2014 Research and EPB projects | El Camino Hospital

2014 Research and EPB projects

Assessment of Nustep Submaximal Test Accuracy for Predicting Exercise Intensity

2014 Research Projects


Craig Clemens, MA, RCEP, CSCS, CPT and Nanette Malgesini, RN MSN FNP-C

PICO question: Can a Nustep Submaximal Test serve as a viable alternative to the 6-Minute Walk Test to develop an initial exercise prescription for outpatient Cardiac Rehabilitation patients?

This study was approved by expedited IRB review in December 2014 and work continues in 2015.

Background: The American Association for Cardiovascular and Pulmonary Rehabilitation (AACVPR) requires a functional assessment to be conducted to determine an appropriate exercise prescription for new patients in outpatient Cardiac and Pulmonary Rehabilitation. Medicare requires individualized treatment plans, which should include an appropriate exercise prescription. Historically, the 6-Minute Walk Test was used for this purpose. However, there are several shortcomings with the 6-Minute Walk Test; it is not well tolerated in low-functioning patients, high fall risks and those who require assistance with ambulation (wheelchair, walker, cane). The test is often not meaningful for patients with a high functional capacity. Exercise Physiologists lead a multi-disciplinary team collaborating with nurses for this investigational project to improve individualized patient assessment.

A new self-paced, 6-minute test protocol was developed utilizing a Nustep recumbent cross trainer as a potential alternative to the 6-Minute Walk Test. The Nustep recumbent cross trainer is an exercise modality commonly used in Cardiac and Pulmonary Rehabilitation settings. Participants in this study will perform both the Nustep Submaximal Test and 6-Minute Walk Test prior to starting outpatient Cardiac Rehabilitation. The results of both tests will be analyzed to determine if there is a statistical correlation between the two tests and whether the Nustep Submaximal Test is a viable alternative.

Creating a Sustainable Nursing Workforce: An Operating Room Residency Program for Experienced Nurses and New Nurse Graduates

2014 Research Projects


Luis Enrique Barberia, DNP©, MSN, RN, CNL

PICO question: Will new nurse graduates enrolled in an operating room residency program become as competent advance beginners as the non-OR experienced nurses also enrolled in the same residency program?

This project received an exempt quality review from the IRB on 1/24/14.

Background: Workforce development is essential for any organization to achieve and sustain operational excellence. Nursing, the largest labor force within the U.S. health care system, is currently experiencing a major aging shift. Nearly half of this workforce will be considering retirement within the next decade (Budden, Zhong, Moulton, & Cimiotti, 2013). New nurse graduates comprise the largest available workforce in the job market; however, hospitals would rather hire experienced nurses rather than clinically inexperienced novice nurses. This behavior has become the norm, at least temporarily, since the 2008 U.S. economic recession forced health care organizations to rigorously tighten their budgets.

Most recently, the Patient Protection and Affordable Care Act, signed into law by President Barack Obama in 2010, has motivated health care institutions to enhance efficiency and quality of care. To reach these objectives, they must rely on experienced professionals who can achieve clinical results in keeping with organizational goals. Currently new nurse graduates are not an attractive hiring option: they lack the clinical experience to seriously compete for jobs and require costly orientations, up to six months or more, to become clinically competent. With so many experienced nurses contemplating retirement in the next decade, the need to make new nurse graduates employable is urgent.

Highly specialized areas such as the operating room will be affected most by the forecasted nursing shortage. According to a 2011 survey, the average age of operating room nurses is 55 years old (Saver, 2011). Statistically this is congruent with national data forecasting that about half of the nursing workforce nationwide will be considering retirement in the next decade (American Nurses Association, 2014). These are alarming and worrying facts for institutional leaderships in acute care settings as it can seriously compromise operations and patient safety. To address the fore-coming crisis, The University of San Francisco and El Camino Hospital, Mountain View, CA, have forged a partnership to implement a Residency Program for Operating Room Nurses. The goal of this new program is to transition experienced nurses and new nurse graduates into the operating room to fill the gap that will be left behind by the expected high volumes of operating room nurses considering retirement within the next decade. If successful, this program could lay the foundation for a sustainable workforce.

The project was strategically conceived to last six months including didactic and clinical sessions. The core curriculum that will be used to guide the training is the Perioperative 101 module, developed by the Association of Operating Room Nurses (AORN). This curriculum includes didactic and clinical hours that must be successfully completed to qualify for final exam. The didactic portion will be managed by a faculty employed by the University of San Francisco, while clinical will be pursued at assigned hospitals under the direct supervision of trained preceptors and a clinical instructor.

This project underscores the need to address educational gaps and develop meaningful partnerships with academic institutions to enhance nursing education and develop a nursing labor force that can meet the needs of health care organizations.

Identifying Clinical Complications in the Post Anesthesia Recovery Period to Guide Implementation of Best Practice Guidelines

2014 Research Projects


Lori Story BSN RN and Judy Moreno RN

PICO question: Can a retrospective review of the adult patients who screen postive for obstructive sleep apnea in the preoperative are, identify complications in the post-anesthesia recovery period?

The purpose of this review is to guide the development and implementation of an appropriate clinical protocol for managing thses patients using best practice guidelines.

The project received an exempt status review by the IRB in May 2014.

Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder in the adult population and is frequently undiagnosed in the general population as well as in the surgical patient setting. OSA is characterized by airway obstruction with periods of apnea. Patients with OSA have increased incidence of perioperative morbidity, postoperative complications, difficult intubation, longer length of stay, and higher rates of admission to higher levels of care (1-5). Complications during the immediate postoperative period include airway collapse, hypoventilation, hypoxemic and hypercarbic derangements, and respiratory depression after opioid-analgesic administration, making close monitoring in the post-anesthesia care unit (PACU) essential (6). Pre-surgical evaluation of patients for OSA has been recommended, as well as perioperative and postoperative management to prevent or minimize complications (7). The STOP BANG questionnaire has been validated for efficacy of identification of OSA in the adult population (18 years of age and older) (8) and in surgical patients (9, 10).

El Camino Hospital conducted a quality project trial to evaluate the ease of administration of the STOP BANG tool from April 7, 2014 through April 18, 2014. All adult patients (18 years of age and older) scheduled to undergo general anesthesia (n=186) completed the STOP BANG questionnaire preoperatively. Of these, 20 patients were identified as having OSA (10.8%). The study population for this project is those 20 patients identified as having OSA.

Data to be extracted from electronic medical records will include:

Preoperative data:

  • Pre-existing diagnosis of OSA
  • Home CPAP availability
  • Utilization of home CPAP

Perioperative and post-anesthesia PACU data:

  • Documentation of hypoventilation
  • Documentation of apneic events
  • Documentation of hypoxemic events
  • Documentation of hypercarbic events
  • Length of time for required airway support
  • Length of time for required for oxygen support
  • Length of postanesthesia Phase I recovery stay
  • Requirement of positive airway pressure treatment

Post-operative and post-discharge data

  • Number of required transfers to higher levels of care
  • Number of unplanned re-admissions

Work now continues to implement a standardized screening process for OSA for best practice patient care, and to allow further evaluation.

Santa Clara County Assessment of Missed Posterior Strokes (SCAMPS) trial

2014 Research Projects


Sherril Hopper MSN, FNP-C, NVRN-BC, CN, RN and Alida Lorenz RN MSN

PICO question: Will a 2-item patient exam used by paramedics in the field accurately identify posterior circulation stroke symptoms, thereby improving suspicion and advance notification of stroke patients to Emergency Departments.

This project received an exempt quality review from the IRB on 7/9/14.

Background: Approximately 20% of all ischemic strokes are a result of posterior circulation occlusion. The stroke assessment tools used by most EMS agencies nationwide are the Cincinnati Prehospital Stroke Scale (FAST) and the Los Angeles Prehospital Stroke Scale. Neither of these assessment tools assess for posterior circulation stroke. Posterior circulation strokes commonly affect the brainstem and other life-supporting structures in the brain. However, the symptoms are not as commonly recognized as those of anterior circulation strokes.

The importance of identifying possible stroke syndromes in the field cannot be understated. Paramedics routinely notify hospital emergency departments of their patient assessment and condition while enroute. When stroke is identified during their assessment, this is communicated to the receiving hospital. During the time between notification and arrival, the hospital emergency department is preparing for the arrival of the patient. In the case of suspicion for stroke, the stroke team is mobilized, the CT scanner is prepared to immediately accept the patient, and laboratory personnel prepares to obtain and process the highest level of all stat labs requested in the hospital.

Through the use of retrospective data analysis, the SCAMPS trial is attempting to validate the use of 2 additional assessments in the field by paramedics for the purpose of identifying possible posterior circulation strokes. The paramedics have agreed to assess all possible stroke patients for Ataxia (Balance) and Visual Changes (Eyes), adding the acronym BE to the currently used FAST assessment. Review of records for all stroke patients who arrive by EMS at participating hospitals will be used to validate this assessment through comparison with the final discharge diagnosis. This retrospective review is scheduled to begin in February, 2015.

Factors Leading to Rapid Response Team Intervention in Medical-Surgical Patients

2014 Research Projects


Christine Tarver, MS, RN, CNS

PICO question: Can a retrospective chart review identify factors common to adult medical surgical patients who had an RRTI (Rapaid Response Team Intervention) to guide creation of a Proactive Risk Assessment Tool to predict patients at risk for deterioration, leading to improved interventions earlier in the hospital course, and thereby increase the potential for improved outcomes with regard to transfer to ICU or in-hospital mortality.

This study received exempt status IRB review in July 2014 and work continues in 2015.

Background: Patient data is being collected through retrospective chart review for patients admitted over a 12-month period to 3 medical-surgical units from July 1, 2013 – June 30, 2014. The sample includes Rapid Response Patients as well as three control patients for each sample patient randomly selected for comparison.

Comparisons will be made between those who received RRT and those who did not, in particular looking at: demographic information, diagnoses, medical history items/co-morbidities, vital signs, medications prescribed, ED admission within eight hours, transfer from CCU within 8 hours if extubated less than 24 hours, CCU length of stay greater than seven days, using chi square and means tests to determine differences between the two groups. Characteristics held in common among RRTI patients that differ from those not requiring RRTI will inform the development of a protocol and guideline for nurses to use in determining the need to call for RRT.