• Application of a Clostridium difficile Diagnostic Algorithm to Decrease Hospital-Occurring Infections

      Harrison, Laura B.; Callender, Kimberly (2021-05)
      Problem: A geriatric specialty unit within a community hospital has an average monthly rate of two per 1000 patient days of hospital-occurring Clostridium difficile infections. A knowledge deficit among nursing staff regarding Clostridium difficile was identified as a potential cause of inappropriate testing. Purpose: To implement a Clostridium difficile diagnostic algorithm to eliminate overuse of Clostridium difficile testing and obtain more accurate rate of infections. Methods: An evidence-based Clostridium difficile diagnostic algorithm was implemented and evaluated over 14-weeks to increase the nursing staff’s ability to identify the appropriate patients for obtaining diagnostic samples. Algorithm education was provided to registered nurses and patient care technicians and measured by rate of completion. Weekly chart reviews on collected tests, measured the rate of appropriate Clostridium difficile tests and the rate of intensive care unit transfers related to Clostridium difficile. The rates of positive and hospital-occurring Clostridium difficile were measured by weekly extraction of lab data. Results: There was an 82% (n=62) education completion rate among staff. Appropriate Clostridium difficile testing increased from 14% (n=7) to 76% (n=18) (p=.02). The rate of hospital-occurring Clostridium difficile infections increased from 0% (n=7) to 14% (n=21), and positive infections decreased from 29% (n=7) to 14% (n=21); neither were statistically significant. There were zero critical care transfers. Conclusion: A Clostridium difficile diagnostic algorithm increased the number of appropriate tests performed. The algorithm was found to be feasible to use with low cost. To maintain these results, a continuation of unit feedback on Clostridium difficile results and additional training is necessary.
    • Implementation of a Fall Prevention Toolkit on a Medical Surgical Unit

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

      Arjoon, Amanda V.; Fitzgerald, Jennifer (2021-05)
      Problem & Purpose: Hypoglycemia in childhood is a low frequency, high-risk event that can lead to coma, seizures, and even death. Symptomatic hypoglycemia occurs when plasma glucose levels are low enough to cause signs and symptoms of impaired neurological function, increasing risk of neurogenic sequalae. In the pediatric emergency department at an urban academic medical center in the Mid-Atlantic region, delays in treatment occur due to pediatric-specific barriers including time intensive, weight-based calculations for drug doses and availability of multiple dextrose concentrations. Although there is no national benchmark for comparison, the average time from identification of symptomatic hypoglycemia to treatment on this unit is 35 minutes. The purpose of this quality improvement project was to implement an algorithm for treatment of symptomatic hypoglycemia for pediatric patients between one and five years of age in the proposed setting. Methods: An algorithm was created based on recommendations from the Pediatric Endocrine Society, the American Academy of Pediatrics, and other accredited organizations. Thirty-two small educational sessions with 59 nurses and three physician assistants were conducted over two months to provide education on algorithm use. Anonymous pre- and post-surveys were administered during the educational sessions to assess for improvements in knowledge of evidence-based care for symptomatic pediatric hypoglycemia patients. The primary outcome was to reduce time from symptomatic hypoglycemia identification to enteral or parental treatment. Results: The sample size (N=4) was smaller than expected due to a significantly reduced census on this unit during the COVID-19 pandemic. Three males and one female met inclusion criteria, with a mean age of 2.75 years. The mean time to treatment was reduced to 6.5 minutes. The most observed symptom was nausea, which appeared in all four cases. Nearly 93% of staff demonstrated improved knowledge in caring for pediatric symptomatic hypoglycemic patients through improved survey scores after the educational sessions. Conclusion: Findings suggest that use of a standardized algorithm contributes to reducing the time from identification of symptomatic hypoglycemia to time of treatment. All patients meeting inclusion criteria received interventions consistent with the algorithm. Future directions include expanding implementation of an algorithm to incorporate pediatric patients of all ages.
    • Implementation of a Quiet Time Protocol in the Neurosurgical Intensive Care Unit

      Payida-Ansah, Damata; Bundy, Elaine Y. (2021-05)
      Problem: Sleep disruption among critically ill patients is associated with detrimental health outcomes such as reduced immune and neuroendocrine function. In a large metropolitan hospital’s Neurosurgical intensive care unit (ICU), 80% of staff surveyed reported high noise levels which can contribute to environmental ICU sleep disturbances. In this ICU, the average sound level was measured at 55.96 decibels, exceeding the Environmental Protection Agency’s recommended daytime hospital limit of 45 decibels. Purpose: The purpose of this quality improvement project was to implement a Quiet Time protocol in a neurosurgical intensive care unit. The Quiet Time protocol was implemented as a practice change to create a quieter and more sleep-friendly environment by minimizing patient sleep disruption, Methods: A Quiet Time protocol was developed and implemented over 10 weeks in a 14-bed neurosurgical intensive care unit following a review of best practices and unit policies, and staff education. The protocol included reduced noise and light levels, and clustering patient care activities from 2:00 to 4:00 pm daily. Nurses completed a protocol audit form daily documenting patients’ demographic data, sleep status and adherence to the protocol. Nursing documentation compliance to the protocol was monitored weekly. Data was collected and tracked weekly via run charts. Unit sound levels were measured with a decibel meter before and during quiet times. Results: Nursing staff Quiet Time protocol compliance rose from 30.77% in Week 1 to 78.26% by Week 10 and with full protocol compliance, patients were reported as asleep 60% of the time. Of the staff surveyed post-implementation, 44% agreed and 44% strongly agreed (totaling 88%) that they would like to use the protocol frequently. Average noise levels from 3:00 to 4:00 pm dropped by 6 decibels from 59.4 dB pre-implementation to 53.3 dB during implementation. Conclusions: Quieter and less stimulating hospital environments can be achieved with Quiet Time protocols when adequate education, nurse buy-in and administrative support exists. Further quality improvement projects on how hospital environments and workflow can be modified to reduce ambient noise are necessary.
    • Implementation of a Violence Checklist to Reduce Seclusion/Restraint on Inpatient Psychiatry

      Newton, Nakeia D.; Bode, Claire (2020-05)
      Problem & Purpose: The effective management of patient aggression and violence presents a significant challenge to inpatient psychiatry units, with seclusion and restraint (S&R) commonly utilized to manage these crisis situations. The purpose of this quality improvement (QI) project is to implement an aggression/violence screening tool on an adult acute psychiatry unit to promote the early identification and management of potential for patient aggression/violence. Methods: The Brøset Violence Checklist (BVC) is an aggression/violence screening tool that assesses for six objective risk factors to establish the potential risk for patient aggression/violence. Aggression is defined as behavior carried out with the intent to harm another person, while violence is an extreme form of aggression that has severe harm (i.e. physical injury or death) as the end goal (Allen & Anderson, 2017). Staff nurses on a 15-bed high acuity inpatient psychiatry unit were trained on the use of the BVC and the least restrictive interventions to implement when a patient has been identified as at risk for aggression/violence. The BVC was to be completed on each patient admission on the unit over a 10-week period. Pre and post implementation surveys were conducted to assess the perception of staff nurses on their knowledge and skill set in the effective management of aggression/violence. Results: During the implementation period, the project leader provided training to 100% of staff nurses (n=43) under the adult inpatient psychiatry service on the use of the BVC to assess for early manifestations of risk for aggression/violence. Staff nurses screened 43% (n=38) of new patient admissions during the project implementation period. Staff nurses reported feeling that a screening tool would be useful in assessing for patient aggression/violence both pre and post implementation. Conclusion: Aggression/violence screening tools are an essential component in the effective management of patient aggression/violence and reducing S&R on inpatient psychiatry. While this QI project was successful in implementing the BVC to aid in the early assessment of patients at risk for aggression/violence, future QI projects should assess the role that least restrictive interventions play in reducing patient aggression and S&R events.
    • Implementation of an Early Warning System to Decrease Intensive Care Unit Transfers

      Powers, Lindsay M.; Seidl, Kristin L. (2021-05)
      Problems & Purpose: Extended periods of unrecognized clinical deterioration lead to increased intensive care unit (ICU) admissions and mortality. When deteriorating patients are recognized, appropriate interventions can be implemented, which leads to a decrease in unplanned ICU admissions and improved outcomes. The ability to detect deterioration requires critical appraisal of assessment data, and evaluation of trends. Early warning systems (EWS) have been shown to help clinicians predict deterioration based upon objective physiologic parameters and assessment data. At a 187-bed hospital in Western Maryland, no standardized protocol existed to aid in the detection of early deterioration. Current practice is calling the rapid response team (RRT) based upon a single vital sign or symptom. Retrospective chart review of RRT calls, discovered patients often exhibited deterioration several hours before recognition. Methods: The purpose of the quality improvement project is to implement an EWS, specifically the national early warning system 2 (NEWS2), in a medical-surgical intermediate care area (IMC) to increase early recognition of clinical deterioration. Process measures monitored during implementation included compliance with calculating and accuracy of the calculated NEWS2 score. Outcomes included rate of ICU admissions and rate of RRT calls. Results: Throughout the twelve-week implementation phase, compliance with NEWS2 score decreased from 86% during week one of implementation, to 26% in the final week, however NEWS2 score accuracy increased from 86% in week one to 94% in the final week. Pre-implementation the rate of RRT calls for the IMC were 7.2 per 1000 IMC patient days (IPD) and 30.7 per 1000 IPD post-implementation. The rate of ICU transfers was 26.5 per 1000 IPD pre-implementation and 16.1 per 1000 IPD post-implementation. Conclusion: Overall uptake of the intervention was low, desired outcomes of increased RRT calls and decreased ICU transfers was achieved. Plans to overcome compliance include integration of the NEWS2 in the electronic medical record (EMR). NEWS2 integration into the EMR with best practice advisory may increase compliance by decreasing the workload of score calculation and providing a notification for staff that must be acknowledged. NEWS2 education for new hire orientation may increase compliance and foster a culture of patient safety.
    • Implementation of Eat, Sleep, Console Approach to Care for Opioid Exposed Newborns

      da Graca, Malissa M.; Reid, Rachel (2021-05)
      Problem: Rates of neonatal abstinence syndrome (NAS) have seen a fivefold rise in Maryland. Current management strategies include the Finnegan Neonatal Abstinence Scoring System (FNASS) and opioid pharmacotherapy for symptom management placing tremendous burden on health care system due to increased length of stay, admission to special care nurseries, and disruptions to family bonding. Purpose: The purpose of this quality improvement project was to implement the “Eat, Sleep, Console” (ESC) method in the care of newborns with in-utero opioid exposure to reduce average length of stay (ALOS) for infants with NAS. Secondary outcomes were reduced doses and amount of morphine and increased breastfeeding initiation rates. Methods: A quality improvement (QI) methodology was used to implement ESC on an inpatient floor. Hospital NAS policy was revised to adopt ESC tool, as needed morphine for symptoms management, and emphasis on nonpharmacologic care. The ESC assessment tool was integrated into the electronic health care record (EHR). ESC scores, nonpharmacologic interventions, and parental presence were recorded in the EHR. Infants ≥ 32 weeks gestation with opioid exposure were included in the QI project. Data to be collected included average length of stay (ALOS), number and total morphine doses, and breastfeeding rates during admission. Preliminary Results: Evidence shows that organizations that have made the transition to ESC have seen reduction in opioid agonist therapy, reduced length of stay, and improvement in breastfeeding initiation rates for newborns with NAS. We aim to demonstrate that implementing the ESC will result in similar benefits to our institution. Updates to several structure and process measures are now in the implementation phase. Preliminary Conclusions: Changing the treatment model for newborns with NAS requires a multidisciplinary approach with providers across various specialties. Success of this Quality Improvement project required buy in from all units/care providers with education throughout the staff and families to support ESC.
    • 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.
    • Implementation of the National Early Warning Score in a Military Hospital

      Garrett, Stacy L.; Seidl, Kristin L. (2021-05)
      Problem & Purpose: Unrecognized clinical deterioration leads to poor outcomes including unanticipated intensive care unit (ICU) admission, cardiac arrest and death. Statistics show 59.4% of patients have one abnormal vital sign one to four hours prior to cardiac arrest. The National Early Warning Score (NEWS) assists nurses to identify early clinical decompensation and intervene to prevent poor outcomes. Previous attempts to implement NEWS and a dedicated rapid response nurse (RRN) at a community sized military treatment facility were unsuccessful for improving early recognition of clinical deterioration. Prior to implementation less than 8.3% of patients at moderate risk for clinical decompensation were assessed by the RRN. The purpose of this quality improvement project was to improve early recognition of clinical deterioration by implementing a dual approach that targets both the RRN and ward nurses. Both approaches target patients at moderate to high risk of clinical decompensation to achieve early stabilization or transfer to a higher level of care. Methods: A standardized communication tool was created and utilized by the RRNs to track and trend patients with a NEWS of three to five and as a reminder to document their assessment in the electronic health record (EHR). Re-education and a workflow diagram for ward nurses was presented during a skills fair to increase assessment and vital sign frequency according to the existing NEWS protocol. Results: Over 13 weeks, 698 NEWS triggers were analyzed. Of these NEWS greater than or equal to five triggers, 76% (n= 57) were assessed by the RRN using the communication tool. Of the 76%, 84% (n=48), were physically assessed. Increased vital sign and assessment frequency by the ward nurses was highly variable throughout the implementation phase, 6.7-80% and 0- 27.2%, respectively. Conclusions: A standardized communication tool utilized by the RRNs increased RRN adherence to the NEWS protocol, achieving early identification and assessment of patients with a NEWS of three to five. NEWS greater than or equal to five identified patients at greater risk for deterioration and were associated with increased ward nurse adherence to the NEWS protocol. Improved early identification of deterioration may decrease unanticipated intensive care unit (ICU) admissions.
    • Implementing Quiet Time on an Acute Care Unit

      Brown, Janet L.; Edwards, Lori A. (2021-05)
      Problem: Hospitals are very noisy places, and the excessive level of noise has deleterious effects on patients. After discharge, patients often comment about the noise and rate their hospital stay poorly because of the noise. In 2019, nationally, 60.3% of patients stated that the hospital environment was always quiet. In the same year, on an inpatient, neuroscience, acute care unit on the east coast of the US, 45.1% of patients stated that the hospital environment was always quiet. Purpose: The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of quiet time in an inpatient, neuroscience, acute care unit to achieve improved patient satisfaction. Methods: All staff were assigned a learning module on quiet time to be completed prior to implementation. Decibels were measured prior to and during quiet time each day. A quiet time checklist was used daily to ensure each element of quiet time took place. These elements included dimming the unit lights, closing each patient’s door, posting signs on the unit entrances to alert any visitors, limiting non-emergent bedside procedures, prohibiting over-head paging, and discussion with patients and visitors on admission quiet time. The survey Patient Survey on Noise During Hospital Stay was collected at discharge from appropriate patients to understand their feelings on quiet time and noise on the unit. Patient satisfaction data was analyzed, by date of discharge, for questions “Rate quietness of the hospital environment” and “Noise level in and around room.” Results: Results show decreased decibel levels during quiet time, a majority of patients stating they felt quiet time was effective and promoted a restful environment and varying patient satisfaction scores related to noise. Conclusion: Implementing quiet time on an inpatient hospital unit has a positive effect on lowering the overall noise on the unit during quiet time hours and providing patients a quiet, restful environment.
    • Improving Influenza Vaccination Rates in Inpatient Pediatrics

      Hoffer, Amy; McComiskey, Carmel A. (2021-05)
      Problem: This quality improvement project was implemented on an inpatient pediatric unit at an urban academic medical center whose rate of influenza vaccination prior to discharge was only 39% of eligible patients. This gap in vaccination is not unique to this unit and morbidity and mortality of influenza is high despite widespread availability of a vaccine and the recommendation that all children over six months of age receive the vaccine. Purpose: The purpose of this project was to increase vaccination rates by providing education and rescreening prior to discharge. Methods. The electronic health record (EHR) was modified to populate a prompt to the nursing task list for every patient who initially refuse the flu vaccine. Bedside nurses then provided education to all patients and parents who refused. They documented this education and asked the parents if they would reconsider vaccinating prior to discharge. The outcome measures of this project included improving EHR nursing documentation of education and rescreening and increasing vaccination rates prior to discharge. Results: Of patients whose caregiver refused the flu vaccine on admission, 61% received the intervention and 27% of these caregivers reconsidered and decided to vaccinate. The vaccination rate of eligible patients prior to discharge for this unit increased from 39% to 60%. Conclusion: Optimizing the use of the EHR to automatically remind nurses to provide education and additional vaccination opportunity can increase vaccination rates. This unit’s improvement in vaccination rates and the number of caregivers who received the intervention and subsequently agreed to vaccinate demonstrates that this is a valuable tool if there is otherwise no process in place to prioritize vaccination. This intervention can be easily modified to be used in other patient populations and for other vaccinations.
    • Reducing Falls Utilizing a Fall Prevention Toolkit, Tailored Interventions for Patient Safety

      Morales, Flor M.; Gourley, Bridgitte (2021-05)
      Problem: Despite the use of numerous evidence-based interventions, in 2019, a medical surgical unit at a community hospital had a higher fall rate than its peers. The average fall and fall with injury rates were 2.6 and 1.17 per 1,000 patient days. Purpose: To implement and evaluate the effectiveness of the Tailored Interventions for Patient Safety (TIPS) fall prevention toolkit (FPTK) in an inpatient medical-surgical unit. Methods: The intervention is a three-step evidence-based tool which provided individualized universal fall precautions. Nurses completed a fall risk assessment on every admission and transfer to the floor. Then, they completed a falls poster at the bedside with the patient, educating them on their individualized fall risks and fall prevention interventions. The poster was hung at the door as a reminder tool for staff and patients. Data collected during the project included staff education, poster completion audits, and the organizations reported monthly fall rates. The data was analyzed using run charts and bar graphs. Reminders, morning huddles, and staff education were used to promote compliance. Results: Nurses and patient care technicians (100%) were all educated prior to intervention implementation. The average compliance rate of completed TIPS posters was 67%. The fall rate increased during the intervention phase by 18% compared to the pre-interventions phase. There were no changes in fall with injury rates post intervention when compared to pre-intervention. Despite an increase in falls during the implementation phase, there was a positive trend that showed that as compliance rates increased from October to December, fall rates decreased. Conclusions: The compliance rate was not met and fall rates were higher post-intervention. Additional reminders, weekly huddles, and meetings could be held to re-educate staff and allow for discussion of barriers and facilitators. October and November’s low rate of poster completion may correlate with the higher fall rates. In December, there were less falls and compliance rates were higher. Strategies and tactics should be utilized in order to increase intervention compliance, increase sustainability, and decrease fall and fall with injury rates in the future. Limitations included a COVID pandemic and forgetfulness in completing the poster.
    • Reducing Falls with Tailored Intervention for Patient Safety on a Neuro Unit

      Lockard, Darlene; Gourley, Bridgitte (2021-05)
      Problem & Purpose: Falls on the neuro care unit at a suburban hospital in 2019 averaged 2.4 falls per month. This unit has the second highest fall rate at the medical center. Compared to the National Database of Nursing Quality Indicators for total falls in 2019, the neuro care unit was higher than the benchmark and averaged 2.98 falls per 1000 patient days with the benchmark at 2.95 falls per 1000 patient days. The purpose of this quality improvement project is to implement and evaluate the effectiveness of a Tailored Intervention for Patient Safety toolkit to reduce falls on an adult inpatient neuro care unit. The Tailored Intervention for Patient Safety is a 3 step fall prevention process that includes Universal Fall Precautions that apply to all patients admitted or transferred to the neuro care unit. Methods: Methods employed for assessing completeness and accuracy of data were done by spot checking audits twice weekly to make sure Tailored Intervention for Patient Safety poster at bedside and handout in admissions folders were properly filled out. This data was analyzed and graphed in a run chart to analyze for trends by looking for runs, shifts, and alternating points that suggest cause variation exists. The hospital provided monthly falls and falls with injury was and calculated using falls per 1000 patient days. This was plotted in a bar graph to compare pre-intervention and post-intervention to ensure completeness and accuracy of the data. Results: TIPS poster compliance was 90%, with 100% of staff trained. Falls decreased by 67% compared to pre/post-intervention data from 2019 to 2020. Falls with injury decreased by 14% compared to pre/post-intervention data from 2019 to 2020. TIPS handout compliance was 0%. Conclusions: TIPS adherence reduced falls and falls with injury. This reduces hospital cost and improves patient care.
    • Standardization of Access for Administration of Intravenous Contrast for Computed Tomography Scans

      Cariaga, Retzer; Nawrocki, Lauren (2021-05)
      Problem and Purpose. The extravasation rate from Computed Tomography (CT) scans with intravenous contrast (IVC) in a large academic medical institution is 0.36% (inpatient 0.39% and outpatient 0.30%), higher than the national benchmark of 0.26%. A survey also showed that 16% of inpatients arrive at the CT scan department with peripheral intravenous (PIV) lines that may be kinked, dislodged, phlebitis or thrombose formation, or dressings are not intact. These conditions delay the CT scan procedure and put the patient in an unsafe condition. The purpose of this Quality Improvement (QI) project is to implement a protocol to standardize the preparation of PIV lines for inpatients for the administration of IVC to promote patient safety, prevent delays in CT scan, and eliminate common risk factors for extravasations. Methods. The QI project involved inpatients from a 23-bed adult medical telemetry nursing unit with CT scan orders with IVC using a PIV line. It required a coordinated effort between the bedside Registered Nurses (RNs), CT Technologists, Vascular Access Team (VAT) RNs, and Radiology RNs. The protocol involved the proper assessment of the PIV lines before leaving the bedside, using a test flush technique with 10 mL saline to flush in two seconds (5 mL/sec). Failure of the PIV line to accommodate the test flush required re-cannulation by the VAT RN. Results. During the 16-week implementation period, 17 patients (33%) ordered for CT scan with IVC underwent the protocol to standardize PIV lines' preparation. Among these patients, five (29%) did not pass the test flush and were re-cannulated by the VAT RNs. Conclusions. Bedside RNs play essential roles in preparing patients for CT scans with IVC. Adequate assessment of the PIV lines using the test flushing technique at the bedside before transporting patients to the CT Scan Department ensured that non-patent PIV lines receive re-cannulation. This protocol eliminated a common risk factor for extravasation and prevented potential harm to the patient and CT scan delays.
    • Timed Reminders within the Electronic Health Record to Improve Pain Reassessment Documentation

      Noll, Rebecca L.; Bundy, Elaine Y. (2021-05)
      Problem & Purpose: Ineffective reassessment and documentation of a patient’s pain level can lead to physical and psychosocial impairments compromising the ability to participate in milieu activities among psychiatric inpatients. In a large community hospital’s inpatient psychiatric unit, pain reassessments were only completed 57% of the time. The purpose of this quality improvement project was to implement modifications to the pain assessment flowsheets in the electronic health record on an adult inpatient psychiatric unit to improve nurse adherence to reassessment and documentation of pain scores. Methods: Pain reassessment timed reminders were added into the electronic health record flowsheets and tracked over a 13-week period on an inpatient psychiatric unit in a large community hospital. An algorithm of the unit’s pain management policy was developed laying out step by step guidance for pain reassessment timelines and medication management. Twenty staff nurses from a unit with a 19-bed patient capacity participated in this quality improvement project. Nurses received education on how to add timed reminders into the electronic health record flowsheets prior to project implementation. Pre and post implementation surveys were administered to evaluate how often nurses reassess and document pain levels within the appropriate timeframe. Weekly run charts were used to analyze and track data on nursing staff compliance rates. Results: Data collected in the weekly audits reflected a 20% improvement in pain reassessment overall at the conclusion of the project timeline. A displayed pain assessment algorithm helped to boost reassessment documentation rates by 10% initially. The next week reassessment documentation decreased by 22% after posting names of individual nursing staff adherence rates. Documentation adherence rates increased within two weeks by 20% after posting a certificate of achievement displaying nursing staff achieving 100% weekly pain reassessment documentation. Conclusion: The use of timed reminders embedded into electronic health record flowsheets, a pain management algorithm, and recognition of staff with 100% documentation compliance contributed to improvement in pain reassessment documentation practices. Implications for practice included timely documentation of pain reassessments improving pain management among psychiatric inpatients.