Case Study: Improving Hospital Care

Virginia QIO Uses Evidence-Based Interventions To Improve Hospital Care From 1998-2001, the Virginia Health Quality Center worked with hospitals throughout the state to improve care for patients experiencing heart attacks and heart failure. Through its efforts, VHQC helped improve statewide performance on 7 out of 8 quality indicators for Acute Myocardial Infarction and Congestive Heart Failure and improved its national ranking from 21st to 18th among all states. VHQC also made strong gains in flu and pneumonia screening. Some examples: Lewis Gale Medical Center, a large urban hospital in Salem, VA increased the early administration of beta blockers by 37%, beta blockers at discharge by 33%, and smoking cessation counseling by 59% over 18 months. Working with the Virginia Health Quality Center, Lewis Gale implemented several effective system changes to improve heart care for patients. Ann Latstetter, director for Quality and Risk Management, attributed the hospital’s success to persistent case management, a strong physician champion and other physicians who felt passionately about the importance of heart care indicators, as well as tremendous support from hospital administration. "This was truly an interdisciplinary effort," said Latstetter. To promote improvement, staff began presenting quality data at every medical staff meeting, developed indicator-specific progress notes, incorporated heart care indicators into emergency room protocols, and implemented routine AMI/Chest Pain/ACS orders. Additionally, prompts built into the hospital’s electronic medical record ensured that patients received appropriate medications at discharge, including aspirin, beta blockers, and ACE inhibitors. VHQC assisted by providing evidence-based guidelines and interim data reports that allowed Lewis Gale to assess progress in improving heart care. These changes resulted in a significant decrease in one-day stays and average-length-of-stays for patients admitted with cardiac diagnoses, providing the facility with financial rewards as well as quality improvements. Latstetter also noted that Lewis Gale recognized smoking cessation counseling as an integral part of a good heart care treatment plan. Counseling was implemented hospital-wide by adding a question to the hospital’s electronic medical record prompt to ensure that all appropriate patients were assessed for the need for smoking cessation counseling. Sample materials and interventions suggested by the VHQC also helped educate patients and staff. Ann Latstetter can be reached at 540-776-4835. CJW Medical Center, a large urban hospital in Richmond, VA, increased flu screening by 48% from the 2000 to the 2001 flu season and increased pneumococcal screening by 43% over 18 months. Additionally, CJW cut the time to antibiotic administration for patients admitted with pneumonia. CJW operates two facilities in the Richmond area. With help from VHQC, CJW enhanced its system to ensure more high-risk patients receive flu and pneumococcal vaccinations. Through participation in the VHQC’s Inpatient Initiative, CJW identified screening and vaccinations as new hospital priorities. "We focused on what nurses can do," said CJW Infection Control Practitioner Donna Alvis. "We developed screening questions for the computerized admission history form and reviewed them at Nursing Executive Meetings and Nurse Practice Councils." CJW reached beyond the original scope of the pneumonia project and began screening all patients—not just high-risk patients—to find those who needed flu and pneumonia vaccines. "Our goal now is not only to screen, but to vaccinate high-risk patients," says Alvis. Alvis also noted that focus on the pneumonia population brought additional patient benefits. Patients admitted with pneumonia now receive their initial antibiotic more quickly, and the hospital achieved a 7% improvement over 18 months. Donna Alvis can be reached at 804-323-8868. Russell County Medical Center, a small rural hospital in Lebanon, VA increased pneumococcal immunization screening by 56% over 18 months. Russell County Medical Center recognized the need to improve patient screening for flu and pneumococcal immunizations, and data provided by VHQC served as an impetus for the hospital to implement system changes to increase assessments for immunizations. The hospital added flu and pneumococcal screens to the nursing admission assessment, implemented physician order sheets and developed a patient consent form used in both outpatient and inpatient clinical settings. Using samples provided by VHQC, the hospital also developed pre-printed clinical protocols to facilitate screening for flu and pneumococcal immunizations. "Use of medical staff-approved protocols improves compliance with recommended treatment guidelines and core measure outcome indicators," says Donna Jennings, director of Performance Improvement. Jennings also noted that a respected clinical champion is critical to success. At Russell County Medical Center a staff pharmacist and a nurse manager stepped forward to provide leadership in promoting inpatient screening and administration of flu and pneumococcal immunizations, Jennings said. Donna Jennings can be reached at 276-889-1224.