Enhancing Patient Safety in the Neonatal Intensive Care Unit: A Quality Improvement Initiative to Reduce Unplanned Extubations with Ivy Hepler
Between September 2022 and March 2023, the Neonatal Intensive Care Unit noted an increase in unplanned extubations (UPE), primarily attributed to endotracheal tube securement concerns. Using a multidisciplinary team approach, a quality improvement project launched to implement targeted interventions to decrease the incidence of UPE.
Improving Medication Administration Safety Through Barcode Scanning Compliance with Justin R. White
Frontline stakeholders joined forces to increase barcode scanning compliance to eliminate medication-related preventable harm events for all patients. Cultivating awareness, garnering buy in and providing user-friendly, actionable data were crucial to this initiative's success.
Workplace Violence Prevention Pilot for Ambulatory Care Areas with Michaela Reynolds
The Workplace Violence (WPV) Prevention Pilot for Ambulatory Care areas provides an update on current trends in WPV within outpatient settings and details the work of the OBGYN Clinic at Barnes-Jewish Hospital to increase staff safety.
My name is Beth Brzyski. I'm a neonatologist and the Chief medical Officer for Children's and the Vice President for Quality and Safety. And I'm really um happy to kick off this last session. Um Tammy asked me to let you all know that the survey, um the surveys are still not working, the website is still not working. So, um hopefully that will be working later on this afternoon. So I'll kick it off here by introducing Ivy Heer. Um Ivy is um is a nurse in the neonatal intensive care unit at ST Louis Children's Hospital and where she's been for almost 10 years, she transitioned to the NICU leadership team in January and she has a passion for quality safety and evidence-based practice. As you'll see by the fact that she supports um three quality improvement initiatives. She's the co-lead of the small baby team, the tri lead of the NICU breastfeeding initiative. And she's inc included, she oversees the nu um unplanned Extubation Committee and that's what she's going to talk about today. Um Enhancing patient safety in the NICU a quality improvement initiative to reduce unplanned excavations. Ivy. Good morning. As doctor Brzyski said, my name is Ivy Heppler. I'm an assistant nurse manager in the NICU at children's and I am excited to share with you some initiatives that we implemented to reduce unplanned extubation. I have nothing to disclose, unplanned. Excavations are opies are the uh premature removal of endotracheal tubes or et tubes by the patient family member or um staff during care. Opies are an adverse effect in all IC us within a pediatric hospital and can con contribute to uh pediatric harm. The uh vulnerable population of infants that we see in our neonatal intensive care unit or the NICU um from opies pose a significant risk. And the effects of opies include extended hospital stays, increased cost, the need for reintubation and increased morbidity and mortality between September of 2022 and March of 23 we noted an increase within uh NICU and oop. So, um by tracking the activities that occurred at the time of excavation shown on this chart here and then our ideology of unplanned excavation. Uh We found that our et tube concerns um secure concerns were contributing to our unplanned excavations. So, over a 12 month period by March of this year, we set a goal to reduce our rate of unplanned excavations below our baseline of 0.4. Our intervention started in March of 23. Um We implemented daily airway rounds to um um have nurse practitioners and respiratory therapists round with our bedside nurses for every intubated patient in the NICU. Um they assessed the ET tube the need for the ET tube. Uh made sure that safety equipment was present and provided in the moment feedback with our front line staff, we saw a decrease in unplanned excavations from that. And following another increase in unplanned excavations of in June of 23 we had our NICU educators and respiratory therapist leads um review proper re taping of ET tubes with our staff members through roving skill stations um where they walked through the unit, review the policies with our staff members and gave them a um um hands on, check off with a doll to um re secure an ET two for additional practice. We also then moved to twice daily or once per shift airway rounds to ensure that we are providing in the moment feedback with um each shift, we saw a reduction in our unplanned excavations following those implementations. Um And in Ju July of 23 we um created an OPI prevention time out, which was a script that was to be reviewed prior to re taping to ensure that all of our necessary team members were present that our emergency equipment was available. And it also created a psychologically safe to speak environment. So this was a designated time that anyone who was involved in the re taping um could ask clarifying questions, um define roles, request additional support if they needed it. Um And make sure that everybody who was involved in the re taping was on the same page with what exactly we're doing with this baby's breathing tube in August of 23 an escalation pathway was created and this was um a clear pathway with associated numbers for who to call if additional support is uh needed prior to re taping as identified in the OPI prevention time out. And then um towards the end of September and through October, we pulled together a multidisciplinary team to um create uh a scenario for an OPI prevention escape room. Um This was an interactive educational offering for all of our NICU nurses and NICU respiratory therapists to review a scenario and prevent an OPI from occurring. Um And that went live in January of 24. So this figure um up on the top shows the number of airway roundings that were completed per month along with our SPS bundle compliance. Uh based off of questions that were being asked during airway rounds. The um bottom figure here is our um we ask that safety events be placed to capture any near misses that were being found on airway rounds um that could have potentially led to an unplanned extubation. So things such as the markings were worn off the ET tube, the et tube secure was loose or incorrectly sized. Um and if any safety equipment was missing and if the ET tube was in the incorrect position, um So we saw that there were 22 opportunities captured within this 30 day snapshot. And um this was viewed as 22 prevented opies within a month from our airway rounds. We also created a communication cascade to our front line care team um by adding in airway rounding themes to our tier one huddle. This is reviewed with our front line staff prior to every shift and um ensured that any common findings or room for improvement that we were seeing from airway rounds were communicated to our front line staff. The UB prevention time out uh really calls attention to the importance of the ET tube as a lifeline for our patients. Um And made sure that all of our members could speak up and felt prepared. A debrief form was created to be filled out after the re taping occurred. Um And of the 516 time outs, uh debriefs that were filled out um 511 times the roles were clearly assigned and all comfortable with the task assessed. Um This other that is noted here was a nurse who was on orientation um and expressed comfort with re taping with the help of her preceptor. Uh We also tracked who was at the bedside to ensure that all parties were um relevant parties were participating. Um And the other that is noted on here is um additional support that was requested based off of the op prevention time out. So that could be an additional nurse. Um Additional respiratory therapist, medical provider, et cetera. This is our escalation pathway that was created um and it was developed so that any team member who was involved in the re taping had a clear pathway to follow to call um with associated numbers. If additional support was needed, our UB prevention escape room um that was created was consisted of a multidisciplinary team coming together to review our common airway rounding findings and create a scenario um to offer an interactive educational um scenario for our all of our Niki nurses and respiratory therapists. And in order to escape the room, the staff members had to identify the safety concerns. Um and then also participate in re taping of an ET tube with the doll. Um So this provided another hands on experience for them. Our preliminary results show a reduction in the rate of unplanned extubation. Our latest data is from January of 24. Um And it shows that our unplanned extubation rate is at 0.42. We had great compliance with our airway rounding at 89% greater than 96% of our staff received ET two re taping education. And since the implementation, we have an average of uh 56 re-taping timeouts per month that's recorded, we also have 100% compliance with our daily communication cascade with that tier one huddle. Um We have had one reported delay of re secure while awaiting a trained RT since the implementation of the escalation pathway but shown here on this graph. Since our um implementation of our interventions in March, we had seven out of eight months um below our baseline of 0.4 oops per 100 ventilator days. The successes that we've had with this project, a lot of it is contributing to our multidisciplinary team effort that um we've worked through. We um also have recognized that communication in real time to the front line providers plays a big role in this in celebrating our successes. We um have also noted that for sustained engagement, positive feedback has been integral for our front line staff. We hope that the initiatives um from the um interventions that we've implemented can serve as a valuable model for all IC us to implement similar multidisciplinary interventions. And our NICU has joined the Children's hospital SPF unplanned extubation improvement cohort for 2024 so that we can learn from other facilities as well as share our successes. Thank you Ivy. Um We're gonna hold questions until the end and then we're gonna have all uh three of our presenters sit here in the front and then you can ask your questions. I just want to say I'm particularly proud of this project as a neonatologist and that, that rate of 0.42 extubation per for per 100 ventilator days really is rivals anyone in the country. So thanks to the NICU for presenting that effort. So our next speaker is Justin White. Um Justin has been a nurse at ST Louis Children's Hospital for over 20 years. In his current role as a patient safety and quality specialist at ST Louis Children's Hospital. He supports the emergency department, trauma services and the critical care transport team. He's also the co-lead for the children's hospital adverse um event preventative harm team. And in that role, he's going to present to us today improving medication administration safety through bar scanning, barcode scanning compliance. His partner in Crime in Crime is Alex Milligan and Alex is sitting somewhere in the middle. You want to raise your hand, Alex. So Alex will join um Justin um after the presentations um to answer the questions if you have any, Justin, thank you. Doctor began Brezinski and uh good morning everyone. So I'd like to start off by saying that I have no financial relationships to disclose during this presentation. I will be talking about a couple of tools that are used uh during this project, some software uh that was what is available to us through the BJC system. We didn't specifically choose those tools. It's just what we had at our disposal. So, uh as doctor Brezinski said, I've been here at uh ST Louis Children's for over 20 years. My background is in nursing. Uh I was blessed to be hired directly out of school into the level one trauma center emergency department. Uh I also was proud to serve as a flight nurse on the critical care transport team for five years flying around in airplanes, helicopters, Laurie uh and riding around in our mobile IC U semi trucks, bringing neonates, pediatric patients and pregnant moms back to our campus for world class care. I took this position in quality improvement and safety. Uh coming up on three years in the fall, it didn't exist uh prior to that. So uh because I support those areas that Dr Brzezinski described, it almost was like, this was tailored specifically for me. The quality and safety team itself at ST Louis Children's Hospital is small, but it's mighty. And we've been strategically placed in the preventable harm teams to help support their efforts. Barcode uh compliance uh is a standard of care uh and safety tool that is a part of knowledge based medication administration, which is a system which additionally includes other safety tools such as the five rights of medication administration, which to some is now seven, right? Because we have a reason and charting after those and addressing situations such as Pius over IB utilized for a sense of urgency and not a true emergency. Barcode medication compliance for scanning has been a long-standing struggle at ST Louis Children's Hospital has demonstrated by a core compliance rate of 92.3% at the start of this initiative and we'll be disclosed uh discussing that today. So ST Louis Children's Hospital utilizes a safety event surveillance program we happen to call it safety event management system or S EMS that is a, has a robust process of review, review and escalation, which includes our medication related safety events that are reported by front line staff and providers. Our journey at ST Louis Children's Hospital to becoming a high reliable organization included a restructure of our adverse drug event preventable harm team that was initiated in 2022 to help address the issues that are brought forward in that S EMS system, ST Louis Children's Hospital has uh additionally initiated other programs such as our safety coach program that helps to empower all providers and staff to speak up in the moment to use safety tools to create an environment of persistent mindfulness about safety. This cultivates productivity, safety and resilience. So 2023 brought Alex to our team as a pharmacist, but it also brought a refresh and renewal of the adverse drug event team as well as refresh of goals and alignment with the other preventable harm teams in the hospital, barcode scanning compliance, smart pumps, guardrail usage and Pius override compliance were all on our radar for our improvements for knowledge based medication administration. This is an interdisciplinary team that includes front line leaders, quality and safety specialists, pharmacists, and uh providers. We also outside of our team ta tap into other resources such as our performance measurement team who happens to be here today, our informatics which we lean on heavily to help us with um showing the data appropriately. So utilizing the model for improvement, we identified the goals and data needed to measure meaningful improvement. So we en engage those front line stakeholders, we wanted to know specifically on the front lines, what are the barriers for compliance? A user-friendly tableau dashboard which you see here was created with those front line leaders to specifically address those barriers and increase transparency with the front line staff members. So we noted that the key factors that were a challenge for us were lack of meaningful data reporting to the uh leaders themselves, inconsistencies of practice of the actual barcode scanning itself and also an insufficient awareness of the value of actually using that scan as a safety tool and a standard of care. So this is our tableau dashboard here. This is uh gonna show the month of 2024. So this is the total compliance for the entire hospital down here. You can see the top performers, the top 10 units and what the really good information that comes forward is these top top five medications that are in fact not scanned. We use a lot of buffer lidocaine for our procedures and for our peripheral IV starts. And then over here, we have the reasons why the medications were actually not scanned. We recently partnered with our BJC Wide CIS team to help address some of these other issues. We are switching from our current barcode scanning system. To a rover system, which is like a handheld device like a phone which hopefully will help address this and push our rates even higher. This is our rolling 12 month right here. So this is kind of where we started. We initially were that 92.3 we've consistently been above the goal of 95%. That was our, our smart aim there. Uh And what's nice about this is that the front line leaders can look at this in live time, but it's actually automated and monthly data reports actually go to them specifically and target the high risk users which we identify as somebody who has had 30 or more missed opportunities for uh barcode scanning to help sustain this project. So we made all this fancy stuff, we talked about it, we made goals. So then what do we do while we knew we had to jump in there and we had to cultivate awareness with the staff, we had to garner their buy in and we had to provide this user-friendly actionable data. And these were all crucial to the success of this initiative. So we embedded ourselves in the workflow. So we went there directly to them and asked what the barriers were a perfect example will be my uh Cole Alex who is a pharmacist, went directly to a unit, talked with the unit manager, talked about the concerns they had and went directly to one of the folks that are actually there as a front line person on the unit, a nurse and said, tell me your process, tell me, tell me what goes on. And so finding out in this interaction that this nurse consistently said I use the five rights of me medication administration. So I don't have to barcode scan. It wasn't an either or it's an all inclusive. And so just having those conversations alone just helped increase this and also create that buy in. So these are some of our results here. So we talked before about how we started at 92.3 went up to 95.9. So 3.6 at face value doesn't seem like it's that big of a number. But we've found is is approximately 10,000 additional medications administered are being used with barcode skin. That's 10,000 opportunities to not give the wrong medication. This was very important through the dashboard because those unit leaders because every unit functions differently has different needs, can identify the specific improvements needed there. And that also led to some development of creative unit specific interventions to sustain this. So we started seeing signs up that said these are the top 10 performers for barcode scanning on our unit. We didn't talk to the leaders about that. We didn't initiate that. They started doing that on their own, which is fantastic. So we took it one step further. So this looks super fancy. This is nice, you know, this is our run diagram that looks really nice because it goes up. But we again tapped into our informatics, our friends there in performance measurement and said, we want to know that the wrong medications are being caught. We know it's being scanned, but we find sometimes the medication is given, then they scan the medication we want, we want to know that we're stopping harm. So this chart was created by our friend Derek there for performance measurement to help us out and show this is actually wrong medications that were in fact scanned and not given. So this is a big win for us here on this chart. We also stressed that the data provided was intended for safety and process improvement and never intended to be used for punitive purposes at all. We had some concern with this. So we had to take this on head on with those unit leaders and those staff because the staff would come forward and say, well, I can't scan this. I don't want to be held accountable for this. This is, you know, and what we came back with was we wanted the front line leaders and that staff to be reassured that this process was rooted in just culture. Individuals are res sponsored responsible for their own actions but are not held responsible for flawed systems in which dedicated and trained people can still make mistakes. We want that staff to feel empowered to come to us and identify errors, defects, and system failures that could lead to an unsafe environment for our patients. So this is the uh Fancy Little award that Alex and I kind of created. So this is given out to the, the best performers, the the least to best. So they started off with our hematology group. Big shout out to them. They're a great partner in this. Uh And so what we're redoing now is we're aligning our celebrations with the rest of our preventable harm teams in the hospital. So along with that will come some other prizes and things that we can provide with those units. What we found was obviously, you know, the adverse drug even preventable harm team is doing their best to get our preventable harm errors down to zero. But these unit based competitions, these targeted things that these units are doing themselves, that is what's going to sustain everything for us. So uh the system itself actually fed itself and those front line staff are now coming to us and saying I want to be 100%. I can't scan a saline bullet. There's nothing to scan, but it's in the mar. And so that's where we're at now. So the staff are coming to us now. So we've garnered that buy in. I am truly honored to be a co-lead with my quality and safety colleague and pharmacist, Alex Milligan and also to represent the ST Louis children's hospital adverse drug event preventable harm team at the symposium. Uh We are truly safe together, time and attention are gifts. I would like to thank the patient safety and Quality Symposium committee for the time to come here today and speak to you all and I want to thank you all for your attention. Thank you, Justin. OK. Last but not least we have uh prevention on uh a presentation on preventing workplace violence. You know, it's near and dear a topic near and dear to the heart of many of you here. Um as well as getting a lot of attention in the state and national scene as as evidenced by John Dolittle from uh this presentation earlier this morning and this will be given by um Michaela. Um Reynolds Michaela earned her bachelor's degree in health management and policy and a master's of Health Administration from Saint Louis University. Michaela joined BJC health care as a strategy and operations intern at the Center for Clinical Excellence before becoming a fellow at Barnes Jewish Hospital. Um and she currently serves as the senior project manager for emergency and patient trauma and surgical services. And her topic is workplace violence prevention, a pilot for ambulatory care areas, Michaela. Hello, everybody. Um Thanks so much for coming out today, as was stated, I'm Michaela Reynolds. I am currently working as a senior project manager in the emergency department and through my work with the workplace violence committees at the hospital and system levels have been able to now work with our uh ambulatory spaces as well and I have no relevant financial relationships or conflicts to disclose today. So I wanna start with a little bit of some national background. Unfortunately, some people might not need the background um because we're experiencing it and living it. But um just to kind of set the stage for what type of an issue this is, um the Bureau of Labor Statistics reports that the rate of injuries from violent attacks against medical professionals grew from uh grew 63% from 2011 until 2018. And keep in mind, this is also pre-covid, we know that um just kind of the climate during COVID increased workplace violence incidents. So by 2021 77% of healthcare workers reported being involved in at least one workplace violence incident. And as of right now, health care workers are actually five times as likely to experience workplace violence in their workplace as opposed to employees in any other industry. So what have we been doing here at BJC? Um a couple of years ago, uh we created a system wide workplace violence prevention committee and BJH also has a hospital wide workplace violence prevention committee with a couple of different branches that are focused on different topics. What we started to notice though was that as we were doing this work, a lot of this work was really focused on the inpatient side of the house and we wanted to be able to support our colleagues in ambulatory spaces as well. So that's where we came up with the idea to run a pilot and take the work that we had done in the inpatient space and be able to translate that to our outpatient settings. So um we have the OBGYN Clinic to thank for being the first area to undergo the pilot and to set a little bit of background for the OBGYN clinic. They see approximately 100 and 25 patients per day. They have 40 plus staff members in various roles and they have a variety of patient types and conditions that they see. So the bulk of the pilot was really run over about eight weeks or 10 weeks and we had about eight weeks of tip sheet distribution or essentially huddle talking points. And so we would work through these talking points and have discussions with staff, bringing them information and resources about workplace violence prevention. Yeah. So before we even got to starting the pilot, we needed to take a look at what are the main differences between what we're doing in the inpatient space and what that is going to look like in the outpatient space. So we started to um kind of take a look at all of the key differences that we would need to address. One that we found was signage on doors was going to be really difficult and in patient space we can put um some kind of a symbol or a note on a door that will let people know to be a little more cautious when entering that patient's room. Unfortunately, in the outpatient space, patients are moving through spaces so quickly. That isn't always feasible. We also worked with Epic because there are lots of different epic views. And so the um epic view that our um outpatient staff see is a little bit different from the inpatient side. So worked to make sure that they had um visibility to all of the resources that they needed. And then lastly, we created some algorithms and process maps that were very specific to the outpatient setting. So the first is how to address a um verbally aggressive patient via a phone call. The next is how to prepare for a patient who's coming back in for a visit when we know that they might have an aggressive history. And then the last is how to identify and de escalate situations as they're actively occurring. So here's just a quick example, this is the um epic D A or department appointments report as you can see on the far side. Um we do have the workplace violence column that has been added. So this is something that on the inpatient side, you can kind of see the flag at a glance. So we were able to get that Fy I in the column there so that clinicians can take a look at their schedule um for the coming days or maybe for later that day and they can see at a glance whether or not they need to open that chart, take a look at what that flag is saying so that they can be prepared. And then this is also the epic schedule. So same thing here. We've got that column that has the workplace violence flag so that we can see that at a glance when we look at our schedules, um we're also working on now getting that into the Epic Snap board as well. So there's some continuing work in Epic enhancements that are ongoing. And then here's an example of just one of the process maps that we've made. I chose this one because it's definitely the least detailed and others would not fit on the screen. So um as you can see, it walks through a lot of different scenarios. This one is to prepare for a patient who's coming back in for a follow up appointment when they might have already had an aggressive history. So how can we best um prepare our clinicians to make sure that they have the resources they need before the patient even arrives? So by the time we finished all of this, we were able to actually bring our um pilot to staff. So we started with a pre survey and up on the screen is just a screenshot of the um questions that we asked. We essentially asked staff to rank how comfortable they are in different situations. And we took that information to kind of inform where we wanted to focus some of this um information that we were gonna give out. So one of the things that we found is in the OBGYN Clinic, um 75% of all staff members did not know where to find uh workplace violence resources. We were really surprised by this and then this is kind of a breakdown of the survey questions into three categories. So we really wanted to look at how comfortable do people feel when deescalating a situation in the moment? How comfortable do people feel filling out a report, whether that is S ems occupational health or police report? And then how comfortable do people feel working with our public safety partners and using them as an additional resource? So as you can see, there's a good amount of people who do not feel confident and we're only somewhat confident and the highest confidence rate that we had among staff was 55% in working with public safety. So we really wanted to see all of those um rise throughout the pilot. So here are the tip sheets or essentially the huddle talking points that we focused on. We started with what is workplace violence? A lot of people um are finding that some of the normal behaviors or behaviors that they think are normal, really are not normal and we don't want that to become normalized. Um Then we moved into um environmental awareness. So really trying to make sure that people are aware of where they are in their environment and where the patient is also looking for escalating behaviors. Then we spent quite a bit of time on the last two topics that's flagging and reporting. So we wanted to make sure that people not only understood how to enter a flag or report, but also understood what happens after they do that and why that's so important. Here's a quick example of one of the workplace violence flags that was entered that we use as an example quite often because it is so detailed and we want to make sure that people understand the value of entering these. So this stays with the patient's chart and can be seen by anybody within BJC who has access to Epic. And it is really a great tool for us to be able to kind of give each other in the moment notice of um some of the things that may escalate a patient and then also some of the things that may help the patient deescalates. And then here is the board that the um OBGYN clinic created as we went through each of these huddle talking points, they had some really robust discussions about what that meant for them. Specifically, we were able to have conversations about in their own environment, what they should do during different situations and then they were able to take all of those resources, post them up in a common area so that those discussions could be continued. And if people needed those resources, um at any time they had access to those. So to end the pilot, what we did is a post plot survey. It was the exact same survey that we started with. But we were able to then track the differences in um people's confidence levels. We were excited that we were able to increase the percentage of staff members who knew where to find workplace violence resources from just 25% when we started to 80% when we were done. And then here are the three categories. Again that we were mainly taking a look at. The first was deescalating a situation in the moment we did see a rise up to um a confident level of 60%. Next was filling out any kind of reporting. And we are excited to see that rise to a confidence level of 90% of staff feeling confident doing that and then 100% for working with public safety. So what this tells us is that we have been um really excited to bring that information to people, but there's definitely ongoing work. So some of the key takeaways, one we learned that staff are very comfortable with escalating behaviors. Part of this is because we are trained to be caretakers. We've seen a lot of people as, as they recognize escalating behaviors, actually leaning into the patient. Um And so understanding how can we be a caretaker and while also being safe ourselves in that environment, a lot of staff were also unaware of how to partner with public safety. There are a lot of different resources that public safety can provide. And we wanted to make sure that staff understood how to best work with them, also unaware of how to safely enter a room or identify those escalating behaviors and be aware of what is in the environment. We um we're really excited, we have a lot of resources on workplace violence and we need to work on connecting people to them a little bit better. So excited that we were able to um identify that as an opportunity and then also that leadership success or leadership support is very crucial for this work to be successful. We want the leaders to be um really supportive of this work and supportive of the staff going through these things. So after the pilot, the next steps, we um wanted this to be the start of a conversation about workplace violence but not the end. So we do have regular meetings um set up and continue to work through different concerns and topics. The staff were also great and created um some scenarios that they were able to run through in huddles things that they had actually experienced. And now we're working on bringing these pilot findings to other areas in the ambulatory space. Thank you. Thank you, Michaela. Three great topics and three great presentations. If the three of you and Alex would like to, to uh come down and this, this session will now be open for questions. So while everybody's um thinking about the questions they wanna ask, I'll start, Mia what is your um what's the first unit, the next unit that you're planning to roll this project out to? Sure is, is, can everyone hear me? Ok. Sure. Um So we have already um rolled the pilot out in the Pain Management Center saw very similar results and we actually um were able to have some separate conversations with them too about some concerns that they had. So we were able to go back in and have um another session with them specifically about S EMS reporting and where those reports go, what we do with them after they're submitted. So, one of the things we're really working on is closing the loop um with staff members once they have experienced a workplace violence event. Um And then we are also currently working with uh radiation oncology. So they're going to be kind of the next area that we um run the pilot with. Thank you. Hi, Justin. Um Over here down here right here. Hey, hi. It's like where's Waldo? You might have said this? And I was honestly texting because we're still checking on the surveys and they're not working. But anyhow, how did you get people to be care about? Because 92% was, you know, you look at that number go, hey, that's, that's ok, but we need to make it even better. So how did you get people to be interested? Do you know what I mean? I do. That's actually a great question. So like a lot of the initiatives that we do. Um our quality and safety team, we come up with safety stories. We share those throughout the hospital. So we go to our senior leader huddles in the mornings and we say, uh for instance, like a medication uh situation, like we've had some that were where there are issues with uh either a weight or height being documented incorrectly and it has downstream effects and then it can lead to harm. Well, we're very transparent about that. We take away all the things that would, you know, identify patients and staff that's involved because we don't care about specifically who did it. We care about how it was done and how we're going to fix it. And so then after we do those things and we investigate it, we bring it back to the entire leadership team and say, please take this back to your team. So that's part of it. But also we also round um you know, not in just the areas that we uh represent, but um you know, I'm very fortunate to have, you know, Alex as a pharmacist, we also have a nurse practitioner in our hematology group. We also have uh, you know, inpatient, uh IC U behavioral health. We round often together. So we're out there, you know, boots on the ground talking with people. Do you have any safety concerns? What can we help you with today? And that's one of the reasons why we got the buy in because they, we, we didn't just talk the talk or just send them or say do this. We said tell us why you're not doing this and that's how we got to buy in. Hi. Um My question is for Ivy and I was wondering about, have you noticed any indirect benefits after decreasing those unplanned extubation? Because this morning, we've been talking about the patient experience and I also wonder about the staff's like perception. Ha have you noticed any sort of um just indirect benefits of having that change? Yeah, I think, can you hear me? OK. Um I think one of the things that comes to mind is um just staff feeling a lot more comfortable to bring those concerns um and escalate things in the moment. Um since they uh they know that airway rounds are happening and that somebody will be there to help um kind of escalate things if they feel that they need to be escalated. Um I think that that has helped our staff to feel more comfortable and then therefore helping our family members to feel more comfortable that their um baby's breathing tubes are being protected. Awesome. Thank you. Because I imagine the unplanned excavation is stressful for like everyone. Yes. Yes. Especially when family members are involved. It can um be, be a very seemingly chaotic um for, for people who um are not um used to how our codes are ran in the NICU. Um There is a, a lot of people who, who come to be involved. Um And so if we can alleviate some of that stress from family members for having to go through that and then the stress on the patient as well? Awesome. Thank you. I, I have another question. Am I allowed to do that too? Ok. Um This one's for Mia actually. Um So what is the, I noticed the one factor that didn't move jump up quite as much was the staff's confidence with de escalation. So, did you learn anything about like, why are you guys not comfortable with it? Was it that the education didn't include that? Like what, what kind of, what happened with that? Sure. I think um honestly, I think that's probably the most difficult one to move as well because there's a lot to be aware of in the moment. And um so that that was kind of what we had expected. Um um I do know that we are working through CP I training um which is I believe crisis Prevention Institute training. So we're hoping to get more of our staff into the training so that they can really be hands on. They can understand what does verbal deescalating look like. What are some of those escalating behaviors in real time? Because I think until you kind of experience it, um I think there were a lot of learnings when we were able to actually do those kind of mock scenarios with people. Um But until you really experience it and you're in the moment, it can be very difficult to kind of understand how you would react or what the right thing to do would be. So, I think, um that's certainly an area that we want to continue to focus on because we know it's gonna be one of those difficult areas and continuing to work with our public safety partners and with the workplace violence prevention committees to make sure people are getting into those trainings, they're having that kind of hands on experience. That's great. I know it's, it's a skill that has to be practiced. So it's not easy to guess. Yes, definitely. Thank you. Um I have a question for Michaela as well up here. Um With the flags, I, I wonder about the potential for them being like stigmatizing or potentially affecting patient care. Is that a consideration or how do you guys address that? Yes, it certainly is. We've had lots of conversations about that. Um And we want to reemphasize to staff too that using the flag is not supposed to be stigmatizing or anything like that. What we want the flag to be a tool for is helping people understand how to interact with patients um specifically if there are certain triggers or things that we need to be aware of. And so using them to put details into um that flag that help us understand what some of the I guess details about that patient working with that patient are. Um It's also something that we want the whole care team to be involved in. So we don't want it to just be one person. It should really be a discussion after interacting with that patient. Um And it's also the best tool that we have to kind of give other caregivers uh heads up about this. So with that detail understanding, you know, here's the situation here, maybe some of the triggers that we're aware of just more of a conversation to have when you see that flag, not so much um you know, something to be afraid of or anything, but really a tool that we can kind of start that conversation about how can we provide the best care that we can while also keeping ourselves and our colleagues safe? I have a question for Jason and Alex, I'm up here at the top. Um I know you had mentioned um that you were also tracking wrong meds that were pulled but not given. Um has that become a process or project of its own of how you can decrease the amount of wrong meds being pulled. Um, that's when we're still kind of like working on. Like we're, we're definitely, I think we're, what we're focusing on now is Pius overrides because that's where we see a lot of the wrong medications being pulled. Um, and then we're also trying to increase barcode scanning in the pharmacy because, um, we have, uh, a lot of opportunity for our non formula, nonformulary medications that we send um to implement barcode scanning. So we're not sending those down to the floor um, incorrectly since those don't um use our safety features. Um And then, um in general, just epic dispense prep has a lot of opportunities for increasing barcode scanning as well. So, um I think that's kind of our next focus is Pius overrides. And then um overall just improving barcode scanning process in the pharmacy to help reduce the risk of a wrong med being sent or the wrong med being pulled. Thank you questions for Mia. Did you have conversations about neuro neuro diverse populations and how de escalation works with that patient population? Yes, I think that's, that's a great question and um I do believe that that is going to be included in some of the training that we have. Um So some of the I think CP I training and then some of the other conversations that we're having as well. Um Hopefully some of the tools that are in place will help once again, kind of start that conversation so that those details can be shared. And it's more of a really a care plan that we want to put together for patients. Um So understanding what are some of the things that are happening with the patient. Um So understanding, you know, all of that that would come along with that. Um but then also understanding there are going to be things that maybe we can prepare to help keep our staff safe and the more that we're aware of this and the more that we can prepare have the right support in place, hopefully, then um can create not only excellent patient care but also a safer environment and a more aware of our environment for our staff to work in as well. My question is based on uh the uh violent the flags that you have up there. Is there a way that they can get off of that? I mean, it's not like a permanent flag on a, on a patient? No, no, it's not a permanent flag. This is something that we are hoping will be updated at every patient visit as well. So uh it is a, it's a live flag. Um So it it can be taken out of the patient's chart at any time. Um It's also not at all visible to the patient. Um We've done a lot of education on the flagging process because there are so many different intricacies, but it's also a very helpful tool, the flag that was up on the board um during the presentation was one that was entered by some of the staff at the primary care medicine clinic. Um This particular patient did not want any kind of conversation happening before they were alone in a room with a clinician. Not even uh you know, how are you doing today and things like that on the way to the room, that was all the note was saying is that there were some details of how the patient escalated when um when she thought that too much personal information was shared outside of a safe environment for her. And so once that was communicated, the patient went to another clinic and the staff were able to put together a plan to essentially say we need to wait until we get alone in the room with the patient to have any kind of conversation. Um And so now that they know that hopefully that flag can be very helpful, but also um we want to create that awareness for people um and understanding the intricacies of, you know, working with specific patients to keep them safe. Um But then if that is no longer something that we're worried about, we can of course, have a discussion with the care team and take that flag out potentially for sure. Yeah, I understand that the process that you guys are working on was mainly focusing on work at the stop. You mean in terms of LA? Ok, sure. I, I think that's a great point. Um I would say the, the work that we um were doing was really more focused on uh patient to staff. But I think that that's also something that we can probably include moving forward. Um I also want to say that with some of these pilots, we're working really closely with the clinics to make sure that whatever their needs are being addressed. So every clinic has been a little bit different that we've worked with and if that were ever to, you know, come up and, and be something that was a concern, we would definitely work to um you know, focus on that as well. But I think also, um you know, it, it happens unfortunately. And so um something that we can start to include a little bit more and focus on a little bit more, especially if that's a particular concern for an area. Um is the, is the flag part of the legal medical record. I'm up here, I apologize, I can't see over there. Um So the flag, um I will double check on that. Um I know that the notes and all of that is completely hidden from the patient. So there's a way that you can enter a note, um an incident note that will not be seen by the patient. Um I do not believe the flag is part of the medical record, but I can double check on that. Um That's been a question that we've been getting a lot, been working a lot with our legal team on. Um And so we, we want people to feel confident in submitting the flag because we know how helpful of a tool it can be. Um And we are aware of the need to protect staff from any kind of retaliation. So it is something that we're considering. Um And I wanna say it's not part of the legal medical record. Um And it should not be, but um that's there's still some ongoing conversations with them. Yeah. Any other question. So you said um anyone can submit a flag, you don't have a, a disruptive behavior team that those complaints go to and then the team makes a determination on putting a flag, placing a flag. Correct? Yeah. So what we typically suggest is that it be a discussion with the care team. So anyone who is kind of in that patient interaction um would be able to submit that flag. Of course, there are team members who do not have access to Epic. Um So that's something that we want to work on communicating with them. You know, if I can't see Epic before I interact with a patient, how can we otherwise communicate with them about the situation? Um But yes, it can be any team member who has access to Epic is able to put that flag in, there should be a date and some details about what happened and um some advice on things that could help de escalate the patient. Um And then the, the care team should come to a consensus on whether or not that flag is needed because we're, we're with the va and so we have an entire disruptive behavior team so that you can put in a uh incident report And then the team works to ensure that the flags are placed and then the providers review the flag. Um But the patients do know they have a flag, they, they are aware they have a flag, ok, that I can take that back to the team. Um And we can kind of continue working through that. I know that there's some ongoing work there. Um So I I appreciate that, hey Michaela, so it is not part of the permanent medical record, but it is discoverable. So it's not visible to uh you know, your patients and families, but it is discoverable. So it's very important that we utilize these tools, you know, smartly and effectively and document well. Um but uh not part of the medical record. So, ok, can I just ask you after the workplace violence if it continuously happens over and over, despite the health care workers' best interests, that's trying to make it not happen. Is there a dismissal process? Yes, there is. And there that would be kind of escalated through a team. So typically, what would happen is um you know, there would be some initiatives or things that we would work on first with the patient there, you know, to my understanding, be multiple conversations with the patient and with the the entire care team. Um if there was really something going on where we felt we could not continue to have a relationship with that patient, we would then escalate things. There would be a team that would take a look at that um and be able to handle that. So it wouldn't happen on the front with the front line staff. Um But all of the information, um the notes and things like that that are kept are really helpful to um understand kind of a, a pattern of behavior or kind of what the risk is. Um But there's certainly a process if needed. Well, thank you very much. Thank, thank you to the speakers and Jody will not close this up. Yeah. All right. All right, everyone. Thank you so much. Um So want to apologize that the surveys did not work earlier, but they work now. So please, uh take the surveys and you'll have till March uh 19th at like 2359 to get them done. The only way to obtain continuing education units is to complete all the surveys in the platform. You can get your certificates through the platform minus the continuing medical education and ac pe you'll get those from um from Washu CME office. And finally, if you could please provide us feedback, we use this every year and we really also want to crowdsource your thoughts on topics and speakers. And if you have somebody wonderful, please let us know, reminder to the poster presenters, please grab those um if they've not been removed. If you have any questions, see Fabulous, Tammy and Robin uh for questions. So attendance prizes. I know that's why you're hanging out here. So we have 15 prizes and the first. So what I'm gonna ask you to do is if I say your name, can you go? Hey, I'm here and shake the wave your hand because if you're not, we need to draw another name. So the cal the call these coffee Jerry Sova. So Va Jerry Yay yay, Jerry, the BJC set of tickets, Jason Soto. I know you're here. Yay Lucky Duck. Another called these Coffee Amy Swan. Amy Swan is Amy Swan here. Yes. Thank you, Amy. And if you could just yell here here, so that helps uh a complimentary one hour massage uh therapy session to Ayanna Brown. A Yann A oh yay. All right. See these prizes make you guys stay, don't they? All right. Um The next set of tickets, Katrice Park Stacy. I I'm hearing a lot of woohoo. So that means she's here. Uh the $25 cafeteria coupon. Christina Adcock. Do we have a Christina Adcock in the house. Oh, she's got a dance. Ok. We should make that a requirement. Gift basket from the BJH gift shop. Jon Tatum. Jon. All right. It's a nice basket. I've seen it a $10 gift card to Cal's Amy Floyd, Amy Floyd. All right. The other set of tickets to the Cardinals Suite is Amber Francis. Do we have Amber Francis in the house? Yes. Yes. Ok. Thank you. The Doubletree by Hilton is Nicole Yates, Nicole Yates. All right. This is like a game show. I like the standing up and waving Washington, manual patient safety and quality improvement. Matt Bader is Matt Bader in the house. All right. Yes. It's like this is your life. The next set of tickets uh for the Cardinals game which by the way, it's to be determined is Tanya Schrader. All right, I see this. So I take that as and for the uh $10 gift card to Seattle's Best Coffee bar, which is on north and south campus here at BJC is Aaron Simmons, Aaron Simmons. All right. The three month complimentary membership gift certificate to move goes to Kylie Patterson. We have Kylie Patterson in the house. I hear clapping waving. Thank you. Apparently I can't see with my readers beyond here and the final prize drum roll for the last pair of tickets to the Cardinal game. Oh, I like it. Um I'm gonna spell it, Sean A Shana Allen. All right, guys that concludes today. We want to just thank you so much for coming. Thanks. So thanks again time.
