2015 Research and EPB projects | El Camino Hospital

2015 Research and EPB projects

2015 Research and EPB projects

The Effect of Music Intervention on CAM Scores in Hospitalized Older Adults Experiencing Delirium

Mae Lavente RN, ANP-BC

Mae Lavente RN, ANP-BC

PICO question: Does classical music played for 30 minutes twice daily for patients 65 years and older identified to be experiencing delirium result in a decrease in the CAM score?

This study received expedited IRB review in July 2015 until June 2016.

Background: As the “graying” of America continues, it is becoming increasingly important for healthcare professionals to be aware of the issues that surround this segment of the population. One of the most common clinical complications for older adults in the acute care setting is delirium (Inouye, 2014). Based on the Diagnostic and Statistical Manual of Mental Disorders (2013), delirium is defined as a disturbance of attention and awareness that develops over a short period of time with clinical features of reduced ability to focus, disorientation, and fluctuation of symptoms throughout the day. Delirium is associated with considerable negative consequences. It has been linked to increased morbidity and mortality, especially in older adults.

This quantitative study will employ a pre-post intervention design. The study participants will act as their own control with the before and after the Confusion Assessment Method (CAM) score. Patients determined to be experiencing delirium will be randomly assigned into two groups. Those in Group 1 will receive the music intervention on the first day and those in Group 2 will receive the music intervention on the second day. Both groups will receive 30 minutes of the same classical music that has been pre-selected by the investigator played in their room via a CD player twice a day, once in the morning and once in the afternoon. Comparison of CAM scores will occur on both days of the study for both groups to help determine the effectiveness of music intervention. Aside from the score, descriptive statistics will also be collected: gender, age, diagnosis (categorized by system), race, and history of cognitive impairment (yes vs. no), length of stay at time of intervention, English as the primary language (yes vs. no), and whether antipsychotic medication was provided during the course of the study (yes vs. no). Potential findings will aid in the validation of implementing non-pharmacological interventions as the first-line of treatment for delirium patients with behavioral symptoms, which advocates for a holistic nursing approach. Finally, the research will evaluate the short-term effect of music intervention by conducting, which will be more applicable to the acute care setting where delirium often manifests.

Sepsis Enterprise Process Vigilance





EBP Grant Project: A grant, “Spotlight on Success,” was awarded by the Moore Foundation to disseminate our cumulative efforts regarding the care of patients with sepsis.  The results of our efforts have been shared at the International Sepsis Forum in Paris, France; as well as in partnership with the Surviving Sepsis Campaign at multiple regional multi-site events.

Background: The Integrated Nurse Leadership Program (INLP), a regional quality improvement initiative to reduce deaths from sepsis, began in 2008.  Nine participating hospitals were provided networking opportunities and training on: care of the septic patient, program and leadership development, and data collection and analysis. Over the span of six years El Camino Hospital (ECH) applied these concepts during implementation of the early goal-directed therapy (EGDT) bundle (as recommended by the Surviving Sepsis Campaign and the Institute for Healthcare Improvement) and achieved a relative reduction of 68% in the mortality rate among those with severe sepsis and septic shock (p=.03); equating to 1,456 lives saved.  As a result of this initiative ECH has built a multidisciplinary Sepsis Program that continues to drive improvements in the care of patients with sepsis.

READI (Readiness Evaluation and Discharge Intervention)

Ann Marie Barsanti

PICO question: What is the impact on patient outcomes, including costs, when nurses assess for discharge readiness as a standard practice?

This study received exempt status IRB review on September 2015.

Background: Preparation of patients for discharge is a primary function of hospital-based nursing care and readiness for discharge is an important outcome of hospital care.  Inadequacies in discharge preparation have been well-documented and linked to difficulty with self-management after hospital discharge and with increased likelihood of emergency department (ED) use and readmission. Prior studies by the research team have led to recommendations for implementation of discharge readiness assessment as a standard nursing practice for hospital discharge.

The READI (Readiness Evaluation and Discharge Intervention) study is a Multi-site study being conducted at 34 MagnetR hospitals to evaluate the impact of unit-based implementation of discharge readiness assessment on readmission and ED use within 30 days post-discharge. Three phases, each adding a component to discharge readiness assessment, will be used to introduce, in sequence: (1) discharge readiness assessment by the discharging nurse; (2) discharge readiness assessment by the discharging nurse informed by patient’s self-assessment; and (3) a final modification to the-patient-informed nurse assessment protocol. The nurse and patient will be completing a standard 8 question form to assess for discharge readiness in the areas of personal status, knowledge, coping ability, and expected support.

The study will use a prospective, parallel cohort, stepped implementation design with four steps (baseline and the 3 discharge readiness protocols implemented in sequence) and two study conditions (implementation units and usual care control units). The study will compare patient outcomes at baseline and each of the 3 steps on the implementation units to outcomes on the control units, adjusting for hospital, unit, and patient-level control variables. The optimal implementation protocol will be identified through these methods.

Implementation of the ABCDE Protocol



EBP Grant Project: A “Spotlight on Success,” grant was awarded by the Moore Foundation to disseminate our ABCDE quality improvement work: The A (awake state), B (Breathing/liberation from ventilator), C (communication/collaboration of patient centered care), D (delirium prevention/management), E (exercise/progressive mobility), and now added F (family involvement), and G (good nutrition) bundle aims to improve ventilator weaning, delirium, and mobility by coordinating multidisciplinary care.

Background: With an original grant from the Moore Foundation in 2013, our multidisciplinary team collaborated with a regional initiative to imbed best practice mobility protocols into care for mechanically ventilated patients. Patients suffering from critical illness are at high risk of developing delirium and or neuromuscular weakness. Evidence indicates that this is often the result of life saving critical care practices. Previous management for patients developing delirium included restraints and sedation; Current management looks at delirium as a symptom to an early sign of sepsis or the result of modifiable environmental influences. Bedrest, for example, was once thought to be therapeutic but in fact can be the cause of an iatrogenic acquisition of a potentially life altering muscular weakness.

This year El Camino Hospital’s multidisciplinary staff (RN, MD, RT, PT, OT, and RD) was able to share our work with other health care organizations who are seeking to implement best practice in this area. 11 team members, led by Barbara Callens, RN traveled to New York to spend two days with the North Shore Long Island Jewish Health System (NSLIJ), the 4th largest health system in the country with 40 critical care units. NSLIJ had rolled out early work with this bundle in just 4 of their units. They defined a goal to inspire and explore strategies to standardize their work and implement across their organization. 178 of their critical care staff from 12 hospitals attended our presentations. The ECH team spoke about the journey to improve patient outcomes, lessons learned from our front line staff, research that enabled education and process improvement and patient testimony about their experience. In addition to podium presentations, the team displayed posters that have been shared at regional venues, and video footage of ventilated patients moving, multidisciplinary testimony on fears and challenges, and patient care tools that have been customized and design to improve patient participation, satisfaction and continuity of care.

Survey of Nurses Opinion on Methods of Quality Improvement

Allison Gorman, MSN, RN, RNC-EFM

PICO question: How do RNs rate the effectiveness of project improvement interventions for reducing cord blood specimen labeling errors?

This study received exempt status IRB review on September 2015.

Background: This quality review research project studied nurses’ opinions of interventions that were most effective in helping improve their practice related to cord blood specimen labeling.  The end goal was to provide nurse leadership with a more focused intervention plan. Historically the implementation strategies were based on the findings of a PDSA cycle:

  • Education to unify the practice. Staff were required to read and sign the policy and procedure for cord blood specimen labeling, so knowledge was consistent. This intervention provided some positive effect but not enough to bring the error rate to zero.
  • Reminder Systems - Awareness/ Motivation.  Error rates were communicated during change of shift huddle messages and nurses were encouraged to take their time and do it right. A weekly newsletter was also used to raise awareness. Nurses were encouraged to have a peer review check off on cord blood specimen labeling prior to putting it in the transport system to the lab.
  • Visual Quality Tool - A visual (VIS) display board was used to provide transparency about metrics and performance to the team.
Methodology: Nurses received a survey and were asked to rate the interventions on the Likert-scale.  Findings were consistent with current evidence based practice in literature.

Results: Nurses gave the highest rating to the peer review intervention. The same was found when ranking the interventions against each other.
Based on the consistency between the literature and results of the survey; peer review would be recommended as the intervention of choice to help reduce the rate of cord blood labeling errors.

Comparing Pain Management Modalities and Post-Op Ambulation for Total Knee Replacement Patients

Debbie Smyth, RN, BSN

PICO question: The research aim of the inter-disciplinary team was to improve knowledge base by conducting a quality review research project evaluating clinical variation and pain management as related to early ambulation for the TKR patients.  Does the method of pain management after total knee replacement (TKR) surgery affect the distance ambulated on Day of surgery and post-op day 1?

This study was approved by expedited IRB review in June 2015

Background: Pain management modalities in total knee replacement (TKR) vary and effective analgesic modalities are essential to facilitate early rehabilitation and postoperative recovery 1. Recent efforts have focused on multi-modal protocols improving pain control while decreasing side effects 2. Timing of pain medication, activity and periods of rest is a key role for the clinical nurse working with post-op patients. It is vital to improving patient outcomes for the clinical nurse to understand the effects of various pain management modalities.

Methodology: A multi-disciplinary team of orthopedic nurses and surgeons developed a research proposal of current methods of post-operative pain management for the TKR patients to determine which method resulted in increased ability to mobilize within the first 24 hours while managing pain to a functional level.    Data was collected retrospectively for adult patients who had routine total knee replacement surgery from July 2014 through August 2015 (n=94).  Variables collected included: Post-op pain management modality, Morphine equivalents used, pre and post ambulation pain score, distance ambulated, intraoperative use of liposomal bupivacaine, and length of stay.

Results: ANOVA (analysis of variance) was used to compare postoperative ambulation for different pain modalities:  “Oral only pain medication patients” (n=38) ambulated statistically significantly farther (M=44 feet, p=.009) than either “oral and IV pain medication patients” (n = 46; M=12.6 feet) and “Epidural route pain medication patients” (n = 8; M = 1.43 feet)
Also, patients receiving an intraoperative injection of liposomal bupivacaine prior to the end of surgery (n = 54), were able to ambulate farther (M=34.2 feet) as opposed to patients without the injection (n=40, M=10.7 feet), used less opioids and experienced a shorter length of stay. Some of these patients received oral medications as well.
This study highlights previous research demonstrating that epidural pain management compromises early ambulation post-operatively.  Results were shared with the orthopedic team including surgeons and clinical nurses and change in practice has resulted in the elimination of epidural route as a routine method for pain management

1. (Anahi Perlas, et al. July-August 2013)
2. (Joseph D Lamplot, Eric R. Wagner and David W. Manning 2014)

Analyzing Retrospective Data to Determine Patients Needing PSA (Patient Safety Attendant) Services on Medical Unit

Shefali Desai RN-BC, Clinical Nurse III

PICO question: Can an analysis of factors that trigger PSA/Sitter service utilization among adult medical patients at a local community hospital, identify common patterns to better understand patient safety needs.

This study was approved by expedited IRB review in September 2015.

Background: Increasing PSA service utilization has been a significant cost concern for the adult medical unit. To reduce these expanses without compromising the quality of care, we need to understand and study the factors that prompt PSA service utilization.

Methodology: Unit daily assignment sheets were used to identify the appropriate patients who were admitted to this medical service unit from January-June 2015 who received PSA services. 88 patients were identified. The patients’ Electronic Medical Records (EMR) were reviewed. Age, gender, language, (top 2) discharge diagnosis, (top 2) comorbidities, length of stay, and fall-risk were analyzed using descriptive statistics.

Results: The project has highlighted many factors that are noteworthy in improving interdisciplinary awareness. Statistically, more than half of the patients in need of PSA services were over 65 years old (pvalue <0.001). In addition, pneumonia, urinary tract infections (UTI) and 5150/overdose were the top three most frequent discharge diagnoses accounting for 32% of the 88 patients. The principle clinical cause of PSA usage was confusion (39%).

Conclusion: Upon admission, elderly patients presenting with infection could possibly be at risk for safety issues due to the pattern of confusion that was frequently documented. Increased awareness by the healthcare team for these patients could play a role in fall prevention. Family education should be initiated in a timely fashion focusing on the acute confusion of this elderly population.