Bundles of quality
AMDIS award winner Dr. Steve Arendt and his colleagues at Eisenhower Medical Center in Rancho Mirage, Calif., saw the number of cases of ventilator-acquired pneumonia drop to zero during the past year while caregivers for stroke patients attained better than 90% compliance with core stroke-care measures.
Part of the reason for their success, Arendt believes, is the implementation of a pilot program to test a system of computerized real-time “quality bundles” to help clinical staff monitor optimum patient care in real time.
The system reminds and prods them in simple, green, yellow and red color overlays whether they are meeting or missing quality-of-care targets.
For ventilator patients, the monitoring system looks over caregivers’ shoulders about assessing a patient’s readiness to be weaned off the ventilator, prevention of venous thromboembolism, ensuring that the patient’s head is elevated and position is changed, and for stroke patients, the administration of anti-coagulation medications, use of statins to lower cholesterol, provision of stroke education information and assessments of rehabilitation potential.
The system was introduced about a year ago. Initially, its display was placed on the electronic health-record system used by caregivers, but it was moved about four months ago to its own free-standing, flat-screen monitors in the patient rooms in Eisenhower’s intensive-care unit and neurology (stroke) unit.
“One of the problems with the data we have now is that people generate reports, and that’s fine, but it’s after the event,” says Arendt, 53, chief medical information officer at 313-bed Eisenhower. “You can do educational sessions to prevent events in the future.” But with the green, yellow and red signals on the wall, “we leverage the data already being entered, but make it presentable in a bedside friendly heads-up.”
“We want the nurses to be at the bedside to take care of the patients,” Arendt says, so the more decision support that can be simplified and provided at the bedside the better.
And the system is amenable to calibration, just as were earlier decision-support tools, such as drug/drug and drug/allergy alerts.
“We don’t want to overwhelm our staff with too much stuff flashing at them,” Arendt says. “We can decide if there is a parameter that doesn’t make sense. We can decide not to display it or we can dial it up or down.”
“There can be alert fatigue,” Arendt says, adding that he also doesn’t want nurses “so dialed into the monitors they don’t take care of their patients.”
To create the system, Arendt helped steer a project team through a gap assessment of current documentation, flow sheets and order sets to produce the quality bundles. Arendt also led the development of decision-support tools for physician-order entry that guides them to the most appropriate therapy for a given patient.
To better obtain user buy-in, and promote the system, Eisenhower labeled the campaign “Go Green,” and held much of the initial system training and education during informal rounding across shifts. At shift changes, handoffs included indicators from the quality monitoring system. The stroke management team even held their meetings around the monitors.