Changing Names: CARE Assistants
To avoid the use of physical or chemical restraints, many institutions have resorted to hiring “sitters” who stay at the bedside of confused or delirious patients to calm them; if patients try to get out of bed, sitters are there to coax them back in. A number of HELPS institutions shared the idea that using the term “sitter” might have been inadvertently encouraging inactivity: Too many sitters were doing just that, sitting all day, often watching television.
One of the collaborative sites now calls these employees CARE assistants, an acronym for Caring Alternative to a Restraint-free Environment. The group has predicted that calling them something different will inspire these people to “do more caring and less sitting,” says Dr. Saint. After a HELPS session, Dr. Saint submitted this idea to the key decision makers at the VA. “I could have tried by myself to resolve this dilemma for years and not come up with that idea,” he says. “Why not just take what they’ve done and modify it to suit your own environment?”
Weighty Problem: Heparin Dosing
One hospital in the consortium conducted a project on medication safety that focused on appropriate use of heparin in hospitalized patients. When the site’s hospitalists began studying the problems they were having, they realized that the weights they were using for dosing decisions were being generated in the emergency department (ED). Studying it further, they saw that, most of the time, those patients weren’t actually being weighed; nurses were simply estimating their weights. Having traced the problem to the ED, they were then able to intervene, fix the problem, and show that by doing so their rates of bleeding complications from inappropriate dosing of anticoagulants improved.
At his own institution, Dr. Flanders was participating in a group committee meeting discussing this problem. Consequently, “I was able to ask, ‘Have we looked at weights [being assessed] in the emergency department?’ Everyone involved with that project said, ‘No, why?’ And, sure enough, a similar problem existed.”
Care Transitions and Multidisciplinary Rounding
One member-team of the consortium was able to come up with a multidisciplinary team that met and rounded on patients each day and focused on the care transitions. They were able to dramatically improve staff communication, the overall discharge process, and patient satisfaction. As a result of what he learned of their successes, Dr. Flanders’ institution plans to use a similar strategy to enhance communication among healthcare providers involved in the discharge process on their hospitalist unit.
Rapid Response Teams and Input from Residents
“It’s very helpful to hear, from another site, the challenges and benefits of having hospitalists involved with the rapid response teams,” says Dr. Saint. “How did they operationalize it? What were the remaining challenges? What outcome measures did they use? How do you assess whether it’s worth the cost? What do residents think about this?
This last point turned out to be a valuable question to ask. The group included some residents at the site where this project was piloted and had a fruitful discussion. Adding the perspective of residents along with faculty, says Dr. Saint, as well as a couple of nurses and quality care managers, allows a synergy and combination of ideas that led to effective solutions. “Those are exactly the individuals who need to be around a table to overcome some of the challenges.” They have also considered inviting nursing students. “Before they get inculcated in thinking a certain way,” he says, “why not hear what they have to say?”
Dr. Saint believes, however, that this is not a step to be taken lightly. If you are going to include people, “then you have to act on their suggestions or at least hear them out and say why you’re not going to take their suggestions because a good way to get people to become jaded is to listen to their feedback and then just ignore it.”