Kathleen D. Sanford
At a Glance
Nursing and finance leaders can encourage evidence-based nursing by:
- Investing in best practice procedure products
- Providing continuing education to nursing care teams
- Encouraging accountability-and empowerment
There is a growing emphasis in health care on evidence-based practice, or identifying the most effective treatments and approaches for various diagnoses. The American Recovery and Reinvestment Act allocates $1.1 billion for comparative effectiveness research. Many healthcare leaders think the day is coming when providers will be paid only for those procedures/treatments that are proven to be most effective-not for procedures/treatments that evidence shows to be less effective.
Nurses, physicians, and other clinicians are well aware of the quality and safety issues in our hospitals. We even have a name-iatregenic-which refers to illnesses or injuries that patients develop as a result of the care and treatment we provide. Another term currently being used: hospital-acquired conditions (HACs).
Despite the common ethical goal to "first, do no harm" to patients, the healthcare system sometimes fails patients. As a result, as documented by the Institute of Medicine (IOM), the percentage of patients who develop preventable HACs is unacceptable (Crossing the Quality Chasm: A New Health System for the 21st Century, IOM, 2001). The good news is that hospitals are making progress in reducing HAC rates. But we have more work to do-and the development of evidence-based practices is one key tool we are employing.
Evidence-based practices are typically considered medical, or physician, practices. However, healthcare leaders also need to consider the patient care that is provided by other professions, especially nursing. Wide variances exist in the way nurses carry out traditional nursing practices.
Practice Versus Prescription
Many people assume that everything nurses do is based on physicians' orders. But this is not true. Physicians generally prescribe treatments and tests, medications, and diet and activity levels. However, registered nurses (RNs) are licensed to provide certain types of patient care without a physician's prescription. One example is skin care for immobile patients. Physicians typically do not feel they need to write a prescription for skin care and assume the nurses will handle it independently. Nurses have policies and procedures about how often they turn patients and how they protect bony prominences to prevent decubitus ulcers, which usually happen where bones are close to the skin.
Preventing falls is another example. Nurses use a variety of practices to ensure patients don't fall. These care practices are not prescribed by physicians; they are handled independently by nurses. As early as the Crimean War of the 1800s, Catherine McAuley, foundress of the Sisters of Mercy, emphasized the importance of nursing interventions for the promotion of caring and healing. Her Careful Nursing model, first articulated in the1800s, emphasized the unique and separate interventions that comprise professional nursing practice. "Nursing interventions are specific healing procedures developed logically from ideas about nursing care or from observation in practice" (Meehan, T.C., "Careful Nursing a Model for Contemporary Nursing Practice," Journal of Advanced Nursing, October 2003, pp. 99-107).
Even when patient care is dictated by a physician's prescription, nurses often have to rely on nursing practice to carry out the order. Physicians typically prescribe what they want done for a patient (e.g., a specific diagnostic test or treatment)-not how that order is to be carried out.
For example, a physician may order a Foley catheter for a patient, but that physician's order does not detail how the Foley is to be inserted. In another example, a physician might order a fluid to be given to a patient intravenously. The physician will prescribe what the fluid is and how much of the fluid the patient needs to receive. However, the physician's order doesn't say what size needle the nurse should use or what vein the nurse should put the needle in. Nurses determine these practices themselves.
Physicians and other hospital leaders assume that nurses know how to do their jobs, yet many leaders do not realize the large amount of variance that exists in nursing practice. Until recently, this variance has not been widely studied, and its associated quality, safety, and cost implications are just beginning to be uncovered.
Take, for example, Foley catheter insertion and care. Catheter-associated urinary tract infections (CAUTIs) are a common source of complications for hospitalized patients. Most urinary catheters are placed and managed by nurses. Evidence-based procedures for avoiding CAUTIs include not routinely changing the catheters, using the smallest diameter that will promote drainage but not leak, and avoiding catheter irrigation. The chance of infection is increased if nurses change the catheter frequently or routinely irrigate to avoid blockage of the catheter tube. There is an intermittent method of irrigation that can be used to relieve obstructions, but nurses who use other procedures for irrigation increase the likelihood of their patients developing urinary tract infections.
Variations in nursing controlled practice can also impact the cost of care. Bed making is one example. Even though housekeeping personnel make beds along with nursing assistants, nursing leaders control a number of practices related to bed making that have financial ramifications: What kind of linen should be put on the beds? Should the unit use draw sheets (i.e., an extra flat sheet to help move patients and prevent mattress soiling) on all beds, even if the patients are not confined to bed? Should linen be changed every day, or less frequently?
Nursing leaders can help their hospitals save money by establishing cost-effective practices related to bed making. Most hospitals in the Catholic Health Initiatives (CHI) system, which is based in Denver, do not change linens on a daily basis-except for bedridden patients, when linens become soiled, or whenever patients/families request it. Nursing aides refresh the linen of patients who get up and move around (by smoothing wrinkles, fluffing pillows, and making beds). The system is currently making this a policy in all CHI hospitals, with a projected systemwide savings of $3 million.
Heeding Policies and Procedures
The Joint Commission requires nursing leaders to have defined policies and procedures, which detail common nursing practices, available on every hospital unit. These policies and procedures are typically developed by a committee of nurses and other caregivers. The chief nursing officer (CNO) must sign off on all nursing policies and procedures.
Policies are what you will do; procedures are how you will do it. For example, a policy might read: "Do not change linens every day on the medical-surgical unit, unless the linen is soiled." The procedures for this policy would then detail, for example, how many pillows to put on each bed and whether to use a draw sheet.
In theory, all nurses follow the policies and procedures in their unit manuals. However, like physicians, nurses have variances in practice. For example, a nurse may get into the habit of inserting an IV in a certain way, even though that approach varies from the practice documented in the hospital's policy and procedure manual.
These discrepancies are often not illuminated until something goes wrong. A hospital's root-cause analysis committee may find that the reason a patient developed a urinary tract infection was that a nurse did not precisely follow the procedure related to inserting Foley catheters. Or during a malpractice lawsuit, a plantiff's lawyer may request the hospital's policies and procedures and then go on to prove that the plaintiff's nurse did not follow hospitalwide practices.
In addition, different nursing units or different professions (respiratory therapy versus nursing) within the same hospital may perform the same procedures in different ways. For example, the physical therapy department may have a procedure related to ambulating a weak postoperative patient that tells the physical therapy aide to use a gait belt. However, a nursing unit in the same hospital may have a procedure that does not require the use of a gait belt for ambulating a patient with the very same likelihood of losing his balance. Clearly, hospital leaders do not want to risk having a patient or staff member injured-or the accompanying legal issues-because of conflicting procedures.
The financial implications related to variation in nursing practice have become more significant now that Medicare is beginning to tie payment to performance. Consider Medicare's current Hospital-Acquired Conditions and Present on Admission (POA) Indicator Reporting program. The Centers for Medicare & Medicaid Services (CMS) is currently tracking 10 HACs (see exhibit). If a patient acquires any of these conditions during his or her hospital stay, the facility will not be reimbursed for related treatment costs. However, CMS will reimburse the hospital if the patient presents at admission with these conditions.
Nurses are key players in ensuring that hospitals are paid for POA conditions. They are the ones who perform the initial evaluations of admitted patients and document whether a patient has any specific conditions or infections on admission for documentation purposes. It is important that hospitals have policies and procedures that detail what needs to be done during these POA exams, and how nurses need to carry out these practices. Variation in these practices could potentially lead to loss of revenue if, for example, a nurse skips giving a patient a thorough skin exam on admission and discovers a skin breakdown only after the patient has been in the hospital for a day.
Nursing practice is also integral in preventing HACs. In fact, many current HACs revolve around issues that are controlled by nurses rather than physicians (see the exhibit on page 43). Take, for example, blood incompatibility. Nurses are typically the staff members who hang and administer blood. So the nurse is the last stopgap-or the last staff person to ensure the right blood type is being given to the right patient.
In other instances, preventing HACs involves a team effort between physicians, nurses, and other staff. The entire operating room (OR) team should work together to ensure no foreign objects are left in after surgery. Yet OR nurses have a key role preventing these types of HACs; they are the ones who keep count of the sponges.
There is some skepticism over how much money hospitals are actually losing under the POA reporting program. But many healthcare experts believe this CMS program is just the beginning and expect to see stronger links between performance and payment in the near future. The recent healthcare reform legislation has already earmarked penalties and payment reductions for hospitals with high HAC rates and high readmission rates.
Three Steps to Evidence-Based Nursing
The time is right for finance and nursing leaders to place more emphasis on evidence-based nursing. Nurse leaders need support from finance leaders in three specific areas.
Invest in best practice procedure products. In the past, teams of nurses at CHI conducted extensive literature searches once a year or so to discover new evidence-based or best practices-and update nursing policies and procedures to reflect these practices. However, this labor-intensive task is much easier now that publishing companies have developed online nursing procedure manuals. The publishers comb the literature for evidence-based and best practices on an ongoing basis-and regularly update their online procedure manuals based on the latest evidence. Some of these products even have accompanying educational videos for nurses that show, for example, how to insert a nasogastric tube.
CHI has purchased these online manuals for all of our hospitals. The nursing leaders at the hospitals still need to write their own policies, but they can simply adopt the related procedures described in the online manuals. By making the manuals available on a hospitalwide basis, we ensure that all units/departments are using the same procedures.
Our patients also are benefiting from our nurses' knowledge of the latest research developments. For example, we changed our procedures related to heparin locks based on research led by Colleen Goode, RN, PhD, vice president of patient services and CNO, University of Colorado Hospitals. A heparin lock is a device that allows medicine to be given to a patient through a vein. Nurses have traditionally injected the locks with heparin to keep the lines open. However, some patients have developed allergic reactions or clotting problems from the heparin. Goode's research shows that saline works just as well as heparin in keeping the line open-with fewer side effects.
Provide continuing training to nurses on policies/procedures. In hard economic times, hospital leaders need to be careful about how they spend their organizations' limited dollars. However, it is important not to cut back on staff education budgets. When education dollars are reduced, it is difficult to train staff in best practices, which can ultimately affect the quality of care.
Encourage accountability-and empowerment. Job descriptions should include reference to the need for nurses and other clinicians to follow hospital policies and procedures. Just as important, however, is the need for senior leaders to create an organizationwide culture of accountability and to educate staff on the need to adopt evidence-based practices.
At the same time, it is vital for leaders to recognize that medicine and science are not exact sciences. Nurses, physicians, and other clinicians need to be empowered to make decisions that are in the best interest of individual patients-even if those decisions deviate from hospitalwide policies and procedures or from a physician's order. In those cases, the clinicians must be required, by policy, to document their reason for choosing a different action.
All licensed nurses have the legal right, as well as a moral and professional obligation, not to carry out a physician's order if they feel the order will endanger a patient. For example, if a physician orders a lethal dose of a medication, and a nurse administers that prescription, the nurse is as responsible as the prescribing physician and risks suspension or loss of his or her license. The hospital is also liable. Even if the prescribing physician is not an employee of the hospital, the hospital could be sued because it gave privileges to the prescribing physician and because the nurse carried out the order.
We need to decrease variance in nursing practice as well as medical practice. By decreasing variance, we will enhance quality and safety and improve hospital margins, which are becoming increasingly linked to performance-based payment structures. Hospital CFOs and CNOs need to partner to make appropriate decisions for individual patients and for the fiscal health of the organizations.
Kathleen D. Sanford, RN, MA, DBA, FACHE, is senior vice president and chief nursing officer, Catholic Health Initiatives, Denver (firstname.lastname@example.org).
Sidebar: Best Practice Versus Evidence-Based Practice
Evidence-based practice. Rigorous research studies, preferably controlled studies, indicate that an evidence-based medical or nursing practice is more effective than other practices in achieving a desired outcome (e.g., reduced incidence of infection, a lower length of stay).
Best practice. There may be some research that supports this practice, but it is not yet backed by rigorous research studies. A hospital may determine that a particular best practice has resulted in improved outcomes (e.g., improved patient satisfaction, reduced supply costs) for its patient population.
Publication Date: Monday, November 01, 2010