QI project makes good program even better
Here's how VNA improved dyspnea care
The quality manager of Lee (MA) Visiting Nurse Association had no complaints with how the agency did on its first annual outcomes report using data collected as part of an Outcome and Assessment Information Set (OASIS) demonstration project.
"We didn't do badly; some of our outcomes were slightly poorer than the national average, and some were better," says Suzanne Hatch, BSN, MED, CPHQ, quality manager and staff development coordinator for the Lee VNA.
Still, Hatch wanted to use the report to start a quality improvement project. It would be good practice for the staff. And since the Center for Health Services and Policy Research (CHSPR) of Denver would send them an updated report the following year, they could easily see how well their efforts worked.
Because no glaring problems cropped up on the report, Hatch decided to make a quality improvement project out of one of the agency's more positive outcomes. "This was going to be a learning experience, and I wanted it to be positive and to engage our nurses so they would be interested in participating in this quality project," Hatch says.
Hatch decided to focus on dyspnea, or breathing difficulties. The agency had done well in this area when compared to the national reference group, which was part of the demonstration project. The report showed that 59.6% of the Lee VNA's patients improved in dyspnea, compared with 51.9% of the reference group, in a period from May 7, 1996, to June 19, 1997.
The dyspnea QI project came at a good time to boost the staff's morale, as the home care agency struggled last year with cost cutting and staff layoffs because of changes from the increasingly stricter interpretation of Medicare regulations, Hatch says.
"One of the bright spots of the year was our work with improving dyspnea outcomes," Hatch adds. "The staff was excited to think they had done this well, and the potential was there to do better."
The QI project resulted in a number of changes in how nurses handled dyspnea patients, Hatch says. However, because the changes were not fully implemented during the first half of the year, the latest outcomes report did not provide a full picture of the agency's improvements, Hatch says. "Our latest OASIS report showed we had a slight improvement in dyspnea patients' outcomes between Aug. 15, 1997, and May 25, 1998," Hatch says.
Lee VNA's QI project followed this pattern:
1. Meet criteria to prove project's relevance.
The CHSPR instructed demonstration project agencies to choose an outcome to improve based on the following criteria:
· at least 30 patients had to be affected by it;
· importance to the agency's goals;
· statistical significance and magnitude (i.e., how big was the difference between the reference group and the agency?);
· clinical significance;
· agency's ability to influence patient outcomes by changing care behavior.
2. Review patient records.
Hatch gave all of the agency's nurses one week to help review charts of chronic obstructive pulmonary disease (COPD) patients and congestive heart failure (CHF) patients. The staff found that in half of the records, patients improved. In the remainder, some patients were stable, and others worsened.
The agency had been using a very thorough standard initial assessment, and that helped nurses immediately identify the items pertaining to dyspnea, Hatch says.
3. Draw some conclusions based on research.
A pattern soon began to emerge. "It was like we discovered gold," Hatch says. In all the cases where patients' dyspnea improved, the nurses had done the following:
· assessed patients for dyspnea in relation to rest and activity tolerance;
· took patients' respiratory rates and assessed their breath sounds and weight;
· performed finger oximetry to measure oxygen level in patients' blood;
· taught patients specific signs and symptoms to report to the physician;
· reviewed patients' medication use and energy conservation, and taught patients or families how to use and clean all equipment on each visit. Nurses also reviewed signs and symptoms to report and disease process.
"This was striking because for all the patients who improved, this constellation of behavior was there," Hatch says. "We thought this was a good thing, but while we were better than the reference group, we saw we had room for improvement internally."
4. Devise plan for improvement.
Hatch and the agency's nurses and managers decided the following changes would result in the best outcomes:
· Have nurses perform a finger oximetry on all dyspnea patients. Lee VNA is a small agency and only had one finger oximeter device, so Hatch asked the agency to purchase more of these.
· Increase staff education on how to use finger oximetry.
· Take a multidisciplinary approach to dealing with dyspnea. "We decided it'd be a good idea to collaborate with occupational therapists and physical therapists in terms of improving patients' exercise and energy conservation," Hatch says.
· Provide therapists and nurses with a good background on medication so they would be familiar with how the medications affect patients' endurance during exercises.
· Have nurses use a standardized care plan for dyspnea, which would allow necessary modifications.
· Provide aides with more education on COPD and CHF.
· Give patients packets of information about CHF and COPD. Have nurses distribute the packaged materials to each new patient.
5. Implement the plan as well as possible.
Lee VNA made the changes listed in the plan, although some changes took longer to implement because of the high cost, Hatch says.
For example, each finger oximeter costs between $400 and $600, so funds were not readily available to purchase all additional devices, Hatch says. Now the agency has three finger oximeters.
The agency began working toward a multidisciplinary approach by holding group discussions. Nurses were given target behaviors to look for in patients. When they observed these behaviors, they were told to refer the patients to the occupational and physical therapists.
Hatch set up an inservice program in which respiratory therapists would teach nurses and physical therapists how to use the finger oximeter. "Then we tested for competency on use of the finger oximeter," Hatch says. "The respiratory therapist also talked about the use of inhalers and activity and rest when you're assessing patients." Staff inservices also covered medication and how that affects the patient.
The agency also held inservices for aides on CHF and COPD. "In the course of that, we went over the anatomy and signs to observe and skills that would be helpful," Hatch says. Aides are then given competency tests that assess their knowledge of the following:
· how to take blood pressure;
· how to take the apical pulse;
· how to put on TED stockings;
· how to measure edema, and signs and symptoms of CHF and COPD to report.
The agency developed a standardized, one-page care plan that included the features that it was important for nurses to assess in order to make a difference in the patient's outcome for dyspnea. "The nurse can adapt it very easily," Hatch says. (See Lee VNA's care plan for CHF, p. 135.)
Now nurses receive an admission packet with each CHF patient that has information for both patients and nurses. It includes a booklet on CHF, standard patient teaching information, the care plan, a "cheat sheet" for home health aides on the signs, symptoms, and diet of CHF, and checklist of the types of things aides can do help patients. For example, the aides might measure the patient's legs for edema or encourage them to eat foods high in potassium. Hatch says the agency now is working on packets for COPD.
"We have everything in place now," Hatch says. "It evolved slowly, and it will take us a while to show big improvements."
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