2016 Research and EBP projects

Kathleen Hall, R.N. and Ellen Smith, R.N., Ph.D.   (L to R) Kathy Barry, R.N., Ellen Smith, R.N. Ph.D., Shelly Reyes, R.N., Sarah Rosenquist, R.N., Kathleen Hall, R.N., Hannah Crocker, R.N., Charis Spielman, R.D., Theresa Shea, R.N., Chris Tarver, R.N., and Jessica Miles, R.N.

Study Aim: Will nursing knowledge and clinical practice change around patient assessment and education for chemotherapy-induced peripheral neuropathy (CIPN) Cancer Center patients after implementation of evidence based practice (EBP) CIPN education. Project Goal: To bring EBP discussion and education to the El Camino Hospital Cancer Center staff resulting in quality improvement for cancer patients to integrate consistent practices into the unit’s workflow. This project was granted an expedited review by the IRB on December 11, 2015 and was conducted beginning January 2016.

Problem Statement / Background: CIPN causes chronic pain, tingling, and numbness—mainly in the hands and feet—that can interfere with a patient’s ability to perform everyday activities and to receive needed doses of chemotherapy. CIPN affects 20 to 30 percent of cancer patients treated with taxane and platinum-based chemotherapy drugs, which can damage nerve cells. CIPN may continue for months or even years after treatment is stopped and may worsen over time. Fifty percent of current patients in the infusion center are receiving these treatments.

An initial chart review revealed inconsistent documentation and a lack of evidence of nursing education/assessment of CIPN for appropriate patients. Staff nurses anecdotally express their frustration at needing more information and a defined practice expectation to deliver best care for these patients.

Methodology: This quality improvement research project was for all nursing staff practicing in the El Camino Hospital Cancer Center. Multi-disciplinary staff are a part of the care team, i.e. physicians, Nurse Practitioners, Oncology coordinators, Survivorship Nurse and were invited to attend and participate.

The Cancer Center hosted a workshop focusing on:

• Pathophysiology of CIPN
• Clinical Manifestations of CIPN
• Assessment of Patient including comorbidities
• Potential Interventions for/Treatment of CIPN: Use of dietary supplements, Safety Education, Quality of Life Questionnaire for tracking effect of CIPN over time, Consistency in documenting relevant aspects of the assessment of CIPN

The workshop was led by a national expert Ellen M. Lavoie Smith, PhD, APN-BC, AOCN(r) Assistant Professor Director, University of Michigan School of Nursing PhD Program, author of Nursing Knowledge, Practice Patterns, and Learning Preferences Regarding Chemotherapy-Induced Peripheral Neuropathy Peripheral Neuropathy Nurse Education, ONF 2014, 41(6), 669-679 DOI: 10.1188/14.ONF.669-679

Funding was from the “Diana Russell Nursing Leadership Grant” and the “Nursing Research and Innovation Foundation Fund” managed by the El Camino Hospital Foundation

Measurement Tools: A pre/post knowledge survey was utilized as the measurement tools. The pre-test was conducted prior to the workshop. The post-test was conducted 10 months after the workshop.

• Oncology Nurses Society (ONS) Foundation 2013 Peripheral Neuropathy Survey. This knowledge test tool was validated through an ONS research project that used a stratified random sampling to obtain a representative sample of all ONS nurses. (408 out of 10,000 nurses completed the survey). Oncology Nursing Forum • Vol. 41, No. 6, November 2014

A pre-post chart audit was done comparing documentation on patients receiving Oxaliplatin looking for evidence of clinical manifestations specifically, numbness.

• The last three visits of all qualifying patients in 2015 prior to CIPN education, was compared to the last three visits of all qualifying patients in 2016 post CIPN education.

Data analysis: Descriptive statistics (means, standard deviations, frequencies) was used to describe the study sample and ONS Peripheral Neuropathy Survey results. A one sample paired t-test was used to determine if there was a statistically significant difference between the pre and post-intervention survey scores.

The analysis will be done in the statistical package R, to determine statistical significance, with alpha set at .05.

Results: Nurse Survey: Ten months after education, there was some positive change in areas where nurses “always assessed temperature sensation” for CIPN patients, but the sample size was small and change did not reach statistical significance. A larger sample size could validate the results seen or provide significance to the question trends.

Chart Audit assessment documentation: In 2016 there was a 13% increase in the numbness and tingling assessment compared to 2015 for CIPN patients looking at their last three patient visits. This increase is marginally significant with a pvalue of 0.058. When we consider the visits individually, all see an increase for 2016 vs 2015 but none are significant.

 

Education: Following the CIPN Workshop, education continued including in-services, handouts and posters regarding CIPN-causing drugs and signs and symptoms of CIPN. Emphasis and availability of education was incorporated as part of the Unit’s Quality Board. Best practice documents including Putting Evidence Into Practice (PEP)® from the Oncology Nurses Society was presented and made available. Peer-to-Peer nursing performance improvement education also occurred.

Conclusions: Formal education regarding CIPN requires repeated effort and reinforcement to increase nurses’ knowledge and skill regarding the assessment and interventions for CIPN.

Ann Aquino, MSN RN and Jessirée Primitivo, MSN, RN, PCCN, PHN

Study Aim: Can a quality improvement initiative aimed at educating and motivating nurses on an adult medical-surgical oncology unit about the importance of restorative sleep and sensory reduction strategies increase patient use of non-pharmacological sleep-enhancing items? Project Goal: To facilitate learning through staff education geared towards model sleep-sensitive behaviors resulting in actions that will enhance the patient experience by promoting rest and healing through noise reduction strategies and use of non-pharmacological sleep-enhancing items at night. This project qualified for an expedited review by the IRB and approval was granted on November 2, 2016.

Problem Statement / Background:

• Restorative sleep is essential for adequate wound healing, recovery, and physiological and cognitive wellbeing. However, sleep in the hospital setting can be severely impaired by environmental noise, which has been identified to contribute to increased pain perception, anxiety, and irritability (Litton, Carnegie, Elliott, & Webb, 2016; Tamrat, Huynh-Le, & Goyal, 2013)
• Nurses play an integral role in enhancing their patient’s experience of care by promoting rest and healing through noise-reducing strategies supportive to a sound-sensitive healing environment.
• The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores for a 32-bed adult medical-surgical oncology unit located in a northern California community hospital suggests that improvements in the noise level around the care environment at night is necessary to reach benchmarked performance standards.
• There was notable decline in the survey category of “quietness” of the hospital care environment beginning July of 2016.

Methodology: A pre and post-environmental audit on the use of sleep-promoting items (i.e. ‘Quiet Please’ door hangers, ear plugs, eye mask, warm blanket, aromatherapy, etc.) was utilized as the measurement of change. The study was conducted in the Medical-Surgical Oncology Unit (4B).

Pre-intervention: Prior to the intervention, patients were asked by their nurse if any nonpharmacological sleep enhancing items were offered to them during the course of their stay. The nurse also conducted an environmental audit of any visible sleep promoting items in the patient’s room. This is routine best practice for 4B RNs interacting with their assigned patients.

The nurse asked their patients the following questions:

• Have any nonmedicinal items to help you sleep been offered to you tonight or during the course of your stay?
• Can I offer you an eye mask, lavender oil or lotion, a warm blanket, ear plugs, dim the lights, or turn on soothing music to help you sleep?
• Please let us know if there is anything we can do to improve the noise level at night?

A checklist/ grid was used to quantify data by the indication of ‘Yes’ or ‘No’ to the presence of items/ answers to questions. There is no need for nursing identification.

Evening and night shift nurse teams had the opportunity to view an educational presentation highlighting:

• The short and long term physiological effects of sleep-deprivation
• Nonpharmacological nursing interventions to reduce environmental noise at night
• Increasing the use of nonpharmacological items to promote sleep
• Definition and impact of the Hospital VBP program and HCAHPS survey scores to the unit
• Evidence-based research articles supporting the interventions and available resources

Post-intervention: One week following the educational presentation, a second environmental audit was conducted to measure compliance (using the format above). Patient identity was not needed for the study. All data was entered and stored on a password protected excel document.

Patients' responses are part of routine care and no consent was required. Patients were not required to respond.

Results:

• Unit specific HCAHPS patient satisfaction scores for “quietness of the care environment at night” post intervention increased soon after the education but declined the months after.
• Patients felt that non-pharmacological sleep-enhancing items had been offered to them during the course of their stay consistently, and a warm blanket remained a favored item to enhance sleep, both pre and post-education
• Soon after education was provided there was an improvement in the “quietness of hospital environment” score due to heightened awareness. The decline in score for subsequent months could be attributed to a number of factors such as an increase in the unit’s census and patient acuity. There was shift in the unit’s focus.

Conclusions: This was a very small study and done in a small amount of time, The Noise Reduction initiative is an important quality improvement project to enhance the patient's overnight experience of care through nursing education and motivation. The non-pharmacological sleep-enhancing items described in the study do not affect the direct cost of the project, as they are readily available in the hospital. Incorporation of a unit champion will assist in reinforcing the material covered in the educational presentation, act as a resource on the unit, and serve as a patient advocate for safe restful sleep. Additionally, the research and data generated from the Noise Reduction initiative can be used as beginning steps to develop a standardized process throughout the organization. Continuous investment in refining the patient experience has the potential to transform the healthcare organization into a high-quality, high-performing establishment recognized for enhancing the patient experience at all hours of the day during the patient’s hospital stay.

References:

Comeaux, T. & Steele-Moses, S. (2013). The effect of complementary music therapy on the patient’s postoperative state anxiety, pain control, and environmental noise satisfaction. Medsurg Nursing, 22(5), 313-318.

Lillehi, A.S., Halcon, L.L., Savik, K., Reis, & Reilly. (2015). Effect of inhaled lavender and sleep hygiene on self-reported sleep issues: A randomized control trial. The Journal of Alternative and Complementary Medicine, 21(7), 430-438. doi: 10.1089/acm.2014.0327.

Tamrat, T., Huynh-Le, M.P., & Goyal, M. (2013). Non-pharmacologic interventions to improve the sleep of hospitalized patients: A systematic review. Journal of General Internal Medicine, 29(5), 788-795.

Jennifer Meaney, MS, BSN, RNBC Beya Sioson, BSN, RN, CDE

Study Aim: Will focused diabetes education offered to nurses on a medical surgical unit improve their knowledge and perceived comfort for inpatient diabetes management? Project Goal: To deliver an eight hour educational program to inform the educational needs of an enterprise wide change in insulin therapy and to assess the nursing knowledge and perceived comfort for diabetes management patient care. This project qualified for an expedited review by the IRB and approval was granted on November 2, 2016

Background:

The American Diabetes Association (ADA) recommends a target glucose range of 140 -180 mg/dL for both critically and non-critically ill hospitalized patients. Both hypoglycemic and hyperglycemic episodes in hospitalized patients can lead to adverse outcomes. Patients with hyperglycemia in the hospital have longer lengths of stay, higher readmission rates, and lower patient satisfaction scores.

An analysis of point of care testing (POCT) on a medical unit from January through June 2016 revealed 33% of time points were above the ADA target range (>180 mg/dL).

Previous studies reveal bedside nurses lack the current knowledge and confidence needed to adequately treat and educate patients with diabetes. Newer tools to assess these areas are available. Assessment is necessary prior to the implementation of a basal-bolus protocol.

Methodology: An eight hour course (7 Continuing Education Units) advertised to all nurses across the enterprise Topics reviewed included:

• Carbohydrate counting
• Types of insulins and action profiles, oral and injectable insulins, insulin pumps
• Basal-bolus method of insulin therapy

Measurement Tools: A baseline survey was administered at the beginning of the class. Basic demographic data, primary unit, work status (FTE), years of nursing experience, time of most recent diabetes education, number of patients treated each week, and personal experience with diabetes was obtained. The Diabetes Management Knowledge Assessment Tool (DMKAT) and the Confidence in Teaching Diabetes Education (CTDE) were administered. Participation was voluntary and anonymous using a student-derived code.

The survey was administered again at one month (mail) and three months (email). Responses remained anonymous and this analysis was based on aggregate data.

Results: Participants attending classes work mostly on medical/telemetry units (37.5%) and were female (92%).  The majority has personal experience with diabetes (55%), hold a BSN (67%), and work 8-hr day shift (55%).

The response rate at 1 month was 14% and 27% at 3 months after class attendance.

There was a statistical increase in all metrics between baseline and month 1. At month 3, the increase remained, however this was no longer statistically significant.