Seven Legal Tips For Safe Nursing Practice

DELIVERING CARE that conforms to the standards of practice for nursing protects both your patients and you. Legally, nurses are held accountable to deliver care in a manner that any prudent nurse would render in the same or similar circumstances.

Nursing standards of care are based on the latest scientific data from nursing literature. Federal and state laws, nurse practice acts, court decisions, organizations such as the American Nurses Association and The Joint Commission, nursing organizations that offer specialty certification, facility policies and procedures, and job descriptions also come into play. As nursing standards change to accommodate advancements in medicine, nursing, and the law, keeping up with them can be challenging.

To help you maintain a high standard of practice and protect against legal problems related to your nursing care, I'll spell out seven key principles you should follow when providing patient care. I'll also provide examples of how lapses in the standard of care can expose nurses to legal liability.

Follow the nursing process

The five steps of the nursing process are recognized as a universal approach to nursing practice. A failure on your part during any of these steps can lead to trouble:

* nursing assessment —collecting data regarding your patient's signs and symptoms

* nursing diagnosis —appropriately identifying the patient's problems

* planning —setting goals of care and desired outcomes and identifying appropriate nursing actions

* implementation —performing the nursing actions identified in planning

* evaluation —determining if the goals were met and the outcomes were achieved and appropriately revising the care plan based on the patient's response.

Most legal actions brought against nurses arise because a patient or a patient advocate claims that the nurse breached a standard of care and that the breach resulted in harm to the patient. Although your primary concern is patient safety, adhering to the seven key principles that follow will also help protect you legally.

1. Administer medications properly

Medication errors jeopardize patient safety and are all too frequent. They can also be costly: Besides harming patients, they can lead to expensive follow-up care, litigation, and monetary awards for damages.

Knowing the drugs you administer is a vital element in the nursing standard of practice for medication therapy. Before giving an ordered medication, you must understand its purpose and actions, the dosage appropriate for your patient's condition, the administration route, possible adverse reactions, and any contraindications.

As the last line of defense before an error reaches the patient, you must also remain vigilant for problems at other points in the medication administration process, including the ordering, dispensing, and labeling of medications. If you're unfamiliar with a medication, check a current drug reference or ask the pharmacy.

When administering a drug, make sure you follow the traditional “five rights” of medication administration:

* right patient

* right medication

* right dose

* right time

* right route (delivery method or site of administration).

A “wrong” in any of these basic steps could harm or even kill a patient. But medication safety experts say these five points are just the tip of the iceberg. Other potentially serious lapses implicated in medication errors include failure to check the medication administration record (MAR) against the order, use of banned abbreviations leading to administration of a wrong drug or dosage, mistaken interpretation of illegible penmanship, failure to obtain clarification as needed, and transcription errors.

Consider the many ways a patient could miss a medication dose or get an extra dose. For example, he may miss a dose if the order wasn't transcribed, if he or the medication wasn't available when the dose was due, if a medication order was overlooked, or if his dose was mistakenly given to another patient. On the other hand, he could receive a duplicate dose if one nurse fails to document that she gave a dose and another nurse administers a second dose. This is more likely at breaks or mealtimes, when a second nurse may temporarily assume the patient's care.

Hospitals can implement safety mechanisms such as independent double checks to help prevent errors associated with single-unit doses of high-alert medications, especially in pediatric patients. According to your facility's policy, an independent double check may call for one nurse drawing up the medication and another nurse independently determining that the medication, dose, and route are correct; both then sign the entry in the MAR or enter the details in the electronic medical record. The facility determines which medications require this extra precaution; common examples include the high-alert drugs intravenous (I.V.) heparin and insulin.

The following scenario details a medication error due to lapses in prescribing, dispensing, and administering the drug.

A physician writes an order for the antibiotic doxycycline as Vibramycin, 100 mg I.M. b.i.d. But parenteral Vibramycin can be administered by the I.V. route only, not intramuscularly (I.M.). The pharmacist who reviews the order catches the error and includes a package insert with the vial indicating that the medication must be administered I.V. However, the nurse either doesn't see or disregards the pharmacist's instruction and follows the written order. As a result, the patient gets the medication via the wrong route.

The physician writing the prescription triggered this error. The pharmacist should have contacted the physician to clarify the order and also should have advised the nurse that the drug is to be given I.V. The nurse, unfamiliar with the right route for Vibramycin, should have consulted a current drug reference. Instead, she administered the medication according to the incorrect order. 1

2. Monitor for and report deterioration

According to the nursing process, the recognized standard of care calls for continually assessing your patient. Once you've performed an initial assessment, made a nursing diagnosis, and initiated a care plan, you must continue to evaluate his condition and communicate the effectiveness of his treatment. Worsening signs and symptoms or a lack of response suggest that you need to modify the care plan.

Many legal actions brought against nurses center on an allegation of failure to monitor or recognize changes in a patient's condition. But your duty goes beyond careful monitoring and prompt documentation of any changes. Even if you've done these well, failing to recognize the significance of the changes or to communicate them clearly and promptly to the attending practitioner could endanger your patient and leave you open to liability.

In some lawsuits, nurses have been charged with failure to communicate or “failure to rescue” (not responding appropriately to the patient's deteriorating condition). The following example shows why.

A woman is admitted to the hospital with severe abdominal and lower back pain. Based on the results of diagnostic testing, her physician suspects left lower lobe pneumonia. He starts the patient on a broad-spectrum antibiotic and her condition improves. Then her pulse rate rises, and she begins experiencing distress, shortness of breath, and diffuse pain. Her nurse, however, doesn't advise the physician of the change in her condition. Two hours later, the patient goes into cardiac arrest and dies. 2

3. Communicate effectively

Besides informing a practitioner about your patient's current or changing condition, you need to clearly communicate with patients and colleagues at every point of patient care. Good communication skills are essential when:

* transferring your patient's care to another person

* speaking with and educating your patient

* interacting with the patient's family or other visitors.

Communication is a two-way street that requires good listening skills too. Listen carefully to family members, who may be the first to know that something is wrong with their child or other loved one.

A growing challenge for health care providers in the United States is that more and more patients and their family members have limited proficiency in English. Rely on a professional medical interpreter to translate your instructions or questions to your patient and his responses. Hospitals have a duty to provide these interpreters as necessary. If a competent medical language interpreter isn't provided, you could face charges of substandard nursing care. (See “Speaking Up for Medical Language Interpreters” in the December issue of Nursing2007 to learn more about this topic . )

The Joint Commission has set a standard for communication when one caregiver transfers patient care to another caregiver. According to The Joint Commission requirements, the nurse transferring care must give the nurse taking responsibility for the patient all appropriate information about his condition, how he's responded to treatment during the shift, any changes in his condition or treatment plan, and any other information that will help the next nurse plan for his care. The standard requires that communication during transfer of care be interactive so that both parties can ask questions and that interruptions be minimal. 3 (A handy way to remember what information to include when you talk with other caregivers at such times appears in Think “SBAR” when discussing care .)

The following scenario shows how poor communication can lead to legal trouble.

A neonate is receiving an infusion of calcium gluconate through an I.V. line in his right foot when the nurse notes discoloration and edema at the injection site. As the baby is being transferred to another unit, a transfer note indicates the time the infiltration was discovered and the fact that the nurse checked the area before the transfer; however, these details don't appear in the medical record. In the medical record are flow sheets on which some of the original writing is scratched out and written over.

When the baby's parents arrive and ask the staff about the injury, they're told it's a blister. With time, however, it leads to considerable scarring and loss of motion. The parents sue the nurse who cared for the baby when the infiltration occurred. 4

Think “SBAR” when discussing care

To ensure effective, comprehensive communication when you report on your patient's condition or transfer care, remember the abbreviation SBAR :

S is for situation. (Identify the patient and why he was admitted.)

B is for background. (Provide a brief and significant medical history, including any tests or treatments completed.)

A is for assessment. (Describe the patient's current condition.)

R is for recommendation. (Discuss the plan of care for the patient.)

If you're receiving a new patient, be sure to get all this information from the prior caregiver.

You can learn more and download copies of two SBAR tools at the Institute for Healthcare Improvement Web site, http://www.ihi.org .

4. Delegate responsibly

In general, today's hospitalized patients are more acutely ill than those of the past. Because experienced nurses are in short supply, nursing teams that include unlicensed assistive personnel (UAPs) are making a comeback. As an RN, you must know who has the appropriate skills and competencies to meet a patient's needs when assigning a portion of her care to someone else. When you establish a work assignment, you're still responsible for the patient's care, and you must delegate appropriately and supervise the person carrying out the assignment.

To delegate safely, you must first know what your state board of nursing allows you to assign to others. Some states don't specify which duties may be delegated, but others may spell out tasks you may delegate, such as hygiene care or insertion of an indwelling urinary catheter. The “five rights” for delegating to another caregiver provide an easy-to-remember guide: right person, right task, right circumstances, right direction, and right supervision.

The right person refers to both the nurse who's delegating and those who'll perform the task. To direct and supervise appropriately, you must be a licensed nurse and you must understand the qualifications and competencies of your staff.

The right task is one that may be safely delegated for a specific patient. Typically, safe tasks are those that recur frequently in the patient's care; involve an unchanging, standard procedure; and have minimal risk and predictable results. Don't delegate complex tasks that require nursing assessment or nursing judgment.

To determine the right circumstances , consider all relevant factors, including appropriateness of the patient setting and available resources. Even tasks that fit the criteria for “right task” may not be appropriate if circumstances such as the patient's condition don't allow for delegating them. For example, assigning a UAP to help ambulate a patient who's at high risk for falls may not be appropriate.

Giving the right direction means providing a clear, concise description of the task you're delegating, including objective limits and expectations. Here's an example: “When you take Mr. Brown's blood pressure, the acceptable range is between 120/80 and 140/80. If you get a reading outside this range, please report your findings directly to me as soon as you get the reading.”

Providing the right supervision calls for knowing the qualifications and competencies of your staff, knowing the results of the delegated task, and evaluating performance. At times, you may need to intervene in the care being given. As the supervising nurse, you remain responsible for the patient and need to evaluate her condition and response to the tasks performed.

Here's an example of inappropriate delegation posing a great risk to the patient:

A charge nurse asks a UAP to use a meter to determine a patient's blood glucose level. The UAP goes to the patient's room and apparently does as asked. At the change of shift, the charge nurse asks the UAP for the test results. The UAP reports that when she did the test, “EEEEE” appeared on the meter screen. Asked if she repeated the test, the UAP replies that she hasn't but that she did document the reading in the patient's chart. A repeat test indicates that the patient's blood glucose reading is over 800 mg/dL, and she's transferred to the intensive care unit for treatment.

Violations in the “five rights” of delegation are evident in this scenario. The UAP apparently didn't have proper education to use the blood glucose meter and wasn't the right person to perform the task under the circumstances. Was the patient's blood glucose level stable before the nurse assigned the task? Proper direction and supervision were lacking too. The charge nurse should have specified a range for the patient's blood glucose reading and told the UAP to immediately report the findings to the charge nurse if they weren't within that range. Waiting until the end of the shift to ask for the results was another serious error in judgment.

5. Document in an accurate, timely manner

Accurate, timely documentation in your patient's medical record is crucial for these reasons:

* The medical record is a legal document required by state laws and regulations.

* It's a means of communication between caregivers that ensures continuity of care.

* It's used for education and research.

* It's used to substantiate insurance reimbursement claims.

* It can be used as evidence in legal proceedings to establish whether or not the care rendered met the legal standard of care.

A basic rule of safe documentation is to know and follow your facility's documentation policies and procedures. Institutional policies typically detail the forms of documentation to use, how to make a late entry, and how to correct an error in an entry. Failure to follow facility policy can result in inconsistencies; in turn, these may compromise patient safety and create legal problems if the record ends up in court. Regardless of how professional a nurse appears on the witness stand, careless documentation can make a profoundly negative impression on a jury.

The following situation demonstrates the dangers of careless documentation.

A man injures his left leg falling off the back of a truck. A cast is applied to his leg in the emergency department, and he's admitted to the hospital for his injuries. The next day, he begins to develop numbness in his left foot. The physician examines the patient and notes in the medical record that his “toes are cool and getting more numb,” so he removes the top part of the leg cast.

The next day, the patient complains of severe pain in his left foot and the nurse alerts another physician of the change. Examining the patient and noting that he has compartment syndrome, the second physician performs a fasciotomy, but the patient's circulatory problems continue and his left leg has to be amputated.

A malpractice suit is brought against the physicians, hospital, and nursing staff. Because hourly circulation checks weren't documented in the patient's medical record, one of the decisions the court has to make is whether nursing negligence was partially responsible for the loss of his leg. 5

6. Know and follow facility policies and procedures

Institutional policies and procedures help establish the nursing standards of care you'd be held to in court. Patient-care policies and procedures must be based on current and recognized practice. They must be updated regularly, and they should be realistic.

Any deviation from a policy or procedure that harms the patient can subject you and the facility to liability exposure, so some flexibility is necessary. For example, rather than stating that patients' vital signs must be taken every 4 hours, a policy stating “within 4 hours” or “every 4 hours plus or minus 30 minutes” allows some leeway.

The nurse in the following scenario is sued after failing to follow hospital policy and procedure.

A nurse in an acute care hospital applies wrist restraints to a patient before briefly leaving his room. When she returns, the patient is next to the bed, hanging by his arms from the restraints. He subsequently develops pain in his right wrist and has X-rays, which show a fracture.

The patient sues the nurse, claiming that the restraints caused his injury. Court testimony shows that applying wrist restraints to the patient was inconsistent with hospital policy, but the patient can't prove that the restraints caused his injury. 6

7. Use equipment properly

As a nurse, you have a duty to make sure you've received adequate training on the equipment you use to provide patient care. You must understand the equipment's intended use, know how to operate it properly, and follow policies and procedures for using it if they exist. Never try guessing how to use equipment.

The following scenario demonstrates how a patient is harmed when medical equipment is misused.

A patient is undergoing hysteroscopy. The equipment is missing a clip, and the nurses improperly connect an exhaust line that's hanging loose to an outflow port. The patient dies, and the family sues the hospital.

Evidence submitted at trial indicates that when the equipment used for the procedure left the manufacturer, it was properly set up. It also shows that two of the nurses assigned to the patient's case had no training on the use of the equipment and that their lack of training may have resulted in improper unclipping of the tube. 7

Standards put into practice

By adhering to the seven principles of nursing care spelled out here, you help protect your patients, meet the standard of nursing care in your daily practice, and avoid legal problems.

Source nursingmedia.com

The Quest for Best Practice in Caring for the Home Care Patient With an Indwelling Urinary Catheter: The New Jersey Experience (Part II)

Findings From the Project

In reviewing the data gathered over 18 months, it was discovered that the newly adopted best practices in the management of indwelling urinary catheters was again in need of remediation. Many urine cultures continue to be obtained without sound reason, based merely on a change in the urine character only. At chart review, an elevated temperature was rarely noted, or more than 1 symptom identified, to support the urine culture. This occurred in 65% of the cases in 2006 in 1 agency when the number of UTIs was investigated further. Of course, the culture showed an elevated organism count. It has been documented by Haus (1998) , as well as Cravens and Zweig (2000) , that long-term catheter users are always colonized with bacteria, and that treatment should be instituted only if symptoms are present. Re-education was clearly indicated.

Equally upsetting was that 46% of the cases in 2006 involved patients who were prescribed antibiotics in the absence of a urine culture and in the presence of only 1 symptom. Ultimately, this practice can result in inappropriate antibiotic therapy, consequently contributing to the widespread antimicrobial resistance currently reported nationwide.

The Infection Control Committee of the Quality Network, after review of the data, has recently been challenged regarding the practice of changing the catheter before obtaining a urine specimen for culture and sensitivity. Although there is no empirical evidence to support this practice, Haus (1998) suggests that there is a benefit to changing the catheter before obtaining a specimen in that this practice is more likely to produce a urine specimen not contaminated with excess colonization. This may be an area for further research designed to determine whether changing the Foley before specimen collection does indeed result in the collection of a noncontaminated urine specimen and a more accurate laboratory result. The UTI Benchmarking Project is exploring the possibility of a research component to our specimen collection process by collecting a specimen from the indwelling catheter before removal, then another specimen after Foley reinsertion to assess colonization of the specimen. The intent is to use this evidence to support or not support the recommendation that the Foley be changed before the specimen is taken to avoid contamination of the urine specimen.

Dissemination and Education

To effect a change in this area, re-education should focus on several issues. The Infection Control Committee recommends that a culture be taken only if at least 2 of the established symptoms are present. The importance of temperature taking should be reiterated. Additionally, it should again be stressed that according to the Project criteria, a urine specimen must be obtained from a new catheterization pending evidence to the contrary. In 1 agency that has an average of 3,000 catheter days per month and an average of 110 patients with indwelling urinary catheters monthly, which currently is 8% to 10% of the agency's total patient population, implementation of these best practices has resulted in a UTI rate of less than 1.75% per month. In this same agency, 95% of urine cultures were obtained with a new catheterization, leaving some room for improvement.

It is anticipated that the biggest challenge will be breaking old habits. Staff as well as patients and caregivers have been conditioned to obtain a culture whenever there is a change in the character of the urine. This ideation must be changed if progress is to occur in the fight to decrease inappropriate use of antibiotics and to prevent antimicrobial resistance. Both physician practice and caregiver education are needed to break through these barriers. Often, caregivers persuade physicians to put patients on antibiotics without cultures being taken, not realizing the impact of inappropriate antibiotic treatment.

Currently, with a full year of data collected, standardization of home health practice is being realized. This initiative also has resulted in other serendipitous discoveries, such as the number of colonized patients prescribed antibiotics and the number of patients started on antibiotics with no justification

Lessons Learned

The following were lessons learned:

• Information sharing among state agencies has been very helpful in developing a program needed to demonstrate evidence-based nursing practice for the home care patient.
• Breaking old habits is difficult but possible with evidence to support the change in practice.
• Stopping the inappropriate use of antibiotics for UTIs continues to require attention and research for support.
• The use of a standard definition for UTI has afforded the agencies consistency in collecting the same data, which is useful for benchmarking results.
• Participation in the Antimicrobial Resistance/UTI Collaborative brings about sharing of information across all healthcare lines and hopefully results in consistency in practice.

Next Steps

As a result of the UTI Benchmarking Project, the Association was invited in August of 2006 to join the New Jersey Hospital Association's Antimicrobial Resistance/UTI Collaborative (AR/UTI). This Collaborative was made possible by a grant with the New Jersey Department of Health and Senior Services to assist acute and long-term care facilities as well as home healthcare agencies in reducing UTIs among patients with indwelling catheters, across the continuum, in reducing the use of antibiotics, and in effecting a change in the antimicrobial resistance. Two members of the Association's UTI Benchmarking Project joined the AR/UTI Collaborative Advisory Panel.

On the basis of evidence presented through this Project, the AR/UTI Collaborative adopted the same definition of UTI as the UTI Benchmarking Project, creating an opportunity for standardization of results among all the home health agencies within the Collaborative. The experts sponsored through the Collaborative have reinforced the lack of evidence-based research in the home care arena.

The Association's Benchmarking UTI Project currently is continuing data collection for another year. In addition, it currently is collecting the prevalence data of Foley catheter use in the home care setting with participating agencies because there are few data identifying just how much Foley catheter use is seen in home care. It continues to be a “work in progress.”

Conclusion

The use of a standard definition for UTI in home care is critical to the provision of a reliable rationale for the appropriate use of antibiotics in the treatment of UTIs. Consistency in practice and care of indwelling catheters is needed to foster best practice in the care of the home care patient.

The Association hopes that by participating in evidence-based nursing research it can create better care practices, resulting in better patient outcomes and improved clinical practice.

The UTI Benchmarking Project is a “work in progress.” Through collaboration, nurses in our member agencies have the satisfaction of knowing they have begun data collection and research that have the potential to change and improve care to patients and reduce unnecessary antibiotic therapy use, thus decreasing antimicrobial resistance.

Project Description and Criteria Sent to Each Agency in Advance of Participation: UTI Benchmarking Project

An estimated 4 million patients are subjected yearly to urinary catheterization and thus are at risk for catheter-associated infection and its related sequelae. One of the most important infection control measures is to limit the use of urinary catheters to carefully selected patients, thereby reducing the size of the population at risk. Generally, urinary catheterization is indicated to relieve urinary tract obstruction, to permit urinary drainage in patients with neurogenic bladder dysfunction and urinary retention, to aid in urologic surgery or other surgery on contiguous structures, and to obtain accurate measurements of urinary output in critically ill patients. Specifically, urinary catheterization should be discouraged as a means of obtaining urine for culture or certain diagnostic tests such as urinary electrolytes when the patient can voluntarily void or as a substitute for nursing care of the incontinent patient ( Wong & Hooton, 1983 ).

For home care patients and agencies, determination of the UTI rate for the agency is important not only for adverse event OBQM data collection, but also to ensure that patient outcomes and best practices are instituted and followed.

The UTI Benchmarking Project collects data on UTIs in home care and collates the information for benchmarking purposes. The agencies participating agree to collect and report the information according to the following criteria:

I. Define catheter infection using draft guidelines from APIC (see later)

Urinary Tract Infection

Only symptomatic urinary tract infection is defined. Symptomatic urinary tract infection, in either catheterized or noncatheterized patients, must meet 1 of the following criteria:

A. Exhibit at least 3 of the following 4 signs or symptoms:

1. Fever (>100.4ºF) OR chills

2. Flank pain OR suprapubic pain OR tenderness OR frequency OR urgency

3. Worsening of mental status/functional status

4. Changes in urine character (e.g., new bloody urine, foul odor, increased sediment) AND urinalysis or culture not performed

B. At least 2 of the 4 preceding signs or symptoms AND at least 1 of the following:

1. Urinalysis with pyuria (urine specimen with >=10 WBC/mm ³ or >=3 WBC/high-power field of unspun urine) AND positive nitrite and/or positive leukocyte esterase

2. Presence of organisms by culture >=10 ⁵ cfu/mL of urine AND no more than 2 different uropathogens

NOTE: For urine specimens to be of value in determining whether an infection exists, they must be obtained aseptically using an appropriate technique such as clean catch collection, bladder catheterization, or suprapubic aspiration ( Chinnes, Dillon, & Fauerbach, 2002 , pp. 24–25).

II. Select population for data collection

All patients 18 years and older with an indwelling catheter (either Foley or suprapubic) who experience an infection within 72 hours of admission to the agency are eligible for the UTI Benchmarking Project.

NOTE: If patients do not meet the criteria established by the Project, then they are not counted as having a UTI. Exception: A patient with signs and symptoms of a UTI who was hospitalized and subsequently discharged from the hospital with a diagnosis of UTI is counted.

III. If the patient is symptomatic, take a culture after the catheter is changed (include it as part of the patient's standing orders)

IV. Use the following measurement criteria for the infection rate

Number of UTIs divided by the number of patient days with an indwelling catheter multiplied by 1,000. The UTI rate will be calculated up to 2 places after the decimal point (i.e., 1.27).

Suggested information for the surveillance tool:

[black small square] Demographic data (name, episode, diagnosis, start-of-care date, primary nurse)

[black small square] Date of first symptoms

[black small square] Criteria met for UTI: List them here

[black small square] Foley catheter

[black small square] Suprapubic catheter

[black small square] No. of days with catheter during this review period

[black small square] Factors associated with infection

[black small square] MD notified promptly

[black small square] Antibiotic used

[black small square] Culture results

The Quest for Best Practice in Caring for the Home Care Patient With an Indwelling Urinary Catheter: The New Jersey Experience

Josephine Sienkiewicz RN, MSN Ginny Wilkinson RN, MSN Kathleen D. Emr RN, MSN, CNAA, BC Taken from NursingCenter Home Healthcare Nurse - Featured Journal February 2008 Volume 26 Number 2 Pages 121 - 12

Acknowledgment The authors recognize the mentorship of Linda Flynn, PhD, RN, BC, Assistant Professor and Director of Research, New Jersey Collaborating Center for Nursing, Rutgers College of Nursing for her advice and assistance in the preparation of this manuscript. The authors also recognize the contributions to the UTI Benchmarking Project through the data collection efforts of the home health agency members of the Infection Control-Quality Network Committee of the Home Care Association of New Jersey. Without their commitment and support, the Project could not have been completed.Abstract

This article describes the development of a urinary tract infection (UTI) benchmarking project by the Home Care Association of New Jersey for New Jersey's home care agencies. In the quest for best practice in caring for the home care client with an indwelling urinary catheter, identification of an acceptable UTI rate for indwelling catheter patients was needed to use as a benchmark for care practices.

A literature search showed a paucity of evidence. Therefore, the Association agreed to lead a project aimed at identifying what was currently happening in home care settings as a beginning benchmark.

Foley Catheter Use in Home Care

Patients at home may have indwelling catheters necessary for diagnoses such as urinary retention, but they also may have a catheter placed for incontinence. Although the literature recommends bladder training for incontinent patients ( Sterling-Fischer & Naryan, 2004 ), this is often unrealistic for the elderly, especially when they are unable to ambulate. Many times, no reliable or able caregiver is available to assist the patient with transfers to the toilet or commode, which puts the incontinent person at risk for skin breakdown.

Although not ideal, nor recommended, some patients and families, with physician approval, have made a decision to have an indwelling urinary catheter placed to manage the patient's care. Although this may not be the “best practice,” for the elderly homebound patient, it frequently is the approach decided.

Medicare-certified home health agencies as well as agencies that serve clients with long-term care needs at home frequently have patients with long-term Foley catheter placement. Under Medicare regulations, a Foley catheter is seen as reasonable and necessary for continued provision of skilled home health nursing service. Reimbursement is provided for skilled assessment and change of the Foley catheter together with other related needs such as the home health aide who provides personal care, assistance with activities of daily living, and minimal light housekeeping related to the patients needs.

Some of the problems with managing patients who have long-term indwelling catheters are the risk of UTIs and overprescription of antibiotics.

The Role of the State's Home Care Association

In 2004, the Home Care Association of New Jersey, the State's nonprofit trade association representing the full spectrum of home care in New Jersey, created a statewide quality improvement network to enrich the overall quality of home healthcare and to enhance infection control in the home. For this purpose, the Association initiated a Quality Network Committee as a subcommittee of the Professional Practice Committee. The intent of this committee was to identify issues pervasive in the state specific to home care and to foster networking among members to improve care. The Infection Control Committee was born of this initiative and has grown to become an active subcommittee of the Association's Professional Practice-Quality Network Committee.

Some members of the Infection Control Committee also are active members in the North/South Jersey chapters of the Association of Professionals in Infection Control and Epidemiology (APIC). These dual members discuss relevant home care infection control practices at Association meetings and bring to APIC any pertinent issues or findings for action, comments, or discussion.

The Role of the Infection Control Committee

One initial charge of the newly created Infection Control Committee was to look at UTIs among the home care population with indwelling urinary catheters and to develop guidelines for best practice to share with the Association's member agencies. Two members of the Infection Control subcommittee identified the lack of available literature in the area of UTIs in the home care population and issues within their own agency that were not consistent with some known best practices. This agency examined its current practices and compared them with the evidence-based practices recommended in the available, albeit limited, literature regarding care of indwelling urinary catheters of home care patients. This comparison showed that what had been done to manage indwelling urinary catheters at home was not evidence based.

A catheter management program was initiated on the basis of the findings. The staff was re-educated, and some improvements were realized. This initiative was chronicled in the article “Best Practice for Indwelling Catheter in the Home Setting” ( Emr & Ryan, 2004 ).

These best practices were presented to the Infection Control Committee of the Quality Network. Immediate interest was generated because most agencies had no set definition for UTIs, nor any identifiable benchmarks for UTI assessment. Moreover, there was concern that many patients were being treated for UTIs unnecessarily ( Cravens & Zweig, 2000 ; Haus, 1998 ). The Committee was now challenged to collect data for benchmarking across the state based on best practice guidelines identified and shared with the Committee.

UTI Benchmarking Project Development

The Infection Control Committee began its journey by defining a UTI. The group decided to use the APIC UTI draft definitions ( Chinnes et al., 2002 ). Next came selection of the population. The criteria specified all patients 18 years of age and older with an indwelling catheter, either Foley or suprapubic, who experienced symptoms 72 hours after admission to the agency.

The calculation of a UTI rate was standardized by dividing the number of UTIs by the number of days the patients had an indwelling urinary catheter and multiplying by 1,000. The rate is calculated on a quarterly

Agency Readiness

Initially, 6 Association member home health agencies agreed to participate in the data collection. To maintain anonymity, the rates would be submitted to the Association's Director of Education and Clinical Practice for comparison. Data were shared with the Association by each agency, and then collated by the Association. In subsequent Quality Network meetings, the data were presented via charts from which all agency identifiable data were removed to retain anonymity and eliminate any concerns regarding competitive comparisons. As word of this Project began to spread, further interest was generated, and the 6 original agencies grew within 1 year to 16 agencies submitting data for comparison.

Initially, the Project began with a trial period for the pilot of the Project so that members of the group could get comfortable with following the APIC UTI criteria and calculating rates. A Project description was developed and sent to each interested home health agency (see “Project Description and Criteria Sent to Each Agency…” sidebar). The group convened on a quarterly basis to discuss the Project, review the data, and refine identified issues. At completion of the pilot program, full implementation of the Project was achieved in January of 2005.

Assessment of Need

Officials from the New Jersey Department of Health and Senior Services (NJDHSS) as well as infection control practitioners in the state have chosen “to control the emergence and spread of antimicrobial resistant organisms in New Jersey through partnership, strategic planning, and education” ( NJ CAUSE Task Force, 2005 ). Consequently, in August 2006, the NJDHSS and the New Jersey Hospital Association joined to form a Collaborative to address the issue of antimicrobial resistance in the state. A focus on catheter-related UTIs was identified as a priority, and grant funds were sought to begin the Project. The Association subsequently was asked to join in this effort to support the mission of the Collaborative and to encourage home health agency participation. In the Collaborative's letter of August 28, 2006, signed by Gary Carter, CEO of the New Jersey Hospital Association, and Fred Jacobs, MD, JD, Commissioner of NJDHSS, the Collaborative reports that

Antimicrobial resistance has been increasingly recognized as a global public health threat, to the extent that some believe we are heading into a postantibiotic era in which the drugs that are now effective at curing commonly encountered infections will be useless. As a sign of this bleak future, consider that the number of bacteria resistant to multiple antibiotics has increased dramatically in recent years. In fact, some bacteria are resistant to many antimicrobials currently on the market. Antimicrobial use, especially inappropriate use, is believed to be a major contributor of antimicrobial resistance.

In response, the NJDHSS has formed a task force known as NJ CAUSE ( New Jersey Careful Antibiotic Use Strategies and Education, 2005 ), whose mission is to control the emergence and spread of antimicrobial-resistant organisms through partnership, strategic planning and education. The goal of this new statewide Collaborative is to build working relationships between hospitals, long-term care facilities, and home health agencies to achieve an improvement in infection control and foster judicious antimicrobial use. Participants will focus their efforts on facilitating the implementation of best practices for reducing the use of indwelling urinary catheters, reducing UTIs, and managing bacteriuria and curbing the use of antibiotics.

Urinary tract infections in patients/residents/clients with indwelling catheters are associated with medical, social, and economic burdens. In addition, healthcare providers often administer antibiotics inappropriately to patients with indwelling catheters. The Campaign to Prevent Antimicrobial Resistance in Healthcare Settings, a Center for Disease Control and Prevention Initiative identifies catheter removal as a key step in preventing antimicrobial resistance. The Association for Professionals in Infection Control and Epidemiology and the Centers for Medicare and Medicaid Services (CMS) have focused on issues related to urinary catheters. In addition to improving the practice of urinary catheter use and monitoring in healthcare organizations, the Collaborative seeks to improve physician prescribing patterns with respect to antibiotic treatment of UTIs associated with indwelling catheters.
(To be continued......)

---

Home Care Today: Preventing Rehospitalization Through Effective Home Health Nursing Care (Part ll)

Mr. Smith's diagnosis is heart failure and diabetes, 2 priority conditions that have available evidence-based practices for nurses to follow in all healthcare settings ( Peterson, 2006 ). Mary Ann's agency, ABC Home Care, has developed disease management programs for each of Mr. Smith's disease processes.

Patient/Caregiver Education

Patient and caregiver education is essential to the improvement of outcomes. Mary Ann explains its importance and teaches Mr. Smith and his wife how to monitor his blood sugars, blood pressure, and daily weights, showing them how to log the results each day in a notebook. Mr. Smith has staples to his chest and leg incisions from his coronary bypass surgery. Mary Ann teaches signs and symptoms of infection and how to prevent an infection. She ensures that Mr. Smith keeps his follow-up appointment with his cardiac surgeon, who removes his staples. She also instructs Mr. Smith and his wife about possible abnormal findings and when to call nursing.

Patients who have received a bypass are at risk and need help in managing their disease and its care ( Lord, 2006 ). According to Hollenbeak et al., (2000) , the risk of chest and donor-site infections for patients who receive a bypass range from 0.84% to 17.7%, and approximately 470,000 coronary artery bypass surgeries are performed annually. Patients and their caregivers must be taught what to look for, and the nurse must inspect all incisions for the first few weeks after surgery so nothing is missed. Table 1 describes a possible teaching tool to provide for patients such as Mr. Smith.

---

It is important to note that proper handwashing is vital in the care for any type of wound. Mary Ann stresses the importance of washing hands before and after caring for Mr. Smith's incisions. She also emphasizes that an elevation in Mr. Smith's temperature, pulse, blood pressure, weight, or blood sugars may be an indication of an infection and must be reported to her immediately. Mr. Smith is instructed to cover dressings with plastic before bathing to prevent them from getting wet and to redress them if they do get wet.

Telehealth

Telehealth is used by 8% of the top home health agencies, according to the study performed by Briggs Corporation (2006) . Briggs Corporation (2006) defines telehealth as strategy using devices that transmit video images or patient data to the agency from the patient's home as part of the plan of care in an effort to improve outcomes and potentially reduce unplanned hospitalizations. Mary Ann's agency does not have the telehealth equipment, but she does help Mr. Smith to obtain a glucometer, a digital blood pressure monitor, and a scale. She calls Mr. Smith several times each week and asks him whether he is taking his medications, what his weight, blood sugar, and blood pressure readings were, and documents results in the medical record. When results are above his normal levels, Mary Ann places a call to his physician and obtains orders to bring these results back to normal levels. These are just a few of the questions she asks him.

This ongoing monitoring is essential, especially for heart failure, because there are approximately 5 million Americans suffering from this disease, and an average of 500,000 new cases are diagnosed each year. Heart failure is one of the most common diagnoses requiring hospitalization for geriatric patients. This diagnosis accounts for 875,000 hospitalizations ( Giacini & Lehmann, 2004 ).

---

Common Pitfalls

Daily and Newfield (2005) discuss common pitfalls leading to home care risk. Some of these pitfalls are

* unsafe admissions;

* rushed or incomplete assessment;

* incomplete or missing documentation;

* rushed procedures or failure to follow steps laid out in standards.

Unsafe Admissions

It is imperative that home health nurses know how to identify a safe and unsafe admission. A patient who lives alone and cannot ambulate or perform activities of daily living such as meal preparation, bathing, dressing, and the like may be an unsafe admission. The nurse must then decide how to ensure that this patient is safe. An important resource with which nurses should be familiar is Adult Protective Services (APS), which “investigates reports of abuse, neglect, and exploitation of elderly people and people with disabilities … provides or arranges for protective services, including referral to other programs, respite care, guardianship, transportation, counseling, and emergency assistance care with food, shelter, and medical care” ( Texas Department of Family and Protective Services, 2006 ).

Rushed or Incomplete Assessment

When the assessment is rushed or incomplete, the nurse has more room for error, and important findings may be missed. An example of an incomplete assessment would be forgetting to assess Mr. Smith's incisions. There may be dehiscence of the incision or an infection, which can cause a costly unplanned hospitalization. The home health nurse is the chief component in the monitoring of complications and the communication of findings to physicians. Early interventions can be initiated, and a hospital admission may be avoided.

Incomplete or Missing Documentation

Another important issue that may lead to home care risk is incomplete or missing documentation. It is vital to document all findings and interventions. For example, in documenting calls to physicians, it is important to document the date and time of the call and the name of the person taking the message. Follow-up evaluation also is very important. There are many instances in which the physician had a full caseload and did not get the message on time or, for whatever reason, was unable to return the call. Follow-up interventions also should be well documented.

Rushed Procedures or Failure to Follow Steps Laid Out in Standards

Rushed procedures or failure to follow steps laid out in standards also can lead to risk. Croke (2003) has listed failure to follow standards of care as one of the major categories of negligence resulting in a lawsuit. It is crucial that home health agencies provide updates to staff on new evidence-based practices. Daily & Newfield (2005 , p. 96) plainly state that “education and expertise regarding appropriate documentation, screening for complex case management for high-risk cases, and patient advocacy are keys to success in reducing litigation risk and improving outcomes.”

Mr. Smith's Outcome

Mr. Smith and his wife Betty were very involved in his care. Both were cooperative and learned important ways to keep him healthy. He kept in touch with his nurse, Mary Ann, throughout his course of care. Mr. Smith maintained a log of his temperatures, blood pressures, blood sugars, and daily weights, taking them with him when he visited his physicians. He kept an updated medication list to show each of his physicians as well. Mr. Smith has regained the strength and endurance he had before his surgery. Mary Ann was able to care for Mr. Smith with the resources she had and to meet his outcomes in a cost-effective manner.

Conclusion

While it must be acknowledged that many patients may need to be hospitalized, it is a universally accepted fact that with the proper interventions, many others could have avoided hospitalizations. It is a reality that has significant implications for patients and their families. It is a reality that causes great stress and frustration to home care agencies and their staff. ( Briggs Corporation, 2006 , p. 1)

Nursing is “based on a systematic body of theory and abstract knowledge”( Ellis & Hartley, 2004 , p. 156). Nursing students spend many years learning the basics of nursing either at a community college or at a university. It is not until after graduation and after accepting a nursing position that the knowledge embedded into a nurse's brain is put to a test. Something new is learned every day from patients or nursing colleagues or even from the community.

It has been difficult to come up with ways to care for patients under PPS. Just when care finally is becoming more manageable, another new cost control measure is in its early stages of development to be implemented by CMS in the near future ( CMS, 2006 ). This new cost measure is called pay-for-performance, whereby the agencies with better outcomes will receive more reimbursement. This will definitely add to the impact of home healthcare for patients.

The nurse drives the plan of care. Mr. Smith's case scenario is an ideal case, with outcomes every home health agency would like to achieve. It is important to keep abreast of the many changes in healthcare. Keeping patients out of the hospital is a major focus in home health and will continue to be for years to come.

Taken From Nursingcenter

Home Care Today: Preventing Rehospitalization Through Effective Home Health Nursing Care

Home Care Today: Preventing Rehospitalization Through Effective Home Health Nursing Care

Monica S. Vasquez RN, BSBA, COS-C

Home Healthcare Nurse - Featured Journal
February 2008
Volume 26 Number 2
Pages 75 - 81

Of the 10 outcomes listed in Home Health Compare, acute hospitalization has been the main focus of many home health agencies. After the Medicare change in payment for services, the prospective payment system, improving outcomes has been a difficult journey for most home health agencies, but many have been able to accomplish this great task.

The Centers for Medicare and Medicaid Services (CMS) have made drastic changes in reimbursement for home health agencies in an effort to decrease the cost of care for patients. Because of these changes, to make a profit, agencies are limited to only a few visits to provide care for each patient. More than 2.4 million elderly and disabled people are Medicare beneficiaries, receiving care from the more than 8,100 Medicare-certified home health agencies throughout the United States ( CMS, 2006 ). Home health agencies must devise new ways to provide quality care with limited funding.

On October 1, 2000, the home health prospective payment system (PPS) was implemented ( Outcome Concept Systems, Inc. [OCS], 2004 ). Under PPS, home health agencies receive a single payment for a 60-day episode of care for a Medicare beneficiary. A standardized assessment tool called the Outcome and Assessment Information Set (OASIS) was developed to calculate a base payment and to evaluate the quality of care provided by Medicare-certified agencies ( OCS, 2004 ).

In the future, CMS will be changing home healthcare reimbursement from PPS to pay for performance. According to CMS (2006) , pay for performance “will link to actual activities and efforts of providers using evidence-based practices and systems (in the form of structural measures that will be collected at agency level) to promote use of such practices.” This means that all home health agencies must strive to show an improvement in outcomes to receive a higher reimbursement rate for their efforts. It is critical for a home health agency to monitor its own outcomes and devise ways to improve each outcome.

Acute Hospitalization After Home Health Admission

The growing population of patients discharged to home health is chronically ill and elderly with complex clinical needs ( Daily & Newfield, 2005 ). In 2003, 42% of seniors 65 to 79 years were admitted to the hospital via the emergency room and 52% of those 80

years of age or older ( Giacini & Lehmann, 2004 ). This is one of the reasons why CMS has selected the acute hospitalization measure for national focus and will be identifying a target-attainable rate and goals for a reduction in hospitalization rates ( Home Health QIOSC, 2005 ).

Between April 2003 and March 2004, the national episode rate for acute hospitalization after home health admission was 28.13% of all episodes, and the average agency rate was 30.80%. Among all home health agencies, 25% had rates lower than 23.16%. The average rate for the 25% of agencies with the best rates was 17.35%, and the average rate for the 25% of agencies with the highest rates was 47.38% ( Home Health QIOSC, 2005 ).

Findings show that one fourth of all hospitalizations of home health patients occur within 7 days after admission to a home health agency, and that 58% occur within 3 weeks after admission ( Home Health QIOSC, 2005 ). According to a study sponsored by Briggs Corporation and cosponsored by the National Association for Home Care and Hospice and Fazzi Associates, Inc., the “unplanned or preventable hospitalization was 28% when CMS first began reporting this measure on 11/03/03. It is 28% today, which means that every year, more than 1 million patient episodes result in unplanned hospitalization” ( Briggs Corporation, 2006 , p. 1).

Case Scenario

Mr. William Smith is a 68-year-old man discharged from the hospital with a diagnosis of heart failure, non–insulin-dependent diabetes mellitus, hypertension, and high cholesterol. He had been hospitalized for complaints of chest pain and after many tests received a diagnosis of myocardial infarction with 4 coronary arteries affected.

Mr. Smith underwent quadruple coronary artery bypass and was discharged after 7 days. Before this hospitalization, he independently performed all activities of daily living, and he and his wife Betty Smith were planning a vacation. This hospitalization set him back in his plans, and he fears things will not be the way they were before it occurred. He is referred to ABC Home Care to be followed at home. Mr. Smith is not familiar with home health and is a little anxious about his situation. Mary Ann Jones is his home health nurse and case manager.

Nursing Interventions

What is the best way for Mary Ann to care for Mr. Smith? Few clinical practice guidelines have been developed specifically for home health. Of 1,026 guidelines summarized in the National Guideline Clearinghouse™ (2003) , only 35 (3.4%) mention “home care” ( Peterson, 2006 ).

Nurses working in the home health setting must devise creative ways to care for their patients. In the home, the nurses do not have all the supplies and equipment found in a hospital setting. According to Daily and Newfield (2005) , home care nurses not only need to understand current laws and practice standards, but also must develop and use successful strategies to manage risks. Daily and Newfield (2005 , p. 94) also state that “home health nurses are uniquely prepared to promote improved care outcomes, thereby reducing costly legal exposure, preventable rehospitalization, and emergency use; other adverse events; and premature or preventable long-term care institutionalization.”

According to Medicare standards, and those of CMS, a registered nurse shall make the initial patient assessment and continue to reevaluate patient needs throughout the course of care ( Fairnot & Hogue, 2006 ). The home health nurse must look at the patient as a whole. According to Fairnot and Hogue (2006) , the assessment of an elderly person, in particular, should cover a broad range of conditions including medical, mental, nutritional, and functional conditions, as well as home safety. The nurse must examine the patient's environment to determine whether the home is appropriate for home health.

What the Top Agencies Are Doing to Improve Outcomes

Many strategies are used by top home health agencies. These strategies are described in the following discussion. According to Briggs Corporation (2006) , some of the strategies performed by home health agencies are as follows:

* Front-loading visits

* 24-Hour availability/response programs

* Medication management

* Case management

* Disease management programs

* Patient/caregiver education

* Telehealth.

Frontloading Visits

Front loading visits are a strategy whereby the agency increases visit frequency or service at the beginning of care to reduce potential for unplanned hospitalization ( Briggs Corporation, 2006 ). Mary Ann develops a plan of care and ensures that Mr. Smith is seen 3 times in the first 2 weeks for assessment and teaching and will have follow-up visits throughout his episode of care. This is the most critical time to ensure that Mr. Smith does not have an unplanned hospitalization.

24-Hour Availability/Response Program

The 24-hour availability/response program involves availability of a nurse around the clock ( Briggs Corporation, 2006 ). Mary Ann ensures that Mr. Smith has the numbers to call for any questions any time of the day. She teaches him reasons to call nursing and when to call 911. This is very important. If the patient is misinformed or not given enough information, his first response to any complication of his disease process is to go to the emergency room.

Medication Management

Medication mismanagement accounts for 30% of all hospitalizations and 45% of readmissions among the elderly ( Briggs Corporation, 2006 ). Mary Ann discovers that Mr. Smith is receiving a total of 5 different medications, whereas he was taking only vitamins before this hospitalization. She teaches Mr. Smith and his wife about each of his medications and discusses the reasons the medications were prescribed, the side effects of each medication, the time of day each medication is to be taken, and whether to take the medication with or without food. She also explains the importance of him taking his medications as ordered. Mary Ann explains that one of the best ways to keep up with the times for taking medications and to ensure compliance is to fill a weekly pill box. She assists both Mr. Smith and his wife in setting up his medications in such a box.

Case Management

Mary Ann is not only Mr. Smith's nurse. She also is his case manager. She is responsible to look at the whole picture and to use community resources as well as other clinicians while ensuring cost-effective outcomes for her patient. Fairnot and Hogue (2006 , p. 53) explain case management duties using the following list:

* Assessing the needs of each patient

* Planning and implementing a care plan

* Coordinating resources

* Monitoring the patient's progress and the delivery of services

* Evaluating the medical status of each patient on an ongoing basis.

Mary Ann performs the initial assessment. She then plans and implements a care plan that includes goals for Mr. Smith to achieve before discharge. She coordinates resources that Mr. Smith's needs and refers Mr. Smith to physical therapy to help improve his endurance and develop a home exercise program. She will continue to monitor his progress with each visit and to evaluate his status through interdisciplinary communication. Mary Ann will continuously evaluate his status in meeting each of his goals. She documents the date each goal is met, and if Mr. Smith does not meet a goal within the allotted time frame, the care plan is revised.

Fairnot and Hogue (2006) further explain that the “more attuned the nurse case manager is in assessing the patient's needs, the better the case management process will be in providing access to the right care resources and in preventing unnecessary emergency room visits, hospital admissions, and life-threatening complications.”

Disease Management Programs

A disease management program is a system of evidence-based coordinated healthcare interventions and communications developed for specific diseases to improve patient care and prevent unplanned hospitalizations. The patient and caregiver play a vital role in these programs. (To Be continued.....)