EP33EO.   Describe and Demonstrate how the Allocation and/or Reallocation of Resources Improved the Quality of Nursing Care.

Example #1:   Reallocation of Rapid Response Team Resources with the Opening of the New Prentice Women’s Hospital

With the opening of the new Prentice Women’s Hospital early in fiscal year 2008, nurse leaders recognized the need to extend Rapid Response Team (RRT) coverage to Prentice. This change was seen as critical in light of the move of our Oncology Units to Prentice 15 and 16 from the Feinberg Pavilion. As a result of the move, travel time from the Oncology Units to an intensive care unit, all of which are in Feinberg, increased by 10-12 minutes one way.

Nurse leaders involved in the reallocation of resources to ensure the quality of care in Prentice included Michelle Janney, RN, PhD, NEA-BC, our Wood-Prince Family Chief Nurse Executive, Kristin Ramsey, RN, MSN, MPPM, NE-BC, then Director of Operations, and Pat Murphy, RN, MSN, MBA, NEA-BC, Director of Oncology Nursing. To provide the needed coverage for both Prentice and Feinberg 24 hours a day, seven days a week, an additional 4.7 FTES were hired at the cost to the organization of an additional $346,780. An increase in supplemental RN staffing support also was required for several months until the additional RN FTEs could be hired. The total approved budget variance to expand the RRT program to support Prentice in fiscal year 2008 was $562,780. The ongoing program cost for the expanded team was $638,000 in fiscal year 2009.

As part of the new coverage model, one RRT nurse was assigned exclusively to Prentice and one to Feinberg. Handoffs from shift to shift occurred in the assigned Pavilion. Hospital Operations Administrators were expected to provide back up assistance in the event of multiple calls and to solicit back up assistance from an ICU RN in the event of multiple calls requiring immediate assistance.

Key to the success of our RRT model overall is the team’s proactive active approach to code prevention. The team uses Modified Early Warning Scores (MEWS), which are available via our electronic medical record every four hours, to identify patients at risk for clinical deterioration. RRT nurses round on at risk patients, discuss changes in the patient’s condition with the assigned direct care nurse, and intervene as appropriate to avoid any worsening of the patient’s condition. A screenshot of the MEWS is shown below:

Screen Shot of the MEWS in the Electronic Medical Record

Since the implementation of the RRT in Q2 of fiscal year 2006, RRT members have seen 15,870 patients. In addition, as shown in the graph that follows the preventable code rate during the past 12 quarters has decreased 61%.

Preventable Codes Per Patient Days
(Lower is Better)

The RRT has also specifically impacted preventable codes among our vulnerable oncology patient population. Semico Miller, RN, BHA, CCRN, CNRN, one of our RRT nurses, participated on a DMAIC team to address preventable codes on the oncology units. The team developed a new protocol to better assess clinical deterioration among our oncology patients. (More information on this project can be found in NK7 and NK7EO.) The project resulted in an 80% decrease in the preventable code rate in oncology, from 1.66 codes per month to 0.33 codes per month (from 0.60 to 0.15 preventable codes per 100 discharges). The overall code rate dropped 40% from 3.7 per month to 2.2 per month.

Example #2:   Allocation of Resources to Create the Skin Expert Nurse Role

The skin expert nurse role was created in February of 2008 as part of a larger DMAIC project designed to advance Northwestern Memorial’s nosocomial pressure ulcer outcomes. The team realized that the inpatient units would benefit greatly by having unit based experts available to provide coaching and oversight of unit-based skin care practices and pressure ulcer treatment approaches.

A budget of $22,000 was allocated for initial training of registered nurses who were chosen to serve in these roles. Wound and Ostomy Nurses, Connie Kelly, RN, MSN, WOCN and Mary McCarthy, RN, MSN, WOCN, CNS, led a team of staff nurses and APNs to design an intensive 8 hour skin expert training that included two major goals: (1) to train at least two skin expert nurses (SENs) per unit; and (2) to disseminate evidence-based knowledge on the assessment and treatment of pressure ulcers. Topics covered in the courses included skin pathophysiology, pressure ulcer prevention strategies, and treatment options for more severe pressure ulcers.

A total of 62 nurses participated in the training. These nurses were expected to return to their units to share their new knowledge by educating, mentoring, and serving as the “go to person” for all skin care related issues. Specific responsibilities include:

·         Maintaining a skin/pressure ulcer bulletin board or other media and disseminating information about any new skin care or pressure ulcer updates/data on a regular basis

·         Acting as the unit resource for questions about skin care management and pressure ulcer treatments

·         Attending bimonthly skin expert meetings led by Northwestern Memorial’s Wound and Ostomy Nurses to gain new knowledge to take back to their respective units

·         Working with unit leadership on skin care practices and ensure that skin care supplies are available and used appropriately by staff.

·         Attending weekly skin care rounds which include unit staff nurses, patient care technicians, and members of the Skin DMAIC team to discuss the current state of the unit’s pressure ulcer prevalence and to go over high risk patients.

·         Attending unit based root cause analyses when a pressure ulcer “never event” takes place to discuss the patient and assist in developing an action plan

Another key responsibility of the SENs is participating in data collection during our quarterly skin prevalence day. On prevalence day, our skin experts work with our Wound and Ostomy Nurses to do skin assessments on all eligible inpatients and to monitor skin assessments and interventions in the electronic medical record. SENs are provided with time out of staffing to participate in prevalence day and have demonstrated a significant commitment to the success of this quarterly endeavor. The cost of prevalence day is approximately $11,100 per quarter or $44,400 annually.

According to Jena Bruhn, RN, BSN, CMSRN, Clinical Coordinator, 12 East Feinberg, “The training I have received while participating in skin prevalence day has helped me to better assess staging, learn which are the best products and effectively use the resources available. It has also increased my awareness about skin breakdown on my unit and throughout the hospital.”

These sentiments are echoed by another of our skin expert nurses, Margaret Mensing, RN, BSN, CMSRN, Staff Nurse, 16 West Feinberg, “Being a member of Northwestern Memorial’s skin care team and participating in prevalence day has helped me put a greater focus on wound care and prevention on my unit. Through our skin care board, I keep my co-workers updated on pressure ulcer treatments, prevention measures, and appropriate charting. We have begun identifying patients at risk for skin breakdown during our safety huddles. My co-workers regularly come to me with questions about wound staging and treatment recommendations. This experience has inspired me to pursue my WOCN certification in the future.”

We believe that the resources allocated to the skin expert role are one of the key factors that have driven improvements in our nosomocial pressure ulcer rate. A graph that depicts our aggregated progress over the past two years with pressure ulcer reduction across the nursing units that participate in the NDNQI database is shown below. (Unit level data is shown in EP35EO.)

Hospitalwide Aggregated Pressure Ulcer Prevalence