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Influencing Health through

Community-Engaged Hospitals

Debra L. Schutte, PhD RN Nurse Researcher, Sparrow Hospital, Lansing MI

Associate Professor, Wayne State University, College of Nursing, Detroit MI

April 2018Methodist Hospital Research Day

Sparrow Health System Lansing, Michigan

Objectives Define hospital community orientation.

Describe the characteristics and consequences of hospital

community orientation.

Discuss selected hospital-based EBP and QI project exemplars that

extend into the community.

Community

A feeling of fellowship

A political entity

A functional spatial unit meeting sustenance needs

A unit of patterned social interaction

An interacting population of various kinds of people in

the same location.

(Leroy, Bilbeau, Steckler, & Glanz, 1988)

Socio - Ecological Model

IndividualInterpersonal

InstitutionalCommunity

Policy

Community Orientation

A set of activities that healthcare organizations must perform to

manage community health.

Organization wide generation, dissemination and use of area

intelligence to address present and future community needs

(Proenca, 1998).

Indicators of community health orientation

o Long term planning to improve community health

o Commitment of resources for community benefit

o Conducting community health assessments to identify unmet

community needs

o Use of health status indicators

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Community Orientation Scale Does your:

o hospital’s mission statement include a focus on community health?

o hospital have a long-term plan for improving the health of its community?

o hospital have dedicated staff to manage community benefit activities?

o hospital provide support for community building activities?

o hospital make financial contributions, provide in-kind support, or participate in fundraising or community

programs not directly affiliated with the hospital?

o hospital partner with you local school system to offer health or wellness programs to your community?

o hospital work with other providers, public agencies, or community representatives to conduct a health

status assessment of the community?

o hospital use health status indicators to design new services or modify existing services?

o hospital work with other local providers, public agencies or community representatives to develop a

written assessment of the appropriate capacity for heath service in the community?

o hospital work with other providers to collect, track, ad communicate clinical and health information

across cooperating organizations?

o hospital either by itself or in conjunction with others disseminate report to the community on the quality

and costs of health care.

(Proenca, 1998)

Factors that Influence Hospital Community Orientation

Organizational Factors

o Hospital ownership

o Hospital size

o System and Network Affiliation

Environmental Factors

o Scarcity or abundance of resources

o Degree of instability or uncertainty

o Market complexity

(Jennings et al., 2017)

Consequences of Hospital Community Orientation

Benefit to the Community

o Provision of

uncompensated care

o Community engagement

o Reasonable pricing of

services

Benefit to the Hospital

o Higher quality care

o Higher patient satisfaction with care

(Kang et al., 2013)

What does Community Orientation Look Like at the Macro Level?

Health Screenings

Nutrition Programs

Community Outreach

o Patient education

o Fitness centers

o Support groups

Population Health Departments

What about Community Orientation at the Micro Level?

Does community orientation bubble up from the bedside caregiver?

o Outreach to and engagement with community

o Innovation at the bedside

o Assessment of community need from bedside caregiving

An EBP Project to standardize NG tube verification practice and align practice with evidence across the pediatric units.

Layna Korcal, RN CPN, Staff Nurse Pediatrics Subspecialty Clinic, EBP FellowMary Kisting, MSN RN CCNS CCRN-K, Clinical Nurse Specialist PediatricsDebra L. Schutte, PhD RN

Example 1: Lose the Whoosh

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Project Triggers Evaluating Evidence and Practice Literature Synthesis

o The “gold standard” for

confirming the position of a

NGT is a radiograph. However,

radiograph is inappropriate

and harmful for frequent and

routine use and only provides

a snapshot in time of the NGT

location.

o Lose the Whoosh:

Auscultation is ineffective in

verifying tube placement!

o A combination of methods to

verify placement, such as pH

testing and tube

measurement/marking, are

recommended.

Performance Gap Assessmento 74% of respondents accurately indicated

that the primary problem with auscultation is that sounds can be transmitted to the epigastrium regardless of tube location.

o Across units, auscultation was the most likely to be used strategy; checking pH was the least likely to be used strategy.

o Less than 10% of respondents accurately indicated the pH of stomach aspirate (pH = 1.0-5.0).

o Years of experience was not related to the likelihood of using a particular tube placement verification strategy.

Evidence-based Algorithm for Management of Naso/orogastric tubes in infants and children

Initial Insertion(Abdominal x-ray

recommended after initial placement)

Placement verified by radiologist/physician

Tube is marked at the exit site of the nare

Measurement is documented in medical record

Begin feedings or medications

X-ray not obtained

X-ray obtained

Tube in place

Check pH of aspirate

Aspirate clear, light yellow, or light green

Obtain aspirate

Unable to obtain aspirate

Check markings on tube match documentation

Document verification in medical record

Reposition infant/childInject 1 – 5 mL of air

Aspirate with a 10-20mL syringeIf still unable to aspirate, wait 5-10

minutes and repeatAdvance or retract tube 1 – 2 cm

and attempt aspiration

pH > 6.0, the tube may be malpositioned; it may be in the lung or

intestineRemove tube

pH 1.0-5.0 (Stomach acid )

Confirm position following insertion and prior to administration of any medications or fluids

Infants or children with absent gag

reflex, significant neurologic deficits or

dyspagia require x-ray to confirm tube

placement

Coughing, cyanosis, apnea, bradycardia, vomiting, difficulty

talking may indicate malpositioning

ASSESS PATIENT

Korcal, L., Goodell, J., Kisting, M. (4/2015)

Evidence-based Algorithm for Management of Naso/orogastric tubes in infants and children

Initial Insertion(Abdominal x-ray

recommended after initial placement)

Placement verified by radiologist/physician

Tube is marked at the exit site of the nare

Measurement is documented in medical record

Begin feedings or medications

X-ray not obtained

X-ray obtained

Tube in place

Check pH of aspirate

Aspirate clear, light yellow, or light green

Obtain aspirate

Unable to obtain aspirate

Check markings on tube match documentation

Document verification in medical record

Reposition infant/childInject 1 – 5 mL of air

Aspirate with a 10-20mL syringeIf still unable to aspirate, wait 5-10

minutes and repeatAdvance or retract tube 1 – 2 cm

and attempt aspiration

pH > 6.0, the tube may be malpositioned; it may be in the lung or

intestineRemove tube

pH 1.0-5.0 (Stomach acid )

Confirm position following insertion and prior to administration of any medications or fluids

Infants or children with absent gag

reflex, significant neurologic deficits or

dyspagia require x-ray to confirm tube

placement

Coughing, cyanosis, apnea, bradycardia, vomiting, difficulty

talking may indicate malpositioning

ASSESS PATIENT

Korcal, L., Goodell, J., Kisting, M. (4/2015)

Implementation Strategy

• Staff training at fall skills competency fair• Recruited a champion from each unit• Developed unit-specific processes for obtaining

and storing pH paper• Changes to EMR to support documentation

Evaluation of Practice Change

Increase in staff knowledge

Increased use of pH checks

Evaluation of Practice Change

Chart Audit for Adherence to Protocol

o 231 NG/OG insertion events.

o 23% checked for placement on insertion with CXR.

o Of those without CXR, 65% had pH check documented.

o Of those without CXR and pH, 15% documented inspection of visual aspirate.

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Expanding Project Impact• Developed education

plan and resources that were incorporated into EMR to provide consistent and comprehensive parent education.

• Pediatric Subspecialty Clinic launching a coordinated clinic day to meet needs of families related to feeding assistance.

An EBP Project to improve strategies for assessing pain and assisting women in coping with pain in the Labor and Delivery Unit.

Miranda Stoneman, BSN RNC-OB, Staff Nurse Labor & Delivery, EBP FellowJennifer Thompson Wood, MSN RN c-EFM, ACNS-BC, Clinical Nurse Specialist—Mother-Baby ServicesDebra Schutte, PhD, RN

Example 2:

CALM--Coping Assessment for Laboring Moms

Project Triggers

Opportunity to improve Patient Satisfaction with their labor experience.

Need to meet Joint Commission pain assessment requirements.

Opportunity to improve performance related to Healthy People 2020 National Goalo Reduce cesarean births

among low-risk (full-term, singleton, and vertex presentation) women to 23.9%

Evaluating Evidence

ACOG Position Statement (2017)

o Recommend use of a coping scale in conjunction with tailoring non-pharmacologic and pharmacologic interventions to best meet needs of each woman.

Coping with Labor Algorithm (Roberts, Gulliver, Fisher, & Cloyes,

2010)

o Developed by a team of nurses at The University of Utah

o Associated with improved nurse satisfaction

o No adverse outcomes identified

Current Steps

Implementation Interdisciplinary, nurse-led team

formed.

On-line staff training module developed and ready to implement.

Modifications made to EPIC

o “What are your plans to manage your pain during labor?”

o Incorporating the Coping Algorithm

o “How are you coping with labor?”

Obtaining and stocking non-pharm intervention cart.

Evaluation Staff adherence to protocol

through chart audit

Patient Outcomes

o NTSV cesarean rate

o Epidural rate

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Expanding Project Impact

“We really need to back this up into the OB clinics so that

moms are coming to us with birthing plans”

“Providing anticipatory guidance in the clinics about

what to expect----what questions will I be asked?

What strategies are available to help me cope with pain?

An EBP Project to standardize oral care practice and align practice with evidence hospital-wide.

Chastity Warren, DNP, MSN/Ed, RN, CCRN, Clinical Nurse Specialist-Critical CareMary Kathryn Medei, BSN, RN, CMSRN, Staff Nurse, EBP FellowBrooke Wood, BSN, RN, CMSRN, Staff Nurse, EBP FellowDebra Schutte, PhD, RN

Example 3: Oral Care Protocol

Project Triggers

Successful implementation of improved evidence-based oral care products on a single unit (surgical floor) led by 2 bedside nurses.

Opportunity to partner with a community stakeholder to expand implementation of an evidence-based oral care protocol house-wide.

Evaluating Evidence and Practice Literature Synthesis

o Hospital-acquired pneumonia accounts for 22% of all hospital-acquired infections, and is associated with increased mortality, length of stay, and costs.

o Standardized oral care is associated with a decrease in hospital acquired pneumonia (Quinn et al, 2014; Sjogren et al., 2016).

o Improved outcomes are associated with the following products:

• Tooth brushing for 120 seconds two to three times daily or after meals (Kaneokaet al, 2015)

• Debridement toothpaste, antiseptic mouth rinse, and mouth moisturizer (Kaneoka et al., 2015, Quinn et al, 2014)

• Inclusion of patient education and resources (Quinn et al., 2014)

• Early dysphagia screening (Sorenson et al, 2013)

Performance Gap Assessmento What is your oral care plan for your

patient today?

Ventilator oral care bundle (18%)

At risk oral care (3%)

Regular oral care PC and HS (55%)

None (17%)

Practice Changeo Expanded Oral Care Protocol

o Bundled manufacturer pre-packaged Oral Care Kits

o Oral Care Protocol built into nursing documentation workflow

o Extensive RN and PCT training

Oral Care Protocol Oral Care Protocol

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Short-term Oral Care Kits

Components

• Ergonomically appropriate toothbrush

• Alcohol free, anti-septic mouth rinse

• Baking soda toothpaste

• Mouth moisturizer

• Oral care swabs with baking soda

Frequency

• 4 times daily

Co-branded Patient Education Handout

Evaluation of Practice Change

Average protocol compliance by caregivers across units: 76% (Range 36-100%)

o *Calculated from documentation vs. product use vs. patient days

Compared HAP events pre and post implementation of the Oral Care Protocol

o Charts reviewed for November-May of 2014/2015 (pre-implementation) & 2015/2016 (post-implementation) for any adult patient who had an ICD 9 or 10 code for pneumonia

o Identified HAP using CDC criteria.

Evaluation of Practice Change

Average protocol compliance by caregivers across units: 76% (Range 36-100%)

o *Calculated from documentation vs. product use vs. patient days

Compared HAP events pre and post implementation of the Oral Care Protocol

o Charts reviewed for November-May of 2014/2015 (pre-implementation) & 2015/2016 (post-implementation) for any adult patient who had an ICD 9 or 10 code for pneumonia

o Identified HAP using CDC criteria.

PreN = 202

PostN = 215

NV-HAP events 52 26 p = .000354

Deaths in NV-HAP events 20 4 p = .037373

NV-HAP rate per 1000 patient days

0.683 0.325

NV-HAP events per 1000 patient discharges

2.84 1.41

Evaluation of Practice Change

18% of caregivers in the pre-implementation survey indicated that they had no oral care plan for their patient that day compared to 0% of caregivers in the post-implementation survey (χ2 = 13.83, p=.000).

There was a small improvement in mean attitudes toward oral care following implementation of the Oral Care Protocol, although not statistically significant (3.73 [pre] vs. 4.10 [post], t=1.74, p=.083).

There were no differences in perception of resources and barriers by nurse by age or years of experience in either the pre- or post-implementation responses.

Knowledge scores increased across all 10 questions post implementation of the practice change.

88% of nurses post-implementation indicated they currently follow an oral care protocol compared to 56.8% of nurses completing the survey pre-implementation.

Expanding Project Impact• System-wide

implementation of the Oral Care Protocol.

• Partnering with area long-term care facilities to tailor and implement.

• Partnering with area homeless shelters to offer oral care kits and resources.

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In each of these examples…. Advances in care driven by bedside caregivers.

Awareness of community need and impact.

Recognition of need to reach out beyond the hospital boundaries to further improve patient experience and outcomes.

Engaging with stakeholders (patients, families, primary care provider clinics, long term care facilities, community health agencies, health insurance company foundation) to improve patient experience and outcomes:

o Individual

o Community

Concluding Thoughts

Community orientation is for everyone.

o As much a bedside caregiver attribute as an organizational attribute

Caregiver community orientation can make things happen.

Community health is best served by integrated approaches to community orientation:

o Administrative-level down

o Bedside caregiver-level up

ReferencesAmerican College of Obstetricians & Gynecologists. (2017). Committee Opinion No 687. Approaches to Limit Intervention During Labor and

Birth. Retrieved from: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Approaches-to-Limit-Intervention-During-Labor-and-Birth

Jennings, J.C., Landry A.Y., Hearld, L.R., Weech-Maldonado, R., Snyder, S.W., & Patrician, P.A. (2017). Organizational and environmental factors influencing hospital community orientation. Health Care Management Review, doi: 10.1097/HMR.0000000000000180. [Epub ahead of print]

Kaneoka, A., Pisegna, J., Miloro, K., Lo,M., Saito, H., Riuqelme, L., LaValley, M. & Langmore, S. (2015). Prevention of healthcare-associated pneumonia with oral care in individuals without mechanical ventilation: A systematic review and meta-analysis of randomized control trials. Infection Control and Hospital Epidemiology, 1-8.

Kang, R., & Hasnain-Wynia, R. (2013). Hospital commitment to community orientation and its association with quality of care and patient experience. Journal of Healthcare Management. 58(4), 277-289.

Leroy, K.R., Bilbeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15(4), 351-377.

Proenca, E.J. (1998). Community orientation in health services organizations: The concept and its implementation. Health Care Management Review, 23(2), 28-38.

Quinn, B., Baker, D., Cohen, S., Stewart, J., Lima, C., & Parise, C. (2014). Basic nursing care to prevent non ventilator hospital-acquired pneumonia. Journal of Nursing Scholarship. 46(1), 11-19.

Roberts, L., Gulliver, B., Fisher, J., Cloyes, K.G. (2010). The Coping With Labor Algorithm: An alternate pain assessment tool for the laboring woman. Journal of Midwifery & Women’s Health, 55(2), 107-116.

Sjögren, P., Wårdh, I., Zimmerman, M., Almståhl, A., & Wikström, M. (2016). Oral Care and Mortality in Older Adults with Pneumonia in Hospitals or Nursing Homes: Systematic Review and Meta‐Analysis. Journal of the American Geriatrics Society, 64(10), 2109-2115.

Sørensen, R. T., Rasmussen, R. S., Overgaard, K., Lerche, A., Johansen, A. M., & Lindhardt, T. (2013). Dysphagia screening and intensified oral hygiene reduce pneumonia after stroke. Journal of Neuroscience Nursing, 45(3), 139-146.