nursing department
O v e rv i e w a n d O u t c O m e s r e p O rt 2 0 0 8
Nursing Department

Overview and Outcomes Report 2008
Table of Contents
1     Letter from the Vice President of Patient Ca...

Letter from the Vice President of Patient Care Services

                      it is my pleasure to present t...
Vision/Core Beliefs

           Allina’s Mission               Allina’s Nursing Vision
           We serve our communit...
professional nursing practice model

 Built on the foundations of the                                                    ...
Sendlebach also says that the                 the development of evidence-based               sendlebach also says that th...
 Support    PROf E S SIONA L N u RSI Ng PR AC t IC E MOdEL

Systems Support
Consistent stroke education
          Relationships     PROf E S SIONA L N u RSI Ng PR AC t IC E MOdEL

             PROf E S SIONA L N u RSI Ng PR AC t IC E MOdEL

Magnet™ designation—
a journey to suc...
          Collaborative   PROf E S SIONA L N u RSI Ng PR AC t IC E MOdEL
Development    PROf E S SIONA L N u RSI Ng PR AC t IC E MOdEL

Professional                                ...
         of Practice/
         Dimensions     PROf E S SIONA L N u RSI Ng PR AC t IC E MOdEL

Remaining Standards                          protocol for at-risk patients. By the end    WomenCare Community
Critical Care Community (PB2000, H4100,
         reducing the incidence of Ventilator-Assisted
Spine Institute – H7000                        Orthopaedics Community – H7200/H8200
  Using learning paths to improve     ...
Surgical Services                           as a result, the number of patients whose temperature was >36˚c within 15 minu...
Sister Kenny® Rehabilitation
Institute – W2300
Using care navigation to
improve outcomes
sister Kenny rehabilitation insti...
         enhancing the patient experience
         through care continuity                                     ...
ED/CDART                                                                   Patient Flow Indicators—Time Intervals in Minut...
Mental Health Services
         Outpatient Mental Health Clinic
         enhancing Services
         this outpatient menta...
Abbott Northwestern’s                      achievement. additionally, the           Electroconvulsive
Infectious Disease C...
OB Homecare                                  to questions about overall satisfaction and recommending OB Homecare to other...
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
Nursing Outcomes/Annual Report
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Nursing Outcomes/Annual Report


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Overview of the Abbott Northwestern Nursing Department\'s philosophy, model of care, accomplishments and outcomes.

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Nursing Outcomes/Annual Report

  1. 1. nursing department O v e rv i e w a n d O u t c O m e s r e p O rt 2 0 0 8
  2. 2. Nursing Department Overview and Outcomes Report 2008 Table of Contents 1 Letter from the Vice President of Patient Care Services 2 Vision/Core Beliefs 3 Professional Nursing Practice Model 23 Celebrating Excellence, Innovation and Advanced Learning 34 About Abbott Northwestern Hospital
  3. 3. Overview Letter from the Vice President of Patient Care Services it is my pleasure to present the 2008 abbott Allina nurses are the northwestern nursing department annual Outcomes embodiment of the art and report. the features, outcomes and recognition presented science of caring. Every day, here are a snapshot of the outstanding work nurses are more than 5,200 nurses across the organization use doing every day. their expertise and passion to advocate and provide abbott northwestern nurses comprise nearly half of care for patients, while allina Hospitals’ & clinics’ nursing workforce. as elevating the standards a magnet™-designated hospital and leaders in this of exceptional nursing organization, the bar on our standards of excellence practice. continues to rise. Our mission, vision core beliefs and professional nursing practice model are the foundations that have poised us to meet and exceed these standards. terry Graner, rn, ms, nea-Bc vice president, patient care services NuRS I Ng dE PA Rt M E Nt 1
  4. 4. Vision/Core Beliefs Allina’s Mission Allina’s Nursing Vision We serve our communities • Allina will be nationally known and trusted for exceptional by providing exceptional nursing practice. care, as we prevent illness, • Allina nurses combine the best of science and caring restore health and provide to provide exceptional patient care through trusted partnerships and effective stewardship. comfort to all who entrust • Allina’s healing environment fosters nursing practice that us with their care. is evidence-based, innovative, and patient/family centered. • Allina nurses are powerful, passionate and diverse in talents and thought. • Nursing career paths provide Allina nurses with dynamic opportunities for career enhancement to help them achieve their highest potential. • Nursing leadership is relationship-centered, holistic, progressive, and responsive. Nursing Core Beliefs • Advocacy • Caring • Continuous Improvement • Cultural Awareness and Recognition • Ethics • Leadership • Relationships • Stewardship 2 O u t CO M E S R E P O Rt 2 0 0 9
  5. 5. professional nursing practice model Built on the foundations of the Outcomes individual relationships nurses establish with patients and s Ou me tc families, the Professional Nursing o om Systems Interdisciplinary tc Practice Model incorporates all Ou Support Relationships e s of the components necessary for the delivery of exceptional nursing care. Vision/ Leadership Core Beliefs Patient- Coordination Centered of Care Outcomes Outcomes the diagram of the professional nursing practice model is designed patient to provide a visual representation & Family of the fundamental components of Clinical nursing practice that are defined in Standards Caring Competence Research/ the allina charter for professional of Practice/ Evidence-Based Dimensions Practice nursing practice. the model is meant to demonstrate all of the things nurses inherently know as part of their s Ou Professional e professional practice. om Professional Nursing tc o Development tc Collaborative me Ou Governance s Outcomes Research/ Evidence-Based PROf E S SIONA L N u RSI Ng PR AC t IC E MOdEL Practice Research/Evidence- Based Practice – Evidence-Based Practice Fellowship teaches nurses to question it is one thing to discover through research. it is another to apply research to clinical practice. that is what is behind the evidence- Based practice Fellowship at abbott northwestern Hospital. the Fellowship provides staff nurses with classroom instruction and mentoring to investigate clinical questions and integrate their findings into nursing practice. NuRS I Ng dE PA Rt M E Nt 3
  6. 6. Sendlebach also says that the the development of evidence-based sendlebach also says that the Fellowship has a domino effect. practice. clinical nurse specialists act Fellowship has a domino effect. as mentors, helping nurses translate “nurses who have participated in the “Nurses who have participated research findings into practice. Fellowship share with their colleagues, in the Fellowship share and colleagues see that it works.” with their colleagues, and By giving nurses time each month colleagues see that it works.” within their work agreement to focus the value of involving staff nurses in on a clinical question, the Fellowship evidence-based practice is that there also helps to address one of the is often immediate relevance in their challenges that the profession faces work. “working at the bedside results Launched in 2008, the Fellowship is a in emphasizing evidence-based care. in unique questions and insights,” 12-month program that partners a staff “nurses are so busy – it’s impossible to said sendelbach. “i can help nurses nurse with a clinical nurse specialist to add time for this kind of work within understand what the literature shows, address a nursing practice question. it the work day,” said sendelbach. but i don’t implement practice changes. was created by sue sendelbach, phd, it’s really much more challenging to rn, clinical nurse researcher and clinical sendelbach believes that the think about how to change practice.” nurse specialist, with her colleagues, Fellowship makes nurses think Kathi Koehn, rn, staff nurse, and differently about many aspects of terry Graner, ms, rn, nea-Bc, vice nursing practice, raising their awareness president of patient care services, as a of the importance of evidence-based way to introduce evidence-based practice practice and ways to incorporate it in to the nursing staff. their work. “i’ve had nurses tell me that this inspires them to go to the literature the Fellowship teaches participants how much more frequently, not only to to analyze research literature and use it address situations they face at work, as a tool to solve clinical questions. it but also in their personal health,” said also encourages them to use their own sendelbach. experience and knowledge to guide Evidence-based Practice Fellows 2008-09 Fellow Mentor topic Meghan Davitt, E3100/W3500 Sue Sendelbach Care of patients wearing graduated compression stockings Laura Genzler, PB2000 Sarah Pangarakis Clustering of nursing activities and end tidal CO2 Linda Isenberg, W6300 Sandy Hoffman Parental involvement following a mother’s C-section Geraldine Sjoblom, H4100 CV-ICU Sue Sendelbach Care of critically ill patients experiencing ETOH withdrawal 2009-10 Fellow Mentor topic Laura Genzler (continuing) Same as above Same as above Damon Gates , H4200 CV-ICU Anita Anthony Interventions to prevent falls of hospitalized patients Jolene Laurence, SK4800/3900 Sue Sendelbach Weighted blankets and their impact on sleep Brad Lind, H5000 Sue Sendelbach Interventions for spiritual care 4 O u t CO M E S R E P O Rt 2 0 0 9
  7. 7. Systems Support PROf E S SIONA L N u RSI Ng PR AC t IC E MOdEL Systems Support Consistent stroke education improves documentation applying care standards consistently among patients with similar needs is a hallmark of effective patient care. the challenge for nurses is incorporating such standards into their workflow as they manage a multitude of patient care tasks. On H8000, excellian (the clinical documentation system) has been enhanced to better support nurses in meeting a key quality standard: providing documented education to a stroke team revised existing patient stroke patients to help reduce the education tools and incorporated them risk of a recurrent stroke or transient into excellian. nurses were educated ischemic attack. about the required elements and Completion of All Post-Stroke the stroke team also used excellian Education Criteria the american stroke association, to provide staff alerts about needed Joint commission and centers for education documentation. 80% disease control and prevention jointly 70% identified five topics that all stroke documentation of all five stroke 60% patients should be educated on during education elements increased to 50% Rate hospitalization. these are: 76 percent in the second half of 2008. 40% 30% • modifiable risk factors “excellian gives us a process check,” 20% • warning signs said Gordon mcarthur, H8000 patient 10% • accessing emergency care if care manager. not only does it provide 0% symptoms occur Jan-June July-Dec 2 tools to track each patient’s learning 2009 009 • follow-up care after discharge progress, it helps nurses tailor education to the patient’s needs. “part of the • medications prescribed at discharge. All five patient process includes a learning assessment, education elements so nurses know how a patient learns documented in the first half of 2008, an audit best and what barriers might exist, such of both nursing and physician as cognitive status or language.” documentation revealed that all five elements were documented only 59 it’s also useful for auditing. “it tells us percent of the time. Further analysis exactly how we are doing in meeting showed that the standard and helps us prioritize • it was primarily as issue of which areas we need to focus on for documentation, rather than a lack of improvement,” said mcarthur. patient education • Excellian could be enhanced to simplify and facilitate documentation of stroke patient education • nurses were not fully aware of the required education elements. NuRS I Ng dE PA Rt M E Nt 5
  8. 8. Interdisciplinary Relationships PROf E S SIONA L N u RSI Ng PR AC t IC E MOdEL Interdisciplinary anita anthony, rn, ms, ccrn-cnc, that when the therapy is used with cns-Bc, a cardiovascular clinical patients who have other co-morbidities, Relationships nurse specialist who helped lead the the outcomes are not as good,” said New therapy brings heart aquapheresis work group. anthony. failure care providers in august 2008, the treatment was made But many other individualized decisions together available on H400, a cardiovascular are required to ensure that the therapy thanks to the work of a multidisciplinary telemetry unit. the work group believed is used safely and effectively with each work group, a treatment for fluid overload that expanding the use of aquapheresis patient. that’s where the huddle concept in chronic heart failure patients, is on the telemetry units would make comes in. being used more effectively at abbott it readily available to the type of northwestern. patients who could most benefit from Key disciplines, including nursing, it, including pre-transplant patients and leadership, cardiology, pharmacy and iv the treatment, called aquapheresis, patients with chronic heart failure. they nursing, gather before therapy is initiated removes excess fluid through placement also wanted to improve the effectiveness to determine the appropriate iv access, of an intravenous (iv) catheter. the of the therapy, which requires careful anticoagulation therapy, fluid removal rate therapy gently pulls blood through a monitoring of anticoagulant therapy and treatment goal. circuit that filters out water and sodium and renal function while ensuring that and returns the blood to the patient. a clot doesn’t form in the circuit. “if a since initiating the huddle for clot begins to form, nurses have about aquapheresis in august 2008, the therapy among the work group’s recommendations 10 minutes to troubleshoot the problem,” has been used 24 times, including 12 in was to implement the huddle concept said anthony. if the filter does clot, the icu and 12 in the telemetry unit. when initiating the therapy. the the therapy must be stopped before the circuit use per patient has decreased huddle concept brings together a varied treatment goal is achieved, or the circuit from 2.19 to 1.3, while treatment times team of professionals who support and must be replaced—at a significant cost. increased from 45 hours to 49 hours. complement each other’s skills in order “the longer the to make decisions about a patient’s care. a first step was patient can be treated identifying the right Thanks to the work of a on one circuit, the although aquapheresis was developed kind of patient for multidisciplinary work more cost-effective it as a non-intensive care unit (icu) the therapy, an issue group, a treatment for fluid is, and the more likely therapy, abbott northwestern had used that the equipment overload in chronic heart it is that the treatment it exclusively in the cardiovascular manufacturer helped goal will be achieved,” the team address. failure patients, is being said anthony. abbott icus. “Often, we had to transfer patients to the icu just to get the therapy,” said “we’ve learned used more effectively at northwestern’s Abbott Northwestern. aquapheresis treatment time now exceeds the national average, which is 46 hours. “this interdisciplinary work has improved the effectiveness of aquapheresis in the icu and in the telemetry units,” said catherine Houda, ms, Bsn, rn, ne-Bc, patient care manager of H4000. “it’s also bonded the staff from each unit as they learned from each other how to best manage patients receiving the therapy.” 6 O u t CO M E S R E P O Rt 2 0 0 9
  9. 9. Leadership PROf E S SIONA L N u RSI Ng PR AC t IC E MOdEL Leadership Magnet™ designation— a journey to success although it was called the magnet journey, the 2008 effort that led to abbott northwestern’s magnet accreditation might well be described as an all-out mobilization. tonya montesinos, director of professional nursing practice and magnet coordinator, led the charge, involving nurses in all job classifications and specialties to assemble the mammoth documentation and prepare for the onsite survey required for accreditation. dedication to the success of the project moreover, montesinos and tucker started at the top with terry Graner, say that the process of documenting she was assisted by dawn tucker, vice president of patient care services, nursing excellence allowed nurses to marketing and communications who wrote major sections of the report step back from their day-to-day practice consultant. together (and with and helped montesinos and tucker and see their work in a new light. “this significant help from many nursing track down the people, data and stories really gave nurses a chance to look at colleagues) they planned, researched, their work in-depth,” said tucker. “it wrote, verified, edited and assembled made them stop to recognize and be the 2,000-page application document, “This really gave nurses a recognized for the amazing things they a process requiring countless hours in chance to look at their work do every day. it also created a deeper their designated “war room.” in-depth,” said Tucker. “It awareness of the excellence happening in every corner of the hospital.” made them stop to recognize For tucker, just thinking about the size and be recognized for the the process also demonstrated of the project was overwhelming. “You had to figure out how to section off the amazing things they do every to montesinos the importance of work. if you got stuck, you needed to day. It also created a deeper leadership and commitment in move on and come back to it later.” awareness of the excellence accomplishing any goal. Good planning, attention to detail and happening in every corner of follow-up, communication, flexibility But the volume of work leading to magnet accreditation is only part of the hospital.” and perseverance helped to transform the story. it was eclipsed by the energy the project into an organizational and enthusiasm generated among milestone. “For myself, the motivation nurses and their non-nursing colleagues that would help document the nursing was obtaining this international throughout the hospital. department’s accomplishments. recognition for the nurses. Our nurses deserved this honor and that’s what “we were successful because everyone credit also goes to many other kept me going,” she said. wanted this award,” said montesinos. contributors. “it was phenomenal. at “it wasn’t just us in the war room. it the end, we had so many people calling “tonya has a no-fail clause in was everyone pitching in together. this us with examples and stories to include everything she does—it was never in came together because nobody said no.” in the documentation. You could feel her mind that abbott northwestern the energy and pride in every story that was not going to get magnet was shared,” said montesinos. accreditation,” said tucker. “You can’t ask for better leadership than that.” NuRS I Ng dE PA Rt M E Nt 7
  10. 10. Professional Nursing Collaborative PROf E S SIONA L N u RSI Ng PR AC t IC E MOdEL Governance Professional Nursing when patient/visitor safety report data the new process involves calling a showed errors with endoscopy specimen hard stop at the end of the endoscopy Collaborative labeling and handling, the endoscopy procedure to: Governance council implemented a new “hard stop” process and shared accountability for • re-verify the patient’s name and medical record number Change begins at the bedside specimen handling with physicians. • verify that label information there is a simple premise behind correctly identifies the specimen “we were averaging about one or two collaborative governance: change and confirm the accuracy of other incidents a month in which a specimen happens from within. information on the specimen label wasn’t identified correctly or the labeling was incorrect or the specimen • have the physician sign the that’s because the people who are best was missing,” said diana nissen, center histopathology form. able to plan and implement a change for advanced endoscopy patient care are those who are most affected by it. manager. the number of errors has dropped significantly since the process was at abbott northwestern, collaborative endoscopy nurses collaborated with implemented in the first quarter of governance begins with local councils surgical services on the process, 2009. there were 10 errors during organized around patient care communities sharing ideas for process improvement. 2008. in the first quarter of 2009, there that are empowered to make changes the council also sought endorsement were two errors, and there have been to improve practice, education, quality and support from the endoscopy no errors since march 2009. and research. the councils have links medical staff committee. to hospital-wide nursing governance “when you’re in management, you through representation on the nurse the endoscopy council focused on ways need that connection to reality that practice council. to accomplish safety objectives without the direct patient care nurse has,” said adding too many steps to the workflow. nissen. “i can provide the data that a recent process change enacted by “that’s where it’s really important to tells what’s wrong, but they are much the endoscopy council illustrates how have input of the people who do the better at identifying how to fix it.” collaboration among different care work,” said nissen. communities and disciplines can improve patient care. 8 O u t CO M E S R E P O Rt 2 0 0 9
  11. 11. Professional Development PROf E S SIONA L N u RSI Ng PR AC t IC E MOdEL Professional in 2007, Blake joined an interdisciplinary showed how room set-up and cord team of nurses and physicians who entanglement could impede an Development completed simulation training at emergency patient transfer. Simulation training helps the stanford school of medicine’s center for advanced pediatric and But she has found that simulation create a better reality perinatal education (cape) program. training is particularly useful in when Barbara Blake, rnc-OB, started state-of-the-art simulation equipment enhancing critical thinking skills, her nursing career, obstetrical nursing was acquired in 2008 and has allowed teamwork and communication. had an immediate appeal. “i jumped abbott northwestern to develop one of participants learn the importance of into Labor and Delivery nursing and the only simulation programs of its kind voicing their concerns or observations have remained in this area for most of in the region. out loud and how to do so productively. my career,” she said. she has worked at “it also helps you see how your behavior abbott northwestern’s Birth center for Led by Birth Center educators Jone affects care. it really opens your eyes,” 22 years. tiffany, ms, rnc-OB, and Katie said Blake. molitor, rnc-OB, the team has But recently she has had the opportunity created a variety of lifelike scenarios to in addition, many of the lessons learned to apply her knowledge and experience in help train for situations like shoulder in simulation training can be applied a new way—by learning to use simulation dystocia, emergency cesarean sections, to a variety of patient care situations. training to help colleagues better prepare newborn resuscitation, anesthesia “nursing has always been focused on for obstetrical emergencies. emergencies and more. tasks and skills, but this is developing much more than that,” said molitor. in doing so, she has not only found a simulation training includes a pre- “it encourages people to look at their new avenue for her own professional briefing, the videotaped exercise and a behaviors and communication style. growth—she is helping others de-briefing. “most of the learning takes this really gets at the art of nursing.” enhance their skills and improve their place in the de-briefing,” said molitor. effectiveness in a variety of patient care that is where participants review situations. “this felt like a natural step the videotape, leading to insights at this point in my career,” said Blake. about system failures, communication “it was nice to feel that i was valued breakdown and behavioral issues. enough to be given this opportunity.” For example, Blake said that simulation Simulation training includes a training highlighted the need for a single phone call alert to the entire pre-briefing, the videotaped emergency c-section team. it also exercise and a de-briefing. “Most of the learning takes place in the de-briefing,” said Molitor. That is where participants review the videotape, leading to insights about system failures, communication breakdown and behavioral issues. NuRS I Ng dE PA Rt M E Nt 9
  12. 12. Stamdards of Practice/ Dimensions PROf E S SIONA L N u RSI Ng PR AC t IC E MOdEL Standards of Practice/ tomography (ct) contrast dye and supporting materials, including laminated can be flushed with saline instead of instruction cards, were distributed. then Dimensions— heparin. with growing awareness of they took time to do rounds on patient Elevating nursing standards, the danger and prevalence of heparin care units and demonstrate the technique allergies, the team felt it would offer for available staff. one PICC line at a time clear benefits to patients. Olson also used a simple demonstration the word static simply doesn’t apply But soon after introducing the catheters, with blue dye in a clear catheter that to nursing. the team began receiving reports of clots showed how blood could reflux into the in the lines and increased use of tissue end of the catheter if the flushing wasn’t practice standards, technology, procedures plasminogen activator (tpa) to clear the done properly. Blood in the catheter can and medications are in constant flux and clots. similar reports surfaced at other lead to a clot. “it’s one thing to talk about it’s up to nursing specialists to ensure that hospitals using the catheters, including a new procedure, but sometimes if you as patient care evolves, it does so safely, other allina hospitals. don’t see it, it doesn’t click,” said Olson. effectively and efficiently. Olson and others immediately began “we felt that this was the best vascular the intravenous (iv) team is one investigating the situation and contacted device to use because it didn’t require such group of nursing specialists. the manufacturer for assistance. initially, heparin—but we also needed to do all we “this is an engaged group,” said Jenny it was believed that changing the cap could to make it user friendly,” said Olson. enstad, patient care manager. “they do used on the device would help, but research on their own and bring it to my problems still occurred. it became since the flushing procedure was clarified attention. they have a focused role that clear that nurses needed to learn a new in mid-2008, the number of picc line is constantly evolving.” flushing procedure to prevent clotting. clots has come down. Olson and others continue to work with the manufacturer in 2008, the iv team began using a working with the picc and cap to determine if design changes could new generation of peripherally inserted manufacturers to clarify the proper help to further reduce the problem. central catheters (picc). according to technique, iv team representatives went carol Olson, rn-Bc, the new catheter to local nurse practice councils throughout “this kind of clinical leadership is critical allows for power injection of computed the hospital to teach the flushing protocol. to good nursing care,” said enstad. 10 O u t CO ME S R E P O Rt 2 0 0 9
  13. 13. Remaining Standards protocol for at-risk patients. By the end WomenCare Community of 2008, the number of pressure ulcers improving care for patients who are of Practice/Dimensions had decreased from 30 percent in the Morbidly obese During pregnancy first quarter of 2008 to zero percent in patients who are morbidly obese during Cardiovascular Community the fourth quarter of 2008. pregnancy are at a significant risk for reducing Heart Failure readmissions medical and obstetric complications. improving the critical care a multi-disciplinary team is working Heart failure is the most common orientation process to improve quality of care and safety discharge diagnosis in center for the critical care design team was for these patients while providing medicare services (cms) patients and formed as a collaborative effort to compassionate care. patients are referred is a leading cause of hospitalization, standardize and enhance the critical to an obstetric care coordinator who re-hospitalization and clinic visits. care orientation process for H4100, works with the clinical nurse specialist the cardiovascular community H4200, pB2000, post-anesthesia to develop an individualized plan of significantly reduced heart failure care unit and critical care Float care. this addresses any specialized readmissions (for any cause) within pool. in 2008, the team implemented needs related to hospitalization, labor, 30 days, achieving a 16.2 percent a centralized critical care orientation surgery and post-partum care. the readmission rate for fourth quarter. calendar. it includes standardized care coordinators arrange for specialty this is a 23 percent reduction from introductory and closure days for consultation as needed, and patients the 2006 baseline rate. a variety of all orientees (while maintaining a complete an activities of daily living strategies contributed to the reduction, station-specific component), a single assessment to help identify needs related including nurse follow-up phone calls critical care orientation book and to mobility, sleep apnea and personal within 24-48 hours, one-time home folder, streamlined and standardized care. an obstetric/bariatric equipment nurse visits for high risk patients who learning packets and a variety of other and supply cart is being developed to did not qualify for home care, a care tools and support materials. it also ensure easy access to items that are management pilot, and advanced care incorporates the essentials of critical essential for the care of these patients. planning sessions for heart failure care Orientation (eccO) online patients through palliative care. program and classes, simulation training, float days and clinical shifts. this has reducing Hospital-Acquired resulted in a more efficient and effective pressure Ulcer incidence orientation process and has created many the incidence of pressure ulcers is a key opportunities for the various critical nursing quality indicator. in spring 2008, care teams to learn from each other. the pressure ulcer incidence rate peaked on H4200 cardiovascular medical intensive care. the pressure ulcers were related to equipment used to secure the patients’ airways. a multi-disciplinary team addressed the problem by changing The Cardiovascular Community significantly endo-tracheal products, educating the reduced heart failure readmissions (for any staff about the use of tubes and plates against the skin, reviewing and updating cause) within 30 days, achieving a 16.2 percent procedures related to the care of the readmission rate for fourth quarter. intubated patient, emphasizing the nursing skin assessment upon admission, initiating weekly skin rounds and piloting a medical nutrition therapy NuRSI Ng dE PA RtM E Nt 11
  14. 14. Critical Care Community (PB2000, H4100, H4200) reducing the incidence of Ventilator-Assisted pneumonia (VAp) through increased nursing Oral Care Adherence Adherence to oral care protocol PB2000 the american association of critical-care nursing 140% (aacn)has established an evidence-based protocol 120% 120% 112% for providing oral care to the critically ill patient. Q4hr Adherence Rate 96% while all patients should received oral care based on 100% 86% the protocol, ventilated patients are of special concern 80% because mechanical ventilation can contribute to 60% mucositis and gram negative bacteria colonization, placing them at risk for vap. the protocol recommends 40% brushing every 12 hours and swabbing and suctioning of 20% the oral pharynx every 2-4 hours. 0% Sept 07 Oct 07 Mar 08 Apr 08 an oral care initiative was piloted on pB2000 in march-april 2008. results were compared with pre-implementation data gathered in september- October 2007. results during the pB2000 pilot, adherence to the protocol: Oral Care Adherence Critical Care Units • increased by 25 percent for the minimum 140% 124% 123% 125% recommendation of oral care every four hours 120% 112% 102% 104% • increased by 12 percent for the optimum 100% Q4hr Adherence Rate 100% 92% recommendation of oral care every two hours. 80% 63% vap occurrence during the pB2000 pilot was 0/1,000 60% 49% ventilator days, compared to 1/1,000 ventilator days 40% during pre-implementation. 20% in fourth quarter 2008, the oral care initiative was 0% implemented in all three intensive care units (pB2000, PB2000 H4200 H4100 H4100, H4200). By the end of 2008, adherence to Critical Care Unit the protocol at three-hour intervals had increased in all three units (see chart). also, H4100 and H4200 Baseline Oct 08 Nov 08 Dec 08 sustained 0 vap from may to dec 2008 while pB 2000 maintained a vap rate of 0.8 compared to national benchmark of 3.1 for like units. Note: Adherence Rate = The times of acutal clearnings divided by times of predicated cleanings 12 O u t CO ME S R E P O Rt 2 0 0 9
  15. 15. Spine Institute – H7000 Orthopaedics Community – H7200/H8200 Using learning paths to improve creating a patient-centered experience the orientation process in september 2008, abbott northwestern Hospital implemented the Joint replacement with an increased volume of newly center, a multi-faceted program dedicated to care for joint replacement patients. it hired nurses, the spine institute provides a patient-centered experience focusing on patient preparation and education introduced the concept of learning (before and during hospitalization), innovative and proven surgical techniques, multi- paths to improve the orientation modal pain control and an accelerated post-operative recovery program offering skilled process for both preceptors and and compassionate care. patients are cared for on a dedicated floor by an experienced orientees. Learning paths: staff and participate in group therapy. the Joint replacement center’s multidisciplinary • help track an orientee’s progress team meets monthly to evaluate strategies to improve the care they deliver. through the orientation process since the center opened, discharges to home have more than doubled for patients with • provide guidance to the total hip replacement and almost tripled for those with total knee replacement. Length preceptor on areas in which of staff has decreased by two-thirds of a day for total hip replacement patients and half a the orientee has demonstrated day for total knee replacement patients. competency • identify areas of needed Total Knee Replacement Patient development sooner in the Discharge Disposition orientation process 50% 46.9% • assist the charge nurse in making 42.4% Non-JRC Patients assignments that are appropriate 40% 34.8% Jan 08-Mar 09 for the orientee 32.9% Percentage of Patients JRC Patients • help preceptors keep each 30% 23.7% Sep 08-Mar 09 other informed about an 20% orientee’s progress. 14.6% 10% 3.5% results 1.1% 0.3% 0% Learning paths were introduced 0% Discharged to Discharged/ Discharged/ Discharged/ Expired in July 2008. in 2007, 16 nurses home or self transferred transferred to transferred spent an average of 41 shifts in care (routine to home skilled nursing to inpatient discharge) under care of facility rehabilitation orientation; in 2008, 16 nurses organized home facility (RF) spent an average of 25 shifts in health service organization orientation. Note: Non-JRC patients are those who received arthroplasty at Abbott Northwestern but were not treated in the Joint Replacement Center. Average Number of Shifts Nurses Spent in Orientation Medical/Surgical Community – E4100 50 Achieving recertification of transplant center 41 e4100 cares for post-operative patients who have received kidney transplants (from 40 both live donors and cadavers). the e4100 staff helped to assure recertification of Number of Shifts 30 25 abbott northwestern’s Kidney transplantation program. this center for medicaid services survey was in response to new federal regulations and affected all transplant 20 centers in the united states. 10 e4100 nurses receive annual education on caring for kidney transplant patients. 0 new employees are given additional education upon hire. the staff also works 2007 2008 closely with the Kidney transplant coordinators and the other members of the interdisciplinary team to collaborate on the plan of care. NuRSI Ng dE PA RtM E Nt 13
  16. 16. Surgical Services as a result, the number of patients whose temperature was >36˚c within 15 minutes Maintaining normothermia in of leaving the Operating room increased significantly. data monitoring will the perioperative Setting continue to ensure this improvement is sustained. maintaining perioperative normothermia improves patient outcomes. unplanned hypothermia can result in impaired wound healing, adverse cardiac events, Percent of Patients with a Temperature of >36˚C increased risk of infection and prolonged Within 15 Minutes of OR Out Time hospitalization. Main OR 100% 95% preoperative, intraoperative and 92% 81% 83% 84% postoperative nurses collaborated 80% 80% with anesthesia providers to maintain patient normothermia (>36˚c). steps 60% taken included: 40% • warming patients preoperatively using a forced-air gown 20% • warming the operating room for patient arrival and wake-up 0% 2006 2007 Jun 2008 Oct 2008 Nov 2008 Dec 2008 • ensuring accurate temperature Average Average (N=1033) (N=810) (N=751) (N=908) measurement upon arrival to the post-anesthesia care unit. Mental Health Services – the impact of this work was assessed results Adult Units: SK3900 / by monitoring the length of stay • The length of stay decreased by SK4800 and SK4700 & Child / and the patient/family response to about 0.5 days from 2007 to 2008. Adolescent: SK3700 two satisfaction survey statements: I participated in planning my discharge and Developing pathways for I received helpful education regarding my individualized care diagnosis and treatment. staff in mental Health services developed pathways to individualize care for each patient based on his or her diagnosis. pathways involve: Satisfaction Survey Percent Saying Percent Saying • rounding on each shift on patients Statement Agree/Strongly Agree – Agree/Strongly Agree – First Quarter 2008 Fourth Quarter 2008 • working with patients to meet daily goals I participated in planning my • education to teach patients discharge (for child/adolescent) 74% 90% about their condition how to I received helpful education (for adult) 73% 78% manage symptoms. I am satisfied with the overall quality of care and services (for child/adolescent) 84% 92% I am satisfied with the overall quality of care and services (for adult) 84% 90% 14 O u t CO ME S R E P O Rt 2 0 0 9
  17. 17. Sister Kenny® Rehabilitation Institute – W2300 Using care navigation to improve outcomes sister Kenny rehabilitation institute implemented the care navigation role in July 2008. the role is filled by licensed registered rehabilitation nurses, who are ideally positioned to help individuals affected by chronic illness physical disability adapt to their disabilities, achieve their greatest potential and work toward productive, independent lives. care navigators help patients achieve goals that are necessary to Float Pool the study analyzed three 8-hour shifts transition successfully from the acute and two 12-hour shifts (total of 217 comparing Assignment Difficulty rehabilitation setting to home, while shifts) in medical/surgical, orthopaedic, Among Unit Staff and Float pool Staff helping the facility meet or exceed spine, neurology, cardiovascular and the Float pool has more than 170 quality care outcome benchmarks. they critical care patient care units. data was employees who serve more than 30 coordinate resources and services and collected on patient difficulty (acuity, different departments at abbott collaborate with the interdisciplinary patient flow, volume and “other”). northwestern. this flexible workforce rehabilitation team to ensure that the although there was a tendency for is critical to the hospital’s success. patient’s needs are met in the most Float pool nurses to receive more in 2008, the Float pool focused on effective manner. difficult patient assignments, this was ways to increase staff satisfaction and engagement and decrease turnover. not statistically significant. Because of care navigation helps to achieve high study limitations, including the study a key issue is ensuring that patient levels of patient safety, coordination of size and the way in which the data was care assignments are fair and equitable care along a health continuum, patient collected and analyzed, funding is being for all. in response to concerns raised satisfaction, regulatory compliance and sought to repeat the study using a larger by Float pool staff, a quantitative efficient use of resources. the result is sample size, separate analysis per shift study (the first of its kind in nursing improved quality of care and patient and separate analysis of medical/surgical literature) was done to compare outcomes. and critical care data. assignments between unit staff and Float pool staff. Comparison of the Difficulty Between Float RN Assignments and Unit RN Assignments 2008 20 18 15 16 14 14 Difficulty 12 10 8 6 4 2 0 Float Staff RN Unit Staff RN Note: Difficulty = Acuity + Flow + Volume + Other NuRSI Ng dE PA RtM E Nt 15
  18. 18. Outpatient enhancing the patient experience through care continuity Overall Quality of Care and Services nurses in the ambulatory surgery 90% 100% center (asc) provide care and 78% 73% 71% 75% continuous evaluation for outpatients 80% 69% 71% 67% 68% 61% 64% undergoing procedures that require 60% % Excellent 60% local anesthesia, intravenous sedation or general anesthesia. 40% nursing assignments are structured to support care continuity throughout 20% a patient’s visit. For example, the 0% asc peri-operative nurse performs a Jan 08 Feb 08 Mar 08 Apr 08 May 08 Jun 08 Jul 08 Aug 08 Sep 08 Oct 08 Nov 08 Dec 08 pre-operative assessment and is able to develop a rapport with each patient. at this assessment, integrative therapies may be initiated, such as music therapy or televised relaxation instruction. the patients are randomly selected to receive a patient satisfaction survey at home asc operating room nurse meets the after discharge. in 2008, 70 percent of patients rated the overall quality of care and patient before the procedure and cares service as excellent. asc scores on the question “How would you rate the overall for him or her during the procedure. quality of care and services?,” exceeded the allina goal every month. after surgery, most patients return to the same peri-operative nurse for care until discharge. Bariatric Center templates as the national template. staff post-operative bariatric surgical patients. earning national recognition for also participated in a national workgroup Based on the findings of this review, care pathways that created guidelines for care of the it was agreed to exempt the bariatric in 2008, Bariatric center staff focused bariatric patient that will be used by new surgery patient population from the on achieving re-designation as a centers trying to obtain the initial center policy on using Gcs and scd together surgical review corporation Bariatric of excellence designation and for those on the post-operative nursing unit. surgery center of excellence. not that are updating current pathways. only did the Bariatric center receive the designation—it also has received Assessing Skin integrity risk national recognition for the care a skin integrity prevalence and pathways it developed as part of the incidence survey showed that bariatric re-designation process. the Bariatric surgical patients developed areas of center pathways articulate the patient pressure when graduated compression experience from initial seminar visit stockings (Gcs) with sequential through the surgical experience and compression devices (scd) are used lifelong follow-up. pathways addressed together. But patients who are morbidly patient education, consent, radiology, obese also have a significant risk of wound management, pain management, deep vein thrombosis, especially when anesthesia, peri-operative care and subjected to the surgical positioning and more. when the survey was completed abdominal pressure that occurs with in september 2008, the surveyors asked laparoscopic surgery. a review of skin to use the Bariatric center’s pathway integrity issues was conducted on 100 16 O u t CO ME S R E P O Rt 2 0 0 9
  19. 19. ED/CDART Patient Flow Indicators—Time Intervals in Minutes improving patient Flow and wait times Jan-08 Dec-08 the emergency department total visits increased from 46,218 in 2007 Arrival to Admit/Discharge 199.2 183.3 to 47,052 in 2008. improvements in Arrival to Admission 261.2 265.2 2008 have focused on patient flow and Arrival to eD Bed 27.2 16.1 patient satisfaction Arrival to Discharge 169.4 157 eD Bed to Assigned rn 5.6 5.3 each month department leaders and staff review the patient flow eD Bed to Assigned MD / np 19.3 16.3 indicators, identify barriers and take steps to improve the flow through the department. several time intervals are tracked—these results are total minutes from one interval to the next and show How long did you wait before being taken to the treatment area? significant improvement in times during 2008. arrival to admission has many 100% 100% variables, including hospital census/ bed availability, and creates the greatest 80% Responses Indicating 69% 64% challenge in patient flow. No Waiting Time 60% 60% 56% 56% 48% 44% the patient satisfaction survey question 40% 38% 37% 33% 40% regarding wait times also shows significant improvement. By december 20% 2008, 60 percent of patients reported 0% no wait time from arrival to being taken Jan 08 Feb 08 Oct 08 Mar 08 Apr 08 May 08 Jun 08 Jul 08 Aug 08 Sep 08 Nov 08 Dec 08 to treatment area: Clinical Decision and Rapid Treatment (CDART) the numbers below show improvement reducing length of Stay in the length of time patients are in cdart is a 23-hour observation unit that sees a wide variety of patients, including cdart. total patient count is up those needing extended observation for chest pain monitoring and testing, pain slightly but the total observation hours management prior to surgeries and other patients needing stabilization or extended are down by 2,244 hours from 2007 time before being safe to be sent home. to 2008. in 2008, cdart has focused on decreasing the length of stay. steps taken include: 2007 2008 • implementing the treatment plan immediately upon arrival total patients 3331 3,340 • getting consultations promptly total observation Hours 50,730 48,486 • educating the patient and family about the purpose of CDART and what they should expect in the unit. the cdart nurses work closely with both the ed physicians and hospitalists to provide the best and most efficient experience possible for patients. NuRSI Ng dE PA RtM E Nt 17
  20. 20. Mental Health Services Outpatient Mental Health Clinic enhancing Services this outpatient mental health clinic is staffed by a multidisciplinary team that includes two registered nurses and four nurse practitioners. the clinic moved from the medical Office Building to wasie 6th floor to provide an environment better suited for patients needing outpatient follow-up care. in collaboration with the womencare community, the outpatient clinic was set up as a second location for the post-partum depression program. a transitions program was created to assist people in making a successful ANW Adult Partial Hospital Program - 2008 transition from inpatient care or the intensive therapy received in the Qtr 01 Qtr 02 Qtr 03 Qtr 04 partial hospitalization program to the community. My therapists answered my questions so that I could 69% 55% 74% 80% understand the answers Mental Health Services Partial My therapists treated me with courtesy and respect 72% 62% 74% 73% Hospital Program The staff provided helpful education regarding my 51% 46% 57% 59% improving participant Attendance diagnosis and treatment the adult partial program worked to Groups were helpful to me 58% 50% 66% 64% improve program attendance. the top My therapists listened to my concerns and opinions 69% 55% 74% 80% three reasons for missing program days were identified as illness/headache, other My nurses answered questions so I could understand 53% 43% 52% 57% appointments and being tired/exhausted. the answers improvement plans included: My nurses treated me with courtesy and respect 59% 48% 63% 66% • educating patients on program rules My nurses listened to my concerns and opinions 50% 44% 55% 53% and expectations for attendance and participation • assessing patients’ understanding of the program and their individualized treatment plans Mental Health Services Assessment & Referral • teaching the most effective ways of coping and integrating skills learned identifying opportunities for improvement into daily life. a tracking tool was developed that accurately captures all calls, emergency department patient assessments, direct admissions, the number of patients declined compliance in program attendance for admission, and reasons for patient diversion to other hospitals or programs. this improved from 82.2 percent in march has helped to identify opportunities for future improvement projects including: 2008 to 89.4 percent in december • decrease the number of patients declined for admissions 2008. patient satisfaction scores also • increase the number of providers improved. the table below shows • increase communication from admitting source to inpatient units the percentage of “strongly agree” responses. • improve collaboration in care delivery to meet the patients’ needs. 18 O u t CO ME S R E P O Rt 2 0 0 9
  21. 21. Abbott Northwestern’s achievement. additionally, the Electroconvulsive Infectious Disease Clinic initial work-up (a repeat ua) for an Therapy (ECT) abnormal test was significantly more improving renal Health Among improving patient education likely to be completed after guideline people with HiV Materials implementation. recently, the increased risk for chronic electroconvulsive therapy (ect) kidney disease for people with Hiv educational materials for patients practice changes occurred among has come to the forefront. a nurse-led and families were improved through the physicians, nursing, social work, evidence-based practice improvement development of a video with up-to- and dietary staff, which resulted project was successfully implemented date information about ect. an in improved renal health care for with the multidisciplinary team. allina-wide educational teaching individuals with Hiv. identification this project had two components: sheet was developed to compliment and involvement of key stakeholders implementing agency-specific renal the video so that patients/families was imperative for success. Ongoing care guidelines by care providers and have current information about reinvention includes development of initiating renal and general health choosing this treatment option. all a clear follow-up protocol to manage education by supporting clinical staff. patients receive this information abnormal renal screening tests and before starting the treatment program. continued data analysis to sustain the Overall, after implementing the practice changes. guidelines, there was statistically significant improvement in the proportion of urinalyses (ua) and estimated glomerular filtration rate (eGFr) completion for patients during their initial clinic visit (ua p < .001, eGFr p =.002) and for those requiring yearly (ua p < .001, eGFr p < .001) or twice yearly (ua p < .001, eGFr p < .001) renal testing. the rate of renal health education was 60.7 percent, which was less than the anticipated rate of success. However, close analysis revealed partial implementation NuRSI Ng dE PA RtM E Nt 19
  22. 22. OB Homecare to questions about overall satisfaction and recommending OB Homecare to others, increasing patient Satisfaction Scores post-partum patient satisfaction scores increased from 2007 to 2008. “excellent” OB Homecare nurses make a special responses for overall quality increased by 6.8 percent; “definitely Yes” responses for effort to encourage patients to recommending OB Homecare to family and friends increased by 8.1 percent. provide feedback on their nursing care and the services they receive from OB Homecare. this, combined Postpartum Patient Satisfaction with workflow changes to improve 100% continuity of care, is believed to have 87% 79% contributed to increases in patient 80% 66% 73% satisfaction scores. Overall Quality of Care (% Excellent) 60% staff nurses explain to patients how Would you recommend important it is to them to receive 40% OBHC (% of Yes) their feedback. they also add their initials at the bottom of the survey 20% form before handing it out at the end of their visit. in comparing responses 0% 2007 2008 Minnesota Perinatal Physicians enhancing care through nursing coordination a fetal surgery/intervention program that serves patients throughout the upper midwest has highlighted the need for registered nurse care coordination for patients with complex pregnancies. the midwest Fetal care center was developed through collaboration with minnesota perinatal physicans, pediatric surgical associations, and children’s Hospitals and clinics of minnesota. rn care coordinators assist patients with transportation needs and resources within the twin cities area. they have been vital in addition to improving care would result in more convenient to program development in areas such as: coordination for fetal therapy patients, services for patients and enhanced care • patient education materials the perinatal clinic at abbott continuity and were able to incorporate • community resources northwestern made it possible for testing into an already busy workflow. patients to have any fetal testing done • order set development at the clinic site instead of at the • outreach maternal assessment center, which • staff development is located in a separate building on campus. nurses recognized that this • monthly care planning meetings • care continuity from diagnosis through delivery. 20 O u t CO ME S R E P O Rt 2 0 0 9