RSS 1.0School of Nursing
Browse by
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.
Collections in this community
Recent Submissions
-
Burden and Mental Health of Family Caregivers of Cancer Patients: The Impact of SpiritualityBackground: 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 PhysicalsProblem & 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 CareProblem & 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 DEVICESProblem 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 StaffProblem & 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 NewbornsProblem & 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.
-
Universal Suicide Screening in a Pediatric Gastroenterology Outpatient ClinicProblem and Purpose: Suicide is the second leading cause of death in young people ages 10-24 in the United States. The Joint Commission issued a sentinel event recommending healthcare providers screen all patients for suicide. Universal screening is a key strategy to prevent suicide in the pediatric population. This quality improvement (QI) project implemented an evidence-based suicide screening tool for patients ages 10-21 who presented to a multidisciplinary pediatric gastroenterology (GI) outpatient clinic affiliated with a large urban academic medical center and referred at risk patients for further evaluation and treatment. Methods: The Ask Suicide-Screening Questions (ASQ) screening tool was chosen for its robust reliability and validity among pediatric medical patients. The GI clinicians were trained to use the ASQ tool and to further assess at risk patients with a brief suicide safety assessment (BSSA). The clinic social worker screened all patients meeting inclusion criteria, and results were entered into the electronic health record (EHR). Patients were excluded from screening if they were less than age 10, the guardian refused, or the patient could not answer the questions due to a developmental delay. Patients at risk for suicide received a safety plan and follow up resources. Results: The clinicians self-reported 100% competency prior to implementation. During the implementation phase, sixteen patients met inclusion criteria, and one guardian refused screening. Ten patients had screening results recorded in the EHR (66%), and two patients (20%) were found to be at risk for suicide. Both patients screened positively due to previous suicide attempt(s) which is a strong predictive factor for future suicidal behaviors. Conclusions: With proper training, the GI clinicians were confident to implement suicide screening using the ASQ tool. Twenty percent of patients screened at risk for suicide and received mental health resources. This QI project validates the feasibility and value of suicide screening in a pediatric subspecialty clinic and suggests screening could be implemented in other subspecialty clinics within the hospital system.
-
The Effect of Pre-Procedural Video Education on Patients Undergoing Cardiac CatheterizationProblem & Purpose: Nearly half of adult Americans demonstrate poor health literacy and have difficulty understanding health information. Utilizing video in education supports multiple learning styles, promoting better learning outcomes. The standard of care for patients receiving cardiac catheterization is providing outpatient education prior to the procedure date. Evidence has shown that pre-procedural video-based education improves patient satisfaction. Using video in the Cardiac Preparation and Recovery Unit benefits patients by providing audiovisual education the day of cardiac catheterization. Standardizing a process to utilize these videos and increasing the number of patients they are played for, may improve patient satisfaction. Methods: At the start of implementation, the Cardiac Preparation and Recovery Unit was added to the medical center patient education video viewing system for data tracking and reporting. The pre-procedure checklist in the electronic health record was edited to include the education method provided to the patient, allowing staff to document that video education occurred during admission. Staff received a resource sheet on the process of playing, documenting, and tracking the videos. Monthly staff meetings were attended to provide updates on project progress. Follow up phone call surveys were completed by a patient care coordinator then audited for videos played, benefit, and overall patient satisfaction. Using Microsoft Excel® software, an independent t-test was performed to determine statistical significance (p<0.05) of patient satisfaction between patients who watched the pre-procedural video and those who did not. Results: The median percentage of videos played per week increased from 0% during the pre-implementation phase to 64.5% during the implementation phase. 100% of total patients who watched the video (n=38) found it beneficial. Combining pre-implementation and implementation patient satisfaction scores, total satisfaction scores of patients who watched the video (n=38) was not statistically significant (p=0.46) from scores of patients who did not (n=89). Conclusions: 100% of cardiac catheterization patients reported that the video-based education was beneficial, even though patient satisfaction was not statistically significant when associated with pre-procedural video-based education. In settings within the organization where non-emergent surgical procedures are conducted, it is recommended that the staff utilize pre-procedural videos for patient education.
-
Palliative Care Screening Implementation within the Medical Intensive Care UnitProblem & Purpose: There are over 5 million intensive care unit (ICU) admissions each year with a mortality rate up to 29% and $108 billion dollar cost of care (SCCM, 2018). Palliative care is an essential part of comprehensive care in the ICU, however, it is underutilized in the medical intensive care unit (MICU) of a large urban academic medical center despite the unit reporting the highest mortality rate in the hospital. The purpose of the quality improvement (QI) project is to increase palliative care utilization in the MICU through the integration of nurse driven screening criteria that, when met, suggests the need for a palliative care consult. Methods: The QI project took place over a 13-week period. All patients admitted to the MICU during the implementation phase received a validated palliative care screening completed by the bedside nurse (George et al., 2015). Positive screenings were then discussed and plan of care documented by the interdisciplinary team on daily rounds. Completed screening tools were reviewed every other day to determine screening completion, documentation of family meeting notes, palliative care consults placed, and reason for not consulting palliative care despite positive screening. Results: Compliance with palliative care screening ranged from 79-100% (average 92%). Percentage of positive screenings ranged 18-50% (average 29%). Percentage of positive screenings with a consult ranged 0-60% (average 20%). The most common reason for lack of palliative consult was a planned “family meeting” (42%), however, less than 50% of these patients had a family meeting note documented. Comparing data 8 months pre-implementation to 13 weeks of implementation: average length of stay (LOS) for patients with palliative care consult decreased from 68.61 to 11.75 days; admission to consult mean decreased from 22.69 to 9.16 days; Palliative care consultation rate decreased from 13.86% to 10.39%. Conclusion: Despite utilization of a validated screening tool, palliative care consultation rates decreased. Physician preference greatly impacted consultation rates and highlighted the need to change knowledge and opinions related to palliative care. Finally, results support that screening leads to earlier palliative care consult, decreased LOS, and likely associated cost.
-
Aromatherapy Blend for Postoperative Nausea in Ambulatory Surgery PatientsProblem and Purpose: Postoperative nausea (PON) is one of the most undesirable outcomes after surgery, affecting 30% of surgical patients nationwide. PON increases patient dissatisfaction and risk for postoperative complications such as hematoma and dehiscence. In the Post-Anesthesia Care Unit (PACU) at an urban hospital outpatient surgery center, PON occurs in about a third of postoperative patients. Use of alcohol swab inhalation is ineffective and pharmacological methods can lead to prolonged PACU stays, decreased patient satisfaction and increased hospital costs. The purpose of this project was to implement and evaluate the effect of an aromastick on nausea in post-operative patients at a surgery center. Method: Implementation occurred over twelve weeks in the Fall of 2019. The first two weeks PACU RNs were educated and completed a competency around aromatherapy, aromastick use, and documentation. For the following ten weeks, PACU RNs offered aromasticks to patients with PON upon arrival to the PACU as a non-pharmacological means to mitigate nausea; anti-emetic medication was not withheld. The quantity of aromasticks provided and baseline and post-intervention PON scores were obtained to determine the effect of aromastick on PON. Results: 100% of PACU RNs (n=20) were educated and demonstrated competence in aromatherapy intervention, 70.6% of patients with PON utilized an aromastick for PON treatment, and of those patients who received an aromastick for PON 94.4% had improved PON scores. Conclusion: Aromatherapy is an effective non-pharmacological treatment in reducing PON score for patients recovering from surgery. These results offer support for nursing practice to utilize aromatherapy as an additional method to enhance patient experience, improve outcomes, and reduce cost in recovery rooms. Utilization of aromatherapy for nausea in other areas should be explored to enhance available non-pharmacological treatment methods for nursing practice.
-
A Clinical Practice Guideline for Postoperative Cognitive Impairment: Anesthetic InterventionsProblem & Purpose: Postoperative delirium and postoperative cognitive dysfunction, collectively referred to as postoperative cognitive impairment (PCI), are two neurocognitive risks that accompany anesthesia. The incidence of developing PCI can be as high as 50% and is heightened after the age of 65. Currently, the anesthesia department at a mid-sized community hospital in Baltimore City does not have a structured process for the perioperative management of these patients. A Clinical Practice Guideline (CPG) was written recommending a strategy to preoperatively assess and identify high-risk surgical patients, and includes evidence-based anesthetic interventions recommended for this population. The purpose of this scholarly project was to identify the anesthetic interventions included within this CPG: a guide which outlines the perioperative anesthetic management of patients >65 in order to decrease the incidence of PCI. Methods: CPG content was derived from a literature search identifying evidence published within the past 10 years and included five systematic reviews, two randomized control trials, and the current recommendations of the American Geriatrics Society and American College of Surgeons. The CPG was designed, analyzed by key stakeholders, and revised according to criteria found within the AGREE II tool. The CPG was presented to anesthesia staff and analyzed for applicability and acceptance using the Practitioner Feedback Questionnaire (PFQ). Results: AGREE II results by key stakeholders provided >88% positive feedback showing CPG quality in scope, content, and development. PFQ results demonstrated an overall average positive feedback and agreement of 70% (SD=19.1) among anesthesia providers (n=13). Feedback regarding the overall Quality of the CPG was both positive (88%) and neutral (12%). Applicability of Recommendations received the least encouraging feedback: 35% positive, 38% neutral, and 27% negative. Conclusion: Analysis demonstrates that the CPG’s content was regarded by anesthesia staff as high quality and that the majority of providers believe the CPG to be an improvement compared to what is currently practiced. While the majority of the polled anesthesia providers felt favorably towards the interventions, there remains reluctance towards its applicability into practice. Even so, 70% of anesthesia staff answered positively when asked if the CPG should become a guideline. Further staff education is recommended to enhance user buy-in.
-
Improving Medication Adherence Among Diabetes Patients Utilizing Mobile App and PamphletProblem and Purpose: The American Diabetes Association set the antidiabetic oral medication adherence rate to 80%. Medication nonadherence is strongly associated with poor glycemic control resulting in more healthcare services utilization. A family practice clinic noted that the majority of patients with diabetes are nonadherent to their medication. The purpose of this quality improvement (QI) project was to improve the medication adherence of patients with type 2 diabetes mellitus (T2DM) through the implementation of mobile health application reminder (MHAR) and diabetes adherence education pamphlet (DAEP). Methods: This project was implemented over thirteen weeks at a suburban primary care practice using the Mobilize, Assess, Plan, Implement, Track process framework. During an office visit, participants (N = 6) completed the likelihood of nonadherence (LON) online survey before the intervention and receive the DAEP. The participants used MHAR for four weeks and self-reported medication adherence rates. They also completed a post-LON survey via phone call by the project leader. Results: All the of participants (N=6) achieved low to medium LON post scores. There were no differences (z=0.577, p > 0.05) between pre- and post-intervention LON scores using the sign test as an alternative statistic. Only 67% (average) of patients seen received the DAEP at the last week of implementation. After four weeks of usage of the MHAR of each participant, 67% (n=4) reported adherent with an 80% or higher adherence rate, and 33% (n=2) nonadherent. The Pearson correlation coefficient for dichotomized compliance data predicted by post-intervention LON scores was found to be -0.31. This result indicated a weak negative correlation between adherence rate and post-LON. Conclusion: With the availability of MHAR, this tool must be leveraged to help patients adhere to their medication as prescribed. This project has demonstrated that when combined DAEP and MHAR have the potential to improve medication adherence among patients with T2DM. Providers can optimize the efficacy of these interventions to enhance verbal education during clinic visits.
-
Implementing Posttraumatic Stress Disorder Screening at an Adult Substance Use Disorder ClinicProblem & Purpose: Posttraumatic stress disorder (PTSD) is a prevalent co-occurring disorder among substance use disorder patients. Often, urban substance use disorder clinics do not screen for PTSD, and patients are not referred to available mental health services unless in crisis. When PTSD is left undetected and unaddressed, it adversely affects patients' symptoms severity and treatment outcomes. The purpose of this quality improvement project was to identify adult substance use disorder patients with probable PTSD using the Primary care PTSD Screen for the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (PC-PTSD-5), and evaluate the effectiveness of the screening to trigger referral for additional mental health assessment. Methods: The project occurred over 12 weeks and included all qualified substance use disorder patients, 18 years, and older in an urban, outpatient substance use disorder clinic. Screening was implemented by a team of champions trained in the administration and scoring of the Primary care PTSD Screen for the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (PC-PTSD-5). Education regarding PTSD symptoms was required for all screened patients. Data were analyzed using descriptive statistics of the sample and a Chi-square test to determine the association between referral and PC-PTSD-5 score. Weekly progress of screening, referral, and education was tracked using a run chart. Results: Of the 116 eligible patients, 62 were screened for PTSD. Thirty-five screened patients received a referral for further assessments. A chi-square test of independence was performed to examine the relation between PC-PTSD-5 score and referral. The relation between these variables was significant, X2 (2, N = 62) = 11.2, p = .0037. Patients with a higher PC-PTSD-5 score were more likely than those with a lower score to receive a referral for further mental health assessment. Conclusions: The PC-PTSD-5 screening tool was successful at increasing mental health services awareness and utilization by substance use disorder patients through the score-based referral process. PTSD screening and score-based mental health referrals were recommended to become standard practice. Digitalization and integration of the screening tool in the electronic health record are instrumental in ensuring sustainability and compliance.
-
Evidence-Based Policy Toolkit Supporting Full Practice Authority for Veterans Affairs Nurse AnesthetistsProblem: The Department of Veterans Affairs (VA) Office of Inspector General’s (VA/OIG) (2017) audit of the Veterans Health Administration (VHA) for the fiscal year 2015 determined approximately 80% of newly enrolled veterans seeking care waited more than 30 days, and 53% of newly enrolled veterans seeking care finished their first appointment greater than 30 days over the established eligibility date. To address veteran’s access to care issues, the VA finalized a rule, RIN 2900-AP44, granting full practice authority to three roles of the VA’s advanced practice registered nurses (APRN) but excluded certified registered nurse anesthetists (CRNAs) (VA/OPA, 2016). Purpose: The purpose of implementing this evidence-based health policy toolkit was to provide resources on how to amend the current rule, RIN 2900-AP44, to include CRNAs. Methods: The health policy toolkit along with the evaluation survey (Appendix F) was implemented via SurveyMonkey. Data was also collected via SurveyMonkey. Results: The survey revealed (Appendix G, Figure 4) most participants, 83.3%, strongly agree granting CRNAs full practice authority will decrease delays in patient access to anesthesia care in the VA vs. 16.7% who strongly disagree. The survey (Appendix G, Figure 10) also revealed 83.3% of participants strongly agree and 16.7% agree the health policy toolkit is needed and will likely be supported by a vast majority of VA CRNAs in Maryland. Conclusion: Data analysis demonstrates there is a need for the health policy toolkit, and granting CRNAs full practice authority would decrease delays in patient access to anesthesia care in the VA.
-
Postoperative Cesarean Section Outcomes Following Standardized Oxytocin Dosing: Rule of Three’sProblem & Purpose: Currently there is no standardized guidelines for the administration of oxytocin during a cesarean section to prevent uterine atony, which has led to anesthesia providers administering varying doses of oxytocin to prevent postpartum hemorrhage (PPH). Oxytocin that is delivered at high rates of infusion have been associated with myocardial depression through hypotension, tachycardia, and myocardial ischemia. The literature has shown that the use of regimental low dosed oxytocin like the “Rule of Three’s” improves its efficacy. The purpose of this quality improvement (QI) project is to overcome the lack of standardization with the delivery of oxytocin during a cesarean section by developing a clinical practice guideline (CPG) for low dose oxytocin administration following the “Rule of Three’s” algorithm. This manuscript will highlight the development with a primary concentration on the post-cesarean section oxytocin administration. Methods: The CPG was developed through 4 phases. The first phase involved stakeholder recruitment along with the development of the CPG using the AGREE II tool to evaluate it. During the second phase the CPG was appraised by the chief anesthesiologist for initial approval. The third phase consisted of a formal presentation to the anesthesia staff that was based on oxytocin management. A Provider Feedback Questionnaire (PFQ) was used to evaluate providers response to CPG. During the fourth stage, approval for the use the CPG was granted by the chief anesthesiologist for use. The data was analyze confidentially using both inferential and descriptive statistics. Results: The CPG was assessed using the AGREE II Tool resulting in an overall average of 93%, which was indicative of a high-quality guideline recommended for clinical use at the facility. The PFQ (n=12) assessed the CPG’s quality, acceptance, applicability, value, and outcome had an overall agreement of 80.7%. Conclusion: The “Rule of Three’s” was proven to be the optimal dosing regimen during cesarean section and throughout the postoperative period. During the postoperative period the prevention of uterine atony is vital to reduce the incidence and severity of PPH, which is effectively achieved when using the “Rule of Three’s” CPG. A limitation of the quality improvement (QI) project was anesthesia provider were resistant to changing their practice. The next phase of the QI project will include reducing provider resistance and monitoring quantitative blood loss during surgery.
-
Implementation of Cognitive Stimulation Therapy in Long Term CareProblem and Purpose: Individuals with dementia are often treated with psychotropic medications despite harmful side effects. Cognitive Stimulation Therapy (CST) has been shown to improve cognitive functioning and quality of life (QOL) in individuals with dementia and reduce adverse behaviors. The aim of this quality improvement (QI) project was to implement a CST program in a long term care facility for residents with dementia to decrease the number of adverse behaviors, reduce the use of psychotropic medications and improve cognition and quality of life. Methods: This quality improvement project was implemented in a 200 bed long term care facility in Baltimore City. Nine residents were selected to participate in a sevenweek CST program. A DNP student performed the CST sessions twice a week for 45 minutes. Content was based on activities outlined in the CST program manual, with a different theme for each session that incorporated cognitive stimulation, reality orientation, reminiscence therapy, and validation therapy. Outcome measures included the St. Louis University Mental Status (SLUMS) Exam and the Quality of Life in Alzheimer’s Disease (QOL-AD) Scale. Assessments were completed pre- and post-implementation. Psychotropic medication use and the frequency of adverse behaviors were monitored through chart audits performed bi-weekly. Results: Eight residents completed the full seven-week CST program. All participants attended at least half of the sessions. There was an overall average increase in SLUMS scores of 19% with a mean pre-implementation score of 16.75 and mean post implementation score of 20. QOL scores improved an overall average of 12% for six of the eight participants, and an average decrease of 20% for two participants. Deficiencies existed which prohibited the ability to accurately evaluate behavioral charting completed by the staff. There was no change in the use of psychotropic medications for residents enrolled in CST. An important secondary outcome was the observation of increased sustained socialization of residents when not participating in CST. Conclusion: CST improves cognitive functioning and may be correlated with the improving QOL of some residents. Additional research is needed to further investigate the effect CST has on increasing or sustaining socialization for long term care residents.
-
Secured Messaging in Patient Portal: Improving Efficiencies in Patient-Provider CommunicationProblem: Patient portals are an easily accessible health care application, allowing patients and parents/caregivers 24/7 access to their health information and the ability to engage with their providers through asynchronous communication. Emailing patients is not a reliable form of communication if personal health information is discussed. Secure messaging within the patient portal is an appropriate substitute for emails as it fulfills are the requirements of the HIPAA Security Rule without compromising the conveniences of mobile technology or security Purpose : The purpose of this quality improvement project was to improve enrollment and patient engagement in the patient portal to increase the use of secure messaging amongst cardiology patients and providers (primary cardiology, electrophysiology, and adult congenital). Methods : To increase the enrollment of portal users by patients techniques were implemented in the clinic to include: patients informed about the portal at the front desk and with the nursing staff; each patient visit focused attention on the secure messaging feature; additionally, patients over the age of 13 were given the option to self-enroll on iPads in the clinic. Providers were required to complete an online module related to secure messaging. Results : The Patient Engagement Team tracked the number of messages sent, received, and other portal related statistics for the pediatric cardiology clinic for 12 weeks before the intervention and 12-week post-implementation. These messages were collected and analyzed. Pre-implementation, the pediatric cardiology department received an average of 60 messages and sent an average of 39 messages back to patients or other providers. During the implementation period, the messages received increased to 102 per month, and messages sent by our staff also increased to 66 messages per month. Significant barriers during implementation included parent/caregiver delays receiving the portal enrollment email notification and the portal closing for a month during execution. Conclusion: Despite limitations, messaging increased by near 60 percent for inbound and outbound messages. Patient-provider secure messaging communication is a viable and effective method for non-urgent communication between patients and providers. A renewed focus on the importance of secure patient communication is highlighted in this patient improvement initiative. Sustainability of messaging within the portal use will require time, consistency, and support from the entire cardiology team, including cardiologists.
