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Quality ImprovementHealthcare Associated Infection Collaborative
IV System Conversion
Palliative Care Team
For Information about these or any of the quality improvement projects at Northeastern Vermont Regional Hospital, contact:
Colleen Sinon, VP Quality Management
802-748-7349
c.sinon@nvrh.org
PO Box 905
St. Johnsbury, VT 05819
| PROJECT NAME: Vermont Healthcare Associated Infection MDRO (Multi-Drug Resistant Organisms) Prevention Collaborative | TIME FRAME: August 2010 – present
DESCRIPTION OF THE PROBLEM: Healthcare providers in Vermont have a long history of working to reduce and eliminate healthcare associated infections. Preventing health-care associated infections is a public health priority in Vermont. In 2009, the CDC awarded the Vermont Department of Health a grant to strengthen healthcare-associated infection prevention activities throughout the state’s hospitals. With the guidance of the Vermont Infection Reporting and Prevention Work Group, the Vermont Healthcare Associated MDRO Prevention Collaborative was formed to bring hospitals and long-term care facilities together to focus on the prevention of MDRO infections
NVRH and our neighboring long-term care facility St. Johnsbury Health and Rehabilitation Center joined the Collaborative at its inception in August 2010.
PROJECT GOAL: The long-term goal is preventing and reducing healthcare associated infections, and specifically MDRO’s, at NVRH and St. Johnsbury Health and Rehab. The goal for the pilot phase during the Collaborative is for hospitals and long-term care facilities to work together toward the prevention and elimination of healthcare associated MDRO infections by:
· Becoming familiar with the principles of infection prevention in both the hospital and long-term care setting
· Implement basic process improvement measures
· Network and learn from other Collaborative members
DESCRIPTION OF THE INTERVENTION:
NVRH and St. Johnsbury Health and Rehab have implemented interventions under these three headings:
A. Communication: Inter-facility communication upon transfer of patients between facilities.
B. Environment of Care: Implementation of cleaning and disinfection methods and products at both NVRH and St. J Health and Rehab to reduce transmission of MDRO.
C. Hand hygiene
EVALUATION PROCESS AND RESULTS:
A. Identification of possible MDRO infections through review of the patient electronic medical records, combined with daily tracking of communications between the two facilities about MDRO infections. The two facilities meet every two weeks to study the process and adjust as needed.
B. Spot checking of high touch surface areas for effective cleaning by marking the surface with an invisible agent and testing to see if the agent is still present after cleaning.
C. Discreet, direct observation of hand hygiene practices in patient care areas.
Data from all the Vermont hospitals and long-term care partners is collected and submitted electronically to the National Safety Health Network at the CDC, and the entire Vermont initiative will be evaluated for effectiveness.
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| PROJECT NAME: Intravenous (IV) System Conversion | TIME FRAME: March 2010 – present
DESCRIPTION OF PROBLEM:
Both nationally and internationally medication errors are the significant cause of medical injuries. Intravenous infusions frequently contribute to injuries received due to a drug error. The introduction of smart pump technology/dose error reduction systems (DERS) in the early 2000’s has advanced the clinician’s ability to improve medication safety for IV infusion therapy. The continuous quality improvement data is automatically collected by the pumps to help in the process of achieving best practice, quality and financial improvements. There were two identifying factors that assisted in expediently advancing medication safety at Northeastern Vermont Regional Hospital. The first one being the need to change from a mechanical patient controlled anesthesia device to a pump infusion and the second was that the current IV pump contract was coming up for renewal. NVRH participated in the New England Health Alliance (NEHA) IV demo/vendor day at Dartmouth Hitchcock Memorial Hospital (DHMC). While contractual costs were considered it was the window of opportunity to advance quality improvement initiatives for NVRH.
PROJECT GOAL:
The long-term goal is the reduction in the frequency and severity of medication errors by implementing the Gold Standard Practice of the smart pump technology throughout NVRH thereby improving patient outcomes. The initial goal is to ensure that clinicians are not exceeding the “soft and hard” limits of the infusion’s pump drug library. Continuous quality improvement (CQI) which is automatically collected by the individual pumps and wirelessly downloaded into an excel spreadsheet for analysis by the Quality Management Team. Once compilation is complete the information will be presented to MERT for further evaluation and planning.
DESCRIPTION OF INTERVENTION:
NVRH has been proactive in this initiative by implementing a multidisciplinary task force to develop the Drug Library which is unique to the practice of clinicians within the organization. Special attention to details specific to infusion medications was done to ensure maintaining compliance to all policies, procedures and protocols that relate to medication infusion administration.
· Development of the Drug Library to incorporate all IV medications in the NVRH formulary.
· Testing the accuracy of the drug library was done prior to implementation by designated “supper users”.
· Testing of the wireless technology throughout the hospital was coordinated with vendors by the Informatics Systems Department.
· Training of staff was done utilizing an online learning program followed with a live training.
· Processes were put in place to include staff in changes to the Drug Library.
· Processes were put in place for staff to report any challenges or barriers in the function or operation of the Sigma Smart Pump.
· The IV Task Force (Smart Pump Team) meets every other week or as needed to evaluate and address the effectiveness of the implementation of smart pump technology.
· CQI reporting is being developed with the mentoring from DHMC’s smart pump quality manager.
· CQI training by the Baxter Company will be arranged within 3-6 months after the implementation of the smart pumps.
· The Smart Pump Team will turn this initiative over to MERT in July 2011.
EVALUATION PROCESS AND RESULTS:
At the time of this report the Sigma Smart Pump has only been in use for 3 months which is the minimal amount of time to run CQI data regarding quality measures. There was some violation of hard and soft limits noted which was related to further training for staff in use of the expanded features unique to this pump. The decision was made to have the Smart Pump in the Nursing Education Office be the designated training pump so that all data collected will reflect accurate usage.
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| PROJECT NAME: Palliative Care Team | TIME FRAME: October, 2009 – present
DESCRIPTION: In May 2009 the Vermont Legislature passed Act 25. The purpose of the act is to improve the quality of palliative care and pain management available to all Vermonters, to ensure that Vermonters are aware of their rights and of the care options available to them, and to expand access to palliative care services for children and adults in the state.
Act 25 defines Palliative Care as comprehensive care and management of the physical, psychological, emotional and spiritual needs of patients of all ages and their families with serious and/or life threatening illness. Palliative care may be complementary to curative care or life-prolonging therapies that are being used to meet patient defined goals.
DESCRIPTION OF THE PROBLEM: In January 2009, the Palliative Care, End-of-Life Care, and Pain Management Study Committee of the Vermont Legislature released their report. The report cited a 2007 study conducted by Dr. Ira Byock, Director of the Palliative Care Service at Dartmouth Hitchcock Medical Center. Dr. Byock’s study found that people want quality in dying, as well as life. The study went on to state that it is very important to patients to have clear and honest communication with doctors and health care providers, and to have their dignity respected and their choices honored. The study also concluded that information about, and timely access and referrals to, quality hospice and palliative care can ensure that more Vermont children and adults have satisfying end-of-life experiences.
The legislative report contained several conclusions and recommendations, including: that a multidisciplinary approach is the best practice for end-of-life care and palliative care; that Vermonters are not sufficiently informed about their options for end-of-life care and palliative care; there is no coordinated system for referrals or treatment; most Vermonters do not know about the options available to them or to their families when faced with an end-of-life situation; and patients do not receive timely information about or referrals to hospice and palliative care, resulting in unnecessary pain and suffering.
PROJECT GOAL: To create a structure for palliative care referrals that includes the development of an interdisciplinary palliative care team, and a palliative care assessment tool to better identify patients who would benefit from palliative care services. Progress will be measured by the number of referrals made to the palliative care team.
DESCRIPTION OF THE INTERVENTION: In October, 2009, an in-house palliative care task force was created at NVRH. In 2010, the task force was expanded to a true interdisciplinary palliative care team. The interdisciplinary team at NVRH includes the Hospitalist, Care Managers, Community Connections staff, and the Chaplain.
The palliative care team has defined a process for referrals to palliative care services at NVRH:
*A referral is made to the Palliative Care team (by patient, physician, family member, nurse).
*A palliative care assessment is completed by the Hospitalist, Care Managers or Community Connections staff and filed in the hospital electronic medical record.
*A palliative care consult/meeting is scheduled with staff, patient and caregivers.
* A plan of care is created and filed in the hospital electronic medical record. This plan of care follows the patient if they are transferred to another healthcare facility, thereby providing continuity of care while supporting patients’ goals and wishes.
*The Palliative Care team continues to meet with the patient and caregiver on a regular basis to evaluate, assess, implement and alter the plan of care as the patient’s desires and needs dictate.
Palliative Care at NVRH provides:
*Coordination of care with your health care providers, including your primary care physician.
*Support for your family members and caregivers.
*Pain and symptom management.
*The opportunity to discuss personal goals and wishes during treatment.
*Patient-centered decision making about treatment and care.
*Referrals for complementary therapies such as massage, reiki, meditation, art therapy, journaling.
*Connections to resources in the community that may be helpful to patients and their families.
EVALUATION PROCESS AND RESULTS: To best evaluate the new structure, palliative care referrals were reset to a baseline of zero. Palliative care referrals will be measured annually. The palliative care team meets three times weekly to review cases and assess, and adjust as needed, the process. To date, patients and their families consistently say that palliative care consults and care plans have improved their lives. One benchmark of the success of the palliative care team’s work was a substantial financial donation earmarked for NVRH palliative care services from the grateful family of a patient receiving palliative care services at NVRH.
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