Browsing Doctor of Nursing Practice (DNP) Projects by Subject "Postoperative Complications--surgery"
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Implementation of an Intraoperative Prevention Protocol and Post-Operative Treatment for Corneal AbrasionsProblem: The incidence of corneal abrasions (CAs) at a medium-sized urban community hospital in the Mid-Atlantic region of the United States occurs approximately three-to-five times per month. CAs are the most common ocular injury in patients undergoing general anesthesia for non-ocular procedures and are the result of mechanical, thermal, or chemical damage directly to the corneal epithelium. Development of a perioperative CA is incredibly painful for most patients, and poses the risks of keratitis, infection, corneal scarring, and vision loss. During general anesthesia, the normal protective reflexes of the eye become absent, further exposing the patient to injury. When the eyelid does not completely close, up to 44% of patients develop a CA. Evidence-based methods of eye protection such as taping the eyes closed, using goggles, methylcellulose-based lubrication, or gel drops during general anesthesia decrease the incidence of CAs to less than 0.02%. If a corneal abrasion is suspected, patients require eye patching, anesthetic eye drops, antibiotic ointment, and an Ophthalmologic consultation. Purpose: The purpose of this quality improvement (QI) project was to implement and evaluate an evidenced-based prevention plan and treatment algorithm for CAs, decreasing the number of ocular injuries and streamlining the treatment process in those patients who sustain a corneal abrasion. Methods: The anesthesia Quality Assurance (QA) documentation form was updated with a checklist for anesthesia providers to document CA prevention methods and patient positioning. Formal education was provided to the anesthesia department regarding current anesthesia practice recommendations, proper documentation, objectives and goals of the QI initiative. Data collection was achieved with weekly paper QA form audits. Data analysis was based on completion of the checklist on the QA form. Results: Documentation of CA prevention methods increased from 0% to a median of 80% during the 15-week implementation and data collection phase. Peak compliance reached 85% during week nine. The rate of CAs decreased to zero and remained there for weeks 11-15. Conclusions: Implementation of an intra-operative CA prevention plan and documentation system decreased the number of corneal abrasions experienced at a medium-sized urban community hospital.
Perioperative Corneal Abrasion Prevention Protocol in Prone and Lateral Positioned PatientsProblem & Purpose: Corneal abrasions (CAs) are the most common anesthesia-related perioperative ocular injury in non-ocular surgery. Studies show the most common patient-related risk factors include advanced age, dry eyes, and an ophthalmic history. Procedure-related risk factors include general anesthesia, lateral or prone positioning, longer procedures, and robotic surgery. Properly taping eyes closed prior to airway manipulation can prevent corneal abrasions. Anesthesia providers at a medium-sized community hospital found approximately five CAs out of 500 cases occurred in adult surgical patients despite preventative efforts. This Quality Improvement (QI) project implemented a preoperative CAs risk assessment and intraoperative CA prevention protocol to improve the detection of risk factors and implement intraoperative prevention methods. Methods: Inclusion criteria for the preoperative risk assessment were adult patients, scheduled for elective surgery, and receiving general anesthesia. Exclusion criteria included pediatrics, parturient, non-elective surgery, and not receiving general anesthesia. The inclusion and exclusion criteria for the intraoperative prevention protocol remained the same, with the addition of those placed in lateral or prone position to be included and other positions to be excluded. Ocular occlusive dressings were stocked in all operating rooms. Implementation of yes/no checklist forms included a Preoperative CA Risk Assessment of Patient-Related Factors (five-item) and Procedure-Related Factors (four-item), and an Intraoperative CA Prevention Protocol (15-item). Education was provided to preoperative nurses and anesthesia providers. Completed forms were deposited into a locked box in the anesthesia lounge. Baseline data collection began at the start of the implementation period, and weekly thereafter. Data was recorded without identifiers using a secure data management Excel spreadsheet based on inclusion and exclusion criteria. Outcome measures included use of the preoperative risk assessment and the intraoperative prevention protocol with compliance rates displayed using run charts. Results and Conclusion: The risk assessment had compliance rates from 5% to 61% (median=30%). The prevention protocol had compliance rates from 6% to 100% (median=89%). The occurrence of corneal abrasion decreased from 2 to zero per week. A QI project implementing a preoperative CA risk assessment and an intraoperative prevention protocol will improve the delivery of quality care and patient outcomes in the perioperative period.