For the leaders at Eisenhower Medical Center, a 524-bed, community hospital located in Rancho Mirage, Calif., complying with evidence-based medicine practices came down to two specific challenges. As Steven Arendt, M.D., Eisenhower’s CMIO tells it, there was the challenge of getting the staff to understand evidence-based medicine and then how to deploy it so that it didn’t disrupt their workflow. Looking for a way to make the transition easy, Eisenhower teamed with McKesson (San Francisco), which helped develop a quality dashboard monitor.
The monitor, with a stoplight-like functionality, helps clinicians, mostly nurses, know whether or not they are compliant in how they perform interventions for various tasks or quality bundles, whether it’s suctioning, preventing ventilator acquired pneumonia (VAP), or something else. It’s set up with certain parameters. For instance, if it’s a half-hour before a patient is due to be sectioned, then the dashboard will turn yellow. It will turn red before the section is due, not because the clinician is past-due, but because they are getting to that end-point.
“It’s the first tool I’ve implemented at the bedside that proactively allows the caregiver to know where they stand with some of the evidence-based care they are supposed to deliver,” Arendt says.
For the initial roll-out, Eisenhower focused on two specific bundles: VAP and stroke management. Annette Brown, R.N., the director of nursing informatics at Eisenhower, says this was because those two bundles were actually available at the time from McKesson. According to Arendt, before the implementation of the dashboard, Eisenhower’s VAP rate wasn’t “out of line,” but it could have been better – specifically, at zero percent. Also, he says, as a “Stroke Center of Excellence,” it’s always looking to improve care in that area.
In the case of both of its VAP rate and its stroke performance goals, Eisenhower was looking for a significant improvement. In the case of both, that’s exactly what they got.
Steven Arendt M.D.
Results
In the beta test of the dashboard, Brown says Eisenhower was hoping to decrease its VAP rate, which represents the number of patients that acquire VAP within 1000 ventilator days, by 20 percent. Instead, the dashboard decreased the VAP rate by 33 percent. When it launched, in the first quarter of last year, the VAP rate was 2.48; within the very first launch it went all the way down to 0. Interestingly enough, in the third quarter of 2011, when Eisenhower turned off the dashboard because of another go-live, its VAP rate went up to 4.68.
Once the dashboard returned, the VAP rate went back down to 1.23 and then in the first quarter of 2012, it was down to 0.9. “It’s a very, very effective tool,” Brown notes.
In terms of stroke management, she says the dashboard has been just as successful. For deep vein thromboembolism (DVT) prophylaxis treatment, Eisenhower was at 78 percent before the launch. Once the monitor went live, the DVT prophylaxis treatment was up to 95 percent. When it went away in the third quarter of 2011, it was down to 85 percent. In the fourth quarter it went up to 91 percent when the monitor returned, and currently it’s at 93 percent.
The dashboard’s success, Brown says, strives from the competitive nature of nurses derived from the dashboard and their natural compassion. “The minute we put up our dashboard, there was just an intolerance to anything that was yellow or red,” she says. As an example of this competitive spirit, she says after the go-live, the nurses began coordinating more frequently with their respiratory therapists in an attempt to better figure out when a patient should be weaned off their ventilator.
Annette Brown, R.N.
“The person who it benefits the most is the patient, because then the care-delivery model is actually executed in a much timelier, more effective, patient-centered manner that achieves a reduction in complications,” Brown says. “Reduction in complications should equal a reduction in length-of-stay, reduction in length-of-stay should equate to financial savings.”
Workflow
One of the reasons, both Brown and Arendt say, the application was so successful upon launch, was it fit neatly into the clinicians’ workflow. Brown says the dashboard is directly linked to the nurses’ documentation, thus there’s no double documentation and the alert appears in one episodic moment. Even in communicating from nurse-to-nurse during a shift change, she says, the monitor allows for charged nurses to see whether or not there was compliance before a nurse goes home.
According to Arendt, the ease-of-use of the application, and the simplicity of the stoplight like format, was the key part to its success. “The education for the end-user was really nothing other than understanding what red, yellow and green meant,” he says. “Beyond that, there was nothing special that anyone needed to do. What we tried to do is leverage the orders or documentation that they were already doing to feed this dashboard, so they didn’t have to change around their workflow.”
With the triumphs of the monitor’s first go-around with the VAP rates and stroke management metrics, Eisenhower will continue to use it for other quality metric bundles, Brown says. The next bundles EMC will explore is likely to be catheter-related urinary tract infections (UTIs), heart failure, and other chronic diseases, mainly because of its specific patient population, which is 70-80 percent Medicare at an average age of 78, she says.
In addition, Brown says Eisenhower will pilot for McKesson a summary indicator, set to appear on a different monitor, called Horizon Enterprise Visibility, which looks at patient throughput information. This application will take the summary metrics from a quality bundle and have it visualized on the 55-inch monitor that looks at throughput. Overall, she says, this is just another example of her institution going above and beyond for patient care.
“I’m very proud of our institution, of our executive leadership, and I’m honored to have a tremendous synergy with our CMIO and our nursing world,” Brown says. “You can sense my passion I’m guessing because I’m really for advancing excellence.”
