Implementation of a Quality Improvement Initiative Reduces ......Ankica Djurcic–Jovan, MN, BScN,...
1
Ankica Djurcic–Jovan, MN, BScN, RN, CHPCN(C), Alexandra Eisener, MEd, BScN, RN, Sheryl McDiarmid, MEd, MBA, BScN, RN, CVAA, CRNI, Andrea Jewell, MN, RN Describe the implementation of a quality improvement initiative which reduced the incidence of Peripherally Inserted Central Catheter (PICC) migrations at a complex continuing care (CCC) hospital. This project was realised in collaboration with an acute care facility. Implementation of a Quality Improvement Initiative Reduces PICC Migrations in a Complex Continuing Care Hospital • If PICC line is not functioning properly – DO NOT use the PICC catheter until it is unblocked or replaced. • NRT in Conjunction with Ottawa Hospital. Process LEGEND Decision Beginning/End process 5 cm or less Fax to the TOH PICC office at 613-761-4286 Report the migration and ask them if chest x-ray is required Continue to use PICC line YES NO External PICC Migration during the regular work week. Confirm that blood can be withdrawn from the line and that it flushes well. 5 cm or less If patient is not receiving chemo therapy continue to use PICC Call the TOH PICC office 613-798-5555 ext.17692. Report the migration (leave a message) and ask if chest x-ray is required. (Follow up on Monday or next business day.) Fax to the TOH PICC office at 613-761-4286 NO YES YES NO External PICC Migration during the weekend and/or “Stat” holidays. Confirm that blood can be withdrawn from the line and that it flushes well. Greater than 5 cm If patient is not receiving chemo therapy – Evaluate the patient’s peripheral veins and determine if peripheral access is a possibility & if patient is in agreement to start peripheral IV. Call MD If peripheral access is obtainable & the MD orders it; the medication may be given peripherally YES NO Continue to use PICC line Obtain Chest x-ray Greater than 5 cm Obtain Chest x-ray Continue to use PICC line Continue to use PICC line YES NO Continue to use PICC line Obtain Chest x-ray PICC tip is in the Superior Vena Cava (SVC) NO YES Use the peripheral access, obtain chest x-ray next working day Continue to use PICC line until next working day YES NO Continue to use PICC line PICC tip is in the Superior Vena Cava (SVC) Obtain Chest x-ray PICC tip is in Superior Vena Cava (SVC) PICC line is in the Superior Vena Cava (SVC) a) b) Do not use PICC line, notify M.D. Consider starting a peripheral IV line, if necessary a) b) Do not use PICC line, notify M.D. Consider starting a peripheral IV line, if necessary a) b) Do not use PICC line, notify M.D. Consider starting a peripheral IV line, if necessary a) b) Do not use PICC line, notify M.D. Consider starting a peripheral IV line, if necessary a) b) Purpose Quantitative: Measured success indicators by comparing pre and post project data including: • Retrospective chart review using a chart audit tool to identify frequency of PICC migration and cross verification with health records and data from pharmacy to confirm use of tissue plasminogen activator (tPA). Collect migration rates with tPA treatment. Qualitative • Each education strategy was evaluated throughout the project to gather feedback on content and delivery for continual improvement. • Post project surveys measured: – Patient satisfaction related to their experience with the stabilization device insertion, care, and maintenance. – Nursing satisfaction of education strategy and material received. – Nursing perception of the ease of care and maintenance (i.e. dressing changes) of PICCs with stabilization device. – Physician satisfaction with the nursing care after PICC bundle implementation (anecdotal). Evaluation • Use a recognized tool such as the Force Field Analysis developed by Lewin (1951) to inform decision making when planning and implementing a change within an organization. The Force Field Analysis provided structure for assessing and identifying factors needing to be addressed and monitored throughout the initiative to be successful. • Integrate multiple interventions and strategies within an implementation plan to increase the chance of clinician acceptance. For example, the CCC hospital combined several education approaches and incorporated PICC migration guidelines into hospital policy with the application of a stabilization device at PICC insertion site to reduce catheter migration. • Collaborate and build partnerships with many health care organizations to continually improve patient care. This collaborative quality improvement initiative between regional partners reduced PICC migration resulting in improved patient satisfaction and outcomes with a decrease cost to the healthcare system. Recommendations Ouslander, J. G, Perloe, M., Givens, J. H., Kulge, L., Rutland, T., and Lamb, G. (2009). Reducing potentially avoidable hospitalizations of nursing home residents: Results of a pilot quality improvement project. Journal of the American Medical Directors Association, 10(9), pp. 644-652. Lewin. K. (1951). Field theory in social science. New York: Harper & Row. Brager, B., & Holloway, S. (1992). Assessing Prospects for Organizational Change: The uses of Force Field Analysis. Organizational Change and Development. Haworth Press, INC New York). Reference 1. A Force Field analysis tool based on Lewin’s change theory was used to assess the prospect of change and to identify barriers and facilitators for change resulting in strategies for improvement (Lewin, 1951 & Brager & Holloway, 1992). 2. Collaborated with the Advanced Practice Nurse of the PICC to develop guidelines for PICC migration centered on evidenced-based practice. 3. A revision of hospital PICC policy to include the new guidelines as well as care and maintenance of stabilization device. 4. Insertion of a stabilization device - SecurAcath© - to prevent catheter migration. 5. Use of a variety of clinician education strategies including best practice recommendations for nurses and physicians re: revised policy and stabilization device. a. Communication of the initiative to clinical teams, managers, and physicians (verbal, emails, internal website, etc.); b. Teleconference to reach the physician group; c. In services provided to nursing staff during all shifts (on all units) at start of implementation and six months post implementation. d. Hands on education at the bedside for nurses during PICC care and maintenance; e. Stabilization device’s product educational videos posted on the CCC hospital’s internal website. 6. Use of quantitative and qualitative evaluation strategies. Post-implementation: three reinsertions from February to September 2015 noted. An estimated 10, 149$ of savings is noted on patient transportation to PICC clinic alone. There was no documented external migration on patients with the PICC stabilization device in situ. Soft savings were revealed through reduction of clinician time coordinating care and ease of manipulating PICC during care and maintenance. Methods Results This initiative occurred at a 336 bed hospital which is the sole provider of complex continuing care in Ottawa, ON. The PICC clinic, at the nearby acute care facility, is responsible for the majority of CCC patients PICC insertions, and trouble-shooting including addressing line issues and migrations. Background Purpose A CCC hospital noted a large number of PICC migrations, and noncompliance to best practices resulting in potential patient harm, delays in infusion therapy, and unnecessary healthcare costs. • Fifty-four patients had a PICC in situ from January 10, 2014 - February 10, 2015. A total of 60 PICC reinsertions occurred during that time as a result of catheter migration. • X-ray tip placement confirmation is required prior to use if line migration is suspected. CCC hospital’s x-ray services are only available Monday to Fridays, 0800 – 1600. A number of physicians continued to order the use of the PICC without tip confirmation. A few physicians even pulled the line out to create “midline” catheters. • Patients must be transferred offsite to an outpatient PICC clinic in acute care for PICC insertions. Transfers can have a negative physical and psychological effect on patients which are more pronounced in an elderly population (Ouslander, Perloe, Givens, Kulge, Rutland, & Lamb 2009). • Increased workload for nurses at the CCC hospital and at the PICC clinic. Potential reasons for external migration of the PICC catheter at CCC: • Change of patient population requiring long term use of the PICCs • Inadequate dressing changes by nurse Specialized Complex Care: • Patients with progressive disease and multiple medical conditions that require ongoing monitoring by an interprofessional team. Including: Dialysis, Complex, Ventilator, Wounds, Bariatric Programs Transitional: • Assisting patients with the coordination and continuity of health care as they transfer from one healthcare setting to either another or to home. Supportive: • Patients with severe functional impairment and require a higher level care than what can be provided by community agencies. Restorative: • Care aimed at functional improvement over an extended period of time. No. of Beds 101 100 43 92 A significant decrease in PICC reinserts resulted in cost savings 20, 215$. Nsg Practice 03-A - Guidelines for External Migration of PICC lines Inserted at TOH Catheter Remains Stable and Secure During Cleaning Minimizes Catheter Migration Ease of Dressing Application Overall Use of the Device Very Good Good Neutral Poor Very Poor Very Good Good Neutral Poor Very Poor 0% 0% 67% 28% 5% 53% 42% 5% 0% 0% 76% 12% 6% 6% 0% 74% 5% 21% 0% 0% PICCs with and without stabilization device Total ($) with and without SecurAcath Total Cost ($) with and without SecurAcath Without SecurAcath© With SecurAcath© 45 54 3 60 3 60 3 60 0 60 3 60 3 30 0 # PICCs # PICC Reinsertions Transfer to PICC clinic via Ambulance X Ray tPA 10 20 30 40 50 60 70 Nursing time coordination care (hrs) Physician time (hrs) 1125 0 75 0 510 10200 210 4200 0 3600 105 2100 225 2250 0 # PICCs # PICC Reinsertions Transfer to PICC clinic via Ambulance X Ray tPA 2000 4000 6000 8000 10000 12000 Nursing time coordination care (hrs) Physician time (hrs) 2145 22350 0 Total Cost 5000 10000 15000 20000 25000 Total: 100% Total: 100% Total: 100% Total: 100%
Transcript of Implementation of a Quality Improvement Initiative Reduces ......Ankica Djurcic–Jovan, MN, BScN,...
-
Ankica Djurcic–Jovan, MN, BScN, RN, CHPCN(C), Alexandra Eisener, MEd, BScN, RN, Sheryl McDiarmid, MEd, MBA, BScN, RN, CVAA, CRNI, Andrea Jewell, MN, RN
Describe the implementation of a quality improvement initiative which reduced the incidence of Peripherally Inserted Central Catheter (PICC) migrations at a complex continuing care (CCC) hospital. This project was realised in collaboration with an acute care facility.
Implementation of a Quality Improvement InitiativeReduces PICC Migrations in a Complex Continuing Care Hospital
• If PICC line is not functioning properly – DO NOT use the PICC catheter until it is unblocked or replaced.• NRT in Conjunction with Ottawa Hospital.
Process
LEGEND
Decision
Beginning/Endprocess
5 cm or less
Fax to the TOHPICC office at613-761-4286
Report the migrationand ask them if
chest x-rayis required
Continueto use
PICC line
YESNO
External PICC Migration during the regular work week.Confirm that blood can be withdrawn from the line and that it flushes well.
5 cm or less
If patient is not receivingchemo therapy continue
to use PICC
Call the TOH PICC office613-798-5555 ext.17692.
Report the migration(leave a message) and ask
if chest x-ray is required.(Follow up on Mondayor next business day.)
Fax to the TOH PICCoffice at 613-761-4286
NO
YES
YES
NO
External PICC Migration during the weekend and/or “Stat” holidays.Confirm that blood can be withdrawn from the line and that it flushes well.
Greater than 5 cm
If patient is not receiving chemo therapy– Evaluate the patient’s peripheral veins and determine
if peripheral access is a possibility & if patient is in agreementto start peripheral IV. Call MD
If peripheral access is obtainable & the MD orders it;the medication may be given peripherally
YES
NO
Continueto use
PICC line
Obtain Chest x-ray
Greater than 5 cm
ObtainChest x-ray
Continueto use
PICC line
Continueto use
PICC line
YES
NO
Continueto use
PICC line
ObtainChest x-ray
PICC tip is inthe Superior Vena
Cava (SVC)
NOYES
Use the peripheral access,obtain chest x-raynext working day
Continue to usePICC line until
next working day
YES
NO
Continueto use
PICC linePICC tip is inthe SuperiorVena Cava
(SVC)
ObtainChest x-ray
PICC tip is inSuperior Vena Cava (SVC)
PICC line is inthe Superior Vena
Cava (SVC)
a)
b)
Do not use PICCline, notify M.D.
Consider startinga peripheral IV line,
if necessary
a)
b)
Do not use PICCline, notify M.D.
Consider startinga peripheral IV line,
if necessary
a)
b)
Do not use PICCline, notify M.D.
Consider startinga peripheral IV line,
if necessary
a)
b)
Do not use PICCline, notify M.D.
Consider startinga peripheral IV line,
if necessary
a)
b)
PurposeQuantitative: Measured success indicators by comparing pre and post project data including:• Retrospective chart review using a chart audit tool to identify frequency of PICC migration and cross veri�cation with health records and data from pharmacy to con�rm use of tissue plasminogen activator (tPA). Collect migration rates with tPA treatment.Qualitative• Each education strategy was evaluated throughout the project to gather feedback on content and delivery for continual improvement.• Post project surveys measured: – Patient satisfaction related to their experience with the stabilization device insertion, care, and maintenance. – Nursing satisfaction of education strategy and material received. – Nursing perception of the ease of care and maintenance (i.e. dressing changes) of PICCs with stabilization device. – Physician satisfaction with the nursing care after PICC bundle implementation (anecdotal).
Evaluation
• Use a recognized tool such as the Force Field Analysis developed by Lewin (1951) to inform decision making when planning and implementing a change within an organization. The Force Field Analysis provided structure for assessing and identifying factors needing to be addressed and monitored throughout the initiative to be successful.• Integrate multiple interventions and strategies within an implementation plan to increase the chance of clinician acceptance. For example, the CCC hospital combined several education approaches and incorporated PICC migration guidelines into hospital policy with the application of a stabilization device at PICC insertion site to reduce catheter migration.• Collaborate and build partnerships with many health care organizations to continually improve patient care. This collaborative quality improvement initiative between regional partners reduced PICC migration resulting in improved patient satisfaction and outcomes with a decrease cost to the healthcare system.
Recommendations
Ouslander, J. G, Perloe, M., Givens, J. H., Kulge, L., Rutland, T., and Lamb, G. (2009). Reducing potentially avoidable hospitalizations of nursing home residents: Results of a pilot quality improvement project. Journal of the American Medical Directors Association, 10(9), pp. 644-652.Lewin. K. (1951). Field theory in social science. New York: Harper & Row.Brager, B., & Holloway, S. (1992). Assessing Prospects for Organizational Change: The uses of Force Field Analysis. Organizational Change and Development. Haworth Press, INC New York).
Reference
1. A Force Field analysis tool based on Lewin’s change theory was used to assess the prospect of change and to identify barriers and facilitators for change resulting in strategies for improvement (Lewin, 1951 & Brager & Holloway, 1992). 2. Collaborated with the Advanced Practice Nurse of the PICC to develop guidelines for PICC migration centered on evidenced-based practice.
3. A revision of hospital PICC policy to include the new guidelines as well as care and maintenance of stabilization device. 4. Insertion of a stabilization device - SecurAcath© - to prevent catheter migration. 5. Use of a variety of clinician education strategies including best practice recommendations for nurses and physicians re: revised policy and stabilization device. a. Communication of the initiative to clinical teams, managers, and physicians (verbal, emails, internal website, etc.); b. Teleconference to reach the physician group; c. In services provided to nursing staff during all shifts (on all units) at start of implementation and six months post implementation. d. Hands on education at the bedside for nurses during PICC care and maintenance; e. Stabilization device’s product educational videos posted on the CCC hospital’s internal website.
6. Use of quantitative and qualitative evaluation strategies.
Post-implementation: three reinsertions from February to September 2015 noted. An estimated 10, 149$ of savings is noted on patient transportation to PICC clinic alone. There was no documented external migration on patients with the PICC stabilization device in situ. Soft savings were revealed through reduction of clinician time coordinating care and ease of manipulating PICC during care and maintenance.
Methods
Results
This initiative occurred at a 336 bed hospital which is the sole provider of complex continuing care in Ottawa, ON.
The PICC clinic, at the nearby acute care facility, is responsible for the majority of CCC patients PICC insertions, and trouble-shooting including addressing line issues and migrations.
Background
PurposeA CCC hospital noted a large number of PICC migrations, and noncompliance to best practices resulting in potential patient harm, delays in infusion therapy, and unnecessary healthcare costs. • Fifty-four patients had a PICC in situ from January 10, 2014 - February 10, 2015. A total of 60 PICC reinsertions occurred during that time as a result of catheter migration.• X-ray tip placement con�rmation is required prior to use if line migration is suspected. CCC hospital’s x-ray services are only available Monday to Fridays, 0800 – 1600. A number of physicians continued to order the use of the PICC without tip con�rmation. A few physicians even pulled the line out to create “midline” catheters.• Patients must be transferred offsite to an outpatient PICC clinic in acute care for PICC insertions. Transfers can have a negative physical and psychological effect on patients which are more pronounced in an elderly population (Ouslander, Perloe, Givens, Kulge, Rutland, & Lamb 2009).• Increased workload for nurses at the CCC hospital and at the PICC clinic.
Potential reasons for external migration of the PICC catheter at CCC: • Change of patient population requiring long term use of the PICCs• Inadequate dressing changes by nurse
Specialized Complex Care:• Patients with progressive disease and multiple medical conditions that require ongoing monitoring by an interprofessional team. Including: Dialysis, Complex, Ventilator, Wounds, Bariatric
Programs
Transitional:• Assisting patients with the coordination and continuity of health care as they transfer from one healthcare setting to either another or to home.
Supportive:• Patients with severe functional impairment and require a higher level care than what can be provided by community agencies.
Restorative:• Care aimed at functional improvement over an extended period of time.
No. ofBeds
101
100
43
92
A significant decrease in PICC reinserts resulted in cost savings 20, 215$.
Nsg Practice 03-A - Guidelines for
External Migrationof PICC lines
Inserted at TOH
Catheter Remains Stable and Secure During Cleaning Minimizes Catheter Migration
Ease of Dressing Application Overall Use of the Device
Very GoodGoodNeutralPoorVery Poor
Very GoodGoodNeutralPoorVery Poor
0% 0%
67%
28%
5%
53%42%
5%0% 0%
76%
12%6% 6%
0%
74%
5%21%
0% 0%
PICCs with and without stabilization device Total ($) with and without SecurAcath Total Cost ($) with and without SecurAcath
Without SecurAcath©With SecurAcath©
45
54
3
60
3
60
3
60
0
60
3
60
3
30
0# PICCs # PICC
ReinsertionsTransfer to
PICC clinic viaAmbulance
X Ray tPA
10
20
30
40
50
60
70
Nursing timecoordination care
(hrs)
Physiciantime (hrs)
11250 750
510
10200
210
4200
0
3600
105
2100
225
2250
0# PICCs # PICC
ReinsertionsTransfer to
PICC clinic viaAmbulance
X Ray tPA
2000
4000
6000
8000
10000
12000
Nursing timecoordination care
(hrs)
Physiciantime (hrs)
2145
22350
0Total Cost
5000
10000
15000
20000
25000
Total: 100%
Total: 100%
Total: 100%
Total: 100%
