Hospitalwide Effort to Improve Care and Outcomes for Patients at Risk for Delirium, Alcohol Withdrawal and Suicide Harm
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(Oak Brook, Ill., June 30, 2015) Joint Commission Resources, Inc. today released the July 2015 issue of The Joint Commission Journal on Quality and Patient Safety, featuring the article “A Population-Based Care Improvement Initiative for Patients at Risk for Delirium, Alcohol Withdrawal and Suicide Harm” by Barbara E. Lakatos, D.N.P., PCNS-BC, A.P.N. and colleagues at Brigham and Women’s Hospital, Boston. The article highlights how a hospitalwide interprofessional care redesign was conducted to provide optimal evidence-informed care for patients at risk for delirium, alcohol abuse and suicide harm (DASH).
An interprofessional group from medicine, nursing and psychiatry jointly led the effort to improve care and outcomes for patients with a DASH diagnosis. The care improvement process consisted of four phases: development of guidelines; implementation/rollout; integration into practice; and sustainability, including ongoing practice development and evaluation. As part of the process, the group developed interprofessional practice guidelines and educational resources related to DASH, and also implemented enhanced standardized screenings.
Implementation outcomes were evaluated using eight parameters—acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration and sustainability. Patients were compared pre- and post-program implementation from 2010 through 2013. Findings showed that while the average length of hospitalization remained consistent for DASH patients, the readmission rate decreased by 9 percent—from 15.1 to 13.7 percent, approaching the hospital’s overall rate of 13.3 percent.
“For the program to be considered a true success, the components of the program will need to become embedded in the clinical culture of the institution in a way that achieves sustainability of the program. Successful adoption of the DASH program by other organizations requires strategies for education and implementation aligned with existing processes and resources,” concluded the authors.
The remaining articles from the July 2015 issue are as follows:
Teamwork and Communication
Nurse Knowledge ExchangePlus: Human-Centered Implementation for Spread and Sustainability
Mike Lin; Scott Heisler, RN, M.B.A.; Linda Fahey, RN, NP, M.S.N.; Juli McGinnis, RN, M.S.N.; Teri L. Whiffen, RN, M.H.A.
Kaiser Permanente implemented a new model of nursing communication at shift change in the bedside nursing report known as the Nurse Knowledge Exchange (NKE) in 2004—but noted variations in its spread and sustainability. In 2009, the Innovation Consultancy and frontline staff developed NKEplus. In January 2011, Kaiser Permanente Southern California began implementing NKEplusin 125 nursing units across 14 hospitals. Human-centered design principles were used to create shared understanding of the need for change, minimum specifications and customization by frontline staff. The mean score on the nursing behavior bundle improved from 65.9 percent in 2010 to 71.3 percent in the first quarter of 2014. Human-centered implementation appeared to help spread a new model of nursing handoffs and change the culture of professional nursing practice related to shift change.
Methods, Tools and Strategies
Redefining Overuse to Include Costs: A Decision Analysis for Computed Tomography in Minor Head Injury
Edward R. Melnick, M.D.; Joshua Keegan, M.D.; R. Andrew Taylor
A study was conducted to determine the testing threshold for head computed tomography (CT) in minor head injury in the emergency department using decision analysis with and without costs included in the analysis. Outcomes were assigned values on the basis of effectiveness (quality-adjusted life-years) and cost. The testing threshold for obtaining head CT when only effectiveness was considered was 0.039 percent versus 0.421 percent when only net monetary benefit was considered. If only effectiveness is considered, current clinical decision rules might not provide a sufficient degree of certainty to ensure identification of all patients for whom the benefits of CT outweigh its risks. These results suggest that the term overuse should be redefined to include the provision of medical services with no benefits or for which harms including cost outweigh benefits.
Process Performance Measures for Inpatient Glucose Management Programs
Susan S. Braithwaite, M.D.
In determining optimal targets for control of hyperglycemia, there is increasing recognition of the possible importance of tailoring targets to subcategories of patients rather than using specific targets according to condition. In combination with a metric related to hypoglycemia, a propitious choice of process measures related to hyperglycemia should be deployed to assess an institution’s capability of achieving the outcome goals of reduction of length of stay, morbidity, and costs, and an increase of patient satisfaction.
Modeling Inpatient Glucose Management Programs on Hospital Infection Control Programs: An Infrastructural Model of Excellence
Nestoras Mathioudakis, M.D.; Peter J. Pronovost, M.D., Ph.D.; Sara E. Cosgrove, M.D., M.S.; Daniel Hager, M.H.A.; Sherita Hill Golden, M.D., M.H.S.
Given the dramatic success of infection control programs, it might be advantageous to apply the scientific and organizational methodology that formed the basis of these programs to more broadly reduce other types of preventable harm. Inpatient glucose management programs should achieve three goals—(1) eliminate preventable harm from hypo- and hyperglycemia (“dysglycemia”), (2) optimize patient outcomes and experience, and (3) eliminate waste in health care.