Introduction: Central line-associated bloodstream infections (CLABSIs) have been designated as a “never event” and may result in increase in hospital cost and increased risk in morbidity and mortality. There are an estimated 250,000 bloodstream infections that occur in the U.S. annually. The CLABSI rate is estimated to be at 0.8 per 1000 central line days in ICUs (CDC.gov, 2019). The data are sparse in the number of cases outside of ICU. In 2019, the Centers for Disease Control (CDC) reported through the National Healthcare Safety Network (NHSN), the acute care hospital reporting to NHSN of CLABSIs by state differentiating ICU cases versus non-ICU cases. That year, there were 12,039 cases in ICUs and 13,784 cases in the wards. In all cases, 35% of mortality was attributed to CLABSI infections.
This story began in a 35-bed medicine/telemetry unit of a large urban academic level-one hospital on July 25, 2017. A patient was admitted with an accessed central line in situ and developed severe sepsis that day. It progressed rapidly and resulted in negative patient outcome which was attributed to CLABSI. This devastating loss resonated with the staff and served as an impetus for the unit leadership to prompt initiatives towards a zero-CLABSI standard.
Purpose: The purpose of the initiative is to optimize central line maintenance care and surveillance of practices and reduce and potentially eliminate CLABSI in a non-ICU setting of an urban academic medical center. An objective is to elevate the knowledge base and skill set of direct care nurses.
Description: The theoretical framework of Lewin’s change theory was used for the unit’s CLABSI eradication program.
Unfreeze: Education of staff regarding the problem of CLABSI, contributing factors and outcomes, established CLABSI prevention practices.
Change: CLABSI champions, just-in-time coaching, leadership rounding, daily central line audit tool; two RN-site and dressing assessment in-between shifts.
Refreezing: Post number of days without CLABSI daily on the quality board, check necessity of central lines daily during multidisciplinary rounds or huddles with health care team and spot checks.
Other interventions implemented as supplemental to the core measures are:
• Patient and visitor education about central lines and prevention of infection tactics
• Utilization of checklists when manipulating central lines like dressing changes, drawing of blood specimen, de-clotting of line by CLABSI unit champions
• Collaboration with physicians for blood culture draws as baseline data on patients with pre-existing central lines on admission to the hospital
• Implementation of a 10 must-haves list for CLABSI eradication for the staff to include in daily practice as standard work
Outcome: Since July 25, 2017, the unit has zero CLABSI. It has been 1,390 days without CLABSI as of May 15, 2021. The next steps are to maintain and sustain the standard work surrounding CLABSI eradication with new staff to ensure the continuation of this successful story.
Purpose: This study focuses on employer perceptions of new graduate nurse (NGN, as defined by less than 12 months of experience) readiness for independent practice given limited access to clinical rotations.
Background/significance: The definition of competence in nursing practice is ambiguous, with scarce appreciation of the thought processes and executive cognitive function required for competent practice (Levine & Johnson, 2014). In the complex and dynamic health care climate, acute care nurses voice growing concern regarding that the preparation and competence of health care professionals and their ability to autonomously provide high-quality patient care (Bennett, Grimsley, Grimsley, & Jodd, 2017; Edward, Ousey, Playle, Giandinoto, 2017). Conversely, health care employers need nurses that can demonstrate the competencies needed to work with interprofessional teams in various settings (NACNEP, 2010). There has not been much research reported on the employer’s perception of NGN preparation for autonomous practice given limited availability of clinical rotations.
Methods/design: Mixed methods (quant > qual) research design. For the quantitative portion, the researchers obtained permission to use a minimally modified version of the Casey-Fink Graduate Nurse Experience Tool (Casey & Fink, 2008). Participants (n=97) were recruited on the Magnet learning community website and email distribution lists. Upon completion, the results were assessed using the mean score for four survey domains and indicated perceptions of NGN comfort and confidence in performing nursing skills. As the survey was anonymous, consent for this portion was obtained using applied consent indicated in the survey. The aggregated data was assessed for potential themes, which informed the semi-structured interviews for the qualitative portion. A virtual interview was conducted with volunteer participants (n=11) recruited using the same website and distribution lists. Informed consent was obtained before the interview and retained in a file folder on the password-protected computer with the survey data.
The interview lasted approximately one hour, discussing the results of the quantitative portion and their perceptions of NGN readiness for practice surrounding the themes identified. Following the interview, the recording was transcribed verbatim and sent to the participants for validation. No names or identifying information were recorded in the transcription, and the transcript was stored on a password-protected device.
Data were analyzed by the descriptive phenomenology method of inquiry using bracketing, analyzing, intuiting, and describing (Kumar, 2012). The data was rigorously assessed using Colaizzi’s process for phenomenological data analysis examining the interviews (Creswell, 2009).
Results: Employer’s perceptions indicated that NGNs might some essential competencies for independent practice, such as clinical problem-solving, communication, documentation, prioritization, and delegation. Although NGNs
have developed professional identity, academic learning techniques did not prepare NGNs for practice. The nursing skills that NGNs struggles with included code response, ECG/telemetry monitoring and interpretation, IV insertion, tracheostomy care, and giving verbal reports.
Conclusions/implications: This study adds to the growing body of evidence that calls for transforming nursing education. Although transition-to-practice programs assist NGNs in developing competence, changes to nursing curriculums are needed. More study is needed to guide the changes to nursing education.
Background and purpose: Strong nurse communication is essential in involving patients in their care and engaging them in self-care and positive health outcomes. Active empathetic listening (AEL) is also required for truly understanding what the patient concerns and questions are. It was noticed that our HCHAPS scores were inconsistent in the "nurse explain" domain. Even though bedside nurses explain almost everything during their shift, if the patient is overwhelmed or not feeling understood then communication is not received.
Review of literature: Meyrs et al. (2020) determined a key indicator of patient experience is enhanced when the nurse listens using active empathic listening and explains things in a way the patient can understand. Negative outcomes can also occur when patients feel they are not understood or listened to. The nurse needs to make sure they do a good job of explaining so the patient understands. (Landis, 2021).
Goal statement: The goal of this project is to improve the quality of patient care as evidenced by an increase the percent box top Hospital Consumer Assessment of Healthcare Providers and Systems (HCHAPS) scores in the nurses explain domain.
Methods: The process for this project was initiated by our clinical nurses participating in our unit shared governance council. To raise awareness, journal club focused on articles that addressed nurse communication from the perception of the patient. During bedside report, plan of care rounds, and general nursing care, nurses verbalized that they would explain. Instead of just asking if the patient had questions, they would use scripting to explain the procedure, medication, or any process that is impacting the patient. Colorful signs were hung in the patient room that read “Nurses love to explain.” When the nurse manager rounded, she would ask the patient to provide an example of
something that the nurse explained. Paper was also provided to the patient with pre-set questions about medications, discharge questions, and tests or procedures.
Outcome data: Data was obtained monthly from HCAHPS top box scores. The target was 79.1%. December pre-intervention actual was 75%, January was 78.3%, February was 83.3%, and March was 87.5%. Results show a steady increase in satisfaction with nurse explains from initiation of project in January. That is a 17% increase is patient satisfaction with how our nurses explain in a way that can be understood.
Implications for nursing: Patient experience is a key component of the performance metric in the hospital. Improving health literacy and understanding can also directly impact and improve patient outcomes and value-based care.
Purpose: The purpose of this interprofessional, patient-centered project was to implement a unit-based 6-component evidence-based pain management bundle (PAIN-X Therapy) to improve medical-surgical patients’ perception of pain care quality, 24-hour pain experience outcomes, and opioid usage.
Background/significance: Pain in the United States is a public health crisis. Inadequate and undertreatment of pain among hospitalized adults potentially contributes to chronic pain syndromes and opioid dependency. There is some evidence to support a benefit in pain care quality associated with using a bundle that includes non-pharmacologic options. Pain care bundling 1) actively engages patients as a treatment partner, 2) applies complementary and conceptually aligned components, and 3) improves patients’ ability to cope with pain.
Method(s): A quasi-experimental design was used to test whether PAIN-X therapy on 1 acute surgical unit (intervention) vs. usual care on 1 trauma surgical unit (control) improved: patients’ perception of pain care quality (PainCQ-I© & PainCQ-N©); 24-hour pain experience outcomes (average pain, time in severe pain, medication administration
frequency, % pain relief, ability to cope with pain), and monthly unit opioid usage. Outcomes were measured each week using a convenience sample of eligible patients (on unit >24-hours, >18 years, acute pain, active opioid order). Unit characteristics (% BSN, RN experience, skill mix, FTEs, RN:patient ratio, RN-HPPD, RN productive
hours, combined patient days, and opioid usage were collected monthly.
Results: Data from 127 (intervention, n=59; control, n=68) consented participants were included in this 6-month interim analyses (age M=44.79, Mdn=44, IQR=34-57). Differences in mean monthly unit staffing characteristics included 75% BSNs on intervention, 61% on control; 2.1 years’ experience on intervention, 3.7 on control; and 16.33 FTEs on intervention, 22.4 on control. No group differences (p>0.05) identified between groups for participant characteristics (age, sex, race, ethnicity, marital status, education, chronic pain, opioid naive). No differences (p>0.05) between groups for pain care quality: PainCQ-I© (α=0.66; intervention M=3.94, SD=1.24; control M=4.31, SD=1.03) or PainCQ-N© (α=0.92; intervention M=5.00, SD=0.95; control M=5.11, SD=1.01). Three 24-hour pain experience outcomes had significant between group differences: pain medication administration frequency, % pain relief, and ability to cope with pain. Control reported receiving pain medication significantly more often (26-50% of the time, 63/68 [92.7%] than intervention (37/59 [62.7%], Fisher exact, p=0.0002, two-tailed). Intervention reported a significant increase in 1) % relief from pain medication (M=65.4%, Mdn=70, IQR=50-80; U=4438, n1=68, n2=59, p=0.0012, two-tailed) vs. control (M=51.47%, Mdn=23.13, IQR=40-70) and 2) ability to cope with pain (M=7.49,
SD=2.75) vs. control (M=6.32, SD=2.49), (U=4377, n1=68, n2=59, p=0.0032). Unit-based opioid oral milligram morphine equivalent (MME) usage reflected the intervention (M=34,935.83) unit used 6.63% more MME than control (M=32,694.89).
Conclusions/implications: Intervention group participants did not perceive an increase in pain care quality compared to those in the control group. However, intervention group participants reported a higher % relief from pain medications and an increased ability to cope with pain than the control group. Continuation of the study is warranted to test the causal link between PAIN-X therapy and pain-related outcomes, including the impact of intervention fidelity and confounding variables such as unit staffing characteristics.
Purpose: The purpose of this quality improvement initiative is to prevent falls and allow safe passage of our medical-surgical patients. This initiative will introduce an auditing tool that will be used to ensure evidence-based practices are in place to help prevent these falls from occurring. The patient population on Baylor Scott and White’s fourth floor 36-bed unit includes orthopedics, stroke, surgical, and cardiac catheterization. This unit realized that there was an opportunity for improvement after determining the unit fall ratio was greater than the NDNQI benchmark of 3 falls per thousand patient days. The project was undertaken as a quality improvement initiative reviewed by IRB. It was determined IRB oversight was not required for this project.
Description: During the prior 12 months, the fourth floor had a total of 40 falls in which 11 patients were injured. In the month of September 2020, the fourth-floor leadership began auditing all patients scoring moderate or high on the Johns Hopkins Fall Risk Assessment Tool (JHFRAT). According to research, having a fall bundle and daily auditing tool in place decreases the number of falls by educating and partnering with patients (Loresto, Grant, Solberg, & Eron, 2019). The fourth-floor falls committee created an evidence-based fall bundle audit that includes daily patient education, updated fall risk sign on door, gait belt in room, bed in lowest position with alarm
activated, fall risk band, yellow non-skid socks on patient, room clear of all tripping hazards, and patient possessions within reach. After completing the daily audit, the leader coaches the nurse and care technician on any missing components. This coaching occurs in real time and allows the team to come together to ensure all aspects of the fall bundle are in place moving forward. In addition to one-on-one coaching, the results of the shift fall audit are discussed during safety huddle which occurs once per shift. Any barriers found during huddle are elevated to interdisciplinary department leadership. As this project unfolded, there was an opportunity to partner with other clinical areas to align facility goals and best practices. As a result, a facility falls committee was created which includes front-line staff from other inpatient units, radiology, physical and occupational therapy, physicians, quality department, and the vice president of patient care.
Evaluation: Prior to creating the fall bundle audit, the fourth floor had a total of 14 patients fall, 3 with injury, in the 5-month period of April to August 2020. This translates to an overall fall rate of 3.04 and fall with injury rate of 0.43. In the 5-month period post-intervention, the fourth floor had a total of 8 falls, 1 with injury. The overall fall rate was 1.59 and fall with injury rate was 0.21. Therefore, the fall rate decreased by 47.7 % and fall with injury rate decreased by 52.32%. Through interdisciplinary collaboration, we are continuing to work towards zero harm by decreasing patient falls.
Recently, front-line nurses in the medical-surgical specialty have self-reported increased levels of workplace-related stress due to the COVID-19 pandemic. While volunteer therapy dogs were often used to provide self-care and stress relief to nurses, access had been restricted due to mandated visitor restrictions. Traditionally, studies have shown a decrease in stress, depression, and chronic pain in the patient population in coordination of therapy dog programs. Animal-facilitated therapy programs research has shown an improvement in workplace satisfaction of medical-surgical nurses (Ginex et al., 2018). The intervention of interaction with animals shows purpose to improve physical, mental, emotional, and cognitive abilities in subjects (Hall, 2018). A program partnering with a national organization providing comfort dog services was brought to the organization virtually to reach nursing associates during their shifts. Following the implementation, nurses reported a 37% reduction of workplace-related stress immediately following the virtual comfort dog visits.
The clinical educator for medical-surgical nurses developed the plan to partner with the comfort dog organization to implement virtual sessions for all shifts caring for patients on COVID units. The implementation included coordinating technology to offer the sessions during nurses’ shifts and creating an environment to promote stress relief during busy shifts.
Virtual comfort dog sessions included time for nurses to gather and reflect on their workplace-related stress levels prior to and after the virtual session. They were asked to rank their workplace-related stress from mild to severe. Virtual comfort dog sessions lasted from 10 to 45 minutes, with staff rotating through for the opportunity. While unable to touch the dogs, nurses were able to verbally interact with the dogs and handlers during the virtual visit to both reflect on and discuss coping mechanisms. Telemedicine has become a more widely accepted form of communication in health care as a result of the restrictions placed on face-to-face communications during the
COVID-19 pandemic. A virtual approach to stress relief using comfort dogs can be utilized in other organizations to promote workplace-related stress relief and a healthy work environment. A further recommendation includes implementation of virtual pet therapy sessions to include patients that were excluded due to isolation barriers.
Purpose: In adult incontinent patients, how does not using adult incontinence briefs compare with the use of adult incontinence briefs affect moisture-associated skin damage within the hospitalized community?
It was found on a medical-surgical unit that patients who were using briefs have an increased incidence of moisture-associated skin damage. There was no correlation to severity of diagnoses or level of care needed. This prompted the project.
Research: Evidence appraisal via the 2017 Johns Hopkins Model. Pub Med and Ovid were searched using the search terms moisture-associated skin breakdown, briefs vs. ads, pads, briefs, from 1994 until present. A total of 8 articles were used. 7 of the articles were level-three quality B or higher. The remaining article was level V, quality B.
Research recommendations: Practice change with incontinent patients was implemented to no longer use briefs while patients were in bed or in the chair greater than 2 hours. Incontinent patients were only briefed with ambulation.
Results/conclusions: Overall, by not using briefs while in the bed or chair, our data shows that patients had an improvement in their skin integrity. The total number of MASD patients with the intervention decreased by 68% with the intervention of using pads only.
Poor communication contributes to unnecessary transfers of skilled nursing facility (SNF) residents to acute care hospitals (Ashcraft & Owen, 2017). Approximately 25% of admissions from SNFs are deemed to be avoidable (Ashcraft & Owen, 2017). The Centers for Medicare and Medicaid Services impose penalties for patients who are readmitted within 30 days of discharge (Haley et al., 2016). Two small community hospitals were challenged with readmissions from local skilled nursing facilities. After performing a literature search, the team decided to standardize handoff communication to the skilled nursing facilities verbally and in the discharge paperwork. The situation, background, assessment, recommendation (SBAR) method of communication was designed to ensure critical information regarding patients was not missed. We hypothesized that an SBAR report from the hospitals to the SNFs would reduce readmission rates.
A retrospective cohort design study with pre- and post-intervention arms was conducted. From September 2019 to February 2020, patients discharged from the two small community hospitals were enrolled in the pre-intervention group. The standardized SBAR report was created in collaboration with the post-acute care coordinator, managers, bedside nurses at all facilities, directors of nursing, and the clinical nurse specialist. In September 2020, the SBAR to the SNFs was implemented, and patients discharged to the SNFS were enrolled.
The pre-intervention group contained data from September 2019 to February 2020 and had an average of 9.35 readmissions per month. The post-intervention group contained data from September 2020 to February 2021 and had an average of 6.3 readmissions per month. This data yielded a 32.6% reduction in 30-day readmissions from SNFs with a p
During the COVID-19 pandemic, medical-surgical nurses at a small rural community hospital accepted the challenge to care for more acutely ill patients. During the initial wave of the COVID-19 pandemic, patients were intubated; however, during the second wave, the decision was made to utilize high-flow nasal oxygen therapy (HFNO) when appropriate and maintain patients outside of critical care units. The institution had already created a tool to identify patients at high risk for requiring critical care that was completed daily. The clinical nurse specialist for the institution recognized the need to provide an objective measure for medical-surgical nurses to identify declining COVID-19 patients on HFNO. A literature search was performed, and the evidence-based tool the ROX Index for Intubation was implemented (Suliman et al., 2021). The ROX index predicts the likelihood that a patient will require intubation (Mellado-Artigas et al., 2021). The authors hypothesized that using the ROX index would assist with the early identification of those patients requiring intubation.
The clinical nurse specialist received approval to institute its use and began education. Nurses and respiratory therapists downloaded a free application that calculated the ROX score for the clinician. The score was then communicated with the hospitalist and pulmonologist. Patients initially placed on HFNO's ROX score was calculated at 2, 6, and then 12 hours for the duration of their stay unless there was a change in condition. If the patient’s condition changed or the settings on the HFNO were adjusted, the ROX was again performed at 2 and 6 hours before being performed every 12 hours.
Patients admitted from September 2021 to December 2021 were included in this retrospective review. The sample included 80 patients on HFNO, with only 8% requiring intubation. The ROX score was 90% effective in identifying those that required intubation, allowing for the intubation to be performed in a controlled setting before transferring the patient to critical care.
The ROX score was a valuable tool to ensure patients received appropriate care during the COVID-19 pandemic and empowered the medical-surgical nurse to have an objective measure of patient decline. Additionally, the ROX application was free to download; therefore, it was a fiscally responsible intervention to ensure patient safety. This project could easily be replicated in any medical-surgical unit caring for patients on HNFO. Limitations to the study include a retrospective review; unknown compliance rates for ROX use, as it is not built into the electronic medical record; and the impact of experimental treatments during the second wave.
• Mellado-Artigas, R., Mujica, L. E., Ruiz, M. L., Ferreyro, B. L., Angriman, F., Arruti, E., Torres, A., Barbeta, E., Villar, J., & Ferrando, C. (2021). Predictors of failure with high-flow nasal oxygen therapy in COVID-19 patients with acute respiratory failure: a multicenter observational study. Journal of Intensive Care, 9(1), 1–9. https://doi.org/10.1186/s40560...
• Suliman, L. A., Abdelgawad, T. T., Farrag, N. S., & Abdelwahab, H. W. (2021). Validity of ROX index in prediction of risk of intubation in patients with COVID-19 pneumonia. Advances in Respiratory Medicine, 89(1), 1–7. https://doiorg.lopes.idm.oclc....
As part of a clinical nurse leader (CNL) capstone project, the primary investigator performed a gap analysis on hematology/oncology unit to determine the concerns staff had that prevented them from taking the best care they could of their patients. One opportunity that arose multiple times was that there was a lack of standardization when taking care of patients admitted with sickle cell disease (SCD).
One way that nurses can foster standardization of care is in the creation of smart notes (dot phrases) in the electronic health record, a relatively simple way to inform and guide care. In this project, a smart note was developed to guide nurses in writing their daily nursing notes for patients admitted with SCD. This smart note prompted nurses to answer a series of choices or yes/no questions and write an individualized note on the patient. This project was submitted to the Drexel University Institutional Review Board, protocol #2012008263, and was classified as “not human research determination.”
The primary investigator presented the smart note to nurses on the unit, who were shown how to toggle through choices. In addition, reminder stickers were placed on all nursing touchdown stations about how to access the smart note. The primary investigator ran reports from the EHR from February 1, 2020, through April 30, 2020, and from February 1, 2021, through April 30, 2021, to track the number of SCD ER visits and inpatient admissions. These reports contained information on the type of encounter (ER vs. inpatient), the admit date/time, the discharge date/time, admitting department, age, sex, admitting source (ER, outpatient clinic, or another facility), encounter diagnoses, admission diagnosis, inpatient readmission (yes or no), and inpatient/ER readmission (yes or no). These reports were exported as Excel spreadsheets so that the data could be sorted and tabulated more easily. In addition, reports were run to determine compliance in the utilization of smart notes by nurses.
The goal for this project was to see a 10% decrease in average LOS between 2020 and 20201; however, in comparing the same three-month time period in 2020 and 2021 for 7 Schiedt, the average LOS increased from 4.76 days to 5.05 days, representing a 6.09% increase, which did not support the hypothesis. It is difficult to draw specific conclusions from the study time period because during 2020 the COVID-19 pandemic began and health care systems were faced with incredible uncertainly, intense pressure on health care workers, and a lack of proper resources necessary to protect staff and treat patients. There were many variables that contributed to the overall results. However, staff and the primary nurse practitioner caring for this population appreciated its ease of use and amount of information that was included. Because standardizing care of patients with SCD was a major concern during the microsystem assessment, this first effort was deemed successful, and the use of the SCD smart note will be taught to other nurses who care for SCD patients in the hospital.