12/5/2016

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Strategies to Reduce Readmissions, Sepsis, and Health-Care Associated Infections

DavidRenfro,MS,RNNE‐BCKellyFarnam,BSN,RNGloriaMartinez,MS,RN,NEA‐BCDeniseRenfro,MS,RNJenniferEllman,MSN,RN,NE‐BC,CEN

C10This presenter has nothing to disclose

Tuesday,December61:30pm

#IHIFORUM CoordinatedbyEmilyStallings

Session ObjectivesP2

#IHIFORUM

• Describe proven strategies for leveraging nurses to improve rates of readmission, sepsis, and healthcare‐associated infections

• Understand the potential impact of direct‐care nurse leadership

• Identify focus areas at your facility in which nurse‐driven improvement could have a positive impact on clinical outcomes

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Session GuideP3

• Four short presentations about improvement work led by direct-care staff.

1. Readmission Reduction (Project RED)2. Transition Education3. Reducing Sepsis Mortality4. Reducing Healthcare-Associated Infections

• Time for questions between each presentation

• Lessons learned and advice to take with you

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VA Palo Alto Health Care SystemP5

• Enrolled Veterans 84,432• Veterans treated in FY 15: 67,640 • Outpatient visits: 829,990• Inpatient Admissions: 6,144• Catchment area: 13,500 Square miles• Total Budget: $930 million• Total FTE: +4,000• Academic Affiliation

Characteristics for Nurse-Driven ImprovementsP6

• Patient‐safety‐ or satisfaction‐focused

• Evidence‐based practice change

• Includes a range of environments

• Willingness to lead at the direct‐care level

• Strong leadership commitment, support and coaching

• Change evident in patient outcomes

• Commitment to developing confident, competent, credible nursing staff

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Leveraging the Expertise of Direct-Care Staff to Reduce

Hospital Readmissions

P7

Kelly Farnam, BSN, RNWillie Payton Jr., MHSA

Nicole Briones

Identifying a ProblemP8

• Lack of standardized discharge process • Readmission rates rising• 2011 rate of 13%• Medication discrepancy rate of 38%

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Choosing a StrategyP9

• Strategy options: BOOST, STAAR, TCM, Project RED

• Existing case management structure• Nurse engagement for planning

The RED Model: 12 ElementsP10

1. Educate the patient throughout the hospital stay

2. Make post‐discharge appointments  prior to discharge with patient input

3. Discuss pending tests and studies and how to learn results

4. Organize post‐discharge services5. Medication reconciliation6. Reconcile the discharge plan with 

national guidelines and clinical pathways

7. Review what to do in an emergency and who to contact

8. Ensure discharge summary follows patient to next care location

9. Utilize teach‐back to assess patient understanding of instructions

10.Give the patient a written discharge plan

11.Call the patient after discharge to answer any questions and follow up on any pending items

12.Ascertain the need for language assistance

1.Educate the patient throughout the hospital stay

7. Review what to do in an emergency        and who to contact

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Empowering Direct Care StaffP11

Standardize Discharge Across the Board• Multidisciplinary collaboration• Focus on the whole transition of care• Empower bedside nurse to ensure a safe discharge• Discharge education documents are created by 

nurse to eliminate education gaps

P12

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A Strategy for SuccessP13

Direct actions for bedside nurses• Voice concerns about readmission before dischargeTransition Coordinators• Access patient data for those readmitted within 30 days

• Facilitate communication between inpatient and outpatient providers

• Attend daily multidisciplinary meeting to identify patients with key diagnosis, and assess need for enrollment in Project RED

A Strategy for SuccessP14

ICU Discharge• All Intensive Care Unit patients being discharged 

directly home have their care coordination assessed by Project RED Transition Coordinators

Discharge Appointment Coordinator• Works with each individual patient prior to 

discharge to schedule follow up appointments at the most convenient time and date for the patient

After Hospital Care Plan (AHCP)

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OutcomesP15

• Decreased readmissions by >30%• Established reliable nursing discharge process• Increased nursing communication with 

interdisciplinary teams• Created a culture focusing on process, not people• Decreased medication discrepancies

P16

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Determined Preventability of ReadmissionsP17

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Lessons LearnedP18

NOT EVERY READMISSION IS PREVENTABLE!

• Daily review is necessary to identify gaps for early resolution

• Post‐discharge calls by RN help bridge any gaps in care

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Questions?

P19

Improving Education Through Engaging Direct-Care Staff

P20

Gloria Martinez, MS, RN, NEA‐BCKelly Farnam, BSN, RN

Nicole Briones

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State of EducationP21

Call to Action: • Only 40% of patients at discharge could state why 

they had been admitted• Discharge Instructions confusing and hard to readSolutions Implemented:• Began discharge education process at admission• Implemented a new teaching tool (After Hospital 

Care Plan)• Educated the patient utilizing teach back• Have direct‐care nurses lead and coach the process• Created teach back videos to train staff

Video- The BadP22

#IHIFORUM

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P23

Video- The Good

Maintaining the MomentumP24

• Teach back as the only way to educate patients• Taking ownership of the teaching process• Teach back champions on each unit to address unit 

specific challenges (OR/PACU‐ how to make teach back relevant)

• Ensure all nurses get teach back education as part of their new hire orientation

• Incorporate teach back as a part of nursing documentation

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Educational MaterialsP25

#IHIFORUM

P26

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Get Feedback from Patients!P27

• Veteran and family friendly information. No medical jargon

• Allows for sharing of pertinent information with family/caregivers

• Has a notes section for patient or family to write questions to ask PCP

Lessons Learned and OutcomesP28

Lessons Learned• Staff development• Investment• Actively listen• Patients learn better when you engage themOutcomes• Peer accountability• Active partner in care• Patients love the care plan! 

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Questions?

P29

Sepsis Initiative: Developing Nurses as Leaders and Evidence-Based

Practitioners

P30

Denise Renfro, MS, RN

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GoalP31

Develop emerging nurse leaders with the ability to be:1. EBP Practitioners2. Change Agents3. Facilitators of learning4. Consultants and initiative champions5. Collaborators across disciplines6. Confident communicators and presenters

While also improving a facility clinical practice

StrategyP32

Evidence‐Based Practice Fellowship Program• Rigorous application process• Investment of 72 hours (9 learning sessions)• Theory and Application• Development of Leadership Skills

Regional goal to reduce sepsis mortality rate by 10%

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Staff-Driven ImprovementsP33

Johns Hopkins Model

Sepsis Guidelines

Pilot tests of change

Screening Tool

Order Set Simulation

OutcomesP34

• Leadership development of direct‐care nurses• Skill development and confidence• Peer accountability and recognition

Decreased sepsis mortality by 12% and saved 14 lives!

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Lessons LearnedP35

• Team stability

• Just‐in‐time coaching

• Interdisciplinary champions

• Evolving learner milestones

Special ThanksP36

EBP Fellows:

Kristina Castro, MSN, RN, CNL

Kristen Valente, BSN, RN

Desiree Picazo, BSN, RN

Leisa Ann Bunte, BSN, RN

Support From:

Jane He, MD

Roberta Oka, PhD, Nurse Scientist

Jennifer Ellman, MSN, RN

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Questions?

P37

Developing Nurse-Led Teams

to Reduce Hospital-Acquired Infections

P38

Jennifer Ellman, MSN, RN, NE‐BC, CEN

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Call to ActionP39

C. difficile

MRSA

CLABSI

Plan: Partner for ExcellenceP40

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Develop Direct Care StaffP41

• Align units under common goal

• Support psychological safety

• Create a culture to “improve from within”

Strategy: Leverage the WorkforceP42

• Discover common challenges

• Appreciate uniqueness of specific practice environments

• Develop an inclusive plan

• Collaborate to remove barriers

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Create a Roadmap

Assemble the “right” team

Observe current state

Review best practices

Develop strategy and plan

Accountability

P43

Root Cause AnalysisP44

Why were we not meeting our goals? 

• Education and Training

• Documentation and Communication

• Variability in Practice

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Develop a Mindset for Continuous Improvement P45

OutcomeP46

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FY14Qtr1 FY14Qtr2 FY14QTR3 FY14QTR4 FY15QTR1 FY15QTR2 FY15QTR3 FY15QTR4 FY16QTR1 FY16QTR2 FY16QTR3

Rate per 10,000 bed days of care

Quarter

Hospital Onset Healthcare Facility Associated (HO‐HCFA) CDI Rate

Acute Care Units

CDI rate VAPAHCS Acute Care rate goal Linear (CDI rate)

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OutcomeP47

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FY14Q1 FY14Q2 FY14Q3 FY14Q4 FY15Q1 FY15Q2 FY15Q3 FY15Q4 FY16Q1 FY16Q2 FY16Q3

Infection rate per 

1,000 urinary catheter days

Quarter

Catheter Associated Urinary Tract Infections (CAUTI)Acute Care Units 

CAUTI rate VAPAHCS Rate Goal (<=1.25)

Lessons LearnedP48

Challenges

• Hardwire the process

• Resistance

• High‐risk population

Keys to success:

• Focus on the patient

• Leverage direct‐care staff and decentralize improvement teams

• Use evidence‐based practice

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Questions?

P49

Lessons LearnedP50

• Developing direct‐care leadership is an investment

• Focus only on processes, and not on people

• Develop coaching relationships with your direct‐care staff

• Encourage your nurses to showcase their capabilities 

• Provide the time and resources to allow PDCA to work 

• Listen to staff and to patients

• Empower and appreciate

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Translating To Your FacilityP51

• Take the time to plan

• Build a strong team and include opinion leaders, direct‐care staff and patients

• Set ground rules for communication

• Assign champions and accountability

Translating To Your Facility

• “Chunk and check”

• Daily management

• Don’t take no for an answer. Challenge the status quo

• Bust the myth

• Take risks and celebrate wins!

P52

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Final Questions

P53