Example1: Exploration of Heart Rate Variability Biofeedback Among Generalized Anxiety Disorder Treatment

Purpose
Anxiety treatment is challenging due to increased rates of diagnoses, co-morbidities, and stigma seeking treatment. Variations among modalities and shortages of psychiatric providers indicate the need for effective individualized non-pharmacological complementary treatment options in addition to treatments as usual (TAU). The purpose of this practice change project was to assess the impact of two weeks use of the Lief Smart Patch heart rate variability biofeedback tool on self-reported symptoms by clients diagnosed with Generalized Anxiety Disorder (GAD).

Methods
Twenty adult clients with GAD at a private psychiatric practice in Colorado were identified via chart review and invited to participate. Ten agreed, enrolled, and were provided with education surrounding the use of the Lief HRVbF device. Baseline GAD7 screenings were collected. Usage was monitored via a digital dashboard and the GAD7 was repeated two weeks after six hours of daily Lief use.

Results
A paired-samples t-test was performed to compare individual GAD7 scores for clients (N=10). There was a significant difference in GAD7 scores between pre-intervention (M= 16.6, SD=3.09) and post-intervention (M=12.6, SD=3.4); t(9)=6.5079, p= 0.0001.

Implications for Practice
Lief HRVbF use had positive impact on self-reported anxiety symptoms from baseline GAD7 scores. These results support HRVbF as a beneficial adjunct to TAU in this practice.

Example2: Increasing Post Thrombotic Syndrome Screening and Documentation in Pediatric Patients with Extremity Associated Deep Vein Thrombosis

Purpose
Post thrombotic syndrome (PTS) is a complication of deep vein thrombosis (DVT) impacting patient outcomes and quality of life. The modified villalta scale (MVS) is one of the PTS screening tools approved for use in the pediatric population to determine the severity of PTS. To improve outcomes in patients with DVT, we implemented a standardized process for PTS screening to increase the number of pediatric patients screened for PTS at a large pediatric hematology center from 0% to 80% over a 6-week period.

Methods
A quality improvement (QI) project design was used to implement the use of the MVS tool for patients with extremity related DVT diagnosed at least 6 months prior to office visit. Eligible patients were identified via chart review. Providers received PTS education, PTS resources, and weekly reminders to facilitate PTS screening in the electronic health record (EHR) via a PTS flowsheet containing the MVS screening criteria.

Results
Seventy-five patients aged 2 months – 24 years with extremity related DVT were scheduled for follow up visit during a 6-week period. Forty-five (60%) patients were due for PTS screening. Sixteen patients did not show to their clinic visit. Of the 29 patients due for PTS screening and present for their clinic visit, 62% (18/29) were screened for PTS. Mild to moderate PTS was detected in 66.7% (12/18) patients screened.

Implications for Practice
A missed PTS diagnosis or delayed treatment can lead to severe symptoms, worsening quality of life and invasive interventions that may otherwise be prevented with early recognition. Additionally, PTS is a clinical diagnosis that is confirmed via screening instruments such as the MVS. In this study, the implementation of the MVS increased the number of pediatric patients identified with PTS, a step toward improving outcomes of patients with DVT.

Example3: Processes and Nursing Efficiency

Purpose
The purpose of this DNP quality improvement project was to design a process flow map for phone call management by nursing staff at PCHS and assess their perception of the new process to provide recommendations to stakeholders for future policy development at a rural nonprofit community health center.

Methods
This project involved the development of a nursing action team (NAT) consisting of two registered nurses and two nurse aids to gain collaborative input on a process flow map designed to streamline call management by nursing staff. A post product development analysis was used to observe the NATs collaborative input.

Results
Descriptive statistics were calculated to delineate data derived from questionnaires completed privately by individual members of the NAT. The team unanimously agrees the process flow map will make patient care more efficient, increase nursing role satisfaction and improve efficiency of the process. Data suggest respondents perceived decreased errors and increased patient connection with appropriate care in 75% of responses. All respondents agreed the flow map will increase nursing satisfaction and half provided exemplars.

Implications for Practice
Nurses are the frontline of healthcare. With the nursing shortage and increasing healthcare demand well documented, efficiency must increase. Nurses must take a vital role in the development of policies that will increase efficiency. The outcome of this project demonstrates the utility of nurses using LEAN methodology in the development of policy.

Example4: Template Implementation to Increase the Rate of Foot Exam Documentation in a Federally Qualified Health Center

Purpose
The quality improvement project aimed to implement a diabetes foot exam template that would increase the rate of foot exam performance and documentation in a federally qualified health center. The project evaluated the effectiveness of the intervention, which was designed to address barriers identified in the evidence including time, disruption of patient flow, and ease of charting.

Methods
The Model for Improvement and Kurt Lewin’s framework were used to design this quality improvement initiative. The nursing staff and provider met in a morning huddle to identify the flow for the day and discuss project goals, team roles, and expectations. Each problem list was reviewed in the huddle to determine people with diabetes to include in the intervention. The nursing staff and provider reviewed the nurse protocol to have the monofilament and tuning fork out and to have the patient remove socks and shoes. The provider performed the foot exam on eligible patients, and the foot exam was documented in the template. A retrospective chart audit was performed, and descriptive statistics were calculated to describe the rate of implementation of the foot exam template.

Results
Fifty-five eligible patients were seen during the 4-week implementation period. Forty-five of 55 eligible patients (81.8%) had documented foot exams using the template, which was considerably more than the 33% rate of documentation prior to the template implementation. Most exams during the implementation period were comprehensive with monofilament, vibratory, and visual exam. Two ulcerations to ankles and 1 small ulceration to foot were identified.

Implications for Practice
The observations from this project suggest that using a standardized template may be an effective method for improving foot exam performance and documentation. Foot exams may interrupt the trajectory of foot ulcer formation and progression. An electronic template may address barriers to foot exam documentation, including time, flow disruption, and ease of documentation.

Example5: Barriers to Prescribing SGLT2 Inhibitors by Nephrology Providers

Purpose
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been shown to reduce the incidence and progression of chronic kidney disease (CKD) in multiple randomized controlled trials.  Despite initial regulatory approval of the first SGLT2i several years ago, SGLT2i use remains low. Data reviewed from an electronic medical record system utilized by 91 nephrology providers showed that just 7.2% (381/2732) of patients with diabetic kidney disease have been initiated on SGLT2is.  Prior research has shown that there are multiple barriers to initiating SGLT2i therapy, but much of this research has focused on primary care providers, endocrinologists and cardiologists. The purpose of this project was to determine barriers experienced by nephrology providers who are seeking to initiate SGLT2i therapy in patient’s with diabetic kidney disease (DKD).

Methods
An 8-question anonymous survey was given to 80 nephrology providers to identify potential knowledge and specialty culture barriers and methods of support in the prescribing process. The survey included demographic, Likert scale, multiple choice, and open-ended questions. The survey was built in Microsoft Forms and distributed to providers by the practice information systems director. Quantitative responses were reported using descriptive statistics and qualititative responses were reported using thematic analysis.  Demographics were reported in pivot tables. Likert-scale responses were given a numerical code and data were analyzed via Microsoft Excel. Responses to multiple answer questions were entered as a dataset and analyzed via Microsoft Excel.  A list of ‘other’ responses were generated and grouped thematically.

Results
Twenty-seven providers (24 physicians and three advance practice providers) responded. Physicians had an average of 21 years of experience and APPs had an average of 9 years of experience. Related to selected randomized controlled trials, providers believed they had adequate or superior knowledge of the EMPA-kidney (55%), EMPA-reg outcome (44%), CREDENCE (74%), and DAPA-CKD (59%). When asked who should initiate prescribing and monitoring of SGLT2i in patients with DKD, respondents indicated nephrologists (59%), primary care physicians (26%), endocrinolgists (11%), and other (4%). When asked about their comfort level prescribing SGLT2is, 85% reported they were either very or somewhat comfortable. When asked about level of comfort educating patients regarding SGLT2is, 81% reported they were either very comfortable or somewhat comfortable. Information thought to be most helpful when prescribing SGLT2is included a summary of randomized controlled trials and a flowchart for prescribing and monitoring patient progress. The three main barriers to prescribing identified were cost (29%), pre-authorization issues with insurance companies (29%), and patient resistance to new medication (16%).

Implications for Practice
This project demonstrated the need to simplify prescribing SGLT2i and to give providers critical information concisely to facilitate their use. As indicated by results of the survey, flowcharts may be used to increase provider knowledge and confidence and thereby impact prescribing rates. The proiect also showed that some nephrology providers do not want to be responsible for prescribing SGLT2i. As such, it will be imperative for us to take ownership of the prescribing.  Working with primary care physicians, APRNs, cardiologists, and endocrinologists as a cohesive team will be critical in overcoming ownership and inter-specialty conflict. Lastly, this project confirmed that cost and issues with insurance pre-authorization remain a significant and possibly the greatest barrier. SGLT2i cost several hundred dollars to up to five thousand dollars a month. As a result, the most vulnerable patients are unable to access SGLT2i therapy. To address this disparity, health care providers should continue to advocate for coverage and direct patients to financial assistance programs. The overwhelming evidence that SGLT2i reduce the incidence and progression of CKD should motivate providers to proactively ensure that all patients who medically qualify for this medication have the opportunity to receive it.

Example6: Improved Adherence to Vitamin D Guidelines for Exclusively and Partially Breastfed Newborns

Purpose
The American Academy of Pediatrics (AAP) recommends vitamin D supplementation for all infants. Adherence to AAP guidelines remains low despite evidence supporting the effectiveness of supplementation. The aim of this quality improvement project was to improve provider adherence to AAP vitamin D guidelines in a newborn nursery.

Methods
This project used a Plan-Do-Study-Act (PDSA) cycle to develop and implement a standardized discharge order set for prescribing vitamin D supplementation for breastfed newborns. Provider adherence to guideline recommendations following order set implementation was assessed via chart review and descriptive statistics were used to assess the effectiveness of interventions.    

Results
There were 883 patient encounters from January 17, through February 28, 2022. Adherence to guideline recommendations was 41.6% (n = 121) for exclusively breastfed newborns and 16.9% (n = 71) for partially breastfed newborns. Overall provider adherence was 30.5% (n = 75) at 2 weeks and 27.0% (n = 192) at six weeks.

Implications for Practice
Findings were consistent with previous reports, noting improvements in prescribing rates after implementing a standardized discharge order set. Barriers to implementation included a lack of provider awareness or agreement with recommendations. Although goal adherence was not achieved, electronic order sets can be effective in improving provider adherence to evidence-based practice guidelines.

Example7: Burnout During the Covid-19 Crisis: Can Peer Intervention Make a Difference?

Purpose
Evaluate the perception of burnout amongst HCWs during the pandemic. Burnout exists among HCWs yet there is no formal evaluation and treatment protocol to manage this issue. Peer intervention can reduce burnout.

Methods
10 voluntary participants completed a pre and post intervention Maslach Burnout Inventory (MBI) over two weeks. Interventions included follow up discussions performed face-to-face, by telephone or video conferencing. Comparison of the MBI results were analyzed utilizing descriptive statistics.

Results
A reduction in the HCWs perception of burnout was noted in 2 of the 3 categories, occupational exhaustion and depersonalization. Perception of personal achievement increased. 12 HCWs volunteered, 10 HCWs remained in the study for the duration of the project, 8 engaged in peer-intervention; all 8 endorse using alcohol, prescribed medications, and/or tobacco products to cope with stress of the pandemic. All participants expressed increased awareness of their “feelings of burnout” after survey completion.

Implications for Practice
Peer intervention has a positive impact on burnout of HCWs; leadership can facilitate methods to reduce HCW burnout. Future studies should increase size of participants and length of study.

Example8: Implementing a Nurse-Driven Mobilization Protocol for Patients on Mechanical Ventilation

Purpose
Mobilization of patients on mechanical ventilation is an aspect of the Intensive Care Unit liberation bundle established by the Society of Critical Care Medicine that is overlooked in many Critical Care settings. A lack of protocol for early mobilization is a common problem in many facilities. The purpose of this project is to evaluate the impact of implementing a nurse-driven early mobilization protocol on reducing ventilator days and the rate of re-intubation for patients on MV.

Methods
The method utilized in this project is retrospective chart reviews for 50 adult patients in the Medical ICU with acute respiratory failure who received any level of early mobilization while on MV. EM was associated with a reduction in overall ventilator days, reduced sedation and vasopressor needs, and a reduction in preventable complications.

Results
Subjective results obtained from staff through pre- and post- surveys revealed a positive change in staff attitudes and engagement. Objective results demonstrated reduced ventilator days and sedation needs, earlier extubation, reduced need for tracheostomy, improved sepsis survival, mortality index, and rate of readmission in patients who received mobilization compared to the prior practice of postponing mobilization until extubation.

Implications for Practice
Early mobilization of patients on mechanical ventilation is beneficial in improving patient outcomes and in reducing healthcare cost through the prevention of complications and decreasing overall hospital days. Improvement in patient outcomes also led to increased job satisfaction for nurses and other members of the multidisciplinary critical care team.

Example9: Integration of Point of Care Ultrasound in the Emergency Department for Shoulder Dislocation Management

Purpose
Musculoskeletal dislocations compromise neurovascular integrity promoting loss of limb function. Direct observation determined limited use of point of care ultrasound (PoCUS) in a rural emergency department (ED) for timely management of shoulder dislocation. The purpose of this quality improvement project aims to assess and improve the use, knowledge, and confidence of PoCUS in a rural ED with a focused musculoskeletal educational intervention managing shoulder dislocations.

Methods
Using a validated survey tool, Evaluation Tool for Ultrasound Skills and Development, survey data was disseminated and collected via a professional survey platform via Survey Monkey to maintain confidentiality. An educational intervention via PowerPoint lecture and survey was emailed to all ED providers inviting participation. Participation served as consent. Surveys contain self-reported data related to provider demographics, education, use, knowledge, confidence, and barriers using ultrasound at the bedside.

Results
The survey obtained a 60% response rate (N=3). For musculoskeletal complaints, respondents reported using POCUS less than five times per month. None of the participants were certified in ultrasound or emergency ultrasound.  After the educational intervention, participants reported they could use POCUS to identify shoulder dislocation. Results determined low confidence levels in two respondents before intervention and after educational intervention, two respondents improved confidence and knowledge levels. Barriers to use of POCUS include lack of education/training and time constraints.

Implications for Practice
This study demonstrates that a focused quality improvement educational intervention improves confidence and knowledge applied to musculoskeletal complaints in novice scanners. Limitations include a small sample size and time constraints. Further research is needed secondary to the gap in the literature related to use of POCUS in rural emergency departments. Recommendations include replicating this study in multiple rural ED locations with the ability to collect patient outcomes data.

Example10: Program Evaluation of Peer Mentoring/Training for Labor Positioning Techniques: Pilot Study

Purpose
The purpose of this project was to evaluate a peer mentoring/training program with a group of professional labor and delivery (L&D) clinicians who participated in peer training on active labor positioning on the unit and to assess perceptions of benefit and application to clinical practice.

Methods
This project was a program evaluation of a pilot study of the peer mentoring/training program conducted in 2020 on the L&D unit.  A validated and reliable survey tool was adapted to assess value and uptake (Acceptability [AIM], Appropriateness [IAM] and Feasibility [FIM]) of the program and determine changes that may or may not need to be done. Since the completion of the pilot study, staff were encouraged to continue to utilize methods of peer mentoring/training for learning to refresh and teach labor positioning techniques among L&D professional staff.

Results
The survey was sent to 98 labor and delivery professional staff and 34 (34.7%) individuals completed in the survey. Participants gave high ratings to labor positions techniques/ use of childbirth tools and peer mentoring/training in terms of acceptability, appropriateness, and feasibility. Overall, the implementation and unit uptake of the use of labor positioning techniques and childbirth tools was found to have a high level of agreement across the participants (94-100%). Participants reported a high rate of continuing to utilize peer mentoring/training to reinforce labor positioning techniques demonstrated by the result of 18 (52.9%) of the 34 survey respondents reported engaging in peer mentoring/training on the unit since the initial peer sessions offered.

Implications for Practice
The evaluation of the peer mentoring/training and use of labor positioning techniques/childbirth tools allows for insight for further educational opportunities among the L&D professional staff. Expansion of topics through the model of peer mentoring/training can be improved with greater availability of added scheduled sessions and structure to one-on-one sessions on the unit.

Example11: Utilization of SCOFF Screening for Eating Disorders in the Adolescent Population

Purpose
To gauge whether a questionnaire administered to adolescent patients during their annual well child visit will help increase eating disorder diagnoses made in this population group by increasing the number of adolescents screened.

Methods
This study uses a quality improvement project design with the main objective being to increase the number of eating disorder screenings administered to adolescents at a privately-owned pediatric office.

Results
Of the 80 participants 55% were male and 45% were female; 88.8% of the participants had a negative screen, while 11.2% of the participants had a positive screen.

Implications for Practice
The results indicate utilization of a screening tool for eating disorders in the adolescent population will help clinicians better understand if a patient is involved in an eating disorder and if the patient needs further evaluation for treating his or her disorder.

Example12: Evaluating the use of a Checklist to Improve Antibiotic Stewardship for Urodynamics Studies

Purpose
Urodynamics studies (UDS) are considered to be a low-risk urological procedure where antibiotic prophylaxis is often not necessary. The Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) has set forth a best practice policy statement (BPPS) of recommendations for antibiotic use during this procedure. The purpose of this project was to improve antibiotic stewardship for patients undergoing UDS based on the BPPS published by SUFU.

Methods
At an outpatient urology clinic, an in-service education for providers was delivered to describe recommendations for antibiotic prophylaxis via PowerPoint presentation. A checklist was then implemented to assist the providers in identifying appropriate individuals who should receive antibiotics. Pre- and post-implementation data was collected and compared to determine if there was an improvement in provider adherence of antibiotic administration based on the BPPS.

Results
A total of 70 charts were included in the project and analyzed using descriptive statistics. The data demonstrated a 37.2% improvement rate in overall antibiotic guideline adherence (57.1% pre- vs 94.3% post-implementation) and a 46.5% improvement rate in administering antibiotics for high-risk individuals (46.4% pre- vs 92.9% post-implementation).

Implications for Practice
This program evaluation provides insights into the effectiveness of providing education and a checklist to help improve appropriate use of antibiotics for UDS. Post-procedure urinary tract infections are the most common-known risk to performing a UDS, making antibiotic prophylaxis a fundamental component of provider planning for the procedure. By utilizing a BPPS, providers can make informed decisions in an effort to promote antibiotic stewardship.

Example13: Evaluating the Impact of Hemoglobin A1C Point-of-Care Testing in a Primary Care Clinic

Purpose
HBA1C is the gold standard for measuring glycemic status, making it a critical component of diabetes management. Despite this, Winchester Medical Associates has been unable to reach organizational Comprehensive Diabetes HBA1C control metrics (82%). The specific aim of this practice improvement project was to increase HBA1C control metrics (74%) through revision and implementation of an existing HBA1C Point of Care (POC) standing order.

Methods
This project follows a mixed-methods approach which includes a focus group to identify facilitators and barriers to standing order development and implementation, followed by HBA1C POC standing order implementation, and finally, a post-implementation survey with focus group to discuss emerging themes from survey responses.

Results
Following implementation, there was a 1% increase in Comprehensive Diabetes Quality Measures with nearly 22 patients achieving HBA1C goals. Pre-implementation survey responses revealed perceptions of prompt decision making and enhanced clinical outcomes but was opposed with concerns of extended patient-provider interactions. Post-implementation perceptions validated that 100% of respondents (n=12) found HBA1C useful, allowed for rich patient discussion opportunities, and was a model that could aid in achieving quality measure expectations.

Implications for Practice
POC standing orders improve clinical operations; increase patient, provider, and staff satisfaction; and provide an opportunity for healthcare provider discussions regarding treatment plans.

Example14: Post Kidney Transplant Diabetes Education and Evaluation Positively Impacts Outcomes

Purpose
Diabetes mellitus (DM) is the leading cause of end-stage kidney disease (ESKD) and accounts for one-third of all patients initiating renal replacement therapy worldwide. However, the outcomes of patients with DM treated with dialysis or kidney transplant remain inferior to those without DM, and graft survival remains the lowest among patients with DM. Psychological disorders also have been frequently associated with poor outcomes in those with a DM diagnosis. The aim for the project is to investigate the impact of an interactive and collaborative education program on DM disease management to improve glycemic control and mitigate psychological distress associated with a poor understanding of diabetes management in transplant recipients with DM.

Methods
A single center, program evaluation utilized a retrospective chart review with a pre- and post- survey to assess glycemic control (HbA1c) and psychological distress (Diabetic Distress Scale) before and after educational sessions. The project received institutional review board approval, and informed consent was obtained from all participants. The surveys were distributed to a convenience sample of eleven kidney transplant recipients who were 1 year or less post-transplant with a documented diagnosis of DM as the cause of ESKD. An evidence-based written education was developed and utilized as the content outline for at least 2 hours of multidisciplinary diabetic educational sessions.

Results
Participation in a post-transplant tailored, multidisciplinary diabetic educational session resulted in a reduction of HbA1c [7.98 (SD 1.29) vs. 6.94 (SD 1.21)] and psychological distress as measured by Diabetes Distress Scale [2.14 (SD 0.57) vs. 1.39 (SD 0.89)]. The median time of education provided was 2.5 hours (IQR 2.5-2.75).

Implications for Practice
Participation in a post-transplant tailored, multidisciplinary diabetic education can improve glycemic control and mitigate the psychological distress in kidney transplant patients with DM comorbidity. Potential for further education on disease process would positively impact outcomes in transplant patient with DM.

Example15: Factors Influencing Registered Nurses’ Adoption of Video Monitoring to Improve Patient Safety

Purpose
To survey RNs on four inpatient units at Vanderbilt University Medical Center (VUMC) to identify factors that influence their adoption of video monitoring technology (VMT). The survey instrument was adapted from Barnett et al. (2020) Remote Video Monitoring Acceptance Tool (RVMAT).

Methods
The adapted survey included 13 demographic items, 22 closed-ended items using a five-point Likert scale, and two free-text questions. Descriptive statistics were used to report the findings and a thematic analysis was conducted for the free-text items.

Results
Twenty-four RNs completed the survey for a response rate of 17.8%. The results revealed strong engagement with VMT (M 3.99/SD 0.66). Participants reported agreement on intention to use (M 4.25/SD 0.60) and attitude towards using VMT (M 4.09/SD 0.58). Facilitating factors included patient condition (confusion), ability to redirect patients, and lack of sitters. Fifty-eight percent of the participants disagreed or were uncertain that VMT monitoring was continuous, and identified it as a barrier to using VMT. Lack of education across units was also identified as a barrier.

Implications for Practice
Understanding nurses’ acceptance of VMT into nursing practice is critical to mitigate its underutilization and to ensure patients’ experience the best possible outcomes (Barnett et al. 2020). Nurse leaders using the RVMAT can identify facilitators and barriers with adoption of VMT. These findings can assist nurse leaders with implementing strategies which decrease patient self-harm events, decrease costs, and improve patient outcomes.

Example16: Barriers to Metabolic Monitoring of Antipsychotic Medications in an Integrated Care Clinic

Purpose
Second generation antipsychotic medications (SGAs) carry both short-term and long-term side effects of metabolic side effects. The current problem addressed by this project are provider perceived barriers to adherence to the guidelines for monitoring of metabolic side effects for SGA medications. The purpose of this project was to assess providers perceived barriers to monitoring of SGAs and conduct an educational intervention on the monitoring of SGAs.

Methods
REDCap was utilized to administer pre and post educational intervention surveys. Providers were surveyed about barriers to metabolic monitoring of SGA medication. Utilizing the pre-survey data an educational intervention was held to provide training on evidence-based practice for metabolic monitoring. Clinical patient data of those patients prescribed SGAs within the clinic was collected from the EMR to establish current baseline adherence to clinical practice guideline.

Results
100% of providers were unaware of the current clinical practice guidelines for metabolic monitoring of SGAs. Most providers felt that SGAs should be monitored. Most providers reported patients being seen telehealth only as the most significant barrier to monitoring.

Implications for Practice
This project was a quality improvement project developed to assess provider perceived barriers to adherence and to provide an educational intervention based upon metabolic monitoring guidelines to promote adherence to these guidelines. Despite having evidence-based practice guidelines when patients are treated on SGAs poor adherence to the recommendations continue (Mitchell et al., 2012). Improved rates of metabolic monitoring according to the established NCQA guidelines in patients prescribed SGA medications aid in mitigating or reducing long-term side effects of SGAs.

Example17: The Implementation of Evidence Based Practice Guidelines for Sedation Management in the Pediatric Intensive Care Unit

Purpose
Current pediatric critical care recommendations suggest that the implementation of unit specific goal directed sedation titration may decrease sedation exposure for pediatric patients as well as increase staff satisfaction.  The purpose of this quality improvement project was to develop a set of sedation titration guidelines to streamline sedation practice and improve nursing satisfaction with patient sedation management in a high acuity 28 bed mixed medical and cardiac PICU.

Methods
A set of evidence-based sedation titration guidelines were developed by a multi-disciplinary PICU team.  Prior to implementation, a survey on nursing perception of current sedation practice was emailed to all PICU nurses.  Education sessions were provided for all participants prior to project implementation.  Compliance data was collected during the initial six-week implementation period to ensure implementation by all staff.

Results
A total of 39 out of 100 registered nurses completed the sedation satisfaction survey for a response rate of 39%.   The majority of nurses surveyed felt that provider variation was the largest barrier to sedation management on our unit (62%, n=24).  90% of respondents felt strongly that caring for a patient that was not adequately sedated affected their job satisfaction.  At the start of the observation period, less than half of patients had an appropriate sedation score ordered, despite that having been the practice on the unit prior to the project.  This improved to 100% by the conclusion of the initial 6-week period.  The guidelines also recommended that bolus doses of sedation were equivalent to the drip rate, which was a new practice for our providers.  The compliance for dosing was 0% for the first two weeks but improved to 78% by the end of the initial 6-week implementation period.

Implications for Practice
Job satisfaction of nurses in our PICU is affected by their patient’s level of sedation, as well as their perception of how well providers listen to their concerns.  Sedation guidelines may help to increase nursing autonomy by providing clear parameters for contacting providers regarding sedation related concerns.  Additional PDSA cycles are required to determine whether the total exposure to sedation agents also occurs when multi-disciplinary guidelines are in place.

Example18: Screening of Primary Care Patients on Opioid Pain Medications for Potential Opioid Abuse

Purpose
The purpose of this DNP quality improvement project was to implement the use of an opioid abuse screening tool in a rural primary care clinic setting, where previously none existed.

Methods
This quality improvement project used the Model for Improvement (MFI) which included the Plan-Do-Study-Act (PDSA) cycle. Using the Webster Opioid Abuse Screening Tool (Webster, 2005) a project team was created and objectives set. The tool was implemented over a 5 week period, with 53% of the participants identifying as Native American. The tool asks several questions which are scored, the higher the score, the greater the risk for opioid abuse.

Results
An adult primary care population of 34 patients, seen in the pain management clinic, were screened. Following successful implementation of the tool, 28 of the 34 scored in the high-risk category, indicating the tool provided valuable information to assess risk. It was also discovered that gender and cultural bias may exist in the tool and need further evaluation.

Implications for Practice
The findings of this project support using an opioid risk screening tool. The tool provided insight into patients at high risk for opioid abuse and may be useful in guiding decisions related to care and referrals.

Example19: Influence of Interventions/External Factors on ACP Rates of Hospitalist Providers in Inpatient Hospitalized Elderly Patients (65+ years old)

Purpose
Analyze interventions/external factors which may have increased ACP rates by hospitalist providers to a goal of 15% or greater, from 1/16/2016, through 12/31/2021, for hospitalized, elderly (65+ years-old) inpatients. Analyze ACP rates that were increased and sustained for at least two quarters (quarter = one of four periods of three months each of a calendar year) from 1/16/2016, through 12/31/2021, for hospitalized, elderly inpatients. 

Methods
This retrospective project analyzed ACP rates of a hospitalist group at a 400-bed community hospital in Vancouver, Washington. Quarterly ACP billing rates (only way to track ACP)  for inpatients aged 65+ from January 1, 2016, through December 31, 2021, were obtained and displayed on a run chart. The dates of initiation of educational modules (1st, 2nd and 3rd versions), the start of $20 bonus incentive payments, the end of the $20 bonus incentive payments for each ACP completed, and the start of the COVID-19 pandemic were marked on a run sheet to analyze the influence of these interventions/external factors.

Results
The greatest and longest sustained increase in ACP rates occurred from quarter 3 of 2016 (0.08%) to quarter 4 of 2017 (13.06%). This was an increase of 12.98% over 5 quarters. The first educational module and the second educational module were released during this time. Rates did not reach goal of 15% during this time period. Initiation of second educational module and start of ACP $20 bonus incentive increased ACP rates from 3.9% to 13.06% (increase of 10.82%) from first quarter of 2017 to the fourth quarter of 2017. Rates did not reach goal of 15% during this time period. The sharpest increase in the shortest amount of time and over the 15% ACP goal was 11.89% in quarter 1 of 2020 to 24.48% in quarter 2 of 2020. This took place at the start of the COVID-19 pandemic at this site. This was the first time that ACP rates met or exceeded goal of 15%. The highest ACP rate was 28.39% in quarter 4 of 2020. ACP rates declined from 23.57% to 12.75% from quarter 1 of 2021 to the quarter 2 of 2021 (sharpest decline of 10.82%) which is when ACP $20 bonus incentives stopped. The longest sustained period of increased ACP rates over the goal of 15% was from quarter 2 of 2020 (24.48%) through quarter 1 of 2021 (23.57%). Notably, the third educational module was released at this time as well as the start of the COVID-19 pandemic.

Implications for Practice
Educational modules had the greatest and longest influence to increase ACP rates at this site. Ongoing educational interventions are feasible at this site. All providers have access to an online education platform and can complete online educational modules at their convenience. Making these modules mandatory as part of onboarding for new providers and a yearly requirement for current providers may help to increase and sustain increased ACP rates (Back, et al., 2019; Goff, et al., 2019; Nassikas, et al., 2020; Palathra, et al., 2018). At the beginning of the COVID-19 pandemic, this site stopped elective surgeries and Hospitalist providers were furloughed due to a low patient census. This may have allowed Hospitalist providers that worked during that period to have more time with patients. This project only included ACP rates of elderly patients on Medicare. Patients hospitalized at the beginning of the pandemic at this site were elderly, which may also be the reason ACP rates for elderly patients at this site increased during this period. The end of the ACP incentive bonus correlates with ACP rates dropping at this facility. A small monetary incentive for each ACP completed or a stipend for completing educational modules could be implemented at this site. Studies demonstrate that financial incentives help increase and sustain ACP rates by creating long-lasting behavior changes even years after financial incentives were stopped. (Haynes, et al., 2019).

Example20: The Role of Health Literacy on the Impact of a Diabetes Education Intervention

Purpose
The purpose of this project is the implementation of a diabetes education intervention by a nurse practitioner to participants with type-2 diabetes. The aims of this project include: (1) improved diabetes knowledge scores, and (2) analysis of diabetes knowledge scores between type-2 diabetic members with and without low health literacy (LHL).

Methods
A spoken communication strategy using a diabetes education booklet titled, “Taking Charge of Your Diabetes” was implemented during annual wellness visits with diabetic subjects. Health literacy level was assessed prior to the education intervention using the REALM-SF tool. Diabetes knowledge was assessed using a pre and posttest of eight items from the modified T/F version of the Diabetes Knowledge Test (DKT).

Results
Subjects with low health literacy (n= 3) were able to improve their diabetes knowledge score following the intervention. One subject with normal health literacy (REALM-SF = 7) also improved their diabetes knowledge score from pre to posttest. Low health literacy in subjects (REALM-SF < 7) did not prevent them from learning from the intervention. All subjects with low health literacy (n = 3) had <12th grade education level. Good health literacy (REALM-SF = 7) did not necessarily mean better health outcomes.

Implications for Practice
The spoken communication education tool tested during this small study was appropriate to teach diabetic subjects with low health literacy. This study determined there was no relationship between health literacy and glycemic control based on hemoglobin A1C in this small group. The “Taking Charge of Your Diabetes” tool should continue to be utilized for diabetic who have low health literacy during the annual wellness visits.

Example21: Creating an ambulatory workplace violence program

Purpose
Violence toward healthcare professionals by patients, families, or visitors is a growing problem for many healthcare organizations. Workplace violence has been associated with reduced job satisfaction, commitment and efficiency, low quality of life, increased stress, sleep disruption, burnout, and even death. Therefore, we aimed to create a comprehensive and structured ambulatory workplace violence prevention, reporting, and support program among all ambulatory care clinics.

Methods
Create a manager toolkit that will help individuals navigate workplace violence. The workplace violence committee will use the plan, do, study, act (PDSA) improvement model to create materials, present materials to key stakeholders, collect feedback on materials, iterate, and then train on the use of the materials. The toolkit is a manager checklist, instructions on actions, documentation, and adding staff safety flags in EPIC, support resources, and workflow to legally guide the manager through the patient warning and dismissal process.

Results
After the training is conducted, we will measure the number of reported workplace violence incidences in the ambulatory care setting and the managers’ perception of preparedness to handle incidences.

Implications for Practice
Creating an ambulatory workplace violence program will help address workplace violence in the unique outpatient setting and provide support and a much-needed sense of psychological safety for several thousand staff and faculty members.

Example22: Improving Skin Assessments Using Visual Reminders

Purpose
The aim of this quality improvement project was to increase the completion rate of the 4E4H admission skin assessments by RNs in the THH-ICU from 50% to 100% by implementing 4E4H visual reminders placed on the computers used for documentation, and reminder posters placed in east and west staff breakrooms.

Methods
The Model for Improvement was used as the planning and implementation framework. Baseline 4E4H chart audit data from September of 2020 was used to compare to the results of four weeks of 4E4H chart audit data collected after implementation of the visual reminders.

Results
The 4E4H completion rates demonstrated no sustained improvement during the project. The average 4E4H completion rate over the 4-week study period was 50% which was the same completion rate as the baseline completion rate used in this project.  However, there were extenuating circumstances, the COVID-19 pandemic, that may have negatively impacted the results of the project due to nurse emotional exhaustion and fatigue related to caring for the COVID-19 patient population.

Implications for Practice
Although the results of this project did not meet the aim for improving 4E4H admission skin assessment documentation to 100%, improving 4E4H admission skin assessments remains an important mission to reducing HAPIs on THH-ICU which result in decreased patient length of stay and hospital costs (Bauer, 2016) as well as significant patient suffering (Gorecki, 2009).