• A Clinical Practice Guideline for Postoperative Cognitive Impairment: Anesthetic Interventions

      Taylor, Natalie L.; Pellegrini, Joseph (2020-05)
      Problem & Purpose: Postoperative delirium and postoperative cognitive dysfunction, collectively referred to as postoperative cognitive impairment (PCI), are two neurocognitive risks that accompany anesthesia. The incidence of developing PCI can be as high as 50% and is heightened after the age of 65. Currently, the anesthesia department at a mid-sized community hospital in Baltimore City does not have a structured process for the perioperative management of these patients. A Clinical Practice Guideline (CPG) was written recommending a strategy to preoperatively assess and identify high-risk surgical patients, and includes evidence-based anesthetic interventions recommended for this population. The purpose of this scholarly project was to identify the anesthetic interventions included within this CPG: a guide which outlines the perioperative anesthetic management of patients >65 in order to decrease the incidence of PCI. Methods: CPG content was derived from a literature search identifying evidence published within the past 10 years and included five systematic reviews, two randomized control trials, and the current recommendations of the American Geriatrics Society and American College of Surgeons. The CPG was designed, analyzed by key stakeholders, and revised according to criteria found within the AGREE II tool. The CPG was presented to anesthesia staff and analyzed for applicability and acceptance using the Practitioner Feedback Questionnaire (PFQ). Results: AGREE II results by key stakeholders provided >88% positive feedback showing CPG quality in scope, content, and development. PFQ results demonstrated an overall average positive feedback and agreement of 70% (SD=19.1) among anesthesia providers (n=13). Feedback regarding the overall Quality of the CPG was both positive (88%) and neutral (12%). Applicability of Recommendations received the least encouraging feedback: 35% positive, 38% neutral, and 27% negative. Conclusion: Analysis demonstrates that the CPG’s content was regarded by anesthesia staff as high quality and that the majority of providers believe the CPG to be an improvement compared to what is currently practiced. While the majority of the polled anesthesia providers felt favorably towards the interventions, there remains reluctance towards its applicability into practice. Even so, 70% of anesthesia staff answered positively when asked if the CPG should become a guideline. Further staff education is recommended to enhance user buy-in.
    • 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.
    • Perioperative Glucose Management in Orthopedic Surgery

      Madden, Ann Rose; Amos, Veronica Y. (2019-05)
      Background: There is a definitive correlation between perioperative hyperglycemia and negative outcomes in orthopedic surgeries. Vigilant treatment of hyperglycemia (>180 mg/dL) will prevent negative outcomes such as joint failure, infection and pseudarthrosis. Local Problem: A Clinical Practice Guideline (CPG) focusing on the management of perioperative hyperglycemia for patients undergoing orthopedic surgery was created for a community hospital in Southern Maryland. Interventions: Data was collected using the following instruments: Practitioner Feedback Questionnaire (PFQ) and the Appraisal of Guidelines Research and Evaluation II Tool (AGREE II). The acceptance and usability of the clinical practice guideline (CPG) was evaluated through these instruments. Results: The dissemination and collection of the practitioner feedback survey resulted in a 100% response (N=16). The literature search was complete and relevant and the recommendations of the CPG were clear and suitable for the intended patient population. 90% of the clinician’s scores suggested they would feel comfortable utilizing the care model suggested in the CPG. Clinical expertise and demographic variables influenced the responses in the PFQ and Agree II tool. Conclusions: Overall the data collected demonstrated widespread acceptance and approval of this clinical practice guideline.
    • Perioperative Glucose Management to Reduce Surgical Site Infections: Clinical Practice Guideline

      Joseph, Sheilla S.; Gonzalez, Michelle LR; Amos, Veronica Y. (2019-05)
      Background: The association of hyperglycemia during and after surgery has been shown to increase the risk of Surgical Site Infections in multiple surgical specialties. Surgical site infections are a complication that has an annual financial impact of over $3 billion dollars nationally. Patients with poorly controlled glycemic levels are at higher risk for surgical site infections and are commonly predisposed to post-op soft tissue and bone healing complications. Local Problem: A large tertiary medical facility in Maryland requested an updated evidencebased guideline to manage perioperative hyperglycemia to reduce surgical site infections in their adult patient population undergoing elective orthopedic surgeries. A review of the literature revealed current standard of practice recommendations of maintaining glycemic values </= 180 mg/dL demonstrated a stronger link to reducing rates of surgical site infections and other post-op complications. The purpose of this Doctorate of Nursing Practice project was to develop a clinical practice guideline that provided best practice strategies for the management of postoperative hyperglycemia in adult patients undergoing elective orthopedic surgery. Intervention: A clinical practice guideline was developed for this quality improvement project. The project included three Student Nurse Anesthetists as project leaders, and three stakeholders. Stakeholders reviewed and graded the guideline draft using the Appraisal of Guidelines for Research & Evaluation Tool. This tool is an open source appraisal instrument used worldwide to evaluate structure, content and the quality of guidelines. Revisions made to the guideline were based on stakeholder recommendations and the appraisal tool results. Implementation of the project was in the form of a brief formal PowerPoint presentation to the anesthesia department and providers were asked to rate the guideline using the Provider Feedback Questionnaire. The data collected from this questionnaire and the appraisal tool were examined using simple descriptive and correlative statistics. Results were acquired to make final modifications to the guidelines. Results: The overall response to the guideline was favorable. The average percentage scores of the guideline appraisal tool were calculated by domain and showed an overall guideline assessment score of 87%. A total of 23 provider feedback questionnaires were collected; and the most common response was a 3 (Strongly Agree), appearing on 18 out of the 23 survey responses. The overall percentage of respondents’ agreement for the guideline was 79% with a standard deviation of 10%. In total, these results are very promising for continuing to explore the implementation of the guidelines. Conclusion: Perioperative glycemic control of </= 180mg/dL has been demonstrated to reduce the incidence of surgical site infections in adult patients undergoing orthopedic surgery. This clinical practice guideline was developed and implemented specifically for this institution. The guideline found strong support among the end users/stakeholders and both doctors and nurses strongly approved of the guidelines. The results of the provider feedback questionnaire indicated effective and internal reliability in which implementing the Guidelines would result in decreasing the rate of perioperative hyperglycemia and the rates of surgical site infections. Further evaluation of patient outcomes after implementation of the guidelines is recommended to measure continued guideline efficacy.
    • Perioperative Glucose Management to Reduce Surgical Site Infections: Clinical Practice Guideline

      Santiago, Frances; Gonzalez, Michelle L. R.; Amos, Veronica Y. (2019-05)
      Background: The association of hyperglycemia during and after surgery has been shown to increase the risk of surgical site infections in multiple surgical specialties. Patients with poorly controlled blood glucose levels are at higher risk for surgical site infections and are commonly predisposed to post-op soft tissue and bone healing complications. Maintaining blood glucose values < 140 mg/dL demonstrated a stronger link to reducing rates of surgical site infections and other postoperative outcomes. Local Problem: The purpose of this project is to develop a clinical practice guideline that provides clear directions and constitutes best practice strategies for the management of hyperglycemia throughout the perioperative period of adult patients undergoing surgery at a tertiary medical facility in Maryland. This facility identified a rise in the incidence of post-op hyperglycemia with blood glucose levels ≥ 180 mg/dl and an increase in post-op surgical site infections in their patient population. Interventions: This project took place in three phases over a 14-week period. The first phase included recruitment of an expert panel consisting of an anesthesiologist and Certified Registered Nurse Anesthetist. After project buy-in, a draft of the guideline was presented to the panel. They reviewed and graded the guideline draft using the AGREE II Tool. Revisions were made based on the panel’s recommendations and AGREE II results. In phase two, a final meeting was held with the chief anesthesiologist for feedback and approval of the final presentation to the anesthesia providers. In phase three, a brief formal presentation was given to the anesthesia department. Anesthesia providers were asked to rate the guideline using the Provider Feedback Questionnaire. The data collected from the Provider Feedback Questionnaire surveys were analyzed and results were obtained to make final changes to the guideline. Results: The guideline provided clear instructions, produced positive patient outcomes, and was deemed favorable by the anesthesia department. Some providers felt the financial implications would hinder implementation, while others were unsure of changing their practice due to the rigid guidelines. Conclusions: This guideline was successfully developed and implemented at the requesting institution with the support of key stakeholders. Monitoring and managing hyperglycemic blood glucose levels in the perioperative period can decrease the incidence of postoperative surgical site infections.
    • Perioperative Glycemic Control to Reduce Surgical Site Infections: Clinical Practice Guideline

      Labang, Tara M.; Gonzalez, Michelle L.R.; Amos, Veronica Y. (2019-05)
      Background: Surgical site infections are a common postoperative complication that has been identified to be related to perioperative hyperglycemia. During times of stress, including surgical stress and anesthesia, the body responds by increasing levels of glucose to meet metabolic demands and reduces the production of insulin, leading to hyperglycemia. Intraoperative blood glucose monitoring and treatment has been demonstrated to reduce the incidence of hyperglycemic events and reducing the incidence of postoperative complications. Local Problem: A tertiary medical center in Maryland requested an updated, evidence-based clinical practice guideline for perioperative glucose management. This clinical practice guideline will provide an evidence-based approach for the following: intraoperative glycemic control, blood glucose monitoring frequency, intraoperative insulin pump management and insulin administration. Interventions: The purpose of this Doctorate of Nursing Practice project was to develop a clinical practice guideline for perioperative glycemic control to reduce surgical site infections in orthopedic surgical patients. This clinical practice guideline was designed for quality improvement purposes and conducted through a combined effort of three student registered nurse anesthetists as project leaders. Feedback and recommendations of the clinical practice guideline were received by key stakeholders through the utilization of the AGREE II tool. Implementation of the project was done via a PowerPoint presentation of the final clinical practice guideline to the end-users, the anesthesia staff, at the facility during the anesthesia staff meeting. End-users provided feedback of the clinical practice guideline via a Practitioner Feedback Questionnaire and demographic questionnaire to evaluate the clinical practice guideline. Data collected using The Agree II tool and Practitioner Feedback Questionnaire were analyzed using simple descriptive and correlative statistics. Results: The mean overall guideline assessment score of the AGREE II tool results was 87%. Both stakeholders rated the overall quality of the guideline with high quality ratings and indicated “yes” to recommending this guideline for use. Descriptive statistics were calculated for the sample of anesthesia providers (n = 23) who completed a Practitioner Feedback Questionnaire. Demographic data revealed that of the 23 respondents, six were anesthesiologists (26%), 16 were certified registered nurse anesthetists (70%), and one student registered nurse anesthetist (4%). Analysis of the Practitioner Feedback Questionnaire results support this clinical practice guideline. The average total percentage of agreement was 80.5% (SD=0.12); indicating the acceptability and usability of this clinical practice guideline by the anesthesia providers at this institution. Conclusions: Perioperative glycemic control has been shown to decrease surgical site infections rates. Recent evidence-based research demonstrates that a target glucose level of <180 mg/dL is effective in reducing surgical site infections, as well as reducing the risk of intraoperative hypoglycemic events. This clinical practice guideline was developed and successfully implemented specifically for this institution as requested to meet the needs of this anesthesia department. Sustainability and spread of the clinical practice guideline will be dependent on the institution.
    • Preoperative and Intraoperative Interventions for Enhanced Recovery after Gynecological Surgery

      Caalim, April J.; Piscotty, Ronald (2020-05)
      Problem and Purpose: Surgery causes a neuroendocrine and inflammatory stress response on the body that impairs hemostasis (Carli, 2015). Often, many of the interventions implemented during the perioperative care of patients are not evidence-based but rather due to dogmatic traditions. Enhanced recovery after surgery (ERAS) programs consist of evidence-based interventions implemented during the preoperative, intraoperative, and postoperative phases of surgery. Researchers have found that ERAS programs lead to a reduction in hospital length of stay, cost, and complications (Nelson et. al., 2016). At a community hospital in the mid-Atlantic region, anesthesia providers sought ways in which hospital length of stay and complications can be reduced in patients undergoing GYN surgery. In addition, GYN surgery is one of the most frequent types of surgical procedures performed at this institution. The purpose of this quality improvement project was to develop a clinical practice guideline (CPG) regarding ERAS for GYN surgery in order to optimize the perioperative care of patients. Methods: An expert panel was formed consisting of the chief nurse anesthetist and anesthesiologist of the institution. A need for an ERAS CPG was established based on several meetings with key stakeholders. A literature review was conducted to develop the CPG and a draft was presented to the expert panel. Next, a Non-Human Subjects Research (NHSR) review was sought from the Institutional Review Board at the University of Maryland. The Agree II Tool was utilized by the expert panel to evaluate the quality of the CPG. Feedback from the expert panel was then incorporated into the final draft. The CPG was presented to the anesthesia providers of the institution. Practitioner Feedback Questionnaires (PFQs) were distributed and anonymously collected at the end of the presentation. A descriptive statistical analysis was performed utilizing Microsoft Excel with the data obtained from the AGREE II Tool and PFQ surveys. Results: The results of the AGREE II tool were favorable with an overall calculated total domain score of 92%. The individual total domain scores are as follows: scope and purpose 97.2%, stakeholder involvement 100%, rigour of development 87.5%, clarity of presentation 94%, applicability 92.9%, and editorial independence 89.6%. The return rate for the PFQ surveys was 100% (n=15). The PFQ survey results revealed that 100% of providers believed that there is a need for an ERAS CPG for GYN surgery, that its utilization will benefit patients, and that the draft guideline recommendations will be supported by other anesthesia providers of the institution. This is indicative of the usability and wide acceptance of the CPG by the facility. Conclusion: Due to the favorable results of the AGREE II Tool and PFQ survey evaluations, it is evident that the developed ERAS CPG is of high quality and its use will be accepted at this institution.
    • Reducing Unit-Acquired Pressure Injuries on a Cardiac Surgery Progressive Care Unit

      McGinn, Amy E.; Davenport, Joan (2019-05)
      Background: Consequences of pressure injuries can be emotional and physical, including pain, body image distortion, increased risk for infection, increased length of stay in the hospital, and death. Pressure injuries create a significant economic burden for organizations and individuals. Organizations that have the highest incidences of pressure injuries receive less reimbursement for services. Local Problem: Prior to project implementation, 3 pressure injuries were found on the cardiac surgery progressive care unit during a 13-week period. The cardiac surgery progressive care unit in a large academic medical center in the mid-Atlantic region was responsible for 66% of the pressure injuries. The purpose of this quality improvement project was to implement and evaluate the effectiveness of a pressure injury prevention bundle on a cardiac surgery progressive care unit over a 13-week period using the Model for Improvement as a framework for implementation. Intervention: The pressure injury prevention bundle consisted of four steps: the Braden score, a two-nurse skin assessment on admission, a pressure-reducing surface, and a consult to the wound, ostomy, and continence nurse. Two-hundred one subjects were evaluated (n=201). The intervention was evaluated by a before-after design, comparing the number of avoidable unitacquired pressure injuries before project implementation, to after implementation of the PUPB. Results: Post-implementation, 4 pressure injuries were found on the cardiac surgery progressive care unit, but only 25% of the pressure injuries were determined to be the unit's responsibility, and 75% of the pressure injuries were determined to have occurred prior to admission to the unit. A nurse did not complete the two-nurse skin assessment on the one patient who developed a pressure injury during this project timeframe. The pressure injury was discovered 25.5 hours after admission to the unit, deeming it the cardiac surgery progressive care unit's responsibility. Conclusions: The pressure injury prevention bundle should be a standard of care for all new patient admissions. When all of these factors are used together in a bundle, this project demonstrates that the unit could have zero unit-acquired pressure injuries.