population and all in-patient rooms.

•

Pneumovax/ Influenza in-services to inpatient units.

•

SAC and 5Tower now completing Pneumonia/Influenza screens.

•

Monthly ED “dashboard” reports with

timing/outliers provided.•

Provide performance data to Senior Management, Leapfrog Committee, Pneumonia Task Force &all nursing units.

•

EPIC pneumonia & influenza vaccine screening on patient data base. If screen positive, vaccination orders placed by nurse.


Next Steps•

Continue to provide in-services for inpatient units to increase compliance of Pneumococcal and Influenza vaccination screening and administration

•

Continue to monitor effectiveness of vaccination screening on admission data base.

•

Continue individual nurse specific reports for vaccine screening and administration on a bi-weekly basis.

•

Identify physician champion.


HEART FAILURE

TEAM MEMBERSHIPDEPARTMENTS OF CARDIOLOGY, CARDIOVASCULAR SURGERY, MEDICINE, NURSING, QUALITY AND RESOURCE MANAGEMENT,

THE CENTER FOR CLINICAL EFFECTIVENESS, MEDICAL RECORDS, INFORMATION TECHNOLOGIES/EPIC

PROJECT COORDINATORCARMEN BARC, RN TABLE 8

AIM STATEMENT

Improve the quality of care for heart failure patients by providing evidence- based treatment as outlined in the Heart Failure Core Measures 100% of the time

Heart failure accounts for more hospital admissions than any other Medicare diagnosis. Research shows that the following care processes decrease morbidity and mortality rates for heart failure patients*:

Left ventricular systolic function (LVSF) assessment

Angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) prescribed for left ventricular systolic dysfunction (LVSD). Ejection fraction (EF) <40% or description of moderate/severe dysfunction.

Written discharge instructions regarding activity, diet, follow-up, medications, what to do if heart failure symptoms worsen, and weight monitoring

Smoking cessation counseling for patients who have smoked within the last twelve months

*Heart Failure Society of America. HFSA 2006 Comprehensive Heart Failure Practice Guideline

FORCES OF MAGNETISM

Force 6: Quality of CareForce 7: Quality ImprovementForce 9: AutonomyForce 11: Nurses as TeachersForce 13: Interdisciplinary

Relationships

2009 INTERVENTIONSUpdated the EPIC discharge navigator to include the new discharge instructions requirement for what to do if heart failure symptoms worsen

Revised the discharge appointment element to be required and prechecked in the EPIC Medicine and CV discharge order sets

Smoking cessation counseling removed from the discharge order set and incorporated into the EPIC discharge instructions report.

Nursing developed “smart text” for documentation of heart failure patient education

Provided practitioner specific feedback

Heart failure patient lists made available on the portal

Inservices to nursing units and internal medicine residents

NEXT STEPSRemove discharge instructions regarding weight monitoring and what to do if symptoms worsen from the discharge order set and incorporate them into the EPIC discharge instruction report.

Standardize nursing “smart text” for documentation of heart failure patient education

Provide midyear follow-up to internal medicine residents as a group

Add patient diagnosis to physician feedback reports

Ongoing nursing and physician education

Hospital Outpatient Quality Data Reporting Program

(HOP QDRP)

Team Members:Anesthesia

Same Day SurgeryMain Operating Room

Labor & DeliveryNursing Education

Electrophysiology

LabUrology Outpatient DepartmentCenter for Clinical Effectiveness

National Hospital Quality Measures

TABLE 9

FORCES OF MAGNETISM

Force 6: Quality of Care

Force 7: Quality Improvement

Force 8: Consultation and Resources

Force 11: Nurses as Teachers

Force 13: Interdisciplinary Relationships

AIM STATEMENT

Surgical site infections (SSI) are one of the most common causes

of postoperative morbidity and mortality in surgical patients.1

The HOP QDRP is modeled after the established Surgical Care Improvement Project that focuses on surgical in-patients. This project’s guiding principles aimed at preventing surgical site infections are timely administration of

prophylactic antibiotics within one hour of incision and the proper use of recommended prophylactic antibiotics.

Nguyen, N., Yegiyants, S., Kaloostian, C., et al. The surgical care improvement project (SCIP) initiative to reduce infection in elective colorectal surgery: which performance measures affect outcome? The American Surgeon 2008; 74:1012-1016.

QUALITY MEASURES

Timing of Antibiotic ProphylaxisAntibiotic administration within one hour prior to surgical incision

Selection of Prophylactic AntibioticOver 200 Procedure Codes Types of Surgeries:

Cardiac: Pacemaker revisions, battery change-outsVascular: graftsGenitourinary: Transrectal prostate biopsyGastric biliary: peg placements, laparoscopic appendectomy Gynecology: Vaginal hysterectomy, synthetic pubovaginal slingHead and Neck: Treatment of jaw fractures

2009 INTERVENTIONS

Partnered with Nursing Education to abstract charts

Educated nurse abstractors on project specifications and data abstraction

Provided inservices

to Outpatient Urology, Same Day Surgery and EP Lab regarding the project and identification of opportunities for improvement

Placement of EPIC smart text in the outpatient urology nursing note to document antibiotics taken the morning of procedures

Definition: Correct antibiotic selection for procedure Data Source: Data abstracted from LUMC charts by RNs

Analysis: Significant improvement realized after implementation

of smart text in urology nursing note documenting antibiotics taken morning of procedure.

Definition: Documentation that an antibiotic was initiated within 60 minutes (120 minutes for Vancomycin

or Quinolones) prior to surgical incision/procedure start timeData Source: Data abstracted from LUMC charts by RNs

Analysis: Performance remains consistent at 84%. Improvement anticipated with planned 2010 interventions

NEXT STEPS

Creation of physician-specific reports

Follow-up with departments and physicians regarding outliers, opportunities for improvement and celebrate successes

Report to key stakeholders

Re-education of data abstractors to changing specifications

Team meetings to review results

Making Surgery Safer:Making Surgery Safer: Surgical Infection Prevention

Team Members:Dr. W. Jellish, Dr. P. O’Keefe, Dr. J. Parada, M. Altier, C. Barc, J. Bredemeyer, M. Fitzgerald, M. Kawka, J. Keane, D. Marra, C. Schriever, D. Serwa, S. Swanson, A. Tomich, L. Vis, M. Wall:Magnet Forces: 6 - Quality of Care7 - Quality Improvement13 - Interdisciplinary Relationships


TABLE 10

Aim StatementAim StatementThe Surgical Care Improvement Project (SCIP) is a national quality partnership of organizations interested in improving surgical care by significantly reducing surgical complications, specifically surgical site infection, venous thrombo-embolism, and acute myocardial infarction. Loyola’s performance for these measures is publicly reported at:– CMS: www.hospitalcompare.hhs.gov– JOINT COMMISION: www.qualitycheck.org– IDPH: www.healthcarereportcard.illinois.gov


Project GoalsProject GoalsTO ACHIEVE TOP DECILE PERFORMANCE NATIONALLY FOR THE FOLLOWING

MEASURES:

• SSI Measures:• Antibiotic within 60 minutes of surgical incision• Appropriate antibiotic selection• Discontinuation of antibiotics within 24 hours after surgery• Post-operative Glucose control for cardiac surgery patients• Appropriate hair removal• (new) Postoperative temperature control for all surgeries lasting greater than 60 minutes• (new) Removal of urinary catheter by the end of post-op Day 2

• VTE Measures: • VTE prophylaxis ordered• VTE prophylaxis received

• AMI Measures:• Perioperative beta-blocker administration

•Confidential: For Quality Improvement Purposes Only

Solutions Implemented in 2009Solutions Implemented in 20092009 Overall Improvement Activities Included:

1. Comprehensive review/analysis of all outliers

2. Physician-specific reports sent to MD’S

3. Evaluated impact of 2 new measures

4. Antibiotic selection• MRSA screen results added to Anesthesia Record

5. Beta-Blocker Documentation• Prompt added to Pre-Op Checklist• “Last Taken” prompt added with New Epic Medication Reconciliation Tools• Staff Education• Created SAC Manager Portal Report to track compliance

6. SSI is now a National Patient Safety Goal• E-learning module created for staff• Infection Control Practitioner’s monitor post-op SSI rates



Definition: Surgical patients receiving 100% of indicated antibiotic prophylaxis, glucose control, hair removal, temperature control, beta-blocker continuation, and venous thromboembolism therapy / Patients undergoing CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery.Data source: LUMC medical records abstracted by RNs. Analysis: Recent results are consistent with eighty-four percent of selected surgical patients are receiving all indicated care to prevent surgical infections. This performance has recently decreased due to performance on the perioperative beta-blocker medication measure. Education regarding documentation has been provided to improve this performance.

Per

cent

Core MeasuresSurgical Care Improvement Project Composite Performance

Month (number of patients)

UCL = 99.7

Mean = 83.5

LCL = 67.4

Apr 2

008 (

n=54

)May

2008

(n=5

0)Ju

n 200

8 (n=

51)

Jul 2

008 (

n=50

)Au

g 20

08 (n

=54)

Sep

2008

(n=4

8)Oct

2008

(n=5

1)Nov

2008

(n=5

1)Dec

2008

(n=4

5)Ja

n 200

9 (n=

52)

Feb 2

009

(n=48

)Mar

2009

(n=4

8)Ap

r 200

9 (n=

45)

May 20

09 (n

=51)

Jun 2

009 (

n=47

)Ju

l 200

9 (n=

51)

Aug

2009

(n=5

1)Se

p 20

09 (n

=45)

Oct 20

09 (n

=51)

Nov 20

09 (n

=49)

Dec 20

09 (n

=51)

Jan 2

010 (

n=46

)Fe

b 201

0 (n=

5)

0

20

40

60

80

100

120


Definition: Surgical patients who received prophylactic antibiotics within 60 minutes prior to surgical incision / Patients undergoing CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery. Vancomycin and fluoroquinolonestimeframe is extended to 120 minutes prior to incision.Data source: LUMC medical records abstracted by RNs. Analysis: Ninety-seven percent of LUMC patients receive prophylactic antibiotics within the recommended timeframe prior to surgical incision. August 2009 shows an significant change (more) outlier cases have been actively review by clinicians.

Per

cent

Surgical patients receiving prophylactic antibioticswithin one hour prior to surgical incision


UCL = 106.5

Mean = 96.9

LCL = 87.2

Apr 2

008 (

n=29

)May

2008

(n=2

5)Ju

n 200

8 (n=

32)

Jul 2

008 (

n=25

)Au

g 20

08 (n

=33)

Sep

2008

(n=3

4)Oct

2008

(n=3

3)Nov

2008

(n=2

9)Dec

2008

(n=2

5)Ja

n 200

9 (n=

34)

Feb 2

009

(n=35

)Mar

2009

(n=2

9)Ap

r 200

9 (n=

29)

May 20

09 (n

=30)

Jun 2

009 (

n=33

)Ju

l 200

9 (n=

28)

Aug

2009

(n=3

0)Se

p 20

09 (n

=28)

Oct 20

09 (n

=27)

Nov 20

09 (n

=34)

Dec 20

09 (n

=35)

Jan 2

010 (

n=32

)Fe

b 201

0 (n=

3)

0

20

40

60

80

100

120


Definition: Surgical patients receiving prophylactic antibiotics consistent with current guidelines / Patients undergoing CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery.

Data source: LUMC medical records abstracted by RNs.

Analysis: Ninety-seven percent of LUMC patients receive prophylactic antibiotics consistent with current guidelines.

Per

cent

Surgical patients receiving prophylactic antibioticsconsistent with current guidelines


UCL = 106.3

Mean = 97.2

LCL = 88.2

Apr 2

008 (

n=30

)May

2008

(n=2

5)Ju

n 200

8 (n=

32)

Jul 2

008 (

n=28

)Au

g 20

08 (n

=35)

Sep

2008

(n=3

4)Oct

2008

(n=3

2)Nov

2008

(n=2

8)Dec

2008

(n=2

4)Ja

n 200

9 (n=

32)

Feb 2

009

(n=33

)Mar

2009

(n=2

8)Ap

r 200

9 (n=

28)

May 20

09 (n

=27)

Jun 2

009 (

n=33

)Ju

l 200

9 (n=

28)

Aug

2009

(n=2

8)Se

p 20

09 (n

=27)

Oct 20

09 (n

=25)

Nov 20

09 (n

=33)

Dec 20

09 (n

=35)

Jan 2

010 (

n=32

)Fe

b 201

0 (n=

3)

0

20

40

60

80

100

120


Definition: Surgical patients with prophylactic antibiotics discontinued within twenty-four hours after surgery end time / Patients undergoing hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery. CABG and other cardiac surgeries are allowed 48 hours.


Analysis: Performance is consistently above 90%.

Per

cent

Surgical patients with prophylactic antibioticsdiscontinued within the recommended timeframe


UCL = 106.6

Mean = 96.9

LCL = 87.2

Apr 2

008 (

n=29

)May

2008

(n=2

4)Ju

n 200

8 (n=

32)

Jul 2

008 (

n=25

)Au

g 20

08 (n

=33)

Sep

2008

(n=3

4)Oct

2008

(n=3

2)Nov

2008

(n=2

8)Dec

2008

(n=2

4)Ja

n 200

9 (n=

32)

Feb 2

009

(n=33

)Mar

2009

(n=2

8)Ap

r 200

9 (n=

28)

May 20

09 (n

=27)

Jun 2

009 (

n=33

)Ju

l 200

9 (n=

28)

Aug

2009

(n=2

8)Se

p 20

09 (n

=27)

Oct 20

09 (n

=25)

Nov 20

09 (n

=33)

Dec 20

09 (n

=35)

Jan 2

010 (

n=32

)Fe

b 201

0 (n=

3)

0

20

40

60

80

100

120


Per

cent

of C

ardi

ac S

urge

ry P

atie

nts

with

Con

trol

led

Pos

tope

rativ

e G

luco

se Controlled Postoperative Serum Glucose - Cardiac Surgery Patients


UCL = 116.0

Mean = 93.5

LCL = 71.1

Apr 2

008

(n=1

2)M

ay 20

08 (n

=11)

Jun

2008

(n=1

3)Ju

l 200

8 (n

=11)

Aug 2

008

(n=1

1)Se

p 200

8 (n

=12)

Oct 20

08 (n

=12)

Nov 2

008

(n=1

0)Dec

200

8 (n

=12)

Jan

2009

(n=1

3)Fe

b 20

09 (n

=11)

Mar

2009

(n=1

0)Ap

r 200

9 (n

=9)

May

2009

(n=1

3)Ju

n 20

09 (n

=12)

Jul 2

009

(n=1

1)Au

g 200

9 (n

=11)

Sep 2

009

(n=1

1)Oct

2009

(n=9

)Nov

200

9 (n

=11)

Dec 2

009

(n=1

2)Ja

n 20

10 (n

=10)

Feb

2010

(n=1

)

0

20

40

60

80

100

120

140

160

Definition: Percent of cardiac surgery patients with controlled 6AM post-operative glucose. Control is defined as serum glucose reading of 200mg/dL or less on both post-operative day 1 and day 2. Results show cardiac surgery patients with the presence of post-operative day 1 and day 2 glucose measurements, readings closest to 6AM were selected for inclusion.

Data Source: LUMC medical records abstracted by RNs.

Analysis: 6AM postoperative glucose control on both postoperative days 1 and 2 has been consistent at 94%. All outlier cases are shared with clinicians.


Per

cent

of S

urge

ry P

atie

nts

with

App

ropr

iate

Hai

r R

emov

al

Surgical Patients with Appropriate Hair Removal - (Not Razors)


UCL = 102.3Mean = 99.6LCL = 97.0

Apr 2

008

(n=5

4)M

ay 20

08 (n

=50)

Jun

2008

(n=5

1)Ju

l 200

8 (n

=50)

Aug 2

008

(n=5

4)Se

p 200

8 (n

=48)

Oct 20

08 (n

=51)

Nov 2

008

(n=5

1)Dec

200

8 (n

=45)

Jan

2009

(n=5

2)Fe

b 20

09 (n

=48)

Mar

2009

(n=4

8)Ap

r 200

9 (n

=45)

May

2009

(n=5

1)Ju

n 20

09 (n

=47)

Jul 2

009

(n=5

1)Au

g 200

9 (n

=51)

Sep 2

009

(n=4

5)Oct

2009

(n=4

4)Nov

200

9 (n

=48)

Dec 2

009

(n=4

6)Ja

n 20

10 (n

=43)

Feb

2010

(n=5

)

0

20

40

60

80

100

Definition: Number of Surgical cases abstracted without the use of razors for hair removal / Number of Surgical Cases Sampled. Appropriate hair removal includes: use of clippers, use of depilatory, or no hair removal.


Analysis: Performance is consistently near 100%.


Per

cent

of S

urge

ry P

atie

nts

with

Per

iope

rativ

e Tem

pera

ture

Man

agem

ent Surgery Patients with Perioperative Temperature Management


Oct

200

9 (n

=38)

Nov 2

009

(n=33

)

Dec 2

009

(n=38

)

Jan

2010

(n=3

6)

Feb 2

010

(n=4

)

0

20

40

60

80

100

Definition: The percent of patients who had either active warming applied intraoperatively, or who had at least one body temperature equal to or greater than 36 degrees Celsius (recorded within 30 before or 15 minutes after anesthesia end time).


Analysis: This is a new measure. Performance has been in the high 90%’s.


Per

cent

of S

urge

ry P

atie

nts

with

VTE

Pro

phyl

axis

Ord

ered

Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered


UCL = 109.4

Mean = 96.8

LCL = 84.2

Apr 2

008

(n=3

3)M

ay 20

08 (n

=30)

Jun

2008

(n=3

0)Ju

l 200

8 (n

=29)

Aug 2

008

(n=3

2)Se

p 200

8 (n

=28)

Oct 20

08 (n

=16)

Nov 2

008

(n=1

3)Dec

200

8 (n

=12)

Jan

2009

(n=1

3)Fe

b 20

09 (n

=15)

Mar

2009

(n=1

5)Ap

r 200

9 (n

=14)

May

2009

(n=1

7)Ju

n 20

09 (n

=14)

Jul 2

009

(n=1

4)Au

g 200

9 (n

=14)

Sep 2

009

(n=1

4)Oct

2009

(n=1

3)Nov

200

9 (n

=14)

Dec 2

009

(n=1

3)Ja

n 20

10 (n

=10)

Feb

2010

(n=2

)

60

70

80

90

100

110

120

130

Definition: Number of surgery cases in which orders were placed for appropriate measure to prevent venous thromboembolism(VTE; blood clots in legs or lungs) / Patient undergoing intracranial neurosurgery, elective spinal surgery, general surgery, gynecologic surgery, urologic surgery, elective total hip or knee replacement, or hip fracture surgery.


Analysis: The rate of ordering recommended measures to prevent VTE averages 97%. Feedback has been provided to physicians on an ongoing basis.


Per

cent

of S

urge

ry P

atie

nts

with

VT

E P

roph

ylax

is R

ecei

ved

Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Received


UCL = 111.0

Mean = 94.0

LCL = 77.1

Apr 2

008

(n=33

)May

2008

(n=3

0)Ju

n 20

08 (n

=30)

Jul 2

008

(n=29

)Au

g 20

08 (n

=32)

Sep

2008

(n=2

8)Oct

2008

(n=1

6)Nov

200

8 (n=

13)

Dec 2

008

(n=10

)Ja

n 20

09 (n

=13)

Feb

2009

(n=1

5)M

ar 20

09 (n

=15)

Apr 2

009

(n=14

)May

2009

(n=1

7)Ju

n 20

09 (n

=14)

Jul 2

009

(n=14

)Au

g 20

09 (n

=14)

Sep

2009

(n=1

4)Oct

2009

(n=1

3)Nov

200

9 (n=

14)

Dec 2

009

(n=13

)Ja

n 20

10 (n

=10)

Feb

2010

(n=2

)

40

60

80

100

120

140

Definition: Number of surgery cases receiving recommended measures to prevent venous thromboembolism (VTE) / Patient undergoing intracranial neurosurgery, elective spinal surgery, general surgery, gynecologic surgery, urologic surgery, elective total hip or knee replacement, or hip fracture surgery.


Analysis: The rate of administering recommended VTE preventive measures (prophylaxis) is consistent at 95%.


Per

cent

of S

urge

ry P

atie

nts

Con

tinui

ng B

eta-

Blo

cker

s P

erio

pera

tivel

y

Continuing Beta-Blockers Perioperatively to Prevent Myocardial Infarction


UCL = 109.4

Mean = 84.9

LCL = 60.5

Apr 2

008

(n=2

5)M

ay 20

08 (n

=22)

Jun

2008

(n=2

0)Ju

l 200

8 (n

=18)

Aug

2008

(n=2

5)Se

p 20

08 (n

=22)

Oct 20

08 (n

=16)

Nov 2

008

(n=1

4)Dec

200

8 (n

=19)

Jan

2009

(n=2

7)Fe

b 20

09 (n

=22)

Mar

200

9 (n=

18)

Apr 2

009

(n=2

3)M

ay 20

09 (n

=13)

Jun

2009

(n=1

5)Ju

l 200

9 (n

=19)

Aug

2009

(n=1

9)Se

p 20

09 (n

=22)

Oct 20

09 (n

=15)

Nov 2

009

(n=2

7)Dec

200

9 (n

=21)

Jan

2010

(n=2

0)Fe

b 20

10 (n

=2)

20

40

60

80

100

120

140

160

Definition: Number of surgery cases receiving beta-blocker (medication to slow heart rate) during the peri-operative period / Patient undergoing major surgery who received beta-blocker therapy prior to admission. This treatment is designed to reduce the risk of myocardial infarction (heart attack) following surgery.


Analysis: LUMC performance decreased significantly due to lack of documentation of pre-operative beta-blocker dose information (time taken). Education has been provided regarding complete documentation of medications taken before admission and improvement have begun in July 2009.


Per

cent

of S

urge

ry P

atie

nts

with

Cat

hete

rs R

emov

ed P

OD

1 or

PO

D2

Urinary Catheter Removed on POD1 or POD2


Oct

200

9 (n

=25)

Nov 2

009

(n=23

)

Dec 2

009

(n=24

)

Jan

2010

(n=2

5)

Feb 2

010

(n=3

)

0

20

40

60

80

100

Definition: Number of surgery cases where the urinary catheter is removed by the end of post-operative day 2 out of all eligible patients. Patients are excluded from this measure automatically if they are in the ICU with diuretics, or if the procedure was urological, gynecological or perineal .


Analysis: This is a new measure. Performance is recently in the high 90%’s.

Next StepsNext Steps

• Outlier review and analysis• Identify improvement opportunities for

the two new measures based on initial results

• Foley removal• Peri-Op Temperature

• Implement staff, physician, and patient education on SSI reduction


Departments: Pediatrics, Pediatric Critical Care,Medical Center Information Systems and

Center for Clinical Effectiveness

Lindy Champa, BSN, RNKathleen Webster, MD Matthew Leischner, MDMichael Wall, PharmD, MBAConnie Giere, BSN, RNSandra Swanson, BSN, RN, MSOD Jacqulene Camerino, BSN, RN Cindi La Porte, BSN RN

Confidential: For quality improvement purposes only.

ChildrenChildren’’s Asthma Care s Asthma Care Core MeasureCore Measure

TABLE 11

Project AimsTo provide quality and effective care to children with asthmaTo provide education for all pediatric patients and their families with the primary diagnosis of asthmaTo utilize evidence based medicineTo meet the Joint Commission Association Core Measure for Children’s Asthma with 100% compliance

.

Children’s Asthma Care Core Measure


The Joint Commission launched project activities to examine Children’s Asthma performance measures for

inclusion in theORYX® performance measurement initiative. This work was conducted in collaboration with national children’s health care organizations, particularly, the National Association of Children’s Hospitals and Related Institutions (NACHRI), Child

Health Corporation of America (CHCA), and Medical Management Planning, Inc. (MMP)

Magnet Forces of MagnetismForce 7: Quality Improvement


Children’s Asthma Care Core Measure• JCA introduced three measures for implementation effective April 1, 2007:

CAC - 1 Use of Relievers for Inpatient Asthma CAC - 2 Use of Systemic Corticosteroids for Inpatient Asthma CAC - 3 Home Management Plan of Care Given to Patient/Caregiver

• Data collection for the measure set began with April 2007 discharges. CAC-3 was implemented as a test measure pending National Quality Forum (NQF) endorsement. Although included on the hospital’s ORYX Performance Measure Report, data analysis for CAC-3 was not used in the accreditation process or publicly reported on Quality Check.

• The CAC-3 measure has now been endorsed by the NQF and was implemented as a production measure effective with July 1, 2008 discharges. (JCA)


• Percent of pediatric inpatients who: – are given Reliever Medication – are given Systemic Corticosteroids– receive a Home Management Plan of Care that is a separate

document and includes identification of asthma triggers and use of rescue, controller and reliever medication


What are we measuring

• A Pediatric Asthma education board was placed in residents work area in May that showed:• How to find a “Pediatric” Asthma Action Plan• Identified the 3 components of the pediatric asthma care core measure that should be included.• Also included the 6 components for the Pediatric Asthma Home Management Plan of Care• Incoming residents would have this board to refer too for each months rotation.• Identified in Epic that the Asthma Action Plan (adult) comes up before the

Pediatric AAP in the EPIC listing.• This led to a concern that the Adult Asthma Action Plan came under the listing Asthma Action

Plan so the Peds Core Measurement team asked if the Pediatric Asthma Action Plan could come before the Asthma Action Plan and Indicate it as:

• Asthma Action Plan (Pediatric) then Asthma Action Plan ( Adult) respectively• Confidential: For quality improvement purposes only.

Children’s Asthma Care Core Measure Changes that we made:

• Now the residents will have first access to the Pediatric Asthma Action Plan in EPIC

• Also upon reviewing the data the Asthma Action Plan Adult did not have a page break so the Peds Core Measure team asked Connie Giere’s team to do the same for the adult asthma action plan with a page break. 12/2/09

• Lindy spoke with the Chief Resident Rajiv Kumar about next steps with education and the resident impact on the Pediatric Asthma Action Plan.

• After data collected and the discharge MD’s (residents) were noted Not to have a asthma action plan pediatric they were sent a letter with copies to Dr. Leischner, Dr. Kumar and Dr. Webster to share the importance of selection of the AAP Pediatric for their patients.

Audited records of discharge MD, RN and attending for those without AAP.

• All RN staff educated not to discharge Asthmatic patients or Reactive Airway patients without a AAP-Pediatric

• Confidential: For quality improvement purposes only.

Children’s Asthma Care Core Measure Changes that we made:

• We continue to see 100% compliance with the use of relievers and the use of corticosteroids during hospitalization.

• 100% of those patients received Relievers and Systemic Corticosteroids during their hospitalization.

• Number of cases that met all 6 requirements: 59/80= 74% compliance • (pediatric and adult AAPs)• The monthly breakdown below that • October: 15/25= 60%• November: 17/19=89%• December: 12/16=75%• January: 5/9 = 56%• February: 10/11= 90%• Number of cases that were not separate: • Peds: (AAP-Pediatric before 8/10/09) = 0 cases• Adult: (AAP-Adult not separate until 12/2/09) =5/60 = 8.3%• Number of cases that did not have an AAP: 11/60= 18.3%


Children’s Asthma Care Core Measure Results:

Children’s Asthma Care Core Measure Data Tool

Per

cent

Core MeasuresChildren's Asthma Care - Composite Score

Month

UCL = 83.9

Mean = 41.6

LCL = 0.0

Apr 20

08 (n=1

2)May

2008

(n=12

)Ju

n 200

8 (n=

3)Ju

l 200

8 (n=5

)Aug

2008

(n=1

2)Sep

2008

(n=2

8)Oct

2008 (

n=22)

Nov 20

08 (n

=13)

Dec 20

08 (n

=3)

Jan 2

009 (

n=6)

Feb 20

09 (n

=7)Mar

2009

(n=12

)Apr

2009 (

n=7)

May 20

09 (n

=15)

Jun 2

009 (

n=5)

Jul 2

009 (

n=5)

Aug 20

09 (n

=13)

Sep 20

09 (n

=26)

Oct 20

09 (n=2

4)Nov

2009

(n=1

8)Dec

2009

(n=1

6)Ja

n 201

0 (n=

5)

0

20

40

60

80

100

120

Per

cent

Children's Asthma Care - Home Management Plan of Care

Month

UCL = 83.2

Mean = 41.1

LCL = 0.0

Apr 20

08 (n=1

3)May

2008

(n=12

)Ju

n 200

8 (n=

4)Ju

l 200

8 (n=5

)Aug

2008

(n=1

2)Sep

2008

(n=2

8)Oct

2008 (

n=22)

Nov 20

08 (n

=13)

Dec 20

08 (n

=3)

Jan 2

009 (

n=6)

Feb 20

09 (n

=7)Mar

2009

(n=12

)Apr

2009 (

n=7)

May 20

09 (n

=15)

Jun 2

009 (

n=5)

Jul 2

009 (

n=5)

Aug 20

09 (n

=13)

Sep 20

09 (n

=26)

Oct 20

09 (n=2

4)Nov

2009

(n=1

8)Dec

2009

(n=1

6)Ja

n 201

0 (n=

4)

0

20

40

60

80

100

Peds RN data collectors

MD’s / RN education

CAC Asthma Home plan separat

CAC Asthma plan moved aboveadult Asthma plan in EPIC

Adult Asthma plan separated too

RN’s checking problem list

Per

cent

Children's Asthma Care - Use of Relievers

Month

Apr 20

08 (n=1

3)May

2008

(n=12

)Ju

n 200

8 (n=

4)Ju

l 200

8 (n=5

)Aug

2008

(n=1

2)Sep

2008

(n=2

8)Oct

2008 (

n=22)

Nov 20

08 (n

=13)

Dec 20

08 (n

=3)

Jan 2

009 (

n=6)

Feb 20

09 (n

=7)Mar

2009

(n=12

)Apr

2009 (

n=7)

May 20

09 (n

=15)

Jun 2

009 (

n=5)

Jul 2

009 (

n=5)

Aug 20

09 (n

=13)

Sep 20

09 (n

=26)

Oct 20

09 (n=2

4)Nov

2009

(n=1

8)Dec

2009

(n=1

6)Ja

n 201

0 (n=

5)

0

20

40

60

80

100

Per

cent

Children's Asthma Care - Use of Systemic Corticosteroids

Month

Apr 20

08 (n=1

2)May

2008

(n=12

)Ju

n 200

8 (n=

3)Ju

l 200

8 (n=5

)Aug

2008

(n=1

2)Sep

2008

(n=2

8)Oct

2008 (

n=22)

Nov 20

08 (n

=13)

Dec 20

08 (n

=3)

Jan 2

009 (

n=6)

Feb 20

09 (n

=7)Mar

2009

(n=12

)Apr

2009 (

n=7)

May 20

09 (n

=15)

Jun 2

009 (

n=5)

Jul 2

009 (

n=5)

Aug 20

09 (n

=13)

Sep 20

09 (n

=26)

Oct 20

09 (n=2

4)Nov

2009

(n=1

8)Dec

2009

(n=1

6)Ja

n 201

0 (n=

5)

0

20

40

60

80

100

Next Steps• Continue to monitor LUMC records for meeting the core measure.• Continue to monitor asthma core measure compliance.• Continue to provide asthma education to patients, families and staff.• Discuss with the physicians the changes that have been made in EPIC to ensure the

correct AAP-Pediatric is chosen and to make sure the AAP-Pediatric includes the 6 components of the home management plan of care and the 3 other components of the Pediatric Asthma Core Measure.

• Talk with Connie Giere in Epic to see if the discharge instructions could pull the discharge diagnosis of “Asthma” so the staff RN would know to ensure that an Asthma Action plan was completed and given to the patient

• Have the RN’s look at the problem list concurrently with the discharge instructions to see if a discharge diagnosis was asthma or reactive airway disease which would result in needing a Home Asthma Action Plan


Acute Myocardial Infarction (AMI)

• Team Members: – B. Majcher, MSN, CV, CNS, C. Mulhall, MSN, CV, CNS – M. Jarotkiewicz, MBA, – Director of Cardiovascular Line - D. Wilber, MD, K. McLean, MD, – Director of Emergency Medicine - M. Cichon, MD, – Director of Cardiac Cath Lab - F. Leya, MD, – Director of Interventional Cardiology Research - J. Lopez, MD,

Michelle Fennessy, Adult Nurse Practitioner – Nursing Staff of 3 NEWS, 5 Tower, CCU, HTU, Emergency

Department, Cardiac Cath Lab, Medical Records Department, Information Technology Department, and Center for Clinical Effectiveness.

Force of Magnetism Force 1: Quality ImprovementForce 13: Interdisciplinary Relationships

TABLE 12

• Optimal treatment of ST elevated Myocardial Infarction (STEMI) or left bundle branch block (LBBB) patients withPercutaneous Coronary Intervention (PCI) within 90 minutes door-to- balloon inflation.

• Since May 2002 LUMC has been reporting performance on Acute Myocardial Infarction (AMI) patients for Core Measures.

• These Core Measures, developed by the Joint Commission and the Center for Medicare and Medicaid Services (CMS), examine the care of all Acute Myocardial Infarction patients.

• The Core Measures are based on guidelines established by the American Heart Association (AHA) and the American College of Cardiology (ACC).

Project Aim Statement

• In March 2009, LUMC announced, Heart Attack Rapid Response Team (HARRT)

• Nurse Practitioner evaluates the process and timing of the patient’s arrival in the Emergency Department and provides timely feedback to the departments and municipalities involved in the care of the ST elevated Myocardial Infarction (STEMI) patient

• Monthly STEMI committee meetings review all ST elevated Myocardial Infarction (STEMI) cases, a process to find ways to improve the care of the AMI patient; and to use this review process to acknowledge when things are done well.


Solutions Continued

• The ED has ongoing training with local municipalities to help interpret ST elevated Myocardial Infarction (STEMI) cases in the field.

• Annually educate all physicians on the components of Acute Myocardial Infarction Core Measures data.

• In January 2007 stage 2 triage initiated in the Emergency Department to expedite Electrocardiogram (ECG) process.

• In June 2007 coordinated accuracy of clock times with Emergency Department, Cardiac Catheterization Laboratory and Call Connection Center. In addition the concept of Code STEMI was discussed.

Solutions Continued• On a daily basis every newly admitted ST elevated Myocardial

Infarction (STEMI)/ Left Bundle Branch Block (LBBB) case is reviewed by Cardiovascular Clinical Nurse Specialist. This involves looking at time arrival, initial Electrocardiogram, Aspirin in 24 hours, cardiac cath report, changes in patient’s severity and planned discharge date.

• Developed outlier reports in order to improve and inform each physician on corrections to be made.

• January 2009 met with Information Technology Department representative to generate bi-weekly reports of ST elevated Myocardial Infarction (STEMI)/ Left Bundle Branch Block (LBBB) patients that would allow expediting care in a more timely manner.

• September 2009 began a daily review of all inpatient elevated troponin levels within the LUMC system.

Solutions Continued

• On discharge each Acute Myocardial Infarction patient’s chart and discharge summary has been reviewed and assessed by Cardiovascular Clinical Nurse Specialist for accurate documentation of Acute Myocardial Infarction information and discharge medications.

• Physician review is included on all expired patients or when documentation is unclear.

• Report quarterly to the Nursing Quality & Safety Council on Acute Myocardial Infarction (AMI) core measure outcomes.

ResultsP

erce

nt

Core MeasuresAcute Myocardial Infarction Composite Score

Month

UCL = 114.1

Mean = 93.4

LCL = 72.8

Oct 20

07 (n=1

2)

Nov 20

07 (n

=14)

Dec 20

07 (n

=18)

Jan 2

008 (

n=11

)

Feb 20

08 (n

=10)

Mar 20

08 (n

=7)

Apr 20

08 (n=1

0)

May 20

08 (n

=6)Ju

n 200

8 (n=

8)

Jul 2

008 (

n=20)

Aug 20

08 (n

=14)

Sep 20

08 (n

=11)

Oct 20

08 (n=1

4)

Nov 20

08 (n

=11)

Dec 20

08 (n

=18)

Jan 2

009 (

n=14

)

Feb 20

09 (n

=9)

Mar 20

09 (n

=12)

Apr 20

09 (n=1

2)

May 20

09 (n

=15)

Jun 2

009 (

n=16

)

Jul 2

009 (

n=16)

Aug 20

09 (n

=14)

Sep 20

09 (n

=12)

Oct 20

09 (n=1

9)

Nov 20

09 (n

=12)

Dec 20

09 (n

=13)

Jan 2

010 (

n=9)

60

70

80

90

100

110

120

ResultsP

erce

nt

Percutaneous Coronary Intervention Within 90 Minutes

Month

UCL = 159.2

Mean = 71.0

LCL = 0.0

Oct 20

07 (n=2

)Nov

2007

(n=4

)Dec

2007

(n=3

)Ja

n 200

8 (n=

2)Feb

2008

(n=2)

Mar 20

08 (n

=3)Apr

2008 (

n=2)

May 20

08 (n

=1)Ju

n 200

8 (n=

2)Ju

l 200

8 (n=2

)Aug

2008

(n=2

)Oct

2008 (

n=4)

Nov 20

08 (n

=3)

Dec 20

08 (n

=5)

Jan 2

009 (

n=1)

Feb 20

09 (n

=1)Mar

2009

(n=1)

Apr 20

09 (n=2

)Ju

n 200

9 (n=

1)Ju

l 200

9 (n=4

)Aug

2009

(n=4

)Sep

2009

(n=3

)Oct

2009 (

n=5)

Nov 20

09 (n

=1)

Dec 20

09 (n

=1)

Jan 2

010 (

n=1)

0

50

100

150

200

Analysis

– In 2008, the Acute Myocardial Infarction composite score was 89.4%(a composite of all Acute Myocardial Infarction arrival and discharge measures)

– 2009 showed improvements with a composite score to date of 92.6%. The above control chart displays an improvement in outcomes;

– Since January of 2009 we have been at 100% in all months except for April & December 2009.

– Since January 2009 we have been at 100% of Percutaneous Coronary Intervention door to balloon time.

Next Steps• Recommendations for Further Study or Action:

– Continue monthly ST elevated Myocardial Infarction (STEMI) committee meetings to evaluate the processes and address areas where delays occur.

– Continue Annual meetings with the physicians to educate them on Core Measure data points and proper documentation to see that these data points are met

– Educate nursing staff: schedule Bi-annual meetings to educate the Nursing Staff on 5 Tower and 3 NEWS on Core Measure Data points for the Acute Myocardial Infarction (AMI) patient’s.

STROKE PERFORMANCE

MEASURES

TABLE 13

Multidisciplinary Stroke TeamCORE STROKE TEAM

Jose Biller, MDJurate M. Platakis, RN, MSN

Neurologists Neurosurgeons Advance Practice NursesRima Dafer, MD Hazem Ahmed, MD Karen Potocki, APRN – BCMichael Schneck, MD Douglas Anderson, MD Stephen Roberts, APRN – BCJohn Whapham, MD Thomas Origitano, MD

Vikram Prabhu, MDNeurology Residents Neurosurgery Residents Ancillary Team MembersYeeshu Arora, MD John Braca, MD Matthew Eaton, ChaplainFarrukh Chaudhry, MD Ronald Hammers, MD Heather Morris, RD, LDNChandril Chugh, MD Dustin Hayward, MD Elizabeth Fries, MS, OTRLSara Hocker, MD Ahmad Khaldi, MD Martina Novotny, PharmacistAlejandro Hornik, MD Dawid Liniewski, MD Erin Mitchell, DPTRagasri Kumar, MD Nikhil Patel, MD Jenifer Belacastro, DPTSarkis Morales, MD Edward Perry, MD Stacy Scarpetti, MS, CCC-SLPChristopher Morgan, MD Phillip Toussaint, MD Nina Hossa, Social WorkerEva Pilcher, MD Diane Broadley, RNHussam Seif-Eddeine, MD Martha Martin, RNRajinder Singh, MD Michael Jarotkiewicz, ADAlexander Venizelos, MD CCEShawn Wallery, MD Lab, Cardiographics, Radiology

»

• To “harmonize”/blend the AHA/ASA stroke guidelines into specificpatient care for all ischemic and hemorrhagic stroke patients toimprove quality of patient care and outcomes.

• To maintain Primary Stroke Center (PSC) Disease Specific Care (DSC)Certification through the Joint Commission.

• To sustain The Gold Plus Performance Achievement Award delegated by the AHA for achieving 85% or higher adherence to allharmonized measures for consecutive 12 month intervals.


Stroke, Guidelines for the Early Management of Patients With Ischemic Stroke: A Scientific Statement From the Stroke Council of the American Stroke Association. 2003:34;1056-1083Stroke, Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: AStatement for Healthcare Professionals from a Special Writing Group of the Stroke Council, American Heart Association. 2009:40;994-1025

Magnet Forces of MagnetismForce 7: Quality Improvement

The organization has structures and processes for the measurement of quality and programs for improving the

quality of care and services within the organization.

To establish best practice from these guidelines through the collection, analysis and review of identified data elements via the AHA/ASA dataregistry and collection tool Get With the Guidelines (GWTG) of Outcome Sciences, Inc.

Aim Statement Continued

ALL STROKE/TIA PATIENTS SHOULD HAVE IMAGING STUDIES AND EKG DONE ON ADMISSION IF NOT CURRENTLY AVAILABLE

Disease-specific care stroke performance measure set follows harmonization with data elements of the Paul Coverdell National Acute Stroke Registry and American Heart Association/American Stroke Association Get With The GuidelinesSM .

Disease-Specific Care Certification requirements for Primary Stroke Centers require data collection and reporting for all 8 measures in this set except for STK-7 and STK-9. Loyola’s stroke program will continue to monitor all 10.

January 2010

Set No.

Stroke Measure Ischemic

Stroke/TIA Hemorrhagic

Stroke STK-1 DVT Prophylaxis

▪ UF Heparin ▪ LMW Heparin ▪ SCD ▪ Other X X

STK-2 Discharged on Antithrombotic Therapy ▪ Antiplatelet ▪ Anticoagulant

X STK-3 Patients with Atrial Fibrillation Receiving Anticoagulation

Therapy ▪ UF Heparin ▪ Enoxaparin ▪ Warfarin ▪ Other

X

STK-4 Thrombolytic Therapy Administered ▪ Did the patient receive t-PA?

X STK-5 Antithrombotic Therapy by the end of Day 2

▪ Antiplatelet ▪ Anticoagulant X

Discharged on Cholesterol Reducing Medication ▪ Lipid Profile ▪ HA1C ▪ Statin ▪ Fibrate ▪ Niacin ▪ Other

X STK-6

▪ Nutrition consult ▪ Record anthropometric measurements Height, Weight and Abdominal Circumference

X X

STK-7 Dysphasia Screening ▪ Swallow screening and/or evaluation completed and documented

X X STK-8 Stroke Education

▪ Stroke Patient Education Form ▪ Stroke Education Packet ▪ Documentation in IP neuroscience nursing note ▪ Stroke Documentation Checklist

X X

STK-9 Smoking Cessation/Advice/Counseling ▪ Smoking Cessation Consult ▪ Noted on discharge order set

X X STK-10 Assessed for Rehabilitation

▪ Rehab service screening and/or consult noted and documented ▪PM&R X X

STROKE PERFORMANCE MEASURES(STK)

– Revised and implemented Clinical Guidelines and Order Sets– Revised and implemented Neuroscience resident and nursing notes

to include critical documentation components– Revised Stroke Educational Materials and their distribution process

for staff, patients, families and the community

– Standardized swallow screening process– Maintain GWTG data base and analyze results – Enhanced Rapid Response to Acute Stroke Alerts– Increased collaboration between departments and disciplines to

enhance, support and standardize stroke care delivery– Facilitate multidisciplinary team rounding – Support participation in Acute and Preventative Stroke Trials– Engage professional and community activities to promote stroke

awareness


Perc

enta

ge c

ompl

iant

Deep Vein Thrombosis (DVT) ProphylaxisTJC Stroke Measure 1

This information is confidential and to be used for quality improvement purposes onlyMonth

Feb-08

(n=1

)Mar-

08 (n

=2)

Apr-08

(n=7

)May

-08 (n

=6)

June

-08 (n

=3)Ju

ly-08

(n=3)

Aug-08

(n=8)

Sep-08

(n=6)

Oct-08

(n=6

)Nov

-08 (n

=8)Dec

-08 (n

=7)Ja

n-09 (

n=10

)Feb

-09 (n

=5)

Mar-09

(n=1

3)Apr-

09 (n

=9)

May-09

(n=6

)Ju

ne-09

(n=12

)Ju

ly-09

(n=10

)Aug

-09 (n

=7)Sep

-09 (n

=19)

Oct-09

(n=2

8)Nov

-09 (n

=17)

Dec-09

(n=17

)Ja

n-10 (

n=22

)Feb

-10 (n

=17)

99.990

99.995

100.000

100.005

100.010

Mean = 100.0

Definition: Patients with an ischemic stroke or a hemorrhagic stroke and who are non-ambulatory who receive DVT prophylaxis by end of hospital day two/All patients with ischemic stroke.Source: Nurse chart reviewAnalysis: Performance has been at 100% since February of 2008.

Perc

enta

ge C

ompl

iant

Discharged on Antithrombotic TherapyTJC Stroke Measure 2


Feb-08

(n=5

)Mar-

08 (n

=9)

Apr-08

(n=1

8)May

-08 (n

=13)

June

-08 (n

=22)

July-

08 (n

=15)

Aug-08

(n=16

)Sep

-08 (n

=19)

Oct-08

(n=1

6)Nov

-08 (n

=17)

Dec-08

(n=13

)Ja

n-09 (

n=16

)Feb

-09 (n

=19)

Mar-09

(n=1

2)Apr-

09 (n

=23)

May-09

(n=1

5)Ju

ne-09

(n=22

)Ju

ly-09

(n=21

)Aug

-09 (n

=12)

Sep-09

(n=19

)Oct-

09 (n

=17)

Nov-09

(n=15

)Dec

-09 (n

=12)

Jan-1

0 (n=

19 )

Feb-10

(n=1

9)

99.990

99.995

100.000

100.005

100.010

Mean = 100.0

Definition: Patients with an ischemic stroke prescribed antithrombotic therapy at discharge/All patients with ischemic stroke.Source: Nurse chart reviewAnalysis: Performance has been at 100% since February of 2008.

Perc

enta

ge C

ompl

iant

Patients with Atrial Fibrillation Receiving Anticoagulation TherapyTJC Stroke Measure 3


Feb-08

(n=1

)Mar-

08 (n

=2)

Apr-08

(n=5

)May

-08 (n

=1)

June

-08 (n

=2)Ju

ly-08

(n=1)

Aug-08

(n=5)

Sep-08

(n=3)

Oct-08

(n=3

)Nov

-08 (n

=2)Ja

n-09 (

n=5)

Feb-09

(n=3

)Mar-

09 (n

=1)

Apr-09

(n=3

)May

-09 (n

=2)

June

-09 (n

=2)Ju

ly-09

(n=2)

Aug-09

(n=1)

Sep-09

(n=2)

Oct-09

(n=1

)Nov

-09 (n

=2)Dec

-09 (n

=2)Feb

-10 (n

=2)

99.990

99.995

100.000

100.005

100.010

Mean = 100.0

Definition: Patients with an ischemic stroke prescribed antithrombotic therapy at discharge/All patients with ischemic stroke.Source: Nurse chart reviewAnalysis: Performance has been at 100% since February 2008.

Perc

enta

ge C

ompl

iant

Thrombolytic Therapy AdministeredTJC Stroke Measure 4


Apr-08

(n=1

)May

-08 (n

=1)

June

-08 (n

=1)Ju

ly-08

(n=1)

Aug-08

(n=2)

Sep-08

(n=2)

Dec-09

(n=2)

Jan-0

9 (n=

1)Mar-

09 (n

=1)

Apr-09

(n=1

)May

-09 (n

=3)

July-

09 (n

=1)Aug

-09 (n

=1)Sep

-09 (n

=1)Oct-

09 (n

=2)

Nov-09

(n=1)

Jan-1

0 (n=

2 )

0

20

40

60

80

100

120

Mean = 94.2

Definition: Acute ischemic stroke patients who arrive at the hospital within 120 minutes (2 hours) of time last known well and for whom intravenous tissue plasminogen activator (IV t-PA) was initiated at this hospital within 180 minutes (3 hours) of time last known well/All patients with acute ischemic stroke whose arrival is within 2 hours (120 minutes) of time known well.Source: Nurse chart reviewAnalysis: Performance has been at 100% since April 2008. In July 2009, there was one patient who received IV t-PA per the new expanded time frame of up to 4.5 hours and so did not meet criteria for the under 3 hour window.

Perc

enta

ge C

ompl

iant

Antithrombotic Therapy By End of Hospital Day TwoTJC Stroke Measure 5


Feb-08

(n=5

)Mar-

08 (n

=8)

Apr-08

(n=1

6)May

-08 (n

=13)

June

-08 (n

=20)

July-

08 (n

=11)

Aug-08

(n=15

)Sep

-08 (n

=19)

Oct-08

(n=1

5)Nov

-08 (n

=17)

Dec-08

(n=11

)Ja

n-09 (

n=12

)Feb

-09 (n

=18)

Mar-09

(n=1

2)Apr-

09 (n

=18)

May-09

(n=1

0)Ju

ne-09

(n=19

)Ju

ly-09

(n=17

)Aug

-09 (n

=6)Sep

-09 (n

=18)

Oct-09

(n=1

8)Nov

-09 (n

=11)

Dec-09

(n=11

)Ja

n-10 (

n=14

)Feb

-10 (n

=20)

99.990

99.995

100.000

100.005

100.010

Mean = 100.0

Definition: Patients with ischemic stroke who receive antithrombotic therapy by the end of hospital day two/All patients with ischemic stroke.Source: Nurse chart reviewAnalysis: Performance has been at 100% since February of 2008

Perc

enta

ge C

ompl

iant

Discharged on Cholesterol Reducing MedicationTJC Stroke Measure 6


Feb-08

(n=4

)Mar-

08 (n

=6)

Apr-08

(n=1

3)May

-08 (n

=10)

June

-08 (n

=19)

July-

08 (n

=11)

Aug-08

(n=10

)Sep

-08 (n

=15)

Oct-08

(n=1

5)Nov

-08 (n

=13)

Dec-08

(n=9)

Jan-0

9 (n=

12)

Feb-09

(n=1

5)Mar-

09 (n

=12)

Apr-09

(n=1

8)May

-09 (n

=10)

June

-09 (n

=17)

July-

09 (n

=18)

Aug-09

(n=8)

Sep-09

(n=16

)Oct-

09 (n

=12)

Nov-09

(n=11

)Dec

-09 (n

=13)

Jan-1

0 (n=

14 )

Feb-10

(n=1

8)

92

94

96

98

100

Mean = 99.7

Definition: Ischemic stroke patients with low density lipoprotein level (LDL) >100, or LDL not measured, or on cholesterol-reducer prior to admission, who are discharged on cholesterol reducing drugs/All ischemic patients with an LDL>100mg/dL or who were on cholesterol reducing therapy prior to hospitalization or LDL not measured.Source: Nurse chart reviewAnalysis: Reinforced resident education about this measure. Performance at 100% since February 2008 except July 2008.

Consult Service Patient Recommendation for Labs/Meds overlooked

Perc

enta

ge c

ompl

iant

Discharged on StatinTJC Stroke Measure 6


Jan -

09 (n

=3)

Feb-09

(n=1

1)

Mar-09

(n=1

0)

Apr-09

(n=1

5)

May-09

(n=6

)

June

-09 (n

=7)Ju

ly-09

(n=10

)

Aug-09

(n=4)

Sep-09

(n=13

)

Oct-09

(n=1

0)

Nov-09

(n=9)

Dec-09

(n=13

)Ja

n-10 (

n=12

)

Feb-10

(n=1

7)

99.990

99.995

100.000

100.005

100.010

Mean = 100.0

Definition: All ischemic stroke patients diagnosed with ischemic stroke due to atherosclerosis who are discharged with Intensive Statin Therapy/All ischemic patients with a low density lipoprotein level (LDL) >100mg/dL or who were on cholesterol reducing therapy prior to hospitalization or LDL not measured.Source: Nurse chart reviewAnalysis: Performance at 100% since January 2009 when tracking of this measure was initiated.

Perc

enta

ge C

ompl

iant

Dysphagia ScreeningTJC Stroke Measure 7


Feb-08

(n=5

)Mar-

08 (n

=13)

Apr-08

(n=2

4)May

-08 (n

=20)

June

-08 (n

=24)

July-

8 (n=

16)

Aug-08

(n=20

)Sep

-08 (n

=23)

Oct-08

(n=2

0)Nov

-08 (n

=19)

Dec-08

(n=20

)Ja

n-09 (

n=19

)Feb

-09 (n

=24)

Mar-09

(n=1

6)Apr-

09 (n

=30)

May-09

(n=2

0)Ju

ne-09

(n=29

)Ju

ly-09

(n=24

)Aug

-09 (n

=15)

Sep-09

(n=24

)Oct-

09 (n

=33)

Nov-09

(n=19

)Dec

-09 (n

=17)

Jan-1

0 (n=

27 )

Feb-10

(n=2

5)

99.990

99.995

100.000

100.005

100.010

Mean = 100.0

Definition: Patients with ischemic or hemorrhagic stroke with a dysphagia screen before being given anything by mouth/All patients with an acute ischemic or hemorrhagic stroke.Source: Nurse chart review.Analysis: Performance has been at 100% since February 2008. A swallow screening evaluation tool was developed and implemented after successful completion of in-servicing to the neurology residents.

Perc

enta

ge C

ompl

iant

Stroke EducationTJC Stroke Measure 8


Feb-08

(n=5

)Mar-

08 (n

=14)

Apr-08

(n=2

3)May

-08 (n

=20)

June

-08 (n

=24)

July-

08 (n

=16)

Aug-08

(n=20

)Sep

-08 (n

=21)

Oct-08

(n=2

1)Nov

-08 (n

=20)

Dec -0

8 (n=

22)

Jan -

09 (n

=21)

Feb-09

(n=2

4)Mar-

09 (n

=19)

Apr-09

(n=3

3)May

-09 (n

=20)

June

-09 (n

=31)

July-

09 (n

=26)

Aug-09

(n=17

)Sep

-09 (n

=26)

Oct-09

(n=2

0)Nov

-09 (n

=22)

Dec-09

(n=20

)Ja

n-10 (

n=30

)Feb

-10 (n

=24)

90

92

94

96

98

100

102

104

Mean = 98.9

Definition: Patients with ischemic or hemorrhagic stroke or their caregivers who were given education or educational materials during the hospital stay addressing all of the following: personal risk factors for stroke, warning signs for stroke, activation of emergency medical system, need for follow-up after discharge, and medications prescribed/All patients with ischemic or hemorrhagic stroke.Source: Nurse chart reviewAnalysis: Performance at 100% since February 2008 thru November 2008. Staff re-education done Dec’08 on neuroscience note documentation, stroke education packet and available teaching resources. Stroke documentation audit tool initiated in March’09. Staff re-education re stroke education resources done Oct’09. In November ’09, stroke specific educational materials made available in the Electronic Medical Record (EMR).

Staff re -education

Staff re -education

Perc

enta

ge C

ompl

iant

Smoking Cessation/ Advice/ CounselingTJC Stroke Measure 9


Feb-08

(n=1

)Apr-

08 (n

=2)

May-08

(n=1

)Ju

ne-08

(n=5)

July-

08 (n

=2)Aug

-08 (n

=5)Sep

-08 (n

=3)Oct-

08 (n

=2)

Nov -0

8 (n=

5)Dec

-08 (

n=6)

Jan-0

9 (n=

2)Feb

-09 (n

=5)

Mar-09

(n=4

)Apr-

09 (n

=5)

May-09

(n=4

)Ju

ne-09

(n=9)

July-

09 (n

=4)Aug

-09 (n

=5)Sep

-09 (n

=6)Oct-

09 (n

=4)

Nov-09

(n=4)

Dec-09

(n=3)

Jan-1

0 (n=

5 )Feb

-10 (n

=5)

99.990

99.995

100.000

100.005

100.010

.

Mean = 100.0

Definition: Patients with ischemic or hemorrhagic stroke with a history of smoking cigarettes, who are, or whose caregivers are, given smoking cessation advice or counseling during hospital stay/All ischemic or hemorrhagic patients with a history of smoking cigarettes any time during the year prior to hospital arrival.Source: Nurse chart reviewAnalysis: Performance has been at 100% since February 2008.

Perc

enta

ge C

ompl

iant

Assessed for RehabilitationTJC Stroke Measure 10


Feb-08

(n=5

)Mar-

08 (n

=14)

Apr-08

(n=2

3)May

-08 (n

=20)

June

-08 (n

=24)

July-

08 (n

=16)

Aug-08

(n=20

)Sep

-08 (n

=21)

Oct -08

(n=2

1)Nov

-08 (

n=20

)Dec

-08 (

n=22

)Ja

n-09 (

n=21

)Feb

-09 (n

=24)

Mar-09

(n=1

9)Apr-

09 (n

=34)

May-09

(n=2

0)Ju

ne-09

(n=31

)Ju

ly-09

(n=26

)Aug

-09 (n

=17)

Sep-09

(n=26

)Oct-

09 (n

=20)

Nov-09

(n=22

)Dec

-09 (n

=20)

Jan-1

0 (n=

30 )

Feb-10

(n=2

4)

99.990

99.995

100.000

100.005

100.010

Mean = 100.0

Definition: Patients with an ischemic stroke or hemorrhagic stroke who were assessed for rehabilitation services/All patients with ischemic or hemorrhagic stroke.Source: Nurse chart reviewAnalysis: Neurology note edited previously and residents in-serviced. Performance has been at 100% since February 2008.

Next Steps• Continue to actively monitor all stroke performance measures• Support collaborative efforts of the multidisciplinary team to

maximize patient outcomes • Enhance stroke educational efforts professionally and for the

community• Support the Loyola Stroke Network

Susan Finn, MSN; Glynis Adams, MSN; Sandra Swanson, MSOD; Karen Judy, MD;

Linda Rush, PCT; Geri Augustine, BS, MT(ASCP)

COMMUNITY COMMUNITY LEAD SCREENINGLEAD SCREENING

TABLE 14

Lead exposure is a problem which impacts the growth and development of the young child. Early diagnosis and management are critical in preventing damage.

A multidisciplinary team, with nursing as a key stake- holder, implemented a CLIA-waived lead testing method in September 2007. (CLIA: Clinical Laboratory Improvement Amendment 1988)

This new testing method requires less blood for the sample and provides results within three minutes.

Background

Aim Statement/Goals

• To streamline the process for screening at-risk children for lead exposure.

• To optimize time spent with parent and school health staff so appropriate education and intervention may occur.

• To increase the number of children screened for lead exposure by 20% in the first two years of using the CLIA-waived testing method.


Forces of Magnetism:

Force 7: This process improves quality of care in our organization.Decreased waiting time for test results leads to better and more timely follow up.

Force 10: Community presence through this ongoing, long-term outreach strengthens our position as a productive corporate citizen.

Force 13: Interdisciplinary collaboration and mutual respect contribute to positive relationships within our organization and enhanced outcomes.

• Implementation of a CLIA-waived testing method for lead screening - A collaborative effort with our clinical laboratory facilitated the introduction of a CLIA-waived testing method for lead screening. After careful testing of the instrument and correlation with our core laboratory, the instrument was introduced on our pediatric mobile health unit for screening at-risk children for lead exposure.

SolutionsSolutions ImplementedImplemented

ResultsResults

Community Lead Screening

0

10

20

30

40

50

60

70

80

90

FY06Q2

FY06Q3

FY06Q4

FY07Q1

FY07Q2

FY07Q3

FY07Q4

FY08Q1

FY08Q2

FY08Q3

FY08Q4

FY09Q1

FY09Q2

FY09Q3

FY09Q4

FY10Q1

FY10Q2

Lead Care II(CLIA waived testing)Core laboratory testing

Num

ber

of sc

reen

ings

ResultsResultsN

umbe

r of s

cree

ning

s

Community Lead Screening

FY06 Q

2FY06

Q3

FY06 Q

4FY07

Q1

FY07 Q

2FY07

Q3

FY07 Q

4FY08

Q1

FY08 Q

2FY08

Q3

FY08 Q

4FY09

Q1

FY09 Q

2FY09

Q3

FY09 Q

4FY10

Q1

FY10 Q

2

0

20

40

60

80

100

Mean = 25.63

Mean = 34.56

Results/Analysis

• The number of children screened for lead exposure increased by 50% in the first two years of utilizing the CLIA-waived testing method.

• Ongoing education of school health personnel and parents about the risk of lead exposure has facilitated the implementation of this program.

• Shorter time for results (three minutes as compared to an average of five days) improved dissemination of results to parents and school health staff. The result was more timely education and intervention.

Next Steps

• To continue screening for lead exposure within the Chicago metropolitan area.

• To increase the number of children screened through our pediatric mobile health unit by another 10% over the next year.

• To continue to provide outreach education to schools and community centers about the risk for lead exposure to children and need for screening and environmental modifications.

MEDICATION RECONCILIATION

It Only Helps If You Get It Right

TABLE 15

TEAM MEMBERSHIP

Garry Sigman MD

Ramzan Shahid MD

Olivia Mittel MD

Ami Giardina RN MHA

Annette Jenero RN,ADN

Laura Belling RN BSN

PROJECT AIM STATEMENT

Develop a process whereby every patient’s medical record is an accurate reflection of currently prescribed medications.

SOLUTIONS IMPLEMENTED

Multidisciplinary committee formed to improve medication reconciliation practice. Committee’s Decision: Physicians are accountable for medication reconciliation.

Baseline chart audits were conducted for medication accuracy and shared with each physician.


Education provided to all physicians on agreed upon method of medication reconciliation.

Post-implementation audit conducted and shared with each physician.

RESULTS

Percentage of Reconciled Charts

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Attending Physicians Resident Physicians

Baseline DataPost Implementaion

ANALYSIS

There was significant improvement, especially among the resident physicians.

The medical staff has accepted accountability for medication reconciliation.

NEXT STEPS

It is our intention to perform chart review on a quarterly basis and share the data with the physicians. We will continue to educate as needed.

Although there has been improvement, our goal is to have medications reconciled at every patient encounter.

CT RADIATION DOSE: A BALANCE BETWEEN

IMAGE QUALITY AND DOSE

Dr. Kevin Corrigan Ph.D., Dr. Harold Posniak M.D.,Loren Eade BSRT, Lorraine Dean BSRT,

James Ryva BSRTTABLE 16

BACKGOUND & PROJECT GOALS• While pursuing the American College of Radiology (ACR)

accreditation & becoming part of the Image Gently Campaign the issue of radiation dose & image quality surfaced.

• We elected to look at CT exams that offered the greatest opportunity to reduce dose & the most frequently ordered exams which totaled 48% of all our exams.

• Utilizing a team approach, ionization chambers, and anatomical phantoms we measured & calculated patient radiation dose from all of our CT scanners.

• We looked at all the CT technical factors that influence dose & image quality.

• We evaluated CT image quality looking at image sharpness, resolution, contrast, and noise.

• Our project goal was two fold: 1) to reduce CT radiation dose by at least 10%, and 2) to achieve an optimal balance between acceptable CT patient dose and high image quality.

CT SCANNER EVALUATION, ACR TEST PHANTOM

CT PATIENT RADIATION DOSE MEASUREMENT

Use ACR endorsed phantoms which simulateaverage adult body, head.

Scan technique for average adult, child mustproduce < established dose limits.

Adult AbAdult Head

Ion Chamber Dosimeter

SOLUTIONS IMPLEMENTED• Implemented ALARA (as low as reasonably achievable)

with respect to using only the amount of radiation necessary to obtain optimal images.

• Developed CT technical scanning protocols for the selected exams in which we wanted to reduce radiation dose.

• Developed weight based, procedural based, & body part specific scanning protocols.

• Implemented the use of new breast protective shields to reduce radiation dose.

• Utilized prospective gating & ECG Automatic Dose Modulation to reduce radiation dose for our CT Cardiac Angiographic patients.

RESULTS

AVERAGE PERCENT RADIATION DOSE REDUCTION

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Adult Head AdultAbdomen

AdultC ardiac

P ediatricHead

P ediatricAbdomen

S eries 1

20% 33% 45% 23% 40%

RESULTS• ACHIEVED A THREE YEAR ACCREDITATION FROM THE

AMERICAN COLLEGE OF RADIOLOGY (ACR) FOR ALL CT SCANNERS.

• RECEIVED RECOGNITION FROM THE AMERICAN ACADEMY OF PEDIATRICS, ACR, & AMERICAN ASSOCIATION OF PHYSICISTS IN MEDICINE FOR OUR PARTICIPATION IN THE IMAGE GENTLY CAMPAIGN.

• OUR DOSE REDUCTIONS CORRELATED WITH NATIONALLY PUBLISHED DATA FROM THE NATIONAL COUNCIL ON RADIATION PROTECTION & MEASEAUREMENTS & VALIDATED BY THE ACR.

Loyola University Health System

ANALYSIS

• We well exceeded our target of 10% radiation dose reduction in all exam categories.

• By using the reconstructive algorithms we realized that we were able to reduce noise in CT cardiac images and still maintain the ability to visualize small structures.

NEXT STEPS

• Look at all remaining CT protocols to evaluate dose reduction.

• Look at other areas of Radiology such as Interventional Radiology with respect to radiation dose & fluoroscopy time.

• Assess radiopharmaceutical dose in the pediatric population in Nuclear Medicine.

• Work with Radiology equipment vendors to standardize dose assessment & dose reporting.

• When looking at future CT equipment purchases, select vendors that address radiation dose reduction.

Hospital Acquired Pressure Ulcer

TABLE 17

Reduction Project

Jodi Blaszczyk RN, BSN, CWOCN, Kathy Thiesse RN, BSN, CWOCN

Skin Care Liaison Committee, Judy McHugh RN, MSN

Impact of Hospital Acquired Pressure Ulcers

• Annual estimate of treatment costs in US hospitals is $11 Billion with a mean length of stay of 13 days.

• Estimated cost of a stage 3 or 4 pressure ulcer is $9,900.

• Loyola experience- 2007 LUMC Hospital Acquired Cases found =78- 2009 LUMC Hospital Acquired Cases found =39- Cost avoidance ($9,900 x 39) =$386,100

Institute for Healthcare Improvement. Five million lives campaign. Getting started kit: prevent pressure ulcers. IHI, 2008Xakellis, G.C., Frantz, R., (1996). The cost of healing pressure ulcers across multiple health care settings.. Adv Wound Care, 9 (6) 6: 18-22

• Reduce Hospital Acquired “Pressure Ulcers” (PU) Rate– Goal: 0%

• Prevent Hospital Acquired “Heel” Pressure Ulcers– Goal: 0%

• Increase daily Braden Scale Compliance– Goal: 100%

• Documentation of skin assessment on admission– Goal: 100%

• LUMC participates in quarterly National Database of Nursing Quality Indicators (NDNQI) Studies – Point prevalence performed

consists of a one day study in which head to toe skin assessments for pressure ulcers, documentation, Braden Scale, & chart audits.

• Braden Scale Daily* Compliance is monitored monthly*as a proxy Braden Scale daily compliance consists of random audit done 2 times a month.

Aim Statement / Goals PLAN

Policy & Practice:

• Implemented evidenced based Decision Tree for heel pressure relief – MF 6, 7, 8.

• Updated Braden Scale P&P – MF 7, 9.

Staff Education:• Developed 2009 Resources Available Manual &

Skin Care Liaisons provided individual unit education – MF 8,11.

• Initiated additional Night Shift Skin Care Liaison Committee meet 4th Friday of month MF 6, 9.

• Began monthly education for new employee RN/PCT orientation on skin & ostomy care MF 1, 8, 11, 14.

Documentation Improvements:

• Relocated Braden Scale documentation in EPIC to improve compliance – MF 7, 9.

• Added ED documentation on admission POA in ED Admission Navigator – MF 12.

Compliance Monitoring:

• Continue stage I inter-rater reliability of skin surveyor - Magnet Force (MF) 7.

• Created weekly Inpatient Pressure Ulcer report for managers on portal MF 3, 7.

Solutions Implemented to Reduce PU

HW Noso Skin Ulcer Rate

Conf idential f or Quality Improvement Purposes Only

2 Q 06 Jun10.3

3 Q 06 Sep12.1

4 Q 06 Nov13.9

1 Q 07 Mar7.3

2 Q 07 May7.3

3 Q 07 Sep7.8

4 Q 07 Nov5.6

1 Q 08 Feb6.8

2 Q 08 Jun8.1

3 Q 08 Sep5.1

4 Q 08 Dec4.5

1 Q 09 Mar4.1

2 Q 09 Jun3.3

3 Q 09 Sep3.7

4 Q 09 Nov3.0

Quarter1

IndividualsTemporary: UCL=10.91, Mean=6.86, LCL=2.81 (mR=2)

2 Q 06

Jun

3 Q 06

Sep4 Q

06 N

ov1 Q

07 M

ar2 Q

07 M

ay3 Q

07 Sep

4 Q 07

Nov

1 Q 08

Feb

2 Q 08

Jun

3 Q 08

Sep4 Q

08 D

ec1 Q

09 M

ar2 Q

09 Ju

n3 Q

09 Sep

4 Q 09

Nov

4

6

8

10

12

14

UCL = 10.91

Mean = 6.86

LCL = 2.81

NDNQI SurveyTeam Training& Staging

Acute Rehab & ICUAdmission Ulcer DocumentationGreater than 4 Linen Layers

Inter-Rater ReliabilityStage 1

Skin SurveyRe Education

New EPICRN Documentation

Back to BedSave Our Skin

Daily BradenScoring

Manager Meeting Agenda Item

Reduced Linen LayerNon Plastic Adult Briefs

Criticaid Clear Ointment

Prevalon Boots

HW Order Set Education

ED POA doc

HW Hospital Acquired Pressure Ulcer Rate

Bra

den

Sca

le R

ate

HOSPITAL WIDE BRADEN SCALE COMPLIANCE44

DEC 0850451199

45JAN 09

56958098

46FEB 09

55757198

47MAR 09

568568100

48APR 09

58959599

49MAY 09

28529796

50JUN 09

57157699

51Jul 09

492521100

52Sep 09

266270100

53Oct 09

580583100

54Nov 09

517518100

55Dec 09

269270100

NUMBERDATE

ASSESSCENSUS

1Individuals

Temporary: UCL=101.74, Mean=99.08, LCL=96.42 (mR=2)

DEC 08

JAN 09

FEB

09

MAR 09

APR 09

MAY 09

JUN 09

Jul 0

9

Sep 0

9

Oct 09

Nov 09

Dec 09

96

97

98

99

100

101

UCL = 101.74

Mean = 99.08

LCL = 96.42

Goal = 100%

Bra

den

Sca

le R

ate

HOSPITAL WIDE BRADEN SCALE COMPLIANCE44

DEC 0850451199

45JAN 09

56958098

46FEB 09

55757198

47MAR 09

568568100

48APR 09

58959599

49MAY 09

28529796

50JUN 09

57157699

51Jul 09

492521100

52Sep 09

266270100

53Oct 09

580583100

54Nov 09

517518100

55Dec 09

269270100

NUMBERDATE

ASSESSCENSUS

1Individuals

Temporary: UCL=101.74, Mean=99.08, LCL=96.42 (mR=2)

DEC 08

JAN 09

FEB

09

MAR 09

APR 09

MAY 09

JUN 09

Jul 0

9

Sep 0

9

Oct 09

Nov 09

Dec 09

96

97

98

99

100

101

UCL = 101.74

Mean = 99.08

LCL = 96.42

Goal = 100%

Combined Analysis of Data

• Nosocomial PU rate has decreased with implementation of Inter-Rater Reliability on Stage 1 ulcers.

• New ED RN Documentation is assisting in capturing Pressure Ulcers Present on Admission (POA).

• Implementation of Decision Tree for heel pressure relief and low, mod, high risk Braden order sets has reduced nosocomial heel ulcers. Met Zero Heel Pressure ulcers past 2 quarters.

• Met Braden Scale 100% compliance – Identifying who is at risk allows for earlier implementation of a pressure

ulcer action plan.

Next StepsCompliance Monitoring:• Maintain stage 1 inter-rater reliability of skin

surveyor – MF 7.• Evaluate , with clarity report, ED documentation

on admission POA – MF 12.• Utilize weekly Inpatient hospital acquired PU

report to identify and target nursing units with high rates – MF 7.

Policy & Practice:

• Evaluate Wound Care Product line with Med/Surg Value Analysis Team (VAT) –MF 7.

• Adding hyper links to references available to EPIC Braden Scale Order Sets – MF 7.

Documentation Improvements:

• Formulate plan for house wide education on wound documentation – MF 7.

• Submit improvements in EPIC for documentation on wounds – MF 7.

Staff Education:• Night shift Skin Care Liaisons to complete

NDNQI PU training modules with 1.5 CEUs –MF 6, 7, 8.

• Educate managers/skin care liaisons onInterpreting/utilizing weekly inpatient PUreport &NDNQI reports on report channel totarget individual units areas of improvements– MF 3,7,11.

Meet the Skin Care Liaison TeamDay

Jodi Blaszczyk ET, ChairKathy Thiesse ETGail Klotz 7SW Debbie Terrell 2NESusie Irving 7BICUPaula Ferrel 6E Soo Howell 2ICUIsabel Orona 6EMelody Cibock 6WBMT Charlene Wiegland 5RehabMark Beluga 5RehabSandy Carmargo HTUBarb Brower 2ICU Barbara Rumik MICUMary Montevecchi MICUJennifer Data 2WLindsey Keeler PAR

Night

Kathy Thiesse, ET ChairJane Williams MICU Co-ChairSally Ciukaj EDJessica Ray 2WJessica Amundsen 2WJohnson Vachachira HTUTracy Frazzini HTUJamise Gant 3NEWSJason Morandi 4ICUKimberly Simons 4TAnitha Saravanan 5TBobbie Halikowska 5TPaula Farrell 6ESandra Dominguez BICU

Karen Thomas 5TDebra Callender ERMaria Poblete GIMichelle Regasa 3NEWSDivine Tongol GITheresa Pavone 3NEWSMarybeth Jabeguero GIJudy King 4ICULindsey Buckman 4TMegan Pugh PEDSMelinda Mars PEDSGinger Lewis UrologyTheresa Schwenkel 2NEEva Grabala 2WEli Ayala HTURenee Pach PEDSAlona Gomez-Ricar OR

Lori Black MICUDeborah Zatecka 6WPaula Farrell 6EBrianna Piet 6E

Pharmacist Epic Medication Order Verification Training and

the Impact on Order Verification Time.

TABLE 18

Committee Members• George Krempel MBA

ASQ Certified Six Sigma Green Belt

• Richard Ricker RPh MBA• Greg Horner ASQ Certified

Six Sigma Black Belt • Gayle Thompson PharmD• John Ilic PharmD

• Andrea Quinn PharmD BCPS

• Nancy Doulas PharmD• Martina Novotny PharmD• Dan Govoni RPh• Allison Schriever PharmD

Background• TJC requires pharmacist review of medication orders

prior to administration.• Epic medication order verification is one piece of efficient

and appropriate medication delivery to patients.• Order verification directly impacts patient care and

nursing workflow.• Time delays for pharmacotherapeutically correct orders

can occur if pharmacists are unfamiliar with Epic’s full capabilities or specific patient information location.

• Inappropriate verification can occur if patient information is researched inappropriately.

Project Objective & Goal

Assess the impact of pharmacist Epic medication order verification

training on order cycle time.

– Cycle time reflects the time difference between time of order entry and pharmacist verification.

– Goal: Decrease cycle time through training.

Pilot Training• Eight (8) pharmacists from different areas

working 1st and 2nd shifts were included in the pilot assessment. – Four (4) pharmacists underwent verification

training. – Four (4) pharmacists matched for area and

shift served as controls.• Baseline cycle time was measured for select

nursing units(2E, 6N, 6S, 7S, 7W) pre-training (all staff) and post training (select pharmacists).

Results from the Pilot Training

• Average baseline medication order cycle time approximated 24.69 minutes (N=1653 orders)

• Average order cycle time post training initiative approximated 23.61 minutes (N=1304 orders)– Untrained pharmacist average 29.45 minutes

(N= 309 orders)– Trained pharmacist average 21.79 minutes

(N=995 orders)

Expansion of Training Initiative• The results of the pilot training led our team to

provide mandatory pharmacist Epic medication order verification training.– Inpatient and outpatient pharmacists (n=72) were

provided an Epic medication verification training guide, were required to attend small group didactic training which utilized ‘live’ Epic functions and successfully complete an E-learning module.

– Training occurred for 2 weeks in November 2009.• Cycle times were assessed pre and post global

training.

Expanded Training Results

Month Average cycle time (minutes)

Number of medication orders

October 2009 (pre- training)

17.24 48055

December 2009 (post training)

16.8 44801

January 2010 12.2 13741

February 2010 * 15.19 46741

* February data had ~4 times the number of orders and pharmacists were short-staffed!

Expanded Training Results

0

5

10

15

20

October 2009(Pre-training)

December2009 (PostTraining)

January 2010 February 2010

Min

utes Global Verification

times

Conclusions

• Formal Epic medication order verification training impacted overall verification cycle time, resulting in an overall decrease in cycle time from baseline assessment.

• The variations between January and February cycle times may be associated with the increased order volume, pharmacy staffing shortages and potential reporting error.

Limitations• Cycle time analysis does not differentiate

between pharmacotherapeutically appropriate orders and those requiring clarification. Orders requiring clarification may result in longer verification times.

• Cycle time reflects the time the order is entered until it is verified. At this time, Epic is unable to quantify time for pharmacist verification activities.

Next Steps• Epic medication order

verification cycle times will be sporadically monitored.

• Pharmacists will undergo periodic training updates and E-learning assessments.

• The verification guide will be updated with system updates, as deemed necessary.

Implementation of a Pediatric Pressure Ulcer Prevention Tool

Promoting Directed Interventions and Alleviating Risk

POSTER 19

PUPPI-C Team Members

Marsi Appleby BSN, RN (PICU), Team LeaderRenee Pach BSN, RN (PEDS), Co-Team LeaderJudy McHugh MSN, RN, FacilitatorJodi Blaszczyk BSN, RN, CWOCN, Skin ConsultantMelinda Mars BSN, RN (PICU), Data CollectorCindi LaPorte, BSN, RN, Pediatric ManagerKatie Hollish MSN, RN, EducatorSamatha Sage BSN, RN (PEDS)Christine Lewkowicz BSN, RN (PEDS)Kathy Thesse BSN, RN, CWOCN, Skin ConsultantJeanne Sadlik, LUHS LibrarianAda Koch, PharmacistDana Fortado, Occupational TherapistCarly Houston, Registered Dietician

Problem focused triggers Knowledge focused triggerspatient safety & risk management data new research or other literatureprocess improvement data national agencies or organizationalinternal/external benchmarking data standards & guidelinesfinancial data philosophies of careidentification of clinical problem questions from institutional councils & committeesidentification of system problempatient/family concerns

Is this topic apriority for theorganization?

Bring topic to the NsgExecutive Council toevaluate priority inlight of other pendingprojects.

Include input from allrelevent stakeholders.

Consider othertriggers

Form a team

Interdisciplinary whenappropriate

Consider non-clinicalmembers (e.g.,support depts)

Include member w/research competencyIdentify desired outcome(s)

Assesmble relevent research andrelated literature

Critique, weigh evidence, andsynthesize research for use in practice

Pilot the change in practice Implement Rapid-Cycle Improvement

Process Select outcomes to be achieved Collect baseline data Design EBP guideline(s) Implement EBP on pilot units Evaluate process and outcomes Modify the practice guideline

Is there asufficient research

base?

Base practice on other types of evidence: case reports expert opinion scientific principles theory best practice guidelines patient preferences

Conductresearch

Assess feasibility, benefits, and risk ofpractice change

Is changeappropriate for

adoption inpractice?

Continue to evaluate quality ofcare and new knowledge Institute the change in practice

Monitor & analyze structure, process, and outcome data environment staff cost patient & family

Disseminate results

Assess need forchange; identify the

problem to becorrected (may

occur at Unit-Basedor System-wide

level)

No

Yes

Yes No

YesNo

Refer recommendatins for system-wide practicechanges to Nursing Executive Council

Iowa Model of Evidence-Based PracticeAdapted for Use at Loyola University He(Copyright of University of Iowa Hospitals and Marita Titler. Reproduced with permission from Marita Titler, PhD, RN, FAAN; for permission to use or reproduce the model, please contact Dr. Titler at [email protected].)

Quality Pathway

Purpose:To implement an evidenced-based Pediatric Skin Assessment tool to prevent pressure ulcers

Significance/Priority:

Decrease Risk of Pressure Ulcers Reduce pressure ulcers to 0

Clinical PICO Question:

P: Pediatric Hospitalized Patients with Limited or No

Mobility

I: What are the current Skin Care Assessment

Tools/Interventions to prevent pressure ulcers

C: No pediatric evidenced-based skin care

assessment vs an evidenced- based skin care

assessment

O: Decrease Risk of Pressure Ulcers Decrease Pressure Ulcers to Zero

Key StakeholdersPUPPI Committee:•Pediatric Nursing Staff•Pediatric Nurse Manager•ET Skin Care Nurse WOCN•Nursing Performance Improvement•PT/Occupational Therapy•Pharmacist•Registered Dietician•APN •Pediatric Medical Staff

Approvals Obtained: EBP•Nurse Executive Council•Nursing Quality and Safety Council•Nurse Skin Care Committee•Pediatric Nursing Staff Education CommitteeBaseline Date:

Problem FocusedOccipital Pressure Ulcers seen more frequently in PEDS •Potential Pressure Ulcer -12 hrs post adm to PICU•Hospital Acquired Pressure Ulcers-Harm, Increase LOS/Cost

Knowledge-Focus Triggers•Pediatric Skin Assessment Tool- Braden Q or other tools•What are the principal components for early interventions •CMS New Ruling-Hospital Acquired- Discount Hospital Bill or Negative effect

Synthesis of Evidence:

•30 articles, 12 years of research•Adaptation of the Braden Scale for pediatrics iscalled Braden Q by Quigley &

Curley(1996)

Body of Evidence–Multisite prospective cohort descriptive study–Retrospective Cohort–Case Control Study–Systematic Review

Synthesis of Evidence–During committee meetings–Unit Huddles–Through collaboration with ET RN Therapist

EBP InterferencesEvidence Supports:–Utilization of Braden Q no adaptations–Skin Care Assessments every days

Length of intubation

Pilot the Change in Practice

•Did Braden Q Capture Skin Care Risk Level•Evaluated current Pressure Ulcers on Pediatric Units•Evaluated and determine High, Moderate, Low Risk Interventions •Developed LUHS Pediatric Skin Interventions on Paper Form

•Pilot on PICU•Implemented EBP on pilot units•Evaluated Skin Assessment Process and Outcomes•Incorporated into EMR (EPIC)- Braden Q Skin Assessment and LUHS Pediatric Skin Intervention (Order Sets)

Plan, Do, Study, Act (PDSA)

PLAN:

Project Aim Statement:

Prevent and minimize risk for hospital- acquired pediatric pressure ulcers by creating an interdisciplinary team to analyze past pressure ulcer patterns, evaluate current trends, and implement an evidence-based pediatric pressure ulcer prevention.

PLAN:

Measurement Goal & Target:

Reduce hospital-acquired pediatric pressure ulcers to zero

Complete Braden Q assessment upon admission and once a day, and provide skin care interventions when appropriate

PLAN:

Evidence-Base:

An extensive literature review conducted by the committee identified the Modified Braden Q Pressure Ulcer Risk Assessment Scale (Braden Q), which is an evidence- based pediatric assessment tool that modifies the original Braden Scale largely through the inclusion of a subscale addressing tissue perfusion and oxygenation. Approval for the use of this instrument was obtained from Sandy Quigley, RN, CWOCN, CPNP, one of its principal authors.

Through the PUPPI-C literature review, it was also revealed that no evidence-based intervention system for addressing pediatric pressure ulcers existed. So, a pilot pediatric intervention tool was created. This was based upon an adult intervention protocol already in use at Loyola, but was modified based upon a review of the relevant research literature, to render it appropriate for the treatment of pediatric patients. In September of 2009, a pilot study of this intervention protocol was initiated. In March, 2010, the Loyola Pediatric Skin Interventions were introduced into Epic.

PLAN:

Magnet Force:

Quality Improvement # 7

Quality is the systematic driving force for nursing and the organization. Nurses serving in leadership positions are responsible for providing an environment that positively influences patient outcomes. There is a pervasive perception among nurses that they provide high-quality care to patients.

Interdisciplinary Relationships # 13

Collaborative working relationships within and among the disciplines are valued. Mutual respect is based on the premise that all members of the healthcare team make essential and meaningful contributions to the achievement of clinical outcomes. Conflict management strategies are in place and are used effectively, when indicated.

DO:

Solutions Implemented:

Adopted and applied the Iowa Model of Evidence-based Practice to examine current best practices

Developed an interdisciplinary committee derived from the Nursing Quality and Safety Council to evaluate pediatric skin care assessment

Named committee “PUPPI-C”: Pressure Ulcer Prevention Pediatric Interdisciplinary-Committee

Reviewed and discussed relevant literature identifying best practices in pediatric skin assessment

Assessed feasibility of the Modified Braden Q Pressure Ulcer Risk Assessment Scale-a comprehensive tool that has 7 subscales with an additional scale specifically for pediatric population - tissue perfusion and oxygenation

Piloted and adopted the Braden Q Pressure Ulcer Risk Assessment Scale

Built a skin assessment screen for pediatrics in EPIC

Confidential: For Quality Improvement Purpose Only

DO:

Developed and piloted evidence-based interventions through a literature search to help indicate: Low/Moderate/High risk pediatric groups (Loyola Pediatric Skin Interventions)

Developed and implemented an E-Learning education tool for the Braden Q and the Interventions for High/Moderate/Low risk pediatric patients

Developed and educated PEDS and PICU nurses on resource binder and unit education boards

Educated PEDS and PICU nurses on assessment and interventions for pressure ulcer prevention

Created and incorporated the Loyola Pediatric Skin Interventions into EPIC

Created a hyperlink from the intervention order sets to reference material in EPIC about skin protection for pediatric families

Incorporated lessons learned from hospital-acquired pressure ulcers post implementation: Nursing owns each hospital-acquired pressure ulcer and actively investigates solutions and educates nurse on trends if appropriate


DO:

Presentations:

March 2009 LUHS Evidenced-based Practice Day and Shared Governance Day - PUPPI-C

March 2009 LUHS Women and Children’s Conference - PUPPI-C

April 2010 LUHS Patient Safety and Quality Fair - PUPPI-C

April 2010 Sigma Theta Tau - PUPPI-C

April 2010 Poster presentation at University of Iowa Evidenced-Based Practice Conference - PUPPI-C

Applied:

October 2010 Poster Magnet Conference - PUPPI-C


STUDY:

Analysis:

Baseline data was retrieved from the EPIC doc flowsheet for skin integrity

An EPIC clarity report revealed six pressure ulcers that were identified as hospital-acquired from January through August 2008

All six cases were reviewed by the interdisciplinary team:

4 cases were incorrectly classified as pressure ulcers in the EPIC documentation by the staff RN

2 cases were correctly identified:

1. Occipital pressure ulcer where alopecia occurred once the pressure ulcer was healed

2. Gluteal fold, stage two pressure ulcer in PICU


STUDY:

Analysis:

Since the implementation in May 2009 of the Pediatric Pressure Ulcer program:

PICU

100% compliance for Braden Q performed upon patient admission

100% compliance for Braden Q assessment daily

PEDS

99.38% compliance for Braden Q performed upon patient admission

99.38% compliance for Braden Q assessment daily


STUDY:

Analysis:

Total Number of Hospital-Acquired Pressure Ulcer for 2009:

PEDS: 0 Hospital-Acquired Pressure ulcers

PICU: 7 Hospital-Acquired Pressure ulcers

3 of those 7 occurred post implementation (May 2009)

There were no hospital-acquired pressure ulcers since August 2009


Braden Q Assessment Upon AdmissionPEDS and PICU

July 2009 - February 2010

92

94

96

98

100

102

Jul 09 N=17

Aug 09 N=39

Sep 09 N=32

Oct 09 N=32

Nov 09 N=28

Dec 09 N=34

Jan 09 N=34

Feb 09 N=26

Months

Perc

ent C

ompl

ianc

e

Random Braden Q Monthly


Braden Q Assessment DailyPEDS and PICU

July 2009 - February 2010

92

94

96

98

100

102

Jul 09 N=17

Aug 09 N=39

Sep 09 N=32

Oct 09 N=32

Nov 09 N=28

Dec 09 N=34

Jan 09 N=34

Feb 09 N=26

Months

Perc

ent C

ompl

ianc

e

Random Braden Q Monthly



Current

number of

days ‘ulcer

free’PUPPI –C

Project

Implemente

d

ACT:

Continue to:

Evaluate for pressure ulcers on PEDS and PICU

Analyze each case in the PICU to determine what triggered the “skin breakdown” (e.g. paralytics, medications, acuity, diagnosis, LOS, and location of ulcer)

Audit and educate for correct use of tools

Evaluate the Loyola Pediatric Skin Interventions utilizing the High, Moderate, and Low Risk Categories

Educate on Braden Q Scoring, Documentation, and Prevention through data collection and analysis

Develop:

Pediatric Skin Intervention Principles to be incorporated into the patient care policy

Inservice for proper turning of “at-risk” pediatric patients and identify other educational topics arising from the data collection and analysis process

Pediatric Occipital Preservation Program


LESSONS LEARNED:

Post implementation of the PUPPI-C protocol to eliminate hospital-acquired pressure ulcers:

Nurses own each hospital-acquired pressure ulcer

Nurses investigate solutions and educate each other and parents on trends when appropriate

M.Parthasarathy, S.Wojtowicz, C.Delsarto, K.Kiley, N.Porter, M.Volle, M.Payan, M Brush; T.Rodriguez, S.Smith, S.Lichtenstein, P.Mumby ; B.Emami; P.Stiff BMT Clinical Team, Department of Radiation Oncology

M.Parthasarathy, S.Wojtowicz, C.Delsarto, K.Kiley, N.Porter, M.Volle, M.Payan, M Brush; T.Rodriguez, S.Smith, S.Lichtenstein, P.Mumby ; B.Emami; P.Stiff BMT Clinical Team, Department of Radiation Oncology

Can Total Body Irradiation (TBI) for Allogeneic BMT Patients be Administeredin Out-patient Setting Safely?

OPPORTUNITY STATEMENT

• To evaluate administration of Total Body Irradiation (TBI) treatment prior to Allogeneic Stem Cell Transplants in the out-patient setting instead of the traditional inpatient setting.

• This will reduce the number of inpatient days for transplant admission and free up beds in BMT unit for new admissions

• To avoid any delay in admissions due to lack of bed availability for patients to proceed with stem cell transplant

• To be able to administer TBI in out-patient setting to all

eligible Allogeneic transplant patients

• Reduction in hospital length of stay for transplant admission.

• A positive impact on patient satisfaction and quality of life

measures due to decrease in in-patient length of stay

• To increase the capacity and avoid delays to perform more

allogeneic transplants in the transplant unit.

• To analyze data for any cost savings due to change of practice.

RESULTS

• Initiating transplant prep regimen with out patient TBI is safe and not associated with any increased risk of complications during transplant.

• This allows us to maximize our bed utilization on the inpatient unit as we are facing an ever increasing number of transplant procedures at Loyola

• This also leads to substantial cost savings for both patients and the institution.

• The is an ongoing project to evaluate a large number of patients. Comparative Statistical analysis will be performed including quality of life issues on a larger sample size in future. Going forward, all eligible allogeneic transplant patients will receive TBI in outpatient setting.

CONCLUSIONS

REASONS FOR CURRENT OPPORTUNITY

OVERALL SURVIVAL

RESULTS

• Gradual increase in the number of Allogeneic transplants performed over the last 5 years is resulting in a need to asses a change of practice.

• A need To extend our experience (published data) in performing autologous transplants with TBI regimen in the out-patient setting to the Allogeneic transplant population.

• A need to assess the feasibility and safety of administering TBI in out-patient setting for all eligible Allogeneic Stem Cell Transplant Patients.


• Change patients transplant schedule and calendar for Prep Regimen to accommodate out patient TBI

• Train / educate care givers to manage / help patients at home during this treatment

• Coordinate schedule with Radiation Oncology

• Plan in-patient admissions to have a smooth transition to BMTU unit post TBI

• All eligible patients were received outpatient TBI

• A considerable decrease in planned length of stay of 4 days per patient in the OP TBI Group was expected. However we observed a 6 day shortening of hospital stay. The reasons for this are not clear, but could be due to sample size or better acceptance of out patient therapy in our study group.

• No difference in Engraftment time between the two groups.

• No difference in treatment related complications between two groups.

• No difference in Day 100 survival between the two groups

• Cost savings were: $1000 Ambulance charges per patient$20,000 per patient difference for inpatient chargeTotal projected savings per year: $525,000

METHODS

• Change patients transplant schedule and calendar for Prep Regimen to accommodate out patient TBI

• Train / educate care givers to manage / help patients at home during this treatment

• Coordinate schedule with Radiation Oncology

• Plan in-patient admissions to have a smooth transition to BMTU unit post TBI

• All eligible patients were received outpatient TBI

• A total of 15 eligible patients (based on patient performance and payor requirements) out of 25 who received TBI for regimen were given Out Patient TBI.

• Transplant outcome data for this group was compared to the historic control group of 82 patients from 2 prior years who received TBI as In Patient

• Engraftment and In patient length of Stay data was compared

• Data was also collected and analyzed for complications related to this treatment viz. Mucositis, Infections and GI toxicity

• Day 100 survival data was collected for both groups and compared

• Data was analyzed for cost savings

RESULTS

N M/FMedia nAge

Median Days to Engraftment

Median Length of Inpatient Stay

DESIRED OUTCOME

POSTER 20

3 NEWS Cardiac Telemetry

Chart Smart: A plan to improve patient

education nursing documentation

•Confidential: Quality Improvement Material

TABLE 21

Nursing Magnet Forces: Nursing Excellence

Force 1-

Quality of Nursing LeadershipForce 3-

Management Style

Force 6-

Quality of CareForce 7-

Quality Improvement

Force 8-

Consultation and ResourcesForce 11-

Nurses as Teachers

Force 12-

Image of NursingForce 13-

Interdisciplinary Relationships

Force 14-

Professional Development•Confidential: Quality Improvement Material

Aim

To improve patient education nursing documentation

Patient education nursing documentation will increase to achieve 100% compliance


Nursing Documentation Compliance After Cycle 1


Patient Education Documentation Compliance3 NEWS Cardiac Telemetry

0%10%20%30%40%50%60%70%80%90%

May

June Ju

ly

Aug Sep Nov Dec Jan

FebMarc

h

Audit Month

% C

ompl

ianc

e

Focused efforts to document

Data collected without focused efforts

Cycle 1 Plan and Do

•

May and June 09–

Patient Education sheets located at bedside for nursing documentation

•

July 09–

Compliance continued to improve with focus efforts–

RNs voiced concern about created burden of documentation that was not supported by EPIC

•

Aug 2009–

Work collaboratively with IT to develop a teaching sheet that works with the EPIC system

•

Improving systems already in place•

Providing smooth transition to standardized note•

Placing Pt education sheets into EPIC•

Educating RNs about initiative


Cycle 2 Plan and Do

•

September 2009–

EPIC documentation revised with staff input

–

Educated documentation process to RNs•

November 2009–

Further EPIC documentation revision

–

Pt education record documentation simplified–

Continued education efforts

•

January 2010–

EPIC documentation includes plan of care flowsheet



Nursing Documentation Compliance Progress

Patient Education Documentation Compliance3 NEWS Cardiac Telemetry

0%10%20%30%40%50%60%70%80%90%

100%

May

June Ju

ly

Aug Sep Nov Dec Jan

FebMarc

h

Audit Month

% C

ompl

ianc

e

Data collected without focused efforts

Improving systems already in placePlacing Pt education sheets into EPICEducating RNs about initiative

Analysis

•

Manage for daily improvement resulting in greater than 85% compliance

•

Provide a culture for continuous improvement while standardizing a nursing note

•

Create intra departmental process and add value to process


Next Steps

•

Continue to educate staff and work with patient education liaison to improve compliance

•

Monitor sustained compliance•

Share documentation process with other inpatient nursing units

•

Celebrate success


You too can be… TCABLE

Team Members

•

TCAB Team•

3 NESW Cardiac Telemetry Nursing Staff

•

Julia Havey

RN, Sr. Systems Analyst Medical Information System


Radiation Oncology IT Integration

IMAGES, DATA & PAPER CHARTS TO E-RECORDS

Committee Members:

John Roeske, Ph.D., Committee ChairmanTeresita F. McCoo, RT(NM), MS, MBAKevin Albuquerque, MD, Dolores Franco, RN, Angela McCrum, RT(T)Michelle Reynolds, RT(T), Faisal Vali, MD, Douglas Michels, System Analyst, Mohammed Siddiqui, RT(T), CMD

TABLE 22

RADIATION ONCOLOGY E-CHART TEAM MEMBERS

• John Roeske, Ph.D., Committee Chairman• Kevin Albuquerque, MD• Dolores Franco, RN• Teresita F. McCoo, RT(NM), MS, MBA• Angela McCrum, RT(T)• Douglas Michels, System Analyst• Michelle Reynolds, RT(T)• Mohammed Siddiqui, RT(T), CMD• Faisal Vali, MD

Project Goals• Be Compliant with the 2014 government

mandate to have an electronic record • Design & Implement an electronic version of

the Radiation Oncology paper chart within the IMPAC-MOSAIC environment.

• Create an integrated infrastructure that support workflow and safe, high quality care.

Measurement of Success

– Percent Completion of the Project– Access to the record from multiple sites– Implementation of E-environment

Policies

Project Scope & Management• There were multiple sections of the paper chart that had

to be converted into the electronic environment. These sections were used to break the project development /implementation into modules.

TheOrder

The Treatment

Plan

new

Com-munication

Tools

Treatment Delivery Records

Nursing &MD

Patient TXMngt.

Documents

PhysicsRecords Audits

& Reports

DO- Integrate Systems LINAC,CT Scanner, Physics Systems, Data Storage, Treatment PLANS,

End Users….

MOSAIQ

http://www.missioncriticalmagazine.com/MC/Home/Images/MC-0909-Google-5-BIG.jpg

Measurement of Success-Project Completion

Chart Conversion to E-Format: % Completion of Conversion

020406080

100

3rd QTR 4th QTR 1st QTR 2ndQTR

3rd QTR 4th QTR 1st QTR

2008 2009 2010

Period

%Completion ofConversion

Implementation of e-Chart

0

20

40

60

80

100

Mar-09 Jun-09 Sep-09 Dec-09 Mar-10

Perc

ent I

mpl

emen

ted

PrescriptionTreatment PlanTreatment Fields

Various phasesof e-chartimplementedover time

STATUS OF THE IMPLEMENTATION

Measurement of Success

• Policies were developed & implemented• Records are now accessible from all

practice sites • Cancer Center Clinics• LOC Clinics• Offices• Hines Clinic

Result- Better Integration of Care• Created a System of Communicating

Treatment flow

Contours Needed

Contours MD Done

CT SimScheduled

ChartChecked

Spec Proc. Notes

PT Educ.

GOAL

Chart to beChecked

Therapist

Schedulers

DosimetristCT Sim

Billing

MD

Physics

Result- Capture Ancillary Documentation

Example: TimeExample: Time--Out Documentation Out Documentation & IV Contrast Safety Questionnaire & IV Contrast Safety Questionnaire

Example e-Prescription Report

Physicianintent

MD Approval

Dosing andTreatment fields

The prescription & treatment field specifications are now in e-form

Result- Simultaneous Viewing from Multiple sites

Multiple staff are able to work on different parts of the record at the same time.

Comprehensive checklist prior to treatment

Each group completestheir portion of theChecklist prior tohand-off to the next group.

Results-Ease of Auditing Process

• A by-product of the project is the ability to generate a list of pending tasks. It helps in ensuring complete documentation, timely billing, efficient turnaround times.

Result- Standardization of Practice

• Policies and procedures were developed to address how the operation should be conducted in the electronic world.

• Naming of treatment fields• Where documents should go.• How daily treatments and adjustments will be

documented• Approval of plans for treatment

……And more

Other benefits-• Going to a paperless environment has

created a more robust database that could be used for looking at patient mix, frequency of diagnosis, research etc.

• Improved the ease of getting information needed by insurance companies for reimbursement.

Conclusion

• The department achieved its goal of creating an electronic environment to replace the paper chart. It is supported by an infrastructure and by procedural policies that makes it work well.

Hematopoietic Cell Transplantation- Specific Comorbidity Index (HCT-CI) and Karnofsky Performance Scale

IS THERE A CORRELATION WITH SURVIVAL?

TEAM MEMBERS:M. Brush, APN, AOCN; C. DelSarto, RN; K. Kiley, ANP-BC, AOCN; M. Payan, ANP-BC; N. Porter, APN, AOCN; M. Volle, ACNP, OCN; S. Wojtowicz, BSN, OCN; P. Stiff, MD; T. Rodriguez, MD; and S. Smith, MD

TABLE 23

BACKGROUND• The HCT-CI was developed to identify relevant

comorbidities in the allogeneic stem cell transplantation population and to enable risk assessment prior to allogeneic stem cell transplantation.

• The HCT-CI is able to classify patients into three risk groups (low, intermediate and high) which are predictive of 2 year non-relapse mortality post- transplantation.

• The HCT-CI was derived and validated by investigators at the Fred Hutchinson Cancer Research Center[Sorror et al. Hematopoietic cell transplantation (HCT)-specific co-morbidity index: A new tool for risk assessment before allogeneic HCT. Blood 2005: 106 (2912-2919)]

PROJECT AIM• To increase documentation of the HCT-CI

score and Karnofsky score on all patients undergoing hematopoietic stem cell transplantation within one week of transplant admission.

• To determine whether there is a correlation between HCT-CI scores and two year non-relapse survival at LUMC


• All Bone Marrow Transplant (BMT) Advanced Practice Nurses (APN’s) were educated on the HCT-CI form (which included the Karnofsky score) and the expectations for completion of the form.

• A smart set was developed for EPIC to facilitate the use of the HCT-CI form.

• Written and verbal reminders were given to the APN’s on a frequent basis to encourage timely completion of the HCT-CI.

Compliance with Completing HCT-CI Forms

0102030405060708090

100

Per

cent

Com

plia

nce

Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10

Month

0

10203040506070

8090

100

0 (n=5) 1-2 (n=4) > 2 (n=8)HCT-CI Score

100 Day Survival Autologous Stem Cell Transplants

100 Day Survival Autologous Stem Cell Transplants

(Note: The HCT-CI is predictive of non-relapse mortality 2 years post allogeneic transplant)

100% 100% 100%

100 Day Survival Allogeneic Stem Cell Transplants

(Note: The HCT-CI is predictive of non-relapse mortality 2 years post allogeneic transplant)

0102030405060708090

100

0 (n=5 1-2 (n=9 >2 (n=10)HCT-CI Score

100 Day Survival Allogeneic Stem Cell Transplants

100%

80% 80%

ANALYSIS• For the first 8 months of data collection, there was a

compliance rate of 89% which is below the target of 95%.

• As mentioned earlier, the HCT-CI is designed to be predictive of non-relapse mortality 2 years post allogeneic stem cell transplant. Given that we have been collecting data for only 8 months, it is too early to determine whether it is predictive of non-relapse mortality for transplants performed here at Loyola University Medical Center.

• Because the ultimate goal of collecting this data is to determine whether the HCT-CI tool can be used to predict non-relapse mortality here at Loyola, further education will be required regarding the importance of collecting this data.

• Because the HCT-CI purportedly predicts 2 year non- relapse mortality, survival statistics will need to be collected on all patients for a period of 2 years post transplant.

Next Steps

• Continuing education on importance of completion of HCT-CI tool

• Identify barriers to completion of tool• Post monthly audit results • Continue to monitor and post

correlation of HCT-CI tool with 2 year non-relapse mortality rates

the Safety and Efficacy the Safety and Efficacy of a Patientof a Patient’’s Treatment s Treatment on a Clinical Trialon a Clinical Trial

Team Members: Team Members: Chemotherapy QI Committee , BEACON Core Team, Cancer Chemotherapy QI Committee , BEACON Core Team, Cancer Clinical Trials Office, Pharmacy (Clinical and Investigational),Clinical Trials Office, Pharmacy (Clinical and Investigational), Clinical Nurses, and Cancer Center Physicians Clinical Nurses, and Cancer Center Physicians

A Multidisciplinary A Multidisciplinary Approach to EnsuringApproach to Ensuring

TABLE 24

Project AimsProject Aims

•• Identify potential for error in current Identify potential for error in current processes for building, reviewing and processes for building, reviewing and approving BEACON treatment plans approving BEACON treatment plans for Clinical Trials for Clinical Trials

•• Achieve an efficient standardized Achieve an efficient standardized process process

•• Achieve 100% Accuracy of BEACON Achieve 100% Accuracy of BEACON treatment plans for Clinical Trials treatment plans for Clinical Trials

ProblemProblem•• Number of new Cancer Clinical Trials processed a year Number of new Cancer Clinical Trials processed a year

increased by 42% over the past two years increased by 42% over the past two years •• Complexity and variety of trials has increased over the past Complexity and variety of trials has increased over the past

few years.few years.•• Many sources for trials to include access to eleven NCI Many sources for trials to include access to eleven NCI

(National Cancer Institute) Cooperative Groups, Academic (National Cancer Institute) Cooperative Groups, Academic Consortiums, Investigator initiated and Pharmaceutical Consortiums, Investigator initiated and Pharmaceutical companiescompanies

•• Twenty Twenty ––three investigators with varying frequency with three investigators with varying frequency with submitting new trials submitting new trials

•• Process unclear and has potential for error Process unclear and has potential for error •• Process cannot be auditedProcess cannot be audited•• Timeline too narrow to adequately process new BEACON Timeline too narrow to adequately process new BEACON

treatment plans (BEACON is the EPIC oncology module)treatment plans (BEACON is the EPIC oncology module)

Approach to the ProblemApproach to the Problem

•• Used a modified Failure Modes and Effects Analysis Used a modified Failure Modes and Effects Analysis Process (FMEA)Process (FMEA)

•• Flow charted the current processFlow charted the current process•• Identified potential problem steps and processesIdentified potential problem steps and processes•• Determined which steps and processes needed to be revised Determined which steps and processes needed to be revised

based on team discussion and analysisbased on team discussion and analysis•• Revised the processes to reduce potential for errorRevised the processes to reduce potential for error•• Flow charted the new process at a high level and with Flow charted the new process at a high level and with

detaildetail•• Continue to monitor performanceContinue to monitor performance

Research RN notifies

BEACON team

when firstpatient is screened

Previous ProcessPrevious Process

Potential Communication

Error

Potential Communication

error Timeline too narrow

for BEACON to build treatment plan… potential

for excessive workload

Difficult for RN to

manage within short time frame

Individual research RN’s send data to Beacon team, with

no centralized control of what’s

being sent

PI review timeframe too short

Possible Problems

Research RN receives

notice from IRB that study is approved

Potential for inaccurate BEACON

orders

Research RN routes orders

to PI to review

and approved

BEACON team builds

plan and informs

Research RN when ready to review

Orders approved

and released for use

Research RN notifies

Investigationalpharmacist who Processes ERX

BEACON= EPIC Oncology moduleIRB = Institutional Review BoardPI= Principle InvestigatorERX= Electronic drug record

SolutionsSolutions•• Clearly defined workflow for building BEACON Clearly defined workflow for building BEACON

treatment plans between the Information treatment plans between the Information Technology dept, Investigational Pharmacy and Technology dept, Investigational Pharmacy and BEACON TeamBEACON Team

•• Determined earlier submission timeline to Determined earlier submission timeline to BEACON teamBEACON team

•• Formalized the multidisciplinary review processFormalized the multidisciplinary review process•• Centralized coordination and documentation of Centralized coordination and documentation of

the review processthe review process•• Centralized the information about the status of Centralized the information about the status of

the BEACON treatment planthe BEACON treatment plan•• New process initiated in September, 2009New process initiated in September, 2009

Research Nurse reviews

and edits Treatment Plan

Revised ProcessRevised Process High Level Flow ChartHigh Level Flow Chart

Beacon Team has more time to build treatment

plan

Process is centralized

through CCTO

Research nurse has more time to review and edit

plan

PI has more time for review and has a formal sign off

Process begins earlier – when

protocol is submitted to the

IRB

Process allows for a final review

by all

New Changes

CCTO sends protocols to

Beacon Team & Investigational

Pharmacistwhen sent

to IRB

Status of Active Treatment Plans

are posted on CCTO website.

Completed routing form filed.

Beacon Team revises plan followed by final review

by pharmacy, nurses and PI

PI reviews and edits Treatment Plan and

signs off on routing form

Beacon treatment plan released and notification takes place

Beacon Team builds

Treatment Plans and notifies CCTO when

ready forreview

CCTO = Cancer Clinical Trials Office Manager

BEACON Treatment Plans for NEW and Amended Clinical Trials Process for submission of research protocols to BEACON Build team. Process for review and approval of Treatment plans for Clinical Trials

CCTO (Manager) sends all protocols reviewed at Protocol Review Committee (PRC) to

Investigational Pharmacist. Include the order of priority for building

ERX records.PRC meeting 3rd Tues of Month

Investigational pharmacistcreates ERX record for study-supplied and investigational drugs and sets up study in

Investigational Pharmacy Management System

Timeline Cooperative Group Studies

4-6 weeks from PRC

BEACON team builds treatment plan and notifies CCTO manager that treatment plan is ready to

review, returning routing form

Research Nurse Reviews and edits as needed

PI Reviews and edits

BEACON Team revises treatment plan

BEACON treatment plan released and pharmacist notifies CCTO Manager

PI forwards to research nurse or manager and signs off on routing form

Timeline Pharma and PI Initiated

Studies 2-4 months from PRC

Manager notifies the research nurse and PI that the Treatment plan is ready to review

Final review of treatment plan Pharmacy , Research Nurse and PI

Manager notifies PI and nurse, then posts on CCTO Website that the BEACON treatment plan is active.

Completed Routing form will be stored in central file.

RN coordinates with PI for review-Sends routing form to PI

Note:Knowing at what point the treatment plan is in the process is dependent on communication between

pharmacy and the CCTO due to inability to differentiate in BEACON

CCTO (Manager) Sends NEW protocols and routing form to BEACON TEAM at time of IRB Submission

(LU # included)

BEACON TeamTina Cabala 72710Donna Fletcher-Gonzalez 63702Germika Collier 72085Janine Marschalk 72006

Protocol Amendments

Clinical Regulatory Coordinator sends notice to PI, staff and

BEACON builder when the IRB approves an amendment

CRC distributes amendment routing

form for review

Investigational Pharmacist Bushra Muneer 66225

ResultsResults

Goal: 100% Accuracy of BEACON Treatment Plans Built for Clinical Trials June 2009- Feb 2010

75%

80%

85%

90%

95%

100%

June July

Aug

Sept

Oct Nov

Dec

Jan

Feb

Percentage of Protocols with Accurate BEACON Orders

BEACON is the EPIC Oncology ModuleBEACON is the EPIC Oncology Module

Next StepsNext Steps

•• Determine best approach to utilize BEACON with ensuring Determine best approach to utilize BEACON with ensuring study parameters and dose modifications are met.study parameters and dose modifications are met.

•• Elicit end user feedbackElicit end user feedback-- the physicians entering the orders the physicians entering the orders and nurses executing the ordersand nurses executing the orders

•• Define categories within BEACON and the type of Define categories within BEACON and the type of information to include in these categoriesinformation to include in these categories

•• Improve readability for end usersImprove readability for end users•• Differentiate in treatment plan what is standard vs. nonDifferentiate in treatment plan what is standard vs. non--

standard or study relatedstandard or study related•• Develop guidelines for reviewing treatment plans Develop guidelines for reviewing treatment plans •• Determine best method to measure medication errors Determine best method to measure medication errors

associated with treatment plans for clinical trialsassociated with treatment plans for clinical trials

Understanding each otherUnderstanding each other’’s view and role s view and role improves the processimproves the process

EveryoneEveryone’’s view in BEACON is differents view in BEACON is different

Lessons LearnedLessons Learned

Together we all ensure the safety Together we all ensure the safety of the patientof the patient

Team Membership

Sandra M. Weszelits APNNurse Practitioner, Pediatric Surgery

Loretto A. Glynn, MDMedical Director, Pediatric Surgery

Preventing Complications in Preventing Complications in Gastrostomy/JejunostomyGastrostomy/Jejunostomy

Tubes in Tubes in

Pediatric PatientsPediatric Patients

TABLE 25

This project was introduced as a method to identify the best manner to secure Gastrostomy/Jejunostomy

Tubes in place so that

dislodgement is prevented. When discussing various prevention methods, skin care became a prevalent factor to evaluate. If tubes are dislodged or if skin integrity is breached the patient is at risk for serious complication and there is an increased healthcare cost to the patient and hospital

Background

Goal

Reduce the incidence of Gastrostomy/Jejunostomy tube displacement within the initial 30 day post-operative period to 0% and maintain skin integrity around stoma site.

• Standardized suturing protocol by both pediatric surgeons who place Gastrostomy/Jejunostomy Tubes

• Education for nursing and residents on site care and dressings

• Standardized clinical protocol and ordersets for Gastrostomy care

• Standardized teaching material for parents• APN run Gastrostomy Tube Clinic


Results

SUTURING of the Gastrostomy/ Jejunostomy

tube provided the most

stability and prevent dislodgement and skin breakdown in 100% of our patients

Number of Complications by Method of Securing Tube

05

101520253035404550

Number of tubes placed 44 17 25# Complications 5 10 0

Tape Sutured Disk Sutured Tube

010

2030405060

7080

2007 (n=3/26) 2008 (n=12/27) 2009 (n=0/23)

Percentage of Complication by Method and Year

Tape Sutured Disk Sutured Tube

Per

cent

Com

plic

atio

n

DISK

Skin

Stomach

Catheter Tip

Gastrostomy Tube

Analysis

• Tape and suturing of the disk were standard practice for stabilizing the gastrostomy/jejunostomy tube.

• These methods resulted in higher complication rates from tube dislodgment, potential for peritonitis, and skin breakdown

• Current literature supported suturing the tube as the standard method for stabilizing the tubes and resulted in ZERO tube dislodgments and skin breakdown.

Next Steps

• Continue to monitor for complications• Utilize suturing of tube as the standard

method for securing Gastrostomy/Jejunostomy tubes

• Work with other services to standardize their method of securing tube to suturing of tube

• Evaluate PEG tubes and the potential for conversion to open procedure as compared to Laparascopic Assisted PEG placement

APN Gastrostomy Clinic

• Provides– Gastrostomy Tube changes– Maintenance of Gastrostomy Tubes– Skin assessment and treatment– Patient Education– Family Support– Daily Clinic Availability

Magnet Forces• Force 6 Quality of Care

Quality is the systemic driving force for nursing and the organization. Nurses serving in leadership positions are responsible for providing and environment that positively influences patient outcomes and is a pervasive perception among nurses that they provide high quality care to patients.

• Force 12 Image of NursingThe services provided by nurses are characterized as essential by other members of the healthcare team. Nurses are viewed as integral to the healthcare organization’s ability to provide patient care. Nursing effectively influences system-wide processes.

Improving Compliance with Positioning, Splinting & Activity of the Burn Patient

Melissa Drews-Lane, MS, OTR/LKathy Supple, ACNP

Adam Young, PT

TABLE 26

Activity and positioning of the burn patient are key to the patient’s functional outcome. Splints are given to most patients to assure maximal functional outcome. The consequences of immobility should be avoided by this activity. A patient needs to be up out of bed throughout the day to regain strength and maintain functional independence. The multidisciplinary team on the burn unit strives to provide excellence with patient care. We identified an inconsistency among staff with compliance regarding activity, splinting, and positioning of the burn patient. Specifically, we identified a problem with compliance of application and documentation of splints and the activity level of patients.

Background

Goal

1. Improve compliance with patient splinting and activity orders 100% of the time

2. Improve documentation of splinting and activity level in EPIC to 100%

• Staff education on the importance of documentation and compliance

• Implementation of binder for self-education and permanent resource. Available to staff at all times

• Implementation of visual pictures in patient’s room of splints/positioning/activity

• Resident education on activity orders for burn patients


0%

20%

40%

60%

80%

100%

Pre Post

87%

59%

Documentation of OOB

Patients OOB within 24 hours period

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Pre Post

65%

84%

Splint wear schedule provided for patients

0%

20%

40%

60%

80%

100%

Pre Post

100%100%

Splint wear schedule posted in room

100% 100%

0%

20%

40%

60%

80%

100%

Pre Post

Splint wear documented in EPIC

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre Post

14%

86%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre Post

Documentation of splints worn correctly and on schedule

86%

7%

Analysis– Documentation of splint wear and activity has

improved– Compliance with activity orders has increased

Next Steps• Revise Burn ordersets to include splinting orders• Revise Burn ordersets to include specific activity orders• Revise resident education manual• Continue to provide education to RN’s, PCT’s, and

residents• Provide education to all OT staff and extend education

hospital-wide to all RN’s, PCT’s and residents• Continue to monitor progress

Organizational Initiatives to Optimize Organ Donation

Rose Lach, PhD Kim Reeks, RNFred Luchette, MD Cindi Laporte, RNMichael Schneck, MD A. Mostofi, MSNThomas Esposito, MD Megan Kuck, RNHoward Sankary, MD Kathryn Ichniowski, RNDavid Holt, MD Mary McGillicuddy, MSWCharles Alex, MD Marie Coglianese, MPSNandine Calamur, MD Katherine Abhalter, GOHJessica Wanger, GOH

For Quality Improvement PurposesTABLE 27

Background

Over 105,000 persons are waiting for organs yet only 19,000 have been transplanted in 2009.

To narrow the gap between organ need and organ donation, the US Department of Health & Human Services (HHS) has set a goal for each hospital to achieve a 75% organ donation rate or 3.65 organs/person.Since 2003, HHS has promoted a national collaborative to increase organ donation.

For Quality Improvement Purposes

Aim Statement

TargetsLUMC will achieve a 75% organ conversion rate.Timely referrals for organ donation to the Gift of Hope (GOH) will be greater than 90%.

Applicable Magnet ForcesForce 6: Quality of CareForce 13: Interdisciplinary Relationships

LUMC’s Organ Donation Committee launched several initiatives to raise awareness and outlined procedures to increase organ donation.



A multidisciplinary organ donation committee was initiated including ICU physician directors, managers, an ethicist, a chaplian, a social worker, and GOH representatives.

GOH provided bi-monthly data on LUMC’s conversion rate and barriers discussed.

A policy outlining the process for brain death and “donation after cardiac death” was implemented.



GOH given “read only” access to EPIC to review potential donors.

Brain death protocol orders established by the GOH implemented.

A GOH representative exclusive to LUMC assigned.

Organ donation education provided at nurses and physicians orientation and annual continuing education programs.


Per

cent

LUMC Organ Conversion Rate

Quarter

UCL = 97

Mean = 41

1Q 2007

2Q 2007

3Q 2007

4Q 2007

1Q 2008

2Q 2008

3Q 2008

4Q 2008

1Q 2009

2Q 2009

3Q 2009

4Q 2009

0

20

40

60

80

100


Per

cent

LUMC Timely Notification of Potential Donors

Quarter

UCL = 130

Mean = 80

LCL = 31

1Q 2007

2Q 2007

3Q 2007

4Q 2007

1Q 2008

2Q 2008

3Q 2008

4Q 2008

1Q 2009

2Q 2009

3Q 2009

4Q 2009

0

20

40

60

80

100

120


Analysis

Organ Donation conversion rate increased from 41% in January, 2007 to 100% in Dec., 2009

Timely referral rate to the GOH increased from 83% in January, 2007 to 100% in Dec., 2009.


Next Steps

Continue with quarterly analysis of organ conversion rate, however, move report to ICU Committee.

Hold regular “huddles” after organ donation to discuss success and failures.

Provide regular report to senior leadership.

Continue to thank staff for their involvement and report on “lives saved”.


Achieving and Maintaining 80% Compliance with the Use of

Intravenous Pump Safety Software

Dorothy Bourgeois, RN; Joan Howard, RN; Gwen Loes, RN; Richard Mattis, MD; Tom Busse, Pharm

D; Connie Clark, RN

TABLE 28


•

Improve patient safety through the use of “smart pumps”

•

Achieve and maintain at least 80% compliance on all inpatient units

Pertinent Magnet Forces1. Quality of Nursing Leadership2. Management Style6. Quality of Care7. Quality Improvement

13. Interdisciplinary RelationshipsConfidential – for quality improvement purposes only

Solutions ImplementedDepartment Actions and Communications

-

communication of expectations-

achievement standard on performance reviews

Unit Actions and Communications-

Nurse Manager/charge nurse rounds-

identification of super-users on all shifts

Nursing-Pharmacy-Medical Staff Collaboration-

drug library customized for each unitmost frequently used drugs come up first on the screen

-

ease of accessing Code 88 drugs-

patient weight entry calculates weight based medications-

achievement reported at medical Executive and Pharmacy and Therapeutics Committees

Confidential – for quality improvement purposes only

Compliance with Safety Software for MednNet IV Pumps April 2006-February 2010

Perc

ent C

ompl

ianc

e

For Quality Improvement Purposes Only

4/ 1/ 2

0065/ 1

/2006

6/ 1/ 2

0067/1

/2006

8/ 1/ 2

0069/1

/ 2006

10 /1/2

0 06

11 /1/2

0 06

12 /1/2

0 061/ 1

/ 200 7

2/ 1/2

0073/ 1

/ 2007

4/1/2

0075/ 1

/ 2007

6/ 1/2

0077/ 1

/ 2007

8/1/2

0079/ 1

/ 2007

10 /1/2

0 07

11 /1/2

0 07

12 /1/2

0 071/ 1

/ 2008

2/ 1/ 2

00 83/ 1

/2008

4/ 1/ 2

00 85/ 1

/ 2008

6/ 1/ 2

0087/ 1

/2008

8/ 1/ 2

0089/ 1

/2008

10 /1/2

0 08

11 /1/2

0 08

12 /1/2

0 081/1

/ 2009

2/ 1/ 2

0093/1

/ 2009

4/ 1/ 2

0095/ 1

/ 200 9

6/ 1/ 2

0097/ 1

/ 2009

8/ 1/ 2

0099/ 1

/ 2009

10 /1/2

0 09

11 /1/2

0 09

12 /1/2

0 091/ 1

/ 2010

2/1/2

010

20

30

40

50

60

70

80 T a r g e t

Drug library revision and educational in-services



Per

cent

Com

plia

nce

For Quality Improvement Purposes Only

8/2008 (n

=6597)

9/2008 (n

=5711)

10/2008 (n

=6700)

11/2008 (n

=8486)

12/2008 (n

=7155)

1/2009 (n

=7319)

2/2009 (n

=8361)

3/2009 (n

=7944)

4/2009 (n

=7942)

5/2009 (n

=8211)

6/2009 (n

=7468)

7/2009 (n

=7161)

8/2009 (n

=7353)

9/2009 (n

=8551)

10/2009 (n

=7432)

11/2009 (n

=7074)

12/2009 (n

=8364)

1/2010 (n

=8580)

2/2010 (n

=7230)

79

80

81

82

83

84

85

Target

M ean

UCL

M ean

LCL

19

Compliance with Safety Software for MedNet IV Pumps August 2008-February 2010

AnalysisThe safety software has prevented infusion

rate errors* on

224 occasionsIn the past 12 months (0.23% of 95,994

programming events)

*This means that a rate limit warning was displayed and the nurse changed the rate on the pump prior to starting the infusion


Next Steps•

Ensure compliance and consistency in outpatient areas

•

Learn for the future when purchasing programmable equipment


Improve Quality of Care by Instituting Clinical Protocols

in the Gottlieb Wound Healing & Hyperbaric

Medicine Center

TABLE 29

Team Membership

Richard Viglione, M.D. Medical Director

Sung Kim, M.D. Leslie Phillips, Program DirectorLinda Dent, HBO Safety DirectorSari Cairo, R.N. Clinical CoordinatorAndy Cerna, R. N.

Background• An estimated eight million Americans suffer from

chronic wounds. Wounds come from a variety of different medical conditions, and they don't heal for many different reasons. Typically, a wound that does not respond to normal medical care within 30 days is considered a problem or chronic wound.

• Hard to heal wounds such as diabetic ulcers, surgical wound or venous stasis ulcers require specialized treatment with specialized dressings, pressure relieving casts, and hyperbaric oxygen chambers.

Problem Statement

The Wound Healing & Hyperbaric Medicine Center identified two key quality of care indicators that were outside acceptable limits of the national benchmark

• Days to heal

• Healing percentage

Goals:• Reduce the rate of “Days to

heal” to less than 35 days

• Increase the healing percentage of wounds to 88%


Definitions:

Days to heal is defined as the number of days from the wound admission until the wound is healed and measured at 0x0x0 cm.

Healing percentage is defined as the percentage of wounds that are discharged as healed versus an unfavorable outcome (e.g. amputation, etc.).



Magnet Forces of Magnetism

Force 6: Quality of CareForce 7: Quality Improvement Force 8: Consultation & ResourcesForce 13: Interdisciplinary

Relationships

– Formed a multidisciplinary team to investigate best practices.

– Implementation of evidenced-based Clinical Practice Guidelines in July 2007.

– Wound Healing Society Guidelines for the Best Care of Chronic Wounds 2006

– Wound Ostomy Continence Nurses Society Clinical Practice Guidelines 2002-2005

– Oxygen therapy Committee Report of the Undersea and Hyperbaric Medicine Society 2003

– All staff and physicians were educated on the new Clinical Practice Guidelines.


– The Clinical Practice Guidelines include: • Diagnostic criteria• Key therapeutic objectives• Common pathways to non healing• Assessment and intervention recommendations• Timely and appropriate utilization of adjunct therapies

including Hyperbaric Oxygen Therapy and Bioengineered Skin Substitutes.

• Time references for wound progress and interventions

• References


Day

s to

Hea

l

Fo r Q u a lity Imp ro v e me n t Pu r p o s e s O n ly

Jul- S

e p 06

Oct

-Dec

06

Jan -M

a r 07

Ap r-

Jun 0

7

Jul- S

ep 07

Oct

-Dec

07

Jan -M

a r 08

Ap r-

Jun 0

8

Jul- S

e p 08

Oct -D

ec 0

8

Jan -M

a r 09

Ap r-

Jun 0

9

Jul- S

ep 09

Oct

-Dec

09

Jan -M

a r 10

2 0

3 0

4 0

5 0

6 0

7 0

T a r g e t

M e a n

U C L

M e a n

L C L

The Wound Healing & Hyperbaric Medicine Center’s days to heal decreased by 12.4 days from 49.2 to 30 days after project

implementation in July 2007.

Number of days to heal below mean of 40 days for last year.

CPG Implementation 3Q07

Per

cent

age

of W

ound

s H

eale

d

Fo r Q u a lity Imp ro v e me n t Pu r p o s e s O n ly

Jul- S

e p 06

Oct

-Dec

06

Jan -M

a r 07

Ap r-

Jun 0

7

Jul- S

ep 07

Oct

-Dec

07

Jan -M

a r 08

Ap r-

Jun 0

8

Jul- S

e p 08

Oct -D

ec 0

8

Jan -M

a r 09

Ap r-

Jun 0

9

Jul- S

ep 09

Oct

-Dec

09

Jan -M

a r 10

8 5

9 0

9 5

1 0 0

1 0 5

T a r g e t

M e a n

U C L

M e a n

L C L

The Wound Healing & Hyperbaric Medicine Center’s healing percentage consistently remains above the target of 88%

after project implementation in 2007.

The mean average of wounds healed is 95%

CPG Implementation 3Q07

Award Winning Performance

The Wound Healing & Hyperbaric Medicine Center at Gottlieb Memorial Hospital has been recognized as a Center of Distinction in both 2008 and 2009 by it’s parent company, Diversified Clinical Services, Inc. The Center also earned the company’s Robert A. Warriner, M.D., Center of Excellence award in recognition of earning its second consecutive Center of Distinction Award.

These awards recognize the Center's delivery of outstanding results for twelve consecutive months in both 2008 and 2009, through the meeting or exceeding of company benchmarks in Healing Outcomes, Patient Satisfaction, Outlier Management and Days to Heal.

Next Steps

•Increase healing percentage target to 96% •Analyze outliers for common trends•Share results with key stakeholders•Celebrate successes

LEAN Transformation: The GI Lab Journey to Enhance Patient Flow & Volumes

Team Leadership:Claus Fimmel, MDRose Lach, RN, PhDDeb Kull, MBA John Zinkel, MS, BBA, RRT, RCP Lynn Heicher, RN, MS, CGRN, CLNCCarmen Acevedo

Team Membership: The GI Lab Staff and Physicians

Magnet Forces:Force 6: Quality of CareForce 7: Quality ImprovementForce 11:Nurses as teachers

TABLE 30


To utilize LEAN concepts to increase and sustain operational efficiencies in the GI Lab.

Goals:

Increase volume from 35 to 60 average cases per day

Increase gross revenues

Eliminate registry personnel

Sustain transformed areas by using a standard work format

The Value Stream Map November 2-5, 2009

To determine capacity and overall efficiencies of the GI Lab, a Value Stream Map was developed.

Comprehensive time studies to measure patient flow pre, intra, and post procedure.

Baseline 5S (Sort, Straighten, Shine, Standardize, Sustain) scores collected for the nurses station, pre op, post op and procedure rooms.

Baseline data collected for 1 week.

Value stream map created and problem burst areas clearly defined.

The Value Stream Map (VSM)

The VSM is ground zero and drives our GI Kaizens!

A “Road Map” was created to highlight key improvement opportunities. Several Kaizen events

were planned and executed

Date EventNovember 9-13, 2009 5S Pre procedure, Post Procedure and

Procedure RoomsDecember 14-18, 2009 Kaizen - Appointment Scheduling

January 28, 2010 Visual Management Board

February 8-12, 2010 5S Nurse Station

February 8-12, 2010 Room 1, Motility, Capsule Studies,Breath Tests

February 15-19, 2010 Kaizen – Physician Scheduling

March 22-26, 2010 5S Endoscope Reprocessing Room

5S - Sort, Straighten, Shine, Standardize, Sustain

Evaluated the pre-procedure & post-procedure areas

Set standard work flow

Established standard supply par levels

A Standard Work Survey is done daily to sustain what was improved

BEFORE AFTER

Steady improvement in 5S scores demonstrate staff compliance with sustaining the changes made

Target = 5.0 Score

TARGET: 5.0GI Laboratory 5S Scorecard

0.2

1.8

4.2

4.64.8

3

3.63.8

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

11/9/09 11/16/2009 11/25/09 12/4/2009 1/28/2010 2/12/2010 3/19/10 3/26/10

Appointment & Physician Scheduling December 14-18, 2009; February 15-19, 2010

Initiated “first contact” script for schedulers.

Initiated HACC in-basket messaging.

Mirrored scheduling set up for appointments.

Implemented use of the Daily Appointment screens.

Developed and implemented phone tree.

Developed a physician block schedule.

Established an ‘Add On Room’ for in-patients.

Adjusted staffing plan to meet provider and patient care needs.

Time A B C D E F A B C D E F A B C D E F Time A B C D E F A B C D E F700 700730 730800 800830 830900 900930 9301000 10001030 10301100 11001130 11301200 1200 Break1230 12301300 13001330 13301400 14001430 14301500 15001530 15301600 16001630 16301700 17001730 17301800 18001830 18301900 1900

* Schnell may use Add On Rm first thing in morning.

Peds

?

Levi

s

Add

-Ons

/Con

sult

Phys

Add

-Ons

/Con

sult

Phys

A P

illai

Fim

mel

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Monday Tuesday Wednesday Thursday Friday

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Lecture Lecture

Time A B C D E F A B C D E F A B C D E F A B C D E F A B C D E F700730800830900930

1000103011001130120012301300133014001430150015301600163017001730180018301900

LectureLecture

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Monday Tuesday Wednesday Thursday Friday

Old

New

Visual Management January 28, 2010

Re-formatted existing white board in the GI Lab Nurses Station – divided by rooms to create 60 slots

Use board to track patient flow through the system - arrival time, location, and discharge time

Staff and physicians now have a “visual cue” for patient tracking and space utilization

Reduced congestion in the charge nurse area

Average Case Volume per Day

41.15

32.7532.77

37.68

39.837.38

36

41.4239.42

37.8 37.72

15

20

25

30

35

40

45

May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10

Appointment & Physician scheduling changes have increased capacity

The LEAN journey begins

Target: 60 cases/day

Next Steps: Roll out and Implementation

Physician scheduling plan April 15, 2010

Staff scheduling plan April 15, 2010

Mini-Kaizen Events: materials, supply and pharmaceutical ordering processes, endoscope reprocessing room

March 2010

Continue to develop subject matter experts; Divine Grace Tongol and Michalene Facenda will be Loyola’s 1st certified subject matter experts.

March 2010

Build and grow volume. OngoingSustain all areas. Ongoing

Enhancing Quality In Patient Care by Implementing a Lean

Culture

Picture


TABLE 31

Goals and Objectives

• Transform Loyola to a culture of continuous improvement using lean methodology

• Educate 100% of management on lean methodology by July, 2010

• Measure performance of operational initiatives


What is Lean Transformation?


• A change in thinking• Individual optimization to process optimization• Questioning “what we’ve always done”

• A change in behavior• Defining the critical few metrics and opportunities• Measuring performance at all levels

• A change in culture• Engages all employees• Enables daily improvement

Phases of a Transformation

N/10 pace and 1–3% dedicated to Continuous Improvement

ChangingActions

Apply

tools

Borrowing th

en

Develo

ping Technique Developing

New Beliefs Fore

ver I

mprov

e

Cultur

e Cha

nge

Impr

ovem

ents

in H

D, Q

, C, D

Introduction Year 1-2

IntenseYear 3-5

Development Year 5 - 10

ChangingHabits

ChangingValues

Understanding &

EmbeddingPrinciples

Loyola’s Transformation

More People – Improving Faster

Impr

ovem

ents

in S

QDPC

Changing

Culture


We are here

Transferring Knowledge• 100 % of Management

– 35 Trained– 225 Total

Subject Matter Expert Development


Voice of the Customer

“How We Do It” Kaizen Event Week

DAY 1 DAY 5DAY 4DAY 3DAY 2

Tool Specific Training

Observe & Analyze Current

Process / Begin

Improvements

Continued Improvements

Refinement And Finalize

Improvements Final Presentation

Leader Meeting

Leader Meeting

Leader Meeting


GI Lab Nurse to Patient Contact Time

Before Kaizen 60% of the Nurse’s time was

spent hunting and gathering

After Kaizen 87% of the Nurse’s time was spent in direct

patient contact


Sustainment


3.64.2 4.0

5.0

5.9

0

1

2

3

4

5

6

Nov-09 Dec-09 Jan-10 Feb-10 Mar-10

SRP Technician Productivity: Average Trays Per Hour

Average Case Volume per Day

41.15

32.7532.77

37.68

39.837.38

36

41.4239.42

37.8 37.72

15

20

25

30

35

40

45

May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10

Target 60 cases/ per day

GI Lab

The LEAN Journey Begins

Next Steps


• Develop Subject Matter Experts

• Patient Throughput

• Scheduling Access

• Supply Chain Management

Team MembersGreg Horner Brad Helfand Jon Brickman Jose Gonzalez Josephine Servano Jill Anderson Dwayne Walton James Vondra Linda Flemm Gilberto Carnalla Lori Mohito Matt Gimble

Operational Excellence TeamSurgical Reprocessing Staff

Operating Room StaffPP&G, IT, & House Keeping Staff

The Lean Journey: The Lean Journey: Operational Improvement of Operational Improvement of

Surgical ReprocessingSurgical Reprocessing

For Quality Improvement PurposesTABLE 32

Project AimProject AimTo maximize the production capacity of the tray assembly area in order to better align with the demand of the Operating Room.

A misalignment of output vs. demand causes:• OR inefficiencies• Increased flash sterilization rates• Limits the time practitioners have to focus

on our patients• Inflated staffing to keep up with demand


To improve department workflow, production, and quality by reducing process waste and increasing technician productivity.

Our Key Process Indicator: Assembly Technician Productivity

Our Goal:5.0 trays per hour per Assembly Technician

Project GoalProject Goal


Solutions Implemented Solutions Implemented Date Project Description Waste

ReductionNovember 20th, 2009

-Assembly Lane/Decontam Workflow Reconstruction-Standard Work Instructions

56 Steps

November 30th, 2009

Sonic Lane Workflow Reconstruction-Standard Work Instructions

28 Steps

December 22nd, 2009

Picture Catalog Construction N/AFebruary 5th, 2010 Instrument Supply

Reorganization36 Steps

March 5th, 2010 -Missing Instrument Root Cause Analysis-Standard Work Instructions

Results not yet realized


Station 3

Station 4

Station 5

Station 6

Station 7

Station 8

Sonics 2

Station 1

Printers

OnSite

Station

Implant Table &Drawers

Peel Pack and Battery Charger Station

Sterilizers

Cart 1

Cart 3

Cart 4

Cart 5

Cart 6

Cart 2

Priority Cart

Washers

Drill Cart

Inc. Cart

Sterrad

Units

ORIGINAL DEPARTMENT LAYOUT/WORKFLOWORIGINAL DEPARTMENT LAYOUT/WORKFLOW


NEW DEPARTMENT LAYOUT/WORKFLOWNEW DEPARTMENT LAYOUT/WORKFLOW


DO NOT SUBSTITUTE

WITH THE REGULAR VERSION

DO NOT SUBSTITUTE

WITH THE REGULAR VERSION

Project Data AnalysisProject Data Analysis• Available Data indicates a 2.3 tray per hour

average increase from November 2009 to March 2010 – 3.6 to 5.9 trays per hour

• The 2.3 tray per hour increase equates to:– 16.1 additional trays per technician over a

7 hour shift– Or 161 additional trays per ten assemblers

––NO ADDITIONAL NO ADDITIONAL MANPOWER NEEDEDMANPOWER NEEDED


Next Steps & Lessons LearnedNext Steps & Lessons Learned

• Stabilize productivity on a day to day basis– Consistently hitting 5 trays per hour will allow us

to surpass the original goal– Staff accordingly to the OR demand based on the

average tray demand of 400 per day

What we are learning:• The basis of LEAN is to put a structure in place that

promotes “Continuous Improvement”…….• This project has only scratched the surface of

improving the department…several more in the planning stageFor Quality Improvement Purposes

THE ROADMAP FOR IMPROVEMENTTHE ROADMAP FOR IMPROVEMENT


Monitoring Use of Flash Sterilization: Systems approach to documentation and management of

short-cycle steam sterilization

2010 LUHS Quality & Safety FairTeam Members:

Brad Helfand, Surgical Services Debbie Marra, OR Nursing

Alex Tomich, Infection Control Debbie Serwa, ASC

Lu Ann Vis, CCE Jon Brickman, OR Support


TABLE 33

Flash Sterilization = steam sterilization as defined by 3 minute cycle at 270 degree Fahrenheit at 27 to 28 pounds of pressure.

Definition of Flash Sterilization


• Inconsistent flash logs to capture data between Russo and ASC• Internal audits of Russo flash sterilization logs found missing information

such as instrument or tray processed and reason for use of flash cycle• LUMC cited by the Joint Commission in 2007 for instances of flash

sterilization• The Joint Commission released new guidance on flash sterilization in July

2009 announcement to hospitals. This guidance focused on three key elements:

• Cleaning and decontamination: all visible soil must be removed prior to sterilization

• Sterilization: cycle must conform to instrument manufacturer recommendations for proper time, temperature, and pressure

• Storage and return to the sterile field: the sterilized instrument must be protected to ensure that it does not get contaminated prior to placing it on the sterile field

Key Challenges


• Develop consistent methods for documenting the 5 W’s (Who, What, Where, When, and Why) related to flash cycles

• Establish on-going measurement and tracking of flash cycles• Provide education to caregivers on recommended steps for safe use of flash

sterilization equipment• Acquire new tools (e.g., covered flash pans) to meet regulatory guidance• Establish easy access to manufacturer guidelines on sterilization parameters• Monitor and report on flash sterilization trends to key stakeholders

Project Objectives & Goals

Correct ToolsProper Documentation

On-going Tracking


• Formed Flash Committee (July 2009)• Reviewed Literature of Best Practices (July 2009)• Developed Process for Nursing-SRP Collaboration on Decontamination of

Instruments to be Flash Sterilized (July 2009)• Educated Staff on Proper Protocols for Flash Sterilization (August 2009)• Initiated On-Going Data Collection (August 2009)• Launched Revised Flash Sterilization Log (September 2009)• Requested Covered Flash Pans (October 2009)• Assessed Instrument Capital and Inventory Needs (November 2009)• Requested One Source Document Management System for Manufacturer

Guidelines on Sterilization (December 2009)• Implemented Spot Audits of Flash Log Documentation and Clear

Accountability Standards (January 2010)• Conducted Tracer Audits of the End-to-End Process (January 2010)• Implemented Flash Pans and One Source System (March 2010)

Tactics to Improve Monitoring of Flash Sterilization


New Flash Sterilization Log

Sterilizer Location

Receipt with Cycle ID

Name of Instrument

Reason for Flash Cycle

Limit of Two Records Per Page


Flash Sterilization Trends as a Percentage of Overall Steam Sterilization

Flash cycles seen as a percentage of overall sterilization cycles in a given month. Calculation based on number of flash cycles divided by total steam sterilization cycles. Steam sterilization cycles taken from the Horizon Tray Tracking System.


Flash Percentage Trend

8.87%

11.39%

9.46%

10.73%

9.31%

7.96%8.36%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

Base

line

Octo

ber 2

009

Nove

mber

2009

Dece

mbe

r 200

9Jan

uary

2010

Febr

uary

2010

Mar

ch 20

10

Percentage

Analysis of Reasons for Flash Sterilization

Source: Russo and ASC OR Flash Logs, Average December 2009 – February 2009, excludes test cycles and cycles with missing documentation

Contaminated in OR, 34.8%

Sterile Processing Sent Unsterile to OR,

41.9%

Back-to-back procedures, 2.7%

One-of-a-kind instrumentation,

14.2%

Package Integrity, 0.3%

Not for patient use-decontam only,

6.2%


Contaminated in OR, 4%Sterile Processing Sent to

OR Unsterile, 19%

Back to back procedures, 51%

One-of-a-kind instrumentation, 15%

Package integrity, 1%

Not for patient use - decontam only, 11%

RUSSO ASC

• ENHANCED KNOWLEDGE OF STERILIZATION TECHNIQUES

• IMPROVED QUALITY AND SAFETY FOR PATIENTS

• GREATER COOPERATION BETWEEN SRP TECHNICIANS AND OR NURSES

Project Results


• On-going data analysis and tracking of key trends

• Implementation of flash pans and new web-based system to manage manufacturer guidelines for sterilization parameters

• Daily rounding by OR management to monitor staff compliance with documentation standards on flash sterilization

• Continuous process improvement (“kaizen” events) in SRP to improve production capabilities and reduce dependence on flash sterilization

Next Steps
