2006 OPEN FORUM Abstracts
INCREASING PATIENT SAFETY THROUGH ROUTINE MONITORING OF PATIENT WARDS FOR UNIDENTIFIED PATIENTS RECEIVING SUPPLEMENTAL OXYGEN THERAPY
Denise Thompson, RRT, Tim
Frymyer, BS, RRT, David Mussetter, BA, RRT, Mike Trevino, MS, RRT, Gary
Weinstein, MD, FCCP, Presbyterian Hospital of Dallas, Dallas, Texas
Background: Our
hospital is a 903 bed acute care teaching facility in a major metropolitan
area. Our respiratory therapy department strives to meet quality, cost, and
service goals through continuous quality improvement projects. Patients'
receiving supplemental oxygen without our department's knowledge was identified
through one of these initiatives. Our facility has had an active oxygen titration
policy for 15 years which allows the respiratory therapist (RT) to evaluate a
patient and initiate, modify or discontinue oxygen therapy based on the policy
guidelines. The RT then documents and charges the patient for the delivered
oxygen through our data management system. Patients in our hospital receive
supplemental oxygen for an average of 54 hours per hospital stay. The medical
staff has come to rely heavily on the RT's assessment
and intervention in this area. As a result of this environment, sentinel events
or "near misses" could be created if patients are receiving oxygen without our
knowledge and assessment. JCAHO classifies poor communication and patient
assessment as two critical root causes for sentinel events. The nature of this
challenge certainly fits in these two categories. The purpose of this study was
to quantify the amount of patients receiving supplemental oxygen, who were
unknown to our department, through the use of room-to-room checks by our
respiratory staff. Additionally, we were curious as to how many oxygen
charges/work units were not being captured.
Method: Our
department initiated these room-to-room sweeps in an effort to locate patients
receiving oxygen without our knowledge. These were performed over a four month
period. When found, the RT would take appropriate action based on their assessment
of the patient's oxygenation status and clinical condition. The chart was then
reviewed to ascertain when the patient was first placed on oxygen. Each
incident was recorded and analyzed to determine why the respiratory therapy department
was not notified. Hospital staff was educated through the use of posted flyers,
mass electronic communication, safety alert notices and personal one-on-one
conversations. When appropriate, the patient was back charged for the length of
time they had been receiving oxygen as documented by the nurse in the medical
record.
Results: The
average number of patients discovered on oxygen per sweep was 8.6. Two common
root causes were identified: 1) patients transferring to the general care area
from the emergency department or post anesthesia care unit, and 2) the nursing
staff placing their patients on oxygen due to some cardiopulmonary status
change such as tachycardia, hypertension, simple arrhythmias, or dyspnea without a physician order. The remaining
concerns were varied and lacked the kind of frequency associated with these
primary root causes. Financially, lost charges were estimated, based on average
length of time our patients receive oxygen multiplied by an estimated hourly
charge. This amounts to roughly $6K in lost charges per sweep or if performed
twice a week about $600K per year. The impact this may have on full time
equivalents (FTEs) may vary widely from institution to institution. We found at
our facility a loss of slightly over a quarter of an FTE.
Conclusion: Quality
improvement is an excellent way to uncover potential hazards associated with
routine daily operations. Room-to-room checks are an easy way to monitor and
capture patients unknown to our department until a more reliable system is
developed. This increases patient safety and reinforces appropriate
communication among caregivers. Additionally, patient charges and work units will
be more reflective of reality.