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Altering Mechanisms of Frailty in Persons Living with HIVBackground: People with HIV experience frailty more often and earlier than others. Little is known about mechanisms driving early frailty in HIV. There are a lack of effective interventions for frailty in HIV. This study explored the mechanisms of musculoskeletal frailty in people living with HIV and the influence of baseline activity after a six-week aerobic exercise intervention. Methods: A literature review developed an adapted conceptual model for musculoskeletal frailty in HIV for the first manuscript. Due to COVID-19 restrictions, a secondary data analysis utilized the baseline activity measure (Yale Physical Activity Survey) from 11 healthy participants who completed a six-week moderate paced walking program, aged 50 to 65. Cellular energy production and inflammation markers were available pre- and post-intervention. Correlation with baseline activity was assessed using Kendall’s tau-b. Results: Mechanisms of musculoskeletal frailty in people living with HIV include increased inflammation, dysregulated energy metabolism, immune activation, and endocrine alterations. Aerobic exercise has the potential to moderate each of these. The relationship between baseline activity and changes in cellular energy metabolism was not statistically significant. However, strong positive associations were noted between body mass index and change in platelet spare respiratory capacity, the ability of mitochondria to produce more energy upon demand. In examining the effect of baseline activity on inflammatory markers, no significant relationships were found, and no markers showed significant change. Conclusion: Moderate walking did not make significant changes in inflammation after a six-week moderate paced walking intervention. Baseline activity levels did not play a significant role in the change of either inflammation or cellular energy production. This may be because healthy participants did not have impaired levels of inflammation or cellular energy metabolism at baseline. This study should be repeated in people living with HIV who have altered inflammation or cellular energy metabolism.
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Individual, Caregiver, and Family Characteristics Associated with Obesity in Preschool-age ChildrenBackground and Objectives: Eating habits start from early childhood and may contribute to the development of obesity. Food neophobia (FN) occurs among 50% of preschoolers and has shown inconsistent associations with obesity. Caregiver feeding practices (FPs) influence eating habits but have limited evidence about how they employ together and how they associate with childhood obesity. The first paper examines the relationship between FN and preschooler's obesity/overweight. The second paper assesses patterns of FPs and their associated factors. The third paper examines how the patterns of FP relate to preschoolers' Body Mass Index (BMIz), an objective measure of obesity. Method: Data from the Creating Healthy Habits Among Maryland Preschoolers (CHAMP) study including preschoolers (N=500) and caregivers from 50 Maryland childcare centers were examined. Children's weight and height were measured, and BMI percentile and z-score were calculated. Caregivers reported demographics, weight and height, FN, FPs, child temperament via an online survey. Mixed models, factor analysis, latent profile analysis, and structural equation models were used. Results: A quarter of children were obese/overweight; caregiver-reported FN was not associated with preschoolers' obesity/overweight, although children were more likely to be obese/overweight if their caregiver was overweight (aOR=2.6) or obese (aOR=3.9). Three patterns of FP were found. Controlling class had high coercive control and low autonomy practices (69%), Regulating class had high coercive control, but moderate structural and autonomy practices (16%), and Balancing class were moderate in all practices (15%). Caregivers who desired their child to be heavier (aOR=0.40, 95%CI=0.22-0.72), had higher poverty levels (aOR=0.80, 95%CI=0.65-0.98), were single (aOR=0.38, 95% CI=0.18-0.80), and were less likely to be in the Balanced versus Controlling class. Children’s difficult temperament (b=0.09, p=0.008), caregiver’s BMI (b= 0.26, p<0.001), desire for the child to be thinner (b=0.23, p<0.001), desire for child to be heavier (b=-0.37, p<0.001), and Regulating versus Controlling FP (b=-0.09, p=0.03) were associated with child BMIz. Conclusion: Childhood obesity is a multifactorial phenomenon, with interactive effects among the child, family, and environment. FP are associated with preschooler’s weight and should be assessed comprehensively. Caregivers’ perceptions of child size and temperament may also provide insight into FP and obesity.
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Staff-resident Interactions in Assisted Living: Optimizing the Quality of Daily Care InteractionsBackground: A considerable amount of research has focused on understanding and improving staff-resident interactions in long-term care. Much of this work has focused on social communications between staff and residents in nursing home settings. Attention to care interactions in assisted living (AL) is lacking. Purpose: The purpose of this dissertation was to: (1) describe the staff-resident interactions in AL; (2) explore the resident and facility factors associated with the care interactions in AL; and (3) test the feasibility and preliminary efficacy of the Promoting Positive Care Interactions (PPCI)—a four-step intervention designed to establish positive care interactions between the staff and residents with cognitive impairment or dementia in AL. Methods: Utilizing baseline data in a randomized trial that included 379 residents from 59 AL facilities, aim 1 used descriptive statistics to describe the quality of staff-resident interactions in AL and aim 2 used stepwise regression to examine factors influencing interactions. Aim 3 involved pilot-testing of PPCI intervention in one AL community in Maryland using a single group pretest-posttest design. Feasibility was demonstrated with the evidence of delivery, receipt, and enactment of PPCI. Preliminary efficacy was evaluated with repeated measures ANOVA for staff outcomes and descriptive change in summary scores for facility outcomes. Results: Although majority of the interactions observed were positive, almost 25% were negative and neutral suggesting a need to improve the interactions in ALs. Factors influencing interactions included resident agitation and facility ownership which accounted for 8.2% of variance. Additionally, PPCI was implemented as intended with 100% staff exposure to education and considerable staff engagement in mentoring sessions. While there was an improvement in AL environment and policy, no significant changes were observed in staff outcomes post PPCI. Conclusions: Understanding the quality of staff-resident interactions in AL and the factors that influenced these interactions guided the development of PPCI. Pilot testing supported the feasibility and preliminary staff adoption of PPCI in ALs. PPCI will be further tested with a randomized trial, and a hybrid model with both online education and in-person mentoring and coaching of staff to improve staff knowledge and behavior related to care interactions.
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Behavioral symptoms associated with dementia and inappropriate psychotropic medication use in U.S nursing homesBackground: Behavioral symptoms associated with dementia often occur concurrently. Psychotropic medications are used to treat behavioral symptoms in nursing homes (NHs) despite limited efficacy and the risk of adverse effects. Psychotropics are considered an easier solution for behavioral symptoms with fewer nursing staff. Inappropriate psychotropic medication use has been the focus of policy attention due to safety issues. A NH deficiency of care can be cited for inappropriate psychotropics use (F-758 tag). Purpose: The purposes of this dissertation are to examine factors of co-occurring behavioral symptoms of dementia (Aim 1), the occurrence of F-758 tag citations in relation to nurse staffing (Aim 2) and to explore how NH deficiency citations describe inappropriate psychotropics use to manage behaviors (Aim 3). Methods: For aim 1, general linear mixed models were used to explore co-occurring behavior symptoms in relation to cognitive status, physical function and analgesics use among 336 NH older adults diagnosed with dementia. For aim 2, generalized linear mixed models estimated associations between the occurrence of F-758 tags and nurse staffing levels among 13,614 NHs from December 2017 to 2018. Aim 3 used a mixed-method study design that combined descriptive and content analysis of F-758 deficiency reports (n=444 NHs) during January to March 2018. Results: Having multiple behavioral symptoms was negatively associated with better cognitive status and regular analgesics use (p<.001 and p=.009, respectively) (Aim 1). NHs with greater hours per resident day for RNs (OR=0.54, 95% CI=0.44-0.67), certified nurse assistant (OR=0.87, 95% CI=0.77-0.99), total nurse staff (OR= 0.87, 95% CI= 0.79-0.96), and greater RN skill-mix (OR=0.10, 95% CI=0.04-0.26) had significantly lower odds of F-758 tags (Aim 2). Common reasons for inappropriate psychotropic medication use included failure to monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs) and maintain14 day limits on PRN psychotropic medication orders (121 NHs) (Aim 3). Conclusions: Consideration of cognitive function and pain management are important for multiple behavioral symptoms (Aim 1). NHs need to have adequate nurse staffing levels to reduce inappropriate psychotropic medication use (Aim 2). Aim 3 analysis suggests areas for improvement, that could potentially reduce F-758 citations.
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Patient and Intimate Partner (IP) Illness Appraisals in Cancer: A Multi-Methods StudyBackground: Psychological distress for patients with serious illness has been associated with increased physical and spiritual distress, decreased quality of life, and increased medical expenses at end of life (EOL). For both cancer patients and their intimate partners (IPs), appraising the illness and communicating about it can be challenging. Yet, there is little evidence on how best to support them. Objectives: Bodenmann’s Systemic-Transactional Model (STM) of dyadic coping provided foundation to study how living with cancer impacts communication at primary appraisal level in patient/ IP dyad. The purpose of this exploratory multi-methods study was to understand patient/IP illness appraisals. This was investigated through following aims: 1. Describe patient/IP perceptions of dyadic communication before and after diagnosis of advanced cancer (including barriers and facilitators to sharing emotionally vulnerable content); 2. Describe patterns (incongruent/congruent) of patient and IP communication during advanced cancer; and 3. Explore relationships between experiential suffering (Suffering Pictogram) and communication congruency (CCAT-PF measure). Methods: Descriptive phenomenology was used for the qualitative phase. In-depth, semi-structured interviews with dyads were done, followed by individual interviews. The quantitative phase assessed cancer communication and suffering using established measures. Results: The main findings from qualitative analyses included: 1) Vulnerable communication is complicated by balancing two opposing worlds: Hope/Positivity and Uncertainty/Fear of Death; and 2) Vulnerable communication about EOL and hospice is emotional and unfamiliar. Hearing the word ‘hospice’ ends dyad’s uncertainty, confirming death from cancer is definite. Patients and IPs articulated feeling unprepared and needing guidance about skills to cross this vulnerable environment toward open communication. Quantitative data from communication measures showed low to medium discrepancy between dyads yet, patients displayed more discrepant communication behavior than their IP counterparts. IPs consistently exhibited higher suffering scores than patients across Overall Suffering and in 6/8 suffering domains. Worry and Fear were identified as highest domains of suffering for both patients/IPs. Conclusion: For IP dyads to articulate preferences for care with providers they must first be provided external support to facilitate vulnerable conversations within the dyad itself. These dyadic conversations must be initiated early after diagnosis to strengthen available supports during illness and EOL.
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Daily Charge Nurse Leader Rounds on a Cardiac Surgery Progressive Care UnitProblem: Patient satisfaction is the measure of the success of a healthcare system in today’s competitive markets. However, achieving patient satisfaction relies on multiple internal and external factors. The Cardiac Surgery Progressive Care Unit (CSPCU) at an urban medical center in the mid-Atlantic United States was seeking to improve their patient satisfaction scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCHAPS) data. Purpose: The purpose of this quality improvement project (QI) was to implement and evaluate the effectiveness of daily charge nurse leader rounds on patients admitted to a CSPCU. It is anticipated that there will be an increase in the total number of times a nurse leader rounds on a patient that subsequently will result in in an increase in patient satisfaction as measured by HCAHPS nurse communication scores. Methods: The QI project was implemented over a 14- week period in a CSPCU at an urban Maryland academic Medical Center. Charge nurses were educated on the process change and then completed ‘charge nurse leader’ rounds. The project leader checked the rounding rates bi-weekly. Nurse communication scores were collected preand- post implementation using the scores from the HCAHPS surveys. Results: The number of patients rounded on daily over the course of the project was 64.7% and during the implementation period a total of 1140 rounds were completed. The HCAHPS scores increased in the category of ‘RN explanation’ and slightly decreased in the categories of ‘RN listening’ and “RN courtesy”. Patients’ perception of the nurse leader rounding increased from 79.64% to 87.23%. Conclusions: Charge nurses can be utilized as informal leaders to complete nurse leader rounds. Leader rounds are able to be incorporated into the daily routine of the charge nurse. Patient satisfaction scores are impacted by many different factors. The increase seen in one domain of HCAHPS indicates that further studies should be completed to better understand how nurse leader rounds impact patient satisfaction.
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Implementation of an Arterial Blood Gas Indication Algorithm in Cardiac SurgeryProblem: The overutilization of laboratory testing was identified as a national problem by the “Choosing Wisely” campaign, advocating for judicious use of testing in intensive care units (ICUs). Arterial blood gasses (ABGs) account for an estimated 10-20% of all costs during an ICU stay. Non-clinically indicated ABGs increased costs of care, length of stays, ventilator days, and line days, increasing the risk of adverse outcomes to already vulnerable critically ill patients. A cardiac surgery intensive care unit (CSICU) within a large urban mid-Atlantic academic medical center accounted for 31% of the entire institution’s ABG analyses between 2018-2019, and was identified as a top utilizer due to inappropriate ordering practices as compared to current guidelines. Purpose: The purpose of this quality improvement project was to implement an algorithm based upon evidence-based guidelines that identified appropriate standardized clinical indications for ABGs, with the intention of reducing non-clinically indicated blood gas analyses orders within the CSICU. Anticipated outcomes of this practice change included decreasing the total volume of ABGs sent, resulting in reduced costs of care, lengths of stay, and improved morbidity and mortality rates. Methods: An evidence-based ABG indication algorithm was created focusing on acute changes in oxygenation, ventilation, acid base balance; changes in hemodynamics, post-operative baseline, and for patient ABGs to correlate with extra-corporeal membranous oxygenation values. Routine ABGs for monitoring were eliminated. Implementation occurred over fourteen-weeks in the fall of 2020 following staff and provider education. Training emphasized the use of non-invasive monitoring such as pulse-oximetry and capnography. Compliance and gross laboratory totals and indications were obtained from weekly auditing. Results: There was an 8.8% reduction in ABGs sent and 32% decrease in ABGs per patient day. The most common indications were extra-corporeal membranous oxygenation (ECMO)-correlated ABGs, post-operative, and changes in oxygenation and/or ventilation; 7.8% were non-indicated. Conclusions: Implementation of an ABG indication algorithm resulted in fewer ABGs sent, mostly due to a reduction in routine monitoring, and ABGs were more likely to be clinically indicated in response to an acute concern. Implementing an ABG indication algorithm is safe, feasible, and can lead to significant cost reductions for the institution.
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Implementation of an Ultrasound-Guided Algorithm for Difficult Intravenous AccessProblem & Purpose: Obtaining peripheral intravenous (PIV) access is a frequent, but challenging procedure in difficult access patients (DIVA). Emergency medical care frequently requires PIV access to administer medications and perform diagnostic testing. Traditional methods for obtaining PIV access have resulted in repeated painful attempts and treatment delays in this tertiary care emergency department. The purpose of this quality improvement project was to implement and evaluate a nursing-initiated clinical pathway directing the use of ultrasound-guided intravenous techniques for DIVA patients to increase first attempt success rates and reduce treatment delays. Methods: A departmental policy was created to support the practice change. The policy provided an illustration of the DIVA clinical algorithm and specified training and competency validation expectations. Training included 30-minutes of didactic instruction followed by 60-minutes of hands-on training. Competency validated operators documented DIVA screening, ultrasound utilization rates, pain scores, number of venous attempts, and treatment delays. Project compliance and outcome measures were collected over 14-weeks and converted into run charts for weekly unit dissemination. Chi-squared and independent samples t-tests were used to compare pre-and post-implementation results. Results: Sixteen operators completed the education and training program which included nurses (n=8) and technicians (n=8). Operator compliance to DIVA screening and ultrasound-guided intravenous algorithm utilization suggested early adoption (M = 89.25, SD = 7.45). First-attempt success rates for DIVA patients increased from 57% to 87% (p = 0.03) and treatment delays decreased from 20% to 0% (p = 0.01). There was a significant reduction in pain scores (M = 2.2, SD = 1.17) compared to baseline (M = 5.3, SD = 1.65) data; t(58) = 8.08, p < 0.001. Conclusions: The use of a nurse-initiated clinical pathway to identify difficult access patients requiring ultrasound-guided intravenous cannulation increases the likelihood of first attempt access success and ensures timely medication administration, laboratory analysis, and diagnostic testing in the emergency department. The reduction in cannulation attempts optimizes patient outcomes by decreasing pain experienced by the patient, and treatment delays.
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Implementation and Evaluation of a Patient Handoff Tool to Improve Nurses CommunicationProblem & Purpose: Poorly conducted handoffs are implicated in 80% of preventable adverse events in healthcare facilities. Within a sub-acute and rehabilitation facility in Maryland, observational reports revealed that nurse handoffs were poorly conducted and lacked the use of a standardized evidence-based tool, resulting in miscommunication and nurse dissatisfaction with the handoff process. Situation, Background, Assessment, Recommendation (SBAR) is an evidence-based tool recognized by The Joint Commission, Agency for Healthcare Research and Quality (AHRQ), and the World Health Organization (WHO) as an effective tool in improving handoff communication, reducing adverse events, and promoting patient safety. The purpose of this quality improvement (QI) project was to implement and evaluate an SBAR patient handoff tool to improve nurse communication. Methods: Nurses were educated on the SBAR method and tool prior to using the tool. A Handover Evaluation Scale (HES) survey was distributed pre-implementation and again at the end of the 15-week implementation period. Weekly observation audits were conducted to determine nurse compliance with use of the SBAR handoff tool. Results: Findings indicated that nurse compliance with use of the SBAR patient handoff tool was 86% by Week 7, and 100% by Week 13. Comparison of pre and post-HES survey mean responses showed modest improvements in all items relating to the key variables: quality of information, interaction, and efficiency of handoffs. Conclusion: Use of the SBAR tool improved the quality of information, interaction, and efficiency of patient handoffs between nurses, thereby improving communication. Further QI projects are recommended to evaluate the effectiveness of SBAR in reducing adverse patient events and improving patient care outcomes.
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An Algorithm for Diaper Dermatitis Management in the Neonatal Intensive Care UnitProblem: Diaper dermatitis (DD) is inflammation of the skin in the perianal area that ranges from mild erythema to broken skin and bleeding. At baseline, 20% of infants ≥ 30 weeks gestation had DD in the target Level IV Neonatal Intensive Care Unit (NICU). Historically, DD was managed based on individual nursing judgment due to a lack of current standardization of care for infants with DD and resulted in inconsistent care of infants with DD. Purpose: The purpose of this quality improvement project was to implement and evaluate the effectiveness of an algorithm for the prevention and treatment of DD in infants ≥ 30 weeks gestation in a Level IV NICU in an urban, academic medical center. Methods: Bedside nurses were given education on DD and the new algorithm for the management of DD. They also completed pre-and post-knowledge surveys. The algorithm was placed at the bedside of each infant for reference and the educational PowerPoint was emailed to all bedside nurses. Once a week, bedside nurses documented incidence of DD, if prophylactic or therapeutic treatment was performed, and if the algorithm was followed. Continued education was provided throughout implementation, reminder cards were placed on each nurse computer, and reminder texts to document DD data were sent out via unit phones each Monday. Results: The use of the algorithm and the use of prophylactic petroleum jelly increased from 0% at baseline to 100% over the 15-week data collection period. The prevalence of diaper dermatitis decreased from 20% (9/46) prior to implementation to 18% (2/11) on the last week of data collection. Following the education on DD and the implementation of the algorithm, the majority of nurses stated that they were more aware of DD and monitored for it more closely during diaper changes. Conclusions: The use of an algorithm for the management of diaper dermatitis helped to increase the use of prophylaxis and education on the algorithm increases bedside nurses’ awareness of DD in their patients on this unit.
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Implementation of a Mealtime Assistance Training Program for Long Term Care StaffProblem: In nursing homes approximately 70% of residents have a form of dementia and are at risk of malnourishment. Long-term care (LTC) facility residents have varying degrees of cognitive impairment affecting their capacity to feed themselves. The director of nursing at the project site identified that residents are vulnerable to decreased food and fluid intake, which may be reflective of limited feeding skills of the nursing staff. Purpose: The purpose of this quality improvement project was to implement an online staff training program for handfeeding of residents with cognitive impairment (CI) in a LTC facility to optimize the mealtime interaction and improve resident health outcomes. Methods: The project was implemented at a LTC facility in rural Maryland with nine staff participants (2 nurses and 7 geriatric nursing assistants), who worked shifts while meals were served. Data collection occurred through pre- and post-training surveys as well as baseline and final (end-of-project) interviews to evaluate the staff’s perception of improvements in the mealtime interaction and enhanced outcomes for residents. Results: Prior to the training, only 11.1% of the staff reported ever having any formal training/education on feeding assistance beyond their basic nursing educational program. All the staff completed the training program and corresponding skill competency checklists. While 100% of the staff reported via the surveys the training as being helpful, only 87% had the opportunity to use any of the skills or techniques from the training. The primary qualitative finding from the final interviews was 100% of staff said the training has or would improve the mealtime experience and nutritional state of residents. Conclusion: The data collected from surveys and interviews confirms that staff participants found the training program for handfeeding of residents with CI to be valuable in improving feeding interactions as well as the nutritional state of residents.
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Implementation of a Fall Prevention Toolkit on a Medical Surgical UnitProblem: In-hospital falls result in patient harm which includes minor injury, psychological distress and anxiety, and serious injuries like fractures, head trauma, and even death. The Joint Commission consistently ranks falls with serious injury as one of the top sentinel events. An acute care medical surgical unit in a community-based hospital experienced an increase in the number of falls with an overall fall rate higher than that of peer units. Purpose: The purpose of this Quality Improvement (QI) project was to implement and evaluate the benefits of, and staff adherence to, the use of Fall TIPS (Tailoring Intervention for Patient Safety) toolkit to reduce falls on a medical surgical unit. Methods: The Fall TIPS toolkit was designed to decrease the patient fall rate in hospitals and engage patients and their families in a 3-step fall prevention process including performing a fall risk assessment, creating a tailored fall prevention plan, and executing the plan regularly. Implementation of a Fall TIPS toolkit with auditing transpired weekly over 10 weeks on a medical surgical unit. Nurses’ adherence to the Fall TIPS protocol was measured weekly during implementation. Results: The results indicated that nurses’ adherence to use of the Fall TIPS toolkit averaged 78%. The run chart analysis of nurses’ adherence did not show any shifts or astronomical datapoints, and the number of runs was consistent with random variation. However, there was a 6-point upward trend in the data during weeks 2 to 7, indicating a special cause. Fall rates during the first two months of implementation were 3.39 and 2.41 per 1000 patient-days respectively, and dropped to zero during the third month. Conclusion: Nurses’ adherence to a Fall TIPS toolkit was demonstrated on a medical surgical unit, which likely resulted in a decreased patient fall rate during the final month of the project. Additional time will be needed to determine if the practice changes and outcomes are sustainable.
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Goal of Treatment as Part of the Chemotherapy Consent ProcessProblem: Patients consenting for chemotherapy require a clear understanding of the goal of treatment to make an informed treatment decision reflective of their own goals and values. Identified barriers to patient understanding include lack of information on the consent form and the use of ambiguous language by providers. Both the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) recommend goal of treatment as part of the consent process. Purpose: The purpose of this quality improvement project was to develop and implement a new chemotherapy consent form that includes goal of treatment; to improve documentation compliance and to evaluate patients’ understanding of their treatment goal. Methods: A multidisciplinary committee at the project site decided to include three goals of treatment: curative, palliative, and palliative/life-extending as part of the consent form. Goal definitions using plain language were included to ensure consistency across providers in how these terms were defined during consent conversations. Patient surveys were developed to evaluate perceived satisfaction with the information provided during the consent conversation as well as the patient’s own perceived goal of treatment. Results: Between August 31, 2020 and December 11, 2020, 155 patients were consented for chemotherapy with 54% of patients completing the patient survey. Goal of treatment documentation compliance increased from 8% to 99% with adoption of the new consent form. Goal concordance, defined as a patient’s ability to correctly identify their goal of treatment compared to the physician’s documented goal of treatment, increased from 42% to 61%; an increase of 43%. However, a chi-square test of independence revealed no significant association between the rate of agreement and consent form used (X2 (1, N = 84) = 2.72, p = .10). Conclusions: Goals of treatment are a vital part of consent conversations. Including goal of treatment as part of the consent form creates opportunity for meaningful, in-depth goals of care conversations which can help patients make treatment decisions reflective of their own goals and values. Although improvement in goal concordance did not reach statistical significance, a 43% improvement in concordance with the new consent form cannot be overlooked.
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Eliminating Hospital Acquired Pressure Injuries: Prevention Bundles and Two Nurse SkinProblem: A Vascular Surgery Progressive Care Unit (VSPCU) in a large, academic medical center had a year-to-date hospital-acquired pressure injury (HAPI) incidence rate of 1.89 per 1000 patient days in 2019; fifty percent of these HAPI were avoidable. Purpose: The purpose of this quality improvement (QI) initiative was to eliminate HAPI incidence on a Vascular Surgery Progressive Care Unit through implementation of an evidence-based pressure injury prevention bundle (PIPB), including a two-RN skin assessment and co-sign component within 24-hours of patient admission or transfer. Methods: The Vascular Surgery Progressive Care unit consists of 12 beds and averages 53 admitted patients per month. A 16-week implementation period took place from August 31, 2020 to December 22, 2020. Head-to-toe, 2-RN skin assessment with electronic health record cosign and bundle documentation was implemented on the project unit for nurses to identify risks for HAPI, provide all admitted patients evidence-based prevention strategies, and to link staff with institutional skin prevention resources. The QI project was guided by Lippitt’s Change Theory. Staff-received project education was measured by a completion goal date. Nursing staff completed return-demonstration of 2-RN cosign and bundle note documentation within the electronic health record. Documentation of RN bundle compliance was measured by weekly chart audits. Unit HAPI incidence rates were measured by quarterly audits compiled and dispersed by the institutional Skin Integrity Committee. Data used for dissemination and discussion was comprised using run-chart analysis. Results: At Go-live 57% of RNs were PIPB trained (n = 30). A zero avoidable HAPI incidence was maintained during implementation (n = 194 patients). At week nine, 100% bundle compliance was achieved for five consecutive weeks. Conclusions: Implementation of a prevention bundle using a two-nurse skin assessment with cosign, for achieving zero unit-based HAPI is feasible and should be a care standard. Bundle compliance was associated with completed staff training, charge nurses as project champions, compliance email reminders, compliance data-sharing with staff, leadership availability and visibility, and continual team positive reinforcement.
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Implementation of Eat, Sleep, Console Approach to Care for Opioid Exposed NewbornsProblem: Rates of neonatal abstinence syndrome (NAS) have seen a fivefold rise in Maryland. Current management strategies include the Finnegan Neonatal Abstinence Scoring System (FNASS) and opioid pharmacotherapy for symptom management placing tremendous burden on health care system due to increased length of stay, admission to special care nurseries, and disruptions to family bonding. Purpose: The purpose of this quality improvement project was to implement the “Eat, Sleep, Console” (ESC) method in the care of newborns with in-utero opioid exposure to reduce average length of stay (ALOS) for infants with NAS. Secondary outcomes were reduced doses and amount of morphine and increased breastfeeding initiation rates. Methods: A quality improvement (QI) methodology was used to implement ESC on an inpatient floor. Hospital NAS policy was revised to adopt ESC tool, as needed morphine for symptoms management, and emphasis on nonpharmacologic care. The ESC assessment tool was integrated into the electronic health care record (EHR). ESC scores, nonpharmacologic interventions, and parental presence were recorded in the EHR. Infants ≥ 32 weeks gestation with opioid exposure were included in the QI project. Data to be collected included average length of stay (ALOS), number and total morphine doses, and breastfeeding rates during admission. Preliminary Results: Evidence shows that organizations that have made the transition to ESC have seen reduction in opioid agonist therapy, reduced length of stay, and improvement in breastfeeding initiation rates for newborns with NAS. We aim to demonstrate that implementing the ESC will result in similar benefits to our institution. Updates to several structure and process measures are now in the implementation phase. Preliminary Conclusions: Changing the treatment model for newborns with NAS requires a multidisciplinary approach with providers across various specialties. Success of this Quality Improvement project required buy in from all units/care providers with education throughout the staff and families to support ESC.
