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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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Intervention to Reduce Falls on an Intermediate Care UnitProblem & Purpose: During FY2022, a surgical intermediate care unit (IMC) in a large, tertiary academic medical facility did not meet fall prevention goals and reported 14 falls, six with injury; 57% unwitnessed, 36% had contributing cognitive or behavioral factors, and 14% fell from the chair. The purpose of this quality improvement initiative was to implement, and achieve compliance with, a chair alarm setup protocol, and to reduce the incidence of unit falls. Methods: The intervention included a chair alarm setup for every patient room as part of a pre-admission room readiness standardized process. Prior to receiving a patient into a room, unit nursing and supporting staff installed ready-to-use chair alarms into patient chairs, complete with alarm sensor pad, chair alarm, and confirmed working batteries. The project lead (PL) completed one-on-one staff education for 90.9% of all unit staff members and provided education to all staff via email. Unit champions (UCs) were designated to help improve compliance. Visual reminders were placed on the unit assignment boards. The PL and UCs audited clean and ready rooms using a link and QR code generated by the REDCap® software. Fall data was obtained from hospital quality reports and verified with unit leadership. Results: During the project, the PL and UCs completed 79 audits on pre-admission rooms; 87.67% of audited rooms had ready-to-use chair alarms set up. In the 14 weeks pre-project, three patient falls occurred on the IMC; two occurred during the project period. These two falls did not occur from the chair. Conclusions: This pilot study demonstrated promising findings for IMC staff adherence to a pre-admission chair-alarm protocol. High support staff turnover, inadequate supplies, and staffing constraints were likely barriers to 100% protocol adherence. Education of all new staff and improved stocking of alarm supplies promotes project sustainability.
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Implementation of a CPAP Bundle for Standardization of Care and Skin ProtectionProblem: A chart audit report from a 35-bed, level IV NICU, in the mid-Atlantic region found that 18 patients between January-June 2023, managed with headset continuous positive airway pressure (CPAP), had observable incidents of facial skin breakdown. No standardization of nursing care for infants on headset CPAP was in place. Purpose/Goals: This quality improvement project aimed to implement a care bundle to standardize nursing care and reduce skin breakdown in infants managed with the headset CPAP apparatus. Methods: A care bundle was created using evidence-based literature that supports five core elements: use of a preventative dressing, diligent and thorough skin assessment, rotation of mask and prongs, facial massage, and proper apparatus size selection. Education was provided, with a pre and post survey, on the bundle and desired documentation for all nursing staff. Weekly chart audits were performed over a 15-week intervention period. Data collected on 34 neonates was used to evaluate percentage of compliance to bundle elements and the percentage of documented skin breakdown over time. Results: Data analysis demonstrated documentation percentages for the following bundle elements: preventative dressing 90.3% (n=299), facial skin assessment 76.7% (n=254), mask and prong rotation 55% (n=182), facial massage 1.8% (n=6), and apparatus sizes 1.2% (n=4). The percentage of documented Neonatal Skin Condition Score (NSCS) of 3 (normal) on headset CPAP increased over time following initial implementation to 100%. Conclusion: The implementation of an evidence-based CPAP bundle may improve documentation of care as well as improve skin integrity.
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Improving Anesthesia Provider Compliance with a Postoperative Nausea and Vomiting Prophylaxis ProtocolProblem: At a community hospital, an estimated 33% of ambulatory surgery adult patients experience postoperative nausea and vomiting (PONV). The hospital’s chief nurse anesthetist reports 25% compliance among nurse anesthetists with the existing PONV prophylaxis protocol. Purpose: The purpose of this quality improvement project is to increase the compliance of nurse anesthetists with the PONV prophylaxis protocol for adult patients undergoing elective procedures with general anesthesia. Methods: Implementation strategies for the practice change include the placement of a large poster of the protocol in the anesthesia lounge and in each operating room and conducting a formal information session on the protocol. Additionally, the Project Lead performed weekly audits of the facility’s “PONV Dashboard,” wherein the compliance score of each anesthesia provider is tracked, and informed the nurse anesthetists of their weekly compliance and ongoing performance with the protocol. Results: In the first week, there was an average compliance score of 43% with the protocol. In subsequent weeks, the average compliance increased to 58% then 83%. However, there was a decrease in compliance scores from weeks 4 through 9. Of note, a change in the frequency of the PONV Dashboard being updated caused lags in nurse anesthetists receiving feedback on their compliance. After week 9, the compliance scores were updated from the previous month and compliance began to improve until the next time scores were made available. Conclusions: The findings point to the display of a protocol in highly visible spaces and routinely informing providers of how well they comply with the protocol as methods to increase protocol compliance. By keeping providers engaged with their performance, they are more likely to adhere to a PONV protocol, with the implication of a reduction in the occurrence of PONV for patients following general anesthesia.
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Reducing Falls in a Neuro Trauma Intermediate Care Unit Through Intentional RoundingProblem & Purpose: In US hospitals, an estimated 2% of patients will fall during their hospital stay, and 10% of individuals who fall will sustain serious injuries. When a hospitalized individual falls, the cost can be as high as $13,616 per patient. A Neuro Intermediate Care Unit (IMC) at a university medical center in the eastern US experienced an increase in falls from 12 in the fiscal year 2022. to 26 in the fiscal year 2023 (ending June 30th). This project aimed to assess adherence to intentional rounding on 100% of Neuro IMC patients with a Morse Fall Scale (MFS) score > 24 (medium-high fall risk) by implementing in-room erasable rounding boards and a 4-item rounding survey with the overarching goal of decreasing the number of falls on the unit. Methods: Includes documenting hourly to every two hours rounding on erasable, in-room, check-off whiteboards that displayed the “4 Ps” –four common risk factors for falls (Potty, Position, Personal belongings, and Pain). Intentional rounding ranged from hourly (day) to every two hours (night). The project lead (PL) instructed staff to check off rounding completion every one to two hours on each in-room whiteboard. The protocol called for the staff member at shift end to review the whiteboard to determine if staff marked off completion of rounding per QI protocol. Next, the staff member used their personal cell phone to access a 4-item survey via a QR code connected to REDCap, a secure HIPAA-compliant server, to report if staff checked off rounding every one to two hours. The PL compiled data into a time series chart to examine staff adherence to rounding. Results: Out of a maximum possible 5,040 12-hour shifts over 15 weeks, staff completed 117 surveys, (2.32% compliance). Seven falls occurred on the unit during the project. Conclusion: Low end-of-shift survey completions suggest low adherence to a hospital policy that requires intentional rounding on patients with increased fall risk factors.
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Adoption of Double Gloving during Induction to Reduce Anesthesia Workstation Cross-ContaminationProblem: Double glove omission among anesthesia providers during induction contributes to unfavorable patient outcomes resulting from surface contamination of the anesthesia workstation, leading to increased mortality, and increased hospital length of stay and costs. Underutilization of double gloving during routine induction of anesthesia was consistently observed among the majority of anesthesia providers at an inner-city medical center in Baltimore, Maryland. Purpose: The purpose of this quality improvement initiative was to reduce anesthesia workstation cross-contamination by improving the utilization of double gloving usage during induction among anesthesia providers over 15 weeks. Methods: A project team consisting of 16 anesthesia providers and two anesthesia technicians were mobilized to plan an initiative to implement the practice change, which was integrated into routine induction. Implementation strategies included education, visual reminders, badge attachments, weekly collaboration with stakeholders, use of change champions, and data collection and analysis. Data on double gloving compliance were tracked and analyzed on a weekly basis. This information was gathered using an audit tool placed on each anesthesia workstation as a laminated quick response code, which evaluated the percentage of anesthesia providers who performed double gloving during induction. Weekly oversite was provided to promote engagement and mitigate barriers and promote facilitators of the initiative. Results: Data analysis from the double gloving audit tool revealed 98% adherence to the practice change among anesthesia providers. Conclusion: Utilizing double gloving during induction is an evidence-based strategy that has been shown to significantly reduce anesthesia workstation cross-contamination and control the spread of pathogens. Findings suggest that anesthesia providers at this institution were amenable to the incorporation of this practice change. With sustainability and spread of the clinical practice strategy, the expectation is anesthesia providers will comply with double gloving during induction, leading to a cleaner anesthesia workstation and reduction in nosocomial infection potential.
