EXEMPLARY PROFESSIONAL PRACTICE

Stanford nurses deliver exemplary nursing care to our patients, their families, and the community. Our professional practice model is built around this focus and illustrates how nurses live the mission, vision, and values of the organization, as well as national professional standards in their practice. A strong foundation in relationship-based care delivery enables Stanford nurses to form essential therapeutic relationships with patients and families and strong team relationships with colleagues. Stanford nurses practice the art and science of nursing in fulfilling the roles of practitioner, leader, scientist and transferror of knowledge to continuously improve the practice environment, the health care system and outcomes for individual patients.

E2 INTENSIVE CARE UNIT

In FY17, E2 contributed to 38% of CAUTI in SHC Inpatient units (Incidence was 25 out of the 65).  E2’s urinary catheter utilization rate was 66%.  The SHC CAUTI Standardized Infection Ration (SIR )was 1.35 and E2’s CAUTI SIR was 2.82.

SITUATION:

In FY17, E2 contributed to 38% of CAUTIs in SHC Inpatient units (Incidence was 25 out of the 65).  E2’s rate of CAUTI was 3.62.  E2’s urinary catheter utilization rate was 66%.  The SHC CAUTI Standardized Infection Ration (SIR) was 1.35 and E2’s CAUTI SIR was 2.82.

 

BACKGROUND & SIGNIFICANCE

CAUTI is the most common type of healthcare-associated infection, accounting for more than 30% of acute care hospital infections. 13,000 deaths are associated with UTIs each year. There are estimated to be 449,334 CAUTI events per year. Each CAUTI is associated with the medical cost of $758. And, a total of over $340 million spent in health care is attributable to the incident of CAUTI in the U.S. each year. For each day an indwelling urinary catheter remains intact, a patient has a 3% - 7% increased risk of acquiring a catheter-associated urinary tract infection (CAUTI).”

 

ASSESSMENT:

A thorough problem analysis was performed by the E2 ICU management team, CNL, educator, clinical nurses, and physician partners.  Problem identification guided planning for countermeasures and implementation plan.  Daily CAUTI rounds and shift huddles, data visibility, various educational presentations to key stakeholders.

 

OUTCOMES:

  • Indwelling catheter utilization decreased from 66% to 54%

  • CAUTI incidence reduced by 80% (25 to 5) and rate decreased from 3.6 to 0.93 per 1,000 cath days

  • E2 CAUTI SIR decreased to 0.749 and SHC SIR CAUTI SIR decreased to 0.81

--contributed by Maureen Fay, MS, RN, Christine Henley MS, RN, Marisa Holubar, MD,  Tammy Schaffner, RN, Darren Batara, MS, RN,  Pedram Fatehi, MD, Aussama Nassar, MD, Ron Pearl, MD

CAUTI REDUCTION

E29 INTENSIVE CARE UNIT

SITUATION:

In fiscal year (FY) 2016 and 2017, in the Cardiovascular/Thoracic Intensive Care Unit (CVICU) of a large academic medical center, 50 CLABSI were noted (19 and 31 respectively).

BACKGROUND & SIGNIFICANCE

CLABSI, a Healthcare-Acquired Condition, (HAC) poses a threat to the patients’ overallclinical health and safety. Of all HACs, CLABSIs are the most costly; they increase the length of stay (LOS) and can lead to poor patient outcomes to include death. Accordingto the Agency for Healthcare Research and Quality (AHRQ), in 2012 the estimated cost of a CLABSI ranged from $40,412-$100,980 per incident. The risk of acquiring a CLABSI in the CVICU is heightened due to the increased utilization and insertion of central lines. Of note, forty-eight percent of the CLABSI cases in FY 17 were on our high risk, long length of stay (LLOS) patients who were on extracorporeal membrane oxygenator (ECMO). The institution’s compliance with the CLABSI maintenance bundle for FY 16 and FY 17 were 63.11 % and 46.0 % respectively. The largest gap  in compliance was related to the nurses’ ability to maintain an occlusive dressing (specifically no gaps either of the four sides of dressing). The compliance rate was 75.41 % for FY 16 and 64 % for FY 17.

 

ASSESSMENT:

A quantitative approach in data collection using the hospital internal database was used to extract data. In addition, the unit leadership team conducted a needs assessment survey to determine barriers to the maintenance bundle. The result of the survey created an opportunity to seek appropriate and available product to increase the CLABSI maintenance bundle. After the identification of the product and process, a required education on the correct application of
the dressing was conducted by the Clinical Nurse Specialist and the Nurse Educator. The education was extended to the Cardiac Anesthesia physician group as well as they placed the initial dressing post-insertion.

 

 

OUTCOMES:

The inclusion of the bedside nurses’ perceptions of barriers to the CLABSI maintenance bundle allowed for staff ownership and promoted a team approach to problem resolution. Nurses’ feedback on the challenges of maintaining an occlusive dressing provided an opportunity to search for the appropriate dressing that met the needs of this challenging patient population. In addition, staff education on the implications of CLABSI on patient’ outcomes, experience and costs provided, awareness into their clinical practice. Bedside nurse input, targeted education, Availability of appropriate supplies and active daily management rounds improved overall bundle compliance by 38.15 % and promoted accountability of nursing practice at the bedside. FY 18 data to date demonstrates a 90.4 % reduction of CLABSI in CVICU.

--contributed by 

Eileen M Bucoy-Duque RN MSN, Patricia Henry RN CNS,
Tammy Schaffner RN CIC, Sharon Hampton RN PhD

CLABSI REDUCTION

Preventing Operating Room Sacral Pressure Injuries 
in the Cardiac Surgery Population

BACKGROUND & SIGNIFICANCE

Prior to this study at our academic medical center, standard measures to prevent operating room (OR) sacral pressure injuries (PI) for patients who underwent cardiac surgery longer than 3 hours included -
1. Applying a sacral silicone border foam dressing
2. Placing a gel pad under the sacrum/buttock area

OBJECTIVE:

The purpose of this project was to reduce the number of sacral/buttock OR PI in the cardiac surgery population.

 

METHODS

This project was led by the OR Pressure Ulcer Prevention (PUP) team.  The PUP team consisted of OR nurses, the wound care manager, OR educators, OR quality team, and OR management team.
1. Root cause analysis: evaluated sacrum/buttocks OR PI cases in the cardiac surgery population
2. Literature review: studies suggested an air-inflated static seat cushion (ASSC) had the best pressure redistribution properties.
3. Pressure mapping: a healthy male volunteer was placed on a standard 3-inch memory foam OR table.  A gel pad and an ASSC were pressure mapped under the subject’s sacral area in both frog-leg and supine positions. 
4. Soliciting cardiac surgeons’ support
5. Providing staff education
6. Conducting trial: 15 patients who underwent coronary artery bypass graft surgery had the ASSC under their sacrum during surgery. No complications were reported during the trial, e.g. shifting when in reverse-Trendelenburg position or developing sacrum/buttock or PI

RESULTS:

In May 2017, a sacral silicone border foam dressing and an air-inflated static seat cushion under the sacral area became standard measures for all patients requiring cardiac bypass during their OR procedure.
Following implementation, there were zero OR acquired sacral/buttock PI identified in the cardiac surgery population (May 2017 to June 2018).

 

CONCLUSION: 

These results demonstrate a positive relationship between implementing the ASSC during surgery and decreasing the incidence of sacral/buttock OR PI in the cardiac surgery population.  Furthermore, the ASSC is cost-effective and easy to use.  We plan to expand the use of this preventive intervention to other supine OR cases such as colorectal, orthopedic, and neuro procedures.

CONTRIBUTED BY:

Chungmei Shih, MSN, RN, CNS, CWON; Heather Swan, BSN, RN, CNOR

HAPI PREVENTION

A Primary Care and Radiology Collaboration: 
Using the Quadruple Aim as a framework to Improve Breast Screening Care Delivery

Situation:

Mammogram scheduling aimed to improve slot utilization for breast screening services by increasing the referral rate. Primary care sought to partner with mammogram services in order to improve screening rates for breast cancer, to offer patients a better experience and offload provider burden to initiate the process. Together our departments operationalized a process that enabled patients to get their mammograms on the same day of their primary care provider visit through leveraging EMR reporting, care coordination and interdepartmental collaboration.

 

Background:

Primary care has engaged in primary, secondary and tertiary prevention strategies to improve population health. Despite efforts to improve breast cancer screening rates, we were unable to find sustained success. Our process relied heavily on providers and clinic staff. Our patients were frustrated by long wait times for appointments often 1-2 months out. Our value-based incentives were not shared by other departments and services. This dynamic changed when Mammography services expanded and became underutilized. This presented a rare opportunity to partner.

 

Outcome/Impact:

Through a referral process that centered on timely data and care coordination, we improved breast screening rates in Stanford Family Medicine from 73.5% to78.7%. This is a tremendous improvement considering this measure looks back 2 years, performance had previously flatlined and the improvement was achieved in less than 3 months. We were able to increase a baseline of 9% of eligible patients each week to an average of 39% and significantly improve slot utilization. We have since spread the process to all primary care.

 

Conclusion:

Achieving the Quadruple Aim in healthcare can be a difficult task. The rewards for doing this work are multifaceted. Our current process supports providers before patients set foot in the clinic. Our screening numbers have improved, and mammography slot utilization optimized. Most of all, we are now providing greater value and convenience to our patients.

CONTRIBUTED BY:

Jimmy Dang, BSN, RN

POPULATION HEALTH

@Stanford Nursing 2018