Now showing items 21-40 of 1517

    • Implementation of Eat, Sleep, Console Approach to Care for Opioid Exposed Newborns

      da Graca, Malissa M.; Reid, Rachel (2021-05)
      Problem: Rates of neonatal abstinence syndrome (NAS) have seen a fivefold rise in Maryland. Current management strategies include the Finnegan Neonatal Abstinence Scoring System (FNASS) and opioid pharmacotherapy for symptom management placing tremendous burden on health care system due to increased length of stay, admission to special care nurseries, and disruptions to family bonding. Purpose: The purpose of this quality improvement project was to implement the “Eat, Sleep, Console” (ESC) method in the care of newborns with in-utero opioid exposure to reduce average length of stay (ALOS) for infants with NAS. Secondary outcomes were reduced doses and amount of morphine and increased breastfeeding initiation rates. Methods: A quality improvement (QI) methodology was used to implement ESC on an inpatient floor. Hospital NAS policy was revised to adopt ESC tool, as needed morphine for symptoms management, and emphasis on nonpharmacologic care. The ESC assessment tool was integrated into the electronic health care record (EHR). ESC scores, nonpharmacologic interventions, and parental presence were recorded in the EHR. Infants ≥ 32 weeks gestation with opioid exposure were included in the QI project. Data to be collected included average length of stay (ALOS), number and total morphine doses, and breastfeeding rates during admission. Preliminary Results: Evidence shows that organizations that have made the transition to ESC have seen reduction in opioid agonist therapy, reduced length of stay, and improvement in breastfeeding initiation rates for newborns with NAS. We aim to demonstrate that implementing the ESC will result in similar benefits to our institution. Updates to several structure and process measures are now in the implementation phase. Preliminary Conclusions: Changing the treatment model for newborns with NAS requires a multidisciplinary approach with providers across various specialties. Success of this Quality Improvement project required buy in from all units/care providers with education throughout the staff and families to support ESC.
    • Improving Detection of Deterioration Using the Children’s Hospital Early Warning Score Tool

      Petrella, Amanda K.; Connolly, Mary Ellen (2021-05)
      Problem & Purpose: The project site is a 41-bed-pediatric progressive care unit (PPCU) at an urban tertiary hospital that cares for patients with a variety of diagnoses such as congenital heart disease, respiratory illnesses, and surgical cases. Pediatric Early Warning Scores (PEWS) are used to identify at-risk patients for critical deterioration. A rapid response is a situation in which an emergency healthcare team is called to respond to a patient showing signs of medical deterioration. Lengthy intensive care unit (ICU) stays often occur after a rapid response or arrest. Currently, this unit performs PEWS with vital signs. The Children’s Hospital Early Warning Score (CHEWS) is a validated tool developed for earlier detection of deterioration in pediatric patients with complex medical problems. The purpose of this quality improvement project was to implement and evaluate the effectiveness of the CHEWS with a response algorithm on a 41-bed pediatric progressive unit to promote early recognition critical deterioration. Methods: The CHEWS was performed with vital signs using a response algorithm, which was adapted by a multidisciplinary team at the project site prior to implementation. Two components, presence of cardiac disease and patients status post abdominal surgery less than 12 months of age were scored for in addition to the tool. Bedside nurses and providers were educated using a PowerPoint video, survey, and in-person training. Ten champions received one-on-one training to reinforce education. Data was collected by manual chart auditing and evaluated using run charts. Results: Utilization of the CHEWS ranged from 29-69% with an average of 38.5% during the 14-week period. There was no change in average monthly PICU transfers or arrests. There was a decrease of average rapid response calls from pre-implementation from 8 to 5.25 monthly calls. When CHEWS was elevated, 79% of the scores had a corresponding lower PEWS score. Conclusions: These results indicate that higher compliance is necessary to assess effects of CHEWS on PICU transfers, rapid response calls, and arrests. The CHEWS scoring higher than the PEWS is consistent with the literature that demonstrated PEWS scores being lower than CHEWS scores when scored simultaneously.
    • 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.
    • Timed Reminders within the Electronic Health Record to Improve Pain Reassessment Documentation

      Noll, Rebecca L.; Bundy, Elaine Y. (2021-05)
      Problem & Purpose: Ineffective reassessment and documentation of a patient’s pain level can lead to physical and psychosocial impairments compromising the ability to participate in milieu activities among psychiatric inpatients. In a large community hospital’s inpatient psychiatric unit, pain reassessments were only completed 57% of the time. The purpose of this quality improvement project was to implement modifications to the pain assessment flowsheets in the electronic health record on an adult inpatient psychiatric unit to improve nurse adherence to reassessment and documentation of pain scores. Methods: Pain reassessment timed reminders were added into the electronic health record flowsheets and tracked over a 13-week period on an inpatient psychiatric unit in a large community hospital. An algorithm of the unit’s pain management policy was developed laying out step by step guidance for pain reassessment timelines and medication management. Twenty staff nurses from a unit with a 19-bed patient capacity participated in this quality improvement project. Nurses received education on how to add timed reminders into the electronic health record flowsheets prior to project implementation. Pre and post implementation surveys were administered to evaluate how often nurses reassess and document pain levels within the appropriate timeframe. Weekly run charts were used to analyze and track data on nursing staff compliance rates. Results: Data collected in the weekly audits reflected a 20% improvement in pain reassessment overall at the conclusion of the project timeline. A displayed pain assessment algorithm helped to boost reassessment documentation rates by 10% initially. The next week reassessment documentation decreased by 22% after posting names of individual nursing staff adherence rates. Documentation adherence rates increased within two weeks by 20% after posting a certificate of achievement displaying nursing staff achieving 100% weekly pain reassessment documentation. Conclusion: The use of timed reminders embedded into electronic health record flowsheets, a pain management algorithm, and recognition of staff with 100% documentation compliance contributed to improvement in pain reassessment documentation practices. Implications for practice included timely documentation of pain reassessments improving pain management among psychiatric inpatients.
    • Leveraging Technology Solutions to Automate Informed Consent in a Clinical Research Hospital

      Sawyerr, Claribel L.; Van de Castle, Barbara (2021-05)
      Problem: Paper informed consent (PIC) forms are associated with incomplete and or inaccurate information such as missing signatures and incorrect patient identification. The Food and Drug Administration’s Bioresearch Monitoring Program audit for the 2019 fiscal year lists failure to obtain informed consent (IC) requirements as one of the most common violations (2%) by clinical investigators in clinical trials. In a selected practice site, approximately 440 (2%) out of 25,000 PICs were returned by the medical records department to clinicians in 2019 due to incomplete and or inaccurate information. This resulted in significant delays in the start of clinical trials, incurring additional time and effort for participants and clinicians to correct and or re-consent. Purpose: The purpose of this quality improvement project was to implement electronic informed consent (EIC) for research participants in the adult oncology, infectious disease, and digestive diseases outpatient clinics in a clinical research hospital. Methods: Pre and post implementation surveys were administered to clinicians (n = 43) to obtain baseline perceptions, and compare preferences and satisfaction with using PIC versus EIC. The clinicians were trained on using EIC for signatures, then EIC was implemented and tracked for eight specific protocol studies. Results: The average confirmed IC available in the electronic health record (EHR) within one day of signing by clinicians for all three clinics increased from 52.5% (pre) to 61.3% (post). EIC use increased by 20%, and returned consents decreased from an average of 2.2% to 0.6%. Clinician preference to use EIC over PIC increased from 44.8% to 57.1%, Fisher’s Exact Test = 0.5256, 2-sided, p > .05. Conclusions: Replacing PIC with EIC was preferred by clinicians, improved documentation of consent, and decreased the time for consent availability in the EHR. The implications for practice are that automating informed consent is associated with improved consenting processes and supports remote workflows.
    • Reducing Falls with Tailored Intervention for Patient Safety on a Neuro Unit

      Lockard, Darlene; Gourley, Bridgitte (2021-05)
      Problem & Purpose: Falls on the neuro care unit at a suburban hospital in 2019 averaged 2.4 falls per month. This unit has the second highest fall rate at the medical center. Compared to the National Database of Nursing Quality Indicators for total falls in 2019, the neuro care unit was higher than the benchmark and averaged 2.98 falls per 1000 patient days with the benchmark at 2.95 falls per 1000 patient days. The purpose of this quality improvement project is to implement and evaluate the effectiveness of a Tailored Intervention for Patient Safety toolkit to reduce falls on an adult inpatient neuro care unit. The Tailored Intervention for Patient Safety is a 3 step fall prevention process that includes Universal Fall Precautions that apply to all patients admitted or transferred to the neuro care unit. Methods: Methods employed for assessing completeness and accuracy of data were done by spot checking audits twice weekly to make sure Tailored Intervention for Patient Safety poster at bedside and handout in admissions folders were properly filled out. This data was analyzed and graphed in a run chart to analyze for trends by looking for runs, shifts, and alternating points that suggest cause variation exists. The hospital provided monthly falls and falls with injury was and calculated using falls per 1000 patient days. This was plotted in a bar graph to compare pre-intervention and post-intervention to ensure completeness and accuracy of the data. Results: TIPS poster compliance was 90%, with 100% of staff trained. Falls decreased by 67% compared to pre/post-intervention data from 2019 to 2020. Falls with injury decreased by 14% compared to pre/post-intervention data from 2019 to 2020. TIPS handout compliance was 0%. Conclusions: TIPS adherence reduced falls and falls with injury. This reduces hospital cost and improves patient care.
    • Implementation of a Pediatric-Based Algorithm to Improve Care of Symptomatic Hypoglycemia

      Arjoon, Amanda V.; Fitzgerald, Jennifer (2021-05)
      Problem & Purpose: Hypoglycemia in childhood is a low frequency, high-risk event that can lead to coma, seizures, and even death. Symptomatic hypoglycemia occurs when plasma glucose levels are low enough to cause signs and symptoms of impaired neurological function, increasing risk of neurogenic sequalae. In the pediatric emergency department at an urban academic medical center in the Mid-Atlantic region, delays in treatment occur due to pediatric-specific barriers including time intensive, weight-based calculations for drug doses and availability of multiple dextrose concentrations. Although there is no national benchmark for comparison, the average time from identification of symptomatic hypoglycemia to treatment on this unit is 35 minutes. The purpose of this quality improvement project was to implement an algorithm for treatment of symptomatic hypoglycemia for pediatric patients between one and five years of age in the proposed setting. Methods: An algorithm was created based on recommendations from the Pediatric Endocrine Society, the American Academy of Pediatrics, and other accredited organizations. Thirty-two small educational sessions with 59 nurses and three physician assistants were conducted over two months to provide education on algorithm use. Anonymous pre- and post-surveys were administered during the educational sessions to assess for improvements in knowledge of evidence-based care for symptomatic pediatric hypoglycemia patients. The primary outcome was to reduce time from symptomatic hypoglycemia identification to enteral or parental treatment. Results: The sample size (N=4) was smaller than expected due to a significantly reduced census on this unit during the COVID-19 pandemic. Three males and one female met inclusion criteria, with a mean age of 2.75 years. The mean time to treatment was reduced to 6.5 minutes. The most observed symptom was nausea, which appeared in all four cases. Nearly 93% of staff demonstrated improved knowledge in caring for pediatric symptomatic hypoglycemic patients through improved survey scores after the educational sessions. Conclusion: Findings suggest that use of a standardized algorithm contributes to reducing the time from identification of symptomatic hypoglycemia to time of treatment. All patients meeting inclusion criteria received interventions consistent with the algorithm. Future directions include expanding implementation of an algorithm to incorporate pediatric patients of all ages.
    • Improving Influenza Vaccination Rates in Inpatient Pediatrics

      Hoffer, Amy; McComiskey, Carmel A. (2021-05)
      Problem: This quality improvement project was implemented on an inpatient pediatric unit at an urban academic medical center whose rate of influenza vaccination prior to discharge was only 39% of eligible patients. This gap in vaccination is not unique to this unit and morbidity and mortality of influenza is high despite widespread availability of a vaccine and the recommendation that all children over six months of age receive the vaccine. Purpose: The purpose of this project was to increase vaccination rates by providing education and rescreening prior to discharge. Methods. The electronic health record (EHR) was modified to populate a prompt to the nursing task list for every patient who initially refuse the flu vaccine. Bedside nurses then provided education to all patients and parents who refused. They documented this education and asked the parents if they would reconsider vaccinating prior to discharge. The outcome measures of this project included improving EHR nursing documentation of education and rescreening and increasing vaccination rates prior to discharge. Results: Of patients whose caregiver refused the flu vaccine on admission, 61% received the intervention and 27% of these caregivers reconsidered and decided to vaccinate. The vaccination rate of eligible patients prior to discharge for this unit increased from 39% to 60%. Conclusion: Optimizing the use of the EHR to automatically remind nurses to provide education and additional vaccination opportunity can increase vaccination rates. This unit’s improvement in vaccination rates and the number of caregivers who received the intervention and subsequently agreed to vaccinate demonstrates that this is a valuable tool if there is otherwise no process in place to prioritize vaccination. This intervention can be easily modified to be used in other patient populations and for other vaccinations.
    • Reducing Falls Utilizing a Fall Prevention Toolkit, Tailored Interventions for Patient Safety

      Morales, Flor M.; Gourley, Bridgitte (2021-05)
      Problem: Despite the use of numerous evidence-based interventions, in 2019, a medical surgical unit at a community hospital had a higher fall rate than its peers. The average fall and fall with injury rates were 2.6 and 1.17 per 1,000 patient days. Purpose: To implement and evaluate the effectiveness of the Tailored Interventions for Patient Safety (TIPS) fall prevention toolkit (FPTK) in an inpatient medical-surgical unit. Methods: The intervention is a three-step evidence-based tool which provided individualized universal fall precautions. Nurses completed a fall risk assessment on every admission and transfer to the floor. Then, they completed a falls poster at the bedside with the patient, educating them on their individualized fall risks and fall prevention interventions. The poster was hung at the door as a reminder tool for staff and patients. Data collected during the project included staff education, poster completion audits, and the organizations reported monthly fall rates. The data was analyzed using run charts and bar graphs. Reminders, morning huddles, and staff education were used to promote compliance. Results: Nurses and patient care technicians (100%) were all educated prior to intervention implementation. The average compliance rate of completed TIPS posters was 67%. The fall rate increased during the intervention phase by 18% compared to the pre-interventions phase. There were no changes in fall with injury rates post intervention when compared to pre-intervention. Despite an increase in falls during the implementation phase, there was a positive trend that showed that as compliance rates increased from October to December, fall rates decreased. Conclusions: The compliance rate was not met and fall rates were higher post-intervention. Additional reminders, weekly huddles, and meetings could be held to re-educate staff and allow for discussion of barriers and facilitators. October and November’s low rate of poster completion may correlate with the higher fall rates. In December, there were less falls and compliance rates were higher. Strategies and tactics should be utilized in order to increase intervention compliance, increase sustainability, and decrease fall and fall with injury rates in the future. Limitations included a COVID pandemic and forgetfulness in completing the poster.
    • Implementation and Evaluation of a Nonpharmacological Device to Improve Satisfaction During Immunization

      Kim, Tamara K.; Satyshur, Rosemarie D. (2021-05)
      Problem & Purpose: Immunization pain is the most common pain experienced by children when visiting their primary healthcare office. In a pediatric primary care office on Maryland’s Eastern Shore, there are inadequate pain relief options used during immunization. Untreated pain can lead to sensitization to future painful experiences leading to greater fear and anxiety, intense distress with future immunizations, needle phobia, and avoidance of healthcare as the individual ages. The purpose of the project was to implement and evaluate the use of the Buzzy device to improve satisfaction during immunization for children aged four to 18 years. The Buzzy device combines vibration and external cold analgesia to control pain at the injection site. Methods: All families with children aged four through 18 years receiving an immunization were educated on and offered use of the Buzzy device. The LPNs assessed the child’s pain score after all administrations and distributed a satisfaction survey to each family when Buzzy was utilized. Data were collected using an implementation log. Data were analyzed using run charts and were presented to the Clinical Site Representative and staff on a monthly basis to elicit feedback. Results: Results indicate that after receiving education on the Buzzy and project goals, 100% of the children and families were willing to try using the Buzzy device to minimize immunization pain and improve satisfaction. Overall satisfaction was scored at 86.3% and among satisfied families, the average pain rating was two out of 10. Conclusions: Data collected indicate that use of the Buzzy device is effective in improving satisfaction during immunization in children and should continue being offered for distraction during immunization. Buzzy sustainability will continue to be driven by family satisfaction with the device during immunization and the device remaining in the practice. Project results will be disseminated through poster presentations.
    • Implementation of the National Early Warning Score in a Military Hospital

      Garrett, Stacy L.; Seidl, Kristin L. (2021-05)
      Problem & Purpose: Unrecognized clinical deterioration leads to poor outcomes including unanticipated intensive care unit (ICU) admission, cardiac arrest and death. Statistics show 59.4% of patients have one abnormal vital sign one to four hours prior to cardiac arrest. The National Early Warning Score (NEWS) assists nurses to identify early clinical decompensation and intervene to prevent poor outcomes. Previous attempts to implement NEWS and a dedicated rapid response nurse (RRN) at a community sized military treatment facility were unsuccessful for improving early recognition of clinical deterioration. Prior to implementation less than 8.3% of patients at moderate risk for clinical decompensation were assessed by the RRN. The purpose of this quality improvement project was to improve early recognition of clinical deterioration by implementing a dual approach that targets both the RRN and ward nurses. Both approaches target patients at moderate to high risk of clinical decompensation to achieve early stabilization or transfer to a higher level of care. Methods: A standardized communication tool was created and utilized by the RRNs to track and trend patients with a NEWS of three to five and as a reminder to document their assessment in the electronic health record (EHR). Re-education and a workflow diagram for ward nurses was presented during a skills fair to increase assessment and vital sign frequency according to the existing NEWS protocol. Results: Over 13 weeks, 698 NEWS triggers were analyzed. Of these NEWS greater than or equal to five triggers, 76% (n= 57) were assessed by the RRN using the communication tool. Of the 76%, 84% (n=48), were physically assessed. Increased vital sign and assessment frequency by the ward nurses was highly variable throughout the implementation phase, 6.7-80% and 0- 27.2%, respectively. Conclusions: A standardized communication tool utilized by the RRNs increased RRN adherence to the NEWS protocol, achieving early identification and assessment of patients with a NEWS of three to five. NEWS greater than or equal to five identified patients at greater risk for deterioration and were associated with increased ward nurse adherence to the NEWS protocol. Improved early identification of deterioration may decrease unanticipated intensive care unit (ICU) admissions.
    • Implementing a Mobility Scale to Increase Postoperative Mobility Levels

      Marasa, Mary C.; Bundy, Elaine Y. (2021-05)
      Problem: Gynecologic oncology treatment plans often involve invasive surgeries that put patients at risk for complications and long hospital admissions. Enhanced Recovery After Surgery protocols improves outcomes for gynecologic oncology patients, especially when patients are compliant with getting out of bed on postoperative day zero. At an urban Mid-Atlantic hospital, 3% of gynecologic oncology patients got out of bed on postoperative day zero and the average length of stay was 2 days between February 2018 and January 2020. Delaying postoperative mobility increases the risk for longer hospital stays. Purpose: The purpose of this quality improvement project is to implement the Johns Hopkins Highest Level of Mobility (JH-HLM) scale with defined goals to increase postoperative mobility levels and decrease the length of hospital stay for postoperative gynecologic oncology patients. Methods: Quantifiable mobility goals were defined for postoperative patients based on the JH-HLM scale. The nursing staff was educated about the mobility goals and JH-HLM scale through unit presentations, email communication, and annual competencies. Mobility documentation was standardized in the electronic health record. Education materials were disseminated to the inpatient oncology unit, post-anesthesia care unit, rehabilitation department, and patients. Patient age, diagnosis, type of surgery, mobility levels, and length of stay were collected through chart reviews for 3 weeks before implementation and during the 12-week implementation period. Run charts were used to analyze the data. Results: Results showed that average mobility documentation increased (10% to 46%). There was an increase in mobility levels on postoperative day zero (6% to 33%) and by discharge (13% to 45%). The average length of stay during the 3-week pre-implementation period was 1.6 days and after implementation it was 1.8 days. These results were not statistically significant. Conclusion: Findings suggest that quantifying and standardizing mobility goals may increase postoperative mobility levels. However, more investigation is needed to demonstrate statistical significance. Length of stay was not decreased and was likely impacted by a variety of factors. Further investigation of improving mobility documentation, decreasing data variability, and increasing compliance is warranted.
    • Implementation of the National Early Warning Score for Sepsis Screening

      McDearmon, Tierra L.; Nawrocki, Lauren (2021-05)
      Problem & Purpose: Sepsis is a complex syndrome that bears high morbidity and mortality. Sepsis that remains undiagnosed before admission is associated with increased costs and mortality rates. An audit of emergency department (ED) practices within a 244-bed military tertiary medical center found that a systemic inflammatory response syndrome-based tool was being utilized to identify patients with possible sepsis. Studies demonstrate this tool has poor prognostic accuracy and utility in triage, therefore making it an inferior method of sepsis screening. This quality improvement initiative implemented a National Early Warning Score (NEWS)-based sepsis screening tool for adults presenting to the ED to improve sepsis identification and delivery of sepsis core measures. Methods: Adult ED patients were screened for sepsis during triage utilizing a nurse-driven electronic tool. Positive screenings triggered initiation of a sepsis bundle. Manual chart abstraction was used to calculate screening rates and sepsis core measures of time-to-lactate and time-to-antibiotics in minutes. Data were analyzed using descriptive and independent samples ttest statistics to determine the association between screening and sepsis core measures. Results: Overall, the compliance rate for sepsis screening was 81% (n = 912). A comparison of baseline (n =12) to post-implementation data (n = 25) displayed a significant decrease in the delivery time of sepsis core measures. Time-to-lactate significantly decreased (M = 85.76, SD = 29.15) compared to baseline (M = 184.17, SD = 120.99); t(12) = 2.78, p = 0.02. Time-toantibiotics also significantly decreased (M = 110.21, SD = 46.04) compared to baseline (M = 231.73, SD = 145.57); t(11) = 2.71, p = 0.02. Conclusions: Use of a NEWS-based sepsis screening tool during triage facilitates the identification of patients at-risk for sepsis and improves the delivery time of sepsis core measures. Sepsis screening tools should utilize readily accessible data and be integrated into the electronic health record to ensure compliance and sustainability.
    • Implementation of Post Event Debriefing in the Neuroscience Intensive Care Unit

      Dranov, Volha; McComiskey, Carmel A. (2021-05)
      Problem: The Neuroscience Intensive Care Unit (Neuro ICU) team frequently performs emergent resuscitation procedures. Debriefing is a form of learning in which everyone involved reflects on performance and plans on improvement. The Neuro ICU does not have a standardized procedure to debrief after patient resuscitation events. Purpose: The purpose of this quality improvement (QI) project was to implement a structured debriefing program utilizing a debriefing tool for Neuro ICU team members after all medical resuscitation events, including emergency intubations, cardiac arrests, acute changes in patient neurologic status, and any other significant patient events. Methods: The QI project was implemented in the Neuro ICU at an urban academic medical center. The project was implemented over a 14-week period. During the first 2 weeks, education about the process of debriefing and the debriefing tool occurred. Over the next 12 weeks the team implemented the project, which included tracking utilization of the tool after each event. The data were analyzed with descriptive statistics, such as percentage of debriefings competed each week. Results: The Neuro ICU team completed 28 debriefings utilizing the debriefing tool. There was an 80% increase in debriefings, compared to 0% debriefings before the project. Conclusions: Implementation of the new debriefing process has helped the Neuro ICU team to to identify areas and strategies for improvement in patient care, promoted communication between team members, and enhanced their clinical knowledge. Utilization of the Critical Event Debriefing tool created a structure to the debriefing process. To promote sustainability of the project, continuous engagement and support from the project champions, as well as promotion and expansion of the project to other units of the hospital are considered as future strategies.
    • Implementation of a Standardized Gastrostomy Tube Discharge Bundle for Neonates

      Keffer, Lauren E.; McComiskey, Carmel A. (2021-05)
      Problem: Surgical placement of a gastrostomy tube (g-tube) is indicated in pediatric patients who are unable to obtain nutrition by mouth. While a g-tube is an accepted method of long-term enteral nutrition support, post-operative complications occur. A 52-bed level IV NICU cared for 79 infants requiring surgical g-tube placement. Over the same year, 35% of those patients (n=28) visited the Emergency Department (ED) for g-tube complications (dislodgment, irritation dermatitis and leaking), and 15% (n=12) scheduled unplanned outpatient clinic appointments. There is currently a lack of standardized g-tube education accompanied by a nursing knowledge deficit for appropriate caregiver education. Purpose: The purpose of this quality improvement project is to implement and evaluate the effectiveness of a standardized g-tube discharge bundle and electronic health record education title in the Neonatal ICU to prevent unnecessary ED and/or outpatient clinic appointments for g-tube complications. Methods: Staff nurses were trained and knowledge, skills and attitudes were assessed at the conclusion of each educational session. The G-tube Discharge Bundle resided at the bedside of all g-tube patients and the accompanying educational checklist was completed in its entirety by bedside nurses prior to discharge or transfer. Caregiver knowledge was assessed with return demonstration and/or verbalization of understanding. Results: The project revealed that no participant presented in the ED with a g-tube complication within the first two months post-discharge and no scheduled or unplanned outpatient clinic appointments. Conclusions: Caregiver preparation for patients with gastrostomy supports successful discharge and transition to home. The standardized evidencebased g-tube discharge bundle addresses the importance of family-centered care while improving satisfaction among caregivers and health care providers.
    • A Restraint Alternative Program on the Neurotrauma Intermediate Care Unit

      Trinh, Tammie E.; Seidl, Kristin L. (2021-05)
      Problem & Purpose: Restraint use has been associated with risks to patient safety, including physical injury, cognitive and functional impairment, agitation and delirium, increased psychological distress for patients and family, and even death. The Joint Commission, Centers for Medicare and Medicaid Services, and the American Nurses Association all support the reduction of restraint use in order to improve patient safety. On a Neurotrauma Intermediate Care (IMC) unit at an urban, academic medical center, the prevalence of restraint use is consistently higher than the National Database of Nursing Quality Indicators mean. The purpose of this quality improvement project is to implement an evidence-based restraint alternative program consisting of a Restraint Decision Wheel, improved restraint alternative supply, and charge nurse restraint rounding in order to reduce restraint prevalence on the Neurotrauma IMC Unit. Methods: Improvements in restraint alternative supply, provision of the Restraint Decision Wheel, and charge nurse restraint rounds were implemented on the unit. Staff training was provided on restraint alternatives and use of the Restraint Decision Wheel. The project champion team met twice monthly to strategize improvements to project implementation. Data were collected to evaluate adherence to process changes through electronic health record audits, survey, and restraint rounding forms. Outcome and balancing measures tracked included restraint prevalence and unintentional device removal. Data were analyzed using run charts. Results: Restraint prevalence was variable throughout the early weeks of the project, but a non-random pattern was demonstrated by project completion with a shift of 6 consecutive points below the median. The median Restraint Decision Wheel Utilization was 43% and charge nurses rounded a median 21% of shifts per week. 10 unintentional device removal occurrences were reported during the project. Conclusions: Implementation of the restraint alternative program was associated with a significant decrease in restraint prevalence. Use of the Restraint Decision Wheel was incorporated into practice more frequently than charge nurse rounding. No significant safety events occurred from unintentional device removal. Overall, implementation of a restraint alternative program is a low-cost, safe, and effective intervention for reducing restraint prevalence.
    • Implementation of a Geriatric Rib Fracture Pathway in Trauma

      Lee, Janet S.; Wilson, Tracey L. (2021-05)
      PROBLEM: Geriatric trauma patients who have sustained rib fractures are at increased risk for pulmonary dysfunction, prolonged hospitalization, and death. The current literature supports a standardized care approach of evidence-based interventions in this patient population to help improve outcomes. Leadership of a large academic Level 1 Trauma Center, with the highest admission rate of adult traumas in the state, recognized poorer outcomes in geriatrics with rib fractures, and preliminary collated data showed a significant lack of established evidence-based practices on the Trauma Critical Care Unit. PURPOSE: The purpose of this quality improvement (QI) project was to implement and evaluate the use of an evidence-based rib fracture pathway in the geriatric trauma population to determine the compliance of pathway use by staff and possible effects on patient outcomes. METHODS: The project was implemented over a 14-week period from September to December 2020, after the completion of education and training of all staff on the Trauma Critical Care Unit. Eligible patients included patients aged 65 years and older with two or more rib fractures without high risk of respiratory complications due to admitting injury. Weekly chart audits were performed to assess compliance of the geriatric rib fracture pathway based on provider orders placed within 24 hours of admission and nursing documentation of pain assessments, deep breathe and cough, and incentive spirometry. RESULTS: Before the implementation of the project, 85% of nurses (n=49) and 100% of providers (n=12) completed the necessary education and training of the Geriatric Rib Fracture Pathway. After competency training, there was an increase in staff compliance with all components of the pathway including provider orders placed within 24 hours (p<.001) and documentation of the following nursing interventions – pain assessment (p=.068), deep breathe and cough (p<.001), and incentive spirometry (p=.006). CONCLUSIONS: This pilot QI project suggested an increase in staff compliance with the implementation of a rib fracture pathway for geriatric trauma patients after completion of staff education and training. The Geriatric Rib Fracture Pathway is a safe and useful tool in identifying this target population, as well as in early adoption of evidence-based interventions to improve patient outcomes.
    • Written Asthma Action Plan Implementation and Evaluation in Pediatric Primary Care

      Roberts, Courtney O.; Satyshur, Rosemarie D. (2021-05)
      Problem & Purpose: Asthma guidelines recommend the use of written asthma action plans (WAAPs) in the management of pediatric asthma patients, but this is not always practiced in the primary care setting (Global Initiative for Asthma [GINA], 2019; National Asthma Education and Prevention Program [NAEPP], 2007; Ring et al., 2015). Lack of proper asthma management can lead to an increase in asthma related unscheduled sick visits. The purpose of this quality improvement project is to implement and evaluate a WAAP for pediatric asthma patients in a pediatric primary care clinic in the Eastern Shore Maryland area. Methods: Implementation of a WAAP involved one pediatrician, two pediatric nurse practitioners, and the pediatric patients between the ages of 1 to18 years old being seen for asthma management. The project took place at a pediatric primary care clinic on the Eastern Shore Maryland beginning August 31, 2020 and concluding on December 11, 2020. Early on, staff were educated on the WAAP via email that included a recorded PowerPoint presentation as well as a post-test, instructional asthma videos, a WAAP template, and the Asthma Quick Reference Guidelines pdf. After implementation began, weekly chart audits assessed WAAP utilization. Data collected were organized using Excel sheets. Run charts were created and updated weekly to trend the data. Flyers were created and disseminated in the in the office to encourage staff and patient engagement. Weekly WAAP update emails were sent out to staff to update them on the progress of the project. No personal patient or provider information was collected for this quality improvement project. Humans Research Protections Office (HRPO) approval was gained through the University of Maryland. Results: All eight staff members completed the staff education before September 15. The WAAP utilization goal was met, and 100% of asthma patients being seen were given a WAAP by week fifteen. Unscheduled sick visits decreased to 0% by week fifteen. Conclusion: This quality improvement project demonstrated that WAAP utilization by providers for pediatric asthma patients can decrease unscheduled sick visits.
    • Clinical Practice Guideline on Utilizing Low-dose Ketamine Infusions for Treatment Resistant Depression

      Hunt, John H.; Amos, Veronica Y. (2021-05)
      Problem & Purpose: Standardly prescribed medications have increasingly become less effective in mitigating depression. This finding has led practitioners to explore alternative ways to treat refractory depression. Ketamine, a dissociative anesthetic, given as a low-dose infusion has become an efficacious regiment for managing the treatment resistant populations symptomology. Clinicians at an outpatient infusion center observed an increase in infusion related hemodynamic abnormalities due to non-standardized infusion therapies. The development and implementation of an evidence-based clinical practice guideline to standardize the administration of low-dose ketamine infusions aims to help alleviate the identified institutional problem. Methods: An extensive literature review was conducted to evaluate the most current evidence regarding ideal ketamine infusion rates to manage treatment resistant depression. A draft clinical practice guideline was developed with assistance from the institution’s stakeholders. The Appraisal of Guidelines for Research and Evaluation II tool was utilized by the stakeholders to appraise the draft guidelines quality. The finalized guideline was presented to the anesthesia team members and critique via provider feedback questionnaire was elicited. Results: The appraisal tools overall domain rating was an 88.9%, which represented a high-quality practice guideline. Provider feedback questionnaire results showed the developed guideline was accepted by stakeholders and anesthesia staff. Implementation of the new practice guideline was recommended without any changes. Conclusion: The anesthesia team valued the developed guideline which led to its acceptance. However, sustainability will rely on the provider success rates based on the utilization of the guidelines recommended dose range as well as periodically collecting and assessing provider feedback questionnaire data to ascertain the level of continued staff buy-in.
    • Implementing a Volume-based Feeding Protocol in a Neurosciences Critical Care Unit

      Vallangca, Gimmie J.; Costa, Linda L. (2021-05)
      Problem & Purpose: Enteral nutrition is typically delivered through rate-based feeding (RBF) which predisposes patients to malnutrition by providing tube feeding (TF) at a fixed rate without compensating for feeding interruptions. Patients in a neurosciences critical care unit (NCCU) only meet their nutritional goals 63% of the time. Recent studies of volume-based feeding (VBF) have shown efficiency in meeting daily nutritional goals. To optimize TF delivery, this quality improvement (QI) project aims to integrate VBF into practice by involving nurse-driven TF-rate adjustments to compensate for feeding interruptions and to meet daily TF-volume goals. Methods: VBF was initiated within 48 hours for NCCU patients who meet the inclusion criteria. To facilitate compliance, the implementation team provided virtual in-services, online quiz competencies, and deployment of champions. Sustainability measures included policy adoption, creative posters, and regular quantitative feedback about the project's progress. The primary outcome was the percentage of TF-episodes with 80% of volume goal delivered. Each episode was measured as the number of TF days per patient in each week. Secondary outcomes were protocol compliance and feeding intolerance rates. Results: From a total of 104 patients (RBF=57, VBF=47), there were 194 episodes of tube feeding (RBF=97, VBF=97). The Mann-Whitney U test revealed VBF patients received a higher percentage of TF-days meeting the 80% volume goal than RBF (U=2672, p< 0.00001). The Mann-Whitney U test also showed no significant difference in feeding intolerance episodes between the two groups (U=46586, p=0.90). The average nursing compliance rate was 68%. The weekly compliance rate fluctuated and was threatened by staff turnover during the COVID-19 pandemic, but it improved through sustained staff engagement and frequent training. Conclusions: Implementation of VBF delivered more TF volume than the previous feeding modality with RBF. The QI project posed some sustainability challenges due to the competing unit priorities and staff turnover during the pandemic. However, implementing a policy, deploying champions, providing feedback, and employing frequent training may explain sustained nursing compliance rates. Additional studies may be needed to further optimize nutrition delivery, such as integrating VBF workflow processes in the electronic health record and minimizing preventable feeding interruptions.