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2012 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?

Following a review by the IRB, this project was determined to be a quality improvement project and given an exempt status. 

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).


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?"

Following a review by the IRB, this project was determined to be a quality improvement project and given an exempt status. 

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.

A re-administration of the GIAP is scheduled for September 2013 to evaluate the educational curriculum.


IHO Coordinating Team: Christine Lui MS RN, Vivian Low MPH RN-BC FPCNA, Ruby Garma RN MS CNS PCCN, Alicia Potolsky RN, MS, NE-BC, Kathryn Jaramillo, MS RN CNS-BC

PICO question: "Will initiating a standardized patient care plan on heart failure education and providing 48 hour post discharge follow-up on a hospital cardiac telemetry unit, help minimize HF readmission rates?"

This project was submitted to the IRB and approved by expedited review in January 2011. Study work continued through 2012.

A national multi-site study, Improving Heart Failure Outcomes (IHO) was conducted for 40 Magnet Hospitals. This study tested nursing interventions with a direct effect on improved HF patient outcomes. A diagnosis of heart failure (HF) accounts for the third highest cost to the national medical bill of $28.6 billion. Recent estimates indicate that people with chronic conditions receive 54.9% of the recommended care, with only 68% of patients with heart disease receiving the appropriate treatment. There is opportunity to improve the quality of care for HF patients.

The aims of this study were to:

1) conduct a quasi-experimental study to evaluate the effect of standardized education on heart failure patient care (knowledge, self care, and readmissions);

2) identify hospital and nursing characteristics that are associated with improvements in HF patient care; and

3) evaluate the cost effectiveness of nursing interventions to improve HF patient care.

Results: The intervention included standardized patient education and follow up phone calls 48 hours post discharge. Approximately 364 Nurses and 589 patients participated in this multi-site project from across the United States. The telemetry/cardiac unit (3B) was the study unit at El Camino Hospital.

Presentations:
IHO Collaborative in Baltimore MD Oct 6th and 7th, 2011. Kaye Jaramillo, Christine Lui

ANCC Magnet Conference in Los Angeles CA – Research symposium October 9, 2012 Vivian Low, Kaye Jaramillo


Image ofCarolain Peregrino, RN-BC, MSN,  Digant Dave, RN, MSNCarolain Peregrino, RN-BC, MSN, Digant Dave, RN, MSN

PICO question: "Will a change in the care delivery model from a Primary Nursing Model to a Team Model in an inpatient behavioral health unit, impact nursing time at the bedside, use of therapeutic interventions, perceptions of time management among staff, satisfaction of care by staff, satisfaction of care by patients, and occurrences of critical incidents?"

A pre and post implementation staff survey was performed. 

Brief Summary: A recent research study by Seed & Torkelson found that nurses spent a very minimal amount of time on patient care activities focused on wellness and recovery. Most activities were concentrated on paperwork and others not related to patient education. Time with patients is a vital part of psychiatric nursing as this is when treatment occurs. Patient care activities should include symptom management, crisis interventions, diagnosis education and instillation of hope to prevent suicide and relapse. Because of this essential component in psychiatric nursing and the need to improve patient care practices, this study identified multiple interventions to increase nursing time at the bedside. These interventions included a new staffing matrix, nursing model change into team nursing where one registered nurse and one licensed staff partner to support a group of patients in a given shift, and having a PM shift RN arrive early at 1300. These interventions had been implemented in the inpatient psychiatric unit and results are currently being analyzed.


Image of RN's Fe Ann, Jody Charles and Larry Luscher
Ann Fe, RN, Jody Charles, RN, MSN, Clinical Manager NICU and Larry Luscher, BSN, RN-C

Tammy Lee, RN and Dr. Dharshi SivakumarTammy Le, RN and Dr. Dharshi Sivakumar

PICO question: "Can the development and implementation of a standardized discharge readiness bundle of care for the late pre term infant, reduce the 7 day post-discharge readmission rate?"

This work was approved by the hospital IRB as a quality improvement project.

Purpose:Late preterm infants (LPI) defined as 34-36 6/7 weeks of gestation, are less mature and are at a higher risk for morbidity and mortality than term infants. The specific complications include poor feeding, weight loss, temperature instability (hypothermia), hypoglycemia and sepsis. LPIs are 4 times more likely than term infants to have at least one medical condition diagnosed and 3.5 times more likely to have two or more conditions diagnosed during the birth hospitalization, (Engle, 2005).

Methods:Nurses worked under the leadership of Dr. Dharshi Sivakumar, with a Multidisciplinary Quality Improvement Team (MQIT) of neonatologists, community pediatricians, and lactation consultants to develop a LPI program using recommendations by the American Academy of Pediatrics Committee on Fetus and Newborn. A structured bundle of care included monitoring for discharge readiness, parental education, and close follow up. The program was implemented in our Mother Baby Unit and Neonatal Intensive Care Unit (NICU) September 2011. Post-discharge phone calls were made to extend the staff -parent relationship and to verify readmissions elsewhere. The team also participated in A Quality Benchmarking Collaborative through the National Perinatal Information Center Quality Analytic Services (NPIC/QAS): Reducing Readmission of the Late Preterm Birth Infant within 7 (14) days of discharge through Implementation of late Preterm Birth Discharge Criteria.

Results:During the pre-implementation period, 23 (6.5%) were readmitted within two weeks of discharge compared to the post-implementation period, of whom 14 (3.9%) were readmitted. There was a significant reduction in readmissions, primarily attributed to hypothermia (p=0.04)

Conclusion:Follow up phone calls assisted in advising the family and tracking readmissions to other area hospitals. Targeting education, such as for thermoregulation and lower thresholds for phototherapy use would help sustain this initiative’s ability to reduce the readmission rate. Nurses felt empowered by the team support and guidance in creating educational materials that made a difference and felt rewarded by positive parental feedback enhancing parent satisfaction. (Initial work was shared at UCSF Nursing Research Days as a podium presentation by Larry Luscher, RNC, NICU in October 2012.)


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.

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.


Image of Linda Batey and Jina Canson

Linda Batey, MSN, RN, CNN and Jina Canson, RN, MSN

PICO question:  Will administering The Utrecht Work Engagement Scale (UWES) a validated survey tool, help to benchmark and validate issues of staff engagement and provide data to help formulate an action plan to improve staff satisfaction?

This study received an expedited review approval from the IRB.

Background: Employee engagement has emerged as an important topic in the workplace, particularly in healthcare. It has replaced the previously established measure of staff satisfaction and/or burnout. While there are varied and conflicting definitions used for engagement, one commonality to the numerous definitions is the idea that employee engagement is desirable.

Methods/Results:  The Utrecht Work Engagement Scale (UWES) is a 9-question survey divided into 3 subcategories, vigor, dedication, and absorption. The survey was administered to the clinical staff (RNs and PCTs) at the outpatient dialysis units with a 96% participation rate. The level of engagement, when compared to the established norms, was determined to be in the average range for each unit and service line. It is important to note the level of dedication reflected in the data obtained was in the high range.

The survey results yielded an opportunity to explore, develop, and implement interventions that consisted of the following:

1. Education – RN summit
a. Topics discussed included new/revised protocols, RN scope of practice, and charge nurse duties.

2. Care delivery
a. Primary nursing was changed to care coordination involving the entire interdisciplinary team.

3. Product evaluation
a. The Oak RNs piloted a new catheter dressing and dressing kit.

4. Communication
a. Staff have taken ownership for updating the staff communication boards for education, quality, and overall communication.

Engagement is an ongoing process and needs continued commitment from both management and staff.


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. 

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.