Improving General Ward Outcome in Female Geriatric Rehabilitation Unit thru Evidence-based Practice: A Collaborative Approach

Author: Gay-Ann Malaluan, QMC

Executive Sponsor: Dr. Amal Abousaad, AED for Quality and Patient Safety

Team Members: Dr. Faisal Umminiyattle, Geriatrics; Dr. Sabyasachi Ghosh, PM&R; Ligy Roy,HN; Mohamed Abdelhady, CP; Jessy George, QMR; Sheeba Jose,SN; Abegail De Leon, Physiotherapist; Fatma Mohd. , ICP; Anish Paul ,QMC; FGRU Staff

Best Care Always Campaign was designed by Hamad Medical Corporation (HMC) in partnership with Institute of Healthcare Improvement (IHI) The campaign aim is to build the capability within HMC to deliver the safest and the most effective care to the people of Qatar which is HMCs strategic vision of healthcare. The collaboration with IHI will include a focus on understanding HMCs current patient safety culture and review how teams within the organization can work together to improve the quality of care. Female Geriatric and Rehabilitation Unit (FGRU) was selected as pilot unit in Rumailah Hospital. Problems were identified, change concepts were prioritized and the work started by running small tests until we reach the reliable process. For every failures and incidents, we take it as opportunity to learn. And for every success, we take this as reason to celebrate.

Spread the reliable process into other units hospital-wide. Promote the IHI Open School in other units. Start Implementing the Sepsis 3-hour Resuscitation Bundle. Involvement of patient and family. Start the Ventilator Associated Pneumonia Bundle, Tracheostomy Care Bundle, and Aspiration Prevention Bundle in Ventilated and Tracheostomy Units Collaborate with Seating and Positioning Department for proper assessment of positioning needs of each patient. Sustain improvements gained by reinforcing the adopted practices.

Introduction:

Results:

Next Steps:

“ If quality is to become the lifeblood of your healthcare organization, only a transfusion of new ideas will get quality flowing.” -Healthcare Division, Films Incorporated

Our Aim: To improve the general ward outcome by providing the safest and quality

care to the patients by December 2014.

•Ensure early identification of patients at risk of deterioration in 100% of incidents by December 2014.

•Avoid unnecessary catheterization for all patients in FGRU by December 2014.

•Ensure at least 90% compliance to the 5 moments of hand hygiene by December 2014.

•Ensure a reliable process for C. Diff prevention and maintain zero C. Diff infection by December 2014.

•Ensure a reliable process for MRSA prevention and maintain zero MRSA infection by December 2014.

•Ensure all patients with high risk for pressure ulcer receive all skin care bundle elements by December 2014.

•Venous Thromboembolism (VTE) risk assessment is performed for all new admissions and prophylaxis is provided according

to HMC protocol by December 2014

•All geriatric patients are included in the monthly multidisciplinary round and monthly goals set for them by December 2014.

•All rehabilitation patients are included in the weekly multidisciplinary round and weekly goals set for them by December

2014.

•Conduct safety briefing at least once daily with as many as possible of multidisciplinary team members by December 2014.

•Use SBAR tool for at least 95% of all phone communication between RN and doctors by December 2014.

Blame hides the truth about error. Culture must be change. Communicate clearly. Document the facts. Focus on prevention. Hear when you listen. Knowledge must be shared. Learn from your mistakes and others mistakes. Partner with patients and multidisciplinary team and value their perspective. Always ask why to know the root cause. We can make a difference.

Key Learning:

Methodology

%Compliance on SKIN Bundle-FGRU

0

20

40

60

80

100

JAN-14 FEB-14 MAR-14 APR-14 MAY-14 JUN-14 JUL-14 AUG-14 SEP-14 OCT-14 NOV-14 DEC-14 JAN-15 FEB-15

Pressure Redistribution SurfaceSkin AssessmentNutritional Support and Hydration Moisture Management

3/15 Air matress in

use

3 Additional air mattress

received; total of 8/15

Pressure Ulcer Prevention

Female Geriatric and Rehabilitation Unit Pressure Ulcer Count

0

1

2

3

4

5

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb

-14

Mar

-14

Apr

-14

May

-14

Jun-

14

Jul-1

4

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Goal = 0

Start of the IHI Project

289 days

Development of Data

Collection Tool

Additional Air

Mattress received

34

days219 days

Early Warning System

Hand Hygiene

Clostridium Difficile Prevention

MRSA Prevention

VTE

SBAR

Multidisciplinary Rounds

Safety Briefings Percent Compliance with Using Daily Safety Briefings

Median

0%

20%

40%

60%

80%

100%

Jan-

14

Feb-

14

Mar

-14

Apr

-14

May

-14

Jun-

14

Jul-1

4

Aug

-14

Sep-

14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb-

15

%

Started with all nursing

staff at endorsement

Included the

Multidisciplinary

Team

FGRU Clostridium Difficile Count

0

1

2

3

4

5

JAN-

14

FEB-

14

MAR

-14

APR-

14

MAY

-14

JUN-

14

JUL-

14

AUG-

14

SEP-

14

OCT-

14

NOV-

14

DEC-

14

JAN-

15

FEB-

15

Month

GOAL: 0

Recurrence after antibiotic

use (patient is a carrier)

% of RN-Doctor Calls made by using SBAR format

Median

0%

20%

40%

60%

80%

100%

Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15

Weekly Data Collection

Started on first week

of July

% Achievement of Multi disciplinary Rounds (Geriatrics)

Median

0%

20%

40%

60%

80%

100%

Jan-

14

Feb-

14

Mar

-14

Apr

-14

May

-14

Jun-

14

Jul-1

4

Aug

-14

Sep-

14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb-

15

%

MDRs done but no

documentation

MDR done but for

specific patients

Reinforcement done

% Achievement of Multi disciplinary Rounds (Rehabilitation)

Median

0%

20%

40%

60%

80%

100%

Jan-

14

Feb-

14

Mar

-14

Apr

-14

May

-14

Jun-

14

Jul-1

4

Aug

-14

Sep-

14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb-

15

%

% Achievement of Multi disciplinary Rounds and Goals

(Rehabilitation)

Median

80%

90%

100%

Jan

-14

Feb

-14

Mar

-14

Ap

r-14

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-14

Dec

-14

Jan

-15

Feb

-15

%% Achievement of Multi disciplinary Rounds and Goals (Geriatrics)

Median

0%

20%

40%

60%

80%

100%

Jan

-14

Feb

-14

Mar

-14

Ap

r-14

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-14

Dec

-14

Jan

-15

Feb

-15

%

Goals not

documented

Rounds conducted but only

for specific group of patients

(Reminders done)

Use the Model for Improvement.

Frequent Small Test of Change

Empowerment of front-line staff thru training and education

Display of real-time data on the Best Care Always Board

Committed Multidisciplinary Team Approach

IHI Open School

Leadership Active Involvement

% of Patients Assessed with a High Risk for a VTE who Received Appropriate

Follow-up Treatment

Median

0%

20%

40%

60%

80%

100%

Jan-

14

Feb-

14

Mar

-14

Apr

-14

May

-14

Jun-

14

Jul-1

4

Aug

-14

Sep-

14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb-

15

%

No High

Risk Patient

% of Patients Assessed for Risk of a VTE

Median

40%

60%

80%

100%

Jan-

14

Feb-

14

Mar

-14

Apr-1

4

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov-

14

Dec-

14

Jan-

15

Feb-

15

%

40

55

70

85

100

Jan-1

4

Feb-1

4

Mar-

14

Apr-

14

May-1

4

Jun-1

4

Jul-14

Aug-1

4

Sep-1

4

Oct-

14

Nov-1

4

Dec-1

4

Jan-1

5

Feb-1

5

Co

mp

lian

ce R

ate

Phisician Nurses

Other HCW Target

Started Monitoring

5 Momentsstarted to focus on

proper technique

Reinforcement

% Compliance on Hand Hygiene

Percent of observations identified as “at risk" that have Appropriate interventions

undertaken in terms of their management as categorized by the Early Warning Score-

FGRU,Rumailah Hospital

0

20

40

60

80

100

Jan

-14

Feb

-14

Mar

-14

Ap

r-14

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-14

Dec

-14

Jan

-15

Feb

-15

Mar

-15

Education for

doctors and

nurses

Testing

started

Reinforcement

Median

Check the weight weekly monthly and PRN.

•Refer to dietician- Diet as per the assessment of the dietician.

•Blood Investigation if needed.

•Measure Intake and Output if needed.

Nutrition

•Use of Moisture Barriers

•Change linen daily and PRN.

•Perineal care and Incontinent pad change two hourly and PRN

Increased

Moisture

• Change Position every 2 hours and PRN –using pillows or wedges as condition allows.

•Ambulate as per patients tolerance.Keep

Moving

•Bed/mattress/chair- if patient cannot move him or herself into two or more positions in bed and or chair.

•Lift Device/Transfer device- if patient is unable to lift buttocks off bed, use lift sheet, or reusable under pad to pull up in bed.

•Heel Elevation off Bed Surface.

Surface

Redistribution

• Perform Skin Assessment on admission . (Braden Score) on all patients

•Initiate Nursing Plan of Care as per Braden Score.

•Perform Skin reassessment as per Braden Score daily.

Skin

Assessment

Check the weight weekly monthly and PRN.

•Refer to dietician- Diet as per the assessment of the dietician.

•Blood Investigation if needed.

•Measure Intake and Output if needed.

Nutrition

•Use of Moisture Barriers

•Change linen daily and PRN.

•Perineal care and Incontinent pad change two hourly and PRN

Increased

Moisture

• Change Position every 2 hours and PRN –using pillows or wedges as condition allows.

•Ambulate as per patients tolerance.Keep

Moving

•Bed/mattress/chair- if patient cannot move him or herself into two or more positions in bed and or chair.

•Lift Device/Transfer device- if patient is unable to lift buttocks off bed, use lift sheet, or reusable under pad to pull up in bed.

•Heel Elevation off Bed Surface.

Surface

Redistribution

• Perform Skin Assessment on admission . (Braden Score) on all patients

•Initiate Nursing Plan of Care as per Braden Score.

•Perform Skin reassessment as per Braden Score daily.

Skin

Assessment

Where Pressure Ulcers FormWhere Pressure Ulcers Form

G O A L !

“The journey for improvement is never-ending.”

Rumailah Hospital

Safety Briefing

MDR

Communication Board Best Care Always Board