Role Delineation of the Code Blue Team: A Quasi-Experimental Study During COVID-19

IntroductionThe purpose of this study was to assess if implementing a code role delineation intervention in an emergency department would improve the times to defibrillation and medication administration and improve the nurse perception of teamwork.MethodsA quantitative quasi-experimental study used a retrospective chart review to gather data. A pre- and post-test measured nurse perception of teamwork in a code using the Mayo High Performance Teamwork Scale (MHPTS) after a code role delineation intervention using a paired samples t-test. Pearson r correlations were used to determine relationships between nurse participant (N = 30) demographics and results of the MHPTS scores.ResultsA significant increase in teamwork was noted in 5 of the 16 items on the MHPTS regarding improved communication and identified roles in a code: the team leader assures maintenance of an appropriate balance between command authority and team member participation (t = −5.607, P < .001), team members demonstrated a clear understanding of roles (t = −5.415, P < .001), team members repeat back instructions and clarifications to indicate that they heard them correctly (t = −2.400, P = .029), all members of the team are appropriately involved and participate in the activity (t = −2.236, P = .041), and conflicts among team members are addressed without a loss of situation awareness (t = −2.704, P = .016). There was significance between total pre- and post-test scores (t = −3.938, P = .001).DiscussionImplementation of code role delineation identifiers is an effective method of improving teamwork in a code in an emergency department setting.     

Intimate Partner Violence Screening in the Emergency Department: A Quality Improvement Project

IntroductionIntimate partner violence is a serious public health issue that can be addressed through identification and early intervention. Although screening for intimate partner violence in health care settings is recommended by medical and nursing organizations, it is underperformed. The project objectives were to increase intimate partner violence screening rates, identification, and the referrals/resources provided.MethodsThis project was a quality improvement intervention. Intimate partner violence screening training was provided to emergency nurses along with a computer prompt for screening in the emergency department, with a standard referral process to a social service agency. The project data included patient ED visits, partner violence screening rates, positive and negative screening rates, and the number of referrals/resources provided to the patients.ResultsThere was no increase in the screening rates (28%). Although the screening rates varied considerably from week to week, the highest rate of screening was during the intimate partner violence training week. Pre- and postintervention data showed a significant increase in the number of positive screens obtained per week after the nurse intimate partner violence training (7.80 vs 5.22, t = –4.33, P < 0.01). In addition, the referrals/resources provided to the patients doubled from 9 to 18 after the training, which is clinically significant for patient care.DiscussionThis project demonstrates that nurse training along with a computer prompt intervention and standard referral process can contribute to intimate partner violence identification and the referrals/resources provided to the patients. Ultimately, the patients exposed to partner violence may benefit from increased identification and delivery of the referrals/resources.     

Customizing Physiologic Alarms in the Emergency Department: A Regression Discontinuity,Quality Improvement Study

IntroductionClinical alarms promote patient safety by alerting clinicians when there is an indication or change in a condition requiring a response. An excessive volume of alarm fires, however, contributes to sensory overload and desensitization, referred to as alarm fatigue, which has significant implications when alarms are missed. This evidence-based, practice project aimed to implement and evaluate a program that reduces the number of clinically nonactionable, physiologic alarms in an emergency department. Although alarm fatigue is an important negative consequence, the focus of this project is not on alarm fatigue but on measures to reduce the volume of clinically nonactionable alarms that lead to alarm fatigue. The Iowa Model was used as a conceptual framework.MethodsThis project involved adjusting default alarm settings and implementing an education plan on the safe use of alarms. The sample population included all patients on physiologic monitors at an emergency department. Retrospective data were collected, and regression discontinuity design was applied to compare the rate of alarm fires triggered by the physiologic monitor between pre- and postimplementation of an alarm protocol.ResultsA significant change in the rate of alarm fires occurred with an estimated reduction of 14.96 (P = 0.003). There were no reports of adverse outcomes such as a delay in responding to a change in patient condition or delay leading to cardiopulmonary arrest.DiscussionA reduction in nonactionable, physiologic alarms was attained after implementing multimodal strategies inclusive of adjusting default settings, staff education on managing alarms, and emphasis on staff accountability.     

Sepsis Screening in Triage to Decrease Door-to-Antibiotic Time

IntroductionIdentifying patients with sepsis at triage can lead to a decrease in door-to-antibiotic time. Our community hospital emergency department’s mean door-to-antibiotic time was 105.3 minutes, falling short of the Surviving Sepsis Campaign guideline’s benchmark goal of 60 minutes. One of the most common reasons for treatment delays was that patients with sepsis were not identified upon entrance to the emergency department. A solution to the delay was to implement a practice improvement project by having the triage nurse screen all patients for sepsis upon entrance to the emergency department.MethodsA sepsis-screening tool was used to identify patients with sepsis and was based on systemic inflammatory response syndrome (SIRS) criteria. Patients screening positive were prioritized for ED bed space. The change in process allowed more rapid ED physician evaluation and antibiotic administration. Manual chart abstraction was used to calculate door-to-antibiotic time and included 12 months of preintervention data and 2 months of postintervention data.ResultsDoor-to-antibiotic time improved from a baseline of 105.3 minutes to 71.9 minutes.OutcomeThe simple change in patient throughput improved door-to-antibiotic time with minimal obstacles. The sepsis-screening tool implemented at triage decreased the door-to-antibiotic time by 33.4 minutes, without affecting triage time, and enhanced patient throughput of potentially septic patients.     

Sepsis Clinical Criteria in Emergency Department Patients Admitted to an Intensive Care Unit: An External Validation Study of Quick Sequential Organ Failure Assessment

Background

Quick Sequential Organ Failure Assessment (qSOFA) is a prognostic score for patients with sepsis.

Quality Improvement in the Emergency Department: A Project to Reduce Door-to-Electrocardiography Times for Patients Presenting With Chest Pain

IntroductionThe American Heart Association/American College of Cardiology guidelines recommend obtaining electrocardiography for patients who present to the emergency department with chest pain in less than 10 minutes of arrival. Reducing door-to-electrocardiography time is an important step in adhering to the recommended door-to-balloon times (≤ 90 minutes) for patients who present with ST-segment elevation myocardial infarction.MethodsBased on lean sigma principles, a protocol was implemented in an adult emergency department that included deferring nurse triage for patients with complaints of chest pain, chest tightness, and chest pressure and providing them with a red heart symbol as an indicator for clinical technicians to prioritize their electrocardiography order. Pre- and postintervention data were collected over a 12-month period.ResultsBefore the intervention, the mean door-to-electrocardiography time was 17 minutes for patients with chest pain (n = 893). After the intervention, the mean door-to-electrocardiography time for patients with chest pain significantly decreased to 7 minutes (n = 1,057) (t = 10.47, P ≤ 0.001). Initially, the percentage of compliance with door-to-electrocardiography standard of 10 minutes was 31% and improved to 83% after implementation of the new protocol.DiscussionImplementation of the optimized door-to-electrocardiography protocol decreased the time for obtaining diagnostics and improved compliance with the American Heart Association/American College of Cardiology guidelines, potentially decreasing door-to-balloon times for patients who presented with ST-segment elevation myocardial infarction.     

Implementing Bedside Handoff in the Emergency Department: A Practice Improvement Project

Introduction

Handoff in the emergency department is considered a high-risk period for medical errors to occur. In response to concerns about the effectiveness of the nursing handoff in the emergency department of a Midwestern trauma center, a practice improvement project was implemented. The process change required nursing handoff at shift changes to be conducted at the bedside, using an adapted situation, background, assessment, recommendation (SBAR) communication tool.

Septic acute kidney injury patients in emergency department: The risk factors and its correlation to serum lactate

Background

Acute kidney injury (AKI) is a common complication in septic patients, imposing a heavy burden of illness in terms of morbidity and mortality. Serum lactate is a widely used marker predicting the severity of sepsis. A paucity of research has investigated septic AKI in emergency departments (EDs) and its correlation with initial serum lactate level. This study aimed at identifying risk factors for septic AKI and clarifying the link between initial serum lactate level and septic AKI in ED patients.

Report and Prevent: A Quality Improvement Project to Protect Nurses From Violence in the Emergency Department

IntroductionMost nurses experience some form of workplace violence resulting in a stressful work environment, employee injury, and turnover. The aims of this project were to develop and evaluate strategies to improve the reporting of workplace violence as well as to empower emergency nurses to prevent assaults and protect themselves.MethodsThis quality improvement project had 2 phases. The phase I educational intervention focused on the importance of reporting workplace violence. Pre- and postintervention surveys measured experiences with workplace violence and reporting. The phase II educational intervention focused on de-escalation and self-protection strategies, training, safety, confidence, and emergency nurses’ preparedness to defend themselves. Responses were analyzed using Wilcoxon signed-rank and McNemar tests.ResultsTwenty-five emergency nurses participated in phase I, with >90% reporting that they had been assaulted in the past month. Most did not report a workplace assault, which was unchanged after the intervention. Thirty-four emergency nurses participated in phase II, with a postintervention increase reported in the perceived helpfulness of learning self-protection techniques for the emergency nurses’ work life (Z = –2.179, P = 0.029).DiscussionThis study was consistent with the literature in that emergency nurses often do not report workplace assaults. Most of the emergency nurses surveyed had been assaulted. Although the educational interventions did not achieve the desired outcome, it is clear that additional interventions for individual nurses and institutions need to be developed and refined to increase reporting and prevent workplace assaults.     

Nurse-Leader Collaborative Improvement Project: Improving Patient Experience in the Emergency Department

Introduction

Studies show that nurse rounding is an effective means to increase patient satisfaction and quality of care and decrease patient-safety events. There is evidence to support that daily leader rounding improves patients’ hospital experience as well. Patients' experience increased confidence in their care providers, and leaders are able to address service concerns proactively. Furthermore, recent studies have addressed patient satisfaction in the ED setting as having an impact on patients’ perceptions of the health care institution as a whole. Our objective was to demonstrate the effect of hourly nursing rounds and daily leader rounds on the ED patient experience.

Creating a Rapid Assessment Zone with Limited Emergency Department Capacity Decreases Patients Leaving Without Being Seen: A Quality Improvement Initiative

IntroductionPatients leaving the emergency department before treatment (left without being seen) result in increased risks to patients and loss of revenue to the hospital system. Rapid assessment zones, where patients can be quickly evaluated and treated, have the potential to improve ED throughput and decrease the rates of patients leaving without being seen. We sought to evaluate the impact of a rapid assessment zone on the rate of patients leaving without being seen.MethodsA pre- and post-quality improvement process was performed to examine the impact of implementing a rapid assessment zone process at an urban community hospital emergency department. Through a structured, multidisciplinary approach using the Plan, Do, Check, Act Deming Cycle of process improvement, the triage area was redesigned to include 8 rapid assessment rooms and shifted additional ED staff, including nurses and providers, into this space. Rates of patients who left without being seen, median arrival to provider times, and discharge length of stay between the pre- and postintervention periods were compared using parametric and nonparametric tests when appropriate.ResultsImplementation of the rapid assessment zone occurred February 1, 2021, with 42,115 ED visits eligible for analysis; 20,731 visits before implementation and 21,384 visits after implementation. All metrics improved from the 6 months before intervention to the 6 month after intervention: rate of patients who left without being seen (5.64% vs 2.55%; c² = 258.13; P < .01), median arrival to provider time in minutes (28 vs 11; P < .01), and median discharge length of stay in minutes (205 vs 163; P < .01).DiscussionThrough collaboration and an interdisciplinary team approach, leaders and staff developed and implemented a rapid assessment zone that reduced multiple throughput metrics.     

Paramedic-Initiated CMS Sepsis Core Measure Bundle Prior to Hospital Arrival: A Stepwise Approach

Background: To improve patient outcomes, the Center for Medicare and Medicaid Services (CMS) implemented core measures that outline the initial treatment of the septic patient. These measures include initial blood culture collection prior to antibiotics, adequate intravenous fluid resuscitation, and early administration of broad spectrum antibiotics. We sought to determine if Paramedics can initiate the CMS sepsis core measure bundle in the prehospital field reliably. Methods: This is a retrospective, case series from a 3rd service EMS system model in Greenville, South Carolina between November 17, 2014 and February 20, 2016. An adult Prehospital Sepsis Assessment Tool was created using the 2012 Surviving Sepsis guidelines: 2 of 3 signs of systemic inflammatory response (heart rate, respiratory rate, oral temperature) and a known or suspected source of infection. A “Sepsis Alert” was called by paramedics and upon IV access a set of blood cultures and blood for lactate analysis was collected prior to field antibiotic administration. The Sepsis Alert was compared to serum lactate levels and ICD 9 or 10 admitting diagnosis of Sepsis, Severe Sepsis, or Septic Shock. Blood culture contamination, serum lactate, and antibiotic match were determined by in-hospital laboratory analysis. Results: A total of 120 trained paramedics called 1,185 “Sepsis Alerts” on 56,643 patients (50.3% Male, mean age 70). Patients with missing discharge diagnosis were eliminated (n = 31). The admitting diagnosis of sepsis overall was 73.5% (848/1154): Sepsis 50% (578/1154), Severe Sepsis 14.6% (169/1154), Septic Shock 8.9% (101/1154). A total of 946 blood cultures were collected in the prehospital setting, with a 95.04% (899/946) no contamination rate. Contamination was found in 4.96% (47/946). A total of 179 (18.9%) of the uncontaminated blood cultures were found to have positive growth with 720 (76.1%) having no growth. EMS administered antibiotics matched blood culture positive growth in 72% of patients. The lactate level was greater than 2.2 in 46.9% of patients. No adverse effects were reported after prehospital administration of antibiotics. Conclusion: This study demonstrates the successful implementation of an EMS-driven CMS Sepsis Core Measure bundle in the prehospital setting. Paramedics can acquire uncontaminated blood cultures, and safely administer antibiotics prior to hospital arrival among patients who were recognized as sepsis alerts.