• Asymptomatic Bacteriuria: Identification and Management in Long-Term Care

      Liu, Yan; Windemuth, Brenda (2019-05)
      Background: Antibiotics are the most commonly prescribed medication in long-term care (LTC) facilities, and as much as 30% of antibiotic prescriptions are unnecessary. Antibiotic treatment for asymptomatic bacteriuria (AB) is one of the key contributors to antibiotic overuse and the increase in multidrug-resistant organisms in LTC. The guidelines from the Infectious Diseases Society of America suggest that antibiotic treatment of AB can only bring harm to the patient. However, inappropriate antibiotic treatment for AB in LTC remains common. Local Problem: A retrospective chart review on a 40-bed unit in a city-based LTC facility found that 50% of the patients with no definitive diagnosis of urinary tract infection (UTI) were placed on antibiotics without documented reason. Due to apparent overprescribing of antibiotics, a change in practice for proper identification and management of AB was warranted. Objective/Aim: The objectives of this quality improvement project were: 1) to develop and implement an evidence-based clinical pathway (CP) to assist nursing staff to accurately identify and more effectively manage AB, and 2) to educate and mentor nursing staff and leadership to successfully implement the clinical pathway and evaluate the practice changes. The anticipated outcomes of the project were 75% compliance with using clinical pathway and a 15% decrease in the number of patients treated with antibiotics for UTI. Intervention: The pre-post design was used. The setting was a 40-bed unit in an urban LTC facility. The sample consisted of the residents (40) in the unit. The project took place over a 14week period. Education was provided to the staff with six in-services, ongoing instruction, and poster presentation. Baseline data were collected, and weekly chart audits and run charts were conducted. The outcome measures were collected and the comparison with the baseline was made. Results: The risk ratio revealed that patients without specific UTI symptoms in the baseline group had 9 times the risk of being diagnosed with UTI compared to the follow-up group, and there was a statistically significant difference as well as clinical difference between these two groups: RR = 9, 95% CI [68, 1.2], p = 0. Compared with the baseline group, the use of antibiotics for UTI in the follow-up group decreased 38.9%, and overall antibiotic usage decreased 25%. In the last month of the data collection phase, nursing staff compliance with the CP was 100%. Overall, the design and intervention of the project was effective with positive outcomes and there were no adverse events due to usage of the CP during the project. Conclusion: The CP for identification and management of AB in an LTC facility was effective in reducing the number of the patients treated with antibiotics for UTI, and with good staff compliance. Due to the nature of this quality improvement project, its generalizability for application to other facilities or quality improvement projects is limited. However, the findings of this project add to the evidence for the effectiveness of the McGeer and Loeb criteria, upon which the CP is based. Additionally, the project provides valuable information for other similar quality improvement projects.
    • Implementation of a Pneumococcal Immunization Standing Order Protocol in Long-Term Care

      Shittu, Alyson P.; Alessandrini, Erica (2020-05)
      Problem & Purpose Streptococcus pneumonia is a significant cause of morbidity and mortality of adults who are immunocompromised and of advanced age. It is the standard of care to vaccinate all high-risk adults (18-64 years) and adults 65 years and older with two pneumococcal vaccines (Centers for Disease Control and Prevention [CDC], 2015). However, pneumococcal immunization rates remain below the HeathyPeople2020 target goal of 90% nationally and locally (Office of Disease Prevention and Health Promotion [ODPHP], 2019). The objective of this quality improvement (QI) project was to implement the Immunization Action Coalition (2017) pneumococcal standing order protocol to increase the percentage of adult patients screened for vaccine need by 90%, and percentage of total residents vaccinated according to CDC recommendations by 10%. Methods The strategy of this QI project was to educate registered nurses to implement a pneumococcal standing order protocol, in a privately owned, 120-bed, long-term care (LTC) center in suburban Maryland. The design of this QI project was based on the diffusion of innovation theory, the 4 pillars practice transformation program (4 Pillars), and the Mobilize-Assess-Plan-Implement-Track (MAP-IT) process model. Weekly frequency distributions were used to examine the screening and vaccination rates, and a chi squared (X2) test was performed post intervention to examine the significance of intervention on vaccination rates. Results The total number of LTC residents (n=100) were White (66%), Black (32%), other (2%), with an average age of 83 years. Pneumococcal immunization rates increased from 56% pre-intervention to 82% post-intervention, and screening rates for vaccination need increased from 0% to 100%. A chi-squared test for independence indicated a significant relationship between vaccination status and implantation of the SOP intervention (p = 0.046, df = 1, n = 100). Conclusions This QI initiative showed that a systematic process change is feasible and can improve pneumococcal vaccination rates in a single institution. The findings may not be applicable to centers without an electronic medical record software to document immunizations or dedicated QI team. Ongoing work should focus on the perceived self-efficacy of LTC nursing staff to effectively implement a behavior change, and skills to provide strong recommendations for immunizations.
    • Implementation of Cognitive Stimulation Therapy in Long Term Care

      Regan, Claire E.; Yarbrough, Karen (2020-05)
      Problem and Purpose: Individuals with dementia are often treated with psychotropic medications despite harmful side effects. Cognitive Stimulation Therapy (CST) has been shown to improve cognitive functioning and quality of life (QOL) in individuals with dementia and reduce adverse behaviors. The aim of this quality improvement (QI) project was to implement a CST program in a long term care facility for residents with dementia to decrease the number of adverse behaviors, reduce the use of psychotropic medications and improve cognition and quality of life. Methods: This quality improvement project was implemented in a 200 bed long term care facility in Baltimore City. Nine residents were selected to participate in a sevenweek CST program. A DNP student performed the CST sessions twice a week for 45 minutes. Content was based on activities outlined in the CST program manual, with a different theme for each session that incorporated cognitive stimulation, reality orientation, reminiscence therapy, and validation therapy. Outcome measures included the St. Louis University Mental Status (SLUMS) Exam and the Quality of Life in Alzheimer’s Disease (QOL-AD) Scale. Assessments were completed pre- and post-implementation. Psychotropic medication use and the frequency of adverse behaviors were monitored through chart audits performed bi-weekly. Results: Eight residents completed the full seven-week CST program. All participants attended at least half of the sessions. There was an overall average increase in SLUMS scores of 19% with a mean pre-implementation score of 16.75 and mean post implementation score of 20. QOL scores improved an overall average of 12% for six of the eight participants, and an average decrease of 20% for two participants. Deficiencies existed which prohibited the ability to accurately evaluate behavioral charting completed by the staff. There was no change in the use of psychotropic medications for residents enrolled in CST. An important secondary outcome was the observation of increased sustained socialization of residents when not participating in CST. Conclusion: CST improves cognitive functioning and may be correlated with the improving QOL of some residents. Additional research is needed to further investigate the effect CST has on increasing or sustaining socialization for long term care residents.
    • Improving Ineffective Communication in Long Term Care Settings

      Rucker, Airelle P.; Windemuth, Brenda (2019-05)
      Background Ineffective communication contributes to medical errors and sentinel events in healthcare, leading to fatalities and billions in malpractice cost. Nurses have a leading role in communicating patient information. In long-term care, ineffective communication and poor teamwork contributes to adverse events. Adverse events in our older adults can lead to hospitalizations, injuries, and death. Effective communication and teamwork are key components to providing safe patient care. Implementing a standardized handoff tool and team building curriculum can improve communication and teamwork. Local Problem Ineffective communication was a verbalized, observable practice problem at a long-term care facility in a suburban location in the Mid-Atlantic region. The purpose of this Doctor of Nursing Practice quality improvement project was to implement and evaluate the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) curriculum with a standardized handoff tool to improve communication and teamwork between nurses at this long- term care facility. Interventions During this quality improvement project, six nurses at a suburban long-term care facility learned two TeamSTEPPS modules: communication and team structure. Modules included strategies such as use of the Situation-Background-Assessment-Recommendation communication framework and used a validated handoff tool, Safer Sign Out. This quality improvement project occurred over 14 weeks. During week one, the nurses were informed about the practice change. During week two, the DNP project leader administered pre-surveys and educated the nurses on the TeamSTEPPS’s curriculum and handoff tool. During weeks three through thirteen, the nurses utilized the Safer Sign Out handoff tool to give report. Nurses were observed during each shift change during the first week on implementation. The project leader reviewed the handoff log for compliance and gave feedback. During week fourteen, nurses completed post- surveys. Lippitt’s Change Theory was used to guide this practice change. Results (Impact of change) The post- TeamSTEPPS Teamwork Attitudes Questionnaire revealed an increase in overall scores on the team structure and communication category but these changes were not significant, thus indicating only a limited overall improvement in the nurse’s attitudes about teamwork and communication. The post- TeamSTEPPS Teamwork Perceptions Questionnaire, revealed an overall slight increase in the scores from the team structure category and a slight decrease within the communication category; however, neither were found to be statistically significant. The data revealed that use of TeamSTEPPS did not result in significant improvements in the staff’s attitudes and perceptions on teamwork and communication. Conclusion Ineffective communication and poor teamwork in long-term care continues to lead to adverse events. Information is often lost during shift handoff. In this quality improvement project, several limitations may have impacted the results: a small sample size, a lack of involvement of an organizational champion or internal change agent, limited space to free text information on the handoff tool, and many internal organizational changes. Barriers must be addressed before implementing a communication and team-building curriculum. If barriers are addressed, then utilizing the TeamSTEPPS curriculum with nurses to teach teamwork and communication strategies, along with a validated handoff tool, may help to improve communication during shift hand-off.
    • 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.
    • A Team Approach to Improve Wound Care Quality in Long-Term Care

      Haney, Jillian E.; Clark, Karen, Ph.D., R.N. (2020-05)
      Problem and Purpose: Elderly long-term care residents are vulnerable to developing chronic wounds as a result of multiple factors related to aging, immobility, nutritional deficits, and medical comorbidities. Chronic wounds may result in uncontrolled pain, infection, hospitalization, amputation, and increased mortality. On one long-term care unit, lack of adequate wound surveillance and treatment has resulted in delayed healing rates. The purpose of this quality improvement project was to implement a wound care team, consisting of a nurse practitioner and licensed practical nurse to provide direct wound care surveillance and treatment for all residents of one long-term care unit, and collaborate with the inter-professional team to improve outcomes. Methods: On a weekly basis, the team assessed all active wounds, collecting measurements (length, width, depth in centimeters), and data on wound quality (tissue type, drainage, and etiology); and reviewed current treatment modalities. This data was recorded by the licensed practical nurse in the unit wound book, and presented weekly during inter-professional safety meetings, including physical therapy, social work, nutrition, and unit management, with the goal of developing a collaborative, resident-centered plan of care. Results: An average of 5 residents weekly were seen by the wound team. Over the 13-week implementation period, weekly data analysis revealed no overall change in wound incidence or prevalence. The accuracy and completion of nursing documentation improved from nearly 50% at the start of the project, to nearly 90% in the final weeks of data collection. Improved data accuracy allowed better inter-professional team decision-making. Changes facilitated by the inter-professional team process included enhancing the use of offloading devices, nutritional interventions, increasing access to high-quality wound supplies, and clarifying resident and family goals of care. Conclusion: A team approach is a feasible way to improve wound care quality in the long-term care setting. This process allows increased inter-professional communication and collaboration through enhanced data sharing, and enables needed changes made with group decision-making. Longer term studies could provide more insight into the effect of this process on wound incidence, prevalence, and healing rates.