• Food Insecurity Screening and Referral in a Pediatric Emergency Department

      Shock, Chelsea N.; Satyshur, Rosemarie D. (2022-05)
      Problem: Many neighborhoods surrounding a 20-bed pediatric emergency department in an urban medical center are considered food deserts. This suggests patients receiving care are at high risk of experiencing food insecurity. Previous patient care practices in this pediatric emergency department did not screen for food insecurity. Evidence recommends pediatric patients receiving medical care be screened for food insecurity and connected with the necessary resources to limit associated consequences, such as poor health, developmental risks, and mental health issues. Purpose: The purpose of this project was to implement the Hunger Vital Sign, a 2- item food insecurity screening tool, over 15 weeks in a pediatric emergency department located in an urban medical center. This quality improvement project aimed to identify patients with food insecurity concerns and subsequently refer positive screens to social work for resources. Methods: A quality improvement project was designed to implement the Hunger Vital Sign into a pediatric emergency department’s triage process. Using a standardized nursing note in the electronic health record, the triage nurse screened all patients except those arriving by ambulance or requiring immediate medical attention. Positive screens prompted a social work referral to provide the patient and family resources. Weekly chart audits were completed to track the number and percentage of patients screened in triage, positive screens, positive screens with social work referrals, social work consults before patient discharge, and patients who accepted resources. Results: Run charts were used to analyze data variations of the process and project outcome measures. Results collected during the 15 weeks of project implementation determined triage nurses screened 56% of the 3,607 eligible patients and identified 7% as food insecure. Of the 94% referrals, social work consulted 60% of patients with positive screens, with 89% of patients accepting resources. Conclusions: Following project completion, results were analyzed to evaluate the screening process, efficiency, barriers, facilitators, and sustainability. Conclusions indicate the Hunger Vital Sign effectively identifies food insecurity, and there is a need for food insecurity screening in this pediatric emergency department.
    • Implementation of a Distress Screening and Management Protocol for Adult Cancer Patients

      Uzupus, Allison M.; Edwards, Lori A. (2021-05)
      Problem: Approximately 50% of cancer patients experience clinically significant cancer-related distress. Unmanaged distress has been linked to decreased medication adherence, increased visits to the emergency room and oncology clinic, increased hospital stays, decreased quality of life and decreased overall survival. At a university-based cancer center in the mid-Atlantic region, informal assessment of patient distress was provider dependent and as a result was inconsistently conducted and documented. Purpose: The purpose of this quality improvement (QI) project was to implement a systematic screening protocol for distress which included a screening tool, staff training, as well as referral processes to identify and manage distress in adult patients with metastatic colorectal cancer. Methods: The National Comprehensive Cancer Network (NCCN) Distress Thermometer and Problem List (DT&PL) was integrated into the patient portal as a questionnaire and sent to patients with metastatic colorectal cancer prior to treatment to be completed prior to their infusion appointment. Infusion nurses reviewed the distress screening with patients during their appointment and made appropriate referrals to clinic-embedded resources such as social work, psychiatry, pain and palliative care, and/or pastoral care based on questionnaire results. Results: The NCCN DT&PL was successfully integrated into the portal as a questionnaire. Overall, 64% of patients completed the questionnaire at least once and 39% of the completed screens indicated high distress. All patients who indicated high distress had documented nursing interventions and/or referrals. Conclusions: Evidence-based distress screening and referral is a feasible practice change to improve patient outcomes. Key facilitators were integration into the electronic health record and personnel to support to initiative.
    • 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 Referral Criteria for Acute Pain Service

      Alayev, Alina; Wiseman, Rebecca Fortune (2019-05)
      Background: In the United States, pain affects more people than heart disease, diabetes, and cancer combined. Inadequate pain control has many adverse consequences, such as delay in recovery, prolonged length of stay in the hospital, increased medical costs, increased risk of immobility, anxiety and depression, sleep deprivation, and an overall decrease in quality of life. Acute Pain Service (APS) has been shown to lead to better pain management in hospitalized patients. All healthcare facilities are recommended to establish an Acute Pain Service team to provide adequate pain management to the patients. Local Problem: The community hospital where this Doctor of Nursing Practice (DNP) project took place has established an APS team. However, it is being widely underutilized. Pre-implementation data showed a less than thirteen percent Acute Pain Service referral rate on the acute inpatient cardiac telemetry unit. The goal of this project was to implement a referral criteria tool to increase the utilization of the Acute Pain Service on a cardiac telemetry unit in a community hospital in Maryland. Interventions: A quality improvement project took place over a 14-week period on a cardiac telemetry unit. The referral criteria tool was printed out and distributed to all unit staff. DNP student provided educational opportunities for the pain champions, who were designated by the unit manager, who served as resources for the unit nurses on the role and benefit of Acute Pain Service. Nurses assessed patients upon admission and after a change in status using the referral criteria tool to determine if they qualified for an Acute Pain Service referral. Inclusion criteria were patients on chronic opioids, patients receiving patient-controlled analgesia (PCA), patients who were active substance abusers, and patients with uncontrolled pain. Meeting at least one of the criteria qualified a patient for the referral. Nurses would then request a consult from the provider during daily multidisciplinary rounds. DNP student project coordinator was on the unit weekly to provide support, answer any questions, and collect data. Results: A total of 214 patients, who were admitted on the unit during the eight week implementation period, were evaluated to determine if they met Acute Pain Service referral criteria by performing Electronic Medical Record chart audits. A total of 20 patients met referral criteria with 11 of them receiving a consultation by Acute Pain Service (55%). Pre-implementation data on this unit showed an overall 12.7% Acute Pain Service referral rate, with eight out of 63 qualifying patients referred to Acute Pain Service in a four-month period leading up to this DNP project. The difference was found to be statistically significant using Chi-squared test (p<0.001). Conclusions: The implementation of the referral criteria instrument increased the Acute Pain Service referral rate from 12.7% pre-implementation to 55% post-implementation. The recommendation is to continue using the referral criteria tool and eventually make it a hospital-wide assessment tool that is integrated into the Electronic Medical Record.
    • Implementation of a Referral Criteria for Acute Pain Service on a Post-Surgical Inpatient Unit

      Smith Azarcon, Sharon-Marie; Wiseman, Rebecca Fortune (2019-05)
      Background One in every four Americans experience pain for greater than 24 hours. Pain is a major reason Americans access the health care system. Uncontrolled pain can lead to longer hospital stays, increased rate of readmissions, and increased risk of arising complications. Acute Pain Service (APS) is a team that can manage patient’s pain during the hospital stay. APS is found to decrease length of hospital stay and improve pain management in patients. A referral criteria instrument is a tool that guides nurses in assessing patients that meet criteria for APS. This referral criteria instrument can assist in increasing the number of APS consults. Local Problem Low APS consults were observed to be a practice problem in a post-surgical unit of a community hospital. In addition, the unit was observed to have uncontrolled pain as indicated by low patient satisfaction scores collected from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The hospital has an approved referral criteria instrument that nurses could access to determine if patients meet criteria for a referral to Acute Pain Service (APS). However, nurses were resistant to the APS team due to the misperception of pain medication administration and nurses believing that utilizing APS for pain management led to opioid addiction. Interventions This quality improvement project took place over a 14-week period. During weeks 1-2, training on referral criteria via informal meetings was given to the clinical site representative, unit manager, pilot team (i.e. nurses on the unit), and pain champions on the unit. Printed copies of the referral criteria instrument were posted in the nurses’ station, nurses’ break room and walls of the bathroom. Implementation of the project occurred during weeks 3-10. The pilot team was reminded to utilize the referral criteria instrument daily. Patients that met criteria for APS were discussed during daily interdisciplinary rounds. Weeks 11-14 consisted of data collection and analysis for the project. Results The post implementation of the referral criteria instrument revealed an increase in the percentage of patients consulted to APS. Post-implementation results showed that 53.7 % of patients were consulted to APS, compared to pre-implementation results of 25.3% of patients consulted to APS. Findings revealed that the difference was statistically significant using the Chi-Squared test, p = 0.002 (p< 0.05). Conclusion The implementation of the referral criteria for APS was beneficial to the unit based on the increase of APS consults. The percentage of consults to APS post implementation was 53.7 %. This was a 28.4% increase of APS consults on the unit. Training on the referral criteria instrument and understanding the purpose of APS gave positive outcomes for the unit by increasing APS consults on patient that met criteria for APS. In addition, the increase in APS consults should furthermore lead to increased patient satisfaction and increased HCAHPS scores.
    • Implementation of Ask-Advise-Connect Approach with an eReferral to Maryland Quitline

      Cogliandolo, Alba; Miller, Marilyn, Ph.D., C.R.N.P., C.S.P (2022)
    • Improving Inpatient Substance Use Screening and Referral to an Addiction Consult Team

      Figiel, Rachel; Jackson-Parkin, Maranda (2022-05)
      Problem: Substance use is associated with poorer hospital outcomes, increased lengths of stay, higher healthcare costs, and increased mortality. On an adult inpatient medical unit, up to 90% of patients did not receive substance use screening per policy. Implementing the evidence-based model of screenings, brief interventions, and referrals to treatment (SBIRT) in this population would serve to optimize quality of care and patient outcomes. Purpose: To purpose of the QI project was to improve substance use screening and referrals to an Addiction Consult Service (ACS) on an adult Medical Intermediate Care Unit. Methods: This QI project was implemented over a 15-week period on a 16-bed adult medical IMC unit. In order to improve substance use screening in newly admitted patients, staff utilized an existing validated single-item screening question in the electronic medical record. Nursing staff notified the attending physicians for all patients who screened positive; the physician further evaluated the patient and placed an order for the ACS if indicated. Data collection was conducted via manual chart audits; run charts were utilized to track process and outcome measures. Process measures included counts (%) of patients who were screened/assessed for substance use. Outcome measures included counts (%) of patients who screened/assessed as positive and received follow up by a physician and counts (%) of patients who screened positive who were referred to ACS. Results: A total of 53 patients were screened or assessed for substance use. Of these, 100% received a screen or assessment, 49.06% (n=26) were screened by nursing, and 50.94% (n=27) who were missed by nursing received assessments from a physician. Of the patients screened or assessed, 13.21% (n=7) were positive, 11.54% (n=3) of patients screened by nursing were positive and 14.81% (n=4) of the patients missed by nursing but assessed by a physician were positive. Of the patients with positive screenings or assessments, 71.43 (n=5) were referred to the ACS. Conclusion: Implementing nurse-lead substance use screening with a validated screening tool in the electronic medical record is feasible on a busy inpatient medical unit, leads to improved detection rates, improves documentation, and makes screening more convenient.
    • Increasing Communication with Referring Providers to Enhance Patient-Centered Care

      Skojec, Diane Vail; Naquin, Bernadette; Moore, Christal (2014)
      After implementation of a new electronic medical record (EMR) in a large ambulatory surgery clinic, it was noted by the surgeons that referring provider information was lacking in the patient record, preventing after visit auto-routing of clinic notes and resulting in inferior care coordination. Objective: The aim of this project was to identify barriers and implement changes to the current intake process at the time of scheduling and registration. Identifying the referring provider at the time of scheduling an appointment and prior to the clinic visit was expected to promote an increase in outgoing referring provider communication for patients seen in the ambulatory surgery clinic.
    • Pediatric Medical Home Care Coordination

      Meyers, Joanna W.; Connolly, Mary Ellen (2019-05)
      Background: Socioeconomic and social complexities are associated with delays in children receiving a timely evaluation for behavioral health treatment and developmental delays. The American Academy of Pediatrics recognizes the complex needs of these children and the key role of primary care providers in the referral process and care coordination to ensure the timely start of services and treatment. This recommendation is also supported by the Individual and Disability Education Act Part C, that requires children identified with developmental delays to be evaluated for services within 45 days of referral. Local Problem: The purpose of this QI project was to evaluate and implement the care coordination of children referred for early intervention services and behavioral health treatment at a primary care practice in the Mid-Atlantic Region. Interventions: The Care Coordination Measurement Tool was approved by Dr. Antonelli at Boston Children’s Hospital and implemented to quantitatively measure care coordination tasks completed during the 12-week project timeline. The tool was used to track the volume of referrals sent, care plans and consults received, and communication that occurred between providers and specialists. During project implementation, the electronic medical record at the project site received a system upgrade, allowing for real-time interface and data exchange with specialists. This system upgrade allowed for referrals to be sent and care plans to be received electronically. Results: An overall 14-day reduction from referral to evaluation for both behavioral health and early intervention services, and a 16-day reduction for children referred for delayed speech was achieved. The pre-project mean (37.0) for days to evaluation vs. project mean (22.8) was shown to be statistically significant using an alpha of 0.05 and a two-independent sample T-test with unequal variance. Data outliers included maternal drug history and parents not responding to early intervention services. The care coordination tool captured a total of more than 200 care coordination needs, activities, and outcomes over the 12-week project timeline. Over 70 care plans-consults were received through electronic interface, and staff completed greater than 13 behavioral health paper forms. Conclusions: The role of the electronic medical record in primary care can reduce the average number of days from referral to evaluation, improving patient outcomes. Collaboration and communication among specialists and providers will also improve as care plans and consult reports are received electronically. These findings indicate that the communication feedback loop was completed, as referrals were sent, evaluations were completed, services were started, and patient care plans were received.
    • Prediabetes Identification and Diabetes Prevention Program Referral

      Hansen, Shannon C.; Bode, Claire (2019-05)
      Background: Diabetes is a common chronic disease and can lead to comorbidities such as coronary artery disease, stroke, hypertension, peripheral vascular disease, nephropathy, neuropathy, and retinopathy. Prediabetes is an asymptomatic disease that precedes type 2 diabetes and affects 84 million Americans. Participating in a structured diabetes prevention program (DPP) incorporating education on healthy diet, physical activity of at least 150 minutes per week, and weight loss of at least 5-7% can prevent or prolong a diabetes diagnosis. Local Problem: A suburban primary care clinic was inconsistently identifying patients with prediabetes and not referring them to an evidence-based diabetes prevention program. The purpose of this project was to implement and evaluate a quality improvement project incorporating prediabetes identification and referral to a DPP at the primary care clinic. Interventions: At the primary care clinic, adults identified with prediabetes who met inclusion criteria were referred to an evidence-based diabetes prevention program approved by the Center for Disease Control and Prevention (CDC). Criteria included being 18 years of age or older, having lab values in the prediabetes range (HgA1c 5.7-6.4%), and did not have a previous diabetes diagnosis. Medical assistants were educated on the prediabetes identification and referral process for the first two weeks of the project. Implementation began at week three and continued through week 14 with the intention of continuing the program after the project completed. Results: A total of 764 patients were seen in the clinic over a 12-week timeframe. Of the patients who were seen, 335 underwent laboratory analysis of glycated hemoglobin (HbA1c) with 130 of those results between 5.7-6.4%. Considering diabetes prevention program inclusion criteria, 44 patients were removed for having a previous diabetic diagnosis or a BMI < 24 (<22 if Asian). Of the remaining 76 patients, 35 were identified, based on chart review, as having an “elevated HbA1c” or prediabetes. Four of those patients were notified of the DPP and referred to the program. Conclusions: Overall, office staff was willing to learn how to identify prediabetic patients and refer them to a DPP. Patients identified with prediabetes and notified of the DPP were willing to be referred. Limitations of implementation were identified and if altered could improve the volume of patients referred to a DPP. Sustaining the prediabetes identification and referral process at this clinic could help to detect additional patients with prediabetes and help to prevent or prolong a diabetes diagnosis.