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'Culture of safety' sets tone for improvement
Registration times slashed, elopement rate cut
By laying a strong culture of safety as a foundation, ED leaders at Moses Cone Health System in Greensboro, NC, have achieved impressive process improvements tied to patient safety. For example:
It all began about four years ago when Marion C. Martin, RN, MSN, MBA, the system's patient safety officer was (until 2006) director of emergency services for its Level II trauma ED. Martin initiated a series of patient safety education programs.
"Those nurses who had long tenure, leadership skills, and special training were assigned," she says. At Moses Cone, RNs receive a level designation of one to four based on seniority, and the programs were led by RN-3s, says Martin. The programs addressed five specialties: pediatrics, trauma, pulmonary care, neurosurgery/neurology, and behavior health.
The nurses gave their presentations at staff meetings, addressing safety issues, documentation, sharing of data, and so forth. So, for example, the RN-3 addressing trauma talked about how to get the ED physician to the trauma room as quickly as possible when a patient presents, capturing any acute changes in the patient, getting critical values, and conducting a rapid assessment.
"They addressed a number of quality indicators," adds Martin. "When discussing stroke, for example, since our nurses can call a stroke code, they would talk about getting tPAs [Tissue Plasminogen Activator] on board quickly, or how quickly you should get a patient to a CT scan." The messages must have hit home. Moses Cone recently was certified as a Primary Stroke Center by The Joint Commission.
With additional education under their belts and the importance of patient safety effectively communicated, Martin and Kathy Haddix-Hill, RN, MSN, executive director of emergency services, instituted initiatives to improve processes and speed patient care.
For example, in the past, patient identification was inconsistent and time-consuming. "If we were busy, the patient would have to wait in the waiting room; and when the triage nurse got caught up, they'd call them, and then they would get an [identification] armband," says Martin.
Using "Lean" methodology first developed by Toyota, a new system was created. Patients now are triaged upon arrival, then brought straight back to a room to get an armband that has all their vital information: medical record number, visit number, name, and date of birth. "Based on everyone's involvement, we've gone from 47 minutes average time to armband to three minutes and 12 seconds — which is when the protocols start," says Martin. "It also meets one of the National Patient Safety Goals: having [at least] two patient identifiers."
Haddix-Hill adds, "We in ED management are really into keeping the staff and patients safe. This was a big initiative for us."
Another important initiative involves patient flow managers — a number of individuals at a remote location who monitor ED patients 24/7 electronically. "They see when the patient arrives, how long it is until they are seen by a doctor, and when they are admitted to a bed," says Martin. If they note a delay in any process, she continues, they will call the physician or nurse. "This has helped tremendously in elopement, which has gone from 10% to 4.4%," Martin says. "We've also lowered average time in the department by 17 minutes."
Another move that has speeded patient care is the transformation of a small office in the ED into an EKG room. "Now, if patients check in with chest pain, they can get an EKG in 10 minutes or less," says Martin.
Keeping track of meds
Moses Cone also remains compliant with The Joint Commission medication standards using the EmSTAT Emergency Department Information System (EDIS) from A4 Health Systems of Cary, NC, and Dallas. "We have flags in our system that pop up with alerts for the physicians if they attempt, for example, to prescribe a medicine to which the patient is allergic," says Haddix-Hill. "It will also indicate if it will not work well with other drugs they are taking."
Because the system has a safety portal, they have an electronic way to enter any adverse outcomes, adds Martin. She also notes that the system, which was implemented two years ago, will print off a list of the patient's medications, which they will receive as part of the discharge process. This meets another patient safety goal for reconciling the patient's medications, Martin says.
Another initiative set to begin shortly is a remote electronic ICU the system calls e-Link Critical Care. With this system, a team of doctors and nurses specializing in intensive care monitors ICU patients' lab results, heart rates, breathing, and other factors from a dedicated control room. Computers track vital signs and alert the team when a patient's condition begins to deteriorate. The team alerts critical care nurses in the intensive care units before problems develop. "This will be a big safety factor," Martin predicts.
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