Sterling'sAunt

RE: NCFLYGAL Can you tell me, do you also place the data into graphs for analysis. Do you present the data at whatever meeting it is presented to at your organization? Do you put the data into a format to have it available for peer to peer comparison. For example: a graph per element that shows all physicians who had patient s in the sample who had AMI. All of the physician's identification is concealed except the physician getting the individual data. This process is done for all physicians. I was wondering because I am also over JCAHO and CMS compliance, I abstract AMI-CHF, review all fallouts for all projects, collect, analyze and make presentations for all projects. I am the site administrator for the core measures data so deal with all CMS rejects, the validation on QNet, etc, etc. I am on the Safety Com, Qual. Com, am a Team Leader for LEAN. I am the hospital's "go to" person for research, help seeing the big picture, helping any department figure out a better way to do something. I like all of the above, don't get me wrong. I am just worried as to whether I will be effective at any of it since so much has come to my plate, some of it through attrition and most of it because I just have a gift to be able to see solutions. I am not bragging, it is just my God given talent.

I am also interested in the same information. We concentrate on patient flow and "pull the cord" when a patient is waiting for a bed but we don't have indicators to truly reflect what is going on in house. I feel we should have that as well. We do med rec on admission, transfer and discharge and also at post op. We consider that a transfer from one level of care to another. I do not hear others considering this area as one that would require med rec and wonder if we require this unnecessarily. Please share not only your patient flow indicators but also "do you have a position in nursing considered patient flow coordinators". This is different than discharge planners, different than case managers. I see this person as the nurse who knows Mrs Brown will be discharged on Wed and still needs education re: new diabetes, needs to see a social worker for assistance with medications, needs pt for crutch walking, needs dcp as well. Does anyone have this? Another even more important scenerio for this person is: the physician said Mrs. Brown can go home tomorrow if the xyz result comes back normal. You look today and see it is normal so you call the physician today and get the patient discharged today. Hours saved is another patients ability to get care in that bed. Anyone out there doing this? Thank you.

And then we wonder why we have longer than necessary lengths of stay. Where is the case manager if the patient no longer needs to be hospitalized?

Kiyasmom: I too wondered if I was really cut out for this. When I was a nursing student, I was caring for an unresponsive, 20 something, glioblastoma patient. He was a nice looking guy from a very nice family. I had certainly done my homework, I was confident to care for him. He had a trach and needed suctioned. The nursing instructor was there as were all my nursing student peers because it was not something any of us had seen or done before. I prepared to suction him and I had assumed he would lie there lifeless like he had all day. No one told me he would have this wretched, horrendous gagging cough. Needless to say, I ripped the suction catheter out of the trach and the instructor had to peel me off the ceiling. I was pitiful. Through streams of tears she made me do it again. Later she came to me and said, I selected you to care for this patient because of all the students, I knew you could do this and now you have crossed that hurdle. How do you feel. I wanted so much to say, "I feel like punching you out" but didn't. I said, "not too bad". She said good, I think you should have him again tomorrow. I wanted to puke. But a brilliant idea came to me and I said, but I think other students need the experience of suctioning as well so I will gladly care for him and call when he needs suction. She agreed. Whew. 30 years later---I have seen muuucccchhhhh worse things and lived through them all.

Another patient was a bilateral amputee. He put his call light on and asked to see the social worker to help him make out his advance directives. She came and once the paperwork was finished he asked her, "what do I need to do next?" She said "Nothing, I will do the legwork for you." These things are so innocent but you carry the memory forever. Both of these happened to the sweetest people on earth about 24ish years ago.

The call light went off Nurse went to the patient, "can I help you"? the patient only had one eye. He said, I feel feverish. He also felt warm. The nurse went to get the thermometer and when she came back to his room she said, "here put this thermometer under your eye"

Update on bedside report. I previously said we were just rolling this out and had encountered some staff who were uncomfortable. Well we have rolled it out to 3 units. We had about 4-5 days of some being uncomfortable, the next unit it was maybe 2-3 days and the 3rd even less. We had some from the 1st unit go to the next unit and help them. The peer to peer conversion helped. I have heard from several about how much better it is. One nurse said, I get into my patient's room quicker in my shift. Another said, it is so much better to see what the off-going shift is saying rather than just hearing it. One emailed me and said, thanks for bearing with me, change is not easy for me but when I am in charge I see this is going to be a positive change. One nurse got pulled to another floor that has not started it yet and said, please don't pull me to a floor that is not doing bedside report. There was always overtime that the staff related to report, now they are done and out in 10 minutes. We are presently looking at the steps to take at 11pm shift change when the patient is asleep. We also have things checked in the room at the same time. O2, foley (to make sure was emptied), NGs, TPN, PCAs, etc. We will work through those issues, but those are not difficult issues to work though. We also looked at how assignments were made. In order to save steps for our nurses, we started assigning the same nurse to the group of patients in rooms next to each other. So nurse 1 would report off to nurse 2 and both had the patient's in rooms 1-4. That could vary due to acuity though. I think at the present time the acuity might make it rooms 1-3. We have had many questions related to HIPAA. This is no different than the physician talking in the semi-private rooms or the patients who happen to have come from the ED where they might have been in the ward with 7 patients with curtains. HIPAA has even eased up so we can call patients by name to go back to get their radiology exams. I don't really like that practice personally but the outpatient areas did not like calling out numbers. I don't like sign-in sheets either but they are allowed. You can always get around HIPAA by asking the patient if it is ok, if you continue to question it. Or call your risk manager if you still feel uncomfortable. At our hospital the ones who voiced this over and over were the ones who bucked everything we rolled out. They were the naysayers. I am not saying that there are not truly concerned employees as well. I am also one who will double check to make sure we are safe by rolling out new practices. I investigate in tremendous detail before I roll anything out and gladly give phone numbers or website addresses of the legitimate authority on the subject to anyone who questions it so they have their fears relieved. What we have also said for years is that many, many times we do not need to pass on the judgments we have made about patients. I would prefer someone pass on information such as, "this patient will want her pain medication as soon as it is time". Unless it is documented in the record by a physician that the patient is addicted to a medication or comes in frequently with pain medication, who are we to say they are drug seekers? Also if you have a patient who has terrible chronic pain all the time and they usually take 2 medications at home and are then admitted to the hospital and we give them one and refuse to give them 2 because they are just drug seekers, you know what this patient will exhibit??? The need to have that one pain medication on time and would love it even before time but we have been so jaded over the years that we will not do that. We as an industry do not take care of patients in pain well at all. Yes, I agree that the experiences we have related to "drug-seekers" has contributed to it. Also contributing to it are those who orient us to our hospital jobs and our peers. So leave it up to the next nurse to form her own opinion about patients unless, of course, it is information that will contribute to the patient's care by passing it on. The pith information is not necessary, maybe the patient will love the next nurse.

We have struggled with the heart failure LV assessment and ACEI/ARB elements as well. We have put into practice the steps that the case manager is responsible to get the LV assessment on the chart even if it is pulling from a previous admission or calling the physician's office and then the discharging nurse is not to discharge the patient until the ACEI/ARB has either been ordered or documentation as to why not, for those patients who have the EF Pneumonia: We have a pneumonia pathway that includes all the elements but to get them to use it ahs been a stuggle. The last review showed much better compliance with that, but I must say I was really surprised. We have a contract ED MD group and I have started meeting with the medical director and the company each month on those not met in the ED. I hope that helps as well. Not sure if any of this helps or not but thought I would let you know what we are doing here.

We ask the visitors to please step out while we check on the patients. No more is said than would be said if the physician were in the room speaking to the patient. I personally don't think we need to pass on as many "non value added"comments about our patients. If there are necessary items such as, "she will want her pain medication pretty much every 4 hours" then you can say that immediately prior to entering the room or after. I can't say this is right for everyone. When things are rolled out with the very best intentions in mind for quality of care, giving staff back more time to be with the patient, staff and patient satisfaction etc, and if those things do not fit with some nurses style of nursing then one has to make the decision, do I adjust to these changes or do I find a place where they do not do those things that make me unhappy. And that's ok. We all have to be happy with how we provide care to our patients.

What elements are the hardest for you in regards to compliance?

We can only sample SCIP because our volume is not enough with AMI, CHF or PNE. It takes approx 10 per CHF, 15 per AMI, 20-25 for PNE and SCIP. One thing many vendors and corporations do not figure into the statistics is the analysis of the data. Last year I started having the abstractors also analyze the data. They determine, who dropped the ball with the cases not meeting the indicators. Was it MD, nurse, pharmacy who??? The enter into customized fields the nursing unit, the discharging nurse for the discharge meds missed for example, or who was the nurse in ED who did not give the ASA on admission or who was the pharmacist who timed the last antibiotic for the SCIP measure wrong. We then send them a notification of the error along with their manager and we send letters to the physicians and place a letter in their peer review file. I now have the abstractors doing all of these steps rather than me opening the chart back up, reading it to get to the understanding they were at when they were reviewing the chart and then me complete all of these steps. It was the wisest way to use our time and also provided the quickest feedback to those who made a mistake.

There are many advantages to bedside hand-off. You can search the internet for "patient bedside report" and find may success stories. Nurses waiting for report to be over so they can go home and the report taking entirely too long is one reason. How many times have you ever come out of report to find the patient not exactly as the picture you were given in report? How many times did you find the IV infiltrated, the foley not emptied, the patient in distress, some meds not given, pain not controlled etc. Your eyes provide better understanding of what the patient is really like than your ears do. Staff satisfaction with shift report went from 20% to 88% at one hospital and how well-organized the shift report was went from 30% to 80% both in just 30 days. During the first week's trial one of our patients said it made him feel secure. You patients become included in their care. They can now review their medical record at any time during their hospitalization so why not talk to them about how they are doing? Why should it be a secret. For years I listened to report thinking, I can read the Kardex myself so why do I have to listen to you read it to me. Just tell me what my patient came in for and what we are doing for them and how they are responding. When a physician is in the room and asks for the labwork, do you tell him over the patient's bed? I would venture that you are saying yes, so if you will tell him over the patient why do we not tell a coworker nurse? If the patient is going to pull you into something which will take a lot of time, you can say: I am going to take "Lydia" to meet her other 3 patients and then someone will be right back. I would suggest assigning nurses to rooms beside each other for ease of movement for her and less traveling. The main reason is to give time back to our nurses so they can be at the patient's bedside more.

We are rolling this out presently and we are encountering staff who are very uncomfortable with the process. I want to support them in any way I can but at this point I think it would be positive if I and the manager could talk to someone who has implemented this and had success with employee buy-in. Would you MeanDragonBrett or anyone else be willing to talk to me on a call? And how is that arranged on this site, I am new to this. Thank you very much.