• Improved Adherence to Follow-Up Care in the Trauma Patient

  Ables, Kelly L.; Wanzer, Megan (2024-05)

  Problem: Trauma patients discharged from an urban level 1 trauma center are at risk of being lost to follow up care when they are advised to follow up and do not. Interventions around the transition from inpatient to outpatient can positively impact outpatient follow-up rates and decrease readmissions. Purpose: The purpose of this Doctor of Nursing Practice (DNP) quality improvement project was to implement a structured home discharge process that includes scheduling appointments, educating on follow-up appointments, post discharge phone calls, and monitoring of patients who miss their appointments in order to improve adherence to follow-up care in the trauma population. Methods: A structured discharge process that includes the Advanced Practice Providers (APP) requesting an appointment and attaching the updated discharge education, the nurse checking appointments on after-visit summary (AVS) and reviewing clinic discharge education, and the clinic staff contacting patients who did not have a scheduled appointment at discharge or did not complete their scheduled appointment was created and audited throughout the project phase. Results: Appointments scheduled at discharge increased from 28% (n=28) to 62% (n=113), education attached to AVS increased from 86% (n=97) to 92% (n=295), and NRC post discharge phone call answering increased from 38% (n=43) to 46% (n=77). 69 patients where recommended to follow up but did not discharge with an appointment, however, 78% (n=54) were scheduled after discharge. Appointments completion rate was 83% (n=142) post intervention compared to 74% (n=71) pre-intervention. Conclusion: Results show that appointment scheduling, education attached to AVS, answering of NRC post discharge calls, and appointment completion rate all increased with this intervention. There was minimal impact to readmissions, 6% (n=7) at baseline and 7% (n=21) post intervention, as well as lost to follow-up rate, 19% (n=21) at baseline and 18% (n=33) post intervention.
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  Implementing Sugammadex Disclosure to Female Patients in the Preoperative and Postoperative Setting

  Janczur, Emily; Watson, Melissa D.N.P., C.R.N.A. (2024-05)

  Problem: Sugammadex is given to reverse the effects of NMB agents; however, this reversal agent decreases the efficacy of hormonal contraceptives, increasing the risk of unintended pregnancy. At a primary care hospital in Maryland, less than 1% of anesthesia providers correctly completed the sugammadex disclosure form and only 10% of anesthesia providers reported administration of sugammadex intraoperatively during PACU handoff. Purpose: The purpose of this quality improvement initiative was to implement sugammadex disclosure in the postoperative setting and include a completed sugammadex disclosure form in the patient’s discharge packet to all female patients of childbearing age undergoing laparoscopic procedures. Methods: In the months preceding the project, an interdisciplinary team of stakeholders was mobilized to plan evidenced-based structure and workflow changes. Anesthesia and PACU providers were trained on completing the sugammadex disclosure form, reporting intraoperative sugammadex administration, and including the sugammadex disclosure form in the patient discharge instructions. Weekly chart audits were conducted to track project compliance. Approximately eighty female patients of childbearing age were impacted over the implementation period. Results: 60% of PACU and anesthesia providers received in-person training and 100% received electronic communication about the new protocol. The rate of completed sugammadex disclosure forms was 43.5% and 24.7% included the sugammadex disclosure form in patient discharge instructions. Conclusions: Findings suggest low PACU compliance with including sugammadex disclosure in patient discharge instructions. Low compliance may be related to the multi-step process with some steps done electronically and some done on paper. Inclusion of sugammadex disclosure in patient discharge instructions may be increased if added to the electronic health record.
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  Improving Patient Experience by Implementing an Evidence-Based Nurse Leader Rounding Tool

  Hunt, David G.; Connolly, Mary Ellen (2024-05)

  Problem: An identified clinical unit, in a large community hospital was failing to meet organizational expectations of benchmarked top box scoring on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). HCAHPS measures patient experience and impacts hospital reimbursement. The project unit’s HCAHPS score was at 74.4%, versus national top box reporting at 87.4%. Purpose: Intent of this initiative was to optimize service recovery by standardizing and enhancing the unit-based approach to Nurse Leader Rounding (NLR) with the use of a new electronic evidence-based tool to drive process and improve patient experience. It was intended that staff would adopt the project tool to guide their rounding, and that patients would report improved quality of care. The project anticipated that staff would report improved understanding of service recovery and satisfaction with use of a standardized approach. Outcomes were measured by an electronic software solution that patients used to provide real-time feedback on NLR quality and service recovery. Methods: Methodology included assessing participant nurse’s knowledge/ competency, and then implementing formal education for those who conduct unit-based NLR. The project leader, unit educator and nurse manager were identified as key stakeholders. Pre/post review of educational training was analyzed to evaluate feedback. Implementation included establishment of secure data collection plans and baseline data capture. Strategies and tactics to achieve the project goals included training of all staff members who conducted NLR, implementation of an evidence-based best-practice intervention tool, creation of an outcome tool that reflected key questions measured in HCAHPS, and auditing of process with regular team feedback on project outcomes. Patients were given opportunity to provide real-time feedback on the quality of Nurse Leader Rounding. Results: Nurses universally adopted the intervention tool to drive improved process. Patients reported that the quality of NLR improved by at least 25% across all survey questions. Conclusions: Expansion of the evidence-based methodology may yield improved patient experience reporting in similar clinical settings, in key elements of HCAHPS, both at the organization, and potentially beyond.
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  Staff Mediated Reminder Calls: Reducing Pediatric Cardiology Outpatient Nonattendance

  Hu, Caroline E.; da Graca, Malissa (2024-05)

  Problem Appointment adherence is essential to providing high-quality healthcare. However, missed appointments are common in the outpatient setting. Nonattendance has been shown to decrease quality of care, reduce revenue, and increase healthcare burdens. A pediatric cardiology clinic identified an 18% nonattendance rate. Purpose This quality improvement project implemented staff mediated reminder calls to reduce the nonattendance rate at an urban pediatric cardiology clinic. Methods The project team consisted of a Quality Improvement Project Lead (QI-PL), two scheduling specialists, and a nurse practitioner (NP). Scheduling specialists called patients with an appointment reminder 3-7 days prior to their appointment using a standardized script. Staff assessed and addressed barriers to attendance per clinic policy. Outcome measures were nonattendance rates and reminder call compliance. Additional data was collected for attendance barriers. Results The average nonattendance rate after implementation was 12.02%. This was a 33.22% reduction from the pre-implementation nonattendance rate of 18%. Call compliance averaged 80.55%. The most common barriers to attendance identified were directions to the clinic, language barriers, and insurance coverage. Conclusions Staff mediated reminder calls are a feasible solution to reduce nonattendance.
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  Reducing Catheter Insertion Attempts: Implementation of a Difficult Intravenous Access Screening Tool

  Hernandez, Alex; O'Neal, Madelyn (2024-05)

  Problem: Cardiac Surgery Intensive Care Unit (CSICU) nurses at a large, academic tertiary care center identified difficulty with peripheral intravenous (PIV) access skill and indicated an average of 3.2 insertion attempts to obtain PIV access. Root cause analysis highlighted nonstandardized training for ultrasound-guided peripheral intravenous (USGPIV) access skill certification and no screening process to identify patients that are difficult for establishing intravenous access (DIVA). Purpose: To implement the Modified Difficult Intravenous Access Scale for Adult Patients (A-DIVA) screening tool to assist CSICU nurses to screen, identify, and risk-stratify DIVA patients. Patients that score moderate- or high-risk for DIVA prompted use of the ultrasound. Project outcome goals were to improve the weekly average of insertion attempts and to improve PIV access first attempt success rates. Methods: Project implementation took place over 15-weeks and impacted 264 patients and 91 nurses. Nurses were trained for A-DIVA screening tool competency and USGPIV champions completed USGPIV access skill training. Nurses utilized the A-DIVA tool for all patients requiring PIV access prior to insertion. Weekly electronic health record (EHR) PIV insertion audits were compared to A-DIVA screening tool data. Project results and updates were disseminated at staff meetings. Results: By the end of implementation, 11 nurses completed formal USGPIV access skill training, 72.5% of nurses completed A-DIVA screening tool competency, and 31.9% of nurses utilized the A-DIVA screening tool. Ultrasound compliance remained 100% throughout implementation. Weekly average patient A-DIVA scores ranged from 3.5/5 – 5/5. Weekly average number of PIV insertion attempts ranged 1 – 3 on the A-DIVA screening tool and 1.1 – 1.8 in the EHR. Weekly average number of PIV insertion attempts remained below the 1.6 attempts goal for 14 of the 15 weeks. Weekly successful PIV first attempts ranged 66.7% – 100% on the A-DIVA screening tool and 60% – 94.1% in the EHR. Weekly successful PIV first attempts in the EHR remained above the 75% goal for 14 of the 15 weeks. Conclusions: Using the protocol, the A-DIVA Tool was a useful tool that assisted CSICU nurses to reduce PIV insertion attempts and improve PIV first attempt success rates in patients moderate- or high-risk for DIVA.
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  Implementation Adherence of a Therapy Group Addressing Internalized Stigma Among Psychiatric Outpatients

  Euwer, Nikolaus; Rawlett, Kristen (2024-05)

  Problem: Stigma against mental illness brings with it many negative stereotypes that can be internalized by those who live with mental illnesses. The result is called “internalized stigma” or “self-stigma.” The implementation site for this Quality Improvement (QI) project was a 98- patient outpatient clinic providing treatment for schizophrenia-spectrum disorders. An early survey of patients at the site found that nearly half of the patients surveyed (46.94%) experience internalized stigma. There is currently no official treatment approach towards internalized stigma at this site. Purpose: The purpose of this QI project was the implementation of an evidencebased psychoeducational group therapy intervention for the treatment of internalized stigma amongst individuals living with mental illness. The intervention is titled “Ending Self-Stigma” and consists of nine manualized group sessions. Methods: The chosen framework for this QI project was the Promoting Action on Research Implementation in Health Services, or PARIHS model. Implementation included the administration of the nine manualized treatment sessions in addition to one introductory group session and a final feedback session. Attendance at each session as well as availability of each session were measured and analyzed using run charts. Results: Group availability throughout the project implementation period was 100%. Group attendance averaged 94.8%. Program feedback was positive, with participants overwhelmingly reporting enjoyment discussing their experiences with peers. Conclusions: The results show the feasibility and value of implementing this group at the site. High levels of attendance showed patient engagement, and feedback suggested high levels of enjoyment as well as relevance and benefits of the intervention.
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  Assessing Adherence to Enhanced Early Warning Score Assessment on the Transplant Unit

  Ferguson, Taylor M.; Gaines, Susanne (2024-05)

  Problem & Purpose: Patients show subtle changes six to eight hours before clinical deterioration. There was an underutilization of the hospital’s enhanced early warning score (Rapid Evaluation for Safer Care Utilizing Machine Learning and Escalation-RESCUE) in the adult transplant unit in a quaternary care center. This quality improvement initiative aimed to optimize the use of RESCUE through integration into the nurse’s electronic health record (EHR) and report sheets and implementation of a six-hour reassessment with a bedside huddle for critical scores. Methods: Over 15 weeks, bedside nurses reviewed the patient’s RESCUE score during change of shift handoff. This project was expected to affect approximately 45 nurses and 27 patients daily. An updated report sheet to include RESCUE was implemented for 100% of patients. 100% of charge nurses and 90% of the nurses on the unit had RESCUE added to their EHR. Each shift, the charge nurse completed a Research Electronic Data Capture (REDCap) survey to identify if nurses updated the RESCUE score on their handoff sheet. Nurses rechecked the score six hours into their shift and completed the nursing portion of the RESCUE algorithm. The nurse completed a REDCap survey stating their patient’s RESCUE score and huddle interventions. Results: The transplant staff did not use the RESCUE score before implementation. During the implementation phase, there was a 10.5% (n= 551) median compliance rate in RESCUE reassessment compliance. There was an 18% (n= 57) median compliance rate with updating the patient's report sheet. 17 bedside huddles were completed for patients meeting criteria based on the hospital’s algorithm. Conclusions: RESCUE utilization has increased compared to baseline data. Barriers to implementation included staffing shortages and high utilization of agency and float pool nurses. Facilitators of implementation included institutions, management, and charge nurses’ buy-in to the practice change.
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  Prevention of Intraoperative Hypothermia for Patients Undergoing Gynecologic Surgery

  Elias, Quinn T.; Aguirre, Priscilla (2024-05)

  Problem & Purpose: Intraoperative hypothermia, defined as core body temperature less than 36 degrees Celsius, is an anesthetic complication which can lead to adverse events such as increased risk of infection, delayed emergence, and increased cost to the hospital. Intraoperative hypothermia affected approximately 50% of gynecologic surgical patients at an acute care hospital in Baltimore, Maryland. The purpose of this project was to implement and evaluate the compliance of a preoperative warming protocol among patients undergoing gynecologic procedures. The preoperative warming protocol included the use of forced air warming at the maximum setting for the 30 minutes prior to surgery. The goal of the project was for 100% of eligible patients to receive the warming protocol and for 100% of patients to avoid intraoperative hypothermia. Methods: A team of 17 Certified Registered Nurse Anesthetists, seven physician Anesthesiologists, and 12 Registered Nurses were mobilized to implement the evidence based warming protocol. Education was provided via in person sessions and posted information throughout the preoperative area. Providers were expected to warm all eligible patients for 30 minutes using a forced air warming device immediately prior to the procedure. The anesthesia staff used quick response codes to document use of the protocol and incidence of intraoperative hypothermia. Data was monitored weekly and stored on Research Electronic Data Capture. Results: Overall, a total of 41 patients received the warming protocol over 15 weeks. Anesthesia provider compliance with the protocol was 38.2%. Compliance peaked at 100% in week one and 11. A total of 90.2% of patients who received the warming protocol did not experience intraoperative hypothermia. Conclusion: The data suggests the preoperative warming protocol is effective, feasible, and sustainable. Compliance required ongoing reminders and frequent communication.
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  Decreasing the Rate of Seclusion and Restraint Using the Six Core Strategies

  Donovan, Liam D.; Rawlett, Kristen (2024-05)

  Problem: Seclusion and restraint can cause physical injury and psychological harm to both patients and staff, as well as contribute to traumatization of patients. The national average for restraint rate is 0.39 hours per 1,000 patient hours. In March 2022, the project site’s restraint rate was 0.8619 per 1,000 patient hours. From April 2021-March 2022, the project site had only three months where the restraint rate was within 5% variance of the Centers for Medicare and Medicaid Services (CMS) average. Purpose: The purpose of this quality-improvement initiative is to implement a Six-Core Strategy program to modify staff-patient communication and deescalation strategies with the overall goal of reducing seclusion and restraint use on a mixed disorders adult inpatient psychiatric unit. Methods: The initiative will be implemented over a 15-week period in the fall of 2023. This project will measure the rate of project attendance based on rotating schedule established with project unit manager. The rate of project attendance will be measured by dividing the number of actual program attendees by the number of staff members who were scheduled to participate in each week. The rate of seclusion and restraint will be measured using HBIPS-2 and HBIPS-3 reporting criteria to compare the 15 weeks prior to implementation to the 15 weeks following. Results: The project achieved 100% participation during weeks 1, 4, 7, 10, and 12-15. The majority of staff attended program meetings. HBIPS-2 (90.4%) and HBIPS-3 (37.4%) scores decreased in the 15 weeks after project initiation compared to the 15 weeks prior. Conclusions: A major barrier to implementation is ensuring nursing staff participation, as there are competing demands for patient care. Many staff members would rather be available to their patients than taken away from direct patient care. Staff members that attended reported finding the training useful and worthwhile.
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  Implementation Adherence of Malnutrition Screening on Head and Neck Oncology Patients

  Davidson, Marissa; Selway, Janet (2024-05)

  Problem & Purpose: Lack of a standardized nutritional assessment process for patients with head and neck cancer receiving radiotherapy alone (HNC-R) may lead to undiagnosed malnutrition, interrupted radiotherapy, and increased complications. At a northeastern US academic medical center radiation oncology clinic, usual practice includes arranging dietician team referrals for all patients with HNC who receive chemoradiotherapy. In contrast, audits revealed that only two patients with HNC-R received dietician team referrals in FY 2022. This project aimed to promote early detection of malnutrition for all patients with HNC-R by implementing a standardized nutritional assessment process into the clinic's daily workflow. Methods: Before initiation of this 15-week project, the project lead (PL) educated clinic staff (providers/nurses) on administering a nutritional assessment tool, the Patient- Generated Subjective Global Assessment (PG-SGA) to patients with HNC-R. Staff administered PG-SGA during radiation consults at weeks one, four, and final week of radiotherapy. PG-SGA score > 4 initiated a dietician referral. Clerical staff entered data into the electronic medical record (EMR); PL audited EMR and entered data based on EMR audit on a HIPAA-compliant database server, REDCap®. Results: Staff screened 100% (17/17) of patients. Due to lost data on three patients, EMR documentation of PG-SGA scores occurred for 82% (14/17); 64% (9/14) of patients with HNC-R received dietician referrals. Conclusions: Clinic staff adhered to the new workflow process which increased nutritional assessments and dietician referrals for the target subpopulation within this radiation-oncology clinic.
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  Policy Development to Improve the Safety of Pediatric Transport During a Disaster

  Dannenfelser, Jill E.; Franquiz, Renee (2024-05)

  Problem: Children transported by a specialized pediatric critical care transport team, staffed with individuals with pediatric training, have better clinical outcomes and are less likely to deteriorate during transport. A group of national stakeholders involved in disaster response identified deficiencies in the transport of critically injured children following a declared disaster. In the setting of disaster, most children are transported by generalist teams who lack specialized training in pediatric care and transport. Purpose: The purpose of this quality improvement policy project was to identify possible policy solutions for the safe and effective transport of children during a disaster. Methods: The initiative utilized the Centers for Disease Control and Prevention Policy Process to draft a policy to address the purpose of the safe and effective transport of children during a disaster. An environmental scan was conducted with eleven national experts in pediatric critical care transport, using the Centers for Disease Control and Prevention Policy Analysis: Key Questions tool, to inform the following possible policy options to: (1) continue with current practice, (2) modify an existing transport policy, or (3) create an entirely new transport policy. Each option was analyzed to determine feasibility, health, and economic/budgetary impact. Results: Results demonstrated high stakeholder buy-in and willingness to participate in a policy development process. Stakeholders unanimously reported an absence of policy related to pediatric transport following a disaster with a substantial gap in research evidence and identified added value for policy development. Conclusions: Modifying an existing policy for pediatric critical care transport would be the most feasible, with the best economic impact and health benefit. A policy solution is expected to add value and create equitable and timely access to appropriate healthcare to improve outcomes.
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  Postoperative Nausea and Vomiting Screening and Prevention in Laparoscopic Surgical Patients

  Daly, Rachele; Watson, Melissa D.N.P., C.R.N.A. (2024-05)

  Problem and Purpose: At a community hospital in Baltimore, Maryland, the incidence of postoperative nausea and vomiting (PONV) among the adult laparoscopic surgical patient population, excluding gynecologic patients, is 21%. At the stie, there is no evidence based PONV risk assessment or prevention guideline for anesthesia providers to use to assess patients’ risk and create an individualized prophylaxis plan. The purpose of this quality improvement (QI) project was to implement a PONV risk assessment tool (Apfel Score) and prophylactic treatment guideline for non-gynecologic, laparoscopic surgical patients. The outcome goal was to reduce the rate of PONV in this population from a baseline of 21%. Methods: The anesthesia department consisting of approximately 60 anesthesia providers received education about use of the Apfel Score and treatment guideline prior to implementation. The Apfel Score and guideline were emailed to staff and posted throughout the preoperative area and at anesthesia workstations for provider reference. Patient charts were reviewed weekly to track compliance with Apfel Score completion, adherence to the treatment guideline, and to monitor PONV occurrences. Results: Of the 90 eligible patients, 28% were screened for PONV risk using the Apfel Score. Of the 25 patients with a documented Apfel Score, 84% received the appropriate number of antiemetics per the prophylaxis guideline. The overall rate of PONV decreased 5% from the 21% baseline measurement. Conclusions: Use of an evidence based PONV risk assessment tool such as the Apfel Score and an associated treatment guideline are simple, feasible interventions to implement that address the problem of PONV. When staff comply with both the risk assessment and prophylaxis guideline, PONV occurrences decrease. Although PONV incidence decreased from baseline by the end of implementation, bolstered compliance with the two-part intervention has the potential to contribute to a further decrease in PONV.
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  Identifying Human Trafficking: Implementing a Screening Tool in an Adult Emergency Department

  Culler, Ciara A.; Fitzpatrick, Suzanna (2024-05)

  Problem & Purpose: Human trafficking (HT) is defined as “the recruitment, transportation, transfer, harboring or receipt of people through force, fraud or deception, with the aim of exploiting them for profit” (United Nations Office on Drugs and Crime, 2022) and includes both labor and sex trafficking. HT affects approximately 16,000 individuals annually in the United States. HT survivors reported interacting with the healthcare system during their time in trafficking. The project site is a 54-bed adult emergency department (AED), in a large urban academic medical center, serving patients 22 years of age and older, where routine HT screening does not occur. The purpose of this project is to implement a validated HT screening tool in an AED to identify victims and connect them to community resources. Methods: In the Fall of 2023, all patients presenting to the AED were screened for HT using the four-item, Rapid Appraisal for Human Trafficking (RAFT) tool by staff nurses. If the patient answered in the affirmative to any of the RAFT items, they were offered a community resource list and an evaluation by social work. Clinically stable patients who consented to screening were eligible for participation. Results: 195 patients were screened using the RAFT tool. 46 patients met exclusion criteria due to screening refusal, altered mental status, or clinical intoxication. 139 patients screened negative on the RAFT tool requiring no further intervention. 10 patients screened RAFT positive, 8 of whom declined all resources, 1 received a community resource list but declined to speak to SW about their HT experience, and 1 received a community resources list, a SW evaluation, and a psychiatric evaluation. Conclusions: Routine HT screening is a feasible intervention in the ED and can increase the recognition of those experiencing HT for resource provision. Successful screening does require systems in place including education, referral services and re-evaluation measures.
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  Spinal-Induced Hypotension Prophylaxis Using Ondansetron in Non-Obstetric Adult Surgical Patients

  Corbin, Lesley; Gayden, Johnny C. (2024-05)

  Problem: Spinal anesthesia (SA) is commonly used for orthopedic and lower abdominal surgical procedures. Spinal anesthesia frequently results in hypotension and bradycardia, leading to hypoperfusion of the brain and other vital organs. At an academic hospital in Maryland, 70% of adult patients undergoing SA for orthopedic procedures experience spinal-induced hypotension (SIH). Purpose: The purpose of this Doctor of Nursing Practice quality improvement initiative was to implement the administration of 4mg IV ondansetron within 5 to 15 minutes before SA to reduce hypotension among adult patients undergoing SA for non-obstetric procedures. Methods: Anesthesia providers and change champions were mobilized to facilitate implementation. Stakeholders were educated on the intervention and additional resources were provided for clarity via email and as a visual aid. A clinical reminder was created in the electronic documentation system, visible upon opening the spinal documentation. Compliance data was collected weekly for all eligible surgical cases and analyzed via run chart over 15 weeks. Results: A total of 19 data points were collected over 15 weeks. There was 0% compliance with the intervention in the first week, 50% compliance in the second week, and 100% compliance during weeks 3 through 15. No spinals were performed during weeks 8 and 9. One positive run was identified from week 3 to 15, suggesting a consistent change in practice. Conclusions: Findings suggest that ondansetron before SA is a realistic and feasible intervention that can be sustained within the anesthesia department at this facility. Using various strategies and tactics tailored to the project site, the goal of 100% compliance was met early in the implementation phase. Based on current literature, ondansetron before SA is projected to decrease the incidence of SIH and improve patient outcomes at the project site.
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  Implementation of a Simplified Asthma Action Plan in a Pediatric Pulmonary Practice

  Conner, Jessica; da Graca, Malissa (2024-05)

  roblem: Personalized asthma action plans (AAPs) are the gold standard of care in all asthma guidelines and supported by Centers for Disease Control and Prevention and the American Academy of Pediatrics. AAPs improve asthma control, improve impact on parental self-efficacy for asthma management, reduce missed school days, and improve medication compliance. Despite this, the use of AAP’s in the outpatient settings are inconsistent. A chart audit performed within an urban pediatric pulmonary practice located in Baltimore, MD showed 0-33% average rate of AAP use over 14 weeks in the Fall of 2022. Purpose: The purpose of this quality improvement project was to implement an electronic AAP (eAAP) for patients with asthma to improve asthma management and maintenance within a pediatric pulmonary outpatient clinic. Methods: Implementation of this personalized eAAP took place over a 14-week period fall 2023. Project team consisted of two pulmonologists, three nurse practitioner (NP) students, and four nurses. All patients seen in this clinic with a diagnosis of asthma under the age of 18 were included in this project. An electronic AAP template that could be personalized for each patient was developed to be reviewed, updated, and distributed to families in the after-visit summary (AVS) of each visit. Weekly chart audits were completed to track the percentage of patients with completed eAAP on visit discharge, oral steroid prescriptions, and asthma-related emergency room visits within the following 4 weeks. Biweekly meetings, reference card reminders, and email progress updates were used to encourage eAAP usage and compliance. Results: 154 patients with asthma were seen within this 14- week timeframe. Average eAAP compliance was 67% which was a 53% increase from the previous year. New oral steroid prescriptions needed ranged from 6 to 55% over the course of the project compared to a 58% average pre implementation. Asthma-related emergency care visits ranged from 5 to 20% during implementation compared to the 15% average pre-implementation. Conclusions: Implementation of the AAP smart phrase increased asthma action plan usage at an outpatient pediatric pulmonology clinic, fostering improved pediatric asthma self-management for patients and families. No statistically significant correlation between AAP compliance and ER visits and number of oral steroid prescriptions were found.
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  Implementation of a Clinical Nurse Manager Orientation at a Community Clinic

  Clinton, Iman J. (2024-05)

  Problem: Nonprofit community health centers in the mid-Atlantic region provide healthcare services and resources to a vulnerable patient population with many chronic conditions and limited to no health insurance. The community clinics have seen a variation in patient care and nursing practice by the clinical nurse managers (CNM). This variation in practice is secondary to the lack of a formal orientation program. Purpose: This quality improvement initiative aims to implement an orientation program that actively engages the experienced nurse to enhance the application and retention of critical onboarding information. The overall project goal of the CNM orientation program is for the CNM preceptee to rate all American Organization for Nursing Leadership’s (AONL) Nurse Manager competencies at a level of competent, proficient, or expert. Methods: The AONL competency orientation program was implemented over 12 weeks. A 12-week lesson plan was implemented with one new clinical nurse manager. The lesson plan included weekly objectives and resources to ensure the clinical nurse manager is competent to lead and oversee the daily operations of the community clinic. A pre-assessment of the CNM’s knowledge and understanding of the AONL nurse manager competencies was completed before the implementation of the CNM orientation program. The AONL nurse manager competencies were measured weekly after weekly curriculum, content outline, and resource materials were reviewed and applied to clinical practice. Weekly evaluations were completed to ensure the CNM met the weekly objectives. The project lead provided education and support to the preceptor throughout the orientation. A weekly meeting between the preceptee, preceptor, and project lead occurred to provide feedback on the progress of the preceptee in meeting the weekly objectives, orientation expectations, goals, and competencies. Results: The CNM preceptee progressed from novice, advanced beginner, or competent to proficient and expert post the implementation of the AONL Nurse Manager Orientation program. The CNM preceptee rated 48% of the competencies as proficient and 52% of the competencies as an expert. Conclusions: The post assessment results suggest that the clinical nurse manager orientation effectively prepares new clinical nurse managers in a community clinic setting to enhance the application and retention of critical onboarding information.
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  Assessing Adherence to Pain Medication Reassessment and Documentation Using Timed Visual Reminders

  Choi, Jane; Selway, Janet (2024-05)

  Problem & Purpose: In the fiscal year 2022, the completion of pain reassessment documentation was 38% of all oral pain medication administration at the current clinical site, a Neuro Intermediate Care Unit (Neuro IMC) at a large tertiary care hospital. Published evidence shows that timed visual reminders in the electronic health record (EHR) and standardized staff education increase the frequency of timely pain reassessment. This project aimed to improve the rate of pain reassessment and documentation within 60 minutes after PRN oral pain medication administration to 100% by using timed visual reminders within EPIC over 15 weeks in fall 2023 on the Neuro IMC. Methods: Timed visual reminders in EPIC automatically pop up after pain medication administration. The project leader (PL) promoted staff RN adherence by obtaining formal written commitments from key partners, preparing champions and shift huddles, sharing weekly chart audits, and setting up online and in-person educational sessions. The PL performed weekly chart audits, entered data (medical record number [MRN], completion of pain reassessment documentation within 60 minutes) into REDcap, a HIPAA-compliant database, and surveyed staff RNs each month regarding response to a visual reminder tool within EPIC. The PL transformed these data into run charts to identify patterns over the 15 weeks. Results: The project measured the number of times nurses completed pain reassessment within 60 min per total number of times nurses gave oral pain medications. RNs completed 928 oral pain medication administrations. Seventy pain reassessment documentation occurred for another purpose or inadequate timing and were eliminated. Pain reassessment documentation within 60 minutes of administration by RNs occurred for 75.3% of all oral pain medication administration. Conclusions: Timed visual reminders within EPIC improved pain reassessment and timeliness of documentation rate from 38% to 75.3%.
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  Improving Sepsis Recognition and Management in the Adult Acute Care Medical Unit

  Childress, Christy; Conley, Richard P. (2024-05)

  Problem: At a regional hospital, on the adult acute-care medical unit, 83% of the sepsis best practice advisory alerts (BPAs) were cancelled or had no further documentation, leading to delayed recognition of sepsis. Missing documentation of vital signs (VS) and respiratory rates (RR) contributed to inconsistent generation of BPAs. Purpose: The purpose of this Quality Improvement project was to implement a bedside sepsis huddle to improve early recognition of sepsis. Methods: Team members included the project lead (PL), the clinical site representative, the unit clinical director, a unit nurse educator, and 43 staff nurses. Over 15 weeks of implementation, staff nurses were tasked with ensuring VS and RR were documented every four hours. If a BPA was generated, documentation in the sepsis narrator was initiated within one hour followed by a bedside sepsis huddle. Data collection was completed by the PL through chart audits and sepsis reports, with an average of 38 charts audited per week. The primary outcome was the number of patient charts with a BPA generated who had a sepsis huddle initiated. Secondary outcomes were weekly compliance rates for VS and RR documentation. Results were analyzed via a run chart. Results: No BPAs were generated during implementation, although 12 patients were identified as septic by nurses. Of the 12 septic patients, 50% had a bedside sepsis huddle. The baseline compliance rate for VS and RR documentation was 50% and 45% respectively. Following implementation, the median compliance rate for VS and RR documentation was 83% and 77% respectively. Conclusion: Results show education marginally improved compliance rates of VS and RR documentation. In week five, a steep decline in compliance with documentation of VS and RR was observed, which was attributed to the construction of patient rooms on the unit. Currently, no conclusion can be made about the true effectiveness of a sepsis huddle on improving early recognition of sepsis as there is not enough data to make a generalized conclusion. However, a sepsis huddle in conjunction with a computerized early alert system, for the early recognition could be successful if compliance with timely documentation of VS and RR is maintained.
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  Assessing Implementation Adherence to a Blood Culture Bundle to Reduce Contamination Rates

  Chavez, Christopher Brian M.; Yarbrough, Karen L. (2024-05)

  Problem: Blood culture (BC) collection remains the gold standard in diagnosing septicemia. The contamination of collected blood samples by organisms that should not be present results in false-positive cultures. The national benchmark for blood culture contamination rates (BCCR) is less than or equal to three percent. The emergency department of a large, urban, level 1 trauma center is experiencing a 4.02% BCCR, higher than the three percent or less national benchmark for blood culture acquisition. Purpose: This quality improvement project is planned to assess whether adherence to a bundled approach to the blood culture collection process will improve the contamination rates in the emergency department. Methods: The QI Project Lead (QI-PL) mobilized a team of nurses, clinical technicians, providers, and a quality coordinator to review the evidence-based BC acquisition process. A modified intervention bundle included manual diversion of 2-3 ml of blood or “waste” before bottle inoculation, conducting a one-hour education session and competency review, and receipt of performance cards on specimen acquisition. Chart audits were conducted weekly by the QI-PL on each BC specimen collected to retrieve values for contamination rates and compliance with the bundled interventions. Results: The total number of blood culture specimens collected by the participants was four hundred eighteen. After fifteen weeks of implementation, staff compliance with the use of BC manual diversion was 92% (385/418). All 36 participants attended a competency review and received their feedback scorecards. Of these specimens, only ten specimens resulted in contamination upon verification with the hospital’s Microbiology Department. The blood culture contamination rate was 2.39% (10/418). This is a significant improvement from the pre-implementation contamination rate of 4.02%. Conclusions: Findings suggest implementing a bundled approach to blood culture specimen collection, which includes manual diversion or “waste” of initial 2-3 ml blood specimens before inoculation of culture bottles, a competency review, and a peer feedback system have positive effects. However, it is essential to note that these results, while promising, are based on a small number of participants
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  Initiating a Medical Assistant-led Health Coaching Program

  Chard, Alisa; Osuagwu, Ngozi E. (2024-05)

  Problem: Of the 1000 patients with hypertension at the Federally Qualified Health Center (FQHC) in Montgomery County, Maryland, approximately 21% have uncontrolled hypertension. Of the 800 patients with diabetes, approximately 20% have uncontrolled diabetes. Where consistent care might provide time for important patient-provider discussions about the multi-faceted management of chronic diseases, these patients are predominately low-income, uninsured minorities who face many barriers to accessing care and achieving control of their diseases. Purpose: The purpose of this quality improvement project was to implement a formal health coaching program to improve access to care and decrease chronic disease rates at the site. Methods: Using UCSF Center for Excellence in Primary Care’s evidence-based health coaching curriculum, a site-specific training pipeline was created. Two Medical Assistants (MAs) were trained to become health coaches. Clinic staff were trained about the program procedures. Health coaching sessions were audited to establish training fidelity and weekly feedback was provided. Results: Two MAs completed over 40 hours of training. 27 patients were referred to the program, 16 patients opted-in to participate, and 42 sessions were complete. Training fidelity was established. On multiple occasions, health coaches identified patient needs outside their chronic disease management needs and were able to connect these patients with additional resources. Conclusions: The goals of the project were met: a training pipeline was created, the program was standardized across all four sites, and patients with chronic diseases are receiving additional support. To evaluate long term program success, health data among program participants should be analyzed. For the project to be sustained, a dedicated team must take over the program to include training and support of additional coaches. Additional processes should be facilitated to expedite contact with new referrals and incorporate coaching into the MAs daily workflow.

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