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The University of South Alabama Medical Center recently was honored for its participation in a nationwide patient care-centered research project that allowed USA Medical Center to find better solutions for hospital patient care obstacles. Pictured here are staff members who participated in the research survey, from left to right: Felicier Jones, RTN - Wound Care Clinical Specialist; Teresa Aikens, Infection Control Nurse Manager; Sharon Ezelle, Director of Quality Management; Anna Gillman, RTN - Staff Development Inservice Specialist.
From readmission rates to fall prevention, medication use to preventing infection and pressure ulcers, teams at the University of South Alabama Medical Center spent three years keeping close track of problems and looking for ways to solve them.
This year, USAMC earned top honors for participating in the nationwide Hospital Engagement Network quality measurement study, called Partnership for Patients.
But the real beneficiaries of the careful study, group leaders say, are the patients. Because each time a team investigated a particular problem — such as falls with or without injuries — they found new ways to prevent it.
Some 39 hospitals participated in the Alabama segment of the study, sponsored by the Alabama Hospital Association, says Sharon Ezelle, who heads quality management at USA Medical Center. But only 13 submitted data in all the applicable study areas.
Just completing the data was enough to qualify for a plaque.
But the Medical Center accomplished much more than that, making significant strides toward the overall goal of reducing hospital-associated conditions by 40 percent and readmissions by 20 percent. In some cases the Medical Center far exceeded those targets.
USAMC was grateful to participate in this study so the Alabama team could reach its goals and improve patient care.
Readmission rates, for example were a stellar success, with the Medical Center among the very few hospitals not penalized by Medicare/Medicaid for readmissions.
Achieving that goal was a team effort, says Annita Dailey. Now Nurse Manager on the 5th floor, she was Assistant Director of Quality Management when the effort kicked off to prevent readmissions.
She assembled a team representing every discipline that is involved in patient care — physicians, nurses, dietitians, pharmacy and more — and together they reviewed every instance of a patient being readmitted within 30 days for heart failure, acute myocardial infarction or pneumonia.
By adding a staff member focused solely on discharge planning and by spending more individual time with patients and teaching them how to cope with their illness after they got home — what to eat, how to take medication and so forth — they met their goal of reducing readmissions 10 percent in the first six months and 20 percent by the end of a year.
It’s important for the hospital, because achieving the goal qualifies it to receive its full and much-needed reimbursements.
More important, says Dailey, it’s much better for patients because they go home to a much better quality of life.
No one wants a patient to go home with a problem he or she didn’t have on admission, and preventing falls is a key element toward achieving that goal.
While quality measures looked most at falls with injuries, USAMC chose to look at ways to prevent all falls, whether or not they lead to injury, says Valerie Heinl, Nurse Manager on the 3rd floor who led the fall prevention team.
The first step, says Heinl, was calculating the rate of falls with the expectation of reducing the rate.
Next, the team re-emphasized the importance of having a nurse assess each patient’s risk for fall within 24 hours of admission. “We score 97 percent or higher on assessing everyone,” says Heinl.
Finally, each time a patient fell, the nurse and other clinicians went into a “fall huddle” to find ways that the incident could have been avoided. That has led to several simple changes that have trimmed the incidence of falls. For example, the team realized that some patients weren’t wearing gripper socks, which steady their footing, because there weren’t any in their size. “So we got bigger size socks for people with swollen legs,” she says. In some cases, falls occurred because there was no bedside commode — leading to a simple solution of acquiring more equipment.
“Our rate for falls with injuries is very low,” Heinl says. And since the advent of the study, it has been trending even farther downward. And most of the falls that do happen cause no injury or very minor injury.
“We want people leaving the hospital in a better state, not a worse one, so we want to keep them safe while they’re here,” says Heinl. “And people want to feel safe in the hospital — falling worries them and their family members. That’s why we’re so concerned.”
The target for medication studies was making sure that anticoagulants were used appropriately and discontinued as soon as possible, says Dr. Rachel Weaver, a Clinical Pharm D. who led the quality measurement team for anticoagulants.
“Anticoagulants are very useful when blood clots are an issue — like after aortic valve replacement or treatment of a prior pulmonary embolism,” says Weaver.
But if levels get too high, then the patient is at risk for bleeding.
USAMC follows the International Normalized Ratio, or INR, and strives to keep levels at 2 to 3 except in specific cases, where a 3.5 level is suitable, she explains. In keeping with the INR, the goal of the medication studies was to prevent levels above 6 — or well above the standard levels.
“The tricky part of anticoagulants,” says Weaver, “is that they are affected by other medications and also by common foods — especially the green vegetables our mothers taught us to eat — so that each individual’s dose of Coumadin needs to be calculated with a careful eye to favorite foods. Vitamin K rich greens, for example, don’t need to be cut from the diet, just as long as patient and healthcare team work together to plan for them when calculating an appropriate dose of medication.”
Participating in the study was very helpful, Weaver said, because it serves as a reminder to everyone responsible for patient care during the hospital stay and to discharge planners who will help patients stay in control even after they leave the hospital.
“Hospital protocol, which mirrors the Joint Commission requirements, calls for an INR check every day for patients on Coumadin, and the hospital is extremely good in meeting that protocol,” Weaver says.
With the reminder from study participation, now every member of the team is checking to make sure that protocol is followed to the letter.
“We’ve been measuring for two to three years and we’ve seen improvements,” says Weaver. “It’s very worthwhile to pay attention.”
Catheter-Associated Urinary Tract Infection
Eliminating catheter-associated urinary tract infections has been a goal for the Medical Center for several years and the excellent results demonstrate the team’s good work.
Just since last year, the rate has dropped significantly.
“We were above the national average,” says Anna Gillmann, RN, who led the MC team, working with Alicia Lintner, RN, who chaired the Evidence-Based Practice Committee.
That’s not surprising, since MC patients tend to be sicker when they arrive than their counterparts at other hospitals. And, because of its Level 1 trauma center, the Medical Center treats more trauma victims, who may not be able to tell caregivers they are already sick when they arrive, or may need to have their urinary catheter in place longer than other hospitals.
Nonetheless, nurses and other staff members were determined to cut the infection rates. “I don’t want patients to get worse, if we can possibly help it,” she says.
Nurses from the EBP, working in tandem with nursing professors at the USA College of Nursing, looked for ways in which they could make a difference. “Keeping the staff engaged, they can see that they are making a huge difference,” she says. And, since numbers are also being collected for the Centers for Disease Control, nurses can see how their efforts are improving results.
The key, say Gillmann and Lintner, is that nurses insert the catheter, so the solution has been to let nurses take responsibility for maintaining and for suggesting to the physician when it’s time to remove it — as soon as possible, since the duration of use is a key factor in the likelihood of infection.
“We’re definitely excited by the results and how we’re contributing to better patient care,” says Gillmann.
“Our nurses are great,” adds Teresa Aikens, Director of Infection Control. “They’re driven and passionate about everything they do.”
Infection rates have dropped, she says, because Foley catheter use has dropped — 24 percent in the first year of the study, followed by another 30 percent reduction the following year.
Another nursing initiative has also produced spectacular results, said Aikens.
Nurses were concerned about surgical site infections and looking for ways to prevent them.
“We’re a trauma center, so a lot of people come into surgery with no prep,” she says. And staph infection rates were higher than desirable.
In what she calls a not-very-scientific preliminary study, nurses — knowing where staph colonizes — tried swabbing noses on incoming patients, confirming their suspicion that a lot of patients — some 30 percent — brought the staph to the hospital with them. The literature shows that patients colonized with staph pathogens are at a higher risk for developing a surgical site infection with staph.
“Our goal was to reduce the risk of developing an infection associated with staph pathogens,” Aikens says. “We implemented use of a povidone-iodine swab as a standard part of pre-operative care to ‘decolonize’ the patient (remove the bacteria hoping to decrease the risk of infection). Since implementation, we have seen a significant decrease in staph surgical site infections.”
“This is a teaching facility, very top notch, and we’re always looking for ways to improve results,” says Aikens.
One of the most prevalent problems for hospital patients is the incidence of hospital-acquired pressure ulcers. In some hospitals, the incidence can range as high as 40 percent, says Felicher Jones, MSN, a Certified Wound-Ostomy Nurse.
She leads a team to decrease the rate at the Medical Center and the success has been excellent — with a very low rate of 1 to 2 percent.
“Everyone on the team — doctors, nurses, PCAs, everyone — collaborates to do what’s needed to prevent pressure ulcers,” Jones says.
Most at risk are patients who can’t move their own bodies — trauma victims, new stroke patients, new quadriplegics or paraplegics, the elderly, people with chronic illnesses, people with nutrition problems, the morbidly obese and those who’ve had rapid weight loss.
So the team starts by a careful assessment of new patients to determine the risk and then institutes prevention measures — making sure patients are in the most suitable bed, that heels are floated off the bed surface, that patients are turned every two hours, that they’re eating the right foods and bathed properly.
“It takes a whole team,” Jones says.
But the team has the satisfaction of seeing success. The national average is 7 percent, she says, while the Medical Center averages only 1 to 2 percent per month.
And the team is still working to improve those numbers.
About the University of South Alabama Medical Center
The University of South Alabama Medical Center offers patient-centered care to the central Gulf Coast with unique services including Mobile’s only Level I Trauma Center and Regional Burn Center, plus Centers of Excellence in stroke care and cardiovascular diseases, and a wide range of acute care services.
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