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Immunotherapy Serum Mixing: 2023 Best Practice Changes
Eyas Abla MD, Paul Faybusovich DO, Matthew Lies, and Mallory Mondloch
Background Story:
CentraCare - Plaza Allergy & Asthma Clinic compounds immunotherapy serum with advanced training of licensed nurses. Effective November 1, 2023, USP (797) Pharmaceutical Compounding guidelines were updated and endorsed by the American Academy of Allergy, Asthma & Immunology (AAAI). The Allergy Clinic completed a gap analysis to determine what process needed to change to comply with these latest guidelines.
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EYE CODE Protocol
Christina Anderson MD, Maiya Dietz, Kelsey Bade, and Mallory Mondloch
Purpose of EYE CODE:
- Retinal artery occlusion (RAO) is a rare but detrimental adverse effect of cosmetic facial filler injections.
- Requires prompt treatment and reversal to avoid patient blindness.
- EYE CODE is a new protocol in place to avoid this complication.
- Assist staff during a high stress event. •Improve patient safety & staff confidence. Way to receive continuing education credits through the clinic.
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Implementation of a Two-Person Urinary Catheter Insertion Practice Change
Brandy Berends, Elizabeth Kiffmeyer, Jenelle Overgaard, Amy Railson, and Morgan Thiry
Decrease incidence of Catheter Associated Urinary Tract Infections (CAUTIs) for inpatients by implementing a two-person urinary catheter insertion practice change using a checklist.
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You've Got to Move It, Move It!
Jennifer Burris and Elizabeth Plante
An increase in reportable hospital acquired pressure injuries (stage 3, 4, or unstageable) was found to be associated with patients refusing to participate in the prevention plan of care.
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Progression of Care/Discharge Delay Panel
Jennifer Burris, Jennifer Salzer, and LeAnn Volkers
Plan:
- To reduce the number of patients with a length of stay (LOS) greater than or equal to 26 days by 25% (from 199 to 150).
- to reduce the average patient days for patients with a length of stay greater than or equal to 26 days by 25% (from 39.7 to 30).
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Barriers to Implementation of Practice Guidelines against Fluid Restriction in Heart Failure
Mary Geisenhof
The overall goal was to support best practice around fluid restriction in care of the patient with heart failure.
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Healthy Eating & Shift Work
Lisa Kilgard
To provide knowledge and education to individuals who engage in shift work. Which may assist them in maintaining a healthier eating and lifestyle.
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Technology Decreases Treatment Decision Times
Angela Moscho
Patients who experience a stroke while hospitalized have a higher mortality rate than those who present to the emergency department. Our plan is to utilize technology to allow the stroke provider to evaluate the patient while in their hospital room, instead of waiting until the patient is in the CT scanner. Utilizing technology of an iPad for inpatient code strokes will allow for quicker assessment of the patient, resulting in faster treatment decision for this population.
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Research Makes a Difference: Changing Post Surgical Vital Signs
Elizabeth Plante, Sadie Seezs, Jennifer Burris, and Tiffany Omann-Bidinger
Research Question:
Are reduced frequency of vital signs as effective in identifying patient deterioration in postoperative adult orthopedic and spine patients after a post anesthesia care unit stay with transfer to orthopedic and neuroscience spine units when compared to current practice?
Conclusions/Implications:
- Changing the frequency of post operative vital signs provides the same quality, not directly affecting an increased risk of death.
- Reduction in number of times vital signs needed completion, saving time for nurses to complete other duties.
- System wide change to routine post operative vital signs for floor level patients was implemented.
- Recommend future research for obstetric and pediatric patient population
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Strategic Use of Storytelling as an Advocacy Skill for Social Justice in Nursing Practice
Theresa Reichert
The purpose of this practice project is to cultivate storytelling as a nursing skillset, preparing nurses as social justice advocates within nursing practice.
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Sticks and Stones May Break My Bones, But Words Can Hurt Me Too: Psychological Safety and Microaggressions
Theresa Reichert, Janelle Maciej, and Julia Vang
To foster a healthy work environment, address reports of microaggressions, and improve psychosocial safety within the SCH Telemetry team
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ICU CAUTI Incidence Reduction
Michelle Gamble
Situation:
Catheter-Associated Urinary Tract Infection (CAUTI) rates in the adult Intensive Care Unit (ICU) increased from nine infections in FY21 to 18 in FY22.
Backgroud:
CAUTIs are the most reported healthcare acquired infection. It is important for healthcare providers to understand the complications and effects of CAUTIs. CAUTIs contribute to extended length of stay, increased healthcare costs, and patient morbidity and mortality.
Most CAUTIs are directly related to inadequate urinary catheter care. Evidence based practice demonstrates a decrease in CAUTIs related to the use of Theraworx® Protect wipes twice daily (BID) and as needed (PRN) for patients with a urinary catheter.
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Safe Intra-Hospital Transport of Adult Patients on Non-Critical care Units
Teresa Jahn, Janelle Maciej, and Greta Titus
Plan:
Between 2021 and 2022, two non-critical adult patients returning from the imaging department after an invasive procedure developed increased oxygen needs, which ended in death for on patient and a transfer to critical care for the other.
No formal guidelines exist for the intra-hospital transport by unlicensed personnel may be absent. An intra-hospital transport checklist was developed for non-critical care patients leaving the unit for procedures in the imaging department.
Do:
- A "RN Pre-Invasive Procedure Transport Safety Checklist" was created by a telemetry RN (MSN student, Greta Titus) and CNS, Teresa Jahn
- The checklist was designed to answer questions to determine a patient's hemodynamic and respiratory stability prior to transport by an unlicensed person
- The checklist is to be completed prior to transport on all patients leaving the unit for a procedure in the imaging department (i.e. paracentesis, thoracentesis, biopsy, etc.)
- If one of the questions answered is "yes", the next step is to prompt a huddle with Resource RN or Charge RN to identify f a patient is safe for transport without a RN.
- The "why" for the change was presented by Greta Titus during the November 2022 CentraCare Heart and Vascular Center Clinical (CCHVC) Practice meeting
- Staff were also notified of this change during Telemetry daily huddles and weekly updates
- The trial started on Telemetry beginning 11/1/2022
- Follow up on the progress of the practice change was presented by CCHVC CNS during Telemetry Education Days in January-February 2023
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Clinical Nurse Specialists: A Rare Breed
Teresa Jahn, Evalyn Michira, and Elizabeth Plante
What is a CNS?:
- A clinical nurse specialist (CNS) is an advanced practice registered nurse (APRN) with graduate level education in nursing.
- CNSs are prepared to provided leadership, consultation, and clinical expertise for patients and their families, nurses, and systems.
- Have the autonomy to diagnose and treat based on advanced clinical assessment like other APRNs (Nurse practitioners, certified nurse midwives, certified registered nurse anesthetists).
- CNS work in all areas of healthcare like clinics, emergency departments, hospital units, entire healthcare systems, or even as independent practitioners/contractors.
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Recognition of Nonconclusive Seizures in Patients After Cardiac Arrest Using
Teresa Jahn and Elizabeth Plante
Background:
Evidence - Prevalence of nonconvulsive status epilepticus or other epileptiform activity in patients who are comatose after a cardiac arrest is between 12-22%. Consistent with the literature, at this facility approximately 12% were found to have non convulsive seizures. Prolonged epileptiform discharges may cause secondary brain injury and increased mortality. In 2020, the American Heart Association recommended EEG monitoring should be promptly performed and interpreted for the diagnosis of seizures in all comatose patients following cardiac arrest.
Local Problem - Comatose patients admitted to critical care after cardiac arrest who require targeted temperature management (TTM) have continuous EEG monitoring ordered STAT. Neurodiagnostic technologists who apply EEG monitoring are not available 24/7.
Conclusions/Implications:
- While the rapid EEG recording may have limitations compared to continuous recordings for diagnostic purposes, it has immediate feedback for monitoring of nonconvulsive status epilepticus.
- Continuous EEG monitoring can take 45 minutes to set up and much longer to obtain diagnosis of status epilepticus.
- Continuous EEGs have broader diagnostic capabilities, however, are not monitored continuously by neurology providers, which could delay the identification of seizure activity.
Recommendations:
- Continue immediate placement of rapid EEG if technologists are not available within one hour.
- Continue to replace rapid EEG with continuous EEG when technologist becomes available.
- Explore improved capabilities for more timely reading and diagnosis of continuous EEG.
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Sterile Tubing Changes to Prevent CLABSIs in the NICU
Rachel Janson and Megan Meyer
Purpose Statement:
NICU patients have a decreased risk of CLABSI infections when two-person sterile central line changes are implemented into central line maintenance bundles compared to bundles that only use one-person clean line change techniques.
Background:
Neonates admitted to the neonatal care intensive care unit (NICU) often require the placement of central lines for the administration of medications, fluids, parental nutrition, and hemodynamic monitoring. Despite their many advantages, central lines can lead to serious infections, known as cental line associated bloodstream infections (CLABSI). These infections are not related to an infection from another site and develop within forty-eight hours of removal. CLABSIs are a major contributor to morbidity and mortality in the NICU population and are costly to hospital systems. According to Mobley & Bizzarro, infants who develop CLABSIs can cost up to an additional $50,000 and add as many as ten days to their hospital stay when compared to other infants without CLABSIs (2017). An evidence-based approach that has shown to improve patient outcomes and reduce CLABSIs is the use of a bundle, which is utilized upon insertion and during maintenance of the central line. Based on the available research, the most common CLASBI bundle elements include: using maximum standard barrier precautions, using a specific skin preparation & line dressing protocol, daily central line need assessments, a two-person line change technique, specific education and training for staff, and quarterly audits (Payne et al., 2018). The St. Cloud Hospital NICU currently utilizes these practices expect for a two-person line change with sterile technique.
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Transitions to Normal Saline ONLY for CVADs
Megan Lehn and Ann Backes
Purpose Statement:
The purpose of this project is to implement a practice change throughout the system to remove heparin flushes for Central Venous Access Devices (CVADS) pending a successful pilot on Medical Oncology.
Synthesis of Evidence:
- Shama et al (2019) conducted a systematic review and meta-analysis including 886 participants that revealed no clear differences in CVC patency between heparin and NS.
- Klein et al (2018) conducted a pilot study on a 30-patient bone marrow transplant unit, each patient had a new CVC and were divided into two groups. Among 698 catheter-associated events overall incidence of central line issues were similar in both heparin and normal saline group.
- Egnatios & Gloria (2021) studies 37 patients receiving clinical trial infusions, they divided the study into two phases. During heparin phase there were 302 port accesses and four alteplase orders, during the NS study there was 261 accesses and seven alteplases orders. Alteplase was successful every time it was used.
- Zhong et al (2017) performed systematic [sic] review on use of heparin v. flushing protocols. Ten randomized control trials involving 7,785 participants were included in the meta-analysis. No general differences found between heparin v. NS in maintaining patency.
- Goossens et al (2013) oncology patients were randomly selected from 2009-2011. 382 were ultimately selected for normal saline group, and 283 for heparin group. All nurses were trained in proper pulsatile technique before study, it was found intimately heparin was not superior in comparison to NS in maintaining the patency of CVC.
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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
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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