• The Impact of a Sequential Simulation Experience on the Clinical Decision Making of Novice Nurses related to the Care of the Morbidly Obese Post-operative Patient: A Pilot Project

      Dryer, Christy (2012)
      Problem: Errors in healthcare have been linked to new nurses' inability to apply sound clinical decision making/clinical judgment (Dunton, Gajewski, Klaus & Peirson, 2007; Smith & Crawford, 2003; NCSBN, 2009). As more demands are being placed on nurses in the current health care environment, particularly the novice nurse, there is an even greater need for nursing educational strategies that integrate theory and practice for nurses, particularly related to the development of sound clinical judgment, which is often illustrated by the appropriate application of clinical nursing skills. The use of clinical simulation has been proposed as a method that integrates theory, clinical skills application and clinical decision making, thus enhancing novice nurses' clinical judgment. Purpose: The purpose of this Capstone was to implement a program evaluation project that assessed the impact a change in program delivery, the use of a sequential simulation experience, had on the competence of novice nurses' clinical decision making during a nurse residency program in an acute care facility. A sequential simulation experience was created and implemented, and its impact on novice nurses' clinical decision making skills was evaluated. Tanner's Model of Clinical Judgment (2006) was used as the guiding framework and the context was holistic patient care for the morbidly obese post-operative patient. Methods: This project was conducted in three phases: Phase I: Simulation scenarios, case studies, participant surveys, simulation checklists and decision trees, related to the nursing care and associated clinical decision making with the morbidly obese post-operative patient, were developed and reviewed by content experts, with revisions as indicated. Simulation scenarios were piloted with senior nursing students enrolled in an Associate degree nursing program. Phase II: Implementation of project occurred during scheduled nurse residency program. Participants were randomly assigned to one of two groups: simulation or case study. Sequential simulation scenarios were run with eight participants in the morning session of the nurse residency program. Case study group presentation/discussion occurred in the afternoon session with remaining seven participants. All program participants completed surveys prior to and immediately after the teaching intervention. Phase III: Ten novice nurse participants returned two weeks later to complete a simulation scenario related to the clinical decision making of the morbidly obese post-operative patient to assess competence. Competence was individually assessed using a clinical skills checklist and decision tree. Results: Survey results for both subgroups were similar with all participants indicating an increase in knowledge and a majority indicating confidence in their confidence in their clinical decision making skills after educational intervention. Mean score on the assessment checklist for the simulation subgroup participants was 8 versus a mean score of 7.8 for the case study group, indicative of a slight enhancement in skill for simulation group. Decision tree results were also similar for both subgroups. Implications: A summary of program evaluation results was presented to the acute care facility and all materials created were provided for future use. Although the sample size was small, participant self-assessment related to knowledge and confidence, and the slight improvement in the checklist/decision tree results for the simulation subgroup support the conclusion that simulation may be a valuable tool for enhancing the clinical decision making skills of novice nurses.
    • Implementing a Mobility Scale to Increase Postoperative Mobility Levels

      Marasa, Mary C.; Bundy, Elaine Y. (2021-05)
      Problem: Gynecologic oncology treatment plans often involve invasive surgeries that put patients at risk for complications and long hospital admissions. Enhanced Recovery After Surgery protocols improves outcomes for gynecologic oncology patients, especially when patients are compliant with getting out of bed on postoperative day zero. At an urban Mid-Atlantic hospital, 3% of gynecologic oncology patients got out of bed on postoperative day zero and the average length of stay was 2 days between February 2018 and January 2020. Delaying postoperative mobility increases the risk for longer hospital stays. Purpose: The purpose of this quality improvement project is to implement the Johns Hopkins Highest Level of Mobility (JH-HLM) scale with defined goals to increase postoperative mobility levels and decrease the length of hospital stay for postoperative gynecologic oncology patients. Methods: Quantifiable mobility goals were defined for postoperative patients based on the JH-HLM scale. The nursing staff was educated about the mobility goals and JH-HLM scale through unit presentations, email communication, and annual competencies. Mobility documentation was standardized in the electronic health record. Education materials were disseminated to the inpatient oncology unit, post-anesthesia care unit, rehabilitation department, and patients. Patient age, diagnosis, type of surgery, mobility levels, and length of stay were collected through chart reviews for 3 weeks before implementation and during the 12-week implementation period. Run charts were used to analyze the data. Results: Results showed that average mobility documentation increased (10% to 46%). There was an increase in mobility levels on postoperative day zero (6% to 33%) and by discharge (13% to 45%). The average length of stay during the 3-week pre-implementation period was 1.6 days and after implementation it was 1.8 days. These results were not statistically significant. Conclusion: Findings suggest that quantifying and standardizing mobility goals may increase postoperative mobility levels. However, more investigation is needed to demonstrate statistical significance. Length of stay was not decreased and was likely impacted by a variety of factors. Further investigation of improving mobility documentation, decreasing data variability, and increasing compliance is warranted.
    • Patient Engagement to Reduce Postoperative Nausea and Vomiting in Bariatric Surgery

      Ryschkewitsch, Samantha M.; Connolly, Mary Ellen (2021-05)
      Problem and Purpose: Laparoscopic bariatric surgery patients are at high risk for postoperative nausea and vomiting (PONV) due to a combination of demographic and iatrogenic factors including age, sex, laparoscopic surgery of greater than one hour duration, stomach size reduction, and increased requirements for intraoperative hypnotics and opioids. The incidence of PONV after bariatric surgery ranges between 54% and 79% in the literature (Groene et al., 2019). PONV places patients at risk for postoperative surgical complications including wound dehiscence, dehydration, aspiration pneumonia, delayed recovery, and increased length of stay (LOS). In an 800-bed urban American teaching hospital, increased LOS due to PONV occurred in 6% of laparoscopic bariatric surgery patients between 2018 and 2019. The purpose of the project is to implement patient engagement techniques to reduce PONV in laparoscopic bariatric surgery patients and evaluate the results of the implementation. The goal is to eliminate increased LOS that occurs due to intractable PONV. Methods: Literature review and synthesis supported the idea that patient engagement via daily postoperative coaching by nurses combined with a paper-based self-management tool improves surgical outcomes. The practice changes include patient engagement via coaching, provision of a postoperative daily goal sheet, and collaboration with the primary nurse in the postoperative phase to establish and meet daily goals of care. Implementation strategies include patient education, educational inservices provided to nursing staff, reminders provided to nursing staff, and inclusion of a nurse champion among project stakeholders. Results: Results showed incomplete adoption of the intervention with only 10% of all postoperative daily goal sheets returned complete by the end of the implementation phase. Median incidence of LOS increased between the preimplementation phase and implementation phase, while documented PONV decreased and antiemetic administration was unchanged. No definitive association between the intervention and outcomes could be determined. Conclusions: Conclusions regarding the efficacy of the intervention could not be drawn. PONV remains a valuable target for reduction in this population worthy of future quality improvement initiatives.

      Solomon-Adenola, Oluwanife; Gutchell, Veronica (2020-05)
      Problem Statement: Currently, in the United States, there are approximately 3 million patients with Cardiovascular Implantable Electronic Devices (CIEDs). Annually, more than 1 million CIEDs are implanted and 2% of patients with CIEDs undergo cardiac/non-cardiac surgical procedures. With the increase in surgical patients with CIEDs, CIED variations and CIED risk of complications, anesthesia providers must have current knowledge about preoperative and postoperative management of this patient population. Purpose: The purpose of this Doctor of Nursing Practice (DNP) project was to develop an evidence-based clinical practice guideline (CPG) for standardizing the preoperative and postoperative anesthesia management of surgical patients with CIEDs at a large, teaching, level two trauma hospital in Baltimore, Maryland. Currently, there is no existing evidence-based practice for anesthesia management of these patient populations at this facility which provided an educational opportunity to improve patient safety. Methods: An expert panel was convened and included two Certified Registered Nurse Anesthetists (CRNAs), one anesthesiologist, an interventional cardiologist, and a chief information officer. A comprehensive review of literature was conducted. The Appraisal of Guidelines for Research & Evaluation II (AGREE II) Tool was utilized by the expert panels to assess the quality of the CPG. After the dissemination of the CPG via an educational PowerPoint presentation to anesthesia providers at Grand Rounds, the practitioner feedback questionnaire (PFQ) was completed. The PFQ is a 3-point Likert-scale used to assess the accuracy and transparency of the development of the CPG. Results: The domain scores of the AGREE II tool ranged from 70 to 100%. The domain “Editorial Independence” rated highest with a score of 100%. The domain “Stakeholder Involvement” rated lowest with a score of 70% and “Applicability” with a score of 81%. 80% of anesthesia providers (n=30) completed PFQ. Overall, 94% of the anesthesia providers agreed that the guideline should be approved for practice and it would be applied in their practice. Conclusion: This CPG impacted the knowledge deficit among anesthesia providers at this facility to increase awareness and improve patient safety of surgical patients with CIEDs. Even though this CPG was designed based on the need of this institution’s anesthesia providers, stakeholders permitted the application and usability of this CPG at other sister hospitals under this facility’s health system.
    • Postoperative Cesarean Section Outcomes Following Standardized Oxytocin Dosing: Rule of Three’s

      Sanchez, Miguel; Pellegrini, Joseph (2020-05)
      Problem & Purpose: Currently there is no standardized guidelines for the administration of oxytocin during a cesarean section to prevent uterine atony, which has led to anesthesia providers administering varying doses of oxytocin to prevent postpartum hemorrhage (PPH). Oxytocin that is delivered at high rates of infusion have been associated with myocardial depression through hypotension, tachycardia, and myocardial ischemia. The literature has shown that the use of regimental low dosed oxytocin like the “Rule of Three’s” improves its efficacy. The purpose of this quality improvement (QI) project is to overcome the lack of standardization with the delivery of oxytocin during a cesarean section by developing a clinical practice guideline (CPG) for low dose oxytocin administration following the “Rule of Three’s” algorithm. This manuscript will highlight the development with a primary concentration on the post-cesarean section oxytocin administration. Methods: The CPG was developed through 4 phases. The first phase involved stakeholder recruitment along with the development of the CPG using the AGREE II tool to evaluate it. During the second phase the CPG was appraised by the chief anesthesiologist for initial approval. The third phase consisted of a formal presentation to the anesthesia staff that was based on oxytocin management. A Provider Feedback Questionnaire (PFQ) was used to evaluate providers response to CPG. During the fourth stage, approval for the use the CPG was granted by the chief anesthesiologist for use. The data was analyze confidentially using both inferential and descriptive statistics. Results: The CPG was assessed using the AGREE II Tool resulting in an overall average of 93%, which was indicative of a high-quality guideline recommended for clinical use at the facility. The PFQ (n=12) assessed the CPG’s quality, acceptance, applicability, value, and outcome had an overall agreement of 80.7%. Conclusion: The “Rule of Three’s” was proven to be the optimal dosing regimen during cesarean section and throughout the postoperative period. During the postoperative period the prevention of uterine atony is vital to reduce the incidence and severity of PPH, which is effectively achieved when using the “Rule of Three’s” CPG. A limitation of the quality improvement (QI) project was anesthesia provider were resistant to changing their practice. The next phase of the QI project will include reducing provider resistance and monitoring quantitative blood loss during surgery.
    • Preventing Intraoperative and Postoperative Hypothermia

      Tamrakar, Prajjwal; Yarbrough, Karen (2021-05)
      Problem: Hypothermia is defined as a core body temperature of less than 96.8 °F. The prevalence of perioperative hypothermia has been reported to be in the range of 50% -90% of patients undergoing surgical procedures. In a community-based hospital, the quality benchmark for perioperative temperature monitoring and management is 98%. Currently, compliance for perioperative temperature monitoring and management is only 64% presenting an opportunity to improve perioperative hypothermia management. Purpose: The purpose of this performance improvement project was to implement evidence-based warming bundle interventions to prevent intraoperative and postoperative hypothermia on a patient undergoing elective surgery receiving general and/or regional anesthesia in a community-based hospital. Methods: The setting for this performance improvement project was perioperative area of a community-based hospital. The target population included anesthesia providers and perioperative nurses. The use of warming interventions provided by these professional was considered for adult patients over the age of 18 years and undergoing elective surgery under general and/or regional anesthesia for more than 60 minutes. Anesthesia providers provided forced-air warming blankets, warm blankets, and humidifier filter when intubated to eligible patients. Further, eligible patients were administered warmed intravenous fluids. Assessment of compliance of using warming bundle intervention by anesthesia providers was based on completion of a self-reported data collection sheet. Results: A total of 245 data collection sheets were collected from September-November 2020. Seventy- seven percent (188/245) utilized the warming bundle intervention, 9% (23/245) used only forced-air warming devices, and 14% (34/245) utilized passive warming. Among warming bundle intervention, in 91% (172/188) of cases, forced air warming blanket along with passive warming methods were used and 9% (16/188) utilized warming bundle intervention along with warm intravenous fluids. Thus, the compliance with the warming bundle intervention by the anesthesia providers was 77%. Further, the patients treated with warming intervention maintained the intraoperative and postoperative temperature ≥ 97 °F. Conclusions: The warming bundle intervention is successful in preventing intraoperative and postoperative hypothermia in a patient undergoing elective surgery under general and/or regional anesthesia at the community-based hospital. Hospital compliance for perioperative temperature monitoring and management was also increased by using warming interventions.