Problem & Purpose: Early palliative care detection and consultation is correlated with increased cohesion between a patient’s wishes and their medical treatment as well as decreased length of stay, moral distress, and burnout in healthcare staff. Despite these benefits, the palliative care discipline is chronically underutilized in critical care settings such as the Cardiac Care Unit (CCU) of a large urban medical center. The purpose of this quality improvement (QI) project is to increase early detection and consultation for adult cardiac patients with palliative care needs using a nurse driven palliative needs screening tool (PNST). Methods: This QI project took place over a 15-week period. Throughout the implementation phase, patients admitted to the CCU were screened by the bedside nurse for palliative care needs using a validated screening tool (PNST). Patients with a positive screen would be addressed during daily interdisciplinary rounds. Completed screening tools were reviewed weekly to determine completion, and accuracy. Results: 133 patients were admitted to the Cardiac Care Unit over the fifteen weeks of QI implementation. Compliance with the PNST system ranged from 35-100% per week with an overall average of 64%. Percentage of positive PNST screenings ranged from 16-71% per week with an overall average of 52%. When compared to pre-implementation, global palliative consult rates increased from 30% to 33%. Conclusion: Analysis of results shows that screening for palliative care needs, and life-limiting illness was able to increase palliative consultation despite seasonal variations in cardiopulmonary exacerbations causing increased patient acuity and its effect on staffing resources as well as contextual elements such as unclear patient identification and provider preferences.

Problem & Purpose: Postoperative sore throat is a recurrent complication following laryngeal mask airway use and leads to patient dissatisfaction, the need for additional pain medication, and increased length of stay. Up to 25% of surgical patients at a trauma level II hospital complain of postoperative sore throat after procedures requiring the use of a laryngeal mask airway device. Purpose: The purpose of the quality improvement project was to implement and monitor compliance of providers’ use of manometers intraoperatively. The practice change was implemented at this facility to help decrease the incidence of postoperative sore throat in adult surgical patients. Methods: After educating the anesthesia care team and post-anesthesia care unit registered nurses on postoperative sore throat, all eight operating rooms were equipped with the Posey cuff pressure manometers. Anesthesia providers measured cuff pressures intraoperatively to maintain the recommended pressure of less than 60 mmHg. Cuff pressures were then documented. The presence of postoperative sore throat was evaluated and documented by the post-anesthesia care unit registered nurses. Data was analyzed weekly via run charts over 14 weeks. Results: A total of 26 data points were collected. Weeks one through six lacks compliance data points then an upward trend in compliance occurred with a later decrease in compliance, averaging at 41.5% by week 14. Approximately, 92% percent of patients reported an absence of postoperative sore throat. Conclusions: The feasibility of this QI project is proven through successful implementation of LMA cuff pressures at less than 60 mmHg to decrease the incidence of POST. Promotion of practice change by change champions will aid in sustainability. There will be a slight change in work-flow of anesthesia providers with intraoperative use of LMA cuff pressure manometers.

Problem: Diabetes Mellitus (DM) is a complex, chronic condition that if poorly controlled can result in substantial damage to the cardiovascular, visual, renal, and nervous systems. A community clinic in the Western United States saw a rise in uncontrolled DM patients, hemoglobin A1c greater than 9, from 37.0% to 46.1% from January 2020 to March 2021. Knowledge as well as application of daily self-care activities are essential to optimal glycemic control and overall health outcomes. Purpose: The purpose of this quality improvement (QI) initiative was to implement a structured diabetes self-management education (DSME) program including a combination of diabetes group classes, in addition to individualized provider visits to improve glycemic control, disease knowledge, and self-care activities in adults with uncontrolled Type 2 DM (T2DM). Methods: Candidates for the DSME program were identified through direct referrals and chart review for evidence of uncontrolled DM. Those who qualified and agreed to participate in the initiative provided verbal informed consent. Clinic staff were trained on the referral process and education materials were developed from the Association of Diabetes Care and Education Specialists (ADCES) 7 Self-Care Behaviors Framework. The number of new referrals was monitored weekly through chart review. Pre and post implementation chart review was instituted to detect changes in glycemic control, diabetes knowledge, self-care activities, blood pressure, cholesterol, and body mass index (BMI). Results: Results revealed a steady increase in the number of referrals for patients with uncontrolled DM to receive DSME from 0% to 70% respectively with an average of 15.78% of weekly DM referrals over time. Pre-mean A1c was 9.18% and post-mean A1c was 9.05%, for a decrease of 0.13%. There were minimal changes noted to the other clinical measures. Conclusions: A structured DSME program and referral process can be beneficial for glycemic control and DM management.

Problem and Purpose: Preoperative anxiety (PA) in adult surgical patients was about 60 – 80% and adversely influenced surgical outcomes. PA assessment and management guidelines exist but are not being used by nurses at this hospital to routinely monitor and manage PA in patients before their surgery despite evidence-based recommendations. This Quality Improvement project aimed to implement evidence-based PA assessment and management guidelines. Methods: The Amsterdam Preoperative Anxiety and Information Scale (APAIS), a well validated and reliable tool, was used by trained nurses to assess PA in all adult surgical patients scheduled for elective surgical procedures before implementing evidence-based interventions and making appropriate referrals. This was done within a week prior to the surgery date during routine Pre-Anesthesia Testing follow-up call with patients by nurses. Interventions provided for patients with positive anxiety screening included providing educational materials or answers to frequently asked questions about surgery or anesthesia, procedure-specific information and links, surgery suite virtual tour video, and listening to music on the day of surgery. Referrals were made to the surgery or anesthesia team. Results: Compliance with the use of the APAIS tool to assess PA was 73% (276/380), and 100% (161/161) of patients with positive anxiety screening received at least one of the interventions provided before or on the day of surgery. The overall prevalence of PA was 58%. 96.9% of patients with positive anxiety found interventions received prior to the day of surgery very useful. All patients (100%) that required referrals were appropriately referred. Conclusion: Though the goal of 100% compliance was not met, implementation of PA assessment and management guidelines is feasible, and routine implementation helps ensure timely interventions to prevent adverse surgical outcomes. An adequate number and availability of staff nurses is key to implementing these guidelines.

Problem: Anticholinergic (ACH) burden results when there is concurrent use of multiple medications with anticholinergic properties. At an assisted living facility for older adults, at least 50% of the residents there have dementia and at least 25% have behavioral symptoms that often require pharmacological intervention with ACH psychotropic medication. Approximately 75% of those residents take at least one ACH medication daily. Purpose: The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of an anticholinergic burden quantifying tool for use by prescribers and medication administration staff. It was anticipated that the residents would benefit from assessment of medications with ACH effects through provider and staff use of the tool. Methods: Pre-implementation, retrospective chart audits were done to assess ACH use at baseline. Staff were trained on use of the Anticholinergic Burden (ACB) Scale to identify medications with anticholinergic properties. The residents’ medication administration record (MAR) was assessed weekly for new medication orders, then evaluated for anticholinergic scoring according to the ACB Scale. Providers viewed the residents’ ACH scoring sheets and determined whether current medications could be deprescribed or have gradual dosage reductions. Results: Project results revealed, out of a total of 27 residents, three residents had medication adjustments. Two of the three residents had dosage reductions of anticholinergic medication and two of those three had anticholinergic medications deprescribed. Conclusions: The findings suggest that use of a tool to identify and score medications with anticholinergic properties is necessary to increase awareness among providers and medication administration staff. This simple approach can serve as an ideal method for promoting safety for residents of assisted living facilities.

Problem: Dysglycemia during the perioperative setting contributes to unfavorable surgical outcomes of increased hypermetabolic state, inflammation, and increased risk for infection. Glucose management is at provider discretion in the preoperative setting at a small community hospital. Blood glucose level monitored within three hours of surgery in 78% of patients and when monitored in the postoperative unit, 10.8% are hyperglycemic. Purpose: The purpose of this Quality Improvement initiative was to implement and evaluate the effectiveness of a preoperative glucose monitoring guideline over 14 weeks, among inpatients with diabetes undergoing surgery to change practice and improve glycemia throughout the perioperative period. Methods: A project team was mobilized to plan an initiative to implement a glucose monitoring guideline. Stakeholder buy-in was achieved by sharing current practice data and best clinical practices. The practice change was integrated into routine preoperative care for all eligible patients with visual aids and change champions to monitor glucose and administer treatment. Data on adherence and glucose optimization rates (70 mg/dL to 200 mg/dL) were tracked, analyzed, and communicated on a weekly basis with the site. Weekly oversite was provided to mitigate barriers and promote facilitators of practice change. Results: Adherence to the protocol was 82.5%, 82% of inpatients with diabetes undergoing surgery had optimized blood glucose levels prior to entering the operating room, and 89% were optimized in the postoperative unit. Patterns in the data show that when the preoperative glucose monitoring guideline was adhered to, glucose levels were more likely to be optimized throughout the perioperative period. Conclusions: The use of a preoperative glucose monitoring guideline is effective in standardizing blood glucose monitoring in the preoperative unit which can contribute to the optimization of blood glucose levels throughout the perioperative period.

Problem: At one local community emergency department (ED) in the Mid-Atlantic area, pediatric patients presenting for an asthma complaint that do not require hospital admission received no tailored education upon discharge from their ED visit. Published evidence supports distributing asthma action plans (AAPs) from the ED setting to improve asthma control, increase understanding of asthma, and decrease ED utilization. Purpose: The purpose of this quality improvement (QI) initiative was to implement AAPs upon discharge from the ED for these patients over a 15-week period in the fall of 2022. Methods: The QI Project Lead (QIPL) mobilized an interdisciplinary team of stakeholders at the project site to plan evidence-based structure and workflow changes, including documentation of patient heights for tailored peak flow measurements, an integral component to AAPs. Patients were offered an AAP if they were discharged from the ED after being seen for an asthma related complaint and were between the ages of 2 and 17 without structural lung disease. Data was collected weekly on the number of patients who had a height documented during their visit, teaching of peak flow, and receipt of an AAP at discharge. Results: A total of 41 patients presented meeting inclusion criteria. 7% had peak flow documented, 15% had a documented height, and 7% had an AAP given upon discharge. 78% of patients meeting inclusion criteria tested positive for a viral infection during their ED visit. Data noted fallouts on AAP distribution for the many patients presenting with concurrent viral infections. Conclusions: Findings suggest that project adherence is contingent in part upon unit census and acuity, as well as an automated method to remind providers to distribute AAPs. Ongoing discussion is also warranted with pediatric providers to discuss goals of care specifically for patients with an asthma exacerbation triggered by respiratory infections.

Problem: The maintenance of normothermia during surgery is a critical component of patient care provided by the anesthesia provider. A root cause analysis revealed this Level II Trauma Center performed preoperative warming for hysterectomy patients, as part of an Enhanced Recovery After Surgery (ERAS) protocol. However, there were no established preoperative warming protocols for patients receiving colorectal surgery. Intraoperative hypothermia is associated with negative postoperative outcomes to include, increased risk of surgical site infection, increased intraoperative blood loss, increased narcotic requirement following surgery and prolonged hospitalization. If this problem was not addressed, patients could experience adverse postoperative outcomes leading to increased hospital costs and waste of resources. Purpose: To overcome the absence of standardization of preoperative warming for adult surgical patients at this facility, this project implemented a preoperative warming protocol for colorectal ERAS patients prior to surgery. Methods: The quality improvement project was implemented over a 15-week period in the fall of 2022. Change in practice occurred with the implementation of a preoperative warming protocol for colorectal surgical patients. The surgical team initiated the ERAS order set and the nurse initiated warming per protocol at least 30 minutes prior to surgery. The patient’s postoperative temperature in the post anesthesia care unit was also evaluated. Results: If the warming protocol was ordered by the colorectal surgery team 100% of patients received prewarming. Thirty-eight patients were eligible, but only 76% had an order present and received prewarming. All patients who received prewarming were normothermic postoperatively. Conclusion: Project findings cannot conclude if protocol implementation had an impact on patient outcomes at this facility. Patients who received prewarming were normothermic postoperatively. This is associated with improved postoperative outcomes and reduced hospital spending.

Problem & purpose: The aim of this quality improvement project was to implement and evaluate the effectiveness of the Loeb Minimum Criteria within a long-term care (LTC) unit with the goal of decreasing unnecessary testing for urinary tract infections (UTIs). In older adults, a UTI is the most common diagnosis for which antibiotics are prescribed. Prevalence of asymptomatic bacteriuria ranges from 25-50%, and many of these patients are treated with antibiotics that are not warranted. The absence of clinical education and use of evidence-based practices lead to an increase in the potential for unnecessary testing and treatment. Methods: Within a 30-bed LTC unit in Howard County, Maryland, UTI’s are one of the most treated infections, however, there was no antibiotic stewardship program in place. A staff of 15 nurses, and 1 nurse practitioner (NP) participated in education sessions regarding the Loeb Minimum Criteria and were given the algorithm to follow. A post-test was administered to nursing staff following the education session to assess effectiveness. Change in behavior of the nursing staff when communicating symptoms to the provider was assessed by a pre/post- implementation survey completed by the NP. Pre-test results informed ongoing educational efforts. Urinalysis, culture, and sensitivity (UA C&S) orders were monitored pre-implementation and monthly to assess for the effective use of the algorithm on ordering practices. Results: Compared to the year prior, there was an 81% decrease in UA C&S sent during the implementation phase. Following the education session 66% of nursing staff identified greater than 50% of points outlined in the Loeb Minimum Criteria. Provider post-test indicated a 10% increase in the accuracy of reporting symptoms by the nursing staff. Conclusion: This project shows promise that increased education and awareness of antibiotic stewardship programs have the potential to influence the frequency of testing LTC residents receive with the potential to reduce unnecessary prescribing of antibiotics. Internal challenges related to staffing acted as a primary barrier to participation. Critical components of successful implementation of QI projects within the long-term care setting include buy in from administration, and collaboration with clinical staff. NPs are knowledgeable about antibiotic stewardship practices but lack the time needed to implement programs.

Problem: Following the Pandemic, the healthcare system has seen an alarming increase in the rate of workplace violence (WPV), particularly towards registered nurses (RNs). A total of 50 Behavioral Emergency Response Team (BERT) calls, responding to violent and aggressive patients, took place on a 26-bed acute surgical trauma unit at a large, academic medical facility over the last year. Purpose: The purpose of the Quality Improvement (QI) project was to implement the routine use of the Brøset Violence Checklist (BVC) to reduce the incidence of workplace violence incidents on an acute trauma inpatient unit. Methods: Data was collected using the following instruments: the Brøset Violence Screening tool and the modified Staff Observation and Aggression Screening- Revised tool (mSOAS-R). Nurses screened their assigned patients once every shift using the BVC. Nurses were encouraged to implement safety measures for patients scoring ≥ 2 on the BVC tool. The mSOAS-R tool was completed by nurses when a behavioral event requiring security/BERT occurred. Results: 86% of nursing staff (n=38) were educated to use the BVC to assess patients at risk for violence and aggression. Data shows that nursing staff screened about 29.7% of eligible patients and were 79% compliant in documenting violent event using the mSOAS-R. Last year during the months of September through November there were a total of seventeen behavioral events. During implementation of the BVC, twelve total behavioral events occurred, demonstrating a 29.4% decrease in WPV events. Conclusion: Results demonstrate a decrease in the total number of aggressive events compared to the same months from one year prior. Implementation of a standardized risk assessment tool can be an essential component in managing patient aggression and violence.