Embed Size (px)
Citation preview
Implementation of a Protocol-driven Medical Clearance Algorithm in Behavioral Health Crisis Services
Background: • In 2015, 5.7 million visits to the emergency department (ED) were for
psychiatric complaints.• In 2016, 44.7 million adults reported having mental illness and 19.7 sought
treatment from either an ED, inpatient psychiatry, and/or outpatient behavioral health services.
Problem Statement: A lack of standardized recommendations for medical clearance for admissions to inpatient behavioral health units (BHU) from emergency care settings can lead to:
• Increased patient distress• Often unnecessary lab work/diagnostic testing with low yield• Increased health care costs• Increased length-of-stay (LOS) with reduced bed turnover
in emergency services• Delays in receipt of specialty psychiatric services• Increased morbidity and mortality due to increase in medical errors
Practice Change Question: Will a protocol-driven medical clearance algorithm decrease the LOS from patient triage to disposition decision without affecting patient safety?
Setting: Behavioral Health Crisis Intervention Center
Population: Adult patients with psychiatric symptoms presenting to a crisis center for emergency care
Implementation procedure: Weekly data collection and analysis of medical clearance checklist
Short-term Goals:• Approval of the medical clearance algorithm• At least 50% utilization of the algorithm as evidenced by completion of the
medical clearance check list• More comprehensive history and physical assessments (H&P)• Appropriate diagnostic testing for clinically significant findings on H&P• Reduced length of time (minutes) from triage to disposition decision• Balancing Measure: No change in number of transfers to medical units
within 72-hours upon admission to inpatient BHU
Long-term Goals:• Improved patient safety related to more comprehensive H&Ps• Reduction in unnecessary or duplicative lab work• Reduction in related health care costs
Problem Statement, Purpose, & Goals Evidence TableTotal Project: 11-weeks N=425
• 3 weeks Baseline n=115 (LOS and Disposition data only) • 8 weeks Implementation n=310 (received medical clearance algorithm)
• No significant difference in Disposition between Baseline and Implementation: (α < 0.05)x2= .1739 p= .68
• Most patients discharged were seen at the Center’s outpatient clinic within a week of visiting the Crisis Center
• No significant difference in LOS between Baseline and Implementation: (α < 0.05)t(423) = 1.02, p= .15, one-tailed
• Safety Measure: There were no transfers to a medical unit within 72 hours after transfer from the Crisis Center to a behavioral health service (n=0)
Results
Practice Recommendations: Medical Clearance Algorithm
Discussion
Centers for Disease Control and Prevention. (2017). Mental health. Retrieved from: https://www.cdc.gov/nchs/fastats/ mental-health.htm
Chennapan, K., Mullinax, S., Anderson, E., Landau, M. J., Nordstrom, K., Seupaul, R. A.,& Wilson, M. P. (2018). Medicalscreening of mental health patients in the emergency department: A systematic review. The Journal of Emergency Medicine, 55(6), 799-812. doi: 10.1016/j.jemermed.2018.09.014
Conigliaro, A., Benabbas, R., Schnitzer, E., Janairo, M.-P., & Sinert, R. (2018). Protocolized laboratory screening for the medical clearance of psychiatric patients in the emergency department: A systematic review. Academic Emergency Medicine: Official Journal of The Society for Academic Emergency Medicine, 25(5), 566-576. doi: 10.1111/acem. 13368
Janiak, B.D, & Atteberry, S. (2012). Medical clearance of the psychiatric patient in the emergency department. The Journalof Emergency Medicine, 43(5), 866-870. doi: 10.1016/j.jemermed.2009.10.026
Maryland Department of Mental Health. (2019). Emergency department visits related to mental health conditions. Retrieved from: http://ship.md.networkofcare.org/ph/ship-detail.aspx?id=md_ship34
Nazarian, D.J., Broder, J.S, Thiessen, M. E., Wilson, M. P., Zun, L.S., & Brown, M.D. (2017). Clinical policy: Critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Annals of Emergency Medicine, 69(4), 480-490. doi: 10.1016/j.annemergmed.2017.01.036
Pearlmutter, M.D., Dwyer, K.H., Burke, L.G., Rathley, N., Maranda, L., & Volturo, G. (2017). Analysis of emergency department length of stay for mental health patients at ten massachusetts emergency departments. Annals of Emergency Medicine, 70(2), 193-202.e1.doi: 10.1016/j.annemergmed.2016.10.005
References
Synthesis of Evidence: Studies analyzed for algorithm were systematic reviews and well-designed case-control and cohort studies with good quality ratingsLimitations:
• The Crisis Center opened three months prior to project implementation• Lack of onsite laboratory services during implementation; unable to obtain labs
before disposition decision• Lack of full-time medical providers
• Relied heavily on nurses to complete the algorithm checklist; all patients gave history and received assessment by trained RN. Patients not seen by a provider were seen at a follow-up in the outpatient clinic typically within one week
Conclusions: • Patient safety was not compromised with the use of this algorithm
(balancing measure n=0)• LOS did not appear to be compromised by the use of the algorithm (p= .15)• LOS was significantly lower at the Crisis Center (3.3 hrs.), compared to the large study
performed in Massachusetts emergency department (10.9 hrs.) (Pearlmutter, 2017) • A similar algorithm was implemented at a local ED with similarly positive results • Welcome but unintended positive outcome: The algorithm checklist helped to
document a reduction in utilization of emergency department and inpatient behavioral health unit services
Sara Bortner, BSN, RN Katherine Fornili, DNP, MPH, RN, CARN, FIAAN
• Search Terms: “Medical clearance; Emergency department; Laboratory testing; Psychiatric” (447 studies)
• Search Platform: Pubmed, PsychINFO, MEDLINE, CINAHL
• Appraisal of level & quality of evidence: Johns Hopkins Nursing Evidence-based Practice Rating Scale (Newhouse, et al., 2006)
• Project Development: Seven Steps of Evidence-based Practice Model (Melnyk & Fineout-Overholt, 2011)
• Project Implementation: Mobilize, Assess, Plan, Implement and Track (MAP-IT) Framework
Search Strategy/Evidence Appraisal
Disposition Decision Outcome (N=425)Baseline (n=115)
#(%)Implementation (n=310)
#(%)No Admission (Discharge Home) 98 (85.22%) 259 (83.55%)Transfer to Behavioral Health Unit 0 (0.00%) 1 (0.32%)Transfer to local Emergency Department 5 (4.35%) 15 (4.84%)Transfer to Crisis Residential Unit 12 (10.43%) 35 (11.29%)
Length of Stay (LOS) DataMean (SD) Medium Range P-value
Baseline (n=115) 211.70 (199.07) 168.00 1355.00 0.15Implementation (n= 310) 188.90 (205.99) 146.00 2899.00
AUTHOR/YEAR PURPOSE RESULTS
EVIDENCE LEVEL/QUALITY
Chennapan et al. (2018).
To determine the practices for medical screening adult patients that present to the emergency department for psychiatric complaints and which test alter patient care.
1. Age required for additional screening: 65 and older should have additional testing. 2. Routine Screening for laboratory testing: Abnormal test results rarely affect patient disposition. 3. Elements of patient history: Thorough history and physical needed.4. Vital signs: important to measure. 5. Physical exam: Complete physical exam 6. Mental Status Examination (with Orientation): 7. Routine urine drug screenings: Rarely alters care 8: Medical Screening Tools. Weak evidence but may aid in standardization of care.
V (Systematic reviews of descriptive and qualitative studies)B (Good Quality)
Conigliaro et al. (2018).
To determine if a protocol for laboratory screening would be clinically significant for psychiatric patients in an ED.
While abnormal tests were seen from 0-41%, the tests had low clinical significance (0.0- 0.4%).
V (Systematic reviews of descriptive and qualitative studies)B (Good Quality)
Janiak, B.D, & Atteberry, S. (2012).
To determine if routine laboratory screening would affect medical clearance for psychiatric patients in the ED.
All had laboratory studies upon admission to the psychiatric service. N=148 (28.5%) had repeat studies. One patient admitted to psychiatry as manic was found to have hyperglycemia at an unsafe level and was transferred for medical management.
IV (Well-designed case-control and cohort studies)B (Good Quality)
Nazarian et al. (2017).
To determine if:1. routine laboratory testing should be performed on alert adult patients presenting with acute psychiatric symptoms. 2. brain imaging should be obtained acutely when new onset psychosis without focal neurological deficit is present.
Further research is needed for each question. 1. Evidence that supports the use of history, physical exam, and previous psychiatric diagnosis to aid in what testing is needed. 2. Recommendation was to use risk factors to guide brain imaging.
V (Systematic reviews of descriptive and qualitative studies)B (Good Quality)
Parmar et al. (2012). To determine the prevalence of laboratory and radiographic studies
1. 191 patients received testing after history and physical. 1 patient had an abnormal resulting in change in disposition. 2. Lab test frequency: CBC n=146 (33.6 %), BMP n=151 (34.8%), UDS n=141 (32.5%), urinalysis n=97 (22.4%), and TSH n=85 (19.6%). Radiographic ordered infrequently.
IV (Well-designed case-control and cohort studies)B (Good Quality)
Korn, C.S., Currier, G.W., Henderson, S.O. (2000).
To evaluate usefulness of the medical clearance process that includes history, vital signs, physical exam, radiography and laboratory testing for patients with only a psychiatric complaint in the emergency department.
1. n=80 received protocol treatment all were within normal limits. One resulted with positive pregnancy test and one mild leukocytosis. Disposition unchanged.2. Various medical reasons noted and treated before psychiatry consulted.
IV (Well-designed case-control and cohort studies)B (Good Quality)
Amin, M., & Wang, J. (2009).
To determine if laboratory studies are beneficial in ruling out medical illnesses in psychiatric patients presenting to the emergency department.
n=246 normal results. n= 247 abnormal results; from the abnormal results n=72 (29%) of these were related to a positive urine toxicology screen. n=56 (22%) abnormal results n=42 (17%) had a normal history and physical exam n=14 (5%) had an abnormal exam and 4 (1%) required medical treatment but no change in disposition.
IV (Well-designed case-control and cohort studies)B (Good Quality)
ContactSara Bortner: Email [email protected] Fornili: [email protected] Figure 1. Crisis Center Medical Clearance Algorithm
Mechanical Ventilation (MV) is a life-saving modality commonly used in the Intensive Care Unit (ICU) patients.
Sedation used for better patient’s MV tolerance. - Deep sedation occurred in 76% of patients in4 hours of MV and 68% of patients in 48 hours.
- Delirium occurred in 50.7% within 2 days.
Utilized together, it leads to prolonged MV durationand increased risk for MV-associated complications.
Problem Statement
Implementation of a Paired SAT/SBT Protocol• Promote Early Extubation• Reduce MV days• Endorse a Practice Change that includes sedation
guidelines & safety screeningto identify appropriate candidates for extubation
SAT – Spontaneous Awakening TrialThe stopping of IV sedation for a time period to adequately perform a neurological assessment without causing agitation or accidental extubation.
SBT – Spontaneous Breathing Trial The gradual withdrawal of the amount of support the patient receives from the MV so that the patient assumes a greater proportion of respiratory effort to assess the probability of successful extubation. (Synonymous to MV (vent) weaning)
Purpose of the Project
MethodsInterpretation• The staff compliance goal was met.• The MV data is inconclusive: the SUR decreased but the MV days
increased.• Full adoption of the protocol: The critical care provider team
included the SAT/SBT in their progress notes’ quality measures list.
Discussion• Data from the past 24 months have shown a seasonal variance
pattern in the MV days, and a 3-months worth of data duringimplementation period is insufficient to fully analyze the impact ofthe protocol to the target entity.
Limitations• Barriers that affected the project implementation includes:
• The synchronous merging of a Neuro-ICU & CVICU along with thehospital relocation during the implementation month.
• MV data are computer generated but the staff compliance data arefrom manual audits from multiple data collectors.
Discussion
Balas, M. C., Vasileyskis, E. E., Olsen, K. M., Schmid, K. K., … W. Burke (2014). Effectiveness and safety of awakening and breathing coordination, delirium monitoring /management, early exercise/mobility bundle. Critical Care Medicine, 42(5), 1024-1036. https://doi.org/10.1097/CCM.0000000000000129
Girard, T. D., Kress, J. P., Fuchs, B. D., Thomason, J. W., Schweikert, W., .. W. Ely (2008). Efficacy and safety of a paired sedation and ventilator weaning for mechanically ventilated patients in intensive care (Awakening and Breathing Control Trial): a randomized control trial. The Lancet, 371, 126-134. https://doi.org/10/1016/S0140-6736(08)60105-1
Shehabi, Y., Bellomo, R., Reade, M. C., Bailey, M., Bass, F., Howe, B.,… L. Weisbrodt (2012). Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. American Journal of Respiratory and Critical Care Medicine, 186(8), 724-731.https://doi.org.proxy-hs.researchport.umd.edu/10.1164/rccm.201203-0522OC
Conclusions
Results
Implication for Nursing Practice• As a nurse-initiated protocol, nurses are the leaders that have
coordinated the multidisciplinary team of respiratory therapistsand intensivists in the protocol’s successful implementation.
• Positive Impact on patients• Better quality of care and improved outcomes• Decreased MV-related complications• Shorter ICU LOS
Future Projects• Building of the staff compliance audit tracker into the
electronic health record will improve data collection• Work toward the full adoption of the ABCDEF bundle.
(Awakening and Breathing Coordination, Delirium
Monitoring/Management, Early Exercise/Mobility, and FamilyEmpowerment)
References
SURdecreased from 0.99 to 0.89
MV days increasedfrom 154 to 162
% of Mean Staff Complianceincreasedfrom 3% to 82%
• Setting: A 28-bed ICU of a community hospital within the DC Metropolitan Area• Population: All intubated ICU patients ages 18-65 years old who are on sedation and MV support• Implementation Procedure: Implemented over 3-month period from 9/01/2019 – 11/30/2019
- Daily trials started at 07:30 AM, allowing for sleep, shift change, and timing withmultidisciplinary rounds.
- It starts with a safety screening, followed by SAT, then SBT safety screening, followed by SBT.- Follow the algorithm.
Paired Spontaneous Awakening Trial and Spontaneous Breathing Trial Protocol Implementation
Luverne Diaz, BSN, RN, CCRN; Ann Hoffman, DNP, RN, CPN, CNE
Mechanical Ventilation Sedation Prolonged
MV use
EARLY EXTUBATION
• Can prevent MV-associated complications• Improve survival rates• Improve quality of care• Decrease Length of Stay (LOS) & Costs
GoalsShort-term goal• Full implementation of the paired SAT/SBT protocol in the target
entity’s ICU by 11/30/2019 on 80% of patients on MV and IVsedation, with the goal of early extubation.
Long-term goals • Improve quality of care in the target entity ICU by
- Decreasing the MV days and consequently preventingMV-associated complications
- Decreasing the Standardized Utilization Ratio (SUR): A summarymeasure used to track device use at a national, state, or local, or facility over time.
- Maintain > 80% Staff Compliance with protocol implementation
• Project Sustainability
While evidence suggests that
Procedure Algorithm
Median
0
0.2
0.4
0.6
0.8
1
1.2
2018Jan
Feb
Mar
April
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
2019Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
MV- Standard Utilization Ratio (SUR)MV-SUR
Median
0
50
100
150
200
250
2018Jan
Feb
Mar
April
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
2019Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
Mechanical Ventilator Days (MVD)MV Days
Goal
0
10
20
30
40
50
60
70
80
90
100
Aug(Pre)
SeptW
k1
2 3 4 Oct
Wk1 2 3 4 N
ovW
k1 2 3 4 Dec
Wk1
Weekly EHR Charting Compliance% Compliance Date Observed Value GoalAugust (pre-implementation) 3 80September Wk1 (Implementation) 8 80Wk 2 6 80Wk 3 8 80Wk 4 24 80October Wk 1 35 80Wk 2 44 80Wk 3 38 80Wk 4 54 80November Wk 1 56 80Wk 2 71 80Wk 3 95 80Wk 4 88 80
Date Observed MVD SUR
2018 January (pre-implementation) 203 0.96
February 148 0.91
March 169 0.92
April 84 0.56
May 110 0.89
June 165 0.62
July 192 1.09
August 166 0.95
September 157 0.99
October 142 0.78
November 92 0.l63
December 160 0.89
2019 January 197 0.95
February 90 0.53
March 100 0.55
April 167 1.03
May 155 0.80
June 177 0.87
July 203 1.05
August 154 0.99
September (implementation) 162 0.89
October 157 0.83
November 151 0.85
December 173 0.87
SUR and MV Days
% of Mean Staff Compliance
AcknowledgmentShirley Harry, MSN, RN, CCRN - Clinical Site RepresentativeLisa Seldon, DNP, MSA, RN, NE-BC - Administrative Sponsor
Cesarean delivery (CD)Most common surgical procedure 3 million births annually, 32% performed by CDIncreased risks and complications compared to vaginal
delivery
Intraoperative Complications: Spinal Induced Hypotension (SIH)
Maternal hypotension leads to fetal hypotension, bradycardia & acidosis
Incidence: 60-80% Secondary complication: nausea & vomiting
Post Spinal Shivering (PSS) Increased oxygen consumption Incidence: 30-60% Secondary complications: interference with
monitoring, increased maternal irritability
Background
Purpose: Develop a Clinical Practice Guideline (CPG) to optimize and standardize the intraoperative management of women undergoing planned cesarean delivery.
Short term Goals CPG Stakeholder/staff evaluation of CPG Stakeholder/staff acceptance of CPG 100% staff compliance
Long term Goals Improve maternal and neonatal outcomes by
Decreasing incidence of SIH and PSS Increasing Delayed Cord Clamping (DCC) times
Purpose & Goals
CPG Practice Recommendations
Strengths High quality evidence focused
on improving patient outcomes Strong stakeholder involvement Favorable results on AGREE II
and PFQ
Limitations Small sample size of providers Limited response rate (35%) Low applicability scores
CPGs promote standardization of care and evidence basedtreatment modalities Plans for Sustainability Continued stakeholder support Continuous staff education Auditing/data collection/feedback Guideline review and modifications
PFQ Results
Discussion
Institutional Review Board approval
Setting: Community Hospital in Maryland
Population: Women undergoing planned CD
Literature review Stakeholder involvement
and expertise Stakeholder evaluation via
AGREEII Staff education Practitioner Feedback
Questionnaire (PFQ)
Statistical analysis: AGREE II and PFQ results
Implementation Strategies
Results
Conclusion
Practitioner Feedback Questionnaire (PFQ) ( n=39) 17 surveys collected: 6 (35%) anesthesiologists, 4 (23%) Certified
Registered Nurse Anesthetists, and 7 (41%) Student Registered Nurse Anesthetists.
Anesthesia provider years of experience: 0-3 years n=4 (23%), 4-6 years n=2 (11%), and >10 years n=4 (23%).
Total Percent of Agreement: 87.4%, standard deviation: 6.6
Enhanced Recovery after Cesarean Delivery Clinical Practice Guideline: Intraoperative Interventions
Lara Gilmore, BSN, SRNAProject Faculty Advisor: Veronica Amos, PhD, CRNA, PHCNS-BC
Clinical Site Representative: Christina Mack, MD University of Maryland School of Nursing
Bajaj, J., & Choudhary, M. (2018). Study comparing phenylephrine bolus and infusion formaternal hypotension and neonatal outcome during cesarean section under spinal anesthesia. Anesthesia: Essays and Researches, 12(2), 446. doi:10.4103/aer.aer_23_18
Caughey, A. B., Wood, S. L., Macones, G. A., Wrench, I. J., Huang, J., Norman, M., Wilson, R. D. (2018). Special Report: Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations (Part 2). American Journal of Obstetrics and Gynecology, 219, 533–544. https://doi.org/10.1016/j.ajog.2018.08.006
Tie, H. T., Su, G. Z., He, K., Liang, S. R., Yuan, H. W., & Mou, J. H. (2014). Efficacy and safety of ondansetron in preventing post anesthesia shivering: A meta-analysis of randomized controlled trials. BMC Anesthesiology, 14. https://doi.org/10.1186/1471-2253-14-12
97.91
87.5
39
75 78
0102030405060708090
100
Quality Acceptance Applicability ComparativeValue
OutcomeVariable
Perc
enta
ge
Subscales
PFQ PERCENTAGE AGREEMENT SUBSCALES Spinal Induced Hypotension Practice Recommendation: Initiate Phenylephrine infusion 0.5 mcg/kg/min IV and titrate to maternal blood
pressures Co-Load with crystalloid solution Anticipated outcomes
Decreased incidences of hypotension Decreased intraoperative fluid requirements Decreased incidence of nausea and vomiting
Post Spinal Shivering Practice Recommendation Ondansetron 4 mg IV given when patient is sitting for spinal Anticipated Outcomes
Decreased incidence of shivering Decreased incidence of nausea and vomiting
Delayed Cord Clamping Practice Recommendation Delay umbilical cord clamping for up to 60 seconds after delivery
Decreased infant morbidity/mortality
References
Domain Percentage Score
Scope & Purpose 91.7%
Stakeholder Involvement 94.4%
Rigor of Development 86.4%
Clarity of Presentation 91.7%
Applicability 83.3%
Editorial Independence 100%
Overall Guideline Assessment Score 91.7%
AGREE II TOOL RESULTS
• Each year, 33,000 men and women in the United States are diagnosed with a cancer caused by infection from the humanpapilloma virus (HPV), 90% of which could have been prevented through vaccination
• Approximately 14 million new cases of HPV are reported annually, half of which are in individuals aged 15 to 24
• Despite the proven effectiveness of this vaccine, rates of uptake are low nationwide, a mere 53.7% for females and 48.7% for males
• When population-based strategies are not available, multipronged interventions, targeting both the provider and the patient are recommended to increase uptake
Background
The purpose of this project was to implement and evaluate the effectiveness of the 4 PillarsTM Practice Transformation Program1 in increasing uptake of the HPV vaccine among patients aged 11-18 in a pediatric primary care clinic.
• Short term goals: 70% of eligible patients will be offered the HPV vaccine using the same-way, same-day strategy (figure 1); 70% of patients due for the vaccine will be contacted by phone; immunization status will be assessed as part of vital signs for 70% of patient encounters
• Long term goal: 80% of eligible patients aged 11-18 will be vaccinated against HPV
Objectives
Methods
Results
• This project demonstrated successful implementation of the 4 PillarsTM Practice Transformation program to increase HPV vaccination rates among adolescents in primary care
• Sustainability would be enhanced through changes in electronic medical record to include drop-down menu to document reason for vaccine refusal
Conclusions
1. 4 Pillars Practice Transformation Program: A step-by-step guide to improving vaccine uptake in outpatient settings. (n.d.). Retrieved from http://www.4pillarstransformation.pitt.edu/
2. Centers for Disease Control and Prevention. (2017). Provider Resources for Vaccine Conversations with Parents. Retrieved from https://www.cdc.gov/vaccines/hcp/conversations/index.html
References
Figures
Dr. Blanche Brown, Clinical Site Representative
Dr. Kim Kelly-Robinson, Project Champion
Acknowledgements
• Bundle of interventions within the 4 PillarsTM
Program was selected by clinic leaders to increase buy-in and adapt project to the clinic’s specific needs
• Staff education was conducted and patient education materials were posted throughout clinic
Increasing Humanpapilloma Virus Vaccination Rates Among Adolescents in Primary Care
Rachel E. Hodge, MSHS, BSN, RN, CEN, Ann Hoffman, DNP, RN, CPN, CNE
Median
Goal
60
65
70
75
80
85
9/4
9/11
9/13
9/21
9/27
10/3
10/11
10/16
10/22
10/30
11/7
11/15
11/23
% Vaccinated
• Initial HPV Vaccination rate: 68% Final rate: 76.6% representing 8.6% increase (p<0.01)• 100% of patients presenting for 11 year old well child checks were vaccinated (n=32)• 100% of eligible patients were given VIS, immunization status was assessed as part of
vital signs for 100% of patient encounters• No real difference in gender was discovered in the final HPV vaccination rate. Among
males (n=521), there was a 78% final rate and 76% for females (n=574), echoing the closing of the gender gap nationwide
• 15 patients seen who previously refused, consented and were vaccinated
DiscussionThis vaccination tool-kit is an effective way to increase HPV vaccination among adolescents in primary care
Results support the following components as part of bundle of interventions within the 4 PillarsTM:
• Use each patient encounter as an opportunity to vaccinate
• Provide a strong recommendation using the CDC’s Same-Way Same-Day strategy
• Assess vaccination status as part of vital signs and provide VIS to all eligible patients
• Track progress toward goals to motivate staff
Strong recommendation at the 11 year old visit proved 100% effective, echoing literature findings of strong recommendation for vaccine as the single most effective intervention outside of a tool-kit
Recommended areas of improvement:
• Clearly document reason for vaccine refusal to better focus education efforts
• Advocate for vaccine to be mandatory as 50% of refusals in this project were due to deferral until mandatory for school entry
• Tool Kit implemented over a 10-week period:• Pillar 1 Convenience and Easy Access: all patient encounters of those aged 11-18
were used as an opportunity to vaccinate• Pillar 2 Patient Communication: providers issued a strong recommendation for the
HPV vaccine using the Same-Way Same-Day strategy from the CDC2
• Pillar 3 Enhanced Vaccination Systems: Immunization status was assessed as part of vital signs and Vaccine Information Statements (VIS) were given to all eligible patients' parents
• Pillar 4 Motivation: progress toward improving HPV vaccination rates was tracked and posted in staff breakroom
Figure 4. Overall Clinic HPV
Vaccination rate
Figure 2. HPV Vaccines Given During Project (n=103) Figure 3. Reasons for Vaccine Refusal (n=22)
Figure 1. Same-Way Same-Day Strategy and Communication Sheet
31%
14%
47%
8%11 yo WCC
Previously refused
Subsequent shot inseries/overdue
HPV Vaccine specificappointment
27%
50%
23% Declined due to SickVisit
Deferred untilmandatory
Reason for refusalnot documented
Problem Statement
Purpose
Figures Results• From the literature review, the ”Rule of Three’s” regimen demonstrates
similar efficacy in achieving uterine tonicity in comparison to current practices but at a much lower and regulated dose.
• AGREE II Tool (Figure 2) • Calculated Domain Scores: Scope and Purpose (90%), Stakeholder
Involvement (89%), Rigor of Development (90%), Clarity of Presentation (94%), Applicability (97%), Editorial Independence (97%) and Overall Quality/ Recommendation for Use (93%)
• PFQ Results• 12 questionnaires (n=12) were collected, which consisted of 8
CRNAs and 4 MDA responses, respectively (86% total response rate)
• Percentage of Agreement for Subscales of Interest (Figure 3): CPG Quality (96%), Acceptance of Recommendations (76%), Applicability of Recommendations (27%), Comparative Value (88%), and Outcome Variables (86%)
• Chi Square Analysis• We accepted the null hypothesis that the provider type and
completion of the PFQ were independent of one another (X2(1, N=12)= 0.08, p<0.05)
Optimization of Oxytocin Dosing During the Intraoperative Period: Rule of Three’s Xuan Hanh Lam, SRNA
Under the Supervision of Joseph E. Pellegrini, PhD, CRNA, FAAN and Amlakie Gebeyehu, DNP, CRNAUniversity of Maryland School of Nursing
• The lack of a national guideline for oxytocin administration within the United States has resulted in various oxytocin dosing regimens, which include: unregulated, large oxytocin infusions, oxytocin boluses, or the newly proposed “Rule of Three’s” method (Stephens and Bruessel, 2012).
• Large, unregulated administrations of IV oxytocin may result in adverse hemodynamic instability among the parturient population.
• Recent studies reveal a smaller, regulated oxytocin bolus and infusion regimen called the ”Rule of Three’s” is effective in achieving uterine tonicity with a reduced incidence of adverse side effects (Stephens and Bruessel, 2012).
This Doctoral of Nursing Practice (DNP) Quality Improvement (QI) project focused on developing a Clinical Practice Guideline (CPG) and decision making algorithm (Figure 1) for intraoperative oxytocin administration using the ”Rule of Three’s” method during elective and non-elective cesarean deliveries.• Short Term Goal: Review current literature to identify the most
optimal intraoperative oxytocin dosing regimen in order to guide the development of a CPG and decision based algorithm for intraoperative oxytocin administration
• Long Term Goal: 80% of all anesthesia providers will adhere and utilize the intraoperative dosing guidelines for oxytocin outlined in the CPG
• Overall, there is strong evidence to support the utilization of the ”Rule of Three’s” when administering oxytocin during the intraoperative period to attain uterine tonicity.
• Without formal acceptance from recognized organizations, it will continue to hinder change and increase the resistance for a practice change among anesthesia providers.
Discussion
1. Kovacheva, V., Soens, M., & Tsen, L. (2016). A Randomized, Double-blinded Trial of a “Rule of Threes” Algorithm Versus Continuous Infusion of Oxytocin During Elective Cesarean Delivery. Obstetric Anesthesia Digest,36(2), 61-63.doi:10.1097/01.aoa.0000482592.65511.c9
2. Sheehan, S. R., Montgomery, A. A., Carey, M., Mcauliffe, F. M., Eogan, M., Gleeson, R., . . . Murphy, D. J. (2011). Oxytocin bolus versus oxytocin bolus and infusion for control of blood loss at elective caesarean section: Double blind, placebo controlled, randomised trial. Bmj,343, D4661-D4661. doi:10.1136/bmj.d4661
3. Stephens, L. C., & Bruessel, T. (2012). Systematic Review of Oxytocin Dosing at Caesarean Section. Anaesthesiaand Intensive Care,40(2), 247-252. doi:10.1177/0310057x1204000206
References
Methods
Figure 1. Intraoperative Oxytocin Dosing Administration Algorithm
• Setting: Tertiary Hospital Center in Baltimore, MD• Target Population: Elective and Non-Elective Cesarean
Deliveries • Exclusion Criteria: All parturients who require an “emergent”
cesarean delivery due to maternal or fetal instability who require a general anesthetic
• Implementation Phases• Extensive literature review examining the best intraoperative
oxytocin dosing regimen • Approval from University of Maryland Institutional Review
Board for Non-Human Subjects Research • CPG Development:
• A comprehensive CPG was developed by stakeholders • CPG analysis was conducting by stakeholders utilizing
the AGREE II tool and later evaluated by the anesthesia department using the Practitioner Feedback Questionnaire (PFQ).
• Revisions were made based upon these results. • Provider Education:
• Intraoperative oxytocin dosing and management was disseminated at an anesthesia department meeting.
Conclusion
Acknowledgements I extend a special thank you to John Christ, MSN, CRNA and Michael Markas, MD, and all other anesthesia colleagues and clinical support staff for their contribution and endorsement throughout this project.
• The AGREE II tool and PFQ results demonstrate a high quality CPG with a high acceptance of recommendations into clinical practice.
• Outcome: Since presentation, anesthesia provider have incorporated the Rule of Three’s into routine practice.
• Future Recommendations to ensure sustainability: • Collect pre- and post- implementation outcomes in regards to the
incidence of PPH, use of secondary uterotonic agents to achieve uterine tonicity, quantitative blood loss (QBL), and incidence of adverse side effects when using the CPG
• Present pre- and post- CPG implementation results to the anesthesia department to gain further buy in and further re-educate staff
0
20
40
60
80
100
Quality Acceptance ofRecommendations
Applicability ofRecommendations
Comparative Value Outcome Variables
Figure 3. Percentage of Agreement for Subscales of Interest
Strongly Agree Neither Agree or Disagree Strongly Disagree
0102030405060708090
100
Scope and Purpose StakeholderInvolvement
Rigor of Development Clarity of Presentation Applicability Editoral Independence
Domains
Figure 2. Domain Scores from Agree II Tool
• Hospital readmissions within 30-days of discharge are largely acknowledged as a problem.
• Heart failure patients account for a large percentage of these readmissions.
• Not only are these readmissions a problem for hospitals financially, but from a quality standpoint as well.
• Any readmission is also problematic for the quality of life, and overall outcomes for the heart failure patient.
Problem Statement PurposeShort-term:Train at least 80% of PCU RNs in Motivational Interviewing technique. ✅(Trained 96% of RNs and 54% of PCTs)Mid-term:Yield a 5% increase in the questions “Hospital staff took my preference into account” on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey ✅(34.4% increase from CY2019 to CY2020 as of March 7,2020)Long-term:Yield a 10% improvement in the overall self-confidence scores from baseline of the heart failure patients on the PCU as compared to baseline using the validated Self-Care of Heart Failure Index (SCHFI) tool. ❌(6.38% increase)
Goals
Methods
Discussion
Results
Creber, R., Patey, M., Lee, C., Kuan, A., Jurgens, C., & Riegel, B. (2016). Motivational interviewing to improve self-care for patients with chronic heart failure: MITI-HF randomized control trial. Patient Education and Counseling, 99, 256-264. http://dx.doi.org/10.1016/j.pec.2015.08.031Riegel, B., Creber, R., Hill, J., Chittams, J., & Hoke, L. (2016). Effectiveness of motivational interviewing in decreasing hospital readmissions in adults with heart failure and multimorbidity. Clinical Nursing Research, 25(4), 362-377. DOI: 10.1177/1054773815623252Riegel, B., Dickson, V., & Faulkner, K. (2016) The situation-specific theory of heart failure self-care. Journal of Cardiovascular Nursing, 31(3), 226-235. DOI: 10.1097/JCN.0000000000000244
References
• Motivational interviewing (MI) is defined as collaborative dialogue between a provider and a patient with the goal to strengthen the patient’s motivation and commitment to lifestyle changes.
• Literature supports the use of motivational interviewing for improving self-efficacy and confidence in self-care in patients with heart failure.
• By improving self-efficacy patients can more successfully manage their HF at home, thus keeping them out of the hospital and promoting positive outcomes long-term including reducing readmissions to the hospital.
Improving Self-Efficacy in Heart Failure Patients Through Motivational Interviewing
Laura Megan Morrison MS, RN, PCCNLinda Cook, PhD, RN, CNS, ACNP
University of Maryland School of Nursing
July-August 2019: 30 HF patients surveyed within 24 hours of admission and again after day 3 of admissionAugust 2019-September 2019: PCU nursing staff participated in Motivational Interviewing Training (2 hours of pre-work, 4 hours in-person).October 2019: Staff competency confirmed using random auditsDecember 2019-January 2020: 30 HF patients surveyed within 24 hours of admission and again after day 3 of admission.February 2020: Data analyzed for differences in confidence growth during hospitalization for patients cared for by MI-trained nursing vs. non-MI trained nursing staff.
Data Collection Tool
• Overall the mean change in confidence scores went from 3.77 pre-training to 3.97 post-training.
• This was a non-significant change (t=2.99, p=0.02).• Limitations: Small timeframe; No opportunity for continuity
or reinforcement; inability to verify that the motivational interviewing technique was used.
• Future studies should include a strategy to maintain continuity with the patient post-discharge, as well as the ability to reinforce said behavior changes.
• Sustainability is to embed into nursing orientation, train remaining and any new PCTs, eventually train the provider groups.
• Further statistics are being completed to understand which specific questions may have been impacted the most to be used for future patient education efforts.
Personal permission granted from Dr. Barbara Riegel to use only confidence section of the SCHFI tool.
ConclusionIn conclusion, there was no significant difference in the growth of confidence for heart failure patients with the use of motivational interviewing. However, there was a significant impact on the nurse’s attitudes and confidence toward using the motivational interviewing approach to patient education. The recommendation is to train all bedside staff with Motivational Interviewing.
Cesarean Delivery• One of the most common elective procedure performed worldwide
• 46 countries are noted to have a cesarean delivery (CD) rate of > 20%• At the tertiary hospital in Maryland, CD rates account for 30% annually
• Compared to women who give birth vaginally, CD is associated with greater: • Length of stay• Patient dissatisfaction• Infection • Discomfort
Enhanced Recovery After Surgery (ERAS)• ERAS is a set of standardized preoperative interventions implemented to
• Improve surgical outcomes• Reduce hospital costs• Optimize patient care
Problem Description & Background
Purpose• Develop and evaluate preoperative interventions for enhanced recovery
after caesarean delivery (ERAC) clinical practice guideline (CPG)
Goals• Short Term: Develop a sustainable evidence-based CPG that gains
acceptance among practitioners• Long Term: Reduce the incidence of post operative nausea and vomiting
(PONV), surgical site infection (SSI), and discomfort due to fasting
Project Purpose and Goals
CPG-Recommendations Overview PFQ Results
Strengths • High quality evidence review• Strong multidisciplinary support• Overall positive feedback from anesthesia providers
Limitations• Institution specific• Low score on applicability
• Suggestions to overcome limitation: structural changes & alter workflow
Discussion
Next steps• Implement interventions • Elicit feedback from providers and address barriers to implementation
Sustainability Plan• Educational sessions for obstetrics staff• ERAC champions to facilitate and encourage continued use of CPG• Audits to ensure compliance with interventions
Conclusion
Cardoso, M., Leite, A. O., Santos, E. A., Gozzani, J. L., & Mathias, L. (2013). Effect of dexamethasone on prevention of postoperative nausea, vomiting and pain after caesarean section: a randomised, placebo-controlled, double-blind trial. European Journal of Anaesthesiology, 102-105.Corso, E., Hind, D., Beever, D., Fuller, G., Wilson, M., Wrench, I., & Chambers, D. (2017). Enhaced recovery after elective caesarean: a rapid review of clinical protocols, and an umbrella review of systematic reviews. BMC Pregnancy and Childbirth, 1-10.Wilson, D., Caughey, A., Wood, S., Macones, G., Wrench, I., Huang, J., . . . Nelson, G. (2018). Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations (Part 1). American Journal of Obstetrics & Gynecology, 523-532.
Preoperative Interventions
Post-Operative Nausea & Vomiting (PONV) Prophylaxis• Evidence: Pregnant women are at higher risk of PONV due to spinal anesthetic,
hormonal changes, lower esophagogastric tone, and increased abdominal pressure
• Recommendation: Administer ondansetron, famotidine, sodium citrate, metoclopramide, and dexamethasone
• High Risk: transdermal scopolamine patch
Surgical Site Infection (SSI )Prophylaxis• Evidence: Complicates 10% of CD• Recommendation: Administer Cefazolin 2g IV within 60 minutes of incision.
• Women with ruptured membranes will also receive Azithromycin 500mg IV
Fasting Recommendation • Evidence: Current practice of 8 hour fast leads to prolonged recovery, increased
susceptibility to infection, impaired wound healing, and metabolic stress. • Recommendation: Patients can consume clear liquid up to 2 hours prior to
anesthesia induction
Enhanced Recovery After Cesarean Delivery Clinical Practice Guideline: Preoperative Interventions
Angel Patel, BSNUniversity of Maryland, Baltimore, School of Nursing
Project Faculty Advisor: Veronica Amos PhD, CRNA, PHCNS-BCClinical Site Representative: Christina Mack, MD
Methods & Implementation Strategies
Phase I • Setting: Tertiary hospital in Maryland• Population: Women undergoing elective CD• Stakeholders
• Director and Obstetric Anesthesia • Director of Maternal & Fetal medicine
• Develop a CPG: Evidence-based interventions presented to stakeholders• AGREE II Tool: Incorporate feedback and recommendations from
stakeholder to CPG
Phase II• PowerPoint Presentation during anesthesia grand rounds
• Practitioner Feedback Questionnaire (PFQ) to evaluate demographic data, usability, and acceptability of CPGCRNAs• Student registered nurse anesthetists (SRNAs), Certified Registered
Nurse Anesthetists (CRNAs), and Medical Doctors of Anesthesiology (MDAs)
Phase III• Data analysis of the AGREE II Tool and PFQ
AGREE II Tool Results
References
AGREE II ToolStakeholders• Completed by Director of Obstetrics Anesthesia and Director of Maternal & Fetal
Medicine • Overall Quality of CPG: 91.7%• Stakeholders would recommend CPG for practice
AGREE II Tool Results by Domain
Domain Percentage ScoreScope & Purpose 91.7%Stakeholder Involvement 94.4%Rigor of Development 86.4%Clarity of Presentation 91.7%Applicability 83.3%Editorial Independence 100%Overall Guideline Assessment 91.7%
PFQ SurveyDemographic Data• 39 anesthesia providers including MDAs, CRNAs, and SRNAs• 17 PFQ surveys completed: Response rate 43.6%
Results• Quality: Thorough evidence review with research-based recommendations • Acceptance of Recommendations: Interventions will provide benefit to patients
and will be accepted by staff• Applicability of Recommendations: Interventions will be easily implemented• Comparative Value: Interventions will improve care compared to current practice• Outcome Variable: Providers will apply recommendations in their practice
97.9
87.5
39
75 78.1
0102030405060708090
100
Quality Acceptance ofRecommendations
Applicability ofRecommendations
Comparative Value Outcome Variables
Perc
enta
ge
PFQ Results by Subcatergory
BACKGROUND
OBJECTIVES
METHODS
RESULTS
REFERENCES
CONCLUSIONS
ACKNOWLEDGEMENTS
DISCUSSION
Increasing Nurse Participation During Interdisciplinary RoundsAleta Skaanland, BSN, RN, CCRN
Bimbola Akintade, PhD, MBA, MHA, ACNP-BC, NEA-BC
• Errors in healthcare lead to 250,000 preventable deaths each year in the U.S.
• Miscommunication between members of healthcare team contributes heavily to errors through delays in care, serious errors, failure to rescue, and death.
• Interdisciplinary rounds using structured communication tools are designed to improve care quality through increased team collaboration, however:
• Quality Improvement Project: Implement a structured communication tool in a 16-bed intensive care unit (ICU) in a community teaching hospital
• Short Term Goal: Increase nurse participation during rounds by 20% over eight weeks using a structured communication tool
• Long Term Goal: Over one year, increase teamwork scores measured by staff surveys by 5% Institute for Healthcare Improvement. (2015). How-to guide:
Multidisciplinary Rounds. Cambridge, MA: Institute for Healthcare Improvement.
Institute of Medicine. (2000). To err is human: Building a safer health system. Washington DC: The National Academies Press. https://doi.org/10.17226/9728
Makary, M. A., & Daniel, M. (2016). Medical error-the third leading cause of death in the US. BMJ (Clinical Research Ed.), 353, i2139. https://doi.org/10.1136/bmj.i2139
Mercedes, A., Fairman, P., Hogan, L., Thomas, R., & Slyer, J. T. (2016). Effectiveness of structured multidisciplinary rounding in acute care units on length of stay and satisfaction of patients and staff: A quantitative systematic review. JBI Database of Systematic Reviews & Implementation Reports, 14(7), 131–168
• Dean Meadows, MD, FCCP• Terry Herbert, BSN, RN• Katie Reymann, BSN, RN CCRN• Brittany Lewis, BSN, RN, CCRN• Milikka Smith, BSN, RN, CCRN• Michael Allison, MD• Mary Ann Hanson, BSN, RN, CCRN• Linsey Davis, BSN, RN, CCRN• Daniel Neas, BSN, RN, CCRN
• All ICU nurses were asked to present their patients during rounds using:
• Observations of rounds continued during implementation
Analysis:• Nurse participation plotted on
a run chart; t-test compared pre-post participation
• T-tests compared differences in staff survey responses between disciplines and between pre and post data.
Staff Surveys:• Pre-implementation 91% completion
rate (intensivists n=6, residents n=11, and nurses n=34)
• Post-implementation 92% completion rate (intensivists n=9, residents n=12, and nurses n=46)
Passive attendance at rounds does not ensure interdisciplinary engagement.
Use of a structured tool can increase nurse participation
during interdisciplinary rounds.
Increased interdisciplinary participation is associated with improved teamwork, communication, and staff satisfaction.
• Tool implementation empowered increased nurse participation.• Increasing nurse perceptions of teamwork is meaningful as there was a
disparity between disciplines.• Some nurses had difficulty with public speaking; buy-in was not easy.• Support from interdisciplinary leadership was pivotal to the success of
nurses assuming a new role.
Limitations: • Meaningful outcomes not recorded: (1) error or miscommunication identified
or corrected during rounds, (2) patient outcomes.
Implications for Practice• Shifting unit culture requires time and buy-in of the nursing
staff, but early outcomes of this quality improvement initiative have been very positive.
• Units should restructure rounds to include nurses in the presentation.
Potential for Future Development• Engage additional disciplines (e.g. respiratory therapy to
presenting results of ventilator weaning)• Adjust the tool to include future unit-specific quality
improvement projects
zzzSTRUCTURED TOOL
RN Presents:ü Patient name, ageü Summary of hospital
course & acute problemü Intravenous linesü Urinary cathetersü Restraintsü Mobility plan
Resident/NP/PA Presents:ü Plan of care
020406080
100
20-Aug22-Aug23-Aug26-Aug30-Aug4-Se
p5-Se
p14-Se
p21-Se
p26-Se
p28-Se
p30-Se
p1-O
ct3-O
ct5-O
ct11-O
ct19-O
ct2-Nov9-Nov
10-Nov16-Nov19-Nov22-Nov24-Nov
Nurse Participation During Rounds
Series1 Series2Baseline Education Phase Implementation
RN Participation (%) Average RN Participation per phase (%)
TeamworkCommunication
SafetyStaff Satisfaction
(1) a checklist on a badge, or (2) a script template.
• Perceptions of teamwork measured using Safety Attitudes Questionnaire; surveys offered to all ICU staff pre and post-implementation
• Nurse participation during rounds defined as a verbal contribution excluding answering a question or amending content; measured by random observations during rounds
• Six nurse champions presented during rounds using the tools during the education phase
• Baseline: Rounds were well-attended by nurses, however, nurse participation averaged only 3% (224 observations) with a median of 0%. Pre-implementation, nurses perceived less interdisciplinary teamwork than physicians (4.19 vs. 4.54; p=.01).
• Education Phase: 22% nurse participation (109 observations)• Implementation Phase: 100% nurse participation (317 observations)
After implementing use of a badge checklist or paper script: • Nurse participation increased from 3% to 100% (p<.001)
“I did not realize how uninvolved we were in rounds until we started presenting.”
-Clinical Nurse
• Teamwork scores increased for nurses (p=.01); this closed the nurse-physician teamwork gap (4.50 vs. 4.55; p=.69)
• Intensivist satisfaction with rounds increased (p=.01)
u In 2014, the Joint Commission identified combatting alarm
fatigue as a national patient safety goal
u Alarm fatigue is sensory overload when clinicians are
exposed to an excessive amount of alarms, which can
result in desensitization to alarms and missed events
u Cardiac monitors are responsible for 37% of Hospital
alarms. However, 95% of these alarms are false
u The frequency of monitor alarms and calls from monitor
techs was identified by nursing staff as the primary source
of excess noise and alarm fatigue
Background
u The purpose of this quality improvement (QI) project was to
institute a practice change with evidence-based measures
aimed at the reduction of false monitor alarms on an acute
care unit with a goal to reduce alarm fatigue
u Implement Evidence based measures to include changing
electrodes daily and reviewing telemetry necessity daily
during Interdisciplinary rounds (IDR)
u Reduce the number patients on telemetry monitoring and
the number of calls from the remote monitoring station
u To sustain the evidenced based alarm fatigue intervention
and promote adoption by other units within the hospital
Objectives/Purpose Statement
Methods
Results
Conclusions
Drake, D. A., Luna, M., Georges, J. M., & Steege, L. B. (2012). Hospital nurse force
theory: a perspective of nurse fatigue and patient harm. ANS. Advances In Nursing Science, 35(4), 305-314. doi:10.1097/ANS.0b013e318271d104
Sendelbach, S., & Funk, M. (2013). Alarm fatigue. AACN Advanced Critical Care,24(4), 378. Retrieved from
http://survey.hshsl.umaryland.edu/?url=http://search.ebscohost.com.proxy-
hs.researchport.umd.edu/login.aspx?direct=true&db=edb&AN=91955461&site=eds-live
References
Hospital Nurse Force Theory – A perspective of nurse fatigue
and patient harm was used to guide implementation
Development Figures
Elizabeth Regan MSN, RN: Clinical Site Representative
Debra Bingham DrPH, RN, FAAN
An Dinh MD: Medical Director HCGH
Charge Nurses and staff at HCGH
Acknowledgements
uThe result from the pre survey (M=3.07, SD= 1.38) compared to post
survey (M=2.38, SD=0.93) indicates a slight decrease in fatigue level,
t(13)=2.6, p=0.02.
uThere was a 14% decrease (p<0.01) in the number of patients on
telemetry (Figure 2)
uThere was a significant reduction In the numbers of calls from the remote
monitoring station from an average of 72.7 calls per day pre
implementation to 9.1 calls per day post implementation (Figure1)
u On the Acute Care Unit, a validated pre and post alarm fatigue survey
was randomly distributed to nurses to assess their level of fatigue
u The survey was a ten item questionnaire that assessed years
experience, reaction to alarms, coping skills, and overall impact of
alarms on work performance
u A paired T test was done to compare the pre and post alarm fatigue
survey data of the same group of nurses
u Acute Care unit staff were educated on the proposed interventions: daily
electrode changes, patient review & daily telemetry logs
u Patients on telemetry monitoring were tracked daily to ensure electrodes
were changed daily and necessity for continuation reviewed daily
u An audit tool was created to track electrode changes & patient review
u The remote telemetry station kept a daily log of calls to the unit
Combatting Alarm Fatigue on An Acute Care UnitOlawale Wale – Aremu, BSN, RN, CMSRN; Ann Hoffman, DNP, RN, CPN, CNE
0
10
20
30
40
50
60
70
80
90
100
1-Sep-19 8-Sep-19 15-Sep-19 22-Sep-19 29-Sep-19 6-Oct-19 13-Oct-19 20-Oct-19
Telemetry Related Calls Per Day
0.00
5.00
10.00
15.00
20.00
25.00
Mean Pre Implementation Mean Post implementation
Unit Census Vs Telemetry Census
Unit Census
Telemetry Census
Discussionu Staff had buy-in and were compliant the QI project
u This project improved communication between
nurses and telemetry technicians
u Limitation of the study was the small sample size of
nurses (14) and duration of study (6 weeks)
u Study result was comparable to similar studies aimed
at reduction of alarm fatigue
u This QI project demonstrated that implementing
evidence based measures including the changing of
electrodes and reviewing telemetry necessity daily were
effective in
§ Evaluation if patients’ needed telemetry
§ A decrease in nurse perceived fatigue from
monitor calls
§ Significant decrease in the number of phone
call alerts from remote telemetry center
u Future projects with larger sample sizes will add strength
to this evidence based project
u As outlined by the Joint Commission combatting alarm
fatigue is essential in promoting patient safety. This
project could be expanded to assess its effect on patient
safety in future studies
Figure 1. Number of Telemetry calls per day Figure 2. Unit census and Telemetry census
