nurse sensitvie indicators paper

Running head: NURSE SENSITIVE INDICATORS

Nurse Sensitive Indicators and Core Measures

Shannon Hart

Colorado Christian University

NUR-415A Adult Health Nursing II

Diann DeWitt

April 24, 2016

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Nurse Sensitive Indicators

Nurse Sensitive Indicators and Core Measures

At St. Mary’s Hospital cardiac unit, patients are admitted for cardiac monitoring after a

diagnosed myocardial infarction, a suspected myocardial infarction, or when an

electrocardiogram (ECG) shows a patient is experiencing arrhythmias. To provide the best care,

the Joint Commission has set standards of care that hospitals are required to follow. On all units,

measures to prevent falls, urinary tract infections, and infections of central lines are followed, but

the cardiac unit has measures that are specific to patients admitted for myocardial infarctions,

blood clots and other cardiac conditions.

Although nurses do not have the authority to control all parts of each core measure, their

role is to know and initiate actions of nurse sensitive indicators. “Nursing-sensitive indicators

identify structures of care and care processes, both of which in turn influence care outcomes.

Nursing-sensitive indicators are distinct and specific to nursing, and differ from medical

indicators of care quality (Montalvo, 2007).” Although St. Mary’s did not provide access to the

nurse sensitive indicators for the hospital or each unit, Core Measures were found, with roles for

the nurse detailed. This paper will explain a few of these measures and the responsibilities of the

nurse to meet the requirements of each measure.

Fibrinolytic Therapy AMI-7a

The first measure covered is fibrinolytic therapy, which requires that fibrinolytic therapy

is received within 30 minutes of hospital arrival for all patients who present with an acute

myocardial infarction or AMI (Lippincott Advisor, 2016). Timing is imperative because “studies

shows that the time from hospital arrival to the initiation of fibrinolytic therapy in patients

presenting with an AMI is a strong determinant of outcome” (Lippincott Advisor, 2016).

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Fibrinolytic therapies are medications that dissolve thrombi in the coronary arteries and restore

myocardial blood flow (Ignatavicius, Workman, 2013).

When a patient is admitted to the hospital with an AMI, the nurse plays a crucial role in

initiating care. First, the nurse is responsible for assessing the patient for signs and symptoms of

of acute coronary syndrome or cardiac ischemia, which may include dizziness, syncope,

shortness of breath, and chest pain (Lippincott Advisor, 2016). The nurse is also responsible for

obtaining a 12 lead EKG, and ensuring a practitioner reviews it within 10 minutes (Lippincott

Advisor, 2016). Next the nurse can encourage the practitioner to begin immediate fibrinolytic

therapy, and if ordered, ensure that medication is administered within 30 minutes of arrival.

Lastly, the nurse is responsible for accurate and timely documentation of all patient care and

medications given, as well as ensuring that the provider is documenting any deviations from

accountability measures protocol, such as a delay over 30 minutes in the administration of

fibrinolytic therapy (Lippincott Advisor, 2016).

According to Medicare.gov, Colorado’s average was 40% compared to the national

average of 60% (Hospital Care, 2016). Both of these statistics seem incredibly low, which

means efforts to improve timing of fibrinolytic therapy must be evaluated, state wide and

nationally. Unfortunately, St. Mary’s hospital neither provided any statistics for their own

performance in the administration of fibrinolytic therapy, nor information regarding plans to

improve their own care.

Primary PCI AMI- 8a

The next measure covered is AMI-8a, which is indicated for patients presenting with an

AMI with ST-segment elevation and requires that primary PCI, or percutaneous coronary

intervention (PCI), is received within 90 minutes of hospital arrival. Studies show that early

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intervention reduces mortality and morbidity, and results in better outcomes (Lippincott Advisor,

2016). PCI helps to open obstructed coronary arteries, which increases blood flow to the heart,

reducing damage (Lippincott Advisor, 2016). For this reason, National Guidelines strongly

recommend PCI within 90 minutes of patient arrival.

The nurse’s role begins with documentation of arrival time, and continues with an

assessment. The nurse is looking for signs and symptoms of acute coronary syndrome or cardiac

ischemia, which include chest pain, shortness of breath, dizziness or syncope (Lippincott

Advisor, 2016). As with core measure AMI-7a, AMI-8a also requires the nurse to obtain a 12-

lead ECG and ensure that it is read by a provider within 5 minutes of arrival. If indicated, PCI

protocol is initiated and the patient is immediately transferred to the cardiac catherization lab.

The nurse is responsible for ensuring the patient is prepped according to hospital protocol, and

that accurate documentation of the procedure is performed (Lippincott Advisor, 2016).

Statistics for this category came from Medicare.gov and showed that locally, statewide

and nationally, hospitals are meeting the 90-minute timeline for percutaneous coronary

intervention. The national and Colorado average is 96% while St. Mary’s Hospital ranks at 95%

(Hospital Care, 2016). St. Mary’s did not provide any information as to how this goal is met, but

it seems that whatever they are doing is working.

Aspirin on Arrival AMI-1 and 2

The third core measure covered is AMI-1 and 2, which requires that aspirin be given

within 24 hours before or after hospital arrival for all patients presenting with an acute

myocardial infarction, and that aspirin is prescribed on discharge. The importance of this

measure is proven through multiple studies that show reduced severity of cardiac muscle

damage, improve recovery time, and prevention of future events and hospitalizations, with a 20%

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reduction in adverse events and subsequent mortality (Lippincott Advisor, 2016). Additionally,

administration of aspirin is important because studies show the combination of aspirin with

fibrinolytics beneficial for both ST-elevated myocardial infarction and non-ST-elevated

myocardial infarction.

The nurse’s role by meeting this indicator starts by asking the patient if they have taking

aspirin within the last 24 hours and documentation of their response (Lippincott Advisor, 2016).

Next, the nurse needs to assess the patient and find out if there are any contraindications for

aspirin therapy, which would include intracranial bleeding, uncontrolled bleeding, suspected or

proven spinal hematoma, an increased bleeding risk, or any allergies to aspirin. If a

contraindication has been identified or eliminated, documentation in the patient’s record is

required by the nurse, who should also verify the medical practitioner has documented the

prescription or contraindication of aspirin therapy (Lippincott Advisor, 2016).

It is the nurse’s responsibility to administer the aspirin within the 24 hours of patient

arrival if the patient has not already taken aspirin within the last 24 hours, and then document

date and time of administration (Lippincott Advisor, 2016). Lastly, the nurse needs to educate

patients and their family about the importance of aspirin therapy in decreasing the severity of a

heart attack, and the prevention of future events, as well as how to be actively involved in their

own care. Proper documentation of education includes date, time, content and patient/family

understanding of education (Lippincott Advisor, 2016). Upon discharge, the nurse is responsible

for ensuring patients receive a prescription for aspirin and proper discharge instruction, and

ensure patients understand by asking them to teaching back key information. Nurses provide a

copy of discharge instructions to the patient and place a copy in the patient’s medical record

(Lippincott Advisor, 2016).

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Statistics came from Medicare.gov and showed a national average for patients who

received aspirin therapy within 24 hours to be at 97%, with Colorado’s average at 98% (Hospital

Care, 2016). St. Mary’s hospital did not provide information showing their average time for

aspirin therapy administration on Medicare’s website or internally. Due to the significance of

increased positive outcomes in aspirin therapy administration, statistics from St. Mary’s hospital

would be beneficial in evaluating care, especially since St. Mary’s is the biggest hospital

between Denver Colorado and Salt Lake City, Utah.

Venous Thromboembolism Prophylaxis VTE-1

The last measure covered is the administration of venous thromboembolism (VTE)

prophylaxis within the first 1-2 days of admission, on the day of or after surgery. The

importance of this measure is illustrated with statistics that show 100,000 deaths occur in the

United States each year, from the development of a VTE, which may also include a pulmonary

embolus (PE) and/or deep vein thrombosis (DVT) (Lippincott Advisor, 2016).

According to the Agency for Health Care Research and Quality, PE is the most

common preventable cause of death in U.S. hospitals, and the prevention of VTE

should be the number one strategy for improving patient safety in the hospital

Lippincott Advisor, 2016.

In all the measures previously covered in this paper, the nurse has not played a large role.

With this indicator, however, the nurse’s role is critical. Through assessments, problem

solving skills and the nursing process, the nurse plays a vital role in preventing the

development of a potentially fatal VTE, PE or DVT.

First, the nurse is responsible for assessing the patient’s risk for development of a

VTE and bleeding risk, using a validated assessment tool as soon as possible after

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admission (Lippincott Advisor, 2016). The nurse is to verify there are no

contraindications for VTE prophylaxis, an order is obtained from the health care

provider, and administration of non-pharmacological or pharmacological interventions

are administered. Non-pharmacological treatments may include early and frequent

ambulation, pneumatic compression devices, venous foot pump devices, and graduated

compression stockings. Pharmacological interventions include low-molecular-weight

heparin, factor Xa inhibitor, vitamin K antagonist (warfarin), and subcutaneous low-dose

unfractionated heparin (Lippincott Advisor, 2016).

If pharmacological therapy is ordered, the nurse must verify the health care

provider’s order for a baseline CBC, coagulation studies, renal and hepatic function

studies (Lippincott Advisor, 2016). CBCs, Prothrombin time (PTT) and International

Normalized Ratio (INR), are to be monitored throughout therapy if warfarin is ordered.

Platelet counts are monitored if unfractionated heparin or low-molecular-weight heparin

is ordered, to check for thrombocytopenia (Lippincott Advisor, 2016).

As always, the nurse is responsible for patient and family education, which would

include risks for developing VTE, signs and symptoms of a VTE (Lippincott Advisor,

2016). Patients must also know the importance of early and frequent ambulation after

surgery, and adhering to appropriate interventions, as well as potential adverse reactions

to therapy. Patient’s must be educated on the importance of laboratory monitoring, if

necessary, and what lab values indicate for their care. Lastly, the nurse is responsible for

providing discharge information with all previously mentioned information, and

documentation of received discharge information (Lippincott Advisor, 2016).

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Statistics for this core measure come from Medicare.gov and show that across the

board, from local to national hospital, scores are high. The national average for venous

thromboembolism prophylaxis is 96%, with Colorado and St. Mary’s Hospital come in

just slightly higher at 98% (Hospital Care, 2016). Due to the importance of this measure,

and its effects on patient outcomes, the high rankings locally and nationally speak well

overall for patient care.

As nurses, it is our job to provide care that is based in evidenced based practice,

and to ensure that our patients are informed and are an active participant in their own

care. Core Measures and Nurse Sensitive indicators are to crucial in requiring timely,

efficient, and personalized care for all patients, and they provide standards that hold all

hospitals, health care providers, nurses and other health care staff accountable for the care

they provide. The Core measures covered, as well as the actions required by the nurse,

are only a few examples of how health care should be tailored to seek the best outcomes

and provide the best possible care for all patients.

St. Mary's Colorado National93.5

9494.5

9595.5

9696.5

9797.5

9898.5

Comparision of Local, State and National Av-erages

PCI VTE

(Hospital Care, 2016)

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References

Hospital Compare. (2016). Timely and Effective Care. Retrieved from

ttps://www.medicare.gov/hospitalcompare/profile.html#profTab=2&vwgrph=1&ID=060

023&Distn=1.6&dist=100&loc=81501&lat=39.075059&lng=-108.5522531

Ignatavicius, D. D., & Workman, M. L. (2013). Medical-Surgical Nursing: Patient-Centered

Collaborative Care (7th ed.). St. Louis, MO: Elsevier Saunders.

Lippincott Advisor. (2016). Core measures. Retrieved from

http://advisor.lww.com/lna/pages/pringPage.jsp

Montalvo, I. (2007). Nursing Quality Indicators. The Online Journal of Issues in Nursing, 12(3).

doi:10.3912/OJIN.Vol12No03Man02

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http://advisor.lww.com/lna/pages/pringPage.jsp

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