At discharge, patients typically have one thing on their mind: getting home. "At discharge, nursing is the only thing standing between the patient and the door," says Cheryl Bailey, R.N., Cullman's chief nursing officer who served as manager of the discharge summary project. "There is so much information given to the patient and the family. It can be overwhelming. Patients were not listening, did not understand or were afraid to ask questions. Patients get home and they might say to the family, 'they made some medication changes,' but they don't remember them."
Cullman's bedside patient discharge process was time-honored. Responding to the physician's discharge order, a nurse would gather up all the information a patient needed, such as a to-do list for follow-up visits, instructions for current medications and any new prescriptions that needed to be filled and would review the documents at bedside. Nurses also handed out pre-printed instructions on various mediations. The patients would listen, sign a copy and take another copy home. Even though the interaction is typically not long-three minutes on average-patients often underestimated its importance, adds Paula Burks, R.N., director of critical care. "You would be surprised at the number of patients who actually toss the instructions into the garbage when they get home," Burks says. "In the shuffle, the instructions get lost. Then all of a sudden the patients realized what was on the paper and they were left with nothing."
To tackle the problem, Cullman turned to one its long-standing software suppliers, Vocera. Cullman has been using Vocera's voice communications badge for eight years, says Burks. It relays voice messages across a wireless network, dispatching communications directly to the nurse and sidestepping overhead paging. Experia Health, a division of Vocera, contacted Burks to see if she had any interest in serving as a guinea pig for a new patient discharge communications product-which later became "Good to Go." Burks describes Cullman as a very tech-friendly environment. "We love technology at this hospital," she enthuses. "We're on the cutting edge. Experia told me about the new product and it seemed easy" so she agreed to becoming a beta site. "If there is something that could benefit us, we will try it."
That was in the summer of 2011. By October, the hospital had gone live with the unit-which the vendor modified in accordance with nurse input from Cullman. Its set-up is simple, and adds no extra time to the discharge process, Burks says. She explains how the process works: Nurses are given an iPod Touch, which resides at a charging station. When it is time to conduct a discharge meeting, the nurse gathers up the typical documents for signing and takes the device to the bedside. Using the iPod, the nurse records the interaction with the patient, including any questions from the patient and their answers. That information is automatically downloaded to a Web site hosted by the vendor and the voice file becomes part of an online package available to the patient.
The iPod Touch has been stripped down of its standard features, such as music downloads, and has no other activated features, says Bailey. "There no music on the device and it can't be used to make calls," she says. The device, however, is interfaced with the hospital's inpatient EHR, from CPSI. The iPod Touch gets an ADT feed from the EHR, and when the nurse logs on, the device will pull in a list of names admitted to the hospital, organized by floor. During the discharge, the nurse goes to her floor, clicks on the patient name and pulls up a discharge template for a given condition, such as CHF. The system will generate a PIN number for the patient to later use to access the recording, a number which the nurse writes down on a preprinted form for the patient. She then records the conversation, and upon completion, the Good to Go system securely dispatches the voice file to its Web site.
As part of the patient's take-home package, they receive the instruction sheet on how to access the Good to Go Web site, which the vendor hosts remotely and which has customized pages for each patient. Patients can also call an 800 number if they just want to listen to the conversation. The Web site-one of the modifications added during the beta development-includes related hospital-produced videos to the discharge condition, and Bailey says the hospital has "just begun to scratch the surface" of adding related content to the patient page. "Think of all the reasons you're admitted. That is a lot of templates to tailor and a lot of videos to complete." Physicians have expressed interest in adding their own video messages to patients, she notes.
During its first phase of the project, Cullman deployed the technology in Burks' "step down unit," reserved for patients who do not qualify as critical care patients, but who still need more attention than a regular unit. These are typically patients with CHF, pneumonia and acute MI, says Bailey. They're also likely candidates for 30-day readmissions. The 31-bed unit is usually full to capacity, Burks says.
Cullman currently deploys the technology in six departments, including its post-op, maternity and one-day surgery departments. The set-up is used for situations other than discharges, as well. For example, respiratory therapists use the devices to record any specialized patient care instructions the patient might need at home. Those recordings become part of the patient's online package. Bailey's next project is linking in nursing homes with the technology. A case manager planning a nursing home stay will record her dialogue with the patient. And the patient's Web site will include related links to the home itself. "The nursing home can dial in as well and hear exactly what our case manager told the patient. Our goal is to improve communications between hospital and nursing home."
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.
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."
University of Pennsylvania Health System
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.
The vast majority of patients now get a vaccine assessment, and if appropriate, a vaccine. About 13 percent of patients still do not get an assessment, a number U-Penn is trying to reduce.
Meet the Nursing I.T. Innovation Award Winners
Cullman (Alabama) Regional Medical Center took first place in the 8th annual 2013 Nursing I.T. Innovation Award contest, which is conducted by Health Data Management. Cullman's winning entry-judged by a panel of nursing informatics experts and Health Data Management staff-used I.T. to improve discharge communications with patients. Runner-up for the Silver prize was Texas Health Resources, whose project tackled catheter-associated urinary tract infections. Winning the Bronze was Penn Medicine, for its nurse-driven vaccine protocol project. The winners were selected from several dozen entries submitted to Health Data Management last fall. Judges evaluated the entries based primarily on the project's demonstrated benefits, nurse role and overall innovation. The award goes to a team of nurses and is open to provider organizations across the industry.
What the Judges Looked For
To enter the contest, contestants prepared an essay of up to 1,250 words answering the following questions:
1. What is the nursing I.T. project that is worthy of recognition?
2. What is the technology involved?
a. For off-the-shelf products, please describe what additional configuration was required to achieve the system functionality associated with the nomination, and the role that nursing played in making configuration decisions.
b. For home-grown products, please describe the role that nursing played in the development of the system functionality associated with this nomination.
3. What is innovative or groundbreaking about the project?
4. What are the measurable results/outcomes of the project? Be as specific and detailed as possible. Examples of results may include: achieving tangible improvements in the quality of care; reducing the time nurses spend on non-care activities by automating tasks; improving workload management through telehealth technologies and other systems; enabling performance improvement through data analytics and reporting.
5. How does the project support quality improvement?
Focus areas may include the Institute of Medicine's Domains of Quality: effectiveness, efficiency, equity, patient-centeredness, safety, and timeliness. Projects may support other federal and regulatory reporting programs, such as meaningful use or Joint Commission requirements.
In addition, the essay described the contribution of nurses to the project and whether a nurse was the project leader, product manager, trainer, implementer or executive sponsor.
Meet the Judges of the 2013 Nursing I.T. Innovation Award Contest
The award recognizes innovation and excellence in using information technology in the field of nursing to directly improve the quality of care and patient safety while maximizing nursing resources, improve the work experience of nurses, or to help further the professional practice of nursing. The award is presented to a team of nursing professionals at a health care organization (hospital, physician group practice or any other care-giving site). At least one of the primary coordinators of the I.T. project must be a nurse. The project must be ongoing.
To qualify for this award, a health care organization must submit an essay with detailed information on the nursing information technology project and the specific, measurable results of that project. The contribution of nurses to the innovative project must be clearly identified.
Following are profiles of the judges:
* The co-founder of the Nursing I.T. Innovation Award, Susan K. Newbold, R.N., is a healthcare informatics consultant and director of the Nursing Informatics Boot Camp, based in Franklin, Tenn. She is a fellow in the American Academy of Nursing and a fellow in the Healthcare Information Management and Systems Society. A pioneer in nursing informatics, Newbold created a nursing informatics review course in 1995, co-edited five books and has written numerous articles on informatics topics.
* Contest co-founder Dana Womack, R.N., is a senior health informaticist in the Health Strategy & Solutions Group at Intel Corporation. Formerly a consultant, she has helped commercial, non-profit and federal entities launch new health I.T. initiatives, and has helped develop and implement applications for point of care use. Womack holds a master's degree in nursing informatics from the University of Utah, and has particular interest in the intersection of data visualization, operational informatics, and healthcare quality.
* Cindy Esser is the director of emerging technologies at Butler Memorial Hospital in Pennsylvania. Responsible for the strategy and identification of new innovative technologies, Esser was the founder and champion of the award winning technology for the 2009 Nursing Information Technology Innovation Award. Prior to working in healthcare technology at both McKesson and Marconi, she formerly served as director of strategic services for Highmark Blue Cross Blue Shield and a manager of healthcare consulting at Deloite.
* Verna Tereceita (Terry) Laidlow, R.N., is a healthcare initiative specialist at Sinai Hospital of Baltimore and an assistant professor at the University of Maryland, School of Nursing in Baltimore. She holds degrees in trauma critical care, nursing education and nursing informatics. She is currently a member of ANIA-CARING. Laidlow was instrumental in implementing an organization-wide, integrated, electronic protocol that won the bronze award in the 2011 Nursing Information Technology Innovation contest.
* Gary Baldwin, the editorial director of Health Data Management, has been covering health care since the early 1990s. Baldwin has won seven national editorial recognition awards from the American Society of Business Publication Editors and the American Society of Healthcare Publication Editors. He earned a masters degree in journalism from Roosevelt University, Chicago.