2015 Research and EBP projects

Mae Lavente RN, ANP-BC

Study Aim: Does classical music played for 30 minutes twice daily for patients 65 years and older identified to be experiencing delirium result in a decrease in the CAM score?

This study received expedited IRB review in July 2015 until June 2016.

Background: As the “graying” of America continues, it is becoming increasingly important for healthcare professionals to be aware of the issues that surround this segment of the population. One of the most common clinical complications for older adults in the acute care setting is delirium (Inouye, 2014). Based on the Diagnostic and Statistical Manual of Mental Disorders (2013), delirium is defined as a disturbance of attention and awareness that develops over a short period of time with clinical features of reduced ability to focus, disorientation, and fluctuation of symptoms throughout the day. Delirium is associated with considerable negative consequences. It has been linked to increased morbidity and mortality, especially in older adults.

This quantitative study will employ a pre-post intervention design. The study participants will act as their own control with the before and after the Confusion Assessment Method (CAM) score. Patients determined to be experiencing delirium will be randomly assigned into two groups. Those in Group 1 will receive the music intervention on the first day and those in Group 2 will receive the music intervention on the second day. Both groups will receive 30 minutes of the same classical music that has been pre-selected by the investigator played in their room via a CD player twice a day, once in the morning and once in the afternoon. Comparison of CAM scores will occur on both days of the study for both groups to help determine the effectiveness of music intervention. Aside from the score, descriptive statistics will also be collected: gender, age, diagnosis (categorized by system), race, and history of cognitive impairment (yes vs. no), length of stay at time of intervention, English as the primary language (yes vs. no), and whether antipsychotic medication was provided during the course of the study (yes vs. no). Potential findings will aid in the validation of implementing non-pharmacological interventions as the first-line of treatment for delirium patients with behavioral symptoms, which advocates for a holistic nursing approach. Finally, the research will evaluate the short-term effect of music intervention by conducting, which will be more applicable to the acute care setting where delirium often manifests.

Ann Marie Barsanti

Study Aim: What is the impact on patient outcomes, including costs, when nurses assess for discharge readiness as a standard practice?

This study received exempt status IRB review on September 2015.

Background: Preparation of patients for discharge is a primary function of hospital-based nursing care and readiness for discharge is an important outcome of hospital care.  Inadequacies in discharge preparation have been well-documented and linked to difficulty with self-management after hospital discharge and with increased likelihood of emergency department (ED) use and readmission. Prior studies by the research team have led to recommendations for implementation of discharge readiness assessment as a standard nursing practice for hospital discharge.

The READI (Readiness Evaluation and Discharge Intervention) study is a Multi-site study being conducted at 34 MagnetR hospitals to evaluate the impact of unit-based implementation of discharge readiness assessment on readmission and ED use within 30 days post-discharge. Three phases, each adding a component to discharge readiness assessment, will be used to introduce, in sequence: (1) discharge readiness assessment by the discharging nurse; (2) discharge readiness assessment by the discharging nurse informed by patient’s self-assessment; and (3) a final modification to the-patient-informed nurse assessment protocol. The nurse and patient will be completing a standard 8 question form to assess for discharge readiness in the areas of personal status, knowledge, coping ability, and expected support.

The study will use a prospective, parallel cohort, stepped implementation design with four steps (baseline and the 3 discharge readiness protocols implemented in sequence) and two study conditions (implementation units and usual care control units). The study will compare patient outcomes at baseline and each of the 3 steps on the implementation units to outcomes on the control units, adjusting for hospital, unit, and patient-level control variables. The optimal implementation protocol will be identified through these methods.

Debbie Smyth, RN, BSN

Study Aim: The research aim of the inter-disciplinary team was to improve knowledge base by conducting a quality review research project evaluating clinical variation and pain management as related to early ambulation for the TKR patients.  Does the method of pain management after total knee replacement (TKR) surgery affect the distance ambulated on Day of surgery and post-op day 1?

This study was approved by expedited IRB review in June 2015

Background: Pain management modalities in total knee replacement (TKR) vary and effective analgesic modalities are essential to facilitate early rehabilitation and postoperative recovery 1. Recent efforts have focused on multi-modal protocols improving pain control while decreasing side effects 2. Timing of pain medication, activity and periods of rest is a key role for the clinical nurse working with post-op patients. It is vital to improving patient outcomes for the clinical nurse to understand the effects of various pain management modalities.

Shefali Desai RN-BC, Clinical Nurse III

Study Aim: Can an analysis of factors that trigger PSA/Sitter service utilization among adult medical patients at a local community hospital, identify common patterns to better understand patient safety needs.

This study was approved by expedited IRB review in September 2015.

Background: Increasing PSA service utilization has been a significant cost concern for the adult medical unit. To reduce these expanses without compromising the quality of care, we need to understand and study the factors that prompt PSA service utilization.

PICO/Clinical Question: Will implementing the EGDT bundle in treatment for adult sepsis patients in an acute care hospital have an impact on mortality?

EBP Grant Project: A grant, “Spotlight on Success,” was awarded by the Moore Foundation to disseminate our cumulative efforts regarding the care of patients with sepsis.  The results of our efforts have been shared at the International Sepsis Forum in Paris, France; as well as in partnership with the Surviving Sepsis Campaign at multiple regional multi-site events.

Background: The Integrated Nurse Leadership Program (INLP), a regional quality improvement initiative to reduce deaths from sepsis, began in 2008.  Nine participating hospitals were provided networking opportunities and training on: care of the septic patient, program and leadership development, and data collection and analysis. Over the span of six years El Camino Hospital (ECH) applied these concepts during implementation of the early goal-directed therapy (EGDT) bundle (as recommended by the Surviving Sepsis Campaign and the Institute for Healthcare Improvement) and achieved a relative reduction of 68% in the mortality rate among those with severe sepsis and septic shock (p=.03); equating to 1,456 lives saved.  As a result of this initiative ECH has built a multidisciplinary Sepsis Program that continues to drive improvements in the care of patients with sepsis.

PICO/Clinical Question: Will prioritizing early mobilization utilizing the ABCDE bundle have a positive impact on patient outcomes in the adult critical care unit?

EBP Grant Project: A “Spotlight on Success,” grant was awarded by the Moore Foundation to disseminate our ABCDE quality improvement work: The A (awake state), B (Breathing/liberation from ventilator), C (communication/collaboration of patient centered care), D (delirium prevention/management), E (exercise/progressive mobility), and now added F (family involvement), and G (good nutrition) bundle aims to improve ventilator weaning, delirium, and mobility by coordinating multidisciplinary care.

Background: With an original grant from the Moore Foundation in 2013, our multidisciplinary team collaborated with a regional initiative to imbed best practice mobility protocols into care for mechanically ventilated patients. Patients suffering from critical illness are at high risk of developing delirium and or neuromuscular weakness. Evidence indicates that this is often the result of life saving critical care practices. Previous management for patients developing delirium included restraints and sedation; Current management looks at delirium as a symptom to an early sign of sepsis or the result of modifiable environmental influences. Bedrest, for example, was once thought to be therapeutic but in fact can be the cause of an iatrogenic acquisition of a potentially life altering muscular weakness.

This year El Camino Hospital’s multidisciplinary staff (RN, MD, RT, PT, OT, and RD) was able to share our work with other health care organizations who are seeking to implement best practice in this area. 11 team members, led by Barbara Callens, RN traveled to New York to spend two days with the North Shore Long Island Jewish Health System (NSLIJ), the 4th largest health system in the country with 40 critical care units. NSLIJ had rolled out early work with this bundle in just 4 of their units. They defined a goal to inspire and explore strategies to standardize their work and implement across their organization. 178 of their critical care staff from 12 hospitals attended our presentations. The ECH team spoke about the journey to improve patient outcomes, lessons learned from our front line staff, research that enabled education and process improvement and patient testimony about their experience. In addition to podium presentations, the team displayed posters that have been shared at regional venues, and video footage of ventilated patients moving, multidisciplinary testimony on fears and challenges, and patient care tools that have been customized and design to improve patient participation, satisfaction and continuity of care.