- Email: [email protected]
Using Multidisciplinary Rounds to Improve Patient Safety Through Venous Thromboembolism Prevention Awareness
The Joint Commission Journal on Quality and Patient Safety Tool Tutorial
Using Multidisciplinary Rounds to Improve Patient Safety Through Venous Thromboembolism Prevention Awareness Readers may submit Tool Tutorial inquiries and submissions to Steven Berman, [email protected].
Beth Karasin, MSN, APN, AGACNP-BC, RNFA, CNOR; Christina Maund, MS, RN, CPHQ
D
eep vein thrombosis (DVT) occurs in 10% to 40% of hospitalized patients who do not receive prophylaxis.1–3 Increases in hospital-acquired DVTs suggest that the current hospital prevention measures are not successful in reducing this complication despite evidence-based recommendations.4,5 As reported in The Joint Commission’s 2013 Annual Report, fewer than 50% of hospitals—that is, 45.5%—achieved a composite rate of greater than 95% for the five venous thrombo embolism (VTE) accountability measures included in the composite calculation in 2012.6 * Overlook Medical Center (OMC; Summit, New Jersey), a community teaching hospital that is part of one of the largest not-for-profit health care systems in New Jersey, was one of these facilities; its Monthly National Hospital Quality Measures Outcomes Report for the first quarter of 2013 showed VTE core composite compliance at 83.3%. Considering that pharmacologic prophylaxis can reduce a hospitalized patient’s risk of developing a DVT 5–7 by 40% to 60%,1,8,9 compliance with VTE prophylaxis must be improved. Although physician orders of prophylaxis are underused, which contributes to the problem, the OMC performance improvement (PI) staff ’s observations suggested that deeper barriers lie in lack of knowledge and lack of communication. Reeducation regarding the importance of VTE prophylaxis and choosing the appropriate preventative interventions on the basis of patient risk factors need to be emphasized with physicians, nurses, and all health care providers to prevent DVT in hospitalized patients. At OMC, we developed our sit-down, multidisciplinary rounds as a safety tool to integrate VTE prophylaxis into the daily work of the multidisciplinary team on inpatient units. Multidisciplinary rounds are mechanisms through which health care providers from different specialties join together to com* As shown in Table 2. The Joint Commission. Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety 2013. Oak Brook, IL: The Joint Commission, 2013. Accessed Jul 30, 2015. http://www.jointcommission.org /assets/1/6/TJC_Annual_Report_2013.pdf. The 2013 venous thromboembolism (VTE) care result was 50.7%. The VTE composite includes medicine/treatment, medicine/treatment in ICU, patients with overlap therapy, patients with UFH (unfractionated heparin) monitoring, warfarin discharge instructions.
428
September 2015
municate, coordinate patient care, make joint decisions, and manage responsibilities.10 Multidisciplinary rounds can have different names, such as bedside rounds, sit-down rounds, discharge rounds, daily rounds, or morning rounds, depending on their purpose, the unit on which they take place, location, and time frame.10 Rounds, essential for patient care, education, and communication of daily care plans and long-term goals, often vary in structure.11 The structure and process for rounds support effectiveness. Use of scripts, templates, and checklists, and assignment of follow-up responsibilities, are examples of key components to support effective rounds. For purposes of OMC’s patient safety–focused multidisciplinary rounds, an important structural feature was addition of a PI staff member. We incorporated key process elements featured in multidisciplinary rounds, such as order entry review, medication reconciliation, and review of daily goals, and encouraged closed-loop communication. In this article, we describe the development and use of multidisciplinary rounds to improve patient safety through awareness of accountability measures, with a priority focus on VTE.
Tool Development
In 2009 multidisciplinary rounds began on all inpatient units, but it wasn’t until April 2013, at the PI manager’s request, that the PI team—which consisted of coordinators and the manager at OMC—took on the challenge of improving compliance with the five VTE accountability measures,12 shown in Sidebar 1 (page 429). This initiative was consistent with our model of tightly integrating PI staff with assigned departments to address multiple quality components, including standards compliance, patient safety, and priority improvement initiatives. OMC was seeking ways to integrate the right care for every patient every time into the daily work of the nurses and licensed independent practitioners. The initial step was the collection of baseline data from a 45-bed cardiac telemetry unit to evaluate the current compliance regarding VTE risk assessment, prophylaxis orders, and patient education. This unit was chosen because of Volume 41 Number 9
Copyright 2015 The Joint Commission
The Joint Commission Journal on Quality and Patient Safety Sidebar 1. Venous Thromboembolism (VTE) National Hospital Quality Measures Set* Measure ID
Measure Short Name
VTE-1
Venous Thromboembolism Prophylaxis
VTE-2
Intensive Care Unit Venous Thromboembolism Prophylaxis
VTE-3
Venous Thromboembolism Patients with Anticoagulation Overlap Therapy
VTE-4
Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram
VTE-5
Venous Thromboembolism Warfarin Therapy Discharge Instructions
VTE-6
Hospital Acquired Potentially-Preventable Venous Thromboembolism
ID, identification. * VTE-1 through VTE-5 have been designed as accountability measures. Source: The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures, v4.2b (applicable for discharges 1/1/2013–12/31/2013). Accessed Sep 17, 2014. http://www.jointcommission.org/specifications_manual _for_national_hospital_inpatient_quality_measures.aspx.
the nature of the patient population and decreased compliance rates, as evidenced by VTE chart abstraction findings. VTE prophylaxis was the initial focus, which then extended to all six VTE measures12* because of the unit’s inability to reach 100% compliance. No Institutional Review Board approval was needed because the initiative was identified and initiated by the PI department. The baseline data collection, which was completed on April 15, 2013, addressed patient identifiers, admitting physician, VTE prophylaxis order, date and time of order, type of prophylaxis ordered, mechanical prophylaxis ordered and compliance with the order, contraindications to VTE prophylaxis, patient education on prophylaxis, and the nurse caring for the patient on the date of data collection. On the basis of these data, as well as our review and analysis of the VTE core measure data, we were able to identify the cardiac telemetry unit as a priority. The collection of data continued until May 22, 2013, which a member of the PI team [B.K.] undertook once a week for all patients on this unit. After the baseline data were collected, the PI team member joined multidisciplinary rounds with the goals of achieving 100% compliance with VTE accountability measures (Sidebar 1) and of transforming multidisciplinary rounds into a broader * The current version is as follows: The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures, v4.4. 2015. Accessed Aug 5, 2015. http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx.
September 2015
Sidebar 2. Standard Questions Regarding Venous Thombroembolism (VTE) Is VTE prophylaxis ordered? Is it chemical, mechanical, or both? If chemical, is the patient receiving it or refusing it? If patient refused, why, and is the attending physician aware? If mechanical, are they applied? Is VTE prophylaxis properly documented? Is patient educated on VTE, and is it documented? Are there any contraindications to receiving VTE?
patient safety tool. The data collection form, which was initially developed to focus on improving VTE prophylaxis, was used as a guide when each nurse was asked if his or her patient has a VTE prophylaxis order; whether the prophylaxis is chemical, mechanical, or both; and whether there are any patient contraindications. If no order existed, the nurse was then encouraged to follow up with the physician or licensed independent practitioner.
Tool Description
Multidisciplinary rounds occur daily on each patient care unit. Participants include social workers, case managers, nurses, educators, dietitians, pharmacists, a licensed independent practitioner, and other personnel involved in patient care. These rounds review each patient, discussing the patient’s diagnosis, pending lab work, tests, medications, the issues or concerns, as well as patient disposition. Each nurse reviews key elements of his or her patient’s plan of care. Rounds last approximately 1 hour, depending on the census for the day, with staff rotating for 5 to 10 minutes to address their patients. The evolution of the rounds as a patient safety tool began with specific discussion of VTE risk and related prophylaxis as overall safety priorities as well as on a patient-specific level, as follows: What was the patient’s risk and was appropriate prophylaxis in place? If not, what steps would be taken NOW to address and provide appropriate prophylaxis?
How-To
The PI team attended these multidisciplinary rounds on a d aily basis for approximately two months (April 15, 2013–May 22, 2013), during which they prompted discussions on the VTE accountability measures as each nurse gave report on his or her patients. Each week the data were collected and compared to those of the previous week. During the meeting, the PI team member asks a standard list of questions (Sidebar 2, above) and uses a standardized tool (Appendix 1, available in online article) to collect information to Volume 41 Number 9
Copyright 2015 The Joint Commission
429
The Joint Commission Journal on Quality and Patient Safety Venous Thromboembolism (VTE) Composite Scores, Quarter 1 (January–March) 2013 to Quarter 3 (July–September) 2014 100.00% 80.00% 60.00% 40.00% 20.00% 0.00% Score
1st Qtr 2nd Qtr 3rd Qtr 2013 2013 2013 83.3% 94.3% 98.8%
4th Qtr 2013 100%
1st Qtr 2nd Qtr 3rd Qtr 2014 2014 2014 98.3% 97.7% 99.0%
Figure 1. The integration of the VTE requirements into the daily care of patients through the use of multidisciplinary rounds began on April 15, 2013. The composite VTE score improved to 94.3% by the second quarter (2nd Qtr) of 2013, to 98.8% by the third quarter, and to 100% by the end of 2013, with scores for the first, second, and third quarter of 2014 at > 97%.
help identify potential patient safety issues related to VTE. This approach during multidisciplinary rounds encourages the team to communicate about and assess needs or gaps related to standards of care in a structured way. Interventions identified during rounds that increase patient safety and ensure that expected standards are met, are documented and followed up on the same day. In one scenario entailing a patient-specific question during a multidisciplinary round, a reporting nurse confirms a VTE prophylaxis order for a patient but reports that the patient has refused to comply. The nurse is then encouraged to explore the reason for the refusal and work to address patient concerns. The nurse is advised that if the patient still refuses, then the nurse should reach out to the attending physician to make him or her aware and document the refusal as well as the follow-up with the physician in the patient’s chart. In a scenario in which the reporting nurse confirms that there are no orders for VTE prophylaxis, the PI member encourages the nurse to let the licensed independent practitioner know and ask if he or she would be ordering prophylaxis, and, if not, whether there are any contraindications that could be documented. By asking the appropriate questions, providing education, and reinforcing the role of the nurse as patient advocate, as well as aiding in problem solving and coaching on how to proceed regarding patient safety issues, the PI member can use the multidisciplinary rounds to make an impact on improving patient safety through core measure awareness and directed action. 430
September 2015
Results and Lessons Learned
The baseline data revealed that, for 40 patients, VTE order compliance was at 90% and that patient education documentation was at 44%. OMC’s National Hospital Quality Measures Outcomes Report indicated that the composite VTE score improved to 94.3% by the second quarter of 2013, to 98.8% by the third quarter, and to 100% by the end of 2013; for the first, second, and third quarter of 2014 we have achieved greater than 97% (Figure 1, left). An updated review of the first two quarters of 2015 showed a combined average score of 97.0%. Consistent use of structured communication to integrate VTE requirements into the daily care of patients through the use of multidisciplinary rounds as a safety tool was the key intervention in achieving and sustaining the right care for every patient every time. Direct observation and firsthand experience have indicated that an RN quality department resource person attending unitbased multidisciplinary rounds, providing information and educating nursing on the importance of VTE prophylaxis, and reinforcing the care required while reviewing each patient, not only encouraged patient education but also provided coaching in resolving care issues, encouraged communication, promoted licensed independent practitioner engagement, and underscored the need and responsibility to speak up to increase patient safety. Furthermore, the data collection form used during rounds included a core measure key, effectively showing how the team detected and addressed concerns regarding any identified core measure or patient safety points on a daily basis with every patient. What the PI team learned was that this new approach of using multidisciplinary rounds as a safety tool to improve patient safety through core measure and priority safety initiatives awareness was well received and easily adaptable to target all accountability measures and patient safety issues. Coupled with the success of the pilot period, this awareness has prompted an expansion of this approach to all patient care units. The team now uses this process for multidisciplinary rounds on all patient care floors, for all accountability measures, as well as other priority patient safety issues on a daily basis. The focus was switched to urinary catheters in April 2013. Except for a minor modification to the form, implementation remained the same, with the goal of decreasing indwelling catheter days. When a patient was identified as having a urinary catheter, pertinent questions were asked, and again coaching, promoting communication, and following up on whether or not the catheter was needed were encouraged. Analysis of the 2013 data indicated that the average number of indwelling days had decreased from 235 per month (12.3% of total inpatient Volume 41 Number 9
Copyright 2015 The Joint Commission
The Joint Commission Journal on Quality and Patient Safety urinary catheter days) in the first quarter to 165 per month (10.0%) for the remainder of the year. Another lesson learned by the PI team relates to the initial challenges of multidisciplinary collaboration. Focused discussion regarding VTE prophylaxis initially increased the nursing teams’ report times, but after one to two weeks, the teams came to rounds better prepared. This in turn decreased the time necessary for follow-up questions. Also, with coaching and support to address gaps in care, the nurses quickly demonstrated skill in resolving identified gaps. Initially, licensed independent practitioner’s responses to the nurses’ inquiries and follow-up varied. Although some individual licensed independent practitioners responded with resistance, ours is a teaching facility where learning and questioning are encouraged on all levels. Furthermore, most licensed independent practitioners are aware of the importance of addressing accountability measures and supported the PI initiative. The medical department chairs addressed requirements and the need for compliance with the few physicians who continued to fail to respond to follow up to ensure standards were met.
Summary and Next Steps
Accountability measures are designed to improve patient safety and consistently ensure that standards of care are met. One unit at OMC was frequently failing the VTE accountability measures, which triggered the PI team’s involvement. The team was able to improve VTE accountability measure compliance from 83% to 100% in one year by using multidisciplinary rounds as a safety tool; compliance has been sustained at 97% since. Structured coaching by the PI team on a regular basis to promote the importance of VTE accountability measures made an impact on patient safety through improved communication among the health care team, improved documentation of patient education, and increased use of prophylaxis. This team’s success has led to the use of multidisciplinary rounds to address all accountability measures, as well as key patient safety priorities, throughout multiple units in this facility. The unit-based multidisciplinary rounds tool has evolved to list all the accountability measures and additional patient safety issues as a guide for focused discussion.
Contact Us
For additional information and discussion regarding using multi disciplinary rounds as a safety tool, please contact the author by e-mail ([email protected]). J
Beth Karasin, MSN, APN, AGACNP-BC, RNFA, CNOR, formerly RN member, Performance Improvement Team, Overlook Medical Center/Atlantic Health System (OMC/AHS), Summit, New Jersey, is an Advanced Practice Nurse, Northeast Regional Epilepsy Group, AHS. Christina Maund, MS, RN, CPHQ, is Director, Quality and Outcomes Management, OMC/AHS.
Online Only Content
http://www.ingentaconnect.com/content/jcaho/jcjqs See the online version of this article for Appendix 1. Unit-Based Rounds Tool
References
1. Masica AL, et al. Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence. Proc (Bayl Univ Med Cent). 2009; 22(2):103–111. 2. Anderson FA Jr, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med. 1991;151(5):933–938. 3. Anderson FA Jr, et al. The prevalence of risk factors for venous thromboembolism among hospital patients. Arch Intern Med. 1992;152(8):1660–1664. 4. Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Blood Disorders. Meeting Summary: Prevention of Hospital-Acquired Venous Thromboembolism (HA-VTE) Expert Panel Meeting. Aug 19, 2011. (Updated: Apr 30, 2012.) Accessed Jul 30, 2015. http://www.cdc.gov/ncbddd/dvt/documents/12 _232434-a_sayers_ha-vte_workshop_report_508.pdf. 5. Huang W, et al. Risk-assessment models for predicting venous thromboembolism among hospitalized non-surgical patients: A systematic review. J Thromb Thrombolysis. 2013;35(1):67–80. 6. The Joint Commission. Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety 2013. Oac Brook, IL: The Joint Commission, 2013. Accessed Jul 30, 2015. http://www.jointcommission.org /assets/1/6/TJC_Annual_Report_2013.pdf. 7. Geerts WH, et al.; American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians EvidenceBased Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl): 381S–453S. 8. Samama MM, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients: Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med. 1999 Sep 9;341(11):793–800. 9. Cohen AT, et al. Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: Randomised placebo controlled trial. BMJ. 2006 Feb 11;332(7537):325–329. 10. Gurses AP, Xiao Y. A systematic review of the literature on multidisciplinary rounds to design information technology. J Am Med Inform Assoc. 2006;13(3):267–276. 11. Seigel J, et al. Successful implementation of standardized multidisciplinary bedside rounds, including daily goals, in a pediatric ICU. Jt Comm J Qual Patient Saf. 2014:40(2):83–90. 12. The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures, v4.2b (applicable for discharges 1/1/2013–12/31/2013). Accessed Sep 17, 2014. http://www.jointcommission.org/specifications_manual _for_national_hospital_inpatient_quality_measures.aspx.
The author thanks Robyn Postighone, MPA, RN, for her insight and guidance regarding an earlier version of this manuscript.
September 2015
Volume 41 Number 9
Copyright 2015 The Joint Commission
431
The Joint Commission Journal on Quality and Patient Safety Online Only Content
Appendix 1. Unit-Based Rounds Tool UNIT-BASED ROUNDS TOOL
LOCATION: Patient Name
Overlook Medical Center
Date: Attending/Primary Diagnosis
Issues/Intervention
Other
Key Discussion Topics: Discharge Planning is initiated on admission Patient Education is documented Advance Directive is acknowledged POLST Medication Reconciliation—new meds; education Family/SO participation in care Home Care Physical Therapy F/U MD Appt Potential Safety Issues—Foley Core Measure Compliance: AMI—Beta, ASA, Statin; HF—documented EF, ACE/ARB; PNA—correct ABX; VTE—initiated within 24 hours of admission; SC—ABX and Foley D/C; Immunization—Pneumoccocal and Influenza POLST, physician orders for life-sustaining treatment; SO, significant other; F/U, follow-up; Appt, appointment; AMI, acute myocardial infarction; Beta, Beta-blocker; ASA, acetylsalicylic acid; HF, heart failure; EF, ejection fraction; ACE/ARB. angiotensin-converting enzyme/angiotensin receptor blocker; PNA, pneumonia; ABX, antibiotics; VTE, venous thromboembolism; SCIP, Surgical Care Improvement Project; d/c, discontinued.
September 2015
Volume 41 Number 9
Copyright 2015 The Joint Commission
AP1
Using Multidisciplinary Rounds to Improve Patient Safety Through Venous Thromboembolism Prevention Awareness Readers may submit Tool Tutorial inquiries and submissions to Steven Berman, [email protected].
Beth Karasin, MSN, APN, AGACNP-BC, RNFA, CNOR; Christina Maund, MS, RN, CPHQ
D
eep vein thrombosis (DVT) occurs in 10% to 40% of hospitalized patients who do not receive prophylaxis.1–3 Increases in hospital-acquired DVTs suggest that the current hospital prevention measures are not successful in reducing this complication despite evidence-based recommendations.4,5 As reported in The Joint Commission’s 2013 Annual Report, fewer than 50% of hospitals—that is, 45.5%—achieved a composite rate of greater than 95% for the five venous thrombo embolism (VTE) accountability measures included in the composite calculation in 2012.6 * Overlook Medical Center (OMC; Summit, New Jersey), a community teaching hospital that is part of one of the largest not-for-profit health care systems in New Jersey, was one of these facilities; its Monthly National Hospital Quality Measures Outcomes Report for the first quarter of 2013 showed VTE core composite compliance at 83.3%. Considering that pharmacologic prophylaxis can reduce a hospitalized patient’s risk of developing a DVT 5–7 by 40% to 60%,1,8,9 compliance with VTE prophylaxis must be improved. Although physician orders of prophylaxis are underused, which contributes to the problem, the OMC performance improvement (PI) staff ’s observations suggested that deeper barriers lie in lack of knowledge and lack of communication. Reeducation regarding the importance of VTE prophylaxis and choosing the appropriate preventative interventions on the basis of patient risk factors need to be emphasized with physicians, nurses, and all health care providers to prevent DVT in hospitalized patients. At OMC, we developed our sit-down, multidisciplinary rounds as a safety tool to integrate VTE prophylaxis into the daily work of the multidisciplinary team on inpatient units. Multidisciplinary rounds are mechanisms through which health care providers from different specialties join together to com* As shown in Table 2. The Joint Commission. Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety 2013. Oak Brook, IL: The Joint Commission, 2013. Accessed Jul 30, 2015. http://www.jointcommission.org /assets/1/6/TJC_Annual_Report_2013.pdf. The 2013 venous thromboembolism (VTE) care result was 50.7%. The VTE composite includes medicine/treatment, medicine/treatment in ICU, patients with overlap therapy, patients with UFH (unfractionated heparin) monitoring, warfarin discharge instructions.
428
September 2015
municate, coordinate patient care, make joint decisions, and manage responsibilities.10 Multidisciplinary rounds can have different names, such as bedside rounds, sit-down rounds, discharge rounds, daily rounds, or morning rounds, depending on their purpose, the unit on which they take place, location, and time frame.10 Rounds, essential for patient care, education, and communication of daily care plans and long-term goals, often vary in structure.11 The structure and process for rounds support effectiveness. Use of scripts, templates, and checklists, and assignment of follow-up responsibilities, are examples of key components to support effective rounds. For purposes of OMC’s patient safety–focused multidisciplinary rounds, an important structural feature was addition of a PI staff member. We incorporated key process elements featured in multidisciplinary rounds, such as order entry review, medication reconciliation, and review of daily goals, and encouraged closed-loop communication. In this article, we describe the development and use of multidisciplinary rounds to improve patient safety through awareness of accountability measures, with a priority focus on VTE.
Tool Development
In 2009 multidisciplinary rounds began on all inpatient units, but it wasn’t until April 2013, at the PI manager’s request, that the PI team—which consisted of coordinators and the manager at OMC—took on the challenge of improving compliance with the five VTE accountability measures,12 shown in Sidebar 1 (page 429). This initiative was consistent with our model of tightly integrating PI staff with assigned departments to address multiple quality components, including standards compliance, patient safety, and priority improvement initiatives. OMC was seeking ways to integrate the right care for every patient every time into the daily work of the nurses and licensed independent practitioners. The initial step was the collection of baseline data from a 45-bed cardiac telemetry unit to evaluate the current compliance regarding VTE risk assessment, prophylaxis orders, and patient education. This unit was chosen because of Volume 41 Number 9
Copyright 2015 The Joint Commission
The Joint Commission Journal on Quality and Patient Safety Sidebar 1. Venous Thromboembolism (VTE) National Hospital Quality Measures Set* Measure ID
Measure Short Name
VTE-1
Venous Thromboembolism Prophylaxis
VTE-2
Intensive Care Unit Venous Thromboembolism Prophylaxis
VTE-3
Venous Thromboembolism Patients with Anticoagulation Overlap Therapy
VTE-4
Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram
VTE-5
Venous Thromboembolism Warfarin Therapy Discharge Instructions
VTE-6
Hospital Acquired Potentially-Preventable Venous Thromboembolism
ID, identification. * VTE-1 through VTE-5 have been designed as accountability measures. Source: The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures, v4.2b (applicable for discharges 1/1/2013–12/31/2013). Accessed Sep 17, 2014. http://www.jointcommission.org/specifications_manual _for_national_hospital_inpatient_quality_measures.aspx.
the nature of the patient population and decreased compliance rates, as evidenced by VTE chart abstraction findings. VTE prophylaxis was the initial focus, which then extended to all six VTE measures12* because of the unit’s inability to reach 100% compliance. No Institutional Review Board approval was needed because the initiative was identified and initiated by the PI department. The baseline data collection, which was completed on April 15, 2013, addressed patient identifiers, admitting physician, VTE prophylaxis order, date and time of order, type of prophylaxis ordered, mechanical prophylaxis ordered and compliance with the order, contraindications to VTE prophylaxis, patient education on prophylaxis, and the nurse caring for the patient on the date of data collection. On the basis of these data, as well as our review and analysis of the VTE core measure data, we were able to identify the cardiac telemetry unit as a priority. The collection of data continued until May 22, 2013, which a member of the PI team [B.K.] undertook once a week for all patients on this unit. After the baseline data were collected, the PI team member joined multidisciplinary rounds with the goals of achieving 100% compliance with VTE accountability measures (Sidebar 1) and of transforming multidisciplinary rounds into a broader * The current version is as follows: The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures, v4.4. 2015. Accessed Aug 5, 2015. http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx.
September 2015
Sidebar 2. Standard Questions Regarding Venous Thombroembolism (VTE) Is VTE prophylaxis ordered? Is it chemical, mechanical, or both? If chemical, is the patient receiving it or refusing it? If patient refused, why, and is the attending physician aware? If mechanical, are they applied? Is VTE prophylaxis properly documented? Is patient educated on VTE, and is it documented? Are there any contraindications to receiving VTE?
patient safety tool. The data collection form, which was initially developed to focus on improving VTE prophylaxis, was used as a guide when each nurse was asked if his or her patient has a VTE prophylaxis order; whether the prophylaxis is chemical, mechanical, or both; and whether there are any patient contraindications. If no order existed, the nurse was then encouraged to follow up with the physician or licensed independent practitioner.
Tool Description
Multidisciplinary rounds occur daily on each patient care unit. Participants include social workers, case managers, nurses, educators, dietitians, pharmacists, a licensed independent practitioner, and other personnel involved in patient care. These rounds review each patient, discussing the patient’s diagnosis, pending lab work, tests, medications, the issues or concerns, as well as patient disposition. Each nurse reviews key elements of his or her patient’s plan of care. Rounds last approximately 1 hour, depending on the census for the day, with staff rotating for 5 to 10 minutes to address their patients. The evolution of the rounds as a patient safety tool began with specific discussion of VTE risk and related prophylaxis as overall safety priorities as well as on a patient-specific level, as follows: What was the patient’s risk and was appropriate prophylaxis in place? If not, what steps would be taken NOW to address and provide appropriate prophylaxis?
How-To
The PI team attended these multidisciplinary rounds on a d aily basis for approximately two months (April 15, 2013–May 22, 2013), during which they prompted discussions on the VTE accountability measures as each nurse gave report on his or her patients. Each week the data were collected and compared to those of the previous week. During the meeting, the PI team member asks a standard list of questions (Sidebar 2, above) and uses a standardized tool (Appendix 1, available in online article) to collect information to Volume 41 Number 9
Copyright 2015 The Joint Commission
429
The Joint Commission Journal on Quality and Patient Safety Venous Thromboembolism (VTE) Composite Scores, Quarter 1 (January–March) 2013 to Quarter 3 (July–September) 2014 100.00% 80.00% 60.00% 40.00% 20.00% 0.00% Score
1st Qtr 2nd Qtr 3rd Qtr 2013 2013 2013 83.3% 94.3% 98.8%
4th Qtr 2013 100%
1st Qtr 2nd Qtr 3rd Qtr 2014 2014 2014 98.3% 97.7% 99.0%
Figure 1. The integration of the VTE requirements into the daily care of patients through the use of multidisciplinary rounds began on April 15, 2013. The composite VTE score improved to 94.3% by the second quarter (2nd Qtr) of 2013, to 98.8% by the third quarter, and to 100% by the end of 2013, with scores for the first, second, and third quarter of 2014 at > 97%.
help identify potential patient safety issues related to VTE. This approach during multidisciplinary rounds encourages the team to communicate about and assess needs or gaps related to standards of care in a structured way. Interventions identified during rounds that increase patient safety and ensure that expected standards are met, are documented and followed up on the same day. In one scenario entailing a patient-specific question during a multidisciplinary round, a reporting nurse confirms a VTE prophylaxis order for a patient but reports that the patient has refused to comply. The nurse is then encouraged to explore the reason for the refusal and work to address patient concerns. The nurse is advised that if the patient still refuses, then the nurse should reach out to the attending physician to make him or her aware and document the refusal as well as the follow-up with the physician in the patient’s chart. In a scenario in which the reporting nurse confirms that there are no orders for VTE prophylaxis, the PI member encourages the nurse to let the licensed independent practitioner know and ask if he or she would be ordering prophylaxis, and, if not, whether there are any contraindications that could be documented. By asking the appropriate questions, providing education, and reinforcing the role of the nurse as patient advocate, as well as aiding in problem solving and coaching on how to proceed regarding patient safety issues, the PI member can use the multidisciplinary rounds to make an impact on improving patient safety through core measure awareness and directed action. 430
September 2015
Results and Lessons Learned
The baseline data revealed that, for 40 patients, VTE order compliance was at 90% and that patient education documentation was at 44%. OMC’s National Hospital Quality Measures Outcomes Report indicated that the composite VTE score improved to 94.3% by the second quarter of 2013, to 98.8% by the third quarter, and to 100% by the end of 2013; for the first, second, and third quarter of 2014 we have achieved greater than 97% (Figure 1, left). An updated review of the first two quarters of 2015 showed a combined average score of 97.0%. Consistent use of structured communication to integrate VTE requirements into the daily care of patients through the use of multidisciplinary rounds as a safety tool was the key intervention in achieving and sustaining the right care for every patient every time. Direct observation and firsthand experience have indicated that an RN quality department resource person attending unitbased multidisciplinary rounds, providing information and educating nursing on the importance of VTE prophylaxis, and reinforcing the care required while reviewing each patient, not only encouraged patient education but also provided coaching in resolving care issues, encouraged communication, promoted licensed independent practitioner engagement, and underscored the need and responsibility to speak up to increase patient safety. Furthermore, the data collection form used during rounds included a core measure key, effectively showing how the team detected and addressed concerns regarding any identified core measure or patient safety points on a daily basis with every patient. What the PI team learned was that this new approach of using multidisciplinary rounds as a safety tool to improve patient safety through core measure and priority safety initiatives awareness was well received and easily adaptable to target all accountability measures and patient safety issues. Coupled with the success of the pilot period, this awareness has prompted an expansion of this approach to all patient care units. The team now uses this process for multidisciplinary rounds on all patient care floors, for all accountability measures, as well as other priority patient safety issues on a daily basis. The focus was switched to urinary catheters in April 2013. Except for a minor modification to the form, implementation remained the same, with the goal of decreasing indwelling catheter days. When a patient was identified as having a urinary catheter, pertinent questions were asked, and again coaching, promoting communication, and following up on whether or not the catheter was needed were encouraged. Analysis of the 2013 data indicated that the average number of indwelling days had decreased from 235 per month (12.3% of total inpatient Volume 41 Number 9
Copyright 2015 The Joint Commission
The Joint Commission Journal on Quality and Patient Safety urinary catheter days) in the first quarter to 165 per month (10.0%) for the remainder of the year. Another lesson learned by the PI team relates to the initial challenges of multidisciplinary collaboration. Focused discussion regarding VTE prophylaxis initially increased the nursing teams’ report times, but after one to two weeks, the teams came to rounds better prepared. This in turn decreased the time necessary for follow-up questions. Also, with coaching and support to address gaps in care, the nurses quickly demonstrated skill in resolving identified gaps. Initially, licensed independent practitioner’s responses to the nurses’ inquiries and follow-up varied. Although some individual licensed independent practitioners responded with resistance, ours is a teaching facility where learning and questioning are encouraged on all levels. Furthermore, most licensed independent practitioners are aware of the importance of addressing accountability measures and supported the PI initiative. The medical department chairs addressed requirements and the need for compliance with the few physicians who continued to fail to respond to follow up to ensure standards were met.
Summary and Next Steps
Accountability measures are designed to improve patient safety and consistently ensure that standards of care are met. One unit at OMC was frequently failing the VTE accountability measures, which triggered the PI team’s involvement. The team was able to improve VTE accountability measure compliance from 83% to 100% in one year by using multidisciplinary rounds as a safety tool; compliance has been sustained at 97% since. Structured coaching by the PI team on a regular basis to promote the importance of VTE accountability measures made an impact on patient safety through improved communication among the health care team, improved documentation of patient education, and increased use of prophylaxis. This team’s success has led to the use of multidisciplinary rounds to address all accountability measures, as well as key patient safety priorities, throughout multiple units in this facility. The unit-based multidisciplinary rounds tool has evolved to list all the accountability measures and additional patient safety issues as a guide for focused discussion.
Contact Us
For additional information and discussion regarding using multi disciplinary rounds as a safety tool, please contact the author by e-mail ([email protected]). J
Beth Karasin, MSN, APN, AGACNP-BC, RNFA, CNOR, formerly RN member, Performance Improvement Team, Overlook Medical Center/Atlantic Health System (OMC/AHS), Summit, New Jersey, is an Advanced Practice Nurse, Northeast Regional Epilepsy Group, AHS. Christina Maund, MS, RN, CPHQ, is Director, Quality and Outcomes Management, OMC/AHS.
Online Only Content
http://www.ingentaconnect.com/content/jcaho/jcjqs See the online version of this article for Appendix 1. Unit-Based Rounds Tool
References
1. Masica AL, et al. Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence. Proc (Bayl Univ Med Cent). 2009; 22(2):103–111. 2. Anderson FA Jr, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med. 1991;151(5):933–938. 3. Anderson FA Jr, et al. The prevalence of risk factors for venous thromboembolism among hospital patients. Arch Intern Med. 1992;152(8):1660–1664. 4. Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Blood Disorders. Meeting Summary: Prevention of Hospital-Acquired Venous Thromboembolism (HA-VTE) Expert Panel Meeting. Aug 19, 2011. (Updated: Apr 30, 2012.) Accessed Jul 30, 2015. http://www.cdc.gov/ncbddd/dvt/documents/12 _232434-a_sayers_ha-vte_workshop_report_508.pdf. 5. Huang W, et al. Risk-assessment models for predicting venous thromboembolism among hospitalized non-surgical patients: A systematic review. J Thromb Thrombolysis. 2013;35(1):67–80. 6. The Joint Commission. Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety 2013. Oac Brook, IL: The Joint Commission, 2013. Accessed Jul 30, 2015. http://www.jointcommission.org /assets/1/6/TJC_Annual_Report_2013.pdf. 7. Geerts WH, et al.; American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians EvidenceBased Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl): 381S–453S. 8. Samama MM, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients: Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med. 1999 Sep 9;341(11):793–800. 9. Cohen AT, et al. Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: Randomised placebo controlled trial. BMJ. 2006 Feb 11;332(7537):325–329. 10. Gurses AP, Xiao Y. A systematic review of the literature on multidisciplinary rounds to design information technology. J Am Med Inform Assoc. 2006;13(3):267–276. 11. Seigel J, et al. Successful implementation of standardized multidisciplinary bedside rounds, including daily goals, in a pediatric ICU. Jt Comm J Qual Patient Saf. 2014:40(2):83–90. 12. The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures, v4.2b (applicable for discharges 1/1/2013–12/31/2013). Accessed Sep 17, 2014. http://www.jointcommission.org/specifications_manual _for_national_hospital_inpatient_quality_measures.aspx.
The author thanks Robyn Postighone, MPA, RN, for her insight and guidance regarding an earlier version of this manuscript.
September 2015
Volume 41 Number 9
Copyright 2015 The Joint Commission
431
The Joint Commission Journal on Quality and Patient Safety Online Only Content
Appendix 1. Unit-Based Rounds Tool UNIT-BASED ROUNDS TOOL
LOCATION: Patient Name
Overlook Medical Center
Date: Attending/Primary Diagnosis
Issues/Intervention
Other
Key Discussion Topics: Discharge Planning is initiated on admission Patient Education is documented Advance Directive is acknowledged POLST Medication Reconciliation—new meds; education Family/SO participation in care Home Care Physical Therapy F/U MD Appt Potential Safety Issues—Foley Core Measure Compliance: AMI—Beta, ASA, Statin; HF—documented EF, ACE/ARB; PNA—correct ABX; VTE—initiated within 24 hours of admission; SC—ABX and Foley D/C; Immunization—Pneumoccocal and Influenza POLST, physician orders for life-sustaining treatment; SO, significant other; F/U, follow-up; Appt, appointment; AMI, acute myocardial infarction; Beta, Beta-blocker; ASA, acetylsalicylic acid; HF, heart failure; EF, ejection fraction; ACE/ARB. angiotensin-converting enzyme/angiotensin receptor blocker; PNA, pneumonia; ABX, antibiotics; VTE, venous thromboembolism; SCIP, Surgical Care Improvement Project; d/c, discontinued.
September 2015
Volume 41 Number 9
Copyright 2015 The Joint Commission
AP1