Now, as part of their routine bedside documentation of vital signs and blood pressure in the EHR, nurses will check the catheter removal guidelines-which pop up in their documentation tab-and decide if removal is warranted. "We have seen overall catheter days decrease even if the removal protocol is not ordered," says Mitchell. By May 2012, when physicians ordered a catheter with the discontinue per protocol, the average number of catheter-line days fell to 1.41-about half of what it was prior to go-live. When physicians ordered a catheter with no protocol, the line days still fell to 1.88.
Batch says the group considered activating an alert feature in Epic to remind nurses about doing a catheter removal assessment. But when it began the project in early Feb. 2011, the alert feature was not fully developed in the EHR, so they held off. "Nurses are compliant and doctors are using the discontinue order without the alert," says Batch. "That will reduce alert fatigue."
Mitchell, the CNIO, played a lead role in gaining physician acceptance of the new workflow. The medical executive committees at each of the 14 hospitals had to agree to turn over the catheter removal decision to the nurses. "It is a nurse-driven protocol, but physician-initiated," Batch says. "There were a lot of moving parts."
Bronze Prize
University of Pennsylvania Health System
Location: Philadelphia
Size: 1,700 beds across three hospitals
IT Project: Nurse-driven vaccine protocol
U-Penn's project was driven by recent regulations from CMS that call for all patients discharged from acute inpatient facilities to be assessed for, and offered, vaccines for flu and pneumonia. The new measures took effect Jan. 1, 2012, and the academic medical center-also known as Penn Medicine-sprang into action, forming in February a multi-disciplinary team to tackle the problem. The new protocol was activated in late August and resulted in a more streamlined workflow. The project led to both a reduction in inappropriate vaccine orders being fired and ultimately, more vaccines being administered. Nearly 90 percent of patients are now assessed, thanks to modifications in the order entry workflow.
In play are two key EHRs. U-Penn runs an inpatient system, from Allscripts, where all orders originate. In addition, its ambulatory outpatient practices run on Epic. To tackle the vaccination issue, U-Penn charged Terese Kornet, R.N., with convening a disparate group of 35 individuals to map previous vaccine administration workflows. Kornet, the director of nursing systems at the Hospital of the University of Pennsylvania, served as project champion along with Denise Gilanelli, R.N., director of nursing systems at Penn Presbyterian Medical Center, and Mary McCann, R.N., director of informatics at Pennsylvania Hospital.
"We brought in staff from nursing, medicine, pharmacy, quality, data collections and I.T.," says Kornet. "The three hospitals had different workflows, so we had to gain consensus on how the admission order screens should appear and work."
The result? The multi-disciplinary group identified 43 barriers to improvement in the way the health system handled vaccines. "We walked through all the workflows," recalls Christine Vanzandbergen, clinical decision support officer.
The multitude of barriers uncovered for such a seemingly innocuous task did not surprise Kornet. As soon as she got wind of the new regulations, she began reaching out to colleagues. "I was hearing of the challenges from the nursing staff," she says. In its old workflow, vaccine orders were part of the overall admitting order entered by physicians. If a physician did not know if the patient needed a vaccination, they would document the fact in the EHR. But the system was configured to turn that into an order-one without a scheduled time. "That led to confusion among the nurses," says Kornet.
It also led to proliferation of orders, many of which proved to be superfluous-within three months after the new system was rolled out, the number of orders were reduced by about 50 percent. At the same time, there was a 109 percent increase in pneumonia vaccine administration and a 290 percent increase in flu vaccine administration.
Obtaining those numbers required hands-on design work by a core group of nurses in the I.T. department. The project team set about devising changes to the order entry system and clinician workflows around it. The admission order entry was modified. Now, the standard admitting order defaults to a follow-up order for the nurses to conduct a vaccine assessment. Unless the physician overrides the default-for a patient he wants to self-assess-the nurse will follow through and conduct the assessment. To support the nursing assessment, the EHR was modified to include administration guidelines and reminders for the vaccines. Via interface with the ambulatory EHR, the Allscripts system will detect outpatient vaccine administration.
If a patient already has had both a flu and pneumonia vaccine, the set-up will automatically update the nursing assessment form, giving the dates of the vaccines. The vaccines will be included in the EHR admission summary and the nurse will receive no assessment task. If only one of the vaccines was previously given, that too will be noted and the task will be presented an assessment form documenting which vaccine needs to be considered. The interface, Kornet says, "was a huge win. If the EHR indicated a patient had a documented vaccine, the assessment was completed." There were other criteria built into the nursing assessment task list to assure that patients who should avoid getting a vaccine were sidestepped.
Nurses played a key role in tweaking the order system. Mika Epps, R.N., lead clinical analyst, served as I.T. developer along with David Stabile, R.N., senior clinical analyst. "We tried to fit the build into the nursing workflow," says Epps.
If the nurse determines that the patient needs a vaccine, she will first gain patient consent. If the patient says yes, the nurse denotes the need in a medication task list, and the order goes to pharmacy. Pharmacy later schedules a time for administration in Allscripts. The EHR now highlights a message in a red box if the administration is overdue. "The red box is a fail-safe," says Kornet.
