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Promotion of National Certification in Telemetry
Janelle Maciej
Situation:
Goal to bring awareness to telemetry nurses, the specialty certifications they are eligible for, and criteria for eligibility. Currently, six telemetry nurses hold a nationally recognized certification.
Action Plan:
- March 19, 2023 was Certified Nurses Day and was the kickoff for the start of encouragement for telemetry nurses to be certified.
- Each telemetry nurse was delivered a card and lifesaver candy inviting them to consider a nationally recognized certification.
- A certification informational packet promoting CV-BC and PCCN certification was placed at each desk and referenced during huddle for one week.
- Certification preparation books are available upon request.
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From Silos to Collaborative Working Relationships with EMS and ED
Angela Moscho
Opportunity:
To establish a strong, collaborative relationship between St. Cloud Hospital Stroke Center, St. Cloud Hospital Emergency Department and Emergency Medical Services.
Background:
Two separate health care systems with one goal in mind: best stroke care for a community member experiencing stroke-like symptoms.
Current Practice in 2017:
- Code stroke activation with LTKW (last time known well) up to 6 hours.
- Inconsistent pre-notifications and pre-activations by EMS and ED.
- St. Cloud Hospital and Mayo Clinic Ambulance with siloed/individualized protocols for their respective health systems.
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Heated High Flow Oxygen Therapy Management of Respiratory, Swallowing/Dysphagia and Nutrition Needs
Jenelle Overgaard
Problem
- Patients diagnosed with COVID-19 pose challenges for oxygenation. Often requiring heated high flow oxygen therapy (HHFOT) for days to weeks, with literflow commonly over 40 L/min with maximum of 60 L/min.
- There is minimal research on aspiration risk at higher literflow, therefore practice included decreasing liter flow to 20 L/min for oral intake was standard.
- During oral intake, with literflow decreased to 20 L/min, patients' oxygen saturations would quickly trend down.
- Alarms indicating low saturation would create anxiety, cause patients to eat faster potentially increasing risk for aspiration.
Solution
- For adult inpatients meeting criteria, increase maximum literflow allowed during oral intake from to 40 L/min.
- Develop guidelines for:
- oxygen supplementation during oral intake
- how/when to consult Speech Language Pathologist
- inclusion of dietitian earlier in hospitalization
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Stroke Education Compliance Improvement
Natasha Pflueger
Plan:
- Per stroke best practice guidelines, stroke education must be provided verbally and in literature format post stroke. Our plan is to improve compliance and documentation of stroke education by improving staff awareness of patient's stroke education status. by enhancing communication and improving the documentation process, nursing practice can be supported, and best patient care delivered.
- Per stroke guidelines, education on individualized risk factors is preferred by patients. Studies support that patient education is an effective method to improve vascular risk factors (Meschia, Bushnell, Boden-Albata, et al, 2014).
Act:
- As with prior to the implementation of adding notes to the secure chat, charts were audited daily for stroke education compliance and notes were placed for nursing in the Care Team Communication section of EMR.
- A stroke patient list for the hospital is sent to the unit educator Monday through Friday for review and follow up.
- The educator reviews charts for education documentation including individualized risk factors and literature being documented as given.
- We will continue this process as we have seen significant improvement over the last year. This will continue until educator does not have to send secure chat messages.
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Pupillometry
Elizabeth Plante and Casey Schmidt
Background:
- Measuring pupillary light reflex is a standard part of neurological assessment.
- Changes in pupil reactivity may indicate unfavorable outcomes, such as increased intracranial pressure and brain herniation.
- Physiologic and pharmacologic agents may affect pupil reactivity.
- In some instances, pupillary light reflex is the only piece of neurologic assessment readily testable.
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Dynamic Bronchoscopy for Excessive Dynamic Airway Collapse
Jennier Salaski and Krista Ophoven
Definition:
Excessive Dynamic Airway Collapse (EDAC) is a respiratory condition characterized by >50%luminal narrowing on expiration.
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SCH ICU Expanding PICS Throughout CentraCare
Jessica A. Tindal
Purpose:
Sharing information about Post Intensive Care Syndrome (PICS) to all in CentraCare. PICS symptoms do not appear until weeks to months after a critical care illness so patients at home may not know what to do with their symptoms.
Future Plans:
- May 2023 - introducing CICU to the PICS process during their Nurse Practice meeting.
- May 2023 - updating the Hospital Medicine Section CNS
- Fall 2023 - meeting with the Ambulatory Work Cabinet group to see if our system of notification is working
- What opportunities do we have with teaching Progressive RNs about PICS and our Diaries?
- How can we reach out to our patient population even more: MyChart messages, community education, etc?
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What I Need: Self Care at the Unit Level
Jessica A. Tindal
Purpose:
Self-care is individualized and best done when awarded on a small scale.
Goals:
For all employees of the ICU to:
- Feel valued outside of work
- Be recognized for taking care of themselves
- Participate in positive discussions
- Be rewarded for work life balance
- Be reminded of self-care
- Not feel alone with their thoughts
- Pause and reflect
- Help others, spouses, kids, etc.
Future plans include:
- Seasonal questions of things to see, places to explore
- Recipe sharing
- Hobby experts
- Focusing on staffs' interests
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Accelerated Onboarding for Unlicensed Personnel When Preceptors Are Limited
Britney Winkelman
Problem:
The timeframe between hiring unlicensed personnel (UP) to beginning the role within the organization began to increase due to limited orientation resources, rising staff shortages, and insufficient number of preceptors.
Purpose:
Accelerate the onboarding of UPs to decrease the workload for preceptors and reduce staff shortages, while generating competence and reducing costs for the organization.
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NeuroInterventional Post-Procedure Assessment and Documentation Compliance
Chandra Brower
Per stroke best practice guidelines, pulse and groin checks need to be completed post-neurointerventional procedure per orders. Our plan is to improve assessment and documentation of post-procedure pulse and groin checks by improving the flow of the Electronic Medical Record (EMR). By enhancing clinical documentation and improving the documentation process, nursing practice can be supported, and best patient care delivered.
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Very Important Discharge Appointment (VIDA)
Jennifer Burris, Holly Kockler, Gail Olson, Kristi Patterson, Natasha Pflueger, Jennifer Salzer, and LeAnn Volkers
To improve patient flow, access, and decrease strain on resources by enhancing the current process of Discharge and Loop Back Huddle by identifying two patients for early discharge the next day.
Current Practices:
- Discharge huddle and Loopback (Discuss care progression for all pts)
- Discharge planning using the IDEAL Model (Patient and Family Engagement with Discharge)
- Electronic Discharge Readiness Tools (Exp Discharge Date, Discharge milestones, etc.)
Next piece of the puzzle:
- VIDA: a framework to identify 2 patients to be discharged before 11 am – so the bulk of our discharges do not occur between Noon and 4:00 pm.
- Decreasing the strain on internal and external resources.
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Innovative Use of EHR to Support Admission Screening for Emerging Pathogens
Patricia Dumonceaux MSN, RN, CIC, PHN; Carolyn Harlander-Zimny; Elizabeth Kiffmeyer; Ellen Simonson; and Tamara Welle
- CentraCare hospitals were the first in Minnesota to identify a patient with Candida auris (C. auris), an emerging pathogen.
- 2018 Centers for Disease Control and Prevention (CDC) and state health department recommended adoption of enhanced admission screening process to allow for early identification of patients at risk of being colonized with C. auris/Carbapenem-Resistant Organisms (CROs).
- C. auris, a fungus, and CROs, comprised of organisms from the Enterobacteriaceae family resistant to carbapenems, are emerging multidrug resistant pathogens. Emphasis on identification and early isolation of at-risk patients decreases risk of transmission.
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ICU Liberation: Early Mobility and Exercise
Vanessa Fuller and Andrea Nyquist
ICU Liberation:
The Society of Critical Care Medicine’s (SCCM) Intensive Care Unit (ICU) Liberation Bundle was created to reduce the harmful effects of events that occur in the ICU setting. Early mobility and exercise is part “E” of the ICU Liberation Bundle; goals are to reduce ICU and hospital length of stay (LOS), prevent readmissions, reduce discharges to long term care facilities, reduce delirium and coma days, and reduce likelihood of hospital mortality (SCCM, 2021)
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Perioperative Glucose Monitoring Protocol
Nicole Helgeson
Currently, there is no established glucose management protocol for our surgical patients. Poor outcomes related to hyperglycemia may include increased morbidity/mortality, surgical site infection (SSI), sepsis, renal, and cardiac concerns. The purpose of this protocol is to improve the care and outcomes for surgical patients through a consistent standardization of glucose management.
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A Multidisciplinary Approach to Reduce Complications from Blind Small Bore Feeding Tube (SBFT) Insertion
Teresa Jahn, Jennifer Burris, Peggy Lange, Elizabeth Plante, and Mithun Suresh MD
Between 2019 and 2021, six lung perforations related to blind placement of SBFTs.
A multidisciplinary team reviewed current methods of placing SBFTs and the feasibility of each:
- Fluoroscopy
- 2 Step X-Ray
- Capnography
- Electromagnetic visualization
Capnography was selected as a safe and cost-effective way to attempt to identify insertion location in real time.
- Four team members were selected and trained to insert SBFT using capnography
- Each placement attempt and outcome of placement was tracked
- Outcomes were identified as successful or unsuccessful
- Any adverse events were to be tracked
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It's Time to Break Old Habits: Admitting STEMIs to the Telemetry Unit
Teresa Jahn and Tanya Glenz
Beginning December 2020 uncomplicated ST-Elevated MI patients will be admitted directly to Telemetry following intervention instead of CICU.
June 2020: Review and develop evidence- based exclusion criteria for admission to Telemetry
June 2020: Create a process for communication between the nursing supervisor, cath lab, Telemetry Unit and CICU for patient placement
Fall 2020: Meeting with Telemetry and CICU charge nurse, nursing supervisor and cath lab RN to discuss communication process
Dec 2020: Begin tracking STEMI patients
- Unit admitted to (Telemetry or CICU/ICU)
- Requiring transfer to CICU/ICU from Telemetry
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PureWick External Female Catheter
Elizabeth Kiffmeyer and Mallory Mondloch
Catheter-Associated Urinary Tract Infection (CAUTI) rates increased in FY21 compared to FY20, and many units continue to not meet their National Database of Nursing Quality Indicators (NDNQI) target goal even through FY22.
A group of CentraCare stakeholders gathered, including bedside nursing staff, urology techs and nursing leadership, to discuss barriers and areas for opportunity. Representatives from BARD®, our urinary catheter supply company, were invited to conduct an analysis on our urinary catheter/ CAUTI reduction practices. Findings from the analysis included an opportunity to implement an external female catheter.
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Early Detection of Sepsis
Holly Kockler and Evalyn Michira
The aim for this project was to improve early identification and intervention for sepsis to lower mortality rates and increase sepsis order set usage.
Key Drivers:
- Sepsis mortality rate is higher than compare groups
- Sepsis Order Set utilization is low
- Sepsis core measure performance is below benchmark
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Improving the Management of Tardive Dyskinesia on an Inpatient Mental Health Unit
Jennifer Krebsbach
Implement a practice change on the adult mental health unit to improve the accuracy and increase the rate of completion of the abnormal involuntary movement scale (AIMS) for tardive dyskinesia (TD).
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CentraCare Launch of COVID Antiviral Therapy
Jessica Miller, Todd Lemke PharmD, and Dennis Heinen RPh
- Efficiently monitor the limited available stock of oral antiviral COVID therapies during surge states
- Prescribe safely and appropriately
- Dispense to patients close to home.
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Promoting Patient Outcomes: CLABSI Prevention
Woon Paek
What is a CLABSI?
“A central line-associated bloodstream infection (CLABSI) is a serious infection that occurs when germs (usually bacteria or viruses) enter the bloodstream through the central line” (CDC, 2021)
Best practices for preventing CLABSIs:
- Perform hand hygiene
- Don proper PPE
- Sterile/aseptic technique during insertion
- Prioritize for cares related to central line first
- Daily assessment for need of central line
- Daily chlorhexidine gluconate bathing
- Remove catheters that are unnecessary
- "Scrub the hub" BEFORE EVERY access
- Change dressings every 7 days or as needed
- Assessment of site/dressing condition
- Change purple Ultrasite caps with dressings
- Tubing changes per CentraCare policy
- Discard piggyback tubing after disconnection
- Patient education regarding central line
- Staff education and audits
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Open All Hours!: Bariatric Surgery Patients Love CSC
Naomi Schneider and Mallory Mondloch
During the fall and winter of 2020, St. Cloud Hospital saw a dramatic increase in the number of COVID-19 patients. Additionally, elective surgeries in Minnesota were on hold during the early months of the pandemic, and later in 2020 there was a significant backlog of these patients, waiting for their procedure. To serve patients and their families, St. Cloud Hospital teams planned for a way to safely and professionally offer surgical care needs to Central Minnesota.
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ICU Liberation: Early Mobility and Exercise
LeAnn Volkers, Holly Kockler, and Kristi Patterson
The aim of this project was to streamline and standardize the delivery of the follow up Important Message from Medicare (IMM) for IP admissions across CC and Carris-RWF in compliance with regulatory standards of care.
Key drivers identified:
- Site specific variation
- Underutilization of Epic functionality
- Use of data to understand performance
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Preoperative Weight Loss for Patients Undergoing Lumbar Spine Surgery Utilizing Motivational Interviewing to Decrease Postoperative Complications: A Quality Improvement Project
Amanda Welle
Do patients who are obese, based on BMI>30 and are offered lumbar spine surgery, who undergo preoperative MI via telehealth to lose weight, compared to those who don’t undergo MI have decreased postoperative complications at 30 days postoperatively?
Conclusions/Implications:
- Results from this QI project suggest a higher BMI class is associated with postoperative complications-wound infection.
- However, given the small sample size no conclusions could be drawn
- This QI project should be replicated on a larger scale
- The process for recruitment and intervention is established. The Neurosurgical providers are supportive of the continued study.
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Increasing Access to Data through Microsoft's Power BI
Rumana Ahmad and Kristi Patterson
What is Power BI?
- A collection of software services, apps, and connectors that work together to turn unrelated sources of data into coherent, visually immersive, and interactive insights.
What’s in it for me?
- Users can quickly & easily explore trends for CC inpatients across common outcome measures including case counts, length of stay, mortality, & unplanned readmissions to help identify variation & opportunity for improvement. For example, compare COPD patient case counts, length of stay,and in-house mortality across CC hospitals.
Nurses at CentraCare Health are engaged in finding ways to improve all aspects of practice of nursing in the clinical setting. The following are posters created in the process of Evidence-based Practice Projects and clinical improvement.
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