The Science Journal of the American Association for Respiratory Care

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.

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