Clinical Effectiveness Structure
Clinical effectiveness is fundamental to improving patient safety and health service delivery that is current, effective, efficient and equitable.
In membership and structure, ChristianaCare Clinical Effectiveness has executed on the organization-wide commitment to being exceptional today and even better tomorrow to positively impact the quality and safety of care delivered by our caregivers to our patients and the communities we serve. The Clinical Effectiveness Committee, which reports to the Quality & Safety Committee of the ChristianaCare Health Services Board, serves as the interdisciplinary forum to lead the design, governance and implementation of initiatives used to meet our organization’s mission and goals. Clinical Effectiveness oversees integration of the best evidence into practice through processes including the use of evidence-based standards of care, implementation science and effectiveness monitoring. The committee prioritizes collaboration, action and follow-up to achieve strategic plan goals. The six Pillars of Clinical Effectiveness Zero Harm, Quality, Patient Experience, Patient Flow, Health Equity and Care Standardization are the driving force behind our success.
ChristianaCare is nationally recognized for high quality, safe care and was named one of the World’s Best Hospitals by Newsweek. In hospital quality, U.S. News & World Report ranked Maryland as No. 1 and Delaware as No. 2 in the nation. ChristianaCare's Union Hospital is in Maryland, and Christiana and Wilmington hospitals are in Delaware.
ChristianaCare has achieved national recognitions, awards and accreditations for quality and safety. (See next page.)
“This fiscal year has seen phenomenal improvement in the quality and safety of the care provided to our patients—thanks to the exceptional efforts of all of our caregivers.”
Kert Anzilotti, M.D., MBA, System Chief Medical Officer
Preventable Harm
On the journey toward Zero Harm, ChristianaCare’s preventable harm decreases 9% in FY 24
According to the Institute for Healthcare Improvement, despite an increased focus on patient safety over the past twenty years, preventable harm remains an urgent priority for health care systems. A 2023 study published in the New England Journal of Medicine found that 23.6% of admitted patients experienced an adverse event 9% of the admissions suffered serious harm. This resulted in an average hospital stay of 9.3 days compared to 4.2 days for admissions without adverse events.
ChristianaCare tracks 20 measures of harm across our hospital campuses and ambulatory practices, encompassing hospital-acquired infections, complications of care and other preventable events, such as falls.
As seen nationally, harm cases increased during the COVID-19 pandemic. Focused efforts across ChristianaCare led to a reduction in harm this fiscal year. The number of patients with potentially preventable harm decreased
14%, while the harm rate, the number of harm cases per 1,000 patient days in the hospital, decreased 9%.
The reduction in patient harm has led to year-over-year reductions in costs to the system: in the five years since FY 20, there have been estimated cost savings of more than $9.9 million.
Teams responsible for driving improvement in hospital-acquired infections, patient safety indicators (PSI) and ambulatory measures report to the Zero Harm Council. Those teams include the Infection Prevention Steer and Triads, PSI-90 Steer, and designated Ambulatory Safety subcommittees.
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On the
journey
toward Zero Harm, ChristianaCare’s preventable harm decreases 9% in FY 24
Harm Rate
Jul-20Sep-20Nov-20Jan-21Mar-21May-21Jul-21Sep-21Nov-21Jan-22Mar-22May-22Jul-22Sep-22Nov-22Jan-23Mar-23May-23Jul-23Sep-23Nov-23Jan-24Mar-24
Through April, the FY 24 Preventable Harm Rate has decreased 9%, from 1.44 to 1.30. The number of patients harmed decreased by 14%, from 536 to 462.
Since FY 20, reductions in patient harm at ChristianaCare have led to an estimated cost savings of more than $9.9 million.
PREP for the Foley Vacation
From January to September 2022, the Transitional Medical Care Unit (TMU) noted increased use of indwelling urinary catheters, also known as Foley catheters, as well as higher CAUTI rates.
The TMU CAUTI Prevention Team instituted a new protocol called the “Foley Vacation,” empowering nurses to remove Foleys for patients with indications of urinary retention and begin bladder training using bladder scanning and intermittent catheterization. The protocol consisted of an algorithm Post Retention Elimination Protocol (PREP) listing criteria and decision-making steps.
84% reduction in CAUTI cases on TMU
Catheter-Associated Urinary Tract Infections (CAUTI)
Reduction in Foley use contributes to 29% decrease in CAUTI rates
These actions led to a 29% decrease in CAUTI FY 24 to date through April, from 35 to 25. The rate decreased 11%, to 1.01 from 1.14 cases per 1,000 Foley days.
Foley Utilization Rate Foley Utilization SUR
In FY 24, the systemwide CAUTI Steer led several activities to help reduce CAUTI rates. Among them: implementing PREP (see sidebar) systemwide with plans to automate, revising Foley orders and indications and bladder scan/straight catheterization orders, developing competency training kits that include efficient, just-in-time training at bedside and removing the order "Urine Culture if" from all PowerPlans. Systemwide, Foley
Central Line-Associated Bloodstream Infections (CLABSI)
CLABSI cases decrease 31%, perfect care compliance nears 100%
In FY 24, the CLABSI Steer implemented several improvements across all three hospital campuses to lower incidences of CLABSI. When patients are admitted with central venous catheters (central line), nursing documentation of the central line now automatically triggers a daily task for chlorhexidine bathing and treatment and Nasal Povidone
Iodine application. The order “Blood Cultures if” was removed from all PowerPlans and “Obtain blood cultures x 2 for temp>38.5” was removed from order sets. Additionally, there was a transition to the new chlorhexidine (CHG) Tegaderm dressing and a non-CHG wipe has replaced the CHG wipe for patients with a documented CHG allergy.
Perfect Care Monitor
In FY 24, the number of CLABSI cases decreased by 31%, from 54 to 37. The rate decreased 26%, from 0.94 to 0.69 cases per 1,000 line days.
Overall compliance with the set of evidence-based “perfect care” line insertion and maintenance practices that help prevent CLABSI is 98%. Top opportunity is the daily chlorhexidine disinfecting bath.
Clostridioides difficile (C. difficile)
C. difficile SmartZone alert leads to 22% decrease in cases and keeps ChristianaCare below Vizient benchmark
Like CLABSI and CAUTI, hospital-onset C. difficile is part of the CMS hospital-acquired condition pay-for-performance program. The C. difficile Steer identified an opportunity related to the timing of C. difficile identification and testing. Cases found within three days of hospital admission are considered community onset and not counted as patient harm.
To assist clinicians in the timely identification and testing of potential C. difficile, a PowerChart Smart Zone alert was implemented in FY 23.
The alert notifies providers of patients entering the health system with significant diarrhea, enabling identification of a potential C. difficile early. Early identification supports appropriate classification of C. difficile as community vs. hospital onset, leading to timely treatment and reducing harm. Since go-live the Smart Zone alert has identified 24 cases as community onset v. hospital onset contributing to the 22% decrease in C. difficile cases seen this fiscal year.
To further reduce C. difficile, recent actions of the team in FY 24 include implementing an automated C. difficile risk calculator in PowerChart and expanding use of UV light for room cleaning.
Following the SmartZone Alert go-live, the C. difficile standardized infection ratio decreased by 13%, from 0.36 to 0.31, and it remains below the Vizient benchmark.
Colon Surgical Site Infections
(SSI)
Increased compliance with Colon Bundle Pathway shows promise for reducing surgical site infection rates
Surgical site infections (SSIs) are one of the most common causes of health care–associated infections. In FY 24, the Colon Care Pathway team implemented numerous interventions to address SSI infections related to colorectal surgery.
Updates to the Colon Bundle Pathway include requesting feedback from surgeons about barriers to bundle element use and/or other intangible factors that may have contributed to SSI cases, ensuring understanding and accessibility of preop antibiotic ordering, improving capture of emergent/elective cases, changing nursing documentation to ensure wound class reconciliation and expanding the team to include Emergency Medicine, General Surgery and Trauma Surgery.
The team is now reviewing antiseptic irrigation and moving review of SSIs to R2L to improve collaboration. (See page 10.)
While the team has not yet seen an overall trend down, it has seen an increase in compliance with the Colon Bundle components during the fiscal year.
PowerPlan Pre-Op
Chlorhexidine-in Prep & Hold
Chlorhexidine-in OR
Fascial Wound Protector-Surgeon
Fascial Wound Protector-Nurse
New Surgical Gown-Surgeon
New Surgical Gown-Nurse
New Sterile Gloves-Surgeon
New Sterile Gloves-Nurse
New Drape-Surgeon
New Drape-Nurse
Clean Closure Tray-Surgeon
Clean Closure Tray-Nurse
PowerPlan Post-Op
Compliance with the Colon Bundle components during the fiscal year increased by an average of 13%. The greatest improvement was in the use of clean closure trays for fascia closure: 59% increase, from 54% to 86%.
SSI - Bundle Compliance
PSI 90 Steer efforts lead to 18% decrease in the PSI 90 composite Patient Safety Indicators (PSI) 90
ChristianaCare measures 11 Agency for Healthcare Research and Quality (AHRQ) patient safety indicators in our journey to zero harm.
The Patient Safety Indicator Composite (PSI 90) is a weighted composite of 10 individual PSI metrics, largely associated with postsurgical complications. The Centers for Medicare & Medicaid Services (CMS) uses the PSI 90 in its pay-for-performance programs and star ratings. Leapfrog and other national hospital ratings systems also employ the measure to rank hospital performance.
Among the FY 24 activities to drive Zero Harm across all PSI 90 indicators, ChristanaCare’s PSI 90 Steer, under our Surgical service line, created review teams each with a physician, advanced practice clinician, and nurse for every PSI. Each team reviews cases together and then reports observations and opportunities at regular collective PSI 90 Group meetings.
Discharge Quarter PSI 90 Composite Rate 47% Decrease in AKI rates.
Patient Safety Indicators (PSI) 90
ChristianaCare PSI rates come in better than academic medical center peers in 9 of 11 indicators
ChristianaCare's patient safety indicator risk-adjusted rates were better than our comprehensive academic medical center peers in 9 of the 11 PSIs. We are especially strong in perioperative PE/DVT (PSI 12) and postoperative hemorrhage/hematoma (PSI 9). We see the greatest opportunity for improvement in PSI 10 postoperative acute kidney injury (AKI).
In FY 24, informed by its multifaceted review of cases (see previous page), the PSI AKI review team implemented several interventions to improve AKI incidents, including an AKI dashboard and an AKI alert in PowerChart, and is currently developing a predictive model for AKI.
Overall, AKI rates have improved 47% since FY 22, to 1.57 from 2.98 cases per 1,000 procedures.
AHRQ Patient Safety Indicators
FY 24 Year-to-Date vs. AMC Compare Group
Respiratory Failure (PSI11)
PE/DVT (PSI12) Postop Sepsis (PSI13)
Wound Dehiscence (PSI14)
Puncture/Laceration (PSI15)
Adjusted Rate
In FY 24, ChristianaCare's patient safety indicator risk-adjusted rates were better than our comprehensive academic medical center peers in 9 of the 11 PSIs.
ChristianaCare Academic Medical Centers
Universal Protocol for Preventing Surgical Events
Monitoring shows improvement to 95% in perfect care
The Universal Protocol is a set of guidelines that aims to prevent wrong person, wrong procedure and wrong site surgeries in hospitals and outpatient settings.
The protocol consists of three steps to improve patient safety during surgical and nonsurgical procedures: verifying the patient, procedure and procedure site; marking the operative or procedure site; and initiating a Time Out immediately before starting the procedure for all members of the procedure team to raise questions and confirm correct patient, procedure and site.
In FY 24, the Surgical service line began revising ChristianaCare’s Universal Protocol education, which caregivers will need to complete bi-annually when it is relaunched. Also, in October 2023, the team restarted Universal Protocol audits, switching the audits to patient rounds for better participant-level data. January 2024 saw the launch of a live auditing process, where auditors review live cases in the operating room and provide feedback to team members in real time.
The percentage of audited cases meeting all aspects of the Universal Protocol increased 12% from October 2023 to March 2024, from 85% to 95%.
Universal Protocol Perfect Care
Falls decrease nearly 16% across hospital campuses
In FY 24, a multidisciplinary, systemwide Fall Prevention & Mobility team redesigned protocols and implemented new tools to preempt falls with major injuries. In addition to updated documentation, procedure guides and standardized weekly fall reviews, ChristianaCare’s electronic medical record system now triggers mandatory interventions when a patient is at high risk for falls and a QR code added to the foot of all beds links to educational resources about the bed for caregivers to maximize safety with bed exit alarms.
Patient fall rates improved across all three campuses.
Through April 2024, the number of falls across all three hospital campuses decreased by 130 compared to the same period in FY 23, declining from 690 to 560. During the same period, falls with major injury decreased by 4, from 16 to 12. The fall rate decreased almost 16%.
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Acute Care Fall Rate by Campus
Patient fall rates improved across all three campuses, with an overall decrease of almost 16%, from 1.87 to 1.58 falls per 1,000 patient days.
HomeHealth Pressure Injuries
HomeHealth Pressure Injury group meets 0.33% target
Pressure injuries are a core HomeHealth focus. In FY 24, HomeHealth established a Quality & Safety Committee subgroup dedicated to pressure injury identification and reduction.
The multidisciplinary group, comprised of both office- and field-based nurses and therapists, found gaps in our Braden Scale assessment scores.
To drive improvement, the group established virtual visits with a wound specialist and updated the agency care plan with risk-specific interventions aligning with the Braden Scale. This work resulted in a desired reduction in the onset or progression of pressure injuries in patients receiving HomeHealth services
Target: 0.33%
Increase in Pressure Injuries
Jul-22Aug-22Sep-22Oct-22Nov-22Dec-22 Jan-23Feb-23Mar-23 Apr-23May-23Jun-23 Jul-23Aug-23Sep-23Oct-23Nov-23Dec-23 Jan-24Feb-24Mar-24 Apr-24
The percentage of patients with a new or evolving pressure injury of stage 2 or higher in FY 24 through April is at the target of 0.33%.
Medication Safety
Smart Pumps prevents 327 dose “magnitude errors” in medication administration, saving lives and costs
Medication administration is the most error-prone step in a complex medication process that includes prescribing, transcribing, dispensing, and administering. This final step can lead to significant patient harm, especially with intravenous drug administration. To administer medication intravenously, ChristianaCare uses Smart Pumps, which feature Drug Error Reduction Software (DERS).
Developed and maintained by the health system’s Medication Safety Program and Clinical Pharmacy, DERS is a software library with more than 2,000 entries specific to ChristianaCare that calculates safe drug and concentration rates and doses, adding limits and alerts to prevent manual programming errors.
In FY 24, the DERS Team increased the cadence of Smart Pump reviews and updates to monthly, enhancing error prevention safety features and reducing unnecessary alerts.
From July 2023 through April 2024 (10 months), DERS prevented 327 dose magnitude errors, potentially avoiding harm-associated costs of $54,000 to $330,000 (conservative estimates).
Dose Magnitude-Error Good Catches
Drugs
The top volume dose magnitude-error drugs accounted for more than 90% of the 380 “good catches” or interceptions of potential safety events before they reach patients.
Caregiver Safety
ChristianaCare continues trending below national average for recordable and lost-time injury rates
ChristianaCare's total recordable injury rate, including days away from work, restricted work and medical treatment, increased 13% in FY 24 year-to-date through April compared to the same period in FY 23, but remains below the national average for medical/surgical hospitals of 6.1 injuries per 200,000 worked hours.
Needlestick/sharps injuries account for 40% of recordable injuries and decreased 4% due to resolving supply chain issues, and prevention initiatives, such as sharps safety rounds, systemwide safety communications and focused education.
Efforts to reduce other caregiver injuries include the addition of spill stations in off-campus settings to address the 46% increase in Slips, Trips & Falls and Patient Handling initiatives including insulation of ceiling mounted lifts on Cecil County campus and an online educational module to educate caregivers on safe patient handling on non-hospital sites.
Recordable and Lost-Time Injuries
The Total Recordable Injury Rate increased 13%, to 4.5 from 4.0, but remains well below the U.S. Bureau of Labor Statistics (BLS) national average of 6.1. The LostTime Injury Rate increased 25%, to 2.0 from 1.6, and is below the BLS average of 2.2.
Top Recordable Injuries
Number of Injuries
Recordable injuries increased to 425 in FY 24 from 382 during the same period in FY 23. Hours worked for the same period remained fairly consistent, decreasing by 74,999 in FY 24 (18,804,732.79 FY 24 vs. 18,879,731.94 FY 23).
Cut-Puncture Needlestick/Sharp
Daring to de-escalate: Educating caregivers in workplace violence
In response to a rise in reported workplace violence incidents from 574 (FY 21) to 626 (FY 23), ChristianaCare made significant progress in training caregivers in de-escalation techniques, increasing the number of trained staff by 77.59% through FY 23 and far exceeding Our Workplace Civility Steer Committee’s 15% goal. While deescalation training may not necessarily reduce workplace violence incidents, it can improve caregiver knowledge, confidence, attitudes, and skills in identifying and managing escalating behavior and help lessen the impact of aggression and violence.
Nearly 5,000 caregivers received training in Nonviolent Crisis Intervention or Verbal Intervention during FY 23.
Preventing workplace violence with education, enhanced protocols, detection and training Caregiver Safety
Our Interdisciplinary Workplace Civility Steering Committee helps create an environment safe and free of violence for caregivers and visitors.
In FY 24, the committee led activities and outcomes that included creating a Workplace Violence (WPV) Leader Toolkit; implementing a WPV Huddle Response Team activation; and deploying Evolv Weapons Detection System to screen for weapons at our Wilmington campus. Plans include bringing the system to our other campuses; launching HomeHealth caregiver education; training more than 1,500 caregivers in the Medical Groups on ALICE (Alert, Lockdown, Inform, Counter, Evacuate); implementing Dynamic Assessment of Situational Aggression (DASA) in all adult acute care medical, surgical, step-down and ICU units, and increasing use of staff duress badges.
In FY 24, through March 2024, 799 workplace violence events were reported, with nurses accounting for 60% of these reports. The majority (66%) of the incidents were physical or verbal assaults.
Zero Harm Awards
Celebrating love and excellence on the journey to Zero Harm
ChristianaCare’s Zero Harm Awards recognize hospital patient care units, HomeHealth teams, Perioperative Services departments and Ambulatory Practices that have maintained zero cases of preventable harm in one of nine harm categories for at least three consecutive months for falls and at least 12 months for other categories. From July 2023 through April 2024, 179 awards were given, including four awards for 10 years (120 months) with zero harm. Since January 2017, 1,173 awards have been earned.
NEWARK CAMPUS
CLABSI
108 months - 2C
72 months - TSU
48 months - EAD, TNU, 3A
12 months - Hospital at Home, 4E, 3B, 5B, 6MS, 5E
CAUTI
108 months - BMT
60 months - TNU
48 months - CEAD
36 months - WCCU
12 months - 5A, 3C, 5D, 5E, 3A
MRSA
84 months - 4D, TNU
60 months - BMT
48 months - CEAD, 5D
36 months - 6A, 6MS
24 months - 5E
12 months - 7E, TSU, C 5A, 3B, 4E, 5C, CVCC, 6E, SCCC, TMU, 3C
C. difficile
60 months - TNU
48 months - CEAD
24 months - 6MS
12 months - 4B, Hospital at Home, 3A, 7E, TMU, 3C, BMT, 5C, TSU
All Falls
**awardedfor3consecutivemonths(andmultiplesof3)
96 months - NICU
33 months - OB Triage
18 months - TSU
12 months - TNU, 2M
9 months - BMT, CVCCC, SCCC, P6M, 6MS
6 months - 6M/7M, NCCU, TMU
3 months - 3C, CEAD, 4B, MICU, CSSU, 5E, 7E, LBR
Antenatal Steroids
24 months - OB Triage
WILMINGTON CAMPUS CLABSI
108 months - 7S
72 months - W3M
48 months - 6W 36 months - WCCU
months - 8S 12 months - 4W
CAUTI
120 months - 7S
108 months - 4N/5W 84 months - 6S
months - WICU, 6W
months - WCCU
months - 5N
months - 4W, 8S
MRSA
120 months - 7S, 6W
84 months - W3M
36 months - 5N, WCCU
24 months - 7N
12 months - WICU,4N/5W, 8S
C. difficile
120 months - 7S
84 months - 6W
48 months - 7N
36 months - WCCU
24 months - 5N
12 months - 4N/5W, 4W, 6S
All Falls
**awardedfor3consecutivemonths(andmultiplesof3)
9 months - WICU
3 months - WCCU, 6S, 7S, W3M, 8S
Celebrating love and excellence on the journey to Zero Harm
CECIL CAMPUS
CLABSI
24 months - SSU
12 months - PCU, ICU
CAUTI
60 months - ICU, PCU
24 months - SSU, MSU
MRSA
60 months - SSU
24 months - ICU, MSU
C. difficile
36 months - CDU
All Falls
**awardedfor3consecutivemonths(andmultiplesof3)
24 months - FBC
6 months - CDU, SSU
3 months - ICU
HOSPITAL AT HOME
CLABSI
12 months
C. difficile
12 months
HOMEHEALTH
CLABSI
72 months - CD Team 3, NC Team 2, NC Team 7
60 months - NC Team 6
12 months - NC Team 8
CAUTI
12 months - NC Team 2
AMBULATORY PRACTICES
Hypertension Admissions
(primary care & cardiology practices)
36 months - PC Woodstown
24 months - PC Kirkwood
12 months - PC Kennett, CHF CHR 1070, PC Linden Hill, PC Concord, PC Limestone, PC at Home
Complications of Diabetes Admissions
(primary care & endocrinology)
48 months - PC Woodstown
36 months - PC Whitehall
24 months - PC Smyrna, PC Kirkwood
12 months - PC Middletown East
PERIOPERATIVE
Perioperative Services
36 months - GI Lab-Wilmington, PACUWilmington
24 months - OR-Wilmington, Christiana Surgery Center
12 months - HVIS, Endoscopy-Union, Interventional Radiology-Union, Wound Care Center-Union, PACU-Christiana, OR-Union, Wound Care Center
Patient Safety
Zero Hero Awards recognize caregivers who prevent patient harm at the point of care
The Zero Hero program recognizes the importance of caregivers making “good catches” that prevent patient harm at the point of care. A good catch may be an unsafe condition that increases risk for patients or caregivers and needs to be corrected. It may also be a near miss, when a safety risk is corrected before it reaches the patient. Reporting good catches promotes increased learning at the system level and allows caregivers to be proactive in preventing harm. Reporting and learning are vital in our journey to zero harm and advancing a culture of safety.
Every month, a Zero Hero awardee is selected from the nominees. Clinical Effectiveness leaders in the System Support & Resolution Huddle recognize the awardees for contributing to important system improvements, and they’re highlighted throughout internal platforms. Monthly winners are eligible for the annual Zero Hero Award presented at the ChristianaCare Way Awards ceremony (see page 53).
Patient Safety
Zero Heroes 2023–24
May 2023
Timothy Shiuh, M.D., Information Technology
Good catch: When patients were transferred from Union Hospital to a Delaware facility, it wasn’t possible to document their experience as a single encounter in the electronic health record.
As a result: The IT department developed strategies that made it possible to transfer patient health data across state lines without creating new episodes of care.
June 2023
Beth Austin, Respiratory Supervisor, Respiratory Care
Good catch: The Respiratory Care department ran out of medium BiPAP masks for three days; patients who required BiPAP would have been placed on ventilators.
As a result: The Supply Chain department addressed the shortage, correcting the problem within days and maintaining the supply on an ongoing basis.
July 2023
Brittany Drake, Speech Therapist, HomeHealth
Good catch: During a home health visit, a speech therapist realized that the patient’s heart rate and blood pressure levels were elevated and required emergency care.
As a result: The speech therapist recommended calling 911, which the patient refused, but they went the Emergency Department, where they were diagnosed with elevated troponins.
August 2023
Amy Whalen, RN, Performance Improvement
Good catch: A software malfunction ordered C. auris PCR tests for all admitted patients, regardless of their risk factors. This caused Emergency Department delays.
As a result: The IT department identified the misstep in the rule configuration that caused the error, quickly disabled it, corrected the rule and resolved all inappropriately placed orders.
September 2023
Beth Austin, Respiratory Supervisor, Respiratory Care
Good catch: The exhalation housing for ventilators left for sterile processing weren’t cleaned for 24 hours because they were dropped off without identifying details or instructions.
As a result: The Sterile Processing department is creating a system of labeled bins so that items may be dropped off for reprocessing if a tech is unavailable for intake.
October 2023
Michelle Jonkiert, RN, Cardiovascular Critical Care Complex
Good catch: The medication scanners weren’t working, making it impossible for caregivers to use the scanners or the backup system.
As a result: The problem was quickly identified and corrected, and no patients were impacted by the temporary problem.
Patient Safety
Zero Heroes 2023–24
November 2023
Neonatal Intensive Care Unit
Good catch: A newborn in the Neonatal Intensive Care Unit had two medications automatically ordered for them through the system, even though the drugs are inappropriate for newborns.
As a result: The IT department updated the custom rule so that babies in the NICU can no longer be prescribed these two inappropriate medications.
December 2023
Pharmacy
Good catch: The pharmacy received an order for Kevzara 1.14 mL syringes, available in two-packs. The prescription was written for two each, but it should have said 2.28 mL to mean two syringes.
As a result: The pharmacy added product messages to the system to clarify the number of syringes in a package and how many should be dispensed for each prescription.
January 2024
Angelina Marie Stevens, RN, 3D Transitional Medical Unit
Good catch: A medication amount was listed in mL instead of mg in the system because the PCA banner requests mg and the iView documentation is in mL.
As a result: Nurses were told to document the medication volume infused in the nursing task, which then lists the volume in mg in iView. Educational materials were shared to inform nurses.
February 2024
Amanda Williams, NP, 3A
Good catch: Although a patient was given medication once, the Medication Administration Record showed they were given it twice, 10 minutes apart.
As a result: The IT department continues to investigate with Cerner/Oracle the root cause of this incorrect documentation.
Patient Safety
Zero Heroes 2023–24
March 2024
Kari Matthews, RN, Cardiovascular Critical Care Complex
Good catch: An intra-aortic balloon pump (IABP) was malfunctioning and measuring a patient’s heart rate in the 180s when it was actually in the 80s, causing hypotension.
As a result: The IABP has since been repaired and adjusted, with help from the Clinical Engineering department and the IABP’s manufacturer.
April 2024 (Tie)
Alexis Martin, RN, Emergency Department
Good catch: Hours after an Emergency Department patient was sent to an intensive care unit (ICU), the nursing coordinator was told that no beds were available for the patient.
As a result: New processes were developed so that when an ICU is at capacity, other ICUs can take on the overflow patients.
April 2024 (Tie)
Shannan Shelton, Clinical Pharmacy Specialist, Pharmacy
Good catch: Because the PowerChart dosage calculator couldn’t differentiate between elemental and total iron, a patient’s weight-based ferrous sulfate prescription would have been underdosed.
As a result: New language is being developed for weight-based orders relating to the amount of elemental iron that should be prescribed to patients.
May 2024
Judi Smith, Ambulatory Operations Manager
Good Catch: Lynx Messenger was deployed in the PMRI Lab in 2023. During the deployment of the remaining practices and services in PMRI, Public Safety tested one of the workstations in the lab to ensure it had been moved to the correct group and identified that Lynx Messenger was no longer on that desktop. After speaking with the lab caregivers, it was determined that the desktop had been refreshed since the original deployment in 2023. The keyboard was still marked with the panic stickers, but no alert would have been sent if the keys were pressed. The Lab caregivers indicated they were not aware that the new desktop did not have Lynx Messenger on it.
As a result: Ambulatory Workplace Safety & Civility leadership is working with IT and Security to resolve this issue.
Patient Experience
Engage all caregivers to serve our patients with love and excellence, providing an ideal experience across the continuum of care.
New Patient Experience structure to guide improvement work Improving Patient Experience
In FY 24, a key goal and priority for ChristianaCare is year-over-year progress to achieve exceptional patient experience by refining processes to drive improved experience as measured by survey scores.
In early spring 2024, the Patient Experience governance structure was redesigned to include an overall steer responsible for strategy, oversight of projects and metrics; an interdisciplinary improvement team responsible for improving the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPs) metric for “Overall Rating of Hospital,” and a subcommittee structure.
The Patient Experience Improvement team has established focus areas that include executive leader rounding, clinical/discharge follow-up, and a reward and recognition program.
The concentration of the five subcommittees is on data analysis, environment of care elements, establishing service excellence standards, nurse communication, and provider communication.
Patient
Experience
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPs) Survey
HCAHPS scores improve by 4.5 points on DE campuses and by 2.5 points on MD campus
In the first nine months of FY 24, we saw improvements in our HCAHPS survey scores. The HCAHPS survey provides valuable information on how patients perceive our care and their experience.
On the Newark and Wilmington campuses, domain scores increased by an average of 4.5 points and five domains now exceed the CMS 50th percentile benchmark. The greatest improvements are in Cleanliness & Quietness (+7.3), Communication with Medications (+6.5) and Communication with Doctors (+5.4).
The intensive patient experience efforts (see next page) expanded to all Union hospital patient care units, leading to improvements in seven of nine domains. Scores increased an average of 2.5 points. Discharge Information exceeds the CMS 50th percentile.
HCAHPS Domain Scores: Newark & Wilmington
HCAHPS Domain Scores: Cecil County
Intensive Unit and Practice Patient Experience (PX) Work
Intensive hospital initiative increases scores by 2.5
%
In FY 23, Patient Experience began a collaboration with Nursing to drive improvement in PX measures across hospital inpatient units and the emergency departments.
Initially, 17 inpatient units at Newark and Wilmington were selected to receive intensive support based on PX metric performance: intensive, moderate and local leader support. Intensive support included in-depth, unit-specific data reviews; coaching; education; observation and reinforced Nursing Bundle resources over a six-week period. Through February 2024, five additional intensive cohorts were completed. The 27 participating areas increased key survey scores by an average of 2.5%. Improvements have been sustained; scores for the first cohort have exceeded their baseline by five points. Positive results were seen on HCAHPS (see page 33).
PX intensive interventions for the ambulatory practices saw a phased rollout of best-practice bundle components: AIDET (Acknowledge, Introduce, Duration, Explanation and Thank You), HEAT service recovery (Hear, Empathize, Apologize, and Take Action) and Teach-back that incorporated mandatory education for all practice caregivers and toolkits.
and on-site training
Domain Score Improvement - All Inpatient Cohorts
The six PX Intensive cohorts, involving 27 patient care units over six months, improved HCAHPS scores in key domains by an average of 2.5 percentage points an over 5% improvement from their baselines.
Virtual Acute Care Nursing (VACN)
VACN transforms care delivery and helps improve Patient Experience scores
ChristianaCare is in the vanguard of care delivery with our virtual acute care nursing (VACN) program, launched in 2022. Offering a critical extra set of eyes and connection to patients, our virtual nurses are helping to alleviate staffing shortages and improve patient experience.
In the VACN innovative model, nurses use virtual technology (such as computer tablets) to provide care that doesn't require in-person, at-the-bedside care, such as medication and discharge education.
Since the program launch, PX scores in key domains have improved. On the two pilot units (Wilmington 5W and Christiana 4B), patients responding that they always had the opportunity to explain things back after receiving instruction increased by over 40% and scores for receiving information about symptoms to watch for at discharge increased by 14% for 5W and remained high for 4B.
Since the program’s launch in 2022, patient experience scores have risen across all domains.
Explain Things Back
Pre (Jul-Sep 2022) FY24 YTD (Jul-Mar)
The percent of patients saying that they “always” had the opportunity to Explain Things Back increased by 43% for W5W Surgical and by 48% for C4B Medical.
Information About Symptoms
Pre (Jul-Sep 2022) FY24 YTD (Jul-Mar)
The percent of patients saying that they “always” received Information about Symptoms by 14% for W5W Surgical and by 1% for C4B Medical.
Quality
Drive health outcomes as a national leader in clinical excellence through continuous improvement in effectiveness, timeliness and efficiency of care provision.
Vizient
Quality & Accountability Scorecard
Vizient ranking improves 12 points in our journey to Top 25 by 25
Vizient, the health care services organization that supports our comparative risk-adjusted data analyses to drive quality and safety improvements, provides a comprehensive annual Quality & Accountability Performance Scorecard that ranks ChristianaCare among more than 100 comprehensive academic medical centers in six domains: mortality, efficiency, effectiveness, patient centeredness, safety and equity.
In 2020, ChristianaCare was ranked 83. At that point, we set an audacious goal to reach the top 25 by 2025. Extensive efforts, including Clinical Documentation Integrity, patient safety initiatives and service line clinical advancements are driving improved rankings across the domains. Most notably, we are currently ranked 1 in Equity and 17 in Mortality (see next page).
ChristianaCare's ranking against our academic medical center peers improved from 83 of 100 hospitals to 71 of 116 hospitals.
In the second period of 2024 (July–Dec 2023), scores in three domains exceeded the Vizient median: Mortality, Safety and Equity. The greatest opportunity is in Patient Centeredness.
46% improvement in observed-to-expected mortality index
Hospital coding is critical for ensuring accurate risk adjustment and payment as well as reliable comparative quality ratings. At ChristianaCare, incomplete documentation/ diagnosis code capture led to a Vizient mortality ranking based on the observed to risk-adjusted expected index of 72 out of over 100 academic medical center peers, a score that was not reflective of our high-quality clinical care.
A multidisciplinary team led by Clinical Documentation Integrity and Health Information Management Services leaders assured alignment with clinicians, the finance team and coders. The team established a bill-hold process for quality review with a promised 48hour turnaround time, engaged physicians by demonstrating the link between mortality metrics and documentation, and created a process to identify cases with clinical opportunities for improvement. Additionally, the team transitioned to an allcause standardized mortality review model and developed a continuous monitoring process, including case mix index and observed vs. expected service line level data.
The interventions led to a 46% improvement in the mortality index. During the same period, observed mortality decreased to 1.7% from 3.0%. ChristianaCare's Vizient mortality ranking improved to 17.
Observed vs. Expected Ratio
Mortality Index
The Mortality observed vs. expected index improved 46%, to 0.55 in the first quarter of 2024 from 1.01 in the first quarter of 2022. The Mortality domain score increased from 43.2% to 72.8%. The Vizient ranking improved from 72nd to 17th.
Overall Hospital Quality Star Rating
Ratings improve across all measures for Delaware campuses, four
of
five measures for Cecil County campus
The CMS Overall Hospital Quality Star Rating summarizes hospital performance on 45 measures across five areas of quality mortality, readmission, safety of care, patient experience, and timely and effective care into a single star rating. Hospitals earn from 1 (worst) to 5 (best) stars compared to other hospitals in the U.S. CMS used data published on CareCompare (www.medicare.gov) to calculate the star ratings.
In FY 24, ChristianaCare Delaware campuses improved from three to four stars and saw increased scores across all five measures, with an average improvement of over .4 points.
Our Cecil County campus improved from two to three stars, with improvements in four of five measure groups, with an average improvement of .7 points.
Star Rating Measure Group Scores
Jul-23 Jul-24
Scores improved in all five measure groups, with the greatest increases in Readmissions, Timely & Effective Care, and Mortality.
Star Rating Measure Group Scores
Jul-23 Jul-24
Scores improved in four of five measure groups, with the greatest increases in Patient Experience, Safety and Mortality. There is opportunity in Readmissions.
Union Hospital improves Quality-Based Reimbursement
score by 18 points, reduces in -state readmissions by 3%
Quality Based Reimbursement
Maryland’s Total Cost of Care Model combines all-payer global budgets with hospital accountability for quality care. The state’s Quality-Based Reimbursement (QBR) program incentivizes quality improvement in person and community engagement.
Maryland’s Readmission Reduction Incentive Program (RRIP) sets expectations for both in- and out-of-state 30-day readmissions after an inpatient discharges. Both the QBR and RRIP put 2% of inpatient hospital revenue at risk with penalties or rewards based on performance.
This year, Union Hospital improved its QBR score by 18 percentage points and reduced in-state readmissions by 3% leading to an overall reduction in penalties of $1.04 million. By implementing an improvement plan focused on better patient
experience and reduced mortality, Union Hospital increased its QBR score to 34% in CY 23 compared to the CY 22 score of 16%.
To improve performance under RRIP, a campus workgroup implemented multiple initiatives, including creating a workflow so that high-risk patients having challenges being seen at ambulatory practices could have a home visit by a primary care nurse practitioner and optimizing community resources such as smoking cessation programs and mobile health van visits to underserved neighborhoods.
Union Hospital improved the total QBR score to 34% for the FY 25 payment period from 16% for FY 24.
Readmission Rates
Union Hospital reduced in-state 30-day readmission rates by over 3%, to 11.07% for the FY 25 payment period from 11.41% for FY 24.
NutriCatch: Enhancing malnutrition detection in hospitalized patients
In FY 24, our Clinical Documentation Integrity team partnered with dietitians and our Organizational Excellence team on NutriCatch, a multidisciplinary performance improvement initiative that includes Information Technology, Informatics, Nursing, clinicians, Health Information Management Services and others.
This initiative aims to enhance malnutrition screening, detection, treatment and documentation processes to best support our patients and improve appropriate diagnosis capture. It also aims for excellence in compliance with the Global Malnutrition Composite Score, the first nutrition-focused quality measure included in the CMS Hospital Inpatient Quality Reporting Program.
One of the initiative’s key achievements was the implementation of the Malnutrition Screening Tool in PowerChart. Positive screenings trigger a referral to a registered dietitian for evaluation. When malnutrition criteria are detected, a PowerChart Smart Zone alert notifies treating clinicians and updates the patient's chart with a malnutrition diagnosis to drive patient care protocols.
Malnutrition Coding Mar-Apr 2023 Mar-Apr 2024
In the first two months after go - live, coding of Severe Malnutrition increased 74% compared to the same period in 2023; Moderate Malnutrition more than doubled; and revenue increased an average of $77,000 monthly due to the assignment of higher - level Diagnosis Related Groups with improved capture of complications.
Standardization leads to 18% improvement in achieving inpatients’ daily mobility goals
To improve mobility care at ChristianaCare, a multidisciplinary team of nurses, clinicians and Rehabilitation Services caregivers collaborated to pilot the Johns Hopkins Activity and Mobility Promotion (JH-AMP) in four units (5C and 6A at Newark, 4N and 6S/WICU at Wilmington). The JH-AMP sets a Daily Mobility Goal for each patient via validated tools and creates a system to monitor patient mobility at system, campus, unit and patient levels.
During the three-month pilot, the units improved the percentage of patients meeting their daily mobility goals by 18%. Since that time, the program has expanded to all patient care units across all three campuses. Progress is monitored through the Activity and Mobility dashboard; in April 2024, over 70% of all eligible patients met their daily mobility goal.
Next steps are to share the strategies and lessons learned with all nursing units, standardize communication of patient mobility performance to frontline caregivers and leadership, and partner with Care Standardization.
All mobility pilot units improved the percent of patients achieving their mobility goals, with an average improvement of 18%.
Flow
Streamline the flow of patients across our health care system through improved organizational efficiencies, elimination of waste and coordination of transitions of care.
Hospital Length of Stay (LOS)
ChristianaCare’s Flow Committee drives 5% improvement in hospital LOS index
An FY 24 Strengthen the Core annual operating plan goal focused on reducing hospital LOS as well as the observed to risk-adjusted LOS index, which accounts for patient severity.
ChristianaCare’s Flow Committee drives improvement in key opportunity areas that may adversely impact the number of days patients remain in the hospital, such as timely discharge planning, efficient transitioning to postacute care, advancing effective communication among members of the care team and addressing patient complexity.
With care management, the Flow Committee worked to reduce barriers through multidisciplinary rounds, collaboration with post-acute facilities and modifications of the patient/family choice process to reduce delays in placement.
In addition, a Challenging Emergency Department Discharge Process was implemented to avoid inpatient hospital stays for patients presenting to the ED without medical needs but with social or logistic barriers that prolong length of stay. Social workers collaborate with the ED team to support appropriate discharge from the emergency room. These efforts led to
incremental improvement toward the end of FY 24, with a 5% improvement in the LOS index and a decrease in hospital length of stay to fewer than six days.
Hospital Length of Stay
Jul-22Aug-22Sep-22Oct-22Nov-22Dec-22Jan-23Feb-23Mar-23Apr-23May-23Jun-23Jul-23Aug-23Sep-23Oct-23Nov-23Dec-23Jan-24Feb-24Mar-24Apr-24
Overall in FY 24, the LOS Index (observed to expected ratio) improved 5%, from 1.190 to 1.126. During the same period, LOS decreased 2%.
Observation (OBS) Length of Stay
OBS length of stay flat with 22% increase in patients served
Observation care involves treatment, assessment and reassessment to determine if a patient may be safely discharged or requires inpatient care. Generally, observation patients stay in the hospital for less than 48 hours. In FY 24, several improvements were advanced to improve LOS in observation areas:
• Co-located Christiana Hospital complex medical observation patients on two units; new Medical Observation Unit (MOU) opened in April.
• Appointed a dedicated Observation Care team that includes physicians and advanced practice clinicians and embedded daily MDRs and huddles.
• Admission criteria revised to serve higher complexity Medical Observation patients.
• Revised diagnosis-specific observation admission order sets with > 85% utilization adherence.
• Set expectation for use of Vocera to improve timing of consults and communication.
• Collaborated with MRI and transport to expedite observation patients, decreasing Turnaround Time by 2.75 hours.
Through cohorting, the number of OBS patients treated on the MOU increased 22%.
Length of stay remained flat at 26.2 hours increased patient complexity.
Observation Length of Stay Medical Observation
OBS LOS Rolling 3-month
Length of stay for medical observation patients remained flat at 26.2 hours for the most recent three-month period (February–April 2024) compared to February–April 2023.
The number of monthly medical observation patients increased by 22%, from 265 to 325.
In FY 24, a new process improvement subgroup of the HomeHealth statewide Quality & Safety Committee prioritized improving the time it takes to get patients started in home care. Through chart audits, the multidisciplinary group identified staffing challenges and gaps in the referral process. To help improve the process and promote timely admissions, HomeHealth intensified caregiver education on best practices with data entry of referral information.
HomeHealth Timeliness of Service
96% of patients seen within 48 hours of referral
Timeliness of Service
Jul-22Aug-22Sep-22Oct-22Nov-22Dec-22Jan-23Feb-23Mar-23Apr-23May-23Jun-23Jul-23Aug-23Sep-23Oct-23Nov-23Dec-23Jan-24Feb-24Mar-24Apr-24
The percentage of HomeHealth patients seen within 48 hours of referral or on the Physician-Ordered Date improved from 94% in FY 23 to 96% FY 24, exceeding the agency’s 95% target.
Health Equity
Address disparities and achieve equity in our quality of care, assuring culturally, linguistically and socially responsive care, particularly for underserved members of our community.
Sexual Orientation and Gender Identity (SOGI) Information & Race, Ethnicity and Language (REL) Information
Gender identity data collection improves by 25% in four months
The National Institutes of Health, Centers for Disease Control, American Academy of Pediatrics, American Academy of Family Physicians and many other national and international organizations recommend that health care providers adopt patient naming conventions and inclusive models for collecting patient gender identity information.
In FY 24, ChristianaCare's Health Equity Office implemented the "We Ask Because We Care" campaign to improve capture of patientreported SOGI and REL demographic information. The extensive multidisciplinary effort involved updating systemwide protocols for data collection, documentation and reporting of five elements: patient’s name used, gender identity, sex at birth, sex on legal identification and pronouns, educating caregivers and patients as well as modifying the electronic medical record and workflows to appropriately use the additional gender identity data. At the same time, efforts were made to improve the collection and accuracy of patient-reported race, ethnicity and language.
SOGI Data Completeness
12/3/2023 1/3/2024 2/3/2024 3/3/2024 4/3/2024 5/3/2024
Collection of gender identity data across all settings improved 25%, from less than 51% in December 2023 to 75% in April 2024. During the same period, birth sex completeness increased 29%, to 71% from 43%.
82% of eligible patients prescreened for SDoH Social Drivers of Health (SDoH)
To provide equitable care to the communities we serve, we must do more than provide excellent clinical services we must understand who our patients are and what their lives are like. This includes knowing and addressing SOGI, REL and social drivers of health. In 2024, CMS began requiring hospitals to screen patients for five domains of SDoH: food insecurity, interpersonal safety, housing insecurity, transportation insecurity and utilities.
Through the registration and nursing assessment process, all adult medical, surgical and maternity patients are prescreened. When patients indicate social care needs or their needs are undetermined, our Acute Care Social Care Connectors complete a full needs assessment. To address identified needs, the care connectors make appropriate referrals for services to Unite Delaware, which provides a closed loop communication to indicate when services are received.
Overall, 10% of prescreened patients had one or more social needs identified. Positive rates were higher at Cecil County (13%) and Wilmington (12%) campuses.
Cecil County Newark Wilmington Total
SDoH Prescreen Needs Identified
Limited English Proficiency (LEP)
Translated discharge instructions for LEP patients up by 30%
Understanding hospital discharge plans is crucial for patients, as it directly impacts their recovery and overall health outcomes.
Clear instructions in patients’ preferred languages help ensure they follow prescribed medications, adhere to activity restrictions and attend follow-up appointments. Miscommunication can lead to medication errors, complications and readmissions, increasing health care costs and risking patient safety.
In FY 24, ChristianaCare increased the percentage of patients with limited English proficiency receiving translated discharge instructions in their preferred language from 0% to 30%. Among the activities enacted to drive this increase were adding automatic alerts for the Language Services' translation team, improving documentation of interpreters used in the PowerChart ARP, and asking patients for their preferred method to receive discharge instructions.
After the implementation of FY 24 activities, the percentage of patients with LEP who received translated discharge instructions increased from 0% to 30% across ChristianaCare’s three campuses.
LEP Translated Discharge Instructions
ChristianaCare Way Awards
ChristianaCare Way Awards
2023 President’s Award
Clean Catheter, Happy Bladder: A CAUTI Prevention and Foley Vacation Project
A new program reduced the incidence of catheter-associated urinary tract infection (CAUTI) in the Transitional Medical Unit (TMU). Between July and September 2022, the TMU’s CAUTI comprehensive unit-based safety program (CUSP) found an increase in CAUTI rates. They identified that timely Foley removal could prevent infection. In January 2023, an algorithm-based protocol, Foley Vacation, was implemented, empowering nurses to remove Foleys when patients began retaining urine so they could begin bladder training. CAUTI rates dropped from 6.3 to 0.0. No removed Foleys were reinserted, and every patient resumed voiding independently (100%). The algorithm, now called PREP (Post Retention Elimination Protocol), was implemented across all three hospital campuses in May 2023.
Zero Hero Award – Whitney Lane, RN, Labor & Delivery
Incorrect Documentation of Insulin Drip Premix Bags
Insulin drip premix bags were scanning incorrectly in the Medication Administration Record, even with an override. The concen tration was listed as 1 unit to 0.1 mL, instead of 1 unit to 1 mL. After the issue was escalated, a background mapping issue, which had mismatched the adult product concentration (1 unit/mL) with a product for neonates (0.1 unit/mL), was detected and corrected.
Magnet New Knowledge, Interventions & Improvements – Silver Award
To Using the Ipsilateral Arm in Breast Cancer Patients: A Practice Change
Caregivers hadn’t used a patient’s ipsilateral arm (the arm on the side where the procedure occurred) for blood pressure measurement, blood draws or IV access after mastectomy or related procedures, although the practice wasn’t evidence-based. This sometimes led to inaccurate calf blood pressures, foot stick orders for phlebotomy or the need for tunneled central venous catheters. The team replaced patients’ orange “limb restriction – do not use” bands with gray “limb alert” bands, which could be used if the other arm could not be used. After eight months of lifted limb restrictions, there was zero incidence of lymphedema with ipsilateral arm use, zero orders for foot sticks and zero calf blood pressure measurements.
ChristianaCare Way Awards
Magnet New Knowledge, Interventions & Improvements – Gold Award
Harry, Not All Wizards Are Good! Obliviating the Medication Administration Wizard
PowerChart gained a new tool in July 2020, to chart emergency doses of medication to certain patients. The Medication Adminis tration Wizard (MAW) was used to document emergently given medication doses when there was no order in PowerChart and a delay could harm the patient. The MAW was also used at times to bypass required patient and medication bar code scans, and to chart non-emergent doses of active orders. Medication Safety created a report of non-emergent
MAW use and engaged leadership in Nursing and Respiratory Therapy regarding the intended usage of MAW in emergent situations. This helped the overall scan rate increase from 95% to 98%. At the same time, the number of non-emergent doses that were not scanned decreased by 76%.
Magnet Transformational Leadership Award
Innovating Nursing Practice: Virtual Care Nurse Model Delivers Outcome Improvements
A collaboration among Nursing, Information Technology and the Center for Virtual Health resulted in an innovative care delivery model that reduces the burden on clinical nurses while providing high-quality care. The Virtual Acute Care Nurse uses tablet devices so that virtual nurses can see, hear and communicate with patients, family members and clinicians. The virtual nurses handle tasks like patient safety, education, care coordination and discharge. The virtual delivery model was piloted incrementally on Wilmington 5W and Newark 4B between September 2022 and March 2023. The patient experience percentile ranks improved in both units. Length of stay decreased by an average of 0.6 days, and there were 6% fewer readmissions.
Magnet Exemplary Professional Practice Award
Fall Reduction in the Clinical Decision Unit—A Standardized Approach
Seventeen patients in Union Hospital’s Clinical Decision Unit experienced falls in FY 22. The root causes included variations in nursing assessments of patients’ risk for falls, as well as a need for interventions to prevent falls. Different strategies were implemented to decrease the risk of falls. Patients in the unit were not allowed to toilet alone. Exit alarms were placed on all patient beds and room chairs. All ambulating patients were placed in gait belts, and all patients wore nonslip footwear. Patients were taught fall-prevention strategies when they arrived in the unit. These changes helped decrease falls by 70% with only five falls in FY 23.
ChristianaCare Way Awards
Magnet Structural Empowerment Award
Reduce Inpatient HAPI rate by 30% in FY 23, Union Hospital
The rate of hospital-acquired pressure injuries (HAPI) at Union Hospital was too high in FY 22, with 79 cases overall and 25 cases at stage 2 or higher. Despite many initiatives in the second half of FY 22, the HAPI rate didn’t decrease. To change this, a multidisciplinary Pressure Injury Prevention team educated the entire inpatient nursing staff, aligning with the Delaware campuses’ best practices and policies. Nurses learned about the Braden Risk Assessment Tool and interventions, and how to modify documentation for medical device use. After the education initiative, HAPI cases dropped by 53%. There were 30 HAPI cases in FY 23, a decrease from 79, and only 10 HAPI cases reached stage 2 or higher, compared to 25 cases in FY 22.
Transformation Award
Mastering the Mortality Matrix
When ChristianaCare received a Vizient mortality ranking of 71 out of 107 academic medical centers, the numbers did not reflect ChristianaCare’s high-quality clinical care.
The result prompted Clinical Documentation Integrity (CDI) to create a multidisciplinary approach to mortality reviews, to ensure accurate risk capture. In order to capture more complete data, CDI aligned with physicians, finance and coders, and implemented 48-hour bill-hold for case review, query escalation, all-cause mortality review, clinical opportunity improvement and continuous monitoring. The change improved patient acuity capture, which led to a 23% reduction in the observed-to-expected mortality index, from 0.91 to 0.68. ChristianaCare’s Vizient mortality ranking rose to 24 out of 116 academic medical centers
Accelerate Growth: Environmental Sustainability Award
Using an Electronic Tool for MRSA Surgical Status Documentation
Spine surgery patients who test positive for methicillin-resistant Staphylococcus aureus (MRSA) are prescribed perioperative antibiotic prophylaxis to reduce the risk of surgical site infection. Previously, Infection Prevention ordered patients’ antibiotics manually, which involved manual medical record review, manual data entry and faxing prescriptions to clinical pharmacists. The process took more than 11 hours monthly, and more than 120 pages were faxed each month. Infection Prevention had Perioperative Clinical Support create an electronic report that pre -populates with patients’ known MRSA status. Electronic reports are ecofriendly, decreasing paper usage and printing costs. The change has decreased the amount of time that Infection Prevention spends on MRSA perioperative antibiotic prescriptions by 59%.
ChristianaCare Way Awards
Enable Every Caregiver to Thrive Award
Daring to De-escalate: Increasing Caregiver Access to Workplace Violence Education
The number of workplace violence incidents at ChristianaCare increased from 574 in FY 21 to 626 in FY 22. During that time frame, only 848 caregivers were trained in de-escalation techniques. To increase the number of trained caregivers, the Workplace Civility education subcommittee teamed with LearningSpace and iLEAD to expand training. Caregivers in high-risk areas were offered an eight-hour Nonviolent Crisis Intervention course. Caregivers in moderate- and low-risk areas were offered a four-hour Verbal Intervention course. The team increased the number of instructors and created flexible training options. In FY 23, the number of caregivers who were trained in de-escalation techniques increased by more than 77%, to 1,506.
Radically Simplify Access Award – Silver – and People’s Choice Award
Access Made Easy: Improving WAM Follow–up Appointments
Patients who were discharged from the Emergency Department (ED) between September and November 2022 had to wait 29 days on av erage to follow up with their Wilmington Adult Medicine primary care providers because of scheduling conflicts. The team revised their scheduling process, creating specific hold slots for ED follow-ups, pre-op appointments and inpatient follow-ups. They also had a senior scheduler review to ensure correct scheduling. This increased the efficiency of the scheduling process by 62%. By March 2023, patients discharged from the ED waited only seven days, on average, for follow-up appointments.
Radically Simplify Access – Gold
Increasing Wilmington OR Ophthalmology Surgery First Case On-Time Starts
Wilmington Ophthalmology has 63 surgical cases each month, on average, but the percentage of first case on-time starts was only 35%. The team of nurses, surgeons, surgical technicians and anesthesia providers adopted strategies to improve the percentage of on-time starts. Eyedrop orders were prioritized by noon the business day before the scheduled surgery. First case calls were used to emphasize the importance of two-hour patient arrival time. The team provided nursing education and cross-training for post-op focus, to move patients through phase 2 more quickly. Within two months, first case on-time starts increased to 43%.
ChristianaCare Way Awards
End Disparities Award
Expansion of High-Level Imaging on the Wilmington Campus: A Multi-Modality Approach
Imaging discovered disparities in care relating to high-level imaging services at the Wilmington campus compared to the Newark campus. When patients were transferred to the Newark campus, turnaround times for imaging were nearly 24 hours, increasing inpatients’ length of stay. Changes were made on the Wilmington campus so that more patients could be offered high-level imaging there. Software and hardware were implemented, and caregivers received training to support cardiac computed tomography angiography (CCTA) and pacemaker placement, as well as CT - and ultrasound-guided procedures. Within eight months, 86 inpatient CCTA exams were completed on the Wilmington campus. Because patients didn’t nee d to be transferred, the turnaround time decreased from nearly 24 hours to eight hours, and the cost savings was $96,000. Having the ability to offer MRI to patients reduced transfers, saving $44,000. The addition of an on-site radiologist allowed for 36 outpatient procedures.
Strengthen the Core: Flow Award – Bronze
Let’s Get VERT-ical
Because of the COVID-19 pandemic, the ChristianaCare Emergency Department (CED) has experienced a return to greater numbers of patients, including higher acuity patients, as well as throughput barriers. The CED Leadership Team and Organizational Excellence partnered to improve door-to-doctor time, left-without-treatment rates and length of stay. They implemented three pilot programs. During check-in, immediately after window intake, patients had their vital signs collected. A dedicated nursing and physician team provided patient evaluation and triage. And vertical care identified middle-acuity, ambulatory patients who could safely receive care in a nontraditional setting through a new care pathway. These changes led to a 30% improvement in median door-to-doctor time (47 minutes instead of 67 minutes) and left-without-treatment rates decreased by 2%.
ChristianaCare Way Awards
Strengthen the Core: Flow Award – Silver
The Newborn Hospital Stay: Maximizing Value Without Sacrificing Patient Experience
When a mother and baby are medically stable, timely discharge of the couplet is an important cost-saving measure that aligns with ChristianaCare’s organizational goals. Timing of discharge varies, depending on the method of delivery, maternal and neonatal medical conditions and maternal preference. C hristianaCare pediatric hospitalists see more than half of all well newborns. They focused on readiness for discharge with day-of-birth discharge planning, as well as standardized processes and clinical care to increase efficiency. These changes helped increase the number of babies discharged by noon from 59% to 71%. Length of stay decreased from 54.9 hours to 52.2 hours. When these changes were implemented, net promoter scores for the Postpartum unit increased.
Strengthen the Core: Flow Award – Gold
Streamlining Success: Enhancing Efficiency in Express Admissions
In 2019, the Clinical Express Admissions (CEAD) Unit opened to improve flow among patients who were admitted through the Emer gency Department (ED). CEAD completed admission work and started treatment for admitted patients, aiming to move them to their intended medical units within four hours. However, CEAD had become a boarding unit by December 2022, with the median length of stay at 40.2 hours. To improve patient flow, the CEAD staffing model was changed from unit-based with a floating nurse to 100% unit-based. Transitional beds were added, with criteria for low-acuity patients. The role of the charge nurse was changed to a flow resource nurse to facilitate flow among the ED, CEAD and floor units. Within six months, the CEAD median length of stay decreased to 11 hours, saving an estimated $1.3 million.
Strengthen the Core: Quality Award – Bronze
Achieving Inpatients Daily Mobility Goal
Inpatient immobility has been associated with decline in patient function, longer lengths of stay and increased patient harm, such as pressure injuries. The Johns Hopkins Activity and Mobility Promotion (JH-AMP) program standardizes mobility language for inpatients. It embeds tools, so caregivers can set personalized daily mobility goals for each patient and monitor the daily progress toward their goals. After the JH-AMP program was implemented systemwide, a nursing and rehabilitation team established a pilot program, working with four units to focus on meeting daily mobility goals through nursing tasks and physical therapist documentation. All units demonstrated performance improvements, and an additional 9% of patients met their daily goals. There were no adverse effects during the pilot program, such as patient falls or caregiver patient-handling injuries.
ChristianaCare Way Awards
Strengthen the Core: Quality Award – Silver
An Aspiration to Eliminate Aspiration: Implementing a Post -Extubation Swallow Screen
Patients who are intubated for more than 48 hours are at greater risk of dysphagia, silent aspiration and aspiration pneumonia. ChristianaCare’s intensive care units did not have standard protocols to assess patients’ swallowing after extubating. A Post-Extubation Dysphagia Screen was developed and implemented in ICUs across all three hospital campuses. Four hours after extubating, a PowerChart task triggered for nurses to screen for dysphagia. When patients fail the screen, an evaluation by a speech language pathologist is triggered in PowerChart. The screening tool increased the percentage of swallow screens from 43% to 96%. The p ercentage of patients who failed the screen who met with a speech language pathologist increased from 48% to 96%, resulting in a 62% increase in the number of patients who received a modified diet to prevent aspiration.
Strengthen the Core: Quality Award – Gold
Protecting the Preemie Brain: Preventing Intraventricular Hemorrhage in Tiny Babies
Infants born before 29 weeks are at risk of complications, including intraventricular hemorrhage (IVH), or bleeding in the br ain. IVH may cause neurologic damage or death. Hypothermia increases the risk of IVH, sepsis and death. ChristianaCare’s rate of admission hypothermia was higher than peer rates, and there was opportunity to improve IVH rates. The NICU team modified evidence-based protocols to focus on thermoregulation during the first hour of life, known as the Golden Hour. They also developed neuroprotective strategies that focused on markers for the first 72 hours and the first week of an infant’s life. Implementation of these strategies led to a significant decrease in rates of admission hypothermia, dropping from 44% to less than 7%. Despite the fact that the number of extremely premature babies delivered at ChristianaCare has increased, the incidence of severe IVH has decreased by more than 15% above the risk-adjusted expected rate.
ChristianaCare Way Awards
Strengthen the Core: Safety Award – Bronze
I’m OVER the Risk: Pharmacists Find Ways to Reduce ADC Overrides in Women’s Health
Medications dispensed to inpatients from automated dispensing cabinets (ADCs) bypass pharmacist review, which may lead to med ication errors in some instances. The Joint Commission’s medication management standards require that hospitals using ADCs must have a policy that describes the types and frequency of medication override review. ChristianaCare’s Center for Women and Children’s Health did not have a specific override list, and override rates were as high as 30% in some areas. Pharmacy conducted a medication-use evaluation to correct this oversight. They added orders to PowerPlan for commonly overridden medications. They also created an override list specific to women’s health, with 16 additional medications. These changes met Joint Commission standards, and overrides in Women and Children’s Health decreased by over 18%.
Strengthen the Core: Safety Award – Silver
Suicide Prevention Pathway
ChristianaCare was the first hospital in Delaware to routinely screen all admissions for suicide risk, but changes were needed to meet Joint Commission requirements for suicide prevention relating to screening, tracking and follow-ups. A multidisciplinary team led by Psychiatry & Behavioral Health developed a Patient-Answered Risk Prevention Questionnaire to assess patient risk and protective factors, and to improve access for patients at low and moderate risk. The questionnaire created automatic firing for opt-in evaluations, based on patient responses, and a dashboard allowed for improved patient tracking. More than 2,000 risk-stratified patients received evaluations using the new questionnaire, at an opt-in rate of 60%. If only 1% of the evaluations prevent suicide, 22 lives may be saved each year.
ChristianaCare Way Awards
Strengthen the Core: Safety Award – Gold
Don’t Wait! A SmartZone Alert Prevents Hospital-Onset C. difficile
A case review of hospital-onset C. difficile cases found that half of the cases could have been prevented by earlier testing. Hospital-onset C. difficile cases have an incremental average length of stay of 11 days. They also have an attributable cost of $34,000 per patient, while community-onset cases have an attributable cost of $20,000 per patient. A SmartZone alert was created to notify clinicians when patients have diarrhea within the first three days of admission, when the C. difficile is attributable to community onset versus hospital onset. The SmartZone alert was adopted systemwide in March 2023, after a successful pilot program. Within a four-month period, the SmartZone alerts prevented eight cases of hospital-onset C. difficile.
Through August 2023, at least 12 hospital-onset cases were prevented.
Value Award
Maximizing Value of Type and Screen Testing for Obstetrical Patients
Type and Screen (T&S) blood tests may be offered during pregnancy to ensure that patients who need blood transfusions receive transfused blood that is compatible with them to prevent adverse reactions. Most pregnant patients who receive T&S blood tests at ChristianaCare never need blood transfusions, yet more than $1 million has been spent annually on the tests. In 2021, only 7% of obstetric patients who had a T&S test received blood transfusions. Because T&S tests have quick turnaround times and there is minimal risk of using emergency release (uncross-matched) blood, the team created a screening protocol to focus testing efforts on the highest-risk patients. In one year, the OB Type & Screen protocol decreased the number of tests administered by more than 50%, reducing costs by $607,000. There was no increase in the number of patients who needed blood transfusions or emergency-release blood during that time frame.
ChristianaCare by the Numbers
ADMISSIONS
61,103 BIRTHS
6,709 OUTPATIENT VISITS
873,875 RADIOLOGY PROCEDURES
549,391 SURGICAL PROCEDURES 39,425 HOMEHEALTH VISITS 208,075
HOSPITAL - BASED LAB TESTS
4,535,338 PRIMARY CARE OFFICE VISITS
294,844 URGENT CARE CENTER VISITS 209,514 VIRTUAL VISITS 22,188 EMERGENCY DEPT. VISITS
CAREGIVERS 13,784 RESIDENTS & FELLOWS 308 VOLUNTEERS (72,802 Volunteer hours) 669 OUR PEOPLE
227,145
About ChristianaCare
Headquartered in Wilmington, Delaware, ChristianaCare is one of the country’s most dynamic health care organizations, centered on improving health outcomes, making high-quality care more accessible and lowering health care costs.
ChristianaCare includes an extensive network of primary care and outpatient services, home health care, urgent care centers, three hospitals (1,430 beds), a freestanding emergency department, a Level I trauma center and a Level III neonatal intensive care unit, a comprehensive stroke center and regional centers of excellence in heart and vascular care, cancer care and women’s health. It also includes the pioneering Gene Editing Institute.
ChristianaCare is nationally recognized as a great place to work, rated by Forbes as the 2nd best health system for diversity and inclusion, and the 29th best health system to work for in the United States, and by IDG Computerworld as one of the nation’s Best Places to Work in IT. ChristianaCare is rated by Healthgrades as one of America’s 50 Best Hospitals and continually ranked among the nation’s best by U.S. News & World Report, Newsweek and other national quality ratings.
ChristianaCare is a nonprofit teaching health system with more than 260 residents and fellows. With its groundbreaking Center for Virtual Health and a focus on population health and value-based care, ChristianaCare is shaping the future of health care. 800 - 693 - CARE | ChristianaCare.org