Technology Based Nursing System Redesign

1
Technology Based Nursing System Redesign

• John J. Pershing VAMC
• Ginger Potts, BSN, RN, Patient Safety Manager
• Sydney Wertenberger, RN, MSN, CNAA, Associate
  Director Patient Care Services
• Kay Fox, ADN, RN, Facilitator, Patient
  Care/Nursing

2
Background

• The VHA implemented computerized clinical record
  documentation and medication administration
  system which is innovative and designed to
  improve safety in healthcare delivery.

3
Problem

• When the tools were put into use the basic
  clinical work flow process remained unchanged.
  Computers were placed at the nurses station where
  the former paper charts were located and on the
  medication cart where former medication
  administration records.

4
Industry

• Healthcare is continuously striving to enhance
  safe care delivery.
• As an industry we are now looking closely at how
  the manner in which we deliver care can be
  modified to promote safety and efficiency.

5
Challenge

• The IOM report Keeping Patients Safe
  Transforming the Work Environment of Nurses
  (2004) recommends medication administration be
  the first work process redesign initiative.

6
Research

• Documentation accounts for 15-20 of nursing
  workload.
• The IOM reports that in a 12 hour time period the
  average time nurses spend doing assessment and
  direct patient care is only 1.1-3.3 hours.
• The majority of nursing staffs time is spent at
  the nurses station, walking between patient
  rooms, and in the nursing unit core (clean/dirty
  utility, med room, etc.).
• Studies have shown 38 of ADEs (Adverse Drug
  Events) were linked to administration of
  medication.
• AHRQ (Association for Healthcare Research and
  Quality) funded study found and average ADE
  increased length of stay by 4.6 days and
  increased cost of patient stay by 4685.00.

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Vision

• Transform the use of technology to its greatest
  value.
• Reduce non-value added tasks of walking to and
  from the nurses station to perform documentation.
• Make the change electronic records has created in
  nursing workflow come full circle by redesigning
  the method by which we use the tools to perform
  our daily tasks.
• Move the center of our workflow design to the
  location our work is performed (the patients
  bedside rather than at the nurses station).

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Initial Workflow Design

• Charting is performed at the nurses station.
• Team nursing model is utilized.
• Nurses are assigned according to task
• RN performs assessments/documentation for
  patients on unit, and delivers IV push
  medications,
• One nurse administers IVPB medications,
• One administers oral medications,
• Other nurses obtain vital signs and provide hands
  on personal care to patients.
• Documentation was performed mainly at nurses
  station with minimal use of laptop on medication
  carts.
• This workflow ensured the tasks were completed.
  However, all staff were not utilized to full
  potential and this model allowed for less than
  desirable continuity of care.

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Road Map to Achieve Our Vision

• Workflow Redesign
• Place a medication server equipped with computer
  access for documentation and medication delivery
  in each Acute Care patient room.
• Redesign our nursing care model to Primary Care
  model
• Each nurse RN or LPN is assigned dedicated
  patients.
• Patients are assigned to RN vs LPN based on
  acuity.
• One RN assigned as charge nurse to assist with IV
  push medications may have responsibility for a
  smaller group of patients.

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Anticipated Benefits

• By placing medication server in the room
  medications for all patients would not be
  commingled on the same cart eliminating the
  potential for a pill to fall in the wrong
  patients drawer, be misplaced in the wrong
  patients drawer, removed from the wrong drawer,
  etc.
• This would provide (in addition to Bar Code
  Medication Administration) an added barrier to
  medications errors related to administration thus
  decreasing overall medication error rate on the
  unit.
• Allow for real time access to information and
  ability to document patient care.

11
Added Benefits

• On average the cost of a hip fracture related to
  fall in the VA is over 33000.00.
• One intervention frequently used to prevent falls
  is frequent observation. Therefore increasing
  nursing time spent in patient room would likely
  reduce the frequency of falls.

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Benefits Perceived by Patient

• Providing computers in the room to allow for
  medication administration and documentation will
  increase the amount of nursing time spent at
  patient bedside.
• Currently patients only perceive the nurse is
  taking care of them when they are in the room.
  Therefore, they do not realize the time the nurse
  is spending performing documentation at the
  nurses station as time dedicated to their care.
• This change in perception should increase the
  patients awareness of time spent providing their
  care and improve perception of the overall
  quality of care received.
• SHEP scores currently monitor patients awareness
  of overall quality of care.

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Getting The Plan Together

• Demo units of selected computerized medication
  servers were ordered by the facility.
• IRM agreed to configure the thin clients and
  install in the server.
• Facilities management agreed to install.
• The nursing unit agreed to redesign their
  staffing model.
• The projected implementation date was to be
  October 2006. The roll out would begin in the
  five beds used for higher acuity patients then
  extend to the overall unit.
• Outcome data would be collected for falls,
  medication errors, and SHEP scores to evaluate
  impact of the change.

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Bumps In The Road

• Choosing the model of point of care carts.
• Assembling and installing the point of care
  carts.
• Reluctance to change.
• Change in workflow design for nursing and
  pharmacy.

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Equipment

• The original plan was a wall mounted server with
  access from the room and hallway to allow for
  refills of medication by pharmacy. This would
  have required station level project.
• The second option was a wall mounted cabinet,
  however, there was too much computer equipment to
  fit in the cabinet.
• Finally, a point of care medication cart was
  evaluated and our needs were met. The cart has a
  wall lock which allowed it to be secured to a
  wall in the room by a tether. The articulating
  ability of the cart added some flexibility
  allowing staff to document in a comfortable
  position.
• Delivery of the cart delayed implementation.

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• Nurse Server

• Point of Care Cart Chosen

Wall Lock
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Other Delays

• Delivery date of point of care carts delayed.
• Each cart had to have the thin client brick
  installed by IRM.
• Facilities management had to install the tethers
  in each patient room within distance of the
  computer LAN connection and electrical supply.
• Pharmacy workflow would need to be redesigned for
  medication delivery to unit.
• Nursing care model and workflow redesign
  completed.

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Barriers To Implementation

• Some challenges included
• Nurses concern over need to log in to each
  computer in each room during medication pass.
• Reluctance to change normal work process.
• Desire not to disturb the patient during hours of
  sleep.
• Concern about whether the scanners would need to
  be re-initiated in each room. (Name badge
  barcode scanned when BCMA first opens).
• Concerns about privacy of computer screens.
• Concerns about dealing with medications after
  patient discharges.
• Deciding who was responsible for cleaning the
  carts (inside and out) after patient discharge.

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Moving Past The Barriers

• IRM trained staff on use of Citrix desktop server
  which allows the user to disconnect from the
  terminal keeping the connection open to allow to
  reconnect in the next room.
• Scanners do not need to be initiated in each room
  upon the start of BCMA.
• Privacy screens obtained for monitors.
• Pharmacy coordinates medications to reduce need
  for med destruction.
• Nursing has always cleaned carts and continues to
  clean inside, housekeeping cleans outside.

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Preliminary Results

• Ongoing monitoring of results continues.
• Monitoring parameters include
• Med errors
• Falls
• SHEP overall satisfaction

21
Fall Rate

• FY 05 -- 3.91/1000 BDOC
• FY 06 -- 8.85/1000 BDOC
• 1Q FY 07 -- 15.3/1000 BDOC
• 2Q FY 07 -- 4.6/1000 BDOC
• 3Q FY 07 -- 3.13/1000 BDOC

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Medication Error Rate
FY 05 -- 1.56/1000 BDOC FY 06 -- 2.25/1000
BDOC 1Q FY 07 -- 4.47/1000 BDOC 2Q FY 07 --
5.8/1000 BDOC 3Q FY 07 -- 0/1000 BDOC
23
SHEP Overall Quality Inpatient

• FY 05 Avg SHEP Score 70.1
• FY 06 Avg SHEP Score 76.5
• 1Q FY 07 score 71
• 2Q FY 07 score 75.9
• 3Q FY 07 results pending

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Interpretation

• Preliminary data shows significantly improved
  fall rate with bedside point of care medication
  and documentation system.
• Med errors increased overall, however,
  administration type errors were decreased.
• SHEP scores increased for 2nd quarter and
  results pending 3rd quarter.

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Unanticipated Benefits

• The rest of the interdisciplinary patient care
  team, including providers, dieticians, therapy
  staff, also utilize the bedside documentation
  process as an essential tool to provide prompt
  access to information and make work flow more
  efficient.
• Nursing staff report addition benefits of
  increased patient education documentation,
  increased participation of the patient in
  healthcare treatment plan development, and
  improved communication with the patient.