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Assessing Adherence of Smoking History Documentation to Improve Lung Cancer ScreeningProblem: The United States Preventive Services Task Force (USPSTF) recommends annual lung cancer screening with low dose computed tomography (LDCT) for eligible patients. A detailed smoking history informs clinical decision making regarding the recommendation to pursue LDCT. In March 2023, a random chart audit in a rural primary care center revealed a detailed smoking history was missing on 82% of all patients and an evidence-based decision regarding LDCT was missing for 100% of patients. Purpose: This quality improvement (QI) project aims to optimize smoking history documentation, increasing referral for LDCT in order to screen for lung cancer and refer for management. Methods: Prior to project implementation, an interdisciplinary team of stakeholders at the practice site including a physician and six office staff members was mobilized and educated on the proposed practice change including integration of a smoking history data collection tool (SHDCT), establishment of a referral process for appropriate patients, and creation of a follow up procedure for specialist referral. Office staff provides each patient with the SHDCT to complete privately in the waiting room; an estimated 500 patients will complete the SHDCT during the 15-week implementation. The provider then reviews the SHDCT with the patient, determines screening eligibility, and orders LDCT if indicated. Following the encounter, office staff scans SHDCT into the electronic health record and schedules LDCT for suitable patients. After LDCT is obtained, provider reviews the results and refers screening-positive patients to a specialist. Results: Of the 438 patients seen during implementation, 87.7% of patients now have completed SHDCTs documented in the EHR. Of the 54 patients qualified for LDCT, 72.2% have LDCT ordered. Of the ordered LDCTs, 45% are complete by the end of the 15-week implementation. No patients required specialist referral based on LDCT findings. Conclusions: Results reveal the intervention has promoted best Problem: The United States Preventive Services Task Force (USPSTF) recommends annual lung cancer screening with low dose computed tomography (LDCT) for eligible patients. A detailed smoking history informs clinical decision making regarding the recommendation to pursue LDCT. In March 2023, a random chart audit in a rural primary care center revealed a detailed smoking history was missing on 82% of all patients and an evidence-based decision regarding LDCT was missing for 100% of patients. Purpose: This quality improvement (QI) project aims to optimize smoking history documentation, increasing referral for LDCT in order to screen for lung cancer and refer for management. Methods: Prior to project implementation, an interdisciplinary team of stakeholders at the practice site including a physician and six office staff members was mobilized and educated on the proposed practice change including integration of a smoking history data collection tool (SHDCT), establishment of a referral process for appropriate patients, and creation of a follow up procedure for specialist referral. Office staff provides each patient with the SHDCT to complete privately in the waiting room; an estimated 500 patients will complete the SHDCT during the 15-week implementation. The provider then reviews the SHDCT with the patient, determines screening eligibility, and orders LDCT if indicated. Following the encounter, office staff scans SHDCT into the electronic health record and schedules LDCT for suitable patients. After LDCT is obtained, provider reviews the results and refers screening-positive patients to a specialist. Results: Of the 438 patients seen during implementation, 87.7% of patients now have completed SHDCTs documented in the EHR. Of the 54 patients qualified for LDCT, 72.2% have LDCT ordered. Of the ordered LDCTs, 45% are complete by the end of the 15-week implementation. No patients required specialist referral based on LDCT findings. Conclusions: Results reveal the intervention has promoted best
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Implementing a Spinal Induced Hypotension Guideline in Total Knee Arthroplasty PatientsProblem: At a community hospital, approximately 20 total knee arthroplasties are performed each week. In 90% of these patients, spinal anesthesia is used to alleviate surgical pain. Nearly one-third of these patients develop spinal induced hypotension. Administration of 4mg of ondansetron, 5 minutes prior to spinal anesthesia reduces incidence of spinal induced hypotension by antagonizing the Bezold-Jarisch Reflex. Despite this, there was no guideline in place for preventing spinal induced hypotension at this facility. Purpose: The purpose of this quality improvement project was to implement and assess compliance with a spinal induced hypotension guideline supporting administration of 4mg of ondansetron, 5 minutes prior to spinal anesthesia in total knee arthroplasty patients. Methods: A guideline recommending administration of ondansetron prior to spinal anesthesia in total knee arthroplasty patients was created by the Project Lead and approved by anesthesia leadership. Education on the guideline was held both virtually and in-person for all 41 anesthesia providers. Attendance was measured by the Project Lead via quick response code. Following this, anesthesia providers administered 4mg of ondansetron, 5 minutes prior to spinal anesthesia in total knee arthroplasty patients. Over a 15-week period, guideline compliance was measured by the Project Lead via retrospective chart review and disseminated to staff weekly. Total knee arthroplasty patients who did not receive spinal anesthesia and those with documented contraindication to ondansetron were excluded from data collection. Total knee arthroplasty patients who received spinal anesthesia were included. A run chart and descriptive statistics were used to analyze the data. Results: Guideline education was attended by 41% of the anesthesia staff. A total of 262 total knee arthroplasty patients were included in the project data and 23 patients were excluded. Anesthesia providers were compliant with the guideline in 225 total knee arthroplasties, and non-compliant in 37. On weeks 7, 13, and 14, compliance rose to 100%. Median guideline compliance was 87.5%. Conclusion: Findings suggest implementing a spinal induced hypotension guideline is a feasible intervention. When paired with site specific strategies, guideline implementation can initiate and sustain evidence-based practice change.
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Prevention of Spinal-Induced Hypotension in Obstetric PatientsProblem & Purpose: Spinal-induced hypotension is a common side effect of spinal anesthesia that compromises uterine blood flow and fetal circulation, subsequently leading to fetal hypoxia, bradycardia, and acidosis. The general practice in the labor and delivery operating room at a community hospital in Maryland was to administer ondansetron after spinal anesthesia. This has contributed to a 20% incidence of spinal induced hypotension in the obstetric population. The purpose of this quality improvement project was to implement and evaluate the compliance of the use of four milligrams of intravenous ondansetron five minutes prior to spinal anesthesia to reduce the incidence of spinal-induced hypotension. Methods: Key stakeholders and change champions were mobilized to aid in the successful implementation of this project. Two educational sessions were held in person for 24 anesthesia providers including six anesthesia technicians on the current evidence of spinal-induced hypotension, project goals, and workflow changes. Eligible participants included parturients undergoing elective cesarean sections with no contraindications to spinal anesthesia or ondansetron. The anesthesia providers administered and documented four milligrams of ondansetron five minutes prior to spinal anesthesia and documented if parturients experienced spinal-induced hypotension. Data was collected weekly via chart audits to assess project goals. Results: Over 15 weeks, 38 cesarean sections were performed. A total of 32 parturients received four milligrams of ondansetron prior to spinal anesthesia, achieving an overall compliance rate of 84.2%. Of these 32 parturients, 54.3% did not experience spinal-induced hypotension. Conclusion: Findings suggest that implementation of a spinal-induced hypotension evidence-based protocol was feasible at the project site. It was a cost-effective intervention that reduced the incidence of spinal-induced hypotension and improved patient outcomes with minimal workflow changes.
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Assessing Adherence to Updated Inpatient Code Stroke Protocol via Code Stroke TimesProblem & Purpose: At a community hospital in Baltimore, it was found that the inpatient code stroke (CS) protocol was not consistently and promptly enacted upon presentation of stroke signs and symptoms on the med-surg and cardiac units. The average time from the last known normal (LKN) to CS was 154 min (no benchmark), from CS to imaging was 15.4 min (benchmark <20 min), and from CS to intervention was 55 min (benchmark <30 min). After conducting stakeholder interviews and chart reviews, it was identified that the inpatient CS protocol was not followed regularly, used medical jargon, and had steps lacking directional flow. This impacted both staff and inpatients who experience stroke symptoms, as delays in identification delay treatment. The purpose of this quality improvement (QI) initiative was to assess adherence to a revised, evidence-based, inpatient CS protocol assessed by code stroke times. With information collected from existing evidence, it was found that revising inpatient CS protocols improves code stroke times. Methods: The revised protocol was developed by the project lead. Then, education was provided to staff, the protocol was posted, and data collection began. Meetings, educational handouts, unit champions, and quality monitoring were strategies used to refine new practices. Staff education and CS data were entered into REDCap using surveys and CS documentation. Results: Staff rated familiarity increased from 71.4% to 90.7% after education. Neurological assessment completion went from 85% to 84% after implementation. Time from LKN changed from 154 min to 110 min and code stroke activation to CT image from 15.4 min to 15.6 min. No stroke interventions were done during the project period. Conclusions: The protocol revision was a cost-effective solution for improving staff familiarity with CS protocol and improving time from LKN to CS activation. Various extraneous factors impacted code stroke times and can be evaluated further in future QI projects to improve code stroke times and outcomes.
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Improving Nurse Anesthetist Radiation Safety and Dosimetry Badge Compliance in EndoscopyProblem: Nurse anesthetists in the Endoscopy unit of a large quaternary academic medical center are exposed to radiation throughout their workday, but noncompliance with wearing their radiation dosAimetry badge has been as high as 89.5% - 98.7% of nurse anesthesia staff. Chronic fluoroscopy radiation exposure disproportionately increases the risk of cataracts, unilateral brain cancers, and chromosomal damage of healthcare workers. Dosimetry badge compliance is necessary for fluoroscopy radiation exposure to be properly measured and maintain a safe working environment for nurse anesthetists. Purpose: The purpose of this quality improvement project is to increase nurse anesthesia radiation dosimetry badge compliance with the use of a radiation safety timeout over a 15-week period in the Endoscopy unit. Methods: A project team consisting of a project leader, nurse anesthesia champion, and Endoscopy nurse champion instituted a radiation safety timeout practice change in the Endoscopy unit. Project strategies included electronic and unit-based education to 25 nurse anesthetists and 15 nurses (emails and in-services), collaboration (weekly site visits and project champions), and evaluation (data collection and analysis). Nurse anesthetists completed an anonymous QR code survey tool, evaluating the frequency of fluoroscopy cases in which the radiation safety timeout was performed, and dosimetry badges were correctly worn. Results: Fifteen weeks of data collection showed an average reported compliance of 83.8% with proper display of dosimetry badges and 73% with the radiation safety timeout. Survey response rate was 33.9%. Run charts show a nonrandom increase in dosimetry badge compliance, but the trend showing increased radiation timeout compliance may be due to reminders from nurse anesthesia staff, and not the intervention itself. Re-education through email and an in-person in-service led to increased compliance reporting during week 3. A change in leadership contributed to absence of data in weeks thirteen through fifteen. Conclusion: Dosimetry badge compliance did not reach 100%, but non-significant improvement exists since implementation of the radiation safety timeout and education. Knowledge gaps and opportunities for re-education to increase nurse anesthesia buyin and compliance will be assessed and ongoing.
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Improving First Case Start Times in an Interventional Radiology DepartmentProblem: Delays to first case start times (FCST) are defined as the time the first scheduled patient enters the procedure room. A large urban university hospital in the mid-Atlantic region’s Interventional Radiology (IR) current success rate of timely FCST was 35%, resulting in significant interruptions in treatment and reflected in 33% Press Ganey patient satisfaction scores, compared with a 58% target. Purpose: The aim of this project was to improve FCST (at 0800) for IR to 80%, using three interventions to address the key drivers of delayed cases: pre-op nurse arrival time, advance practice provider (APP) availability, and prioritizing inpatients as first cases. Method: Three of the seven procedure rooms started with a prepared inpatient procedure. Preoperative and charge nurses revised shifts started at 0630, the same time first case outpatients were instructed to arrive. Finally, priority was given for one APP to be available to answer procedure questions and consent patients. The charge nurse completed a survey daily for each 0800 procedure to measure compliance with and outcomes for these interventions. The Press Ganey Survey measured patients’ overall satisfaction with their experience and their likelihood to recommend department services to others. Results: At the end of intervention implementation, FCST success rate increased to 56% and ‘likely to recommend’ and patient Press Ganey satisfaction scores increased to 77%. Adjustment of shift times resulted in 100% compliance. APP availability resulted in a 5% improvement to FCSTs. Outpatients (n=72) had more successful start times compared to inpatients (n=60) of the 237 recorded cases. Conclusion Though the 80% goal was not achieved, the project demonstrated resiliency and adaptability seen as the interventions were still implemented daily despite challenges faced with opening a new hospital sector, staffing reallocations, and software disruptions.
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Increasing Uptake of Cervical Cancer Screening Through Text MessagingProblem: Cervical cancer (CC) is one of the most common cancers affecting women. Incidence of CC is significantly reduced through regular and timely cervical cancer screening (CCS). In the US, rates of overdue CCS increased from 14% in 2005 to 26.1% in 2021. A nurse practitioner (NP)-owned primary care clinic in the Mid-Atlantic experienced inadequate tracking and timely uptake of CCS. Baseline data showed 17.6% of 21–29-year-olds and 22.1% of 30–65-year-olds were overdue for CCS with only 12.7% having a documented CCS in the electronic health record (EHR). This sub-optimal tracking and detection increases opportunities for patients to miss CCS. Purpose: The purpose of this quality improvement initiative was to increase CCS uptake among clinic patients through text message invitations to schedule an appointment or obtain a referral. Methods: A new policy standardizing identification, contact, and tracking of soon-due and overdue CCS patients was created. The new workflow sent two text message reminders to patients 21-65 years old who were soon-due or overdue for CCS. Participants were determined by EHR report to include age, sex, history of hysterectomy, and date of last pap smear. Results: 46 patients participated in the project. Of the text messages sent, 32.6% (n=15) responded. 33.3% (n=5) of respondents scheduled their CCS and of those, 60% (n=3) completed it during implementation. 33.3% (n=5) reported an up-to-date CCS. Post-intervention rates of overdue CCS were 13.7% for 21–29-year-olds and 14.5% for 30–65-year-olds, a 3% and 7% improvement. Overall, an 85.8% CCS compliance rate was seen post-intervention. Conclusions: Findings suggest the use of text messaging reminders is a low cost, low barrier way to increase uptake of CCS in this setting. Addressing barriers and organizational processes may help increase patient response to text messaging and increase timely uptake of CCS.
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A Phone Reminder System to Improve Adherence to Long-Acting Injectable Medications.Problem & Purpose: A small, outpatient mental health clinic (OMHC) identified poor attendance for patients receiving a long-acting injectable (LAI) on a walk-in basis. Site data reviewed for August and September 2022 identified an average 20% “no show” rate with some weeks as high as 46%. Current literature has shown that missed appointments contribute to poorer patient outcomes and an increase in morbidity and mortality. Purpose: The purpose of this project was to implement and evaluate the effectiveness of electronic appointment reminders for long-acting injectable appointments in an OMHC. Methods: Implementation was from September 4, 2023, to December 11, 2023. An electronic reminder, text or phone call based on client preference, was sent to all clients due for an injection in addition to pre-existing reminder cards. A list was generated weekly by the injection nurse identifying those who were due for injections and sent to front desk staff to send out reminders. The nurse asked the clients if they received the reminder and recorded this information in a survey in a secure, HIPAA protected database (REDCap) using a secure URL. Data collected included the number of individuals due for an injection that week, those who received their electronic reminders, those who did not receive their reminders, and those who attended. Results: Data collected showed approximately 50% (n=21) of clients did not receive the reminder, despite 100% of clients being sent an electronic reminder. An average of 80% (n=21) of clients attended each week for their LAI. Electronic reminders may not have been received due to incorrect contact information or difficulty reaching group home residents. Conclusions: Reminders were more useful for outpatient clients than group-home residents, as group home residents were less likely to have a dedicated phone line or email.
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Assessing Implementation Adherence of a Rounding Process in Cardiac Intensive CareProblem: In a 15-bed cardiac medical intensive care unit, there has been decreased nurse presence and participation in multidisciplinary rounds. Purpose: The purpose of this quality improvement project was to implement a practice change that improves communication and provides a consistent rounding process while increasing nurse presence and participation in the cardiac intensive care unit during daily multidisciplinary rounds. Methods: Over 15 weeks during the Fall of 2023, the introduction of and utilization of the tool adapted from the Agency for Healthcare Research and Quality (AHRQ) daily goals checklist and served as a daily cue during rounds. The structure change was creating the evidence-based tool. At the start of rounds, nurses discussed overnight events and remained with the team to discuss the care plan for each system. Data was entered into an encrypted data collection system using a QR code embedded in the rounds sheet by the charge nurse. Weekly text reminders were sent to attending physicians to remind them of process changes. Daily huddle announcements were given to the nursing staff to remind them of the process change. Results: Results showed nurse attendance rates ranged from 10% to 100%, with an overall increased median rate of 70 % attendance during rounds. Complete utilization of the tool on all occupied beds ranged from 14% to 93.9%, with a median rate of 53.9%. Conclusions: Results indicate that nurse attendance during rounds has improved during implementation. Adherence to completing the rounding tool was challenged due to the changing rounding location and the location of the rounding tool on the unit. Adherence to process change was also challenged by varying high acuity days and mock surveys for accrediting bodies.
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Implementing and Ultrasound-Guided Peripheral Intravenous Access Clinical Practice GuidelineProblem and Purpose: Patients with difficult intravenous access (DIVA) often require ultrasound (US) guided intravenous (IV) access to facilitate medical treatment. Literature demonstrates nurse-driven USIV training programs can decrease provider interventions and time-to-treatment. At a level 1 academic center's emergency department, a practice gap of USIV placement times greater than three hours for ~13% (22/174) was identified. The purpose of this quality improvement project was to implement an evidence-based (EB) USIV algorithm to facilitate identification of patients with DIVA that require USIV's. The aims of this project are to decrease time-to-IV's, time-to-lab requisition, and time-to-treatment. Methods: The DNP project lead (PL) reviewed with unit leadership an educational competency for the 154 staff nurses to assist with identification of DIVA criteria and facilitation of USIV placement by those trained. The project was approved and deemed non-human research by the institutions office of human research protection. To facilitate, workflow changes were identified by the PL. The primary outcome measured was time-to-IV’s in patients with DIVA. Secondary outcomes included time-to-labs and time-to-blood culture requisitions. Results: Data collection demonstrated an average of 94% (987/1045) of USIV’s being placed within 3 hours, while only 6% (58/1045) of USIV’s took greater than three hours for insertion, meeting the outcome measure goal of >90% (941/1045) inserted within 3 hours. This was a 54% reduction from baseline data demonstrating USIV’s taking >3 hours in 13% (22/174) of patients with DIVA. USIV related lab time collections also met the goal of greater than 90% (540/600) collected within three hours, weeks 5-12, during which time 762 USIV’s were placed. Conclusion: The clinical practice guideline and educational competency appears to have stimulated a staff response through project awareness and workflow changes. There has been a decrease in USIV’s taking greater than three hours and an overall shift from 1-2 hours to <30 minutes and 30-60 minutes. The project relies heavily on the units workflow and culture, which may result in poor external validity. Additionally, the data has obtained the attention of unit leadership and has stimulated discussion on further actions to reduce lengthy time-to-IV’s in this population.
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Implementing Standardized Post-Surgical Follow-Up Calls in Outpatient SurgeryProblem: A community hospital post-anesthesia care unit (PACU), performing 70-100 outpatient surgeries per week, completed 40% of eligible telephone follow-ups (TFUs) secondary to inconsistent nursing workflow and lack of an evidence-based TFU script. Purpose: This quality improvement (QI) project implemented the evidence-based Re-Engineering Discharge Tool-5 (RED-5) and a formal delegation process in the PACU. Methods: Over a 16- week period in the Fall of 2023, the RED-5 script was made available to nursing staff on paper and electronically. Twenty staff nurses were trained with a 1:1 simulation. Weekly audits of delegation, calls attempted/completed, RED-5 adherence, appointment status, and escalations were completed. Project progress was shared with stakeholders through a unit tracking board, staff huddles, and monthly meetings. Run charts were used to demonstrate process adherence. Results: The new delegation process was documented 40% (n=29) of 72 eligible weekdays. In total, 1435 outpatients were discharged from the PACU. Thirty-four percent (n=494) of calls were attempted. Of the 23% (n=324) of calls completed, 71% (n=231) adhered fully or partially to the RED-5 script. Eighteen percent (n=59) required either one or both, clarification of discharge instructions (n=44) and surgeon referral (n=34). No patient was referred to the emergency department (ED). Of the 213 patients assessed, 30% of patients (n=63) had not scheduled follow-up appointments. Conclusions: Implementing the standardized RED-5 script improved postoperative identification of patient needs. Next steps involve collaborating with Information Technology (IT) and management to embed the RED-5 TFU script into the TFU application. During the project implementation period no change was noted in calls attempted or completed. Modifications to workflow processes are needed to support call completion.
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Implementation of a Double-Gloving Technique to Reduce Anesthesia Workspace ContaminationProblem: Anesthesia workspace contamination of oral pathogens poses a direct risk to all patients and healthcare providers. When an anesthesia provider manipulates a patient’s airway on induction, blood and secretions contaminate the gloves and become transmitted to the anesthesia workspace. Microorganisms spread through cross-contamination can lead to intraoperative infections and patient complications. Of the anesthesia providers surveyed at a large academic medical center, only 13.3% admitted to double-gloving on induction or removing the contaminated gloves prior to touching the anesthesia workspace. Purpose: The purpose of this quality improvement project was to reduce contamination by anesthesia providers with the use of a double-gloving on induction technique in Pod 2 over a 15-week period. Methods: Three anesthesia providers led a practice change to implement double-gloving on induction in Pod 2. Project strategies included in-person education (educational video and visual aids), collaboration (weekly site visits and change champions), and evaluation (data collection and analysis). Anesthesia providers collaborated with data collection by completing an anonymous QR code audit tool, evaluating the number of providers performing double-gloving on induction. Results: There were 81/761 (10.64%) surveys received, of the 81 total surveys completed, 88.89% (72) of anesthesia providers double-gloved on induction, 96.30% (78) sheathed the laryngoscope blade after use, and 97.53% (79) removed outer gloves prior to touching the anesthesia workspace. Conclusion: This quality improvement project successfully reduced contamination risks during induction among anesthesia providers in Pod 2. Following the implementation of a doublegloving on induction technique and various educational and collaborative strategies, compliance with double-gloving increased by 75.9% within the 15-week implementation period.
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Reducing Fall Rates in Medical Surgical Unit Using 4AT Delirium Screening ToolProblem: Hospital falls are linked to multiple factors with delirium being one of them. For a teaching hospital, the safety concern data revealed that the total number of falls in 2022 was 459 and the targeted medical surgical unit alone made up 15% (69 falls) of the total fall. Purpose: This quality improvement (QI) initiative aimed to promote safety interventions and decrease fall rate using the 4AT (Arousal, Attention, Abbreviated Mental Test-4, Acute change) delirium screening tool on admission and each shift for patients 65 years and older. The synthesis of literature highly suggests screening elderly patients with the 4AT tool to identify delirious or at risk for delirium and assists with preventive measures including fall. Method: The 4AT delirium screening tool was integrated inti the electronic health record to implement evidence-based structure and workflow changes. Complete 4AT questionnaires to generate automated numbers that determined patients at risk of developing delirium (i.e., score ≥ 3). A workshop, online modules, and PowerPoint were used for education, while the project leader (PL), educator, champions, and nurse manager reinforced education and compliance. Furthermore, implementation included a secure data collection plan and strategies to achieve the project goal. Nurses were required to complete the 4AT tool. Compliance was measured through a weekly audit process done by the PL, then feedback was exchanged regularly on outcomes and improvement needed for the project. Results: The use of 4AT tool resulted in early identification of delirious or at risk for delirium patients prompting the initiation of fall precautions. The compliance rate was 99% and 100% of the delirious patients had a fall precaution order placed. There was a decrease in fall rate (4.5 % compared to last year 15 %) since implementation of this initiative. Conclusions: This QI project highly supports the screening of all elderly patients to identify delirium early and initiating fall precautions for score ≥ 3 to decrease the fall rate in med-surg unit.
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Assessing the Implementation of Dashboards to Increase Adherence and Reduce Inpatient FallProblem: Inpatient falls remain a major challenge in healthcare. In a community teaching hospital on a medical/surgical unit (21 beds), in Fiscal year 2022 11.6% (N total=23) of the falls recorded were classified as repeat falls. Falls impact the patients, patient’s families, healthcare workers, and the facility. Purpose: This quality improvement project aims to assess and evaluate the effectiveness of dashboards in increasing adherence rates with evidence-based fall prevention strategies and reducing the inpatient rate of falls. Methods: A 15-week (n =21) clinical audit was conducted weekly, using evidence-based audit criteria tailored to the unit's needs. The project lead performed clinical audits, reviews, discussions, and re-audits in sequence to increase the adherence rate and improve clinical practice in evidence-based fall prevention strategies. A dashboard of the weekly clinical audit was posted on the unit’s information board. The project lead reviewed the dashboard with a less than 80% adherence rate with fall prevention strategies for discussion with nursing staff biweekly. Results: The clinical audit criteria were grouped into two categories on the dashboard: ‘admission, transfer, and shift documentation’ and ‘care plan documentation’. The results of the adherence rate for ‘admission, transfer, and shift documentation’ in the 15 weeks of implementation range between 34% - 100% (n=129). The results of the adherence rate for the ‘care plan documentation’ ranges from 9% to 90% (n=129). However, there were only four falls recorded since the start of this project (2.89%) compared to 11.3% in 2022 the same period. Conclusion: This project used a dashboard with pre- and post-clinical audit strategies to translate evidence into promoting improved practice with fall prevention strategies. The data shows an increase in adherence rate of the ‘care plan documentation’ audit criteria and some of the other evidence-based fall prevention strategies; however, the run chart did not show any evidence with the reduction in the rate of falls.
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Implementation of Falls Protocol to Improve Falls Rates in Confused Known FallersProblem: Fall rates can decrease when standardized fall interventions and screening tools are used for confused patients who are known fallers (also known as repeat fallers). On an adult medical-surgical unit in an urban medical center, 40% of patients who were confused fell and falls increased from 4.19% in 2021 to 7.19% in 2022. Purpose: The purpose of this Quality Improvement (QI) project is implementation of fall prevention interventions to decrease the number of falls by placing new signage on the doorway for prompt identification of their fall status while hospitalized. Project goals include to reduce the falls rate in patients with a repeat history of falls and 2) to improve door sign accuracy and monitoring. Methods: A team of interdisciplinary stakeholders met and the creation of a new sign identifying “known fallers,” was implemented. Assessment and monitoring of routine metrics were carried out over 15 weeks in fall 2023. Education of nursing staff included new signage and fall prevention protocols. Weekly unit audits assessed the number of falls and initiation of the fall prevention protocol for the new signs. Results: The falls rate at the beginning of September was 13.2% and steadily decreased until December with a rate of 3.3% from 1000 bed days. Results show N=317 total (n=15, 3.3% patients who fell); 15 patients fell (4 known fallers, 11 patients fell who were not confused or had a history of falls). Door sign identification of high Morse fall risk = 42% accuracy; “known fallers” identification= 51.7% accuracy. Conclusion: The QI project revealed that the highest rates of falls were from patients who were cognitively intact and miscalculated their abilities and limitations when out of bed. This QI project emphasized the importance of stringent and consistent screening protocols for all hospitalized patients regardless of mental capacity.
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Implementation of an Electronic Asthma Action Plan at a Pediatric OfficeProblem: Despite being the most common pediatric chronic disease, asthma continues to be a leading cause of primary care office visits each year. A small, pediatric primary care office in Maryland reported 133 preventable asthma related clinic visits between 2021 and 2023, resulting in overbooking of appointments, reduced availability for non-asthma-related visits, and provider and clinic stress. Asthma guidelines recommend use of an Asthma Action Plan (AAP), however, 0% patients at this clinic have one despite seeing at least 5 patients per week with asthma. AAP use is associated with reduced asthma exacerbations/complications and decreased outpatient visits related to asthma. Purpose: The purpose of this quality improvement initiative is to increase utilization of an AAP through integration into the electronic medical record (EMR) for all patients with asthma. Methods: The implementation team, consisting of a project leader, 3 providers, an office manager, and 5 medical assistants, were educated on the data collection tools and the AAP reviewal protocol. An individualized electronic AAP was integrated into the EMR of every asthma patient. Providers reviewed and updated the AAP while providing patient/caregiver education during appointments. Weekly chart audits were completed to collect data on type of visit (scheduled or unscheduled), reason for seeking care, provider acknowledgement of reviewing AAP, and provision of AAP to patient/guardian. Data from these tools was collected in a private location at the practice and entered in REDCap by the project lead. Ongoing strategies for success included reminders to staff of project procedures, frequent audits to assess for compliance, and continued identification of barriers and facilitators. Results: All staff have completed education training on procedures of the QI project. During the 16-week period, 53.1% of asthma patients seen had an Asthma Action plan embedded into their EMR. The AAP was reviewed and updated only 50% of the time for patients with asthma. There was an increase in self-manageable asthma sick visits at 1.92 per week Only 13.3 % of patients received a printed copy of the AAP on discharge. Conclusions: AAP integration into the EHR increased provider and patient discussions of independent asthma management but did not improve the number of self-manageable asthma visits at the practice.
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Fall Prevention for Adult Inpatients with Communication Prompt GuidanceProblem: Adult inpatients are at greater risk for falls causing injury, increased length of stay and additional costs. On an adult inpatient medical/surgical/telemetry unit at a community-based hospital, patient fall rates have increased from 5.2 falls per 1,000 patient days to an average fall rate of 6.2 falls per 1,000 patient days. The increase in falls has prompted concern for improvement in the fall prevention process for nursing staff. Purpose: To reduce fall rates an evidence-based fall communication algorithm was developed and implemented on the unit. The algorithm presented nurses with identified fall prevention items such as distraction techniques, communication guidance, and increased monitoring with tele-sitters. Methods: The algorithm was posted on the unit in the nursing stations, medication rooms, and portable computers for easy availability to nursing staff. Nursing staff voluntarily completed a survey using a QR code when they used the prompt on a specific patient. The survey asked if the prompt was effective in identifying a fall risk patient, fall prevention items, care planning for falls, or the need for tele sitter. The algorithm was used on an estimated 3% of patients. Results: There were no falls on patients with use of the algorithm. Survey results showed that 51.8% (n=44) of nursing staff reported the prompt helped identify fall risk patients, and 51.8% (n=44) reported that the prompt helped identify fall prevention tools. The overall fall rate increased to 7.6 falls per 1,000 patient days. Conclusions: The algorithm was not effective in reducing fall rates. Although no patients fell when identified as a fall risk with use of the algorithm, additional identifiers and prevention measures are needed to prevent falls.
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Improving Perianal Skin Care in a level III Neonatal Intensive Care UnitProblem: In a level III neonatal intensive care unit (NICU) in a large urban hospital, there was a lack of standardization in perianal skin care and inconsistent documentation practices for the perianal region. Assessment of the unit's current practice revealed variable approaches to perianal skin care. A pre-implementation audit revealed that 18% (n=3) of infants had diaper dermatitis and 0% of infants had documentation of topical barrier application or perianal skin care assessment. Purpose: The purpose of this quality improvement initiative was to standardize perianal skin care and prevent diaper dermatitis. Current evidence supports the consistent application of topical barriers to prevent diaper dermatitis, accurate documentation of perianal skin integrity, assessment of dermatitis severity, treatment requirement, length of treatment, treatment strategy, and patient response. Methods: A standardized evidence-based perianal skin care bundle was implemented and included the application of Aquaphor as a topical barrier, and documentation utilizing an evidence-based validated perianal scoring tool. Formal education was provided to the 73 registered nurses and 8 attending physicians regarding topical barrier prophylaxis, when to escalate to treatment, and documentation practices. All infants admitted to the NICU were included, and those with known skin conditions or those whose parents preferred a different product were excluded. Weekly audits were conducted to assess adherence with Aquaphor application and rates of diaper dermatitis. Results: During the project initiative 95% (n= 317) of infants received Aquaphor prophylaxis. The incidence of diaper dermatitis was initially 18% and decreased to 3.7% (n=12) compared to pre-implementation and reached the goal of 0% five times during the project initiative which is reflective of the literature. Conclusions: Findings suggest that the consistent application of Aquaphor to the perianal region helps reduce the incidence of diaper dermatitis in NICU patients. Key words: Perianal, Diaper dermatitis, Diaper rash
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Decreasing Medical Device-Related Pressure Injuries on the Burn UnitIntroduction: Medical devices are crucial for patient care, but misuse can lead to emotional and physical harm. Medical device-related pressure injuries (MDRIs) are preventable injuries that create a cost burden for the organization by impacting service reimbursement and burdening patients by extending hospital stays and increasing infection risks. Burn patients, in particular, are at a high risk of injury due to changes in sensory function related to the degree of sustained burn injury. These preventable injuries remain recurrent on a twenty-bed mixed acuity burn unit. In 2022, there were three MDRIS, and in 2023, four MDRIs occurred. Purpose: of this project was to implement an evidence-based guideline created by a multidisciplinary team to increase nurse documentation and decrease MDRIs in burn patients. Method: Based on the patient's Braden Scale Score of low, moderate, or high-risk risk of injury, nurses documented a set of evidence-based interventions as noted per the guideline. A pre/posttest was given to staff to evaluate knowledge. The PARIHS framework was used to support this intervention. Strategies and tactics used for project success included identifying key stakeholders and project champions and holding monthly meetings with staff to give/receive feedback. Data Collection: The primary outcome measure was Zero MDRIs. The secondary outcome included an increase in documentation of the Braden Scale and JH-HLM score, daily weights, guideline interventions, and 4 eyes in 4 hours. The process measure included the number of charts with completed guideline documentation. Ten charts were audited a week by the project leader. Data was analyzed using run charts with reports of aggregate data to stakeholders for feedback, reinforcement, and results. Results: Concluded zero MDRIs occurred during implementation. Results also indicated a documentation increase of the Braden Scale by 21%, the JHHLM score by 46%, guideline interventions by 32%, daily weights by 5%, and 4 eyes in 4 hours by 3%. Results indicate that standardized guidelines can prevent MDRIs and improve patient outcomes. Conclusion: Data suggests that the guideline should be a standard of care for all patients. The standardized guideline can increase nurse documentation and prevent MDRIs. If any changes were made, all traveling, and float staff will receive education prior to working on the unit.
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Implementing Statin Therapy in Primary Care for Management of Cardiovascular RiskProblem : At a family care practice, a chart audit revealed that 72% of eligible patients ages 40- 75 who met the Atherosclerotic Cardiovascular Disease (ASCVD ) risk criteria were on statin therapy, which is below the practice goal of 80-100%. Purpose: The purpose of this quality improvement initiative is to implement an embedded ASCVD risk calculator in the electronic health record (HER) which will alert providers to calculate the risk of stroke, cardiovascular, and heart disease in order to initiate statin therapy for patients with a 10% and greater cardiovascular risk. Methods: The ASCVD risk calculator format and equation was emailed to the IT department, who will embed the ASCVD risk calculator in the EHR. The equation was reviewed by IT department including plan, format and implementation process. It was determined that the equation should be placed next to the vital signs tool to provide easy access for providers to calculate the ASCVD score, and the score will be very noticeable in bold print and a different color. During implementation, weekly audits was conducted to assess whether eligible patients were screened using the enrollment form, ASCVD risk calculator and if those who were screened and meet criteria were initiated on statin therapy. Results: Twenty four out of twenty- four (100%) patients were screened using the ASCVD risk calculator. Seven (7) out of twenty-four (24) were prescribed statin therapy already or were initiated with statin therapy. Seventeen (17) of the patients screened did not meet the criteria per the ASCVD risk calculator to be initiated on statin therapy or were excluded from the screening because they are on other therapy. Conclusions: Statin therapy is recommended for adults 40 years and older with 10% or more significant cardiovascular risks and one or more risk factors like hypertension and diabetes.