Problem: Trauma patients discharged from an urban level 1 trauma center are at risk of being lost to follow up care when they are advised to follow up and do not. Interventions around the transition from inpatient to outpatient can positively impact outpatient follow-up rates and decrease readmissions. Purpose: The purpose of this Doctor of Nursing Practice (DNP) quality improvement project was to implement a structured home discharge process that includes scheduling appointments, educating on follow-up appointments, post discharge phone calls, and monitoring of patients who miss their appointments in order to improve adherence to follow-up care in the trauma population. Methods: A structured discharge process that includes the Advanced Practice Providers (APP) requesting an appointment and attaching the updated discharge education, the nurse checking appointments on after-visit summary (AVS) and reviewing clinic discharge education, and the clinic staff contacting patients who did not have a scheduled appointment at discharge or did not complete their scheduled appointment was created and audited throughout the project phase. Results: Appointments scheduled at discharge increased from 28% (n=28) to 62% (n=113), education attached to AVS increased from 86% (n=97) to 92% (n=295), and NRC post discharge phone call answering increased from 38% (n=43) to 46% (n=77). 69 patients where recommended to follow up but did not discharge with an appointment, however, 78% (n=54) were scheduled after discharge. Appointments completion rate was 83% (n=142) post intervention compared to 74% (n=71) pre-intervention. Conclusion: Results show that appointment scheduling, education attached to AVS, answering of NRC post discharge calls, and appointment completion rate all increased with this intervention. There was minimal impact to readmissions, 6% (n=7) at baseline and 7% (n=21) post intervention, as well as lost to follow-up rate, 19% (n=21) at baseline and 18% (n=33) post intervention.

Problem: An identified clinical unit, in a large community hospital was failing to meet organizational expectations of benchmarked top box scoring on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). HCAHPS measures patient experience and impacts hospital reimbursement. The project unit’s HCAHPS score was at 74.4%, versus national top box reporting at 87.4%. Purpose: Intent of this initiative was to optimize service recovery by standardizing and enhancing the unit-based approach to Nurse Leader Rounding (NLR) with the use of a new electronic evidence-based tool to drive process and improve patient experience. It was intended that staff would adopt the project tool to guide their rounding, and that patients would report improved quality of care. The project anticipated that staff would report improved understanding of service recovery and satisfaction with use of a standardized approach. Outcomes were measured by an electronic software solution that patients used to provide real-time feedback on NLR quality and service recovery. Methods: Methodology included assessing participant nurse’s knowledge/ competency, and then implementing formal education for those who conduct unit-based NLR. The project leader, unit educator and nurse manager were identified as key stakeholders. Pre/post review of educational training was analyzed to evaluate feedback. Implementation included establishment of secure data collection plans and baseline data capture. Strategies and tactics to achieve the project goals included training of all staff members who conducted NLR, implementation of an evidence-based best-practice intervention tool, creation of an outcome tool that reflected key questions measured in HCAHPS, and auditing of process with regular team feedback on project outcomes. Patients were given opportunity to provide real-time feedback on the quality of Nurse Leader Rounding. Results: Nurses universally adopted the intervention tool to drive improved process. Patients reported that the quality of NLR improved by at least 25% across all survey questions. Conclusions: Expansion of the evidence-based methodology may yield improved patient experience reporting in similar clinical settings, in key elements of HCAHPS, both at the organization, and potentially beyond.

Problem Appointment adherence is essential to providing high-quality healthcare. However, missed appointments are common in the outpatient setting. Nonattendance has been shown to decrease quality of care, reduce revenue, and increase healthcare burdens. A pediatric cardiology clinic identified an 18% nonattendance rate. Purpose This quality improvement project implemented staff mediated reminder calls to reduce the nonattendance rate at an urban pediatric cardiology clinic. Methods The project team consisted of a Quality Improvement Project Lead (QI-PL), two scheduling specialists, and a nurse practitioner (NP). Scheduling specialists called patients with an appointment reminder 3-7 days prior to their appointment using a standardized script. Staff assessed and addressed barriers to attendance per clinic policy. Outcome measures were nonattendance rates and reminder call compliance. Additional data was collected for attendance barriers. Results The average nonattendance rate after implementation was 12.02%. This was a 33.22% reduction from the pre-implementation nonattendance rate of 18%. Call compliance averaged 80.55%. The most common barriers to attendance identified were directions to the clinic, language barriers, and insurance coverage. Conclusions Staff mediated reminder calls are a feasible solution to reduce nonattendance.

Problem: Stigma against mental illness brings with it many negative stereotypes that can be internalized by those who live with mental illnesses. The result is called “internalized stigma” or “self-stigma.” The implementation site for this Quality Improvement (QI) project was a 98- patient outpatient clinic providing treatment for schizophrenia-spectrum disorders. An early survey of patients at the site found that nearly half of the patients surveyed (46.94%) experience internalized stigma. There is currently no official treatment approach towards internalized stigma at this site. Purpose: The purpose of this QI project was the implementation of an evidencebased psychoeducational group therapy intervention for the treatment of internalized stigma amongst individuals living with mental illness. The intervention is titled “Ending Self-Stigma” and consists of nine manualized group sessions. Methods: The chosen framework for this QI project was the Promoting Action on Research Implementation in Health Services, or PARIHS model. Implementation included the administration of the nine manualized treatment sessions in addition to one introductory group session and a final feedback session. Attendance at each session as well as availability of each session were measured and analyzed using run charts. Results: Group availability throughout the project implementation period was 100%. Group attendance averaged 94.8%. Program feedback was positive, with participants overwhelmingly reporting enjoyment discussing their experiences with peers. Conclusions: The results show the feasibility and value of implementing this group at the site. High levels of attendance showed patient engagement, and feedback suggested high levels of enjoyment as well as relevance and benefits of the intervention.

Problem & Purpose: Intraoperative hypothermia, defined as core body temperature less than 36 degrees Celsius, is an anesthetic complication which can lead to adverse events such as increased risk of infection, delayed emergence, and increased cost to the hospital. Intraoperative hypothermia affected approximately 50% of gynecologic surgical patients at an acute care hospital in Baltimore, Maryland. The purpose of this project was to implement and evaluate the compliance of a preoperative warming protocol among patients undergoing gynecologic procedures. The preoperative warming protocol included the use of forced air warming at the maximum setting for the 30 minutes prior to surgery. The goal of the project was for 100% of eligible patients to receive the warming protocol and for 100% of patients to avoid intraoperative hypothermia. Methods: A team of 17 Certified Registered Nurse Anesthetists, seven physician Anesthesiologists, and 12 Registered Nurses were mobilized to implement the evidence based warming protocol. Education was provided via in person sessions and posted information throughout the preoperative area. Providers were expected to warm all eligible patients for 30 minutes using a forced air warming device immediately prior to the procedure. The anesthesia staff used quick response codes to document use of the protocol and incidence of intraoperative hypothermia. Data was monitored weekly and stored on Research Electronic Data Capture. Results: Overall, a total of 41 patients received the warming protocol over 15 weeks. Anesthesia provider compliance with the protocol was 38.2%. Compliance peaked at 100% in week one and 11. A total of 90.2% of patients who received the warming protocol did not experience intraoperative hypothermia. Conclusion: The data suggests the preoperative warming protocol is effective, feasible, and sustainable. Compliance required ongoing reminders and frequent communication.

An oral Controlled Human Infection Model (CHIM) with wild-type S. Typhi was re-established allowing us to explore the development of immunity. In this model, ~55% of volunteers who received the challenge reached typhoid diagnosis criteria (TD), while ~45% did not (NoTD). Intestinal macrophages are one of the first lines of defense against enteric pathogens. Most organs have selfrenewing macrophages derived from tissue-resident progenitor cells seeded during the embryonic stage; however, the gut lacks these progenitors, and all intestinal macrophages are derived from circulating monocytes. After infecting gut-associated lymphoid tissues underlying microfold (M) cells, S. Typhi causes a primary bacteremia seeding organs of the reticuloendothelial system. Following days of incubation, a second bacteremia and clinical disease ensue. S. Typhi likely interacts with circulating monocytes or their progenitors in the bone marrow. We assessed changes in circulating monocytes after CHIM. The timepoints studied included 0 hours (pre-challenge) and days 1, 2, 4, 7, 9, 14, 21 and 28 after challenge. TD participants provided extra samples at the time of typhoid diagnosis, and 48-96 hours later (referred as ToD). We report changes in Classical Monocytes -CM-, Intermediate Monocytes -IM- and Non-classical Monocytes -NCM-. Changes in monocyte activation markers were identified only in TD participants and during ToD. CM and IM upregulated molecules related to interaction with bacterial antigens (TLR4, TLR5, CD36 and CD206). Of importance, CM and IM showed enhanced binding of S. Typhi. Upregulation of inflammatory molecules like TNF-a were detected, but mechanisms involved in limiting inflammation were also activated (CD163 and CD354 downregulation). CM upregulated molecules to interact/modulate cells of the adaptive immunity, including T cells (HLA-DR, CD274 and CD86) and B cells (CD257). Both CM and IM showed potential to migrate to the gut as integrin a4b7 was upregulated. Unsupervised analysis revealed 7 dynamic cell clusters. Five of these belonged to CM showing that this is the main population activated during ToD. Overall, we provide new insights into the changes that diverse circulating monocyte subsets undergo after typhoid diagnosis, which might be important to control this disease since these cells will ultimately become intestinal macrophages once they reach the gut.

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Problem & Purpose: Lack of a standardized nutritional assessment process for patients with head and neck cancer receiving radiotherapy alone (HNC-R) may lead to undiagnosed malnutrition, interrupted radiotherapy, and increased complications. At a northeastern US academic medical center radiation oncology clinic, usual practice includes arranging dietician team referrals for all patients with HNC who receive chemoradiotherapy. In contrast, audits revealed that only two patients with HNC-R received dietician team referrals in FY 2022. This project aimed to promote early detection of malnutrition for all patients with HNC-R by implementing a standardized nutritional assessment process into the clinic's daily workflow. Methods: Before initiation of this 15-week project, the project lead (PL) educated clinic staff (providers/nurses) on administering a nutritional assessment tool, the Patient- Generated Subjective Global Assessment (PG-SGA) to patients with HNC-R. Staff administered PG-SGA during radiation consults at weeks one, four, and final week of radiotherapy. PG-SGA score > 4 initiated a dietician referral. Clerical staff entered data into the electronic medical record (EMR); PL audited EMR and entered data based on EMR audit on a HIPAA-compliant database server, REDCap®. Results: Staff screened 100% (17/17) of patients. Due to lost data on three patients, EMR documentation of PG-SGA scores occurred for 82% (14/17); 64% (9/14) of patients with HNC-R received dietician referrals. Conclusions: Clinic staff adhered to the new workflow process which increased nutritional assessments and dietician referrals for the target subpopulation within this radiation-oncology clinic.