Hospitalizations – Entry 2

Dear Diary:

After helping the nursing staff avoid another hospitalization for Hattie last week, I decided to investigate what we can do to avoid unnecessary hospitalizations. I reviewed some of our recent hospitalizations to see if others could have been avoided. That wasn’t easy since we’re not currently tracking hospitalization rates. I remember at INTERACT training hearing about the Advancing Excellence Safely Reduce Hospitalizations Tracking Tool. We’re registered for that campaign, but I must admit I haven’t been to that website in months. I went to the website and looked at the hospitalization tracking tool. It looks like it’ll be a great way for us to track and trend hospitalization data, as well as do some root cause analysis. My plan is to bring this tool to our next interdisciplinary team meeting to see how we can work together to gather the information, enter it into this tracking tool each month, and use the information to help reduce unnecessary hospitalizations.

I also spent some time walking around the neighborhoods to see how many “Stop and Watch” forms were being turned in to the nurses. Very few! This was one of the tools that was introduced in our facility-wide INTERACT training a few months ago. I guess just introducing tools and not doing any follow up doesn’t lead to success. Mary, one of the nurses on the transitional care unit (TCU), seems excited about this tool and has been encouraging her team to use it. So, I asked her to be the “Stop and Watch” champion. She has agreed to use this tool regularly and get others on the TCU to use it. When they figure out what works best for them, she’ll help me spread their work to the other neighborhoods. Glad I have some support with this!

Once changes have been implemented in our systems to support the use of the “Stop and Watch” forms, I think we should tackle the INTERACT Care Paths. What changes in our workflow will we need to make to successfully implement all of the INTERACT tools?

Signed, Donna


  • Dear Donna,
    We use the hospital transfer portal which is part of our EHR from PointClick Care. It tracks our admissions, transfers, trends, and hospital rates all electronically and alerts us to those residents in their 30 day window at risk for re-hospitlization. We are able to see patterns and which reasons are the most often that our residents are being sent back to the hospital. This helps to identify areas for education.We also use the electroinc “stop and watch” tool in POC which is part of PointClick Care as well. Next month we will be piloting the elctronic version of the interact QI form to analysis if transfer was avoidable and what could have been done to care for our resident in house.(We currently use the paper version) The next step in our process will be the interact electroinc SBAR/Care Path work flow process currently under development. We currenlty have imbeded the care paths into the SBAR for ease and efficiency for the nursing staff along with a trigger to check the residents POLST to maintain the resident choses and direction. We have been using interact for four years now and it has been very exciting to see this come alive in the elctroinic version thru PointClick Care software.
    We have been able to reduce re-hospitlazations since the start of using interact. We have seen an increase in the use of SBAR since developing templates in PCC and anxiously await the electronic version. We have had better compliance with the use of the SBAR since devolping templates in PCC than the paper version.
    We have improved the quality for our residents since using the interact program and use of the electronic version with Point Click Care software.
    Hang in there Donna it does work!

  • Oh my Donna I forgot to tell you we also use the electronic eInteract transfer form in PointClick Care too. Many of the answers auto poplulate from the resident medical record thereby saving the nurse valuable time if a transfer is unavoidable. We will soon be testing transmitting the transfer form to the hospital electronically Imagine this critical information could get to the hospital ER before the resident! The best part is that at some point the nurse can send over all the critical information and go back and finish the transfer form to idenify other areas of care and send that over electronically as well. Imagine no more illegiable handwriting. It only took me less than five minutes to fill out.
    This has been awesome and excitng to think of the improved quality for our residents.

Share your nursing home perspective on this quality improvement issue.