Implementing an Evidence-Based Practice Change for Alcohol Withdrawal in an Acute Care Hospital

Practice Problem: Alcohol Use Disorders (AUD) affects a significant portion of the population in the United States. When AUD is either unrecognized or inadequately treated in the acute care setting it can lead to medical complications, increased length or stay (LOS), increased healthcare expense, and increased patient mortality. PICOT: In a population of adult patients admitted to an acute care hospital progressive care unit (P), how does applying an initial evidence-based screening tool to detect risk for moderate to severe alcohol withdrawal, the PAWSS (I), compare to no standard screening or assessment for potential alcohol withdrawal symptoms (C) affect the occurrence of patient deterioration for acute alcohol withdrawal symptoms (O) within an eight week timeframe (T)? Intervention: The PAWSS tool was utilized to screen all patients admitted to the progressive care unit. Patients identified at moderate to severe risk by a score of ≥4 were treated according to the standard facility practice with included CIWA-Ar monitoring and medication management with benzodiazepine medication. Outcome: The project was able to demonstrate a significant decrease in the mean LOS for those patients identified at risk and treated for AWS, with an average decrease of 50 hours in length of stay for those patients treated during the project implementation. Conclusion: Early recognition of patients at risk for AWS is an important component of effective management and treatment. Further study is needed into best practices for treatment of patients at risk, and internal compliance measures within the organization

Honoring Patient Do Not Resuscitate Wishes and Reducing Harm During Transitions of Care: A Quality Improvement Project

Objectives: The quality improvement project objectives were to honor documented Do Not Resuscitate wishes in emergency departments by examining and improving workflow during primary care to emergency department transitions. A location for advance care planning documentations was designated for advanced directives, yet not utilized. Methods: Mixed method, pre-/post-comparison, and thematic design examined clinicians and patients in a primary care office and two emergency departments in a Midwest healthcare system. Data was collected from patient records, clinician surveys, and observation of workflow. Descriptive statistics, frequency counts and non-parametric tests were used to analyze data. Results: Patient charts were audited (N=261 [pre=124; post=137]), mean age 79.2 years, 59% female. Clinician surveys included 32 emergency department providers (30=pre; 2=post) and 59 registered nurses (38=pre; 21=post). Patient chart audit (N=137) found 97% had a primary care code status with 2.9% in emergency department records. Provider (mean 2.93) and registered nurse (mean 3.14) moral distress was moderate. Pre/post barriers to discuss advanced directives increased from 80.2% to 100%; comfort discussing advanced directives improved from 43.2% to 100%; and providers (13.3-100%) and registered nurses (3-19%) were more aware of where to document advanced directives. Conclusions: Gaps in care placed patients with Do Not Resuscitate at risk for harm due to challenges with documentation. Post-implementation knowledge improved yet workflow and placement of Do Not Resuscitate orders in the record did not change. A clinically significant improvement in clinician knowledge of patient safety and location of advance care planning documents may lead to improved care

Being certain : Moral distress in critical care nurses

Published literature has focused on understanding moral distress from a descriptive standpoint. Missing from the literature is an exploration of the role a nurse can play in his/her/own moral distress.A qualitative study with an interpretive design incorporated Clandinin and Connelly\u27 narrative methodology. Results highlighted assumptions were made by participants in the absence of resources, which led them to know the right action to take from their own perspective

Reducing Central Line-Associated Bloodstream Infections in the Intensive Care Unit by Improving Compliance with Dressing Changes and Curos Caps Use

Background: Reducing central line-associated bloodstream Infections (CLABSI) is a topic of global importance due to associated risk of sepsis, increased length of hospital stay, high healthcare cost, and increased morbidity and mortality among critically ill patients in the intensive care unit (ICU). The mortality rate of patients who acquire CLABSI 15-25% The cost of CLABSI treatment per event is greater than US $16,500. Central cine-associated Bloodstream Infections affect the organization’s national ranking in patient quality and safety as well as reimbursement from the Centers for Medicare and Medicaid (CMS). The aim of the quality improvement project was to improve the compliance of dressing changes and Curos caps use using peer validation and surveillance checklist to reduce CLABSIs in ICU. Methods: This was an observational evidence-based project that investigated whether peer validation and and daily surveillance checklist can improve compliance with central line dressing change and Curos cap use in ICU Results:The compliance of dressing changes improved by 55.9% (44.1% to 100%) and the Curos caps use compliance improved by 75.1% during the post intervention period (18% to 98%

Professionalism in medicine. What is it and how can it be taught?

This study examines the conceptual framework and teaching of medical professionalism from the perspectives of the literature on the subject, clinicians engaged in clinical teaching regarding professionalism, and medical students. I begin with a brief history and overview of the concepts of professionalism in medicine. I follow that with a Best Evidence in Medical Education (BEME) systematic review of the literature to identify the best evidence for how professionalism should be defined and taught. This review found that there is as yet no overarching conceptual context that is universally agreed upon. The development of ways to teach and assess professionalism has been encumbered, and failed to progress, in large part because of this amorphous nature of the various definitions promoted. The review also found no unifying accepted theory or set of accepted practice criteria for teaching professionalism. Evident themes in the literature are that role modelling and personal reflections, ideally guided by faculty, are the important elements in current teaching programs, and are widely believed to be the most effective techniques for developing professionalism. While it is generally agreed that professionalism should be part of the whole of a medical curriculum, the specifics of sequence, depth, detail, and the nature of how to integrate professionalism with other curriculum elements remain matters of evolving theory. No teaching methodology has been demonstrated in the literature to be effective or accepted for use across a wide range of medical schools. I next developed and carried out qualitative studies to discover what conceptual understanding (mental models) of professionalism medical students and clinical educators held, how these two groups view current professionalism training as a component of medical education, and how they think it should be taught. I found that medical students achieve professionalism through the influence of their exposure to seasoned professionals and through informal peer reflection. The doctors in my study group achieved professionalism not through any formal training they received, but as a result of the actions and attitudes they witnessed during their training, which created a path to reflective practice that they have sustained. I conclude by proposing a conceptual model for instilling professionalism through medical education. This model captures the formative influences on professionalism and provides a framework for understanding professional performance. The teaching of professionalism should be integrated into all years of the medical curriculum, and across all disciplines included in the curriculum. Some attributes of professionalism, such as ethics and communication skills, can be introduced in early years. Mentoring and exposure to positive role models hold the most promise as effective teaching methods. Guided reflection turns transient incidents and experiences into true learning moments, solidifying and honing professionalism. Ultimately professionalism should be viewed as an ethos. I hope that my findings will improve our ability to instil professionalism in our students

LEAN AND SUSTAINABILITY MECHANISM FOR INFRASTRUCTURE PROJECTS DELIVERY IN SOUTH AFRICA

Published ThesisAchieving a resilient and sustainable building infrastructure is essential for continuous economic growth, international competitiveness, public health and overall quality of life, especially in developing countries such as South Africa. Calls for the use of innovative practices for changing the unsustainable, ‘Business As Usual’ (BAU) model of contemporary building delivery have been on the increase. In its contribution towards resolving this imbroglio, this study aimed at proposing a mechanism for operationalizing the integrated use of lean and sustainability ethos for sustainable infrastructure delivery in South Africa. In this study that was domiciled in a pragmatic paradigm, a case study research design was adopted. Five purposively selected cases within Gauteng province of South Africa were utilized. The perceptions and working experience of government agencies, developer/clients, consultants, project managers, facility managers, users, academia, general contractors and subcontractors in the selected cases were elicited. The quantitative data was statistically analyzed whilst the qualitative data was transcribed, coded and thematically analyzed. The emergent findings were discussed in line with other sources to give insight into the development of the mechanism – the lean-sustainability mechanism for infrastructure (LSMI) delivery. The results of the study suggested that attaining efficiency in energy, material and water resources forms the major features of sustainable construction in the industry. The major drivers for the lean-sustainability paradigm include: drive to gain an industry competitiveness edge, and the market environment that now requires higher efficiency and effectiveness for success, whereas the one significant barrier to the lean-sustainability paradigm remains the sustainability premium in South Africa. An expert survey was used to test the LSMI’s robustness. It was discovered that the mechanism possessed adequate robustness to engender transformation in the sector. The evaluation validates the LSMI ability to provide an adaptive form of governance needed for building infrastructure delivery systems, in response to the gradual deterioration of the global socio-ecological stability. The developed mechanism provides a transformational route for achieving building infrastructure sustainability. The mechanism also provides a new way of thinking about building infrastructure delivery from a sustainability perspective

THE IMPACT OF RECESS ON CHILDREN’S SOCIAL/EMOTIONAL DEVELOPMENT, CLASSROOM BEHAVIORS, AND TEACHER PEDAGOGY: AN EXPLORATORY CASE STUDY OF ELEMENTARY SCHOOL STUDENTS AT PLAY

Recent reports have stated that schools across the United States have been reducing recess so that more time can be spent in the classroom. There has been little research to prove that more time in the classroom and less recess equals better academic outcomes for children. The purpose of this study was to discover the impact recess on elementary school students’ social competencies, emotional development, classroom behaviors, and teachers’ pedagogy and instructional practices. The elementary school is in a suburban district in United States. It has a population of 457 students. The population is culturally diverse with 10% of the students receiving English as a Second Language. The percentage of students with disabilities is 16%, and 43% of students are socioeconomically disadvantaged. Twelve teachers participated in interviews. Students were observed during various recess breaks over five sessions. The researcher took notes regarding social interactions, communications, and play behaviors. The sample size for assessing classroom behaviors prior to and following recess consisted of 30 first-grade students. The results of this study validate the value of recess and play experiences for children. The study of classroom behaviors exposed the reality that students were more focused and less fidgety following a recess break. Teachers’ responses revealed that recess was valuable for students’ social, emotional, academic, and physical development. It also revealed that teachers feel better about their pedagogy as a result of being permitted to implement recess breaks in between sustained instruction. The literature review provided evidence that block time and more time in the classroom with minimal breaks for students is poor practice and a detriment to proper child development. Research has indicated that recess is essential for children’s social, emotional, creative, and cognitive well-being (American Academy of Pediatrics, 2013; Barros, Silver, & Stein, 2009). Children’s experience, however, varies widely from school to school. Future research should focus on the differences in recess mandates from state to state and the social, emotional, and academic outcomes of children

Interventions to improve team effectiveness within health care

Background: A high variety of team interventions aims to improve team performance outcomes. In 2008, we conducted a systematic review to provide an overview of the scientific studies focused on these interventions. However, over the past decade, the literature on team interventions has rapidly evolved. An updated overview is therefore required, and it will focus on all possible team interventions without restrictions to a type of intervention, setting, or research design. Objectives: To review the literature from the past decade on interventions with the goal of improving team effectiveness within healthcare organizations and identify the "evidence base" levels of the research. Methods: Seven major databases were systematically searched for relevant articles published between 2008 and July 2018. Of the original search yield of 6025 studies, 297 studies met the inclusion criteria according to three independent authors and were subsequently included for analysis. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence. Results: Three types of interventions were distinguished: (1) Training, which is sub-divided into training that is based on predefined principles (i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety), on a specific method (i.e. simulation), or on general team training. (2) Tools covers tools that structure (i.e. SBAR: Situation, Background, Assessment, and Recommendation, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger (through monitoring and feedback) teamwork. (3) Organizational (re)design is about (re)designing structures to stimulate team processes and team functioning. (4) A programme is a combination of the previous types. The majority of studies evaluated a training focused on the (acute) hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements. Conclusion: Over the last decade, the number of studies on team interventions has increased exponentially. At the same time, research t

Getting to Zero Preventable Falls: An Exploratory Study

Objective: The objective of this study is to examine relations between patient safety culture and processes of care, specifically, how patient safety culture influences the prevention of patient falls. The purpose of this inquiry is to identify the barriers and facilitators that can advance an inpatient rehabilitation facility to become a high reliability organization and advance interdisciplinary teamwork. Method: A qualitative phenomenological approach was conducted and an interpretive phenomenological analysis explored the experiences of frontline staff with regard to patient safety culture and fall prevention. The study utilized semi-structured interviews with 24 frontline staff from three inpatient rehabilitation hospitals. Participants were selected using purposive sampling and individually interviewed. Results: Findings revealed barriers and facilitators for each dimension of patient safety culture that drive fall prevention. Teamwork within and across disciplines, such as between nursing and therapy, affect how they communicate with one another. Issues related to staffing were the most common concerns amongst nursing staff; especially the issue of staffing ratio and patient acuity. Leadership played a role in supporting the culture of safety and holding staff accountable. Conclusion: Fall prevention requires collaborative efforts between nursing and therapy in an inpatient rehabilitation setting. Dimensions of patient safety culture such as good teamwork, effective communication, adequate staffing, nonpunitive response to errors, and strong leadership support are essential in maintaining a high reliability process for adaptive learning and reliable performance

Interprofessional Teamwork in Hospital Units: A human factors approach to patient safety

Introduction Human factors, such as teamwork and communication, have an important impact on patient safety in hospitals. Hospitals have a patient safety problem, with more than every 10th patient experiencing errors and adverse events during their hospital stay. Root cause analysis have showed that ineffective teamwork and communication failures are the most common causes of errors and adverse events. To improve patient safety in hospital units, healthcare professionals needs competency in teamwork, such as communication, decision making, leadership, situational monitoring and mutual support. Interprofessional team training is a key strategy for improving teamwork and patient safety in hospital units. Previous research on interprofessional team training in specialty units has showed promising results; however, the impact on surgical wards is uncertain. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program had not been implemented in Norway. Team decisionmaking has not yet been studied previously among multiple healthcare professionals across diverse hospital units. Aim The overall aim of the thesis is to gain knowledge about teamwork in hospital units and to evaluate and explore the impact of an interprofessional team training intervention regarding teamwork and patient safety culture in a surgical ward. The specific aims of the sub-studies are as follows: 1) To translate the CSACD-T questionnaire into Norwegian and test it for psychometry properties. The further aim is to describe and compare healthcare personnel's perceptions of collaboration and satisfaction about team decision-making across hospital units (Study I, paper 1). 2) To evaluate the professional and organizational outcomes of an interprofessional teamwork intervention among healthcare professionals in a surgical ward after 6 and 12 months (Study II, paper 2). 3) To explore if an interprofessional teamwork intervention in a surgical ward changes the healthcare personnel’s perceptions of patient safety culture, perceptions of teamwork, and attitudes toward teamwork over 12 months (Study II, paper 3). Methods Study I (paper 1) had a cross-sectional design. The Collaboration and Satisfaction About Care Decisions in teams (CSACD-T) questionnaire was used for the survey conducted among healthcare professionals across multiple hospital units (hospital A and B). Study II (paper 2) used a pre-post design with re-measurement (hospital C), with surveys (CSACD-T, TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ), and Hospital Survey of Patient Safety Culture (HSOPS)) distributed to healthcare professionals in the intervention ward at baseline and after 6 and 12 months. Study II (paper 3) used a controlled quasi-experimental design, with surveys (CSACD-T, T-TPQ, HSOPS, and TeamSTEPPS Teamwork Attitude Questionnaire (T-TAQ)) distributed to all healthcare professionals in the intervention ward and control ward (hospitals C and D) at baseline and after 12 months. The intervention was a 6-hour TeamSTEPPS interprofessional team training included simulation training, followed by implementation of teamwork tools and strategies in the ward over 12 months (hospital C). The implementation followed Kotter’s eight steps for leading change. The human factors systems engineering initiative for patient safety (SEIPS) model was used as a theoretical perspective. Results The CSACD-T questionnaire showed promising psychometric properties in terms of construct validity and internal consistency. The scores of collaboration and satisfaction with care decisions in teams varied among unit types and were highest among the healthcare professionals in the wards, with a significant difference between the maternity ward and emergency room (paper I). The outcomes from the intervention study showed significant changes in organizational outcomes after six months, and were in the following areas of patient safety culture: “Organizational Learning and Continuous Improvement” and “Communication Openness” (paper 2). After 12 months, significant changes were found in professional outcomes within the intervention ward, which were in three perceptions of teamwork dimensions: “Situation Monitoring,” “Mutual Support,” and “Communication”, in addition to organizational outcomes, which were in three patient safety culture dimensions: “Communication Openness,” “Teamwork Within Unit,” and “Manager’s Expectations & Actions Promoting Patient Safety” (papers 2 and 3). The improved teamwork dimension “Mutual Support” was found to be a predictor of “Patient Safety Grade” (paper 2). The controlled results revealed significant differences favoring the intervention ward in three patient safety culture measures: “Teamwork Within Unit,” “Overall Perceptions of Patient Safety” and “Patient Safety Grade” (paper 3). Conclusion This thesis presents new insights into team decision-making in diverse hospital units, as reported by healthcare professionals from multiple healthcare professions. The thesis also presents new insights into the impact of an interprofessional TeamSTEPPS intervention in a surgical ward in Norway. The outcomes are promising, indicating that TeamSTEPPS intervention improves teamwork and patient safety culture in a surgical ward. The causal relationships among inputs, processes, and outcomes are, however, not certain, and further studies are required to confirm the outcomes of this comprehensive and well-described interprofessional team-training intervention. Nevertheless, the knowledge from this thesis adds to the vast field of teamwork and patient safety research internationally