NK9EOa

 

Innovation NK9EO

 

Using the required empirical outcomes (EO) presentation format, provide one example of an improved outcome associated with nurse involvement with the design or redesign of the physical environment. 

 

 

Example a: Opening Clinical Decision Unit to Improve Average Length of Stay

Problem

Variability of placement of observation patients at Catholic Health Initiatives (CHI) St. Vincent Hot Springs (SVHS) contributed to inefficiencies and extended lengths of stay for this patient population in the summer of 2022.

 

Pre-Intervention

In July 2022, the average length of stay (ALOS) in hours for CHI SVHS observation patients was 30:06. President Douglas Ross, MD, FACHE, charged Joanna Bartley, MHA, Fellow, with opening a clinical decision unit (CDU) to improve efficiency and flow of patients moving through CHI SVHS. Bartley formed an interprofessional team, including nurses, pharmacists, physicians, facilities, information technology, radiology, cardiac rehabilitation services, and environmental services to open a CDU.

 

Goal Statement

To improve CHI SVHS ALOS in hours for observation patients.

 

Participants

 

 

Clinical Decision Unit Workgroup

Name/Credentials

Discipline

Title/Role

Department

Joanna Bartley, MHA

Fellow

Administrative Fellow

Administration

Douglas Ross, MD, FACHE

Physician

President of CHI SVHS, Chief Medical Officer of St. Vincent Market

Administration

Teresa Lambert, MBA, BSN, RN

Nursing

Vice President of Patient Care Services, Assistant Chief Nursing Officer
(role of CNO)

Administration

Jason Pelton, MD

Physician

Physician

Interventional Radiology

Joshua Keithley, MD

Physician

Physician

Emergency Department

Thomas Hollis, MD

Physician

Physician

Hospitalist

Oyidie Igbokidi, MD

Physician

Physician

Interventional
Cardiology

John West, RT (R)

Radiology

Director

Imaging Services

Renee Fechuch, MSN, RN

Nursing

Clinical Director of Nursing

Nursing Administration

Tonya Baier, BSN,
RN

Nursing

Clinical Director of
Nursing

Nursing Adminsitration

David Terry

Facilities

Director

Facilities

Dennis Meyer, MCP, MCDST, CNA

IT

Manager

IT

Tracy Bays

Environmental Services

Director

Environmental Services

Crystal Bohanan

MBA

Vice President of
Operations

Administration

Michael Long, BSN, RN, CNML

Nursing

Nurse Manager

Cardiac Catheterization Lab/Cath Lab Recovery/Cardiac Rehabilitation

David Hickey, AS

Clinical Engineering

Technician Lead

Clinical Engineering

John Bouldin, MD

Physician

Physician

Emergency Department

Lori Musser, AAS

Administration

Manager of Telecommunications Contracts

Administration

Clay Brown

Facilities

Supervisor

Facilities

Leonides Bermejo, MD

Physician

Physician

Neurology

Jessica Wilson, MHA, HACP, CPHQ

Quality

Patient Safety Program Manager

Quality

Kayla Bullard, BSN,
RN

Nursing

Nurse Manager

ED

Marshall Larson

IT

Supervisor

IT

JD Martin

Central Supply

Manager of Operations

Central Supply

Tiffany McCain,
PharmD

Pharmacist

Director

Pharmacy

 

Description of the Intervention

August 2022
Ross scheduled and led a kick-off meeting on August 15, 2022. The attendees included Teresa Lambert, MBA, BSN, RN, Vice President of Patient Care Services/Assistant Chief Nursing Officer (role of CNO); Jason Pelton, MD, Interventional Radiology; Bartley; Joshua Keithley, MD, Emergency Department (ED); Thomas Hollis, MD, Hospitalist; Tonya Baier, BSN, RN, Clinical Director of Nursing; and Oyidie Igbokidi, MD, Interventional Cardiology.

  • The team discussed the problem of slow throughput of observation patients that was affecting inpatient capacity and the number of patients holding in the ED. The team identified the old Chest Pain Unit as the ideal location for the CDU, because it is adjacent to the ED.
  • A follow-up meeting included Ross; Bartley; John West, RT(R), Director of Imaging Services; Renee Fechuch, MSN, RN, Clinical Director of Nursing; Lambert; and Baier. The team discussed the feasibility of relocating the Echo and Ultrasound departments to the old ED. The team determined that this would be doable.

 

September 2022

  • The team met on September 1, 2022, to walk through the old ED to determine what upgrades and updates were needed for the physical environment. The attendees included Lambert; David Terry, Director of Facilities; Dennis Meyer, MCP, MCDST, CAN, Manager of IT; Bartley; Fechuch; Baier; Tracy Bays, Director of Environmental Services; Crystal Bohanan, MBA, Vice President of Operations; Michael Long, BSN, RN, CNML, Nurse Manager, Cardiac Catheterization Lab/Cath Lab Recovery/Cardiac Rehabilitation; David Hickey, Technician Lead, Clinical Engineering; and West. The team determined the following changes to the physical environment were needed: remove the nurses’ station desk, repair cabinets, patch damaged areas on walls, apply new paint, strip and wax floors, and replace ceiling tiles. IT also needed to add data drops to the rooms.
  • Bartley and John Bouldin, MD, ED, met September 12, 2022, to discuss types of CDUs.
  • Members of the CDU workgroup met on September 13, 2022, to discuss logistics and next steps. Attendees included Ross, Lambert, Bartley, Bouldin, Keithley, Fechuch, Hollis, Baier, Pelton, West, and Igbokidi. Bouldin shared the type of CDU we would pursue and used this meeting to update the medical staff on the plan to relocate Echo and Ultrasound. The group also discussed the residents helping support the CDU and ED nurses staffing the CDU.
  • Members of the CDU workgroup met on September 19, 2022, to walk through the old ED again. The attendees included Bartley; Bohanan; Lori Musser, AAS, Manager of Telecommunications Contracts; Baier; Lambert; West; Long; and Clay Bowen, Supervisor Facilities. It was determined during this walk-through that there were not enough rooms in the old ED for Echo and Ultrasound to share, so Ultrasound would be moved to the Nuclear Medicine (NM) hallway. The Ultrasound team shared their needs for computer locations and waiting room design, such as how they would like the chairs to be placed and needing a television in the waiting area.

 

October 2022

  • The facilities team both started and completed the old ED renovations and refresh. Work began on removing the nurses' station desk, repairing cabinets, patching damaged areas on walls, adding new paint, stripping and waxing floors, replacing ceiling tiles, and adding data drops to the rooms.
  • Bouldin determined that chest pain, TIA, and syncope patients would be appropriate for the CDU.

 

November 2022

  • Bartley, Bohanan, Lambert, Baier, West, and Long attended a check-in meeting to discuss the timeline and target opening.
  • Bartley, Bouldin, Keithley, Bermejo, Hollis, Pelton, and Igbokidi attended a physicians’ meeting to draft and edit condition protocols.

 

December 2022

  • Members of the CDU workgroup met on December 5, 2022, to walk through the old ED. The attendees included Bartley, Long, Baier, Bowen Terry, and Hickey. It was determined the Echo and Ultrasound were almost ready to move. Only a few more items needed to be completed, including data drop in the old ED, office staff moving from the NM breakroom to the old ED, the relocation of the NM printer, and the water source added to the NM closet for the eye wash station.
  • Bartley and Jessica Wilson, MHA, HACP, CPHQ, Patient Safety Program Manager, walked through the CDU space on December 6, 2022, to determine what is needed for the space to meet observation unit regulatory requirements. They identified that a call light system was needed.
  • Bartley; Fechuch; Kayla Bullard, BSN, RN, Nurse Manager, Emergency Department; and Lambert met on December 8, 2022, to discuss supplies, Pyxis, additional staffing, nurse and PCT education/training, and call light options needed for the unit.
  • Members of the CDU workgroup met on December 12, 2022, to discuss moving the Echo timeline. The attendees included Bartley; Lambert; Baier; Marshall Larson, Supervisor, IT; and Long.
  • Members of the CDU workgroup met on December 19, 2022, to determine approvals had been granted to start moving Echo and Ultrasound. The attendees included Bartley, Bohanan, Larson, Baier, Bowen, Hickey, West, and Long.
  • Bartley and JD Martin, Manager Operations, Central Supply, walked through the CDU space on December 19, 2022, to determine supply storage and organization needs.

 

January 2023

  • Bartley, Hickey, Lambert, and Fechuch met on January 3, 2023, to discuss the ability and options to monitor patients in the CDU.
  • On January 6, 2023, Bartley and Wilson walked through Echo, using their new space to ensure regulatory requirements were being met.
  • Bartley, West, Larson, and Bowen met on January 8, 2023, to confirm everything that needs to be completed for Ultrasound to move. They determined that office space needed to be converted to a break room. The current break room would need to be converted to a patient room, requiring fresh paint and waxed floors. A closet and printer room would need to be converted to the trophon room, requiring an eye wash station to be installed. Trophon is a high-level disinfection system for ultrasound probes. Regulatory bodies require an eye-wash station to be in the same room for safety.
  • Bartley, Hickey, Fechuch, and Lambert met on January 9, 2023, to continue the discussion of the monitors that would be physically wired and installed in the space.
  • Bartley, Bowen, Terry, and West met on January 24, 2023, to confirm everything was completed for Ultrasound to move to NM hall.
  • On January 26, 2023, a meeting was held to discuss supplies, pharmacy, and EVS support in the CDU. The attendees included Bartley; Hickey; Martin; Bullard; Fechuch; Tiffany McCain, PharmD, Pharmacy Director; and Bays.

 

February 2023

  • Bartley handed off the CDU project to Fechuch, as her Fellow internship had ended.
  • Facilities worked on all remodeling required for all departments involved, including construction and painting.
  • IT worked on all IT needs required for all departments involved, including data drops and computers/phones.
  • Pharmacy and Central Supply worked on all medications and supplies needed for the CDU and other departments.
  • Bullard and Fechuch worked with the education department to get all staff trained on electronic health record needs in Epic and the clinical skills needed to care for these patients.

 

March 2023

  • Facilities completed all remodeling required for all departments involved for the CDU to open.
  • IT completed all the IT needs required for all departments involved for the CDU to open.
  • Pharmacy and Central Supply finished stocking the medications and supplies needed for the CDU to open.
  • The staff for the CDU completed the training needed for the CDU to open.
  • CDU opened on March 6, 2023.

 

The interventions were fully implemented by the end of March 2023.

 

Nurses Lambert, Fechuch, Baier, Long, and Bullard’s involvement with the design of the CDU physical work environment was associated with an improvement in outcome of the CHI SVHS ALOS in hours for observation patients. The CDU’s proximity to the ED made it the ideal location for managing the throughput of observation patients, freeing up ED beds and inpatient beds.

 

References

Blecker, S., Gavin, N. P., Park, H., Ladapo, J. A., & Katz, S. D. (2016). Observation units as substitutes for hospitalization or home discharge. Annals of Emergency Medicine, 67(6). https://doi.org/10.1016/j.annemergmed.2015.10.025

 

Ross, M. A., Hockenberry, J. M., Mutter, R., Barrett, M., Wheatley, M., & Pitts, S. R. (2013). Protocol-driven emergency department observation units offer savings, shorter stays, and reduced admissions. Health Affairs, 32(12), 2149–2156. https://doi.org/10.1377/hlthaff.2013.0662

 

Salvador-Kelly, A., & Kwon, N. (2016, April 15). Emergency department observation units: 2016-04-08: AHC Media:... Relias Media. https://www.reliasmedia.com/articles/137660-emergency-department-observation-units

 

Outcome