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2013 Research and EPB projects


Image of Cheryl and Mae

Cheryl Reinking, RN, MS, NEA-BC and Mae Lavente RN, ANP-BC

PICO question: Will a comprehensive discharge planning and after hospital care intervention reduce re-admissions within 30 days?

This project received an exempt quality status from the IRB in December 2012 and work continues in 2013.

Researchers estimate that up to 90% of hospital readmissions within 30 days of discharge are unplanned. The annual cost to Medicare for these admissions exceeds $17 billion. Fortunately, older patients can avoid a readmission when they receive high quality and evidence-based care during hospitalization, at discharge, and in the immediate period after discharge. This quality improvement project includes an implementation of a transitional care program, comprehensive discharge planning, and intensive medication program. It utilizes a pre-post design to evaluate effects of an evidence-based approach (comprehensive discharge planning and after hospital care intervention) compared to historical data from the baseline year (2010). Components of the project were presented in the 2013 NICHE Conference in Philadelphia as part of a podium panel and at the 2013 Magnet Conference in Orlando as a podium presentation.


Image of Nurses Schutt, Pizzani and Tarver Suann Cirigliano Schutt, MSN, RN-BC, CEP Michelle Pezzani, MD, Chris Tarver, MS, RN, CNS

PICO question: Can a device monitoring patient movement capture turning variability of patients on medical unit? In October 2012, the team received IRB approval to conduct a multi-phase research study using an experimental device. Work continued through 2013.

Background: El Camino investigators Michelle Pezzani, MD, Chris Tarver, MS, RN, CNS and Suann Cirigliano Schutt, MSN, RN-BC, CEP are conducting a study of patient movement on the medical unit. The focus of the study is to understand the ability and efficacy of utilizing an activity monitoring system to promote data-driven care. The first phase of this study was completed June 2013, demonstrating successful deployment of the system in a clinical setting and collection of baseline data. Phase 2 was completed in January 2014 with 138 patients enrolled in all phases of the study obtaining over 8000 hours of patient movement data. Post-intervention turning compliance increased to 98% - a statistically significant finding (p<0.01). Feedback from unit nursing staff: 87% felt patient movement monitoring data at the nurses’ station was helpful to their daily practice.


Image of Mae and Susan

Mae Lavente RN, ANP-BC and Suann Schutt, RN

PICO question: "Will utilizing a nationally recognized assessment tool for nurses effectively identify knowledge and attitude gaps towards best practice care for older adults, thus developing a evidence based educational curriculum?"

This project received an exempt quality status from the IRB in February 2012. Work continued in 2013.

The newly developed Nurses Improving Care For Healthsystem Elders (NICHE) program, administered the Geriatric Institutional Assessment Profile (GIAP) March 2012 to 251 RN's at El Camino Hospital. The GIAP was developed by the National NICHE network and has been administered to hospitals nationwide. The results of the survey highlighted the key gaps in knowledge and attitudes towards the care of the older adult. The El Camino Hospital NICHE committee then evaluated and developed an educational curriculum centered on GIAP findings and best practices for care of the older adult. A core team of nurses are currently working on the Geriatric Resource Nurse (GRN) certification. As of March 2013, ten nurses recieved their GRN certified and one wnet on to become an ANCC Gerontological Certified RN.

The GIAP was readministered September 2013 to evaluate the effectivness of the education curriculum. There were 166 responses and comparison between pre- and post intervention showed statistically signifiacant improvement in the following areas: nursing knowledge (restraints pressure ulcers, sleep, and incontinence), attiude, and geriatric care environment.


ABCDE TeamABCDE Project Leaders - Barbara Callens, RN, CCRN, Project Lead, Esther Nickols RN, CCRN, Data Lead, Michael Purnell, RN, CCRN, Nurse Educator, Margot Flaugher, PT, Douglas Mazur, PT, Sandy Chavez, PT, Mendy Lum, RT, Ray Quintero, RN, CNRN, Manager.

PICO question:  Can a bundled approach to care of the adult critical care patient result in improved provision of timely and coordinated awakening and breathing trials, safe progressive early mobility, and early assessment of delirium, without increasing length of stay (LOS) or ventilator days?

Questionnaire to Assess RN Education Needs for this project received exempt quality status from the IRB in February 2012 and work continues in 2013.

Two thirds of critical care patients develop delirium and almost half develop neuromuscular dysfunction or weakness. Sedation, delirium, and immobility of patients can lead to increased morbidity and mortality, increased length of stay, higher cost of care, and long-term harm that includes cognitive and functional deficits. Studies have shown that mobilization of mechanically ventilated patients significantly decreased both ICU length of stay and overall hospital length of stay (Morris et al, 2008). Despite these findings, the underutilization of mobility practices for mechanically ventilated patients has been contributed to insufficient awareness of its rationale and benefits (Thomas, Paratz, Stanton, Deans, & Lipman, 2006).

A multidisciplinary team collaborated with a regional initiative funded by the Gorden and Betty Moore Foundation to imbed best practice mobility protocols into care for mechanically ventilated patients. Awakening, Breathing, Coordination, Delirium Monitoring and Management, and Early Mobility is known as the ABCDE bundle founded on three primary principles: improving communication; standardizing care processes; and breaking the cycle of over sedation and prolonged attachment to a ventilator that contributes to delirium and weakness. A staff pre-assessment was done to identify variables in knowledge of the rationale, benefits, and contra-indications of moving a ventilated patient and fears of endotracheal tube dislodgement, patient fall, or patient compromise. The results helped to target staff education and training.

Results: Analysis of data for this project occurs quarterly. Data collected includes percent of patients that receive spontaneous awakening trial (SAT), spontaneous breathing trial (SBT), delirium monitoring every shift, and graduated exercise program. Data also includes percent of patients out of bed and delirium free, as well as median length of stay (LOS), average LOS, and average number of days on ventilator. Ventilator data excludes patients that are on the ventilator less than 24 hours. LOS data excludes expired patients.

Initial six-month results of this project are promising. SAT rose from 60% to 98% compliance. SBT rose from 20% to 98% compliance. Every shift delirium assessments rose from less than 10% to 60%. Progressive mobility rose from less than 10% to over 80% and out of bed rose from less than 10% to 40%. Average LOS dropped from 6 days to 5 days and average days on ventilator held steady at 3 days.

Conclusions: Bundling best care practices together along with empowering a group of super users to lead and support the use of the ABCDE bundle has positively impacted patient outcomes during the implementation of the ABCDE improvement project.

ABCDE project presented at: American Heart Association VAP Coaching Webinar, April 2013; Evidence Based Practice Fair, El Camino Hospital, Mountain View Ca, May 2013; Cynosure Summit, Oakland, CA, June 2013; Podium Presentation - Center for Nursing Research & Innovation Oct 2013 Research Days South San Francisco, Ca.


Image of Kristy Coleman-Hass for PICO
Kristi Coleman-Hass, RN, BSN, CCRN

PICO question: Will a structured retrospective review and analysis of staff utilization of procedures for "Removal of Mechanical Ventilation in the Dying Patient", help to identify best practices in the care for this patient population.

This project received an expedited review from the IRB on February 2013

Background: Adult patients at El Camino Hospital that are placed on "comfort care pathway" are patients who are determined to be near death and they or their durable power of attorney have decided to terminate aggressive treatment and to allow the patient to receive compassionate care during their final hours or days with the goal of care being to provide comfort instead of curative measures. Patients that are placed on comfort care pathways have established procedures . For patients in this group who are on mechanical ventilation, there is a separate procedure based on current evidence that specifically covers the removal of mechanical ventilation through a "rapid terminal weaning" of the ventilator and higher narcotic and anxiolytic medication administration to prevent rebound dyspnea from the abrupt removal of the advanced airway. This procedure is called "Removal of Mechanical Ventilation in the Dying Patient" and is intended to bridge the patient in comfort starting just prior to removal of the mechanical ventilator to 3 hours after removal, at which time the patient will be placed onto the standard comfort care order set with no reduction in the narcotics/anxiolytics that the patient is receiving at that time. This project received an expedited review approval from the IRB.

Purpose: To perform a retrospective chart review of 1 year's worth of patient data, unit and time characteristics when utilizing the preapproved procedure of Removal of Mechanical Ventilation in the Dying Patient. The guiding purpose is to gain an understanding of what the staff challenges are in caring for dying patients removed from mechanical ventilation for purpose of withdrawal of life sustaining treatments. The results of this study may be used to assist in creating a comprehensive palliative care education module for the critical care nurse.


Karin Blais, MSN, RN, CNL

 

 

PICO question: Does an ongoing assessment of KBMA(Knowledge Based Medication Administration) barriers maintain a 90% scanning compliance rate?

This project received exempt status from the IRB in June 2013. 

Background: Current research estimates that in in community hospitals alone, medication errors are associated with an increased length of stay of 3.15 days and an increased adjusted cost of over $3,000 per visit. In an attempt to reduce medication errors, healthcare organizations are adopting barcode medication administration (BCMA) at the point-of-care. It is designed to assist the nurse in validating the five rights of medication administration, including patient identification, medication, dose, time, and route of administration. Through the use of a wireless scanner, the patient's wristband and each of the medications are scanned, validating the five rights at the bedside. Yet, despite the recognized benefits to patient safety, research confirms that nurses frequently create workarounds to BCMA, a system that is often perceived as too time consuming. Starting in January 2013, the implementation of a BCMA application, KBMA, began throughout the hospital and the project was completed on May 2, 2013. The organizational benchmark is 95% scanning compliance at nine months post organization activation. Since going live in early February 2013, the inpatient telemetry unit scanning compliance has ranged from 86% to 90%. There have been no sentinel events due to medication errors on the telemetry unit. There have been numerous medication near misses and there have been 72 documented medication errors from May 2013 to August 2013.

Methods: Data was obtained from the following sources:

(1) Voice of the Customer: Focused on identifying medications that nurses perceived as difficult to scan. Nurses were asked to self-rate how comfortable they are with troubleshooting KBMA issues before and after intervention. Pre- intervention, 41 of the 62 nurses completed the survey (return rate of 66%) and post-intervention, 37 of the 62 nurses completed the survey (return rate of 60%).

(2) Staff meetings: In June and July 2013, the author of this project attended all the unit's staff meetings to formally introduce the CNL project as well begin discussions regarding KBMA scanning issues.

(3) Informal interviews were conducted with 26 of the 62 nurses to discuss KBMA scanning issues. Many of these interviews resulted in this author following-up with the IT and Pharmacy teams to address computer workstation and scanner issues, as well problems with certain medication barcodes.

(4) KBMA scanning reports: An extensive component of this project was creating reports to capture the unit's scanning compliance, individual compliance, as well as medication that were overridden. These reports were created, validated, and implemented with a database report writer. These reports were critical in identifying medications that were consistently not being scanned. Practice change example: Pharmacy had stocked a medication from a different manufacturer and the medication's national drug code (NDC) was not in the database. For an entire day, no one could successfully scan the medication, resulting in 13 overrides on one shift. Once identified, pharmacy was notified and the NDC was added.

Outcomes:
Early results demonstrate that with constant assessment and intervention, barcode scanning compliance improved from an average of 89% to 95%, a decrease of almost 60% in the number of overrides.

  

Debbie Smyth, RN, BSN, Orthopedic Surgery Program Coordinator

 

 

PICO question: Can the implementation of use of the Pasero Opioid Sedation Scale (POSS) for the post-operative patient result in a decrease in Narcan use on a surgical unit and improve respiratory assessment.

UCSF The Change Agent Program (CAP) 

Background: Research has shown that patients are at highest risk for opioid induced respiratory depression during the first 24 hours of opioid therapy and that sedation is a very sensitive indicator of impending opioid-induced respiratory depression. The Joint Commission came up with a recommendation that hospitals "create and implement policies and procedures for the ongoing clinical monitoring of patients receiving opioid therapy by performing serial assessments of the quality and adequacy of respiration and the depth of sedation".

Methods: The initial team included Debbie Smyth RN, Annmarie Barsanti RN, and Kris Cana RN. They began working on an education program for the nurses including respiratory assessment and sedation scale use. We held classes for the nurses beginning on units 4A, PACU and 2B as a trial, and developed and administered a questionnaire for the nurses to assess their comfort and ease in using the scale. We also developed pocket cards with the scale on them for easy nurse reference and included the scale and narcotic onset and peak times to our ISBAR handoff form.

Results:
Once the trial was concluded we conducted a survey with 84% of respondents feeling that the information improved their assessment skills and heighten awareness of patients at risk for sedation. We saw a slight decrease in Narcan use on 4A.

The scale was formally added to our pain management protocol and electronic documentation flow sheet and rolled out to all units at both campuses in the spring of 2013 with the exception of CCU and PCU which have their own scale. The poster was presented at the Change Agent Graduation Celebration May 2013.


Jane Truscott, BSN, RN-BC

PICO question: Can a structured educational process and improved tools for managers result in better best practice compliance in how to onboard new hires?

UCSF The Change Agent Program (CAP)

Background: The average 2011 RN turnover per unit at El Camino Hospital was 7 RN's. Saving turnover of just one RN is approximately $81,000 A look at the new hire process revealed:

  • New nurses are dissatisfied when schedules are not available in a timely manner - Basic physiologic need is unmet

  • Dissatisfaction builds, employee/employer relationships can be damaged, leading to costly nurse turnover

  • No standard work exists to effectively and efficiently integrate newly hired nurses into their nursing units.

Goal: Positive manager /employee relationships for workforce stability to promote positive patient satisfaction and care outcomes.

Standard onboarding, for managers to engage new nurses, develop effective teams, and build positive relationships.

Adoption of a standard, best practice onboarding for all newly hired nurses by the end of fiscal year 2014.

By January, 2014, 75% of newly hired RNs will have schedules upon arrival in nursing orientation.

Methodology:

  • Quick and easy manager checklist on Hospital Sharepoint outlines new hire onboarding

  • Manager's use of an onboarding checklist helps standardize best practice

  • Provide orientation that is comprehensive and focused.

Outcome:  Percent of new nursing hires provided with a work schedule by orientation day #2

New Hire Data Outcomes Chart

(Click here for larger view of the chart)

Lessons learned: Some components of onboarding cannot be delegated; development of essential manager/new hire relationships requires early and continuous manager engagement. Immediate schedule availability is an early and significant RN satisfier.

Next steps: Establish business platform for early uploading of new hire schedules

Expand onboarding checklist throughout the enterprise with 30-60-90 manager follow up

Adopt HR policy for Best Practice Onboarding
Establish Retention, Onboarding and Orientation Committee to support managers, track turnover, and guide RN retention measures

Establish RN exit interview and track data

References: Society for Human Resource Management: Onboarding New Employees: Maximizing Success, by T. Bauer (2004); Education Department 650-988-7773 Journal for Nurses in Staff Development, Creating and Implementing a Nursing Role for RN Retention, by E. Creakbaum (2011); Journal of Nursing Care Quality, Providing a Healthy Work Environment for Nurses, by J. Cohen, et. al.D. Stuenkel, (2009) The Journal of Continuing Education in Nursing, An Exploratory Study of the Orientation Needs of Experienced Nurses by C. Dellasega et. al., (2009) The Online Journal of Issues in Nursing, Using Maslow's Pyramid and the National Database of Nursing Quality Indicators™ to Attain a Healthier Work Environment, by L. Groff-Paris and M. Terhaar (2011); El Camino Hospital Magnet Report for Nurse Demographics (2013)