ACCOUNTABILITY AND AUTONOMY
Decreasing Antibiotic Use in the Surgical Intensive Care Unit (SICU) to Reduce Hospital Onset C. Difficile
E2- ICU had a high incidence of Hospital Onset C. Difficile infection. The C. diff Standardized Infection Ratio (SIR) at SHC during FY17 Q2 - FY18 Q1 was 1.18 (104 total infections), while the top decile performance of institutions similar to Stanford was 0.6 (53 total infections). E2 ICU accounted for 34% of the C. Difficile infections at SHC in that time frame.
Clostridium difficile (C.diff) is a spore-forming bacterium that can survive for months and is easily spread from person to person from hands that have touched contaminated surfaces. Patients most at risk of acquiring this infection are those who have taken antibiotics. C. diff is the leading cause of death associated with gastroenteritis (Johnson, 2018). C. diff is the most common cause of healthcare-associated infections in the U.S. and was estimated to cause 14,000 deaths in 2007. Preventing hospital-onset C. diff remains a high priority at SHC to reduce patient harm and improve clinical outcomes.
The healthcare costs related to C. diff infections are estimated to be as much as $4.8 billion for acute care facilities alone (Lessa et al., 2015). These estimates are expected to increase as C. diff morbidity and mortality rise along with increased healthcare costs.
End of 2018 and beginning the year 2019, a multidisciplinary team began addressing the increased incidence of hospital-acquired C. Difficile infection in critically ill patients in the SICU. The team used a formalized approach through Stanford Health Care’s Realization Improvement through Team Empowerment (RITE) program that aims to create lasting changes through quality improvement methodology.
Through this framework, the team embarked to decrease C. diff infection rates in a 33 bed multi-service Intensive Care Unit (ICU) and they collected data on relevant information impacting C. diff in the ICU.
Initiated Antibiotic Stewardship Rounds Twice Weekly with SICU Physician, Infectious Disease Physician and E2 Nursing Leadership to have meaningful discussions at the appropriateness of each patient on antibiotics
Collect Baseline Data on Antibiotic Days of Therapy (DOT)
Educated E2 nursing staff on accurate stool documentation.
Introduced HAI competency that included C. Diff infection
Impact and Conclusion:
Prior to the implementation of stewardship in the ICU, the days of therapy were 8.64. Following the implementation of antibiotic stewardship, the days of therapy dropped to 5.53. This held a significant financial impact as well. The C. diff incident fell from 17 in the fiscal year 2018 to only 5 in the fiscal year 2019. This meeting was driven by the nursing leadership of E2 and is now still in effect in 2020. The days of antibiotic therapy (DOT) tracked the success of the antibiotic stewardship meetings.
B2/J7’s Alarm Management Project
Alarm fatigue is a well-known patient safety issue. If alarms are disabled, silenced, or ignored due to burnout from alarm frequency, patients are at risk for delay of identification and treatment.
Two RNs on B2/J7’s medical cardiac monitored unit, Daisy Mark and Annette Haynes, exemplified exceptional professional practice and identified this urgent patient safety issue. They then developed a quality improvement project to enhance recognition and response to alarms. Based on the principles of nursing autonomy and working within the full scope of nursing practice, B2’s staff completed a questionnaire about how comfortable they were with adjusting alarm settings to individualized patient’s needs with MD approval. The survey also asked questions about personal response time to alarms.
After the questionnaire, the project team was able to analyze the data they received and create an action plan for nursing education. Staff were re-educated with an emphasis on adjusting alarms based on patient’s unique needs and hospital guidelines. Throughout this project, B2’s nurses, their CNS, and the unit’s SLC were involved and case scenario discussions were created to further increase nurses’ understanding.
This quality improvement project was proudly presented at HealthcareCon 2019.
Fground’s Initiation of a Hematology/Oncology Care Cart
In line with nursing advocacy and autonomy of practice, FGR nurses created a care cart for patients and their families to facilitate conversations around end of life. These FGR nurses noticed that many of their patients and families don’t come to the hospital prepared to have crucial conversations about death, dying, and end of life wishes, even when they are facing an unfortunate diagnosis of a terminal illness. The goal of this cart was to support patients making difficult decisions and to provide educational resources to facilitate open dialogue between nursing staff and family members around the human experience at the end of life.
Prior to this project, there were no formalized structures for nurses to offer end of life support or educational materials to patients and their families, and 94% of surveyed nursing staff did not know which resources were available. The team of FGR nurses, including Elizabeth Kelly, Megan Oliveria, Flora Kechedjian, and Theresa Latchford obtained a grant to purchase instructional supplies, informative materials, and helpful booklets to launch the educational care cart. After initiation of the cart, FGR nurses were surveyed again. The nurses expressed that they benefitted greatly from using the cart’s educational tools and they felt empowered to utilize this resource to engage in crucial conversations around the death and the dying experience. The hematology/oncology care cart is an exceptional example of SHC nurses making autonomous decisions to integrate evidence-based practices into their patient and family-centered nursing care.
Action Request Form
Action Request Forms (ARF) highlight Stanford nursing’s ability to shape their work environment and proactively develop their clinical culture. ARFs can be submitted by any RN to spark innovative change or new evidence-based practices. In 2019 SHC had 244 ARFs submitted on the upgraded ARF platform, allowing for ease of submission. ARFs are submitted through the Shared Leadership Councils and are often managed on unit-based councils. Of the submitted ARFs, in 2019 only 4% escalated to the house-wide level, showcasing nursing’s autonomy of practice and ability to collaborate across the network of SHC.