2018 Research and EBP projects

EBP Projects

Evaluation of a Fall Risk Assessment Tool to improve patient fall risk assessment on a Behavioral Health inpatient psychiatric unit.

Authors: Davinne Aurelio BSN RN-BC, Emmalyn Ting MSN RN, Mary Russo PhD RN, CNS

PICO/Clinical Question: Will the Implementation of a fall risk tool with more patient specificity (Edmonson Psychiatric Fall Risk Assessment Tool) improve nurses’ fall risk assessment for the Behavioral Health inpatient population in 3 months?

Project Goal: To evaluate and implement an evidence based fall risk assessment tool specific to patients in a behavioral health inpatient unit and to improve nursing satisfaction with the assessment process for fall prevention.

Background: Nurses expressed dissatisfaction with the current fall risk tool describing it as vague, and not sensitive to psychiatric inpatients. A review of evidence based best practices highlighted The Edmonson Psychiatric Fall Risk Assessment Tool (EPFRAT) described as more sensitive to the inpatient psychiatric population than other fall risk assessment tools. The staff felt identification of risk factors specific to their special population would better guide interventions necessary to improve patient safety.

Methodology: This is an evidence based project that compared Fall Risk Assessment tools (Hendrich and The Edmonson Psychiatric Fall Risk Assessment Tool (EPFRAT) for an inpatient psychiatric population. The Unit Partnership Council and hospital Fall Committee reviewed the findings and agreed to implement the EPFRAT. The nursing staff worked to implement the EPFRAT in the hospital electronic charting system, and also designed and implemented staff training for proper use of the tool. To evaluate the impact on nursing process and nursing satisfaction, the committee designed a survey to measure the nurses’ experience on the ease of use of the tool, and the areas nurses felt it helped better determine the level of risk for this patient population. Fall rates, and the number of patients categorized as high risk using existing standardized reports for patient fall quality improvement and monitoring were also evaluated.

Results: A majority of the nurses found the EPFRAT very helpful. Metrics that were statistically more than a majority were workflow and more specificity. The tool highlighted risk factors (ambulation pattern, mental status and types of medication) important for this patient population (p value <0.001). Falls decreased by 1.5% which is not statistically significant, but trending downward.

Conclusions: Nurses felt empowered to implement a new practice that had a positive impact in how they provide quality assessment for patient safety. This was a first step in the implementation of a new tool. More analysis will continue to make appropriate conclusions about specificity and how to interpret and apply the assessment scores to prevent falls and have an impact on patient outcomes.

Homeless Care Path Resource for Discharge Planning

Author: Aarya Khanal, MSN, RN

PICO/Clinical Question: In the discharge planning process for the homeless population who are admitted for inpatient care, will the use and development of a homeless resource tool decrease the frustration of discharge planners for safe discharge?

Project Goal: The purpose of the evidence based practice project is to implement and evaluate a care path resource guide for discharge planning for the homeless population which currently does not exist for the ECH care coordination department.

Background: A new bill Senate Bill 1152 will require each hospital to include a written homeless patient discharge planning and a clear documentation or develop a log, on specified skilled needs and appropriate referrals made by the discharge planners for this population. The bill is to be implemented on July 1, 2019, requiring all the hospital to have appropriate and effective discharge planning for homeless population with the record of their discharge destination and resources provided to the patient. Violation of the bill may have penalties.

The study aims to tailor a homeless care path so that discharge planners can use the resources at a fingertip, store information within the tool and comply with the new bill. After each use, discharge planners will be asked to evaluate the tool.

Methodology: A care path resource guide will be created specifically for use with homeless patients addressing several factors that have been identified as a barrier for discharge such as housing options, wound care community resources, and financial assistance. The care coordination staff will be educated on the use of the resource guide. After completion with each patient, the users of the tool will then evaluate the helpfulness of the tool by completing a survey. Completed surveys will be collected by the principal investigator.

Results: Statistically more than the majority of those that used the care path found it to be effective in guiding their workflow and improved their efficiency. The majority found the tool to be user-friendly and the resources to be reliable. Users also commented that the tool would enhance their practice if it was incorporated into the electronic medical record. The work was then incorporated into a larger hospital-homeless initiative. It guided the team towards the development of a Homeless Protocol to comply with SB1152.

Mocktail Hour: Promoting Oral Hydration on the Acute Rehabilitation Unit

Authors: Bridget Samano, BSN, RN, CRRN

PICO/Clinical Question: Will a standardized EBP intervention to improve oral intake, and facilitate hydration education with adult patients and family in an inpatient rehabilitation unit help to increase patient hydration to improve patient safety.

Project Goal: To improve patient safety and decrease complications such as episodes of orthostatic hypotension due to dehydration.

Background: The ARU primarily serves two patient populations that are already at increased risk for dehydration and UTIs: age > 65 and stroke patients. Hydration is imperative. Baseline audits after education of staff and patients from 09/2017-05/2018 indicated 75% of patients were routinely taking in less than 1600 mL of oral fluids per day, putting them at high risk for dehydration (goal is 2,000 mL per day!). Patients were still requiring IV fluids because of poor oral fluid intake (this puts them at risk for fluid overload complications, it is also not a functional, long-term solution to poor intake). Episodes for syncope related to orthostatic hypotension were occurring which can be caused in part to poor hydration status. We continued to see post-admission UTIs in our patients. Poor intake put patients at risk for other issues as well (e.g., medication toxicity, falls, incontinence). We concluded there was a need to create a simple evidence based practice intervention to create an environment of hydration promotion, to improve oral hydration intake, facilitate hydration education with patients and family, and to further increase the staff's awareness around hydration needs.

Methodology: A literature review supported discussions at UPC meetings and hydration education for staff. The hydration project team collaborated with management to create a "Mocktail Hour" plan. Discussion regarding hydration promotion starts at admission with patient education flyers in our admission packet. Hydration reminders and education were also posted around the unit and in patient rooms to initiate discussion about hydration, including when patients are admitted. In the evening, for an hour each day non-alcoholic freshly mixed drinks would be available to our patients and visitors in the dining room. Nursing staff were also educated and reminded on the importance of accurate intake & output charting to correctly measure each patient's fluid status. Management worked with central supply to provide our unit with ECH logo water bottles for each patient facilitating hydration while they are out of their room in therapy. The patients receive the water bottles upon admission.

Results: Initial data collection has shown a modest increase in average 24 hour oral fluid intake. Prior average 24 hour oral intake was 985 mls. Post average 24 hour oral intake was 1077 mls. Ongoing barriers and challenges identified included staff "buy-in" and perception of work challenges and staffing to support care goals for patients and maintain accurate intake & output charting. Also patients often felt a lack of thirst and perceived they had insufficient time to finish drinks. There was also fear of increased incontinence episodes with hydration for this population.

Conclusions: The daily "Mocktail Hour" provides patients with a social setting to encourage drinking fluids while interacting with each other and a reminder to check in with themselves about how much fluid they have consumed throughout the day. This practice change has resulted in staff motivation and dedication to evaluating and assessing the hydration status of patients on a regular basis by the entire rehab care team. Ongoing problem solving to address barriers and further data collection will enable continued evidence on the effectiveness of the program and improvements that can be explored.

Nursing research and innovation are supported by donations to El Camino Health Foundation.