Podium and poster presentations from RRH Nursing Research and Evidence-Based Practice Day.
Held on September 30, 2022 at the College of Health Careers.
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Assessing Primary Care RNs Impact on Quality Patient Care
Elizabeth Carreira
The purpose of this work was to examine how a large multi-site primary care based organization established an organizational structure that supported the determination, definition, measurement, and reporting of nursing sensitive indicators (NSIs) specific to ambulatory care nursing. NSIs capture the value of care provided by nurses and are a critical component of ANCC Magnet designation. The organization considered that successful pursuit of Magnet designation in an all ambulatory organization would involve establishing a framework to report NSIs that included defining nursing units and NSIs meaningful to the organization.
A multidisciplinary team led by nursing was established to examine and identify the most meaningful metrics to collect and measure. A review of the Ambulatory Care Nurse-Sensitive Indicator Industry Report: Meaningful Measurement of Nursing in the Ambulatory Patient Care Environment and Healthcare Effectiveness Data and Information Set (HEDIS) measures was conducted, and meaningful NSIs were selected. Additionally, the team worked to establish an organizational structure for NSI reporting that organized practice locations into units accounting for geography and specialty, which supported Magnet requirements for data reporting.
An electronic dashboard was built to monitor the selected NSIs for each defined unit as compared to established benchmarks. This allowed the organization to target improvements by location, monitor the results of improvement initiatives, and establish their eligibility to achieve Magnet designation. Through establishing a means to measure and benchmark NSIs meaningful in ambulatory care, the organization is well-positioned to drive improvements and pursue Magnet designation.
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Immune-Related Adverse Event Management for Oncology Patients
Mary Beth Casselbury, Lori Davis, and Sharon Wilson
Rapid advances in cancer immunotherapy using Immune Checkpoint Inhibitors have led to significantly improved survival of patients. Immunotherapy is also associated with multiple immune-related adverse events (irAE’s). The purpose of this research is to determine if reinforced patient education regarding early recognition/management of side effects/adverse events decreases serious immune-related events. It is hypothesized that utilizing a patient education plan may determine if these interventions can manage immune-related adverse events and thereby decrease the severity of these events.
Our team reviewed literature addressing follow-up care for Oncology patients receiving Immunotherapy. To promote efficient management of immune-related adverse events several major oncology organizations (including Oncology Nursing Society) have published guidelines for diagnosis, grading, treatment and care of patients receiving immunotherapy. However, follow-up care has not been systematically studied.
The results of the literature discussed the importance of patient education, early detection and reporting of side effects as well as continued surveillance after completion of treatment to detect delayed toxicities. From the literature reviewed, it is concluded that early patient reporting of side effects/adverse events demonstrates an increase in resolution and improved management of adverse events during treatment with immunotherapy. However, further studies need to be conducted. The implications of the research inspired our team to pursue development of comprehensive immunotherapy guidelines for telephone triage.
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The Resurgence of Clinical Nurse Specialist Practice in New York State
Elizabeth Duxbury
BACKGROUND: Clinical Nurse Specialist (CNS) practice in New York State (NYS) is not at full scope of practice according to the National Association of Clinical Nurse Specialists (NACNS) Conceptual Model (NACNS, 2019).
METHODS: This legislative evaluation and policy analysis of NYS Education Law Article 139, Nursing §6911 Certification as a clinical nurse specialist was the first step toward making recommendations to update the law (NYS Office of the Professions, 2018). The Eightfold Path Guide was used as a framework for legislative evaluation and policy analysis. A convenience sample of CNSs in NYS was used for input and feedback on the policy brief to present to NACNS.
INTERVENTIONS: Initial data on current practice was collected using an online survey. The Initial NYS CNS Practice Survey results were used to guide discussions related to the current practice in an online focus group. The focus group identified objective concepts for the policy brief. A second online survey was used to validate the concepts in the policy brief.
RESULTS: The results of the Initial NYS CNS Practice Survey, focus group, and second survey all recommended changes to the NYS law governing CNSs. The policy brief will be presented to NACNS to gain support for legislative changes to achieve full scope of practice for CNSs as APRNs in NYS.
CONCLUSIONS: This project has re-invigorated the CNSs in NYS to advocate for full scope of practice. This project brings forward the voice of the NYS CNSs through this policy brief to expand scope of practice within the state.
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Utilizing Distraction Therapy and Parental Presence to Decrease Fear and Anxiety in Pediatric Surgical Patients and their Family
Maxine Fearrington and MaryJane Sage
Research Question: The purpose of this study was to explore distraction and parental presence preoperatively, intraoperatively, and postoperatively, and their effect on fear and anxiety in children and parent.
Hypothesis: It was hypothesized that children who utilize distraction and have parental presence throughout the perioperative process will experience less fear and anxiety as measured by the Fear, Anxiety and Stress Tool (FAS).
Methods: To test the hypothesis, a quasi-experimental study was utilized. The intervention group was provided a tablet pre-loaded with age-appropriate games and the parent was provided a disposable jumpsuit, head and foot covers, and allowed to accompany the child into the operating room until induction of anesthesia, and was also allowed into the PACU as soon as it was deemed safe by the nurse.
Results and Conclusion: The target number of 50 in each group was not reached; there were 37 in the intervention and 20 in the control groups. Using a two-sided Wilcoxon test, no difference was found between groups on the FAS scale; however the intervention group was trending towards statistical significance. Parental surveys indicated parents were very satisfied with being allowed to accompany their child into the operating room.
Implications: The study was terminated prematurely due to lack of continued support from anesthesia for parental presence. It is believed that with continued support and greater numbers, we would have reached statistical significance.
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Development and Implementation of an Ambulatory Nursing Shared Governance Council
Patricia K. Fioravanti and Maria Larner
The purpose of this work was to research, develop, and implement an ambulatory nursing shared governance council (ANSGC) to support the pursuit of Magnet designation within the Primary Care and Specialty Institute (PCASI) ambulatory care nursing environment at Rochester Regional Health. PCASI is comprised of over 115 practices located throughout 8 counties. Literature supports shared governance as a mechanism to increase nurse engagement, nurse retention, improve patient outcomes and promotes partnership between front line nurses and administration. Nursing Shared Governance is a pillar of the American Nurses Credentialing Center (ANCC) Magnet culture and a critical component of Magnet designation.
PCASI nursing leaders, also serving as ANSGC advisors, developed the foundation to support meaningful execution and development of an effective structure, ensuring adequate representation of all PCASI nurses. The ANSGC advisors supported and empowered PCASI nurses throughout the implementation process. Essential to success was evaluation of the perceived baseline management style within PCASI and nurse understanding of shared governance.
The ANSGC advisors identified the Index of Professional Nursing Governance (IPNG) survey, an evidence based tool, to establish baseline understanding of PCASI nurse perceptions around professional governance. Initial survey results indicated the presence of a traditional management style.
Implementation of an ANSGC has launched a structure for shared governance in the ambulatory setting. The ability to measure and benchmark nurse perceptions surrounding shared governance in the ambulatory environment provided PCASI with meaningful information to help drive improvements across and positioned the organization to achieve initial Magnet designation in July 2022.
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Reducing Intubation Time in Adult Cardiothoracic Surgery Patients: A Review of Data under the Direction of a Board Certified Critical Care Intensivist
Rebecca Gooch, Lauren Grip, Chance Nadritch, and Kimberly Vent
Background: Prolonged intubation after cardiac surgery increases the risk of morbidity and mortality and lengthens hospital stays. Factors that influence the ability to extubate patients with speed and efficiency include the type of operation, the patient’s baseline physiological condition, and provider practice patterns. The purpose of this research was to prove that the change of practice patterns that followed the addition of an intensivist lessened extubation times in cardiac surgery patients. It was hypothesized that the interventions brought on by the introduction of an intensivist would greatly reduce the amount of time a patient is intubated while in the intensive care unit.
Problem: Prolonged intubation times contributed to increased length of stay in the intensive care unit, increased morbidity and mortality rates.
Method: Barriers of extubation were identified and a protocol was agreed upon by advanced practice providers along with RN’s. A comprehensive unit based safety initiative was designed and put into practice. From April 2020 to April 2021 data was collected where the cardiac intensive care unit was without an intensivist. Data was then collected from April 2021 to April 2022 when there was an intensivist on site. The data analyzed included the number of patient’s extubated under six hours out of the total number of cases. Cases included in the study consisted of CABG’s and Valves. Cases excluded from the study were aneurysm repairs and minimally assisted CABG’s where the patients came out of the OR extubated. Considerations included the elimination of Morphine/Versed, the introduction of Precedex and Propofol and more attention to the last paralytic/reversal agent out of the operating room.
Results: Extubation in under six hours on the unit without an intensivist occurred in 116/571 patients (20.3%). With the introduction of an intensivist on the unit there was a total of 181/531 patients extubated in under six hours (34%).
Conclusion: The number of early extubations increased with an intensivist in the intensive care unit.
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eHealth@Home: Avoiding Readmissions for Heart Failure Patients
Krysta Harrington
The purpose of this evidence-based project was to reduce readmission rates for congestive heart failure (CHF) patients. It was hypothesized that targeted, nursing led care would reduce readmission rates. To test the hypothesis, we engaged patients post-discharge to enroll in eHealth@Home. eHealth@Home is a program at Rochester Regional Health (RRH) that serves high need CHF patients with frequent acute care utilization. These patients receive intensive monitoring and follow-up from a dedicated eHealth nurse, nurse practitioner and community health worker who work in tandem with a patient’s RRH provider to ensure that seamless and quality care is delivered. Visits were done in person at a patient’s house and through telemedicine; frequency of visits and interventions were dictated by the patient’s eHealth nurse practitioner. All patients received extensive education, medication reconciliation, symptom management and care coordination.
The results of the testing showed a 50.97% reduction in readmissions for patients enrolled in eHealth as compared to the 12 months prior to enrollment. Readmissions were defined as any hospitalization occurring within a 30-day period from discharge. In addition to readmissions, utilization reduction was also seen for admissions, observation stays, and emergency room visits. From the data obtained, it is concluded that the hypotheses was supported.
To further study this topic we would like to compare eHealth patients to that of a randomized control group to rule out any extraneous variables. Additional study opportunities include surveying patient’s perceived benefits of the program and perceived quality of life pre vs post enrollment.
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Evidence-Based Practice Liaisons: Supporting EBP Across the Health System
Tami A. Hartzell and Susan Stell
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NICU Discharge Readiness
Sarah Kiley, Megan Adams, Jennifer Pacheco-Leyva, Paula Sedita, Brooke Swinton, and Michele Wells
After days, weeks or months in the neonatal intensive care unit (NICU), families can be overwhelmed by the discharge preparation and the transition to home. Literature supports that inadequate preparation for discharge from the NICU increases family anxiety, risk for hospital readmission and emergency room visits, as well as infant care issues at home such as feeding difficulty. This quality improvement project was identified to improve and enhance discharge readiness in the NICU.
The project started with the development of a discharge readiness committee. After reviewing the literature, the committee met to identify areas in need of improvement which included improving communication of discharge plan, family/caregiver preparedness, completion of education before day of discharge and nursing documentation of completed education. Initial actions items incorporated the initiation of weekly interdisciplinary health team rounds, development of a standardized discharge teaching tool, inclusion of requested circumcision awareness in OB morning huddle, creation of a badge backer to include a QR code for easy access to required discharge videos, and identification/education of necessary educational documentation required within first 24-48 hours of admission in NICU.
The committee plans to measure length of stay, parent satisfaction and documentation of education to determine the impact of the identified action items. The goal of this quality improvement project is for families to be feel supported during their NICU journey and prepared for discharge well before the discharge day, resulting in increased patient satisfaction, decreased length of stay and decrease nursing workload on the day of discharge.
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Indwelling Urinary Catheter Daily Checklist to Reduce Device Utilization and Catheter Associated Urinary Tract Infections
Holly Kolstad
Question: The purpose of this EBP project was to determine if the implementation of a Bundle (ABCDE) Checklist for CAUTI prevention in the ICU, compared to current practice, would affect CAUTI and device utilization rates over 8-10 weeks.
Hypothesis: It was hypothesized that utilizing a checklist daily would ensure preventive measure were adhered to resulting in decreased CAUTI rates, decreased utilization rates, and increased documentation compliance. To test the hypothesis the checklist is completed daily by a leader or champion. The checklist will serve as an audit tool to ensure the interventions are completed daily on each patient with a urinary catheter. The checklist is also available to use upon insertion of indwelling urinary catheters.
Results: The results compare 8 weeks pre-implementation to 8 weeks post implementation. Pre data showed 353 Foley days, an average rate of 0.8 for device utilization, and a CAUTI rate of 3. Post data showed 221 Foley days, average utilization rate of 0.5 and zero CAUTI. 192 Foley checklists for 67 patients were completed.
Conclusion: Decreasing CAUTI will create improved outcomes for patients, reduce financial burdens to patients and organizations and overall improve the health of the community. The checklist serves to help engage and empower the nurses caring for the patient to reduce catheter use and ensures daily compliance.
Implications: To further study this topic, it would be necessary to implement an electronic version of the checklist, engage more unit champions, and increase the use of the checklist on insertion.
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Development of SHARE: Supportive Holistic Anxiety Reducing Experience in Critical Care
Benjamin Lindsay and Judith V. Treschuk
The purpose of this research/EBP was to develop an evidence-based Interdisciplinary Family-Centered Communication and Support Program in the Surgical/Neuro Intensive Care Unit intended to provide the support that family members and patients need when admitted to the Surgical/Neuro Intensive Care Unit.
It was hypothesized that there is a way to support patients and their family members during their admission to the RGH SICU/NCCU through evidence-based practice decreasing their anxiety and dissatisfaction with communication with the interdisciplinary team. To test the hypothesis, an electronic literature review was completed in March 2021 and May 2021 for the most current research on family-centered communication with the interdisciplinary team and the patient/family. CINAHL, Cochrane, OVID, and Medline databases were searched using the keywords “Family-Centered Care”, “Intensive Care Unit”, “Critical Care”, “Surrogate Decision Maker”, “Satisfaction”, “ICU”, and “Family-Centered Care in Intensive Care.” Many articles were presented initially in all searches and then limiters to the search were selected. Limiter included but was not limited to “2016 to present”. Exclusion criteria were articles published outside of “2016 to present”, and the entire research participant sample aged below 18.
The results of the research showed three strong themes within the literature. The themes identified through the literature search and review are as follows: Patient/Family Communication in the Intensive Care Unit, Interdisciplinary Family-Centered Care, and Strategies for Improving Interdisciplinary Patient/Family /Provider Communication. From the results obtained, it is concluded that the hypothesis was supported. There is a way to support patients and their family members during their admission to the RGH SICU/NCCU through evidence-based practice decreasing their anxiety and dissatisfaction with communication with the interdisciplinary team. To further test the hypothesis the evidence-based program would need to be implemented and evaluated.
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Early Mobilization for Critically Ill Adults: An Integrative Review
Jarvis McGrath
Objectives: Despite emerging evidence on the health benefits of early mobilization (EM) among critically ill patients, immobility and perceived barriers to EM persists. This integrative review aimed to summarize existing data on nurse-led EM, including how EM is defined, how EM protocols were developed, and key components of their protocol.
Methods: The protocol for this integrative review was developed in consultation with a trained librarian. A comprehensive search was conducted using the databases CINAHL, Embase, and ProQuest Nursing and Allied Health in April 2021. 6% of results were independently screened by 2 reviewers and the remaining were screened by a single reviewer. Studies were excluded if they included patients < 18 years old, were not available in English, did not include original data, if the intervention took place outside of the ICU, and if their study protocol excluded mechanically ventilated patients.
Results: Six studies met our criteria and were included. EM definitions commonly included implementing within a specified time frame. Protocols were developed by adapting protocols that were not initially nurse led, by an expert panel at the institution, or unspecified. Positive patient outcomes were associated with nurse-led EM including, but not limited to, reduction or eliminations of hospital acquired infections, reduction of vasoactive agents and sedation, and decreased length of stay along with significant hospital cost savings.
Conclusions: Results highlight the need for consensus on nurse-led EM approaches to facilitate clinical translation and improve patient outcomes. Further research is needed to develop an evidence-based protocol for nurse-led EM among critically ill adults.
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A Depression Screening Protocol for Acute Stoke Patients: A Quality Improvement Project
Celia McIntosh
Background: Depression after stroke is common and is associated with poor functional recovery, suicidal ideation, decreased quality of life, and increased mortality. Despite this knowledge, poststroke depression (PSD) is often underdetected and thus undertreated. PSD is clinically important for the caregiver, the family, and the stroke survivor. Inconsistencies in screening and treatment practices may further contribute to these negative outcomes.
Purpose: The purposes of this evidence-based clinical scholarship project were to (1) determine the efficacy of an evidence-based depression screening protocol in improving early detection and treatment of PSD and (2) identify if there were any relationships between the protocol interventions, depression scores, and diagnosis.
Methods: A retrospective chart review was conducted in a convenience sample of 79 hospitalized patients with acute stroke. Depression was assessed using the Patient Health Questionnaire-9. Demographic data and medical and protocol variables were also collected. Descriptive statistics, chi-square test, and Pearson correlation test were used for data analysis.
Results: Of the 79 participants, 56% were men, 65% were White, 77% were admitted with ischemic stroke, and 48% were identified as being depressed (Patient Health Questionnaire-9 depression scale > 4). Individuals with a history of depression (χ = 17.09, p = .002) were also more likely to have higher levels of depression severity as compared with patients who did not have a history of depression. After the intervention, patients screening positive were more likely to receive an educational booklet on stroke and depression (χ = 30.0, p = .000) and be medically treated for PSD before discharge (χ = 5.57, p = .018). Nurses' documentation of screening results also improved (χ = 9.19, p = .002).
Conclusion: Implementation of the Evidence Based Depression Screening and Treatment (EBDST) protocol improved early detection and treatment of PSD in the hospitalized patients with acute stroke before discharge. The EBDST protocol promoted systematic evidence-based depression screening in the hospitalized patients with acute stroke. Use of the EBDST protocol may further improve long-term health outcomes, decrease mortality, and improve functional recovery and quality of life.
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Nurse Driven Early Mobility in the Intensive Care Unit: Mobility Protocol and a Designated Mobility Champion
Intensive Care Unit, Newark-Wayne Community Hospital, Newark, NY
Decreased mobility in hospitalized patients can lead to various health consequences, including increased morbidity and mortality. In the Intensive Care Unit (ICU), patients are not mobilized as frequently or as often as possible. Barriers to mobilization include limited resources such as time and staffing, perceived risk, and insufficient training in safe patient handling. This quality improvement initiative aimed to increase out-of-bed mobility in ICU patients, address activity orders at interdisciplinary rounds, and trial a designated mobility champion. The America Association of Critical-Care Nurses (AACN) Early Progressive Mobility (EPM) protocol and Bedside Mobility Assessment Tool (BMAT) were adopted and used to discuss patients’ mobility during interdisciplinary rounds. During these rounds, a mobility champion who received additional training from physical therapy in safe patient handling attended these rounds. The mobility champion then coordinated with nursing staff and other care team members throughout the day to mobilize patients.
Increased numbers of patients with COVID-19 did not fit the eligibility criteria during the implementation period, and increased mobility was not seen. However, the ICU team members felt the interventions, especially the use of a mobility champion, were beneficial and decided to extend the new practice for continuing review. The mobility champion is now utilized on all inpatient units. All inpatient units have seen an increase in patients mobilized. Nurse-driven early mobility tools are safe and feasible and give nurses greater autonomy in planning mobility interventions. The use of a dedicated mobility champion compliments these tools and helps reduce barriers to early mobilization.
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RN Managed Warfarin Therapy Improves Patient Outcomes
Beth Ormsby, Stacee Marvin, Viktoria Leblanc, and Ashley Harris
Warfarin, an oral anticoagulant, is a “high-risk” medication with narrow therapeutic range and risks for serious complications if not carefully managed. Therapeutic effect is determined using a blood test called the International Normalized Ratio (INR). Evidence shows a higher percentage of Time in Therapeutic Range (TTR) decreases the risk of adverse events including bleeding, hemorrhagic stroke, and death. An optimal TTR is 60 – 70% or higher. Improving TTR by 2.5 - 5% could significantly impact outcomes.
It was hypothesized that an algorithm based approach to Warfarin management by a consistent team of RN’s would improve TTR and outcomes.
To test this, TTR for a group of patients enrolled in an RN Managed Anticoagulation Program was compared with TTR for two groups of non-enrolled patients. The RNs received training on warfarin management and application of the dosing algorithm, providers placed orders to enroll patients in the RN Managed Program and TTR was monitored post-enrollment.
The results showed an overall improvement in TTR in both groups.
Group One: Pre-enrollment Q4 2018 Average TTR = 59.07%, Enrollment Q1 & Q2 2019, Post-enrollment Q3 2019 through Q2 2020 Average TTR = 65.58% - an increase of 6.51%
Group Two: Pre-enrollment Q1 2019 Average TTR = 57.47%, Enrollment Q2 & Q3 2019, Post-enrollment Q4 2019 through Q2 2020 Average TTR = 67.47% - an increase of 10%
It is concluded that a systematic, algorithm based approach to warfarin management by a consistent team of RNs significantly improved TTR and improved outcomes for these patients.
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Experiences of Nurses and Nurse Leaders During the First Year of the COVID-19 Pandemic: An Integrative Review
Jessica Powell
This research aimed to examine the experiences of nurses and nursing leadership who worked through the COVID-19 pandemic. Understanding their experiences will help better support those suffering from burnout. An integrative review was done by searching three databases in February 2022. Search terms included: burnout, compassion fatigue, Nurs*, leadership, and COVID-19. A total of 288 studies were retrieved, with 11 eligible for review. Seven themes were identified: information, safety, psychological and physical impacts on nurses, patient needs vs. pandemic needs, acknowledgment, protective factors and positive things from their experience, and changes in responsibilities. Understanding the nurses’ and nurse leaders’ experiences throughout the pandemic is imperative to implementing practice and policy changes that mitigate burnout and rebuilding the profession and healthcare system.
Further research is needed to ascertain the experiences of nurses and nurse leaders after the first year and post-pandemic. Experiences likely evolved along with the pandemic. Interventions are urgently needed to assist frontline workers in making sense of their experiences. While there had been an effort to protect clinicians’ well-being and an awareness of the growing prevalence of burnout before the pandemic, the importance of understanding factors that contribute to clinician distress through this pandemic has become increasingly evident.
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The Safe Stay Program: For Care of the Pediatric Patient Boarding in the Emergency Department
Kellie Rorke
The purpose of this evidence-based project was to explore alternative methods to address the process for admitted patients boarding in the pediatric emergency department. It was hypothesized that creating an intentional program of vigilance for safe care of the boarding pediatric patient via a pediatric admission care RN (PAC-RN), supported by interventions including on time medication administration, monitoring, and admission process education. Could reduce adverse events, total inpatient length of stay, morbidity and mortality and improve overall patient/family satisfaction.
A systematic literature search to review patient boarding in the emergency department was conducted. The literature reviewed supported the implementation of a nurse driven program providing oversight and care for the pediatric patient boarding within the ED. The vigilance/patient safety conceptual framework was developed to depict nursing vigilance in combination with patient safety. This framework aims to help create an environment in which the nurse is continuously anticipating needs of the patient through close attention, situational awareness, and readiness to act. The combination of vigilance and patient safety result in a concerted collaborative attempt to protect and prevent harm to the patient.
Cost analysis, return on investment, and project implementation timeline were performed, as well as analysis of facilitators and barriers. This EBP change project holds the potential to improve care for the admitted patient boarding in the pediatric ED. Improving patient outcomes not only is beneficial to patients/families, but to staff and the healthcare institution at large and thus should be brought to fruition.
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Licensed Practical Nurses Working To Maximum Scope of Practice
Lindsey Sippel, Lauren Sicker, Jessie Schiffhauer, and Kristee Aliten
BACKGROUND: Nurses on 4800, a medical-surgical unit, were feeling overwhelmed by an increasing patient load due to Registered Nurse (RN) vacancies. No not only was staff morale at a low, but the staff was concerned about the impact on patient care. Nursing staff on 4800 consists of RNs as well as Licensed Practical Nurses (LPNs). As the team contemplated the high nurse:patient ratio, they identified that LPNs were not working to the full scope of their practice. The team began to wonder if ensuring that LPNs could work at the highest level of their scope of practice if this would help mitigate some of the stress experience by RNs.
A literature search was completed and while there is evidence to support improved patient ratios can lead to a decrease in length of stay and improved patient outcomes, there was not much that discussed LPNs working at their fullest scope of practice in the hospital setting. On 4800, LPNs were not working to their fullest scope. This was due in part to system-wide and EPIC barriers. The EPIC barriers include the verbiage found within the program. There were some modifications made to EPIC, such as the change from “Pain Assessment” to “Pain Observation;” however, EPIC was unable to change the “Head to Toe Assessment” flowsheet. The hospital was able to modify their policy to ensure LPNs were practicing within their scope and documenting “Head to Toe Observations.”
PLANNING: After having reviewed the literature, the leadership team, comprised of the Nurse Manager, Assistant Nurse Manager, Clinical Resource Team, and Lindsey Sippel LPN, felt the next step was to design a new care delivery model that would incorporate LPNs working to their full potential. The team began to work closely with the Clinical Nurse Specialist to learn system and state policies regarding LPNs to create a care delivery model that complied with state and local policies. To compensate for what LPNs are not able to document, a Free Charge RN (FCRN) position was developed. The FCRN’s role consists of acknowledging orders, administering medications outside of the LPNs scope, and completing documentation outside of the LPN’s scope. After identifying key stakeholders and drafting a rollout plan, the team identified measures that could be used to evaluate this QI project’s success.
INTERVENTION: The leadership team designated a Head to Toe competency as the primary focus of the project. Leadership created a PowerPoint designed to educate LPNs on Head to Toe observations and specific observations for each body system. Completing the Head to Toe competency ensured that the LPNs knew how to properly observe their patients and document it accurately. This meant the LPN no longer had to be paired and supervised by a RN, instead the LPN is now able to independently take their own five patient assignment. The FCRN was there to provide supervision and the necessary care that the LPN is unable to provide due the scope of their practice. In addition, the unit RNs were provided education on what is within the LPN’s scope of practice and the FCRN role.
RESULTS: The new care delivery model is still being evaluated; however so far there has been an improvement in nurse to patient ratios.
DISCUSSION: Since introducing this care delivery model, staff cohesiveness has improved when utilizing a FCRN. Since nurse satisfaction was not measured prior to the initiation of this care delivery model, this should be studied in the future if expanded to other units. This care delivery model might be applicable in other medical-surgical units across the system and we encourage other units to consider adopting this care delivery model. The barrier that has been identified since starting the care delivery model is the lack of provider knowledge on the LPN scope of practice. To combat this providers should be educated on what LPNs can and cannot do within their scope, and how 4800 is able to coordinate care that is outside of the LPNs scope, through the use of a FCRN.
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No Pass Zone: Responsiveness Quality Improvement Project Inpatient Acute Care
Joshua R. Smith
Purpose: The purpose of this project was to improve staff responsiveness by implementing a responsiveness intervention plan, known as the No Pass Zone (NPZ) Initiative, for adult inpatients with the goal of increasing the HCAHPS top box percentile and decreasing patient-initiated call bell response times.
Hypothesis: Hypothesis includes that the implementation of the NPZ would: - Increase HCAHPS Responsiveness of Staff top box scores from 57% to 62% in Press Ganey scores within the first three months of project initiation. - Increase Willingness to recommend top box scores from 56% top box to 58% top box scores measured by Press Ganey within three months of project initiation.
Methods: The NPZ Initiative was implemented, requiring each clinical and non-clinical staff member to respond to patient call bells and ensure that immediate needs are acknowledged. In-service education, coaching, and program promotion were integrated into the project. The No Pass Zone Initiative emphasizes the concept that call lights represent patient needs, and the response to those patient needs is a clear reflection of the priorities of that organization.
Results: The 2020-year baseline data measurement of 57% top box (n 976) compared with the post-intervention average top box score of 57% (n 260) representing no change in top box score for Responsiveness of Staff in the inpatient acute care units. However, the hospital's ranking increased from the 13th percentile to the 25th percentile ranking for like-size hospitals in the Press Ganey database. The Willingness to Recommend top box score decreased from 60 (n 729) to 56 (n 282) across the inpatient acute care units when comparing baseline to intervention. The ranking decreased slightly from 16th to 13th percentile of like-size hospitals in the Press Ganey database. Average call bell response times were analyzed pre and post-implementation. Overall, there was a twenty percent reduction in call bell response times across the project areas.
Conclusion: This data will need further analysis to determine the project impact. The initial results indicate improvement in HCAHPS ranking on responsiveness and call bell response times.
Implications: The NPZ has potential for an organization with the goal of improving staff responsiveness and focusing on a patient-centered culture. The opportunities for staff education, prioritizing patient needs, and improving ownership for patient experience are benefits of the program. Additional data will be necessary to determine effectiveness of NPZ intervention.
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Lost in Translation: Mitigating the Effects of Language Barriers on Patient Outcomes
Megan R. Van Dorp
The purpose of this research was to describe the development, implementation, timeline, and future evaluation of an evidence-based initiative to improve the outcomes of limited English proficiency patients. It was hypothesized that bridging the communication gap between patients of lesser English proficiency and their healthcare providers would increase patients' participation and understanding of their hospital stay. Improving discharge instructions and ensuring comprehension would promote well-being and health as patients are adequately equipped at discharge to assume their own healthcare needs. To test the hypothesis, a literature search was conducted of professional databases. Fifteen scholarly articles contributed to the research base of this project.
The research results showed that in 2020, Newark-Wayne Community Hospital saw 4,547 patient discharges (U.S. Centers for Medicare). Given that 16.9% of those patients were readmitted, that would equate to approximately 768 readmissions (U.S. Centers for Medicare). If each readmission costs the national average of $15,200 per case, this will lead to a total cost of $11,673,600 in readmission charges (Weiss & Jiang, 2021). However, an investment of $5,071 into this initiative for patients of lesser English proficiency could prevent those readmissions. Therefore, this program may save more than $10 million on readmission costs annually. The research supports the hypothesis.
To further study this topic, I would utilize a hospital with a higher rate of lesser English proficiency patients. This would provide a more realistic picture of translation software's costs and utilization rate and the resources necessary to facilitate admission and discharge.