Optimizing Quality Improvement Methods in Practice: A Case Study Approach.

BACKGROUND: Quality improvement (QI) initiatives help ensure patients are receiving high-quality care. Iterative Plan-Do-Study-Act (PDSA) cycles are used to test change. Data are evaluated over time, and tests of change can be modified or discarded as needed. PROBLEM: Health care QI teams lack the flexibility to conduct PDSA cycles, often conducting pre/post quasi-experimental research studies instead. APPROACH: This article reviews a case study of a "personal improvement" initiative as an example of QI methods and data evaluation for an individual trying to lose weight. The purpose of this article is to provide guidance on best practices for conducting QI initiatives; common pitfalls that clinicians may face when leading their own QI initiatives are identified and recommendations to overcome these challenges are discussed. CONCLUSIONS: Concepts from this case study, along with supplemental resources provided, can help clinicians optimize QI methodologies in the health care setting.

Evidence-Based Practice Quality Improvement Critical Appraisal Tool.

BACKGROUND: Optimal quality improvement in health care is based on research and other types of evidence. Critical appraisal of evidence is a fundamental component of evidence-based practice (EBP) and is also needed to evaluate the quality of quality improvement (QI) projects. PROBLEM: Currently available EBP or QI critical appraisal tools can be challenging for students learning the critical appraisal process and for practicing clinicians who desire access to a standardized EBPQI approach to inform health care decision-making. The currently available tools are incomplete, too brief, or too complicated for ease of use in education and practice. APPROACH: This article introduces the first combined EBP and QI (EBPQI) critical appraisal tool, which is aligned with the new EBPQI mountain model. CONCLUSION: This newly developed appraisal tool may be used in appraising evidence for an EBPQI initiative and to appraise the quality of disseminated EBPQI.

Memes and Poetry: A Descriptive Analysis on Creative Arts Therapy to Reduce Health Care Worker Burnout.

BACKGROUND: Health care workers (HCWs) face high levels of burnout, which can lead to workforce turnover and poor patient outcomes. Health care leaders should identify strategies to improve staff resilience. PURPOSE: The purpose of this study was to describe HCWs' perspective on using creative arts therapy to reduce burnout and improve resiliency. METHODS: During Infection Prevention week, staff were encouraged to submit and vote on educational memes and haikus. Staff were asked their perspectives on how this activity could be used to reduce burnout and improve resiliency using a 4-point Likert scale. RESULTS: Twenty-two staff members submitted 26 memes and 27 haikus. Staff felt this activity could be an effective strategy to help reduce burnout and improve resiliency. CONCLUSIONS: Further research is warranted to better understand the correlation between this form of art therapy and burnout and resiliency; however, health care leaders may consider using this as a tool for staff well-being.

The impact of nurse staffing on falls performance within a health care system: A descriptive study.

AIM: The purpose of this study was to examine the impact of nurse staffing on inpatient falls performance across a multi-hospital system. BACKGROUND: Evidence to support which staffing variables influence fall performance so that health care organizations can better allocate resources is lacking. METHOD: A descriptive study design was used to analyse the impact of nurse staffing and falls performance, with units dichotomized as either high or low performing based on national benchmarking data. The impact was evaluated using 10 nurse staffing variables. RESULTS: A total of nine units were included (five high and four low performing). Higher performing units showed less use of sitters and travellers, had fewer overtime hours worked by nurses, and employed more expert-level clinical nurses and combined nursing assistant/health unit coordinator positions, than lower performing units. CONCLUSION: Findings provide evidence of how staffing variables affect a unit's falls performance. While significant relationships were found, further evaluation is needed to explore the relationship of staffing variables and quality outcomes. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing managers may consider trying to reduce use of sitters and travellers, and utilize innovative staffing models, such as using combined nursing assistant/health unit coordinator positions, to help improve their falls performance.

Pupillometry in neurocritical care.

ABSTRACT: Though pupillometer use is becoming more widespread, there is a lack of evidence on its use by nurses in the neurosurgical ICU. This article explores the use of the pupillometer among neurocritical care nurses to better understand their experience and the device's clinical utility.

Impact of Citrus Essential Oil Diffusion on Health Care Staff's Stress Levels: An Evidence-Based Practice Project.

Essential oil diffusion can decrease stress. In one hospital, citrus essential oils were diffused over 6 weeks. Staff completed surveys of their stress levels before and after diffusion. Staff did not report a significant reduction in stress; however, there was an increase in feeling "relaxed."

Implementation Strategies to Improve Evidence-Based Bathing Practices in a Neuro ICU.

BACKGROUND: Evidence supports daily bathing using chlorhexidine gluconate (CHG) cloths to decrease preventable hospital-acquired central line-associated bloodstream infections (CLABSIs). However, implementation of this practice is inconsistent. Using multifaceted strategies to promote implementation is supported in the literature, yet there is a gap in knowing which strategies are most successful. PURPOSE: Using the Grol and Wensing Model of Implementation as a guide, the purpose of this study was to determine whether using tailored, multifaceted strategies would improve implementation of daily CHG bathing and decrease CLABSIs in a large neuro ICU. METHODS: An observational pre-/postdesign was used. RESULTS: Following implementation, infection rates decreased (P = .031). Statistically significant improvements were also seen across all process measures: bathing documentation, nursing knowledge, and perceived importance of CHG bathing. CONCLUSIONS: This study assists in closing the research-practice gap by using tailored, multifaceted implementation strategies to increase use of evidence-based nursing care for infection prevention practices.

Inpatient fall prevention from the patient's perspective: A qualitative study.

AIM: The aim of this study was to describe the patient's perspective of fall prevention in an acute care setting to aid in the design of patient centered strategies. BACKGROUND: Falls are one of the most common adverse events in hospitals and can lead to preventable patient harm, increased length of stay, and increased healthcare costs. There is a need to understand fall risk and prevention from the patients' perspectives; however, research in this area is limited. METHODS: To understand the patient perspective, semi-structured interviews were conducted with twelve patients at an academic healthcare center. RESULTS: Qualitative analysis revealed three major themes: (1) how I see myself, (2) how I see the interventions; and (3) how I see us. The theme "How I see myself" describes patients' beliefs of their own fall risk and includes the sub-themes of awareness, acceptance/rejection, implications, emotions, and personal plan. Interventions, such as fall alarms, are illustrated in the theme "How I see the interventions" and includes the subthemes what I see and hear and usefulness of equipment. Finally, "How I see us" describes barriers to participating in the fall prevention plan. CONCLUSIONS: Most fall prevention programs favor clinician-led plan development and implementation. Patient fall assessments needs to shift from being clinician-centric to patient-centric. Nurses must develop relationships with patients to facilitate understanding of their needs. Developing these truly patient-centered programs may reduce the over-reliance on bed alarms and allow for implementation of strategies aimed to mitigate modifiable risk factors leading to falls.

Leveraging Artificial Intelligence for Expediting Implementation Efforts.

Expedited implementation of evidence into practice and policymaking is critical to ensure the delivery of effective care and improve health-care outcomes. Implementation science deals with the designing of methods and strategies for increasing and facilitating the uptake of evidence into practice and policymaking. Nevertheless, the process of designing and selecting methods and strategies for implementing evidence is complicated because of the complexity of health-care settings where implementation is desired. Artificial intelligence (AI) has revolutionized a range of fields, including genomics, education, drug trials, research, and health care. This commentary discusses how AI can be leveraged to expedite implementation science efforts for transforming health-care practice. Four key aspects of AI use in implementation science are highlighted: (a) AI for implementation planning (e.g., needs assessment, predictive analytics, and data management), (b) AI for developing implementation tools and guidelines, (c) AI for designing and applying implementation strategies, and (d) AI for monitoring and evaluating implementation outcomes. Use of AI along the implementation continuum from planning to delivery and evaluation can enable more precise and accurate implementation of evidence into practice.

Misuse of the P Value: Using Quality Improvement Analyses to Identify Clinically Significant Improvements.

INTRODUCTION: Quantitative research and quality improvement (QI) both seek to improve care provided to patients. However, clinicians often blur the lines between how to appropriately analyze data from these methodologies. Clinicians may inappropriately use statistical analyses for QI initiatives, rather than using run and statistical process control (SPC) charts to analyze improvements in outcomes. OBJECTIVE: The purpose of this article was to address the analytic methods used for QI initiatives in the clinical setting in an effort to show clinicians how to identify meaningful improvements in clinical practice. METHODS: In this article, we provide an example comparing the same evidence-based practice/QI initiative (chlorhexidine gluconate bathing in a medical intensive care unit) using a quasi-experimental pretest/posttest research design with statistical analyses completed with t tests with analyses using run and SPC charts to show the data trended over time. Using a pretest/posttest design, chlorhexidine gluconate bathing compliance improved from 63% to 65%, a nonsignificant change, P = .075. These same data plotted on run and SPC charts, however, show a shift and a trend, indicating clinically significant improvements per QI methodologies. CONCLUSION: The example in this article highlights the pitfall of relying only on statistical analyses and P values to determine the importance of a clinical project, and provides a practical example for how run or SPC charts can be used to identify improvements over time.

Cognitive Symptom Awareness Among Patients With Multiple Sclerosis Using a Mobile Application.

PURPOSE: Cognitive impairment is a common complication in persons with multiple sclerosis (MS). Using a mobile application has been shown to improve patient's awareness of cognitive symptoms. The purpose of this quality improvement project was to improve awareness of cognitive symptoms in adult patients with MS using a mobile application. DESIGN: A pre/post-implementation quality improvement design was used. METHODS: Patients were instructed to download the application MS Care Connect. Patients completed a pre/post-questionnaire regarding their awareness of cognitive symptoms and if they were likely to discuss symptoms with providers. They were instructed to use the application to rate the severity of their cognitive symptoms at least weekly. RESULTS: Thirty-two patients completed both pre- and post-implementation questionnaires. No significant change in awareness of cognitive symptoms was found; however, patients were more likely to discuss cognitive changes with their healthcare team. In the 18 patients who used the application, a total of 60 cognitive symptom ratings were reported. CLINICAL RELEVANCE TO THE PRACTICE OF REHABILITATION NURSING: Nurses may recommend use of a mobile application for patients to track their cognitive symptoms; however, further research is needed. CONCLUSION: This project showed that adding a mobile application did not change awareness of patients' cognitive symptoms.

Reducing Clostridioides difficile Infections in a Medical Intensive Care Unit: A Multimodal Quality Improvement Initiative.

BACKGROUND: Clostridioides difficile (C. diff) infection causes significant morbidity for hospitalized patients. A large medical intensive care unit had an increase in C. diff infection rates. OBJECTIVES: The aim of this project was to reduce the C. diff polymerase chain reaction (PCR) test positivity rate and the rate of C. diff PCR tests ordered. Rates were compared between preintervention (July 2017 to December 2019) and postintervention (January 2021 to December 2022) timeframes. METHODS: Unit leadership led a robust quality improvement project, including use of quality improvement tools such as A3, Gemba walks, and plan-do-study-act cycles. Interventions were tailored to the barriers identified, including standardization of in-room supply carts; use of single-packaged oral care kits; new enteric precautions signage; education to staff, providers, and visitors; scripting for patients and visitors; and use of a C. diff testing algorithm. Statistical process control charts were used to assess for improvements. RESULTS: The average rate of C. diff PCR test positivity decreased from 34.9 PCR positive tests per 10 000 patient days to 12.3 in the postintervention period, a 66% reduction. The average rate of PCR tests ordered was 28 per 1000 patient days in the preintervention period; this decreased 44% to 15.7 in the postintervention period. DISCUSSION: We found clinically significant improvements in the rate of C. diff infection and PCR tests ordered as a result of implementing tailored interventions in a large medical intensive care unit. Other units should consider using robust quality improvement methods and tools to conduct similar initiatives to reduce patient harm and improve care and outcomes.

Clean Hands are Caring Hands: Improving Anesthesia Provider Hand Hygiene and Double Glove Compliance During Induction of General Anesthesia.

BACKGROUND: Hand hygiene and double gloving practices during induction of general anesthesia can decrease transmission of bacteria to patients and subsequent healthcare associated infections; however, compliance to these practices is low. METHODS: A pre/post-implementation quality improvement design was used with Plan-Do-Study-Act cycles. Several implementation strategies were used to improve hand hygiene and double glove compliance among anesthesia providers, including printed educational materials, video, in-person, and virtual meetings, visual reminders, audit and feedback, and improved access to hand sanitizer dispensers in the anesthesia workstation. RESULTS: Average hand hygiene compliance increased from 0% to 11.8% and double gloving compliance increased from 18.5% to 34.5%. A decrease in surgical site infections was shown in the post-implementation period. DISCUSSION: Although hand hygiene and double gloving practices increased after the initial implementation, the improvements were not sustained long-term. Practices to support sustainability, such as routine booster sessions, may be considered. CONCLUSIONS: Incorporating these quality improvement measures into practice may improve anesthesia provider hand hygiene compliance during induction of general anesthesia and impact subsequent infection rates.

Evaluation of a Seizure Action Plan in an Adult Epilepsy Center.

Background: Seizure action plans (SAPs) provide valuable information for patients to manage seizure emergencies, but are underutilized in adult epilepsy centers. The purpose of this project was to implement a structured SAP for adult patients with epilepsy. Methods: A pre/postimplementation design was used. Provider SAP utilization rates were analyzed over a 16-week period. A pre and postimplementation survey assessed participant perceived impact of the SAP on knowledge and comfort associated with managing seizure emergencies. Provider barriers and facilitators were also assessed. Results: Average provider SAP utilization rate was 51.45%. A total of 204 participants completed the surveys, which showed a significant increase in knowledge and comfort for all items, p < 0.001. At postsurvey analysis, 98% of participants felt that all patients with epilepsy should have a SAP regardless of seizure burden. Discussion: Implementing a structured SAP increased provider utilization and patient and care partner knowledge and comfort of managing seizure emergencies.

The Role of Doctor of Nursing Practice-Prepared Nurses to Improve Quality of Patient Care.

Translating evidence-based practices (EBPs) and quality improvement (QI) initiatives to the bedside is a significant need among hospitals and outpatient settings to improve the provision of quality nursing care. However, health-care systems continue to struggle with implementing and sustaining EBPs. To improve the application of EBPs and QI initiatives, hospitals should consider using Doctor of Nursing Practice (DNP)-prepared nurses in Quality Improvement roles, as DNP graduates have acquired unique expertise in these topics. However, health-care settings do not routinely maximize the use of DNP-prepared nurses in these roles. This article provides an overview of the challenges to understanding the value and impact of DNP-prepared nurses, along with recommendations and opportunities for future practice.

Implementation Science Toolkit for Clinicians: Improving Adoption of Evidence in Practice.

BACKGROUND: Clinicians are often familiar with quality improvement (QI) and evidence-based practice (EBP) processes, which provides guidance into what evidence should be implemented; however, these processes do not address how to successfully implement evidence. OBJECTIVE: Clinicians would benefit from a deeper understanding of implementation science, along with practical tools for how to use these principles in QI and EBP projects. METHODS: We provide a brief background of the principles of implementation science, an overview of current implementation science models and a toolkit to facilitate choosing and using common implementation science strategies. In addition, the toolkit provides guidance for measuring the success of an implementation science project and a case study showing how implementation science strategies can be used successfully in clinical practice. CONCLUSIONS: Using an implementation science toolkit for designing, conducting, and evaluating a QI or EBP project improves the quality and generalizability of results.

Reduction in patient refusal of CHG bathing.

BACKGROUND: Daily chlorhexidine gluconate (CHG) bathing is a well-supported intervention to reduce patient's risk of central line associated bloodstream infection (CLABSI); however, compliance with this practice is suboptimal. One major barrier is patient refusals of CHG bathing. The purpose of this project was to implement tailored interventions to mitigate this barrier. The specific aims were to reduce patient refusals, increase compliance with CHG bathing, and evaluate CLABSI rates and nursing staff's knowledge of CHG bathing. METHODS: Iterative Plan-Do-Study-Act (PDSA) cycles were implemented over the course of 6 months. Run charts were used to identify signals of improvement. Interventions included printed educational flyers for staff and patients, educational sessions, an electronic learning module, and a "badge buddy." RESULTS: We saw a reduction in the median percentage of patient refusals documented, from 23% to 8% after the PDSA cycles. Documentation compliance with CHG bathing increased only slightly from 46% to 47%. CLABSI rates decreased 6% from 0.69 to 0.65. DISCUSSION: Using interventions tailored to the clinical setting can impact patient outcomes. Other health care systems should consider implementing PDSA cycles to improve evidence-based practices. CONCLUSIONS: Using PDSA cycles can result in a reduction in patient refusal documentation, and may slightly improve CHG bathing compliance and CLABSI rates.