- Email: [email protected]
10. Improving pain management in hospitalized heart failure patients
426
h e a r t & l u n g 4 1 ( 2 0 1 2 ) 4 2 1 e4 3 4
year following ICD implant. These patients should be monitored for any significant weight gain, new edema, ascites and liver congestion, and need to be advised about the added significance of low sodium diet.
9. Implement goal of the day to improve patient and family centered care S. Frazee, J. Schenck, The Christ Hospital, Cincinnati, OH Background: Despite advancements in healthcare and the use of evidence-based practice, we often fail to completely meet patients’ and families’ needs. These needs are related to personalizing care by taking care guidelines and incorporating their desires or goals. We demonstrate respect, build trust, increase satisfaction, and deliver Patient and Family Centered Care (PFCC) by integrating their goals into the daily plan of care. Heart failure patients face unique challenges as their goals may include basic needs, such as, “I want to do my am care without becoming so short of breath”. Staff would then assist the patient in achieving this goal. Our manager attended a PFCC conference that included poignant patient testimonials about their good/bad hospital experiences. Former patients conveyed a message of increased satisfaction, which was directly linked to when consideration was given to their thoughts and feelings as they were included as an active and integral part of the health care team. These patients and their families then believed that they were acknowledged as individuals capable of positively affecting their own recovery. Inspired by their stories, he brought this idea to unit council, which helped to institute GOTD in our 28 bed telemetry unit at a tertiary care, Magnet hospital. The purpose of this project was to institute Goal of the Day (GOTD), monitor outcomes, and increase patient/ family satisfaction. Methods: Implementing GOTD began with staff education about PFCC and meeting patient expectations and goals. At unit meetings attended by all disciplines, a core group of trained staff presented PFCC principles, benefits, and provided examples of GOTD from evidence-based literature. Nurses asked patients/families every shift for initial or revised goals. Their GOTD was then written on the bedside whiteboard. All disciplines reviewed ‘Goal of the Day’ when entering the room and assisted in achieving that goal. This proactive approach to communication emphasized to all staff what concerns and goals had been identified by the patient/family as priority first. A unit bulletin board was placed in a prominent location for patient/family viewing to explain the purpose of GOTD and how this would guide care. Goals were often associated with self care routines such as “I want to take several rest periods during my am care so that I don’t get so tired and short of breath”. Meeting this goal would call for staff to adjust the plan of care. Results: We used 2 outcomes to evaluate the GOTD program. We did audits of goals written on the whiteboard. The initial rate was 48% but increased to 84% with
many nurses having 100% scores. We also used Press Ganey reports to evaluate patient perceptions of care. Staff addressed emotional needs was 87.5% but increased to 90.2%. Staff included you in decisions rose from 85.7% to 89% and paid attention to special/personal needs improved from 86.7% to 93.5%. Patient satisfaction rate jumped from 87.3% to an astounding 94%. Conclusion: Individual care planning can be combined with achievement of goal of the day to give a meaningful measure of the effectiveness of care. Patient/family satisfaction with care is expected to continue to rise with a house-wide effort to improve daily care planning by incorporating GOTD.
10. Improving pain management in hospitalized heart failure patients S. Frazee, S. Dickey, L. Schneller, G. Robison, S. Reed, D. Menon, K. Weber, The Christ Hospital, Cincinnati, OH
Background: Pain that is poorly managed may have physical and psychological ramifications for the hospitalized patient; including loss of sleep, diminished function, decreased ability or desire to participate in self care, depression, and decreased patient satisfaction. Heart failure patients face unique pain challenges due to possible pain occurring due to ischemia, chest discomfort from heart failure, or chronic or acute pain due to a secondary diagnosis. Ischemic pain is promptly addressed but other pain management is more likely to be delayed. The Joint Commission on Accreditation of Healthcare Organizations (TJC) requires institutions to have a comprehensive pain management performance plan. Better pain management was an organizational goal following a TJC visit and participation in the NDNQI/ University of Utah national research study on pain assessment and management. In this study, inpatients were surveyed on adequacy of pain management. Our 28-bed Heart Failure telemetry unit had improvement opportunities in several areas prompting the need for additional intervention. We wanted to see improvement at the 6 month NDNQI follow-up survey as well as the national benchmark data provided by Press Ganey and HCAHPS patient surveys. Methods: We implemented a staff, patient/family educational program that involved multi-modal, multi-disciplinary strategies to improve pain management. Staff (1) distributed and discussed a Patient Pain Bill of Rights brochure with every patient/family (2) created a unit pain management bulletin board and (3) developed, presented, and filmed a pain management skit, which was used as a training tool for staff, hospital-wide. Nurses encouraged the use of resources, such as offering a pain management booklet, helping the patient use a pain assessment guide that illustrated both numerical and facial rating scales, and offering viewing of a video tape titled ‘Pain Management’.
h e a r t & l u n g 4 1 ( 2 0 1 2 ) 4 2 1 e4 3 4
Results: We used 3 reporting tools: (1) Press Ganey (2) HCAHPS and (3) NDNQI to measure the results of the pain management interventions that were chosen and implemented by our nurses. We compared March/April 2011 with November/December 2011 outcomes. All 3 tools reflected dramatically improved scores that exceeded our goals. The Press Ganey question, “How well your pain was controlled” increased from 88.6% to 94.4% of patients responded always. HCAHPS query of “Was Your Pain Controlled?” improved from 64% to 88% reporting always. NDNQI’s question, “My nurse discussed side effects of pain medication increased from a mean of 3.5 to 5.17 on a scale of 1 to 6. Conclusion: Unit specific interventions designed to increase awareness and knowledge of the issues related to pain management of patients with heart failure were successful. A benefit of the unit specific approach was the involvement of many members of the staff in the design and implementation of the intervention. We continue to use and monitor our interventions and extensive hospital resources to improve patients’ pain experiences and increase patient and family satisfaction.
11. Heart failure core measure analysis project and it’s impact on transitional discharge plans and 30 day readmissions
427
understanding. The Charge nurses worked with staff to assure timely and accurate documentation. The Heart Failure APN developed a documentation tool to identify ACE/ARB in the Heart Failure Discharge Form Staff made the physician follow up appointment prior to patient discharge. Lastly, a data analysis table of the 30 day readmissions rate of patients with heart failure was developed to identify failures in the current process. Measurements: Acute Adult Hospitalizations of 759 patients in the 1st and 2nd Q of 2011.were screened by DRG. All Heart Failure patients were identified for the Bundle documentation Heart Failure Discharge Form. In addition, all HF readmission within 30 days were identified and reviewed for prior discharge diposition. Results: Using the PDSA model, our compliance with the All or None Heart Failure Bundle Documentation was maintained at 100% and our 30 day Heart Failure readmissions rate was 2.6% (10/378) admissions in the first quarter and 3.1% (12/ 386) in the second quarter. Limitations: All HF readmission were not admitted to this unit. Patients were d/c to Multiple HHC and SNF without HF programs. Conclusion: Nurse Management and Education of a Heart Failure Patient with Discharge Plan Transitions is needed within 3 days of Discharge.
12. Creation of a low-salt food bank K. Hermes, M. King, C. Rodriguez, M. Blezien, 9 Medical, Advocate LGH, Park Ridge, IL Background: Heart Failure is among the top five most prevalent diagnoses. The 30 day readmissions of HF patients are costly and a burden the health care system. Nursing staff‘s knowledge base increased thorough understanding of Heart Failure Performance Measures, Outcomes and need for transitional plans and it impact on reimbursement to the organization.Despite the focused on discharge instructions for heart failure with systolic dysfunction, the condition continues to cause readmission hospitalization in the elderly populations. Methods: Objective: The purpose of our project was to maintain 100% compliance in the All or None Heart Failure Bundle Documentation in the electronic medical record as well as reduce 30 day readmissions to the Medical Telemetry Unit. Design: Monitoring DRG and Readmission conducted from January 2011 to June 2011. The Plan- Do-Study -Act (PDSA) Model were used in data analysis for baseline data. Setting: The 500+ Level 1, acute care hospital in a suburban Midwest city. Patients: 759 adults who met eligibility with: systolic dysfunction heart failure and discharge Heart failure coding of DRG 291,292, and 293. Results: Intervention: During a 6-month intervention, nurses counseled patients/families on diet, medications, adherence, and self-management of symptoms upon admission and facilitated instructions at discharge. The teach back method was used to assess
M. Midei, J. Hildebrandt, Heart Failure Clinic, Ephrata Community Hospital, Ephrata, PA Background: Heart failure (HF) causes more elderly hospitalizations than any other disease resulting in over 1 million hospital admissions and up to 6.5 million hospital days annually according to the American Heart Association. It has been proposed that over twothirds of hospitalizations are preventable with 24% attributed to dietary nonadherence. Local food banks (FB) traditionally do not offer low-salt (LS) products. Patients in our outpatient clinic often verbalize frustration not only with adhering to a LS diet but also in finding available LS products. They also report difficulty affording these items and incorporating them into their daily meal plans. Methods: The HF multidisciplinary team (MDT) identified the need to create a low-salt food bank (LSFB) to help HF patients improve dietary adherence to a low-sodium diet. A nutrition ad hoc was formed consisting of an inpatient and outpatient dietitian and CRNP. Initially the objective was to offer the FB to all HF Clinic patients only but not limit access based on financial need. Donations were solicited from an employee food drive. Subsequently donations were received through FB boxes placed in various departments. The LSFB opened in November of 2011. An integral part of the program is the availability of a dietitian who navigates participants through the maze of LS meal planning. In February 2012, ALL patients
h e a r t & l u n g 4 1 ( 2 0 1 2 ) 4 2 1 e4 3 4
year following ICD implant. These patients should be monitored for any significant weight gain, new edema, ascites and liver congestion, and need to be advised about the added significance of low sodium diet.
9. Implement goal of the day to improve patient and family centered care S. Frazee, J. Schenck, The Christ Hospital, Cincinnati, OH Background: Despite advancements in healthcare and the use of evidence-based practice, we often fail to completely meet patients’ and families’ needs. These needs are related to personalizing care by taking care guidelines and incorporating their desires or goals. We demonstrate respect, build trust, increase satisfaction, and deliver Patient and Family Centered Care (PFCC) by integrating their goals into the daily plan of care. Heart failure patients face unique challenges as their goals may include basic needs, such as, “I want to do my am care without becoming so short of breath”. Staff would then assist the patient in achieving this goal. Our manager attended a PFCC conference that included poignant patient testimonials about their good/bad hospital experiences. Former patients conveyed a message of increased satisfaction, which was directly linked to when consideration was given to their thoughts and feelings as they were included as an active and integral part of the health care team. These patients and their families then believed that they were acknowledged as individuals capable of positively affecting their own recovery. Inspired by their stories, he brought this idea to unit council, which helped to institute GOTD in our 28 bed telemetry unit at a tertiary care, Magnet hospital. The purpose of this project was to institute Goal of the Day (GOTD), monitor outcomes, and increase patient/ family satisfaction. Methods: Implementing GOTD began with staff education about PFCC and meeting patient expectations and goals. At unit meetings attended by all disciplines, a core group of trained staff presented PFCC principles, benefits, and provided examples of GOTD from evidence-based literature. Nurses asked patients/families every shift for initial or revised goals. Their GOTD was then written on the bedside whiteboard. All disciplines reviewed ‘Goal of the Day’ when entering the room and assisted in achieving that goal. This proactive approach to communication emphasized to all staff what concerns and goals had been identified by the patient/family as priority first. A unit bulletin board was placed in a prominent location for patient/family viewing to explain the purpose of GOTD and how this would guide care. Goals were often associated with self care routines such as “I want to take several rest periods during my am care so that I don’t get so tired and short of breath”. Meeting this goal would call for staff to adjust the plan of care. Results: We used 2 outcomes to evaluate the GOTD program. We did audits of goals written on the whiteboard. The initial rate was 48% but increased to 84% with
many nurses having 100% scores. We also used Press Ganey reports to evaluate patient perceptions of care. Staff addressed emotional needs was 87.5% but increased to 90.2%. Staff included you in decisions rose from 85.7% to 89% and paid attention to special/personal needs improved from 86.7% to 93.5%. Patient satisfaction rate jumped from 87.3% to an astounding 94%. Conclusion: Individual care planning can be combined with achievement of goal of the day to give a meaningful measure of the effectiveness of care. Patient/family satisfaction with care is expected to continue to rise with a house-wide effort to improve daily care planning by incorporating GOTD.
10. Improving pain management in hospitalized heart failure patients S. Frazee, S. Dickey, L. Schneller, G. Robison, S. Reed, D. Menon, K. Weber, The Christ Hospital, Cincinnati, OH
Background: Pain that is poorly managed may have physical and psychological ramifications for the hospitalized patient; including loss of sleep, diminished function, decreased ability or desire to participate in self care, depression, and decreased patient satisfaction. Heart failure patients face unique pain challenges due to possible pain occurring due to ischemia, chest discomfort from heart failure, or chronic or acute pain due to a secondary diagnosis. Ischemic pain is promptly addressed but other pain management is more likely to be delayed. The Joint Commission on Accreditation of Healthcare Organizations (TJC) requires institutions to have a comprehensive pain management performance plan. Better pain management was an organizational goal following a TJC visit and participation in the NDNQI/ University of Utah national research study on pain assessment and management. In this study, inpatients were surveyed on adequacy of pain management. Our 28-bed Heart Failure telemetry unit had improvement opportunities in several areas prompting the need for additional intervention. We wanted to see improvement at the 6 month NDNQI follow-up survey as well as the national benchmark data provided by Press Ganey and HCAHPS patient surveys. Methods: We implemented a staff, patient/family educational program that involved multi-modal, multi-disciplinary strategies to improve pain management. Staff (1) distributed and discussed a Patient Pain Bill of Rights brochure with every patient/family (2) created a unit pain management bulletin board and (3) developed, presented, and filmed a pain management skit, which was used as a training tool for staff, hospital-wide. Nurses encouraged the use of resources, such as offering a pain management booklet, helping the patient use a pain assessment guide that illustrated both numerical and facial rating scales, and offering viewing of a video tape titled ‘Pain Management’.
h e a r t & l u n g 4 1 ( 2 0 1 2 ) 4 2 1 e4 3 4
Results: We used 3 reporting tools: (1) Press Ganey (2) HCAHPS and (3) NDNQI to measure the results of the pain management interventions that were chosen and implemented by our nurses. We compared March/April 2011 with November/December 2011 outcomes. All 3 tools reflected dramatically improved scores that exceeded our goals. The Press Ganey question, “How well your pain was controlled” increased from 88.6% to 94.4% of patients responded always. HCAHPS query of “Was Your Pain Controlled?” improved from 64% to 88% reporting always. NDNQI’s question, “My nurse discussed side effects of pain medication increased from a mean of 3.5 to 5.17 on a scale of 1 to 6. Conclusion: Unit specific interventions designed to increase awareness and knowledge of the issues related to pain management of patients with heart failure were successful. A benefit of the unit specific approach was the involvement of many members of the staff in the design and implementation of the intervention. We continue to use and monitor our interventions and extensive hospital resources to improve patients’ pain experiences and increase patient and family satisfaction.
11. Heart failure core measure analysis project and it’s impact on transitional discharge plans and 30 day readmissions
427
understanding. The Charge nurses worked with staff to assure timely and accurate documentation. The Heart Failure APN developed a documentation tool to identify ACE/ARB in the Heart Failure Discharge Form Staff made the physician follow up appointment prior to patient discharge. Lastly, a data analysis table of the 30 day readmissions rate of patients with heart failure was developed to identify failures in the current process. Measurements: Acute Adult Hospitalizations of 759 patients in the 1st and 2nd Q of 2011.were screened by DRG. All Heart Failure patients were identified for the Bundle documentation Heart Failure Discharge Form. In addition, all HF readmission within 30 days were identified and reviewed for prior discharge diposition. Results: Using the PDSA model, our compliance with the All or None Heart Failure Bundle Documentation was maintained at 100% and our 30 day Heart Failure readmissions rate was 2.6% (10/378) admissions in the first quarter and 3.1% (12/ 386) in the second quarter. Limitations: All HF readmission were not admitted to this unit. Patients were d/c to Multiple HHC and SNF without HF programs. Conclusion: Nurse Management and Education of a Heart Failure Patient with Discharge Plan Transitions is needed within 3 days of Discharge.
12. Creation of a low-salt food bank K. Hermes, M. King, C. Rodriguez, M. Blezien, 9 Medical, Advocate LGH, Park Ridge, IL Background: Heart Failure is among the top five most prevalent diagnoses. The 30 day readmissions of HF patients are costly and a burden the health care system. Nursing staff‘s knowledge base increased thorough understanding of Heart Failure Performance Measures, Outcomes and need for transitional plans and it impact on reimbursement to the organization.Despite the focused on discharge instructions for heart failure with systolic dysfunction, the condition continues to cause readmission hospitalization in the elderly populations. Methods: Objective: The purpose of our project was to maintain 100% compliance in the All or None Heart Failure Bundle Documentation in the electronic medical record as well as reduce 30 day readmissions to the Medical Telemetry Unit. Design: Monitoring DRG and Readmission conducted from January 2011 to June 2011. The Plan- Do-Study -Act (PDSA) Model were used in data analysis for baseline data. Setting: The 500+ Level 1, acute care hospital in a suburban Midwest city. Patients: 759 adults who met eligibility with: systolic dysfunction heart failure and discharge Heart failure coding of DRG 291,292, and 293. Results: Intervention: During a 6-month intervention, nurses counseled patients/families on diet, medications, adherence, and self-management of symptoms upon admission and facilitated instructions at discharge. The teach back method was used to assess
M. Midei, J. Hildebrandt, Heart Failure Clinic, Ephrata Community Hospital, Ephrata, PA Background: Heart failure (HF) causes more elderly hospitalizations than any other disease resulting in over 1 million hospital admissions and up to 6.5 million hospital days annually according to the American Heart Association. It has been proposed that over twothirds of hospitalizations are preventable with 24% attributed to dietary nonadherence. Local food banks (FB) traditionally do not offer low-salt (LS) products. Patients in our outpatient clinic often verbalize frustration not only with adhering to a LS diet but also in finding available LS products. They also report difficulty affording these items and incorporating them into their daily meal plans. Methods: The HF multidisciplinary team (MDT) identified the need to create a low-salt food bank (LSFB) to help HF patients improve dietary adherence to a low-sodium diet. A nutrition ad hoc was formed consisting of an inpatient and outpatient dietitian and CRNP. Initially the objective was to offer the FB to all HF Clinic patients only but not limit access based on financial need. Donations were solicited from an employee food drive. Subsequently donations were received through FB boxes placed in various departments. The LSFB opened in November of 2011. An integral part of the program is the availability of a dietitian who navigates participants through the maze of LS meal planning. In February 2012, ALL patients