UMB Digital Archive
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The UMB Digital Archive is a service of the Health Sciences and Human Services Library (HSHSL) 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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Recent Submissions
Item Implementation of the Oncology Acuity Tool to Create Equitable Nursing Assignments(2025-05)Problem: The pediatric oncology unit at a tertiary care hospital in Maryland lacked a streamlined method for measuring patient acuity. This led to unequal patient assignments and increased staff turnover. At that time, 26% of staff nurses on the unit had less than one year of experience, compared to 18% three years earlier. High patient acuity, combined with unbalanced patient assignments compromised quality of care, resulting in adverse healthcare outcomes such as medication errors, extended lengths of stay, higher healthcare costs, and increased nurse turnover. Purpose: This quality improvement initiative implemented the evidence-based Oncology Acuity Tool (OAT). The tool was used at the end of each shift to predict patient acuity for the upcoming shift, resulting in more equitable nursing assignments. A more balanced workload was attained by carefully considering patient needs during the assignment process, which enhanced patient care and nurse satisfaction. Methods: Implementation occurred from August to December 2024, lasting 15 weeks. All 42 RNs on the unit received training on the Oncology Acuity Tool (OAT). They were directed to assess patients’ acuity levels based on anticipated needs for the upcoming shift. All oncology, hematology, and bone marrow transplant patients were eligible for evaluation with this tool. Results were evaluated using a double-check method involving project champions who verified the acuity scores to ensure accuracy, reliability, and validity. Acuity scores were included on the nursing assignment sheet for the next shift, guiding nurses to organize assignments with 2-3 patients and a total acuity score of 15. Results: Process measures indicated that RNs completed the OAT over 94% of the time. The average acuity scores per nurse were calculated, aiming for a target of 15. Before the implementation of the OAT, average acuity scores varied significantly, averaging around 12. After the OAT was implemented, scores became more consistent, averaging 14 across nurses, which closely aligned with our target. Conclusions: The findings suggested that consistently completing the OAT led to more equitable patient assignments among nurses. These results indicate that the OAT should continue to be utilized in practice, as it contributed to more manageable patient assignments.Item Reducing Postoperative Reintubations and Rapid Responses by Implementing the STOP- Bang Questionnaire(2025-05)Problem and Purpose: Postoperative complications, including reintubations and rapid responses (RR) after discharge from the Post-Anesthesia Care Unit (PACU), remain a challenge at an urban hospital. Obstructive sleep apnea (OSA) is a factor, with literature indicating that patients with a STOP-Bang score ≥3 are at increased risk. An audit from February to May 2024 identified a 4% PACU reintubation rate and a 2.35% RR rate within 24 hours post PACU discharge. Analysis revealed inconsistent management of patients with OSA as a contributing factor. The purpose of this quality improvement initiative was to reduce postoperative reintubations and RRs within 24 hours of PACU discharge in adult surgical patients with diagnosed OSA or a STOP-Bang score ≥3, through STOP-Bang questionnaire implementation. Methods: The 15-week project implemented in the Fall of 2024, engaged over 50 nurses, two Assistant Nursing Directors, one Nursing Director, and one Assistant Vice President of Perioperative Services. Nurses were trained on STOP-Bang use. Patients with a STOP-Bang score ≥3 or diagnosed OSA were identified and received enhanced monitoring per an order set including continuous telemetry and pulse oximetry. Results: Screening remained high, with a median completion rate of 96.67%, supported by electronic health record (EHR) integration. Order set initiation was low, with a median rate of 20.84%. Barriers included unclear ownership of the order set and limited visibility of STOP-Bang scores. There were two isolated PACU reintubations in week 7 and 9. RR rates varied, with a median of 13.89%. Conclusion: Implementation highlighted the gap between screening and interventions. Findings emphasize the need for enhanced protocols, surgical team ownership of the order set, and improved visibility of STOP-Bang scores.Item Perioperative Colorectal Antibiotic Prophylaxis Protocol to Improve Compliance Among Anesthesia Providers(2025-05)Problem & Purpose: Surgical site infections (SSIs) are the most common and costliest infections in healthcare. A rural community hospital experienced an increase in surgical site infections. The Infection Control department compiled data and found a 36% increase in surgical site infections in the first three quarters of 2023 compared to 2022. The surgical area with the highest percentage of infections was colorectal (6.15%). The purpose of this quality improvement (QI) project was to increase compliance with perioperative antibiotic prophylaxis among anesthesia providers in the colorectal surgical operating suites by measuring adherence to a perioperative antibiotic care bundle for patients undergoing colorectal surgeries, an evidence- based, research supported practice change. Methods: A perioperative antibiotic prophylaxis protocol and cognitive aid was created using the American Society of Health-Systems Pharmacists (ASHP) guidelines. All 36 anesthesia providers received via email an education presentation on the cognitive aid and the colorectal antibiotic protocol. A QR code was also sent and anesthesia staff were asked to complete a post-education survey. The cognitive aid was placed in each operating room to encourage buy-in and reminders were sent to all providers to promote compliance. Using the AHRQ Antibiotic Audit Tool, compliance data was collected, analyzed, and synthesized weekly. All colorectal surgeries, both elective and emergent, on adults 18 years of age and older were audited for compliance. A run chart was formulated and used to draw conclusions about the intervention. Results: Project implementation began on September 11th. A total of 36 anesthesia providers received the education materials via email, with three anesthesia providers (7.5%) submitting the post-education survey. A total of 46 colorectal surgical cases met inclusion criteria. Pre-implementation data included 4 surgeries and showed 75% compliance to protocol. Post-implementation data showed a mean compliance of 69% for 42 colorectal surgeries. Of the surgeries where antibiotic compliance was not met (n = 13), noncompliance was due to inadequate antibiotic administration; only one antibiotic administered. Conclusions: Colorectal antibiotic administration remains inconsistent. Antibiotic choice varied among each colorectal surgeon. Future quality improvement efforts should be aimed at streamlining antibiotic administration among these surgeons.Item Increasing Emergency Department Throughput through the Implementation of a Nursing Bundle Intervention(2025-05)Problem: The Emergency Department (ED) plays a crucial role in the delivery of healthcare to patients of various acuity levels. The average ED waiting time between the decision to admit and ED departure to an inpatient unit is significantly prolonged. This overwhelming marker emphasizes issues within the ED, notably, efficiency and patient flow. Factors contributing to prolonged wait times include inappropriate patient placement, staffing shortages, and surges in patient volumes. Purpose: The purpose of this quality improvement project is to reduce ED patient length of stay among patients being admitted to the medical-surgical (MS) unit through the implementation of bundled nursing interventions. . Methods: The QI project lead and the multidisciplinary team worked to identify root causes of this problem. A comprehensive evidence review was conducted, and pre-implementation data was gathered to establish a baseline. Interventions were identified based on average ED LOS metrics and the following ED nursing workflows were implemented; the text message-only system, response time constraints, and a specifically curated handoff template. All charge nurses and administrative coordinators (AC) were trained through monthly online meetings and face-to-face Q & A meetings. PACE metrics containing admission times were tracked weekly and the recording of completed bundled intervention use was tracked weekly. Preliminary Results: Preliminary data showed that 81% (39/48) of the qualifying admitted patients received the bundled nursing intervention. The average time for the decision to admit to actual patient transfer for each week ranged from 360 minutes to 1174 minutes, with a median of 587 minutes. Preliminary Conclusion: The bundled nursing intervention achieved a high level of implementation, reflecting good staff compliance and practicality in routine use. However, the median transfer time shows only moderate improvement, with substantial variability remaining due to systemic factors like bed availability and facility challenges. Further data collection and analysis are necessary to confirm trends, reduce variability, and assess the intervention's sustained impact on throughput.Item Implementation of a Spinal-Induced Hypotension Bundle in Total Hip Arthroplasty Patients(2025-05)Problem: An estimated 85% of patients undergoing a total hip arthroplasty (THA) were experiencing spinal-induced hypotension (SIH) at a small community hospital in Maryland. Additionally, 100% of patients who received a THA at this community hospital were over age 60 and were known to experience SIH at higher rates. Purpose: The purpose of this quality improvement (QI) project was to reduce the incidence of SIH among elderly patients over the age of 60 undergoing a THA at a small community hospital in Maryland by implementing an SIH bundle including a crystalloid co-load of 10ml/kg, 4 mg of intravenous ondansetron administered five minutes before the spinal anesthetic, and a low- dose, weight-based phenylephrine infusion started at the time of the spinal anesthetic. Methods: The Project Lead constructed a three-part SIH bundle approved by the anesthesia department leadership and the clinical site representative (CSR). Bundle education was provided in person and virtually for all 37 anesthesia providers. Immediately following education, anesthesia staff administered the three-part bundle, including a 10ml/kg crystalloid fluid co-load, 4 mg of intravenous ondansetron administered five minutes before the spinal anesthetic, and a low dose weight-based phenylephrine infusion started at the time of the spinal anesthetic. Bundle compliance with each intervention was measured via retrospective chart audits by the Project Lead and disseminated weekly to staff. All THA patients over 18 receiving spinal anesthesia are included in the data collection. Results: To date, 191 patients were eligible for inclusion in the project data. Providers were fully compliant with all three interventions on 44 patients. The intervention with the lowest median compliance rate of 17.5%, was the initiation of the phenylephrine drip. Implementation of the 10ml/mg crystalloid co-load and the administration of 4mg of ondansetron five minutes before the spinal significantly reduced the need to initiate the phenylephrine drip. By the conclusion of the project implementation, overall SIH bundle compliance rates achieved a median rate of 71.5%. Conclusions: The findings suggest implementing an SIH bundle was feasible. The SIH bundle, concurrently implemented with stakeholder buy-in and effective implementation strategies, sustained a successful evidence-based practice change.