Dodge The Fall: A Newborn Fall Prevention Initiative, Lenora Thompson

Master's Projects and Capstones

Problem: This newborn fall prevention initiative was developed in response to an increase in the number of newborn falls at a Bay Area hospital on the postpartum unit. This hospital had gone six years without a newborn fall but by September of 2023 had three falls on the postpartum unit.

Context: The setting for this newborn fall prevention initiative is an urban, NICU level III Bay Area hospital that provides high-risk obstetric care. This Bay Area hospital has 247 licensed patient beds; 10 beds make up the postpartum unit and 11 beds make up the antepartum unit which serve as …

Lovenox Prophylaxis: Improving Lovenox Nurse Education In A Postpartum Unit, Amy T. Nguyen

Master's Projects and Capstones

Problem: This quality improvement project aimed to increase nurse education about Lovenox

prophylaxis within the postpartum unit to reduce risks of pulmonary embolism among high-risk postpartum women in the postpartum unit. Context: A microsystem assessment was completed by Clinical Nurse Leader (CNL) students in the postpartum unit at Hospital X located in the southern Bay Area. This unit accommodates 25 beds and provides care for postpartum mothers after both cesarean section and vaginal births. Intervention: An anonymous pre-intervention survey was distributed to the registered nurses on the unit. Educational handouts were created and distributed to the nurses on the unit. …

Optimizing Sepsis Management Through Enhanced Protocol Compliance In The Emergency Department, Monica P. Rabago Moreno

Master's Projects and Capstones

Problem: This quality improvement project aims to enhance early sepsis management and sepsis bundle compliance among Emergency Department nurses to reduce the risk of sepsis-related deaths as well as hospital length of stays.

Context: A microsystem assessment, in the emergency department (ED) unit, was performed in Hospital A located in the Greater San Francisco Bay area by Clinical Nurse Leader (CNL) students. This ED unit cares for a variety of critical care patients ranging from urgent to life-threatening conditions.

Intervention: An intervention was not implemented in the ED unit due to time constraints and limitations; however, CNL students provided recommendations …

Optimizing Sepsis Management Through Enhanced Protocol Compliance In The Emergency Department, Camila Sanchez

Master's Projects and Capstones

Problem: The purpose of this quality improvement (QI) project revolves around increasing overall staff nurse compliance, enhancing their sepsis education resources, and usage of their provided education and bundle. This goal was created to produce more positive patient outcomes at Hospital X, along with its improved management of sepsis. Hospital X is an acute care facility located in the San Francisco Bay Area.

Context: The unit that was studied during this QI project was the emergency department of Hospital X. This unit provides level I trauma services in addition to other types of emergency care and contains 44 beds. Not …

Improving Triage Accuracy In The Emergency Department, Catriona E. Clohessy

Master's Projects and Capstones

Problem: Hospital Z’s emergency department was experiencing a triage inaccuracy rate that exceeded the accepted national benchmark of 10%. This quality improvement project aimed to reduce triage inaccuracy to less than 10% in the emergency department at Hospital Z, through improved education and availability of supplemental reference materials.

Context: This quality improvement project was conducted in a 40 bed emergency department at Hospital Z. This microsystem serves a diverse patient population from the surrounding community that experience a variety of conditions requiring emergency medical intervention.

Interventions: Clinical Nurse Leader nursing students partnered with unit leadership to create a new ESI …

Improving Triage Accuracy In The Emergency Department, Joselyn Silverman

Master's Projects and Capstones

Problem: High rates of patients being mis-triaged was occurring at Hospital X leading to poor patient outcomes and incorrect staffing levels.

Context: This quality improvement project took place at Hospital X’s emergency department. A stakeholder analysis and a microsystem assessment along with a staff survey was created in order to determine areas of improvement and staff responsiveness.

Interventions: Eight educational seminars were conducted along with Hospital X leadership and students created supplemental materials for the staff to use on a daily basis.

Measures: Two data pulls were conducted over the course of the quality improvement project; one prior to the …

Improving Triage Accuracy In The Emergency Department, Maia E. Baglin

Master's Projects and Capstones

A Northern California emergency department (ED) faced increased triage inaccuracy. An analysis of 400 random ED visits from January to April 2023 discovered a 23% mistriage rate, with under- and over-triage rates at 16.25% and 6.75%, respectively. Mistriage creates an imbalance in unit acuity, leading to inappropriate staffing levels. Potential breaks in the triage process, include inaccurate triaging by the screener or triage nurses, as well as delays in the providers inputting initial orders, leaving patients waiting without appropriate care orders. An educational training focusing on the updated Emergency Nurses Association Emergency Severity Index (ESI) algorithm version 5 was mandated. …

Improving Triage Accuracy In The Emergency Department, Vince Harrington

Master's Projects and Capstones

Problem: Mistriage was occurring at higher than acceptable rates. In turn, this caused poor staffing levels and patient outcomes. This project seeks to improve triage accuracy according to the Emergency Nurses Association’s (ENA) Emergency Severity Index (ESI) algorithm.

Context: The Emergency Department in a prominent bay area hospital that was experiencing high rates of mistriage.

Interventions: The staff nurses were required to attend a retraining on the Emergency Nurses Association (ENA) Emergency Severity Index (ESI) algorithm. Following the retraining, a follow up online exam with sample patients must be passed at 100%. Furthermore, badge buddies containing the ESI algorithm will …

Improving Early Sepsis Recognition: Resocializing Intensive Care Unit Nurses In A Large Hospital On The Inpatient Sepsis Bundle Checklist, Elizabeth Rose Maykel

Master's Projects and Capstones

Problem: In order to lower sepsis morbidity and mortality rates through early recognition and treatment, this quality improvement project sought to raise sepsis awareness and bundle compliance within the Intensive Care Unit.

Context: Clinical Nurse Leader (CNL) students completed a microsystem assessment of the Intensive Care Unit at Hospital X in Northern California. This unit cares for patients with sepsis, organ failure, respiratory failure, different types of shock, acute kidney injury, and traumatic brain injury.

Interventions: The implemented intervention included a refresher huddle on sepsis bundle awareness. Though the intervention was ineffective, the students did offer recommendations …

Resocialization Of An Inpatient Handoff Sepsis Bundle Checklist On A Medical-Surgical Unit, Sophia Kawada

Master's Projects and Capstones

Problem: In September 2023, it was found that only 25% of nurses were familiar with an inpatient handoff sepsis bundle checklist (IHSBC) on a Medical-Surgical Unit in Hospital A. This evidence-based project aimed to improve resocialization of the IHSBC such that compliance to the bundle continues to be maintained well above the benchmark of 75%. Context: Clinical Nurse Leader (CNL) students at the University of San Francisco conducted a microsystem assessment of the Medical-Surgical Unit at Hospital A. This hospital aimed to maintain high rates of compliance with the IHSBC. Interventions: Resocialization of the IHSBC was completed in October, and …

Optimizing Sepsis Management Through Enhanced Protocol Compliance In The Emergency Department, Efrain Perez Trujillo

Master's Projects and Capstones

Problem: This quality improvement (QI) project aims to optimize early sepsis management and sepsis bundle compliance among Emergency Department (ED) registered nurses in order to reduce the risk of sepsis-related deaths and associated hospital length of stay.

Context: Clinical Nurse Leader (CNL) students conducted a microsystem assessment on the ED at Hospital A, located within the greater San Francisco Bay Area. This microsystem, equipped with 115 nurses and 44 rooms, consists of an acuity of care for urgent to life-threatening medical conditions, including sepsis.

Intervention: Following time constraints, and limitations, implementation of an intervention was not feasible; however, CNL students …

Reducing Hospital-Acquired Pressure Injury In An Inpatient Medical-Surgical Telemetry Adult Unit By Educating And Encouraging Basic Wound Care Prior To Wound Care Consult, See Wai (Amy) Kong

Master's Projects and Capstones

Problem: A medical center in the Diablo Service Area had one of the highest rates in hospital-acquired pressure injury (HAPI), benchmarking with other facilities, with the project unit one of the top offenders. The patients and the medical center both suffered from the harm. Barriers to HAPI prevention included lack of patient turnings, skin assessment, and early standard wound care treatment.

Context: This project focused on the primary care team standardizing early wound care treatment to avoid wound progression.

Interventions: Interventions included re-educating the primary care team on early basic wound care using a standard wound care guideline created by …

Mentoring Nurses After Specialty Training Or Orientation In Labor And Delivery, Benjamin Jlopleh Worji

Master's Projects and Capstones

Mentoring Nurses After Specialty Training or Orientation in Labor and Delivery

Abstract

Background: The setting for this project was a northern California hospital-based healthcare system referred to as “Hospital KV.” Hospital KV is a non-profit, integrated hospital that operates to improve the community’s health. Hospital KV’s maternal child health (MCH) department comprises a labor and delivery(L&D) unit, a mother and baby unit (MBU), also referred to as a postpartum unit, and an intermediate nursery (IMN).

Problem: The hospital KV MCH department faced the challenge of a nursing shortage. The nursing shortage was associated with substantial challenges to Hospital KV, its …

Enhancing Diabetic Patient Continuous Glucose Monitoring Access, Colleen Ildefonso

Master's Projects and Capstones

Problem: Diabetic patients utilize treatments that require frequent monitoring and medication changes based on their blood sugar results. Continuous Glucose Monitoring (CGM) is more commonly used for diabetes management as time in range is becoming more prevalent to measure diabetes outcomes. Many diabetic patients find CGM use more accessible than finger sticks and glucometers. In contrast, others utilize the technology to closely monitor their blood sugars for interventions throughout the day. However, older adults have difficulty facilitating new CGM technology and may require further reinforcement using additional education methods such as teach-back.

Context: The endocrinology clinic serves a patient population, …

Reducing Care Companion Utilization In Medical-Surgical And Telemetry Units, Mary Jane B. Sagabaen

Master's Projects and Capstones

Abstract

Problem: The facility highly utilized sitters or care companions, negatively impacting the staffing plan, budget, and productivity. An average of 56 hours of care companions were used daily. This greatly exceeded the budget of 33 hours a day. Reassigning Patient Care Technicians (PCT) as care companions resulted in inadequate nurse support for patient care and increased cost for additional staffing needs. Despite this, the fall rate remained higher than the target.

Context: The patient population is mainly 65 years old and above, sometimes with confusion, dementia, delirium, and at high risk for falls and elopement. The culture included promptly …

Patient Education Improvement Initiative For Self-Management Of Congestive Heart Failure Among Senior Residents Of A Long-Term Care Facility, Abigail A. Abella, Brooke Sheck, Daniela Ramos, Ivy H. Nguyen, Mary Tran, Roshni Nagarajan

Master's Projects and Capstones

The purpose of this quality improvement project was to use evidence-based practices to determine if personalized education on disease self-management would lead to improved treatment adherence in a residential facility. The target population consisted of four elderly female patients who had been diagnosed with congestive heart failure (CHF) and were struggling with the self-management of their disease. Contributing barriers to effective CHF self-management were determined using a root cause analysis, and included a lack of educational templates, declining cognitive ability of the residents, and no electronic health record (EHR). Using the Self-Determination theory, the interventions were implemented. Phase one was …

Dodge The Fall: A Newborn Fall Prevention Initiative, Shirley B. Varela

Master's Projects and Capstones

Problem: There has been a rise in In-hospital newborn falls following evidence-based practices such as breastfeeding and rooming that promote mother and baby bonding (Karlsson et al., (2021). U.S. hospitals have approximately 600 to 1,600 newborn falls annually (The Joint Commission [TJC], 2018).

Context: A San Francisco Bay hospital with a postpartum unit experienced three newborn falls as of 2023. The level III neonatal intensive care unit is a high-risk obstetric facility with more than 3,000 births annually. It comprises 21 hospital beds: 10 on the postpartum and 11 on the antepartum floors.

Intervention: Developing and implementing the “Pledge Form …

Dodge The Fall: A Newborn Fall Prevention Initiative, Linda Nguyen

Master's Projects and Capstones

Problem: In the past year, three separate newborn fall incidents occurred on the postpartum unit at Hospital X. This project aims to increase nurse-to-patient education on newborn fall prevention, thereby reducing the number of newborn falls on the unit.

Context: This quality improvement project was implemented on the postpartum unit at a hospital located in San Francisco County. At this hospital, the postpartum unit consists of 10 beds in postpartum and 11 beds in antepartum. Currently, there is no standardized method used by registered nurses to prevent newborn falls.

Intervention: The requirement for mothers to sign the Pledge Form for …

Feasibility Of Using Podcasts For Knowledge Dissemination To Reduce Health Disparities For Women Targeting Preventative Initiatives And Lifestyle Medicine Interventions, Kristin Stovern

Doctor of Nursing Practice Scholarly Project

The purpose of this feasibility project was to look at podcasts to shed light on the issues that affect the well-being of women with gender-based disparities in healthcare. Women face persistent obstacles when it comes to the quality of healthcare they receive. One of the barriers that has been ever-present is with failure of the medical system to rigorously study the effects of diseases and drugs on women or to fund studies on women’s health conditions. Implicit biases and lack of access to care inhibit the quality of healthcare. Collectively, these issues result in unnecessary sickness, disability, and decreased quality …

Frequency Of Ciwa Scoring In Patients With Alcohol Dependence In A Mental Health Setting, Heather Mcmanis

Doctor of Nursing Practice Scholarly Project

The purpose of this quality improvement project was too assess the knowledge and attitudes of nursing staff toward assessing patients diagnosed with alcohol dependence who are detoxing from alcohol in a mental health facility. An educational intervention was done with nursing staff to assess their knowledge of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale and to stress the importance of frequent and accurate use of the scale. Data was collected for three months before the educational intervention and three months after the educational intervention on the total number of patients admitted to the facility with a diagnosis of …