WINTER 2012

VOL. 5, NO. 1

THE QUALITY AND PATIENT SAFETY NEWSLETTER OF CONTINUUM HEALTH PARTNERS

2011

Quality and Patient Safety Award Winners

Trustees Committee on Quality Care Names 2011 Award Winners

Two years ago, Continuums Board of Trustees Committee on Quality Care introduced its annual Award for Quality and Patient Safety. The acknowledgement recognizes and rewards staff for initiatives aimed at enhancing patient care and safety. Such contributions are critical to helping Continuum maintain its reputation as a national leader and model organization for delivering the highest quality care.

The judging panel, with representatives from each Continuum hospital, received many noteworthy nominations, making the task of selecting a winner difficult and challenging. The 2011 winning submission was Fall Reduction in Beth Israel Rehabilitation Nursing. Honorable mentions went to Neonatal Order Set Implementation at St. Lukes and Roosevelt Hospitals and Prevention of C. difficile Infections across Continuum Health Partners. Winners received both a cash prize and an engraved crystal sculpture commemorating their outstanding achievement.

Congratulations to the award winners, and many thanks for the stellar work of all the nominees!

2011 Trustees Award Winner

Beth Israel Rehabilitation Nursing

The 3 Karpas Inpatient Rehabilitation Team, from left: Jack Valdez, RN, Melissa Grant, RN, Ellen Deane-Ferguson, RN, Marie Garland-Matias, RN, and Wayde Binder, RN.

Lowers
TEAM LEADER: Wayde Binder, RN, Nurse Manager 3 Dazian and 3 Karpas

Incidence of Falls
Beth Israel Medical CenterPetrie Division

On Beth Israel-Petrie Divisions 3 Karpas Inpatient Rehabilitation Unit, the fall rates have fallen dramatically, thanks to a simple yet innovative solution and a committed interdisciplinary team. The initiative involved creating observation rooms for patients considered to be at higher risk for falls, and called upon patient care associates (PCA), nurses, physiatrists, therapists and other related providers. Patients sent to 3 Karpas are an average age of 79 and come from a variety of areas: cardiology, oncology and, primarily, neurology and orthopedics. They often have cognitive issues related to their disability or diagnosis that increase the possibility of falls and, as a result, require greater reinforcement to ensure safe care. Using existing staff and space, the observation room model was developed by team leader Wayde Binder, RN, Nurse Manager, 3 Karpas and 3 Dazian, Beth IsraelPetrie Division, and started in Fall 2010. Heres the way it works: Patients identified as being at higher fall risk are assigned to a designated observation room with a dedicated PCA, who continuously and closely supervises them. Typically, two rooms accommodating four or five patients serve this purpose and are located directly across the hall from one another with doors open to enable the PCAs vigilant monitoring. Nurses trained in fall-risk reduction are nearby for support and backup, and patients and families receive fall-risk education. We didnt come across any similar model in the medical literature. We did find information about restraints, bed alarms and other devices, but we really wanted to stay away from them, says Mr. Binder. Rather than hiring one-to-one companions, we thought about how we could utilize staff in different ways to decrease fall rates while also minimizing costs, and came up with the observation room concept. Statistics reveal sustained success in lowering not only the number of falls, but also the number of falls with injury. The 2009 fall rate of 9.5 falls/1,000 patient days dropped by first quarter 2011 to 5.5, which is below the national average, as per the National Database of Nursing Quality Indicators. For the same period, the fall-withinjury rate of 0.59/1,000 patient days went down to 0.0. The measure also has proven cost-effective, saving $100,000 in one-to-one staffing. And we still havent calculated the savings from MRIs, CT scans and x-rays that havent had to be taken due to the decreased incidence of injuries, Mr. Binder notes. A culture shift has definitely taken place, where the PCAs are offering input on the patients and all staff are highly invested in keeping falls at zero, he adds.

The Trustees Award recognition is very satisfying and rewarding and has brought greater spirit and commitment to the team. Weve worked hard and feel valued and empowered.
Wayde Binder, RN

2011 Trustees Honorable Mention

Neonatal Order Sets Prescription-Related Medication Errors

TEAM LEADERS: Janice Klein, MD Attending Neonatologist St. Lukes and Roosevelt Hospitals Janna Roitman, PharmD Clinical Pharmacy Manager Roosevelt Hospital Nori Yaun, RN NICU Nurse Manager Roosevelt Hospital

Reduce

Prescribing medications for neonatal patients is often a challenging task that cannot accurately rely on modifying medication orders created for adults, or even children for that matter. Beyond a patients weight and clinical condition, there is gestational age to consider. With related medical and pharmacy-preparation issues cropping up nationwide, many hospitals have implemented Joint Commission-driven initiatives to prevent prescription errors and adverse outcomes in their neonatal intensive care units (NICU). In June 2009, a multidisciplinary team comprising an information technology specialist and neonatologists, nurses and pharmacists from throughout Continuum was formed to address the situation in all of the organizations NICUs. The team began by reviewing the most commonly used medications for the neonatal population, which include intravenous solutions, nebulized drugs and ophthalmic preps. Guided by evidence-based practices presented in well-respected references such as Neofax and the Harriet Lane Handbook, the team worked together for nearly two years to develop neonatal order sets independent of those designed for adults. A separate neonatal order button also was created and the new system was activated in May 2010. Previously, we had to adapt adult orders on an ad hoc basis, changing medication strengths, intervals and doses. Now we have a tool for the care of newborns that is more practical and safe, says Janice Klein, MD, team co-leader and Attending Neonatologist, SLR. Using adult order sets posed many questions and proved time-consuming for doctors, nurses and pharmacists, adds team co-leader Janna Roitman, PharmD, Clinical Pharmacy Manager, Roosevelt Hospital. The NICU order sets provide great references to users, and weve since seen a huge increase in compliance. Each order set includes recommended concentration, strength and route of administration, along with education for suggested dosage and a series of warning prompts when dosage has been maximized. Currently, 80 entries representing 99% of NICU medications have been incorporated. The neonatal order sets have not only reduced the risk for ordering errors, they also have standardized care at all Continuum NICUs, streamlined workflow processes and improved communication between prescribers, nurses and pharmacists. Comparing third quarters 2009 and 2010, neonatal-related prescription errors decreased by 40% at SLR (with similar results at BIMC), and pharmacist interventions dropped from 134 to 79. The team did extraordinary work and the staff love the order sets. Its a lot easier now to put orders into practice, says team co-leader Nori Yaun, RN, NICU Nurse Manager, Roosevelt Hospital. Moving forward, the order sets will continually evolve, as we add or change things based on news in the medical literature.

From left: Nori Yaun, RN, Janice Klein, MD, and Janna Roitman, PharmD, review the new neonatal order sets.

2011 Trustees Honorable Mention

Hospital-Associated C. difficile Infections

Left to right: Barbara Smith, RN, BSN, MPA, CIC, Timothy Hill from Environmental Services, and Melissa McCabe, RN, engage in infection prevention practice.

Prevented
across Continuum
TEAM LEADERS: Brian Koll, MD, FACP Medical Director and Chief, Infection Prevention Beth Israel Medical Center Barbara Smith, RN, BSN, MPA, CIC Nurse Epidemiologist St. Lukes and Roosevelt Hospitals

Clostridium difficile (C. diff) is among the most common health careassociated infections and easily transmitted from patient to patient. This, coupled with dramatic increases in its incidence, severity and treatment costs over the past decade, has made preventive interventions more critical than ever before. In 2008, after a survey of C. diff prevention practices throughout Continuum revealed a lack of standardization, interdisciplinary unit-based teams made up of physicians, nurses, patient care associates, transporters and housekeepers were formed to address the problem with the full support of senior leadership. The resultant multifaceted, evidence-based intervention has involved placing patients in a single room or with another C. diff patient at the onset of symptoms, posting contact precautions signs on room doors, making gowns, gloves and other personal protective equipment readily available, and completing compliance checklists. The prevention bundle also has required that rectal thermometers be eliminated and that proper hand hygiene be followed. Perhaps most important has been adherence to environmental cleaning using a hypochlorite-based disinfectant (bleach) on all high-touch surfaces and bathrooms in patient rooms. C. diff is a strong, hardy, resilient bacteria that can live in an environment forever. While cleaning is important for all hospital-acquired infections, it is vital for C. diff. Bleach is the only thing that truly works, says the projects team co-leader Brian Koll, MD, FACP, Medical Director and Chief, Infection Prevention, Beth Israel. This initiative really speaks to the efforts of environmental services staff and transporters, who must scrub rooms and clean stretchers and wheelchairs. Monthly meetings have been held to keep the teams engaged and informed through timely feedback on C. diff rates and compliance. Additionally, a fluorescent marking tool that simulates germs, a la CSI, has allowed the teams to visually assess their level of cleanliness. Ownership of the intervention by frontline staff has been essential to the sustained reduction in hospital-onset C. diff over the past three years, notes Barbara Smith, RN, BSN, MPA, CIC, team co-leader and Nurse Epidemiologist, SLR. Prior to the project, Continuum had almost 600 C. diff cases annually. Since then, that figure has decreased by 27%, length of stay for C. diff patients has fallen by one day, and the time until precautions are implemented from symptom onset has dropped by 17 hours. Moreover, compliance with the prevention bundle rose to 97% and with cleaning practices to 87%.

Our goal was to have a rate of less than five hospital-onset cases per 1,000 patient days. We exceeded that goal with 4.1. We look to continually improve upon that.
Brian Koll, MD, FACP

Golden Hour of Stroke Treatment

TEAM LEADER: Ji Chong, MD, Director,

strokesigns know the

Trouble speaking

Stroke Prevention Program, SLR Stroke Center IV tPA is the only approved treatment for acute ischemic stroke. There is a very small time window for treatment and the earlier it is initiated, the better the neurologic outcome. One of the benchmarks measured

And the

Trouble walking Trouble seeing Weakness on one side

Nominees
Are
Many other initiatives have improved patient care and safety at Continuum. Here we recognize this award years other nominated projects and programs.

by the New York State Department of Health is the door to needle time. The target is to treat patients within 60 minutes of arrival to the ER. This requires rapid identification of possible stroke, appropriate triage and registration, blood tests, IV insertion, CT scan of the brain, assessment by a neurologist, possible management of elevated blood pressure, discussion with the patient and family, and careful preparation of the drug. To achieve all this in 60 minutes, SLRs Stroke Center and Emergency and Radiology Departments modified protocols and triage strategies, trained ED and EMS personnel in recognizing early stroke signs, expedited CT scans and lab tests, and trained nurses to prepare tPA. In recognition of improved performance, the SLR Stroke Center was one of only 114 hospitals nationwide to be honored by the American Heart Association for achieving superior level of stroke care.

Transforming Care at the Bedside (TCAB) Initiative

TEAM LEADERS: Susan Adler, RN, Staff

Nurse, Linda OFlaherty, RN, Nurse Manager, Med-Surg Unit, BIMC-KHD In February 2010, Beth Israel-Kings Highway Division partnered with the RN Labor Management Initiative to conduct a pilot of the Transforming Care at the Bedside program, initially focusing on the hospitals 3 North med-surg unit. TCAB relies heavily on frontline nurse-led teams to redesign work processes for improved clinical outcomes. The 3 North team collected data on disruptions to patient care and then collaborated with staff from other departments, including Food and Nutrition, Admitting, Pharmacy and Housekeeping, to implement strategies for better efficiency. They ultimately achieved enhanced staff and patient satisfaction (68% for the composite communication with nurses for the latter), and improved quality of care, which considers such factors as maintaining the fall rate below the national median and decreasing the incidence of hospital-acquired pressure ulcers.

Weekly Assessment of Emergency Room Dysphagia Evaluation Leads to Gold-Plus Award

TEAM LEADER: Larissa M. Bonilla, Clinical Coordinator, SLR Stroke Center

Dysphagia (swallowing difficulty) is a common complication for acute stroke patients and can lead to pneumonia, which in turn can delay neurological recovery. To better identify patients with dysphagia, the SLR Stroke Center revised its dysphagia screening documentation protocol and worked with St. Lukes and Roosevelts Emergency Departments on its implementation in September 2009. The recent results showed 94% of stroke patients have since been appropriately screened. In June 2011, the SLR Stroke Center was recognized for its significant improvement in dysphagia screening and overall stroke management with the American Heart Associations Gold-Plus Award, the organizations highest national honor.

CIWA Protocol Improves Care of Patients Experiencing Alcohol Withdrawal

TEAM LEADER: Susan Dietz, RN, MA, CNA,
LOS Patients Treated with CIWA Protocol and Not Treated with CIWA Protocol

Vice President, Patient Care Services and Chief Nursing Officer, SLR Introduced to St. Lukes and Roosevelt Hospitals in Spring 2010, the Clinical Instrument for Withdrawal of Alcohol (CIWA) is a nationally known scoring scale and protocol administered by registered

Airway Program Enhances Function and Extends Survival

TEAM LEADER: Faiz Bhora, MD, FACS, FCCP, Codirector, Continuum Airway

Program, and Associate Program Director, General Surgery; Director, Thoracic Surgical Oncology; and Director, Thoracic Surgery Research, SLR More than 20 to 30% of patients with advanced lung cancer experience symptomatic central airway obstruction, which, if left untreated, offers a very poor prognosis. Through the Continuum Airway Program, tracheobronchial stenting was implemented to improve functional outcomes and survival rates in this patient population. Seventy-two stents were placed over two years, with the majority of patients realizing significant improvement in functional status. Furthermore, patients who were stented in a timely fashion had a mean survival of about eight months, compared to less than 30 days for untreated patients. A significant number of the treated patients were then able to receive chemotherapy and radiation. The Airway Program is considered the premier program in New York for managing central airway obstruction due to malignancy and benign disease, and SLR has become a regional referral center for complex airway cases, including stenting.

nurses in emergency rooms and on medical units to evaluate the severity of symptoms related to alcohol withdrawal, and guide the delivery of appropriate medical intervention for positive patient outcomes. Following CIWA education of house staff and ED doctors and nurses, initiation of the CIWA medication protocol rose from 0% in third quarter 2010 to 89% in first quarter 2011. In addition, patient comfort levels increased, the need for physical restraints decreased, and average length of stay for patients who received the protocol was 8.2, compared with 11.8 for those who did not.

The Near Miss Registry

TEAM LEADER: Ethan D. Fried, MD, FACP, Program Director, Internal Medicine

Blood Program Improves Blood Utilization

TEAM LEADER: Sandra Gilmore, Director,

Residency, and Director, Graduate Medical Education, SLR The Near Miss Registry is an anonymous, risk-free reporting system for medical errors that are corrected before a patient is harmed. Created by Ethan Fried, MD, it has been adopted by the New York State (NYS) Department of Health. Initially rolled out to internal medicine residents across NYS, the registry was expanded in 2010 to residents in other specialties and other allied health care personnel. It collects descriptive data on the reporters institution, the error, and the barrier that protected the patient. More than 400 Near Misses have been submitted, over half of which were medication-related. The registry identifies vulnerabilities and effective barriers to errors to help design safer patient care environments.

Blood Management/Bloodless Medicine and Surgery, BIMC Three years ago, a clinical leadership group formed at Beth Israel to create evidencebased guidelines for appropriate blood utilization and for transfusion alternatives for patients who decline donor blood. Their efforts resulted in the Blood Management/Bloodless Medicine and Surgery Program, which has increased Beth Israels overall use of blood-sparing procedures and improved the use of interventional procedures. Physician participation has doubled, and from 2008 to 2009 the number of transfused units of packed red blood cells decreased by 800 and 196 fewer patients were transfused despite larger patient volume. The program now makes available a pocket reference card with a checklist for Jehovahs Witness patients and guidelines for acute bleeding and chronic anemia.

Improved Processing of Intra-ocular Lens for Cataract Cases

TEAM LEADER: Teresita Ignacio, NCC,

Fourth Floor Operating Room, NYEEI Of the nearly 28,000 surgeries performed by The New York Eye and Ear Infirmary in 2010, cataract removal cases requiring the use of an intra-ocular lens (IOL) comprised 43% (12,046) of them. To lessen the chance of both lens implantation error during surgery and risk of infection, the Operating Room Nursing Care Coordinator teamed with management, nursing staff and surgeons to initiate a pilot project to improve the processing of IOLs. By eliminating the labeling and handling of back-up IOLs and streamlining other related procedures, the initiative has saved 800 overtime hours and $22,300 since May 2010. More important, there have been no lens errors.

Therapeutic Hypothermia in the Management of Survivors of Cardiac Arrest

TEAM LEADERS: Janet Shapiro, MD, Director, Medical Intensive Care Unit, SLR;

Eyal Herzog, MD, Director, Critical Care Unit, SLR Based on published studies, therapeutic hypothermia (cooling of the body) improves neurologic outcomes in survivors of out-of-hospital cardiac arrest (OHCA). In 2008, a St. Lukes and Roosevelt Hospitals multidisciplinary team involving cardiology, emergency medicine, critical care medicine, critical care nursing and neurology set about developing a protocol for OHCA survivors that incorporates therapeutic hypothermia. As of March 2011, data shows that survival with good neurologic outcomes has been achieved in 40% of a total of 77 OHCA survivors with shockable rhythma significant improvement compared to historical statistics. SLR has become a leader in publishing this protocol and presenting it to other clinicians.

Pay for Performance (P4P) Program at Continuum Health Partners

TEAM LEADERS: Claudie H. Jimenez, MD, Director, Managed Care Pay for

Performance; Faiz Bhora, MD, Associate Program Director, General Surgery, SLR; Latha Sivaprasad, MD, Medical Director, Quality Management and Patient Safety, BIMC; Michael Leitman, MD, Chief and Program Director, General Surgery, BIMC The P4P Program partners with Continuum physicians to implement more costeffective practice patterns, improve admission and discharge planning, and enhance quality measures aimed at lowering length of stay and health care costs. Ensuing cost savings are shared with the physicians who provide the most efficient quality care overall; performance is gauged using a methodology that adjusts for severity of illness. Since its inception in 2006, P4P has had a direct positive impact on length of stay, core measure compliance, physician documentation and operating room efficiency, and resulted in significant savings. Looking ahead, it will focus on ICU quality protocols and surgery on-time starts.

Collaborative Continuous Quality Improvement of an Integrated Rapid HIV (RHIV) Testing Program in SLRs Emergency Departments
TEAM LEADERS: Dan Wiener, MD, Chair, Emergency Medicine; Victoria Sharp,

MD, Director, Center for Comprehensive Care (CCC); Zachariah Hennessey, MA, Director of Special Projects, CCC Early identification of HIV infection reduces morbidity and mortality and reduces the likelihood of transmission. In 2009, the CCC and the Emergency Departments (ED) at St. Lukes and Roosevelt Hospitals developed a model for implementing fully integrated, point-of-care RHIV testing in the ED as a routine part of medical care. The model, launched in July 2010, involved system improvements and introduced new policies and procedures, including a modified ED electronic medical record to prompt triage nurses to offer the test and training of additional staff in the testing technology. According to first quarter 2011 data, since the models implementation, testing volume has increased six-fold, the percentage of triaged patients offered the test has jumped from 33 to 90 percent, and linkage to care rose to 100%.

thank you for continued efforts to improve patient care and safety at Continuum!

(continued on back page)

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Continuum Health Partners 555 West 57th Street New York, NY 10019

And the

Encouraging the Use of RCA Risk-Reduction Strategies

TEAM LEADERS: Donna Wilson, RN, CPHQ, Director, and Claudia Garcenot,

Nominees
Are
(continued from page 7)
Critical Lab Value Sticker Boosts Documentation and Provider Notification
TEAM LEADER: Donna Wilson, RN, CPHQ,

Assistant Director, Quality Improvement, BIMC In 2008, Beth Israels Quality Improvement Department instituted a tracking system to measure and monitor the hospital-wide use and effectiveness of rootcause analysis (RCA) risk-reduction strategies. A database was created to chart adherence to these strategies as well as produce reports of adverse occurrences when an RCA process was conducted. Outcomes of the project have had a positive impact on such processes as the timeliness of consults, quiet-room documentation, and the immediate recheck of alert potassium values. Furthermore, a 91% compliance rate has been reached for implementation of completed RCA risk-reduction strategies.

Director, Quality Improvement, BIMC With the Joint Commission identifying communication among caregivers as a vital factor in optimal care delivery, the QI team began studying documentation of lab values and notification turnaround time from nurses to providers. It ultimately developed the Critical Lab Value Sticker to be completed by nurses and then placed in the medical record when they receive lab results. Documentation rates quickly increased from a baseline of 65% in 2008 to 95% in June 2011, and notification turnaround time dropped from 20 to six minutes during the same period. The project also prompted other quality and safety improvements, including better overall communication among caregivers and more timely treatment of critical medical issues.

2011 Quality and Patient Safety Award nominees