Nursing Commons^™

The Clinical Nurse Leader As Risk Anticipator: Optimizing The Completion And Accuracy Of The Code Blue Recorder Sheet, Catherine Morano

Master's Projects and Capstones

Abstract

• A small community hospital in northern California implemented a practice improvement project in critical care units to optimize best practices surrounding a “code blue” event. In-Hospital Cardiac Arrest (IHCA) is a high-risk process of care that requires tremendous resources to deliver an efficient, safe, and cost-effective service. The code blue recorder sheet summarizes the whole patient care event; this necessitates careful documentation. As a risk anticipator, the unit clinical nurse leader identified suboptimal variation in documentation after a microsystem assessment. This led to a practice change project and targeted educational intervention for code blue recorders. Fifteen staff members were …

Implementing Risk Tools To Prevent Hospital Readmission, Tara O'Connor

Master's Projects and Capstones

Implementing Risk Tools to Prevent Hospital Readmission

Tara O’Connor

Abstract

Background: Readmission reduction is one of the most important opportunities for reducing cost in today’s health care system.

Global Aim: To operationalize risk tools to reduce hospital readmissions by 5 percent by the end of 2017.

Project Aim: To develop new transitions program (TP) processes that operationalizes the risk tools and ensures 70 percent of all readmission risk score patients referred receive a post discharge phone call within 48 hours, and are assessed for their risk of medication management issues as part of their initial assessment, by August 1^{st, …}

Cnl As Educator In The Emergency Department: Improving Hand Hygiene Outcomes, Michelle Batz

Master's Projects and Capstones

Prevention of hospital acquired infections (HAI) is a National Patient Safety Goal. Proper and frequent hand hygiene (HH) prevents HAI and various cross-infections in any setting. Audits of visual adherence for HH generates low compliance scores. During a yearlong improvement project, low monthly compliance scores of 52% in the Emergency Department (ED) of a community hospital, were reported by hospital auditors and found to be inaccurate by ED staff due to lack of visibility of HH actions because they occurred behind curtains or closed doors. Low scores and challenges were associated with behavioral change among ED team members, requiring multiple …

Improving Pain Management In The Cardiac Procedure Unit, Marisol Aquino

Master's Projects and Capstones

Abstract title: Improving Pain Management in the Cardiac Procedure Unit (CPU)

Unit: Cardiac Procedure Unit

Author: Marisol Aquino RN, BSN

Institution: University of San Francisco; Kaiser Permanente Nurse Scholars Academy; Kaiser Permanente Hospital, San Francisco (CNL practicum site).

Background Information

Cardiac Procedure Unit (CPU) specializes in the care of patients who are undergoing various cardiac procedures. The day-to-day operations are composed of Registered Nurses (RNs), Patient Care Technicians (PCTs), Unit Assistant (UA), and Nurse Practitioners (NPs) with an oversight from the Medical Director and Department Managers.

Patients’ perception of pain in the CPU has continually followed a “see-saw” pattern and …

Pursuing Equity In Diabetes Population, Aisha Rawlinson

Master's Projects and Capstones

Abstract

Background

Poor glycemic control (HbA1c >8) overtime leads to microvascular and macrovascular complications after the first and third years respectively, ultimately resulting in death after five years (Karter, 2016). Current Kaiser Permanente (KP) data stratified by race, ethnicity, age, and gender shows a significant disparity gap between Hispanics/Latino and Caucasian populations. The Pursuing IHI initiative is over a 2-year period completed at a microsystem that is focusing on health equity practices to reduce disparity gaps.

Project aim

KP Riverside, microsystem selected has a large population of Hispanic/Latino KP members, with focus on health equity. The project aim is to …

Newborn Kangaroo Care Immediately After Cesarean Birth, Sarah Abdolcader

Master's Projects and Capstones

Newborn Kangaroo Care Immediately after Cesarean Birth

Sarah Abdolcader

Global Aim: Improve exclusive breastfeeding rates from 76% to 80% in the Perinatal Unit during the newborn’s hospital admission by February 2018.

Project Aim: Improve the percentage of mother/baby skin-to-skin (kangaroo holding) from a baseline of 55% to 65% by August 2017.

Setting: Perinatal Units

Participants: Newborns birthed via cesarean section

Evidence: According to the World Health Organization (2003), hospitals should have a goal of >80% exclusive breastfeeding rates for all newborns during their acute hospital stay and it begins with skin-to-skin contact (SSC), newborn’s bare chest placed on mom’s bare …

Aligning Theory And Evidence-Based Practices To Enhance Human Flourishing In Nurse Executives, Jim D'Alfonso

Doctor of Nursing Practice (DNP) Projects

Today’s nurse executives lead highly complex and bureaucratic organizations undergoing sweeping reform at an unprecedented rate of change. Change and high levels of stress are the norm in health care, and ineffective stress management can hinder organizational performance and adversely impact personal wellbeing. The risks of nurse executive burnout and unprecedented turnover led to the development of a 4-hour program to teach theory-guided and evidence-based stress management techniques. The program was intended to increase awareness, enhance effective stress management skills, and improve the nurse executive’s ability to flourish in high stress environments. A pre-intervention and 6-month post-intervention assessment (n …

Implementation Of An Innovative Early Warning System: Evidenced-Based Strategies For Ensuring System-Wide Nursing Adoption, Shirley S. Paulson

Doctor of Nursing Practice (DNP) Projects

Early deterioration in adult medical-surgical patients is associated with increased intensive care unit and hospital mortality (Goldhill, 2001). Failure to recognize deterioration is a preventable patient safety and quality issue. To address this problem, since 2013, Kaiser Permanente Northern California (KP NCAL) has piloted Advance Alert Monitor (AAM) at two hospitals. This early warning system employs a set of predictive models developed by the KP NCAL Division of Research, which automatically predicts patient deterioration within the next 12 hours based on a complex algorithm of laboratory and clinical data points. Improvements in mortality and length of stay have been realized …

Readiness For Improving Safe Care Delivery Through Web-Based Hospital Nurse Scheduling & Staffing Technology: A Multi-Hospital Approach, Lisa Massarweh

Doctor of Nursing Practice (DNP) Projects

Hospital scheduling and staffing practices are linked to patient safety, nurse satisfaction, and cost outcomes (Steege & Rainbow, 2017). Staffing, while complex, is ultimately central to the overall success of the hospital. Demands to eliminate events that cause death or serious harm, produce high patient satisfaction scores while maximizing workforce productivity, test any administrator’s skillset. Providing qualified staff in the right place at the right time can be challenged by restrictive union contracts, variable patient acuities, staff attendance, and mandated staffing ratios. These demands may lead to overtime utilization. There is a growing understanding of the negative effects of healthcare …

Hap Prevention: One Tracheostomy At A Time, Elenita Gianan

Master's Projects and Capstones

Abstract

The objective of this project is to educate the nursing and respiratory therapist staff, along with the patient and their families on the importance of discarding used suction catheters. The intention of this project is to provide awareness and education on the negative implications of re-using a saved one-time use tracheal suction catheters. As a future CNL, through the competency as the Clinician, designating and coordinating care for the individual to promote health and risk prevention can be practiced. Many times, a single-use tracheal suction catheter was noticed hanging connected to the suction wall, tucked under the patient’s pillow, …

Evidence-Based Verbal De-Escalation Techniques For The Family Nurse Practitioner: Education And Simulation, Rachael K. Misitano

Doctor of Nursing Practice (DNP) Projects

Background: Healthcare workers are 4 times more likely to be exposed to workplace violence than workers employed in private industry, with assault rates as high as 7.8 per 10,000 workers. The National Institute for Occupational Safety and Health defines workplace violence as “violent acts, including physical assaults, and or threats of assault, directed toward persons at work or on duty” (OSHA, 2015, p. 2). Verbal de-escalation techniques that assist with care of the agitated patient are not routinely taught to Family Nurse Practitioners (FNPs) throughout their years of advanced coursework, yet it is something they are likely to encounter …

Promotion Of Advance Care Planning For Individuals Experiencing Homelessness, Sarah A. Hubbell

Doctor of Nursing Practice (DNP) Projects

Vulnerable populations in the United States experience disparities in access to advance care planning and may have significant unmet healthcare needs at the end of life, including unrelieved suffering. People who are homeless have increased morbidity and mortality risks, yet lack opportunities to discuss end-of-life preferences. A Doctor of Nursing Practice project consisted of designing, implementing, and evaluating an educational intervention in two settings for nurse practitioners and other clinicians on advance care planning with individuals experiencing homelessness. The intervention was associated with increased knowledge and confidence in advance care planning ability. Participants expressed positive intention to change individual practice …

Gavage Program For The Preterm Infant, Amanda K. Guina

Master's Projects and Capstones

Preterm infants in the Neonatal Intensive Care unit, are susceptible to hospital acquired infections due to their immature immune systems. To mitigate this occurrence a change project will be implemented to decrease the incidence of nosocomial infection in this population. The project will be focusing on preterm infants working on full nipple feeds. Our project is aiming to discharge this population home with a nasogastric tube to work on feedings, rather than remaining in the hospital. Chart Audits were conducted pre-program and found approximately 18 patients acquired blood stream infections and 2 acquired MRSA. The method used to assist in …

Inpatient & Outpatient Venous Thromboembolism: A Multifactorial Approach To Increase Mechanical And Pharmacological Prophylaxis Compliance, Suzanne E. Scheierling

Master's Projects and Capstones

Venous thromboemboli (VTEs) are a clinical and public health problem as they are commonly linked to inpatient experiences, yet frequently occur in the outpatient setting. VTEs place a significant burden on health care organizations and patients alike, as VTEs are costly, require long-term medications, and frequently reoccur. Research has identified risk factors and determined best practices for VTE prevention and prophylaxis, however little consensus exists among health care organizations and the implementation of best practices is varied. This project studied the challenges and opportunities in VTE prevention and prophylaxis at a large metropolitan hospital in California. Environmental changes were made …

Infection Control: Reducing Hospital Acquired Central Line Bloodstream Infections, Bobbie Joy Hollins

Master's Projects and Capstones

Hospital-acquired infections are a leading cause of morbidity and mortality in neonatal intensive care units (Ceballos, Waterman, Hulett, & Makic, 2013). It’s estimated that each neonatal bloodstream infection costs about $35,000 and adds about two weeks to a baby’s hospital stay (Akron's Children Hospital, 2015). This project was formulated to reduce the incidence of central line blood stream infections in the neonatal population. The setting used for this project was a 40 bed Level III Neonatal ICU. The methods executed include: conducting a root-cause analysis and formulating a unit survey. Kurt Lewin’s Three-Step Change Model was also used to complete …

Hospital Acquired Clostridium Difficile Infection Prevention, Sandy Maalouf

Master's Projects and Capstones

Abstract

The aim of my CNL Internship Project is to decrease the incidence of healthcare acquired C diff infections at the acute care unit 1800 to zero for the next quarter. This will be accomplished by developing an action plan to address the issue by collecting data from audits and developing evidence based practice interventions. The process begins with patient’s admission to the medical surgical unit and ends with patient’s discharge from the medical surgical unit.

By working on the process, the Hospital Acquired Infection (HAI) team expects to improve infection control among all units, increase patient safety, reduce unnecessary …

Breast Cancer Patient Preparedness For Transition To Survivorship: Individualized Survivorship Care Plans, Kimberly Beringer

Master's Projects and Capstones

Purpose. For breast cancer survivors, after-effects of surgery, radiation and chemotherapy can be substantial, and recurrence is a concern requiring constant surveillance. National healthcare organizations have promulgated guidelines that include providing individualized survivorship care plans (SCP’s). At a northern California oncology department, SCP’s will be prepared for breast cancer patients and delivered in-person by the oncology nurse navigator (ONN).

Method. The author worked with the ONN to develop the format and content requirements for the SCP’s. The ONN prepared individualized plans for patients and scheduled in-person appointments to deliver the SCP’s. A feedback survey to assess preliminary impact was then …

Improving Communication And Satisfaction Through Hourly Rounds, Karen E. Sondeno

Master's Projects and Capstones

The focus of this CNL project is quality improvement using high quality hourly rounds to achieve improved patient satisfaction and communication with nurses. It was determined by reviewing survey results that patient satisfaction and nurse communication is below National levels. Data shows that rounds are not being done well on a medical unit before the improvement project. It is proven that patients receive and perceive higher quality care and communication with increased nurse presence at the bedside. The population of the medical unit has high numbers of confused/dementia, and dual-diagnosis patients. It was determined that the unit would benefit from …

Perception And Behavior For Underreporting Workplace Violence, Marissa L. Payne

Master's Projects and Capstones

The project is focused in a medical centers’ emergency department that serves a diverse population, varying in age, health, socio-economic status, and mentation; and at a given 24-hour period, the department will care for about 150 to 200 patients. The focus is on the Clinical Nurse Leader (CNL) essential to advocate a change in the culture of acceptance of workplace violence and the perception of the value of reporting violent behavior. To identify the factors that hindered reporting of workplace violence, a root and cause analysis was performed. The analysis revealed that the most common reason behind underreporting is the …

Reducing Alarm Fatigue In Critical Care, Janice A. Winfrey

Master's Projects and Capstones

Reducing Alarm Fatigue in Critical Care

Abstract

This improvement project took place on the Critical Care Unit (CCU) of a non-profit hospital in Northern California. The unit houses 54 beds, employs over 210 employees, and houses the facility’s central cardiac monitoring station which utilizes unit staff. The objective was to improve patient safety through reducing the risk of alarm fatigue by decreasing the total number of clinical alarms on the unit. Specified goals included a 20% reduction in the number of alarms sounding on the unit with a 20% reduction in telemetry utilization. Goals were chosen based on unit assessment …

Optimizing Electronic Healthcare Records And Improving Process In The Healthcare Clinic, Joana Salazar

Master's Projects and Capstones

Abstract

The purpose of this project is to examine the reasons for low compliance in entering data into the electronic healthcare record (EHR) and implement a change to improve the process. The project consists of generating data and reviewing charts to determine the reasons data on homelessness and income status are not entered in the EHR. If data is not entered, this may lead to a threat to the quality of care provided by the clinic and a potential loss of status as a Federally Qualified Healthcare Center and recognition as a Patient-Centered Medical Home. The baseline data shows that …

Reducing Patient Supply Waste Through Nurse Education To Improve Quality Of Patient Care In The Clinical Microsystem, Lale Johnston

Master's Projects and Capstones

CNL Final Project Abstract

With my CNL project, I sought to reduce patient supply waste in the clinical microsystem by 50% by the end of the second quarter of 2017. The project was conducted in a 19-single-room adult surgical/orthopedic unit in a community hospital. I completed a through microsystem analysis with 5 P’s, SWOT analysis, and hospital HCAHPS scores as well as staff interviews. I then continued doing observational audits for supply use, barcode scanning, supplies in patient rooms, staff efficiency, and challenges facing nurses and their time constraints (Godfrey, Nelson, & Batalden, 2004).

During this process, I also completed …

Improving Breastfeeding Rates By Using Glucose Gel To Treat Newborn Hypoglycemia, Madena Barak

Master's Projects and Capstones

Newborn hypoglycemia occurs in 5-15% of newborns during the postnatal period (Weston et al., 2016). Typical treatment for hypoglycemia includes supplementing with formula, which causes a decrease in breastfeeding rates, decreasing patient satisfaction, and interfering with maternal-infant bonding. To combat this issue, a large community hospital in Southern California used Lewin’s Theory of Planned Change to implement an alternative intervention for the treatment of newborn hypoglycemia. Evidence based articles as well as collaboration with surrounding hospitals was used to support the use of oral dextrose gel instead of supplemental formula to treat newborn hypoglycemia. The hospital’s revised treatment protocol on …

Performance Gap Among Nurses In Splint Application And Crutch Training, Aidalyn P. Carino

Master's Projects and Capstones

Abstract

The aim of this CNL internship project is to improve the current nursing practices by closing the performance gap among nurses on splint applications and crutch training within the 3-month course of this project. This project was implemented in a urgent care setting where Minor injuries such as sprains, strains or fractures are commonly seen by immobilization by application of splints which is given by the nursing staff. Micro assessment of the work flow of unit showed that only a few members of the staff routinely do these procedures and results from a self- assessment survey showed that 50% …

I’M A Big Kid Now: Enhancing Transition Rn Residents’ Confidence During Pediatric Patient Care, Emily W. Lam

Master's Projects and Capstones

The title of the clinical nurse leader project is “I’m a Big Kid Now: Enhancing Transition RN Residents’ Confidence During Pediatric Patient Care”. The project aims to improve the support components for Transition RN residents during their Transition RN Residency at Children’s Hospital Los Angeles. The clinical leadership theme that correlates to this project is communication. The clinical nurse leader’s role is to act as an educator and a facilitator throughout this project. In examining the clinical nurse leader competencies, competencies “use performance measures to assess and improve the delivery of evidence-based practices and promote outcomes that demonstrate delivery of …

Standardization Of Shift Report By Implementing A Nursing Report Sheet And Addressing Patient Values To Meet Patient Needs, Roman A. Salas

Master's Projects and Capstones

Bedside shift report is a complex process, which involves the transition of care from one clinician to another. The Agency for Healthcare Research and Quality (AHRQ) (2013) reported that approximately 70% of patient adverse events are attributed to communication failures between healthcare providers. Nurses remain inconsistent with information sharing during bedside shift report leading to communication gaps. The object of the clinical nurse leader (CNL) internship project is to provide true patient-centered by standardizing bedside shift report by implementing a nursing report sheet and addressing patient needs. The project was conducted in a level-one trauma center in San Diego, CA …

Process Improvement Manual: Front And Back Office, Hafsah Badar

Master's Projects and Capstones

The global aim of this project is to decrease variations and improve efficiency in the tasks assigned to the support staff at an outpatient breast clinic. The breast center has a five-person administrative team who rotate through four positions monthly. The specific aim is by May 1, 2017, 100% of the five employees will have a comprehensive knowledge of their role, and adhere to a standardized way of completing tasks. The CNL Leadership themes used were Educator, Team Leader Manager, and Outcomes Manager. Informative interviews were conducted with the staff to gauge the unique needs of the team. 100% of …

Improving Stroke Documentation On A Stroke Unit, Yvette Melgoza

Master's Projects and Capstones

The aim of this project is to improve adherence of stroke documentation per stroke protocols on a stroke unit at an acute hospital setting through nursing education and EPIC modifications. A comprehensive retrospective data collection was done to determine the inconsistencies of nursing documentation per organizational protocols. Firstly, a randomized sample of 163 stroke patients (Site 1 = 98; Site 2 = 65) was generated for retrospective data collection. For this project, the main focus was Site 1 (n = 98). The sample from Site 1 consisted of 4 types of stroke patients, which were patients who either received alteplase …

An Eicu/Icu Collaborative To Reduce Sepsis Mortality, Laura S. Maples Ms.

Master's Projects and Capstones

Sepsis costs over 20 billion dollars annually to treat making it the most expensive diagnosis for hospitals (Afrefian, et al., 2017) and carries with it an average mortality rate of 45% (SCCM, 2016). The eICU/ICU collaborative project was developed to improve sepsis mortality at Sutter Health’s Solano hospital affiliate from 41.2% to the system-wide goal of 18.8% over the course of a year by implementing two technologies. The first was the onboarding of the non-invasive cardiac output monitoring (NICOM) technology by Sutter Solano to fulfill the 6-hour bundle compliance for septic shock resuscitation. The other technology was the activation and …

Delirium: A Cnl-Led Protocol To Clear Up The Confusion, Shanda N. Whittle

Master's Projects and Capstones

Project objectives: Delirium is a form of organ failure defined as an acute change in cognition, evidenced by altered consciousness and impaired attention that fluctuates over time, and is associated with increased morbidity, mortality, and healthcare services utilization. In the hospital where this evidence-based practice project took place, there was no formal protocol or guideline for assessing or managing delirium. Therefore, this project focused on improving the practice of identifying patients at risk for developing delirium with the AWOL tool and treating patients with signs and symptoms of delirium found using the Short-CAM assessment. Population and setting: This project took …