Doctor of Nursing Practice (DNP) Projects
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The Doctor of Nursing Practice (DNP) project embodies the highest level of knowledge in nursing practice. Influencing health care outcomes through leadership, policy, information technology, systems change, and patient-centered care, the DNP project focuses on translating science into clinical practice and the delivery of patient-centered and/or population-based care.
Recent Submissions
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Improving the Administration of Protein Supplements in the Medical Intensive Care UnitProblem: An academic medical center reported that only 37% of inpatients in the Medical Intensive Care Unit (MICU) receive the ordered amount of protein supplements as part of their enteral nutrition. This is not enough to meet the protein needs for these patients. An increase in a patient’s daily protein intake is associated with improved wound healing, reduced hospital length of stay, reduced infection complications, decreased mortality and improved long-term quality of life. The unit did not have a standardized protocol for protein supplement administration or documentation. Purpose: The purpose of this quality improvement (QI) project in the MICU is to increase the documentation of protein supplement administration through the implementation of a standardized process for protein supplement administration. Methods: As part of the project, a standardized schedule was created for protein supplement administration, which was provided to nursing staff. MICU nursing staff also received education regarding the importance of protein supplements and the importance of the required documentation following administration. Amount of protein supplement administration were collected via chart review, using the REDCap data collection tool. Results: 77 patients were included in the preimplementation audit and 318 patients were included in the post-implementation audit. When comparing the documented administration to the number of protein supplements that are ordered, the average administration rate for the MICU following the QI project implementation is 73.6%, which is higher than the pre-implementation rate of 37%. Conclusions: The findings of this QI project would suggest an increase in the rate of protein supplement administration and documentation through the use of a standardized schedule for administration and the education of bedside MICU nursing regarding the importance of protein supplements for adult critically ill patients.
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Improving Safe Sleep Practice in a Level IV Neonatal Intensive Care UnitProblem: Approximately 3500 infants die of sleep-related deaths in the United States annually, and data from the American Academy of Pediatrics (AAP) suggest that most hospitalized infants who are less than 12 months of age are not consistently placed in a safe sleep environment prior to discharge (Goodstein et al., 2021). A three-month audit of safe sleep practice (SSP) in a level IV urban Neonatal Intensive Care Unit (NICU) showed that 17.5% of infants were eligible for SSP, but only 25% of the 17.5% eligible infants were fully compliant with SSP. Purpose: The purpose of this quality improvement (QI) project was to improve the consistent application of SSP in a 24-bed level IV medical NICU using the unit's SSP bundle. The bundle consisted of the unit's AAP-based SSP algorithm, the discussion of SSP eligibility in daily rounds, and the placement of safe sleep crib cards in the cribs of eligible infants. The crib cards included the SSP algorithm as well as an eligibility statement. Methods: The nursing staff was educated regarding SSP and received a pre and posttest survey after completion of the education. Weekly audits were conducted to identify infants eligible for SSP. In eligible infants, weekly crib audits were conducted to determine overall SSP compliance and compliance with the individual components of SSP. Results: Fifty-six nursing staff (48.7%) completed the offered education. Forty infants were eligible for SSP, and 25 of them (62.5%) were found to be fully compliant with all the components of SSP compared to pre-implementation SSP compliance of 25%. Supine positioning improved from 24% to 85%, and head of the bed (HOB) flat improved from 61% to 82.5%. Conclusions: SSP education for NICU nursing staff, the use of crib cards with an evidence-based SSP algorithm, and daily rounding to identify infants eligible for safe sleep can help promote consistent NICU safe sleep practices.
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Implementation of a Standardized Pre-procedure Handoff BundleProblem & Purpose: Within the Interventional Radiology (IR) department at a large, academic medical center, instances of patient harm and sentinel events have occurred due to improper patient, procedure, or site verification. Literature review reveals the use of a pre-procedure safety checklist may contribute to the prevention of wrong-patient, wrong-procedure, or wrong-site events, and supports the use of the Situation, Background, Assessment, Recommendation (SBAR) model for pre-procedure handoff to improve communication among staff. The aim of this quality improvement (QI) initiative was to implement a pre-procedure handoff bundle to prevent wrong-patient, wrong-procedure, or wrong-site events. Methods: The pre-procedure handoff bundle, including completion of the Procedure Pass checklist and the performance of bedside handoff using SBAR, was implemented over 15 weeks within the IR department. All inpatients and outpatients undergoing vascular or neurovascular intervention who were prepped for a procedure within the prep and recovery area were included for intervention. Weekly chart audits and review of morbidity and mortality reports were performed using the electronic health record to determine whether project outcomes were met. Results: 100% of eligible patients (952/952) were included in data collection, with no occurrences of wrong-patient, wrongprocedure, or wrong-site events. Average Procedure Pass compliance was 31% (295/952), while average pre-procedure handoff compliance was 20% (190/952). Conclusions: Findings suggest that the implementation of a pre-procedure handoff bundle within the IR department was successful at preventing wrong-patient, wrong-procedure, or wrong-site events. The inclusion of a pre-procedure handoff bundle was both feasible and necessary to improve patient safety and staff communication within the IR department. Keywords: handoff, communication, wrongprocedure, wrong-patient, wrong-site events.
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Decreasing Wait Time to Chemotherapy Administration in Outpatient Infusion ClinicProblem: Cancer treatment is often demanding and may last for months. Many patients receive treatment while working and living an active lifestyle, and there is a growing pressure on ambulatory clinics to deliver treatment timely and efficiently. An evidence audit in the outpatient infusion clinic of a large urban hospital identified the need to decrease waiting time to chemotherapy administration. Purpose: The purpose of this quality improvement initiative is to reduce adult cancer patients’ wait time to chemotherapy infusion by implementing a “call ahead” initiative to allow early preparation of chemotherapy in the outpatient infusion clinic. Methods: This project was conducted in a 35-chair outpatient infusion clinic of a large urban hospital. Patients who meet the following criteria were eligible for this program: adult patients with cancer diagnosis who were not requiring laboratories on the day of chemotherapy infusion appointment, cleared by their oncologists for chemotherapy infusion, and received selected chemotherapy agents. We introduced a new workflow where eligible patients were instructed to call the infusion clinic 30 to 60 minutes prior to their arrival to the clinic to confirm their appointment to allow for the pharmacy to begin making their chemotherapy agents earlier. Results: Preimplementation average wait time to chemotherapy administration was 58.04±2.68 minutes. After intervention, wait time to chemotherapy administration was decreased to 34.44±11.75 minutes (by 40.66%, p= 0.000185). Conclusions: Implementation of advanced preparation of chemotherapy using a “call ahead” initiative is an effective way to reduce wait time to chemotherapy administration in outpatient infusion clinic.
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Implementing Turn Rounds in the ICUProblem: Hospital acquired pressure injury rates in the Intensive Care Unit of a community hospital increased above a national average of 5%. Repositioning of vulnerable patients was a modifiable risk factor identified by key stakeholders. Purpose: The purpose of this initiative was to increase staff adherence to patient repositioning by removing barriers through the implementation of unit “turn-rounds” on dayshift. Methods: This project shifted patient repositioning to a simplified process where staff were encouraged to turn their patients at the top of even hours. Every even hour, a message was sent via the unit’s secure messaging system and care associates (CAs) circulated the unit to remind registered nurses to reposition their patients and assist them. Data collected included date and time of rounds, where rounds took place in the ICU, number of eligible patients, number of patients that were repositioned, and reasons if all eligible were not repositioned. Data was collected by CAs after each rounding period through an online survey on a secure data collection platform. Results: Data was collected for 14 weeks. The main structure goal of educating permanent CAs was met with 100% receiving one-to-one education. The process goal for this project was for CAs to circulate their assigned zone six times per shift. Weekly averages ranged from 0% to 54.7% with a mean of 21%. The outcome goal for this project was 100% of eligible patients repositioned during rounds. When rounds were completed, the weekly percentage of eligible patients repositioned ranged from 76.3% to 100% with a mean of 93.9%. No significant trends or shifts were identified in the data. Compliance with turn rounds was far below goal, but almost 100% of patients were repositioned when turn rounds were completed. Conclusions: High patient volumes and decreased staffing were the main barriers identified to conducting turn rounds.
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Enhancing Self-Management of Chemotherapy-Induced Nausea Vomiting with Patient-Reported Outcome MeasuresProblem & Purpose: Chemotherapy-induced nausea and vomiting (CINV) occurs in up to 70% of pediatric patients and is reported as one of the most distressing symptoms of cancer treatment. Within an outpatient pediatric oncology clinic, there was no formalized process to assess for symptoms of CINV. Patient reported outcome measures (PROMs) are self-reports of a patient’s health, quality of life, or functional status associated with their care. PROMs allow the healthcare team to monitor patient symptoms and provide remote support. This quality improvement project aimed to evaluate the use of electronic PROMs with nurse alerts for follow-up in the management of CINV. Methods: Within 24 hours of receiving chemotherapy, a PROM survey with the Pediatric Nausea Assessment Tool (PeNAT) was administered. PeNAT is a validated tool used to measure nausea in children ages 4-18. Patients or caregivers then voluntarily reported their level of CINV. Based on the level reported, nursing support and telephone follow-up was initiated. Nurses received PeNAT and PROM survey education, badge buddy cards, and workstation support cards. Monitored outcomes included new calls for CINV and the percentage of patients reporting “complete control” of symptoms. Over the 15-week implementation period, chart audits were conducted to determine if these interventions increased the number of patients reporting “complete control” with a clinic goal of 75%. Results: 403 patients were eligible to complete the PROM survey, and 97 children participated. Nurse initiated PeNAT administration at the patient’s clinic visit was 73% and patients’ and caregivers’ PROM response rate was 24.6%. These interventions resulted in 93.4% of patients reporting “complete control” of CINV symptoms. Together this allowed for a 62.5% reduction in the number of triage calls for complaints of CINV. Conclusions: The use of the PeNAT helped patients, caregivers, and staff better perceive and quantify CINV symptoms. The PROM survey aided in facilitating patient-provider communication and provided opportunities for at-home assessment of CINV symptoms with nursing support. Together these interventions helped patients and caregivers recognize that CINV is not a symptom to be “coped with” but one that can be prevented.
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Modified Triage to Rapidly Refer Patients from Emergency Department to Urgent CareProblem: An academic medical center Emergency Department (ED) has a problematic referral process to their Urgent Care (UC) creating disruptions in referrals, delays in patient care, and an overcrowded ED waiting room. Overcrowding and long wait times are correlated with increased mortality, nosocomial infections, and violence. In 2021, this ED’s average wait time was 61 minutes and the left without being seen rate was 18%, whereas the UC’s wait time was only four minutes. ED Nurse Practitioners (NPs), the sole decision makers for referral, only referred 12% of patients in 2021. Purpose: The purpose of this quality improvement project was to implement a NP quick triage to rapidly refer patients to the UC to decrease wait times, allow more access to care, and minimize crowding in the ED waiting room to provide proficient and safe care. Methods: Data was collected weekly over 15 weeks. The ER Measures Tool was developed and utilized to determine the percent of ED patients eligible for UC referred, time to UC provider, and length of stay (LOS). Changes were monitored through run charts. Results: Findings suggest the implementation of a NP quick triage can result in rapid, safe, and appropriate referral of patients to the UC. On average 31% of eligible patients were referred, which was higher than the pre-implementation rate of 30%. Findings also suggest NP quick triage did not affect time to provider and LOS. Factors that influenced referrals included patient complexity, availability and communication of the NP and triage nurse, experience of staff, and staffing issues. Conclusions: Findings suggest referral rates can be improved with a NP quick triage intervention, but LOS and referral rates are also influenced by complexity of patients, staffing numbers, communication, and experience of healthcare staff.
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Reducing Throughput Time in the Rapid Evaluation Unit: Meeting the State BenchmarkProblem: An Emergency Department (ED) in the Mid-Atlantic region has encountered challenges meeting the state benchmark for “treat and release” patients. Their throughput time averages 341 minutes, which is 41 percent above the benchmark of 241 minutes. Initial review of throughput time in the Rapid Evaluation Unit (REU) indicated interdepartmental time lost in workflow and processes. An effort to decrease “dwell” time is an organizational priority. Purpose: The practice change implemented was optimized technology supporting visual cue management and an indicator of Computerized Tomography (CT) scan readiness for the ED Radiology Department. The ED Radiology technicians documented a “reason for delay” if patients with CT indicator were not ready for the exam. A column on the tracking board indicated to the REU if the patient was not ready and the reason or that ED Radiology was ready for the patient. REU reports were modified to collect the date/time stamps in the Electronic Health Record (EHR) to measure the time intervals from “CT order” to “CT completed” along with “patient not ready for exam” and the indicator. Methods: All patients (> 18) undergoing CT in the REU were included in the 15-week quality improvement project. Structure goals were to provide an indicator to the tracking board when a patient is ready for CT and implement a form to discretely document delays and measure the order to completed intervals in the EHR. The outcome goal was to reduce the radiology “dwell” time by 25 percent. Results: Data showed variable use of the “Patient not Ready” form and outcome goals were not met. Process goals indicated that 77 percent of CT delays were due to lack of intravenous access, point of care human chorionic gonadotropin (POC-HCG) and laboratory results. Turnaround times for CT remained around the historical baseline of 135 minutes. Conclusions: The structural and process goals of the project were achieved. Conversely, analysis of the data collected did not suggest a consistent decrease in “dwell” time in the radiology process as it related to the visual cue management, optimization in the tracking board and the discrete documentation of reason for delay.
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Increasing Adolescent Suicide Risk Identification Using the Ask Suicide Questions (ASQ)Problem: Suicide is the second leading cause of death in children and adolescents aged 10-19 years old in the United States and the prevalence of depression among adolescents has doubled since the start of the COVID-19 pandemic. A small, privately-owned pediatric primary care clinic in Baltimore County, Maryland noted an increase in adolescent patients presenting for sick visits with a chief complaint of depression or suicidal ideation (SI) between 2018 and 2021. Purpose: The purpose of this quality improvement project was to increase the identification of SI in adolescents at one primary care clinic through standardized screening using the Ask Suicide Questions (ASQ). The main outcome goal was to increase early referral to mental health specialists. Methods: Over a 20-week implementation period, all patients aged 10 and older seen for any well child or non-febrile sick visit were screened using ASQ. On intake, a medical assistant administered the screen following a structured script. A “yes” response to any of the four items indicated a positive screen for suicide risk, and triggered further assessment from the provider using the Brief Suicide Safety Assessment (BSSA). If active risk for suicide was identified, the patient was immediately referred to the emergency department for safety evaluation. Otherwise, the provider created an individualized plan, which included referral to a therapist. Results: 85.3% of eligible patients received ASQ screening, with six non-acute positive results. 100% of these patients received a BSSA and a referral to a mental health specialist. There were no acute positive screens. Conclusions: These results suggest that universal ASQ screening for patients aged 10 and older has increased the identification of SI in adolescents at this primary care clinic, resulting in earlier referral to mental health specialists. Providers reported satisfaction with this the implementation of ASQ screening and believe it provided valuable data. ASQ screening remains a permanent practice change at this site. Efforts to sustain the practice change include training for newly hired staff members and use of change champions.
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Preventing Surgical Pathology Specimen LossProblem & Purpose: Though rare, surgical pathology specimen (SPS) loss is a ‘never event’ that can lead to significant adverse outcomes. From November 2020 to April 2022, operating rooms (OR) at an urban academic center experienced 1 lost SPS and 1 near miss. Electronic health record (EHR) data revealed issues with SPSs being collected but not documented as sent to the lab; collected but not resulted; and missing handoff documentation. The purpose of this quality improvement project was to implement SPS barcode scanning to improve chain of custody and tracking in the OR. Methods: The Translating Evidence into Practice Model facilitated the SPS scanning implementation. Staff were trained to scan the barcoded labels of all SPSs collected in the OR at different checkpoints. The physical location and chain of custody for the SPS was automatically recorded in the EHR. For SPSs transported directly to Pathology from the room, handoff documentation is manually recorded. Adverse event reporting system and EHR reports provided data on scanning compliance, handoff documentation, SPS lab accessioning, and lost SPSs. Results: Hardware installation, software updates, visual reminder posting, and report modifications were completed. At go live, 73% of staff were trained. Of the 1,508 SPSs collected, 100% were accessioned by lab, and none were lost. Over the 15 weeks of the project, scanning compliance for the OR Room checkpoint averaged 89% and for the Surg Path Refrigerator or Staff Picked Up checkpoints the mean was 94%. On average, 49% of SPSs scanned to the Staff Picked Up checkpoint contained handoff documentation. Conclusions: Scanning of SPSs can be used to track physical location, support accessioning by lab; and was associated with improved documentation of handoff in the EHR. Scanning of SPSs may help prevent SPS loss.
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A Perinatal Depression Safety Bundle to Enhance Outpatient Screening & ReferralProblem: The American College of Obstetricians and Gynecologists recommends screening women for depression at least once during the perinatal period and during each postpartum visit using a validated screening tool. Despite this, an outpatient maternity mobile unit predominantly serving immigrant women from racial and ethnic minority groups lacked a standardized perinatal depression screening protocol. Purpose: The purpose of this quality improvement project was to implement a perinatal depression safety bundle to correctly screen and refer 100% of eligible patients. Methods: The safety bundle, compromised of a screening algorithm, the Edinburgh Postnatal Depression Scale (EPDS) in multiple languages, patient education, community resources, and referral lists was implemented over a 15-week period. Screening eligibility criteria include obstetric patients 28-32 weeks gestation and 6-8 weeks postpartum not previously screened within those periods. The medical assistant administered the screening on arrival to the clinic and the EPDS was completed independently by patients unless literacy barriers existed. The clinician reviewed the score and risk factors and initiated interventions based on the screening algorithm. Interventions included a combination of patient education, pharmacologic therapy, referral, and/or community resources. Weekly chart audits were conducted to track the number of patients eligible, screened, and interventions received. Results: 101 eligible patients were screened with an increase in the mean screening compliance rate from 17.8% to 71.3%. 13 patients had a positive EPDS screen with 58.8% referred to mental health services. Overall algorithm adherence, measured by appropriate documentation of screening, patient education, and referral, increased from a mean of 14% to 38.6%. Conclusions: Findings suggest that implementing a screening protocol and safety bundle with patient and clinician resources in the outpatient maternity setting can improve the identification and appropriate management of perinatal depression.
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Improving Safe Sleep Practices in a Level III Neonatal Intensive Care UnitProblem & Purpose: In a level III Neonatal Intensive Care Unit (NICU) at a large inner-city hospital in the mid-Atlantic region, healthcare providers were not uniformly transitioning premature infants to safe sleep positioning (SSP) as recommended by the American Academy of Pediatrics (AAP). Based on a random bedside audit in March 2022, 40% of infants in the NICU met the eligibility criteria for safe sleep, and 0% of those patients were in accordance with the guidelines. The purpose of this quality improvement initiative was to increase the number of neonates in accordance with the AAP’s safe sleep guidelines for hospitalized infants. Methods: An evidence based safe sleep bundle was implemented and included the development of an evidence-based sleep algorithm, standardization of an educational video, and a parent safe sleep discharge survey. Staff completed formalized education on the bundle and new practice. Positioning guidelines were strategically placed in high traffic locations throughout the unit. At discharge, parents completed a survey that assessed their comfort level with safe sleep implementation at home. Weekly bedside audits were conducted to identify infants eligible for safe sleep, and if infants were placed using safe sleep practices. Results: Over fourteen weeks of data collection, the average safe sleep compliance rate was 79%, with 100% compliance met at 3 separate data intervals. Conclusion: The incorporation of an evidence based safe sleep bundle in the NICU can improve compliance with safe sleep practices and reinforce safe sleep strategies at discharge.
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Implementation of Pre-Discharge Appointment Scheduling to Increase Attendance at Postpartum Hypertension ScreeningProblem & Purpose: A Mid-Atlantic community hospital experiences approximately 200 births a month; 50% of these births occur to mothers who self-identify as non-White (NW), and 20% of all patients have a hypertensive disorder of pregnancy (HDP). Blood pressure (BP) can rise without symptoms 3-10 days postpartum, and 75% of maternal deaths are related to HDP postpartum. Early detection of HDP reduces maternal morbidity and mortality. Currently only 40% of eligible hospital patients attend the recommended postpartum BP check appointment within 10 days, and 70% of the patients who do not attend this follow-up appointment self-identify as NW. This quality improvement project aims to increase attendance at the postpartum BP screening by scheduling the appointment prior to discharge. Methods: Patients with HDP are identified in the peripartum period by staff RNs, who share the names with the patient care assistants (PCAs), who use the hospital’s EMR secure message function to notify the maternity care practice scheduling personnel to schedule the appointment. Results: Appointments scheduled prior to discharge increased from 3% to 17.9%, appointments printed on the after-visit summary increased from 0 to 19.7%, and appointment attendance increased from 40% to 65%. When examined by patient identified race, appointment attendance for non-Hispanic White (NHW) patients decreased from 52% to 40.8% and increased from 48% to 59.2% for NW patients. Patients who did not attend the appointment and identified as NHW increased from 30% to 46.3%, while those identifying as NW decreased from 70% to 53.7%. Conclusions: Postpartum BP screening appointment attendance is increased, and racial disparities decreased, when appointment scheduling is initiated prior to discharge.
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Implementation of Screening Tool to Trigger Tracheostomy Decannulation Evaluation by OtolaryngologyBackground: Tracheostomy is a common surgical procedure increasing in prevalence, particularly amid the COVID-19 pandemic. Otolaryngology is often consulted for upper airway evaluation prior to initiating capping trials designed to simulate decannulation readiness. A 22- bed adult long-term acute care hospital (LTACH) recognized an increase in inappropriate Otolaryngology consultations to 20%. At that time, the project site was not utilizing a standardized screening to determine need for consultation. Inappropriate consults led to increased health care costs, provider inefficiencies, and unnecessary patient evaluations. This quality improvement (QI) project sought to develop, implement, and evaluate the success of a tracheostomy decannulation readiness screening tool comprised of eight evidence-based clinical parameters. Methods: Pulmonology providers received training on screening tool utilization prior to implementation. Between September and December 2022, the screening tool was utilized weekly by the Pulmonology team. Otolaryngology was consulted if all parameters were met. Chart audits measured screening tool utilization and appropriate consultation. The overall percentage of inappropriate Otolaryngology consultations and mean length of stay (LOS) were measured. Results: One hundred forty-five screening opportunities were identified among 21 eligible patients, which resulted in 100% compliance with weekly screening. Patients who passed screening (n=6) received an Otolaryngology consultation and capping was recommended for 100% of these patients. There were no inappropriate Otolaryngology consultations during implementation. Pre-implementation mean length of stay (LOS) was 111.9 days which decreased to 92.1 days post-implementation. Conclusions: The screening tool accurately identified patients appropriate for Otolaryngology consultation. Overall, the screening tool improves efficiency, reduces health care costs, decreases LOS, and decreases inappropriate Otolaryngology consultations.
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Nasal Bridling for the Improved Delivery of Enteral NutritionProblem: Critically ill patients are at an increased risk for malnutrition and its adverse effects. Chart audits were conducted on a 22-bed, medical cardiovascular intensive care unit revealed that out of 44 included patients, 37 did not receive at least 80% of their recommended nutrition. After a root cause analysis was conducted, unintentional feeding tube dislodgement was identified as a major contributor to interruptions in tube feed delivery. Purpose: The purpose of this project was to increase the delivery of enteral nutrition to patients in the intensive care unit by implementing nasal bridles as the standard practice for securing nasogastric tubes. Methods: Implementation of nasal bridles as the standard securement of nasogastric tubes was supported through the integration of high-quality staff engagement through hands-on training opportunities, competency development, environment optimization, and clinical advancement incentive opportunities. All patients with nasogastric tubes and enteral nutrition orders for at least 24 hours were included in this quality improvement project. Every 24 hours, patient charts were audited for method of tube securement, and total enteral nutrition delivered compared dietician recommendations. Results: Baseline data collection indicated an average delivery of 44% of enteral nutrition requirements. During the last month of project implementation, the documented delivery of enteral nutrition improved to over 90%. Patients with nasogastric tubes secured with bridles, on average, received more enteral nutrition (88.5%) than those secured by adhesive or tape (70.8%). Lastly, 30 nasogastric tubes secured by adhesive or tape were dislodged compared to zero dislodged tubes secured by bridle over the course of this project. Conclusions: Nasal bridles are an effective method to reduce inadvertent tube dislodgement and increase the delivery of enteral nutrition in this medical cardiovascular intensive care unit.
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Pediatric Bone and Joint Infection GuidelinesProblem & Purpose: Antimicrobial stewardship guidelines are a Joint Commission requirement to address the Centers for Disease Control and Prevention’s call to reduce unnecessary and potentially harmful antibiotics. Pediatric bone and joint infections are traditionally treated with lengthy intravenous antibiotic courses, but evidence shows earlier transition to oral therapy is safe and reduces antibiotic exposure. In the absence of hospital-wide clinical guidelines at an urban academic institution, provider guidance is needed to minimize antibiotic exposure in this population. The purpose of this project is to implement two institution-specific pediatric guidelines for osteomyelitis and septic arthritis with a diagnostic order set and targeted provider education. Methods: The project lead wrote guidelines and order sets based on evidence review, the institution’s protocols and resources, and input from infectious disease, orthopedics, radiology, emergency medicine, microbiology, pharmacy, and advanced nursing. Guideline virtual education for all pediatric providers was provided synchronously and asynchronously. The project was implemented over a 15-week period. Inclusion criteria are acute hematogenous infections in ages one month to 18 years. NICU patients or those with major trauma or other medical history that increases risk for infection such as bone disease, open fractures, existing hardware, or previous surgeries are excluded. Prospective chart reviews and real-time provider education were conducted for all eligible patients. Data collected includes guideline compliance, order set use, and safety outcomes. Results: The guidelines were published on the institution’s stewardship website and mobile application. Two eligible patients have been identified. Management of one patient followed the guidelines. The other transferred from another hospital and empiric antibiotic choices were not consistent with the guidelines; subsequent care has been. Conclusions: A team and multidisciplinary approach successfully implemented new stewardship guidelines. Findings suggest an institution-wide guideline with targeted education is an effective way to ensure more streamlined care for pediatric patients with bone or joint infections and may reduce antibiotic exposure.
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Standardized Postpartum Depression Screening in Pediatric Intensive Care UnitsProblem & Purpose: Postpartum Depression (PPD) affects 1 in 8 women and infants of mothers with PPD are at risk for long-term physical and mental-health problems. Mothers of critically ill children have an increased risk of PPD but may miss outpatient screening opportunities while their child is hospitalized. The Pediatric Intensive Care Unit (PICU) and Pediatric Cardiac Intensive Care Unit (PCICU) in a Children’s Hospital do not have standardized screening for PPD. The purpose of this quality improvement project was to standardize PPD screening for mothers of infants less than 12 months using the validated Edinburgh Postnatal Depression Scale (EPDS). Methods: PPD Screening was conducted by nurses in the PICU and PCICU over a 14-week period. Nurses received education on screening including the use of a decision tree algorithm, an EPDS scoring key, quick tips, and a PPD resource support packet. All mothers of children 12 months and younger were eligible for screening. Nurses approached eligible mothers during admission and provided them with the resource packet and information on PPD screening and support resources. If mothers participated in screening, nurses then scored the completed EPDS tools and initiated a social work referral for borderline and positive scores. Results: 178 mothers were eligible, of which 25 (19.6%) were offered screening. Of those offered, 27 (77%) participated, 4 of whom had not been previously screened. EPDS scores ranged from 0-20 with an average score of 7.2 and 11 (40%) women had borderline or positive scores on the EPDS with one mother identified as having suicidal ideation. Screening compliance was low overall but was better in the PICU than the PCICU. Conclusions: The identification of women struggling with PPD that otherwise would not have been screened shows that screening for PPD in pediatric intensive care units is feasible and beneficial for promoting early support.
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Certified Registered Nurse Anesthetists Strategic Planning for Rebranding and Policy DevelopmentProblem: In 2021, a national association of Nurse Anesthetists announced a professional name change to Nurse Anesthesiology and the descriptor Nurse Anesthesiologist. It is the interest of a Mid-Atlantic state Nurse Anesthetist association to examine if state level legislative changes should be pursued to adopt the name change. Purpose: The purpose of this project was to conduct a comprehensive impact assessment utilizing a standardized analytical tool to generate recommendations to a Mid- Atlantic state Nurse Anesthetist association regarding the decision to pursue the adoption of a name change. Methods: Interviews were conducted over a 15-week period utilizing a Strength, Weakness, Opportunity, and Threat (SWOT) analysis tool with members of a Mid-Atlantic state medical society and state association for anesthesiologists. Data was collected via in-person, phone, and virtual interviews and was stored in REDCAP, a private and secure data collection website. Results: A total of 6 SWOT interviews were completed out of the 20 attempted. The strengths identified were that the current name provides a clear description of the person providing care. Weaknesses are a lack of public familiarity with the title “anesthetist”. Opportunities recognized were the potential for Nurse Anesthetist professional empowerment. Threats included cost and the perceived intent to mislead the public. Conclusion: Overall findings suggest that the members interviewed do not support a name change in the state. All participants reported being very unlikely to advocate for legislative changes if pursued by the Mid-Atlantic state association
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Healthcare Transition in Adolescents with Heart Disease: Assessing Transition ReadinessProblem & Purpose: The American Heart Association, American Academy of Pediatrics, and American Academy of Family Physicians recommend the use of formal transition interventions to support adolescent and young adult (AYA) patients transitioning to adult care. Within a pediatric cardiology clinic in an urban, academic medical center approximately 25% of the patient population is over the age of 16 years. The clinic has no structured transition policy or program and only 2.4% of these patients received documented transition education. The purpose of this quality improvement project was to implement a transition readiness assessment with the goal of ensuring 100% of eligible patients received transition education or appropriate referral to adult services. Methods: Implementation occurred over a 17–week period. Patients over 16 years with ongoing cardiac needs and stable treatment plans were eligible; patients new to the practice were excluded. During a routine cardiology appointment, eligible patients received an introductory letter and QR code for self-administration of the Transition Readiness Assessment Questionnaire (TRAQ). Following completion of the TRAQ tool, a nurse practitioner reviewed the readiness score, and patients received a transition focused appointment or referral to adult services, as appropriate. Eligibility was determined and demographic data obtained via chart audits. Results: Adherence to delivery of the TRAQ tool to eligible patients was high (88%). A total of 17 of 52 eligible patients elected to participate by completing the readiness assessment (n=17). Chart audits of the implementation period demonstrate 35% of patients 16 years and older having documented transition education or referral to adult care. Conclusions: Successful change in practice at the site demonstrates the feasibility of transition initiatives. Findings suggest that implementation of a transition readiness assessment can increase appropriate management of AYA patients.
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Improving Cardiac Functional Status Through Self-Care Assessment and EducationProblem & Purpose: At a large urban tertiary medical center, the 30-day readmission rate for HF patients who attend the Heart Failure Bridge Clinic (HFBC) post-discharge is 14%. On chart review, 70% of HF clinic patients are NYHA functional class III or IV. Deficits in patient self-care is a root cause responsible for low functional status and hospital readmissions. This quality improvement initiative aimed to implement self-care assessment with the Self-Care in Heart Failure Index (SCHFI) and a nurse-led self-care education program. Methods: All new patients to the HFBC and recent hospital discharges received an invitation to participate in the self-care assessment and education program over 15 weeks. Patients completed the SCHFI on paper or electronically at their first visit to the HFBC and post-education. Self-care education consisted of five 30-minute educational sessions administered by two RNs during nurse-led clinic visits. The standardized curriculum was divided into five sessions: (a) understanding and self-management of heart failure, (b) symptoms, (c) medications, (d) diet, and (e) daily life. Results: 100% of HFC staff received education on SCHFI administration and self-care education (SCE) before implementation. Project team members integrated documentation of SCHFIs and SCE into the electronic health record. The average proportion of eligible patients completing the pre-education SCHFI was 75%. The average score was 76, with a score > 70 indicating adequate self-care. Ten patients completed the first education session; no patients completed five sessions. Conclusion: Findings suggest the SCHFI is a practicable tool for assessing self-care in a transitional HF care setting. There is opportunity to target patients with SCHFI scores < 70 for SCE and address barriers to patient follow-up in the future.