Leading the Quest for Quality

2010 PROFILES IN QUALITY AND PATIENT SAFETY HANYS 2010 Profiles in Quality and Patient Safety

INTRODUCTION

The Healthcare Association of CHAPTERS New York State (HANYS) and its The 2010 profiles are cate- members are committed to in- gorized into four themes: novative practices and continu- ■ Clinical Care— ous improvement in quality, Improving Patient Care safety, and efficacy of care. ■ Operations— HANYS’ Pinnacle Award for Improving Systems and Quality and Patient Safety is one Processes forum to recognize organiza- ■ Patient Safety— tions playing a leading role in Falls, Infection Manage- promoting these works. ment, Medication Management, and Leading the Quest for Quality: 2010 Pressure Ulcers Profiles in Quality Improvement ■ Specialty— and Patient Safety is a com- Behavioral Health, pendium of submissions for Emergency Services, Home Care, Long-Term HANYS’ Pinnacle Award for Care, Maternal-Child, Quality and Patient Safety that Outpatient, and Primary met publication standards. Each Care profile includes a program de- scription, outcomes, and lessons learned that provide insight into what it takes to make positive change occur.

There were winners in four categories: multi-entity, large hospi- tal, small hospital, and specialty or division-based. In addition, HANYS recognized submissions in the top 10th percentile based on the scoring guidelines.

HANYS congratulates and thanks all of our members for their willingness to share their ideas, experiences, and successes. We encourage all members to take advantage of the information in this publication as a strategy to inform and accelerate efforts to improve quality and patient safety.

For more information about the Pinnacle Award for Quality and Patient Safety, please contact Nancy Landor, Senior Director of Strategic Quality Initiatives, at (518) 431-7685 or at [email protected]. HANYS 2010 Profiles in Quality and Patient Safety

SELECTION COMMITTEE MEMBERS

NANCEE L. BENDER, PH.D., R.N., a Consultant with Joint Pennsylvania hospitals and health systems with policymakers Commission Resources, has a diverse background in nursing, and other trade and professional associations. In this position, health care administration, education, research, and perform- Ms. Leighton works with Pennsylvania’s hospitals and other ance improvement, and served as the Executive Director for stakeholders to support the development of health care policy Ambulatory Accreditation for The Joint Commission. She cur- with respect to health care quality, patient safety, delivery sys- rently teaches the use of “tracer” methods as a performance im- tem accountability, professional supply, professional practice, provement intervention. Dr. Bender served as a professor in an public health, and workforce development. She has a Bachelor’s academic faculty appointment at the University of Rochester, degree in Nursing from Pennsylvania State University and a School of Nursing. While pursuing research interests in the coor- Master’s degree in Health Services Administration from the Uni- dination of care and performance improvement for quality, versity of Pittsburgh. cost, and patient safety outcomes, she taught leadership, pa- tient safety, population health, ethics and public policy, and ARTHUR A. LEVIN, M.P.H. is co-founder and Director of the evidence-based quality improvement practices. She served as Center for Medical Consumers, a New York City-based non- the Principle Investigator for a Robert Wood Johnson Founda- profit organization committed to informed consumer and pa- tion-funded program that paired nursing graduate students and tient health care decision-making, patient safety, evidence- medical students on performance improvement planning and based, high-quality medicine, and health system transparency. implementation teams. She served on solution teams for the Mr. Levin was a member of the Institute of Medicine’s (IOM) World Health Organization and The Joint Commission focusing Committee on the Quality of Health Care that published the To on prevention of pressure ulcers and patient falls prevention. Err is Human and Crossing the Quality Chasm reports. He served Dr. Bender received her Bachelor’s and Master’s of Nursing de- on the IOM committee that made recommendations to grees from the University of Michigan, Ann Arbor, and her Congress in IOM’s Leadership Through Example report, and was Doctor of Philosophy degree from the University of Rochester. a member of the committee that issued Opportunities for Coordination and Clarity to Advance the National Health DR. MAULIK S. JOSHI, DR.P.H. is President of the Health Information Agenda and Knowing What Works in Health Care: A Research and Educational Trust (HRET) and Senior Vice Roadmap for the Nation. Mr. Levin is co-chair of the National President for Research at the American Hospital Association Committee for Quality Assurance Committee on Performance (AHA). HRET conducts applied research in improving quality Measures that is charged with developing performance meas- and patient safety, reducing costs, eliminating health disparities, ures applicable to health plans. At the state level, he has served improving leadership and governance, payment reform, and on numerous state health department task forces and work- care coordination. Dr. Joshi also leads Hospitals in Pursuit of groups focused on safety, quality, informed consent, and Excellence™, AHA’s strategy to accelerate performance im- bioethics concerns. Recently, he served on a state policy work- provement and support health reform implementation. Before group for office-based surgery. He also serves on the board of joining HRET, Dr. Joshi served as President and Chief Executive Taconic Health Information Network and Community, a not-for- Officer of the Network for Regional Healthcare Improvement profit health information organization in the mid-Hudson Valley, and was previously a senior advisor for the office of the director and is a founding board member of the New York State at the Agency for Healthcare Research and Quality. Dr. Joshi E-Health Collaborative. Mr. Levin earned his Master of Public served as President and Chief Executive Officer of the Delmarva Health degree from Columbia University’s School of Public Foundation. Before that, he served as Vice President at the Health and a Bachelor of Arts degree in Philosophy from Reed Institute for Healthcare Improvement, and Senior Director of College. Quality for the University of Pennsylvania Health System. Dr. Joshi is Editor-in-Chief of the Journal for Healthcare Quality. He DR. VAHE KAZANDJIAN is the President of The Center for also co-edited The Healthcare Quality Book: Vision, Strategy and Performance Sciences, a Maryland-based outcomes research Tools, and authored Healthcare Transformation: A Guide for the center that develops quality measurement and evaluation strate- Hospital Board Member. Dr. Joshi has a Doctorate in Public gies in the Americas, Europe, and Asia. He is the original archi- Health and a Master’s degree in health services administration tect of, and remains responsible for, the Maryland Quality from the University of Michigan and a Bachelor of Science de- Indicator Project (QIP), the largest indicator project of its kind in gree in Mathematics from Lafayette College. the world. He is Adjunct Professor of the Health Policy and Man- agement Department of the Johns Hopkins Bloomberg School ANDREA KABCENELL, R.N., M.P.H. is Vice President at the of Public Health. In addition, Dr. Kazandjian is the author of Institute for Healthcare Improvement (IHI), where she serves on four textbooks on indicator development and quality of care. the research and demonstration team and leads a portfolio of He is an epidemiologist by training and served as Advisor to the programs to improve performance in hospitals. Since 1995, she World Bank for Latin America, USAID for Africa, and is currently has directed Breakthrough Series Collaboratives and other qual- Advisor to the World Health Organization’s European office in ity improvement programs, including Pursuing Perfection, a na- Barcelona. In 2002, Dr. Kazandjian was named President of tional demonstration funded by The Robert Wood Johnson LogicQual Research Institute, Inc., a not-for-profit organization Foundation designed to show that near perfect, leading-edge dedicated to conducting research on clinical practice and ac- performance is possible in health care. Before joining IHI, Ms. countability. From 2005 to 2010, Dr. Kazandjian served as the Kabcenell was a senior research associate in Cornell University’s Principal Investigator for a quality-based reimbursement initia- Department of Policy, Analysis, and Management focusing on tive by Maryland’s Health Services Cost Review Commission. He chronic illness care, quality, and diffusion of innovation. She has published extensively in clinical and health services peer re- also served for four years as Program Officer at The Robert view journals and books on the development of clinical proto- Wood Johnson Foundation. Ms. Kabcenell received her under- cols, indicators of quality, small area variation analysis, and graduate degree and graduate degree in public health from the longitudinal epidemiological studies. He is also a published University of Michigan. poet and novelist. He received his undergraduate and graduate degrees from the American University of Beirut, Lebanon, and LYNN LEIGHTON, R.N., M.H.A. is Vice President, Health his Doctorate from The University of Michigan, Ann Arbor, Services for the Hospital & Healthsystem Association of Department of Medical Care Organization and Policy, School of Pennsylvania, a statewide trade association that represents Public Health. HANYS 2010 Profiles in Quality and Patient Safety

PINNACLE AWARD FOR QUALITY AND PATIENT SAFETY ✦ 2010 AWARDEES ✦

MULTI-ENTITY CATEGORY LARGE HOSPITAL CATEGORY Improving Patient Safety in Obstetrics Prevent Catheter-Associated Urinary Using Crew Resources Management Tract Infections Catholic Health Services of Long Island Beth Israel Medical Center

Joseph Conte, Executive Vice President of Corporate HANYS’ Board Chairman Joseph Quagliata (far right) Services (left) accepts the Pinnacle Award on behalf of presents the Pinnacle Award to Beth Israel Medical Catholic Health Services of Long Island. Presenting the Center. Accepting the award are (right to left) David award is HANYS’ Board Chairman Joseph Quagliata. Bernard, M.D., Chief Medical Officer and Executive Go to page 82 for a profile of this program. Vice President; Brian Koll, M.D., Medical Director and Chief, Infection Control and Hospital Epidemiology; and nurses Marie Moss-Crispino and Alexis Raimondi. Go to page 47 for a profile of this program.

SMALL HOSPITAL CATEGORY SPECIALTY DIVISION CATEGORY Simple Steps Drive Success: How Medication Administration Quality Principles Guide Change Compliance Initiative Clifton Springs Hospital and Clinic Mountainside Residential Care Center

HANYS’ Board Chairman Joseph Quagliata presents the Philip Mehl, Administrator, and Christine Jones, Director Pinnacle Award to Maura Snyder, Wound Center of Nursing, accept the Pinnacle Award on behalf of Director, who accepts it on behalf of Clifton Springs Mountainside Residential Care Center. Presenting the Hospital and Clinic. award is HANYS’ Board Chairman Joseph Quagliata. Go to page 2 for a profile of this program. Go to page 92 for a profile of this program. HANYS 2010 Profiles in Quality and Patient Safety

✦ SPECIAL RECOGNITION ✦ SUBMISSIONS THAT SCORED IN THE TOP TENTH PERCENTILE

Home Care Demonstration Project to Enhancing Performance, Changing Reduce Hospital Readmissions Culture, Improving Communication, and Brookhaven Memorial Hospital Medical Supporting Rapid Cycle Change Across a Center Home Health Agency Multi-Hospital Health Care System North Shore-Long Island Jewish Health System Patient-Centered Medical Home for Diabetes Management Partnering for Quality: Fostering The Brooklyn Hospital Center Multidisciplinary, Organization-Wide Quality Improvement Reversing the Ravages of Chronic NYU Langone Medical Center Wounds: A Community-Based Approach Claxton-Hepburn Medical Center Hardwiring Patient Safety: Eliminating Health Care-Acquired Infections Emergency Department Efficiency Rochester General Health System Improvement Project Ellis Medicine Using an Analgesia/Sedation Protocol to Reduce Mechanical Ventilation Days The Journey to Zero Nosocomial and Mortality in a Surgical Intensive Infections Care Unit Glen Cove Hospital Rochester General Health System

Rapid Medical Evaluation: Improving Reducing Catheter-Associated Urinary the Emergency Department Patient Tract Infections Experience Stern Family Center for Extended Care and Highland Hospital Rehabilitation/North Shore University Hospital Improving Patient Flow at a Non-Academic Hospital Increasing Awareness of the Need for Mercy Medical Center High-Quality Palliative and End-of-Life Care The Community Health and Acute St. Mary’s Hospital Medical Performance Improvement Organizational Network Standardization to Prevent Venous Montefiore Medical Center Thromboembolism Stony Brook University Medical Center HANYS 2010 Profiles in Quality and Patient Safety

TABLE OF CONTENTS

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CLINICAL CARE

General Therapeutic Cooling Initiative...... 1 Albany Medical Center Road to Recovery/Discharge Passport Program—Heart Failure ...... 1 Arnot Ogden Medical Center Simple Steps Drive Success: How Quality Principles Guide Change ...... 2 Clifton Springs Hospital and Clinic Quality: The Core of a Successful Total Joint Replacement Program ...... 2 Community Memorial Hospital Management of Diabetes, Hyperglycemia, and Hypoglycemia in the Hospital Patient ...... 3 Highland Hospital/University of Rochester Medical Center Eliminating Wrong-Site Peripheral Nerve Blocks ...... 4 Hospital for Special Surgery Save That Vein: Preventing Complications Related to Peripheral and Central Venous Access . . 4 John T. Mather Memorial Hospital Post-Kidney Transplant Care Management Program...... 5 Metropolitan Jewish Health System/SUNY Downstate Medical Center Enhancing Performance, Changing Culture, Improving Communication, and Supporting Rapid Cycle Change Across a Multi-Hospital Health Care System...... 6 North Shore-Long Island Jewish Health System Responding to H1N1: Key Principles of Health System Preparedness and Response ...... 6 North Shore-Long Island Jewish Health System Partnering for Quality: Fostering Multidisciplinary, Organization-Wide Quality Improvement ...... 7 NYU Langone Medical Center Reduced Mortality and Codes Following Initiation of a Rapid Response Team...... 8 Oneida Healthcare Center Using an Analgesia/Sedation Protocol to Reduce Mechanical Ventilation Days and Mortality in a Surgical Intensive Care Unit ...... 9 Rochester General Health System Using Multidisciplinary Rounds to Enhance Patient Safety and Decrease Morbidity in a Critical Care Unit ...... 9 Saint Francis Hospital and Health Centers Optimizing a Culture of Interdisciplinary Collaboration to Prevent CLABSIs in Critical Care . . 10 St. Francis Hospital—The Heart Center Enhanced Post-Operative Inpatient Physical Therapy for Patients Undergoing Major Thoracic Surgery ...... 11 St. Luke’s-Roosevelt Hospital Center Keeping the “Never” in Never Events ...... 11 Vassar Brothers Medical Center HANYS 2010 Profiles in Quality and Patient Safety

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Stroke Improving Patient Safety While Decreasing Complications by Strengthening the Dysphagia Screening Process for Stroke Patients ...... 13 Crouse Hospital Improvement with Stroke Patient Education and Documentation Compliance ...... 13 Good Samaritan Hospital/Bon Secours Charity Health System Information Technology and the Stroke Task Force Collaborate to Improve Quality ...... 14 Nassau University Medical Center Interdisciplinary Approach to Stroke Care and Treatment ...... 15 Phelps Memorial Hospital Center When Seconds Count: Employing Six Sigma Strategies to Improve Compliance with Best Practices in Transient Ischemic Attack and Stroke Management ...... 15 St. Catherine of Siena Medical Center

VAP Reducing Patient Ventilator Days and Ventilator-Associated Pneumonia ...... 17 Nathan Littauer Hospital and Nursing Home VAP Prevention in a Community Hospital Setting is Sustainable and Can Be Like Breathing: “Automatic and Painless” ...... 17 St. Catherine of Siena Medical Center Zero Tolerance for Ventilator-Associated Pneumonia ...... 18 St. John’s Episcopal Hospital South Shore Preventing Ventilator-Associated Pneumonia: A “Bundle of Joy” for Patients and Staff ...... 19 St. Joseph’s Hospital Health Center Reduce the Number of Ventilator-Associated Pneumonias to Zero ...... 20 Thompson Health

VTE Improving VTE Prophylaxis in a Community Hospital with CPOE ...... 21 Glens Falls Hospital Improving VTE Prevention Strategies and Patient Outcomes...... 21 Maimonides Medical Center Redesigning Processes to Prevent Hospital-Acquired VTE ...... 22 South Nassau Communities Hospital Standardization to Prevent Venous Thromboembolism ...... 23 Stony Brook University Medical Center

OPERATIONS Operating Room Inventory Control Improvement Project ...... 24 Albany Memorial Hospital and Samaritan Hospital Patient Forum Yields Performance Improvement Opportunities ...... 24 Bassett Healthcare Network/Bassett Medical Center Preventing Significant Events Through a Culture of Safety ...... 25 Catholic Health System HANYS 2010 Profiles in Quality and Patient Safety

PAGE Help From Above: Overcoming Barriers of Geographic Size and Location ...... 26 Claxton-Hepburn Medical Center Improving Physician Compliance with Quality Measures: The Carrot or Stick? ...... 26 Cortland Regional Medical Center Enhancing a Cardiac Rehabilitation Program: Safety, Continuity, and Convenience for Patients ...... 27 Delaware Valley Hospital Controlling Operating Room Supply Chain Expenses ...... 28 Ellis Medicine Transforming a Culture by Engaging the Entire Organization ...... 28 Faxton-St. Luke’s Healthcare Community Drug Information Center ...... 29 Kingsbrook Jewish Medical Center Improving Inpatient Satisfaction Through a Patient-Centered Guest Ambassador Program . . 30 The Kingston Hospital Improving Patient Flow at a Non-Academic Hospital ...... 30 Mercy Medical Center The Community Health and Acute Medical Performance Improvement Organizational Network...... 31 Montefiore Medical Center Improved Efficiency of Platelet Utilization Through Leadership and Cultural Transformation...... 32 Nassau University Medical Center Formal Nurse Preceptor Education Program ...... 32 Nathan Littauer Hospital and Nursing Home Improving Core Measure Compliance Through Education, Standardization, and Accountability...... 33 Orange Regional Medical Center Endoscopy Flow Initiative ...... 34 Oswego Hospital Journey to Improved Quality Outcomes ...... 34 Our Lady of Lourdes Memorial Hospital Reducing Mislabeled Specimens ...... 35 Samaritan Medical Center A Nursing Strategic Plan Built Upon a Foundation of Patient Safety...... 35 Southampton Hospital Improving Pain Management in the Limited English-Proficient Population ...... 36 Southside Hospital/North Shore-Long Island Jewish Health System Decreasing Patient Transfer Time from Floor Beds to Critical Care Beds ...... 37 Staten Island University Hospital Increasing Awareness of the Need for High-Quality Palliative and End-of-Life Care ...... 37 St. Mary’s Hospital Organization-Wide Use of FMEA to Drive High Reliability and Safety ...... 38 Stony Brook University Hospital HANYS 2010 Profiles in Quality and Patient Safety

PAGE Quality of Care Web Site: Transparency of Data ...... 39 Upstate University Hospital Central Service Nursing Supply Cart Revision ...... 39 WCA Hospital Improving Correct Patient Selection Prior to Order Entry Within an Electronic System ...... 40 Winthrop-University Hospital

PATIENT SAFETY

Falls Improve Patient Safety and Satisfaction Using Restraint Reduction Strategies ...... 41 Franklin Hospital Reducing Patient Falls in the Hospital Using Bright Yellow Blankets and Non-Skid Socks. . . . . 41 Kenmore Mercy Hospital/Catholic Health System Acute Inpatient Rehabilitation Unit Falls Prevention Program ...... 42 Mercy Medical Center Restraint Use Reduction ...... 42 Nathan Littauer Hospital and Nursing Home Falls Reduction Program—An Individualized Approach ...... 43 New York Hospital Queens Patient Safety Without Restraints...... 43 New York Hospital Queens Feet First: Enhancing a Culture of Safety to Achieve a Reduction in Patient Falls ...... 44 St. Francis Hospital—The Heart Center Falls Prevention—Methodology and Initiative ...... 45 St. Joseph’s Hospital, Elmira Falls Prevention Intervention Program ...... 45 United Memorial Medical Center

Infection Management Reduce Surgical Site Infections ...... 47 Adirondack Medical Center Prevent Catheter-Associated Urinary Tract Infections...... 47 Beth Israel Medical Center “All Hands on Deck” Infection Awareness: Embracing a Culture of Safety...... 48 Canton-Potsdam Hospital A Vascular Access Team Reduces CLABSIs in Critical Care Units...... 49 Faxton-St. Luke’s Healthcare Journey to Zero Nosocomial Infections...... 49 Glen Cove Hospital Reducing Hospital-Acquired Catheter-Associated Urinary Tract Infections ...... 50 Good Samaritan Hospital/Bon Secours Charity Health System Using a Multidisciplinary Team Approach to Reduce Nosocomial Clostridium Difficile ...... 51 Long Island Jewish Medical Center HANYS 2010 Profiles in Quality and Patient Safety

PAGE A Multidisciplinary Approach to Reducing Surgical Site Infections in Coronary Bypass Patients ...... 51 The Mount Sinai Medical Center Employee Health Seasonal and H1N1 Influenza Vaccination Initiative ...... 52 New Island Hospital Improving the Quality of Patient Care Through an Antimicrobial Management Initiative . . . . 53 New York Hospital Queens Improving Health Care Worker Hand Hygiene Compliance in an Intensive Care Unit ...... 53 North Shore University Hospital Decreasing Incidence of Upper Extremity Deep Venous Thrombus ...... 54 Plainview Hospital Using the Medication Administration Record to Improve Immunization Rates ...... 55 Putnam Hospital Center Hardwiring Patient Safety: Eliminating Health Care-Acquired Infections...... 55 Rochester General Health System Reducing Infections in the Orthopedic Total Hip and Total Knee Arthroplasty Population . . . 56 Rochester General Health System Hospital Point of Dispensing Exercise to Test Response to a Public Health Emergency ...... 57 St. Elizabeth Medical Center Reducing Hospital-Acquired Infections in the Intensive Care Unit by Using Chlorhexidine Bathing and Oral Rinse ...... 57 St. Elizabeth Medical Center Reducing Surgical Site Infections After Knee and Hip Replacement Surgery ...... 58 St. Elizabeth Medical Center Meeting Methicillin-Resistant Staphylococcus Aureus Head-On ...... 59 St. Mary’s Hospital A Catheter-Associated Urinary Tract Infection Prevention Team Models Best Practices and Improves Outcomes ...... 60 St. Peter’s Hospital Central Line Infection Reduction—Not Just in ICUs ...... 60 Strong Memorial Hospital/University of Rochester Medical Center MRSA Active Surveillance Program...... 61 Unity Health System A New Approach to Promote Associate Wellness During Influenza Season ...... 62 Westfield Memorial Hospital “Question the Foley”—Sustained Reduction in Catheter-Associated Urinary Tract Infections ...... 62 White Plains Hospital Center Reducing Clostridium Difficile Risk...... 63 Wyoming County Community Health System

Medications Increasing Safety for Patients with Immune-Mediated, Heparin-Induced Thrombocytopenia...... 64 Huntington Hospital/North Shore-Long Island Jewish Health System HANYS 2010 Profiles in Quality and Patient Safety

PAGE Improving Medication Safety ...... 64 New Island Hospital One Process, One List, Universal Access: Internal Electronic Medication Reconciliation ...... 65 The Mount Sinai Medical Center Antibiotic Stewardship: Reducing Multi Drug-Resistant Organisms ...... 66 Northeast Health Implementation of a Robotic Medication Dispensing System ...... 66 Olean General Hospital/Upper Allegheny Health System Recognizing Ways to Improve the Interdisciplinary Reporting of Pre-Empted Medication Errors ...... 67 St. Charles Hospital Creating a Culture of Medication Safety ...... 68 St. James Mercy Hospital Anticoagulation Nomograms: Not One Size Fits All ...... 68 WCA Hospital

Pressure Ulcers Skin Saver Team Initiative—Helping Hands ...... 70 Beth Israel Medical Center A Team Approach to Pressure Ulcer Prevention Using “Wound Care Champions” ...... 70 Erie County Medical Center Decreasing the Incidence of Hospital-Acquired Pressure Ulcers...... 71 Olean General Hospital Reducing the Incidence of Nosocomial Pressure Ulcers ...... 72 Plainview Hospital/Syosset Hospital Pressure Ulcer Prevention ...... 72 St. Charles Hospital Maintaining Patient Skin Integrity Using Nursing Interventions and Clinical Nurse S.K.I.N. Champions ...... 73 St. Francis Hospital—The Heart Center

SPECIALTY

Emergency Services Emergency Department Quality Improvement Peer Review Process ...... 74 Aurelia Osborn Fox Memorial Hospital Emergency Department Efficiency Improvement Project...... 74 Ellis Medicine Emergency Department Overcrowding Response Plan ...... 75 Faxton-St. Luke’s Healthcare Mid-Track: Solving the Emergency Severity Index Patient Timely Treatment Conundrum . . . . 76 Good Samaritan Hospital Medical Center Rapid Medical Evaluation: Improving the Emergency Department Patient Experience...... 76 Highland Hospital/University of Rochester Medical Center Improving Emergency Department Patient Flow Through HANYS’ ECHO Collaborative ...... 77 Orange Regional Medical Center HANYS 2010 Profiles in Quality and Patient Safety

PAGE Reducing Length of Stay in the Emergency Department’s Minor Treatment Area to 60 Minutes ...... 78 Samaritan Medical Center Maintaining the Momentum on Patient Throughput ...... 78 South Nassau Communities Hospital Implementation of an Electronic Medical Record System with CPOE in Urgent Care ...... 79 Thompson Health

Home Care Home Care Demonstration Project to Reduce Hospital Readmissions ...... 81 Brookhaven Memorial Hospital Medical Center Home Health Agency

Maternal-Child Services Providing a Brighter Future for Infants—Improving Hepatitis B Vaccination Rates to Newborns ...... 82 Brooks Memorial Hospital Medical Center Home Health Agency Improving Patient Safety in Obstetrics Using Crew Resources Management ...... 82 Catholic Health Services of Long Island Twice-Daily Labor and Delivery Multidisciplinary Board Rounds ...... 83 St. Barnabas Hospital Perinatal Simulation: Building a Culture of Teamwork and Safety in Obstetrics ...... 84 Strong Memorial Hospital/University of Rochester Medical Center Code H Obstetrical Hemorrhage—Development of a Team Approach ...... 84 Winthrop-University Hospital Got Milk? Vital Human Milk for Premature Infants...... 85 Winthrop-University Hospital

Mental Health Criminal Justice Treatment Program to Enhance Addiction Treatment and Public Safety . . . . 87 Eastern Long Island Hospital

Outpatient Services Reversing the Ravages of Chronic Wounds: A Community-Based Approach...... 88 Claxton-Hepburn Medical Center Appropriate Control of Sample Medications in Hospital-Owned Physician Practices...... 88 Jones Memorial Hospital Decreasing the Dialysis Catheter-Associated Bacteremia Rate ...... 89 Rochester General Hospital Dialysis Center Defy Diabetes! ...... 90 Seton Health

Primary Care Patient-Centered Medical Home for Diabetes Management...... 91 The Brooklyn Hospital Center HANYS 2010 Profiles in Quality and Patient Safety

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Rehabilitation/Long-Term Care Medication Administration Compliance Initiative ...... 92 Mountainside Residential Care Center Reducing Catheter-Associated Urinary Tract Infections ...... 92 Stern Family Center for Extended Care and Rehabilitation/North Shore-Long Island Jewish Health System Reduction in Catheter-Related Bloodstream Infections in a Pediatric Post-Acute Setting. . . . . 93 St. Mary’s Hospital for Children Reducing Facility-Acquired Clostridium Difficile-Associated Disease...... 94 Stern Family Center for Extended Care and Rehabilitation/North Shore-Long Island Jewish Health System HANYS 2010 Profiles in Quality and Patient Safety 1

CLINICAL CARE—GENERAL

Therapeutic Cooling Initiative figure dropped to 45% for patients in the same Albany Medical Center cohort who received therapeutic cooling.

CONTACT: Gregory J. McGarry, M.A., B.A., Vice President, Communications; (518) 262-3421; [email protected]

PROJECT Road to Recovery/Discharge LESSONS LEARNED DESCRIPTION Passport Program—Heart Failure ■ After careful study Technology devel- Arnot Ogden Medical Center opments must be of protocols used at routinely moni- CONTACT: Kathleen Hale, B.S.N., M.S., M.A.E.D., R.N., ten institutions and tored and Executive Director, Performance Management; (607) intensive training scrutinized. 737-4301; [email protected] of staff, Albany ■ Staff will embrace PROJECT Medical Center in- LESSONS LEARNED new technology DESCRIPTION troduced a multi- once they under- ■ Arnot Ogden Senior leadership stand its merits. disciplinary Medical Center be- must establish ex- ■ Adherence to pro- pectations for team-based thera- lieves that patient/ tocols is essential maintaining im- peutic cooling pro- family-centered care to new technology proved outcomes. gram to save lives is a cornerstone of implementation. ■ Interdisciplinary of cardiac arrest, holistic care. Arnot collaboration Ogden’s heart fail- stroke, and brain- across the contin- injured patients. Studies indicate that many of ure patients and uum of care facili- these critically ill and injured patients could their families are tates seamless benefit from this technique, which reduces the engaged in the pa- transitions. tients’ care plan amount of neurological damage that results ■ It is important to from the time of ad- from these traumatic conditions. The divisions have disease man- mission. The pri- of cardiology/interventional cardiology, neurol- agement programs mary nurse, in in place that func- ogy, emergency medicine, and radiology collaboration with tion as a bridge worked together to achieve dramatic results in the case manager, until the next 2009, the first full year of implementation of reviews the care available appoint- the initiative. plan and anticipated ment with the pa- discharge date with tient’s primary OUTCOMES the patient and his care physician. ■ Fifty-five percent of patients treated with ther- or her family. A apeutic cooling left the hospital alive without “Road to Recovery” documents the patient’s ad- any major complications, compared to 20% mission status, including activities of daily liv- who were not treated with therapeutic cooling. ing, vital signs, dietary needs, pain management, education, and discharge needs. This map out- ■ Previously published studies indicated that lines where the patient should be at the mid- 80% of patients who were comatose after ex- point of his or her stay and what the patient periencing cardiac arrest outside of a hospital must achieve by the anticipated discharge date. and experience a return of spontaneous circu- lation either died or survived with significant Daily patient/family-centered interdisciplinary harmful complications. By contrast, this rounds are key to the success of the “Road to 2 HANYS 2010 Profiles in Quality and Patient Safety

Recovery” program. At discharge, the patient re- building interdisci- LESSONS LEARNED ceives a “Discharge Passport” binder that in- plinary teams, and ■ cludes medication reconciliation information, improved commu- More predictable patient outcomes discharge instructions, educational material, and nication with pri- scheduled follow-up appointments. occur with adher- mary care providers ence to clinical OUTCOMES resulted in an over- practice guidelines. all heal rate of 94% ■ Collaborating with ■ Arnot Ogden achieved a 3% decrease in its in 2009. patients, staff, readmission rate for heart failure and a 12% physicians, and decrease in length of stay for these patients. OUTCOMES leadership in creat- ■ In the pilot unit, patient satisfaction scores ■ The wound heal- ing goals drives success. increased, as evidenced by responses to these ing rate increased ■ key questions: from 68% to Change is simpli- fied when using 98%. ● Included in decisions regarding treatment: established, 81% in 2008; 83.3% in 2009; 88.5% in ■ Days to heal de- proven quality im- 2010 year to date. creased from an provement tools.

● Staff worked together to care for you: average of 42 to 89% in 2008; 91% in 2009; 93.8% year-to- just 28 days. date in 2010. ■ Patient satisfaction increased to 97% in 2009. ■ Wound care service revenue increased 250%. ■ Below-the-knee amputations were limited to 1% of the diabetic population. Simple Steps Drive Success: How Quality Principles Guide Change Clifton Springs Hospital and Clinic

CONTACT: Maura Snyder, M.H.A., Program Director, Quality: The Core of a Successful Center for Wound Care and Hyperbaric Medicine; Total Joint Replacement Program (315) 462-0611; [email protected] Community Memorial Hospital

PROJECT DESCRIPTION CONTACT: Diane E. Potter, B.S., R.N., Staff Education A reported 23 million diabetics live in the Director; (315) 824-6676; [email protected] United States. Each year, five million will de- PROJECT DESCRIPTION velop wound complications and 60,000 will Community Memorial Hospital believes that undergo amputation. The cost of treating these achieving positive patient outcomes requires a wounds is more than $1 billion. When Clifton multidisciplinary, organization-wide approach Springs Hospital and Clinic’s healing rate de- for adhering to established guidelines for safety creased from 84% to a low of 68% in 2008, an and quality care. The orthopedic team wanted to analysis revealed fragmented clinical practices. improve its program by addressing venous In 2007, the Center for Wound Care and thromboembolism (VTE) prevention and estab- Hyperbaric Medicine at Clifton Springs central- lishing guidelines for the use of urinary catheters ized services to provide comprehensive care to and antibiotics. A multidisciplinary team that in- diabetics and others with chronic wounds. cluded doctors, nurses, and pharmacists created a Actions, including setting goals, adopting proactive risk assessment and a standard order practice guidelines, standardizing inventory, HANYS 2010 Profiles in Quality and Patient Safety 3

set. Education was Management of Diabetes, LESSONS LEARNED provided to front- Hyperglycemia, and Hypoglycemia ■ line staff, and input Medical and nurs- ing staff buy-in is in the Hospital Patient was obtained from essential when de- Highland Hospital/University of Rochester these individuals. veloping and Medical Center adopting best CONTACT: Sharon Johnson, M.B.A., C.P.H.Q., Director The infection pre- practices. of Quality Management; (585) 341-8399; vention nurse di- ■ Consistent adher- [email protected] rected a second ence to established initiative. Based on standards ensures PROJECT LESSONS LEARNED data supporting uniformity of care DESCRIPTION and positive ■ The best practice evidence-based Highland Hospital outcomes. for managing best practices, and the University ■ Quality is the re- diabetes and Community of Rochester sponsibility of preventing hypo/ Memorial Hospital every individual in- Medical Center hyperglycemia in limited the use of volved in patient (URMC) are com- the hospital set- urinary catheters care. Sharing infor- mitted to minimiz- ting is anticipatory physiologic insulin to 24 hours, mation regarding ing the occurrence dosing, prescribed discontinued post- desired outcomes of adverse events and the need for as a basal/bolus operative antibiotics related to diabetic improvement is insulin regimen. in 24 hours, and critical for success. and/or insulin man- There is no standardized the agement, recogniz- “auto-pilot” insulin antibiotic choice to ing that optimum regimen for a hos- pitalized patient. reflect compliance with recommended diabetic manage- ■ guidelines. ment, including use Protocolized dia- betes management of insulin, is a spe- OUTCOMES reduces less vari- cialty not well ability in care. ■ Compliance with the VTE prevention pro- understood by ■ Ongoing education gram resulted in an improvement in the rate many caregivers. and Diabetes Nurse of post-operative deep vein phlebitis. The goal of this ini- Educators are vital ■ Community Memorial Hospital leads the area tiative was to re- to the success of this program. in published patient satisfaction surveys. duce variability in blood glucose lev- ■ All three surgical care core antibiotic measures els, particularly the incidence of profound hypo- improved to the current 98% to 99% level. glycemia. Inpatient glycemic control and a standardized care process were used to guide and support providers to achieve benchmark performance.

Use of clinical practice guidelines and an elec- tronic order set were key to helping providers easily understand the patient’s insulin require- ments, nutritional impact, components of in- sulin to be used, and appropriate monitoring. A 4 HANYS 2010 Profiles in Quality and Patient Safety

full-time diabetes nurse practitioner role was cre- helping minimize LESSONS LEARNED ated to provide expert education and to support verification ■ providers, caregivers, and patients/families. All oversight. An effective policy must be reinforced staff received insulin management education, through constant With both of these and diabetes nurse practitioners consulted with monitoring to en- patients and staff regarding complex cases. approaches in place, courage 100% consistency is culti- compliance. OUTCOMES vated and enhanced ■ A perioperative Through this initiative, Highland Hospital and compliance is ex- team approach in- URMC achieved: pected to translate creases efficacy ■ eighty percent compliance with proper proto- into a decrease in and decreases the likelihood that pro- col by attending physicians and mid-level wrong-site periph- cedures will be providers; eral nerve blocks, omitted. thus improving ■ 60% compliance by residents; ■ To maintain high patient safety and ■ significant improvement in blood glucose compliance rates, satisfaction. the hospital devel- variables (minimal, median, and maximum oped an education levels across four participating patient care OUTCOMES program to rein- units); and ■ A unique multi- force the policy and minimize veri- ■ fewer episodes of profound hypoglycemia. disciplinary fication oversight. procedure was adopted to elimi- nate the likelihood that the correct-site Eliminating Wrong-Site Peripheral verification policy would be overlooked. Nerve Blocks ■ Delays and distractions in the operating room Hospital for Special Surgery were minimized by requiring the circulating

CONTACT: Sarah Kennedy, B.S., Assistant Quality nurse to stay at the patient’s bedside until the Assessment and Performance Improvement Coordinator; block is initiated. (212) 606-1806; [email protected] ■ Compliance increased and remained consis- PROJECT DESCRIPTION tent for three years. In 2003, 44% of the 19,500 anesthetics adminis- tered at the Hospital for Special Surgery were peripheral nerve blocks; as such, the importance of a correct-site verification process was undeni- Save That Vein: Preventing able. Through monitoring and evaluation of pro- Complications Related to Peripheral cedures, Hospital for Special Surgery determined and Central Venous Access that a process was needed to ensure confirma- John T. Mather Memorial Hospital tion of the block site by the perioperative team. The hospital developed a pre-anesthetic site ver- CONTACT: Theresa Murphy, R.N., B.S., C.R.N., C.R.N.I., Infusion Therapy Coordinator; (631) 473-1320 ext. ification policy to eliminate reliance on an indi- 5206; [email protected] vidual physician to perform the procedure and encourage a multi-disciplinary approach. An ed- PROJECT DESCRIPTION ucation and monitoring program reinforces Recognizing the risks associated with patients re- compliance and standardizes the process, ceiving various intravenous medications and HANYS 2010 Profiles in Quality and Patient Safety 5

infusions, John T. ■ the hospital-wide CLABSI rate for peripheral LESSONS LEARNED Mather Memorial infusion lines fell 23%. ■ Hospital’s Nursing Patient/situation- specific nursing in- Executive service education Committee estab- drives positive lished a full-time changes in practice Post-Kidney Transplant Care infusion therapy and outcomes. Management Program coordinator posi- ■ Collaboration be- Metropolitan Jewish Health System/ tion. The infusion tween physicians, SUNY Downstate Medical Center therapy coordinator nurses, patients, and caregivers is developed a pro- CONTACT: William Jay Gormley, Director, Planning necessary to en- and Research; (212) 356-5419; [email protected] gram to incorporate sure appropriate the 17 elements of venous access to PROJECT LESSONS LEARNED performance listed improve patient DESCRIPTION outcomes. in The Joint The SUNY The program team Commission’s learned the impor- Downstate Medical tance of: national patient safety goals, including short- Center kidney trans- ■ term peripheral intravenous access. case management plant team identi- and follow-up with fied an increase in post-transplant After conducting a needs assessment, an educa- the difference patients; tional program was developed that included an between expected ■ a tight community introductory lesson plan, opportunities for and actual graft and hospital demonstration and return demonstration, direct rejections/patient partnership; and clinical observation, reward and recognition, ■ expirations rates. using both technol- and re-education/in-service. ogy and hands-on SUNY Downstate, case management Daily vascular access rounds are conducted, with in partnership with to ensure positive emphasis on the performance indicators. When Metropolitan Jewish outcomes. standards are not met, a patient/situation- Health System’s specific nursing education in-service is con- long-term home health care program (LTHHCP), ducted with the appropriate nurse. The patient’s created the Post-Kidney Transplant Care infusion needs are discussed and a determina- Management Program, which offers in-home tion is made to either maintain or remove access, and telephonic follow-up care to help patients or consider an alternate vascular access device. understand how to recognize and respond to changes in their health status. The program pro- OUTCOMES vides reminders for clinic appointments, From 2008 to 2009: arranges transportation, and includes telemoni- ■ intravenous occurrence reports decreased 7%; toring and innovative medication adherence ■ central line-associated bloodstream infections technology to track vital signs and compliance. (CLABSIs) for all central lines (rate per 1,000 The program care managers from the LTHHCP catheter days) in the intensive care unit/ serve as liaisons between the patient, transplan- critical care unit (ICU/CCU) decreased 15%; tation team, and physicians. The use of a home ■ length of stay in the ICU/CCU decreased 9.3%; care agency enables the team to address social issues such as adequate housing, diet, and 6 HANYS 2010 Profiles in Quality and Patient Safety

entitlement programs. Success in the post-trans- the communication LESSONS LEARNED plant programs has led to the inclusion of high- necessary to sustain ■ Transformation can risk pre-transplant patients. these changes. be a simple OUTCOMES process; simplicity Staff training in- supports ■ The overall survival rate increased 4.71% for cluded unit- and sustainability. patients in the program. department-based ■ Frontline staff ■ Program patients experienced a 7.66% in- collaborative care must be engaged crease in graft survival rate. councils, tools to to ensure sustainability. ■ Length of stay of patients who were readmit- support rapid cycle change and commu- ■ Collaborative care ted to the hospital was reduced from six to councils, paired nication. Selected five days for those in the program. with communica- quality, cultural, tion tools, are ef- and safety metrics fective mechanisms were monitored. for communicat- ing, problem solv- Enhancing Performance, Changing OUTCOMES ing, and engaging Culture, Improving Communication, ■ In one year, large, interdiscipli- nary teams. and Supporting Rapid Cycle Change 19,000 employ- ■ Across a Multi-Hospital Health Care ees from 14 hos- The model is more than an initiative; System pitals were it is a way of life. North Shore-Long Island Jewish Health educated on the System model and tools for effective communication. CONTACT: Maureen T. White, M.B.A., R.N., C.N.A.A., Senior Vice President, Chief Nurse Executive; ■ More than 75% of patient care areas use inter- (718) 470-7817; [email protected] disciplinary collaborative care councils, in- cluding those related to support, ancillary, PROJECT DESCRIPTION and allied health services. North Shore-Long Island Jewish Health System (NSLIJ) is determined to provide the highest ■ The program achieved significant improve- quality, safest clinical care. NSLIJ recognized ments by reducing falls and bloodstream and that to attain and sustain its goals in quality and ventilator infections, while improving patient patient safety, it needed the ability to respond to satisfaction. the changing health care environment in an agile manner by transforming the culture and sustaining that change. NSLIJ’s approach en- tailed development and implementation of a Responding to H1N1: Key Principles values-based, patient-centered model intended of Health System Preparedness and to translate its mission, vision, and values into Response the daily practice of patient care. The North Shore-Long Island Jewish Health Collaborative Care Model®, which was started System at a pilot hospital and was later implemented CONTACT: Kenneth J. Abrams, M.D., M.B.A., Senior throughout the system, provides infrastructure Vice President, Clinical Operations and Associate Chief for executing rapid cycle changes and supports Medical Officer; (516) 465-8315; [email protected] HANYS 2010 Profiles in Quality and Patient Safety 7

PROJECT improving vaccination rates among high prior- LESSONS LEARNED DESCRIPTION ity groups in targeted geographic locations. ■ North Shore-Long Emergency opera- tions plans must Island Jewish Health OUTCOMES be adaptable, scal- During the initial, three-month surge of H1N1 System (NSLIJ) set able, and not re- patients: its emergency oper- stricted to a ations plan into mo- specific population ■ More than 12,000 patients were evaluated in tion in spring 2009 or disease. NSLIJ’s emergency departments and triage when it became the ■ Real-time data are centers. epicenter of the essential for estab- ■ More than 36,000 tests were performed; 36% lishing priorities, H1N1 epidemic. were positive for H1N1 and 485 patients were providing decision Critical internal re- support, and allo- admitted. sources were mobi- cating sparse ■ The average age of H1N1 patients was 13.7 lized to meet the resources. years. urgent demands ■ Partnerships with ■ Post-surge, approximately 17,000 individuals placed on the sys- local, state, and (56.2% from high-priority groups) were tem’s hospitals. federal agencies, vaccinated. NSLIJ’s laboratory along with using social media, maxi- rapidly processed mizes coordination thousands of viral of public health specimens, which services. helped define the Partnering for Quality: Fostering scope of the problem and support public policy Multidisciplinary, Organization- on H1N1 testing. Anticipating a potential resur- Wide Quality Improvement gence of H1N1 later in the 2009-2010 influenza NYU Langone Medical Center season, NSLIJ collaborated with the local health CONTACT: Robert A. Press, M.D., Ph.D., Chief commissioner to establish community outreach Medical Officer; (212) 263-2680; and a strategic vaccination program. The success [email protected] of the emergency operations plan and response PROJECT DESCRIPTION to public health needs was achieved through ef- In early 2009, NYU Langone Medical Center fective surge planning, protocol design, expan- strengthened its clinical quality and patient sion of laboratory capabilities, and use of real safety by implementing its Partnering for time data for administrative and clinical deci- Quality (P4Q) program. P4Q pairs physician sion making. leaders and nurse managers on each of 59 Key elements of the program included a social patient care units (inpatient, outpatient, and media campaign, community education perioperative) to develop, execute, and sustain through an influenza Web site, community out- initiatives enlisting a multidisciplinary team to reach, mass immunization efforts, population carry out one or more improvement cycles until mapping based on census data to determine a specified goal is reached. points of vaccine distribution, and partnerships The program is led by the chief medical officer with government agencies. Lessons learned from and the chief nursing officer, who review and the initial outbreak were critical to successfully approve all project proposals and reports and managing the subsequent epidemic and ensure they align with organizational quality 8 HANYS 2010 Profiles in Quality and Patient Safety

and safety goals, in Reduced Mortality and Codes LESSONS LEARNED cooperation with Following Initiation of a Rapid ■ senior leaders. Sen- The program deliv- ered measurable Response Team ior leaders provide results both at the Oneida Healthcare Center support and direc- patient care unit CONTACT: William Griffiths, R.N., M.S.H.S., tion through semi- and organization- Quality Manager; (315) 361-2115; annual team wide levels. [email protected] meetings, more fre- ■ Knowledge about PROJECT quent project pre- quality perform- LESSONS LEARNED ance measurement DESCRIPTION sentations at other ■ and improvement To reduce mortality Earlier intervention meetings, and con- to changes in a varies among par- rates, decrease the tinuous informal ticipating physi- patient’s condition number of codes communication. cians and nurses, can improve Support for quality and support for called, and improve outcomes. performance meas- teams is essential. patient outcomes, ■ The culture must urement and im- ■ The standard re- Oneida Healthcare consider any con- cerns regarding a provement is port format is an Center established a patient’s condition offered through effective means to rapid response team disseminate infor- to be valid. NYU Langone (RRT) in April 2008. mation about local The RRT provides a Medical Center’s achievements multidisciplinary team approach for early and Department of throughout a Clinical Quality large, complex rapid intervention for patients with deteriorating and Effectiveness. organization. conditions. The team includes an advanced car- diac life support-certified registered nurse with A status report, using a standard format, is pro- critical care experience and an experienced respi- vided quarterly by each team and is posted on ratory therapist certified in basic life support. the hospital intranet. Exceptional projects are presented to the board of trustees and at the RRT calls may be initiated by any member of the annual Quality-Safety Celebration. staff based on established criteria (i.e., acute changes in heart rate, blood pressure, etc.) or in OUTCOMES response to concerns voiced by patient, family, ■ Forty-eight (93%) of the 57 P4Q teams made or staff. RRT members will immediately respond measureable progress toward one or more to the patient’s bedside, receive information goals during the first year of the program. about the patient from the patient’s nurse using the Situation, Background, Assessment, ■ Projects addressed a broad range of improve- Recommendation (SBAR) model of communica- ment opportunities such as improving hand tion, and remain with the patient until the hygiene hand-offs, wound and line care pro- situation is resolved. tocols, patient education, and treatment outcomes. OUTCOMES ■ P4Q program projects helped NYU Langone Since inception of the RRT in April 2008, the fa- Medical Center achieve 2009 organization- cility saw a 12% reduction in inpatient mortality wide goals: excellence in national measures, rates and a 74% reduction in inpatient codes. reduced hospital mortality, and minimizing hospital-acquired infections. HANYS 2010 Profiles in Quality and Patient Safety 9

Using an Analgesia/Sedation OUTCOMES Protocol to Reduce Mechanical Pre- and post-ASP data were collected, showing Ventilation Days and Mortality in a that: Surgical Intensive Care Unit ■ post-ASP patients had a shorter median MV Rochester General Health System duration; CONTACT: Kevin Silinskie, Pharm.D., Clinical ■ a 60% reduction in ventilator-associated Pharmacy Specialist, Critical Care; (585) 922-5334; pneumonias was observed between 2008 [email protected] (pre-ASP) and 2009 (post-ASP); PROJECT ■ a lower mortality rate was observed in the LESSONS LEARNED DESCRIPTION post-ASP group compared to the pre-ASP ■ Helping mechani- Standardizing anal- group (10% versus 25%); and gesia and sedation cally ventilated ■ improves out- the success of this project has given Rochester (MV) surgical pa- comes without General Health System the opportunity to tients achieve opti- compromising implement this protocol in the medical inten- mal comfort can be safety in the SICU. sive care unit. challenging due to ■ Involving multiple multiple surgical disciplines ensures procedures, existing protocol compli- ance and surgical incisions, sustainability. Using Multidisciplinary Rounds to drains, develop- Enhance Patient Safety and Decrease ment of delirium, Morbidity in a Critical Care Unit and acute poly-substance withdrawal. Continu- Saint Francis Hospital and Health Centers ous infusions of analgesics and sedatives are commonly administered to MV critically ill CONTACT: Steven Ritter, M.D., F.A.C.P., F.A.A.P., patients to provide optimal comfort. However, a Medical Director of Quality and Compliance—Critical Care, Trauma, and Pediatrics; (845) 483-5073; link has been established between increased MV [email protected] days and the use of continuously infused seda- tives. Although daily sedative interruptions have PROJECT LESSONS LEARNED been shown to improve outcomes, this ap- DESCRIPTION ■ A patient-centered proach may not be feasible in all critically ill In January 2009, care model enables Saint Francis patients. Therefore, Rochester General Health all members of the System formed a multidisciplinary team to im- Hospital and Health team to offer indi- plement an analgesia/sedation protocol (ASP) in Centers imple- vidual expertise. the Surgical ICU (SICU) to standardize the mented multidisci- ■ While emphasizing process used to keep patients calm and coopera- plinary rounds in safety and effi- tive, and decreasing MV days. its mixed intensive ciency, Saint care unit. Estab- Francis benefited from a lower cost In November 2008, the SICU multidisciplinary lished by physician of care and shorter team established the following goals: leaders and focused length of stay. on enhancing qual- ■ reduce MV days; ■ Multidisciplinary ity of care and ■ maintain comfortable and awake patients; and rounds facilitate using evidence- sustained process ■ decrease the use, duration, and dose of con- based guidelines, improvement. tinuously infused sedatives. 10 HANYS 2010 Profiles in Quality and Patient Safety

rounds were trialed twice a week. All disciplines Optimizing a Culture of were invited and a Plan-Do-Study-Act cycle was Interdisciplinary Collaboration to modeled. The rounds were extended to the Prevent CLABSIs in Critical Care trauma unit, and evolved to provide an opportu- St. Francis Hospital—The Heart Center nity for teaching and attaining specific patient care goals. The importance of evidence-based CONTACT: Roy H. Constantine, Assistant Director of Mid-Level Practitioners; (516) 562-6568; care is emphasized. The rounds serve as a means [email protected] to verify inclusion of “bundle” protocols for ventilator-associated pneumonia (VAP) and cen- PROJECT LESSONS LEARNED tral-line associated bloodstream infection DESCRIPTION ■ Developing a (CLABSI), as well as tube feeding, electrolyte, The Institute for CLABSI Task Force Healthcare and sedation/pain protocols. A 24-hour plan of facilitated connec- care is determined for each patient. Improvement’s tions and bridge- 5 Million Lives building—assisting In September 2009, Saint Francis Hospital and Campaign and the in meeting a very Health Centers joined the Institute for National Health complex challenge. Healthcare Improvement (IHI) Multidisciplinary Care Safety Network ■ Effective communi- Rounds Expedition. Through this initiative, provided the stimu- cation helps over- come many Saint Francis added even more practices and lus for a needs barriers. developed a nursing checklist. The rounds last assessment on the ■ Developing a approximately five to eight minutes for each prevention of cen- process that moves patient and are oriented toward organ systems, tral line-associated toward organiza- problems, and protocols. Families are encour- bloodstream infec- tional goals within aged to participate. tions (CLABIs) in a collaborative en- the critical care vironment results OUTCOMES units at St. Francis in a culture that improves em- ■ Ventilator length of stay was reduced by one- Hospital—The Heart ployee and patient half day for trauma patients. Center. A review of satisfaction. ■ Critical care length of stay was reduced 1.1%, the literature, data, with related cost savings of approximately advisory groups, $500,000. and existing expertise provided a foundation for ■ Safety risks are more easily identified. all stakeholders. Increased scientific knowledge and understanding of these underpinnings ■ Errors by omission decreased significantly. allowed St. Francis Hospital to develop a concep- ■ Goals for VAP and CLABSI compliance were tual framework. Barriers were identified and met. effective interventions were applied to improve patient-, provider-, and payer-specific outcomes. Monthly performance improvement team meet- ings, mini root-cause analyses, and implementa- tion of interdisciplinary daily line stickers resulted in a 67% decrease in CLABSI rates. HANYS 2010 Profiles in Quality and Patient Safety 11

OUTCOMES pulmonary medicine, and rehabilitation medi- ■ 2009 quarterly CLABSI rates demonstrated a cine and nursing staff. positive trend, falling from 1.4 to 0.6 CLAB- This initiative included training of the physical SIs per 1,000 line days. therapy team and twice daily physical therapy ■ Results were below the baseline and the tar- sessions, including weekends, for patients under- geted rate of 1.0 per 1,000 line days. going major thoracic surgery. ■ Zero CLABIs were obtained in all critical care units for four months in 2009, with one unit at OUTCOMES seven consecutive months without a CLABSI. ■ This initiative reduced post-operative length of stay (LOS) for these patients significantly. ■ The initiative resulted in excellent patient sat- isfaction. According to a survey of patients, Enhanced Post-Operative Inpatient 90% were satisfied with physical therapy, 90% Physical Therapy for Patients were satisfied with nursing care, and 100% Undergoing Major Thoracic Surgery would recommend the program to a friend or St. Luke’s-Roosevelt Hospital Center relative. ■ CONTACT: Cliff P. Connery, M.D., Chief, Division of The organization saw improved collaboration Thoracic Surgery and Director, Program Development between its physical therapy and nursing in Thoracic Oncology; (212) 523-7475; teams. [email protected]

PROJECT LESSONS LEARNED DESCRIPTION ■ Through this initia- The LOS reduction Keeping the “Never” in Never Events was greatest with tive, St. Luke’s- high-risk patients. Vassar Brothers Medical Center Roosevelt Hospital ■ This program en- CONTACT: Linda Dombroski, R.N., M.S.N., F.N.P., Center addressed hanced an overall Director, Patient Safety; (845) 431-9466; chest surgery in an “team building” [email protected] increasingly older, approach between PROJECT medically chal- nursing, physical LESSONS LEARNED therapy, and physi- DESCRIPTION lenged population. ■ cian staff, in regard In preparing to im- The process must Post-operative com- be replicable and to improving pa- plement the Centers plications are a risk tient care with ear- sustainable within for Medicare and to mortality, long- lier discharges and the working norms term morbidity, and avoiding potential Medicaid Services of the hospital. quality of life. complications. policy of nonpay- ■ Educating all staff St. Luke’s-Roosevelt ment for certain to the importance of eliminating Hospital Center endeavored to improve its post- potentially prevent- able hospital- never events is operative patient care by developing an en- imperative. acquired conditions hanced post-operative inpatient pulmonary ■ (HACs), or “never Ongoing monitor- rehabilitation program in 2009. The goal is to ing, reporting, and events,” Vassar improve patient mobilization, strength, and debriefing improve independence after major thoracic surgery Brothers Medical outcomes. through collaboration among thoracic surgery, Center evaluated 12 HANYS 2010 Profiles in Quality and Patient Safety

how these events were internally identified, re- ported, and reviewed. As a result of that evalua- tion, Vassar Brothers Medical Center decided to focus on three never events in an ongoing per- formance improvement project. The selection focused on high-volume, high-cost events that could be reasonably prevented through imple- mentation of evidence-based guidelines. The never events selected were falls with injuries, stage 3 and 4 pressure ulcers, and catheter- associated urinary tract infections (CAUTIs). The hospital implemented various performance im- provement activities including debriefing ses- sions to achieve the desired outcomes.

OUTCOMES Total HACs: Fourth quarter 2008: 8 Third quarter 2009: 6 First quarter 2009: 5 Fourth quarter 2009: 1 Second quarter 2009: 6 HANYS 2010 Profiles in Quality and Patient Safety 13

CLINICAL CARE—STROKE

Improving Patient Safety While ■ educated neurologists regarding dysphagia Decreasing Complications by screens; and Strengthening the Dysphagia ■ a stroke manager, along with stroke floor Screening Process for Stroke Patients nurses, conducts daily rounds to promote Crouse Hospital dysphagia screen discussions for new patients.

CONTACT: Lori Messick, R.N., B.S.N., Quality OUTCOMES Improvement Analyst; (315) 470-7652; [email protected] ■ Patient safety increased by making nurses and physicians aware of dysphagia concerns and PROJECT LESSONS LEARNED establishing a systematic screening process. DESCRIPTION ■ ■ This initiative produced a statistically signifi- Crouse Hospital Multidisciplinary approaches are cant increase in dysphagia screening, from used the American needed to achieve 72% in 2008 to 80% in 2009. Heart Association’s and maintain a stroke guidelines, change in practice. which emphasize ■ Team “champions” the importance of are invaluable to assessing the pa- organization-wide Improvement with Stroke Patient tient’s ability to improvement Education and Documentation plans. swallow safely be- Compliance ■ fore allowing oral No initiative is im- Good Samaritan Hospital/Bon Secours possible when the intake of any kind, Charity Health System stakes are patient to prevent aspira- safety-driven. CONTACT: Shari B. Gold, M.P.H., R.D., C.P.H.Q., tion and pneumo- Quality Improvement Manager-Six Sigma Black Belt; nia. Initiatives that were implemented included: (845) 368-5260; [email protected]

■ updated the organization’s evidence-based PROJECT LESSONS LEARNED dysphagia (difficulty swallowing) screening DESCRIPTION ■ policy; Good Samaritan Good communica- tion with nurse ■ educated all nurses on the policy and held Hospital is desig- managers and a staff meetings for dysphagia screen education; nated by the multidisciplinary ■ a poster campaign was conducted on all State of New York team that includes stroke floors; and certified by The nursing staff are Joint Commission the keys to suc- ■ computer pop-up screens for every stroke pa- as a Stroke Center. cessful compliance. tient admission remind nurses of mandatory Patient education is ■ Reminders and es- dysphagia screen; tablishing good a best practice for ■ computer documentation of dysphagia screen rapport between stroke patient care pass or fail—for patients assessed with diffi- the quality and one of the indi- improvement culty swallowing, the computer creates an cators required to department and automatic referral to dietary; maintain certifica- multidisciplinary ■ adoption of stroke admission order sets that tion. Good team helps im- prove compliance. contain dysphagia screening and evaluation Samaritan Hospital orders; is working on continued next page 14 HANYS 2010 Profiles in Quality and Patient Safety

continuous im- time-sensitive and LESSONS LEARNED LESSONS LEARNED provement in stroke (continued) that emergency de- ■ care education and partment physicians The organization’s ■ Heightening information tech- documentation need to make criti- awareness helps nology system can using technology, improve cal decisions regard- help with data col- staff reminders, up- compliance. ing treatment, the lection and validity. dated educational ■ Hospital leadership Plan-Do-Study-Act ■ Real-time drill- tools, and various supports the initia- model was applied down with imme- patient identifica- tive to help im- to the patient entry diate remediation tion tools. Stroke prove compliance. component of their can improve outcomes. patients are edu- stay. Issues were ■ cated by the multidisciplinary team on medica- identified with in- Ongoing analysis and continual revi- tions, signs, and symptoms of stroke and proper consistent stroke sion of the Medical dietary needs. With the support of the hospital code initiation, Logic Module sys- leadership, improved communication among problems with vali- tem can improve various disciplines has helped increase compli- dation due to in- processes. ance with the education indicator. Findings are consistent data presented at organizational quality and board sources or missing data, and time lags in practi- meetings. tioner feedback.

OUTCOMES Nassau University Medical Center’s goal was to ■ Good Samaritan Hospital achieved a 30% in- simplify and ensure the validity of documenta- crease in compliance with the stroke educa- tion, and provide real-time “drill-downs” with tion indicator over the last two years. immediate correction plans. To accomplish this goal, an information technology solution ■ 2009 results (January-December average) for stroke education compliance was 96%, and was developed and initiated in April 2008. consistently 90% or higher monthly. Triggered by presumptive stroke International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes, stroke team activation is automatic. A stroke order set populates information fields automatically, and Information Technology and the generates an e-mail capturing key quality indica- Stroke Task Force Collaborate to tors that is sent to all disciplines. Improve Quality Nassau University Medical Center OUTCOMES This initiative achieved: CONTACT: Maureen P. Shannon, C.P.H.Q., M.H.A., Vice President, Quality Management; (516) 572-4877; ■ a 228% increase in the number of stroke [email protected] patients with a recorded National Institutes of Health stroke scale score; PROJECT DESCRIPTION ■ a 36% increase in the number of stroke As a New York State Designated Stroke Center, patients who received a computerized tomog- Nassau University Medical Center follows best raphy scan less than 25 minutes from arrival; practice standards and discharge guidelines de- veloped by the American Heart Association. ■ a 158% increase in the number of stroke Recognizing that stroke management is very patients with a recorded last well and arrival HANYS 2010 Profiles in Quality and Patient Safety 15

time to identify the earliest possible time that proper treatment. A support group was estab- stroke symptoms began; and lished to respond to patient and family needs for ■ a 126% increase in validation of acute is- information and emotional support. chemic stroke patients who are not treated By the start of its third year, the stroke program with intravenous tissue plasminogen activator was awarded the American Heart Association’s (IV t-PA) due to exclusion criteria. Gold Plus Achievement Award to recognize 24 months of consistently excellent performance.

OUTCOMES Interdisciplinary Approach to Results of the initiative included: Stroke Care and Treatment ■ all eligible patients had thrombolysis within Phelps Memorial Hospital Center best practice guidelines; CONTACT: William Reifer, L.C.S.W., Assistant ■ early antithrombotic therapy was provided to Vice President, Quality and Case Management; 99.5% of eligible patients; (914) 366-3314; [email protected] ■ appropriate anticoagulation at discharge for PROJECT atrial fibrillation was provided to 98% of eli- LESSONS LEARNED DESCRIPTION gible patients; Critical elements of Phelps Memorial ■ success include: all eligible patients received smoking cessa- Hospital Center, tion counseling; ■ early involvement embracing the pub- of key physician ■ the hospital achieved 97.7% success on the “7 lic’s increasing need leaders; Consensus Guidelines”; and to be assured that ■ participation of in- ■ Phelps Memorial received the Gold Plus hospitals are pro- formation technol- achievement award from the American Stroke viding evidence- ogy staff early in Association by the end of the second year. based care, achieved the process; New York State des- ■ high standards for ignation as a achievement must Certified Stroke be established from the outset; Center in October When Seconds Count: Employing ■ 2007. Phelps also regular feedback Six Sigma Strategies to Improve to staff; and worked closely with Compliance with Best Practices in ■ concurrent chart the American Heart Transient Ischemic Attack and review whenever Association’s Get possible—to catch Stroke Management With the Guidelines potential omissions St. Catherine of Siena Medical Center program to monitor while the patient CONTACT: Catherine J. Videtto, R.N., M.S.N., A.N.P., can still benefit! stroke care perform- C.C.R.N., C.P.H.Q., Nursing Performance Improvement ance. A team was and Stroke Program Coordinator; (631) 862-3782; identified to evaluate and coordinate the pro- [email protected] gram’s effectiveness, including analysis of aggre- PROJECT DESCRIPTION gated data and individual case presentations. St. Catherine of Siena Medical Center’s goal is to Concurrent care review against established treat- achieve significant, robust, and reliable improve- ment guidelines was essential to reinforce ments in transient ischemic attack (TIA) and 16 HANYS 2010 Profiles in Quality and Patient Safety

stroke patient man- ■ documentation of dysphagia screen increased LESSONS LEARNED agement by using 26%; and ■ Increasing staff ac- Six Sigma process ■ countability yields documentation of stroke education increased improvement strate- improved out- 83%. gies. Senior leader- comes, evidenced ship’s vision for by improved per- 2006 included a formance scores. commitment to im- ■ Sustained culture proving the hospi- changes are tal’s compliance achieved by em- powering and rec- with published best ognizing the practices to mini- contributions of mize the devastating unit-specific stroke functional, emo- champions. tional, and financial ■ Conducting impact of these two monthly stroke emergency events committee meet- on patients. ings and employ- ing daily “huddles” reinforces hot The institution col- topics. laborated with the American Stroke Association and American Heart Association to implement best practices and Get with the Guide- lines performance measures. These collaborative efforts achieved significant improvements in the provision of defect-free care. In addition to pro- viding consistent, reliable care harmonized with evidence-based best practices, St. Catherine of Siena Medical Center is better prepared to attract patients to the facility and assume a strategic po- sition that will ensure appropriate reimbursement when stroke/TIA is added as a core measure.

OUTCOMES St. Catherine of Siena Medical Center achieved the following improvements in stroke/TIA care: ■ rate of rt-PA utilization increased 33%; ■ deep-vein thrombosis prophylaxis compli- ance improved 34%; ■ anticoagulation therapy at discharge in- creased 67%; ■ the number of patients discharged on cholesterol-reducing agents increased 65%; HANYS 2010 Profiles in Quality and Patient Safety 17

CLINICAL CARE—VAP

Reducing Patient Ventilator Days routine instilled saline during suctioning, elimi- and Ventilator-Associated nation of routine circuit changes, and use of Pneumonia metered dose inhalers to deliver medications to Nathan Littauer Hospital and Nursing ventilated patients rather than nebulizers (as Home appropriate) were implemented. The team edu- cated for nursing, respiratory, and physician CONTACT: Barbara DeLuca, R.R.T.-N.P.S., Supervisor, Respiratory Care; (518) 773-5453; [email protected] staffs, implemented new protocols, and con- ducted daily rounds with a respiratory therapist, PROJECT registered nurse, and physician. LESSONS LEARNED DESCRIPTION ■ Nathan Littauer Staff education is OUTCOMES the single most im- Hospital and ■ The average number of ventilator days per portant element to Nursing Home implementing suc- patient was reduced from eight in 2006 to formed an interdis- cessful change. three in 2009. ciplinary team to ■ Monitoring of ■ The number of VAP cases decreased from four investigate ways to parameters, in 2006 to zero in 2009. reduce both the processes, and ■ This initiative fostered improved collabora- number of patient protocols must be ongoing, with tion and communication among staff, and ventilator days and active participa- motivation toward a common goal. cases of ventilator- tion of staff. associated pneumo- ■ Continuous rein- nia (VAP). forcement, accept- Evidence-based ance of change, guidelines from and monitoring of VAP Prevention in a Community the American actions taken is the Hospital Setting is Sustainable and Association of key to success. Can Be Like Breathing: “Automatic Respiratory Care and Painless” and American College of Chest Physicians were St. Catherine of Siena Medical Center used, and the institution participated in HANYS’ CONTACT: Catherine Shannon, F.N.P.-B.C., C.I.C. VAP Prevention Project. Director, Infection Prevention and Employee Health Services; (631) 862-3541; [email protected] A team was established that included the med- PROJECT DESCRIPTION ical director of respiratory therapy, a certified St. Catherine of Siena Medical Center established registered nurse anesthetist, respiratory therapy an initiative to decrease the ventilator-associated supervisor, infection control nurse practitioner, pneumonia (VAP) rate in its critical care and step- and the surgical care unit nurse manager. The down units. A risk assessment was performed to team met monthly for one year and devoted evaluate hand hygiene compliance, sedation inter- time to staff education and developing a ventila- ruption, readiness to wean, maintenance of tor “bundle,” sedation protocol, ventilator semi-recumbent positioning, and oral care, and weaning protocol, and preprinted ventilator all elements of the VAP “bundle.” orders. New, fifth-generation ventilators were purchased. Use of passive versus active humidifi- The following practices were instituted: cation, closed suction catheters, restricting 18 HANYS 2010 Profiles in Quality and Patient Safety

■ a prepackaged oral Zero Tolerance for Ventilator- LESSONS LEARNED hygiene kit is used Associated Pneumonia ■ every four hours Patient outcome improvements St. John’s Episcopal Hospital, South Shore and a Chlorhexi- were realized CONTACT: Kathy Larosch, R.N., C.C.R.N., Nurse dine rinse is used through collabora- Manager, Critical Care; (718) 869-7000 ext. 7241; every 12 hours; tion among all [email protected] ■ families and visi- team members, from senior leader- PROJECT tors are encour- LESSONS LEARNED ship to staff. DESCRIPTION aged to take an ■ ■ Sustaining im- St. John’s Episcopal A coordinated, active role in VAP multidisciplinary proved outcomes Hospital assigned a prevention; is possible when team can effec- critical care nurse tively define a ■ daily assessments changes become manager to lead a problem, craft a of necessity for se- part of the culture. multidisciplinary solution, imple- ■ Small changes to dation and readi- ment the plan, and patient care can team focused on ness to wean; and monitor outcomes. improve patient ventilator-associated ■ a flow sheet to en- outcomes, save pneumonia (VAP) ■ Administrative support and nurse sure systematic lives, and are cost performance im- use of the bundle effective. and physician provement. Upon re- “champions” are elements and stan- viewing the critical to the dardized shift handoffs. literature, including team’s success. the interventions ■ It is important to OUTCOMES supported by the communicate a ■ VAP has been eliminated on the respiratory Institute for well researched step-down unit since January 2008. Healthcare best practice ap- proach, measure ■ Improvement and There was a sustained decrease in the inci- and report the re- dence of VAP in the critical care unit in 2008 HANYS’ VAP sults on a regular and 2009. Prevention Project, basis, and ask for ■ Professional accountability for hand hygiene the team examined feedback to achieve staff align- was instituted. the facility’s data and developed a checklist ment and support. ■ This initiative resulted in high levels of satis- of best practices that faction for all involved. included elevation of the head, daily sedation ■ The institution realized cost savings of about vacation, peptic ulcer prophylaxis, deep vein $280,000. thrombosis prophylaxis, and early mobilization. ■ Mortality decreased, with three lives saved, according to statistics. These interventions were moderately successful; however, based on further research, the team de- cided to introduce a new mouth care product that included Chlorhexidine. The kit was well re- ceived by staff, who found it easy and conven- ient to use. This intervention proved pivotal to the program’s success. In addition, the unit pur- chased new beds that included an automatic HANYS 2010 Profiles in Quality and Patient Safety 19

setting for 30 degrees head elevation, assuring the The committee determined it would include the optimal elevation for this patient population. As following bundled best practices: the team followed the monthly results, it became ■ elevation of the head to between 30 and 45 clear that the protocols were effective, and they degrees; were expanded to a 43-bed pulmonary care unit. ■ daily “sedation vacation” to assess readiness OUTCOMES to extubate; ■ In 2009, the VAP rate was .48 per 1,000 pa- ■ stress ulcer prophylaxis; tient days (one VAP), compared to a 2008 VAP ■ deep-venous thrombosis prophylaxis; and rate of 2.2 per 1,000 patient days (five VAPs). ■ routine (i.e., every two hours) oral care. ■ Outcomes exceeded the National Healthcare Safety Network national average. Staff members were informed of the new initia- tive online and attended a mandatory presenta- tion on the positive clinical impact bundling can have on VAP. The goal was 100% education, with Preventing Ventilator-Associated staff from all disciplines involved. Within a few Pneumonia: A “Bundle of Joy” for months, the bundle concept for VAP reduction Patients and Staff became the hospital network’s “bundle of joy,” reducing VAP rates from the 90th percentile to St. Joseph’s Hospital Health Center nearly zero, enhancing patient care, improving CONTACT: Sally Klemens, M.D., Infectious Disease staff morale and teamwork, and saving the hospi- Specialist; (315) 448-6253; [email protected] tal hundreds of thousands of dollars. PROJECT LESSONS LEARNED OUTCOMES DESCRIPTION ■ ■ Ventilator-associated Prevention of VAP cases in the surgical intensive care unit health care- pneumonia (VAP) has (SICU) were reduced from 22 in 2008 to one associated infec- case in 2009. VAP cases in the medical ICU the highest mortality tions does not nec- were reduced from 23 in 2008 to two cases in rate of all health essarily require care-associated infec- expensive or high- 2009. tions. VAP also in- tech interventions. ■ Reducing total VAP cases from 45 in 2008 to creases the overall ■ A multidisciplinary three in 2009 saved approximately $1.68 length of hospital approach is critical million. to success. Every- stay, adding an addi- one, not just nurs- tional mean cost of ing or medical $40,000 per stay. staff, must be in- St. Joseph’s Hospital cluded in the Health Center process. believed its VAP rates ■ Feedback to those could improve and involved in the convened a Prevent process is critical to continued VAP Committee to success. implement a “bun- dled” approach to preventing VAP. 20 HANYS 2010 Profiles in Quality and Patient Safety

Reduce the Number of Ventilator- and are on the quality committee’s scorecard for Associated Pneumonias to Zero the board of directors. Thompson Health OUTCOMES CONTACT: Gloria Karr, R.N., M.S., B.C., C.I.C., Director, ■ In 2009, Thompson Health had 392 ventilator Infection Prevention/Emergency Preparedness; (585) 396-6654; [email protected] days, with no VAPs. ■ Once the weaning protocol was approved, the PROJECT LESSONS LEARNED process was laminated and attached to the DESCRIPTION ventilators for easy reference. ■ Thompson Health Increased monitor- ing improved com- engaged in a pro- pliance with the gressive and success- protocol; designat- ful journey to ing one registered achieving zero nurse at the point ventilator-associated of care to be re- pneumonias (VAPs) sponsible for the data improved the in 2009. Building compliance rate on the lessons and data integrity. learned from the ■ Staff pride and HANYS’ VAP motivation Prevention Project, increased. a multidisciplinary team started with daily VAP “bundle” monitor sheets at the bedside. Staff were responsible for documenting the daily bundle for each patient, which resulted in the establishment of daily rounds. The infection control practitioner joined the daily rounds to provide continuous re- minders and education. In addition, Thompson Health launched an extensive hand-washing campaign.

The team identified the need for a tool to help wean ventilator patients in a timely manner. A ventilator weaning protocol was approved under the leadership of the respiratory therapy super- visor. This policy was reviewed by the medical executive committee and endorsed by the criti- cal care committee, providing the clinician sup- port required for success. This protocol allowed staff to extubate some patients one day earlier. It became routine to attempt weaning on a daily basis, unless contraindicated. Outcomes are re- ported monthly to the appropriate committees HANYS 2010 Profiles in Quality and Patient Safety 21

CLINICAL CARE—VTE

Improving VTE Prophylaxis in a OUTCOMES Community Hospital with CPOE ■ VTE prophylaxis for medical patients in- Glens Falls Hospital creased from a baseline of 30% to more than CONTACT: Phyllis Western, R.N., B.S., M.P.H., C.P.Q.A., 80% six months after initiation. Executive Director, Quality Management; ■ In 2009, there was a 7% decrease in patients (518) 926-2195; [email protected] with hospital-acquired VTE. PROJECT ■ Planning and implementation was completed LESSONS LEARNED DESCRIPTION in six months. The first meeting was held on ■ For optimal coop- In 2009, the Glens January 15, 2009 and the computerized VTE eration and in- Falls Hospital volvement, engage prophylaxis order process went live on July 6, Department of medical staff be- 2009. Medicine selected fore changing the the rate of deep computerized vein thrombosis provider order entry process. (DVT) prophylaxis Improving VTE Prevention Strategies with low molecular ■ Computer decision support will in- and Patient Outcomes weight Heparin as crease compliance Maimonides Medical Center one of its perform- with evidence- ance improvement based guidelines. CONTACT: Susan Goldberg, R.N., B.S.N., M.P.A., Assistant Vice President, Organizational Performance; indicators. A multi- ■ Use concurrent (718) 283-8337; [email protected] disciplinary team monitoring to eval- evaluated the cur- uate the success of PROJECT LESSONS LEARNED rent process for as- improvement ini- DESCRIPTION tiatives and iden- ■ sessing DVT risk Given its high-risk Implementing stan- tify underlying dardized protocols and interventions population, reasons for failure. is an effective way and identified is- Maimonides Medical to reduce the inci- sues with scoring Center formed a dence of VTE and risks and underutilization of DVT prophylaxis multidisciplinary pulmonary (30%), as well as a higher prevalence in medical team to develop a embolism. patients. After evaluation, the team recom- hospital-wide venous ■ Early end-user mended the program focus specifically on ve- thromboembolism feedback is neces- sary before and nous thromboembolism (VTE). (VTE) risk assessment after implement- and prophylaxis pol- The medical staff developed computerized VTE ing a new process. icy. A point-based prophylaxis orders. A VTE prophylaxis alert ap- ■ When using risk assessment was evidenced-based pears when an adult medical patient is admitted. incorporated into the practice guidelines, When a patient’s score indicates a moderate to paper history and physician consen- high risk for VTE, pharmacological anticoagula- physical document. sus is essential for tion and mechanical prophylaxis alternative op- The American success. tions or contradictions are considered. College of Chest Physicians (ACCP) prophylaxis protocol was incorporated into the Medical Center’s 22 HANYS 2010 Profiles in Quality and Patient Safety

computerized physician order entry (CPOE) sys- Redesigning Processes to tem. A reminder was added to the ordering path- Prevent Hospital-Acquired VTE way if no risk assessment was performed. South Nassau Communities Hospital

Although compliance was more than 90%, out- CONTACT: Maryann Demeo, R.N., B.S.N., M.P.A., Assistant Vice President Quality and Resource comes did not improve to the degree antici- Management; (516) 632-3890; [email protected] pated. An analysis revealed a lack of practitioner understanding of the point-based risk assess- PROJECT LESSONS LEARNED ment. Maimonides collaborated with the Agency DESCRIPTION ■ for Healthcare Quality and Research (AHRQ) to Nationally, pul- “The simpler, the better.” improve its process, and in January 2009, the monary embolism ■ To be effective, following changes were implemented: (PE) resulting from hospital adminis- ■ the assessment was simplified, eliminating the deep vein thrombosis tration, clinical point system; (DVT) is a leading leadership, and cause of death for medical staff must ■ three categories of risk were identified (low, hospitalized patients. be aligned and moderate, and high); Many of these deaths committed to the ■ improvement risk assessment and ordering protocols were can be prevented initiative. incorporated directly into the CPOE system; with the appropriate ■ Physician compli- ■ the assessment was made mandatory and pharmacological pro- ance increases must be completed before admitting orders phylactic measures. with ongoing edu- are entered; and Still, the national rate cation and aware- ■ the CPOE pathway was revised to reflect cur- of appropriate VTE ness programs for rent AHRQ/ACCP-recommended guidelines. prophylaxis ap- medical staff. proaches only 40%. OUTCOMES South Nassau Communities Hospital reviewed its ■ Maimonides achieved a 43.8% decrease in the VTE incidence and compliance with existing pro- number of reportable VTEs in 2009, com- tocols. Standardizing protocols, simplifying the pared to 2007. protocol order set, designing the order set’s inte- ■ There was a 32.8% decrease in the number of gration into the clinician workflow, and present- reportable pulmonary embolisms in 2009, ing mandatory physician education regarding the compared to 2007. problems associated with hospital-acquired VTE were all key to the project’s success. The project ■ National Surgical Quality Improvement began during 2008 and new protocols were fully Program outcome data showed a downward implemented by July 2009. trend in the surgical VTE rate. OUTCOMES ■ Before implementation, South Nassau Communities Hospital’s rate of hospital- acquired VTE was 0.43 for 1,000 patient days. A rate of 0.35 for 1,000 patient days was achieved in the first six months following implementation of this initiative. HANYS 2010 Profiles in Quality and Patient Safety 23

■ The percentage of appropriate prophylaxis result, the hospital identified an opportunity to was initially 66%, increasing to 86% in the improve and standardize deep vein thrombosis six months following implementation. (DVT) risk assessment and orders for prophylaxis ■ The initiative increased physician awareness to improve patient safety. of the need for VTE prophylaxis in the major- To standardize assessments relating to DVT pro- ity of hospitalized patients as evidenced by a phylaxis, an electronic solution was established 30% increase in the percentage of patients re- to systematically deploy a process based on ceiving appropriate VTE prophylaxis, and an National Quality Forum recommendations, 18.6% decline in the incidence of hospital- Joint Commission standards, and American acquired VTE. College of Chest Physicians guidelines. Through this electronic solution, adult patients hospital- wide (excluding psychiatry) are assessed within 24 hours of admission and appropriate orders Standardization to Prevent are established. Venous Thromboembolism Stony Brook University Medical Center OUTCOMES Since initiation of the electronic solution: CONTACT: Mary Lee Schroeter, R.N., B.S.N., Quality Management Practitioner, Continuous Quality ■ VTE events decreased from a rate of .49 per Improvement; (631) 444-9974; 1,000 days in February 2009, to .24 per 1,000 [email protected] patient days in December 2009. PROJECT ■ Before implementation in June 2009, the LESSONS LEARNED DESCRIPTION 24-hour assessment rate was 64%; post- ■ Stony Brook Utilizing electronic implementation (November 2009), this solutions hardwire University Medical percentage grew to 91.2%. systematic Center’s strategic processes to en- ■ More than 90% of patients are assessed on plan focuses on sure compliance. admission. becoming a high ■ Utilizing a “hard reliability organiza- stop” helps control tion (HRO). Patient the process to en- safety is paramount sure systematic deployment. and key hospital ■ work systems are An organization- wide initiative re- deployed systemati- quires consensus. cally for failure-free Key patient re- process outcomes. quirements and Part of the strategic practitioner needs tactics associated must be addressed with becoming an to maximize pa- tient care and HRO is a focus on outcomes. performance im- provement priori- ties that support organizational goals relating to quality improvement and patient safety. As a 24 HANYS 2010 Profiles in Quality and Patient Safety

OPERATIONS

Operating Room Inventory Control The operating room inventory LEAN Kaizen Improvement Project team consisted of the operating room director Albany Memorial Hospital and Samaritan and frontline materials management, finance, Hospital and information technology staff. The team used LEAN Kaizen tools and processes to iden- CONTACT: Lori Santos, C.P.A., Chief Financial Officer/ Vice President, Finance; (518) 471-3135; tify waste, standardize and structure every activ- [email protected] ity, and experiment with small tests of change. The focus throughout was on the process, not PROJECT LESSONS LEARNED the people involved. DESCRIPTION ■ Finding the value of A process owner OUTCOMES must be identified their inventory ex- at the start of the ■ The team standardized receipt of items by ceeded $1 million, process, along materials management staff at both hospitals. Albany Memorial with a senior team ■ Organized storage areas were established with Hospital and “champion.” consistent color-coding and labeling. Samaritan Hospital ■ Design the new ■ One hospital began a daily review of upcom- discovered the process with input ing operating room cases to ensure adequate financial statement from frontline staff to help ensure inventory. valuation was incor- buy-in. rect for several ■ Preference cards were updated for accuracy, ■ Ensure that all months because checked daily for each case, and edited if staff understand necessary. physical counts how their piece of were not being per- the process fits formed on time. In into the whole. addition, the inven- tory valuation Patient Forum Yields Performance process was very labor-intensive, increasing the Improvement Opportunities risk of error. The hospitals decided to standard- Bassett Healthcare Network/Bassett ize the process and to use existing information Medical Center technology to make the process more efficient. CONTACT: Ronette Wiley, Vice President, Performance Improvement and Care Coordination; (607) 547-4693; The hospitals participated in a week-long work- [email protected] shop on LEAN Kaizen, a rapid improvement process that relies on cross-functional teams to PROJECT DESCRIPTION achieve goals. An initial meeting was held to de- To gain a better understanding of the factors fine team goals and objectives. After mapping driving patient perception of care and satisfac- every step of the current process, an “ideal tion scores, Bassett Medical Center instituted pa- state” was described, and barriers to moving tient focus groups in 2008. Patients asked to from the current state to the ideal state were participate in the monthly focus groups are se- identified. The team then conducted a root- lected randomly from a list of surgical and med- cause analysis and developed solutions, which ical inpatients admitted during the previous were tested and implemented. month. During the monthly focus groups ses- sions, patients share their experiences with key HANYS 2010 Profiles in Quality and Patient Safety 25

hospital personnel, Preventing Significant Events LESSONS LEARNED including chief Through a Culture of Safety ■ physicians, hospital- Patients feel em- powered and Catholic Health System ists, nursing leaders, proud when they CONTACT: Denise Bartosz, R.R.T., B.S., Director of administrators, and are helping to Patient Safety; (716) 923-2943; [email protected] the director of serv- make a difference ice excellence. These in health care. PROJECT LESSONS LEARNED one-hour sessions ■ Sharing video ex- DESCRIPTION ■ Actual patient are spent listening cerpts of patients In 2007, Catholic safety examples to and asking ques- with the board has Health System initi- been an extremely are most effective tions of patients as ated a cultural powerful tool for when educating they describe “the change. change to transform physicians and good and bad” of its focus on patient staff. ■ Focus groups help their recent experi- better align admin- safety. The first step ■ Board-level partici- ence. The hospital istration and physi- was to assess the cur- pation is essential team shared what cians around a rent culture through and should be shared with staff they have learned common focus on a multidisciplinary patients. to highlight impor- with colleagues and survey, which in- tance of safety specific items iden- cluded board mem- initiatives. tified for investigation, dialogue, and action are bers, senior leaders, ■ Patient safety is brought to the hospital’s acute care committee. physicians, and asso- everyone’s In addition, with the patients’ permission, ses- ciates. In 2008, the responsibility. sions are videotaped and vignettes of the pa- results of this survey tients’ experiences go to the performance were used for evaluation and planning, followed improvement committee of the board of trustees by system-wide education and training. each quarter for review, as well as to the various inpatient units during staff meetings. It is a pow- The key to this cultural transformation was erful way for the board and staff to hear the transparency—letting everyone in the organiza- voice of the patient. tion know when a harm event occurred, why it happened, and how to prevent it from happen- OUTCOMES ing again. This means looking at patient safety ■ Bassett received 52% fewer inpatient com- system-wide from a global perspective, rather plaints in 2009, compared to 2008. than by individual sites. A system director of pa- tient safety and significant event manager were ■ Hospital Consumer Assessment of Healthcare added to the performance improvement team to Providers and Systems (HCAHPS) ratings re- elevate harm events and root-cause analysis lated to doctor communication improved 14%. from the site level to the system level. Education ■ HCAHPS ratings on medication communica- and follow-up are shared across the system so tion improved 12%. individual sites could learn from one another ■ The hospital’s patient surveys reveal a contin- and develop a uniform “culture of safety.” ued positive trend in resolving issues identi- Catholic Health System publishes Patient Safety fied in patient focus groups. Alert to help facilitate inter-facility, system-wide awareness. 26 HANYS 2010 Profiles in Quality and Patient Safety

OUTCOMES processes that enable staff to successfully pro- ■ Significant events (death, near death, or per- ceed to donation in cases of cardiac death, brain manent loss of function) and potentially sig- death, and most recently, donation after cardiac nificant events (with potential to cause death, death. a cardiac arrest, or permanent loss of function) OUTCOMES decreased 48%. ■ Claxton-Hepburn developed a hospital cul- ■ Daily use of error reduction tools among staff ture that supports evidence-based end-of-life improved 194%. care and recognizes donation as an important ■ Staff willingness to report an event increased element of that care. 9.5%. ■ The overall hospital referral rate for organ do- nation was between 99% and 100% for the past three years, and there has been a high referral-to-acceptance conversion rate in cases Help From Above: Overcoming of brain death. Barriers of Geographic Size and Location Claxton-Hepburn Medical Center CONTACT: Jennifer S. Shaver, R.N., B.S.N., Nurse Improving Physician Compliance Manager, Intensive Care Unit; (315) 393-3600 ext. 5337; with Quality Measures: The Carrot [email protected] or Stick? PROJECT Cortland Regional Medical Center LESSONS LEARNED DESCRIPTION ■ CONTACT: Robert R. Karpman, M.D., M.B.A., Claxton-Hepburn Geographic size and location does Vice President, Medical Affairs; (607) 428-5067; Medical Center’s not preclude organ [email protected] story and vision is or tissue recovery, PROJECT about “paying appropriate alloca- LESSONS LEARNED back.” Despite its tion, or successful DESCRIPTION ■ Physicians respond transplant. Physician compli- rural location and better to positive ■ ance with reporting small size, the hos- Appropriate uti- reinforcement than pital maximized lization of out-of- quality measures punitive measures. area resources can available resources can be a challenge, ■ Physicians are greatly enhance particularly in a competitive by to meet the needs of local services non-employed nature and enjoy patients and fami- provided. physician practice competing with lies in regard to ■ A hospital culture model. Cortland their peers. organ donation. that is open and in- ■ Publishing data Claxton-Hepburn is formed about Regional Medical can leverage peer organ donation fa- Center launched able to provide sup- pressure to im- cilitates processes this initiative to port and guidance prove results. and fosters success to families involved offer physicians in this area. in making end-of- positive reinforce- life decisions, the last of which involves organ ment for compliance with two quality meas- donation. The organization “hard-wired” ures: verbal order authentication and unacceptable abbreviations. HANYS 2010 Profiles in Quality and Patient Safety 27

A nine-member medical staff “World Series” was tation nurse was alone with patients while they created. Each member received a “home run” for exercised—this was a concern should the nurse completing verbal orders and achieving zero un- have questions or issues regarding the exercise acceptable abbreviations per month. Charts were program or equipment. randomly chosen and evaluated for compliance. Results were posted each month outside the Telephone coverage for questions or appoint- physicians’ lounge, with the winning team re- ments from patients or providers was only avail- ceiving a complimentary dinner. The series able during program hours. By moving the lasted four months. program, telephone calls are now answered im- mediately by physical rehabilitation staff mem- OUTCOMES bers, who are available Monday through Friday ■ Compliance with avoiding unacceptable during regular business hours. Communication abbreviations rose from 60% to 100%. between the multidisciplinary team (cardiac re- ■ Compliance with verbal order authentication habilitation nurse, physical therapist, and dieti- increased from 40% to 75%. cian) was time consuming and slow. Working under one roof facilitates timely communication ■ Compliance was maintained, even after the between the team members. In addition, patients World Series ended. on their initial visit no longer need to visit three different sites within the hospital campus.

OUTCOMES Enhancing a Cardiac Rehabilitation ■ The new configuration provides an interac- Program: Safety, Continuity, and tive, team-based approach. Convenience for Patients ■ More equipment options are available to pa- Delaware Valley Hospital tients. CONTACT: Deborah Hitt, Vice President, Quality ■ Telephone calls are answered and responded Management; (607) 865-2100; [email protected] to promptly. ■ Peer support and motivation are encouraged PROJECT LESSONS LEARNED by combining Phase II cardiac rehabilitation DESCRIPTION ■ program patients with Phase III (mainte- Recognizing oppor- Moving a program must be carefully nance) program patients. tunities for improve- planned in ad- ■ The facility achieved increased patient satis- ment, Delaware vance to ensure Valley Hospital made seamless patient faction, as noted through positive verbal pa- plans to move its care. tient feedback. Phase II cardiac reha- ■ Creating a more ef- bilitation program ficient process has from the hospital’s fostered a more comfortable at- cardiopulmonary de- mosphere for both partment to the phys- the patients and ical rehabilitation staff. building located on the hospital campus. With the physical therapist housed in another building, the cardiac rehabili- 28 HANYS 2010 Profiles in Quality and Patient Safety

Controlling Operating Room Supply OUTCOMES Chain Expenses ■ The team achieved its financial savings target Ellis Medicine within four months, and accomplished

CONTACT: Judy Young Symolon, R.N., B.S., Manager, almost ten times the savings goal after seven PACU; (518) 243-4271; [email protected] months. ■ The financial savings were achieved with no PROJECT LESSONS LEARNED reductions to the quality of patient care; DESCRIPTION ■ national recognition of the hospital’s quality When Ellis Medicine Communication is vital for success; of care continued. consolidated three particularly involv- hospitals under ing physicians order of the and senior Commission on management. Health Care ■ Persistence is nec- Transforming a Culture by Engaging Facilities in the 21st essary; all involved the Entire Organization Century, substantial must stay focused Faxton-St. Luke’s Healthcare on the project goal. differences were CONTACT: Mary Beth Dowling, B.S.N., R.N., ■ A global opera- identified in the Relationship-Based Care Coordinator; (315) 624-6035; tional view not perioperative and [email protected] only contributes to operating room the specific project, PROJECT procedures of the LESSONS LEARNED but helps identify DESCRIPTION different institu- savings opportuni- ■ In December 2004, Taking time to tions. A team was ties throughout the build relationships Faxton-St. Luke’s formed with the hospital. across the entire Healthcare’s two goal of reducing organization pro- hospitals merged to duces positive costs by at least $125,000, while maintaining become one health outcomes. existing levels of quality. The team focused on care center. With ■ Engaging the en- standardizing materials and procedures, improv- the process of con- tire workforce em- ing operational efficiency, and improving solidation com- powers employees contracting. to create positive pleted, leadership change. focused on the chal- The team recognized the importance of using ■ Through this cul- lenge of building re- effective change management and communica- tural transforma- tion techniques to achieve necessary participa- lationships and tion, staff from all tion from physicians, staff on the three improving commu- departments rec- ognize the impor- campuses, and senior management. This nication. The leader- tance of their role resulted in two project initiatives: ship team sought to create a caring and and how it con- ■ A materials management component focused tributes to the care healing environ- on reprocessing, custom packs, product stan- of patients and ment where staff dardization, and better contract pricing. their families. would find meaning ■ An operational efficiency component worked and joy in their to enhance communication, expand the post- work, and where patients would want to receive anesthesia care unit (PACU), and improve in- care. The goal was to increase staff involvement formation technology. HANYS 2010 Profiles in Quality and Patient Safety 29

in decision making, improve processes of care, to patients as well as LESSONS LEARNED and promote cooperation to create a positive health care profes- ■ Health care patient experience. sionals. A full-time practitioner ques- clinical pharmacist tions mainly in- The chief nursing officer searched for a model responds to drug in- volve drug dosing that would foster staff participation, build in- quiries in-person, by related to high-risk terpersonal relationships, and keep patients e-mail, or by mail re- medications and their families at the center of all that the garding drug dosing, (e.g., heparin, antineoplastic, organization does. The Relationship-Based Care adverse drug reac- anticoagulants). (RBC) model was chosen and the journey of tions, and appropri- ■ There is a need to cultural transformation began in 2005. Four ate therapies for tap into pediatric years into this journey, the organization is be- specific patients. This drug information ginning to approach the “tipping point” to- timely and appropri- resources and pro- ward transformation. ate medication advice vide information helps prevent med- to health care OUTCOMES ication errors, ad- practitioners. ■ Employee satisfaction improved from the verse drug events, 14th percentile in 2004 to the 60th percentile and unnecessary emergency room and physician in 2009. office visits. Other clinical services provided by ■ There has been a significant increase in the pharmacist include maintaining an elec- employee compliments and a decrease in tronic database of drug inquiries, conducting ac- employee complaints. tivities with hospital staff, preparing drug ■ Staff are rewarded and recognized for good monographs for the pharmacy and therapeutic performance. committee, disseminating drug alerts to the medical staff on pertinent medication-related is- ■ Departments within the organization work sues (e.g., dosing changes, drug recalls, new al- well together. lergy or side effect warnings), providing ■ Staff feel involved in changes made within continuing education to health care profession- departments. als on relevant drug topics, and overseeing the reporting, detecting, and managing of medica- tion errors and adverse drug events.

Community Drug Information Center OUTCOMES Kingsbrook Jewish Medical Center ■ The Community Drug Information Center provides between 1,000 and 2,000 interven- CONTACT: Henry Cohen, M.S., Pharm.D., F.C.C.M., B.C.P.P., C.G.P., Director of Pharmacy Residency tions per year. Programs; (718) 604-5373; [email protected] ■ This program has demonstrated significant savings per medication intervention. PROJECT DESCRIPTION ■ With a plethora of health information available Circulation of timely “drug alert” publications on the Internet and little guidance, consumers serves a vital role in informing staff of imme- need a trusted source for unbiased information diate changes that may affect daily practice. about medication. The hospital-based Commu- nity Drug Information Center provides services 30 HANYS 2010 Profiles in Quality and Patient Safety

Improving Inpatient Satisfaction helpfulness. The hospital staff have expressed Through a Patient-Centered Guest increased satisfaction and morale. The hospital Ambassador Program continues to expand the program with the The Kingston Hospital expectation of taking it hospital-wide by December 2010. CONTACT: Dennis Pignato, M.B.A., Vice President of Support Services; (845) 334-2700; OUTCOMES [email protected] From the second to third quarters of 2009: PROJECT ■ patient satisfaction scores in all seven LESSONS LEARNED DESCRIPTION HCAHPS dimensions improved; ■ Kingston Hospital’s Gaining a patient’s trust and confi- ■ patient surveys showed improvement for all Guest Ambassador dence takes time. three “communication with nurses” Program was imple- ■ Patients generally questions; and mented for patients are pleased with ■ patient satisfaction improved in five out of and families as a the care they re- six of the ancillary departments for pilot program on ceive, as the major- “courtesy/helpfulness.” the hospital’s ity of their Telemetry Unit in concerns are resolved December 2008. immediately. The program ini- ■ Daily visits im- tially included the Improving Patient Flow at a prove patients’ vice president of perception of the Non-Academic Hospital support services, care they receive. Mercy Medical Center director of environ- CONTACT: Daniel Murphy, M.D., F.A.C.E.P., Director of mental services, a charge nurse, and clinical Emergency Department; (516) 705-2874; dietician. It expanded to include ten clinical and [email protected] non-clinical staff members who were assigned two patient rooms. PROJECT DESCRIPTION Emergency Department (ED) admitted patients Program education and a verbal contract were used to wait an average of 24 hours for an inpa- used to assure staff commitment to be “Guest tient bed at Mercy Medical Center. The func- Ambassadors.” Beginning in March 2009, every tional capacity of the ED for “treat and release” patient on the telemetry unit was visited daily patients was impaired, post-anesthesia recovery by his/her assigned Guest Ambassador, who not room flow was adversely affected, and patient only assured that the patient’s medical needs and staff satisfaction suffered. Mercy Medical were attended to promptly, but also acted as a Center began an organization-wide root-cause personal concierge for patients and families. analysis to develop an improvement strategy. It Since implementing the Guest Ambassador revealed physician practice patterns for complex Program, within one quarter patient satisfaction geriatric patients were associated with a mean scores increased in all seven Hospital Consumer length of stay (LOS) in excess of ten days, lifting Assessment of Health Care Providers and Systems the hospital’s overall LOS to 7.6 days. These (HCAHPS) Dimensions for the Telemetry Unit. practice patterns far exceeded national norms. Ancillary Support Services demonstrated satis- faction scores greater than 90% in courtesy/ The solution was to develop a “geriatric care best practice program” and a unique contractual HANYS 2010 Profiles in Quality and Patient Safety 31

arrangement with Network LESSONS LEARNED LESSONS LEARNED physicians. The con- (CHAMPION) ■ ■ tract requires physi- Efficient inpatient initiative is Pay-for- LOS is associated performance cians who treat Montefiore Medical with higher pa- programs can skilled nursing fa- tient satisfaction. Center’s multi- address health care cility patients to use ■ Creating efficien- stakeholder, inte- disparities and standard order sets, cies through im- grated delivery improve quality of systematic monitor- plementing best system pay-for- care for prevalent ing, and feedback practices creates performance pro- conditions in under-served on care outcomes. capacity through- gram. Its primary out the hospital, communities. Patients experienced objective is to including the criti- ■ Providers can play dramatic improve- cal care setting. improve care for a lead role in de- ments in LOS, ED prevalent commu- ■ Hospitalist services signing robust pay- wait time, and can support imple- nity conditions, for-performance nursing-sensitive mentation of new including diabetes programs that en- indicators like pres- initiatives and the mellitus, hyperten- gage payers as stakeholders. sure ulcers. ED and care of complex sion, cardiovascular ■ inpatient satisfac- skilled nursing fa- disease, cardiovascu- Inclusive, transpar- cility patients. ent methods can tion scores skyrock- lar disease risk fac- promote provider eted; these tors, common acute engagement and achievements are sustained to this day. medical conditions, improvement and surgical proce- across perform- OUTCOMES dures. The initiative ance domains. ■ The organization achieved significant im- created provider provement (16-hour reduction) in mean ED financial incentives for performance on 66 inpa- wait time for an inpatient bed between 2007 tient and outpatient measures. Incentivized care and 2009. settings included nine academic departments ■ Hospital patient satisfaction improved 10% to across two hospitals and 140 ambulatory care 20% in every category. providers across 22 practice sites that together provide care to 220,000 adults. ■ Medicare LOS was reduced 20% and overall hospital LOS decreased nearly 15%. Data for two measurement periods were col- lected from medical records and administrative sources, and were externally audited. Incentive monies were derived from a pool consisting of The Community Health and Acute organizational, Department of Health, and Medical Performance Improvement health plan contributions. Individualized per- Organizational Network formance reports and corresponding incentive Montefiore Medical Center payments were generated for inpatient depart- CONTACT: Rohit Bhalla, M.D., M.P.H., Chief Quality ments and outpatient providers. Officer; (718) 920-7303; [email protected] OUTCOMES PROJECT DESCRIPTION ■ All nine inpatient departments and 73% of The Community Health and Acute Medical the 107 outpatient providers who participated Performance Improvement Organizational 32 HANYS 2010 Profiles in Quality and Patient Safety

in both years of the program improved their OUTCOMES performance. ■ Through behavior modification, 64.5 units of ■ The mean performance score for all inpatient platelets were saved during a 332-day period, departments and outpatient providers in- post-intervention. creased significantly, from 75.9% to 79.2%. ■ This decrease represents an annual savings of ■ Scores improved for 70% of the 66 program 70.9 platelet units and $50,631. measures.

Formal Nurse Preceptor Education Improved Efficiency of Platelet Program Utilization Through Leadership and Nathan Littauer Hospital and Nursing Cultural Transformation Home Nassau University Medical Center CONTACT: Kathie Rohrs, R.N., M.S.N., C.D.E., CONTACT: Jen Lin, M.D., Director, Pathology Residency Education Coordinator; (518) 773-5425; [email protected] Program; (516) 572-3201; [email protected] PROJECT PROJECT LESSONS LEARNED LESSONS LEARNED DESCRIPTION DESCRIPTION ■ Formalized train- ■ Nathan Littauer During a Nassau Leadership involve- ing is effective in ment is crucial for Hospital’s formal University Medical improving reten- performance preceptor education tion of new Center leadership- improvement. program is modeled professional driven “town hall ■ Managerial under- after the Vermont registered nurses. meeting,” frontline standing of other Nurses in ■ Preceptors express staff raised the issue departments’ Partnership precep- satisfaction with processes is of unused, expired tor program. This their training and essential. feel better pre- platelet units. Using evidence-based cur- ■ Close observation pared to teach. the Plan-Do-Study- riculum was pro- Act (PDSA) ap- and consultation ■ New staff, includ- by expert staff can moted to New York proach, the blood ing graduate modify behavior. State’s hospitals as a nurses, repeatedly bank department collaborative effort commented posi- identified an oppor- by the New York tively on the orien- tunity for improving knowledge about platelet State Nurses tation process. utilization. Before implementing change, 28.4% Association (NYSNA) of platelet units became outdated. Blood bank to help hospitals retain registered nurses. staff initiated close observation and expert con- sultation during requests for platelets. The inten- In March 2009, two registered nurses attended tion was to identify if modification of behavior comprehensive training sessions in preceptor and culture would result in improvement in development at NYSNA. Information gathered platelet utilization. Monitoring over the ensuing from these sessions was translated into a two- 332 days revealed a 6.3% expiration rate for day instructional program offered to 14 regis- platelet units. tered nurses at Nathan Littauer Hospital. Employees selected by unit managers were HANYS 2010 Profiles in Quality and Patient Safety 33

formally educated in subjects such as compe- ■ a process rooted LESSONS LEARNED tency assessment, adult teaching, learning in accountability ■ theories, conflict management, and communica- in which a stan- Staff want to pro- vide the best care tion. The new preceptors were strongly sup- dardized check- possible to pa- ported by the hospital’s nursing management list is reviewed at tients. A support staff and were given appropriate patient assign- change of shift, system that in- ments to allow time to precept new employees. patient hand-offs cludes continuous, With professional education and management between depart- one-on-one rein- support, the preceptors are better prepared to ments, and at forcement and ed- ucation on current interact with new staff in a more qualified man- discharge; best practice stan- ner, which facilitates a smoother transition into ■ quality staff pre- dards is vital in the workplace for new employees. pare a list of providing the best “core measure” possible care. OUTCOMES patients each day ■ Support and active ■ The number of new registered nurses who that is distributed engagement from executive leader- resigned during the orientation process to the nursing declined. ship is essential to units each morn- success. ■ This program influenced all unit managers to ing for review by ■ Continually im- embrace the theoretical foundations of the nurse leaders; prove processes program and support staff precepting efforts. ■ quality resource and stretch the ■ Since the program began in June 2009, vacan- nurses perform boundaries. cies for full- and part-time RNs decreased daily rounds to from 5.70 in June 2009 to zero on February review the standardized checklist, engage in 28, 2010. discussion with nurses, e-mail follow-up with nurse leaders, and e-mail or telephone contact with physicians; ■ upon patient discharge, the primary regis- Improving Core Measure Compliance tered nurse reviews the standardized checklist Through Education, Standardization, to assure compliance and must obtain a vali- and Accountability dation signature from the nursing director or Orange Regional Medical Center supervisor before the patient leaves.

CONTACT: Susan M. Hodgson, M.H.S.A., R.N., OUTCOMES C.P.H.Q., F.A.C.H.E., Vice President of Quality; The fourth quarter of 2008 indicator compliance (845) 342-7215; [email protected] rate was 58%, and improved to 92% in the PROJECT DESCRIPTION fourth quarter of 2009. Orange Regional Medical Center launched a one- year project to increase the number of reported core measures at or above 90% compliance through a collaborative process. Developing grassroots awareness with accountability was the first hurdle. The team set forth the following: 34 HANYS 2010 Profiles in Quality and Patient Safety

Endoscopy Flow Initiative ■ ensure a designated number of beds are avail- Oswego Hospital able each day in the unit for endoscopy patients; CONTACT: Valerie Favata, R.N., B.S.N., M.S., Associate ■ Administrator for Nursing; (315) 349-5567; using Fentanyl instead of Demerol (causes [email protected] less nausea, drowsiness, and hypotension; and returns the patient to a pre-sedation state PROJECT LESSONS LEARNED almost immediately post-procedure); DESCRIPTION ■ ■ anesthesia providers in the endoscopy suite Oswego Hospital There is great value in process owner- provide support; and developed this ini- ship, stakeholder ■ provision of dedicated support staff to trans- tiative to address engagement, and port discharged patients. an increase in including all key endoscopy volume players at the be- OUTCOMES ginning of the and lengthy sched- Successes included improved patient satisfac- initiative. uling wait times. A tion, a 10% increase in schedule volume, a 10% key challenge was to ■ Recognize and ad- dress the potential decrease in patient lead time (time between re- identify ways to im- impact of changes ferral to available opening in schedule), and de- prove patient “flow” on other depart- creased length of stay. in the facility while ments and ensuring patient maintain commu- safety. Using a col- nications with laborative approach, other service de- partments and Journey to Improved Quality a 12-week study specialties to Outcomes revealed several ensure a clear Our Lady of Lourdes Memorial Hospital opportunities for understanding and improvement support of the CONTACT: Susan M. Fuchs, R.N., B.S.N., Nurse including registra- initiative. Director; (607) 798-5420; [email protected] tion delays, early ■ Recognize that PROJECT arrivals, inconsistent achieving desired LESSONS LEARNED DESCRIPTION bed availability, pro- goals is the pri- ■ Listen to the voice mary objective, Our Lady of Lourdes longed patient stays of nurses. not setting an end Memorial Hospital related to sedatives, ■ Encourage decision date. examined its patient staffing issues, and making through outcomes, commit- unit-based practice splitting services tee structures, and councils. between endoscopy and the operating room. leadership model to ■ When staff take plan for the future. ownership of qual- The following procedure and process changes The hospital identi- ity data and pa- were implemented: fied multiple oppor- tient care, better ■ outcomes are staff education on the registration process; tunities for achieved. ■ engagement of and collaboration with physi- improvement. cian office staff to confirm schedules and com- Committees existed, but without ownership, municate appropriate arrival times to patients; accountability, and communication, and, as a result, outcomes were unacceptable. Hospital charge nurses on the units were responsible for HANYS 2010 Profiles in Quality and Patient Safety 35

staffing, scheduling, disciplinary issues, and a staff were engaged to develop solutions to full assignment of patients, resulting in incon- achieve this process improvement goal. sistent charge nurse practices, “burnout,” and turnover. Samaritan Medical Center used the Plan-Do- Study-Act (PDSA) performance improvement To address these issues, the hospital developed model. Staff participated in team meetings, gen- a strategy to ensure open and ongoing erating ideas, testing recommendations, and col- communication with staff, charge nurses, and lecting data. These led to many changes to committees. The leadership model was trans- ensure procedures were written and followed formed, a new committee structure established, clearly and correctly. Data were shared with staff and unit-based practice councils were developed. on a regular basis. Celebrating success was an important part of the process as well. OUTCOMES Highlights include: OUTCOMES Samaritan Medical Center realized a 150% de- ■ pressure ulcers decreased 40%; crease in mislabeled specimens from 2008 to ■ falls decreased 39%; 2009. The number of mislabeled specimens was ■ patient satisfaction, as indicated by the Net 20 in 2008. The number of mislabeled speci- Promoter Score, increased from 67 to 72; and mens was eight in 2009. ■ nursing satisfaction exceeds the national mean and increased in all areas, including nurse-nurse interaction, decision making, nurse-physician interaction, autonomy, pro- A Nursing Strategic Plan Built Upon fessional status, and job enjoyment. a Foundation of Patient Safety Southampton Hospital

CONTACT: Patricia A. Darcey, R.N., M.S., N.E.-B.C., Chief Nursing Officer and Vice President, Reducing Mislabeled Specimens Patient Care Services; (631) 726-8323; Samaritan Medical Center [email protected] CONTACT: Tony Marra, F.A.C.H.E., M.B.A., Director, PROJECT DESCRIPTION Laboratory Services; (315) 785-4506; [email protected] In 2006, Southampton Hospital’s department of PROJECT nursing conducted a needs assessment focusing LESSONS LEARNED DESCRIPTION on the quality of patient outcomes, staff recruit- ■ Reducing misla- Involve staff; they ment and retention, and patient safety. Part of know the process. beled specimens the assessment included distribution of the Hold them ac- Agency Healthcare Research and Quality was a key patient countable for the (AHRQ) Hospital Safety Survey to staff. Respon- safety goal for changes made. dents rated “Overall Perception of Safety” at Samaritan Medical ■ Share data fre- Center. Using quently with all 33%, “Communication Openness” at 49%, and process improve- staff and make “Patient Handoff” safety at 28%. ment techniques data-driven decisions. The goal was to create a strategic nursing plan and LEAN princi- ■ focused on leadership and patient safety. The ples, laboratory Celebrate successes. 36 HANYS 2010 Profiles in Quality and Patient Safety

organization imple- Improving Pain Management in LESSONS LEARNED mented numerous the Limited English-Proficient ■ processes to pro- Embrace negative outcomes as they Population mote transparency are drivers for Southside Hospital/North Shore-Long with key stakehold- change. Island Jewish Health System ers, including chief ■ Quality and pa- CONTACT: Felice Jones-Lee, R.N., M.A., Ph.Dc., executive officer/ tient safety must Associate Executive Director; (631) 968-3413; chief nursing offi- be intentional and [email protected] cer patient rounds, planned. ■ PROJECT real-time coaching, While each individ- LESSONS LEARNED and an emphasis on ual is accountable DESCRIPTION ■ Attentiveness to the nursing code of for providing pa- In 2004, Southside tients with safe details for one ethics and account- Hospital’s Nursing care, the system or group (in this case, Performance ability. A recruit- process provides LEP patients) may ment and retention the framework. mprovement improve outcomes plan was developed, Department began for all patients. quality measures analyzing pain man- ■ Attentiveness to significant vari- and benchmarks were established, and commu- agement performance data for limited ables such as cul- nication was enhanced through a redesign of ture may improve English-proficient the rapid response team debriefing, improve- patient outcomes ments in shift-to-shift reports, and inclusion of (LEP) patients. In ad- in areas such as patients in the daily plan of care. dition to chart re- pain management. view, an initial ■ Raising staff OUTCOMES analysis of Press awareness of LEP ■ “Overall Perception of Safety” increased 40%. Ganey scores sug- issues may increase gested there was a compliance with ■ “Open Communication” increased 24%. strong negative rela- monitoring patient ■ “Patient Handoff” safety increased 32%. outcomes. tionship between ■ Registered nurse vacancies decreased (from nursing staff’s sub- 15.2 in 2007, to 5.1 in 2009). jective scores on how well they managed pain ■ The average monthly turnover rate decreased and patients’ subjective scores on how well they (from 2.92 to 1). believed their pain was managed during their ■ Hours per patient day increased (from 4.8 to hospitalization. 6.2). Consequently, interviews with staff about pain management suggested language barriers often prevented them from doing a better job for LEP patients. As a result, three initiatives were imple- mented in the perinatal areas: ■ better use of interpreter services; ■ physicians’ orders for patient-controlled anal- gesia (PCA) or round-the-clock (RTC) admin- istration of analgesia; and HANYS 2010 Profiles in Quality and Patient Safety 37

■ provision of education and awareness training Transfer delays from floor to critical care beds for nursing staff and physicians with regard to caused dissatisfaction among Staten Island pain management in a diverse community. University Hospital’s physicians, nurses, staff, and patients. Data indicated that patient transfer OUTCOMES times averaged 3½ hours to a maximum of al- This program achieved the following results: most seven hours. In addition to delaying pa- ■ a significant increase in patient satisfaction tient treatment, delayed transfers affected scores for pain management among English- medical residents, who were required to stay and Spanish-speaking patients between 2005 with patients until they were transferred to a and 2007; and critical care bed. The team standardized the ■ a significant increase in patient satisfaction process for physician transfer orders and in- scores for pain for all patients between 2005 stalled “tele-tracking” in all critical care units. and 2007, in all service areas. OUTCOMES ■ Pre-intervention, floor-to-critical-care transfer times averaged 214 minutes, with a 75.5% suc- Decreasing Patient Transfer Time cess rate. from Floor Beds to Critical Care Beds ■ After one month, transfer times decreased Staten Island University Hospital 57.0%, averaging 92 minutes, with a 98.6%

CONTACT: Karen Lefkovic, R.N., Vice President, success rate. Quality/Risk Management; (718) 226-9514; ■ Five months post-intervention, transfer times [email protected] fell an additional 12%, with a success rate of 97.7%. PROJECT LESSONS LEARNED DESCRIPTION ■ Staten Island Culture change re- quires the inclu- University Hospital sion, buy-in, and assembled a ten- involvement of all Increasing Awareness of the Need member, multidisci- team members. for High-Quality Palliative and plinary team to ■ Technical, cultural, End-of-Life Care drive a performance and political barri- St. Mary’s Hospital ers can be improvement initia- CONTACT: Susan Duross, M.S., R.N., C.H.P.N., Director, overcome. tive to evaluate, im- Palliative Care; (518) 770-7523; [email protected] prove, and sustain ■ It is necessary to an increase in pa- standardize the PROJECT DESCRIPTION process for transfer tient “throughput” St. Mary’s Hospital recognizes that most individ- orders, and to use uals would prefer to die at home; however, sta- by decreasing trans- electronic fer time from floor bed tracking tistics indicate that nearly 59% of people die in a beds to critical care technology. hospital. In New York State that figure is pro- beds. The team jected to be as high as 70% in recent years. The identified opportunities to improve process flow goal of St. Mary’s Hospital’s palliative care pro- and communications, and implement a stan- gram is to ensure excellent end-of-life care and dardized process. improve the quality of life for all patients living with chronic diseases. The program strives to in- 38 HANYS 2010 Profiles in Quality and Patient Safety

crease referrals to Organization-Wide Use of FMEA to LESSONS LEARNED palliative care and Drive High Reliability and Safety ■ the percentage of An interdiscipli- nary, inter-agency Stony Brook University Hospital patients discharged collaboration ap- CONTACT: Carol A. Gomes, M.S., F.A.C.H.E., C.P.H.Q., to hospice. proach is critical to Associate Director, Quality Management; Ultimately, this pro- program success. (631) 444-0575; [email protected] gram strives to nur- ■ In addition to pa- PROJECT ture a model health tients and families, LESSONS LEARNED care community physicians and DESCRIPTION ■ The FMEA method- comprised of in- medical staff are Stony Brook customers too— ology encourages spired, compassion- University Hospital’s their buy-in is consensus building chief executive offi- ate caregivers who equally imperative. to focus on consistently con- cer established be- evidence-based ■ Emotional and coming a high strategies geared sider and tend to spiritual care corre- toward achieving patients’ and fami- late with patient reliability organiza- higher reliability. lies’ physical, emo- satisfaction scores; tion (HRO) as a key ■ Conducting proac- tional, and spiritual compassion, re- strategic objective. tive risk assess- wishes, needs, and spectful care, com- One of the primary munication, ments creates a concerns. Through tools in this effort, empowerment, transparent and Failure Mode and model behavior, and responsiveness blameless vital presence, em- are the underpin- Effect Analyses environment. powering knowl- nings of a success- (FMEA), enables staff ■ FMEAs should be edge, and trusted ful palliative care to proactively study applied to high- risk and newly de- partnerships, the program. high-risk processes to identify potential signed processes to program is posi- identify potential failure modes, and as- tively impacting delivery of care to all patients. pitfalls and process sess the severity and failures. OUTCOMES frequency of failure First year palliative care program results (April modes using standardized scales. By calculating a 2006 - March 2007): risk priority number, a team may identify areas ■ 299 referrals; of significant risk that require risk reduction ■ 45% referral rate by physicians; and strategies to improve performance and safety. To ensure success, these interventions are measure- ■ 0.6% of total hospital discharges to hospice. able and focus on systematic process deployment. Post-palliative care program results (April 2008 - Every leader, department head, and nurse man- March 2009): ager was provided FMEA training and tools. They ■ 515 referrals (a 72% increase); were required to select high-risk processes and ■ 98% referral rate by physicians (a 118% apply the FMEA methodology to identify and increase); implement risk-reduction strategies, and meas- ■ 2.4% of total hospital discharges to hospice (a ure the effectiveness of interventions. 300% increase); and Continual implementation of multiple, simulta- ■ 2.66% raw mortality rate (a 27.9% reduction). neous FMEAs allowed the organization to quickly and systematically deploy key processes that will reduce error while improving safety. HANYS 2010 Profiles in Quality and Patient Safety 39

OUTCOMES shots” that highlight specific quality initia- ■ The ratio of falls to falls with injury de- tives, and up-to-date data than can be found creased from 34% to 15%. on other public report card Web sites; and ■ ■ Employee annual physical assessment rates measures focused on clinical quality, patient improved from 74% to 97%. safety, and patient satisfaction. ■ The number of quarterly safety incident re- For each quality measure: ports generated by bedside nurses increased ■ the latest data are compared to appropriate from ten to 25 on a unit. benchmarks; ■ Endotracheal intubation by paramedics relat- ■ an explanation is provided to help consumers ing to medication and dosing improved from understand what each measure means; and 82% to 100%. ■ a statement is included to explain why each measure is important to consumers.

OUTCOMES Quality of Care Web Site: Transparency of Data ■ The hospital is the first in the region to pub- Upstate University Hospital lish a Web site dedicated to communicating quality measures to the community. CONTACT: Julie Briggs, R.N., M.S.N., Deputy Director ■ of Quality and Patient Safety; (315) 464-6170; The Web site highlights multiple quality ini- [email protected] tiatives, and is consumer-friendly and easy to navigate. PROJECT LESSONS LEARNED DESCRIPTION ■ Upstate University The design and de- velopment of a Hospital developed quality data Web Central Service Nursing Supply Cart a quality of care site must be Revision Web site to provide multidisciplinary. WCA Hospital the community ■ Commit resources with a transparent to the project as CONTACT: Molly Purdy, Senior Central Services and easily under- development, Technician; (716) 664-8162; [email protected] stood source of hos- deployment, and maintenance are pital quality data. labor-intensive. PROJECT Key aspects of this LESSONS LEARNED ■ Ensure the public DESCRIPTION project included: ■ Education and can find the Web To be efficient and reinforcement of ■ multidisciplinary site easily from the effective in patient important informa- hospital home approach to plan, care, appropriate tion is key. design, and page. supplies and equip- ■ Implementation develop the Web ment must be read- was more efficient site; ily available to when completed in ■ commitment to proactively share key quality hospital staff. WCA stages. and safety measures with the community; Hospital identified ■ There will always inefficiencies with be resistance to ■ the Web site contains a Frequently Asked central service change. Questions section, quality of care “snap- 40 HANYS 2010 Profiles in Quality and Patient Safety

supply carts on every nursing unit. Supply carts PROJECT LESSONS LEARNED were dysfunctional, overstocked, not user- DESCRIPTION ■ Passive acknowl- friendly, and compliance with charging supplies Clinical information edgement of data systems address was poor. This led to inconsistent availability of becomes “just an- needed supplies. WCA Hospital developed an many of the safety other screen” for initiative to standardize equipment, supplies, issues identified with the user to get and their location on supply carts. Data were paper processes; through. collected and changes were made, including however, this tech- ■ Adding active par- color-coded categories such as intravenous, nology also creates ticipation forces urinary/output, personal patient care, dressing, new challenges and the user to stop and think before respiratory/vital signs, specimen collection, patient safety con- proceeding, reduc- ulcer prevention, and miscellaneous. cerns. When ing the “robotic” Winthrop-University effect of point-and- Items for each color-coded category are listed Hospital imple- click technology. alphabetically and posted near their respective mented computer- ■ The process must area on the cart. Brightly colored posters detail- ized physician order be changed every ing the color-coded categories are located in the entry (CPOE) in July few months to supply cart area. 2006, it also ad- keep it fresh. dressed the patient OUTCOMES identification policy. ■ Charging compliance increased 5.5%. ■ Efficiency of cart utilization and replenishing Despite careful implementation, there was a rise increased. in wrong patient selection. Investigations re- ■ There is greater availability of nursing sup- vealed the ease with which a provider could un- plies as evidenced by decreased calls for addi- intentionally select the wrong patient, due to tional supplies. distraction or keystroke errors. The verification screen was not enough; providers became “im- ■ This project led to increased communication mune” to the screen and went to the “OK” but- between departments. ton without verifying the information. To ■ The process for rotation of patient care sup- address this, a verification screen was created ply items was improved. that uses visual cues and requires active entry of information. This forces the provider to pause and think before proceeding. The active input portion of the screen is moved to different areas Improving Correct Patient Selection every three months to promote visual stimula- Prior to Order Entry Within an tion and prevent task-oriented behavior. The re- Electronic System sults of this change were dramatic. Winthrop-University Hospital OUTCOMES CONTACT: Maureen Gaffney, R.P.A.-C., R.N., Chief In 2009, through the electronic reporting sys- Medical Information Officer; (516) 663-9606; tem and verbal reports, the hospital learned of [email protected] 37 instances of the wrong patient being selected. After deploying the custom patient verification screen, only one incident of wrong patient selec- tion has occurred. HANYS 2010 Profiles in Quality and Patient Safety 41

PATIENT SAFETY—FALLS

Improve Patient Safety and ■ The hospital created a night shift falls/ Satisfaction Using Restraint restraint committee and developed a Reduction Strategies “Fall Contract” to engage patients in their Franklin Hospital own care. CONTACT: Joan Creighton, R.N., Director, Nursing Quality; (516) 256-6084; [email protected]

PROJECT LESSONS LEARNED Reducing Patient Falls in the DESCRIPTION ■ Hospital Using Bright Yellow Franklin Hospital Staff no longer use restraint as a first Blankets and Non-Skid Socks used the Plan-Do- method for dealing Study-Act (PDSA) Kenmore Mercy Hospital/Catholic Health with difficult pa- System methodology to tient behavior. reduce use of ■ Staff are aware of CONTACT: Laura Verbanic, P.T., C.P.H.Q., Director, restraints by 10% in alternatives to re- Quality and Patient Safety; (716) 447-6252; [email protected] 2009. The initiative straint that are included adherence equally effective, but more respect- PROJECT to internal and LESSONS LEARNED ful and dignified. DESCRIPTION ■ external standards, Recognizing a need Simplicity is key to ■ The night shift ensuring staff par- increased use of to reduce patient falls/restraint com- ticipation and pa- effective alternatives mittee increased falls resulting in tient acceptance of to restraint use, and awareness of alter- injuries, Kenmore the program. documentation sys- natives and em- Mercy Hospital re- ■ Effective communi- powered staff to tems. During the viewed the existing cation among evaluate appropri- “do” phase, a multi- departments ate use of restraints process for identify- disciplinary com- enhances patient to address the ing high-risk pa- safety. mittee focused on higher use of re- tients and found it ■ staff education, doc- straints on evening was complicated Celebrating suc- cess with frontline umentation review, and night shifts. and not routinely staff keeps them and monitoring. followed. Conse- engaged and quently, a simpler motivated. The team analyzed data comparing internal strategy was devel- changes over time and against external bench- oped. Upon admission, patients identified as a marks. Gaps were identified for further quality high risk for falls are now given a bright yellow improvement, and continuous monitoring of lap blanket and bright yellow non-skid socks to patterns, trends, and best practices was initiated. wear throughout their hospital stay. The blanket This enabled the hospital to provide data to the and socks are kept with patients at all times, in- staff, continue to identify exceptions and barri- cluding during transfers between departments for ers, make ongoing improvements, and ultimately testing or rehabilitation. When the patient is in measure success. bed, the blanket is placed on the end of the bed. OUTCOMES The result is a highly visible, less cumbersome ■ Restraint use decreased 22%, while the hospi- system for identifying and carefully monitoring tal increased the use and availability of alter- patients at high risk for falls. In addition, all natives to restraint. 42 HANYS 2010 Profiles in Quality and Patient Safety

associates know that extra precautions must be fell had left-sided LESSONS LEARNED taken and patients are encouraged to take the CVAs, 67% had right- (continued) items when discharged to reduce the likelihood sided CVAs, and 11% ■ Include phenom- of falls at home. had bilateral CVAs. ena such as spatial/ These data led the fa- perceptual control First piloted in January 2009 on a single nursing cility to further study limitations in nurs- unit, the program was launched hospital-wide in right-sided brain in- ing care plans. April 2009 after a hospital-wide education pro- juries and offer an gram. Kenmore Mercy is developing a video to educational program for staff. As a result, celebrate its success and will share it with staff changes were initiated to focus the hospital’s to reinforce this positive outcome. falls prevention program on right-sided brain in- jury patients. OUTCOMES ■ Kenmore Mercy Hospital achieved a 55% OUTCOMES reduction in falls with injury in 2009 com- In one month’s time after initiating the revised pared to 2008. falls prevention program with a focus on right- sided brain injury, Mercy Medical Center’s fall ■ This successful strategy will be implemented rate decreased 27% for this population. across three other campuses in the system.

Acute Inpatient Rehabilitation Unit Restraint Use Reduction Falls Prevention Program Nathan Littauer Hospital and Nursing Mercy Medical Center Home

CONTACT: Margaret Reddan, M.S., R.N., Nurse CONTACT: Cathy Burek, R.N., Manager, Manager, Acute Rehabilitation Unit; (516) 705-6466; Medical-Surgical; (518) 773-5743; [email protected] [email protected] PROJECT LESSONS LEARNED PROJECT DESCRIPTION LESSONS LEARNED ■ DESCRIPTION Nathan Littauer Continuous staff ■ education is neces- In keeping with Use bed and chair Hospital established alarms to address sary to achieve a Mercy Medical a multidisciplinary impulsive behav- positive outcome. Center’s culture of iors in right-sided team, comprised of ■ Patient/family edu- safety, falls preven- brain injury nursing, rehabilita- cation about their tion monitoring led patients. tive medicine, envi- role in patient to a closer look at its ■ Engage all staff to ronmental services, safety is essential. acute inpatient reha- identify right- nutritional services, ■ Communicate and bilitation population. sided brain injury and purchasing staff celebrate successes patients and im- with staff. It was noted that 90% to identify ways to plement patient promote patient of patients who fell falls prevention in December 2009 strategies. safety, enhance the existing Falling Star Program, were cerebral vascular continued next column a patient falls prevention program, and reduce accident (CVA) restraint use, consistent with the hospital’s mis- patients. Twenty-two percent of the patients who sion to provide safe, high-quality care. HANYS 2010 Profiles in Quality and Patient Safety 43

Initiatives included relocation of high-risk pa- Hospital Queens LESSONS LEARNED tients closer to nursing stations and collabora- initiated a program ■ tion with rehabilitative medicine in the use of to identify those at Individualizing preventive inter- appropriate occupational therapies and equip- risk for falls using a ventions to reduce ment. New equipment was purchased, including standardized assess- falls is more suc- beds with alarms to alert staff of patient move- ment tool. Simulta- cessful than a ment. Patient and family education is accom- neously, the facility “one-size-fits-all” plished through written information provided implemented indi- approach. on admission and reinforced throughout the vidualized preven- ■ Creating a hospital- stay by the nursing staff. tive interventions wide symbol for patients at risk of to meet patient- OUTCOMES falls helps height- specific needs. ened awareness of ■ The restraint rate per 1,000 patient days de- patient safety. New York Hospital creased from 15.4 in 2006 to 5.8 in 2009. ■ There is no “cookie Queens realized the ■ The patient fall rate per 1,000 patient days de- cutter” solution for creased from 2.82 in 2006 to .97 in 2009. importance of fos- preventing falls. tering hospital-wide ■ There were no patient injuries in 2009 related understanding of to a fall. the falls reduction program. The “red sock” be- ■ Reducing the use of restraints did not increase came a universal symbol for fall risk because the number of patient falls/injuries. each patient identified as “at risk” wears red, ■ Falls prevention is everyone’s responsibility. non-skid slipper socks, and these patients’ doors Environmental service, rehabilitative medi- and charts bear a picture of red socks. The hospi- cine, and nursing staff were instrumental in tal invested in state-of-the-art patient beds, decreasing the use of restraints. equipped with bed exit alarms, low-bed position features, and pressure redistribution.

OUTCOMES New York Hospital Queens achieved a 32% reduc- Falls Reduction Program— tion in inpatient patient falls between 2008 and An Individualized Approach 2009, and a 28% reduction in inpatient injuries New York Hospital Queens resulting from falls during the same period. CONTACT: Gail Holtz, R.N./N.P., C.R.R.N., M.S.N., M.S., A.C.N.S.-B.C., Performance Improvement Manager; (718) 661-8834; [email protected]

PROJECT DESCRIPTION Patient Safety Without Restraints In the past decade, New York Hospital Queens New York Hospital Queens made incremental strides to reduce the rate of in- CONTACT: Gail Holtz, R.N./N.P., C.R.R.N., M.S.N., M.S., patient falls; then, in 2008, the facility’s falls and A.C.N.S.-B.C., Performance Improvement Manager; restraint committee created a comprehensive (718) 661-8834; [email protected] falls reduction program that positively impacted patient safety and significantly reduced the falls PROJECT DESCRIPTION rate, injuries, and cost. After reviewing medical Although New York Hospital Queens’ patient literature and analyzing its data, New York falls were below National Database of Quality 44 HANYS 2010 Profiles in Quality and Patient Safety

Indicators (NDNQI) ■ professional nurses’ geriatric assessment skills LESSONS LEARNED benchmarks in were enhanced; ■ Patient safety 2008, the facility ■ starts with an idea. hourly rounding was implemented; and wanted to reduce ■ Mittens can be ■ appropriate care is provided for patients at the rate by 30% used to prevent re- high risk for falls. without restraints. moval of medical To accomplish this devices. goal, New York ■ Established prac- Hospital Queens tices do not neces- developed a per- sarily prove to be Feet First: Enhancing a Culture of formance improve- good practices. Safety to Achieve a Reduction in ment program that The medical litera- Patient Falls ture supports use addressed the simul- St. Francis Hospital—The Heart Center of restraints, staff taneous implemen- education, docu- CONTACT: Patricia Lupski, M.S.N., R.N., N.E.-B.C., tation of protocols mentation, obser- Nurse Manager; (516) 277-4910; [email protected] to reduce falls and vation, and PROJECT use of restraints. The allowing the LESSONS LEARNED patient to move DESCRIPTION facility started with ■ Interdisciplinary about at intervals. Although St. Francis a daily surveillance collaboration is a Assessment of Hospital—The Heart highly effective and analysis of alternatives is Center’s patient falls practice for identi- every restraint and required. However, rate in the patient fying learning these steps often patient fall occur- care division is con- opportunities. rence. Once the data distract the care- sistently below the ■ Continuous moni- were gathered and giver from explor- ing new ways to national benchmark toring and commu- analyzed, the hospi- enhance safety. of 3.5 per 1,000 pa- nication is essential tal revised its falls tient days, the hospi- to sustain results. prevention protocols, staff education, rounding tal constantly strives ■ Patient and family behaviors, and supervisory activities. to improve. The tar- participation is es- geted population sential for success. All nursing staff participated and, by the end of consists of many elderly patients who often ex- 2009, New York Hospital Queens decreased its hibit polypharmacy, and frequently use antico- falls by 30% (including falls with injury) while agulants, which could complicate injuries remaining a restraint-free hospital. During the sustained during a fall. first three quarters of 2009, restraint usage fell 90% below NDNQI benchmarks and the falls The innovative process developed to reduce falls rate remained more than 50% below NDNQI incorporates a multifaceted approach: benchmarks. ■ A risk assessment tool is completed every 12 hours, requiring clinical nurses to score pa- OUTCOMES tients on their gait, mental status, falls history, New York Hospital Queens achieved the use of narcotics/sedatives, hemodynamic sta- following: tus, and other factors. A score of <18 indicates ■ the falls rate was reduced below NDNQI the patient is at high risk for falls. benchmarks without the use of restraints; ■ The falls prevention program emphasizes ap- propriate interventions. The prevention plan HANYS 2010 Profiles in Quality and Patient Safety 45

of care lists nursing interventions categorized committees were created to redesign the falls as Functional, Equipment, Education, and assessment and educate employees. Education Toileting (FEET). targeted the importance of patient assessment ■ Upon admission, patients and families partner and available interventions. Nursing documenta- with staff and receive a falls contract, which tion was monitored for compliance with the remains posted on patients’ bulletin boards assessment and results were shared with nursing for the duration of hospitalization. units. ■ In the event of a patient fall, an interdiscipli- In addition, St. Joseph’s Hospital: nary team meets to analyze contributing fac- ■ tors and develop an action plan to prevent purchased additional bed alarms and wander further occurrences. guards; ■ placed falls prevention posters in all patient OUTCOMES care rooms; In 2009, the rate of falls was 1.0 per 1,000 pa- ■ placed “falling star” posters on patient doors tient days, down from 1.2 per 1,000 patient days to identify high-risk patients; in 2008. ■ required low beds and fall mats for patients identified as at highest risk for falls; ■ educated families about the need to inform Falls Prevention—Methodology and staff if a patient is at high risk for a fall; and Initiative ■ redesigned occurrence reports to include fac- St. Joseph’s Hospital, Elmira tors contributing to the fall, and post-fall interventions. CONTACT: Mary Vosburgh, M.S.M., B.S.N., R.N., Vice President, Nursing; (607) 733-6541; OUTCOMES [email protected] ■ St. Joseph’s Hospital achieved a 25% decrease PROJECT in patient falls in 2009. LESSONS LEARNED DESCRIPTION ■ There is increased awareness by all about ■ Communication St. Joseph’s Hospital those at risk for falls. and reinforcement restructured and of potential risks ■ Families are more informed of the measures reevaluated acute for patient falls implemented to protect patients. inpatient patient helped all disci- ■ Medical rounds for patients include the ques- falls prevention plines improve tion, “Is there anything I can do for you?” strategies after a safety measures spike in reported specific to the patient. falls in September ■ All patients, re- 2008. This included gardless of age, revamping nursing need to be as- assessment on ad- sessed for fall risk. mission and post- ■ Remembering the fall, modeled on the “3 Ps” (position- Sparrow Hospital ing, pain, and Falls Prevention “pottying”) helps Program. Several decrease falls. 46 HANYS 2010 Profiles in Quality and Patient Safety

Falls Prevention Intervention OUTCOMES Program ■ The rate of patient falls decreased below the United Memorial Medical Center benchmark average of 3.14 falls per 1,000 pa-

CONTACT: Daniel P. Ireland, B.S.N., M.B.A., tient days as published by the Maryland Indi- Vice President of Operations; (585) 344-5345; cator Project, and has been maintained. [email protected] ■ The hospital has become a safer place to work and visit. PROJECT LESSONS LEARNED DESCRIPTION ■ The compliance rate shows that staff success- ■ In 2009, United Hourly rounds fully adapted to the new policies and were the most Memorial Medical procedures. challenging Center determined change for staff, ■ Letters from the community confirm that that its patient falls but with persist- United Memorial Medical Center has prevention program ence, they accli- advanced quality of care. did not meet the mated to this desired level of process. quality. After re- ■ A hospital environ- ment is always searching various evolving and it is policies and gather- important for poli- ing organizational cies and proce- input, the facility dures to adjust. developed a new ■ Visual cues are im- policy and proce- portant risk identi- dure. Hourly nurs- fiers for staff and ing rounds were patients. established, which increased communication between staff and pa- tients and reduced the number of times patients get out of bed by themselves, thereby reducing the chance of a fall. Risk assessments using the Morse Fall Scale were used to identify high-risk patients. The organization added identifiers such as pictures of waterfalls and purple wristbands for patients at high risk for falls, which im- proved communication across medical disci- plines. Bed checks are used to warn staff about high-risk patients who may attempt to get out of bed without assistance. The key to United Me- morial Medical Center’s success is persistence. Staff and patients continuously communicate with one another to inform each other of their needs. HANYS 2010 Profiles in Quality and Patient Safety 47

PATIENT SAFETY—INFECTION MANAGEMENT

Reduce Surgical Site Infections ■ Incision and deep incision infection rates de- Adirondack Medical Center creased 50%. ■ CONTACT: Arthur Handley, R.N., Director, Statistics demonstrate improved processes Perioperative Services; (518) 897-2720; and consistency in practice. [email protected]

PROJECT LESSONS LEARNED DESCRIPTION ■ Adirondack Medical Increasing and sus- Prevent Catheter-Associated Urinary taining staff edu- Center implemented Tract Infections cation supports a comprehensive success. Beth Israel Medical Center surgical site infec- ■ Staff involvement CONTACT: Brian S. Koll, M.D., F.A.C.P., Hospital tion reduction pro- is essential to suc- Epidemiologist, Medical Director and Chief, Infection gram that included: cessful system/ Prevention; (212) 420-2853; [email protected] methodology re- ■ revamping flash view and revision. PROJECT sterilization in LESSONS LEARNED ■ Communicating DESCRIPTION the operating ■ Involvement of desired goals and Catheter-associated room (OR), in- frontline champi- outcomes is urinary tract infec- ons to assist in risk cluding revising essential. tions (CAUTIs) are assessment, de- flash sterilization the most common velop educational log sheets, edu- hospital-acquired tools, and monitor cating OR staff, purchasing new instrumenta- infection (HAI), and outcomes allowed tion, monitoring, and assigning personnel to are the leading staff to take own- facilitate sterilization processes in the OR suite; ership of the pro- cause of secondary gram, change the ■ increasing the percentage of pre-operative an- hospital-acquired culture, and tibiotics started within 60 minutes of incision bloodstream infec- achieve success by implementing a collaborative process, in- tions. Beth Israel without the need cluding a revised OR nurse circulator process, Medical Center for additional synchronized digital clocks, and documenta- conducted a risk resources. tion of anesthesiology administration; and assessment that ■ Support from sen- ior leadership, in- ■ hand hygiene education for staff and patients; determined inten- cluding the board and the use of a hand hygiene “superteam” sive care units of trustees, was convened to advance health care worker com- (ICUs) were the pri- equally important pliance. Pamphlets were given to patients and mary at-risk areas. in effecting families and hand hygiene was reinforced Multidisciplinary change. during pre-operative teaching. CAUTI teams were ■ Timely feedback formed, led by was important in OUTCOMES frontline physician, rapidly effecting and sustaining ■ Flash sterilization usage was reduced 85%. nursing, and CAUTI reductions. ■ The surgical site infection rate declined from transporter infec- 1% in 2008 to 0.8% in 2009, a 20% reduction. tion prevention “champions” in the ICUs. After achieving initial 48 HANYS 2010 Profiles in Quality and Patient Safety

success in three ICUs, the project expanded “All Hands on Deck” Infection throughout the facility. Awareness: Embracing a Culture of Safety Starting in 2008, the CAUTI teams implemented Canton-Potsdam Hospital programs, practices, and interventions using the Plan-Do-Study-Act (PDSA) methodology, CONTACT: Rebecca Sutcliffe, Ph.D., Vice President, Corporate Communications; (315) 261-5401; including: [email protected] ■ staff education through computer-based, self- PROJECT learning modules and a test developed by the LESSONS LEARNED champions on catheter use, insertion, and DESCRIPTION ■ Canton-Potsdam An open mind can maintenance; make a big differ- Hospital initiated a ■ daily assessment of the need for a urinary ence when effect- comprehensive catheter with removal during multidisciplinary ing change in a antimicrobial stew- rounds, and use of automatic stop orders; surgical ardship program environment. ■ involvement of materials management staff to after senior leader- ■ A multifaceted ap- ensure availability of correct catheter inser- ship noted unaccept- proach works bet- tion kits on each unit; able infection rates. ter than imple- menting initiatives ■ feedback and monitoring of CAUTI rates and The hospital’s patient individually. catheter usage; and safety director and ■ Surgical site infec- ■ infection prevention root-cause analyses for CAUTIs. tions can be re- officer led a task OUTCOMES duced when force comprised of teamwork is a criti- ■ Appropriate indication for urinary catheters key frontline staff cal component of increased from 83% to 100%. from across the the project and the same staff are as- ■ Urinary catheter duration decreased by three organization. They signed to these days and utilization decreased from the 64th implemented auto- cases. percentile to the 55th percentile when com- mated screening pared to National Healthcare Safety Network systems, improved hospital statistics. signage, educated non-clinical staff on their role, ■ The number of CAUTIs decreased 83% and and held education sessions for the entire staff the rate decreased from 4.6 to 0.5 per 1,000 and physicians. catheter days. Infection rates subsequently plummeted. The ■ Sixty-six percent of patient care areas main- hospital went eight consecutive months without tained a zero CAUTI rate after six months. a hospital-acquired C-difficile infection and had only one case in 2010 to date. The one case was thoroughly investigated and results shared widely; staff interviewed the patient and traced room assignments to identify the cause. The hospital instituted the program as part of its ori- entation for new employees and newly affiliated physicians. Sharing incidence of cases, reporting investigation results, and widely sharing best HANYS 2010 Profiles in Quality and Patient Safety 49

practices across the organization encouraged a A CLABSI reduction team was formed with VAT preventive, rather than compliance-oriented, members and infection prevention, critical care, approach to infection prevention. and oncology staff. Initial changes to the care and maintenance of central lines included insti- OUTCOMES tution of standardized dressing changes, stan- ■ In 2008, the hospital had 18 cases of hospital- dardized insertion kits, a Chlorhexidine acquired C-difficile; in 2009, 14; and year-to- impregnated disk at the insertion site, and a date for 2010, only one. “Save That Line” campaign focused on provid- ■ Hospital-acquired Methicillan-resistant ing simple strategies to improve compliance. Staphylococcus aureus dropped from five cases in 2009 to zero cases year-to-date in 2010. The team expanded on the Institute for Healthcare Improvement (IHI) “bundle,” initi- ated in 2005, with daily attention for patients with central lines, consistent care, and mainte- nance by a core group of nurses certified in vas- A Vascular Access Team Reduces cular access. Daily practice includes timely CLABSIs in Critical Care Units dressing changes, rounds, timely and appropri- Faxton-St. Luke’s Healthcare ate end-cap changes, and review of necessity. CONTACT: Heather L. Bernard, R.N., B.S., C.I.C., Infection Prevention Manager; (315) 624-6334; OUTCOMES [email protected] ■ This program resulted in a 73% reduction of CLABSI incidence between 2008 and 2009. PROJECT LESSONS LEARNED The 2008 rate was 2.76 infections per 1,000 DESCRIPTION ■ device days; the 2009 rate was 0.73 infections In 2008, the inci- A small, core group of nurses with a per 1,000 device days. dence of central primary focus on ■ There were zero CLABSIs between May and line-associated evidence-based November 2009 institution-wide, with an bloodstream infec- central line care tion (CLABSI) at can improve average of 12,000 line days per year. Faxton-St. Luke’s outcomes. Healthcare in- ■ Consistent round- creased, making it a ing and daily at- tention to lines priority for infec- Journey to Zero Nosocomial improves tion prevention. The outcomes. Infections facility instituted a ■ A VAT can be cost Glen Cove Hospital vascular access team effective in many CONTACT: Darlene Parmentier, R.N., M.S.N./M.B.A., (VAT) that uses best ways. Nurse Manager, Critical Care/Telemetry; practices to improve (516) 674-7794; [email protected] patient outcomes. Formed in 2009, the team proactively assesses pa- PROJECT DESCRIPTION tients who will be receiving long-term or high- Every year, approximately two million people risk intravascular medications. VAT also tracks develop central line infections resulting in quality markers to assess program effectiveness. increased costs, and more importantly, in- creased morbidity and mortality. Glen Cove Hospital recognized an opportunity for 50 HANYS 2010 Profiles in Quality and Patient Safety

improvement in Reducing Hospital-Acquired LESSONS LEARNED 2005 when its Catheter-Associated Urinary Tract central-line associ- ■ It is important to review the neces- Infections ated bloodstream sity of central lines Good Samaritan Hospital/Bon Secours infection (CLABSI) with daily multi- Charity Health System rate in critical care disciplinary CONTACT: Susanne Z. Stone, B.S.N., R.N., C.I.C., was 6.5/per 1,000 rounds. Infection Prevention and Control Director; line days. Glen ■ Staff must be (845) 368-5538; [email protected] Cove Hospital used empowered to Root Cause achieve culture PROJECT LESSONS LEARNED Analysis and change. DESCRIPTION ■ Failure Mode and ■ Strong leadership Good Samaritan Practical initia- tives, such as a Effects Analysis participation is Hospital focused on pre-packaged bath methods to iden- necessary to facili- the relationship be- product to cleanse tify issues and to tate change. tween pre-packaged patients, in addi- prioritize and mod- bath products and tion to compliance ify practices. Changes in culture and practice infections. Many with the urinary led to excellent outcomes, improved patient studies have shown catheter bundle, safety, decreased length of stay, and cost proved useful in that prepackaged avoidance. reducing CAUTIs. bath products de- ■ Staff accepted this OUTCOMES crease infection bathing product as rates in hospitalized ■ 812 CLABSI-free days as of March 15, 2010; a superior method patients. The facil- for reducing bacte- ■ heightened staff awareness of a culture of ity successfully rial load for bed- safety; prevented catheter- bound patients ■ and decreasing the staff recognition that CLABSIs are preventa- related urinary tract ble and unacceptable; potential for infections (CAUTIs) infection. ■ sustained improvements in hand hygiene; through adherence ■ Ease of use drives ■ increased compliance in use of personal pro- to urinary catheter increased staff tective equipment; “bundles,” with the compliance. ■ adherence to the Institute for Healthcare additional interven- Improvement CLABSI prevention “bundle”; tion of daily bathing with prepackaged bath and products. A significant reduction in hospital- ■ increased staff pride. acquired CAUTIs occurred during the six-month study, compared with the prior six-month period measured. This direct improvement was observed after two adult medical/surgical units switched to the prepackaged bath products and required daily baths for all bed-bound patients on these units.

OUTCOMES ■ The facility experienced 3.5 CAUTIs per 1,000 catheter days pre-study, versus 0.5 CAUTIs per HANYS 2010 Profiles in Quality and Patient Safety 51

1,000 catheter days during pre-packaged bath change. Members of the patient care team were product use. assigned different tasks to decrease the inci- ■ Ten CAUTIs were avoided, saving $30,000. dence of Clostridium difficile. OUTCOMES ■ The nosocomial Clostridium difficile rate for 2007 was 1.50 per 1,000 patient days, com- Using a Multidisciplinary Team pared to 1.82 per 1,000 patient days in 2008, Approach to Reduce Nosocomial with a high monthly rate of 3.22 observed in Clostridium Difficile the first quarter of the year. Year-to-date in Long Island Jewish Medical Center 2009 (post-implementation), the rate was 0.87 CONTACT: MaryAnn Haran, R.N., Manager, per 1,000 patient days. Epidemiology; (718) 470-7532; [email protected] ■ In the medical/oncology units, the pre- initiative nosocomial Clostridium difficile rate PROJECT LESSONS LEARNED DESCRIPTION was 1.857 cases per week, with a seven-week ■ post-initiative rate of 0.125 cases per week. North Shore-Long Establish a collabo- rative, interdiscipli- Island Healthcare nary approach to System’s priority identify barriers quality goal is to re- and share owner- duce preventable ship of the A Multidisciplinary Approach to harm. At an individ- initiative. Reducing Surgical Site Infections in ual hospital site, ■ Communication of Coronary Bypass Patients rising rates of simple process The Mount Sinai Medical Center changes is key to Clostridium difficile getting “buy-in,” CONTACT: Bruce Darrow, M.D., Ph.D., Assistant prompted a quality compliance, and Professor, Director of Telemetry Services, Chair, Mount improvement initia- sustainability from Sinai Heart Performance Improvement Committee; (212) 241-8544; [email protected] tive. Members of the staff. interdisciplinary ■ Real-time data col- PROJECT DESCRIPTION team created a lection, analysis, Cardiothoracic surgeons at The Mount Sinai Best Practice Manual and education of Medical Center perform about 450 coronary both staff and visi- for Prevention artery bypass graft (CABG) operations annually. tors are key. and Control of The 30-day thorax surgical site infection rate Transmission of was 4.6% in 2007, 4.7% in 2008, and 6.3% the C Diff. The team used a number of key initia- first seven months of 2009. The state average tives including proper isolation and training 40 and benchmark for this measure in 2009 was staff members as infection prevention coaches 2.1%. A multidisciplinary committee was who “spread the word” about best practices to formed and targeted: decrease transmission of all infections. As part ■ hair removal and skin preparation; of the larger initiative, a 39-bed medicine/ ■ sterilization of the surgical site in the operat- oncology nursing unit formed an interdiscipli- ing room; nary team for a collaborative approach to this ■ antibiotic administration timing; problem. Rapid hypothesis testing with real- ■ scrub, wound irrigation/closure, and time analysis of data (weekly) by frontline staff gown/glove practice; helped to illustrate the results and quickly effect 52 HANYS 2010 Profiles in Quality and Patient Safety

■ operating room Employee Health Seasonal and H1N1 LESSONS LEARNED sterility and Influenza Vaccination Initiative cleaning between ■ A multidisciplinary approach to reduc- New Island Hospital operations; and ing surgical infec- CONTACT: Barbara A. Smith, R.N., L.N.C., Director, ■ wound covering tion can be highly Performance Improvement and Risk Management; and post- and immediately (516) 520-2371; [email protected] operative care. effective. ■ PROJECT Successful inter- LESSONS LEARNED The initiative began ventions relied DESCRIPTION ■ in June 2009 with more on adherence New Island Hospital Ongoing staff edu- cation and senior an analysis of pub- to standardized approached its an- practices than to staff vaccination licly reported data. nual employee in- high-technology (leading by exam- In July, the team solutions. fluenza vaccination ple) remove barri- met, presented, and program with re- ers to vaccination. ■ Public reporting of discussed cardiotho- data can be a newed passion in ■ The Push POD racic surgeon strong stimulus for 2009 because of the methodology in- rounds, with follow- quality improve- recent outbreak of creased access to influenza vaccina- up; and a draft ment initiatives. H1N1 influenza action plan was tion for patient and anticipation of developed and dis- care staff. seasonal influenza tributed. The plan was finalized and implemented ■ Weekly communi- prevalence. Using in August, with results and enhancements in cation of depart- the hospital’s mental vaccina- January 2010. “Emergency Pre- tion compliance OUTCOMES paredness Point of rates facilitated the process. Data were analyzed for seven months before and Distribution (POD) six months after the intervention. The average Plan for the Mass number of CABG operations per month was the Distribution of Medications/Vaccinations to same before and after the intervention (36 per Employees and their Immediate Family,” New month). Results included: Island Hospital launched its influenza vaccina- ■ the number of total thorax infections de- tion program on September 24, 2009. The initial creased from 16 to 5; POD vaccinated 446 of 840 employees (53%). To ■ the infection rate decreased from 6.3% to facilitate further employee vaccination, espe- 2.3%; cially of direct patient caregivers, a “Push” POD methodology (vaccinating directly on the units) ■ deep infections (involving the sternum or vis- was used. The second phase of this H1NI initia- ceral organ space) decreased from nine to three; tive was launched on November 11, 2009 with the hospital president receiving the vaccination ■ the deep infection rate decreased from 3.6% at a hospital-wide meeting. to 1.4%; and ■ about seven infections (including five deep OUTCOMES infections) were prevented over six months. ■ Ninety-two percent of employees (or 769 of 840) were vaccinated against seasonal influenza. HANYS 2010 Profiles in Quality and Patient Safety 53

■ Thirty-five percent (295) of employees were It includes a physician education program, a vaccinated against H1N1 influenza. prospective audit of all antibiotic use, and, as ■ Eight percent (71) of employees declined in- necessary, recommendations to the prescriber. fluenza vaccination in writing. These recommendations included changing the antibiotic, de-escalation, dose optimization, dis- ■ Thirty-eight hospital volunteers and members continuation, and switching from intravenous of the voluntary medical staff were provided to enteral administration. Improvements in influenza vaccination. length of stay (LOS) and decreased antibiotic days serve as the measurements of the efficacy of this program.

Improving the Quality of Patient OUTCOMES Care Through an Antimicrobial New York Hospital Queens achieved the follow- Management Initiative ing results: New York Hospital Queens ■ significant discontinuation of antibiotics (59.9%); CONTACT: Deborah Figueroa, B.S., Pharm.D., Infectious Disease Clinical Pharmacist; (718) 670-2586; ■ no recurrence of infection or readmission [email protected] among patients where discontinuing antibi- otic was recommended; PROJECT LESSONS LEARNED DESCRIPTION ■ decreased LOS to an average of 4.8 days per ■ New York Hospital Combating central patient; line infections is Queens’ surveil- ■ antibiotic use decreased by 5.2 days per not just a critical lance showed that care problem. patient; 50% of admitted pa- ■ Implementing a ■ hospital-acquired Clostridium difficile de- tients receive antibi- checklist to reduce creased 25%; and otics at some point central line infec- ■ mortality rates among patients were reduced during their hospi- tions has a signifi- 50% where the recommendation was accepted. talization. Examina- cant positive impact. tion of antibiotic ■ utilization revealed Ongoing monitor- ing of outcomes that often these an- and process com- Improving Health Care Worker tibiotics are unnec- pliance is critical to essary or are not success. Hand Hygiene Compliance in an used optimally. The Intensive Care Unit hospital data high- North Shore University Hospital lighted high rates of Clostridium difficile infec- CONTACT: Donna Armellino, R.N., D.N.P., C.I.C., tions and the presence of multi-drug resistant Director, Epidemiology; (516) 562-3573; organisms (MDROs). The primary goal of this [email protected] initiative was to optimize clinical outcomes PROJECT DESCRIPTION while reducing the risk of toxicity and MDROs. In March 2008, North Shore University Hospital The initiative is a collaborative effort including a placed video cameras with views of every sink clinical pharmacist, infectious disease physicians, and hand sanitizer dispenser in hallways and pa- a microbiologist, and infection preventionists. tient rooms to record hand hygiene compliance. 54 HANYS 2010 Profiles in Quality and Patient Safety

Sensors mounted in Decreasing Incidence of Upper LESSONS LEARNED doorways identified Extremity Deep Venous Thrombus ■ when health care Remote video au- diting without Plainview Hospital workers entered or feedback does not CONTACT: Laura Tafone, R.N., B.S., M.B.A., exited, indicating significantly Supervisor, Quality Management; (516) 719-2514; hand hygiene change hand hy- [email protected] events. When video giene compliance. ■ PROJECT auditors observed Video cameras and LESSONS LEARNED health care workers continuous feed- DESCRIPTION ■ The size of the using the hand sani- back produced a Peripherally inserted significant and sus- PICC lumen can tizer dispenser or central catheters tained improve- contribute to the (PICCs) are conven- washing hands with ment in hand development of an soap and water, they hygiene ient, safe, and cost- UEDVT. assigned a “pass” to compliance. effective in both the ■ Inserting a catheter the event. Auditors ■ Sustained hand hy- inpatient and outpa- tip into the axillo- reported a “fail” giene compliance tient settings. The subclavian or in- nominate vein is when they observed may have a tempo- incidence of PICC associated with a the practice not ral association usage has increased with fewer health higher incidence of being performed. dramatically over the care-acquired UEDVT. years. Plainview Four months of infections. ■ Utilizing a double baseline rates for Hospital focused its lumen catheter in- hand hygiene compliance were recorded, and on efforts and strategies stead of a triple October 6, 2008 the results of the audits were on preventing upper can decrease the incidence of cen- displayed on two electronic boards visible to all extremity deep-vein thrombosis (UEDVT) tral line blood- staff in the unit. The results were updated every stream infections. ten minutes with current shift, weekly, and in those patients who monthly rates. Unit managers also received have indwelling PICC e-mailed summaries delineating shift, weekly, lines. A proactive risk assessment determined and monthly rates. Leadership responded to low the PICC process needed improvement. A multi- rates of hand hygiene compliance largely on an disciplinary team was established and included aggregate basis, but coached individuals as representation from physicians, nurses, radiol- needed. Hand hygiene compliance increased and ogy, and quality management departments. has been sustained. Improvements to the PICC process included establishing The Joint Commission’s 2010 OUTCOMES Patient Safety Goal requirements for central ■ With continuous real-time feedback, hand venous catheters, a re-design of the organiza- hygiene exceeded 85.7%, for 14 months. tion’s current PICC process, reinforcement of ■ The weekly compliance rate for physicians proper PICC care, recommendations for PICC (70.5%) was lower than that of other health insertions, and process improvements. These care providers (87.4%). strategies led to a major reduction in the devel- opment of UEDVTs, and decreased the number ■ Rates during the day shift (81.9%) were lower of central line bloodstream infections. than during the night shift (88.4%). HANYS 2010 Profiles in Quality and Patient Safety 55

OUTCOMES OUTCOMES LESSONS LEARNED ■ The number of PICC UEDVTs decreased from ■ Compliance with ■ Consistency in 26 in 2008 to four in 2009. core measures in- follow-up was ■ Compliance with completion of PICC con- creased from improved by incor- sents improved from 61% in May 2009 to 87% to 92% for porating tracking into the medica- 98% in August 2009. pneumococcal vaccine and from tion administration ■ There was a significant decrease in the num- record. 76% to 97% for ber of PICCs inserted, from 902 in 2008 to ■ The success of this seasonal in- 677 in 2009. program de- fluenza vaccine. pended on an ef- ■ Revision of the PICC checklist and PICC inser- ■ The hospital de- fective system for tion note improved compliance with comple- veloped informa- “hard-wiring” tion of the catheter insertion note: from 17% tional text alerts communication in May 2009 to 98% in August 2009. between depart- placed on the ments and external medication ad- caregivers. ministration ■ Involving medical, record by the nursing, and phar- Using the Medication Administration pharmacist to as- macy “champions” Record to Improve Immunization sist in communi- assured a success- Rates cating and ful outcome. Putnam Hospital Center tracking immu- Contact: Alfred Dioguardi, R.Ph., M.H.A., Director of nization status throughout the patient stay. the Pharmacy; (845) 279-5711 ext. 3833; ■ A standing vaccination order and pre-printed [email protected] order form were implemented. PROJECT DESCRIPTION Putnam Hospital Center undertook an initia- tive to improve pneumococcal and influenza immunization rates, which were 87% and 76%, Hardwiring Patient Safety: respectively, in 2007. A screening mechanism Eliminating Health Care-Acquired was developed to identify patients who met the Infections criteria for immunization. This led to the devel- Rochester General Health System opment of a protocol for assessment and stand- CONTACT: Linda G. Nicholson, R.N., M.S., C.N.A.A., ing orders. This protocol approved by the B.C., Vice President for Clinical Excellence; (585) 922-4231; [email protected] medical staff allows the vaccine to be given by nursing staff based on the results of the assess- PROJECT DESCRIPTION ment process. The assessment information is By aligning goals to eliminate health care- transcribed to the medication administration acquired infections (HAIs) and by linking these record by the pharmacist and serves as a flag goals to performance measurement and compen- for the nursing staff, telling them to proceed sation, Rochester General Health System was able with immunization if indicated, or not if to achieve rapid, significant reductions in health contraindicated. care-acquired infections. The organization estab- lished a system-wide goal requiring 80% of all 56 HANYS 2010 Profiles in Quality and Patient Safety

affiliate-specific in- Reducing Infections in the LESSONS LEARNED fection prevention Orthopedic Total Hip and Total Knee ■ goals to be met. Unit goals must be linked to the per- Arthroplasty Population Each affiliate evalu- formance of each Rochester General Health System ated its annual data unit to be CONTACT: Doreen Baldasarre, R.N., B.S.N., Nurse to identify specific meaningful. Manager, Orthopedics; (585) 922-3575; infections or ■ Clinical and non- [email protected] processes affecting clinical area goals PROJECT HAIs and with sup- can be specific to LESSONS LEARNED one’s work, yet DESCRIPTION port of system ■ align to clinical sys- Recognizing the need A multidisciplinary “champions,” devel- approach ensures tem goals. to decrease post- oped challenging protocol compli- ■ Data must be stan- improvement goals operative infections ance and encour- dardized and in orthopedic total ages staff specific to address transparent to all joint patients, participation. each issue. Many af- leaders. Rochester General ■ filiates set goals to Standardization Hospital convened a of processes im- decrease specific HAI rates. For example, the be- multidisciplinary proved clinical out- havioral health network focused on hand hy- clinical group to de- comes for patients. giene and employee influenza immunization velop and implement ■ Hardwiring proto- rates. Departments such as housekeeping and di- an aggressive cols and pathways etary identified process improvements such as infection control into day-to-day work helps im- isolation practices and cleaning techniques. plan, including prove patient Methicillan-resistant Progress toward these goals is measured accord- safety and clinical Staphylococcus aureus outcomes. ing to pre-determined scales linked to compen- (MRSA). sation. Monthly scorecards and 90-day action plans were used to support and align leadership The infection reduction plan was implemented and resources within the system. on April 1, 2009 and requires all orthopedic sur- gery patients are nasally cultured for MRSA col- OUTCOMES onization prior to or upon admission for ■ The system achieved 86% of all the affiliate- orthopedic services. Colonized patients are specific infection-related goals, exceeding its placed on “contact isolation” to prevent trans- target by 6%. mission. Patients are also nasally cultured for ■ Five of seven affiliates met at least 80% of MRSA on discharge day. All orthopedic patients their work unit goals. receive Mupirocin nasally twice each day until discharge, with elective patients receiving their ■ Thirty-six of the 42 unit infection control first dose on the morning of their surgery. goals were met. Elements of environmental planning included appropriate placement of alcohol hand gels, dis- infectant wipes in each room and on portable equipment, designated thermometers for each patient unit, and Chlorhexadine pre-operative skin preparation cloths both the night before and morning of surgery. HANYS 2010 Profiles in Quality and Patient Safety 57

OUTCOMES orders. Upon completion, staff returned to nor- ■ By the fourth quarter of 2009, compliance mal operations, were redeployed, and an evalua- with Mupirocin administration and MRSA tor was assigned to analyze the process and swabbing reached 90%. assess inventory management. In addition, inter- nal and external site security and communica- ■ Zero MRSA infections in orthopedic total tion functions such as barriers, radios, and joint surgical patients were reported between signage were reviewed. March 2009 and March 2010. ■ The hospital saved $50,000 for each MRSA OUTCOMES infection avoided in orthopedic total joint ■ Out of a pool of about 3,000 eligible people, surgery patients. 1,202 participants were vaccinated during a 12-hour period. ■ On average, the vaccination process took 6.4 minutes, from the time an individual arrived Hospital Point of Dispensing Exercise at the registration station until he or she to Test Response to a Public Health exited. Emergency ■ Appropriate vaccination strategies were imple- St. Elizabeth Medical Center mented in a timely manner upon onset of the CONTACT: Filomain Talerico, R.N., B.S., M.S., Trauma event (just-in-time training). and Emergency Preparedness Coordinator; ■ (315) 734-3097; [email protected] Quick and efficient vaccine administration re- sulted in short wait times.

PROJECT ■ LESSONS LEARNED Security and access controls were very DESCRIPTION effective. ■ St. Elizabeth Activation of the hospital incident Medical Center exe- command system cuted a unique plan helped ensure ef- to meet seasonal fective manage- Reducing Hospital-Acquired influenza manage- ment of the Infections in the Intensive Care Unit ment and mass program. by Using Chlorhexidine Bathing and emergency objec- ■ The location of the Oral Rinse tives. The organiza- vaccination site played an impor- St. Elizabeth Medical Center tion coordinated a tant role in effec- CONTACT: Linda Kokoszki, R.N., B.S.N., C.I.C., mass prophylaxis tive and efficient program that in- Director, Infection Prevention; (315) 798-8100; management and [email protected] cluded direct mail- distribution of ings to target prophylaxis. PROJECT DESCRIPTION populations, staff ■ It is important to St. Elizabeth Medical Center’s medical-surgical include a mental education, patient and cardiothoracic intensive care units (ICUs) screening and docu- health team in the vaccination pro- have made reducing hospital-acquired infections mentation, and ad- gram to address (HAIs) a priority for many years. However, results ministration of psycho-social have not been consistent. When bathing with vaccine through issues. chlorhexidine (CHG) exclusively became a rec- standing medical ommended treatment in 2009 for ICU patients, 58 HANYS 2010 Profiles in Quality and Patient Safety

St. Elizabeth Reducing Surgical Site Infections LESSONS LEARNED Medical Center con- After Knee and Hip Replacement ■ ducted a trial to de- Patients were satis- fied with the Surgery termine if reducing cloths and did not St. Elizabeth Medical Center skin and mouth miss soap and CONTACT: Linda Kokoszki, R.N., B.S.N., C.I.C., flora would de- water baths. Director, Infection Prevention; (315) 798-8100; crease the incidence ■ Surveillance and [email protected] of HAIs. Starting in feedback to staff is PROJECT June 2009, CHG critical to sustain LESSONS LEARNED cloths and mouth results. DESCRIPTION ■ An open mind can ■ VAP and CLABSI Recognizing the rinse were added to make a big differ- rates fell after im- devastating and patients’ oral care ence when effect- plementing CHG regimen and admin- costly impact of ing change in hygiene into the surgical site infec- a surgical istered every 12 patient care tions in patients atmosphere. hours (oral care regimen. without CHG is ad- undergoing knee ■ A multifaceted ap- proach works bet- ministered every four hours). The facility com- and hip replace- ment, St. Elizabeth ter than imple- pared the incidence of hospital-acquired menting initiatives Medical Center ventilator-associated pneumonia (VAP) and individually. implemented a central line-associated bloodstream infection ■ A team-based ap- “bundle” approach (CLABSI) before and after the intervention. proach to infection to eliminate infec- control is critical OUTCOMES tions, reduce length for success. ■ Overall, ICU HAIs decreased 9% in the three of stay, and improve months following the introduction of CHG overall outcomes. The orthopedic team initiated compared to the preceding three months, evidence-based standards and innovative with the number decreasing from 32 to 29. technology including active pre-operative cul- ture surveillance for Methicillan-resistant ■ Overall, VAP decreased 81.8%, from 11 cases Staphylococcus aureus (MRSA) for all patients; in 2008 to just two the following year. nasal administration of Mupirocin for those ■ Overall, CLABSI in the ICU decreased 57.1% with positive cultures; substitution of Van- in 2009, from seven cases in 2008 to three comycin for pre-operative antibiotic for these the following year. patients; isolation upon admission to minimize ■ HAIs caused by Methicillan-resistant transmission between patients in the unit; use Staphylococcus aureus (MRSA) decreased 83% of Chlorhexidine cloths for pre-operative skin in the ICU, from six in 2008 to one in 2009. preparation the evening before and morning of surgery; and application of Nanocrystalline sil- ver dressings on all incisions. Antibiotic bone cement with Tobramycin was used for patients undergoing total knee replacement.

Electronic surveillance alerts infection control staff to reportable infections and enhances feed- back to surgeons and staff to sustain results. HANYS 2010 Profiles in Quality and Patient Safety 59

OUTCOMES patients per year, LESSONS LEARNED ■ with a potential St. Elizabeth Medical Center significantly re- ■ cost savings of Increased staff duced the surgical site infection rate for hip awareness results $36,000 per pre- replacement surgery (from 3.3% in 2004 to in early zero in 2007, 2008, and 2009). vented hospital- recognition. acquired MRSA ■ The overall infection rate for knee and hip re- ■ Continuous feed- infection. placement surgery decreased from 1.6% in back, information sharing, and real- 2004 to 0.3% in 2009 (zero in 2008). Early identification time audits con- ■ No wound infections caused by MRSA were and isolation of tribute to a sense reported after the bundle was implemented in MRSA carriers and of staff ownership and pride in the 2007. isolation of these program results. ■ Average length of stay was reduced by 1.05 patients reduces ■ Staff made real transmission to days for this population. progress in “break- ■ More than $250,000 was saved between 2006 other patients. The ing old habits” re- and 2009. screening program garding specific also increased isolation tech- awareness and com- niques and gained pliance with stan- a better under- standing of MRSA dard hygiene Meeting Methicillin-Resistant transmission measures such as Staphylococcus Aureus Head-On routes. hand disinfection, St. Mary’s Hospital isolation, and appropriate use of personal CONTACT: Patricia Streeter, R.N., C.I.C., Infection protective equipment (PPE). Preventionist; (518) 841-3826; [email protected] OUTCOMES PROJECT DESCRIPTION ■ The hospital-acquired MRSA rate before pro- In 2007, St. Mary’s Hospital saw a remarkable gram implementation (January 2005 - Octo- increase in both community and hospital- ber 2007) was 3.66 per 1,000 discharges. acquired Methicillan-resistant Staphylococcus ■ The hospital-acquired MRSA rate one year aureus (MRSA) infections. The hospital launched post-program implementation (November an initiative to identify and treat community- 2007 - October 2008) was 2.57 per 1,000 acquired colonized or infected MRSA admissions discharges. and to decrease hospital-acquired MRSA infec- tions by 20% within one year. ■ Implementation of the MRSA program resulted in a 29.78% reduction in hospital- Data were analyzed to identify high-volume/ acquired MRSA, exceeding the hospital’s goal. high-risk cases. Despite the relatively low num- bers (180 per year), St. Mary’s Hospital opted to consider total joint surgeries as high-risk proce- dures, as these represented the highest number of hospital-acquired MRSA infections. Intensive care unit (ICU) admissions (390 per year) met the high-volume/high-risk test. Together, these areas net an estimated 15.7 new MRSA-identified 60 HANYS 2010 Profiles in Quality and Patient Safety

A Catheter-Associated Urinary Tract OUTCOMES Infection Prevention Team Models ■ Inappropriate catheters were identified and Best Practices and Improves removed before 48 hours. Outcomes ■ There was a sustained reduced incidence of St. Peter’s Hospital CAUTI. CONTACT: Dorothy Urschel, M.S., A.C.N.P.-C., ■ The protocol was easy to use and increased Director, Medical-Surgical Unit; (518) 525-1703; collaboration with physicians, while improv- [email protected] ing patient, nurse, and physician satisfaction. PROJECT ■ The hospital realized savings by reducing LESSONS LEARNED DESCRIPTION CAUTIs. ■ Catheter-associated Newer nurses re- quire mentoring urinary tract infec- from senior nurses tions (CAUTIs) to develop the are the most com- confidence to re- Central Line Infection Reduction— mon health care- move urinary Not Just in ICUs associated infection catheters. Strong Memorial Hospital/University of in the United States. ■ Frontline nurse Rochester Medical Center The Institute for “champions” are key to reducing Healthcare CONTACT: Patricia Reagan, Ph.D., Associate Quality CAUTI. Officer; (585) 273-4438; Improvement (IHI) ■ Nurses respond [email protected] provided bundles of positively to the protocols that are PROJECT protocol and the LESSONS LEARNED proven to decrease autonomy it DESCRIPTION ■ CAUTIs. St. Peter’s provides. When comparative Combating central line infections is Hospital developed information was not just a critical a multidisciplinary CAUTI prevention team to made available care problem. implement the IHI bundle’s insertion, manage- through the ■ Checklists have a ment, and early removal strategies to prevent National Healthcare significant positive CAUTIs. Following national and international Safety Network, impact in reducing clinical practice guidelines, the team focused on Strong Memorial CLABSIs. device placement, aseptic technique, and man- Hospital identified ■ Ongoing monitor- agement and removal of unnecessary catheters. central line- ing of outcomes Initial strategies included education, compe- associated blood- and process com- pliance is critical to tency assessment, and use of a reminder form. stream infections success. (CLABSIs) as a sig- As a result, there has not been a CAUTI for nine nificant hospital-acquired infection concern. In months on the pilot unit. A combination of January 2008, a multidisciplinary team was con- nurse-driven audits, physician reminders, and vened to focus on reducing CLABSIs in the in- staff education relative to urinary catheter asep- tensive care units (ICUs). The team reviewed tic technique and management succeeded in re- performance data collected by Strong’s infection ducing the duration of urinary catheters and the control practitioners, along with the literature incidence of CAUTI. on best practices and piloted new products. Line HANYS 2010 Profiles in Quality and Patient Safety 61

insertion and maintenance “bundles” were de- resistant LESSONS LEARNED veloped from the adult and pediatric ICUs. Staphylococcus ■ aureus (MRSA) and Identifying pa- tients with MRSA The team then focused on educating residents its potential impact infections before and staff and revised the blood culture policy to on care and recov- admission enables minimize the risk of contamination. Line inser- ery, providing timely implemen- tion forms were also revised to include a check- patients a hospital- tation of infection list for each element in the bundle. A system was developed MRSA prevention developed to monitor bundle compliance. Im- educational pam- strategies. plementation of the bundles was then extended phlet. When a posi- ■ Evidence-based prophylactic use of beyond the ICUs to acute care floors where pa- tive MRSA culture antibiotics is key. tients with long dwelling central lines receive is identified, a sur- ■ Educating pa- care. To ensure continued progress, data are re- gical pre-testing tients, families, viewed weekly by hospital leadership and the staff person con- providers, and governing board. tacts the physician, staff before, dur- surgery is scheduled ing, and after sur- OUTCOMES as the last case of gery increases ■ Strong Memorial Hospital had 51 fewer the day, infection MRSA awareness and promotes in- CLABSIs in 2009 than in 2008. prevention is noti- fection control. ■ There was a significant reduction in the num- fied, and the chart bers of CLABSIs in all ICUs. is flagged. Upon admission, the patient is put on ■ The medical ICU went six months without a contact precautions and is administered CLABSI. Vancomycin as a substitute for prophylaxis. ■ The hospital achieved a 15% reduction in OUTCOMES CLABSIs on its ten acute care floors. ■ Before active surveillance (2005-2007), the number of joint replacement surgeries was 3,224 and there were five related MRSA infec- tions, for a rate of 1.55 per 1,000 joint re- MRSA Active Surveillance Program placement surgeries. Unity Health System ■ Post-active surveillance (2008-2009), there CONTACT: Katie O’Leary, R.N., B.S.N., C.P.H.Q., were 2,440 joint replacement surgeries and Director, Clinical Quality and Patient Safety; zero MRSA infections. (585) 723-7133; [email protected]

PROJECT DESCRIPTION In this initiative, Unity Health System focused on reducing joint replacement surgical site in- fections. An active screening and surveillance program was implemented for all patients sched- uled for elective total joint replacement surgery. Scheduled patients visit the surgical pre-testing unit several weeks before surgery where they are nasally swabbed for a bacterial culture. The nurse provides education about Methicillan- 62 HANYS 2010 Profiles in Quality and Patient Safety

A New Approach to Promote ■ In 2009, 89% of associates were immunized Associate Wellness During Influenza with seasonal influenza vaccine and 11% had Season documented “Declination of Vaccination Westfield Memorial Hospital Administration.” CONTACT: Tina Newell, R.N., B.S., Quality Assurance Coordinator; (716) 793-2240; [email protected]

PROJECT LESSONS LEARNED “Question the Foley”—Sustained DESCRIPTION Reduction in Catheter-Associated Westfield Memorial Staff education can achieve high vaccina- Urinary Tract Infections Hospital set a goal tion rates. Through White Plains Hospital Center to improve the this initiative’s educa- health and wellness tional focus, Westfield CONTACT: Paul Quinn, M.S., C.N.M., R.N.-B.C., of hospital associ- Memorial Hospital N.E.-B.C., C.E.N., C.C.R.N., Director of Nursing; (914) 681-2394; [email protected] ates by promoting a was able to increase seasonal influenza its influenza vaccina- tion/declination rate PROJECT vaccination adminis- LESSONS LEARNED to 100%. DESCRIPTION ■ tration program and Foley catheters serve Use of specific, evidence-based instituting infection a variety of clinical criteria increases control measures to prevent the spread of in- purposes, but are success. fluenza. In fall 2009, Westfield Memorial often left in place ■ Nurse-driven Hospital’s associates attended a mandatory educa- for prolonged peri- processes ensure tion training program presented by the infection ods, leading to the continuity and control department. Objectives for this training development of consistency. were to review the hospital’s pandemic guide- catheter-associated ■ Daily surveillance, lines, institute infection control measures to pre- urinary tract infec- monitoring, and vent influenza, and coordinate effective strategies tions (CAUTIs). accountability are essential. to stop the spread of influenza among patients, White Plains visitors, and staff, and increase vaccination rates Hospital Center’s among associates. Nursing Division spearheaded “Question the Foley,” an organization-wide campaign to com- The training increased staff awareness of tech- bat the problem of prolonged dwell times for niques for preventing the influenza virus, in- Foley catheters and to decrease overall incidence cluding vigilance with patients and visitors, of hospital-acquired UTIs. A series of specific cri- appropriate respiratory protocols, and meticu- teria for maintaining a Foley catheter was out- lous hand hygiene. lined under the “Question the Foley” umbrella, providing nurses a standardized framework to OUTCOMES review indications for continuing the use of ■ In 2008, 60% of associates were immunized Foley catheters and steps to initiate removal with seasonal influenza vaccine and 18% had when a patient no longer meets the criteria for documented “Declination of Vaccination keeping a Foley catheter in place. Administration.” HANYS 2010 Profiles in Quality and Patient Safety 63

OUTCOMES appropriate sanitation procedures. The dietician ■ In 2007 (before the initiative), the facility had screens for risk and initiates standing orders for 110 CAUTIs. at-risk patients. ■ In 2008, there were 53 CAUTIs (18,588 OUTCOMES catheter days, 4,273 catheterized patients, and ■ The Clostridium difficile rate dropped from 4.3 average dwell days). 2.4 per 1,000 patient care days at the project’s ■ In 2009, the total fell to 13 CAUTIs (15,513 start in early 2008 to 1.3 per 1,000 patient catheter days, 4,174 catheterized patients, and care days in 2009. 3.7 average dwell days). ■ Individualized education helped the hospital achieve widespread patient and resident acceptance.

Reducing Clostridium Difficile Risk Wyoming County Community Health System

CONTACT: Veronica Smith, R.D., Registered Dietitian; (585) 786-2233 ext. 4717; [email protected]

PROJECT LESSONS LEARNED DESCRIPTION ■ In the early months There is great value in using of 2009, Clostridium evidence-based difficile rates were research. climbing at ■ The dietary and Wyoming County housekeeping de- Community partments are key Hospital. The infec- to addressing this tion preventionist clinical issue. wanted to establish ■ An interdiscipli- a protocol that nary team with common goals is would proactively needed to achieve mitigate the risk success. of contracting Clostridium difficile for all patients. An interdisciplinary team was es- tablished and a protocol was developed. A screening tool, standing orders, patient educa- tion material, and in-service education of staff were promptly developed.

Reducing environmental risks for contamination became a priority, focusing on hand-washing techniques, isolation precautions, and 64 HANYS 2010 Profiles in Quality and Patient Safety

PATIENT SAFETY—MEDICATIONS

Increasing Safety for Patients with electronic clinical decision-support tool that Immune-Mediated, Heparin-Induced uses laboratory and clinical data to prompt the Thrombocytopenia physician to order the optimal testing and man- Huntington Hospital/North Shore-Long agement protocols for suspected heparin- Island Jewish Health System induced thrombocytopenia. In a second phase, the hospital evaluated the care of 56 patients CONTACT: Michael B. Grosso, M.D., F.A.A.P., Senior Vice President for Medical Affairs and Quality; managed with its electronic decision support (631) 351-2645; [email protected] tool (EDST) to ensure efficacy.

PROJECT OUTCOMES LESSONS LEARNED DESCRIPTION Overuse impact: ■ A “proof of con- Heparinoids serve as ■ Total heparin-induced platelet antibody cept” was estab- the cornerstone of lished for (HIPA) tests decreased 55.6%, while negative venous thromboem- standardizing care HIPA assays decreased 84.0%. bolism (VTE) pre- with electronic ■ Serotonin release assay testing decreased 25%. vention and are clinical decision ■ Unnecessary argatroban courses decreased administered to support tools to from six in 2008 to zero in 2009. 77% of all inpatients improve outcomes. at Huntington ■ Immune-mediated heparin-induced Underuse/safety impact: Hospital. However, thrombocytopenia ■ Total argatroban use increased by 41% in the immune-mediated is a high-volume, post-implementation period, reflecting fewer heparin-induced high-risk, and “under-use” errors than were detected during thrombocytopenia high-cost problem; the baseline phase. may occur in 1% to wide implementa- 5% of patients re- tion of the ■ Under-use outliers decreased from seven methodology im- ceiving heparin patients to zero. proved safety and products. A direct efficiency, while thrombin inhibitor reducing costs. (DTI) must be ■ Multidisciplinary administered collaboration is Improving Medication Safety promptly to prevent crucial in develop- New Island Hospital complications. ing, testing, and CONTACT: Ihab Ibrahim, Pharm.D., Vice President, When thrombocy- implementing process change. Patient Safety and Clinical Development; topenia is observed (516) 520-2421; [email protected] in patients receiv- ing heparin, it is a challenge to distinguish im- PROJECT DESCRIPTION mune-mediated heparin-induced Recognizing the positive impact safe medication thrombocytopenia from other, more common administration can have on the overall culture of causes. The high cost of testing and treatment, patient safety, New Island Hospital secured a along with potential side effects of DTIs, make it clinical pharmacist to spearhead a medication desirable to reduce variation in treatment by ap- safety program to decrease inappropriate use of plying evidence-based approaches. A workgroup intravenous (IV) antibiotic therapy. Efforts were developed an evidence-based algorithm in the aimed at improving compliance with hospital policy outlining clinical criteria for “Intravenous HANYS 2010 Profiles in Quality and Patient Safety 65

to Oral Antibiotic One Process, One List, Universal LESSONS LEARNED Switch.” The initia- Access: Internal Electronic ■ tive, which targeted Physician- pharmacist collab- Medication Reconciliation patients receiving oration enhances The Mount Sinai Medical Center IV antibiotic ther- medication man- CONTACT: Lori Finkelstein-Blond, M.A., R.N., C.I.C., apy for five days, re- agement and Director, Quality Management and Performance quires the clinical safety. Improvement; (212) 241-8108; pharmacist to col- ■ Appropriate uti- [email protected] lization of IV an- laborate with physi- PROJECT cians to assess the tibiotic therapy LESSONS LEARNED reduces risk of DESCRIPTION clinical appropriate- ■ Electronic systems Clostridium difficile Medicare’s core must be user- ness of IV therapy, infections. heart failure dis- IV/oral conversion, friendly and ■ Linking laboratory charge instructions compatible with or discontinuing and pharmacy in- include a composite work flow. therapy. The Sentri formation systems score requiring all ■ Electronic systems 7 system was used positively impacts six elements (activ- alone do not guar- the management to connect clinical antee 100% com- of patient-specific ity, diet, follow-up, laboratory informa- pliance and do not regimens. worsening symp- eliminate the need tion with the pa- toms, weight moni- tient’s pharmacy for provider toring, and a vigilance. profile, to alert pharmacists to abnormal values reconciled list of affecting the patient’s medication regime. ■ DMAIC can serve discharge medica- as an effective tions) to achieve a OUTCOMES model for improv- positive outcome. ing organizational ■ New Island Hospital achieved a four-fold Before implement- performance. increase in IV-to-oral antibiotic conversion ing its Electronic between the third quarter of 2008 and third Medication Reconciliation Process (eMed Rec), quarter of 2009. The Mount Sinai Medical Center conducted a ■ The program achieved a 56% decrease in the monthly drill-down and analysis and identified rate of Clostridium difficile infections be- medication reconciliation as the primary driver tween the fourth quarter of 2008 and fourth of non-compliance. Recognizing the need for quarter of 2009. transformational change, senior leadership dedi- ■ There was a 65% increase in pharmacy/ cated information technology resources to de- physician interventions between the fourth velop an electronic medication reconciliation quarter of 2008 and fourth quarter of 2009. system. Using the Define, Measure, Analyze, Im- prove, and Control (DMAIC) approach, the eMed Rec team implemented electronic medication reconciliation that achieved significant positive change.

OUTCOMES ■ Medication reconciliation defects as a percent of total defects decreased from 45% (July- 66 HANYS 2010 Profiles in Quality and Patient Safety

December 2006) to 10% (July-December OUTCOMES 2009), a 77% reduction. In 2009, the following goals were accomplished: ■ Medication as the unique driver in non- ■ Directed order sets were created and man- compliant cases decreased from 49% to 21%, dated for antibiotic administration. a 56% reduction. ■ Antibiotic orders must be renewed with the ■ Performance on Medicare’s heart failure pharmacist after four days. measure improved from 68% in the second ■ The pharmacist can now convert the route of quarter of 2009 to 85% in the fourth quarter administration for several different antibi- of 2009. otics after 48 hours of intravenous (IV) treat- ment without a physician’s order, based on certain criteria. ■ Use of Trigecycline is now restricted. Antibiotic Stewardship: Reducing ■ Zosyn is administered every eight hours in- Multi Drug-Resistant Organisms stead of every six, and infused by IV pumps Northeast Health over four hours to improve bioavailability CONTACT: Daniel Silverman, M.D., Vice President, and reduce costs. Medical Affairs; (518) 271-3965; ■ The pharmacy can measure aminogylcoside [email protected] levels without a physician’s order; calls are PROJECT made to physicians when levels are below or LESSONS LEARNED DESCRIPTION above a therapeutic range. ■ In May 2009, Staff education and restricting an- Northeast Health tibiotic agents ap- convened the first pear to be the meeting of its an- most effective Implementation of a Robotic tibiotic stewardship strategies for re- Medication Dispensing System ducing emergence committee to ad- Olean General Hospital/Upper Allegheny dress variations in of multi-drug resistance. Health System prescribing prac- ■ Daily prospective tices and drug uti- CONTACT: LeRoy Allen Hanchett, Pharm.D., Ph.D., audits and feed- Director of Pharmacy; (716) 375-6251; lization in different back are essential [email protected] locations within the for monitoring an- health system. A tibiotic use. PROJECT DESCRIPTION full-time pharma- On average, Olean General Hospital administers cist was hired to 2,600 doses of medication each day. The chal- focus on antibiotic surveillance, concurrent re- lenge in medication management is to plan a dis- view and intervention, and staff education. Stan- tribution system that is as error-free as possible, dardized order forms were implemented for using standardized processes and appropriate pre-operative, post-operative, and site-specific technologies. Medication availability at the point treatment. The committee determined the pro- of care is critical to timely administration. Steps gram could save $180,000 in 2010. Additional in the drug distribution process that require formulary restrictions are anticipated to increase someone to read a medication name or confirm a this number substantially, and help prevent the dosage are subject to error. Electronic verification emergence of multi-drug resistant organisms. HANYS 2010 Profiles in Quality and Patient Safety 67

of medication ad- Recognizing Ways to Improve the LESSONS LEARNED ministration using Interdisciplinary Reporting of ■ bar-code technology Implementation of a hospital-wide Pre-Empted Medication Errors has been shown to change with com- St. Charles Hospital reduce medication plex processes re- CONTACT: Kathleen LeDoux, M.S., R.N., B.C., C.P.H.Q.. errors at the point quires dedicated Performance Improvement Nurse; (631) 474-6201; of care. Using bar time and resources. [email protected] code verification at ■ Repetition of com- PROJECT every step in the munication, educa- LESSONS LEARNED tion, and feedback DESCRIPTION medication distribu- ■ to all stakeholders Medication error A system of checks tion process pro- and balances is is needed to incul- reporting at St. vides redundancy, cate new policies, critical when the Charles Hospital is eliminates errors, procedures, and medication order- and allows inven- processes. an interdisciplinary ing process in- process. Beginning cludes both tory to be tracked ■ Technology alone electronic and throughout the sys- does not guarantee in 2004, team mem- paper components. tem. The hospital quality. bers began to ex- plore ways to ■ Incorporating staff implemented scan- suggestions im- recognize and im- ning technology throughout its distribution sys- proved buy-in and tem, installed a robotic dispensing system in the prove the reporting utilization. pharmacy, and deployed computer-controlled of avoided errors. medication carts with automated dispensing While traditional re- cabinets on all nursing units. This system allows porting via the formal occurrence reporting sys- inventory to be tracked and delivered to medica- tem and other venues was encouraged, the team tion carts with bar code verification at each step, determined that certain categories of clinical in- providing nurses with an adequate supply of terventions performed by pharmacy and the medications at the point of care. medication administration record (MAR) could appropriately be recognized as pre-empted med- OUTCOMES ication errors. The facility implemented a ■ Picking errors were reduced by 98% and cabi- facility-wide electronic MAR. The conversion to net fill errors decreased 94%. an electronic record that is generated daily, in conjunction with the use of the “Hard Stop,” ■ Drug inventory stored on the nursing units placed emphasis for transcription on the pharma- was reduced by $112,000. cist instead of the nurse transcription on each unit. The nurse is now required to review the printed MAR for transcription omissions or dis- crepancies. The pharmacy developed and im- proved the tracking of clinical interventions, which occur before medications are dispensed.

OUTCOMES ■ The workflow process for both nursing and pharmacy staff was simplified. 68 HANYS 2010 Profiles in Quality and Patient Safety

■ MAR communication changes included wireless connection. This initiative required dis- adding categories for incorrect or missing al- ciplined cooperation from the members of the lergy information, printing the order number multidisciplinary committee to meet St. James attributed to the profile entry on the MAR, Mercy Hospital’s objectives to: and allowing the pharmacy to access the spe- ■ decrease medication-related errors; cific order in question immediately. ■ redesign workflows; ■ Improved capture of clinical intervention ■ computerize medication administration data was achieved by refining the interven- records; and tion categories and developing an electronic ■ database. involve end-users in selection of hardware. OUTCOMES Results of the bar-coding project include: ■ the overall number of medication errors de- Creating a Culture of Medication creased 44% from 2008 to 2009; Safety ■ the number of omitted medication errors de- St. James Mercy Hospital clined 28% from 2008 to 2009; CONTACT: Nancy Khork, R.N., B.S., M.P.S., Vice ■ the number of wrong dosage of medication President, Performance Improvement; (607) 324-8114; decreased 38% from 2008 to 2009; and [email protected] ■ the electronic medication administration PROJECT record is accessible to all clinicians. LESSONS LEARNED DESCRIPTION ■ St. James Mercy Technology alone does not improve Hospital’s journey to medication safety; a culture of medica- clinical expertise Anticoagulation Nomograms: tion safety is a of the staff is Not One Size Fits All multifaceted, non- essential. WCA Hospital punitive approach ■ Data collection that fostered signifi- and evaluation are CONTACT: Deborah Caruso, Registered Pharmacist, Director, Pharmacy; (716) 664-8225; cant and lasting key to establishing success and meas- [email protected] gains. Hospital lead- uring milestones. ers invested in tech- PROJECT ■ Dedicated clinical LESSONS LEARNED nology and systems DESCRIPTION and non-clinical re- ■ Best practices re- to help reach speci- WCA Hospital’s sources must be search and involve- medical staff identi- fied goals, such as represented on the ment of local implementation of a team. fied the need for experts is essential bedside medication weight-based, dis- for success. verification system that uses bar-coding. Staff ease process-related ■ An ongoing discus- scan bar codes on the patient’s wristband and on nomograms for an- sion following ini- the medication to assure the proper medication ticoagulation. A tial implementation is being given to the proper patient. A computer multidisciplinary increases the likeli- hood of utilization. at the bedside assists the nurse with bedside team reviewed best charting and documentation, using an elec- practices gathered tronic medication administration record and a from a wide range of sources, provided input on HANYS 2010 Profiles in Quality and Patient Safety 69

the content and ease of use, and developed three disease-specific heparin nomograms in cardiac, neurologic, and deep vein thrombophlebitis/ pulmonary, with standing orders for Warfarin and Enoxaparin. After extensive education of physicians, nursing, pharmacy and laboratory staff, the order sets were implemented.

Physicians now use nomograms for anticoagula- tion tailored to each patient’s disease process and weight. Pharmacy staff are responsible for consis- tent weight-based dosing per the nomograms, and medication administration records include any ongoing lab tests to be completed. Nomo- grams specify maximum initial and maintenance dosing, enabling nurses to easily check subse- quent dosing changes prompted by laboratory re- sults. The pharmacy also works in conjunction with the laboratory to assure completion of ap- propriate tests and dosing changes.

OUTCOMES ■ Safer, more effective anticoagulation treat- ment is based on each patient’s diagnosis and weight. ■ Follow-up laboratory testing is assured when it is built into the nomogram. ■ Ongoing staff education regarding the avail- ability and benefit of using the anticoagula- tion order sets increased utilization 66%. 70 HANYS 2010 Profiles in Quality and Patient Safety

PATIENT SAFETY—PRESSURE ULCERS

Skin Saver Team Initiative—Helping OUTCOMES Hands ■ Beth Israel achieved a sustained reduction in Beth Israel Medical Center hospital-acquired pressure ulcers. ■ Peer-to-peer, unit-based education increased CONTACT: Irene M. Jankowski, M.S.N., A.P.R.N.-B.C., C.W.O.C.N., Wound Ostomy Continence Nurse hospital-wide awareness. Practitioner; (212) 420-4155; [email protected] ■ The Skin Saver team participated in preva- lence and incidence surveys, and initiated PROJECT LESSONS LEARNED unit-based quality improvement projects to DESCRIPTION ■ Ongoing unit- prevent pressure ulcers. The wound ostomy based education, continence nurses at especially by peers, Beth Israel Medical enhances compli- ance with best Center’s two cam- A Team Approach to Pressure Ulcer puses collaborated practice protocols. ■ Prevention Using “Wound Care to develop a pres- PCAs must be rec- ognized as vital Champions” sure ulcer preven- members of the Erie County Medical Center tion initiative. A team. CONTACT: Charlene Ludlow, R.N., M.S., C.I.C., Patient number of goals ■ Risk status and Safety Officer; (716) 898-3628; [email protected] were identified, such planned interven- as sharing best prac- tions for pressure PROJECT ulcer prevention LESSONS LEARNED tices with bedside DESCRIPTION ■ must be included Erie County Medical Implementation of staff; improving in handoffs. prevention meas- Center implemented communication be- ures can result in a an interdisciplinary tween nurses and patient care associates (PCAs); significant decrease pressure ulcer pre- and tapping into the knowledge, talents, and of full thickness vention program pressure ulcers. committed work each group provides. Confu- that changed the ■ Pre-admission sion about accountability for certain tasks was model for wound areas require pre- discovered. During handoffs, communication care by developing vention measures (positioning and/ between nurses and PCAs about which patients “Wound Care were at risk for pressure ulcers was often missed. or pressure relief Champions” on all devices) to reduce As a result, efforts to protect patients from pres- nursing units on all incidence and sure ulcers were sometimes disjointed. shifts. Clinical and severity of pres- educational support sure ulcers. This initiative consisted of an all-day educa- was provided by tional program that focused on a team-based adding a wound ostomy nurse practitioner who approach to patient care that increased staff sat- partnered with a wound clinician to lead train- isfaction and improved patient outcomes. After ing for frontline staff on staging and prevention training, registered nurses and PCAs returned strategies. Education on pressure ulcer staging to their units as experts in pressure ulcer and prevention methods, and support for clini- prevention. cal rounds was extended to physicians and resi- dents to promote early identification and HANYS 2010 Profiles in Quality and Patient Safety 71

documentation of pressure ulcers, and initiation according to the LESSONS LEARNED of interventions. The program was supported by National Database of ■ A multidisciplinary administration and the board of directors, who Nursing Quality team including allocated capital resources to purchase 250 new Indicators. To ad- nursing, physi- beds with pressure relief surfaces, establishing a dress this issue, the cians, wound care new standard throughout the acute care and hospital developed a nurses, pharmacy intensive care units. comprehensive staff, and nutrition wound and skin care staff optimizes pressure ulcer A multidisciplinary team that included nurses, program. prevention. physicians, physical therapists, dieticians, infor- ■ matics, and patient safety staff identified at-risk A certified wound An evidence-based skin care protocol patients and implemented early prevention care nurse began directed by a strategies. A revised standard of care incorpo- tracking pressure wound care nurse rated evidence-based practices requiring fre- ulcer incidence ensures consis- quent assessments utilizing the Braden scale and using the national tency in patients’ bedside rounding every two hours to trigger Institute for care and prevents changes in the patient’s plan of care, toileting, Healthcare pressure ulcers. and repositioning. Improvement pres- ■ Pressure ulcer met- sure ulcer improve- rics collected by trained staff pro- OUTCOMES ment methodology. vide valid measures ■ The prevalence of hospital-acquired pressure Decreasing the num- for monitoring ulcers (HAPUs) decreased 67% post- ber of hospital- improvement. implementation. acquired pressure ■ Monthly audits indicated sustained HAPU ulcers by 50% was established as a goal and tar- incidence rates of less than two per 1,000 geted by interventions including: patient days. ■ concurrent surveillance of at-risk patients by ■ Completion of Braden risk assessment on a wound care nurse; admission achieved 100% compliance. ■ provision of skin care education programs to ■ Inclusion of pressure ulcer prevention in care nursing staff; plans or care of patient with a pressure ulcer ■ forming a multidisciplinary skin care team; reached 99% compliance. ■ development and implementation of evidence-based skin care protocols, a refer- ence manual, and order sets; ■ providing pressure-reducing mattresses on Decreasing the Incidence of Hospital- inpatient units; and Acquired Pressure Ulcers ■ development and implementation of a patient Olean General Hospital education brochure about prevention of CONTACT: Julie Kenyon, R.N., Wound Care/Patient pressure ulcers. Education Nurse; (716) 375-6412; [email protected] OUTCOMES PROJECT DESCRIPTION The incidence of hospital-acquired pressure Olean General Hospital noted the hospital was ulcers decreased 90%, from 13.67 per 1,000 above the national benchmark for preventing patient days to 1.27 per 1,000 patient days as a hospital-acquired Stage I and II pressure ulcers, result of the program. 72 HANYS 2010 Profiles in Quality and Patient Safety

Reducing the Incidence of OUTCOMES Nosocomial Pressure Ulcers ■ The facility reduced nosocomial pressure Plainview Hospital/Syosset Hospital ulcers to 1%, well below the national average

CONTACT: Mary P. Donovan, R.N., B.S., C.W.C.N., of 5.3%. C.O.C.N., C.R.R.N., Wound Care Specialist; ■ A standardized formula was used to permit (516) 719-2515; [email protected] comparison of the hospital’s results with nationally recognized databases. PROJECT LESSONS LEARNED DESCRIPTION ■ A wound care algorithm promoted 100% ■ In 2009, Plainview Nurses value edu- compliance with product selection. cation. Recogniz- Hospital began an ■ ing improvement Costs of rented wound care surfaces were initiative to accu- in the nursing reduced 50%. rately identify process, they con- ■ Documentation of pressure ulcers at the time community- tinue to seek of admission improved by 50%. acquired and noso- knowledge and comial pressure feedback. ulcers; provide ■ Use validated tools to promote critical appropriate, cost- thinking and en- Pressure Ulcer Prevention effective treatment; courage individual- St. Charles Hospital and collect data for ization of a comparison with patient’s care plan. CONTACT: Magdalena Pupiales, M.P.H., M.S., other validated data- ■ Regular reporting C.W.O.C.N., A.N.P.-C., Wound Care Nurse; (631) 476-5688; [email protected] bases. The hospital’s of data and trends to the performance ultimate goal was to PROJECT improve outcomes improvement coor- LESSONS LEARNED dinating group DESCRIPTION by reducing the in- ■ Online education supports success. St. Charles Hospital’s is a successful cidence of facility- pressure ulcer pre- acquired pressure method to dissemi- vention initiative nate information, ulcers from 2.0% to 1.5%. used annual point ensure compliance, prevalence survey re- and accommodate The hospital recognized its high-risk, high- sults as benchmarks staff schedules. volume population—patients from the commu- for improvement. ■ Discrepancies exist nity including those who reside in nursing Objectives of the in the general homes, rehabilitation facilities, and group understanding of pressure ulcer pre- homes. Approximately 65% of the hospital’s interventions for vention program population is older than 70 years. To succeed, patients at risk. include: the nursing process was restructured following a ■ Inter-rater reliabil- ■ review of current literature and clinical practice improve identifi- ity and fear of re- porting pressure guidelines. A multidimensional initiative was cation of patients at risk for skin ulcers contribute introduced that included nursing education, to variability in breakdown on team building, and standardization. outcomes. admission; HANYS 2010 Profiles in Quality and Patient Safety 73

■ implement interventions to prevent pressure opulations. The skin LESSONS LEARNED ulcers, focusing on the support surface, turn- care bundle was im- ■ ing/positioning the patient, and nutrition; and plemented hospital- Empowering staff to make decisions wide in the fourth ■ decrease the rate of facility-acquired pressure is important. quarter of 2008. ulcers. ■ Education on pre- vention of pressure OUTCOMES In addition to the ulcers must be ■ The facility-acquired pressure ulcer incidence skin care bundle, the consistent and rate decreased from 15% in 2005 to 3.3% in S.K.I.N Champions accessible. 2009. initiative was imple- ■ Leadership support mented, which for appropriate ■ The initiative increased availability of and requires a three- staffing levels and access to resources for prevention. month commitment resources is essen- ■ The frequency of risk assessments and imple- tial for success. for staff nurses on mentation of interventions increased. ■ Collaboration each patient care among members ■ Standardized education and incorporated unit to become of the interdiscipli- pressure ulcer prevention topics are now part S.K.I.N. Champions. nary team must be of the annual nursing skills fair. The nurses commit encouraged. ■ Revised forms, including pre-printed physi- to participate in ed- cian orders, were used to facilitate implemen- ucational seminars, support their peers, and tation and documentation of prevention model best practices in pressure ulcer preven- measures and treatment. tion. In combination, these two innovative ini- tiatives dramatically reduced the incidence of hospital-acquired pressure ulcers.

OUTCOMES Maintaining Patient Skin Integrity ■ In 2008, 1,005 patients were evaluated, with Using Nursing Interventions and an overall 5.47 rate of hospital-acquired pres- Clinical Nurse S.K.I.N. Champions sure ulcers per 1,000 patient days. St. Francis Hospital—The Heart Center ■ In 2009, 1,121 patients were evaluated, with CONTACT: D. Denielle Lawtum, R.N., Clinical Nurse an overall 2.4 rate of hospital-acquired pres- Specialist; (516) 277-4846; [email protected] sure ulcers per 1,000 patient days, a decrease PROJECT DESCRIPTION of 56% between 2008 and 2009. St. Francis Hospital—The Heart Center reviewed the evidence and decided to use a skin care “bundle” of interventions to reduce hospital- acquired pressure ulcers. The implementation promoted teamwork, as support personnel as- sisted professional nurses with turning, posi- tioning, and addressing basic comfort care measures. The skin care bundle was initiated in the critical care unit (CCU) to leverage the expe- rience of CCU nurses in preventing pressure ulcers and in providing care to high-risk 74 HANYS 2010 Profiles in Quality and Patient Safety

SPECIALTY—EMERGENCY SERVICES

Emergency Department Quality OUTCOMES Improvement Peer Review Process ■ Within three months, the compliance rate for Aurelia Osborn Fox Memorial Hospital documentation of allergies improved from

CONTACT: Laura Palada, B.S.N., R.N., Patient Safety 65% to 100%. Coordinator; (607) 431-5045; ■ Compliance with documentation of medica- [email protected] tion history improved from 70% to 96%. PROJECT ■ Compliance with documentation of IV start LESSONS LEARNED DESCRIPTION time improved from less than 50% to 95%, ■ Aurelia Osborn Fox Changes and im- which enabled the hospital to accurately bill provements are Memorial Hospital for the service. easier to facilitate identified opportu- when critiques nities for improve- come from peers. ment during its ■ Separating peer re- recent implementa- view from perform- Emergency Department Efficiency tion of electronic ance evaluation Improvement Project documentation in helped change the culture of “fear of Ellis Medicine the emergency retribution” to one department (ED). CONTACT: John Voight, R.N., Director of Emergency of empowerment Services; (518) 243-4777; [email protected] Initially, the nursing and teamwork. director for the ED ■ PROJECT Simple documenta- LESSONS LEARNED reviewed documen- tion can save thou- DESCRIPTION ■ tation, and compli- sands of dollars. In response to the Patients are hard to predict—when ance with state’s Commission the hospitals con- documentation requirements such as allergies, on Health Care solidated, patients medication history, and intravenous (IV) start Facilities in the 21st moved to the and stop times were low. An estimated $900,000 Century, Ellis larger ED even was lost each year in billable services because of Medicine consoli- though the smaller poor documentation of IV insertion. dated two hospitals, one remained open. which resulted in a ■ Size counts—the The ED nursing staff began a nursing peer re- significant increase view program without links to supervisory re- higher patient vol- in emergency de- umes could not view or disciplinary processes. Every two weeks, partment (ED) wait have been handled nurses are assigned charts to review based on times at the larger without the addi- their work status. Full-time nurses are asked to facility. That facility tional examination review six charts; part-time nurses are assigned a undertook initia- rooms and beds. chart for every shift worked. While initially hes- tives to reduce wait ■ Collaborative itant to critique each other, the nurses became times and improve “patient flow meetings” and adept at the chart review process and documen- patient satisfaction, innovations such tation improved dramatically. including construct- as “physician in ing 17 new ED treat- triage” measurably ment rooms, improved moving an 82-bed efficiency. HANYS 2010 Profiles in Quality and Patient Safety 75

skilled nursing facility to another campus, and various score levels LESSONS LEARNED opening 70 new inpatient beds in that space. up to and including ■ A decreased LOS notification of the increased patient Operational changes included adding additional administrator on satisfaction. physician and nursing staff, streamlining the call. The ED charge ■ Service level agree- triage and registration process, expanding the nurse calculates the ments from sup- hours of case managers in the ED, and conduct- score every four port services play a ing thrice-weekly “patient flow meetings” with hours; every two vital role in patient the chief operating officer and ED, admitting, hours if the score is “throughput.” nursing, and case management staff. A 12-hour between 141 and ■ Recognizing the “physician in triage” program was implemented 180. When the level ED as the “front door,” the hospital for early assessment of patients. In addition, the changes, the ED supports ED ED collaborates with the family health clinic to uses the “patient throughput ensure that patients without primary care and throughput improvement. insurance receive follow-up care. response plan” for level-specific OUTCOMES responsibilities. Each level within the response ■ Wait times (triage to physician) declined plan requires a specific hospital-wide response re- from a high of 135 minutes in June 2008 to lated to departmental operations, bed capacity, 46 minutes in February 2010. supplies, and communications. At the point of ■ Time for disposition to floor declined from reaching “dangerously overcrowded,” the ED nearly 200 minutes in June 2008 to about 70 charge nurse notifies the nursing supervisor, who minutes in December 2009. develops a plan of action with the administrator. ■ Press Ganey patient satisfaction scores rose OUTCOMES from a zero percentile in June 2008 to the 65th percentile in December 2009. ■ Within one month of using the plan, Faxton- St. Luke’s decreased the ED length of stay (LOS) by an hour. ■ The organization created a hospital-wide Emergency Department response to ED overcrowding, including serv- Overcrowding Response Plan ice level agreements with clinical engineer- Faxton-St. Luke’s Healthcare ing, environmental, linen services, and transport staff. CONTACT: Angela Belmont, R.N., M.S., Director of ■ Patient and employee satisfaction increased. Nursing; (315) 624-6734; [email protected]

PROJECT DESCRIPTION Faxton-St. Luke’s Healthcare used a valid, reliable method to identify emergency department (ED) and hospital overcrowding and initiate a hospi- tal-wide response plan. The National Emergency Department Overcrowding Score (NEDOCS) was linked to the charge nurses’ computer in the ED and was made available to all staff. The response plan identifies specific roles and functions at 76 HANYS 2010 Profiles in Quality and Patient Safety

Mid-Track: Solving the Emergency ery system will be permanently incorporated Severity Index Patient Timely into the operating procedures for patients pre- Treatment Conundrum senting at the ED. Good Samaritan Hospital Medical Center OUTCOMES CONTACT: Susan Dries, R.N., M.S., C.P.H.Q., C.C.M., ■ Vice President, Quality/Care Management; The LWBS rate for all mid-severity patients (631) 376-4393; [email protected] fell by 36%, and by 42% for the study group. ■ The overall LWBS rate was reduced by nearly PROJECT LESSONS LEARNED 24%. DESCRIPTION ■ ■ ED patient satisfaction has improved Good Samaritan Processes took longer than ex- significantly. Hospital Medical pected because of Center was honored the need to ad- to be chosen to par- dress nuances of a ticipate in a national new model of collaborative to im- health care Rapid Medical Evaluation: prove patient flow delivery. Improving the Emergency and reduce emer- ■ The multidiscipli- Department Patient Experience nary approach gency department Highland Hospital/University of Rochester highlighted the es- (ED) overcrowding. sential functions Medical Center Patients entering an and contributions overcrowded ED face of every team CONTACT: Sharon Johnson, M.B.A., C.P.H.Q., Director, Quality Management; (585) 341-8399; longer wait times for member. [email protected] care, which often re- ■ Through proper sults in people leav- measurement tech- PROJECT LESSONS LEARNED ing without being niques, the vari- DESCRIPTION ability of patient ■ seen (LWBS). Good In 2009, Highland An area specifically flow (the peaks designed to Samaritan deter- Hospital’s emer- and troughs) can accommodate the mined that Emer- be identified, gency department program is gency Severity Index which allows for (ED) was revamped, essential. staff planning, (ESI) 3 (mid-severity) which decreased ■ Clearly establish thereby improving patients had the bed capacity, con- criteria for patients operational longest wait times who can be seen in efficiency. tributing to a high and high LWBS rates. number of ambu- the rapid medical evaluation area. Under this initiative, lance diversion ■ a designated physician manages the diagnostic hours, left without Staff must be com- mitted to the pro- phase for these patients directly after their triage. being seen (LWBS) gram’s success. The patients are treated in the ambulatory sur- rates above stan- gery unit located directly over the ED and their dards, and low patient satisfaction scores. A pa- care is directed by that same physician and coor- tient care delivery model was designed to reduce dinated by nurse practitioners. This clinically- the queuing phenomenon by eliminating time driven team approach is highly successful in spent by a patient waiting for a bed; a physician reducing wait times and the LWBS rate for ESI 3 to see, exam, and treat the patient; and the nurse patients. This innovative and effective care deliv- “to do” orders and care. Under the new rapid HANYS 2010 Profiles in Quality and Patient Safety 77

medical evaluation program, a physician assis- departments and in- LESSONS LEARNED tant and a registered nurse are available in a spe- dividuals working ■ cially designed self-contained area near the independently to do Standardizing the language and front of the ED. This enables the patient to re- whatever it took to format of bed ceive a rapid medical evaluation upon arrival, get patients an management com- enabling patients with minor conditions to be available bed, with- munication boards treated and discharged rapidly. out being fully on all inpatient aware of available units was key to fa- For patients with minor conditions, simple diag- resources or activi- cilitating immedi- ate recognition of nostics such as x-rays or laboratory tests are ties in other areas bed availability. completed while the patients are in a comfort- of the hospital that ■ Using hospital re- able waiting area. Patients with complex condi- strain the hospital sources (i.e., case tions are seen by the physician assistant. Orders and increase emer- management, are then undertaken by the assigned nurse be- gency department transport, and fore moving the patient into the main emer- (ED) length of stay housekeeping) gency room and assigning him or her to medical and diversion time. effectively and vacant space is staff members best able to continue care. The Orange Regional critical to ED process is designed so that patients do not oc- Medical Center decompression cupy the treatment bed in the rapid medical assembled an inter- during high- evaluation area for more than 30 minutes. disciplinary, collab- volume periods. orative team to ■ An interdisciplinary OUTCOMES identify improve- approach at the From February 2009 to February 2010: ment opportunities daily bed manage- ■ ambulance diversion hours decreased from 77 and initiate correc- ment meeting is vital in facilitating hours to 33 hours; tive actions to timely patient ■ the LWBS rate decreased from 3.75% to 1.5%; decrease the ED movement from ■ patient satisfaction scores increased from the length of stay and the ED to the ad- 12th to the 89th percentile; and diversion hours. mitting unit. ■ ■ length of stay for low-acuity patients de- The hospital creased from 149 minutes to 90 minutes. established daily interdisciplinary team mem- ber bed management meetings for assessing, planning, and evaluating hospital patient flow. Improving Emergency Department ■ Vacant space in the hospital is used to care for Patient Flow Through HANYS’ ECHO newly admitted patients when inpatient units Collaborative are full. Orange Regional Medical Center ■ Agreeable admitted patients are sent to a part- ner campus, instead of holding them in the CONTACT: Susan M. Hodgson, M.H.S.A., R.N., C.P.H.Q., F.A.C.H.E., Vice President, Quality ED during high inpatient capacity periods. Management; (845) 342-7215; [email protected] ■ A timely “admission orders to inpatient bed” practice was instituted, with a goal of one PROJECT DESCRIPTION hour. Before this initiative, Orange Regional Medical Center’s patient flow process was facilitated by 78 HANYS 2010 Profiles in Quality and Patient Safety

OUTCOMES measurement points, and selected leaders for ■ ED diversion hours were reduced from 190 each: total hours in 2008 to five total hours in ■ arrival to triage (nursing and patient 2009. registration); ■ Admitted patients’ mean length of stay ■ triage to bed (nursing); decreased from 329 minutes in April 2009 ■ bed to care complete (laboratory, radiology, to 293 minutes in December 2009. and providers); and ■ ED patient satisfaction scores improved, from ■ care complete to discharge (nursing). an average score of 53% in 2008 to a score of 80% for fourth quarter of 2009. The ED uses the MedHost documentation system ■ The ED employee engagement score increased and parameters for these measurements and re- from 3.63 in 2008 to 3.89 in 2009. sults reported during weekly meetings. A work- group of staff from each area was identified to brainstorm ideas for the action plans. This group met three times during the year and Reducing Length of Stay in the helped implement 32 initiatives that led to the success of this project. These initiatives were Emergency Department’s Minor piloted using 90-day action plans; those con- Treatment Area to 60 Minutes tributing to a decrease in LOS were adopted. Samaritan Medical Center CONTACT: Diana K. Woodhouse, Ph.D., R.N., Chief OUTCOMES Nursing Officer/Vice President, Patient Care; LOS decreased over three quarters, from 160 (315) 786-4936; [email protected] minutes during the first week of March 2009 to 74 minutes during the last measurement week of PROJECT LESSONS LEARNED DESCRIPTION December 2009. ■ In response to com- Using an interdisci- plinary team en- plaints regarding sured that all long lengths of stay departments were in Samaritan committed to the Maintaining the Momentum Medical Center’s goal. on Patient Throughput minor treatment ■ Soliciting ideas South Nassau Communities Hospital area (MTA), the facil- from staff and in- ity set a goal to re- volving them in CONTACT: Colleen Beirne, R.N., Director of Nursing— implementation Quality, Patient Care Services; (516) 632-4399; duce the length of strategies identi- [email protected] stay (LOS) to 60 fied real opportu- minutes by the end nities for LOS PROJECT DESCRIPTION of 2009. After re- reduction. To address patient flow throughout the facility, viewing data related ■ Establishing quar- South Nassau Communities Hospital analyzed to LOS components, terly time targets interdepartmental processes on patient admis- an interdisciplinary enabled staff to sion, staffing, registration, bed turnaround achieve and cele- team identified four time, patient discharge, and transport and place- brate success distinct process time incrementally. ment. Operational and systems-based initiatives were designed to increase efficiency and HANYS 2010 Profiles in Quality and Patient Safety 79

timeliness, includ- unit” over six months, and a 16% decrease in LESSONS LEARNED ing enhancement of “ED treat and release” time over six months. ■ Successful the bed demand es- ■ throughput initia- The hospital achieved a 28% decrease in calation plan and tives require every- “red” (total bed capacity) hours in 2009. hiring a bed coordi- one’s participation ■ Average daily availability of cardiac monitors nator and assistant across the contin- increased since inception of the admission director of nursing uum of care. criteria. oversight for patient ■ Expansion of throughput. Daily throughput initia- tactical bed board tives requires in- clusion tactics to care coordination improve smooth- Implementation of an Electronic team meetings were ing of operating held to identify pa- room schedules. Medical Record System with CPOE tient placement ■ Supporting staff in Urgent Care needs and discharge work/lifestyle bal- Thompson Health barriers. An emer- ance optimizes CONTACT: Anthony Geraci, M.D., Director of gency department staff satisfaction, Emergency and Outpatient Services; (585) 396-6420; (ED) patient track- performance, and [email protected] engagement. ing dashboard pro- PROJECT vides a quick view LESSONS LEARNED DESCRIPTION of patient diagnostics and disposition. ■ In 2009, Thompson To succeed, the project must be Health’s emergency Additional initiatives included: mandatory. department (ED) ■ ■ All users must devising specific cardiac monitoring admis- added computerized sion criteria, resulting in increased availabil- adopt the new sys- physician order tem on the go-live ity of cardiac monitors; entry (CPOE) to the date. ■ cohorting hospitalist admissions on a dedi- electronic medical ■ A physician cham- cated unit; record system. The pion is essential. ■ bedside patient registration in the ED; and director of emer- ■ The product must be robust, easy to ■ execution of critical care nurse bedside hand- gency and outpa- tient services took use, and supplied offs of care reports in the ED. by a company that on the role of the provides service OUTCOMES physician champion, excellence for im- ■ The hospital achieved a 27% increase in favor- establishing the plementation and able patient responses (Hospital Consumer basic design and ongoing support. Assessment of Healthcare Providers and coding of the order Systems “Time Spent in ED” question). sets based on ED physician consensus. The proj- ect went live in four months. Then the urgent ■ The initiative resulted in a 19% decrease in care department implemented an electronic total average time in the ED, with a 30% de- medication administration records system with crease in time from “ED to critical care pa- CPOE. The physician “champion” adjusted the tient transfer” over three months, a 24% software templates to meet urgent care needs. decrease from “time of admit to arrival on This went live in two months. 80 HANYS 2010 Profiles in Quality and Patient Safety

Among the most significant benefits realized was immediate communication of orders and interventions to the nurses, leading to better outcomes. Because of the new changes: ■ the urgent care center increased hours and tripled volume without adding staff; ■ satisfaction of health care providers and end users has improved; ■ orders, progress notes, and discharge instruc- tions are legible and available immediately; and ■ the patient receives a typed list of medica- tions and appropriate educational informa- tion at discharge.

OUTCOMES ■ All nursing staff use a computerized system, allowing immediate access to medical infor- mation for all patients. ■ The initiative enhanced communication among all health care providers in the deliv- ery of medical care. ■ This initiative improved compliance in meet- ing and exceeding regulations, and increased work flow process efficiency. HANYS 2010 Profiles in Quality and Patient Safety 81

SPECIALTY—HOME CARE

Home Care Demonstration Project OUTCOMES to Reduce Hospital Readmissions The readmission rates for chronic pulmonary Brookhaven Memorial Hospital Medical obstructive disease were consistently lower for Center Home Health Agency telehealth home care. CONTACT: Gerrianne Griffin, R.N.C., B.S.N., Director of Quality Management; (631) 758-3600; [email protected]

PROJECT LESSONS LEARNED DESCRIPTION ■ Brookhaven Telehealth should be used as a stan- Memorial Medical dard of care, not Center set a goal to an option for the increase home care patient to refuse or referral and tele- accept. health care models ■ Rapidly advancing to address varia- technology re- tions in 30-day quires the ability to exchange equip- readmission rates ment; therefore, for patients with leasing is prefer- pulmonary diseases. able to buying. Brookhaven’s home ■ Telehealth is an health agency ac- efficient use of cepted these pa- nursing staff. tients, with full provision of home care services and added tele- health monitoring to proactively manage symp- toms before emergent need. Patients who did not accept telehealth were still seen in the stan- dard manner with intermittent in-home visits. Those that accepted telehealth were seen for fewer in-home visits. Telehealth patients had scales, blood pressure cuffs, pulse oximeters, and stethoscopes in their homes, as well as inter- active visual computers. Patients took their vital signs and sent them to the nurse daily via com- puter connection. Patients whose vital signs var- ied out of prescribed range were contacted by the nurse more frequently than those whose vital signs were stable. 82 HANYS 2010 Profiles in Quality and Patient Safety

SPECIALTY—MATERNAL-CHILD SERVICES

Providing a Brighter Future for immunoglobulin can protect 85% to 95% of Infants—Improving Hepatitis B newborns from infection, even if they were ex- Vaccination Rates to Newborns posed at birth. About 90% of children who con- Brooks Memorial Hospital Medical Center tract Hepatitis B infection go on to have chronic Home Health Agency infections. CONTACT: Roselle Atzrott, R.N., B.S.N., C.L.C., OUTCOMES Obstetric Clinical Nurse Manager; (716) 363-7330; ■ [email protected] Before the birth, parents are educated about Hepatitis B and the vaccine and give consent PROJECT for vaccination. LESSONS LEARNED DESCRIPTION ■ ■ The vaccine is available and ready to adminis- Brooks Memorial In 2009, 100% of all eligible new- ter immediately after birth in the delivery Hospital’s obstetrics borns were vacci- room or upon entry to the newborn nursery department began an nated for Hepatitis if the birth is by cesarean section. initiative to ensure B upon delivery in that newborns are the birthing room vaccinated for or in the nursery Hepatitis B without immediately after cesarean section. Improving Patient Safety in delay. ■ The Department of Obstetrics Using Crew Resources Health awarded The Centers for Management the obstetrics de- Catholic Health Services of Long Island Disease Control and partment a Prevention (CDC) Certificate of CONTACT: Joseph G. Conte, M.P.A., Executive Vice emphasizes the im- Excellence for vac- President, Corporate Services; (516) 705-3716; [email protected] portance of vaccina- cinating more than tion of newborns at 90% of all eligible newborns with the PROJECT DESCRIPTION birth. CDC believes birth dose of the In 2005, Catholic Health Services of Long Island’s that the birth dose of Hepatitis vaccine. perinatal service experienced a cluster of adverse the Hepatitis vaccine ■ Longstanding poli- events. A task force was convened to develop a provides early pro- cies are not always strategic plan for performance improvement in tection for the infant the best practice. the 6,500 deliveries per year perinatal service who may be at risk ■ Success is meas- line. Studies suggest that as many as 50% of ob- after the perinatal ured by the num- stetrical mistakes are preventable by implement- ber of patients period, and infants ing high reliability safety processes. After who receive the birth cared for in an op- timal manner, not researching options, the task force selected the dose have higher just the number of Crew Resource Management (CRM) model as the rates of finishing the patients. method for change. complete series on ■ Evidence-based time. In the United medicine opti- A core team received CRM education and States, one of five ba- mizes outcomes. trained more than 235 clinicians. Principles bies born to mothers around communication, team structure, situa- with Hepatitis B do not receive the treatment tion monitoring, mutual support, and team be- known to prevent infection in newborns. Given havior were adopted, along with team rounding within 24 hours of birth, Hepatitis B vaccine and HANYS 2010 Profiles in Quality and Patient Safety 83

and huddles on anesthesiologist, LESSONS LEARNED LESSONS LEARNED each patient. Blame- neonatology staff, ■ ■ free debriefings There is an inverse students, nurses, The quality of association be- rounds is only as were conducted fol- ancillaries, and in- tween frequency good as the infor- lowing near-miss or of adverse events vited guests) has en- mation presented. adverse events. and level of team gaged in discussion ■ Missing persons at Emergency drills training achieved and planning with rounds, especially were conducted to in obstetrical care. the labor and deliv- nurses, lead to a sharpen critical in- ■ Objective measure- ery patient board significantly in- cident awareness ment of care out- twice daily (10 a.m. creased chance for comes with a tight incomplete or erro- and response. and 8 p.m.). All pa- feedback loop to neous information tients are discussed OUTCOMES staff reinforces being passed training and sus- in detail, including along. ■ Adverse events tains its impression an in-depth review ■ All participants in were reduced be- on behavior. of fetal tracings, as rounds must feel tween 26% and ■ Liability reduction needed. Clinical comfortable asking 42%. is achievable in concerns such as questions, includ- high-risk clinical ing those that chal- ■ The severity obesity, asthma, areas. lenge the current hypertension, and index of events management. dropped between other comorbidities 9% and 17%. are reviewed and ■ Malpractice claims were reduced by 66%. the implications discussed with all disciplines. Nurses present the latest information about their ■ Unexpected admissions to the neonatal inten- patients’ conditions. Social issues or other condi- sive care unit declined by more than 60%. tions that may delay discharge or affect post-de- ■ Staff perception of safety culture increased livery/post-birth care are also reviewed. 50%. ■ Results have been sustained for 36 months. Board rounds serve as a generic “huddle” before ■ No additional costs were incurred after initial scheduled operating room cases begin. If a pre- training expenses. term, ill, unstable, or very large infant is antici- pated within a short time, the delivery team may ask to delay a scheduled case until the other delivery has occurred. In cases of morbidly obese patients, options for pain control, airway Twice-Daily Labor and Delivery management, and anesthesia for operative deliv- Multidisciplinary Board Rounds ery are discussed. Post-delivery management of St. Barnabas Hospital patients with significant comorbidities is re- CONTACT: Sally Urang, R.N., C.N.M., M.S., Maternity viewed and suggestions are made. For cases of Performance Improvement Coordinator/Safety Nurse; anticipated difficulties, individual roles of par- (718) 960-5030; [email protected] ticipants may be assigned in advance at board rounds. This has been shown to improve the PROJECT DESCRIPTION efficiency of responders in emergencies. Since 2007, St. Barnabas Hospital’s labor and delivery team (including the assigned 84 HANYS 2010 Profiles in Quality and Patient Safety

OUTCOMES sessions each year, LESSONS LEARNED ■ featuring a simu- St. Barnabas Hospital enhanced “situational ■ lated video recorded Simulation-based awareness,” resulting in faster response times training is an inno- event and a team de- in emergencies and greater efficiency of vative adult learn- responders. briefing. The goal of ing tool that can the debriefing is to reinforce and teach ■ The hospital standardized the language used link team training team training when presenting patients. tools and strategies components. ■ The learning needs of staff are regularly re- to team performance ■ Laboratory-based viewed so that the organization can focus fu- and to identify op- simulation training enables providers ture educational efforts on perceived deficits. portunities for from different de- ■ Board rounds have helped to bring about a improvement. partments and dis- culture change conducive to using CRM tech- ciplines to train in niques and principles. OUTCOMES a safe educational ■ The “safety cli- environment. mate” score on ■ The majority of the safety attitude participants ask for questionnaire im- simulation every Perinatal Simulation: Building a six months; cur- proved from 68% Culture of Teamwork and Safety in rently, the organi- Obstetrics in 2007 to 78% in zation offers it Strong Memorial Hospital/University of 2009. once a year to cap- Rochester Medical Center ■ The “teamwork ture 79% of the climate” score on obstetric staff. CONTACT: Joanne Weinschreider, R.N., M.S., Perinatal Safety Nurse; (585) 275-2773; safety attitude [email protected] questionnaire improved from 58% in 2007 to 72% in 2009. PROJECT DESCRIPTION ■ The facility’s Press Ganey Obstetric/ Strong Memorial Hospital identified team train- Gynecology Service score improved from ing as a key component for building a culture of less than the 80th percentile in 2008 to the safety in medicine. Communication and organi- 99th percentile in 2009. zational culture are routinely cited as barriers to effective communication and teamwork in ob- stetrics. The addition of an innovative perinatal simulation program enabled Strong to enhance its culture of safety and improve quality care in Code H Obstetrical Hemorrhage— obstetrics. Development of a Team Approach Winthrop-University Hospital Key leaders from the obstetric and neonatal de- CONTACT: Margaret Celenza, R.N., M.S., Clinical partments first collaborated in 2007 to develop Nurse Educator, Labor and Delivery; (516) 663-9364; an interdisciplinary simulation-based team train- [email protected] ing (SBTT) program to augment perinatal safety. SBTT focuses on improving communication, PROJECT DESCRIPTION teamwork, and quality in obstetrics. Strong Hemorrhage is the leading cause of maternal holds 25 interdisciplinary high-fidelity SBTT mortality. Health care providers can prevent maternal deaths by improving recognition of HANYS 2010 Profiles in Quality and Patient Safety 85

excessive blood loss, Got Milk? Vital Human Milk for LESSONS LEARNED since blood loss is Premature Infants ■ frequently under- Never stop moni- toring processes Winthrop-University Hospital estimated and and training all CONTACT: Eileen Magri, M.S.N., R.N., N.E.-B.C., response to hemor- members of the Director of Nursing, Maternal Child Health; rhage requires a multidisciplinary (516) 663-9364; [email protected] rapid and coordi- team. ■ PROJECT nated approach. Interventions to LESSONS LEARNED Winthrop- abate hemorrhage DESCRIPTION ■ Awareness and a University Hospital occur sooner when Recognizing that single message to Code H is called. Nassau County has established a multi- mothers are ■ Chart review re- disciplinary task one of the highest essential. veals multiple risks force that devel- preterm birthrates in ■ present in most A dedicated lacta- the state, Winthrop- oped and imple- hemorrhages, tion consultant in- mented strategies some developing University Hospital creases awareness including staff edu- during labor. began an initiative for families, nurses, and medical staff. cation on estima- to foster the use of ■ tion of blood loss, response to hemorrhage, breast milk for Donor milk pro- vides a viable establishment of a massive transfusion protocol, preterm infants. option. and facilitation of the release of blood products Compared to their and laboratory results. In addition, a “Code H” full term counter- cart was created containing emergency equip- parts, pre-term infants are at considerable risk ment and a reference manual with emergency for increased morbidity and mortality, including contact numbers, diagrams of emergency learning disabilities, cerebral palsy, sensory maneuvers, and medication information. deficits, respiratory illnesses, and gastrointesti- nal illnesses. OUTCOMES ■ Staff recognize and respond to significant Mothers’ own milk (MOM) programs have blood loss sooner. demonstrated nutritional, gastrointestinal, im- ■ A team approach fosters better defined roles, munological, developmental, and psychological communication, and patient-focused nursing benefits for pre-term infants. Breastfed pre-term care. infants have lower rates of ear, respiratory, and gastrointestinal infections, and lower mortality ■ The blood bank’s response to blood product rates. In addition, breastfed pre-term infants are requests is more timely and efficient. discharged earlier from the neonatal intensive ■ Nurses feel supported because they can acti- care unit (NICU). vate Code H. ■ Hemorrhages are reviewed with specified data This project’s goal was to increase the amount of criteria for process improvement follow-up. MOM and provide donor milk in the NICU. This was achieved by providing a dedicated NICU lac- tation consultant, educating nurses and resi- dents, using “premie” pumps/insurance-covered rental pumps, and donor milk. 86 HANYS 2010 Profiles in Quality and Patient Safety

OUTCOMES This initiative: ■ increased the percentage of mothers provid- ing MOM from 73% to 93%; ■ increased MOM production using the premie pump; and ■ increased insurance reimbursement for breast pump rentals, decreasing the program’s cost. HANYS 2010 Profiles in Quality and Patient Safety 87

SPECIALTY—MENTAL HEALTH

Criminal Justice Treatment Program and case management for individuals being re- to Enhance Addiction Treatment leased from incarceration and those who are at and Public Safety risk of parole violation due to substance abuse. Eastern Long Island Hospital OUTCOMES CONTACT: Jack Hoffmann, L.C.S.W., Director, ■ Behavioral Health and Clinical Relations; Treatment groups were provided within two (631) 477-1000 ext. 132; [email protected] correctional facilities for three years. ■ About 880 inmates per year were served in PROJECT LESSONS LEARNED both correctional facilities. DESCRIPTION ■ ■ There were four graduating classes from the This innovative col- Cognitive behav- ioral therapy cre- RIC. Graduation criteria included a minimum laboration between ates positive of one-year of court compliance and continu- criminal justice or- changes in criminal ous sobriety. ganizations and thinking. ■ Eastern Long Island ■ Education for be- The hospital-based behavioral health contin- Hospital’s behav- havioral health uum treated 156 parolees. ioral health treat- staff regarding ment continuum criminality and criminal thinking is focused on: imperative for the ■ treatment groups successful treat- within the ment of offenders. county correc- ■ Appropriate use of tional facilities; drug court sanc- tions within the ■ providing a clini- psycho-social pro- cal advisor to file is successful local drug courts; in reducing and recidivism. ■ hospital services providing primary treatment and assessment for the county’s re-entry program.

Treatment at county correctional facilities con- sisted of weekly groups and ongoing drop-in ses- sions for both men and women that challenge criminal thinking and stress cognitive behav- ioral changes. The drug court clinical advisor is a member of the treatment team for the Regional Intervention Court (RIC) who sits twice weekly with the judge, coordinator, and probation officer to review and design the court’s treatment assessment and plan. The re- entry task force and hospital collaboration facili- tates appropriate behavioral health treatment 88 HANYS 2010 Profiles in Quality and Patient Safety

SPECIALTY—OUTPATIENT SERVICES

Reversing the Ravages of Chronic certified diabetes educator and nutritionists to Wounds: A Community-Based ensure patients are able to manage their comor- Approach bid conditions. The center collects data to moni- Claxton-Hepburn Medical Center tor, track, trend, and improve heal rates and patient satisfaction. CONTACT: Judy B. Tubolino, B.S.N., M.S.H.C.A., Program Director, Wound Healing Center; OUTCOMES (315) 394-0426; [email protected] ■ Claxton-Hepburn Medical Center more than PROJECT doubled the number of patient encounters LESSONS LEARNED DESCRIPTION from 2007 to 2009. ■ Claxton-Hepburn A rural community can successfully ■ Sixteen-week heal rates were 76% in 2007, Medical Center re- develop a compre- 87% in 2008, and 94% in 2009. sponded to a com- hensive wound ■ Overall wound heal rates were unavailable in munity need for healing center that 2007, 73% in 2008, and 85% in 2009. effective, compre- provides protocol- hensive wound serv- based, state-of- ■ The amputation rate was 1%. ices by opening a the-art wound healing services. dedicated wound ■ An evidence-based healing center. program aimed at Claxton-Hepburn’s healing patients Appropriate Control of Sample rural community can be cost effec- Medications in Hospital-Owned has a high incidence tive and lead to in- Physician Practices of diabetes and obe- dividual patient Jones Memorial Hospital sity, with a subse- success. CONTACT: Cheryl Feeman Macafee, M.B.A., R.H.I.A., ■ A multidisciplinary quently high rate of Director, Quality Management; (585) 596-4020; non-healing physician-led ap- [email protected] proach to wound wounds. Before care significantly PROJECT DESCRIPTION opening the wound enhances patients’ Dispensing sample medications from physician healing center, pa- quality of life. tients either lived practices not only allows the patient to begin with chronic wounds or traveled more than 100 therapy sooner by receiving the medication at miles to the nearest center. The center uses evi- the conclusion of the office visit, but it enables dence-based clinical pathways and treatment the practitioner to determine the patient’s toler- protocols, and continuous review of best prac- ance to the medication and dose before giving tices with a multidisciplinary team approach led the patient a prescription for a complete regi- by trained physicians. Treatment protocols in- men. There was no standardized process to con- corporate traditional wound treatments, hyper- trol, dispense, and recall medication samples in baric oxygen therapy, use of tissue of human or Jones Memorial Hospital’s physician practices. bio-engineered origin, growth factor therapy, Following the Failure Mode and Effects Analysis and negative pressure wound therapy. Claxton- (FMEA) process, the original process was flow- Hepburn Medical Center also individualized charted and potential failures were identified. treatment plans to meet the physiological needs The “failures” were redesigned and the final of each patient. The facility works closely with a process includes these steps: HANYS 2010 Profiles in Quality and Patient Safety 89

■ A point person Decreasing the Dialysis Catheter- LESSONS LEARNED for each practice Associated Bacteremia Rate Before this initiative: ensures that each Rochester General Hospital Dialysis Center sample medica- ■ Medications were being dropped off CONTACT: Marie Wade, B.S.N., R.N., C.N.N., tion is appropri- with no determina- Director, Dialysis Services; (585) 922-0304; ately signed into tion of need in the [email protected] the sample med- practice. PROJECT ication room log. ■ The process to doc- LESSONS LEARNED ■ ument the sample DESCRIPTION A new three-part ■ Ongoing training medication dis- The risk of death script pad was and competency pensed contained from bacteremia in- developed—one observation make too many steps fection is high for a difference in as- part goes to the and required docu- patients undergoing suring best care patient, one for mentation in three dialysis because and outcomes. the patient’s different locations, their immune sys- ■ record, and one creating an inaccu- The decrease in tems are compro- cost from hospital- for the log. rate inventory. izations and subse- ■ The pharmacy did mised due to a ■ The script copy quent maintenance not have knowl- variety of renal of treatment vol- for the log en- edge of what was factors and other ume in the outpa- ables the point in stock. comorbidities. tient setting more person to adjust Rochester General than offset the ad- the balance of the medication to reflect the Hospital began qual- ditional supply correct number of medications that are left ity improvement expense. on the shelf. work in this area, ■ Collaboration be- ■ Inventory is reconciled with each script writ- using Centers for tween involved departments is ten. Expired medications are sent back to the Disease Control and necessary to sup- pharmacy with the log. In addition, once the Prevention (CDC) port and assure lot is depleted, the log is sent back to the data on bacteremia best practices. pharmacy. rates. The nursing leadership at Rochester General Hospital’s dialy- OUTCOMES sis center worked closely with infection control, ■ This initiative achieved 100% accurate inven- infectious disease, and pharmacy staff to review tory of sample medications in five out of six the evidence and modify procedures to ensure practices. best practices. The following interventions were ■ There is 100% recall ability after the log is implemented between 2003 and 2009: sent to the pharmacy. ■ alcohol scrub of connections prior to opening; ■ The practices completed 100% documenta- ■ excluding technicians from exit site care; tion reflecting what is given to each patient, ■ in-service education of nursing staff and including dose, route, and education. annual competency observation; ■ using Biopatch dressing at exit site; ■ changing to citrate lock instead of 10,000- unit heparin locks drawn from multiple vials by a registered nurse; and 90 HANYS 2010 Profiles in Quality and Patient Safety

■ changing to Gentamycin/citrate locks. Defy Diabetes also LESSONS LEARNED targeted improving ■ This project makes a clear statement that diabetes care and pa- The “train the trainer” model, Rochester General Hospital puts patient safety tient outcomes de- although time- first. Despite the significant increase in supply livered by health intensive, is costs involved with several of the above inter- care providers. Defy effective. ventions, there was absolute support to move Diabetes engages the ■ The church and the forward. primary care health faith community system to improve nurses are ex- OUTCOMES outcomes by pro- tremely powerful as sustainable and ■ Post-intervention, the bacteremia rate was moting the effective providers below the CDC benchmark for all of 2009. American Diabetes of diabetes ■ There were fewer hospitalizations of dialysis Association (ADA) education. outpatients related to catheter bacteremia. guidelines through ■ The diabetes nurse ■ Mortality rates are below the national average the role of diabetes champion is very for hemodialysis patients. nurse “champions.” effective as a Providers receive on- transformative going education and agent within the health care deliv- support from the ery system. Defy Diabetes team Defy Diabetes! and their nurse Seton Health champions. A unique chart assessment tool pro- CONTACT: Debra Frenn, R.N., M.S.N., F.A.C.H.E., vides individual feedback to providers. Chief Nurse Executive; (518) 268-5520; [email protected] OUTCOMES In the faith communities: PROJECT DESCRIPTION ■ More than 1,000 people heard pulpit talks, 18 Seton Health’s Defy Diabetes program provides health fairs with screenings and 65 Healthy training and a curriculum to faith community Living classes were held, and there are 78 on- nurses located in churches in high-risk commu- going support groups. nities. This education has led to pulpit talks, screening health fairs, and a four-class “Healthy ■ Research is underway to measure improved Living Series” with a holistic body, mind, and health status (measuring BMI, waist circum- spirit perspective. This was followed by ference, weight, blood pressure, self-care monthly support groups where participants’ activities, etc.). blood pressure, body mass index (BMI), waist In the physician offices: circumference, and weight were measured. Par- ticipants also completed self-empowerment and ■ Thirty-two provider teams were engaged, 14 self-care surveys. The intent is to help people nurse champions were trained, a random sam- with diabetes and those at risk of developing ple of 1,230 medical charts were audited, and diabetes make modest lifestyle changes that can there were seven successful applications (to prevent progression or delay the onset of Type 2 date) for the National Commission for Quality diabetes. Assurance Diabetes Recognition Program. HANYS 2010 Profiles in Quality and Patient Safety 91

SPECIALTY—PRIMARY CARE

Patient-Centered Medical Home for Regular medical monitoring and patient self- Diabetes Management management can dramatically reduce morbidity The Brooklyn Hospital Center and mortality. Physical activity and appropriate nutrition have been shown to reduce the disease CONTACT: Vasantha Kondamudi, M.D., Chair, progression in those at highest risk by 60%. Department of Family Medicine; (718) 250-8444; [email protected] Controlling HbA1C, blood pressure, cholesterol, and smoking is key. PROJECT LESSONS LEARNED DESCRIPTION OUTCOMES ■ A multidisciplinary The Brooklyn ■ Eighty-four percent of the intervention group diabetes education Hospital Center re- program that is had an HbA1c level of less than 9.0, com- sponded to the dia- culturally appro- pared with 45% in all of New York City. betes crisis with an priate in terms of ■ Sixty-five percent of the intervention group language, social initiative designed had blood pressure of less than 130/80, com- emphasis, nutri- to test the impact of pared with 50% in all of New York City. multilingual, cultur- tional guidance, and acknowledg- ■ Sixty-seven percent of the intervention group ally appropriate, ment of cultural had less than a 100 level of low-density comprehensive dia- health beliefs im- lipoprotein cholesterol, compared with 35% betes education on proves outcomes. in all of New York City. outcome measures ■ Application of the in African American patient-centered ■ Eighty-six percent of the intervention group and Latinos with medical home con- received aspirin, compared with 23% in all of Type 2 diabetes, cept to manage New York City. chronic disease im- and to evaluate the proves compliance effectiveness of self- with various as- awareness interven- pects of diabetes tion in promoting management. diabetes self-care. A study in Diabetic Care found that fewer than 10% of New Yorkers with diabetes are control- ling their disease. Diabetes disproportionately affects black, Latino, and low-income New York- ers. These disparities are evident in diabetes prevalence, hospitalization, and mortality rates. In these neighborhoods, diabetic health literacy remains extremely poor. In Brooklyn, 80% of adults with diabetes report having had a gly- cated hemoglobin (HbA1C) test in the past year; however, only 16% of these adults know their HbA1C levels. 92 HANYS 2010 Profiles in Quality and Patient Safety

SPECIALTY—REHABILITATION/LONG-TERM CARE

Medication Administration ■ consistent observation of skin conditions Compliance Initiative with designated treatment nurses; Mountainside Residential Care Center ■ efficient use of current full-time staff and an CONTACT: Christina Jones, R.N., B.S.N., C-N.E., increase in staff productivity; Director of Nursing; (845) 586-1800, ext. 3318; ■ appropriate use of per diem staff; and [email protected] ■ facility cost savings due to efficiency gained PROJECT from staff restructuring. LESSONS LEARNED DESCRIPTION ■ Mountainside With the focus on patient safety, the Residential Care facility was able to Center imple- restructure the Reducing Catheter-Associated mented an elec- nursing staff, even Urinary Tract Infections with staff hesita- tronic medical Stern Family Center for Extended Care record medication tion about the an- and Rehabilitation/North Shore-Long administration sys- ticipated changes. Island Jewish Health System tem in March 2009 ■ The need for com- munication can and began to run CONTACT: Jeanine A. Filardi, R.N., B.S.N., Infection never be underes- Control Coordinator; (516) 562-8191; [email protected] reports that re- timated and needs vealed that medica- to be consistently PROJECT LESSONS LEARNED tions were being reinforced during DESCRIPTION ■ given outside the any transition. The Stern Family Compliance with the standard of one-hour time- ■ Staff required con- Center for Extended practice exempli- frame. Baseline data stant encourage- Care and fies optimum showed that, on av- ment that the facility would not Rehabilitation expe- outcomes. erage, 10.75% of the allow staff to “fail” rienced a marked ■ Facility-acquired medications were with the new sys- increase in facility- CAUTI can be re- given late on the tem and that the acquired catheter- duced through ed- two units (ranging process would be associated urinary ucation, adherence continually to policy and pro- from 8% to 14% tract infections late) for the day and evaluated. cedure, and close (CAUTIs) in 2006. monitoring. night shifts. An in- These findings were ■ LOS and Medicare terdisciplinary team began to brainstorm ideas presented and dis- costs are reduced to improve medication administration compli- cussed at monthly by decreasing in- ance, with a goal of less than 10% given late. performance im- fections, labora- The team determined that a process redesign provement coordi- tory diagnostics, would be necessary to improve the compliance nating group and medication usage. rate. The new restructuring took effect in meetings. A task November 2009. force was formed and a facility-wide approach was initiated to: OUTCOMES There was significant improvement in medica- ■ review and revise policies and procedures; tions administered within the one-hour time- ■ provide interdisciplinary staff education; frame, with secondary gains in: HANYS 2010 Profiles in Quality and Patient Safety 93

■ revise the standard of practice to effect the re- PROJECT LESSONS LEARNED moval of catheters within 24 hours; DESCRIPTION ■ Specialty hospitals ■ St. Mary’s Hospital assess patients upon admission for continued have a longer for Children is in its catheter use within 24 hours, if indicated; length of stay, in- second year of a col- ■ promote a culture of safety by infection con- creasing the likeli- laboration with the trol staff enforcing and monitoring appropri- hood of acquiring National Association a health care- ate hand hygiene; of Children’s associated ■ provide frequent and adequate perineal care; Hospitals and infection. ■ insert indwelling catheters using an aseptic Related Institutions ■ Maintaining a sterile field con- technique; (NACHRI) to tributes signifi- ■ change indwelling catheters monthly; decrease central cantly to decreas- ■ maintain urinary drainage bags below the line-associated ing CLABSIs. level of the bladder; bloodstream infec- ■ Ongoing evalua- tions (CLABSI) in tion of new and ■ use a clean receptacle to empty the drainage children who reside existing products bag; in a pediatric post- associated with ■ monitor indications for indwelling catheter acute setting. The central lines is es- sential to the use; Centers for Disease process. ■ use trial voiding when appropriate; and Control and ■ Collaboration with ■ monitor post-void residual. Prevention’s similar facilities National Healthcare helps align stan- OUTCOMES Safety Network dards of care and ■ Over three years, the Stern Center reduced (NHSN) established establish realistic benchmarks and facility-acquired CAUTIs by 75%. national bench- best practices. marks for neonatal ■ This increased patient satisfaction while de- creasing length of stay (LOS) and the cost of and pediatric inten- treatment and medical supplies. sive care units, but those benchmarks do not represent St. Mary’s long-term patients. The ■ Nursing staff efficiency was enhanced. team began by establishing nationally accepted ■ Antimicrobial usage was reduced. definitions for data collection, tracking, and re- porting infection rates. The next step involved a careful review of standards of care and clinical practice guidelines. The team concurred that the Reduction in Catheter-Related most common cause of infection for this popula- Bloodstream Infections in a tion is contamination at the skin level. Once the Pediatric Post-Acute Setting skin is contaminated, organisms move into the St. Mary’s Hospital for Children tract of the catheter, contaminate the catheter hub, and ultimately move into the patient’s CONTACT: Marianne Pavia, M.T., C.L.S., C.I.C., Infection Control Coordinator; (718) 281-8532; bloodstream. This project focused on preventing [email protected] the contamination of the skin and subsequently, the catheter. 94 HANYS 2010 Profiles in Quality and Patient Safety

OUTCOMES ■ Environmental LESSONS LEARNED ■ services staff Criteria were established to define one for- ■ schedule a mini- Continuous, open mula for calculating rates. communication mum of one ■ Overall infection rates decreased. and compliance T-Team member with best practices ■ Total parenteral nutrition was identified as a for each day of improves contributing factor for increased infections the week. outcomes. that must be evaluated separately. ■ Hand hygiene is ■ Facility-acquired ■ A consolidated kit was created to maintain a reinforced and CDAD can be re- duced through ed- sterile field. monitored ucation, adherence ■ When cleaning the hub of a catheter, regularly. to policies and pro- alcohol and betadine were replaced with ■ Facility-wide cedures, and close Chlorhexadine. communications monitoring of feedback. ■ Policies related to practice and products were included periodic ■ revised. infection control Length of stay and Medicare costs can updates by be reduced by e-mail, and a eliminating infec- nursing alert to tions—an esti- Reducing Facility-Acquired environmental mated savings of services when $3,000 to $7,000 Clostridium Difficile-Associated per infection. Disease precautions were Stern Family Center for Extended Care discontinued or and Rehabilitation/North Shore-Long in advance of discharge. Island Jewish Health System ■ The use of quinolone antimicrobials was limited. CONTACT: Jeanine A. Filardi, R.N., B.S.N., Infection Control Coordinator; (516) 562-8191; [email protected] ■ Maintenance staff painted rooms and replaced ceiling tiles. PROJECT DESCRIPTION ■ Administration increased the environmental The Stern Family Center for Extended Care and services budget. Rehabilitation experienced a marked increase in facility-acquired Clostridium Difficile-Associated OUTCOMES Disease (CDAD) during second quarter of 2008. ■ The Stern Center achieved a 33% reduction in The infection control committee formed a sub- facility-acquired CDAD. committee to improve performance. Based on ■ The environmental staff’s self-esteem has im- the sub-committee findings, a facility-wide proved because of this initiative. approach to reduce CDAD was adopted: ■ Success was recognized by an employee party ■ A terminal clean team (“T-Team”) was created and an article and photo in the facility with trained environmental personnel and newsletter. each T-Team member was issued additional uniforms that were laundered onsite. ■ A cleaning checklist was developed for the two-step, two-person, 1½-hour cleaning process. HEALTHCARE ASSOCIATION OF NEW YORK STATE One Empire Drive, Rensselaer, NY 12144 (518) 431-7773 www.hanys.org