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PublicationImplementing and Evaluating a Sepsis Algorithm to Mitigate Acute Care Readmissions in an Inpatient Rehabilitation Facility(2020-12-28) Lockett, Michelle L; Lockett, Michelle LBACKGROUND: 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 PublicationFall Prevention and Injury Reduction Utilizing Virtual Sitters in Hospitalized Patients(2020-12-08) Quigley, Beth; Quigley, BethFalls 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. PublicationIntravenous Magnesium Sulfate Use in Hip Arthroscopy Patients and Anesthesia Provider Satisfaction with Patient Care at an Ambulatory Surgery Center(2021-06-28) Song, Naomi; Song, Naomi; Yi, Erica; Bagley, JulianneHip 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. PublicationPreoperative Warming for Inadvertent Perioperative Hypothermia(2020-01-01) Zamarelli, Danielle; Yim, Tabitha; Hazan, EinbarInadvertent 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. PublicationAssociation of Clinical Timing with Self-Efficacy Among Student Registered Nurse Anesthetists(2021-05-01) Le Dang, Diana; Vacca, Kevin; Carrillo, Emily; Le Dang, Diana; Vacca, Kevin; Carrillo, EmilyObjectives: To uncover new findings on how best to implement education and training among students in nurse anesthesia programs. Design and Methods: The target participants are nurse anesthesia students currently enrolled in an accredited Doctor of Nursing Practice (DNP) program that met inclusion criteria. An online survey was distributed to measure self-efficacy using the 10-item Likert-style Schwarzer & Jerusalem General Self-Efficacy Scale. Participants were recruited from a convenience sample of 72 Council of Accreditation (COA) accredited nurse anesthesia programs. Contact was made with program leadership to obtain permission and facilitate the dissemination of the surveys. Inclusion criteria: enrolled in accredited DNP program, integrative or non-integrative curriculum as defined by the study and expected graduation date within 12 months. Sample size, n=847 senior nurse anesthesia students. Independent variable: curriculum structure (integrative or non-integrative). Dependent variable: composite score on General Self-Efficacy Scale, ranging from 10-40. Primary Results: Mean composite scores on the GSE survey were (33.37 ± 3.23) and (33.91 ± 3.52) for integrative and non-integrative programs, respectively. The mean composite score for participants in a non-integrative curriculum was 0.54 (95% CI, -1.69 to 0.60) higher than mean composite score for participants in an integrative curriculum. The independent samples t-test concludes that there was not a statistically significant difference in the mean composite scores between participants in an integrative and non-integrative curriculum t (138) = -0.940, p = 0.35, d= 3.40. Principle Conclusions: There is no statistically significant difference between the reported self-efficacy scores among students in both integrative and non-integrative curriculum. PublicationReducing Unplanned Extubations in the Pediatric Intensive Care Unit(2020-01-22) Torres, Sherman J; Palma, Carmela; Mongiello, Michael; Torres, Sherman J; Palma, Carmela; Mongiello, Michael PublicationThe Use of Liposomal Bupivacaine in Interscalene Nerve Blocks(2021-07-05) Begley, Kirby; Aboff, Alyssa; Nasritdinova, Dilnoza; Begley, Kirby; Aboff, Alyssa; Nasritdinova, DilnozaThis paper outlines an educational research project at an urban hospital concerning the standardization of the use of liposomal bupivacaine (LB) for an interscalene block (ISB). The PICOT question guiding this project was: In adult surgical patients (P), how does the use of LB for shoulder peripheral nerve blocks, (I) compared to the administration of plain bupivacaine (PB) for shoulder peripheral nerve blocks, (C) affect postoperative pain scores (O) within 48 hours after surgery (T)? Using the numerical rating scale (NRS) for pain, a validated and reliable tool, patients who received LB had their 48-hour pain scores measured and compared to those patients who received PB. Satisfaction scores at 48 hours, a secondary project outcome, were assessed using a single question with a response scale of agree very much – disagree very much. Data was collected over a period of four weeks in those who were appropriate for the project. Data was collected by telephone and recorded on a data collection tool. Both PB and LB had the same mean immediate postoperative pain score (mean = 0.57), however, the mean 48-hour postoperative pain score was lower for those who received LB (mean = 3.29) compared to those who received PB (mean = 6.86). Patients who received LB were more satisfied with their anesthetic care (100% agree very much) compared to those who received PB (57.14% agree very much). From this data, it was concluded that LB provides a superior postoperative analgesic and surgical experience in comparison to PB. PublicationMeasuring Nurses’ Graph Literacy(2020-01-01) Villalba, Cyd CharisseIncreasingly, healthcare data used in nursing practice is visualized using graphs. However, studies show that low graph literacy is found in significant numbers in both the general population and in nurses. Even so, the concept of graph literacy is relatively unknown within healthcare and measuring baseline graph literacy isn’t standardized. The 4-item GLS questionnaire is a brief, validated, healthcare-domain-specific scale developed by Galesic and Garcia-Retamero (2011), and assesses graph literacy by measuring comprehension of four frequently used graphs (simple pie, bar and line charts and icon array). Along with measuring baseline graph literacy, a video tutorial reviewing the four graphs and a re-designed graph used to test usability and utility were implemented to better understand and enhance graph comprehension in recently onboarded, entry-level, hospital nurses. The self-selecting, small sample size garnered enough data to run non-parametric tests, and although there were no statistically significant findings in tests for differences or correlations, measuring baseline graph literacy and identifying ways to enhance graph comprehension remain clinically significant. The qualitative and quantitative analysis challenged assumptions and will inform future graph literacy studies in hospital nurses. PublicationDoes Administration Timing of Ondansetron, a 5-HT3 Receptor Antagonist, Affect Inhibition of the Bezold-Jarisch Reflex in OB C-section Patients Receiving Spinal Anesthesia(2021-08-03) Zaharie, Spenser; Rowley, Matthew; Zaharie, Spenser; Rowley, MatthewOndansetron (a 5HT-3 receptor antagonist) has been shown in multiple randomized controlled trials (RCT’s) and meta-analysis to inhibit activation of Bezold-Jarisch Reflex (BJR) in response to spinal anesthesia for elective cesarean section patients. Studies have not determined whether the timing of administration changes the inhibitory affect of ondansetron in this patient population. This project addressed the following question: Does administration timing of Ondansetron, a 5-HT3 receptor antagonist, affect inhibition of the Bezold-Jarisch Reflex in obstetric cesarean section patients receiving spinal anesthesia? De-identified aggregated electronic medical record data for a one-year period was obtained. Data was grouped by ondansetron administration timing prior to spinal administration: ≤ 15 minutes (G1), > 15 minutes and ≤ 30 minutes (G2), > 30 minutes (G3). Blood Pressure (BP) data, including systolic, diastolic and mean arterial pressure (MAP), was included for four time points: pre spinal, 5-, 15- and 30-minutes post spinal. Change in BP from baseline were used for analysis. Total vasopressor usage was also included for analysis. Sixty-six obstetric cases were included, (G1 n=24), (G2 n=24) and (G3 n=18). Data was analyzed using the one-way ANOVA test for BP change scores and the Kruskal-Wallis for evaluating vasopressor use. No statistical significance between groups was found in BP change scores or vasopressor use. However, G3 did show greater drops in BP and increased vasopressor usage compared to G2 and G1. Further evaluation is recommended through either a large-scale retrospective study or randomized control trial (RCT). PublicationImplementing an Enhanced Recovery After Breast Surgery Protocol to Reduce Opioid Use(2020-12-22) MacDonald, Kendall S; Reynolds, Kelsey D; MacDonald, Kendall S; Reynolds, Kelsey DPatients undergoing breast surgery are at risk of developing persistent post-operative pain and prolonged opioid use. Most patients who receive breast surgery do not have chronic pain pre-operatively, but up to 60 percent will experience chronic pain post-operatively. AtlantiCare Medical Center made opioid minimization a top priority in the institution and has openly adopted Enhanced Recovery After Surgery (ERAS) protocols for other surgical specialties. After performing a systematic literature review, an ERAS protocol for breast surgery patients was developed for use in a quality improvement project. Patients selected included those undergoing unilateral or bilateral mastectomy and/or, staged reconstruction surgery. The protocol was implemented via an electronic application utilized by the Anesthesia Department for ERAS anesthesia techniques. Key aspects of the protocol were broken down into pre-operative, intra-operative and post-operative aspects. Preoperatively, Acetaminophen and Gabapentin were administered. Intraoperatively, pectoralis blocks were performed by anesthesia, administration of long-acting opioids were minimized, and adequate prevention of post-operative nausea and vomiting (PONV) were utilized. Post-operatively, patients were encouraged early oral intake and reduced use of opioid for pain control. Total morphine milliequivalents (MMEs) during anesthesia care were analyzed pre- and post-protocol implementation via deidentified medication administration reports. Patients of similar American Society of Anesthesiologists (ASA) status, weight and surgical procedure were compared to provide consistent analysis between pre-intervention and post-intervention groups.