The Art of Care: A Report on the 2019 Vizient Connections Education Summit

s and presenting at conferences. In 2018, 6 nurse resident groups shared their work as either a poster or podium presentation at conferences. Residents, managers, and educators evaluate the nurse residency EBP projects. Nurse residents rate the EBP overall as an excellent learning experience that enhanced their understanding of the impact of the project. They stated unit nurses, the charge nurse, and educators helped identify the unit-specific clinical issue, participated in surveys, and supported project completion. Nurse residents felt participation in the nurse residency EBP gave them more confidence in improving care. Nurse managers and educators agreed the nurse residency EBP project impacted practice. Managers stated that the EBP curriculum provides the tools and sets the standards for involvement in EBP as part of professional nursing. Build a Juggernaut Opioid Stewardship Team to Stomp Out Adverse Events Cathleen Lammers, MD, Ashley Trask, PharmD, and Eddie Eabisa, CSSGB UC Davis Health Background. In 2016, a gap analysis revealed opportunities to improve the existing structure for opioid use. Our organization lacked a uniform opioid guideline for treating patients with acute or chronic pain. Policies and procedures existed but were targeted to special populations such as pediatrics, or situations such as range orders; a generalized policy on pain management was needed. Pain orders were located in more than 150 different order sets; therefore, many different approaches to treating pain existed, which generated confusion, order duplication, and waste. Nursing assessments post opioid administration were focused primarily on pain scores and the timing of reassessment was not linked to predicted peak medication effect. Sedation assessments were not temporally linked to opioid administration and did not utilize a sedation scale specific to opioids. Patient screening and education also were not standardized, and there were large gaps in patient monitoring. In December 2016, UC Davis was selected to participate in Reducing Adverse Drug Events related to Opioids, a mentored quality improvement program through the Society of Hospital Medicine. Our chief quality officer and chief medical officer identified funding to start an Opioid Stewardship Program consisting of a parttime physician champion and a part-time pharmacist, as well as key participation and co-leadership from our medication safety officer. Our electronic health record (EHR) medical director and chief medical information officer were enlisted to help identify ways to use information that already exists in the EHR to build novel EHR tools to assess and display patient risks for opioid adverse events. These included coexisting diseases, renal dysfunction, concomitant benzodiazepines, obstructive sleep apnea, and age. We worked closely with nursing leadership to develop new workflows to enhance patient assessment following each dose of opioid to include comprehensive respiratory and sedation assessment. Intervention Detail. In order to improve the safety of opioids, our first step was to squeeze more value from our EHR system. We developed an algorithm for the EHR to constantly screen for discrete data points and identify patients at high risk for developing respiratory adverse events from opioids. It is done in real time such that it continuously updates if patient characteristics change during their hospitalization. The tool creates a banner in the patient chart that notifies care teams and displays the patient’s one or more characteristics that increase risk with opioids. We created and deployed an electronic STOP-Bang tool to screen for obstructive sleep apnea, including compliance aids to promote use. Both types of screening were applied to all patients in our intervention units, along with enhanced registered nurse assessments following opioid administration, staff education, and patient education. An Inpatient Pain Task Force led by the Opioid Stewardship physician champion and the executive nurse director of patient care services developed Pain Guidelines, an Inpatient Pain Policy, and a Standardized Multimodal Pain Management Order set. The order set can stand alone or be embedded into existing subspecialty-specific order sets and includes nonpharmacologic, scheduled nonopioid pharmacologic, and opioid treatments. Opioid “range orders” are replaced by “rescue” orders, a method to start low and provide rescue doses to titrate to the lowest effective opioid dose utilizing a preferred oral route of administration. It also includes nonsedating supportive medications for respiratory depression, itching, nausea, and bowel care. The A Report on the 2019 Vizient Connections Education Summit 67S urgent and emergent triggers and response to sedation or respiratory depression also are now uniform. We created animated pain education videos for acute and chronic pain patient education, via a collaborative project with the UC Davis design department, that are displayed for patients receiving opioids. The outpatient videos are distributed via patient portals and the Emmi platform. The inpatient video is shown on the inpatient TV educational channels. Outcomes and Impact. Overall, we reduced our inpatient intravenous opioid administered doses by approximately 30%. Oral opioid dosing also decreased by 7%, reflecting an overall decrease, despite advocating for a preferred oral route of administration. During the same months that opioid doses decreased, patient satisfaction data regarding pain management increased on pilot wards. This appears to be attributed to increased conversations, assessments, and patient and staff education surrounding pain management. One hundred percent of patients on pilot wards received screening for opioid high-risk factors as a result of the EHR tool design. Patients who met the criteria for being at high risk for opioid-induced depression were identified in the EHR by a decision-support banner that displays continuously. The decision-support banner is effective and remains part of the EHR tool design. Compliance with the completion of the STOP-Bang assessment tool for obstructive sleep apnea is sustained above 90% completion. To expand the impact of our work, we presented our EHR tools at the Epic XGM expert group meeting in 2018. Furthermore, our pain education videos are now utilized by many hospitals (including Vizient members), posted on public websites, and available with subtitles in various languages. We are planning a spring 2020 “big bang” launch to continue to shape our culture of pain management. This will include systemwide implementation of the pilot project tools and enhanced nursing assessments, as well as new pain guidelines, an inpatient pain policy, and standardized multimodal order sets. As part of the launch, we are creating one education module that will target physicians, pharmacists, and nurses as a team—a novel approach to our usual method of providing separate education modules for each. Innovative and Evidence-Based Bundle Reduces Hospital-Onset Clostridium difficile by 53% Julie Wardinsky, RN, BSN, CIC, and Catherine Adamson, MSN, RN UC Davis Health Background. Annually, there are 500 000 Clostridium difficile (CDI) cases and 15 000 related deaths in the United States. Our academic hospital exceeded internal and national hospital-onset CDI (HO-CDI) benchmarks. Our 2014 HO-CDI rate, at 5.85 per 10 000 patient days, far exceeded our internal target. In 2015, the National Healthcare Safety Network introduced the HO-CDI standardized infection ratio (SIR), a risk-adjusted calculation. Our January to June 2015 SIR was 1.326; our target was a SIR of less than 1. Our unique care bundle stems from our root cause analysis. First, growing evidence points toward asymptomatic C difficile carriers as a significant source of HO-CDI transmission, and carriers may outnumber infected patients by up to 10 to 1. Second, injudicious use of antimicrobials increases the risk of developing CDI. Third, a significant proportion of our HO-CDI cases actually displayed CDI symptoms at admission, yet were not tested until on or after the fourth hospital day—thus classified as “hospital-onset,” when likely they were truly community-onset. Finally, some of our patients (carriers and noncarriers) were inappropriately tested for CDI for nonclinically significant diarrhea or while receiving laxatives. In 2013, our original small project group identified these root causes and sought the support of hospital administration. Together with the executive suite, we secured a generous grant from the Gordon and Betty Moore Foundation. Executive leadership supported the creation of a multidisciplinary team with all stakeholders engaged. Extensive planning included developing strategies to mitigate a potentially negative impact on hospital throughput, because one bundle element included initiating isolation on an estimated 4% to 7% of patients who otherwise would not have been identified as contagious. With patients as our end customers, much care also went into patient education and satisfaction. It was important for our patients and their families to understand that we care about their health, as well as their safety. Intervention Detail. In early 2014, an adult antimicrobial stewardship program (ASP) was implemented by our infectious disease colleagues. This included recommending de-escalation, cessation, or even escalation of antimicrobial therapy in our high-risk patients. In order to launch C difficile active surveillance and isolation of carriers, nursing, physicians, bed control, environmental services (EVS), pharmacy, information technology (IT), and the microbiology laboratory were extensively educated. Multiple new systems were put into place, such as an isolation rooming guide, policy revision, automated electronic medical record (EMR) alerts/reminders, laboratory protocols/new equipment, EVS cleaning protocols/signage, and patient/prov