• An Alpha-1 Antitrypsin Deficiency Screening Tool to Identify Patients at Risk

      Fitzpatrick, Heather N.; Scheu, Karen (2020-05)
      Problem & Purpose: Early identification of Alpha-1 Antitrypsin Deficiency (AATD) could prevent widespread pathological destruction of the lung parenchyma, possibly delaying time to death. On average AATD patients experience a diagnostic delay of six years and have to consult three physicians until diagnosis is established. With the implementation of established guidelines, unidentified individuals at risk for AATD may be identified and treated earlier to prevent premature death. The purpose of this quality improvement project is to implement a clinical practice guideline-based screening tool to identify at-risk patients for AATD at a rural primary care practice where the patient population is at risk. Methods: An evidence –based screening tool was administered for every patient with an appointment at the primary care practice. Patients who met inclusion criteria based upon personal or family medical history were screened for AATD using an evidenced-based tool during routine provider visits. Patient’s found to be at-risk with a were offered testing for AATD in the practice. Results: A total of 235 patients were screened over 12 weeks with an overall screening rate of 96.8% after implementation of the screening tool. 11% of patients screened were found to be atrisk for AATD, 35% were male and 65% were female. There was no difference between gender and being at-risk, p <.0005. Conclusion: Improvements of identifying patients at risk for AATD were accomplished by implementing staff education as well as paper evidenced-based screening tools during each appointment resulting in with 11% positive results.
    • Implementation of a Preoperative Risk Assessment for Post-Operative Nausea and Vomiting

      Soliman, Safa; Conley, Richard (2022-05)
      Problem: Currently 6.1% of post-surgical patients at this institution experience post-operative nausea and vomiting (PONV). Prophylactic measures for PONV are often based on provider preference, price, and availability contributing to significant variability in PONV prevention techniques. Since PONV risk ranges from patient to patient depending on risk factors such as gender, age, and type of anesthetic it is imperative preventative measures are individualized to each patient. Purpose: The purpose of this quality improvement project was to implement a preoperative risk assessment for adult surgical patients and evaluate its effectiveness in identifying patients at high-risk for PONV and guide anesthesia provider’s prophylactic interventions to decrease the incidence of PONV. Methods: Over 15-weeks a preoperative risk assessment was integrated into patient forms and filled out during intake. The anesthesia provider was expected to assess the risk score and administer preventative medications per the established PONV guideline. Data on compliance and post-operative nausea and vomiting rates was tracked throughout the implementation period. Results: The data reflected an average compliance of 96% and 90% with the documentation of PONV risk assessment on each patient’s perioperative record and identification of patients at high-risk for PONV during the first nine weeks of implementation. The anesthesia providers review of each patient’s risk score remained at an average of 54% during that time. Compliance with all three measures dropped significantly weeks 11 through 15 due to a clerical error which resulted in risk assessment not being included in the patient forms. During this time, the average compliance rate with risk assessment completion and high-risk identification was 18%. The compliance rate with the anesthesia provider’s review of the PONV score decreased to 17%. Conclusions: Due to the variable and limited nature of the compliance data, no statistically significant conclusions can be drawn. However, when compliance was at its highest, the rate of PONV trended down from a rate of 5% to 2.6% and as compliance dropped in November, PONV rates rose again to 4.5%.
    • Implementation of Screening for High Fall Risk Medications in Hospitalized Older Adults

      Friesen, E.; Jackson-Parkin, Maranda (2022-05)
      Problem: Accidental falls are a leading cause of injury and death in older adults, leading to loss of function and increased healthcare costs. Falls are also commonly reported sentinel events in hospitals. A community hospital identified falls as an organizational priority with 73 inpatient falls last year. Expert guidelines recommend multifactorial fall risk assessment modalities, including screening for medications that increase risk of falling in older adults and deprescribing or adjusting inappropriate medications, however, the institution has no such process in place. Purpose: The purpose of this quality improvement (QI) project was to implement an interdisciplinary process for screening older adults’ prescriptions for medications that increase risk of falling and mitigate unnecessary high-risk medication use. Methods: Between September and December 2021, the Screening Tool for Older Persons’ Prescriptions (STOPP) Tool was utilized for daily medication screening on patients aged 65 and older during interdisciplinary rounds on the 12-bed Intensive Care Center (ICC). STOPP is a Delphi-validated tool to screen for potentially inappropriate prescriptions (PIPs) in adults aged 65 and older, with demonstrated efficacy in reducing PIPs and adverse drug reactions (ADRs). Registered nurses (RNs), pharmacists, and intensivists received education on the standard of care, and the screening process prior to implementation. Daily screening and deprescribing were measured through weekly chart audits. Data were analyzed utilizing Microsoft Excel. Descriptive statistics were calculated to evaluate goal attainment for the process measure (medication screening) and outcomes (deprescribing). Results: One hundred percent of intensive care providers (n=7), 66% of ICC RNs (n=19) and 60% of pharmacists (n=3) received a review of the medication screening process and STOPP tool. Sixty-six percent of RNs (n=19) completed education through Nurses Improving Care for Healthsystem Elders (NICHE) on the role of nurses in deprescribing. Seventy-four patients were eligible for screening with 167 daily screening opportunities, with median weekly screening compliance of 54%. High-risk medications identified through screening had a median weekly deprescribing rate of 20%. There were two falls in the implementation period. Conclusions: Interdisciplinary medication screening is a feasible adjunct fall prevention measure. Ongoing outcome measurement is necessary.
    • Implementing Guidelines to Manage Postoperative Nausea and Vomiting in Laparoscopic Surgery Patients

      Homayouni, Del; Alessandrini, Erica (2022-05)
      Problem: Postoperative nausea and vomiting (PONV) is estimated to affect 30% of patients for 24 to 48 hours after general surgery, and up to 80% of patients who are considered high-risk. PONV causes distress, discomfort, and subsequent reduction in patient satisfaction. Furthermore, PONV can cause postoperative complications such as incisional stress, bleeding, fluid and electrolyte disturbances, and aspiration. In this community hospital, it was reported approximately 10% of surgical patients experience PONV. While this rate appears lower than the national average, PONV rates have been increasing during the past year and continue to rank high in measures of patient dissatisfaction, prompting administration and anesthesia staff to examine current practice. When baseline data was measured, the PONV rate was 44%. Purpose: The purpose of the doctor of nursing practice project was to reduce PONV among laparoscopic surgical patients in the perioperative setting by identifying patients at high risk for PONV and implementing an evidence-based prophylactic medication protocol based on risk levels. Methods: Anesthesia providers were educated about the incidence of PONV, common risk factors contributing to PONV, and the multimodal prophylactic medications to administer based on the PONV risk score. Data collection via chart audit was performed to evaluate PONV rates and the use of the prophylactic medication protocol by anesthesia providers. Results: 119 eligible patients were scheduled for laparoscopic surgery during project implementation. Documentation of the PONV risk assessment score in the preoperative note occurred 29% (n=34) of the time, and adherence to the prophylactic PONV medication protocol based on risk score was 29% (n=35). Despite the low adherence rate, PONV rates decreased to 25% during the 14-week period. Conclusions: Implementation and adherence to the evidence-based PONV guidelines is a
    • Implementing Medicare Annual Wellness Visits with a Health Risk Assessment in Primary Care

      Owens, Tiffany N.; Bundy, Elaine (2019-05)
      Background: Within the primary care setting, there is a deficiency of comprehensive, personalized treatment care plans that identify modifiable risk factors and endorse preventive care. The Medicare annual wellness visit presents an opportunity for patients aged 65 years and older to identify, plan, and optimally manage chronic health conditions and increase preventative care. The health risk assessment, which is part of the annual wellness visit, is intended to identify health behaviors and risk factors that can be discussed with the patient and utilized to collaboratively create a personalized prevention plan that aims to reduce risk factors and related diseases. Local Problem: In a small, single practitioner primary care office, there was a low performance of completion of annual wellness visits with the Medicare population and lack of a consistent method to assess health risks within this population. This practice serves a Medicare population of greater than 300 patients yet only billed a total of 39 annual wellness visits in 2017 and 15 in 2018. The purpose of this quality improvement Doctor of Nursing Practice project was to increase the number of Medicare annual wellness visits, which included the use of a Health risk assessment in a primary care practice, for Medicare patients aged 65 years and older with chronic health conditions. Interventions: The project was implemented over a 14 week period. Mail and telephonic outreach were conducted to all eligible Medicare patients. For beneficiaries with preexisting appointments, annual wellness visits were added to the appointments. Health risk assessments were mailed to the patient after the appointment was scheduled with instructions to complete prior and bring to the scheduled appointment. Health risk assessments were collected when the patient checked in for the scheduled appointment. Results: The percentage of annual wellness visits completed or not completed (among eligible patients) during the pre- intervention and post- intervention was determined by dividing the total number of eligible patients who completed their annual wellness visits by the total number of eligible patients. At the conclusion of the project, there was a 23.7%, or five- fold- increase in the annual wellness visits completed, which is statistically significant. Post- intervention chart audits revealed health risk assessments in 100% of the charts when an annual wellness visit was completed. Conclusions: Annual wellness visits can be integrated successfully in a busy outpatient primary care practice within the time allocated for office visits. Completion of annual wellness visits increased significantly over the project two month implementation timeframe. A tracking tool revealed a higher capture rate when annual wellness visits were scheduled with pre- arranged office visits. Patient and provider participation in the process increased referrals for preventative screenings and vaccinations. The annual wellness visit also has the opportunity to increase practice revenue gained from Medicare reimbursement and increased relative value units.
    • Perioperative Corneal Abrasion Prevention Protocol in Prone and Lateral Positioned Patients

      Cortez, Alison R.; Conley, Richard (2022-05)
      Problem & 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.
    • Testing a 30-day readmission risk calculator in a veteran population with heart failure: A pilot study

      Gannuscio, Jacqueline R. (2012)
      index HF hospitalization between September 2007 and October 2010 were reviewed for the presence of 15demographic and clinical risk predictors, the majority of which were from a VA Readmission Risk Calculator. Additional variables specific to HF population were added to the risk calculator and included ejection fraction, substance abuse, and Black race. Binary and multiple logistic regression models were used to predict 30-day ACR. C-statistic was calculated to assess how good the model is in predicting who will be readmitted. Results. The patients studied were mostly male (98%), black (73.1%), and averaged 68 years old (SD 13.2). Of the 271 patients, 79 (29%) had at least 1 readmission; 8.1% had >1 readmission within 30 days of discharge. In bivariate logistic regression, patients with Creatinine > 2 were more than two times more likely to be readmitted (OR=2.35: 95% CI 1.32, 4.19). Patients with COPD had a similar likelihood of readmission (OR=2.36; 95% CI 1.25, 4.47), as did patients with renal failure (OR=2.41; 95% CI 1.25, 4.62). Black race, an added HF specific variable, had a significant influence on the likelihood of readmission (2.60; 95% CI 1.31, 5.16). In multivariate logistic regression with all of the predictors, only COPD (OR=2.70; 95% CI 1.32-5.52) and Black race (OR=2.07; 95% CI .97, 4.37) significantly predicted readmission. The C-statistic for the original model was .52, and improved only to .61 with the additional variables. Conclusion. The VA IPEC Readmission Risk Calculator derived in a medical-surgical population does not predict all-cause 30-day ACR after an index heart failure hospitalization. The addition of HF specific variables also did not improve the model. The study was limited by small sample size and use of a non-heart failure specific model. A future implication is that a heart-failure specific model with better C statistics could be tested and potentially be integrated into an electronic medical record so that an alert with an automated risk score could be developed and implemented. The impact of interventions based on risk assessment an open field of investigation.