BEST CARE ALWAYS: GENERAL WARD CHANGE PACKAGE

General Ward

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Best Care Always Change Package: General Ward Driver Diagram Developed by the Institute for Healthcare Improvement · Updated 9/25/2013

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Best Care Always Change Package: General Ward Developed by the Institute for Healthcare Improvement · Updated 9/25/2013

Provide appropriate, reliable, and timely care to patients using evidence based therapies

Change Concept Ideas To Try

1. Use the Early Warning

System (EWS) to identify

patients at risk for

deterioration

Assess patient risk for deterioration using the Early Warning Scoring System

2. Use an Early Response

System (Outreach or

Rapid Response Team

(RRT)) to respond to

patient deterioration

Establish a coordinated team to rapidly respond to deteriorations in a patient’s condition

3. Prevent healthcare

associated infections

and cross contamination

Establish reliable hand hygiene practices

o Ensure staff are knowledgeable about infections, transmission principles, hand hygiene, and

hand washing techniques

o Make hand washing facilities, soap, alcohol hand rub solution, and gloves available at the point

of care

o Monitor and provide feedback on infection data and hand hygiene compliance to clinicians

o Create a culture that supports reliable hand hygiene practices

o Do not use alcohol hand rub solution alone when Clostridium difficile is known or suspected, or

when hands have been contaminated with any soilage/organic matter

Identify patients with antibiotic resistant organisms (AROs) through active surveillance cultures (ACS)

o Identify patients at risk of having AROs and create a process to ensure they are screened

o Create a reliable process to obtain and process cultures

o Create a reliable and timely process for notification of culture results

o Create a protocol for the management of colonized patients

o Monitor and provide feedback on ACS testing and patient management procedures

o Flag colonized patients

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3. Prevent healthcare

associated infections

and cross contamination

[Continued]

Use contact precautions and dedicated equipment for patients with known or suspected

infection/colonization spread via direct or indirect contact

o Ensure staff are knowledgeable regarding contact precautions (including current staff, new

employees, and rotating staff)

o Place infected and colonized patients on contact precautions as per the Centers for Disease

Control (CDC) or other guidelines

(http://www.cdc.gov/mrsa/prevent/healthcare/precautions.html)

o Place infected and colonized patients in a single room if possible. If necessary, cohort patients

If neither is possible, create a “security zone” around the bed space (e.g. red tape on

the floor)

o If the patient must be transported, alert the receiving area/ward/service

o Monitor and provide feedback

Use appropriate room cleaning and disinfection procedures

o Put environmental services personnel on the improvement team

o Educate staff on cleaning and disinfection procedures and assess competence

o Ensure staff wear appropriate attire (gown, gloves, etc) when cleaning

o Make it easy to distinguish disinfected equipment from contaminated equipment

o Disinfect reusable equipment

o Prioritize room cleaning and disinfection by focusing on frequently touched surfaces (e.g;,

bedrails, doorknobs, bathroom fixtures, etc)

o Create a checklist for room cleaning and disinfection

o Monitor and provide feedback

Use dedicated equipment for colonized patients

o Educate staff on appropriate management of equipment

o Ensure the availability of required supplies

Monitor and provide feedback on availability of equipment and compliance with management

http://www.cdc.gov/mrsa/prevent/healthcare/precautions.html

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3. Prevent healthcare

associated infections

and cross contamination

[Continued]

Optimize antimicrobial prescribing

o Use protocols and auto-stop points for antibiotics

o Establish formulary restrictions

o Establish clinical practice guidelines with standardized order sets

Standardized order sets contain pre-approved indications (it’s best if part of a

computerized physician order entry system)

o Use computer assisted antibiotic management

o Use pharmacy substitutions and protocol driven IV/PO switches

o Use therapeutic de-escalation

o Consider antibiotic cycling

o Provide unit and/or provider specific utilization feedback

o Monitor and provide feedback

o Establish an antibiotic stewardship program

Use decolonization to decrease the burden of organisms

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4. Prevention of Catheter

Associated Urinary Tract

Infections (CAUTI)

Avoid unnecessary use of urinary catheters

Develop criteria for appropriate catheter insertion based on published guidelines and require

verification prior to every insertion

Ensure there is an adequate supply of alternatives to indwelling catheters

Insert urinary catheters using aseptic technique

o Utilize appropriate hand hygiene

Maintain urinary catheters based on published guidelines

o Maintain a sterile, continuously closed drainage system

o Keep catheter properly secured

o Keep collection bag below the level of the bladder at all times

o Maintain unobstructed urine flow

o Empty the collection bag regularly, using a separate collection container for each patient

Review urinary catheter necessity daily against criteria

o Include catheter necessity in the nursing assessment at every shift, with a requirement that a

physician must be contacted if criteria is not met

o Develop nursing protocols that allow for the removal of urinary catheters if criteria is not met

and if there are no contraindications for removal

o Implement automatic stop orders for 48-72 hours after insertion, with continuation only when

indication has been documented in a renewal order

Use reminders or other alerts requiring physicians to document indication for the continuation of a

catheter

5. Prevent Clostridium

difficile infections

Use protocols provided by Hamad Medical Corporation

6. Prevent Staph. aureus

(both MRSA and MSSA)

blood stream infections

Use protocols provided by Hamad Medical Corporation

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7. Provide timely care for

patients with sepsis

Reliable Sepsis Screening

o Identify sepsis using EWS charts + SIRS screening o Implement screening tool

EWS trigger (local guidelines) with 2 out of 4 SIRS criteria o Temperature: 38oC

o Pulse: ≥ 90 beats per minute

o White Blood Count 12 cells/mm3

o Respiratory Rate >20 breaths per minute

Ensure reliable delivery of the Sepsis Six within 1 hour to all septic patients o Give oxygen therapy to achieve target SpO2 92-94% (In COPD patients, achieve target SpO2

88-92%) o Take blood cultures ideally before antibiotics and consider source control o Administer broad spectrum antibiotics according to local protocol o Administer an IV fluid challenge (crystalloid, minimum 500 mls. within 1 hour), reassess and

repeat as indicated o Measure lactate o Assess urine output and consider urinary catheterisation

Use the Severe Sepsis 3-Hour Resuscitation Bundle (to be completed within 3 hours of the time of

presentation with severe sepsis)

o Measure lactate level

o Obtain blood cultures prior to the administration of antibiotics

o Administer broad spectrum antibiotics, ideally within the hour

o Administer 30mL/kg crystalloid for hypotension or lactate ≥4mmol/L

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7. Provide timely care for

patients with sepsis

[Continued]

Use the 6-Hour Septic Shock Bundle (to be completed within 6 hours of the time of presentation with

severe sepsis)

o Apply vasopressors for hypotension that does not respond to initial fluid resuscitation to

maintain a mean arterial pressure (MAP) ≥65 mmHG

o In the event of persistent arterial hypotension despite volume resuscitation or initial lactate ≥ 4

mmol/L (36 mg/dL):

measure central venous pressure (DVP)

measure central venous oxygen saturation (ScvO2)

o Remeasure lactate if initial lactate was elevated

Targets for quantitative resuscitation are CVP ≥ 8 mmHg, ScvO2 ≥ 70%, and normailisation of lactate

8. Prevent Pressure Ulcers Conduct pressure ulcer assessment on all patients upon admission(within 4 hours from time of

admission) Reassess risk of pressure ulcers for all patients daily

Use full SSKIN pressure ulcer prevention bundle

o S- SURFACE Ensure patient is on the correct surface

o S –SKIN INSPECTION-Inspect skin daily

o K- KEEP MOVING – Minimize pressure by ensuring patients keep moving when in bed and

seated

o I- INCREASED MOISTURE- Ensure skin moisture is effectively managed and skin is kept

clean and dry

o N- NUTRITION- Optimize nutrition and hydration

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9. Prevent Venous

Thromboembolisms

Provide reliable VTE prophylaxis

o Standardize assessment for risk

o Ambulate low risk patients early in the post-operative period

o Consider one of the following for moderate risk patients:

low dose heparin (LDH)

low molecular weight heparin (LMWH)

dextran

aspirin

elastic stockings

intermittent pneumatic compression (IPC)

o Consider LDL or LMWH plus elastic stockings or IPC for high risk general surgery patients

o Consider LDH, LMWH, or therapeutic warfarin for hip replacement patients

o Consider LMWH and IPC for knee replacement patients

o Consider unfractionated heparin (UFH), LMWH, heparinoid, IPC, and foot impulse for hip

fracture patients

o Consider insertion of inferior vena cava (IVC) filters in high risk trauma patients

Continue prophylactic treatment post-discharge when appropriate

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Create a highly effective and collaborative multidisciplinary team and safety culture

Change Concept Ideas to Try

1. Create a highly effective

multidisciplinary team and

safety culture

Institute Multidisciplinary Rounds

o Include doctors, nurses, pharmacy, physiotherapy, nutrition, case managers, social

workers, family members, and other key care team members in rounds

o Use discipline specific rounding and prep sheets to prompt clinicians on key items to

address during rounds

Institute unit based safety briefings

o Focus on patients with increased risk for injury, for example increased fall risk, receiving

high risk drugs, similar names, etc

Institute debriefings post adverse events/serious incidents

Consider the use of critical assertion language to maintain safe practice

Use simulation of low frequency, high-risk events and reenactments to maintain competency and

enhance system capability

Standardize clinical communications and handoffs

o Use SBAR: Situation, Background, Assessment, Recommendation

o Use standard handoff templates

Conduct formal team training programs

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Ensure patient and family centered care

Change Concept Ideas to Try

1. Involve the patient and family

in the daily goal setting

process

Include the patient and family during multi-disciplinary rounds

Include the patient and family in daily goal setting

Actively engage patients and family in preventing harm

Provide comprehensive information for patients and families to enable them to make more

informed choices

Co-design patient information and care processes with patient and family involvement

Use patient shadowing exercises and patient stories to help staff understand the process of care

from a different perspective

Actively seek patient and family opinion and use the information to improve

2. Promote open communication

among the patient, family, and

members of the care team

Establish processes to promote open communication among patients, families, and the care team

such as:

o allowing open visitation for families

o encouraging families to ask questions

o using white boards to enhance communication between the family and the care team

o using voicemail or other messaging systems for family communication with the care team

o educating the family about various care processes such as the risk of pressure ulcers and

falls to alert them to the risk and to involve them in reducing the risk of harm

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