Recent Submissions

  • SINI 2019: Moral Distress with Burden of Documentation: A Call to Action

    McBride, Susan, P.h.D., R.N.-B.C., C.P.H.I.M.S., F.A.A.N. (2019-07)
  • Peterson's Nursing Schools Online Survey-UMB 2020

    University of Maryland at Baltimore. School of Nursing (2020)
  • Substantive Change Review Notification Letter from CCNE 2020

    Commission on Collegiate Nursing Education; Hanson, Mary Jane (2020-08-04)
  • American Association of Colleges of Nursing Faculty Vacancy Survey 2020

    University of Maryland, Baltimore. School of Nursing (2020)
  • Enhanced Recovery After Surgery for Cesarean Delivery Clinical Practice Guideline: Postoperative Interventions

    Wali, Alexandra; Amos, Veronica Y. (2020-05)
    Problem & Purpose: In the United States, the cesarean delivery rate is approximately 32% of all births, with well over a million performed each year. Compared to women who performs spontaneous vaginal births, cesarean deliveries are associated with a prolonged length of stay. These women are usually young and healthy, possess the ability to achieve a rapid recovery, and have a unique incentive to return to their baseline functional capacity in order to care for their newborn. Enhanced Recovery After Surgery (ERAS) is a standardized set of perioperative interventions implemented to improve surgical outcomes, optimize patient care, and reduce hospital costs. Even though there is an enormous amount of evidence to support the improvements ERAS has made for perioperative care pathways among many surgical specialties, obstetrical surgery lacks established protocols based on such principles. The purpose of implementing the ERAS clinical practice guideline (CPG) is to standardize care throughout the perioperative period and optimize recovery for parturients undergoing elective cesarean deliveries. Methods: The CPG was created using high quality evidence and subsequently evaluated by elected stakeholders using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. Dissemination took place following the incorporation of stakeholder recommendations and feedback. A Practitioner Feedback Questionnaire (PFQ) survey following the formal presentation or the CPG during grand rounds was given to anesthesia staff to assess acceptability and usability of the CPG. Results: Feedback received from the AGREE II Tool and PFQ show satisfactory results on the quality, usability, applicability, and acceptance of the CPG. Conclusion: The favorable AGREE II Tool assessment results, widespread acceptance of the interventions among staff as evidenced by the PFQ results, as well as the strength of evidenced utilized to create the recommendations included in the CPG, will facilitate the quality and safety of recovery for elective cesarean deliveries at the institution of interest.
  • Screening for Depression in a Rural Primary Care Setting

    Wallander, Jacquelyn C.; Yarbrough, Karen (2020-05)
    Problem and Purpose: The United States Preventative Services Taskforce recommends depression screening in the general adult population. Patients with untreated depression have higher morbidity rates in many diagnosis groups. Detecting and managing depression allows patients to better self-manage chronic diseases and contributes to an overall sense of improved well-being. In a private primary care setting a practice gap existed in which patients were not routinely screened for depression. The purpose of this quality improvement (QI) project was to implement a screening process for adults in a primary care practice to detect depression symptoms and offer treatment if indicated. Methods: The primary aim of this QI project was to implement a depression screening process for adults in a primary care practice using the Patient Health Questionnaire-9 (PHQ-9), a validated depression screening instrument. Primary outcomes measured: provider compliance in obtaining depression screenings and calculating the percentage of patients identified with depression. Eligible patients were aged 18-64 being seen for an annual exam with two Nurse Practitioners (NP). The NPs were provided PHQ-9 education and weekly reminders to complete the screening. During each patient annual exam, the patient was provided a copy of the PHQ-9. The NP reviewed results and treated when indicated. Charts were audited weekly for: provider compliance and depression classification. Results: Depression screening compliance was 67%, (n=30/45) and 30% of patients screened (n=9/30) were diagnosed with depression. All depressed patients were offered treatment. 20% were new depression diagnoses (n=6/30) and 10% had a history of depression (n=3/30). 13% (n=4/30) of patients were provided referrals to psychotherapy and 7% (n=2/30) were started on a medication for depression. The majority of the positive depression screenings (67%, n=6/9) were detected as mild. Conclusion: Depression screening using the PHQ-9 instrument is an effective way to detect depression. This will reduce the untreated depression rates in the practice and connect patients to proper treatment. Once depression is managed, patients are able to better self-manage chronic diseases. Implementation of the PHQ-9 into the provider workflow will increase depression screening compliance. As a result of this project, the primary care practice built the PHQ-9 instrument into the electronic health record to facilitate provider compliance.
  • Implementation of an Algorithm for Goal-Directed Hemostatic Resuscitation in Trauma

    Westbrook, Lauren M.; Akintade, Bimbola F. (2020-05)
    Problem & Purpose Hemorrhage is the leading preventable cause of death following an injury and causes 30 to 40 percent of all trauma deaths. Trauma patients are highly susceptible to life-threatening coagulopathies which potentiate bleeding and require specialized diagnostics to identify and manage. Thromboelastography (TEG) effectively identifies trauma-induced coagulopathies, and offers customized strategies for hemostatic resuscitation, resulting in less blood product transfused, better survival rates, and shorter lengths of stay. The purpose of this evidence-based quality improvement project was to facilitate the process of goal-directed hemostatic resuscitation in trauma patients requiring massive transfusions by protocoling the use of an algorithm for rapid TEG (rTEG) guided hemostatic resuscitation during massive transfusion events (MTE). Methods For a Level I Trauma Center admitting unit with rTEG capabilities, an evidence-based algorithm for rTEG interpretation and application was modified to include rTEG in the existing MTE criteria. Multi-modal educational resources for rTEG interpretation were provided, and processes impeding unit workflow and practices to facilitate integration of rTEG in to active trauma resuscitation were addressed. Total number of blood products given during MTEs were compared with unpaired T-tests between implementation (September – October 2019) and baseline (September – October 2018) timeframes. Staff perceptions of TEG value and application in trauma were assessed before and after implementation of the algorithm. Results Despite numerous challenges throughout project implementation, staff were significantly more comfortable with interpreting TEGs (p=0.002) and teaching TEG interpretation to other nurses (p=0.04) following implementation of the algorithm. Cryoprecipitate (CRYO) administration increased despite having less MTEs in the implementation period, which may reflect increased awareness of hemostatic resuscitation strategies (ratio of CRYO to MTE in 2018: 0.48; 2019: 0.78). No significant difference was found between the volumes of blood products transfused during implementation and baseline timeframes. Conclusion Algorithmic approaches to rTEG application in trauma resuscitation should be considered to enhance nurses’ confidence in rTEG interpretation. Protocoling the use of TEG in traumarelated MTEs may improve adherence to evidence-based goal-directed hemostatic resuscitation strategies through the use of hemostatic blood products. Point-of-care rTEG procedures require extensive multi-disciplinary collaboration, which can be facilitated by a designated process champion.
  • Bathtime Shenanigans: Implementing Evidence-Based Bathing Practices

    Williams, Keiara D.; Felauer, Ann (2020-05)
    Problem: Bathing practices vary among neonatal intensive care units (NICU), despite guidelines developed by the Association of Women’s Health, Obstetrics and Neonatal Nurses (AWHONN). Bathing should occur allowing for optimal outcomes in the neonate, while attempting to minimize negative physiologic effects due to the stress of bathing. Purpose: The purpose of this project was to implement evidence-based bathing practices in a level IV NICU, where practices vary. Through the utilization of AWHONN’s Neonatal Skin Care Guidelines (NSCG), the goal was to reduce signs of neonatal stress, particularly temperature and behavioral signs of distress during bathing. Methods: The population consisted of neonates ranging in age from 24 to 40 weeks’ gestation in a 52 bed NICU. Implementation occurred over a twelve-week period in the fall of 2019, which included collection of baseline data, identification of unit-based champions, staff education, competency assessments, and development of resources and reminders for staff. Guideline-based algorithms were created, which determined inclusion and exclusion criteria for bathing. Documentation on bedside charts included the age of the infant, the type of bath given, and measures of tolerance to bath assessed by pain/sedation scores and patient temperature 15 minutes post bath. Results: Training resulted in guideline competency among 16% of the NICU nurses. The bedside documentation tool was completely filled out 36 times over the six-week period of implementation, on a unit where the patient census averages 45-52 patients a day. Although, limited, there were some apparent trends in the data that suggests evidence-based bathing practices are needed on this unit. There were no negative effects of increased pain/sedation scores when the infants were swaddle bathed, pain/sedation scores remained < 3, requiring no interventions. Normal temperatures were more likely if the infant was swaddled bathed. However, about 36% of the documented temperatures were <36.5, despite the type the bath. Conclusion: Evidence-based bathing practices help to reduce negative outcomes in the neonatal population. Implementing a practice change within a large unit requires continuing education to enforce the strategies set forth by AWHONN and cement strategies for sustainability and accountability into practice.
  • Let’s Talk: Post Critical Incident Debriefing Project

    Wiseman, Tamara L.; Wise, Barbara V. (2020-05)
    Problem and Purpose: Structured debriefings inconsistently occur in a level IV Neonatal Intensive Care Unit (NICU). Lack of a structured debriefing process negatively impacts provider physical/emotional health and patient outcomes. Lack of debriefing conversations leads to unconstructive feedback and unidentified areas for team and patient outcome improvement. The purpose of this quality improvement (QI) project is to implement, the Team Strategies and Tools to Enhance Performance and Patient Safety Debriefing Tool (TeamSTEPPS) following high-risk deliveries in infants 22-32-week gestation and emergency/resuscitation codes in a 52 bed, level IV NICU in the mid-Atlantic region. The goal is to facilitate debriefings after 100% of the critical events and enhance positive team communication during debriefings. Methods: The project was implemented for 12 weeks. The population included a multidisciplinary NICU staff. The project involved training staff on the use of the standardized debriefing tool, documenting high-risk deliveries, frequency of debriefing guided by the TeamSTEPPS debriefing tool, and evaluating debriefing outcomes using the REFLECT Tool. The primary QI metrics included the number of staff trained and educated, patient gestational age, high-risk delivery and emergency codes, occurrence of debriefing, debriefings guided by TeamSTEPPS Debriefing Tool, and staff assessment of the debriefings using the REFLECT Tool. Data was analyzed using descriptive statistics to identify trends in the percentage of debriefings that occurred following 22-32 weeks gestation deliveries and emergency/resuscitation codes. Results: During implementation phase, twenty percent of the NICU staff were trained/educated in the debriefing process. A total of four debriefings occurred using the TeamSTEPPS Debriefing Tool. Post critical events debriefings increased from one percent to fifteen percent. Team communication, role delineation, and patient stabilization time improved during a subsequent critical event. Conclusions: This QI project demonstrated the feasibility of implementing a structured debriefing tool in a high acuity NICU, to improve team communications and patient outcomes following critical events. Increased nursing and provider staff engagement, and ongoing training would enhance debriefing facilitation. Future considerations include expanding debriefing after all emergent deliveries, including the labor and delivery team, and piloting in smaller NICUs.
  • Improving Allergen Immunotherapy Assessment and Follow-up Utilizing a Screening Tool

    Witt, Ashley A.; Scheu, Karen (2020-05)
    Problem & Purpose: Allergen immunotherapy (AIT) is an effective treatment for environmental allergies and/or allergic asthma involving the administration of subcutaneous injections at regular intervals. Treatment guidelines recommend the routine use of questionnaires and annual follow-up visits to monitor patients’ symptoms, AIT tolerance and efficacy, and guide overall treatment plans. Poor follow-up rates and a lack of routine assessment with screening tools were identified at a suburban Maryland allergy and asthma specialty care clinic. Methods: A pre-screening tool was administered every 4 to 6 weeks prior to AIT injections. The screening included health questions and validated assessments of allergy and/or asthma symptom severity and disease control. Individualized patient follow-up plans were determined based on screening results and evidenced based improvements were also made to patient educational materials, and AIT administration records. Results: Over 14-weeks, 85 adult patients completed a total of 204 screenings. The overall screening completion rate was 86.1%, with 41.2% of screenings identified as positive, and timely appointments scheduled for 66.7% of positive screenings. Overall compliance with AIT follow-up within 12 months improved significantly, from a baseline of 62.35% (n=53), to 98.82% (n=84) over the course of the project (p>0.001). Conclusions: Significant improvements in AIT patient assessment and provider follow-ups were noted during the course of this quality improvement DNP project. These improvements demonstrate that the quality improvement interventions were successful and over time may improve the overall disease management and health outcomes of AIT patients. demonstrating over time that patients may improve their overall disease management and health outcomes.
  • Evaluating Antidepressant Use in Nursing Home Residents with Moderate to Severe Cognitive Impairment

    Nalls, Victoria; Galik, Elizabeth; Resnick, Barbara (2020)
    Background: Antidepressants are commonly prescribed medications among nursing home residents and used to treat symptoms of dementia. Concerns have been raised, however, about disparities and potential inappropriate use of these medications within this population. Purpose: The purpose of this dissertation was to: (1) Describe factors associated with antidepressant use in nursing home residents with moderate to severe cognitive impairment; (2) Describe differences in antidepressant use between white and black nursing home residents with moderate to severe cognitive impairment; (3) Evaluate trends in antidepressants and antipsychotics prescribing among nursing home residents with moderate to severe cognitive impairment. Methods: This secondary data analysis used data from the Function and Behavior Focused Care (FBFC) for Nursing Home Residents with Dementia randomized control trial. A total of 336 residents were included in the study, who were mostly white, female, severely cognitively impaired (MMSE=7.8, SD=5.1) and the average age was 82. Data collection was done at baseline and 12 months and based on chart reviews, input from staff, and observation of residents. Descriptive statistics and logistic regression were used to address aims 1 and 2. Generalized linear mixed modeling with a binary distribution and logit link function was used for aim 3. Results: At baseline, 59% of the sample was taking an antidepressant. Race was significantly associated with antidepressant use (β=0.51; p=0.01). Black residents were half as likely to be on antidepressants compared to white residents (OR=0.499 CI=0.305-0.817) and received lower dosages of sertraline (t=2.68; p=0.01). There was no significant change in antidepressant or antipsychotic use at 12 months. Conclusions: Black nursing home residents with moderate to severe cognitive impairment were significantly less likely to be on antidepressants and when treated, were likely to be on lower dosages of some antidepressants. It is unknown if this is due to misdiagnoses and disparities in treatment or lack of need for antidepressants or differences in responses to specific drug classes. Further research is needed to explore these differences and evaluate the influence of resident, prescriber, and facility factors on the use of antidepressants among nursing home residents with moderate to severe dementia.
  • Burden and Mental Health of Family Caregivers of Cancer Patients: The Impact of Spirituality

    La, In Seo; Johantgen, Mary E. (2020)
    Background: As the primary source of care for individuals with cancer, family caregivers are relied on for treatment support and emotional care during the cancer trajectory. Studies on caregiver burden and psychological sequelae among cancer caregivers have been conducted cross-sectionally. Spirituality has been suggested as a potential buffer between burden and sequelae. Yet, there have been very few longitudinal studies addressing burden, depression, and spirituality, and there is limited information on psychometric properties of the spirituality measures in cancer caregivers. Purpose: The aims of this study were to: 1) evaluate validity of the Spiritual Perspective Scale (SPS) and explore differences in spirituality across caregiver and patient characteristics, 2) describe caregiver burden during active cancer treatment and explore caregiver and patient factors influencing caregiver burden, and 3) examine changes in caregiver burden, spirituality, and depression and explore the moderating effect of spirituality on burden-depression relationship over time. Methods: A secondary analysis of data from a longitudinal study of cancer caregivers from the NIH Clinical Center was conducted. Caregivers completed measures, including the Spiritual Perspective Scale (SPS), Caregiver Reaction Assessment (CRA), and NIH Toolbox and PROMIS® measures. Structural equation modeling and linear mixed modeling were used for testing study aims. Results: The SPS was found to have satisfactory psychometric properties in cancer caregivers. Adjusting for a direct effect of race did not alter the pattern of results, and caregivers who were older, female, racial/ethnic minorities, less educated, affiliated with a religion, and who provided care to anyone other than the patient reported higher levels of spirituality. Baseline mutuality between the caregiver and patient was negatively associated with initial burden. Changes in caregiver burden were related to being spouse caregivers, sole caregivers, and income. Scores on total burden, spirituality, and depression remained stable over time. Caregivers’ spirituality moderated the link between burden and depression (-1.26, p = .025). Conclusions: Higher levels of spirituality may act as a protective factor in the relationship between burden and depression during active cancer treatment. Identified factors related to burden and strategies to strengthen spirituality should be considered to improve caregiver mental health.
  • Implementation of a Standardized Screening Tool and Referral Process for Sports Physicals

    Schafer, Chelsea M.; Scheu, Karen (2020-05)
    Problem & Purpose: Sudden cardiac death (SCD) from hypertrophic cardiomyopathy (HCM) is the leading cause of death in student athletes 12-25 years of age in the United States (US). To decrease the risk of SCD, the American Heart Association (AHA) recommends preparticipation screenings using a standardized cardiac screening tool. The purpose of this project is to implement a standardized screening tool and referral process for sports physicals in an urgent care center to identify those at risk. Methods: During implementation of this quality improvement project, the urgent care’s preparticipation sports physical form was updated to include the screening recommendations from the AHA. These changes were communicated through multiple modalities to increase provider and staff awareness of the practice change. Results: Over 14-weeks, 70 student athletes presented for preparticipation sports physicals and 24 (34%) of these athletes were screened utilizing the updated screening tool. Of the 70 total athletes screened, four screened "at-risk" and were cleared for sports activity without referral for the recommended cardiovascular evaluation. Conclusion: Improvements in screening student athletes using the AHA guidelines were made, however follow-up with referrals to cardiology for athletes at risk was not completed. Future recommendations to improve the process may include incorporating forms into the electronic health record with the inclusion of pop-up alerts for a cardiology referral for any student athlete that identifies with risk for heart disease.
  • Implementation of a Pneumococcal Immunization Standing Order Protocol in Long-Term Care

    Shittu, Alyson P.; Alessandrini, Erica (2020-05)
    Problem & Purpose Streptococcus pneumonia is a significant cause of morbidity and mortality of adults who are immunocompromised and of advanced age. It is the standard of care to vaccinate all high-risk adults (18-64 years) and adults 65 years and older with two pneumococcal vaccines (Centers for Disease Control and Prevention [CDC], 2015). However, pneumococcal immunization rates remain below the HeathyPeople2020 target goal of 90% nationally and locally (Office of Disease Prevention and Health Promotion [ODPHP], 2019). The objective of this quality improvement (QI) project was to implement the Immunization Action Coalition (2017) pneumococcal standing order protocol to increase the percentage of adult patients screened for vaccine need by 90%, and percentage of total residents vaccinated according to CDC recommendations by 10%. Methods The strategy of this QI project was to educate registered nurses to implement a pneumococcal standing order protocol, in a privately owned, 120-bed, long-term care (LTC) center in suburban Maryland. The design of this QI project was based on the diffusion of innovation theory, the 4 pillars practice transformation program (4 Pillars), and the Mobilize-Assess-Plan-Implement-Track (MAP-IT) process model. Weekly frequency distributions were used to examine the screening and vaccination rates, and a chi squared (X2) test was performed post intervention to examine the significance of intervention on vaccination rates. Results The total number of LTC residents (n=100) were White (66%), Black (32%), other (2%), with an average age of 83 years. Pneumococcal immunization rates increased from 56% pre-intervention to 82% post-intervention, and screening rates for vaccination need increased from 0% to 100%. A chi-squared test for independence indicated a significant relationship between vaccination status and implantation of the SOP intervention (p = 0.046, df = 1, n = 100). Conclusions This QI initiative showed that a systematic process change is feasible and can improve pneumococcal vaccination rates in a single institution. The findings may not be applicable to centers without an electronic medical record software to document immunizations or dedicated QI team. Ongoing work should focus on the perceived self-efficacy of LTC nursing staff to effectively implement a behavior change, and skills to provide strong recommendations for immunizations.
  • PERIOPERATIVE ANESTHESIA MANAGEMENT OF SURGICAL PATIENTS WITH CARDIAC IMPLANTABLE ELECTRONIC DEVICES

    Solomon-Adenola, Oluwanife; Gutchell, Veronica (2020-05)
    Problem Statement: Currently, in the United States, there are approximately 3 million patients with Cardiovascular Implantable Electronic Devices (CIEDs). Annually, more than 1 million CIEDs are implanted and 2% of patients with CIEDs undergo cardiac/non-cardiac surgical procedures. With the increase in surgical patients with CIEDs, CIED variations and CIED risk of complications, anesthesia providers must have current knowledge about preoperative and postoperative management of this patient population. Purpose: The purpose of this Doctor of Nursing Practice (DNP) project was to develop an evidence-based clinical practice guideline (CPG) for standardizing the preoperative and postoperative anesthesia management of surgical patients with CIEDs at a large, teaching, level two trauma hospital in Baltimore, Maryland. Currently, there is no existing evidence-based practice for anesthesia management of these patient populations at this facility which provided an educational opportunity to improve patient safety. Methods: An expert panel was convened and included two Certified Registered Nurse Anesthetists (CRNAs), one anesthesiologist, an interventional cardiologist, and a chief information officer. A comprehensive review of literature was conducted. The Appraisal of Guidelines for Research & Evaluation II (AGREE II) Tool was utilized by the expert panels to assess the quality of the CPG. After the dissemination of the CPG via an educational PowerPoint presentation to anesthesia providers at Grand Rounds, the practitioner feedback questionnaire (PFQ) was completed. The PFQ is a 3-point Likert-scale used to assess the accuracy and transparency of the development of the CPG. Results: The domain scores of the AGREE II tool ranged from 70 to 100%. The domain “Editorial Independence” rated highest with a score of 100%. The domain “Stakeholder Involvement” rated lowest with a score of 70% and “Applicability” with a score of 81%. 80% of anesthesia providers (n=30) completed PFQ. Overall, 94% of the anesthesia providers agreed that the guideline should be approved for practice and it would be applied in their practice. Conclusion: This CPG impacted the knowledge deficit among anesthesia providers at this facility to increase awareness and improve patient safety of surgical patients with CIEDs. Even though this CPG was designed based on the need of this institution’s anesthesia providers, stakeholders permitted the application and usability of this CPG at other sister hospitals under this facility’s health system.
  • Improving Teamwork and Communication for Child Psychiatric Staff

    Smith, Ciara M.; Rowe, Gina C. (2020-05)
    Problem & Purpose: There is a critical need for mental health staff to work well as a team, particularly with the increase in high acuity behavioral health patients and shortage of experienced psychiatric nurses in recent years. Staff members on an inpatient pediatric psychiatric unit have recognized elements that underpin effective teams and include efficient, effective communication, transparency and trust. Leadership on the unit have identified team communications skills as an area of opportunity to improve the staff’s perception of teamwork. The purpose of this quality improvement (QI) project is to establish a baseline measure of teamwork, equip staff with evidence-based teamwork tools based on TeamSTEPPS 2.0: Strategies and Tools to Enhance Performance and Patient Outcomes (TeamSTEPPS), evaluate success of the tools, and make recommendations for improvement. Methods: Thirty-four inpatient child psychiatric nurses and mental health technicians received education on strategies from the Mutual Support and Situational Monitoring modules of the TeamSTEPPS® 2.0 fundamental curriculum, such as C-U-S, DESC Script, and cross monitoring. These strategies helped improve the process of communication during therapeutic groups by improving staff’s interactions. Staff used the TeamSTEPPS strategies to communicate when they needed support and to actively seek out opportunities to help their team members. Charge nurses audited staff members’ communication patterns during an evening therapeutic group twice a week to assess the team’s ability to use the new TeamSTEPPS strategies. Results: Data from the domains of Mutual Support and Situation Monitoring of the Teamwork Perceptions Questionnaire (T-TPQ) were collected at baseline and post-implementation. Staff’s perception of Situation Monitoring increased significantly (p=0.01). Staff’s perception of Mutual Support increased; however, this increase was not significant (p=0.11). Although staff did not consistently meet the targeted goal of “Good” (4), the run charts of both outcomes revealed a positive trend, and staff met the goal 32% of the time during the implementation period. Conclusions: TeamSTEPPS offers a standardized approach to teach mental health providers how to support each other during therapeutic groups. Future studies should focus on reinforcement strategies and the long-term relationship between TeamSTEPPS implementation and rates of workplace violence.
  • Implementation of Dextrose gel for Asymptomatic Hypoglycemia in Newborns

    Solaiman, Anjana; Wise, Barbara V. (2020-05)
    Problem & Purpose: Neonatal asymptomatic hypoglycemia is a common problem that may contribute to poor health outcomes. Firstline treatment includes formula feeding, and/or transfer to the Neonatal Intensive Care Unit (NICU) for intravenous glucose. Both of these treatment options are sub-optimal because breastfeeding/bonding are disrupted, and costs may be increased due to NICU care. The purpose of this quality improvement (QI) project was to implement 40% buccal dextrose gel as the first line treatment of asymptomatic hypoglycemia in newborns at an academic medical center in the mid-Atlantic region to improve glycemic outcomes. Methods: This QI project was implemented during a 12-week period in the Fall of 2019. The target population included infants admitted to the newborn nursery who were less than 24 hours of life (HOL) with an identified risk factor for hypoglycemia (birthweight >3800 grams or <2500 grams, gestational age <37 weeks, LGA or SGA, or is an infant of diabetic mother), with asymptomatic hypoglycemia (blood glucose levels between 20- 40mg/dl). The QI project involved modifying the hospitals current neonatal hypoglycemia clinical practice guideline (CPG), to implement 40% dextrose gel as initial therapy in conjunction with feeding, developing an order set, creating documentation in the electronic health record, training personnel and collaborating with pharmacy to stock the gel. Results and Conclusions: During the implementation 16 newborns received glucose gel (N=16). Treatment success, defined as blood glucose levels >40mg/dL following the first and/or second administration of gel, was achieved in 87.5% of newborns. Newborns who did not respond favorably to glucose gel had an initial blood glucose level of <20mg/dL, a deviation from the modified CPG. Fifty five percent of newborns who were exclusively breastfeeding (N=9) received medically indicated formula supplementation. Five patients were transferred (N=5) to the NICU, 2 patients had achieved treatment success, but were unable to maintain adequate glycemic levels. Future QI cycles should include exploration of treatment failure with modifications to improve CPG adherence, consideration for increasing doses for responsive newborns as well widening the gestational age criteria. Overall the outcomes of this QI project demonstrated that glucose gel as the initial treatment for infants with asymptomatic hypoglycemia is effective.

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