Improving the Visibility of Intravenous (IV) Site in Pediatric Patients to Reduce IV Site Related Complications - An Evidence-based Utilization Project.

PURPOSE: This project aims to improve the visibility of the IV site using more adhesive transparent dressings to attain 90% compliance based on the frequent and proper inspection of the IV site and decrease the incidence of IV complications. DESIGN AND METHOD: The project was conducted in a 43-bedded general pediatric ward from March 2016 to February 2017. To address the poor visibility of the IV site due to bandaging caused by poor adhesive strength of the IV securement dressing, a more adhesive securement dressing was introduced. The study team conducted pre-implementation, immediate post-implementation, and sustainment audits, cost-analysis, and comparison of the number of reported occurrences of phlebitis and extravasation between 2015 and 2017. RESULTS: The post-implementation audit showed 100% visibility of the IV site, from 73% pre-implementation, and 87% compliance on frequent IV site inspection, from 70% pre-implementation. Both criteria attained 100% compliance during the sustainment audit. Incidences of extravasation and phlebitis were reduced from eight to seven, an improvement of 13%. These seven cases were also generally less severe compared to those from the previous year. CONCLUSION: This project has greatly improved the visibility of the IV site as well as nurses' compliance in checking the IV site. This is because nurses can monitor the IV site without having to remove any additional bandage over the site and causing unnecessary distress to fretful pediatric patients. IMPLICATIONS: The use of an adhesive transparent dressing can lead to prevention and earlier detection of phlebitis and extravasation. Additionally, the new IV securement dressing brought about manpower cost savings enabling staff time directed to other patient care activities.

Development and Validation of a Simplified Falls Assessment Tool in an Acute Care Setting.

An easy-to-use assessment tool, which contains reversible risk factors, might influence the success of a falls prevention program. A 2-phase study was undertaken to develop and validate a simplified falls assessment tool. Risk factors of confusion, dizziness, altered elimination, and difficulty with mobility were found to be significantly associated with fall status. The simplified falls assessment tool that contains these 4 risk factors yielded a comparable predictive value to Hendrich II Falls Risk Model.

A 10-year journey in sustaining fall reduction in an academic medical center in Singapore.

BACKGROUND: The incidence rate of falls at 1.3 falls/1000 patient-days at a tertiary hospital in 2004 was found to be high when benchmarked against other hospitals' fall rates in Singapore. This marked the starting point of a journey of reducing fall incidence by successfully combining evidence-based healthcare measures with quality-improvement strategies. AIM: The aim of this project was to implement fall-reduction strategies in the inpatient care areas in an acute care tertiary hospital. METHODS: Two action research studies commissioned for ascertaining an appropriate fall-risk assessment and effectiveness of targeted individualized interventions formed the foundation of fall-reduction strategies. Evidence-based healthcare measures were combined with quality-improvement strategies that addressed fall risks to prevent falls and mitigate injuries. The process of managing fall-related incidents was standardized as the fall rate continues to be a key nursing performance indicator. RESULTS: The overall fall trend decreased from 1.09/1000 patient-days in 2008 to 0.82/1000 patient-days in 2012. The decreasing trends were sustained in 2013 and 2014 at 0.91/100 and 0.85/1000, respectively. The fall injury rate reduced from 0.31/1000 patient-days in 2008 and was maintained at a rate of 0.20-0.24 during 2009-2012. CONCLUSION: The implementation of fall-reduction strategies reduced the fall incidence rate in this acute care setting. However, more work is required to ensure the changes made to the fall assessment, interventions, and processes are sustained and incorporated in patient care.

Evidence utilization project: implementation of kangaroo care at neonatal ICU.

BACKGROUND: Kangaroo care is no longer performed for the initial purpose of maintaining a small baby's body temperature in the developed countries where there are now sufficient medical equipments to keep babies warm. The objectives of kangaroo care in advanced neonatal ICUs have changed to provide benefits such as bonding and attachment, physiologic stability of newborn babies, successful breastfeeding and positive effects on infant development. Kangaroo care is not new to many neonatal nurses, but not every neonatal center is routinely practicing kangaroo care in Singapore. Inadequate nurses' knowledge and lack of guidelines on kangaroo care hinder its practice. AIM: The aim of this project was to implement kangaroo care in very low birth weight babies in a systematic and structured approach. METHODS: The team followed Larrabee's The Model For Evidence-Based Practice Change, used the available evidence on kangaroo care to develop guideline that was specific and suitable for the local setting. The team organized kangaroo care road shows for nurses and parents to create and enhance awareness. Evaluation of the project was done through two audits. The audit tool consisted of correct baby positioning and nursing documentation, with a sample size of 30 episodes. RESULTS: The ages of the babies audited were from 24 to 34 weeks of gestation with their weight ranging from 850 to 1500 g. The compliance rate for correct baby positioning during kangaroo care was 100% for both audits. The compliance rate for nursing documentation improved from 93% in the first post-implementation audit to 96.7% in the second post-implementation audit. CONCLUSION: The systematic and structured approach in kangaroo care implementation has created awareness among nurses and led to improvements in their knowledge and practices of kangaroo care. The implementation process of kangaroo care has also aided in training the ward Evidence-Based Nursing Unit team members to engage in critical thinking, which ultimately benefited the babies and parents.

Fall prevention among children in the presence of caregivers in a paediatric ward: a best practice implementation.

AIM: This study aims to reduce the incidence of falls in paediatric inpatients aged 3 and below by implementing fall prevention strategies. METHODS: The Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice programmes were used for this project. The project was carried out in three phases over a 4-month period from March to June 2011. A fall prevention poster was introduced during the implementation phase, and pre- and post-implementation audits were carried out in a 43-bed acute care paediatric ward in Singapore, with a sample size of 30. RESULTS: The audit result of Criterion 1, evaluating the effectiveness of the fall prevention measures, improved by 13%, to 93%. Criterion 2, measuring nurses' compliance in the regular reinforcement of safety, improved significantly by 27%, to 40%. However, Criterion 3, which measured nurses' compliance in identifying patients at high risk of falls by placing a green identification wrist tag on such patients, decreased by 23%, to 50%. DISCUSSION: A multi-language poster on fall prevention was strategically positioned at the foot of all the cots. The poster served as an effective reminder and communication method between nurses and caregivers and also among caregivers of the child. Caregivers' increased awareness and knowledge of fall prevention contributed to a 50% decrease in fall incidence of patients aged 3 and below in the presence of a caregiver from January to June 2011, as compared with the incidence rate in 2010. CONCLUSION: This project has shown that fall incidents can be reduced when caregivers' awareness of fall prevention measures in the hospital setting were to be improved. The poster on fall prevention has increased caregivers' awareness and reduced inpatient falls in the acute care setting. The pre- and post-implementation audits showed that the presence of a poster on fall prevention to remind parents/caregivers to raise and securely lock the cot rails at all times was effective in reducing the number of falls for children aged 3 years and below. The experience gained from this project was that communication to every staff member and caregivers is essential in implementing practice change. As a result of the study, the hospital plans to implement constant monitoring and reminders to nurses and caregivers to improve compliance to the recommended measures on fall prevention in the near future.

Hand hygiene in the nursery during diaper changing.

AIM: This project aimed to improve hand hygiene practice during diaper changing among nurses working in the nursery. METHODS: This project was conducted in one of the nurseries in a 935-bed acute care hospital with a sample of 15 nurses. A pre- and post-intervention audit was conducted utilising the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice module. A revised written workflow, which specified the occasions and process for hand hygiene during diaper changing, was introduced. Modifications to the baby bassinets and nursery were made after barriers to good hand hygiene were identified. The project was carried out over 4 months, from March to June 2011. RESULTS: The post-intervention audit results show an improvement in performing hand washing after changing diapers (20%) and performing the correct steps of hand rubbing (25%). However, the compliance rates decreased for the other criteria that measured whether hand rubbing or hand washing was performed prior to contacting the infant and after wrapping the infant, and whether hand washing was performed correctly. The improvement in compliance with hand washing--the main focus of the new workflow--after changing diapers was especially significant. CONCLUSION: The results indicated that having a workflow on the occasions and process for hand hygiene during diaper changing was useful in standardising practice. Pre- and post-implementation audits were effective methods for evaluating the effect of translating evidence into practice. However, this project had limited success in improving compliance with hand hygiene. This suggested that more effort is needed to reinforce the importance of hand hygiene and compliance to the proposed workflow. In addition, this project showed that for change to take place successfully, environmental modifications, increased awareness and adequate communication to every staff member are essential.

Reliability, validity and feasibility of quality of life instruments for adult patients with cancer undergoing chemotherapy: result from a systematic review.

AIM: The aim of this review was to analyse the literature critically and present the best available evidence related to quality of life (QoL) instruments that consists of all four subscales of physical, psychological, social and spiritual, which can be used in the clinical setting to assess adult patients with cancer on chemotherapy. INCLUSION CRITERIA: This review included randomised control trials and observational studies without control group related to QoL instruments used for cancer chemotherapy. The types of participants for this review included all adults with cancer over the age of 18 years who have undergone chemotherapy. The QoL instruments for this review included instruments that consist of all subscales of physical, psychological, social and spiritual. In order to retrieve QoL instruments that were current and not outdated, this review included studies reported in the recent 10 years. SEARCH STRATEGY: A three-step search strategy was utilised to search for primary research articles published in the English language from January 1998 to December 2009. An initial search of MEDLINE and CINAHL was undertaken followed by analysis of the text words contained in the title and abstract, and the text terms used to describe the article. A second search strategy using all the identified keywords and the index terms was used for the 20 databases. The third search strategy was to search for additional studies from the relevant list of all identified articles. METHODOLOGICAL QUALITY: The two independent reviewers appraised the included articles for methodological quality using the modified Elliot tool for reliability and validity. RESULTS: A total of 3149 references was retrieved during the initial search. Only 13 articles with validation of the QoL instruments that contained all the four subscales of physical, psychological, social and spiritual were included in this review. Four QoL instruments were identified. These include the City of Hope QOL - Ovarian Cancer Tool (QOL-OVCA), QOL-Breast cancer version (QOL-BC), New India QoL tool and QoL Index-Cancer version (QLI-CV). Among the four identified QoL instruments, the frequency of assessment was more than once for QLI-CV, with intervals of 2 weeks to 6 months. Regarding the number of items, the QOL-BC instrument has the most number of items. All identified QoL instruments have content validity done. For reliability examination, all the identified QoL instruments have Cronbach's alpha of 0.7 and above for subscales. The correlation between subscales scores and overall QoL score was 0.53-0.93, 0.39-0.95 and 0.65-0.83 for QOL-OVCA, QOL-BC and QLI-CV, respectively. CONCLUSION: In this review, there was one article on development of new QoL instrument, the New India QoL tool, which has comprehensive validity examinations - the least number of items that may be useful in the clinical setting but need further psychometric testing in different settings or languages. The QLI-CV instrument has had comprehensive intra- and inter-method validation on different languages, different cultural settings and various types of cancer. However, the instrument may not be feasible because the method to calculate the QoL score is not straightforward.

eEvidence: Information Seeking Support for Evidence-based Practice: An Implementation Case Study.

We propose to collect freely available articles from the web to build an evidence-based practice resource collection with up-to-date coverage, and then apply automated classification and key information extraction on the collected articles to provide means for sounder relevance judgments. We implement these features into a dual-interface system that allows users to choose between an active or passive information seeking process depending on the amount of time available.

Improving Search for Evidence-based Practice using Information Extraction.

The search for applicable and valid research evidence-based practice articles is not supported well in common EBP resources, as some crucial study data, such as patient details, study design and results, are not available or presented explicitly. We propose to extract these data from research articles using a two-step supervised soft classification method. Compared to manual annotation, our approach is less labor-intensive and more flexible, hence opening up the possibility of utilizing these data to facilitate the evidence selection process in information seeking support systems.

eEvidence: supplying evidence to the patient interaction.

Nursing demands that all care offered to patients is appropriately assessed, delivered and evaluated; the care offered must be up to date and supported by adequately researched published evidence. A basic logic suggests that information and communications technology can help the nurse in maintaining his/her care provision to the highest level through presenting relevant evidence. The nursing need for evidence to support the delivery of care is a global phenomenon. Within the project this is demonstrated by the fact that the project lead is resident in England and the project is being carried out in Singapore with the help of the National University Hospital, the Alice Lee Centre of Nursing Studies and the School of Computing at the National University of Singapore. The project commenced in January 2008, this paper will present the background thinking to the project design and will describe the outcomes which will provide nurses with individual supportive evidence for their practice gleaned from quality assured sources. The project will use information and communications technology to provide the evidence on an individual basis. The paper will outline the four key elements of the project, these being the development of user (professional) profiles; the design and development of an automatic crawler search engine to deliver quality assured evidence sources and software design; there will be some mention of hardware design and maintenance which is the fourth key element. Within the paper, consideration will be given to the added value of the project to the nurses, their patients/clients, the research agenda and the employing organisation: The drive for information is determined by the nurses in clinical and community practice. Evidence available immediately at the point of intervention with patient/client. No patient information stored within structure. All technology and almost all support software already available. Additional information can flow both ways for quality and activity audits. Identification of areas weak in evidence requiring supportive research will be driven by practice. Immediate dissemination of new generic practices and principles can be delivered to each nurse on syncopation, removing the requirements for paper updates etc. Process can be transferred across all healthcare clinical professions In conclusion, information will be given on progress to date in terms of technical applicability and user acceptance by the nursing staff. In addition, an insight will be given as to managing a multiprofessional, multi-organisational project from a distance.