A federal mediator has called Minneapolis-St. Paul hospitals and their nurses back to the negotiating table in a bid to head off what could be a costly and extended work stoppage. Both sides said they have agreed to meet Thursday, though it remains unclear if that would lead to extended talks. The union has voted to authorize a strike. "Our nurses look forward to returning to the bargaining table Thursday and are hopeful we can engage in meaningful negotiations with the Twin Cities Hospitals," the Minnesota Nurses Association said in a written statement.
Systemic change requires visionary leadership. The board of trustees for our facility established a new three-year strategic plan based on our six indicators of success. One such indicator is Quality & Patient Safety, and the board determined that this indicator should include a vision "to eliminate all preventable harm."
Given this direction, we chose to focus on patient falls and began to ask ourselves whether we could eliminate all falls. The prior year baseline for our organization was 3.8 falls per 1,000 patient days. When compared to the National Database of Nursing Quality Indicators, we were within the benchmark for our medical-surgical units.
We still believed there was opportunity for improvement. To ensure organizational involvement, we added the organizational fall rate as part of the leadership merit-based performance management system. This includes all supervisors, directors, and the administrative team. This step was crucial to remove barriers and to demonstrate support for this common goal.
Our strategy was simple: First, we organized a multidisciplinary team to meet monthly and began to look at the data. We found that although our falls had reduced over the past five years, there was still great variability from month to month and from unit to unit. We evaluated our fall reduction policy/program and felt it was relevant and remained current to the evidence-based literature we researched, with one exception: We implemented a national strategy promoted by the Iowa Healthcare Collaborative, which was to place a yellow wristband on all patients identified as a fall risk. We then reeducated our staff on their roles and the importance of the program.
Next, we went back to the data, which we stratified manually into day of week, time of day, level of fall prevention in place at time of fall, staffing adequacy, etc. We found through our data review that 42% of our falls occurred with bathroom activities, and there was a pattern of falls occurring at change of shift.
To address these issues, we educated our nursing staff on the data and modified our hourly rounding program so nursing staff were required to assist fall risk patients to the bathroom hourly. We also adjusted change of shift activities to free up the patient care technicians so they could make bathroom rounds prior to performing their vital signs and other duties. We use shift huddles to reinforce the fall prevention strategies and report successes, as well as issues, with falls that occur.
When a fall occurs—and, yes, they do occur—we conduct an immediate root cause analysis. We evaluate whether the patient was assessed correctly and interventions were implemented, and then determine the cause variable that led to the patient's fall. Each fall is reported at the monthly meeting for further evaluation and education.
Other fall reduction strategies that we continued to utilize are as follows:
Bed alarms. We purchased more units and increased use of the bed alarms through our call light to the two-way communication device.
Volunteer sitter program. We are fortunate to live in a university community and have tapped into the university to establish a sitter pool for students to volunteer once provided the competency development.
Companion program. We have hired staff to work in our float pool to function as companions for patients needing one-to-one care. The companions function as patient care technicians for the one patient assignment, thus freeing up time for nursing staff to care for other patients.
Daily fall risk assessment and falling star program. We evaluate patients for fall risk at least once per day to see what variables have changed. In addition, if a patient has suffered a fall, we attach a falling star symbol to the outside of the patient room to alert staff to the greater potential of a repeat fall.
Monthly celebration. We track the unit fall rates daily. The unit that goes the most days without a patient fall within the month receives a celebration.
Poly-pharmacy review. We are implementing a poly-pharmacy review of all fall risk patients on 10 or more medications to identify opportunities to reduce the impact of medications on the patient's outcome.
The results through the first six months of this fiscal year demonstrate our fall rate as 2.8/1,000. This is a 26% reduction in falls from the previous year baseline rate of 3.8/1,000, and the monthly variation in fall rate has diminished. We have not eliminated falls, nor do I know whether that is possible; however, we are well on our way to reducing the potential of this harm for our patients.
Neal T. Loes, RN, BSN, MS, is chief nursing officer at Mary Greeley Medical Center in Ames, IA.For information on how you can contribute to HealthLeaders Media online,please read our Editorial Guidelines.
When a patient is on standard contact precautions, the healthcare worker caring for that patient should be wearing the appropriate personal protective equipment (PPE), including gloves, a gown, and a mask.
The problem with contact precautions is ensuring that staff members are complying with proper PPE protocol.
A study published in the May issue of Infection Control and Hospital Epidemiology found that a universal gloving policy could be equally as effective as placing patients under contact precautions for a multidrug-resistant organism (MDRO) infection.
The 12-month prospective study in an 18-bed surgical ICU at Virginia Commonwealth University Medical Center in Richmond included two phases. The first phase (first six months) measured the rate of compliance with contact precautions, and the second phase (second six months) measured the rate of compliance with universal gloving. Results showed that policy compliance was higher in phase two (78%) than phase one (67%), and hand hygiene compliance was higher in phase two before patient care (40% vs. 35%) and after patient care (63% vs. 51%).
"Throughout the entire study, both the first and second phases, we did active surveillance cultures twice a week on all patients to see if they were carrying MRSA or VRE, and we also did concurrent or real-time surveillance for hospital-acquired infections like we do here with the hospital infection prevention unit," says Gonzalo Bearman, MD, MPH, lead author of the study and associate hospital epidemiologist at Virginia Commonwealth.
Infection rates stayed the same or decreased with universal gloving. Bloodstream and urinary tract infections decreased, while ventilator-associated pneumonia increased only slightly. Additionally, hand cultures of healthcare workers showed fewer positive MRSA cultures during phase two of the study.
"Research shows in outbreak situations, heightened infection prevention—which includes hand hygiene, the use of gloves, and the use of gowns—is probably what is preferred," Bearman says. "However, using those measures for standard care in endemic settings may not be necessary; it may be too aggressive. So what we're saying is that maybe a less restrictive option—just issuing universal gloves—appears to work for the control of multidrug-resistant organisms and should be considered."
Improved compliance rates
One of the major positive results from the study was the increased compliance with the universal glove policy and hand hygiene.
Bearman believes that compliance with the policy increased because it was well received by staff members.
A survey given to healthcare workers at the conclusion of the study indicated that the majority of workers welcomed the idea of universal gloving and believed it was not too cumbersome, says Bearman. Only 15% said they thought that universal gloving was impractical.
"Generally, healthcare workers don't like having to put on gowns and gloves to go see patients," Bearman says. "It's much easier to don gloves than put on the gown for patient care. So I think that twist on isolation precautions was well received by the healthcare workers."
Improved skin health
The study also indicated improved skin health among healthcare workers at Virginia Commonwealth, largely due to the fact that staff used emollient-impregnated gloves. The gloves themselves were not a new product, but the fact that staff members wore them so consistently led to an improvement in skin health.
This may have contributed to increased hand hygiene compliance rates as well, since healthcare workers most often complain that dry, irritated skin deters them from washing their hands.
"It's believed that if you wear the gloves long enough and intensely enough or frequently enough, then they do have a benefit on the health of the skin—in other words, decreased redness or dermatitis or flakiness," Bearman says. "A lot of times I'm seeing patients and I constantly have to put cream on my hands because the alcohol rubs are so caustic."
Is it a viable option?
Unfortunately, probably not enough information can be gleaned from the study to make general recommendations, but it's possible to see the potential translation of this study to other units or hospitals, depending on the risks that are present, Bearman says. "I think the results of the study are certainly unique to this unit," he adds. "Whether you can actually generalize that to other units is a bit of a stretch. However, I will say the mechanisms of disease transmission, whether it's medical intensive care or surgical intensive care, are going to be largely the same, although the patient populations might be a little bit different.
"As such, since the mechanisms of disease cross-transmission are the same, it's reasonable to think that this may work in a nonsurgical ICU, whether it's medicine, neurosurgery, pediatrics, cardiothoracic, etc."
Bearman also notes that during the study's 12-month duration, there were no outbreaks of infectious disease. During possible outbreaks, universal gloving alone may not be as effective.
However, this method could be particularly helpful for smaller facilities such as ambulatory surgery centers, clinics, or physician offices that may not have the space for isolation rooms or single-occupancy rooms.
"If there aren't enough single-occupancy rooms, it may be helpful to do universal gloving for multiple or dual-occupancy rooms," Bearman says. "The important thing, however, is clearly the gloves need to be changed between patients, and hand hygiene must occur before and after patient care, even in between patients in the same room. If there is a breakdown in that, there is going to be a breakdown in the effectiveness.
This article was adapted from one that originally appeared in the July 2010 issue of Briefings on Infection Control, an HCPro publication.
Members of the Minnesota Nurses Association turned out by the thousands to authorize an open-ended strike at 14 hospitals. No date has been set, and union officials have said they would hold off on giving the required 10-day notice if the two sides were in "productive negotiations." At the earliest, a strike could begin in early July. After conducting a one-day strike on June 10, union officials decided they needed the leverage of the strike authorization to pressure the hospitals to reach a favorable agreement.
Minneapolis-St. Paul hospitals say they're ready to go back to the bargaining table with the Minnesota Nurses Association, but only if the union agrees not to strike until at least July 31. The union had no immediate response to the hospitals' offer, which came two days after the nurses asked to resume talks. The two sides have been in a standoff since contract talks broke down on June 4, and nurses staged a one-day walkout on June 10. The nurses are scheduled to vote June 21 on whether to authorize an open-ended strike.
A San Francisco judge will hold a hearing to consider issuing an injunction preventing thousands of University of California registered nurses from striking. Superior Court Judge Peter J. Busch issued a temporary restraining order last week that averted a planned June 10 strike of about 11,000 UC nurses. He based that decision on the university's argument that the striking nurses would pose a threat to public safety. In essence, an injunction would prevent the nurses from rescheduling the one-day strike, the San Francisco Chronicle reports.