Prophylactic Sacral Dressings and Skin Assessments in Acute Care Emergency Surgery Patients

Caroline Brown, BSN, RN, CCRN & Rosemarie D. Satyshur, PhD, RNUniversity of Maryland School of Nursing

• Hospital acquired pressure injuries (HAPIs) are defined as a localized injury to the skin and/or tissue due to excessive, unrelieved pressure.

• 2.5 million individuals in the United States will develop a pressure ulcer (Sullivan & Schoelles, 2013).

• 60,000 people will die from complications associated with HAPIs (Sullivan & Schoelles, 2013).

• Approximately $26.8 billion is spent annually on treating HAPIs in the United States (Padula & Delarmente, 2019).

Background

The purpose of this evidence based quality improvement project is to implement a prophylactic sacral dressing and nurse practitioner (NP) and registered nurse (RN) skin assessments in Acute Care Emergency Surgery (ACES) patients to decrease the incidence of HAPIs. • Short term goals include:

• 100% of RNs will comprehend and appropriately apply the Braden Scale by completing online education.

• 100% of ACES patients who meet criteria will have a prophylactic sacral dressing and RN/NP skin assessment completed.

• Long term goals include: • HAPI rate will be zero in 100% of ACES patients.

Objectives

Results

Conclusions

• Padula, W.V. & Delarmente, B.A. (2019). The national cost of hospital-acquired pressure injuries in the United States. International Wound Journal. 1-7.

• Sullivan, N. & Schoelles, K.M. (2013). Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Annals of Internal Medicine. 158, 410-416.

ReferencesA quality improvement project was conducted, implementing a prophylactic sacral dressing and NP/RN skin assessments among ACES patients on a 24- bed SICU at a large, tertiary, academic medical center in Baltimore, Maryland. The project was implemented in three phases over 10 weeks.• Phase 1: Identification of unit champions and education

pertaining to the Braden Scale and prevention of HAPIs occurred over the two weeks.

• Phase 2: Lasted 7 weeks and included ACES patients, 18 years of age or older, admitted to the SICU with admission Braden scores less than or equal to 14, without preexisting sacral pressure injury.

• Phase 3: Consisted of data collection and analysis.

Methods

Figures

Thank you to Dr. Tisherman, SICU leadership, SICU nurses, and ACES NPs for their unrelenting support, hard work, dedication, and cooperation.

Acknowledgements

Post-Implementation

Pre-Implementation

• Using the Braden Scale to identify high risk patients and implementing a prophylactic sacral dressing and skin assessments can improve patient outcomes, decrease the incidence of HAPIs, and decrease unnecessary healthcare costs.

• Dissemination of the project includes expanding the prophylactic sacral dressing to to other surgical services.

• Integrating the prophylactic sacral dressing into unit procedure as standard of care will facilitate improved patient outcomes; decreasing and potentially eliminating the incidence of HAPI.

Discussion• Pre-implementation Braden Scores ranged from 8-14, with

an average of 12.• Post-implementation Braden Scores ranged from 10-14,

with an average of 13. • Evidence suggests implementation of a prophylactic sacral

dressing can alleviate the incidence the HAPIs.• The Braden scores is a validated tool that identifies patients

at high risk for developing skin breakdown. • Outcomes from this quality improvement project have shown

to be successful in demonstrating a reduced incidence of HAPIs in the SICU when a prophylactic sacral dressing and RN/NP skin assessments were utilized.

• Limitations included several nurses not having the electronic app to contact ACES NP, lack of staffing, lack of time, differing priorities among staff, and issues with compliance regarding documentation, assessment, and enrollment of patients.

0

1 1 1

0

1 1 1

JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST

Num

ber o

f Sac

ral H

APIs

Month

Baseline Sacral HAPIs by Month

0 0 0

SEPTEMBER OCTOBER NOVEMBERN

umbe

r of S

acra

l HAP

IsMonth

Sacral HAPIs by Month

Results

• Short term goals:• 85% of SICU RNs completed the online education (Goal: 100%).• 96% of ACES patients who met criteria had a prophylactic sacral dressing applied

(Goal: 100%).• 100% of ACES patients who met criteria had a skin assessment completed and

documented by RNs (Goal: 100%).• 35% of ACES patients who met criteria had a skin assessment completed and

documented by ACES NPs (Goal: 100%).• NP/RN data collection form compliance was 44% (Goal:100%).

• Long term goals: • Pre-implementation, there were a total of 6 HAPIs. • Post implementation, there were zero HAPIs (Goal: zero).

• Workplace violence (WPV)significantly impacts all health care workers.

• Those working in volatile settings such as emergency departments and behavioral health are most impacted.

• 27% of fatalities in health care and social service settings are due to assaults and violent acts.

• Common factors of workplace violence are a history of violence, under the influence of drugs and alcohol and inadequate security.

Problem Statement

The purpose of this quality improvement project was to implement a procedure for the electronic utilization of the Broset Violence Risk Assessment tool within an urban emergency department. Goals:• Short term: For Emergency Department (ED)

nurses to utilize the BVC to assess all patients for violence during the initial triage.

• Midterm: For patients that score a 3 or > on the BVC, security personnel will visit twice per shift.

• Long term: To reduce the number of WPV incidents that occur within the ED.

Purpose/Goals

Results

Discussion

Recommendations:• Create a forcing function, such as a mandatory field for the BVC

assessment tool. • Adopt electronic technology for the notification of patients with scores

>3.• Continue daily compliance audit tool to target individual accountability. • Enforcement of procedures need to be hard wired into the workflow of

the nurses and security personnel. • The BVC is a reliable and valid tool for assessing workplace violence. • Anecdotally, both nurses and security stated that when utilized the

assessment was accurate and did provide them with cues on how to approach the patient.

• Continue this project as workplace violence continues to be underreported. The findings from the survey are in line with the literature that staff feel that nothing will be done about the violence if reported to leadership.

Conclusions

References

14-week Quality Improvement Project• Sample: Includes patients >18 years old. • Setting: Emergency Department within an urban

community hospital.• Staff Education: mandatory education, direct

conversations, staff huddles and weekly e-mail updates.

• Survey: completion of a pre/post survey via Survey Monkey on staff perceptions of workplace violence.

• Audits: daily violence assessment compliance audit tool.

MethodsJanine Good, MD Clinical Site RepresentativeSara Delkoon, RN Nurse Manager Emergency DepartmentJoann Couser, Security ManagerWalter Brown, Assistant Director Security

Acknowledgements• 6,944 patients were treated in the ED. • 4,566 patients were assessed with the BVC, 67%

compliance rate with completing the assessment.• Of significance, is the decline in compliance during the

implementation phase (p=0.014). • Only 18 patients scored a >3 on the BVC (p=0.68), 78%

male, 22% female. • There is a significant relationship (p=0.035) between nurses

not reporting workplace violence and feeling that leadership will act upon the incident.

• Anecdotally, both RNs and Security feel the tool is useful. • Limitations: time constraint for the implementation, limited

availability to technology (printer and paging), survey and diverse education methods did not reach 100% of the staff.

Mitigating Workplace Violence Utilizing the Broset Violence ChecklistKaren E. Doyle, MBA, MSN, RN, NEA-BC, FAAN

Hazel Jones-Parker, DNP, FNP-BC, AACRNPaul Thurman, PhD, RN, ACNPC, CCNS, CCRN

University of Maryland School of Nursing

• Blando, J., McGreevy, K., O’Hagan, E., Worthington, K., Valiante, D. & Peek-Asa. (2012). Violence: Recognition, management and prevention. The Journal of Emergency Medicine, 42(3), 329-338. doi:10.1016/j.jemermed.2008.06.026

• Hvidhjelm, J., Sestoft, D., Skovgaard, L. & Bjorner, J. (2014). Sensitivity and specificity of the Broset Violence Checklist as a predictor of violence in forensic psychiatry. Nordic Journal of Psychiatry, 68(8). 536-542. doi:10.210908019488,2014.880942

• Partridge, B. & Affleck, J. (2018). Predicting aggressive patient behavior in a hospital emergency department. An empirical study of security officers using the Broset Violence Checklist. Australasian Emergency Care, 21, 31-35. doi:org/10.1016/j.auec.2017.11.001

0%

20%

40%

60%

80%

100%

120%

Compliance with Broset Violence Checklist

Compliance Median Goal

Implementation

Training began and pre-implementationsurvey distributed

BVC moved to initial triage

Pre-implentation Following Education Following addition of BVC to TriageMean SD Median IQR Min Max Mean SD Median IQR Min Max Mean SD Median IQR Min Max

Percentage of ER Patients whose BVC were assessed

74% 15% 76% 25% 38% 95% 62% 20% 58% 35% 31% 92% 67% 20% 71% 34% 23% 96%

Percentage of Patients with a BVC greater than or equal to 1 who were assessed

3% 2% 2% 2% 0% 9% 3% 3% 3% 4% 0% 13% 3% 2% 3% 3% 0% 7%

Percentage of Patients found to have a BVC greater than or equal to 1 who came to the ER

2% 1% 2% 1% 0% 5% 2% 1% 2% 2% 0% 4% 2% 1% 2% 1% 0% 5%

Percentage of Patients found to have a BVC greater than or equal to 3 who came to the ER

0% 0% 0% 0% 0% 2% 0% 1% 0% 0% 0% 3% 0% 1% 0% 0% 0% 4%

Mann-Whitney UU p

Percentage of ER Patients whose BVC were assessed 1355 0.014Percentage of Patients with a BVC greater than or equal to 1 who were assessed

2061 0.251Percentage of Patients found to have a BVC greater than or equal to 1 who came to the ER 1910 0.71Percentage of Patients found to have a BVC greater than or equal to 3 who came to the ER 1888 0.68

Background

Objectives

Discussion

Conclusions

References

Methods

Results

• All eligible patients were mobilized minimum of Q shift without adverse events

• Improvement in frequency of PT consults and assessments• Nurses felt better equipped at recognizing when patients were ready

for mobilization and assured that mobilization was safe• Sustainability enhanced via addition of flowsheet and online resources• Focus on multidisciplinary approach and tailoring PT consults to

ensure providers are working at height of skill set• Consistent with literature that supports implementation of an Early

Mobility Program to improve mobilization in the PICU setting• Need for more research, implementation of full delirium protocol

Christina Graham, MSN, RN, CPNP-ACWalter Reed National Military Medical Center

Dr. Karen Clark, PhD, RNUniversity of MarylandSchool of NursingFaculty Advisor

• Implementation site lacks formal assessment tool to determine patient readiness for mobilization

• Underutilization of physical and occupational therapy• Staff lack awareness of importance of patient mobilization• Electronic Health Record (EHR) is not built to accurately

document mobilization activities

Short Term• Implementation of a Nurse Led Early Mobility assessment tool

to increase percentage of patients assessed by PT and mobilized in the PICU

• Increase nursing awareness of importance of Early Mobility• Collaboration with Physical Therapy team to improve

multidisciplinary approach to mobilizationLong term

• Long term goal to decrease prevalence of delirium in the PICU

Setting:• Five bed PICU in mid Atlantic metropolitan area; ages 1

month to 19 yearsInclusion criteria:

• All patients admitted to PICU between September 17th, 2019 and December 6th, 2019

Exclusion criteria:• Critical airway, neuromuscular blockade, open abdomen/chest,

unstable fracture, spinal precautions, intubated patients with FiO2>60%, PEEP>8, SBS -3 to -2

Implementation plan:• Staff education with pre/post Likert scale questionnaire• Initiation of assessment to tool to determine readiness for

mobility and guide multidisciplinary approach to patient mobilization

• Addition of Upward Mobility Flowsheet to EHR nursing documentation

• Cameron,S., Ball, I., Cepinskas, G., Choong,K., Doherty, T., Ellis,C.,…Fraser, D. (2015). Early mobilization in the critical careunit: A review of adult and pediatric literature. Journal of CriticalCare, 30, 664-672

• Joyce, C., Taipe, C., Sobin, B., Spadaro, M., Gutwirth, B., Elgin,L.,…Traube, C. (2018). Provider beliefs regarding earlymobilization in the pediatric intensive care unit. Journal of PediatricNursing, 38, 15-19

• Wieczorek, B., Ascenzi, J.,Kim, Y., Lenker, H., Potter, C., Shata, N.,Kudchadkar, S. (2016). PICU Up!: Impact of a quality improvementintervention to promote early mobilization in critically ill children.Pediatric Critical Care Medicine, 17, e559-e566

Nurse Led Early Mobility in the Pediatric Intensive Care Unit

• Hospitalization related exposure is associated with estimated 30% of cases of pediatric critical care delirium

• ICU Delirium associated with:• Longer hospitalization• Higher costs• Increased morbidity/mortality (Cameron, et al. 2015)

• Perceived safety, comfort, and clinical status results in suboptimal patient mobilization (Wieczorek, et al. 2016)

• Early mobilization has been shown to be beneficial in optimizing patient outcomes and preventing ICU delirium

• Safe and developmentally appropriate physical activity

• Initiated within 2 to 5 days of PICU admission (Cameron, et al. 2015; Joyce, et al. 2018)

Problem

• 45 admitted to PICU during implementation; average LOS < 2.5 days• 93% patients eligible for mobilization• 64% patients had PT consults entered• 55% patients assessed by PT• 100% eligible patients mobilized• No adverse events related to mobilization activities

9%

69%

21%

Mobilization Activities

% passive ROM

• 9% of patients received in bed-passive ROM

• 90% of patients actively mobilized via in-bed active movement or out of bed therapy (21% and 69% respectively)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Patients eligible(n=41)

Patients with PTconsults (n=28)

Patients assessedby PT (n=24)

Eligible Patientsmobilized (n=41)

Adverse events(n=0)

Patient Eligibility Data

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

mobilization activities are an integral component topatient care

mobilization activities improve patient outcomes

mobilization activities are safe

comfortable with providing my patients with ROMexercises

comfortable with determining when a patient is eligiblefor mobilization

Likert Questionnaire Results

POST PRE

• Physical Therapy team have 72 hours to complete assessment which influenced total number of patients assessed in the PICU.

• Average length of PICU stay shorter than consult timeframe which may explain number of entered PT consults and PT assessments

• Characteristic of staffing at implementation site may have influenced Likert scale responses due to staff turnover and poor post-implementation response rate (22 vs 9)

• Addition of upward mobility flowsheet in nursing documentation promoted nursing compliance and mobilization of all eligible patients

• Leadership and dedication of change champions were the largest influencers in shaping unit culture and facilitating implementation of early mobility project

Obstructive Sleep Apnea (OSA) is a largely unrecognized condition within the pediatric primary care setting even though sleep concerns rank among the top chief complaints for children and parents.

The current clinical practice guidelines developed by the American Academy of Pediatrics (AAP) 1 recommends screening for snoring at all well child visits which is the hallmark symptom for detecting the condition.

Nearly 50% of parents report that their primary care provider did not inquire about their child’s sleep habit or provide screening questionnaires during well child visits.

Lifelong consequences of OSA include behavioral disorders, difficulties excelling in academics, neurologic developmental delays, failure to thrive, and cardiac dysfunction.

Background

Purpose: Implement the pediatric OSA screening questionnaire, ‘I’M SLEEPY’2, within a primary care clinic during well child visits for children 7 to 12 years of age to increase detection of possible OSA

Short term goals: 1. Increase the utilization of the ‘I’M SLEEPY’ questionnaire during

well child visits from 0% to 100%2. 100% of those who screen positive have a documented action

plan by the provider

Long term goals: 1. 100% of children ages 2 and older are screened during well

child visits using the ‘I’M SLEEPY’ questionnaire 2. 100% of those who screen positive have a documented action

plan by the provider.

Objectives

Implementation Discussion

The ‘I’M SLEEPY’ questionnaire is an effective screening tool for pediatric OSA that is easily incorporated into the primary care setting

Sustainability is supported by the clinic’s ability to expand the use of the questionnaire beyond well child visits

Future project recommendations:• Expand screening to children 2 – 18 years of age• Addition of the ‘I’M SLEEPY’ questionnaire into the electronic

charting systems well child visit template

Conclusions

1. Marcus, C.L., Brooks, L.J., Draper, K.A., Gonzal, D., Halbower, A.C.,Jones, J., …Shiffman, R.N. (2012). Diagnosis and management of childhood obstructive sleep apnea. Pediatrics,130(3), 576-584.

2. Kadmon, G., Chung, S.A., & Shapiro, C.M. (2014). I’M SLEEPY: Ashort pediatric sleep apnea questionnaire. International Journalof Pediatric Otorhinolaryngology, 78, 2116-2120.

References

Figures

Dr. Ann Felauer, DNP, CPNP-AC/PC Faculty Advisor

Dr. Daniel Tuckey, MD, FAAP, Clinical Site Representative

Ms. Amy Pinkerton, RN, Project Champion

Acknowledgements

The ‘I’M SLEEPY’ questionnaire was integrated over a 12-week period into well child visits for children 7 to 12 years of age who had not previously been diagnosed with pediatric OSA.

Screening process• The questionnaire was provided on paper, asking eight ‘yes/no’ questions• Three ‘yes’ answers resulted in a positive screening• Providers investigate further for OSA and document action plan with positive screens• Action plans may include education, weight management, or specialty referrals

Implementation StrategiesStructures:

• Lunch and learn sessions• Educational binder as a staff reference

Processes: • Screening process posted in triage rooms • Daily morning huddle announcements with staff reminders• Bi-weekly data collection and sharing

Detecting Pediatric Obstructive Sleep Apnea in the Primary Care Setting

Krystal M. Howell, MSEDM, BSN, RNAnn Marie Felauer DNP, CPNP-AC/PC

Questionnaire readily received by clinic staff and easy to implement into primary care• 100% of staff members received education (n=27)• 16 additional screenings completed during sick visits for patients with

sleep related complaints

Results support current literature recommendations to incorporate routine screening into well child visits as evidenced by:

Increased detection of OSA • 21.6% positive screens requiring further evaluation for OSA• 87.5% of positive screens reported snoring• 25% positive screen were referred for polysomnography and

formally diagnosed with OSA (n=2)

Improved patient care• 100% documentation rate of action plans for positive

screenings

Barriers and limitations of implementation:• Hurricane Dorian altered baseline data collection• Staff changes required re-education and daily reminders• Project timeline led to small sample size (n=37)

Figure 2. Pediatric OSA Screening During Well Child Visits

Figure 1. ‘I’M SLEEPY’ Pediatric OSA Screening Questionnaire Figure 3. Analysis of Positive Questionnaire Results

Problem Statement

Purpose

Methods

Results

• The CPG was well received by anesthesia staff as evidenced by scores of greater than 65% achieved within the strongly agree section of the PFQ (n=25).

• Three specific scales out of the 23 were used to analyze overall provider acceptance of the practice change.

• The expert panel was in full support of CPG as evidenced by a greater than 85% score rating per each of the 7 domains in the Agree II tool.

• Limitations: Evidence expressed a higher need for ocular protection measures in spine/prone cases more so than robotic cases.

***CPG has officially been accepted and can be adopted into practice at this level II trauma hospital and is in full accordance with the evidence for demonstrating significance at preventing POVL.

Discussion

• Sustainability: Appoint a CPG champion to work with anesthesia providers to ensure adherence and provide updates on progression of CPG.

• Project champions will be responsible for meeting with expert panel to share findings of the ongoing process with the CPG.

• This process will include frequent interviews with the providers as well tracking of outcomes.

• The CPG warrants a re-analysis every 2 years to determine its relevance as well as how well providers are adhering to it.

Conclusion

Short-Term Goals:• By February 1, 2020, CPG will be accepted by the facility into practice.• By February 15, 2020, all members of the implementation team will be

fully educated by expert panel on the impact of POVL and the steps of the approved clinical practice guideline to reduce POVL.

• By March 1, 2020, clinical practice guideline will go live and be incorporated into practice.

Long-Term Goal• By May 15, 2020, full compliance of the clinical practice guideline will

reduce postoperative vision loss/associated ocular complications in robotic assisted surgeries.

Short and Long-term Goals

CPG Recommendations

• Setting: Level II trauma hospital in Baltimore, Maryland• Population: Anesthesia Providers

Implementation strategies:• An extensive literature review was completed on POVL and formally presented to the clinical site

representative. The CPG was then submitted to IRB inquiry and presented to Expert Panel where the Agree II tool was disseminated. Modifications were made, CPG was officially presented to anesthesia department during grand rounds where practitioner feedback questionnaires (PFQ) were disseminated.

• Expert Panel: 1 staff DNP prepared certified registered nurse anesthetist (CRNA ), 1 Chief CRNA, and 1 Chief Anesthesiologist

• Sample: Anesthesia providers consisting of Student Nurse Anesthetists (SRNAs), CRNAs, and Anesthesiologists (n =25)

• Data Collection Methods: • AGREE II Tool: A practice guideline appraisal tool used to evaluate the quality and comprehensiveness

of the CPG.• PFQ: a 23 item survey (evaluated the feasibility for a practice change) was disseminated to all

anesthesia personnel including student registered nurse anesthetists who were in attendance of the official presentation of the CPG on November 14, 2019.

Intraoperative and Postoperative Anesthesia Management of Postoperative Visual Loss in Robotic

SurgeriesKesiah Louis, BSN, RN

Advised by: Veronica Gutchell, DNP, CRNP

• Postoperative visual loss (POVL) associated with robotic surgeries occurs at a rate of 1.9 events per 10,000 cases.

• Patients with POVL experience increased lengths of stay of 8.6 days from 4.1 days with a financial impact of $49,532 from the standard $22,697.

Risk factors for POVL include:• Optic nerve ischemia (anterior/posterior)• Steep Trendelenburg (ST) at an incline of 30 to 45 degrees

for extended periods of time which can lead to intraocular pressure changes.

Purpose: To create a clinical practice guideline (CPG) to prevent the occurrence of POVL in robotic assisted surgeries.

Intraoperative:• Tight Blood Pressure Control- keep blood pressure within 20% of baseline.• Fluid administration- maintain euvolemia (20ml/kg).• Neutral head position and no external compression on eyes.• 5-minute supine intervention for every 90 minutes that the patient is in ST. Postoperative:• Post-operative visual acuity assessment will be performed by anesthesia staff.• Ophthalmology consult will be requested should deficits be found and persist past 24 hours.

References• Alwon, K., & Hewer, I. (2016). Perioperative vision loss:

Considerations and management. AANA Journal, 84(5), 363-370

• Anesthesiology. (2019). Practice advisory for perioperative visual loss associated with spine surgery 2019: An updated report by the American Society of Anesthesiologists Task Force on perioperative visual loss, the North American Neuro-Ophthalmology Society, and the Society for Neuroscience in Anesthesiology and Critical Care. Retrieved from https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2718348

• Molloy, B, and C Watson. “A Comparative Assessment of Intraocular Pressure in Prolonged Steep Trendelenburg Position Versus Level Supine Position Intervention.” Anesthesiology and Clinical Science, vol. 12, no. 2, 2012.

• Heart failure (HF) is an incurable chronic condition and a leading cause of hospitalizations and readmissions.

• According to the Centers for Disease Control and Prevention (CDC, 2016): HF affects more than 5.7 million people in the U.S. Almost half of HF patients die within five years of

diagnosis. Healthcare for HF costs about $30.7 billion annually.

• Nurses and healthcare providers on a cardiac progressive care unit (CPCU) in an academic center were providing patient discharge education based on their own knowledge. Inconsistent patient education can lead to poor self care and increased readmission rates (Cleland et al., 2011).

Background

• The purpose of this quality improvement (QI) project was to implement a standardized discharge protocol for all adult HF patients admitted to the CPCU based upon HF care guidelines.

• Short-Term Goals: Educate 80% of staff nurses on discharge protocol. 80% of nurses will administer protocol by week 6. 80% of patients will receive the protocol by week 6.

• Long-Term Goals: 100% of nurses will administer protocol by week 10. 100% of patients will receive protocol by week 10. HF discharge protocol will result in reduced 30-day

readmission rates.

Objectives

Figures

Results

• HF is a chronic condition that affects millions of people nationwide, costs billions of dollars annually, and leads to high readmission rates.

• Consistent and adequate discharge instructions based on guidelines can improve self care and quality of life and lead to reduced hospital readmissions.

• The findings in this project are consistent with other studies where standardizing the discharge education process is essential to improving knowledge, self-care behaviors, and reducing readmission rates.

• The participants in this QI project were a convenience sample of nurses from a unit within an organization; therefore, the findings cannot be generalized to other settings.

Discussion

• Centers for Disease Control and Prevention. (2016). Heart failure fact sheet. Retrieved fromhttps://www.cdc.gov/heartdisease/heart_failure.htm

• Cleland, J. G., Troatman-Beasty, A., Atkins, P., Crundall, A., Cassiello, T., & Antony, R. (2011). Education for patients with heart failure: Rationale, evidence, and practical implication. Medicographia, 33(4), 409-417. Retrieved from https://www.medicographia.com/2012/02/education-for-patients-with-heart-failure-rationale-evidence-and-practical-implementation/.

References

• The standardized discharge protocol was developed by members of Congestive HF Pathway Committee.

• This QI project was conducted over 14 weeks.

Staff education was completed in the first 3 weeks. Pre- and Post-test analysis was conducted to

assess change in nurses’ knowledge. Implementation of standardized discharge protocol

took place over the next 10 weeks. A System Usability Scale (SUS) was used to

evaluate the ease of use of the standardized HF discharge protocol in the last week.

Methods

Carol Wade, DNP, CRNP leader of the CHF Pathway Committee and the Patient Education Task Force. The Task Force developed the Heart Failure Patient Handbook used as the tool to standardize Discharge Protocol.

Acknowledgments

• 100% of staff nurses completed the education training. A paired sample t-test was used to compare the mean pre-test (M=76.5,

SD=10.1) and post-test (M=93.7, SD=6.4) scores for knowledge of HF and its management. Nurses’ knowledge improved significantly (p< 0.001).

• Short-term goals achieved by week 6: 100% of nurses administered the discharge protocol (goal 80%). 100% of patients received the discharge protocol (goal 80%).

• Long-term goals achieved by week 10: 100% of nurses administered the discharge protocol (goal 100%). 100% of patients received the discharge protocol (goal 100%).

• Readmission rates for the Cardiology Department three months prior the intervention (July, August, and September, 2019) were 13.9%, 10.2%, and 13.1%, respectively. The readmission rate for October was 10.2%.

• The average SUS score was 86.7 (range 70-100); a grade “A” rating.

A Standardized Discharge Protocol for Heart Failure Patients to Reduce Hospital Readmissions

Misbah Naureen, BSN, RNGina Rowe, PhD, DNP, MPH, FNP-BC, PHCNS-BC, CNE

University of Maryland School of Nursing

Conclusions• Nurses’ knowledge improved significantly after an education

session on HF and its management.

• The SUS score suggests that the standardized education protocol was fairly easy to use and implement.

• Although it is early to make any definitive conclusion, the readmission rate a month into implementation (October,2019) was 10.2%, lower than the previous month (September 2019) 13.1%.

• A standardized discharge process and patient education can improve patient self-management of HF and is essential to improve quality of life and reduce 30-day readmission rates. 0

5

10

15

20

25

30

35

40

45

50

1 2 3 4 5 6 7 8 9 10Pe

rcen

tage

of N

urse

s

1= Least likely 10= Very likely

How Likely Are You To Continue Using The HF Discharge Protocol?

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51

Test

Sco

res

Nurses

Heart Failure and its Management: Pre and Post Tests Scores

Pre-test Score Post-test Score

0

2

4

6

8

10

12

14

16

18

Awful Poor Okay Good Excellent

F D C B A

<51 51-67 68 69-80.3 >80.3

Num

ber o

f Sur

veys

SUS Scores

Results of The System Usability Scale (SUS)

0

1

2

3

4

5

6

7

8

9

10

1 2 3 4 5 6 7 8 9 10

NU

MB

ER O

F PA

TIEN

TS

WEEK

Comparison of Number of Patients Who Actually Received HF Discharge Protocol Vs. Number Eligible to Receive

# of Patients Who Received # of Patients Eligible but did not Receive

Certified Registered Nurse Anesthetists (CRNAs) have provided anesthesia services for over 150 years Provide over 45 million anesthetics yearly Settings include hospitals, clinics, and the Veterans Affairs (VA) The Veterans Health Administration (VHA) under the VA Provides care to over 9 million veterans annually Internal audit of VHA determined

80% of newly enrolled veterans seeking care waited over 30 days

53% completed their first appointment > than 30 days To address veteran’s access to care issues VA finalized a rule, RIN 2900-AP44 which granted full practice

authority to the VAs advanced practice registered nurses However, CRNAs were excluded

Background

PurposeDevelop and implement an evidence-based health policy toolkit supporting CRNA full practice authority in the VA. The toolkit provides resources on amending rule, RIN 2900-AP44, to include CRNA.

Short-Term Goal Develop a toolkit supporting CRNA full practice

authority

Long-Term Goals VA will grant CRNA full practice authority Increase veterans’ access to anesthesia-related care

Project Purpose and Goals

Methods & Implementation StrategiesInterpretation: 83.3% of participants strongly agree granting CRNA full practice authority will decrease delays in veterans’ access to anesthesia care. Consistent with recommendations by VA/ Office of Inspector

General (OIG) (2018) Grant CRNAs full practice authority to increase patient

access to anesthesia-related care and decrease delays. 66.7% strongly agree the policy toolkit highlights the need to

amend rule, RIN 2900-AP44, to include CRNAs. RAND Corporation’s (2015) study recommends granting

CRNA full practice authority to decrease anesthesia provider shortages.

Limitations Small sample size (N= 30) Low yield of responses from sample size (40% responded) Homogeneous sample (CRNAs)

Discussion

Data analysis and literature review demonstrates the need for a health policy toolkit supporting CRNA full practice authority to decrease delays in veterans’ access to care in the VA.

Implications for Practice Increase veterans access to anesthesia-related care Eliminate anesthesia provider shortages Savings of $2.9 billion annually in provider salary cost with CRNA

alone model (Cintina et al., 2018) Decrease cost of care

Sustainability Visual management in the form of performance boards

Performance boards will be used to disclose improvement results with CRNA full practice authority.

Standard Work- written policy granting CRNAs full practice authority

Conclusions

Policy Toolkit created and includes:CRNA profession history Significance of delays in veterans’ access to

anesthesia care Literature review Elevator speech Policy decision brief Personal story

Development

Results

• Cintina, I., Hogan, P. F., Schroeder, C., Simonson, B. E., & Quraishi, J. A. (2018). Cost effectiveness of anesthesia providers and implications of scope of practice in a medicare population. Nursing Economic$, 36(2), 67–73. Retrieved from http://survey.hshsl.umaryland.edu/?url=http://search.ebscohost.com.proxy-hs.researchport.umd.edu/login.aspx?direct=true&db=rzh&AN=129092700&site=ehost-live.

• Department of Veterans Affairs: Office of Inspector General (VA/OIG). (2018). OIG Determination of veterans health administration’s occupational staffing shortages. Retrieved from https://www.va.gov/oig/pubs/VAOIG-18-01693-196.pdf

• RAND Corporation. (2015). Assessment B (Health care capabilities) Appendices E-I. Retrieved from https://www.va.gov/opa/choiceact/documents/assessments/Assessment_B_Health_Care_Capabilities_Appendices_E-I.pdf

References

Setting: Maryland Association of Nurse Anesthetists (MANA) Fall Conference 2019

Population: Non-retired CRNAs in the state of Maryland.

Implementation Strategies: Project presentation at MANA Conference Policy Toolkit emailed to participants via SurveyMonkey Data analyzed from policy toolkit evaluation survey

Evidence-Based Policy Toolkit Supporting Full Practice Authority for Veterans Affairs Nurse Anesthetists

Mariyam Popoola, BSNUnder Supervision of Veronica Amos, PhD, CRNA, PHCNS-BC

Clinical Site Representative, Brittney Taylor, DNP, CRNAUniversity of Maryland School of Nursing

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

Perc

enta

ge

Participants’ Response

Granting CRNAs full practice authority will decrease delays in veterans’ access to anesthesia care in the VA

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

Perc

enta

ge

Participants’ Response

The policy toolkit highlights the need to amend the rule to include the VA CRNAs

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

• Cardiovascular Implantable Electronic Devices (CIED)• Pacemakers - bradycardia arrhythmia.• Internal cardiovascular defibrillators (ICDs) - ventricular arrhythmia.• Variations in CIED devices – ~ 2000 CIED models.

• In the United States, :• 3 million patients are with CIEDs• Annually, 1 million CIEDs are implanted. • Annually, 2% of patients with CIED will undergo surgical procedures.

• There are increasing use of possible sources of electromagnetic interference (EMI) along with confusing recommendations of caring for these patient population during the perioperative phases.

• Local Problem: With the increase in surgical patients with CIEDs, there was no standard of evidence-based practice for anesthesia management of this patient population at this large community hospital located in Baltimore, Maryland.

Problem Description

• Purpose of this DNP Project: Develop a clinical practice guideline (CPG) for the perioperative anesthesia management of surgical patients with CIEDs.

• Standardize evidence-based care for patients with CIEDs among a multidisciplinary patient centered team, including anesthesia providers, cardiology and electrophysiology physician leaders.

• Anticipated Outcomes:• 90% of surgical patients with CIEDs will receive the pre and post-operative CPG

assessment.• 90% of the anesthesia providers will utilize the pre and post-operative assessment

CPG.• 80% reduction in electromagnetic interference (EMI) incident and hemodynamic

instabilities associated with these surgical patient population.

Purpose and Goals

CPG Recommendations

Results

• The guideline was implemented by leadership and stakeholders at the facility on January 28, 2020.

• Limitations: • Bipolar cautery is more expensive than the standard unipolar electrocautery

• Implementing CPG may disrupt workflow and delay surgeries.

• According to American Society of Anesthesiologists and Heart Rhythm Society, recommendations for surgical patients with CIEDs are based on expert clinical opinion due to lack of high-quality clinical evidence concerning the statistical occurrence of EMI during surgery.

• To Address this: • The usage of a bipolar cautery is an important measure in preventing EMI especially in surgeries

above the umbilicus. Benefit/risk of the cautery will be discussed with surgery team before surgery.

• All tasks within the guideline were clearly designated for a specific perioperative provider to limit confusion and facilitate speed and ease of use of the guideline.

• More high-leveled studies focused on perioperative assessment of CIED patients are needed to increase patient safety.

• of patients with CIEDs.

Discussion and Limitations

• Plans for Sustainability of the Project• Continued inclusion of CIED protocol champions from the facility to facilitate change and

encourage continued use of the CPG’s recommendations.• Follow up with anesthesia staff on the perceived helpfulness and effectiveness of this guideline in

improving patient safety.• Revision of the CPG every 3 years by designated champions to incorporate the most recent

evidence-based research.

• Future QI Projects : • Extension of this quality improvement project:

• Incorporating perioperative staff nurses responsibilities to the CPG.• Educating sessions for perioperative staff nurses on the perioperative management

• Creation of on-site cardiology led CIED Team that suggested by the Chief anesthesiologist. • Responsible for interrogating the CIED and assisting in developing plan of care.

ConclusionsCPG Recommendations

Methods• Expert Panel: 2 CRNAs, 1 Interventional Cardiologist and 1 Chief Information Officer.• Key Stake Holders: 1 Certified Registered Nurse Anesthetist (CRNA) and 1 Anesthesiologist.• Sample: Anesthesia providers consisting of Student Nurse Anesthetist (SRNAs), CRNAs and

Anesthesiologists (n =37).• Setting: Perioperative department of a large hospital center in Baltimore, Maryland.

• Data Collection Methods:• AGREE II Tool: A practice guideline appraisal tool used by expert panel members.

• Used to evaluate the quality of the CPG.• Utilized descriptive statistics.

• Practitioner Feedback Questionnaire (PFQ): Given in paper format to all anesthesia personnel who attended the formal CPG presentation during anesthesia grand rounds.

• Paper-based questionnaire used to assess the implementation of the CPG.• Utilized descriptive statistics.

Perioperative Anesthesia Management of Surgical Patients with Cardiac Implantable Electronic Devices

Oluwanife Solomon-Adenola, BSN, RNVeronica Gutchell, DNP, RN, CNS, CRNP

References• Bernstein A.D., Daubert, J.C., Fletcher, R.D., Hayes, D.L., Luderitz, B., Reynolds, D.W… Sutton, R. (2002). The

revised NASPE/BPEG generic code for antibradycardia, adaptive-rate, and multisite pacing. North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group. Pacing Clinical Electrophysiology, 25(2):260-4

• Crossley, G.H., Poole, J.E., Rozner, M.A., Asirvatham, S, J., Cheng, A., Chung, M.K…Thompson, A. (2011). The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert consensus statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and patient management. Heart Rhythm Society, 8(7), 1114-1154. Doi: 10.1016/j.hrthm.2010.12.023

Provider Feedback Questionnaire Result

AGREE II Tool Result

Pre-Operative Assessment• Physical assessment, pulse regularity and

location of the device are assessed.• Type of procedure and unpredictable

outcome?• Location of incision for surgical

procedure?• Patient’s position during surgery?• Type of electrocautery will be used?

Bipolar preferred than Unipolar?• Patient's disposition after surgery?• Patient's response to pre-induction magnet

application documented by an electrocardiography report or by anesthesia provider if planned intraoperative magnet use over the CIED.

• Anesthesia team will inform cardiologist and surgery team if further evaluation is needed.

CIED Evaluation Note• Date of last device interrogation:

recommend within 6 months for ICD and 12 months for pacemaker.

• Device type, manufacturer, and model.• Indication for device placement.• Battery longevity.• Any leads placed within the last 3 months.• Current programming.• Is the patient pacemaker-dependent?• Device response to magnet placement.• Any alert status on device? (such as

manufacturing issues).• Last pacing threshold.• Individualized perioperative

recommendation/prescription based on patient information, device characteristics, and surgical factors.

Provider Feedback Questionnaire Result

Results

Postoperative• Before patient discharge, CIEDs will need to

be reactivated to pre-operative settings if it was reprogrammed before surgery.

• Patient will be continuously monitored with ASA standard monitors until CIED settings are restored.

• External pacing/defibrillator pads will not be removed until CIED setting is restored.

• Follow up CIED appointment after discharge.

• The United States Preventative Services Taskforce recommends depression screening in the adult population.

• Patients with untreated depression have higher morbidity rates in many diagnosis groups.

• Detecting and managing depression allows patients to better self-manage chronic diseases.

• In a rural primary care setting, a practice gap existed where patients were not routinely screened for depression.

Problem Statement

• The primary aim of this quality improvement project was to implement a depression screening process using the Patient Health Questionnaire-9 (PHQ-9).

• Primary outcomes/project goals measured:• Provider compliance in obtaining depression

screenings.• Calculating the percentage of patients

identified with depression and treatment offered.

Project Purpose and Goals

Methods

Discussion

• Depression screening using the PHQ-9 instrument is an effective way to detect depression.

• Implementation of the PHQ-9 into the provider workflow will increase depression compliance.

• Depression screening will reduce the untreated depression rates in this rural practice and will connect patients to proper treatment.

• Once depression is managed, patients are able tobetter self-manage chronic diseases.

Conclusions

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. Retrieved from http://survey.hshsl.umaryland.edu/?url=http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=11556941&site=eds-live

Maurer, D. M. (2012). Screening for depression. American Family Physician, 85(2), 139-144. Retrieved fromhttp://survey.hshsl.umaryland.edu/?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=104519361&site=eds

United States Preventative Services Task Force (USPSTF). (2016). Final recommendation statement: Depression in adults: screening. Retrieved from: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-adults-screening1

References

Results

Screening for Depression in a Rural Primary Care Setting

Jacquelyn Wallander, RN, BSNKaren Yarbrough, DNP, ACNP-BC, CRNPUniversity of Maryland School of Nursing

• Providers identified limited time available with patients and PHQ-9 not being built into provider note as largest barriers to compliance.

• As a result of this project, the primary care practice has built the PHQ-9 instrument into the electronic health record to facilitate provider compliance.

• Eligible patients 18-64 having an annual exam• Exam being performed by two Nurse Practitioners• Patient was provided a copy of PHQ-9 and asked to complete• NP reviewed PHQ-9 and discussed results with patient• NP treated when clinically indicated and referred to behavioral health

specialists if necessary• Weekly chart audits: provider compliance and depression classification

• Depression screening compliance by NPs was 67% (n=30/45)• 30% (N=9/30) of all patients screened were diagnosed with

depression, of which 67% were classified with mild depression (n=6/9)

• 20% (n=6/30) were newly diagnosed with depression and 10% (n=3/30) had a history of depression

• All depressed patients were offered treatment• 13% (4/30) of the patients were referred to psychotherapy• 7% (n=2/30) were started on an antidepressant