Fletcher Allen, a Vermont university hospital and medical center, serves all of
Vermont and the northern New York region. Located in Burlington, Fletcher Allen is a regional, academic healthcare center and teaching hospital in alliance with the University of Vermont.
2012 Quality Improvement Initiatives
The following are three examples of the numerous quality improvement initiatives that Fletcher Allen staff engaged in during 2012. For more information on these or other QI initiatives, contact the James M. Jeffords Institute for Quality & Operational Effectiveness at Fletcher Allen at (802) 847-0554.
- ImproveCareNow: A National Pediatric Collaborative Network
- STEMI Nursing Feedback Program
- Dialysis Infection Prevention
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ImproveCareNow: A National Pediatric Collaborative Network
Time Frame: 2011-2012
Description/Problem
ImproveCareNow is dedicated to improving the care and outcomes of children with Crohn’s disease and ulcerative colitis. The program, in which pediatric gastroenterologists at 35 centers – including Fletcher Allen – work together to improve the quality of care delivered to more than 10,000 children and adolescents with inflammatory bowel disease. Fletcher Allen's Dr. Richard Colletti, a pediatric gastroenterologist at Vermont Children’s Hospital, was the founder of the ImproveCareNow Network and serves as its National Director, with leadership and organizational responsibilities.
Until recently, it was difficult to share information and provide benchmarks to improve care across the United States for this population of patients. The program’s results demonstrate that patients in the ImproveCareNow network are receiving better care and there is a substantial increase in the percentage of patients in remission of these chronic diseases.
Project Goals
- Build a sustainable national network to improve care and outcomes of children with Crohn’s disease and ulcerative colitis.
- Key drivers include:
- A prepared, proactive practice team
- Accurate diagnosis and disease classification
- Appropriate drug selection and dosage
- Adequate nutritional intake
- Appropriate growth monitoring
- Informed, active and engaged patients and families
Specific Project Goals:
By September 2012, ImproveCareNow centers will have:
- Greater than or equal to 80 percent of patients in remission
- Greater than or equal to 95 percent of patients not taking prednisone
- Greater than or equal to 95 percent of patients complete with documentation bundle
Interventions
1. Enrollment and Data Quality
- Identify and enroll all of the enrollable population
- Develop standardized template for data elements
- Collect visit data for all enrolled patients on a timely basis
- Develop and implement a data quality plan
2. Consistent, reliable care
- Implement Model IBD Care with reliability of >90%
- Implement Pediatric IBD Nutrition Algorithm with reliability of >90%
3. Population management
- Insure patients are being seen regularly (using PM report)
- Contact those who have not been seen in past 6 months
- Score patients using risk stratification scale
- Identify patients/subgroups for proactive care
- Design, coordinate and manage care for specific segments of the practice population
- Generate reports of overall patient health across the practice
4. Pre-visit planning
- Review important data
- Obtain or provide additional information to the patient
- Identify and arrange for needed resources
- Identify and “flag” variables that fall outside of protocol guidelines
- When feasible, meet as a team to review patients and determine recommendations
5. Self-management support (SMS)
- Provide patient education
- Define team roles and responsibilities for SMS
- Elicit patient and family priorities for visits
- Confirm patient understanding of new information
- Set patient goals collaboratively
- Monitor and document progress toward SMS goals at each visit
Fletcher Allen Health Care Results
(March 2012):
1. Vermont Children’s Hospital remission rate is 78 percent (network target is 80 percent; average network rate is 76 percent).
2. The Vermont Children’s Hospital steroid free remission rate is 77 percent (network target is 76 percent; average network rate is 73 percent).
3. The Vermont Children’s Hospital sustained remission rate is 64 percent (network target is 45 percent; average network rate is 56 percent).
4. The percentage of Vermont Children’s Hospital patients off prednisone is 92 percent (network target is 95 percent; average network rate is 92 percent).
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STEMI Nursing Feedback Program
Time Frame: 2009-2012
Description/Problem
After the STEMI Rapid Transfer program was initiated at Fletcher Allen in 2007 the nurses in the cath lab looked for ways to be more impactful with the program and to help improve door-to-balloon times. The project began by collecting data from nurses at our referring hospitals regarding the amount and quality of the feedback they were receiving about the STEMI transfers they were sending. We identified a lack of feedback in terms of patient results as well as any data tracking the STEMI system involving rapid triage and transport. We also identified a lack of knowledge and education surrounding the work of the cardiac cath lab and treating STEMI patients. This lack of data and feedback was a dissatisfier for the nurses at our referring hospitals and also made working towards system improvement difficult. Karen McKenny, RN, nurse educator for invasive/non-invasive cardiology at Fletcher Allen, presented the initial program and data at EuroPCR in Paris, France May 2010, and have provided updated and on-going phases of this project at Vermont Cardiac Network Stowe Vermont April 2011 and the UHC (University Health Consortium) Annual Conference Chicago in September 2011.
Project Goals
The goal of this nurse-driven program is to improve door-to-balloon times for STEMI patients and to increase the satisfaction of nursing colleagues at sending hospitals through education and collaboration. Through nurse-to-nurse feedback, data collection, and roundtable meetings data was analyzed and systems improvements began.
Specific Project Goals
1. Improve door-to-balloon times for STEMI patients.
2. Provide STEMI feedback to nurses in our referring hospitals.
3. Improve satisfaction and teamwork of nursing colleagues through collaboration and education
4. Establish a roundtable forum with representation of all disciplines that are involved in caring for STEMI patient, to include nurses from the cath lab, all referring emergency departments, emergency operators, and EMS crews, to meet and work on continuous systems improvement.
Interventions
1. Sent out survey to sending hospitals – Copley, Porter, Central Vermont Medical Center and Northwestern Vermont Medical Center – to assess the quality or quantity of feedback regarding their patients or system data. Overwhelmingly, the nurses from those hospitals responded that they received little to no feedback.
2. Implement system for a follow up phone call within 28-48 hours (cath lab nurse to referring ED nurse) for feedback and patient outcome report. This is followed by a form that includes all data points for system tracking and is emailed to all members of the team that were involved in that patient’s care.
3. Establish a multidisciplinary round table program, held twice a year, open to nurses, EMS, physicians and ED staff to review STEMI data and share ideas on continued system improvement leading to improvement in door-to-balloon times. These roundtables have led to uniform algorithms, treatments and standardized documentation to assist in streamlining the system.
4. Provide ongoing education by cath lab nurses at our referring hospitals regarding all aspects of care for the STEMI patient and what we do in the cath lab.
5. Build a team of nurses and other disciplines that are networked and working towards excellent patient care and continuous system improvement for the STEMI patient.
Results
1. Since the feedback program was established, the door-to-balloon time has improved dramatically. At the start of our program in Jan 2009 the average Door To Balloon time for our referring hospitals was 124 minutes. In 2011, the average door-to-balloon time for this same group was 89.5 minutes .The national goal is 120 minutes for transfers. At Fletcher Allen Health Care our DTB time remains consistent at an average of 62 minutes. The national goal for DTB times at Primary PCI sites (FAHC) is 90 minutes.
2. The nurse feedback program includes hospitals in Zone 1 – Copley, Porter, Central Vermont Medical Center and Northwestern Vermont Medical Center. The program also provides feedback for any Zone 2 hospital that sends a STEMI patient. Even if the patient ends up not being a STEMI, the Primary PCI Site will call the sending hospital to follow up.
3. The satisfaction level between nursing peers has improved significantly. The average Lickert Scale satisfaction scores for the four sending hospitals and Fletcher Allen increased from 1.75 pre-intervention to 4.5 post-intervention.
4. After the first year of the program, the average triage time decreased from 29 minutes to 19 minutes. The door to balloon time decreased from 124 min to 86 minutes.
5. Standardized algorithms and treatment plans, documentation, STEMI tool box, improvements in emergency paging and single pager system, communication algorithms, intake forms and field activation by EMS crews are examples of system improvements.
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Dialysis Infection Prevention
Time Frame: 2009-2012
Description/Problem
Bloodstream infections (BSIs) are a potentially devastating complication of hemodialysis. The CDC estimates that 37,000 central line-associated BSIs may have occurred in hemodialysis patients in the United States in 2008. An improvement project was designed to reduce the rate of access-related BSI (ARB) in outpatient hemodialysis centers. The focus was on those patients with a central line (CL).
Project Goals
To reduce the rate of central-line access-related BSI (CL-BSI) in six out-patient hemodialysis centers at Fletcher Allen.
Specific Project Goals
1. Staff engagement and education
2. Participate in the CDC Dialysis BSI Prevention Collaborative
3. Standardize bedside practices
4. Standardize the measurement system and report the data to staff
Interventions
1. Established advocate team for basic infection prevention education and to brainstorm on best practices. Monthly feedback of BSI rates and adherence to recommended practices. Staff and leaders communicate back to units.
2. Implementation of CDC core interventions, including standard practices of catheter and vascular access care and use of an observation audit tool to educate and assess compliance.
3. Establish Fistula First initiative – multidisciplinary team reviewed roadblocks to fistula creation and catheter discontinuation. Established access coordinators at each unit and empowered hemodialysis technician staff to provide input.
4. Implementation use of alcohol-based chlorhexidine solution for skin antisepsis.
5. Implementation of enhanced catheter hub cleansing method and time.
6. Establish surveillance of hand hygiene and glove use.
7. Implementation use of antimicrobial ointment at catheter exit site.
8. Establish a commitment to patient education.
Results
The combined incidence of CL-ARB decreased from 4.8/100 patient-months during the baseline period (11/07-5/09) to 2.0 for the most recent 12 months (4/11-3/12), a 58 percent reduction. The data show sustained reduction in CL-ARB in each of the six dialysis centers although the magnitude of the reduction varied by site; two sites experienced zero CL-ARB for more than 12 months. Reductions were associated with the use of bedside best practices including standard surveillance methods with frequent feedback and the use of the CDC core interventions.
Over the past three years, the Fletcher Allen Dialysis teams have prevented an estimated 146 dialysis-related bloodstream infections.
In an effort to share Fletcher Allen's best practices at a national level, Sally Hess, MPH, CIC, Manager of Infection Prevention became a founding member of the CDC’s Dialysis BSI Prevention Collaborative Steering Committee. The collaborative members developed and implemented a package of practice interventions based on evidence where available and incorporated theoretical rationale when published evidence was unavailable. These interventions are being spread nationally by the CDC as well as through professional organizations and national scientific publications. Sally Hess has been a speaker at national and state meetings describing the interventions and sharing the success of the Fletcher Allen program.
