The job of the PSP would consist of: a) assessing patients on his/her assigned unit for risk of hospital-acquired complications following explicit protocols relevant to a short list of safety targets; b) prioritizing identified complications based on morbidity, mortality, and hospital costs; c) developing a plan to decrease hospital-acquired complications, in consultation with physicians and staff nurses on the unit; d) implementing the plan (to be carried out by nurses, physicians, the PSP – depending on the patient safety issue); and e) evaluating the effectiveness of the plan by measuring pre-identified outcomes, and making revisions if necessary. This type of approach would ensure that the PSP is monitoring his/her own unique environment and unit culture to devise specific interventions for that unit. Vignettes #1 and #2, written by our PSP, provide more detail regarding the daily routine.
Vignette #1 – “Daily Routine”
I am a Clinical Nurse Specialist working as a patient safety professional in a Veterans Affairs (VA) Medical Center. I arrive at work by 7am to start my day, which consists of personally assessing approximately 20 patients on a general medical floor. I begin each day by assessing patients by focusing on prevention measures for the following hospital-acquired complications: catheter-associated urinary tract infection (CAUTI), venous thromboembolism (VTE), pressure sores and falls. Before entering the room I review the flow chart for any other pertinent data, such as the Morse Fall Scale Score, which is used to determine if the patient is in the low or high risk level of falling; 50 or less is low risk while 51 or greater is high risk.
I then enter the patient’s room and introduce myself as follows. “Good Morning Mr. /Ms_____ my name is Debbie Zawol. I’m the Clinical Nurse Specialist working here on the fifth floor with the nurses as the Patient Safety Professional. Our goal is to cause you no harm with special focus on preventing urinary catheter infections, bloods clots, pressure sores and falls…” Their usual response is “Great, sounds good to me”. I then begin the assessment process.
For example, I ask the patient how s/he goes to the bathroom. This information lets me know if the patient has a catheter, or uses a urinal or ambulates with or without devices. If the patient has an indwelling Foley catheter I check to see if the Foley care is being performed: Is the catheter clean? Are there crustations forming? Is the bag hanging below the patient’s bladder? Is tubing is secured to patient’s thigh? Are there any signs of infection? I ask the nurse if s/he knows why the patient has the catheter. If the indwelling urinary catheter does not meet the criteria of insertion, the doctor is contacted to inform him/her of the removal. On occasion when reviewing charts, I have found no indication for continuing the indwelling urinary catheters.
As another example, I ask the patient if s/he has any sores on his/her body anywhere. I have found on several occasions patients will tell me about recurring pressure sores that may be almost healed but easily could break down, especially when confined in a hospital bed. Later, I review the Braden Scale Score, which is used to assess patient risk of skin breakdown. If the Braden Scale Score is 12 or less the nurse will request a wound care consult, which is a click of one key in the electronic file at the end of the skin assessment notes. When the patient is unable to turn without assistance, I then reinforce putting the patient on a turning schedule every 2 hours, if not already started. When there are signs of skin breakdown or the nurse has documented problems I ensure the wound care nurse has been consulted. Upon my chart review I have found documentation of stage I and ll pressure sores but no consult to the wound care nurse.
Using VTE prevention as an example, the PSP would evaluate daily each patient to ascertain whether or not VTE prophylaxis was prescribed, likely also evaluating the patient’s risk of VTE using a risk assessment tool.16
In those patients deemed at sufficient risk to warrant VTE prophylaxis – this will vary by unit and hospital – appropriate pharmacologic prophylaxis with a heparin-based product would be given unless contraindicated; mechanical sequential compression devices would be used in patients with contraindications to heparin products. Standing orders at the time of hospital admission coupled with explicit protocols would allow PSPs to institute VTE prophylaxis themselves. As we have observed in our own hospitals, even if sequential compression devices are ordered by the physician, patients may not wear them either because they were not delivered to the bedside for some reason or because wearing them is burdensome. The PSP would be yet another person who would help ensure VTE prophylaxis is being used on every appropriate patient.
Vignette #2 – “Venous Thromboembolism (VTE) Assessment”
I review the chart for VTE prophylaxis or contraindications. If there is no VTE prophylaxis ordered I will have the nurse call the physician so s/he will become familiar with the VTE prevention measures.
I look at the foot of the bed for the sequential compression device (SCD). If the SCDs are off the patient I reattach the SCDs; if they are on the patient, I ensure the machine is on. I educate the patients about why prophylaxis is necessary. On occasion I have found the SCDs were ordered by the physician, verified by the nursing staff in the computerized chart, but never implemented. I will retrieve the SCD machine and leg attachments that are kept in the equipment room on the floor and place the SCDs on the patient.
A similar approach – standing orders and explicit protocols developed at each hospital – would apply to the prevention of catheter-related urinary tract infection (with the focus on removing indwelling Foley catheters) and other endemic patient safety problems.
In some hospitals, infection preventionists may already perform some of the functions we would assign to a PSP. However, the primary goal of infection control programs is to eliminate hospital-acquired infections through the use of surveillance and sound epidemiological principles, 17
while PSPs would be focused on individual patients and would be charged with reducing a broader range of hospital-acquired complications. In addition, the PSP would focus on finding local solutions to identified problems, solutions that may vary unit by unit, let alone hospital by hospital. Studies have reported striking differences in error rates across units within the same institution, 18
suggesting that unit level influences are powerful contributors to hospital-acquired complications.
We envision an individual – such as an advanced practice registered nurse (APRN) – who conducts a safety assessment on every hospitalized patient in the unit(s) assigned to him or her in order to ensure that evidence-based preventive methods are being used. The safety assessment would consist of two components: a risk assessment for various hospital-acquired complications, such as those listed in the Table, and an assessment of the efficacy of preventive measures in place. If preventive measures are either not in use or ineffective, the PSP would implement a plan to institute appropriate measures, and may wish to document findings as “safety progress notes” in the medical record.
Having safety progress notes documented in the medical record would be one way to monitor the ongoing presence of invasive devices which, surprisingly, are often poorly documented in hospital charts. For example, urinary catheters are often present without any documentation in the medical record that they exist.19
Specifically, there is often no order for a catheter and no mention of the catheter in either the physician or nursing notes. But we know this “immaculate catheter” is present since we have noticed it emerging from the patient. Less commonly, the presence of central venous catheters in patients transferred from intensive care can easily be overlooked, thereby remaining in place far past the time they are still necessary for intravenous access.
By functioning in the manner we have just described, PSPs will not merely be identifying unmet targets of care and bringing them to the attention of front-line personnel for subsequent action, which could end up overwhelming and perhaps even annoying other staff members. Rather, through their implementation function, PSPs will be able to fix many problems without waiting for physicians’ orders. For instance, if a urinary catheter is in place unnecessarily, a PSP will remove the catheter using pre-existing catheter removal guidelines which s/he helped develop. Similarly, if a patient should be receiving VTE prophylaxis but is not, the PSP would speak with the physician to make sure these are ordered or – using standing orders authorizing the use of VTE prophylaxis in various circumstances – order the appropriate VTE preventive measure themselves.
We also envision PSPs providing additional benefits to the organization. Specifically, such an individual could serve as an educational resource or consultant to other clinicians and take responsibility for staying up to date on new advances and recommendations in the area of patient safety. Additionally, a PSP could improve the coordination of services between care providers such as ensuring the receipt of services that might be provided by other ancillary providers (e.g., dieticians, physical or occupational therapists). Finally, the PSP could perform additional tasks, described in the vignette below, that make patients feel welcome and special.
Vignette #3 – “The Most Important Patient in the World”
At the end of each patient assessment I always say: “What can I do for you today?” I pause and wait for a response. My goal is to make every patient feel that s/he is the most important patient in the world at that moment. I may give him/her a warm blanket, warm up his/her coffee, put non-skid socks on his/her feet, assist him/her to the bathroom, put lotion on his/her feet, or give him/her my arm to hold as we ambulate down the hallway. One vivid episode is that a patient’s prosthetic leg sleeve/liner was lost for several days. He had been transferred several times during his hospitalization. When I was informed about the situation I went to the patients’ belongings room in the basement of the medical center and dug through several bags of his belongings to find this sleeve/liner (worth about $400). He was very happy to finally be able to put on his prosthetic leg.
Another patient asked me to write a note of recognition to a radiation technician who made a special effort to help him get through throat radiation. I have also called the maintenance department when a patient’s room heater was not working. I contact the linen department when we don’t have enough pillows to turn our patients from side to side to prevent pressure sores. I also retrieve lip balm, water, juice, extra food, and anything else the patient needs to be safe and happy. These are just a sampling of the various things that I try to tackle that matter to the patient.
A couple days per week nursing students from the local college take care of our patients as well. I use every opportunity to reinforce the safety and prevention practices to the students such as preventing pressure sores by turning patients every 2 hours and preventing falls by removing all obstacles from the floor and learning about the patient’s limitations.