Recent Submissions

  • Daily Charge Nurse Leader Rounds on a Cardiac Surgery Progressive Care Unit

    Peed, Brittany L.; McComiskey, Carmel A. (2021-05)
    Problem: Patient satisfaction is the measure of the success of a healthcare system in today’s competitive markets. However, achieving patient satisfaction relies on multiple internal and external factors. The Cardiac Surgery Progressive Care Unit (CSPCU) at an urban medical center in the mid-Atlantic United States was seeking to improve their patient satisfaction scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCHAPS) data. Purpose: The purpose of this quality improvement project (QI) was to implement and evaluate the effectiveness of daily charge nurse leader rounds on patients admitted to a CSPCU. It is anticipated that there will be an increase in the total number of times a nurse leader rounds on a patient that subsequently will result in in an increase in patient satisfaction as measured by HCAHPS nurse communication scores. Methods: The QI project was implemented over a 14- week period in a CSPCU at an urban Maryland academic Medical Center. Charge nurses were educated on the process change and then completed ‘charge nurse leader’ rounds. The project leader checked the rounding rates bi-weekly. Nurse communication scores were collected preand- post implementation using the scores from the HCAHPS surveys. Results: The number of patients rounded on daily over the course of the project was 64.7% and during the implementation period a total of 1140 rounds were completed. The HCAHPS scores increased in the category of ‘RN explanation’ and slightly decreased in the categories of ‘RN listening’ and “RN courtesy”. Patients’ perception of the nurse leader rounding increased from 79.64% to 87.23%. Conclusions: Charge nurses can be utilized as informal leaders to complete nurse leader rounds. Leader rounds are able to be incorporated into the daily routine of the charge nurse. Patient satisfaction scores are impacted by many different factors. The increase seen in one domain of HCAHPS indicates that further studies should be completed to better understand how nurse leader rounds impact patient satisfaction.
  • Implementation of an Arterial Blood Gas Indication Algorithm in Cardiac Surgery

    Wanzer, Megan B.; Wilson, Tracey L. (2021-05)
    Problem: The overutilization of laboratory testing was identified as a national problem by the “Choosing Wisely” campaign, advocating for judicious use of testing in intensive care units (ICUs). Arterial blood gasses (ABGs) account for an estimated 10-20% of all costs during an ICU stay. Non-clinically indicated ABGs increased costs of care, length of stays, ventilator days, and line days, increasing the risk of adverse outcomes to already vulnerable critically ill patients. A cardiac surgery intensive care unit (CSICU) within a large urban mid-Atlantic academic medical center accounted for 31% of the entire institution’s ABG analyses between 2018-2019, and was identified as a top utilizer due to inappropriate ordering practices as compared to current guidelines. Purpose: The purpose of this quality improvement project was to implement an algorithm based upon evidence-based guidelines that identified appropriate standardized clinical indications for ABGs, with the intention of reducing non-clinically indicated blood gas analyses orders within the CSICU. Anticipated outcomes of this practice change included decreasing the total volume of ABGs sent, resulting in reduced costs of care, lengths of stay, and improved morbidity and mortality rates. Methods: An evidence-based ABG indication algorithm was created focusing on acute changes in oxygenation, ventilation, acid base balance; changes in hemodynamics, post-operative baseline, and for patient ABGs to correlate with extra-corporeal membranous oxygenation values. Routine ABGs for monitoring were eliminated. Implementation occurred over fourteen-weeks in the fall of 2020 following staff and provider education. Training emphasized the use of non-invasive monitoring such as pulse-oximetry and capnography. Compliance and gross laboratory totals and indications were obtained from weekly auditing. Results: There was an 8.8% reduction in ABGs sent and 32% decrease in ABGs per patient day. The most common indications were extra-corporeal membranous oxygenation (ECMO)-correlated ABGs, post-operative, and changes in oxygenation and/or ventilation; 7.8% were non-indicated. Conclusions: Implementation of an ABG indication algorithm resulted in fewer ABGs sent, mostly due to a reduction in routine monitoring, and ABGs were more likely to be clinically indicated in response to an acute concern. Implementing an ABG indication algorithm is safe, feasible, and can lead to significant cost reductions for the institution.
  • Implementation of an Ultrasound-Guided Algorithm for Difficult Intravenous Access

    Robertson, Michael T.; Nawrocki, Lauren (2021-05)
    Problem & Purpose: Obtaining peripheral intravenous (PIV) access is a frequent, but challenging procedure in difficult access patients (DIVA). Emergency medical care frequently requires PIV access to administer medications and perform diagnostic testing. Traditional methods for obtaining PIV access have resulted in repeated painful attempts and treatment delays in this tertiary care emergency department. The purpose of this quality improvement project was to implement and evaluate a nursing-initiated clinical pathway directing the use of ultrasound-guided intravenous techniques for DIVA patients to increase first attempt success rates and reduce treatment delays. Methods: A departmental policy was created to support the practice change. The policy provided an illustration of the DIVA clinical algorithm and specified training and competency validation expectations. Training included 30-minutes of didactic instruction followed by 60-minutes of hands-on training. Competency validated operators documented DIVA screening, ultrasound utilization rates, pain scores, number of venous attempts, and treatment delays. Project compliance and outcome measures were collected over 14-weeks and converted into run charts for weekly unit dissemination. Chi-squared and independent samples t-tests were used to compare pre-and post-implementation results. Results: Sixteen operators completed the education and training program which included nurses (n=8) and technicians (n=8). Operator compliance to DIVA screening and ultrasound-guided intravenous algorithm utilization suggested early adoption (M = 89.25, SD = 7.45). First-attempt success rates for DIVA patients increased from 57% to 87% (p = 0.03) and treatment delays decreased from 20% to 0% (p = 0.01). There was a significant reduction in pain scores (M = 2.2, SD = 1.17) compared to baseline (M = 5.3, SD = 1.65) data; t(58) = 8.08, p < 0.001. Conclusions: The use of a nurse-initiated clinical pathway to identify difficult access patients requiring ultrasound-guided intravenous cannulation increases the likelihood of first attempt access success and ensures timely medication administration, laboratory analysis, and diagnostic testing in the emergency department. The reduction in cannulation attempts optimizes patient outcomes by decreasing pain experienced by the patient, and treatment delays.
  • Implementation and Evaluation of a Patient Handoff Tool to Improve Nurses Communication

    Nwaukwa, Stacian S.; Satyshur, Rosemarie D. (2021-05)
    Problem & Purpose: Poorly conducted handoffs are implicated in 80% of preventable adverse events in healthcare facilities. Within a sub-acute and rehabilitation facility in Maryland, observational reports revealed that nurse handoffs were poorly conducted and lacked the use of a standardized evidence-based tool, resulting in miscommunication and nurse dissatisfaction with the handoff process. Situation, Background, Assessment, Recommendation (SBAR) is an evidence-based tool recognized by The Joint Commission, Agency for Healthcare Research and Quality (AHRQ), and the World Health Organization (WHO) as an effective tool in improving handoff communication, reducing adverse events, and promoting patient safety. The purpose of this quality improvement (QI) project was to implement and evaluate an SBAR patient handoff tool to improve nurse communication. Methods: Nurses were educated on the SBAR method and tool prior to using the tool. A Handover Evaluation Scale (HES) survey was distributed pre-implementation and again at the end of the 15-week implementation period. Weekly observation audits were conducted to determine nurse compliance with use of the SBAR handoff tool. Results: Findings indicated that nurse compliance with use of the SBAR patient handoff tool was 86% by Week 7, and 100% by Week 13. Comparison of pre and post-HES survey mean responses showed modest improvements in all items relating to the key variables: quality of information, interaction, and efficiency of handoffs. Conclusion: Use of the SBAR tool improved the quality of information, interaction, and efficiency of patient handoffs between nurses, thereby improving communication. Further QI projects are recommended to evaluate the effectiveness of SBAR in reducing adverse patient events and improving patient care outcomes.
  • An Algorithm for Diaper Dermatitis Management in the Neonatal Intensive Care Unit

    Crampton, Laura K.; Fitzgerald, Jennifer (2021-05)
    Problem: Diaper dermatitis (DD) is inflammation of the skin in the perianal area that ranges from mild erythema to broken skin and bleeding. At baseline, 20% of infants ≥ 30 weeks gestation had DD in the target Level IV Neonatal Intensive Care Unit (NICU). Historically, DD was managed based on individual nursing judgment due to a lack of current standardization of care for infants with DD and resulted in inconsistent care of infants with DD. Purpose: The purpose of this quality improvement project was to implement and evaluate the effectiveness of an algorithm for the prevention and treatment of DD in infants ≥ 30 weeks gestation in a Level IV NICU in an urban, academic medical center. Methods: Bedside nurses were given education on DD and the new algorithm for the management of DD. They also completed pre-and post-knowledge surveys. The algorithm was placed at the bedside of each infant for reference and the educational PowerPoint was emailed to all bedside nurses. Once a week, bedside nurses documented incidence of DD, if prophylactic or therapeutic treatment was performed, and if the algorithm was followed. Continued education was provided throughout implementation, reminder cards were placed on each nurse computer, and reminder texts to document DD data were sent out via unit phones each Monday. Results: The use of the algorithm and the use of prophylactic petroleum jelly increased from 0% at baseline to 100% over the 15-week data collection period. The prevalence of diaper dermatitis decreased from 20% (9/46) prior to implementation to 18% (2/11) on the last week of data collection. Following the education on DD and the implementation of the algorithm, the majority of nurses stated that they were more aware of DD and monitored for it more closely during diaper changes. Conclusions: The use of an algorithm for the management of diaper dermatitis helped to increase the use of prophylaxis and education on the algorithm increases bedside nurses’ awareness of DD in their patients on this unit.
  • Implementation of a Mealtime Assistance Training Program for Long Term Care Staff

    Griffin, Joshua W.; Windemuth, Brenda (2021-05)
    Problem: In nursing homes approximately 70% of residents have a form of dementia and are at risk of malnourishment. Long-term care (LTC) facility residents have varying degrees of cognitive impairment affecting their capacity to feed themselves. The director of nursing at the project site identified that residents are vulnerable to decreased food and fluid intake, which may be reflective of limited feeding skills of the nursing staff. Purpose: The purpose of this quality improvement project was to implement an online staff training program for handfeeding of residents with cognitive impairment (CI) in a LTC facility to optimize the mealtime interaction and improve resident health outcomes. Methods: The project was implemented at a LTC facility in rural Maryland with nine staff participants (2 nurses and 7 geriatric nursing assistants), who worked shifts while meals were served. Data collection occurred through pre- and post-training surveys as well as baseline and final (end-of-project) interviews to evaluate the staff’s perception of improvements in the mealtime interaction and enhanced outcomes for residents. Results: Prior to the training, only 11.1% of the staff reported ever having any formal training/education on feeding assistance beyond their basic nursing educational program. All the staff completed the training program and corresponding skill competency checklists. While 100% of the staff reported via the surveys the training as being helpful, only 87% had the opportunity to use any of the skills or techniques from the training. The primary qualitative finding from the final interviews was 100% of staff said the training has or would improve the mealtime experience and nutritional state of residents. Conclusion: The data collected from surveys and interviews confirms that staff participants found the training program for handfeeding of residents with CI to be valuable in improving feeding interactions as well as the nutritional state of residents.
  • Implementation of a Fall Prevention Toolkit on a Medical Surgical Unit

    Khandagale, Usha; Windemuth, Brenda (2021-05)
    Problem: In-hospital falls result in patient harm which includes minor injury, psychological distress and anxiety, and serious injuries like fractures, head trauma, and even death. The Joint Commission consistently ranks falls with serious injury as one of the top sentinel events. An acute care medical surgical unit in a community-based hospital experienced an increase in the number of falls with an overall fall rate higher than that of peer units. Purpose: The purpose of this Quality Improvement (QI) project was to implement and evaluate the benefits of, and staff adherence to, the use of Fall TIPS (Tailoring Intervention for Patient Safety) toolkit to reduce falls on a medical surgical unit. Methods: The Fall TIPS toolkit was designed to decrease the patient fall rate in hospitals and engage patients and their families in a 3-step fall prevention process including performing a fall risk assessment, creating a tailored fall prevention plan, and executing the plan regularly. Implementation of a Fall TIPS toolkit with auditing transpired weekly over 10 weeks on a medical surgical unit. Nurses’ adherence to the Fall TIPS protocol was measured weekly during implementation. Results: The results indicated that nurses’ adherence to use of the Fall TIPS toolkit averaged 78%. The run chart analysis of nurses’ adherence did not show any shifts or astronomical datapoints, and the number of runs was consistent with random variation. However, there was a 6-point upward trend in the data during weeks 2 to 7, indicating a special cause. Fall rates during the first two months of implementation were 3.39 and 2.41 per 1000 patient-days respectively, and dropped to zero during the third month. Conclusion: Nurses’ adherence to a Fall TIPS toolkit was demonstrated on a medical surgical unit, which likely resulted in a decreased patient fall rate during the final month of the project. Additional time will be needed to determine if the practice changes and outcomes are sustainable.
  • Goal of Treatment as Part of the Chemotherapy Consent Process

    Boord, Christina E.; Connolly, Mary Ellen (2021-05)
    Problem: Patients consenting for chemotherapy require a clear understanding of the goal of treatment to make an informed treatment decision reflective of their own goals and values. Identified barriers to patient understanding include lack of information on the consent form and the use of ambiguous language by providers. Both the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) recommend goal of treatment as part of the consent process. Purpose: The purpose of this quality improvement project was to develop and implement a new chemotherapy consent form that includes goal of treatment; to improve documentation compliance and to evaluate patients’ understanding of their treatment goal. Methods: A multidisciplinary committee at the project site decided to include three goals of treatment: curative, palliative, and palliative/life-extending as part of the consent form. Goal definitions using plain language were included to ensure consistency across providers in how these terms were defined during consent conversations. Patient surveys were developed to evaluate perceived satisfaction with the information provided during the consent conversation as well as the patient’s own perceived goal of treatment. Results: Between August 31, 2020 and December 11, 2020, 155 patients were consented for chemotherapy with 54% of patients completing the patient survey. Goal of treatment documentation compliance increased from 8% to 99% with adoption of the new consent form. Goal concordance, defined as a patient’s ability to correctly identify their goal of treatment compared to the physician’s documented goal of treatment, increased from 42% to 61%; an increase of 43%. However, a chi-square test of independence revealed no significant association between the rate of agreement and consent form used (X2 (1, N = 84) = 2.72, p = .10). Conclusions: Goals of treatment are a vital part of consent conversations. Including goal of treatment as part of the consent form creates opportunity for meaningful, in-depth goals of care conversations which can help patients make treatment decisions reflective of their own goals and values. Although improvement in goal concordance did not reach statistical significance, a 43% improvement in concordance with the new consent form cannot be overlooked.
  • Eliminating Hospital Acquired Pressure Injuries: Prevention Bundles and Two Nurse Skin

    Snider, Victoria E.; Callender, Kimberly (2021-05)
    Problem: A Vascular Surgery Progressive Care Unit (VSPCU) in a large, academic medical center had a year-to-date hospital-acquired pressure injury (HAPI) incidence rate of 1.89 per 1000 patient days in 2019; fifty percent of these HAPI were avoidable. Purpose: The purpose of this quality improvement (QI) initiative was to eliminate HAPI incidence on a Vascular Surgery Progressive Care Unit through implementation of an evidence-based pressure injury prevention bundle (PIPB), including a two-RN skin assessment and co-sign component within 24-hours of patient admission or transfer. Methods: The Vascular Surgery Progressive Care unit consists of 12 beds and averages 53 admitted patients per month. A 16-week implementation period took place from August 31, 2020 to December 22, 2020. Head-to-toe, 2-RN skin assessment with electronic health record cosign and bundle documentation was implemented on the project unit for nurses to identify risks for HAPI, provide all admitted patients evidence-based prevention strategies, and to link staff with institutional skin prevention resources. The QI project was guided by Lippitt’s Change Theory. Staff-received project education was measured by a completion goal date. Nursing staff completed return-demonstration of 2-RN cosign and bundle note documentation within the electronic health record. Documentation of RN bundle compliance was measured by weekly chart audits. Unit HAPI incidence rates were measured by quarterly audits compiled and dispersed by the institutional Skin Integrity Committee. Data used for dissemination and discussion was comprised using run-chart analysis. Results: At Go-live 57% of RNs were PIPB trained (n = 30). A zero avoidable HAPI incidence was maintained during implementation (n = 194 patients). At week nine, 100% bundle compliance was achieved for five consecutive weeks. Conclusions: Implementation of a prevention bundle using a two-nurse skin assessment with cosign, for achieving zero unit-based HAPI is feasible and should be a care standard. Bundle compliance was associated with completed staff training, charge nurses as project champions, compliance email reminders, compliance data-sharing with staff, leadership availability and visibility, and continual team positive reinforcement.
  • 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.

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