NICHE Members Choosing Wisely® to Ensure High-Value Care

Within the past year, Nurses Improving Care for Healthsystem Elders (NICHE), a program of the NYU Rory Meyers College of Nursing, and the ABIM Foundation formed an alliance to reinforce their mutual goal of improving the quality of care. In November 2020, the organizations launched the NICHE-ABIM Foundation Choosing Wisely® Trailblazer Award. This award recognizes NICHE members who have implemented nurse-led programs that eliminate low value care and align with one of six Choosing Wisely recommendations from the American Academy of Nursing (see #1 – #6 in Box 1) or one of three additional improvement areas vital to quality care for older adults (see #7 – #9 in Box 1). Leaders of nearly 100 projects that demonstrated improvements or substantive changes in practice in these categories received this new award. Three of these projects—on antibiotic stewardship, sleep hygiene and hospice care—were highlighted during NICHE’s fall conference.

During the conference, the three project leaders discussed their projects, their change management and practice improvement approaches, and lessons learned, with the goal of inspiring other NICHE members to take on similar projects.

Antibiotic stewardship program

Dorothy Macintosh-Waddy, BSN-RN, associate director of nursing at NYC Health + Hospitals, Sea View, a 304-bed long-term care and comprehensive rehabilitation center on Staten Island,  discussed their antibiotic stewardship program. The clinical team set out to reduce the use of inappropriate antibiotic prescribing for asymptomatic bacteriuria and routine prophylaxis for skin infections and urinary tract infections (UTIs) in older adults. The team reviewed practice protocols and order sets to identify inappropriate antibiotic orders and created new order sets based on national standards. They then launched an intensive education program about appropriate use of antibiotics aimed at prescribers, nurses, and pharmacists. Nurses were empowered as de-prescribing champions to question orders and suggest alternative strategies. Within 12 months, the organization decreased inappropriate use of Augmentin for asymptomatic bacteriuria and routine prophylaxis for skin infections and UTIs by 35 percent.

Uninterrupted sleep for patients in the ICU

Susan Molitoris, BSN, RN-BC, staff nurse and interim clinical nurse educator at Riddle Hospital at Main Line Health (PA), spoke about her and her colleagues’ project Hospital ZZZZZs, which promoted a protocol to provide five hours of uninterrupted sleep for patients in the ICU. Practice changes included providing patients with earplugs, dimming lights, disconnecting phones, decreasing monitor alarm volumes, and organizing nursing care to minimize waking patients. The team designed a randomized control trial to assess the intervention’s effect on the outcomes of delirium and length of stay (LOS), and they measured delirium using the Confusion Assessment Method. Of the 338 patients in the trial, 19 developed delirium; only one of those 19 was in the sleep protocol group, a statistically significant difference. Additionally, the average ICU LOS for patients receiving the sleep protocol was 5.5 days, compared to 8.1 days for patients in the control group; they had an average hospital LOS of 11 days, compared to 13.4 days for the control group.

Expand access to hospice services for older adults

Nancy Pregnar, ScM, RN, manager of nursing professional development at Medstar’s Montgomery Medical Center (MD), established a Hospital/Hospice Relationship for General Inpatient (GIP) Care. In collaboration with a hospice partner, the Medstar team set working goals, cross walked guidelines, and established protocols and workflows to create a seamless experience for patients admitted to a GIP unit in order to expand access to hospice services for older adults. They provided education to staff at both organizations and identified metrics for success, including the number of referrals to home or GIP care, percentage of inpatient clients who fit the hospice’s admission criteria who were referred and admitted to care, and percentage of nursing documentation that met GIP requirements. Other measures of success include positive feedback from patients, families, and associates of both organizations, appropriateness of referral patterns, efficiency of the admission process, and chart audits for compliance with GIP requirements. At the time of reporting, 27 appropriate referrals to the hospice program had been made. Forty-seven percent were admitted to GIP care, and 100% of nursing documentation met regulatory requirements.