Nursing: QUALITY IMPROVEMENT

Leadership Strategy Analysis – Quality Improvement Process

Ferris State University

Nursing 440

Adrian Duke

Vivian Liverance

Lesley Morgan

Elaine Yeiter

Nursing: QUALITY IMPROVEMENT

Introduction

As future nursing leaders and managers we are preparing for a quality improvement

environment. This involves knowing current research and theory in this area. This paper is

going to analyze the process of a patient that has a hip fracture and the risk of mortality when

waiting to fix the fracture. According to the American Nurse Association (ANA) standards of

professional practice standard number 7: “The registered nurse systematically enhances the

quality and effectiveness of nursing practice.” (ANA, 2016).

Clinical Need

Each year over 300,000 adults over the age of 65 are hospitalized for hip fractures

(Centers for Disease Control and Prevention, 2016). Women experience three-quarters of all hip

fractures, because of their higher probability of having osteoporosis (CDC, 2016). Once

hospitalized it will be discovered if the patient is in need of surgery. If the patient does need

surgery, they often have to wait many hours to get to the operating room. A study by Vidan,

Sanchez, Gracia, Maranon, Vaquero, & Serra (2011) found the longer the patient waits for

surgery, the higher the risk for mortality, major medical complications, and length of stay. There

are multiple reasons why surgery is delayed; operating room availability, acute medical reason,

need for antiplatelet treatment, clinical instability, no blood supply for transfusion, and delay in

signing consent. The most common reason was lack of operating room, followed by acute

medical reason (Vidan, et al., 2011).

With the majority of hip fracture patients being over 65 years old, they usually have other

health conditions put them at a higher medical risk. Research shows the sooner the patient is in

surgery, the better the recovery and the less of a change for developing a medical complication

Nursing: QUALITY IMPROVEMENT

(Vidan, et al., 2011). There is a clear clinical need to improve the process of getting hip fracture

patient to surgery within 24 hours of the fracture.

Design Interdisciplinary Team

The interdisciplinary team consists of: med/surg nurse, orthopedic surgeon, OR nurse,

anesthesiology, pharmacist, physical therapist, and QI/Risk management expert. According to

Yoder-Wise, 2015 “Once an activity is selected for possible improvement, an interprofessional

team implements the QI process. QI team members should represent a cross section of workers

who are involved with the problem.” (P 368). The team members selected are involved in the

care of a hip fracture patient and all share a role in the care. The med/surg nurse takes care of the

patient pre and post-op. The surgeon is the one that fixes the fractures. The OR nurse notices

how the patient tolerates the surgery. The anesthesiologist analyzes the patient and their history

for the best route of anesthesia (spinal, general) for the surgery. The pharmacist is involved with

the medication, they are aware of allergies and risks with opioids. The physical therapist is

involved with how well the patient does after surgery and what equipment the patient will need.

The QI/Risk management expert is involved in all aspects of the patient’s stay, verifying that all

procedures and encounters with hospital staff is appropriate and beneficial. This team will meet

twice monthly to discuss the outcomes of the goals set and areas that need improvement.

Data Collection Method

The team has been selected and will now start to gather data to measure the current status

of mortality in hip fracture patients. In an article by Simunavic, Devereaux and Bhandi (2011), it

is suggested that an observational study is conducted instead of using retrogressive. They state

that “well-done prospective observational studies remain generally less biased than retrospective

studies because the predictor variable is measured before the outcome; thus establishing a time

Nursing: QUALITY IMPROVEMENT

sequence of events and preventing predictor measurements from being influenced by knowledge

of the outcome.” A bar chart would be beneficial in a comparison of length of delay and

contributing factors. This chart would allow the interdisciplinary team to visualize the most

significant problems and begin with those. It might look something like this:

Operating room avaiability

Medical reasons Clincally unstable Antiplatlet tx05

1015202530

Number of Hours of Delay

Analyzing this chart, the team can easily see that the biggest delay is with clinically

unstable patients, they can further collect data of the specifics of how and why.

Establish Outcomes

According to Colon-Emeric (2012) there are generally three long-term outcomes

measured after a hip fracture. These outcomes include functional disability, secondary fractures

and mortality. “Functional disability, especially gait impairment is alarmingly common after hip

fracture” (Colo´n-Emeric, 2012, p.1). Furthermore, “fewer than half of hip fracture patients

regain their prior level of ambulation at 1 year… These functional declines may be made worse

if the patient experiences another osteoporotic fracture” (Colo´n-Emeric, 2012, p.1).

Additionally, the patient’s risk of death is extremely high. “The overall mortality at 1 month was

13.3%, 3–6 months 15.8, 1 year 24.5 and 2 years 34.5%.  Among nursing home residents with

hip fracture, mortality is as high as 75 %”(Colo´n-Emeric, 2012, p.2). Consequently, outcomes

need to be established to decrease the risk of complication for these patient’s’ which in turn

decrease the risk of mortality. “Complications occurring in the post-operative period can negate

any gains made by successful surgery” (Leung, Lau, Kwan, Chow, & Kung, 2010)

Nursing: QUALITY IMPROVEMENT

The first outcome established is: the patient will obtain surgical intervention within

twenty-four hours.

Current guidelines recommend that surgeons perform hip fracture surgery within 24

hours of injury as observational studies suggest earlier surgery is associated with better

functional outcome and lower rates of nonunion, shorter hospital stays and duration of

pain, and lower rates of complications and mortality (Leung, et al., 2010).

There are numerous reasons for earlier surgical interventions especially in connection with

avoiding complications. “An important goal of treatment of fragility hip fractures is the

avoidance of complications” (Leung, et al., 2010). Impaired mobility increases the risk of

pressure sores, increased pain, pneumonia, and urinary tract infections. All of these issues can

impair healing and increase the risk of mortality.

The second outcome established is: patient participates in progressive ambulation

program to decrease risk of falling. A patient that has a hip fracture is generally one that is

fragile. The risk of a fall following hip surgery is high. A number of things can contribute to

this increased risk such as use of pain medications, delirium and changes in ambulation.

The ambulatory dysfunction resulting from hip fracture further increases the fall risk of

this frail population. Persistent delirium, use of psychoactive pain medications, and

frequent changes in care location are additional risk factors for falls. Therefore, careful

attention to fall prevention is an important part of post hip fracture care (Colo´n-Emeric,

2012, p. 3).

The third outcome is: patient will not demonstrate symptoms of post surgical deep vein

thrombosis (DVT) by using the National Institute for Health and Care Excellence (NICE)

guidelines. “Patients undergoing hip fracture surgery are at increased risk of deep vein

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thrombosis” (Matharu, & Porter, 2010, p. 203). There are many concerns about whether or not to

give prophylaxes to hip fracture patients due to co morbidity and other risks. “Despite

thromboprophylactic measures being effective in reducing the incidence of DVT and pulmonary

embolism, the complex nature of the elderly hip fracture patient often makes the decision of

whether to initiate thromboprophylaxis a difficult one” (Matharu, & Porter, 2010, p. 203).

However in 2010, NICE developed guidelines to assist in when and what kind of prophylaxes

should be given. “The network meta-analysis performed to produce the guideline

recommendations included 23 studies critically appraised to be of a high quality” (Matharu, &

Porter, 2010, p. 206).

The fourth outcome is: patient will describe a decrease in pain within 24-48 hours after

surgery using a pain scale of 0 to 10. Pain control is an important part in a patient’s care.

Controlling pain contributes to better outcomes and decrease in incidences of delirium. “Severe

pain is experienced by nearly all hip fracture patients in the pre and postoperative periods, and

contributes not only to poor quality of life, but is also associated with a higher risk of

postoperative delirium” (Colo´n-Emeric, 2012, p.2). Postoperative delirium will significantly

increase the risk of mortality.

The final outcome is: patient will participate in the delirium elderly at risk (DEAR) Tool

to identify pre and post surgical risk of delirium. “Delirium occurs in a quarter of patients

without baseline dementia, and over half of dementia patients who experience a hip fracture…

delirium is associated with lower functional recovery 1 year after fracture, and higher mortality

rates”( Colo´n-Emeric, 2012, p.2). Furthermore, “Delirium is a common problem in elderly

orthopedic patients and is associated with adverse outcomes, including longer length of hospital

stay, decline in function and cognition, increased risk of nursing home placement, and death”

Nursing: QUALITY IMPROVEMENT

(Freter, Dunbar, Koller, MacKnight, & Rockwood, 2015, p. 212). Consequently, it is extremely

important to identify patients with symptoms of delirium. Using the DEAR will help in

identifying the patients at most risk for delirium. “One potential benefit of improving the ability

to identify who is at risk of post-operative delirium is the possibility of implementing targeted

prevention measures in high-risk patients” (Freter, et al., 2015, p. 213).

Implementation Strategies

The interdisciplinary team will meet twice monthly to discuss how to make the wanted

outcomes possible and then the progress outcomes. For patients to obtain surgical intervention

within 24hrs, they will need to obtain an x-ray within an hour of being brought to the hospital.

Once it is discovered that there is a fracture, the patient will go through the protocol for surgery,

within an hour of discover of a fracture. This will include; CBC, BMP, INR, PTT, Type and

Screen, EKG, being made NPO, and med clearance. The patient will be placed as a priority

surgical patient and will not be pushed for elective surgeries.

In regards to pain, patients will learn about the pain scale of 0-10 and be able to use this

scale to describe their pain. Nurses and physicians will use the latest Evidenced-Based Research

in attempt to control pain using physical, psychological, and pharmacologic measures. A copy

of the pain scale will be on the communication white board in each patient’s room and nurses

will write the latest pain number on this white board. Within 24-48 hours after surgery the

patients will have a decrease in the amount of pain. The pain ratings and what measures were

taking will be audited weekly, along with the results of the measures taken.

For faster and easier recovery, it is imperative that patients begin moving as soon as

possible after surgery. The nurses will work closely with physical and occupational therapy to

begin rehabilitation process, once patients are free from sedation from surgery. The goal is to get

Nursing: QUALITY IMPROVEMENT

the patient moving in some form, even if this is just a dangle at the bedside. Nurses will have a

light they will turn on above the room to alert therapy that the patient is ready to be seen.

Patients will receive a survey at home that will ask them about the rehabilitation process and how

comfortable they felt with therapy.

Patients will receive a blood thinner of some kind and this will be either; aspirin,

lovenox, warfarin, etc. What they receive will depend on their risk of DVT. The patient will

receive education prior to surgery on the blood thinning medication and will have to verbalized

and/or demonstrate the purpose of the blood thinning medication. The hospital will receive back

information if a patient experienced a DVT and this will be tracked on a monthly basis.

Elderly hip fracture patients have an average of 35% of developing post-op delirium

(Deiner & Silverstein, 2009). Medication that is given during surgery and after is most often the

cause of post-op delirium. Patients will be assessed using the delirium elderly at risk tool

(DEAR). If a patient develops post-op delirium, there pain medication will be looked over by

physicians and adjusted as needed. Narcotics will not be given, unless absolutely necessary.

The amount of patients with post-op delirium will be followed and their medication examined.

Patients falling is very troublesome and can lead to many problems. When that patient

recently had a hip replacement, it can be disastrous. In order to help prevent falls, nursing staff

will not attempt to get patient out of bed, until physical therapy goes in and assesses the patient.

Nursing staff will then follow their recommendations and follow it. Each patient will have to use

a gait belt, even if they are a minimal assist or stand by assist. Chair alarms and bed alarms will

be used for all patients. A falls committee will follow all patient falls and identify each fall as;

unavoidable or preventable.

Nursing: QUALITY IMPROVEMENT

The Press Ganey questions are a way to reveal the quality of the services provided by the

medical facility. It’s all dependent on the patient’s experience. The survey helps to improve

clinical outcomes for the patient after admissions. “Press Ganey Seal of Integrity acknowledges

that the patient satisfaction data we share meets scientifically-rigorous standards as put forth by

Press Ganey” (Wake Forest Baptist Health, 2014). The more ratings a provider receives the

more accurate and statistically reliable the data. By allowing previous and future patients to

review ratings and surveys can assist the patients in choosing quality healthcare providers.

Press Ganey Score

Press Ganey Survey

Hospital Consumer Assessment of Healthcare Provider Systems (HCAHPS) survey is the

first national, standardized, publicly reported survey of patients' perspectives of hospital care.

Nursing: QUALITY IMPROVEMENT

HCAHPS (pronounced "H-caps"), also known as the CAHPS Hospital Survey, is a survey

instrument and data collection methodology for measuring patients' perceptions of their hospital

experience. The survey contains 18 core questions about critical aspects of patients’ hospital

experiences ( communication with nurses and doctors, the responsiveness of hospital staff, the

cleanliness and quietness of the hospital environment, pain management, communication about

medicines, discharge information, overall rating of hospital and would they recommend the

hospital (Centers for Medicare & Medicaid Services, 2014).

HCAHPS Survey

Evaluation

“One way to evaluate the quality of outcomes is to compare one agency’s performance

with that of similar organizations,” (Yoder-Wise, 2015). Gordon’s theory, functional health

patterns, is used by nurses to provide a comprehensive nursing assessment of the patient. It’s a

framework that uses the client’s health and the way they manage it. Gordon’s theory also allows

the patient to elaborate on the perception of their health practices. The theory allows nurses to

use a standardized method of to assess the patient and collect data needed to help the patient

Nursing: QUALITY IMPROVEMENT

reach their goals. The 11 functional health patterns are Health Perception – Health Management,

Nutritional – Metabolic, Elimination, Activity – Exercise, Sleep – Rest, Cognitive – Perceptual,

Self-perception – Self-concept, Role – Relationship, Sexuality – Reproductive, Coping – Stress

Tolerance, and Value – Belief.

Quality improvement (QI) utilizes a system to evaluate the quality and relevance of the

healthcare outcomes based on Evidence Based Practice. Patient outcomes that are determined to

be nursing sensitive are those that improve if there is a greater quantity or quality of nursing care

(e.g., pressure ulcers, falls, intravenous infiltrations), (Yoder-Wise 2015). The National

Database of Nursing Quality Indicators (NDNQI) is a national nursing quality measurement

program from the ANA that provides hospitals with unit-level performance reports with

comparisons with regional, state, and national percentile ranking (ANA, 2013).

Conclusion

The analysis of hip fractures, treatments for patient’s pre, and post- surgery was

researched in this paper. Pharmacological and other nursing interventions were explored to assist

patients in meeting their goals. Methods that nurses use to assess patient outcomes were also

summarized. Gordon’s theory was integrated as a variety of her health patterns collaborate with

the different aspects of healthcare as perceived by the patient. The healthcare outcomes were

based on EBP and it was stated how quality improvement are measured depending on the care

received. “Sometimes, the step from best evidence to best practice is simple; however, most of

the time it is not, and we need various strategies targeting obstacles to change at different levels,

which could even present conflicting values for individual practitioners” (Grol and Grimshaw,

2003).

Nursing: QUALITY IMPROVEMENT

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Center for Medicare & Medicaid Services. (2014). HCAHPS: Patients' perspectives of care

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Colo´n-Emeric, C. S. (2012). Postoperative management of hip fractures: interventions

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Freter, S., Dunbar, M., Koller, K., MacKnight, C., & Rockwood, K. (2015). Risk of pre-and post-

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