Nursing Annual Report 2023 | Advancing a Healthy, Strong and Safe Practice Environment

The Progressive Care Unit (PCU) houses some of El Camino Health's most vulnerable and complex patients. The PCU staff are challenged daily with ethical dilemmas, difficulties with patient flow, and high-risk patients. Despite these obstacles, the PCU staff has prioritized patient safety and improving qualities outcomes. Areas of focus include:

• Fall Reduction
• Hospital Acquired C. Difficile Transmission Reduction

Fall Reduction

One of the PCU's biggest challenges during FY22 was the issue of patient falls. To address this need, daily fall prevention audits were implemented in the department. Our staff on the day shift and night shift assessed the fall risk for each patient and ensured fall prevention interventions were in place. These interventions include:

• Having beds in their lowest positions
• Non-slip socks
• Fall prevention signage visible to staff and visitors prior to entering patient rooms

These audits began in June 2022, the start of FY2023, and to date the department had only one fall, which is a 60% reduction in falls for the department. The PCU also achieve the milestone of being fall-free for more than 120 days.

Reducing C. Difficile

Hospital acquired infections (HAI) have been a large area of focus for El Camino Health. One of the biggest challenges for our frontline staff is reducing the spread of C. difficile, and the PCU HAI committee representatives have taken extra steps to reducing C. difficile.

Brenda Gaidies-Smith, RN and Angela Gates, RN initiated a "C. diff audit form," a tool that the charge and resource nurses use to ensure that all appropriate C. difficile interventions are in place, which include:

• Yellow isolation stethoscopes and bleach wipes in room
• Correct signage in front of doors, etc.

We also used surgical caps to cover the alcohol dispensers in patient rooms, which encouraged everyone to wash their hands with soap and water. The audits we had in place along with promoting proper hand hygiene resulted in no hospital acquired C. difficile cases in more than 90 days.

The PCU team has demonstrated that going back to the basics of nursing care, practicing nursing diligently, and reinforcing best practices can result in outstanding patient outcomes and improve quality of patient care. The team will continue to reinforce these practices until we achieve our enterprise goal of Zero Preventative Harm.

Fall injuries have significant implications on disease trajectory and outcomes on cancer patients. Approximately one in 10 falls result in injuries, such as hip fracture, subdural hematoma, and traumatic brain injury. Older patients with cancer and chemotherapy toxicity have additional risk factors for falls. In 2019, the 32-bed inpatient medical-surgical oncology unit had 19 fall incidents. Care team members explored interventions to improve fall prevention and reduce the number of falls.

Our team utilized apparent cause analysis (ACA) and root cause analysis (RCA) to extensively review our falls incidents. We explored the "Five Why's" to identify improvement opportunities and best practice interventions. Interventions to improve falls included:

• Promoting staff engagement – to lead and audit the unit's fall prevention initiatives, each shift has at least one volunteer as fall prevention lead.
• Increasing staff awareness – unit-specific patient falls data are reviewed during team huddles to reinforce effective strategies and idea-sharing on falls prevention.
• Creating a fall prevention kit – to promote standard use of Heindrich Fall Risk Assessment with interventions for scores less than five.

Our direct care staff leading fall prevention initiatives continue to share our lessons learned with the entire team to increase awareness and risk assessment proficiency. This led to a reduction in falls from 2021 to 2022. ACA and RCA revealed common causes, which our team maximized to keep our patients safe.

Increases in patient census and acuity within Maternal Child Health (MCH) has led to capacity and staffing concerns. The average length of stay for patients having scheduled cesarean birth at term was 3.27 days with 21.6% of these patients being discharged home on post-operative day four.

The Enhanced Recovery After Cesarean (ERAC) Committee was formed in October 2022 with the following goals:

• Reducing the length of stay for patients having scheduled a cesarean birth at term with singleton pregnancy
• Enhanced maternal infant bonding/breastfeeding
• Decreased pain
• Improved patient satisfaction

The interdisciplinary committee consists of obstetricians, anesthesiologists, direct care nurses, educators, lactation specialties, managers, service line director, clinical nurse specialist, and administrative analysts. Zoom meetings were conducted every two weeks.

A consensus statement by the Society of Obstetric Anesthesiologist and Perinatology (SOAP) was published in 2021 aimed to provide evidence-based recommendations along with level of evidence recommendations for patients having cesarean birth. The ERAC improvement committee reviewed and evaluated implementation feasibility of 24 recommendations that occur during the five phases of care of surgical birth:

• Prior to surgery
• Night before surgery
• Day of surgery
• Upon admission
• Intra-operatively
• Immediate post-op (PACU)
• Postpartum

Implementation was carried out individually and in small groups. The members reported on progress, addressed barriers, and discussed the interventions they were working on at scheduled meetings. Forty-eight patient interviews were conducted from November-December 2022. Based on audit findings, recommendations were prioritized based on greatest need. For example:

• Early Oral Intake – Our interventions included gum chewing for 30-minutes in the post-anesthesia care unit (PACU), followed by ice chips, and clear liquids. Overall, patients were relieved to know they could have ice chips and surprised they could drink apple juice. Offering gum was accepted by most patients. Some patients even requested more gum after transfer to postpartum.
• Promote Breastfeeding and Maternal Infant Bonding – Our intervention was to provide mother/infant skin-to-skin (STS) contact as soon as the mother/infant were comfortable. The patient interviews revealed that STS promoted maternal relaxation, reduced infant crying, and enhanced the immediate post-birth transition process. Additionally, newborn temperature remained normal and maternal shivering was reduced.

For the past four months, education that included data reports highlighted bimonthly progress at every Labor & Delivery and Mother Baby Partnership Council meeting. Further nursing education was presented at every staff nurse meeting, in emails, at shift huddles at Mountain View and Los Gatos Campuses.

In the mother-baby unit, audits are beginning to reflect improvements in Foley catheters being removed as 6-12 hours after surgery. Additionally, our average length of stay has decreased from 3.27 days to 2.59 days with only 8.7% of patients staying four post-op days, down from 47.6%.

The ERAC improvement interventions will now be applied to patients with unscheduled surgical birth. The committee will continue to work on full implementation of all recommendations aimed to optimize surgical recovery.