Perhaps the biggest impact was on the culture of the unit. Because identified issues had become opportunities for improvement instead of problems, a new sense of optimism prevailed. Care on one patient typified this evolving approach induced by the TCAB initiative. An 81-year-old demented man was admitted for behavioral problems because the family could no longer handle him; he appeared destined to languish in the hospital. We have all taken care of patients like this, and difficulties in their management combined with no obvious disposition usually result in prolonged hospitalizations. The staff immediately saw this patient as an opportunity to work closely with the family. Making arrangements for the wife to spend time with the patient in the hospital and aggressively devising a care plan that involved the family resulted in the patient’s return home after just 4 days. The patient’s family was delighted with the care, and everybody on the unit shared a real sense of accomplishment.
A concrete example of using the white board for communication resulted in optimization of care for another gentleman who was admitted after a complicated bowel resection with a projected length of stay of 8–10 days according to the surgeon. The Two South staff worked closely with the surgeon and placed daily goals on the white board for all to see. Additionally, the nurses and patient were actively involved in the decision-making process, particularly with regard to increasing ambulation and decreasing narcotic use. This resulted in more rapid achievement of goals and recovery by the patient, with discharge from the unit occurring after just 4 days.
With the success of phase I at Kaiser Roseville, the staff anxiously set forth to participate in Phase II. Phase II increased the number of hospital sites to 13 and increased the rapid-cycle testing module. Ten areas of focused improvement were selected, including attempts to reduce unplanned transfers to the ICU and decreasing adverse events for hospitalized patients. During Phase II, Roseville developed its own Rapid Medical Response Team (RMRT). The RMRT is composed of the charge nurse for the ICU, a respiratory therapist, and a house supervisor. This team responds emergently at the request of any Medical-Surgical nurse to evaluate any patient about whom the nurse has concerns. These patients usually have a quickly evolving medical crisis such as respiratory distress, hypotension, or an altered level of consciousness. The primary goal of the RMRT is to quickly evaluate the patient, obtain physician support if needed, and stabilize the patient promptly on the floor or transfer them in a controlled fashion to the ICU. A secondary goal pertains to another TCAB aim, staff vitality, in that the medical-surgical nurse is now placed in a safe environment where he or she interacts with peers from the RMRT and gain additional critical thinking and physical assessment skills through that interaction. It is still early, as we just started the RMRT in September 2004, but the early data suggest we have significantly decreased transfers to the ICU, Code Blues outside the ICU, and unplanned mortality on the Medical-Surgical floors.
In an effort to minimize patient falls, Roseville instituted hourly safety rounds in which a direct care provider (RN, LVN, or NA) quickly looks at all the patients and their current status and implements a fall prevention protocol as needed. Another intervention they have adopted is the use of portable bed alarms, which alerts staff that a patient is attempting to get out of bed. The net result of this has been a dramatic reduction in the fall rate on the floor from a California average of 3.1 falls/thousand patient days to 0.8 falls/ thousand patient days on Two North, demonstrating expansion of the TCAB initiative to other floors in the hospital.