Reducing Avoidable Hospitalizations for Nursing Home Residents: Role of the Missouri Quality Initiative Intervention Support Team No abstract available

A Randomized Trial Comparing Outcomes of 3 Types of Peripheral Intravenous Catheters Background: There was an increase in peripheral intravenous catheter (PIVC) complications and adverse patient events after product conversion during the merger between a rural hospital and a larger hospital system. A review of the existing literature identified a gap in evidence evaluating 2 closed PIVC systems compared with an open PIVC system. Purpose: The purpose of the current project was to ascertain whether open or closed PIVCs are best for patients, staff, and the health care system in terms of 3 main criteria: quality, safety, and cost. Methods: A prospective, 2-site randomized controlled trial was used to compare outcomes. Results: There were no differences in the complication rates between catheter types. There was a statistically significant increase in blood leakage and a decrease in clinician satisfaction with the open-system catheter. Conclusions: Our project supports current clinical recommendation that a closed PIVC system, regardless of type, is not only safer and cost-effective but also preferred by patients and clinicians.

Implementing a Clinical Practice Guideline on Opioid-Induced Advancing Sedation and Respiratory Depression Background: Opioid-induced respiratory depression (OIRD) is a serious adverse reaction associated with opioid administration. Local Problem: The purpose of this quality improvement study was to evaluate the impact of implementing a clinical practice guideline for OIRD in a medical-surgical setting lacking standardized monitoring techniques and reporting criteria for patients receiving opioid analgesia. Methods: An American Society for Pain Management Nursing protocol was implemented in 4 medical/surgical units. The impact on OIRD-related nurse knowledge, documentation, and opioid-related rapid response calls was measured pre- and postimplementation. Results: Nurse OIRD-related knowledge significantly increased. The number of naloxone administrations associated with prior intravenous opioid analgesic administration did not significantly change. However, there was a significant decrease in the postimplementation number of respiratory distress–related rapid response calls. Conclusions: Implementation of the American Society for Pain Management Nursing guidelines had a positive impact on knowledge, documentation, early intervention of OIRD, and the number of opioid-related rapid response calls.

Nurse-Led Mobility Program: Driving a Culture of Early Mobilization in Medical-Surgical Nursing Background: Hospitalized medical-surgical patients are at risk for adverse health outcomes due to immobility. Despite well-documented consequences, low mobility is prevalent. Local Problem: In a 547-bed hospital, medical-surgical patients were mobilized less frequently than expected. Physical therapists were inappropriately consulted 22% of the time for routine mobility of patients. A preimplementation survey of registered nurses indicated a lack of knowledge and confidence to safely mobilize patients. Methods: This quality improvement project implemented a nurse-led mobility program in an effort to increase early mobilization, reduce physical therapy referrals for routine mobility, and reduce the sequelae of immobility. Interventions: The Bedside Mobility Assessment Tool and standardized interventions were implemented on 5 medical-surgical units. Results: Postimplementation, nurse-led patient mobilizations increased by 40%, inappropriate physical therapy orders decreased 14%, and no significant change in patient falls or pressure injuries was noted. Conclusion: A nurse-led mobility program was effective in increasing safe, early mobilization of patients and improving the culture of mobility.

Leveraging Electronic Health Records and Machine Learning to Tailor Nursing Care for Patients at High Risk for Readmissions Background: Electronic health record–derived data and novel analytics, such as machine learning, offer promising approaches to identify high-risk patients and inform nursing practice. Purpose: The aim was to identify patients at risk for readmissions by applying a machine-learning technique, Classification and Regression Tree, to electronic health record data from our 300-bed hospital. Methods: We conducted a retrospective analysis of 2165 clinical encounters from August to October 2017 using data from our health system's data store. Classification and Regression Tree was employed to determine patient profiles predicting 30-day readmission. Results: The 30-day readmission rate was 11.2% (n = 242). Classification and Regression Tree analysis revealed highest risk for readmission among patients who visited the emergency department, had 9 or more comorbidities, were insured through Medicaid, and were 65 years of age and older. Conclusions: Leveraging information through the electronic health record and Classification and Regression Tree offers a useful way to identify high-risk patients. Findings from our algorithm may be used to improve the quality of nursing care delivery for patients at highest readmission risk.

Impact of Kamishibai Card Process on Compliance With the Central Venous Line Maintenance Bundle Background: The Kamishibai Card (K-Card) process is a storytelling methodology designed to help identify barriers and remove or redesign them. Purpose: The purpose of this study was to evaluate the effectiveness of the K-Card process for central venous line (CVL) maintenance bundle compliance in a pediatric intensive care unit. Methods: A retrospective evaluation of the implementation of the K-Card process was performed using a pretest and posttest design. Results: A total of 1003 central venous catheter maintenance observations were completed during the study period. A statistically significant change was noted in one element of the CVL maintenance bundle, tubing timed and dated. The most frequent cause for noncompliance with the CVL maintenance bundle was incomplete communication during handoff, followed by device associated factors (failure of device, use of device, and availability of device). Conclusions: The K-Card process had a positive impact on CVL maintenance bundle compliance in the study setting.

Effect of a Systemwide Approach to a Reduction in Central Line–Associated Bloodstream Infections Background: Unit-based initiatives were deployed independently creating silos in practice variability across the system with little impact on reduction of central line–associated bloodstream infections (CLABSI). Problem: The goal was to decrease CLABSI systemwide by establishing standardized evidence-based practice (EBP) procedures to advance nursing practice. Approach: A new innovative method, the Ferrari Method for Practice Standardization, enhanced the quality infrastructure by merging EBP and lean methodology to translate nursing innovations into practice. Leveraging a culture of shared decision making to support autonomy, as well as collaborating interprofessionally, allowed the organization to standardize and sustain CLABSI prevention. Outcomes: The Ferrari Method for Practice Standardization successfully reduced CLABSI rates by 48% over a 1-year improvement cycle. Eight standardized EBP clinical procedures were developed and implemented across the organization. Conclusion: The implementation of the Ferrari Method for Practice Standardization swiftly moves new knowledge into clinical practice to improve outcomes. Using standardized improvement methodology, it eases the interprofessional approval processes, maximizes autonomy, and focuses on quality care.

Improving Lower Extremity Bypass Patient Outcomes: Enhanced Recovery After Surgery Implementation Project Background: Care variation is associated with poor quality outcomes. Clinical practice guideline implementation is one method to decrease care variation and improve outcomes. Enhanced Recovery After Surgery (ERAS) is a clinical pathway encompassing best practices across the surgical patient care continuum. Local Problem: The lower extremity bypass (LEB) population had high length of stay (LOS), readmissions, and surgical site infections. Methods: A comprehensive and systematic project management process was utilized to implement the ERAS pathway in the LEB population with the help of an interdisciplinary team. Interventions: Clinical practice guidelines were created to integrate ERAS elements into the LEB population care continuum. Patient education was revised or created to ensure standardized information was communicated to patients from consultation through discharge and early follow-up. Results: Preliminary data show 4.57 mean LOS (n = 21) compared with the prior year's mean of 6.81 (n = 53). Conclusion: ERAS pathway introduction to the LEB population is suggestive of improved outcomes based on preliminary data.

Systemwide Practice Change Program to Combat Hospital-Acquired Pressure Injuries: Translating Knowledge Into Practice Background: Considerable evidence exists on how to prevent hospital-acquired pressure injuries (HAPIs). However, processes employed to implement evidence play a significant role in influencing outcomes. Problem: One Australian health district experienced a substantial increase in HAPIs over a 5-year period (by almost 60%) that required a systemwide practice change. Approach: This article reports on the people, processes, and learnings from using the Promoting Action on Research Implementation in Health Services (PARiHS) framework taking into account the evidence, context, and facilitation to address HAPIs. Outcomes: Applying this approach resulted in a significant decrease in pressure injuries and positive practice change, leading to improved patient outcomes in a shorter time frame than previous strategies. Conclusion: Processes guided by the PARiHS enhanced the effectiveness of translating evidence into practice and positively assisted clinicians to promote optimal patient care. This approach is transferrable to other health care settings.

Brown Bag Medication Review: Using AHRQ's Brown Bag Medication Tool Background: Medication nonadherence has been linked to health literacy and poor patient outcomes. The Health Literacy Universal Precautions Toolkit addresses both issues. Purpose: A brown bag medication review was implemented to identify medication nonadherence in a Midwestern clinic. Methods: Adult patients were instructed to bring all prescribed and over-the-counter medication to office visits. A reviewer transcribed administration directions and the patient's verbal instruction of how the medication is taken. Results: The study found 58% (n = 28) of 48 participants were nonadherent for at least 1 medication; 26% (n = 72) of all medications were nonadherent; and mental health drugs were the highest nonadherence category at 38% (n = 11). The majority of medication nonadherence was due to lack of access. Conclusions: This drug utilization review was found helpful in identification of causes for medication nonadherence, assisting prescribers, and improving patient education.