2017 Annual Nursing Report

EXEMPLARY PROFESSIONAL PRACTICE

Designations Chest Pain Center Re-Accreditation LewisGale Hospital Montgomery was first accredited as a chest pain center (CPC) in 2009, with subsequent re-designations in 2011, 2014, and again in March, 2017. We choose to pursue this accreditation because we, along with the Society of Cardiovascular Patient Care, are striving to eliminate heart disease as the number one cause of death in our world. To do this, we need to be on our toes, and measure and track everything, from the initial 9-1-1 call, through hospitalization, to the rehabilitation process post discharge. Accreditation is our way of ensuring the science of cardiovascular care reaches our patient’s bedside and positively impacts quality outcomes. This version of CPC accreditation had us focus on the following: • Governance: Making sure we have the right leaders, equipment, and facilities • Community Outreach: Ensuring our message is out there, especially as it relates to the less-than-obvious signs of acute coronary syndrome, and the need to call 9-1-1 if a heart attack is suspected • Pre-hospital: Our relationships with our EMS providers are absolutely essential • Early Stabilization/Acute Care: What are our pathways, order sets, processes, policies, etc. to make sure every patient gets high- quality rapid assessment and treatment throughout their time with us? • Transitions: How do we get folks back into their productive lives after an event? • Clinical Quality: We track and trend many metrics for chest pain, STEMI, and NSTEMI patients None of this would have been possible without the dedication of all of the medical, nursing, and ancillary staff involved in the care of this patient population. Thanks for being part of our journey! Sepsis Certification LGHM earned the Gold Seal of Approval for Sepsis Certification from The Joint Commission. The Gold Seal of Approval is a symbol of quality that reflects an organization’s commitment to providing safe and effective patient care. The Joint Commission survey evaluated compliance with national, disease-specific care standards as well as sepsis-specific requirements. A team, led by Ashley- Day Costa, Sepsis Coordinator, made great strides in reducing mortality across the population, showing compliance with evidence- based care bundles, patient satisfaction, and patient education outcomes. This achievement signifies a Culture of Clinical Excellence across our organization, with teamwork and collaboration to drive performance. Total Joint Re-Certification LGHM achieved Orthopedic Joint Re-Certification from The Joint Commission in October, 2017. During this survey, we were able to highlight best practices in regards to elective hip and knee replacements. Joint Camp, a pre-education class, is offered three times a month with 92 percent of all elective joint replacement patients attending. Joint Camp has been instrumental in educating patients about the establishment of reasonable pain goals and activity expectations. 90 percnet of elective joint patients are mobilized within four hours post-operatively, decreasing length of stay to 2.2 days and improving overall outcomes.

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