“We talked to the people in nursing, we talked to the people in respiratory therapy, we talked to the medical staff, and talked to the people in radiology. Everybody agreed, ‘Yep, there’s a problem. Let’s look at this a little deeper.'”
September 2023
In this session of Quality Time: Sharing PIE, mentors Kathe Bryant from Covington County Hospital in Collins, Mississippi, and Cara Cruz from Carson Valley Medical Center (CVMC) in Gardnerville, Nevada, share the proactive approaches they took to improve their swing bed programs.
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 Kathe BryantCovington County Hospital Collins, MS |
 Cara CruzCarson Valley Medical Center Gardnerville, NV |
Transcript: Improving Swing Bed Quality
Note: Quality Time: Sharing PIE is produced for the ear and designed to be heard. This transcript is intended to augment the recording.
Narrator: In this session of Quality Time: Sharing PIE, mentors Kathe Bryant from Covington County Hospital in Collins, Mississippi, and Cara Cruz from Carson Valley Medical Center (CVMC) in Gardnerville, Nevada, share the proactive approaches they took to improve their swing bed programs.
Cara: Both your hospital and our hospital have Swing Bed Programs, so we are here to talk about swing bed quality and critical access hospitals. Kathe, do you wanna tell us a little bit about your hospital?
Kathe: Covington County Hospital is a 25-bed critical access hospital. We carry a large volume of swing bed patients who come in from hospitals much larger around us within usually a 30-to-60-mile radius. we take a lot of patients who have joint replacement, who have had cardiac surgery or a long extended illness, even COVID and they’re just too weak to go home but not sick enough for a nursing home. Maybe they still need, you know, significant nursing care. So, they’ll come to swing bed, and the general stay is about 20 days. There are some whose insurance allows them to stay longer. Some of them can do their therapy and feel like they could manage it at home and may not stay the full 20 days. But it’s generally about a 20-day stay.
Cara: Awesome. And then our hospital, we are Carson Valley Health in Gardnerville, Nevada, just over the hill from Lake Tahoe. We are a 23-bed critical access hospital. And we get basically two types of patients in our area. Almost all of them are inpatient with us first. Sometimes, we get transfers some from some of the bigger hospitals in Reno, Nevada, but typically we have swing patients who either need extended antibiotics extended rehab, or physical rehabilitation. We have also a very large amount of orthopedic surgeons and surgeries here. That’s our biggest specialty. We do probably around 400 orthopedic cases every month. We’re a larger size critical access hospital. Kathe, you had a great story in regards to reducing healthcare-associated infections with pneumonia and/or swing-bed patients.
Kathe: Several years ago, we noticed that we had a cluster of patients who were swing bed patients, not here with anything that should have cause them to get pneumonia, but they were developing pneumonia. So, we talked to the people in nursing, and we talked to the people in respiratory therapy, we talked to the medical staff, talked to the people in radiology. Everybody agreed, “Yep, there’s a problem. Let’s look at this a little deeper.” So, we all got together as a group to discuss what’s happening? Why is this happening? Where are we falling short? Or is this just some sort of strange coincidence that these many patients have picked up pneumonia? And it was like, we would never have any hospital-onset pneumonias and all of a sudden, we have three.
So, when we sat down together as a group to talk about what could be the problem, we discovered a few things that were alarming and things that as an infection preventionist, I was thinking, “Oh, my goodness, I should have had my finger on this already and known that we were gonna have a problem before we ever had this problem.” And I say that because, we found out that even though our patients were being transferred in from other hospitals with an incentive spirometer device, nobody here was having them use it. it just sort of came with them in their packed clothes and their suitcase, and somebody would lay it on the side table and just assume that the patients had been trained on it at the previous hospital and would continue to use it. Well, we should have known better.
So the nurses weren’t saying, “Hey, here’s your incentive spirometer. You should be using this. Let’s do this together.” They were just leaving it on the bedside table and assuming that either the patient was doing it or that respiratory therapy was coming in and doing it. So respiratory therapy immediately said, “We never go in those patients’ rooms unless we are doing treatment or something on a patient. We don’t go in their rooms.” So that backed us up to thinking, “Well, you know, is this a patient, if we did an evaluation on them, to begin with, we could maybe figure out as soon as they’re admitted this person has potential for pneumonia. We need to go ahead and get proactive and try to start some treatments, teach ’em some postural drainage, and do incentive spirometry and get those things part of this patient’s routine.”
We asked the providers, “Can we just go ahead and order a respiratory therapy evaluation upon admission?” Because we already had physical therapy, occupational therapy, and speech evaluations upon admission, so let’s go ahead and see what they are like in their pulmonary status when we get them and if we need to jump on something early, we can. The provider that was in the meeting said, “I think it’s a good idea. Let’s take it to medical staff.” As the infection prevention nurse here and the director of quality and safety, I go to the medical staff meetings, and I brought it up in there, and the physician champion backed me up and said, “You know I think this is a good idea. I think we should see what we can do on the front end and try to get this averted before it begins.” So the medical staff ask lots of questions about it, and we showed them the number, why we were so concerned about it, and that these were not patients who might have been prone to pneumonia because of the surgery they had, instead they were just patients who may be had a knee or a hip and there was no reason for them to be getting pneumonia. So, once we agreed that it would appropriate for the nurses to order a respiratory therapy consult on admission, that’s when our respiratory people stepped in they would go in and assess each new swing bed patient, they would listen to their lungs, check at O2 set, look at their work of breathing and ask them some history about their respiratory status. And then they could make a recommendation, such as well, this patient already sounds like he might have some atelectasis going or some decreased breath sounds. Let’s start this patient on nebulizers, and they would make a recommendation to the provider. So, we became really proactive about it and within one month we have no more pneumonias, and we now do that, we’ve been doing it for several years, and we have not had another pneumonia since we started doing it.
Cara: Wow! That’s pretty amazing.
Kathe: It was amazing. It was such a simple communication. You know, everybody thought somebody else saying, “Hey, you should use this instead of spirometer,” and nobody was doing it, and so consequently, they were not doing any pulmonary respiratory therapy. And it was really alarming how quickly they were actually progressing to pneumonia.
Cara: Yeah, and just one little thing that you discovered made such a huge improvement.
Kathe: Yeah, we were really pleased about it.
Cara: So for us, one process improvement that we are still actively doing, just improving the documentation and coordination of our swing bed patients. We have anywhere between one and three swing bed patients a day here. And so, when we started our swing bed patient program, we did really great, and we went to other hospitals and saw how they met their quality metrics and how the process work for them. And then we said, “Okay, we have a great Swing Bed Program,” and then didn’t really pay a whole lot of attention to it for a little while, and when we circled back to it, looking at documentation we found that, oh, we’re not doing so great with all of our documentation and a lot, and what prompted that is a lot of the regulations were updated or changed so we went back to see how we were, falling with them.
So, we started really doing the audit. We created an audit template of metrics that are based pretty much right off the regulation or the appendix for swing beds. Stratis Health has that if anybody wants to see what that looks like. And so, we started every month now, and we audit our compliance on every swing bed patient I would discharge. So sometimes we have as low as one in a month, sometimes we have seven in a month. It just depends on our volumes. We found we weren’t scoring well, and we didn’t have consistent documentation, so we got a group together to really look into this and start looking for opportunities for improvement. Our group contains our chief nursing officer, our inpatient manager, our rehab manager, our clinic, clinical act, analyst who is the one that does the chart reviews and quality, and myself, I’m a director of risk and quality, also our infection prevention and patients’ safety officer. We also included one of our EMR staff for liaisons too so that when we identified issues in our documentation, she can help us fix it. Our metrics that we started really looking at our weighted and non-weighted metrics. We broke it up into two sections. We said we’re gonna have a score. What are the really important metrics, and those metrics are scored overall compliance? And then those roll up to our quality dashboard for the whole organization so we can easily look at how we’re doing with those. And then they also are tied to scorecards for the people who are responsible for swing bed like our rehab and our inpatient manager. They have it on their scorecard as well. And then we have non-weighted metrics which are things that we just say, “Okay, we wanna keep an eye on this, we’re not sure if this is a problem. Let’s put it on, take it off. If we’re doing fine or, gosh, we just wanna make sure that we’re compliant with that.” So those are our non-weighted metrics or things that really are physician-related. We look at comprehensive assessments that are completed timely per with every discipline which is within seven days. we look at swing bed comprehensive care plan and make sure that it’s complete and it has measurable goals per applicable discipline (laughs) and that’s our biggest struggle and that continues to be our biggest struggle, but we are finally starting to see improvement on that because the multidisciplinary team is big. That’s your dietician, your inpatient nurse. Even now, the regulation includes the CNA which it didn’t used to, social worker, rehab, pharmacist all these people that have something do with the care plan of the patient. So, we meet with our swing patients and do our interdisciplinary team meetings with the patient and their family every Wednesday. One of things we found is that’s not how we’re documenting it. People are not always documenting consistently, and there is an issue with our EMR.
Cara: And then we also assigned our case manager to kinda be the lookout person. If one person misses their documentation or doesn’t include measurable goals, et cetera, then the whole entire measure gets marked off. So, we have a case manager now every day after the Wednesday meeting at the end of our shifts. She’ll circle back around and say, “Okay, did we get all the players to document in here, and were there measurable goals?” And if not, she’ll follow up with those team members and say, “Hey, remember, do your documentation.” So that’s really made a big improvement for us, having someone to really watch over that and make sure it’s being completed. We look out for the resident rights being signed in the chart, whether our skilled rehab therapy services are completed five days a week. If it’s a patient here for therapy, we make sure that the notice of Medicare non-coverage is presented to the resident when swing services are ending and within the right timeframe. All those metrics were our weighted metrics, and then some of our non-weighted metrics are on the baseline care plan being complete within 48 hours and we move that down to non, measured because we always were getting a very high score like 98 to 100% compliance. And our discharge orders from acute inpatient present before the patient is changed to swing status, are there actual orders from the physician in there? Are the resident absent release forms completed when applicable and, and before the trip resident would transfer from the facility was a resident or representative notified in writing. We meet every month and we go back and we review in depth the chart audit result and if there’s anyone discipline falling out, then that leader will be responsible to go back and follow up and make sure there’s improvement there, and we always look at success stories like what were the positive things we were able to do and change and we always have a section to look at what are the barriers and problems we’re facing and how can we remove those every month. So, our biggest problem and barrier really is just the documentation and the EMR ’cause everybody had a document a different way in their template. We’re in the process of streamlining that to make everybody has the same kinda documentation workflow and just make it easy to do the right documentation that we need.
Kathe: That sounds great. It sounds like you have been working very, very hard.
Cara: Yes (laughs). Still, it just is difficult because it’s an all-or-nothing. Everybody has to do their piece, or we don’t get credit. (laughs)
Kathe: I guess it kinda helps to have a little bit of you don’t wanna be the one to let the team down.
Cara: Yes, (laughs) absolutely. Are there any other quality metrics that you look after for your swing patients in your hospital that you haven’t already mentioned?
Kathe: Ah, well, one thing we’re looking at is, how often does a patient go from our observation service to our acute care service and then onto our swing bed service, and then how are we doing at placing them back at their regular, level of function did they go back to their home? Did they go to a nursing home? you know, how are we doing? Are we making sure that they get services after discharge that they need? We are having to really work to make sure that the whole picture is in the chart.
Cara: Yes, great point. We also look at, are all our other quality metrics are also considered for our swing patients as well? So even though they’re kind of like an outpatient or have a different status, we still monitor them for a healthcare-associated condition, healthcare-associated infection medication event falls and everything else that we would monitor and take interventions for our normal inpatients. We also include our swing bed patients in those metrics just to make that they’re still having the same level of, of safety and expectations at our hospital as well.
Kathe: We do our swing bed meeting a little differently from you. You were saying that you include the patient or their family in the meeting and we sometimes will have a family member in the meeting but we have all the players at the table except the patient because we discuss all the patients in the meeting. And then each provider or service line goes back to the patient and tells them about the meeting, but they’re actually not in that meeting because all of the patients are discussed. Maybe we need to think about trying to figure out a way to add them in ’cause I really think that that is a really great thing to be doing.
Cara: Yeah. We don’t have as many as you do on a daily basis but we’ll kinda just move from room to room and we’ll do this patient with this family in the room, and then we’ll move to the next room and do the meeting there. So we just kind of are a mobile show. (laughs)
Kathe: I like it.
Cara: With disciplinary team meetings, just once a week.
Kathe: I think that’s a great idea. we might not be able to get them all done in one day, but we could split it up and still get it done in the patient’s presence.
Cara: Some of our other barriers are just like I said, the metrics are all or nothing. Just keeping everybody informed and and making sure everyone knows the expectations of documentation is a challenge in and of itself.
And then also the last barrier for us that’s notable is when we consider accepting patients into our Swing Bed Program, making sure that they have a safe discharge plan. If they don’t have safe discharge plan, a lot of times we can’t accept them into the program. We have a process in place to have the physician, case management or utilization review team, and nursing review the potential patient to make sure that they’re an applicable patient for us and they have a safe discharge plan. So that has also been a bit of a challenge as well.
Cara: We’ve really had to beef up our screening process to make sure they have safe discharge plan before we can accept patient in the program.
Kathe: Well, I think that’s a really smart measure to be looking at. I, we could probably focus a little more on that ’cause we get that challenge as well.
Cara: Yeah.