Now showing items 1-20 of 203

    • Early Hearing Detection: Using Pre-Discharge Education and Standardized Referrals to Reduce Lost-To-Follow-Up Rates

      Riggs, Julie; Gourley, Bridgitte; Clark, Karen (2019-05)
      Background: There are lags in ensuring that infants who do not pass their hospital newborn hearing screens receive the follow-up testing they need by the recommended three-month benchmark. The purpose of this project is to address disparities in infants lost to follow-up (LTF) by implementing a program for pre-discharge education and referral plan to free follow-up care at a suburban hospital in a mid-Atlantic state. Intervention: A partnership between the state department of health and a local university audiology program provided education and free follow-up testing of infants who did not pass the newborn hearing screen. Audiology technicians provided a screening result card to families, which also included hearing developmental milestones. Families received brief verbal education about the test result and the urgent need for a retest for those who did not pass. Infants requiring follow-up received appointments with the partner audiology clinic for a free evaluation. Results: 216 infants were born at the site and 214 babies received the in-hospital hearing screens. All 214 babies passed the in-hospital screens and did not require referral. An additional three babies were referred to the university clinic from other sites. Conclusion: This project did not yield opportunities for evaluation of LTF due to low birth volume during the short data collection period. However, this project indicated future potential for positive change. Families responded well to the cards and engaged with the education. This partnership provided opportunities for follow-up of at-risk infants in the region and is likely a model worth continuing and expanding.
    • 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.
    • Use of Cord Blood for Admission Lab Testing in High Risk Neonates

      George, Ronie; Bode, Claire (2019-05)
      Background: As part of their care in the neonatal intensive care unit (NICU) most neonates require routine admission labs, which could equal up to 10% of their total blood volume. This, and the subsequent lab draws while in the NICU can predispose them to anemia and hypovolemia with the possibility of needing blood transfusions. Local Problem: This QI project is being done in a twenty four bed level three NICU and in a twelve bed labor and delivery (L & D) unit in a major urban medical center in the Mid –Atlantic region. The current practice is to draw admission labs directly from the baby which is not only invasive but also traumatic and expensive considering the supplies used. Participants include registered nurses, neonatal nurse practitioners, neonatologists, laboratory personnel, and information technology staff. Aim: To implement the feasibility of drawing admission labs from the cord blood as an alternative to the current practice of neonatal phlebotomy. The data collected will be the number of staff who are trained to the number of staff working in the L&D and NICU and the number of samples collected from the cord blood to the number of NICU admissions during this timeframe. Interventions: The theoretical framework used here was the Plan Do Study Act. All nurses working in the labor and delivery and NICU and all high risk infants between 22 and 42 weeks who were admitted to the NICU were eligible to participate. An evidence based literature review guided improvement of current practice. Unit based practice guideline, power point presentation, competency checklist and data collection tools were prepared for education, training and data collection. Champions were selected and individual and group training sessions were done. Select cord samples were collected and sent to lab. Results: Education was completed by 80% L & D nurses, and 80% NICU nurses. Samples were collected on 64.47% neonates admitted to the NICU. Based on the posttest administered after the education, 98% agreed that using cord blood for admission labs is safe and reliable and helps prevent pain and other complications. Conclusion: The procedure has a high degree of usability and staff are continuing to collect samples from cord blood. In this present era where our focus is on quality improvement initiatives, making a wise use of available resources like umbilical cord blood will bring about a better outcome for the sick neonate and cost containment for the patients and their family as well as for the organization where it is implemented. In conclusion, cord sampling as an alternative to neonatal phlebotomy is an easily accessible procedure with the potential to improve the outcome of the sick neonates.
    • Improving Inhaler Technique Education in a Pediatric Emergency Department

      Bell, Lisa M.; Bundy, Elaine (2019-05)
      Background: Efficacy of inhaled medications for asthma is dependent upon proper administration technique. Rates of metered dose inhaler and spacer misuse are high among both patients and healthcare providers, and gaps in patient education practices are widespread. Practice guidelines recommend patient technique be demonstrated and assessed at every encounter using a checklist of critical steps with repetition until competency is achieved. Local problem: The purpose of this project was to improve metered dose inhaler and spacer technique education provided by registered nurses in a pediatric emergency department. Nurses in this setting do not receive training on metered dose inhaler technique, and patient technique demonstrations are not routinely assessed or documented utilizing checklists. Interventions: All nurses working in the pediatric emergency department (n=20) received education on metered dose inhaler and spacer technique at the initiation of the project. Training checklists were developed and incorporated into the electronic medical record based upon practice guidelines. Prior to discharge, patients with asthma were asked by a nurse to demonstrate their technique using a metered dose inhaler and spacer. The nurse used the checklist in the patient’s electronic medical record to assess and document competency in the critical steps of metered dose inhaler and spacer technique. Instruction was provided by the nurses to remedy any patient errors until competency was demonstrated. Results: In patient chart audits conducted over a 10-week period 138 charts met audit criteria; 95 of which had documented checklists. One-hundred percent of patients and/or caregivers with documented checklists were able to demonstrate competency in all critical steps prior to discharge, with 35% requiring additional education to correct errors in technique. Conclusions: This project demonstrated the benefit of maximizing a pediatric emergency department encounter to provide evidence-based asthma education on a critical component of asthma management. Similar projects are needed that focus on inhaler technique in other settings, as well as with other inhalation devices.
    • Screening and Referral of Orthopedic Patients into Care Coordination to Decrease Readmissions

      Miller, Danielle; Davenport, Joan (2019-05)
      Background The negative impact on patient outcomes due to unplanned hospital readmissions places a financial strain on the health care system. The Centers for Medicare and Medicaid reported 30day readmission rates as a fair indicator of quality services. Hospitals face monetary penalties for readmission rates exceeding the national benchmark under the Affordable Care Act. Hip and knee replacements were added to the list of conditions in 2014 authorizing Centers for Medicare and Medicaid to penalize hospitals for readmissions within 30 days of discharge. Local Problem When comparing an urban academic hospital to other hospitals in the state of Maryland, 44 hospitals have lower readmission rates for knee and hip replacement patients. Analysis of knee and hip replacement readmissions for two hospitals in Maryland within the same system for year 2017 reported readmission findings of 21 for both knee and hip, 79 for hip only, and 91 for knee only. Both hospitals had a 12% readmission rate in 2017. Interventions The healthcare team identified high, intermediate, and low risk total hip or total knee revision replacement patients at discharge by using the LACE risk-screening tool. Patients were referred into care coordination. Low-risk patients received a telephone phone call prior to their first appointment post-discharge. Intermediate and high-risk patients received follow-up phone calls for 30 days post-discharge, and then received a visit by the care coordinator during their outpatient follow-up visits with the surgeon to review the plan of care. Readmissions, emergency department visits, and no-show appointment rates were tracked before and after implementation of the LACE risk screening and care coordination. Results Readmission rates, emergency department visits, and no-show appointments in the first quarter (July-September, 2018) were compared to the second quarter (October-December, 2018) when the LACE screening tool was implemented. Readmissions within 30 days post-discharge decreased from one to zero. The no-show appointments were zero in Q1 and five in Q2 were a Pvalue of 0.02. Reasons for no-show appointments included diarrhea and transportation issues. There was an increase from one to three emergency department visits with a P-value of 0.32. The reasons for the emergency department visits post-LACE included wound check, abdominal pain, and femur fracture related to the revision of hip arthroplasty surgery. Conclusions The LACE Index scoring found to be helpful in this orthopedic care coordination program for identifying patients at low, intermediate, and high-risk for readmission within thirty days postdischarge. Introducing care coordination appeared to enhance post-discharge support and improve hand-offs between the inpatient and outpatient setting of healthcare.
    • Implementing a Locator Protocol to Support People Living with Human Immunodeficiency

      Scott, Katherine; Hammersla, Margaret (2019-05)
      This quality improvement (QI) project implemented and evaluated a locator protocol in an urban hospital to community transitional care program for persons living with HIV to minimize the number of people lost to follow-up. Background: In the United States over 50% of people living with HIV (PLWH) are not engaged in HIV care. Individuals not engaged in HIV care do not have access to combination antiretroviral therapy, prophylactic medications or medical services which increases their risk of morbidity, mortality, and HIV transmission to others. Local Problem: The HIV population in Baltimore is highly transitory with high rates of substance use and mental health disorders, and homelessness. An urban HIV organization in Baltimore, Maryland connects PLWH who are newly diagnosed or out of care to medical care. Clients are enrolled in the transitional care program during hospitalization and staff initiate individualized care plans to address barriers to care and provide support services. After discharge from the hospital clients receive 90 days of intensive case management including home visits, transportation to medical visits and connection to resources. During enrollment in this program, up to 50% of clients may be lost to follow-up at various time points because phone numbers are disconnected, or client transience. Intervention: A locator protocol tool was developed and initiated to collect detailed social and personal information from clients in the transitional care program to minimize the number of clients lost to follow up. Inclusion criteria included consented clients age 18 or older who were newly diagnosed or out of care for HIV for at least six months and had 1 of the following: unstable housing, substance use and/or a mental health disorder. Questions in the locator protocol included local hang outs, identifying a person of trust who could be contacted in case the client was not found, programs, agencies or businesses frequented, and dwelling locations including shelters. Community health workers (CHW) completed the form with clients at the bedside before discharge from the hospital. The locator protocol was initiated if a client missed a medical appointment or when the CHW could not locate a client via phone or address. Results: Twenty clients were enrolled in LTC+ from September 10 to December 17, 2018. Outcomes: 1) Seventeen (85%) clients completed the locator protocol. 2) Clients were frequently lost and then found again with the locator protocol. 3) Thirteen (76%) were actively retained in care. Conclusions: People who have unstable housing, substance use or mental health disorders struggle to maintain their health in traditional medical care models. The locator protocol centralizes client information and standardizes internal protocols which results in more consistent communication between staff and clients. The more detailed social and personal information collected, the longer and more likely staff stayed in touch with clients and got them to appointments and engaged in HIV care.
    • Immediate Debriefing after Pediatric Critical Incidents

      Laboy, Yvette; Simone, Shari (2019-05)
      Background: Critical incidents are described as events that induce strong emotional responses that can increase stress levels thereby impeding a nurse’s ability to provide good care. Nurses working in the pediatric environment are frequently exposed to critical incidents that affect their well-being. This repeated exposure may result in burnout and eventually leading to compassion fatigue. Local Problem: Nurses working in a community hospital expressed a need for immediate debriefings after pediatric critical incidents. Debriefings were occurring days to weeks after the critical incident. The purpose of this quality improvement project was to implement an immediate debriefing program for the interprofessional care team, after pediatric critical incidents to decrease stress associated with critical incidents and increase overall staff satisfaction. Examples of critical incidents include resuscitation of patients after cardiac or respiratory arrest, patient death, sudden or acute clinical changes requiring transfer to the Pediatric Intensive Care Unit (PICU), and conflicts with patients’ and/or their family members. Interventions: The quality improvement project was implemented on the pediatric unit at a community hospital in Baltimore, Maryland. Project implementation was conducted over a 14-week period. During the first two weeks, charge nurses who served as project champions attended a 30-minute training session led by the project leader on critical incident stress debriefing and conducted debriefings on the unit. Participants completed a pre- and post-implementation critical incident debriefing survey. All debriefing sessions were identified by the charge nurse and held during the same shift as the critical event. After each debriefing session, staff completed a post critical incident debriefing survey. Data collection included elements from the post critical incident debriefing survey. Responses to pre- and post-implementation surveys were compared to assess the impact of the debriefing sessions in decreasing staff stress and increasing satisfaction following a critical incident. Results: Eleven critical incidents occurred, with a debriefing session conducted after each incident. A total of 51 team members participated in these sessions, of which 13 participated in more than one session. Critical incidents included patients with sudden or acute clinical changes requiring transfer to the PICU, conflicts with patients, and patients at end of life. Post critical incident debriefing survey results revealed 94% of staff strongly agreed or agreed the debriefing session was held at an appropriate time, 81% strongly agreed or agreed debriefings helped decrease feelings of stress and unease, 77% strongly agreed or agreed debriefings were meaningful, and 81% strongly agreed or agreed debriefings improved satisfaction with debriefing session. Post-implementation survey results revealed the implementation of debriefing sessions immediately postcritical incidents decreased staff stress associated with critical incidents most of the time (74%) and increased overall staff satisfaction most of the time (61%). Conclusion: Critical incidents in Pediatrics/PICU can cause a significant amount of staff stress. Implementation of a debriefing process was found to be helpful in decreasing stress associated with critical incidents and increasing overall staff satisfaction with the debriefing process. The debriefing process also helped identify barriers to patient care, discuss patient and staff safety concerns, and identify potential solutions.
    • Impact of Automated Post-Discharge Phone Calls on 30-Day Hospital Readmission Rates

      Polla, Tara; Akintade, Bimbola (2019-05)
      Background Reducing 30-day readmissions is a priority among hospitals nationwide as it is tied to reimbursement and used as a surrogate quality indicator. As an all-payor system, Maryland has the added challenge to reduce 30-day readmissions to below the national rate to be in compliance with its contract with the Centers for Medicare and Medicaid Services. Local Problem Readmission rates among trauma patients in a level-1 trauma center of a large, urban academic medical center in Baltimore, MD have been increasing over the first few months of 2018. The purpose of this quality improvement project was to implement and evaluate the effect an automated post-discharge phone call program had on 30-day readmissions and Hospital Consumer Assessment of Healthcare Providers and Systems scores on an acute care trauma unit. Interventions This project implementation took place over nine weeks. The first week was dedicated to staff education. Patients were given verbal as well as written materials regarding the phone call they were going to receive during their discharge education by the nurse. In weeks 29, post-discharge phone calls went out to adult patients being discharged home within 24-72 hours. Three attempts were made to contact the patient, after which a message was left for them to call back. Patients were asked questions about their current health status, follow-up care, medications, instructions, and satisfaction. If they answered negatively, the system would trigger an alert and a registered nurse would follow-up with them the same day. Demographic data including age, gender, primary diagnosis, and mechanism of injury was collected weekly along with survey completion rates, number and type of alerts generated. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and 30-day readmission rates were evaluated one month after the last phone call. Results 104 patients were called, 55.7% of patients completed the survey. 44.8% of those who completed triggered an alert. 29% of alerts were related to follow-up care, 23% related to instructions. Mean age was 6.6 years higher for patients who completed the survey compared to those that did not (40.9 vs 34.3). Readmissions decreased by 2.9%. There were no statistically significant associations between completing the survey and readmission rates (p=0.46). Hospital Consumer Assessment of Healthcare Providers and Systems scores increased in two categories: 4.6% in Care Transitions and 9.6% in Good Understanding of Managing Health. There was not a large enough sample size to determine significance. Conclusions Automated post-discharge phone calls have the potential to reduce 30-day readmission and improve patient satisfaction scores. Further analysis of additional data should be completed at six months to test for a significant association between survey completion, readmission rates, and HCAHPS scores. The potential costs of savings of this project was estimated to be $181,500. Future similar quality improvement projects should be aimed at increasing the number of follow-up appointments and improve patient understanding of instructions before discharge home.
    • Assessing Motivation and Readiness for Treatment for Substance Use Disorders

      Scott, Melvin; Scrandis, Debra (2019-05)
      Background: Patients who complete inpatient treatment and receive appropriate aftercare such as follow-up doctor appointments and referral to outpatient therapy, have better sobriety rates and health outcomes. Patients who chose to leave a substance abuse treatment center against medical advice experienced worse health outcomes and re-admissions compared to those who were successfully discharged after thirty-day in-patient program completion. Patients who were discharged against medical advice were seven times more likely to be admitted or readmitted within fifteen days. Local Problem: Over the last three years a substance abuse treatment center experienced a significant increase of patients leaving treatment against medical advice. The against medical advice discharge rate at this facility increased almost ten percent over this timeframe. A designated team complete a quality improvement project, using a self-reporting assessment tool to determine if readiness for treatment improved retention rates. Interventions The purpose of this quality improvement project was to assess the circumstances, motivation and readiness for treatment of newly admitted substance use disorder patients at a Mid Atlantic substance abuse treatment center. The Circumstances, Motivation Readiness (CMR) scale was used for these purposes. Results: The majority of the patients scored in the moderately high to high for the CMR subscales and total scale, indicating lower risk of leaving against medical advice. Yet, there was no significant difference between the total scores of those who remained in treatment for the full 30-day requirement or left AMA. However, there were positive correlations between LOS and the readiness subscale (p= 0.047) and total scores (p= 0.0346). There was no significant difference scores for either gender, ethnicity or drug of choice. Conclusion The CMR scale presented a feasible mechanism to identify substance use disorder patients’ readiness for treatment and risk for dropping out. The CMR scale may be of greater use in assessing risk for AMA discharges by counselors during initial intake into the facility by focusing on the individual statements to specifically identify characteristics that would place patients at higher risk for AMA.
    • Implementing a Neuro-Bundle in a Level III Neonatal Intensive Care Unit

      Steiner, Itta; McComiskey, Carmel (2019-05)
      Background: Intraventricular hemorrhage (IVH) is a complication primarily associated with preterm birth, specifically those born before 32 weeks gestation and weighing less than 1500 gram. With increasing survival rates for the most premature infants, IVH rates have remained stagnant at approximately 20% with severe IVH at approximately 5%. The incidence of IVH is highest within the first 24 hours of life and approximately 90% of cases occur within the first 3 days of life. IVH is associated with long term neurologic consequences such as hydrocephalus, seizures, and cerebral palsy. Midline positioning and minimal handling as part of a bundleintervention have been proven to decrease the incidence of IVH. Local Problem: This Level III NICU recognizes the risk IVH poses to its patients and wants to put in place all measures that will improve their outcomes. Prior to Implementation the unit did not utilize a neuro-bundle for IVH prevention. The purpose of this project was to implement a neuro bundle consisting of midline positioning and minimal handling for the first 72 hours of life for preterm infants born before 32 weeks and weighing less than 1500 grams. Interventions: A quality improvement project measuring nursing education and utilization of a neuro-bundle was implemented in a Level III NICU in a community hospital in Baltimore, Maryland. The project took place over a 14 week period. The first 2 weeks consisted of a presurvey and nursing education module to be completed via the hospital’s online education system. This was followed by the implementation of the neuro-bundle during weeks 3-13 and concluded with a post-implementation survey during week 14 to evaluate the change in practice. During implementation, a checklist was completed for each infant meeting criteria for the neuro-bundle. The checklist documented midline positioning, minimal handling, reasons for not adhering to the bundle, and other pain/stress reducing techniques that were used. Results: The bundle was utilized for 94% of babies admitted to the NICU meeting inclusion criteria. For those whom the neuro-bundle was utilized, midline position was maintained 97.59% of the time and minimal handling was used 86.4% of the time with pain/stress minimizing measures used 100% of the time. Only a single baby in the project had an IVH. Conclusion: Use of a neuro-bundle has been proven to decrease IVH rates. The neuro-bundle was successfully implemented and during this time the IVH rate was low. More information is needed to quantify the benefits since the sample size and duration of the project were small. The unit should continue to monitor the use of the neuro-bundle and its associated outcomes.
    • Transfer Bundle Use in the Intensive Care Unit: a Quality Improvement Project in a Neurosurgical Intensive Care Unit

      Wagner, Claire M.; Clark, Karen (2019-05)
      Background: Transfer out of the intensive care unit (ICU) is known to be one of the most stressful times in a patient’s hospital course. “Transfer anxiety” or “relocation stress” is affected by factors including: higher nurse to patient ratios outside of the ICU, decreased monitoring and surveillance, and poor planning and preparation for the transfer itself. A 14-bed neurosurgical ICU at a large, urban, academic hospital had no transfer process in place. An informational transfer bundle was implemented over 13-weeks as part of a quality improvement (QI) project. Methods: Data were collected using a pre and post-test survey, a transfer checklist, and the Systems Usability Scale survey tool. Descriptive data analysis was performed at the conclusion of the 13-week QI project. Results: Nurses perceptions of having an appropriate transfer process in place, and patients and families viewing transfer in a positive light increased post-implementation, however, notification of transfer itself was still low. The transfer brochure use was viewed favorably nurses, with greater than 90% reporting “agree” or “strongly agree” that its use helped in the transfer process. Patients/families reported increased comfort with transfer process through feedback during dissemination of the brochure. The Checklist showed that 29% of respondents had less than 24-hour notice of transfer and 62% had no family present at the time of brochure review. The goal of 20 completed checklists was met with 20 total transfers completed with checklist, although 5 appropriate transfers were missed. Conclusions: There is a need for a more formal transfer process and timely notification of impending transfer. Nursing, support staff, and management viewed the project favorably, stating the brochure helped patients and their families feel more prepared for transfer. Sustainability of the project will include use of the brochure on at least 2 other ICU’s and addition to current ICU checklist used during rounds. Overall, the project helped facilitate smoother transfer process for patient/family.
    • Perioperative Glucose Management in Orthopedic Surgery

      Madden, Ann Rose; Amos, Veronica Y. (2019-05)
      Background: There is a definitive correlation between perioperative hyperglycemia and negative outcomes in orthopedic surgeries. Vigilant treatment of hyperglycemia (>180 mg/dL) will prevent negative outcomes such as joint failure, infection and pseudarthrosis. Local Problem: A Clinical Practice Guideline (CPG) focusing on the management of perioperative hyperglycemia for patients undergoing orthopedic surgery was created for a community hospital in Southern Maryland. Interventions: Data was collected using the following instruments: Practitioner Feedback Questionnaire (PFQ) and the Appraisal of Guidelines Research and Evaluation II Tool (AGREE II). The acceptance and usability of the clinical practice guideline (CPG) was evaluated through these instruments. Results: The dissemination and collection of the practitioner feedback survey resulted in a 100% response (N=16). The literature search was complete and relevant and the recommendations of the CPG were clear and suitable for the intended patient population. 90% of the clinician’s scores suggested they would feel comfortable utilizing the care model suggested in the CPG. Clinical expertise and demographic variables influenced the responses in the PFQ and Agree II tool. Conclusions: Overall the data collected demonstrated widespread acceptance and approval of this clinical practice guideline.
    • Decreasing the Incidence of Clostridium Difficile by Improving the Environmental Services Decontamination Process

      Anderson, Mary; Gourley, Bridgitte (2019-05)
      Background Clostridium difficile (C. diff) is a highly infectious organism that contributes to morbidity, mortality, and the cost of healthcare due to the organism spreading and being extremely difficult to kill. Oncology patients are highly susceptible to contracting C. diff due to their immunosuppression. The local hospital’s oncology unit has not been meeting their benchmark for decontamination of patient rooms. The purpose of this doctorate of nursing practice project was to decrease the incidence of C. diff by improving the EVS (environmental service) cleaning system through standardizing daily cleaning, with a focus on high touch surface areas, using Clorox Bleach wipes and a checklist in all rooms within the oncology unit. Intervention The DNP student developed a teaching simulation, using a SMARTER TOOL, to educate the EVS staff on how to clean the high touch surface objects and how to document the cleaning on the checklist. Each room in the unit was cleaned daily using Clorox Bleach wipes, with a focus on high touch surface areas. The checklist remained in the patient’s room for one week or unless discharged. After the rooms were cleaned, the hospital infection control staff and doctoral student tested for ATP on the high touch surface areas and recorded the data. Once the room cleaning was completed, the EVS staff member signed the checklist. The doctoral student collected the checklists at the end of each week. Methods The data analysis was conducted using descriptive statistics (mean, frequency, and percentage) evaluating the ATP results and items from the high touch surface checklist. There was an analysis of the high touch surface areas cleaning compliance and the quality of the cleaning based upon the ATP scores; items needed to score below 25 in order to pass. Microsoft Excel and PSPP were used to compute the data analysis. Results Data results showed a statistically significant reduction in the ATP levels when using the checklist and Clorox Bleach wipes. Both the IV pump and blood pressure machine showed sustained improvements across the entire intervention timeframe. The bedrail, bedside table, and call light each showed substantial reductions in ATP levels; however, these reductions did not reach statistical significance. Collectively, these findings indicate that the intervention significantly improved how the rooms were cleaned. The data related to staff compliance with the EVS checklist was transformed into a Likert scale to allow for analysis. On average, the staff was fully compliant < 4 days per week. There was a statistically significant difference between the compliance rating and the ATP levels for the variables of interest, only the blood pressure machine was not significant. Conclusion The project was successful in demonstrating that there was a significant decrease in ATP while using a daily checklist and Clorox Bleach wipes. This decrease in ATP suggests that the environment is less viable for organisms, especially such multi-drug resistant organisms such as C. diff. Since this project’s completion, the hospital has used Clorox Bleach wipes in all C. diff patient rooms for daily cleaning and as a standard for all terminal cleaning.
    • Hospital Acquired Pressure Ulcer Prevention: Admission Bundle

      Hicks, Courtney Crane; Rowe, Gina (2019-05)
      Background: The development of a pressure ulcer is detrimental to the patient, their family, providers, and hospital-based systems. Pressure ulcer development is not only costly but they are associated with an increase in morbidity and mortality. Hospital acquired pressure ulcers (HAPUs) are prevalent nationally and their incidence was on the rise in the state of Maryland as of 2015. Local Problem: In 2017, a heart/vascular unit within a community hospital in Maryland identified the development of HAPUs among five patients, with one patient ultimately succumbing to their pressure ulcer due to sepsis from infection in their HAPU. In 2018 five HAPUs were identified prior to implementation in September 2018. Aims/Objectives: In order to reduce rates of HAPUs on this unit and improve patient care, an evidence-based admission bundle was implemented. Specific aims for this project included an increase in compliance with aspects of the bundle, and an increase in nurse knowledge and confidence post implementation of the bundle. Methods/Interventions: After a survey of current practice completed by staff revealed knowledge gaps and specific areas for improvement, an educational online module was developed and an evidence-based admission bundle was implemented. The admission bundle included a two-skin assessment upon admission with a turning schedule for every patient, with sacral preventative dressings and pressuring reducing mattresses recommended based upon a patient’s Braden Scale scores. The Plan-Do-Study-Act model was utilized to help facilitate implementation. Results: Prior to implementation of the bundle, there was 100% completion of education by the nursing staff. There was an overall 79.7% compliance with the two-nurse skin assessment and a 56.5% compliance rate with the use of sacral preventative dressings. In regards to the pressure reducing mattresses, 31 out of the 33 patients were either in a pressure reducing mattress at time of audit or had an order placed. This yielded a 93.9% compliance rate with this aspect of the bundle. There was a 54.5% compliance rate with the turning schedules posted in patient’s rooms. During the implementation period, six pressure ulcers were identified. Based on the postimplementation survey of current practice, there was little change in knowledge and confidence levels. Conclusions: Compliance rates with the admission bundle varied among the different aspects. There was higher compliance with the skin assessments and use of pressure reducing beds, however there were lower compliance rates with the sacral preventative dressings and turning schedules. Knowledge and confidence levels with HAPUs did not change dramatically post implementation with the HAPU admission bundle. There was an increase in HAPUs during the implementation period of this bundle which could correlate to low compliance with several aspects of the bundle as well as the low levels of change measured in nurse knowledge and confidence levels regarding pressure ulcer prevention. Implications: The use of a nurse-driven admission bundle can promote early identification of risk and lead to early implementation of preventative measures to stop HAPUs before they start.
    • Nurse-Led Peer Facilitated Diabetes Prevention and Early Intervention Program

      Adejumo, Oluremi Abiodun; Bode, Claire (2019-05)
      BACKGROUND: Prediabetes, an antecedent to type 2 diabetes (T2D) - the 7th leading cause of death and disability in the U.S., poses a greater impact on marginalized populations. The risk factors include excessive weight, unhealthy eating habits, sedentary lifestyle, and smoking. Diabetes prevention program (DPP) lifestyle intervention can delay or halt the progressions of prediabetes to T2D. PROBLEM: The formerly homeless men in an inner-city residential employment center on the East Coast of the U.S. exhibited high rates of risk factors for T2D: tobacco use (83%), obesity (54%), pre-hypertension (39%), hypertension (14%), and family history of diabetes (42%). OBJECTIVES: This nurse led DPP project implemented and evaluated a peer facilitation approach for reduction of T2D risks among the formerly homeless men in this employment program. METHODS: Five formerly homeless men who were previously trained as diabetes prevention lifestyle coaches (“peer facilitators”) using the Group Lifestyle Balance curriculum delivered twelve (12) weeks of the DPP core interventions to their peers. Each peer kept weekly logs of dietary and smoking habits, the number of times per day that they replaced sugar-sweetened beverages (SSB) with water, and physical activity. Data analyses of changes in all variables were conducted using self-reported data from the participants’ weekly logs and statistical significance was analyzed using the paired t-tests. RESULTS: All these men (N=15) met the required inclusion criteria of having a score of five (5) or higher on the American Diabetes Association (ADA) risk assessment test (mean=5.53; SD=0.74; range=5-7 of a maximum 11 points) combined with being aged 18 years or older. At baseline, most of these men were smokers (73%) and had a family history of diabetes (73%). Data from the participants’ weekly logs for weeks 1 to 12 showed statistically significant changes in behavioral modifications except for physical activity between weeks 1 and 4 (p=0.5). However, there was a significant increase in the participants’ mean number of days for physical activity from week 1 to week 8 (p=0.007) and week 1 through week 12 (p<0.001). Significant reductions were also observed in participants’ mean weights from weeks 1 to 12 (p<0.001). CONCLUSION: Implementation of a nurse-led, peer-facilitated, diabetes prevention in formerly homeless men significantly reduced their risks for T2D; fostered strong relationships among peers; increased program’s relevance and participants’ attendance, as well as provided enormous opportunities for these facilitators to seek employment in other community-based support programs. As well-informed community leaders, these men can also reach numerous other, often hard-to-reach individuals in their network of family and friends. Thus, commitments from local partners will be extremely valuable for sustainability and future evaluations of this tailored, community-based, quality improvement project.
    • Improving Staff Communication and Teamwork As a Psychiatric Day Program

      Aitken, Molly K.; Michael, Kathleen (2019-05)
      Background: The Institute for Healthcare Improvement has identified four foundational principals for making health care systems and processes safer and more reliable: Standardized processes and care, Simplified processes, Reduced autonomy, and Highlighting deviations from practice. They recommend use of the TeamSTEPPS Situation, Background, Assessment, Recommendation/Request (SBAR) technique to maximize communication between members of healthcare teams. TeamSTEPPS is a training program that was developed by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD), with the most recent version being TeamSTEPPS 2.0. It consists of five key principals: Team Structure, Communication, Leadership, Situation Monitoring, and Mutual Support. Local Problem: A behavioral health provider in Baltimore City recognized the need to improve teamwork, communication, and efficiency during shift-change report among staff members at their psychiatric day program. Interventions: Fall of 2017, training was done with staff members at this psychiatric day program on TeamSTEPPS 2.0’s key principals of Communication and Leadership. October 3, 2018, training was done on the key principal of Situation Monitoring, implementation of the mnemonic “I PASS THE BATON” – the new evidence based standard for handoffs, and refresher training on Communication and Leadership. Participants completed the Teamwork Attitudes Questionnaire (T-TAQ) prior to training and again after a seven-week implementation period. Results: Eleven staff members (n=11) were trained on October 3, 2018. Comparison of the pretraining and post-training T-TAQ questionnaires yielded evidence of improved staff attitudes toward team structure (38%), leadership (9%), situation monitoring (23%), and communication (38%), as evidenced by a greater number of Strongly Agree responses on the post-training questionnaires. Although there was a 14% improvement in the number of Strongly Agree responses for the category of mutual support, the overall percentage of Strongly Agree responses remained fairly low at only 33%. This agency continues to encourage its staff members to utilize the “I PASS THE BATON” mnemonic during shift reports. Conclusions: TeamSTEPPS 2.0 is a good fit for improving teamwork, communication, and efficiency of shift-change reports for this psychiatric day program. Continued training and refresher training, as well as inclusion of this training as competencies for new-hires, will be essential for maintaining these skills and improving patient outcomes.
    • Day of Discharge Planning Utilizing the n-by-T Strategy

      Fichter, Michelle; Gourley, Bridgitte (2019-05)
      Background: Hospital discharges are a complex process that can directly impact a patient’s length of stay and decrease the quality of care that the patients receive. An ineffective discharge process increases the number of unplanned readmissions, which are costly to hospitals and affect patients negatively. Local Problem: The medical providers on the General Surgery Unit at a Maryland hospital recognized the need for a discharge process that would increase the number of before-noon discharges. The unit experienced many late-day discharges which would contribute to increased night shift admissions. The unit also experienced higher than average readmission rates when compared to the rest of the organization. Interventions: The purpose of this Doctor of Nursing Practice project was to implement and evaluate the n-by-T strategy into the discharge process for the medical patients on a 30-bed general surgery unit starting October 1, 2018. The quality improvement project involved utilizing a discharge checklist with the n-by-T strategy during morning rounds to safely schedule a number of patients (n) for same day discharge by a goal time (T). The medical director set a daily goal of two patients discharged by noon. Pre-implementation data was collected from September 1-30, 2018. Post-implementation data was collected from October 1, 2018 through November 30, 2018. Data collection included the use of the discharge checklist Monday through Friday during discharge rounds, the average time of discharges, the average length of the discharge process, and the unit’s 7-day and 30-day readmission rates. Results: Pre-implementation data collected in September 2018 showed an average time of discharge of 15:30, the average speed of the discharge process was 2.80 hours, the 7-day readmission rate for the unit was 7.27%, and the 30-day readmission rate for the unit was 21.82%. The average discharge time post-implementation was 15:26 and the average discharge process time was 2.99 hours. The 7-day readmission was 2.22% and 4.91% for October 2018 and November 2018, respectively. The 30-day readmission rate was 6.22% and 10.27% for October 2018 and November 2018, respectively. The discharge checklist was completed 38 out of 45 days, with an 84% completion rate Conclusions: There was no statistically significant change in the average discharge time or the average length of the discharge process. The readmission rates showed statistically significant improvement in 7-day and 30-day rates post-implementation. Post-implementation provider feedback was positive from the providers for placing an emphasis on prioritizing patients for earlier same-day discharges. The process of this quality improvement project was successful, though sustainability at the project site was dependent on a re-evaluation of the discharge checklist due to the time burden associated with it. Future projects are recommended to assess other methods, besides an independent discharge checklist, in assessing patient readiness for before-noon same-day discharges. Future projects also include implementation on other inpatient units within the organization or to outpatient settings, such as subacute rehabilitation facilities.
    • Implementation of a Transition of Care Process to Reduce Patient/Family Relocation Stress/Anxiety

      Spelta, Jennifer M.; Costa, Linda (2019-05)
      Background Transitions of care in the acute care system are a process patients encounter frequently, involving vulnerable populations such as the intensive care unit patients. The transition process in the intensive care unit aims for minimal disruption, however, patients/families still experience stress/anxiety. Transitioning from a secure and specialized care area to another unit induces fear of the “unknown.” A support process during the transfer is essential for a positive patientcentered transition of care. Local Problem The project goal of this quality improvement project was to develop and implement a transition process in the surgical intensive care unit to reduce patient/family relocation stress/anxiety. Interventions The project took place over an 8-week timeframe within a 24-bed adult surgical intensive care unit. Meleis’ Middle-Range Transition Theory Framework was used to develop the project. The PDSA model guided the development and implementation. A pre-post design was used with separate populations, the pre-group providing baseline information. Surgical intensive care unit nurses were educated on the process during staff meetings prior to implementation. Patients transitioning to the surgical intermediate care unit participated. The process included an algorithm checklist for nurses addressing: unit information, decreased patient monitoring, family visiting, patient safety, transition brochure of expectations, and self-reported post-transition data. Surgical intensive care unit champions collected data within 48 hours of transfer from patient/family self-report using the data sheet, composed of the Faces Anxiety Scale, brochure feedback, and staff compliance data. Post implementation, nurses complete the transition of care- system usability survey to evaluate process feedback. Results Pre-implementation Faces Anxiety Scale data (N=6), 33% displayed a little bit more stress/anxiety with transitions and 50% a bit more, with 83% from patient completion of data and 17% family. Post-implementation (N=24), 42% displayed no stress/anxiety and 37% just a little, 75% completed by patients and 25% family. Pre demographics displayed majority male gender, and post-indicated equivalence of gender, however both were patients over family completing the data. Pre-implementation data found a majority in the 20-39 and 60-79 age groups, and postimplementation date, majority was in 40-59 and 60-79 age groups. The transition of care- system usability survey indicated 97% of surgical intensive care unit nurses would like the transition process continued. Conclusions The surgical intensive care unit transition of care process for patients/families is paramount to impacting goals toward reducing relocation stress/anxiety. Outcomes discussed indicated success, and positive surgical intensive care unit nurse feedback indicated the need and want for the transition of care process to all transitioning units for surgical intensive care unit patients, as well as identifying the clear need for the practice change.
    • Implementing Mobile Text-messaging to Improve Attendance at Well Visits in Primary Care Pediatrics

      Osuagwu, Ngozi E.; Connolly, Mary Ellen (2019-05)
      Background: Missed appointments are a long-standing problem encountered both in the United States and abroad with rates ranging anywhere from 5% to 55%. It is a major cause of inefficiency in the medical system and consequences include poor health outcomes, wasted health care dollars, waste of provider time and adverse effect on patient -provider relationship. Local Problem: No-shows are a significant problem in primary care especially in underserved populations. The implementation site for this quality improvement project provides care to an underserved population with a no-show rate of 35%. The purpose of the DNP quality improvement project was to implement and evaluate the use of mobile text messaging to reduce the non-attendance rate to routine well visits in a primary care pediatric clinic in inner city Baltimore. There is evidence to support the use of text message reminders to improve both medication adherence and attendance rates when compared to other available appointment reminder systems. Intervention: The project was implemented in a sample of patients by nurses, front office staff and providers. The intervention involved sending text message appointment reminders to patients. The attendance rate was later analyzed and compared to the attendance rate prior to the implementation period. Inclusion criteria for the patient population was patients aged 18 years and older or the legal parent or guardian of a patient who was under the age of 18 years. Staff attended a 4-hour training session, which was led by the project leader and I.T. personnel. A preimplementation survey was conducted to determine patients’ and parents’ perception of the planned mobile text-messaging system. The questionnaire was quantified, averaged and the result was favorable. During the implementation period, data was collected that reflected the rate of attendance during the project. This information was aggregated and stored by the EHR system. Data was retrieved from the EHR and Run charts were used for data analysis. Results: The attendance data from the intervention showed that there was no significant increase in attendance to well visits for October, November and December compared to the preceding months of July, August, and September 2019. Conclusions: Though the result of the intervention did not reflect the expected impact, several lessons were learned. There were some positive unexpected findings, including an increase in portal registration, improvement in the update of patient phone numbers in the EHR database, and greater rapport among staff due to teamwork.