January 3, 2008

1. PPMCEmergency Department Performance and Quality Improvement Committee Martin Manno, Clinical Nurse SpecialistAllen Fasnacht, Nurse Manager January 3, 2008

2. PI/QI Innovations in the ED at PPMC • Purpose/Objectives: • The terms “performance improvement” (PI) and “quality improvement: (QI) are used interchangeably • PI/QI provides a means to initiate, monitor and improve care delivered to patients in the Emergency Department • The PI/QI Plan and related processes allow for a systematic approach to focus on the aspects of care most critical to patient safety

3. PI/QI Innovations in the ED at PPMC • Scope/Responsibilities: • PI/QI in the ED follows a multidisciplinary approach with a close collaborative relationship between the nursing staff, medical staff and others • The Shared Governance model in the ED will implement the PI/QI Plan through the ED Unit Leadership council • Performance Improvement and Quality • Evidence-Based Practice and Translational Research • Professional Development and Education • Leadership and Stewardship

4. PI/QI Innovations in the ED at PPMC • Organization/Processes: • Priorities are identified by hospital and departmental leadership • All staff may have input regarding opportunities for improvement • Seek and clarify current knowledge of processes • Explore and understand root causes and failure modes • Apply the PDCA improvement cycle • Plan • Do • Check • Act

5. Nursing PI/QI Focus • Focused Performance Areas • Pain Re-Assessment • Moderate Sedation • 1:1 Constant Observation • Restraints for Behavioral Management • Rationales • Patient safety risk • Frequency versus acuity • Problem prone

6. Nursing PI/QI Focus • Sample Sizes: • Pain Re-Assessment: 70 charts/month • Moderate Sedation: 100% • Constant Observation: 100% • Restraints for Behavioral Management:100% • Quantifiable Metrics/Compliance Goals: • Pain Re-Assessment: 90% • Moderate Sedation: 100% • Constant Observation: 100% • Restraints for Behavioral Management:100%

7. Indicators: Pain Re-Assessment • IV versus PO or other interventions • If no medication, why? • If medication was given, was it re-assessed timely? • If not reassessed, why? • EMTRAC and other enhancements

8. Expanded EMTRAC Triage Pain Assessment

9. Pain Tool for ED Rooms & Triage

10. Indicators: Moderate Sedation • Flow sheet, consent, procedure & site verification form • Pre-sedation checklist and assessment • Procedure assessment • Personnel in room and Pause for Safety • Vital Signs and I/O • Signatures • Aldrete Scoring System • Patient Discharge Disposition • Recovery noted in nurses note • Moderate Sedation discharge instructions • Noted for follow-up by NP • Reversal agent used • Admitted

11. Indicators: 1:1 Constant Observation • Safety Observation Record: • Constant Observation (1:1) • Suicide Precautions • Demographics: Age and gender • RN assessment: • Specifics (Cognitive, behavioral, motor, delirium) • Alternative interventions • MD order and nurse signature • CNA Documentation • RN documentation in EMTRAC • Includes suicide risk assessment

12. Indicators: Restraints for Behavioral Management • Demographics: Age and gender • MD order/reorder • Progress Note: Restraint/Seclusion for Behavioral Management • Alternatives, interventions and evaluation documented • Release of restraints/seclusion • Debriefing and RN signature • Restraint and Seclusion Behavioral Observation record • Care criteria indicated • Staff and RN initials and signatures • RN documentation in EMTRAC • Includes suicide risk assessment

13. Improvement Interventions • Continued reinforcement of pain re-assessment criteria • Implementation of pain tools in triage and patient rooms • Inservice regarding expectations for care of the patient receiving moderate sedation • Inservice regarding expectations for care of the patient requiring constant observation (1:1), suicide precautions or restraints for behavioral management • Communication of all results on the ED Performance Improvement bulletin board

14. PI/QI Next Steps • How do we want to distribute the data collection responsibilities? • Which areas of focus do we distribute? • Do we assign project leaders? • Development of 2008 PI/QI Plan? • Other questions??????