Nursing Posters

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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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.
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.
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)
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.
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
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
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.
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
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).
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.
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
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.
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
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.
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.
No One Goes Missing: Creating an Elopement Risk Safe Plan of Care

Jennifer Burris, Kathryn Collins, Holly Kockler, Tiffany Omann-Bidinger, and Elizabeth Plante

To identify patients at risk for elopement by developing an evidence-based elopement risk screening tool and plan of care.
Admission Documentation Overhaul

Jennifer Burris, Holly Kockler, and Hillary Waldum

Improve the admission documentation workflow by revamping the admission Navigator and Functional Health Assessment
Implementation and Standardization of Evidence Based Practice for Reprocessing of Flexible Endoscopes

Patricia Dumonceaux, Jenna Rooda, and Dena Walz

To improve patient safety and quality of care by implementing a standardized process for high level disinfection (HLD) of flexible endoscopes
A New Approach to Sternal Precautions: Keep Your Move in the Tube

Kelijo Fernholz, Jayna Theis, and Erik Anderson

Purpose:
- To guide patients and staff in a new approach to sternal precautions following median sternotomy
Current Practice:
- 10-pound lifting restriction for 4 weeks
- 20-pound lifting restriction until 3 months post operation
- Limited arm exercises
- Sit to stand push restrictions
Why Change:
- Literature review demonstrates great variation in sternal precautions
- Currently too restrictive; may hinder recovery and long-term mobility. Too many restrictions can create fear of movement, resulting in short term rehab discharge needs
- To create more independence for the patient, less reliant on family members for ADLs and basic needs. Patients to return to regular home and work activities sooner
- To decrease sternal wound complications
Contemporary Treatment Options for Pulmonary Embolism

Tanya Glenz and Teresa Jahn

Purpose:

Provide RNs education on the classifications of PEs and new catheter directed treatment options.

Significance:
- PE remains a common and lethal entity
- PE is the 3rd leading cause of cardiovascular death in hospitalized patients (60,000-1000,000 per year)
- 150,000-250,000 PE related hospitalizations per year
- RNs must be knowledgeable of the classifications of PEs and catheter directed therapies to promote positive patient outcomes
- Prior to catheter directed therapies, submassive PEs had a mortality rate up to 20% at 3 months and were traditionally treated with IV heparin, or oral anticoagulant therapy
High Reliability Principles in Safety

Abby Henderson and Leigh Klaverkamp
- Subject matter experts compare actual performance to expected performance.
- A standard set of questions for specific subtypes of events help establish trends.
- HRO's (High Reliability Organization) equip leaders and frontline staff to spot systemic causes of human error.
Routine Post Surgical Vital Signs: Time for a Change

Kristina Kjellberg, Elizabeth Plante, and Sadie Seezs

Purpose Statement:

The purpose of this evidence-based practice project is to evaluate the current routine post operative vital signs and determine if reduced frequency of vital signs is as effective in identifying deterioration after a post anesthesia care unit (PACU) discharge.

Synthesis of Evidence:
- Patient survival in the post operative time period is maximized with the recognition and management of abnormal vital signs
- Post op periods can carry great respiratory and circulatory complications, which are identified by abnormal vital signs especially heart rate and blood pressure
- Multiple sources have identified that current frequency of post operative vital signs is based on traditional rather than literature
- There are minimal resources identifying any standards of practice for post surgical vital sign monitoring after a patient leaves the PACU
Suspension of Independent Double-Check for SubQ Insulin Administration

Mallory Mondloch and Jennifer Watson

Study:

After a 1-month pilot of suspending the dual sign-off/independent double-check process, 160/163 random subQ insulin administrations from various units were administered correctly. This yielded a 98% success rate. No patient harm occured.

Plan:

Per Institute of Safe Medication Practices, dual sign-offs/independent double-checks are more effective for select high risk meds and not all. Since implementation of the insulin calculator, medication errors related to subQ insulin administration have reduced compared to previously when solely two licensed staff members performed a manual, independent double-check. After implementation of the validated eMAR tool - the insulin calculator - it was still required for two licensed staff members to perform independent double-checks. Due to caring for COVID patients in isolation, nurses observed workaround practices with great variation related to subQ insulin administration and documentation because of this independent double-check requirement. Nurses raised concern for patient safety and workflow efficiencies. A literature review was conducted which revealed support for utilization of the insulin calculator without the need for the additional manual independent double-check/dual sign-off in Epic.
Improving Hepatitis B Vaccination Rates in Nephrology Patients with Chronic Kidney Disease: A QI Initiative

Jill Swanson
- Hepatitis B vaccination is an important health maintenance preventative measure for patients with chronic kidney disease (CKD)
- Prior to initiating dialysis, hepatitis B vaccination administration is proven to be more effective than waiting until patients begin dialysis treatments.
- Efficacy and immune response of the hepatitis B vaccine is greater when kidney function is greater
- To better improve hepatitis B vaccine administration among the CKD stage 4 population, education measures and Epic modifiers will be implemented to achieve change
- Nursing knowledge and hepatitis B vaccine administration will improve after implementation of these measures
Rapid Evaluation Teams (RET): No Longer Just for Hospitals

Amanda Thorson

Study:

Everyone goes to the Nursing Home for End of Life - Right? Wrong Cumulatively, over a 4-year study there were 678 residents with Full Code status residing at Carris Health Care Center and 687 residents the DNR/DNI status. That is only a 10-resident different between Full Code and DNR/DNI

Plan:
- Improve long-term care staff's ability to call for, and receive, support to rapidly evaluate and address an urgent or concerning situation.
- Need for this plan is supported by increased number of OHFC substantiated events related to code status in MN and number of residents with Full Code status in long term care facilities.
- Barriers to Change: amount of education needed to increase number of CPR certified staff and to train on RET process, establishing one true source for code status for residents, establishing facility equipment needs for crash cart.