Ann Hendrich

Validation of the Hendrich II Fall Risk Model: A large concurrent case/control study of hospitalized patients

This large case/control study of fall and non-fall patients, in an acute care tertiary facility, was designed to concurrently test the Hendrich Fall Risk Model. Cases and controls (355/780) were randomly enrolled and assessed for more than 600 risk factors (intrinsic/extrinsic). Standardized instruments were used for key physical attributes as well as clinician assessments. A risk factor model was developed through stepwise logistic regression. Two-way interactions among the risk factors were tested for significance. The best fitting model included 2 Log L chi square statistic as well as sensitivity and specificity values retrospectively. The result of the study is an easy to use validated Hendrich Fall Risk Model with eight assessment parameters for high-risk fall identification tested in acute care environments.

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

Background:The Joint Commission on Accreditation of Healthcare Organizations is proposing that hospitals measure culture beginning in 2007. However, a reliable and widely used measurement tool for the operating room (OR) setting does not currently exist. Methods:OR personnel in 60 US hospitals were surveyed using the Safety Attitudes Questionnaire. The teamwork climate domain of the survey uses six items about difficulty speaking up, conflict resolution, physician–nurse collaboration, feeling supported by others, asking questions, and heeding nurse input. To justify grouping individual-level responses to a single score at each hospital OR level, the authors used a multilevel confirmatory factor analysis, intraclass correlations, within-group interrater reliability, and Cronbach’s &agr;. To detect differences at the hospital OR level and by caregiver type, the authors used multivariate analysis of variance (items) and analysis of variance (scale). Results:The response rate was 77.1%. There was robust evidence for grouping individual-level respondents to the hospital OR level using the diverse set of statistical tests, e.g., Comparative Fit Index = 0.99, root mean squared error of approximation = 0.05, and acceptable intraclasss correlations, within-group interrater reliability values, and Cronbach’s &agr; = 0.79. Teamwork climate differed significantly by hospital (F59, 1,911 = 4.06, P < 0.001) and OR caregiver type (F4, 1,911 = 9.96, P < 0.001). Conclusions:Rigorous assessment of teamwork climate is possible using this psychometrically sound teamwork climate scale. This tool and initial benchmarks allow others to compare their teamwork climate to national means, in an effort to focus more on what excellent surgical teams do well.

The Quality ‘Journey’ At Ascension Health: How We’ve Prevented At Least 1,500 Avoidable Deaths A Year—And Aim To Do Even Better

A decade ago the Institute of Medicine estimated that 44,000-98,000 preventable deaths occur each year in US hospitals. The leaders of Ascension Health-one of the nations largest health care delivery networks, with sixty-nine hospitals in twenty states and the District of Columbia-dedicated themselves to preventing equivalent numbers of deaths in their system. In 2003 they set a goal of reducing preventable deaths by 900 each year by 2008. By fiscal year 2010 Ascension Health had reduced preventable deaths by more than 1,500 people annually and, by some calculations, by more than 5,000 people annually, compared to 2004. Ascension Health had also achieved important improvements in preventing birth trauma and reducing rates of pressure ulcers and hospital-acquired infections. The health care system could achieve even greater results by adopting the safety principles used in high-reliability entities such as the nuclear power industry. The adoption of such principles can lead to impressive improvements in health care quality.

A proclamation for change: transforming the hospital patient care environment.

Mounting evidence describes inefficiencies in the hospital work environment that threaten the safety and sustainability of care. In response to these concerns, diverse experts convened to create a set of evidence-based recommendations for the transformation of the hospital work environment. The resulting Proclamation for Change, now endorsed by multiple health systems and professional and consumer organizations, cites patient-centered design, systemwide integrated technology, seamless workplace environments, and vendor partnerships as the cornerstones of transformational change.

Avoiding Potential Harm by Improving Appropriateness of Urinary Catheter Use in 18 Emergency Departments

STUDY OBJECTIVE Urinary catheters are often placed in the emergency department (ED) and are associated with an increased safety risk for hospitalized patients. We evaluate the effect of an intervention to reduce unnecessary placement of urinary catheters in the ED. METHODS Eighteen EDs from 1 health system underwent the intervention and established institutional guidelines for urinary catheter placement, provided education, and identified physician and nurse champions to lead the work. The project included baseline (7 days), implementation (14 days), and postimplementation (6 months, data sampled 1 day per month). Changes in urinary catheter use, indications for use, and presence of physician order were evaluated, comparing the 3 periods. RESULTS Sampled patients (13,215) admitted through the ED were evaluated, with 891 (6.7%; 95% confidence interval [CI] 6.3% to 7.2%) having a catheter placed. Newly placed catheters decreased from 309 of 3,381 (9.1%) baseline compared with 424 of 6,896 (6.1%) implementation (Δ 3.0%; 95% CI 1.9% to 4.1%), and 158 of 2,938 (5.4%) postimplementation periods (Δ 3.8%; 95% CI 2.5% to 5.0%). The appropriateness of newly placed urinary catheters improved from baseline (228/308; 74%) compared with implementation (385/421; 91.4%; Δ 17.4%; 95% CI 11.9% to 23.1%) and postimplementation periods (145/158; 91.8%; Δ 23.9%; 95% CI 18% to 29.3%). Physician order documentation in the presence of the urinary catheter was 785 of 889 (88.3%), with no visible change over time. Improvements were noted for different-size hospitals and were more pronounced for hospitals with higher urinary catheter placement baseline. CONCLUSION The implementation of institutional guidelines for urinary catheter placement in the ED, coupled with the support of clearly identified physician and nurse champions, is associated with a reduction in unnecessary urinary catheter placement. The effort has a substantial potential of reducing patient harm hospital-wide.

First step to reducing infection risk as a system: Evaluation of infection prevention processes for 71 hospitals

BACKGROUND Hospitals can better focus their efforts to prevent health care-associated infections (HAIs) if they identify specific areas for improvement. METHODS We administered a 96-question survey to infection preventionists at 71 Ascension Health hospitals to evaluate opportunities for the prevention of catheter-associated urinary tract infection, central line-associated bloodstream infection, ventilator-associated pneumonia, and surgical site infection. RESULTS Seventy-one (100%) infection preventionists completed the survey. The majority of hospitals had established policies for urinary catheter placement and maintenance (55/70, 78.6%), central venous catheter maintenance (68/71, 95.8%), and care for the mechanically ventilated patient (62/66, 93.9%). However, there was variation in health care worker practice and evaluation of competencies and outcomes. When addressing device need, 55 of 71 (77.5%) hospitals used a nurse-driven evaluation of urinary catheter need, 26 of 71 (36.6%) had a team evaluation for central venous catheters on transfer out of intensive care, and 53 of 57 (93%) assessed daily ventilator support for continued need. Only 19 of 71 (26.8%) hospitals had annual nursing competencies for urinary catheter placement and maintenance, 29 of 71 (40.8%) for nursing venous catheter maintenance, and 38 of 66 (57.6%) for appropriate health care worker surgical scrubbing. CONCLUSION We suggest evaluating infection prevention policies and practices as a first step to improvement efforts. The next steps include implementing spread of evidence-based practices, with focus on competencies and feedback on performance.

Definitional Change in NHSN CAUTI Was Associated with an Increase in CLABSI Events: Evaluation of a Large Health System

BACKGROUND The National Healthcare Safety Network (NHSN) catheter-associated urinary tract infection (CAUTI) definition was revised as of January 2015 to exclude funguria and lower bacteriuria levels. We evaluated the effect of the CAUTI definition change on NHSN-defined central-line-associated bloodstream infection (CLABSI) outcomes. METHODS We compared CAUTI and CLABSI NHSN-defined outcomes for calendar years 2014 and 2015 in the adult intensive care units (ICUs) of a single large health system. Changes in the event rates, the associated organisms, and the standardized infection ratio (SIR) were evaluated. RESULTS The study included 137 adult ICUs from 65 hospitals. The CAUTI SIR dropped from 1.04 in 2014 to 0.58 in 2015 (-44.2%), while the CLABSI SIR increased from 0.36 in 2014 to 0.47 in 2015 (+30.6%). CAUTI rates dropped 44.8% from 2.09 to 1.15 events per 1,000 device days (P<.001). Gram-positive-associated CAUTI rates dropped 36.7% from 0.34 to 0.22 per 1,000 device days (P=.007). CLABSI rates increased 27.1% from 0.71 to 0.90 per 1,000 device days (P=.027). Candida-associated CLABSI increased by 91.1% from 0.104 to 0.198 per 1,000 device days (P=.012), and Enterococcus-associated CLABSI increased by 121.6% from 0.071 to 0.16 per 1,000 device days (P=.008). CONCLUSIONS The revised CAUTI definition led to a large reduction in CAUTI rates and, in turn, an increase in candidemia and enterococcemia cases classified as CLABSI events. These findings have important implications on the perceived successes or failures to eliminate both infections. Infect Control Hosp Epidemiol 2017;38:685-689.

Decreasing intrapartum malpractice: Targeting the most injurious neonatal adverse events

Medical malpractice expenditures are mainly due to the occurrence of preventable harm with some of the highest liability rates in obstetrics. Establishing delivery system models which decrease preventable harm and malpractice risk have had varied results over the last decade. We conducted a case study of a risk reduction labor and delivery model at 5 demonstration sites. The model included standardized protocols for the most injurious events, training teams in labor and delivery emergencies, rapid reporting with cause analysis for all unplanned events, and disclosing unexpected occurrences to patients using coordinated communication and documentation. Each of the models components required buy in from the hospitals clinical and administrative leadership, and it also required collaboration, training, and continual feedback to labor and delivery nurses, doctors, midwives, and risk managers. The case study examined the key elements in the development of the model based on interviews of all team members and document review. We also completed data analysis pre and post implementation of the new model to assess the impact on event reporting and high liability occurrence rates. After 27 months post implementation, reporting of unintended events increased significantly (43 vs 84 per 1000 births, p < .01) while high-risk malpractice events decreased significantly (14 vs 7 per 1000 births, p < .01). This decrease enabled money allotted for malpractice claims to be reallocated for the implementation of the new model at 42 additional labor and delivery sites. Due to these results, this multilevel integrated model showed promise.

Population-Based Risk Factors for Shoulder Dystocia

Objective: To re‐examine the risk factors for shoulder dystocia given the increasing rates of obesity and diabetes in pregnant women. Design: Retrospective observational study. Setting: Five hospitals located in Wisconsin, Florida, Maryland, Michigan, and Alabama. Participants: We evaluated 19,236 births that occurred between April 1, 2011, and July 25, 2013. Methods: Data were collected from electronic medical records and used to evaluate the risk of shoulder dystocia. Data were analyzed using a generalized linear mixed model, which controlled for clustering due to site. Results: When insulin was prescribed, gestational diabetes was associated with an increased risk of shoulder dystocia (odds ratio = 2.10, 95% confidence interval [1.01, 4.37]); however, no similar association was found with regard to gestational diabetes treated with glycemic agents or through diet. Use of epidural anesthesia was associated with an increased risk for shoulder dystocia (odds ratio = 3.47, 95% confidence interval [2.72, 4.42]). Being Black or Hispanic, being covered by Medicaid or having no insurance, infant gestational age of 41 weeks or greater, and chronic diabetes were other significant risk factors. Conclusion: With the changing characteristics of pregnant women, labor and birth clinicians care for more pregnant women who have an increased risk for shoulder dystocia. Our findings may help prospectively identify women with the greatest risk.

Consent and enrollment process: achieving high enrollment rates for obstetric research.

AIM The aim was to study the development, design, and implementation of a patient consent and enrollment initiative to identify strategies that enhanced participation. BACKGROUND Consent and enrollment of patients, especially pregnant women, remains a challenge in healthcare research. Although many barriers have been identified, strategies to consistently improve consent and enrollment are less defined. METHODS A case study was conducted on a consent and enrollment approach aimed at optimizing participation of mothers who delivered their infants from July 1, 2010 through June 30, 2013. Data were gathered through practitioner interviews, focus groups, and documentation review for each year of the study. RESULTS A total of 19,236 mothers enrolled, representing an 85% enrollment rate at the five study sites. Enrollment rates improved over time with increased nursing engagement in patient recruitment, site specific adaptations and patient education strategies. CONCLUSIONS Nursings active role in implementation and rapid feedback loop of a multifaceted consent and enrollment program showed promise.