Quality Corner
I wanted to share a few physician and advanced practice clinician (APC) opportunities from recent root cause analysis (RCAs). In healthcare, the RCA process refers to a structured process that we use to identify underlying causes of a medical error, adverse event, or a precursor event. The goal of an RCA is to develop solutions to prevent similar occurrences in the future. RCAs focus on system failures rather than individual blame, getting to the “why” behind an event rather than the “who” or “what”
1) Hyperkalemia Order Set – RCA identified potential harm to patient related to failure to adjust interventions based on blood glucose levels and/or failure to monitor blood glucose after interventions. Use of the complete, modifiable order set includes all of the important monitoring considerations including nursing intervention and guidance. Recommendation to increase awareness and use of the Hyperkalemia order set, particularly when treating with insulin and D50.
2) Medication Reconciliation – RCA identified harm to patient with adjusted dosing in medication reconciliation performed for discharge when after visit summary (AVS) printed but not updated (without check-back/closed-loop communication) or confirmed with bedside nurse. Recommendation to use closed-loop communication with nursing at discharge, especially if medication reconciliation or other orders are updated.
3) Admitting vs. Consulting Orders – RCA identified miscommunication on admission regarding ordering of Keppra for seizure prophylaxis. Recommendation to clarify that admitting/attending is ultimately responsible for reconciling (to include ordering new and recommended medications) on admission to ensure necessary/recommended medications are ordered. Recommend clear, closed-loop communication among provider team to ensure all necessary medications are ordered on admission.
4) Draft Policy on care of patients with Substance Use Disorder (SUD): PICC Guard workflow and naloxone in hand at discharge – Two different RCAs identified opportunities around patients with substance use disorder (SUD). One involved a patient with a PICC in place in which staff used multiple appropriate measures to avoid tampering, however patient was able to gain access to PICC and medications resulting in harm. A separate RCA identified a patient with SUD who at discharge had a prescription placed for naloxone at an offsite retail pharmacy which was never filled. Discussion and interpretation around 2SB 5195 (Distributing opioid overdose reversal medications) with best practice recommendation to discharge patient with naloxone in-hand at discharge. Recommendations above resulted in a policy pertaining to care of patients with substance use disorder, currently being circulated in draft form.
Length of Stay
1) LOS Trends – January ended with increased volumes at both ministries and some tough periods including multiple Code Surge – Throughput days based on either low availability of ICU beds or high ED boarding volumes with prolonged stays (> 24 hours). Data through Feb. 8 has St. Peter with an ALOS of 6.38 days and GMLOS O:E of 1.50 (increased/unfavorable from December) and Centralia at 4.46 days and GMLOS O:E of 1.10 (decreased/favorable from December).
2) Early Progressive Mobility – Jan. 15 we went live with our Early Progressive Mobility program, with an emphasis on mobilizing patients early and consistently and standardizing communication and documentation of mobility using the Johns Hopkins Highest Level of Mobility Scale. Use this link for additional information… three biggest asks are:
a. Ensure activity orders are placed in “Current Activity Orders” and “Precaution Orders” and not as a communication order
b. Use bedrest orders ONLY when medically necessary. Ensure all patients have activity orders and update them as necessary.
c. Talk with patients about mobility and consider walking rounds with your patients to get them up and moving!
Respiratory season
We are in full swing, with flu rates much higher than we saw last year. We are masking in patient care areas, in conjunction with agreed upon (Northwest Health Response Network) NWHRN recommendations based on Thurston County data for transmission alert thresholds. See latest data (through Feb. 5) below for Influenza. COVID-19 remains below transmission threshold but is trending upward, RSV remains above threshold.
