NCH Healthcare System in Naples, FL, has seen a considerable decrease in the prevalence of ulcers, along with a significant savings associated with its prevention plan.
"Assuming that each time a pressure ulcer case was prevented the cost would be $3,000, we calculated that NCH saved $11.5 million annually," says Joan A. McInerney, MSN, RN-BC, CWOCN, wound ostomy continence (WOC) nurse coordinator at NCH.
Over the five-year period from January 2002 to January 2007, NCH's rate of pressure ulcers dropped from 12.8% to 1.9%. During that time, the number of heel pressure ulcers alone dropped from 6.7% to 1.1%.
In January 2002, staff members at NCH realized the facility's prevalence of hospital-acquired pressure ulcers (HAPU) was 12.8%, high above the national average of 8.5%. Heel ulcers made up more than half of this number.
After hearing these statistics, McInerney and her partner, a newly hired WOC nurse, met with physicians, risk managers, and members of the leadership team to find a solution to help lower future heel ulcer outbreaks.
However, before McInerney and her fellow staff members had a chance to implement a new product, a patient in the critical care unit suffered a serious injury due to a heel ulcer.
This sentinel event, along with the recently discovered statistics, accelerated NCH's implementation of a new boot product to help lower the incidence of HAPUs, specifically on patients' heels.
At the time of the sentinel event, NCH was using the Braden Scale for Predicting Pressure Sore Risk and had implemented an electronic medical records system, says McInerney.
In 2002, NCH decided that when a new patient came into the facility, a nurse would assess the patient's skin integrity and ask him or her to answer a series of questions. Based on the assessment and the patient's answers, the computer would score the answers according to the Braden scale and all six subscales.
NCH staff members continue to use this practice to assess a patient's risk for HAPU upon admission to the facility.
"The electronic record allows us to capture every patient that is at risk for developing any sort or pressure ulcer," says McInerney. "We set up several alerts on the program in the event a patient qualifies for a boot, and automatic orders are placed, as well as needed consults with myself or the other wound ostomy continence nurse."
Trend analysis and boot protocol implemented
In addition to using the electronic record to determine whether a patient needs a boot, NCH also began a trend analysis of the prevalence of pressure ulcers every six months for the five years between January 2002 and January 2007.
The results of more frequently recorded pressure ulcers were seen almost immediately, and within the first six months, pressure ulcer prevalence dropped from 12.8% to 7.5%, McInerney says. Heel ulcers dropped from 6.7% to 3.5%.
"I was so excited and thrilled by the initial results with heel ulcers," says McInerney. "Everyone was very happy and maybe a little relieved that we seemed to be on the right track."
To further NCH's goal of improving pressure ulcer prevention, specifically heel ulcers, a team came together to search for a new boot and to develop specific protocols to determine which patients should wear the boot. The team consisted of McInerney, her partner, a critical care physician, a podiatrist, and a risk manager. The team solicited samples from boot companies, and from those options, staff members tried on the boots to see which ones elevated the heel. After some deliberation, the group chose the Heelift Suspension Boot by DM Systems in Evanston, IL.
The team—with the help of the chief medical officer, the chief nursing officer, an information technology staff member, and the heads of central distribution, the operating room, education, and critical care—determined protocols for which patients were to receive the boot.
Along with using the initial assessment during a patient's admittance, McInerney and her team determined that all patients with end-stage renal disease who were on hemodialysis and all patients using ventilators would automatically be required to wear the boots.
McInerney says it was important to empower staff members to use their discretion when judging whether the use of a boot is necessary with a particular patient.
"[Even though we were already using the] initial assessment—less than 13 on the Braden scale—and the boot protocol [as indicators], we also wanted to make it clear to staff that if they thought a patient was at risk, and they did not fall into predetermined categories, to give them a boot," says McInerney.
Visible success and results maintained
Since NCH first saw its pressure ulcer prevalence numbers drop between January and July 2002, the facility has continued to see success.
"The fact that the idea of lowering NCH's pressure ulcer prevalence has been drilled into the staff members' heads has really helped our numbers," says McInerney. "It's such a part of our life now, and I have no painful memories of this process."
McInerney created posters and flyers displaying a foot on a mattress with a red slash to illustrate that patients at risk for pressure ulcers should not have their feet on the bed, but rather elevated in a boot. In addition, NCH's CEO discussed the pressure ulcer rate in his weekly newsletter.
Another factor that helped NCH maintain a low pressure ulcer rate was the decision to upgrade the system's hospital beds. In 2004, nurses purchased pressure-relieving, continuous lateral rotation therapy air mattresses for critical care units, and other units in the hospital received pressure-reducing foam mattresses.
NCH continues to have great success keeping pressure ulcer numbers low. In the past two years, NCH's pressure ulcer rate has remained under 2%, reports McInerney.
"I attribute a lot of our success to the product itself," she says. "But you have to remember that it takes persistence. The idea of electronic records which force consults to make sure everyone is covered may cause some overlap. But compared to what you save on preventing pressure ulcers and that it is the right thing to do, one has to focus on the bigger picture."
This article was adapted from one that originally appeared in the June 2009 issue ofBriefings on Patient Safety, an HCPro publication.
New York state health officials have suspended a ruling that would have forced healthcare workers across the state to get vaccinated against the swine flu by the end of November or risk losing their jobs, saying in a decision issued Thursday that they did so because the vaccine is in short supply. New York will be getting only about 23% of its anticipated supply of the vaccine for the swine flu virus by the end of the month, and that should be reserved for those most at risk for serious illness and death, according to Gov. David Paterson's office.
With the economic crisis affecting the healthcare arena, hospitals large and small must tighten the budgetary belt. This difficult task weighs heavily on hospital CEOs across the nation. Should leadership positions be eliminated? Should nursing FTE's be cut?
Historically, one of the first hospital departments to experience the crunch is the nursing education department. Reimbursement for seminars and out-of-facility education is an easy expense to eliminate and monies once budgeted for training are frozen. With a short-term perspective, it's easy to believe these cuts will have little effect on hospital operations and those currently employed within the facility, but unfortunately, this is a false assumption.
The future of ongoing improvement in quality healthcare has a strong dependency on life-long learning that is hosted and encouraged by staff development departments and their educators across the country. It is a Joint Commission requirement that the competency of all clinicians be validated at least once per year, but without needed equipment and budgeted salaries for qualified practitioners to validate competency, that mandate cannot be met.
Each day there are evidence-based changes and updated techniques surfacing as the result of clinical research and testing of best practices around the world. Communicating these changes and teaching new techniques to clinical staff in healthcare facilities is the responsibility of staff development professionals and clinical educators. Positive patient outcomes rely directly on the skills and knowledge of the clinicians caring for them.
During the past year, several sentinel events and near misses have been reported related to the administration of Heparin. As a result, safety measures have been created and implemented in healthcare facilities around the world, such as a double check system in which two clinicians independently calculate the dosage of Heparin and then compare the calculated dose, and a tighter control of the anticoagulant by the hospital pharmacy. The need for clinician education and post-education validation was mandatory. Without this education, future critical events and deaths are likely to occur.
The Joint Commission defines negligence as a “failure to use such care as a reasonably prudent and careful person would use under similar circumstances.” The cost of nursing negligence by far outweighs the savings that staff development budget crunching results in, let alone dangers to our patients from medical errors caused by incompetent clinicians.
In light of these concerns, too stringent cuts from the staff development department's budget during economic hardship should be a warning sign. Consideration must be given to future costly litigation fees as a result of substandard care and the difficulty of launching new quality improvement initiatives without educated staff development professionals to oversee them.
Deanna R. Miller, RN, MSN/HCE, is the manager of critical care and staff development at University Hospitals Geneva Medical Center in Geneva, OH.For information on how you can contribute to HealthLeaders Media online, please read ourEditorial Guidelines.
A union is threatening a one-day strike involving 16,000 registered nurses at 39 hospitals in California and Nevada, saying hospitals aren't providing enough protections against swine flu for its members. The union said one of its members died in August after contracting swine flu and that dozens of others have been sickened by the disease. It wants to use the contract negotiations to establish safety procedures around the United States.
Nashville hospitals have started to receive shipments of the injectable version of the H1N1 vaccine, which can be taken by people who aren't eligible for the nasal spray. Baptist Hospital received 600 of the 3,000 shot doses it ordered, and Vanderbilt University Medical Center also got about 2,500 doses. Like the H1N1 FluMist nasal spray, the shot will be given to healthcare workers first. Any remaining doses probably will go to hospitalized patients.
Staff development specialists are well aware that the way new employees are oriented to an organization has a significant effect on their job satisfaction and, ultimately, on retention. It is essential that we take this belief and translate it into evidence-based practice. One very innovative educator did just that when she revised her nursing orientation program to help increase nursing retention rates in her organization.
Sylvia E. Prickitt-White, RN, BSN, MEd, is the nursing education/wound care clinical coordinator at the Heart of Lancaster Regional Medical Center, a 140-bed hospital in Lititz, PA. As the educator in the hospital, Prickitt-White found that orientation was taking more and more of her time. The demand for orientation was linked to the need to hire and orient new nurses on a very frequent basis. In 2005, she began to notice what she calls a "drastic turnover" of both new and experienced nurses.
"They would stay for about three to six months and then resign," says Prickitt-White. "Our retention rate of newly-hired nurses was about 25% to 30%."
At that time, general orientation took one week and unit-based orientation lasted for three months. She wanted to know why nurses were leaving so began contacting nurses who had left the organization. She says new nurses reported feeling "removed and disjointed once they left the safety of new employee orientation" and also reported a lack of connection after orientation was completed.
New orientation initiatives
As part of her efforts to find a solution to the problem, Prickitt-White conducted an extensive literature review on the topic of retention and orientation. According to the literature, nurse retention is boosted by some type of formal program that extends beyond orientation, such as a residency or mentoring program, that allow for regular contact with designated peers throughout the first year of employment.
Armed with evidence from her literature review, she approached administration and received permission to implement a new program. She designed an extended orientation program that lasts throughout the first year of a nurse's employment. She says the purpose is to "bring new employees together to give them information they may have heard during orientation, but may not have absorbed due to the extensive amount of information thrust upon new employees."
This program also gives them a chance to reconnect with each other and share comments, concerns, and triumphs. The year-long program is called Connections and consists of four components: Connecting the dots, focusing the picture, keeping the focus, and completing the puzzle.
Connecting the dots
"Connecting the dots" is a half-day program designed to help "pull the pieces together," says Prickitt-White. Held one month after the initial general orientation of a group of nurses, it brings the group back together.
The half-day program gives nurses a forum to reconnect with their group and allows them to ask questions and express concerns—both to each other and to Prickitt-White—in a supportive, non-threatening environment. It also fosters cohesiveness and a support network.
In addition to taking part in open discussions, the group has a chance to meet with people important to their practice, but who were not part of their general orientation due to time constraints, such as the diabetic educator. The chief nursing officer (CNO) also attends, giving the nurses an opportunity to discuss issues with her as well.
Focusing the picture
The next part of the program, "focusing the picture," is held three to four months after the group's hire date. The hospital may have more than one orientation group depending on how many orientations have been held during this time period. "Focusing" is held between the first and second shift and the second and third shift and is a two-hour program. Nurses are financially compensated if attending the class on off-duty hours, and, thus far, attendance has been good.
"Focusing" concentrates on hospital processes that may not have been addressed or were only briefly addressed in previous classes. Some topics include rapid response teams, hand-off communication, and a discussion of how they are doing with the documentation system and bar code medication administration. Depending on the response, Prickitt-White might offer some remediation work with nurses regarding medication administration and documentation.
And of course, a key part is the ongoing emphasis on communication and support.
Keeping the focus
"Keeping the focus" is split into two sessions, one at six months after hire and one at the nine month mark. Classes are offered to accommodate the needs of nurses who work various shifts. The content is flexible so that additional topics and issues can be addressed as needed. Topics addressed may include updates on National Patient Safety Goals, annual competencies, risk management, Medicare reimbursement, or Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results. Prickitt-White notes that discussing HCAHPS results, which reflect patients' experiences of their hospitalization, helps to focus nurses on thinking about customer service as well as clinical interventions.
The program also makes sure to allot time for open-ended discussion.
Completing the puzzle
The final component of the program, "completing the puzzle," is a class held about one year after hire. The session is scheduled for a time when most of the group is scheduled to work and is presented as a breakfast or lunch buffet.
The group members themselves guide this open-ended discussion, which serves to bring closure to the first year of employment. They also evaluate the orientation program to provide feedback on their experiences.
Results
Prickitt-White is "thrilled" with the link between her new program and retention rates.
"The retention rate one year after program implementation jumped to 65%," she says. "Today, three years later, retention has reached 80%."
Although many factors influence retention, it is clear that there is an association between the new program and improved retention. Other program strengths include enhanced communication, increased feelings of support among and for orientees, and more time for orientees to become assimilated into the organization. Challenges include the ongoing need to work with new administrators and managers to maintain buy in for the new program, scheduling nurses to attend the third and fourth program sessions (by this point they are carrying full patient loads and need to be covered on their units), and finding ways to effectively utilize orientation feedback.
Editor's note: Prickitt-White presented her findings at the Pennsylvania Workforce Investment Board conference in March 2009. She is currently working on developing a manuscript for publication to share her success with other staff development specialists. Prickitt-White's innovation has not only helped her organization and its newly-hired nurses, but has added to the evidence-based body of staff development knowledge as well.This article was adapted from one that originally appeared in the October 2009 issue ofThe Staff Educator, an HCPro publication.