Chris Black, MSN, RN, CEN (left) and Elissa Crum, MSN, RN, CEN (right) presenting the team’s work at the 2018 Emergency Nurses Association Conference in Pittsburgh, PA.
How do you make health care better, more affordable, and safer for patients? In some cases, it starts with identifying challenges as opportunities for improvement. Clinicians at Pennsylvania Hospital (PAH) noticed an increased length of stay for patients receiving intravenous (IV) antibiotics in the emergency department (ED). This means more time spent in the ED and a potential delay for the patient’s next level of care.
Utilizing oral antibiotics over IV antibiotics can be more beneficial for patients visiting the ED. For one, IV antibiotics can take up to two hours to infuse, and they are roughly 10 to 20 times more expensive compared to oral antibiotics. It can also be a challenge if a patient needs to continue an antibiotic treatment after they are discharged. It isn't always the case, but there are many instances where providing oral antibioitics is the best pathway for our patients.
PAH decided to take this on as their project to study and improve as part of Penn Medicine’s performance improvement “learning lab” – Performance Improvement in Action (PIIA) program for selected groups across the organization as well as Foundations of Performance Improvement (FPI), an online learning program.
“Performance or process improvement initiatives enable our patients to experience the same level of care, experience, and outcomes in every Penn Medicine hospital and clinic, while also ensuring patients are constantly receiving the best care possible,” said Caryn Douma, MS, RN, IBCLC, CPPS, corporate director, Patient Safety at Penn Medicine.
Manifesting the “Form” in Performance
Quality and process improvement (PI) are integral for successful patient outcomes and woven into the health care system’s culture. When groups have the opportunity to work on projects such as the PAH ED team, they tend to bring multiple points of view together so many voices can be heard to improve care together. “We approach our PI work with cultural humility because promoting an inclusive culture benefits the treatment of our patients as well as our faculty, staff, and students. Valuing one another translates to how we care for patients,” said Patricia Garcia Sullivan, PhD, chief quality officer for Penn Medicine.
To achieve these outcomes, Penn Medicine has PI processes in place to support clinical and non-clinical teams, which allow them to not only identify opportunities for improvement but execute solutions to take on those gaps. All of this is done with the goal of improving patient outcomes, which can include improving the process between transitions in care from one setting to another.
FPI and PIIA were both developed as resources to embed and promote the science of performance improvement at Penn Medicine. FPI grounds employees in the basics of performance improvement. Penn Medicine employees learn how to practically execute, implement, and sustain performance improvement initiatives. In addition, PIIA is a live, coaching experience that supports group collaboration and teamwork to solve more complex performance improvement initiatives.
“Both FPI and PIIA enable Penn Medicine to continue to provide excellence in patient and clinical experience and outcomes. Empowering employees with performance improvement tools are a key advantage in enabling us to deliver flexible and adaptable solutions that provide the safest care with the best outcomes,” said Cindy Morgan, vice president, Learning and Organization Development.
This brings us back to PAH and their efforts to improve the process used for providing antibiotics to patients.
The Improvements That Led to Enhanced Performance
Angel McCullough, MSN, RN, MBA, CCRN, NEA-BC; Phil Landis, DNP, RN, CEN, NPD-BC; Marc Crane, PharmD, BCPS; Lauren Ellis, MSN, RN, CEN, NE-BC; Ken Wing, MS, CMA, CSSBB (Left to right). The Pennsylvania Hospital emergency department PIIA team accepting their 2019 Sustainability Award recognized by the Quality and Patient Safety Awards.
The PAH team focused on three of the most common diseases where IV antibiotics were being administered in the ED and then discharged the patient home on oral antibiotics: urinary tract infections, pyelonephritis (kidney infection) and cellulitis (skin infection). Of most importance, they wanted to understand why providers were ordering IV antibiotics over oral antibiotics for these patients.
The team leveraged PI tools to uncover and understand the primary reason behind utilizing IV antibiotics in the ED. Using what’s called the Voice of the Customer, a structured process to glean customer expectations and experiences, it helped yield deeper discussions into defining the opportunity for improvement. Teams [CMA1] gathered data and performed analyses to identify that it came down to providers needing a quick and easy way to order the right antibiotics at the right time.
“Having pharmacy, nursing, providers and our PI advisor all at the same table thinking together had an impact on our success,” said Marc Crane, PharmD, BCPS, clinical pharmacy specialist at PAH. “We shared our thoughts and perspectives and got down to ‘why we do the things we do’ which helped us drive towards a real solution.”
Crane, along with Phil Landis, DNP, RN CEN NPD-BC, a clinical nurse educator, supported their team in creating a prescribing algorithm for oral antibiotics and piloted the workflow. They monitored the change through weekly progress reports, nursing huddles and departmental e-mails. “Anyone can see the progress report right there, including in safety huddle with nurses. We rounded with providers and offered to help with difficult conversations around the use of IV antibiotics.”
At the end of the pilot with the new prescribing algorithm, the team reduced length of stay in the ED by 4.5 percent and supply cost by 30 percent.
“The sustainability of this work is impressive. With recent spikes in the emergency department, I am thankful we had this practice in place. Our ability to reduce length of stay and drive efficient care transitions is critical to patient quality of care and safety,” Landis said.
Even more impressive, the team has sustained this process for over three years and garnered several awards and accolades, including Patient Safety & Quality Symposium Award Winner and sharing their successes at the Emergency Nurses Association Annual Conference.
In fact, this experience led to an increase of physicians and nurses at PAH participating in PI projects — clinicians and employees in the ED at PAH are engaged in their third PI project.
To date, Penn Medicine has hosted 222 projects over 24 PIIA cohorts impacting more than 2,300 employees.
Sullivan added, “We do what’s right, not only because it is required by a regulatory body. It is why our patients trust us.”