Case Study Week 10

A newly hired registered Nurse (RN) is assigned to work at the telehealth work center.  The RN is monitoring the in coming data from home-bound (based) patients from arount the county, checking to see if there are any situations which require nursing interventions and taking the appropriate actions. One (1) patient is a type II diabetic. He reports his fasting blood sugar level of 54. Another patient who has congestive heart failure (CHF) and regularly reports in on daily basis does not send in any information (data).

·         What is the best course of action for the RN to take regarding the diabetic patient?

·         How should the RN proceed regarding the lack of information from the CHF patient?

1) The best course of action regarding the patient with a blood sugar of 54mg/dL is to have the patient immediately ingest 15 grams of carbohydrates. (This is fine because the patient is alert and communicating with you, showing they are capable of tolerating oral forms of glucose). I would stay online (via telehealth) with the patient and have the patient recheck his blood sugars in 15 minutes to see if there is improvement. If his blood sugars remain low, I would have the patient repeat the steps again, even until a third time if necessary. I would then ask the patient what doses of insulin he takes and how often, and what his blood sugar trends were this past month. After I would inform the physician (via telephone or electrical transmission) about the patient’s status and blood glucose trends to determine if insulin doses needed to be adjusted or lowered for the patient.

2) The RN should call the CHF patient on the phone to determine how he is doing. If the patient does not answer, the nurse can call an emergency contact to see if they can get a hold of the patient. If there is still no response, the RN can have emergency services go to the patient’s home to ensure they are safe or if they are needing immediate transport to the nearest Emergency Department.  The fact that the patient did not send any information, when he usually does on a regular basis, is of concern and requires these actions by the nurse. 

Critical Thinking- Week 10

The registered nurse (RN) is reviewing orders and completing the medication reconciliation (Med Rec) in the electronic Medical Record (EMR). Med Rec is a process for double checking medications, where the RN verifies that the details of the medications written on the provider's orders match those recorded in the medication administration record (MAR) used by the nurse. During the Med Rec process, several alarms/alerts go off.

·         Does the use of EMR guarantee error-free patient care? If yes, why? If no, why?

The use of EMR most definitely does NOT guarantee error-free patient care. I actually worry these standardized systems of EMR charting means care won’t be individually tailored to the patient (i.e. specific health issues of patients won’t be factored in; certain medications they are taking won’t show up and prompt the physician to be careful on what they are ordering; maybe the patient has a blood clotting issue like Factor 5 and the physician won’t notice this since it was entered in a big long list for the medical history and doesn’t stand out amongst the others; doses may not be weight-based since the physician can just use the CPOE drop-down menu and accidentally order/prescribe it for the patient without thinking about their weight or age (i.e. adult vs pediatric doses)). I feel like it is so easy to just click through things on computers without actually reading the prompts or what it is saying. This can be hazardous for patient care. This is why I am glad alerts are generated at times to help staff members think through what they are doing and ask themselves if what they are doing/charting is really safe or not.

EMR is definitely a more efficient way to enter, store, collect, and share information, but it does not mean it is error-free. It requires just as much diligence from nurses as does the old-fashioned hand-written charting.   

·         What types of nursing behavior regarding the use of EMRs might contribute to jeopardizing patient safety?

Nurses getting sloppy and not thoroughly reading computer prompts, such as just clicking through them to get to more familiar screens or cancelling/silencing alarms, are types of behavior that can contribute to jeopardizing patient safety.  

Nurses can be reluctant to change from paper to computer charting because they are set in their ways. They may avoid becoming educated or familiar with the computer charting system and this can lead to error-prone charting on patients.

Due to the ease of computer charting, some nurses may purposefully procrastinate and leave their charting to the end of the shift. This sets them up for making more mistakes because they may forget very important details about the patient’s status and critical information will be missed for continuity of care because of the nurse’s accidental omission.  

·         What are the dangers of excessive system alerts in computer charting systems?

Too many system alerts in computer charting systems can lead nurses to quit reading them and do anything to just silence the alarms such as skipping through alerts quickl. Ignoring these alarms results in increased mistakes that affect patients and communication among healthcare personnel.

·         How can the nurse guard against the potential effect? 

Nurses need to be more diligent in their charting and reading of the electronic health record. They must slow down and read each prompt and be familiar with and educated in the computer charting system. If not, they are more prone to charting on the wrong patient by simply clicking too close to another patient’s name by accident, they may neglect to chart important patient information, or they may just browse through information too quickly without thinking about the alarms/alerts relevance or importance. 

Reflective Journal Week 9: Quality Improvement Strategies IV

1) I expected to learn more about quality improvement strategies and how they pertain to my role as a nurse. 

2) From this unit and chapter 7 of our textbook (Sollecito & Johnson, 2013), I learned about the role of the patient in quality improvement (QI), how to involve patients in QI and different models of patient involvement. Since health systems have changed and become more developed, patients have been expected to be involved in healthcare. A greater knowledge of health has increased knowledge of errors in the media and public domains. Health systems have been forced to acknowledge the patient or caregiver perspectives. CQI is part of the shift to patient-centered health care because patients are ultimately customers. Factors affecting patient involvement are their willingness to participate due to health literacy or self-efficacy, minority social positions, severity of conditions, the health setting and issues around power relations. Clinician attitudes and beliefs also affect patient involvement.  

Measuring patient involvement via customer satisfaction surveys has become widespread in healthcare. HCAHPS are posted online for patients to review results and compare different hospital levels and quality of care. Different models to facilitate patient involvement have been designed, including the MAPR model. National Patient Safety goals have been implemented to involve patients in their own safe care. The Joint Commission published a “Patients as Partners” toolkit to support patients and caregivers in identifying safety issues. These efforts, in addition to many others, are supportive of involving patients in their care and hopes to identify how patient involvement can have a positive impact on the medical errors/rates that continue to exist in health care.  

3) I enjoyed the Root Cause Analysis (RCA) critical thinking assignment where we asked the question “Why?” five times to a certain problem I have been struggling with as of late. I decided to try this method on another problem I have been facing and interestingly, both answers to my fifth WHY question were the same for both problems. I am excited to learn more about RCA because this is what our team will be presenting on for the final project.

The discussion was more difficult to come to a consensus on since everyone seemed a bit confused about creating indicators for preventing Surgical-Site Infections. I enjoyed learning that clipping hair, as opposed to shaving hair, is the standard of care. It makes sense that clipping would be performed instead of shaving, so hair follicles aren’t entirely exposed leading to bacteria becoming embedded in the follicle and not scrubbed off during the surgical scrub procedure.

4) I plan to continue involving patients more in their own health care by educating them more thoroughly during their discharge about instructions, who to follow up with, and their medications/side effects. I also plan to encourage patients to keep a list of their current medications and bring them with them to all doctor’s appointments, urgent care visits, or hospital stays.

5) I enjoyed this unit on quality improvement. The patient is the customer. Involving them in their healthcare, I feel, can help us find ways to reduce medical errors, HAIs, etc.

Reference

Sollecito, W. A., & Johnson, J. K. (2013). Mclaughlin and Kaluzny's continuous quality improvement in health care. Burlington, MA: Jones & Bartlett Learning.

Reflective Journal Week 8: Quality Improvement Strategies III

1)         I expected to learn about more quality improvement strategies that I can implement into my work environment.

2)         I actually learned about measures of consumer satisfaction and its effect on healthcare. Sollecito and Johnson (2013) stated that consumer satisfaction data is now recognized as the best source on communication, education, and pain management. It is a requirement of patients and payers in health systems. Who is the consumer? In healthcare it is the patient or any party that will be potentially using the product or service on offer (Sollecito & Johnson, 2013). So, hospitals purchasing from vendors, managed care organizations contracting doctors for clients, and Medicare contracting with insurers can all be considered consumers.

            Measuring patient satisfaction in healthcare is of utmost importance since hospitals desire to maintain public images of quality and service. Government and other authorities regulate and continue to require patient satisfaction data. Ratings about different hospitals are displayed online so patients can look up information and then make an informed decision about their choice of providers or hospitals (CMS, 2015).  A Balanced Scorecard influences patient’s choices of hospitals as well.

            HCAHPS surveys to patients include communication with doctors, nurses and the responsiveness of staff. Questions also include if pain was managed, education was given on medication, discharge information was given, and how quiet and clean the hospital environment was. Patient feedback and ratings help guide Continuous Quality Improvement (CQI) measures in healthcare.

3) I enjoyed our discussion on how nurses can implement evidence-based practice (EBP) in their work environment. Our group members thought of ideas for incorporating EBP by questioning the nursing practice and then actively researching scholarly articles that show EBP. This can be presented in staff meetings or to the chain of command in healthcare. Teams can then be created to design quality improvement processes to implement the EBP standards of care. We discussed an important point that nurses likely are not engaged in EBP implementation because they feel they are of only modest education and lack the ability to understand research and statistical terminology (Majid, et al., 2011).  Nurses may not feel there is enough incentive too. I wondered if nurses who engage in EBP could be monetarily compensated for their efforts. Another idea we considered is if nursing schools could require EBP courses where they simulate implementing research into different possible healthcare environments. These courses could be so beneficial for new graduate RNs since they would feel more competent in research and implementing EBP in their practice when they land their first jobs.

4) My goal is to look up EBP whenever I have a question in my nursing environment and speak up about it to my provider I am working with. I work in an InstaCare and even though it is a part of a large corporation, practices and processes still differ from the other Medical Group settings and the larger hospital. This variance is largely due to traditions and healthcare team members’ levels of experience.

5) My personal feelings are that EBP is the gold standard of care.  Healthcare team members should continually strive to be knowledgeable about and implement EBP in their own personal environments. Their examples of engagement will help others want to be committed as well. Patient care would begin to improve on a larger scale and this would be reflective in consumer satisfaction data.   

References

Centers for Medicare and Medicaid Services (2015). Medicare.gov: Hospital compare. Retrieved from https://www.medicare.gov/hospitalcompare/search.html

Majid, S., Foo, S., Luyt, B., Zhang, X., Theng, Y., Chang, Y., & Mokhtar, I. (2011). Adopting evidence-based practice in clinical decision making: nurses' perceptions, knowledge, and barriers. Journal of the Medical Library Association, 99(3), 229-236

Sollecito, W. A. & Johnson, J. K. (2013). Mclaughlin and Kaluzny’s continous quality improvement in health care. Burlington, MA: Jones and Bartlett Learning, LLC. 

Reflective Journal Week 7: Quality Improvement Strategies II

1) I had expected to learn more quality improvement strategies during this unit.

2) I actually learned a great deal how not to confuse Common Causes with Special Causes.  According to our lecture video provided from the Mayo Clinic (2012) which presents Edward Deming’s theories of profound knowledge, reacting to common causes is like scraping burnt toast. One might ask what a common cause is? A Common Cause is an occurrence that is constantly active within a system (Mayo Clinic, 2012). It is predictable. A Special Cause, on the other hand, is the new, unanticipated, emergent or previously neglected occurrence within a system (Mayo Clinic, 2012). Special Causes are unpredictable. Deming stated not to react to common causes, because they are already going to be present in a system, and it will only make things worse. For example, a Common Cause is the burnt toast produced by a poorly designed toaster. Continually scraping the burnt toast to make it look better only makes things worse and doesn’t fix the problem. In contrast, a Special Cause is the toaster.  If the heat is turned down on the toaster, burnt toast will no longer be produced.

            Quality Improvement teams need to remember not to react to Common Causes, because they will always be present in a system—there is no point in scraping burnt toast. The focus should be fixing the Special Causes in a system. Ways to recognize the Special Causes is through collection of data and creation of a control chart with upper and lower controls. A sequence of seven or more points continuously moving upward or downward is considered a “trend.” A clump of eight points above or below the upper/lower control limits is called a “run.” These runs are the Special Causes that must be paid attention to in a system. They are unpredictable and need fixing to produce better outcomes.

3) I enjoyed the team discussion on our burn victim patient that had second and third degree burns on 75% of his body. Our burn victim had a poor nutritional status with a decreased appetite.  One member of my team brought up research about the caloric needs for victims with a burn covering 25% of total body surface area (TBSA). Caloric needs can exceed 5,000 calories per day. Our group discussion focused on possible reasons why this patient had a decreased appetite and ways to increase his nutritional status.

            We concluded that pain was likely a large contributing factor to this patient’s decreased appetite. Dehydration secondary to his burns likely increased his feelings of nausea and compounded his poor appetite too. We also assumed the patient may be depressed from trying to cope with this disfigured body, and those feelings of depression were possibly reasons why he may not feel like eating as well.

            We decided the healthcare team needed to focus their efforts on increasing his appetite via pain control, ensuring adequate hydration via intravenous fluids and oral intake, beginning tube feedings with a high-calorie/high-protein formula, make snacks readily available for the patient, and administer anti-nausea medications and appetite stimulant medications such as marinol to help meet this patient’s nutritional needs and stimulate his appetite. The nurse would include the patient’s family in encouraging him to eat high calorie/high-protein snacks throught the day as well. We concluded that these efforts implemented by the healthcare team would increase his nutritional status allowing for better wound healing to take place and for his immune system to be improved.

4) I plan to utilize the information I have learned in my nursing practice by trying to recognize common causes in our process improvement systems, and not react to them. They are predictable and will always be present in a system. I will, however, recognize the special causes and try to fix them, so process improvement plans can carry on, and lead to better patient outcomes.   

5) I enjoyed the material covered. I want to become more familiar with statistical analysis, variation, data collection and research in my nursing practice. This way I can use statistical tools such as flow charts, diagrams, or control charts (Sollecito & Johnson, 2013, p. 77-116) to help analyze and improve processes.

References

Mayo Clinic (April 2012). Common cause and burnt toast. Retrieved online from     https://www.youtube.com/watch?v=ctn1JFsNiCE&list=PLUuOgSK-0gzHmArwz4iwLy0zz_EeP0JSN

Sollecito, W. A., & Johnson, J. K. (2013). Mclaughlin and Kaluzny's continuous quality improvement in health care. Burlington, MA: Jones & Bartlett Learning.

Week 6 Reflective Journal- Quality Applications

1) I expected to learn about applying quality measures to healthcare.

2) I actually learned from this unit what benchmarking and balanced scorecards are, in addition to best practices for urinary catheters and venous thromboembolism prevention guidelines.  Benchmarking is “the use of external comparisons to understand how one is doing compared to one’s peers and/or one’s competitors” (Sollecito & Johnson, 2013, p. 173). It requires a type of decision regarding the standards that should be used when comparing outcomes across facilities or within a facility over time including Normative, Empirical, and Institutional. The Normative approach are standards that reflect best possible outcomes that can be achieved under optimal circumstances, so results are determined by evidence-based medicine. In the Empirical approach, results are assessed relative to other institutions treating similar patients (Sollecito & Johnson, 2013, p. 174). The Institutional approach is where results are based on a self-comparison over time.

I was able to look up different hospital balanced scorecards, via a google image search, indicating how well institutions have performed over time. They would post targeted goals in an organized framework and then post their actual percentages to determine if they met their goals. These scorecards made performance information easily accessible and showed where improvement was needed in different categories such as patients (customers), employees, enablers, and financers. By viewing their companies’ scorecard, quality improvement teams could easily compare their benchmarks with other organizations to determine their level of standing.

I also looked up the guidelines for preventing catheter-associated urinary tract infections from the Center for Disease Control and Prevention. The Case Study activity I completed reminded me of the trainings I went through while working at Utah Valley Specialty Hospital. We completed ERASE CAUTI programs and implemented them on our patients. We followed specific protocols by assessing our patients for the actual need of a catheter, inserted them aseptically with the specialized/updated kits, ensured we removed them as soon as possible with documentation, and then did bladder retraining for the patients to help with urinary continence afterwards. This program helped decrease UTIs in our patients, and helped us ensure our patients only received catheters if indicated.

3) I enjoyed the team discussion on best practice guidelines for preventing venous thromboembolism (VTE). It was a great refresher to remind me of standards of care and how pharmacists, physicians, and nurses are all needed to help prevent VTEs in patients. The team approach is what will provide the most thorough and safe care to patients, leading to better benchmark outcomes.

4) I plan to look at my own hospital’s benchmarks, determine where improvement is needed, and help implement that with my manager. This way, patient outcomes will be better  because they are based on standards of care, and our benchmark scores will improve.  

5) I enjoyed this unit on Quality Applications. I didn’t realize how much is involved when it comes to measuring the strengths and weaknesses of one’s company. It is an intricate process involving a lot of analyzing, planning, implementation, and additional research on ways to improve--a definite difficult task requiring teamwork.  

Reference

Sollecito, W. A., & Johnson, J. K. (2013). Mclaughlin and Kaluzny's continuous quality improvement in health care. Burlington, MA: Jones & Bartlett Learning.