Most hospitalists see the value in eliminating unnecessary inpatient tests and procedures. But, ironically, implementation of high-value care, whether it's removing catheters or turning off telemetry, can sometimes be too time-consuming.
“Frequently, these [practices] occur because it is often difficult to change processes of care in a busy clinical environment,” said Jerome Leis, MD, MSc, an associate scientist at Sunnybrook Health Sciences Centre in Toronto.
Some hospitals are finding nurses to be in the best position to lead these necessary changes. Hospitalist leaders often take the first step of determining why a change is needed but then partner with nursing staff to put a project into practice.
A nurse's perspective is crucial in the implementation and success of workflow changes in a hospital setting, according to Richard Lindrooth, PhD, professor in the department of health systems, management, and policy at the University of Colorado School of Public Health in Aurora. “It is important that there are clinical nurse representatives in the room when programs are being considered for implementation, calling on those representatives to talk with people who are on the frontline to get their input prior to the decision making,” he said.
A catheter initiative
Eliminating unnecessary urinary catheters is an example of an agreed-upon method to improve both outcomes and cost that's often hard to implement. “Even when urinary catheters are appropriately used initially, they are often left in place for no other reason than that they are difficult to reassess on a daily basis,” said Dr. Leis.
At Sunnybrook, a large academic hospital with over 600 beds, he and his colleagues developed a program that is implemented by nurses to reduce urinary catheter use. The medical directive allows nurses to remove urinary catheters according to prespecified criteria and to provide standardized postcatheter care using an algorithm to detect and manage urinary retention.
Before implementation, project leaders obtained a consensus among all the hospitalists and other physicians that catheter overuse was a problem and needed a solution. A team led discussions about criteria that justify placing a urinary catheter and partnered with nurse leaders to develop the medical directive.
“Nurses have to feel that the change is fully supported by the physicians, that there is good consensus about the criteria for removal of urinary catheters, and that they can feel empowered to do that without a feeling of any disagreement,” Dr. Leis said. “From very early on, we had nurse leaders and nurse educators from the wards who had worked on various drafts of the directive that was eventually piloted for use.”
Hospitalists at Sunnybrook played a leadership role in developing the criteria for appropriateness and, to a large extent, engaging nurses in developing the directive, according to Dr. Leis. “The key issue is ensuring that nurses are active participants in the development of the intervention so that they arrive at the point where they own the intervention,” he said.
When empowered to implement the medical directive, nurses no longer need to spend significant time “chasing down residents” to reassess a patient's urinary catheterization order, Dr. Leis noted.
The change at Sunnybrook resulted in a significant decrease in use of urinary catheters and catheter-associated urinary tract infections (compared to wards that continued with usual practice). Relying on nurses to implement the new policy and protocol resulted in no inappropriate urinary catheter removals, and the directive has now been implemented on all medical wards at the hospital, he said.
At Christiana Care Health System in Delaware, the high-value target was overuse of cardiac telemetry. The health system has one of the largest cardiac telemetry volumes on the East Coast with a capacity to monitor 350 patients outside the ICU. Prior to 2012, there was a perception that the technology was being overused, but efforts to reduce its use had not been successful, according to Robert Dressler, MD, MBA, FACP, quality and safety officer for academic and medical affairs at Christiana.
Telemetry at Christiana is monitored by technicians at an offsite center. The communication link between the offsite monitoring center and the 2 hospitals in the system was suddenly interrupted without warning for a 14-hour period a few years ago, resulting in a “complete inability to communicate into and out of the offsite center. We didn't have enough of the old-style monitors, so people had to triage which patients received a monitor,” Dr. Dressler said. No adverse events or patient complications resulted from the shutdown.
This event prompted an in-depth look at how the hospital was using the technology. An interdisciplinary team of hospitalists, nurses, pharmacists, cardiologists, and others came together “to tease apart all the challenges with our telemetry program,” Dr. Dressler said.
The team redesigned and standardized all cardiac telemetry orders by integrating the American Heart Association practice standards within the electronic ordering system. Guidelines to help nurses assess the need for telemetry were embedded in the system to facilitate safe and timely discontinuation of telemetry. If vital signs and the results of nursing assessment are within certain parameters, the guidelines enable nurses to discontinue the monitoring after a specified time interval based on the patient's diagnosis.
The change led to a sustained 70% reduction in telemetry use and a 47% reduction in the mean duration of monitoring with no increase in adverse outcomes. The annual savings for the health care system is about $4.8 million, Dr. Dressler said.
Physicians and nurses both have key roles in such a project. “Patient success is contingent on that partnership,” said Dr. Dressler. “We had a lot of buy-in from hospitalists and nurses, with good reports that the new protocol provided value, didn't cause harm, and didn't interrupt the clinical workflow.”
He added, “Hospitalists can champion improvements in their hospital's procedures or processes.”
Nurses take the lead
Of course, nurses can be champions, too. Keisha Perrin, RN, at Johns Hopkins Hospital in Baltimore, was the pilot lead on a similar telemetry project. The hospital created a protocol regarding telemetry use outside the ICU and included it in the electronic order entry system.
Physicians must now base an order for monitoring on an indication that meets American Heart Association practice standards, Ms. Perrin explained. Additional electronic interventions are coming later this summer, including automatic clinical decision support for physicians and reminders for nurses to reevaluate patients' need for cardiac monitoring.
“The collaborative effort has made the use of the cardiac monitor decrease overall by approximately 25 hours on average per patient. We were able to decrease the use of monitors by 75%. We are able to turn around those monitors more quickly by identifying patients who do not need the monitor and make it available to others, thereby decreasing ED wait time for a monitored bed,” Ms. Perrin said.
Having a nurse leading the pilot was critical to the success of the initiative. “It is important to empower nurses so that they have a voice and so that they can be acknowledged as having expertise in the subject,” Ms. Perrin said. This type of project takes “dedication, education, encouragement, and a lot of inter-professional teamwork.”
Encouragement came from both nurse and hospitalist leaders. “Collaborative effort of our nursing and physician leaders and unit staff monitoring compliance and applying an electronic smart order set...was important to the success and sustainability of this project,” Ms. Perrin said.