Thorough documentation, accurate assessments add up to improvement
Raising dyspnea scores requires education for staff and patients
Increasing the percentage of patients who show improvement in dyspnea from the 2005 baseline score of 57.6% to 73% in November 2007 earned a certificate of achievement from the Oklahoma Foundation for Medical Quality (OFMQ) for Sequoyah Memorial Homecare-Home Health in Sallisaw, OK.
The higher score was the result of a performance improvement effort that focused on dyspnea, according to Penny Martin, RN, director of home health for the agency. "We developed a plan of action and used tools from OFMQ to help us improve our care of patients with dyspnea," she says.
Assessing shortness of breath
One of the first steps taken at Sequoyah Memorial HHA was formal training on how to score the OASIS items related to shortness of breath, says Martin. "We realized that we were not always getting a good baseline during the initial assessment so we held training classes to make sure everyone assessed shortness of breath the same way," she says.
Consistency is also important when teaching patients, points out Bonnie Dixon, RN, BSN, director of Dunn Memorial Hospital Home Care in Bedford, IN. Dixon's agency improved its rates for improvement in dyspnea from a baseline of 49.44% to 63.07% in the first year the agency tackled dyspnea as a performance improvement project. The rates have fluctuated some since the first year of the program but remain around the national average of 61%, she adds.
"I've learned that just by starting a performance improvement project and talking about a specific issue, you raise awareness and see some improvement," admits Dixon. The real challenge is putting tools into place to keep staff members aware of the ongoing importance of activities such as teaching, she says. "We reviewed literature and tools that are available from different sources and selected best care behaviors to implement in our agency," she says.
"We developed a dyspnea teaching packet and we developed a care pathway for dyspnea," says Dixon. By standardizing the teaching and the clinical decisions, all staff members were able to make sure that nothing was overlooked, she says.
Understanding the population
"We also saw a need for a smoking cessation program," says Dixon. Her patients live in rural areas in southern Indiana, and are farmers and foundry workers, she says. "There are a lot of smokers and ex-smokers so we have a lot of patients with lung cancer and chronic obstructive pulmonary diseases," she says.
A home health nurse who works in wellness programs for local companies put together a smoking cessation program and educational literature directed at patients and their families, says Dixon. "We did not have a lot of luck getting a large number of people to quit smoking, but we did educate people so that they do understand the link between smoking and their health problems," she adds.
The teaching packet contains information on dyspnea and tips on how to minimize shortness of breath, says Dixon. "We have tips such as elevate the head of the bed, avoid crunching the stomach, use a fan to blow air directly at the face to minimize hunger for air, use oxygen if necessary, and stop to rest before activities that increase shortness of breath," she says.
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Energy conservation strategies for dyspnea Ambulation
Bathing
Dressing
Grooming
Toileting
General
Source: Krulish, L. Oklahoma Foundation for Medical Quality, Oklahoma City. |
"We use occupational therapists to help patients learn how to pace their activities and use assistive tools to minimize shortness of breath," says Martin. The use of spirometers and pulse oximeters, as well as increasing the number of visits at the start of care have proved to be effective ways to help the patient improve dyspnea, she says.
"We also have patients monitor their oxygen levels at night so we can see when they are having the most difficulty," says Martin. Patients use a pulse oximeter with a printout that is read by the nurse because at this time the agency does not have telehealth services, she says. "Telehealth is a service we are looking at for the future," she adds.
A team approach is the best way to improve dyspnea scores, says Dixon. Although she has no full-time therapists on staff, physical therapy and occupational therapy are called in to help with patients as needed. "We meet as a team to discuss patients and evaluate our performance in all quality measures, including dyspnea," she says.
In addition to keeping the importance of treating dyspnea in front of staff members, Dixon also found threats effective. She laughs as she explains, "When we were talking about the necessity for an accurate assessment and complete documentation at the start of care, I told everyone that they needed to fill out the OASIS completely. Then I threatened to create a respiratory evaluation sheet that would give them another document to complete if the OASIS wasn't filled out completely. The threat worked; I didn't need to develop another form!"
Sources/resources
For more information about improvement in dyspnea, contact:
- Bonnie Dixon, RN, BSN, director, Dunn Memorial Hospital Home Health, 1530 23rd Street, Bedford, IN 47421. Phone: (812) 276-1245. E-mail: [email protected].
- Penny Martin, RN, director of home health, Sequoyah Memorial Hospital, 213 East Redwood, Sallisaw, OK 74955. Phone: (918) 774-1171. E-mail: [email protected].
For tools, literature, and action plans to address dyspnea improvement, contact:
- Medicare Quality Improvement Community. This on-line source of information is provided by the Centers for Medicare and Medicaid Services. Go to www.medqic.com. Under "What do you want to do?" select "browse by topic." Scroll down to "dyspnea" to be linked to tools, literature, and other resources.
- Oklahoma Foundation for Medical Quality. Go to http://www.ofmq.com/tools-and-resources and scroll down to "dyspnea tools" to find a list of assessment forms, care plans, strategies, and more resources.
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