Recent Submissions

  • Implementation of Resuscitated Cardiac Arrest Debriefing in the Medical Intensive Care Unit

    Fraser, Ruth-Anne M.; Jackson-Parkin, Maranda (2022-05)
    Problem: In 2020, a medical intensive care unit (MICU) at a large academic hospital experienced 47 resuscitated cardiac arrests, achieving return of spontaneous circulation (ROSC) in 66% (n = 33). An audit of the practices of the MICU identified that following cardiac arrest resuscitations, no processes existed for performing staff debriefing possibly contributing to inferior resuscitation quality. Debriefing is a focused, interdisciplinary discussion that provides participants with feedback and is demonstrated to improve patient outcomes including return of spontaneous circulation, and team performance. Purpose: The purpose of this Quality Improvement (QI) project was to implement a sustainable, structured, interdisciplinary debrief after all resuscitated cardiac arrest events in the MICU. Debriefing after resuscitated cardiac arrest events could improve CPR quality, return of spontaneous circulation rates, and communication. Methods: The QI project methods involved Resource Registered Nurses (RRN) facilitating an interdisciplinary debriefing following each resuscitation event in the MICU (September - December 2021), using the institution’s debrief tool. The debriefing tool was comprised of open-ended questions and quality metrics. Practice changes were achieved by using teach-back methods to train the RRNs on debrief facilitation. Emotional support was offered to staff. Compliance with debriefing and number of staff involved with events and debriefs were recorded. In addition, anonymous indicators of CPR quality as measured by chest compression depth, rate, and fraction was collected from the defibrillator. Finally, the rate of return of spontaneous circulation (ROSC) was collected. Results: During implementation, 92% (n = 13) of resuscitated cardiac arrests were debriefed, and 8 to 17 staff participated in each debrief. Comparison of CPR quality before and after implementation demonstrated marked improvement in median chest compression quality according to the American Heart Association (AHA) guidelines. Compression depth and rate medians increased from 22.0% to 39.5% (p = 0.012) and 63.9% to 75.6% (p = 0.497) respectively, and compression fraction median decreased from 95.3% to 94.9% (p = 0.35). Return of spontaneous circulation was achieved in 50% of the arrests. Conclusions: Project outcomes demonstrate that debriefing is associated with improved CPR quality and provides support for MICU staff after resuscitated cardiac arrest events.
  • Decreasing Bedding Time for Patients Admitted to the Telemetry Unit

    Foryoung, Bernice; Gourley, Bridgitte (2022-05)
    Problem: Improving care in the Emergency department (ED) is a goal of Healthy People 2030. One of the objectives of this goal is to reduce wait times in the ED. Increased wait times have been shown to cause poor patient outcomes and avoidable medical errors. Several factors affect ED wait times, one of which is a decrease in patient flow throughout the hospital. A community hospital in Maryland identified an increase in the time from when admission orders were entered for the telemetry unit to when patients were bedded. Purpose: This quality improvement project aimed to implement and evaluate the effectiveness of a Logistics Management Program (LMP) to decrease the time from when an admission order was placed to when an adult patient was admitted to a bed in the telemetry unit from the ED. Method: The QI project was implemented on a 63-bed Telemetry unit in a small community hospital. The unit admitted approximately12 adult patients from the ED each day. The innovation of this project was the implementation of the LMP. It included the already existing electronic bed board and a Nurse coordinator who oversaw admissions from the ED to the Telemetry unit. The outcome monitored was the percentage of patients that were bedded within 90 minutes of the admission order. Results: The percentage of ED patients admitted and transported to telemetry within 30 minutes increased from 17.9 to 36.6 percent. The percentage of ED patients admitted to the telemetry unit within 90 minutes of the written admission order increased from 19.7 to 25.1 percent. Conclusion: During the COVID-19 pandemic, the Logistics Management Program improved the flow of patients from the ED to a telemetry inpatient unit.
  • Implementation of Screening for High Fall Risk Medications in Hospitalized Older Adults

    Friesen, E.; Jackson-Parkin, Maranda (2022-05)
    Problem: Accidental falls are a leading cause of injury and death in older adults, leading to loss of function and increased healthcare costs. Falls are also commonly reported sentinel events in hospitals. A community hospital identified falls as an organizational priority with 73 inpatient falls last year. Expert guidelines recommend multifactorial fall risk assessment modalities, including screening for medications that increase risk of falling in older adults and deprescribing or adjusting inappropriate medications, however, the institution has no such process in place. Purpose: The purpose of this quality improvement (QI) project was to implement an interdisciplinary process for screening older adults’ prescriptions for medications that increase risk of falling and mitigate unnecessary high-risk medication use. Methods: Between September and December 2021, the Screening Tool for Older Persons’ Prescriptions (STOPP) Tool was utilized for daily medication screening on patients aged 65 and older during interdisciplinary rounds on the 12-bed Intensive Care Center (ICC). STOPP is a Delphi-validated tool to screen for potentially inappropriate prescriptions (PIPs) in adults aged 65 and older, with demonstrated efficacy in reducing PIPs and adverse drug reactions (ADRs). Registered nurses (RNs), pharmacists, and intensivists received education on the standard of care, and the screening process prior to implementation. Daily screening and deprescribing were measured through weekly chart audits. Data were analyzed utilizing Microsoft Excel. Descriptive statistics were calculated to evaluate goal attainment for the process measure (medication screening) and outcomes (deprescribing). Results: One hundred percent of intensive care providers (n=7), 66% of ICC RNs (n=19) and 60% of pharmacists (n=3) received a review of the medication screening process and STOPP tool. Sixty-six percent of RNs (n=19) completed education through Nurses Improving Care for Healthsystem Elders (NICHE) on the role of nurses in deprescribing. Seventy-four patients were eligible for screening with 167 daily screening opportunities, with median weekly screening compliance of 54%. High-risk medications identified through screening had a median weekly deprescribing rate of 20%. There were two falls in the implementation period. Conclusions: Interdisciplinary medication screening is a feasible adjunct fall prevention measure. Ongoing outcome measurement is necessary.
  • Implementation of a Phlebitis Prevention Bundle on a Neurotrauma Critical Care Unit

    Del Barco, Alexandra W.; Jackson-Parkin, Maranda (2022-05)
    Problem: Peripheral intravenous catheter (PIVC) associated phlebitis is a significant cause of morbidity leading to increased healthcare costs, prolonged lengths of stay, additional medical treatments, and increased mortality. Phlebitis, an inflammation of the vein, presents as redness, pain, warmth, streak formation, or a palpable cord. Annually, 80,000 patients with catheter-related blood stream infections are admitted to intensive care units; a large portion of these are attributed to PIVC phlebitis. The Society of Infusion Nurses supports the removal of emergently placed PIVCs and early detection of phlebitis. A neurotrauma critical care (NTCC) unit identified 68 cases of phlebitis over a 17-month period (M=4). PIVCs that are emergently placed or used for vesicant medication infusions are critical risk factors. Purpose: The purpose of this quality improvement (QI) project was to implement a Phlebitis Prevention Bundle (PPB) in a 13-bed NTCC unit of a major academic urban trauma center, determine adherence to the practice change, and monitor the incidence of phlebitis following vesicant-prone medications. Methods: This project was implemented over 15-weeks following education and training of the project champions and Registered Nurse (RN) staff (N=40). The PPB consisted of two practice changes, specifically the removal of emergently placed PIVCs, within 24 hours of admission to the unit and education pertaining to assessment of phlebitis, knowledge of common vesicants and documentation. Registered nurses completing the PPB training were recognized with a pin and certificate. Results: Registered nurses (n=40) completed education and training. Following educational sessions, adherence to the PPB reached 100% by Week 4 and was sustained for the last 9 weeks at 100%. During implementation, 25 (62.5%) PIVC were removed for early phlebitis, despite an increase in the mean incidence (M=13). Conclusions: Implementation of the PPB has the potential to increase quality of care for trauma patients and decrease the incidence of late phlebitis and its associated complications. Nursing assessment of phlebitis and its related complications has improved RN awareness prompting earlier removal of phlebitis PIVCs. Weekly display of PPB data using run charts helped to communicate practice change efforts, improve RN adherence, which in turn promoted acceptance and sustainability of the practice change.
  • Implementation of Bedside Shift Change Handoff on a Cardiac-Surgical Intensive Care Unit

    Cataldi, Shannon N.; Jackson-Parkin, Maranda (2022-05)
    Problem: Medication errors are a significant cause of patient morbidity and mortality, often resulting in serious injuries, prolonged length of stays, and incurred medical costs. In 2019, a Cardiac Surgical Intensive Care Unit (CSICU) at a large academic hospital identified 40 medication errors through a hospital incident reporting system. Reviews of error reports identified that 70% (n=28) involved medications administered through intravenous infusion pumps and estimated that one third could have been detected much earlier if a standardized shift handoff method such as bedside shift-change handoff (BSCH) had been in place. Purpose: The purpose of this quality improvement (QI) project was to implement BSCH with the guidance of a BSCH tool on a CSICU to reduce pump related medication errors. Methods: This QI project took place from August 30 until December 12, 2021. The initial BSCH process incorporated nursing handoff start to finish inside patient rooms; however, observational audits identified inconsistent participation and barriers to this process. At the halfway point of implementation, a rapid cycle Plan Do Study Act (PDSA) change was required to address barriers to implementation. This change allowed nurses to enter rooms at the end of handoff and perform aspects on the BSCH tool, which improved nursing adherence to the practice change. Chart and observation audits collected throughout implementation identified trends in BSCH adherence and duo verification of high alert infusions. Results: One hundred percent of nursing staff (n=103) were educated on the initial process change of BSCH as well as the rapid cycle PDSA change (n=88). Staff adherence to BSCH ranged from 20-51% during the initial phase of the project, and then improved during the second half, ranging from 80-96%. Adherence to duo verification of high-alert infusions doubled, increasing from 41-49% to a range of 82-96% during the last four weeks. Pump related medication errors decreased by 75% (n=2) from the first quarter of 2021 (n=8) and staff identified 13 potential errors, or “good catches”, during BSCH. Conclusion: Implementing BSCH results in many good catches, improving safety and preventing patient harm. Findings support the implementation of BSCH to decrease pump related medication errors
  • Improving Inpatient Substance Use Screening and Referral to an Addiction Consult Team

    Figiel, Rachel; Jackson-Parkin, Maranda (2022-05)
    Problem: Substance use is associated with poorer hospital outcomes, increased lengths of stay, higher healthcare costs, and increased mortality. On an adult inpatient medical unit, up to 90% of patients did not receive substance use screening per policy. Implementing the evidence-based model of screenings, brief interventions, and referrals to treatment (SBIRT) in this population would serve to optimize quality of care and patient outcomes. Purpose: To purpose of the QI project was to improve substance use screening and referrals to an Addiction Consult Service (ACS) on an adult Medical Intermediate Care Unit. Methods: This QI project was implemented over a 15-week period on a 16-bed adult medical IMC unit. In order to improve substance use screening in newly admitted patients, staff utilized an existing validated single-item screening question in the electronic medical record. Nursing staff notified the attending physicians for all patients who screened positive; the physician further evaluated the patient and placed an order for the ACS if indicated. Data collection was conducted via manual chart audits; run charts were utilized to track process and outcome measures. Process measures included counts (%) of patients who were screened/assessed for substance use. Outcome measures included counts (%) of patients who screened/assessed as positive and received follow up by a physician and counts (%) of patients who screened positive who were referred to ACS. Results: A total of 53 patients were screened or assessed for substance use. Of these, 100% received a screen or assessment, 49.06% (n=26) were screened by nursing, and 50.94% (n=27) who were missed by nursing received assessments from a physician. Of the patients screened or assessed, 13.21% (n=7) were positive, 11.54% (n=3) of patients screened by nursing were positive and 14.81% (n=4) of the patients missed by nursing but assessed by a physician were positive. Of the patients with positive screenings or assessments, 71.43 (n=5) were referred to the ACS. Conclusion: Implementing nurse-lead substance use screening with a validated screening tool in the electronic medical record is feasible on a busy inpatient medical unit, leads to improved detection rates, improves documentation, and makes screening more convenient.
  • Implementation of Fall TIPS (tailoring Intervention for Patient Safety) to Reduce Patient Fall Rate

    Thang, Kathy; Bennet, DeNiece (2022-05)
    Problem: Inpatient falls are the most common safety event that negatively impacts both patients and the healthcare systems. In a suburban community hospital, the progressive care unit (PCU) experienced a 25% higher fall rate in 2020 than all other units in the hospital combined despite comprehensive fall prevention protocols. Therefore, a quality improvement (QI) project was implemented on this floor and on the Immediate Care Unit (IMCU). Purpose: This QI project aimed to implement a bedside Fall TIPS poster to communicate patientspecific risk factors to the multidisciplinary teams and use a tailored fall prevention plan based on their fall risks while engaging patients and their families to reduce fall rates. Methods: This project was implemented over 13-weeks during the fall of 2021. Clinical nurses on PCU and IMCU were educated on the bedside Fall TIPS posters with their patients and family members. Clinical nurses went over the bedside Fall TIPS poster at admission and every shift with their patients and families. The poster was placed on the wall next to the whiteboard as a reminder for the patient and a visual aid for the multidisciplinary team involved in the patient’s care. All patients admitted to the units between September 2021 and mid- December 2021, were included. All clinical nurses on both units completed a competency checklist before implementation. Data on the Fall TIPS poster use was collected using an audit tool created by the project leader. Unit fall rate data was collected through the hospital incident reporting system. Results: 100 % of clinical nurses were educated on the use of the Fall TIPS. Based on weekly audits, approximately 20-80% of the nurses adhered to the use of the Fall TIPS poster. There was a total of 4 falls on PCU and one fall on IMCU. Conclusion: Bedside Fall TIPS poster helped patients, families, and the care team understand the patient’s fall risk and interventions.
  • Implementation of Delirium Screening in Thoracic and Surgical Intermediate Care Units

    Faherty, Karen M.; Jackson-Parkin, Maranda (2022-05)
    Problem: Delirium is a disorder experienced by 13-50% of patients over the age of 50 during their hospital stay. The thoracic and surgical intermediate care units (TIMC and SIMC) at a large, teaching hospital care for many elderly patients at high-risk of delirium, but unit-level chart audits revealed a 0-5% incidence of detected delirium. Current practice did not include delirium screening, which placed patients at higher risk for undetected delirium. Unrecognized and untreated delirium may lead to longer hospital stays, higher risks of falls, and longer duration of delirium episodes. Purpose: The purpose of this quality improvement project was to implement delirium screening using a validated screening instrument to improve delirium detection on the thoracic and surgical intermediate care units. Methods: The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), a validated screening instrument (sensitivity 81%, specificity 95.8%; inter-rater reliability kappa=0.79-0.96), was implemented on two high-acuity intermediate care units over a fifteen-week period (September to December 2021). The CAM-ICU was located in the electronic health record (EHR), and all registered nurses (RN, n=47) and advanced practice registered nurses (APRN, n=16) on the two units were educated on how to complete the screen and manage screening results. Chart audits of the EHR were completed weekly for every patient admitted to the two units to assess adherence to the screening procedures. Results: Staff on both units achieved and sustained a high (>90%) rate of adherence to delirium screening among SIMC patients (n=110) and TIMC patients (n=101). Of the patients screened, 10% were identified as positive for delirium on the SIMC and 12.8% were identified as positive for delirium on the TIMC. Nurses notified the APRN or covering medical provider about patients with first-time positive screens 100% of the time. No special-cause variation was noted in the number of transfers to a higher level of care, falls, or restraint use. Conclusions: Implementing the CAM-ICU can increase delirium detection and interdisciplinary team communication on thoracic and surgical intermediate care units. Having the instrument in the EHR was a major factor in assuring adherence to and sustainability of the delirium screening procedures.
  • Implementation of Standardized Patient Handoff on a Medical Surgical Inpatient Unit

    Delgado, Jamie L.; Bode, Claire (2022-05)
    Problem: Poor communication within a health care organization was cited as a main cause of error and poor patient outcomes especially during transition of care. An estimated 80% of medical errors in patient care are related to miscommunication in handoff. Inadequate patient handoff communication can lead to delay in treatment or hospital discharge. Improved communication with standardized handoff has shown to have a positive correlation to conveying necessary information, preventing errors, and improve patient safety. The Report and Learn (RL) is an incident reporting system that monitors patient safety events at a community hospital. Approximately one to six safety incidents were reported weekly by the inpatient medical/surgical unit. Communication delivery may have accounted for two to six incidents of error or near error in monthly safety reports. Evidenced reviewed showed that a structured handoff tool can help to promote sufficient input from the nurse to communicate pertinent patient care information at change of shift to improve giver to receiver communication and prevent error. Purpose: The purpose of this project was to implement and evaluate the effectiveness of a standardized handoff tool for nursing shift report to improve communication and reduce medical errors. Evidence reviewed supports the I-PASS (Illness severity, patient summary, action list, situation awareness and contingency plan, and synthesis by the receiver) handoff tool for this implementation. Methods: This was a quality improvement (QI) project that measured percent errors related to poor handoff on the medical/surgical unit. The medical/surgical unit has 36 beds with 35 full time nursing staff. The QI project collected data on communication with use of I-PASS over a 15-week period. STANDARDIZED PATIENT HANDOFF 3 Results: Findings indicated a 69% staff education of use with the I-PASS tool. There was a 23% decrease in error over the course of project implementation and a 50% decrease from start of project to completion. Conclusion: The I-PASS tool was useful and relevant to decreasing communication error and patient safety events. Opportunity to further expand use of the I-PASS tool to other units would further validate the tool’s effectiveness.
  • Implementation of an Algorithm to Prevent Pressure Injuries Among Immobile Residents

    Robinson, Maria Esther; Callender, Kimberly (2022-05)
    Problem: Pressure injuries (PI) stages II, III, and IV became a serious health problem at a long-term care (LTC) facility in Maryland during the unprecedented times of the Coronavirus 2019 (COVID-19) pandemic. The executive director reported that several immobile residents in each of the facility’s (n=12) three units developed PIs: seven sacral ulcers, stages II, III, and IV; five heels, consisting of two right outers; and three left outers, stages II and III. In addition, (n=2) PIs stage III became infected. Purpose: The purpose of this quality improvement (QI) project was to implement a PI algorithm for prevention and expeditious intervention for PIs. Methods: The QI project was implemented August-December 2021. Pre-implementation, in person, the DNP student educated change champions, registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs)/geriatric nursing assistants (GNAs), on the algorithm. After the education session, a copy of the algorithm was laminated and posted at each nursing station in the three units. Additional strategies included training CNAs/GNAs on adhering to the turning schedule and filling out the log posted in each resident's room. In addition, each nursing staff member completed a pretest, then viewed an educational PowerPoint, and completed a post-test to evaluate knowledge of PIs. During implementation, the DNP student tracked structure, process, and outcome measures weekly through chart audits and PI prevention rounding audit tool. Results: A pie chart displayed structure measures; 80% (n=20) of nursing staff were trained on the algorithm. Zero new PIs stages II, III, and IV were reported during implementation of the algorithm. Sacral PIs stages II (n=7) improved. At week ten, 100% algorithm compliance was achieved; additionally, 90% was achieved at weeks twelve and thirteen. Conclusion: Implementation of the PI algorithm at the LTC facility during COVID-19 effectively improved residents' quality of life, prevented PIs, and decreased morbidity and mortality. Continuing education and training will be needed to maintain sustainability.
  • Fall Prevention: A Purposeful Rounding Quality Improvement Project

    Fourhman, Shelly K.; Bennett, DeNiece (2022-05)
    Problem: Patient falls within the hospital setting continue to be a problem and are associated with increased patient morbidity and mortality. A medical-surgical unit within a community hospital has identified falls as a problem and fall rates have exceeded the unit assigned benchmark. Many healthcare facilities are using the method of rounding addressing the 4P’s (possessions, position, pain, and potty). Despite using the 4 P’s rounding, there has been an increase in patient falls and miscommunication among staff and patients. Purpose: The purpose of this project was to increase utilization of the rounding clock, a complementary tool for purposeful rounding which assesses the 4P’s on a medical/surgical unit of a community hospital. Methods: The QI project focused on utilizing the rounding clock, which encompasses the 4P’s. Through random observation of the nursing assistant and patient interaction, weekly data collection and analysis highlighted purposeful rounding while achieving the goal of 100% reduction in falls by the end of the QI project. Data collection was entered weekly and analyzed by the project leader. Falls knowledge and self-assessment of competency was collected pre-implementation. Results: Nursing assistants (81%) received education pre-implementation. Compliance averages for rounding observations increased 16%, rounding clock 18%, and communication board documentation (24%) from September which was used as a baseline to October through December. The unit had 16 falls in calendar year 2020 with a falls rate of 3.16 (falls rate per 1,000 patient days); total falls decreased to 9 in calendar year 2021 with a fall rate of 1.187, which was below the target of 1.86 or less. Conclusion: The goal of 0% falls was not met. Though the QI project did not yield the target goal of 0% falls, with the increase in purposeful rounding, despite the multifaceted limitations, the overall patient fall rate decreased by 44% which is supported by the literary reviews. Keywords: purposeful rounding, hourly rounding, fall prevention, nurse communication, patient satisfaction, patient outcomes.
  • Utilization of Deterioration Index Model to Improve Sepsis Management in Medical Unit

    Sherpa, Phudorji L.; Gourley, Bridgitte (2022-05)
    Problem and Purpose: One third of inpatient deaths are related to sepsis. In a medical unit, a sample of 245 sepsis patients in 2020, 28.4 % failed timely sepsis treatment and 35.4% lacked blood culture within 3 hours sepsis recognition. The implementation site was a 35-bed adult medical unit where the utilization of the existing sepsis best practice alert (BPA) in the EHR was substandard. From November 2020 to February 2021, unit nurses bypassed or ignored 84% of sepsis BPA. This DNP project sought to improve recognition of early sepsis complications and management in a medical unit by implementing a new EPIC BPA Deterioration Index with Sepsis Score (DISS) and sepsis bundle. Methods: Based on Press Ganey Sepsis Workflow, nursing staff in the unit were provided education and training on sepsis, sepsis bundle, and early identification and management of sepsis. Nurses were also provided training on DISS, which was incorporated into the hospital EPIC system. Measurements included DI BPA encounters, length of stay (LOS), and Blood culture draw compliance. The intervention site was a 35-bed adult medical unit. Results: Blood Cultures in <3 hours improved an average of 30% for the intervention period, and the average monthly length of stay trended down during the intervention. The number of alerts decreased significantly during the intervention period. Conclusion: Machine learning prediction models such as DISS with sepsis bundle can be utilized to identify early sepsis complications and improve timely blood culture compliance, and may lower LOS for patients with sepsis.
  • Promoting Early Mobility in The Medical Intensive Care Unit

    Lanier, Tatyauna M.; Bundy, Elaine Y. (2022-05)
    Problem: Evidence has shown that early mobilization can improve patient outcomes, expedite recovery time, and shorten the length of stay for hospitalized patients. However, early mobilization of critically ill patients is not routinely practiced in an academic medical center's medical intensive care unit (MICU). The MICU has a higher immobility rate than other units, with only 29% of patients receiving early routine mobilization. Plans to encourage mobility are not routinely discussed during patient care rounds by the multidisciplinary healthcare team in the MICU. Purpose: The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of an evidence-based nurse-driven mobility algorithm for adult patients admitted or transferred to the MICU. Methods: The mobility algorithm was implemented in an adult MICU over 15 weeks from August to December 2021. A mobility algorithm was developed based on evidence-based practice recommendations. Following staff education, the mobility algorithm was reviewed with each patient admitted or transferred to the MICU by the oncoming shift during nurse handoff to assess the patient's mobility level and plans to promote mobility. Weekly mobility reports, electronic chart audits, and observation audit tools were utilized to collect staff compliance on utilizing the mobility algorithm. The data was analyzed using run charts to track changes in mobility screens, mobility level door signs, and patient activity. Results: There were positive and negative trends among 520 patients with mobility rates. Results showed that average mobility screen increased (30% to 100%) and mobility level door signs (5% to 100%). There was an increased in patients’ mobility level (29% to 80%) during the fourth week of implementation. Analysis of all run charts showed no shift in trends with rates of early patient mobility utilizing a mobility algorithm. Conclusion: The anticipated outcomes of this QI project were achieved with improvement in inpatient mobility screening, mobility level door signs, and documented patient activity to increase early patient mobility.
  • Implementation of a Blood Product Conservation Project on the Cardiac Surgery Intensive Care Unit

    Gutwald, Cecilia; Jackson-Parkin, Maranda (2022-05)
    Problem: In 2020, 16 blood products were wasted (0.34% of products issued) on a 22-bed Cardiac Surgical Intensive Care Unit (CSICU), reflecting over $2,000 in wasted revenue. Wasting these limited life-saving resources infers disrespect to donors and indicates systemrelated inefficiencies. Incorrect storage conditions of unused Massive Transfusion Event (MTE) products render them unsuitable for re-entry into blood bank circulation due to internal product temperatures deviating from established safe parameters, contributing to 50% of the wastage in 2020. Purpose: The purpose of the quality improvement (QI) project was to implement and evaluate an evidence-based blood cooler checklist presented on MTE coolers that identifies the storage and transport conditions of blood products for registered nurses (RNs) in the CSICU. Methods: Registered nurses (RNs) were able to access a blood product storage checklist by scanning Quick Response (QR) codes on MTE cooler lids. CSICU RNs completed and submitted these checklists through Smartsheet, a HIPAA-compliant file-sharing system, permitting data collection on RN adherence to the practice change. One-on-one education and knowledge comprehension assessments for CSICU RNs, advanced practice providers (APPs), and blood bank staff were delivered by project champions. The project outcome, blood waste, was measured using the institution’s event-reporting system. Results: Post-implementation data revealed 100% (n=122) of CSICU RNs and 100% (n=19) of CSICU APPs were educated on blood product conservation techniques, 100% of MTE coolers issued (N=52) contained a QRcode accessible checklist, 67% (n=35) of the MTEs were associated with a completed checklist, and 13 blood products were wasted (0.86% of products issued [N=1,510]). While blood product wastage as a percentage issued increased from 0.34% pre to 0.86% post-implementation, there was a reduction in MTE blood waste due to improper storage conditions (50% pre versus 46% post-implementation). Blood waste due to improper storage was associated with only one MTE cooler post-implementation, as opposed to multiple MTE coolers pre-implementation. Conclusions: The use of an evidence-based checklist on MTE coolers in addition to RN and APP-directed educational sessions on blood conservation techniques can serve to increase staff adherence with proper blood product storage conditions, decreasing blood product wastage.
  • Nursing Process Change with Task Reminder to Improve Inpatient Colonoscopies

    Kutch, Victoria; Gourley, Bridgitte (2022-05)
    Problem: At a community hospital in the mid-Atlantic region, a pattern of frequent cancellations and repeated colonoscopies were identified due to inadequate bowel preparations. Root causes of poor practice included a gap in protocols, missing documentation, poor communication, leadership changes, budget, and high patient ratios. Purpose: This project aimed to increase the quality of bowel preparation and decrease canceled and rescheduled procedures through a nurse process change with a task reminder. Methods: Three units were identified with frequent colonoscopy orders. Nursing staff were educated about administration standards and the evidence supporting adequate bowel preparation. The task reminders include start/stop times, percentage consumed, and additional feedback. Charts were audited over eight weeks. The staff received documentation feedback and education weekly. Results: Due to many COVID-19 related barriers, only 27 percent of nurses were educated. Five percent of the task reminders were placed in the drop boxes during the eight weeks. The run charts revealed an upward trend of successfully completed colonoscopies over eight weeks Conclusion: Evidence has shown that nurse facilitated bowel prep and increased education increases successful bowel prep and decreases adverse events. Task reminder submissions were minimal; however, many nurses were further educated about bowel preparation and the number of inadequate bowel preparations decreased. A future recommendation is to adopt this project in the medication administration record, which will allow for simpler and easier documentation by nursing staff.
  • Implementation of a Cue Card Tool to Increase Adherence to Chlorhexidine Treatments

    Kuntz, Tamra; Wise, Barbara V. (2022-05)
    Problem: Hospital acquired infections (HAIs) place a significant economic burden on healthcare institutions and increase patient risk for morbidity and mortality. Daily chlorhexidine gluconate (CHG) treatments decrease the incidence of HAIs. Non-adherence to CHG treatments on a 30-bed general pediatric unit increases the risk of HAIs. Cue cards, a form of Kamishibai cards (K-cards) are utilized in the health care setting to improve adherence to protocols or as a communication tool for evidence-based practice and daily auditing processes. Purpose: The purpose of this quality improvement (QI) project is to implement CHG Cue Cards during nursing handoff to improve communication and increase adherence to CHG treatments. Methods: The QI project was implemented on a general pediatric unit from September- December 2021. A multidisciplinary team facilitated the implementation using the MAP-IT framework. A Cue Card tool was created, modeled from the concept of K-cards. Parent education material included in the unit orientation packets highlighted the benefits of CHG treatments. Cue cards were utilized during nursing handoffs to improve communication about infection control measures. Weekly electronic and paper audits tracked daily CHG treatments, presence of central lines (CL), utilization of cue cards, and occurrence of HAIs. Strategies included emails, observations, and reminder cards placed at each nurse computer. Results: In the first implementation period, initial data of all inpatients showed a 48% treatment adherence rate versus 44% post implementation, with zero percent cue card use. In the second implementation period which examined patients with CL and/or indwelling catheters, initial data revealed that 61% received treatment versus 62% post implementation; mean of seven percent cue card use. There was one HAI noted during the 15-week period.
  • Implementing the Early Onset Sepsis Calculator in a Neonatal Intensive Care Unit

    Levy, Stephanie R.; Fitzgerald, Jennifer (2022-05)
    Problem& Purpose: While intrapartum antibiotics have decreased the incidence of early onset sepsis (EOS) in infants > 34 weeks, there has not been an equal decrease in how often antibiotics are administered to treat suspected EOS. The use of an EOS calculator to help guide management has been shown to safely decrease the use of antibiotics. In this 52-bed neonatal intensive care unit (NICU), providers did not use an EOS calculator and the interpretation of the recommendations across providers greatly varied. There is no standard algorithm to stratify at risk infants for EOS in order to differentiate infants requiring antibiotics from those who can be safely observed. The purpose of this quality improvement project is to implement and evaluate the effectiveness of the early onset sepsis calculator in a level IV NICU for infants > 34 weeks gestational age on reducing antibiotics usage. Methods: Over a 15-week period in the fall of 2021, a multidisciplinary team implemented the EOS calculator to be utilized in the electronic health record (EHR). Data collection occurred through chart review of any infant > 34 weeks gestation that was admitted to the NICU. Data that was collected included gestational age, calculator use and recommendations, antibiotic administration, was a CBC and a blood culture obtained, and was there adherence to the calculator recommendations. Results: Post implementation 10% (n=110) of infants admitted to the NICU that were eligible for use of the EOS calculator had documentation of use within the EHR. The goal remains that 100% of infants > 34 weeks will have recommendations documented on the EOS calculator. Approximately, 50% of infants received antibiotics on admission. Conclusions: The education disseminated on the location and use of the EOS calculator has led more providers to utilize the calculator than prior to the implementation. The use of the EOS calculator has created better communication amongst providers about how to manage infants at risk for EOS.
  • Implementing an Electronic Telemetry Downgrade Score on a General Surgical Unit

    Jenkins, Helena B.; Bode, Claire (2022-05)
    Problem: The problem at a Magnet® designated medical center was the continued use of telemetry monitoring when the monitoring was no longer indicated on adult non-intensive care patients. Continued telemetry past patient need, limits the availability of this monitoring for patients who require it when there is a limited supply of telemetry-monitoring packs. The hospital has a Clinical Decision Support (CDS) Telemetry Downgrade Score (TDS) tool in the electronic health record (EHR); however, it is underutilized. Evidence supports the use of both CDS and TDS by providers and nurse helps to yield fewer telemetry orders and less time on telemetry. Inappropriate ordering of telemetry monitoring may adversely affect both patient and staff satisfaction and increase the length of stay (LOS). Purpose: The purpose of this quality improvement project was to implement the use of the TDS tool for the providers and nurses to evaluate the patients need for continued telemetry. Methods: The providers and nursing staff were educated on the use of the TDS tool and the 2017 AHA guidelines. Mentoring and support were given to providers and nurses through emails, rounds, and meetings. During a 15-week implementation timeline, retrospective audits were completed collecting data on the duration of telemetry hours’ time stamps and indication for use, including pre and post intervention audits. Using run charts, measurement trends were analyzed. Results: Nurses and providers were educated on the intervention meeting the goal for day shift of 65 staff or 30% of the total staff. Over the 15 weeks, 415 patients were placed on telemetry. Telemetry hours for the pre-intervention period was 1034 median hours compared to 614 post-intervention period. Displaying evidenced-based guidelines and an electronic TDS, appropriate ordering improved by almost 20% and duration decreased by 422 hours. Moreover, this project provided more availability to monitoring packs for those patients’ requiring placement. Conclusions: When a TDS tool was used following education and active stewardship, more patients were appropriately placed as well as appropriately discontinued on telemetry, resulting in increased telemetry monitoring packs capacity.
  • Implementation of Trauma Survivors Screen to Improve Utilization of Trauma Survivors Network

    Sweeney, Liane S.; Wilson, Tracey L. (2022-05)
    Problem & Purpose: At a large, level-one trauma center, there is a lack of screening for post-traumatic stress disorder (PTSD) and depression among the adult trauma population. Routine screening for PTSD/Depression risk among this patient population is recommended by national professional organizations, due to the significant impact they can have on long-term outcomes. The purpose of this quality improvement project was to educate trauma nursing staff on the importance of screening patients for PTSD/Depression, implement the Injured Trauma Survivors Screen (ITSS) into the routine care of traumatically injured patients, and increase patient education on the available support network program present within the organization. Methods: Data was tracked and analyzed through de-identified HIPPA compliant excel spreadsheets. Measures tracked throughout implementation were the following: nursing staff that received education on ITSS and support network, patients screened using the ITSS, patients identified as being “at-risk” through scoring of the ITSS, and patients educated on the available support network. Results: More trauma patients were screened for PTSD/Depression risk and educated on the support network compared to baseline data. Trends in the data analyzed showed a positive correlation between patients screened with the ITSS (9.6%, 6/62 eligible) and patients educated on the support network (46%, 29/62 eligible). Conclusions: Numerous barriers/limitations were encountered, emphasizing the need for the continuation of educating staff and patients on the incidence, and potential implications, of the development of PTSD/Depression in this already vulnerable population. Efforts should continue to address the mental health of trauma patients, working to decrease the incidence of PTSD/Depression and improve the trauma survivors’ resiliency and long-term outcomes.
  • Implementing the Infant Positioning Assessment Tool in a Neonatal Intensive Care Unit

    Buchynsky, Ivanna; Connolly, Mary Ellen (2022-05)
    Problem: Infants in the neonatal intensive care unit (NICU) are at increased risk for long-term complications and disability. Developmentally supportive positioning improves neurodevelopmental outcomes in this patient population. Infants hospitalized in NICUs with standardized positioning practices benefit from enhanced developmental outcomes. The valid and reliable Infant Positioning Assessment Tool (IPAT) promotes appropriate infant positioning and encourages caregiver accountability in developmentally supportive positioning practices when used with bedside education. In an academic community medical center NICU, there was no standardized positioning practice in place. Baseline data indicated that 75.1% of infants were being positioned in a developmentally supportive manner. Purpose: The purpose of this quality improvement project was to implement the IPAT to improve consistency in developmentally supportive positioning by promoting appropriate positioning and encouraging accountability in positioning practices. The goal was for 100% of eligible patients to have an acceptable IPAT score of ≥9 by completion of the implementation period. Methods: The project took place in a 26 bed, Level III NICU from November 2021 to January 2022. All infants over 32 weeks gestation, 1,500 grams, past the first 72 hours of life, and admitted to the unit for more than one twelve-hour shift were eligible. Implementation involved a bedside IPAT reference, an online educational training module, informational reference posters, and ongoing bedside education. Data was collected semiweekly on IPAT scores of eligible patients once per shift. A percentage of IPAT scores ≥9 was calculated for weekly averages.

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