2025 National Teaching Institute Evidence-Based Solutions Abstracts

Rebecca Vargas, Rosalie Grantoza, Holly Kozna; Old Bridge Medical Center, Old Bridge, New Jersey

Early patient-mobility programs (EPMPs) have been recognized for improving patient outcomes and decreasing use of hospital resources. The purpose of an EPMP is to promote early mobilization and decrease adverse outcomes for patients. Adverse outcomes associated with prolonged immobility include prolonged length of stay (LOS), hospital-acquired pressure injuries (HAPIs), and falls.

A literature search was conducted in the CINAHL, PubMed, and Google databases using the following terms: early patient mobility, patient mobility programs, and telemetry units. Articles published between 2018 and 2023 were included. Research suggests low mobility is prevalent in the hospitalized adult population and places patients at high risk for adverse health outcomes. An increasing amount of evidence shows that early mobilization is a safe and cost-effective initiative for decreasing adverse outcomes.

The EPMP setting was a single 22-bed telemetry unit in New Jersey. The Bedside Mobility Assessment Tool (BMAT) was used to assess patient mobility levels and determine which patients were appropriate for the EPMP. The BMAT defines 4 levels of mobility, each assessing the patient’s ability to perform a physical task. Patients with a BMAT score of 3 or greater were selected for our EPMP.

Starting in August 2023, the nurse leader reviewed the patient’s charts. A magnet in the image of a walking shoe was placed by the room number of patients with a BMAT score of 3 or greater. The registered nurses (RNs) and patient care technicians (PCTs) ensured these patients were taken on supervised walks throughout the day. The interprofessional team was supported by physical therapists (PTs), who specifically focused on walking patients who had orders for physical therapy.

The 24-month data collection before and after implementation of the EPMP ranged from August 2022 to July 2023 and August 2023 to July 2024. Primary outcomes for both patients and staff included fall rates, incidence of HAPIs, and LOS. Fall rates declined from 2.1 falls per 1000 days to 1.7 per 1000 days. Fall rates with injuries declined from 0.5 falls per 1000 days to 0.16 per 1000 days. HAPIs declined from 1.19 per 1000 occupied beds to 0.27 per 1000 occupied beds. LOS stayed relatively unchanged from 5.3 median days to 5.02 median days.

EPMPs are effective interventions for improving strength and physical function, as well as decreasing fall rates and HAPIs. One of the major barriers was the additional burden on staff, which was relieved by using an interprofessional approach involving RNs, PCTs, and PTs. Our findings indicate the EPMP decreased adverse outcomes and improved patient safety.

Jenna Vledder, Isabella Shattenkirk, Chelsea Weaks, Diana Ellis, Catherine Knapp; Sentara Heart Hospital, Norfolk, Virginia

The Sentara Norfolk General Hospital cardiac intensive care unit (ICU) had 24 health care–acquired pressure injuries (HAPIs) in 2023, contributing to higher health care costs and poor patient outcomes. Evidence-based preventive measures were implemented to decrease HAPI rates and thus improve patient care.

Data were sourced from the EBSCO and National Center for Biotechnology Information databases. Key terms were HAPI, HAPI bundles, ICU pressure injury, specialty beds, and pressure injury prevention. Fifteen articles were reviewed. Sources indicated that effective HAPI prevention protocols require not just one but rather a set of evidence-based practices used together to reduce HAPI incidents. Supported interventions include frequent rounding, topical products to maintain skin integrity, and pressure-redistributing devices.

In 2024, 5 evidence-based interventions were implemented on an 11-bed cardiac ICU in southern Virginia. Notable patient populations included bed-bound, bariatric, and intubated and/or sedated patients. Interventions included weekly photo monitoring, application of a moisture-barrier product to the sacrum upon admission, nurse-driven specialty bed orders, universal use of waffle overlays, and weekly room rounding with the clinical nurse specialist and wound care team.

Charting audits and room rounding helped identify high-risk patients and areas for immediate improvement. Charge nurses were responsible for identifying any interventions that were missing for each patient. Education was given during daily huddles, and suggestions for improving compliance with interventions were discussed during monthly practice council meetings.

Following implementation of these protocols, pressure injury rates fell by greater than 50%, with 8 HAPIs (stage 2 or greater) being identified by September 2024, compared with 24 HAPIs in 2023. These data support previous evidence that multiple interventions bundled together can effectively reduce HAPI rates in the critical care setting.

Lower HAPI rates lead to improved patient outcomes, shortened hospital stays, and reduced costs to the organization. These interventions have been successfully implemented in other units as well. These data support previous findings that bundled HAPI interventions are effective in reducing HAPI rates in the critical care setting.

Katie Reese, Kara Leopold, Mazen Kherallah, Megan Moore, Margaret Standifer, Karen Baatz, Greg Clark, Jayden Desai; Sanford Health, Fargo, North Dakota

After the COVID-19 pandemic, core tenets of intensive care unit (ICU) nursing practice were lost, affecting patient outcomes. At a large academic hospital, a team set out to improve length of stay (LOS) and mortality rates of critical care patients through integration of the Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) guidelines.

Literature supporting the PADIS guidelines is well established. First published in 2013, elements of the 2018 guidelines include adequate pain management, light sedation, delirium prevention, early mobility, and sleep promotion. A multicenter prospective study found a dose-dependent relationship between A-F bundle element completion and patient outcomes. In another report, authors suggested team rounding and staff education as part of a multimodal implementation strategy.

This medical center, which has more than 500 beds and is part of the largest rural health system in the United States, has level I trauma and Advanced Comprehensive Stroke designation. Patients receive care across 4 specialized ICUs with a 66-bed capacity. The interprofessional team conducted a gap analysis. Recommended practice changes included analgesia-first light sedation, interprofessional team rounds using the A-F bundle, and interprofessional education. Collaboration and commitment across disciplines formed the project’s foundation.

To promote an analgesia-first light sedation approach, a clinical algorithm was created and physician order sets were aligned. Workflow changes addressed system barriers, including changes to rapid sequence intubation and improved medication availability. Nurse-led interprofessional team rounds, guided by an A-F bundle–derived script, fostered communication and ensured accountability to core elements. Comprehensive interprofessional education, called PADIS Academy, provided the latest evidence and emphasized patient dignity.

At baseline in the second quarter (Q2) of 2022, the all-hospital LOS for adult patients who received ICU care was 10.95 days and the all-hospital mortality rate was 12.84% (n = 740). In Q2 2024, the all-hospital LOS was 7.16 days (n = 903), a decrease of 3.79 days, or a 35% reduction. The Q2 2024 all-hospital mortality rate decreased 4% to 8.75% (n = 903). During this period, propofol and fentanyl use decreased 53% and 48%, respectively. Midazolam use decreased by 48%.

Decreases in LOS and mortality rates result in benefits to patients, families, and the interprofessional team. Interprofessional team rounding was key. A culture change is achieved when common goals put patients and best practice first. Electronic medical record changes, including a renewed emphasis on mobility, will take the team closer to awake and walking patients in the ICU.

Airton Lonnstrom, Rose Roelant, Nikki Taylor; University of Michigan Medical Center, Ann Arbor, Michigan

Reduce postoperative sepsis in the cardiovascular population caused by nonventilator hospital-acquired pneumonia (NVHAP). NVHAP has a mortality rate of 22%, increases length of stay by 7 to 9 days, may require care in the intensive care unit (ICU), and can cost an additional $20 000 per patient. In fiscal year 2022, there were 15 cases in the cardiovascular center (CVC) that cost about $18 000 per patient.

A literature review of the CINAHL database, using the key terms non-ventilator hospital-acquired pneumonia, nursing care, and postoperative, yielded 51 references, from which 3 articles were selected for in-depth analysis. The literature emphasizes that the most effective practices for preventing NVHAP involve a care bundle that includes regular oral hygiene, use of an incentive spirometer, and early ambulation. Patient education and active participation in their care were shown to enhance prevention efforts.

A bundled care strategy called COMMIT was implemented on 4 units. The bundle comprised early ambulation at least 4 times daily, oral care twice daily, and incentive spirometer (IS) use 10 times every hour. Nursing staff and patients were educated about these elements. Patients received a worksheet to track ambulation, oral care, and IS use. Documentation in the electronic medical record was enhanced for improved accuracy in IS use. Additionally, oral hygiene kits were created to provide patients with all necessary supplies.

Most postoperative sepsis cases in the population of cardiovascular patients stemmed from NVHAP. We reviewed the literature for best practices in pneumonia prevention and conducted GEMBA walks to identify gaps and assess performance. The COMMIT program was developed, outlining all prevention strategies. Signage and education sessions were placed in the units, and data audits were conducted electronically to evaluate compliance before and after the intervention. Weekly updates were provided to unit leadership to track progress.

After implementation of the COMMIT bundle, the number of postoperative NVHAP cases in the CVC was reduced by 60%. The postoperative sepsis rate improved significantly, dropping from an observed to expected ratio of more than 1 to 0.68, representing nearly a 54% decline. Key factors contributing to the project’s success included the use of a care bundle, providing oral care kits, and encouraging active patient participation.

Through the implementation of the COMMIT bundles, we successfully reduced NVHAP and postoperative sepsis rates during this project. Based on this success, a toolkit was developed to expand this practice hospital wide.

Taryn Tougas, Cailin Ford, Jeanne Hlebichuk, Julie Mackenzie; Aurora St Luke’s Medical Center, Milwaukee, Wisconsin

Our debriefing practice was inconsistent and lacked a standard approach. Clinical nurses in our cardiovascular intensive care unit (ICU) setting identified an opportunity to improve the debriefing process. Thus, the purpose of this project was to evaluate nurse-developed and nurse-implemented hot and cold debriefing sessions after resuscitation events.

Literature was searched using the key words critical events, debriefing, nursing, and resiliency. Synthesis of articles (n = 30) highlighted that ICU staff are at an increased risk for distress related to higher acuity, death, and stressful events. Debriefing after critical events promotes teamwork, performance improvement, and communication. Critical care collaborative statements recommend team debriefings and structured communication tools to prevent burnout and promote healthy work environments.

The project implemented a structured hot and cold debriefing process after code events in a 30-bed cardiovascular ICU in a 938-bed medical center. The goal was to incorporate debriefing education in annual training and evaluate hot and cold debriefing. The system policy guided the project with unit-specific variation due to an increased number of critical events. Hot debriefing occurred immediately after a code event at the bedside. Cold debriefing occurred 2 to 7 days later with in-person follow-up.

Debriefing education and a presurvey were provided to registered nurses (RNs) at annual training. Concurrently, audit materials, a hot-debrief form, and cold-debrief email with resources (eg, employee assistance, chaplain services, peer-support program) were developed by clinical RN leaders. The new workflow was piloted. Immediately after an event, the code RN conducted a hot debriefing with the team and forms were sent to champions who then contacted the RNs involved, providing a cold debriefing within the scope of their role and resources.

Pre-post surveys compared participants’ comfort with code, role delineation, and occurrence and benefit of debriefings. Comfort (rated on a scale of 1–10) with being a member of the code team increased on average from 6.97 to 8.31. Preimplementation hot debriefings occurred less than 25% of the time; this rate increased to 67% after implementation (n = 29). Hot debriefing evaluations following implementation had a mean score of 7.74 (0, not beneficial; 10, extremely beneficial), indicating positive benefits. The majority of RNs identified opportunities for improvement. Cold debriefings occurred 92% of the time (n = 33) and half (n = 17; 47%) were beneficial.

Formal evaluation of hot debriefings after code events resulted in increases in the practice and efficacy. Cold debriefings by RN peers were beneficial. Both helped identify areas of improvement. Future opportunities include expansion to other ICU settings, spiritual support sessions, and enhancing informal peer-support networks.

Opal Dy, Erika Guevara, Zorina Hernandez; Arrowhead Regional Medical Center, Colton, California

Our intensive care unit (ICU) faced low engagement with American Association of Critical-Care Nurses (AACN) membership (27%) and Critical Care Nurse (CCRN) certification (only 4 nurses). This gap represented missed opportunities for enhancing practice and improving patient outcomes. We wanted to increase both AACN membership and CCRN certification, fostering a culture of continuous learning and professional development.

We used the PubMed database as our reference source. Our literature review focused on the benefits of professional association membership and specialty certification in nursing. Key findings highlighted improved patient outcomes, enhanced job satisfaction, and increased professional growth associated with AACN membership and CCRN certification. Based on this evidence, we developed strategies to increase engagement, including education, financial support, and recognition programs.

We implemented a multifaceted approach in our ICU. First, we created informational packets on AACN membership and CCRN certification benefits. Second, we negotiated a 50% discount for online CCRN review courses. Third, the application process was simplified by providing prefilled application packets. Fourth, we established a “Wall of Distinction” to recognize CCRN-certified nurses. Fifth, discussions on professional development were integrated into staff meetings.

The unit-based council worked closely with staff representatives and nursing leadership to coordinate efforts and ensure alignment with organizational goals. Senior leadership actively participated in events celebrating newly certified nurses, boosting morale.

Our initiative yielded significant results. AACN membership in our unit increased by 84%, from 27% to 51% of staff; the number of CCRN certifications increased from 4 to 7 nurses (a 75% increase); 9 additional nurses received funding approval for the CCRN examination; and there was improved awareness of professional development opportunities.

This initiative fosters a culture of continuous learning and professional excellence. It enhances patient care quality through evidence-based practice and specialized knowledge. The project demonstrates the impact of targeted strategies on professional development, potentially improving job satisfaction and retention.

Candace Zobenica, Stacy Hull, Jamie Guilbeau; Kaiser Permanente, Santa Clara, California

The COVID-19 pandemic highlighted a mobility challenge for patients receiving extracorporeal membrane oxygenation (ECMO) support on our unit. These patients required 5 staff members for safe transfer to our only manual tilt table. Our ECMO population increased from 1 to 8 patients per day who required tilting 3 to 5 times a day. There was a need to find a safe and effective option for early mobilization in this ECMO population.

Evidence states that early mobilization of patients receiving venovenous (VV) ECMO support is beneficial and improves patient outcomes. Our literature search generated 42 articles from the National Institutes of Health National Library of Medicine using the key search terms early mobilization in VV ECMO and mobilizing ECMO. We reviewed 19 articles and referenced systematic reviews and initial studies. Current recommendations state mobilizing patients receiving ECMO support improves outcomes, but safety and modality of mobilization are areas of needed study.

In a major metropolitan hospital, our 20 bed cardiovascular intensive care unit (CVICU) cares for patients who have undergone cardiac surgery and those receiving mechanical circulatory support (MCS). In 2020, our unit was caring for an increasing number of patients receiving VV ECMO support; these patients were immobile. The team wished to increase the number of mobility times per day per patient. The evidence states early mobility improves patient outcomes. The unit trialed an electric tilt bed with a goal of tilting 3–5 times per day per patient.

Strategies focused on staff education, and hands-on and how-to guides. A representative from the bed manufacturer led in-service sessions on how to use the mechanical bed and where to place patient straps for safety. Our clinical nurse specialist educated staff on cannula safety, patient safety, and how to document angle of tilt and percentage of weight bearing for each tilt. Further education included how to manage tilting challenges; low flows/chugging and hypoxia, and how to use only-needed personnel.

Chart audits were used to track the number of daily tilts. Financial costs were used for cost savings and injury data. The manual tilt-bed process cost $259.99 for an average of 35 minutes with 5 staff members. Our electric tilt bed decreased the cost to $138.89 for 30 minutes with 2 staff members, equaling a cost savings of 47%. One registered nurse (RN) workplace injury led to at least 1 shift lost by the RN, with costs being the wages of $1250 plus the potential medical cost of workers’ compensation estimated at $2059.

This project simplified mobility of patients receiving VV ECMO support, cut costs by reducing staff needed for mobility, and reduced staff injury. The project led to the purchase of 6 electric tilt beds for our CVICU. The tilt beds are now used for early mobilization with all patients receiving MCS and other long-stay or at-risk cardiac patients.

Kayla Witthoeft; Prisma Health Upstate, Prisma Health Oconee Memorial Hospital, Seneca, South Carolina

Nurses noticed a high occurrence of emergence delirium (ED) in pediatric patients after surgery, which led to increased staffing demands, patient and staff injury, and patient dissatisfaction. The purpose of this project was to decrease ED in pediatric patients aged 1 to 10 years through administration of intravenous (IV) dexmedetomidine intraoperatively.

Emergence Delirium is a dissociative state of consciousness with nonpurposeful agitation and inconsolability during emergence from anesthesia. Between 30% and 50% of pediatric patients experience ED after surgery, causing harm to the patient and staff, increased staffing demands, and prolonged behavior changes with sleep disturbances, anxiety, and poor attention. A score of 10 or higher on the Pediatric Anesthesia Emergence Delirium (PAED) scale signifies ED. Dexmedetomidine administered to pediatric patients after surgery can significantly reduce the rates of ED.

Before implementation of this project, dexmedetomidine was not being used in this community hospital postanesthesia care unit (PACU) to prevent ED. Nursing and anesthesia staff collaborated to implement IV dexmedetomidine as a prevention strategy for ED. A literature review showed that best results occurred when dexmedetomidine was administered IV 10 to 15 minutes before emergence from anesthesia. The policy was revised and anesthesia staff would include this in their plan unless contraindicated.

Anesthesia staff held a meeting to discuss the change and review the latest evidenced-based practices. PACU nursing staff hosted a journal club and were given classes on dexmedetomidine, ED in pediatric patients, and the PAED scale. PACU nurses were given a badge buddy with a copy of the PAED scale. Additionally, a champion PACU nurse was selected to assist nurses with questions, collect data, and ensure accurate scoring on the PAED scale.

By comparing the PAED scores of patients who received dexmedetomidine with those that did not, we found that dexmedetomidine administration reduced the occurrence of ED in patients from a preintervention PAED score of 10.0 to a postintervention score of 4.9. PAED scores in the preintervention group ranged from 4 to 20 and 0 to 12 after the intervention. Overall, the patients given IV dexmedetomidine before emergence had a 51% lower score for ED.

Lessening ED reduces injury to patient and staff, parental anxiety, postoperative nausea, and narcotic use. Staff feedback showed a 100% positive response to the practice change. By collaborating with interprofessional partners and successfully implementing this evidence-based practice, ED was decreased and patient care was improved.

Laura Lance, Sandra Yopko; Cleveland Clinic Hillcrest Hospital, Mayfield Heights, Ohio

Sepsis is a leading cause of death in US hospitals. In 2021, the mortality rate for patients with sepsis not present on admission (NPOA) was 45%, above the national average of 35%. This highlights the urgency of developing a dedicated team to focus on NPOA sepsis deaths.

The 2021 NPOA mortality rate was high. The 2021 Surviving Sepsis Campaign guidelines emphasized Code Sepsis teams could be beneficial but that primary focus should be on timely antibiotic administration. In 2023, the Centers for Disease Control and Prevention’s evidence-based protocols included implementing multidisciplinary response teams and alerts to identify sepsis early. The Code Sepsis team uses standardized screening tools, provides education, and aligns practice with the evidence-based guidelines.

In 2021, the Code Sepsis guidelines were created and approved by the hospital committee. In 2022, the Code Sepsis team was expanded to include a critical care–trained nurse practitioner, a rapid response nurse, a phlebotomist, a pharmacist, and a nursing operations manager to respond to all inpatient nursing units. The development of the Code Sepsis team and standardized guidelines provided a foundation for changing the culture to treat sepsis as a medical emergency.

Implementation guidelines were initiated to engage leadership in supporting the Code Sepsis team. Code Sepsis team members and the Sepsis Program manager assisted in education of all multidisciplinary caregivers. Code Sepsis debriefs were completed with required feedback from all team members. Sepsis nurse champions were trained and placed on all inpatient nursing units. Staff members were educated on best-practice advisories and how to successfully call a Code Sepsis.

Code Sepsis debriefs are conducted for all Code Sepsis calls. Feedback from all team members is required to identify opportunities for improvement. Adjustments to protocols and training are based on the feedback received from these debriefs. Postimplementation steps include leadership commitment, guidelines, staff education, sepsis nurse champions, and continuous data monitoring. NPOA sepsis mortality data indicate a 45% sepsis mortality rate in 2021, when the team was not well integrated. In 2022, the rate was 34.4%, with the team initiated and implemented. In 2023, the sepsis mortality rate was 19%, with the active team in place.

The Code Sepsis team is committed to evidencebased, high-quality sepsis care to decrease deaths resulting from NPOA sepsis. Inpatient nursing benefits from clear guidelines, reduced variability in treatment, and continuous support from the Code Sepsis team members, thus increasing nurse satisfaction and patient safety.

Jamie Rossetto, Debra Eastman, Shannon Brunt, Lori Pelham; Michigan Medicine, Ann Arbor, Michigan

The aim of this project was to reduce pain during burn dressing changes, which typically are very painful and require daily changes during extended inpatient stays. Although music and pain medications have been used historically, no advanced technology has been used for distraction and pain management.

A literature search of the CINAHL, PubMed, and Scopus databases using key terms wound care, dressing change, inpatient, and virtual reality identified 18 relevant articles. Through the review, we found that virtual reality (VR) reduces pain during dressing changes, decreases medication use, and enables nurses to scrub more effectively in less time.

This project was conducted at a verified burn center in the US Midwest. Virtual reality was introduced as an adjunct therapy during wound care, offering a cart racing game and a meditation application. Guidelines were established for patient safety and suitability. Implementation occurred from December 2023 to February 2024. Future adjustments include having 2 VR headsets with preset applications, changing the available games, and including a patient trial of VR before use during wound care.

To implement this project, nursing staff were educated on the benefits of using VR during wound care based on evidence by the project lead, a staff registered nurse from the trial unit. Guidelines for use and a logo were created for all related materials as a marketing strategy and provided to staff. Two wound care nurses acted as champions, promoting VR use, assisting with setup, and reporting challenges. Real-time data and patient experiences were shared to encourage continued use.

Effectiveness of adjunct VR was assessed using these metrics: the percentage of patients with a pain score of 7 of 10 or greater after 1 hour of wound care, average intravenous sedation medication dose, and percentage of patients given an opioid medication after care. Results showed a 28% decrease in pain scores of greater than 7 of 10, a 5% reduction in fentanyl use, and a 25% reduction in midazolam use. There was no change in opioid use 30 to 60 minutes after care. Virtual reality helped decrease pain and the need for intravenous medications during wound care.

Using VR during wound care improves pain management for patients and reduces the need for sedation medications. These beneficial effects lower the risk of complications from sedation and enhance patient satisfaction. Next steps include collecting data on a larger scale and exploring the most effective games and applications for patient care.

Lillian Olson, Julia Langin, Nichoals Poch, Kirsten Hanrahan; University of Iowa Hospital and Clinics, Iowa City, Iowa

Hospital-acquired pressure injuries (HAPIs) are a problem in 10% to 41% of patients. Hospital-acquired pressure injuries limit Medicare reimbursement, which can result in up to $70 000 in costs. The goal of this project was to decrease the number of sacral HAPIs by eliminating the use of pillows for turning and minimizing linens to help decrease friction and heat under a patient.

Literature has shown pillows are an ineffective turning method, because they cannot maintain a 30° turn. In 1 study, 28% of patients developed a stage 2 HAPI when pillows were tested as a turning method. In phase 2 of the study, a turning device was used with no resulting sacral HAPI. The European Pressure Ulcer Advisory Panel recommends the use of low-coefficient linen to help decrease friction and shear. Reducing layers decreases heat and moisture, creating a better microclimate.

The practice change took place in a 26 bed medical intensive care unit (MICU) at a large teaching hospital. Patients ranged from those with respiratory, liver, and kidney failure, to various other medical conditions. Pillows have long been used to promote positioning; however, their effectiveness to shift pressure points is questioned. The intervention was to de-implement the use of pillows and fitted sheets with draw sheets, and continue use of lateral rolling and wedge positioning devices.

Using the Iowa Model, nurses were surveyed about their knowledge, attitudes, and behaviors. Instead of standard education related to positioning devices, we focused on the ineffectiveness of pillows (unlearning), hands-on training, using the positioning devices, and effects of heat and friction from layers of linen (learning). Passive constraint was a challenge with this de-implementation due to the inability to completely remove pillows from rooms and staff being able to obtain fitted sheets.

Pre- and postsurvey data showed nurses understood the importance of HAPI prevention and were knowledgeable and comfortable using roller devices. Documentation, resources, and having time to turn patients all improved. The rate of sacral HAPI development in the MICU was reduced from an average of 2.6 per month over 12 months before project implementation to 0.7 per month over 7 months after implementation. Estimated cost avoidance is up to $70 000 per full-thickness HAPI, which demonstrated $133 000 in cost savings per month.

Clinicians should consider opportunities for de-implementation of pillows before implementing a practice change. De-implementation of linens and use of existing positioning devices demonstrated a return on investment and a reduction in the number of sacral HAPIs in the MICU that has been sustained over 12 months.

Kayla Fuller, Leah Haught, Lacey Spangler, Miranda Scoggins, Karla Brown; Carolinas Medical Center Atrium Health, Charlotte, North Carolina

Missed or delayed palliative care consultations occurred in intensive care units (ICUs), with an average time of 8.69 days to consultation. Early palliative care improves patients’ quality of life while reducing length of stay (LOS). It can also lower readmissions and health care costs. The literature shows that a screening tool registered nurses (RNs) can use can effectively identify patients appropriate for palliative care.

Seeing palliative care only as an end-of-life service leads providers to see it as a separate pathway rather than a supportive option. This approach results in less integration with curative treatment and in delayed consultations. Palliative care consultations within 72 hours of admission positively affect patients’ quality of life, emotional needs, and ICU and hospital LOS. Cost implications include reduced readmission rates and direct care cost savings. A literature review led to adoption of an RN palliative care screening tool to encourage early palliative care consultations.

A nurse-driven palliative care screening tool was developed to identify patients in the ICU who were appropriate to refer for consultation. The tool factors in basic disease processes and acute conditions. Each element scores 1 point. Based on pilot results and collaboration with the palliative care team, a score of 3 or higher suggests the attending provider team should consider involving palliative care. This tool was tested across 5 ICUs in a large academic facility. It was used to screen all patients during the pilot period to determine eligibility and the most accurate scoring.

Education for ICU RNs and providers was delivered via a narrated PowerPoint presentation, followed by a knowledge assessment. Lean methodology serves as the foundation for our project’s implementation. Rapid plan-do-study-act cycles identified areas to enhance the completion of the RN palliative care screening tool, such as adding a convenient link on each ICU computer. The Managing for Weekly Improvement framework enables stakeholders to meet weekly to monitor progress toward targets and address any obstacles to success.

Positive screens were split into 3 groups for analysis: those who received a palliative care consultation within 3 days (n = 102), those who received a consultation beyond 3 days (n = 194), and those with no palliative care consultation (n = 369). Propensity score matching and inverse probability of treatment weighting were used. Hospital LOS and ICU LOS were shorter for patients who received a palliative care consultation within 3 days compared with those who received a consultation later, with no significant difference compared with those with no PC consult. The 30-day readmission rate was also lower for the group that received timely consultation.

These findings show early PC consultation can reduce LOS and readmissions. With positive outcomes linked to early screening and PC consultation, the RN PC screening tool is now being built in the electronic medical record and is being used in other facilities across the system. The estimated cost implications include saving $3348.09 per patient per ICU-day.

Rachael Bird; Northwestern Medical Central DuPage Hospital, Winfield, Illinois

Patients in intensive care units (ICUs) are at increased risk for pressure injuries (PIs). Temperature assessment can reveal PIs missed by visual skin assessments. This initiative aimed to assess thermal imaging for early intervention and ability to assist in reduction of PI rates. The unit chosen for the pilot had historically the highest number of PIs of the 3 ICUs.

Hospital-acquired pressure injuries (HAPIs) are the most common hospital-acquired condition. Nurses commonly rely on visual and tactile skin assessment techniques as the gold standard for identification of PIs, but the clinical practice guidelines of multiple organizations recommend assessing skin temperature, especially for patients with darker skin tones. Studies report that integrating thermal imaging into existing skin assessment processes can drive early intervention and HAPI reduction.

During a 60-day pilot study, staff of our 14-bed cardiac ICU (CICU) enhanced our skin assessment protocol by incorporating a handheld thermal imaging device to capture temperature changes not visible to the naked eye. Within the first 8 hours of admission to the CICU, nurses scanned the sacrum/coccyx and bilateral heels (the areas most prone to PI development). If temperature change revealed a suspected PI, preventive interventions were reinforced, documented as “present on admission” and “wound consult placed.”

Bedside nurses in leadership positions and those on the skin protection committee were given special training on how to capture and review images; these nurses were deemed superusers. This pilot study leveraged a shared responsibility model between the superuser and bedside nurse. Superusers provided education and feedback to bedside nurses on image capture. Nursing workflows were a top priority and a primary reason for incorporating into an existing protocol (versus creation of a new nursing task).

To determine the success of this pilot project, we used our CICU’s historical HAPI incidence rate to determine the expected number of HAPIs versus the actual number of HAPIs during the pilot period. Based on calendar year 2022 to 2023 data, the HAPI rate was 2.22%, with associated costs estimated as high as $1.9 million. A total of 100 patients were included in the pilot study, and it was expected that there would be between approximately 2 HAPIs and up to $86 000 in increased costs. No patients in the pilot study developed a HAPI.

The pilot study results demonstrated that assessing skin temperature change can enhance a nurse’s ability to document early signs of PI and expedite clinical interventions. All data are integrated in our electronic medical record to further expedite workflows. A secondary practice change emerged from patients returning from the operating room.

Lauren Boniello, Lisa Blumer, Dawn Mattera; Holy Name Medical Center, Teaneck, New Jersey

The purpose of our project was to establish a protocol that would allow all patients in the intensive care unit (ICU) to receive a palliative care screening, and those who met criteria would receive timely access to palliative care services in the ICU setting at a community-based medical center.

A quality improvement project was designed using a plan-do-study-act framework to establish this protocol. The team sought to increase palliative consultations in the ICU by 30% for appropriate patients, using a standardized screening tool. A literature search was conducted to validate evidence-based resources. The Palliative Care Referral Criteria established by the Center to Advance Palliative Care was used as a framework to establish our workflow and protocol.

We created a process whereby all patients were screened for palliative care on admission to this community-based medical center’s 19-bed medical-surgical ICU located in Bergen County, New Jersey. An interprofessional team was established. In September 2023, a new policy was created and embedded into the ICU admission policy to include this standardized palliative care screening tool. On September 20, 2023, palliative care screening for all patients admitted to ICU began.

To implement this new workflow, education was provided to ICU and palliative care staff. We worked with information technology staff to create protocol orders that would trigger a work list of new ICU admissions for palliative care screening. A spreadsheet was maintained by the palliative care team and cases were discussed on palliative care and ICU daily rounds. If a palliative care screen was positive, orders were entered by the palliative care registered nurse manager or designee. Any of the members of the palliative care team could respond to consultations based on patient need.

Our outcome measures focused on the number of patients screened for palliative care on admission to the ICU, the number of palliative care consultations placed in the ICU, the number of code blue events, and ICU staff satisfaction. Palliative care consultations in 2024 increased by 139% compared with 2023 (n = 115 consultations in 2023 and 275 in 2024). In 2023, there were 19 code blue events in the ICU compared with 14 in 2024. The majority of ICU staff (75%) felt the palliative care screening process had a positive impact on staff.

The implementation of palliative care screening and consultations in the ICU resulted in ICU staff positive feedback. There was a significant increase in consultations, patient access to care, and in hospice referrals. Future goals will be enhancing data collection, automating screening and consultation orders, and expanding the program throughout the organization.

Opal Dy; Arrowhead Regional Medical Center, Colton, California

Our level I trauma and comprehensive stroke center faced a critical challenge: a 14.63% cerebral spinal fluid (CSF) infection rate among patients in the intensive care unit (ICU) who had external ventricular drains (EVDs). This alarming trend jeopardized patient outcomes and increased health care costs. We initiated this project to dramatically reduce EVD-related infections and enhance patient safety.

We conducted a literature review using PubMed and American Association of Critical-Care Nurses guidelines, focusing on the key terms EVD management and CSF infections. A total of 7 articles were located, of which 4 were selected for in-depth review. Existing practice recommendations were limited, prompting us to synthesize available evidence into our own recommendations. These included implementing standardized care bundles, enhancing aseptic techniques, and developing comprehensive staff education programs to reduce EVD-related infections.

We implemented an EVD care bundle in our ICU. Key components included checklists for consistent EVD care from insertion to maintenance, weekly dressing changes using chlorhexidine gel and transparent dressings, and intensive staff education on infection prevention. The bundle was piloted over 6 months (January through June 2023). Adjustments were made based on staff feedback and outcome measures, following the plan-do-check-act cycle. This approach allowed for real-time refinement of our practices.

Our implementation strategies included (1) formation of an interprofessional task force; (2) root cause analysis of current practices; (3) development of comprehensive checklists and protocols; (4) intensive educational initiatives led by the ICU educator; (5) regular discussions during staff meetings; (6) empowering nurses as vigilant ambassadors of EVD care; and (7) sharing best practices with other units and hospital leadership.

This project dramatically reduced our CSF infection rate from 14.63% (n = 6 of 41 EVDs) in the 6 months before the care bundle implementation to 0% 6 months after implementation. The result highlights the power of evidence-based interventions in enhancing patient safety.

This evidence-based practice significantly enhances patient safety, reduces potential harm, and may decrease length of stay. It fosters a culture of continuous improvement in our unit. Next steps include sharing our protocol house-wide to improve EVD care across all departments.

Tracy Montesa, Lindsey Merrick, Angela Flynn; Lutheran General Hospital, Park Ridge, Illinois

The intensive care unit (ICU) division had an increase in turnover of registered nurses (RNs) of 21.9% (benchmark, 13.1%), and subsequently 7 times more new graduate nurses (NGNs) were hired than before the COVID-19 pandemic. Currently, the new graduate residency curriculum does not offer ICU-level critical thinking, skills training, or provide specialty-specific resources.

A literature search was conducted in the hospital’s library Sharepoint using the PubMed, CINAHL, and Scopus databases. Key term searches included new grad residency programs in ICU and critical care new grad residency programs. The literature indicates that new graduate residency programs (NGRPs) decrease first-year turnover and support NGNs in their transition to practice. In-person NGRPs foster relationships among peers, nurture wellness, and help NGNs adjust to the increased acuity in an intensive care environment

A learning needs assessment identified 6 key domains for the NGRP. During the postorientation phase, an interprofessional team of experts and a leader hosted each session. The framework included interunit collaboration, didactic education, wellness exercises, skills training on nurse-sensitive indicators, and high-risk, low-volume scenarios. Participants completed Likert scale–based and free-text surveys before and after sessions and 6 months after the program to assess confidence.

The program included 6 sessions of 4 hours each. New graduates were assigned cohorts from each ICU. Leaders provided nonclinical education hours for attendance. Class began with a confidence survey, followed by subject matter expert–led presentations with case studies and critical thinking exercises, and then hands-on skills stations. Sessions end with take-aways and a postsession confidence survey. Graduates received completion certificates during recognition ceremonies.

Confidence levels increased from 61% to 83%, and further increased to 88% 6 months after residency. The first-year retention rate increased to 97% (1 nurse resignation), resulting in greater than $150 000 in cost savings. Participants reported stronger peer connections, greater confidence, and that they felt leadership support. The NGRP created a culture of engagement with the organization’s high-reliability practices. The program was internally and externally disseminated and was a highlight of the Magnet site visit.

By using evidence-based practice to enhance orientation and retention strategies, this program provided substantial cost savings and strengthened clinical outcomes and organizational culture. Incorporating evolving evidence and feedback will ensure its effectiveness and sustainability. This program may be applicable to other units experiencing influx of NGNs.

Naurin Kajani, Pach Yongque; Memorial Hermann Hospital, Houston, Texas

A low level of hand hygiene compliance jeopardizes patient safety by increasing the risk of hospital-acquired infections (HAIs). In the heart failure intermediate unit (HFIMU), due to the immunocompromised patient population, improving hand hygiene practices was critical for safeguarding patient health and ensuring compliance with infection control standards.

We searched several databases for peer-reviewed articles that included terms such as hand hygiene compliance and team-based interventions. The evidence supports that team-based approaches significantly improve and sustain hand hygiene compliance. Studies demonstrate how competition and real-time feedback lead to adherence to hygiene protocols. The World Health Organization and the Centers for Disease Control and Prevention also recommend multimodal, interactive strategies to reduce HAIs, aligning with our practice change.

In March 2024, the HFIMU started a team-based hand hygiene initiative whereby interprofessional teams and visitors were held accountable for compliance. Teams competed to catch and educate each other on the spot on missed hand hygiene opportunities, with scores tallied to foster engagement. This competitive approach was integrated into daily routines, reinforced by policy updates and real-time feedback.

To improve handwashing compliance, we formed teams named after infectious diseases to foster camaraderie and competition. Real-time feedback was provided for missed hand hygiene instances. We introduced an imaginary line as a reminder for hand hygiene before entering patient rooms, and each team documented on the storyboard individuals they educated. Progress was tracked visually using a scoring system, with leadership ensuring accountability through ongoing monitoring, recognition, and support.

Before the hand hygiene initiative, the compliance rate stood at 64% in January 2024. Through continual monitoring, recognition, and support from leadership, our compliance surged to 94.6% in April 2024 and has remained above 90% since. The initiative emphasized the value of teamwork and peer observation for enhancing engagement, staff motivation, and compliance, while underscoring the need for ongoing education and open feedback to foster a culture of improvement.

In the HFIMU, our competitive approach and active engagement to hand hygiene compliance has increased rates from 64% to greater than 90% among interprofessional staff and visitors, reducing HAIs and thereby ensuring patient safety. We will emphasize ongoing education, regular assessments, and open feedback to sustain these improvements and foster accountability.

Lindsay Brant, Monica Mojca Nemanic, Caitlin Borja, Taline Marcarian: Ronald Reagan UCLA Medical Center, Los Angeles, California

The purpose of this initiative was to implement a postexpiration ritual called Moment of Silence (MOS). The end of life is a profound and meaningful event to family and staff. Creating a collective ritual around death can bring solace to family and foster resilience among staff.

A review of the literature was conducted using the CINAHL, PubMed, and Google Scholar databases, and 99 articles were identified. Key terms used were moment of silence and pause. After screening, 8 articles were critically appraised and synthesized. Evidence shows that an MOS has many benefits, including honoring the deceased patient, initiating closure, and providing team cohesion. Evidence related to the implementation includes using a script, having champions, and voluntary participation.

Before this initiative, the team in this 24-bed cardiothoracic intensive care unit (CTICU) in a level I trauma center did not gather at the bedside after a patient death. The CTICU population includes surgical patients, those undergoing transplant, and those receiving extracorporeal membrane oxygenator and ventricular-assist device support. In June 2024, inspired by Jonathan Bartels’ “The Pause” project and available evidence, the CTICU team implemented an MOS during which the interprofessional team gathers around the deceased and honors the patient, the family, and the care provided.

A unit-specific committee called Community acted as champions and piloted this initiative using multiple strategies. Community designed script cards, educated staff, and called upon unit leadership and providers for support and participation. Community educated staff on the MOS through email, staff meetings, huddle messages, and face-to-face educational rounding. Staff also learned by directly participating in an MOS ritual. Community collected pre- and postimplementation surveys from the staff.

Since July 2024, 9 MOS rituals were completed in the CTICU. Postimplementation survey data collected from those who participated in the MOS showed 87% of the respondents reported that they agreed that the MOS initiated a process of closure regarding the death of the patient, 83% felt the MOS helped in processing complex emotions, and 91% reported improved family and staff connection. Also, 65% of the staff reported improved resilience, decreased moral distress (57%), and decreased burnout (30%).

An MOS has a positive impact not only on nurses but also other team members. The sustainability plan includes the integration of an MOS into the unit standard of practice for end-of-life care. The success of this pilot program in the CTICU warrants its expansion within the organization and research opportunities to assess its benefits for family and staff.

Jenelle Overgaard, Liz Kiffmeyer, Brandy Berends, Amy Railson, Morgan Thiry; CentraCare St Cloud Hospital, St Cloud, Minnesota

Although our hospital was seeing a decrease in catheter-associated urinary tract infections (CAUTIs), there was not a significant reduction with current practice. The purpose of this project was to follow the Minnesota Hospital Association CAUTI road map for CAUTI reduction by implementing a 2-person urinary catheter insertion practice.

The cost of CAUTIs ranges from $115 million to $1.82 billion annually. CAUTIs are the most common health care–associated infections and are associated with increased length of stay, higher health care financial expenditure, and antibiotic overuse in the intensive care unit (ICU). CAUTIs occurring at 6 days or fewer after insertion are more likely related to insertion technique, and breaks in aseptic technique have been observed in up to 59% of insertions. A 2-person insertion practice technique has been shown to reduce CAUTIs by 39%.

A 2-person insertion trial began in adult critical care on November 1, 2023. A checklist was created that guided correct 2-person aseptic technique. During the 6-month trial, there were no CAUTIs attributed to insertion. Based on these results, policy revisions were implemented on April 30, 2024, to include 2-person insertion of indwelling urinary catheters. This practice change is also being initiated at all regional sites within the hospital system.

A situation, background, assessment, and recommendation communication was sent to all staff before implementation of the trial and then again before hospital-wide implementation. This communication reviewed the goal of CAUTI reduction by means of 2-person technique, using the checklist. This information was disseminated in twice-daily unit huddles. Checklists were audited for compliance. In the electronic health record, a row was created to document the involvement of the second person. CAUTI champions reiterated the purpose of the practice change.

Before the trial, the rate of CAUTIs per 1000 catheter days for the hospital was 1.55 for all CAUTIs and 0.79 for CAUTIs occurring at 6 days or fewer. The trial occurred only in the cardiac ICU and ICU, and there were no infections occurring at 6 days or fewer during this time. After implementation, the rate of infection for the hospital was 0.77 for all CAUTIs, a 50% reduction, and the rate for CAUTIs occurring at 6 days or fewer was 0.46, a 42% reduction.

A reduction in insertion-related CAUTIs can be associated with decreased length of stay, lower health care financial expenditures, and decreased use of antibiotics. This project increased staff awareness of cost and prevalence of CAUTIs. Additionally, it has encouraged staff to consider alternatives before insertion of indwelling urinary catheters.

Anna Marie Bentic; El Camino Hospital, Mountain View, California

The aim of this work was (1) to prevent patients not receiving ventilatory support from developing pneumonia, by implementing clinical interventions in a 24-bed critical care unit (CCU) in partnership with the hospital nonventilator hospital-acquired pneumonia (NVHAP) committee from fiscal year (FY) 2019 to FY23, and (2) to evaluate improved clinical outcomes with staff, enculturating critical care interventions into critical care practice year over year.

NVHAP accounts for 0.55 events per 100 US hospitalizations. In addition to a range in crude mortality rate of 15% to 30%, NVHAP is associated with increased antibiotic use, high intensive care unit (ICU) utilization rates, and high readmission rates for survivors. Regular monitoring and evaluation of prevention efforts are necessary to track data and identify new opportunities for improvements.

At a community hospital, a committee was established to develop standard practices for NVHAP prevention. With collaborative efforts from quality, infection control, and critical care teams, evidence-based practice clinical interventions were implemented in the CCU. Emphasis was placed on oral care at least 3 times daily for patients not receiving ventilatory support, encouraging patients to cough and deep breathe, and keeping the head of the bed at 30° at least, if not contraindicated.

Staff were trained on evidence-based practice and clinical interventions to prevent NVHAP. Education and updates were completed during unit huddles, via emails, and one-to-one teaching. Posters were placed in each patient room as visual prompts for staff but also to engage patients and their families to participate in care. Challenges included availability of supplies, oral care product changes, ease of documentation, and knowledge on how to access computer-generated data.

Enterprise-wide cases of NVHAP per 1000 patient days improved incrementally despite the challenges of pandemic and public health crises: FY19 = 1.89, FY20 = 1.29, FY21 = 2.44, FY22 = 1.86, and FY23 = 1.59. The sustainability of implementing the clinical interventions helped lower the number of NVHAP cases in the CCU in FY24 to 4, and, thus far in FY25, to 1.

Although year-over-year compliance improved, there is still an opportunity to reinforce best practices for NVHAP prevention. This opportunity motivates continuous process improvement for ease and timely documentation of clinical interventions completion, patient and staff reeducation, and monitoring of staff compliance.

Samantha Ahle, Julie Marshall, Katie-Anne Walsh, Lauren Lavallee, Cynthia Gomez; Lahey Hospital & Medical Center, Burlington, Massachusetts

Critical care registered nurses (RNs) work in a fast-paced setting and require competency in many skills. “On the Fly” (OTF) was initiated to address critical care RNs’ gaps in knowledge and confidence with high-risk and low-volume skills. Classroom training was not feasible due to staffing constraints and the number of skills requiring education.

A literature search of the EBSCOhost, ScienceDirect, and Google Scholar databases using the key terms microlearning, critical care nursing, and bedside education identified 45 relevant references, from which 4 articles were selected. The evidence supports microlearning as an effective method for improving knowledge, confidence, and competency related to low-volume skills. Microlearning integrates concentrated and applicable knowledge that is easy to understand into small learning nuggets.

Based on a review of evidence, on-unit microlearning was piloted in one critical care unit at a level I trauma and academic medical center in the northeastern United States. Monthly rotating microlearning OTF sessions targeted specialty-specific skills identified via needs assessment and were offered during clinical shifts. Stakeholders included nursing leadership, nurse educators, and bedside RNs. As a result of the pilot, session timing was adjusted, contact hours were offered, and OTF was implemented in all critical care units.

A critical care RN needs assessment helped identify and prioritize microlearning OTF topics that were customized for each unit to ensure education was applicable to each specialty area. Custom flyers with catchy titles, education materials with handouts, interactive activities, and contact hours were used to promote engagement. Feedback was collected through postsession evaluations. As a result, OTF session timing, topics, and educational delivery methods were adjusted.

Microlearning OTF was evaluated using a Microsoft Forms survey. Before the OTF sessions, 89% of critical care RNs reported limited knowledge on OTF topics. After the evaluation, 100% of critical care RNs reported an increase in knowledge and confidence related to the topics presented. Additionally, 99.5% of critical care RNs reported that future OTF sessions would be beneficial to their practice. Key lessons include the importance of bite-sized, easily accessible, interactive education for critical care RNs on high-risk and low-volume skills.

The success of OTF warrants sustainment of rotating microlearning sessions across critical care units with continued engagement of bedside RNs. In addition to the desired education outcomes, there was substantial cost and time savings due to sessions taking place during prescheduled shifts. Next steps include expanding OTF throughout the hospital.

Maria Luna; Keck Hospital of USC, Los Angeles, California

Registered nurses (RNs) in the abdominal transplant intensive care unit (ATICU) recognize that certified critical care nurses (CCRNs) have demonstrated advanced knowledge and skills to treat complex patients and note the importance of certification. In 2022, 35% of unit RNs were certified. The ATICU created a goal to increase CCRN certification by 10%.

Although RNs acknowledge the value of nursing certifications, barriers prevent nurses from certifying or recertifying. Identified barriers include costs associated with the examination, inadequate compensation for certification, lack of institutional support, and lack of institutional recognition. Strategies noted within the literature to increase certifications include on-site review courses, interactive learning methods, financial compensation, and recognition of certified RNs.

Unit champions assessed for barriers to obtaining certification. The lack of an in-person and affordable review course was addressed through collaboration with the local American Association of Critical-Care Nurses chapter. The course was offered on-site, and the cost of class was reimbursed with proof of test completion. The hospital’s nursing administration provided a class location, meals, and printing access. Unit champions encouraged staff to attend and offered study support. The unit manager optimized scheduling.

Implementation strategies included distributing printed materials advertising the on-site certification course and the reimbursement offered, and using staff champions to promote the course and to assist individuals to sign up for the course. Once the course was completed, champions pivoted to a new role, coordinating impromptu study sessions, and assisting with certification test enrollment and completion of reimbursement documents.

The project was successful. In 2022, 2 RNs attended a review course, but in 2023, 13 staff members attended—a 550% increase. The percentage of staff certified increased from 35% in 2022 to 38% by the end of 2023. The unit plans to continue to encourage and increase nursing certification and to determine if it is feasible to offer a formal study-buddy program in the future.

The project demonstrated that RN staff can influence unit certification rates through evidence-based interventions. Assessing staff needs, collaborating with employers and professional organizations, and offering study support may be a model for other units seeking to increase professional certifications among staff.

Ashlee Doll, Samantha Steich, Cassandra DeStefano; Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

The rate of central line–associated bloodstream infection (CLABSI) in a pediatric intensive care unit (PICU) of a children’s hospital increased by 31% from 2022 to 2023. This project aimed to reduce the CLABSI rate in the PICU by enhancing the accountability and engagement of nursing champions involved in the CLABSI Prevention Committee.

A CINAHL database search was conducted focusing on the following key terms: engagement, accountability, education, and shared governance. This search yielded 8 articles, of which 3 were incorporated into the project. Literature supports accountability to enhance participation as an effective way to increase peer-to-peer teaching. We developed a procedure to improve accountability. Evidence shows an engaged team enhances staff competency, showing the importance of a high-functioning group for CLABSI prevention.

The project ran for the 2024 fiscal year in a 75-bed PICU. Requirements for the champions included completing 7 peer-to-peer education or 7 Kamishibai cards monthly, attending bimonthly meetings, and participating in 2 CLABSI training days per year. For accountability, champions not meeting requirements received an email, with supervisors copied if the issue persisted. At 3 months of noncompliance, they were no longer a champion. The information was shared and reviewed each meeting to ensure transparency.

Several strategies were used to enhance the management of the PICU CLABSI nursing champions. These included transparent accountability practices, regular engagement audits, and efforts to promote independence and purpose among the champions. Additionally, increased support from the CLABSI leadership team and stronger encouragement from PICU unit leadership motivated bedside nurses to get involved in harm prevention.

After implementation, participation in Kamishibai card rounds increased by 42.6%, peer-to-peer education sessions increased by 792.7%, and participation on CLABSI training day increased by 184.6%. Although the champions did not reach 100% of their requirements, overall engagement improved significantly, resulting in greater CLABSI prevention education for staff.

Better-engaged champions increased staff knowledge of best practices to prevent CLABSIs and helped achieve a 12.5% decrease in the unit’s CLABSI rate. The simple, effective strategy was adopted by other unit champion groups, also helping their engagement. We plan to sustain this approach to maintain high levels of engagement in the coming year.

Chung Hee Kim, Nicole Rodriguez, Christina Garcia, Kristina Tuazon, Jennifer Connolly; Keck Hospital of USC, Los Angeles, California

Prolonged bed rest by patients may lead to complications, including physical and mental decline. Evidence-based nursing mobility protocols reduce mobility-related complications and hospital length of stay. Data indicated low unit compliance with the hospital’s mobility protocol. Registered nurses on the unit decided to improve compliance to ensure best outcomes.

The hospital’s mobility protocol formed the groundwork for this project. Articles reviewed were related to mobility, mobility protocol, chart audit, real-time education, and huddle and mid-shift huddles. The evidence confirmed that establishing an intensive care unit (ICU) early mobilization protocol resulted in reduced ICU and hospital lengths of stay. Huddles are widely used and proven to improve clinical team members’ understanding of aspects such as mobility compliance and interventions. Chart audit is an effective way to monitor quality improvement.

This surgical ICU is a part of an acute care medical center. The unit admits various types of postsurgical patients, including those recovering from complex vascular and thoracic procedures. Previous attempts to improve mobility compliance focused on compliance with all 5 levels of the nursing mobility protocol. Data demonstrated only small improvements. The unit shifted its efforts to a targeted approach to 1 high prevalence intervention: specifically, cardiac chair positioning.

Barriers to improved compliance were identified by the mobility team. The unit then focused on 2 actions to improve compliance. First, the mobility team performed daily chart audits with real-time education to ensure the correct assessment, and interventions were documented. Second, the unit conducted mid-shift huddles at 11 am and 11 pm to identify staff and patient needs and ensure compliance.

After the 3-month period, cardiac chair positioning compliance increased to 61.1% from 36%. Overall nursing mobility protocol compliance increased from 46.6% to 54.7% during this time. The time for the huddle was changed to 11:15 am and 11:15 pm to accommodate the workflow. The barriers identified were nurses’ lack of knowledge and understanding of protocol. Staffing shortages continued to hinder progress. The high acuity of the unit made compliance difficult. The auditor fatigue was noticed.

Efforts to improve nursing mobility protocol compliance should target high-prevalence interventions. Successful process-improvement projects require staff engagement, knowledge, and skills.

Lydia Downs, Bonnie Decker; Harborview Medical Center, Seattle, Washington

In 2022, the neuroscience intensive care unit (NICU) had the most false-positive central line–associated bloodstream infections (CLABSIs) from contaminated blood cultures in the hospital. Culture contamination results in delayed disease workup, increased length of stay, affected antibiotic stewardship, and increased costs, which prompted a practice change.

The CINAHL Complete and PubMed databases were searched using key terms standardization of practice, CLABSI, and nursing care. This search resulted in identification of 66 publications, of which 4 articles were used. The evidence shows that standardization of practice and reinforced education can improve outcomes in blood culture contaminations, thus promoting a practice change and prompting creation of a blood culture quality improvement project.

The blood culture policy was summarized in a step-by-step handout and later made into an infographic by infection prevention personnel. Blood culture kits and the infographic were created with all the peripheral and central venous catheter (CVC) supplies. The NICU expected samples for cultures to be collected with an additional nurse to verify proper technique and assist. The project was piloted in the NICU; however, the data were collected starting in December 2022 using a convenience sample of adult patients who required CVC.

The strategies used to implement the blood culture quality improvement project included education, the creation of a simplified policy displayed in an infographic that served as a practice prompt when collecting blood samples for cultures, and continual feedback provided by the second nurse, the “blood culture buddy.”

The goal of the Centers for Disease Control and Prevention and the Clinical and Laboratory Standards Institute for contaminated cultures is less than 3%. In 2022, the NICU contamination percentage was 3.73%. After initiating the quality improvement project, the NICU contamination percentage was 2.6% in 2023 and 1.8% in 2024. Additionally, the percentage of CLABSIs in the unit went from 5.48% in 2022 to 0.97% in 2024. The standardized infection ratio for CLABSI went from 4.47 in 2022 to 0.75 in 2023.

The NICU blood culture quality improvement project resulted in a decrease in the number of culture contaminations and reduced false-positive CLABSI results. These results led to the conclusion that standardizing collection techniques and increasing nurse education led to fewer contaminations. An implication for this project is expanding its use to other units.

Ronald Tate, Allison Fox; Duke University Health System, Durham, North Carolina

Ineffective communication between team members has contributed to delayed discharges and critical details being missed. Treatment plan changes often are not communicated to nurses. Delayed discharges lead to poor patient outcomes and more stress on staff. Multidisciplinary communication is paramount for the success of patient discharge.

A search of the CINAHL database was conducted using the search terms nurse, rounds, and multidisciplinary. Literature supports multidisciplinary rounding in the intensive care unit (ICU) setting. There is limited guidance on non-ICU rounds or multidisciplinary communication, which supports the need for standardization of communication.

We developed a standardized template for nurses to instant message providers on a medical cardiac step-down unit at a large academic medical center that uses a mixed medical model with multiple treatment teams. Registered nurses (RNs) unavailable for morning rounds used the template to communicate with providers about the care plan each weekday. This nurse-driven pilot was implemented for 4 weeks on our step-down unit in collaboration with our provider colleagues.

During the pilot, we disseminated the template and expectations via email. We created signage and posted it on the huddle board and around the nurses’ station. We discussed the pilot during morning huddles each day throughout the week. Senior staff reinforced the process, provided individual education to nursing staff, and checked in regularly throughout the pilot.

We surveyed RNs in the cardiology unit (n = 35) to determine perceptions of communication challenges, the effectiveness of communication, and impact on discharge to compare pre- and postimplementation results. When asked how often they witnessed delayed discharges due to miscommunication in the past month, 67% of RNs reported “sometimes,” and 33% reported “often.” After implementing the pilot, 27% reported “never” witnessing delayed discharges due to miscommunication, and 73% reported “sometimes.” Missed delayed discharges and missed critical details decreased from 11% to 0%.

A standardized approach to communication should be adopted to reduce miscommunication and delayed discharges outside of the ICU. An ongoing evaluation plan was established between nursing and providers to pilot feasibility of this communication template on similar nursing units.

Opal Dy, Zorina Hernandez; Arrowhead Regional Medical Center, Colton, California

Despite a low 6.67% turnover rate in 2022, our intensive care unit (ICU) faced ongoing challenges from pandemic-related stress. With each lost nurse costing $52 350 and taking 6 months to replace, retaining experienced staff was crucial. We aimed to maintain or decrease our turnover rate while enhancing staff satisfaction and patient care quality.

We conducted a literature review using American Association of Critical-Care Nurses guidelines and searching the PubMed literature database, focusing on nurse retention strategies and their impact on patient outcomes. Evidence suggested that flexible scheduling, stress reduction interventions, professional development opportunities, and recognition programs could significantly improve job satisfaction and retention. We also examined the role of experienced nurses in mentoring and maintaining clinical excellence.

We implemented a multifaceted approach: (1) flexible self-scheduling system; (2) a “lavender room” for relaxation and stress reduction; (3) a diversity, equity, and inclusion (DEI) initiative; (4) a quarterly nursing journal club; and (5) a Circle of Excellence peer recognition program. These changes aimed to enhance work-life balance, reduce stress, foster inclusivity, promote professional development, and boost morale. Implementation began in early 2023 and continued throughout the year.

Our implementation strategies included collaborating with unit-based council and leadership; introducing self-scheduling and providing training; repurposing space for the lavender room; conducting a DEI survey and educational initiatives; organizing quarterly journal club meetings; establishing a peer-driven recognition program; and regular communication and feedback sessions.

In 2023, we maintained our 6.67% turnover rate, significantly below the 22% national average. Postimplementation surveys showed dramatic improvements in work-life balance (score 4 of 5), job satisfaction (4.08 of 5), and likelihood to stay (4 of 5). The lavender room received a 4.38 (of 5) impact score. Patient outcomes improved with low rates of hospital-acquired conditions. The project facilitated the transition of a per diem nurse to full time and enabled 4 job-sharing arrangements.

This multifaceted approach enhances nurse retention, job satisfaction, and patient care quality. It demonstrates the impact of innovative strategies on creating a supportive work environment. The project’s success offers a model for other ICUs facing retention challenges.

Maria Daveiga Etheart, Ruth Jones, Jillian Boyce; Brigham and Women’s Hospital, Boston, Massachusetts

Within our intermediate medical division, registered nurses (RNs) lacked confidence, knowledge, and skills managing chest tubes. Nurses are crucial in recognizing and preventing chest tube complications. Because of limitations in staffing and indirect education time, we developed a mobile, simulation-based education initiative on chest tube management.

In 2014, The Joint Commission published a sentinel events alert that included the mismanagement of chest tubes. We also identified, from safety reports and a learning needs assessment, practice gaps in chest tube management within our division. We performed a literature review using the CINAHL database and the key terms simulation, chest tube, and just-in-time teaching. We found evidence supporting the implementation of simulation-based education was for both formative and summative learning.

Our intermediate medical division comprises approximately 200 RNs and 241 beds. We are part of an 800-bed academic hospital. Our division consists of 2 clinical nurse educators (CNEs) and 3 professional development managers who develop and provide staff education. Previously, we held our education sessions in a classroom environment. However, this setting was no longer feasible, due to staffing shortages. Instead, we designed a mobile simulation station to provide education.

The CNEs conducted educational sessions during all shifts, 7 days a week. These sessions were approximately 20 minutes long and limited to 2 to 4 learners. During the simulation, learners demonstrated skills with chest tube management. The short duration of the sessions was intended to maintain the learner’s attention and minimize interruptions to patient care. Additionally, small-group learning promoted psychological safety when providing feedback and debriefing.

In total, 199 RNs attended the education sessions. We asked RNs to assess their confidence in 4 aspects of chest tube management, using a Likert scale, before and after education. The scale ranged from 1 (very unconfident) to 5 (very confident). We calculated the percent change from the mean before and after scores. Confidence increased from 76% to 91% on all 4 measurements.

Mobile simulation-based education is an innovative strategy to provide education, especially when there are nursing shortages and budget constraints. Other divisions have adopted our mobile simulation education, and we are using this teaching modality for other education initiatives. This teaching modality provides experiential learning.

Allison Fox, Bradi Granger, Joosung Lim, Erica Parent, Mandi Ballard, Jeanne Jung, Megan Holder, Helen Seitz, Jonathan Thai; Duke University Hospital, Durham, North Carolina

Hospital-associated immobility leads to prolonged length of stay and iatrogenic complications. Early mobility, an evidence-based component of cardiac rehabilitation, prevents deleterious effects of immobility. Guidelines recommend patients move 3 times daily, yet our baseline audits revealed low performance on daily patient mobility.

Clinical practice guidelines from the American Heart Association, the American Association of Cardiovascular and Pulmonary Rehabilitation, and other professional organizations recommend early, structured mobilization for cardiovascular events such as coronary revascularization, myocardial infarction, heart failure, and others. Regulatory agencies including the Centers for Medicare and Medicaid Services and The Joint Commission support the use of in-hospital cardiac rehabilitation.

Based on existing evidence, a 3-part educational intervention was implemented by registered nurses (RNs) and nursing assistants (NAs) with patient-family dyads to explain the value and the measurement of mobility practices. First, education on the Banner Mobility Assessment Tool (BMAT) was provided. Next, documentation expectations were reviewed with RNs and NAs using modules. Last, patients and family members were taught to use an innovative “patient mobility map” to encourage engagement in mobility goals.

The implementation of the 3-part mobility protocol practice change included the measurement of (1) frequency of daily mobility, (2) engagement of patients and families in the goal-setting process, (3) achievement of mobility goals, and (4) barriers to mobility. We piloted the practice change over 12 months using a pre-post, 2-cycle quality improvement comparison to evaluate outcomes in patients admitted with a cardiac diagnosis to cardiology and cardiothoracic step-down units (6 units; 165 beds).

We conducted baseline audits (200) over 4 weeks and then postaudits (174) over 4 weeks 6 months after implementation. Audits included documentation for mobility scores using the BMAT, frequency of mobility every 24 hours (0-3 times), and barriers to mobility. Eligible patients scored greater than 4 on the BMAT. Frequency of mobility improved significantly (the percentage of compliance with walking 3 times a day after the intervention was 63% vs 37% at baseline [z = –4.17; P < .001]).

Implementation of a 3-part educational intervention significantly improved mobility and patient-family engagement in goal setting before discharge. Interprofessional collaboration also improved teamwork, accuracy of documentation, and timeliness of patient mobility. Future work will focus on longer-term outcomes including length of stay.

Karla Brown, Lacey Spangler; Carolinas Medical Center Atrium Health, Charlotte, North Carolina

This process improvement (PI) project aimed to enhance patient mobility through the development of a standardized process. This process included use of an interprofessional team for proactive goal planning and barrier mitigation. The primary goal was to increase mobility compliance of patients within the surgical trauma intensive care unit (ICU) to 30%.

The Society for Critical Care Medicine’s nationally recognized A-F bundle has been shown to improve patient outcomes. The E component of the bundle, early mobilization, enhances functional outcomes and quality patient care and decreases delirium rates, mortality rates, need for mechanical ventilation, and hospital length of stay. Further evidence demonstrates that interprofessional rounds improve patient outcomes. Moreover, interprofessional rounds are recognized as a national standard of patient care.

Mobility compliance was defined as 30% of eligible patients receiving 2 or more mobility occurrences daily, including focused episodes of dangling, standing, sitting, using the bathroom, and ambulating. Each occurrence was documented in the electronic medical record. Compliance was reviewed during interprofessional rounds, facilitating discussions to optimize mobility. This process involved reviewing activity orders, setting daily goals, and addressing barriers to enhance patient movement.

The PI initiative was implemented from October 1, 2021, to September 30, 2022 (postintervention group). Compliance was compared with that of the preintervention group from January 1 to May 31, 2021. A mobility compliance report was generated at midnight, excluding patients on comfort care or bed rest. Monthly compliance data were shared with the clinical team for awareness and adjustments. Data from April to June 2022 were excluded due to an electronic medical record transition to ensure accurate compliance assessments.

The initiative’s efficacy was assessed by comparing mobility compliance between the preintervention and postintervention groups. In the preintervention group, 949 patients, with a mean age of 55.2 years, were eligible; their inhospital mortality rate was 8.9%. The postintervention group comprised 1843 patients (mean age, 54.4 years); their inhospital mortality rate was 7.1% (P > .05). Mobility compliance was 13.5% (486 of 3590 patient days) in the preintervention group and 38% (2831 of 7450 patient days) in the postintervention group (P < .001).

Successful implementation of this initiative requires key stakeholders, a standardized mobility process, an interprofessional team, and technical support. This approach effectively increased mobility compliance in our complex ICU population. Proactive tracking and reporting kept the team engaged and highlighted its positive impact on patient care.

Angela Flynn, Abigail Magdaleno, Megan Hanson, Milena Fatta-Kenar; Lutheran General Hospital, Park Ridge, Illinois

To establish an educational pathway to educate medical-surgical registered nurses (RNs) to insert small-bore feeding tubes (SBFTs), decrease delay in care, and increase confidence in the high-risk skill. At this 638-bed hospital, 1 rapid response team (RRT) RN is responsible for all adult inpatient SBFT insertions, which account for 17.62% of 4000 annual calls.

A literature review was conducted to identify peer-reviewed articles published within the past 5 years in English. Key search terms included education, skill, nasogastric, small-bore, feeding, placement, and nurse, yielding 7 results, 3 of which met the inclusion criteria. The evidence supports a multimodal approach to cater to diverse learning styles and enhance skill acquisition. Updated techniques guided the quality of training to improve SBFT insertion success rates.

The practice change implemented was adding a well-rounded approach to educating RNs on how to insert, assess, secure, and maintain SBFTs and other nasogastric tubes, although within the scope of practice, medical-surgical RNs were not allowed to insert SBFTs but could insert large-bore nasogastric tubes. Nurses on the pilot unit were trained through a rigorous process to close the knowledge gap, received hands-on practice, and received support from superusers.

A stroke unit was chosen for the pilot due to its 25% share of SBFT-related calls, full RN staffing, and leader support. Training was provided in 3 phases: an online module, in-person hands-on practice, and patient insertion with guidance from an SBFT superuser. Participants completed a Likert scale–based and free-text survey 1 month after training to evaluate confidence and provide feedback. SBFT insertion complications were monitored through a safety event reporting platform.

This initiative significantly increased bedside RN satisfaction and decreased SBFT RRT RN calls by 93%. The time RRT RNs spent on SBFT calls decreased from 10.5 hours to just 45 minutes per quarter. Survey results show that 86% of bedside nurses feel confident in their ability to insert and maintain SBFTs. Additionally, no serious SBFT-related safety events have been reported since the project began.

This multimodal educational framework was successful in increasing RN confidence in the low-volume, high-risk skill, decreased patient care delays, and resulted in no safety events. This framework has been built to RN orientation on the pilot unit and has been successfully implemented on 2 additional medical-surgical floors with similar results.

Edna Sarino, Vivien Lee, Floricel Guillermo, Christine Kiamzon, Marion McNamara; Ronald Reagan UCLA Medical Center, Los Angeles, California

Given the complexity of liver cirrhosis and its impact on multiorgan systems, daily nurse-led rounding was implemented. The process and bundle incorporated the nurses’ valued knowledge and input, empowered nurses to drive discussions targeting multiorgan system issues, and fostered a high-level dynamic of teamwork and collaboration.

A literature review was guided by the key terms liver failure, transplant, and nurse led rounds. The search revealed existing practices in other complex populations. In a study from 2012 to 2016, the estimated hospitalization costs in patients with liver disease reached $81.1 billion. The complexities of end-stage liver disease with concomitant comorbidities are best managed by interprofessional input. Nurse-led rounds is a best-practice initiative to standardize and structure interprofessional care.

In 2017, stemming from an evidence-based practice project, a 26-bed, liver transplant medical-surgical unit piloted a standard rounding schedule with required participants. In 2019, because of variations in practice, nurse champions collaborated with nurse practitioners (NPs) to establish a rounding bundle. In 2022, we enhanced the bundle to be more comprehensive of patients’ medical, psychosocial, and physical needs, which also integrated 4 of the American Association of Critical-Care Nurses Healthy Work Environment essential standards.

Nurse champions conducted one-on-one education and role modeled succinct communication with staff nurses. An educational video was created to reinforce role expectations. Charge nurses took ownership of rounds and provided oversight and feedback to nurses. Preceptors instilled the standards of practice when teaching newly hired nurses and nurse residents. Nurse practitioners fostered a safe environment for information sharing and decision-making. Patients and family members were encouraged to participate in care.

Over 3 years after implementation, this unit achieved an average 18% decrease in falls (rate per 1000 patient days), a 33% decrease in central line–associated bloodstream infections (CLABSIs; rate per 1000 central catheter days), a 28% decrease in catheter-associated urinary tract infections (CAUTIs; rate per 1000 Foley catheter days), and a subsequent 23 consecutive months of Zero Harm for CAUTI. The Press Ganey Nurse Engagement Survey category of interprofessional relationship improved from a mean score of 3.67 before implementing rounding to 3.85 after implementation and exceeded the benchmark score.

Nurse-led rounding has improved nurse engagement and satisfaction scores by empowering nurses to have a more confident voice and providing a tool to enable them to be the drivers of change for this complex population. Outcomes show a sustained decrease in CLABSI, CAUTI, and fall rates, and provided a combined maximum cost savings of $1 996 011.03 over 3 years.

Christa Stultz, Ashley Waak, Eleanor Davis; University of Maryland Medical Center, Baltimore, Maryland

During the COVID-19 pandemic, a community hospital in our system safely moved 70% of their patients with ST-elevation myocardial infarction (STEMI) to intermediate care (IMC) and decreased the average length of stay (LOS) for these patients from 3 to 1.7 days. Our academic medical center had long admitted all patients with STEMI to the intensive care unit (ICU) for at least 24 hours after cardiac catheterization, but critical care often seemed unnecessary.

We searched the MEDLINE database, using the terms STEMI and ICU admission and found limited results reported in peer-reviewed, English-language articles published between January 2019 and May 2024. We screened 494 abstracts, of which 5 practice guidelines and 7 articles that met our criteria. STEMI level of care is controversial. Current US guidelines do not address it, although previous versions suggested non-ICU care for low-risk patients. European guidelines recommend ICU care. Most patients with STEMI (65%-95%) have no ICU needs and non-ICU care is safe for them and feasible with appropriate triage.

Leadership approved a 1-year pilot to admit stable patients with STEMI to the IMC in our urban tertiary referral center. Clinical criteria for IMC admission were identified, including hemodynamic stability, resolving or no chest pain, and no changes in mental status from baseline. Appropriate patients were taken directly from the cardiac catheterization laboratory to the 19-bed cardiac progressive care unit (CPCU) or another IMC instead of the 12-bed cardiac ICU or another ICU.

Stakeholders from the ICU, CPCU, the cardiac catheterization laboratory, leadership, and cardiovascular medicine formed a work group and met monthly to discuss recent cases, review data, and identify challenges. All CPCU nurses received education on STEMI pathophysiology, possible complications, and documentation; this information remained available in the unit and learning management system. The CPCU already routinely cared for patients after cardiac catheterization, so existing admission processes were essentially unchanged.

We compared IMC and ICU STEMI admissions and impact on mean LOS and complications. At baseline, 88 patients with STEMI had a mean LOS of 9.4 days. All went to the ICU, but only 51% required the ICU per chart review. After project implementation, 51 patients with STEMI had a mean LOS of 7.4 days; 68% required the ICU, 24% went to the IMC, and 8% were stable but admitted to the ICU anyway, either unnecessarily or because no IMC beds were open. One patient in the IMC later had severe chest pain requiring transfer to the ICU for high-dose intravenously administered nitroglycerin.

STEMI admissions to the IMC are limited by high acuity and available beds. Even so, the average LOS decreased by 2 days. Many initially unstable patients were transferred out of the ICU in less than 24 hours. This project positively affected bed optimization and throughput within the organization. It had no adverse outcomes and is now our standard of care.

Katherine Nelsen, Dawn Frias, Tammy Matthews; Northwestern Medicine Delnor Hospital, Geneva, Illinois

Patients receiving ventilatory support in the critical care unit (CCU) routinely received an oral chlorhexidine (CHG) rinse as part of the standard ventilator-associated event (VAE) prevention bundle performed every 2 hours. The team learned that both practices did not align with current evidence-based procedures and wondered if there was a financial impact.

The Society for Epidemiology of America and Infectious Diseases Society of America recommend oral care without CHG, because of its uncertain efficacy and possible association with increased mortality rate in the population of patients receiving ventilatory support. CHG aspiration may precipitate acute respiratory distress syndrome in a small fraction of patients. The meta-analyses also showed better oral health scores among patients randomized to CHG de-adoption.

The interprofessional team of a bedside nurse, clinical practice specialist, and a respiratory therapist (RT) worked with leadership and supply management personnel to implement use of a ventilator-associated pneumonia (VAP) kit every 4 hours. The kit did not contain CHG oral rinse. Respiratory therapy leadership agreed to complete and document all VAP care in the electronic medical record (EMR), alleviating documentation burden on nursing. The community hospital’s procedure was updated and implemented in the 20-bed CCU.

Education for nursing on the practice change was disseminated electronically and verbally in daily shift huddles. EMR adjustments were implemented for streamlined RT documentation that nursing could easily view, and physicians were coached not to order CHG as part of any order sets. The program manager performed monthly chart audits for any missed occurrences and followed up with the RT leader.

The average of oral care compliance completion in the 4 months before implementation of the new process was 84%, which increased to 98% in the 4 months after implementation. No identified VAEs in the CCU occurred due to nursing or RT care or practice. Additionally, this practice change saved the CCU an estimated $14 000!

The de-adoption of CHG and change in oral care frequency keep patient safety as the top priority. These steps have decreased the nursing documentation load, nurtured interprofessional collaboration, and provided $14 000 in cost savings. Other system hospitals are considering changing oral care kits and adjusting their workflows to match.

Kathryn Kay Lopez; UC Irvine Health, Orange, California

Nurse managers at an academic medical center reported feeling isolated and unsupported as they tried to solve issues and develop processes alone in their new role. Lack of a formal mentorship program and limited leadership development resources to address the unique challenges faced by the nurse managers contributed to feelings of isolation and inadequacy.

Work-life balance and burnout continue to lead the reasons nurse managers’ intent to leave. Mentoring new nurse leaders is crucial to the future of nursing because nurse managers directly affect strategic plans, staff satisfaction, and patient outcomes. Current leadership must set realistic expectations and be reminded that leadership is a skill that requires practice and partnering with a seasoned leader.

Nurse leaders paired with Human Resources Health and Wellness Partners to create a peer-to-peer assistant nurse manager and nurse manager mentorship pilot program to support and mentor new organizational nurse leaders. The 6-month program included monthly training webinars, with topics that ranged from discrimination, harassment, and reporting to navigating conversations about mental health to work-life balance and stress management and integrating well-being concepts into work environments as a manager.

A total of 22 nurse leaders participated in the pilot; 7 mentors paired with 15 mentees based on their profiles submitted. One-to-one check-ins were scheduled to support the mentees, allowing a safe psychological space to share experiences, challenges, and resources. Mentees were responsible for creating the agenda and goals for the 1:1 meetings. Topics ranged from how to balance 24/7 nurse manager responsibilities with family life to when to counsel a new staff member and to self-scheduling best practices.

Mentees reported above average and excellent levels of support after the completion of the program. Both mentors and mentees reported above average and excellent connections with their mentor or mentee. Direct participant feedback included “I enjoyed the experience of learning that I am not alone in the challenges that exist in leadership. Having a safe space to be open and honest about struggles and learning from the experience and input from other leaders were very helpful.”

The role of a new nurse manager is overwhelming. Once expert clinicians, the new nurse manager transitions into a novice with little preparation, training, and support. With this mentorship program, new nurse managers were able to create meaningful relationships with their colleagues to learn best practices and “not feel so alone.”

Rose Richmond, Megan Caffey; Memorial Hermann Hospital, Houston, Texas

A review of hospital-acquired pressure injury (HAPI) data in the heart failure intensive care unit (HFICU) revealed a high rate of pressure injuries, 33% of which were on patients’ heels. Prevention of HAPIs on heels requires different methods compared with other anatomic locations. HAPIs are linked to increased morbidity and mortality and incur a high financial burden.

An extensive literature review was performed in the CINAHL and Google Scholar databases, using the key terms heel, hospital acquired pressure injuries, and prevention. The literature indicated multiple factors contributing to heel HAPIs, especially in the critically ill patient population, and that HAPIs are associated with a high financial burden. Strategies to aid prevention include nursing assessments, taking pressure of the patient’s heels (“off-loading”), and prompt identification.

The HFICU is a 20-bed unit in a large academic medical center that provides care for patients with advanced heart failure. Existing practices included off-loading heels; however, heels were completed off-loaded only 66% of the time. Off-loading is a priority in heel HAPI prevention. A specialty pillow replaced use of current resources (boots and a waffle) for off-loading and was used for all patients. The pillow, which kept its shape, allowed for quick visualization and versatility for use in the diverse patient population.

A fishbone diagram to identify possible causes revealed variations in heel off-loading. Visual audits showed 35.29% of the patients with specialty boots did not have complete off-loading. The work group brainstormed solutions with a solutions and criteria matrix. Based on evaluation, boots were removed from supply rooms and use of specialty pillows was proposed. The work group educated staff about pillows for heel off-loading, facilitated stocking in supply rooms, and completed visual audits after implementation of the specialty pillow.

Postintervention audits showed heels were off-loaded with specialty pillows 97.56% of the time versus 73.33% before implementation (P = .002). Staff could visualize off-loading with specialty pillows more quickly than when the boots were used. From February to December 2023, there were 19 heel HAPIs, whereas in the postintervention time frame of January to September 2024, there were 5 heel HAPIs (P = .046).

By focusing on a single anatomic location for HAPI prevention, the unit successfully decreased the incidence of HAPIs. The unique use of products easily available endorsed efficiency and practicality, empowering bedside clinicians by providing visible results. This practice is being shared, sustainment plan is in place, and a cost analysis is being conducted.

Lena Dahl, Sophia Corso; Providence St Vincent Medical Center, Portland, Oregon

In the first quarter (Q1) of 2023, the cardiac intensive care unit (CICU) experienced a drastic increase in the incidence of oral HAPIs related to endotracheal tubes (ETTs): 5 patients were affected in 2022 and then 5 patients in Q1 of 2023. There was an observed staff practice variation in consistency of ETT repositioning and oral care.

A literature review of at least 9 evidence-based articles demonstrated that consistent repositioning of the ETT and maintaining a clean and moist oral environment were best practices for preventing skin breakdown. The CICU coalition also consulted leaders from the respiratory therapy department, welcoming collaborative interventions.

The CICU coalition created an ETT care clock that was posted in every patient room above the head of the bed. The clock promoted repositioning of the tube every 2 hours, rotating among right, center, and left. Bedside nursing staff and respiratory therapists were provided in-person education on best practices for repositioning the ETT, proper oral care, and Hollister AnchorFast Guard Oral Endotracheal Tube Fastener placement.

The practice change was promoted through staff education at the bedside, during unit meetings, and via email. The CICU coalition members acted as superusers and educators. Staff were asked to fill out a brief 5-question Likert scale survey before the project was implemented and again after 5 months of practice. Staff were reminded of the project at shift huddle. Charting reminders were posted at every nursing station.

The team tracked the incidence of skin breakdown related to ETTs through event reporting such as Datix and PressGaney. In Q1 of 2023, 4 patients developed mucosal HAPIs related to ETTs (incidence rate of 0.9%) and 5 patients in Q2 of 2023 (incidence rate of 1.2%). Staff were educated about the project in June. ETT-related HAPIs then decreased to 2 patients in Q3 (incidence rate of 0.5%) and then 0 in Q4 of 2023. Staff reported increased comfort and compliance with ETT care.

Frequent and standardized oral and ETT care are essential to prevent mucosal wounds in intubated patients. Thorough oral care is required in addition to ETT repositioning to prevent tongue wounds. Communication and collaboration between nursing and respiratory therapy staff are vital for success.

Tina Hall; Brooke Army Medical Center, San Antonio, Texas

In 2022, an acute care hospital in Texas had 239 pressure injuries (PIs) among patients, with 73 occurring in the intensive care unit (ICU). The purpose of this project was to decrease the most common ICU PIs, which occurred on the coccyx, sacrum, and heels of patients 50 years old or older and caused increased pain, length of stay, risk for infection, nurse workload, and treatment cost.

The PubMed, MEDLINE, CINAHL, and EBSCO databases were searched using the key terms intensive care, ICU, pressure ulcer/injury, silicone dressing, prophylaxis, sacrum, coccyx, heels, geriatric, and elderly. The author reviewed 64 articles and identified 7 applicable studies published between 2018 and 2023, of which 4 studies were chosen as applicable to this project. The studies were conducted in an ICU, focused on adults at least 50 years old, and involved using a prophylactic, multilayer, silicone adhesive dressing to prevent PIs on the sacrum, coccyx, and heels.

The project included 2 ICUs (20 beds) and focused on critically ill patients who were at least 50 years old. Stakeholders included patients, nurse managers, staff nurses, wound nurses, health care providers, and organizational leadership. The author piloted the 10-week change, which focused on PI prevention via the application of a prophylactic silicone dressing (Mepilex) and nursing education. ICU skin champions and staff nurses were vital in promoting the change.

Nurses were briefed on the project’s purpose. A QR code was used for the consent, demographics, and a preintervention survey. Nurses were educated via a PowerPoint presentation and a QR code was used for the postintervention survey. A hands-on training session was conducted using a manikin to demonstrate proper placement of the silicone dressing. “Moving Mondays” involved turning patients in the appropriate age group to evaluate the skin for PIs. Skin Care Aware badges were given as PI prevention reminders.

The PI project was monitored for 10 weeks with a benchmark goal of a 10% reduction in PIs and a 20% increase in nursing knowledge. A 10-item preintervention survey (mean score, 65.24), postintervention survey (mean score, 74.42), and time-delayed postintervention survey (mean score, 86.39) (P < .001) were completed by 61 nurses. The number of PIs decreased from 4 in 10 weeks before the change to 0 PIs after the change. The data were evaluated via descriptive statistics, QR generator, and Microsoft Excel, revealing a 32% increase in nurses’ knowledge and a 100% decrease in PI number.

The PI results were gratifying to nursing staff and leadership. The use of silicone dressings and collaboration of skin champions, nurses, and leadership promoted PI prevention. Continued PI education, Moving Monday skin evaluations, and Skin Care Aware badges stimulated policy change and discussions on dissemination of information to other units.

Sarah D’Angelo; Baylor Regional Medical Center at Plano, Plano, Texas

Stroke-associated pneumonia (SAP) results in poor outcomes, increased morbidity, mortality, length of stay, and costs. In 2023, 6.04% of patients with stroke admitted to our suburban hospital were diagnosed with SAP. Nurses identified a need to implement and standardize best practices to prevent SAP.

A comprehensive literature search was conducted using the CINAHL and MEDLINE databases and the help of the hospital librarian. Search terms included stroke-associated pneumonia, hospital-acquired pneumonia, SAP prevention, oral care, mobility, early mobilization, SAP prevention bundle, and cluster nursing. Review and appraisal of the evidence identified 19 relevant articles. Evidence indicates implementing routine oral care on all patients with stroke and a care bundle for the critically ill prevents SAP and improves outcomes.

New evidence-based nursing protocols were developed to prevent SAP in hospitalized adult patients with acute stroke. Nurses were asked to provide oral care every 4 hours for all patients with stroke and to apply a care bundle combining oral care with keeping the head of bed at 30° or higher, repositioning every 2 hours, and early mobility every shift for all critically ill patients with stroke. Practice changes were presented to hospital leaders for approval. The pilot began April 1, 2024, and ended June 30, 2024.

Nursing staff were provided multiple in-service sessions, educational flyers, handouts, and emails more than 2 weeks before the pilot start date to prepare for the upcoming practice changes. Posters, visual aids, and reminder cards were posted on each stroke unit in the hospital. Two unit champions were assigned to each stroke unit to support staff, collect data, and monitor compliance throughout the pilot period. Staff were updated monthly on compliance, progress, and effectiveness of the project.

Three months of pre- and postimplementation data were collected and analyzed for project evaluation. Before implementation of the project, 3.85% of patients with stroke who were admitted to the hospital were diagnosed with SAP. After implementation, 0% of patients with stroke who were admitted to the hospital were diagnosed with SAP. Analysis of the data indicates routine oral care for all hospitalized adult patients with stroke and implementing a care bundle for critically ill patients with stroke reduced the hospital’s SAP rate from 3.85% to 0% over 3 months.

Implementing an action plan that includes routine oral care and a care bundle for the critically ill can prevent SAP in our hospital. Because of the positive results, the project will be sustained and effectiveness monitored. Next steps are dissemination of these findings and practices throughout the organization, hospital system, and beyond.

Janine Giordano, Stephanie Akanbi, Charina Ballesteros, Kathleen Peschetti, Jennifer Angelesco; Hackensack University Medical Center, Hackensack, New Jersey

Cardiac surgery patients in a 800-bed northern New Jersey hospital experienced challenges in early mobility postoperatively due to pain, catheters and tubes, hemodynamic instability, and lack of resources. This project aimed to promote consistent ambulation in the early postoperative period to improve patient outcomes.

A literature search was conducted of the PubMed database using the terms early mobility ICU and early ambulation after surgery. Eleven articles were reviewed and graded. These articles supported the principles of early mobilization to improve patient outcomes, decrease hospital length of stay (LOS), and reduce 30-day readmission rates, while decreasing hospital costs.

The interprofessional team for both a 25-bed cardiac surgery intensive care unit (ICU) and 25-bed step-down unit developed an ambulation protocol defined as at least twice-daily ambulation within 72 hours after extubation. In 2022, the preliminary data identified limitations such as inconsistency of ambulation and lack of documentation. As a result, a sustainability bundle was proposed to encourage consistent documentation and improve inter-rater reliability.

The strategies used to implement change consisted of staff educational sessions via Zoom, PowerPoint presentations, and annual mandatory cardiac surgery seminars. Unit champions promoted compliance and weekly audits were performed. Frequent communication was maintained with staff through huddles and monthly staff and unit-based council meetings to provide feedback and reinforcement. A smart phrase was developed to improve documentation and track contraindications to ambulation.

Data analysis over 12 months, from February 2023 to February 2024, included a review of 768 cases. The following results were reported: ICU LOS decreased from 5.2 to 4.4 days (P < .001), postoperative LOS decreased from 8.52 to 8 days (P < .001), rate of patient discharge to home increased from 75.6% to 79.3%, rate of discharge to rehabilitation increased from 19% to 19.5%, and the readmission rate decreased from 13.63% to 10%. Although the rate of discharge to rehabilitation did not improve, the readmission rate decreased and both the ICU LOS and postoperative LOS improvements were statistically significant.

The results of this project support the principles of a structured ambulation protocol to improve patient outcomes and increase staff engagement to extend beyond the cardiac surgery patient population. Its conclusions serve as a foundation for developing a sustainability bundle aimed to improve compliance with ambulation and thorough documentation.

Hee Jeong Kim, Jacob Chang, Katherine Feril; Stanford Health Care, Palo Alto, California

At our medical center, we noticed more intra-aortic balloon pump (IABP) use for patients before they underwent heart transplant. However, femoral IABP leads to prolonged bed rest and patient deconditioning. To address this problem, we implemented a protocol using a tilt bed, lift vest, and treadmill in our intensive care unit (ICU) to promote mobility, safety, and ambulation for these patients.

The literature offered several studies relating to the mobilization of patients with a femoral IABP. Databases used included PubMed, UpToDate, CINAHL, and OVID. Key words used included IABP, femoral, ambulation, transplant, and mobilization. Seven articles were used in the final project. An existing protocol, the Ramsey Protocol, was identified and modified for this project to accommodate the unit’s patient population and risk factors.

A mobilization protocol with guidelines was developed from literature for patients with afemoral IABP before undergoing heart transplant and piloted from January 2023 to April 2024 at a cardiac ICU at an academic medical center in California. The practice changes involved nurses incorporating patient screening for tilting into their workflow and collaborating with physical therapy personnel to have patients ambulate on a treadmill. The pilot led to adjustments in monitoring frequency and session discontinuation parameters.

The protocol, endorsed by department leaders, was shared with staff through instructional sessions at meetings. An awareness campaign occurred during shift huddles, with educational sessions for nurses and physical therapists (PTs). The clinical nurse specialist provided guidance and oversight during tilting and treadmill sessions. To promote patient engagement and decrease anxiety, patients were educated about the process of mobilization and participated in daily planning with nurses and PTs.

In this project, 33 patients were included who had a femoral IABP while awaiting heart transplant. Nineteen patients met the criteria for tilting. Nurses initiated tilting, on average, 3 days after IABP insertion, with 167 total tilt sessions occurring over 91 days. Eleven patients walked on a treadmill within 5 days of IABP placement, covering 7163 meters of total distance over 24 sessions. There was no patient harm or device failure. Therefore, femoral IABP patients were able to mobilize safely.

A nurse-driven protocol and team collaboration enable patients with femoral IABP to mobilize safely using equipment, boosting patient mobility and satisfaction. Ongoing protocol use sustains the project. Future efforts will explore preoperative mobilization benefits and assess the impact of the safety device and treadmill on safety and staffing.

Holly Rodriguez; Houston Methodist Hospital, Houston, Texas

Central line–associated bloodstream infection (CLABSIs) pose a significant threat to patient safety, particularly among patients receiving continuous renal replacement therapy (CRRT) in the intensive care unit (ICU). Prolonged vascular access increases infection risk, driving up morbidity, mortality, and costs. Despite standard protocols, elevated CLABSI rates in our unit led to the initiation of this quality improvement (QI) project.

A literature review conducted of the PubMed and CINAHL databases identified 25 relevant studies, of which 10 were selected to inform the intervention. The findings supported the implementation of standardized dialysis access kits alongside comprehensive educational strategies. Practice changes were also guided by recommendations from the Centers for Disease Control and Prevention and the Society for Healthcare Epidemiology of America.

Based on the evidence, a standardized dialysis access and de-access kit was implemented in our 30-bed ICU, which serves high-risk cardiac patients requiring CRRT. A comprehensive staff education program was introduced alongside the kit. The plan-do-care-act framework guided the 7-month pilot, during which compliance audits and staff feedback led to iterative adjustments. These changes improved infection control practices and ensured adherence to the new protocols, fostering a safer unit environment.

The intervention used a comprehensive educational approach featuring video-based learning management system training, hands-on demonstrations during daily staff huddles, and just-in-time learning at the point of care. Members of the ICU catheter-associated urinary tract infections and CLABSI shared governance acted as change champions, actively driving the initiative forward. Compliance with the new protocol was tracked through regular audits, and adherence was reviewed during monthly shared governance and staff meetings.

Before the intervention, the ICU had 4 CLABSIs over 7 months, with 75% occurring in patients receiving CRRT. After the intervention, only 3 CLABSIs occurred, with a reduction in CRRT-correlated infections to 33%. Additionally, dialysis kit use increased by 40%, and 95% of staff completed the mandatory training. Compliance monitoring and audit feedback were integral to success.

The project led to a significant reduction in CLABSI rates among high-risk patients receiving CRRT and increased staff compliance. The intervention improved patient safety and fostered a culture of infection prevention in the ICU. Next steps include scaling the intervention across other units with similar high-risk populations.

Edina Muran, David Michael Gabriel, Stella Lyubin; El Camino Hospital, Mountain View, California

Hospital-acquired pressure injury (HAPI) prevention remains a nursing focus because skin plays a vital role in health and well-being. Patients are vulnerable to skin breakdown because of medical conditions and the nature of treatments; these complications hinder recovery. In 2022, the progressive care unit (PCU) saw an increase in HAPIs; there were 13 occurrences from January to December.

A search of the National Center for Biotechnology Information database, using key terms hospital-acquired pressure injuries, skin bundle, and medical devices associated with HAPI, yielded thousands of articles on prevention. Five specific articles focused on the creation and implementation of skin bundles. Key aspects that significantly decreased HAPIs included early assessment of skin—by sight and touch—by 2 nurses, comprehensive charting, mobility, nutrition, and incontinence management.

The hospital, a nonprofit tertiary care center in northern California, houses a 16-bed PCU that treats patients with acute respiratory and heart failure, withdrawal, and sepsis, often with complex comorbidities and psychosocial factors. A skin bundle was piloted from January 30 to June 1, 2023. It included 2-nurse skin checks during bathing upon arrival, photographing skin breakdown, weekly wound photographs, visual turn schedules, cushioning devices with dressings, and readily accessible prophylactic supplies.

The new practice was introduced by the clinical manager during morning huddles for 1 week. The unit’s 2 wound and ostomy champions developed and implemented the skin bundle. Over the next month, the champions educated staff during huddles. Detailed information, including a laminated cheat sheet summary, was shared via email and posted in every patient room. Although skin bundle compliance was not initially tracked, leadership monitored all HAPI occurrences relative to the intervention’s effectiveness.

Leadership monitored HAPI rates. Between July 2020 and June 2021, 15 HAPIs occurred; from July 2021 to June 2022, 12 HAPIs occurred. From July 2022 to January 2023, 9 HAPIs occurred. From February to August 2023, 4 HAPIs developed, marking a 50% reduction from the prior 6 months. Notably, there were 0 HAPIs in March and May 2023. Key lessons included the importance of early, consistent skin assessments. Skin breakdown was identified proactively, and pressure injury staging became more consistent with involvement of 2 nurses.

Positive outcomes motivated sustained commitment to the skin bundle. Interprofessional collaboration and frontline nursing accountability are crucial for improved patient outcomes. Next, the WoundVision Scout, a digital and long-wave infrared camera, was introduced to detect skin injuries earlier. For fiscal year 2024, 8 HAPIs have been attributed to the PCU.

Wendy Simpson; Memphis VA Medical Center, Memphis, Tennessee

Because of increasing intensive care unit (ICU) central line–associated bloodstream infection (CLABSI) rates between 2021 and 2022, we assessed the impact of an intervention bundle that included a new evidence-based stethoscope-hygiene practice and a standardized chlorhexidine (CHG)-impregnated dressing on CLABSI rates.

We performed a systematic review of the PubMed database for results between 2020 and 2022 using the search terms disposable stethoscope and CHG impregnated dressing. There was no evidence of infection control efficacy with disposable stethoscopes, although 3 articles supported the use of touch-free diaphragm barrier systems. Three articles reinforced CHG-impregnated dressing for preventing central catheter infections.

We implemented a CLABSI prevention bundle in an 18-bed, high-acuity ICU from March 2022 to June 2024. This bundle included installing automated aseptic stethoscope barrier dispensers (AseptiScope, Inc) in each room and eliminating disposable stethoscopes. Furthermore, CHG-impregnated dressings were used for all central catheters. The bundle included daily nursing and infection prevention rounds and daily catheter checks, alerts for ordered blood cultures, and prompt removal of central catheters when appropriate.

Strategies included placing the stethoscope barrier system in patient rooms near the hand hygiene station for maximum use. ICU champions were appointed to ensure continued adoption. Instruction placards were placed above each system as reminders. Standardization of CHG dressings across all dialysis and central catheters was implemented with ongoing rounding and aseptic dressing change education. Surveys were deployed to collect clinician feedback and refine implementation processes.

The postimplementation group had a significant reduction in CLABSI rates, from an average of 3.49 to 0.97 infections per 1000 catheter days. Clinician survey responses reported the implemented systems were easy to use, and the majority believed the new stethoscope hygiene method was superior to disposables stethoscopes. The standardized CHG dressing eliminated the problem of staff not addressing compromised dialysis dressings.

We found that a CLABSI bundle that included an aseptic stethoscope hygiene dispenser as well as a standardized CHG dressing was effective to decrease infection rates. Furthermore, removal of the disposable stethoscopes resulted in clinician satisfaction improvement. The next steps involve expanding the system’s use hospital wide.

Jennifer Ricker, Korey Roman, Sarah Kelichner; St. Joseph’s University Medical Center, Paterson, New Jersey

In the third quarter (Q3) of 2023, the medical intensive care unit (MICU) missed American Heart Association (AHA) stroke core measures by administering medication to 3 patients who had had a stroke before conducting swallow evaluations. Investigation revealed 87% of MICU nurses lacked formal swallow-screen training. Various discrepancies in screening procedures were found.

Proper swallow evaluation of patients who have had a stroke reduces the risk of aspiration pneumonia, malnutrition, physical decline, and increased length of stay. Swallow screening tools enable nurses to assess a patient’s ability to swallow before evaluation by a speech-language pathologist (SLP), expediting safe oral intake and preventing aspiration. Despite the availability of several validated swallow screens, the MICU sought a nurse-specific tool that could be universally applied throughout the hospital system.

The MICU, 1 of 4 adult ICUs in a 2-hospital health care system, frequently cares for patients with acute stroke. MICU nurses and SLP leadership noted a lack of standardized swallow-screen approaches, education, and policy within the hospital system. An MICU and SLP team created an evidence-based, pass/fail, water-only, bedside swallow-screening tool with an intuitive workflow. After a successful MICU pilot, the screening tool was implemented in all adult inpatient units in the system.

The team collaborated with key stakeholders to develop a bedside swallow-screen policy addressing system-level gaps. The new screening tool was highlighted during shared governance meetings and accreditation surveys. Targeted education and handouts were integrated into huddles and yearly nursing competency requirements. The screening tool is now universally used for all adult inpatient indications in the system. Electronic health record modifications were introduced to guide nursing practice and documentation.

All surveyed MICU nurses reported improved knowledge, practice, and confidence using the screening tool, compared with 65% of nurses before the initiative. Since the initiative rollout in Q4 2023, the MICU has had 0 AHA stroke core measure fallouts, compared with 8 from Q1 through Q3 2023. The hospital system has seen a downward trend in medication administration before swallow assessment from 2023 to 2024. In addition, aspiration pneumonia cases decreased by 8.2% system wide from 2022 to 2023.

Standardizing the bedside swallow screen has enabled nurses to provide safe, evidence-based care with greater confidence, empowering nursing practice and improving patient outcomes. Next steps for the project include validating the screening tool and investigating the match between bedside nursing swallow screens and SLP dysphagia evaluations.

Sari Viitaniemi, Jennifer Hernandez-Trujillo; Delray Medical Center, Delray Beach, Florida

Our trauma intensive care unit (ICU) team explored the best practices for coordinating awakening and breathing trials for patients receiving ventilatory support. We investigated whether pairing and establishing a protocol for spontaneous awakening and breathing trials could reduce ICU length of stay (LOS) and the number of days a patient spends receiving mechanical ventilatory support.

The B of the evidence-based ABCDEF bundle represents both spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs). Studies have shown that standardized ventilator weaning trials can reduce the ICU LOS and the number of days receiving ventilatory support. A protocol for paired SAT and SBT, driven by nurses and respiratory therapists (RTs), can improve the success of ventilator weaning.

The current SAT and SBT ventilator weaning protocol underwent review by a team of nurses, RTs, and physicians. Safety screening for SAT and SBT was revised to better suit the patient population in our unit. The algorithm worksheet, which details safety screening and failure criteria, was updated. Additionally, a daily weaning protocol timeline was established for nurses, RTs, and physicians. A staff education plan was made with the clinical practice specialist.

Staff education was implemented, and protocol compliance was monitored with periodic reeducation. A daily weaning protocol timeline was established for nurses, RTs, and physicians The SAT and SBT trial began with a safety screening by nurses and sedation interruption, followed by a safety screening by RTs and the weaning trial. If at any point during the protocol the patient failed the safety screening, sedation and ventilator settings would be resumed.

The standardized protocol was hardwired with reeducation and compliance audits. The data on ventilator days and LOS were retrieved from the trauma registry. The data revealed a 6.7% decrease in trauma ICU LOS from the first quarter (Q1) of 2023 to Q1 2024 (3.30 days vs 3.08 days) and a 37.7% decrease in trauma patient ventilator-days (4.5 days vs 2.8 days). Although we do not have comparable ventilator-associated pneumonia (VAP) data, we have seen a decreasing trend in VAP rates from 2023 to 2024.

To enable the successful implementation of SATs and SBTs, it is important to create an interprofessional team and a standardized, unit-specific protocol. In our unit, it is now standard practice to pair SAT and SBT trials. Through this project, we have recognized opportunities to improve other nurse-driven ABCDEF bundle processes.

Julie Hartney, Lauren Liberio; University of Chicago, Chicago, Illinois

Approximately 66% of patients obtain a return of spontaneous circulation after in-hospital cardiac arrest. Prior facility decision guides for post–cardiac arrest care addressed only some of the tasks recommended by the American Heart Association. A new mnemonic was created to approach this clinical period more holistically with better adherence to practice.

The PubMed database was reviewed for evidence on organizing postarrest care for in-hospital cardiac arrests. Bundles used for postarrest care, reported in the literature, were successful in promoting task completion, documentation, and communication. In other projects, nurses were identified as key clinicians in arrest events, given their actions as bedside clinicians, members of the resuscitation team, and in administrative roles, who analyze events for quality or educational purposes.

A mnemonic (MOTIVATED) was created using recommendations from the literature and American Heart Association’s Get With the Guidelines program on postarrest clinical management. This mnemonic was used in a “smart-phrase” template that could be inserted into notes by rapid response team nurses. It was also encouraged to be used by these nurses in their discussions with ordering providers after cardiac arrests on the general wards of a 848-bed, urban, academic medical center.

In-person education sessions using slide-deck presentations were completed with ordering providers (physicians, advanced practice providers) from the internal medicine and hospital medicine departments before implementation of the pilot period. Additional sessions were completed with rapid response team nurses, using similar methods, with attention paid to clinical aspects and use of the smart-phrase in electronic health record documentation. Badge cards with the mnemonic were also provided to these nurses.

Chart and defibrillator cloud data were gathered for 2 separated 3-month periods: the first using a standard of care (n = 13) and the second using the novel mnemonic (n = 16). Improvements were noted in the time elapsed between return of spontaneous circulation and completion of 12-lead electrocardiogram and chest radiography, with reductions in average time of completion by 13.5 minutes and 23.5 minutes, respectively. Additional improvements were noted in documentation of goals of care and debriefing with staff.

In addition to tangible clinical improvements, rapid response nurses found the mnemonic helpful in encouraging use of best practices, staying organized during the postarrest period, and fostering trust in their working relationships with ordering providers. An increase in the number of patients surviving to discharge was also noted.

Diana Alexander, Golda Cabanban; Lakeland Regional Medical Center, Lakeland, Florida

From 2017 through 2022, our surgical intensive care unit (SICU) experienced challenges with ventilator weaning and extubation processes, resulting in increased prolonged ventilation (PV) rates. The purpose of this quality improvement (QI) project was to identify and develop strategies to reduce PV rates for patients who had undergone isolated coronary artery bypass graft (CABG).

Delayed extubation of patients after cardiac surgery can result in higher morbidity and mortality rates, prolonged hospitalization, and higher health care costs. The Enhanced Recovery After Surgery Society has identified that early and safe extubation (within 6 hours of ICU arrival) is feasible with structured protocols and adequate, multimodal, nonopioid pain management. Multidisciplinary approaches are successful in reducing ventilatory support times for patients who had undergone cardiac surgery.

In our 18-bed SICU in central Florida, beginning in March 2023, we focused on developing strategies to reduce PV rates for patients who had undergone isolated CABG. Based on identified trends since 2017, our PV rates remained higher than that of those in like groups and the industry standard for patients after isolated CABG. Strategies included modification of order sets, revision of the cardiac surgery ventilator management protocol, development of tracking tools, and increased visibility of extubation timelines for providers.

A multidisciplinary approach was used to include the pharmacy and respiratory therapy departments, leadership, nurses, and cardiac surgeons. Cardiac surgery order sets were modified to include multimodal opioid-sparing agents. In conjunction with cardiac surgeons, respiratory therapists modified the pH goals for extubation identified in the cardiac surgery ventilator management protocol. Signage was developed to display extubation timelines in the patient’s room, and tracking tools were developed.

The average observed PV rate from 2017 to 2021 for isolated CABG was 9.4%. In 2022, before project implementation, the observed PV rate was 9.0%. After implementation of the project, in 2023, the PV rate decreased to 3.5%, and through May 31, 2024, the PV rate was 2.9%, reflecting ongoing sustainability. This QI initiative relied on multidisciplinary engagement to achieve these results. Limitations of the project included staff turnover and the unavoidable physiological challenges related to ventilator weaning.

Early and safe extubation carries many positive implications for patient care and staff satisfaction. Ongoing discussions are warranted to ensure sustainability and optimal outcomes. Next steps include determining the impact of PV rates on length of stay, complications, and cost, and expanding strategies to include all patients undergoing cardiac surgery.

Heather Libby, Sandra Harryman, Emily Loza; University of Missouri Health System, Columbia, Missouri

In adult inpatients, the number of hospital-acquired pressure injuries (HAPIs) remain high, negatively affecting patient care, hospital budgets, and national rankings. A 2-phase, longitudinal, evidence-based initiative, spanning 3 years, led to an additional 2 years of sustained HAPI rate reduction.

A literature search was conducted on the PubMed and Google Scholar databases. Key terms were pressure injury and deep tissue injury, with the limitation that articles must be peer-reviewed and published within the past 10 years. Seven selected articles reviewed 4 Eyes in 4 Hours, a thermal imaging device, Capture App, safety debriefs, policy development, and medical device–related pressure injury reduction programs. Implementation sustainment literature included importance of information technology integration, continued policy updates, and audits and compliance monitoring.

A 669-bed academic medical center in the US Midwest implemented a 2-phased approach for HAPI reduction over 3 years. Both implementation phases used an interprofessional team and focused multidisciplinary interventions. Phase 1 included 4 policy revisions and 2 technological integrations from 2019 to July 2020. Phase 2 (2021) implemented 6 additional interventions of electronic health record (EHR) modifications, data analytics, and product changes. Sustainment evaluation occurred through 2024.

Nursing education occurred for Capture App, whereas thermal imaging device education included general instruction and Super User training. Interprofessional education was provided for new products and EHR changes. Several EHR modifications prompted new patient-care processes, automated skin-care consultations and alerts. Metric dashboards compiled hospital and unit-specific data for ongoing sustainability. After audits and safety debriefs, implementation reminders occurred at shift huddles and through the situation, background, assessment, and recommendation framework.

After project implementation, HAPIs (all stages) were reduced by 50%, with reportable HAPIs maintained at the top quartile or better among National Database of Nursing Quality Indicator and Vizient comparison groups. The Patient Safety Indicator 03 metric decreased from an average of 2.1 per month to 0.5 per month with interventions, and an average of 0.2 HAPIs per month was sustained over 2 years. Costs decreased by an estimated $1.8 million with 1195 saved patient days. Reductions in tracheostomy and nasal cannula pressure-related injuries were statistically significant (P=.000).

Despite the pandemic, a multidimensional interprofessional approach with people-, process-, and technology-driven interventions resulted in HAPI reduction. Leveraging the EHR and electronic metric dashboards to provide real-time, actionable information is key in HAPI reduction intervention and sustainment.

Elizabeth Davis, Fatima Abdeljaleel, Lorri Martin; Cleveland Clinic Fairview Hospital, Cleveland, Ohio

The Surviving Sepsis Campaign (SSC) emphasized improving the care of patients in the intensive care unit (ICU) with sepsis. A critical care interprofessional team introduced initiatives that increased antibiotic administration rates within 1 hour to reduce sepsis-related death. These initiatives improved the antibiotic administration rate by 30%.

A review of 10 articles identified in the CINAHL database revealed a significant need for improved closed-loop communication between ordering antibiotics and the administration time to reduce sepsis mortality rates. To track antibiotic medication administration times, an electronic health record dashboard, sepsis order sets, and software flag systems were used. This thorough review of Centers for Medicare & Medicaid Services sepsis guidelines and our recommendations form the basis of our practice change.

A 488-bed Magnet regional hospital system with 51 beds across 3 ICUs was the focus for project implementation. During 3 months, an interprofessional team piloted 3 plan-do-study-act (PDSA) cycles. These cycles involved introducing timed antimicrobial guidance (TAG), education, and positive reinforcement. Providers placing antibiotic orders gave a TAG to the nurse to decrease administration time and improve closed-loop communication. Adjustments were made to include patient information, improving auditing.

Implementation of 3 PDSA cycles involved TAG tickets, reminders, educational sessions, and positive reinforcement. The provider places a new antibiotic order, fills out a TAG ticket, then hands it to the bedside registered nurse (RN). The slogan we used was “TAG you’re it”: the provider tagged the RN to complete the administration of antibiotics. A winning ticket was drawn at the end of each month. Adjustments to the TAG ticket were made to include patient information for auditing purposes.

This project compared STAT antibiotic administration rates for patients in the ICU with sepsis. From January to December 2023, 36 antibiotic orders were placed with a resulting 44.4% 1-hour administration rate. During the pilot period, March to August 2024, 31 orders were placed with an improved 74.2% 1-hour administration rate. Closed-loop communication between provider and nurse fostered teamwork, collaboration, and efficiency. Positive reinforcement motivated caregivers and boosted performance.

Implementing TAG significantly improved ICU antibiotic administration times for patients with sepsis. The ICU mortality index decreased 13.5%, and antibiotic administration times improved. Overall, the team improved closed-loop communication. Because of the success of this project, TAG will expand to other hospital care areas.

Kristin Bowen; Levine Children’s Hospital, Charlotte, North Carolina

Education and professional development are essential components of excellence in nursing. The absence of formal educational resources, exposed by the pandemic, affected all experience levels of the pediatric ICU (PICU) nursing team. A need for learning opportunities was recognized and an educational forum, Teach Me Tuesday (TMT), was created.

More than 50 references from the OVID and EBSCO databases using the key terms nursing, continuing education (CE), and retention revealed the impact of CE on clinical practice. Discussions presented CE as a professional responsibility and a crucial element of current and safe clinical practice. Studies imply CE increases an individual’s confidence and has a positive impact on patient care. Suggestions that organizations create flexible and accessible learning environments are reflected in the literature.

The pandemic halted all in-person education at a 247-bed urban children’s hospital, creating a need for alternative modes of gaining new knowledge. Early in April 2021, physicians, advanced practice providers, leaders, and teammates were asked to share their expertise on topics requested by the PICU team. Lectures were presented via Microsoft Teams. Attendance for TMTs continues as a virtual platform; however, there is now an in-person option.

Implementing TMT forums involved the following steps: identifying the need for structured education; selecting topics; scheduling, preparing, and holding engaging sessions; acquiring feedback; providing alternative modalities; and planning for sustainability. Virtual forums began in April 2021, expanding to in-person sessions later that year. TMT leverages talents within the organization, inviting providers, clinical leaders, and bedside nurses to share their expertise on requested topics.

TMT attendance has increased from an average of 18 participants per session in 2021 to 33 in 2024. PICU nurses excitedly request topics for TMT lectures and are empowered to present subjects of personal expertise. Throughout the organization, several units initiated similar forums. Pediatric Service Line and Daisy Leader Awards support the impact on clinical knowledge and practice. Retention rates increased from 93% in 2021 to 97% through July 2024, suggesting a positive effect on staff satisfaction.

TMT has become an integral part of the PICU (and our institution’s) education framework. TMT continues to expand and bridge teammates from different units and disciplines, with the goals of engaging the nursing workforce, inspiring expert and excellent care for patients and families, and empowering clinicians with evidence-informed practice.

Angela Schrage, Ellen Arrington, Michele Hnath, AnnMarie Chase; Salem Hospital, Salem, Massachusetts

Central line–associated bloodstream infections (CLABSIs) increase mortality risk significantly for patients in the intensive care unit (ICU). CLABSI rates spiked during the COVID-19 pandemic as focus shifted away from routine infection-prevention stewardship. This team sought a goal of 0 CLABSIs in the setting of increased CLABSI rates and decreased hand hygiene (HH) compliance.

The PubMed database was used to search the key terms hand hygiene, compliance, infection prevention, and CLABSI. Evidence continues to support HH as the most important way to reduce hospital-acquired infections, although achieving goal compliance can be challenging. Leadership involvement is crucial in implementation of successful infection-prevention practices and both leader role modeling as well as real-time feedback increase HH compliance rates.

This 20-bed, general ICU in a complex community hospital with a small teaching service implemented 3 practice changes to improve HH: (1) incorporating assigning of HH audits into the charge nurse standard work to consistently reach a goal of 200 audits per month; (2) incorporating real-time feedback into the HH audit process to improve compliance; and (3) restructuring central catheter dressing kits to include sanitizer and improve in-room HH.

The team met weekly and used plan-do-study-act methodology to enact tests of change to achieve goals. Charge Nurse Standard Work was created to summarize expectations of charge nurse participation in quality improvement work, including assigning HH audits. A campaign was implemented to accompany HH audits with real-time feedback and was supported by signage, staff meeting discussions, and leader role modeling. Comprehensive education was provided on the new central catheter dressing kits with a focus on HH.

A P chart with 3 sigma upper and lower control limits demonstrated success in increasing mean HH compliance from 70% to 87.4%. An X chart demonstrated success in increasing the mean number of HH audits per month from 99 to 212. Pre- and postproject spaghetti maps demonstrated an improved central catheter dressing change process. The team’s patients have been CLABSI free for longer than 1 year. The year-to-date standard infection ratio (SIR) is 0, compared with a preproject implementation average of 1.3 CLABSIs per quarter and a 2023 SIR of 1.803.

HH audit programs are common among health care organizations, although structure and consistency vary. Sharing this work will assist others in implementing effective HH improvement programs that seek to integrate HH audits into daily practice and increase staff comfortability with providing real-time HH feedback.

Melissa Schmidt, Kristen Stein; Barnes Jewish Hospital, St. Louis, Missouri

The purpose of this quality improvement initiative was to implement an educational session on urine culture stewardship (UCS) including recognizing asymptomatic bacteriuria (ASB) compared with urinary tract infection with providers in the neurology intensive care unit.

Catheter-associated urinary tract infection (CAUTI) rates may be inflated due to detection of ASB. Implementation of a UCS program with set criteria for urine testing, in alignment with the Infectious Diseases Society of America (IDSA) 2019 Clinical Practice Guideline for the Management of ASB, may help decrease CAUTI incidence. A UCS program was a safe and effective way to reduce CAUTIs without affecting length of stay, death, or hospital-onset sepsis events related to urinary tract infection (UTI).

An educational program for nursing and providers was deployed to review the IDSA 2019 recommendations for treating UTIs and appropriate testing practices in alignment with the established criteria as part of the UCS protocol. All intensive care unit providers and main consulting services were provided education. The protocol was made widely available across the nursing division.

To promote practice change, daily feedback was provided to ordering providers to encourage alignment with the UCS protocol. The feedback served as a 2-way communication pathway about the practice change and also to gain insight into any missed criteria for future revisions.

A pre-post study design was used to evaluate provider confidence in recognizing ASB and UTIs. There was an increase in confidence (n = 6). There was a statistically significant decrease in CAUTI rate (P = .003) and a nonsignificant decrease in CAUTI standard infection ratio (P = .25) over 12 months after implementing UCS. There was no difference in length of stay, mortality, or hospital-onset sepsis events related to UTI.

This project adds to the growing body of evidence to suggest UCS is a safe and effective way to decrease CAUTI rates while maintaining high-quality patient care. Implementation of a UCS program requires interdisciplinary support. Engagement of the electronic medical record team may also help support the practice change.

Jennifer Tokarski, Tracy Montesa; Lutheran General Hospital, Park Ridge, Illinois

After analyzing safety events and 2 learning needs assessments, an opportunity for improving cardiovascular and respiratory knowledge was evident. In situ education was implemented to accommodate competing priorities such as time constraints and patient acuity. The education evaluated learners’ knowledge, skills, and confidence.

Evidence shows that interactive, simulation-based activities effectively engage learners and enhance critical thinking through application to clinical scenarios. There is also support for implementing a traveling education cart to disseminate information in a concise, flexible, small-group format. The CINAHL, PubMed, and Google Scholar databases were used to locate 19 references and adopt 6 articles to support this project.

The education cart was piloted over 3 months in a 14-bed neurological intensive care unit at a Magnet-designated, comprehensive stroke, teaching hospital. A multimodal approach included case studies, gamification, discussions, and guided small-group simulations with high-risk, low-volume equipment. One cart featured an interactive activity for recognizing electrocardiogram (ECG) rhythms and managing a defibrillator, and another included a Jeopardy-like game with hands-on respiratory devices and case-study applications for escalating care.

The education cart advertisement was shared via email, unit meetings, and in person. A facilitator captured available nurses by rounding at nurse stations twice weekly for 3 months during the day shift. Each week, 1 to 2 topics were covered, depending on attendance and prior participation. Teammates scanned a QR code before and after sessions to assess learning and provide feedback, which helped influence future topics.

Pre- and postsurveys conducted via QR code gathered qualitative and quantitative data. Multiple-choice and short-answer questions assessed knowledge and a 5-point Likert scale measured confidence changes. Data on use of the ECG cart showed a 25% increase in confidence and an 18.75% improvement in knowledge. Data on use of the respiratory cart showed 21% knowledge improvement; with 1 erroneous question removed, this result increased to 44%. Qualitative feedback was positive overall, with comments such as “helpful,” “necessary,” and “great.”

Positive results and feedback indicate that the education cart can effectively meet learners’ needs with its flexible, brief, and engaging small-group format. Next steps include partnering with a night-shift champion and presenting the data to professional governance and hospital educators in other departments to adopt this innovative approach.

Jason Johnson; NYU Langone Medical Center, New York, New York

The purpose of this project was to address the need to provide clinical registered nurses (RNs) with increased opportunity to participate in champion roles, prepare for charge nurse orientation, and work on evidence-based practice projects, while diminishing overtime and time spent outside of work by standardizing a group leader role during a standard shift.

A literature review was conducted using the search terms protected time, flexible staffing, professional development, and nurse champion. Five articles relevant to this topic were found. Protected time is discussed, pointing to the issue of inability to participate in research and evidence-based practice during a standard shift due to conflicting responsibilities. Nurses cite increased time spent on work outside of normal hours as barriers to participating in champion roles or projects.

The intervention occurred in a high-acuity, 34-bed medical intensive care unit at an urban academic hospital. At the start of each shift, an RN was designated as the group leader and had an accommodated lower acuity assignment or open bed. During the shift, the RN would complete quality audits, work on evidence-based practice (EBP) projects, or support the charge nurse as an assistant charge nurse (for those identified for charge nurse orientation), depending on the specific needs of the individual RN. Clinical care was prioritized when needed.

The practice change was discussed in unit practice council, staff and charge nurse meetings, huddles, and via email. The group leader assignment was rotated among all RNs completing EBP projects, unit champions, or those identified for charge nurse orientation. The standardization of the role was discussed initially during a charge nurse meeting to obtain feedback on how this role can best support unit operations. A checklist on group leader responsibilities was subsequently created and disseminated among all staff.

Employee engagement survey results were reviewed before and after the intervention—specifically the categories of growth and development and engagement index. Presurvey data demonstrated a growth and development score of 65.3% (hospital average, 74.3%), and engagement index of 65.3% (hospital average, 76.8%). Postsurvey results for were 95.7% (hospital average, 71.6%) and 84.4% (hospital average, 84.3%), respectively. An increase in the number of RN champions was also noted in the postsurvey.

The group leader role has become a unit standard every shift, every day. It is correlated with an increased interest in champion roles, working on projects, and completing charge nurse orientation, because RNs now have the time and ability to complete the tasks relevant to each role without requiring significant extra time, thus increasing satisfaction and reducing burnout.

Amber Hinton, Jenna Olson; Indiana University Health North Hospital, Carmel, Indiana

Labeling intravenous (IV) tubing is a time-consuming, labor-intensive manual process for nursing, yet is an important intervention for patient safety and prevention of central line–associated blood stream infection (CLABSI). Daily CLABSI bundle audits revealed lack of compliance with labeling IV tubing despite education and real-time feedback.

One important intervention within the CLABSI prevention bundle is maintaining current infusion tubing. National guidelines recommend discarding intermittent infusion tubing after 24 hours and continuous IV tubing at 7 days. Intravenous tubing should be labeled consistently with medication name, date and time tubing was hung, and date and time tubing is expired. Infusion tubing must be labeled at 2 sites with medication name: above the IV pump and at the point of patient access.

The trial occurred in a 12-bed mixed intensive care unit (ICU) in a suburban Midwest hospital. The 60-day trial, conducted during the third quarter of 2024, evaluated IV tubing label compliance using a label printer compared with previous methods of handwriting tubing labels. By scanning the IV infusion barcode, a label automatically prints with the infusion name, date initiated, and expiration date; 2 drug labels also are printed. The trial was split: 5 rooms had printers at point of use and 5 rooms were supported by a label printer in the medication room.

To ensure early adoption of the practice change, roving in-service sessions were completed by the unit educator, CLABSI champion, and clinical nurse specialist (CNS) before initiating the pilot. The CLABSI champion discussed the IV label printers in huddles to communicate updates and obtain feedback from staff, and the CNS rounded with nurses to obtain feedback and audit the IV tubing label compliance. Nursing feedback led to updates to the drug library, additional label options, and change of printer location.

Pre- and posttrial surveys were used to evaluate the process of labeling IV tubing. Nurses were satisfied with the label printer process, found it easy to use and time efficient, and that it improved workflow. Weekly audits showed the preimplementation label compliance averaged 75% and postimplementation label compliance is greater than 95% with printers at point of use. The CLABSI rate in the ICU in May 2024 was 9.52 per 1000 patient days and remains at 0 since implementation of the printers.

The label printer is an innovative technology that improves efficiency in labeling IV tubing and is viewed by nurses as a superior process improving proficiency in the nursing workflow. Increased IV tubing labeling compliance has improved the CLABSI rate in the ICU.

Melissa Parodi, Alexandra Navarro, Alejandro Gonzalez-Quevedo; Baptist Health South Florida, Coral Gables, Florida

Ventilator-associated events (VAEs) are associated with significantly increased morbidity and mortality rates. Our critical care unit (CCU) exceeded the National Database of Nursing Quality Indicator benchmark for VAEs, requiring targeted interventions. The aim of this project was to reduce VAEs through an interprofessional approach involving education, surveillance, and practice changes to improve patient safety and outcomes.

In the third quarter (Q3) of fiscal year 2023 (FY23), the VAE rate in our CCU was 36.14. An interprofessional team, including CCU leaders, nurses, respiratory therapists, and physicians, developed a VAE reduction plan. Using resources like UpToDate and the CINAHL database, 5 key articles on VAE strategies were identified. Implementing best practices, such as incremental positive end-expiratory pressure (PEEP) changes and frequent weaning trials, reduced VAE occurrences. Staff was educated on VAE criteria. An auditing tool was created to monitor settings in real time.

The CCU implemented real-time surveillance, staff education on ventilator management, and practice modifications, including incremental PEEP adjustments and 2-hour weaning trials. These changes were designed to reduce VAEs and improve patient outcomes through enhanced collaboration and documentation.

Staff were educated on VAE components and management, and a VAE tracker tool was introduced to monitor ventilator settings. Real-time surveillance during rounds ensured adherence to best practices. Communication between disciplines was enhanced, with daily discussions on ventilator settings and patient progress.

VAEs decreased from 3 in Q3 FY23 to 1 in Q4 FY23, achieving a 77.4% reduction. Pre- and postimplementation metrics were tracked using a VAE tracker tool and showed reduced ventilator-days, shorter lengths of stay, lower morbidity, and improved patient outcomes. The data validated the effectiveness of these interventions in mitigating VAEs.

This project highlights the importance of interprofessional collaboration, real-time monitoring, and education to reduce VAEs. The structured approach can be applied in other CCUs, improving patient outcomes, safety, and quality of care through effective ventilator management practices.

Leslie Anderson, Adrienne Oswalt, Victoria Ball, Iris Ng, Unit Practice Council; Kaiser Permanente Vacaville Medical Center, Vacaville, California

Self-contained within hospital walls, an intensive care unit (ICU) can be unfamiliar and intimidating. Patients and their families and nurses may have differing views on unit processes. A welcome packet was developed to enhance communication and understanding of activities in the ICU. The welcome packet details what to expect, providing an opportunity for shared decision-making and planning.

Using the ClinicalKey database, we searched for literature using the terms communication and critical care unit, and ICU and family satisfaction. A total of 2000 citations were identified, of which 4 articles were selected on best informed practice. Family satisfaction with the ICU is based on quality of communication, more so than their evaluation of care given. The practice change recommended was implementation of the welcome packet to provide knowledge about resources, empowering patients and their families and increasing communication. We created a 6-question survey based on evidence asking for yes/no answers to knowledge about the ICU.

In May 2024, before implementation of the welcome packet, patients and their families were tested on their knowledge of visitor policy, the plan of care, need for a spokesperson, Health Insurance Portability and Accountability Act (HIPAA) awareness, and time and meaning of interprofessional rounds. Pretests surveys revealed inconsistent family communication and the need for change. We created a comprehensive welcome packet, and nurses reviewed the information in a standardized, scripted format on admission and allowed the patients and their families time to ensure understanding. A posttest survey was conducted in August 2024. Patients and their families improved scores in all areas.

After identifying that there is no standardization of how ICU-specific information was disseminated, the Unit Practice Council (UPC) created a welcome packet with a focus on improving communication. The UPC educated all nurses about the packet and huddled daily for 1 month leading up to its launch. The welcome packet was reviewed by senior leadership and Public Affairs personnel and was branded with the medical center’s logo. Working with engineering, visitation guidelines were posted at the entrance to the ICU and in patient rooms.

Before the pilot, 46% of patients and their families reported understanding the overall care provided in the ICU. After the pilot, 78% reported understanding. Improvement was statistically significant at P < .05. Overall, the welcome packet increased communication among the patients, their families, and health care personnel. We learned that ensuring the plan of care and ICU processes are clearly communicated helps families make informed decisions and fosters a collaborative environment for patient care.

After implementing the welcome packet, patients and their families had a better understanding of and participation in the plan of care. Our goals now are to assess nurses’ perception of improved patient and family communication, ensure use of the welcome packet is sustained, and determine the potential to implement similar welcome packets in other hospital units.

Noor Bontz, Matthew Lemke; Aurora Sinai Medical Center, Milwaukee, Wisconsin

Health care–acquired pressure injuries (HAPIs) cause significant harm to patients across the United States, and it can cost as much as $70 000 to treat a single wound. When HAPI tracking restarted in 2021, this intensive care unit (ICU) saw a 285% increase in injury incidence, from 19 injuries in 2019 to 60 injuries in 2021.

The PubMed database was queried with the key term pressure injury prevention intensive care, with 1034 results returned. Seven articles were identified as applicable to our situation. Practice guidelines from The Joint Commission and 2 other agencies were reviewed, as was current system policy. Many guidelines had been implemented previously, such as routine use of a Braden score and associated interventions, injury huddles, and preventive creams and dressings. Newer studies considered the source of injury.

This urban ICU, serving largely medical-respiratory patients, implemented a interprofessional drill-down team who met once monthly to analyze all injuries occurring during the previous month. Wound care nurses began real-time injury discovery with a new injury tool. New skin champions communicated areas to improve to nursing staff and provided hands-on education during shifts, with shift huddle in-service sessions. Respiratory therapy leaders developed skin assessment documentation and released new device policies.

The skin initiative began with “What the Butt?” month, with a themed education board and one-to-one assessment of competency. Product representatives provided “Save Their Butts” in-service sessions at shift huddle, and daily rounding included the question “What does their butt look like?” Newly appointed skin champions performed audits and provided feedback on demand and in monthly emails. A team approach to respiratory patients encouraged both nursing and respiratory therapy staff to engage in injury prevention.

The drill-down team used pre- and postintervention data, as well as National Database of Nursing Quality Indicator (NDNQI) prevalence survey results, to evaluate the success of this program, with an initial goal of 10% reduction. Pressure injuries decreased by 43% in 2022 (n = 35), then by an additional 11% in 2023 (n = 31.) After What the Butt month, 3 consecutive NDNQI prevalence surveys reported no HAPIs, with only 3 of 10 surveys since the first quarter of 2022 seeing reportable injury. Using humor and feedback to address a dry topic prompted culture change.

Data collected during the second year allowed us to verify sustainability of the practice, along with established minimum communication requirements. Patient safety improved. The interprofessional drill-down team continues to meet monthly, and new teams have started in the medical-surgical units. Respiratory therapy skin assessment documentation has become system-wide policy.