In addition, the hospital will use the devices to record conversations between patients and members of the patient financial services department. The financial services staff often makes bedside visits to explain payment options. These recordings will be used solely for quality improvement purposes-with department managers reviewing the interactions-and not be part of the patient's post-discharge Web site. The goal, says Bailey, is to ensure that finance staff are "communicating appropriately with patients."
So far, the patient response to the service has been positive-with an improvement in satisfaction scores on the topic of clear communications. The hospital also witnessed a 7 percent drop in readmissions in Burks' step-down unit after six months of deployment. That came as no surprise, says Jim Weidner, CEO. "Many times readmissions are caused by patients not following instructions," he says. "We're seeing fewer complications." Other benefits did surprise the hospital, the CEO adds. "There is a psychological impact at discharge. When the nurse says, 'I will record our conversation,' patients tend to pay more attention." And the tool has helped with quality reviews by nurse executives, he says. Now, nursing leaders listen to the discharge sessions and give feedback to their staff.
Nurses also have a back-up when physicians complain about readmissions. Bailey recounts the story of one disgruntled physician who pinned a readmission to improper discharge planning. "The physician told me how nurse the told the patient to do the wrong things, which the patient did and was readmitted," she recalls. Bailey retrieved the recording. "The nurse was spot on. Everything she told the patient was correct. I went back to the physician and offered to let him listen. He said that wouldn't be necessary."
Texas Health Resources
Location: Arlington, Texas
Size: 14-hospital health system
I.T. Project: Urinary tract infection prevention
Catheter-associated urinary tract infection is a condition that is relatively easy to prevent-removing the catheter within two days greatly reduces the chance of infection, according to medical literature. But acting on that well-established principle is not necessarily easy, particularly in a complex inpatient setting. Texas Health Resources tackled the problem by modifying its order entry system, gaining physician buy-in to a new role for nurses, and then empowering nurses to remove catheters when medically appropriate. Within 90 days post go-live of the set-up in early December 2011, THR saw a 26 percent decrease in catheter-line days-a measure of average duration of catheter insertion. Its incidence of infection is below national averages. And the hospital is now sidestepping financial penalties from CMS, which deems the condition as preventable and will not pay for its treatment as part of the admission.
Texas Health runs an enterprise EHR from Epic, which spans inpatient, ambulatory, pharmacy, anesthesia, the OR, and multiple other departments, so it's no rookie with information technology. But as Mary Beth Mitchell, chief nursing informatics officer, points out, the EHR is only as valuable as its embedded clinical decision support tools. "That is the critical piece that impacts care," says Mitchell, one of seven nurses who led the project. And the UTI prevention effort falls squarely into the decision support fold. Catheter insertion, says Mitchell, is "an easy procedure. The nurse puts it in and takes it out. But that requires a physician order."
And establishing new workflows around those orders was the heart and soul of Texas Health Resources' project. Patients typically get catheters when they are in medical-surgery units, says Ellen Batch, R.N., applications system analyst, who helped redesign the EHR around the new workflows. But Mitchell notes that the procedure falls to background once surgery is over. "The catheter gets put in during surgery and then gets forgotten. It's not top of mind to remove it. The longer it stays in, the more the risk of infection increases."
Prior to the project, only a handful of Texas Health hospitals compiled catheter-related statistics. "We tracked infections, but not consistently," says Mitchell. Now, the EHR can generate data showing when catheters are inserted, when they are removed, and how related guidelines are applied. But getting there was not easy. The project, Mitchell says, required a high degree of interdisciplinary collaboration. "Physicians, nursing, quality and analysts-no one group alone could have done this," she says, ticking off a list of the departments involved.
Here's how the set-up works: When a physician wants to order a catheter insertion in the EHR, the order entry system pops up two possibilities. The first is straightforward order to insert the catheter. Another order gives a second option: discontinue (or remove) per protocol within 48 hours. In the second case, the order empowers the nurse to remove the catheter if all the medical requirements are met. That removal might happen within a few hours. Even if the doctor skips the discontinue order, nurses still go in and review the catheter insertion against clinical guidelines. They will call the physician if removal is warranted.
Some patients, says Batch, have legitimate reasons for leaving a catheter in. "If you are monitoring urine output, you need to leave it in," she says. Batch played a key role in reconfiguring the order entry system to accommodate the discontinue-per-protocol order. She led a group of four I.T. application builders, who are also nurses. The task was exhaustive: the group had to rewrite and test changes to more than 1,600 order sets. That's because a catheter insertion order is usually embedded in order sets tackling a much broader range of procedures and conditions, such has open heart surgery and pneumonia. "We identified the order sets which had 'insert foley' and replaced with a combined order/discontinue protocol," Batch says.
To streamline the build, Texas Health used Sharepoint, from Microsoft. The I.T. department used the document sharing tool to create a worklist and dashboard for the department, Batch says. Using Sharepoint, she could monitor progress on the order set builds-a task which was divvied out among the nurses-and also track queries and comments from physicians.