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  Palliative Needs Screening Initiative within a Cardiac Care Unit

  Johnson, David E.; Swing, Taylor (2023-05)

  Problem & 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 Debriefing

  Isaacs, Brittany E.; Rawlett, Kristen (2023-05)

  Problem: 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 Patients

  Igboko, Angela U.; Aguirre, Priscilla (2023-05)

  Problem & 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 Device

  Huppmann, Susan E.; Wanzer, Megan (2023-05)

  Problem/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 Clinic

  Howell, Chelsea C.; McGinty, Kelsey (2023-05)

  Problem: 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.
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  Pressure Injury Prevention of At-Risk Adult Patients in the Emergency Department

  Heese, Robin L.; Van de Castle, Barbara (2023-05)

  Problem & Purpose: The average adult inpatient hospital acquired pressure injury (HAPI) prevalence in this hospital increased from 5.46% in the fourth quarter 2021 to 12.12% in the first quarter of 2022, 59% (n=13) of which were sacral pressure injuries. Emergency department (ED) boarding times greater than 2 hours have been significantly correlated with HAPIs. Both the increased prevalence of HAPIs and average ED boarding times for 2020-2021 of 6.5 hours justified the need for additional sacral pressure injury prevention starting in the ED. The purpose of this quality improvement project was to document a Braden risk score while patients are in the ED and implement a standardized pressure injury (PI) prevention intervention that targets at-risk (Braden score of < 18) admitted patients, boarding for at least six hours in the ED through the application of a prophylactic sacral foam bordered dressing. During the week prior to implementation only 15% (n= 6) of at-risk patients received the intervention and 67% (n=60) of admitted at-risk patients had Braden scores calculated while in the ED. Methods: In the two months prior to implementation, staff were educated about the increase in hospital wide HAPI prevalence, the needed intervention and appropriate documentation. The sacral dressings were relocated from the stock room to inside the patient care rooms and restocked each shift. A weekly electronic health record (EHR) report identified patients in the ED whose first documented Braden scores were <18. These charts were audited in the EHR for first documented Braden scores completed in the ED and prophylactic use of the sacral dressing. Results: Results from weeks 1 though 15, suggested that there was an 18% increase in the number of patients who received prophylactic sacral dressings and a 5% increase in the number of admitted at-risk patients had PI risk scores documented in the ED. Conclusions: The findings suggested that education, identification of PI risk and implementation of a standardized intervention for boarding patients in the ED, enabled PI prevention to start before admission.
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  Decreasing Preoperative Anxiety: Implementing Assessment and Management Guidelines

  Ekenja, Betrand A.; Callender, Kimberly (2023-05)

  Problem and Purpose: Preoperative anxiety (PA) in adult surgical patients was about 60 – 80% and adversely influenced surgical outcomes. PA assessment and management guidelines exist but are not being used by nurses at this hospital to routinely monitor and manage PA in patients before their surgery despite evidence-based recommendations. This Quality Improvement project aimed to implement evidence-based PA assessment and management guidelines. Methods: The Amsterdam Preoperative Anxiety and Information Scale (APAIS), a well validated and reliable tool, was used by trained nurses to assess PA in all adult surgical patients scheduled for elective surgical procedures before implementing evidence-based interventions and making appropriate referrals. This was done within a week prior to the surgery date during routine Pre-Anesthesia Testing follow-up call with patients by nurses. Interventions provided for patients with positive anxiety screening included providing educational materials or answers to frequently asked questions about surgery or anesthesia, procedure-specific information and links, surgery suite virtual tour video, and listening to music on the day of surgery. Referrals were made to the surgery or anesthesia team. Results: Compliance with the use of the APAIS tool to assess PA was 73% (276/380), and 100% (161/161) of patients with positive anxiety screening received at least one of the interventions provided before or on the day of surgery. The overall prevalence of PA was 58%. 96.9% of patients with positive anxiety found interventions received prior to the day of surgery very useful. All patients (100%) that required referrals were appropriately referred. Conclusion: Though the goal of 100% compliance was not met, implementation of PA assessment and management guidelines is feasible, and routine implementation helps ensure timely interventions to prevent adverse surgical outcomes. An adequate number and availability of staff nurses is key to implementing these guidelines.
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  Dexamethasone or Dexmedetomidine Adjuvants to Peripheral Nerve Blocks for Total Knee Replacement

  Fitzsimmons, Dean A.; Conley, Richard (2023-05)

  Problem and Purpose: At a community hospital, Total Knee Arthroplasties (TKAs) comprise 6.5% of all scheduled procedures, approximately 40 per month. Adequate postoperative pain control is critical for avoiding complications. The adductor canal block (ACB) and the interspace between the popliteal artery and capsule of the knee (IPACK) peripheral nerve blocks (PNBs) control postoperative pain; however, they only last 12–18 hours. Addition of dexamethasone or dexmedetomidine to local anesthetics used for PNBs have been identified to prolong their duration and improve postoperative pain control. The purpose of this project was to implement a guideline on additions of dexamethasone or dexmedetomidine to ACB and IPACK PNBs for TKAs to prolong the PNB for pain control. Methods: A guideline regarding use of dexamethasone and dexmedetomidine was created with input from anesthesia leadership. The anesthesia staff were educated during a staff meeting, the guideline was posted in operating rooms, and staff started adding either adjunct medication to the local anesthetic used for PNBs for TKAs. Over a 15-week period, compliance with the guideline was measured, along with pain scores in the post anesthesia care unit, 8, 16, 24 hours, or until discharge after a 23-hour observation. Data was collected weekly and analyzed using a run chart and descriptive statistics. Exclusion criteria were revision TKA, anxiety or depression on medication, and chronic pain on home opioids. Results: 94 patients were included. 38.9% of patients receiving PNBs had dexamethasone added (n=37). No PNBs used dexmedetomidine. 61.1% of PNBs did not have any adjunct added (n=58). 30.8% of patients had severe pain scores postoperatively (n=29). 24.2% of patients with severe pain had dexamethasone added (n=7). Median compliance with guideline use was 28%. Conclusions: There was no association with the implementation of the guideline and increased use of adjunct medications. Patients who received dexamethasone hadless incidence of severe pain. Addition of dexamethasone to PNBs is a low-cost way to improve pain scores postoperatively. Less severe pain scores improve patient satisfaction and removes a barrier to mobilization, reducing incidence of postoperative complications.
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  Addressing Anticholinergic Burden in Assisted Living Residents Through Scoring and Deprescribing

  Gilliard, Renada L.; Bullock, Lynn Marie Elizabeth (2023-05)

  Problem: Anticholinergic (ACH) burden results when there is concurrent use of multiple medications with anticholinergic properties. At an assisted living facility for older adults, at least 50% of the residents there have dementia and at least 25% have behavioral symptoms that often require pharmacological intervention with ACH psychotropic medication. Approximately 75% of those residents take at least one ACH medication daily. Purpose: The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of an anticholinergic burden quantifying tool for use by prescribers and medication administration staff. It was anticipated that the residents would benefit from assessment of medications with ACH effects through provider and staff use of the tool. Methods: Pre-implementation, retrospective chart audits were done to assess ACH use at baseline. Staff were trained on use of the Anticholinergic Burden (ACB) Scale to identify medications with anticholinergic properties. The residents’ medication administration record (MAR) was assessed weekly for new medication orders, then evaluated for anticholinergic scoring according to the ACB Scale. Providers viewed the residents’ ACH scoring sheets and determined whether current medications could be deprescribed or have gradual dosage reductions. Results: Project results revealed, out of a total of 27 residents, three residents had medication adjustments. Two of the three residents had dosage reductions of anticholinergic medication and two of those three had anticholinergic medications deprescribed. Conclusions: The findings suggest that use of a tool to identify and score medications with anticholinergic properties is necessary to increase awareness among providers and medication administration staff. This simple approach can serve as an ideal method for promoting safety for residents of assisted living facilities.
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  Standardized Protocol for Sensory Room Use on an Inpatient Child Psychiatry Unit

  Graham, Taylor; Connolly, Mary Ellen (2023-05)

  Problem: The American Psychiatric Nurses Association recommends that psychiatric facilities reduce restraint and seclusion use, with a goal of elimination. The inpatient child psychiatry unit at a freestanding pediatric hospital has not met this goal. From January to April 2022, there were six seclusions and three physical holds. Purpose: The purpose of this quality improvement initiative is to implement a standardized protocol for sensory modulation room use to decrease restraint and medication use. Methods: A multidisciplinary team developed a protocol for the sensory room. All nursing and child psychiatry specialist staff employed on the child psychiatry unit were trained on the standardized sensory room protocol. Data was collected regarding staff comfortability of sensory room implementation, rate of sensory room use by eligible patients, rate of as-needed medication use, and restraint and seclusion use after sensory room utilization. Results: 100% of staff were trained on how to utilize the sensory room. There was a 60% adherence to the use of the sensory room for eligible patients. A total of 6 seclusions were documented after the start of implementation, a 50% increase from 12 weeks prior to implementation. There were no significant trends in either seclusion use, or sensory room use. Conclusions: Further investigation should be done to analyze the effectiveness of a sensory room as an alternative to chemical or physical restraints. Adequate staffing and patient acuity was noted to be the biggest barrier in adherence to the sensory room protocol. Diagnoses such as autism and anxiety may benefit from the room more than other psychiatric disorders.
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  Optimizing the Patient with Diabetes Undergoing Surgery in the Preoperative Setting

  Gray, Jordyn S.; Franquiz, Renee (2023-05)

  Problem: Dysglycemia during the perioperative setting contributes to unfavorable surgical outcomes of increased hypermetabolic state, inflammation, and increased risk for infection. Glucose management is at provider discretion in the preoperative setting at a small community hospital. Blood glucose level monitored within three hours of surgery in 78% of patients and when monitored in the postoperative unit, 10.8% are hyperglycemic. Purpose: The purpose of this Quality Improvement initiative was to implement and evaluate the effectiveness of a preoperative glucose monitoring guideline over 14 weeks, among inpatients with diabetes undergoing surgery to change practice and improve glycemia throughout the perioperative period. Methods: A project team was mobilized to plan an initiative to implement a glucose monitoring guideline. Stakeholder buy-in was achieved by sharing current practice data and best clinical practices. The practice change was integrated into routine preoperative care for all eligible patients with visual aids and change champions to monitor glucose and administer treatment. Data on adherence and glucose optimization rates (70 mg/dL to 200 mg/dL) were tracked, analyzed, and communicated on a weekly basis with the site. Weekly oversite was provided to mitigate barriers and promote facilitators of practice change. Results: Adherence to the protocol was 82.5%, 82% of inpatients with diabetes undergoing surgery had optimized blood glucose levels prior to entering the operating room, and 89% were optimized in the postoperative unit. Patterns in the data show that when the preoperative glucose monitoring guideline was adhered to, glucose levels were more likely to be optimized throughout the perioperative period. Conclusions: The use of a preoperative glucose monitoring guideline is effective in standardizing blood glucose monitoring in the preoperative unit which can contribute to the optimization of blood glucose levels throughout the perioperative period.
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  Manuscript: Depression Screening in Oncology Hematology Clinic

  Du, Cuiqiong; Davis, Allison D.; Barbara, Van de Castle (2023-05)

  Problem & purpose: Prior to the start of this project, an oncology hematology clinic used Patient Health Questionnaire-2 (PHQ-2) to screen only a small minority of patients for depression. Three out of 180 patients (2%) were scored above 3 (positive) during the period of Jan 1st to Sep 1st, 2021. However, chart reviews showed that approximately 60% of patients had symptoms of depression at this clinic. Therefore, a low rate of depression screening existed in this clinic. The main reasons for the low rate were that the depression screening did not cover all cancer patients, and the previous process of only social worker and nurses being involved in depression screening was inadequate in this clinic. Purpose: The purpose of this Quality Improvement (QI) project was to develop a standardized process for implementing Patient Health Questionnaire-9 (PHQ-9) depression screening procedure for all new cancer patient visits at this clinic. Methods: Approximately 750 new cancer patients were expected during the 15 weeks period in this clinic. Patients completed the PHQ-9 forms under the instruction of Medical Assistants (MAs) (Figure 5). Social workers entered the data including the number of patients, the number of completed form, and the number of the PHQ-9 form scored  10 into a paper document table daily. A run chart with a line graph of the data plotted over time was used to analyze trends or patterns of the project implementation process over the 15-week project. REDCap was used for weekly data collection. Charts audit was used to check the number of screenings and referrals. Results: 755 new patients, including 680 cancer patients and 75 non-cancer patients, visited the clinic during the 15-week project period of Sep 26th, 2022, to Jan 6th, 2023. Of the approximately 47.8% (325/680) of patients who completed the PHQ-9 forms, thirty-two patients with scores ≥10. All thirty-two patients received interventions. Twenty-two patients refused to complete the PHQ-9 form. Conclusion: Findings suggest the new standard depression screening process with the PHQ-9 tool is a reliable method of screening for depression in cancer patients in an outpatient setting.
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  Asthma Action Plans in the Emergency Department for Low Acuity Pediatric Patients

  Doyle, Allison A.; Greely, Carolyn (2023-05)

  Problem: At one local community emergency department (ED) in the Mid-Atlantic area, pediatric patients presenting for an asthma complaint that do not require hospital admission received no tailored education upon discharge from their ED visit. Published evidence supports distributing asthma action plans (AAPs) from the ED setting to improve asthma control, increase understanding of asthma, and decrease ED utilization. Purpose: The purpose of this quality improvement (QI) initiative was to implement AAPs upon discharge from the ED for these patients over a 15-week period in the fall of 2022. Methods: The QI Project Lead (QIPL) mobilized an interdisciplinary team of stakeholders at the project site to plan evidence-based structure and workflow changes, including documentation of patient heights for tailored peak flow measurements, an integral component to AAPs. Patients were offered an AAP if they were discharged from the ED after being seen for an asthma related complaint and were between the ages of 2 and 17 without structural lung disease. Data was collected weekly on the number of patients who had a height documented during their visit, teaching of peak flow, and receipt of an AAP at discharge. Results: A total of 41 patients presented meeting inclusion criteria. 7% had peak flow documented, 15% had a documented height, and 7% had an AAP given upon discharge. 78% of patients meeting inclusion criteria tested positive for a viral infection during their ED visit. Data noted fallouts on AAP distribution for the many patients presenting with concurrent viral infections. Conclusions: Findings suggest that project adherence is contingent in part upon unit census and acuity, as well as an automated method to remind providers to distribute AAPs. Ongoing discussion is also warranted with pediatric providers to discuss goals of care specifically for patients with an asthma exacerbation triggered by respiratory infections.
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  Reducing Hospital Acquired Pressure Injuries among Spinal Cord Injury Patients

  Etack Djambe, Natacha G.; Watson, Melissa D.N.P., C.R.N.A. (2023-05)

  Problem: The spinal cord injury (SCI) unit of a local rehabilitation hospital in Baltimore, Maryland experienced hospital acquired pressure injury (HAPI) incidence rates above the facility standard rate of 0.77. HAPI incidence rate was 1.53 in 2021. A new benchmark was established in 2022 based on the Uniform Data System reporting at 1.20%. Despite implementation of interventions to address this problem, the HAPI rate was 3.45% at the end of August 2022. Purpose: the purpose of the quality improvement was to implement a HAPI prevention admission bundle on the SCI unit to reduce HAPI rates. Methods: Nurses (RN and LPN) were educated on the HAPI prevention admission bundle and took a paper-based post-test to evaluate assimilation of the educational objectives. Implementation of the bundle began on the second week. Within four hours of admission, two nurses initiated a comprehensive skin assessment. The admitting nurse (RN) documented the skin findings in the electronic health record (EHR) visual skin tool, inserted the tool into a progress note, and requested a co-sign from the second nurse. All new admissions ages 18 years and older were included. Bundle compliance was measured weekly by chart audits in the EHR. Results: 86% of nurses (n = 13) were trained with a post-test average score of 95%. Over a period of 14 weeks, 64 patients were admitted to the unit. Overall HAPI bundle compliance rate was 90% (n = 57), and 97.4% of admissions (n = 62) had an admission skin assessment completed within 4 hours of admission. Documentation on the visual skin tool was completed for 91% of admissions (n = 59) and two-nurse co-sign completed for 90% (n = 57). Post-implementation HAPI rates dropped to 1.87%. Conclusions: The HAPI prevention admission bundle was effective in reducing HAPI rate. Formal staff education, unit champions, leadership involvement, and staff reminders were important tactics utilized for the adherence and adoption of the implementation
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  Preoperative Warming and Improved Postoperative Outcomes in Colorectal Surgical Patients

  Dikeman, Elizabeth C.; Conley, Richard (2023-05)

  Problem: The maintenance of normothermia during surgery is a critical component of patient care provided by the anesthesia provider. A root cause analysis revealed this Level II Trauma Center performed preoperative warming for hysterectomy patients, as part of an Enhanced Recovery After Surgery (ERAS) protocol. However, there were no established preoperative warming protocols for patients receiving colorectal surgery. Intraoperative hypothermia is associated with negative postoperative outcomes to include, increased risk of surgical site infection, increased intraoperative blood loss, increased narcotic requirement following surgery and prolonged hospitalization. If this problem was not addressed, patients could experience adverse postoperative outcomes leading to increased hospital costs and waste of resources. Purpose: To overcome the absence of standardization of preoperative warming for adult surgical patients at this facility, this project implemented a preoperative warming protocol for colorectal ERAS patients prior to surgery. Methods: The quality improvement project was implemented over a 15-week period in the fall of 2022. Change in practice occurred with the implementation of a preoperative warming protocol for colorectal surgical patients. The surgical team initiated the ERAS order set and the nurse initiated warming per protocol at least 30 minutes prior to surgery. The patient’s postoperative temperature in the post anesthesia care unit was also evaluated. Results: If the warming protocol was ordered by the colorectal surgery team 100% of patients received prewarming. Thirty-eight patients were eligible, but only 76% had an order present and received prewarming. All patients who received prewarming were normothermic postoperatively. Conclusion: Project findings cannot conclude if protocol implementation had an impact on patient outcomes at this facility. Patients who received prewarming were normothermic postoperatively. This is associated with improved postoperative outcomes and reduced hospital spending.
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  Decreasing Anxiety Levels and use of Antianxiety Medication in the Behavioral Health Inpatient Setting

  Dickson, Michael E.; Connolly, Mary Ellen (2023-05)

  Problem: Reducing the anxiety of patients on an adult inpatient psychiatric unit can be challenging. Prescribed benzodiazepines are the primary medication of choice in reducing anxiety. In 2013, approximately 31% of fatal overdoses involved benzodiazepines in United States. Approximately 70% of the patients admitted to a 16-bed inpatient psychiatry unit in the mid-Atlantic are prescribed anti-anxiety medications to include benzodiazepines. Patients with high levels of anxiety tend to request pro re nata (PRN) anti-anxiety medications 2-3x more than patients that do not request for PRN anti-anxiety medication. Purpose: This quality improvement (QI) project aimed to implement mindfulness education techniques and resources to reduce the use of PRN anti-anxiety medications. Methods: This project was implemented over 14 weeks from October-January 2022. A mindfulness education module for staff was developed to ensure that all necessary documentation (e.g., Dynamic Appraisal of Situational Aggression (DASA), mood rating, group therapy attendance, and Mindfulness iPad usage) were conducted and documented in the electronic health record (EHR). Social work introduced and reinforced mindfulness techniques in group therapy. Patients’ attendance is documented in their EHR every shift. Nurses assessed DASA scores, mood ratings and usage of Mindfulness iPad in the EHR. Once a week team project lead audits EHR charting and collects data on the usage of anti-anxiety medication in addition to the documentation. Results: The data reflects 20% utilization of the Mindfulness iPad by nursing staff, and no appreciable reduction in PRN anti-anxiety medication. Analysis of the data’s mindfulness group attendance component reflects a sustained rate of group attendance at 85%. Conclusions: Project implementation was met with many challenges including the acuity of the unit and the introduction of new technology. A continuous education plan and a user-friendly mindfulness application is recommended.
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  A Multidisciplinary Approach to Antibiotic Stewardship in Long-Term Care

  Cummings, Kelsey J.; Watson, Melissa D.N.P., C.R.N.A.; Regan, Claire (2023-05)

  Problem & purpose: The aim of this quality improvement project was to implement and evaluate the effectiveness of the Loeb Minimum Criteria within a long-term care (LTC) unit with the goal of decreasing unnecessary testing for urinary tract infections (UTIs). In older adults, a UTI is the most common diagnosis for which antibiotics are prescribed. Prevalence of asymptomatic bacteriuria ranges from 25-50%, and many of these patients are treated with antibiotics that are not warranted. The absence of clinical education and use of evidence-based practices lead to an increase in the potential for unnecessary testing and treatment. Methods: Within a 30-bed LTC unit in Howard County, Maryland, UTI’s are one of the most treated infections, however, there was no antibiotic stewardship program in place. A staff of 15 nurses, and 1 nurse practitioner (NP) participated in education sessions regarding the Loeb Minimum Criteria and were given the algorithm to follow. A post-test was administered to nursing staff following the education session to assess effectiveness. Change in behavior of the nursing staff when communicating symptoms to the provider was assessed by a pre/post- implementation survey completed by the NP. Pre-test results informed ongoing educational efforts. Urinalysis, culture, and sensitivity (UA C&S) orders were monitored pre-implementation and monthly to assess for the effective use of the algorithm on ordering practices. Results: Compared to the year prior, there was an 81% decrease in UA C&S sent during the implementation phase. Following the education session 66% of nursing staff identified greater than 50% of points outlined in the Loeb Minimum Criteria. Provider post-test indicated a 10% increase in the accuracy of reporting symptoms by the nursing staff. Conclusion: This project shows promise that increased education and awareness of antibiotic stewardship programs have the potential to influence the frequency of testing LTC residents receive with the potential to reduce unnecessary prescribing of antibiotics. Internal challenges related to staffing acted as a primary barrier to participation. Critical components of successful implementation of QI projects within the long-term care setting include buy in from administration, and collaboration with clinical staff. NPs are knowledgeable about antibiotic stewardship practices but lack the time needed to implement programs.
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  Implementation of the PECS II Block in Mastectomy Patients

  Davis, Brianna O.; Conley, Richard (2023-05)

  Problem: Acute pain associated with mastectomies occurs 60% of the time in the postoperative phase. In addition to acute pain, these patients can develop chronic pain and upper arm restrictions due to untreated pain. There has been a shift in utilizing regional anesthetic techniques to counteract increased opioid consumption and misuse. At a community hospital located in Maryland, those undergoing mastectomies required Dilaudid, a narcotic, 80% of the time for postoperative pain. Purpose: The purpose of this Quality Improvement Project was to implement a protocol for anesthesia providers to utilize when performing the PECS II nerve block to reduce postoperative pain in mastectomy patients. Methods: The quality improvement project took place over 15 weeks. The PECS II nerve block protocol was readily available for anesthesia providers for local anesthetic dosing and criteria. Compliance with the protocol was measured along with pain scores in the postoperative area. Results: There were a total of 24 mastectomy cases. The compliance rate during weeks 1-3 was 50%. Compliance for weeks 4 through 6 was 33%. There was a 50% compliance rate for weeks 7-9. The median increased from 16.5% in weeks 9-11 to 75% for weeks 12-15. Out of the patients who received a PECS II nerve block, 11 out of those 13 had pain scores of less than five throughout the entire postoperative period. For those who did not receive a PECS II nerve block, only seven out of 11 patients had a pain score of less than five in the first 15 minutes of entering the post anesthesia care unit (PACU). Conclusions: The number of anesthesia providers adhering to the PECS II nerve block protocol steadily increased as more providers were trained to perform the block. The incidence of pain scores above five in those who received the block was considerably lower. Out of those patients, 92% receiving the block had a pain score of less than five throughout their stay in the PACU.
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  Implementation of the Brøset Violence Checklist on an Acute Inpatient Unit

  Coleman, Sareena A.; Greely, Carolyn (2023-05)

  Problem: Following the Pandemic, the healthcare system has seen an alarming increase in the rate of workplace violence (WPV), particularly towards registered nurses (RNs). A total of 50 Behavioral Emergency Response Team (BERT) calls, responding to violent and aggressive patients, took place on a 26-bed acute surgical trauma unit at a large, academic medical facility over the last year. Purpose: The purpose of the Quality Improvement (QI) project was to implement the routine use of the Brøset Violence Checklist (BVC) to reduce the incidence of workplace violence incidents on an acute trauma inpatient unit. Methods: Data was collected using the following instruments: the Brøset Violence Screening tool and the modified Staff Observation and Aggression Screening- Revised tool (mSOAS-R). Nurses screened their assigned patients once every shift using the BVC. Nurses were encouraged to implement safety measures for patients scoring ≥ 2 on the BVC tool. The mSOAS-R tool was completed by nurses when a behavioral event requiring security/BERT occurred. Results: 86% of nursing staff (n=38) were educated to use the BVC to assess patients at risk for violence and aggression. Data shows that nursing staff screened about 29.7% of eligible patients and were 79% compliant in documenting violent event using the mSOAS-R. Last year during the months of September through November there were a total of seventeen behavioral events. During implementation of the BVC, twelve total behavioral events occurred, demonstrating a 29.4% decrease in WPV events. Conclusion: Results demonstrate a decrease in the total number of aggressive events compared to the same months from one year prior. Implementation of a standardized risk assessment tool can be an essential component in managing patient aggression and violence.
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  Implementation of Daily Goals Tool to Structured Multidisciplinary Rounds

  Choi, Sarah Y.; Coasta, Linda L. (2023-05)

  Problem: A Surgical Intermediate Care Unit (SIMC) within a large urban academic medical center is covered by multiple rotating Advanced Practice Providers (APP), leading to varied multidisciplinary rounding (MDR) formats. This lack of structure leads to communication breakdown, delayed communication, poor collaboration, and staff dissatisfaction. Five safety reports submitted from November 2021 to April 2022 were related to communication errors and inadequacy of communication. Purpose: This quality improvement (QI) project aims to implement a Daily Goals Tool (DGT) into the current MDR in the SIMC to evaluate the effectiveness of the structure rounding to improve staff collaboration, communication, and satisfaction. Methods: A unit-specific DGT was created with the input of SIMC staff. A DGT was utilized during MDR to discuss the plan of care for each SIMC patient over fourteen weeks following staff education. The use of the DGT was audited three times per week to measure compliance. Participants were asked to complete the Collaboration and Satisfaction about Care Decisions (CSACD) tool as a pre-and post-intervention survey. Results: Nine participants of MDT completed the pre-intervention survey and ten completed the post-intervention survey. Compliance audit found 60-100% weekly completion of the DGT. Post- CSACD result indicated that the structured rounding tool improved team members' satisfaction with decision-making, team communication, and team collaboration compared to the pre-CSACD result. Conclusion: Implementing a unit-specific structured rounding tool can organize the rounding process to improve staff collaboration, satisfaction, and communication among healthcare members.

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