• Decreasing Time to Palliative Care Consultation in an Intensive Care Unit

      Leath, Marcella E.; Van de Castle, Barbara (2021-05)
      Problem: A significant problem for patients in the intensive care unit (ICU) is that palliative care is not involved early in the patient stay. By implementing a screening tool to identify palliative care needs within 72 hours of admission, patient’s palliative care needs can be addressed early in ICU stay. Purpose: The purpose of this quality improvement (QI) project is to implement and evaluate a screening tool to identify patients with palliative care needs in a community ICU to decrease time to referral to palliative care. Methods: The Palliative Care Screening Tool was developed using verified and validated criteria and implemented into practice in a community ICU over a twelve-week period from September 2020 to December 2020. A distribution and collection center for the completed screening tools was created and education occurred for the nurse practitioners on the implementation team and ICU nursing staff regarding the project. Electronic medical record chart audits were completed weekly; data was collected from completed screening tools as well as electronic chart reviews. Screening tool users were surveyed at the completion of this QI project. Results: A total of 193 patients were admitted to the ICU during the implementation phase. Of the patients admitted with a length of stay greater than 72 hours (n=115), 89.6% (n=103) were screened with the tool, and 10.4% (n=12) were not screened. Fifty-five percent of patients screened (n=57) were identified as having palliative care needs. Of those with needs, 50.9% (n=29) were referred to palliative care. Over a 12-week period, there was a decrease in time from ICU admission to referral to palliative care by 68.9%, from 3.95 days at baseline to 2.72 days with the use of a screening tool. Conclusion: The use of a screening tool to assess patient needs for palliative care early in the ICU admission can standardize the process for patient referral and ensure early referral to palliative care.
    • Evaluating the Effectiveness of a Multicomponent Care Bundle Among Intubated Patients

      Givens, Sarma Klimanis; Gourley, Bridgitte (2022-05)
      Problem: At a community hospital, the current intensive care unit (ICU) length of stay (LoS) is increasing. In January 2021, the LoS was 3.84 days, and in December 2020, it was 3.0. Also, it is above the average ICU LoS in the United States, which according to the Society of Critical Care medicine, is 3.8 days. Prolonged LoS can lead to ICU delirium, higher hospital bill costs, decreased quality of life, long-term physical impairments, and is associated with increased risk of long-term mortality after hospital discharge. Purpose: The purpose of this quality improvement project is to implement and evaluate the effectiveness of the ABCDEF bundle in an adult medical/surgical ICU. ABCDEF stands for: assess, prevent, and manage pain; both spontaneous awakening and breathing trials; choice of analgesic/sedation; delirium: assess, prevent, and manage; early mobility and exercise; and family engagement. It is anticipated that the implementation of this bundle could result in a shortened LoS among intubated patients. Methods: Data was collected using an observational checklist adopted from the Society of Critical Care Medicine’s website. All nurses were educated on how to use this tool. The tool was completed once a day, around the time of rounds, by charge nurses to assess which of the ABCDEF bundle elements were applied to intubated patients. The observational checklists were collected and analyzed weekly. Results: By the end of the implementation phase, 100% of staff nurses have received education on patient eligibility for the bundle, 22.9% of intubated patients (who met criteria) received all components of the ABCDEF bundle, and 67.4% of intubated patients were assessed via Observational Checklist, and the average LoS during the 15 weeks was 7.53 days. Conclusions: Though LoS was not decreased, progress was achieved. Nurses demonstrated proficient skills when applying the bundle to patients and nurses gained confidence in initiating SAT/SBTs and early-mobility practices. Post-implementation the SAT/SBT provider order became available for use in EPIC and the SAT/SBT policy has been updated and published on the institution’s intranet. Limitations such as high staff turnover may have negatively impacted this project.
    • The experience of new nurses beginning critical care practice: An interpretive phenomenologic study

      Davenport, Joan Marie; Morton, Patricia Gonce, 1952- (2000)
      New nurses who choose to begin their nursing practice in the Intensive Care Unit (ICU) are faced with many varied experiences. In this interpretive phenomenologic study, the researcher met with and had conversations with eight new nurses who recently completed orientation to their respective ICUs. Ten themes were uncovered and analyzed. Each theme speaks to a particular aspect of the experience lived by the new nurses. Finding a home gives voice to the decisions of the new nurses as they chose to work in an ICU. A few of the hardest things depicts the struggles of the new nurses with organization, with their fears and uncertainties, with the possibility of making mistakes, and with equipment and technology ubiquitous in the ICU. Uncovering the theme of family care led to questions about the new nurses' relationships with the patients' families. Relationships with colleagues presents the associations of the new nurses with preceptors, other nurses and physicians in the ICU? The theme of socialization asks what impact does socialization have on new nurses' experiences in ICU. The importance of team work and the need to depend upon colleagues as teammates in the patient care were voiced. Questions played a vital role in the experience of these new nurses. Their progress in orientation was often gauged by their questions and relationships with colleagues were formed over the activities of questioning. In an ICU, emergencies and deaths were a focus of much anticipation for the new nurses. Many of the participants in this inquiry discussed being watched as a theme of the orientation process. For some, this was a supportive gaze; for others, the watchfulness was experienced as intrusive. The theme of moving on describes the transition experienced by the new nurses as they began to provide their own caring practices in the ICU. This research has implications for the graduate of nursing school beginning to select a work environment, for the experienced nurses who act as preceptors, and for the nurse educator, preparing the student and new graduate for a role in ICU nursing.
    • Implementation of a Blood Product Conservation Project on the Cardiac Surgery Intensive Care Unit

      Gutwald, Cecilia; Jackson-Parkin, Maranda (2022-05)
      Problem: In 2020, 16 blood products were wasted (0.34% of products issued) on a 22-bed Cardiac Surgical Intensive Care Unit (CSICU), reflecting over $2,000 in wasted revenue. Wasting these limited life-saving resources infers disrespect to donors and indicates systemrelated inefficiencies. Incorrect storage conditions of unused Massive Transfusion Event (MTE) products render them unsuitable for re-entry into blood bank circulation due to internal product temperatures deviating from established safe parameters, contributing to 50% of the wastage in 2020. Purpose: The purpose of the quality improvement (QI) project was to implement and evaluate an evidence-based blood cooler checklist presented on MTE coolers that identifies the storage and transport conditions of blood products for registered nurses (RNs) in the CSICU. Methods: Registered nurses (RNs) were able to access a blood product storage checklist by scanning Quick Response (QR) codes on MTE cooler lids. CSICU RNs completed and submitted these checklists through Smartsheet, a HIPAA-compliant file-sharing system, permitting data collection on RN adherence to the practice change. One-on-one education and knowledge comprehension assessments for CSICU RNs, advanced practice providers (APPs), and blood bank staff were delivered by project champions. The project outcome, blood waste, was measured using the institution’s event-reporting system. Results: Post-implementation data revealed 100% (n=122) of CSICU RNs and 100% (n=19) of CSICU APPs were educated on blood product conservation techniques, 100% of MTE coolers issued (N=52) contained a QRcode accessible checklist, 67% (n=35) of the MTEs were associated with a completed checklist, and 13 blood products were wasted (0.86% of products issued [N=1,510]). While blood product wastage as a percentage issued increased from 0.34% pre to 0.86% post-implementation, there was a reduction in MTE blood waste due to improper storage conditions (50% pre versus 46% post-implementation). Blood waste due to improper storage was associated with only one MTE cooler post-implementation, as opposed to multiple MTE coolers pre-implementation. Conclusions: The use of an evidence-based checklist on MTE coolers in addition to RN and APP-directed educational sessions on blood conservation techniques can serve to increase staff adherence with proper blood product storage conditions, decreasing blood product wastage.
    • Implementation of a Hospital-Acquired Pressure Injury Prevention Admission Bundle

      Berry, Mickaela E.; Callender, Kimberly (2021-05)
      Problem: Within a community hospital located in central Maryland, an adult intensive care unit (ICU) had an increased Hospital Acquired Pressure Injury (HAPI) incidence average rate of 2.2% per month during the months of July and August 2020. A potential cause identified was an inadequate nursing skin assessment on patient admission. Purpose: The purpose of this quality improvement project was to implement a HAPI prevention admission bundle that has been shown to reduce the number of HAPIs in an adult population. The bundle included four care components: completion of the Braden Scale score, performance of a two-nurse skin assessment, use of a pressure reducing surface, and application of a prophylactic sacral foam dressing. Methods: The adult ICU consisted of 30-beds and treated approximately 200 patients per month. The bundle was initiated by nursing staff at patient admission and all components were expected to be completed within 24-hours. Nursing education was administered and completed by the staff who worked in this unit. The use of the bundle was measured twice per week by chart audits. The HAPI rate was measured monthly by the hospital’s incident management system (RL6). Bundle documentation compliance and monthly HAPI rate were analyzed using run-chart analysis. Results: 86% of staff nurses were educated about the bundle. The documentation compliance of the bundle during the last four weeks of data collection was a 79% average. The post-implementation HAPI monthly incident rate average increased to 4.1%. Conclusions: The HAPI prevention admission bundle did not improve the average monthly ICU HAPI incident rate during a 14-week implementation effort. The documentation compliance of the bundle components improved over time, due to regular feedback of the chart audit results. COVID-19 precautions altered the standards of care during the implementation phase, which may have influenced the increased HAPI incidence rates during November and December. The HAPI prevention admission bundle was useful in increasing documentation compliance of four vital skin care components. A future quality improvement project should focus on adding additional evidence-based skin care components to the bundle and extending the implementation phase to ensure 100% of staff are educated to improve utilization of the bundle elements.
    • 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.
    • The Implementation of a Nurse-Driven Palliative Care Trigger Tool

      Spurry, Sawyer E.; Alessandrini, Erica (2022-05)
      Problem: Palliative care (PC) providers at an academic medical center stated medical intensive care unit (MICU) patients are often referred late in their hospital stay, with an average PC consult rate of 65% over the last 6 months. This falls below the hospital quality performance metric of 80% of eligible patients receiving a PC consult within 48 hours of admission. Purpose: The purpose of this quality improvement (QI) project is to increase PC utilization in the MICU by implementing a nurse-driven Palliative Care Trigger Tool to prompt referral for specialty PC consults. Methods: MICU nurses and providers received education regarding underused PC services and the evidence supporting the use of nurse-driven PC trigger tools to increase PC referral. A MICU specific criteria of PC triggers was formulated by the QI implementation team based upon the best available evidence. Nursing staff were asked to screen patients daily using the PC Trigger Tool and present findings during bedside rounds. MICU providers were asked to consult PC for patients meeting trigger criteria. Rates of eligible patients and PC consults were collected via electronic medical record data reports, de-identified, and analyzed for trends via run charts. Results: Over 150 MICU nurses were educated on the PC trigger QI initiative along with 10 MICU providers, and 4 PC providers. During the 15-week project period, more than 220 patients were admitted to the MICU and an average of 91% were screened for PC triggers within 48 hours of admission. Approximately 63% of screened patients were identified as having positive PC triggers and 90% of these received a PC consult. Following implementation, the mean time for admission to consult decreased from 22.39 to 7.28 days; mean PC consultation rate within 48 hours of admission increased from 65% to 90%. Conclusion: PC consultation rates increased through the use of an evidence-based PC trigger tool, exceeding the hospital’s quality benchmark for PC referrals. Provider preference greatly impacted consultation rates and emphasizes the need to change knowledge and perspectives related to PC.
    • Implementation of a Quiet Time Protocol in the Neurosurgical Intensive Care Unit

      Payida-Ansah, Damata; Bundy, Elaine Y. (2021-05)
      Problem: Sleep disruption among critically ill patients is associated with detrimental health outcomes such as reduced immune and neuroendocrine function. In a large metropolitan hospital’s Neurosurgical intensive care unit (ICU), 80% of staff surveyed reported high noise levels which can contribute to environmental ICU sleep disturbances. In this ICU, the average sound level was measured at 55.96 decibels, exceeding the Environmental Protection Agency’s recommended daytime hospital limit of 45 decibels. Purpose: The purpose of this quality improvement project was to implement a Quiet Time protocol in a neurosurgical intensive care unit. The Quiet Time protocol was implemented as a practice change to create a quieter and more sleep-friendly environment by minimizing patient sleep disruption, Methods: A Quiet Time protocol was developed and implemented over 10 weeks in a 14-bed neurosurgical intensive care unit following a review of best practices and unit policies, and staff education. The protocol included reduced noise and light levels, and clustering patient care activities from 2:00 to 4:00 pm daily. Nurses completed a protocol audit form daily documenting patients’ demographic data, sleep status and adherence to the protocol. Nursing documentation compliance to the protocol was monitored weekly. Data was collected and tracked weekly via run charts. Unit sound levels were measured with a decibel meter before and during quiet times. Results: Nursing staff Quiet Time protocol compliance rose from 30.77% in Week 1 to 78.26% by Week 10 and with full protocol compliance, patients were reported as asleep 60% of the time. Of the staff surveyed post-implementation, 44% agreed and 44% strongly agreed (totaling 88%) that they would like to use the protocol frequently. Average noise levels from 3:00 to 4:00 pm dropped by 6 decibels from 59.4 dB pre-implementation to 53.3 dB during implementation. Conclusions: Quieter and less stimulating hospital environments can be achieved with Quiet Time protocols when adequate education, nurse buy-in and administrative support exists. Further quality improvement projects on how hospital environments and workflow can be modified to reduce ambient noise are necessary.
    • The Implementation of Nocturnal Earplugs and Eye Masks to Improve Sleep in the Cardiac Surgery Intensive Care Unit

      Ivusich, Kelsey s.; Amos, Veronica Y. (2019-05)
      Background: Sleep deprivation is a major concern among intensive care unit patients, with more than 60% recounting poor sleep, often lasting six to twelve months after discharge. Consequences of poor sleep include disruptions in immunity and endocrine function, impaired cognitive function, and increased length of stay and mortality. Excess noise and light frequently contribute to sleep and circadian disturbances in the intensive care unit. The use of nocturnal earplugs and eye masks is suggested to increase sleep quality among patients in the intensive care setting. Local Problem: Sleep disturbance was identified as a problem in the Cardiac Surgery Intensive Care Unit at a large, academic hospital in Maryland. The purpose of this project was to implement and evaluate the usability and feasibility of nocturnal earplugs and eye masks in the Cardiac Surgery Intensive Care Unit at this institution. Interventions: The Plan-Do-Study-Act Cycle was used to provide an organizing structure for the implementation of this 11-week, quality improvement project. Extubated, oriented, nonsedated Cardiac Surgery Intensive Care Unit patients were asked to wear earplugs and eye masks from 2200 to 0400. At 0600, patients completed a Patient Usability Survey evaluating the amount and quality of sleep, and the comfort of the earplugs and eye masks. The bedside nurse simultaneously completed a Nursing Questionnaire evaluating which intervention(s) was worn and duration of wear, if they believed the sleep aids helped their patient sleep through nursing interventions, and if they would recommend earplugs and eye masks to a future patient. Surveys were completed the first night after earplug and eye masks use. Results: 63 surveys were completed and returned, of which 51% (32 patients) refused to use the earplugs and eye masks. Of the 31 patients who participated, 68% (n=21) reported at least four hours of sleep, and 42% (n=13) rated their sleep quality as “More than average/normal” or “Much more than average/normal.” 45% (n=14) of patients rated the earplugs as “Comfortable” or “Very comfortable,” and 61% (n=19) rated the eye mask as “Comfortable” or “Very comfortable.” 45% (n=14) of participating patients wore both the earplugs and eye mask for the majority of the time between 2200 and 0400, with 68% (n=21) wearing them for at least four hours. 81% (n=25) of nurses “Agreed” or “Strongly Agreed” that the sleep aids helped their patient sleep through nursing interventions, and 90% (n=28) “Agreed” or “Strongly Agreed” to recommend their use to a future Cardiac Surgery Intensive Care Unit patient. Conclusions: Most patients who accepted the earplugs and eye masks found them comfortable and beneficial. Nurses believed they helped patients sleep through interventions and recommended their use. Despite positive outcomes in those who participated, a high refusal rate suggests the use of earplugs and eye masks may not be well suited for the Cardiac Surgery Intensive Care Unit patient population. Sleep aids should continue to be offered due to the benefits noted in those who utilized them and be encouraged for use in other units in the hospital with a broader inclusion and exclusion criteria.
    • Implementation of Resuscitated Cardiac Arrest Debriefing in the Medical Intensive Care Unit

      Fraser, Ruth-Anne M.; Jackson-Parkin, Maranda (2022-05)
      Problem: In 2020, a medical intensive care unit (MICU) at a large academic hospital experienced 47 resuscitated cardiac arrests, achieving return of spontaneous circulation (ROSC) in 66% (n = 33). An audit of the practices of the MICU identified that following cardiac arrest resuscitations, no processes existed for performing staff debriefing possibly contributing to inferior resuscitation quality. Debriefing is a focused, interdisciplinary discussion that provides participants with feedback and is demonstrated to improve patient outcomes including return of spontaneous circulation, and team performance. Purpose: The purpose of this Quality Improvement (QI) project was to implement a sustainable, structured, interdisciplinary debrief after all resuscitated cardiac arrest events in the MICU. Debriefing after resuscitated cardiac arrest events could improve CPR quality, return of spontaneous circulation rates, and communication. Methods: The QI project methods involved Resource Registered Nurses (RRN) facilitating an interdisciplinary debriefing following each resuscitation event in the MICU (September - December 2021), using the institution’s debrief tool. The debriefing tool was comprised of open-ended questions and quality metrics. Practice changes were achieved by using teach-back methods to train the RRNs on debrief facilitation. Emotional support was offered to staff. Compliance with debriefing and number of staff involved with events and debriefs were recorded. In addition, anonymous indicators of CPR quality as measured by chest compression depth, rate, and fraction was collected from the defibrillator. Finally, the rate of return of spontaneous circulation (ROSC) was collected. Results: During implementation, 92% (n = 13) of resuscitated cardiac arrests were debriefed, and 8 to 17 staff participated in each debrief. Comparison of CPR quality before and after implementation demonstrated marked improvement in median chest compression quality according to the American Heart Association (AHA) guidelines. Compression depth and rate medians increased from 22.0% to 39.5% (p = 0.012) and 63.9% to 75.6% (p = 0.497) respectively, and compression fraction median decreased from 95.3% to 94.9% (p = 0.35). Return of spontaneous circulation was achieved in 50% of the arrests. Conclusions: Project outcomes demonstrate that debriefing is associated with improved CPR quality and provides support for MICU staff after resuscitated cardiac arrest events.
    • Improving Sleep Quality in the Adult Intensive Care Unit

      Lubis, Crystal J.; Bundy, Elaine Y. (2021-05)
      Problem: Intensive care unit patients are at increased risk for poor sleep quality due to high incidences of night time nursing interventions, leaving little time for restorative sleep. Poor sleep can arise from stress, pain, and misaligned circadian rhythms as well. Sleep deprivation is harmful and can cause cognitive, ventilatory, cardiovascular, hormonal, and immune problems. The prevalence of perceived poor sleep quality was determined in the adult intensive care unit over a 3-month period. Most patients (54%) rated their sleep quality as less than average. Purpose: The purpose of this quality improvement project is to improve sleep quality for stable adult intensive care unit patients by placing them on a multi-component sleep protocol that provides a 4-hour window of uninterrupted sleep. Methods: A multi-component sleep protocol was implemented over a 12-week timeframe which prioritized a disturbance free 4-hour sleep window between midnight and 4 a.m. Staff were educated through a poster board presentation and by email. Protocol components included offering sleep masks and ear plugs to the patient, hanging a sleep protocol sign on room doors, re-timing routine medication and blood draws, and nurses serving as gatekeepers to prevent in-room disturbances. Patient’s self-reported sleep quality was charted afterwards in the electronic medical record. Ancillary departments (phlebotomy, pharmacy, and respiratory care) were notified of the new practice change as well. Weekly run charts were used to analyze and track data on percent of staff educated, patient’s sleep quality, and nursing staff compliance rates. Results: Results show that 100% of night shift nurses were educated on the protocol, 84% of nurses documented patient’s stated sleep quality in the electronic health record, and of the 106 sleep observations performed, 70% were rated as good or excellent. Fifty-eight patients total were placed on the sleep protocol during the 12-week project. Conclusions: Sleep disturbances are multifactorial. A multi-component sleep protocol was shown to improve sleep quality for adult intensive care unit patients. Therefore, a sleep protocol that diminishes or eliminates preventable disturbances is beneficial to the overall health of critically ill patients and should be a part of standard practice.
    • Leveraging a Tele-ICU Program to Provide Palliative Care to All ICU Patients: a Pilot Study

      Stear, Courtney (2014)
      In an effort to improve the quality of care to all patients in their ICU's, OSF ConstantCare tele-ICU launched a pilot program to provide key aspects of palliative care to all patients without a palliative care consult. Palliative care specialists are in short supply and the vision of OSF is for all patients to be treated with the greatest care and love. To meet that vision, a partnership between the ICU care team and the tele-ICU team was established to promote patient- and family-centered care that incorporated major domains of palliative care for all patients in the pilot ICU.
    • Palliative Care Screening Implementation within the Medical Intensive Care Unit

      Troiani, Nicole; Satyshur, Rosemarie D. (2020-05)
      Problem & 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.
    • Palliative Care Screening Tool Implementation in a Medical Intensive Care Unit

      Keadle, Emily C.; Hood, Catherine (2022-05)
      Problem: Palliative care is underutilized and not prioritized in a large metropolitan teaching hospital medical intensive care unit. On average, it takes 6.7 days for a patient to receive a palliative care consultation but can take as long as 49 days. Only 15.74% of patients admitted to the medical intensive care unit will receive a palliative care consult. There is not a consistent method by which palliative care recommendations are made or how patients in need of palliative care services are identified in this medical intensive care unit which contributes to a delay in, or lack of, palliative care. Purpose: The purpose of this quality improvement project is to implement and evaluate the effectiveness of a palliative care screening tool in a medical intensive care unit. Methods: A validated palliative care screening tool was added to the admission documentation in a 19-bed medical intensive care unit to be completed by the nursing staff on each admission. When completed, a total score of 4 or greater creates a task for the nurse via the electronic health record to notify the provider of unmet palliative care needs. Results: Nurses utilized the screening tool 74% of the time. The number of palliative care consults increased from 15.74% to 23.75%. Time from admission to palliative care consult decreased from 6.68 days to 6.25 days. Conclusions: The implementation of a palliative care screening tool was associated with decreased time to palliative care consult and an increase in number of palliative care consults in a medical intensive care unit.
    • Palliative Needs Screening in a Surgical Intensive Care Unit

      Lu, Lauren B.; Wilson, Tracey L. (2022-05)
      Problem: A surgical intensive care unit (SICU) at a large academic medical center did not have a process to identify patients with palliative needs. Published evidence demonstrates that screening criteria can help identify those with unmet palliative care needs and increase the rate of appropriate consultations. Purpose: To implement a screening process for identification of unmet palliative care needs among Acute Care Emergency Surgery (ACES) patients in the SICU. Methods: Once the process was developed using available evidence and a validated screening tool, staff were educated on the protocol. The goal was for all admitted ACES patients to receive palliative needs screening by the bedside nurse within 48 hours of admission. For positively screened patients, a palliative care consult would be placed by the SICU provider following approval from the ACES team. ACES patients were re-screened weekly while they remained in the SICU. Results: There were 34 patients admitted during the project period. The total percentage of patients that received screening within 48 hours of admission was 70.6% (24 out of 34 admitted patients). The total percentage of eligible patients that received weekly re-screening was 82% (23 out of 28 eligible patients). The total percentage of positively screened patients that received consultation was 53.8% (7 consults out of 13 positively screened patients). The overall palliative consult rate was 20.6% (7 consults out of 34 total patients). This is greater than the anecdotal baseline of 10%. Conclusions: Barriers were met during the project that affected screening compliance, but the screening tool identified many patients with palliative care needs. While SICU providers were receptive to hearing positive screening results, consultation was deferred at times. But the project may have prompted earlier discussions regarding palliative involvement. With modifications, future initiatives to screen for unmet palliative needs could be extended to other surgical patients in the SICU.
    • Promoting Early Mobility in The Medical Intensive Care Unit

      Lanier, Tatyauna M.; Bundy, Elaine Y. (2022-05)
      Problem: Evidence has shown that early mobilization can improve patient outcomes, expedite recovery time, and shorten the length of stay for hospitalized patients. However, early mobilization of critically ill patients is not routinely practiced in an academic medical center's medical intensive care unit (MICU). The MICU has a higher immobility rate than other units, with only 29% of patients receiving early routine mobilization. Plans to encourage mobility are not routinely discussed during patient care rounds by the multidisciplinary healthcare team in the MICU. Purpose: The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of an evidence-based nurse-driven mobility algorithm for adult patients admitted or transferred to the MICU. Methods: The mobility algorithm was implemented in an adult MICU over 15 weeks from August to December 2021. A mobility algorithm was developed based on evidence-based practice recommendations. Following staff education, the mobility algorithm was reviewed with each patient admitted or transferred to the MICU by the oncoming shift during nurse handoff to assess the patient's mobility level and plans to promote mobility. Weekly mobility reports, electronic chart audits, and observation audit tools were utilized to collect staff compliance on utilizing the mobility algorithm. The data was analyzed using run charts to track changes in mobility screens, mobility level door signs, and patient activity. Results: There were positive and negative trends among 520 patients with mobility rates. Results showed that average mobility screen increased (30% to 100%) and mobility level door signs (5% to 100%). There was an increased in patients’ mobility level (29% to 80%) during the fourth week of implementation. Analysis of all run charts showed no shift in trends with rates of early patient mobility utilizing a mobility algorithm. Conclusion: The anticipated outcomes of this QI project were achieved with improvement in inpatient mobility screening, mobility level door signs, and documented patient activity to increase early patient mobility.