• Adolescents with Chronic Kidney Disease: Transition to Adult Care Program Development

      Hill, Tamara (2017)
      Problem: Increasing numbers of children with chronic conditions, including those with Chronic Kidney Disease (CKD) survive into adulthood (Watson, 2012; Ferris, Gipson, Kimmel and Eggers, 2006). A diagnosis of CKD also includes many comorbidities in a vulnerable population. Without a structured approach, poorly managed healthcare transition (HCT) from pediatric-to adult-focused care, can be fatal or have consequences such as losing a kidney transplant. Recognizing the barriers to HCT emphasizes the need for a collaborative effort by pediatric and adult-focused providers. HCT is complex and demanding. Sudden changes in provider aspects and health care system processes may be disorientating to pediatric patients accustomed to intense and involved care all of their lives (Samuel et al., 2014). This, along with the increase in survival to adulthood, increases the need to have systematic processes in place to successfully transition these youth to adult care services. Purpose: The purpose of this scholarly project was to develop a structured HCT preparation program for adolescents with CKD while maintaining their trust and assuring continued medical care. Methods: This quality improvement project, completed in a large Mid-Atlantic urban outpatient nephrology clinic, aimed to successfully transition adolescent CKD patients to adult health care and involved four steps. The first was recruitment of participants, with specific criteria including English speaking, ages 15-23 and no hospitalizations in the past 3 months. The second phase was evaluation of ability to participate with the use of a readiness assessment; a formal validated scale, created by the National Alliance to Advance Adolescent Health (NAAAH, 2016 ) and development of an individualized, interprofessional treatment plan. Lastly, application of the transition plan and patient evaluation involved the use of a formal, published teaching tool, called TRxANSITION (Ferris, 2012) which includes 7 domains of care. The UNC TRxANSITION Scale™ inter-rater reliability is strong (r= 0.71) and item-total correlation scores were moderate to high (Ferris et al, 2012). BUN and creatinine levels were also monitored during the program change to assure stability. Success was noted by full transition from pediatric to adult care, indicated by keeping the first independent appointment with the adult provider. Results: Nineteen participants were enrolled; ages between 16 and 27 years; 54% females; 75% with CKD and 26% were renal transplant recipients. Patient responses to the TRxANSITION Scale variables were evaluated using the Pearson Correlation coefficient. Sub-scales that had the highest correlation coefficients with the total score and with a strong positive relationship to their domain were self- management (N=19, r=0.91, p<0.01, two-tailed), insurance (N=19, r=0.83, p<0.01, two-tailed) and school (N=19, r= 0.82, p<0.01, two-tailed). During the program development process, four participants successfully transitioned from pediatric to adult nephrology services without incident, while others continued with preparation for transition. Conclusion: Purposeful HCT preparation provides youth with ongoing access to subspecialist care, promotes competence in disease management, fosters independence, social, and emotional development through teaching self-advocacy and communication skills, and allows for a sense of security for support of long-term health care planning and life goals.
    • Fall Prevention for Adult Patients in Perioperative Units

      Pruitt, Beth A.; Rowe, Gina; Hoffman, Ann G. (2019-05)
      Background: In the United States, patient falls have become a critical issue that negatively impacts our healthcare system. Even with continued emphasis on fall prevention, falls continue to occur frequently in hospitals across the United States. Falls are not benign events, and often lead to some level of patient harm or even death. Furthermore, since falls have been designated preventable hospital acquired conditions in acute care settings, they are no longer be reimbursed by insurance companies. The risk to patient safety as well as lack of reimbursement for falls are two major factors that support the need to prevent falls in acute care settings. In perioperative units, a highly vulnerable population exists, along with barriers to fall prevention. Local Problem: In a community-based hospital located in a Maryland suburban community, a comprehensive fall prevention plan was initiated to promote safety and prevent falls in this population. Interventions: Based on an extensive literature review, a fall prevention bundle was initiated on all adult patients in the perioperative units. This bundle included the following components: high fall risk wrist bands, non-skid socks, fall prevention signs, and fall education. Bundle compliance was tracked and measured using compliance audit tools. Additionally, falls were calculated as number of patient falls per 1,000 bed days. Results: After initiation of the comprehensive fall prevention bundle, staff had a high compliance rate with measures: wrist bands present, 97%; signs present, 100%; call bell within reach, 97%; education given, 89%; and non-skid socks on, 99%. Furthermore, no falls have occurred since bundle implementation. Therefore, the falls rate during this time is 0. Conclusions: Based on this data, the successful implementation of a fall prevention bundle has the potential to decrease the number of falls in a vulnerable population.
    • Implementation of the Confusion Assessment Method on a Medical Intermediate Care Unit

      Outen, Katharine; Akintade, Bimbola F. (2019-05)
      Background Delirium is a clinical syndrome characterized by acute onset fluctuations in mental status accompanied by inattention, an altered level of consciousness, and impairment in cognition. For all hospitalized adults, the prevalence of delirium is estimated at 20%, with an incidence ranging from 18% to 64%. Several hospital interventions put a patient at risk for developing delirium, including mechanical ventilation, medication interactions, urinary catheters, interrupted sleep cycles, and use of physical restraints. Developing delirium leads to an increased length of stay in an intensive care unit, length of overall hospital stay, likelihood of requiring nursing home care after discharge, and risk of mortality following hospitalization. Longer periods of delirium worsen cognition, executive functioning, ability to complete activities of daily living, and sensory-motor functioning. Local Problem The lack of delirium screening was identified as a potential patient safety issue on a medical intermediate care unit of a large, urban academic medical center on the East Coast. Interventions The Confusion Assessment Method is a widely used, specific and sensitive tool utilized to screen adult patients for delirium. A quality improvement project was conducted over a 13week period to implement and assess the nurse-perceived usability of the Confusion Assessment Method screening tool for patients on the medical intermediate care unit. Inclusion criteria was any patient over age 18 who transferred to the medical intermediate care unit directly from a medical intensive care unit. Eligible patients had a Confusion Assessment Method screening completed once per shift by the primary bedside nurse. The nurse was also asked to complete a System Usability Scale survey, a Likert-style questionnaire, to evaluate the nurse-perceived usability of the Confusion Assessment Method for this patient population. Participation by the nursing staff was voluntary. Results There were 329 eligible patient encounters with 183 Confusion Assessment Method screenings completed. Nurse compliance rate with completing the screening was 55.6%. Of the completed screenings, 8.7% (n=16) were “positive,” or suggestive that a diagnosis of delirium was present. A total of 181 System Usability Scale surveys were completed by the nursing staff with scores ranging from 35 to 100. The mean score was 77.94 (SD ±12.21), indicating above average usability. Conclusions Healthcare providers need to be aware of the risk of developing delirium for hospitalized adults and routinely screen patients. This quality improvement project provides initial support regarding the usability of the Confusion Assessment Method screening tool for non-critically ill adult patients on a medical intermediate care unit. Integration of delirium screening tools into the electronic medical records may improve compliance with screening.