Problem and Purpose: The setting for this quality improvement project was an inpatient psychiatric unit at a large, urban medical center. In 2022, this unit lost 30% of its nursing staff, leading to significant under-staffing. Exit interviews indicated that nurses were seeking new employment due to excessively high levels of acuity on the unit and subsequent nurse burnout. A literature review found that acuity tools may increase satisfaction among nurses and can be useful in mitigating sentinel events. This Quality Improvement (QI) project implemented an evidence-based tool to assess and manage acuity with the intention of decreasing nurse burnout and seclusion and restraint events. The project was implemented over a 15-week period in the Fall of 2023. Methods: The Project Lead mobilized an interdisciplinary team of invested stakeholders at the project site to integrate the Vanderbilt Acuity Tool (VAT) into the mandated charge nurse documentation each shift. New protocols included scoring the VAT each shift and communicating the score during handoff to the oncoming charge nurse and during discussions with the admitting physician, nurse manager, and admissions officer to ensure all relevant stakeholders were aware of the acuity levels in the context of the ability to continue taking admissions. Results: Seclusion and restraint incidence showed significant variability with no interpretable trends. There was a 20% decrease in emotional exhaustion scores (consistent with overall decrease in burnout), a 29% decrease in depersonalization scores (consistent with overall increase in burnout), and a 5% decrease in personal accomplishment scores (consistent with overall increase in burnout). Informal feedback from nurses suggests staff were largely satisfied with the tool’s applicability and usefulness, however the compliance rate for completion of the VAT was only 56.5%. Conclusions: There was an overall decrease in nurse burnout following the intervention period, suggesting the VAT may have been useful in managing acuity and subsequently decrease nurse burnout. The VAT did not, however, have a measurable impact on seclusion/restraint incidence. Data supports the conclusion that the VAT may be a successful way to measure acuity, however further research is needed to determine how to better integrate the VAT into the nurse workflow. Keywords: nurse burnout, acuity, acuity tool, seclusion, restraint

Problem: In a 10-bed adult Surgical Intensive Care Unit (SICU) at an academic medical center, seven incidents of hospital-acquired pressure injury (HAPI) were recorded from January to December of 2022. The average pressure injury intervention and documentation compliance rate was 72.27% within the first 24 hours of admission, 69.17% with ≥ 48 hours of stay, and 68.76% for the entire stay. Purpose: The aim of the quality improvement (QI) was to implement a standardized pressure injury prevention intervention bundle (PIPB) and checklist to improve staff compliance with HAPI prevention strategies and documentation. Methods: The implementation was from August to December 2023. Participants included 14 registered nurses (RNs) and two certified nursing assistants (CNAs) who completed the education and training. RNs performed the Braden Scale Risk Assessment and skin inspection/assessment for all patients in the SICU on admission, every shift, and with any significant change in condition and documented details in the Skin Inspection/Assessment Note in the electronic health record (EHR). Patients with Braden scores of ≤ 18 received bundle interventions, which were recorded in the PIPB Checklist Audit Tool. Compliance was measured weekly over 14 weeks and analyzed using a run chart. Results: Data showed a consistently high compliance rate of 96.88% (n=1028) with skin inspection/assessment and documentation over 14 weeks. The PIPB intervention and checklist compliance of 90.05% (n=543) demonstrated the effectiveness of implementing the evidence-based intervention, strategies, and tactics. Conclusion: Implementing a standardized PIPB and checklist in SICU can increase staff compliance with HAPI prevention intervention and documentation practices for accurate assessment, intervention, monitoring, and early detection of pressure injuries. Keywords: hospital-acquired pressure injury, care bundle, intensive care unit, compliance

Problem: At an Ambulatory Surgical Center (ASC) associated at a large urban academic medical center, a high frequency of perioperative hypothermia was noted. In the Fall of 2022, between 79.2% and 92.1% of patients were within the normothermia range of 36ºC within 15 minutes of arriving to the Post Anesthesia Care Unit (PACU), falling below the benchmark goal of 95%. Purpose: Literature shows that postoperative temperatures below 36ºC can negatively impact patient comfort, recovery, and risk for infection. This project aimed to implement and evaluate an evidence-based warming bundle intervention perioperatively to decrease incidences of postoperative hypothermia. Methods: Staff were educated on the current normothermia policy, context of the project, methods of evaluation, as well as how to properly use temporal artery thermometers and forced air warming (FAW) devices, and education was reinforced through email communication. Nurses in the preoperative unit performed screening of patients meeting criteria, and implementation team members accessed audit tools using QR codes and web links at discharge. Data was collected via a HIPAA compliant, password-protected server, which was only accessible by the Quality Improvement Project Lead (QI-PL) and project faculty. Results: Over a 15-week period in the Fall of 2023, the warming bundle was utilized for 196 patients. Of those, 71 patients (36.2%) had all elements of the warming bundle completed. Within the 71 patients, 100% had a documented normal temperature; averaging 36.3ºC in the PACU post bundle implementation. Conclusions: Implementation of an evidence-based warming bundle intervention has been found to decrease incidences of postoperative hypothermia. Hypothermia and future considerations should include standardizing warming interventions, which could potentially reduce postoperative hypothermia. Keywords: perioperative warming, postoperative hypothermia, normothermia, warming bundle

Problem: Patient falls remain an expensive medical cost in the United States (U.S). Between October 2022 to August 2023, a 271-bed community hospital reported 42 falls in their emergency department (ED). Rounding, though required by staff, is not frequently performed. Purpose: The intent of this quality initiative (QI) was to reduce patient falls in the ED by instituting and evaluating pain, potty, possession, and positioning, the 4Ps of hourly rounding. Methods: Non-human subject’s approval was received prior to implementation. This evidence-based QI initiative was implemented over 15 weeks. Data was collected using participant surveys (Pre-Readiness/Post-Implementation Surveys, and the Fall Tracer Observation Form) and chart audits (Hourly Rounding Chart Audits). Data was collected at the dichotomous and categorical levels. The initiative was composed of an interdisciplinary team of nurse administrators (nurse leaders, informatician and director of quality and patient safety). All ED nurses (n = 87), patient care technicians (PCTs, n = 36), participated in the invervention; patients over 18 years old had their charts audited. A weekly hourly rounding education session was provided to staff. Chart audits were conducted weekly to assess adherence. Strategies from the Bingham ABCDE format was used to facilitate implementation. Results: Among the starting ED staff (100%, N = 123), 67% (n = 80) completed the Pre-Readiness Survey (RN = 67, PCT = 13). Rounding occurred every 1 hour (24.6%), 2 hours (20.1%), or at various times (55.3%). The Fall Observation Form showed that staff could categorize patients as low (36.7%), medium (26.1%), or high fall risk (37.2%). The post-implementation survey was completed by 67% of staff members (RN, n = 55; PCT, n= 5), with 78.3% (n = 47) reporting a level of comfort performing hourly rounding. A total of 14 falls occurred during project implementation (a 33.3% decrease from the 42 falls). Conclusions: This initiative did not result in a decrease of falls. Though most patients in the ED were categorized as high fall risk, further guidance is needed to ensure that interventions are in place for these patients. This project has implications for practice: reduce patient falls and improve the hospitals’ financial resources. Keywords: hourly/purposeful rounding, preventing/reducing falls, emergency department/room

Problem & Purpose: Patients in the post-anesthesia care unit (PACU) of a midsize community hospital experienced average wait times of 80 minutes and median times of 35 minutes post-anesthesia discharge due to suboptimal handoff and communication to the inpatient telemetry unit, as illustrated by chart audit performed during the month before project implementation. Lack of communication contributed to fourteen reported adverse patient events on the telemetry unit over six months in 2023. The literature base supports the implementation of standardized electronic handoff (SEH) to improve throughput, communication, patient safety, and decrease medication errors. This quality improvement) project aims to measure adherence to the implementation of SEH for patients from PACU to the telemetry unit and the effects on communication and throughput. Methods: PACU staff entered SEH using a dot phrase in the patient’s chart under the notes section. The telemetry nurse read the SEH and called for any additional report questions prior to patient transfer to the floor. After the patient transferred, the receiving telemetry nurse completed a communication satisfaction survey using QR codes available on the unit. The project lead performed chart audits to determine throughput times and evaluated completed surveys for nurse perception of handoff. Results: Average transfer times dropped from 80 to 51 minutes; however, median times went from 35 to 43 minutes but remained under the goal of 60 minutes or less. At 11% compliance, nurses agreeing to positive questions about handoff increased from 78% to 81% and disagreeing to negative questions improved from 57% to 82%. Conclusion Practice recommendations include the implementation of SEH. Findings suggest adherence to SEH use, correlates to improved transfer times from PACU to the telemetry unit and improved communication perception with handoff. Keywords: Electronic, Handoff, Communication, Perception, Adherence, Throughput, Time

Problem: On a 41-bed mixed surgical unit in a community hospital, patient assignments have historically been based on unit layout geography. This practice has resulted in unbalanced workloads which, per the literature base, can influence patient outcomes such as increased falls and missed turning and repositioning (T&R). At the project site, fall rates increased from seven falls in 2020 to 16 falls in 2022, and T&R compliance was 40.5% in August 2023. Literature shows patient outcomes and quality of care were significantly improved after implementation of the Perroca patient acuity tool (PPAT). Purpose: This quality improvement (QI) project aims to apply the PPAT based on tailored unit needs, educate unit nurses, assess PPAT compliance, measure patient outcomes, and improve workload balance during a 15-week period. Methods: Prior to implementation, nurses were educated by utilizing mock patient scenarios. During the intervention period, nurses completed the acuity tool by scoring an average daily census of 30 patients from one (lowest acuity) to three (highest acuity). Using the acuity scores, charge nurses evenly distributed the highest acuity patients among the oncoming nurses. Random audits were conducted twice a week to evaluate tool utilization compliance. Fall rates and T&R data were assessed weekly to evaluate patient outcomes. Results: On average, staff utilized the acuity tool 81.8% of the time and charge nurses used the tool 76.7% of the time to make nurse assignments. Fall rates improved by 25% post implementation. Average T&R compliance was 26.1%. Conclusions: Findings suggest that fall rates improved post-implementation. However, there was no improvement in average T&R compliance. Anecdotally, nurses appreciate more equitable assignments. Implications for practice include further research utilizing artificial intelligence to promote equity among patient acuity and nursing assignments. Key words: Patient acuity, nurse assignments, workload, falls, turn and reposition.

Problem: The American College of Emergency Physicians asserts that Emergency Department (ED) overcrowding is a result of patient flow problems impacted by workflows across the organization, including the outflow of admitted patients. At a large community hospital in Maryland, the time from the decision to admit to depart was greater than 2 hours. In alignment with Maryland’s Health Services Cost Review Commission’s Emergency Department Dramatic Improvement Effort (EDDIE project) the organization wanted to reduce this to less than 60 minutes, with an interim goal of 110 minutes, a 25% improvement. Purpose: The project aimed to improve patient throughput by decreasing the time from bed assignment to depart by creating and implementing an Admission Nurse (AN) role and workflow for patients admitted to the cardiac acute care unit. Methods: Creating the AN role required redefining responsibilities for each task in the admission process. After the ED provider decides to admit a patient, bed management remained responsible for assigning the patient to a bed. The primary ED nurse completed the electronic SBAR (eSBAR) note. The AN was responsible for transporting the patient from the ED to their assigned room, completing the admission forms within the electronic health record, initiating telemetry if ordered, and orienting the patient to their room. The AN role was piloted one evening each week for 15 weeks. Results: The median decision to admit to depart time for patients admitted by the AN was 11 minutes faster than hospital performance. The median time from bed assignment to admission for patients admitted by the AN was 27 minutes faster than hospital performance, 60 minutes compared to 87. Conclusions: The AN can expedite patient movement and decrease the time from bed assignment to admission. Additional barriers and processes need to be addressed to decrease the overall time from decision to admit to admission including bed availability and alignment of goals between the ED and acute care units.

Problem & Purpose: Postoperative nausea and vomiting are associated with patient dissatisfaction, prolonged hospital stays, unanticipated hospital admissions, and increased cost of care. Approximately 40% of patients undergoing laparoscopic procedures at a community hospital experienced postoperative nausea and vomiting. The purpose of this quality improvement project was to implement and evaluate compliance with the evidence-based Apfel risk screening and prophylaxis treatment tool. Methods: A multidisciplinary team, including a Clinical Site Representative, Certified Registered Nurse Anesthetist, Sponsor, Chief Certified Registered Nurse Anesthetist, and the nurse managers of the pre-operative and Post Anesthesia Care Unit were mobilized to implement a new protocol. Educational materials were disseminated to all providers through in-person meetings and protocol copies. Following the training, providers utilized the Apfel screening tool, treated the eligible patients with the recommended antiemetics, and documented the postoperative nausea and vomiting risk score. Eligible patients included 227 adults undergoing laparoscopic surgeries. Results: Of the 227 eligible patients, a total of 68 patients (30%) were appropriately screened and treated. Of the 68 patients screened and treated, a total of 47 patients (70%) did not require antiemetics during the postoperative period. The median provider compliance with the protocol was 30%. The median percentage of laparoscopic patients not requiring antiemetics during the postoperative period improved from 40% (baseline) to 70%. Conclusion: Findings suggest that implementing a postoperative nausea and vomiting protocol was a feasible and sustainable intervention at this site. Compliance and treatment with the protocol reduced the incidence of postoperative nausea and vomiting.

Problem: Development of a surgical site infection (SSI) is a risk after pediatric scoliosis surgery, with rates ranging from 1-24% and may be higher for children with neuromuscular or syndromic disorders. Intranasal colonization of Methicillin Resistant Staphylococcus Aureus (MRSA) can be a cause of SSIs in pediatric spine patients as it is transferred from the nares to the surgical incision. Purpose: The purpose of this quality improvement project is to streamline the intranasal MRSA screening process in at-risk pediatric patients < 26 years of age who were scheduled for scoliosis spine surgery. Methods: A defined process was developed beginning in the pediatric orthopedic clinic where neuromuscular, at-risk scoliosis patients were identified and screened for intranasal MRSA by performing a nasal swab at their pre-operative visit and then treated with an intranasal antibiotic for 7 days prior to day of surgery. The swabbing result is tracked by the care team, and if positive for MRSA colonization, targeted intravenous antibiotics were administered within 60 minutes of surgical incision. The patient was then followed for any signs or symptoms of an SSI during the hospital stay and at discharge. Results: Implementation of this MRSA surveillance program identified at-risk preoperative pediatric spine patients who were potential nasal carriers of MRSA, nasal swabbed at the pre-op visit, and monitored for a positive colonization result. Treating with intranasal antibiotic ointment before surgery has been the standard process and adding MRSA surveillance offered an additional opportunity to identify MRSA colonization and prevent SSIs. Results demonstrated negative results for pre-op MRSA colonization on eligible patients and one SSI on a patient who was not swabbed pre-operatively. Conclusions: Adding an extra layer of MRSA surveillance to the at-risk pediatric scoliosis surgical patient can diagnose a life-threatening infection and prevent development of SSIs.

Problem & Purpose: More than 40% of patients admitted with diagnosis of non-ST elevation myocardial infarction (NSTEMI) in the emergency department, remain as NSTEMI by discharge despite majority being ruled out by cardiology and do not receive NSTEMI management in accordance with the American Heart Association-Get with the Guideline (AHA-GWTG) protocol. This lack of diagnosis reconciliation by discharge portrays the cardiology program as noncompliant with the AHA-GWTG reporting system that recommend 85% management rate. The purpose of this process quality improvement project is that by discharge, the type 1 NSTEMI patients are confirmed, and matched to therapeutic management, excluding the non-NSTEMI patients. Methods: A best practice advisory (BPA) was built into the electronic medical records (EMR), that prompted providers at discharge to accept if patient was a true NSTEMI. The BPA is built into the admission, discharge, and transfer (ADT) section of the EMR and is triggered by the AHA-GTWG entry criteria: “Chest pain”, “angina”, and “NSTEMI” with corresponding ICDcodes in the hospital’s diagnostics database. Any of these three presenting index problems is matched with an elevated troponin 5th >/= 10 ng/dL to trigger the BPA. Results: In the 14 weeks of data collection, result shows the BPA met target for patient population and units, it triggered 100 times on 100 patients. Duplicates triggers were eliminated. Providers responded to the BPA 11.1% of the time and confirmed 10 NSTEMI patients out of actual 34 according to audit. Compliance rate of 100% was achieved in weeks 6 & 7 with more responses to the BPA. Response rate dropped down to 0 as providers needed frequent reminders to engage. Conclusions: Selective use of BPAs are effective tools to manage patients using set guidelines. This BPA was not a hard stop; hence it was easy to bypass. Internal goal of 100% compliance rate is achievable if providers are made to respond 100% of the time.