Nurse-led Initiatives Improve Patient Safety on the Neuroscience Acute Care Unit
Identifying potential problems quickly, before they become emergent situations, has improved safety on Mischer Neuroscience Institute’s Neuroscience Acute Care Unit. On the 51-bed unit, process improvement initiatives have led to a dramatic reduction in preventable serious safety events – from three in fiscal year 2015 to zero in 2017.
“We’re doing a better job of identifying patients who need a higher level of care and transferring them to monitored units before their condition escalates into a rapid response situation,” says Janelle Headley, B.S.N., RN, clinical nurse manager of the Neuroscience Acute Care Unit. “Many of our new initiatives came out of the Rapid Response and Higher Level of Care Transfer Committee, a large group that includes medical directors, neuroscience service line managers, stroke coordinators, educators and other staff members who review our data on a daily and weekly basis. If we discover a problem, we resolve it quickly to make things safer for our patients. Nurses complete a debriefing post-rapid response worksheet that identifies opportunities for improvement, and the information is shared during our regular shift huddles.”
Among those spearheading the safety improvement effort is intensivist H. Alex Choi, M.D., medical director of the Neuroscience Acute Care Unit and an assistant professor in the Vivian L. Smith Department of Neurosurgery at McGovern Medical School at UTHealth. “A strong partnership between nurses, physicians and other caregivers is essential in ensuring patient safety,” says Dr. Choi, who views his role as a facilitator, bringing staff members together to enhance collaboration. “Out of the Rapid Response Committee came several initiatives that led to new processes. None of them would have been possible without the collaborative work of Gabby Edquilang, our quality improvement coordinator, and Stephanie Cooper, our stroke coordinator; Kim Vu, our complex care specialist; Janelle Headley, the unit manager; and Dr. Andrea Xavier, our hospitalist.”
Working together, the Neuroscience Acute Care Unit team implemented a post-procedure algorithm specific to the unmonitored med/surg unit. “By examining our data, we noticed that some patients were leaving the unit for procedures and returning with hemodynamic instability,” says Gabby Edquilang, B.S.N., RN, SCRN.
“Our unit standard is to round hourly and check vitals every four hours. We aimed to increase the monitoring of vital signs once patients returned to the unit after a procedure.”
The patient’s primary nurse now alerts the physician when the patient returns. Nurses check vitals every 15 minutes for the first hour and every 30 minutes for the second hour. After the two-hour post-procedure window, they return to their normal schedule. Since the team implemented the algorithm, care of all unstable patients has been escalated quickly to attending physicians.
To prevent aspiration pneumonia, the Acute Care team also introduced an oral care protocol that was trialed in the Neuroscience Intermediate Care Unit and rolled out to the Neuroscience ICU and Stroke Unit in fall 2016. “The number one line of defense against aspiration pneumonia is obvious: to prevent aspiration of food or liquid into the lungs,” Edquilang says. “Whether they’re independent or dependent, patients now have oral care completed every six hours.”
Multiple physician teams guide patient care on Mischer Neuroscience Institute’s largest unit, making it challenging for nursing staff to get in touch with the appropriate physician. To solve the problem, all team members now enter their pager numbers in one centralized location – the patient record. To improve nurse-physician communication, they also instituted two new protocols: Code 1, for emergent situations, and Code 2, for non-emergent situations. Code 1 is nurse driven and ensures that attending physicians, as well as residents, are notified of changes in a patient’s neurological, respiratory or hemodynamic status. Code 2 is bedside-nurse driven; if a non-emergent change in status renders the plan of care inappropriate, the nurse communicates with the attending physician.
“It’s a great process,” says Headley, whose unit has a strong culture of teamwork. “It helps ensure that the attending physician is always in the loop and that we’re all on the same page for better management of the patient.”
Frances Jaime, RN-BC, is the Neuroscience Acute Care Unit’s patient experience ambassador, a position created in 2014. “I’m an extension of all the nurses on the unit, letting patients know we’re here to meet their needs,” she says. “I visit everyone on the unit, and if a patient or family member needs help, I make it happen. My long-term goal is to make every nurse on the unit a patient ambassador.”
As medical director, Dr. Choi acknowledges the importance of this kind of teamwork. “Nurses know our patients best because they’re at the bedside,” he says. “They’re also very good at determining where and how processes can be improved. We’ve found that empowering nurses at the bedside to implement quality initiatives has led to dramatic improvement in our quality metrics. The next step for our team is to share what we’ve learned with the rest of the medical community to influence care on an international stage. Many of our initiatives have been submitted for abstracts at national conferences with nurses as the primary presenters.”