• Implementation of Depression Screenings in a Cardiac Surgery Specialty Practice

      Dizon, Kristen; Davenport, Joan (2019-05)
      Background: Depression does not typically occur in isolation; it is a major risk factor for heart disease. The neuroendocrine disturbances, endothelial dysfunction, enhanced platelet activation, and inflammation associated with depression increase patients’ risk for cardiovascular disease. Local Problem: Although cardiac surgery providers in an academic medical center located in the Mid-Atlantic region were aware of the prevalence of depression in cardiac patients, patients were not routinely screened for depression after cardiac surgery using a validated tool. Intervention: The purpose this quality improvement project was to implement the Patient Health Questionnaire-9 depression screening tool coupled with a referral, if needed, in a cardiac surgery practice. Using the Plan-Do-Study-Act cycle as a framework for implementation, cardiac surgery nurse practitioners screened eligible patients using the Patient Health Questionnaire-9. Eligible patients were adults who understood English, were being seen for their postoperative coronary artery bypass grafting surgery visit, and were not being treated for depression at the time of the screening. The first cycle of implementation involved just-in-time training of nurse practitioners for Patient Health Questionnaire-9 administration, interpretation, and referral. Before the second cycle, barriers and facilitators were identified before implementation continued. During the second cycle, providers performed the screening using an algorithm to streamline screening and appropriate referral. Results: Two nurse practitioners in the cardiac surgery practice were trained to administer, score, and interpret the PHQ-9. Out of the 38 patients eligible for screening, 29 were screened for depression and had the PHQ-9 documented in their chart. The mean percentage of patients screened during each clinical day was 83.3%, with an upper limit of 100% and lower limit of 0%. During implementation, two patients screened positive for depression. Conclusions: The Patient Health Questionnaire-9 is a feasible and useful screening tool for depression in a busy cardiac practice. Adapting the addition of the depression screening tool to the workflow and minimizing the additional workload incurred by implementation increased the likelihood of compliance. As undertreated mental health comes to the forefront of many issues worldwide, increased depression screening in various settings that can connect patients to care is an important and necessary addition to public health resources.
    • 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.
    • Mitigating Workplace Violence Utilizing the Broset Violence Checklist

      Doyle, Karen E.; Jones-Parker, Hazel (2020-05)
      Problem & Purpose: Workplace violence impacts all health care workers especially those working in behavioral health, emergency departments (EDs), and trauma centers. The Broset Violence Checklist (BVC) is an evidence-based, valid and reliable tool demonstrating high sensitivity and specificity with predicting potentially violent patients within a 24-hour period of assessment. The tool is available to nurses in the ED but is not widely used within the system due to a lack of procedure, education and monitoring of compliance. Methods: A quality improvement project developed a procedure to increase the use of the BVC. ED nurses and security personnel were trained and compliance with utilization of the tool was measured. A pre/post implementation survey was conducted to determine perceptions of workplace violence. A daily report detailing the use compliance and the BVC scores of each patient was automatically distributed to the emergency department and security leadership. The outcome measures are: (a) 90% of adult patients > 18 years old seeking treatment in the ED will be assessed for potential violence using the BVC during the intake and triage process and (b) overall incidences of workplace violence are reduced. Data were analyzed using descriptive statistics. Results: A convenience sample of 6,944 adults > 18 years old entered the ED in an academic acute care setting for evaluation and treatment in a 14-week period. Compliance with completion of the BVC pre-implementation was a mean of 74% and implementation of 67% (u = 1355, p = 0.014); 18 patients scored > 3 on the BVC (u = 188, p = 0.68). Conclusion: This quality improvement project illustrates it is difficult to improve compliance based on education alone. Enforcement of compliance with the procedure and assessment tool needs to be hard wired into the workflow of nursing and security personnel. It remains essential that hospitals incorporate violence assessment tools and strategies in the ED setting. As part of routine care, ED staff can use screening tools such as the BVC to identify people at high risk of violence. These tools can offer appropriate behavioral interventions to those who screen high on the assessment tool.
    • Using a Clinical Indicators Checklist to Determine Family Meeting Needs

      Heng, Christina L.; Alessandrini, Erica (2020-05)
      Problem & Purpose: Patients admitted to the surgical intensive care unit (SICU) are critically ill and may be unable to participate in their care, passing the burden of decision-making onto their family. Family members often express dissatisfaction with the healthcare team communication, making it difficult for them to make informed decisions about their loved ones. Studies have shown implementing family meetings within 72 hours of ICU admission improves communication between family members and the healthcare team. This quality improvement project aimed to improve family satisfaction with the healthcare team communication by implementing interdisciplinary family meetings within 72 hours of SICU admission for families of patients who meet specific clinical indicators. Methods: A checklist was developed based on the literature and input from the nurse educator, nurse manager, and medical director, to recognize specific clinical indicators with which a patient presents that likely require proactive communication from the healthcare team. The presence of at least one indicator prompted a response in which the dayshift nurse notified the unit social worker and SICU provider to initiate a family meeting within 72 hours of ICU admission. To determine a family member’s level of satisfaction with the healthcare team communication, the SICU family liaison distributed the Family Satisfaction With Intensive Care Unit 24R (FS-ICU 24R) questionnaire after the patient was discharged from the SICU. Results: There was a statistically significant increase in the completion of the clinical indicators checklists, X2 (1, n=964) = 75.96, p < 0.001. The number of family meetings did not increase significantly from pre- to post-implementation. The Fisher exact test statistic value was .52. The result was not significant at p < .05. Fifteen families were updated at the bedside (46.9%). Questionnaires returned resulted in satisfaction scores of greater than 75%. Conclusion: Using the clinical indicators checklist may have increased staff awareness for family meeting needs. However, conclusions could not be drawn from the relationship between family satisfaction and attendance at formal family meetings. Other methods of communication such as updates at the bedside and daily rounds may provide sufficient communication for families of patients who meet minimal clinical indicators.