Provider Focus

June 2015

UnityPoint Health – Des Moines

Doctor Communication:

Quint Studer, former hospital CEO who owns a very successful organization called The Studer Group has co - written a great book called “The HCAHPS Handbook”. In Section Two: “Doctor Communication”, Quint takes three questions on our patient satisfaction surveyand divides them into 3 chapters:

1. During this hospital stay, how often did doctors treat you with courtesy and respect?

2. During this hospital stay, how often did doctors listen carefully to you?

We will focus on the third HCAHPS question in this issue:

3. During this hospital stay, how often did doctors explain things in a way you could understand?

To achieve this goal, physicians need to do 3 things:

  1. Explain the patient’s diagnosis in really clear simplistic terms.
  2. Explain medications to the patient in a way that shares the name of the medication, the purpose of the medication, how long the patient is going to be taking the medication, and what the potential side effects are.
  3. Confirm that the information the patient is provided is helpful and that the patient understands it. Ask, “Is there any more information you need?

…And the tactics that make “ALWAYS” responses more likely=

Tactic 1: Focus on the “E” in AIDET, EXPLANATION.

AIDET is an acronym that represents the framework to effective communication with patients. It has been proven to not only improve the patient experience but also impact more clinical outcomes. Patients are more likely to comply with medications and treatment regimens and follow the recommendations of their care providers. They have less anxiety and better comply with the care plans as outlined in their discharge instructions.

AIDET: A = Acknowledge; I = Introduce; D = Duration; E = Explanation: Providing patients with information on treatment, medications, diagnosis, and therapy options. T - Thank you.

Area 1. Diagnosis: The quality of information patients receive and the level of understanding they have regarding their diagnosis and treatment plan can improve adherence to treatment regimen.

  • Provide diagnosis in a clear order
  • Share the name of the diagnosis
  • Use language the patient understands
  • Let the patient know about diagnostic testing
  • Share the recommendations for treatment
  • Share the clinical course of the diagnosis
  • Share the information several times
  • Provide written information on the diagnosis
  • Ask the patient if they understand
  • Ask for the patient’s partnership

  • Show empathy

Area 2. Medications: How and what a physician says to a patient about a medication can heavily impact the probability that the patient will take the medication properly and completely. Not surprisingly, doing this well will also impact the HCAHPS Communication of Medications composite.

  • Share the name of the medication
  • Share the purpose of the medication
  • Let the patient know the duration of treatment
  • Explain why, if possible let the patient choose
  • Call potential side effects what they are
  • Ask the patient if they understand
  • Create a collaborative environment
  • Give patients a central location for important information, as a folder.

Chikungunya Virus (chic-en-gun-ye)

DID YOU KNOW?

  • This disease is spread by mosquitoes.
  • Four importedcases found in Iowa and many more in our surrounding states.
  • International travel risks are: Parts of Africa, S. Europe, SE. Asia, the Americas and

Islands in the Indian and Pacific Oceans.

  • Chikungunya Virus is now found in the Americas.
  • There have been over 600,000 cases found in the Caribbean and 600 cases in the U.S. in

2014(including both imported and cases locally acquired in Florida).

WHY Should I Be CONCERNED?

  • Chikungunya is transmitted by the same mosquitoes as Dengue Fever and has similar clinical features.
  • Both of these diseases circulate in the same areas and can cause co-infections in the same person.
  • It is important to see your physician and have them evaluate for Dengue Fever if considering Chikungunya.
  • Avoidance of specific meds can improve the outcome of anyone infected with the severe form of Hemorrhagic (bleeding or clotting issues)Dengue Fever.

WHAT SIGNS AND SYMPTOMS OF DISEASE COULD I SEE?

  • Symptoms usually begin 3-7 days after being bitten by an infected mosquito.
  • Common symptoms are fever and severe joint pain, often in the hands and feet.
  • Other findings may include headache, muscle pain, joint swelling, or rash.

You should feel better within a week, most people do. Some people develop longer-term joint pain that can last weeks to months.

  • People at increased risk for severe disease include newborns exposed during delivery, adults (>65 years), and people with high blood pressure, diabetes, or heart disease.

ARE TREATMENTS AVAILABLE TO HELP MANAGE MY SYMPTOMS OF CHIKUNGUNYA?

  • Treatment is symptomatic. No specific antiviral treatment exists for Chikungunya.

  • You may need help in maintaining good hydration ancirculatory status and providing supportive care.
  • Your physician may evaluate for other serious conditions (e.g., Dengue, Malaria, and bacterial infections) and treat or manage appropriately.
  • Acetaminophen has shown helpful for fever and pain. Avoid aspirin and NSAID if your physician is considering a possibility of positive Dengue Fever due to increased risk of bleeding.

Information on Chikungunya and Dengue diseases is available at

Welcome to New Physicians and Providers

Emergency / Plain Language
Red / Fire / Fire Alarm + location + action required
Green / Aggressive Behavior / Safety assistance requested + location + action required
White / Decontamination / Decontamination team needed + location
Bro / Utility Outage / Electrical/Water/Sewer outage + location + action required
Blue / Adult or Pediatric Medical Emergency / Adult/Pediatric medical emergency + location
Pink / Neonatal Medical Emergency / Neonatal medical emergency + location
Tornado/high wind / Tornado/high wind watch or warning / Already plain language

Wait! I don’t see Code Black and Code Yellow on this list!

Code Black (bomb threat) and CodeYellow(hostile threat) will remain coded.

Code black response involves staff only, with no need for patients or visitors to take action. In fact, we do not want them taking action in an actual bomb threat for a variety of safety reasons.

Code Yellow (hostile threat) is reserved for those very serious situations where there is an immediate threat on campus, such as an active shooter. In these cases, every attempt will be made to provide you with accurate, timely information as we know it. By keeping the Code Yellow option, we have more opportunities for future drilling without unduly alarming patients and visitors.

What if I have additional questions or concerns?

We realize that this transition may prompt additional concerns or questions. Please do not hesitate to contact Scott Draper at 515-241-8377 or send an e-mail

Directions in Quality: ISO Audits Completed at UPHDM During 2014

By Jan Freese, Accreditation Specialist

DNV-accredited hospitals are required to do internal audits of key processes defined by the hospitals. Here are the results from 2014 ISO audits at UPH-DM.

Key Process & Campus / Noteworthy efforts / Corrective action needed/Opportunity for improvement
Lock-out/Tag-out (LOTO) = control of hazardous energy-IMMC, ILH /
  • Documentation of LOTO was very good.
  • LOTO tag & logss are readily available & used
  • LOTO training is provided by 3 trainers: Ivan Wooster, John Green, & Tim Neal
  • Applicable departments use a Hiring for Success checklist, NetLearning modules & extensive training for new hires
  • Contractors LOTO requirements are included in bid packets.
/
  • New LOTO procedure for chiller & air handling unit was written & approved 1/22/2015.
  • Clinical Engineering started using the Facilities log for LOTO.

Pre-op histories and physicals (H&Ps) for outpatient surgery- IMMC /
  • Surgery registration board & scheduling board are synchronized by updates from scheduling desk, so families can be informed via a pager where patient is in the surgical process.
  • There are multiple checks for H&Ps during the intake process 3 days prior to scheduled surgeries
/
  • Some interval H&P notes are not charted prior to patient’s arrival at hospital.
  • Scheduling icons have to be manually turned off by surgical RN
  • Since enforcement of H&P policy, some surgical cases are still missing H&P and/or interval note.
  • Process gap was identified between Pre-op and O.R. about who is responsible for follow-up on day of surgery

Advance Directives (A.D.)- ILH & IMMC /
  • Good documentation on surgical patients
  • Daily parameters report at nurses’ station is color-coded to quickly identify status of patient’s advance directives
/
  • Confusing wording on Survey Monkey tool was reworded for clarity
  • Nursing Standards & Practice Committee & Documentation Standards Committee will review documentation expectations in policy #004 to assure consistency with Epic & staff workflow.
  • Staff need to document attempts to obtain AD by second business day

Nursing Care Plans – ILH & IMMC /
  • New employees work with preceptors on care plan elements, using focused follow-up on charting in Epic.
  • Care plans were updated when patient condition changed.
  • Care plan family conference is done within 72 hours after rehab admission.
  • 99% of care plans initiated within 24 hours of admission
/
  • Continue auditing on specific nursing units for more improvement: Need to document in Epic that care plan was reviewed/updated with RN change
  • Continue auditing for more improvement on specific nursing units. Include pre-existing conditions and comorbid conditions that are being treated
  • Need additional detailed care plan training for staff.
  • Request additional choices on some Epic templates (eg. Ortho) if template can be changed

Infection Prevention: What’s the Deal with CRE?

By Molly Hall, Drake University, SR Student Health Science

  • CRE stands for a bacteria: Carbapenem (broadspectrum antibiotic) resistant Enterobacteriaceae
  • These bacteria are found in the gut and are resistant to most antibiotics
  • Infections with CRE can be very difficult to treat and can be deadly
  • CRE is typically spread through contact with an infected or colonized person (occurs when a microorganism is found on or in a person without causing a disease), mainly through contact with stool or wounds
  • CRE have also been spread through ERCP (endoscopic retrograde cholangio-

pancreatography) procedures

  • An ERCP procedure involves the use of a specialized endoscope called a

Duodenoscope. It is inserted into the mouth and down into the intestine in order to

access the biliary (gallbladder and/or bile ducts) or pancreatic ducts

  • Duodenoscopes are unique from other endoscopes because they contain an

“elevator”channel that can change the angle of the scope

  • This “elevator” channel makes cleaning and reprocessing duodenoscopes a greater

challenge

  • Meticulous attention to detail must be followed when cleaning these scopes

At UPHDM we have implemented a multi-step safety plan in response to recent CRE outbreak reports associated with ERCPs:

Patients who are undergoing duodenoscope procedures will be informed that

there is a risk of patient-to-patient bacterial transmission as part of the consent

process.

All staff who reprocess endoscopes undergo regular competency assessment

In March 2015 all staff involved in reprocessing were re-educated and

demonstrated competency according to manufacturer recommendations

A plan to evaluate effectiveness of our scopes reprocessing is currently underway

No duodenoscope related infections have been identified at UPHDM.

All measures are being implemented to minimize the risk of CRE

or any infection associated with ERCP scopes.

Quality in Motion: RL Solutions Monthly Featured Forms

By Janice McCullough, Clinical Quality

Keep watching for the Monthly Featured Form in Quality in Action. Each month, you will be provided with information about a specific form in the RL Solutions Event and Feedback program. This month’s forms:

Adaptive Design - Solving Problems & Improving Patient Care:

My Nurse Didn’t Know About My Status Post-Op

By Nurse Residency Project – Younker 7

Current State: Ideally my nurse would have known my status before returning to Younker 7, but this time nurse was unaware.

  • PACU nurse gives telephone report to floor nurse.
  • There is no specific format or protocol for what is to be included in telephone report.
  • Typically, the PACU nurse states meds given during procedure, (i.e. fentanyl & versed), the latest set of vitals, and any new LDA (lines, devices, access).
  • PACU nurse calls patient transport to transfer patient back to floor.

Questions Raised:

  • Is there a standard post-op report that PACU follows?
  • What do PACU nurses typically include in telephone report?
  • Is there a better way to communicate directly from PACU to floor RN?
  • How can we make the transfer from PACU to the floor SAFER for the patient?

Assumption(s):

  • Floor RN
  • No narcotics had been administered since report was given from PACU RN
  • PACU nurse would call floor RN if there had been changes since telephone report
  • PACU RN
  • Patient would be stable during transport
  • Floor RN could see MAR for additional narcotics administered.

Problem Statement: My nurse did not know my current status before I returned to Younker 7.

5 Why’s:

Why:Pain medications that I received in PACU were not communicated to the Younker 7 nurse.

Why:An updated report was not called before my transfer to Younker 7.

Why:No one identified that additional communication was needed.

Why:There is no standard process between the PACU and admitting unit for when to call report or what should be included in report.

Ideal State: Ideally, my nurse would have known my current status before returning to Younker 7.

  • Changes in patient condition will be identified in PACU before sending to floor after medication administration.
  • PACU nurse will call the floor nurse to state that multiple IV narcotic doses had been administered prior to transport.
  • PACU RN and Floor RN will have a clear line of communication for nurse to nurse report.

Countermeasures:

  • Floor nurses went to PACU and spoke with several nurses regarding report process
  • Collaborate with PACU AD team to formulate a list of “must have” items for report
  • Patient identification and procedure completed, i.e., endoscopy, colonoscopy, paracentesis
  • Vital signs: Current vitals & sedation level; during the procedure were there any vital signs that were abnormal
  • Medications: Sedative, pain medications, cardiac meds
  • Fluid gain/loss: how much was removed during a paracentesis?
  • New LDAs: JP drain, incision, pressure dressing, etc.
  • ASCOM telephone number for any changes or questions after initial telephone report.
  • PACU discussed signal at their unit meeting in December
  • Update: Decided that when getting/giving report floor nurse will share with PCU nurse their ASCOM phone numbers to eliminate going through unit clerk.

Outcomes:

ACT  the only option is safety

  • Increase the detail in PACU report to floor nurse
  • Floor nurses encouraged to ASK as many questions as possible concerning any new LDA, change in status, and patient condition.
  • PACU nurse encouraged to CALL ASCOM phone in order to TALK to floor RN about any additional meds or changes in condition since original telephone report has been called.

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