The six affiliates of Memorial Health System work together to fulfill our mission to improve the health of the people and communities we serve.
Nursing

 

Memorial Medical Center

Exemplary Professional Practice

Psychiatric Readmission Team

Psychiatric Readmission Team (from left): Debbie Taylor, LCSW, Vicki Cruz, RN, Jesse Gutierrez, BS, Lorna Scoggins,
RNBC, MSN, Kathy Lee, MS, APN, PMHCNS-BC and Jackie O’Brien RN, BS

30 The percent in reduction of 30-day readmissions for patients following the launch of a Psychiatric Readmission Team on Memorial’s inpatient psychiatry unit.

In the fall of 2010, a group consisting of two nurse case managers, the unit’s nurse manager, director of clinical operations for Psychiatric Services, a licensed clinical social worker and a psychiatric social services specialist convened to review the number of readmissions on the unit and identify possible interventions to reduce the rate. After conducting a literature review and defining the data they needed to collect, the group began meeting weekly and reviewing cases in which a patient was readmitted, from any hospital, within the past 30 days.

The team determined which readmissions were avoidable or unavoidable and evaluated what could have been done to avoid a readmission. Soon, the team noticed trend in which patients were at risk for readmission. Once they understood who fell into that high-risk group, the team worked with the appropriate caregivers — including nursing staff, therapists and physicians — to ensure they had the appropriate tools needed to best prepare and educate their patient for discharge. The team began measuring their progress in the second quarter of fiscal year 2011 and quickly saw their avoidable admission rates decline as the result of their work.

Labor Induction Compliance

65 The percent improvement in compliance with labor induction bundles since implementation on the Family Maternity Suites.

This four-part bundle is intended to protect both the mother’s and baby’s well-being by requiring that all four steps be met before an elective induction is initiated. These include: ensuring the baby is at or past 39 weeks’ gestation; fetus status is normal before introducing Pitocin; a pelvic exam is completed; and the absence of uterine tachysystole. Research indicates taking these steps provides better outcomes for the infant, especially if the induction occurs after the 39-week mark.

FMS has been 100-percent compliant in not allowing elective inductions prior to 39 weeks since January 2011. The unit also has seen improvement — 83 percent — in compliance to its four-part labor augmentation bundles since 2009. This bundle has the same criteria as the induction bundle but does not take into account gestational age if a mother has gone into spontaneous labor prior to 39 weeks; instead, the team considers the estimated fetal weight before deciding whether to augment the labor with Pitocin.

Heart Failure Support Team

 

Heart Failure Support Team (from left):
Marilyn Prasun, PhD, CCNS, CNL, FAHA, Valerie McKnight, BS, Brandy Dennis, RN-BC, CHFN, Tracy Kesinger, RN,
MS, ACNS, BC, Erin Nelson, RN, BS, Kimmie Crawford, BSN, RN-BC, Becky Smith, RD, LDN

9% The 30-day readmission rate for patients who participated in Memorial’s Heart Failure Clinic in the first three quarters of 2012.

Our Heart Failure Support Team takes a proactive, interdisciplinary team approach to preventing and treating heart failure.

Since its implementation in 2005, the team has seen all patients admitted for heart failure to improve their outcomes by standardizing patient teaching in preparation for discharge, improving compliance with core measures, and successfully transitioning patients to outpatient management, such as through our tele-management program and an APN-led Heart Failure Clinic. All heart failure patients are referred to the outpatient clinic within 10 days of discharge and benefit from the expertise of registered nurses, a pharmacist, dietitian, social worker and exercise specialists. Patients also can chose to participate in monthly Heart Failure Support Group meetings, during which they are educated on taking medications, cooking and other topics to help achieve a better quality of life.

As a result of these efforts, our 30-day readmission rate for Heart Failure Clinic patients decreased from 11.07 percent to 9 percent, one of the lowest rates reported nationally. Length of stay also has decreased for these patients.

Memorial Stroke Center

458 The number of stroke patients who presented at Memorial Medical Center in 2012.

Our nursing staff and nurse leaders have led the way in developing a strong stroke program for patients, which now includes Telestroke technology, a neurointerventional radiology program and the “Star 45” protocol for treating patients who present in our Emergency Department with stroke symptoms.

Implemented in August 2012, Memorial’s Telestroke program places high-definition audio-video conferencing technology at outlying facilities, with a focus on rural hospitals, which do not typically have immediate access to fellowship-trained stroke neurologists. The program was developed with significant assistance by a stroke coordinator, a new nursing position implemented in early 2012. Nurses also helped develop our Star 45 program, which seeks to diagnose patients and begin to apply the appropriate interventions within 45 minutes of patient presentation, by looking at the process from a patient-flow perspective so that an appropriate ICU bed is available after an intervention is applied.

Additionally, our Nursing team helped develop our new neurointerventional radiology program by researching evidence-based practices for care of stroke patients requiring neurointerventional radiology and collaborating with neurologists, surgeons and other providers on developing state-of-the-art practices to best treat these patients. Memorial’s Stroke Center was recertified by The Joint Commission in the summer of 2012, further reaffirming the quality outcomes Memorial has achieved in caring for its patients requiring stroke care.