11th Annual Evidence-Based Practice/Research Conference Shifting Safety From “Priority” to “Purpose”: Accelerating Safety of Patients, Families, and Our Workforce September 27, 2019

S 11th Annual Evidence-Based Practice/Research Conference Shifting Safety From “Priority” to “Purpose”: Accelerating Safety of Patients, Families, and Our Workforce September 27, 2019 Podium Abstracts 1.2-3.2 Poster Abstracts P1-P21 Ochsner Health System, Center for Evidence-Based Practice and Nursing Research Louisiana State University Health New Orleans, School of Nursing New Orleans, LA Volume 20, Number 2, Summer 2020 e1 Research Conference Abstracts

Conclusion: Generalizability of findings may be limited due to the utilization of a convenience sample. Nursing staff are comfortable in addressing spiritual care at the bedside and initiating spiritual care referrals without further training or guidance. However, personal biases pertaining to preexisting beliefs may influence the delivery of spiritual care at the bedside and warrant future qualitative studies.

Ochsner Medical Center -Westbank
Background: Many emergency departments (EDs) are facing increasing challenges due to growing patient numbers and an inability to flex capacity to meet demand. Due to the increase in patient visits, ED lobbies and hallways have become crowded with patients, and negative outcomes are increasing, such as patients who leave without being seen and delays in care times. Ochsner Medical Center (OMC) -Westbank ED saw a need to optimize the ED throughput process to decrease negative outcomes related to delay in ED care.

Methods:
In response to this significant challenge, OMC -Westbank sought to identify barriers and improve patient flow with the assistance and support of the Schumacher Group. Utilizing the change model of FOCUS-PDSA (find a problem, organize a team, clarify the problem, understand a problem, and select an intervention-plan, do, study, act), the ED team worked to improve patient outcomes through decreasing door-to-room, door-to-provider, and door-to-electrocardiogram (EKG) times, which led to a reduction in the number of patients that were leaving without being seen. Key changes included implementing a SOrT process (sort, order, and treatment) by placing a provider in triage, adding an additional nurse to implement the orders, and educating all ED stakeholders.
Results: Prior to the change, the OMC -Westbank ED average census was 150 patients per month, with a monthly left without being seen rate as high as 7.1% and average door-to-room time of 27 minutes, door-to-doctor time of 38 minutes, and door-to-EKG time of 24 minutes. Postimplementation, times decreased to an average of 8 minutes for door-to-room time, 10 minutes for door-to-provider time, and 9 minutes for door-to-EKG time, and a left without being seen rate <0.05% has been sustained for the past 10 months.
Conclusion: By identifying barriers, utilizing best practices, and refocusing on patient-centered outcomes, the OMC -Westbank ED was able to reduce the door-to-provider time by implementing a front-end process that overall reduced the delay in treatment times and the left without being seen rate.

Ochsner Medical Center -New Orleans
Background: Historically, rapid response systems (RRS) have been used reactively as a safety intervention to decrease rates of cardiac arrests and prevent unplanned transfers into the intensive care unit (ICU). Proactive resuscitation models have also demonstrated prevention of adverse events, dissemination of expertise, provision of staff support, and discovery of quality improvement opportunities. A resuscitation program redesign included new approaches to patient safety by reducing preventable deaths and resuscitation events outside the ICU.
Methods: This patient safety program combined novel artificial intelligence alerts, expert nurse rounding, interprofessional training, closed-loop quality improvement, and targeted outcome measurement to offer a systematic and standardized approach to patient safety that could be customized to any hospital.

Results:
Since January 2018, cardiopulmonary arrests outside the ICU decreased by more than 70%, and cardiopulmonary arrests inside the ICU decreased by more than 36%. The Risk Adjusted Mortality Index decreased to a goal approaching 0.85, and the hospital saw an improved peer group ranking on the Hospital Survey of Patient Safety and in the areas of communication openness, nonpunitive response to errors, and frequency of events reported, suggesting a positive cultural shift in perception of patient safety.
Conclusion: Implementation of a structured resuscitation program is likely to prevent adverse events and support frontline staff.

LSU Health New Orleans, School of Nursing
Background: Predatory journals and publishers arose out of the open access movement in the early 2000s. While many open access journals and publishers are legitimate, almost half are not. These predatory journals and publishers unprofessionally exploit the open access model, luring unsuspecting authors with a promise of rapid publication. Predatory publishers dilute and corrupt the process of scientific communication, foster counterfeit science, and have little if any peer review or editorial oversight. Articles published in the predatory venue lack scientific and methodological rigor. Predatory conferences have been widespread since the late 2000s and are an outgrowth of the predatory publishing multibillion-dollar industry. Predatory conferences are not organized by scholarly associations but by revenue-generating companies, often predatory publishers, to exploit and profit from researchers who want to present at international conferences. Predatory conferences are poorly organized and poorly attended, with low quality and little to no peer review of submitted abstracts. Some estimates have predatory conferences outnumbering legitimate conferences. Predatory publications and predatory conferences reduce trust in science; thus, it is incumbent on all of us engaged in scholarly work and publishing to ensure we avoid predatory venues when disseminating our scholarly work.
Methods: Predatory publishing and predatory conference evaluation tools and checklists can assist researchers and clinicians to identify suspect venues. Attendees will use a free, online, and copyright-free sample checklist with scoring sheet to ascertain legitimacy of publications and conferences. A discussion of the elements of the journal evaluation tool will enable attendees to apply individual components of the tool.
Results: Attendees of this presentation used a journal evaluation tool to discern legitimate from suspicious and phony invitations for publication and conferences.
Conclusion: Use of free, readily available, evidence-based predatory publication and conference evaluation tools and checklists offers feasible strategies for the identification and avoidance of predatory publications and conferences.

Baylor Scott & White Medical Center
Background: In 2015, the Occupational Safety and Health Administration (OSHA) reported that healthcare workers were four times more likely to experience workplace violence (WPV) than workers in private industry. Between July 2015 and June 2018, twenty employees suffered injuries related WPV. Nine required medical care. WPV can have harmful effects and negative career impacts. The aim of this study was to examine the difference in the cognitive knowledge of nurses in addressing violent behavior of patients and visitors and to assess the difference in perception of WPV before and after an educational intervention.
Methods: This was a one group before and after intervention study. The sample size was calculated at 93. Ten employee safety program (ESP) sessions were offered over three months. Participants were asked to complete a knowledge test at the beginning of class and at the end of class. Participants were asked to complete a WPV perception survey at the beginning of class and 3 months later. This institutional review board-approved study took place at an acute care, not-for-profit, nonacademic, 143-bed, full-service community hospital. One hundred and four participants completed before and after surveys.
Results: There was a statistically significant difference in the participants' knowledge in addressing violence. Many felt violence has increased over the past year, a significant number feel safe at work, and more felt able to manage violent behaviors after attending training. Staff suggested using bright-colored nametags for visitors and placing a lighting system outside patient rooms to alert others that patient behaviors were escalating.

Conclusion:
Recognizing escalating patient behaviors is the first step to maintaining a safe environment. Organizations must provide healthcare workers with de-escalation training to stay safe at work.

P1. Journey to Implementing a Comprehensive Inpatient Fall Prevention Program in a Community Hospital
Kenesha Bradley, MSN, APRN, ACNS-BC; Jennifer Guillot

Ochsner Medical Center -Westbank
Background: Despite the vast amount of evidence regarding risk factors associated with falls and fall prevention strategies and guidelines, falls continue to present challenges in acute care settings. Because falls are the result of complex patient-and environmental-related factors, we set out over the course of four years to initiate and sustain a comprehensive fall prevention program for our inpatient hospital setting that included a multidisciplinary team to oversee the strategic plan for the fall program, optimization of the electronic medical record (EMR) for accurate assessment and intervention documentation, staff and patient education, and creation of a safe environment for patients and staff.
Methods: Utilizing the plan-do-study-act framework and the Roadmap to a Comprehensive Falls Prevention Program by the Minnesota Hospital Association and AHRQ Preventing Falls in Hospitals, our facility strategically piloted many recommended best practices, only choosing to sustain those efforts with the greatest impact on our fall outcomes.

Results:
Outcomes measured throughout implementation included compliance, number of falls, and fall rates. Over the past 4 years, we have seen a consistent steady decrease in the number of falls each year, with the number of falls since 2015 decreasing by 39%. There has also been a 47% fall rate decrease to 1.76 in 2018 since implementing the program.

Conclusion:
Of the recommendations, we have seen the greatest impact through our multidisciplinary committee, post-fall investigations, and safety rounding with coaching in the moment. We continue to work to decrease patient falls through staff accountability and individualized patient interventions.

The University of Alabama -Tuscaloosa
Background: Patient falls present an acutely problematic challenge in hospitals. Despite many programs and interventions to prevent falls and fall-related injuries, these rates have remained high. Advancements in technology have afforded the opportunity to implement novel video monitoring (VM) systems to observe and support inpatient settings from remote locations. VM offers a cost-effective way to address fall challenges by providing additional fall risk intervention, thereby maintaining patient safety and helping to decrease fall rates. The purpose of the study was to examine the effect of VM technology as a fall prevention intervention in four inpatient units-stroke unit (CVA), traumatic brain injury unit (TBI), comprehensive medical rehabilitation unit (CMR), and spinal cord injury/multitrauma unit (SCU)-at a rehabilitation hospital in the southeastern United States.
Methods: This retrospective review assessed the fall rates of four inpatient units (from October 2016 to February 2018) before and after the implementation of VM. Historic fall rate data for all four units were collected for the two-year period prior to the implementation of the VM system (May 2015 to September 2016) and used as the baseline data.
Results: VM has been effective in reducing falls in four inpatient units. Prior to implementation, the average fall rate was 7.8. After the implementation, the average decreased to 6.4. Furthermore, 75% of the units (CVA, CMR, SCU) included in this study experienced an average 30.86% decrease in fall rates. Changes in level of injury and fall event types were also analyzed and will be shared.
Conclusion: Falls and fall potential are a significant concern in rehabilitation settings. Current fall prevention strategies are often not effective at reducing fall rates. Implementation of new VM technology helped to reduce fall rates among three inpatient rehabilitation settings in our institution.

P3. HUSH: The Creation of a Sleep Protocol to Limit Sleep Interruptions on a Medical-Surgical Unit
Shaun Lampron, DNP, RN; Donna Copeland, DNP, RN, NE-BC, CPN, CPON, AE-C

University of South Alabama
Background: Hospitalized patients often experience poor sleep quality due to unnecessary noise and sleep disruptions. The importance of sleep in maintaining physiological and psychological well-being are well documented. In addition to the physiological and psychological effects, sleep disruptions also affect patients' perceptions of the overall hospital experience. By coordinating care, noise and sleep disruptions can be reduced to improve patients' perceptions of the hospital experience and promote a healing environment. A quality improvement project was developed to improve the patient perceptions of quietness and reduce sleep disruptions by 5% over 16 weeks.
Methods: An interprofessional team developed a Help Us Support Healing (HUSH) protocol to coordinate patient care activities to minimize sleep interruptions, allowing patients six or more hours of uninterrupted sleep. Inclusion criteria for the HUSH protocol were patients with a modified early warning score of 2 at 24 hours after admission to the medical-surgical unit. Changes in patient perceptions of noise and number of hours of restful sleep were compared preimplementation and postimplementation of the HUSH protocol utilizing the Hospital Consumer Assessment of Hospital Providers and Systems (HCAHPS) quiet domain scores and patient interviews during daily nurse leader rounding.

Results:
Twenty-four patients were included on the HUSH protocol, 63% female and 37% male. Patients ranged in age from 40-91 years with the mean age group 70-79 years. Overall results of the quiet domain scores indicated a 9% improvement from 44% six months before implementation of the project to 53% postimplementation. Patient interviews during nurse leader rounding indicated a positive response, with patients reporting more restful sleep and a decrease in sleep interruptions during the nighttime hours.
Conclusion: This quality improvement project demonstrated that coordinating care can improve patients' perceptions of quietness and sleep quality. However, due to a small sample size, further studies are needed to confirm the findings and to evaluate the impact of a sleep protocol in other populations and settings. Further investigation is needed for limiting sleep disruptions and the effects on patient outcomes.

University of South Alabama
Background: Students do not inherently know how to work in an interprofessional (IP) team; faculty observations confirmed that students were unable to establish mutual goals, select a team leader, or decide who was responsible for tasks in the clinical setting. Consequently, students' ability to work collaboratively was diminished. When healthcare professionals do not communicate effectively, patient safety is at risk; therefore, communication and team collaboration are essential to patient outcomes. TeamSTEPPS ® training has been proven effective in enhancing communication and teamwork. In addition, team-based learning (TBL) has been shown to enhance student engagement; however, little has been written on TBL for TeamSTEPPS ® training among IP students. Therefore, an institutional review board-approved study was designed to determine whether TBL is feasible for the delivery of TeamSTEPPS ® training and whether TeamSTEPPS ® training would improve students' capacity for IP collaboration.
Methods: Two cohorts of students from five disciplines enrolled in an IP course participated after consent was obtained. TeamSTEPPS ® training consisted of one 4-hour session for multiple teams of 4-5 students over the semester. Each session included pre-readings, individual and team readiness assurance testing, and application activities to assimilate the training into practice. The Student Perceptions of IP Clinical Education-Revised 2 was administered preimplementation and postimplementation of the training.
Conclusion: Findings indicate that TBL is feasible for the delivery of TeamSTEPPS ® training. This study shows promise in short-term improvements in attitudes of IP students in collaborative practice.

Children's Hospital New Orleans
Background: Over a period of six months in early 2017, central line-associated blood stream infection (CLABSI) maintenance reliability in our pediatric intensive care unit (PICU) was consistently below 70%, coinciding with an uptick in our CLABSI infection rate. Senior nursing leadership (CNO), noting the drift in reliability, implemented leadership rounding with the intention of rounding on each patient every day to assess CLABSI maintenance reliability.

Methods:
The quality improvement intervention began in August 2017 with the unit director attempting to round on each patient daily. PICU patient volumes fluctuate, and the unit manager found it more effective to round with bedside nurses throughout the week on both day and night shifts. Each interaction lasted approximately 20 minutes and began with asking the bedside nurse to identify what hospital-acquired conditions the patient was at risk for and reviewing all applicable bundle elements. Clinical leaders were added to the rounding process in December 2017, reinforcing best practice with staff on all shifts. Staff members were encouraged to join quality improvement teams and act as unit champions.

Results:
Since the intervention, the PICU went 10 months without a CLABSI and had a statistically significant improvement in CLABSI maintenance reliability (P=0.02, 2 proportion test).

Conclusion:
The initial objective was to round on all patients every day and increase auditing. The PICU implemented this change through leadership involvement, bedside education, and increasing situational awareness to reinforce best practice. A new electronic medical record implementation in April 2018 resulted in a decrease in reliability associated with documentation, but the unit remained infection free for 10 months, indicating hardwiring of the process on the unit.

Children's Hospital New Orleans
Background: Over a period of six months in early 2017, central line-associated blood stream infection (CLABSI) maintenance reliability in our hematology/oncology unit was inconsistent, with rates ranging from 44% to 100%. During that time period, 7 patients were diagnosed with a CLABSI. Senior nursing leadership responded to the drift in reliability by implementing daily leadership rounding on every patient to assess CLABSI maintenance reliability. The hematology/oncology unit developed a variety of interventions in fall 2017 designed to improve CLABSI maintenance reliability and reduce CLABSI infection rates. Specifically, the unit focused on hygiene measures to reduce the incidence of mucosal bloodstream infections (MBIs), which hematology/oncology patients are particularly at risk for.

Ochsner LSU Health Shreveport
Background: Urinary tract infections (UTIs) are the fourth most common type of healthcare-associated infection (HAI). A catheter-associated UTI (CAUTI) is the leading cause of secondary nosocomial bloodstream infections; about 17% of hospital-acquired bacteremias are from a urinary source, with an associated mortality of approximately 10%. An estimated 17% to 69% of CAUTI may be preventable with recommended infection control measures, which means that up to 380,000 infections and 9,000 deaths related to CAUTI per year could be prevented. The purpose of this project was to test a new CAUTI prevention protocol.
Methods: A quality improvement project was initiated July 2018-September 2018 at Ochsner LSU Health Shreveport in the medical intensive care unit (MICU) comparing CAUTI rates with our CAUTI prevention protocol in the third quarter with CAUTI rates in the previous two quarters. We used the standardized infection ratio (SIR) to evaluate our number of CAUTIs. The SIR compares the actual number of HAIs reported to the number that would be predicted, given the standard population (ie, National Healthcare Safety Network baseline), adjusting for several risk factors that have been found to be significantly associated with the differences in infection incidence. The CAUTI SIR goal for our facility is <0.8, which is the value-based purchasing threshold.

Results:
After implementation of the new protocol, we had a CAUTI SIR of 0.726, achieving our SIR goal of <0.8. HAI were reduced, and patient safety outcomes were improved. The one CAUTI we had was due to an asymptomatic bacteremic UTI in a patient who had multiple other sources.

Conclusion:
The new protocol was successful in reducing the number of CAUTIs identified in our MICU. Because of this success, the protocol has recently begun to be implemented throughout the hospital.

Ochsner Medical Center -New Orleans
Background: Nurses are uniquely positioned to recognize improvement opportunities, identify costeffective changes, design innovative workflows, and lead sustainable change. There are more than four million active nurses in the United States who could be empowered to pursue innovative ideas and translate evidence into practice and positive patient outcomes. An investment in non-clinical nursing time offers exciting opportunities to enhance creativity, decrease burnout, and engage frontline staff in designing a healthy work environment.

Methods:
In 2019, a large health system in the southern United States embarked on a journey in partnership with a large national nursing organization. A structured curriculum was used to train frontline nurses in leadership topics, communication, change concepts, quality improvement methods, project management, and data management and analysis. Each nurse was supported to commit to 96 hours of non-clinical time to identify a specific clinical problem and solve the issue with a team.
Results: Ten teams participated in the program from 9 intensive care units (ICUs) and one medical/surgical unit. Four ICUs choose to look at emergency response, four teams implemented interdisciplinary rounds, one chose to tackle burnout, and one looked at noise reduction. Each team will be able to demonstrate positive patient, nurse, and fiscal outcomes at the end of the one-year program.
Conclusion: Staff nurses can make substantial contributions to their organizations in clinical and fiscal outcomes when provided with non-clinical time.
Methods: Lean methodology and A3 structured problem solving were utilized to address the sepsis screening accuracy gaps. Efforts focused on three units. Interventions were visual management tools to assist with sepsis screening, sepsis champions on each pilot unit, an education packet with self-paced workbook, sepsis screening education to champions, and education of nursing staff by champions. Also, weekly data of accurate screening were posted on units' huddle boards for discussion, emails were sent to registered nurses who did not screen accurately, and nurses were recognized who screened accurately.

Results:
In February 2019, accurate sepsis screening on pilot units was 21%. On April 28, 2019, accurate screening reached 91%, and the goal of 75% was sustained for 5 weeks through the end of the pilot project.

Conclusion:
Nursing plays a key role in identifying patients who become septic. Knowing how to accurately screen for sepsis and notifying the provider with effective communication prompt treatment that can be initiated to save lives. Education is being provided throughout BUMC so that all nurses will get ahead of sepsis by accurately screening.

Ochsner Medical Center -New Orleans
Background: Rapid response systems (RRS) are a patient safety framework for bedside staff to summon a team of providers when a patient demonstrates signs of clinical deterioration. The RRS goal is to intervene early and prevent the need for critical care transfers or cardiopulmonary arrest. Staff perceptions can impact the success of a hospital's RRS. The purpose of this study was to explore differences in staff perceptions of RRS knowledge and satisfaction before and after a process change.
Methods: An exploratory analysis was conducted using pretest and posttest data from the Rapid Response System Staff Knowledge and Satisfaction Survey. After the pretest, the RRS process was modified to incorporate a technology-based patient risk stratification system, to do proactive rapid response nurse (RRN) rounding, and to encourage RRN telephone consults. The posttest survey was administered the following year. Respondents included in this analysis were registered nurses (RNs) who self-identified as emergency response team callers (n=111 in 2017; n=144 in 2018). Descriptive statistics were used to analyze survey data, including frequency distributions. Each survey item was investigated using chi-square tests of association to assess change in distribution of responses across years. The sample was analyzed in totality with subgroup analysis (by years of experience) for statistically significant findings.

Results
: Results demonstrated significant change on two survey items for all RNs, indicating improved support for the decision to activate RRS and postcall care documentation. For novice nurses, there was significant change in perception of willingness to use the RRS. For experienced nurses, there was significant change in perceptions about physician support for activating the RRS.

Conclusion:
Technology-based risk scores allow RRS teams to anticipate and prevent patient deterioration. Proactive RRS consultation can improve staff perceptions, building confidence in the system and encouraging utilization.

P17. Standardizing Chemotherapy Education
Jessica Christi Gaubert, RN, BSN, OCN Our Lady of the Lake Regional Medical Center Background: The purpose of this quality improvement project was to identify the education practice issue within the organization and demonstrate a quality improvement plan, with change theory as an underpinning for the process.

Methods:
The oncology outpatient infusion center nurses completed surveys consisting of self-reported rates of patient education. More than 90% of the nurses reported an inability to provide thorough chemotherapy education to all patients. Barriers to providing proper chemotherapy education to their patients were assessed. Knowledge base of supportive interventions, time restraints, increasing patient loads, and higher patient acuity were identified as barriers. Education was inconsistent among nurses. Patient satisfaction surveys consistently reflected deficits in the areas of "education to manage symptoms," "what to expect during chemo," and "explained how to manage chemo side effects." Results: Six Sigma was used as a quality improvement model to provide a better understanding of the process being improved and how to reach a solution through a cycle to define, measure, analyze, improve, and control the practice improvement initiative. The process issue can be defined as inconsistent and inefficient education of first-time cancer patients receiving chemotherapy. When measuring the process, the expectation is that 100% of new patients receiving chemotherapy will be educated by the infusion nurse, but the current audits reveal not all patients are receiving thorough education. Analysis reveals inconsistencies in educational material and nursing time restraints limiting and preventing patient education.
Conclusion: Structure measures in the outpatient oncology clinic should include a nursing supervisor always available with a manager or charge nurse available in the supervisor's absence. Process measures should ensure all first-time chemotherapy patients are educated and consistently provided with the same handouts and binders. Outcome measures should evaluate patient safety through compliance with home care techniques and decreased problem visits and triage calls for symptom management. The structure, process, and outcomes will be measured through monthly audits of education rates, patient satisfaction survey scores, unscheduled problem visits with oncologists, and phone calls to triage nurses for symptom management.

P18. Trialing Use of the Difficult Intravenous Access (DIVA) Tool
Kimone Wright, BSN, RN

Tampa General Hospital
Background: Peripheral intravenous (IV) catheters are commonly used in hospitalized patients to deliver medical care. Approximately 200 million peripheral IV catheters are inserted in hospitals across America each year. At times, trying to establish IV access can be challenging because of comorbidities, scar tissue, hydration status, age, and a variety of other factors. Multiple studies have shown beneficial effects of determining the difficulty of an IV placement by using the difficult intravenous access tool.

Methods:
The project authors collected data from 43 nurses in five different units in a large urban teaching hospital. Data were collected using an edited version of the clinical predictor tool to help identify patients with difficult IV access (DIVA tool). A score of five or greater suggests that the patient has a difficult IV access and should prompt a consult to the vascular access team (VAT). The group added a question to determine if IV access was ultimately obtained by the hospital's VAT.
Results: Nearly all surveyed nurses felt the DIVA tool was a helpful predictor for IV insertion success. Fiftythree percent of patients with a score of five or greater required the VAT to obtain peripheral IV access. The average number of peripheral IV insertion attempts per patient was two.
Conclusion: Project data suggest that the DIVA tool was helpful to predict when IV insertions would be difficult, warranting a consult to the VAT. Further testing of the tool should occur before housewide implementation.

Tampa General Hospital
Background: A new nurse guide was designed as a residency project by new nurses to help fellow new nurses integrate into the culture of their large urban teaching hospital.

Methods:
The group created and tested the guide's content and evaluated the perceived usefulness of the guide during their year in residency. An established residency cohort was surveyed to establish key topics to include in the guide. The guide was then tested on a newer nurse residency cohort. The new cohort was surveyed to determine baseline knowledge of topics included in the guide, but only the control group received the guide. One month later, the control and experimental groups completed the same survey again to measure change in knowledge level. The experimental group was asked additional questions about the usefulness of the book.