Why They Stay and Why They Leave: Stay Interviews With Registered Nurses to Hear What Matters the Most.

Registered nurse retention is declining, with a national turnover rate in 2021 of 27%. After implementing a toolkit, nursing leaders in 1 organization completed 75 stay interviews with nurses in a cardiothoracic telemetry and a cardiothoracic surgical intensive care unit. Nurses reported that unit culture, team/peers, and scheduling were important in decisions to stay in their positions, but respondents considered leaving for salary, growth/development, and traveling opportunities. The stay interview process affords nurse leaders an opportunity to examine why nurses stay or leave and supports the development of targeted retention strategies.

Ensuring Rapid Response Team Care Aligns With Patients' Limitations of Medical Therapy: A Quality Improvement Project.

BACKGROUND: Rapid response teams (RRTs) are designed to improve patient care during deterioration in clinical condition. LOCAL PROBLEM: Patients' desired limitations of medical therapy (LOMTs) were not documented or communicated to the RRT, and patients received care not aligned with their wishes. METHODS: A multidisciplinary team developed a process for improving documentation, communication of LOMTs, and care delivery on 3 medical cardiology units. The team implemented 3 Plan-Do-Study-Act (PDSA) cycles over 6 months. INTERVENTIONS: In cycle 1, team members taught the unit nurses, RRT members, and physicians to share LOMTs during handoff communications. Cycle 2 engaged case managers in LOMT documentation. In cycle 3, unit-based RRT simulation was conducted. RESULTS: All care delivered by the RRT aligned with the documented LOMTs. Documentation of LOMTs increased from 76% to 82.5% ( P = .014). CONCLUSIONS: Education, scripting, and simulation were successful strategies to ensure that care given during RRT events aligned with patients' wishes.

Improving PACU Throughput Using an Electronic Dashboard: A Quality Improvement Initiative.

PURPOSE: Patients boarding in a 14-bed postanesthesia care unit (PACU) impacted throughput in a large university hospital in West Virginia. The PACU and operating room (OR) boarder rate in 2019 was 12% (n = 1241) and 5% (n = 503), respectively. The purpose of this initiative was to improve PACU throughput by developing an efficient and evidence-based handoff communication process between the PACU and the medical-surgical floors. DESIGN: The design of the project was evidence-based quality improvement. METHODS: An interprofessional team created a nursing patient dashboard in the electronic medical record to be used during handoff communication between the PACU and medical-surgical floor nurses. The dashboard displayed real-time vital signs, patient history, medications, and laboratory results. When the patient met Aldrete score requirements for transfer, PACU nurses notified the floor that the patient was ready for transfer. After allowing 20 minutes for the floor nurse to view the dashboard, the PACU nurse and floor nurse spoke on the phone to discuss any outstanding questions. PACU and OR boarder rates were obtained from the electronic medical record 12 months before and after implementing the nursing patient dashboard. User feedback was gathered via plan-do-study-act cycles, posters, and interviews. FINDINGS: The electronic dashboard was a successful strategy to improve handoff communication between the PACU and receiving units. The dashboard was accepted by the staff with 70% (n = 24) of the comments being positive. A significant decrease in the number of PACU (χ2(1, n = 20,608) =122.63, P < .00001) and OR boarding (χ2 (1, n = 20,283) =14.55, P = .000136) of patients was found in the C-year compared to 2019. For patients who were boarded in the PACU, no significant difference in PACU delay duration was found (t(11) =1.49, P = .149) with the mean in 2019 of 166.96 (SD = 68.38) and the C-Year mean 132.84 (SD = 39.74). For patients who boarded in the OR, there was a significant difference (t(11) =15.590162, P <.00001) between groups for average duration of boarding with the mean in 2019 of 19.06 minutes (SD = 3.72) compared to 1.62 (SD = 1.1) in C-year. However, in July 2020 the PACU intermittently opened 2 flexible beds when the PACU was full, suggesting that OR boarding was not a reliable measure, but PACU boarding remained an accurate measure. CONCLUSIONS: The findings of this evidence-based quality improvement project demonstrated the usefulness of an electronic dashboard tool combined with verbal report to improve patient throughput by decreasing the number of patients boarding in the PACU.

Using Technology to Improve Capacity Management at a Pediatric Hospital.

Bed flow decisions should be based on current information about capacity. The purpose of this project was to develop a real-time, enterprise-wide, capacity management dashboard. The dashboard successfully used information from the electronic medical record to create a comprehensive standardized data source, which was used to drive patient flow decisions optimizing bed space, allocating resources and maintaining safety.

Reducing Missed Appointments for Patients With HIV: An Evidence-Based Approach.

BACKGROUND: High rates of missed appointments for routine HIV care are associated with unsuppressed viremia, increasing morbidity. LOCAL PROBLEM: The Clinic no-show rate ranged between 30% and 35%, and only 69% of patients were considered retained in care within a 24-month time frame. METHODS: The Woodward Risk Prediction Tool was completed on all patients to stratify patient risk for missing the next appointment. INTERVENTIONS: All patients were offered text message along with standard phone message appointment reminders, and patients who missed appointments were called within 24 hours to reschedule. Medium-risk patients received a previsit planning call to remove barriers to appointment attendance, and high-risk patients received a home visit from the peer navigator. RESULTS: The project resulted in a 3.8% reduction rate in the overall no-show rate in the first 5 months of implementation. Using risk stratification and targeted interventions allowed valuable resources to be allocated where they were needed.

Implementation of a Vital Sign Alert System to Improve Outcomes.

BACKGROUND: Patients at risk for clinical deterioration often show changes in vital signs up to 24 hours before a critical event. Use of modified early warning scores has demonstrated effectiveness in identifying patients at risk for clinical deterioration and improving outcomes. LOCAL PROBLEM: Documentation of vital signs, timely recognition of clinical deterioration, and compliance with the sepsis bundles remained a challenge. METHODS: An interprofessional team developed an electronic vital sign alert (VSA) system with a concurrent running sepsis screen, along with clinical protocols. INTERVENTIONS: Education was provided and the VSA system was implemented on 3 nursing units. RESULTS: After implementation, the number of unplanned transfers to the intensive care unit increased. Mortality rate and length of stay in the intensive care unit for patients transferred for respiratory failure and sepsis significantly decreased. There was a 21% increase in identification of sepsis. CONCLUSIONS: The VSA system was an effective tool to identify patients at risk for clinical deterioration and help to improve outcomes.

Health Care Provider in Triage to Improve Outcomes.

PROBLEM: Emergency departments throughout the nation are experiencing crowding related to increased patient volumes and decreased hospital inpatient bed capacity. As a result of lengthy wait times, patients are leaving without having medical treatment, and satisfaction is poor. The purpose of this quality improvement initiative was placing a provider in triage to complement the existing split-flow process aimed to decrease wait times to see a provider, length of stay (LOS), left without being seen (LWBS) rates, and improve patient satisfaction. METHODS: A multiprofessional team was established. Nurses, advanced practice providers, and physicians collaborated on a project to place a provider in triage to assist in seeing patients as soon as possible and begin care or treatment. RESULTS: The outcomes of the initiative were positive for ED LOS metrics and patient satisfaction. Door-to-provider time decreased from a high of 56 minutes to a low of 13 minutes. The percentage of patients LWBS decreased from a high of 12% to a low of 1.62%. DISCUSSION: The project showed that the evidence-based practice of a combined split-flow and provider-in-triage model resulted in improvements in throughput for patients who were treated and released from the emergency department.

Improving the Patient's Experience With a Multimodal Quiet-at-Night Initiative.

This project describes a multifaceted noise reduction program on 2 hospital units designed to ensure a quiet hospital environment, with the goal of improving the patient experience. The noise committee in an urban city hospital developed a plan to control noise including scripted leadership rounding, staff education, a nighttime sleep promotion cart, and visual aids to remind staff to be quiet. Postintervention improvement in patient satisfaction scores was noted.

Implementation of Human Trafficking Education and Treatment Algorithm in the Emergency Department.

PROBLEM: Health care professionals have not been successful in recognizing or rescuing victims of human trafficking. The purpose of this project was to implement a screening system and treatment algorithm in the emergency department to improve the identification and rescue of victims of human trafficking. The lack of recognition by health care professionals is related to inadequate education and training tools and confusion with other forms of violence such as trauma and sexual assault. METHODS: A multidisciplinary team was formed to assess the evidence related to human trafficking and make recommendations for practice. After receiving education, staff completed a survey about knowledge gained from the training. An algorithm for identification and treatment of sex trafficking victims was implemented and included a 2-pronged identification approach: (1) medical red flags created by a risk-assessment tool embedded in the electronic health record and (2) a silent notification process. Outcome measures were the number of victims who were identified either by the medical red flags or by silent notification and were offered and accepted intervention. RESULTS: Survey results indicated that 75% of participants reported that the education improved their competence level. The results demonstrated that an education and treatment algorithm may be an effective strategy to improve recognition. One patient was identified as an actual victim of human trafficking; the remaining patients reported other forms of abuse. IMPLICATIONS FOR PRACTICE: Education and a treatment algorithm were effective strategies to improve recognition and rescue of human trafficking victims and increase identification of other forms of abuse.

Interprofessional Collaboration to Improve Sepsis Care and Survival Within a Tertiary Care Emergency Department.

PROBLEM: Sepsis is a leading cause of death in the United States; however, health care providers struggle with timely recognition, diagnosis, and treatment of patients. Both the Centers for Medicare and Medicaid Services and the National Quality Forum have identified this diagnosis as a priority. Presently, many patients with sepsis are identified late, resulting in significant morbidity and death. METHODS: In this project, a collaborative, interprofessional approach was created for screening and early identification of ED patients with possible sepsis. The department has 38 beds with annual patient volumes of more than 40,000 visits. Education was provided about the symptoms and treatment of patients with sepsis. A screening and management algorithm tool was instituted that consisted of early identification triggers and how to intervene according to Surviving Sepsis Campaign recommendations. The tool allowed for assessment of the patient by the ED team; the team worked to determine if sepsis was present and the extent of the illness. RESULTS: During the first 4 months after implementation, more than 240 patients were screened, assessed, and treated according to the algorithm. Project outcomes resulted in an increase in staff knowledge of sepsis, a decrease in length of stay by 3 hours, and a significant decrease in mortality when compared with the previous year's coded data. IMPLICATIONS FOR PRACTICE: This project demonstrates that sepsis education and team collaboration are an integral part of identifying and treating patients with sepsis. An interprofessional collaborative approach could be implemented in other institutions to combat the life-threatening complications of sepsis.

Improving Inpatient Colonoscopy Preparation in a University Hospital: An Evidence-Based Practice Project.

The majority of inpatient colonoscopy preparations at Virginia Commonwealth University Medical Center were rated as suboptimal, leading to incomplete or aborted procedures. These procedures needed to be rescheduled and delayed the patient's discharge from the hospital. An evidence-based practice model was used to implement an electronic colonoscopy order set. This resulted in improved quality of colon preparation and reduced canceled procedures. The potential savings for the hospital attributed to improvements in the bowel preparation processes for inpatient colonoscopies were calculated to be $418,200.00 annually.

Vascular access team collaboration to decrease catheter rates in patients on hemodialysis: utilization of Kotter's change process.

Long-term central venous catheter (CVC) use among patients on hemodialysis increases the risk of infection, morbidity, and mortality. This article describes the use of Kotter's process of change to establish a multidisciplinary vascular access team to facilitate the replacement of CVCs with long-term accesses. Through the implementation of vascular access teams and the execution of Kotter's eight-step process for leading change, hemodialysis clinics will have the tools needed to reduce CVC utilization rates and improve patient healthcare outcomes.

Interprofessional Telerounds in a Pediatric Intensive Care Unit: A Quality Improvement Project.

BACKGROUND: Family-centered rounds are standard practice in pediatrics. However, some parents of children in the pediatric intensive care unit cannot attend rounds. LOCAL PROBLEM: A 36-bed academic, tertiary care pediatric hospital implemented telerounds during the COVID-19 pandemic. After visiting restrictions were lifted, nurses were interested in continuing telerounds for families who could not attend daily rounds. The aim of this evidence-based quality improvement project was to develop a standardized, family-centered telerounding process that satisfied parents, nurses, and physicians. METHODS: Nurses offered telerounds to pediatric intensive care unit family members who could not attend rounds. Families received a unique link to telerounds using a secure connection. Nurses completed electronic satisfaction surveys after each session; physicians completed surveys at the end of their weeklong pediatric intensive care unit rotation; families received surveys at the end of the pediatric intensive care unit stay. RESULTS: Twenty families qualified for telerounds; 16 families completed sessions. Enrolled patients and families participated in 93 telerounding events. Nine family members (56%) returned satisfaction surveys revealing an overall satisfaction level of 9.9 out of 10. Thirty nurses reported an overall satisfaction level of 8.8 out of 10. Eleven physicians reported a mean satisfaction level of 8.8 out of 10. CONCLUSIONS: This project demonstrated that a standardized process of secure telerounding was feasible in a pediatric intensive care unit. Families, nurses, and physicians reported satisfaction with the process. Telerounds can be implemented without considerable inconvenience to staff and enable continuation of family-centered care when parents are absent from the hospital.

Implementing Best Practices for Decreasing Nurse Hesitancy to Call the Rapid Response Team: An Evidence-Based Quality Improvement Initiative.

BACKGROUND: Nurses, regardless of experience, sometimes wait for the Modified Early Warning Score to indicate physiological decline before initiating the hospital's Rapid Response Team (RRT). The goal of this quality improvement initiative was to reduce nurse hesitancy to call the RRT, as indicated by the monthly number of proactive calls before the Modified Early Warning Score increased and triggered an automated page. METHOD: Education, planned handoff communication, debriefing, and good catch emails were the educational strategies used in the implementation of the quality improvement initiatives, encouraging RRT calls sooner. Increasing RRT knowledge and communication is an evidence-based practice strategy to reduce nurse reluctance to call the RRT. RESULTS: After implementation, monthly proactive RRT calls increased (χ2 [1, n = 1,964] = 14.6085, p = .000159). Bedside interventions, unscheduled transfers, and Acute Physiologic and Chronic Health Evaluation scores did not differ. CONCLUSION: Education, structured handoff communication, and acknowledging good catches reduced nurses' reluctance to call the RRT proactively. [J Contin Educ Nurs. 2023;54(6):281-288.].

Critical Thinking Tools for Quality Improvement Projects.

TOPIC: This article explores the use of 4 quality improvement tools and 2 evidence-based practice tools that, when used within the nursing process, encourage critical thinking about quality issues. CLINICAL RELEVANCE: Patients and families expect to receive patient-centered, high-quality, and cost-effective care. Caring for critically ill patients is challenging and requires nurses to engage in quality improvement efforts to ensure that they provide evidence-based care. PURPOSE OF PAPER: To explore the use of critical thinking tools and evidence-based practice tools in assessing and diagnosing quality issues in the clinical setting. CONTENT COVERED: The nursing process serves as the framework for problem solving. Some commonly used critical thinking tools for assessing and diagnosing quality issues are described, including the Spaghetti Diagram, the 5 Whys, the Cause and Effect Diagram, and the Pareto chart.

Implementing Trauma-Informed Strategies for Mothers of Infants with Neonatal Abstinence Syndrome.

PURPOSE: To improve outcomes of infants with neonatal abstinence syndrome (NAS) by implementing an evidence-based approach to care. METHODS: An interdisciplinary team developed and implemented an educational module about the elements and principles of trauma-informed care (TIC) and standardized education on NAS for mothers with substance use disorder (SUD). The team collaborated with community behavioral health professionals to secure the services of a certified recovery specialist. Primary outcome measures of average length of stay (LOS) and admissions to special care nursery (SCN) for NAS infants were analyzed. RESULTS: Following health care team education on TIC and implementation of the standardized NAS brochure, average LOS decreased significantly from 6.5 to 5.1 days from baseline period (January-December 2019) to the implementation period (February-June 2020; p = 0.03). There was no difference in SCN admission from the baseline period (February-June 2019) to the implementation period (February-June 2020). Referrals to certified recovery specialists did not change. CLINICAL IMPLICATIONS: Education on the impact of trauma on new mothers with SUD can promote collaboration between them and the neonatal team. Standardizing education for new mothers of infants with NAS can help to engage families of infants with NAS and improve clinical outcomes.

Enhancing Cancer Pain Assessment and Management in Hospice.

Pain is one of the most common symptoms in individuals with cancer and is directly associated with significantly reduced quality of life. The purpose of this project was to enhance assessment and management of cancer-related pain for patients in the hospice setting. Nurse attitudes and knowledge about pain were evaluated using the Nurses' Knowledge and Attitudes Survey Regarding Pain before and 6 weeks after an educational program. Nurses completed a pain assessment at each home visit and followed an algorithm based on the National Comprehensive Cancer Network Clinical Practice Guidelines to manage pain. Baseline data were collected on the last 30 patients admitted into hospice with cancer as the primary diagnosis before project implementation. Following the practice change, chart audits of the patients' reported pain and adherence to recommended management were manually extracted from 26 patient records. Results revealed statistically significant differences in acquired knowledge (t = 3.95, P < .05) and attainment of patient-identified pain goals (t = 23.904, P < .05). Patient-reported pain levels decreased by 21%, and comprehensive pain assessment completion rates increased by 10% during the project. Current knowledge of evidence-based pain interventions and a management algorithm improved pain control in patients with cancer.

Good Catch Campaign: Improving the Perioperative Culture of Safety.

Although health care workers feel pressure to reduce adverse events in the perioperative department, a lack of education, communication, and leadership can prevent hospital personnel from reporting good catches. The purpose of this evidence-based quality improvement project was to improve the culture of safety in our perioperative department by implementing the Good Catch Campaign. An interprofessional team led staff member education after implementing a standardized electronic reporting system and debriefing process to occur after good catches. Staff members reported 391 good catches from all perioperative areas during the six-month postimplementation period. Staff members completed the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture before and six months after implementation; scores improved in five areas: communication openness, feedback and communication about error, frequency of event reporting, nonpunitive response to error, and organizational learning and continuous improvement. The campaign was a successful strategy for improving perioperative patient safety.

Implementation of the Re-Engineered Discharge (RED) toolkit to decrease all-cause readmission rates at a rural community hospital.

OVERVIEW: National hospital readmission rates average 19%. One in 5 Medicare patients are readmitted within 30 days of discharge each year, resulting in $17.5 billion in additional costs. OBJECTIVE/PURPOSE: The aim of this quality improvement project was to use the methodology outlined by Joint Commission Resources-Hospital Engagement Network and Project Re-Engineered Discharge (Project RED) to redesign the discharge process, reduce hospital 30-day all-cause readmission rates, and improve patient/family involvement in the discharge process. METHOD: The methodology of the Joint Commission Resources-Hospital Engagement Network and the Agency for Healthcare Research and Quality Project RED toolkit, the After Hospital Care Plan, and a patient discharge questionnaire were used to incorporate best discharge practices into patient care and evaluate the outcomes of the project. Monthly readmission rates and patient/family involvement in the discharge process were examined for 336 patients discharged from a dedicated 30-bed medical-surgical unit in a rural community hospital over a 4-month period. RESULTS: During the 4-month project, readmissions were reduced by 32% (rate 7.12); the overall monthly reduction from baseline was 27%, with a 44% reduction from baseline during the previous 6 months. The patient and family perception of their discharge process was positive.

Choosing the best evidence to guide clinical practice: application of AACN levels of evidence.

Evidence-based nursing care is informed by research findings, clinical expertise, and patients' values, and its use can improve patients' outcomes. Use of research evidence in clinical practice is an expected standard of practice for nurses and health care organizations, but numerous barriers exist that create a gap between new knowledge and implementation of that knowledge to improve patient care. To help close that gap, the American Association of Critical-Care Nurses has developed many resources for clinicians, including practice alerts and a hierarchal rating system for levels of evidence. Using the levels of evidence, nurses can determine the strength of research studies, assess the findings, and evaluate the evidence for potential implementation into best practice. Evidence-based nursing care is a lifelong approach to clinical decision making and excellence in practice.