Disease-Specific Patient-Reported Outcome Tool in Head and Neck Cancer Patients

Kathryn M. Campion, BSN, RN, CENBimbola F. Akintade, PhD, MBA, MHA, ACNP-BC, NEA-BC

Background

Purpose

Methods

Results Discussion

Conclusions

Acknowledgements

• Head and neck cancers (HNC) have a five-year survival rate of 62%• Effects of chemotherapy, radiation, and the disease can be

debilitating• Common side effects: dysphagia, dysgeusia, insomnia, nausea,

vomiting, fatigue, and mucositis• Patient reported outcome tools (PROs) provide a quantitative

measurement of symptoms• Can improve symptom management, communication, and

patient satisfaction• The Functional Assessment of Cancer Therapy: Head and Neck

Symptom Index (FACT: HNSI) is a validated and reliable HNC PRO

The purpose of this quality improvement project (QI) is to implement the FACT: HNSI PRO tool among dual modality HNC (DMHNC) patients in outpatients at a large, academic, urban hospital by December 1, 2019

Short-term goals:• Interview the team to assess barriers to use of the PRO tool• >65% of DMHNC patients completing the PRO tool each week• >65% of the HNC team referring to the PRO in progress notes

Desired long-term impact: decrease in DMHNC treatment deviations, unplanned admissions, ER visits, and oncology urgent care visits

Inclusion criteria:• All new adult DMHNC patients with access to patient portal• In weeks one to three of treatment as of October 1, 2019

Exclusion criteria:• Decline to participate, non-DMHNC, no access to patient portal

Implementation: October 1, 2019- December 1, 2019Structure change:

• Imbed FACT: HNSI into the patient portal• Interdepartmental approval, dedicated information technology

specialist, funding for expedited buildProcess changes:

• Patients completing PROs each week• Staff using dedicated smartphrase in weekly progress notes

Procedures:• Staff and patient education (verbal and written)• Pre- and post- implementation surveys to evaluate perceived

usefulness of the PRO tool and ease of use• Weekly audits to monitor staff/patient compliance• Chart audit on 20 encounters to evaluate staff’s consistency of

capturing symptoms from the FACT:HNSI before implementation

Eleven patients participated in the weekly PROs• Overall use of PRO by patients was 68.2%

Six HNC treatment staff participated in utilization of the designated smartphrase• Overall use of smartphrase by staff was 78.8%

68%

32%

Patient Compliance

Compliant

Non-compliant 79%

21%

Staff Compliance

Compliant

Non-compliant

Staff survey results revealed an overall view that PROs are beneficial, the FACT: HNSI was a useful tool, easy to use, and it did not extend the length of visits

012345

PROs arebeneficial.

FACT:HNSI isuseful in alerting of

symptoms.

PRO extends thelength of patient

visits/assessments.

Perceived ease ofuse.

Aver

age

Res

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=Stro

ngly

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e;

5= S

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ly A

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)

Survey Questions

Pre- and Post- Staff Survey Comparison

Pre- Implementation Average Post-Implementation Average

In the retrospective chart audit:• 46% of the symptoms listed in the FACT-HNSI were routinely captured by

the HNC treatment team in the six months before PRO implementation

Staff feedback: • Instances of smartphrase omission were unintentional

Patient feedback: • Helpful in communicating with team; discomfort with technology• Difficulty completing surveys with more severe side effects

Limitations:• English as a second language, illiteracy, no home computer and

smart devices limits widespread patient use• Small sample size and limited implementation time• Unverified PRO author may introduce bias

Lessons Learned:• Training staff to manually enter results can help mitigate barriers• Champions useful to maintain patient and staff compliance• Survey in the electronic health record facilitated use by patients

and staff

References

• This QI project achieved the short-term goals of >65% compliance for patient and staff participation during the nine-week implementation

• The chart audit revealed 46% of the FACT: HNSI symptoms were identified by staff in the six months prior to implementation. During implementation 100% of the symptoms were captured each time a PRO was completed by a patient and reviewed with a staff member

• Future QI projects: • Impact of the FACT: HSNI on unplanned admissions, emergency

department visits, and oncology urgent care visits long-term• Facilities treating outpatient HNC patients should incorporate the

FACT: HNSI to improve the detection of symptoms and patient and staff communication

Niska, J. R., Halyard, M. Y., Tan, A. D., Atherton, P. J., Patel, S. H., & Sloan, J. A. (2017). Electronic patient-reported outcomes and toxicities during radiotherapy for head-and-neck cancer. Quality of Life Research, 26, 1721- 1731. doi: 10.1007/s11136-017-1528-2

Peng, L. C., Hui, X., Cheng, Z., Bowers, M. R., Moore, J., Cecil, E., … & Quon, H. (2018). Prospective evaluation of patient reported swallow function with the Functional Assessment of Cancer Therapy (FACT), MD Anderson Dysphagia Inventory (MDADI) and the Sydney Swallow Questionnaire (SSQ) in head and neck cancer patients. Oral Oncology, 84, 25-30. https://doi.org/10.1016/j.oraloncology. 2018.05.0

◇ Dr. MiKaela Olsen ◇ Dr. Tanguy Lim-Seiwert◇ Mr. Benjamin Smith ◇ Implementation team◇ Skip Viragh staff

0 10 20 30 40 50 60 70 80

General pain

Swallowing

Trouble breathing

Nausea

Worry

% of Time Symptoms Present on Chart Audit

Sym

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ACT:

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SI

Retrospective Chart Audit

*Question three is phrased in the negative*

Integration of TeamSTEPPS Framework and Escape Room to Improve Teamwork and Collaboration

Suzanna Fitzpatrick, MS, CRNP; Dr. Hazel Jones-Parker, DNP, CRNP, AACRN;& Dr. Andrea Smith, MBA, DNP, CRNP

University of Maryland School of Nursing

Difficulty with communication and teamwork in a large adult emergency department has been identified and senior nursing leadership wanted to enhance collaboration and communication in their workplace. This DNP project leveraged the integration of TeamSTEPPS training and tools in an escape room setting in order to optimize team performance of a group of senior nurse leaders. • Currently, standard leadership courses, conferences and other

didactic learning methods are utilized for teamwork improvement. • Poor communication and team work can threaten patient safety• Escape rooms, live action, team-based exercises (Adams & Crawford,

2018), supplemented with TeamSTEPPS tools can assist in optimizing team performance, while keeping the participant engaged in a new learning environment and has been shown to improve leadership skills.

Problem Statement

An evidence-based Quality Improvement project at a large inner city Adult Emergency Room with senior clinical nurses aimed to:

• Improve communication and teamwork skills• Utilize an escape room as a training tactic• Assess escape room concept as a training tool

Goals: • Short Term: 4-6 members of the quality improvement team will

have completed TeamSTEPPS training and familiarization with escape room and exercise so they may train others on TeamSTEPPS utilizing the escape room tactic and team dynamics and leadership improvement for project sustainability.

• Long Term: All SCN Emergency Department nurses will change their leadership skills and improve team cohesiveness by completing an escape room and TeamSTEPPS course

Purpose

ResultsThis group of ED nurses completed 2 escape rooms and a TeamSTEPPS training and all agreed that an escape room can be a fun way to motivate while providing an effective team building activity. • This group of nurse leaders validated the integration of

TeamSTEPPS tools and strategies in an escape room setting• All participants voiced the experience was enjoyable and an

engaging way to learn while providing an effective team building activity.

• This small cohort, in line with the literature, demonstrates that new methods of learning such as an escape room should be explored for engaging participants and improving communication and teamwork skills.

Limitations: • Small sample size• Time constraints• Varying escape room exercises• Lack of demographics• Not all survey questions were answered by all participants

Further recommendations:• Larger sample size • Dedicated time for TeamSTEPPS training and strategies

Discussion

Escape rooms can be a dynamic and interactive way to promote team training and education. Integration of TeamSTEPPS tools and strategies within the escape room framework provides for an engaging learning environment where participants can deepen their understanding of concepts through active learning. While this was just a small sample in one intercity hospital, new methods for learning should be reviewed for successful teamwork

Conclusions

Study Design• 14-week Quality Improvement Project

Guided by MAP-IT Framework Includes Observation at staff meetings Weekly check-ins with manager and assistant manager Escape room exercise with TeamSTEPPS training completion of

perceptions tools Weekly education on teamwork via email following escape room

• Completion of pre/ post-escape room toolsSample• 12 senior clinical nurse (n=12)

1- less than 1 year SCN experience 5 – 1-4 years SCN experience 6- greater than 4 years SCN experience

• Including 1 nurse manager• Including 1 assistant nurse manager

11 female: 1 male

Methods

• Adams, V., Burger, S., Crawford, K., & Setter, R. (2018). Can you escape? Creating an Escape Room to facilitate active learning. Journal for Nurses in Professional Development 34 (2). E1-E5. doi:10.1097/NND.0000000000000433.

• Sheppard, F., Williams, M., & Klein, V. (2013) TeamSTEPPS and patient safety in healthcare. Risk Management. 32(3); 5-10. doi: 10.1002/jmrm.21099.

• Yi, Y. (2015). Effects of team-building on communication and teamwork among nursing students. International council of nurses. 63 (1) 33-40. doi: 10.111/inr.12224.

References

Figure 1: Feedback Results

Figure 2: Perceptions Tool Results

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Total Feedback During Project

Negative Written Feedback Positive Documented Feedback

Perceptions Category Before Intervention After Intervention Score Change

Team Structure 3.39 3.76 0.37

Leadership 3.86 4.22 0.36

Situational Monitoring 3.27 3.72 0.45

Mutual Support 3.75 3.73 -0.02

Communication 3.5 3.82 0.32

Standard Deviation 0.163535929

p= 0.0111

Figure 3 : Observation Tool Results

Observational Category Before Intervention After Intervention Score Change

Team Structure 11 12.5 1.5

Communication 9.5 15.5 6

Leadership 15.5 24 8.5

Situational Monitoring 14.5 19 17.5

Mutual Support 9.5 15.5 6

Standard Deviation 6.73764301

p=0.004933

1. Ajzen I. (1985) From Intentions to Actions: A Theory of Planned Behavior. In: Kuhl J., Beckmann J. (eds) Action Control. SSSP Springer Series in Social Psychology. Springer, Berlin, Heidelberg

2. American Academy of Pediatrics. (2014). Addressing adverse childhood experiences and other types of trauma in the primary care setting. American Academy of Pediatrics.

3. Purewal, S. K., Bucci, M., Wang, L. G., Koita, K., Marques, S. S., Oh, D., & Harris, N. B. (2016). Screening for adverse childhood experiences in an integrated pediatric care model. Zero to Three, 36(3), 10-17.

• Training was effective in increasing stakeholder knowledge, ability, and value towards screening for ACEs

• Results support that an ACEs screening program using the CYW ACE-Q screening tools is an effective strategy for pediatric primary care providers to identify and refer children at high risk for mental and physical illnesses to MHS

• Underscreening attributed to patient/caregiver factors or workflow constraints

• Under-referral attributed to provider oversight or unfamiliarity with procedure

• Failure to make referral appointment suggests gap in obtaining mental health care after referral

• Low overall need for referral reflects high sociodemographic of practice site, supports tool reliability and the current literature

• Barriers and Limitations: • Limited generalizability of findings• Sensitive nature of screening subject• Non-electronic format• Completed screens not being seen by the provider

Adverse Childhood Experiences (ACEs) are stressful or traumatic events experienced before age 18 years old that correlate with increased risk for poor physical, mental, and behavioral health outcomes• 50-60% of children have >1 ACE and over 25% have >3

ACEs• ACEs cross all demographics and socioeconomic strata• There is a graded relationship between number of ACEs

and risk for physical and mental illness• Screening for ACEs allows for early identification and

referral to mental health services (MHS) to reduce risk for poor physical and mental health outcomes

Background

To evaluate implementation of an ACEs Screening Program in a pediatric primary care practice to identify and refer children at high risk for mental illnessShort-term Goals• Increase staff and health care provider’s knowledge,

ability, and value for ACEs screening• Screen >25% of eligible patients at the project site during

the first month of implementationLong-term Goal• Screen >80% of eligible patients at the project site by

project end• Refer 100% of positive-screening patients to MHS by

project end

Purpose Statement and Goals Results

Discussion

Conclusions

• Ajzen’s Theory of Planned Behavior guided the Quality Improvement project in a privately-owned pediatric primary care practice in N.W. Washington, D.C.

• Target Sample: Caregivers of patients ages 8-18 years old and patients ages 13-18 years old presenting for well visits or consults

Pre-Intervention• Pre-Implementation chart audits to collect baseline data

on documented ACEs and referrals to mental health care• Training session to educate all staff and health care

providers on ACEs and the upcoming Screening ProgramIntervention• ACEs Screening Tool completed by guardian or patient at

time of check-in for scheduled primary care appointment• ACEs Screening results reviewed with health care

provider during visit• Patients with a positive screen referred by health care

provider to MHS• Follow up phone calls by nurses to all referred patients 60

days after referral to see if MHS appointment obtained

Methods

References

Screening for Adverse Childhood Experiences in Pediatric Primary Care

Sarah M. Gross, BSN, RN & Renee Franquiz, DNP, RN, CNE University of Maryland School of Nursing

• This project demonstrated that successful implementation of an ACEs screening program in the pediatric primary care setting is feasible and valued by health care providers

• Data supports the CYW ACE-Q screening tools as accurate and reliable for detecting ACEs as the first step in the mental health care continuum

• Gaps exist in continuity of care as evidenced by limited patient follow-up with mental health services after referral

• Future initiatives recommended to improve use of tool’s symptom criteria, referrals, and referred patient follow-up with MHS. Ideas for strengthening include using an electronic tool, robust tracking after referral, and expanding the population demographic

Median

Goal

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100.00

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Week 9

Week 10

Week 11

Week 12

Week 13

Percentage of Eligible Patients Screened for ACEsPercentage of Completed ACEs Screens

25%

50%

80%

71%

MeasuresStakeholder Knowledge-Skill-Attitude Survey of ACEs Screening:• 8 item Likert, student developed, anonymous survey, administered electronically

pre, mid, and post-implementationACEs Screening Tool- Center for Youth Wellness Adverse Childhood Experiences Questionnaires (CYW ACE-Q):• Age-dependent, 17-19 item, yes/no, aggregate-level validated screening tool• Higher score equates with higher risk of health and social problems• Three Versions: Child or Teen Caregiver Report and Teen Self-Report Project Tracking/Audit Tool• ACEs Screening Audit Tool and Referral Follow-Up Tracking Tool• Weekly tracking of progress to goals

ACEs Screening Program Outcomes

Post-Implementation Stakeholder Survey n %“Agree” or ”Strongly Agree” Responses: Screening Program is Feasible 8* 88%Desire to Continue ACEs Screening Program 8* 100%

Screening ResultsScreens Distributed to Eligible Patients 245/325 75%Screens Completed 232/325 71%Positive Screens• Currently under MHS• Referred for MHS

32/23226/32 4/6

14%81%66%

Referral Follow-Up with MHS 1/4 25%Note. *= 8 stakeholders completed surveys out of 12 total stakeholders; MHS= Mental Health Services

Special thanks to Jessica Long, M.D. (Clinical Site Representative) and Angel Jackson (Project Champion) for their continued support and guidance through this project

• Primary care practice in rural Maryland county reported high rates of alcohol or drug use disorders

• County drug related overdoses: 2016=412; 2017=510• Practice lacked screening tools and referral resources• SBIRT is a comprehensive early intervention approach that

includes universal substance screening and appropriate interventions to help patients reduce substance-related risks

Background Results

• Monitor missed screening opportunities • Acknowledge staffing issues and time constraints • Use validated screening tools • Facilitate team approach • Foster organizational leadership and physician involvement• Increase knowledge of alcohol and drug use• Reduce stigma of addiction

Practice Recommendations

Short Term Goals:• Universal screening of at least 80% of eligible patients; • 100% of all individuals with a positive screen will receive

either a Brief Intervention or a Referral to TreatmentLong Term Goals:• Improved rates of treatment referrals• Improved rates of treatment completion • Reduction of substance-related risks

Objectives

Evidence Table/Selected Results

Aldridge, A., Linford, R., & Bray, J. (2015). Substance use outcomes of patients served by a large US implementation of screening, brief intervention, and referral to treatment (SBIRT). Addiction. 112(2), 43-53. doi:10.1111/ass.13651

Gryczynski, J., Mitchell, G.S., Peterson, T.R., Gonzales, A., Moseley, A., & Schwartz, R.P. (2011). The relationship between services delivered and substance use outcomes in New Mexico’s screening, brief intervention, referral and treatment (SBIRT) initiative. Drug and Alcohol Dependence. 118,152-157. doi:10.1016/j.drugalcdep.2011.03.012

Moyer, V.A. & U.S. Preventive Services Task Force (2013). Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. Preventive Services Task Force recommendation. Annals of Internal Medicine.159, 210-218.

References

• Practice Question: • Can SBIRT be implemented feasibly and effectively within

a small, rural Maryland primary care practice?• Population: Adults 18 years old and older• Search Platform: PubMed and the Cumulative Index of

Nursing and Allied Health Literature • Keywords searched: “substance use screening”; “SBIRT in

primary care”; “screening brief intervention and referral to treatment in primary care”

• Appraisal of level & quality of evidence: Johns Hopkins Nursing Evidence-based Practice Rating Scale (Newhouse, et al., 2006)

• Project Development: Seven Steps of Evidence-based Practice Model (Melnyk & Fineout-Overholt, 2011)

• Project Implementation: Mobilize, Assess, Plan, Implement and Track (MAP-IT) Framework

• SBIRT Instruments:• Alcohol Pre-Screen: 3-item Alcohol Use Disorders

Identification Test (AUDIT-C)• Alcohol Full Screen: 10-item full AUDIT• Drug Screen: Single Drug Question• Readiness to Change: Readiness Ruler

EBP Model & Appraisal Methods

Substance Screening, Brief Intervention, and Referral to Treatment in Rural Primary Care

Kabrina Johnson, MS, AGNP-CKatherine Fornili, DNP, MPH, RN, CARN, FIAAN

82.3%

14.7%0.0% 2.9%

0%10%20%30%40%50%60%70%80%90%

Level I (Low risk orabstainers; AUDIT

score= 0-7)

Level II (Moderate Risk;AUDIT score=8-15)

Level III (High Risk;AUDIT score 16-20)

Level IV (Very High Risk;AUDIT score= >20)

Perc

enta

ge o

f Pat

ient

s

Level of Alcoholism Risk

Full Alcohol Use Disorders Identification Test (AUDIT) Scores

Table 1. Statistical Analysis: Relationship between Gender and Screening ResultsNote: *= Fisher’s Exact test; **= Chi Square Test; p<0.05= significant

• 290 eligible patients seen over 10 weeks• Received Pre-Screen: n=199 (68.6%) • Of all screened, most were low risk or abstainers: n=28 (82.3%)• Positive Pre-Screen: n=38 patients (19.1%)

• Brief Intervention for alcohol misuse (n=6, 15.7%) • Referral to Treatment for probable alcohol dependence (n=1, 2.6%).

• Significant gender differences among those with positive screens (Table 1)• All with a positive drug screen (n=4, 2.0 %) received a Brief Intervention• Low rates of screening may be due to short duration of implementation,

low patient census, busy clinic days, and staffing issues

Authors Study Objective Design Sample (N) Outcomes studied Results *Level and

Quality Rating

Aldridge, Linford, & Bray, 2017

To assess substance use behaviors of patient who received SBIRT services.

Pre-post comparison of outcomes within individual patients screened and recommend-ed to one of the screen-positive categories. (intention-to-treat)

Sample consisted of 17,575 randomly selected adult patients

Substance misuse data, pre- and post-SBIRT services

Statistically significant decreases for most substance use measures (p=<0.01). Patients who consumed alcohol, drank 1.8 fewer days at follow-up. Greater intervention intensity was associated with larger decreases in substance use. Brief intervention patients decreased days of drinking by 1.0, compared to 2.2 for brief therapy patients, and 4.7 for referral to treatment patients. Number of days of consuming alcohol and illicit drugs increased slightly in the brief intervention group and decreased 0.6 days in the brief therapy group (p<0.1).

II, B

Gryczynski, Mitchell, Peterson, Gonzales, Moseley, & Schwartz 2011

To assess the relationship between unhealthy substance use outcomes and service variables within SBIRT implementation.

Quasi-Experimentalnaturalistic pre–post services study

55,000 adult patients systemically screened for substance misuse, (n=1208) received SBIRT services

Administrative services record and the Government Performance and Results Act (GPRA) Questionnaire at Baseline and 6 months post intervention

Significant decrease in the participant’s frequency of illicit drug and alcohol use six months after receiving SBIRT services (p<.001 for each). Participants who received brief therapy and referral to treatment has higher reductions in alcohol use and intoxication (p<.05 for each). The number of brief intervention sessions were linked to decrease frequency of alcohol use (p<.01) and alcohol intoxication (p< .05)

IV, B

Moyer & U.S. Preventive Services Task Force, 2013

To provide recommendations on screening and behavioral interventions in primary care for alcohol misuse

Clinical Practice Guideline

RCT Trials, meta-analysis, systematic reviews

23 RCTs-Compared effects of behavioral counseling interventions with usual care.Meta-analysis and systematic reviews measures adults screening detected alcohol misuse drinking habits

Brief counseling interventions in adults with screening-detected alcohol misuse positively affect several unhealthy drinking behaviors in the primary care setting (P = 0.04)Unhealthy, risky alcohol misuse includes consuming more than 4 drinks/day or 14 drinks weekly for men and 3 drinks/day or 7 drinks weekly for women and a pattern of drinking that leads to damage to physical to mental healthProject TrEAT (N=774). Reported a statistically significant difference in hospital days in the last 6 months for the intervention group compared with the control group at 6, 12, and 48 months (35 vs. 180, 91 vs. 146, and 420 vs. 664, p<0.001, p<0.001, and p<0.05)

I,A

*Not all studies included in Evidence Table

Relationship Male Female p valueGender and Positive Drug Prescreen Results

Drug Screen PositiveDrug Screen Negative

459

0136 p=0.0094*

Gender and Alcohol Prescreen Results (AUDIT-C)Alcohol Prescreen PositiveAlcohol Prescreen Negative

2241

12124 p<0.001**

Gender and Full AUDIT Results Level I (0-7)Level II-1V (8- >20)

594

1342 p=0.061205*

Contact Information: Kabrina Johnson- kjohnso3@umaryland.eduKatherine Fornili- fornili@umaryland.edu

Following ZapVAP implementation:• Staff met/exceeded 80% adherence 11 weeks in a row, after Week 4.• VAP rate decreased from 6:1000 VD to 0:1000 VD. • Total number of sputum cultures decreased 16%.• Positive sputum cultures decreased 30%, with a 58% decrease in the

sputum rate.• An appreciable change in sputum organism noted:

• 2018: S. aureus, K. pneumoniae, E. coli• 2019: M. catarrhalis, H. influenzae, S. aureus

An interdisciplinary, evidence-based, VAP bundle can improve care and is effective in reducing VAP rates.

• A ZERO VAP rate is attainable and best achieved by bedside interventions that prevent infection, most importantly effective oral care and standardized equipment rotation.

• Outcome findings are consistent with prior evidence that support ZapVAP as a means to improve care and patient outcomes.

• Limitations include inability to control for alternative explanations or outcomes.

• Given the low patient risk and cost/benefit analysis, ZapVAP is recommended as a feasible, high-value practice change.

This Nursing and Respiratory Therapy (RT) quality improvement project, implements ZapVAP in a 19-bed Pediatric Intensive Care Unit (PICU) in an urban, academic medical center.

• Introduction: Team Mobilization • Registered Nurses (RN), RTs, nurse assistants (NA), medicine,

pharmacy, infectious disease receive presentation of ZapVAP• Preparation: Education and Resource Mobilization

• Education competency• Post-test validation for RNs, RTs, & NAs

• 100% of bundle supplies obtained• Pre-Implementation: roll-out of one bundle component/week

• Bedside audits introduced by RN/RT champions• Ineffective oral care – algorithm developed to improve

effectiveness of oral care with tooth brushing• Full Implementation: all bundle components implemented

• Bedside, observational audits of bundle adherence tracked daily by RN/RT champions

• Real-time feedback given at bedside• RN/RT monthly lottery with prizes for ZapVAP adherence

• Bi-weekly stakeholder communication of outcomes

Lauren Manrai, BSN, RN, CCRN & Renee Franquiz, DNP, RN, CNE

Ventilator-Associated Pneumonia (VAP) is the development of pneumonia 48 hours after endotracheal intubation.

• VAP increases morbidity and mortality due to prolonged ventilator dependence that increases length of stay.

Evidence supports bundles as a means to reduce VAP • Oral care, suctioning techniques, equipment management,

positioning with head of bed elevation, and hand hygieneNational VAP benchmark is 1.8 per 1000 ventilator days (National Health and Safety Network).• Project site VAP rate in 2018, was 6 per 1000 ventilator days (VD).

BACKGROUND

RESULTS

DISCUSSION AND CONCLUSIONS

.

To develop, implement, and evaluate a VAP bundle, called ZapVAP, that improves bedside care and decreases the VAP rate.Short term goal:

• Exceed 80% adherence with ZapVAP.• Reduce the sputum rate by 50% after ZapVAP implementation.

Long term goal: • Reduce VAP rate below the National benchmark of 1.8 per 1000 VD.

PURPOSE

MEASURES

REFERENCESMETHODS

ACKNOWLEDGEMENTS

American Associated for Respiratory Care [AARC]. (2010). Endotracheal suctioning of mechanically ventilated patients with artificial airways. Respiratory Care, 55(6), 758-764. Klompas, M., Branson, R., Eichenwald, E., Greene, L., Howell, M., Lee, G., … Berenholtz, S. (2014). Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology, 35(8). doi:10.1086/677144McBeth, C., Montes, R., Powne, A., North, S., Natale, J. (2018). Interprofessional approach to the sustained reduction in ventilator-associated pneumonia in a pediatric intensive care unit. Critical Care Nurse, 38(6), 36-45.

ZapVAP Adherence:• Audit Tool measured adherence (one tool per bed; scored yes/no)• Adherence achieved when all ZapVAP components were met

VAP Rate:• VAP = ICD-10 VAP diagnosis tracked in 2018/2019 and used to

calculate a VAP rate. VAP Rate per 1000 VD = (VAP/VD) x 1000

Sputum Rate:• Sputum cultures (SC) tracked during pre/post intervention period

and scored positive/negative• Sputum Rate per 1000 VD = [(Positive sputum cultures that

occurred >48 hours after intubation)/VD] x 1000

Thank you: Adrian Holloway, MD, Mary Jo Simke, MS, BSN, RN, Greg Ludvik MS, RRT-NPS, Helen Felps, MSN, RN, Jennifer Arrington, MS, RN, CPN, CNL, Mary Ellen Connolly, DNP, CRNPChampions: Sarah Branigan, MSN, RN, Robby Guanzon, RRT, Sara Hartropp, BSN, RN, Melanie Hershberger BSN, RN, CCRN, Kelly Ho, BSN, RN, Kristin Lewis, BSN, RN, CCRN,Katie Martin BS, RRT-NPS, Brittany O’Branski, BS, RRT-NPS, Megan Tuma BSN, RN, Carl Wikerson, AS, CRT, & Karen Wockenfuss, RRT-ACCS

Equipment Maintenance:98.7%

FINAL ZapVAP ADHERENCE

PreZapVAP

(Sept-Dec) 2018

PostZapVAP

(Sept-Dec) 2019

Result

VentilatedPatients (N) 66 90 +36%

Total SC (N) 69 58 -16%Positive SC (N) 27 19 -30%

Positive SC>48 hours (N) 14 3 -79%

VD (N) 681 345 -50%

Sputum Rate 20.6 8.7 -58%

2018 2019VAP ICD-10 (N) 11 0

VD (N) 1830 1496VAP Rate 6 0

HOB & Positioning:98.6%

Oral Care: 95%

Hand Hygiene: 100%

Suctioning Techniques:95%

30%

48%

77%72%

83% 83%

93%

86%

79%

90%93% 94%

83%

97%

83%

0%

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100%

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12 Week 13 Week 14 Week 15

PER

CEN

TAG

E

IMPLEMENTATION OVER 15 WEEKS

ZapVAP PERFORMANCE

Goal >80%

Circled items checked with daily audit

• In the United States:o Pacemakers: ~ 3 million patients o Implantable Cardioverter Defibrillators (ICD): ~300,000 patientso New CIED implantation: ~ 1 million patients yearlyo 2% of patients with CIEDs eventually undergo subsequent

surgical procedures.• Intraoperative significance to anesthesia:

• Electromagnetic interference (EMI): o Pacemaker = inhibition of pacing.o ICD = untimely delivery of anti-tachycardia therapy.

• This facility lacks a:• Clinical Practice Guideline (CPG) for anesthesia care.• Cardiology-led CIED team to interrogate the CIED and estimate

the battery life. The recommended interrogation schedule:o Pacemaker: ~ 1 year prior to surgeryo ICD: ~ 6 months prior to surgeryo Battery Life of < 3months = risk of CIED pulse generator

damage from EMI.

Problem Statement

• The purpose of this quality improvement (QI) project is to develop an evidence-based CPG for intraoperative anesthesia care of surgical patients with CIEDs.

• Short-term goal:o By October 31, 2019 all the anesthesia providers would be

educated on the approved CPG. • Long-term goal:

o By March 31, 2020, 90% of surgical patients with an implantable device will have a completed intraoperative documentation showing utilization of the approved CPG.

Purpose and Goals

Methods

Results

• PFQ: ~80% (30 out of 37) were collected post CPG presentation. Demographic data indicated: 47% CRNAs, 27% Anesthesiologist, 26% SRNAs.

• Evidence Limitations: Due to the limited amount of level 1 studies available, four Professional Societies including The American Society for Anesthesiologists, The Heart Rhythm Society, the Canadian Anesthesiologists’ Society and the Canadian Cardiovascular Society have developed the Perioperative advisories for this patient population.

• Strength: CPG was approved as policy by the chief anesthesiologist. Documentation section for CIED care already present on pre-existing electronic health record.

• Practice Implications: o This facility still lacks a Cardiology-led CIED Team

readily available for CIED interrogation for both routine and emergency surgeries.

Discussion

• The CPG created was successfully adopted by the anesthesia department as a standard of practice on January 28, 2020.

• Implementation of the approved CPG by anesthesia providers during intraoperative care will be paramount to patient safety.

• Sustainability:o A Unit Champion is essential to complete

quarterly chart audits, regular anesthesia staff interviews, track patient outcomes.

o Future QI projects should investigate the feasibility of a Cardiology-led CIED Team.

Conclusions

CPG Recommendations

• Setting: A Level II Trauma Hospital in Baltimore, Maryland. • Sample (N=37): Anesthesiologists, CRNAs, SRNAs.• CPG Development:

o Phase I: IRB Approval and Expert Panel: 2 CRNAs, 1 Anesthesiologist, and 1 Cardiac Electrophysiologist.

o Phase II: AGREE II Tool – completed by the expert panelo assess for reliability and quality of CPG.

o Phase III: Practitioner Feedback Questionnaire (PFQ)o assess for applicability of the CPG,o completed by the Anesthesia Providers during ground rounds on October 31,

2019.

Intraoperative Anesthesia Care of Patients with Cardiovascular Implantable Electronic Devices

Chioma Nwankwo, BSN, RN Faculty Advisor: Veronica Gutchell, DNP, RN, CNS, CRNP

References• Crossley, G.H., Poole, J.E., Rozner, M.A., Asirvatham, S, J., Cheng, A.,

Chung, M.K…Thompson, A. (2011). The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert consensus statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and patient management. Heart Rhythm Society, 8(7), 1114-1154. Doi: 10.1016/j.hrthm.2010.12.023

• Gifford, J., Larimer, K., Thomas, C., & May, P. (2017). ICD-ON Registry for Perioperative Management of CIEDs: Most Require No Change. Pacing and Clinical Electrophysiology: PACE, 40(2), 128–134.https://doi.org/10.1111/pace.12990

• Intraoperative Recommendations:o Magnet available to switch CIED to asynchronous mode.o Bipolar electrocautery preferred for surgeries.o Positioning should allow for optimized surgical exposure and

CIED management.o High risk patients (surgery location within 6 inches of device):

o external pacer,o defibrillation pads attached, o arterial pressure monitoring.

CPG Recommendations

50.00%

23.30%

6.70%0%

6.70%

13.30%

0-5 years 5-10 years 10-15 years 15-20 years 20-25 years >25years

Anesthesia Staff Years of Experience

Gifford et al., 2017

Implementation of Cognitive Stimulation Therapy in Long Term Care Claire Regan, BSN, RN

Karen Yarbrough, DNP, ACNP-BC, CRNPGloria Lay, MSN, BSN, RN

University of Maryland School of Nursing

• Psychotropic medications are frequently prescribed to older adults with dementia to manage behaviors despite harmful side effects

• 40% of residents at selected facility prescribed at least one psychotropic

• Cognitive Stimulation Therapy (CST) is a non-pharmacological intervention for individuals with dementia that may improve quality of life, cognition, and reduce behaviors

Problem Statement

• Implement a CST program to:• Improve quality of life and cognition• Reduce behaviors and psychotropic drug use

• Short term goals:• 100% attendance and participation from all

enrolled residents• Barriers to attendance and participation identified

• Long-term goals:• Modest increase of 15% or maintenance of quality

of life and cognitive functioning scores• Decrease of 50% in frequency of behaviors and

psychotropic use• Achieve sustainability for program

Methods

Results

• One resident excluded due to death• Variance in attendance of sessions• Time constraints resulted in inability to incorporate

exercises during sessions• Challenges with differing auditory and cognitive ability• Evidence to show decreases in rates of depression• Most significant effects on promotion of language

function and orientation in the literature• Executive function plus extrapolation most affected in

this project• Observation of increased sustained socialization of

residents when not participating in CST

Discussion

• CST improves cognitive functioning• CST may be correlated with improving quality of life for

some residents• Additional research is needed to further investigate the

effect CST has on socialization of residents

Conclusions

Berg-Weger, M. & Stewart, D. (2017). Non-pharmacologic interventions for persons with dementia. Missouri Medicine, 114(2), 116-119.Folkerts, A., Roheger, M., Franklin, J., Middelstadt, J. & Kalbe, E. (2017). Cognitive interventions in patients with dementia living in long-term care facilities: systematic review and meta-analysis. Archives of Gerontology and Geriatrics, 73, 204-221.Spector, A., Orrell, M & Woods, B. (2010). Cognitive stimulation therapy: effects on different areas of cognitive function for people with dementia. Geriatric Psychiatry, 25, 1253-1258. Stewart, D., Berg-Weger, M., Tebb, S., Sakamoto, M., Roselle, K…& Hayden, D. (2017). Making a difference: a study of cognitive stimulation therapy for persons with dementia. Journal of Gerontological Social Work, 60(4), 300-312.

References

• 200 bed long term care facility in Baltimore City• Nine residents selected

• Mild to moderate dementia• Can participate in meaningful conversation• Prescribed a psychotropic medication

• CST sessions: twice a week , 45 minutes, 7 weeks• cognitive stimulation, reality orientation, reminiscence therapy, and

validation therapy• Weekly staff education about behavioral charting• Pre and Post Testing

• St. Louis University Mental Status Exam • Quality of Life in Alzheimer’s Disease Scale• Medication administration record audit • Behavioral chart audit

Purpose and Goals

Psychotropic Use in Selected Facility Pre Implementation Antidepressants

Antipsychotics

Anxiolytics

Sedative/Hypnotic

0

5

10

15

20

25

3026

1716

18

13

18

14

12

28

22

19

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SLUMS Scores Pre and Post Implementation

05

101520253035404550

26

3537

20

32 31

39

46

24

35

41

26

36 36

28

46QOL Scores Pre and Post

Implementation

• Average increase in SLUMS scores of 19%• Average increase in quality of life scores of 12% for six participants and

decrease of 20% for two participants• Psychotropic medication use remained 100%

Clock Drawing Pre and Post CST Program Participation

Background

Setting & Population: CPG to be utilized by anesthesia providers when guiding perioperative anesthetic decisions. Subjects include high-risk surgical patients (identified through preoperative screening or patients with baseline cognitive dysfunction) at a hospital in Baltimore, MD specializing in orthopedic surgery. CPG Development:

• CPG recommendations synthesized from recent literature published within ten years including: meta-analysis, systemic reviews, randomized controlled trials (RCTs), and current perioperative recommendations published by the American College of Surgeons & American Geriatric Society

• CPG draft revisions based on AGREE II Tool feedback by key stakeholders• AGREE II Tool critiques the CPG for methodology of development based on

6 Domains (Figure 1)CPG Presentation & Evaluation:

• Presentation to Anesthesia Department with solicitation of Practitioner Feedback Questionnaires (PFQ)

• PFQs assess CPG for quality, acceptability, applicability, and comparative improvement to current practice (Figure 2)

Results

Anesthetic Prevention Interventions for Postoperative Cognitive Impairment

Natalie Leikus Taylor, BSN, RNUnder the Supervision of Joseph Pellegrini, PhD, CRNA, FAAN & Natasha Hopkins, DNP, CRNA

Doctor of Nursing Practice Project University of Maryland School of Nursing

Postoperative Cognitive Impairment (PCI) includes:• Postoperative Delirium (POD): An acute and fluctuating change affecting a

patients cognition and ability to concentrate. • Incidence: 50% of elderly patients after orthopedic and emergency

surgeries• Postoperative Cognitive Dysfunction (POCD): A delayed onset resulting in

changes to memory and information processing. • Incidence: 40% of elderly patients after general anesthesia

Short-term goals: Development of a Clinical Practice Guideline outlining anesthetic prevention interventions for PCI & CPG presentation to anesthesia hospital staffLong-term goal: Perioperative CPG institutional acceptance & decreased incidence of PCI at a mid-sized community hospital in Baltimore, Maryland

Intraoperative• Bispectral Index (BIS) monitoring to minimize anesthesia depth• Dexmedetomidine administration• Minimize Volatile Agents- TIVA/Regional • Avoid/Minimize Benzodiazepines• Adequate Pain Control

Postoperative• Cognitive Reorientation- presence of family members • Early return of visual and hearing aids • Maintain oxygenation and pain control • Early mobility and physical rehabilitation • Nutrition and fluid repletion

AGREE II Tool (Figure 1)• Over 88% positive feedback within 5 responses by key stakeholders across

all 6 domains demonstrates CPG quality regarding scope, content, and development

Practitioner Feedback Questionnaire (Figure 2)• 37% (n=13) of hospital anesthesia staff polled (CRNAs & Anesthesiologists)• Overall positive feedback and agreement of 70% (SD=19.1)• Strong CPG Quality (88% positive) and CPG Acceptance (73% Positive) • Mixed opinions regarding CPG Applicability: Positive Response (35%) and

Neutral Response (38%) and Negative Response (27%)

• Key stakeholders regard CPG recommendations as clinically relevant for management of HIGH-RISK patients in minimizing postoperative cognitive impairment.

• Anesthesia providers (n=13) at this Baltimore hospital demonstrate reluctance in applicability of CPG content.

• Further education may enhance anesthesia staff buy-in prior to future CPG implementation.

• Limitations:• Small sample size (n=13) provided data for PFQ analysis• Available Evidence: Limited number of RCTs have been conducted in the

operating room setting concerning benzodiazepine and narcotic usage in the elderly.

• Outcomes: Based upon quality and applicability of CPG and not quantitative clinical outcomes regarding incidence of postoperative cognitive impairment.

Problem & Purpose

Methods

CPG Recommendations

Conclusion & Limitations

ReferencesDiscussion

• American College of Surgeons & American Geriatrics Society. (2016). Optimal perioperative management of the geriatric patient: Best practices guideline from ACS NSQIP/American geriatrics society.

• American Geriatrics Society Abstracted clinical practice guideline for postoperative delirium in older adults. (2015). Journal of the American Geriatrics Society, 63(1), 142–150.

• Punjasawadwong, Y. (2018). Processed electroencephalogram and evoked potential techniques for amelioration of postoperative delirium and cognitive dysfunction following non-cardiac and non-neurosurgical procedures in adults. Cochrane Database of Systematic Reviews, (10).

• Zhou, C., Zhu, Y., Liu, Z., & Ruan, L. (2016). Effect of dexmedetomidine on postoperative cognitive dysfunction in elderly patients after general anaesthesia: A meta-analysis. The Journal Of International Medical Research, 44(6), 1182–1190.

Figure 1

Figure 2

DNP Project Goals

Consequences of Postoperative Cognitive Impairment:• Loss of independence• Increased mortality rates • Increased costs for both patients and providers

Purpose: The purpose of this DNP project was to identify evidence-based anesthetic interventions to be included in a clinical practice guideline (CPG) that outlines preoperative screening and perioperative anesthetic management of patients >65 in order to decrease the incidence of postoperative cognitive impairment.

➢ Allergen immunotherapy: (AIT, “allergy shots”)

▪ Sub-q injections in treatment (Tx) of allergies/allergic asthma▪ Tx goal: de-sensitize patient (Pt) to allergens & reduce symptoms

➢ AIT guidelines recommend:

▪ Monitoring Pt symptoms, Tx tolerance & efficacy:▪ Monthly Pt questionnaires▪ Allergist follow-up every 6 — 12 months

➢ Problem: Poor Pt follow-up during AIT → unknown Tx outcomes & potential sub-optimal care

▪ Baseline Pt data: 42.4% (n=32) overdue for follow-up (F/U)▪ Days since F/U: mean: 581, median: 261, range: 5 — 4165

Background & Problem

➢ Purpose & Long-term Goal: Improve AIT Tx safety and efficacy by

improving routine assessment and F/U utilizing a screening tool

➢ Process Measures & Short-term Goals:

1. Screening completion▪ Goal: 100% screening every 4 — 6 weeks

2. Positive screenings (indicating a need for F/U)3. Follow-up appointments scheduled (for positive screenings)

▪ Goal: 100% follow-up

Results

▪ Cox, L., Nelson, H., Lockey, R., Calabria, C., Chacko, T., Finegold, I., . . . Blessing-Moore, J. (2011). Allergen immunotherapy: A practice parameter third update. Journal of Allergy and Clinical Immunology,127(1).

▪ Cox, L., Esch, R. E., Corbett, M., Hankin, C., Nelson, M., & Plunkett, G. (2011). Allergen immunotherapy practice in the United States: Guidelines, measures, and outcomes. Annals of Allergy, Asthma & Immunology,107(4), 289-299.

▪ Lee, S., Stachler, R. J., & Ferguson, B. J. (2014). Defining quality metrics and improving safety and outcome in allergy care. International Forum of Allergy& Rhinology, 4(4), 284-291.

Improving Allergen Immunotherapy Assessmentand Follow-up Utilizing a Screening Tool

Ashley Witt, BSN, RN; Karen Scheu, DNP, FNP-BC; Elaine Y. Bundy, DNP, FNP-C

➢ Over 14 weeks:

▪ 85 Pt’s completed 204 screenings▪ Mean screenings/Pt: 2.4 ▪ Weekly screening: 0% → 86.1%

➢ Improved assessment:▪ 41.2% + screenings, identified:

▪ 35 concerns / symptoms▪ 50 overdue visits

➢ Improved follow-up:

▪ Weekly/screening F/U: 66.7%▪ Pt F/U guideline compliance:▪ 62.4% (n=53) → 98.8% (n=84)

▪ p>0.001

➢ Limitations:▪ Design:

▪ Small sample, adults only, short duration▪ Clinic documentation: electronic and paper charting

▪ Challenge for providers to review screenings▪ Improved with F/U chart review

▪ Knowledge deficits & compliance challenges ▪ Improved with education

▪ …

➢ Setting: Suburban MD asthma & allergy clinic

➢ Sample: Adult AIT patients (N=85)

➢ Interventions:

1. Monthly pre-AIT screening tool:a) Health questions:

▪ AIT concerns, side effects, reactions?▪ New medications or health changes/concerns?

b) Symptom severity questionnaires:▪ RCAT: Rhinitis Control Assessment Test▪ ACT: Asthma Control Test

c) Date of last visit:▪ Verified by clinic staff

2. Follow-up scheduling guide for staffa) Timeframe based on screening results

3. Pt & staff education4. AIT administration record revision, results trend

68%

50%40%

50%

100%

57%

100%

0%

86%100%

33% 33%

100%

80%

0%

20%

40%

60%

80%

100%

120%

0

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4

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1 2 3 4 5 6 7 8 9 10 11 12 13 14

% O

F SC

HEDU

LED

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TIEN

TS S

CHED

ULE

D

WEEK NUMBER

Process Measure 3: Follow-up Scheduled

Follow-up Scheduled Percentage of Scheduled Follow-up Median (80%) Trend Line

9.4%

58.8%

8.2%

23.5%

Process Measure 2: Positive Screenings

Multiple Factors (n = 8)

Overdue Visit (>12months) (n=50)

Health Screening Concern (n=7)

Uncontrolled Symptoms (RCAT/ACTSignificant) (n=20)

Figure 1: Process Measure 1: Rates of weekly screening completion = screenings completed (204)/patients eligible for screening (237): 86.1% screening completion, median: 100%.

Figure 3: Process Measure 3: Follow-up appointment scheduled (56)/number of positive screenings (84): 66.7% overall follow-up for each positive screening, median of 80%.

62.4%

98.8%

42.4%

1.2%

0

10

20

30

40

50

60

70

80

90

PRE POST

AIT

PATI

ENTS

F/U COMPLIANCE PRE VS. POST INTERVENTION

AIT Follow-up: Guideline Compliance

> 12 months (non-compliant)< 12 months (compliant)

Figure 4. AIT Follow-up Compliance

Pre vs. Post Intervention

0%

96%80%85%

100%

80%71%

50%36%

84%100%

82%

100% 100%

0%

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CO

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ETED

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CO

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ETED

BY

ELI

GIBL

E PT

’S

WEEK NUMBER

Process Measure 1: Screening Completion

Number of Screenings Completed Percentage of Sceening Completion Median (100%)

Project Purpose & Goals

Methods

Discussion

➢ Implications for practice:

▪ Improved AIT assessment and F/U▪ Increased guidelines knowledge & compliance▪ Ability to trend Pt screening data over Tx

➢ Future improvements:

▪ Inclusion of pediatric Pt’s ▪ Use of technology to improve screening and FU scheduling/reminders▪ Administer ACT prior to each asthma Pt injection▪ Improved safety, decreased reactions

➢ Additional clinic education, AIT quality improvement:▪ Guideline recommended: peak flow prior to AIT for asthma

Conclusion

References

Figure 2: Process Measure 2: Positive Screenings, N= 84, mean: 41.2%, median: 50%.