Nurse Knowledge Exchange Plus: Human-Centered Implementation for Spread and Sustainability.

BACKGROUND: Kaiser Permanente implemented a new model of nursing communication at shift change-in the bedside nursing report known as the Nurse Knowledge Exchange (NKE) in 2004-but noted variations in its spread and sustainability across medical centers five years later. METHODS: The six core elements of NKEplus were as follows: team rounding in the last hour before shift changes, pre-shift patient assignments that limit the number of departing nurses at shift change, unit support for uninterrupted bedside reporting, standardization for report and safety check formats, and collaboration with patients to update in-room care boards. In January 2011 Kaiser Permanente Southern California (KPSC; Pasadena) began implementing NKEplus in 125 nursing units across 14 hospitals, with the use of human-centered design principles: creating shared understanding of the need for change, minimum specifications, and customization by frontline staff. Champion teams on each nursing unit designed and pilot tested unit-specific versions of NKEplus for four to eight weeks. Implementation occurred in waves and proceeded from medical/surgical units to specialty units. Traditional performance improvement strategies of accountability, measurement, and management were also applied. RESULTS: By the end of 2012, 100% of the 64 medical/surgical units and 47 (77.0%) of the 61 specialty units in KPSC medical centers implemented NKEplus-as had all but 1 of the specialty units by May 2013. The mean KPSC score on the NKEplus nursing behavior bundle improved from 65.9% in 2010 to 71.3% in the first quarter of 2014. The mean KPSC Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score for nurse communication improved from 73.1% in 2010 to 76.4% in the first quarter of 2014 (p < . 001). CONCLUSION: Human-centered implementation appeared to help spread a new model of nursing handoffs and change the culture of professional nursing practice related to shift change.

Making hospitals safer for older adults: updating quality metrics by understanding hospital-acquired delirium and its link to falls.

The medical care of hospitalized geriatric patients must differ from the care of younger adults. Because of reduced "reserve capacity," hospitalized older adults are at high risk of development of geriatric syndromes such as delirium and falls. Geriatric syndromes often lead to functional decline and dependence. Patients who experience geriatric syndromes in the hospital are more likely to have a longer length of stay, higher risk of readmissions, and worse medical outcomes. Incident delirium in hospitalized geriatric patients has been shown to be preventable by intervening in established risk factors. Prevention of hospital-related falls has not been consistently demonstrated. Analysis from Kaiser Permanente data demonstrated a correlation with delirium and hospital-related falls. We propose that age-specific quality metrics should be made to reduce the risk of the development of geriatric syndromes in hospitalized older adults. By preventing delirium, we believe that health care practitioners can reduce hospital-related falls in geriatric patients and improve the quality of care delivered to hospitalized older adults. An illustrative fictional case study is presented.

Experience using peripherally inserted central venous catheters for outpatient parenteral antibiotic therapy in children at a community hospital.

BACKGROUND: Outpatient parenteral antibiotic therapy with peripherally inserted central catheters (PICCs) is safe, clinically effective, and cost effective in pediatric populations cared for at academic and free-standing pediatric hospitals. Our study evaluates the transferability of these findings to a community hospital setting. METHODS: Data were retrospectively collected on PICCs used in children at a community hospital from December 2003 to September 2006. The Fisher exact test and a logistic regression were used for statistical analysis. RESULTS: Thirty-nine PICCs were placed in 34 patients. The total number of catheter days at home was 800 (mean 20.5 +/- 13.9). We demonstrated a 97% success rate in completing therapy at home, with 82.3% completion with a single PICC. Our overall complication rate was 33.3%, consisting of occlusion, accidental displacement, cracks in the catheters, and local irritation. There were no instances of phlebitis or suspected or confirmed catheter infection or sepsis. There were no statistically significant differences in these values compared with reports from major pediatric centers. The cost savings was $1070 per day of home health care when compared with costs of inpatient hospitalization. CONCLUSIONS: We believe that this is the first study to demonstrate the effectiveness of PICC use for outpatient parenteral antibiotic therapy in pediatric patients in a community hospital setting, and demonstrates the ability for this to be done at the standard of care expected at major pediatric centers.