Supporting the Safe Use of the Dorsogluteal Intramuscular Injection Site: An Evidence-Based Quality Improvement Project.

INTRODUCTION: Administering intramuscular (IM) injections is common in the adult mental health patient care setting, using the deltoid, vastus lateralis, ventrogluteal, or dorsogluteal site. Mental health nurses frequently use the dorsogluteal site to administer short and long-acting IM injections as specified in the drug package insert or because of patient agitation. However, the site is often not recommended due to the potential risk of nerve injury. AIMS: Aims of this evidence-based quality improvement project were to (1) determine the best evidence for supporting the safe use of the dorsogluteal site for short and long-acting IM injections and (2) implement this evidence through nurse education. METHOD: This project had two phases: Determining best evidence through an integrative literature review and implementing the recommendations to use the dorsogluteal site when directed by the drug package insert, clinical need, nursing judgment, or patient preference. Implementation followed the Plan-Do-Study-Act quality improvement process and involved written resources and simulation. RESULTS: Evidence supported the use of the dorsogluteal site in four instances and the importance of education. Nurses were highly satisfied with the education and opportunity to practice their skills with feedback during return demonstration. After studying nurses' follow-up survey results, a refresher simulation and medical center guideline were completed. There were no reports of IM injection patient injuries after 2 years and approximately 768 dorsogluteal and ventrogluteal IM injections in the academic medical center. CONCLUSION: Pursuing recent and possibly overlooked evidence provided guidance in supporting the safe use of the dorsogluteal site for IM injections.

Implementing and Sustaining Bedside Shift Report for Quality Patient-Centered Care.

BACKGROUND: Two evidence-based practice projects and an innovative model provided best evidence and a framework for the implementation and sustainment of a bedside shift report (BSR) quality improvement project. PROBLEM: Without a standardized BSR process, there was a lack of Veteran involvement in care planning decisions and nurse dissatisfaction related to missed communication of pertinent patient information. APPROACH: Facilitators and barriers were identified and addressed during planning. Key elements of BSR were incorporated. After approval by shared governance, unit-based champions and leaders supported the change. Implementation began every 2 weeks on a different unit. OUTCOMES: Implementation was completed in 4 months for 11 units. After 15 months, there was consistent BSR on 82% of the units and improved patient satisfaction with nurses taking time to listen. CONCLUSIONS: Best evidence, unit-based champions, leadership support, project coordinators, and persistence are critical to implementing and sustaining practice change.

Development and Implementation of a Model for Research, Evidence-Based Practice, Quality Improvement, and Innovation.

BACKGROUND: Our medical center nursing council evaluated its current evidence-based practice (EBP) model and decided to consider alternatives. PROBLEM: No models were inclusive of major nursing activities, such as EBP and quality improvement (QI) projects and research studies. APPROACH: A model was developed, meeting the criteria of accessibility, ease of use, and reflective of professional practice activities: EBP and QI projects, research studies, and innovation. In the new model, I Model for Advancing Quality Patient Centered Care, professional practice is represented by 3 "I's": Inquiry, Improvement, and Innovation. OUTCOMES: The model provides an algorithm with steps and decision points for nurses to follow based on a question from a clinical issue or problem. The model was approved by nursing-shared governance and is used for guiding relevant projects. CONCLUSION: The I Model guides the nurse in inquiry or improvement while supporting a culture of innovation in professional practice.

Developing a Web-Based Nursing Practice and Research Information Management System: A Pilot Study.

Many hospital information systems have been developed and implemented to collect clinical data from the bedside and have used the information to improve patient care. Because of a growing awareness that the use of clinical information improves quality of care and patient outcomes, measuring tools (electronic and paper based) have been developed, but most of them require multiple steps of data collection and analysis. This necessitated the development of a Web-based Nursing Practice and Research Information Management System that processes clinical nursing data to measure nurses' delivery of care and its impact on patient outcomes and provides useful information to clinicians, administrators, researchers, and policy makers at the point of care. This pilot study developed a computer algorithm based on a falls prevention protocol and programmed the prototype Web-based Nursing Practice and Research Information Management System. It successfully measured performance of nursing care delivered and its impact on patient outcomes successfully using clinical nursing data from the study site. Although Nursing Practice and Research Information Management System was tested with small data sets, results of study revealed that it has the potential to measure nurses' delivery of care and its impact on patient outcomes, while pinpointing components of nursing process in need of improvement.

Organizational and Practice Outcomes of a Post-Baccalaureate Registered Nurse Residency Program.

A nurse residency for newly licensed registered nurses is best practice. A novel model for transitioning new nurses is a 1-year, postbaccalaureate residency that is rotation based with protected time for supervised clinical and didactic learning. After 10 years with this program, a summative evaluation found that retention rates for 1, 2, 3, and 5 years after program completion were 93%, 83%, 73%, and 82%, respectively, higher than similar programs in the literature.

Outcomes of an Interprofessional Patient Safety Fellowship Program.

BACKGROUND: Interprofessional training for patient safety is essential in developing leaders and advocates who are versed in patient safety science and interprofessional collaboration. We describe an interprofessional patient safety fellowship program and its outcomes over 8 years. METHODS: Programmatic data were reviewed and a survey was sent to all program graduates with a known email address (N = 18). RESULTS: Fellows obtained interprofessional skills, knowledge, and methods of patient safety science, as well as preparation as patient safety experts through didactic and experiential training. Program outcomes included sustained quality improvements, publications (n = 8), presentations (n = 29), and recruitment of graduates into quality and safety leadership positions (67%). DISCUSSION: Facilitators and barriers that influenced the success of the fellowship program were noted at institutional and individual levels. The development and sustainability of interprofessional safety training programs depends on concerted efforts by leadership, academic-practice partnerships, and committed faculty and learners.

Implementing daily chlorhexidine gluconate (CHG) bathing in VA settings: The human factors engineering to prevent resistant organisms (HERO) project.

BACKGROUND: Daily use of chlorhexidine gluconate (CHG) has been shown to reduce risk of healthcare-associated infections. We aimed to assess moving CHG bathing into routine practice using a human factors approach. We evaluated implementation in non-intensive care unit (ICU) settings in the Veterans Health Administration. METHODS: Our multiple case study approach included non-ICU units from 4 Veterans Health Administration settings. Guided by the Systems Engineering Initiative for Patient Safety, we conducted focus groups and interviews to capture barriers and facilitators to daily CHG bathing. We measured compliance using observations and skin CHG concentrations. RESULTS: Barriers to daily CHG include time, concern of increasing antibiotic resistance, workflow and product concerns. Facilitators include engagement of champions and unit shared responsibility. We found shortfalls in patient education, hand hygiene and CHG use on tubes and drains. CHG skin concentration levels were highest among patients from spinal cord injury units. These units applied antiseptic using 2% CHG impregnated wipes vs 4% CHG solution/soap. DISCUSSION: Non-ICUs implementing CHG bathing must consider human factors and work system barriers to ensure uptake and sustained practice change. CONCLUSIONS: Well-planned rollouts and a unit culture promoting shared responsibility are key to compliance with daily CHG bathing. Successful implementation requires attention to staff education and measurement of compliance.

The relationship of nurses' professional characteristics to levels of clinical nursing expertise.

Many hospitals are searching for guidelines for professional practice models, which are a requirement for Magnet recognition. This study was undertaken to determine the professional nursing characteristics that may contribute to the development of clinical nursing expertise. Experience as an RN was found to be highly correlated with initial level of expertise. Educational preparation and certification were not correlated with expertise. This research suggests that nurses may require more on-the-job experience for the development of clinical nursing expertise than what has been reported in the literature.

Registered Nurses' Self-Assessed Knowledge of Evidence-Based Practice and Research: Moving Forward With New Information.

By 2020, most clinical decisions should be supported by best evidence. Therefore, nurses need institutional support and education about evidence-based practice (EBP) and research. The aim of this study was to describe nurses' self-assessed knowledge of EBP and research. Findings revealed nurses' knowledge of EBP and research ranged from no knowledge to high knowledge with opportunities for education. Providing for the use of best evidence is a dynamic process involving clinicians, educators, and administrators.

Preparing Family Caregivers to Recognize Delirium Symptoms in Older Adults After Elective Hip or Knee Arthroplasty.

OBJECTIVES: To test the feasibility of a telephone-based intervention that prepares family caregivers to recognize delirium symptoms and how to communicate their observations to healthcare providers. DESIGN: Mixed-method, pre-post quasi-experimental design. SETTING: A Midwest Veterans Affairs Medical Center and a nonprofit health system. PARTICIPANTS: Forty-one family caregiver-older adult dyads provided consent; 34 completed the intervention. INTERVENTION: Four telephone-based education modules using vignettes were completed during the 3 weeks before the older adult's hospital admission for elective hip or knee replacement. Each module required 20 to 30 minutes. MEASUREMENTS: Interviews were conducted before the intervention and 2 weeks and 2 months after the older adult's hospitalization. A researcher completed the Confusion Assessment Method (CAM) and a family caregiver completed the Family Version of the Confusion Assessment Method (FAM-CAM) 2 days after surgery to assess the older adults for delirium symptoms. RESULTS: Family caregivers' knowledge of delirium symptoms improved significantly from before the intervention to 2 weeks after the intervention and was maintained after the older adult's hospitalization. They also were able to recognize the presence and absence of delirium symptoms in the vignettes included in the intervention and in the older adult after surgery. In 94% of the cases, the family caregiver rating on the FAM-CAM approximately 2 days after the older adult's surgery agreed with the researcher rating on the CAM. Family caregivers expressed satisfaction with the intervention and stated that the information was helpful. CONCLUSION: Delivery of a telephone-based intervention appears feasible. All family caregivers who began the program completed the four education modules. Future studies evaluating the effectiveness of the educational program should include a control group.

Engaging Nursing Staff in Research: The Clinical Nurse Specialist Role in an Academic-Clinical Partnership.

PURPOSE: The purpose of this article is to describe the processes of exploring and implementing an academic-clinical study, engaging nursing staff in research, and maintaining their enthusiasm within the context of an academic-clinical research partnership. DESCRIPTION: The core competencies of the clinical nurse specialist (CNS) role address evidence-based practice, quality improvement, and research. Studies and exemplars of the CNS role in the literature illustrate expert practitioner and facilitator of evidence-based practice, but less attention is given to methods used by the CNS to engage staff in clinical research. OUTCOME: The CNS was successful in obtaining staff engagement in the research project from exploration through sustainment. CONCLUSION: Collaborative research between academic and clinical partners enhances the educational and professional environment for students and clinicians, promotes evidence-based practice, and from this project may promote Veteran and family-centered care. The CNS played a key role in engaging and sustaining staff commitment, which contributed to the success of this study.

Vancomycin-resistant Enterococcus co-colonization rates with methicillin-resistant Staphylococcus aureus and Clostridium difficile in critically ill veterans.

A prospective study was conducted to identify risk factors for vancomycin-resistant Enterococcus, including co-colonization with methicillin-resistant Staphylococcus aureus and Clostridium difficile infection in patients admitted to the intensive care unit in 2 Veterans Affairs facilities. Methicillin-resistant Staphylococcus aureus and Clostridium difficile infection co-colonization were significant risk factors for vancomycin-resistant Enterococcus colonization. Further studies are needed to identify measures for preventing co-colonization of these major organisms in veterans.

Intermittently delivered IV medication and pH: reevaluating the evidence.

The Infusion Nurses Society's Infusion Nursing Standards of Practice has treated pH as a critical factor in the decision-making process for vascular access device selection, stating that an infusate with a pH less than 5 or greater than 9 is not appropriate for short peripheral or midline catheters. Because of the Standards, drug pH is not an uncommon factor driving the decision for central vascular access. In this era of commitment to evidence-based practice, the pH recommendation requires reevaluation and a critical review of the research leading to infusate pH as a decisional factor. In this narrative literature review, historical and current research was appraised and synthesized for pH of intermittently delivered intravenous medications and the development of infusion thrombophlebitis. On the basis of this review, the authors conclude and assert that pH alone is not an evidence-based indication for central line placement.

Respiratory depression in adult patients with intravenous patient-controlled analgesia.

Patient-controlled analgesia (PCA) has been widely implemented to provide better pain relief and increased patient satisfaction with relatively few side effects. However, patients using intravenous (i.v.) PCA are at increased risk for specific adverse effects, especially respiratory depression. A review of the literature from 1990 to present was done to identify the incidence and risk factors for respiratory depression and recommendations for care. Several studies have documented the incidence of respiratory depression with i.v. PCA; rates ranged from 0.19% to 5.2%. Variation in incidence existed because authors defined respiratory depression differently. Methods for monitoring oxygenation include sedation; respiratory rate, depth, and rhythm, and oxygen saturation using pulse oximetry. No single parameter is the single indicator for respiratory depression. Risk factors for respiratory depression with i.v. PCA include age greater than 70 years; basal infusion with i.v. PCA; renal, hepatic, pulmonary, or cardiac impairment; sleep apnea (suspected or history); concurrent central nervous system depressants; obesity; upper abdominal or thoracic surgery; and i.v. PCA bolus > 1 mg. Structures and processes should be in place to guide appropriate dosing, identify risk factors, and activate pertinent monitoring and frequency. Finally, respiratory depression occurs infrequently in comparison to the 10% of patients who are undertreated for pain.

Regional differences in vancomycin-resistant Enterococcus colonization rates in critically ill veterans.

Screening for vancomycin-resistant Enterococcus (VRE) has not been universally implemented within the Department of Veterans Affairs (VA). A prospective study was conducted to identify the admission prevalence rate of VRE in patients admitted to the intensive care unit in 2 VA facilities. Significant regional differences were found between the 2 facilities. Further studies are needed to account for regional differences in VRE admission prevalence, to optimize infection control interventions.