McGill University Health Centre improves quality of care on nurse-sensitive indicators
In 2003, the nursing department at the post-merger McGill University Health Centre (MUHC) made an internal commitment to improve quality of care on nurse-sensitive indicators. It was widely recognized that there was significant variation in practice from one professional to the next, and that harmonization of practices, based on the best evidence, was needed. The best practices initiative was an attempt to reduce risks to patients by increasing the reliability and quality of nursing care. The three indicators selected as targets for improvement were pressure ulcers, falls and fall injuries, and moderate to severe pain. In Canada, one in four patients in acute care hospitals develop a pressure ulcer, which cost on average $24,050 to treat, and result in up to 50% increases in nursing time. Falls with injury are the leading type of adverse events reported in acute and long-term hospital settings.
In 2004, the MUHC received $100,000 in funding when selected as a National Spotlight Organization for the implementation of best practice guidelines (BPGs) developed by the Registered Nurses Association of Ontario. An evidence-informed best practices program was then launched in five teaching hospitals. Outcomes were monitored over a six-year period and two studies were conducted to examine nursing practice change, patient outcomes and organization-level impacts following implementation of three best practice guidelines. The implementation strategies included: infrastructure development (steering committee, interdisciplinary task forces, champions at the unit and organizational level, executive co-leadership), 8- to 12-week implementation cycles on inpatient units, varied educational interventions, audit and feedback, and multiple communication vehicles. Annual prevalence surveys were begun. The prospective research studies, which included 17 intervention and 14 control units, looked at changes six months (study 1) and 18 months (study 2) post-implementation. Study 1 included 1,807 patients and 1,306 nurses. Study 2 had 496 patients & 264 nurses.
Performance management relies on accurate and timely measurement information, a challenge at the MUHC given the absence of incidence or prevalence data on pain and pressure ulcers. While falls were counted annually, a benchmarkable rate of falls was not in place. Persistent efforts by the falls task force ultimately led to new falls reporting methods by the quality department. The lack of basic bedside fall prevention equipment posed another serious challenge.
Overall, 73 implementations occurred on 39 units between 2004 and 2008. Once benchmarks were established, the goal was to reduce pressure ulcers and fall injuries by at least 20%, and reduce the percentage of patients reporting moderate to severe pain. Falls were reduced by more than 20% between 2003 to 2008. The MUHC now performs better than national and international benchmarks, with a rate of 2.6 falls per 1000 patient days. More importantly, the fall injury rate came down from 33% to 22.5%; with severe injuries at 0.5%. Pressure ulcers were reduced almost 50%, from a rate of 21.3% (2003) to 10.9% (2008), well under international benchmarks of 15%-26% (stage 1-4). Pain management proved far more challenging: 2008 marked the first decrease in the number of patients experiencing moderate to severe pain. In four of the last five years, there was an increase in the number of patients with unrelieved pain. There was evidence that practice changes did occur and were sustained. At six months, 15 out of 17 implementation units had at least moderate practice improvement; only three comparison units showed change. At 18 months, 14 of 17 units sustained at least moderate levels of practice change. However, no clear relationships between practice changes and patient outcome changes could be identified.
There were several important lessons learned. The first was that evidence-based fall prevention care could not be delivered without providing nurses more tools at the bedside. To gain essential resources, nursing leadership learned how to build a successful business case, translating quality improvement into cost savings terms. For example: at $34,000 per hip fracture, the MUHC’s annual expenditure for approximately 11 hip fractures was $374,000. The falls task force calculated equipment expenses for preventing such injuries at $143,000, or $3,400 per unit — a sum which was seen as far preferable to the “status quo” expenses. And by decreasing falls by 50%, 2,277 patient days would become available for other admissions. An additional $5 million investment in beds that could be lowered and had built-in alarm devices also became part of the organization’s priorities. Over $600,000 in new resources was obtained during this period, including research funding.
It was critical to broadly engage executive leadership levels in supporting these quality improvement efforts given the scope and magnitude of changes needed. Matched with a “bottom-up” approach using many practitioners and managers as champions, the implementation work was quite labour intensive and time consuming. More efficient, real-time measurement and feedback systems will greatly aide in sustainability of improvements.
Find out more... Read the research paper: Patricia O’Connor, Joann Creager, Sharon Mooney, Andrea Maria Laizner and Judith A. Ritchie. Taking Aim at Fall Injury Adverse Events: Best Practices and Organizational Change. Healthcare Quarterly, 9(Sp) 2006: 43-49.
Contact: Patricia O’Connor, Associate Director of Nursing, Neuroscience Mission, MUHC, patty.oconnor@muhc.mcgill.ca