This Month’s Issue:
Nurse-sensitive indicators con’t
outcome measures in rehab
partners ecare corner
january | 2016
A monthly newsletter from Nursing and Patient Care Services at Brigham and Women’s Hospital
Impacting Malnutrition in Critically Ill Patients Kris Mogensen, MS, RD, LDN, CNSC, team leader and dietitian specialist, Department of Nutrition
alnutrition in hospitalized patients has been recognized as a major problem since the 1970s. There are many causes of malnutrition in this population, including poor appetite as a result of illness or medical therapies, prolonged periods without oral nutrition in preparation for tests and procedures, postoperative complications that affect bowel function, and underlying disease that increase a patient’s need for calories and protein. The Department of Nutrition’s inpatient clinical dietitians conduct rigorous nutrition assessments to identify patients with malnutrition or those at risk for developing malnutrition.
Left to right: Emily Leung, research assistant, Kathleen McIntosh, RN, nurse-in-charge, and Patricia Dykes, PhD, RN, FAAN, Haley nurse scientist, hold up the newly-designed patient-centered fall prevention plan used by nurses and patients.
Nurse-Sensitive Indicators Ensure Quality Patient Care
he Department of Nursing is committed to providing the highest-quality patient care. To accomplish this, nurses track an array of outcomes. “These measures are part of our Professional Practice Model and one of our highest priorities,” said Deb Mulloy, PhD, RN, CNOR, associate chief nurse for Quality and the Center for Nursing Excellence.
Nursing Excellence, quality is all about learning best practices. “Collaboration is important,” said Sipe. “We partner with other health care facilities, national organizations and collaboratives to ensure our interventions are grounded in current evidence to achieve the best outcomes.”
Kris Mogensen, MS, RD, LDN, CNSC, of the Department of Nutrition, has collaborated with Kenneth B. Christopher, MD, of the Renal Division in the Department of Medicine, to evaluate the impact of malnutrition, as assessed by a registered dietitian, on outcomes in critically ill patients.
Mulloy describes the quality practice at BWH as an “improvement science,” whereby evidencebased quality improvement processes are enacted and results are measured and compared to baseline to evaluate whether a change in outcome has occurred as a result. A number of nurse-sensitive quality indicators – called “nurse-sensitive” because they are responsive to nursing care – are routinely assessed. Each one is expertly measured and tracked in a different way.
Preventing falls with injuries is a priority for BWH. Fall data is analyzed and evaluated to identify trends. Based on this analysis, targeted interventions are implemented to continuously improve BWH fall prevention processes.
Approximately 7,700 critically ill patients received a comprehensive nutrition assessment from
According to Margie Sipe, DNP, RN, NEA-BC, program director for quality in the Center for
There are many small-scale studies that identify malnutrition and the negative outcomes associated with it. Results show that malnourished patients have a high risk for infectious complications, poor healing after surgery, longer stays in the hospital and higher death rates than non-malnourished patients. A limitation of these studies is that malnutrition is not identified in the same way in each study and registered dietitians do not always conduct assessments of nutrition status.
At admission, each patient is assessed by a nurse to determine his or her fall risk and risk of injuries from a fall. “A personalized falls care plan is created to address each patient’s specific risk factors,” said Escel Stanghellini, RN, MSN, CPHQ, director of Nursing Quality Programs. Patients are reassessed every eight hours or when there
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Excellent care to patients and families • The best staff • In the safest environment
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Dear Colleagues, “Outcome-focused measures” is the answer to the question, “How do we as caregivers, and the public we collectively serve, know if we are making a difference in advancing health?” We know that busyness on its own doesn’t always equate to better outcomes. More and more of our patients are looking for value, defined as good clinical outcomes combined with their human experience of our care at a cost that is affordable. This value equation is driving us more than ever before to inform our practice with evidence, to enter into risk contracts with our payers that tie reimbursement to quality patient outcomes, and lastly, to share our outcomes publicly so patients and payers can exercise choice. One example is Patients First, a Massachusetts Hospital Association website, where we report our rates on hospital acquired pressure ulcers, falls and falls with injury. Our patient satisfaction scores continue to drive improvements across our organization. This level of transparency continues to drive us to critically evaluate our practice and to stop doing things that do not create or add value. Doing things that keep us busy, because we have “always done it that way,” prevents us from implementing innovative practices that create greater value.
I challenge each of us to reflect on our practice through the lens of our current and prospective patients, families, payers and communities. Outcome-focused measures, which is a part of our Professional Practice Model, helps us keep this in our line of sight. This is exciting work and the right work for us. What brings each of us to Brigham and Women’s Hospital every day is our individual and collective commitment to making a difference in the health and humanity of those who seek our care. This is our privilege. Warm Regards,
Jackie Somerville, PhD, RN Chief Nursing Officer and Senior Vice President of Patient Care Services
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is a change in their status. In collaboration with the inter-professional team, nurses engage the patient and their families during the assessment process as well as in developing an individualized plan of care using the Falls TIPS education poster. To supplement the verbal teaching, nurses may use other tools such as the fall prevention brochure or the fall prevention video. Patients at greatest risk for injuries from a fall are placed on a “fall precaution plus” program, which incorporates a bundled intervention, including increased frequency of rounds and support while toileting, more sensitive bed alarms and medication review. Part of the fall prevention program is the implementation of continuous virtual monitors (CVM). The CVM, a monitoring device placed in patient rooms, allows a specially-trained patient care assistant, working closely with a nurse, to observe and monitor fall and injury prone patients, to potentially prevent them from falling or engaging in harmful behavior. Reducing Pressure Ulcers Once each quarter, a hospital-wide pressure ulcer prevalence survey led by nurses and certified wound care experts (WOCNs) takes place. Nurse teams examine each eligible patient for evidence of pressure ulcers. “Over time, we have implemented many new evidence-based initiatives to decrease pressure ulcer incidence,” said Sipe, citing some examples, including education, careful skin inspection and risk assessment, initiateingsystematic patient re-positioning, replacing heavy linen underpads with thin moisture-wicking pads and purchasing silicon nasal canulas to reduce pressure. “We have seen tremendous improvement in our pressure ulcer rates based on these practice changes.” Monitoring Restraint Use The restraint prevalence survey is conducted at the same time and mirrors
the process of the pressure ulcer prevalence survey. “The teams’ aim is to minimize the use of restraints as much as possible, to reduce agitation, trauma, delirium and skin conditions,” states Mulloy. Over the last 10 years, the hospital has reduced its use of restraints by using alternate measures and evidence based guidelines including early mobilization, Falls TIPS, and the DASH program, . “Past practice was to restrain patients so they wouldn’t fall,” said Stanghellini. “Today, science has taught us to address the underlying etiologies and try to use alternative, less restrictive measures to minimize time in restraints. The reduction in restraint use has not contributed to an increase in falls. In fact, it is better for patients because they experience less adverse events from physical restraints.” The data gathered during the survey is evaluated for accuracy and any trends in contributing factors, and then submitted to National Database of Nurse Quality Indicators (NDNQI). This allows BWH to compare its outcome measures to those of other academic medical centers. Additionally, the data is sent to the Massachusetts Hospital Association (MHA) data base, called PatientCareLink. This data is compared to hospitals of similar size in Massachusetts and can be viewed by the public. Other quality indicators that are monitored and reported at the national level are the incidence of central line infections, sepsis, deep vein thrombosis, catheter-associated urinary tract infections (CAUTI), patient satisfaction, pain and safety during blood transfusions. “This work highlights nursing’s ongoing contributions to improving patient outcomes. In addition, evidence continues to support the importance of an interprofessional team approach to positively impact these challenging patient care issues,” said Mulloy. “This inclusive approach benefits patients.”
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H e art & Sc i enc e
Outcome Measures in Rehab: current and future By Linda Arslanian, PT, DPT, MS, director, Rehabilitation Services
whether or not there has been a measurable change in patients’ baseline functionality over time. How Outcome Measures Are Used These data are captured during the initial evaluation of the patient, where we use impairment tests and measures of functionality. These data help identify underlying causes of impaired functionality and become the basis for our treatment plans as well as establishing the baseline functional status of the patient.
Jessica Meiley, senior orthopedic technician, Laura Engelman, OTR/L, occupational therapist, and Jillian Ng, PT, physical therapist
he use of outcome measures by occupational therapists, physical therapists and speech and language pathologists is at the very foundation of all three professions, which measure human functionality using tests and measures. Types of Outcome Measures Used These metrics fall into two categories: impairment measures and functionality measures. Impairment measures objectively capture data on clinically significant factors, such as strength (manual muscle testing), range of motion (goniometry), gait, cognition, sensation, reflexes and more. These measures may be thought of as the “vital signs” of human movement and functionality. Functional measures objectively quantify functionality (anything related to the human “movement” system), including whether a patient can ambulate and perform activities of daily living. There is a strong relationship between impairment and functional measures, which is the basis for the therapist’s involvement. For example, we know that a person needs at least 120 degrees of knee flexion in order to go up and down stairs, and that there is a direct correlation between decreased strength (manual muscle strength measures) in the legs and an increased risk of falls. Some measures of functionality include tests administered by the therapist, while others are reported in patient surveys (called patient reported outcome measures or PROM). Research efforts to design valid and reliable therapist-administered tests, measures and PROM have increased dramatically, as a result of a shift toward patientfocused care and value-driven payment methodology. Medicare part B requires us to submit codes that identify patients’ baseline functional status, functional goal and final functional status at discharge with claims in order to receive payment for care. Many believe that in the near future, payment will be based on
A physical therapist who sees a patient with a history of increased falls might administer one of a number of valid and reliable tests to quantify risk. The “timed up and go” test is a reliable predictor of risk for falls that can be administered by the therapist. If the score is high, the therapist would take several different impairment measures to determine which are contributing most to increased risk. The parameters with the greatest deficit become the basis for establishing the patient’s treatment plan and are the baseline data we use to measure the patient’s progress. We periodically reassess the patient against baseline measures to determine whether treatment has been effective. This facilitates our ability to adjust care based on changes and ensures that clinical documentation objectively reflects changes in patients’ functionality. While outcome measures are used to manage individual patients, increasingly, we can use these data in aggregate to support clinical improvement initiatives and clinical research. One of our well-known clinical improvement initiatives, care of patients undergoing total knee replacement, established a standardized data set of outcomes and used them to compare the effect of changes in patient management, such as eliminating the use of continuous passive motion machines (CPM) post-operatively and increasing the frequency of physical therapy treatment. Current Challenges and Future Vision Our challenges lie in establishing a standardized set of outcome measures (for a specific diagnosis), gathering the data in a consistent and standardized way, and capturing it in a system that enables clinicians to effectively use it. Our colleagues across Partners have worked hard to identify hundreds of clinical impairment and functional outcome measures that have been “built” into the system. Another challenge is learning how to analyze data across time for an individual patient, or aggregating it for clinical improvement activities and research. In many ways, this is also our greatest opportunity because it will help us more accurately measure the effectiveness and value of our care. We are now pursuing strategies that will facilitate our ability to capture PROM, either with iPads in our ambulatory clinics or by sending surveys to patients through Patient Gateway. In a value-driven health care system, capturing these data is the new imperative.
Learn about several tests and measures that can prognosticate the risk of falls for several different clinical diagnosis here: http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=903
H e art & Sc i enc e
january 2 016
Partners eCare Corner
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Kris Mogensen, MS, RD, LDN, CNSC
BWH dietitians from 2004 to 2011. Malnourished patients were found to have a higher likelihood of many conditions, including sepsis, bloodstream infections, acute kidney injury and death. Patients who survived an intensive care unit (ICU) stay also had higher odds of mortality after discharge from the ICU to the floor or a rehabilitation facility if they had preexisting malnutrition. Malnourished patients who are able to be discharged from the hospital after an ICU stay had higher rates of readmission compared to those patients who were not malnourished upon admission to the ICU.
These important findings emphasize the important work of registered dietitians, who carefully assess the nutritional status of their patients and develop tailored nutrition intervention plans based on presence or absence of malnutrition, underlying disease and appropriate route of feeding.
Magnet® Matters Magnet Conference Takeaways Two nurses recently reflected on their participation in the National Magnet® Conference, held this past fall in Atlanta, Georgia, and shared a few of the “takeaways” they brought back to BWH. Kim Smelstor, MSN, RN, nurse director in Foxborough, noted: “I learned the value of empowering ambulatory nurses with the importance of shared governance, since ambulatory nurses often don’t feel connected to the more commonly known nursing work of the hospital’s main campus, even though these ambulatory nurses are managing practices and engaged in clinical work.” One realization Smelstor came away with from the conference is that ambulatory nurses have their own unique contributions to make on the Magnet® journey, so she has begun to explore strategies such as “lunch & learn” sessions to strengthen ambulatory nurses’ engagement in the application and designation process. Dorothy Bradley, MSN, RN, program director in the Center for Nursing Excellence (CNE), is the third nurse from the CNE to have participated in the National Magnet® Conference. This has led Bradley and her colleagues to ensure that CNE orientation and professional development programs incorporate and reflect Magnet® values and principles, such as structural empowerment and exemplary professional practice. According to Bradley, incorporating concrete examples of exemplary professional practice as essential components of their programs has contributed to a much better understanding of the concepts the CNE attempts to foster and promote.
On Nov. 2, the Surgical, Burn and Trauma Unit staff appeared on the Channel 5 morning news with an EyeOpener greeting filmed on Tower 8.
publisher Jackie Somerville design Johanna Odwara
editorial board Stacey Bukuras, Brian Conley, Mary Lou Etheredge, Kathryn Horne, Yilu Ma, David McMahon and Kathy McManus
In Epic, there are often many different ways to document the same item – and some ways are better than others. A dedicated group of clinical nurse educators, with support from the Nursing Informatics team, are developing a set of PeC Documentation Best Practices to help facilitate and standardize nursing documentation. Electronic nursing documentation has the benefit of making the output of our patient care assessments and interventions more visible in the patient’s record. Standardization of nursing documentation in the electronic health record (EHR) has the added benefit of making the important information nurses document easier for all clinicians to locate and consume. Additionally, it allows nursing as a discipline to evaluate the impact of nursing care interventions on patient outcomes and potentially generate new nursing knowledge. These best practices can be found in the Clinical Practice Manual under the chapter titled “Documentation Best Practices.” Recent additions to this folder include: Intake and Output, Nursing Notes, Drains, Ostomies, Urine, and Stool. If you have any questions regarding the content of the documents please feel free to contact the Nursing Informatics Team at [email protected]
partners.org or your unit based clinical nurse educator.
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