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UWHC,

Nursing,

UW Health,Ambulatory Education,Educational Opportunities,Grand Rounds,Nursing Grand Round Presentation Video Archive 2012,Leading and Managing in a Clinical Practice Discipline 2012,03/14/2012 - Using Evidence-Based Practice and Nurse Sensitive Outcomes to Transform Health Care,Resources

Presentation

Presentation - UW Health, Ambulatory Education, Educational Opportunities, Grand Rounds, Nursing Grand Round Presentation Video Archive 2012, Leading and Managing in a Clinical Practice Discipline 2012, 03/14/2012 - Using Evidence-Based Practice and Nurse Sensitive Outcomes to Transform Health Care, Resources



Using Evidence-Based Practice
& Nurse Sensitive Outcomes to
Transform Healthcare
Ruth M. Kleinpell PhD RN FAAN FCCM

Rush University Medical Center
Chicago, Illinois


Objectives
• Discuss the use of outcome
measurement to demonstrate the impact
of nursing care
• Identify how measuring the outcomes of
nursing care highlights the unique roles
of nurses

Overview
•Measurement of outcomes:
◊No longer an option
◊A mandated component of providing
healthcare
Expectations of today:
▪ High quality health care
▪ Cost effective
▪ Good outcomes

Why Measure Outcomes?
◊What do you do as a nurse?
◊ What is your impact on:
▪ Clients
▪ Health care
▪ Costs of care
▪ Other measures

True or False?
A nurse should be in practice for many
years before attempting to measure
outcomes
In order to be able to measure
outcomes, a nurse has to conduct
research
The best outcomes to measure are the
traditional medical outcomes – eg.
length of stay, costs


True or False?
As nursing care is often “invisible” it is
best not to try and measure outcomes of
nursing care
Outcomes should only be measured with
instruments
An outcomes project takes
years to develop & complete


Focus on Outcomes
•Aids in describing impact of care on
patients’ lives
• Describes disease course
• Aids in evaluating alternate ways of
treating patients
Davies et al. J Qual Improv 2009

Focus on Outcomes
• Aids in comparing performance of
providers
• Allows evaluation of care effectiveness
• Facilitates identification of areas needing
improvement


Davies et al. J Qual Improv 2009

Outcome
•“Something that follows as a result or
consequence”

• End result of a process, treatment or
intervention
Webster’s Dictionary

Outcome Measure
•Parameter that can be assessed to
reflect:
◊ Change
◊ Result
◊ Effect
▪ of a treatment, procedure
or intervention
Houston & Miller, 2003

Classic List of Outcome Measures
“The 5 D’s”
Death
Disease
Disability
Discomfort
Dissatisfaction
(Lohr, 1988)

Current Emphasis
• Positive aspects of health are preferred
concepts:
◊ Survival
◊ States of physical and emotional health
◊ Satisfaction
◊ Social functioning
◊Quality of life

Nurses Role on Outcomes
Nursing care represents a majority of the hours
of care provided in most care delivery settings
(hospitals, nursing homes, home health and
community agencies)
Therefore it is important to evaluate the
contribution of nurses' interventions to patient
outcomes

Maas M. Nursing's role in interdisciplinary accountability for patient outcomes.

What Outcomes Relate to
Nursing?
• Did the outcome result from a nursing
intervention?
• Is the outcome related to some aspect of
nursing care?


Assessing Outcomes of Nursing
Care
● Effect of Nursing Rounds on Patients’ Call
Light Use, Satisfaction, and Safety
◊ 6 week nationwide study
Purpose: Assess impact of nursing rounds at 1 & 2
hour intervals
• 27 nursing units in 14 hospital


Meade C et al Am J Nursing 2006

Meade C et al Am J Nursing 2006

Meade C et al Am J Nursing 2006

Meade C et al Am J Nursing 2006

Meade C et al Am J Nursing 2006

What Outcomes Relate to
Nursing?
• Does the outcome have significance for
patient care and/or healthcare?
• Is the outcome nurse sensitive?

Criteria for Evaluating Nursing
Sensitivity of Outcomes
• A nursing intervention:
• Produced a positive outcome
• Influenced a positive outcome
• Had the intent to produce or influence an outcome
• Produced improvement/prevented deterioration
• Occurred before the outcome observation
• That influenced the outcome is within nursing
scope of practice
Johnson et al Nursing Outcomes Classification. 2005

Assessing Outcomes of Nursing
Measures to Consider:
Patient Outcomes
●Prevention of complications:
• Pressure ulcers
• Patient falls
• Adverse events
● Patient and family satisfaction





AHRQ Quality Indicators
http://qualityindicators.ahrq.gov/downloads.htm
● Hospital Acquired Conditions
● Patient Safety Indicators
◊ PSI 3 Pressure ulcer
◊ PSI 7 Central Venous Catheter-related BSI
◊ PSI 12 DVT
● Prevention Quality Indicators
◊ PQI 12 – Urinary tract infection
◊ PQI 11 - Pneumonia

National Quality Forum
● National Voluntary Consensus Standards for
Patient Outcomes
◊ Have focused on AMI, heart failure care
◊ ICU focused measures proposed:
◊ ICU length of stay
◊ ICU mortality
◊ 30 day readmission rate
www.qualityforum.org


Ventilator Bundle
VTE Prophylaxis
Glycemic Control with
Intravenous Insulin

Identifying Outcomes
● Quality Indicators:
◊Institute for Healthcare Improvement
□ 100,000 Lives Campaign
□ How-To Guides
● Rapid Response Teams
● Preventing Adverse Drug Events
● AMI Care
● Preventing Surgical Site Infections
● Preventing Central Line Infections
● Preventing Ventilator-Associated Pneumonia

http://www.ihi.org/IHI/Programs/Campaign/

720 bed University Medical Center
83% BSN staff
Magnet Designated

Project Example: VAP Prevention
Initiative
Rush University Medical
Center




Focusing on Prevention of VAP: Increasing Awareness



Audits
were
conducted
on Oral
care
practices

24 hour Oral Kit at bedside
2nd quarter N=71
3rd quarter N=81
0
10
20
30
40
50
60
70
80
90
100
2nd Qtr 3rd Qtr
yes
no
Results of the
audits reveal
increased use of
oral care

Document Oral Care on Flowsheet
(swab, brush, oropharyngeal)
0
10
20
30
40
50
60
2nd Qtr 3rd Qtr
yes
no
Results of the
audits reveal
increased
documentation

Audits were
conducted on
head of bed
(HOB)
Positioning

HOB Actually Up 30 Degrees

0
10
20
30
40
50
60
70
80
90
2nd Qtr 3rd Qtr
Yes
No
Results of the
audits
reveal increased
HOB positioning to
recommended
levels

HOB Up 30 Degrees or More Documented
2nd quarter N=71
3rd quarter N=81
0
10
20
30
40
50
60
70
80
90
2nd Qtr 3rd Qtr
Yes
No
Results of the audits
reveal increased
documentation

# of VAP
0
1
2
3
4
5
6
7
Jan
90th
Feb
75-
90th
March
50-
75th
April
75th
May
25-
50th
June
50-
75th
July
<25th
Aug
50-
75th
Sept
50-
75th
Oct Nov
Results revealed
decreased
infection rates

Examples of other nurse-sensitive
outcome measures
♦Nosocomial infection rates
♦Adverse events (e.g., accidental extubation,
hypoglycemia)
♦Skin breakdown
♦Patient and family education

Project Example: Targeting Hypoglycemia
Reduction With Use of Insulin Infusions
Surgical ICU Rush University
Medical Center


Project Problem
Glycemic Control
Despite the acknowledgement of the importance of
tight glycemic control in the intensive care unit
(ICU), a common clinical problem is how to achieve
and maintain the strict glucose control without
episodes of hypoglycemia

A single episode of severe hypoglycemia increases
the risk of mortality (Krinsley & Grover, 2007 and
Brunkhorst et al 2008)




25% reduction of hypoglycemia

25% reduction in protocol adherence deviations

Increase knowledge of glycemic control and
hypoglycemia


Project Goals

Hypoglycemia Occurrences
with Insulin Infusions (BG<60mg/dL)
pre and post new protocol
pre: Feb/Mar-62, April-22, May-11
post: July-19, Aug-14, Sept-8
0
5
10
15
20
25
30
35
40
F
e
b
/
M
a
r
c
h
A
p
r
i
l
M
a
y
J
u
l
y
A
u
g
u
s
t
S
e
p
t
2008
#

o
f

o
c
c
u
r
r
e
n
c
e
s
SICU
NSICU
MICU
CCU
New protocol
2009

Protocol Adherence Deviations
with Hypoglycemic Events
Protocol deviations
0
5
10
15
20
25
30
March April May July Aug Sept
months
#

o
f

d
e
v
i
a
t
i
o
n
s
Protocol deviations
New protocol
2009

Results

25% reduction of hypoglycemia
Over 50% reduction 3 months post new
protocol implementation

25% reduction in protocol adherence deviations
Over 50% reduction 3 months post new
protocol implementation

Increase knowledge of glycemic control and
hypoglycemia
17% average increase for department


Philips Grant Session: Targeting
Hypoglycemia in the ICU With
Evidence Based Practice Strategies

Identifying Nursing Outcomes
● What are important quality indicators
currently being monitored?
● Have there been situations/sentinel
events that indicate new areas to target?
● What are best practices that can be
incorporated?

Identifying Outcomes
Quality Indicators:
National Quality Forum, Nursing–Sensitive
Performance Measures
www.qualityforum.org/bcNQFprojectsummary+SClistnursingcare
Falls/patient injuries
UTI
Hospital-acquired pneumonia
Post op pulmonary embolism/DVT
Post op infections
Sepsis
Decubitus ulcer prevalence
Post op hip fracture

Project Example: UTI Prevention
Initiative
Rush University Medical
Center


Purpose
● To implement and evaluate the efficacy of a
multidisciplinary initiative to reduce CAUTIs in a Medical
ICU by decreasing urinary catheter device use

During 6 month period, reinforced
assessment of appropriate use of
urinary catheters and monitored
catheter device days and
rates of CA-UTI’s compared to
prior 11 month timeline

Elpern et al. Am J Crit Care 2009;18;535-541

Elpern et al. Am J Crit Care 2009;18;535-541

NDNQI are nurse sensitive:
Nursing hours per patient day,
patient falls, nosocomial
infections, nursing satisfaction,
etc.

Importance of Outcomes
□ Affordable Care Act
◊ Hospital Inpatient Value-Based Purchasing
Program
Focuses on a hospital’s performance on 25 quality
measures related to clinical process of care measures
and patients’ experience of care.
Under the program, incentive payments will be made to
hospitals based on performance of certain quality
measures as well as improvement in performance.
Centers for Medicare & Medicaid Services. https://www.cms.gov/hospitalqualityinits/

VBP Program
●The Hospital Value-based Purchasing Program, applies
beginning in FY 2013 to payments for discharges
occurring on or after October 1, 2012.
Under the initiative, CMS will "withhold" a portion of
hospital payments each year (1% in FY 2013
and gradually increasing to 2% by FY 2015 and
beyond) and redistribute these funds as incentive
payments to hospitals based on their performance
across select groups of quality measures.
http://www.cms.gov/HospitalQualityInits




Summary
• Nurses are making an impact on a daily
basis on outcomes for patients
• The measurement of outcomes is an
important part of providing nursing care
• Measuring the outcomes of nursing care
can provide important information on
nurses contributions to patient care


Measuring Nurse Sensitive Outcomes: It’s Easy!