Great Plains QIN had the opportunity to work with Custer Health on a quality improvement project centered around respiratory assessments. The goal was to prevent patients from returning to the emergency department post discharge and to prevent a hospital readmission. The quality improvement process included implementation of a respiratory assessment, prior to discharge, and ordering of a home pulse oximeter.
We recently had the opportunity to speak with Jess Whitney; RN, MSN, FNP-C; Clinical Quality Coordinator with Custer Health, to learn more about this process improvement and her role.
During the COVID 19 pandemic, we were discharging many patients home with oxygen. In an effort to reduce avoidable hospital admissions and emergency department visits, we implemented a policy to ensure a respiratory assessment was completed along with ordering a home pulse oximeter prior to discharge.
The implementation team included our director of nursing, James Woodhead; Emily Dirkes, a case manager; Dr. Lisa Brown and myself, a clinical quality coordinator. The broader team included nurses, providers, respiratory therapy and case management.
I was responsible for ensuring audits were completed on every patient discharged with a respiratory diagnosis. I offered education to our nursing staff and the respiratory therapy team. Increasing staff awareness and an understanding of respiratory assessments was really important to our success. The assessment is so much more than listening to an individual’s lungs and charting that. When an individual is on oxygen, a thorough respiratory assessment should involve:
- Q shift weaning trials;
- an oxygen assessment done while walking and at rest,
- documentation of any additional therapies (incentive spirometry, vibratory PEP);
- oxygen determination at discharge; ensuring a thorough assessment is completed (including the Sp02 levels while walking and resting). Sp02 readings on the pulse oximeter show the percentage of oxygen in a patient’s blood; and
- patient education on home oxygen so they can be successful at home
Adding more documentation requirements for our nursing team was an adjustment. There are already so many tasks required and computer documentation needs; adding another assessment was challenging. In the beginning, we had a respiratory therapist in the building Monday – Friday; this assessment was part of their workflow. Our nursing team was able to rely on them for completion of the assessments (especially the O2 determination, which can be time consuming). Respiratory therapy coverage has became very sporadic and often times, we do not have respiratory therapy on site, which is a barrier. Our nursing team had to re-orient themselves to doing these assessments.
As we have seen surges of COVID and with the cold/flu season upon us, we want to ensure this process doesn’t go to the wayside. My personal goal is to have oxygen determination and home medical equipment education to our system’s “discharge checklist” as reminders to complete those prior to discharge. We want to deliver the best care possible and through this process improvement, we hope to see readmissions and emergency department visits (post-discharge) decline.