Reducing Hospital Readmissions for Otolaryngology Patients through Post-Discharge Phone Calls

Identification: P01

Purpose: The purpose of this project was to reduce hospital readmissions for post-operative otolaryngology (ENT) patients discharged to home through the implementation of nurse-to-patient post-discharge phone calls. Post-operative otolaryngology patients have complex discharge planning requirements, including the need for home care, equipment and supplies, and detailed patient/family teaching. The risk for complications is high, and emergency department (ED) visits and/or hospital readmissions are not uncommon in this patient population.

Description: The unit leadership recognized the need for follow-up calls to patients on discharge day 2 to confirm that ongoing care have been properly addressed. The call confirms that ongoing care needs have been properly addressed: home care nurse visits are arranged, supplies are delivered, prescriptions are filled, and post-operative appointments are scheduled with the providers. It also provides an opportunity for the patient/caregiver to express concerns about patient’s care and condition. The responses can be categorized as: no issues (offered reassurance), nursing care (provided patient and family education), medical problems (routed to the physician team), logistical concerns (contacted home health care), or urgent evaluation (referred to the emergency department or outpatient ENT clinic). The charge nurse recognized when there is a need to escalate the call to the ENT intern, ENT clinic, home care liaison, etc. It is important to have consistency within the charge nurses making the phone calls. We provided charge nurse educational sessions and worked with the unit-based hospital unit clerk (HUC) to populate demographics to the follow-up tool. We also worked with the physician unit partner (PUP) to obtain dedicated ENT clinic access for patients that may need to be seen prior to their scheduled post-discharge appointments. The quality indicators for this project are the otolaryngology (ENT) 7-day readmission rate and monthly post-discharge call data.

Outcomes/evaluation: This project began in 2018 and has continued with a remarkable decrease in readmission rates. The 2018 (baseline) mean 7-day readmission rate was 7% (range 4-15%). The 2019 (post-implementation) mean 7-day readmission rate was 5% (range 3-15%) Through focused calls to the patients and families, the 2020 (sustained 0-mean readmission rate was 2.80% (range 0-8%). The 2020 mean number of monthly post-discharge phone calls was 32.1 (range 18-51). Post-intervention calls correlated with reduced readmission rates.

Ongoing: We continue to evaluate the discharge follow-up tool for effectiveness, streamline the data collection process, encourage input from charge nurses, audit charge nurses to ensure consistency with follow-up phone calls, and update the unit staff on the progress of the project and the significance of in-depth patient education.


A Proactive Model of a Discharge Lounge Impacts Throughput During COVID-19

Identification: P02

Improving throughput or patient flow of timely discharges can positively impact patient safety and satisfaction. A large metropolitan level-1 trauma center with a 530-inpatient bed capacity with a daily census of 103% capacity implemented a hospitality suite, the discharge lounge, in 2015. Common practice was for staff to refer patients to the discharge lounge. Initial metrics demonstrated low utilization of the discharge lounge; the average volume of patients per month was 51.

2016 hospital leadership tasked the Gonda observation unit to reimagine the discharge lounge to meet the needs of patients with discharge orders that remained in a hospital bed. Gonda observation unit collaborated with hospital leadership, bed control, case management, and front-line staff on non-ICU medical-surgical units through focus groups and surveys. Re-evaluation of the process in March of 2016 resulted in implementing a proactive discharge lounge strike team. Barriers to discharge were identified, systematic interventions were formulated, and a policy for the inclusion criteria and scope of practice for the discharge lounge was implemented.

The discharge strike team was staffed with two full medical-surgical registered nurses that could deploy to the bedside, review the after-visit summary; clarify appointments; discharge medication; and provide bedside teaching for management of surgical drains, urinary catheters, central line dressing care, peripheral intravenous catheter removal, facilitation of discharge medications, and medical equipment delivery. Discharged patients were escorted to the discharge lounge or valet drop-off. The discharge lounge offered concierge services for discharged patients, including assistance for meals when waiting in the discharge lounge for ride pick-up, taxi, or UBER assist, and an opportunity for just-in-time service recovery.

Organizational leadership initiated a daily census alert of the green, yellow, and red census. The yellow census indicated patients were at risk for boarding in the pre-operative care unit and emergency room. The red census put the emergency service at risk for diverting patients. Yellow or red census alerts triggered a system-wide response to identifying barriers to discharge. Bed control partnered with the discharge strike team and lead nurses to strategically identify and discharge patients that met the criteria for the discharge lounge. Collaboration of stakeholders for discharge and utilization of the discharge strike team demonstrated a 35% improvement of throughput in the emergency room.

The volume of facilitated discharges average per month increased from 51 in 2015 to 434 in 2018. The discharge lounge strike team expanded staff and services in 2019, operating seven days a week with four full-time medical-surgical registered nurses. In 2020, COVID-19, an unprecedented pandemic, impacted hospital census and the need for open beds with emergency surge capacity and urgent admissions of COVID-19 patients who would otherwise be admitted through emergency services. The optimization of the discharge lounge strike team of facilitating discharges and urgent admissions of low- and high-suspicion COVID-19 patients significantly impacted throughput, patient safety, and satisfaction as volume discharges expanded to average of 586 per month and average volume of facilitated admission of 85 per month in 2020.


Developing a Decompensation Workshop for Medical-Surgical Nurses to Increase Rapid ResponseCalls

Identification: P03

Background and purpose: Evidence-based practice shows that early identification and treatment of patient deterioration and effective use of rapid response teams reduce unplanned ICU readmissions and out-of-ICU arrests, decreasing hospital LOS and mortality (Al-Omari, 2019). A need was identified for a formal, specialized educational program to empower med-surg nurses with knowledge and skills to aid in early recognition and treatment of patient deterioration. The decompensation, assessment, recognition and treatment (DART) workshop is a quality initiative developed to support med-surg nurses in recognition of patient deterioration, effective interprofessional communication, and patient management during emergencies in acute care.

Description: The workshop consists of one 7-hour session monthly with 8-10 med- surg nurses utilizing 5 simulation scenarios with debriefing sessions, audience response, hands-on training, and lecture. Topics include respiratory compromise, sepsis, cardiac arrhythmias, neurological changes, vital signs/early warning systems, and SBAR/effective communication. A pre- and post-test is used to assess clinical knowledge and self-reported confidence in caring for acutely decompensating patients. Additionally, an objective tool is used to measure simulation performance throughout the day (Liaw, 2011).

Evaluation/outcome: An analysis of pre/post-test scores found that the overall post-test scores were significantly higher (M=78.79, Gmd=12.91) than the pre-test scores (m=78.79, Gmd=11.49), t (99) = -13.589, p


Critical Stress Management: You Are Not Alone

Identification: P04

Purpose: The purpose of this project was to develop and implement a critical stress management program for nurses and other health care providers within a 600+-bed hospital. Crisis intervention is situational “first aid” and consults can be initiated for a variety of situations. An abnormal event can cause stress and/or distress in an average person, and the goal is to mitigate stress and prevent escalating distress. While this program has been functioning for approximately 3 years, requests for consults have increased over the past year during the COVID-19 pandemic.

Description: Nurses are on the front lines of managing patient care and frequently encounter unique challenges and stressors. Stress may be affecting staff members physically and emotionally and in their personal relationships, both within and external to the hospital. Health care providers can experience many acute and chronic often-unpredictable occupational stressors (e.g., sudden death, managing critical trauma cases, dealing with patients with great potential for violent behavior) as well as a sense of not being heard, lack of support, and/or powerlessness/helplessness. This may lead to compassion fatigue and burnout. To support staff members through these difficult situations, we developed and implemented a critical stress management program. We initially sought staff members who were willing and able to attend the combined 3-day assisting individuals in crisis and group crisis intervention courses offered by the International Critical Incident Stress Foundation, Inc. Following successful completion of the courses, the facilitators are able to respond to requests and initiate contacts in a compassionate and helpful way. When a consult is received, a call goes to the facilitators to determine availability as well as background and experience. Participation is voluntary, confidentiality is essential, and only staff members involved in the event should participate. The facilitator takes time to actively listen and encourage the participants to talk about their thoughts and reactions as well as review stress management/coping techniques. For some situations, it is appropriate to offer follow-up or encourage professional resources.

Outcomes/evaluation: In response to staff requests, our organization also provides “comfort carts” for units/departments following a stressful/distressful event and “respite rooms” for staff members to use 24/7. A peer support group gives health care providers the opportunity to both give and receive support with other nurses. This creates a sense of shared experience, reminding them that they are not in this alone.


Virtual Reality for Postoperative Robotic Colorectal Patients

Identification: P05

Background: Virtual reality (VR) is a 3-dimensional immersion experience and allows for multiple sensory experiences involving visual and auditory olfactory senses. VR has shown success in the pediatric populations in reducing post-procedural pain. Limited research is available to support VR use in adult patients.

Objective: Evaluate the feasibility and effectiveness of virtual reality (VR) in middle to older adults following robotic colorectal surgery with a mean hospital length of stay of 2.5 days.

Methods: A prospective self-controlled intervention study of N=10 post-operative patients with a pain score of at least three on a scale from 0-10 were provided a VR headset in their room to use at least three times a day and on-demand per their preferences from September 2020 to February 2021.

Results: Patients (N=10) had an average age of 61.9 years. Genders were balanced. 80% of patients were white. The patients had a median length of stay of 3 days (Q1-Q3 = [2, 7]). The average pain score was 3.89 (SD=1.40). For each patient, the VR usage rate on average is 3.5. On a scale from 0-5, patients answered an average of 4.08 (somewhat satisfied) to the question of “How satisfied were you with the VR experience?” and 4.29 (somewhat effective) to the question of “How effective was the VR in relieving your patient’s pain?” We stratified the participants into 1) patients who ONLY used VR for diversion/entertainment and 2) patients who ONLY used VR for pain (note that this group could have used VR for entertainment as well). We found that in the entertainment/diversion-only group, length of stay, questions 2 and 3 are positively correlated. We found a positive correlation between VR usage and VR satisfaction rates in pain patients. We found that patients who used VR for entertainment only were younger than the average age, tend to be males, had a shorter length of stay, had less pain, had a higher VR access rate, and are more satisfied with VR.

Conclusion: This feasibility initially supports positive outcomes in adult post-operative patients. During the COVID-19 pandemic, we found that patients used the VR for entertainment diversion due to not having visitors during their hospital stay. In future studies, adding a non-intervention control group can increase the validity of the intervention.


Outpatient Care Coordination: Reduction of Readmissions Using Telephone Intervention

Identification: P06

Background: Readmission rates for traditional Medicare at the hospital were 13.4% and 12.5% in 2019 and 2020, respectively, which are not within the desired readmission rates. To improve patient outcomes, reduce readmission rates, and ensure financial viability, the hospital embarked on a pilot project in October 2020 that targeted patients who meet the following criteria: discharge to home who are not on hospice services; at highest risk of readmissions based on readmission scores; diagnoses of acute myocardial infarction, acute and chronic congestive heart failure, pneumonia, and chronic obstructive pulmonary disease; and certain insurance coverage with Medicare.
Purpose: This outpatient care coordination pilot project provided patient assistance within 24-72 hours after discharge. The project ensured the care plan on discharge outlined in the after-visit summary is followed through for continuity of care. The plan of care may include a) follow-up appointments with primary care physician (PCP) and/or specialists; b) medication compliance and/or problems encountered on new prescriptions; c) home health and/or palliative care services as ordered; d) durable medical equipment and supplies are available as ordered; e) education on
disease process, medications’ indications, and side effects; f) provide PCP and specialists referrals as needed; and g) other health care needs.

Methods: Discharged patients are telephoned using structured interview questions to elicit patient needs or gaps in knowledge or care. These are then coordinated with departments and/or entities within and outside the hospital system to meet patient needs. These interventions reduced emergency room visits leading to readmissions.

Results: After five months of implementing the pilot project from October 2020 to February 2021, the pilot readmission rate was 5.14%. Compared to the hospital’s traditional Medicare readmission rate of 12.78% for the same period, the pilot project’s readmission rate was lower by 7.64%.

Evaluation/outcome: With the sustained positive outcomes, the pilot project was developed to become a permanent department of the hospital. Effective care coordination has shown improved patient outcomes and reduced readmission rates while ensuring the financial sustainability of the hospital.


An Innovative Approach to Orienting New Grads: A Skill-Based Intensive Orientation on a Medical Unit

Identification: P07

Graduate nurses (GN) coming into health care may lack confidence in skills contributing to a challenging and lengthy orientation. Tenured nurses leaving health care led to an “experience complexity gap” noted by the advisory board. GNs are required to take care of higher acuity patients with little experience and lack confidence in basic skills. A literature search was completed, and many low-level, high-quality articles were found.

Many of the articles noted institutions completing a quality improvement for the orientation. The recommendations of the evidence were to provide GNs time to practice skills including daily tasks, medication pass, assessments, computer systems, and
high-risk/low-volume scenarios (blood, falls, codes). Ideally the learning environment would be a safe place outside of an assignment, led by an intensive leader, and cohorts of four or less.

An intensive period (IP) curriculum was created with an intensive leader overseeing a cohort of GNs. Each IP was 10 eight-hour days. Curriculum was based upon the literature, quality indicators, and system orientation checklist for competencies. GNs completed “task objectives” as listed in the curriculum and received a binder with policies, standard work, or handouts that complimented the tasks. Both didactic and clinical methods were utilized during the IP. Skills that required hands-on would be completed on the clinical unit by utilizing a “pop-up skills” list where the staff could identify opportunities for the GNs. Debriefing was completed at the end of each day and homework was assigned to prepare for the next day.

Seven GNs over three months participated in this skills-based intensive orientation and reported satisfaction with the program. Further evaluation of their confidence and competence will be collected throughout the first year. Preceptor perception was evaluated using new graduate nurse performance survey with additional encouragement of the GN’s overall preparedness.

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• Gavlak S. (2007). Centralized orientation: retaining graduate nurses. Journal for Nurses in Staff Development, 23(1), 26–30.
•    Gregg, J. C. (2020). Perceptions of Nurse Managers and Nurse Preceptors. Journal for Nurses in Professional Development, 36(2), 88-93.
•    Shahsavari, H., Ghiyasvandian, S., Houser, M. L., Zakerimoghadam, M., Kermanshahi, S. S. N., & Torabi, S. (2017).
•    Effect of a clinical skills refresher course on the clinical performance, anxiety and self-efficacy of the final year undergraduate nursing students. Nurse Education in Practice, 27, 151–156.
•    Santucci, J. (2004). Facilitating the Transition into Nursing Practice: Concepts and Strategies for Mentoring New Graduates. Journal for Nurses in Staff Development (JNSD): 20(6), 274–284.
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The Use of Non-Pharmacological De-Escalation Method Education to Promote Trauma-Informed Healthcare

Identification: P08

Background: As violence in health care settings increases, the need for using de-escalation techniques has become more prevalent as a first-line response to reduce potential violence and aggression. The Centers for Disease Control and Prevention (CDC) has noted a rise in workplace violence, with the greatest increases of violence occurring against nurses and nursing assistants (Brous, 2018). Nurse residents (NRs) in an academic Magnet® facility noted frequent use of behavioral 1:1 sitters and patient restraint use in their 30-bed step-down trauma unit. Clinical nurses received network-supported crisis management training annually; however, nurses verbalized the need for ongoing education and support in order to incorporate these practices naturally and confidently into their daily clinical practice. Additionally, novice nurses to the unit often began clinical practice before receiving the benefit of this training designed to promote safety and reduce harm to both patients and staff.
Purpose: This presentation shares a nurse resident-led evidence-based practice project designed to offer strategies to promote de-escalation behaviors in combative and agitated trauma patients and emphasizes the vital role of the trauma nurse in the promotion of trauma-informed health care.

The learner will gain strategies to
• Prevent violent behavior in the agitated/combative trauma patient.
•    Enable patients to manage their own emotions and to regain personal control.
•    Decrease the use of patient restraints.
•    Maintain the safety of staff and patients.
•    Improve staff/patient connections and relationships.

Description: A pre-survey was created and distributed to assess clinical nurses’ awareness and confidence in utilizing non-pharmacological de-escalation methods in the trauma population. Results revealed 40% of unit RNs were both confident using and aware of non-pharmacological de-escalation methods. Nurse residents incorporated a
behavior management technique, T-A-DA (tolerate, anticipate, don’t agitate) which allows behaviors which do not have the potential for harm, anticipates patient needs (i.e., food and toileting), and reduces agitation by using distraction and redirection. Nurse residents created an educational handout detailing the technique, which was reviewed with nurses at daily unit safety huddles and shift change, posted on the unit, and provided to staff caring for behavioral 1:1 patients. Post-implementation survey results revealed 92% of RNs felt confident and 100% of RNs verbalized knowledge of non-pharmacological de-escalation resources to use in the trauma patient population.
Evaluation/outcomes: Key project outcomes included an increase in staff mindfulness recognizing and responding to signs of agitation and anxiety in the trauma patient by possessing enhanced skills to reduce violent patient behaviors. “Lessons learned” include the need to provide education to new unit and float unit staff and intermittently reinforce education with all unit staff to promote awareness and maintain competency. Additionally, sharing information on individual successful behavior management techniques in bedside shift report is beneficial to promote consistency and reduce violent behaviors in this population. Potential future recommendations can include monitoring unit restraint use in trauma patients who received the intervention to assess for a reduction in physical restraint utilization. Attendees at this session will gain knowledge/pragmatic strategies to reduce violent behavior in the agitated/combative trauma patient.


Early Ambulation and Documentation for Total Hip and Knee Replacements to Decrease Length of Stay

Identification: P10

Purpose: Increase post-operative day-0 ambulation in total hip and knee replacement (THKR) patients to decrease length of stay (LOS).

Description: This quality improvement (QI) project consisted of interventions that support and promote the evidence-based practice of post-operative day-0 ambulation. a) Hallway ambulation markers
b) Documentation that reflects the revised change (documentation tip sheet)

a) Hallway ambulation markers: Markers were added to each of unit’s hallways utilizing Minnesota landmarks to help quantify and motivate patient ambulation. Each landmark marker equaled 25 feet of ambulation.

b) Documentation tip sheet: Displayed a tip sheet to reinforce how to document ambulation in the electronic health record (EHR). It was placed in the middle of the nursing station for easy accessibility.

Evaluation/outcome: It will be evident that this project is successful if the chart reviews show an increase in the percent of patients ambulated on post-operative day 0 by nursing staff, decrease in LOS, and increase in staff documentation of ambulation.

Purpose: Increase post-operative day-0 ambulation of 75 feet of THKR patients in the first 8 hours by nursing staff, increase documentation on ambulation in feet in the EHR, and decrease LOS.

Background: Early ambulation of THKR patients on post-operative day 0 has been found to decrease LOS. Post-operative day-0 ambulation is a core performance measure of the Joint Commission, and 75 feet is the target for THKR patients as a part of the total joint optimal care pathway. Inpatient ambulation of adults has been found to be one of the most frequently missed components of nursing care. Further, immobilization has been directly correlated with increased LOS. Although post-operative day-0 ambulation had been increased by physical therapy staff on this 23-bed orthopedic unit, there was still a gap in mobilization of patients on post-operative day 0 by nursing as well as inadequate documentation.

Method(s): The design was a six-week pre-/post-intervention QI project. 30 chart reviews on THKR patients were completed in the EHR before and after the intervention.

Result(s): A post-intervention chart review showed that the average LOS for 30 THKR patients was an average of 1.5 days, which was an 8% decrease. 90% of patients were ambulated on post-operative day 0 and 80% were by nursing. 40% of patients hit their goal of 75 feet ambulated on post-operative day 0. Documentation of feet ambulated was 77% and was in the correct place 63% of the time.

• Post-operative day-0 ambulation by nursing almost doubled 1-month post-intervention.
•    Documentation improved with a 76% increase overall and a 63% increase in the accuracy of documentation.
•    LOS decreased by 8%.
•    This project showed promising trends with increasing post-operative day-0 ambulation and documentation. Continued ambulation promotion to meet goal of 75 feet in first 8 hours post-surgery is needed.
•    Post-operative day-0 ambulation was added to new hire orientation for sustainment.

References available upon request


Building a Culture of Compassion: Improving Patient Experience While Preserving Nurse Resiliency

Identification: P11

During the last year, nurses have experienced extreme stress, with one study of over 1200 nurses reporting 71% experienced psychological distress, 50% depression, and 44% anxiety (APNA Issue Brief, 2020). Those at greatest risk include nurses treating COVID-19 patients, young in age, female, history of mental challenges or traumatic events, and lack of coping skills (APNA Issue Brief, 2020). Another study reported 64% of nurses had experienced acute stress disorder, placing them at risk for post-traumatic stress disorder (Shahrour & Dardas, 2020). Nurse leaders must anticipate these mental health challenges and promote wellness and resilience. A compassionate culture can improve the overall physical well-being of our employees, increase employee retention, reduce burnout, and positively impact the patient experience. Compassion is inversely correlated with burnout and positively correlated with workforce well-being (Lown et al., 2019). Research has also shown empathy and compassion associated with better adherence to medications, decreased malpractice cases, fewer mistakes, and increased patient satisfaction (Lown et al., 2019). Our aim statement was to implement empathetic communication tactics into standard daily work in the acute care service line to increase nurse communication HCAHPS domain score to 81.0 (75th percentile ranking) by April 30, 2021.

Using evidence-based practice, the acute care service line (7 inpatient units, 222 medical/telemetry beds, 4 COVID-19 containment units) within an urban academic level-one hospital implemented empathetic communication techniques that increased resiliency of our team and increased nurse communication HCAHPS domain scores above goal. A compassion campaign, “Compassion Before Action,” was initiated in October 2020, providing education on empathetic communication to the team through daily team huddles. During this month, the team also had a self-compassion weekly activity to engage the team and increase their well-being. The team then started adding empathetic tactics into standard daily work. Beginning with a compassionate connection in which each team member had a goal to make one compassionate connection with each patient daily. In December 2020, we established empathetic communication tactics into bedside shift report, had skills labs, and trained champions to mentor and coach the team. In January, purposeful rounding was incorporated, and empathetic tactic training occurred with patient care technician champions. Nurse leader rounding was utilized to hardwire the practice of compassionate connection, and charge nurses, supervisors, and nurse managers were trained in this skill.

The team set the goal of 81.0 for nurse communication HCAHPS domain to reach the 75th percentile. Baseline data from July to October 2020 showed an average score of 77.75. Post-implementation data from November 2020 to April 2021 showed an average score of 81.96, with five of six months being above goal post-implementation. We also had an engagement survey during this period, which resulted in 85% engagement and an increase from the previous engagement survey. The survey also resulted in a 4.34 of 5 engagement rating, indicating the strong resiliency of our team. The project is now being shared across the system as a best practice. This evidence-based implementation improved patient experience and preserved resiliency by building a culture of compassion.