Location
Virtual Conference
Start Date
24-6-2022 1:30 PM
End Date
27-6-2022 2:10 PM
Description
BACKGROUND:
Transfusion of blood products (transfusion) occurs infrequently for most nurses yet is a high-risk procedure for patients. To ensure patient safety, Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) created regulatory standards for transfusion administration and documentation. To meet regulatory standards, transfusion events require documentation of all six critical steps and nurse leaders must monitor compliance with regulatory transfusion documentation, taking action when rates are suboptimal. Yet, transfusion documentation in the electronic health record (EHR) has been described as fragmented, confusing, and devoid of built-in prompts to facilitate completion. Checklists can organize tasks with multiple steps to enhance compliance, and automated reports eliminate the need for leaders to spend extended time manually auditing charts. In one large hospital in the Pacific Northwest where regulatory transfusion documentation compliance was suboptimal, nurses did not have a checklist for transfusion documentation and no automated report existed for reviewing transfusion documentation compliance.
PURPOSE/AIMS:
The primary objective of this quality improvement (QI) project was to increase clinical nurse compliance with regulatory transfusion documentation.
The secondary objective was to reduce the amount of time nursing leaders reported spending on transfusion compliance chart audits.
METHODS/APPROACH:
To improve transfusion regulatory compliance in a large medical center, a regulatory transfusion documentation checklist was developed in late 2020 based upon review of hospital policies, regulatory requirements, and stakeholder input. A paper copy of the checklist was supplied by blood bank with every non-emergent blood unit to be transfused. Upon completion of the paper form, the nurse returned the checklist to the manager for review against dashboard data. To streamline ongoing transfusion compliance audits, an EHR-linked transfusion dashboard was created and shared with all nurse managers to illustrate individual nurse compliance on the six aspects of regulatory transfusion documentation.
RESULTS:
A total of 2500 transfusion events were assessed across the medical center. Compliance with regulatory transfusion documentation increased from 62% to 92% following implementation of the checklist. Subsequent TJC and CMS laboratory and hospital surveys reflected compliance with transfusion documentation regulations. Nursing leadership reported that the new automated reports facilitated improved patient care due to an increase in transfusion regulatory compliance, enhanced nursing accountability and action planning to support compliance, a reduction in manager transfusion reporting workload, and streamlined transfusion compliance reporting to senior leadership.
CONCLUSION:
The process of using a paper blood transfusion checklist combined with EHR-linked dashboard auditing of transfusion compliance increased compliance with regulatory transfusion documentation and reduced nurse manager workload.
IMPLICATIONS FOR PRACTICE:
Deconstructing a complex, high-risk procedure like transfusion into a simple checklist may enhance nursing satisfaction, promote patient safety, and contribute to regulatory compliance. In addition, removal of manual audits may ease nurse leader burden to follow-up with staff who may need coaching on proper documentation practices. Next steps for this work include implementing the paper checklists and transfusion documentation dashboards across all hospitals in the entire region to monitor continued patient safety benefits for transfusion events.
References
Dang, D., & Dearholt, S. (2018). Johns Hopkins Nursing Evidence-Based Practice Third Edition: Model and Guidelines (3rd ed.). Sigma Theta Tau International.
McNett, M., Tucker, S., Thomas, B., Gorsuch, P., & Gallagher-Ford, L. (2021). Use of Implementation Science to Advance Nurse-Led Evidence-Based Practice in Clinical Settings. Nurse Leader. https://doi.org/10.1016/j.mnl.2021.11.002
Speroni, K., McLaughlin, M., & Friesen, M. A. (2020). Use of Evidence-Based Practice Models and Research Findings in Magnet-Designated Hospitals Across the United States: National survey Results. Worldviews on Evidence-Based Nursing.
Recommended Citation
Berg, Nannette and Togioka, Jennifer, "Optimization of Transfusion Administration Process: A Quality Improvement Project" (2022). 2022 Providence Nurse Research Conference. 7.
https://digitalcommons.providence.org/prov_rn_conf_22/2022/posters/7
Included in
Optimization of Transfusion Administration Process: A Quality Improvement Project
Virtual Conference
BACKGROUND:
Transfusion of blood products (transfusion) occurs infrequently for most nurses yet is a high-risk procedure for patients. To ensure patient safety, Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) created regulatory standards for transfusion administration and documentation. To meet regulatory standards, transfusion events require documentation of all six critical steps and nurse leaders must monitor compliance with regulatory transfusion documentation, taking action when rates are suboptimal. Yet, transfusion documentation in the electronic health record (EHR) has been described as fragmented, confusing, and devoid of built-in prompts to facilitate completion. Checklists can organize tasks with multiple steps to enhance compliance, and automated reports eliminate the need for leaders to spend extended time manually auditing charts. In one large hospital in the Pacific Northwest where regulatory transfusion documentation compliance was suboptimal, nurses did not have a checklist for transfusion documentation and no automated report existed for reviewing transfusion documentation compliance.
PURPOSE/AIMS:
The primary objective of this quality improvement (QI) project was to increase clinical nurse compliance with regulatory transfusion documentation.
The secondary objective was to reduce the amount of time nursing leaders reported spending on transfusion compliance chart audits.
METHODS/APPROACH:
To improve transfusion regulatory compliance in a large medical center, a regulatory transfusion documentation checklist was developed in late 2020 based upon review of hospital policies, regulatory requirements, and stakeholder input. A paper copy of the checklist was supplied by blood bank with every non-emergent blood unit to be transfused. Upon completion of the paper form, the nurse returned the checklist to the manager for review against dashboard data. To streamline ongoing transfusion compliance audits, an EHR-linked transfusion dashboard was created and shared with all nurse managers to illustrate individual nurse compliance on the six aspects of regulatory transfusion documentation.
RESULTS:
A total of 2500 transfusion events were assessed across the medical center. Compliance with regulatory transfusion documentation increased from 62% to 92% following implementation of the checklist. Subsequent TJC and CMS laboratory and hospital surveys reflected compliance with transfusion documentation regulations. Nursing leadership reported that the new automated reports facilitated improved patient care due to an increase in transfusion regulatory compliance, enhanced nursing accountability and action planning to support compliance, a reduction in manager transfusion reporting workload, and streamlined transfusion compliance reporting to senior leadership.
CONCLUSION:
The process of using a paper blood transfusion checklist combined with EHR-linked dashboard auditing of transfusion compliance increased compliance with regulatory transfusion documentation and reduced nurse manager workload.
IMPLICATIONS FOR PRACTICE:
Deconstructing a complex, high-risk procedure like transfusion into a simple checklist may enhance nursing satisfaction, promote patient safety, and contribute to regulatory compliance. In addition, removal of manual audits may ease nurse leader burden to follow-up with staff who may need coaching on proper documentation practices. Next steps for this work include implementing the paper checklists and transfusion documentation dashboards across all hospitals in the entire region to monitor continued patient safety benefits for transfusion events.
References
Dang, D., & Dearholt, S. (2018). Johns Hopkins Nursing Evidence-Based Practice Third Edition: Model and Guidelines (3rd ed.). Sigma Theta Tau International.
McNett, M., Tucker, S., Thomas, B., Gorsuch, P., & Gallagher-Ford, L. (2021). Use of Implementation Science to Advance Nurse-Led Evidence-Based Practice in Clinical Settings. Nurse Leader. https://doi.org/10.1016/j.mnl.2021.11.002
Speroni, K., McLaughlin, M., & Friesen, M. A. (2020). Use of Evidence-Based Practice Models and Research Findings in Magnet-Designated Hospitals Across the United States: National survey Results. Worldviews on Evidence-Based Nursing.
