When Kathleen Mikos, RN, MSN, CNO and vice president of patient care, came to Ingalls Memorial Hospital in Harvey, IL, she couldn't shake the sense of déjà vu when she found that patient handoffs took an hour to 90 minutes to complete.
At her previous hospital, Mikos had dealt with a similar issue—performing patient handoffs took longer than it should have. The lengthy amount of time became an issue with incremental overtime and also got in the way of patient care.
"I was concerned because during a period of an hour, where so many nurses are tied up, who is taking care of the patients?" says Mikos.
Drawing on her past experience, in May 2008 Mikos began to develop a new, efficient method for patient handoffs that allowed for more patient-nurse interaction and reduced nurse overtime at Ingalls.
The old and the new
For years, nurses nationwide have used different methods for handling handoff reports. One technology was the use of taped records. This caused problems because if an interruption occurred while the nurse was reporting, the nurse had to make a note on the recorder where the tape left off, causing confusion later on.
There were also instances when the tape recorder broke or someone had recorded over a report, causing the nurses to take more time to rerecord each patient report.
More recently, nurse-to-nurse interaction between shifts is how patient handoffs are handled. As the nightshift is coming on and the day shift is leaving, and vice versa, the nurses discuss each patient and how the shift went.
Although effective, this process takes a lot of time, and many nurses go into overtime.
"Between shifts, I can have up to 20 nurses tied up," says Mikos. "Having that many nurses tied up, trying to get reports, cuts into the patient care."
Much of the delay occurred because not all nurses shared the same patients. Mikos turned to The White Stone Group, Inc., for a technological solution to facilitate a new handoff process. This company provides healthcare organizations with software to help improve the management of healthcare communication events.
Having had experience with The White Stone Group in the past, Mikos was confident in setting up OptiVox, a voice technology program for handoffs, and made the program accessible to all staff members through any telephone in the hospital system.
Other similar programs that facilitate the patient handoff process include the PatientKeeper Sign-Out technology and Vocera's communication systems. Physicians use the PatientKeeper program as a continuity of care tool and enter patient care details that the next shift's physician will need. Vocera's wireless devices enable instant communication among staff members.
Voice technology OptiVox
OptiVox is a computer-based voice platform technology that is built into the phone system, says Mikos. Nurses can dial into OptiVox and record their patient reports or listen to the patient reports from any phone in the health system.
Nurses coming off a shift and needing to report on their patients dial in an individual access code, pull up each patient's medical record number, and begin recording a report on that patient.
In addition to using OptiVox to record their reports, the nurses are also encouraged to use the SBAR format. The SBAR technique helps guide communication between staff members on a patient's condition.
To identify each patient in the system, Ingalls uses the patient's medical record number to prevent confusion, says Mikos.
"You are always up against potential patient safety issues, and some patients may have the same name or date of birth, but medical record numbers are always going to be unique," says Mikos.
When nurses arrive to start their shifts, they can access the reports from the previous shift the same way nurses record them. Using any phone in the health system, the nurse dials in with an individual access code and uses his or her patients' medical record number in order to listen to the reports.
"To receive reports on five or six patients should take about 15-20 minutes of shift report time," says Mikos.
Now, with extra time, the nurse can find the previous shift nurse to clear up any unanswered questions and visit his or her patients for brief assessments and introductions.
"Here at Ingalls, we believe there is a need for face-to-face, or bedside rounding," says Mikos. "After the nurses [listen to the] handoff report, they should immediately go out to their patients, introduce themselves, and have a brief discussion on how the previous shift went."
Advantages for the entire hospital
OptiVox received a positive reaction from patients, nurses, and the management team, says Mikos.
For the nurses, there are features in OptiVox that help make recording and listening to the reports easier and more convenient than listening to a normal tape recording.
The program gives the nurses the option to slow down or speed up a recording if the nurse who recorded the report is a fast or slow talker.
In addition, OptiVox provides the capability for nurses to go back to where they left off if they were interrupted while recording any reports.
The program also allows managers and nurse leaders to leave a broadcast message there for all staff members to hear.
"Typically, if there is something of importance that I need to get out, I can have that message presented for as many shifts and days as I believe necessary to penetrate my staff," says Mikos.
OptiVox is also beneficial to the nursing students that come through the Ingalls health system, says Mikos. The program allows the students to listen to reports and helps them become more acclimated to real-life situations, says Mikos.
Another benefit of this technology is that the records can be kept for any length of time, depending on how long the organization wants.
"We hold on to the records for two weeks," says Mikos.
By keeping the records for this length of time, Ingalls ensures that in the event of a near miss or an error, the report is on file and can be listened to again.
Involvement with other departments
The OptiVox technology is also beneficial when it comes to patient throughput and alerting an area of the hospital to expect a patient from the ED, says Mikos.
Prior to implementing the technology, ED nurses had difficulty reaching nurses on other floors and units.
"We tried all sorts of things, from bringing the patient up to a certain floor to attempting to keep calling back and forth," says Mikos.
Now, with OptiVox, when a nurse needs to transfer a patient from the ED to another unit, he or she simply voices the report into OptiVox and the system automatically sends a voice message to a designated unit telephone number. That patient's report is then available for the receiving nurse.
The ED nurse also includes his or her name and telephone number in the event the receiving nurse has any questions.
"This has really taken away the bottlenecks that were created when giving reports," says Mikos. "This gives us a precise process to user report and helps expedite the patients out."
Savings and positive thoughts
One of Mikos' goals when implementing the new technology was decreasing incremental overtime. "With the new process, we saw a great reduction in overtime," she says. "And the savings helped pay for the technology."
However, Mikos warns that there has to be a strong message sent from the leadership team about incremental overtime and backing the system.
"There are some nurses that aren't so in tune with us managing incremental overtime," says Mikos. "You have to monitor the time and send a message so no one resorts back to the old ways of recording incremental overtime."
Overall, Ingalls staff members have been pleased with the new handoff process, and even the unit secretaries noted how much the noise level decreased, Mikos says.
Once, the halls were filled with nurses chattering, trying to catch up on reports. Now, the halls are noticeably more quiet because nurse-to-nurse communication for handoff reports has been replaced by telephones and computers, says Mikos. "The healing environment has improved tremendously."
Anne Mitchell, a Texas nurse, is being indicted and threatened with 10 years in prison for informing state regulators that a doctor at her rural hospital was practicing bad medicine. Mitchell is scheduled to stand trial in state court for "misuse of official information," a third-degree felony in Texas. The prosecutor said he would show that Mitchell had a history of making "inflammatory" statements about Rolando G. Arafiles Jr., MD, and intended to damage his reputation when she reported him last April to the Texas Medical Board, which licenses and disciplines doctors.
Typically when infection preventionists (IP) evaluate bloodstream infection rates, their initial thoughts turn to central line compliance. Rarely is there much attention given to the use of multichamber bags versus compounded bags for parenteral nutrition.
But a study that was presented at the Infectious Diseases Society of America's (IDSA) 47th annual meeting October 29–November 1 found that the way in which parenteral nutrition is delivered could affect bloodstream infections among high-risk patients.
Authors of the study focused their research specifically on the oncology unit because patients in that unit are already susceptible to infections, says Robin Turpin, PhD, senior director of health economics in IV nutrition at Baxter Healthcare Corporation in Deerfield, IL.
"In this particular analysis, we were interested in looking at the oncology population because they were high risk," Turpin says. "They already have a compromised immune system, so we had thought they might be at a higher risk [for bloodstream infections]."
By evaluating data among 19,540 patients, Turpin and her colleagues found that patients who were given compounded bags were more likely to have major or extreme illness severity, more days of parenteral nutrition, more days in the ICU, and a longer overall hospital length of stay. After adjusting baseline differences, the study concluded that the adjusted probability for bloodstream infections was 19% higher for compounded bags compared to multichamber bags.
"It has been fairly well documented in literature that parenteral nutrition is a risk factor for bloodstream infections, but we were curious as to, in general, if different types of preparation may have a higher risk versus another," Turpin says. "Because compounding parenteral nutrition is a very different process than a multichamber bag, we were curious."
Compounding is more popular
Compounding parenteral nutrition is a process in which a pharmacist takes the amino acids, dextrose, and perhaps lipids, depending on the physician's prescription, and literally mixes the nutrients in the pharmacy under aseptic conditions. Multichamber bags are dual-chamber bags with premixed solution that can be mixed by rolling the chambers together. Additional vitamins and micronutrients can be added if needed.
For whatever reason, the compounding process has become a standard of practice in the United States, says Turpin. The IDSA study found that more than 18,000 of the 19,540 patients were given compounded parenteral nutrition. Other countries, such as France, favor multichamber bags.
"I don't think there is necessarily clinical evidence for that," Turpin says. "In the U.S., there is just a lot of compounding."
Developing a standardized process
The reason multichamber bags may lead to fewer bloodstream infections is because they involve a much more uniform process. Compounded bags provide a much larger window for human error by breaking a sterile barrier.
"A multichamber bag is really a standardized parenteral nutrition [process], and we believe, and sometimes you see thought leaders that publish this, probably a good number of patients can really be serviced with a standard parenteral nutrition," Turpin says. "Some [patients] certainly would need some customized, which is where compounding is ideal. In other words, there are some patients for which compounding is ideal, then there is a large group of patients where a multichamber bag is great too."
Unlike some infection prevention checklists or processes, there is no cut-and-dry determination for when each approach produces the most favorable results. Because this was a retrospective study, the final numbers produced very limited evidence. Turpin says Baxter does have some prospective studies in the works that may provide much more consistency across all units and populations.
"But it's not just a prospective study within the hospital, we also have a study looking at home care patients as well," Turpin says. "It's looking at various patient populations. [We will know more] assuming we find similar results."
Raising questions
This study is not intended to be the final recommendation for parenteral nutrition use across all hospital units, Turpin says. Although authors of the study had a vast amount of variables and data to work with, they still only focused on the oncology unit, and there are likely many more factors yet to be determined.
Rather, it's a chance for IPs to look at the process that is used at their hospital and consider whether an alternative solution might help in particular instances.
"I think for infection control practitioners, what they love about this is really just raising the issue," Turpin says. "It's providing some more information for people to understand a little bit more about these issues, raise the issue, and say, 'Wait a minute, let's look a little bit more carefully.' "
The study was well received by IDSA meeting attendees. "I think people seemed to be very, very interested in the bloodstream infection issue, and I think people hadn't considered the whole parenteral nutrition piece of it before," Turpin says.
This article was adapted from one that originally appeared in the January 2010 issue ofBriefings on Infection Control, an HCPro publication.
Florida Gov. Charlie Crist has paved the way for nurses from outside Florida to fill in for colleagues in Miami who want to go to Haiti in the wake of the catastrophic earthquake.
Crist signed an executive order that allows out-of-state nurses to be licensed to work in Florida for the next 90 days. About 200 nurses from Miami-based Jackson Memorial Hospital have signed up to go to the island, hospital officials said.
Two Connecticut legislators said they've formed a bipartisan group to find a way to reinstate a licensed practical nurse adult education program that Gov. M. Jodi Rell suspended to help close the budget deficit. The group, formed by state Senate President Pro Tem Donald E. Williams and Sen. Jonathan A. Harris, will meet January 22. The nursing program produces about 350 licensed practical nurses every 16 months. The state labor department forecasts a need to fill 325 licensed practical nurse openings each year through 2016, the Hartford Courant reports.
It takes more than one method to bring a hospital's hand hygiene compliance rate above 90%. At Barnes-Jewish St. Peters (MO) Hospital (BJSPH), it was a matter of trial and error to reach its compliance goal.
"We started collecting hand hygiene observations back in 2004," says Kathleen Dougherty, RN, MSN, manager of professional practice and leadership development at BJSPH. "We wanted to see where we were with compliance for guidelines from the Centers for Disease Control and Prevention [CDC]."
Taking 100 observations per quarter, the organization found its hand hygiene compliance rate was 57%. Conversations began on how to reach the CDC goal. The 2004 numbers illustrated the need for increased compliance; the renewed awareness alone caused a significant jump in compliance in 2005.
"We got our rates up to 79% [in 2005]," says Dougherty. "This came about just based on a general heightened awareness of hand hygiene. We didn't have a pointed focus or implementation plan."
Although the jump was encouraging, it still did not bring the organization's compliance numbers to an acceptable level. But the organization was collecting data.
The facility has seen significant rates of improvement each year since this time—remaining over 90% and at times hitting 99% compliance in 2009.
Education and training
BJSPH is a member of BJC HealthCare, a 13-hospital system in Missouri. The hospitals share a center for healthcare quality and effectiveness, which works closely with all facilities to develop standards and practices to be used across the system.
"The center looks at regulations that relate to clinical quality and patient safety and assists with development of protocols and procedures to facilitate positive results," says Dougherty. The center knew hand hygiene compliance was about to explode on the national level. At the time, The Joint Commission (formerly JCAHO) was increasing its focus on this issue, and BJC wanted to be prepared.
"We also knew we'd be accountable to publish data [on hand hygiene compliance] on a regular basis," says Dougherty. Thus, in 2006, mandatory training was implemented. "Every employee was provided with training on hand hygiene in 2006," she says.
However, the increase in compliance was minimal, climbing to 80% that year. Simultaneous to the training, the organization started using hand hygiene auditors—essentially undercover agents looking for hand hygiene compliance—to act as observers.
"These auditors were on all shifts like secret shoppers," says Dougherty.
They came from all walks of hospital life—not just physicians and nurses, but secretaries, housekeepers, lab techs, and others.
When the numbers did not rise as much as expected, extra training was provided, additional auditors were trained, and compliance rates were reported at departmental meetings.
You've been spotted
"In 2007, we knew we had to do more, and we wanted to do more," says Dougherty. "We wanted to be at 90% hand hygiene compliance by the end of that year."
BJSPH increased the frequency of the audits to a minimum of 100 per month.
"Our point of view was if you increase your 'n,' you have a better chance of being successful," Dougherty explains.
In February 2007, after a brief discussion with a Joint Commission surveyor, BJSPH learned of the idea to use cards as a method of feedback during audits. The hospital took this idea and developed it further into a very simple but highly effective concept: "You've Been Spotted" cards.
These cards—adorned with a Dalmatian to support the "spotted" theme—come in two varieties. At a distance, they appear indistinguishable, but up close, the two varieties are unique.
For positive reinforcement, some of the cards are flagged for incidents in which the receiver has been spotted using good hand hygiene practices. These cards include a $2 coupon that's good in the hospital cafeteria or gift shop, which is enough for a cup of coffee or candy bar.
Receivers of multiple positive reinforcement cards can use them together to purchase lunch. Funding for these coupons came from the infection prevention budget.
On the spot
The second type of card reads, "We are putting you on the spot for not using hand hygiene."
The reason the cards look nearly identical is to prevent embarrassment for the people involved. It's impossible to tell from a few feet away whether you've received a positive or negative card.
"We needed something nonconfrontational," says Dougherty. "We wanted something with positive reinforcement, but also something to notify you if you got caught. We didn't want this to be a public display."
The dynamic is an interesting one, especially because the auditors can be from any area of the hospital hierarchy. For example, secretaries have had to give cards to physicians.
The introduction of the cards showed an increase in compliance, but not enough of a jump to be completely satisfactory. "We saw an increase that year. We made it to 90% one month, but for year-to-date we were at 86%," says Dougherty.
Posting names was the next step toward improvement. "We continued the positive rewards program, but . . . we started reporting both those who did well and those who needed to improve," explains Dougherty.
The good with the bad
There was much deliberation within the leadership team on the concept of posting names. Leaders made a conscious decision to hold everyone accountable while continuing to use the carrot instead of the stick, staying with positive reinforcement to motivate their employees to higher hand hygiene compliance.
To temper the negative reinforcement of posting names—which helped improve compliance as well—BJSPH implemented an additional, and very public, way of rewarding those who were spotted using proper hand hygiene processes.
"Any [month] we meet or exceed our goal, we will take the names of everyone who was recognized as doing a good job, put their names into a drawing, and have a 'hand hygiene hero' drawn in the cafeteria," says Dougherty.
The cafeteria is shared by staff members and guests, so the congratulatory ceremony, which includes the loud playing of Bonnie Tyler's 1980's hit "Holding Out for a Hero," can be witnessed not only by staff members, but also patients and their visitors. The winner of the drawing receives a $25 gift certificate, and in months in which the goal is exceeded, multiple names are drawn.
Winners' pictures are taken and posted throughout the building and even made into screensavers on hospital computers. The tactic has been well received by staff members, and when a winner is present in the cafeteria during the drawing, cheers have been known to break out.
Handling positive recognition is easy. Those spotted to be noncompliant can be more of a challenge.
Non-staff members are not immune to the card system. If a physician or advanced practice nurse is spotted not following hand hygiene protocol, the hospital's risk manager follows up with the independent practitioner separately.
It's not all "gotcha," either. BJSPH uses the "Just Culture" concepts, acknowledging human error, and the follow-up for noncompliance is not without managerial discretion. The factors leading up to an incident are taken into consideration when a noncompliant employee is spotted. "Managers are expected to hold staff accountable," says Dougherty.
To the program's benefit, the auditors have remained remarkably consistent over its duration. To keep the secret shopper concept fresh, the auditors don't continually work the same shifts or areas of the building. A fluid schedule allows the auditors to remain anonymous even as they keep their role year after year.
"We've sent the message that these patients belong to all of us," says Dougherty.
This article was adapted from one that originally appeared in the December 2009 issue ofBriefings on The Joint Commission, an HCPro publication.