Daily bathing with chlorhexidine gluconate (CHG) soap reduces infection rates, but patient non-compliance prevents

consistent bathing.

Problem Statement

Purpose & Goals

Discussion

Implications for Practice:• Scripted patient education ensures message consistency• Integration of practice changes into new employee orientation

promotes sustainability

Implications for Future Development:• Future projects to focus on addressing causes of patient

refusals.• Continue to audit daily bathing using checklists.

Conclusions

• Development of standardized CHG bathing module reviewed by nursing staff on cardiac surgery stepdown unit.

• Data Collection Weekly:• Percentage of patients

receiving standardized CHG bath.

• Percentage of patients receiving education handout on admission.

• Treatment refusal rates and reasons.

• CAUTI, CLABSI, CDI & MRSA assessed monthly.

Methods

Results

• Patient education goal was met, however, patient refusals continued.

• Inconsistent use of checklist can be related to staff turnover, staffing, and patient changes due to pandemic.

Limitations:• Cancelation of elective admissions during COVID-19

pandemic led to higher-acuity patient mix on unit.• Novice charge nurses may have found these practice

changes to be burdensome.• Inconsistent documentation of bathing checklist use.• Patient refusals associated with patients who experienced

increased LOS.

Purpose: Implement a protocol for adult cardiac surgery inpatients involving:• Formalized patient education• Standardization of the bathing process

Goals:• Patient refusal rate of 0%, or 100% of reasons for refusals

documented [October 2020]• CHG baths for 100% of unit inpatients for several

consecutive months [March 2021]• HAI incidence rate of 0% [December 2021], including:

• catheter-associated urinary tract infection (CAUTI)• methicillin-resistant Staphylococcus aureus (MRSA)

bacteremia• Clostridium difficile infection (CDI)• central line associated bloodstream infections (CLABSI)

Implementation of Daily Chlorhexidine Gluconate Bathing for Cardiac Surgery Stepdown Inpatients

Samantha Crisp, BSN, RN; Mary Ellen Connolly, DNP, CRNP; Michelle Kirwan, PhD, MSN, RN, CRNP University of Maryland School of Nursing

a bathing checklist was posted in each unit room

an educational handout was given upon admission

References

• 100% of all new admissions to the unit received the CHG educational handout• Rate of patient refusals averaged 11% (greater than 12% in 2019)

• 78.5% of reasons for patient refusal were documented• Average CHG treatment compliance increased to 85.5% from 60%• Incidence of HAIs remained 0%• Average rate of baths given using standardized checklist: 41.5%

Compliance to daily CHG treatment for all inpatients continues to be a significant challenge due to factors related to staffing, patient acceptance of bathing, and

shift leadership.

Acknowledgments• Mary Evans, MS, MBA, RN – Clinical Site Representative• Martha Lusby, BSN, RN – Infection Preventionist for Cardiac

Surgery Stepdown• Cindy Dove, BSN, RN – Administrative Sponsor & Nursing

Director

Cigarette smoking is the leading cause of preventable disease and death in the US and individuals who have behavioral health issues are more likely to be dependent on nicotine.

Most common causes of death among people with behavioral health disorders are heart disease, cancer, and lung disease, all of which can be caused by smoking.

Individuals with serious mental health disorders who use tobacco products have a decreased life expectancy of 15 years.

• Patients who accepted NRT had moderate to high levels of nicotine dependence and readiness to change. While 56.5% (n=13) were at least moderately ready to

change, only 21% (n=3) accepted NRT. • Patients who accepted brief counseling had an average

readiness score of 4.68 (moderately ready). These patients may benefit additional counseling following

discharge from the residential crisis unit (tobacco cessation in the treatment plan).

• None of the patients accepted quit line referrals. This was consistent with a similar project previously

implemented in the same hospital's inpatient behavioral health unit, where only one patient accepted a quit line referral (Erondu, unpublished manuscript, 2020).

It may not be advisable to include quit line referrals for individuals with acute behavioral health disorders.

Problem Statement

Purpose: To implement a comprehensive tobacco cessation quality improvement (QI) project to reduce tobacco use among patients receiving services in a residential behavioral health crisis unit.

Short Term Goals:● 100% of behavioral health patients who screen

positive for tobacco use will be assessed for:● Level of nicotine dependence using the

Fagerstrom Test for Nicotine Dependence (FTND), and

● Level of readiness to change using the Readiness Ruler (RR).

● 100% of behavioral health patients who use tobacco will receive a brief counseling intervention designed to help them quit or cut down their tobacco use.

● 100% of behavioral health patients for whom nicotine replacement therapy (NRT) is indicated based on their FTND score will receive NRT, varenicline or bupropion either on admission, during their residential stay, or at discharge.

Long Term Goals:● Increased rates of tobacco cessation.● Improved health; decreased morbidity and mortality.

Purpose of Project/Goals

Conclusions

ResultsSetting/Duration: Behavioral health residential crisis center; implemented over12 weeks.Population: Adult behavioral health patients with tobacco useInterventions for patients who use tobacco: • Assess readiness with the Readiness Ruler • Assess level of nicotine dependence with FTND• Add smoking cessation to individualized treatment plan • Offer evidence-based tobacco cessation interventions: Medications (NRT patches; varenicline, bupropion) Brief counseling interventions Referrals to telephone quit line for coaching/counseling and

assistance with NRT access• Titrate NRT doses to level of nicotine dependence on FTND Implementation Strategies: • Identify experienced nurse champions and early adopters Role modeling and enthusiasm for adherence to protocols

• Weekly data collection• Monthly meetings to provide feedback and answer questions• Virtual trainings and planning meetings

Methods

Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults in the United States. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm

Heatherton T.F., Kozlowski L.T., Frecker R.C., Fagerstrom K.O. (1991). The Fagerstrom Test for Nicotine Dependence: A revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addiction 86:1119-27.

Miller, W. & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.) Guilford Press.

Discussion

• Screened for tobacco use: 100% (n=76) Positive for tobacco use: 39.5% (n=30) • Assessed for Readiness to Change (Readiness Ruler): 76.7% (n=23 of 30)

56.5% (n = 13 of 23) were at least moderately ready to change• Assessed with Fagerstrom Test of Nicotine Dependence (FTND): 83.3% (n=25)

56% (n = 14 of 25) were at least moderately dependent• Received Brief Interventions and Cessation Counseling: 50% (n=15 of 30) • Accepted Referrals to Quit Line: 0% (n=0 of 30) • Accepted Nicotine Replacement Therapy (NRT) or Other Medications: 13.3% (n=4 of 30)

Average Readiness Score was 6.25 of 10; and average dependence score was 6; No significant association between readiness to change and acceptance of NRT

X2 (N-1, n=76) = 2.11, p = .35 No significant association between level of dependence and acceptance of NRT

X2 (N-1, n=76) = 1.8, p = .41 • No relationship between levels of nicotine dependence (low, moderate, or high) and

levels of readiness to change (low, moderate, or high), X2 (4, n=23) = 2.16, p = .71.

Implications:• Pushing people into smoking cessation when they are not ready to change

can promote resistance and be counterproductive.• Medications for tobacco cessation help with nicotine withdrawal and cravings,

but all pharmacological therapy should be accompanied by behavioral counseling, including motivational interviewing.

• Allowing smoking breaks at the facility could contribute to low acceptance of NRT; Consider developing policies for a “Smoke Free” environment.

Recommendations for future QI or research projects: • Future QI projects to explore methods for improving readiness for changing

smoking behaviors among patients in behavioral health residential and inpatient units; • Future research to explore reasons for low rates of acceptance of referrals

to telephone quit lines among behavioral health patients.

Limitations: • Small sample size – Fewer than expected admissions due to the COVID-19 pandemic.• Pandemic restrictions prevented project lead from conducting in-person training and

being available onsite to answer staff’s questions or concerns.• Evaluation data were manually extracted from the electronic health record (EHR) and were

recorded on a paper audit sheet; staff were accustomed to inputting data using the EHR.

Tobacco Cessation Interventions in a Behavioral Health Residential Crisis Center

Leo Ernie Domingo BSN Katherine Fornili, DNP, MPH, RN, CARN, FIAANLynn Oswald, PhD, RNSherry Kizielewicz, LCSW-C

Bibliography

Baseline Weeks 1-3

PROBLEM STATEMENT

• Approximately 34.2 million people are diagnosed with diabetes.

• Identificationofdiabetes-relateddistress(DD)isessentialfordiabetesmanagement,

reducinghealthcarecosts,andimprovingqualityoflifeforpeoplewithdiabetes.

• UsingProblemAreasinDiabetes-5(PAID-5)tool,DDwaspresentin36%ofpersons

withdiabetesacross55studies.

Adults with diabetes are at higher risk of psychological distress.

RESULTS DISCUSSION

• ThePAID-5toolsuccessfullyidentifiedpatientswithdiabetesthatareatriskfordiabe-

tes-relateddistress.

• ImplementationofthePAID-5toolrevealedthechallengessurroundingthestigmaof

mental health.

• Theresultfindingsareconsistentwiththeliterature;31%ofthepatientsscreenedhave

DDcomparedto36%reportedinameta-analysis.

• Holidaysandlimitedofficehoursresultedindecreasedscreeningduringweek18.

Limitations:

• TheCOVID-19pandemicincreasedtelemedicineutilization.

• MeaningfuloutcomessuchaschangesinthePAID-5scoreandA1Cpost-intervention

werenotincludedduetotheshortimplementationtimeframe.

Screening for DD with the PAID-5 tool is feasible in an outpatient endocrine clinic.

CONCLUSIONS

Implications for Practice:

• ScreeningforDDisaholisticandcomprehensiveapproachforthemanagementofdia-

betesanddiabetes-relatedoutcomes.

Future Practice Implications:

• IdentifymethodstoincreasementalhealthreferralsforpatientsexperiencingDD.

• Datacollectionoveralongertimeframeisnecessarytotrackmeaningfulpatientout-

comes.

The PAID-5 tool can facilitate the referral of distressedpatients to mental health providers.

PURPOSE

• Quality Improvement Project:ImplementaDDscreeningandreferralprograminan

outpatientendocrineclinic.

• Short-term goal:Screen100%ofpatientsencounteredafterthekickoffusingthePAID-

5screeningtool.

• Long-term goal: Refer100%oftheindividualswithPAID-5scores≥8toamentalhealth

provider(MHP).

METHODS

• Setting: Outpatientendocrinologyspecialtyclinicofalargeacademicmedicalcenter.

• Population: Patientswithadiagnosisofdiabetes,age≥18,andnon-pregnantwomen.

• Pre-implementation: ThePAID-5questionnairewascreatedinEPICandroutedtoMy-

Chart.

• Implementation:

-18-weekimplementationguidedbytheMAP-ITframework.

-ThePAID-5toolwascompletedonMyChartoneweekbeforethevisit,in-person,or

provider-facilitatedduringTelemedicineencounters.

-ProvidersreferredpatientswithaPAID-5score≥8toaMHP.

-EmbeddedEPICSmartPhrasesintheprovidernotetemplateforincreasedclinical

utility.

-ProvidedaphysicalordigitalcopyoftheDDbrochure.

DD was measured using the PAID-5 scale (0 – 20) points.

ReferencesAcknowledgements

AspecialthankyoutoMarlaSpring,MSN,FNP-C,CDEforyourguidanceandsupportduringtheimplementationofthisproject.

Screening for Diabetes-Related Distressin an Outpatient Endocrine Clinic

| University of Maryland School of Nursing

Pre-implementation:TherewasnostandardizedworkflowforDDscreeninginanoutpa-

tientendocrineclinicthatmanagesapproximately2000personswithdiabetes.

Implementation:

• 72%or744/1028patientswerescreenedusingthePAID-5tool.

• Thepatientpopulationwas55%femaleand45%male.

• TheaveragePAID-5scorewas5andthebaselineA1Cwas8%(<5.7%).

• Ofthose228patients,only24%werereferredtoaMHP.

• Halfthepatientsrefusedareferraland7%werealreadyseeingaMHP.

744 patients (72%) were screened in the outpatient endocrine clinic.

228 patients (31%) had a PAID-5 score ≥ 8.

%ofPatients

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Instructions:Whichofthefollowingdiabetesissuesarecurrentlyaproblemforyou?Circlethenumberthatgivesthebestanswerforyou.Pleaseprovideananswerforeachquestion.

Not a Problem Minor ProblemModerate

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PAID-5

• Problem: Treatment Resistant Major Depressive Disorder (TRMDD)• Over 300 million people diagnosed worldwide• Leading cause of disability worldwide • Standard medication regimens are increasingly ineffective

• Organizational Problem: Inconsistent therapy administration Inappropriate infusion dosages Absence of proper infusion CPG/protocol Inadequate education on infusion recommendations

• Purpose:• To design and implement an infusion administration clinical

practice guideline (CPG)• To facilitate the anesthesia provider’s ability to safely administer

ketamine infusions

• Short-term goals:• Acceptance of the CPG by stakeholder

• Long-term goal:• Staff administering Ketamine infusion therapy in compliance with the newly developed CPG• Patients will not experience dissociative or hemodynamic side effects

• Patients will receive a clinically effective dose of ketamine

• Patient is aware of the FDA’s approved medication usage• Infusion benefits should outweigh potential harm• The provider should be an anesthesia team member• Emergency equipment should be always available• Assessment of history and physical should be done prior to

each infusion• Vital signs should be monitored prior to, during, and after the

infusion• Infusionist must be aware of cognitive dissociation signs• Informed consent must be obtained to:

• Inform the patient that ketamine is an experimental therapy• Disclose possible side effects (i.e. dissociative,

hemodynamic, hallucinogenic, dependance, and tolerance) • Other medications may be explored with the prescribing

psychiatric clinical provider

• Level 3 and 4 evidence used to develop CPG• CPG is not generalizable

• Future QI projects evaluating incidence rates will be beneficial

• Strengths• 100% acceptance by anesthesia team.• Improved outcomes have been noted based on

preliminary results after pre-implementation education

• Limitations• Limited technical support incorporating CPG onto

facility intranet • Possible reluctance due to change in customary

practice

• Developed and accepted CPG serves as a basis for limiting the frequency in which patients experience negative side effects as a result of unguided ketamine infusions

• CPG is to be utilized as a means of educating staff on the possible complications associated with insufficient or excessive ketamine delivery

• Sustainability• PFQ data will be collected and analyzed to

ensure sustained buy-in

• CPG will be updated every 3 years based on current evidence and PFQ feedback

• Setting: Anesthesia department of a small outpatient infusion center in Washington, DC

• Phase I• Initial meetings to confirm project goals and objectives• Draft CPG submitted to the key stakeholder for initial appraisal via the AGREE II tool

• Phase II• International Review Board (IRB) approved by IRB analyst

• Phase III• Presented CPG to anesthesia staff• Practitioner Feedback Questionnaire (PFQ) data collected and analyzed to assess provider buy-in and CPG applicability

• Data Collection Methods:• AGREE II Tool:

• Utilized for the appraisal of a CPG by the stakeholders• Assessed the quality and comprehensiveness of the CPG

• PFQ: • Document given to the anesthesia personnel who attended

the formal presentation • Used to assess the teams buy-in to the developed CPG.

Problem Statement

Purpose of Project/Goals

Results

• Cuff pressure measurement:• There was 100% anesthesia provider

compliance with manometry after one-on-one feedback and ideal positioning of manometer.

• Denying POST• There was a positive trend of patients denying

POST when cuff pressure was in the recommended range.

• In accordance with literature findings, there was a positive association between optimal cuff pressure measurement and no complaints of POST.

• Project Limitations• COVID-19: project low priority• Scheduling conflicts• PACU staffing issues

Discussion

• Implications for Practice• Reiterate the importance of

manometry.• Positive patient outcomes.• Manometry as the standard of

care for patients getting ETTs.• Increased patient satisfaction.

• Future Quality Improvement Projects and Education

• Repeat QI project during optimal time.

• Provide frequent education about manometry.

Conclusions

References

• 19 observation days• 50 observations:

• 100% provider compliance with manometry.• 100% of cuff pressures within the

recommended range.• 86% of patients reported no complaints of

POST

• Setting• Operating rooms at the community hospital• 30 cases a day with half requiring intubation

• Population• Surgical patients that require an ETT• Exclusion criteria: pediatric patients (0-17 years of age),

ear/nose/throat/airway cases, pregnant patients, traumas patients, emergency cases, and COVID positive patients.

• Implementation• Manometer use• Documentation• Assessment of POST

• Strategies and Tactics• Accountability: Obtain formal commitments.• Buy-In: Offer incentives.• Collaboration, Communication, and Changes in Structure

• Build a coalition.• Conduct local census discussions.• Remind clinicians.

• Education: Provide manometry demonstrations.• Data: Perform random observations and provide feedback.

Using Manometry to Assess Endotracheal Cuff Pressures to Prevent Sore Throats

Bradley Kretzer, BSN, RN; Priscilla Aguirre, DNP, CRNA; Linda Cook PhD, RN, CNS, ACNP

Purpose

• Implement the use of manometry after ETT intubation for adult surgical patients undergoing general anesthesia.

Goals

• Anesthesia providers will measure intraoperative cuff pressure using manometers to maintain pressure within the recommended range.

• No patient who had an ETT will complain of a sore throat while in the PACU.

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Percentage of Patients Denying Post-Operative Sore Throats (POST) Values Goal

Methods

Figure 1. Posey Cufflator

Incidence

Patients undergoing

endotracheal intubation

during general anesthesia reported a

postoperative sore throat

(POST) between 11%

and 48%.

Factors that contribute to

POST

Diameter of the

endotracheal tube (ETT)

Cuff design

Cuff pressure

Manipulation of the ETT or

trachea during surgery

Suburban Community

Hospital

Estimation techniques

used

High prevalence of POST

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•Most of the ICU staff completed competency the Geriatric Rib Fracture Pathway (nurses: 86% provider: 100%)

•Increased compliance of the Geriatric Rib Fracture Pathway evidence-based interventions, consistent with literature findings •✓ Orders placed within 24 hours (p<.001)•✓ Pain assessment (p=.068)•✓ Deep breathe and cough (p<.001)•✓ Incentive spirometry (p=.006)

•Results were limited by•▶ Small sample size•▶ Repetition of same patients for data•▶ Lack of random sampling•▶ Lack of prioritization due to COVID-19 pandemic

Staf

f Com

pete

ncy •Training and

education of the pathway was provided to all ICU staff•Compliance of pathway implementation was audited weekly and determined by • Nurses:Documentation of pathway assessments –pain, deep breathe and cough, & incentive spirometry • Providers: Pathway orders placed within 24 hours of patient admission to the ICU

Ger

iatr

ic R

ib F

ract

ure

Path

way •Used to

determine eligible patients and subsequent evidence-based interventions (see Figure 1)•Setting: In a trauma ICU at a large academic medical center•Inclusion criteria: Trauma patients ≥65 years old with ≥2 rib fractures •Exclusion criteria: High risk of pulmonary complications due to admitting injury

Ana

lysi

s •Chi-square test for nursing documentation compliance Independent t-test for provider order compliance

Implementation of a Geriatric Rib Fracture Pathway in TraumaJanet Lee, BSN, RN

Tracey Wilson, DNP, CRNPVeronica Gutchell, DNP, CNS, CRNP

University of Maryland School of Nursing

• Geriatric trauma patients, aged 65 years and older, with rib fractures have double the incidence of mortality and morbidity compared to younger trauma patients.

• Rib fractures in the geriatric population increase the risk for:◦ ↑ Pain ◦ ↑ Hospitalization ◦ Pulmonary complications ◦ Death

• Standardization of care using evidence-based interventions can optimize outcomes in this patient population.

Figures

Results

Discussion

• This pilot QI project suggested an increase in staff compliance with implementation of a rib fracture pathway for geriatric trauma patients.

• The ICU staff felt that the Geriatric Rib Fracture Pathway was a safe and useful in identifying the target population and in early adoption of evidence-based interventions.

• Further research is recommended with possible future interventions targeted at evaluating the effects of the pathway on patient outcomes.

Conclusion

Use QR code for a complete list of references.

Acknowledgements

Figure 1. Geriatric Rib Fracture Pathway in Trauma

References

• Karen McQuillan, RN, MS, CNS-BC, CCRN, CNRN, FAAN

PURPOSE STATEMENTTo implement and evaluate the use of an evidence-based

pathway in the geriatric trauma population in a trauma intensive care unit (ICU).

GOALS

SHORT-TERM100% of ICU nurses and

providers will be educated on the Geriatric Rib Fracture

Pathway.

LONG-TERMThe Geriatric Rib Fracture

Pathway will be utilized 100% of the time on the

trauma ICU.

Background

Purpose

Methods

• Gynecologic Oncology (GYN/ONC) patients often have complicated treatment regimens that include surgery

• Enhanced Recovery After Surgery (ERAS) protocols improve GYN/ONC patient outcomes

• Ambulation on postoperative day zero is an important ERAS protocol element because it decreases hospital length of stay

• At an urban Mid-Atlantic hospital, only 3% of GYN/ONC patients ambulated on postoperative day (POD) 0 between February 2018 and January 2020

• Not ambulating on POD 0 increases risks for postoperative complications and longer hospital stays

Problem Statement

• The purpose of this quality improvementproject was to implement the Johns Hopkins Highest Level of Mobility (JH-HLM) scale with defined goals

• Standardize mobility documentation • Quantify postoperative mobility goals

• Goals of the project were to have 100% of postoperative GYN/ONC patients…..

• Have a documented mobility level on POD 0 • Ambulate at least 10 steps on POD 0• Ambulate at least 250 feet by discharge• Be discharged within 48 hours

Purpose and Goals

Results Discussion

• JH-HLM scale with defined goals is a useful tool to increase postoperative mobility levels

• Standardizing mobility documentation and goals can increase compliance with the ERAS recommendations of having patients ambulate on postoperative day 0

• Implications for future QI projects• Expand patient population to other surgical and medical

populations • Standardize preoperative ambulation education• Lengthen implementation period to see the impact on

postoperative complications

Conclusions

References

• Setting and Population• Inpatient oncology unit with 32 beds at an Urban

Mid-Atlantic community hospital with 42 nursing staff members

• Included patients who had surgery for potential uterine/ovarian cancer and can ambulate 250 feet before surgery

• Implementation Strategies and Tactics• Educate nursing staff about the JH-HLM scale• Incorporate the JH-HLM scale into the electronic

health record• Communicate compliance rates to staff and give

frequent reminders• Collaborate with perioperative and rehabilitation

departments

Methods

During the 12-week implementation period in the Fall of 2020….• All (100%) of staff members were educated on the JH-HLM scale and

mobility goals • A total of 162 patients met the inclusion criteria• Nursing staff compliance with documenting patient’s mobility level:

- Average of 46% documentationcompliance

• Patient ambulation on postoperative day 0:

- Average of 33% of patientsambulated at least 10 steps on POD 0

• Patient mobility level at discharge:

- Average of 45% of patients ambulated atleast 250 feet by discharge

• Average length of stay in the hospital:

- Length of stay decreased from 2 dayspre-implementation to 1.8 days post-implementation

- A total of 67% of patients weredischarged within 48 hours

Implementing a Mobility Scale to Increase Postoperative Mobility LevelsMary Marasa, BSN, RN, OCN, Elaine Bundy, DNP, CRNP, FNP-C

Crystal DeVance-Wilson, PhD, MBA, PHCNS-BC, Nicole Hammond, MSN, CRNPUniversity of Maryland School of Nursing

• JH-HLM Scale Impact on Outcomes• Nursing staff mobility documentation increased

from 10% to 46%• Number of patients who ambulated on POD 0

increased from 3% to 33%• Number of patients who ambulated at least 250

feet by discharge increased from 13% to 45%• Average length of stay decreased from 2 days

to 1.8 days

• Results align with the literature that recommends using the JH-HLM scale and having quantifiable mobility goals to increase mobility levels and decrease the length of hospital stay

• Barriers and Limitations• Delayed incorporation of JH-HLM scale into EHR• Inconsistent documentation• COVID 19 pandemic impacts• Limited generalizability due to patient population

and impact of other elements of the ERAS protocol

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Patient Outcome Measures ● Group Attendance:

o Attended at least one group: 56.58% (n=43)• Attended a nutrition group only: 31.58% (n=24)• Attended an exercise group only: 13.16% (n=10)• Attended both a nutrition group and an exercise group: 11.84% (n=9)

● Verbalization of Intent to Adopt at Least One (1) Healthy Behavior Changeo Verbalized intent to adopt a healthy behavior change: 36.84% (n=28)

Discussion

Conclusion

References

Setting: ● 8-bed residential behavioral health unit located in a community

crisis center.Population:● Adult patients admitted for acute behavioral health (psychiatric

and/or substance use) disordersEvidence-based multi-modal health promotion program implemented over 10-weeks:● Program curriculum included five nutrition and health psychoeducation

lessons and six recorded chair yoga sessions● Nutrition psychoeducation groups conducted three times per week by

nursing staff and counselors.● Exercise groups conducted three times per week by nursing staff.On admission, all patients completed a Nutrition Readiness Ruler and an Exercise Readiness Ruler.● 1 to 10 rating scale

o Low readiness= 1 to 3o Medium readiness= 4 to 7o High readiness= 8 to 10

Evaluation Data Collected:● Demographics: Gender, Age, Race, Body Mass Index (BMI), and

Date of Admission and Discharge● Date of first nutrition group attendance (“x” if no group attendance)● Date of first exercise group attendance (“x” if no group attendance)● Reason for group non-attendance● Verbalization of Intent to Adopt a Healthy Behavior Change (yes/no)● Brief Description of Healthy Behavior Change

Multi-Modal Health Promotion Program to Reduce Obesity Risks Among Behavioral Health Patients

Althea Miller-Umar, BSN, RN; Katherine Fornili, DNP, MPH, RN, CARN, FIAAN; Lynn Oswald, PhD, RN; & Sherry Kizielewicz, LCSW-C

● Individuals with a mental health disorder have a risk of obesity that is 2 to 3 times that of the general population (Avila, Holloway, Hahn, Morrison, Restivo, Anglin, &Taylor, 2015).

● Individuals with a severe mental illness experience a life expectancy 13 to 30 years less than people without a serious mental illness, largely as a result of increased cardiometabolic disease risk (Looijmans, Schoevers, Bruggeman, Stolk, & Corpelejin, 2014).

● There is evidence to support the use of interventions that promote healthy nutrition and include physical activity to reduce weight and reduce cardiometabolic risk factors in people with serious mental illness (Bruins, Bruggeman, Slooff, Corpleijn, & Pijnenborg, 2014).

● However, the delivery of these interventions is currently lacking in the behavioral health crisis center where this project was implemented.

Problem Statement

Purpose

Methods

Goals and Objectives

The purpose of this project is to implement a multi-modal nutrition and exercise program for adult patients receiving treatment on a residential behavioral health unit located in a community crisis center.

Short-term Goal(s): 100% of RNs and counselors that work in in the behavioral health unit during evening shift will be trained to administer the nutrition education and exercise program.

Mid-term Goals(s):

1. Clinical staff in the residential crisis unit will conduct planned nutrition psychoeducation and exercise intervention 100% of the time (process).

2. 100% of patients receiving residential treatment will attend at least 1 nutrition and 1 exercise group and be able to verbalize intent to adopt a healthy behavior change (patient outcome).

Long-term Goal(s) : Reduced rates of obesity and metabolic syndrome among adults with behavioral health disorders

Results

Patient Characteristics

● Feasible and Sustainable: Staff successfully implemented this multi-modal nutrition and exercise program for patients receiving treatment on at a residential crisis center in Maryland. This suggests that it is feasible to implement a nutrition and exercise program in the residential behavioral health crisis setting.

● Nurse-Led Group Intervention: The majority of groups at this facility are conducted by Masters’ level counselors and include process and structured dialectic behavior therapy (DBT) groups. Several nurses had expressed an interest in conducting groups, but they felt uncomfortable due to lack of experience. The unit nurse manager stated that “this curriculum is great for nurses” due to its psychoeducation and health promotion content.

● Positive Patient Responses: The Clinical Site Representative (CSR) and unit nurse manager reported that patients who attended the nutrition and/or exercise groups had a “positive responses” to the groups and enjoyed the program curriculum.

Avila, C., Holloway, A.C., Hahn, M.K., Morrison, K.M., Restivo, M., Anglin, R., & Taylor, V.H. (2015). An overview of links between obesity and mental health. Current Obesity Reports, 4(3), 303-310. Doi:10.1007/s13679-015-0164-9

Bruins, J., Jörg, F., Bruggeman, R., Slooff, C., Corpeleijn, E., & Pijnenborg, M. (2014). The effects of lifestyle interventions on (long-term) weight management, cardiometabolic risk and depressive symptoms in people with psychotic disorders: A meta-analysis. PLoS ONE, 9(12), 1-20. Doi: 10.1371/journal.pone.0112276

Looijmans, A., Jorg, F., Schoevers, R.A., Bruggeman, R., Stolk, R., & Corpelejin, E. (2014). Changing the obesogenic environment of severe mentally ill residential patients: Elips, a cluster randomized study design. BMC Psychiatry, 14(293). http://www.biomedcentral.com/1471-244X/14/293

Barriers:● Program initially designed to include chair aerobics, but nursing staff were

concerned that it would be too strenuous for this patient population. Project was implemented using chair yoga sessions for the exercise groups instead.

● Staff reported that patients with a history of eating disorders and/or poor body image did not respond well to the nutrition psychoeducation sessions. Therefore, during Week 3, content about positive self-image was added for staff to use when deemed appropriate.

● The COVID-19 pandemic was a primary barrier.o Project lead was unable to conduct in-person staff training or engage in

routine site visits due to social distancing and safety protocols. o Staff shortages resulting from COVID-19 exposures limited the staff’s

ability to conduct three (3) nutrition and three (3) exercise groups per week as scheduled during Weeks 6-8.

o Patients were isolated and unable to attend groups until they received a negative COVID test.

Limitations:● Data were collected via pen-and-paper data collection audit forms.

Data collection may have been improved if included in the electronic medical record (EMR).

● Cannot determine whether group attendance was associated with increased intentions to adopt healthy behavior changes because only patients who attended groups were asked about their intentions.

● Cannot determine whether group attendance affected readiness to change nutrition or exercise behaviors because Readiness Ruler scores were only assessed at time of admission.

Recommendations for Future Directions:● Future research and/or QI projects to explore methods for increasing patient

engagement in health promotion activities while receiving acute behavioral health treatment.

● BMI for all patients receiving residential treatment at this facility.o Mean= 28.76; SD= 8.27; Median= 44.04; range= 18.19 – 69.89

● Percent of Groups Conducted as Scheduledo Staff conducted nutrition psychoeducation groups as scheduled (3 groups per week) an average

of 80.00% (SD=28.11%) percent of the time.o Exercise groups were conducted as scheduled (3 groups per week) an average of 70.00% (SD=24.56%)

of the time.

● Longer length of stay (LOS) was associated with exercise group attendance, but not nutrition group attendance or verbalization of intent to adopt a healthy behavior change.

o LOS and exercise group attendance, X2 (1, N=76)= 4.47, p= .0345o LOS and nutrition group attendance, X2 (1, N=76)= 1.75, p= .1861o LOS and verbalization of intention to adopt a healthy behavior change, X2 (1, N=76)= 0.82, p= .3751

● Group Attendance and Verbalization of Intent to Adopt a Healthy Behavior Changeo Attending both a nutrition and exercise group was associated with increased likelihood to verbalize an

intention to adopt a healthy behavior change when compared to patients who attended only a nutrition group or only an exercise group, X2 (2, N=43)=8.01, p=0.0182

• Attended a nutrition group only and verbalized intent to change: 70.83% (n=17)• Attended an exercise group only and verbalized intent to change: 30.00% (n=3)• Attended both a nutrition and exercise group and verbalized intent to change: 88.89% (n=8)

Figure 1.

Figure 2. Figure 3.

Figure 4.Figure 5.

Figure 6. Run Charts of Adherence to Nutrition and Exercise Group Schedule (Process Measure)

• Catheter Associated Urinary Tract Infection(CAUTI)-most common preventable hospital acquired infection

• Errors in the hospitals leads to over 500,000 patients to develop CAUTI annually in the U.S. and associated with significant mortality and morbidity1

• infection, discomfort, pain, miserable, longer hospital stay and increased cost.

• About 12-25% of patients receive foley catheters during hospital admission and 75% of urinary tract infections (UTI) linked to foley.2

• Maryland hospitals’ goal of CAUTI rate=Zero

• Maryland monthly mean CAUTI rate in 2015 ranges from 0.8-1.2

• Local problem:* Pre audit data reveled high DUR (31%)• CAUTI rate high at 4%

• Nurse-Driven Protocol empowers nurses with thedecision support to assess and discontinue foley

Background and Problem

The purpose of this quality improvement (QI) project is to implement a Nurse-Driven Protocol to discontinue foleys without waiting for a provider’s order. Short-Term Goals • Train 100% of nursing staff in intermediate care unit

(IMCU) on Nurse-Driven Protocol • Decrease Device Utilization Ratio (DUR) by 15% over

the twelve weeks using the protocol Long-term Goals• Over twelve weeks, decrease CAUTI infection rates to

“zero” in the IMCU

Objectives

Figures

• We found that catheter utilization remained common prior to the intervention and the many were placed without medical indication

• The protocol increased nurses' knowledge about CAUTI risk factors and prevention techniques

• Nursing staff adherence greatly impacted safety of the patients

• Protocol implementation enhanced communication among staff, empowered nurses' confidence and increased sense of teamwork

• Early discontinuation Reduced DUR Reduced CAUTI rates and results are consistent with the literatures

• Limitation: the unit was turned to COVID-19 unit which might have impacted DUR

Discussion

1. Agency for Healthcare Research and Quality, Rockville, MD.https://www.ahrq.gov/hai/cauti-tools/impl-guide/implementation-guide-appendix-k.html

2. Catheter-associated Urinary Tract Infections (CAUTI) HAI CDC. (2019, October 1). https://www.cdc.gov/hai/ca_uti/uti.html

3. American Nurses Association CAUTI Prevention Tool. (n.d.). ANA. Retrieved March 6, 2020, from https://www.nursingworld.org/practice-policy/work-environment/health-safety/infection-prevention/ana-cauti-prevention-tool/

References

Results

Thank you, my faculty adviser Linda Costa, PHD, RN, NEA-BC, Clinical Site Representative Adriane Blassingame, RN, MSN, and Champion Leaders

Acknowledgement

Nurse Driven Protocol to Decrease Catheter Associated Urinary Tract Infection Melaku Misikir, RN, BSN

Linda Costa, PhD, RN, NEA-BCUniversity of Maryland School of Nursing

Conclusions

Methods

• Setting: A 30-bed intermediate care unit of local community hospital

• Population: Adult inpatients with indwelling foley catheters • Interventions:

• Quality improvement project implemented over 12 weeks • All unit nurses invited to receive CAUTI prevention

education and Nurse-Driven Protocol training• Poster boards, videos, in services, emails, huddle times

utilized • Champion leaders identified • Post training/education, nurses are asked to use the Nurse-

Driven Protocol for urinary management • Charts and algorithm utilized for the decision support to

assess and discontinue foley without medical indications

• Baseline: Pre audit data reveled high DUR (31%) , compliance rate 74%, and CAUTI rate was 4%

• Implementation phase: After the twelve weeks implementation period, DUR was reduced by 19.2% , staff compliance rate increased to 92.5%, and CAUTI rate reduced to zero.

• Both DUR and CAUTI rates improved with the implementation of a Nurse-Driven-Protocol. Champion leaders and nurses played significant

contribution for the successful implementation of the protocol.

Urinary Catheter Discontinuation Algorithm

020406080

100120140160180200

Biweekly Chart Audit Results

Number Catheter daysNumber of pateint daysNumber of New CAUTI

Pre-Intervention Data Twelve weeks post intervention

• DUR 31% • 25% increase in

CAUTI from the previous year

• CAUTI 4%

• DUR reduced by 19.2% (Median DUR=11.2%)

• 100% reduction of CAUTI

MedianGoal

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Device Utilization RatioUtilization ratio=(Device

Use of structured Nurse Driven Protocol is effective in reducing DUR, CAUTI rates and enhanced communication among interdisciplinary teams.

Future implication for practice:Incorporation of the protocol as part of

the organization’s procedure manual to improve patient outcomes require time and potential buy-in

1. Urinary catheter present? 2. CDC recommended indication?

3. If not=Initiate Nurse-Driven Protocol

4. Post discontinuation, monitor patient void5. Contact provider with concerns

• Bundle had no detrimental effects on NICU sleep environments and does not increase adverse events

• A Safe Sleep Practice bundle may be useful to increase safe sleep modeling by nurses

• More evidence is needed to determine if a single component led to the increase in compliance

• 3,500 infants <1year of age die each year from Sudden Infant Death Syndrome.

• Cause unknown• Risk factors: Poverty, race, prematurity, low birth weight,

no prenatal care• In 2013-2017, D.C. infants died at a rate of 108.8 per 100KProblem StatementNurses in a level IV NICU in an academic hospital in the Mid-Atlantic region were observed to inconsistently model safe sleep practice (SSP) for hospitalized infants.

Problem Statement

Conclusions

Methods Interventions: Based on similar studies/bundles• 70 beds were provided with bundle folders• Weekly audits of SSP, individual component use, documentation Setting & Population70 bed Level IV NICU; August to December 2020• Infants gestational ages ≥ 32 weeks ≤ 1 year• Weigh >1500 grams• No respiratory support greater than 1/2L NCTactics and Strategies• DNP project board for updates, email, sleep champions• Digital and in person education offerings• Workflow designed for low nursing task burden• Prize drawings and clinical ladder letters offeredEducation: ~50% of nurses educated on bundle use• Medical and nursing leadership also provided with education

Purpose: Implement a nurse driven safe sleep bundle to improve safe sleep practice (SSP) modeling by NICU nursesBundle Parts:1. Algorithm2. Bedside crib cards 3. DocumentationShort & Long-Term Goals• 100% of SSP infants will not have extra bedding in crib• 100% of SSP infants who qualify will receive it• Nurses will utilize the algorithm daily for 100% of patients

Purpose of Project & Goals

Safe Sleep Bundle and References

Bundle to Improve Safe Sleep Modeling by NICU NursesKatelyn Schmidt, RN, BSN

University of Maryland, Baltimore School of NursingJennifer Fitzgerald DNP, NNP-BC;

Susan Bindon DNP, NPD-BC, CNE, CNE-clSofia Perazzo, MD

Safe Sleep Bundle Components

References

A special thanks to the NICU staff, especially the Safe Sleep Champions: Emily Black, RN; Hannah Bourne, RN; Jasmine Rhodes RN; Jessica Simmons RN; Lisa Zell RN; MacKenzie Bergstrom RN, Madylyn Austin RN; Sarah Gaskins RN and Tatiana McGee RN; Dr. Sofia Perazzo Dr. Lamia Soghier, and NICU nursing leadership for their guidance and support.

Contact Information: katelyn.schmidt@umaryland.edu; kschmidt@childrensnational.org

Acknowledgements

Figure 1. Safe Sleep Bundle Crib Cards

See QR code for algorithm and documentation form

ResultsOutcomesTotal audits n= 238; SSP n=97• Pre- implementation 19%; final 55% compliant with all 6

measured items • T-test: significant change in compliance rates (p<0.001, ⍺=0.05)• No adverse events • Individual category increased:No positioning aids: 18%No extra bedding/items: 28%HOB flat: 9%

• Nursing used the bundle routinely Algorithm use 20-92%; crib card 67-80%; documentation 4%

DiscussionBundle Implementation• Has no detrimental effects on patients• Increased overall compliance by 36%• Components increases reflective of other studies• Increased staff SSP awareness• Increased nurse-parent conversations regarding SSPLimitations• COVID-19: limited education, audits; PPE conservation• High acuity/workload during implementation• Project known to staff prior to start• No EMR documentation/order entry for tracking• Bundle item tracking (physical components)

Figure 2. Safe Sleep Modeling Compliance by NICU Nurses After Implementation of Safe Sleep Bundle

Figure 3. Most Improved Safe Sleep Bundle Components

Results (continued)

Average

Problem

Quality Improvement (QI) Project: To implement daily therapeutic music listening sessions for geriatric patients with dementia/Alzheimer’s disease on a single BHU

Short Term Goal:• Staff nurses will offer at least one music listening session to each

geriatric patient with dementia during patient’s hospitalization at 100% adherence rate.

Long Term Goals:• Sustained daily music listening sessions on programming

schedule;• Improved symptom management for patients with dementia.

Purpose & Goals

Results

Discussion

Conclusions

ReferencesSetting: 27-bed inpatient BHU for adults ages 18 years and older

Inclusion Criteria: adults ages 65 years and older with a DSM-5 diagnosis of dementia or Alzheimer’s disease (N=10)

Implementation Strategies:• Flyers posted on unit to disseminate project information

• Virtual education seminar delivered to nursing staff

• Subset of 8 nurses trained to safely facilitate music sessions and document data in EHR

• Individual music listening sessions offered for 20-60 minutes each day in the milieu using wireless FM radio headphones

• Feedback to nurses regarding weekly adherence rates

• Protocols established for direct observation, patient safety, and headphone hygiene for infectious disease control

Methods

Baseline: No therapeutic activities provided to geriatric patients (median 0%)

Implementation: Nurse adherence rate averaged 89.7% (median 88.9%)

• Run of data points weeks 6-10 with 100% adherence rate signals process change

• Significant drop in adherence rate week 11 (likely due to Covid-19 related absences), with return to median and goal rate weeks 12-14

Music Intervention for Geriatric Patients with Dementia on a Behavioral Health Unit

Miriam Sperling, BSN, RN Katherine Fornili, DNP, MPH, RN, CARN, FIAAN

Lynn Oswald, PhD, RN

Acknowledgments

Music Intervention Adherence by Week

Limitations:• Small sample size due to Covid-19 social distancing restrictions (fewer geriatric

admissions)• Did not assess cognitive status or behaviors pre and post participation in the music

intervention

• Implementing the music activity is simple, inexpensive, sustainable, and enjoyed by patients;

• May be beneficial for use by family caregivers at home or in long term care facilities, should be included in treatment planning.

Implications for Practice:Tactics used to decrease staff resistance and promote adherence

Fakhoury, N., Wilhelm, N., Sobota, K. F., & Kroustos, K. R. (2017). Impact of music therapy on dementia behaviors: A literature review. The Consultant Pharmacist: The Journal Of The American Society Of Consultant Pharmacists, 32(10), 623–628. https://doi.org/10.4140/TCP.n.2017.623.

Shiltz, D. L., Lineweaver, T. T., Brimmer, T., Cairns, A. C., Halcomb, D. S., Juett, J., Beer, L., Hay, D. P., & Plewes, J. (2018). “Music first”: An alternative or adjunct to psychotropic medications for the behavioral and psychological symptoms of dementia. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 31(1), 17–30. https://doi.org/10.1024/1662-9647/a000180.

Motivation

Weekly staff meetings to

address barriers

Unit staff nurse

appointed as change

champion

Incentives: catered brunch & certificate of achievements

Many thanks to the following individuals for their contributions of ongoing support, staff encouragement, and valued guidance throughout this quality improvement initiative:

• Clinical Site Representative: Katherine Kaiser, MS, LCPC, ACS• Unit Manager: Claire Kidwell MS, RN • Staff nurses who implemented the project

Problem Statement

Problem Significance

Evidence-Based

Practice

75 77.871.4

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% Nurse Adherence

Average patient acceptance rate of music intervention was 26.2%; refusal rate was 73.8%

• Statistically significant association between gender and acceptance of the music intervention: Females had a higher rate of accepting the music intervention (14 observations) compared to males (5 observations). X2 2(1, N = 73) = 5.4, p =0.019.

Insufficient therapeutic activities specifically for geriatric adults with dementia/Alzheimer’s on an inpatient behavioral health unit (BHU)

Lack of geriatric specific therapeutic activities to manage dementia symptoms such as aggression may necessitate use of coercive measures, contributing to poor mental health outcomes

Listening to music is effective in reducing negative symptoms of dementia, decreasing the need for restrictive or coercive measures and medications

Recommendations for Future Project Developments: • Use of a standardized assessment instrument to evaluate

neuro-cognitive status pre/post intervention

Background/ Problem Statement

Purpose

Methods

Unmanaged significant distress linked to decreased medication adherence, increased emergency rooms, oncology clinic visits, and hospital stays, and decreased quality of life and survivalDistress screening and management recommended by NCCN per the Distress Screening Clinical Practice Guidelines (2019)

Results Discussion

• Short term goals included distress protocol development, staff education, and imbedding distress screening tool into the patient portal

• Long term goals include expanding distress screening to all oncology patients treated at the site

Implementation: September 21st, 2020 – November 20th, 2020Structure changes:• Imbedded NCCN Distress Thermometer and Problem List (DT&PL) into patient portal• Infusion nurse (RN) training to conduct and interpret distress screening and make

appropriate referrals to clinic specialty resource personnel: psychiatry liaison, pain and palliative care nurse, social worker, and/or unit chaplain

• Distress screening policy creationProcess changes:• Patients completed distress screening prior to each cycle of treatment• Infusion RNs documented distress screening review, intervention, and referrals in

nursing notesProcedures:• Staff and patient education• Weekly chart audits to monitor infusion RN adherence in distress screening review,

referrals made, and specialty resource consults with patients post referral

• Out of 42 eligible patients, 27 completed the NCCN DT&PL at least once (64%)• Out of 69 screens sent to patients, 43 screens were returned completed (62%)

Limitations:• Non-English-speaking patients did not have access to the screening• Patients without portal access did not have access to the screening• Nursing staff time constraints in fielding distress screening and promoting adherence

Conclusions

References

Acknowledgements

• Dr. Nilofer Azad• Lynn Billing, RN• Nicole Garbarino, MSW, MPH

• Rhonda Cooper, M. DIV• Laura Hoofring, CNS• Skip Viragh Nursing Staff

• A systematic protocol for distress screening in patients with mCRC is successful in identifying patients with high distress (≥4 on NCCN DT&PL)

• Appropriate consultations were initiated and completed in a timely manner• Staff compliance was generally high, especially for patients with high distress• A distress screening program can assist with identification of distress and ensure

patients are provided appropriate resources to manage distressing factors

Future directions:• Use clinic embedded nurses and/or social workers to assist with distress screening

triage to minimize burden on infusion RNs• Consider best practice advisories built into the electronic health record (EHR) to

automate interventions and referrals• Distress screening via EHR-linked tablets to support access to screening for patients

without portal access• Incorporation of the screening tool in multiple languages and the use of language

interpreters will expand screening to non-English speaking patients

• The Sidney Kimmel Comprehensive Cancer Center at The Johns Hopkins Hospital

No Documentation

38%

Documentation/Other Rationale

62%

STAFF DOCUMENTATION FOR ENSURING TOOL COMPLETION

Completed62%

Not Completed38%

TOTAL DISTRESS SCREEN COMPLETION

High Distress39%

Low Distress61%

PERCENT PATIENTS WITH HIGH DISTRESS (≥4 ON DT)

National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. (2019). Distress management (Version 3.2019). Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/distress.pdf

Implementation of a Distress Screening and Management Protocol for Adult Cancer Patients

• Out of all patients who completed the NCCN DT&PL, 39% were identified as having high distress (≥4 on the DT) and 100% of those with high distress had documented RN interventions and/or referrals in nursing progress notes

• Out of all patients with high distress, 58% requested a referral to specialty resources and all but one patient received same-day consult

• RN documentation was missing in 38% of patients who failed to complete the screening

• RN documentation was missing in 9% of patients who completed the screening. All those patients had low distress (<4 on DT)

Inclusion Criteria Exclusion Criteria• mCRC diagnosis• On standard of care infusion treatment• Day 1 of each treatment cycle• Patient portal access• English-speaking

• Other cancer types• On research protocols• Cycle 1 day 1 treatment of newly diagnosed

patients• No portal access/use• Non-English-speaking

Allison Uzupus, BSN, RN, OCN ● MiKaela Olsen, DNP, APRN-CNS, AOCNS, FAAN ● Renee Franquiz, DNP, RN, CNE ● Lori Edwards, DrPH, BSN, RN, CNS-PCH, BC

Up to 50% of oncology patients experience clinically significant cancer-related distress: Defined by NCCN as “a multifactorial unpleasant

experience of a psychological, social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical

symptoms, and its treatment”

The purpose of this QI project was to implement a systematic screening protocol for distress including a screening tool, staff training, and referral

processes to identify and manage distress in adult medical oncology outpatients with metastatic colorectal cancer (mCRC) at a large, tertiary,

academic medical center

Patients:• Percent of patients with high distress similar to literature

Infusion RNs:• Reported that triaging distress during the infusion appointment was

time consuming

Specialty resource personnel:• Successfully completed same day consultations for patients with high

distress• If more than one referral was indicated/requested, specialty resource

personnel felt some patients were overwhelmed having more than one specialty consult in the same day

75

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PATIENT ADHERENCE IN COMPLETING DISTRESS SCREENING