Background: Sepsis is a life-threatening condition that accounts for greater than 215,000 deaths per year and has a financial impact that exceeds $20 billion of total hospital expenditures. The SSC guidelines recommend timely administration of appropriate antibiotics. Despite this recommendation, compliance with giving appropriate and timely antibiotics in septic patients remains low.
Methods: We conducted a nonrandomized cohort study analyzing patients diagnosed with sepsis and septic shock treated in the emergency room from May 1, 2016 through April 30, 2017. A protocol was developed for the emergency department (ED) pharmacist to help identify potential septic patients in the ED. If a patient was identified and no antibiotics ordered, the ED physician was contacted. If deemed appropriate, antibiotics were ordered and the pharmacist assisted the ED nurse by pulling the antibiotics from the Pyxis and ensuring no barriers to administration. The primary outcome was to determine if the addition of a pharmacist in the collaborative care of septic patients in the ED would reduce time to antibiotic from admission and order. Secondary outcomes were in-hospital mortality and length of stay.
Results: Median time to antibiotic from admission was 65.5 minutes vs 100 minutes (Z=4.2231, P≤0.001), mortality was 8.1% vs 19.1% (P=0.023), and length of stay was 11.1 days vs 8 days (P=0.002). A nursing survey was also performed to identify if nurses found pharmacist involvement beneficial. Sixty-two nurses were surveyed; 72.41% had the pharmacist help with a sepsis patient, and 86% found that it was beneficial to the patient, physician, and nurses.
Conclusion: Patients with sepsis remain a significant challenge for the entire team in any ED. For this reason, collaborative care is of the utmost importance to potentially improve patient outcomes. The results of this study show collaborative care with the addition of a pharmacist may reduce time until appropriate antibiotics and in-hospital mortality.
Background: The cardiothoracic service line performs more than 600 open heart surgeries annually. The 30-day readmission rate during 2014-2015 Q1 was 14.7%.
Methods: The team implemented the Multidisciplinary Cardiovascular Transitions of Care Program in March 2015 to better meet the needs of cardiovascular surgical patients while they are in the hospital and postdischarge. The program is centered on daily, multidisciplinary rounds. The team reviews patient history, current status, and needs assessment from all team members and develops a plan of care. Critical elements of patient acuity, clinical and social needs, quality standards, length of stay (LOS), projected date of discharge, discharge planning, resource utilization, and clinical pathway planning are discussed in an efficient and effective manner. Additionally, patients are provided with discharge education by a pharmacist, and they are offered bedside prescription fill services at discharge.
Results: After 6 months of implementing our pilot, we were able to reduce unnecessary 30-day readmissions for this population by 3%. From April 2015 to September 2015, there were 454 heart patients with a readmission rate of 11.6%. We saved $238,000 in charges through the diminished number of hospital readmissions. At 6 days, the average LOS did not fluctuate. The mortality rate improved, declining from 4.46% to 3.44%.
Conclusion: The Multidisciplinary Cardiovascular Transitions of Care Program is designed to build a collaborative partnership with patients and families and to help them to become owners in the healthcare process. Daily, multidisciplinary rounds provide a way for team members to develop a patient-centered care plan, allowing the team to problem solve and implement the patient's unique plan accordingly. The team uses best practice to review each patient's specific medications and pathology. The multidisciplinary approach to patient-centered care with quality transitional vision is crucial to the program's success. The collaborative partnership among care providers and patients empowers and fosters shared decision-making and optimal care throughout the continuum.
Background: Mobilizing critically ill patients with ICH represents a specific challenge due to issues of intracranial pressure and hemodynamic instability in the early period poststroke. The aim of this study was to evaluate the effect of a transdisciplinary progressive mobility program in the neuroscience critical care unit (NCCU) on the time elapsed to earliest mobility activities in patients with ICH.
Methods: Utilizing the Plan-Do-Study-Act model, we sought to examine current mobility practices for patients with ICH after rollout of the mobility algorithm in our NCCU. An algorithm was developed to direct all NCCU patients to structured, progressive, passive or active mobilization programs. Baseline data were collected retrospectively from electronic medical records for two 6-month periods, one before and one after program implementation using this quasi-experimental design. Time of first mobilization and frequency of mobilization were reported for baseline and postintervention comparison and adjusted based on patient characteristics.
Results: Two groups of ICH patients (prerollout, n=28; postrollout, n=29) were similar on baseline characteristics, with the exception of mean ICH severity scores, which were greater in the postrollout group (P=0.07). Patients in the postintervention group were significantly more likely to be mobilized within the first 7 days after admission (55% vs 29% in the preintervention and postintervention groups respectively, P=0.04). No episodes of hypotension, falls, or line dislodgements were reported in association with the early mobility intervention.
Conclusion: Use of a progressive mobility algorithm in stroke patients with spontaneous ICH increases the percentage of patients who are mobilized in the early critical period without issues of safety. Additional work in larger prospective cohorts is needed to evaluate the reasons for delay of mobilization on day one of hospitalization and to enhance data support for best practice timing recommendations.
Background: Many studies have explored the role of acculturation on health behaviors and outcomes; however, no studies to date have examined the relationship between acculturation and the traumatic stress of childbirth among Hispanic adolescents.
Methods: This descriptive, cross-sectional study was institutional review board approved by both academic and healthcare settings. Using convenience sampling, 66 Hispanic adolescents 13-19 years of age provided information related to acculturation via the Acculturation Rating Scale for Mexican Americans-II (ARSMA-II) and 4 common proxy measures, demographics, and traumatic stress level via the use of a birth appraisal rating scale and the Impact of Event Scale within 72 hours of birth.
Results: Analysis using Spearman rank correlation coefficients found significant associations between the ARSMA-II subscales and acculturation proxy variables, excluding language preference. Further, the ARSMA-II Mexican Orientation Subscale and generations in the United States proxy variable were found to associate with birth experience. These findings suggested that Hispanic adolescents identifying closer with the Mexican culture (rather than Anglo culture) and reporting fewer family generations residing in the United States were more likely to show symptoms of a traumatic childbirth in early postpartum.
Conclusion: In this unstudied area of research, our findings support the need for additional work related to the traumatic stress of childbirth among Hispanic adolescents. By using multiple acculturation measurements, including the ARSMA-II, with larger, more diverse samples of adolescents equally balanced between all categories of acculturation and placement within the 5-tier generation matrix, insightful information can be gained. Identification of overlooked areas of assessment related to acculturation may provide additional thought for practitioners and influence healthcare management of childbearing Hispanic adolescents.
Background: Asthma is the number one chronic illness among school-aged children <18 years of age and is a major cause of morbidity, loss of school days, and increased hospitalizations. Asthma disproportionately affects low-income, minority, and urban city youth in Alabama. Asthma control and self-management are complicated by limited access to healthcare and availability of specialty programs in medically underserved areas. Benefits from improving asthma control and self-management have significance for improving school achievement with lifelong benefits. This study aimed to answer the following questions: (1) what is the feasibility of implementing a school-based program specific for asthma self-management education; (2) what are changes in asthma self-management; and (3) what are changes in symptoms, asthma responsibility, and self-efficacy before and after the program?
Methods: Institutional review board and Mobile County Public School Board/Research Department approvals were obtained. This quasi-experimental study examined the effects of an interprofessional self-management education program for middle school students with asthma. Nursing (NS) students, respiratory (RT) students, residents, and faculty provided assessments, one-to-one coaching, and group education utilizing the Power Breathing curriculum. Instruments used included spirometry, the Asthma Responsibility Questionnaire, the Asthma Control Test, self-efficacy scale, and self-report diaries.
Results: The pilot program included 18 middle school students (minority or otherwise at risk), 13 NS/RT students, and one resident. Spirometry testing revealed that all teen participants had moderate to severe obstruction indicating a classification of not well or poorly controlled asthma. After completion of the program, asthma symptoms decreased, control increased, and self-efficacy and asthma responsibility increased over the intervention period.
Conclusion: A school-based interprofessional self-management education program was found to be feasible. One-on-one interactions including education and coaching with NS/RT students enhanced engagement with teen participants, and NS/RT students reported that the program provided an authentic opportunity for creating collaborative partnerships with each other and with the teen participants.
Background: The research builds upon a pilot study of a critical care IPE elective for upper level nursing and medical students at the University of Alabama completed in spring 2015. Preliminary findings suggested that a critical care IPE may contribute to more effective collaboration among future physicians and nurses. Research hypotheses were students who participate in the intervention will have increased (1) knowledge of AACN standards of Healthy Work Environments (HWE) and (2) confidence regarding their ability to practice in interdisciplinary teams and to address interprofessional conflict.
Methods: University institutional review board approval was obtained prior to data collection, and signed consents were obtained. Students who self-selected to take the co-enrolled spring semester 2016 course attended a semester long 2-hour critical care elective. The intervention group was 20 fourth- and fifth-semester nursing and 11 third- and fourth-year medical students. The control/comparison group was 50 fifth-semester nursing and 29 third- and fourth-year medical students from the same cohort. Participants were invited to complete the surveys at the start of the course and at semester end. The Interprofessional Socialization and Valuing Scale and a 12-item Likert-type researcher-designed tool, the AACN HWE Survey, were administered via Qualtrics.
Results: Males felt more comfortable than females working as teams, and nursing students placed greater value in working with others compared to medical students. Nursing students reported greater awareness of AACN standards than medical students did.
Conclusion: Although the findings of the study cannot be generalized, one can assume that without courses that focus on the development and sustenance of healthy work environments, future critical care nurses and physicians will be unable to create environments that support healthy, collaborative healthcare teams.
Background: It has been reported that up to 12% of all patients fall during the course of a hospital stay. Patient falls are associated with a wide range of adverse physical, psychosocial, and economic consequences. The purpose of this study was to identify factors most commonly associated with falls among hospital inpatients and to determine if identified factors were congruent with factors reported in the literature.
Methods: This descriptive study employed content analysis of incident reports of patient falls, supplemented with data extracted from case records. The study cohort included all (105) adult patients who experienced one or more falls during hospital admission during a 6-month period in 2015. The setting was a 726-bed, private, nonprofit urban hospital. Conventional content analysis strategies included counting recurring words and phrases, developing a coding scheme to create variables, collecting data jointly to ensure reliability, and applying descriptive and inferential statistics. The study was reviewed and approved by the institutional review board governing research at the study hospital.
Results: Fifteen variables with potential influence on falling were identified in the content analysis. Most were consistent with previous literature, but some had paradoxical associations. For instance, fall alarms were significantly associated with history of previous falls but were only active in 50% of eligible patients with previous falls. The likelihood of falling in the bathroom increased as fall risk scores increased, but staff assistance with toileting was not significantly related to fall risk score. Patients were 81% less likely to fall in the bathroom if they received staff assistance with toileting.
Conclusion: Inferential possibilities of this study are limited due to sampling only fallers. Future research will compare fallers and nonfallers. Practice recommendations include, among others, consistent staff assistance during toileting for patients with higher fall risk scores and rational utilization of bed alarms.
Background: Care for Hansen's disease (HD), also known as leprosy, is administered in ambulatory care clinics (ACC) throughout the United States with a 1- to 2-year multidrug therapy regimen. A lack of understanding regarding treatment plans, individual behaviors, feeling better after initial treatment, poor communication with providers, and distance from treatment centers adversely affect treatment compliance and can lead to relapse, reinfections, and disabilities. A preliminary review of records revealed treatment default rates in excess of 50% in 4 ACCs and involved 33 patients. The purpose of this project was to determine whether a telephone outreach intervention would be useful in reengaging patients in treatment default.
Methods: A 2-phase quality improvement project included a nonrandomized, purposive sample of participants who missed clinic visits or medication refills for 30 days or more. Participants who met the criteria received a telephone intervention to facilitate getting them back into treatment. Phase 2 of the project used a root cause analysis framework to determine the underlying cause of misclassifying patients between the National Hansen's Disease Program (NHDP) and the ACCs.
Results: This project was inconclusive in determining the usefulness of a phone intervention to improve medication adherence due to inconsistencies in categorizing patients. A performance improvement team was assembled to assess a clinical gap in the classification of patients.
Conclusion: There is a need for (1) a standardized list of terms to describe HD patient types to be used by the NHDP and ACC, (2) a standard operating procedure (SOP) to accompany the standardized terms, and (3) a clinical practice guide depicting the provisions of HD care from diagnosis to the point of stabilization. The SOP for universal classification of HD will improve communication among providers, improve contract negotiations, guide clinical management, define workload, and serve as a framework for future database development.
Background: Approximately 202 million people worldwide have lower extremity peripheral artery disease (PAD). PAD affects the lives of 8.5 million Americans aged ≥40 years and significantly impacts morbidity, mortality, and quality of life.
Methods: The American Heart Association (AHA) and American College of Cardiology (ACC) led the development of a new guideline to manage patients with lower extremity PAD. Writing committee members with expertise in PAD were selected as representatives from professional cardiovascular organizations. Two doctoral-prepared nurses were selected to serve on the writing committee representing the Society for Vascular Nursing and the Society for Vascular Medicine. Committee work consisted of face-to-face meetings and numerous biweekly conference calls spanning a 2-year time period. Literature was systematically reviewed and appraised. Quality and level of evidence were peer reviewed by the writing committee, voted upon, and submitted for external peer review.
Results: Guidelines were presented at the 2016 AHA scientific sessions and jointly published by the AHA and ACC. Specific recommendations encompass the clinical assessment, history and physical examination, resting and exercise ankle-brachial indexes, physiologic testing, and imaging studies. Guidelines include the role of pharmacologic agents, such as antiplatelets, oral anticoagulants, statins, antihypertensives, and cilostazol. Recommendations on glycemic control, smoking cessation, vascular screenings, and exercise interventions are described. Options to minimize tissue loss and surgical revascularization for claudication are discussed.
Conclusion: Nurses can assume a pivotal role in the development of national evidence-based guidelines. Nurses should be aware of and use current evidence-based guidelines to care for patients with PAD.
Background: Engagement, quality, and safety are leading concerns for hospitals. Perceived stress that is unmanaged can lead nurses to become apathetic and detached and can increase absenteeism. Nurse leaders are seeking evidence-based interventions that can impact the nurse's ability to deal with work-related stress.
Methods: The Donabedian framework was used to guide this evidence-based project. Emergency department nurses were invited to participate in a guided meditation program. Meditation sessions were scheduled over a variety of days at the end of a 12-hour shift for a 20-week period. Outcomes were measured using (1) the 10-item Perceived Stress Scale at baseline (PSS1) and postintervention (PSS2) and (2) participant program evaluation.
Results: Consented participants (n=24) completed both the PSS1 and PSS2; only 15/24 attended at least one meditation session. All participants demonstrated some degree of stress at baseline and a reduction in the PSS score at project end. Percent decrease in PSS score was categorized by the number of sessions attended: 4 sessions (n=1), 15%; 3 sessions (n=3), 43.34%; 2 sessions (n=6), 25.83%; 1 session (n=5), 9.52%; no sessions (n=9), 1.61%. The sample was inadequate to test for significant differences. Program evaluation findings (n=13) were as follows” 97% reported overall positive experience, 97% appreciated sessions offered at work, 95% indicated they would continue the program if available, and 97% would recommend the program to others.
Conclusion: All nurses who participated in this project, irrespective of whether they attended a meditation session, reported a reduction in perceived stress. Nurses who attended at least one session reported a positive experience and indicated they would attend future program offerings and would recommend the program to others. The small sample precludes generalizing findings outside of the nurses who participated. However, findings suggest that a project with a sufficiently sized sample to test the effect of the number of sessions attended on PSS is warranted.
P2. Is an Acuity-Adaptable Model Right for the Rural Intensive Care Unit Setting?
Background: The acuity-adaptable (AA) care delivery model aims to provide care in the same space from admission to discharge regardless of patient acuity. Little evidence supports published claims that AA care improves patient or staff satisfaction or nurse productivity in rural intensive care units (ICUs). The object of this study was to test the hypothesis that AA care affects patient/staff satisfaction or productivity in a rural hospital setting.
Methods: Patients (n=71) admitted to a 6-bed ICU were randomly allocated to receive AA or usual care. Patients in AA care remained in the ICU room until discharged. Patients in usual care were transferred out of ICU when their acuity permitted. Patient mood, anxiety, and perception of emotional care were measured at discharge with valid and reliable quantitative tools. Worked hours/patient day were measured quantitatively, and staff responses to AA care were assessed qualitatively.
Results: The belief that patients or staff are more satisfied with an AA model of care than a traditional model was not supported by the study data. AA patients reported higher anxiety and lower satisfaction with emotional care than those following the conventional progression of moving to a lower acuity bed from ICU. The AA model did not reduce transfer time or improve nurse productivity. ICU staff nurses were reluctant to provide AA care.
Conclusion: The major limitation of the study was the difficulty keeping patients in assigned groups; therefore, both per-protocol and intention-to-treat analyses were performed. This rural ICU, like many others, is flexible by necessity, serving patients with a range of acuities as hospital needs change. ICU patients remain in the ICU throughout their hospitalization when census and staffing demand. More attention to the emotional aspects of care may help patients adjust better to remaining in an ICU environment throughout the entire admission when they must.
Background: The ideal method for accurate tracking of antimicrobial resistance patterns in a community may be laboratory-based surveillance systems that collect strains for susceptibility testing in a laboratory. The use of antimicrobial drugs in day-to-day practice is suboptimal and responsible for multidrug resistance in a number of common pathogens. Aggregating antibiogram data appears to be an inexpensive, effective way of accomplishing goals of decreasing resistance. The data will also be useful in monitoring resistance trends in a region over time and assessing the effects of interventions to reduce antimicrobial resistance. Judicious use of antibiotics is essential for their continued effectiveness.
Methods: The aim of the project was to report the most frequently isolated bacteria recovered in clinical cultures and compare it to the 2015 antibiogram to determine trends. The setting was a health system with 8 community-based outpatient clinics and a 6-bed ambulatory procedural unit transitioning to a 200-bed inpatient medical center. The stakeholders were all staff involved in the continuum of care. The 2016 antibiogram was a collaboration between pathology and laboratory medicine service and pharmacy service to report the most frequently isolated bacteria recovered in clinical cultures. This antibiogram covered the time frame of January 1, 2016 through December 31, 2016. The 2016 antibiogram was compared to the 2015 antibiogram.
Results: In urinary tract isolates, Klebsiella oxytoca exhibited an 11% increase in resistance to aztreonam and a 12% increase in resistance to ceftriaxone. Coagulase-negative staphylococcus displayed a 36% increase in resistance to ciprofloxacin. In nonurinary tract isolates, Escherichia coli increased in resistance to gentamicin by 9%, and Enterococcus species exhibited a 10% increase in resistance to ampicillin.
Conclusion: Improving antibiotic effectiveness by teaching about antimicrobial resistance and educating providers that the antibiogram can be found on the intranet site can help address problems with antibiotic resistance.
Background: Operational costs in the operating room (OR) are affected by start times, turnover times, cancellation rates, and adequate supplies, equipment, and staffing. At the core of OR efficiency is how well an institution matches its resources to its demands. Perioperative services require the orchestration of multiple staff, space, and equipment. Our aim was to identify whether the implementation of operations management and an EHR improved perioperative performance. Inefficiency in the OR can increase costs and lead to dissatisfied patients, physicians, and staff members.
Methods: The aim of the project was to alter surgery's morning report to make the data meaningful and actionable. The setting was a health system with 8 community-based outpatient clinics and a 6-bed ambulatory procedural unit transitioning to a 200-bed inpatient medical center. The stakeholders were all staff involved in the continuum of care. Surgery's morning report included the cancellation rate, percentage of first cases started on time, lag time, and utilization rate. The report lacked direction, targets, and national comparison. The National Surgery Office criteria were applied to give each percentage a score. The scores were graphed on a donut report daily. This allowed for a visualization of the specific areas that did not meet the goal which in turn allowed for a deeper look and targeted improvements.
Results: Lag time is a metric that is most easily targeted for improvement and improving overall OR efficiency. Lag time was examined and found to be measured incorrectly and was corrected. Lag time thresholds were being missed by minutes in most cases.
Conclusion: Circulating and surgical technicians are identified as champions to keep the OR running safely and efficiently.
Background: Cancer and its treatment frequently cause pain, anxiety, tension, overall decrease in mood, and depression. Several investigations provide support for a benefit in reducing chemotherapy-induced anxiety in specific populations when limited types of interventions were used. There is a paucity of research regarding the relationship between multiple therapeutic activities, the time of usage, and chemotherapy-induced anxiety. Therefore, the purpose of this study was to explore the relationship between patients' use of therapeutic activities and perceived chemotherapy-induced anxiety.
Methods: A descriptive, correlational study was used to explore the relationship between patients' use of and preference for therapeutic activities during chemotherapy sessions and perceived chemotherapy-induced anxiety before and after each session. Oncology patients, aged ≥18 years and having outpatient chemoinfusion treatments, were asked to complete the 20-item State-Trait Anxiety Inventory (STAI) before and after their chemoinfusion. The type (table-delivered diversional activities or chair massage) and time of utilization of self-selected therapeutic activities were measured.
Results: To date, 13 participants have enrolled in the study; mean age was 58.23 years (SD=13.21) and 77% were female. Oncology diagnoses of the participants varied but more than 50% of participants had breast cancer. The self-directed intervention was delivered for a mean 67.85% (SD=41.23) of the chemoinfusion time (M=135.77 minutes [SD=69.10]). Eight of 13 (62%) participants chose massage over diversional activities. Overall, there was a mean 5.85% decrease in STAI scores following the intervention (preintervention, M=33.54 [SD=10.53]; postintervention, M=30.00 [SD=11.30]).
Conclusion: To achieve a sufficient sample size, 60 unique patients will need to be recruited. However, interim findings in this small sample reflect a small decrease in perceived chemotherapy-induced anxiety following self-directed therapeutic activities during chemotherapy infusion sessions.
Background: Acute site setting patients often require intravenous (IV) access for diagnostic tests and treatment. Many patients, because of factors including diabetes, advanced age, and obesity, fall into a “difficult access” category, meaning it takes >2 attempts for peripheral IV access using traditional means. A recent facility practice change allows specially trained RNs using ultrasound guidance (USG) to place peripheral IVs. An ultrasound-guided peripheral IV (USGIV) involves a live feed ultrasound for visualization from skin puncture to vein cannulation. Although multiple studies describe the efficacy and safety of USG lines, there is a dearth of information concerning their optimal dwell time and evidence-based removal time recommendations. Because it is proposed that USG lines are unaffected by variables associated with early traditionally placed IV failure, our study's purpose was to examine if there are differences in the indwelling times of USGIVs vs traditionally inserted IVs.
Methods: This exploratory study received expedited institutional review board approval. Data collection is currently in progress and involves reviewing medical records of patients hospitalized following a USGIV placement in the emergency department. A group of similar patients who have had traditionally inserted IVs are the control group. Data analysis will include descriptive statistics and calculation of confidence intervals to examine differences between the indwell times of traditionally placed IVs to the USGIVs.
Results: Preliminary data suggest the following: (1) USGIVs last until scheduled removal time or until patient discharge, (2) USGIV indwelling times are unaffected by measured variables, and (3) a USGIV negates the need for other types of IV access during hospitalization.
Conclusion: Preliminary findings suggest that USGIVs last as long as traditionally placed IVs and therefore should have the same removal policy. Results generalization is limited because this is a single-site study.
Background: Despite the increased safety and cost-effectiveness of prefilled syringes (PFS), some healthcare facilities continue to use self-filled syringes (SFS) to administer intravenous (IV) anesthetic agents. SFS have been associated with delayed administration, cross-contamination, mislabeling, potential inconsistent dilution, and wasted product. Failure to standardize PFS utilization for IV anesthetic medications can lead to safety and workflow conundrums. Interprofessional collaboration between anesthesiology and pharmacy services can eliminate barriers to PFS utilization, improving perioperative patient safety.
Methods: This quality improvement project used the Donabedian conceptual framework to demonstrate structure, process, and outcomes of proposed evidence-based practice (EBP) changes. A review of the literature identified gaps between current practice trends and EBP recommendations. PubMed, CINAHL, MEDLINE, and OVID were searched using the keywords prefilled syringes, self-filled syringes, single-use medication, and hospital medication and accreditation. Twelve articles were finally selected for applicability and relevance. The Joanna Briggs Level of Evidence grading system was utilized. The purpose of this EBP recommendation was to identify the accuracy and safety of prefilled, ready-to-use IV anesthesia medications vs SFS in the perioperative arena.
Results: PFS are readily available and result in reduced anesthesia-related medication errors, increased patient safety, and improved anesthesia workflow. Standardizing anesthesia practice patterns pertaining to PFS utilization is a cultural shift, but the patient safety benefits weigh heavily against any adversity to change anesthesia medication administration rituals.
Conclusion: Anesthesia providers administer a high number of high-alert medications without secondary verification. Interprofessional collaboration between anesthesiology and pharmacy services not only reduces adverse medication errors but also establishes a culture of interprofessional accountability, ultimately improving work efficiency and patient safety. The systematic review of literature offers evidence-based recommendations to adopt the Anesthesia Patient Safety Foundation (APSF) medication safety paradigm of standardization, technology, pharmacy/prefilled/premixed, and culture.
Background: Patients discharged from the intensive care unit (ICU) are at risk for short- and long-term effects related to their ICU stay. Effects include physical, cognitive, and emotional symptoms known as post-ICU syndrome (PICS). Family members of ICU patients are at risk for post-ICU family syndrome. These syndromes are common, and strategies to reduce risk factors, such as implementation of ICU diaries, should be employed. An evidence-based practice interprofessional ICU diary project was implemented in 2 ICUs. The project's effect on family satisfaction and rates of referral to an interprofessional, physician-run, post-ICU recovery clinic were studied.
Methods: Using the San Diego 8A's Evidence-Based Practice model, ICU staff nurses from two 12-bed ICUs in the same hospital system created, implemented, and measured outcomes for ICU diaries within their ICUs. The project started in June 2016 with education classes for staff nurses; physicians; respiratory care practitioners; and physical, occupational, and speech therapists. The classes provided background information for the project, inclusion criteria, and guidelines for use. Education for referrals to the clinic where patients are screened for PICS was also provided. Family satisfaction was measured using the validated Family Satisfaction with Care and Decision-Making in the ICU (FS-ICU) questionnaire.
Results: Family satisfaction scores increased 1.5% over 3 quarters. Referrals to the clinic increased 100% over 3 quarters.
Conclusion: ICU diaries may have contributed to an increase in family satisfaction scores. Feedback received from families was that diaries fostered feelings of compassion and caring from the staff. There was a significant increase in referrals to the clinic that was directly attributable to the diary program. Based on program success, the diary program and measurement tools are being implemented in all 7 of the hospital system's ICUs.
Background: Headache, a common complaint, accounts for approximately 4% of all patient visits to primary care clinics. Ninety percent of headaches are considered primary, for which costly diagnostics are unnecessary, and 10% are secondary headaches considered to have an underlying cause. This distinction can be challenging for primary care clinicians and especially for nurse practitioner (NP) students, as the severity of the headache does not provide clear differentiation. Integration of evidence-based practice (EBP) guidelines into clinical practice policies in primary care clinics will enhance differentiation between primary and secondary headaches, thus improving patient care.
Methods: The quality improvement project framework was the Institute for Healthcare Improvement's Plan-Do-Study-Act. Stakeholders were patients, clinicians, and NP students. The setting was an NP-owned primary care clinic with 3 NP clinicians who often precept NP students from 3 universities. The timeline was 1 semester: January 1, 2017 to May 1, 2017. The process measures included researching current EBP guidelines, selecting appropriate guidelines, obtaining approval, and integrating guidelines into the clinic's practice policies. Outcome measures included utilization of the Alberta Guideline for Primary Care Management of Headache and the associated treatment algorithm by clinicians, NP student review of the clinical policy during orientation, and clinician utilization of the algorithm for headache.
Results: As a result of this project, clinicians, including NP students, are incorporating guideline recommendations into workups for primary headaches, thus preventing unnecessary costs of laboratory tests and imaging, and clinicians are carefully evaluating for secondary headache. Importantly, implementation of this project facilitated the diagnosis of 3 patients with secondary headache: 1 with confirmed meningitis and 2 others with unruptured cerebral aneurysms requiring surgical interventions.
Conclusion: EBP guidelines, including the Alberta Guideline and algorithm referenced from this guideline, enhance clinical decision-making, are appropriate, and should be incorporated into management of primary care clinic patients with headache.
Background: Hemolysis in patients' samples has been shown to be a recurring problem during treatment in various types of facilities, including acute care facilities. It is imperative that there are specific, monitored guidelines to collect and submit blood samples to prevent errors that can affect patient care and to ensure quality laboratory testing. The aim of this project was to utilize a prescribed educational program for nurses regarding proper preanalytical procedures to decrease errors and increase accuracy of laboratory results.
Methods: This process improvement project occurred at an adult medical surgical unit (ages 18+) and involved nurses over a 6-month period. The nurses were observed during the preanalytical phase of laboratory collection, evaluated (pretest) to discover procedural shortcomings, educated on the standardized blood specimen collection process, and reevaluated (posttest) to ensure learning was successful.
Results: The hemolysis observations and survey data provided a baseline assessment of the learning needs (education) required for improvement and to gauge the nurses' current knowledge and standard practices. Over the 6-month period, the interventions (including education) resulted in a reduction of hemolysis rates (approximately 11.3%) in the unit compared to previous collection methods (through laboratory data).
Conclusion: The educational interventions improved specimen collection performed by nurses, resulting in a reduction of hemolysis rates within the medical surgical unit. Hemolysis can be reduced with gentle collection, use of minimal pressure, and ensuring the tourniquet is not left on >1 minute. To ensure quality laboratory sample collection and patient safety, hospitalwide procedures should be clearly written and education provided to nursing staff. However, continued monitoring and evaluations will be necessary to prevent stagnation or reverse learned knowledge, as well as educational resources including a yearly educational skill session.
Background: Current recommendations for pediatric providers are that all adolescents ages 12-18 years should be screened for depression annually; high-risk adolescents should be screened more frequently. High-risk adolescents are identified as minorities, being of low socioeconomic status, having a parent with a mental illness, or living in communities lacking access to behavioral health specialists. Nationally, <2% of adolescents are screened for depression. The research site where this quality improvement project took place only screens 27% of adolescents. Patients who have a history of depression or other behavioral health disorders should be screened at each visit. Depression among adolescents ages 12-18 years in the United States continues to rise, especially among high-risk adolescents. Suicide is the third leading cause of death, and depression is the leading cause of disability in the United States. Untreated or undertreated depression leads to poor cognitive and physical functioning, high-risk sexual behaviors, and substance abuse.
Methods: The quality improvement project utilized the Plan-Do-Study-Act framework to guide the process of increasing the use and frequency of depression screenings among high-risk adolescents. The screening tool is the Patient Health Questionnaire-9 modified for Adolescents (PHQ-9A). During the 3-month implementation, all adolescents will be given a PHQ-9A in their native language. Adolescents with a score ≥9 will be considered a positive screening.
Results: The screening rate increased from 27% to 96%. Twelve percent of adolescents screened positive for depression, and 11% were positive for suicidality. Seven percent of adolescents were positive for suicide but not for depression.
Conclusion: Reducing untreated depression and preventing adolescent suicide are the primary implications. Increasing patient-provider communication, education, and awareness regarding depression and suicide are secondary objectives. Further nursing research and guidelines are imperative in reducing this national epidemic.
Background: Enhancement of interprofessional care delivery has a direct effect on positive patient outcomes. Ensuring interprofessional care delivery in the perioperative setting requires multidisciplinary collaboration between all members of the surgical team, including personnel in the Sterile Processing Department (SPD). A multidisciplinary collaborative approach can improve relationships and communication between personnel which contributes to reducing errors and misunderstandings while increasing morale, productivity, and operations. Strategies include a team focus on improving interdepartmental communication, fostering teamwork and positive relationships, improving decontamination processes, reducing instrument set errors, and ensuring compliance with policies that are based on the most current evidence available. The purpose of this project was to improve efficiency and work quality in the SPD by focusing on perioperative team training and competency verification on a new instrument cleaning process.
Methods: In December 2016, a multidisciplinary team, including perioperative nurses, surgical technicians, and sterile processing personnel was formed. Using a huddle instrument, patient safety concerns about the SPD were evaluated. Using a Plan-Do-Study-Act methodology, changes were made to both sterile processing procedures and staff-related operational procedures.
Results: During the period from December 2016 to May 2017, the process changes included standardization of documentation, competency validation for all staff, improved work stations and instrument sets, revised instrument count sheets, and updated logs/forms. Changes to leadership, staffing restructuring, and staff communication also resulted. Project outcomes resulted in a reduction in SPD adverse events by 9%.
Conclusion: This multidisciplinary collaborative approach helped improve work stations, instrument sets, instrument count sheets, and communication. Optimizing outcomes of SPD processes through enhancement of interprofessional care delivery in the perioperative setting has improved work quality, work efficiency, communication, and positive patient outcomes by 9%.
Background: Increasing the opportunities for interprofessional education (IPE) among health profession student populations through team training and interprofessional learning has the potential to break the vicious cycle that leads to persistent team dysfunction.
Methods: This project was guided by the Salas framework, the Big Five of Teamwork. Educational pedagogies included a variety of shared didactic and clinical learning activities with an emphasis on experiential learning and application to actual clinical practice, including grand rounds, evolving case studies, high-fidelity simulation, student and faculty presentations, journal club, and online webinars that revolved around diverse populations and veterans with behavioral health disorders (BHDs) and their families.
Results: An evaluation was conducted on the extent to which IPE with a focus on caring for persons with BHDs was integrated into the curriculum. The Teamwork Training for Interprofessional Students (TTIPS) project director, project coordinator, grants project manager, and project statistician served as the evaluation team. Results were transferred to the TTIPS Excel spreadsheets and were analyzed, monitored, and trended by the project statistician. Paired t tests were used to compare the students' performance before and after training. We found that nurse anesthesia, medical, and allied health profession graduates significantly improved in all aspects of teamwork measurements (eg, team-based behaviors and shared mental model, P<0.00001) through the training by third-party evaluation, self-evaluation, or peer evaluation.
Conclusion: The TTIPS project contributed to the ability of nurse anesthesia, medical, and allied health profession graduates to assume practice roles upon graduation and enter into the professional workforce. The nurse anesthesia program faculty collaborated with the Schools of Medicine and Allied Health to integrate a sustainable IPE program into the curricula. In this manner, nurse anesthesia and other graduate healthcare students are equipped with the necessary knowledge, skills, and attitudes to provide patients with quality care during their clinical encounters.
Background: Deficits in memory performance are often nonspecific predictors of cognitive decline and may portend a future diagnosis of mild cognitive impairment (MCI).
Methods: This study had 2 aims: (1) identify participants who might have MCI and (2) evaluate how this subgroup of participants fared over the 24 months in this longitudinal randomized trial. MCI was defined as a subjective change in cognition, impairment in episodic memory, preservation of independence of functional abilities, and not demented. Participants were assigned to 12 hours of either memory or health training. The Senior WISE intervention was derived from Bandura's self-efficacy theory and provided a unique package of cognitive skill development. The memory-training intervention consisted of 4 components: stress inoculation, health promotion, memory self-efficacy, and memory strategy training. The control group received 18 hours of health training. Of the 263 total participants, 39 met the criteria for MCI. The sample was 79% females, 71% Caucasian, 17% Hispanic, and 12% African American with an average age of 75 years and an average education level of 13 years.
Results: There were 19 adults in the memory training and 20 in the health training conditions. Compared with the normal group, the MCI group was younger, was more likely to be African American, was more depressed, had lower MMSE and episodic memory scores, reported more memory complaints, and had lower scores of daily functioning. Over 24 months, the MCI group in the memory training condition showed better objective and subjective memory outcomes compared with the health training condition.
Conclusion: Memory training delivered in small groups was a robust mechanism to reduce the negative consequences of declining cognitive ability in persons with MCI and sustain the benefit over 2 years in both subjective and objective memory function.
Background: With the increasing number of obese, end-stage renal disease, and septic patients, traditional peripheral intravenous (PIV) placement is becoming more difficult for the bedside registered nurse (RN) which posits delays in blood draw, fluid resuscitation, and antibiotic therapy. In an effort to combat this problem, we implemented an ultrasound-guided PIV training program.
Methods: Standardized training for RNs included a 4-hour didactic and hands-on course in addition to 7 successful proctored attempts with a mandated 26-point criteria checkoff competency list observed by a trained instructor. The need for ultrasound placement PIV data was collected before training the RNs/EMTs. To document the objective need for ultrasound-placed IVs, data were collected over 1 month in our hospital with 37 requests for ultrasound-guided PIV placement. Once the objective need for ultrasound-guided PIVs was established with objective documentation, step-by-step efforts to help guide a successful ultrasound-guided PIV placement training course were established.
Results: Thirty-six bedside senior nurses/EMTs attended the didactic hands-on training portion over the course of 6 months, with 8 nurses/EMTs successfully completing the ultrasound training program. Twenty-two patients were collected after successful training completion. The average number of attempted PIV sticks before ultrasound was 2.7. The average number of attempted sticks with ultrasound was 1.2. These data show that nurses adequately trained with ultrasound to place PIVs have more success and cannulate with fewer attempts when compared to traditional placement.
Conclusion: Studies show that the success of ultrasound-guided IV cannulation is more likely in nurses who have more proctored attempts with the instructor. With the increasing need of ultrasound-guided access, it is imperative that proper training is instilled with providers to ensure patient safety and user accuracy.
Background: Renovations took place in the hospital to expand the emergency department. The purpose of this study was to examine the effects of noise reduction with an education intervention on the noise level, patient satisfaction scores, and stress levels of the clinical nurses using an experimental design with a preintervention and postintervention approach.
Methods: Subjects were randomly selected for the study. Baseline assessments included measuring the noise level at the doorways of patient rooms at consistent times. Nurses in the experimental group implemented interventions to decrease noise levels on the units. Patients in the experimental group used white noise generators and quiet kits. Nurses in the control group read an article on noise reduction. Nurses completed the Perceived Stress Scale (PSS) survey preintervention and postintervention. Patients were asked to complete the patient satisfaction survey at discharge.
Results: A Mann-Whitney U test was used to demonstrate a difference in the decibel readings of noise levels in the experimental vs control groups with a P value <0.05. There was a significant decrease in noise levels in the experimental group compared to the control group at the nurses' station; however, there was no difference in the noise levels away from the nurses' station. Perceived stress level scores decreased from the baseline assessment to the postassessment. Patient satisfaction scores did not change overall for the hospital.
Conclusion: As a result of the implementation of interventions to decrease noise levels during renovations, the stress levels of the nurses and noise levels on the nursing units were reduced over the 18-month period. Patients had an increased awareness of the quiet times during their hospital stay. Further research is necessary to develop other methods to promote quiet times and zones in the acute care settings.
Background: Pediatric and adolescent obesity has reached epidemic proportions. Pediatric obesity-related comorbidities can have lifelong effects on morbidity and mortality. With 1 of every 3 children in Louisiana affected, obesity is a major concern for healthcare providers in Louisiana. The AMA, CDC, HRSA, AAP, and ICSI strongly recommend screening overweight and obese children/adolescents for obesity-related comorbidities based on their risk factors and/or body mass index (BMI) percentile. This recommendation is not currently being implemented at a pediatric clinic in Kenner, LA. The purpose of this knowledge-to-action project was to assist providers in implementing the recommended ICSI evidence-based clinical practice guideline for the identification and assessment of overweight and obese children/adolescents.
Methods: Descriptive statistics were used to evaluate the adoption rates of the guideline. Data stratification was based on overweight and obese patients at the clinic.
Results: The overall adoption rate of the guideline was 91% at the end of the 8-week implementation period. The total number of overweight/obese patients seen during the 8-week period was 16%, with 5.2% classified as overweight and 9.9% as obese.
Conclusion: The ICSI guideline was easily adopted by nurse practitioners in a pediatric community clinic as evidenced by the benchmark of implementation being met at least 75% during the entire 8-week period. Using the ICSI guideline and algorithm provides practitioners an evidence-based tool to assist in decision-making regarding which screening labs to assess for comorbidities associated with pediatric obesity.
Background: Identifying factors surrounding nursing practice errors, also called nursing practice breakdown (NPB), supports a comprehensive, just pathway to error resolution and provides a proactive approach in assuring patient safety. NPB occurs across a continuum from minor incidents to reportable conduct. Categorizing similar types of NPB provides a mechanism to further examine the impact of the NPB. The aim of this study was to learn more about minor incidents in hospital settings.
Methods: Nursing peer-review committees in participating hospital settings reviewed NPB that was not board reportable and voluntarily used a confidential 44-item online instrument. The instrument captured data related to various characteristics thought to influence the NPB, including characteristics of the nurse and factors beyond the nurse's control. Names of patients and nurses were not used in the database. Each NPB was categorized into distinct groups, including clinical reasoning, intervention, prevention, professional responsibility, interpretation of provider orders, and attentiveness. The final sample consisted of 318 events collected from September 1, 2012 through August 31, 2016.
Results: Most employers retained the nurse involved in the NPB. A wide variety of remediation strategies were utilized including remediation and policy revision. The system factors and categories of NPB were analyzed. The results of the chi-square test of equal proportions showed that the categories of intervention and prevention had elevated rates of patient harm (P=0.0012 and 0.0005, respectively).
Conclusion: The NPB categories of prevention and intervention were associated with higher rates of patient harm than other NPB categories. Therefore, strategies to improve nursing practice in these areas warrant a closer examination. Generalization is limited due to a convenience sample with predominately urban hospitals participating voluntarily.
Background: Effective clinical practice requires the acquisition and utilization of knowledge, judgment, and high-quality decision-making that is based on research evidence. Evidence-based practice (EBP) allows clinicians to utilize evidence that has been synthesized from research studies and developed into clinical practice guidelines (CPGs). CPGs are important in providing quality healthcare and achieving excellent patient outcomes. The National Guideline Clearinghouse provides health professionals access to more than 10,000 clinical guidelines. CPGs have increasingly played a significant role in the practice of medicine in the United States and abroad. Hence, healthcare providers should consider the quality of the CPGs being utilized in clinical practice. The purpose of this knowledge-to-action (KTA) project was to provide student and clinical practitioners, with limited formal research skills, the ability to appraise CPGs utilizing an uncomplicated approach to appraisal, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) appraisal method.
Methods: Two clinicians independently reviewed the GRADE Appraisal Tool for practicality of use. Three CPGs were evaluated to determine their quality. After the clinicians' review, the GRADE method was introduced to nurse practitioner (NP) students in the classroom setting. Students were then given the same 3 CPGs to evaluate.
Results: The GRADE Appraisal Tool was identified as a comprehensible tool for clinicians and students with limited research experience to assist in the incorporation of EBP in practice. The tool allowed the reviewers and NP students to appraise and rate the quality of CPGs and determine the credibility, clinical significance, and applicability of the guideline.
Conclusion: The recommendation of this KTA project is that NP students and clinicians utilize the GRADE method as a standard approach to the appraisal of CPGs to evaluate and determine the quality of the guideline. All guidelines appraised by nonresearchers should be conducted with the GRADE appraisal method.
Background: Transition to practice (TTP) is a challenging period for new nurses and is associated with high turnover rates. TTP programs offer many benefits, but limited TTP programs exist in long-term care (LTC) settings. A literature review of TTP in LTC identified recommendations, including the need to support nurses in transition to LTC settings and a call to establish education, regulation, and practice partnerships to maximize resources in providing support. The purpose of this quality improvement (QI) project was to establish a multientity partnership to develop and pilot a 3-day training program aimed at supporting the newly employed nurses in LTC settings in Texas. This QI project aimed to increase the intent to stay and self-efficacy of nurses. The training comprises 8 expert-reviewed modules.
Methods: After a needs assessment was conducted, a steering committee was created representing education, practice, and government settings. The steering committee generated content for the TTP training program. The structure of the program, process delivery, and evaluation of outcomes were based on both the Donabedian framework and the Tyler Curriculum Model. Outcome measures were geriatric nursing self-efficacy (GNSE), intent to stay pre-post training, and evaluation of learning objectives. Process measures were to establish a panel to review and rate the modules, to use valid instruments for GNSE and intent to stay, and to obtain certified nurse educators for the training.
Results: Stakeholders provided systematic input during monthly meetings and emails. One hundred percent of the program content was reviewed and rated by the panel. A dry run was conducted before the pilot. No significant differences were found in pre-post self-efficacy and intent to stay (N=10).
Conclusion: The Texas HHS and UT Center for Excellence in LTC partnered to develop a novel training program for nurses new to LTC. The pilot phases of the QI project yielded data to aid in process improvement. Texas HHS will begin implementing this training in October.
Background: The purpose of this project was to develop and provide junior and senior prelicensure nursing students with disaster-focused, high-fidelity (HF) simulation scenarios prevalent in the Gulf Coast region. The aim of the HF disaster scenarios was to increase exposure to disaster situations without the risk of harm to students, faculty, or patients. Disaster training is not typically part of prelicensure education. Faculty at a large, metropolitan New Orleans school of nursing recognized this gap. The need arose for prelicensure nursing students to have access to a safe, experiential learning environment to improve their overall disaster and emergency preparedness before entering practice. HF simulation provided the disaster training.
Methods: Approval was obtained through the Health Science Center's institutional review board. Using a pretest/posttest design, the project was implemented during the fall and spring semesters of academic year (AY) 2016-2017 and continues into the fall and spring semesters of AY 2017-2018. Following informed consent, junior and senior level students participated in a Gulf Coast HF disaster scenario. Study components included a disaster knowledge pretest, prebriefing, HF disaster scenario, debriefing, and posttest.
Results: Preliminary results revealed an increase in each of the scores following participation in the HF simulation at every student level. The junior students' (n=142) posttest scores increased by 15.7%, and the senior students' (n=144) posttest scores increased by 31%.
Conclusion: The disaster scenarios provided junior and senior prelicensure students exposure to regional-specific disasters. The conclusion can be drawn that junior and senior level nursing students responded positively to HF disaster training through improvements in disaster knowledge.