Recent Submissions

  • Advance Care Planning in Advanced Heart Failure

    Armstead Wulf, Janet
    Background. Nearly one in five patients recently admitted to the hospital for heart failure will die within 30 days of discharge. Despite this poor prognosis, most do not recall discussing end of life preferences with a health care provider. Advance care planning helps to ensure that patients receive care that aligns with their goals and wishes, and helps engage them in shared decision making with providers in an ongoing and iterative process. The American College of Cardiology 2017 ACC Pathway for Optimization of Heart Failure Treatment recommends the use of patient decision aids followed by personalized advance care planning conversations. Local Problem. Patients with advanced heart failure who are referred to the outpatient heart failure clinic are generally not candidates for advanced interventions such as transplant or ventricular assist devices and are at high risk for hospital readmission. The purpose of this project was to align clinic practice with current recommendations by increasing the number of ACP conversations conducted by nurse practitioners through implementation of a patient video decision aid as a catalyst for conversation. Interventions. During a follow-up outpatient visit to the clinic after hospitalization, patients were shown a 6-minute video introducing them to ACP. The video describes levels of medical care they may choose if they become sick including life prolonging care, limited medical care, and comfort care. The video was shown by clinic staff, which included a community health worker, a nurse coordinator and an infusion nurse. Follow-up conversations were conducted by clinic nurse practitioners and documented in the electronic health record using standardized documentation. Data collection occurred over 10 weeks and data were compared to a comparable period in the preceding year. Results. Nearly one third (n=62, 30%) of eligible patients were shown the ACP video and nearly two thirds (n=40, 65%) of those who saw the video had a follow up ACP conversation with a nurse practitioner. This was a 20-fold increase from two documented ACP conversations in a comparable period in the preceding year. A chi-square test was used to test associations of the occurrence of ACP conversations at baseline and after the instructional video was added to visits. Using a nominal scale, patients seen after the video was added were significantly more likely to have an ACP conversation initiated by the provider (x 2 = 19.66, df = 1, p =<.001). There was no difference between the baseline and implementation groups in whether patients had an advance directive in the medical record (x 2 = .14, df = 1, p < .05). Conclusion. Use of a video decision aid was an effective way to increase the number of ACP conversations with patients who have advanced heart failure. The sustainability of this practice change hinges on access to appropriate patient video decision aids. The use of Medicare ACP billing codes may offset the cost of video access.
  • Implementation of the Fall Round Checklist in Hospitalized Adult Patients

    EBONGUE, JULIENNE; Clark, Karen (2019-05)
    Background: One million inpatient falls occurs in U.S hospitals annually, with medical units incurring the highest fall rates. In fiscal year 2018, 325 falls occurred in patients at high risk for falls at a local academic hospital. One hundred and forty-eight or 46% were found to have gaps in fall prevention practices at the time of fall. As costs associated with falls are no longer reimbursed by the Centers for Medicare and Medicaid, the organization’s goal was to improve fall prevention practices in low performing units. Clinical audits on falls have been found to directly measure fall prevention practices by assessing nursing compliance. Methods: This Doctorate of Nursing Practice project was implemented over a 14 week period. Data was collected while conducting an electronic health record audit and direct bedside observations using the “Fall Round Checklist” by the project leader and resource nurse participants. Percentages were used to evaluate nursing compliance with each item on the checklist from data entered into Excel. Results: Eleven medical-surgical units were audited. Two hundred and fifty- five patients were identified as high risk for falls. Consistent fall prevention interventions were observed in fall risk assessment documentation (87%). Environmental measures (call bell in sight and within reach, bed in low position, table and personal items within reach, clutter free room) averaged 96% compliance. Lack of consistency was noted with documentation of fall interventions (41%), turning the bed alarm on (46%), yellow armbands (50%), or supervision with toileting (41%). Conclusion: Successful implementation of the “Fall Round Checklist” identified gaps in practice that will assist the organization in improving fall prevention practices in low performing units through corrective actions of care processes, thus ensuring safe and quality care.
  • Prediabetes Identification and Diabetes Prevention Program Referral

    Hansen, Shannon C.; Bode, Claire (2019-05)
    Background: Diabetes is a common chronic disease and can lead to comorbidities such as coronary artery disease, stroke, hypertension, peripheral vascular disease, nephropathy, neuropathy, and retinopathy. Prediabetes is an asymptomatic disease that precedes type 2 diabetes and affects 84 million Americans. Participating in a structured diabetes prevention program (DPP) incorporating education on healthy diet, physical activity of at least 150 minutes per week, and weight loss of at least 5-7% can prevent or prolong a diabetes diagnosis. Local Problem: A suburban primary care clinic was inconsistently identifying patients with prediabetes and not referring them to an evidence-based diabetes prevention program. The purpose of this project was to implement and evaluate a quality improvement project incorporating prediabetes identification and referral to a DPP at the primary care clinic. Interventions: At the primary care clinic, adults identified with prediabetes who met inclusion criteria were referred to an evidence-based diabetes prevention program approved by the Center for Disease Control and Prevention (CDC). Criteria included being 18 years of age or older, having lab values in the prediabetes range (HgA1c 5.7-6.4%), and did not have a previous diabetes diagnosis. Medical assistants were educated on the prediabetes identification and referral process for the first two weeks of the project. Implementation began at week three and continued through week 14 with the intention of continuing the program after the project completed. Results: A total of 764 patients were seen in the clinic over a 12-week timeframe. Of the patients who were seen, 335 underwent laboratory analysis of glycated hemoglobin (HbA1c) with 130 of those results between 5.7-6.4%. Considering diabetes prevention program inclusion criteria, 44 patients were removed for having a previous diabetic diagnosis or a BMI < 24 (<22 if Asian). Of the remaining 76 patients, 35 were identified, based on chart review, as having an “elevated HbA1c” or prediabetes. Four of those patients were notified of the DPP and referred to the program. Conclusions: Overall, office staff was willing to learn how to identify prediabetic patients and refer them to a DPP. Patients identified with prediabetes and notified of the DPP were willing to be referred. Limitations of implementation were identified and if altered could improve the volume of patients referred to a DPP. Sustaining the prediabetes identification and referral process at this clinic could help to detect additional patients with prediabetes and help to prevent or prolong a diabetes diagnosis.
  • Implementation of a Referral Criteria for Acute Pain Service on a Post-Surgical Inpatient Unit

    Smith Azarcon, Sharon-Marie; Wiseman, Rebecca (2019-05)
    Background One in every four Americans experience pain for greater than 24 hours. Pain is a major reason Americans access the health care system. Uncontrolled pain can lead to longer hospital stays, increased rate of readmissions, and increased risk of arising complications. Acute Pain Service (APS) is a team that can manage patient’s pain during the hospital stay. APS is found to decrease length of hospital stay and improve pain management in patients. A referral criteria instrument is a tool that guides nurses in assessing patients that meet criteria for APS. This referral criteria instrument can assist in increasing the number of APS consults. Local Problem Low APS consults were observed to be a practice problem in a post-surgical unit of a community hospital. In addition, the unit was observed to have uncontrolled pain as indicated by low patient satisfaction scores collected from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The hospital has an approved referral criteria instrument that nurses could access to determine if patients meet criteria for a referral to Acute Pain Service (APS). However, nurses were resistant to the APS team due to the misperception of pain medication administration and nurses believing that utilizing APS for pain management led to opioid addiction. Interventions This quality improvement project took place over a 14-week period. During weeks 1-2, training on referral criteria via informal meetings was given to the clinical site representative, unit manager, pilot team (i.e. nurses on the unit), and pain champions on the unit. Printed copies of the referral criteria instrument were posted in the nurses’ station, nurses’ break room and walls of the bathroom. Implementation of the project occurred during weeks 3-10. The pilot team was reminded to utilize the referral criteria instrument daily. Patients that met criteria for APS were discussed during daily interdisciplinary rounds. Weeks 11-14 consisted of data collection and analysis for the project. Results The post implementation of the referral criteria instrument revealed an increase in the percentage of patients consulted to APS. Post-implementation results showed that 53.7 % of patients were consulted to APS, compared to pre-implementation results of 25.3% of patients consulted to APS. Findings revealed that the difference was statistically significant using the Chi-Squared test, p = 0.002 (p< 0.05). Conclusion The implementation of the referral criteria for APS was beneficial to the unit based on the increase of APS consults. The percentage of consults to APS post implementation was 53.7 %. This was a 28.4% increase of APS consults on the unit. Training on the referral criteria instrument and understanding the purpose of APS gave positive outcomes for the unit by increasing APS consults on patient that met criteria for APS. In addition, the increase in APS consults should furthermore lead to increased patient satisfaction and increased HCAHPS scores.
  • Incorporating Advance Care Planning Discussions into Annual Wellness Exams

    Smith, Danielle L. C.; Bundy, Elaine (2019-05)
    Background: Advance care planning, a part of the Medical Orders for Life-Sustaining Treatment (MOLST) form and Advance Directives (ADs), is an important discussion that older adults may use to review and record their goals of care in the event of incapacitation or inability to communicate. Conducting regular advance care planning discussions with older adults can help avoid unnecessary hospitalizations and high healthcare costs. However, there is a lack of advance care planning regulation in independent living centers, which creates inconsistencies between documents and patients’ wishes. Local Problem: The nurse practitioner at an urban continuing care retirement community identified advance care planning as a priority that required a quality improvement project in the independent living facility’s ambulatory care center. A formal audit of resident charts had not been conducted to evaluate completion of advance care planning forms and whether resident preferences matched between MOLSTs and ADs. There was also a lack of a systematic approach to ensure advance care planning discussions were occurring at regular intervals. The purpose of the quality improvement project was to audit charts for MOLST and AD discrepancies and to implement a systematic approach to prompt discussions about patients’ preferences for care. Interventions: Prior to the intervention, a chart audit comparing independent living facility residents’ MOLSTs and ADs was performed over four weeks to assess for inconsistencies in goals of care such as desire for transfer to the hospital, placement and use of feeding tubes, and intravenous therapy. After the audit, the 10-week implementation phase occurred, consisting of a systematic approach to implementing advance care planning discussions during scheduled Medicare annual wellness visit. The advance care planning discussions helped determine if any preferences had changed and required a MOLST or Advance Directive documentation change. Results: A total of 174 residents’ charts were reviewed. Of the 61 residents who had both a MOLST and AD in the chart, two of those residents had a discrepancy regarding artificial hydration and nutrition. There was a total of eight Medicare annual wellness visits – all residents had an advance care planning discussion but no resident desired a change to the plan of care that required a MOLST change. Unintended results showed that 15 residents were missing MOLSTs, 12 residents had different paper and electronic MOLSTs, and 24 residents had MOLSTs that were voided incorrectly in various ways including not voiding the old MOLST or only voiding one page of the old MOLST. Conclusions: Advance care planning is a valuable discussion to not only decrease hospitalizations and health care costs, but to improve quality of life for older adults. Audits can be instrumental in discovering discrepancies in patient preferences and workflow issues. This can help staff identify ways to fix MOLST tracking processes and to sustain routine advance care planning discussions. Though hospitalization rates were unable to be determined during the short implementation period, systematic processes can provide a basis for consistent advance care planning discussions to assess patient preferences in independent living facilities.
  • A Quality Improvement Project Using Fall Management Algorithms in Long-Term Care

    Lopez, Bianca E.; Windemuth, Brenda (2019-05)
    Background: Falls have been an ongoing and reportable problem in long-term care facilities. Moreover, falls can lead to serious physical, psychological and financial consequences for residents, their families and the staff. Each resident has individual risk factors that may lead to falling. Multifactorial interventions, or strategies that target multiple risk factors for falls, have been shown to reduce the number of falls and are recommended for fall prevention and management. The initial step in fall prevention and management includes identifying each resident’s risk factors upon admission into the facility, and after each fall. Local Problem: The medical administrators from a Mid-Atlantic facility expressed a need for a fall prevention and management intervention because of the increased number of falls, despite frequent changes to the facility’s fall management protocol. The latest protocol included fall risk assessment upon admission and fall incident documentation by nurses after each fall. The purpose of this project was to improve fall management in a long-term care unit through implementing the Post Fall Algorithm and reinforcing the Fall Assessment Algorithm with the goals of improving identification of fall risk factors, compliance on post-fall algorithms and overall reducing the number of falls. Interventions: The quality improvement project occurred over a 10-week period in a 33-bed long-term care unit located in a Mid-Atlantic facility. Participants included the certified nursing assistants, certified medicine assistants, registered nurses, nursing administration and providers. The first two weeks included collecting baseline data, recruiting of champions, and training of participants on the algorithms and the fall forms. The Fall Assessment Algorithm provided the staff with a list of intrinsic and extrinsic fall risk factors. The Post Fall Algorithm listed the process to complete forms and assessments within 72 hours after a resident fall. The algorithms were implemented during weeks three through ten, and the impact was monitored by tracking fall rates and compliance with the process of the post-fall algorithm. Descriptive statistics were used to analyze the completion of the Post Fall Algorithm, and determination of trends on fall incidences through the data on the forms. The generated report on fall incidence was analyzed to determine the relationship between the implementation of the algorithm and the fall incidence in the long-term care unit. Results: There was an overall decrease in the average number of falls in the unit from before (𝑥̅=3.33) to after (𝑥̅=2.63) implementation of the Post Fall Algorithm, accompanied by more than 75% staff compliance on documentation of the post fall forms. An inverse relationship was noted between staff compliance and the number of falls. Incidental finding included that the majority of the falls happened in the resident’s room (90%) and during a change in position (86%). Conclusion: Identifying each individual’s risk factors for falls and performing comprehensive evaluation by a proactive multidisciplinary team after a fall are important in developing individualized plans of care and may potentially reduce the number of falls.
  • Implementation of Function Focused Care to Change Practice Behaviors of Staff

    Kim, Jade S.; Windemuth, Brenda (2019-05)
    in an assisted living community by implementing a Function Focused Care philosophy. Function focused care involves teaching direct care workers to evaluate older adults’ underlying capability with regard to function and physical activity and optimize their participation in all activities. Background: Assisted living communities are home to over 830,000 adults, who are mostly 85 years and older. Residents spend the majority of their waking time sedentary and experience more decline in functional performance compared to nursing home residents. Decreased physical activity and functional impairment are strong predictors of adverse outcomes, institutionalization, and decreased quality of life. Routine care provided by direct care workers traditionally focuses on task completion, which limits residents’ function and physical activity. Task-focused care is perceived to be safer and more time efficient. Conversely, examples of function focused care interactions include: modeling behavior for residents (i.e. oral care, eating), providing verbal cues during dressing, walking a resident to the dining room rather than transporting via wheelchair, doing resistance exercises with resident prior to meals, and providing recreational physical activity. Prior research supported the benefits of Function Focused Care, which have included improving or maintain function, mood, and behavior, and decreasing falls and transfers to the hospital for non-fall related events. Function Focused Care is implemented using a four-step approach, which includes: (1) Assessment of environment and policies, (2) Education of staff, residents, and/or families, (3) Development of Function Focused Care goals in service plans for residents, and (4) Mentoring and motivating the staff and residents. Quality improvement methods: This quality improvement project was implemented over a 16week period using the Evidence Integration Triangle, the Social Ecological Model, and Social Cognitive Theory. A stakeholder team and champion within the setting were identified and monthly meetings were held with the stakeholder team and setting champions to implement the four steps of the intervention. The site was an 81-bed assisted living community with 25 direct care workers. Outcomes were obtained at baseline and 4 months post-baseline and included knowledge of Function Focused Care and evidence of Function Focused Care behaviors provided by direct care workers. Results: A total of 19 out of 25 direct care workers were exposed to education and demonstrated evidence of knowledge of Function Focused Care based on an average of 82% correct score on the knowledge quiz. The mean number of Function Focused Care behaviors performed by direct care workers increased from 3.55 (SD=2.5) to 9.22 (SD=4.81) out of a total of 19 possible activities. Conclusions: Function Focused Care in assisted living was successfully implemented. Changes were noted in DCWs with regard to knowledge post education. Also, the mentoring and motivating of FFC champions increased the direct care workers’ performance of Function Focused Care activities during care interactions with residents.
  • Implementation of an Oral Health Program in a Prenatal Practice Setting

    Gorschboth, Susan; Idzik, Shannon (2019-05)
    Background Untreated periodontal disease during pregnancy can contribute to adverse health outcomes involving both oral health and pregnancy. Medicaid has offered full dental benefits in its coverage to pregnant women, but there has been a steady decrease in usage with only 26.8% of women enrolled utilizing this benefit. An oral health program that includes screening and referrals, and partnering with a Medicaid accepting dental provider addresses the barriers that pregnant women with Medicaid benefits encounter. Local Problem Prenatal practices have expressed difficulty addressing the oral health care needs of their Medicaid patients. The purpose of this quality improvement project was to implement a dental screening and referral program that would link Medicaid recipients within a prenatal practice to a clinic for oral health care. Interventions The structure of the program was based on the Oral Health Delivery Framework, and implementation occurred over fourteen weeks. The screenings consisted of a three-question selfassessment of dental concerns and one question determining if the patient had seen a dentist within the past twelve months. The purpose of the screenings was to assess the acuity of the dental needs and the level of urgency needed for the referral. All patients screened were then referred for dental care to a local Medicaid dental clinic. A pre-printed dental referral form was used to specify safe medical and dental treatments during pregnancy. Results All patients screened were referred to the clinic resulting in a 100% referral rate. The goals of having a patient’s first appointments scheduled within three weeks of the date of referral (mean time was 3.2 weeks) and subsequently, having treatment plans established within three weeks were not met. Only 7.5% of the women screened had seen a dentist within the past twelve months. The disease burden was found to be high when 70% of those screened had at least one dental concern, and 88.9% of the patients required more than just oral prophylaxis at their dental visit as a treatment plan needed to be established. Conclusion Prenatal practices are an optimal location for assisting women with Medicaid benefits to access dental care early in pregnancy. Prior identification of a Medicaid dental clinic was a critical component to the program’s success. The screenings provided the opportunity to determine the urgency of the referral. Using a dental referral form was beneficial to communicate safe treatments to the dental provider. Establishing the first scheduled appointment within three weeks of being referred to the dental clinic was the most significant barrier encountered. Expanding this program to include additional providers would potentially address this barrier and assist with increasing access to dental care for this population.
  • Advance Care Planning With Adolescent and Young Adult Stem Cell Transplant Patients

    Ott, Lindsey V.; Hoffman, Ann (2019-05)
    Background: Advance care planning is not routinely performed with adolescent and young adult hematopoietic stem cell transplant patients, despite their critically ill status and the possibility that immediate medical decisions will need to be made on their behalf. The lack of advance care planning discussions or documentation can lead to incongruence between adolescent and young adult patients and caregivers about end-of-life preferences, poor communication between patients and providers, and unwanted medical interventions. Early initiation of advance care planning has been shown to be safe and feasible for adolescent and young adult patients facing life-threatening illnesses. Local Problem: In the Blood and Marrow Transplant Division at a large, urban freestanding pediatric hospital in the mid-Atlantic, it was determined that advance care planning was not routinely introduced to adolescent and young adult hematopoietic stem cell transplant patients during the transplant process. The purpose of this quality improvement project was to implement a standardized procedure for the initiation of advance care planning discussions and completion of advance care planning documentation for adolescent and young adult patients ages 15 years and older undergoing allogeneic hematopoietic stem cell transplant. Interventions: A standardized process for advance care planning meetings with adolescent and young adult patients was created, detailing procedures for identifying eligible patients, scheduling meetings for advance care planning during the pre-transplant process, and standardizing the documentation of advance care planning discussions. Five blood and marrow transplant team members participated in a one-hour training session conducted by a palliative care physician to increase knowledge and comfort level with advance care planning and the selected advance care planning document, Voicing My CHOiCESTM. Results: Four eligible adolescent and young adult patients were admitted for transplant between October and December 2018. All four patients completed Voicing My CHOiCESTM prior to hospital admission, and their completed documents were all easily located in the medical charts throughout their admissions. Documentation of the advance care planning discussion by the facilitating provider was present in the electronic health record for 100% of the patients. One hundred percent of the blood and marrow transplant team members rated the training session as “very helpful,” and rated Voicing My CHOiCESTM as helpful, easy to use, and appropriate for adolescent and young adult stem cell transplant patients. Conclusions: Early introduction of advance care planning is feasible for adolescent and young adult hematopoietic stem cell transplant patients. A standardized process for advance care planning helped to increase the number of adolescent and young adult hematopoietic stem cell transplant patients who participated in advance care planning discussions and completed Voicing My CHOiCESTM. This approach has the potential to improve communication and increase congruence between patients, caregivers, and providers.
  • Implementation of a High-Risk Alcoholism Relapse Scale Post-Liver Transplantation

    Tholen, Rebeca V.; Bundy, Elaine (2019-05)
    Background: Transplantation will reverse the complications of end-stage liver disease, but it does not treat underlying alcoholism or reduce the risk of relapse after transplant. Local Problem: In the United States, relapse rates are 20-50% among liver transplant recipients. Relapse after transplant has been identified as a problem among liver transplant recipients at a large urban academic transplant center. The purpose of this quality improvement project was to implement and evaluate the effectiveness of a High-Risk Alcoholism Relapse scale to screen and identify patients at high-risk for alcohol relapse post-transplant. Interventions: The scale was used to screen new adult liver transplant recipients prior to hospital discharge. The scale is a predictive tool designed to determine severity of alcoholism and risk of relapse after transplantation. The scale consists of three variables identified as having the highest predictive power for early relapse, including daily number of drinks, history of previous inpatient treatment for alcoholism, and the number of years of heavy drinking. Results: Descriptive statistics revealed 33 patients were screened with the scale. Forty percent of patients (n=13) were identified as being a high-risk for relapse and 60% low-risk (n=20). Fiftyfour percent reported drinking nine to 17 drinks per day, and zero patients consumed fewer than nine drinks per day. Fifty-four percent reported drinking more than 25 years. One third of highrisk patients received inpatient treatment for alcoholism at least once. Conclusions: Early identification and close monitoring of alcohol relapse is an essential determinant of long-term outcomes after liver transplantation. Findings validate the effectiveness of the scale to screen and identify patients at high-risk for post-transplant relapse. Results support the scale as a more efficient method to identify heavy alcohol use than other screening methods. Recommendations for future studies include performing a follow-up study to compare HRAR results with relapse rates, and modifying the scale to appropriately capture and identify young adults at high-risk for relapse after transplant. Recommendations to help maintain post-transplant sobriety include starting a transplant support group within the organization for all high-risk patients.
  • Early Mobility of Mechanically Ventilated Adult Medical-Surgical Critical Care Patients

    Eder, Teresa; Akintade, Bimbola F. (2019-05)
    Title: Early Mobility of Mechanically Ventilated Adult Medical-Surgical Critical Care Patients. Background: Lack of early mobilization in hospitalized patients requiring mechanical ventilation in the intensive care setting is associated with a decline in physical function, prolonged number of ventilator days, cognitive impairment, and prolonged hospitalization. These associated factors contribute to an increased risk for falls, morbidity, and poor patient outcomes. Despite long-standing evidence that early mobility decreases deconditioning and delirium, bedrest continues to be a standard of practice in most intensive care settings. A multidisciplinary mobility protocol combining an automatic computerized provider order for early mobility accompanied by a validated nurse-driven mobility algorithm to increase mobility may overcome barriers and improve outcomes. Local Problem: In a Medical-Surgical Intensive Care Unit at a community hospital in Baltimore, Maryland, barriers to implementing early mobility practices and poor patient outcomes associated with prolonged immobility concerns the administration. Administration and staff members are also concerned by the high rates of patients assessed with intensive care unit delirium, increased number of ventilator days and the decreased frequency in which mechanically ventilated patients receive prompt early mobility treatment. There was no formal early mobility protocol in place, and medical providers ordered physical therapy daily on an individualized basis after a physical examination using professional judgment. Intervention: Formal and informal survey of medical providers, nursing, and physical therapy staff provided insight into barriers to early mobilization. An automatic, computerized medical provider early mobility order and a nurse-driven early mobility protocol were developed and implemented over a six-week period to overcome these barriers and improve the timeliness of mobility treatments. Education surrounding the new processes utilized a multidisciplinary approach. Results: A total of 87 employees within three departments participating in the project were eligible to receive early mobility education. Of all of the eligible employees, 92% (n= 80) received formal education by either the project leader, the unit educator or designated project champions. There were 104 qualifying ventilator days for screening algorithm assessment. Overall, there was a 66.3% (n= 69) compliance rate of screening algorithm utilization by nursing. Of the 104 ventilator days, 21 screening algorithm assessments measured patients as appropriate to receive the early mobility intervention. Of the 21 possible patients eligible to receive treatment, 61.9% (n=13) participated. Conclusions: A mobility protocol combining a provider order and a nurse-driven mobility algorithm has significantly increased the mobility of hospitalized mechanically ventilated patients and may overcome barriers to improve outcomes. Hospitals and patients may benefit by evaluating their current mobility practices and utilize validated tools to change practices to increase patient mobility and improve outcomes.
  • Implementing Posttraumatic Stress Disorder Screening, Brief Intervention, and Referral in Primary Care

    Weston, Tarleen K.; Wiseman, Rebecca (2019-05)
    Background: Posttraumatic Stress Disorder (PTSD) has a prevalence of 8.7% in the United States. This disorder is associated with increased social, occupational, and physical impairments which lead to increased healthcare utilization and expense. Ethnic minorities, individuals with inadequate social support, those of low-income, and urban residents are at greater risk of developing PTSD. Identifying PTSD in the primary care setting can lead to improved overall patient health, improve overall population health, and alleviate the economic and healthcare utilization burden. However, this disorder often goes unrecognized and untreated due to a lack of formal screening in primary care. Local Problem: A mobile primary clinic serving an uninsured population that is predominately Latino with limited English proficiency did not have a consistent PTSD screening process. Clients whose screening score was positive for possible PTSD did not have a consistent followup that included a brief intervention and referral for treatment. Interventions: The purpose of this Doctor of Nursing Practice project was to pilot the implementation of the Primary Care PTSD Screen (PC-PTSD) in either English or Spanish and provide a brief intervention with referral for treatment (PTSD SBIRT) in the patient’s preferred language. This project was implemented over a period of 15 weeks via the PTSD SBIRT protocol. The inclusion criteria for those screened included all newly admitted patients age 18 or older with no cognitive impairment and the ability to understand and speak English or Spanish. The estimated sample size (n=36) for the pilot period was based on the average rate of three new patient admissions per week over 12 weeks. The University of Maryland Baltimore Institutional Review Board gave a Non-Human Subjects Research determination for project implementation. Results: The total number of new patients meeting the inclusion criteria was 46 (n=46). The percentage of new patients screened was 97.8% (n=45). Of those screened, 6.7% (n=3) had a positive screen score, and 100% of patients with positive screening received the brief intervention with referral for treatment. Some barriers to the project implementation included scheduling conflicts, initial staff resistance, lack of protocol clarity, and confusion over the fourth item of the Spanish PC-PTSD. The main facilitators of the project were collaboration between project leader and staff, staff’s proactivity with communication, ease of screen use, and high compliance rate. Conclusions: The PC-PTSD was an easy tool to administer, interpret, and incorporate within the intake process of the mobile primary care unit. The project highlighted the lack of available treatment resources for this patient population. After the pilot period, the project leader met with the director and staff to discuss sustainability of the protocol for new admissions and to begin implementation annually for current patients. The mobile clinic director made plans to integrate the PTSD SBIRT protocol into their electronic health record with modified item-4 in the Spanish PC-PTSD. The clinic director’s goal is to continue integrating screenings with regular practice as a means to advance primary care behavioral health integration, increase mental health awareness, and improve population health outcomes through enhanced quality of care.
  • Implementation of SBIRT Services for Individuals with Substance Use Disorder in Urgent Care

    Mincin, Michael L.; Burda, Charon (2019-05)
    Background Statistics indicate that nearly 21 million Americans in 2015 suffered from Substance Use Disorder. Alcohol is the third leading cause of preventable death in the United States with nearly 88,000 people dying annually. Roughly 115 individuals within the United States die daily from an opioid overdose. Local Problem In 2017, Baltimore City, Maryland experienced 761 alcohol and drug related deaths. Patients with Substance Use Disorder continue to go undetected and do not receive appropriate care. The purpose of this project was to implement the SBIRT program as a quality improvement project to provide screening, a brief intervention, and referral to treatment for patients with Substance Use Disorder. Interventions This quality improvement project took place within a Baltimore City urgent care clinic that lacked an existing program screening for Substance Use Disorder. Team members included licensed practitioners, medical assistants, peer counselors, and front desk personnel. The project extended over a twelve-week period. Initial preparation required confirming staff roles, reviewing procedures, and identifying project champions. The subsequent period was spent disseminating project details as well as training staff members. All staff were trained by the project leader. The process of screening, brief intervention, and referral to treatment for Substance Use Disorder began in week five and continued through week twelve. The AUDIT-C questionnaire and a single substance use question were utilized as the screening tool. When a patient screened positive for Substance Use Disorder, the patient received a brief intervention by an SBIRT trained peer counselor. Patients received a referral for outside treatment depending upon the magnitude of substance use as well as the patient’s readiness for intervention. Results The implemented quality improvement project screened (n=556) patients or 38.6% of registered patients for Substance Use Disorder. Of those patients screened, (n=45) 8.1% screened positive for either alcohol or other substance misuse. Of the patients that screened positive (n=17) 37.8% received a brief intervention from a trained peer counselor or licensed provider. SBIRT screening as well as data collection and analyses processes were successfully implemented within the clinic’s electronic health record. Clinic administrators elected long-term adoption of the SBIRT program by making the SBIRT program a fixed function within the clinic. Conclusion This project indicated that nearly 10% of the population in Baltimore City continue to go unrecognize and untreated for Substance Use Disorder. Seventeen patients (37.8%) that screened positive for SUD received a brief intervention from a trained peer counselor or licensed provider and were provided with appropriate resources for treatment. The achievements of this quality improvement project demonstrate that the SBIRT program can be successfully implemented within an urgent care. The extension of similar programs is highly recommended to further reach out to this vulnerable population. Continuation of the program will allow an opportunity to refine processes, address the role of peer counselors, further train licensed providers to administer brief interventions, and work toward increasing the number of screenings, brief interventions, and referrals to treatment.
  • Reducing Pediatric Vaccine-Associated Pain Using The Buzzy

    Hoke, Brittany M.; Connolly, Mary Ellen (2019-05)
    Background: Vaccinations are recognized as a major cause of iatrogenic pain in childhood. Currently no pain management protocol exists at a large suburban pediatric primary care clinic in the mid-Atlantic, for children undergoing vaccination. Local Problem: The purpose of this DNP project was to implement and evaluate the usage of the Buzzy device during vaccination of children ages 4-17 years, at this pediatric primary care clinic. Buzzy is an effective combination of vibration and external cold analgesia, which significantly reduces injection pain in children. The project was designed to improve patient care at this clinic, by addressing the pain management needs of children undergoing vaccination. Interventions: The project took place over the course of 16 weeks. During the first two weeks, the project leader posted Buzzy advertisements throughout the clinic and distributed brochures to families. Nurses (n = 11) and medical assistants (n = 1) were individually trained during this time, regarding proper technique and usage of the device. During weeks 3-16, the nurses and medical assistant utilized Buzzy when vaccinating children ages 4 to 17 years. The project leader collected data using two audit tools: (1) a running log documented by the nurses/MA that tracked the number of patients receiving the Buzzy intervention, and (2) a running log documented by the project leader that randomly tracked those who utilized Buzzy. Staff provided a satisfaction survey to each patient who received Buzzy during vaccination that was submitted anonymously prior to patients leaving the clinic. During weeks 3-16, the project leader reviewed and entered data into an Excel spreadsheet and conducted an analysis of data utilizing descriptive statistics. Data was also analyzed via a run chart to track Buzzy usage and to identify trends over the course of the 14-week period. Results: Staff offered Buzzy to a total of 761 patients. Six hundred and eighteen patients used the device during vaccination, while 143 patients declined. The mean number of patients using Buzzy per week was 43. A total of 523 surveys were completed, yielding an 84.6% survey response rate. Ninety-seven percent of parents and patients surveyed reported satisfaction with their vaccination experience using Buzzy, which well surpassed the project’s goal of 50%. One hundred percent of nurses (5 out of 5) offered Buzzy to patients during audit weeks 3, 5-9, 11 and 14. The satisfaction rate among nurses who utilized Buzzy ranged from 67% during week 4, to 100% during weeks 6-16. Conclusion: The positive response from patients, parents, and staff demonstrates the device’s efficacy and the success of this project, and will aid in its sustainability at this clinic. With continued provider and nursing support, Buzzy has potential to become standard of care during vaccination at this clinic. Implications for future research include use of the device on a younger population of patients, application during additional needle stick procedures, as well as incorporating Buzzy usage into the clinic’s EHR. This project can be utilized as a model for pediatric clinics seeking methods to decrease vaccine-associated pain for their patients.
  • Implementation of an Oral Care Protocol on an Acute Geriatric Inpatient Unit

    Jones, Lanaya; Rowe, Gina (2019-05)
    Background: Hospital acquired pneumonia is the second most common hospital acquired infection, and is responsible for 20-33% of mortality rates from infection. Patients with HAP also have higher 30-day hospital readmission rates compared to patients without a hospital acquired infection. Nationwide, hospital acquired pneumonia accounts for 32.5-35.4 million discharges annually. According to the Centers for Disease Control, 5-7% of hospitalizations due to pneumonia end in death. The oral cavity is a high reservoir for infection, and evidence-based practice suggests oral hygiene interventions to prevent hospital acquired pneumonia. Hospital acquired pneumonia is more common in at risk individuals, and there are four routes of transmission: (1) through aspiration of oral contents (food, oropharyngeal secretions, or gastrointestinal contents), (2) from infectious sites, (3), from inhalation of aerosols that are infected, and (4) from extra-pulmonary sites. Aspiration of infectious organisms remains the number one way to acquire hospital acquired pneumonia, so reducing oral bacteria is critical in hospital acquired pneumonia prevention. Local Problem: The focus site had no oral care protocols in place. Oral care supplies that were used were not ones recommended by evidence-based practice. Interventions: This project was implemented over a 12-week time span beginning in September of 2018. Education sessions were provided to staff to ensure appropriate use of oral care equipment. A five-question pre and post education test was administered to measure retention of information. Staff documented each time oral care was performed in addition to documenting all of the supplies that were used. Oral care compliance was measured through point prevalence, and hospital acquired pneumonia incidences was tracked through manual extraction of infection data. Hospital acquired pneumonia percentages was calculated using the number of hospital acquired pneumonia incidences divided by the number of patient visits. Results: Pre-implementation oral care compliance rates were (May-Aug) 36%. Postimplementation rates were (Sep-Dec) 52%. The average pre-pneumonia rate (May-Aug) was 25.8 and average post pneumonia rate (Sep-Dec) was 29.6. In addition, the average pre implementation aspiration pneumonia rate (May-Aug) was 7.3, and the average post aspiration pneumonia (Sep-Dec) was 5.5. The average grade on the pre-test was 77.8% and 82.5% on the post-test. Conclusion: There was a 16% increase in oral care compliance with implementation of this quality improvement project. In addition, there was an appreciative decrease in aspiration pneumonia rates with the increase in oral care compliance. However, there was a surge in nonaspiration pneumonia rates in October in November. From the results of this quality improvement project, one can conclude there is a potential decrease in hospital acquired pneumonia from oral care compliance. The mixed results of this project suggest more research is needed to determine if comorbid conditions (i.e. influenza) affect hospital acquired pneumonia rates.
  • Implementation of Daily Quiet Time on a Postpartum Unit

    Stinefelt, Megan; Gourley, Bridgitte (2019-05)
    BACKGROUND: A lack of quiet time during their hospital stay can have multiple deleterious effects on patients. Studies have shown that patients are exposed to multiple interruptions by hospital staff and louder than recommended noise levels while they are admitted in the hospital. LOCAL PROBLEM: The unit leaders at one local community hospital in Maryland noticed that a lack of quiet time was a daily problem on their unit. INTERVENTION: The purpose of this project was to implement and evaluate the effectiveness of daily quiet time on a postpartum unit at a community hospital in Maryland. In this quality improvement project, daily quiet time was implemented during the hours of 1:30pm to 3:00pm. Lights on the unit were dimmed. Nurses and other staff stayed out of patient rooms unless it was medically necessary or by patient request. Data collection occurred from October 2018 to November 2018 and included observing and recording the number of times staff entered a patient room and timing how long they were in the room. RESULTS: Pre-implementation data collection occurred on four days and post-implementation data collection occurred on nine days. On average, staff interruptions to patient rooms were 5.18 pre-implementation and 1.30 post-implementation per 90 minutes (P < 0.001). On average, interruptions in patient rooms by staff lasted 4.09 minutes pre-implementation and 3.66 minutes post-implementation. CONCLUSIONS: Due to the overwhelming acceptance of this quality improvement project by the postpartum staff as well as other departments in the hospital and the observed decrease in staff interruptions to patient rooms, daily quiet time is a sustained intervention that has become part of the standard workflow on the postpartum unit at a local community hospital.
  • Improving Linkage to Care in the Human Immunodeficiency Virus Clinic Setting

    Cuffee, Denisha; Wiseman, Rebecca (2019-05)
    Background At the end of 2015, an estimated 1.1 million individuals in the United States aged 13 and older were living with human immunodeficiency virus (HIV), including 162,500 (15%) of persons who are undiagnosed. The state of Maryland is currently ranked seventh among 50 states in HIV diagnoses. Linkage-to-care of people living with HIV is a major problem for health care providers. Linkage-to-care can be summarized as a completion of a visit with a primary care or HIV medical provider within 30 days of diagnosis. Linkage-to-care is currently below average at an estimated 66% in the United States with a national goal of 80%. Local Problem A linkage-to-care template inside the clinic patients’ electronic medical records ensures there is a standard of care when linking patients to a primary care provider after diagnosis. However, site staff may not be completing the template at discharge and closing the charts within three days according to protocol. The purpose of this DNP project is to raise linkage-to-care protocol adherence by implementing a pop-up point-of-care reminder in Outlook Calendar. Interventions A Quality improvement Project with pre-post intervention measurements was implemented at a Suburban HIV clinic in the United States. The project used a convenience sample consisting of five clinic case managers. Retrospective pre-intervention EMR audits (n = 20) were used to assess baseline rate of linkage-to-care closure within three days of opening. Records were randomly selected from all records discharged in April through August 2018. Pre-intervention surveys were given to clinic case managers to assess barriers to completing linkage-to-care templates within three days of opening and completing patient discharges. The intervention consisted of point-of-care electronic calendar reminders. Post-intervention surveys were given to assess satisfaction with the intervention and to seek recommendations on other ways the intervention can be utilized. Post-intervention records audits (n = 16) were used to assess whether linkage-to-care templates were closed within three days of opening at a higher rate than during pre-intervention. Results The pre-implementation survey revealed barriers in completing the discharge template, including complexity of the discharge, difficulty navigating through the record, template too wordy, too time consuming, and lack of patient cooperation. Pre-intervention audits indicated that 40% were not closed within three days. Five of 16 new records audited post-intervention were not closed within three days. A nine-percentage point increase in discharges completed within three days post-intervention was observed but was not statistically significant (p > 0.05). In the postimplementation survey, all subjects reported that reminders were important and helped with remembering to complete the discharge templates and other patient-related tasks. Conclusions This project suggests that there is a correlation between setting reminders in the outlook calendar and closing of linkage- to-care templates within 3 days. Closing of linkage-to-care templates within 3 days improved from 60% to 69% after the implementation of Outlook Calendar reminders. The results of this project further reinforce the notion that reminders at the point of care help staff complete patient-related tasks.
  • Implementation of a Ventilator Associated Pneumonia Prevention Bundle in the Emergency Department

    Schulz, Cory; Idzik, Shannon (2019-05)
    Background Despite the ability to save lives, mechanical ventilation places patients at an increased risk for adverse events; specifically, ventilator associated pneumonia (VAP). VAP is associated with increased duration of mechanical ventilation, hospital and intensive care unit (ICU) length of stay, hospital costs, and mortality risk. Implementing guideline directed VAP prevention bundles has been shown to reduce hospital VAP rates. Local Problem One specific population at risk for VAP are mechanically ventilated patients in the Emergency Department (ED). Since the risk for VAP begins at the time of intubation, and patients can spend many hours in the ED waiting for bed availability, there is utility in implementing a VAP prevention bundle in this setting. Interventions The purpose of this quality improvement project was to develop, integrate, and evaluate a VAP prevention bundle in the ED at a suburban community hospital system. The long-term goal was to decrease VAP rates in mechanically ventilated patients admitted from the ED. The short-term goal was to have a 100% compliance rate with the bundle during the sixweek implementation period. The bundle was developed based on the recommendations from the Institute for Healthcare Improvement. Then, with help from a multidisciplinary team, it was incorporated into an order-set that was available in the clinical information system. The ED staff was educated during weeks one to four. The order-set was then made available at the beginning of week four and monitoring of compliance occurred from week four to week ten. Results For education, 133 out of 142 ED nurses completed the assigned online learning module (82.1%) and 45 nurses attended the in-services hosted by the project leaders (31.2%). Eleven of the 23 ED physicians attended a formal presentation by the project leader at their departmental meeting (47.8%). During the six weeks following the order-set integration, 16 patients were recorded as being intubated, of which five were excluded because they were terminally extubated in the ED. A total of 11 patient encounters were analyzed for compliance. Sixty-four percent of the patients received all three components of the VAP prevention bundle, 90% for HOB, 64% for CHG mouth care, and 80% for oral care every two hours. There were multiple contextual barriers and limitations to implementation that could have affected the results. These included a high patient census and acuity during project implementation, a cyber-security breach, an accrediting body hospital survey, the annual hospital-wide nursing competency evaluations, a documentation related malfunction, and the process for nurses to obtain the CHG oral solution. Conclusions This quality improvement project demonstrates the feasibility of implementing a ventilator bundle in the ED. The limitations and barriers encountered during this project are a reflection of the challenges associated with translating evidence into practice. There is a need for similar projects in the future and research regarding implementation science in general.
  • Prevention of Newborn Hypoglycemia Algorithm

    Parajon, Cecilia M.; Hoffman, Ann (2019-05)
    Background: Newborns at a higher risk for developing hypoglycemia are defined as newborns born small or large for gestational age, late-preterm (34-36 and 6/7 weeks gestation), those born to mothers with diabetes and any newborn exhibiting clinical signs of hypoglycemia. Identified newborns are monitored and often fed formula to stabilize their blood glucose level. Many mothers plan to breastfeed exclusively, but when formula is fed to their newborns exclusive and long-term breastfeeding is decreased. Applying the Baby-Friendly Hospital Initiative interventions like skin to skin care, frequent breastfeeding and feeding hand expressed colostrum to the at-risk newborns may prevent hypoglycemia, stabilize the glucose levels, lessen formula supplementation, and increase exclusive breastfeeding rate. The Prevention of Newborn Hypoglycemia Algorithm supports the AAP Screening and Management of Postnatal Glucose Homeostasis Algorithm, the Academy of Breastfeeding Medicine and the Baby Friendly guidelines to prevent and reduce newborn hypoglycemia and related formula use, increase breastfeeding rates and thereby improve delivery of care. Local Problem: The community hospital was initiating the process of becoming a Baby Friendly Hospital and recognized that their use of formula to manage hypoglycemia in at-risk newborns was very high and sought to decrease its use and consequently increase breastfeeding rates. The hospital currently uses an algorithm based on the AAP Hypoglycemia Algorithm that does not incorporate some of the Baby Friendly interventions. There are inconsistencies of the management in the care of the at-risk newborns. Interventions: The purpose of this quality improvement project was to implement and evaluate the effectiveness of the Prevention of Hypoglycemia Algorithm for the at-risk newborns in a community hospital. The implementation included instruction and guidance of the nursing staff in the components and the use of the algorithm. The use of the algorithm was assessed in the overall and the at-risk number of newborns that were ever and exclusively breastfed during the intervention period. At the end of the implementation, the nurses evaluated the usability of the algorithm with the Algorithm Usability Questionnaire. Results: Overall the ever-breastfeeding rate increased slightly but the exclusive breastfeeding rate dropped. During the intervention, all of the at-risk newborns were managed with parts of the algorithm and 100% breastfed some of the feedings. The exclusively breastfeeding rate was 67% in the first month and 20% the second month. There was a 70% staff approval for ease of use of the algorithm. Conclusions: All at-risk newborns breastfed for some of the feedings in the hospital during the intervention. There was an increase in the awareness of at-risk newborn hypoglycemia prevention and the use of the algorithm recommendations for all newborns. The algorithm served as a prompt to apply the Baby Friendly interventions while preventing hypoglycemia, managing the blood glucose levels, lessen formula supplementation and preserving the newborns breastfeeding abilities. The Algorithm remained posted on the nursing unit to assist this practice change to manage the at-risk newborns and help the hospital become a Baby-Friendly designated facility.
  • Increasing Early Skin-to-Skin for Newborns of Uncomplicated Cesarean Birth

    Showunmi, Harsana; Hoffman, Ann (2019-05)
    Background: Following a cesarean birth (CB), newborns can be separated from the mother for up to 3 hours, delaying skin-to-skin contact (SSC). Immediate or early SSC is recommended as a standard of care to prevent hypothermia, hypoglycemia, tachypnea in newborns and to increase bonding, yet few newborns of CB engage in this practice. When mothers are unable to engage in SSC, fathers/support persons are viable options to facilitate early SSC in newborns. Local Problem: The proposed clinical site houses a small labor and delivery unit where it was not standard practice for newborns of cesarean births to engage in SSC within 1 hour following delivery. The purpose of this quality improvement (QI) project is to implement early SSC between fathers/support persons and stable, full-term newborns of uncomplicated cesarean births when the mother is unable to provide SSC. For this QI project, early SSC was considered to be SSC within 1 hour of birth Interventions: A process change was introduced to allow fathers/support persons perform SSC soon after CB. Nurses learned how to identify eligible participants and a checklist was used to serve as a reminder for when and how to execute the new process. Once identified, families were educated on SSC, then the mother appointed an alternative SSC provider. Unit practice was changed to allow fathers/support persons to follow the newborn and the nurse to the nursery after an uncomplicated CB for an opportunity to perform early SSC. If newborns were determined to be stable, SSC was initiated. During the course of the project, goals, information and results were disseminated on the unit via presentations, discussions, posters and handouts. Results: There was a total of 21 CBs during the implementation timeline; nine ineligible cases and twelve eligible cases. Out of the 12 eligible cases, 5 newborns received SSC in less than 1 hour, 5 newborns received SSC more than 1 hour but less than 2 hours and 2 newborns did not receive SSC in the required time frame. The nurses also engaged mothers in early SSC with their newborns. As a result, outcomes included 6 mothers who performed SSC with their newborns within 2 hours of birth. Conclusions: Creating an environment that incorporates early SSC as a standard of care, regardless of method of delivery, is important to improving newborn and family outcomes. In situations where mothers are not available to perform SSC, it is feasible for fathers/support persons to act as alternative SSC provider. This process change allows the newborns of uncomplicated CB to safely enjoy the same benefits as newborns of vaginal deliveries, who routinely perform immediate or early SSC. During this QI project, the checklist made it easier for the nurses to facilitate early SSC. Although adoption to utilize the checklist was slow, when used, it served to streamline the process change. By the end of implementation there was an increased awareness of fathers/support persons as alternative SSC providers and increased action to initiate SSC earlier for newborns of uncomplicated CB on the unit.

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