Memorial Medical Center
Exemplary Professional Practice
ICU Daily Huddles
Because critical care patients are especially vulnerable to hospital-acquired conditions (HACs), the 2C Surgical Intensive Care Unit (SICU) adopted a national “best practice” for patient safety in 2013—daily huddles. The 2C Unit-Based Council members led the way by outlining the specific content that would be covered during the huddles, creating informational bulletin boards that highlighted unit quality data and key nursing interventions associated with the common HACs (pressure ulcers, pain and infections), and championing the initiation of huddles with their colleagues.
The 2C daily huddles occur each morning at 6:45 a.m. prior to shift change. Both day- and night-shift
staff participate, identifying the most at-risk patients and monitoring daily performance data on the quality bulletin boards. At the end of the five-minute huddle discussion, daily goals are agreed upon and incorporated into the day’s nursing plan for each of the high-risk patients.
The rates of hospital-acquired conditions improved on 2C SICU after implementation of the new process. The unit nurse manager and staff attributed the improvement to the increased accountability between team members facilitated by these huddles. The huddles also provide increased leader-staff communication and relationship-building opportunities.
Following the successful pilot on 2C SICU, the process for daily huddles was shared with the Critical Care Collaborative, a monthly quality improvement-focused forum attended by representatives from all nursing units caring for critical care patients. Based on the success of the initiative on 2C, the decision was made to spread the practice to the other critical care units. By the end of 2013, daily huddles were in place on each of the critical care units, providing a daily interactive forum to discuss quality initiatives and upcoming critical care nursing practice changes. The huddles have strengthened the culture of nursing excellence in the critical care units by improving peer-peer and leader-staff communication, creating urgency for action to improve patient outcomes and, most importantly, by preventing harm to critical care patients.
Obstetrics Care Delivery Transition
Emerging trends in maternal-child care delivery models led MMC's Family Maternity Suites nurse leaders and staff to evaluate their current Labor, Delivery, Recovery and Postpartum (LDRP) model. In an LDRP model, all four stages of the birth experience occur in a single patient room. The nursing unit transitioned to a LDRP model in April 2013, aiming to improve patient safety and satisfaction. In the new model, the high-intensity care associated with labor, delivery and recovery occurs in one room, and, once stabilized, the mother and infant move to another room. This allows postpartum care and education to be provided in a calm, quiet atmosphere, enabling a better environment to prepare mother and infant for their eventual discharge.
Benefits of the change were identified and process challenges were proactively addressed by the staff during Unit-Based Council discussions. Patient satisfaction ratings, which are typically high for maternal-child units, further improved following the change. Nurses and physicians observed improved care team efficiency and communication, thus contributing to a more satisfying work experience. Based on the positive response from patients, nurses and physicians, the decision was made to permanently adopt the new model.
Perioperative and Procedural Patient Safety
To promote patient safety, MMC strengthened its use of the Universal Protocol, an evidence-based approach used to minimize the risk of wrong person, wrong site and/or wrong procedure for patients undergoing invasive and surgical procedures. Following national guidelines from The Joint Commission and the World Health Organization, a preoperative preparation checklist was adopted to clarify and streamline the pre-procedure steps for surgical and procedural patients. Use of this "prep list" in all surgical and procedural departments, as well as in the Emergency Department and critical care units, has assisted nursing staff and physicians to clearly delineate between patient preparation activities and the three critical elements of the Universal Protocol. This essential patient safety process is routinely audited to ensure every patient has a completed preoperative preparation list before entering the OR or procedural suite and that the Universal Protocol is completed on every patient prior to the start of the procedure.
The Rescue Champions are a new group of unit-based clinical nurse "champions" focused on early identification and rapid initiation of appropriate interventions for patient clinical status declines. This effort is the most recent component of MMC's work to address the phenomenon referred to as "failure to rescue." As members of the hospital-wide RESCUE (Review and Evaluation of STAT Codes and Untow ard Events) Committee, Rescue Champions serve as content experts and change agents by conducting timely and detailed case reviews for every Rapid Response Team (RRT) call or stat code that occurs on their nursing unit.
The Rescue Champions were patterned after other successful unit champion roles focused on pain management and wound/skin care. With the help of the nurse manager and staff caring for the patient, the Rescue Champion evaluates whether the nursing care provided on the unit was appropriate and provides constructive feedback to peers involved in the case. Following the unit case review, a summary of learning is provided to the RESCUE Committee for discussion and identification of any house-wide trends or issues. Committee members then take the summaries back to their Unit-Based Councils in order to share the learning and improve nursing practice across the organization.
ED-Inpatient Handoff Process
Patient and nurse satisfaction has been positively impacted by implementation of the new ED-to-inpatient bedside handoff process for patients admitted from the Emergency Department to the medical-surgical units. The registered nurses on 2G were instrumental in researching and developing the new process during participation in a Lean Six Sigma improvement team.
When a patient is admitted to the hosptial through the ED, patient information acquired in the ED is traditionally sent to the inpatient nursing unit through a faxed report or a phone conversation between the nurses. In the redesigned process, both nurses have a face-to-face conversation in the ED. Following the bedside handoff of key patient information, the inpatient nurse returns to the unit to prepare for the patient's arrival, ensuring that all necessary supplies and equipment are readily available when the patient arrives on the unit.
The success of the new process has been due to the leadership skills of the 2G nurses who embraced the redesigned process, piloted it to ensure it was operationally sound, and served as change agents for implementation across the organization. A team of 2G nurses attended Unit-Based Council meetings on the medical-surgical units and used their professional communication skills to successfully "sell" the benefits of the change to their colleagues throughout the hospital.
Patient and family feedback has been rewarding to hear. Said one patient, "I really liked knowing who was going to take care of me after I was admitted and that the information I shared in the ED was actually passed on to my new nurse."
Rapid Intervention for Acute Stroke Patients
Emergency Department nursing staff helped redesign the process for initial assessment and diagnostic testing of patients presenting with acute stroke symptoms. As members of an interdisciplinary performance improvement team, they found the acute stroke evaluation took an average of 114 minutes. A goal was set to reduce that time to less than 45 minutes as outlined in the recently updated American Heart Association evidence-based guidelines for optimal stroke care.
In this redesigned Star 45 process, the triage nurse initiates a rapid sequence of parallel diagnostic activities as soon as a potential stroke patient is identified. The charge nurse notifies the ED staff via an overhead page, immediately activates the electronic stroke order set and alerts the ED physician to assess the patient within five minutes. The patient’s nurse ensures rapid transport to the CT suite located in the ED.
The new process has resulted in a 60-percent improvement in “cycle” time from patient presentation to completed diagnostics with a new mean of 33.9 minutes. This outperforms the national standard by 24 percent and enables patients to receive the appropriate treatment intervention within a timeframe that promotes a more positive outcome and recovery.