Time, For a Change
How one group of nurses formed a buddy system that resulted in more time spent at the patient bedside and a lot less walking the halls.
Photos by Keith Weller
If August 6 had been a typical day on Nelson 7, Jill Trachta would have faced a typical conundrum. It was the morning after one of her patients had undergone a kidney transplant, and as his nurse, Trachta was just beginning to explain the 20 (yes, 20) different medications he'd now be taking several times a day. She also knew that despite his incision and all the lines he was hooked to, he was willing right then to try his first post-surgery walk. Trachta had a teachable moment, and she didn't want to lose it.
Out on the floor, however, a unit of blood had arrived, earmarked for another of her patients. But she'd checked all the charts-the one patient who had orders for blood had gotten it the night before. Clearly there was some mix-up, and on an ordinary morning Trachta's only option would have been to leave the room, track down the cause before the blood went bad, and hope that by the time she got back, her patient was still in the mood to listen and move.
Instead-thanks to some creative thinking and a bit of technology-Trachta was able to solve the case of the mysterious blood unit without ever leaving her patient's side.
TWO YEARS AGO, WITH THE country's nursing shortage deepening, Hopkins Medicine Dean/CEO Edward Miller convened a high-level meeting aimed at making care delivery safer and more efficient. From that meeting emerged Hopkins' Center for Innovations in Quality Patient Care, headed by outpatient administrator Richard "Chip" Davis (who'd led several key systems and revenue-recovery initiatives), and anesthesiologist Peter Pronovost (who'd conducted studies on eliminating medical errors and improving quality care). Among the center's charges was to help administrators, faculty and nurses work together to catch system problems and come up with solutions.
The concept instantly resonated with nurses. This year, when the center asked for Hopkins Hospital nursing units to help find ways to double the amount of time nurses spend providing direct patient care, nine units volunteered. Furthermore, when Hopkins Hospital Executive Vice President Judy Reitz invited surgical nursing director Lisa Rowen to collaborate on redesigning care delivery, Rowen's response was instantaneous: "We'd love to!"
Reitz, who directed nursing practice at Hopkins Hospital 20 years ago, understands how easy it is to get entrenched in an existing system. "The hardest thing," she says, "is conceiving of a new way of delivering care. Then, it can be hard to make headway because there are multiple systems that need to be changed. It's an inter-related process, with an extraordinary domino effect. I'm in a position where I can look at all the sacred cows, so it was important for me to see if I could help tear down barriers."
Reitz and Rowen set their sights on Nelson 7, a 28-bed acute care unit for solid-organ transplant, vascular, and trauma surgery patients. Nelson 7 was one of the units that stepped forward in response to the call for volunteers from the Center for Innovations in Quality Patient Care. It had a high nurse-vacancy rate (about half the positions were being staffed by agency nurses filling in until permanent R.N.'s could be hired). And a time-motion study showed that less than 40 percent of the nurses' time was spent at the bedside-the rest went to duties such as documenting and clarifying orders, assembling the thousands of pills that arrive on the unit each day, arranging consultations. And running. On a unit with long corridors streaming away from command central at the front, the nurses were walking one mile every hour. "They almost needed roller skates," says Rowen.
Fortunately, they're also young (most are in their 20s), enthusiastic and eager to test new ways of doing things.
IT WAS LISA ROWEN WHO CAME UP WITH the concept of the nursing partner, and she tossed her idea on the table at one of Nelson 7's staff meetings. If the goal is to keep nurses at the bedside, she asked, what needs to be done outside the patient's room to support that? What do Nelson 7 nurses have to do? Can someone else follow up on the phone? Document under the nurse's direction? Can someone who has the same critical-thinking skills take over some of the important but time-consuming parts of the job?
One of the biggest cheerleaders was Nurse Manager Jennifer Janecek. "I thought it was exactly what my floor needed," she says. "We do a huge amount of teaching, especially with the transplant patients. Their care is very complex, they're at high risk for infection, they take a lot of meds. The vascular patients also are very dependent on the nurse. They have a hard time getting up on their own."
Jill Trachta, however, admits she was skeptical. "I'm a control freak," says the School of Nursing graduate who signed on with Nelson 7 when she got her degree in 2000. "I didn't know that I wanted someone else checking the orders or talking to the social worker. If I do it, I know it's done."
Still, Trachta agreed to be one of three nurses who'd try out the idea, partnering with Arnita Washington, a social worker in the pediatric outpatient speciality clinic who's earning her bachelor's degree in nursing at Hopkins and spends eight hours a week as a Nelson 7 clinical nurse intern. Though Washington wasn't interested in taking the job if it panned out, everyone thought she was the ideal candidate for a short pilot to see if the idea was feasible. Their first morning working together, Washington made Trachta a believer.
The two communicated via microphone headsets-at first, a bulky, fast-food-looking arrangement that's since been abandoned in favor of a sleeker model. Despite its overly techno appearance, though, the set-up allowed Trachta to stay with her patients (Nelson 7 nurses typically care for up to five at a time) while Washington hovered near the nurses' station, checking for new physicians' orders, ordering supplies, pulling together all the medications Trachta's patients would need at 8 a.m.
Then the unexpected unit of blood arrived. Washington alerted Trachta, who asked her partner to review the patients' charts. While Trachta continued helping her kidney transplant patient, Washington confirmed that the only blood ordered had already been given. Trachta then had Washington phone the hospital blood bank, which discovered a duplicate fax. Now confident of the next step, Trachta told Washington to return the fragile blood right away.
"The amazing part," she says, "is that without Arnita, I would have had to leave the patient. Of course, he wanted to know why I was talking into the microphone, but when I explained, he was just as excited as we were. It was for his benefit, and he got it right away."
And he wasn't the only one who appreciated having his nurse's full attention when he needed it most. After the three-week nursing partner test-run, Nelson 7's patient satisfaction scores jumped nearly 10 points, surpassing by seven points the overall organizational goal of hitting the 80th percentile.
Rowen admits she doubted whether the Department of Surgery could ever achieve such a feat. "We've worked hard to shift our scores and increase our percentile rankings, and we've seen some positive movement," she says. "But we've never seen a leap in patient satisfaction like we now see on Nelson 7."
"This is the best it's ever been," agrees Melanie Memmen, who started her nursing career on the unit four years ago. "The days I partnered with Arnita, I was definitely at the bedside more because she could anticipate what I needed. When there was a physician's order for a dressing change, she gathered all the supplies and put them right in the patient's room for me-something that could have taken me half an hour. We don't want to feel like we're bad nurses because we have so much to do we can't get it all done. Now we're feeling like we can make a difference."
ANITA WASHINGTON'S STINT IN A previously untried role proved that, with a lot of tweaks along the way, it could work, at least on Nelson 7.
"It's important to understand that this is one unit," says Rowen. "The partner idea is not for intensive care units where the amount of time at the bedside is already much greater, and it might not even be appropriate for other surgery units. Our hands would have been much more tied if we were trying to design the perfect care system for all hospitalized patients. We're coming up with an idea and trying it the next day. If it doesn't work, we stop it."
Still, in typical Hopkins fashion, a big part of evaluating the role meant developing criteria to measure its usefulness. Everyone involved in the pilot provided copious amounts of feedback, much of which went into developing the actual job description. Of particular importance to Rowen was that the job itself be satisfying. "We wanted it to be substantive, a role that people would want to stay in. When I thought of who would be right for it, I always thought of someone who's motivated to help people and has some understanding of the workings of a hospital, someone who's flexible and can think on their feet."
Washington, who fit that bill to a T, says she did indeed find the job worthwhile. "You think independently," she says. "You work with the nurse, but you do a lot on your own. I learned that when I saw certain doctors on the unit, they were probably writing orders. I gave the nurses the heads-up, which gave them more time with their patients."
In fact, Washington was so good that when she partnered with Jennifer Butts, they were able to care for six patients instead of five. "Arnita made it very easy," says the two-year veteran of Nelson 7. "I was able to spend more time working on patients' discharge needs."
ON OCT. 28, IRIS TURKEL REPORTED for work on Nelson 7, the first person hired as a Hopkins Hospital nurse partner. She has a bachelor's degree in kinesiology and previously was an aide in a private physical therapy practice. Michele Walton, the nurse who's showing her the ropes, initially had misgivings about turning over a huge chunk of her duties, but says Turkel's speed in catching on immediately won her over. "It's kind of like team nursing," says Walton. "Now I can take my time with patients instead of running in and out."
After Turkel gets fully up to speed, she'll work with two nurses at a time. And, says Nurse Manager Jennifer Janecek, the eventual goal is to hire three more partners.
So far, the biggest stumbling block seems to be finding the right communications technology. For the time being, Walton and Turkel are using a walkie-talkie, but Nelson 7's young, computer-savvy nurses are convinced there's a better way and are ready to embrace other ideas.
Karen Haller, Hopkins Hospital vice president for nursing, agrees that developing better technological support is key, and not only for Nelson 7. "Perinatal Services, for example, is now using cell phones so people can talk to each other within the department," she says. "But for the most part, research and development of systems to increase the efficiency of the nurse is either rudimentary or it's vaporware. The health care industry has not yet invested in technologies that work for the nurse as much as in systems that require nurses to work for them."
Meanwhile, besides ironing out technical kinks, Nelson 7 will continue to fine-tune the nurse partner role. And that means measuring everything-including the financial effects-along the way.
"We're still at the beginning stages," says Janecek, "but our vision is to increase the nurses' time at the bedside to 90 percent. After all, why do people want to be a nurse in the first place? It's to care for patients, not to be running around."