How SWAT Changed the Conversation: Implementation of a Discharge SWAT Team Improves Morale and Facilitates Communication During the COVID-19 Pandemic.

PURPOSE OF STUDY: Hospital overcrowding and delays in discharge are serious issues in the modern health care landscape and can lead to poor patient outcomes and health care personnel (HCP) burnout. The goal of this project was to develop a collaborative forum where HCP representing the entire spectrum of the inpatient care team, including case management team members, could connect to discuss challenges and barriers to patient discharge. The following describes the development, implementation, and outcomes of the discharge SWAT (Solutions, Wins, Actions, and Tactics) team, which is a 30-min virtual daily meeting where discussion is primarily centered around challenges in discharging individual patients and addressing case manager needs. The primary aim of SWAT meetings is fostering a positive atmosphere to address barriers to discharge while prioritizing patient care and outcomes. PRIMARY PRACTICE SETTING: This study was conducted in a 40-hospital academic health system in the United States. METHODOLOGY AND SAMPLE: SWAT meetings were first implemented at a representative flagship facility in a health system. HCP at this first facility were surveyed to assess satisfaction with SWAT meetings. SWAT meetings then were implemented at the majority of facilities in a 40-hospital academic health system. During SWAT implementation, average inpatient length of stay (LOS) and patient care transitions were monitored for participating and nonparticipating service lines. RESULTS: Among surveyed HCP, the majority view SWAT meetings favorably and reported that it was a valuable use of their time and positively impacted their work in the patient discharge space. Nonprovider and case management staff in particular valued the SWAT meetings and found them beneficial. LOS remained stable for patients under the care of participating providers, despite the upheaval of the ongoing COVID-19 pandemic, and the research team also observed a positive impact of SWAT meetings on appropriate inpatient care transitions.

A Current State Assessment on Nursing Work Activities: An Observational Study.

BACKGROUND: Nationwide nursing shortages have led to higher patient-to-nurse ratios, nursing burnout, and decreased quality of care. LOCAL PROBLEM: Staffing challenges and nursing burnout were becoming growing concerns and success was contingent upon efficient use of existing resources. METHODS: Direct observation current state assessment was completed on medical-surgical specialty units to better understand work activities of registered nurses (RNs) and unlicensed assistive personnel (UAPs). RESULTS: RNs spent more time performing indirect care (eg, documentation) than direct patient care. Interruptions and problems consumed 17.4% and 5.6% of their time, respectively. UAPs performed more direct patient care but had a higher proportion of downtime. RNs underdelegated nonclinical tasks. CONCLUSIONS: Direct observation current state assessment offers a better understanding of workflow and workload inefficiencies. This information is critical to provide informed, evidence-based recommendations to develop future patient care models with more capacity to deliver high-quality care with greater efficiency and lessen nursing burden and burnout during the nursing shortage crisis.

Healthcare-associated infections during the coronavirus disease 2019 (COVID-19) pandemic and the modulating effect of centralized surveillance.

We analyzed efficacy of a centralized surveillance infection prevention (CSIP) program in a healthcare system on healthcare-associated infection (HAI) rates amid the coronavirus disease 2019 (COVID-19) pandemic. HAI rates were variable in CSIP and non-CSIP facilities. Central-line-associated bloodstream infection (CLABSI), C. difficile infection (CSI), and surgical-site infection (SSI) rates were negatively correlated with COVID-19 intensity in CSIP facilities.

Development and implementation of a centralized surveillance infection prevention program in a multi-facility health system: A quality improvement project.

Objective: To develop, implement, and evaluate the effectiveness of a unique centralized surveillance infection prevention (CSIP) program. Design: Observational quality improvement project. Setting: An integrated academic healthcare system. Intervention: The CSIP program comprises senior infection preventionists who are responsible for healthcare-associated infection (HAI) surveillance and reporting, allowing local infection preventionists (LIPs) a greater portion of their time to non-surveillance patient safety activities. Four CSIP team members accrued HAI responsibilities at 8 facilities. Methods: We evaluated the effectiveness of the CSIP program using 4 measures: recovery of LIP time, efficiency of surveillance activities by LIPs and CSIP staff, surveys characterizing LIP perception of their effectiveness in HAI reduction, and nursing leaders' perception of LIP effectiveness. Results: The amount of time spent by LIP teams on HAI surveillance was highly variable, while CSIP time commitment and efficiency was steady. Post-CSIP implementation, 76.9% of LIPs agreed that they spend adequate time on inpatient units, compared to 15.4% pre-CSIP; LIPs also reported more time to allot to non-surveillance activities. Nursing leaders reported greater satisfaction with LIP involvement with HAI reduction practices. Conclusion: CSIP programs are a little-reported strategy to ease burden on LIPs with reallocation of HAI surveillance. The analyses presented here will aid health systems in anticipating the benefit of CSIP programs.

Healthcare personnel early return-to-work program after higher-risk SARS-CoV-2 exposure: A learning health system quality improvement project.

BACKGROUND: Incidence of health care personnel (HCP) with a higher-risk SARS-CoV-2 exposure and subsequent 14-day quarantine period adds substantial burden on the workforce. Implementation of an early return-to-work (RTW) program may reduce quarantine periods for asymptomatic HCP and reduce workforce shortages during the COVID-19 pandemic. METHODS: This observational quality improvement study included asymptomatic HCP of a multi-facility health care system with higher-risk workplace or non-household community SARS-CoV-2 exposure ≤4 days. The program allowed HCP to return to work 8 days after exposure if they remained asymptomatic through day 7 with day 5-7 SARS-CoV-2 nucleic acid amplification test result negative. RESULTS: Between January 4 and June 25, 2021, 384 HCP were enrolled, 333 (86.7%) remained asymptomatic and of these, 323 (97%) tested negative and were early RTW eligible. Mean days in quarantine was 8.16 (SD 2.40). Median day of early RTW was 8 (range 6-9, IQR 8-8). Mean days saved from missed work was 1.84 (SD 0.52). A total of 297 (92%) HCP did RTW ≤10 days from exposure and days saved from missed work was 546.48. CONCLUSIONS: Implementing an HCP early RTW program is a clinical approach for COVID-19 workplace safety that can increase staffing availability, while maintaining a low risk of SARS-CoV-2 transmission.

SafeNET: Initial development and validation of a real-time tool for predicting mortality risk at the time of hospital transfer to a higher level of care.

BACKGROUND: Processes for transferring patients to higher acuity facilities lack a standardized approach to prognostication, increasing the risk for low value care that imposes significant burdens on patients and their families with unclear benefits. We sought to develop a rapid and feasible tool for predicting mortality using variables readily available at the time of hospital transfer. METHODS AND FINDINGS: All work was carried out at a single, large, multi-hospital integrated healthcare system. We used a retrospective cohort for model development consisting of patients aged 18 years or older transferred into the healthcare system from another hospital, hospice, skilled nursing or other healthcare facility with an admission priority of direct emergency admit. The cohort was randomly divided into training and test sets to develop first a 54-variable, and then a 14-variable gradient boosting model to predict the primary outcome of all cause in-hospital mortality. Secondary outcomes included 30-day and 90-day mortality and transition to comfort measures only or hospice care. For model validation, we used a prospective cohort consisting of all patients transferred to a single, tertiary care hospital from one of the 3 referring hospitals, excluding patients transferred for myocardial infarction or maternal labor and delivery. Prospective validation was performed by using a web-based tool to calculate the risk of mortality at the time of transfer. Observed outcomes were compared to predicted outcomes to assess model performance. The development cohort included 20,985 patients with 1,937 (9.2%) in-hospital mortalities, 2,884 (13.7%) 30-day mortalities, and 3,899 (18.6%) 90-day mortalities. The 14-variable gradient boosting model effectively predicted in-hospital, 30-day and 90-day mortality (c = 0.903 [95% CI:0.891-0.916]), c = 0.877 [95% CI:0.864-0.890]), and c = 0.869 [95% CI:0.857-0.881], respectively). The tool was proven feasible and valid for bedside implementation in a prospective cohort of 679 sequentially transferred patients for whom the bedside nurse calculated a SafeNET score at the time of transfer, taking only 4-5 minutes per patient with discrimination consistent with the development sample for in-hospital, 30-day and 90-day mortality (c = 0.836 [95%CI: 0.751-0.921], 0.815 [95% CI: 0.730-0.900], and 0.794 [95% CI: 0.725-0.864], respectively). CONCLUSIONS: The SafeNET algorithm is feasible and valid for real-time, bedside mortality risk prediction at the time of hospital transfer. Work is ongoing to build pathways triggered by this score that direct needed resources to the patients at greatest risk of poor outcomes.

Hospital Nurses' Work Activity in a Technology-Rich Environment: A Triangulated Quality Improvement Assessment.

The aim of this project was to describe hospital nurses' work activity through observations, nurses' perceptions of time spent on tasks, and electronic health record time stamps. Nurses' attitudes toward technology and patients' perceptions and satisfaction with nurses' time at the bedside were also examined. Activities most frequently observed included documenting in and reviewing the electronic health record. Nurses' perceptions of time differed significantly from observations, and most patients rated their satisfaction with nursing time as excellent or good.

Comparing Trainee and Staff Perceptions of Patient Safety Culture.

PURPOSE: The Accreditation Council for Graduate Medical Education implemented the Clinical Learning Environment Review (CLER) program to evaluate and improve the learning environment in teaching hospitals. Hospitals receive a report after a CLER visit with observations about patient safety, among other domains, the accuracy of which is unknown. Thus, the authors set out to identify complementary measures of trainees' patient safety experience. METHOD: In 2014, they administered the Hospital Survey on Patient Safety Culture to residents and fellows and general staff at 10 hospitals in an integrated health system. The survey measured perceptions of patient safety in 12 domains and incorporated two outcome measures (number of medical errors reported and overall patient safety). Domain scores were calculated and compared between trainees and staff. RESULTS: Of 1,426 trainees, 926 responded (65% response rate). Of 18,815 staff, 12,015 responded (64% response rate). Trainees and staff scored five domains similarly-communication openness, facility management support for patient safety, organizational learning/continuous improvement, teamwork across units, and handoffs/transitions of care. Trainees scored four domains higher than staff-nonpunitive response to error, staffing, supervisor/manager expectations and actions promoting patient safety, and teamwork within units. Trainees scored three domains lower than staff-feedback and communication about error, frequency of event reporting, and overall perceptions of patient safety. CONCLUSIONS: Generally, trainees had comparable to more favorable perceptions of patient safety culture compared with staff. They did identify opportunities for improvement though. Hospitals can use perceptions of patient safety culture to complement CLER visit reports to improve patient safety.

A paradigm shift toward systemwide quality improvement education: meeting the needs of a rapidly changing health care environment: meeting the needs of a rapidly changing health care environment.

BACKGROUND: Widespread changes in the health care landscape require a paradigm shift from an educational model where quality improvement (QI) expertise is centralized to a model where foundational and functional QI knowledge is widespread through all levels of a health care organization. METHODS: To support a new educational structure prioritizing QI education as a stand-alone priority, a 6-month educational course was introduced for operational leaders (requiring completion of a real-life improvement project) and a second, introductory QI education set of 5 stand-alone classes was introduced for managers and frontline staff; the latter is provided at centralized sites, on-site, and via webinars. Additional QI courses have been introduced for board members. RESULTS: Sixty operational leaders attended the first 2 offerings of the 6-month course and completed 50 associated QI projects, as of July 2012; nearly 1500 participants have attended the "Just-in-Time" classes, representing 13 University of Pittsburgh Medical Center hospitals and affiliated facilities. Eighty-three percent of recent participants rated the 6-month course a 4 or 5 in terms of efficacy. Two-thirds of participants from both 6-month series reported that they continued to work on their project once the class was over. DISCUSSION: The number of course attendees and their feedback regarding efficacy of this educational approach, as well as the volume of associated completed projects, indicate success in providing greater numbers of staff at all levels of the organization with QI education and tools. This educational format shows promise for further refinement and replicability.

Separating predictable and unpredictable work to manage interruptions and promote safe and effective work flow.

Predictable and unpredictable patient care tasks compete for caregiver time and attention, making it difficult for patient care staff to reliably and consistently meet patient needs. We have piloted a redesigned care model that separates the work of patient care technicians based on task predictability and creates role specificity. This care model shows promise in improving the ability of staff to reliably complete tasks in a more consistent and timely manner.

A relational leadership perspective on unit-level safety climate.

OBJECTIVE: This study compared nursing staff perceptions of safety climate in clinical units characterized by high and low ratings of leader-member exchange (LMX) and explored characteristics that might account for differences. BACKGROUND: Frontline nursing leaders' actions are critical to ensure patient safety. Specific leadership behaviors to achieve this goal are underexamined. The LMX perspective has shown promise in nonhealthcare settings as a means to explain safety climate perceptions. METHODS: Cross-sectional survey of staff (n = 711) and unit directors from 34 inpatient units in an academic medical center was conducted. RESULTS: Significant differences were found between high and low LMX scoring units on supervisor safety expectations, organizational learning-continuous improvement, total communication, feedback and communication about errors, and nonpunitive response to errors. CONCLUSION: The LMX perspective can be used to identify differences in perceptions of safety climate among nursing staff. Future studies are needed to identify strategies to improve staff safety attitudes and behaviors.