Quality and Excellence Winter 2012 Newsletter

7/31/2019 Quality and Excellence Winter 2012 Newsletter

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VOL. 5, NO. 1 THE QUALITY AND PATIENT SAFETY NEWSLETTER OF CONTINUUM HEALTH PARTNERS

2011Quality and Patient Safety

Award Winners

WINTER 2012


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Congratulations to theaward winners, and manythanks for the stellar

work of all the nominees!2

Two years ago, Continuums Board of Trustees Committee

on Quality Care introduced its annual Award for Quality and

Patient Safety. The acknowledgement recognizes and rewards staff

for initiatives aimed at enhancing patient care and safety. Such

contributions are critical to helping Continuum maintain its

reputation as a national leader and

model organization for delivering thehighest quality care.

The judging panel, with representatives

from each Continuum hospital, received

many noteworthy nominations, making

the task of selecting a winner difficult

and challenging. The 2011 winning

submission was Fall Reduction in

Beth Israel Rehabilitation Nursing.

Honorable mentions went to Neonatal

Order Set Implementation at St. Lukes

and Roosevelt Hospitals and Prevention ofC. difficileInfections

across Continuum Health Partners. Winners received both a cash

prize and an engraved crystal sculpture commemorating their out-

standing achievement.

TrusteesCommittee

on Quality Care

Names 2011Award Winners


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The 3 Karpas Inpatient Rehabilitation Team, from left: Jack Valdez, RN, Melissa Grant, RN,

Ellen Deane-Ferguson, RN, Marie Garland-Matias, RN, and Wayde Binder, RN.

Beth IsraelRehabilitation Nursing

LowersIncidence of Falls

3

2011 Trustees Award Winner

TEAM LEADER:

Wayde Binder, RN, Nurse Manager

3 Dazian and 3 Karpas

Beth Israel Medical CenterPetrie Division

On Beth Israel-Petrie Divisions 3 Karpas Inpatient Rehabilitation Unit,

the fall rates have fallen dramatically, thanks to a simple yet innovative solution and a

committed interdisciplinary team. The initiative involved creating observation rooms

for patients considered to be at higher risk for falls, and called upon patient care

associates (PCA), nurses, physiatrists, therapists and other related providers.

Patients sent to 3 Karpas are an average age of 79 and come from a variety of areas:

cardiology, oncology and, primarily, neurology and orthopedics. They often have

cognitive issues related to their disability or diagnosis that increase the possibility of

falls and, as a result, require greater reinforcement to ensure safe care.

Using existing staff and space, the observation room model was developed by

team leaderWayde Binder, RN, Nurse Manager, 3 Karpas and 3 Dazian, Beth Israel-

Petrie Division, and started in Fall 2010. Heres the way it works: Patients identified

as being at higher fall risk are assigned to a designated observation room with a

dedicated PCA, who continuously and closely supervises them. Typically, two rooms

accommodating four or five patients serve this purpose and are located directly across

the hall from one another with doors open to enable the PCAs vigilant monitoring.

Nurses trained in fall-risk reduction are nearby for support and backup, and patients

and families receive fall-risk education.

We didnt come across any similar model in the medical literature. We did find

information about restraints, bed alarms and other devices, but we really wanted to

stay away from them, says Mr. Binder. Rather than hiring one-to-one companions,

we thought about how we could utilize staff in different ways to decrease fall rates

while also minimizing costs, and came up with the observation room concept.

Statistics reveal sustained success in lowering not only the number of falls, but also

the number of falls with injury. The 2009 fall rate of 9.5 falls/1,000 patient days

dropped by first quarter 2011 to 5.5, which is below the national average, as per the

National Database of Nursing Quality Indicators. For the same period, the fall-with-

injury rate of 0.59/1,000 patient days went down to 0.0. The measure also has proven

cost-effective, saving $100,000 in one-to-one staffing. And we still havent calculated

the savings from MRIs, CT scans and x-rays that havent had to be taken due to the

decreased incidence of injuries, Mr. Binder notes. A culture shift has definitely

taken place, where the PCAs are offering input on the patients and all staff are highlyinvested in keeping falls at zero, he adds.

The Trustees Award recognition is verysatisfying and rewarding and has brought

greater spirit and commitment to the team.

Weve worked hard and feel valued and

empowered.

Wayde Binder, RN


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From left:Nori Yaun, RN, Janice Klein, MD, and

Janna Roitman, PharmD, review the new neonatal order sets.

Neonatal Order Sets

ReducePrescription-Related

Medication Errors

2011 Trustees Honorable Mention

TEAM LEADERS:

Janice Klein, MD

Attending Neonatologist

St. Lukes and Roosevelt Hospitals

Janna Roitman, PharmD

Clinical Pharmacy Manager

Roosevelt Hospital

Nori Yaun, RN

NICU Nurse Manager

Roosevelt Hospital

Prescribing medications for neonatal patients is often a challenging task

that cannot accurately rely on modifying medication orders created for adults, or even

children for that matter. Beyond a patients weight and clinical condition, there is

gestational age to consider. With related medical and pharmacy-preparation issues

cropping up nationwide, many hospitals have implemented Joint Commission-driven

initiatives to prevent prescription errors and adverse outcomes in their neonatal

intensive care units (NICU).

In June 2009, a multidisciplinary team comprising an information technology

specialist and neonatologists, nurses and pharmacists from throughout Continuum

was formed to address the situation in all of the organizations NICUs. The team

began by reviewing the most commonly used medications for the neonatal population,which include intravenous solutions, nebulized drugs and ophthalmic preps. Guided

by evidence-based practices presented in well-respected references such as Neofax and

the Harriet Lane Handbook, the team worked together for nearly two years to develop

neonatal order sets independent of those designed for adults. A separate neonatal order

button also was created and the new system was activated in May 2010.

Previously, we had to adapt adult orders on an ad hoc basis, changing medication

strengths, intervals and doses. Now we have a tool for the care of newborns that is

more practical and safe, saysJanice Klein, MD, team co-leader and Attending

Neonatologist, SLR.

Using adult order sets posed many questions and proved time-consuming for

doctors, nurses and pharmacists, adds team co-leaderJanna Roitman, PharmD,Clinical Pharmacy Manager, Roosevelt Hospital. The NICU order sets provide great

references to users, and weve since seen a huge increase in compliance.

Each order set includes recommended concentration, strength and route of adminis-

tration, along with education for suggested dosage and a series of warning prompts

when dosage has been maximized. Currently, 80 entries representing 99% of NICU

medications have been incorporated.

The neonatal order sets have not only reduced the risk for ordering errors, they also

have standardized care at all Continuum NICUs, streamlined workflow processes and

improved communication between prescribers, nurses and pharmacists. Comparing

third quarters 2009 and 2010, neonatal-related prescription errors decreased by 40%

at SLR (with similar results at BIMC), and pharmacist interventions dropped from

134 to 79.

The team did extraordinary work and the staff love the order sets. Its a lot easier

now to put orders into practice, says team co-leader Nori Yaun, RN, NICU Nurse

Manager, Roosevelt Hospital. Moving forward, the order sets will continually evolve,

as we add or change things based on news in the medical literature.


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Left to right:Barbara Smith, RN, BSN, MPA, CIC, Timothy Hill from Environmental Services, and

Melissa McCabe, RN, engage in infection prevention practice.

Hospital-AssociatedC. difficile Infections

Preventedacross Continuum

2011 Trustees Honorable Mention

TEAM LEADERS:

Brian Koll, MD, FACP

Medical Director and Chief, Infection Prevention

Beth Israel Medical Center

Barbara Smith, RN, BSN, MPA, CIC

Nurse Epidemiologist

St. Lukes and Roosevelt Hospitals

Clostridium difficile (C. diff) is among the most common health care-

associated infections and easily transmitted from patient to patient. This, coupled

with dramatic increases in its incidence, severity and treatment costs over the past

decade, has made preventive interventions more critical than ever before.

In 2008, after a survey ofC. diffprevention practices throughout Continuum

revealed a lack of standardization, interdisciplinary unit-based teams made up of

physicians, nurses, patient care associates, transporters and housekeepers were formed

to address the problem with the full support of senior leadership. The resultant multi-

faceted, evidence-based intervention has involved placing patients in a single room or

with another C. diffpatient at the onset of symptoms, posting contact precautions

signs on room doors, making gowns, gloves and other personal protective equipment

readily available, and completing compliance checklists. The prevention bundle also

has required that rectal thermometers be eliminated and that proper hand hygiene be

followed. Perhaps most important has been adherence to environmental cleaning using

a hypochlorite-based disinfectant (bleach) on all high-touch surfaces and bathrooms in

patient rooms.

C. diffis a strong, hardy, resilient bacteria that can live in an environment forever.

While cleaning is important for all hospital-acquired infections, it is vital for C. diff.

Bleach is the only thing that truly works, says the projects team co-leader Brian Koll,

MD, FACP, Medical Director and Chief, Infection Prevention, Beth Israel. This

initiative really speaks to the efforts of environmental services staff and transporters,

who must scrub rooms and clean stretchers and wheelchairs.

Monthly meetings have been held to keep the teams engaged and informed through

timely feedback on C. diffrates and compliance. Additionally, a fluorescent marking

tool that simulates germs, a la CSI, has allowed the teams to visually assess their

level of cleanliness.

Ownership of the intervention by frontline staff has been essential to the sustained

reduction in hospital-onset C. diffover the past three years, notes Barbara Smith, RN,

BSN, MPA, CIC, team co-leader and Nurse Epidemiologist, SLR. Prior to the project,

Continuum had almost 600 C. diffcases annually. Since then, that figure has decreased

by 27%, length of stay for C. diffpatients has fallen by one day, and the time until pre-

cautions are implemented from symptom onset has dropped by 17 hours. Moreover, com-pliance with the prevention bundle rose to 97% and with cleaning practices to 87%.

Our goal was to have a rate of less than

five hospital-onset cases per 1,000 patient

days. We exceeded that goal with 4.1. We

look to continually improve upon that.

Brian Koll, MD, FACP


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Transforming Care at the Bedside (TCAB) Initiative

TEAM LEADERS: Susan Adler, RN, Staff

Nurse, Linda OFlaherty, RN, Nurse

Manager, Med-Surg Unit, BIMC-KHD

In February 2010, Beth Israel-Kings Highway

Division partnered with the RN Labor

Management Initiative to conduct a pilot

of the Transforming Care at the Bedside

program, initially focusing on the hospitals

3 North med-surg unit. TCAB relies heavily on frontline nurse-led teams to

redesign work processes for improved clinical outcomes. The 3 North team

collected data on disruptions to patient care and then collaborated with staff

from other departments, including Food and Nutrition, Admitting, Pharmacy

and Housekeeping, to implement strategies for better efficiency. They ultimately

achieved enhanced staff andpatient satisfaction (68% for the composite

communication with nurses for the latter), and improved quality of care,

which considers such factors as maintaining the fall rate below the national

median and decreasing the incidence of hospital-acquired pressure ulcers.

Airway Program Enhances Function and Extends Survival

TEAM LEADER: Faiz Bhora, MD, FACS, FCCP, Codirector, Continuum Airway

Program, and Associate Program Director, General Surgery; Director, Thoracic

Surgical Oncology; and Director, Thoracic Surgery Research, SLRMore than 20 to 30% of patients with advanced lung cancer experience symp-

tomatic central airway obstruction, which, if left untreated, offers a very poor

prognosis. Through the Continuum Airway Program, tracheobronchial stenting

was implemented to improve functional outcomes and survival rates in this

patient population. Seventy-two stents were placed over two years, with the

majority of patients realizing significant improvement in functional status.

Furthermore, patients who were stented in a timely fashion had a mean survival

of about eight months, compared to less than 30 days for untreated patients. A

significant number of the treated patients were then able to receive chemotherapy

and radiation. The Airway Program is considered the premier program in New

York for managing central airway obstruction due to malignancy and benign

disease, and SLR has become a regional referral center for complex airway cases,

including stenting.

Golden Hour of Stroke Treatment

TEAM LEADER: Ji Chong, MD, Director,

Stroke Prevention Program,

SLR Stroke Center

IV tPA is the only approved treatment for

acute ischemic stroke. There is a very small

time window for treatment and the earlierit is initiated, the better the neurologic out-

come. One of the benchmarks measured

by the New York State Department of Health is the door to needle time. The

target is to treat patients within 60 minutes of arrival to the ER. This requires

rapid identification of possible stroke, appropriate triage and registration, blood

tests, IV insertion, CT scan of the brain, assessment by a neurologist, possible

management of elevated blood pressure, discussion with the patient and family,

and careful preparation of the drug. To achieve all this in 60 minutes, SLRs

Stroke Center and Emergency and Radiology Departments modified protocols

and triage strategies, trained ED and EMS personnel in recognizing early stroke

signs, expedited CT scans and lab tests, and trained nurses to prepare tPA. In

recognition of improved performance, the SLR Stroke Center was one of only

114 hospitals nationwide to be honored by the American Heart Association for

achieving superior level of stroke care.

Weekly Assessment of Emergency Room Dysphagia Evaluation

Leads to Gold-Plus Award

TEAM LEADER: Larissa M. Bonilla, Clinical Coordinator, SLR Stroke Center

Dysphagia (swallowing difficulty) is a common complication for acute stroke

patients and can lead to pneumonia, which in turn can delay neurological recov-

ery. To better identify patients with dysphagia, the SLR Stroke Center revised its

dysphagia screening documentation protocol and worked with St. Lukes and

Roosevelts Emergency Departments on its implementation in September 2009.

The recent results showed 94% of stroke patients have since been appropriately

screened. In June 2011, the SLR Stroke Center was recognized for its significant

improvement in dysphagia screening and overall stroke management with the

American Heart Associations Gold-Plus Award, the organizations highest

national honor.

CIWA Protocol Improves Care of Patients

Experiencing Alcohol Withdrawal

TEAM LEADER: Susan Dietz, RN, MA, CNA,

Vice President, Patient Care Services and

Chief Nursing Officer, SLR

Introduced to St. Lukes and Roosevelt

Hospitals in Spring 2010, the Clinical

Instrument for Withdrawal of Alcohol(CIWA) is a nationally known scoring scale

and protocol administered by registered

nurses in emergency rooms and on medical units to evaluate the severity of

symptoms related to alcohol withdrawal, and guide the delivery of appropriate

medical intervention for positive patient outcomes. Following CIWA education

of house staff and ED doctors and nurses, initiation of the CIWA medication

protocol rose from 0% in third quarter 2010 to 89% in first quarter 2011. In

addition, patient comfort levels increased, the need for physical restraints

decreased, and average length of stay for patients who received the protocol

was 8.2, compared with 11.8 for those who did not.

And the

NomineesAre

6

Many other initiatives have improved patient care

and safety at Continuum. Here we recognize this

award years other nominated projects and programs.

LOSPatientsTreated with

CIWA Protocol and Not Treated

with CIWA Protocol

strokeknow the signs

Trouble speaking

Trouble walking Trouble seeing

Weakness on one side


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The Near Miss Registry

TEAM LEADER: Ethan D. Fried, MD, FACP, Program Director, Internal Medicine

Residency, and Director, Graduate Medical Education, SLR

The Near Miss Registry is an anonymous, risk-free reporting system for medical

errors that are corrected before a patient is harmed. Created by Ethan Fried, MD,

it has been adopted by the New York State (NYS) Department of Health. Initially

rolled out to internal medicine residents across NYS, the registry was expanded in2010 to residents in other specialties and other allied health care personnel. It

collects descriptive data on the reporters institution, the error, and the barrier

that protected the patient. More than 400 Near Misses have been submitted,

over half of which were medication-related. The registry identifies vulnerabilities

and effective barriers to errors to help design safer patient care environments.

Improved Processing of Intra-ocular Lens for Cataract Cases

TEAM LEADER: Teresita Ignacio, NCC,

Fourth Floor Operating Room, NYEEI

Of the nearly 28,000 surgeries performed

by The New York Eye and Ear Infirmary in

2010, cataract removal cases requiring the

use of an intra-ocular lens (IOL) comprised

43% (12,046) of them. To lessen the

chance of both lens implantation error

during surgery and risk of infection, the Operating Room Nursing Care Coordi-

nator teamed with management, nursing staff and surgeons to initiate a pilot

project to improve the processing of IOLs. By eliminating the labeling and han-

dling of back-up IOLs and streamlining other related procedures, the initiative

has saved 800 overtime hours and $22,300 since May 2010. More important,

there have been no lens errors.

Pay for Performance (P4P) Program at Continuum Health Partners

TEAM LEADERS: Claudie H. Jimenez, MD, Director, Managed Care Pay for

Performance; Faiz Bhora, MD, Associate Program Director, General Surgery,

SLR; Latha Sivaprasad, MD, Medical Director, Quality Management and Patient

Safety, BIMC; Michael Leitman, MD, Chief and Program Director, General

Surgery, BIMC

The P4P Program partners with Continuum physicians to implement more cost-

effective practice patterns, improve admission and discharge planning, and

enhance quality measures aimed at lowering length of stay and health care

costs. Ensuing cost savings are shared with the physicians who provide the most

efficient quality care overall; performance is gauged using a methodology that

adjusts for severity of illness. Since its inception in 2006, P4P has had a direct

positive impact on length of stay, core measure compliance, physician documen-

tation and operating room efficiency, and resulted in significant savings. Looking

ahead, it will focus on ICU quality protocols and surgery on-time starts.

Blood Program Improves Blood Utilization

TEAM LEADER: Sandra Gilmore, Director,

Blood Management/Bloodless Medicine

and Surgery, BIMC

Three years ago, a clinical leadership group

formed at Beth Israel to create evidence-

based guidelines for appropriate bloodutilization and for transfusion alternatives

for patients who decline donor blood. Their

efforts resulted in the Blood Management/Bloodless Medicine and Surgery

Program, which has increased Beth Israels overall use of blood-sparing proce-

dures and improved the use of interventional procedures. Physician participation

has doubled, and from 2008 to 2009 the number of transfused units of packed

red blood cells decreased by 800 and 196 fewer patients were transfused despite

larger patient volume. The program now makes available a pocket reference card

with a checklist for Jehovahs Witness patients and guidelines for acute bleeding

and chronic anemia.

Therapeutic Hypothermia in the Management

of Survivors of Cardiac Arrest

TEAM LEADERS: Janet Shapiro, MD, Director, Medical Intensive Care Unit, SLR;

Eyal Herzog, MD, Director, Critical Care Unit, SLR

Based on published studies, therapeutic hypothermia (cooling of the body)

improves neurologic outcomes in survivors of out-of-hospital cardiac arrest

(OHCA). In 2008, a St. Lukes and Roosevelt Hospitals multidisciplinary team

involving cardiology, emergency medicine, critical care medicine, critical care

nursing and neurology set about developing a protocol for OHCA survivors that

incorporates therapeutic hypothermia. As of March 2011, data shows that sur-

vival with good neurologic outcomes has been achieved in 40% of a total of 77

OHCA survivors with shockable rhythma significant improvement compared

to historical statistics. SLR has become a leader in publishing this protocol and

presenting it to other clinicians.

Collaborative Continuous Quality Improvement of an Integrated

Rapid HIV (RHIV) Testing Program in SLRs Emergency Departments

TEAM LEADERS: Dan Wiener, MD, Chair, Emergency Medicine; Victoria Sharp,

MD, Director, Center for Comprehensive Care (CCC); Zachariah Hennessey, MA,

Director of Special Projects, CCC

Early identification of HIV infection reduces morbidity and mortality and reduces

the likelihood of transmission. In 2009, the CCCand the Emergency Departments

(ED) at St. Lukes and Roosevelt Hospitals developed a model for implementing

fully integrated, point-of-care RHIV testing in the ED as a routine part of medical

care. The model, launched in July 2010, involved system improvements and

introduced new policies and procedures, including a modified ED electronicmedical record to prompt triage nurses to offer the test and training of additional

staff in the testing technology. According to first quarter 2011 data, since the

models implementation, testing volume has increased six-fold, the percentage of

triaged patients offered the test has jumped from 33 to 90 percent, and linkage

to care rose to 100%.

thank you for continuedefforts to improve patientcare and safety at Continuum! (continued on back page)


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555 West 57th Street

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(continued from page 7)

And the

NomineesAre

Critical Lab Value Sticker Boosts Documentation

and Provider Notification

TEAM LEADER: Donna Wilson, RN, CPHQ,

Director, Quality Improvement, BIMC

With the Joint Commission identifying

communication among caregivers as a vital

factor in optimal care delivery, the QI team

began studying documentation of lab

values and notification turnaround time

from nurses to providers. It ultimately

developed the Critical Lab Value Sticker to be completed by nurses and then

placed in the medical record when they receive lab results. Documentation rates

quickly increased from a baseline of 65% in 2008 to 95% in June 2011, and

notification turnaround time dropped from 20 to six minutes during the same

period. The project also prompted other quality and safety improvements,

including better overall communication among caregivers and more timely

treatment of critical medical issues.

Encouraging the Use of RCA Risk-Reduction Strategies

TEAM LEADERS: Donna Wilson, RN, CPHQ, Director, and Claudia Garcenot,

Assistant Director, Quality Improvement, BIMC

In 2008, Beth Israels Quality Improvement Department instituted a tracking

system to measure and monitor the hospital-wide use and effectiveness of root-

cause analysis (RCA) risk-reduction strategies. A database was created to chart

adherence to these strategies as well as produce reports of adverse occurrences

when an RCA process was conducted. Outcomes of the project have had a

positive impact on such processes as the timeliness of consults, quiet-room

documentation, and the immediate recheck of alert potassium values. Further-

more, a 91% compliance rate has been reached for implementation of

completed RCA risk-reduction strategies.

2011 Quality and Patient

Safety Award nominees

Documents

Quality and Excellence Winter 2012 Newsletter