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SPHS – Mercy Medical Center, Implements a Program to Decrease Pressure Ulcers

As the Centers for Medicare & Medicaid Services (CMS) continue to provide less payment for hospital acquired pressure ulcers, increased demands are placed on nurses to reduce the number of patients who acquire these conditions. As pressure-ulcer incidence rates continue to rise, more hospitals are implementing intervention and prevention programs in order to combat pressure ulcer occurrence and improve patient care.

To prevent potential pressure ulcers, Mercy Medical Center, Springfield, MA, decided to create and utilize a Pressure Ulcer Prevention Program (PUPP). The program was designed specifically for the hospital's respiratory unit, which was experiencing the highest pressure ulcer incidence rate of any unit throughout the acute care facility. The purpose of the PUPP was to decrease the number of hospital acquired pressure ulcers in patients with multiple co-morbidities who were being treated here.

Mercy Medical Center's success was featured in this article of Advance For Nurses.

MetroWest Medical Center Demystifies Outpatient Satisfaction

For MetroWest Medical Center, a 319-bed regional healthcare system with hospital campuses and outpatient facilities in the adjacent towns of Framingham and Natick, Mass., seven was just the right number of tactics needed to put its outpatient scores where they belonged - at the top. In fact, throughout fiscal year 2011, MetroWest's outpatient scores have consistently remained above the 96th percentile, and the goal is to bring them even higher. MetroWest's success was featured in this article of partners, a publication of Press Ganey.

BID – Milton Hospital Reduces Catheter-Associated Urinary Tract Infections

 10-04-28PCLMILTONphotoNEWCatheter Associated Urinary Tract Infections (CAUTIs) are an often preventable healthcare- associated infection (HAI) common in hospitals across the country.  These infections can be a serious complication for patients, can increase the time they are hospitalized and add to the cost of care. On occasion, antibiotic treatment of CAUTIs can also pose potential health risks for the patient.

PLAN: Identifying Issues and Goals

Using a Plan-Do-Study-Act performance improvement model, Milton Hospital launched a comprehensive patient safety initiative program to reduce this type of infection. A multidisciplinary care team consisting of nurses, physicians, clinical educators and Infection Prevention Specialists set a goal to achieve zero incidences of CAUTI for inpatients by October 2010.

After an extensive review of current literature and best practices, Milton Hospital decided to adopt a practice bundle described by the Institute for Healthcare Improvement (IHI). This set of care practices called for more restrictive catheter use, prompt removal, and hygiene management of catheters while inserted and patient and staff education.

DO: Implementing and Reinforcing New Practices

Following this practice bundle as a guide, the hospital updated its catheter insertion criteria to reduce unnecessary catheter use.

"Limiting catheter use and minimizing the duration of its insertion are important strategies to reduce CAUTIs," said Alex Campbell, MSN, RN, EN, BC, Director, Healthcare Quality.

To determine the need for catheter insertion, Milton Hospital purchased a portable bladder ultrasound scanner, which can identify whether the patient is unable to empty his/her bladder fully. This device often eliminates the need for urinary catheterization in some patients.  Nursing staff was trained in the proper use of this device. Additionally, all nursing staff were re-educated on the proper sterile procedure for inserting catheters, as well as the appropriate post-insertion management process.

Procedures were developed and implemented to improve communication between nurses and physicians regarding catheterized patients.  On a daily basis, all catheterized patients are evaluated to determine the earliest opportunity to remove the catheter. Also on a daily basis, clinical educators monitor staff for compliance with updated insertion and management procedures.  Educational materials, including brochures and posters, were developed not only to reinforce staff training, but also to inform patients of their role in reducing the risk of infection related to catheter use.

STUDY: Measuring the Affects of Process Changes

To establish a reliable means of tracking CAUTI rates, the hospital developed data collection processes relating to this infection type and relating to compliance with new practice expectations. Data is reviewed on an ongoing basis by Infection Prevention, Nursing, Medical Staff and hospital leadership.

In August 2009 (prior to the roll out of the practice bundle), Milton Hospital experienced four incidents of healthcare-associated CAUTIs in that month.  After introducing its performance improvement plan in September 2009, a significant reduction in the incidence of CAUTIs was achieved. Between September 2009 and March 2010 (seven months) only three incidents of CAUTI occurred at Milton Hospital. This is an 89% reduction in comparison to August 2009.

In addition, the Urinary Catheter Device Utilization rate, which measures the percentage of patients who had a catheter in place and the duration of catheter use, dropped from 25.9% in September 2009 to 18.1% by March 2010 (a decrease of more than 30%).  As a final measure of success, in October 2009, the Centers for Medicare and Medicaid (CMS), based on best practice recommendations, required hospitals to ensure that all post-operative patients with urinary catheters had them removed when appropriate by their second post-operative day. Although this is a new expectation for hospitals, by January 2010 Milton Hospital achieved and has maintained a compliance score of 100% with this expectation.

ACT: Maintaining and Improving Momentum

Today, Milton Hospital continues to work toward its goal of eliminating CAUTIs.  Ongoing analysis and investigation identify new opportunities for improvement, as the Plan-Do-Study-Act process continues to evolve.

Healthcare Acquired Infections

Healthcare acquired infections (HAIs), also known as nosocomial infections, are infections that patients get while receiving treatment for medical or surgical conditions. HAIs occur in all settings of care, including hospitals, surgical centers, ambulatory clinics, and long-term care facilities such as nursing homes and rehabilitation facilities.

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Newton-Wellesley Hospital: eMAP Rx for Medication Errors?

According to the Institute of Medicine (IOM), "medication-related error … is one of the most common types of error, substantial numbers of individuals are affected, and it accounts for a sizable increase in health care costs."*  In order to decrease the potential for medication-related errors, Newton-Wellesley Hospital launched a major patient safety initiative in 2009 - the implementation of an electronic Medication Administration Process (eMAP).

The eMAP process maximizes the use of clinical information systems to standardize the encoding of data used to identify medications, patients, and clinicians and to protect patients from preventable medication errors. In addition, electronic documentation allows readily available viewing access by all healthcare providers to the medication administration record.  eMAP combines the technology of an electronic Medication Administration Record (eMAR) and bar-code technology to confirm patient, medication, and provider bedside medication verification (BMV).  The use of the technology is an additional tool for clinicians to provide safer patient care. 

Newton-Wellesley Hospital implemented eMAP across 14 units in 2009.  eMAP maximizes the use of clinical information systems and bar-coding to ensure that the right patient receives the correct medication and dose; it also provides warnings to the nurses who administer the medications if there are discrepancies. This initiative required extensive planning from many departments, including clinical informatics, nursing, education, pharmacy, information services, and physicians.  More than 120 order sets, 2,000 formulary medications, dose instructions, and administration criteria were evaluated.  New hardware required in-depth evaluation and testing.  Intensive training and support were provided before, during, and after implementation. 

As a way of evaluating the effectiveness of eMAP implementation, the number of medication errors reported in the Safety Reporting System (SRS) was analyzed.  The majority of medication errors reported in the SRS are near misses and/or errors that caused no patient harm.  Nevertheless they provide an opportunity to review practices and recommend positive changes.  An analysis of the data revealed that since implementation of eMAP in November 2008, the rate of reported errors has decreased.  Looking at specific points in time (November 2008 & June 2010), the percentage of change for all reported  transcription, administration, and total medication errors decreased by  56%, 53%, and 56% respectively. 

NEWEST

Additional monitoring is performed quarterly on eMAP quality monitoring day to identify other opportunities to improve the overall performance related to safe medication practices.  On these days, staff members observe their peers as they use the process, and data is collected from current medical records.  A review of this data allows the team to determine other enhancements in the system, the process, or both.  For example, it was recently noted that one oral medication was not being scanned consistently by nursing.  Based on further information, it was identified that the medication was packaged in such a way as to make it difficult to scan with the bar-coding technology.  Pharmacy has identified a vendor with a more readable bar code and is working with nursing to change the inventory. 

This hospital-wide endeavor highlights one step on the journey to continuously improve the quality and safety of the care given to our patients and the efforts and support of all involved in this pursuit.

* Institute of Medicine, To Error is Human; Building a Safer Health System (Washington, DC,: National Academy Press, 2000), p. 28

-- by Sandy Abboud, RN, MPH; Manager, Clinical Informatics
 and Sue Scott, RN, Ed.M, Nursing Quality Program Manager

Norwell VNA Fights Readmissions

A program at the Norwell VNA and Hospice that targets patients with Heart Failure (HF) has proven successful in reducing hospital admissions and readmission.

The Norwell model relies on two foundational elements: (1) a strong clinical commitment to chronic care management using a wide-ranging team of providers and the patient, and (2) early intervention using telehealth technology.

All of Norwell's patients with a history of heart failure are entered into its care management program, but are managed differently depending on the severity of their illness. All interventions consist of two teams - the telehealth team and the home healthcare team coordinating care.

The telehealth team includes a nurse practitioner, three registered nurses on a rotating schedule, and one technician to manage the telehealth equipment. The home health team includes the home health nurse, the agency's medical director, occupational and physical therapists, case managers, home health aides, nutritionists, and medical social workers.

Readmission programs also rely heavily on case management personnel at area hospitals, a patient's primary care physician, patients themselves, and patients' families

A key element of the Norwell program is "front-loading" visits to high-risk patients during the first week of care. Within the first 24 and 48 hours, two visits are made to conduct initial assessments, set up the telehealth equipment, and involve the patients in their own care.

The telehealth technology provides real-time information to the care team to support their decision making and helps patients recognize the signs and symptoms that may indicate their heart failure is worsening. For example, it can provide a comparison to the prior day's weight. (A patient with congestive heart failure that gains weight quickly - 2 to 3 pounds in 24 hours - is retaining water and is at risk for rehospitalization.) The telehealth system can also provide daily health status assessment and education. Based on the patient's responses, the telehealth equipment helps the patient connect their daily behaviors to their health status.

The Norwell VNA's care management program combined with the telehealth technology successfully reduced the organization's overall acute care hospitalization (ACH) rate from 25% to 20% as reported in Home Health Compare. The ACH rate for just heart failure patients in the program was 19%. Of the 115 people enrolled in the heart failure program, 22 were re-hospitalized, and the most prevalent reasons for those hospitalizations were falls and shortness of breath (dyspnea).

This publication from the Alliance for Home Health Quality & Innovation gives more information about Norwell VNA and Hospice's successful program.
The Norwell VNA and Hospice's initiative is just one of the many programs underway in Massachusetts and throughout the U.S. to reduce hospital readmissions. MHA has played a role in coordinating many of those efforts within the state, which include: STAAR (STate Action on Avoidable Rehospitalizations); Potentially Preventable Readmissions (PPR) Project with 3-M; MOLST (Medical Orders for Life-Sustaining Treatment); and Project BOOST (Better Outcomes for Older Adults through Safe Transitions).

Partners Study on Falls Featured in JAMA

Reducing falls and the injuries that arise from such falls is a major goal of Massachusetts hospitals, which report their falls data through PatientCareLink. And our hospitals are developing the best practices, innovative strategies, and measurement tools that other states are using to address the issue.

In the Vol. 304, No. 17, November 3, 2010, issue of JAMA - the Journal of the American Medical Association - researchers from Partners HealthCare System, Brigham and Women's Hospital, Harvard Medical School, and Massachusetts General Hospital, report on whether a fall prevention tool kit using health information technology decreases patient falls in hospitals.

JAMA is available through subscription only, but the Abstract text below, outlines the key points of the study:

Fall Prevention in Acute Care Hospitals
A Randomized Trial

Patricia C. Dykes, RN, DNSc; Diane L. Carroll, RN, PhD, BC; Ann Hurley, RN, DNSc; Stuart Lipsitz, ScD; Angela Benoit, BComm; Frank Chang, MSE; Seth Meltzer; Ruslana Tsurikova, MSc, MA; Lyubov Zuyov, MA; Blackford Middleton, MD, MPH, MSc

JAMA. 2010;304(17):1912-1918. doi:10.1001/jama.2010.1567
Context  Falls cause injury and death for persons of all ages, but risk of falls increases markedly with age. Hospitalization further increases risk, yet no evidence exists to support short-stay hospital-based fall prevention strategies to reduce patient falls.

Objective  To investigate whether a fall prevention tool kit (FPTK) using health information technology (HIT) decreases patient falls in hospitals.
Design, Setting, and Patients  Cluster randomized study conducted January 1, 2009, through June 30, 2009, comparing patient fall rates in 4 urban US hospitals in units that received usual care (4 units and 5104 patients) or the intervention (4 units and 5160 patients).

Intervention  The FPTK integrated existing communication and workflow patterns into the HIT application. Based on a valid fall risk assessment scale completed by a nurse, the FPTK software tailored fall prevention interventions to address patients' specific determinants of fall risk. The FPTK produced bed posters composed of brief text with an accompanying icon, patient education handouts, and plans of care, all communicating patient-specific alerts to key stakeholders.

Main Outcome Measures  The primary outcome was patient falls per 1000 patient-days adjusted for site and patient care unit. A secondary outcome was fall-related injuries.

Results  During the 6-month intervention period, the number of patients with falls differed between control (n = 87) and intervention (n = 67) units (P=.02). Site-adjusted fall rates were significantly higher in control units (4.18 [95% confidence interval {CI}, 3.45-5.06] per 1000 patient-days) than in intervention units (3.15 [95% CI, 2.54-3.90] per 1000 patient-days; P = .04). The FPTK was found to be particularly effective with patients aged 65 years or older (adjusted rate difference, 2.08 [95% CI, 0.61-3.56] per 1000 patient-days; P = .003). No significant effect was noted in fall-related injuries.

Conclusion  The use of a fall prevention tool kit in hospital units compared with usual care significantly reduced rate of falls.

Trial Registration  clinicaltrials.gov Identifier: NCT00675935

Author Affiliations: Partners HealthCare System (Drs Dykes and Middleton, Ms Benoit, and Messrs Chang and Meltzer), Brigham and Women's Hospital (Drs Dykes, Hurley, Lipsitz, and Middleton, and Ms Tsurikova), Harvard Medical School (Drs Dykes, Lipsitz, and Middleton), and Massachusetts General Hospital (Dr Carroll and Ms Zuyov), Boston.

Patient Falls

The National Quality Forum (NQF) defines a fall as an unplanned descent to the floor (or extension of the floor e.g., trash can or other equipment) with or without injury to the patient.

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Partners: Coordinating Care for High-Risk Patients

The results are in from Partners HealthCare's Medicare demonstration project that was conducted at Massachusetts General Hospital (MGH).

In August, 2006, the Centers for Medicare and Medicaid (CMS) funded the MGH and the hospital's physician organization to launch the Care Management Program at MGH, one of six demonstration projects nationwide. During the three-year demonstration, the MGH developed new strategies to improve the way health care is delivered to its most vulnerable high risk patients - those with multiple health conditions and chronic disease.

The program integrates nurse care coordinators into primary care practices to coordinate each patient's medical and psychosocial needs. It focuses on the sickest patients because 10 percent of Medicare patients represent nearly 70 percent of Medicare spending.

Here's the results: Hospital readmissions dropped 20 percent, and emergency room visits dropped 13 percent for patients enrolled in the program. Patients and caregivers rated it highly. And the program resulted in annual net savings of 7 percent among enrolled patients after accounting for the management fee paid by CMS to MGH. Over the first three years, MGH invested more than $8 million to operate the program, but the return on investment is high; for every dollar spent, the program saved $2.65 in health care costs.

In 2009, CMS renewed the MGH program for another three years (only three of the original demonstration projects were renewed) and expanded it to two more Partners hospitals, Brigham and Women's and North Shore Medical Center. To date, the Care Management Program has enrolled almost 5,000 patients and is expected to involve more than 8,000 total patients over the next few years.

 

MetroWest’s Readmission Intervention Strategies

 

In 2011, MetroWest HomeCare & Hospice, in partnership with MetroWest Medical Center, initiated a strategic and evidence based effort to reduce their emergent care visits and acute care hospitalization rates. 

The effort was initiated with the formation in November 2011 of MetroWest's Re-Admission Intervention Strategy Council (RISC).  The RISC includes representatives from management, nursing, rehabilitation, palliative care, and a heart failure nurse specialist.  In addition, RISC invites specific expertise - for example, social worker, wound nurse, physician specialists - when needed to address particular issues. The Council took a multi-disciplinary approach to reducing unnecessary re-hospitalizations, improving quality of care and optimizing patient outcomes.  In the beginning, RISC met every other week and eventually was decreased to a monthly meeting.  Often special projects or educational programs require additional time of some RISC members.

Together these efforts have proven successful in reducing overall acute care hospitalization rates.  In June 2012, only six months into RISC, MetroWest Home Care's readmission percentile ranked 46th in the state and 55th in the nation, according to CMS's Home Health Compare and CASPER reporting system. In May 2013, after all RISC initiatives had been implemented, MetroWest was ranked in the 4th percentile for the state and the 6th percentile for the nation.  These numbers have been maintained.

The goals of RISC include:

  • Use data collection and analysis to identify any trends in hospital transfers;
  • Increase team awareness of patients who return to the hospital, especially repeat visitors;
  • Use of Case Conferences and Plan of Care modifications to keep patients at home;
  • Reduce hospital re-admissions and improve patient quality outcomes.

To identify trends, RISC developed a user-friendly data collection tool tracking patients transferred to the hospital.  Based on the data collected and analyzed, RISC developed a dashboard to illustrate key trends, summarizing the primary reasons for hospitalization, risk factors, and which hospitalizations might be preventable based on the documentation, and why. For example, if a heart failure patient who does not follow the plan of care with weights, and whose Lasix dose was not adjusted accordingly, is re-hospitalized, then that re-hospitalization would be considered potentially avoidable through better medication management at home. An RISC Nurse Specialist completes the OASIS Transfer Assessment and reviews the clinical documentation.  The whole RISC team presents data and cases at regular meetings of the hospital's Quality Council.

As a result of the RISC analyses, MetroWest's RISC has implemented a host of interventions and strategies to meet its readmission reduction goals:

  • Created the Patient at Increased Risk for Transfer (PIRT) Alert Process, which identifies a patient that has been transferred to the hospital more than once in a 60-day episode. The PIRT Alert is communicated at time of transfer to the clinical managers and clinicians who have been involved with the patient's case so timely follow up and interventions can be implemented. 
  • Created and implemented Heart Failure & COPD Management Programs, in which high-risk patients for re-hospitalization with heart failure or chronic respiratory diagnoses are identified at intake for program protocol.  Patients on program receive a specialized schedule of visits - such as medication intensive visit and case manager continuity - all of which are tracked for compliance and presented at RISC meetings.  All patients in this program receive a program booklet as a teaching guide; cardiac and respiratory nurse and physician specialists contributed to the content of the final programs.
  • Developed a specialized education program called the "RISC Think Tank" which introduces the RISC initiatives to all staff and provides them with tools and strategies to reduce avoidable re-hospitalizations.  The RISC Think Tank is given at least annually and includes presentation of actual patient cases and informal open discussion to engage staff in sharing of new ideas and/or strategies.
  • Created a collaborative nursing and therapy wound management program with 1.5 CEU accreditation.
  • Developed tri-fold colorful and easy to read Patient & Family Guides (for e.g. Bladder Health, Dehydration Prevention, and Constipation.)

RISC continues to meet to review trends and discuss innovative strategies to keep patients at home and out of the hospitals.

Reducing Surgical Site Infections at New England Baptist Hospital

By John C. Richmond, MD and Maureen Spencer, RN, M.Ed, CIC

This article is reprinted from the August 2010 First Do No Harm newsletter produced by the Quality and Patient Safety Division of the Massachusetts  Board of Registration in Medicine

A post-operative infection can be a devastating complication for any patient. This is particularly true in elective orthopedic surgery, where the patient typically chooses to undergo the procedure in the anticipation of decreased pain and improved function. Deep infection following orthopedic surgery may drastically alter the outcome. The national benchmark from the CDC for orthopedic surgery is 1.25%.

At the New England Baptist Hospital (NEBH) more than 90% of our surgeries are elective orthopedic procedures and as part of our continuous improvement process, we have embraced the goal of reducing surgical site infections (SSI's) to zero. This report outlines a major step forward in that journey.

Staphylococcus aureus is considered the most important pathogen in terms of SSI. Epidemiologic studies have demonstrated that most cases of SSI are caused by strains of S. aureus that are brought into the hospital environment by patients themselves, i.e. most patients who develop S. aureus SSI are carriers of the strains causing infection. The anterior nares may be the most common niche for S. aureus among carriers, and multiple studies have established that nasal carrier status is a significant risk factor for the development of S. aureus SSI.

In July of 2006, we began screening the nares of all patients scheduled for inpatient orthopedic surgery at NEBH. Rapid screening of preoperative patients utilizing a polymerase chain reaction (PCR) based diagnostic test was used to identify methicillin-resistant S. aureus (MRSA) carriers. Standard microbiologic culture methods were used to identify methicillin-sensitive S. aureus (MSSA) strains. Patients testing positive for either MRSA or MSSA were treated with intranasal 2% mupirocin ointment applied to the interior of each nares twice daily for five days and a daily 2% chlorhexidine shower wash for five days. PCR was then repeated to confirm eradication of the MRSA carrier state.

By the end of 2007, with the S. aureus identification and elimination program fully functioning, our overall orthopedic infection rate had been reduced from an already low 0.51% to 0.43%. This, however, was not the case with certain spine procedures (laminectomy and microdiscectomy), where the infection rate had actually increased to 1.34%. We put together a team from our infection control unit and our spine surgery and research divisions to investigate this anomaly. At that time, many of our spine surgeons were utilizing peridural methylprednisolone to reduce post-operative pain and adhesions. While this treatment has established benefits, corticosteroids are immunosuppressive and are known to be associated with septic arthritis if used intra-articularly during arthroscopy.

In order to identify the potential risk factors for SSI following lumbar spine procedures, a retrospective case-control study was performed, reviewing almost 6000 lumbar spine procedures, which had been done at NEBH between 2005 and 2007. A multivariate logistic regression analysis was carried out. This revealed that the use of peridural methylprednisolone was associated with a nearly 7 fold increased risk of infection (95% confidence interval 1.8-25.8). When this information was conveyed to our spine surgeons, they immediately discontinued the routine use of peridural methylprednisolone. Simultaneously the use of high dose (6+ mg) intravenous dexamethasone given intra-operatively by anesthesia to help with post-operative nausea and vomiting was also decreased to 4 mg.

Over the 2 years 2008-2009, the infection rate following lumbar laminectomy and microdiscectomy at NEBH fell to zero and our continued S. aureus identification and eradication program has lead to a reduction in our overall infection rate to 0.31%, highlighting how a focused infection eradication program, in conjunction with a superior infection control unit, can be successful in minimizing the risk of SSI.

-- Dr. Richmond is Chair of the NEBH Department of Orthopedic Surgery. Ms. Spencer is NEBH Infection Control Manager and holds national Certification in Infection Control (CIC).

Southcoast Health System: Reducing the Use of Safety Sitters

Southcoast Health System’s well thought-out program to reduce patient “sitters” – the individuals who spend time with patients to ensure that they do not fall and injure themselves – makes sense financially for the system, but has its genesis in improving patient safety and strengthening the caregiving team.

“They’re not just sitting there. They are now interacting with the patients” says Joyce Dolin, R.N., the director of patient services at Southcoast. “So we changed the name.”

But the changes go far beyond the two new titles – Patient Care Observer and Therapeutic Assistant. Southcoast, which is the parent of Charlton Memorial Hospital (Fall River), St. Luke’s Hospital (New Bedford), and Tobey Hospital (Wareham), instituted a whole new program of re-training, clustering of fall risk patients, more coordinated handoffs between caregivers, plus new equipment, and a new “culture” among the observers and assistants and the other caregivers with which they work.

ASSESSING THE ISSUE

Southcoast hospitals each had their own fall prevention team, but beginning in 2009, hospital officials put together a falls team across the entire system. They also hired a consultant, assessed all the numbers at the various-sized hospitals, reviewed new equipment, assessed alarm systems, and more, ultimately coming up with a multi-pronged plan.

“An overriding goal was to move away from the use of restraints – which are used as a last resort,” says Karen Pehrson, psychiatric clinical nurse specialist at Southcoast. “So we had to see what was out there, while reducing the amount of sitters, which was a tall order.”

NEW EQUIPMENT

The falls team looked at acquiring a new form of patient beds that are constructed very low to the floor; they’re about six inches high with a two-inch pad next to them, so if patients roll off the beds, they only have a four-inch fall. But re-fitting 750-beds in the entire Southcoast system proved to be very capital-extensive and  not necessary for all patients, so  the beds are used on select patients.

Southcoast then looked at various alarm systems before finally settling on one manufactured by Posey Healthcare Products.

“Their alarm is very clear so you can hear them outside of the room, plus they don’t need to be reactivated,” Pehrson said. “Every time you add another layer of decision making, you add another layer of potential error, which is why Posey’s auto-reactivation capabilities appealed to us.”

Plus the new alarm, which warns patients that they may be at risk of falling, is able to be recorded in the patient’s native language, using the voice of a relative or loved one.

And rather than use restraints to stop, say, an elderly, mentally-impaired patient from pulling out their IV (a common occurrence at hospitals), Southcoast uses a knit sleeve which runs over the thumb and almost up to the shoulder. It not only covers the IV site, but elders like it because it is warm and protects frail elbows as well. Southcoast is also experimenting with a “freedom splint,” a large blue, plastic balloon arm covering that gives people a large range of motion but, again, prevents damage to the IV area.

Patients with dementia are also outfitted with an activity apron, which contains many zippers, buttons, Velcro tabs, and more to occupy those patients who have a need to be busy.

“Some people are very fidgety and their attention is turned to the apron,” Dolin says. “For those with dementia, it’s good to redirect their attention.”

Other patient safety and fall preventers include torso support that holds patients upright in their chairs. It’s not a restraint because they can easily release themselves – at which point they hear a recorded voice reminding them they may be at risk.

“It’s all about finding humane ways to give people reminders and cues,” Pehrson said. “You don’t restrain people just because they are at risk of a fall”.

NEW SAFETY ZONES

Aside from the use of new equipment, Southcoast began to coordinate how high-risk fall patients are served in the hospital. First, they clustered patients so that one observer could watch four people at once. But gradually they took their concept to the next level, creating “safety zones,” which are two semi-private rooms (four patients) staffed by personnel who are trained in dementia and psychiatric issues.  A brochure developed through the hospital’s education department explains the safety zone to patients and their families.

Admissions criteria was created for the safety zone and patients are reassessed every shift to see if they still should be located there.

Attempts are made to make patients in the safety zone as comfortable as possible, meaning Southcoast attempts to find out from family members the person’s daily routines. What time do they usually go to bed and get up? When do they eat? Do they play cards? By keeping patients to a familiar routine and surrounding them with familiar touchstones, such as pictures of family, the patient feels less compelled to move around and risk a fall.

One of the biggest fall risks is the transition from one area of the hospital to another, so Southcoast assessed the entire handoff hierarchy. Like other hospitals, Southcoast uses the “red slipper” logo on charts (and actually provides them to patients) so everyone, from nurses, to patient transporters, to technicians in the radiology department, knows that a patient is a fall risk.

IT’S ABOUT THE PEOPLE

Even though Southcoast reconsidered the equipment it uses, the places in the hospitals where fall risks are clustered, and more, the biggest change – and the one that goes to the heart of care at the hospitals – involves the people it hires as Patient Care Observers and Therapeutic Assistants.

“In the past we had unlicensed people with only three hours of training serving as sitters,” says Karen Pehrson. “This wasn’t good enough. People dealing with patients who have drug and alcohol issues, or who are suicidal, really need more in-depth training.”

Southcoast surveyed the literature from Chief Nursing Officers and others throughout the U.S., and developed two new job descriptions – Patient Care Observers for those who have a high-risk of falls, and Therapeutic Assistants for those dealing with patients with psychiatric or drug abuse problems.

“People are not always adept at dealing with both populations,” Dolin notes.

Patient Care Observers (PCO) are given 8.5 to 9 hours of classroom training. They learn a great deal about elders, about Alzheimer and dementia. “We do role playing where they have to intervene with someone who is escalating,” Pehrson says. “We want them to I.D. an escalating situation and know how to diffuse it.” The PCOs can help someone from bed to chair or from chair to bathroom but they don’t handle any blood or fluids.  However, Pehrson says they are taught core emergency skills – CPR, how to recognize stroke symptoms and, most importantly, how to get help fast.

“I’ve seen our people do wonders by just using a soothing voice to really keep patients  safe,” Dolin says.

Training for the Therapeutic Assistants is the same for the first five hours of the classroom but then they focus on behavioral issues and psychiatric patients.

“These are much more aggressive types of behaviors,” Pehrson says, and it takes a different type of personality.

One of the training exercises Southcoast does is to put the TAs in full four-point restraint so that they can “experience that situation and have compassion for what it is like for patients,” Pehrson says. “We don’t want them to stigmatize people because they have a brain disorder.”

THE RESULTS

Southcoast’s fall rate per 1,000 patient days fell from 3.01 to 2.98 – a small drop but a drop nonetheless. “Plus there’s better patient care,” Dolin notes.

The system’s next steps are to try to find flexibility between the PCO and TA positions so that one can fill in for the other at peak times.  (There’s a peak time for elder care, during flu season, for example, and even a peak time for suicides around the holidays, the hospital has found.)

But no matter who they work with, or at what times, the PCOs and TAs are making a difference, Southcoast’s Pehrson says. “When our observers and TAs have compassion for patients, it’s really good to see what they can do. It’s not so much what you do with your hands to help someone, but what you do with your whole person. They really get the message that they are a key part of the caregiving team. They have an important role,” she says.

–by John LoDico