Glossary
EP - Exemplary Professional Practice

EP32EO.  Culture of Safety - Describe and Demonstrate that Nursing Sensitive Indicator Data Aggregated at the Organizational Level Outperform the Mean of the National Database Used. Provide Analysis and Evaluation of Data Related to Patient Falls, Nosocomial Pressure Ulcer Prevalence and/or Incidence, and Two (2) of the Following:

  • Blood Stream Infections,
  • Urinary Tract Infections,
  • Ventilator-Associated Pneumonia,
  • Restraint Use,
  • Pediatric IV Infiltrations
  • Other Specialty-Specific Nationally Benchmarked Indicators (Use only for Units for which the above do not Apply).

JCMC adopts an evidence based practice approach to preventing falls, pressure ulcer, catheter related bloods stream infections, and ventilator associated pneumonias. During the past two years JCMC has focused on these initiatives using the Patient Centered Family Focused Model of Care. Nurses are committed to placing the patient at the center of care through the implementation of best practices, enhanced communication, and collaboration between all members of the health care team.

Patient Falls

Preventing falls has been a main concern for many years at Jersey City Medical Center. Peggy Petrucelli BSN, RN, fall coordinator, the Quality Improvement Department, and Nursing Staff, have worked diligently over the last two years to increase awareness and implement strategies aimed at reducing falls.

Specific Strategies to prevent falls during 2010 and 2011 include:

  • Use of the Hendricks II assessment tool
  • Falls Risk Patient Identification
    • Yellow identification wristband worn by patients
    • Yellow “falling star” placed outside the patient’s room
  • Safety huddles
  • Hourly Rounding by RNs and PCTs
    • Offer toileting frequently
    • Medicating for Pain
    • Reposition the patient
    • Evaluation the patients perimeter for safety
  • Ongoing education provided to nursing staff and PCTs, including hospital wide orientation and competency days
  • Interdisciplinary Falls Prevention Team: conduct monthly reviews and discussions of events

Falls Data 2010 - 2011

Analysis and Evaluation of Data

All falls are monitored and reported to the National Database of Nursing Quality Indicators. This data is shared to help make decisions regarding patient care.

The data reveals the following:

During 2010 and 2011, the data revealed that four out of six units exceeded the benchmark the majority of the time. 6E, 6W, and SICU/MICU exceeded the benchmark during five of eight quarters and CCU exceeded the benchmark four of eight quarters. 7W and 7E did not exceed the benchmark during the eight quarters.

Peggy Petrucelli BSN, RN assesses each fall event to identify patterns or opportunities for improvement. The falls occurring on 7E and 7W were caused by multiple factors making it difficult to draw any specific conclusion about why an increase in the falls rate within these units occurred. These units comprise of 70 beds combined and provide care to adolescents, adult, and geriatric patients with a variety of diagnosis. Among the most common diagnosis are respiratory, cardiac, renal, sepsis, and diabetic related injuries. Patient ages range from 18 – 100 years, and the patient to nursing ratio is 6:1. PCTs assist nurses with patient care and they are staffed according to the census. An extensive literature review done on patient fall revealed that medical surgical patients are at higher risk for falling due to factors such as medications, mobility, poor balance, advanced age and incontinence.

Process Improvements Strategies

Due to the increase in falls, an organizational SWOT analysis was conducted by Theresa Conder BSN, RN, an Executive Intern from Seton Hall University, to identify strengths, weaknesses, opportunities, and threats related to the current process at JCMC (Appendix EP32EO-A). The SWOT analysis, ongoing assessment of the NDNQI data, and factors related to the falls occurring house wide, led to the development of an action plan (Appendix EP32EO-B) targeting three specific areas during 2010 and 2011: (1) post fall assessments, (2) increase family involvement (3) increase staff awareness and communication

A. Improved Post Fall Assessment Process

A comprehensive post falls assessment is an essential component of falls prevention because it provides key information needed to determine preventable causes of falls. A standardized approach to assessing falls was needed to better understand the factors influencing falls at JCMC. A new post fall assessment process was developed using the electronic incident reporting system. Targeted questions regarding the fall incident are mandatory fields and must be answered by the healthcare provider reporting the incident. These targeted questions focus on patient and environmental factors relating to the fall. Focus areas include:

  • Poly pharmacy 
  • Blood pressure control 
  • Patients family involvement 
  • Hourly rounding by the nursing staff 
  • Environmental factors such as clutter, wet floors, etc  
  • Daily living issues such as call bell in reach, toileting, food tray close by, and non skid slippers  

This information is aggregated at the end of each week to identify trends. In addition, root cause analyses are conducted on all falls with injuries. This analysis includes a multidisciplinary review of each fall immediately following the event with key individuals involved with the patient.

 B. Patient and Family involvement:

Involvement of patients and family members is necessary to prevent falls because they are an essential part of the fall prevention program at JCMC. Patients and family members are educated daily on the fall prevention program and the patient’s individualized plan to reduce falls. Other interventions include:

  • Orienting the patient to there environment
  • Placing call bells within reach
  • Instructing patients on when and how to call for assistance

In order to improve upon this process, the “teach back” method was adapted to the education provided by nursing staff. Using this method, the nurse confirms that the patient was taught fall preventions strategies in a way that he/she could understand. The Patient’s understanding is confirmed when interventions are verbalized back to the nurse. The patient is asked to sign the “teach back” form on admission and transfer to a new unit. This is done to establish a contractual agreement between the nurse and the patient/family member. It acknowledging that education was provided and the patient agrees to use the call bell and ask for assistance when getting out of bed. This intervention was established due to the result of a root cause analysis.

Consistent and innovative communication between patients, family members, and staff involved in patient care is critical for preventing and reducing falls. Increase family involvement in the falls prevention process can assist in reminding the patient to ask for assistance when getting out of bed, especially when the patient believes assistance is not necessary. Communication between the family and the nurse is reinforced during hourly rounding to assist family members to partner with the nursing staff. For example, family members are asked to notify the nurse when they leave the room so that increase monitoring and vigilance can occur.

C. Increase staff awareness and communication

Increasing the staff awareness regarding fall rates is one of the most important tasks for the nursing staff. Every unit is provided their falls numbers and rates to inform the staff how their unit is performing in comparison with previous months and year. This statistical data is displayed in visible areas near the nurse’s station. This strategy empowers nurses to continue strategies to reduce falls. To increase momentum “Fall Champions” took on the role of becoming expert resources to the nursing staff. Peggy Petrucelli BSN, RN, holds monthly falls reduction meetings and shares her post fall evaluations with them. The nurse champions are responsible for bringing this information to the Nursing staff on their units through their Unit Practice Councils (UPC). Peggy Petrucelli also reports monthly falls data to the Quality and Safety Council. This Council also brings forth ideas regarding strategies to reduce falls. Staff feed back and awareness through these councils is ongoing.

“Unit Specific Fall Champions”

The unit champions focused on strengthening the handoff process by highlighting patients who are at high risk for falling or who had a previous fall event. This assisted in providing improved continuum of care from shift to shift and during transfer to different units or level of care. In order to facilitate this process a notification is placed in the electronic STAR system allowing nurses to place an alert when a patient fall occurred. This notification maintains an electronic history of falls and places an alert on the patients’ face sheet alerting the nursing staff upon transfer and readmission.

Peggy Petrucelli BSN, RN, also increased staff nurses’ awareness and maintained staff momentum by providing ongoing education regarding patient falls and prevention. Peggy provides education at all nursing and PCT orientations and competency days. In addition, poster presentations were presented during the 2011 Safety Summit and Nursing Research Fun Fair.

Additional Efforts in 2012

Despite increased efforts in improving post fall assessments, increasing family involvement, and increasing staff awareness and communication, falls at JCMC continued to maintain above the national benchmark. During 2012, fall prevention strategies focused on changing JCMC’s falls assessment tool to the John Hopkins Falls Prevention Assessment because of its ability to better evaluate the patient population at JCMC. A new fall prevention protocol based on a two tier system was launched in July 24th 2012. Please refer to NK7 for more information regarding this process.

Pressure Ulcer Prevalence

Preventing hospital acquired pressure ulcers is a main priority at JCMC. During the past two years a patient centered family focused approach has been used to eliminate or decrease the incidence of hospital acquired pressure ulcers. JCMC participates in the quarterly NDNQI Falls Prevalence Study. Designated Nurse Champions turn and examine every patient on quarterly bases to survey the number of patients with hospital acquired pressure ulcers. This data is tracked and benchmarked against the NDNQI database national mean. Graphs are displayed on every unit to increase awareness and assist in increase nursing momentum with prevention strategies.

Pressure Ulcer Prevention Nursing Unit Champions

Nursing Unit Champions have received additional training on staging and pressure ulcer prevention. They serve as resources to their nursing colleagues when questions arise. They work closely with Peggy Petrucelli BSN, RN, Wound Care Coordinator to address the needs of the nursing staff on each unit.

Each Unit strives to maintain a goal of zero hospital acquired pressure ulcers. Unit Specific Strategies to prevent hospital acquired pressure Ulcers Include (Reference EP32EO-A)

  • Braden Score Risk Assessment: All patients are assessed upon admission, every shift, and prior to discharge
  • Safety Measures are applied to any patient with a score of 18 or less
    • Reposition every 2 hours
    • Frequent re-distributing tissue loads - Use of pillows, foam wedges, and heal boots
    • Reposition at least every hour when sitting in the chair
  • Skin Care product
  • Daily Patient and Family Education
  • Maintaining proper dietary intake for all patients
  • Hourly Rounding
  • Safety Huddles
  • All pressure ulcers are reassessed, measured, and documented every Thursday, during dressing changes, at time of transfer, and discharge

Hospital Acquired Pressure Ulcer Data 2010 – 2011

Analysis and Evaluation of Data

Results from the NDNQI prevalence study reveal that the all of the units exceeded the benchmark the majority of time. CCCU and 6E exceeded the benchmark 8 of 8 quarters and 6W, 7E, and 7W have exceeded the benchmark 4 of 8 quarters. The SICU/MICU exceeded the benchmark six of eight quarters. However, during the fourth quarter of 2010 an increase in the prevalence of hospital acquired pressure ulcers was noted in the MICU/SICU. This prevalence rate decreased by 50% during the first quarter of 2011 and further decreased back to their baseline rate of zero during the 3rd and 4th quarter of 2011.

Process Improvements Strategies

Peggy Petrucelli BSN, RN and the Pressure Ulcers Prevention Champions strive to eliminate or reduce hospital acquired pressure ulcers. They do this by increasing staff awareness, autonomy, and knowledge. All incidences of hospital acquired pressure ulcers are reviewed. Ongoing feedback is provided to the nurse managers and the nursing staff, with the goal of creating increased awareness of progress with prevention strategies. Quarterly assessments of Braden Scale usage on admission revealed 100 % compliance on all nursing units. Therefore the primary focus for 2010 and 2011 was to provide education to all nursing staff on skin assessment (Appendix EP32EO-C) and prevention strategies (Appendix EP32EO-D).

Enhancing nursing autonomy with pressure ulcer prevention was a goal for 2010 and 2011. Nurses at JCMC can request a wound care consult and nutritional evaluation for any patient who is high risk for skin breakdown without a physician order. Peggy Petrucelli BSN, RN was instrumental in placing the wound care manual on the liberty intranet. This provides nurses resources at the point of care to manage and prevent pressure ulcers. The nurses at JCMC strive to promote a culture of safety and preventing pressure ulcers has been imbedded in this culture through ongoing communication, education and autonomy.

Prevention of Central Line Associated Blood Stream Infection (CLABSI) and Ventilator Associated Infections

BSI Bundles Sign placed in Nursing Bedside Charts
 BSI Bundles Sign placed in Nursing Bedside Charts  


VAP Bundles Sign placed in Nursing Bedside Charts
 VAP Bundles Sign placed in Nursing Bedside Charts  

Prevention of Central Line Associated Blood Stream (CLABSI) Infections and Ventilator Associated Pneumonias (VAP) is imbedded in the culture of the critical care units. The goal of the critical care division is to achieve zero incidences of VAP and CLABSI, and to maintain below the NDNQI and NHSN benchmarks. Nurse in the critical care adhere to the BSI and VAP bundles regularly. Multidisciplinary collaboration during interdisciplinary rounds has been essential in preventing of theses events. During rounds nurses discuss bundle components to ensure patient safety.

The following measure were implemented in 2010 – 2011 to increase awareness

  • Ongoing education provided to nursing and medical staff
  • Provide updates and reports through the unit practice councils
  • Nurses collaborate closely with infection control to implement best practices and reduce rates
  • Bundles are included in critical care competency Days
  • Bundles were added to Critical Care flow sheet and Handoff tool
  • Clinical Nurse leaders periodically review and evaluate bundle compliance and plan of care with staff nurses

CLABSI Evidence Based Measures Implemented
In addition to the above strategies, the nurses in the Critical Care Division, utilize the bedside procedural checklist to assure aseptic technique during line insertion. Using the checklist (Appendix EP32EO-E) empowers nurses to stop procedures if sterility is not maintained during line insertion. In addition, during daily interdisciplinary rounds it is routine for nurses and physicians to discuss the removal of unnecessary lines and avoidance of femoral lines when possible. In October 2010, the use of chlorhexedine impregnated dressing (Reference EP32EO-B) was introduced to the critical care units. These dressings are applied to all indwelling venous and arterial catheter sites upon insertion and following dressing changes according to the central line policy (Reference EP32EO-C).

CLABSI Data

Analysis and Evaluation of Data

The NDNQI data reveals that the two out of two units exceeded the benchmark the majority of the time. The CCU has exceeded the benchmark eight of eight quarters and the MICU/SICU has exceeded the benchmark five of eight quarters. Each CAUTI is thoroughly reviewed by the medical and nursing staff. This data is provided to the nursing staff to increase awareness with the CLABSI bundle Prevention strategies.

Evidence Based Ventilator Associated Pneumonia (VAP) Strategies Implemented

During the last two years efforts to reduce the incidences of VAP have been concentrated on implementing chlorhexedine oral care mouthwash protocol, improving glucose control and improving the sedation vacation and weaning protocols.

Information regarding the process of revising the oral care policy can be seen in NK7

For more information regarding the updated insulin drip protocol please refer to EP7EO

A review of the literature, staff feed back, and case reviews of patients’ who developed VAPs led to the development of a standardized protocol for spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) in mechanically ventilated patients. This protocol (Appendix EP32EO-F) allows nurses to be autonomous in weaning the patient if they pass the established SAT and SBT safety screens. At 8 am every morning the respiratory therapist and primary nurse work together to assess the patient’s readiness to be extubated (Reference EP32EO-D). The results of the trial are discussed during interdisciplinary rounds. This new protocol has assisted in the early extubation of patients reducing the potential of acquiring a VAP.

Data for VAP

Analysis and Evaluation of Data

Through the hard work and dedication of the nursing staff all units exceeded the benchmark the majority of the time. CCCU has exceeded the benchmark 8 of 8 quarters and the MICU/SICU has exceeded the benchmark 4 of 8 quarters.