• An Algorithm for Diaper Dermatitis Management in the Neonatal Intensive Care Unit

      Crampton, Laura K.; Fitzgerald, Jennifer (2021-05)
      Problem: Diaper dermatitis (DD) is inflammation of the skin in the perianal area that ranges from mild erythema to broken skin and bleeding. At baseline, 20% of infants ≥ 30 weeks gestation had DD in the target Level IV Neonatal Intensive Care Unit (NICU). Historically, DD was managed based on individual nursing judgment due to a lack of current standardization of care for infants with DD and resulted in inconsistent care of infants with DD. Purpose: The purpose of this quality improvement project was to implement and evaluate the effectiveness of an algorithm for the prevention and treatment of DD in infants ≥ 30 weeks gestation in a Level IV NICU in an urban, academic medical center. Methods: Bedside nurses were given education on DD and the new algorithm for the management of DD. They also completed pre-and post-knowledge surveys. The algorithm was placed at the bedside of each infant for reference and the educational PowerPoint was emailed to all bedside nurses. Once a week, bedside nurses documented incidence of DD, if prophylactic or therapeutic treatment was performed, and if the algorithm was followed. Continued education was provided throughout implementation, reminder cards were placed on each nurse computer, and reminder texts to document DD data were sent out via unit phones each Monday. Results: The use of the algorithm and the use of prophylactic petroleum jelly increased from 0% at baseline to 100% over the 15-week data collection period. The prevalence of diaper dermatitis decreased from 20% (9/46) prior to implementation to 18% (2/11) on the last week of data collection. Following the education on DD and the implementation of the algorithm, the majority of nurses stated that they were more aware of DD and monitored for it more closely during diaper changes. Conclusions: The use of an algorithm for the management of diaper dermatitis helped to increase the use of prophylaxis and education on the algorithm increases bedside nurses’ awareness of DD in their patients on this unit.
    • Bundle to Improve Safe Sleep Modeling by Neonatal Intensive Care Unit

      Schmidt, Katelyn E.; Fitzgerald, Jennifer (2021-05)
      Problem: Neonatal Intensive Care Unit (NICU) nurses in a level IV NICU were noted to provide inconsistent safe sleep environments for hospitalized infants. The NICU population is at high risk for Sudden Infant Death Syndrome (SIDS). Nurses should provide consistent safe sleep modeling to educate and influence families. At the inception of this project, no structures were in place to evaluate infant readiness to receive safe sleep or to document sleep environments. Purpose: The purpose of this quality improvement project was to implement nurse-driven safe sleep modeling in the form of a safe sleep bundle. The bundle consisted of an inclusion algorithm, bedside crib reminder cards, and nursing documentation. Methods: A root cause analysis was conducted with nursing to determine appropriate bundle components. Nurse safe sleep champions provided unit education and performed bedspace audits. Measures included safe sleep compliance comprised of six components supported by the American Academy of Pediatrics, bundle utilization rates, and adverse events. Data was a convenient random sample and bedspaces were selected randomly by champions. The baseline compliance rates were then compared to implementation rates and nursing documentation. Results: Pre-implementation data was obtained from all seventy bed spaces. Overall, the rate of safe sleep compliance (all six categories) increased 37%. The greatest improvement in individual categories was “no position aids” (18% increase) and “no extra bedding” (58% increase). The other categories were mostly unchanged post-implementation with rates greater than 90%. Nursing documentation showed a greater than 80% compliance rate in all categories. No new adverse events were recorded for those infants receiving safe sleep. Nursing used the bundle routinely (algorithm use 20-92%; crib card 67-80%; documentation 4%). Conclusions: Results indicate a bundle improves compliance with safe sleep modeling. Some components gained wider acceptance than others. It appears a bundle has no detrimental effects on sleep environments and does not increase rates of adverse events. Overall, the bundle implementation improved awareness of safe sleep environments by nurses, and it has the potential to significantly increase safe sleep modeling and environments for hospitalized infants.
    • Clinical Practice Guideline on Utilizing Low-dose Ketamine Infusions for Treatment Resistant Depression

      Hunt, John H.; Amos, Veronica Y. (2021-05)
      Problem & Purpose: Standardly prescribed medications have increasingly become less effective in mitigating depression. This finding has led practitioners to explore alternative ways to treat refractory depression. Ketamine, a dissociative anesthetic, given as a low-dose infusion has become an efficacious regiment for managing the treatment resistant populations symptomology. Clinicians at an outpatient infusion center observed an increase in infusion related hemodynamic abnormalities due to non-standardized infusion therapies. The development and implementation of an evidence-based clinical practice guideline to standardize the administration of low-dose ketamine infusions aims to help alleviate the identified institutional problem. Methods: An extensive literature review was conducted to evaluate the most current evidence regarding ideal ketamine infusion rates to manage treatment resistant depression. A draft clinical practice guideline was developed with assistance from the institution’s stakeholders. The Appraisal of Guidelines for Research and Evaluation II tool was utilized by the stakeholders to appraise the draft guidelines quality. The finalized guideline was presented to the anesthesia team members and critique via provider feedback questionnaire was elicited. Results: The appraisal tools overall domain rating was an 88.9%, which represented a high-quality practice guideline. Provider feedback questionnaire results showed the developed guideline was accepted by stakeholders and anesthesia staff. Implementation of the new practice guideline was recommended without any changes. Conclusion: The anesthesia team valued the developed guideline which led to its acceptance. However, sustainability will rely on the provider success rates based on the utilization of the guidelines recommended dose range as well as periodically collecting and assessing provider feedback questionnaire data to ascertain the level of continued staff buy-in.
    • Daily Charge Nurse Leader Rounds on a Cardiac Surgery Progressive Care Unit

      Peed, Brittany L.; McComiskey, Carmel A. (2021-05)
      Problem: Patient satisfaction is the measure of the success of a healthcare system in today’s competitive markets. However, achieving patient satisfaction relies on multiple internal and external factors. The Cardiac Surgery Progressive Care Unit (CSPCU) at an urban medical center in the mid-Atlantic United States was seeking to improve their patient satisfaction scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCHAPS) data. Purpose: The purpose of this quality improvement project (QI) was to implement and evaluate the effectiveness of daily charge nurse leader rounds on patients admitted to a CSPCU. It is anticipated that there will be an increase in the total number of times a nurse leader rounds on a patient that subsequently will result in in an increase in patient satisfaction as measured by HCAHPS nurse communication scores. Methods: The QI project was implemented over a 14- week period in a CSPCU at an urban Maryland academic Medical Center. Charge nurses were educated on the process change and then completed ‘charge nurse leader’ rounds. The project leader checked the rounding rates bi-weekly. Nurse communication scores were collected preand- post implementation using the scores from the HCAHPS surveys. Results: The number of patients rounded on daily over the course of the project was 64.7% and during the implementation period a total of 1140 rounds were completed. The HCAHPS scores increased in the category of ‘RN explanation’ and slightly decreased in the categories of ‘RN listening’ and “RN courtesy”. Patients’ perception of the nurse leader rounding increased from 79.64% to 87.23%. Conclusions: Charge nurses can be utilized as informal leaders to complete nurse leader rounds. Leader rounds are able to be incorporated into the daily routine of the charge nurse. Patient satisfaction scores are impacted by many different factors. The increase seen in one domain of HCAHPS indicates that further studies should be completed to better understand how nurse leader rounds impact patient satisfaction.
    • Depression Screening Protocol for MS patients in a Neurology Clinic

      Yeasmin, Selina; Edwards, Lori A. (2021-05)
      Problem and Purpose: Depression is the most common symptom in Multiple Sclerosis (MS) patients with reported lifetime prevalence of 25-50%. Undetected and untreated depression in MS patients has been associated with poor psycho-social and treatment outcomes. Early detection and management of depression has been shown to ameliorate those negative outcomes and improve quality of life. Time constraints in ambulatory clinic settings can impact providers’ ability to perform a thorough psychological as well as physical evaluation. To address this gap adoption of a standardized depression screening tool in the care of MS patients was an important opportunity to address a critical need and improve quality of patient care. The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of a Depression Screening Program in adult ambulatory outpatient neurology clinic with MS patients using the Patient Health Questionnaire (PHQ-9) screening tool. Methods: The primary aim of this QI project was to implement a depression screening protocols for adult MS patients in an outpatient neurology clinic using the Patient Health Questionnaire-9 (PHQ-9), a validated depression screening instrument. Medical assistants (MAs) completed the PHQ-9 with patients during telemedicine visits. The MS providers reviewed and provided brief intervention and referrals if warranted. The project leader mobilized a site team, trained MS providers and MAs, mentored champions, tracked the project on a weekly basis, and provided the staff with weekly data updates. Results: PHQ-9 tool was utilized for depression screening in 144 out of 149 patients who had health visits during the 13-week period (97% compliance). Out those of 144 patients who were screened, 50% (n=72) were positive (PHQ-9 scores 5-27) for depression. 100% (n= 144) PHQ-9 scores were discussed and reviewed by MS providers. The treatment and referrals contributed to, 27.7% of patients were prescribed antidepressant,12.5% were referred to mental health providers. One patient had suicidal ideation, necessitating an urgent transfer to the emergency department (ED). Conclusion: Depression screening program using the PHQ-9 was adopted by the neurology clinic for MS patients. This program was able to identify depression in adult MS patients and facilitate treatment or referral to mental health providers. Early detection, treatment, or referral of adult MS patients with depression may help prevent ED visit or hospitalizations and will improve the quality of life for these patients.
    • Discarding Residuals: Implementing a Feeding Algorithm in a Neonatal Intensive Care Unit

      Ruccio, Lucy R.; Wilson, Janice (2021-05)
      Problem: Routine gastric residual (RGR) monitoring is not reliable in detecting necrotizing enterocolitis (NEC) or feeding intolerance (FI). This practice remains the primary cause of enteral feeding interruption in premature infants. It delays the achievement of full enteral feeds and increases the threat of poor growth and neurodevelopmental injury. Checking RGRs before feedings was standard practice at the target hospital’s Neonatal Intensive Care Unit (NICU). At baseline, over 40% of preterm infants had at least one checked per week. Purpose: The purpose of this quality improvement project is to implement and evaluate an evidence-based feeding guideline removing the use of RGR as an indicator of FI. Methods: The setting was a 30-bed Level III NICU and included all preterm infants, <37 weeks’ gestation, who required an oral or nasogastric feeding tube. Six weeks of background data and nine weeks of post-implementation data was collected using chart audits and informal interviews with key stakeholders. A survey of attitudes and knowledge was administered to all staff. Implementation consisted of in-service education with multiple visual aids, the dissemination of feeding algorithm cards and a “Fast Feeding Facts” bulletin. Data was collected and analyzed via run charts and descriptive statistics. Results: Data showed a decrease in patients with gastric residuals checked from 42% to 8%. The days to regain birthweight dropped from seven to six days. Staff knowledge of the role of RGRs and comfort with eliminating their routine use increased substantially. Conclusions: Implementation of an updated feeding guideline was associated with a decrease in the frequency of gastric residual checks, days with an IV in place and time to regain birthweight. This supports the research that monitoring of pre-feed RGRs should not be used for preterm infants.
    • Early Screening Algorithm for Depression After Stroke (E-SAD)

      Yates, Steven M.; Yarbrough, Karen (2021-05)
      Problem: Post-stroke depression (PSD) is common and associated with poor functional recovery, decreased quality of life, and increased mortality. At a community hospital, less than 10% of patients admitted for stroke are screened for post-stroke depression. This practice is not in compliance with the American Heart Association ischemic stroke guideline recommendations. Purpose: The purpose of implementing this quality improvement project was to establish the feasibility of an evidence-based post-stroke depression screening algorithm in a community hospital. In addition, this project sought to provide early interventions to support patients’ psychological wellbeing. Methods: A PSD screening algorithm, was created for this quality improvement project incorporating the Patient Health Questionnaire-9 (PHQ-9) depression screening tool. The PSD algorithm establishes screening score ranges for depression severity and recommends specific actions based on the score to promote patient psychosocial wellbeing. Action items included: providing patient education on post-stroke depression, updating the primary health care provider of the patient’s screening results, outpatient psychiatry referral, inpatient psychiatry referral, and the consideration of starting an antidepressant medication. Patients were considered eligible to have the algorithm applied if they suffered a new ischemic stroke, were hospitalized on the stroke unit, and did not meet exclusion criteria (aphasia, critical illness, hospice, dementia, non- English speaking, and patient refusal). Results: Charts of 65 patients admitted with ischemic stroke were audited between August 30, 2020 and December 1, 2020. Of the 44 ischemic stroke patients admitted, 31 (70.46%) were assessed using the PSD algorithm, by evidence of documentation in the electronic health record PHQ-9 flowsheets. Of those 31 patients, 19 (43.18%) patients were screened with the PHQ-9 while the rest met exclusion criteria. Of the patients screened with the PHQ-9, 13 patients had a screening score indicating no depression, 4 had mild depression symptoms, and 2 patients had moderate to high depression symptoms. The median PHQ-9 score was a 3. Conclusion: Screening for post-stroke depression is feasible in a community hospital setting. Implementing a PSD screening algorithm creates greater awareness of poststroke depression and increases psychosocial support after hospitalization.
    • Effects of a Post-Discharge Telephone Follow-up Call on Psychiatric Readmission Rates

      Gorey, Michelle L.; Costa, Linda L. (2021-05)
      Problem & Purpose: Preventing early psychiatric readmissions presents a significant challenge to inpatient psychiatric units. Thirty-day readmission rates continue to rise using a significant amount of resources and increasing hospital costs. An inpatient psychiatric unit specializing in treating severe mental illness has a high readmission rate (20%). A quality improvement (QI) project was designed to reduce inpatient psychiatric readmission rates. The purpose of this QI project was to implement a nurse-led follow-up phone call within 72 hours post-discharge to identify issues related to patient understanding and ability to adhere to discharge plans. Identification of barriers encountered in the follow-up plan and early resolutions was posited to reduce thirty-day readmission rates. Methods: Psychiatric nurses in a 24-bed adult high acuity unit were educated to conduct post-discharge phone calls using a detailed script tailored to the organization. A corresponding documentation tool evaluating data collected on medication reconciliation, confirmed follow- up appointment, the patient’s medication regime, and the patient's understanding of discharge instructions was assessed and an intervention during the call was provided as needed. Night shift RNs audited the documentation tool. The phone call was to be completed on each patient discharging over a twelve-week period. Phone call and audit completions were tracked weekly and thirty-day readmission rates were tracked monthly. Results: Findings suggest the use of a post-discharge phone call was a successful intervention that can be adopted on psychiatric units. Phone call and audit completions reached the goal of 100%. This indicates nurses were able to accommodate the extra tasks without disrupting the milieu. Thirty-day readmission rates decreased 2% compared to the same time in the year prior. Conclusions: Post-discharge phone calls is a cost effective intervention that has shown to be a successful in reducing thirty-day readmission rates in this psychiatric settings. Future QI projects should consider this intervention in different psychiatric specialties.
    • Eliminating Hospital Acquired Pressure Injuries: Prevention Bundles and Two Nurse Skin

      Snider, Victoria E.; Callender, Kimberly (2021-05)
      Problem: A Vascular Surgery Progressive Care Unit (VSPCU) in a large, academic medical center had a year-to-date hospital-acquired pressure injury (HAPI) incidence rate of 1.89 per 1000 patient days in 2019; fifty percent of these HAPI were avoidable. Purpose: The purpose of this quality improvement (QI) initiative was to eliminate HAPI incidence on a Vascular Surgery Progressive Care Unit through implementation of an evidence-based pressure injury prevention bundle (PIPB), including a two-RN skin assessment and co-sign component within 24-hours of patient admission or transfer. Methods: The Vascular Surgery Progressive Care unit consists of 12 beds and averages 53 admitted patients per month. A 16-week implementation period took place from August 31, 2020 to December 22, 2020. Head-to-toe, 2-RN skin assessment with electronic health record cosign and bundle documentation was implemented on the project unit for nurses to identify risks for HAPI, provide all admitted patients evidence-based prevention strategies, and to link staff with institutional skin prevention resources. The QI project was guided by Lippitt’s Change Theory. Staff-received project education was measured by a completion goal date. Nursing staff completed return-demonstration of 2-RN cosign and bundle note documentation within the electronic health record. Documentation of RN bundle compliance was measured by weekly chart audits. Unit HAPI incidence rates were measured by quarterly audits compiled and dispersed by the institutional Skin Integrity Committee. Data used for dissemination and discussion was comprised using run-chart analysis. Results: At Go-live 57% of RNs were PIPB trained (n = 30). A zero avoidable HAPI incidence was maintained during implementation (n = 194 patients). At week nine, 100% bundle compliance was achieved for five consecutive weeks. Conclusions: Implementation of a prevention bundle using a two-nurse skin assessment with cosign, for achieving zero unit-based HAPI is feasible and should be a care standard. Bundle compliance was associated with completed staff training, charge nurses as project champions, compliance email reminders, compliance data-sharing with staff, leadership availability and visibility, and continual team positive reinforcement.
    • Endotracheal Tube Cuff Pressure Monitoring Utilizing Manometers

      Morrissey, Amy L.; Aguirre, Priscilla (2021-05)
      Problem: Over-inflation of the endotracheal tube cuff has been linked to higher instances of post-operative sore throat in patients undergoing general endotracheal tube anesthesia. Purpose: The purpose of this quality improvement project is to implement manometer use among anesthesia providers at a community hospital in Maryland to maintain endotracheal tube cuff pressures between 20-30 cmH20 to reduce the incidence of postoperative sore throat. Methods: Education on the proper use of manometers and evidence-based practice recommendations was provided to the anesthesia providers via educational handouts. Education on evaluating post-operative sore throat was provided to the Post-Anesthesia Care Unit nurses using educational handouts. A Random Observational Tool was created to track cuff pressures and completed by the anesthesia providers. A Post-Operative Sore Throat assessment tool was used by the Post-Anesthesia Care Unit Nurses to assess and track post-operative sore throat rates. Manometers were placed in two operating rooms. The post anesthesia care unit charge nurse was notified of manometer room selection to follow up on post-operative sore throat assessments and completion of the data collection tool. Results: Out of the 60 observations obtained during a 10-week period, analysis showed that 80% of patients denied experiencing a post-operative sore throat when assessed in Post Anesthesia Care Unit. 100% of anesthesia providers used manometers to maintain cuff pressures within recommended ranges. Out of the 60 random observations, 19 cuff pressures were initially measured out of the recommended range of 20 to 30 cmH20 and were adjusted appropriately to the recommended range with a manometer by the provider. Conclusions: This site has a post-operative sore throat incidence of rate of 20% which is lower than what current literature cites (44%). At the conclusion of the project, cuff pressure monitoring improved (0% vs 66%). There was a positive trend with respect to the use of manometry and reduction in POST rates. Change champions within the anesthesia department and PACU staff were identified to maintain sustainability for the practice change.
    • Evidence-Based Approach for Identification of Malnutrition and Prevention of Skin Breakdown

      Bederak, Dmitry; Windemuth, Brenda (2021-05)
      Problem: Geriatric patients have an increased risk for skin breakdown due to advanced age, immobility, comorbidities, and poor nutrition. As malnutrition contributes to impaired skin integrity, patients may experience ulceration, infection, and pain. Administrators within a long-term care (LTC) facility expressed concerns about undetected malnutrition or the risk of malnutrition leading to skin breakdown. The incidence rate of skin breakdown in January of 2020 was 6.37%. Purpose: The purpose of this quality improvement (QI) project was to implement and evaluate use of the Mini Nutritional Assessment (MNA) for patient admissions/readmissions within a LTC setting, for early recognition of malnutrition and prompt intervention to prevent skin breakdown. Methods: Implementation relied on Lewin’s Change Theory, utilizing evidence to manifest and sustain change. Strategies/tactics included meetings with administrative and nursing staff to review current processes for patient admission and dietary evaluation, training nursing staff on use of the MNA, and implementation of an improved communication system for dietary referrals. The project was implemented at a 130-bed LTC facility and clinicians included 12 nurses, 2 providers, and 1 dietician. Inclusion criteria included all admissions/readmissions. Implementation data was collected at weekly intervals using electronic reports and chart audits. Protection of confidentiality/privacy included collection of anonymous data. Data was analyzed using run charts to evaluate trends and variation in MNA use. Results: Over 14-weeks of implementation, 38 patients were admitted/readmitted to the LTC facility. The MNA was completed for 32 (84.1%) of patients, and 18 (56.3%) of those patients were identified as being malnourished or at risk for malnutrition. Run chart analysis indicated no shifts, trends, astronomical data points or abnormal variation in runs. Prior to implementation of the practice change, the rate of compliance in utilizing the MNA increased from 0% at baseline to vary weekly between 40% and 100%, indicating initial adoption of the screening tool by nurses. Conclusions: The MNA provided an effective means for establishing nutritional status in order to prompt early nutritional intervention to prevent skin breakdown. The MNA has the potential to enhance prevention efforts, reduce costs associated with in-house acquired wounds, and minimize factors contributing to patient decline.
    • Goal of Treatment as Part of the Chemotherapy Consent Process

      Boord, Christina E.; Connolly, Mary Ellen (2021-05)
      Problem: Patients consenting for chemotherapy require a clear understanding of the goal of treatment to make an informed treatment decision reflective of their own goals and values. Identified barriers to patient understanding include lack of information on the consent form and the use of ambiguous language by providers. Both the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) recommend goal of treatment as part of the consent process. Purpose: The purpose of this quality improvement project was to develop and implement a new chemotherapy consent form that includes goal of treatment; to improve documentation compliance and to evaluate patients’ understanding of their treatment goal. Methods: A multidisciplinary committee at the project site decided to include three goals of treatment: curative, palliative, and palliative/life-extending as part of the consent form. Goal definitions using plain language were included to ensure consistency across providers in how these terms were defined during consent conversations. Patient surveys were developed to evaluate perceived satisfaction with the information provided during the consent conversation as well as the patient’s own perceived goal of treatment. Results: Between August 31, 2020 and December 11, 2020, 155 patients were consented for chemotherapy with 54% of patients completing the patient survey. Goal of treatment documentation compliance increased from 8% to 99% with adoption of the new consent form. Goal concordance, defined as a patient’s ability to correctly identify their goal of treatment compared to the physician’s documented goal of treatment, increased from 42% to 61%; an increase of 43%. However, a chi-square test of independence revealed no significant association between the rate of agreement and consent form used (X2 (1, N = 84) = 2.72, p = .10). Conclusions: Goals of treatment are a vital part of consent conversations. Including goal of treatment as part of the consent form creates opportunity for meaningful, in-depth goals of care conversations which can help patients make treatment decisions reflective of their own goals and values. Although improvement in goal concordance did not reach statistical significance, a 43% improvement in concordance with the new consent form cannot be overlooked.
    • Hand-Feeding Nursing Facility Residents with Dementia Competency Training Modules

      Naugler, Ashley M.; Windemuth, Brenda (2021-12)
      Problem: Residents with dementia are at a greater risk for developing dehydration and malnutrition due to a decline in cognitive and physical function. The Director of Nursing (DON) at the facility expressed concern for the lack of staff skill to adequately provide hand-feeding assistance to residents with dementia. The DON discussed concern for residents’ risk for malnutrition due to a lack of staff skill. Purpose: The purpose of this quality improvement (QI) project was to implement and evaluate the use of the evidence-based Hand-Feeding Nursing Facility Residents with Dementia competency training modules on assistive hand-feeding techniques within a long-term care setting, to change direct care workers’ (DCW) feeding-assistance behavior. Methods: The methodology included providing DCWs (n=9) with the virtual Hand-Feeding Nursing Facility Residents with Dementia competency training modules, a program codeveloped by Dr. Melissa Batchelor-Murphy with the Texas Health and Human Services Commission and the Texas Health and Human Services Quality Monitoring Program, based on current evidence-based hand-feeding techniques and recommendations. A train-the-trainer strategy was utilized, and a registered nurse project champion was trained on the competency modules and how to perform the post-training skills-check using a competency checklist. Preand post-training surveys as well as baseline and post-training final interviews of the DCWs were completed to evaluate their utilization of skills and perceived benefits of the training. Results: Pre-training, 55.6% of the DCWs reported via a survey that it was a challenge to assist a resident with dementia during mealtimes when they exhibited difficult feeding behaviors. Posttraining, eight (89%) participants reported utilization of the information and skills learned from the training, which they felt improved managing residents’ challenging mealtime behaviors. During a final interview, all the staff reported that the competency training modules were very helpful and beneficial to the residents and their mealtime experience or their nutritional state. Conclusions: Online competency training modules improved DCWs knowledge and skill to provide hand-feeding assistance to residents with dementia. Sustainability of the project was achieved through a train-the-trainer strategy and the DCWs holding each other accountable to continue the practice change.
    • Implementation and Evaluation of a Patient Handoff Tool to Improve Nurses Communication

      Nwaukwa, Stacian S.; Satyshur, Rosemarie D. (2021-05)
      Problem & Purpose: Poorly conducted handoffs are implicated in 80% of preventable adverse events in healthcare facilities. Within a sub-acute and rehabilitation facility in Maryland, observational reports revealed that nurse handoffs were poorly conducted and lacked the use of a standardized evidence-based tool, resulting in miscommunication and nurse dissatisfaction with the handoff process. Situation, Background, Assessment, Recommendation (SBAR) is an evidence-based tool recognized by The Joint Commission, Agency for Healthcare Research and Quality (AHRQ), and the World Health Organization (WHO) as an effective tool in improving handoff communication, reducing adverse events, and promoting patient safety. The purpose of this quality improvement (QI) project was to implement and evaluate an SBAR patient handoff tool to improve nurse communication. Methods: Nurses were educated on the SBAR method and tool prior to using the tool. A Handover Evaluation Scale (HES) survey was distributed pre-implementation and again at the end of the 15-week implementation period. Weekly observation audits were conducted to determine nurse compliance with use of the SBAR handoff tool. Results: Findings indicated that nurse compliance with use of the SBAR patient handoff tool was 86% by Week 7, and 100% by Week 13. Comparison of pre and post-HES survey mean responses showed modest improvements in all items relating to the key variables: quality of information, interaction, and efficiency of handoffs. Conclusion: Use of the SBAR tool improved the quality of information, interaction, and efficiency of patient handoffs between nurses, thereby improving communication. Further QI projects are recommended to evaluate the effectiveness of SBAR in reducing adverse patient events and improving patient care outcomes.
    • Implementation of a Chemotherapy Administration Checklist

      Dougherty Soper, Katelynn G.; Edwards, Lori A. (2021-05)
      Problem: Chemotherapeutic medication errors have previously been described as the second most common cause of fatal medication errors. On an inpatient oncology unit, two near-misses related to chemotherapy administration posed a threat to both patients’ and nurses’ safety. Furthermore, 83% of inpatient oncology nurses reported a lack of confidence in safe chemotherapy administration processes. A low volume of chemotherapy patients, an outdated Chemotherapy Administration Checklist and a lack of familiarity with current hospital policies and resources were identified as contributing factors. Purpose: The purpose of this evidence-based quality improvement project was to implement and evaluate the effectiveness of a Chemotherapy Administration Checklist on a 32-bed inpatient oncology unit. The intended outcome was to standardize the chemotherapy administration and documentation processes in accordance with national guidelines while improving nursing confidence and preventing patient harm. Methods: The 2016 ASCO/ONS Chemotherapy Administration Safety Standards were used to revise the Chemotherapy Administration Checklist in the electronic medical record (EMR) at a small urban community hospital. Chemotherapy certified nurses on the inpatient oncology unit were trained on the revised checklist as well as the new processes for chemotherapy administration and documentation. Weekly chart audits were conducted to track checklist utilization and chemotherapy associated nursing documentation. A pre/post survey was conducted to assess nurses’ experience of chemotherapy administration. Results: Nurses successfully documented on the new Chemotherapy Administration Checklist 73% (n=11) of the time. Nurses’ self-reported confidence in being able to safely administer chemotherapy increased from 47% (n=15) pre- to 86% (n=14) post-implementation. There have been no recorded chemotherapy administration errors since implementation. Chemotherapy associated nursing documentation remains variable. The most frequently missed areas of documentation include: intake flowsheets (58%), nursing care plans (70%), patient education (67%) and the chemotherapy administration note template (73%). Conclusions: Implementation of a Chemotherapy Administration Checklist into the EMR streamlines chemotherapy administration and nursing documentation processes in accordance with ASCO/ONS guidelines, while improving nursing confidence and preventing patient harm. Continued variability in nursing documentation suggests additional interventions are needed to ensure all chemotherapy associated documentation is completed with each chemotherapy administration.
    • Implementation of a Distress Screening and Management Protocol for Adult Cancer Patients

      Uzupus, Allison M.; Edwards, Lori A. (2021-05)
      Problem: Approximately 50% of cancer patients experience clinically significant cancer-related distress. Unmanaged distress has been linked to decreased medication adherence, increased visits to the emergency room and oncology clinic, increased hospital stays, decreased quality of life and decreased overall survival. At a university-based cancer center in the mid-Atlantic region, informal assessment of patient distress was provider dependent and as a result was inconsistently conducted and documented. Purpose: The purpose of this quality improvement (QI) project was to implement a systematic screening protocol for distress which included a screening tool, staff training, as well as referral processes to identify and manage distress in adult patients with metastatic colorectal cancer. Methods: The National Comprehensive Cancer Network (NCCN) Distress Thermometer and Problem List (DT&PL) was integrated into the patient portal as a questionnaire and sent to patients with metastatic colorectal cancer prior to treatment to be completed prior to their infusion appointment. Infusion nurses reviewed the distress screening with patients during their appointment and made appropriate referrals to clinic-embedded resources such as social work, psychiatry, pain and palliative care, and/or pastoral care based on questionnaire results. Results: The NCCN DT&PL was successfully integrated into the portal as a questionnaire. Overall, 64% of patients completed the questionnaire at least once and 39% of the completed screens indicated high distress. All patients who indicated high distress had documented nursing interventions and/or referrals. Conclusions: Evidence-based distress screening and referral is a feasible practice change to improve patient outcomes. Key facilitators were integration into the electronic health record and personnel to support to initiative.
    • Implementation of a Fall Prevention Toolkit on a Medical Surgical Unit

      Khandagale, Usha; Windemuth, Brenda (2021-05)
      Problem: In-hospital falls result in patient harm which includes minor injury, psychological distress and anxiety, and serious injuries like fractures, head trauma, and even death. The Joint Commission consistently ranks falls with serious injury as one of the top sentinel events. An acute care medical surgical unit in a community-based hospital experienced an increase in the number of falls with an overall fall rate higher than that of peer units. Purpose: The purpose of this Quality Improvement (QI) project was to implement and evaluate the benefits of, and staff adherence to, the use of Fall TIPS (Tailoring Intervention for Patient Safety) toolkit to reduce falls on a medical surgical unit. Methods: The Fall TIPS toolkit was designed to decrease the patient fall rate in hospitals and engage patients and their families in a 3-step fall prevention process including performing a fall risk assessment, creating a tailored fall prevention plan, and executing the plan regularly. Implementation of a Fall TIPS toolkit with auditing transpired weekly over 10 weeks on a medical surgical unit. Nurses’ adherence to the Fall TIPS protocol was measured weekly during implementation. Results: The results indicated that nurses’ adherence to use of the Fall TIPS toolkit averaged 78%. The run chart analysis of nurses’ adherence did not show any shifts or astronomical datapoints, and the number of runs was consistent with random variation. However, there was a 6-point upward trend in the data during weeks 2 to 7, indicating a special cause. Fall rates during the first two months of implementation were 3.39 and 2.41 per 1000 patient-days respectively, and dropped to zero during the third month. Conclusion: Nurses’ adherence to a Fall TIPS toolkit was demonstrated on a medical surgical unit, which likely resulted in a decreased patient fall rate during the final month of the project. Additional time will be needed to determine if the practice changes and outcomes are sustainable.
    • Implementation of a Geriatric Rib Fracture Pathway in Trauma

      Lee, Janet S.; Wilson, Tracey L. (2021-05)
      PROBLEM: Geriatric trauma patients who have sustained rib fractures are at increased risk for pulmonary dysfunction, prolonged hospitalization, and death. The current literature supports a standardized care approach of evidence-based interventions in this patient population to help improve outcomes. Leadership of a large academic Level 1 Trauma Center, with the highest admission rate of adult traumas in the state, recognized poorer outcomes in geriatrics with rib fractures, and preliminary collated data showed a significant lack of established evidence-based practices on the Trauma Critical Care Unit. PURPOSE: The purpose of this quality improvement (QI) project was to implement and evaluate the use of an evidence-based rib fracture pathway in the geriatric trauma population to determine the compliance of pathway use by staff and possible effects on patient outcomes. METHODS: The project was implemented over a 14-week period from September to December 2020, after the completion of education and training of all staff on the Trauma Critical Care Unit. Eligible patients included patients aged 65 years and older with two or more rib fractures without high risk of respiratory complications due to admitting injury. Weekly chart audits were performed to assess compliance of the geriatric rib fracture pathway based on provider orders placed within 24 hours of admission and nursing documentation of pain assessments, deep breathe and cough, and incentive spirometry. RESULTS: Before the implementation of the project, 85% of nurses (n=49) and 100% of providers (n=12) completed the necessary education and training of the Geriatric Rib Fracture Pathway. After competency training, there was an increase in staff compliance with all components of the pathway including provider orders placed within 24 hours (p<.001) and documentation of the following nursing interventions – pain assessment (p=.068), deep breathe and cough (p<.001), and incentive spirometry (p=.006). CONCLUSIONS: This pilot QI project suggested an increase in staff compliance with the implementation of a rib fracture pathway for geriatric trauma patients after completion of staff education and training. The Geriatric Rib Fracture Pathway is a safe and useful tool in identifying this target population, as well as in early adoption of evidence-based interventions to improve patient outcomes.
    • Implementation of a High-Risk Alcoholism Relapse Scale Post-Liver Transplantation

      Tholen, Rebeca V.; Bundy, Elaine (2019-05)
      Background: Transplantation will reverse the complications of end-stage liver disease, but it does not treat underlying alcoholism or reduce the risk of relapse after transplant. Local Problem: In the United States, relapse rates are 20-50% among liver transplant recipients. Relapse after transplant has been identified as a problem among liver transplant recipients at a large urban academic transplant center. The purpose of this quality improvement project was to implement and evaluate the effectiveness of a High-Risk Alcoholism Relapse scale to screen and identify patients at high-risk for alcohol relapse post-transplant. Interventions: The scale was used to screen new adult liver transplant recipients prior to hospital discharge. The scale is a predictive tool designed to determine severity of alcoholism and risk of relapse after transplantation. The scale consists of three variables identified as having the highest predictive power for early relapse, including daily number of drinks, history of previous inpatient treatment for alcoholism, and the number of years of heavy drinking. Results: Descriptive statistics revealed 33 patients were screened with the scale. Forty percent of patients (n=13) were identified as being a high-risk for relapse and 60% low-risk (n=20). Fiftyfour percent reported drinking nine to 17 drinks per day, and zero patients consumed fewer than nine drinks per day. Fifty-four percent reported drinking more than 25 years. One third of highrisk patients received inpatient treatment for alcoholism at least once. Conclusions: Early identification and close monitoring of alcohol relapse is an essential determinant of long-term outcomes after liver transplantation. Findings validate the effectiveness of the scale to screen and identify patients at high-risk for post-transplant relapse. Results support the scale as a more efficient method to identify heavy alcohol use than other screening methods. Recommendations for future studies include performing a follow-up study to compare HRAR results with relapse rates, and modifying the scale to appropriately capture and identify young adults at high-risk for relapse after transplant. Recommendations to help maintain post-transplant sobriety include starting a transplant support group within the organization for all high-risk patients.