Susan Rees

Improving reassessment and documentation of pain management

BACKGROUND The Joint Commission standards on pain management address the documentation of assessment and reassessment. Yet, little has been published to describe when and how nurses perform and communicate reassessment of pain. In 2005, the University of Wisconsin Hospital & Clinics (UWHC) was inconsistently reassessing pain after interventions, and documented reassessments were primarily confined to pain-intensity ratings. PLAN-DO-CHECK-ACT: A large-scale plan-do-check-act (PDCA) cycle was implemented to improve the documentation of pain reassessments, including development of an evidence-based administrative policy, repetitive education efforts with bedside coaching, changes in daily bedside documentation flow sheets, and audit and feedback. RESULTS From May 29, 2006, through July 16, 2008, a cumulative rate of 94.9% appropriately documented pain reassessments was achieved. DISCUSSION Despite implementation of an evidence-based policy to clarify requirements for pain reassessment, repetitive educational efforts, changes in daily bedside flow sheets, direct and extensive leadership involvement in the form of continuous bedside coaching, combined with more timely and persistent audit and feedback and clear accountability and alignment with goals, was necessary for substantial change. Strategies to sustain improvements include daily administrative and monthly staff documentation audits with prompt feedback to clinical nurse managers and staff. Nurses are instructed on the importance of pain reassessments and on the policy and specific documentation requirements. Reassessment of pain is a routine variable displayed on unit and departmental quality dashboards. Further study should examine if the intensity of this requirement for pain reassessment documentation ultimately facilitates the safety and effectiveness of pain management.

Catheter-associated urinary tract infection: a successful prevention effort employing a multipronged initiative at an academic medical center.

An interdisciplinary clinical improvement workgroup was formed at this academic medical center with the goal of reducing catheter-associated urinary tract infections (CAUTIs). In 2011, the CAUTI rate was noted to be 4.7 CAUTIs per 1000 catheter days. Rounding by 2 lead clinical nurse specialists revealed deficiencies in current practice, which were addressed with multifaceted strategies, including evidence-based indwelling urinary catheter and bladder management protocols, education of staff, reporting of data, and utilization of an icon in the electronic health record (EHR). After the implementation of these strategies, the CAUTI rate decreased and was noted to be 2.4 in February 2013. In addition to this, there was a downward trend line for catheter days.

Success of a multimodal program to improve hand hygiene compliance.

The purpose of this article was to describe the successful implementation of a quality improvement initiative focusing on a hand hygiene program that used the multimodal interventions of tailored education, monthly feedback, and reminders. Compliance rates improved from July 2011 to December 2012 by 57.4%. Efforts are continuing to ensure program sustainability.

Moving data to nursing quality excellence.

Data must make their way to front line staff if performance improvement efforts are to be successful and sustainable. The steps of focus, display, distribute, and reward may be used as a process to ensure that data are delivered to and used by the front line staff. The focus on specific key measures, with subsequent consistent display and distribution, had a positive impact on the selected measures. Rewarding units with annual awards further encouraged staff to improve on important nurse-sensitive measures.

Creating a culture of safety for safe patient handling.

Healthcare workers who handle patients have little guidance to help them identify when to use the existing equipment for moving patients. Manual lifting of patients and healthcare worker injuries continue despite equipment installation and training. The purpose of this project was to decrease the number and severity of healthcare worker injuries by implementing a culture of safety for safe patient handling. A multicomponent safe patient handling program was deployed on one inpatient unit at a Midwest academic acute care hospital. There was a 36% decrease in the number of patient handling injuries, a 71% reduction in the number of lost work days, and a 60% reduction in costs in 1 year related to patient handling injuries. The RN Satisfaction Survey question regarding having enough help to lift/move on last shift improved from 41% presurvey to 69% postsurvey.

Reducing specimen identification errors.

In 2006, the University of Wisconsin Hospital and Clinics identified that the number of specimen identification errors each month was much greater than desired and represented a significant patient safety issue. A collaborative performance improvement approach between nursing and the laboratory was undertaken for the inpatient, ambulatory, and surgical services areas, with the focus on creation of a just culture. Between 2007 and 2011, interventions were successful in significantly reducing the number of errors by 85%.

Improving inpatient pneumococcal and influenza vaccination rates.

Since 2004, pharmacists at the University of Wisconsin Hospital and Clinics have screened all adult inpatients for pneumococcal and influenza vaccination. Rates of screening patients improved to nearly 100% between 2004 and 2009, but the rate of actual administration of the vaccines hovered around 45%. A review of the process identified failure modes. This prompted a collaborative effort between pharmacy and nursing for improvement that focused on ensuring that the ordered vaccinations were actually administered. The rates of administration improved from approximately 45% in June 2009 to approximately 78% by mid-2010.

Creating a culture for publication through education and mentoring.

Nursing administrators and researchers are well positioned to achieve innovative progress in clinical practice, leadership, and research through creating a culture of publication. Direct care nurses and advanced practice nurses often have fresh ideas about delivery of patient care but may consider publication of those ideas and results an impossible task. Creating a culture for publication can be challenging. By using a change model and focusing on mentoring, role modeling, education, securing appropriate resources, and celebration/recognition as key components, this important culture can be created.

Supporting nurse manager certification.

Professional certification is desirable for nursing staff and leaders to demonstrate high levels of knowledge and expertise. Nurse managers can be role models for staff by attaining certification. The organization highlighted in this article developed a process that included an in-house nurse manager certification review course resulting in increased certification rates from 33% to 50% for nurse managers in a 14-month period.

Leadership rounds to reduce health care–associated infections

Background: Evidence‐based guidelines exist to reduce health care–associated infections (HAIs). Leadership rounds are one tool leaders can use to ensure compliance with guidelines, but have not been studied specifically for the reduction of HAIs. This study examines HAI leadership rounds at one facility. Methods: We explored unit‐based HAI leadership rounds led by 2 hospital leaders at a large academic hospital. Leadership rounds were observed on 19 units, recorded, and coded to identify themes. Themes were linked to the Consolidated Framework for Implementation Research and used to guide interviews with frontline staff members. Results: Staff members disclosed unit‐specific problems and readily engaged in problem‐solving with top hospital leaders. These themes appeared over 350 times within 22 rounds. Findings revealed that leaders used words that demonstrated fallibility and modeled curiosity, 2 factors associated with learning climate and psychologic safety. These 2 themes appeared 115 and 142 times, respectively. The flexible nature of the rounds appeared to be conducive for reflection and evaluation, which was coded 161 times. Conclusions: Each interaction between leaders and frontline staff can foster psychologic safety, which can lead to open problem‐solving to reduce barriers to implementation. Discovering specific communication and structural factors that contribute to psychologic safety may be powerful in reducing HAIs.