The CKHS nursing staff has made a significant impact on CKHS efforts to achieve the Joint Commission’s National Patient Safety Goals across all of the health system’s hospitals. Following are some highlights of our success. Click on the links below to read examples of our success.
CKHS Ranks Among Best Nationwide for Controlling Hospital Infections
Nursing Staff Drives Dramatic Reduction in VAP
Success with Glycemic Control in Critical Care Patients
Reducing Blood Stream Infections with Central Line Bundle
Electronic Documentation in the ED Improves Patient Care
CKHS Ranks Among Best Nationwide for Controlling Hospital Infections
Gwen Smith, RN, CCRN, MSN, MBA, left, president of Springfield Hospital, celebrates the VHA Leadership Award with Acute Care Center nurses, left to right, Denise Moriarty, RN, Jei Park, RN, Lisa Schmidt, RN, Maria Chandy, RN, and Susan Serviano, RN.
Crozer-Keystone ranks among the best VHA hospitals nationwide in reducing and preventing hospital acquired infections, such as ventilator associated pneumonia (VAP). In 2008, Springfield Hospital won the VHA Leadership Award for Clinical Excellence for exceeding national performance standards for clinical care in the prevention of VAP. In the fourth quarter of 2007, Crozer-Chester Medical Center’s MICU, CVU and STU ranked among the top VHA hospitals nationally for glycemic control, a critical factor in reducing hospital acquired infections; the units placed third, fifth and sixth respectively.
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Nursing Staff Drives Dramatic Reduction in VAP
In 2006, Crozer-Keystone set a goal of reducing the incidence of VAP by 10 percent system wide. Since that time, multidisciplinary teams at each CKHS hospital have worked vigorously to implement and maintain the VHA ventilator bundle, a series of evidence-based interventions that include elevation of the head of the bed, appropriate sedation, daily weaning assessments, peptic ulcer prophylaxis, deep venous thrombosis prophylaxis and glycemic control. An important new rigorous oral care measure was added to the ventilator bundle, and nurses across the system agree that this has contributed significantly to a dramatic improvement in preventing VAP.
As of June 2008, Springfield had no cases of VAP for 24 consecutive months.
At Taylor Hospital, the Intensive Care Unit had no VAP cases for 8 months as of June 2008, and the 3A Unit had been 100 percent VAP free for 17 months.
At Crozer-Chester Medical Center, all critical care units far exceeded the system’s 10 percent VAP reduction goal. As of June 2008, Crozer’s Medical Intensive Care Unit had been 100 percent VAP-free for 14 months and the Burn Treatment Center for seven months. The Cardiovascular Unit was down to 1.4 cases per 1,000 ventilator days and the Shock Trauma Unit was at 1.5.
Over the last two years, Delaware County Memorial Hospital has decreased the number of VAP cases by 25 percent, and the hospital continues to work toward a 10 percent decease over last year’s performance with intensive educational efforts. As a result, DCMH has experienced marked improvement with zero cases of VAP for 4 months as of June 2008.
“There’s no question that our nursing staff is at the forefront of our success in preventing VAP,” says Nancy Bucher, RN, MSN, CNAA-BC, vice president and chief nursing officer. “We are very proud of their collaboration with respiratory therapists, physicians and pharmacists, as well as their commitment and diligence in maintaining the VAP bundle to meet this challenge.”
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Success with Glycemic Control in Critical Care Patients
Physicians and employees of the Shock Trauma Unit, Medical Intensive Care Unit and Cardiovascular Unit at Crozer celebrate the awards they received for achievements in quality of care.
Closely related to the reduction in VAP is Crozer-Keystone’s success in achieving glycemic control in critical care patients. Numerous studies have shown that improving glycemic control results in better outcomes for critically ill patients, including fewer blood transfusions, less renal failure, fewer days on ventilator and shorter stays. In March 2005, Crozer-Keystone set a goal of tightening glycemic control by maintaining 75 percent of ICU ventilator patients within the blood glucose range of 70-120mg/Dl. At that time, only 28 percent of ICU patients were within that range.
The history of Crozer-Keystone’s path to improved glycemic control dates back to 2004 when Trauma Center professionals at Crozer-Chester Medical Center observed that glycemic control in the Shock Trauma Unit (STU) was less than optimal. Riad Cachecho, M.D., director of Trauma, established a multidisciplinary team that included the ICU nursing staff to address the issue.
The team reviewed the literature about blood glucose control in ICUs across the country. After selecting the approach that best fit the Crozer STU, team members developed a new insulin infusion protocol. After successfully piloting the new protocol in the STU, the team applied it to other medical and surgical patients at Crozer, where it was equally effective.
Multidisciplinary teams were also established at Delaware County Memorial Hospital (DCMH) and Taylor Hospital, and the new insulin infusion protocol was adopted throughout Crozer-Keystone, with some variations to best suit the needs of each hospital.
Over the last few years, team efforts to continuously examine and improve the process and protocols to achieve tight glycemic control have enabled the critical care units across the system to achieve dramatic improvement. In July 2006, only 41 percent of patients maintained a morning blood glucose in the acceptable range. By April, 2008, 67 percent of ventilated patients in our critical care units had a blood sugar in the 70 – 120 mg/Dl range, a 62 percent improvement in less than 2 years. In addition, these results are consistent and reproducible. For FY 2008, the critical care units across the system hit 71 percent compliance, beating their 65 percent goal. In addition, at DCMH, team efforts to constantly improve the infusion protocol have cut the incidence of hypoglycemia nearly in half to 3 percent, well below the national average of more than 5 percent.
In addition to ranking among the top VHA hospitals nationally for glycemic control in the fourth quarter of 2007, Crozer-Chester Medical Center also ranked second out of a group of 130 hospitals sharing results through their point-of-care testing lab vendor.
“The nurses are the ones who have made this work through their diligence,” says Gary Wendell, M.D., medical director of the Medical Intensive Care Unit at Crozer. “Although this is a very labor intensive protocol, the nurses really got behind it because they understand the value of glycemic control.”
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Reducing Blood Stream Infections with Central Line Bundle
Jerri LaRocco, RN, MSN, CNAA-BC
In 2007, Crozer-Keystone established a system-wide multidisciplinary Central Line Committee, chaired by Jerri LaRocco, RN, MSN, CNAA-BC, assistant vice president for Patient Services at DCMH, to evaluate central line procedures and determine ways to reduce the rate of central line infections. The committee included nurses, physicians, radiology technicians, materials management and information systems.
After discovering that practice varied significantly among the four CKHS hospitals, the committee decided that it was most important to standardize the equipment and the process by developing a central line bundle based on best practices found in the literature. The bundle includes all equipment needed for central line insertion as well as a printed form to serve as a protocol checklist and a permanent record. Nurses have played a key role in ensuring compliance with the new protocol by making a commitment to assist physicians with all central line insertions.
Nursing education included an inspirational presentation by nurses from Children’s Hospital of Philadelphia about their success in preventing central line infections in their pediatric population through nursing-driven innovation.
By using the central line bundle, each CKHS hospital has significantly decreased the number of central line infections. Some units at each hospital have gone more than six months without one. (See figure below.)
Reduction in Central Line Infections at CKHS
|
|
FY’07 |
Goal FY’08 |
FY’08 |
|
Crozer |
2.3 |
1.8 |
1.6 |
|
Burn Center |
3.7 |
3.0 |
0.6 |
|
CVU |
3.0 |
2.4 |
0.4 |
|
MICU |
2.3 |
1.8 |
0.0 |
|
STU |
1.0 |
0.8 |
1.8 |
|
|
|
|
|
|
DCMH |
2.2 |
1.8 |
1.5 |
|
ICU |
1.6 |
1.3 |
2.0 |
|
|
|
|
|
|
Springfield |
7.2 |
6.1 |
1.4 |
|
ICU |
7.2 |
6.1 |
1.4 |
|
|
|
|
|
|
Taylor |
3.5 |
2.8 |
2.6 |
|
ICU |
5.7 |
4.6 |
4.6 |
|
|
|
|
|
Sue Anne Machemer, RN
This year, SueAnne Machemer, RN, nurse manager of the Short Procedure Unit and Cancer Infusion Unit and member of the Central Line Committee, spearheaded an initiative to develop a central line care bundle record and tool for the daily assessment and care of the line after insertion. This is expected to enhance efforts to drive central line infections down to zero system-wide.
CKHS Central Line Committee
Jerri LaRocco, RN, MSN, CNAA-BC, Chair
Laura Balawejder, RN
Eric Dobkin, M.D.
Lorraine Erieg, RN
SueAnne Machemer, RN
Angel McCullough, RN, MBA, NE-BC
Dolores Porri, RN, BSN
Lisa Schmidt, RN, BSN
Connie Sonder, RN, BSN, MBA
Christine Young, CIC, MBA, BS, MT (ASCP)
Eileen Young, RN, MSN
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Electronic Documentation in the ED Improves Patient Care
Using the new Emergency Department Information System at Crozer-Chester Medical Center are employees, left to right, Kaheria Scott, Samantha Kunstek, RN, and Brooke Y. Childs.
In 2007, all four CKHS Emergency Departments implemented a state-of-the-art electronic documentation information system (EDIS) that is improving patient care by helping ED staff save time, improve accuracy and enhance patient safety. Two ED nurses from each hospital played a key role on the EDIS build team that designed and implemented the system. The system went live well ahead of the 2014 target date set by the federal government for health care institutions nationwide to convert all medical records to electronic documentation.
The system’s time-saving features include pre-treatment guidelines for nurses to use with patients who present with certain symptoms such as chest pain. A medication quick list provides nurses with easy access to information about more than 100 of the most commonly prescribed medications. Test results come back in real time on the system and become part of the patient’s electronic chart. These and other time-saving features improve patient care as well as patient flow through the ED, decreasing diversion times and reducing the time that patients spend in the ED waiting room.
The EDIS build team requested that many patient safety features be built into the system, including warnings about drug interactions and medication allergies. Computerized physician order entry improves accuracy and reduces the chance of medical errors due to illegible handwriting.
The new system also has comprehensive patient tracking capabilities. Built-in timers track the length of time that has passed since the patient signed into the ED and enable the ED staff to identify delays and the reasons for them.
Crozer-Keystone
EDIS Build Team
Lee Cowley, RN
Jennifer Cummins, RN, MSN
Pat Eckenrode, RN
Elaine Foy, BS, MT, ASCP
Terri Hoffecker, RN, MSN
Amy Meehan, RN
Sandy Mitchell, RN, MSN
Patti Montella, BSN
Bev Relyea,BSN
Mary Pat Towne, RN, BSN, MSN, CEN
Don Webb, RN
Jeannine Wilk, RN, BSN, MA, BSBA
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