Vol. 2 Issue 18
Eisenhower Medical Center safety protocols are rooted in the fundamentals
"You can't really go wrong if you stick to the basics. Protocols and guidelines are put in place for a reason. In most cases, if you look at situations where someone made a mistake, it's usually because they forgot to do something very basic."
That's how Lisa D. Berg, BA, RN, CCRN, director of critical care and dialysis at Eisenhower Medical Center (EMC) in Rancho Mirage, described the facility's approach to patient safety. The success of any new protocol relies heavily on how strong the foundation is. Before any new policy change can be effective, certain fundamentals must be in place. Is there a clear understanding of the practice? Is it evidence-based? Is there a cohesive commitment from staff members at all levels?
Taking an unbiased look at internal procedures, asking tough questions like these and having the courage to answer honestly takes a leadership that places patient safety at the top of the priority list. When it came time to create new ventilator and barcoding protocols, nurses at EMC knew that to be successful, they had to take it back to the basics the patient.
At EMC, patient safety has always been more than a practice. It's a way of thinking. Long before the Institute of Medicine's To Err Is Human report was released in 1999, sending shockwaves through the healthcare community, EMC already was turning the magnifying glass on itself to examine how it could improve its patient safety standards. Even today, with the formation of performance excellence teams, computerized education programs for patients, medication standardization and a fall prevention program, EMC continues to integrate patient safety into the daily consciousness of the healthcare environment. That's why when it came time to create a prevention protocol for ventilator-associated pneumonia (VAP) in the ICU, it was almost second nature.
An Honest Look
"We knew from infection control reports that, historically, we had a ventilator-associated pneumonia rate that was above benchmark," said Nancy Wolf, RN, chair of the VAP task force. "We know that according to the CDC, the VAP benchmark for a med/surg, ICU, non-teaching hospital is six per 1,000 vent days. At the time, ours was higher than that, so we knew we had to create a plan."
That plan involved organizing a multidisciplinary team of critical care staff nurses, a nurse practitioner, critical care clinical nurse specialist, unit director, infection control nurse and respiratory therapist. Although no uniform written standards were in place to address VAP, the committee was undaunted by the challenge and unafraid to ask themselves the tough questions, some of which came from the American Association of Critical-Care Nurses (AACN) practice alert on VAP in 2004.
According to AACN, patients who were intubated for more than 24 hours were 21 times more likely to acquire VAP, increase their hospital stay by up to 9 days, at risk of a mortality and morbidity rate of up to 41 percent and cost an additional $40,000 per episode. (AACN, 2004 Feb.) Since it began as an internally driven initiative, the VAP task force already has seen the success of its efforts.
Sometimes the most difficult problems can have simple solutions. After all their in-depth research, the VAP task force realized nurses could make some of the most significant changes in VAP prevention and that the new protocol wouldn't have to go through a lengthy administrative approval process.
"Based on these statistics, we knew this was a patient safety issue that had to be addressed," recalled Wolf. "More importantly, we realized there were significant changes nurses could make to improve patient outcomes that wouldn't require a physician's order."
Some of those changes included elevating the head of the bed to 30 degrees, regular monitoring of cuff pressure on endotracheal tubes, suctioning endotracheal tubes every 12 hours, turning patients every 2 hours, oral care and suctioning every 4 hours, brushing teeth and gums every 12 hours and using oral gastric tubes instead of nasal gastric tubes to avoid sinusitis. When the program began in March 2004, EMC's VAP rates were at double digits. Today, the number of overall VAP cases has dropped by greater than 50 percent. In fact, between March 2004 and May 2005 their rates came in well below the CDC benchmark. Based on the AACN statistics, EMC's accomplishments transfer into an incredible number of lives saved. The only thing that makes it sweeter is that it began with nurses.
"What makes this change so significant is that we're saving so many more lives and raising the bar on safety, all created by nursing interventions," Wolf provided proudly. "From a facility standpoint, you can see what an impact it makes just by adding up $40,000 saved for each individual case that was prevented. The nurses certainly took the initiative seriously and felt empowered by the opportunity to employ changes in an area in which they are the experts patient care."
A New Light
Berg sees the success of the ventilator program as a credibility booster not only to the nurses who created it, but to nursing as a profession. She believes it was a much-needed and long overdue recognition that has everyone seeing nurses in a new light.
"The success of this protocol speaks volumes to the value of nurses in the issue of safety within the hospital," Berg stressed. "Nursing today is now being viewed as a much more influential factor in patient advocacy. Although nurses have always known that, it seems with accomplishments like these, administrators are finally buying into that reality. The nurse's role in safety is essential. It's never been more important to have an engaged, highly educated and energized nursing staff."
"Anytime you need to identify how to solve a problem, you go right to the source. When it comes to what happens at the bedside, it's the nursing staff that leads the way," agreed Wolf. "With regard to the VAP protocol, they identified the problem and created the steps that needed to be put into place. It really is a credit to the role of nursing in safety."
Because of the enormous success of the ventilator protocol, safety has become an even more important part of every employee's agenda at EMC. As the numbers get lower and the morale soars higher, it's nearly impossible to believe one person can't make a difference in patient safety. Berg sees raising the bar on safety as a welcomed challenge and one that EMC is only too eager to meet.
"The hidden benefit from the success of the VAP protocol is that it has caused other staff members, who might think they can't impact safety, to re-examine the part they play in this issue and it definitely raised the bar on the quality of work that is now demanded of everyone."
While creating a new ventilator protocol alone was a formidable task, EMC also was approaching patient safety from yet another front early last year.
Meeting the Challenge
"To implement a system like this is no small task. It sounds great, even easy in theory, but the reality of implementing it at the beside involves a multifaceted and multidiscipline approach."
That's how Beverley Ingelson, BSN, RN, patient safety officer, described the challenge of implementing a new medication barcode system, which is currently the subject of a study that examines the practice's efficacy of decreasing errors at the bedside. While the hospital already had barcode scanning on two floors at the time, with plans to go facility wide, it was hard to say no to a grant from the U.S. Department of Defense in January 2004 to officially study the program. Given their dedication to patient safety and their belief in the protocol, EMC was more than ready to meet the challenge.
"The core of the study is to examine whether barcoding medications and administering them with this safety mechanism in place actually impacts the number of medication errors that an organization incurs," explained Ingelson. "As we went forward with the study, it was important for us to know that the effort and cost of the implementation was going to benefit our patients by actually decreasing the number of errors at the bedside."
Although it might seem very new age, the barcoding of medication is really quite simple and complements the nurse's responsibility. Once medication is ordered and scheduled, the nurse retrieves it from the supply station. With the barcode scanner in hand, she logs in her personal ID at the bedside by scanning her name badge. The patient's wrist band is then scanned to confirm identity as well as the medication. While it all seems quite automated, Ingelson made it clear the technology is only in place to support the safety practices of the bedside nurse.
"The nurses have all been very positive about the impact the system has had on their daily work roles," Ingelson provided. "They actually feel a friendly support and a sense of security from the tips and cues the system provides along the way."
The system regularly provides reminders to nurses such as, "Is the patient taking one pill or two?" or "Remember to give two pills." Ingelson also believes the new scanning system helps support the practice that patients receive the five rights to medication: right patient, right medication, right dose, right route and right time.
"I have always felt that barcoding is a very solid system when it comes to safety support. It helps to ensure the goal of patient safety and gives us automatic backup support," Ingelson added. "It's a safety measure that complements everything else we do here and I believe Eisenhower Medical Center was really on the cutting edge when it came to employing this as a facility-wide protocol for patient safety."
Although the results of the study won't be calculated until it's completed in March 2006, Ingleson seems confident, based on EMC outcomes, that barcoding is here to stay.
Back to Basics
Even as the EMC staff relishes the success of their efforts in barcoding and ventilator safety protocols, they've never allowed themselves to forget why they started these journeys in the first place. The ultimate prize is the gift of life they're giving back to their patients. Ingelson brought it all back to the basics.
"We're getting very heart-felt feedback from patients regarding their experiences here at EMC. They tell us they really felt they were cared for on a personal level. They felt secure in a safe environment and really appreciated the follow-up and support information given to them. Most of all, they see our efforts in safety as being thorough in their care. Getting that kind of response says they not only see what we've done as good for EMC, but good for them, too."
American Association of Critical-Care Nurses (2004 Feb.) Practice alert: Ventilator associated pneumonia. Retrieved Sept. 20, 2005 from the World Wide Web: http://www.aacn.org/AACN/practiceAlert.nsf/Files/VAPi/$file/VAP.pdf
Luke Cowles is regional editor at ADVANCE.