Purpose: Examine unique contributors to falls among hospitalized adult cancer patients with hematologic malignancies.
Significance: Falls represent a major cause of morbidity, mortality, and functional decline in hospitalized adult patients with a cancer diagnosis. In this population, falls may result in various injuries such as bone fractures, loss of independences, and higher medical expenses from increased length of stay. Sequelae of falls may also result in
post-fall anxiety with a subsequent increase in dependence on health care providers, and fear of a repeat fall. According to the World Health Organization, an estimated 684,000 individuals die from falls and adults older than 60 years of age suffer the greatest number of fatal falls. Complications that may result from a fall in this population include subdural hematoma, excessive bleeding, and death. The identification of strong fall predictors is essential in implementing an effective fall prevention program.
Method(s): A retrospective case-control study reviewing 94 medical records was conducted to answer the following research question: “What unique predictors of falls exist in hospitalized adult hematology patients?” A convenience sample of 94 participants was drawn from a larger parent study sample of 2,472 individuals who were hospitalized for care associated with leukemia, lymphoma, multiple myeloma, or stem cell transplantation. The parent study examined the impact of a video-based educational intervention on the occurrence of falls among hematology patients hospitalized for the management of cancer treatment and its complications. In this study, the Donabedian’s quality care model served as the conceptual framework to guide the retrospective review.
Result(s): There was no statistical demographic and clinical significance in age, race, gender, underlying diagnoses, and complete blood count (CBC) values. However, there was a statistically significant relationship between fall incident and fall risk assessment score on admission (p = .013). More than half of participants who fell were identified to be at a higher risk for falling (63.6%) than medium fall risk (38%). The three themes of care processes, technology-related interventions, and physical environment modifications provided insight into the proportion of patients who fell with the fall risk assessment score utilizing the Hester Davis scale. A stepwise regression model revealed that fall risk assessment scores were significant predictors of falls in this population. Nurse-reported data on fall prevention procedures demonstrated a lack of consistency in the implementation of required prevention measures on patients who were identified to be at a higher risk of falling.
Implications: Fall prevention research conducted in hospitalized patients has not examined patients with cancer independently to determine why they are at greater risk for falls and fall-related injuries. Ongoing utilization of the Hester Davis scale for fall risk assessment and consistent evaluation and modification of fall prevention measures
is imperative for sustainable fall prevention efforts. Recommendations for nurse leaders on fall prevention in hospitalized adult patients with hematologic malignancies include replication of the current study with a larger sample, consistent implementation and monitoring of fall prevention measures, and further studies of fall prevention that include patient engagement and interdisciplinary collaboration in fall prevention efforts.
Background: Clostridioides difficile (C. difficile) is a spore-forming anaerobic bacterium that causes diarrhea to life-threatening intestinal conditions. According to the study done by Centers for Disease Control in 2011, clostridioides difficile infection (CDI) can cause immense suffering and mortality for thousands of Americans. CDI is acquired from an endogenous source or from spores in the environment, most easily acquired during hospitalization. Compliance with evidence-based practices is known to reduce hospital-onset C. difficile infections and increased patient safety.
Problem: The rate of hospital-onset CDI among the adult inpatient population at Johns Hopkins Bayview increased in 2017 and through 2018.
• To reduce hospital-onset C. difficile infection rate to the hospital benchmark
• To implement a multidisciplinary, multi-faceted approach to reduce hospital-acquired C. difficile
Pre- and post-measures
• NHSN hospital-onset C. difficile rate
• Clostridiodes difficile heat map
Action steps: C. difficile heat map updated weekly and available to all staff
• Daily C. difficile rounding by HEIC team
• Nursing orientation revised to include pertinent C. difficile care and prevention strategies
• Represented organization in the Maryland SPARC (Statewide Prevention and Reduction of C. Difficile Collaborative)
• High-impact C. difficile prevention tips article developed for in-hospital publication for nursing
• Feedback provided at unit-based safety rounds
• Developed isolation guidelines disseminated to staff and patient care coordinators Conducted a one-year follow-up survey on earlier knowledge gaps identified
• HERO events entered to provide for individual feedback to staff as needed
• Developed a clostridiodes difficile provider guide and posted in work areas
• Included C. difficile information in annual intern orientation
• Daily calls to EVS to identify patient care rooms for UV light terminal cleaning
Conclusion: There was a 30% reduction in the hospital-onset C. difficile rate for JHBMC for calendar year 2019. These efforts saved patients’ lives and helped significantly reduce unnecessary health care-associated costs. The multidisciplinary efforts have contributed to the recent improvement in hospital-onset C. difficile cases. It is likely that this multifaceted approach will be sustained to ensure early detection, reduce risk of transmission, and increase patient safety.
Description: Nurses provide the bedside care required to safely navigate the COVID-19 patients through the disease process. The purpose of a playbook and workflow changes in the medical-surgical COVID-19 areas was to deliver quality direct patient care with decreased risk of exposure to the front-line staff. Workflow changes needed to be put in place to limit front-line staff exposure as well as to conserve personal protective equipment while caring for patients. Goals were identified: 1) follow infection prevention and control recommendations, including conserving PPE; 2) ensure proper use of PPE and education; 3) provide in-person care in the safest way and reduce contact time to minimize disease transmission to care givers; 4) identify means for communication to patient and families; and 5) develop process to keep staff informed of most recent CDC and facilities recommendations.
Application: Review of pre-COVID-19 workflow and PPE use was examined. In relation to communication to patient and families a plan using technology (Facetime, iPhone, etc.) and daily phone calls was instituted. Location of equipment such as IV pumps outside of room to decrease staff exposure time, number of staff members in room during CODE blue. Placement of patients in rooms with windows for viewing. Bundling of staff care activities such as vitals, medications, dressing changes, etc.
Communications through team huddles and facility intranet on recommendations, as well as available PPE supplies and equipment. Information related to changes to medical and nursing care of the COVID-19 patients were communicated as care evolved to the nursing team and other disciplines.
COVID-19 sheds light on how vital it is to use PPE properly. Receiving comprehensive training on when and what PPE is necessary; how to don (put on) and doff (take off) PPE; limitations of PPE; and proper care, maintenance, and disposal PPE were critical. Nursing accomplished this by utilizing a CDC video, one-on-one training, guidelines on when and what PPE to use, and demonstration of donning and doffing PPE. When team members enter a COVID-19 patient’s room, a second nurse observed the individual’s use of PPE to ensure proper procedure was followed.
Educators rounded to support and re-education on proper PPE use, donning, and duffing. The focus was on protecting staff as well as patients.
Discussion and conclusion: Nurses working on the front line providing direct care to individuals with COVID-19 are required to be competent and knowledgeable about PPE and a planned daily workflow to care for these patients. The immediate efforts to control and prevent COVID-19 is an evolving process as new information is discovered about this disease. As result of the workflow changes, PPE was conserved; staff exposure and room time were reduced; and effective communication strategies for staff, patient, and families resulted.
Purpose: To improve implementation of safety measures for mental behavioral health patients on medical-surgical units. To develop new policies and procedures reflecting the new Joint Commission (JC) standards related to patient safety of these patients.
Mental and behavioral patients are frequently placed on medical-surgical units for treatment of medical problems. As a result, to increase awareness of the Joint Commission (JC) standards related to patient safety. Our organization formed a task force to review best practices to address the safety of this population.
Effective July 1, 2019, the Joint Commission rolled out new requirements in the National Patient Safety Goals (NPSG 15.01.01) to address suicide prevention. These goals were designed to improve the quality and safety of care of patients who are at high risk for suicide. Suicide is the 10th leading cause of death in the US. The safety goals and
requirements apply to patients admitted to psychiatric units, as well as psychiatric patients being evaluated or treated for psychiatric event requiring admittance to general hospital for medical reasons. These patients require a safe environment to minimize their potential for self-harm or harm to others.
Description: A lack of available mental health facilities capable of treating both physical and mental health emergencies exist. Care and maintaining safety of mental behavioral health patients on medical-surgical units, as well as emergency departments, present unique challenges. The most common mental health problems experienced by acute hospital inpatients are self-harm, depression, dementia, adjustment reactions, and abuse disorders. The balance of providing quality and safe mental health in these areas have been recognized by JC. Staff in acute hospitals have limited knowledge about legal processes for detaining mental health patients and mental health care. Medical-surgical staff are often unprepared to meet these patient’s needs and do not recognize potential items of harm in the environment.
A dedicated multidisciplinary team was established to develop processes to ensure safe environments and staff training. A literature review was conducted. JC guidelines on ligature risks and mitigation and environmental concerns were reviewed and considered in developing processes and policy for medical-surgical units.
Evaluation and outcome: Based on the information obtained mitigation plan with processes to help in preventing self-harm and harm to others, monitoring guidelines for high-risk patients were developed. Staff was educated on the processes, including training and assessments related to observations, care of patients with mental behavior diagnoses, and establishing a safe environment. A monitoring process was put in place to measure compliance to new guidelines and procedures.
Background: Patients with dementia, encephalopathy, TBI, autism, psychiatric illness, etc., frequently suffer from anxiety and/or agitation during hospitalization. Among items which have demonstrated an effective calming modality are weighted blankets (Mulen, Champagne, Krishnamurty, Dickson, & Gao, 2008). For the months of June through
November 2019, patients on the trauma medical-surgical unit required more than 2,600 hours of constant supervision from their admission throughout their stay in rehabilitation or discharge to home, with an average of 435 hours per month. The goal of this quality improvement project was to decrease the need for one-on-one constant supervision with the integration of the “let’s be calm” boxes. Falls prevention was also monitored during the intervention period. This particular unit maintains a consistent falls rate below the national benchmark. These boxes included multiple non-invasive interventions such as weighted blankets, fidget spinners, baby dolls, and other distraction items for patients suffering from agitation or dementia. The cost of the boxes was funded by an internal
Purpose/aims of project
• Decrease unit-based constant supervision rate from baseline (average of 435 hours) per month to an average of 370 or less
• Increase compliance of use of the boxes to 90% of constantly supervised patients
• Reduce falls rate by 10%; current benchmark (2.20 falls per 1000 pt days)
Methods: The grant allowed for the initial purchase of 20 baby dolls, 20 weighted blankets, word search books, and fidget spinners. Let’s be calm boxes were created with these items and stored on the unit. Criteria for use were established, shared with staff, and posted on the actual boxes. Staff were instructed to use items they felt would benefit their patients, and a list was created to track the results. The nurse manager created a spreadsheet in her computer where patient outcomes (constant supervision hours and falls) were tracked. The staff received monthly feedback regarding the boxes and the positive impact they were having on constant supervision while maintaining the unit’s falls rate well below benchmark.
Subjects/setting: All patients admitted to the acute trauma unit at risk for falls at a level-1 trauma academic medical center were included. The unit has an average daily census of 24, the length of stay of 3.37 days, and there is a staff of 33 registered nurses and 16 ancillary staff.
Results: The unit achieved a decrease in the average monthly use of constant supervision of 195 hours for a 5-month period, with two months at zero constant supervision hours. This was a decrease of 55% from the baseline. This was paired with a 36% decrease in the unit falls rate and well below the national benchmark for falls of 2.28 falls per 1,000 patient days.
Implications for nursing: Agitation is extremely distressing to both family and caregivers alike. Dissemination of knowledge and best practices regarding managing agitation, sharing of distraction strategies, and implementation of calming interventions has improved the management of agitation on this unit and throughout the medical-surgical service line.
Background: In a very busy, high-acuity, and high-intensity general medicine unit, Magnet-designated teaching hospital, graduate nurses find it very challenging to manage, prioritize, and hardwire competing tasks and skills in the increasingly complex hospital environment and complex patient populations. Some graduate nurses caught in the pandemic were not able to get adequate clinical exposure to help prepare them transition to professional nursing practice. The hurdle of effective time management can be particularly distressing for newly licensed registered nurses (Pellico, Brewer, Kovner, 2009;57, Unruh, Zang, 2013;50). The top reasons for leaving include perceptions of excessive workload, stress, and inability to do quality work (Unruh, Zang, 2014; 30).
Historically, the model we used in onboarding graduate nurses was focused on their ability to manage multiple patients, from one patient up to five patients in a span of 12 weeks, which also included 6 days of internship classes and week one as general hospital and nursing orientation. 34 interns completed post-orientation survey. We recognized then the need to standardize nursing orientation to support both novice and tenured clinical coaches.
• Conducted a literature review on skills stacking and cognitive framework.
• Developed an orientation plan that includes skills stacking and routinization to guide both the intern and the clinical coach. Skills stacking is a workflow management process which enables the graduate nurse to organize, prioritize, and manage their time. Routinization is developing habits or practices that are repeated in routine situations. Improving stacking skills decreases stress among newly licensed registered nurses and helps promote a healthier work environment, supporting safety and quality in health care (Ebright, 2010).
• Provided clinical coach POW wows.
• Reviewed concept of skills stacking and routinization, discussed expectations and implications of the new model and required paperwork documentation.
• Conducted bi-weekly check-ins with the intern, educator, clinical coach, and a member of the unit leadership team as able.
• Discussed what is going well, areas of improvements, skills stacking progression, concerns, and goals for the next two weeks.
• Discussed clinical coach concerns as applicable.
• Performed just-in-time mentoring to clinical coaches as needed.
Results: Completed post-orientation survey showed favorable results. 18 of the 19 interns felt that skills stacking helped prepare them develop a routine and master basic concepts and skills of assessment, documentation, and medication administration. Clinical coaches are in favor of the skills stacking model versus the increasing number of patient progression model. Qualitative data revealed great guide for the interns by knowing what to expect and focus on and great guide for the coaches especially when handing off the intern to a new coach or a secondary coach.
Length of orientation decreased from 12 weeks to 10 weeks.
Five other nursing units adopted the skills stacking model. The center for nursing education and research department plans to adopt this model throughout the facility.
Purpose/goal: Patients today have a number of options to consider when determining the optimal location for receiving outpatient infusion therapy and specialty treatments. Defining the benefits and challenges of each site of care will assist nurses to help patients make informed decisions related to infusion therapy treatments.
Background: Chemotherapy, infusions for autoimmune disorders, and other medication treatments are frequently administered outside of the hospital setting, especially during the COVID-19 pandemic, and forecasts indicate these site-of-care
trends will continue in the future.1, 2 In addition to the hospital outpatient department (HOPD), infusions may also be administered in a stand-alone infusion center, a dedicated infusion area within a specialty medicine clinic or office building, or a patient home when coordinated through a qualified home health agency. Each service delivery
platform has benefits and challenges as well as cost considerations. Expanded health care coverage through the Affordable Care Act has supported access to infusion services previously unavailable for many; however, reimbursement and out-of-pocket expenses vary and can limit where these services are delivered.3
• According to the American Cancer Society Facts & Figures (2021), almost 1.9 million new cancer cases are expected to be diagnosed in 2021. These numbers do not account for the unknown impact of COVID-19 and delays in seeking care.4
• Approximately 80 autoimmune disorders exist. In 2012, Drs. Scott Hayter and Mathew Cook published a study showing there is an estimated prevalence in the US of 14.7 million people with an autoimmune disorder (based on the current US population of 320 million).5
• The 2019 National Home Infusion Association (NHIA) study reported that home infusions increased 300% since the last industry study in 2008.2
Method: A systematic review of medical literature, infusion nursing publications and websites, governmental regulations and insurance coverage, and private insurance policies related to outpatient infusions were utilized to formulate the treatment location options and associated requirements, benefits, and challenges.
Results: The four outpatient site-of-care options noted previously were categorized with benefits and challenges of each to provide a reference guide for nurses and patients. Factors that may limit treatment location choices include type of drug administered, patient health status, and insurance coverage.
Conclusion: Nurses, patient navigators, discharge planners, and infusion therapy managers play a vital role in patient hospital discharge planning or management of outpatient infusion therapy care. In order to make informed decisions, it is important that patients understand the options and requirements associated with each treatment site.
1. 2019 Medical Pharmacy Trend Report. Magellan Rx Management Medical Pharmacy Trend Report™.
2. National Home Infusion Association (NHIA). About Home and Specialty Infusion. https://www.nhia.org/aboutinfu...
3. American Cancer Society. Cancer Facts and Figures. 2021 https://www.cancer.org/content/dam/cancerorg/research/cancer-facts-and- statistics/annual- cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdf
4. Autoimmune Registry, Inc. (ARI), 501(c)(3) non-profit umbrella organization that provides a hub for research, statistics, and patient data on all autoimmune diseases. https://www.autoimmuneregistry.org/autoimmune- statistics
5. Advisory Board Company. Payer trends impacting health system infusion services. Published on October 27, 2020. Accessed on 01-27-2021 from www.advisory.com/topics/classic/2020/10/payer-trends-impacting-healthsystem-infusion- services
Purpose: Research has shown that hospital staff are responsible for most of the noise and interruptions occurring at night. A decrease in sleep has been linked to increased length of stay, the risk for falls, and delirium while in the inpatient setting. Sleep disruption often begins around midnight with laboratory testing and continues throughout the night due to frequent vital signs and radiology procedures. To date, nighttime quality improvement projects found in research have been focused on the critical care environment. As a result, the quiet at night initiative was created to improve patient experience at night in the medical-surgical setting.
Description: The Quiet at Night pilot was initiated on two units from September 1 through October 31, 2020. Quiet at Night was defined in collaboration with the interprofessional team, which included laboratory, radiology, environmental services, public safety, and the medical executive committee. Through this team, quiet hours were established from midnight until 5 AM to allow patients to rest. During this time, staff dimmed the lights and care was clustered to allow for a period of uninterrupted sleep. Each patient was provided with a sleep menu that lists several available options for patients to help them have a restful night. The sleep menu included items such as a quiet kit (which contained an eye patch, earplugs, lip balm, word puzzle, and pencil), an extra blanket or pillow, a warm washcloth/oral care, a warm beverage, earphones, a care channel card, and aromatherapy. Unit decibel meters, also known as "yacker trackers" were also utilized at the nursing station during quiet hours to serve as a visual and auditory reminder to staff when they are too loud.
Evaluation/outcome: Through Quiet at Night, a decrease in noise levels resulted in fewer interruptions at night and improved patient restfulness. When patients were offered items from the sleep menu before bedtime, they reported an improvement in the number of hours of sleep. The project also increased staff awareness about the impact of noise on patients’ sleep. When staff became aware of patient feedback, staff seemed more motivated to act. The use of quiet hours likewise resulted in decreases in call light use, which decreased stress levels among nurses and promoted a healthier work environment.
Post-trial rounding Press Ganey patient survey results, in addition to HCAHPS results, were reviewed and analyzed for improvement in patients’ quality of sleep and perception of the quietness of the hospital environment. Of these results, 85-91% of patients reported experiencing a restful environment at night. In addition, an improvement was seen in 2nd and 3rd quarter HCAHPS scores, moving the hospital out of the bottom quartile percentage.
Quiet at Night has become one of the first initiatives to have successfully embraced interprofessional collaboration across this facility. After completing the trial, the night council presented an executive summary of recommendations to the hospital administration detailing lessons learned, challenges, and new changes to test and spread Quiet at Night to other hospital departments.
Introduction: Nursing students are the future of nursing. Faculty are tasked to teach students to think critically and prepare the student for practice. Innovative strategies are used to improve student success in clinical settings. Of high importance is the ability to quickly and easily access facility policies, clinical practice guidelines, and instructional materials. Often students are unable to locate policies and guidelines that directly guide the care provided. Jamu, Lowi- Jones, & Mitchell, 2016, found the use of quick response (QR) codes may be especially beneficial to technologically savvy health care professionals. Morrison, 2018, found QR codes improve the confidence of nurses using high-acuity, low-frequency equipment.
Innovative strategy: QR code “badge buddies” containing codes to access policies, clinical practice guidelines, and instructional materials were given to students along with verbal instructions for their use. Verbal discussion regarding student perception of important materials was the basis for the inclusion of each item.
Findings: Initial anecdotal feedback from piloting this strategy was positive. Faculty have also expressed the helpfulness of the strategy. “This is the coolest thing anyone has done for us.” “It is so cool that you can get to these without having to dig in the computer.” “These are so helpful, thank you!”
Implications for nursing: Future research will explore student perceptions regarding the QR codes and badge buddies. Statistical results will reinforce anecdotal findings.
Nurses must grow and develop technologically savvy strategies to improve speed and accuracy. This strategy allows nurses/nursing students to quickly access the information needed to provide safe, timely, and evidence-based care.
Purpose: The purpose of this evidence-based practice project was to evaluate whether the implementation of a nursing communication huddle, specific to clostridium difficile (Cdiff) testing criteria, would be associated with a reduction of the number of Cdiff specimens sent to the lab that did not meet criteria for testing.
Relevance/significance: Over-testing for Cdiff can lead to detection of asymptomatic colonization, not active disease. This can prompt overtreatment and detrimental sequalae. Prior to the implementation of this intervention, White Plains Hospital did not have a standard process of nursing validation for Cdiff testing on inpatients. Although
hospital criteria existed for test ordering, it was not consistently followed. This resulted in provider orders and nurses sending specimens without thorough evaluation of whether patients met criteria for testing. The aim of this project was to decrease the number of inappropriate samples sent to the lab, which can lead to avoidance of unnecessary antibiotic use and a reduction in the number of reportable Cdiff infections in the hospital.
Strategy and implementation: The hospital had developed an algorithm and criteria for Cdiff testing, based on the Centers for Disease Control and Prevention guidance. For this project, the primary RN reviewed the algorithm and criteria each time an order was received to test for Cdiff. This review was done collaboratively with their nursing technician and nurse leader to decide whether the patient’s clinical status met criteria to send for testing. If the criteria were met, then the stool was collected and sent to the lab. If any of the criteria were not met, then the RN would discuss the test with the ordering provider. If the provider endorsed testing despite not meeting criteria, then the case was escalated to the associate medical director for approval. The nursing team was educated on the nursing communication huddle in May 2019, and the huddle was implemented on an inpatient pilot unit from June-September 2019. Data was collected via huddle sheets throughout implementation.
Evaluation/outcomes: 26 Cdiff nursing communication huddles were included in this analysis. Although the difference is not statistically significant, the proportion of events where the test was not performed due to divergence from testing criteria was higher post-implementation (43%) than during the preliminary period (28%), Χ2 = 1.71, p = .19. This finding suggests that after implementation of the Cdiff nursing communication huddle, more cases of inappropriate specimens were not processed for testing.
Implications for practice: The Cdiff nursing communication huddle has provided the opportunity for a culture change in the nursing team to collaboratively evaluate the criteria for testing and confirm accordance. The Cdiff nursing communication huddle has become standard practice on all nursing units. The implementation of this
communication tool or a similar tool could benefit nursing units and nursing practice at other hospitals or organizations as well, by providing education and an opportunity for nurses to be a part of evaluating the criteria for testing.