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  • Publication
    Decreasing Continuous 1:1 Observation of Patients Experiencing Delirium by Improving Nursing Knowledge
    (2020-12-15) Frankel, Sunne E
    Abstract BACKGROUND: Nursing leadership identified that Certified Nursing Assistants (CNAs) and Registered Nurses (RNs) on the Acute Care for Elders (ACE) unit lacked delirium knowledge. Patients were being placed on continuous 1:1 observation without proper delirium assessment which the CNO identified as an opportunity to improve resource utilization. METHODS: A quality improvement project was conducted on the ACE unit at Penn Presbyterian Medical Center (PPMC). The CNAs and RNs completed a delirium knowledge survey prior to and after viewing an evidence-based dynamic education module based on the Hospital Elder Life Program (HELP) protocols. Pre- and post-survey mean scores were compared. Continuous 1:1 observation utilization was analyzed two months prior to and two months post-implementation to determine if the education impacted continuous 1:1 observation utilization. RESULTS: 17 CNAs and 34 RNs completed the pre-survey. Mean pre-survey scores were: 11.76 (sd 1.92, range 7-15) for the CNAs and 13.5 (sd 2.11, range 9-17) for the RNs. Ten CNAs and 20 RNs completed the post-survey. The post-survey mean scores were: 13.5 (sd 2.68, range 9-16) for the CNAs and 14.7 (sd 1.76, range 11-18) for the RNs. Bi-weekly continuous 1:1 utilization decreased from 5.0 to 3.4 after implementation of the evidence-based dynamic education module. CONCLUSION: Evidence based education on delirium prevention, identification, and interventions using the HELP protocols can improve CNA and RN knowledge and help reduce the financial strain on the health system by decreasing continuous 1:1 observation utilization.
  • Publication
    Implementing and Evaluating a Sepsis Algorithm to Mitigate Acute Care Readmissions in an Inpatient Rehabilitation Facility
    (2020-12-28) Lockett, Michelle L
    BACKGROUND: Readmissions from post-acute care to acute care hospitals is well documented in the literature. Inadequate management of infection is a top readmission diagnosis and is often preventable. Nurse driven, protocolized treatment is the gold standard for treating sepsis patients in post and acute care settings. A quality improvement (QI) project was implemented in a 58-bed inpatient rehabilitation facility (IRF) to determine if a nurse-driven sepsis algorithm would decrease readmission rates to acute care hospitals, increase nursing staff sepsis knowledge, clinical confidence and communication. METHODS: This QI project was performed during a 3-month period in 2020. Readmission findings were compared before and after the study intervention implementation. Changes overtime in sepsis frequency were assessed through run charts. Pre- and post- survey data of sepsis knowledge, clinical confidence caring for a sepsis patient and care provider and clinician communication was assessed using a Wilcoxon Signed Rank Test. INTERVENTION: By utilizing the Systemic Inflammatory Response (SIRs) criteria, the Situation, Background, Assessment and Recommendation (SBAR) tool and Surviving Sepsis Campaign guidelines, a nurse driven sepsis algorithm was created and implemented in the rehabilitation facility. Additionally, pre-and post-surveys were administered to assess nurses’ knowledge of sepsis, clinical confidence in caring for a patient with suspected sepsis and bedside clinician to provider communication. RESULTS: Results show a decrease in readmissions to acute care hospitals post intervention but no statistically significant change in pre-post survey of sepsis knowledge, confidence or communication. CONCLUSIONS: An additional PDSA cycle of this QI project is needed to determine a true sepsis decrease overtime using the sepsis algorithm. A sepsis pre and post-test, and role play simulations may be key to a change in sepsis knowledge, confidence and communication. Keywords: inpatient rehabilitation facility, IRF, readmissions, sepsis, infection, surviving sepsis campaign, algorithm
  • Publication
    Pressure Injury Prevention in Cardiac Surgery Using Risk Factor Assessment and Standardization
    (2021-08-05) Madeira, Timothy H
    Cardiac surgical patients are more susceptible to pressure injury (PI) than other surgical specialties, and little is known about PI prevention (PIP) in this population. How do PIP strategies, compared to standard care, affect the incidence of PI during the post-operative recovery among adult cardiac surgery patients? The aim was to reduce the incidence of UAPI in an adult CVSICU by 5% in six weeks. The conceptual framework chosen was The Iowa Model Revised, and the theoretical framework employed was the Theoretical Model for Lesion Development. Quality improvement, single-group pretest-posttest design. Sample consisted of 69 cardiac surgery, LVAD, ECMO patients at Johns Hopkins CVSICU. The intervention was a standardized PIP bundle provided to “highest risk” patients screened before surgery. Outcome measures were UAPI count and incidence rates. Process measures were percentage of patients screened, prophylactic sacral dressing, rental bed cost. Balancing measures were PI severity, anatomic location, and time between wounds. Baseline data consisted of historic data and intervention data consisted of weekly survey observations. Implementation consisted of staff education, daily preoperative screening, weekly wound rounds. 33% of patients screened as “highest risk” and received the PIP bundle. PI count decreased from 25 to 13 during implementation and wound stages improved. Chi Square test of 2-proportions showed a reduced PI incidence of 8.56% (Z=1.66, p= .048) and 2-sample Poisson rate showed significance in count (Z=1.95, p=.036). Location changed to nose, buttocks, and occipital locations. There was an overall cost savings of $78,660. Reducing PI lead to reduced morbidity and cost.
  • Publication
    The Impact of a Preoperative Screening Tool for Adults Ages 40 and older on Surgical Cancellations: A Quality Improvement Project
    (2021-07-20) Bole, Colleen B; Herron, Emilsy S; Sweeney, Allison J
    Patients ages 40 and older are at increased risk for postoperative complications but are often under-optimized preoperatively due to a lack of proper screening tools. The clinical question for this project was: In patients ages forty and older undergoing elective Otolaryngology (ENT) procedures, how does the use of a preoperative risk assessment tool compared to standard preoperative care influence the rate of same-day surgical case cancellations due to improper preoperative optimization? A pre- and post-implementation design was conducted at an academic medical center with ENT surgical cases. The primary outcome was the rate of same-day anesthesia-led cancellations. Eligible cases included patients forty and older undergoing elective procedures scheduled at least five days prior to surgery. The National Institute for Health and Care Excellence (NICE) tool was implemented preoperatively as patients were assessed by the team leaders. NICE tool recommendations were documented and reviewed by a Certified Registered Nurse Anesthetist (CRNA). The CRNA forwarded the recommendations to the ENT service. Data was collected for five weeks pre-implementation (n=107) and four weeks post-implementation of the NICE tool (n=109) to determine if cases were cancelled. Pre-implementation same-day anesthesia-led cancellation rate was 4.67%; post-implementation, the same-day anesthesia-led cancellation rate was 8.4%. Cancellations had no association with NICE tool implementation (χ2(1) = 1.144, p = 0.285).
  • Publication
    The Individualized Multidisciplinary Immediate Fall Response Program
    (2021-07-20) Awotundun, Adenike Y
    Abstract Falls are frequent in older residents in the United States. 800,000 falls occur yearly, one in three residents will fall again within a year (Agency for Healthcare Research and Quality [AHRQ], 2017). In Frey Village, about 25 falls occur monthly with annual fall-injuries of 1.9%. This project focused on the Individualized Multidisciplinary Immediate Fall Response Program (IMIFRP). PICOT Question: In the older adults in a long-term facility (P), does an implementation of the individualized multidisciplinary immediate fall response program (I), improve fall care processes, and reduce fall rate (O) within 2-months post-intervention (T), compared to 2-months pre-intervention (C)? Conceptual and Theoretical Model: The IHI Plan-Do-Study-Act cycle was the conceptual framework that directed IMIFRP. The Theory of Bureaucratic Caring reinforced the impacts of providing quality, ethical, legal, and compassionate care. Methods: This pre/post-design quality improvement project included residents in long-term units, ³ 65 years. The IMIFRP was initiated with each fall. Project outcomes: usage of the IMIFRP form ([TRIPS]— Tracking Record for Improving Patient Safety) for falls data documentation, number of falls and repeated falls. Data were analyzed, using descriptive statistics, and run chart. Result: Fall rate reduced from 41 falls pre-intervention to 30 falls during the intervention. 27% reduced fall rate, 90% compliance rate in utilization of the TRIPS form and creation of a fall management team. Conclusion: The IMIFRP was well supported by the stakeholders and the IMIFRP led to development of a multidisciplinary fall committee.
  • Publication
    Fall Prevention and Injury Reduction Utilizing Virtual Sitters in Hospitalized Patients
    (2020-12-08) Quigley, Beth
    Falls and fall-related injuries occur far too often in hospitals every year. The goal of the quality improvement (QI) project reported here was to reduce the number of falls and fall injuries in hospitalized patients using virtual sitters and continuous video monitoring (CVM) cost effectively. Run charts portray data trends for fall rates and fall related injury rates at the inpatient care facility in two-week increments over a six-month period. Descriptive statistics were collected to characterize the sample and setting, and differentiate components of the falls, falls with injuries and related costs. The literature review noted positive outcomes regarding both cost savings and reduction in fall rates with the launch of virtual sitters. The QI project with the implementation of CVM with virtual sitters depicted a 14% decline in fall rates and a 6% decrease in fall-related injury rates with a cost savings to the hospital. Plans for expansion of the program were underway with integration into the electronic health record. As modalities such as CVM with virtual sitters are adopted by more institutions, additional at-risk patients will be monitored for fall prevention and additional uses continue to prevail. Fall prevention and injury reduction remain at the forefront of quality care, keeping patients safe.
  • Publication
    Patient Experience with Provider-Patient Communication in CenteringPregnancy® Compared to Traditional Prenatal Care: A Program Evaluation
    (2020-11-23) Reale, Barbara
    Background: CenteringPregnancy group prenatal care has been demonstrated to improve patient satisfaction and patient experience. (Ickovics, 2019). Patient experience is one aspect of patient satisfaction; it relates to patient perceptions of respect and involvement in decision-making that bestows a sense of agency and autonomy upon the individual. Objective: To evaluate a newly implemented CenteringPregnancy program and compare outcomes with traditional prenatal care in the same institution, in terms of patient experience of respect, agency and autonomy. Design: Evidence-based program evaluation, descriptive study with analysis. Setting: Patients who had received group prenatal care or traditional prenatal care at an urban academic hospital between May 2019 and May 2020. Patients: All patients registered in CenteringPregnancy group prenatal care were recruited. Patients who were registered for traditional prenatal care and were of similar risk status and gestation, were recruited from the same clinic during the same period. Measurements: The author developed a survey that collected demographic data, and responses to closed-ended items from two reliable and validated surveys, the Mothers Autonomy in Decision Making (MADM) scale (Vedam, Stoll, Martin, et al., 2017a) and the Mothers on Respect (MOR) index (Vedam, Stoll, Rubaskin, et al., 2017b). Demographic data was reported by group. Surveys used Likert scales and results were scored, totaled and analyzed for each survey and each group. Results: One hundred and six CenteringPregnancy patients were recruited and a similar number from traditional prenatal care. Sixty-nine respondents with completed survey responses were included in the program evaluation. The CenteringPregnancy group had 38 respondents and the traditional prenatal care group had 31. Pearson Chi Square tests were performed, and groups were similar in all categories: ethnicity (p = 0.834), age (p = 0.735), race (p = 0.613), parity (p = 0.076). There were no significant differences between groups for the MADM scale, (p = 0.244) or the MOR index, (p = 0.156). Limitations: This was a program evaluation and the sample size was limited by the number of patients registered in the newly implemented program. The sample may not have represented all patients and all patient experiences being measured. Subjects were self-selected resulting in potential selection bias. Self-reporting allowed for errors in assignment to groups. The facilitators of group prenatal care may have lacked sufficient experience to conduct prenatal sessions with fidelity to the model of CenteringPregnancy care. Conclusions: This program evaluation demonstrated that CenteringPregnancy patients experienced high levels of autonomy and respect in patient experience, similar to the traditional prenatal care group. There were no significant differences in outcomes for the MADM and MOR surveys.
  • Publication
    Intravenous Magnesium Sulfate Use in Hip Arthroscopy Patients and Anesthesia Provider Satisfaction with Patient Care at an Ambulatory Surgery Center
    (2021-06-28) Song, Naomi; Yi, Erica; Bagley, Julianne
    Hip arthroscopy patients experience high levels of postoperative pain. Intravenous (IV) magnesium sulfate is widely used in anesthesia practice as a multimodal analgesic but is infrequently utilized at Penn Presbyterian Medical Center (PPMC). Does the option of adding intravenous magnesium sulfate to the current pain pathway increase provider satisfaction with patient care and magnesium use? The purpose was to add IV magnesium sulfate to the multimodal analgesic pathway for hip arthroscopy patients to evaluate anesthesia provider satisfaction and use of IV magnesium sulfate. The Middle Range Theory of Acute Pain was used to provide a theoretical framework. The conceptual framework utilized was the Plan-Do-Study-Act cycle. Anesthesia providers were refamiliarized with IV magnesium sulfate's analgesic properties to encourage its administration in hip arthroscopy procedures yielding high levels of postoperative pain. A survey was distributed to assess provider satisfaction using the Accessibility of Intervention Measure (AIM) and magnesium use. Frequency counts were used to determine provider satisfaction with patient care and a run-chart was created to analyze changes in IV magnesium sulfate usage before and after implementation. Compared to the pre-implementation phase, there was an 85.7% increase in IV magnesium use among anesthesia providers. Over 12 weeks, ten CRNAs participated in a total of fourteen hip arthroscopy cases. Nine out of ten providers would consider using magnesium in future practice. The project served to re-introduce IV magnesium sulfate as an analgesic adjunct for many surgical procedures and hoped to promote a culture that utilizes IV magnesium sulfate readily.
  • Publication
    Airway Fire Prevention in the Operating Room
    (2020-12-07) Patel, Dipika; Smith, Kendall; Woodmansee, Scott
    Airway fires during surgical procedures are preventable events that result in devastating outcomes for patients, healthcare providers, and healthcare facilities. Minimization of the risk of fires is a subsection of Standard 6 of the American Association of Nurse Anesthetists’ Standards for Nurse Anesthesia Practice. A central priority of operating room fire mitigation is the minimized use of oxidizing agents. Oxygen is one component of the fire triad responsible for increasing the likelihood of these events, which is controlled by anesthesia providers in the operating room. The primary aim of this quality improvement project was to increase anesthesia provider knowledge pertaining to airway fire risk mitigation strategies through the implementation of an evidenced-based educational intervention. The secondary aim of this quality improvement project was to demonstrate a quantitative reduction of airway fire risk through a comparison of pre-intervention and post-intervention supplemental oxygen administration levels during surgical procedures. The overall goal of this project was to highlight the value of optimized provider knowledge regarding airway fire risk mitigation techniques, especially among high-risk airway fire procedures.
  • Publication
    Preoperative Warming for Inadvertent Perioperative Hypothermia
    (2020-01-01) Zamarelli, Danielle; Yim, Tabitha; Hazan, Einbar
    Inadvertent perioperative hypothermia (IPH) is a significant contributor to adverse patient outcomes, and ultimately translates to increased hospital expenditures. Evidence strongly supports the efficacy of prewarming surgical patients to reduce risk of IPH. While various surgical facilities have successfully implemented different methods of warming to reduce the frequency of IPH at their respective sites, the Veterans Affairs Medical Center (VAMC) does not currently have a standardized protocol for prewarming. With input and discussion from site stakeholders and project leaders, the authors developed a data collection tool to record temperatures at five pre/intra/postoperative intervals in 30 patients undergoing robotic procedures. The intervention was a minimum of 10 minutes of forced-air warming prior to surgery. More than half the patients (63%) experienced IPH. These findings suggest that IPH occurrence in a modest-sized patient group exposed to prewarming is not different than the national occurrence of IPH when compared to the national IPH frequency.