• Implementing a Standardized Nursing Handoff between the Emergency Department and Inpatient Departments

      Foltz, Kimberly A.; Quattrini, Veronica (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.
    • Modeling Nursing Flowsheet Data for Quality Improvement and Research

      Westra, Bonnie (2015-07)
      Introduction: 1. Describe the relevance of flowsheet data for continuing business operations, quality improvement, and research. 2. Identify challenges in current use of flowsheet data to achieve the above perspectives. 3. Explore principles for consistent and reliable mapping of flowsheet data to clinical data models for continuing (secondary) use of the data. 4. Learn about national initiatives and how to get involved to apply the principles in additional health care settings.
    • Quality Improvement Targeting Early Phase of Hepatitis C Care Delivery

      Price, Angie; Bundy, Elaine (2019-05)
      Background: In the United States, chronic hepatitis C is the leading cause of liver transplantation, and there are more than 3.5 million people infected with hepatitis C virus. Liver fibrosis evaluation is the most important assessment because individuals with hepatitis C are predisposed to liver fibrosis and liver failure. Individuals with advanced fibrosis and cirrhosis are at increased risk of developing advanced liver disease related complications such as variceal bleeding and hepatocellular carcinoma. Therefore, early recognition of these patients and providing recommended imaging surveillance for hepatocellular carcinoma, and gastroesophageal varices are imperative in reducing negative outcomes. Local problem: In an inner-city infectious disease clinic, more than 30% of patients with hepatitis C did not have complete evaluation for liver fibrosis. The lack of liver fibrosis staging can potentially lead to negative clinical outcomes, such as cirrhosis, liver failure and hepatocellular carcinoma. Hence, the purpose of this quality improvement project was to increase the completion rate of liver fibrosis staging for adult patients with chronic hepatitis C in an outpatient infectious disease clinic. Intervention: A quality improvement project was developed to improve and standardize liver fibrosis evaluation through the implementation of electronic order set in the electronic medical record. Following education on the evidence-based components of the order set, provider compliance was monitored through electronic reports to determine whether the completion rate of liver fibrosis evaluation for patients with chronic hepatitis C increased. Result: The implementation of the electronic order set was effective in increasing the fibrosis evaluation completion rate. Before order set implementation, 68.7% of patients had complete fibrosis evaluation as compared with 89.7% after order set implementation (p= 0.016). Conclusion: The implementation of an evidence-based hepatitis C order set improved liver fibrosis staging completion rates by more than 20%, and improved patient clinical outcomes by reaching evidence-based treatment goals for patients with hepatitis C. Electronic order sets are a sustainable method to implement evidence-based practice guidelines, and to ensure standardization of practice across all providers in a facility.
    • Screening and Referral of Orthopedic Patients into Care Coordination to Decrease Readmissions

      Miller, Danielle; Davenport, Joan (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.
    • Telephone Follow-up to Reduce Thirty Day Readmission in Heart Failure Patients

      Simon-Waterman, Christie M. (2016)
      Background: Unplanned hospital readmissions occur frequently in the United States (U.S.), placing great financial burdens on the healthcare industry and creating complications for patients. Approximately 20% of patients are readmitted to the hospital within 30 days of discharge and three-quarters of these readmissions could have been prevented (Chaudhry, Barton, Mattera, Spertus, & Krumhoiz, 2006). A 30-day hospital readmission rate of 19.6% among Medicare fee-for service enrollees has also been reported. The estimated cost of approximately US $17.4 billion in unplanned hospital readmissions for Heart failure (HF) complications has been reported (Purdy 2012). Telephone follow-up is thought to be an effective strategy in reducing the 30- day readmission rate for adults with heart failure, and this intervention will be explored. Early readmission is a common and costly occurrence, particularly among HF patients. HF remains a high risk, chronic disease and readmission within 30 days is common. Because of the complexity of HF treatment, discharged patients find it difficult to manage all required aspects of their care effectively. Telephone follow-up addresses gaps of uncertainty that may exist and allows patients to gain clarity or further explanation about their conditions. Objective: The purpose of this DNP scholarly project is to design, implement and evaluate an NP telephone follow-up policy for HF patients discharged from the targeted sub-acute rehabilitative institution to a home setting. Design and Methods: The design for this project is a quality improvement initiative project. The setting will include a Long term care / sub-acute rehabilitative institution where the DNP student leader made phone calls to patients in their places of residence (to include personal homes and/or other residential sites). Patients were advised about the project and asked to sign a participation consent form prior to discharge from the LTC/ sub-acute rehabilitative setting if they are willing to participate. The telephone call, and subsequent interventions to patient, occurred only after patients were discharged to their homes or place of residence. Sample: A sample of 44 patients total was studied. Retrospective chart reviews were completed and data collected on 21 people. The other 23 people were contacted 1-3 days post discharge and then weekly for 30 days. Patients were considered for participation in the project based on certain predetermined criteria, as follows. Be scheduled for discharge from the facility to their place of residency within the project implementation timeframe, have a diagnosis of HF for their most recent hospital admission, primary admission diagnosis of heart failure needs to be clearly noted in the medical record. Be alert, verbally responsive, and able to hear clearly, and speak/understand English and have a working telephone. Results: no differences between the groups from the demographic characteristics age, gender, and race. Participants largely female, Caucasian between ages 71-80. Mean age 70.45. . Retrospective chart reviewed indicated 43.47% of the intervention group and 47.61% of the non-intervention group were readmitted within 30 days prior to this last admission. Decrease noted in the 30 days readmission rate for both groups. Patients who received telephone intervention had a 17.39% readmission rate post 30 days compared to those who did not receive the intervention at 38% readmission rate Conclusions: The results of this study demonstrates that telephone follow-up provided by an NP post discharge from a LTC facility , at least initially decreased 30 day hospital readmission, but the difference did not reach statistical significance.