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Scholarship & History
The UMB Digital Archive is a service of the Health Sciences and Human Services Library (HS/HSL) that collects, preserves, and distributes the academic works of the University of Maryland, Baltimore. It is a place that digitally captures the historical record of the campus.
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Palliative Needs Screening Initiative within a Cardiac Care UnitProblem & Purpose: Early palliative care detection and consultation is correlated with increased cohesion between a patient’s wishes and their medical treatment as well as decreased length of stay, moral distress, and burnout in healthcare staff. Despite these benefits, the palliative care discipline is chronically underutilized in critical care settings such as the Cardiac Care Unit (CCU) of a large urban medical center. The purpose of this quality improvement (QI) project is to increase early detection and consultation for adult cardiac patients with palliative care needs using a nurse driven palliative needs screening tool (PNST). Methods: This QI project took place over a 15-week period. Throughout the implementation phase, patients admitted to the CCU were screened by the bedside nurse for palliative care needs using a validated screening tool (PNST). Patients with a positive screen would be addressed during daily interdisciplinary rounds. Completed screening tools were reviewed weekly to determine completion, and accuracy. Results: 133 patients were admitted to the Cardiac Care Unit over the fifteen weeks of QI implementation. Compliance with the PNST system ranged from 35-100% per week with an overall average of 64%. Percentage of positive PNST screenings ranged from 16-71% per week with an overall average of 52%. When compared to pre-implementation, global palliative consult rates increased from 30% to 33%. Conclusion: Analysis of results shows that screening for palliative care needs, and life-limiting illness was able to increase palliative consultation despite seasonal variations in cardiopulmonary exacerbations causing increased patient acuity and its effect on staffing resources as well as contextual elements such as unclear patient identification and provider preferences.
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Perinatal Mental Health: Preventing Postpartum Psychiatric Illness through DebriefingProblem: Postpartum women often experience psychiatric illnesses, including postpartum blues, depression, psychosis, or anxiety, that frequently go undetected and untreated following the birth of their child. Postpartum illness can result in maternal and infant morbidity and mortality and poor health outcomes. A few structures are in place to assess, evaluate, and debrief postpartum women about their experience on the units, and to provide support services. Purpose: The project aims to implement clinician therapeutic debriefing and counseling post-delivery to trigger early interventions. Early interventions include referrals to social work, the postpartum depression specialist, mental health providers, and follow-up appointments with their OB/GYN. A nurse-led debriefing occurs after the newborn's birth and before discharge by the clinician when completing a postpartum depression screening. Methods: A root cause analysis was conducted with nursing to determine appropriate healthcare clinicians to lead the debriefing and the education necessary for the staff. In the Trauma-Informed Care approach (TIC), gaps in knowledge were identified through staff surveys. An informative recorded presentation was provided to the unit staff on the TIC approach. Results: Of 39 patients who screened positive for anxiety, 13% were provided the intervention by the nurse navigator over the fifteen weeks. Conclusions: The results conclude that clinician therapeutic debriefing improved communication regarding the patient’s history, including trauma and anxiety, and supports nurses to provide appropriate care. The nurses are able to internally communicate the patient’s needs and the patients expressed appreciation for the validation of their thoughts and feelings.
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Reducing the Incidence of Postoperative Sore Throat in Adult Surgical PatientsProblem & Purpose: Postoperative sore throat is a recurrent complication following laryngeal mask airway use and leads to patient dissatisfaction, the need for additional pain medication, and increased length of stay. Up to 25% of surgical patients at a trauma level II hospital complain of postoperative sore throat after procedures requiring the use of a laryngeal mask airway device. Purpose: The purpose of the quality improvement project was to implement and monitor compliance of providers’ use of manometers intraoperatively. The practice change was implemented at this facility to help decrease the incidence of postoperative sore throat in adult surgical patients. Methods: After educating the anesthesia care team and post-anesthesia care unit registered nurses on postoperative sore throat, all eight operating rooms were equipped with the Posey cuff pressure manometers. Anesthesia providers measured cuff pressures intraoperatively to maintain the recommended pressure of less than 60 mmHg. Cuff pressures were then documented. The presence of postoperative sore throat was evaluated and documented by the post-anesthesia care unit registered nurses. Data was analyzed weekly via run charts over 14 weeks. Results: A total of 26 data points were collected. Weeks one through six lacks compliance data points then an upward trend in compliance occurred with a later decrease in compliance, averaging at 41.5% by week 14. Approximately, 92% percent of patients reported an absence of postoperative sore throat. Conclusions: The feasibility of this QI project is proven through successful implementation of LMA cuff pressures at less than 60 mmHg to decrease the incidence of POST. Promotion of practice change by change champions will aid in sustainability. There will be a slight change in work-flow of anesthesia providers with intraoperative use of LMA cuff pressure manometers.
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Surviving Shock: Nurse Driven Protocol for Application of Hemodynamic Monitoring DeviceProblem/Purpose: Shock is a problem seen in Intensive Care Units (ICU) and in its early stages are reversible, but a delay in diagnosis and/or timely initiation of treatment can lead to organ failure and death. A Surgical ICU (SICU) within a large urban academic medical center was identified as the project site. The purpose of this quality improvement (QI) project was to implement an algorithm that will allow nurses to apply advanced hemodynamic monitoring to patients exhibiting shock states given the array of shock states frequently seen on the unit and lack of utilization of monitoring. Advanced hemodynamic monitoring platforms have been shown to be effective in providing goal-directed fluid therapy (GDFT). Methods: A nurse driven protocol was created to assist nurses in recognizing patients who would qualify. Implementation occurred over 14 weeks in Fall of 2022. Education occurred during week one and included basic education on hemodynamics, device set-up, appropriate patient selection and the protocol. Weekly audits evaluated the number of patients who met criteria and the number of patients who were applied. Results: Prior to the implementation of the protocol a survey of patients on the unit revealed that no patients who met criteria were applied to advance hemodynamic monitoring. A total of 268 patients were audited over 14 weeks. Since initiation of the protocol there has been an 60% (n=15/25) increase in recognition of patients who exhibit shock states. Conclusion: In conclusion, the nurse driven protocol for advance hemodynamic monitoring is a safe and effective way for nurses to identify patients who are exhibiting shock states and that qualify for monitoring. Future studies could evaluate whether patients with advanced hemodynamic monitoring had a reduction in post-operative complications and ICU LOS which could be potentially cost effective for hospitals.
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Diabetes Self-Management Education to Improve Glycemic Control in a Community ClinicProblem: Diabetes Mellitus (DM) is a complex, chronic condition that if poorly controlled can result in substantial damage to the cardiovascular, visual, renal, and nervous systems. A community clinic in the Western United States saw a rise in uncontrolled DM patients, hemoglobin A1c greater than 9, from 37.0% to 46.1% from January 2020 to March 2021. Knowledge as well as application of daily self-care activities are essential to optimal glycemic control and overall health outcomes. Purpose: The purpose of this quality improvement (QI) initiative was to implement a structured diabetes self-management education (DSME) program including a combination of diabetes group classes, in addition to individualized provider visits to improve glycemic control, disease knowledge, and self-care activities in adults with uncontrolled Type 2 DM (T2DM). Methods: Candidates for the DSME program were identified through direct referrals and chart review for evidence of uncontrolled DM. Those who qualified and agreed to participate in the initiative provided verbal informed consent. Clinic staff were trained on the referral process and education materials were developed from the Association of Diabetes Care and Education Specialists (ADCES) 7 Self-Care Behaviors Framework. The number of new referrals was monitored weekly through chart review. Pre and post implementation chart review was instituted to detect changes in glycemic control, diabetes knowledge, self-care activities, blood pressure, cholesterol, and body mass index (BMI). Results: Results revealed a steady increase in the number of referrals for patients with uncontrolled DM to receive DSME from 0% to 70% respectively with an average of 15.78% of weekly DM referrals over time. Pre-mean A1c was 9.18% and post-mean A1c was 9.05%, for a decrease of 0.13%. There were minimal changes noted to the other clinical measures. Conclusions: A structured DSME program and referral process can be beneficial for glycemic control and DM management.
