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The School of Nursing, a national leader in health sciences research, public service, and patient care, is dedicated to creating a research-intensive environment that will advance the science of nursing through research and scholarship.
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SINI 2022: Embracing Health Care Complexity Through Informatics InnovationsUniversity of Maryland School of Nursing, 2022-07
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Margaret Rose School of Nursing Scrapbook, 1933-1936Scrapbook belonging to Margaret Rose, graduate of the School of Nursing Class of 1936
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School of Nursing Convocation 20222022-05-19
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Implementation of Resuscitated Cardiac Arrest Debriefing in the Medical Intensive Care UnitProblem: In 2020, a medical intensive care unit (MICU) at a large academic hospital experienced 47 resuscitated cardiac arrests, achieving return of spontaneous circulation (ROSC) in 66% (n = 33). An audit of the practices of the MICU identified that following cardiac arrest resuscitations, no processes existed for performing staff debriefing possibly contributing to inferior resuscitation quality. Debriefing is a focused, interdisciplinary discussion that provides participants with feedback and is demonstrated to improve patient outcomes including return of spontaneous circulation, and team performance. Purpose: The purpose of this Quality Improvement (QI) project was to implement a sustainable, structured, interdisciplinary debrief after all resuscitated cardiac arrest events in the MICU. Debriefing after resuscitated cardiac arrest events could improve CPR quality, return of spontaneous circulation rates, and communication. Methods: The QI project methods involved Resource Registered Nurses (RRN) facilitating an interdisciplinary debriefing following each resuscitation event in the MICU (September - December 2021), using the institution’s debrief tool. The debriefing tool was comprised of open-ended questions and quality metrics. Practice changes were achieved by using teach-back methods to train the RRNs on debrief facilitation. Emotional support was offered to staff. Compliance with debriefing and number of staff involved with events and debriefs were recorded. In addition, anonymous indicators of CPR quality as measured by chest compression depth, rate, and fraction was collected from the defibrillator. Finally, the rate of return of spontaneous circulation (ROSC) was collected. Results: During implementation, 92% (n = 13) of resuscitated cardiac arrests were debriefed, and 8 to 17 staff participated in each debrief. Comparison of CPR quality before and after implementation demonstrated marked improvement in median chest compression quality according to the American Heart Association (AHA) guidelines. Compression depth and rate medians increased from 22.0% to 39.5% (p = 0.012) and 63.9% to 75.6% (p = 0.497) respectively, and compression fraction median decreased from 95.3% to 94.9% (p = 0.35). Return of spontaneous circulation was achieved in 50% of the arrests. Conclusions: Project outcomes demonstrate that debriefing is associated with improved CPR quality and provides support for MICU staff after resuscitated cardiac arrest events.
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Decreasing Bedding Time for Patients Admitted to the Telemetry UnitProblem: Improving care in the Emergency department (ED) is a goal of Healthy People 2030. One of the objectives of this goal is to reduce wait times in the ED. Increased wait times have been shown to cause poor patient outcomes and avoidable medical errors. Several factors affect ED wait times, one of which is a decrease in patient flow throughout the hospital. A community hospital in Maryland identified an increase in the time from when admission orders were entered for the telemetry unit to when patients were bedded. Purpose: This quality improvement project aimed to implement and evaluate the effectiveness of a Logistics Management Program (LMP) to decrease the time from when an admission order was placed to when an adult patient was admitted to a bed in the telemetry unit from the ED. Method: The QI project was implemented on a 63-bed Telemetry unit in a small community hospital. The unit admitted approximately12 adult patients from the ED each day. The innovation of this project was the implementation of the LMP. It included the already existing electronic bed board and a Nurse coordinator who oversaw admissions from the ED to the Telemetry unit. The outcome monitored was the percentage of patients that were bedded within 90 minutes of the admission order. Results: The percentage of ED patients admitted and transported to telemetry within 30 minutes increased from 17.9 to 36.6 percent. The percentage of ED patients admitted to the telemetry unit within 90 minutes of the written admission order increased from 19.7 to 25.1 percent. Conclusion: During the COVID-19 pandemic, the Logistics Management Program improved the flow of patients from the ED to a telemetry inpatient unit.
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Implementation of Screening for High Fall Risk Medications in Hospitalized Older AdultsProblem: Accidental falls are a leading cause of injury and death in older adults, leading to loss of function and increased healthcare costs. Falls are also commonly reported sentinel events in hospitals. A community hospital identified falls as an organizational priority with 73 inpatient falls last year. Expert guidelines recommend multifactorial fall risk assessment modalities, including screening for medications that increase risk of falling in older adults and deprescribing or adjusting inappropriate medications, however, the institution has no such process in place. Purpose: The purpose of this quality improvement (QI) project was to implement an interdisciplinary process for screening older adults’ prescriptions for medications that increase risk of falling and mitigate unnecessary high-risk medication use. Methods: Between September and December 2021, the Screening Tool for Older Persons’ Prescriptions (STOPP) Tool was utilized for daily medication screening on patients aged 65 and older during interdisciplinary rounds on the 12-bed Intensive Care Center (ICC). STOPP is a Delphi-validated tool to screen for potentially inappropriate prescriptions (PIPs) in adults aged 65 and older, with demonstrated efficacy in reducing PIPs and adverse drug reactions (ADRs). Registered nurses (RNs), pharmacists, and intensivists received education on the standard of care, and the screening process prior to implementation. Daily screening and deprescribing were measured through weekly chart audits. Data were analyzed utilizing Microsoft Excel. Descriptive statistics were calculated to evaluate goal attainment for the process measure (medication screening) and outcomes (deprescribing). Results: One hundred percent of intensive care providers (n=7), 66% of ICC RNs (n=19) and 60% of pharmacists (n=3) received a review of the medication screening process and STOPP tool. Sixty-six percent of RNs (n=19) completed education through Nurses Improving Care for Healthsystem Elders (NICHE) on the role of nurses in deprescribing. Seventy-four patients were eligible for screening with 167 daily screening opportunities, with median weekly screening compliance of 54%. High-risk medications identified through screening had a median weekly deprescribing rate of 20%. There were two falls in the implementation period. Conclusions: Interdisciplinary medication screening is a feasible adjunct fall prevention measure. Ongoing outcome measurement is necessary.
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Implementation of a Phlebitis Prevention Bundle on a Neurotrauma Critical Care UnitProblem: Peripheral intravenous catheter (PIVC) associated phlebitis is a significant cause of morbidity leading to increased healthcare costs, prolonged lengths of stay, additional medical treatments, and increased mortality. Phlebitis, an inflammation of the vein, presents as redness, pain, warmth, streak formation, or a palpable cord. Annually, 80,000 patients with catheter-related blood stream infections are admitted to intensive care units; a large portion of these are attributed to PIVC phlebitis. The Society of Infusion Nurses supports the removal of emergently placed PIVCs and early detection of phlebitis. A neurotrauma critical care (NTCC) unit identified 68 cases of phlebitis over a 17-month period (M=4). PIVCs that are emergently placed or used for vesicant medication infusions are critical risk factors. Purpose: The purpose of this quality improvement (QI) project was to implement a Phlebitis Prevention Bundle (PPB) in a 13-bed NTCC unit of a major academic urban trauma center, determine adherence to the practice change, and monitor the incidence of phlebitis following vesicant-prone medications. Methods: This project was implemented over 15-weeks following education and training of the project champions and Registered Nurse (RN) staff (N=40). The PPB consisted of two practice changes, specifically the removal of emergently placed PIVCs, within 24 hours of admission to the unit and education pertaining to assessment of phlebitis, knowledge of common vesicants and documentation. Registered nurses completing the PPB training were recognized with a pin and certificate. Results: Registered nurses (n=40) completed education and training. Following educational sessions, adherence to the PPB reached 100% by Week 4 and was sustained for the last 9 weeks at 100%. During implementation, 25 (62.5%) PIVC were removed for early phlebitis, despite an increase in the mean incidence (M=13). Conclusions: Implementation of the PPB has the potential to increase quality of care for trauma patients and decrease the incidence of late phlebitis and its associated complications. Nursing assessment of phlebitis and its related complications has improved RN awareness prompting earlier removal of phlebitis PIVCs. Weekly display of PPB data using run charts helped to communicate practice change efforts, improve RN adherence, which in turn promoted acceptance and sustainability of the practice change.
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Implementation of Bedside Shift Change Handoff on a Cardiac-Surgical Intensive Care UnitProblem: Medication errors are a significant cause of patient morbidity and mortality, often resulting in serious injuries, prolonged length of stays, and incurred medical costs. In 2019, a Cardiac Surgical Intensive Care Unit (CSICU) at a large academic hospital identified 40 medication errors through a hospital incident reporting system. Reviews of error reports identified that 70% (n=28) involved medications administered through intravenous infusion pumps and estimated that one third could have been detected much earlier if a standardized shift handoff method such as bedside shift-change handoff (BSCH) had been in place. Purpose: The purpose of this quality improvement (QI) project was to implement BSCH with the guidance of a BSCH tool on a CSICU to reduce pump related medication errors. Methods: This QI project took place from August 30 until December 12, 2021. The initial BSCH process incorporated nursing handoff start to finish inside patient rooms; however, observational audits identified inconsistent participation and barriers to this process. At the halfway point of implementation, a rapid cycle Plan Do Study Act (PDSA) change was required to address barriers to implementation. This change allowed nurses to enter rooms at the end of handoff and perform aspects on the BSCH tool, which improved nursing adherence to the practice change. Chart and observation audits collected throughout implementation identified trends in BSCH adherence and duo verification of high alert infusions. Results: One hundred percent of nursing staff (n=103) were educated on the initial process change of BSCH as well as the rapid cycle PDSA change (n=88). Staff adherence to BSCH ranged from 20-51% during the initial phase of the project, and then improved during the second half, ranging from 80-96%. Adherence to duo verification of high-alert infusions doubled, increasing from 41-49% to a range of 82-96% during the last four weeks. Pump related medication errors decreased by 75% (n=2) from the first quarter of 2021 (n=8) and staff identified 13 potential errors, or “good catches”, during BSCH. Conclusion: Implementing BSCH results in many good catches, improving safety and preventing patient harm. Findings support the implementation of BSCH to decrease pump related medication errors
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Improving Inpatient Substance Use Screening and Referral to an Addiction Consult TeamProblem: Substance use is associated with poorer hospital outcomes, increased lengths of stay, higher healthcare costs, and increased mortality. On an adult inpatient medical unit, up to 90% of patients did not receive substance use screening per policy. Implementing the evidence-based model of screenings, brief interventions, and referrals to treatment (SBIRT) in this population would serve to optimize quality of care and patient outcomes. Purpose: To purpose of the QI project was to improve substance use screening and referrals to an Addiction Consult Service (ACS) on an adult Medical Intermediate Care Unit. Methods: This QI project was implemented over a 15-week period on a 16-bed adult medical IMC unit. In order to improve substance use screening in newly admitted patients, staff utilized an existing validated single-item screening question in the electronic medical record. Nursing staff notified the attending physicians for all patients who screened positive; the physician further evaluated the patient and placed an order for the ACS if indicated. Data collection was conducted via manual chart audits; run charts were utilized to track process and outcome measures. Process measures included counts (%) of patients who were screened/assessed for substance use. Outcome measures included counts (%) of patients who screened/assessed as positive and received follow up by a physician and counts (%) of patients who screened positive who were referred to ACS. Results: A total of 53 patients were screened or assessed for substance use. Of these, 100% received a screen or assessment, 49.06% (n=26) were screened by nursing, and 50.94% (n=27) who were missed by nursing received assessments from a physician. Of the patients screened or assessed, 13.21% (n=7) were positive, 11.54% (n=3) of patients screened by nursing were positive and 14.81% (n=4) of the patients missed by nursing but assessed by a physician were positive. Of the patients with positive screenings or assessments, 71.43 (n=5) were referred to the ACS. Conclusion: Implementing nurse-lead substance use screening with a validated screening tool in the electronic medical record is feasible on a busy inpatient medical unit, leads to improved detection rates, improves documentation, and makes screening more convenient.
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Implementation of Fall TIPS (tailoring Intervention for Patient Safety) to Reduce Patient Fall RateProblem: Inpatient falls are the most common safety event that negatively impacts both patients and the healthcare systems. In a suburban community hospital, the progressive care unit (PCU) experienced a 25% higher fall rate in 2020 than all other units in the hospital combined despite comprehensive fall prevention protocols. Therefore, a quality improvement (QI) project was implemented on this floor and on the Immediate Care Unit (IMCU). Purpose: This QI project aimed to implement a bedside Fall TIPS poster to communicate patientspecific risk factors to the multidisciplinary teams and use a tailored fall prevention plan based on their fall risks while engaging patients and their families to reduce fall rates. Methods: This project was implemented over 13-weeks during the fall of 2021. Clinical nurses on PCU and IMCU were educated on the bedside Fall TIPS posters with their patients and family members. Clinical nurses went over the bedside Fall TIPS poster at admission and every shift with their patients and families. The poster was placed on the wall next to the whiteboard as a reminder for the patient and a visual aid for the multidisciplinary team involved in the patient’s care. All patients admitted to the units between September 2021 and mid- December 2021, were included. All clinical nurses on both units completed a competency checklist before implementation. Data on the Fall TIPS poster use was collected using an audit tool created by the project leader. Unit fall rate data was collected through the hospital incident reporting system. Results: 100 % of clinical nurses were educated on the use of the Fall TIPS. Based on weekly audits, approximately 20-80% of the nurses adhered to the use of the Fall TIPS poster. There was a total of 4 falls on PCU and one fall on IMCU. Conclusion: Bedside Fall TIPS poster helped patients, families, and the care team understand the patient’s fall risk and interventions.
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Implementation of Delirium Screening in Thoracic and Surgical Intermediate Care UnitsProblem: Delirium is a disorder experienced by 13-50% of patients over the age of 50 during their hospital stay. The thoracic and surgical intermediate care units (TIMC and SIMC) at a large, teaching hospital care for many elderly patients at high-risk of delirium, but unit-level chart audits revealed a 0-5% incidence of detected delirium. Current practice did not include delirium screening, which placed patients at higher risk for undetected delirium. Unrecognized and untreated delirium may lead to longer hospital stays, higher risks of falls, and longer duration of delirium episodes. Purpose: The purpose of this quality improvement project was to implement delirium screening using a validated screening instrument to improve delirium detection on the thoracic and surgical intermediate care units. Methods: The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), a validated screening instrument (sensitivity 81%, specificity 95.8%; inter-rater reliability kappa=0.79-0.96), was implemented on two high-acuity intermediate care units over a fifteen-week period (September to December 2021). The CAM-ICU was located in the electronic health record (EHR), and all registered nurses (RN, n=47) and advanced practice registered nurses (APRN, n=16) on the two units were educated on how to complete the screen and manage screening results. Chart audits of the EHR were completed weekly for every patient admitted to the two units to assess adherence to the screening procedures. Results: Staff on both units achieved and sustained a high (>90%) rate of adherence to delirium screening among SIMC patients (n=110) and TIMC patients (n=101). Of the patients screened, 10% were identified as positive for delirium on the SIMC and 12.8% were identified as positive for delirium on the TIMC. Nurses notified the APRN or covering medical provider about patients with first-time positive screens 100% of the time. No special-cause variation was noted in the number of transfers to a higher level of care, falls, or restraint use. Conclusions: Implementing the CAM-ICU can increase delirium detection and interdisciplinary team communication on thoracic and surgical intermediate care units. Having the instrument in the EHR was a major factor in assuring adherence to and sustainability of the delirium screening procedures.
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Implementation of Standardized Patient Handoff on a Medical Surgical Inpatient UnitProblem: Poor communication within a health care organization was cited as a main cause of error and poor patient outcomes especially during transition of care. An estimated 80% of medical errors in patient care are related to miscommunication in handoff. Inadequate patient handoff communication can lead to delay in treatment or hospital discharge. Improved communication with standardized handoff has shown to have a positive correlation to conveying necessary information, preventing errors, and improve patient safety. The Report and Learn (RL) is an incident reporting system that monitors patient safety events at a community hospital. Approximately one to six safety incidents were reported weekly by the inpatient medical/surgical unit. Communication delivery may have accounted for two to six incidents of error or near error in monthly safety reports. Evidenced reviewed showed that a structured handoff tool can help to promote sufficient input from the nurse to communicate pertinent patient care information at change of shift to improve giver to receiver communication and prevent error. Purpose: The purpose of this project was to implement and evaluate the effectiveness of a standardized handoff tool for nursing shift report to improve communication and reduce medical errors. Evidence reviewed supports the I-PASS (Illness severity, patient summary, action list, situation awareness and contingency plan, and synthesis by the receiver) handoff tool for this implementation. Methods: This was a quality improvement (QI) project that measured percent errors related to poor handoff on the medical/surgical unit. The medical/surgical unit has 36 beds with 35 full time nursing staff. The QI project collected data on communication with use of I-PASS over a 15-week period. STANDARDIZED PATIENT HANDOFF 3 Results: Findings indicated a 69% staff education of use with the I-PASS tool. There was a 23% decrease in error over the course of project implementation and a 50% decrease from start of project to completion. Conclusion: The I-PASS tool was useful and relevant to decreasing communication error and patient safety events. Opportunity to further expand use of the I-PASS tool to other units would further validate the tool’s effectiveness.
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Implementation of an Algorithm to Prevent Pressure Injuries Among Immobile ResidentsProblem: Pressure injuries (PI) stages II, III, and IV became a serious health problem at a long-term care (LTC) facility in Maryland during the unprecedented times of the Coronavirus 2019 (COVID-19) pandemic. The executive director reported that several immobile residents in each of the facility’s (n=12) three units developed PIs: seven sacral ulcers, stages II, III, and IV; five heels, consisting of two right outers; and three left outers, stages II and III. In addition, (n=2) PIs stage III became infected. Purpose: The purpose of this quality improvement (QI) project was to implement a PI algorithm for prevention and expeditious intervention for PIs. Methods: The QI project was implemented August-December 2021. Pre-implementation, in person, the DNP student educated change champions, registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs)/geriatric nursing assistants (GNAs), on the algorithm. After the education session, a copy of the algorithm was laminated and posted at each nursing station in the three units. Additional strategies included training CNAs/GNAs on adhering to the turning schedule and filling out the log posted in each resident's room. In addition, each nursing staff member completed a pretest, then viewed an educational PowerPoint, and completed a post-test to evaluate knowledge of PIs. During implementation, the DNP student tracked structure, process, and outcome measures weekly through chart audits and PI prevention rounding audit tool. Results: A pie chart displayed structure measures; 80% (n=20) of nursing staff were trained on the algorithm. Zero new PIs stages II, III, and IV were reported during implementation of the algorithm. Sacral PIs stages II (n=7) improved. At week ten, 100% algorithm compliance was achieved; additionally, 90% was achieved at weeks twelve and thirteen. Conclusion: Implementation of the PI algorithm at the LTC facility during COVID-19 effectively improved residents' quality of life, prevented PIs, and decreased morbidity and mortality. Continuing education and training will be needed to maintain sustainability.
