Let me be the first to wish you a Happy New Year 2024! It is hard to believe that in less than a month we will ring in a new year. It is a time of great change here at UI Health Care. Perhaps one can consider this the start of a new era. We have welcomed a new VPMA and a new CEO who are already actively engaged and moving us forward in our missions. We will bring Mercy Hospital, with its great tradition of community-based healthcare, into our family by the end of January. The North Liberty hospital is moving forward on time, and the planning for how we will care for our patients there is well underway. Finally, we are planning a new inpatient tower, and though it won’t be a reality for several years, it is inspiring to think of the benefits of this wonderful new space. So much change… so much opportunity… so much unknown. In the same breath, I will say we have so much that is constant and very good. We have a great team that continues to do great things each and every day. Health care organizations have gone through so much change in the last few years, and we have weathered this storm, and for that and so much more, I am proud to be a part of this team and this organization.   

It is a great time to look forward and to look back. So many efforts are ongoing to improve our quality of care, our satisfaction (both for patients and for our staff), our safety, and the efficiency and effectiveness of our systems and processes. So many times, in this blog, we have talked about change. I believe that there is only one constant in health care today, and that is change itself. We must never be satisfied with the journey to excellence in how we care for our patients, how we engage and value our employees and how we change medicine for the future through research and education. Change is difficult, there is no doubt about that, and it takes energy and intent to make it happen. Eleanor Roosevelt once said, “The future belongs to those who believe in the beauty of their dreams.” As we move forward into 2024, with all these imminent changes, we must remember that it first took someone to dream of a new opportunity in order for it to become our future reality.  

Many thanks to each of you for all you have done this year to make UI Health Care a great place to work, to be a patient, and to learn. Your efforts each and every day have and will set us up for great success in the many years to come. I wish you peace and joy, much happiness, and some well-deserved rest and relaxation during this holiday season. 

-Theresa Brennan

Hand hygiene is the single most important measure for reducing the spread of infection. Cleaning your hands reduces the transmission of potentially deadly germs to patients and reduces the risk of health care provider colonization or infection caused by germs acquired from the patient.  

Did you know? A systematic review in 2022 with 35 articles found that higher compliance with hand hygiene was associated with lower rates of hospital associated infections. 

How is UI Health Care performing?  
Our institutional compliance goal for hand hygiene is set at >90%. However, in March 2023, only 6 out of 30 inpatient units were able to achieve this goal. If you’re curious about how well your unit is performing, you can access the hand hygiene data on Tableau.  

(Hand Hygiene: Hand Hygiene Dashboard – Last Month – Tableau Server (uiowa.edu)) 

UI Health Care will transition from secret-shopper observation approach to a transparent, peer-to-peer observation and stop-the-line approach 
UI Health Care will be participating in the Leapfrog Hospital Safety Grade survey in June. (https://www.leapfroggroup.org/sites/default/files/Files/2022%20Hospital%20Survey_20220608_v8.3%20%28version%202%29.pdf.) The Leapfrog Group is an independent organization that conducts an annual survey of hospitals in the United States to assess their performance in key areas related to patient safety, quality of care, and efficiency.  

As part of their assessment of hospital safety and quality, they include a measure of hand hygiene. To meet the Leapfrog standard, each inpatient unit is required to have at least 200 hand hygiene observations per month, which will be observed and documented by nurses and physicians.  

How to submit a hand hygiene observation 
It’s easier to play your part in documenting hand hygiene compliance when you see it. Simply complete the RedCap survey linked here.  (Hand Hygiene Survey (uiowa.edu)) 

Take a moment for hand hygiene 
Health care workers may need to clean their hands as many as 100 times during a shift. Keeping hands clean and healthy is a challenge that requires all everyone—no matter your role—to be knowledgeable on when to clean their hands as well as how to clean them effectively.   

Did you know? The “5 Moments for Hand Hygiene” approach was designed by the World Health Organization to minimize the risk of transmission of microorganisms between a health care worker, the patient, and the environment. Five moments you should pause and clean your hands are:  

• Before touching a patient 
• Before clean/aseptic procedures 
• After body fluid exposure/risk 
• After touching a patient 
• After touching patient surroundings  

The U.S. Centers for Disease Control and Prevention (CDC) also recommends hand hygiene: 

• Before moving from work on a soiled body site to a clean body site on the same patient 
• Immediately after removing gloves 

Most hospitals and clinics emphasize hand hygiene at the time of room entry and exit and prior to any procedure. 

Alcohol-based hand sanitizer vs soap and water: Does it make a difference? 
Alcohol-based hand sanitizer has several advantages over soap and water hand washing in health care settings. It is faster, more convenient, and sanitizers are the most effective products for reducing the number of germs on the hands of health care providers. This makes it easier to perform hand hygiene frequently and consistently, which is essential to reducing the risk of health care-associated infections.  

Hand washing with soap and water is recommended in situations where hands are visibly soiled or contaminated with body fluids, such as after using the bathroom, or handling bodily fluids.  

Fingernails and artificial nails: Is the glam worth the grime? 
Health care worders who wear artificial nails, nail enhancements, or have very long natural nails are more likely to harbor gram-negative bacteria and yeast both before and after handwashing. The CDC recommends that natural nail tips should be kept short and clean.   

Message from the Program of Hospital Epidemiology 
Looking for a way to keep your patients safe and healthy? It all starts with your hands! You have the power to prevent the spread of infection and illness simply by practicing good hand hygiene. By prioritizing hand hygiene, you’re not only protecting your patients—you’re also protecting yourself and your colleagues. So don’t wait; make hand hygiene a top priority today! 

Citations: 

• World health organization. World hand hygiene day. https://www.who.int/campaigns/world-hand-hygiene-day 
• SHEA/IDSA/APIC Practice Recommendations SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent healthcare-associated infections through hand hygiene: 2022 Update. file:///C:/Users/tkobayashi/Downloads/sheaidsaapic-practice-recommendation-strategies-to-prevent-healthcare-associated-infections-through-hand-hygiene-2022-update.pdf 
• Hand hygiene compliance in the prevention of hospital-acquired infections: a systematic review. J Hosp Infect. 2022 Jan;119:33-48.doi: 10.1016/j.jhin.2021.09.016. Epub 2021 Sep 25. 
• Centers for Disease Control and Prevention. Hand Hygiene in Healthcare Settings. https://www.cdc.gov/handhygiene/providers/index.html 
• Reduction of Healthcare-Associated Infections by Exceeding High Compliance with Hand Hygiene Practices. Emerg Infect Dis. 2016 Sep; 22(9): 1628–1630.doi: 10.3201/eid2209.151440 
• Rigorous Hand Hygiene Practices Among Health Care Workers Reduce Hospital-Associated Infections During the COVID-19 Pandemic. J Prim Care Community Health. 2020 Jan-Dec;11:2150132720943331.doi: 10.1177/2150132720943331. 
• UpToDate: Infection prevention: Precautions for preventing transmission of infection https://www.uptodate.com/contents/infection-prevention-precautions-for-preventing-transmission-of-infection?search=hand%20hygiene&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H2557723252 
• Leapfrog survey. https://www.leapfroggroup.org/sites/default/files/Files/2022%20Hospital%20Survey_20220608_v8.3%20%28version%202%29.pdf 

I came to work this week with new energy and excitement! For the last many months, I’ve started each Monday wondering if The Joint Commission would arrive and each week, I would feel both disappointment that they didn’t come, as well as a bit of relief—knowing the stress that survey week often brings.  

But once the surveyors arrived, our months-long preparation and hard work was rewarded. We left a positive impression on the surveyor team, who noted it was clear we have a wonderful team of people who are passionate about being here. On top of that, our final report showed zero condition level findings and no need for a resurvey. Every Joint Commission survey provides the opportunity for improvement and we have some, and we will work together to address them. Rarely, though, does a hospital hear the great praise that we heard last week. We heard about how you welcomed the surveyors, how you are constantly focused on the quality of care and safety of our patients through consistent practices, how you work so well together, and overall, what a great team of people you are. I speak for the entire leadership team when I say that this is no surprise to us and that we are so proud of how you handled the survey and for what you do each and every day for our patients and for each other. 

We have faced many obstacles during these last three years, and I know how challenging it has been for each of you.   I am grateful that you have chosen to remain a part of this great team and that you come to work each day focused on helping people. 

I ask that—as you start this new month in this new year—you take a moment to reflect on all the good you and your colleagues have done. I hope that this fills you with the same great energy, excitement, and gratitude that I feel.    

You make a difference! 

-Theresa Brennan, MD 

The Ethics Consult Service (ECS) is a free clinical resource for UI Health Care personnel who feel they have reached the limits of their own ability to address an ethical question or problem. The ECS is designed to identify and/or clarify ethical problems in the care of a particular patient and promote discussion. The ethics consultant may make recommendations or share resources with those requesting the consult.  

Requests for an ethics consult are especially encouraged when:  

• You want to discuss important ethical dimensions of a patient’s care 
• A patient’s care raises unusual, unprecedented, or very complex ethical issues 
• You need help making an ethically-significant decision 
• Efforts by the patient, family, and professional staff to resolve an ethical problem have stalled 

With five trained ethics consultants providing 24/7 coverage, An ethics consult can be requested by paging #2922. These consultants can provide guidance about how to place an Epic order for a formal ethics consult if indicated. The ECS reviews all cases with the interdisciplinary Ethics Working Group and reports to the Chief Medical Officer.

Questions? Contact bioethics@healthcare.uiowa.edu  

First, I hope you were all able to enjoy the holiday and spend time with your loved ones. For those of you who were here caring for patients, thank you so much. Thanksgiving is a time for us to reflect on the many things we are grateful for. I’ve said it before and I’ll say it again, what makes our UI Health Care team amazing is each and every one of you and what you do every day. Because of you, I’m confident we can meet any challenge, and I have great hope for our future.  

For many years, we have struggled to efficiently use our time and our patient’s time during their inpatient stay, and it’s an issue that is not unique to this organization. When we compare ourselves to other health systems across the country, we commonly refer to the Length of Stay Index (LOSI). The LOSI allows us to look at the time it takes us to care for the patient and discharge them based on the patient’s diagnosis. 

This is an area of focus for many reasons: 

• It is a challenge drawing focus from health care organizations across the country. 
• UI Hospitals & Clinicshas experienced sustained high patient volume year over year. 
• Given our high census, we need open beds to provide care to the next patient who needs us, so we must also focus on an early discharge when it is safe and feasible. 

But perhaps the most important reason to focus on length of stay is that it’s the right thing to do for our patients.  If you or a loved one has ever been hospitalized you know  that waiting for discharge can be a difficult experience for the patient and their family. This waiting period is sometimes the last impression our patients have of us on the day of discharge, making it even more important that we try to make it as efficient and easy a process as possible.  

In order to provide high quality and efficient care for our patients and their families, we must: 

• Have strong collaboration and communication across our multi-disciplinary teams 
• Start thinking about and discussing discharge planning when the patient is admitted 
  • Think about the expected day of discharge (ask about it in huddles, and wrench it into your EPIC dashboard)  
  • Know the plan of care for the day and proactively think about the plan of care for each day until discharge 
    • What do we need to accomplish for the patient to prepare for a safe discharge? 
    • Do all members of the team know the plan and what is needed for discharge? 
• Tell the patients and their families when we anticipate discharge and confirm it the day prior whenever possible 
• Discuss with the patient and family the expectation of the 1100 discharge time 
  • If their ride home will be later in the day, let them know they will be sent to our discharge lounge—if they qualify—to await their ride. 
• Engage our nurse navigators early and schedule the follow-up appointments early in the patient’s stay 
• Engage our social workers early if the patient has potential needs for medical equipment at home, or a post-acute facility stay (SNF, rehab, etc.) 
• Complete what you can before the day of discharge (discharge summary, patient education, consults, imaging, prescriptions, final labs, etc.) 
• Prioritize the patients who are going home that day 
  • Physicians should first round on those patients who we anticipate going home that day and write the discharge order by 0930. 
  • Nurses should complete the discharge tasks as soon as the order is written 
• Tell us the barriers that prevent patients from discharging  
  • Are there delays in tests/procedures being completed? 
  • Are consults pending? 
  • Do you feel empowered to escalate concerns and delays? 
  • What are the system challenges? 
    • Remember to put these into the BlindSpots portal so we can look at how these challenges may be overcome. 

We know that a patient’s status may change, and we cannot always predict when they will be healthy and able to discharge, but for those we can predict, let’s do everything we can to be ready. 

By decreasing our patient’s length of stay, not only are you helping your present inpatients, but you are improving access for patients  in our Emergency Department, operating rooms, ambulatory clinics, and outside hospitals who need our help. Lastly, when a patient is efficiently prepared for a safe discharge, you save time for yourself and your colleagues. 

Please keep your eyes open for more communication on length of stay and early discharge as we work to continue improving these processes. We look forward to continuing this journey with all of you! 

Blog contributors: 

• Ami Gaarde, MBA, BSN, RN, OCN, Director, Nursing and Patient Care, Care Coordination (Adult) 
• Theresa Brennan, MD, Chief Medical Officer 
• Evelyn Kinne, MHA, Quality and Operational Improvement Engineer, Office of the Chief Medical Officer 

This blog is part of an ongoing series focused on introducing the current quality initiatives. Thank you to the Quality Improvement Program team for sharing their important work with us, and thank you for taking the time to learn more about the vital work that goes on to improve the care we provide to our patients.   

Learn more about the other initiatives by viewing the introduction to this series and previous topics.

Why do some people need a urinary catheter? 

Urinary catheters are used for urinary drainage or as a means to collect urine for measurement. Indications for catheterization are as follows: 

• Urinary retention  
• Urine output measurement in ICU patients 
• During surgery to evaluate fluid status  
• During and following specific surgeries of the genitourinary tract 
• Hematuria associated with clots  
• Neurogenic bladder  

Although urinary catheters provide many patient benefits, there are also associated risks. Due to these risks, urinary catheters should be removed as soon as the benefits no longer outweigh the risks. 

Epidemiology 

According to the Centers for Disease Control and Prevention (CDC), between 15 to 25% of hospitalized patients receive urinary catheters during their hospital stay. Bacteriuria (positive bacteria in urine) in patients with indwelling catheters occurs at a rate of approximately 3 to 10% per day. Of those with bacteriuria, 10 to 25% develop symptoms of urinary tract infection (UTI). In the U.S., based on surveillance data reported to the CDC National Healthcare Safety Network (NHSN), the incidence of CAUTI in 2012 was 1.4 to 1.7 per 1,000 catheter days in inpatient adult and pediatric medical/surgical floors. This means if all the patients at UI Hospitals & Clinics had a urinary catheter today, between one and two of them will develop a CAUTI. 

The duration of catheterization is an important risk factor for CAUTI and is a major target of prevention efforts. Other risk factors include female sex, older age, diabetes mellitus, bacterial colonization of the drainage bag, and improper catheter care.  

Issues with CAUTI 

Health care-associated infections cost U.S. hospitals an estimated $40 billion each year. CAUTIs are among the most common types of health care-associated infections. Research suggests CAUTIs are highly preventable and that perhaps as many as 50 to 70% of these episodes can be prevented. Complications associated with CAUTI result in increased length of stay, patient discomfort, excess health care costs, and contribute to increased mortality. The estimated total U.S. cost per year for CAUTI is $340–450 million. Since October 2008, the Centers for Medicare & Medicaid Services no longer reimburses costs associated with hospital acquired CAUTI.  

How do we prevent CAUTI? 

In general, the most important aspects of CAUTI prevention are avoidance of unnecessary catheterization, use of sterile technique when placing the catheter, proper catheter care, and removal of the catheter as soon as possible.  

The need for a urinary catheter should be evaluated for every patient, every day by both physicians and nurses. It is important to insert catheters only for appropriate indications and leave them in place only if needed. The catheter should not be kept solely for the convenience of patient care. It is also important to consider using alternatives to indwelling urethral catheterization in selected patients when appropriate, such as external catheter or intermittent catheterization. If intermittent catheterization is used, perform it at regular intervals to prevent bladder overdistension. We can use a bladder scanner to assess urine volume in patients undergoing intermittent catheterization and reduce unnecessary catheter insertions. 

Proper technique during catheter insertion is critical. Health care personnel must perform hand hygiene immediately before and after insertion. We need to use aseptic technique and sterile equipment, and properly secure indwelling catheters after insertion to prevent movement and urethral traction.

Ideal catheter care is also instrumental to CAUTI prevention. Meatal care (cleaning around the catheter) once per shift and after every bowel movement is essential. In addition, daily bathing with chlorhexidine is necessary and is reported to reduce CAUTIs.  

The way a urine culture is collected also has a significant impact on CAUTIs. For instance, urine cultures should never be obtained from a catheter that has been in place for more than 24 hours, because urine cultures collected from an existing catheter will almost always come back positive but may not be clinically significant. Once a CAUTI is suspected urinary catheters should be removed and urine specimens should be obtained from either a newly placed urinary catheter or via intermittent catheterization 

CAUTI reduction initiative 

In August 2022, a multidisciplinary CAUTI committee, led by Karen Brust, MD, hospital epidemiologist, was formed in an effort to reduce CAUTI across UI Hospitals & Clinics’ adult units. Members of the CAUTI committee provided feedback on contributing factors from the perspective of leaders and bedside nurses. Their feedback provided a foundation for potential future data collection and process improvement. The discussions and work of the CAUTI initiative led by Brust also aligned with another CAUTI committee led by the Department of Nursing Services and Patient Care. Since its initiation, the nursing-led committee reviewed and updated existing protocols and policies related to CAUTI. The group identified opportunities for additional guiding documents, specifically for bladder scanning and intermittent catheterization protocol, which is actively being developed. The team collaborated with clinicians to understand the current process of ordering urine cultures and how urine specimens are collected after an order is placed. The results of these conversations revealed variation in practice by the ordering provider and the nurse collecting the urine sample. This led to the ongoing development of an “ideal state” for both actions with recommendations brought to the clinical and nursing informatics teams.

Blog contributors:
-Karen Brust, MD, Clinical Associate Professor of Internal Medicine, Infectious Diseases, Hospital Epidemiologist
-Takaaki Kobayashi, MD, MPH, Clinical Assistant Professor or Internal Medicine, Infectious Diseases

Citations: 

• Agency for Healthcare Research and Quality. Overview | Agency for Healthcare Research and Quality (ahrq.gov) 
• Cather-associated urinary tract infection. Centers for Disease Control and Prevention. Catheter-associated Urinary Tract Infections (CAUTI) | HAI | CDC 
• UPTODATE: placement and management of urinary bladder catheters in adults. Placement and management of urinary bladder catheters in adults – UpToDate 

This blog is part of an ongoing series focused on introducing the current quality initiatives. This month, we are featuring the work being done to reduce injuries resulting from falls. Thank you to the Quality Improvement Program team for sharing their important work with us, and thank you for taking the time to learn more about the vital work that goes on to improve the care we provide to our patients.  

Learn more about the other initiatives by viewing the introduction to this series and previous topics.   

What is the problem 

A cesarean delivery is the most common major surgical procedure performed in the United States, with well over one million procedures performed each year. Unfortunately, postoperative surgical site infections (SSIs) and wound complications affect approximately 10% of these deliveries across the nation. A number of risk factors for these SSIs have been identified, some of which are inherent characteristics of that particular pregnancy and cannot be changed. However, there are evidence-based strategies that have been shown to reduce the risk of post-cesarean infections and wound complications, including processes such as administering appropriate antibiotic prophylaxis within 60 minutes of the surgical skin incision and using chlorhexidine-alcohol solutions for skin antisepsis.   

What is a surgical site infection after cesarean section 

According to the Centers for Disease Control and Prevention, cesarean SSIs are defined as superficial or deep incisional infections—or infections involving organs/spaces—that occur within 30 days of surgery. In general superficial SSIs involve only the skin and subcutaneous tissue of the incision, while deep incisional SSIs involve the deeper soft tissues of the incision such as the fascial or muscle layers. Organ space SSIs involve any other part of the patient’s anatomy that was entered at the time of surgery. At UI Hospitals & Clinics, the Program of Hospital Epidemiology monitors and tracks surgical site infections.  

Core team  

In fall 2020, a multidisciplinary core team consisting of representatives from the Departments of Nursing, Obstetrics and Gynecology, Anesthesia, Pharmacy, Hospital Epidemiology and the Quality Improvement Program came together to begin reviewing the current performance data and identifying opportunities for improvement.  

Metrics being tracked 

In addition to comprehensively reviewing each reported cesarean delivery SSI, we conduct periodic observations in the operating room (OR) to ensure recommended best practices—such as having a surgical debrief after each case that includes discussing the wound classification, urgency of the delivery, and quantified blood loss—are being completed. We monitor compliance with a variety of evidenced-based process metrics, including the following: 

• Administration of appropriate antibiotic prophylaxis within 60 minutes before skin incision 
• Maintenance of maternal normothermia  

• Hair removal using clippers instead of razors before entering the OR prior to surgery 
• The use of chlorhexidine-alcohol solutions for skin antisepsis, except in emergency cesarean deliveries where povidone-iodine is recommended  
• The use of chlorhexidine vaginal preparation 
• Redosing of antibiotics if the duration of the procedure exceeds 2 half-lives of the drug or there is excessive blood loss during the procedure (>/= 1500 mL) 

What is the team doing to improve metrics  

Upon review of UI Health Care’s cesarean section SSI trends, a significant number were found to be superficial SSIs, for which expanded efforts on skin antisepsis and antibiotic prophylaxis were identified as improvement opportunities. The core team facilitated an adjustment to the antibiotic prophylaxis regimen to expand the indications for azithromycin use and implemented an expanded use of daily chlorhexidine gluconate (CHG) bathing for select patient populations. The pre-operative abdominal skin preparation process prior to a cesarean delivery has been adjusted based on recommended best practices to enhance skin antisepsis. A review of the literature concerning cesarean delivery incisional wound care was conducted, and there is now a standard preferred dressing that is recommended for use. A standard script for post-operative wound care education instructions was created and each patient who undergoes a cesarean section delivery receives a follow-up phone call after discharge.  

Recommendations for prophylactic antibiotics for patients with chorioamnionitis during labor who deliver by cesarean were reviewed and order sets were updated. These changes are all intended to help mitigate the likelihood that superficial SSI occurs.      

There have been multiple other improvement steps taken as a result of this project, including the purchasing of new surgical instruments, expanded staffing of Environmental Services personnel to assist with routine cleaning of the labor and delivery ORs and creation of a best practice alert to help identify pregnant women with a self-reported penicillin or cephalosporin allergy who may benefit from referral to the Allergy Clinic for further allergy testing so that appropriate antibiotics can be used when indicated at the time of delivery.   

The multidisciplinary core team that has been focused on this work has been integrated into the Obstetrics Quality & Safety Committee who will continue to oversee this important work for the organization moving forward.   

Blog contributors:
-Noelle Bowdler, MD, Clinical Professor of Obstetrics and Gynecology, Physician Value Officer
-Derek Zhorne MD, Clinical Associate Professor of Pediatrics, Associate Chief Medical Officer

Team, 

As you know, we’re preparing to soon welcome a group of Joint Commission surveyors between now and September. I hear a lot from different groups about being “Joint Commission ready.” While this is absolutely important—as their survey provides us with a benchmark of our hospitals and clinics’ quality and safety standards—the real question we should ask ourselves is, “Are we patient ready?” 

Our protocols and policies are not in place for the Joint Commission. They exist—and we follow them—because it’s the right thing to do for our patients and visitors to keep them safe. If we’re diligent and mindful of maintaining a safe environment day in and day out, a visit from the Joint Commission becomes just another week. 

With that in mind, we should all be taking a proactive approach to patient-readiness, each and every day.  

How do we do this? I encourage you to review the host of resources available to us from our Quality and Safety teams. Resources—from quick tips to downloadable fact sheets—can be found on The Loop to help us all be patient (and Joint Commission) ready.  

Thank you for all you do. 

Theresa Brennan, MD, FACC 
Chief Medical Officer 

This blog is part of an ongoing series focused on introducing the current quality initiatives. This month, we are featuring the work being done to reduce injuries resulting from falls. Thank you to the Quality Improvement Program team for sharing their important work with us and thank you for taking the time to learn more about the vital work that goes on to improve the care we provide to our patients.   

Patient falls are a challenging problem to solve since there is no one-size-fits-all approach to reducing falls and preventing injuries. All health care team members (e.g., provider, nursing, therapy, transport teams, etc.) have the ability—and responsibility—to make a difference in the safety of our patients. A fall event typically occurs unexpectedly, but many of these falls can also be anticipated through the completion of a thorough fall risk assessment. 

 What risk factors are patients assessed for? 

The fall risk assessment is completed to assess for multiple risk factors including:  

• Elimination: Most common activity contributing to falls 
• Mobility/Ambulation: Gait, unsteadiness, weakness, assistive devices, etc. 
• Mental Status: Delirium is a major risk factor for falling and is preventable. 
• Sensory/Communication Deficit: Neuropathy, vision, hearing, etc.  
• Medications: Cardiac and central nervous system medications 
• Last fall: Including admission due to a fall or a fall during hospitalization 
• Age-related risk 
• Nursing judgment: Alcohol withdrawal, encephalopathy, impulsivity, impaired judgment, etc. 

Fall prevention interventions are multifactorial and individualized. Recognizing what makes your specific patient population unique and using the information obtained from the fall risk assessment to understand your patient’s fall risk factors will aid in initiating appropriate fall prevention strategies.  

 What is a fall with injury? 

We have standard definitions that are provided to us by the National Database of Nursing Quality Indicators (NDNQI) to ensure a standard process in defining a patient fall and the level of injury. A patient fall event is defined as a “sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface (e.g., a counter), on another person, or on an object (e.g., a trash can).” The NDNQI further defines the injury levels by providing a framework of examples including but not limited to: 

•  No injury: Resulted in no signs or symptoms of injury as determined by post-fall
• Minor injury: Resulted in application of ice or dressing, cleaning of a wound, limb elevation, topical medication, pain, bruise or abrasion 
• Moderate injury: Resulted in suturing, application of steri-strips or skin glue, splinting, or muscle/joint strain 
• Major injury: Resulted in surgery, casting, traction, required consultation for neurological (e.g., basilar skull fracture, small subdural hematoma) or internal injury (e.g., rib fracture, small liver laceration), or patients with any type of fracture regardless of treatment, or patients who have coagulopathy who receive blood products as a result of a fall 
• Death: The patient died as a result of injuries sustained from the fall (not from the physiological events causing the fall) evaluation” 

 Core Team: 

There is a monthly multidisciplinary Fall Prevention Committee that consists of nursing leaders, staff nurses, nursing assistants, physical therapists, occupational therapists, a pharmacist, and a provider. We are also developing a task force consisting of a smaller core team that will review the data on current themes with opportunities for patient falls and quick decision-making for opportunities in fall prevention, as well as the correlation of other patient factors to their fall risk.   

 Metrics being tracked: 

In addition to the total number of patient falls each month, we also monitor the number of assisted falls and falls that result in an injury within Tableau. Each quarter, we also submit our data on total patient falls and falls with injury to the NDNQI. We use this data from the NDNQI to benchmark against other academic medical centers and other comparative units (down to the unit level), allowing for fair comparison for each unit/clinic that submits data to the NDNQI. Inpatient and ambulatory/non-inpatient falls and falls with injury are monitored and shared each month (data is through the month of May 2022). 

What is the team doing to improve metrics? 

Generally, patient falls are multifactorial, which is why a thorough fall risk assessment and understanding of how each risk factor impacts the patient’s risk of falling is important. In some instances, the fall risk assessment may have been completed just to “check the box,” ultimately missing the correlation between risk factors and the appropriate fall prevention interventions. 

Reinstituting post-fall huddles is one way UI Health Care is working to improve metrics. Additionally, the post-fall huddle form was redone, including the development of an electronic version. The updated form is broken down by risk factor to assist staff with making the connections and linking appropriate interventions with the patients identified risk factors. The team is continuing to work with various departments to assist staff with making the connections between risk factors, interventions, and hardwiring practices that will promote routine use of patient-specific strategies for fall prevention.  

Patient fall events have been an ongoing national concern that has resulted in The Joint Commission’s sentinel event definition in January 2021. Any patient fall that results in a major injury or death (as defined above) is now reported to the Joint Commission as a sentinel event.  

So, as we continue our work reducing falls and preventing injuries for our patients, it’s important to remember that change doesn’t happen overnight. We encourage you to make short-term attainable goals that are specific for your area that include realistic components that will help you hit those milestones. Understand what the top three risk factors/causes are for patient falls in your area, build a plan with your team with realistic interventions, and implement those interventions to  minimize those identified risks. A good rule of thumb is to start with the primary risk factor and continue to build as you make progress.  

Focus areas for improvements 

• Education for thorough and accurate fall risk assessment 
• Education on connecting risk factors with appropriate interventions 
• Complete a multidisciplinary post fall huddle (paper or electronic version) after every fall to learn from fall event 

Sometimes when we’re working, someone says something in a way that makes us uncomfortable. Often, we give people the benefit of the doubt, but if we feel threatened, we should not take chances when it comes to our safety. Everyone has the right to come to work and feel 100% safe.

It is our responsibility as leaders to provide you with a safe working environment and methods to address concerns when they arise. For the last 10 months, we have focused on how to stay safe from the virus that causes COVID -19. That is very important, and I hope you are following recommendations both inside and outside our UI Health Care facilities.

I want to highlight some of the available resources if you find yourself in a situation where you feel emotionally or physically threatened. Whether the situation involves a colleague, patient, or visitor, please know we have systems in place to address your concerns.

Following are four situations and instructions for dealing with each.

Unprofessional interaction with a coworker:

• If you experience an unprofessional interaction with a coworker, please attempt to have a professional and productive conversation with that coworker. Wait until emotions are even and meet in a neutral and private location. Addressing conflict is a very productive way to build teams. If your conversation is not productive, if there is a power differential, or if there is a significant reason you two cannot meet, I encourage you to enter a report into the CORS (Co-worker Observation Reporting System). CORS uses a process aimed at delivering feedback in a non-judgmental way. This allows the identified staff member to reflect on their practice and associated interactions with co-workers, as well as the opportunity to self-regulate behaviors. I’ve learned we may not be aware of how we’re perceived or the impact of our words, their delivery, or our actions. Without feedback, none of us can learn. CORS provides a mirror into how we are perceived by others, insight on how that affects our team, and a gauge of the quality and safety of our care. After a CORS report is filed, trained peer messengers will share information with their colleagues to inform them about specific issues and provide the opportunity to improve their communication practices. This is an anonymous process, and information regarding who reported the incident is not shared with the peer messenger or colleague.

Threatening interaction:

• If a workplace experience with an individual leaves you feeling threatened (i.e., he or she is exhibiting the potential for future violence or harm), but the individual is not presently violent, call Safety and Security at 319-356-2658. Safety and Security will work with the Threat Assessment Program to investigate the nature of the threat and respond accordingly. The Assessment and Care team provides an integrated and coordinated process for identifying and responding to students, faculty, staff, patients, and others affiliated with the University of Iowa who may be at risk of harming themselves or others.
• If the person threatening you is a patient or visitor, it’s best to use language to diffuse the situation. We all have empathy and compassion for those who are sick and those who are worried about their loved ones. We may feel they are just “blowing off steam” and that we shouldn’t escalate the situation by taking their words seriously. For example, if a patient or visitor says something like “you’ll regret this,” “if he gets worse, I will be back and you won’t like it,” or “it won’t be good for you if she doesn’t get better,” their words may have been said in the heat of the moment; however, these declarations are actually signals that the person may not be thinking or acting in a logical way. These threats may also be warnings they may follow through with action and harm you or others. For example, I treated a sick patient in the ICU, and her husband was afraid he would lose her and threatened, “If she dies, I will be back with my gun.” We took that seriously and called for help. The Threat Assessment Program was great, both with our team and with the patient and her husband. He did own a weapon and may have never used it, but the Threat Assessment Program protected us. As in many of these situations, the husband regretted his words. By directly addressing this threatening interaction, we discussed boundaries and better methods for expressing his concerns in the future.

Violent interactions with a patient:

• A Code Green violent patient management team is available to respond to potentially violent patient situations. Any staff member may declare a Code Green by dialing 192 if assaultive, combative, or uncontrolled patients pose a threat to themselves, staff members, patients, visitors, or hospital property. When calling the Code Green number, please:
  1. Identify that you need the Code Green team
  2. Identify yourself
  3. Identify the unit, building, and room number where help is needed.

Violent interactions with a visitor, family member, or staff member:

• Contact Safety and Security by dialing 195 or 911 during situations when visitors, family, or staff are being disruptive, hostile, or threatening others. Safety and Security will work with hospital administration and local law enforcement agencies to control these situations.

As I mentioned above, we have resources available for all our staff members. If you’ve experienced a threat or violence, please seek emotional support after this event from any of the following sources:

• The COPE team is comprised of volunteers including chaplains, physicians, social workers, psychiatrists, nurses, therapists, and others and strives to provide emotional support and healing to health care providers who have experienced difficult situations.
• The Employee Assistance Program (EAP) provides integrated services to faculty, staff, and their family members to promote emotional well-being and to increase engagement and productivity among members of our UI community.
• Office of the Ombudsperson is a resource for any member of the university community— including students, faculty, and staff—with a problem or concern. They provide informal conflict resolution, mediation services, and advocacy for fair treatment and fair process.
• Diversity, Equity, and Inclusion @Iowa provides services related to human rights, anti-harassment, violence, anti-retaliation, and discrimination.
• The Office of Diversity, Equity, and Inclusion provides cultural enrichment and acclimation programs for members of the Carver College of Medicine and UI Health Care community.
• Office of the Sexual Misconduct Response Coordinator (OSMRC) coordinates the university’s response to reports of sexual harassment and sexual misconduct.
• Ethics Point should be used to file an anonymous complaint related to a financial crime or misconduct.

Just as you hear at the Eastern Iowa airport: “If you see something, say something,” you should apply this idea at work as well. Know your resources and have a plan to utilize them if the need arises. Your safety matters, as does the safety of your team.

UI Health Care is on a constant quest for improvement, and as an institution we can’t address what we don’t know. We want to hear from you.

I wish you a happy and safe 2021. I am hoping for a year where we all have many opportunities to share our great stories. Thanks for your perseverance, your resiliency, and all you do each and every day.

– Theresa Brennan, MD

References:
UIHC Policies Manual 
Code Green Violent Patient Management Policy EOC-Safety-01.030 
Workplace Violence Policy, EOC-Security-02.007