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.

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.     

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.

Implementing a Human Trafficking Educational Module and Protocol in the Emergency Department

IntroductionThe purpose of this quality improvement initiative was to educate emergency nurses and social workers about human trafficking and implement a human trafficking screening, management, and referral protocol adapted from the National Human Trafficking Resource Center.MethodsA human trafficking educational module was developed and delivered at a suburban community hospital emergency department to 34 emergency nurses and 3 social workers through the hospital’s e-learning platform, with learning outcomes evaluated via a pretest/posttest and program evaluation. The emergency department electronic health record was revised to include a human trafficking protocol. Patient assessment, management, and referral documentation were evaluated for protocol adherence.ResultsWith established content validity, 85% of nurses and 100% of social workers completed the human trafficking educational program, with posttest scores being significantly higher than pretest scores (mean difference = 7.34, P ≤ .01) along with high (88%-91%) program evaluation scores. Although no human trafficking victims were identified during the 6-month data collection period, nurses and social workers adhered to the documentation parameters in the protocol 100% of the time.DiscussionThe care of human trafficking victims can be improved when emergency nurses and social workers can recognize red flags using a standard screening tool and protocol, thereby identifying and managing potential victims.     

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.     

Improving Timeliness of Pediatric Emergency Department Admissions

IntroductionThe goal of this quality improvement project was to improve timing, communication, and continued care for pediatric patients who present to the emergency department at a Level I pediatric trauma center and require inpatient admission.MethodsUsing continuous improvement methodology, a patient flow process was created to improve the throughput of pediatric patients requiring inpatient admission from the emergency department, aimed at decreasing the time from decision to admit to actual admission. The new workflow included ED and inpatient nursing collaboration, with nursing leaders coordinating patient transfer.ResultsBaseline data indicated that, in 2019, patients admitted to a short-stay pediatric unit from the emergency department had an average time of 106.8 minutes from decision to admit to the actual admission. After the implementation of a new admission process, time from decision to admit to actual admission decreased from a mean of 106.8 minutes to 82.84 minutes for patients admitted to a short-stay unit. This illustrates an improvement from 59.75% to 68.75% of patients admitted within 60 minutes from ED admission to arrival on a short-stay unit. This model was then replicated throughout other units in the hospital.DiscussionThere are no known benchmark data to guide practice for rapid admission from the pediatric emergency department to inpatient units and continuing care. This quality improvement project demonstrates a model that has been successful admitting patients in an efficient, time-controlled manner. Additional research is needed to document benchmarks for admission timing and to demonstrate other measurable outcomes in patient care.     

Changing Team Member Perceptions by Implementing TeamSTEPPS in an Emergency Department

Introduction

The emergency department is an environment where teamwork and communication are of utmost importance and are the foundation for improved patient satisfaction, staff satisfaction, patient safety, and the reduction of clinical errors. An ED staff perceptions of communication and teamwork influences their ability to provide efficient, high quality care to patients.

A Quality Improvement Initiative on Reducing Blood Culture Contamination in the Emergency Department

IntroductionContaminated blood cultures may have detrimental effects on patients, the organization, and antimicrobial stewardship. Patients in the emergency department may need blood cultures collected before antimicrobial therapy. Contaminated blood culture samples may contribute to prolonged hospital stay and also are associated with delayed or unnecessary antimicrobial therapy. This initiative aims to improve the emergency department’s blood culture contamination rate that will eventually benefit the patients who will receive timely and proper antimicrobial therapy, and benefit the organization fiscally.MethodsThis quality improvement initiative used the Define–Measure–Analyze–Improve–Control (DMAIC) process. The organization targets blood culture contamination rate of ≤2.5%. Control charts were used to study how blood culture contamination rate changed over time. In 2018, a workgroup was formed to work on this initiative. Improved site disinfection using 2% Chlorhexidine gluconate cloth before the standard procedure of blood culture sample collection was initiated. Chi squared test of significance was used to compare blood culture contamination rates 6 months before and during feedback intervention as well as contamination rate from source of blood draw.ResultsBlood culture contamination rates 6 months before and during feedback intervention showed significant decrease (3.52% before intervention and 2.95% after intervention; P < .05). Contamination rates differed significantly based on the source of blood culture draw (7.64% via line, 3.05% via percutaneous venipuncture, and 4.53% via other; P < .01).DiscussionBlood culture contamination rate continued to decrease with the use of a predisinfection process with 2% Chlorhexidine gluconate cloth before blood sample collection process. Practice improvement also was evident with effective feedback mechanism.     

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.     

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.