Total Quality and Patient Safety Council
Highlights from the May meeting of the Total Quality and Patient Safety Council (TQPSC) follow. Questions may be directed to Adele Towers, MD, MPH, vice chairwoman, Quality Improvement, Department of Medicine, at towersal@upmc.edu.
MERIT Committee
Carol Scholle, RN, MSN, clinical director, Transplant and Dialysis Services, and Dan Shearn, RN, MSN, clinical director, Critical Care, presented an update on the Medical Emergency Response Improvement Team (MERIT) committee activities. The goal of the committee is to increase focus on timely intervention and prevention of codes, simplifying and clarifying criteria for those who call codes, and providing enhanced clarity for responders who are on assigned code teams.
One significant change brought about by the MERIT committee was the development of a small laminated card to be worn on the employee’s ID badge holder. This card identifies revised criteria for calling a Condition C. Criteria were revised to be broader and to give staff more autonomy in deciding when to call a Condition C. Revised criteria include breathing difficulty, certain heart rate changes, neurologic changes, chest pain, and, notably, any concern that there is a deteriorating clinical condition. Mr. Shearn noted that Joseph Darby, MD, Critical Care, was instrumental in simplifying these changes.
A number of changes have been made in how codes are called at UPMC Presbyterian to make it easier for staff to call codes and for code teams to respond. Operators have transitioned to using the phonetic location for each code location (with the exception of the letter W), and room numbers now are included in the code location announcement. Work is being completed on system response with simultaneous conditions. Furthermore, roles of responders have changed. The bedside nurse now is in charge of documentation rather than medication administration, and a role of nurse team leader has been created to direct nurses during a code call. To meet various regulatory requirements, narcotics also have been removed from the crash carts.
Food and Nutrition Services
Kelly Danis, manager, Food and Nutrition Services, presented an update on several areas of interest in the department. These areas include nutrition risk assessment, malnutrition as it relates to NPO and clear liquid diet days, and nutrition interventions to prevent altered nutritional status.
Ms. Danis said that approximately 90 percent of patients at UPMC Presbyterian are considered to be at nutrition risk and require intervention. Nutrition risk is determined if the patient is at risk for poor nutrition intake and outcomes. Ms. Danis noted that this is a similar profile to previous years, although the trends during the past five years have shown a decrease in low-risk patients yet a corresponding increase in moderate- and high-risk patients.
The risk of malnutrition is greater in patients who are either NPO or on clear liquid diets for more than three consecutive days, Ms. Danis said. Reducing the number of days that patients are NPO or on a clear liquid diet has been a priority in the department. Although no formal initiative has been put in place, Ms. Danis noted, there has been a significant decrease in the number of days that inpatients are on these diets. The average amount of time for intensive care unit patients is 4.78 days (a 42 percent decrease) and the average is 6.04 days for patients in other units (a 28 percent decrease).
Unit 10 North and the transplant ICUs have the longest average because of postoperative recovery and awaiting gastrointestinal function to return. Ms. Danis noted that there are plans in the department to conduct a formal quality initiative about early enteral nutrition, with a primary focus in the ICUs. Improved outcomes are expected through targeted education and awareness projects associated with this initiative.
Interventions to prevent altered nutritional status are evaluated by the percentage of oral nutrition supplements ordered by physicians, as compared to clinical nutrition staff, and the percentage of patients on modified consistency diets that are ordered by physicians as compared to the number adjusted by clinical nutrition staff. Modified consistency diets include pureed, dysphagia, mechanical soft, and thickened liquids. Oral supplements are a common intervention, Ms. Danis noted, but physician orders create only 13 percent of the orders; 48 percent are initiated by clinical nutrition staff. Physicians ordered 100 percent of modified consistency diets. However, 13 percent of dysphagia diets had no liquid level specified.
UPMC Stroke Institute
Lori Massaro, UPMC Stroke Institute, presented an update on performance measures and activities. The UPMC Stroke Institute treats more than 1,200 patients each year, and provides consultation for other patients through the UPMC Stroke Telemedicine Program. The UPMC Stroke Institute is preparing for a Joint Commission on-site recertification visit to be held sometime between July and September of this year. It is anticipated to be a two-day survey that will include both UPMC Presbyterian and UPMC Shadyside.
The Stroke Institute reports on eight performance measures. Through analyzing areas of concern on a daily basis, staff are able to identify opportunities to improve care before patients are discharged. The UPMC Stroke Institute also is participating in the Highmark initiative. Highmark and UPMC’s benchmark goal is to achieve 90 percent “defect-free care.” This means that 90 percent of patients must have no gaps in the care they receive. Additional data collected through the initiative includes the rate of aspiration pneumonia, 30-day readmission rates, and mortality. A discharge survey that Highmark conducts also collects information about adherence to prescribed medications and therapies.