Stop, Communicate and Listen

Massachusetts General Hospital (Boston, Massachusetts)

CSI Summary

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CSI Presentation

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CSI Toolkit

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Added to Collection

Project Topic

Improving communication between nurses and patient care associates (PCAs)

Hospital Unit

Medicine – White 10

CSI Participants

Lisa Bourgeois, BSN, RN
Christina Carmody, BSN, RN
Katherine Guanci, BSN, RN

Project Goals/Objectives

  1. To decrease falls 50%
  2. To decrease catheter-associated urinary tract infection (CAUTI) 50%
  3. To decrease hospital-acquired pressure injury (HAPI) 50%
  4. To create a new communication tool that 80% staff will use
  5. To increase staff responsiveness via text communication 50%

Project Outcomes

  1. Decreased falls 25% (from 16 to 12)
  2. Decreased CAUTI 50% (from 2 to 1)
  3. Decreased HAPI 33% (from 3 to 2)
  4. Achieved 100% compliance with staff using the new tool

Project Overview

In meetings with PCAs, our Nurse Director received feedback that the PCAs felt they didn’t have enough information to take optimal care of our patients. In a 2017 hospital survey on patient safety, in the area of “Handoff and Transitions,” the PCAs’ scores decreased, so our CSI team felt there was a need to tackle this problem.

We developed a “worklist” communication tool, designed to be kept at our PCA desk area, that communicates important information to the PCAs about tasks, safety concerns and pertinent patient information. This tool was created in collaboration with the PCAs. The night nurses fill out the worklist for the day shift. Next, the charge RNs huddle with the PCAs in the morning to review the patients and answer any questions.

We believed that if the PCAs had all the correct information to take care of the patients, we could decrease falls, CAUTI and HAPI. All of these nurse-sensitive indicators did decrease during our project.

Our tool has already been shared with other units in the hospital, and we plan on working to see how we can implement more PCA-specific information into our electronic health record, as well.

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The materials associated with this AACN Clinical Scene Investigator (CSI) Academy project are the property of the participating hospital noted above, not AACN. Requests to use content contained in the CSI team’s summary, presentation or toolkit should be directed to the hospital. We suggest reaching out to the hospital’s Communications, Marketing or Nursing Education department for assistance.

The AACN CSI Academy program supports change projects based on quality improvement methods. Although CSI teams seek to ensure linkage between their project and clinical/fiscal outcomes, data cannot be solely attributed to the project and are estimations of impact.