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(HealthNewsDigest.com) – Issues of quality and safety are central to health care reform and of paramount importance to consumers, payers, and the professionals who deliver care. Because of their unique set of skills, knowledge and experience, nurses are well positioned to help improve outcomes and reduce errors. Two new reports published by the Robert Wood Johnson Foundation feature innovations spearheaded by nurses in the areas of work flow processes and health information technologies.
A number of reforms focus on increasing nurses’ time spent at the bedside with patients and taking aim at waste and errors. South Dakota’s Prairie Lakes Healthcare System, for example, has developed “agile teams” consisting of an R.N., L.P.N., and a cross-trained secretary or nursing assistant. Team members determine their respective roles on shifts on the basis of patient needs and patient census, covering 10 to 12 patients. They are supported by a “resource nurse” who takes on admissions tasks, answers questions, gives advice and more.
The approach represents a marked difference for the staff at Prairie Lakes. “It felt like bedside nurses were deprofessionalized,” remembers Shell Turbak, R.N., B.S.N., director of the medical-surgical unit. “We had gotten into a ‘Momma, may I?’ culture—with floor nurses having to go through charge nurses to get information to and from doctors. There were too many policies, no teamwork, a sink-or-swim mentality, and a 65-percent turnover rate.”
A particular source of agitation was the 90-minute admissions process. In the past, a lone medical-surgical nurse would have to gather supplies from distant storage areas, assess the patient, write a plan of care, give medication and other treatments, and complete 14 separate paper records, many redundant. But putting admissions tasks in the hands of the resource nurse has helped create time and space for the rest of the team. In these and other ways, the agile team approach encourages nurses to exercise their own clinical judgment in caring for patients and empowers all team members to collaborate in deciding who does what on a particular shift.
The effort is supported by a redesigned electronic medical records system, accessible by nurses’ wireless portable computers, allowing for bedside charting, automatic referrals, and clinical decision support. The teams have dramatically increased staff efficiency and increased nurse time at the bedside by about 27 percent. At the same time, the turnover rate in the medical-surgical unit has dropped from 65 percent to less than 10 percent since the introduction of agile teams.
A ‘Universal’ Floor
In Los Angeles, California, Cedars-Sinai Medical Center has implemented patient-safety reforms that rely on advanced on-the-job training for nurses. The hospital’s new “universal floor” approach allows patients to remain in one adaptable room and bed throughout their entire hospital stay, eliminating the costs, labor and patient risks associated with transfers from one unit to another. On average, 40 to 70 percent of patients on the typical inpatient nursing unit are transferred every day, and many move as many as six times during their stays, inviting a variety of problems, including lost information, treatment delays, incompatibilities in record-keeping, and wasted supplies and staff time.
Cedars-Sinai established a 30-bed unit for the program and created interdisciplinary teams of eight nurses. Work stations next to rooms and supply carts in the rooms reduce wasteful travel time for nurses, and their on-the-job training is supplemented by compensation incentives for certifications earned by nurses in additional specialties. The result, according to Linda Burnes Bolton, Dr.Ph., R.N., F.A.A.N., vice president and chief nursing officer at Cedars-Sinai: “We have increased nurses’ time in direct patient care by decreasing documentation, placing patient supplies inside the room, and improving teamwork.” Cedars-Sinai is extending its use of the concept to two additional units.
Borrowing from What Works in Other Industries
Another effort aimed at increasing efficiency and maximizing time nurses spend with their patients borrows from an unexpected source: the automotive industry. In Seattle, Washington, the Telemetry Unit at Virginia Mason Medical Center has adapted “Lean Principles” from Toyota, with the goal of eliminating waste and delivering the care patients need on time, every time, without errors. So where nurses once bounced from one end of long hallways to the other, responding to patient call lights, they now care for patients in rooms organized in a U-shaped cell, minimizing walking.
In addition, morning rounds in the two units are now sequenced to meet all the immediate needs of one patient before moving to the next. Also, nurse-to-nurse patient handoffs during shift changes are scripted to avoid errors, and conducted at the bedside so that patients are involved. The changes have dramatically reduced both waste and health complications for patients.
Harnessing Technology’s Promise
The nursing profession has always been especially sensitive to, and eager for, technological innovation – new and better tools for diagnosing, curing and caring for patients. But the power and reach of new technologies is greatly dependent on how well they fit into the workplace, how well nurses are trained to use them, and how well work flow adapts to the improvements the innovation makes possible.
The current push for increased use of electronic health records (EHRs) makes clear that paper records are headed the way of mercury thermometers. EHRs offer advantages beyond accessibility across institutions, and workplace innovation is beginning to demonstrate the possibilities.
The University of Pittsburgh Medical Center, for example, has put electronic records to use in 22 specially equipped hospital “smart rooms.” In-room sensors detect the presence of a nurse and trigger the display of selected information from the patient’s electronic health record on a bedside monitor, including such information as known allergies and a listing of prescribed medicines, doses, and methods of administration – the information nurses need to provide good, safe care.
“We are trying to give nurses instant access to the information they need, when they need it, so they can take care of their patients,” says Lucy Thompson, R.N., a former ICU nurse and member of the smart rooms design team. “A lot of thought has gone into what not to put on the screen,” she says. The concept grew out of an incident in which a nurse mistakenly wore latex gloves while caring for a patient with a known allergy to rubber. Such information is commonly included in a patient’s medical charts, but designers focused on imagining ways to prominently and quickly display such facts.
From Grocery Store to Hospital Bedside
The universal product codes common on retail products can carry much more information than prices, and the technology is now being deployed in support of the “five rights” of medication administration – making sure that the right patients get the right medication at the right time in the right dose by the right route. The Veterans Health Administration has had a bar code medication administration (BCMA) system in place system-wide for about a decade, in a program that was the brainchild of a nurse. The VA system is not alone; approximately 25 percent of U.S. hospitals equip nurses with handheld devices for scanning bar-coded drug labels and patient wristbands before administering medications.
In addition to getting medications right, the bar code devices also collect data about workflow, and nurses have helped fine-tune hospital systems by putting that data to work. For example, one hospital relied on information from the bar code system to reform its pharmacy cart schedule, ensuring that units had the freshest supplies of medications when they needed them. Nurses also used data gathered via bar code to make the case that Sunday evenings were a bad time for computer system upgrades, because medications needed to be ordered for pre-surgical admissions the following morning. The IT staff rescheduled downtimes to Saturdays in response.
Nursing from a Distance
Another emerging technology involves providing nursing care from a great distance. In New York State, the Visiting Nurse Association of Hudson Valley has developed a telehealth program that essentially provides an extra layer of monitoring for home care patients at high risk of rehospitalization. The agency’s telenurse makes “virtual visits” to patients via webcam, reviewing vital signs and more. Similarly, Sentara Healthcare has developed an “eICU” program – the first in the nation – under which 100 of its intensive care patients at five acute care hospitals in Virginia are electronically monitored from an off-site central command station. The eICU team supplements care delivered by bedside nurses, and has shortened lengths of stay for critical care patients and reduced the rate of ventilator-associated pneumonia.
“To face the health care challenges of the 21st century, we’ll need to harness available technologies in ways that work for patients and the professionals who deliver care,” says Maryjoan D. Ladden, Senior Program Officer at the Robert Wood Johnson Foundation. “It’s not enough simply to develop software and hardware that can keep track of vast quantities of data. We also need workplace systems that put the technology to its best use, and that allow nurses and other medical professionals to do what they do best: care for patients.”
These and other reforms are highlighted in two new publications from the Robert Wood Johnson Foundation. “Case Studies in Transforming Hospital Nursing and Building Cultures of Safety,” and “How Nurses Are Shaping, and Being Shaped by, Health Information Technologies,” are part of RWJF’s Charting Nursing’s Future series, and are available online for free at http://www.rwjf.org/humancapital/product.jsp?id=38074. The publications were researched and written by Spann Communications, LLC (Pittsburgh, PA).
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