• Implementation of a Hospital-Acquired Pressure Injury Prevention Admission Bundle

      Berry, Mickaela E.; Callender, Kimberly (2021-05)
      Problem: Within a community hospital located in central Maryland, an adult intensive care unit (ICU) had an increased Hospital Acquired Pressure Injury (HAPI) incidence average rate of 2.2% per month during the months of July and August 2020. A potential cause identified was an inadequate nursing skin assessment on patient admission. Purpose: The purpose of this quality improvement project was to implement a HAPI prevention admission bundle that has been shown to reduce the number of HAPIs in an adult population. The bundle included four care components: completion of the Braden Scale score, performance of a two-nurse skin assessment, use of a pressure reducing surface, and application of a prophylactic sacral foam dressing. Methods: The adult ICU consisted of 30-beds and treated approximately 200 patients per month. The bundle was initiated by nursing staff at patient admission and all components were expected to be completed within 24-hours. Nursing education was administered and completed by the staff who worked in this unit. The use of the bundle was measured twice per week by chart audits. The HAPI rate was measured monthly by the hospital’s incident management system (RL6). Bundle documentation compliance and monthly HAPI rate were analyzed using run-chart analysis. Results: 86% of staff nurses were educated about the bundle. The documentation compliance of the bundle during the last four weeks of data collection was a 79% average. The post-implementation HAPI monthly incident rate average increased to 4.1%. Conclusions: The HAPI prevention admission bundle did not improve the average monthly ICU HAPI incident rate during a 14-week implementation effort. The documentation compliance of the bundle components improved over time, due to regular feedback of the chart audit results. COVID-19 precautions altered the standards of care during the implementation phase, which may have influenced the increased HAPI incidence rates during November and December. The HAPI prevention admission bundle was useful in increasing documentation compliance of four vital skin care components. A future quality improvement project should focus on adding additional evidence-based skin care components to the bundle and extending the implementation phase to ensure 100% of staff are educated to improve utilization of the bundle elements.
    • Implementation of a Mealtime Assistance Training Program for Long Term Care Staff

      Griffin, Joshua W.; Windemuth, Brenda (2021-05)
      Problem: In nursing homes approximately 70% of residents have a form of dementia and are at risk of malnourishment. Long-term care (LTC) facility residents have varying degrees of cognitive impairment affecting their capacity to feed themselves. The director of nursing at the project site identified that residents are vulnerable to decreased food and fluid intake, which may be reflective of limited feeding skills of the nursing staff. Purpose: The purpose of this quality improvement project was to implement an online staff training program for handfeeding of residents with cognitive impairment (CI) in a LTC facility to optimize the mealtime interaction and improve resident health outcomes. Methods: The project was implemented at a LTC facility in rural Maryland with nine staff participants (2 nurses and 7 geriatric nursing assistants), who worked shifts while meals were served. Data collection occurred through pre- and post-training surveys as well as baseline and final (end-of-project) interviews to evaluate the staff’s perception of improvements in the mealtime interaction and enhanced outcomes for residents. Results: Prior to the training, only 11.1% of the staff reported ever having any formal training/education on feeding assistance beyond their basic nursing educational program. All the staff completed the training program and corresponding skill competency checklists. While 100% of the staff reported via the surveys the training as being helpful, only 87% had the opportunity to use any of the skills or techniques from the training. The primary qualitative finding from the final interviews was 100% of staff said the training has or would improve the mealtime experience and nutritional state of residents. Conclusion: The data collected from surveys and interviews confirms that staff participants found the training program for handfeeding of residents with CI to be valuable in improving feeding interactions as well as the nutritional state of residents.
    • Implementation of a Pediatric-Based Algorithm to Improve Care of Symptomatic Hypoglycemia

      Arjoon, Amanda V.; Fitzgerald, Jennifer (2021-05)
      Problem & Purpose: Hypoglycemia in childhood is a low frequency, high-risk event that can lead to coma, seizures, and even death. Symptomatic hypoglycemia occurs when plasma glucose levels are low enough to cause signs and symptoms of impaired neurological function, increasing risk of neurogenic sequalae. In the pediatric emergency department at an urban academic medical center in the Mid-Atlantic region, delays in treatment occur due to pediatric-specific barriers including time intensive, weight-based calculations for drug doses and availability of multiple dextrose concentrations. Although there is no national benchmark for comparison, the average time from identification of symptomatic hypoglycemia to treatment on this unit is 35 minutes. The purpose of this quality improvement project was to implement an algorithm for treatment of symptomatic hypoglycemia for pediatric patients between one and five years of age in the proposed setting. Methods: An algorithm was created based on recommendations from the Pediatric Endocrine Society, the American Academy of Pediatrics, and other accredited organizations. Thirty-two small educational sessions with 59 nurses and three physician assistants were conducted over two months to provide education on algorithm use. Anonymous pre- and post-surveys were administered during the educational sessions to assess for improvements in knowledge of evidence-based care for symptomatic pediatric hypoglycemia patients. The primary outcome was to reduce time from symptomatic hypoglycemia identification to enteral or parental treatment. Results: The sample size (N=4) was smaller than expected due to a significantly reduced census on this unit during the COVID-19 pandemic. Three males and one female met inclusion criteria, with a mean age of 2.75 years. The mean time to treatment was reduced to 6.5 minutes. The most observed symptom was nausea, which appeared in all four cases. Nearly 93% of staff demonstrated improved knowledge in caring for pediatric symptomatic hypoglycemic patients through improved survey scores after the educational sessions. Conclusion: Findings suggest that use of a standardized algorithm contributes to reducing the time from identification of symptomatic hypoglycemia to time of treatment. All patients meeting inclusion criteria received interventions consistent with the algorithm. Future directions include expanding implementation of an algorithm to incorporate pediatric patients of all ages.
    • Implementation of a Quiet Time Protocol in the Neurosurgical Intensive Care Unit

      Payida-Ansah, Damata; Bundy, Elaine Y. (2021-05)
      Problem: Sleep disruption among critically ill patients is associated with detrimental health outcomes such as reduced immune and neuroendocrine function. In a large metropolitan hospital’s Neurosurgical intensive care unit (ICU), 80% of staff surveyed reported high noise levels which can contribute to environmental ICU sleep disturbances. In this ICU, the average sound level was measured at 55.96 decibels, exceeding the Environmental Protection Agency’s recommended daytime hospital limit of 45 decibels. Purpose: The purpose of this quality improvement project was to implement a Quiet Time protocol in a neurosurgical intensive care unit. The Quiet Time protocol was implemented as a practice change to create a quieter and more sleep-friendly environment by minimizing patient sleep disruption, Methods: A Quiet Time protocol was developed and implemented over 10 weeks in a 14-bed neurosurgical intensive care unit following a review of best practices and unit policies, and staff education. The protocol included reduced noise and light levels, and clustering patient care activities from 2:00 to 4:00 pm daily. Nurses completed a protocol audit form daily documenting patients’ demographic data, sleep status and adherence to the protocol. Nursing documentation compliance to the protocol was monitored weekly. Data was collected and tracked weekly via run charts. Unit sound levels were measured with a decibel meter before and during quiet times. Results: Nursing staff Quiet Time protocol compliance rose from 30.77% in Week 1 to 78.26% by Week 10 and with full protocol compliance, patients were reported as asleep 60% of the time. Of the staff surveyed post-implementation, 44% agreed and 44% strongly agreed (totaling 88%) that they would like to use the protocol frequently. Average noise levels from 3:00 to 4:00 pm dropped by 6 decibels from 59.4 dB pre-implementation to 53.3 dB during implementation. Conclusions: Quieter and less stimulating hospital environments can be achieved with Quiet Time protocols when adequate education, nurse buy-in and administrative support exists. Further quality improvement projects on how hospital environments and workflow can be modified to reduce ambient noise are necessary.
    • Implementation of an Early Warning System to Decrease Intensive Care Unit Transfers

      Powers, Lindsay M.; Seidl, Kristin L. (2021-05)
      Problems & Purpose: Extended periods of unrecognized clinical deterioration lead to increased intensive care unit (ICU) admissions and mortality. When deteriorating patients are recognized, appropriate interventions can be implemented, which leads to a decrease in unplanned ICU admissions and improved outcomes. The ability to detect deterioration requires critical appraisal of assessment data, and evaluation of trends. Early warning systems (EWS) have been shown to help clinicians predict deterioration based upon objective physiologic parameters and assessment data. At a 187-bed hospital in Western Maryland, no standardized protocol existed to aid in the detection of early deterioration. Current practice is calling the rapid response team (RRT) based upon a single vital sign or symptom. Retrospective chart review of RRT calls, discovered patients often exhibited deterioration several hours before recognition. Methods: The purpose of the quality improvement project is to implement an EWS, specifically the national early warning system 2 (NEWS2), in a medical-surgical intermediate care area (IMC) to increase early recognition of clinical deterioration. Process measures monitored during implementation included compliance with calculating and accuracy of the calculated NEWS2 score. Outcomes included rate of ICU admissions and rate of RRT calls. Results: Throughout the twelve-week implementation phase, compliance with NEWS2 score decreased from 86% during week one of implementation, to 26% in the final week, however NEWS2 score accuracy increased from 86% in week one to 94% in the final week. Pre-implementation the rate of RRT calls for the IMC were 7.2 per 1000 IMC patient days (IPD) and 30.7 per 1000 IPD post-implementation. The rate of ICU transfers was 26.5 per 1000 IPD pre-implementation and 16.1 per 1000 IPD post-implementation. Conclusion: Overall uptake of the intervention was low, desired outcomes of increased RRT calls and decreased ICU transfers was achieved. Plans to overcome compliance include integration of the NEWS2 in the electronic medical record (EMR). NEWS2 integration into the EMR with best practice advisory may increase compliance by decreasing the workload of score calculation and providing a notification for staff that must be acknowledged. NEWS2 education for new hire orientation may increase compliance and foster a culture of patient safety.
    • Implementation of an Ultrasound-Guided Algorithm for Difficult Intravenous Access

      Robertson, Michael T.; Nawrocki, Lauren (2021-05)
      Problem & Purpose: Obtaining peripheral intravenous (PIV) access is a frequent, but challenging procedure in difficult access patients (DIVA). Emergency medical care frequently requires PIV access to administer medications and perform diagnostic testing. Traditional methods for obtaining PIV access have resulted in repeated painful attempts and treatment delays in this tertiary care emergency department. The purpose of this quality improvement project was to implement and evaluate a nursing-initiated clinical pathway directing the use of ultrasound-guided intravenous techniques for DIVA patients to increase first attempt success rates and reduce treatment delays. Methods: A departmental policy was created to support the practice change. The policy provided an illustration of the DIVA clinical algorithm and specified training and competency validation expectations. Training included 30-minutes of didactic instruction followed by 60-minutes of hands-on training. Competency validated operators documented DIVA screening, ultrasound utilization rates, pain scores, number of venous attempts, and treatment delays. Project compliance and outcome measures were collected over 14-weeks and converted into run charts for weekly unit dissemination. Chi-squared and independent samples t-tests were used to compare pre-and post-implementation results. Results: Sixteen operators completed the education and training program which included nurses (n=8) and technicians (n=8). Operator compliance to DIVA screening and ultrasound-guided intravenous algorithm utilization suggested early adoption (M = 89.25, SD = 7.45). First-attempt success rates for DIVA patients increased from 57% to 87% (p = 0.03) and treatment delays decreased from 20% to 0% (p = 0.01). There was a significant reduction in pain scores (M = 2.2, SD = 1.17) compared to baseline (M = 5.3, SD = 1.65) data; t(58) = 8.08, p < 0.001. Conclusions: The use of a nurse-initiated clinical pathway to identify difficult access patients requiring ultrasound-guided intravenous cannulation increases the likelihood of first attempt access success and ensures timely medication administration, laboratory analysis, and diagnostic testing in the emergency department. The reduction in cannulation attempts optimizes patient outcomes by decreasing pain experienced by the patient, and treatment delays.
    • Implementation of Depression Screening in a Primary Care Practice

      Flores, Jacqueline N.; Davis, Alison D. (2021-05)
      Problem & Purpose: Depression is a common mood disorder that affects over 19.4 million adults annually in the United States. Depression is a leading cause of disability, absenteeism, and suicide. Primary care providers can diagnose and treat depression; yet, 50% of all depression diagnoses are missed in the absence of effective screening. Clinical practice guidelines support routine use of the Patient Health Questionnaire-9 depression screening tool among primary care patients. The purpose of this quality improvement project was to implement and evaluate the effectiveness of depression screening using the Patient Health Questionnaire-9 among adult patients at a suburban primary care clinic. Methods: The project was implemented by a team of primary care providers and nurse practitioner students during a 12-week period beginning in September of 2020. Staff and students received education on the importance of depression screening and intervention prior to implementation. Participants included primary care patients ages 18 or older who could speak and understand English, presenting for sick- or well-visits, either in-person or through telehealth. Participants were asked to complete the Patient Health Questionnaire-9 prior to their visit. Each patient’s sum score was calculated to determine presence of depression, severity, and assign corresponding interventions: watchful waiting, counseling referral and/or pharmacotherapy referral. Screening rates, specific scores, intervention rates, and specific interventions were collected weekly through chart audit and review of Patient Health Questionnaires. Results: Clinic personnel screened 61.3% (n=233) of eligible patients and 18.5% of these patients (n=43) had scores > 5 requiring intervention. All patients identified with depression were offered an intervention, of which 86% (n=37) accepted intervention and 14% (n=6) refused. Conclusions: The implementation of Patient Health Questionnaire-9 screening may increase rates of depression identification and facilitate treatment. Routine depression screening in primary care settings may guide patient management, staging of depression, and corresponding treatment plans.
    • Implementation of Dextrose gel for Asymptomatic Hypoglycemia in Newborns

      Solaiman, Anjana; Wise, Barbara V. (2020-05)
      Problem & Purpose: Neonatal asymptomatic hypoglycemia is a common problem that may contribute to poor health outcomes. Firstline treatment includes formula feeding, and/or transfer to the Neonatal Intensive Care Unit (NICU) for intravenous glucose. Both of these treatment options are sub-optimal because breastfeeding/bonding are disrupted, and costs may be increased due to NICU care. The purpose of this quality improvement (QI) project was to implement 40% buccal dextrose gel as the first line treatment of asymptomatic hypoglycemia in newborns at an academic medical center in the mid-Atlantic region to improve glycemic outcomes. Methods: This QI project was implemented during a 12-week period in the Fall of 2019. The target population included infants admitted to the newborn nursery who were less than 24 hours of life (HOL) with an identified risk factor for hypoglycemia (birthweight >3800 grams or <2500 grams, gestational age <37 weeks, LGA or SGA, or is an infant of diabetic mother), with asymptomatic hypoglycemia (blood glucose levels between 20- 40mg/dl). The QI project involved modifying the hospitals current neonatal hypoglycemia clinical practice guideline (CPG), to implement 40% dextrose gel as initial therapy in conjunction with feeding, developing an order set, creating documentation in the electronic health record, training personnel and collaborating with pharmacy to stock the gel. Results and Conclusions: During the implementation 16 newborns received glucose gel (N=16). Treatment success, defined as blood glucose levels >40mg/dL following the first and/or second administration of gel, was achieved in 87.5% of newborns. Newborns who did not respond favorably to glucose gel had an initial blood glucose level of <20mg/dL, a deviation from the modified CPG. Fifty five percent of newborns who were exclusively breastfeeding (N=9) received medically indicated formula supplementation. Five patients were transferred (N=5) to the NICU, 2 patients had achieved treatment success, but were unable to maintain adequate glycemic levels. Future QI cycles should include exploration of treatment failure with modifications to improve CPG adherence, consideration for increasing doses for responsive newborns as well widening the gestational age criteria. Overall the outcomes of this QI project demonstrated that glucose gel as the initial treatment for infants with asymptomatic hypoglycemia is effective.
    • Implementation of Early Mobility Screening in the Surgical Intensive Care Unit

      Jones, Lindsay K.; Bundy, Elaine Y. (2021-05)
      Problem: A lack of early mobility screening in the adult critical care population may lead to adverse healthcare outcomes. In the past months preceding the practice change, a Surgical Intensive Care Unit (SICU) experienced seven hospital-acquired pressure injuries (HAPIs) and three inpatient falls. Purpose: The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of early mobility screening via the Johns Hopkins Highest Level of Mobility (JH-HLM scale) in a 12-bed adult SICU in a community hospital setting. Methods: The JH-HLM scale was implemented over a 13-week period and was used to assess patient’s daily mobility level. Data on nursing compliance of use of mobility scale and improvement in mobility scores were collected via manual chart audits, and run charts were used to track and analyze results. Falls and HAPIs were also tracked. Results: Analysis of run charts for nursing compliance in use of the scale and improvement in mobility scores showed no shifts, trends, or non-random variation of runs, suggesting no effect due to the practice change. However, nursing compliance with use of the scale was consistently 85% to 100% and improvements in patient mobility occurred in 41 (35%) out of 116 patients screened. Although there was no decrease in patient falls, HAPIs decreased when compared to the previous eight months. Conclusion: The JH-HLM scale was found to be a safe and feasible screening tool useful by nurses in promoting early mobility in an acutely ill population. Additional QI projects are needed to determine if improved patient outcomes are associated with early mobility screening within 72 hours of ICU admission through discharge.
    • Implementation of Eat, Sleep, Console Approach to Care for Opioid Exposed Newborns

      da Graca, Malissa M.; Reid, Rachel (2021-05)
      Problem: Rates of neonatal abstinence syndrome (NAS) have seen a fivefold rise in Maryland. Current management strategies include the Finnegan Neonatal Abstinence Scoring System (FNASS) and opioid pharmacotherapy for symptom management placing tremendous burden on health care system due to increased length of stay, admission to special care nurseries, and disruptions to family bonding. Purpose: The purpose of this quality improvement project was to implement the “Eat, Sleep, Console” (ESC) method in the care of newborns with in-utero opioid exposure to reduce average length of stay (ALOS) for infants with NAS. Secondary outcomes were reduced doses and amount of morphine and increased breastfeeding initiation rates. Methods: A quality improvement (QI) methodology was used to implement ESC on an inpatient floor. Hospital NAS policy was revised to adopt ESC tool, as needed morphine for symptoms management, and emphasis on nonpharmacologic care. The ESC assessment tool was integrated into the electronic health care record (EHR). ESC scores, nonpharmacologic interventions, and parental presence were recorded in the EHR. Infants ≥ 32 weeks gestation with opioid exposure were included in the QI project. Data to be collected included average length of stay (ALOS), number and total morphine doses, and breastfeeding rates during admission. Preliminary Results: Evidence shows that organizations that have made the transition to ESC have seen reduction in opioid agonist therapy, reduced length of stay, and improvement in breastfeeding initiation rates for newborns with NAS. We aim to demonstrate that implementing the ESC will result in similar benefits to our institution. Updates to several structure and process measures are now in the implementation phase. Preliminary Conclusions: Changing the treatment model for newborns with NAS requires a multidisciplinary approach with providers across various specialties. Success of this Quality Improvement project required buy in from all units/care providers with education throughout the staff and families to support ESC.
    • Implementation of Intravenous Lidocaine Infusion Order Set in Military Medical-Surgical Unit

      Santiago, Manuel; Costa, Linda L. (2021-05)
      Problem/Purpose: The current opioid epidemic is not only a problem in the outpatient setting but also an inpatient problem that has brought great concerns to hospitals. Despite new medications and minimal invasive surgeries, the use of opioids continues to be one of the basic modalities for pain management. Opioids can provoke side effects including nausea and vomiting, ileus, and post-administration cognition dysfunction, leading to longer hospital stays, increase risk of complications and negative quality of life, function and recovery. The host organization noted an increased use of opioid medications among medical-surgical patients with daily ranges between 120-150 morphine milligram equivalents (MME) per patient over six months. The purpose of this quality initiative is to determine if the use of a standardized electronic intravenous lidocaine infusion (IVLI) order set would be associated with a lower amount of opioid use, increase order set compliance, and consequently a decreased-on length of stay without impacting acute and chronic pain management. Methods: A pre- and post-implementation study was conducted on adult acute and chronic pain patients consulted by the Acute Pain Service department on a medical-surgical unit at a large military medical center. The electronic health record IVLI order set included baseline electrocardiograms (ECG), baseline laboratory studies, medication verification by nurses, medication dosages for various conditions, supportive care for adverse events, and monitoring of vital signs, pain scores and sedation scores. The primary endpoint was the difference in opioid use between the post-implementation of IVLI order set patients and the pre-implementation opioid group. Secondary endpoints included hospital LOS and compliance rate of the order set. Results: The six patients included in the pre-implementation phase were patients consulted on who received opioid patient-controlled analgesia (PCA) for various conditions. Double was completed 82% of the cases (28 times out of 34 possible opportunities). Sedation scores were documented only on 3% of the cases (3 out of 94 possible opportunities). Baseline vital signs were documented 100% but only 17% at the expected times post-initiation (1 out of 6 patients). There was a decrease of pain scores at 4-, 8-, 12-, and 24-hour after initiation with the greatest decrease at 8 hours post initiation (83% decrease). The average length of stay for patient on opioids was 12.9 days. Conclusions: Electronic order sets have the potential to decrease medication errors, increase application of evidence-based care, and decrease nursing workflow. There was a low compliance on the documentation of ordered vital signs (post-initiation), and sedation scores on the opioid PCA order sets potentially increasing the length of stay and consequently hospital costs.
    • Implementation of Post Event Debriefing in the Neuroscience Intensive Care Unit

      Dranov, Volha; McComiskey, Carmel A. (2021-05)
      Problem: The Neuroscience Intensive Care Unit (Neuro ICU) team frequently performs emergent resuscitation procedures. Debriefing is a form of learning in which everyone involved reflects on performance and plans on improvement. The Neuro ICU does not have a standardized procedure to debrief after patient resuscitation events. Purpose: The purpose of this quality improvement (QI) project was to implement a structured debriefing program utilizing a debriefing tool for Neuro ICU team members after all medical resuscitation events, including emergency intubations, cardiac arrests, acute changes in patient neurologic status, and any other significant patient events. Methods: The QI project was implemented in the Neuro ICU at an urban academic medical center. The project was implemented over a 14-week period. During the first 2 weeks, education about the process of debriefing and the debriefing tool occurred. Over the next 12 weeks the team implemented the project, which included tracking utilization of the tool after each event. The data were analyzed with descriptive statistics, such as percentage of debriefings competed each week. Results: The Neuro ICU team completed 28 debriefings utilizing the debriefing tool. There was an 80% increase in debriefings, compared to 0% debriefings before the project. Conclusions: Implementation of the new debriefing process has helped the Neuro ICU team to to identify areas and strategies for improvement in patient care, promoted communication between team members, and enhanced their clinical knowledge. Utilization of the Critical Event Debriefing tool created a structure to the debriefing process. To promote sustainability of the project, continuous engagement and support from the project champions, as well as promotion and expansion of the project to other units of the hospital are considered as future strategies.
    • Implementation of Text Messaging and Brief Phone Counseling to Improve Medication Adherence

      Akolo, Omolola; Davis, Allison D. (2021-05)
      Problem & Purpose: Among persons infected with human immunodeficiency virus (HIV), suboptimal adherence to antiretroviral therapy (ART) decreased treatment efficacy, increased hospital admissions, delayed viral suppression, and increased subsequent onward transmission. As of March 2020, of the approximately 350 HIV-positive patients receiving continuity HIV care at an urban public sexual health and wellness clinic, 41 (13.1%) were not virally suppressed. The purpose of this Quality Improvement (QI) project was to implement and evaluate the effectiveness of weekly medication reminder text messaging and brief phone-based counseling on adherence to ART among HIV-positive adults seen at this clinic. Methods: Implementation, led by Registered Nurse Case Managers (RN-CMs) trained on project procedures, was conducted among a sample of new and existing HIV-positive patients aged 18 years or older who were newly initiating treatment, had sub-optimal medication adherence, had an unsuppressed viral load, had a functioning cell phone, and who agreed to participate. Following ethical approval, the intervention was conducted over 14 weeks (August 31, 2020-December 4, 2020). Data were collected and tracked weekly using a specially designed audit sheet, projected into run charts, and analyzed using Microsoft Excel. Results: Twenty-two (n=22) HIV-positive patients, including four new and 18 existing patients, participated in this project. All 22 (100%) patients received weekly medication reminder text messages, but only seven of the 22 (31.8%) patients agreed to also receive weekly phone-based adherence counseling sessions. Adherence was measured through phone-based unannounced pill counts at weeks four, eight, and 12. The proportion of the total participants who completed pill count with an adherence level of >95% was 71.4% (n=10 of the 14 patients) at four weeks, 86.7% (n=13 of the 15 patients) at eight weeks, and 85.7% (n=12 of the 14 patients) at 12 weeks. Conclusion: Reminder text messages and phone-based adherence counseling were feasible and potentially effective interventions to improve ART adherence. Pill count adherence completion was highly dependent on participants’ availability. However, weekly phone-based counseling sessions were less acceptable to participants.
    • Implementation of the National Early Warning Score for Sepsis Screening

      McDearmon, Tierra L.; Nawrocki, Lauren (2021-05)
      Problem & Purpose: Sepsis is a complex syndrome that bears high morbidity and mortality. Sepsis that remains undiagnosed before admission is associated with increased costs and mortality rates. An audit of emergency department (ED) practices within a 244-bed military tertiary medical center found that a systemic inflammatory response syndrome-based tool was being utilized to identify patients with possible sepsis. Studies demonstrate this tool has poor prognostic accuracy and utility in triage, therefore making it an inferior method of sepsis screening. This quality improvement initiative implemented a National Early Warning Score (NEWS)-based sepsis screening tool for adults presenting to the ED to improve sepsis identification and delivery of sepsis core measures. Methods: Adult ED patients were screened for sepsis during triage utilizing a nurse-driven electronic tool. Positive screenings triggered initiation of a sepsis bundle. Manual chart abstraction was used to calculate screening rates and sepsis core measures of time-to-lactate and time-to-antibiotics in minutes. Data were analyzed using descriptive and independent samples ttest statistics to determine the association between screening and sepsis core measures. Results: Overall, the compliance rate for sepsis screening was 81% (n = 912). A comparison of baseline (n =12) to post-implementation data (n = 25) displayed a significant decrease in the delivery time of sepsis core measures. Time-to-lactate significantly decreased (M = 85.76, SD = 29.15) compared to baseline (M = 184.17, SD = 120.99); t(12) = 2.78, p = 0.02. Time-toantibiotics also significantly decreased (M = 110.21, SD = 46.04) compared to baseline (M = 231.73, SD = 145.57); t(11) = 2.71, p = 0.02. Conclusions: Use of a NEWS-based sepsis screening tool during triage facilitates the identification of patients at-risk for sepsis and improves the delivery time of sepsis core measures. Sepsis screening tools should utilize readily accessible data and be integrated into the electronic health record to ensure compliance and sustainability.
    • Implementation of the National Early Warning Score in a Military Hospital

      Garrett, Stacy L.; Seidl, Kristin L. (2021-05)
      Problem & Purpose: Unrecognized clinical deterioration leads to poor outcomes including unanticipated intensive care unit (ICU) admission, cardiac arrest and death. Statistics show 59.4% of patients have one abnormal vital sign one to four hours prior to cardiac arrest. The National Early Warning Score (NEWS) assists nurses to identify early clinical decompensation and intervene to prevent poor outcomes. Previous attempts to implement NEWS and a dedicated rapid response nurse (RRN) at a community sized military treatment facility were unsuccessful for improving early recognition of clinical deterioration. Prior to implementation less than 8.3% of patients at moderate risk for clinical decompensation were assessed by the RRN. The purpose of this quality improvement project was to improve early recognition of clinical deterioration by implementing a dual approach that targets both the RRN and ward nurses. Both approaches target patients at moderate to high risk of clinical decompensation to achieve early stabilization or transfer to a higher level of care. Methods: A standardized communication tool was created and utilized by the RRNs to track and trend patients with a NEWS of three to five and as a reminder to document their assessment in the electronic health record (EHR). Re-education and a workflow diagram for ward nurses was presented during a skills fair to increase assessment and vital sign frequency according to the existing NEWS protocol. Results: Over 13 weeks, 698 NEWS triggers were analyzed. Of these NEWS greater than or equal to five triggers, 76% (n= 57) were assessed by the RRN using the communication tool. Of the 76%, 84% (n=48), were physically assessed. Increased vital sign and assessment frequency by the ward nurses was highly variable throughout the implementation phase, 6.7-80% and 0- 27.2%, respectively. Conclusions: A standardized communication tool utilized by the RRNs increased RRN adherence to the NEWS protocol, achieving early identification and assessment of patients with a NEWS of three to five. NEWS greater than or equal to five identified patients at greater risk for deterioration and were associated with increased ward nurse adherence to the NEWS protocol. Improved early identification of deterioration may decrease unanticipated intensive care unit (ICU) admissions.
    • Implementation of the National Early Warning Score in the Emergency Department

      Southerland, Esther H.; Seidl, Kristin L. (2021-05)
      Problem & Purpose: Delayed recognition of clinical deterioration is associated with increased risk for serious adverse events, including unplanned intensive care unit (ICU) admissions. The rate of transfer of general ward patients to the ICU within 24-hours of admission from the emergency department (ED) have increased, identifying process gaps in the recognition of clinical deterioration and disposition of admitted patients from the ED. The purpose of this quality improvement project was to implement the National Early Warning Score (NEWS) in the adult ED and monitor use to promote patient admission to the appropriate level of care. Methods: The ED nursing staff were educated about NEWS prior to project implementation. NEWS values were manually calculated at the time of ED rooming and time of admission. Patients with NEWS five and greater were considered for ICU admission based on inpatient ICU acceptance policies. A 10% sample of weekly census (10 patients/day) and all admissions were obtained for data collection. Weekly chart audits were conducted over a 14-week period to monitor adherence to the new practice, observe trends, and identify potential ICU admissions for patients with NEWS five and greater. Results: Over 75% of patients received NEWS screening with appropriate documentation (n=873). Overall accuracy of NEWS calculation was 99.4%. Of the 21 patients with ED NEWS greater than five, 14 (66.7%) were admitted directly to the ICU. Of the seven patients with ED NEWS greater than five not directly admitted to the ICU, four (57%) required an unplanned ICU or interfacility transfer within 24-hours of hospitalization. Conclusion: The ED staff reported NEWS improved patient monitoring, detection of deterioration, and communication of findings to providers. Integrating NEWS into electronic health systems may promote adherence and accuracy. Higher NEWS were associated with ICU admission but admitting decisions for higher NEWS varied between admitting services. The NEWS can establish a common language across disciplines and can facilitate admitting decisions with consideration for patient acuity and resource availability. Use of NEWS five and greater in other ED settings may predict ICU admission and potentially reduce unplanned transfers.
    • Implementation of Wound Photography for Pressure Injury Documentation in Trauma

      Pyzik, Amber S.; Wilson, Tracey L. (2021-05)
      Problem: Pressure injuries that are present on admission but not documented within 24 hours of admission are deemed a hospital acquired pressure injury (HAPI) per Centers for Medicare & Medicaid Services (CMS) guidelines. Anecdotal data has reported at least three known cases of patients admitted via the admitting trauma unit of an academic medical center with a pressure injury (PI) that was not documented in the electronic health record (EHR) within 24 hours of admission. This documentation deficit can have a significant impact since the financial burden of any PI deemed a HAPI is the responsibility of the organization. Purpose: The purpose of this evidenced-based quality improvement (QI) project was to implement and evaluate the effectiveness of wound photography via a smartphone application on PI documentation in the EHR for patients treated in the admitting trauma unit. Methods: Wound photography was implemented as method to document a PI in a timely manner. Educational resources were provided to the staff nurses prior to implementation. Throughout implementation, barriers to workflow changes were addressed to facilitate compliance with wound photography PI documentation. PI documentation compliance at 24-hours post admission from outside hospital (OSH) was compared using a chi-square test of independence. Results: The findings presented numerous challenges educating the nursing staff due to the limited time that can be spent on unit, therefore a virtual learning platform was used as a primary method to educate the staff. Of the seven patients admitted with a PI, all PIs were documented with wound photography. According to the WOCN, there were no incidents of missed PI documentation within 24 hours of admission from the trauma admitting unit for the duration of this QI project. Conclusions: The conclusions suggest that wound photography is a valuable and simple tool that could increase efficiency of PI documentation in a fast-paced level I admitting trauma unit.
    • Implementing a Standardized Nursing Handoff between the Emergency Department and Inpatient Departments

      Foltz, Kimberly A.; Quattrini, Veronica (2019-05)
      Background It is estimated that 80% of serious medical errors have a component of miscommunication between caregivers when a patient is being transferred. Ineffective handoffs can lead to delays in, or inappropriate treatments, and increased length of stay. Approximately half of hospital staff indicate information related to the patient is lost during handoffs. For a handoff to be successful, the following is needed: (1) standardized content, forms, tools, and methods; (2) the opportunity to ask questions; (3) staff accountability and monitoring; and (4) education and coaching. Additionally, the electronic health record should be used to enhance handoffs between senders and receivers. Local Problem The purpose of this quality improvement project was to implement and evaluate evidence-based patient-centered handoff from the emergency department to inpatient medicine departments within an urban, academic medical facility based in Maryland. Prior to this project, there was not a handoff report which contained all of the critical elements, an easy way for the inpatient nurse to contact the emergency department nurse with questions, and/or the ability to document that handoff was complete. Interventions Lewin’s change theory was used as the framework. The interventions were: (1) create a new report in the electronic health record, which contained all elements noted to be critical content by The Joint Commission, and (2) add a field to the electronic health record which the inpatient nurse completed after the report has been reviewed. The inpatient nurse was able to document ‘Chart reviewed, no questions’, ‘Chart reviewed, questions answered’, or ‘Other’ with the ability to add a comment. Results There was a reduction of handoff related patient safety events from four preimplementation to two post-implementation. Though the theme of all of the events was communication, there was a difference in miscommunication versus lack of communication. The percentage of compliance with the new process was 48.6%. Not all of the responses to the preimplementation and post-implementation survey questions are statistically significant; however, there was a statistically significant difference in ‘I am satisfied with the process for emergency department to inpatient handoff’ on both the inpatient (pre-data (M=2.3, SD=1.1) and post-data (M=3.3, SD=1.3); t=-2.8, p=0.006) and emergency department (pre-data (M=3.3; SD=1) and post-data (M=4.4, SD=0.7); t=-3.9; p=0.0003) surveys. Nurse satisfaction with the handoff process has increased. Conclusions The project decreased patient safety events, and increased overall nurse satisfaction related to handoff from the emergency department to inpatient medicine units. As all transfers from the emergency department to non-intensive care inpatient areas followed the same process pre-implementation, expanding the use of the new process into those areas is recommended. The emergency department to intensive care unit process is currently a verbal handoff with no specific format. In the future, it will be guided by the new electronic health record report. There are opportunities to implement an improved handoff process in other areas of the medical center. Patients are transferred between units, procedural areas, and from one clinician to another frequently. The model used in this project could be the foundation for improvements in those handoffs.
    • Implementing a Stroke Narrator and Stroke Team Debrief to Improve Transfer Times

      Baez-Diaz, Domingo; Gourley, Bridgitte (2021-05)
      Problem. According to the American Stroke Association (2020), strokes represent the fifth cause of death and the leading cause of disability in the United States. The Brain Attack Coalition recommends transferring stroke patients requiring advanced management within 120 minutes. In 2019, the host organization, a Primary Stroke Center, managed over 700 strokes per year and completed more than 100 transfers to Comprehensive Stroke Centers (CSC). The host organization has multiple procedures to help identify, diagnose, and treat strokes but struggles to consistently reach the recommended transfer times of less than two hours. Purpose. The purpose of this quality improvement (QI) project was to reduce the door-to-transfer times for large vessel occlusion and hemorrhagic strokes, requiring a higher level of care at a CSC. Methods. The QI project's primary goal was to achieve a door to transfer time of less than two hours. Key best practice strategies, including clinical supporting tools as the Electronic Medical Record (EMR)- embedded nurse narrator and a clinical debrief, were conceptualized to improve patient outcomes. Results. The current data did not suggest a statistically significant reduction in transfer times but displayed a clinically significant reduction in large vessel occlusion transfer times during the implementation period. The use of the stroke debriefs was not analyzed thoroughly due to a limited completion of the Stroke Debrief forms, with only 20% completion of the forms. Additional education and training were conducted to ensure compliance with new stroke care procedures. Conclusion. The use of prompt feedback to the Emergency Department staff assists with identifying deviations from the current stroke algorithm, errors, and provides lessons learned. These lessons learned could be applied to future stroke transfers resulting in the improvement and achievement of transfers in less than two hours.