• Decreasing Time to Palliative Care Consultation in an Intensive Care Unit

      Leath, Marcella E.; Van de Castle, Barbara (2021-05)
      Problem: A significant problem for patients in the intensive care unit (ICU) is that palliative care is not involved early in the patient stay. By implementing a screening tool to identify palliative care needs within 72 hours of admission, patient’s palliative care needs can be addressed early in ICU stay. Purpose: The purpose of this quality improvement (QI) project is to implement and evaluate a screening tool to identify patients with palliative care needs in a community ICU to decrease time to referral to palliative care. Methods: The Palliative Care Screening Tool was developed using verified and validated criteria and implemented into practice in a community ICU over a twelve-week period from September 2020 to December 2020. A distribution and collection center for the completed screening tools was created and education occurred for the nurse practitioners on the implementation team and ICU nursing staff regarding the project. Electronic medical record chart audits were completed weekly; data was collected from completed screening tools as well as electronic chart reviews. Screening tool users were surveyed at the completion of this QI project. Results: A total of 193 patients were admitted to the ICU during the implementation phase. Of the patients admitted with a length of stay greater than 72 hours (n=115), 89.6% (n=103) were screened with the tool, and 10.4% (n=12) were not screened. Fifty-five percent of patients screened (n=57) were identified as having palliative care needs. Of those with needs, 50.9% (n=29) were referred to palliative care. Over a 12-week period, there was a decrease in time from ICU admission to referral to palliative care by 68.9%, from 3.95 days at baseline to 2.72 days with the use of a screening tool. Conclusion: The use of a screening tool to assess patient needs for palliative care early in the ICU admission can standardize the process for patient referral and ensure early referral to palliative care.
    • Implementation of a Hospital-Acquired Pressure Injury Prevention Admission Bundle

      Berry, Mickaela E.; Callender, Kimberly (2021-05)
      Problem: Within a community hospital located in central Maryland, an adult intensive care unit (ICU) had an increased Hospital Acquired Pressure Injury (HAPI) incidence average rate of 2.2% per month during the months of July and August 2020. A potential cause identified was an inadequate nursing skin assessment on patient admission. Purpose: The purpose of this quality improvement project was to implement a HAPI prevention admission bundle that has been shown to reduce the number of HAPIs in an adult population. The bundle included four care components: completion of the Braden Scale score, performance of a two-nurse skin assessment, use of a pressure reducing surface, and application of a prophylactic sacral foam dressing. Methods: The adult ICU consisted of 30-beds and treated approximately 200 patients per month. The bundle was initiated by nursing staff at patient admission and all components were expected to be completed within 24-hours. Nursing education was administered and completed by the staff who worked in this unit. The use of the bundle was measured twice per week by chart audits. The HAPI rate was measured monthly by the hospital’s incident management system (RL6). Bundle documentation compliance and monthly HAPI rate were analyzed using run-chart analysis. Results: 86% of staff nurses were educated about the bundle. The documentation compliance of the bundle during the last four weeks of data collection was a 79% average. The post-implementation HAPI monthly incident rate average increased to 4.1%. Conclusions: The HAPI prevention admission bundle did not improve the average monthly ICU HAPI incident rate during a 14-week implementation effort. The documentation compliance of the bundle components improved over time, due to regular feedback of the chart audit results. COVID-19 precautions altered the standards of care during the implementation phase, which may have influenced the increased HAPI incidence rates during November and December. The HAPI prevention admission bundle was useful in increasing documentation compliance of four vital skin care components. A future quality improvement project should focus on adding additional evidence-based skin care components to the bundle and extending the implementation phase to ensure 100% of staff are educated to improve utilization of the bundle elements.
    • Implementation of a Nurse-Driven Nonpharmacological Sleep Bundle to Reduce Delirium in a Surgical Intensive Care Unit

      Turnbaugh, Lindsey D.; Hammersla, Margaret (2019-05)
      Background: The prevalence of delirium, an acute syndrome causing changes or fluctuations in baseline mental status leading to inattention, disorganized thinking, and altered levels of consciousness, afflicts patients residing in the intensive care unit. Several negative outcomes may occur in patients diagnosed with delirium in the intensive care unit, including increased mortality, hospital length of stay, cost of care, and long-term cognitive impairment. Sleep, a critical component of health and recovery, is noted to be disrupted in intensive care unit settings resulting in a correlative effect between sleep deprivation and delirium. Multicomponent nonpharmacological interventions are intended to reduce the predisposing factors of this syndrome and have been shown in randomized control trials and systematic reviews to be effective in preventing delirium. Local Problem: The purpose of this quality improvement project was to implement a nursedriven non-pharmacological sleep bundle with a checklist of interventions to reduce intensive care unit delirium, which was noted by staff as an increasing problem, in an adult 12-bed Surgical Intensive Care Unit at a community hospital in Towson, Maryland. Interventions: An evidence-based checklist of nonpharmacological interventions related to reducing noise, light, and patient care interruptions was implemented by the Surgical Intensive Care Unit nurses on patients admitted over an eight week period. Checklist compliance was measured during the eight weeks of implementation by counting the number of completed checklists and comparing that to the number of admissions per week. The interventions performed on all completed checklists were evaluated using descriptive statistics. Delirium was measured by the Confusion Assessment Method Intensive Care Unit tool in the electronic health record and evaluated through an electronic chart review. A data analysis was performed using a chi-square test and odd’s ratio to compare the Confusion Assessment Method Intensive Care Unit scores pre-implementation versus post-implementation of the sleep bundle. Results: During the first four weeks of project implementation, the weekly completed checklist compliance rate was 98%, however, the remainder of the implementation phase was at 100%. There was a high rate of noise, light, and patient care interventions labeled as “not-complete” due to patient refusal or “not-applicable” due to the inappropriateness of the intervention for the patient population. In the pre-implementation phase, delirium was reported as positive on the Confusion Assessment Method Intensive Care Unit tool 22% of the time versus 51% of the time in the post-implementation phase. A chi-square test determined a statistically significant association between the variables (p<0.001), though an odd’s ratio test (OR=0.26) revealed no association between the nonpharmacological sleep bundle and delirium scores. Conclusions/Implications: Documentation compliance was sustained by having the Confusion Assessment Method Intensive Care Unit documentation already embedded in the electronic health record. There was an increase in the awareness and nursing documentation of Confusion Assessment Method Intensive Care Unit scores during and after project implementation. Despite an increase in delirium among patients post-implementation, the literature still suggests a correlative effect between sleep deprivation and ICU delirium. Further studies are needed to determine whether multicomponent nonpharmacological sleep bundles can reduce delirium.
    • 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.
    • The Implementation of Nocturnal Earplugs and Eye Masks to Improve Sleep in the Cardiac Surgery Intensive Care Unit

      Ivusich, Kelsey s.; Amos, Veronica Y. (2019-05)
      Background: Sleep deprivation is a major concern among intensive care unit patients, with more than 60% recounting poor sleep, often lasting six to twelve months after discharge. Consequences of poor sleep include disruptions in immunity and endocrine function, impaired cognitive function, and increased length of stay and mortality. Excess noise and light frequently contribute to sleep and circadian disturbances in the intensive care unit. The use of nocturnal earplugs and eye masks is suggested to increase sleep quality among patients in the intensive care setting. Local Problem: Sleep disturbance was identified as a problem in the Cardiac Surgery Intensive Care Unit at a large, academic hospital in Maryland. The purpose of this project was to implement and evaluate the usability and feasibility of nocturnal earplugs and eye masks in the Cardiac Surgery Intensive Care Unit at this institution. Interventions: The Plan-Do-Study-Act Cycle was used to provide an organizing structure for the implementation of this 11-week, quality improvement project. Extubated, oriented, nonsedated Cardiac Surgery Intensive Care Unit patients were asked to wear earplugs and eye masks from 2200 to 0400. At 0600, patients completed a Patient Usability Survey evaluating the amount and quality of sleep, and the comfort of the earplugs and eye masks. The bedside nurse simultaneously completed a Nursing Questionnaire evaluating which intervention(s) was worn and duration of wear, if they believed the sleep aids helped their patient sleep through nursing interventions, and if they would recommend earplugs and eye masks to a future patient. Surveys were completed the first night after earplug and eye masks use. Results: 63 surveys were completed and returned, of which 51% (32 patients) refused to use the earplugs and eye masks. Of the 31 patients who participated, 68% (n=21) reported at least four hours of sleep, and 42% (n=13) rated their sleep quality as “More than average/normal” or “Much more than average/normal.” 45% (n=14) of patients rated the earplugs as “Comfortable” or “Very comfortable,” and 61% (n=19) rated the eye mask as “Comfortable” or “Very comfortable.” 45% (n=14) of participating patients wore both the earplugs and eye mask for the majority of the time between 2200 and 0400, with 68% (n=21) wearing them for at least four hours. 81% (n=25) of nurses “Agreed” or “Strongly Agreed” that the sleep aids helped their patient sleep through nursing interventions, and 90% (n=28) “Agreed” or “Strongly Agreed” to recommend their use to a future Cardiac Surgery Intensive Care Unit patient. Conclusions: Most patients who accepted the earplugs and eye masks found them comfortable and beneficial. Nurses believed they helped patients sleep through interventions and recommended their use. Despite positive outcomes in those who participated, a high refusal rate suggests the use of earplugs and eye masks may not be well suited for the Cardiac Surgery Intensive Care Unit patient population. Sleep aids should continue to be offered due to the benefits noted in those who utilized them and be encouraged for use in other units in the hospital with a broader inclusion and exclusion criteria.
    • Improving Sleep Quality in the Adult Intensive Care Unit

      Lubis, Crystal J.; Bundy, Elaine Y. (2021-05)
      Problem: Intensive care unit patients are at increased risk for poor sleep quality due to high incidences of night time nursing interventions, leaving little time for restorative sleep. Poor sleep can arise from stress, pain, and misaligned circadian rhythms as well. Sleep deprivation is harmful and can cause cognitive, ventilatory, cardiovascular, hormonal, and immune problems. The prevalence of perceived poor sleep quality was determined in the adult intensive care unit over a 3-month period. Most patients (54%) rated their sleep quality as less than average. Purpose: The purpose of this quality improvement project is to improve sleep quality for stable adult intensive care unit patients by placing them on a multi-component sleep protocol that provides a 4-hour window of uninterrupted sleep. Methods: A multi-component sleep protocol was implemented over a 12-week timeframe which prioritized a disturbance free 4-hour sleep window between midnight and 4 a.m. Staff were educated through a poster board presentation and by email. Protocol components included offering sleep masks and ear plugs to the patient, hanging a sleep protocol sign on room doors, re-timing routine medication and blood draws, and nurses serving as gatekeepers to prevent in-room disturbances. Patient’s self-reported sleep quality was charted afterwards in the electronic medical record. Ancillary departments (phlebotomy, pharmacy, and respiratory care) were notified of the new practice change as well. Weekly run charts were used to analyze and track data on percent of staff educated, patient’s sleep quality, and nursing staff compliance rates. Results: Results show that 100% of night shift nurses were educated on the protocol, 84% of nurses documented patient’s stated sleep quality in the electronic health record, and of the 106 sleep observations performed, 70% were rated as good or excellent. Fifty-eight patients total were placed on the sleep protocol during the 12-week project. Conclusions: Sleep disturbances are multifactorial. A multi-component sleep protocol was shown to improve sleep quality for adult intensive care unit patients. Therefore, a sleep protocol that diminishes or eliminates preventable disturbances is beneficial to the overall health of critically ill patients and should be a part of standard practice.
    • Palliative Care Screening Implementation within the Medical Intensive Care Unit

      Troiani, Nicole; Satyshur, Rosemarie D. (2020-05)
      Problem & Purpose: There are over 5 million intensive care unit (ICU) admissions each year with a mortality rate up to 29% and $108 billion dollar cost of care (SCCM, 2018). Palliative care is an essential part of comprehensive care in the ICU, however, it is underutilized in the medical intensive care unit (MICU) of a large urban academic medical center despite the unit reporting the highest mortality rate in the hospital. The purpose of the quality improvement (QI) project is to increase palliative care utilization in the MICU through the integration of nurse driven screening criteria that, when met, suggests the need for a palliative care consult. Methods: The QI project took place over a 13-week period. All patients admitted to the MICU during the implementation phase received a validated palliative care screening completed by the bedside nurse (George et al., 2015). Positive screenings were then discussed and plan of care documented by the interdisciplinary team on daily rounds. Completed screening tools were reviewed every other day to determine screening completion, documentation of family meeting notes, palliative care consults placed, and reason for not consulting palliative care despite positive screening. Results: Compliance with palliative care screening ranged from 79-100% (average 92%). Percentage of positive screenings ranged 18-50% (average 29%). Percentage of positive screenings with a consult ranged 0-60% (average 20%). The most common reason for lack of palliative consult was a planned “family meeting” (42%), however, less than 50% of these patients had a family meeting note documented. Comparing data 8 months pre-implementation to 13 weeks of implementation: average length of stay (LOS) for patients with palliative care consult decreased from 68.61 to 11.75 days; admission to consult mean decreased from 22.69 to 9.16 days; Palliative care consultation rate decreased from 13.86% to 10.39%. Conclusion: Despite utilization of a validated screening tool, palliative care consultation rates decreased. Physician preference greatly impacted consultation rates and highlighted the need to change knowledge and opinions related to palliative care. Finally, results support that screening leads to earlier palliative care consult, decreased LOS, and likely associated cost.