Problem: The United States Preventive Services Task Force (USPSTF) recommends annual lung cancer screening with low dose computed tomography (LDCT) for eligible patients. A detailed smoking history informs clinical decision making regarding the recommendation to pursue LDCT. In March 2023, a random chart audit in a rural primary care center revealed a detailed smoking history was missing on 82% of all patients and an evidence-based decision regarding LDCT was missing for 100% of patients. Purpose: This quality improvement (QI) project aims to optimize smoking history documentation, increasing referral for LDCT in order to screen for lung cancer and refer for management. Methods: Prior to project implementation, an interdisciplinary team of stakeholders at the practice site including a physician and six office staff members was mobilized and educated on the proposed practice change including integration of a smoking history data collection tool (SHDCT), establishment of a referral process for appropriate patients, and creation of a follow up procedure for specialist referral. Office staff provides each patient with the SHDCT to complete privately in the waiting room; an estimated 500 patients will complete the SHDCT during the 15-week implementation. The provider then reviews the SHDCT with the patient, determines screening eligibility, and orders LDCT if indicated. Following the encounter, office staff scans SHDCT into the electronic health record and schedules LDCT for suitable patients. After LDCT is obtained, provider reviews the results and refers screening-positive patients to a specialist. Results: Of the 438 patients seen during implementation, 87.7% of patients now have completed SHDCTs documented in the EHR. Of the 54 patients qualified for LDCT, 72.2% have LDCT ordered. Of the ordered LDCTs, 45% are complete by the end of the 15-week implementation. No patients required specialist referral based on LDCT findings. Conclusions: Results reveal the intervention has promoted best Problem: The United States Preventive Services Task Force (USPSTF) recommends annual lung cancer screening with low dose computed tomography (LDCT) for eligible patients. A detailed smoking history informs clinical decision making regarding the recommendation to pursue LDCT. In March 2023, a random chart audit in a rural primary care center revealed a detailed smoking history was missing on 82% of all patients and an evidence-based decision regarding LDCT was missing for 100% of patients. Purpose: This quality improvement (QI) project aims to optimize smoking history documentation, increasing referral for LDCT in order to screen for lung cancer and refer for management. Methods: Prior to project implementation, an interdisciplinary team of stakeholders at the practice site including a physician and six office staff members was mobilized and educated on the proposed practice change including integration of a smoking history data collection tool (SHDCT), establishment of a referral process for appropriate patients, and creation of a follow up procedure for specialist referral. Office staff provides each patient with the SHDCT to complete privately in the waiting room; an estimated 500 patients will complete the SHDCT during the 15-week implementation. The provider then reviews the SHDCT with the patient, determines screening eligibility, and orders LDCT if indicated. Following the encounter, office staff scans SHDCT into the electronic health record and schedules LDCT for suitable patients. After LDCT is obtained, provider reviews the results and refers screening-positive patients to a specialist. Results: Of the 438 patients seen during implementation, 87.7% of patients now have completed SHDCTs documented in the EHR. Of the 54 patients qualified for LDCT, 72.2% have LDCT ordered. Of the ordered LDCTs, 45% are complete by the end of the 15-week implementation. No patients required specialist referral based on LDCT findings. Conclusions: Results reveal the intervention has promoted best

Problem & Purpose: Spinal-induced hypotension is a common side effect of spinal anesthesia that compromises uterine blood flow and fetal circulation, subsequently leading to fetal hypoxia, bradycardia, and acidosis. The general practice in the labor and delivery operating room at a community hospital in Maryland was to administer ondansetron after spinal anesthesia. This has contributed to a 20% incidence of spinal induced hypotension in the obstetric population. The purpose of this quality improvement project was to implement and evaluate the compliance of the use of four milligrams of intravenous ondansetron five minutes prior to spinal anesthesia to reduce the incidence of spinal-induced hypotension. Methods: Key stakeholders and change champions were mobilized to aid in the successful implementation of this project. Two educational sessions were held in person for 24 anesthesia providers including six anesthesia technicians on the current evidence of spinal-induced hypotension, project goals, and workflow changes. Eligible participants included parturients undergoing elective cesarean sections with no contraindications to spinal anesthesia or ondansetron. The anesthesia providers administered and documented four milligrams of ondansetron five minutes prior to spinal anesthesia and documented if parturients experienced spinal-induced hypotension. Data was collected weekly via chart audits to assess project goals. Results: Over 15 weeks, 38 cesarean sections were performed. A total of 32 parturients received four milligrams of ondansetron prior to spinal anesthesia, achieving an overall compliance rate of 84.2%. Of these 32 parturients, 54.3% did not experience spinal-induced hypotension. Conclusion: Findings suggest that implementation of a spinal-induced hypotension evidence-based protocol was feasible at the project site. It was a cost-effective intervention that reduced the incidence of spinal-induced hypotension and improved patient outcomes with minimal workflow changes.

Problem: Nurse anesthetists in the Endoscopy unit of a large quaternary academic medical center are exposed to radiation throughout their workday, but noncompliance with wearing their radiation dosAimetry badge has been as high as 89.5% - 98.7% of nurse anesthesia staff. Chronic fluoroscopy radiation exposure disproportionately increases the risk of cataracts, unilateral brain cancers, and chromosomal damage of healthcare workers. Dosimetry badge compliance is necessary for fluoroscopy radiation exposure to be properly measured and maintain a safe working environment for nurse anesthetists. Purpose: The purpose of this quality improvement project is to increase nurse anesthesia radiation dosimetry badge compliance with the use of a radiation safety timeout over a 15-week period in the Endoscopy unit. Methods: A project team consisting of a project leader, nurse anesthesia champion, and Endoscopy nurse champion instituted a radiation safety timeout practice change in the Endoscopy unit. Project strategies included electronic and unit-based education to 25 nurse anesthetists and 15 nurses (emails and in-services), collaboration (weekly site visits and project champions), and evaluation (data collection and analysis). Nurse anesthetists completed an anonymous QR code survey tool, evaluating the frequency of fluoroscopy cases in which the radiation safety timeout was performed, and dosimetry badges were correctly worn. Results: Fifteen weeks of data collection showed an average reported compliance of 83.8% with proper display of dosimetry badges and 73% with the radiation safety timeout. Survey response rate was 33.9%. Run charts show a nonrandom increase in dosimetry badge compliance, but the trend showing increased radiation timeout compliance may be due to reminders from nurse anesthesia staff, and not the intervention itself. Re-education through email and an in-person in-service led to increased compliance reporting during week 3. A change in leadership contributed to absence of data in weeks thirteen through fifteen. Conclusion: Dosimetry badge compliance did not reach 100%, but non-significant improvement exists since implementation of the radiation safety timeout and education. Knowledge gaps and opportunities for re-education to increase nurse anesthesia buyin and compliance will be assessed and ongoing.

Problem: Cervical cancer (CC) is one of the most common cancers affecting women. Incidence of CC is significantly reduced through regular and timely cervical cancer screening (CCS). In the US, rates of overdue CCS increased from 14% in 2005 to 26.1% in 2021. A nurse practitioner (NP)-owned primary care clinic in the Mid-Atlantic experienced inadequate tracking and timely uptake of CCS. Baseline data showed 17.6% of 21–29-year-olds and 22.1% of 30–65-year-olds were overdue for CCS with only 12.7% having a documented CCS in the electronic health record (EHR). This sub-optimal tracking and detection increases opportunities for patients to miss CCS. Purpose: The purpose of this quality improvement initiative was to increase CCS uptake among clinic patients through text message invitations to schedule an appointment or obtain a referral. Methods: A new policy standardizing identification, contact, and tracking of soon-due and overdue CCS patients was created. The new workflow sent two text message reminders to patients 21-65 years old who were soon-due or overdue for CCS. Participants were determined by EHR report to include age, sex, history of hysterectomy, and date of last pap smear. Results: 46 patients participated in the project. Of the text messages sent, 32.6% (n=15) responded. 33.3% (n=5) of respondents scheduled their CCS and of those, 60% (n=3) completed it during implementation. 33.3% (n=5) reported an up-to-date CCS. Post-intervention rates of overdue CCS were 13.7% for 21–29-year-olds and 14.5% for 30–65-year-olds, a 3% and 7% improvement. Overall, an 85.8% CCS compliance rate was seen post-intervention. Conclusions: Findings suggest the use of text messaging reminders is a low cost, low barrier way to increase uptake of CCS in this setting. Addressing barriers and organizational processes may help increase patient response to text messaging and increase timely uptake of CCS.

Problem: In a 15-bed cardiac medical intensive care unit, there has been decreased nurse presence and participation in multidisciplinary rounds. Purpose: The purpose of this quality improvement project was to implement a practice change that improves communication and provides a consistent rounding process while increasing nurse presence and participation in the cardiac intensive care unit during daily multidisciplinary rounds. Methods: Over 15 weeks during the Fall of 2023, the introduction of and utilization of the tool adapted from the Agency for Healthcare Research and Quality (AHRQ) daily goals checklist and served as a daily cue during rounds. The structure change was creating the evidence-based tool. At the start of rounds, nurses discussed overnight events and remained with the team to discuss the care plan for each system. Data was entered into an encrypted data collection system using a QR code embedded in the rounds sheet by the charge nurse. Weekly text reminders were sent to attending physicians to remind them of process changes. Daily huddle announcements were given to the nursing staff to remind them of the process change. Results: Results showed nurse attendance rates ranged from 10% to 100%, with an overall increased median rate of 70 % attendance during rounds. Complete utilization of the tool on all occupied beds ranged from 14% to 93.9%, with a median rate of 53.9%. Conclusions: Results indicate that nurse attendance during rounds has improved during implementation. Adherence to completing the rounding tool was challenged due to the changing rounding location and the location of the rounding tool on the unit. Adherence to process change was also challenged by varying high acuity days and mock surveys for accrediting bodies.

Problem: A community hospital post-anesthesia care unit (PACU), performing 70-100 outpatient surgeries per week, completed 40% of eligible telephone follow-ups (TFUs) secondary to inconsistent nursing workflow and lack of an evidence-based TFU script. Purpose: This quality improvement (QI) project implemented the evidence-based Re-Engineering Discharge Tool-5 (RED-5) and a formal delegation process in the PACU. Methods: Over a 16- week period in the Fall of 2023, the RED-5 script was made available to nursing staff on paper and electronically. Twenty staff nurses were trained with a 1:1 simulation. Weekly audits of delegation, calls attempted/completed, RED-5 adherence, appointment status, and escalations were completed. Project progress was shared with stakeholders through a unit tracking board, staff huddles, and monthly meetings. Run charts were used to demonstrate process adherence. Results: The new delegation process was documented 40% (n=29) of 72 eligible weekdays. In total, 1435 outpatients were discharged from the PACU. Thirty-four percent (n=494) of calls were attempted. Of the 23% (n=324) of calls completed, 71% (n=231) adhered fully or partially to the RED-5 script. Eighteen percent (n=59) required either one or both, clarification of discharge instructions (n=44) and surgeon referral (n=34). No patient was referred to the emergency department (ED). Of the 213 patients assessed, 30% of patients (n=63) had not scheduled follow-up appointments. Conclusions: Implementing the standardized RED-5 script improved postoperative identification of patient needs. Next steps involve collaborating with Information Technology (IT) and management to embed the RED-5 TFU script into the TFU application. During the project implementation period no change was noted in calls attempted or completed. Modifications to workflow processes are needed to support call completion.

Problem: Hospital falls are linked to multiple factors with delirium being one of them. For a teaching hospital, the safety concern data revealed that the total number of falls in 2022 was 459 and the targeted medical surgical unit alone made up 15% (69 falls) of the total fall. Purpose: This quality improvement (QI) initiative aimed to promote safety interventions and decrease fall rate using the 4AT (Arousal, Attention, Abbreviated Mental Test-4, Acute change) delirium screening tool on admission and each shift for patients 65 years and older. The synthesis of literature highly suggests screening elderly patients with the 4AT tool to identify delirious or at risk for delirium and assists with preventive measures including fall. Method: The 4AT delirium screening tool was integrated inti the electronic health record to implement evidence-based structure and workflow changes. Complete 4AT questionnaires to generate automated numbers that determined patients at risk of developing delirium (i.e., score ≥ 3). A workshop, online modules, and PowerPoint were used for education, while the project leader (PL), educator, champions, and nurse manager reinforced education and compliance. Furthermore, implementation included a secure data collection plan and strategies to achieve the project goal. Nurses were required to complete the 4AT tool. Compliance was measured through a weekly audit process done by the PL, then feedback was exchanged regularly on outcomes and improvement needed for the project. Results: The use of 4AT tool resulted in early identification of delirious or at risk for delirium patients prompting the initiation of fall precautions. The compliance rate was 99% and 100% of the delirious patients had a fall precaution order placed. There was a decrease in fall rate (4.5 % compared to last year 15 %) since implementation of this initiative. Conclusions: This QI project highly supports the screening of all elderly patients to identify delirium early and initiating fall precautions for score ≥ 3 to decrease the fall rate in med-surg unit.

Problem: Fall rates can decrease when standardized fall interventions and screening tools are used for confused patients who are known fallers (also known as repeat fallers). On an adult medical-surgical unit in an urban medical center, 40% of patients who were confused fell and falls increased from 4.19% in 2021 to 7.19% in 2022. Purpose: The purpose of this Quality Improvement (QI) project is implementation of fall prevention interventions to decrease the number of falls by placing new signage on the doorway for prompt identification of their fall status while hospitalized. Project goals include to reduce the falls rate in patients with a repeat history of falls and 2) to improve door sign accuracy and monitoring. Methods: A team of interdisciplinary stakeholders met and the creation of a new sign identifying “known fallers,” was implemented. Assessment and monitoring of routine metrics were carried out over 15 weeks in fall 2023. Education of nursing staff included new signage and fall prevention protocols. Weekly unit audits assessed the number of falls and initiation of the fall prevention protocol for the new signs. Results: The falls rate at the beginning of September was 13.2% and steadily decreased until December with a rate of 3.3% from 1000 bed days. Results show N=317 total (n=15, 3.3% patients who fell); 15 patients fell (4 known fallers, 11 patients fell who were not confused or had a history of falls). Door sign identification of high Morse fall risk = 42% accuracy; “known fallers” identification= 51.7% accuracy. Conclusion: The QI project revealed that the highest rates of falls were from patients who were cognitively intact and miscalculated their abilities and limitations when out of bed. This QI project emphasized the importance of stringent and consistent screening protocols for all hospitalized patients regardless of mental capacity.

Problem: Adult inpatients are at greater risk for falls causing injury, increased length of stay and additional costs. On an adult inpatient medical/surgical/telemetry unit at a community-based hospital, patient fall rates have increased from 5.2 falls per 1,000 patient days to an average fall rate of 6.2 falls per 1,000 patient days. The increase in falls has prompted concern for improvement in the fall prevention process for nursing staff. Purpose: To reduce fall rates an evidence-based fall communication algorithm was developed and implemented on the unit. The algorithm presented nurses with identified fall prevention items such as distraction techniques, communication guidance, and increased monitoring with tele-sitters. Methods: The algorithm was posted on the unit in the nursing stations, medication rooms, and portable computers for easy availability to nursing staff. Nursing staff voluntarily completed a survey using a QR code when they used the prompt on a specific patient. The survey asked if the prompt was effective in identifying a fall risk patient, fall prevention items, care planning for falls, or the need for tele sitter. The algorithm was used on an estimated 3% of patients. Results: There were no falls on patients with use of the algorithm. Survey results showed that 51.8% (n=44) of nursing staff reported the prompt helped identify fall risk patients, and 51.8% (n=44) reported that the prompt helped identify fall prevention tools. The overall fall rate increased to 7.6 falls per 1,000 patient days. Conclusions: The algorithm was not effective in reducing fall rates. Although no patients fell when identified as a fall risk with use of the algorithm, additional identifiers and prevention measures are needed to prevent falls.

Introduction: Medical devices are crucial for patient care, but misuse can lead to emotional and physical harm. Medical device-related pressure injuries (MDRIs) are preventable injuries that create a cost burden for the organization by impacting service reimbursement and burdening patients by extending hospital stays and increasing infection risks. Burn patients, in particular, are at a high risk of injury due to changes in sensory function related to the degree of sustained burn injury. These preventable injuries remain recurrent on a twenty-bed mixed acuity burn unit. In 2022, there were three MDRIS, and in 2023, four MDRIs occurred. Purpose: of this project was to implement an evidence-based guideline created by a multidisciplinary team to increase nurse documentation and decrease MDRIs in burn patients. Method: Based on the patient's Braden Scale Score of low, moderate, or high-risk risk of injury, nurses documented a set of evidence-based interventions as noted per the guideline. A pre/posttest was given to staff to evaluate knowledge. The PARIHS framework was used to support this intervention. Strategies and tactics used for project success included identifying key stakeholders and project champions and holding monthly meetings with staff to give/receive feedback. Data Collection: The primary outcome measure was Zero MDRIs. The secondary outcome included an increase in documentation of the Braden Scale and JH-HLM score, daily weights, guideline interventions, and 4 eyes in 4 hours. The process measure included the number of charts with completed guideline documentation. Ten charts were audited a week by the project leader. Data was analyzed using run charts with reports of aggregate data to stakeholders for feedback, reinforcement, and results. Results: Concluded zero MDRIs occurred during implementation. Results also indicated a documentation increase of the Braden Scale by 21%, the JHHLM score by 46%, guideline interventions by 32%, daily weights by 5%, and 4 eyes in 4 hours by 3%. Results indicate that standardized guidelines can prevent MDRIs and improve patient outcomes. Conclusion: Data suggests that the guideline should be a standard of care for all patients. The standardized guideline can increase nurse documentation and prevent MDRIs. If any changes were made, all traveling, and float staff will receive education prior to working on the unit.