Left to right: Emily Leung, research assistant, Kathleen McIntosh, RN, nurse-in-charge, and Patricia Dykes, PhD, RN, FAAN, Haley nurse scientist, hold up the newly-designed patient-centered fall prevention plan used by nurses and patients.

The Department of Nursing is committed to providing the highest-quality patient care. To accomplish this, nurses track an array of outcomes. “These measures are part of our Professional Practice Model and one of our highest priorities,” said Deb Mulloy, PhD, RN, CNOR, associate chief nurse for Quality and the Center for Nursing Excellence.

Mulloy describes the quality practice at BWH as an “improvement science,” whereby evidence-based quality improvement processes are enacted and results are measured and compared to baseline to evaluate whether a change in outcome has occurred as a result. A number of nurse-sensitive quality indicators – called “nurse-sensitive” because they are responsive to nursing care – are routinely assessed. Each one is expertly measured and tracked in a different way.

According to Margie Sipe, DNP, RN, NEA-BC, program director for quality in the Center for Nursing Excellence, quality is all about learning best practices. “Collaboration is important,” said Sipe. “We partner with other health care facilities, national organizations and collaboratives to ensure our interventions are grounded in current evidence to achieve the best outcomes.”

Preventing Falls

Preventing falls with injuries is a priority for BWH. Fall data is analyzed and evaluated to identify trends. Based on this analysis, targeted interventions are implemented to continuously improve BWH fall prevention processes.

At admission, each patient is assessed by a nurse to determine his or her fall risk and risk of injuries from a fall. “A personalized falls care plan is created to address each patient’s specific risk factors,” said Escel Stanghellini, RN, MSN, CPHQ, director of Nursing Quality Programs. Patients are reassessed every eight hours or when there is a change in their status. In collaboration with the inter-professional team, nurses engage the patient and their families during the assessment process as well as in developing an individualized plan of care using the Falls TIPS education poster. To supplement the verbal teaching, nurses may use other tools such as the fall prevention brochure or the fall prevention video. Patients at greatest risk for injuries from a fall are placed on a “fall precaution plus” program, which incorporates a bundled intervention, including increased frequency of rounds and support while toileting, more sensitive bed alarms and medication review.

Part of the fall prevention program is the implementation of continuous virtual monitors (CVM). The CVM, a monitoring device placed in patient rooms, allows a specially-trained patient care assistant, working closely with a nurse, to observe and monitor fall and injury prone patients, to potentially prevent them from falling or engaging in harmful behavior. 

Reducing Pressure Ulcers

Once each quarter, a hospital-wide pressure ulcer prevalence survey led by nurses and certified wound care experts (WOCNs) takes place. Nurse teams examine each eligible patient for evidence of pressure ulcers. “Over time, we have implemented many new evidence-based initiatives to decrease pressure ulcer incidence,” said Sipe, citing some examples, including education, careful skin inspection and risk assessment,  initiateingsystematic patient re-positioning, replacing heavy linen underpads with thin moisture-wicking pads and purchasing silicon nasal canulas to reduce pressure. “We have seen tremendous improvement in our pressure ulcer rates based on these practice changes.”

Monitoring Restraint Use

The restraint prevalence survey is conducted at the same time and mirrors the process of the pressure ulcer prevalence survey. “The teams’ aim is to minimize the use of restraints as much as possible, to reduce agitation, trauma, delirium and skin conditions,” states Mulloy.

Over the last 10 years, the hospital has reduced its use of restraints by using alternate measures and evidence based guidelines  including  early mobilization, Falls TIPS, and the DASH program, . “Past practice was to restrain patients so they wouldn’t fall,” said Stanghellini. “Today, science has taught us to address the underlying etiologies and try to use alternative, less restrictive measures to minimize time in restraints. The reduction in restraint use has not contributed to an increase in falls. In fact, it is better for patients because they experience less adverse events from physical restraints.”

The data gathered during the survey is evaluated for accuracy and any trends in contributing factors, and then submitted to National Database of Nurse Quality Indicators (NDNQI). This allows BWH to compare its outcome measures to those of other academic medical centers. Additionally, the data is sent to the Massachusetts Hospital Association (MHA) data base, called PatientCareLink. This data is compared to hospitals of similar size in Massachusetts and can be viewed by the public.

Other quality indicators that are monitored and reported at the national level are the incidence of central line infections, sepsis, deep vein thrombosis, catheter-associated urinary tract infections (CAUTI), patient satisfaction, pain and safety during blood transfusions.

“This work highlights nursing’s ongoing contributions to improving patient outcomes. In addition, evidence continues to support the importance of an interprofessional team approach to positively impact these challenging patient care issues,” said Mulloy. “This inclusive approach benefits patients.”