Interprofessional Education Commons^™

Don’T Fall For It: Just-In-Time Staff Education To Reduce Patient Falls On An Adult Telemetry Unit, Forrest Wilcox, Kyle Knight, Jennifer Paiz, Zaira Garcia-Vega

Master's Projects and Capstones

Objective: Patient falls remain a leading cause of preventable harm among hospitalized adults and carry significant clinical and financial consequences. On an adult medical-surgical telemetry unit at this study site, a one-year review of 45 fall events found that most falls occurred among patients classified as high risk on the Morse Fall Scale, frequently without continuous observation or consistent purposeful rounding. Aim: The aim of this project is to reduce falls on the telemetry unit to the national benchmark of 3.2 falls per 1,000 patient days within a 6-month period. Methods: A just-in-time (JIT) education intervention was delivered to registered …

The Comfort Cart Initiative: A Quality Improvement Intervention To Improve Patient Satisfaction In The Emergency Department, Heidy Cladimir Ayala

Doctor of Nursing Practice Final Project Abstract

The Comfort Cart Initiative: A Quality Improvement Intervention to Improve Patient Satisfaction in the Emergency Department

Purpose

The Comfort Cart QI project aimed to improve Emergency Department patient, parent, and guardian satisfaction by 10% over an 8-week implementation period.

Background

In healthcare, patient satisfaction is an important indicator of the quality of care provided, and many literature reviews suggest it is closely associated with patient-centered care.

 Methodology

The Comfort Cart intervention is an evidence-based quality improvement project employing a pre- and post-intervention design, conducted over an 8-week period, in the Emergency Department. The project was guided by Kolcaba's Comfort Theory …

Skin Is In: Promoting Breastfeeding Through Immediate Cesarean Skin-To-Skin, Autumn Spencer

All Doctor of Nursing Practice (DNP) Scholarly Projects

Problem: The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) and the American College of Obstetricians and Gynecologists identify immediate, uninterrupted skin-to-skin contact as a standard of care that improves neonatal stability, breastfeeding outcomes, and maternal satisfaction. Despite these recommendations, timely initiation following cesarean birth remains inconsistent. At the project site, skin-to-skin initiation averaged 72 minutes after birth, exceeding the 10-minute benchmark, and exclusive breastfeeding rates were below the national standard of 70%. Contributing barriers included workflow variability, unclear role expectations, and inconsistent communication.

Aim of the Project: The aim of the project was to improve infant and maternal …

Expanding Waste Segregation Initiatives To Reduce Regulated Medical Waste: A Multi-Departmental Quality Improvement Project, Emily M. Su, Anuja L. Sarode, Mohammed Sami, David R. Nehring, Erica L. Laipply, Mustafa Culcuoglu

HCA Healthcare Journal of Medicine

Background

Regulated medical waste (RMW) drives up health care costs, largely due to misclassification of general waste, especially in operating rooms (ORs), intensive care units (ICUs), and obstetrics and gynecology (OBGYN) departments. This study aimed to reduce RMW volume and costs at Akron City Hospital (ACH) through department-specific interventions aligning with Occupational Safety and Health Administration (OSHA) and Ohio Environmental Protection Agency guidelines.

Methods

Periodic analyses compared hospital-wide aggregate RMW volume, pick-up frequency, and disposal costs before and after interventions. The ORs initiated interventions in October 2022, expanding to ICUs and OBGYN by February 2024. Strategies included staff education, flyers …

Introducing Education For Sensory Approaches In Mental Health-Related Emergency Department Visits: A Quality Improvement Project To Enhance Patient-Centered Care, Jesse O'Neill

Master's Theses and Capstones

Background: Barriers to specialty care access have resulted in emergency departments (ED) operating as temporary psychiatric hold facilities for their communities. Patients boarding in the ED are demonstrated to use a disproportionate percentage of facility resources with minimal benefit to the patient. The Institute for Healthcare Improvement identifies the impact of the healthcare environment on patient outcomes and suggests staff training to foster trauma-informed practice culture (Schall et al., 2020).

Local Problem: High-stress healthcare environments can escalate maladaptive patient behaviors and the use of restrictive interventions. Traditional use of restrictive interventions lacks supportive evidence and contradicts person-centered care goals (Molloy …

Improving Dka Protocol Adherence In The Emergency Department, Anjolaoluwa Lawani

Master's Projects and Capstones

Problem There was inconsistency in implementation of the DKA protocol by nurses in the emergency department at the Hospital A. Only 58% of the nurses reported feeling comfortable following the DK protocol, and 84% of the nurses described the DKA order set as confusing. Context Hospital A is a large magnet-recognition hospital system in the Bay Area. The emergency department at Hospital A averages about 12 DKA patients per quarter. Intervention Education sessions were held during pre-shift cuddles across day and night shifts to clarify the DKA protocol and answer any questions or nurses may have. Measures Baseline surveys and …

Streamlining Nuclear Theranostic Clinic Workflow, Charisma Desai, Anne Fisher

Advances in Cancer Education and Quality Improvement

Nuclear medicine clinic needs have drastically changed with the emergence of theranostics, exciting new agents in the fight against cancer. However, administering these agents is a resource-intensive task, increasing demand for physician consultation time with patients, clinic office space, and scanner time. We examined our institution’s nuclear medicine clinic workflow and interviewed the clinic’s front desk staff, technologists, nurses, managers, physicians, and patients to find sources of delays, dissatisfaction, and decreased efficiency. An Ishikawa diagram and decision matrix helped us determine the most impactful intervention with our available resources. For this cycle, we focused on the consent process. Theranostic patients …

Enhancing Patient Outcomes: Developing A Comprehensive Database For Tracking Post- Dural Puncture Headache Incidence And Contributing Factors, Meredith B. Auge, Brittany Bogonovich

Doctor of Nurse Anesthesia Practice (DNAP) Manuscripts

Post-dural puncture headache (PDPH) is a debilitating complication following labor analgesia, often resulting from unintentional dural puncture (UDP). While national incidence is approximately 1.5%, institutional rates may vary due to provider experience, documentation practices, and patient factors. This Doctor of Nurse Anesthesia Practice (DNAP) quality improvement project aimed to improve identification and monitoring of UDP and PDPH through a revised tracking tool, retrospective review of 2024 data, and planning for an electronic registry. A multidisciplinary team of anesthesiologists, Certified Registered Nurse Anesthetists (CRNAs), Student Registered Nurse Anesthetists (SRNAs), and IT and quality specialists revised an existing tracking tool to better …

Implementation Of A Standardized Onboarding Program, Sarah J. Wall

Doctor of Nursing Practice Final Project Abstract

Purpose: To evaluate the impact of a standardized onboarding program on Advanced Practice Provider (APP) retention and productivity within an academic department.

Background: High APP turnover in specialized settings disrupts care and leads to financial losses. Previously, onboarding lacked structure, leading to early attrition and delayed productivity. A 24-week phased, competency-based orientation program was developed to improve retention, job satisfaction, and clinical performance.

Methods: The program, implemented in April 2024, included clinical precepting, didactic modules, and mentorship. Retention and Relative Value Units (RVUs) were measured before and after implementation. Qualitative data was collected through mentorship surveys and APP focus groups. …

Unsuitable Underlying Cause-Of-Death Statements: Implementation And Evaluation Of A Structured Process For Healthcare Providers Certifying Natural Causes Of Death In An Outpatient Setting, Naida Rutherford

Doctor of Nursing Practice Projects

Background: Accuracy in death certification is crucial for effective public health initiatives. Inaccuracies in unsuitable Underlying Cause-of-Death (UCOD) statements can distort mortality statistics, influence health policy, and impact resource allocation. In South Carolina, changes in the death registration process and the introduction of an unsuitable cause-of-death list highlighted an urgent need for structured training among certifiers to enhance accuracy in death documentation.

Purpose: The purpose of this project was to implement a standardized training program for healthcare providers certifying natural causes of death and assessing the impact of reducing the unsuitable underlying cause-of-death inaccuracies in an outpatient hospice setting.

Project …

Reducing The Percentage Of Intubation Time On Continuous Infusion Midazolam, Arsemen Brown, Emily Highsmith, Michelle Horng

Advances in Cancer Education and Quality Improvement

This quality improvement study was conducted at a comprehensive cancer care center with the aim to decrease the percentage of on continuous infusion (CI) midazolam by 30% by May 5, 2023. The pre-intervention and post-intervention data collection phases occurred from January 1, 2022, to October 31, 2022, and March 7, 2023, to May 5, 2023, respectively. Sedation was assessed utilizing the Richmond Agitation and Sedation Scale (RASS), and delirium was assessed utilizing the Intensive Care Delirium Screening Checklist (ICDSC). A sedation pathway and associated educational materials were developed by a multidisciplinary team and frontline staff. Interventions in the sedation pathway …

Persistent Improvement In Opioid Perceptions And Prescribing For Cancer Surgery: 5-Year Follow-Up, Brittany C. Fields, Timothy E. Newhook, Heather A. Lillemoe, Jessica E. Maxwell, Jose M. Soliz, Keyuri U. Popat, Christina L. Roland, Jean-Nicolas Vauthey, Matthew H. G. Katz, Ching-Wei D. Tzeng

Advances in Cancer Education and Quality Improvement

Background and Objectives

We previously reported that implementation of a department-wide opioid education program led to post-education improvements in opioid perceptions and prescription recommendations, with one-month and one-year retention. With ongoing programmatic and quality improvement efforts, we sought to re-evaluate the retention of these improvements five years after initial efforts.

Methods

Attending surgeons, clinical fellows, and advanced practice providers were surveyed five years after implementation of a comprehensive, departmental opioid reduction framework in August 2018. This framework initially consisted of dedicated opioid education sessions and retrospective assessment of prescribing practices, and subsequently expanded over time to include prospective quality improvement …

Evaluating The Impact Of A Renal Dosing Refreshable Sidebar Report On Appropriateness Of Antimicrobial Dosing At A Large Acute Care Cancer Hospital, Emily Fox, Jovan Borjan, Nancy Vuong, Hannah Aune, Claire Marten, Joshua Hendrickson

Advances in Cancer Education and Quality Improvement

Background: Appropriate antimicrobial dosing is vital in the treatment of patients with infectious diseases, though adherence to guideline recommended doses is often suboptimal.

Outcomes: This study was conducted to evaluate the impact of a renal dosing refreshable sidebar report, which displayed recommendations from a previously developed institutional antimicrobial dosing guide at the time of antimicrobial order entry. The primary outcome was adherence to daptomycin dosing guideline recommendations before and after implementation.

Methods: This was a pre- and post-quasi-experimental study at a 600-bed acute care cancer hospital. Adult patients (≥18 years old) that received daptomycin from February-April 2021 (pre-intervention phase) and …

Improving Vitamin B12 Monitoring In Metformin-Treated Patients: A Quality Improvement Project, Himal Kharel, Zeni Kharel, Abdullah A. Orakzai, Aditya Sanjeevi, Prajjwol D. Bhatta, Ali S. Mohamed, Tripti Jain, Aniket-Vijay Rao, Daniel Idoate Domench, Mouna Reghis, Hassan Saeed

Advances in Clinical Medical Research and Healthcare Delivery

Background: Although periodic vitamin B12 monitoring is recommended for patients on chronic metformin therapy, the recommendation is not adequately followed. Similar quality improvement project in the past had failed due to ongoing COVID-19 pandemic.

Objectives: The main objective of this study is to evaluate the impact of focused educational lectures on vitamin B12 screening rates. Our target study population included diabetics and prediabetics on chronic metformin therapy.

Design: Quality improvement pre-post design

Participants: Internal Medicine residents

Intervention: Educational sessions on the importance of vitamin B12 screening in this population

Outcomes: Proportion of patients undergoing vitamin B12 screening pre and post-intervention …

Increasing Serious Illness Conversations In Patients At High Risk Of One-Year Mortality Using Improvement Science: A Quality Improvement Study, Kanishk D. Sharma, Sandip A. Godambe, Prachi P. Chavan, Agatha Parks-Savage, Marissa Galicia-Castillo

Department of Family and Community Medicine Faculty Publications

Background: Serious illness conversation (SIC) in an important skillset for clinicians. A review of mortality meetings from an urban academic hospital highlighted the need for early engagement in SICs and advance care planning (ACP) to align medical treatments with patient-centered outcomes. The aim of this study was to increase SICs and their documentation in patients with low one-year survival probability identified by updated Charlson Comorbidity Index (CCI) scores. Methods: This was a quality improvement study with data collected pre- and post-intervention at a large urban level one trauma center in Virginia, which also serves as a primary teaching hospital to …

Enhancing Patient Safety: The Role Of Interdisciplinary Teams In Reducing Blood Culture Contamination, Austin Patrick Eisenberg, Fady M. Awad, Brian Watson, Mohammed Faris

HCA Healthcare Journal of Medicine

Background

Blood cultures are vital to diagnostic workups among many hospitalized patients, providing valuable information about bloodstream infections (BSIs), which cause roughly 250 000 deaths annually between North America and Europe. Despite advances in health care, blood culture contamination remains a substantial problem, with deleterious effects on patient mortality, patient and hospital costs, and microbial resistance. This article reviews the repercussions of blood culture contamination on the health care system and delineates evidence-based strategies to decrease contamination rates.

Methods

To reduce blood culture contamination rates, our health care facility undertook a quality improvement initiative. A task force was created, consisting …

Post Anesthesia Care Unit Comprehension Safety Program Quality Improvement Project On De-Escalation Of Patients, Mary M. Gaukler Giannavola, Basil George Verghese, Deborah Maier

Advances in Clinical Medical Research and Healthcare Delivery

Background:

Violence within the healthcare setting has risen significantly, and has crossed into areas where staff are less prepared to manage and deescalate challenging patient encounters. This lack of preparedness and confidence has led to increased staff stress, burn out, and can potentiate poor patient outcomes.

Methods:

A pre/post-simulation quality improvement project was performed within a tertiary hospital Post-Anesthesia Care Unit in Upstate New York to evaluate the effect of simulation on feelings of confidence and preparedness in patient de-escalation with PACU nurses and patient care technicians. The project evaluation included the Thackrey’s Clinician Confidence in Coping with Patient Aggression …

Quality Improvement In Healthcare: A Practical Guide For Providers (Part 3), Jeremy Ellis

Transformative Medicine

No abstract provided.

Outpatient Fall Prevention In Ambulatory Adults 65 Years Old And Over, Dorothy L. Osborne-White

Doctor of Nursing Practice (DNP) Scholarly Projects - Archive

Background: In the United States (U.S.), falls are the leading cause of injury among adults 65 and over, resulting in 36 million falls yearly (Moreland et al., 2020). According to the Centers for Disease Control and Prevention (CDC, 2023), one in four older adults experiences a fall each year. Falls are the world's second most prominent cause of accidental deaths (World Health Organization [WHO], 2021). Falls are the leading cause of both fatal and non-fatal injuries among older adults (Moreland et al., 2020).

Methods: A quality improvement project that included a fall bundle was implemented in a primary clinic. A …

Scares: A Clinician Guide To Spinal Cord Awareness, Response, And Emergency Support Creation And Implantation Of Scares Protocol Among Hospitalist Advanced Practice Providers, Brittany Biega

DNP Scholarly Projects

While they are more common in patients with oncological disease and trauma, SCE still exist among patients without these comorbidities. Less has been established regarding care protocols in this population. The absence of standardized procedures has been linked to preventable, adverse patient outcomes, including cases of permanent damage due to delayed treatment. This project employs Lean Six Sigma methodologies and Johns Hopkins Evidence- Based Practice to devise a robust SCE protocol, aimed at standardizing care and improving patient outcomes. A multidisciplinary team including general medicine, neurology, neurosurgery, and neuroradiology developed “Spinal Emergency Management Guidelines” protocol, which was implemented within the …

Non-Clinical Perspectives On Sepsis: A Project For Enhanced Awareness, Anjali Kumari Singh

Master's Projects and Capstones

Problem: This project aimed to enhance non-clinical staff knowledge of sepsis through a targeted awareness campaign, while also seeking to uphold or enhance the organization's sepsis-related performance.

Context: Clinical Nurse Leader students conducted a microsystem assessment in five crucial non-clinical departments of an urban Bay Area hospital, each playing a vital role in the organization's efficiency at different levels.

Intervention: During Sepsis Awareness Month, a sepsis awareness campaign was implemented. This involved a concise presentation on sepsis, its consequences, and the significance of awareness in each department. Additionally, informational fliers detailing sepsis signs and symptoms were distributed.

Measures: A pre-and …

Patient Safety Workshop: A Graduate Medical Education Interprofessional Simulation Half-Day, Ans Albustamy, Roque Mifuji, Michelle Lopez, Teresa Villagomez, Chelsea Chang

Research Symposium

Introduction: As per the National Academy of Medicine, patient safety is considered indistinguishable from the delivery of quality health care, and is referred to as the foundation upon which all other aspects of quality care are built. Throughout the years, graduate medical education (GME) across the world has evolved to ensure the training of future medical professionals includes exposure to many of the elements that compose patient safety, such as implementing root cause analysis, systems thinking, and disclosing adverse events. University of Texas Rio Grande Valley (UTRGV) is the sponsoring institution for 19 GME programs across different specialties. As part …

Implementation Of A Virtual Interprofessional Icu Learning Collaborative: Successes, Challenges, And Initial Reactions From The Structured Team- Based Optimal Patient-Centered Care For Virus Covid-19 Collaborators, Simon Zec, Nika Zorko Garbajs, Yue Dong, Ognjen Gajic, Christina Kordik, Lori Harmon, Marija Bogojevic, Romil Singh, Yuqiang Sun, Vikas Bansal, Linh Vu, Kelly Cawcutt, John M. Litell, Sarah Redmond, Elly Fitzpatrick, Kirstin J. Kooda, Michelle Biehl, Neha S. Dangayach, Viren Kaul, June M. Chae, Aaron Leppin, Mathew Siuba, Rahul Kashyap, Allan J. Walkey, Alexander S. Niven

Jefferson Hospital Staff Papers and Presentations

IMPORTANCE: Initial Society of Critical Care Medicine Discovery Viral Infection and Respiratory illness Universal Study (VIRUS) Registry analysis suggested that improvements in critical care processes offered the greatest modifiable opportunity to improve critically ill COVID-19 patient outcomes. OBJECTIVES: The Structured Team-based Optimal Patient-Centered Care for Virus COVID-19 ICU Collaborative was created to identify and speed implementation of best evidence based COVID-19 practices. DESIGN, SETTING, AND PARTICIPANTS: This 6-month project included volunteer interprofessional teams from VIRUS Registry sites, who received online training on the Checklist for Early Recognition and Treatment of Acute Illness and iNjury approach, a structured and systematic method …

Bundle Up To Improve Cauti, Jennifer Anderson, Valorie Dearmon

DNP Manuscripts

Catheter Associated Urinary Tract Infections (CAUTIs) are a leading cause of healthcare acquired infections. Strong evidence for CAUTI best practices exists, however, the struggle to translate best practice evidence into everyday practice remains a challenge. Catheter associated urinary tract infection rates continue to be a problem despite organizational efforts to implement best practice guidelines; the challenge is to effectively translate and embed best practices into everyday practice. The Centers for Medicare and Medicaid Services (CMS) will no longer reimburse hospitals for expenses associated with hospital acquired CAUTI; moreover, hospitals are subject to penalties for high rates of hospital acquired CAUTIs. …

Sepsis Inservice And Video At An Urban Hospital In California, Angela T. Ho

Master's Projects and Capstones

The emergency department at an urban hospital in California was performing below institutional goals related to sepsis protocols over the past few months. This intervention was targeted at nurses and was composed of a PowerPoint in-service on compliance to SEP-1 protocols and follow-along video on using the correct sepsis order set and documentation in the electronic health record (EHR). Goals included increased compliance to the SEP-1 protocol and documentation, (2) reduced time between the onset of symptoms, recognition, and intervention, (3) decline in sepsis rates and mortality rates, and (4) lower cost of care. Data was collected from the EHR …

Multicomponent Approach To Delirium Prevention In The Acute Care Setting: An Evidence-Based Quality Improvement Project., Kelley James

Doctor of Nursing Practice Papers

Background: Acutely ill, hospitalized individuals are at an increased likelihood of developing delirium. Between 30-35% of those patients admitted to the hospital will develop delirium, and as a result, these individuals will face an increased risk of mortality, adverse medical events, restraint usage, and incur a more extended hospitalization. The literature supports early screening utilizing the Confusion Assessment Method (CAM) tool and nurse-driven, multicomponent interventions to aid in preventing its development.

Environment: This project was implemented in a long-term, acute care facility specializing in patients requiring long-term mechanical ventilation, advanced wound care, pulmonary and respiratory care, and the rehabilitation of …

Asking The Question ‘What Matters To You?’ In A London Intensive Care Unit, Harriet Pittaway, Laura White, Karen Turner, Angelique Mcgillivary

Journal of Patient-Centered Research and Reviews

Purpose: At the heart of the paradigm shift in approach to patient care from paternalism toward shared decision-making lies the international “What Matters To You?” (WMTY) movement. However, WMTY principles are not frequently applied to the critical care setting. The aim of this quality improvement project work was to design and integrate a tool for all patients admitted to the intensive care unit (ICU) that helped answer WMTY.

Methods: Using Plan-Do-Study-Act (PDSA) methodology across 8 cycles, a multidisciplinary team designed and integrated a bedside poster into the ICU. Quantitative and qualitative data were collected via a bedside audit process on …

Implementation Of A Drive-Through Covid-19 Mass Vaccination Site: Experiences From Louvax–Broadbent In Louisville, Kentucky, Ruth Carrico, Sarah Beth Hartlage, Valenchia Brown Msn, Aprn, Fnp-C, Sarah M. Bishop, Luanne Didelot, William Hayden, Beverly Williams Coleman, Sarah Tan, Delanor Manson, Kellie Kane, Dawn Balcom, Paul Kern

The University of Louisville Journal of Respiratory Infections

Background: Response to the COVID-19 pandemic has required innovative approaches to vaccination, including methods to rapidly and safely immunize communities. A major challenge to such a response involved access to untapped healthcare worker resources. The Louisville, Kentucky, response involved the use of a large volunteer workforce to supplement local public health employees in planning and implementing a large-scale drive-through vaccination event. The objective of this manuscript was to outline processes involved in training a mass immunization workforce and implementating a large-scale COVID-19 community vaccination.

Approach: Competency-based and standardized training was provided for every volunteer before working their shift. Volunteers worked …

Reducing Pressure Injuries In The Intensive Care Setting: Nursing Knowledge And Best Practices Approach, Michelle Harvey

Doctor of Nursing Practice Projects

Background: For many health care organizations, pressure injury (PI) prevention strategies have become a priority focus to improve patient outcomes and associated costs.

Problem: A rural community hospital located in the Eastern U.S. experienced an increase in hospital acquired pressure injuries (HAPIs), predominantly in the intensive care unit (ICU). In 2018, 17.4% of HAPIs occurred in the ICU.

Approach: Implementation of a Quality Improvement project in an adult ICU, providing education and on-going learning activities to nursing staff, and applying a standardized plan of care “bundle” for prevention interventions.

Outcomes: The approach resulted in improved documentation of flotation of heels, …

Getting On The Same Page: A Quality Improvement Project To Reduce Overnight Nursing-To-Resident Physician Pages In An Inpatient Rehabilitation Unit, Renae Fisher Md, Rajbir Chaggar Md, Anthony Zenger Md, Susan Hamilton Rn, Bsn, William Carter Md

Graduate Medical Education (GME) Resident and Fellow Research Day Posters

Introduction
Many Physical Medicine and Rehabilitation (PM&R) residency programs utilize “home call” systems for nighttime coverage of inpatient services. In this system, trainees are expected to work at full capacity the following day after taking nocturnal call. While “on call,” trainees receive both urgent and non-urgent pages throughout the night, which disrupt sleep. To mitigate fatigue, improve hand-offs and improve timing of patient care, this study targeted reducing non-urgent overnight pages from nurses to home call PM&R residents between 11pm to 6am.

Methods

We implemented a prospective quality improvement study with interventions including holding “Getting on the Same Page” meetings …