Nurse-Led Initiatives Are Improving Patient Safety

In the first study, Victoria Shemaria, BSN, RN, CCRN, of the Cancer Treatment Centers of America in Philadelphia, PA, and colleagues examined the safety and efficacy of a progressive upright mobility (PUM) program in critically ill ventilated patients with cancer to determine the compliance and sustainability of the program in measuring patient ventilator days, intensive care unit (ICU) use, and hospital length of stay.

The researchers first collected 12 months of baseline data on these items, then developed and implemented a stepwise, multidisciplinary PUM protocol in all mechanically ventilated patients admitted to a single subspecialty cancer hospital ICU. They excluded patients with hemodynamic instability and those who needed continuous sedation or neuromuscular blockade. The charge nurse assessed accountability daily to ensure adequate and consistent documentation. The researchers then collected 12 months of post-intervention data for comparison.

Following the PUM program, the three outcomes saw statistically significant improvement: ventilator use was reduced from 6.3 to 3.7 days (p = 0.001755), ICU length of stay decreased from 10.2 to 7.5 days (p = 0.011016), and hospital length of stay decreased from 20.9 to 14.1 days (p = 0.000364).

The patient population with high disease severity and advanced age showed the same beneficial results of early mobilization as other patient groups, the researchers noted. “The nurse-driven PUM protocol provides evidence of safe, positive patient outcomes while decreasing cost of care,” they concluded.

Stephanie Everitt, RN, BSN, OCN^®, of the University of Maryland Medical Center in Baltimore, and colleagues then discussed their work in developing and evaluating a standardized oncology nursing unit visitation process that supports patient-centered care. Often, child visitation in the oncology inpatient setting is restricted for infection prevention; however, that consideration is not rooted in evidence-based guidelines and it conflicts with goals of patient-centered care.

The researchers developed visitation guidelines and screening criteria in conjunction with infection control and infectious disease personnel to detect signs and symptoms of infection in all visitors. Thirty-five oncology staff members—including nurses, nursing assistants, and unit secretaries—completed a nine-item survey about screening practices and barriers, which had a 39% response rate. The responses were used to guide staff education through provided in-services and a mandatory continuing education module, with a 69% completion rate. Laminated copies of the developed guidelines were posted in each patient room, and a binder was created with additional resources.

After three months, 36 staff members (47% response rate) completed a post-survey. After the intervention, staff were significantly more likely to agree that:

• A unit-specific visitation guideline is in use (p = 0.000).
• They were comfortable explaining current visitation practice reasons (p = 0.012).
• They screen all patients (p = 0.013).

Staff were less likely to report that lack of visitation guidelines was a screening barrier (p = 0.000). However, other barriers—such as awareness of visitors on the unit and time commitment—did not significantly improve, and the researchers noted that they are looking to address the remaining barriers. “Standardized visitation guidelines increased oncology staff’s reported comfort level with explaining visitation rationale and screening process,” the researchers concluded.

In the next study, Ashley Keppel, RN, MSN, OCN^®, PCCN, of the Roswell Park Cancer Institute in Buffalo, NY, and colleagues sought to decrease noise levels in the oncology care unit and improve patient outcomes, as well as decrease nursing alarm fatigue through a nurse-led action plan.

Based on the results of a needs assessment, the unit presented an action plan and collaborated with physicians and administration. Interventions were initiated in three areas of concern: staff fatigue, inappropriate default settings, and multiple systems monitoring one patient. Staff nurses ordered equipment necessary to monitor critical care patients on one monitor, and nurse-to-nurse reporting began to include checking of alarms and settings. Peer-to-peer education occurred regarding the removal of duplicate alarms/monitoring systems, qualifications for utilizing alarms, processes for adjusting alarms to the individual patient, and the importance of responding to alarms.

Following implementation, the researchers reported improved patient satisfaction related to noise levels: patients who reported that the area around their room was “always” quiet at night improved from 50.9% to 68%. A follow-up survey revealed that 90.9% of staff surveyed were checking and adjusting settings on their monitor, and 100% believed that the single monitor was safer for patients. In addition, 71% said alarm fatigue was reduced.

“Empowering nurses to develop and implement patient safety initiatives required support from nursing leadership to promote oncology nursing excellence,” the researchers concluded.

Thanyanee McNinney, BSN, RN, OCN^®, of New York Presbyterian in New York City, and colleagues discussed the final study, which sought to reduce fall rates in patients who received hematopoietic cell transplantation (HCT) with the creation of the Fall TIPS (Tailored Intervention for Patient Safety) program. The intervention was enacted on a 16-bed HCT unit in an academic medical center.

Fall TIPS involved three steps:

• Fall risk assessment focusing on modifiable risk factors
• Individualized fall prevention strategy
• Consistent implementation

Nurses completed an online module prior to implementation. The protocol included posting a sign in the patient room with tailored, simple visual intervention icons, as well as educational materials. Unit fall champions performed monthly compliance audits, encouraged team communication and engagement, and identified areas of improvement.

In the pre-intervention period (January 2016–January 2017), the fall rate was 1.46 patients per month, and 46% of falls resulted in injury. During the Fall TIPS intervention period (February 2017–September 2017), the fall rate was 1.12 patients per month, and no falls resulted in injury. After the intervention, the fall rate decreased by 23.3%, and the unit saw a 100% improvement in falls resulting in injury.

“To effectively prevent falls, nurses and the multidisciplinary team should proactively and consistently implement the individualized patient interventions,” the researchers concluded.