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Early Hearing Detection: Using Pre-Discharge Education and Standardized Referrals to Reduce Lost-To-Follow-Up Rates(2019-05)Background: There are lags in ensuring that infants who do not pass their hospital newborn hearing screens receive the follow-up testing they need by the recommended three-month benchmark. The purpose of this project is to address disparities in infants lost to follow-up (LTF) by implementing a program for pre-discharge education and referral plan to free follow-up care at a suburban hospital in a mid-Atlantic state. Intervention: A partnership between the state department of health and a local university audiology program provided education and free follow-up testing of infants who did not pass the newborn hearing screen. Audiology technicians provided a screening result card to families, which also included hearing developmental milestones. Families received brief verbal education about the test result and the urgent need for a retest for those who did not pass. Infants requiring follow-up received appointments with the partner audiology clinic for a free evaluation. Results: 216 infants were born at the site and 214 babies received the in-hospital hearing screens. All 214 babies passed the in-hospital screens and did not require referral. An additional three babies were referred to the university clinic from other sites. Conclusion: This project did not yield opportunities for evaluation of LTF due to low birth volume during the short data collection period. However, this project indicated future potential for positive change. Families responded well to the cards and engaged with the education. This partnership provided opportunities for follow-up of at-risk infants in the region and is likely a model worth continuing and expanding.
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Implementing a Standardized Nursing Handoff between the Emergency Department and Inpatient Departments(2019-05)Background It is estimated that 80% of serious medical errors have a component of miscommunication between caregivers when a patient is being transferred. Ineffective handoffs can lead to delays in, or inappropriate treatments, and increased length of stay. Approximately half of hospital staff indicate information related to the patient is lost during handoffs. For a handoff to be successful, the following is needed: (1) standardized content, forms, tools, and methods; (2) the opportunity to ask questions; (3) staff accountability and monitoring; and (4) education and coaching. Additionally, the electronic health record should be used to enhance handoffs between senders and receivers. Local Problem The purpose of this quality improvement project was to implement and evaluate evidence-based patient-centered handoff from the emergency department to inpatient medicine departments within an urban, academic medical facility based in Maryland. Prior to this project, there was not a handoff report which contained all of the critical elements, an easy way for the inpatient nurse to contact the emergency department nurse with questions, and/or the ability to document that handoff was complete. Interventions Lewin’s change theory was used as the framework. The interventions were: (1) create a new report in the electronic health record, which contained all elements noted to be critical content by The Joint Commission, and (2) add a field to the electronic health record which the inpatient nurse completed after the report has been reviewed. The inpatient nurse was able to document ‘Chart reviewed, no questions’, ‘Chart reviewed, questions answered’, or ‘Other’ with the ability to add a comment. Results There was a reduction of handoff related patient safety events from four preimplementation to two post-implementation. Though the theme of all of the events was communication, there was a difference in miscommunication versus lack of communication. The percentage of compliance with the new process was 48.6%. Not all of the responses to the preimplementation and post-implementation survey questions are statistically significant; however, there was a statistically significant difference in ‘I am satisfied with the process for emergency department to inpatient handoff’ on both the inpatient (pre-data (M=2.3, SD=1.1) and post-data (M=3.3, SD=1.3); t=-2.8, p=0.006) and emergency department (pre-data (M=3.3; SD=1) and post-data (M=4.4, SD=0.7); t=-3.9; p=0.0003) surveys. Nurse satisfaction with the handoff process has increased. Conclusions The project decreased patient safety events, and increased overall nurse satisfaction related to handoff from the emergency department to inpatient medicine units. As all transfers from the emergency department to non-intensive care inpatient areas followed the same process pre-implementation, expanding the use of the new process into those areas is recommended. The emergency department to intensive care unit process is currently a verbal handoff with no specific format. In the future, it will be guided by the new electronic health record report. There are opportunities to implement an improved handoff process in other areas of the medical center. Patients are transferred between units, procedural areas, and from one clinician to another frequently. The model used in this project could be the foundation for improvements in those handoffs.
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Use of Cord Blood for Admission Lab Testing in High Risk Neonates(2019-05)Background: As part of their care in the neonatal intensive care unit (NICU) most neonates require routine admission labs, which could equal up to 10% of their total blood volume. This, and the subsequent lab draws while in the NICU can predispose them to anemia and hypovolemia with the possibility of needing blood transfusions. Local Problem: This QI project is being done in a twenty four bed level three NICU and in a twelve bed labor and delivery (L & D) unit in a major urban medical center in the Mid –Atlantic region. The current practice is to draw admission labs directly from the baby which is not only invasive but also traumatic and expensive considering the supplies used. Participants include registered nurses, neonatal nurse practitioners, neonatologists, laboratory personnel, and information technology staff. Aim: To implement the feasibility of drawing admission labs from the cord blood as an alternative to the current practice of neonatal phlebotomy. The data collected will be the number of staff who are trained to the number of staff working in the L&D and NICU and the number of samples collected from the cord blood to the number of NICU admissions during this timeframe. Interventions: The theoretical framework used here was the Plan Do Study Act. All nurses working in the labor and delivery and NICU and all high risk infants between 22 and 42 weeks who were admitted to the NICU were eligible to participate. An evidence based literature review guided improvement of current practice. Unit based practice guideline, power point presentation, competency checklist and data collection tools were prepared for education, training and data collection. Champions were selected and individual and group training sessions were done. Select cord samples were collected and sent to lab. Results: Education was completed by 80% L & D nurses, and 80% NICU nurses. Samples were collected on 64.47% neonates admitted to the NICU. Based on the posttest administered after the education, 98% agreed that using cord blood for admission labs is safe and reliable and helps prevent pain and other complications. Conclusion: The procedure has a high degree of usability and staff are continuing to collect samples from cord blood. In this present era where our focus is on quality improvement initiatives, making a wise use of available resources like umbilical cord blood will bring about a better outcome for the sick neonate and cost containment for the patients and their family as well as for the organization where it is implemented. In conclusion, cord sampling as an alternative to neonatal phlebotomy is an easily accessible procedure with the potential to improve the outcome of the sick neonates.
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Improving Inhaler Technique Education in a Pediatric Emergency Department(2019-05)Background: Efficacy of inhaled medications for asthma is dependent upon proper administration technique. Rates of metered dose inhaler and spacer misuse are high among both patients and healthcare providers, and gaps in patient education practices are widespread. Practice guidelines recommend patient technique be demonstrated and assessed at every encounter using a checklist of critical steps with repetition until competency is achieved. Local problem: The purpose of this project was to improve metered dose inhaler and spacer technique education provided by registered nurses in a pediatric emergency department. Nurses in this setting do not receive training on metered dose inhaler technique, and patient technique demonstrations are not routinely assessed or documented utilizing checklists. Interventions: All nurses working in the pediatric emergency department (n=20) received education on metered dose inhaler and spacer technique at the initiation of the project. Training checklists were developed and incorporated into the electronic medical record based upon practice guidelines. Prior to discharge, patients with asthma were asked by a nurse to demonstrate their technique using a metered dose inhaler and spacer. The nurse used the checklist in the patient’s electronic medical record to assess and document competency in the critical steps of metered dose inhaler and spacer technique. Instruction was provided by the nurses to remedy any patient errors until competency was demonstrated. Results: In patient chart audits conducted over a 10-week period 138 charts met audit criteria; 95 of which had documented checklists. One-hundred percent of patients and/or caregivers with documented checklists were able to demonstrate competency in all critical steps prior to discharge, with 35% requiring additional education to correct errors in technique. Conclusions: This project demonstrated the benefit of maximizing a pediatric emergency department encounter to provide evidence-based asthma education on a critical component of asthma management. Similar projects are needed that focus on inhaler technique in other settings, as well as with other inhalation devices.
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Screening and Referral of Orthopedic Patients into Care Coordination to Decrease Readmissions(2019-05)Background The negative impact on patient outcomes due to unplanned hospital readmissions places a financial strain on the health care system. The Centers for Medicare and Medicaid reported 30day readmission rates as a fair indicator of quality services. Hospitals face monetary penalties for readmission rates exceeding the national benchmark under the Affordable Care Act. Hip and knee replacements were added to the list of conditions in 2014 authorizing Centers for Medicare and Medicaid to penalize hospitals for readmissions within 30 days of discharge. Local Problem When comparing an urban academic hospital to other hospitals in the state of Maryland, 44 hospitals have lower readmission rates for knee and hip replacement patients. Analysis of knee and hip replacement readmissions for two hospitals in Maryland within the same system for year 2017 reported readmission findings of 21 for both knee and hip, 79 for hip only, and 91 for knee only. Both hospitals had a 12% readmission rate in 2017. Interventions The healthcare team identified high, intermediate, and low risk total hip or total knee revision replacement patients at discharge by using the LACE risk-screening tool. Patients were referred into care coordination. Low-risk patients received a telephone phone call prior to their first appointment post-discharge. Intermediate and high-risk patients received follow-up phone calls for 30 days post-discharge, and then received a visit by the care coordinator during their outpatient follow-up visits with the surgeon to review the plan of care. Readmissions, emergency department visits, and no-show appointment rates were tracked before and after implementation of the LACE risk screening and care coordination. Results Readmission rates, emergency department visits, and no-show appointments in the first quarter (July-September, 2018) were compared to the second quarter (October-December, 2018) when the LACE screening tool was implemented. Readmissions within 30 days post-discharge decreased from one to zero. The no-show appointments were zero in Q1 and five in Q2 were a Pvalue of 0.02. Reasons for no-show appointments included diarrhea and transportation issues. There was an increase from one to three emergency department visits with a P-value of 0.32. The reasons for the emergency department visits post-LACE included wound check, abdominal pain, and femur fracture related to the revision of hip arthroplasty surgery. Conclusions The LACE Index scoring found to be helpful in this orthopedic care coordination program for identifying patients at low, intermediate, and high-risk for readmission within thirty days postdischarge. Introducing care coordination appeared to enhance post-discharge support and improve hand-offs between the inpatient and outpatient setting of healthcare.
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Implementing a Locator Protocol to Support People Living with Human Immunodeficiency(2019-05)This quality improvement (QI) project implemented and evaluated a locator protocol in an urban hospital to community transitional care program for persons living with HIV to minimize the number of people lost to follow-up. Background: In the United States over 50% of people living with HIV (PLWH) are not engaged in HIV care. Individuals not engaged in HIV care do not have access to combination antiretroviral therapy, prophylactic medications or medical services which increases their risk of morbidity, mortality, and HIV transmission to others. Local Problem: The HIV population in Baltimore is highly transitory with high rates of substance use and mental health disorders, and homelessness. An urban HIV organization in Baltimore, Maryland connects PLWH who are newly diagnosed or out of care to medical care. Clients are enrolled in the transitional care program during hospitalization and staff initiate individualized care plans to address barriers to care and provide support services. After discharge from the hospital clients receive 90 days of intensive case management including home visits, transportation to medical visits and connection to resources. During enrollment in this program, up to 50% of clients may be lost to follow-up at various time points because phone numbers are disconnected, or client transience. Intervention: A locator protocol tool was developed and initiated to collect detailed social and personal information from clients in the transitional care program to minimize the number of clients lost to follow up. Inclusion criteria included consented clients age 18 or older who were newly diagnosed or out of care for HIV for at least six months and had 1 of the following: unstable housing, substance use and/or a mental health disorder. Questions in the locator protocol included local hang outs, identifying a person of trust who could be contacted in case the client was not found, programs, agencies or businesses frequented, and dwelling locations including shelters. Community health workers (CHW) completed the form with clients at the bedside before discharge from the hospital. The locator protocol was initiated if a client missed a medical appointment or when the CHW could not locate a client via phone or address. Results: Twenty clients were enrolled in LTC+ from September 10 to December 17, 2018. Outcomes: 1) Seventeen (85%) clients completed the locator protocol. 2) Clients were frequently lost and then found again with the locator protocol. 3) Thirteen (76%) were actively retained in care. Conclusions: People who have unstable housing, substance use or mental health disorders struggle to maintain their health in traditional medical care models. The locator protocol centralizes client information and standardizes internal protocols which results in more consistent communication between staff and clients. The more detailed social and personal information collected, the longer and more likely staff stayed in touch with clients and got them to appointments and engaged in HIV care.
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Immediate Debriefing after Pediatric Critical Incidents(2019-05)Background: Critical incidents are described as events that induce strong emotional responses that can increase stress levels thereby impeding a nurse’s ability to provide good care. Nurses working in the pediatric environment are frequently exposed to critical incidents that affect their well-being. This repeated exposure may result in burnout and eventually leading to compassion fatigue. Local Problem: Nurses working in a community hospital expressed a need for immediate debriefings after pediatric critical incidents. Debriefings were occurring days to weeks after the critical incident. The purpose of this quality improvement project was to implement an immediate debriefing program for the interprofessional care team, after pediatric critical incidents to decrease stress associated with critical incidents and increase overall staff satisfaction. Examples of critical incidents include resuscitation of patients after cardiac or respiratory arrest, patient death, sudden or acute clinical changes requiring transfer to the Pediatric Intensive Care Unit (PICU), and conflicts with patients’ and/or their family members. Interventions: The quality improvement project was implemented on the pediatric unit at a community hospital in Baltimore, Maryland. Project implementation was conducted over a 14-week period. During the first two weeks, charge nurses who served as project champions attended a 30-minute training session led by the project leader on critical incident stress debriefing and conducted debriefings on the unit. Participants completed a pre- and post-implementation critical incident debriefing survey. All debriefing sessions were identified by the charge nurse and held during the same shift as the critical event. After each debriefing session, staff completed a post critical incident debriefing survey. Data collection included elements from the post critical incident debriefing survey. Responses to pre- and post-implementation surveys were compared to assess the impact of the debriefing sessions in decreasing staff stress and increasing satisfaction following a critical incident. Results: Eleven critical incidents occurred, with a debriefing session conducted after each incident. A total of 51 team members participated in these sessions, of which 13 participated in more than one session. Critical incidents included patients with sudden or acute clinical changes requiring transfer to the PICU, conflicts with patients, and patients at end of life. Post critical incident debriefing survey results revealed 94% of staff strongly agreed or agreed the debriefing session was held at an appropriate time, 81% strongly agreed or agreed debriefings helped decrease feelings of stress and unease, 77% strongly agreed or agreed debriefings were meaningful, and 81% strongly agreed or agreed debriefings improved satisfaction with debriefing session. Post-implementation survey results revealed the implementation of debriefing sessions immediately postcritical incidents decreased staff stress associated with critical incidents most of the time (74%) and increased overall staff satisfaction most of the time (61%). Conclusion: Critical incidents in Pediatrics/PICU can cause a significant amount of staff stress. Implementation of a debriefing process was found to be helpful in decreasing stress associated with critical incidents and increasing overall staff satisfaction with the debriefing process. The debriefing process also helped identify barriers to patient care, discuss patient and staff safety concerns, and identify potential solutions.
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Impact of Automated Post-Discharge Phone Calls on 30-Day Hospital Readmission Rates(2019-05)Background Reducing 30-day readmissions is a priority among hospitals nationwide as it is tied to reimbursement and used as a surrogate quality indicator. As an all-payor system, Maryland has the added challenge to reduce 30-day readmissions to below the national rate to be in compliance with its contract with the Centers for Medicare and Medicaid Services. Local Problem Readmission rates among trauma patients in a level-1 trauma center of a large, urban academic medical center in Baltimore, MD have been increasing over the first few months of 2018. The purpose of this quality improvement project was to implement and evaluate the effect an automated post-discharge phone call program had on 30-day readmissions and Hospital Consumer Assessment of Healthcare Providers and Systems scores on an acute care trauma unit. Interventions This project implementation took place over nine weeks. The first week was dedicated to staff education. Patients were given verbal as well as written materials regarding the phone call they were going to receive during their discharge education by the nurse. In weeks 29, post-discharge phone calls went out to adult patients being discharged home within 24-72 hours. Three attempts were made to contact the patient, after which a message was left for them to call back. Patients were asked questions about their current health status, follow-up care, medications, instructions, and satisfaction. If they answered negatively, the system would trigger an alert and a registered nurse would follow-up with them the same day. Demographic data including age, gender, primary diagnosis, and mechanism of injury was collected weekly along with survey completion rates, number and type of alerts generated. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and 30-day readmission rates were evaluated one month after the last phone call. Results 104 patients were called, 55.7% of patients completed the survey. 44.8% of those who completed triggered an alert. 29% of alerts were related to follow-up care, 23% related to instructions. Mean age was 6.6 years higher for patients who completed the survey compared to those that did not (40.9 vs 34.3). Readmissions decreased by 2.9%. There were no statistically significant associations between completing the survey and readmission rates (p=0.46). Hospital Consumer Assessment of Healthcare Providers and Systems scores increased in two categories: 4.6% in Care Transitions and 9.6% in Good Understanding of Managing Health. There was not a large enough sample size to determine significance. Conclusions Automated post-discharge phone calls have the potential to reduce 30-day readmission and improve patient satisfaction scores. Further analysis of additional data should be completed at six months to test for a significant association between survey completion, readmission rates, and HCAHPS scores. The potential costs of savings of this project was estimated to be $181,500. Future similar quality improvement projects should be aimed at increasing the number of follow-up appointments and improve patient understanding of instructions before discharge home.
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Assessing Motivation and Readiness for Treatment for Substance Use Disorders(2019-05)Background: Patients who complete inpatient treatment and receive appropriate aftercare such as follow-up doctor appointments and referral to outpatient therapy, have better sobriety rates and health outcomes. Patients who chose to leave a substance abuse treatment center against medical advice experienced worse health outcomes and re-admissions compared to those who were successfully discharged after thirty-day in-patient program completion. Patients who were discharged against medical advice were seven times more likely to be admitted or readmitted within fifteen days. Local Problem: Over the last three years a substance abuse treatment center experienced a significant increase of patients leaving treatment against medical advice. The against medical advice discharge rate at this facility increased almost ten percent over this timeframe. A designated team complete a quality improvement project, using a self-reporting assessment tool to determine if readiness for treatment improved retention rates. Interventions The purpose of this quality improvement project was to assess the circumstances, motivation and readiness for treatment of newly admitted substance use disorder patients at a Mid Atlantic substance abuse treatment center. The Circumstances, Motivation Readiness (CMR) scale was used for these purposes. Results: The majority of the patients scored in the moderately high to high for the CMR subscales and total scale, indicating lower risk of leaving against medical advice. Yet, there was no significant difference between the total scores of those who remained in treatment for the full 30-day requirement or left AMA. However, there were positive correlations between LOS and the readiness subscale (p= 0.047) and total scores (p= 0.0346). There was no significant difference scores for either gender, ethnicity or drug of choice. Conclusion The CMR scale presented a feasible mechanism to identify substance use disorder patients’ readiness for treatment and risk for dropping out. The CMR scale may be of greater use in assessing risk for AMA discharges by counselors during initial intake into the facility by focusing on the individual statements to specifically identify characteristics that would place patients at higher risk for AMA.
