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Reducing Seclusion and Restraints in Adolescent Patients

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Seclusion and restraint (SR) continue to be used in psychiatric settings when a patient is a harm to self or others despite growing concern and calls to eliminate the practice due to its harmful, potentially life-threatening effects on patients. The

Seclusion and restraint (SR) continue to be used in psychiatric settings when a patient is a harm to self or others despite growing concern and calls to eliminate the practice due to its harmful, potentially life-threatening effects on patients. The purpose of this evidence-based project was to assist a hospital in the southwestern United States decrease their seclusion and restraint rates among their adolescent patients. Trauma-informed care approaches have been shown to significantly reduce the incidence of SR in inpatient settings.

The nurses and behavioral health technicians (BHTs) received a two-hour trauma-informed care training in November of 2019. SR rates three months pre-training and post-training were compared. In the three months prior to the training, SR rates averaged 23.4 events per 1000 patient days. Comparatively, the three months after the training SR rates averaged 19.5 events per 1000 patient days. This shows a clinically significant decrease in SR rates after the TIC training. This evidence-based project (EBP) highlights the need to address this problem and gives an intervention option that can reduce harm for patients and address the needs of healthcare organizations seeking to improve patient care.

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2020-05-03

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Strategies for Help in Crowded Emergency Rooms

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Objective: Pediatric patients with asthma are frequently cared for in the emergency department (ED). Many studies show early administration of corticosteroids (CS) can improve outcomes for children experiencing an asthma exacerbation. Despite the evidence, delays in care remain. The purpose

Objective: Pediatric patients with asthma are frequently cared for in the emergency department (ED). Many studies show early administration of corticosteroids (CS) can improve outcomes for children experiencing an asthma exacerbation. Despite the evidence, delays in care remain. The purpose of this study is to streamline the process for nurse-initiated, triage-based CS administration and determine the effect on overall length of stay (LOS). Methods: For this quality improvement initiative, ED nurses at a large, freestanding, children’s emergency department in the southwestern United States were given education on inclusion and exclusion criteria for nurse-initiated CS in ED triage. Time to CS administration, LOS, and whether the ED nurse or provider ordered the CS were evaluated through chart reviews of patients presenting with a chief complaint of difficulty breathing. These metrics were compared to charts from the previous year during the same timeframe to evaluate for improved timeliness of CS delivery. Results: Time to CS administration decreased from a mean of 98.6 minutes to 57.6 minutes. LOS decreased from an average of 259.3 minutes to 169.6 minutes. The effect of timely CS on LOS was significant for December p =.003, January p =.002, and February p = <.001. Conclusion: A streamlined process for CS delivery to pediatric patients experiencing an asthma exacerbation can enable providers to achieve efficient and effective care in the ED and decrease a patient’s overall LOS.

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2021-04-23

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Evaluating the Efficacy of Calcium Chloride versus Calcium Gluconate in ECMO Initiation for Neonates

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Purpose: Neonates who require Extracorporeal Membrane Oxygenation (ECMO) are at risk for calcium derangements and associated adverse outcomes. A large children’s hospital in the Southwest changed their practice from using calcium gluconate in priming their neonatal ECMO to using calcium

Purpose: Neonates who require Extracorporeal Membrane Oxygenation (ECMO) are at risk for calcium derangements and associated adverse outcomes. A large children’s hospital in the Southwest changed their practice from using calcium gluconate in priming their neonatal ECMO to using calcium chloride. The impact of this change was not investigated.
Methods: A retrospective chart review of 56 neonates who required ECMO support one year prior to and one year following the practice change was conducted. Descriptive data was collected along with the first ionized calcium measured following ECMO initiation.
Results: Upon review of the data, the post-ECMO calcium levels were not significant between the calcium gluconate and calcium chloride groups using a Mann Whitney U test (U = 315.5, z = -1.25, p = .213). However, a Chi-square test was significant (χ2(1) = 4.94, p = .026) for having calcium values outside of a normal range in the calcium gluconate group. Fisher’s exact test revealed an odds ratio of 3.43 for the first calcium being outside normal range in the calcium gluconate group.
Implications: While comparison of the first measured ionized calcium post-ECMO between the two groups was not statistically significant, there was a significant correlation with normal post-ECMO calcium in the calcium chloride group. This suggest that both calcium gluconate and calcium chloride are appropriate for use in priming the neonatal ECMO circuit, however calcium chloride may provide tighter control of calcium during ECMO initiation in neonates.

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2021-04-25

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Teach-Back Method; Improvement of Patient Comprehension of Nuss Procedure

Description

Successful management of pediatric procedures is challenging. Many procedures have a detailed list of pre-procedural requirements and post-procedural pain control regimens. Patients and families often get lost in the many requirements needed before scheduling the procedure and often delay intervention.

Successful management of pediatric procedures is challenging. Many procedures have a detailed list of pre-procedural requirements and post-procedural pain control regimens. Patients and families often get lost in the many requirements needed before scheduling the procedure and often delay intervention. This delay can cost both the families and facility time and money but often leave the patient needlessly suffering. Inadequate pain control results in emergency room (ER) visits or hospital admissions for acute postoperative pain management. The opioid epidemic has significantly impacted postoperative opioid prescriptions at discharge. The limited prescriptions available after discharge, paired with inadequate understanding and support of discharge postoperative instructions by the family, result in increased acute postoperative pain management admissions. Postoperative pain is the leading cause of hospital readmissions within 48 hours of discharge. These ER visits are typically for issues that are easily addressed at home. Teach-back methods have shown to be the cornerstone of education, resulting in knowledge gained and increased pain regimen adherence. A literature review exploring current evidence regarding postoperative pain control and interventions coupled with teach-back was conducted to address this concern, and an evidenced-based intervention is proposed.

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Date Created
2021-04-20

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Reducing Polypharmacy with Mobile Apps Among Mental Health Patients

Description

Polypharmacy among psychiatric patients is a concerning trend. From 2007-2010, 58.2% of women and 41.8% of men reported taking five or more prescription drugs within the last 30 days (CDC, 2014). Negative outcomes include prescription drug abuse, side effects, interactions,

Polypharmacy among psychiatric patients is a concerning trend. From 2007-2010, 58.2% of women and 41.8% of men reported taking five or more prescription drugs within the last 30 days (CDC, 2014). Negative outcomes include prescription drug abuse, side effects, interactions, treatment failure, patient dissatisfaction, and lack of treatment control. The associated practice challenges have led to the following PICOT question. In persons with mental health issues receiving care at an outpatient mental health clinic, does engaging in mindfulness practice versus no mindfulness practice change polypharmacy use over a 3-month period?

The project purpose was to evaluate the effectiveness of Insight Timer mobile mindfulness app at helping patients self-manage distressing symptoms and reduce polypharmacy. Over three weeks, mental health clinic nurse practitioners (NPs) voluntarily recruited patients (n=12) over age 18 using as needed prescriptions (PRNs), and agreed to use Insight Timer mobile mindfulness app for adjunct symptom management. Consenting participants downloaded the mobile app, and completed a brief questionnaire measuring PRN use at the start of app use, and PRN use at their next visit. A Wilcoxon signed-rank test indicated a 10-week mindfulness app trial did not significantly lower total PRN doses compared with pre-app dosing (Z = -.534, p = .593). Paired t-tests revealed no significant change in pre (M = 65.17, SD = 28.64) versus post (M = 67.75, SD = 20.22) OQ45 life functionality results (t(11) = -.420, p = .683) (d = .121) as a result of app use.

Clinically relevant results illustrated 83.33% of participants taking greater than nine PRN doses over the study period used the app six times or more in place of medication. High PRN users employed the app frequently in place of medication regardless of total PRN doses taken. Practice implications and sustainability recommendations include incorporating mobile app use in treatment plans for high PRN users and educating NP’s on the tangible benefits of mindfulness apps in reducing polypharmacy and easing symptom distress on an ongoing basis.
Keywords: mindfulness, mhealth, mobile apps, mobile smart phone, online, RCT, behavior change, polypharmacy.

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2019-04-29