Improving PACU Throughput Using an Electronic Dashboard: A Quality Improvement Initiative.

PURPOSE: Patients boarding in a 14-bed postanesthesia care unit (PACU) impacted throughput in a large university hospital in West Virginia. The PACU and operating room (OR) boarder rate in 2019 was 12% (n = 1241) and 5% (n = 503), respectively. The purpose of this initiative was to improve PACU throughput by developing an efficient and evidence-based handoff communication process between the PACU and the medical-surgical floors. DESIGN: The design of the project was evidence-based quality improvement. METHODS: An interprofessional team created a nursing patient dashboard in the electronic medical record to be used during handoff communication between the PACU and medical-surgical floor nurses. The dashboard displayed real-time vital signs, patient history, medications, and laboratory results. When the patient met Aldrete score requirements for transfer, PACU nurses notified the floor that the patient was ready for transfer. After allowing 20 minutes for the floor nurse to view the dashboard, the PACU nurse and floor nurse spoke on the phone to discuss any outstanding questions. PACU and OR boarder rates were obtained from the electronic medical record 12 months before and after implementing the nursing patient dashboard. User feedback was gathered via plan-do-study-act cycles, posters, and interviews. FINDINGS: The electronic dashboard was a successful strategy to improve handoff communication between the PACU and receiving units. The dashboard was accepted by the staff with 70% (n = 24) of the comments being positive. A significant decrease in the number of PACU (χ2(1, n = 20,608) =122.63, P < .00001) and OR boarding (χ2 (1, n = 20,283) =14.55, P = .000136) of patients was found in the C-year compared to 2019. For patients who were boarded in the PACU, no significant difference in PACU delay duration was found (t(11) =1.49, P = .149) with the mean in 2019 of 166.96 (SD = 68.38) and the C-Year mean 132.84 (SD = 39.74). For patients who boarded in the OR, there was a significant difference (t(11) =15.590162, P <.00001) between groups for average duration of boarding with the mean in 2019 of 19.06 minutes (SD = 3.72) compared to 1.62 (SD = 1.1) in C-year. However, in July 2020 the PACU intermittently opened 2 flexible beds when the PACU was full, suggesting that OR boarding was not a reliable measure, but PACU boarding remained an accurate measure. CONCLUSIONS: The findings of this evidence-based quality improvement project demonstrated the usefulness of an electronic dashboard tool combined with verbal report to improve patient throughput by decreasing the number of patients boarding in the PACU.

Enhancing Implementation of Complex Critical Care Interventions through Interprofessional Education.

Background: Many critical care interventions that require teamwork are adopted slowly and variably despite strong evidence supporting their use. We hypothesize that educational interventions that target the entire interprofessional team (rather than professions in isolation) are one effective way to enhance implementation of complex interventions in the intensive care unit (ICU). Objective: As a first step toward testing this hypothesis, we sought to qualitatively solicit opinions about team dynamics, evidence translation, and interprofessional education as well as current knowledge, attitudes, and practices surrounding the use of one example of a team-based practice in the ICU-preventive postextubation noninvasive ventilation (NIV). Methods: We conducted a qualitative evaluation using semistructured interviews and focus groups with nurses, respiratory therapists, and physicians working in four ICUs in four hospitals within an integrated health system. ICUs were selected based on variation in academic versus community status. We iteratively analyzed transcripts using a thematic content analysis approach. Results: From December 2018 to January 2019, we conducted 32 interviews (34 people) and 3 focus groups (20 people). Participants included 31 nurses, 15 respiratory therapists, and 8 physicians. Participants had favorable views of how their teams work together but discussed ways team dynamics (e.g., leader inclusiveness) impact care coordination. Participants viewed interprofessional education favorably and shared suggestions regarding preferred content and delivery (e.g., include both profession-specific and team-oriented content). Though participants reported frequently using NIV as a treatment, they described rarely using NIV as a preventive strategy, and nurses and respiratory therapists described challenges to use such as perceived patient discomfort. There were ICU-specific differences in management of patients at a high risk for respiratory failure after extubation, with some preferring to delay extubation. Conclusion: Participants reported optimism that interprofessional education can be an acceptable and effective way to improve translation of evidence into practice. Participants also detailed patient-specific and ICU-wide barriers to the implementation of preventive postextubation NIV. This information about teamwork in the ICU, suggestions for interprofessional education, and barriers and facilitators to use of a target evidence-based practice can inform the development of novel educational strategies in ways that increase acceptability, appropriateness, and feasibility of the intervention.

Clinical Practice Guideline: Safe Medication Use in the ICU.

OBJECTIVE: To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill. DATA SOURCES: PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015. STUDY SELECTION: Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system. The committee collectively developed Population, Intervention, Comparator, Outcome questions and quality of evidence statements pertaining to medication errors and adverse drug events addressing the key components. A total of 34 Population, Intervention, Comparator, Outcome questions, five quality of evidence statements, and one commentary on disclosure was developed. DATA EXTRACTION: Subcommittee members were assigned selected Population, Intervention, Comparator, Outcome questions or quality of evidence statements. Subcommittee members completed their Grading of Recommendations Assessment, Development, and Evaluation of the question with his/her quality of evidence assessment and proposed strength of recommendation, then the draft was reviewed by the relevant subcommittee. The subcommittee collectively reviewed the evidence profiles for each question they developed. After the draft was discussed and approved by the entire committee, then the document was circulated among all members for voting on the quality of evidence and strength of recommendation. DATA SYNTHESIS: The committee followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation system to determine quality of evidence and strength of recommendations. CONCLUSIONS: This guideline evaluates the ICU environment as a risk for medication-related events and the environmental changes that are possible to improve safe medication use. Prevention strategies for medication-related events are reviewed by medication use process node (prescribing, distribution, administration, monitoring). Detailed considerations to an active surveillance system that includes reporting, identification, and evaluation are discussed. Also, highlighted is the need for future research for safe medication practices that is specific to critically ill patients.

Overcoming nursing barriers to intensive care unit early mobilisation: A quality improvement project.

OBJECTIVES: To increase adherence with intensive care unit mobility by developing and implementing a mobility training program that addresses nursing barriers to early mobilisation. DESIGN: An intensive care unit mobility training program was developed, implemented and evaluated with a pre-test, immediate post-test and eight-week post-test. Patient mobility was tracked before and after training. SETTING: A ten bed cardiac intensive care unit. MAIN OUTCOME MEASURES: The training program's efficacy was measured by comparing pre-test, immediate post-test and 8-week post-test scores. Patient mobilisation rates before and after training were compared. Protocol compliance was measured in the post training group. RESULTS: Nursing knowledge increased from pre-test to immediate post-test (p<0.0001) and pre-test to 8-week post-test (p<0.0001). Mean test scores decreased by seven points from immediate post-test (80±12) to 8-week post-test (73±14). Fear significantly decreased from pre-test to immediate post-test (p=0.03), but not from pre-test to 8-week post-test (p=0.06) or immediate post-test to 8-week post-test (p=0.46). Post training patient mobility rates increased although not significantly (p=0.07). Post training protocol compliance was 78%. CONCLUSION: The project successfully increased adherence with intensive care unit mobility and indicates that a training program could improve adoption of early mobility.

Transcatheter aortic valve implantation options for treating severe aortic stenosis in the elderly: the nurse's role in postoperative monitoring and treatment.

Severe calcific aortic stenosis (AS) is a progressive cardiac disease that predominantly affects elderly adults. The hallmark symptoms of AS include exertional dyspnea, angina, and syncope. Adults of advanced age do not usually seek treatment for symptoms until their quality of life is greatly diminished. The 2 standard treatments for severe AS are open aortic valve replacement and percutaneous valvuloplasty. As adults age, their comorbid medical conditions often make them too high of a surgical risk for traditional aortic valve replacement, and percutaneous valvuloplasty, although less invasive, often produces only temporary relief of AS symptoms. To provide severe AS patients with alternative less risky treatment options in their later years, transcatheter aortic valve implantation (TAVI) devices were developed. Through this overview of the disease progression of AS and the different TAVI devices and the insertion procedures, a better understanding of the initial postoperative nursing care associated with postoperative TAVI patient management will be achieved.

Lung transplant.

The ICU period is only one time point among many in the complex, multidisciplinary postoperative management required for patient survival and improved QOL. The care required on step-down units and after discharge to home each has unique care aspects that impact successful patient outcomes.

SPEACS-2: intensive care unit "communication rounds" with speech language pathology.

Intensive care unit (ICU) nurses occupy an essential role in facilitating patient communication and preventing the detrimental effects experienced by critically ill patients who are unable to speak, yet most are not equipped with the tools or training to enable communication most effectively with patients who are unable to speak. The goal of the Study of Patient-Nurse Effectiveness with Assisted Communication Strategies (SPEACS-2) is to explore the impact of an innovative, Web-based instructional package for ICU nurses with pocket reference guides, an instructional manual, and the provision of "low-tech" augmentative and alternative communication materials on nursing care quality and patient clinical outcomes. We hypothesize that this intervention will 1) improve nurses' skills in assessing and communicating with ICU patients who are unable to speak and 2) increase the collaboration between nursing and speech-language pathology in addressing complex patient communication needs in the ICU.

Nursing implications for prevention of adverse drug events in the intensive care unit.

Adverse drug events are common in the intensive care unit setting. Despite the existence of many long-standing safety principles (such as the "five rights") and new mechanisms to promote medication safety, there is still a gap between practice and the goal of patient safety. This is the result of the many human and system factors that impact care delivery. Research supports the role of the nurse as having a positive impact on patient outcomes. Future research requires the evaluation of new strategies and technologies to support safe medication administration. For example, patient simulation is being used to teach student and novice nurses principles of medication administration in a "safe" setting that more closely resembles the clinical environment. The Institute of Nursing repeatedly has stressed the need to address the organizational, technical, and human issues that impact patient safety, with an emphasis on the need to transform the nurse work environment to keep patients safe. This transformation will require a new level of interdisciplinary research and nursing involvement to address better care for our patients and, in particular, reduce adverse drug events.

The role of the clinical nurse specialist in facilitating evidence-based practice within a university setting.

There are many changes occurring within the healthcare system today, bringing forth multiple challenges for nurses. Changes in reimbursement for hospitals and staffing shortages are impacting the ways that nurses are delivering care. During these changing times, it is essential that healthcare providers strive to maintain high-quality care and patient safety. Utilizing evidence-based practice (EBP) to guide the delivery of care is one way to ensure that high-quality outcomes are achieved. EBP is one of the driving forces to improve clinical practice and ensure patient safety within the healthcare system. The clinical nurse specialist is very instrumental in facilitating quality care and implementing EBP within the healthcare setting. Through the development of a multidisciplinary committee, the clinical nurse specialist can lead professional nurses in the implementation of EBP and facilitate practice changes to improve patient outcomes.

A process for instituting best practice in the intensive care unit.

Goals of health care are patient safety and quality patient outcomes. Evidence based practice (EBP) is viewed as a tool to achieve these goals. Health care providers strive to base practice on evidence, but the literature identifies numerous challenges to implementing and sustaining EBP in nursing. An initial focus is developing an organizational culture that supports the process for nursing and EBP. An innovative strategy to promote a culture of EBP was implemented in a tertiary center with 152 critical care beds and numerous specialty units with diverse patient populations. A multi-disciplinary committee was developed with the goal to use evidence to improve the care in the critical care population. EBP projects were identified from a literature review. This innovative approach resulted in improved patient outcomes and also provided a method to educate staff on EBP. The committee members have become advocates for EBP and serve as innovators for change to incorporate evidence into decision making for patient care on their units.

To pump or not to pump?

Coronary artery bypass grafting is performed on the beating heart and thus requires the use of cardiopulmonary bypass. To avoid the complications associated with cardiopulmonary bypass, off-pump bypass (OPB) is viewed as a desirable alternative. Technological advancements have made OPB a viable option in an expanding population of patients. As a result, the number of OPB surgeries performed annually in the United States has increased. Critical care nurses are increasingly likely to provide care for patients after off-pump surgery. The differences between on-pump and OPB surgeries affect the postoperative nursing care requirements. While there are many common aspects of postoperative cardiac care for these 2 groups of surgical patients, there is a need to focus on the unique aspects of care for OPB patients. Despite promising short-term results in OPB patients, questions surrounding this procedure remain. Studies are under way to determine long-term graft patency.

Effect of positioning on oxygenation in single-lung transplant recipients.

BACKGROUND: Many benefits and adverse effects of positioning are related to changes in ventilation and perfusion. A number of unique factors related to the allograft make the effects of positioning difficult to determine in single-lung transplant recipients. OBJECTIVES: To determine the effect of 3 body positions (supine, lateral with allograft lung down, and lateral with native lung down) on oxygenation and blood flow in single-lung transplant recipients in the 24 hours immediately after surgery. METHODS: A quasi-experimental repeated-measures design with stratified assignment to 1 of 3 different sequencing patterns for turning group was used to study 15 transplant recipients, 9 with emphysema and 6 with fibrosis. Oxygenation, ventilation, and blood flow measures (heart rate, blood pressure) were assessed after each turn. The effect of ischemic reperfusion injury was also explored. RESULTS: The oxygenation, ventilation, and bloodflow variables did not differ significantly across group, diagnosis, or time. Oxygenation variables measured when the allograft lung was dependent did not differ significantly from such measurements obtained when the native lung was dependent. CONCLUSIONS: No single position maximizes oxygenation in the immediate postoperative period in single-lung transplant recipients. Although a single standard protocol for positioning cannot be supported, the study does support the idea that transplant recipients can be safely turned in the immediate postoperative period without compromising oxygenation or hemodynamic status.