• Embedding IPE: It's Easier Than You Think

      Guerin, Toby Treem; Hammersla, Margaret; Shdaimah, Corey S. (2017)
    • Implementation of a Nurse Preceptor Simulation to Foster Feedback Skills

      Murray, Toni; Hammersla, Margaret (2019-05)
      Background: Effectual feedback is an essential skill crucial to the preceptor role; preceptors are often hesitant and uncomfortable with providing feedback. Inadequate preceptorship is a consistent problem that has continued to affect the onboarding and retention of a qualified registered nurses. In a national survey, timely and effective feedback was ranked the most critical preceptor skill by new nurses entering the practice. The provision of timely constructive feedback is one of the core competencies of nurse preceptors. Feedback education is successfully provided through simulated crucial conversations by using standardized actors in communication learning activities. The use of simulation in training can provide a safe and effective learning environment where new skills can be acquired. The use of standardized actors, role-playing, scripted responses, and simulation has the potential to improve communication skills by offering its participants life-like experiences. Nurse preceptors can benefit from educational activities that can improve feedback skills in the clinical setting during preceptorship Local Problem: Nursing leadership and nurse preceptors at a community hospital in Baltimore, Maryland identified preceptor development as an institutional priority. During the fall of 2017, preceptors (n=260) completed a needs assessment survey. In the survey results that over 44% of the nurse preceptors had no formal training for preceptorship; of those who had training, 42% of them received it over three years ago. Additionally, almost one-third of the preceptors perceived they were not proficient in feedback skills to new nurses and many were unsure if they were previously taught the skill during their program. The purpose of this Doctor of Nursing Practice (DNP) quality improvement project was to implement a feedback simulation into a current preceptor program, to foster preceptors’ skills for providing constructive feedback to new to practice nurses. Intervention: A quality improvement project with a simulation workshop was implemented to incorporate standardized feedback strategies. The simulation workshop included the use of standard actors, video-vignettes, and classroom learning activities to foster feedback skills. Results: Twelve experienced nurse preceptors from a 64-bed medical-surgical-telemetry unit participated in the project. The preceptors’ perception of their knowledge before the simulation was rated as good (3.33 =/- 1.15) and very good post-simulation (4.5 +/- 0.52) on a 5-point Likert scale. Using a specially designed feedback assessment form two Nursing Professional Development Specialists observed and scored the preceptors’ feedback behavioral skills during the pre and post-simulation. A paired t-tests and repeated-measures ANOVA statistical method was used to measure the trend in preceptor scoring. All preceptor scores showed statistical significance (p <= 0.5) in all categories post simulation (establishing an engaging learning environment, maintains an engaging learning environment, structure the feedback conversation in an organized way, provokes an engaging discussion, identifies and explores performance gaps, and helps the learner achieve good future performance). Conclusions: The results of this project can be used to inform educational activities to support preceptor development in feedback skills. Simulated educational activities is a useful teaching strategy that can improve nurse preceptor feedback skills in the clinical setting during preceptorship with the new nurse entering practice.
    • Implementation of a Nurse-Driven Nonpharmacological Sleep Bundle to Reduce Delirium in a Surgical Intensive Care Unit

      Turnbaugh, Lindsey D.; Hammersla, Margaret (2019-05)
      Background: The prevalence of delirium, an acute syndrome causing changes or fluctuations in baseline mental status leading to inattention, disorganized thinking, and altered levels of consciousness, afflicts patients residing in the intensive care unit. Several negative outcomes may occur in patients diagnosed with delirium in the intensive care unit, including increased mortality, hospital length of stay, cost of care, and long-term cognitive impairment. Sleep, a critical component of health and recovery, is noted to be disrupted in intensive care unit settings resulting in a correlative effect between sleep deprivation and delirium. Multicomponent nonpharmacological interventions are intended to reduce the predisposing factors of this syndrome and have been shown in randomized control trials and systematic reviews to be effective in preventing delirium. Local Problem: The purpose of this quality improvement project was to implement a nursedriven non-pharmacological sleep bundle with a checklist of interventions to reduce intensive care unit delirium, which was noted by staff as an increasing problem, in an adult 12-bed Surgical Intensive Care Unit at a community hospital in Towson, Maryland. Interventions: An evidence-based checklist of nonpharmacological interventions related to reducing noise, light, and patient care interruptions was implemented by the Surgical Intensive Care Unit nurses on patients admitted over an eight week period. Checklist compliance was measured during the eight weeks of implementation by counting the number of completed checklists and comparing that to the number of admissions per week. The interventions performed on all completed checklists were evaluated using descriptive statistics. Delirium was measured by the Confusion Assessment Method Intensive Care Unit tool in the electronic health record and evaluated through an electronic chart review. A data analysis was performed using a chi-square test and odd’s ratio to compare the Confusion Assessment Method Intensive Care Unit scores pre-implementation versus post-implementation of the sleep bundle. Results: During the first four weeks of project implementation, the weekly completed checklist compliance rate was 98%, however, the remainder of the implementation phase was at 100%. There was a high rate of noise, light, and patient care interventions labeled as “not-complete” due to patient refusal or “not-applicable” due to the inappropriateness of the intervention for the patient population. In the pre-implementation phase, delirium was reported as positive on the Confusion Assessment Method Intensive Care Unit tool 22% of the time versus 51% of the time in the post-implementation phase. A chi-square test determined a statistically significant association between the variables (p<0.001), though an odd’s ratio test (OR=0.26) revealed no association between the nonpharmacological sleep bundle and delirium scores. Conclusions/Implications: Documentation compliance was sustained by having the Confusion Assessment Method Intensive Care Unit documentation already embedded in the electronic health record. There was an increase in the awareness and nursing documentation of Confusion Assessment Method Intensive Care Unit scores during and after project implementation. Despite an increase in delirium among patients post-implementation, the literature still suggests a correlative effect between sleep deprivation and ICU delirium. Further studies are needed to determine whether multicomponent nonpharmacological sleep bundles can reduce delirium.
    • Implementing a Locator Protocol to Support People Living with Human Immunodeficiency

      Scott, Katherine; Hammersla, Margaret (2019-05)
      This quality improvement (QI) project implemented and evaluated a locator protocol in an urban hospital to community transitional care program for persons living with HIV to minimize the number of people lost to follow-up. Background: In the United States over 50% of people living with HIV (PLWH) are not engaged in HIV care. Individuals not engaged in HIV care do not have access to combination antiretroviral therapy, prophylactic medications or medical services which increases their risk of morbidity, mortality, and HIV transmission to others. Local Problem: The HIV population in Baltimore is highly transitory with high rates of substance use and mental health disorders, and homelessness. An urban HIV organization in Baltimore, Maryland connects PLWH who are newly diagnosed or out of care to medical care. Clients are enrolled in the transitional care program during hospitalization and staff initiate individualized care plans to address barriers to care and provide support services. After discharge from the hospital clients receive 90 days of intensive case management including home visits, transportation to medical visits and connection to resources. During enrollment in this program, up to 50% of clients may be lost to follow-up at various time points because phone numbers are disconnected, or client transience. Intervention: A locator protocol tool was developed and initiated to collect detailed social and personal information from clients in the transitional care program to minimize the number of clients lost to follow up. Inclusion criteria included consented clients age 18 or older who were newly diagnosed or out of care for HIV for at least six months and had 1 of the following: unstable housing, substance use and/or a mental health disorder. Questions in the locator protocol included local hang outs, identifying a person of trust who could be contacted in case the client was not found, programs, agencies or businesses frequented, and dwelling locations including shelters. Community health workers (CHW) completed the form with clients at the bedside before discharge from the hospital. The locator protocol was initiated if a client missed a medical appointment or when the CHW could not locate a client via phone or address. Results: Twenty clients were enrolled in LTC+ from September 10 to December 17, 2018. Outcomes: 1) Seventeen (85%) clients completed the locator protocol. 2) Clients were frequently lost and then found again with the locator protocol. 3) Thirteen (76%) were actively retained in care. Conclusions: People who have unstable housing, substance use or mental health disorders struggle to maintain their health in traditional medical care models. The locator protocol centralizes client information and standardizes internal protocols which results in more consistent communication between staff and clients. The more detailed social and personal information collected, the longer and more likely staff stayed in touch with clients and got them to appointments and engaged in HIV care.
    • Improving Provider Documentation and Billing Through the Implementation of a Standardized Note

      Silverman, Dawn Marie; Hammersla, Margaret (2019-05)
      Background: As the demand for critical care services grow and the intensivist provider pool diminishes, advanced practice providers are increasingly integrated into intensive care units. However, advanced practice providers often enter the profession without proficiency in the billing practices necessary to ensure their work is reimbursed. Critical Care Management, Current Procedural Terminology codes 99291 and 99291, are services exclusive of any global payment. These two codes represent a significant amount of a provider’s billable activities in the intensive care setting. In the absence of education addressing billing requirements for these codes, provider documentation often fails to meet the standard for reimbursement. Money is left on the table and provider work is not adequately represented in reimbursement. Targeted education and standardized documentation can improve the quality of documentation, billing competency, and contribute to increased revenue. Local Problem: In surveys conducted pre-implementation, the majority of advanced practice providers at the project site reported a lack of billing and requisite documentation training and competency. Additionally, documentation audits validated that, often, advanced practice provider notes did not support their billable activities. The aim of this quality improvement project was to implement and evaluate the effectiveness of a standardized Event Note to improve documentation and billing of critical care management. Interventions: The implementation of this quality improvement project took place over a 12week period. Primary components of the implementation included: pre-implementation survey, pre-implementation online education module, implementation of a standardized Event Note, and post-implementation survey. Data were collected from all primary components. Results: Post-implementation of the standardized Event Note and online education module, 87.2% of providers agreed or strongly agreed with the statement, “The online billing education improved my billing competency.” Additionally, 94.9% agreed or strongly agreed with the statement, “This project heightened my awareness regarding the importance of documenting critical care events.” Further, 116 events notes and 5,777 critical care minutes were documented post-implementation compared with 64 event notes and 2,184 critical care minutes entered in the pre-implementation period. Critical care evaluation and management codes require the reporting of time in minutes. The standardized Event Note includes a prompt to enter the number of minutes spent in exclusive attention to a patient. Twenty-four event notes made no mention of time in the pre-implementation period and only six notes omitted a time element in the postimplementation period. This demonstrates a 75.00% decrease in event notes without a time element. The six event notes without a time element were the result of the provider using free text to document (n=2) or using an older unit-based event note (n=4). Post-implementation, 82.76% of all event notes submitted utilized the vetted, standardized Event Note. Conclusions: Advanced practice provider education and use of the standardized Event Note increased billing competency and awareness related to thorough and timely documentation of critical care management. Engaging providers in targeted education and providing standardized notes, built with attention to communication and required billing elements, is an effective and efficient means of improving documentation and reimbursement.
    • Sarcopenia and PRAISEDD-2 Intervention's Impact on Diet, Physical Activity, and Body Composition

      Hammersla, Margaret; Resnick, Barbara (2017)
      Background: Older adults with a low socioeconomic status and African Americans are more sedentary than the general population. This contributes to the development of sarcopenia and has a negative impact on the health and function of these individuals. PRAISEDD-2 was a 24-month quasi-experimetnal study of low income adults living in senior housing. A focused 3-month intervention included education about stroke prevention and heart health through adherence to heart healthy diets, regular exercise, and prescribed medication combined with exercise classes that included verbal encouragement, blood pressure feedback, and role modeling. Classes continued to be offered in months 4-24 but only included a monthly motivational intervention. The impact of the PRAISEDD-2 intervention on diet (fat, sodium, and protein intake), time spent in physical activity, and body composition are examined in the study reported here. Design: Diet and body composition measures were collected at baseline, 3, 6, 12, and 24 months. Sample included 29 residents of a low-income senior housing complex in Baltimore, MD. Complete data was obtain from 13 participants. Generalized estimating equations (GEE) were used to examine change over the time periods. An intention-to-treat (ITT) paradigm was followed. Results: At 3 months, participants experienced a decrease in sodium (p<0.01) and fat intake (p<0.01), as well as in a decrease in percent body fat (p<.001). However, at 24 months, fat intake (p<0.001) and percent body fat (p<0.001) increased, although protein intake increased (p<.001). No significant change was noted in physical activity (p=.056) or sodium intake (p=0.69) at 24 months. Conclusions: The findings from this study provided some support for the feasibility and preliminary efficacy of the PRAISEDD-2 intervention. The changes that occurred in the early 3 month period were likely due to the intensive nature of the education and exercise classes. Future research should focus on building a stronger self-efficacy based motivational component into the exercise classes to strengthen long term adherence to the recommended dietary change and physical activity, essential to promote decrease in body fat and increases in muscle mass. Interventions may need to be sustained longer to achieve more permanent changes in diet and exercise.