As more individuals and organizations recognize the need to make our communities work better for the growing number of people living with Alzheimer’s or a related disorder, and their families and friends (“care partners”), it is helpful to define what it means to work toward becoming a “dementia-friendly” community.
ALZConnected® , powered by the Alzheimer’s Association®, is a free online community for everyone affected by Alzheimer’s or another dementia, including:
Through the work of over 35 national, leading organizations, the Dementia Friendly America initiative is catalyzing a movement to more effectively support and serve those across America who are living with dementia and their family and friend care partners. The lead organizations represent all sectors of community and are collectively leveraging their national reach to activate their local affiliates, members and branches to convene, participate in and support dementia friendly community efforts at a local level.
An estimated 5.4 million people in the United States and more than 120,000 Massachusetts residents are living with dementia, which is a general term for changes in thinking such as memory loss and difficulty planning and communicating. Dementia may be caused by Alzheimer’s disease or other conditions. Despite the widespread impact of dementia, lack of information, fear, and stigma can prevent those affected from feeling safe, socially connected, and able to thrive in their communities.
The Centers for Disease Control and Prevention launched Get Ahead of Sepsis, an educational initiative to protect Americans from the devastating effects of sepsis. This initiative emphasizes the importance of early recognition and timely treatment of sepsis, as well as the importance of preventing infections that could lead to sepsis.
Sepsis is the body’s extreme response to an infection. It is life-threatening, and without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death. Each year in the U.S., more than 1.5 million people develop sepsis, and at least 250,000 Americans die as a result.
Public education is critical to save lives since, for many patients, sepsis develops from an infection that begins outside the hospital.
Get Ahead of Sepsis calls on healthcare professionals to educate patients, prevent infections, suspect and identify sepsis early, and start sepsis treatment fast. In addition, this work urges patients and their families to prevent infections, be alert to the symptoms of sepsis, and seek immediate medical care if sepsis is suspected or for an infection that is not improving or is getting worse.
“Detecting sepsis early and starting immediate treatment is often the difference between life and death. It starts with preventing the infections that lead to sepsis,” said CDC Director Brenda Fitzgerald, M.D. “We created Get Ahead of Sepsisto give people the resources they need to help stop this medical emergency in its tracks.”
Get Ahead of Sepsis offers exciting new resources for healthcare professionals and patients – including fact sheets, brochures, infographics, digital and social media, and shareable videos for both the healthcare professional and for the consumer.
As addiction to opioids is ravaging our country, parents and community groups continue to ask us what they can do to prevent addiction in their families and community. In response to these questions, we’ve developed a list of things you can do to help prevent and/or stop addiction, especially among adolescents.
That’s the number of central line-associated bloodstream infections (CLABSI) that Westerly Hospital in Rhode Island has experienced in both its ICU and medical/surgery units from 2015 to today. Its performance in containing catheter-associated urinary tract infections (CAUTI) is equally as remarkable; in the hospital’s ICU and med/surg units there has been just one CAUTI, in the ICU, since 2016.
Westerly Hospital – a 125-bed facility that is part of Yale New Haven Health system – implemented a nurse-driven protocol to combat CAUTI. The hospital used guidelines developed by the Healthcare Infection Control Practices Advisory Committee (HICPAC) – the federal panel that advises the Centers for Disease Control and Prevention (CDC). From that, Westerly developed a CAUTI prevention algorithm for registered nurses to use, essentially to help them decide: does the patient still need the catheter or should it be removed? Such a determination could be based on a patient, say, being transferred from an ICU to another unit.
RNs assess patients on a daily, or shift, basis and follow best practices relating to removal protocols. Daily interdisciplinary rounds include reviews of all patients with urinary catheters to verify clinical indications.
“An important component is having online learning modules that educate the staff on the procedures,” said Patricia Egan, Westerly’s Nursing Professional Development Specialist. “The modules also produce a transcript that managers can use to verify that each person in the unit has passed the online lessons.” Staff were also trained in the use of the algorithm in 1:1 sessions with Nurse Leaders and Professional Development Staff.
To prevent CLABSI, Westerly set up learning stations which are essentially mock patients so that managers could observe staff performing “hands on” central IV line care and maintenance. Staff were also educated on best practices and participated in on-line learning modules. The hospitals also implemented daily Chlorhexidine Gluconate (CHG) bathing for all patients with central lines – which is recommended best practice by the CDC.
Westerly’s infection fighting strategy was developed by an inter-disciplinary team consisting of the Quality and Risk Management department, front line RNs, and Nurse Leaders. The successes are shared with staff through Westerly’s Infection Prevention Committee.
“New staff are trained on the procedures, and now that we are two years into our successful program, we are re-training all staff,” Egan said. “The program has been good for our staff, good for the hospital by avoiding value-based penalties, but especially beneficial for our patients.”
South County Hospital of Wakefield, R.I., in 2014-15 noted a spike in post-cesarean surgical site infections (SSI). An inter-professional team was established to review current practice and opportunities for improvement, and settled on a goal of “zero harm.”
To meet the goal, the hospital made changes to its “Best Practice Care Bundle,” instituted provider and staff education, as well as patient education and communication, and ongoing surveillance.
In order to measure improvement strategies, South County initially implemented small tests of change but did not see significant change in its SSI rates. Then the hospital implemented a series of nurse-driven practices that included:
Staff used reminder phones calls for CHG wash for planned C-sections and the SSI data was shared continually shared with staff/providers. Educating patients about the risk of SSI was also part of the process.
The results of the new care bundle were impressive. In a 16 month time frame, South County reduced its SSI rate by 87% with a rate of .66 for fiscal year 2016 and for FY 2017 YTD < 1% (superficial only).
It’s important to note that the majority of the changes made were nursing driven or nursing influenced. Surgical site infection prevention is multi-dimensional and is most effective when all significant parties – patients, nurses and providers – are brought together to affect change.
Kent Hospital’s Good Catch Award is a way to demonstrate the hospital’s commitment to keeping patients, visitors and employees safe by rewarding those individuals who "speak up" to prevent harm and improve the culture of safety. The Good Catch Award creates positive incentives for providers and staff to report patient safety events.
Kent Hospital’s staff strives continuously to enhance the culture of safety and realizes the importance of recognizing individuals who promote safety. High-reliability organizations de-stigmatize failure. Medical errors that are detected and corrected before harming patients are called near-misses. High-reliability organizations treat these events differently from other hospitals. They encourage employees to come forward with near-misses and they focus on which processes and safeguards work best.
A near miss or a "Good Catch" is an error that happened but did not reach the patient, thereby avoiding any patient harm. These errors are captured and corrected either through staff awareness or designed system controls that have been put into place. Kent Hospital recognizes that good systems equal good outcomes and the Good Catch Award program supports this philosophy.
Risk Management and the hospital’s dedicated Management Team review and investigate all reported safety events daily. The investigations provide Kent the opportunity to identify systems or human factor variables to ensure that a similar event doesn’t occur again. Extensive research has shown that most events, both serious and catastrophic, were preceded by warnings or near-miss events. Reporting near miss-events is important to Kent Hospital, as these events occur usually at a much higher rate than actual events.
Risk Management tracks and trends all patient safety event data from the hospital’s electronic safety event reporting system – Quantros. That data, as well as lessons learned, is shared among senior leaders and other interdisciplinary team members at the weekly Performance Improvement and Patient Safety Committee (PIPS) meeting. At each weekly PIPS meeting, Kent Hospital’s management team members collectively review near-miss events in an effort to determine where there is a potential to improve current processes, procedures, and practices. By identifying areas of opportunity, the organization has a better chance of assuring positive outcomes by preventing similar occurrences from happening again.
Since the inception of the Good Catch Program in June 2016, the numbers of near-miss events that have been reported into Quantros have increased significantly. Remember: recognizing and reporting near misses – as opposed to ignoring them – is a positive trend to help improve systems and improve patient safety. To date Kent Hospital has awarded 136 Good Catch awards.
Here are just a few examples of near-miss events:
Near Miss: RN noted Heparin drip order set in Cerner was automatically changing the initial lab draw post initiation. This was a near miss event as it could have led to a delay and/or an omission in the initial post anti- factor Xa resulting in patient harm.
Actions: Heparin Nomogram in Cerner updated; initial 6 hour anti- factor Xa (after the start of infusion) is now automatically pre-checked for drawing by the lab.
Near Miss: RN noted there was 2g Magnesium in the 125mg Cardizem pockets of the Pyxis machines; both have similar packaging and are stored next to each other in the Pyxis.
Actions: Labels were placed on the Cardizem bags to differentiate them from the Magnesium in the pharmacy storage bins. The Cardizem and Magnesium vials were relocated to different drawers in all of the Pyxis machines.
Near Miss: CNA noted that the shower heads in rehab could easily shoot off the nozzle and potentially injure a patient.
Actions: Risk & Engineering investigated, design flaw of the shower heads noted, and all were changed out to a different model.
Any staff member who makes a “Good Catch” is presented with a Good Catch Award certificate, Good Catch lapel pin, and their picture is taken with Kent Hospital’s leadership team members. In addition, the award recipients have their pictures displayed prominently. The staff member’s name is published in Kent Hospital’s ‘Vital Signs’, which is sent not only to all of Kent Hospital, but also via e-mail to all Care New England employees as well.
At the end of each fiscal year, Kent Hospital nominates recipients for awards that are an extension of this program: The All Star Award (1 winner) and the Golden Glove Awards (1 winner from every clinical and non-clinical department within Kent Hospital). These nominees are presented to our Performance Improvement and Patient Safety Committee for voting. Click the link for Good Catch Program highlights.
