adelaide - Joanna Briggs Institute

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A DELA I D E
Fellows Monographs 2011 - 2012
The Joanna Briggs Institute
www.joannabriggs.org
Fellow Monographs 2011/2012
~ Adelaide ~
Copyright © The Joanna Briggs Institute 2014
Compiled by the Joanna Briggs Institute
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Faculty of Health Sciences
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Title: Adelaide Fellows Monographs 2011-2012 - The Joanna Briggs Institute
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CONTENTS
Pressure ulcer prevention and management among inpatients at the Royal Hobart Hospital: a best
practice implementation project��5
Carol Baines
Pam Sykes
Fetal monitoring among high risk pregnant women at the affiliated hospital of Nantong University: a
best practice implementation project��11
Jing Cheng
Xujuan Xu
Meiyun, Shen
Feng Zhang
Lin Ye
Chenmei Wu
Fall prevention and management in an acute care setting: a best practice implementation project��20
Dr Imke Fischer
Irene Lake
Jill Parkes
Dr Maria Cynthia (Cindy) Leigh
Prevention of oral mucositis among cancer patients at a teaching hospital in China: a best practice
implementation project��35
Yanhong Gu
Risk factor modification among vascular patients with peripheral vascular disease in an acute hospital
setting: a best practice implementation project��44
Marie Haydon
Measurement, documentation and interpretation of patient observations for the early detection of
clinical deterioration in patients at a private acute hospital in Queensland: a best practice implementation project��51
Pam Hoadley
Self-management of rheumatoid arthritis: a best practice implementation project��63
Hua Shuangqi
Jiang Hong
Huang Ying
Wei Li
Bao Chengcheng
Zhou Jiayi
Improvement of occupational therapy cognitive assessment and rehabilitation among adult stroke
patients in sub-acute rehabilitation: a best practice implementation project��72
Emma Hutchinson
A best practice implementation project on peripherally inserted central catheter (PICC): dressing and
flushing among adult patients in six medical/surgical ward areas and one outpatient unit within Logan
Hospital in Brisbane, Queensland��84
Jeannette Kassulke
Christopher Cronk
Susan Legge
Dale McKenzie
Rose McSorley
Sharon Hill
Amanda Blair-Brown
A best practice implementation project to review the nursing care and clinical pathway requirements
for patients who have undergone a total laryngectomy��93
Allana King
Michelle Oaklands
Ward Q5 Associate Clinical Services Coordinator
Royal Adelaide Hospital
Cancer-related fatigue assessment by oncology nurses in outpatient chemotherapy and radiotherapy
departments: a best practice implementation project��122
David Larkin
Professor Violeta Lopez
Jill Parke
Bed bathing among adult patients in a private oncology ward within an acute care hospital: a best
Dora Lang
Peripheral intravascular access devices (PIVAD) management among registered and enrolled nurses in
a tertiary hospital setting: a best practice implementation project��138
Jill Parke
David Larkin
Tarkan Tez
Management of physical restraints in critically ill patients in a university hospital: a Best Practice
implementation project��148
Li Zheng
Xu Yan
Shi Hui-lin
Fang Jing
Nursing inter-shift handover process in mental health settings: a best practice implementation project��154
Chee Lien Poh
Rajni Parasuram
Capillary blood glucose monitoring by registered and enrolled nurses among older persons in a tertiary
hospital setting. a best practice implementation project��166
Jill Parke
David Larkin
Dr Imke Fischer
Dr Cindy Leigh
Maria Trudinger CNC
Marian van Meurs CNC
Sandra Hives CNC
Ellen Scanes and Michelle Warnock
Libby Bancroft CDE
Preoperative fasting times among emergency orthopaedic patients in an acute hospital setting: a best
Kristian Sanchez
Anita Taylor
Implementing evidence-based practice for falls prevention among residents in a dementia specific aged care facility�186
Jovy Tesani
Documentation of medication and food allergies on clinical records: a best practice project��193
Judith Vercoe
Philippa Pringle
Clinical handover among nursing staff in an acute care setting: a best practice implementation project��201
Anne Blunden
Loendi van der Westhuizen (author)
Maria Holswilder
Salma Yasmeen
Administration of BCG for cancer in situ of the bladder: a best practice implementation project��208
Caroline Whiteford
Julie Aldridge
Cassandra Haynes
Implementation of best practice in nasogastric tube feeding of critically-ill patients in a neurosurgical
intensive care unit��216
Xu Yan
Shi Weilin
Jin Yufeng
Yang Yu
Once upon a clinical leader…
Folktales have existed for centuries and often provide a roadmap, of sorts, to success.
They share whimsical, yet powerful, images, messages and lessons aimed at guiding
children to live honestly, to explore, to be adventurous and creative, to overcome adversity
and ultimately to find happiness and success.
There is usually a brave ‘hero’ (or ‘leader’) in a folktale who takes responsibility and inspires,
motivates, encourages, guides, overcomes and is brave enough to do what others cannot
or will not. These leaders can see beyond their current situation, hold a vision, express it
clearly to others, believe that it is possible and make it happen.
Of course heroes and leaders like these do not just exist in folktales. In health care they
are not always those who hold specific management or executive positions. Often they
are simply the individuals who are brave enough to ask the challenging questions, like ‘if
I did this differently, what could I achieve?’ It is these individuals who spark engagement
around shared responsibility for continuous quality improvement, be it across an entire
facility or in relation to a single patient or client.
Generating solutions based on ‘possibilities’ and how things could be done differently is no
easy task, and it relies on not only knowledge but also the ability and personality to inspire
others to work together.
The Joanna Briggs Institute Evidence Based Clinical Fellowship program is aimed
at celebrating the skills of these individuals and facilitating their further growth and
development. They are indeed heroes within their contexts who strive to improve care
provision and health outcomes for patients. Every report in this monograph series is a
testimony to their bravery, creativity and determination to make a difference, whatever part
of the world they are from.
These individuals and their achievements are not the stuff of fairy tales or folklore. While
others may dream of the possibilities, these clinical leaders take it upon themselves to
make change a reality.
Professor Alan Pearson AM
Executive Director
JBI Fellows Monographs 2011-2012 - Carol Baines
5
Pressure ulcer prevention and management
among inpatients at the Royal Hobart Hospital: a
best practice implementation project
Carol Baines
Clinical Nurse
Department of Diving and Hyperbaric Medicine
Royal Hobart Hospital
Tasmania
Pam Sykes
Clinical Nurse Educator (Quality and Risk)
Practice Development Unit
Tasmania
Abstract
Pressure ulcer prediction and management is an area of nursing practice and patient suffering that has been much
studied and written about. The Royal Hobart Hospital is a 550 bed tertiary referral centre that facilitates treatment
of more than 20,000 patients per annum. It has a well established, comprehensive pressure ulcer management
policy and endorses the use of a validated skin assessment tool, Braden. The aim of this audit is to identify if the
strategies that are in place are effective in protecting patients who have been admitted to the hospital and their
compromised skin.
A documentation audit was performed on 100 patients’ medical notes in January and July 2011; this data was
then entered into the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES) online
audit system. Five criteria were addressed concerning skin assessment, documentation, reporting and support
surface provision.
The January audit demonstrated clearly that nurses may be assessing their patients using the Braden assessment
tool but that they were not routinely documenting this action. A re-audit six months later demonstrated improvement
in several key areas.
The Royal Hobart Hospital was quick to ascertain the reasons for non-compliance and provided processes
to facilitate nurses’ re-engagement with the policy. This document discusses these strategies and provides
recommendations for further Best Practice initiatives.
Keywords: pressure ulcer, pressure ulcer management, skin assessment, audit
Background
The Royal Hobart Hospital (RHH) is a 550 bed public, teaching hospital. It serves as Tasmania’s tertiary referral
centre and is physically located across two separate sites. The inpatient diagnosis is eclectic as would be
reasonably expected for an institution that serves 200,000 people and comprises both a cradle to grave age range
and physical status.
This best practice project was designed to review The Royal Hobart’s current situation in relation to inpatient
pressure ulcer prevention and management. A pressure ulcer has been defined as:
‘An area of localised damage to the skin and underlying tissue caused by pressure, shear, friction and/or a
combination of these’.1
Pressure ulcer prediction, prevention and management are widely studied topics and have received much attention
in peer reviewed journals for decades. The significant challenges of all aspects of assessment and management
have been acknowledged and many documented attempts have been made to improve the situation. Multiple
assessment tools have been developed, critiqued and adopted by a number of clinicians which is clearly illustrated
by the interest and the vast amounts of literature produced on the subject matter.
6
However, as noted by the Australian Wound Management Association (AWMA) in their 2001 Clinical Practice
Guidelines 2
‘despite a general consensus that pressure ulcers are preventable adverse events, they continue to remain a
problem in all health care settings and extract a considerable fiscal and social cost’.
As an aspect of the Royal Hobart’s Hospitals’ ACHS responsibility clinical audit of inpatient pressure ulcer
prevention and management has been undertaken on several occasions in the last decade. The prevalence of
pressure ulcers has dropped from 24.5% in 2004 to 18% in 2008.3 The more recent audit provided a focus for
information dissemination across the key stakeholders and allowed the data gained from this repeated process
to result in some valuable changes to clinical practice. A significant amount of funds were invested in support
services for all inpatient beds, a group of key clinicians established a focus group to be actively involved with end
point education, and a comprehensive inpatient information booklet was developed.
The hospital has a strict protocol for the prevention and management of pressure ulcers (COC-54)4. This states that
the RHH nursing risk assessment tool which incorporates the Braden Score5 should be used to assess all patients’
skin integrity on admission with repeated skin assessment determined by their clinical condition.
Since 2008 the key investigator observed a change in momentum and commitment with compliance in the
management of pressure ulcer prevention. This best practice project is designed to explore if the strategies
instituted in 2008 are still effective and providing quality research-based patient care.
Methods:
Ethics approval was not sought for this project as it was deemed not to be required by the key investigator or
Safety and Quality Practice Director of RHH. All aspects of patient privacy were considered and data will continue
to be treated confidentially and de-identified.
The Royal Hobart Hospital has a pre-established network of registered nurses (RN) self titled ‘The Braden
Champions’ and it was perceived they would be key in the gathering of raw data. The Braden Champions are a
professional group with a portfolio responsibility for clinical pressure ulcer management or a keen interest in this
specialist area. The nurses have met for topic specific education on several occasions and their network would be
able to embrace this planned audit as part of their on-going professional best practice responsibility.
As the Braden Champions are a hospital-wide network, they were asked to audit their own clinical area. This
approach has worked well on previous occasions and received support from the ward managers; however, this
support was reduced on this particular occasion. Although the Champions were keen, the ward managers seemed
less enthusiastic and consequently the hospital-wide audit of 100 patients was conducted by the key investigator
and a co-investigator.
A total of 100 patients with an inpatient stay greater than 48 hours were randomly selected from a general bed
list generated by the RHH discharge clinical coding team. A sample size of 100 was chosen as a valid numerator
representative of the hospital population size.
The aim of adopting this random process was to reflect current inpatient acuity throughout the hospital and
minimise selection bias. This raw data could be gained from the patients’ notes which are available electronically.
The Maternity, Paediatrics and the Emergency Departments were not requested; these are high turnover areas and
could be argued to be considered outside of the current RHH policy.
The data was then entered by the investigator in to JBI-PACES6, the Joanna Briggs Institute’s evidence evaluation/
audit computer program.
Several criteria were selected by the key investigator for this best practice audit:
1.A pressure ulcer that is classified as partial thickness skin loss involving epidermis and or dermis (stage 2) or
above is documented as a critical incident.
2. An initial risk assessment with a valid tool is performed and documented on admission
3. Individuals have a documented repositioning regime
4. Patients are encouraged to actively mobilise and change their position
5.Patients with stage 1 or 2 ulcer have either high specification foam mattress or cushions with pressure reducing
capabilities
The criteria for this audit was taken from the JBI selection of best practice criteria as provided to professionals
through application to JBI. These criteria are a demonstration of best practice evidence utilisation and approved
by JBI for audit use.
A comprehensive report is generated by JBI-PACES which visually demonstrates the entered data. The January
2011 cycle highlighted areas within current practice that should be reviewed as a priority to facilitate improved
7
patient care. The investigator then used the Getting Research in to Practice (GRIP), JBI’s online action planning
facility, to create an action plan. This plan included several important points:
• K
ey investigator and Braden Champions to review report via email network and meet seven days later to
discuss.
• G
roup discussion and brainstorming sessions over afternoon tea – ‘Braden break’. Key investigator to inform
all stakeholders of audit results and proposed plan.
• P
lan to include ward based education of colleagues, pink sticker day (RHH preferred method of inpatient skin
assessment documentation) to highlight practices available to RN’s and other professional disciplines.
• Review of clinical practice guidelines by key investigator.
• Move, move, move campaign in conjunction with allied health colleagues.
• Meeting with Executive Director of Nursing to garner her support and keep an open line of dialogue.
This first phase of the audit conducted in January 2011 demonstrated several points for consideration by the key
investigator which consequently influenced the flow and the follow-up audit in July. It is apparent that criteria 2:
‘An initial risk assessment with a valid tool is performed and documented on admission’, is a pivotal criterion
which must be met in order for criteria 3 and 4 to be meaningful. If patients have not been assessed for their risk
of pressure ulcer then further prevention assessment such as the patients need for a formal instruction on how to
move in the bed and chair or a document detailing patients turning schedule will not be evident. Once this became
apparent to the key and co-investigator it was deemed appropriate to adapt the sample size for criteria 3 and 4.
Consequently 100 patients were assessed for criteria 2 and the amount of patients that had been assessed for
their risk of developing a pressure related injury became the sample for criterion 3 and 4.
Criteria used for audit:
Criterion 2: An initial risk assessment with a valid tool is performed and documented on admission
Criterion 3: Individuals have a documented repositioning regime
Criterion 4: Patients are encouraged to actively mobilise and change their position
A further consideration was also made of the sample size for criterion 1 and 5:
Criterion 1: A pressure ulcer that is classified as partial thickness skin loss involving epidermis and or dermis (stage
2) or above is documented as a critical incident.
Criterion 5: Patients with stage 1 or 2 ulcer have either high specification foam mattress or cushions with pressure
reducing capabilities
It was virtually impossible to consider that if patients did not meet criteria 2 and had not actually been assessed
using the Braden scale for their risk of developing a pressure related injury then they would not be identified as
having a stage able pressure ulcer nor would they have a high specification foam mattress in place. Consequently
the sample size for this group is not 100 but only those identified in the patients’ notes with a pressure injury.
Having accepted these changes in sample size, the project team presented the January audit data to the RHH
Executive Director of Nursing (EDON) as noted in GRIP. The realisation that only 22 patients out of the 100
audited had been assessed for their risk of pressure damage (criterion 2) galvanised managerial support and very
quickly a hospital-wide meeting was convened by the EDON. This was attended by all Nurse Unit Managers and
other significant stakeholders. The outcome of this meeting was a hospital-wide audit to be conducted by ward
staff using the JBI-PACES system. The audit was designed to give the wards ownership of the issue and some
engagement with the JBI system. Each ward was to audit 10 patients using criterion 2 for three consecutive weeks.
The next phase of this process is a replication of previous paperless audit with the aim of the same sample size to
provide comparative data. This was undertaken in July 2011.
8
Results
Criteria legend
1. A pressure ulcer stage 1 or above is documented as a critical incident (1 of 1 samples taken)
2.An initial risk assessment with a validated tool is performed and documented on admission. (100 of 100
samples taken)
3. Individuals have a documented repositioning regime (3 of 3 samples taken)
4. Patients are encouraged to actively mobilise and change their position. (3 of 3 samples taken)
5.Patients with grade 1/2 pressure ulcer have either high specification foam mattresses or cushions with pressure
reducing capabilities. (1 of 1 samples taken)
Figure 1
The above graph demonstrates two cycles of audit. The five criteria as listed above were used to assess 100
patients discharged from the RHH with a stay greater than 48 hours on two separate occasions: January 2011 and
July 2011.
The follow-up audit in July 2011 illustrated some exceptions to the hospital’s policy. An inpatient had a stage 2
pressure ulcer reported via the RHH electronic monitoring system but this was not documented in their medical
notes.
None of the ‘at risk’ patients (as identified by Braden scale) had received the ‘Move-Move-Move’ leaflet nor was
there a documented re-positioning regime.
It is also apparent that criterion 5, which addresses the issue of specialist mattresses, may require clarification,
for example, all inpatient beds at the RHH have specialist high-density foam mattresses. These were instituted
at a great cost hospital-wide following the 2008 audit. Therefore when the audit criterion is raised there is 100%
compliance; however, it is possible that the intent of the question is to establish if patients with existing pressure
ulcers are nursed on highly sophisticated low air loose or alternate cell mattresses or an additional support surface
rather than specialist foam.
9
Discussion
This JBI supported best practice project can be interpreted as a success and considered as the start of a
comprehensive review of both clinical practice and data collection at the Royal Hobart Hospital. The subject
matter is a much discussed nurse sensitive clinical indicator but its value is maligned by nurse complacency.
Nurses know and understand why it is essential that patients are assessed for their risk of developing pressure
injuries while they are inpatients. This is demonstrated by the amount of attention the subject is given in nursing
literature and the enormous finances absorbed by specialist equipment such as mattresses.
This audit conducted in January 2011 clearly demonstrated that RNs at the RHH were not routinely assessing and
documenting their assessment of patients’ risk of skin breakdown or their risk of developing pressure injury in the
first 24 hours of an inpatient admission. Only 22 of 100 patients had a documented assessment. Of the 22 patients
six had breaks in their skin which had not been reported on the RHH electronic incident monitoring system.
Following a comprehensive intervention focusing on encouraging clinical nurses to take ownership for their own
area and leading the way in demonstrating that this issue is a nurse sensitive indicator, the statistics have improved
by 100% in the July 2011 audit. The nominated RNs have had the opportunity to use the JBI-PACES system
(organisational audit) to perform a weekly audit on 10 of their own patients.
They have been asked to audit only one criterion:
‘An initial risk assessment with a valid tool is performed and documented on admission’.
This has facilitated several things. Firstly the general rate of skin assessment and documentation has doubled
(100% increase) from 22/100 to 44/100 over six months; secondly, pressure ulcer prevention is back on everyone’s
agenda. The EDON has articulated her aim for 100% compliance with the hospital policy. This will ensure 100% of
inpatients at the Royal Hobart Hospital will be assessed for their risk of developing a pressure injury and have that
assessment documented within 24 hours of admission.
Regular audit is often of great value to patient care; it can highlight areas of practice that may have slipped off the
nurses’ priority agenda. Gardiner et al7 present evidence of this following their trial of best practice implementation
in maintaining skin integrity, although all of the strategies they describe are already available to nurses at the Royal
Hobart Hospital. Nurses may well be attributing each patient in their care a pressure risk assessment score but
they are not routinely documenting that score. Essentially skin integrity has lost its daily profile and momentum.
When nurses are questioned why this is their habit they explain that, as experienced practitioners, they can easily
predict which patients are at risk – that essentially they do not need a tool. This intuition is not supported by
literature. Pancorbo-Hidalgo et al8 consider prediction tools such as the Braden are better than nurses’ clinical
judgement. Best practice management for inpatients in a hospital setting advocates that each patient should be
assessed daily using a validated tool such as the Braden; this audit has highlighted to the nursing fraternity at the
Royal Hobart Hospital that slackness in documentation does not reflect that they are caring for their patients using
evidence-based practice.
It is anticipated by the key investigator that the current organisational audit will gain momentum as nurses become
familiar with the JBI-PACES system. Enjoyment of success by achieving 100% in regular audits will encourage
pressure ulcer assessment to be a daily priority. Once this is achieved it is logical to consider that management of
patients with pressure ulcers will be enhanced. The old adage, ‘prevention is better than cure’, could not be more
appropriate than in the case of pressure injury.
Recommendations for practice:
• Support a small group of interested and dynamic advocates for the specialist area. The Braden Champions are
on the clinical floor daily reminding their colleagues why skin assessment is important to their practice. They
support and encourage a team collegiate approach to management and changes.
• B
reak down ‘Best Practice’ into small achievable goals – people want to do the right thing; they just need help
to turn recommendations into practice.
• M
aintain momentum; we are all busy and things are quickly forgotten. Morning teas, posters, raffles, guest
speakers, etc, can quickly re-ignite a practice that has lost its profile.
• Strong clear leadership is essential.
10
Acknowledgements
Pam Sykes – Clinical Nurse Educator RHH
Professor Mary Fitzgerald – Director Nurse Education RHH
Dr Aye Aye Gyi – Clinical Fellow Facilitator, JBI
Susan Price – Director of Nursing RHH
References
1. European Pressure Ulcer Advisory Panel, European Pressure Ulcer Prevention Guidelines; 2009 (updated 2011
Jan07; cited 2011 Jan 25) http://www.epuap.org
2. Australian Wound Management Association, Clinical Practice Guidelines for the prediction and prevention of
pressure ulcers. West Leederville WA, Cambridge Publishing, 2001.
3. Royal Hobart Hospital PUPPS report 2009
4. Royal Hobart Hospital Protocol, Prevention & management of pressure ulcers; 2009,COC-54.
5. Braden B, Bergstrom N. Predictive validity of the Braden scale for pressure sore risk in a nursing home population.
Research in Nursing and Health 1994; 17, 459-470.
6. Joanna Briggs Institute;(updated July 25 2011; cited 2011July)http://www.joannabriggs,edu.au
7.Gardiner L, Lampshire S, Biggins A, McMurray A, Noake N, van Zyl M, Vickery J, Woodage T, Lodge J, Edgar M.
Evidence-based best practice in maintaining skin integrity. Wound Practice and Research 2008; 16(2):5-15.
8. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, Alvarez-Nieto C. Risk assessment scales for
pressure ulcer prevention: a systematic review. Journal of Advanced Nursing 2006; 54(1):94-110.
JBI Fellows Monographs 2011-2012 Jing Cheng
11
Fetal monitoring among high risk pregnant
women at the affiliated hospital of Nantong
University: a best practice implementation project
Jing Cheng
Feng Zhang
Nursing teacher
Nantong University, Peoples’s Republic of China
Nursing Teacher
Xujuan Xu
Lin Ye
Director of Nursing Department
Doctor of Obstetrical Clinic
Meiyun, Shen
Chenmei Wu
Nursing Director of Obstetrical Department
Nursing of Obstetrics Department
Abstract
Background:
High risk pregnant women were increasingly being detected along with technical development. These high risk
conditions may lead to poor outcomes for their babies. Thus more rigorous monitoring and screening of fetal wellbeing is required.
Aims/objectives:
To improve the practice in fetal monitoring among pregnant women according to the best-available evidence.
Methods:
An audit project was conducted in the Obstetrics Department of the affiliated hospital of Nantong University. Staff
training sessions, pregnancy education lectures and materials, and fetal monitoring flowcharts were implemented.
Five criteria were used in the clinical audit based on JBI evidence summary and recommended practice. The
project consisted of a baseline and follow-up audit using the Joanna Briggs Institute Practical Application of
Clinical Evidence System (JBI-PACES) and Getting Research into Practice programs (GRIP).
Results:
A big improvement in compliance was found and ranged from 12 to 40% in staff interpretation of cardiotocographic
(CTG) results, pregnancy education, ultrasound application and diabetes monitoring comparing two audit phases.
CTG tests were successfully performed in cases where fetal movements were decreased during the two audit
cycles.
Conclusion:
The implementation of audit project largely improved clinical practice of fetal monitoring in high risk pregnant
women. Ongoing implementation of evidence-based practice will continue to take place in the hospital.
Key words: fetal monitoring, high risk, pregnancy
12
Background
The goal for care during pregnancy is a healthy baby and a satisfied mother. In most documents, ‘high-risk
pregnancy status’ includes maternal conditions associated with increased perinatal mortality and morbidity such
as diabetes, hypertensive disorders (chronic hypertension and pre-eclampsia), thrombophilias (congenital and
acquired), cardiac, renal and autoimmune disorders. Some conditions during pregnancy such as fetal growth
restriction, antepartum haemorrhage, multiple pregnancy and prolonged pregnancy also tend to be regarded as
‘high risk’.1
High risk pregnant women were increasing being detected along with technical development. These high risk
conditions may lead to poor outcomes for the babies. Thus more rigorous monitoring and screening of fetal wellbeing is required.
There are many methods of fetal monitoring during pregnancy, such as fetal movement counting, auscultation
with the fetal stethoscope, cardiotocography, ultrasound examination, fetal echocardiography and so on. The
most common ways for the assessment of fetal well-being in high-risk pregnancies are fetal cardiotocography and
Doppler ultrasound.
Fetal movement counting is a method by which a mother counts the movements she feels to evaluate her baby’s
condition. It is a simple method which can be used by the mother without any equipment, whether at home or
in the workplace. Most women start feeling their baby moving at about 16 to 20 weeks. Fetal movements are
maximal between 28 and 34 weeks and they usually decrease in late pregnancy2. It can vary from four to 100
movements per hour in a healthy fetus. Fetal movement counting is recommended for women with high-risk
pregnancies where fetal well-being is a concern.3 If the woman does not feel her baby moving for one or more
days, this is usuallyan indication that fetal well-being is compromised. Decreased fetal movements may be due to
decreased amniotic fluid, drugs, sedatives, sleep state in the fetus and fetal compromise.4 Evidence suggests that
in high risk pregnancies, fetal movement counting may be of some benefit, even though it has not been shown to
decrease perinatal mortality, and increase interventions such as cardiotocography.3
CTG is a continuous electronic record of the fetal heart rate obtained via an ultrasound transducer placed on the
mother’s abdomen.5 It usually lasts for 30 minutes and is performed in the third trimester of pregnancy. It is being
used widely in high-risk pregnancies to assess the fetal condition. During the fetal heart rate monitoring, baseline
rates, baseline variability, accelerations, decelerations and uterine activity are recorded simultaneously on paper.
When the fetus is hypoxic, baseline variability and accelerations may decrease or disappear while decelerations
may occur.6 Evidence suggests that for women presented with decreased fetal movements, performing a nonstress test/cardiotocography and an ultrasound scan to check fetal activity, amniotic fluid volumes and fetal
growth provide the best outcome.7
Sometimes the CTG may show a false negative, which can result in an inappropriate interpretation and subsequent
false assessment of fetal well-being for the mother and clinicians. Evidence highlights the potential for differences
in interpretation of fetal heart rates by practitioners, either with continuous CTG or intermittent auscultation. Staff
undertaking fetal heart rate monitoring should be appropriately trained and have their skills updated regularly.8
Ultrasound examination plays an important role in a variety of specific conditions during pregnancy, such as with
clinical complications, high risk of fetal malformation, or where there are concerns regarding fetal growth. Routine
screening examinations may be planned for early pregnancy, late gestation, or both. Routine early pregnancy
ultrasonography has been shown to detect multiple pregnancy earlier, and to reduce induction of labour for postterm pregnancy, both of which could be clinically useful if resources allow.9
Pregnant women with diabetes are at increased risk of having a baby with macrosomia, which is a risk factor
for shoulder dystocia, brachial plexus injury, asphyxia or prolonged labour, operative delivery and postpartum
haemorrhage. The clinical guideline for diabetes in pregnancy suggests that they should be offered ultrasound
monitoring of fetal growth and amniotic fluid volume every four weeks from 28 to 36 weeks.10
This project was implemented in the Obstetrics Department of the affiliated hospital of Nantong University. It is
one of the largest hospitals in Jiangsu Province and the east of China. Approximately 90 pregnant women undergo
antenatal examinations in the clinic everyday and more than 200 babies are born in the hospital every month, of
which there are about 20% of pregnant women with high risk conditions.
13
Audit question
Is fetal monitoring among high risk pregnant women at the affiliated hospital of Nantong University done in
accordance with evidence-based recommendations?
Aims
• To improve nursing practice in cardiotocography examinations.
• To teach pregnant women knowledge on fetal monitoring.
• To improve compliance of regular fetal monitoring.
• To decrease poor outcomes of infants and labour.
• To establish the fetal monitoring protocol for high risk pregnant women.
Methods
Settings
There are 35 registered nurses in the Obstetrics Department who shift between the ward and clinic. The risk
conditions of pregnant women such as multiple pregnancy, older pregnancy, diabetes, hypertension, amenia,
placenta previa, breech position, abnormal pregnant history (caesarean section and multiple abortions) are
presented generally.
Audit criteria
The audit criteria were developed by JBI based on evidence based recommended practices and record in JBIPACES. The audit includes the following five criteria.
1.All staff undertaking fetal heart rate monitoring and its interpretation should be appropriately trained and have
their skills updated regularly.
A short survey was conducted to all relevant staff at the Obstetrics Department.
2.All women with high risk pregnancies have received information on fetal monitoring.
The tailored information regarding fetal monitoring was provided to the high risk pregnant women.
3.Fetal heart rates were monitored by cardiotocography (CTG) in cases where fetal movements were
decreased.
A CTG result was documented in the case reports of the women with deceased fetal heart rate.
4.Further monitoring techniques, such fetal and umbilical ultrasound, were taken in cases where the fetal heart
rate was not within normal limits.
An ultrasound result was documented in the case reports of the women with deceased fetal heart rate.
5.Pregnant women with diabetes should be offered ultrasound monitoring of fetal growth and amniotic fluid
volume every four weeks from 28 to 36 weeks.
At least two ultrasound tests were ordered and recorded on the case reports of the pregnant women with
diabetes.
Data collection of nurses was performed by the nurse manager, while data of pregnant women was collected by
the nursing teacher. Compliance with each criterion was recorded in a spreadsheet.
Phase 1
Team establishment:
A team was formed comprising the Director of the Nursing Department, the doctor incharge of antenatal
examinations, the nurse manager, two registered nurses and two nursing teachers. A team was formed as follows:
• The director of the Nursing Department and nurse manager coordinated the audit project.
• A doctor and two registered nurses took charge of pregnancy education.
• A doctor and one nursing teacher prepared and conducted staff training.
• A nursing teacher collected data.
A baseline audit was conducted to identify practices in the assessment of fetal monitoring among high risk
pregnant women from 18 July to 20 August in the Obstetrics Department.
14
A questionnaire survey consisting of five questions was conducted among 35 nurses in the Obstetrics Department,
including the method of fetal heart rate monitoring and interpretation of CTG results.
An interview about fetal monitoring was conducted to 53 pregnant women in the clinic. Questionnaires were
handed out and the antenatal examination records were reviewed during the interview. The questionnaire consisted
of nine simple questions regarding the method of fetal movement counting, normal and abnormal conditions of
fetal movement, and compliance of regular examination.
When fetal movements felt by the mother numbered less than 10 in 12 hours, it is a clue to decreased fetal
movement.
The WHO criteria of 2 hour 75g OGTT were used in our clinic. (Table1)
Table 1: World Health Organization criteria for the 75g OGTT
Whole blood venous
Whole blood capillary
Plasma venous
Plasma capillary
fasting
≥6.1mmol/litre
≥6.1mmol/litre
≥7.0mmol/litre
≥7.0mmol/litre
2 hours
≥6.7mmol/litre
≥7.8mmol/litre
≥7.8mmol/litre
≥8.9mmol/litre
JBI-PACES was used as an audit tool to record the data.
Phase 2
Team meetings were held after baseline information collection. Potential barriers of the project were discussed by
all team members. This phase was the implementation of Best Practice from 26 September to 4 December.
All the barriers and strategies for GRIP are as follows:
1. Lack of awareness and knowledge among staff.
(1) The nurses were given a 30 minute presentation about the method and interpretation of CTG via a demonstration
of the CTG machine and practice sessions after the lecture.
(2) Handing out a simple manual about CTG to the nurses involved.
2. Lack of the pregnancy education materials.
(1) The doctor in charge of antenatal examinations provided information about fetal movement counting to the
pregnant women when they came in for examinations at about their 20th gestation week.
(2) Pamphlets were handed out to the pregnant women, including a simple introduction of high risk pregnancy
and fetal monitoring methods.
(3) Pregnancy education programs were offered weekly in the clinic. Two registered nurses ran the lectures to
inform pregnant women fetal monitoring techniques and demonstrated fetal movement counting methods.
3. Low compliance of regular fetal monitoring for pregnant women.
(1) The purpose and schedule of antenatal examination was imparted to pregnant women through tailored
pamphlets and educational programs.
(2) Supervision of pregnant women who were doing regular fetal monitoring at home via weekly phone interviews.
(3) Reminders to the pregnant women coming to the hospital a day before the monitoring was due to be taken.
4. Low compliance of scheduled ultrasound monitoring for pregnant women with diabetes.
(1) The purpose of ultrasound examinations was imparted to pregnant women with diabetes via an educational
presentation and interviews by the doctor.
(2) Recommended ultrasound monitoring of fetal growth and amniotic fluid volume at their 30th week and 36th
week pregnant women with diabetes. If there are signs of fetal compromise, extra ultrasound monitoring should
be performed during 28 to 36 weeks.
(3) Ultrasonic application was given to the pregnant women ahead of schedule.
Phase 3
A post implementation audit was conducted in the same manner as the baseline audit to identify improvements in
practice. The data was collected by the members of project.
15
Results
Pregnant women information
The numbers of pregnant women in the baseline and follow-up audits were 53 and 45 respectively. The risk
conditions of the pregnant women during the two audits include multiple pregnancy, older pregnancy, overweight
pregnancy, diabetes, hypertension, anemia, thrombocytopenia, cardiac disorder, placenta previa, uterine myoma,
breech position, abnormal pregnant history such as caesarean section, fetal death or neonatal death, still birth and
multiple abortions. There were 22 pregnant women between 20th to 28th gestation weeks and 31 pregnant women
over 28th gestation weeks for the baseline audit. There were 18 pregnant women between 20th to 28th gestation
weeks and 37 pregnant women over 28th gestation weeks for the follow-up audit.
Baseline audit
Criteria legend
1. Staff undertaking fetal heart rate monitoring and its interpretation have received up to date training in this area.
(35 of 35 samples taken)
2. Women with high risk pregnancy have received information on fetal monitoring. (53 of 53 samples taken)
3. Fetal heart rate was monitored by cardiotocography (CTG) in cases where fetal movements were decreased. (1
of 1 sample taken)
4. Further monitoring techniques, such as fetal and umbilical ultrasound was undertaken in cases where the fetal
heart rate was not within normal limits. (10 of 10 samples taken)
5. Pregnant women with diabetes were offered ultrasound monitoring of fetal growth and amniotic fluid volume
every 4 weeks from 28 to 36 weeks. (5 of 5 samples taken)
Follow-up audit
Criteria legend
1. Staff undertaking fetal heart rate monitoring and its interpretation have received up to date training in this area.
(35 of 35 samples taken)
2. Women with high risk pregnancy have received information on fetal monitoring. (45 of 45 samples taken)
3. Fetal heart rate was monitored by cardiotocography (CTG) in cases where fetal movements were decreased. (6
of 6 samples taken)
16
4. Further monitoring techniques, such as fetal and umbilical ultrasound was undertaken in cases where the fetal
heart rate was not within normal limits. (4 of 4 samples taken)
5. Pregnant women with diabetes were offered ultrasound monitoring of fetal growth and amniotic fluid volume
every 4 weeks from 28 to 36 weeks. (5 of 5 samples taken)
Criteria 1
All staff undertaking fetal heart rate monitoring and its interpretation should be appropriately trained and have skills
updated regularly.
The staff compliance for this criteria both at the baseline and at the follow-up audits was high, with staff achieving
82% and 94% consecutively. Due to the high compliance rate of completion for this criteria during the baseline
audit, minimal follow-up education was given. The educational session concentrated on the interpretation of CTG.
There was a 12% positive change.
Criteria 2
All women with high risk pregnancy have received information on fetal monitoring.
During the baseline audit this was achieved 63% of the period. The interventions were aimed at pregnant women
who knew the method of fetal movement counting and did it regularly. The follow-up audit showed thisoccurred
82% of the period. There was a 19% positive change.
Criteria 3
Fetal heart rate was monitored by cardiotocography (CTG) in cases where fetal movements were decreased.
The compliance for this criterion both at the baseline and at follow-up audits was 100%. This was assessed by
reviewing the antenatal examination records. During the baseline audit, only one pregnant woman was detected
with this condition.
Criteria 4
Further monitoring technique, such fetal and umbilical ultrasound was taken in cases where the fetal heart rate
was not within normal limits.
During the baseline audit this was being achieved only 60% of the period. This was assessed by reviewing the
antenatal examination records. Due to the high expense of ultrasound examinations or the lack of understanding
of the purpose of ultrasound examinations, pregnant women may refuse the further examination. The doctor would
then suggest to them to take a CTG examination again to check their fetal condition. The education focused on
the purpose of ultrasound examination and outcome of abnormal CTG. The follow-up audit showed this was now
occurring at 100%. There was a 40% positive change.
Criteria 5
Pregnant women with diabetes should be offered ultrasound monitoring of fetal growth and amniotic fluid volume
every 4 weeks from 28 to 36 weeks.
For the baseline audit there was 0% compliance for this criteria. The interventions were aimed at the women with
diabetes who did regular ultrasound monitoring. The follow-up audit showed this was now occurring 40% of the
period. There was a 40% positive change.
Discussion
This was the first time a clinical audit was conducted at Obstetrics Department in the affiliated hospital of Nantong
university. Despite significant time constraints, it was very encouraging to note in the audit significant improvements
in clinical practice in all criteria.
1. Staff training (criteria 1)
Cardiotocography is a normal examination conducted in the Obstetrics Department, especially for high risk
pregnancy. Hence registered nurses undertaking fetal heart rate monitoring should be appropriately trained. During
the second audit cycle, all staff received sufficient and updated knowledge of CTG at education sessions, and the
tailored pamphlets helped the pregnant women to interpret pregnant the results of the CTG. After staff training,
most of nurses (29/35) could monitor fetal heart rates and interpret the results correctly.
17
2. Pregnant education (criteria 2, 3, 4)
During the project, more pregnant women acquired information on fetal monitoring through the pregnancy
education program weekly and tailored pamphlets. Most of them paid more attention to fetal movement counting
and did this regularly at home by referring to the checklist in the pamphlet. During the baseline audit, 11 pregnant
women focused on fetal movement counting and only one woman felt decreased fetal movement, whereas during
the follow-up audit, 26 pregnant women counted their babies’ movements regularly and six women felt abnormal
fetal movements. Due to improvements in the regular fetal monitoring, fetal comprise could be detected and
intervened earlier.
Approximately 90 pregnant women undergo the antenatal examination in the clinic everyday, with only one doctor
and two nurses on shift. More doctors and nurses are required to fill the increased workload and more rigorous
pregnant screening. It is suggested that at least two doctors and four nurses in clinic are available to examine
and educate the pregnant women everyday. Although the compliance at the baseline audit was 100%, there were
still some latent barriers for the third criteria, and strategies related to regular antenatal examination are still to be
developed.
3. Ultrasound examination for pregnancy with diabetes (criteria 5)
Diabetes in pregnancy is associated with risks to the woman and to the developing fetus. Miscarriage, preeclampsia and pre-term labours are more common in women with pre-existing diabetes. Among 462 pregnancies
in research by Casson,11 351 (76%) resulted in a liveborn infant, 78 (17%) aborted spontaneously, nine (2%)
resulted in stillbirth, and 24 (5%) were terminated. Of the terminations, nine were for congenital malformation. Of
the 273 pregnancies in research by Penney,12 40 (14.7%) ended in miscarriage, 20 (7.3%) in abortion and 213
(78%) in delivery.
In addition, diabetic retinopathy can worsen rapidly during pregnancy. Stillbirth, congenital malformations,
macrosomia, birth injury, perinatal mortality and postnatal adaptation problems (such as hypoglycaemia) are more
common in babies born to women with pre-existing diabetes.10
Due to the improved awareness of healthcare professionals, regular ultrasounds examinations conducted on
pregnant women increased. There has been acknowledgement by staff that further improvement needed to occur
and this is one of the areas that they will be focusing on. Strategies for further improvement have yet to be
developed.
Since time of the project was limited and the second audit coincided with a long term national holiday, the number
of pregnant women enrolled in the second cycle was less than the number in the initial audit cycle.
Conclusion
The implementation of this project achieved change in clinical practice of fetal monitoring in high risk pregnant
women. Continuous education programs and consumer pamphlets provided knowledge on CTG and increased
ultrasonic application in our Obstetrics Department. Ongoing implementation of evidence-based practice will
continue to take place in our department. Longer term strategies to improve compliance with Best Practice will
occur in time.
Acknowledgements
The author would like to acknowledge the following people for their assistance and support throughout this project.
Dr Yifan Xue, Research Fellow, Joanna Briggs Institute
Alexa McArthur, Research Fellow Joanna Briggs Institute
Professor Jianhua Zhu, Vice-Director, Affiliated Hospital of Nantong University as well as other members of this
project.
18
References
1. Zarko Alfirevic, Tamara Stampalija, Gillian ML Gyte. Fetal and umbilical Doppler ultrasound in high-risk
pregnancies. Cochrane Database Syst Rev. 2010:1
2. Mangesi L, Hofmeyr GJ. Fetal movement counting for assessment of fetal wellbeing. Cochrane Database Syst
Rev. 2007:1.
3. Su LL, Chong YS. Common modalities for routine antepartum foetal monitoring: are they evidence-based?
Singapore Med J 2006; 47(10):830.
4. Sellers PM. Midwifery. Vol. 2, Johannesburg & Cape Town: Juta & Co. Ltd, 1993.
5. Grivell RM, Alfirevic Z, Gyte GML, Devane D. Antenatal cardiotocography for fetal assessment. Cochrane
Database Syst Rev. 2010:1.
6. Gribbin C, Thornton J. Critical evaluation of fetal assessment methods. In: James DK, Steer PJ, Weiner CP
editor(s). High risk pregnancy management options. Elsevier, 2006.
7. Froen JF, Holm Tveit JV, Saastad E, Bordahl PE, Stray-Pedersen B, Heazell AEP, Flenady V, Fretts RC.
Management of decreased fetal movements. Semin Perinat. 2008, 32:307-311.
8. Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring
(EFM) for fetal assessment during labour. Cochrane Database Syst Rev. 2006:3.
9. Whitworth M, Bricker L, Neilson JP, Dowswell T. Ultrasound for fetal assessment in early pregnancy. Cochrane
Database Syst Rev. 2010:4.
10. National Institute for Health and Clinical Excellence. Diabetes in pregnancy: management of diabetes and its
complications from preconception to the postnatal period. London: NICE, 2008.
11. Casson IF. Outcomes of pregnancy in insulin dependent diabetic women: results of a five year population
cohort study. BMJ. 1997;315:275–8.
12. Hawthorne G. Prospective population based survey of outcome of pregnancy in diabetic women: results of the
Northern Diabetic Pregnancy Audit, 1994. BMJ. 1997;315:279–81.
19
Appendix 1: Implementation period
Barriers
Strategies
Resources
Outcomes
Lack of
awareness and
knowledge of
staff.
Conduct educational sessions and make
available materials for nurses.
• Educational
PowerPoint
• CTG machine
for demonstration
purposes
• A tailored
pamphlet on
CTG
• Increased awareness
of nurses regarding
CTG.
• Improved nurses’
skills of using CTG.
• More nurses
can interpret CTG
accurately.
Lack of the
pregnancy
education
materials.
• The doctor in charge of antenatal
examinations educated pregnant women
on fetal movement counting to the when
they came for examinations at about 20
weeks.
• Pamphlets were printed for pregnant
women, including a simple introduction
to high risk pregnancy and the fetal
monitoring methods.
• Pregnant education programs were
offered weekly in the clinic looked
after by two registered nurses. Fetal
monitoring techniques were imparted and
methods for fetal movement counting was
demonstrated to the pregnant women.
• A pamphlet
about fetal
monitoring
• Educational
PowerPoint
CTG machine to
introduce and
demonstrate
• More high risk
pregnant women are
aware of their own
condition.
• Improved skill in fetal
movement counting.
• Increased chances of
detecting decreased
fetal movement.
Low compliance
of regular fetal
monitoring for
pregnant women.
• The purpose and schedule of antenatal
examination was imparted to pregnant
women through tailored pamphlets and
educational presentations.
• Supervised pregnant women did the
regular fetal monitoring at home by phone
interviews once a week.
• Reminders topregnant women coming
to the hospital one day before the
monitoring was due to be done.
• Tailored
pamphlets
• Educational
PowerPoint
• Telephone
interview
• Improved
compliance in
scheduled antenatal
examination in high
risk pregnant women.
• Increased detection
of decreased fetal
movements.
Low compliance
of scheduled
ultrasound
monitoring for
pregnant women
with diabetes.
• The purpose of ultrasound examination
was imparted to pregnant women with
diabetes via educational presentations
and interviewing by the doctor.
• Recommendations to pregnant women
with diabetes for ultrasound monitoring of
fetal growth and amniotic fluid volume on
their 30th week and 36th week.
• Ultrasonic application was given to the
pregnant women ahead of schedule.
• Educational
PowerPoint
• Ultrasonic
application
Increased times of
scheduled ultrasound
examination in
pregnant women with
diabetes.
20
JBI Fellows Monographs 2011-2012 Imke Fischer
Fall prevention and management in an acute care
setting: a best practice implementation project
Dr Imke Fischer
Research Associate
Australian Capital Regional Centre for Evidence-based Nursing and Midwifery Practice: an Affiliated Centre of the
Joanna Briggs Institute
Irene Lake
Program Director
Jill Parkes
Project Officer
Research Associate
Abstract
Background: The project was undertaken in an acute major 500-bed hospital in Canberra ACT. The audit was
requested by hospital and health authorities to reduce the number and improve the management of falls.
Aim/objective: To ascertain whether Best Practice for falls prevention is used in the care setting.
Methods: Two wards volunteered, the Neurology and Age-care Wards. The research team undertook the pre- and
post audits of care plans within a seven-month period. Between the audits, nurses were encouraged to study the
new education package developed to update nurses in Best Practice of falls prevention management.
Results: The post audit results revealed an improvement in all categories. A higher rate of falls risk screening
(84%) was performed at the admission point, using the correct risk screening tool (89%). Fewer patients had to be
transferred between wards, only five on the Age-care Ward, resulting in a shift from 63% to 96% ‘non applicable’
rate. Once fewer patients needed transfers, the number of re-screenings was reduced.
Conclusion: In all it can be stated that the practices used for falls prevention could be improved. The primary
results indicate a lack of education for patients and their carers. The publication of a brochure to explain and
enhance prevention interventions could not only foster closer collaboration between patients, carers and staff, but
also support staff in their busy schedule. It is also suggested that the hospital explores a wider range of, and more
appropriate, interventions.
Keywords: Falls, fall management, fall prevention, prevention intervention, risk of falls
Background
The Australian Commission on Safety and Quality in Healthcare “Preventing Falls and Harm from Falls in Older
People” has stated that falls-related injury is one of the leading causes of morbidity and mortality in older
Australians. Incident rates vary between wards and departments within the hospital.2 Falls can contribute greatly
to the quality of life and ability to function for the individual. If the patient should be hurt, the injury is a significant
cost burden to the community. It has been predicted that costs associated with falls will increase threefold to an
estimated $1375 Million in 2051, and an increase of 886,000 additional bed days per year.3 To maintain the current
health costs it will be necessary to reduce the incidence of falls-related hospitalisation by 66% by the year 2051.
One of the major hospitals in a capital city in Australia and the respective health authorities reported 719 falls
between March 2010 and February 2011, a reduction from 801 falls recorded in the previous year. The records
indicated that a greater number of patients sustained an insignificant outcome, not considering the psychological
effect such an incident would have had on the person. In the last three years the nursing staff achieved a reduction
in moderate outcome falls from 2.7% in 2008 to 1.1% of total falls in 2010.
21
Whilst this is a significant achievement there is still improvement to be made as there are still over 700 falls
recorded in a 12-month period. This equates to a rate of 3.1 falls per 1,000 beds.
Aims
The aims of the project were to ensure that the nursing practices in place to prevent and manage falls in the
hospital were in accordance with hospital regulations and Best Practice guidelines:
• To conduct a pre- and post audit of falls prevention and management
• To increase staff knowledge of the intrinsic and extrinsic risk factors contributing to falls
• To reduce the incidence of hospital acquired falls
• To reduce the harm from falls
Methods:
This audit was conducted by the Research Centre for Nursing and Midwifery Practice in Canberra as a part of the
new affiliation with the Joanna Briggs Institute over a period of seven months.
The Canberra Hospital is a public, tertiary hospital with 600 beds, catering for a population of 520,000 people in
the ACT and the South Eastern region of New South Wales, Australia.
The project consisted of a pre- and post audit of staff compliance to falls prevention and management in two
wards (7B Neurology and 11A Age-care). The audits assessed the risk screening compliance for falls, using a risk
screening tool, for patients being admitted to hospital and the implementation of appropriate interventions when
a patient was deemed to be at risk.
An ethics application was submitted to the Hospital Research Committee for approval.
The project was organised in three stages:
Stage 1
A baseline audit using Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES)was
conducted in two wards (7B and 11A), applying the following criteria:
• Falls risk screening is done using a falls risk screening tool
• Falls risk screening is done on admission
• Falls risk screening is done on transfer
• Falls risk screening is done when the patient’s condition changes (within the last 24 hours)
• If “at risk”, risk prevention interventions have been implemented and documented
• Patient and family education has been conducted.
The data collection stretched over a period of six weeks, assessing the ward population every two weeks. In both
wards patients were not staying over a longer period of time, hence the Clinical Nurse Consultant of each ward
recommended the once-a-fortnight data collection schedule to involve new admissions to the wards and avoid
double entries. All patients were included, regardless of age or reason for admission, a total of 157 men and
women.
Stage 2
A project member experienced in falls prevention and management and the lead researcher together developed
a staff questionnaire to ascertain the knowledge level of the nursing staff. This questionnaire was used as the
baseline and the follow-up staff education tool.
A comprehensive educational CD was developed, including the nurses’ guidelines published by the Health
Department. To make the information more attractive, the CD was produced with voice over.
The roll-out occurred after the patient baseline data audit had been completed. The nursing staff could access the
education CD on their work computers at any time, at their convenience. The education phase was four weeks
long. The feedback indicated that 26 staff of 34 or 76% from the Neurological Ward had viewed the CD, while 34
of the 39 staff members of the Age-care Ward, or 87% had looked at the educational tool.
All staff were very extremely helpful with both the audit, and the staff assessment and training.
22
Stage 3
Once the education phase had been completed, no further intervention took place.
After approximately another two months, the (post) follow-up fall prevention and management audit occurred.
Results
Baseline audit:
The first audit included 157 care plans while the post-audit involved 124.
The pre-audit results set the basis for compliance comparison. The very first question asked whether the falls
screening was carried out, using a falls risk tool. In the Age-care Ward, 69% of all new patients were screened,
while for Neurology admittance 91% of patients were assessed, resulting in a total of 82 percent. The same result
(81%) confirmed that the screening had been performed on admission to the hospital.
For both wards the third question was less pertinent; a few patients (37%) had been transferred from another ward,
hence there was a need for an additional falls risk screening. The remaining 63% had been immediately allocated
to the ward after admission; hence the staff answered the question with ‘not applicable’, ‘no’ or left the column
blank.
Few patents’ conditions altered during the stay in the wards. Only 25%in Neurology and 13% in Age-care had
to have their interventions reassessed after their condition changed. That means that an average of 82 were not
reviewed, or the care plan indicated ‘not applicable’.
The education of patients and their families in fall prevention proofed to be one major area of investigation. In
Neurology 40 percent of patients and their families were educated, while the rate in Age-care was reduced to 13
percent, resulting in an average of 32 percent.
Once a patient had been identified ‘at risk’, the prevention intervention had to be implemented and documented.
According to the survey results, this happened in 64 percent of cases. The other 36 percent option was either
marked as ‘not applicable’, ‘no’ or the tick box was left blank.
Criteria legend
1 Fall risk assessment is done accurately using a falls assessment tool.
2 Fall risk assessment is done on admission.
3 Fall risk assessment is done upon transfer.
4 Fall risk preventative interventions are evaluated.
5 Patient and family education is carried out for patients at risk of falls.
6 Targeted interventions are implemented according to risk factors.
Figure 1: Compliance Report – pre- and post-tests (both wards)
23
The post audit:
The post test results primarily indicated an improvement in the results. Eighty-nine percent reported accurate fall
risk assessments using the falls assessment tool. This is a 5% improvement after the pre-test and education of the
nursing staff. There was little progress in when the assessment took place. Only an additional 3%, in total 84%, of
patients were assessed on admission, meaning that there were still 16% not assessed at all.
There were only very few patients (4%) re-assessed after transfer during the post test data collection. For the
majority of patients in the ward the reassessment became not applicable or the staff answered the question with
‘no’.
The percentage of falls risk screening when the patients’ conditions changed remained steady for the pre- and
post audits in the Neurology Ward (25%), in the Age-care Ward however, the patients’ conditions hardly altered
during the post audit data collection, with only 2%requiring a re-assessment. This is a reduction of 11%.
The requirement to educate patients and families had been low (32%) in the pre-test. The post audit data, in spite
of the staff education, remained low, with only 40%of patients and families instructed about safe ways to prevent
falls.
Implementing the prevention intervention is a major way to manage and reduce falls in the hospital environment.
Although the pre-audit results had indicated a 64%compliance rate, the post audit results were disappointing, only
showing an improvement of 5%. Looking at the detail, the Age-care Ward actually reduced the implementation
rate by 2%, while the Neurology Ward improved their observance to guidelines rate by 5%.
Discussion
Falls prevention and management has been an important issue for hospitals, health authorities and the federal
government for the last 15 years. Reducing the adverse effects has been the objective ever since.4 As a result,
hospitals have introduced policies, systems, processes and protocols to assist patient safety. According to a
safety culture survey conducted by the Australian Commission on Safety and Quality in Healthcare, Windows into
safety and quality in healthcare, the most important culture domains that required improvement are teamwork,
working conditions and safety climate. The safety climate is comprised of staff attitude, beliefs and behaviour,
elements that are very difficult to change.4
The prevention of falls is a challenge to each hospital and individual staff member. The high number of falls in
the Canberra hospital alerted hospital authorities and staff alike. Therefore the audit was conducted to assist the
nursing staff who are primarily responsible for the safety of the patients in their endeavour to keep the wards as
‘falls-free’ as possible.
The audit results did not come as a surprise, as working in a team requires flawless communication between
rotating nursing staff. In a number of cases,information that the patient might need support was not available
because the falls risk assessment had either not been done, or not recorded on admission. In those cases, staff
could assume the patient was not at risk and would only have asked for a risk assessment once the patient had an
incidence or a near-incidence. As the assessment is relying on the patient’s falls history, there is also no indication
how the person, particularly if it is an older patient, will respond in an unknown environment, without a family
member assisting, and under the influence of medication.
It became evident that educating patients and their families was a major communication gap. The initial 32%in the
pre-audit, which increased to 40% in the post audit, included any mode of education. There is a concern that there
was no written falls risk safety measures brochure available, hence patients and their families had to absorb the
verbal information within the short period of time at a stressful point in their life. Although the hospital stipulates
that patients and their carers ought to be involved with hospital staff in formulating an individual injury risk reducing
strategy, there was no evidence available that this practice is adhered to.1
The second major concern was the stimulated risk prevention interventions. The use of call bells, hip protectors
and ‘assist x1’ were the most frequently suggested interventions. As a large number of patients were well over
80 years of age, the use of call bells, which is a general device to be available to all patients, would be unfamiliar
to them, or they may not know at the time what to do with it. Hence there is no opportunity to communicate with
any staff member. On the other hand, staff may be very busy and may not be able to discontinue with the task
at hand which may lead to a longer waiting time for the calling patient. The third risk prevention intervention was
again relying on the availability of staff, the ‘assist x 1’. Here the patient has to wait for a staff member to help in
getting out of bed to mobilise. As perception of time varies, there is a likelihood that the patient may get impatient,
particularly if home support was always available. Impatience or impulsiveness could easily cause the patient to
attempt to leave the bed without any support. Part of general practice is also to allocate hip protectors to soften
the fall. Hip protectors may be effective if the angle of fall is such that the hip is not pressurised in vulnerable
places, the patient is not too heavy and the protectors are positioned correctly at the time of fall.
24
At no time was there evidence that staff were alerted to the importance of keeping the bedside table close to the
bed so the patient can reach easily for fluids or their glasses, or that footwear be assessed for fit, support and
non-slippery soles when the patient first enters the ward. This would be an ideal time to communicate with family
members/carers to create a risk prevention intervention plan together.
Conclusion
Although this study has been conducted only in two wards of a 14-ward hospital, it is believed that the findings are
representative of the culture and practices in the hospital. It is recommended that the safety culture in the hospital,
team work,working conditions and safety be strengthened by reconsidering practices to reduce the risk of falls
in the hospital environment. More consistent documentation about risk screening, including more appropriate
assessment tools together with meaningful education of patients and their families or carers, could improve the
workload of staff. Creating an explanatory pamphlet illustrating safety measures in words and pictures would be
helpful for families and the patient, and would assist staff in the reinforcement of guidelines. It could also provide
the basis for collaboration between hospital, patients and carers to generate a falls prevention plan requited by the
new regulations from the Australian Commission on Safety And Quality in Healthcare.4, 5
Acknowledgements
I would like to express a special thank-you to members of the Australian Capital Regional Centre for Evidencebased Nursing and Midwifery Practice for their ongoing support and inspiration. I also like to thank the JBI
facilitators for their assistance and encouragement.
References
1. ACU Government. Policy. Reducing falls and falls injury across the Health Directorate. 2011.
2.Ang E, Mordiffi SZ, Wong HB. Evaluating the use of a targeted multiple intervention strategy in reducing patient
falls in acute care hospital: a randomised controlled trial. J Advanced Nursing. 2011; 67(9) 1984-1992.
3.Australian Commission on Safety and Quality in Healthcare. Preventing falls and harm from falls in older
people, ACSQHC. 2009. http://www.safetyandquality.gov.au/wp-content/uploads/2009/01/30459-HOSPGuidebook.pdf
4.Australian Commission on Safety and Quality in Healthcare. Windows into safety and quality in healthcare,
ACSQHC. 2011
5.
Australian Commission on Safety and Quality in Healthcare.
standards, ACSQHC. September 2011.
National safety and quality health service
6.Bueno-Cavanillas A, Padilla-Ruiz F, Jimenez-Moleon JJ, Peinado-AlonsCA, Galvez-Vargas R. Risk factors
in falls among the elderly according to extrinsic and intrinsic precipitating causes. Euro J of Epidemiology.
2000;16:849-859.
7. C
oussement J, De Paepe L, Schwendimann R, Denhaerynck K, Dejaeger E, Milisen K. Interventions for
preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis. JAGS. 2008;56:2936.
8.Oliver D, Daly F, Martin FC, McMurdo ET. Risk factors and risk assessment tools for falls in hospital in-patients:
a systematic review. Age and Aging. 2004; 33(2):122-130.
9. S
chwenimann R, Buehler H, De Geest S, Milisen K. Characteristics of hospital inpatient falls across clinical
departments. Gerontology. 2007; 54:342-348.
10.Jones D, Whitaker T. Preventing falls in older people: assessments and interventions. Nursing Standard,
2011;25(52):50-55.
25
Appendices
Implementation
Demographics and site characteristics:
Barriers
Strategies
Resources
Outcome
Lack of education of
nurses
Creation of educational
package
CD
Improved knowledge
Lack of education of
patients and their carers
Explanatory pamphlet
suggested
Pamphlet / brochure
Patient pamphlet to be
developed
Limited risk assessment
tool
Include gait and
continuous assessment
Staff
Tool needs extending in
future
Limited types of risk
prevention intervention
tools
Uncluttered environment,
orientation to ward
suggested
Staff
Fewer falls
Inconsistency in
documentation
Recommendation in
report.
Staff
Better communication
with rotating staff
New regulations by the
ACSQHC
Appendix 1: Draft policy - reducing falls and injury across the Health Directorate,
Canberra Hospital 2011
Appendice 1
Policy
Reducing Falls and Falls Injury Across the Health Directorate
Policy Statement
Falls related injury is one of the leading causes of morbidity and mortality in older Australians, with more than 80%
of injury related admissions in people aged 65 years and over due to falls and falls related injuries (Kannus, Khan
& Lord, 2006).
The Health Directorate is committed to preventing falls by ensuring that the Best Practice guidelines; Guidelines
for Preventing Falls And Harm From Falls In Older People: Best Practice Guidelines For Australian Hospitals,
Community Care and Residential Care Facilities 2009 are implemented in acute and community care settings and
promoted and supported in Residential Aged Care Facilities.
In the Health Directorate, all patients/consumers, particularly older adults, will be screened for falls risks as
appropriate on entry to the service. This may include using risk screening and assessment tools to identify the level
of falls risks and the appropriate management of these risks. On the completion of the Health Directorate services,
the risks and interventions will be evaluated and patients/consumers will be referred on to the appropriate agency
as required.
Purpose
This document provides the Health Directorate with a policy for reducing falls and outcomes of falls in all patients/
consumers, particularly older people aged 65 and over or 55 years for Aboriginal and Torres Strait Islander adults.
It is based on the current Australian best practice guidelines and articulates the need for collaboration and early
26
intervention. It is acknowledged, however, that there may be falls risks present in younger adults and children due
to a medical condition, disability or other health related factors.
The purpose of this policy is to:
• E
stablish an approach to the prevention and management of falls across the Health Directorate that is in
accordance with the Australian best practice guidelines.
• Increase the awareness of all staff, both clinical and non-clinical, patients/consumers and the public of the
importance of being proactive in the prevention of falls.
• P
rovide governance which clearly outlines divisions/services and the Health Directorate staff responsibilities in
relation to the prevention and management of falls.
Scope
Who does the policy apply to?
The policy relates to services provided to the general public in the following settings:
• A
cute Care
This includes all acute and sub-acute facilities within the Canberra Hospital.
• T
he Community
This includes clinical services provided in health centres, people’s homes and other facilities. The policy also
extends to community health promotion and education activities including collaboration with organisations
providing services to the community, with an importance on older adults in the community.
• R
esidential Aged Care
Unlike other states in Australia there are no government owned Residential Aged Care Facilities (RACF) in the
ACT. Many the Health Directorate services interface with RACF, particularly in the area of clinical handover.
This policy covers those interactions, for instance in discharge planning.
Guidelines Principles
Figure 1: Using the Guidelines to prevent falls in Australia.
The following describes the principles for implementing falls prevention in Australia according to the Guidelines
for Preventing Falls And Harm From Falls In Older People: Best Practice Guidelines For Australian Hospitals,
Community Care and Residential Care Facilities 2009. Each area is responsible for developing, maintaining and
reviewing SOPs outlining how to implement these principles.
Ensure standard falls prevention strategies are in place:
1.Conduct individualised assessment:
•
Falls risk screening must be conducted and a follow up falls risk assessment should be undertaken
when falls risks are identified.
2.Implement targeted, individualised falls and injury prevention interventions:
•
A multi-factorial approach is used to control falls risk and implement prevention interventions.
3.Review and monitor:
•
Appropriate review and monitor when patient’s/consumer’s health, functional status or environment
changes.
Involve the patient/consumer and their carers:
• P
atient/consumer and carers involvement is important in the assessment and implementation of falls and
injury risk reducing strategies.
Roles & Responsibilities
27
The Health Directorate is responsible for integrating falls prevention into the organisation’s culture, to provide
management and staff with strategic direction and resources to improve the safety of patients/consumers by
reducing the risk of falls and fall related injury. Implementation of these principles is enhanced by the responsibilities
outlined below.
Each Division is responsible for operationally implementing the Health Directorate‘s falls prevention principles by:
• P
articipation in the development of a standard operating procedure (SOP) for falls and fall injury prevention.
The procedures will be consistent with the Guidelines for Preventing Falls And Harm From Falls In Older
People: Best Practice Guidelines For Australian Hospitals, Community Care and Residential Care Facilities
2009 (see above for principles in falls prevention management).
• P
roviding employees with the education and resources relevant to their scope of practice required to implement
procedures to reduce falls and related injuries.
• Providing representation on the TCH Campus Falls Prevention & Management Reference Group.
• Evaluating the effectiveness of its local operational procedures for falls prevention.
• A
llocating fall prevention activities and resources as a priority (both physical and financial).
This should also include a health promotion component, for example:
• R
aising awareness of risk factors for falls and appropriate risk reduction strategies in patients/consumers, their
carers and the community.
• W
orking collaboratively to promote concepts of healthy lifestyle, including safe environments and physical
activity programs, especially those that aim to improve balance.
The Falls Injury Prevention Service (Community based Falls Clinic) is responsible for providing multidisciplinary
risk assessment and health promotion to the ACT community, as well as education and advice to individuals, staff
of the Health Directorate and community agencies through a number of mediums, including the Falls Prevention
e-learning program for clinical and clinical support staff across the Health Directorate.
TCH Campus Falls Prevention & Management Reference Group is responsible for providing leadership,
advice and direction to all staff in the prevention and management of falls to the patients/consumers of the Health
Directorate.
Health Directorate staff are responsible for implementing, promoting, managing and evaluating falls and falls
injury prevention to patient/consumers of the Health Directorate services, in accordance with:
• Relevant ACT Health Standard Operating Procedures.
• Evidence based practice.
• G
uidelines for Preventing Falls And Harm From Falls In Older People: Best Practice Guidelines For Australian
Hospitals, Community Care and Residential Care Facilities 2009.
Evaluation
• Outcome Measures
oAll divisions implement a Standard Operating Procedure (SOP) for implementing the falls guidelines as
stated above.
oRisk assessments and interventions are documented within the clinical record and on Riskman. The
outcomes evaluated on a regular basis via TCH Campus Falls Prevention & Management Reference
Group and other relevant committees.
o
Referrals are made appropriately to the Community based Falls Clinic where a risk is identified.
o
Staff will be trained in using the guidelines as appropriate.
• Method
oEach division is responsible for reviewing the outcomes of local procedures and training tools by using
Riskman data, clinical record audits and risk assessment tool audits.
Related Legislation and Policies
Legislation
• Occupational Health and Safety Act 1991.
• Occupational Health and Safety (Safety Arrangements) Regulations 1991.
• Occupational Health and Safety (Safety Standards) Regulations 1994.
Related Policies
• ACT Health Riskman Incident Reporting Policy (CED07-032).
• ACT Health Occupational Health & Safety (OH&S) Policy (CED08-066).
• Aged Care & Rehabilitation Service (ARCS) Clinical Guidelines for Physiotherapy Falls Management (TCH10/11).
28
Standards
• ACHS EQUIP 5 Standard 1.5.4.
Definition of Terms
• A
fall: An event which results in a person coming to rest inadvertently on the ground or floor or other lower level
(World Health Organisation (WHO), 2005).
• Older Person: A person aged 65 years of age or over, or 55 years for Aboriginal and Torres Strait Islander adults.
• Interventions can be described as:
oSingle intervention: an intervention targeting one risk factor, such as a balance and strength exercise program,
medication adjustment, vision improvement, home/environmental modification, footwear adjustment or
educational program.
oMultifactorial intervention: an intervention made up of a set of interventions that are intended to address some
or all of the specific risk factors that were identified through an individual’s fall injury risk assessment. This is
ideally provided by a multidisciplinary team.
References
Australian Commission on Safety and Quality in Health Care. 2009. Preventing falls and harm from falls in older
people: Best Practice Guidelines for Australian Hospitals. Available at: http://www.safetyandquality.gov.au/
internet/safety/publishing.nsf/Content/FallsGuidelines-AustHospitals
Australian Commission on Safety and Quality in Health Care. 2009. Preventing falls and harm from falls in older
people: Best Practice Guidelines for Australian Community Care. Available at: http://www.safetyandquality.gov.au/
internet/safety/publishing.nsf/Content/FallsGuidelines-AustCommunityCare
NSW Falls Injury Prevention Network Website: http://www.powmri.edu.au/fallsnetwork
National Physical Activity Guidelines for Older Australians: http://www.health.gov.au/internet/main/publishing.nsf/
Content/phd-physical-rec-older
Prevention of Falls Network Europe: http:/www.profane.eu.org
NHS National Institute for Health and Clinical Excellence. Falls Guidelines: http://guidance.nice.org.uk/CG21/
Guidance/pdf/English
Cochrane Library 2005.SR: Hip protectors for preventing hip # in older people. Parker MJ & Gillespie WJ & LD.
www.cochrane.org.au/library/
National Public Health Partnership. 2005. The National Injury Prevention and Safety Promotion Plan: 2004 – 2014:
http://www.dhs.vic.gov.au/nphp/publications/sipp/nipspp.pdf
Kannus, P, Khan, K and Lord, S. (2006). Preventing falls among elderly people in the hospital environment. Medical
Journal of Australia, 184(8): 372-373.
Disclaimer: This document has been developed by Health Directorate, <Name of Division/Branch/Unit> specifically
for its own use. Use of this document and any reliance on the information contained therein by any third party is
at his or her own risk and Health Directorate assumes no responsibility whatsoever.
Appendix 2: Standard operational procedure: Falls prevention and management for
Health Directorate inpatients/consumers. Canberra Hospital. 2011
Appendice 2
Standard Operating Procedure
Falls Prevention and Management for Health Directorate Inpatients/consumers
Purpose
To provide management and staff with strategic direction and resources to improve the safety of patients/
consumers by identifying the level of risk to patients/consumers and reducing the risk of falls and/or falls related
injury.
29
Scope
This SOP relates to all employees providing care to all patients/consumers, particularly those who have contact
with and care for people over the age of 65yrs (55yrs for Aboriginal and Torres Strait Islander Adults)
Principles
Each division within the Health Directorate will be responsible for implementing the standard operating procedure/s
for falls and falls injury prevention.
Health professionals who are providing clinical services will require education, information and training to ensure
they have the necessary skills, knowledge and attitudes to provide Best Practice in falls prevention relevant to their
scope of practice. Each Division will provide education and resources to employees, to implement procedures to
reduce falls and related injuries, including evaluation of these strategies.
The procedure will be consistent with the Guidelines for Preventing Falls And Harm From Falls In Older People:
Best Practice Guidelines For Australian Hospitals, Community Care and Residential Care Facilities 2009 and
should include the following steps in falls prevention management:
1. Prevention through education and practice.
2. Screening of patients/consumers for risk of falls
3. Assessment of patients/consumers at risk of falls
4. Consumer and carer involvement
Procedure
Education
• Staff should have access to education around intrinsic and extrinsic risk factors that increase the individual’s
risk of falling, how to conduct risk screening and assessment using the appropriate tools, and how to implement
a management plan specifically to meet the individual patient/consumer’s needs.
• Mechanisms should be in place such as signs above the bed, alert on CRIS/ACTPAS, recorded on care plan,
and handover sheet, to allow the risk of falling alert to be conveyed to all staff caring for the patient.
Staff
• Consideration should be given to each ward appointing a “falls Prevention” champion.
• Establish and promote team ownership of the risk screening and assessment, and problem solving plans.
• Establish a culture of improved falls reporting and documentation.
• Ensure staff undertakes the e-learning package.
• Make available relevant falls prevention information within the ward/department.
• Staff should be aware of the ACT health policy “Reducing Falls and Falls Injury across the Health Directorate”.
Patient
• On admission the information re risks and interventions should be a part of the patient/consumer and family’s
orientation to the ward.
• Provide patient with information brochure and relevant fact sheets.
• If at risk, explain the need for a physiotherapist review.
• If it is deemed safer for the patient to use a walking aid, educate the patient and family as to why the equipment
is needed and how to use equipment correctly.
• If at risk, explain the need for an Occupational Therapist home assessment.
Risk Screening and Risk Assessment
Risk screening
• A falls risk screening for all patients/consumers is important as it can form part of routine clinical management
and inform when a more comprehensive assessment and management is required.
• Risk screening should be conducted as soon as possible after admission within the first 24 hours. Consideration
should be given to conducting the risk screening within the emergency department for older persons presenting
for admission.
• A risk screen should be undertaken when there has been a change in the patient’s condition or a change in the
environment.
• A risk screening tool should include basic questions such as history of falls, falls contributing to current
admission, cognitive impairment and mobility status.
30
Risk Assessment
• If the risk screen exceeds the threshold, i.e. a patient is deemed at risk on the screening tool, referral should be
made to other allied health professionals for a comprehensive risk assessment.
• The risk assessment should include identifying intrinsic and extrinsic factors that may increase the patient’s
risk of falling. Refer Chart 1
• Appropriate interventions should be implemented and documented for the individual patient/consumer’s risk
factors indentified from the risk assessment.
Interventions
• A multifactorial and team approach is needed to achieve a significant reduction in falls and falls related injury.
• It is important to identify both intrinsic and extrinsic interventions.
• Interventions and plan of care will be determined by the risk assessment and risk factors identified.
• Individual falls prevention programs/interventions should be flexible enough to accommodate the patient/
consumer needs, circumstances and interests.
Restraint
• ACT Health staff must utilize the range of Best Practice alternatives to restraint interventions available, prior to
use of restraint being considered.
Use of any restraint chemical or physical needs to be ordered by a doctor in line with the Health Directorate
“Restraint of Patients/consumers“ policy.
If a need for a physical restraint is identified and approved, then it should be used in conjunction with interventions
and plan of care and regularly reviewed.
Medical advice and /or orders for physical restraints is required if the patient is at risk of harm.
Chart 1: Risk Assessment Factors and Interventions
31
32
Falls reporting
• Following a fall immediate steps should be taken to care for the patient such as calling a MET if condition meets
criteria. Document in patient’s record including a set of observations, neurological observations and any evidence
of injury.
• Notify medical staff caring for patient.
• Continue observations at regular intervals.
• Complete a RiskMan report. See appendix 1 for checklist for RiskMan reporting
• Inform the relatives/carer of the fall.
• Discuss management plan with patient and relatives.
• Document any injuries obtained in the fall.
• Document and handover the ongoing risk management of the patient including the specific preventative
strategies to reduce the risk of further falls.
• An in-depth analysis of the fall if serious injury or death has occurred will be conducted. (CRC review)
• A post fall analysis should identify any changes required to practice.
Discharge Planning
• Planning for discharge should commence at admission at the time the risk screen is conducted.
• The physiotherapist needs to be an integral part of the discharge plan to enable a discharge safety assessment
to be done.
• The plan needs to be completed allowing adequate time for the home assessment to be carried out by the
Occupational Therapy prior to discharge.
• Adequate time for equipment availability. E.g. home oxygen needs to be considered to prevent any delays in
discharge.
• If patient is being discharged with new equipment adequate time needs to be given to enable education of the
patient and family.
• Referrals to Community based Falls Clinic if appropriate.
• If required referral is made to appropriate community services such as physiotherapist or occupational therapist.
33
Evaluation
Outcome Measures
• 100% compliance to risk screening • A reduction in the rate of falls (number of falls/number of bed days x 1000)
• Falls are documented in RiskMan
• The outcome of falls injury is reduced in severity
• Greater than 90% compliance with completing falls e-learning
Method
• Audits of the number of completed falls risk screening tools
• Falls data is reported to Falls Injury Prevention and Management Reference Group
• Documented evidence that local falls data is analyzed and disseminated to improve patient care
• Audits to indicate that risk reducing intervention are included in patient’s care plan and discharge plan
documentation
• Analysis is conducted on falls that have a moderate or above outcome for the patient
• Falls are documented in RiskMan
• Monitor compliance quarterly to completing falls e-learning
Related Legislation and Policies
NHMRC – A Guide to the Development, Implementation and Evaluation of Clinical Practice. (1999)
National Falls Prevention for Older People Initiative (2000) Commonwealth Department of Health and Ageing,
Canberra.
Patient Health and Safety ACT 2003
ACT Health Policy – Reducing Falls and Falls Injury in Older adults across the ACT
Guidebook for Preventing Falls and Harm From Falls in Older People: Australian Hospitals, Australian Commission
on Safety and Quality in Healthcare.
References
Australian Safety & Quality Council’s Preventing Falls and Harm From Falls In Older People: Best Practice Guidelines
For Australian Hospitals, Community Care And Residential Aged Care Facilities for further examples and tools.
http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/Fall Guidelines
Evans D, Hodgkinson B, Lambert L, Wood J, Kowanko I, Falls in acute hospitals: a systematic review. Joanna
Briggs Institute. 1998: 1:1-59 (Level 1)
Leveille SG, Joness RN, Kiely DK. Hausdorff JM, Shmerling RH, Guralnik JM, et a. Chronic musculoskeletal pain
and the occurrence of falls in an older population, JAMA 2009; 302(20): 2214-21. (Level 111)
Swinkels A, Newman JH, Allain TJ. A prospective onservatioonal study of falling before and after knee replacement
surgery. Age ageing. 2009;38(2):175-81. (Level 111)
Moreland J, Richardson J, Goldsmith C, Clase C. Muscle Weakness and Falls in Older Adults. J Am Geriactic
Society 2004;52:1121-1129 (Level 1)
Medical Journal of Australia 2006: 184:379-382
Version
Issue Date
Review Date
1.0
August 2011
2014
Area Responsible
Print Date
27/07/11
34
Appendix 3: Falls prevention screening and management. Pre- and post-audit tool
JBI Fellows Monographs 2011-2012 Yanhong Gu
35
Prevention of oral mucositis among cancer
patients at a teaching hospital in China: a best
practice implementation project
Yanhong Gu
Associate Director
Nursing Department, Affiflated Hospital of Nantong University
People’s Republic of China
Abstract
Background: As a frequent complication of anticancer treatment, oral mucositis threatens the effectiveness of
therapy because it leads to dose reductions, increase in healthcare costs, and impairs patients’ quality of life.
Recommendations regarding the evidence for preventing mucositis are available from the Cochrane Database
Systematic Review, the Multinational Association of Supportive Care in Cancer/International Society for Oral
Oncology (MASCC/ISOO) guideline and the ONS PEP Card.
Aims/objectives: To improve local practice in the prevention and management of oral mucositis in cancer patients
according to the best available evidence.
Methods: Using the standard recommended by the MASCC/ISOO updated guideline and the ONS PEP card, a
clinical audit was conducted using the Joanna Briggs Institute Application of Clinical Practice Evidence System
(JBI-PACES)program and Getting Research into Practice (GRIP) tool. The sample consisted of 85 patients who
received the initial anticancer treatment, another 55 patients/caregivers, 30 nursing staff and 14 medical staff from
two oncology wards at the Affiliated Hospital of Nantong University (AHNU), measured against seven audit criteria.
Results: The results revealed disparity between clinical practice and audit criteria. There were high rates of
changes in compliance for the seven criteria from the baseline audit to the follow-up audit.
Conclusion: The project had significant successes and generated some momentum around prevention and
management of oral mucositis in cancer patients. Ongoing engagement with key stakeholders is required in order
to bring about future changes to clinical practice.
Key words: prevention, oral mucositis, cancer patient, best practice
Background
Antineoplastic therapy-induced mucositis is the inflammation and/or ulceration of the oral mucosa caused by
chemotherapy and radiation therapy.1-2 It is a frequent and debilitating complication of cancer treatment. Varying
severity degrees of mucositis may be found in patients receiving cytotoxic therapy, ranging from mild sensation
changes to multiple, even confluent, ulcerative, bleeding lesions.3 The incidence and severity of oral mucositis
depends on the patient’s characteristics and treatment regimens. Incidence of grade 3 or 4 oral mucositis in patients
receiving high-dose head and neck radiation is up to 85%,4 and 75% in patients undergoing haematopoietic
stem-cell transplantation (HSCT), depending on the intensity of the conditioning regimen used.5 The incidence
of mucositis associated with standard multi-cycle chemotherapy for non-Hodgkin’s lymphoma and breast, lung
and colorectal cancers is approximately 20–60%.1 Meanwhile, the risk factors for the development of mucositis
and the subsequent changes with cancer treatment are multifaceted, which consist of two categories:6 patientrelated (such as age, gender, oral health and hygiene, body mass index, salivary secretory function, smoking) and
cytotoxic therapy-related (such as specific chemotherapy agents, dose of agent and administration schedule, type
of transplant, radiation site and fractionation of radiation).
Mucositis induced by antineoplastic therapy significantly affects cancer patients’ clinical outcomes included
morbidity and mortality by reducing their quality of life (QOL) and tolerance to cancer treatment.7, 8 It is typically
accompanied by pain, ulceration, dysphagia and diarrhea, which often results in communication impairment,
reduction in fluid and food intake, and consequent dehydration and weight loss. In some haemotological cancer
patients, ulcerative mucositis is associated with life-threatening complications such as bacteremia and sepsis
resulting from opportunistic infections of the oral cavity.9 Mucositis also can have a direct impact on survival by
leading to treatment delays, interruptions and dose reductions, which ultimately compromise the effectiveness of
cancer treatment.
36
Furthermore, the economic burden caused by cancer therapy-induced mucositis can also be significant because
it often requires the use of prescription medications, clinic visits, prophylactic antibiotics and, in more severe
cases, prolonged hospitalisation or unplanned re-admission for hydration, parenteral nutrition and narcotic pain
medication.10 It was estimated that the cost of hospitalisation may exceed US$3500 per cycle with mucositis.
Sonis and colleagues reported hospital charges exceeding US$40,000 per patient with oral ulcerations during the
100-day post-transplantation engraftment period.11 Beyond that, individuals reported oral mucositis as the most
common symptom they experienced. In a study, 38% of adult cancer patients experienced depression attributed
to changes in the oral cavity.12 Therefore, the management of mucositis is an important nursing practice for patients
receiving cancer therapy, including assessing, oral care education, administering pharmacologic interventions,
and helping patients to cope with symptom distress.
A Cochrane systematic review evaluated 29 interventions for preventing of cancer treatment-related mucositis and
determined ten interventions had some benefits for patients. These interventions included amifostine, antibiotic
pastille or paste, benzydamine, calcium phosphate, honey, hydrolytic enzymes, ice chips, oral care, povidone and
zinc sulphate.13
Another Cochrane review indicated nine interventions were found to have some benefits for preventing or reducing
the severity of mucositis associated with cancer treatment. There were allopurinol, aloe vera, amifostine, cryotherapy,
glutamine (intravenous), honey, keratinocyte growth factor, laser, and polymixin/tobramycin/amphotericin (PTA)
antibiotic pastille/paste.14
An evidence-based guideline developed by the Multinational Association of Supportive Care in Cancer/International
Society for Oral Oncology (MASCC/ISOO) recommended oral care protocols using a soft toothbrush, patient
and staff education regarding the oral care protocols, valid assessment tools of pain and oral cavity health, and
the inclusion of dental professionals.15 Patient controlled analgesia (PCA) with morphine was recommended to
treat oral mucositis pain in patients with HSCT. Benzydamine was recommended for radiation-induced mucositis
in patients with head and neck cancer receiving moderate-dose therapy. Cryotherapy was recommended for
bolus 5-fluorouracil (5-FU) and suggested for bolus edatrexate and in patients receiving high-dose melphalan.
Keratinocyte growth factor-1 (palifermin) was recommended for three days before conditioning treatment and three
days post-transplant for patients receiving high-dose chemotherapy and total body irradiation with autologous
stem cell transplant for hematologic malignancies.
Although it is based on expert opinion, the following nursing care practices are widely accepted in most oncology
settings worldwide:16
• Collaborate with a multi-disciplinary team in all phases of treatment.
• Brush all tooth surfaces for at least 90 seconds at least twice daily using a soft toothbrush.
• Allow toothbrush to air dry before storing.
• Floss at least once daily or as advised by the clinician.
• Rinse mouth four times a day with a bland rinse.
• Avoid tobacco, alcohol and irritating foods (acidic, hot, rough and spicy).
• Use water-based moisturisers to protect lips.
• Maintain adequate hydration.
• Provide written instruction and education to patients on above items. Verify understanding with return
explanation and demonstration.
• Bland rinses (normal saline, sodium bicarbonate, and a saline and sodium bicarbonate mixture) to remove
loose debris and aid with oral hydration.
Although there are many best practice recommendations, practice application of rigorous evidence still needs to
be promoted in the clinical setting.
The Affiliated Hospital of Nantong University is located in the middle area of Jiangsu province, has 2000 beds
and treats patients with a wide range of solid and blood cancers. There are two 64-bed oncology wards specially
providing chemotherapy and radiotherapy for cancer patients. Two hundred cancer patients are admitted in both
wards and 20% of them receive their initial cancer therapy there.
37
Aims
• To improve local practice in the prevention and management of oral mucositis in cancer patients
• T
o ensure the practice of oral mucositis prevention in cancer patients is performed according to the best
available evidence.
• To improve oral care knowledge among patients, caregivers and staff.
• To decrease the incidence of oral mucositis in cancer patients.
Methods
Setting and sample
The Affiliated Hospital of Nantong University is a large teaching hospital, which is located in the middle area of
Jiangsu province in China. It has 2000 beds and provides a wide range of health care services to solid and blood
cancer patients. The implementation project was conducted across two 64-bed oncology wards which mainly
include patient groups treated by chemotherapy and radiotherapy. The first audit of compliance with best practice
involved a review of 45 case reports of patients treated by chemotherapy or radiotherapy for the first time, while 29
nursing staff, 14 medical staff and another 70 patients/caregivers were involved in the audit program.
In the re-audit phase 29 nursing staff, 15 medical staff and 70 patients/caregivers were involved. Apart from the
staff group, 40 patients with initial treatment of cancer were involved.
Audit criteria
The initial and second audits assessed the seven criteria from JBI-PACES, which were predominately based
on Updated Clinical Practice Guidelines for the Prevention and Treatment of Mucositis9 and a comprehensive
systematic review.12 The criteria are as follows:
1. Staff education regarding oral mucositis and oral care protocols has been conducted.
A seminar and consequent short assessment was provided to all staff in both wards.
2. Patient education regarding oral mucositis and oral care protocols has been conducted.
A patient education seminar was provided for all patients with initial cancer therapy and at least 60% of correct
answers was required in the consequent assessment.
3. Standard oral hygiene care protocols including teeth brushing are in place for patients.
This criterion was considered to be met if the patient can brush all tooth surfaces for at least 90 seconds and twice
daily using a soft toothbrush, rinse his mouth four times a day with a bland rinse, maintain adequate hydration and
use water-based moisturisers to protect the lips.
4. Prior to receiving cancer treatment, dental examinations and treatment are carried out.
This criterion was considered to be met when there were dentist consulting records or orders in the patient case
report before the patients began their cancer treatment.
5. Initial assessment of the oral cavity is conducted using a validated tool.
Compliance was reported the nursing records and the patient case report.
6. Ongoing assessment of the oral cavity is conducted using a validated tool.
Compliance was documented the nursing records and the patient case report.
7. For patients receiving cancer treatment, preventative oral care regimens are in place.
This criterion was considered to have been met when there were records in the doctor’s order sheet. The preventive
oral care regimen can be one of the followings: cryotherapy, palifermin, low-level laser therapy (LLLT), oral aloe
vera, Zinc supplementation, flurbiprofen tooth patch, and Chinese traditional medicine.
Phase 1
This phase includes three steps:
1. Establishing the audit team
The project team comprised the Nurse Manager, Consult Nurse, Registered Nurse and Dentist. The audit team
members are as follows:
Yanhong Gu (Associate Director of Nursing Department, AHNU): project coordinator, responsible for staff
education, data collecting and analysis, report writing
38
Yujuan Xie (Registered Nurse, Nursing Supervisor of Oncology Department, AHNU): staff education and data
collecting
Xiaohong Jing (Registered Nurse, Head Nurse of Oncology Ward, AHNU): assessment of oral cavity using a
validated tool.
Xiaolin Yan (Registered Nurse, Nurse of Oncology Ward, AHNU): patient education
Xiaoyan Chen (Registered Nurse, Head Nurse of Oncology Ward, AHNU): oral hygiene care
Jun Lu (Dentist, AHNU): dental examination and treatment prior to receiving cancer treatment for the patient.
A short training program was provided to all participants.
2. Developing the audit questionnaires for the patient /caregiver and clinical staff respectively.
Questionnaires were used to assess knowledge and attitude of the patient/caregiver and staff. Each questionnaire
was determined by focus group discussions and expert content reviews.
3. Conducting the baseline audit
Using the online JBI-PACES program, baseline audit was conducted from 21 July to 10 August 2011. The details
of the measurement methods include the following: collecting the data against best practice criteria; using tailored
questionnaires to investigate the compliance of staff, caregiver and patients against the first and second criteria;
looking through the documents and medical records of patients to survey the compliance of the other five criteria.
The data were collected using JBI-PACES by the leader of the project team.
Phase 2: Implementation of best practice
Following the baseline audit, the results were reported and disseminated to the project team on 15 August 2011 in
a team meeting. Reviewing the audit results enabled the team to begin the initial step in the GRIP component, ie
identifying and discussing the barriers to achieving 100% compliance with best practice. Following this discussion,
actions were identified to address the barriers and these were transcribed into the GRIP program. The potential
barriers included:
1. For staff, lack of knowledge about evidence-based practice and the best evidence for preventing oral mucositis.
2. For patients and caregivers, lack of awareness about preventing oral mucositis.
3. No standard protocol for staff to follow in the wards.
4. Low compliance to the criteria by staff due to workload and shifts.
5. Patients’ limitations inimplementing the prevention of oral mucositis due to physical consstraints.
Another meeting was held on 22 August to discuss the strategies and next project plan. All stakeholders were
invited to the meeting. The information collected in the meeting was then used to develop and execute the plan and
strategies to facilitate and promote awareness and implementation of best practice (see Appendix 2). Meanwhile
a staff education seminar was held in the forth week of August 2011. Patient education pamphlets and standard
protocol for the nursing staff were developed in the next two weeks. Actions commenced to improve clinical
practice.
Phase 3
The post implementation audit was a replication of the Phase 1 audit utilising the JBI-PACES program. Based on
the GRIP process, re-auditing was conducted in the early half month of November 2011.
Ethical considerations
Formal ethical approval was not required as the project was in accordance with the hospital clinical continuous
quality improvement policy.
Results
Baseline audit
The initial auditing process and data collection was conducted over the two weeks from 21 July to 10 August 2011,
utilising the criteria identified previously. The results were transcribed into JBI-PACES for review and compliance
was assessed against recommended guidelines (see Figure 1). There was little variation in results between the two
ward areas audited in the process. All wards showed low compliance with the identified criteria except criterion 3.
39
Criteria legend
1. Staff education regarding oral mucositis and oral care protocols has been conducted. (43 of 43samples taken)
2. Patient education regarding oral mucositis and oral care protocols has been conducted. (70 of 70samples taken)
3. Standard oral hygiene care protocols including teeth brushing are in place for patients. (45 of 45samples taken)
4. Prior to receiving cancer treatment, dental examinations are carried out. (45 of 45 samples taken)
5. Initial assessment of the oral cavity is conducted using a validated tool. (45 of 45 samples taken)
6. Ongoing assessment of the oral cavity is conducted using a validated tool. (45 of 45 samples taken)
7. For patients receiving cancer treatment, preventative oral care regimens are in place. (45 of 45 samples taken)
Figure 1: Baseline audit and criteria
Follow up audit
The re-audit phase was conducted from 1 Nov to 15 Nov 2011. The re-audit phase showed improvement in
compliance in the seven identified criteria (see Figure 2).
Criteria Legend
1. Staff education regarding oral mucositis and oral care protocols has been conducted. (44 of 44 samples taken)
2. Patient education regarding oral mucositis and oral care protocols has been conducted. (70 of 70 samples
taken)
3. Standard oral hygiene care protocols including teeth brushing are in place for patients. (40 of 40 samples taken)
4. Prior to receiving cancer treatment, dental examinations are carried out. (40 of 40 samples taken) 4
5. Initial assessment of the oral cavity is conducted using a validated tool. (40 of 40 samples taken) 5
6. Ongoing assessment of the oral cavity is conducted using a validated tool. (40 of 40 samples taken) 6
7. For patients receiving cancer treatment, preventative oral care regimens are in place. (40 of 40 samples taken)
40
Figure 2: Re-audit results and criteria
Criterion 1
Staff education regarding oral mucositis and oral care protocols has been conducted.
During the baseline audit, we investigated 43 staff, including 29 nurse and 14 doctors who were working in the
oncology ward for more than three months. In the follow up audit, a total of 44 staff were involved. The compliance
in the initial period was only 12% and reached 100% in re-audit phase. The positive change was as high as 88%.
Criterion 2
Patient education regarding oral mucositis and oral care protocols has been conducted.
This criterion was audited via a short questionnaire for 140 patients/caregivers.. If there were more than 60% of
correct answers, we regarded the criterion to have been met. The data showed that there was only 6% compliance
in the baseline audit, but compliance was 97% in the re-audit period. There were only two patients who could not
answer 60% of the questions correctly.
Criterion 3
Standard oral hygiene care protocols including teeth brushing are in place for patients
The graph in Figure 2 indicates that the compliance for this criterion reached 67% during the baseline audit. It
was higher than any of the six criteria. We assessed it by reviewing the case reports of patients of the 45 patients.
During the follow up audit, only 40 case reports were reviewed because of time limitations. The graph in Figure
2 shows that 100% compliance was achieved in second audit. Although this represented only a 33% positive
change, it still demonstrated that the strategies for this criterion worked well.
Criterion 4
Prior to receiving cancer treatment, dental examinations and treatment are carried out.
There were only five records that contained the dental examination or treatment among 45 patients in the baseline
audit. In the follow up audit, the 90% compliance was achieved, representing a 79% positive change.
Criterion 5
Initial assessment of the oral cavity is conducted using a validated tool.
Criterion 6
Ongoing assessment of the oral cavity is conducted using a validated tool.
These two criteria were considered to have been met by checking the nursing records or case diaries of the case
reports. The baseline audit revealed that there were not any validated tools being used at the time. After the
implementation of the intervention, compliance for these two criteria increased to 90% and 88% respectively.
Criterion 7
For patients receiving cancer treatment, preventative oral care regimens are in place.
Figure 3 indicates that compliance for this criterion increased from 22% to 100%. This criterion was regarded to
be fulfilled according to records by the doctor’s orders in the patient case reports. The sample for the two audits
was 45 and 40 patients who accepted the initial antineoplastic treatment.
Discussion
A clinical audit project was implemented in our two oncology wards in the last six months. A total of 44 healthcare
staff, and 140 patients and caregivers were involved in the project.
There is significant improvement in all audit areas ranging from 33% to 91%, with the compliance for criteria 1, 3,
7 achieving 100%.
For the education of clinical staff (criterion 1), three seminars were provided in the forth week in August 2011.
Approximately 100 healthcare professionals attended which included 44 doctors and nurses working in the two
wards. The seminars related to oral mucositis and evidenced-based practice, with topics such as ‘prevalence,
pathological mechanism of oral mucositis’, ‘assessment, prevention and management of oral mucositis’ and
‘evidence based nursing practice’ which delivered by Professor Hu and Professor Mao. After that the questionnaires
were distributed and completed by the involved clinicians.
For patient education (criterion 2), a pamphlet on ’oral mucositis education pamphlet for patients’ was provided to
every patient admitted to the ward. In addition, daily bedside education was offered by the charge nurse according
to the patient’s oral assessment.
41
The education consisted of signs and symptoms of oral mucositis, risk factors, prevention, oral hygiene, selfassessment, and regiments for complication treatment. The compliance of the two criteria increased compared
with that in the baseline audit by 88% and 91%, respectively.
For criterion 3, the use of standards or protocols facilitated routine care for some patients with antineoplastic
therapy in clinical practice. The compliance for documenting oral care was significantly increased after the
introduction of oral care protocol and an evidenced-based plan for oral mucositis. The protocol included the
following processes: mucositis assessment, planning, implementation and evaluation. And in different cycles of
antineoplastic therapy, the highlighted interventions were varying (see Appendix 2). Thus 33% positive change was
achieved during the follow up cycle.
In criterion 4 and criteria 7, the baseline audit indicated low compliance (11% and 22%). This was because
the clinician paid much more attention to medical and surgical interventions, and was less concerned about
oral mucositis. After staff education, the doctors were aware of the importance of preventing oral mucositis.
Therefore communication between the clinician and the dentist facilitated the dental consult. At the same time,
more prescriptions for preventing oral mucositis were offered to patients than before the staff training. Finally in the
follow up cycle, compliance for these two criteria increased by 79% and 78%.
Assessment is vital to the prevention and treatment of mucositis. An evidence-based guideline identified
assessment as the most significant clinical intervention by nurses caring for patients with oral mucositis.6 Oral
assessment is an ongoing process, and its findings guide the development of a plan. Commonly validated tools
include the WHO oral mucositis scale, the Oral Assessment Guide (OAG), Oral Mucosa Rating Scale (OMRS), Oral
Mucositis Index (OMI) and the Oral Mucositis Assessment Scale (OMAS).7, 9 Unfortunately, in the initial audit, we did
not use any validated tool to assess the patient’s oral cavity. Then initial and ongoing assessments were put into
standard care plan by the audit team and meanwhile the WHO oral mucositis scale was used as a validated tool
in the care plan for patients with antineoplastic therapy. This scale is widely used in research and clinical settings,
especially for mucositis in patients undergoing head/neck radiation, chemotherapy or HSCT. The measurements
of the scale include symptom (pain), signs (erythema, ulceration) and type of dietary intake.
Despite time restriction on the audit project, it was very encouraging to identify the significant improvements in
clinical practice for all audit criteria during the follow up audit.
Conclusion
During the six-month project, patients and healthcare professionals were aware the importance of oral care and
mucositis prevention during chemotherapy and radiotherapy in our two oncology wards. An evidence-based
mucositis prevention protocol was established and worked well in our two wards. Ongoing engagement with key
stakeholders is required in order to guide future changes to clinical practice. Following audit program will ensure
the sustainability of evidence-based mucositis prevention although it is a big challenge in busy cancer care units.
Reporting
The results and outcomes of the project will be disseminated to key stakeholders within the Affiliated Hospital of
Nantong University via an in-service presentation, hospital publications and forums. JBI-PACES and GRIP reports
will be available to interested stakeholders and other clinicians.
The project findings and impact will be distributed more widely via publications and possible conference
presentations.
Acknowledgements
I would like to acknowledge the following people for their assistance and support through this project:
Dr Zachary Munn, Research Fellow, Joanna Briggs Institute
Dr Yifan Xue, Research Fellow, Joanna Briggs Institute
Dr Rie Konno, Research Fellow, Joanna Briggs Institute
Alexa McArthur, Research Fellow, Joanna Briggs Institute
Professor Jianhua Zhu, Vice-director Affiliated Hospital of Nantong University
Professor Yan Hu, Vice-director Nursing College of Fu Dan University.
42
References
1.Peterson D. E, Bensadoun R. J, Roila F. Management of Oral and Gastrointestinal Mucositis: ESMO Clinical
Practice Guidelines. Annals of Oncology, 2010, 21: 261-265.
2.Rajesh V. Lalla, Stephen T. Sonis, Douglas E. Peterson. Management of Oral Mucositis in Patients with Cancer.
Dent Clin North Am, 2008, 52 (1): 61.
3. S
tokma M.A, Spijkervet F.K.L, Boezen H.M et al. Preventive Intervention Possibility in Radiotherapy and
Chemotherapy induced Oral Mucositis: Result of Meta-analyses. Journal of Dental Research. 2006, 85(8):690700.
4.Tratti A, Bellm LA, Epstein JB et al. Mucositis Incidence Severity and Associated Outcomes in Patients with
Head and Neck Cancer Receiving Radiotherapy with or without Chemotherapy: A Systematic Literature
Review. Radiotherapy Oncology, 2003, 66: 253-262.
5.Filicko J, Lazarus HM, Flomenberg N. Mucosal injury in patients undergoing hematopoietic progenitor cell
transplantation: new approaches to prophylaxis and treatment. Bone Marrow Transplant, 2003, 31: 1-10.
6.June Eilers, Rita Million. Prevention and Management of Oral Mucositis in Patients with Cancer. Seminars in
Oncology Nursing, 2007, 23 (3): 201-212.
7. S
tephen T. Sonis, Linda S. Elting, Dorothy Keefe et al. Perspectives on Cancer Therapy-Induced Mucosal
Injury:Pathogenesis, Measurement, Epidemiology, and Consequences for Patients. CANCER Supplement,
2004, 100 (9): 1995-2025
8.Spencer W. Redding. Cancer Therapy-Related Oral Mucositis. Journal of Dental Education, 2005, 69 (8): 919929.
9.Elenir B. C. Avritsche, Catherine D. Cooksley, Linda S. Elting. Scope and Epidemiology of Cancer Therapyinduced Oral and Gastraointesdinal Mucositis. Seminars in Oncology Nursing, 2004, 20 (1): 3-10.
10.Linda S. Elting, Catherine Cooksley, Mark Chambers et al. The Burdens of Cancer Therapy: Clinical and
Economic Outcomes of Chemotherapy-Induced Mucositis. Cancer, 2003, 98 (7): 1531-1539.
11.Sonis S, Oster G, Fuchs H, et al. Oral mucositis and the clinical and economic outcomes of hematopoietic
stem-cell transplantation. J Clin Oncol. 2001;19:2201–2205.
12.Rose-Ped AM, Bellm LA, Epstein JB et al. Complications of Radiation Therapy for Head and Neck Cancers:
The Patients’Perspective. Cancer Nursing, 2002, 25 (6): 461-4677
13.Worthington HV, Clarkson JE, Eden OB. Interventions for preventing oral mucositis for patients with cancer
receiving treatment. Cochrane Database of Syst Rev 2006;
14.Worthington HV, Clarkson JE, Bryan G et al. Interventions for preventing oral mucositis for patients with cancer
receiving treatment .The Cochrane Library, 2011,(4)
15.Dorothy M. K, Mark M. S, Linda S. Elting et al. Updated Clinical Practice Guidelines for the Prevention and
Treatment of Mucositis. Cancer, 2007 ,109( 5): 820-831.
16.Oncology Nursing Society. Evidence based practice resources area. Available at. http://www.ons.org/evidence.
43
Appendix 1: Summary of core findings
Barriers
Strategies
Resources
Outcomes
Staff lack knowledge
about evidence-based
practice and the best
evidence for preventing
oral mucositis
Hold staff education
seminars
Provide education
materials to all staff
working in the two wards
Team leader to prepare
and organise seminars
All staff took part in the
education seminar
for staff
Staff passed the
examination
Patients and caregivers
lacked of awareness on
preventing oral mucositis
prevention
Develop and distribute
patient education
pamphlets when patients
are admitted
Audit team members
There was no united oral
care protocol for cancer
patients receiving cancer
treatment for the nursing
staff to follow in the
wards
Invite a specialist to
teach evidence-based
practice
Educate nurses in the
two wards
Carry out routine patient
education plan
Educational material for
dissemination to cancer
patients
Establish evidencedbased oral care protocol
The Cochrane Database
Systematic Review
The protocol was
determined by local
setting policy maker
Multinational Association
of Supportive Care in
Cancer/International
Society for Oral Oncology (MASCC/ISOO)
guideline
Patient/caregivers
paid more attention
to prevention of oral
mucositis and changed
their daily actions
Built an evidence-based
care plan and Standard
Operating Procedures
Established a
documented oral care
records in patient case
reports
ONS PEP card
Workload and shifts
Re-allocate duties
Hold weekly team
meetings
Communicate with staff
and provide feedback on
the audit results
Feedback fromthe
project team
Made suggestions to
the Human Resources
Department
Enhanced
communication between
audit team and staff
Appendix 2: Mucositis assessment , planning, implementation and evaluation process
44
JBI Fellows Monographs 2011-2012 Marie Haydon
Risk factor modification among vascular patients
with peripheral vascular disease in an acute
hospital setting: a best practice implementation
project
Marie Haydon
Associate Clinical Service Co-ordinator, Ward A7, Royal Adelaide Hospital
Davina Mungall,
Clinical Service Co-ordinator Ward A7, Royal Adelaide Hospital
Ewan Macaulay
Vascular Consultant, Royal Adelaide Hospital
Sandra Leith
Vascular Case Manager, Royal Adelaide Hospital
Marianne Lupson
Associate Clinical Service Co-ordinator, Ward A7, Royal Adelaide Hospital
Vanessa Hiedenrich
Registered Nurse, Ward A7, Royal Adelaide Hospital
Brianna Cornish
Registered Nurse, Ward A7, Royal Adelaide Hospital
Leanne Wells,
Enrolled Nurse, Ward A7, Royal Adelaide Hospital
Abstract
Background
Peripheral Vascular Disease (PVD) is considered to be an important cause of mortality and morbidity in many
Western countries with intermittent claudication (IC) often the first sign of PVD.1,2 Patients diagnosed with PVD will
often require some intervention and possible revascularisation, and potentially death, as the disease progresses.3
Major cardiovascular risk factors predict the occurrence of IC better than they predict coronary heart disease.1 The
risk factors that are most prevalent in PVD are: hypertension, smoking, dyslipidaemia, physical inactivity, and male
gender, age, obesity and diabetes mellitus.4
Aims/objectives
The aim of this project is to develop a risk factor assessment tool which will identify risk factors, optimise patients’
medications to reduce the risk factors of PVD and review any diabetes management.
Methods
A baseline audit was performed to determine current effectiveness in managing risk factors for PVD. A risk factor
tool was developed and implemented along with an education package for staff particularly junior medical staff. A
further case note audit was performed to assess the effectiveness of the tool in determining risk factors.
Results
The result of the initial audit identified that the medical officers were in fact performing quite well in optimising the
patients’ medication to reduce the effects of the risk factors; however no tool was being used to demonstrate that
this was actively being assessed. A stamp was developed which has been moderately accepted and there has
been a slight improvement overall in the management of diabetes and the optimisation of appropriate medications.
Discussion/conclusion
Auditing can be a useful tool in identifying current processes and can assist with developing strategies to overcome
deficits.
Keywords: cholesterol, diabetes, hypertension, peripheral vascular disease (PVD), risk factors, screening tool
45
Background
People suffering from Peripheral Vascular Disease (PVD) experience the same atherosclerotic changes to their
circulatory system as those who have Cardiovascular Disease.1 PVD in Australia is called Peripheral Artery Disease
(PAD) in USA. PAD is considered to be an important cause of mortality and morbidity in many Western countries.2
Intermittent Claudication (IC) is often the first sign of PVD, often leading to intervention and revascularisation, or
even death, as the disease progresses.3
The major cardiovascular risk factors predict the occurrence of IC better than they predict coronary heart disease.1
The risk factors that are most prevalent in PVD are: hypertension, smoking, dyslipidaemia, physical inactivity,
and male gender, age, obesity and diabetes mellitus.4 The management of vascular risk starts with an overall
assessment of these risk factors.5 This project focused on the risk factors of hypertension, dyslipidaemia, and
diabetes mellitus.
At several recent Australian and New Zealand Society for Vascular Nurses (ANZSVN) (2009, 2010) there have
been presentations given from other vascular units around Australia regarding the development of risk factor
modification plans within their units. Nursing staff from the vascular unit (A7) at Royal Adelaide Hospital (RAH) have
become interested in implementing a risk factor modification plan for the patients on A7. Much of the evidence
available is predominantly based around cardiovascular risk factor management rather than PVD and is primarily
Level IV evidence; however this is still considered to be of value as expert knowledge is recognised as being
relevant.
A7 is a 16 bed Vascular Surgical ward at the RAH. The RAH is a tertiary hospital set in metropolitan Adelaide, and
is the major trauma unit for Central and Northern Adelaide, with a significant feed in much of South Australia and
parts of new South Wales and Victoria. The Vascular Medical team consists of three visiting consultants and a
resident consultant, who oversee the management of the patient population along with two vascular trainees (one
international) and a general surgical trainee. Two interns complete the medical team. A Vascular Case Manager
provides patient support and wound guidance to the ward and the medical team, and is an integral member of the
vascular team. The nursing team on the ward consists of 35 nurses ranging from Level 3 to enrolled nurses. Many
staff are permanent staff with several years of vascular nursing experience.
Aims
The topic of this audit is: risk factor modification among vascular patients with Peripheral Vascular Disease in an
acute hospital setting
The aim of this project is to develop a risk factor modification plan which will
• Develop a tool for identifying risk factors
• Address optimisation of patients medications to reduce the risk factors of PVD
• Review of diabetes management.
Methods
An audit was conducted utilising patient case notes, medication charts and accessing OASIS (Software program
for blood results); therefore there was no need to have direct contact with patients. All information collected was
de-identified and treated as confidential. The audit was performed using the Joanna Briggs Institute Practical
Application of Clinical Evidence System (JBI-PACES). There was no requirement to obtain ethics committee
approval; however I had permission from Ms Kathy Read, the Director of Nursing, Cardiovascular Service; and Mr
Larry Ferguson, Head of Surgery, Vascular Unit, RAH
46
Phase 1:
Mr E Macaulay, Resident Consultant, was instrumental in supporting this project through initial direction and
reference provision, and was available for comment/feedback throughout the process.
Ms S Leith, Vascular Case Manager, and Ms D Mungall Clinical Service Co-ordinator, were specifically included
in the project team as they are senior nursing staff and were interested in the outcome of this project and the
development of a Risk Factor tool. Ms Marianne Lupson, Associate Clinical Service Co-ordinator; Ms Vanessa
Hiedenrich, Registered Nurse; Ms Brianna Cornish, Registered Nurse; Ms Leanne Wells, Enrolled Nurse; all
expressed an interest in being involved in the research process. They were participants in the Getting Research
into Practice (GRIP) process and assisted in its implementation.
Using JBI-PACES, a baseline audit was conducted to determine the current level of risk factor identification
undertaken.
The initial/baseline audit involved identification of patients who were admitted to A7 with PVD. For the purpose of
the audit I accessed the patient case notes on discharge, and reviewed the medication chart to determine whether
patients were on an antithrombolytic, an antihypertensive or an HMG Co-A Reductase Inhibitors (Statin), and, if
they were diabetic, accessed the OASIS System and determined if a Glycosylated Haemoglobin test had been
performed at any point in the past three months.
A discussion was held with the team and with Mr Macaulay regarding the type of antihypertensive prescribed.
While research identifies an Angiotensin Converting Enzyme Inhibitor (ACEI) and Thiazide are the most effective
treatments for this cohort of patients, it was determined for this project to accept any antihypertensive therapy as
acceptable therapy. From the data collected 13 patients had hypertension as a diagnosis; of these nine were on
ACEI while four were on either a Beta Blocker or Calcium Channel blocker. Initially I determined there would be 10
discharges per week over a four-week period; however numbers were small, and I was only able to audit 21 case
notes in this period.
The following criteria, based on the JBI Evidence Summary, were considered:6
In symptomatic PAD patients, lipid lowering therapy with a statin is prescribed.
- Assessed by identifying a statin being prescribed for the patient.
Hypertensive patients with PAD are treated with thiazides and angiotensin converting enzyme inhibitors to reduce
their blood pressure.
- A discussion with Mr Macaulay identified that as long as a patient was on any type of antihypertensive agent
that this would be a satisfactory outcome.
Blood Glucose levels (HbA1c) are lowered to < 7.0% or as close to 6.0 % as possible in patients with diabetes
and PAD.
- Assessed by identifying an HbA1c having been measured on the patient either within the admission or within
the past three months.
Antiplatelet drugs such as aspirin or clopidogrel are prescribed for patients with symptomatic PAD.
- Assessed by identifying an antiplatelet being prescribed for the patient.
Patients with established vascular disease are screened for risk factors
- Assessed through the presence of a risk factor tool being present within the patients’ case notes at some point
in their admission.
Phase 2:
Once the audit results were compiled the team were called together to discuss the audit results and how best
to improve the compliance with evidence. At the brainstorming session GRIP was implemented to identify the
barriers to increasing compliance and identify the strategies and resources required to improve participation (see
table below).
47
Implementation
16 acute bed Vascular Surgical Unit in a large metropolitan hospital
Barriers
Strategies
Resources
Outcome
No risk factor
identification tool
Develop a tool
Nursing staff input
Design initiated
Pharmacist input
Pharmacy input
Medical staff input
Further adaptation of
design
Lack of knowledge nurses
Printer
Stamp purchased
Review other hospital
tools
Royal Brisbane Hospital Teresa O’Keefe
The Queen Elizabeth
Hospital - Wendy
McInnes
Received copies from
other hospitals
Provide education
Develop resource
package
Package disseminated to
Team
Pharmacist discussion
Potentially develop a
poster
Medical Staff buy-in
Provide information to
medical staff, particularly
interns
Information session
Provided to interns
Patient acceptance
Meet with senior medical
officer
Meeting held
Provide risk factor
modification tool
Develop tool
Tool developed
Support medical staff to
utilise tool
Communication
Ongoing
Develop a patient
information booklet
JBI printing service
To be attended
Development of a simple tool addressing the criteria occurred as part of the GRIP process.
There was much discussion around a tool and what it would look like. Eventually a rough idea was drafted, and I
showed Mr Macaulay what had been decided. He recognised the value in the tool and had some additional ideas
of his own. Mr Macaulay took the layout to a printer and developed a stamp (Appendix 1).
A follow-up meeting was held with most of the team present. It was decided to provide education primarily to the
interns but with some discussion at the regular ward meeting. The team decided to identify those patients who did
not have the stamp present in their case notes and to bring this to the attention of the interns. While the prescribing
of medications is a medical officer’s responsibility, the nursing staff were keen to alert the medical officers to any
omissions of required medications.
Mr Macaulay was supportive in explaining to the interns the relevance of the risk factor stamp and the interns
gradually implemented the stamp. With encouragement from the team, the interns increased usage, but just as I
was about to begin the follow-up audit the interns’ rotation completed and new interns commenced. The current
interns were educated about the risk factor stamp and have been have utilising the stamp regularly.
Phase 3:
Using JBI-PACES and the same criteria for consistency, I completed a post implementation audit. Due to the
change of interns, there was only a three-week period available to collect data and at the end of this period only
eight discharges had occurred that met the sample selection requirements. To this end I determined for suitable
evidence comparison it was necessary to access the current admissions that met the selection criteria. A spot
audit was carried out of the patients currently on the ward and 17 patients were identified as meeting the selection
criteria. A total of 25 patients were then included in the data collection for the post implementation audit.
48
Results
From the table above it can be seen that at the initial audit there was already a good compliance with the
understanding of optimisation of medications for patients with PVD, and with Diabetes control. The criterion that
performed less than 90% was the use of Statins in this cohort of patients, and there is some discussion around
this particular factor in efficacy surrounding patients with ‘normal’ cholesterol levels.
The only criterion that performed poorly was the use of a screening tool. Once a tool was developed and implemented
the prescription of Statins improved and 76% of patients were appropriately screened with a screening tool. There
was some slight decrease in the observation of HbA1c; however this is not statistically significant.
Discussion
The aim of this project was primarily to implement a risk factor screening tool for patients with a primary diagnosis
of Peripheral Vascular Disease, to enable modification and management of these risk factors through optimisation
of medications and awareness of diabetes management.
The audit process determined that the Vascular Surgical Unit was in fact performing well on the optimisation of
medications for this patient cohort; however the initial audit did highlight that no particular screening tool was in
fact being utilised. The argument could certainly be made that in this instance there is no need for a screening
tool to be utilised as the medical officers were obviously correctly identifying the medications that are essential in
the management of these patients; however Best Practice recommendations support the systematic screening
of risk factors, followed by evidence-based, tailored treatment advice should be considered, for better risk factor
reduction in patients with established vascular disease.5
This result recognises that the current group of medical officers are in fact very proactive in determining the risk
factors of the vascular patients admitted to our service. It will be of interest to repeat this process in12 months’
time with a different group of registrars in particular to determine if this is an ongoing awareness or just the current
situation.
49
There have been some mixed responses to the utilisation of the risk factor stamp. The first group of interns that
used the stamp complained that it was just an additional burden of work that they were required to attend to,
whereas the current group of interns were very keen to utilise the stamp on a patient’s admission to the ward as
they believed it supported their understanding of the patient’s current factors, and gave them a more complete
picture of the patient’s issues. The stamp is kept on the intern’s desk and is within ease of reach by the interns.
Mr Macaulay would like the risk factors to be referred to in the discharge letters back to the general practitioners
so that they are aware that the optimisation had been set in place while the patient was hospitalised. There is the
potential for this to be addressed in the future.
While this has been a nursing initiated tool, the nursing staff have had little influence on the utilisation of the tool.
The main task of the nursing team has been to encourage the interns to utilise the tool and to highlight if the case
notes have not been stamped. This is particularly important when a patient has been an outlier in another ward and
has been transferred across to the unit.
The process of undertaking this interventional research has been an interesting one. The initial response from staff
when asked for assistance for this project was very positive and the team assembled have endeavoured to be of
assistance at every phase. The difficulty with nurses however is the shift work required with the job and organising
meetings around this has proven to be quite a difficult challenge. Add in sick leave and holiday unavailability and
it is not surprising that not all team members were available for every meeting. The use of internet, email and
personal letters and minute taking were taken advantage of.
For future reference it may be useful to set out a timetable of meetings and implementation points, so that staff are
able to make themselves available in advance.
The process has been a good opportunity for putting JBI-PACES into use in our unit. The implementation of the
risk factor tool was initially considered to be a burden by the intern, but the current interns were very open to
the stamp, so the results were close to what were expected. There is still room for improvement as six of the 25
final audit patients did not have a stamp in their admission. The reason that so many case notes were stamped is
because of the experiences of the interns and their willingness to capture this information. Having the Consultant
supporting the use of the stamp was also very encouraging for the process and for the interns. While the audit
results have shown a positive outcome of the utilisation of the stamp, it is only relevant as a snap shot of the
current situation. If there is no ongoing education and encouragement to use the stamp then there will most likely
be a decline in its usage.
As for future utilisation of the stamp, this will depend upon the interest of the interns and whether there is ongoing
support for the stamps use. There are plans to develop a poster and to develop a patient information booklet for
patients to discuss their risk factors with their general practitioner. There are also plans to have other stamps made
to be used in the Outpatient Department so that the registrars can also identify patient risk factors prior to any
intervention
Conclusions
The process of implementing the audit and developing the risk factor tool has been a useful process for
demonstrating to the medical staff that nurses are able to make a contribution into the management of patients
risk factors. It has also demonstrated that some staff are interested in the policy and practice of the ward and
others are not at all interested. Trying to get all staff interested in the project was not a high priority of the process;
however it is an issue that will need to be addressed for the continuation of the project. It is good to identify that
there are good practices in place around the management of medication for the patients presenting with PVD, and
hopefully in the future there will be a greater recognition within the wider community about management of PVD.
Acknowledgements
I would like to acknowledge the Royal Adelaide Hospital, in particular the Cardiovascular Service for providing me
with the opportunity and the wages to attend the Joanna Briggs Institute Fellowship Program, as well as Mr Ewan
Macaulay for funding the cost of the risk factor tool.
I would also like to acknowledge Sandeep Moola from the Joanna Briggs Institute for his assistance in researching
articles to determine the criteria addressed in this research as well as supporting me with preparing this paper.
50
References
1.
Hiatt, W. Risk factor modification in intermittent claudication: effect
and walking capacity. European Heart Journal Supplement 2002 Vol
Available from eurheartjsupp.oxfordjournals.org
on
4,
life expectancy
pages B50-B54
2. Watson L, Ellis B, Leng GC. Exercise for intermittent claudication. Cochrane Database Syst Rev. 2008; 4
3.Murabito,J.M; D’Agostino, R.B; Silbershatz, H; Wilson, P.W.F. Intermittent Claudication, a risk profile form the
Framingham heart study. Circulation, 1997 vol 96, pages 44-49
4.Hirsch A.T. Gotto, A.M. Undertreatment of dyslipidaemia in peripheral arterial disease and other high risk
populations: an opportunity for cardiovascular disease reduction. Vasc Med 2002, Vol 7 pages 323-331
5.Brouwer BG, Visseren FL, Algra A, et al. Effectiveness of a hospital-based vascular screening program (SMART)
for risk factor management in patients with established vascular disease or type 2 diabetes: a parallel-group
comparative study. J Intern Med. 2010; 268(1):83-93.
6. Moola, S. Peripheral Arterial Disease: Risk Factor Modification. JBI Evidence Summary 2011
Appendices
Appendix 1 – Stamp developed for Risk Factors
JBI Fellows Monographs 2011-2012 Pam Hoadley
51
Measurement, documentation and interpretation
of patient observations for the early detection
of clinical deterioration in patients at a private
acute hospital in Queensland: a best practice
implementation project
Pam Hoadley
Clinical Nurse Educator
St Andrews Toowoomba Hospital
Queensland, Australia
Abstract
Background
The Australian Commission on Safety and Quality in Health Care National Standards have 10 mandates within its
Consensus Statement. It is mandated that observational response charts are to be developed and implemented
to ensure the timely escalation of care for patients whose vital parameters indicate the patient’s condition is
deteriorating. With this in mind, although the assessment data is being documented appropriately, the deterioration
is not being acted upon in a timely manner and we need to know why.
Aims/objectives
The aim of this project is to improve local practice in the detection of clinical deterioration in patients in an acute
care setting and timely escalation of treatment options.
Methods
This project utilised a pre- and post implementation audit design using the Joanna Briggs Institute Practical
Application of Clinical Evidence (JBI-PACES) and Getting Research into Practice (GRIP) programs. The project
occurred over an 18-month period to enable a trial and evaluation in one surgical ward to determine potential
barriers to implementation.
Results
The results of the project demonstrated that nurses were conducting assessment and documentation of the
patient’s vital parameters using the Adult Deterioration Detection System Chart (ADDS) in accordance with
organisational policy and procedure. The concern though is that in the presence of the new ADDS Chart with built
in ‘track and trigger’ strategies, clinical deterioration in adult patients was not being initiated in a timely manner.
The project related to the timely recognition and response of nurses to the clinical deterioration of acute care
patients. The project provided nurses with prompts to detect measurable physiological abnormalities prior to
adverse events such as cardiac arrest/respiratory arrest which may lead to unexpected death.1 Following the
strategies to manage the potential barriers to the development and implementation of this project, the ADDS
Chart has been updated to Version 3 (Appendix 4). Results indicate that further education of novice and new
nurses at the point of care may improve clinical decision-making when managing patients who have the potential
to experience clinical deterioration.
Keywords
Vital signs, clinical deterioration, Medical Emergency Teams (MET), escalation of care
52
Background
The traditional patient observation chart comprised temperature pulse and respiration (TPR), blood pressure
(BP) and Oxygen Saturation (O2 Sat %) and Oxygen delivery in L/min (Appendix 1). In line with the Australian
Commission on Safety and Quality in Healthcare Standard, Recognising and Responding to Clinical Deterioration,
Version 1 of the Adult Deterioration Detection System (ADDS) Chart (Appendix 2) was developed and trialled in
one of the two surgical wards. The chart incorporated the required vital parameters that nurses need to assess
and document to create a linear graph. This is known as ‘tracking’. Tracking enables the visualisation of peaks and
troughs in the patient’s condition that should ‘trigger’ the nurse to respond in accordance with the scoring system
embedded in the chart and the actions required also embedded in the chart. The purpose of this system is to
facilitate the escalation of patients experiencing deterioration and this could mean initiating a medical emergency
response by Medical Emergency Teams (MET).
Patient observations have traditionally been assessed according to organisational policy and procedures which
have not been evidencedbased. Key physiological parameters are used, and the ranges of each are scored. An
aggregate of the score is known as the Adult Deterioration Detection System (ADDS Score). The selection and
grading of the physiological parameters are similar to the criteria used for medical emergencies and are known as
a MET Criteria. Both the ADDS and MET Call criteria are based on levels of the patient’s haemodynamics that are
likely to cause rapid clinical deterioration. Most MET criteria focus on hyperthermia/hypothermia, tachycardia >140
or bradycardia <40, respiratory rate <6 or >35, systolic blood pressure <70 or >200, oxygen saturation<90% and
altered level of consciousness.
It is paramount that the nurse tracks these measurements and aggregates the score according to the legend to
reach a Total Score. It is the combination of the score and nursing clinical judgement that directs the nurse to
initiate a MET Call .
Aims
The aim of this project is to improve local practice in the detection of clinical deterioration in patients in an acute
care setting through measuring and documenting the patient’s clinical status, and to ensure that this method is
performed according to the best available evidence
The following criteria were evaluated to analyse if timely escalation occurred in a timely manner
1. Observations are taken on time of admission or initial assessment on all patients in acute care settings.
2. A clear monitoring plan outlining physiological observations to be recorded and the frequency of observations
is developed for each patient.
3. Monitoring plans are reconsidered and modified where needed according to changes in clinical circumstances.
4. The following physiological observations are taken: respiratory rate, oxygen saturation, heart rate, blood
pressure, temperature and level of consciousness. Physiological observations are documented in a structured tool
such as an observational response chart.
5. Each observation chart displays information in the form of a graph and includes: a system for tracking changes
in physiological parameters over time, thresholds for each physiological parameter that indicates abnormality,
information about the response/action required when abnormal thresholds are reached or deterioration is identified
and the normal physiological ranges for the patient are compromised.
These six criteria were developed in accordance with the 2010 National Consensus Statement developed by the
Australian Commission for Quality, Health and Safety.1 based on Level IV evidence (expert opinion).
53
Method
Baseline audit
A retrospective baseline audit measured practice in the assessment and documentation of the patient’s
physiological parameters. The chart audited was the traditional observation chart comprising temperature pulse
and respiration (TPR), blood pressure (BP) and Oxygen Saturation (O2Sat%) and Oxygen delivery in L/min. Audit
data was entered into JBI-PACES and analysed. GRIP was used to assist in developing implementation programs
to overcome barriers identified. As such, it was beneficial to include representation of key stakeholder groups in
the situational analysis approach embedded in GRIP.
All patients’ charts were reviewed by the project leader in consultation with the Nurse Unit Managers (NUM)
and key stakeholders. Each of the three wards (general surgical, Medical/Palliative Care and Orthopaedics and
faciomaxillary) have 25 patients at any one time resulting in a total of 75 patient records available for audit. A power
analysis conducted in the JBI-PACES program indicated a sample size of 55 patients would meet statistical power;
however 25 patient charts from each of the three areas were used for optimal comparison to stimulate a challenge
amongst the three areas resulting in a retrospective situational analysis of baseline data of 75 charts.
Implementation
Below is a list of the overall barriers and/or obstacles to change that were overcome with the involvement of
not only the clinicians at the point of care, but from the Leadership and Governance of the Medical Advisory
Committee, the Critical Care Forum and the Senior Nurse Management Committee. The trial in the one surgical
ward was conducted and resulted in modifications to the chart for the following reasons:
Barriers to change – Nursing
1. Format of chart (size, readability, cumbersome)
2. Track and Trigger Mechanisms (language was unfamiliar to nursing culture)
3. ‘Rounding off’ the patient’s physiological parameters to enable documentation of data into the ranges provided
4. Scoring the patient’s ADDS Score and using both ’Actions Required’ which are context specific
5. View of the ADDS Chart was an additional work
6.Fear of reprisal from VMO’s when the nurse reported that the patient needed to be reviewed in light of changes
in the patient’s condition as identified by the ADDS Score and/or the ‘inherent feeling’ of the nurse.
7. Apprehension of nurses making a ‘wrong call’
8.Disagreement with Nurse Unit Manager (NUM), Team Leader (TL), After Hours Nurse Manager (AHNM) as to the
need to contact the Visiting Medical Officer (VMO) or General Practitioner (GP).
Barriers to change – Medicine
1. The format of the ADDS chart - too complicated
2.The ranges of the physiological parameters were not specific enough eg temperature, heart rate and O2
Saturation %
3. Most reported that the ADDS Chart was for ‘dummy’ nurses
4. Medical staff would place more trust in the nurses inherent feeling than an ADDS Score
5.Intensive Care Medical Staff hold the belief that nursing staff will make inappropriate use of the MET Call
system.
Post implementation
Figure 1 illustrates that at the baseline audit, compliance was 100% for five of the six criteria. There was no score
possible for the 6th criteria as the traditional TPR Chart is historic in nursing and this criterion did not exist. Once
the new ADDS Chart was trialled in the Orthopaedic Ward, modifications were made based on feedback from
nursing and medical staff. As a result Version 2 was created implemented across all wards. Concurrently the
proposed eight strategies identified in GRIP were implemented to overcome identified barriers.
54
Figure 1: Assessment and documentation of compliance of audit criteria at baseline (yellow) and final
audit (blue) in three clinical areas. Compliance was measured as a percentage.
Follow up audit revealed 100% compliance in all areas including Criteria 6 with the documentation of patient
assessment. This result was surprising given the many barriers to implementation of an Observational Response
Chart (ADDS Chart) at the host acute care facility.
Table 1: Total MET Calls Activated over six months (1 June to1 Dec 2011) and the analyses of each call for their
validity.
False Alarms
MET calls activated MET calls not done in MET calls activated Total MET Calls
by other means
by ADDS criteria/ a timely manner
score
39
8
6
20
73
False alarms were predominantly due to inadvertent activation.
MET calls that should have been activated by the ADDS Score but where not done in a timely manner or otherwise
were related to the following:
1. A
DDS Chart not used in the department where MET Call was initiated eg Recovery Room, Oncology –
Chemotherapy; Cardiac Catheter laboratory – three patients
2. Head injury secondary to patient; fall occurred – three patients
3. Chest pain but patient’s physiological parameters were stable
4. Syncopal episodes – two patients
5. Seizure; patients physiological parameters were stable – five patients
6. Cardiac Arrest – six patients
7. Ventricular Tachycardia/ SupraVentricular Tachycardia – patient on telemetry
MET Calls that were not activated in a timely manner as reported by the MET staff and presented at Critical Care
Forum
1. ADDS Score and required actions not followed
2. Observations of the patients vital signs were documented but on review with staff member, critical thinking/
problem solving not evident
3. Severe hypertension only criterion; patient history not taken into consideration
4. Acute pulmonary oedema with cyanosis
Making a MET Call has been viewed by nursing staff as a decision to be made by the Nurse Unit Manager (NUM),
Team Leader (TL) or after business hours, by the After Hours Nurse Manager (AHNM). As a result timely escalation
of care has not been managed well.
55
Discussion
The ADDS Chart has been updated to Version 3 (Appendix 4) and is embedded in St Andrews Toowoomba
Hospital policies for Nursing Clinical Practice. The MET call team and VMO’s have developed a flow chart so that
all stakeholders are aware of their roles and responsibilities when admitting patients and referring patients for
physician/intensive care review. These policies endorse the use of the ADDS Chart and include:
1. Assessment and documentation of vital signs supporting the use of clinical judgement of the team leaders
2. Review of pathology results, X-rays and ECGs are to be reported on within four hours of admission
3.Initiation of MET Calls based on clinical assessment, ADDSs Score and critical decision making by the nurses
at the point of care
4.Responsibilities of VMOs on admission of patients and when collaboration is best sought from the Intensive
Care VMOs and the MET Call team members.
Factors that impact timely escalation of the patients who are symptomatic of clinical deterioration are:
Ownership of patient:
Admission and management of patients to a private hospital places ownership of the patient with the VMO/GP.
As a result, nursing staff are obliged to consult with the responsible VMO/GP and follow the treatment prescribed.
If the Registered Nurse (RN) is not satisfied with the direction given, then the RN is then to escalate the issues to
the NUM/TL/AHNM. It is then their responsibility to escalate as warranted. This adds levels of complexity to the
patient’s monitoring procedures which lead to confusion/fear and/or reluctance to escalate care.
Competency and confidence
With an increase in new graduate nurses and the natural attrition of experienced nurses, the skills mix at the grass
roots is immature and requires timely clinical support to facilitate opportunistic teaching and learning. For the
development of novice nurses (postgraduate Registered Nurses) the Clinical Nurse facilitator’s role is paramount to
the development of novices. For novice nurses and even experienced new nurses to the private health care facility,
the decision to call a VMO/GP is daunting and it is this aspect at St Andrews Toowoomba Hospital that assertiveness
training using case studies, e-learning programs and face-to-face role play could make a difference. There is also
another aspect of communication between nurses and VMOs/GPs which the audit process highlighted.
St Andrews Toowoomba Hospital has re-introduced the contemporaneous reporting via the Clinical Notes, together
with Variances that do not necessarily require a MET Call response. Anecdotal data to date is very positive from
both the VMOs/GPs and nursing staff.
Recommendations:
Establishment of the Review/Committee for analysis of causal factors and follow-up with staff in a non-punitive
manner.
Further clinical audit of the ADDS chart to assess where errors in clinical judgement or inexperienced skills mix in
the clinical wards continue to be the root cause of not initiating a MET Call in accordance with the ADDS Chart.
Also continuing education at the point of care and ongoing assessment of MET Calls to determine reliability of the
ADDS Chart ‘track and trigger’ mechanisms.
56
References
1.Australian Commission on Safety and Quality in health Care (ACSQHC). National Consensuus Statement:
essential elements for recognising and responding to clinical deterioration. 2010.
2.Preece MHW, Horswill MS, Hill A, Watson MO. The Development of the Adult Deterioration Detection System
(ADDS) Chart. 2010.
3. H
orswill MS, Preece MHW, Hill A, Christofidis MJ, Karamatic R, Hewett D, et al. Human factors research
regarding observation charts: Research project overview. QueenslandMark S. Horswill, Megan H. W. Preece,
Andrew Hill, Melany J. Christofidis, Rozemary Karamatic, David Hewett, and Marcus O. Watson. p. 1-20.
4. Z
eitz K, McCutcheon H. Observations and vital signs: ritual or vital for the monitoring of postoperative patients?
Appl Nurs Res. 2006 Nov;19(4):204-11.
5. G
ao H, McDonnell A, Harrison D, Moore T, Adam S, Daly K, et al. Systematic review and evaluation of
physiological track and trigger warning systems for identifying at-risk patients on the ward. Intensive Care
Medicine. 2007;33(4):667-79.
6.Smith GB, Prytherch DR, Schmidt PE, Featherstone PI. Review and performance evaluation of aggregate
weighted [`]track and trigger’ systems. Resuscitation. 2008;77(2):170-9.
7.Centre, for, Clinical, Practice, at, NICE. Acutely Ill Patients in Hospital: Recognition of and Response to Acute
Illness in Adults in Hospital. 2007 Jul Adults in Hospital.
8.Australian Commission on Safety and Quality in health Care (ACSQHC). Recognition and Responding to
Clinical Deterioration, Survey of Findings 2011
9.Patient Safety and Quality Matters, Centre for Healthcare Improvement, 2010, Recognition nd Management of
the Deteriorating Patient, Queensland Health data
10.Patient Safety and Quality Matters, Centre for Healthcare Improvement, 2011, Recognition nd Management
of the Deteriorating Patient, RMDP) update; ‘What’s the Score’ Patient Safety and Quality Matters, Centre for
Healthcare Improvement, 2010, Recognition and Management of the Deteriorating Patient, Queensland Health
data
Appendices
Appendix 1: Traditional TPR and BP Chart
57
58
Appendix 2: Evidence of Obstacles to Change (ADDS Continuation Chart)
Appendix 3: Improved usage to ADDS Chart
59
60
Appendix 4: Illustration of compliance and detection of deterioration
Appendix 5
61
62
JBI Fellows Monographs 2011-2012 Hua Shuangqi
63
Self-management of rheumatoid arthritis: a best
Hua Shuangqi
Huang Ying
Bao Chengcheng
Registered Nurse
Huashan Hospital
Fudan Unversity
Registered Nurse
Huashan Hospital
Fudan Unversity
Registered Nurse
Huashan Hospital
Fudan Unversity
Jiang Hong
Wei Li
Zhou Jiayi
Registered Nurse
Huashan Hospital
Fudan Unversity
Registered Nurse
Huashan Hospital
Fudan Unversity
Registered Nurse
Huashan Hospital
Fudan Unversity
Background: Rheumatoid arthritis (RA) reduces life expectancy in severe cases by six to ten years. It can affect
all aspects of the person’s life including their roles in their positions, relationships and independence. Selfmanagement skills are vital in helping people cope with the impact of this condition and to be able to make
informed choices about treatment options. Patient education plays a major role in regular management of RA,
which includes information about disease, self-management, exercise and psychology. Recent guidelines and
standards related to the care of people with RA have emphasised the importance and desirability of access to
self-management programs. In recent years, self-management programs have been a topic of interest to many
clinical researchers in China.
Aims/Objectives: This clinical audit is concerned with the implementation of Best Practice in the self-management
for patients with rheumatoid arthritis in hospital.
Methods: Using the standard recommended for self-management of rheumatoid arthritis. Eight audit criteria
were selected, based on high-level evidence sourced through JBI evidenced summaries. A clinical audit was
conducted using the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES) and
Getting Research into Practice (GRIP) process. Seventy-five patients (with level 2 rheumatoid arthritis) and seven
clinicians attended the audit project in Huashan Hospital.
Results: The results revealed disparity between clinical practice and guidelines. It was noted that the re-audit
phase revealed great improvements in compliance relating to five of the eight identified criteria. It resulted in big
improvements in the use of the assessment tool and education.
Conclusion: The project was successful and helped set up a self-management program in the Rheumatoid Ward.
It increased the patients’, nurses’ and other staff’s knowledge and awareness on self-management. It was a great
groundwork for further exploration.
Keywords: self-management, rheumatoid arthritis in hospital
Background
RA is a chronic inflammatory condition found in approximately 1 to 2% of the total population,1 and about 0.4% in
China.2 It is reported3 that 10% of patients completely lose their capacity to work in several years, and it is one of
the main reasons that people lose their capacity to work and for physical disability.4
RA reduces life expectancy in severe cases by six to ten years5 either through co-morbidity such as cardiovascular
disease or treatment-related adverse effects. It can affect all aspects of the person’s life including their roles in
their positions, relationships and independence.6,7 Liu did a research on 136 patients with RA in China, and it was
reported that 37% of patients suffered anxiety, and 62% suffered depression. These mental disorders decreased
the quality of their life.8
Evidence suggested that adopting an aggressive approach to suppressing the progress of the disease is the
current best practice in controlling the RA.9,10 This involves the use of disease-modifying anti-rheumatic drugs
(DMARDs), corticosteroids, biologic drugs, non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics.9,10
64
Self-management is defined as an individual’s ability to manage the symptoms, treatment, physical and
psychological consequences and lifestyle changes inherent in living with a long term condition.11 Self-management
skills are vital in helping people to cope with the impact of their condition and their ability to make informed choices
about treatment options.
Patient education plays a major role of the regular management of RA, which includes information about disease,
self-management, exercise and psychology. Recent guidelines and standards relating to the care of people with
RA have emphasised the importance and desirability of access to self-management programs.9,10,12,13
Expert Patient Programme Community Interest Company (EPP CIC) has identified a number of skills that, once
acquired, can help individuals have more understanding of and confidence to manage their condition on a daily
basis. These include: (EPP CIC, 2007)
• Setting goals and making action plans
• Developing communication skills
• Communicating with health and social care professionals
• Finding other healthcare resources in the community
• Understanding the importance of exercise, keeping active and healthy eating
• Managing fatigue, sleep, pain, anger and depression.
In recent years, self-management programs have been a topic of interest to many clinical researchers in China.14
A clinical trial was conducted in an acute care hospital, and 210 patients were enrolled in the program. The
program introduced self-management principles, helped patients set up their tailored management goals, provided
knowledge of the disease and medications, provided information regarding healthy lifetsyles and dealt with their
mental condition. The results found that self-management programs significantly improved patients’ compliance
and quality of life.14
The Huashan Hospital is a teaching hospital in Shanghai, China. There are 1200 hospital beds and more than 2.7
million clinical visits annually. In 2010, more than 1500 patients were admitted to the Rheumatoid Ward. About
160 patients have been treated in the hospital. There are 10 beds in the Rheumatoid Ward. Four nurses and three
doctors are working there. About 60% of patients are admitted to the hospital several times because of relapse.
The self-management programs have been confirmed very important to increase the quality of life for RA patients.
This project was undertaken to concern with the implementation of Best Practice in the self-management for
the patients with rheumatoid arthritis in hospitals. And it significantly improved patients’ compliance of medical
therapy and quality of life.
Aims
This clinical audit is concerned with the implementation of Best Practice in the self-management for patients with
rheumatoid arthritis in a teaching hospital in China.
• To set up a self-management program in a rheumatoid ward.
• To reduce the level of pain induced by RA.
• To reduce disability induced by RA.
• To improve patient compliance of self-management.
• To improve the quality of life among patients with RA.
Methods
Setting and population
The Huashan Hospital is a teaching hospital in Shanghai China. There are 1200 hospital beds and more than
2.7million clinical visits annually. In 2010, more than 1500 patients were admitted to the Rheumatoid Ward. About
160 patients have been treated in the hospital. There are 10 beds in the Rheumatoid Ward. Four nurses and three
doctors are working there.
As patients with level 2 rheumatoid arthritis are common in Huashan Hospital, we observed that these patients are
able to do self-management.
65
Assessment tools
The Arthritis Impact Measurement Scales 2 (AIMS2) is an improvement on an evaluation instrument that was
developed to measure patient outcomes in rheumatic diseases.
The scaling properties, reliability and validity of the AIMS2 approach was documented and the results showed that
Cronbach’s alpha was 0.72-0.91 and reliability of AIMS2 was 0.78-0.94.15
The AIMS 2 instrument is a 78-item questionnaire. The first 57 items are broken down into 12 scales: mobility level,
walking and bending, hand and finger function, arm function, self-care tasks, household tasks, social activity,
support from family and friends, arthritis pain, level of tension while doing work, and mood. The number of items in
each scale is either four or five. Item 58 concerns respondent satisfaction with each of the 12 health status scales.
Item 59 needs respondents to report how much of their problem with any of these twelve areas is attributable
to arthritis. Item 60 requires the patient to prioritise the three areas in which he or she would most like to see
improvement. Items 61-65 ascertain general perceptions of current and future health. Item 66 estimates the overall
impact of arthritis. Items 67 and 68 allow the patient to identify the type and duration of her or his arthritis. Item
69 provides an estimate of medication usage. Items 70-72 explore for comorbidity, and items 73-78 deal with
demographics. (AIMS 2 User Guide. Boston University 1992.)
In order to express these scores in similar units, a normalisation procedure is then performed so that all scores can
be expressed in the range 0-10, with 0 representing good health status and 10 representing poor status. In this
way, 12 health status scale scores ranging from 0-10 can be obtained. Assessment of AIMS 2 takes approximately
20 minutes to complete.
The initial and second audits assessed the following eight criteria:
• A validated assessment tool is used to assess individuals with chronic conditions.
• A
ssessment and reassessment of patients with chronic conditions includes individual’s accomplishments and
concerns, self efficacy and readiness to change.
• Clients are assisted with creating action plans.
• Clients are assisted with goal setting.
• Clients have received education regarding self-management.
• Clients receive support regarding self-management.
• Health beliefs have been discussed with clients.
• S
taffs dealing with clients with chronic conditions have received education in the delivery of self-management
strategies.
Phase 1
In the first week of November, we established a project team with six members, and everyone played different
roles, as team leader, information collector, date collector and quality controller. Then the team met to develop a
proposal including the scope of the audit, the eight criteria requirements, and the process and measurement of
the eight audit criteria.
Using the JBI-PACES program, an audit was conducted by members of the project team. The audit commenced
on 7 November 2011 and was conducted overfour weeks on patients in the hospital. We did the audit one week
before patients left the hospital.
Following the completion of the auditing process, the project team met to discuss the results of the audit using
the JBI-PACES program.
Phase 2- GRIP component - Implementation of Best Practice
The audit results were collected using JBI-PACES and disseminated to the project team in the second week
of December 2011. We held a meeting and reviewed the audit results. At the meeting, we progressed to the
initial step in the GRIP component, ie identifying and discussing the barriers to increasing compliance with Best
Practice. As we were short of human resources and funding, no validated assessment tool used by nurses and
lack of knowledge regarding self-management among nurses were identified at team meetings.
Following this discussion, we summarised some resources and barriers in order to develop strategies to improve
compliance with the criteria. We applied for project funding, communicated with the doctors, gave nurses materials
and lectures regarding self-management and patient education.
The strategies identified by the GRIP process are listed in the discussion section. The re-audit phase was from 12
December 2011 to 6 April 2012.
66
We provided patients with education regarding self-management in our ward and clinic. Four nurses attended
as instructors of patient education. The individual educational session was delivered by one of the nurses, and
every session took about 30 minutes. The nurse communicated with all patients face-to-face, and showed them
the patient booklets, with contents such asthe concept of self-management, communicating with health and
social care professionals, finding other healthcare resources in the community, understanding the importance of
exercise, keeping active and healthy eating, managing fatigue, sleep, pain, anger and depression.
Phase 3
The post implementation audit was a replication of the Phase 1audit utilising the JBI-PACES program. Guided by
the GRIP process, assessment tools were made available on the ward and staff were educated on how to utilise
tools to maximise future efficiency and compliance with best practice.
This project is a quality improvement exercise and hence formal ethical approval is not required. There are no
identifiable details regarding the patients entered through the data collection process within the JBI-PACES
program. Patient and staff confidentiality is maintained during data collection, analysis and write-up.
Results
Initial audit
The initial auditing process and data collection was conducted from 7 November to 4 December 2011, utilising the
criteria identified by JBI-PACES. Twenty-one patients and three nurses attended this process.
The results were transcribed to the JBI-PACES program for review and interpretation of compliance with
recommended guidelines (see Figure 1). It showed that patient assessment was not a part of nursing care in our
hospital, and no established assessment tools were available in the ward. Eighty-six percent of patients were
assisted with goal setting and creating of action plans based on current local policy.
Only 14% of patients discussed their health beliefs with nurses, because of low awareness on it.
Figure 1: Initial audit and criteria
67
GRIP
Criteria 1: A validated assessment tool is used to assess individuals with chronic conditions.
• Barriers: there was no assessment tool by the end of initial audit.
• Strategies: use a validated assessment tool.
• Actions: found a suitable tool and trained nurses how to correctly use the scale system.
Criteria 2: Assessment and reassessment of patients with chronic conditions includes individual’s accomplishments
and concerns, self-efficacy and readiness to change.
• Barriers: nurses lacked knowledge on assessment.
• Strategies: provided nurses with education about patient assessment.
• Actions: hold a lecture for nurses and disseminate evidence-based training materials.
Criteria 3: Clients are assisted with creating action plans.
• Barriers: patients had no idea of the consequences of RA, their condition and care of RA.
• Strategies: improved the patients’ knowledge of RA.
• Actions: hold a seminar on patient education. Communicate with patients by face-to-face to provide them with
knowledge about RA and self-management.
Criteria 4: Clients are assisted with goal setting.
• Barriers: doctors were not confident about nurses’ knowledge and cability to educate patients.
• Strategies: teamwork with doctors.
• Actions: communicate with doctors and showed them the self-management program.
Criteria 5: Clients have received education regarding self-management.
• Barriers: nurses lacked knowledge regarding self-management and the delivery of self-management.
• Strategies: Provide the nurses with education about this.
• Actions: Educate the nurses via lectures, multimedia, materials andbooklets.
Criteria 6: Clients receive support regarding self-management.
• Barriers: there were not enough human resources and patients had low awareness of getting support actively.
• Strategies: Set up a client service platform.
• Actions: Give the office phone number to patients when they leave the hospital. Ask patients to return for visits
on time. Set up a follow-up team and call patients after they have left hospital. Gve the patients information about
their community hospital.
Criteria 7: Health beliefs have been discussed with clients.
• Barriers: both patients and staffs had low awareness of it
• Strategies: Improve patients’ awareness.
• Actions: Make it a rule that staff need to discuss health beliefs with patients actively.
Criteria 8: Staff dealing with clients with chronic conditions have received education in the delivery of selfmanagement strategies.
• Barriers: there was no education about this.
• Strategies: educate staff and give them delivery strategies.
• Actions: educate nurses via lectures and materials. Develop booklets on patient self-management.
Re-audit
The re-audit phase was conducted from 12 December 2011 to 6 April 2012. Fifty-four patients, four nurses and
three doctors attended this re-audit. It was noted that the re-audit phase revealed great improvement in compliance
relating to five of the eight identified criteria (see Figure 2).
Compliance relating to the assessment tool increased by 100%. So did the compliance relating to patients and
staff receiving education.
Compliance relating to the criteria about assessment and reassessment was 93%, which was a remarkable
improvement.
Patients were assisted with creating action plans and setting goals. These criteria achieved 100% compliance in
the re-audit phase, compared with initial audit of 86%.
68
While the result in relation to ‘patients received support regarding self-management’ had low compliance (11%),
this result is further explored in the discussion section of this paper. Although there was an improvement, many
patients had not received any contact from our patient services.
It was noted that the number of patients who discussed health beliefs had increased from 14% to 89%. This was
as a result of intervention by doctors.
Figure 2: re-audit results and criteria
Discussion
The overall challenge of the project was to influence practice change to comply with evidence-based recommended
practice ie that implementation of Best Practice in self-management by patients with rheumatoid arthritis in
teaching hospitals. The results indicated there was a significant increase in the number of patients who were
recorded Best Practice compliance with evidence-based guidelines on self-management.
AIMS2 is considered a valid measure of health status in arthritis.15 It is reported that a consecutive cohort of
patients with knee osteoarthritis were required to complete AIMS2, the Short Form Health Survey (SF-36) and
four visual analog scales for pain, joint stiffness, and patient’s and physician’s global assessment. In addition, 30
randomly-selected patients were required to complete the questionnaire two days later for the second time for
test-retest reliability. Finally the factor structure of AIMS2 was performed using the principal component factor
analysis. The results showed that AIMS2 had reasonably good internal consistency, test-retest reliability, and
convergent validity in patients with osteoarthritis of the knee.16
In studies on the effect of patient education on patients with polyarthritis, the majority of the interventions has
been delivered to groups of patients17,18 and less in a one-on-one format.17 Also, patients with RA have reported
that they are mostly satisfied with individual nurse-delivered education19 and that one-on-one communication on
certain themes related to living with RA is preferred.20
69
A Cochrane review from 2003, which included mainly group-based patient education, showed small benefits to
RA patients’ physical and psychological health status when the education included behavioural components.18 A
recent review from 2010 on group-based patient education in patients with inflammatory polyarthritis (RA, PsA, early
RA) also showed beneficial outcomes when explicit social cognitive or cognitive behavioural theory was used.17 An
individual education program on joint protection showed improved joint protective behaviours after attendance.21 It
is also suggested that patient outcomes might be improved through individual nursing interventions.22
Although self-management is required by most discharged RA patients, the limitation of human resources and
short-term funding mean the service cannot be supported over a longpeirod. On the other hand, most of patients
discharged from our wards have little confidencein our service and prefer to visit doctors when their condition
changes.
During the implementation stage, we found that helping patients to undertake self-management could not be
done by the nurses independently. Cooperation with the doctors was essential. Some doctors wanted to discuss
the action plans and the goal setting with patients themselves, and the organisational policy and procedures
required doctors to do so. On the other hand, some doctors did not have full confidence about the nurses’level of
knowledge.
This was the first patient self-management project, involving combined patient education, patient services, patient
follow-up for discharged patients by telephone and emails. We envisage that there will be further improvement of
the program over the coming months as more comments and feedback are received.
Conclusion
The project was successful in setting up a self-management program in the Rheumatoid Ward. It increased
patients’, nurses’ and staff’s knowledge and awareness on self-management. It rrepresented great groundwork
for further exploration. But we still have a long way to go in maintaining the high compliance of the criteria and
giving patients support regarding self-management.
Reporting
The results and outcomes of the project will be disseminated to key stakeholders within the Royal Adelaide
Hospital via in-service presentations and hospital forums. The JBI-PACES and GRIP reports will be available to
interested stakeholders and other clinicians.
The project findings and impact will be distributed more widely via publications and possible conference
presentations.
Table 1: Summary of core findings
Barriers
Strategies
Resources
Outcome
Lack of human resource
More staff
Re-allocating workload
Get a nurse team for this
project
Lack of funding
Funding application
Nurse Department
Awaiting responses
Organisational policy
and procedures do
not support the use
of a validated chronic
condition tool
Implementation of
assessment by AIMS2/
SF-36
Medical literature
Validated chronic
condition tool available
in the ward
The nurses lack
knowledge on selfmanagement
Conduct lectures to
provide information to
nursing staff
Existing literature on selfmanagement
Increase in awareness of
self-management
Nurses’ attitude
Provide enough time and
other support
Human resource
educational material,
teamwork with other staff
Nurses have interest in
participating the program
The project overlapped
with doctors’ work
Communication and
collaboration
Meetings with doctors
teamwork with doctors
70
Acknowledgements
We would like to express our appreciation to the Joanna Briggs Institute for providing us with the opportunity and
support for this Clinical Fellowship, particularly, to Dr Yifan Xue, our JBI facilitator, for his dedication, concern,
patience and guidance.
A big thank you to the Fudan University Nursing College and Huashan Hospital which gave me the opportunity to
attend this fellowship.
Finally, we wish to extend our appreciation to the staff from the Rheumatoid Ward of Huashan Hospital for
participating in and allowing us to conduct this fellowship project.
References
(1)
Rheumatoid Arthritis: National Clinical Guideline for Management and Treatment in Adults. National
Collaborating Centre for Chronic Conditions (UK). London: Royal College of Physicians (UK); 2009 Feb.
(2)Zhang YB, Liu ZM, Xiong LS. Mechanisms of Rheumatoid Arthritis and advantages of treatment. Chinese
Journal of Cellular and Molecular Immunology. 2005;21: 88-94.
(3)Haozhu Chen. Practice of internal medicine [M]. 10th ed. Beijing: People’s medical publishing house, 1998.
Page 2085.
(4)Rengao Ye, Zaiying Lu. Medicine [M]. 6th ed. Beijing: People’s medical publishing house, 2005; page 885891.
(5)Pincus T, Callahan LF. The‘side effects’ of rheumatoid arthritis: joint destruction, disability and early mortality.
Rheumatology. 1993; 32 (suppl1): 28-37.
(6)Young A, Dixey J, Cox N, et al. How does functional disability in early rheumatoid arthritis (RA) affect patients
and their lives? Results of 5 years of follow-up in 732 patients from the Early RA. Study (ERAS) Rheumatology.
2000;39 (6):603-11.
(7) L
empp H, Scott D, King’sley G. The personal impact of rheumatoid arthritis on patients’ identity: a qualitative
study. Chronic Illn. 2006; 2: 109–20.
(8)Liu J, Yang MY, Fan HX. An analysis of the quality of life relatives with anxiety and depression of the rheumatoid
arthritis patients. China recovery. 2007; 22(1):11-13.
(9)Luqmani R, Hennell S, Estrach C, et al. British Society for Rheumatology and British Health Professionals in
Rheumatology Guideline for the Management of rheumatoid Arthritis (the first 2 years). Rheumatology. 2006;
45(9): 1167–9.
(10)National Institute for Health and Clinical Excellence. Rheumatoid Arthritis: The man agement of rheumatoid
arthritis in adults. London: NICE. 2009
(11)Barlow J, Sturt J, Hearnshaw H. Self-management interventions for people with chronic conditions in primary
care: examples from arthritis, asthma and diabetes. Health Educ J.2002; 61(4): 365–78.
(12)Arthritis and Musculoskeletal Alliance. Standards of care for people with inflammatory arthritis. London:
Arthritis and Musculoskeletal Alliance. 2006
(13)Department of Health. Our health, our care, our say, a new direction for community services. London: DH.
2004
(14)Deng SY, Chang CY, Li XL, Deng FY. An analysis of Self-management Behavior intervention of patients with
rheumatoid arthritis. J Nurs Train. 2010; 25(6): 532-535.
(15) M
eenan RF, Mason JH, Anderson JJ, Guccione AA, Kazis LE. AIMS2. The content and properties of a revised
and expanded Arthritis Impact Measurement Scales Health Status Questionnaire. Arthritis Rheum 1992; 35:110.
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(16)Sayed Javad MousaviMohamad, et al. Translation and validation study of the Persian version of the Arthritis
Impact Measurement Scales 2 (AIMS2) in patients with osteoarthritis of the knee. BMC Musculoskeletal
Disorders. 2009; 10:95.
(17)Iver MD, Hammond A, Betteridge N. Self-management of rheumatic diseases: state of the art and future
perspectives. Ann Rheum Dis 2010; 69:955-63.
(18) R
iemsma RP, Taal E, Kirwan JR, Rasker JJ. Systematic review of rheumatoid arthritis patient education.
Arthritis Rheum. 2004; 51:1045-59.
(19) M
akelainen P, Vehvilanen-Julkunen K, Pietial AM. Rheumatoid arthritis patient education: RA patients’
experience. J Clin Nurs. 2009; 18:2058-65.
(20)Barlow JH, Cullen LA, Rowe IF. Educational preferences, psychological well- being and self-efficacy among
people with rheumatoid arthritis, Patient Educ Couns. 2002;46:11-9.
(21) N
iederman K, de Bie RA, Kubli R, Ciurea A, Steurer-Stey C,Villiger PM, et al. Effectiveness of individual
resource-oriented joint protection education in people with rheumatoid arthritis. A randomizes controlled trial.
Patient Couns. 2011; 82:42-8.
(22) S
uhonen R, Valimaki M, Leino-Kilpi H. A review of outcomes of individualized nursing interventions on adult
patients. J Clin Nurs 2008; 17:843-60.
72
JBI Fellows Monographs 2011-2012 Emma Hutchinson
Improvement of occupational therapy cognitive
assessment and rehabilitation among adult
stroke patients in sub-acute rehabilitation: a best
Emma Hutchinson
Rehabilitation Allied Health Team Leader/Senior Occupational Therapist
Repatriation General Hospital
South Australia
Abstract
Background – Cognitive deficits in adult stroke patients can affect an individual’s quality of life post stroke. Cognition
in adult stroke patients can be difficult to assess because of the many factors that influence an individual’s cognitive
capacity, such as previous level of education, language abilities and existing co-morbidities, such as dementia.
Cognitive deficits may be identified using cognitive screening tools; however, there are a myriad of screening and
assessment tools for cognition, but no universally agreed gold standard. Therefore, even in one hospital, there is
a lack of consistency in the approach taken to further investigate and rehabilitate cognition. This is a report of a
quality improvement project conducted in the rehabilitation unit of a 300-bed urban teaching hospital in Adelaide,
South Australia.
Methods – The method of baseline audit, intervention and follow-up audit using the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES) program, developed by Joanna Briggs Institute,
aided the project over a six-month period. Following the first audit of case notes, (which used seven criteria related
to cognitive screening, assessment, rehabilitation and documentation) interventions were developed. These
included the development of an educational website and education sessions. A follow-up audit was conducted to
evaluate the effectiveness of the intervention.
Results – The first audit’s compliance rate was between 10% and 97% for the seven criteria. After the intervention,
the follow-up audit using the same criteria revealed a significant increase in compliance in the documentation of
screening, standardised and functional assessment, and rehabilitation related to cognition using evidence-based
practice.
Conclusion – The project reviewed the occupational therapy practices of cognitive assessment and rehabilitation
in adult stroke patients. It provided an opportunity to encourage an environment of change management and
leadership in the use of evidence based practice. Following the interventions, there was a greater adherence to
evidence-based practice related to cognitive assessment and rehabilitation as evidenced by the increased use of
standardised assessments and subsequent rehabilitation, as reviewed in the documentation.
Keywords – occupational therapy, stroke, cognitive deficits, audit, cognitive assessment, cognitive rehabilitation
Introduction
Stroke, cognitive deficit, cognitive assessment and rehabilitation
Stroke is Australia’s second single greatest killer after coronary heart disease and a leading cause of disability.1
The long-term effects of stroke are determined by the site and size of the initial stroke lesion and by the extent of
the subsequent recovery.2 Strokes cost Australia an estimated $2.14 billion a year.3
For the purpose of this project, stroke is defined as an event when the supply of blood to the brain is suddenly
disrupted, either by a blocked artery (blood clot or plaque) or because the artery breaks or bursts.4
Cognitive impairment is common in acute stroke with 45% of patients with cognitive deficit on admission.2
Cognitive changes after a stroke may be general (for example, slowing of information processing) or may occur
within specific domains (for example, orientation, attention, memory, mental flexibility, planning and organisation).2
Cognitive impairment may be missed in those who present with mild stroke and can have a significant impact on
their life after stroke.5 Not only is the individual affected, but also their family and those around them. Cognitive
impairments in stroke patients can also affect other outcomes, such as length of hospital stay, discharge destination
and Functional Independence Measure (FIM) scores.5
73
The appropriate assessment and subsequent treatment of cognition following stroke in sub-acute rehabilitation is
a pertinent issue. Cognitive screening of stroke patients is important, so that further assessment and subsequent
rehabilitation can commence.6 Cognition is difficult to assess because of the many factors that influence an
individual’s cognitive capacity, such as previous level of education, language abilities and existing co-morbidities,
such as dementia. Cognitive deficits may be identified using a cognitive screening tool; however, there is a myriad
of screening and assessment tools for cognition, but no universally agreed gold standard.5 Therefore, even in one
hospital, there is a lack of consistency in the approach taken to further investigate and rehabilitate cognition.
Substantial evidence supports multidisciplinary team care as the basis for delivery of stroke rehabilitation.1,6
Occupational therapy is a vital component of the multidisciplinary team. Occupational therapists treat people
who have impairments, restricted activity levels and limited abilities as a result of injury or illness, to achieve the
highest level of independence possible. They use purposeful activity to promote the restoration of function and to
maximise participation in meaningful activities, such as occupations of self-care, domestic, social and work roles.7
According to clinical guidelines, all patients who have problems with activities of daily living, including in areas of
cognition following strokes should have access to an occupational therapist with specific knowledge and expertise
in neurological care.8
Context and justification of project
Stroke rehabilitation typically involves a cyclical process involving assessment to identify and quantify the
patient’s needs; goal setting to define realistic and attainable goals for improvement; rehabilitation, to assist
in the achievement of goals; and reassessment to assess progress against agreed goals.2 Furthermore, early
rehabilitation for cognition is required to optimise improvements.8 In the Occupational Therapy Department at
the Repatriation General Hospital these steps are followed and adhered to. Initial assessments are conducted on
all patients, including a screen of cognition. Goal setting, subsequent rehabilitation and reassessment are then
conducted.
An opportunity arose for the researcher to participate in an evidence-based practice review funded through the
SA Health Allied Health Professional Development Reimbursement Program (AHP+PDRP). The reason for the
project leader choosing this topic was that at the Repatriation General Hospital, there is a lack of consistency in
the approach taken to further investigate and rehabilitate cognition. It was predicted that more clear and structured
guidelines about how to assess and rehabilitate cognition would provide a more thorough and consistent approach,
especially for staff who are new to the profession or to the area of stroke rehabilitation. The primary reason for the
project is to improve cognitive outcomes for adult stroke patients of the Repatriation General Hospital.
Aims
• To improve the health of adult stroke patients in sub-acute rehabilitation, especially in regards to optimising
their cognitive recovery.
• To ensure that occupational therapy cognitive assessment and rehabilitation is performed at the Repatriation
General Hospital according to best-available evidence.
• To improve Occupational Therapy Department practices at the Repatriation General Hospital in the area of
cognitive assessment and rehabilitation of adult stroke patients in sub-acute care.
Methods
Setting and sample
The project took place at the Repatriation General Hospital, which is a 300-bed urban, teaching hospital in South
Australia. At the hospital there are two inpatient stroke rehabilitation wards, a Day Rehabilitation Service with a
specialised neurological stream and a Rehabilitation Service in the Home program. The target population for the
project were patients admitted with stroke. In a given month, approximately 40 patients will be admitted to the
Repatriation General Hospital with a diagnosis of stroke. The average age of stroke patients during the months of
the audits was 72 years of age. The severity and location of the strokes included in the audit varied, with an almost
equal number of right and left strokes. Although only stroke patients were reviewed in the audit, it is acknowledged
that cognition can be affected by other diagnoses. The target staff population were Occupational Therapists
employed at the Repatriation General Hospital.
74
Table 1 shows the number of patients from each rehabiltation area who were audited in
the baseline and follow-up audits
Location
Number of patients
Baseline audit
Follow-up audit
Rehabilitation A
16
12
Rehabilitation B
7
12
Rehabilitation in the home
7
11
Day rehabilitation service
6
5
Stages of the project
Initial meeting
It was decided that a quality improvement project would be conducted in the Occupational Therapy Department
at the Repatriation General Hospital in the area of cognitive assessment and rehabilitation. It was recognised that,
following initial screening, there was a lack of consistency in the approach taken to further assess and rehabilitate
cognition.
At the beginning of July a meeting was held with senior staff in the Occupational Therapy Department, a group
of occupational therapists who are involved in a quality assurance working party targeting cognition and another
occupational therapist who is currently completing her PhD in the area of cognitive rehabilitation. At this meeting,
the attendees identified current gaps in knowledge and reviewed what work had already been covered by the
quality assurance working party and by the PhD candidate, to minimise the amount of duplication in the project.
It was identified that, given the lack of consistency in cognitive assessment and rehabilitation, there was a need
to review the practices used at the Repatriation General Hospital, to ensure a higher level of competence in the
area and to establish greater consistency in the approaches to cognitive assessment and rehabilitation used by
the staff. Although only half of the Occupational Therapy Department staff work in stroke rehabilitation, given the
rotational nature of staff positions, it was felt all occupational therapy staff at the Repatriation General Hospital
would benefit from being involved in the project, so that consistency in the approach to cognitive assessment and
rehabilitation could be achieved.
Prior to the meeting, the project leader had identified some potential barriers that could affect project compliance.
These were included in the JBI GRIP (Getting Research Into Practice) tool. These presumed barriers were:
• L
ack of consistency amongst occupational therapists in their manner of documenting cognition from initial
assessment screening. This lack of consistency, in part, stemmed from the level of experience of the OT and
the importance they place on cognition.
• Lack of awareness of the requirement to assess cognition and the resources available to do so. • Lack of awareness of the resources available for cognitive rehabilitation.
• L
ack of funding available for occupational therapy time to implement thorough cognitive assessment and
rehabilitation.
In discussions at the meeting, it was acknowledged that the presumed barriers were valid; however, the lack of
funding should not be a barrier to this important aspect of treatment. At the meeting, a list of actions for the project
was generated:
-
To evaluate the current knowledge base regarding cognitive assessment and rehabilitation amongst
occupational therapy staff.
-To review the literature to ascertain if each cognitive assessment is validated according to evidence.
-To develop a comprehensive but concise algorithm to assist staff in deciding what type of cognitive assessment
to administer on a given patient.
-To develop a list of rehabilitation interventions to help guide cognitive therapy, especially in relation to the use
of the newly purchased iPad.
Monthly emails providing an update on the project were sent to all occupational therapy staff. The project was
also discussed at staff meetings, enabling any staff members the opportunity to provide input or comment into the
project if they wished to do so.
75
Ethical issues
The audit was conducted without any patient contact by the auditor that would not normally be conducted as part
of standard hospital practice. Any information obtained during the course of the audit was treated confidentially
and has not led to any identification or contact with an individual patient. Usual care was provided for patients
identified as having cognitive deficits as per standard hospital practice. The need for ethics approval was not
indicated.
Evidence summary was established
A search of JBI Connect was performed for useful evidence-based documents related to cognitive assessment and
rehabilitation. There were no existing JBI evidence summaries directly related to the topic of the audit; therefore, in
order to review whether cognitive assessment and rehabilitation amongst adult stroke patients in sub-acute care
at the Repatriation General Hospital was performed according to best-available evidence, an evidence summary
was developed, using clinical guidelines and systematic reviews.9
Audit criteria were determined
As a result of completing the evidence summary, the following seven criteria were generated and through use of
the JBI-PACES program were used as the audit questions.
1. Cognition was screened and documented in the initial Occupational Therapy assessment. For compliance with
this criterion, the patient must have their initial screening conducted within two working days of admission. Two
working days is the current time frame requirement for occupational therapy staff to complete initial assessments
and is a Key Performance Indicator. 2. For patients with cognitive deficits, cognition rehabilitation was identified and documented as a goal in patient
goal setting. For compliance with this criterion, a goal with a cognitive focus must be included in the case notes
(on the Goal Setting Proforma; in the Occupational Therapy Initial Assessment Proforma; or in the Occupational
Therapy Neurological Initial Assessment Proforma).
3. For patients identified as having cognitive deficits in the screening, in depth Occupational Therapy assessment
is conducted and documented using a standardised assessment tool. For compliance with this criterion,
documentation in the patient case notes must report which standardised assessment was conducted and what
was found as a result of performing the assessment.
4. For patients identified as having cognitive deficits in the screening, in depth Occupational Therapy functional
assessment is conducted and documented. For compliance with this criterion, the functional assessment must be
documented clearly in patient case notes and the domain of cognition must be included in the assessment report.
5. Cognitive rehabilitation is implemented and documented based on the assessment. For compliance with this
criterion, documentation reporting the cognitive rehabilitation must be included in patient case notes.
6. Staff have attended a training session on cognitive assessment and rehabilitation. For compliance with this
criterion, staff must attend one of the project education sessions or have provided evidence that they have read
the email providing education about the project. Evidence was provided via an email ‘read receipt’ sent to the
project leader.
7. Cognition is documented in the discharge summary. For compliance with this criterion, cognition must be
reported on by the occupational therapist in the patient discharge summary in some capacity – whether cognitive
deficits were identified or not.
Baseline audit
This was conducted to identify current practice pertaining to documentation enabling identification, assessment and
rehabilitation of cognitive deficits in adult stroke patients admitted to the Rehabilitation Wards, Day Rehabilitation
Service and Rehabilitation in the Home Program of the Repatriation General Hospital. The audit occurred over a
one-month period using the Open Architecture Clinical Information System (OACIS) system, ward diaries and ward
clerk records to identify eligible patients – those who were admitted with a diagnosis of stroke in the month of
June. Allied Health reception staff assisted in locating the files required for the audit. The initial baseline audit was
conducted in July 2011 on the 36 auditable patients admitted during the month of June with a diagnosis of stroke.
76
This involved a review of each patient’s case notes specifically looking at the following documentation to identify if:
1) Cognition was screened in the initial assessment, as per the Occupational Therapy Initial Assessment Proforma.
2)Cognitive deficits were further investigated or commented upon in other occupational therapy case note entries
for that admission.
3) Cognition was documented in goal setting.
4) Occupational therapy rehabilitation was conducted in the area of cognition.
5) Results of cognitive assessments and rehabilitation were documented in the discharge summary.
Case notes are a medical record including a systematic documentation of a single patient’s medical history and
care. The discharge summaries are medical documents provided to relevant care providers at the end of a patient’s
admission. They are centralised on OACIS .
The JBI-PACES software tool facilitates a process for practice change using an audit, feedback and re-audit cycle.
Two options are available within the tool: a clinician-based option which is designed for smaller scale practice
and an organisation-based option for large scale practice. The type of JBI-PACES cycle used in this project
was clinician-based. The data entered was evaluated by JBI-PACES and a report generated showing per cent
compliance for criteria in each area.
Interventions
• A
review of all standardised cognitive assessment tools available at the Repatriation General Hospital was
undertaken. The assessments included:
oCognistat
o MOCA (Montreal Cognitive Assessment)
o RUDAS (Rowland Universal Dementia Assessment Scale)
o MMSE (Mini Mental State Examination)
o LOTCA-G (Lowenstein Occupational Therapy Cognitive Assessment – Geriatric
o Trail Making Test
o FAB (Frontal Assessment Battery)
o Texan Functional Scale
o Westmead Post Traumatic Amnesia Scale
o Praxis Screen
o AMPS (Assessment of Motor and Process Skills)
• E
vidence for each of the assessments was reviewed and information was collated in a table, summarising
which domain of cognition each assessment was validated to assess. The full table is available on request
from the author.
• A
n algorithm/decision tree in the form of a website was developed. The website can be found at: https://sites.
google.com/site/cognitiveassessmentandrehab/ The aim of the website was that staff could:
o Confirm the patient’s area of cognitive deficit according to the definitions provided.
o Determine which cognitive assessments were validated to assess the area of cognition in question.
oFollowing the cognitive assessment, determine what kind of approach to take with the patient and what type
of rehabilitation would be of benefit to the patient.
oIdentify which applications available on the iPad could be used in rehabilitation for the area of cognition in
question.
• Inservices for all occupational oherapy staff were held, providing education about the evidence base for
cognitive assessment and rehabilitation in occupational therapy. Instructions about the use of the website
were also provided. Three inservice sessions of 30 minutes each were held during the months of August and
September. Some staff were unable to attend the inservices, therefore an email providing further explanation
and education was sent to all occupational therapy staff.
77
Follow-up audit
The follow-up audit was conducted using the case note documentation for all stroke patients admitted to the
Repatriation General Hospital with a diagnosis of stroke during the month of October. The case notes of the
patients were reviewed and the same audit criteria were used to evaluate the effectiveness of the intervention.
Results of the audits were evaluated
These results are discussed later in this report.
Results
Initial audit
Data from the initial audit were entered into the JBI-PACES audit software program which then generated
percentage compliance for each of the seven criteria audited.
Forty patients were admitted with a diagnosis of stroke to the rehabilitation unit of the Repatriation General Hospital
during the month of June; however, at the time of audit, four of the patients’ medical files could not be located,
therefore only 36 of them were audited. Of those 36 patients, 21 of them where identified in the initial cognitive
screening as having a cognitive deficit.
Table 2 shows the sample size audited in the baseline audit.
Baseline Audit (June 2011)
Criterion
Sample size
Cognition was screened and documented in the initial Occupational Therapy assessment.
36
For patients with cognitive deficits, cognition rehabilitation was identified and documented as
a goal in patient goal setting.
21
For patients identified as having cognitive deficits in the screening, in depth Occupational
Therapy assessment is conducted and documented using a standardised assessment tool.
21
Therapy functional assessment is conducted and documented.
21
Cognitive rehabilitation is implemented and documented based on the assessment
21
Staff have attended a training session on cognitive assessment and rehabilitation
32
Cognition is documented in the discharge summary
36
Figure 1 shows the compliance rate to the seven criteria in the baseline audit.
It was promising to observe that, according to Criterion 1, almost all patients received cognitive screening on
admission. The lowest compliance rate was related to goal setting (Criterion 2). An explanation of this is that
occupational therapy staff did not have an awareness of the importance of documenting cognition in goal setting.
There was also a low compliance rate related to use and documentation of standardised and functional assessment
tools (Criteria 3 and 4). A possible explanation for this is the lack of awareness of cognitive assessments available
and a lack of clinical judgment utilisation when choosing cognitive assessments. There was also a low compliance
rate for discharge summary documentation (Criterion 7). This could be related to the fact that occupational therapy
staff were unaware of the requirement to document cognition in the discharge summary. Less than half of the staff
received education prior to the interventions (Criterion 6).
78
Follow-up audit
In the month of October another 40 patients were admitted to the rehabilitation unit with a diagnosis of stroke. All
40 of them were audited in the follow-up audit cycle. On initial screening 24 of them were identified as having a
cognitive deficit.
Table 3 shows the sample size audited in the baseline audit
Follow-Up Audit (October 2011)
Criterion
Sample size
Cognition was screened and documented in the initial Occupational Therapy assessment.
40
For patients with cognitive deficits, cognition rehabilitation was identified and documented
as a goal in patient goal setting.
24
Therapy assessment is conducted and documented using a standardised assessment tool.
24
Therapy functional assessment is conducted and documented.
24
Cognitive rehabilitation is implemented and documented based on the assessment
24
Staff have attended a training session on cognitive assessment and rehabilitation
32
Cognition is documented in the discharge summary
40
Figure 2 shows the compliance rates to the 7 criteria, comparing the follow-up audit to the baseline audit.
79
Table 4 compares the baseline audit compliance with the follow-up audit compliance.
Audit Criteria
Baseline Audit
Number
Audited
Follow-Up Audit
Number
Compliant
% Compliant
Number
Audited
Number
Compliant
% Compliant
Criterion 1
36
35
97
40
40
100
Criterion 2
21
2
10
24
11
46
Criterion 3
21
8
38
24
12
50
Criterion 4
21
8
38
24
16
67
Criterion 5
21
12
57
24
15
63
Criterion 6
32
15
47
32
32
100
Criterion 7
36
14
39
40
19
56
As indicated in the table above, compliance with each of the auditable criteria increased. The audit indicated that
a high level of compliance was reached in Criterion 1 (initial screening and documentation of cognitive deficit).
Significant increases in compliance were indicated in Criterion 2 (cognition documented as a goal in patient goal
setting), Criterion 3 (use of standardised cognitive assessment), Criterion 4, (use of functional assessment) Criterion
5 (implementation of cognitive rehabilitation) and Criterion 7 (reporting of cognition in the patient’s discharge
summary). These increases in compliance may, in part, be due to the high level of compliance shown in the followup audit of Criterion 6 (staff were provided with education about cognitive assessment and rehabilitation). For
Criterion 7 in the follow-up audit, 6 of the patients were still inpatients and therefore a discharge summary had not
yet been written. Those patients were scored as Not Applicable for Criterion 7 in the audit.
Table 5 compares the variety of cognitive assessments utilised by occupational
therapists in the baseline audit and the follow-up audit
Cognitive Assessment
# of Times Cognitive Assessment Used
Baseline Audit
Follow-up Audit
MOCA
7
7
RUDAS
1
0
Cognistat
0
2
Texan Functional Scale
0
1
Trail Making Test
0
2
Discussion
The purpose of this project was to evaluate whether staff of the Occupational Therapy Department at the
Repatriation General Hospital are currently using Best Practice, according to the evidence in cognitive assessment
and rehabilitation. In the discussion below, each of the criteria are analysed and evaluated.
Criterion 1 – The audits indicated that a high level of compliance was reached and maintained in the initial
screening of patients within 48 hours of admission and that cognition was screened on all occasions. During the
first month, one patient was not screened for cognitive deficit. This patient had been transferred to acute care from
rehabilitation, due to the onset of an acute illness. On return to rehabilitation, a further screen of cognition was not
conducted. Screening of patients in this situation is still required, because of the impact an acute illness can have
upon cognition.
The high level of compliance to this criterion could be attributed to the user-friendly format of the Occupational
Therapy Initial Assessment proforma and Occupational Therapy Initial Neurological Assessment proforma, which
prompt staff to screen the patient for cognitive deficits. From review of the patient case notes, there appears to be
a lack of consistency in the type and thoroughness of cognitive screening conducted. This is an area that could be
improved upon to ensure that adequate cognitive screening is taking place.
80
The Initial Assessment proforma is used hospital-wide, suggesting that cognition be screened for all patients seen
in occupational therapy – not just those admitted with stroke. This ensures that all occupational therapy staff are
considering all patients’ cognitive capacities and not just those admitted with stroke.
Criterion 2 – The audits indicated that a significant increase of including cognition in patient goal setting was
reached in the follow-up audit. This may be due to the heightened awareness of occupational therapy staff of
the need to include cognition in rehabilitation. However, at the time of the second audit, a quality assurance goal
setting project was being conducted on the inpatient rehabilitation unit. This project involved allied health staff
establishing more specific, measureable, and time-dependent rehabilitation goals to guide management. The
heightened awareness of cognition, coupled with the goal setting project may have influenced the significant
improvement in goal setting.
This project did not look at the outcomes of goal setting; therefore’ it is not known if the cognitive goals set were
appropriate, realistic or if they were indeed reached during rehabilitation.
Criterion 3 – A greater number of the patients identified as having cognitive deficits in initial screening were
further assessed using standardised cognitive assessments in the second follow-up audit. Again, this may be
attributable to the interventions. Furthermore, as indicated in Table 5, a greater variety of cognitive assessments
were utilised during the month of the follow-up audit. It could be suggested that the intervention (website) assisted
staff in choosing which assessment to conduct, depending on the deficit they wished to assess further, rather than
reverting to the standardised assessment they had used before or were most familiar with.
This project did not look at whether the choice of cognitive assessment was indeed appropriate for the patient
assessed. The project reviewed only whether or not a standardised assessment was conducted.
Criterion 4 – An increase in the use of functional assessments for the patients with cognitive deficits was seen in
the second follow-up audit. It must be noted that a functional assessment is often conducted by the occupational
therapist to assess not only cognition, but also physical, social and behavioural capacities. For compliance to
be reached in this criterion, the patient’s cognition had to be reported on in the case notes as an area that was
assessed. The types of functional assessments used by occupational therapy staff during the months of the two
audits included:
- Kitchen task assessment (preparation of a hot drink, snack or meal)
- Self-care assessment (showering/grooming/dressing)
- Laundry task assessment (ironing/hanging out washing)
- Money management assessment.
The types of functional assessments used did not differ greatly from one audit to the other. The number of functional
assessments conducted for patients without cognitive deficits increased during the month of the follow-up audit.
This could be attributed to changes in staffing in the rehabilitation wards from one month to the other. Some
Occupational Therapists take a more functional approach to their assessment and rehabilitation.
This project did not review the outcome of the functional assessment or whether the choice of functional
assessment by the occupational therapist was optimal for the patient.
Criterion 5 – In the follow-up audit, a greater number of patients identified as having cognitive deficits participated
in cognitive rehabilitation with the occupational therapist. This again may be attributable to the rehabilitation ideas
provided in the intervention (website and education sessions), which hopefully provided occupational therapy staff
with increased confidence in their clinical judgment when choosing the rehabilitation treatment.
For compliance to this criterion, the use of cognitive rehabilitation had to be reported on in the patient’s case
notes by the occupational therapist or allied health assistant (relevant only in the Rehabilitation in the Home
program and Day Rehabilitation Service). For patients admitted to the Rehabilitation in the Home program and
Day Rehabilitation Service, it was easy to identify whether cognitive rehabilitation had been utilised, because the
occupational therapist must document every time he/she sees a patient. This may indicate why a greater number
of patients from these services appeared to participate in cognitive rehabilitation. On the other hand, occupational
therapy staff on the inpatient wards need only summarise patient progress once a week in the patient’s case
notes (unless a specific assessment is conducted or if an event occurs). This weekly summary can lack the
detail of individual sessions, thereby omitting details of cognitive rehabilitation, especially if other more pertinent
rehabilitation is occurring, such as upper limb therapy. Occupational therapy staff keep daily progress notes
separate to the patient case notes. These occupational therapy progress notes were not reviewed. Therefore,
it is possible that a larger amount of cognitive rehabilitation was conducted than what was documented in the
patient case notes. The same could be said for the amount of standardised cognitive assessments conducted and
functional assessments conducted; however, there is an expectation that those assessments are documented in
the patient’s case notes on the day they are conducted.
81
This project did not critique whether the choice of rehabilitation treatment was appropriate for the patient and his/
her cognitive deficit.
Criterion 6 – During the first audit in June, less than half of the occupational therapy staff attended an inservice
about the project, which provided information about the project, highlighting the importance of assessing and
rehabilitating cognitive deficits according to the best available evidence. By the time of second audit, all 32
occupational therapy staff at the Repatriation General Hospital had received education about the project and
the website and the importance of assessing and rehabilitating cognitive deficits according to the best-available
evidence, thereby achieving 100% compliance for this criterion. Results from the audit of this criterion indicate that
staff attendance at relevant in services is realistic and that dissemination of information via email is an effective
mode of information delivery.
Criterion 7 – Occupational Therapy staff achieved greater compliance on Criterion 7 in the follow-up audit. The
requirement for this criterion was that occupational therapy staff document cognition in all patient case notes, not
just those with cognitive deficits. For patients without cognitive deficits, a comment such as ‘cognition intact’ or
‘cognition within average range’ sufficed. For those patients with cognitive deficits, compliance for this criterion
was reached if the occupational therapist reported any of the following:
- The patient’s cognition on admission to rehabilitation
- The patient’s cognition upon discharge
- Results of standardised cognitive assessments
- Cognitive capacity in functional assessments
- Impact of cognition on a patient’s performance on the ward
- Impact of cognition on a patient’s discharge destination.
Further discussion
The framework provided by the JBI-PACES program gave the project direction in identifying Best Practice criteria,
providing a focus for future strategies and measurable goals to work towards achieving Best Practice.
The GRIP component of JBI-PACES was effective in encouraging the auditor to plan the change management
process side by side with stakeholders and to identify barriers to change prior to implementing strategies.
Since the website was established in August, positive and constructive feedback has been received about its
usefulness. Occupational therapy staff from Flinders Medical Centre also requested access to the site and have
reportedly found it to be a useful tool. The usefulness of the implementation tool has not been formally evaluated.
The website remains a work in progress, as it requires updates when new cognitive assessments are introduced
to the Occupational Therapy department.
The ongoing application of the website lies especially in the orientation of new staff members who do not have
experience with patients with cognitive deficits. It provides structure to facilitate a more consistent approach to
cognitive assessment and the subsequent rehabilitation provided. This implementation tool also has potential to
be used more widely than the Repatriation General Hospital, as evidenced by its use at Flinders Medical Centre.
Conclusion
The success of this project appears to have increased the awareness of the importance and relevance of cognitive
assessment and rehabilitation. Occupational therapy staff are actively thinking and reacting to situations with a
greater emphasis to clinical judgement and use of evidence. This has been evidenced by their choice of cognitive
assessment, which seems to be more educated, rather than using the same assessment every time.
As a result of the project, there has been an increase in the awareness of the importance of cognitive assessment
and rehabilitation in adult stroke patients. This has translated into practice, as evidenced by the increase in the
use of standardised cognitive assessments, functional assessments and cognitive rehabilitation. This, in turn, has
resulted in better outcomes for patient’s health in relation to cognition.
The development of a website outlining the assessments available and suggested rehabilitation ideas are part of
the overall strategy to improve cognitive assessment and rehabilitation, which will hopefully improve outcomes
of adult stroke patients, and influence other key performance indicators, such as by reducing length of stay,
improving quality of life, improving destination outcomes on discharge and increasing Functional Independence
Measure scores. This has positive financial implications on the hospital and is in keeping with Best Practice
guidelines.
82
The development and use of the website and education sessions with evidence based content is an indication
of staff using evidence based practice. Occupational therapy cognitive assessments and rehabilitation are
now performed according to best-available evidence to an increased proportion of adult stroke patients at the
Repatriation General Hospital.
Implications for further research
• T
his project evaluated whether occupational therapy staff at the Repatriation General Hospital are using Best
Practice in cognitive assessment and rehabilitation of stroke patients. It did not review whether compliance
with this Best Practice impacted upon other key performance indicators or outcome measures used in the
Occupational Therapy department or the hospital as a whole. It would be interesting to conduct further study
to determine whether compliance with Best Practice in this area impacts upon a patient’s length of stay, quality
of life, discharge destination or Functional Independence Measure (FIM) score.
• F
rom review of the patient case notes, there appeared to be a lack of consistency in the type and thoroughness
of cognitive screening conducted. This is an area that could be researched further to seek to ensure adequate
cognitive screening is taking place.
• T
he effectiveness of the interventions has not yet been formally evaluated. The effectiveness of a web-based
learning tool in cognitive assessment and rehabilitation could be conducted.
• Other areas that were not reviewed in this project, but that could be researched further are:
o Whether the choice of cognitive assessment was appropriate for the patient assessed.
o Whether the choice of rehabilitation treatment was appropriate for the patient and his/her cognitive deficit.
oWhether the choice of functional assessment by the occupational therapist was optimal for the patient and
what its outcome was.
o Whether the cognitive goals set were appropriate, realistic or if they were reached during rehabilitation.
Implications for practice
• T
he use of proformas in initial assessment is an effective way to ensure necessary screening of the patient
takes place, as the proforma can serve as a prompt to the occupational therapist. The Initial Assessment
proforma is used hospital-wide, suggesting that cognition be screened for all patients seen in occupational
therapy – not just those admitted with stroke.
• T
he screening of patients on return to rehabilitation from an acute up-transfer is important, as cognitive changes
may have occurred as a result of the acute illness.
• T
his project indicates that initial cognitive screening, further standardised cognitive assessment and cognitive
rehabilitation of patients is a feasible and manageable task. Some standardised assessments can be time
consuming to conduct, especially if a patient’s cognitive state is complex. However, the use of the assessments
can assist in guiding rehabilitation and can positively affect a patient’s outcomes.
• W
eekly summaries written in the inpatient rehabilitation notes can lack the details, compared with notes written
following every session with a patient. The depth of rehabilitation may not be reflected in the documentation.
• F
unctional assessments are often conducted by the occupational therapist to assess not only cognition, but
also physical, social and behavioural capacities. The amount and type of functional assessments conducted
with a patient can vary depending on the occupational therapist providing the interventions. This is because
some occupational therapists take a more functional approach to their assessment and rehabilitation.
• A
n individual’s understanding of the background and validity of a standardised cognitive assessment can
influence whether the assessment is chosen for use or not.
• Education via a user-friendly website is an effective way to improve practice. • R
esults from the audit indicate that staff attendance at relevant in services is realistic and that dissemination of
information via email is an effective mode of information delivery.
83
• It is a requirement of occupational therapy staff that they document cognition in all patient discharge summaries,
not just those with cognitive deficits. For patients without cognitive deficits, a comment such as ‘cognition
intact’ or ‘cognition within average range’ would suffice. For patients with cognitive deficits, the occupational
therapist may report any of the following:
o The patient’s cognition on admission to rehab
o The patient’s cognition upon discharge
o Results of standardised cognitive assessments
o Cognitive capacity in functional assessments
o Impact of cognition upon a patient’s performance on the ward
o Impact of cognition upon a patient’s discharge destination
• In keeping with Best Practice, it is possible with raised and sustained awareness to create positive changes in
cognitive assessment and rehabilitation. This, in conjunction with continued education sessions targeted at all
members of the health care team, contributes to improved outcomes.
Acknowledgements
I would like to acknowledge the following agencies and individuals for their assistance and support throughout
this project:
• O
ccupational Therapy staff at the Repatriation General Hospital, especially Karen Brown, Sharyn Chaplin, Kate
Laver and Catherine McMahon
• Julie Organ, Allied Health Administration
• Dr Catalin Tufanaru, Facilitator, Research Fellow, Joanna Briggs Institute
• AHP+PDRP (Allied Health Plus + Professional Development Reimbursement Program, SA Health)
References
1.Australian Institute of Health and Welfare 2006. Australia’s Health; 2006. http://www.strokefoundation.com.au/
facts-figures-and-stats (cited December 8 2011
2. Langhorne P, Bernhardt J, Kwakkel G. Stroke Care 2, Stroke Rehabilitation, The Lancet 2011; 377:1693-1702.
3.Cadilhac DA, Carter R, Thrift AG, Dewey HM. Estimating the long-termcosts of ischemic and hemorrhagic
stroke for Australia: new evidence derived from the North East Melbourne Stroke Incidence Study (NEMESIS).
Stroke 2009 Mar;40(3):915-21.
4.Australian Institute of Health and Welfare 2006. Australia’s Health; 2006. http://www.strokefoundation.com.au/
what-is-a-stroke (cited December 8 2011)
5. National Stroke Foundation. Clinical Guidelines for Stroke Management. 2010.
6.Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients.
Cochrane Database Syst Rev 2005;2:CD000443.
7. G
ovender P, Kalra L. Benefits of occupational therapy in stroke rehabilitation, Expert Review of Neurotherapeutics 2007;7.8:1013-1020.
8.Scottish Collegiate Guidelines Network. Management of patients with stroke: Rehabilitation, prevention and
management of complications, and discharge planning: A national clinical guideline. 2010.
9.Hutchinson, E Tufanaru, C. Adult Stroke Patients in Sub-acute Rehabilitation: Occupational Therapy Cognitive
Assessment and Rehabilitation, Evidence Summary JBI Connect+. 2011. http://connect.jbiconnectplus.org/
ViewDocument.aspx?0=5403 (Accessed 8 December 2011)
84
JBI Fellows Monographs 2011-2012 Jeanette Kassulke
A best practice implementation project on
peripherally inserted central catheter (PICC):
dressing and flushing among adult patients
in six medical/surgical ward areas and one
outpatient unit within Logan Hospital in Brisbane,
Queensland
Jeannette Kassulke
Rose McSorley
Nurse Educator – Acute Service
Nursing and Midwifery Practice Development Unit
(NMPDU)
Logan Hospital
Infection Control CNC
Logan Hospital
Christopher Cronk
Clinical Facilitator – Surgical
Logan Hospital
Susan Legge
ACNC Palliative Care
Logan Hospital
Sharon Hill
Nurse Unit Manager
2I Orthopaedics
Logan Hospital
Amanda Blair-Brown
Nurse Unit Manager
3C Cardiology
Logan Hospital
Dale McKenzie
Acting Nurse Unit Manager
Day Therapy Unit
Logan Hospital
Abstract
Background
Peripherally inserted central catheters (PICC) lines are a central access device inserted peripherally to provide
secure access for treatment of patients with poor peripheral access. Care needs to be taken when dealing with
these lines to avoid complication with infection in this patient group.
Aims/objectives
To assess staff adherence and demonstration of Best Practice principals, identify any barriers and education to
correct any issues identified.
Methods
The project was conducted as a pre- and post implementation clinical audit project and included five phases.
The current practices at Logan were measured against Best Practice guidelines from the Joanna Briggs Institute
Application of Clinical Practice Evidence System (JBI-PACES). The required sample was 34 through JBI-PACES;
however, two out of the three areas audited did not make the final number. The pre-audit was conducted. The
project team met to review the results and identified concerns and discussed strategies for improvement of
practice in the care of the peripherally inserted central catheters (PICC) lines. The Getting Research into Practice
(GRIP) tool was used to plan the strategies and for implementation. Education completed and a post audit was
completed using JBI-PACES.
85
Results
At the end of post audit 100% compliance to relevant criteria was achieved. The documentation process was
highlighted as an issue and addressed in the education strategies. Two follow-up audits are planned for six months
and 12 months.
Evidence shows the importance minimising infection as a complication for these patients. The staff at Logan
Hospital met the audit criteria well; however, other issues around documentation were highlighted, and education
and a new form were introduced to meet documentation principles.
Keywords: administration lines, dressings, flushing, peripherally inserted central catheters (PICC)
Background
Peripherally inserted central catheters (PICC) lines are a central access device inserted peripherally to provide
secure access for administration of fluids, parenteral nutrition, administration of long term medications, including
chemotherapy, administration of blood, antibiotics and frequent blood collection over long periods. While catheters
provide necessary vascular access, their use puts patients at risk of local and systemic infectious complications
and are an important cause of patient morbidity and mortality, as well as increased hospitalisation and health care
costs.1
A PICC is a polyurethane or silicone uncuffed catheter , usually 50 to 55 centimetres in length, inserted into the
veins of the antecubital fossa, or the basilica, brachial or cephalic veins. It is fed via the subclavian vein into the
superior vena cava. PICCs are used in both inpatient and outpatient settings in Logan Hospital for intermediate to
long-term IV access, typically providing access for at least one week and up to an indefinite period.
Due to the positioning of the catheter it is important that care is taken to prevent intravascular catheter related
infections. The Centre for Disease Control and Prevention has produced guidelines for 1) educating and training
healthcare personnel who insert and maintain catheters; 2) using maximal sterile barrier precautions during central
venous catheter insertion; 3) using a >0.5% chlorhexidine preparations with alcohol for antisepsis; 4) avoiding
routine replacement of central venous catheters as a strategy to prevent infection.2
Conducting this audit was to identify that staff are utilising Best Practice principals for the safe management of
PICCs including changing of dressings, lines and bungs, and safe flushing of lines. We knew Logan Hospital’s
policy is based on the best evidence from The Centre for Disease Control and Prevention in The United States of
America and the systematic reviews from Joanna Briggs Institute (JBI) and Centre for Healthcare Related Infection
Surveillance and Prevention (CHRISP). The audit was to identify if staff were adhering to Best Practice procedures
outlined in the Logan Hospital Policy and were adhering to recommended techniques and aseptic procedure
ensuring patient safety and ensuring best possible patient outcomes from the therapy delivered by the PICC lines.1
Logan Hospital is a 350-bed hospital located between Brisbane and the Gold Coast areas. It has four medical
wards: general medicine and specialties including palliative care, respiratory medicine, and endocrine and renal
medicine. There are two surgical areas: general surgical: ears, nose and throat; gynaecology and orthopaedics.
These areas have a population of patients from the elderly sector, and from diverse cultural backgrounds and
economic demographics. This can cause difficulties on admission to hospital with comorbidies and nutritional
deficits. Difficulties in cannulation lead to the need to insert a PICC.
The project was to measure current practice, enable education to correct any identified practice outside the
recommended guidelines and to re-audit after review changes had been implemented. This took place on the six
medical and surgical inpatient wards of the hospital where lines are inserted in patients who have been identified
with poor peripheral vascular access who are requiring long term therapy of some kind. These patients are primarily
the elderly and the most vulnerable. One outpatient ward area in Day Therapy Unit where patients on long term
chemotherapy, medication or regular blood transfusion.
This was identified as a topic to audit as a vulnerable patient group who require Best Practice principal applied to
their care and measure the compliance of staff to Best Practice principals and standards. My role was primarily
the collection of the data in the medical /surgical areas. Educate the staff in the care, dressing techniques and
documentation of PICC lines. Review of the current policy and procedure and implementation of the Best Practice
principals and guidelines through education.
86
Aims
Do nursing staff across the ward and outpatient areas comply and deliver Best Practice principles for the dressing
and flushing of PICC lines based on research evidence described in the hospital’s policy and procedures?
The aims and objectives are:
• T
o establish the current level of compliance with Best Practice guidelines in relation to dressing, flushing and
care of PICC lines by staff at Logan Hospital.
• To improve the local practice of management of PICC lines and dressings
• To ensure the techniques practised are according to best-available evidence.
• To review, monitor and maintain the optimal outcomes for patients having insertions of PICC lines.
• To review current guidelines and protocols in the management of PICC lines within the organisation
Audit criteria
1.PICC is flushed with 10 mls or larger syringe before all medication administration or access for blood tests to
ascertain patency
2.PICC is flushed with 10mls or larger syringe after medication, blood product infusions, lipid infusions and blood
draws to prevent occlusion
3.Tubing is changed within 24 hours after the administration of blood products or lipid emulsions
4.Administration sets are including secondary sets and add-on devises are not changed more frequently than 72
hour intervals, unless catheter related infection is suspected.
5. Correct Transparent dressings are used for the insertion site
6.Dressing is changed at least every 7 days or whenever the dressing becomes dampened, soiled and/or when
inspection of site is necessary.
7. Staff have received educational training on the management of PICC
Methods:
No formal ethical approval was sort as there was no collection of personal details of either staff or patients.
To complete the audit at Logan Hospital, JBI-PACES was utilised to identify gaps, implement change by education
and review the effectiveness of the project.
This was achieved by a pre- and post implementation clinical audit project and included five phases. The project
was conducted within the structure of the Joanna Briggs Institute Clinical Fellowship Program. The duration of the
program was six months; however, the expectation is that improvements to practice would be sustained in the
longer term. The practice and monitoring of changes implemented during this project would be continued every
six months initially and reviewed in 12 months.
The following phases outline the methods and timing for each element of the project plan.
The method was completed in five phases:
Phase 1
A project team was formed with the above participants as key stakeholders regarding the implementation of the
project, collection of data and reporting processes. Christopher and I were to collect the data from the patients and
nurses in the wards, and analyse the data. This was to be done against the criteria outlined in JBI-PACES. We also
had to check documentation in care plans and medical notes on the process and timing of care given.
Medical imaging was to notify myself of the insertion of the catheters to enable us to follow-up. We were to followup with these patients within a week to assess them against the data from JBI-PACES. The Day Therapy Unit
monitored their patients from an outpatient perspective on a daily basis as patients were presented for treatment
and dressing changes.
Phase 2
The baseline audit was conducted to identify current practice in all in/out patients who have PICC lines inserted
within Logan Hospital for a one-month period. This commenced later than planned due to availability of staff to
collect data. This was reliant on the available patient base that required a line insertion. Due to the decrease in
patient numbers it was difficult to get the allocated numbers; however there was enough data for us to collect for
the audit.
87
The Medical Imaging Department was unable to contact us daily with information as staff decreases caused
workload issues. However we visited the Medical Imaging Department daily for a list of insertions for that day.
We identified early the difficulty in collection of data. Data collection also involved observation of the dressing
procedures and reading charts. There was often no data documented and it became apparent that there was no
process for documentation that was consistent across the hospital. The Day Therapy Unit had a set patient base
as their core business, and in this area it was care of cancer patients in an outpatient setting for blood transfusions,
medication delivery and care of PICC lines and dressings on a weekly basis. Data collection in the area did not
pose a problem and we were able to obtain numbers for the audit. The documentation process was set as in the
medical notes at each presentation. All criteria were the same for all areas for ease of comparison.
Phase 3
Implementation of strategies developed by the project team utilising Getting Research into Practice (GRIP) outlining
the education strategies, possible barriers and how we as a team overcame these identified barriers.
Strategies for GRIP (Getting Research into Practice)
Education was conducted throughout the organisation in the form of an in-service when the policy was revised and
distributed in 2006 and 2009. No audit has been conducted within the organisation to measure compliance with
the policy and Best Practice standards.
The primary audit education strategies included:
Implementation
Barriers
Strategies
No standard
Include in-service
documentation process
session to revise Best
Practice principles and
documentation practices
In-service session
In-service through normal
in service calendar
Clinical skill assessment
To observe dressings
and sign staff off to meet
service area requirement
yearly
Review and dissemination Discussion with Nurse
Unit managers at the
of documentation chart
through the hospital ward grade 7 meeting to gain
approval
areas.
Resources
Nurse education and
clinical facilitator
Nurse educator and
Nurse educator and
Nurse educator and
Outcome
All ward areas educated
on documentation and
revision of Best Practice
principals
All areas revision on Best
Practice principals
All areas staff who
attended dressing were
deemed competent
Included in in-service
session
Phase 4
The follow-up audit 1 clinical audit was conducted to measure the effects of the implementation of the strategies
according to the project with all in/out patients with PICC lines inserted within Logan Hospital. This audit utilised
the same criteria as the baseline audit and was conducted after the education sessions. There were fewer numbers
again but these were sufficient for us to gather data for reporting
Phase 5
Development of a final report for presentation to Logan Hospital Nursing Grand Rounds and the Joanna Briggs
Institute Facilitator team.
Results
The results of the audit were quite surprising as there was a high compliance over all with all the Best Practice
principles and adherence to hospital policy. The results are displayed in the flowing tables.
88
Table 1
Table 2
Table 3
89
90
Discussion
The audits showed that Logan Hospital met Best Practice standards in the delivery of care of PICC lines. The
number of patients was decreased due to several events; however, enough patient data was collected. All staff
involved were committed to help with the process of data collection for both audits. The project team was engaged
throughout the whole process.
Criteria 1: Both the medical and surgical areas had different cases and in the post audit the patients were having
total parental nutrition and blood transfusion. As in the baseline audit the patients required antibiotics and other
medication to be administered and did not require lines to be attached. The day therapy unit remained at 0 for both
audits due to the fact that the patients were day cases and did not remain for longer than a few hours so lines were
disconnected prior to leaving the hospital.
Criteria 2: All areas adhered to the policy of dressing changes to be done the day after the insertion and then
seven days later on a regular basis. Several ward areas had assigned days for these dressings to be attended. This
practice was met. However some patients were discharged for treatment at home prior to the seven days. These
patients were then followed up in the Day Therapy Unit or by the Home Intravenous Service.
Criteria 3 and 4: In the use of a syringes pre- and post delivery of medication, the surgical wards had different
patient demographics. Due to the hospital policy on the use of pumps for all patients in medication delivery
and surgical patients having to maintain a fluid balance with intravenous fluids, the use of the syringes was not
required and therefore not applicable in these cases. For both the pre- and post audits, this criterion was adhered
too. It is hard to judge if this was due to patient demographics or education after the pre-audit. The Day Therapy
Unit complied in both pre- and post audits as the PICC lines are their core business on a daily basis.
Criteria 5: Staff commented that they had not had any formal education but had received peer support in learning
the standards and following the policy and procedures. Staff in all areas had received education. In-service
sessions were repeated several times to ensure all staff were able to attend.
Criteria 6: All areas were compliant in both pre- and post audits
Criteria 7: All areas were compliant to the policy. In the surgical areas there was no Total Parental Nutritional
requiring this to be met; however in the post audit the patient demographics allowed us to see that the policy
was meet. In Day Therapy, this again was excluded as the lines were removed on a daily basis for discharge and
medical areas were compliant.
Even with the difficulties in staffing and patient presentation, we were able to collect enough data for both audits.
The highlight was that while we met Best Practice principles, we were not documenting well and often the data
in the pre audit was reliant on staff being present to confirm the dressings had been done within the time frame.
The surgical ward used a care plan format and this was distributed to other areas. This form (Appendix 1) was
included in the education sessions and was not formally included in the data collection for the post audit; however
at the six month and twelve month review cycles, we will include the documentation data.
91
Conclusion
This was the first time that the audit was conducted within the General Medical and Surgical areas. It was received
well and all staff contributed and engaged in the process. We have highlighted what we do well and will celebrate
our achievement in delivering quality evidencebased practice to our patients. We highlighted documentation as an
area needing improvement and addressed this issue as a team and during the follow-up audit process to ensure
it becomes embedded into practice. We were able to demonstrate that with organisational and staffing issues
addressed, we can and do provide a quality service.
Acknowledgements
We thank the Metro South Health Service District for their funding the cost of the course, travel, accommodation
and wages during the week in Adelaide to develop the project and return to report and present the findings. We
also acknowledge the support and guidance of:
Veronica Casey
Executive Director Nursing and Midwifery Services
Metro South Health Service District (MSHSD)
Tracey Duke
Director of Nursing and Midwifery
Logan Hospital
Susan Rath
Director of Nursing and Midwifery Practice Development Unit (NMPDU)
Project Team at Logan Hospital
Rie Konno
JBI Facilitator
References
1.
CHRISP
QH.
Preventing
intravascular
device
(IVD)-related
bloodstream
infections(BSI’s)
Recommended practices for the insertion and management of peripherially inserted Central Venous
Catheters(PICC). In: Queensland Health A, editor. Brisbane CHRISP; 2009. p. 1-16.
2.
O’Grady NP, Alexander M, Burns L, Dellinger P, garland J, Heard S, et al. Guidelines for Prevention of
Intravascular Catheter-Related Infections,2011. In: U.S.A DoHHS, editor.: Centers for Disease Control And
prevention (CDC) 2011. p. 83.
92
Appendices
Appendix 1
1. CHRISP QH. Preventing intravascular device (IVD)-related bloodstream infections(BSI’s)
Recommended practices for the insertion and management of peripherially inserted Central Venous Catheters(PICC).
In: Queensland Health A, editor. Brisbane CHRISP; 2009. p. 1-16.
2. O’Grady NP, Alexander M, Burns L, Dellinger P, garland J, Heard S, et al. Guidelines for Prevention of Intravascular
Catheter-Related Infections,2011. In: U.S.A DoHHS, editor.: Centers for Disease Control And prevention (CDC)
2011. p. 83.
JBI Fellows Monographs 2011-2012 Allana King and Michelle Oaklands
93
A best practice implementation project to
review the nursing care and clinical pathway
requirements for patients who have undergone a
total laryngectomy
Allana King
Ward Q5 Clinical Services Coordinator
Michelle Oaklands
Ward Q5 Associate Clinical Services Coordinator
Abstract
Background
This paper outlines a Best Practice implementation project which reviewed the nursing care and clinical pathway
requirements for patients who had undergone a total laryngectomy. This was a six-month project and utilised the
Joanna Briggs Institute Clinical Fellowship program to assist with the gathering of evidence, the auditing process
and putting evidence into practice. A total laryngectomy is a surgical procedure which involves the complete
removal of the larynx and some surrounding structures. This is an invasive procedure which impacts on the
patient’s physical appearance, functional ability to speak and at times swallowing ability as well as psychological
and lifestyle changes.
Aims/objectives
The aim of the project was to compare local practice with the best available evidence to improve local practice
in the management of total laryngectomy care and create clinical guidelines, pathways and a patient information
sheet based on Best Practice. The aim was to assist nursing staff in the management of these patients and ensure
patients are well informed of their on-going care requirements.
Methods
The Joanna Briggs Practical Application of Clinical Evidence System (JBI-PACES) was used to develop an audit
criteria based on a literature search of best-available evidence. A baseline audit was performed and there were
a total of 15 audit criteria. This was followed by a JBI Getting Research into Practice (GRIP) program which was
used to identify any barriers and enabled the establishment of strategies, such as recognising and involving key
stakeholders and the development of clinical guidelines. There was a follow-up audit cycle which evaluated the
success of the implementation strategies.
Results
The results indicated an improvement in 12 of the 15 audit criteria and the remaining three had a decrease of less
than 10%. This decrease may be a result of an increased sample size in the follow-up audit cycle. Even though
100% compliance was not achieved in all areas with on-going education,it is hoped compliance will continue to
improve.
Conclusion
In conclusion this Best Practice project has been beneficial in identifying areas which require improvement. It has
also used a collaborative approach in establishing guidelines, clinical pathway and patient information sheet to
ensure consistent practice amongst nursing staff to improve patient outcomes.
Keywords:
Evidence-based practice, total laryngectomy, stoma care, clinical pathway, laryngectomy education
94
Background
A total laryngectomy is the ‘surgical removal of the larynx’ (1983 p. 608).1 Surgery also involves the removal of
surrounding structures such as the ‘hyoid bone, true and false vocal cords, epiglottis, cricoid cartilage and two
to three tracheal rings’ (2003 p.5).2 In health technology website states ‘The larynx, also called the voice box, is
the organ in the throat that creates speech and, in conjunction with the epiglottis, prevents food from entering the
airway during swallowing.’3 The trachea is then sutured to the skin and a permanent end stoma is created. This
results in no connection between the upper airway and lower airway. Figure 1 demonstrates normal anatomical
structures and Figure 2 demonstrates how the connection between the upper airway is separated following a total
laryngectomy.
Figure 1: Before Total Laryngectomy3
Figure 2: Post Total Laryngectomy3
A total laryngectomy is primarily performed for the removal of tumours of the larynx and surrounding structures. It
is also performed for the prevention of aspiration of secretions and oral intake.4
There are four forms of laryngectomy surgical procedures
• total laryngectomy
• supra-glottic laryngectomy
• partial laryngectomy
• vertical laryngectomy4,5
A total laryngectomy is an invasive surgical procedure and results in anatomical and physiological changes. The
patient also experiences an altered body image, lifestyle changes and communication difficulties following surgery.2
One of the main risk factors is high alcohol intake and tobacco consumption and there is a greater incidence in
men than women.2, 6, 7
The nursing care requirements are specialised and consist of pre-operative care, post-operative care, education,
discharge planning, and on-going follow-up. Nurses caring for these patients need to have a clear understanding
of the resultant anatomical changes; this is particularly important in the event of a respiratory/cardiac arrest,
as resuscitation needs to occur via the end stoma. Bressler (2003 p.5) states the need for nurses to be aware
of ‘airway management, wound care, nutrition, communication, body-image changes and home-care needs.’2
Bressler (2003) further discusses the necessity to have emergency equipment available at the bedside.2
It is important that the nurses and the patient are aware that the end stoma needs to be protected from foreign
bodies and water entering the stoma. The upper airway is by-passed so the natural ability to warm, humidify and
filter inspired air no longer occurs; consequently the need to humidify and protect the stoma is vital. These patients
also have specific care needs in regards to stoma care, nutrition, hydration and communication. As Hanna et al.
(1999) discuss, the multi-disciplinary input is valuable in developing clinical pathways as patient outcomes are
predetermined with set goals and timeframes8 which ensures the whole team are aware of progress. There are
significant adjustments required for the patient and his/her family nurses play a valuable role. As Noonan et al.
(2010 p.294) discuss, nurses need ‘to act as advocates to ensure the patient’s journey …is uncomplicated and
results in the best health outcomes, both short and long term’.7
As there are various forms of laryngectomies, this project focused on patients who underwent a total laryngectomy
as the nursing and surgical care requirements differ as the partial, vertical and supra-glottic do not result in a
permanent end stoma. The patients involved in this study all had laryngeal cancers and had also undergone
adjunctive surgical procedures at the same time such as neck dissections, pectoral major flaps and radial-free
forearm flaps.
95
The multi-disciplinary team on the ward consists of Medical, Nursing, Speech Pathologists, Dietitians, Social
Workers and Physiotherapists. The patients also had input from dental and radiation-oncologists as all but one
of the patients will be having radiotherapy as an adjunctive therapy to the surgery; the remaining patient had
previously undergone radiotherapy in an attempt to prevent surgery and preserve his larynx; however, the tumour
returned. It is common practice to use a combination approach of surgery and radiation/chemotherapy in laryngeal
cancer therapies. Genden et al (2007 p.431) discuss how laryngeal surgery has evolved and that in recent years
‘the value of planned combinations of irradiation, chemotherapy and surgery became the standard of care for
advanced laryngeal cancer, permitting maximal laryngeal preservation with the highest attainable cure rates.’9
The above highlights the necessity for expert nursing care when caring for patients who have undergone a total
laryngectomy and for extensive patient and caregiver education for the on-going management at home. This project
was undertaken to ensure consistent practice as the hospital had no organisational or service specific instruction
(SSI) on the care management of these patients and the information provided to patients was limited. This resulted
in inconsistent and ambiguous practice amongst nursing staff which was evident by varying knowledge, skill levels
and not all staff comfortable with discharging patients who have had a total laryngectomy.
As Hanna et al. (1999 p. 1247) and Sherman et al. (2001 p.119) describe, the development and implementation of a
clinical pathway for patients undergoing total laryngectomy may reduce the length and cost of hospital stay without
increasing complication rates.8,10 This project focused on the establishment of a service specific wide (Appendix 1)
instruction and a clinical pathway (Appendix 2) to create a clear understanding of the care requirements. A patient
information sheet was also developed (Appendix 3).
Audit topic:
A Best Practice implementation project to review the nursing care and clinical pathway requirements for patients
who have undergone a total laryngectomy
Aims
The aims of the project were:
• To compare local practice to the best-available evidence.
• To improve local practice in the management of total laryngectomy care.
• To create an SSI wide instruction on the nursing care requirements for patients who have undergone a total
laryngectomy based on Best Practice.
• To create a clinical pathway for a laryngectomy patient based on Best Practice.
• To create a patient information sheet on the on-going care and management based on Best Practice.
Audit criteria:
The pre-operative management of patients undergoing a total laryngectomy is essential in ensuring patients are
prepared physically and psychologically.7 These patients are often not seen on the ward until postoperatively.
Therefore the audit excluded the pre-operative component. Education and assessment is however performed in
pre-anaesthetics and clinics prior to their admission.
The audit criteria for postoperative care of total laryngectomy patients were obtained from JBI-PACES program.
The audit was divided into two audits: (1) Postoperative care and (2) Education and discharge. The audit criteria,
and how they were measured, are below.
Postoperative period on ward
1. Nursing staff caring for total laryngectomy patients have received education
This criterion is met through a verbal questionnaire and attendance at education sessions by nursing staff
2. Following removal of trachesotomy tube, the laryngectomy stoma is cleaned and crusting removed.
This criterion is met if nursing staff have documented it in the observation chart
3. Trachea-oesphageal tube is observed for leakage or dislodgement 4-8 hourly or as per organisational
protocol.
This criterion is met if nursing staff have documented it inthe observation chart
4. Total laryngectomy in-patients have a complete set of resuscitation equipment by their beds.
This criterion is met by visual observation of the resuscitation equipment
5. Total laryngectomy in-patients have their humidification needs assessed
This criterion is met if nursing staff have documented it in case notes and visual observation of the patient
96
6. Total laryngectomy in-patients have their hydration needs assessed.
This criterion is met if nursing staff have documented it in thefluid balance chart and case notes
7. Total laryngectomy in-patients have their nutrition needs assessed.
This criterion is met if nursing staff have documented it in thefluid balance chart and case notes
8. Dieticians and speech pathologists have been contacted regarding total laryngectomy patients.
This criterion is met if nursing staff have documented it in case notes
9. Total laryngectomy in-patients have been provided with a means of communication.
This criterion is met if nursing staff have documented it in case notes and visual observation that patients had been
supplied with communication aids
10. Drainage sites are assessed 4 hourly
This criterion is met if nursing staff have documented it in the observation chart and case notes
11. Total Laryngectomy surgical/stoma incisions are cleaned 4-8 hourly or as per organisational protocol
This criterion is met if nursing staff have documented it in the observation chart and case notes
Education and discharge
1. Nursing staff have provided the patient with on-going education regarding total laryngectomy care.
This criterion is met if nursing staff have documented it in case notes and patient received pamphlet
2. Nursing staff have provided the patient with supplies.
3. Nursing staff have organised ongoing nursing support.
This criterion is met if nursing staff have submitted a referral letter
4. Nursing staff have organised patient follow up.
Method
Setting and sample
The project was conducted on a surgical ward within the Surgical Specialties Service at Royal Adelaide Hospital
(RAH). The RAH is the largest tertiary referral service in South Australia (SA) and has referrals from areas such as
the Northern Territory, Regional SA and Broken Hill. The RAH has a budgeted bed capacity of 554 general beds
and 44 specialised beds for ICU, Burns and Spinal. The surgical ward has 28 beds and the care requirements are
complex – there are a variety of specialties which nurses are required to be skilled in in the delivery of high quality
patient care. The surgical ward has 28 beds and the ward specialties include otorhinolaryngology, head and neck
surgery, ophthalmology, craniofacial and oral surgery. There is a total of 40 nursing staff employed to the unit and
this can vary depending on recruitment and retention of staff.
Sample:
Due to the limited number of Total Laryngectomies performed in the Royal Adelaide Hospital each year, two
patients were chosen for the baseline audit. The baseline audit was conducted in December 2011; two patients
met the criteria and were included in the baseline audit. The average length of stay for this procedure is 14 days so
the auditors collected data for a two-week period; however, all patients stayed longer than 14 days.
There were a total of forty nurses involved in the baseline and follow-up cycle audit. The Graduate Nurses were
excluded from the audit criteria as they are only allocated to the ward for four months; however, they were included
in education sessions. Fortunately there was no turnover of staff in this period enabling all those who participated
in the baseline audit to be involved in the follow-up audit
There was varying sample sizes for each of the audit criteria as data was collected on interventions performed
for each of the participating patients. Some of the interventions only required data collecting once whilst others
required three-hourly data collecting. This was collected retrospectively through documentation records. The
numbers of each sample size collection is available in the results section of this paper.
Ethical considerations:
This was a quality improvement project and therefore formal ethical approval was not required by the Organisation.
Data was entered through the JBI-PACES program and as a result all subject information was de-identified.
Throughout the project staff and patient confidentiality was maintained.
97
Clinical audit:
The clinical audit involved utilising JBI online tools including JBI PACES, which is an acronym for Practical
Application of Clinical Evidence System, and JBI-GRIP which is an acronym for Getting Research into Practice.
This project was conducted over six months and involved four phases as outlined below.
Phase 1:
Identification of the topic:
A literature search to establish Best Practice regarding the nursing care and clinical pathway requirements for
patients who have undergone a total laryngectomy was conducted, and audit criteria were formed from this.
Establishment of the audit team:
The audit team consisted of Allana King (Clinical Services Coordinator, ward Q5, RAH) and Michelle Oaklands
(Associate Clinical Services Coordinator, ward Q5, RAH). Our role included gathering the information through the
audit process and implementing quality improvement strategies.
Phase 2:
Baseline Audit:
The audit team utilising the JBI-PACES program developed a baseline audit and this involved a verbal questionnaire,
visual observation and a review of patient case notes. The questionnaire was conducted to determine the
knowledge base of ward nursing staff caring for a patient following a Total Laryngectomy.
Phase 3:
Strategies for Getting Research into Practice (GRIP):
The findings from the baseline audit were discussed with key stakeholders including senior nursing staff, along with
medical and allied healthcare staff to develop strategies for areas of improvement. The baseline audit identified
compliance deficits in all but four of the postoperative care criteria and one from the education and discharge
audit. The barriers are outlined in the implementation table which identifies knowledge deficits, inexperienced
staff and the lack of policies and procedures regarding Total Laryngectomy care and management. The table also
outlines the strategies, resources utilised to overcome these barriers and what the outcomes have been.
Table 1: Implementation table
Barriers
Strategies
Resources
Outcome
No policy or procedure
available regarding total
Laryngectomy care
Develop a Service
Specific Instruction (SSI)
and make available on
e-centrahl
Input from Medical
and Allied Health Staff
Intensive Care Unit
collaboration
A SSI is now available
for staff
Inexperienced nursing
staff resulting in some
knowledge deficits
-Education sessions
provided
-Competency
assessment
Record of Staff
progression through
tracheostomy workbookDevelopment of clinical
pathway and educate
staff on use
-Develop SSI
-Provided 10 education
sessions to staff
-Provided less
experienced staff
practical sessions
regarding Laryngectomy
care
- Tracheostomy video
and workbook available
to all staff on intranet
Staff feedback positive
Increase in staff
providing education to
patients
Pathway in use enabling
consistency in practice
Limited information
for patients in regards
to on-going care of
laryngectomy
Develop a Patient
Information Sheet (PIS)
and make available on
e-Centrahl
Time
Medical and Allied
Health collaboration
Approval required from
Consumer Advisory
Council (CAC)
PIS developed and
was sent to CAC for
approval, required minor
modification. Currently
pending final approval
to publish on e-Centrahl
and circulate for patient
use
98
Further information on the strategies used is below:
1.To improve compliance and practice, education sessions for the staff were developed. This involved a onehour session, outlining postoperative care, airway management, hydration, nutritional supplementation, wound
care, changes in body image, patient education and home care requirements.
2.A Service Specific Instruction based on total laryngectomy care was developed and has now been published to
the hospitals e-Centrahl which is an online catalogue of local policies and procedures. This instruction required
input from the medical staff, allied health and intensive care unit.
3.A clinical pathway for staff to follow outlining patient care requirements was developed and included as part of
the patient care plan. The pathway was developed utilising a multi-disciplinary approach with consultation from
Medical Staff, Allied Health (in particular speech pathology) and senior nursing staff. The pathway has clear
guidelines on the care required and expected milestones and timeframes for care to be provided.
4.The development of a patient information sheet to enable patients and their caregivers to have a greater
awareness of their home care requirements and as an ongoing reference. Unfortunately, the Patient Information
Sheet is still awaiting final approval from the Consumer Advisory Council (CAC). This is expected in May.
5.The findings and strategies were discussed with nursing staff throughout the project at ward quality meetings
and their feedback and recommendations were sought.
Phase 4:
The post implementation audit was conducted from 6 January 2012 and concluded on the 15 April 2012. The same
methods were used as the baseline audit; however, the sample size differed. This was due to a longer period in the
post implementation phase which allowed us to capture more patients who had undergone this procedure. The
sample size doubled as four patients’ data was utilised whereas data of two patients was used in the baseline audit
data. The location and nursing staff number of 40 participants remained the same.
Results:
The data collection results are summarised in Table 2 which demonstrate the baseline and post implementation
compliance audit results based on the audit criteria in terms of sample sizes for the postoperative care audit.
Table 2: Baseline and post implementation Results Postoperative Care
Baseline audit
Follow up cycle 1 audit
Audit criteria
Sample size
YES
NO
N/A
Sample YES
Size
NO
N/A
1 Nursing staff caring for total
laryngectomy patients have
received education
40
17
23
0
40
40
0
0
2 Following removal of
trachesotomy tube, the
laryngectomy stoma is cleaned
and crusting removed.
168
160
8
0
336
224
34
78
3 Trachea-oesphageal tube
is observed for leakage or
dislodgement 4-8 hourly or
earlier as per organisational
protocol.
168
3
81
84
336
88
80
168
4 Total laryngectomy inpatients have a complete set of
resuscitation equipment by their
beds.
2
2
0
0
4
4
0
0
5 Total laryngectomy in-patients
have their humidification needs
assessed.
224
187
37
0
448
383
42
23
99
have their hydration needs
assessed.
84
67
17
0
168
153
12
3
have their nutrition needs
assessed.
84
67
17
0
168
152
13
3
8 Dieticians and speech
pathologists have been
contacted regarding total
laryngectomy patients.
2
2
0
0
4
4
0
0
have been provided with a
means of communication
2
2
0
0
4
4
0
0
10 Drainage sites are assessed
4 hourly.
36
14
22
0
72
45
27
0
11 Total Laryngectomy surgical/
stoma incisions are cleaned
4-8 hourly or earlier as per
organisational protocol.
168
160
8
0
336
304
32
0
Figure 3: Post-operative baseline and follow-up cycle 1 results (Postoperative care)
100
The data collection results are summarised in Table 3 which demonstrates the baseline and post implementation
compliance audit results based on the audit criteria in terms of sample sizes for the education and discharge audit.
Table 3: Baseline and post implementation Education and Discharge
Baseline audit
Follow up cycle 1 audit
Education audit criteria
Sample
size
YES
NO
NA
Sample
size
YES
NO
NA
1 Nursing staff have
provided the patient
with on-going education
regarding total
laryngectomy care.
28
25
3
0
56
47
9
0
2 Nursing staff has
provided the patient with
supplies.
2
2
0
0
4
4
0
0
organised ongoing
nursing support.
2
2
0
0
4
4
0
0
organised patient follow
up
2
2
0
0
4
4
0
0
Figure 4. Education and discharge baseline and follow up cycle results
Discussion
To undertake this project in a short time frame has been challenging and rewarding. The majority of our aims and
objectives have been achieved with some of our compliance criteria increasing by as much as 61%.
The audit criteria developed were based on best-available evidence. This was challenging at times as there was
a combined total of 15 audit criteria with some of these having large sample sizes, which meant that finding the
documentation on three different charts was often time consuming with only two of us in the data collection team.
There was overall improvement in all but three of the criteria. In two of these it was related to a decrease in
documentation regarding stoma cleaning and suture line care. The decrease was less than 10% in each of these
criteria and the sample size was 336 in the follow-up cycle 1 compared with 168 in the baseline audit. Having
such a large sample size for some criteria (for example three per hour) makes compliance quite difficult to achieve.
An additional contributing factor could be relieving nursing staff who may not be familiar with documentation
guidelines regarding laryngectomy patient’s stoma care.
The third criteria which declined was in relation to patients being provided ongoing education regarding
laryngectomy care as this dropped by 5%. The decline could be attributable to a lack of documentation rather than
not providing the education. The decline of 5% is concerning and an area which will require ongoing education
and monitoring to ensure patients and their care givers have the adequate information and education required. The
nursing staff also need to ensure that they document all care and information provided to the patients.
101
We collected data on whether patients had received supplies, on-going nursing support and organised patient
follow-up in the education and discharge audit. In the baseline audit there was a 100% compliance rate. It was
exciting to see in the follow-up audit that this was maintained and all three criteria had a compliance rate of 100%.
As the data collection continued in the baseline audit we noted a concerning trend regarding nursing staff advising
us that they had not had sufficient education regarding caring for a total laryngectomy patient. The baseline data
revealed that only 43 % felt that they had education on how to discharge and educate a patient who had undergone
this procedure. The project team acknowledged the varying levels of knowledge and clinical experience; however,
following discussions with the senior nursing staff it was decided that all staff would be asked to attend in-service
sessions. The project team also took this opportunity to discuss the new service-specific instruction and clinical
pathway. Overall the education sessions were well received and those who had experience felt it was a good
reminder and all staff acknowledged that having a clinical pathway and service specific instruction to follow would
give them guidance with their care delivery. The follow up audit cycle achieved 100% compliance with all 40 staff
attending education sessions. This was a fantastic achievement and the education sessions will be provided to all
new staff to the area in the future. The baseline audit also revealed that not all staff had completed the tracheostomy
work book and competencies; however, this was not an audit criteria, although staff were advised to complete
the workbook and competencies within four weeks. Although the nursing staff attended further education the
project team recognises that education is an on-going process and some of the staff will still require assistance in
discharging and educating these clients.
Another area which showed significant improvement was checking for dislodgement of the tracheo-oesophageal
tube. Even though the follow-up audit only reached 52 % compliance, this is a large improvement compared to
the the baseline audit of only 4%. Staff advised that they did not realise that they needed to document the tube
placement as they thought they needed to document it only if it had dislodged. The tracheo-oesophageal tube is
used for enteral feeding and it is important to document its position and any potential leaking around tube.
The development of the service-specific instruction and clinical pathway for patients who have undergone a Total
Laryngectomy has provided nursing staff with easy reference points when caring for these patients who have
complex nursing requirements . All patients now have a clinical pathway inserted into their care plan post surgery.
There was a lot of collaboration with medical, allied health and nursing staff to develop these protocols. The
need for the development of these two documents was identified prior to the commencement of the project as
it was recognised that there was limited information available for staff regarding the care requirements of these
patients. The development of the service-specific instruction was difficult as several people needed to upload
the publication onto the intranet site. The project team also had to learn how to utilise the e-Centrahl program
and needed to undertake a couple of training sessions. This, whilst time consuming, has been another benefit
from undertaking this project as we now know how to load, seek stakeholder feedback and get service-specific
instructions published. A patient instruction sheet outlining home care requirements was also developed. This also
required loading onto e-Centrahl and was sent to the Consumer Advisory Council for stakeholder input. The first
draft required modification and these amendments have been made and we are now awaiting final approval so the
patient information sheet (PIS) can be published onto e-Centrahl. The development of the PIS was something the
project team was excited about as previous information was limited and conflicted with current Best Practice. It
is important that patients are provided with relevant and updated care management guidelines as ‘preparing the
laryngectomy patient for discharge is one of the nurse’s most important responsibilities’ (2003 p.6).4
The development of the SSI, clinical pathway and PIS has been a significant undertaking and required a multidisciplinary approach and thankfully we had the support and input willingly from the entire multidisciplinary team.
The literature also discusses the importance of the multidisciplinary approach when developing clinical pathways
for laryngectomy patients as ‘all parties have a vested interest in promoting the success of the established clinical
pathway (1999 p.1250).8 It is also important that all staff are educated and aware that the clinical pathway is a
guide and needs to be individualised to meet the specific patient requirements.
If we were to undertake this project again we would either reduce some of the audit criteria or recruit more
data collectors as some of the sample sizes exceeded 300. However overall we felt that the data captured was
informative and enabled us to share with others our knowledge which resulted in a collaborative approach to
improve patient outcomes and staff education. Even though 100% compliance was not achieved in all criteria at
the completion of the project, with ongoing education it is hoped that compliance will continue to improve.
102
Conclusion
In conclusion this Best Practice project has been extremely beneficial and will have positive benefits for patients
who have undergone a total laryngectomy. The nursing staff caring for these clients will be informed and there will
be consistency in their care delivery. Prior to undertaking this project the project team had identified that there
was inconsistent and ambiguous nursing care practices largely due to a lack of evidence-based resources. It was
decided that this issue needed to be investigated further and strategies developed to assist in improving nursing
staff knowledge. The project team utilised JBI-PACES to perform audits and the GRIP cycle to ensure that best
current available evidence was put into practice. The audit process was informative and components will be
utilised for future audits.
The project achieved all of the set aims and the development of the Service Specific Instruction and Clinical
Pathway has been well received by nursing staff. The response to the education sessions was positive. The Patient
Information Sheet has been developed and plans are to have it published by May 2012 for patient use. This project
highlighted the need for a multi-disciplinary approach to ensure best outcomes for clients.
Acknowledgements
We would like to thank the following for assisting us in undertaking this project: Su White for allowing us to attend
and undertake the project, the ward nursing staff and the multidisciplinary team for their valuable input and time.
The Joanna Briggs Institute staff in particular Zachary Munn for his guidance and support, and finally Dr Aye Aye
Gyi who provided the evidence summary.
References
1 Manning TA. Mosby Medical Dictionary, 1983. P. 608. ISBN 0-8016-5194-8
2 Bressler C. Post operative care of the laryngectomy patient. Houston: Cross Country University2003 Contract
No.: 1.
3. InHealth Technologies viewed 27th October 2011 <http://www.inhealth.com/voicerestorationwhatsalary.htm>
4. Rassekh CH, Haughey BH. Total laryngectomy and laryngopharyngectomy. In Gaertner R, Halpine R, editors.
Cummings Otolaryngology Head and Neck Surgery 5th ed. Philadelphia: Mosby Elsevier; 2010. p. 1563-1575.
5. Derose TJ, Artz G. Otorhinolaryngologic surgery. In Myers T, Selkirk L, editors. Care of the Patient in Surgery
14th ed. St Louis, Missouri; 2011. P. 657-718.
6. Dobbins M, Gunson j, Bale S, neary M, Ingrams D, Brown M. Improving patient care and quality of life after
laryngectomy/glossectomy. British Journal of Nursing. 2005;14(12):634-40.
7. Noonan B and Hegarty J. The impact of total laryngectomy: the patient’s perspective. Oncology Nursing Forum.
2010;37(3):293-301.
8. Hanna E, Schultz S, Vural E, Stern S, Suen J. Development and implementation of a clinical pathway for patients
undergoing total laryngectomy. Arch Ontolaryngol Head Neck Surg. 1999;1247-59.
9. Genden EM, Ferlito A, Silver C, Jacobson A, Werner J, Suàrez. Evolution of the management of laryngeal cancer.
Oral Oncology. 2007; 43. P. 431
10. Sherman D, Matthews TW, Lampe H, S L. Laryngectomy clinical pathway: development and review. J
Otolaryngol. 2001;30(2):115-20.
Appendices
Appendix 1: Service Specific Instruction (total laryngectomy care)
103
104
105
106
Appendix 2A: Total laryngectomy pathway day 1 to day 7
107
108
109
110
111
112
113
114
Appendix 2B: Total laryngectomy pathway day 8 onwards
115
116
117
118
119
Appendix 3 - Patient Information Sheet (total laryngectomy home care instructions)
120
121
122
JBI Fellows Monographs 2011-2012 David Larkin
Cancer-related fatigue assessment by oncology
nurses in outpatient chemotherapy and
radiotherapy departments: a best practice
David Larkin
Research Nurse
ACT Health Directorate Research Centre for Nursing and Midwifery Practice and Australian Capital Regional Research
Centre for Evidence-based Nursing and Midwifery Research Practice: an Affiliated Centre of Joanna Briggs Institute
Professor Violeta Lopez
Director
ACT Health Directorate Research Centre for Nursing and Midwifery Practice and Australian Capital Regional Centre
for Evidence-based Nursing and Midwifery Practice: an Affiliated Centre of Joanna Briggs Institute, Professor of
Nursing, Medical School, Australian National University
Jill Parke
Project Officer
ACT Health Directorate Research Centre for Nursing and Midwifery Practice and Australian Capital Regional Research
Centre for Evidence-based Nursing and Midwifery Research Practice: an Affiliated Centre of Joanna Briggs Institute
Abstract
Background
Cancer-related fatigue (CRF) has emerged as the most prevalent and distressing symptom of cancer and its
treatment. This is due to better management of symptoms such as pain and nausea, and also because of increased
recognition by healthcare professionals of the impact of fatigue on quality of life. Oncology nurses are well placed
to assess and educate patients regarding this debilitating symptom of cancer.
Aims/objectives
The aim of this project is to identify oncology nurses’ baseline knowledge and practice of CRF assessment and
management and then to compare this with their knowledge and practice after the provision of an interventional
ward-based education program. The objective is to improve nurses’ compliance with evidence-based practice
when assessing and managing CRF.
Methods
A pre-and post implementation survey of nurses and audit of medical records was conducted. An education
inservice program was conducted immediately after the pre-audit. Eight weeks after the delivery of the inservice
program the post audit was conducted, replicating the pre-audit method.
Results
The post audit results showed an increase in compliance with six of the audit criteria, with the largest increases
in compliance in assessing patients’ fatigue on admission and documenting patients’ own determination of their
fatigue. Awareness of health professionals experienced in fatigue evaluation and management decreased in the
post audit results, as did documentation of the provision of education to patients regarding self care abilities to
cope with fatigue.
These results demonstrate Best Practice education interventions in the workplace can make practice change
happen. However, ongoing education is required in order to maintain and increase practice improvements. Senior
nurses need to support nurses to achieve change within the workplace.
Keywords: Cancer-related fatigue, assessment, documentation, evidence-based practice, clinical audit
123
Background
Fatigue is one of the most common and most debilitating symptoms of cancer and side effect of cancer treatment.1
The problem of cancer-related fatigue is multidimensional, and multiple aetiological factors may account for it.
Cancer fatigue negatively impacts a person’s functional status and quality of life. It affects the ability to work,
participate in family, maintain social and personal activities and can be accompanied by guilt, anger, boredom and
loss of self-esteem. CRF affects recovery and has also been shown to affect treatment compliance.2,3
CRF has not traditionally received serious attention from health professionals or researchers. It was seen as an
unavoidable part of the cancer experience or was often subsumed under other symptoms such as pain or nausea.4
Physical symptoms such as pain, nausea and vomiting have become well controlled and so fatigue has emerged
as the most prevalent and distressing symptom of cancer and its treatment.5,6 While CRF cannot be entirely
mitigated, effective non-pharmacological interventions have been identified to lessen the impact.
Despite receiving increased attention in the literature since the early 1990s, CRF remains under-recognised and
under-treated.7 Additionally, it has been identified that health professionals are either unaware of the principles of
assessment and management or not including this as part of their routine practice.4,8,9 Further, documentation of
cancer-related fatigue in patients’ medical records is not commonly undertaken.10
Healthcare professionals should not be waiting for patients to volunteer information relating to cancer or cancer
treatment symptoms and side effects, particularly fatigue. Waiting for patients to initiate the subject is a known
barrier to fatigue assessment and management.10 Nurses in outpatient oncology departments are well placed to
initiate the subject with patients at the time of admission for treatment, and to follow up throughout the patients’
treatment journey.
Due to these issues, there is a need to assess the practice and knowledge of nursing staff caring for oncology
outpatients. The auditing of CRF in the outpatient oncology clinics will provide information for comparison of preand post audit clinical practices for CRF using evidence-based Best Practice guidelines.
Aims
The aim of the project is to identify oncology nurses’ baseline knowledge and practice of CRF assessment and
management and then to compare this with their knowledge and practice in assessing and managing CRF after
the provision of an interventional ward-based education program. This will be achieved by:
• Conducting a pre- and post audit of nursing staff knowledge and practice of assessing and managing CRF
• D
eveloping an evidence based education program for nurses who assess and manage CRF, to be delivered
between the pre- and post audits
• Improving nurses’ compliance with evidence-based practice when assessing and managing CRF through the
provision of an evidence-based education program
Methods:
The project consisted of pre- and post surveys of oncology nurses to ascertain their knowledge and practice of
evidence-based assessment and management of CRF. Medical records of all patients being treated during the
data collection periods were reviewed to measure compliance with evidence-based practice. The Joanna Briggs
Institute Practical Application of Clinical Evidence System (JBI-PACES) audit criteria (Appendix 1) were used for
the survey and medical record audit. The study was conducted from October 2011 to April 2012 and consisted of
three phases as follows:
Phase 1 – Baseline audit
Registered Nurses and Enrolled Nurses in Medical Oncology and Radiation Oncology outpatient clinics completed
a survey (Appendix 2) to provide baseline data. The medical records of patients treated were reviewed from the
time of admission to the service to ascertain compliance against audit criteria 4 to 8.
Phase 2 – Intervention
An evidence based educational inservice program was provided to staff following the pre-audit. The researchers
designed this program using the JBI-PACES criteria and literature review for evidence-based practice as the basis
for the content of the inservice.
Possible barriers to compliance with the audit criteria were identified and a Getting Research Into Practice (GRIP)
report was created, including possible strategies and resources for overcoming the identified barriers (Appendix 3).
124
Phase 3 – Follow-up (post intervention)
A replication of the Phase 1 method of data collection was conducted two months after the conduct of the inservice
program. This allowed for the effect of the education program to dissipate and then measure the retention and
behaviour change in the nurses. The post audit was conducted using the same survey as the Phase 1 baseline
survey; however, some nurses who had been on leave at the time of the baseline survey and education were on
duty for the follow-up survey. Additionally, there had been some staff turnover in both departments in the two
months following the inservice program.
The GRIP report was reviewed and expanded, incorporating the results and experiences of the project to this point.
Data analysis
Data was analysed by entering the results into JBI-PACES to compare nurses’ knowledge and practice against
the eight audit criteria.
Ethics approval to conduct the project was given by ACT Health Directorate Human Research Ethics Committee.
A Participant Information Sheet was provided with information regarding the purpose and nature of the study as
well as assuring participants of privacy and confidentiality.
Results
Table 1 shows the number of nurses and medical records by department for each of the phases. A total of 28
nurses participated in Phase 1 and 27 in Phase 3. The medical records of all patients being treated during the
three-day data collection period were audited against the JBI-PACES criteria. In total, 144 records were reviewed
during Phase 1 and 159 records were reviewed in Phase 3.
Table 1. Sample sizes
Phase 1 (baseline)
Phase 3 (follow-up)
Med Onc1
Rad Onc2
Med Onc1
Rad Onc2
Nurses surveyed3
16
8
15
8
Medical records audited
74
75
70
84
1 Medical Oncology (Chemotherapy and Bone Marrow Transplant)
2 Radiation Oncology
3 Four nurses in both Phase 1 and Phase 3 did not provide their workplace in the survey
In Phase 2, two inservice sessions were provided. Twenty-seven nurses attended in total, 19 from Medical
Oncology and 8 from Radiation Oncology. This represents 95% of medical oncology nurses and 89% of radiation
oncology nurses.
Pre- and post audit results
Figure 1 shows the pre- and post audit results based on the eight audit criteria for cancer-related fatigue. Criteria
1 to 3 were obtained from the survey of nurses and the remaining criteria were from the audit of medical records.
125
Criteria legend:
1. Education programs on cancer-related fatigue are available to all healthcare staff
2. Health care professionals experienced in fatigue evaluation and management are available for consultation
3.There is a record of healthcare professionals attendance at education programmes related to the assessment
and management of fatigue in patients with cancer
4. There is documented evidence that fatigue has been systematically assessed
5.There is documented evidence that patients have received education regarding self care abilities to cope with
fatigue
6. There is documented evidence that the patients own determination of their fatigue has been recorded
7. There is evidence that fatigue is assessed at regular intervals
8. There is evidence that fatigue is assessed on admission
For criteria 1 and 2, nurses were also given the option to indicate they were unsure if education programs are
available or whether healthcare professionals experienced in fatigue evaluation and management are available. In
Phase 1, 71.4% (n=20) of nurses were unsure if education programs are available. In Phase 3 this had decreased
to 55.6% (n=15). For the question regarding availability of healthcare professionals for fatigue evaluation and
management, 53.6% (n=15) of nurses in Phase 1 and 55.6% (n=15) of nurses in Phase 3 responded with ‘unsure’.
In the survey of nurses, criteria 4, 6, 7 and 8 were included to collect information on the nurses’ self-reporting of
their documentation in order to compare with the data collected from the audit of medical records. Table 2 shows
the numbers of nurses in each phase that indicated their compliance with documentation according to criteria 4
and 6. Table 3 shows the frequency of assessment indicated by the nurses in each phase.
Table 2. Nurses stating compliance with documentation criteria
Phase 1 (baseline)
Phase 2 (follow up)
% (n)
% (n)
Criteria 4
53.6 (15)
51.9 (14)
Criteria 6
50 (14)
63.0 (17)
Table 3. Frequency of assessment by nurses
Phase 1 (baseline)
Phase 2 (follow up)
% (n)
% (n)
Daily, or every visit
75.0 (21)
70.4 (19)
Weekly
14.3 (4)
0.0 (0)
On admission
7.1 (2)
3.7 (1)
On discharge
0.0 (0)
3.7 (1)
Discussion
The aim of this project was to ensure the assessment and management of cancer-related fatigue by nurses in
outpatient chemotherapy and radiotherapy departments of Canberra Hospital were performed according to the
best available evidence, much of which related to documentation of assessment and management. The pre-audit
results showed that nurses did not always practice or understand the skills and knowledge required to carry out
CRF assessment. The nurses were also unaware of education programs or whether healthcare professionals
skilled in fatigue evaluation and management were available for consultation. The post audit results following
evidence-based education in each clinical area showed an improvement in compliance for six of the eight criteria
audited in this project.
The relatively small improvements in compliance for six of the criteria, and the decline in compliance for two of
the criteria, is likely to be attributable to a turnover in nursing staff since the provision of the inservice program. It
is possible that the two-month delay between Phases 2 and 3 (to allow for the effect of the education program to
dissipate and then measure the retention and behaviour change in the nurses) may be a strategy for reconsideration
during periods of high staff turnover.
It was worthwhile to have surveyed the nurses on their behaviours against all eight audit criteria and compare
this with actual findings in the medical records. While the discrepancy between nurses’ self-reported behaviour
and the reality of poor documentation findings in the medical records may be disheartening, dissemination of this
information may serve to improve the rate of documentation.
126
The results of this project demonstrate interventions such as evidence-based educational inservices in the
workplace can, and do, make clinical practice change happen. It is difficult to pinpoint if this was the only factor
in achieving compliance change. The possibility, however, that the project itself raised the nurses’ awareness of
CRF, and thus impacting on the improvement in the post audit compliance, is questionable. During Phase 3, five
medical records of patients on daily treatment were checked on each of the three days of data collection and,
despite the presence of the Project Team and the nurses completing the survey, there was no documentation in
the five medical records relating to fatigue.
Anecdotally, oncology nurses do incorporate fatigue assessment and management during their care of patients;
however, they do not necessarily always document it. The importance of documenting to track a patient’s fatigue
status needs emphasising. This allows healthcare professionals to target interventions, measure change in fatigue
status and assess effectiveness of interventions.
In settings such as these outpatient departments, when there is high staff turnover, the need for an ongoing
education program is evidenced by the results of this project. This would not only serve to educate new staff, it
would also remind retained staff and reinforce the concepts of fatigue evaluation, management and, particularly,
documentation of the evaluation and management.
The results from this project will be disseminated to each clinical area so the nurses can be aware of the
improvements they made in delivering evidence-based practice to their patients and the areas that still require
further improvement. The Director of Nursing will be provided with the results of this project that demonstrate that
educational interventions improve the practice of evidence-based healthcare.
Conclusion
This project provided evidence that by implementing evidence-based education intervention strategies within the
clinical areas, practice change is achievable, even if in small amounts at a time. It also provided evidence that the
education needs to be ongoing in order to reinforce the concepts to retained staff as well as educating new staff
members. To achieve nursing practice change it is essential to have the collaboration and support of recognised
nurse leaders, educators and mentors. These people are the ones who can motivate nurses to change their
behaviours and implement evidence-based nursing practices in order to improve patient outcomes.
Acknowledgements
The Nursing and Midwifery Office, ACT Government Health Directorate, has provided the funding for travel
expenses related to this project. For this I thank the ACT Chief Nurse, Ms Veronica Croome, who believes in and
wholeheartedly supports her nursing staff to undertake such projects as JBI Clinical Fellowships.
I would also like to thank Professor Violeta Lopez, Director of the Research Centre for Nursing and Midwifery
Practice (RCNMP) and the Australian Capital Regional Research Centre for Evidence-based Nursing and Midwifery
Practice: an Affiliated Centre of Joanna Briggs Institute, whose encouragement, mentorship and assistance
has been invaluable; and Gaynor Stevenson, Acting Director of Nursing, Capital Region Cancer Services, ACT
Government Health Directorate, whose support made this project possible.
Thanks also to my colleague, Jill Parke, for her assistance, advice and friendship throughout the project.
I offer my heartfelt thanks to the two clinical areas and the nurses who participated in this clinical audit, even when
their patient workload was high.
My grateful thanks also to the wonderful JBI staff and JBI mentors Sandeep Moola and Rebecca Cook-Johnson
who so kindly persevered with me throughout this project.
127
References
1.Hoffman AJ, von Eye A, Gift AG, Given BA et al. The development and testing of an instrument for perceived
self-efficacy for fatigue self-management. Cancer nursing. 2011; 34 (3): 167-175.
2. Krishnasamy, M. Fatigue. In Cancer nursing: Care in context. 2nd ed. New Jersey: Wiley-Blackwell; 2009.
3. M
orrow GR, Shelke AR, Roscoe JA, Hickok JT, Mustian K. Management of cancer-related fatigue. Cancer
Investigation. 2005; 23: 229-239.
4. Nail, LM (2002). Fatigue in patients with cancer. Oncology Nursing Forum. 29(3), 537-544.
5. Ruckdeschel, JC (2005). Fatigue is becoming an exhausting problem. Cancer. 103(2), 213-215.
6.National Comprehensive Cancer Network (2009). Cancer-related fatigue. NCCN Practice Guidelines in
Oncology. Retrieved from
http://www.nccn.org/professionals/physician_gls/f_guidelines.asp Accessed 22 February 2011.
7. M
itchell SA, Beck SL, Hood LE, Moore K & Tanner ER (2007). Putting evidence into practice: Evidence-based
interventions for fatigue during and following cancer and its treatment. Clinical Journal of Oncology nursing.
11(1), 99-113.
8. B
orneman T, Koczywas M, Sun V, Piper BF, Smith-Idell C, Laroya B et al. Effectiveness of a clinical
intervention to eliminate barriers to pain and fatigue management in oncology. Journal of Palliative Medicine.
2011; 14 (2): 197-205.
9. K
irschbaum M. Cancer-related fatigue: a review of nursing interventions. British Journal of Community
Nursing. 2010 May; 15 (5): 214-9.
10.Piper BF, Borneman T, Sun V, Koczywas M, Uman G, Ferrell B, James RL. 2008 Oct; 12 (5) Supp: 37-47.
Appendices
Appendix 1: JBI PACES audit criteria for cancer-related fatigue
128
Appendix 2: Survey tool
129
130
Appendix 3: Barriers and strategies for Getting Research Into Practice (GRIP)
Barriers
Strategies
Resources
Outcome
1. Nurses do not receive
ongoing formal education
on cancer related
fatigue assessment and
management.
Involve Clinical
Development Nurses
(CDNs) and other audit
staff members to facilitate
education.
CDNs and other audit
staff members. Allocated
time for in-services to be
held. DON governance.
Improved compliance
from all clinical areas with
most audited criteria.
Evidence-based inservice
program improved
nurses’ compliance
with evidence-based
practices.
2. Competing education
priorities in the clinical
areas.
CNC and CDNs
Prioritise with Clinical
Nurse Consultant (CNC)
educational in- services.
Encourage Clinical
Development Nurses
(CDN) to incorporate
cancer related fatigue
assessment, management
and documentation
into their orientation/
mentoring of staff.
Clinical area staff
understood that
education regarding CRF
was a priority.
3. Lack of knowledge
of all aspects of CRF,
from assessment to
nursing interventions for
managing fatigue.
Attendance by staff at
evidence-based inservice
program.
Audit team members.
Allocated time for
provision of inservice
program.
Evidence-based inservice
program improved
nurses’ knowledge
and compliance with
evidence-based
practices.
4. Nursing documentation
inadequate
Liaise with CNCs and
CDNs to remind staff at
handover, staff meetings,
etc the importance
of documentation.
Attendance at evidencebased inservice program.
Dissemination of results
of audit to staff to
highlight improvements
and encourage further
improvement.
CNCs, CDNs and Project
Team members
No improvement in
nursing documentation
pertaining to cancer
related fatigue. Ongoing
education is needed to
reinforce concepts to
retained staff and educate
new staff.
5. Staff turnover
Recruitment of
champions among the
nursing staff to provide
ongoing education
Interested and enthusiast
nurses
Improvement in
compliance with
assessment and
documentation
JBI Fellows Monographs 2011-2012 Dora Lang
131
Bed bathing among adult patients in a private
oncology ward within an acute care hospital: a
best practice implementation project
Dora Lang
Nurse Clinician
National University Cancer Institute
Singapore
Abstract
Background
Bed bathing cleanses the skin, removes odour and enhances personal hygiene, leading to high self esteem.
Therefore, it is essential to perform bed bathing based on best-available evidence so that hospitalised patients are
receiving high quality of care.
Aims
• To ensure bed bathing is performed according to the best-available evidence
• To provide a pleasant bed bathing experience for patients
• To promote evidence-based practice within the clinical culture
Methods
The project was implemented in three phases using a system of audit and feedback. The Joanna Briggs Institute
Practical Application of Clinical Evidence System (JBI-PACES) was utilised to set up a team and undertake data
collection and data analysis, getting research into practice and report writing. The Getting Research into Practice
(GRIP) module was used for barriers identification, formulation of strategies and resources identification.
Results
There were 100% and 90% improvement for criteria 1 and 2 respectively. There were 21 sub criteria in criteria1. The
21 sub criteria were detailed steps to follow when performing bed bathing. Criterion 2 was referring to evidence of
bed bathing was documented in patient’s file.
This project has successfully introduced best-available evidence practice on bed bathing among the assistant
nurses. They have increased confidence in the assistant nurses in performing high quality care, making them ready
to be ambassadors for evidence-based practice among their other colleagues.
Keywords
Acute care, bed bathing, evidence-based practice, GRIP, JBI-PACES
Background
Bathing is a day-to-day activity in a normal functional person. It cleanses the skin, removes odour and enhances
personal hygiene, leading to high self esteem. Therefore, if a person is unable to perform bathing independently,
it can cause physical and emotional distress.
Admission of patients to the oncology ward in an acute care hospital is for a variety of reasons. The two major
reasons are to receive chemotherapy that require close monitoring of physiological changes, and management
of either cancer or therapy-related complications. There are also a minority of caregivers who prefer their family
members to spend their last days in hospital. There are some medical conditions that prevent patients from
bathing independently, for example, but not limited to, idiopathic thrombocytic purpure (ITP) with severely low
platelet counts and patients who are critically ill. Therefore, patients’ activities of daily living including bathing
will be usually performed in bed. Other patients’ conditions related to old age andfunctional disability and those
critically ill will also require bed bathing.
132
Bed bathing is like a two-edged sword. It refreshes and promotes overall well being for a bedridden person.
Conversely, it can also be associated with unpleasant, embarrassing, difficult, uncomfortable, dry, cold,
incomplete, inhuman, long and unsatisfactory experiences.1, 2 A qualitative research study has reported on the
elderly perspective on bathing. They described bathing as an important and meaningful activity to maintain
cleanliness and also the notion of well being and good virtue.3 In a group of patients with acute myocardial infarct
(AMI), patients’ anxiety levels were found to be significantly higher in those in bed bathing groups, compared to
showering group.1
Bed bathing is a simple concept yet a complex nursing procedure. Reflecting on current practices, some steps
of bed bathing are not in accordance with the best-available evidence. For example, nurses struggle in removing
clothes as patients have multiple intravenous lines connected, use only one basin of water repeatedly, the basin
is usually only half full of water,they do not ask the patients if they prefer to clean their genital area themselves, and
they do not document the patients’ skin condition. Many nurses assume that documentation is only needed if an
undesirable event occurs, for example, sudden collapse during bed bathing.
Patients’ hygiene needs are an essential element in holistic care. They entrust their body to nurses to help
themselves to be clean, free of endogenous infection,4 especially when they are in an immunocompromised state;
in return, nurses owe them a duty of care to perform high quality bed bathing with respect and maintain their
dignity at all times.
A clinical practice manual on bed bathing is available to guide nurses to perform high quality care. This Best
Practice project focused on four assistant nurses who performed the majority of the bed bathing procedures in a
private oncology ward with 16 beds in total in an acute care hospital.
Aims
The audit topic is related to bed bathing. The aims of the project were:
• To ensure bed bathing is performed according to the best-available evidence
• To provide a pleasant bed bathing experience for patients
• To promote evidence-based practice within a clinical culture
• T
o determine the correlation between evidence-based bed bathing with the frequency of reporting development
of pressure injury and skin tears by assistant nurses
Audit criteria
The audit criteria were:
1.Bed bathing is performed according to institute clinical practice manual (refer to Appendix I for specific steps
of procedure)5
2. Documentation on skin condition or any abnormal finding is evident in the person’s case file5
Setting and sample
National University Cancer Institute Singapore (NCIS) is a member of National University Health System (NUHS)
that is situated within the National University Hospital (NUH) located at the west region of Singapore. It is the
second largest cancer institute in Singapore. There are four oncology wards under the division of NCIS that
consists of a total of 72 beds. The four wards are subdivided into subsidised, private and high dependency units.
The targeted sample was from the private oncology ward that consists of a total of 16 beds. Although the ward is
designated for oncology patients, it does admit patients with diagnoses other than cancer.
There are seven assistant nurses (AN) on rotating shifts providing basic nursing care for the patients such as bed
bathing. However, only four ANs were available for the clinical audit. One AN was trained as an auditor, another
one was on maternity leave and the final one was in the transition program to be upgraded as staff nurse (SN).
Methods:
Clinical audit was targeted at the ANs skills in performing bed bathing as part of the clinical improvement project.
Therefore, ethics approval from NHG Domain Specific Review Boards (DSRB) was not required. Nevertheless, the
approval for the project was obtained from the Head of the Oncology Nursing Department. Patients’ privacy and
dignity was maintained throughout the audit period.
133
Phase 1: Preparation of baseline audit
Prior to conducting this project, a Principle Assistance Nurse (PAN) was invited to participate as a team member.
The project was implemented in three phrases using a system of audit and feedback. JBI-PACES was utilised to
set up a team, data collection, data analysis, getting research into practice, and report writing. GRIP was used for
barrier identification, formulation of strategies and resource identification.
In preparation for the baseline audit, the nurse clinician (NC) who was the driver of this project had partnered with
the PAN to perform the bed bathing together to reach consensus between them in regards to audit criteria. The
PAN was then taught to use JBI-PACES for data entering.
During the baseline audit, either the NC or PAN had performed the bed bathing with any assistant nurse on duty.
To facilitate the direct observation for auditing bed bathing procedure, the AN was assigned as ‘commander’
during the bed bathing. The ‘commander’ AN would park the bed bathing trolley on her side and give instructions
to her helper (the auditor). Therefore, the auditor must refrain from interfering with the ‘commander’ AN instructor
to prevent data contamination. After completion of the procedure, the auditor would audit the patient’s file to
ascertain if documentation on patients’ skin was found.
The baseline audit was conducted over a period of three weeks including four ANs who performed eleven episodes
of bed bathing.
Phase 2: Implementation of Best Practice
The team members analysed the baseline audit together and identified the gaps in performing bed bathing
procedures in accordance with Best Practice. GRIP was utilised to identify the potential barriers and strategies to
overcome the barriers. There was 0% compliance to both of the two audit criteria.
There were four barriers which were identified through direct observation and interview with the staff:
1. Lack of knowledge of best-available evidence regarding bed bathing
2. Lack of awareness on proper use of bed bathing equipment
3.Attitude of taking for granted the requirements for the bathing procedures, and not including individual patient
preferences.
4. Documentation of the patient’s skin condition is not required by the organisational policy
Strategies employed to tackle the barriers were:
1.Conducted group and one-on-one sharing sessions in regards to the best-available evidence of bed bathing
using audio-visual aids
2. Provided instruction to ANs on using bed bathing equipment effectively
3.Provided verbal reinforcement with the ANs on the evidence-guided techniques during actual bed bathing with
patients
4. ANs were given feedback and positive encouragement after each episode of bed bathing.
The implementation of bed bathing in accordance to Best Practice took place from 1 September 2011 to 24
October 2011. The duration of Phase 2 took approximately seven weeks.
Phase 3: Post implementation audit
The post implementation audit was conducted using the same criteria to check for consistency of compliance rate.
The method of assessment was the same as that used for the pre-implementation audit.
One of the initial objectives of tracking the frequency of ANs reporting pressure ulcers and skin tear could not be
achieved in this project. This was because within the culture of clinical practice, there was no requirement for ANs
to document any abnormal findings in the patient’s case notes. Reporting any abnormality of skin conditions to the
SN verbally is their sole responsibility, and deemed acceptable and appropriate. The role of ANs in documentation
will be further explored and discussed in departmental meetings.
Although a sample size of four ANs was anticipated in the beginning of the project, a total 11 episodes and 10
episodes were observed in the pre- and post implementation phase. The greatest challenge. iethe small sample
size, was due to no ANs being scheduled on morning shifts when the auditors were not around and one of the
auditors was asked to take over the administrative roles in the ward as the designated ward clerk was on annual
leave during the post implementation phase.
134
Results
There was a 0% compliance rate for both criteria 1 and 2 (Figure 1) prior to the implementation of the Best Practice
project. Criteria 1 could be expanded into the 21 sub criteria as presented in chart 1. It was considered not met
when any of these 21 sub criterion were not met.
Figure 1 Baseline audit result for bed bathing
Legend
1 Bed bathing is performed according to institute clinical practice manual
2 Documentation on skin condition or any abnormal finding is evidence in the person’s case file
Chart 1: 21 Sub criteria from criteria 1 in baseline cycle
There was 100 and 90% compliance rate for both criteria 1 and 2 (Figure 1) after implementation of Best Practice
project (Figure 2). All sub critera under the criteria 1 were all met (Chart 2)
Figure 2 Comparison audit findings for baseline and follow up cycle 1
Legend
1 Bed bathing is performed according to institute clinical practice manual
2 Documentation on skin condition or any abnormal finding is evidence in the person’s case file
135
Chart 2: 21 Sub criteria from criteria 1 in follow up cycle 1
Discussion
There was a 100% and 90% increase in compliance rates in criteria 1 and 2 respectively. Criteria 1 was very
stringent as it consisted of 21 sub criteria. The sub criteria of criteria 1 has shown great improvement in the
following areas: fill the basin with 2/3 full of warm water; adjust bedrail; cover patient with bath towel; position
patient comfortably; untuck the linen; ask the patient if he would like to clean his own face; change the basin when
water becomes dirty; clean the toes; and clean the buttocks.
Initially, one of the ANs was very sceptical about the topic. However, during the sharing of audit findings, the
opportunity arose for ANs to reflect upon how they had been performing bed bathing leading to improvement of
nursing care. Therefore, this project created greater awareness among ANs about evidence-based practice and
best-available evidence in regards to bed bathing. It has provided greater confidence for the ANs to deliver high
quality care and increase patient’s satisfaction.
The sample size collected was smaller than the initial projection due to both auditors being on different shifts,
and one of the auditors being removed from the clinical area to do administration work. It was noticed that there
may not always be ANs on duty every shift, especially when the bed bathing procedure is usually performed in the
morning shift. Therefore, moving forwards, there is an imminent need to extend the project to the SNs in the ward,
as they will be the ones who will be performing bed bathing instead of ANs. According to information shared from
the ANs, they observed that SNs did not perform in accordance to Best Practice as well. The next implementation
project will involve the four ANs who were well-trained during this period to audit on the RNs and promote high
quality bed bathing.
A slight modification was made during the pre-implementation audit. This was because both auditors found some
of the descriptions of the bed bathing steps not suitable for the local context. Refer to Appendix 1 for the original
and amended version of the bed bathing clinical practice manual.
Conclusions
This project has successfully introduced best-available evidence practice on bed bathing among the assistant
nurses. It has increased their confidence in performing high quality care, and made them feel more prepared to be
ambassadors for evidence-based practice among their other colleagues.
136
Acknowledgements
Thanks to Dr Emily Ang and Nurse Manager Keren Heng for their support in this projects, and Dr Rie Konno and Ms
Alexa McArthur for their teaching and guidance in protocol formulating and report writing. I would also acknowledge
my team member, PAN Eileen Tan, who shared her expertise in bed bathing procedures and conducted the audits.
Lastly, thanks to the four assistant nurses who participated in this project.
References
1.Lopes Jde L, Nogueira-Martins LA, Goncalves MA, de Barros AL. Comparing levels of anxiety during bed and
shower baths in patients with acute myocardial infarction. Rev Lat Am Enfermagem. 2010 Mar-Apr;18(2):217-23.
2.de Oliveira AP, de Lima DV. Evaluation of bedbath in critically ill patients: impact of water temperature on the
pulse oximetry variation. Rev Esc Enferm USP. 2010 Dec;44(4):1039-45.
3.Ahluwalia SC, Gill TM, Baker DI, Fried TR. Perspectives of older persons on bathing and bathing disability: a
qualitative study. J Am Geriatr Soc. 2010 Mar;58(3):450-6.
4.Massa J. Improving efficiency, reducing infection, and enhancing experience. Br J Nurs. 2010 Dec 9-2011 Jan
13;19(22):1408-14.
5.The Joanna Briggs Institute. Bed bathing. Recommended Practice, JBI COnNECT+. . 2010 [cited 21 June
2011]. Available from: http://connect.jbiconnectplus.org/ViewDocument.aspx?0=4989.
Appendices
Appendix 1: Bed bathing procedure
1. Gather equipment.
2. Fill basin 2/3 full of warm water and check temperature.
3. Explain procedure and gain the person’s consent. Provide privacy.
4.Wash hands and put on gloves if contact with blood, body fluids, secretions, excretions or contaminated items
is anticipated.
5. Adjust bed if needed; check brakes and lower bed rail.
6.Assist with removing the older person’s clothing. If IV device is present or extremity is injured, remove clothes
on unaffected side first.
7. Cover the person with drawsheet or bath towel.
8. Place the person in supine position on side of bed closest to you.
9. Untuck linen, remove bedspread and/or blanket.
10.Ask the person if they would like emollient on their face. Wash, rinse and pat dry face, ears, and neck.*
11.Place towel across the person chest. Wet washcloth and squeeze out excess water.
12.Wash, rinse and pat dry top half of body starting with side furthest away from you. Change basin water when
it becomes dirty or cool.
13.Wash, rinse and pat dry each leg and foot, remembering to dry in between toes.
14.Use clean water to wash genital area. The person may prefer to do this themselves if possible. Rinse and pat
dry, taking care with indwelling catheters, if present
15.Assist the person to turn onto their side. Wash buttocks using disposable wipes.
16.Return the person to supine position.
17.Place dirty linen in appropriate container.
18.Remove and discard gloves. Wash hands.
19.Place clean clothing on the person, and brush hair if required.
20.Change bed linen if needed.
21.Wash hands and ensure the person is comfortable.
22.Document and report any abnormal findings.
*This step is omitted if patient is unconscious.
137
Appendix 2: GRIP report
Barriers
Strategies
Resources
Outcome
Lack of knowledge
of best available
evidence regarding
bed bathing
Conduct group and one-on-one
sharing session in regards to the
best available evidence on bed
bathing using audio-visual aids
Computer and
projector
The ANs have incorporated
evidence based practise in bed
bathing. The strategy is effective
in creating awareness.
Provide feedback and positive
encouragement for the ANs after
each episode of bed bathing
NA
The ANs are being encouraged
through their facial expression.
This strategy is effective
Lack of awareness
on proper use of bed
bathing equipment
Inform the nurses of using
shower hose to fill the basin with
water based on the marking on
the basin
Shower hose
is accessible
in every room
The basin is filled with 2/3 full of
warm water for bed bathing. This
strategy is effective
Attitude of taking
for granted the
requirements of bed
bathing procedure
Provide verbal reinforcement with NA
the ANs on the evidence guided
techniques during actual bed
bathing with patient
Documentation
of patient’s skin
condition is not
required by the
organisation policy
The team leader will bring this
matter to the departmental
meeting for further discussion
The ANs are receptive towards
evidence based practice.
However, verbal reinforcement
is semi-effective as they forget
some steps occasionally
Departmental Outcome pending while
preparing the report
meeting will
be next held in
January 2012
138
JBI Fellows Monographs 2011-2012 Dr Maria Cynthia Leigh
Peripheral intravascular access devices (PIVAD)
management among registered and enrolled
nurses in a tertiary hospital setting: a best practice
Project Team Leader and Research Associate
Australian Capital Regional Centre for Evidence-based Nursing and Midwifery Practice: an Affiliate Centre of the
Jill Parke
Project Officer
David Larkin
Research Nurse
Tarkan Tez
Summer Research Student Scholar
Dr Imke Fischer
Research Associate
Abstract
Background
The most common invasive procedure performed in hospitals is the insertion of intravascular devices not only
for administering medications but for administering fluids, nutrients and blood products, and for monitoring the
hemodynamic status of patients. A clinical audit was undertaken to determine whether nurses at The Canberra
Hospital (TCH) were using best practice management of patients with peripheral intravascular access devices
(PIVAD), and to identify and implement changes when needed to ensure the delivery of efficient and effective
clinical care.
Aims/objectives
The aims of the project were to identify whether enrolled nurses (ENs) and registered nurses (RNs) in TCH were
using best practice management of patients with PIVAD and, in areas where the best available evidence was
not informing clinical practice, to implement and evaluate changes to ensure that best practice guidelines were
subsequently met by nurses.
Methods
A three-phase clinical audit was undertaken: Phase 1 involved a baseline survey of nurses’ knowledge and practice,
and an audit of patient records to determine the degree of compliance with the audit criteria,; Phase 2 consisted of
identifying and problem solving the barriers to implementation of best practice; Phase 3 involved a follow up audit
conducted to ascertain any change in compliance.
Results
Good compliance was obtained at baseline on nurses’ knowledge of best practice in relation to PIVAD management
and documentation which further improved in the follow up survey. However documentation audit showed low
compliance in the baseline cycle on the four selected criteria which moderately improved in the follow up cycle.
139
Conducting this clinical audit had a positive impact on the nurses’ capacity to incorporate evidence-based best
practice into their management of patients with PIVAD. Considering a short implementation phase and concurrent
demands for quality care delivery and accurate documentation, the results affirmed the commitment of TCH
nurses to continuously improve patient care.
Keywords
Best practice, clinical audit, peripheral intravascular access devices, IV cannula, IV therapy management
Background
The administration of intravenous/intravascular (IV) medications has become an increasing and routine part of
practice in most acute care settings. Medication incidents (defined as ‘any preventable event that may cause
or lead to inappropriate medication use or patient harm while the medication is in control of health professional,
patient or consumer’ by US National Coordinating Council for Medication Error Reporting and prevention) occur
worldwide and in many health care settings. A study on medication error and adverse drug events in Australia has
highlighted the problem.1 Considerable work has been undertaken, often at a local level, to reduce the potential
for error through good assessment and management since there are many consequences of medication incidents
including overall poor quality of patient care and occasional deaths, impact on health care staff (personally and on
their practice), costs and damage to the reputation of clinical unit and organisation.2
The most common invasive procedure performed in hospitals is the insertion of intravascular access devices not
only for administering medications but for fluids, nutrients and blood products, and for monitoring the hemodynamic
status of patients.3 Although no specific report on the prevalence of IV related complications in Australia has been
found, Australian Capital Territory (ACT) Health Riskman data for 2011 (1 Jan to 30 Sept) reports 161 IV related
incidents. Though this data is not restricted to peripheral intravascular devices and does not indicate comparative
increase or decrease from previous years, it is acknowledged that the number of incidents are unknown because
many incidents are never discovered, acknowledged or reported.4 In ACT, despite receiving attention in literature
in the past decade, PIVAD management and education is not included in the ‘Education Essential Policy’ of the
ACT Government Health Directorate March 2011 which outlines the education updates to be undertaken on an
annual basis.5,6 At the Canberra Hospital, the monthly nursing and midwifery orientation program for new staff
prepared by the Staff Development Unit only includes a 45-minute PCA/Epidural session and a one-hour session
on the use of Alaris Pumps. Actual cannulation education sessions are separately organised and coordinated by
the Cancer and Intravenous Education Coordinator. She signs off the ENs’ and RNs’ capability to manage patients
with PIVAD. Nurses’ skills and knowledge of evidence-based PIVAD policy and procedures are not monitored on a
regular basis. The ACT Health Directorate, hospital nursing executives/managers and Research Centre staff were
keen to pursue the study.
The ACT Research Centre for Nursing and Midwifery Practice based at the Canberra Hospital identified a strategic
need to explore and review current practice around clinical management of several nursing interventions at the
hospital. A project team took on the PIVAD management implementation project. TCH is a 500-bed tertiary
metropolitan teaching hospital providing a wide range of health care services to ACT and the south eastern NSW
(population 520,000).
This project surveyed the knowledge and practice of nurses who carry out PIVAD management on a regular basis.
It included an educational intervention. The auditing of documentation of patients with PIVAD in selected clinical
areas will provide information for comparison of pre- and post audit clinical practices for PIVAD management using
evidence-based policy and procedural guidelines.7
Aims
The aims of this project were:
• To conduct a pre- and post audit of nursing staff knowledge and practice based on evidence-based protocols
for undertaking PIVAD management
• To develop an education program using evidence-based protocols and procedures for nurses who undertake
PIVAD management
• To improve nurses’ knowledge and the use of evidence-based practices when undertaking PIVAD
management.
140
Methods
This project utilised a pre- and post implementation strategy using the Joanna Briggs Institute Practical Application
of Clinical Evidence System (JBI-PACES) program and Getting Research Into Practice (GRIP) module. These are
online tools that facilitate a process of change using an audit, feedback and a re-audit cycle as a strategy to
improve practice. This project was implemented over a six-month period from November 2011 to April 2012.
Ethics approval was sought from the ACT Health Human Research Ethics Committee to survey the nurses and
review patient records. Approval was granted on 18 November 2011. A participant information sheet was provided
to nurses explaining the purpose and nature of the project as well as ensuring them of privacy and confidentiality.
All data was de-identified and entered into a password protected computer. The data is managed as per the ACT
Government Health Directorate Research Policy.
Phase 1
The topic was identified as: nurses’ knowledge and practice of PIVAD management and documentation audit to
show knowledge application to practice.
A project team from the Research Centre for Nursing and Midwifery Practice (RCNMP) was formed. It was led by a
Research Associate of the Centre assisted by a Project Officer, Research Nurse and another Research Associate.
Several wards were invited to participate in the project and an organisational meeting was scheduled with those
who expressed interest. The meeting was attended by CNCs/ADONs of Renal, Aged Care, Gastroenterology,
Orthopaedics and Hospital in the Home wards and CNC-nominated ward champions. The discussion included
why the audit was being done, suggested timeline for the study, proposed phases of the study, the expected
involvement of “champions” and staff nurses, and incentives for participation.
Data collection
Two data collection instruments based on JBI-PACES audit criteria for PIVAD management were prepared in
consultation with key stakeholders. All ENs and RNs from the five wards (n = 182) were provided a Project
Information Sheet and invited to participate by completing the Nurses Knowledge Survey (see Appendix 1). Two
weeks were allocated for the return of the completed survey to the RCNMP. A documentation audit using a PIVAD
Management Audit Tool (see Appendix 2) of the Patient Assessment and Clinical Care Plan was conducted by
the project team on all patients that had or are currently on PIVAD in the five participating wards. JBI-PACES
application was used to enter the baseline cycle data and calculate compliance with the audit criteria.
Phase 2
Baseline data showed that compliance could be improved both in knowledge and application of this knowledge
through accurate and timely documentation. Potential barriers to compliance were identified and strategies
to overcome barriers were discussed by the project team with stakeholders. Resources needed to assist with
improving compliance and expected outcomes were also noted. These are summarised as a table at the end of
this report.
A PIVAD education CD using evidence-based literature (eg research articles, Best Practice sheets, technical
reports, ACT Health guidelines and TCH standard operating procedures) was prepared in consultation with the
ward CNCs and active participation of the Cancer and IV Education Coordinator and Senior RNs from Hospital
in the Home. An Information Sheet for the ward’s Clinical Development Nurse accompanied the CD (five copies
per ward) distributed to the wards at the beginning of the three-week education phase that followed the baseline
audit dates.
Phase 3
A replication of Phase 1 data collection method was conducted one month after the Phase 2 education program
was completed. The same Nurses Survey and Documentation Audit tools were used and the same five clinical
areas were involved. The follow-up cycle data was entered in JBI-PACES to determine change on compliance
rates with the audit criteria.
141
Results
Figure 1: Comparison of pre (baseline cycle) and post (follow-up cycle) survey of nurses’ knowledge about
PIVAD management
Criteria legend
1. Administration sets are replaced every 72-96 hours.
2. Catheter site and patency is monitored frequently as per hospital policy.
3.
Handwashing and aseptic technic are performed when palpating, inserting, replacing or dressing an
intravascular device.
4.
Healthcare professionals have attended education sessions regarding the insertion and management of
peripheral intravascular devices.
5. The IV cannula is removed as soon as its clinical use is no longer justified.
6.The IV cannula is removed between 72-96 hours of placement, or if there are any signs of phlebitis, infiltration
or extravasation.
7.There is a standard documented policy on maintenance of all equipment and medication utilised for IV therapy.
Nurses survey data
A small increase (range of 5% to 25%) for Criterion 2 (monitoring catheter site and patency), 3 (hand washing and
aseptic technique required), 5 (IV cannula removed when no longer needed), 6 (IV cannula removed 72 to96 hrs
after placement) and 7 (standard documented policy exists) and a large increase of 61% on Criterion 1 (replacement
of administration sets every 72 to 96 hrs). Reasons for the differences and actual rates reported can be based
on current practice in different wards, nature of patients in the wards and common procedures undertaken in the
wards.
Data for Criterion 3 (attendance in education session) is mainly influenced by the active involvement of the Cancer
and IV Education Coordinator in this project. Data shows 100% compliance in both Phase 1 and Phase 3 of the
project.
142
Figure 2: comparison of pre (baseline cycle) and post (ollow-up cycle) pivad management documentation
in the patient assessment and clinical care plan
Criteria legend
1. Administration sets are replaced every 72-96 hours.
2. Catheter site and patency is monitored frequently as per hospital policy.
3. Handwashing and aseptic technic are performed when palpating, inserting, replacing or dressing an
intravascular device.
4. Healthcare professionals have attended education sessions regarding the insertion and management of
peripheral intravascular devices.
5. The IV cannula is removed as soon as its clinical use is no longer justified.
6. The IV cannula is removed between 72 to 96 hours of placement, or if there are any signs of phlebitis, infiltration
or extravasation.
7. There is a standard documented policy on maintenance of all equipment and medication utilised for IV therapy.
Documentation audit data
Only four of the JBI-PACES audit criteria were considered relevant for the documentation audit.
Overall, there is much to be desired with regards to documenting PIVAD management in the Patient Assessment
and Clinical Care Plan. Many of the Clinical Care Plans examined had incomplete, not legible or absent information.
In many occasions, the doctor’s orders for medication charts and the Fluid Balance Charts have to be searched
to make sense of what should have been a daily record of care provided to the patient with PIVAD. However, there
was a large increase (range from 48% to135%) on all four criteria examined between Phases 1 and 3 when the
education package/CD was made available to all staff in the participating wards.
143
Discussion
Clinical audits in the context of best practice implementation projects, though becoming better known and
accepted, are not routinely conducted at TCH. This is the first time that nursing knowledge of PIVAD management
has been surveyed and the Clinical Care Plan documentation supporting that knowledge is concurrently audited.
Despite significant time constraints in this fellowship, it was encouraging to note small to moderate improvements
on compliance rates for six of the seven criteria when Phase 1 and Phase 3 Nurses Survey data were compared;
and large improvements on compliance rates for the four selected criteria when comparing Phase 1 and Phase 3
Documentation Audit data. Compared with marked increases in compliance rates, small positive increments may
be more meaningful and sustainable in this clinical setting.
The results demonstrate that an educational intervention can be successful in implementing the guidelines when
complemented with administrators/ward support and project team prompts. However, it is recommended that a
follow up study be conducted to address the unattended details about participant recruitment, preparation and
completion of data collection instruments, data entry and analysis, and overall project timelines. Such a follow up
study may help determine the sustainability of this intervention in maintaining evidence-based practice in TCH.
Undertaking this project has helped to illustrate the effectiveness of clinical audits in highlighting what could
be improved in our current clinical practice so our nursing actions align with evidence-based guidelines and
procedures. After all, evidence-based clinical decision making when we deliver nursing care will definitely achieve
not only better patient outcomes but also move towards realising our personal motivation as to why and how we
do nursing.
Conclusion
Conducting this clinical audit had a positive impact on the nurses’ capacity to incorporate evidence-based best
practice into their management of patients with PIVAD.
Considering a short implementation phase and concurrent demands for quality care delivery and accurate
documentation, the results affirmed the commitment of TCH nurses to continuously improve patient care.
Acknowledgements
The staff of the Research Centre for Nursing and Midwifery Practice (RCNMP) and nurses from selected clinical
areas at the Canberra Hospital for their assistance in the conduct of this study.
Linden Chapman (Cancer and IV Education Coordinator, TCH) for her clinical expertise, advice and participation
in the education CD production.
Tarkan Tez (Summer Research Scholar, University of Canberra) for assistance in literature search, preparation of
the education CD and liaising with TCH clinical and administrative staff.
References
1. Dean, B, Schachter, M, Vincent, C, Barber, N. Prescribing errors in hospital in patients: their incidence and
clinical significance. Quality and Safety in Health Care. 2002; 11: 340-344.
2. Joanna Briggs Institute. Management of peripheral intravascular devices. Best Prac-tice: Evidence based
Information Sheets for Health Professionals. 2008; 12(5):1-4.
3. O”Connell A, Lockwood C, Thomas,P.. Management of peripheral Intravascular Devices. JBI Technical Report.
2008; 4(5):51-64.
4. Lopez, V, Malassiotis, A, Chan, WK, Ng, F, Wong, E. An intervention study to evaluate nursing management of
peripheral intravascular devices. Journal of Infusion Nursing. 2004; 27(5):322-331.
5. O’Grady, NP, Alexander, M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related
infection [report]. Infection Control Hosp Epidemiology. 2002; 23:115-125.
6. Runciman, W, Roughhead E, Semple, S, Adams, R. Adverse drug events and medication errors in Australia.
International Journal for Quality in Health Care. 2003; 15(Suppl1): 49-59.
7. Wimpenny, P, Kane, J. The effectiveness and feasibility of routine IV medication administration systems and
processes to prevent medication incidents in acute care settings: a systematic review. JBI Systematic Review
Protocol. June 2007.
144
Appendices
Appendix 1
PIVAD nurses survey
Appendix 2
PIVAD documentation audit
145
146
Appendix 3
TCH Clinical Care Plan (without patient assessment, referral and discharge planning pages)
147
Implementation
Barriers
Strategies
Resources
Outcome
Concurrent involvement
of wards staff in several
projects
Plan w/ CNCs a suitable
schedule so diff projects
can be threaded through
a workable time chart
CNCs & Project Team
Planning meetings set
Identify project
champions so time &
focus can be optimised
GANTT chart of
concurrent activities
Staff volunteers
Project involvement
becomes manageable
and outcomes realised
Staff current knowledge
updated with increased
chances of being applied
in practice
Inadequate knowledge of
staff re updated hospital
SOPs & evidence-based
PIVAD practice criteria
Promote with CNC and
IV education Coordinator
In-service sessions
CNC
Lack of updated PIVAD
education package
deliverable in different
modes
Pocket-size booklet on
basic hospital SOPs
Project team &
nominated staff
champions
Incomplete or absent
PIVAD documentation in
care plan
Attractive and laminated
posters prepared & made
available to staff
Workable participation of
ward staff
IV Coordinator
TCH Educ/IT personnel
Project team
Interactive CD that when
viewed can gain credit
(Capabiliti record in TCH)
TCH IT personnel
Meet w/ relevant hospital
admin to discuss specific
sugg changes in Care
Plan format to improve
PIVAD documentation
Project team
CNC, DON, other
relevant Hosp
administrators
Hospital SOPs
transformed into
attractive, handy & easily
understood document
CD made and
disseminated
Improved documentation
compliance – accurate,
complete, & timely
148
JBI Fellows Monographs 2011-2012 Li Zheng
Management of physical restraints in critically ill
patients in a university hospital: a Best Practice
Li Zheng
Senior Lecturer
School of Nursing, Fudan University
Xu Yan
Senior Intensive Care Unit Nurse
Huashan Hospital (affiliated to Fudan University)
Shi Hui-lin
Fang Jing
Jin Yu-feng
Abstract
Background: A primary reason for the application of physical restraints in intensive care units is to protect
the patients against self-harm because of delirium and agitation. However, the use of physical restraints also
induces potential or substitute patient injuries. The recommended evidence-based restraint standards for the
management of physical restraint according to The Joanna Briggs Institute include nursing education, informed
consent, optimum application, assessment and monitoring before and during the restraint period. Best Practice
implementation allows for appropriate management plans to be applied for patients to achieve better outcomes
for patients and the organisation.
Aims/objectives: To improve local practice in the management of physical restraints in critically ill patients
according to the best-available evidence.
Methods: Using the criteria recommended by The Joanna Briggs Institute evidence-based restraint standards
for the management of physical restraint in critically ill patients, a clinical audit was conducted using the Joanna
Briggs Institute Practical Application of Clinical Evidence Systems (JBI-PACES) program and the Getting Research
into Practive (GRIP) process. The sample consisted of 54 nursing staff, 45 patients (184 patient days) in the initial
audit phase and 67 patients (324 patient days) in the re-audit phase in the neurosurgery ICU at Hua Shan Hospital,
measured against five audit criteria.
Results: The results indicated that clinical practice came near the evidence-based restraint standards. Whilst no
variation of the practice had been detected concerning the criterion of informed consent, there were improvements
in the implementation of criteria relating to nursing education, proper use of material, needs assessment and
complication monitoring, though differing in degree.
Conclusion: The project has succeeded to a great extent. Further improvement is required in order that practices
are up to speed with existing standards.
Key words: Physical restraint, neurosurgical patient, intensive care unit
149
Background
Physical restraint is defined as any manual method or physical or mechanical device, material or equipment
attached or adjacent to a patient’s body, that he or she cannot easily remove, that restricts freedom of movement
or normal access to one’s body.1 It is used primarily in nursing homes and psychiatric hospitals to prevent falls
and stop confused patients from harming themselves.2 In intensive care units (ICUs), patients are often at risk of
harming themselves because of delirium and agitation. 2 Protection of patients in ICUs against self-harm is the
commonest reason for application of physical restraints.3 A systematic review found that up to 21% of acute
care patients were subject to some forms of physical restraints during their period of hospitalisation.4 The use of
physical restraints was recently reported in 35.1% of ICU patients in Chinese tertiary hospitals.5
Use of physical restraints also induces potential or substitute patient injuries. A large number of studies reported
that physical restraints introduced direct or indirect injuries.6 The direct injury is caused as a result of the external
pressure from the restraining device, including lacerations, bruising or strangulation. Indirect injury refers to the
enforced immobility of a person, including increased mortality rate, development of pressure sores, falls, or failure
to discharged.4 Furthermore, a review paper reported fatal pulmonary embolism and thrombophlebitis when
patients were immobile for a long time.8 By now, there is limited information on the prevalence of restraint-related
injury.6 Many statements identified and highlighted the negative impact of physical restraints. The most the patient
experiences is restriction and discomfort, and comments from patient relatives are anger and discomfort.4
Patients in intensive care units are at high risk of the development of delirium and agitation because of pre-existing
medical conditions, multisystem failure and use of sedatives, resulting in poor compliance with life-saving treatment.2
Delirium is a primary reason for introducing restraints.1 The delirium is a change in mental status characterised by
a reduced awareness of the environment and a disturbance in attention.7 This may be accompanied by perceptual
symptoms (hallucinations) or cognitive symptoms including disorientation or temporary memory dysfunction.7 The
patient may express hypoactive, hyperactive, or mixed psychomotor behaviors.8 Postoperative delirium (POD) is
one subtype of delirium, and patients with POD may be lucid in the postanaesthesia care unit. However, after this
initial lucid interval, the patients develop the classic bipolar mental status, most commonly between postoperative
days one and three. Some postoperative patients may reside in the ICU.8 Delirium was reported in numbers up to
80% of mechanically ventilated patients during the course of their ICU stay,1 and incidence rate of POD ranged
from 5 to 15% among studies.8
Agitation is also a common event in ICUs. Agitated patients may show constant fidgeting and movement, pulling
at bed sheets, invasive devices and catheters; trying to get out of bed; shouting and hitting and disorientation to
time and place.2 The consequences of agitation in critically ill adults are associated with potentially dangerous
complications such as self-extubation, removal of arterial and venous lines and poor compliance with life-saving
treatment.2 Agitation has been reported in 52% of the patients in a medical-surgical ICU.1
The Joanna Briggs Institute evidence-based restraint standards for the management of physical restraint
recommended:
1. All staff have received education regarding the correct use of restraint
2. Restraint is applied as per manufacturers instruction
3. There is a documented assessment identifying the need for restraint
4. There is a documented client monitoring during the episode of physical restraint to ensure the well-being and
safety of the patient
5. Informed consent is obtained from the patient or the next of kin or other legally authorized person for the use
of physical restraint.
Patient safety is the priority of heathcare systems worldwide, and it is the major indicator of quality of care. Great
efforts to improve patient safety and quality of care are being made by the Chinese healthcare system. For this
clinical audit, the decision making and the application of physical restraint should be served for the safety of the
patients.
Hua Shan Hospital is a university hospital with 1216 beds, 875 doctors and more than 1300 nurses in Shanghai,
China. It is a generally acute care hospital including one intracranial trauma ICU, one medical and surgical ICU
and one neurosurgery ICU, and more than 60 specialised wards. This project was conducted in the neurosurgery
ICU, which includes 29 beds, 54 nurses and 76 rotation doctors. The rotation rate of the patients is approximately
450 individuals every month. More than 30% patients with physical restraint are performed daily. Limb edema, the
most common complication of physical restraint, is detected in 65% restraint patients, and 60% patients show
bruising in their ICU stay. It is well known that altered consciousness occurs most frequently in the neurosurgical
patients, especially after surgical operations. Thus, it was appropriate that the neurosurgery ICU was a suitable
setting to undertake the project.
150
Aims
To ensure the practice of physical restraint management in the ICU patients is performed according to the bestavailable evidence.
To improve local practice in the management of physical restraint.
Methods
Setting and sample
Hua Shan Hospital is a 1216-bed university hospital in Shanghai, China. It is a large comprehensive acute care
organisation including one intracranial trauma ICU, one medical and surgical ICU and one neurosurgery ICU. The
implementation project was conducted in the neurosurgery ICU which includes 29 beds. The rotation rate of the
patients is approximately 450 every month. More than 30% rate of physical restraint is administered per day.
Physical restraint is allowed by senior nurses and delivered by registered nurses of varied experience according
to the organisation policy.
The baseline audit of compliance with the Best Practice involved 45 patient notes in the ICU, a total of 184 patient
days with physical restraints and 54 nursing staff working in the ICU. The documentation audited consisted of
medical and nursing documents; these included hard and soft copies.
In the post implementation audit stage, 67 patients’ (324 patient days) case notes and 54 nursing staff were
audited. It needs to be noted that the number of case notes audited was higher than that in the first audit stage
because of the double time spent in this period.
Compliance audit criteria:
The first and second audits assessed the following five criteria:
1.All staff have received education regarding the correct use of restraint.
Compliance was based on a quick assessment including related questions after physical restraint training had
been done.
2.Restraint is applied as per manufacturers instruction.
Whether this criterion had been met or not was decided depending on the result of the senior nurses’ inspection
every day.
3. There is a documented assessment identifying the need for restraint.
Whether this criterion had been met or not was estimated through a retrospective examination of the patients’
nursing records.
4. There is a documented client monitoring during the episode of physical restraint to
ensure the well-being and safety of the patient.
Whether this criterion had been met or not was estimated by means of a retrospective examination of the patients’
nursing records.
5. Informed consent is obtained from the patient or the next of kin or other legally
authorized person for the use of physical restraint.
This criterion was considered to have been met if written informed consent could be found in the patients’ medical
or nursing records.
Phase 1
Using the JBI-PACES program an audit was conducted by members of the project team. The audit commenced
in the last week of November 2011 and was conducted over four weeks. Following completion of the auditing
process the project team met to discuss the results of the audit obtained using JBI-PACES.
Phase 2
GRIP - Implementation of Best Practice
The audit results were collected by JBI-PACES program and the feedback information was disseminated to the
project team in the first week of January 2012. Review of the audit results allowed the team to progress to the
initial step in the GRIP component, identifying and discussing the barriers to achieving 100% compliance with
Best Practice. There were two barriers:
• unsatisfactory adherence to the best practice
• lack of knowledge in physical restraint.
151
The problem-solving strategies included communication with key stakeholders, routine inspection and modification
of senior nurses and nurse education. Following this discussion, actions were identified to address the barriers
and these transcribed into the GRIP program. Actions were taken commencing in the second week of January
to improve clinical practice. The date for commencement of the re-audit phase was identified as the first week of
February 2012. The implementation period time frame was over four weeks.
Phase 3
After implementation of the strategies to improve evidence-based practice, a post implementation audit took place
in the first week of February 2012 and was conducted over nine weeks. This was a replication of the baseline audit
process.
This project was conducted in accordance with the principles of clinical audit and quality improvement and did not
require direct interaction with the patients. There were no confidential details regarding the patients and the nurses
could be identified during the audit process.
Results
Baseline audit
The baseline audit was conducted from the last week of November 2011. The data collection process took four
weeks utilising the criteria identified previously in this paper. The results of the audit were transcribed into JBIPACES for review and interpretation of compliance with the five criteria (see Figure 1). The ward showed low
compliance with three of the criteria relating to nursing education, informed consent and restraint-associated
complication monitoring whilst the other two criteria registered high levels of compliance.
Figure 1: Initial audit and criteria
Re-audit
The re-audit phase commenced in the first week of February 2012 and was conducted over nine weeks. It was
noted that the re-audit phase revealed improvement in compliance relating to four of the five identified criteria (see
Figure 2). In reviewing these audit criteria individually it was found that they all achieved 100% compliance in the
re-audit phase even if in different ranges. Only one of the five criteria revealed no change in the re-audit period
compared to the baseline audit. These results are further explored in the discussion section of this paper.
152
Figure 2: Re-audit and criteria
Discussion
The objective of the project was to transform the clinical practice to comply with evidence-based standards from
The Joanna Briggs Institute for the management of physical restraint. The results demonstrated that four of the
five criteria were met completely in the re-audit phase. To a certain extent, these results were based on the initial
high levels of compliance with some criteria. This indicates the high level of success of the project and the reason
for this is explained below.
Before the initial audit phase, only five (9%) senior nurses of the ward had received education through a lecture
provided by the Nursing Department of Hua Shan Hospital. Thus, the majority of the nurses applied physical
restraints based on their individual experience and sometimes with the help of others who had the necessary
experience to be able to guide them. The limitations of time was compounded by the fact that nurses were having
Chinese New Year holidays by turns. Education was provided for nurses using two approaches: education sessions
as well as handouts placed on the home pages of the nursing records in every room of the ICU. Each nurse was
asked to read the information before their scheduled time and was informed to have a quick assessment later.
Finally, 100 percent of the ICU nurses finished the physical restraint education after Phase 2.
The second and third criteria also achieved 100% compliance in the re-audit phase.. Since the hospital was
certificated by the Joint Commission International in 2010, a physical restraint team has been developed and has
been working at the management of physical restraint for one year. The team has provided a lecture to nurses on
the use of physical restraint and has improved the evaluation tool comprising needs assessment and restraint
related complication monitoring items. This why in the baseline audit period, 93% and 97% of the patient days
were detected in accordance with the two criteria respectively. However, there was still a gap between practice
and recommended standards. In the GRIP component of this audit project, strategies were developed to address
the barriers and improve the outcomes, including routine inspection and modification of three senior nurses. These
led to the successful results.
Although the physical restraint team laid a good foundation in practice, compliance for the fourth criterion was
slightly low in the initial audit phase. The reason for this is discussed in the GRIP process. It shows that nurses
tended to omit writing down some of the restraint-related complications such as bruises and limb edema because
they were extremely common in these patients.
153
The criterion yielded a more positive outcome and saw a 69% increase in the number of days where restraints on
patients are correctly recorded due to the strategies mentioned before.
As we know, informed consent is a basic ethical issue. However, the fifth criterion is the only one recommended
standard which had low compliance initially and had no change in the re-audit phase. In the audit ICU, approximately
20% of restraint patients were from VIP wards where they stayed before neurosurgical operations. In those wards,
the patients or their relatives would be asked to sign a preoperative guideline which including an item of physical
restraint before they had the surgeries. The restraint patients in the ICU who were from the other wards had no
written informed consent, according to the head nurse of the ICU, due to no requirement raised by the nursing
department. That was one reason. The other reason was that, in the ICU, if patients who needed physical restraint
refused to accept the practice, the consequences would be serious. In reality, subsequent interpretations were
always accepted by the relatives of the patients. It has failed to engage stakeholders and implement changes in
the policy. This issue needs to be explored in more detail.
Besides, during the audit process, some suggestions concerning the items of the evaluation tool were raised by
the audit team. They were submitted to the quality improvement department of the hospital.
Conclusion
From the results of the re-audit phase, it seems that the project has succeeded to a great extent. Further
engagement with key stakeholders is required in order to achieve compliance with standards in practice.
Reporting
The results and outcomes of the project will be disseminated to key stakeholders within the neurosurgery ICU via
in-service presentations and forums. The JBI-PACES and GRIP reports will be available to interested stakeholders
and other nurses.
The project findings and impact will be distributed more widely via publications and academic activities.
Acknowledgements
I would like to express our appreciation to the Joanna Briggs Institute for providing us with the opportunity and
support for this Clinical Fellowship. A a big thank you also to Dr Yifan Xue, our JBI facilitator in this project, for his
time, patience, support and guidance.
Many thanks to the audit team who supported us in this project:Xu Yan, Shi Hui-lin, Jin Yu-feng and Fang Jing.
Lastly thank you to the Neurosurgery ICU of Hua Shan Hospital for participating and allowing us to conduct this
fellowship project in its area.
References
1. H
ofso K, Coyer FM. Part 1. Chemical and physical restraints in the management of mechanically ventilated
patients in the ICU: Contributing factors. Intensive and Critical Care Nursing 2007; 23: 249-255.
2. Karen H. The use of physical restraint in critical care. Nursing in Critical Care. 2007;12 (1): 6-11.
3. H
ofso K, Coyer FM. Part 2. Chemical and physical restraints in the management of mechanically ventilated
patients in the ICU: A patient perspective. Intensive and Critical Care Nursing. 2007; 23, 316—322.
4.Evans D, Wood J, Lambert L. Physical Restraint - Part 1: Use in Acute and Residential Care Facilities. Best
Practice. 2002; 6 (3).
5.Xu LF, Zheng XH. Investigation of physical restraint in ICU. Chinese Journal of practical Nursing. 2010; 26(10C):
58-59.
6.Evan D, Wood J, Lambert L. Patient injury and physical restraint devices: a systematic review. Journal of
Advanced Nursing. 2003; 41(3): 274–282.
7.Deiner S, Silverstein JH. Postoperative delirium and cognitive dysfunction. British Journal of Anaesthesia.
2009; 103 (BJA/PGA Supplement): i41–i46.
8. M
ohr WK, Petti TA, Mohr BD. Adverse Effects Associated With Physical Restraint. Can J Psychiatry. 2003;
48(5): 330-337.
154
JBI Fellows Monographs 2011-2012 Chee Lien Poh
Nursing inter-shift handover process in mental
health settings: a best practice implementation
project
Chee Lien Poh
Assistant Director, Nursing (Education)
Institute of Mental Health
Singapore
Rajni Parasuram
Senior Staff Nurse
Institute of Mental Health
Singapore
Abstract
Aims:
Nursing inter-shift handover remains an important traditional ritual in nursing. Timely and effective handover of
critical information ensures continuity of patient care and safe delivery. This project took place in a tertiary mental
health institution in Singapore. The project aims to 1) examine existing handover practices/process in the tertiary
mental health institution; 2) determine the strengths and limitations of the existing handover practice/process; and
3) identify, implement and evaluate an evidence-based nursing inter-shift handover process to enhance patient
safety and service delivery.
Methods:
This project was conducted in three phases using the Joanna Briggs Institute Practical Application of Clinical
Evidence System (JBI-PACES) and Getting Research Into Practice (GRIP) programs. It was implemented over a
period of four months, from end August 2011 to beginning December 2011. Evidence-based strategies such as
town hall meetings and education sessions that reinforce proper handover techniques and their importance were
implemented to enhance the handover processes and practices in four acute admitting wards. Pre- and post audit
data were observed and recorded for each case handover during each inter-shift handover session in four acute
admitting wards.
Results:
The handover processes for 317 cases for four acute admitting wards were observed using the seven audit
criteria. Post implementation audit findings show that compliance rates had improved significantly for the four
criteria: an improvement of 49% compliance rates in the use of standardised documentation during shift handover
session; an increase of 74% compliance rates in proper identification of patient at the start of each case report; a
31% increase in proper handing over of significant patient’s history; and 18% increased compliance in providing
detailed observation of patients.
Conclusion:
This project had shown that handover sessions can be made effective by translating evidence into practice
through ongoing evidence-based audit. Continuous evidence-based evaluation, identification and implementation
of nursing inter-shift handover process are imperative to enhance patient safety and service delivery.
Keywords: nursing inter-shift handover, shift handover, mental health, best practice, communication
155
Introduction
Nursing verbal inter-shift handover is a traditional practice in all care settings and disciplines.6,10 It is defined as
“the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or
group of patients, to another person or professional group on a temporary or permanent basis (p.7).”3 Over past
decades, there have been growing concerns about this traditional practice among the researchers, clinicians,
hospital administrators, educators and policymakers.10
With increasingly high occupancy rates, higher patient acuity, multidisciplinary interactions, staff changes and
growing reliance on part-time staff,6 many have came to realise that ineffective inter-shift handovers can be
hazardous to patients and healthcare professionals. Ineffective handover could also result in misuse of scarce
resources,4,5,6,7,10 discontinuity of patient care, loss of information, incorrect treatments, delays in diagnosis,
adverse events, patient complaints, greater health care expenditure, and increased lengths of stay.6
Globally, major healthcare institutions are looking at strategies to strengthen the efficacy and efficiency transfer of
essential patient care information during nursing inter-shift handovers.2,3,6,13,14 The World Health Organization has
ranked communication during patient care handover as its 5th priority in patient safety initiatives.14 In 2009, clinical
handover was identified as one of the key focus areas for the Australian Commission on Safety and Quality in Health
Care (ACSQHC).2 The Joint Commission International in the United States (US) has ranked improving effective
communication among hospitals as the second most important international patient safety goal (IPSG),11,13 which
all hospitals in the US and public hospitals in Singapore must meet in order to maintain their accreditation status.
The Institute of Mental Health (IMH), the largest tertiary mental health institution in Singapore, is obligated to
ensure that quality care and services are delivered to patients. IMH needs to map their care standards with those
laid by prestigious global healthcare organisations, in order to achieve the vision of being the world leader for
mental healthcare by 2020. As such, there is a crucial need to review their existing nursing handover practices or
processes, reduce the increasing incidences of inter-shift miscommunication, and ensure safe delivery of patient
care.
Although many studies have showed that nursing inter-shift handover is ubiquitous and widely practised across
all health care settings and disciplines,6,10 it is impossible to have a single approach that addresses the needs
of all handovers due to the diversity and complexity of health care.9 Effective and efficient transition of patient
care information requires an evidence-based handover approach.9 Such an approach has been shown to include
elements such as face-to-face communication;6,13,14 documenting handover using a structured tool;9,11,13 patient
identification;6 relevant history of the patient has been stated;11 detailed observation of the patients have been
stated;6,7 the handover process includes an agreed plan of care for the patient;10,11 and responsibility transfer.1,12,13
Audit questions
In view of these, this project seeks to answer the following audit questions:
• Are existing handover practices/process in the institution effective and efficient in transferring patient
information accurately and timely?
• Are existing handover practices/process based on the best-available evidence?
Aims/objectives
This project took place in a tertiary mental health institution in Singapore.
The project aimed to:
• Examine existing handover practices/process in the tertiary mental health institution
• Determine the strengths and limitations of the existing handover practice/process.
• Identify, implement and evaluate an evidence-based nursing inter-shift handover process to enhance patient
safety and service delivery.
156
Methods
This project was conducted in three phases using the JBI-PACES and GRIP. These are online database systems
designed to collect data and facilitate clinical improvement through audit, problem identification, action planning,
action implementation and re-audit processes.8 The project was implemented over a period of four months from
end August 2011 to beginning December 2011.
Phase 1: Preparation phase
In phase 1 of this project, a project guideline that explained and outlined the entire process of the project was
developed.
Identification of topic
The topic selected for this project is nursing inter-shift handover process in mental health settings. This topic was
chosen because a recent root cause analysis of a hospital sentinel event indicated misinformation and a lack of
vital data during inter-shift handover as the main root cause. Hence, it is crucial to review existing nursing handover
practices or processes in order to minimise incidences of inter-shift miscommunication and prevent the next
disruption to patients’ continuity of care.
Establishment of audit team
Key stakeholders were informed about the project to garner their support. Approval to implement the project was
sought from these key stakeholders prior to its commencement. A project team comprising five members was
formed. These five members included one Senior Nurse Educator, one Nurse Educator and four Registered Nurses.
The team was led by a Senior Nurse Educator and assisted by a Nurse Educator, who was both participants of the
Joanna Briggs Evidence-based Clinical Fellowship program. The team members were informed of their roles and
responsibilities in this project.
Determine setting and sample size
The project took place in a tertiary mental health institution in Singapore. The mental health institution houses
approximately 2000 inpatients and provides comprehensive mental health services that meet the needs of children,
adolescents, adult and the elderly. More specifically, baseline data was collected from four acute admitting inpatient mental health wards (two male and two female wards), once a week for one month by four auditors using
JBI-PACES and GRIP.
Audit criteria
The four auditors sat through the inter-shift handover sessions in the afternoon shifts once a week in each ward.
Observation was recorded based on a list of evidence-based audit criteria for each case which was handed over
to the next shift in each selected ward. The details of the audit criteria were computed into JBI-PACES, which
included the following:
1.Handover is done through face-to-face communication.6,13,14 This criterion was considered met when nurses
conducted face-to-face inter-shift handover session in the afternoon shifts.
2.Handover is documented using a structured tool.9,11,13 This criterion was considered met when nurses used the
handover reminder template for each patient during inter-shift handover sessions.
3.The patient is being identified.6 This criterion was considered met when nurses identified each patient by
reciting the patient’s two identifiers (name and hospital registration number), age, gender, race and diagnosis
at the start of each case report.
4.Relevant history of the patient has been stated.11 This criterion was considered met when information about
patient admission history, past mental and medical (if any) conditions and medication was handed over for
each case report.
5.Detailed observation of the patients have been stated.6,7 This criterion was considered met when detailed
observation about the patient’s mental status, behaviour and medical conditions (if any), specific concerns and
forwarding pending tasks was handed over during the inter-shift handover session.
6.The handover process includes an agreed plan of care for the patient.10,11 This criterion was considered met
when an agreed plan of care for each patient was handed over to the nurses taking over the shift.
7.Transfer of responsibility of the patient from one nurse/shift to another nurse/shift occurred.1,12,13 This criterion
was considered met when the nurse who was taking over the shift acknowledged or agreed to take over the
care responsibility for the patients.
157
Baseline data collection
The baseline data was collected in end August 2011 for one month using the audit criteria in JBI-PACES. The
purpose of collecting baseline data was to assess the efficacy and efficiency of existing handover practices or
process. During the baseline data collection, one auditor sat in the handover session in each selected ward and
observed the session once a week for a period of one month. Checklists with JBI-PACES criteria were used to
assess each case handed over during the sessions. All data was entered into the JBI-PACES system after each
audit session by the auditors.
Phase 2: Implementation of Best Practice
Prior to the implementation of best handover practice, the project team proceeded to analyse the data for criterion
that did not achieve 100% compliance.
Identification of practice gaps
The team used the GRIP program to identify existing practice gaps relating to nursing inter-shift handovers that
prevented the nurses from achieving 100% compliance. The gaps identified were:
1.Lack of proper handover techniques among registered nurses during handover reports.10,13 This resulted in
misinformation and disrupted continuity of patient care.
2.Resistance to change among registered nurses.13 Most nurses did not follow the proper handover report
process when handing over to the next shift. Their handover reports were largely medical or technical and had
a limited nursing focus. In mental health institution, often times, detailed observation and handover of mental
health related issues, such as patients’ mental states and behaviours were missing in the nurses’ handover
processes.6
3.Misuse of time.10,13 Cleary et al. (2009) report that handovers can take up a significant amount of time every shift
in mental health settings.6 This greatly reduces the time available for the patients.6
Strategies to improve handover practice
The GRIP program was also used to identify evidence-based strategies to address the practice gaps during
baseline data collection. The following strategies were implemented to address the gaps identified:
1.The project team organised town hall meetings with key stakeholders, namely, the Nurse Managers, Nurse
Clinicians, registered nurses and enrolled nurses. Findings of sentinel events and electronic hospital occurrences
reports were shared with these nurses during the town hall meetings to create awareness and highlight the
importance of proper handover techniques.
2.Education sessions based on the evidence-based handover strategies were also conducted for the nurses. In
addition, all newly recruited nurses were taught proper handover techniques in their orientation programs to
inculcate the right culture on day one of their employment.
3.Registered nurses were also taught to appoint a time keeper and focus on handing over specific information
and pending tasks pertaining to patient care and avoid side tracking. This reduced the length of time spent in
inter-shift handover reporting.
Baseline findings and evidence-based strategies were presented to the key stakeholders including the ground
nurses in wards involved in the audit to garner their support for post implementation audit.
One month after the implementation of the strategies to improve handover practices, a follow up audit was
conducted in the four selected acute admitting wards to evaluate the effectiveness of the evidence-based
strategies using the same set of audit criteria in JBI-PACES. Data was analysed using GRIP to identify practice
gaps in the post implementation audit.
This project does not require ethics approval because it was conducted in accordance with IMH clinical quality
improvement policy. It did not infringe on patients’ confidentiality and care in any manner.
158
Results
Audit results for all wards
Figure 1 shows the baseline and post implementation comparison audit for Ward 32A. Baseline data is represented
in the bar diagram in yellow (n=53). All three audit criteria in the baseline audit scored less than 50% indicating
poor compliance to Best Practice. Poor compliance was especially observed in the identification of patients
during clinical handovers, reporting a rate of 0%. Relevant patient history and detailed observations in criteria 4
and 5 shared near similar baseline results (28% and 43% respectively).
Post implementation results is represented in the bar diagram in blue (n=59). All three audit criteria that scored less
than 50% showed increased compliance rates after post implementation. Results in criteria 3, 4 and 5 reported
an increase in compliance rates of 14%, 48% and 13% respectively, when compared to the pre-implementation
audit, indicating a significant improvement in clinical handover practices.
Figure 1: Baseline and post implementation comparison audit for Ward 32A
In Figure 2, baseline data is represented in the bar diagram in yellow (n=74). All six audit criteria scored above
50% indicating compliance to Best Practice. Poor compliance was again observed in the identification of patients
during clinical handovers, reporting a rate of 0%. This audit criterion finding was similar in Figure 1.
Post implementation results is represented in the bar diagram in blue. Slight improvement in audit criterion 3 was
seen at 37%. However, comparing pre- and post implementation results for Ward 32B should be done with caution
in view of the difference in the total number of cases audited (n=27). Due to the lesser volume of cases audited, post
implementation results for criterion 4, 5, 6 and 7 reports appeared to be lesser than the pre-implementation stage.
Cases audited were significantly lesser due to the low patient census in the ward during the post implementation
phase in November compared to that in August.
159
Figure 2: Baseline and post implementation comparison audit for Ward 32B
Figure 3 shows the pre-implementation audit results (yellow bar) in Ward 33A. All four audit criteria scored less
than 50% indicating poor compliance to Best Practice during clinical handover (n=75). Poor compliance was
noted towards identification of patients during clinical handovers (0%), relevant patient history (20%) and detailed
observations of the patient (16%). Both Figure 1 and 2 had also reported similar baseline findings in audit criteria
3, 4 and 5.
Meanwhile the post implementation results (blue bar) in almost all audit criteria showed increased compliance
rates with the greatest significance seen in criterion 3 with a post implementation compliance score of 94%.
However, comparing pre- and post implementation results should be done with caution in view of the difference
in total number of cases audited.
Figure 3: Baseline and post implementation comparison audit for Ward 33A
160
Figure 4 shows the pre-implementation audit results (yellow bars) in Ward 33B (n=92). Audit criteria 2 and 3 both
reported 0% baseline compliance rates which was similar to Figure 1. Poor compliance was again observed in the
identification of patients during clinical handovers (0%), relevant patient history (20%) and detailed observations
of the patient (16%). Both Figures 1 and 5 had also reported similar baseline findings to audit criteria 3, 4 and 5.
All post implementation audit criteria represented by the blue bars showed increased compliance rates with the
greatest significance noted in criteria 2 and 3 with a post implementation compliance score of 93% (n=92).
Figure 4: Baseline and post implementation comparison audit for Ward 33B
Figure 5 shows the baseline audit records of the handover sessions for 294 cases observed in four acute admitting
wards. The audit criteria listed in Figure 5 were used to audit the 294 cases. Results of baseline audit show that:
1. Only 43% of the cases used standardised documentation in the handover sessions.
2.None of the nurses identified their patients by reciting the patient’s two identifiers (name and hospital registration
number), age, gender, race and diagnosis at the start of each case report
3. Only 61% of the cases had their relevant history handed over to the next shift.
4.Only 60% of the cases had their detailed observation about the patient’s mental status, behaviour and medical
conditions (if any), specific concerns and forwarding pending tasks handed over during the inter-shift handover
session.
Figure 5: Baseline Aggregated Audit Results
161
Criteria legend
1. Verbal (face-to-face) communication has occurred. (294 of 294 samples taken)
2. Standardised documentation has been used. (294 of 294 samples taken)
3. The patient has been identified. (294 of 294 samples taken)
4. Relevant history of the patient has been stated. (294 of 294 samples taken)
5. Detailed observations of the patient have been stated. (294 of 294 samples taken)
6. The handover process includes an agreed plan of care for the patient. (294 of 294 samples taken)
7.Transfer of responsibility of the patient from one nurse/shift to another nurse/shift occurred. (294 of 294 samples
taken)
Post implementation audit
Figure 2 shows the results of the post implementation audit. The handover processes for 317 cases for four acute
admitting wards were observed using the seven audit criteria listed in Figure 2. Results show that compliance rates
had improved significantly for the four criteria, which had low compliance rates in the baseline audit. Results of the
post implementation audit indicate that:
1.Compliance rates for criterion 2 was 92%, which showed an increase of 49% compliance as compared to the
baseline audit results.
2.Criterion 3 showed an increase of 74% compliance rate as compared to the baseline audit.
3. Criterion 4 was 92%, which showed an increase of 31% compliance rate as compared to the baseline audit.
4.Criteria 5 showed 78% compliance, which indicated an increase of 18% compliance as compared to the
baseline audit.
Criteria legend
1. Verbal (face-to-face) communication has occurred. (317 of 317 samples taken)
2. Standardised documentation has been used. (317 of 317 samples taken)
3. The patient has been identified. (317 of 317 samples taken)
4. Relevant history of the patient has been stated. (317 of 317 samples taken)
5. Detailed observations of the patient have been stated. (317 of 317 samples taken)
6. The handover process includes an agreed plan of care for the patient. (317 of 317 samples taken)
7.Transfer of responsibility of the patient from one nurse/shift to another nurse/shift occurred. (317 of 317 samples
taken)
Figure 2: Post implementation aggregated audit results
162
Discussion
This was the first time JBI-PACES had been introduced and utilised in the hospital. The system was user-friendly
and practical in carrying out change within a tertiary psychiatric care hospital. Despite the time constraints
encountered during this project, it was gratifying to note that the interventions had yielded positive outcomes after
post implementation.
The result of the second criterion relating to the use of standardised documentation tool for clinical handovers
showed an improvement of 49%. The same was seen in the third criterion which saw a 74% increase in cases
that identified patients during handovers. The improvement of these results could be attributed to the town hall
meetings that were used to highlight the realities and root causes of sentinel events and electronic hospital
occurrence reports. Town hall meetings that present incidents and preventable adverse events promote learning
and provide opportunities for nurses to learn from mistakes.2,12 This strategy might have created awareness among
nurses and increased their abidance in using the standardised tool.
The success of improving awareness among nurses in stating patients’ relevant history in criterion 4 displayed
an increase from 61% to 92%. This highlighted that equipping nurses with the required knowledge and updated
skills on proper handover techniques is paramount.2 These education sessions might have created opportunities to
correct practices, reinforce clear protocols and change mindsets, especially when staff do not meet this required
standard for effective handovers.2,12
Besides these, several other strategies might have also contributed to the significant improvement in the post
implementation audit findings. Firstly, the camaraderie and enthusiasm shown by all team members and stakeholders
created a high level of motivation that was essential for the success of this project. since communication is
influenced by personal feelings and can be shaped by positive organisational culture.2 Hence, the briefings might
have led to a clear understanding of the importance in adopting an evidenced-based audit tool. Feedback about
the performance of the new practice was delivered in a non-punitive, positive manner to help reduce nurses’
resistance towards the new practice.2 In addition the constant presence and collaboration of the project leaders
served as a reminder to the nurses of how important it was to adopt and implement practices that would improve
and enhance patient care.
Recommendations
The team recommended for the handover process to be audited using JBI-PACES and GRIP on an ongoing basis
to ensure compliance and continuous improvement of the handover process. Plans for sustaining the improved
rates of compliance had also been designed. One ward will be audited monthly and the audits will be conducted
in the first or second week of the month between 2pm-5pm. This will see the team conducting one audit per
12 months. This translates into 120 audits per year with the aim of achieving the JBI threshold of at least 90%
compliance rate. A limitation of this project was having only four months to implement this project and during the
implementation period, the hospital was undergoing its re-accreditation for JBI. Nevertheless the outcome of this
project and the audit criteria tool will serve as a basis for Best Practice that will eventually be incorporated into all
wards within the hospital.
Conclusion
Nursing inter-shift handover remains a highly valuable and important nursing communication tool. Nurses rely
heavily on information gathered from handover sessions to prioritise and make clinical decisions that impact patient
care. This project had shown that handover sessions can be made effective by translating evidence into practice
through ongoing evidence-based audit. Continuous evidence-based evaluation, identification and implementation
of nursing inter-shift handover processes will enhance patient safety and service delivery.
163
Acknowledgements
The team members of this project would like to extend their gratitude and thanks to:
1.A/Prof Prema and the Senior Nursing Management Team at the Institute of Mental Health, Singapore, for their
unwavering support.
2. The Joanna Briggs Institute for conducting the Evidence-based Clinical Fellowship program.
3. Dr Rie Konno for organising the Evidence-based Clinical Fellowship program.
4. Dr Kylie Porritt for her support and guidance.
Potential conflict of interest
No areas of potential conflict of interest have been identified.
References
1. A
lvarado K., Lee R., Christoffersen E, Fram N, Boblin S, Poole N, Lucas J, Forsyth S. Transfer of accountability:
transforming shift handover to enhance patient safety. Healthcare Qaulity. 2006; 9 (Special Issue): 75-79.
2.Australian Commission on Safety and Quality in Health Care. External evaluation of the national clinical
handover initiative pilot program. Sydney, Australia, 2011 February; [cited 2011 June 23]; Available from:
http://www.safetyandquality.gov.au.
3.Australian Medical Association. Safe handover: Safe patients’ guidelines on clinical handover for clinicians and
managers. 2006. Available from URL: http://www.ama.com.au/node/4064. Accessed 20 June 2011.
4.Chaboyer W, McMurray A, Johnson J, et al. Bedside handover: quality improvement strategy to “transform
care at the bedside.” J Nurs Care Qual. 2009; 24:136-142.
5.Clemow R. Care plans as the main focus of nursing handover: information exchange model. Journal of Clinical
Nursing. 2006; 15(11): 1463-5.
6.Cleary M, Walter G, Horsfall, J. Handover in psychiatric settings: is change needed? Journal of Psychosocial
Nursing & Mental Health Services. 2009; 47(3): 28-33.
7.Cohen MD, Hilligoss PB. Handoffs in hospitals: a review of the literature on information exchange while
transferring patient responsibility or control. 2009; [cited 2011 June 23]; Available from: http://deepblue.lib.
umich.edu/.../Handoffs_in_Hospitals_Literature_Review_081014.pdf
8.Joanna Briggs Institute. Joanna Briggs Institute Practice Application of Clinical Evidence System [database on
the Internet] 2011. Accessed December 2011. Available from: http://connect.jbiconnectplus.org/Utilise.aspx
9.Manser T, Foster S. Effective handover communication: an overview of research and improvement efforts. Best
Pract Res Clin Anaesthesiol. 2011 Jun; 25(2):181-91.
10.Matic J, Davidson PM, Salamonson Y. Review: bringing patient safety to the forefront through structured
computerisation during clinical handover. Journal of Clinical Nursing. January 2011; 20(1-2): 184-9.
11.Poletick EB, Holly C. A systematic review of nurses’ inter-shift handoff reports in acute care hospitals. JBI
Library of Systematic Reviews. 2010 Apr 7; 8(4): 121-172.
12.Riesenberg LA, Leisch J, Cunningham JM. Nursing handoffs: a systematic review of the literature. Am J Nurs.
2010 April; 110: 24-34.
13.Wong MC, Yee KC, Turner P. Clinical handover literature review. Tasmania, Australia: eHealth Services Research
Group, University of Tasmania; 2008.
14.World Health Organization. Patient safety. [cited 2011 June 23]; Available from: http://www.who.int/patientsafety/
events/07/01_11_2007/en/index.html.
164
Appendix 1
Demographics and Site Characteristics:
Barriers
Strategies
Resources
Outcomes
Lack of proper handover
techniques among
registered nurses during
handovers10,13
Organise training
sessions for all nurses
Education sessions for
all staff
Redesign of orientation
program to teach proper
handover techniques for
newly-recruited nurses.
Nurses show increased
compliance rates
in adopting proper
handover techniques
during the handover
sessions.
Resistance to change
among registered
nurses13
Town hall meetings
with key stakeholders,
namely: the Nurse
Managers, Nurse
Clinicians, registered
nurses and Enrolled
Nurses.
Sharing of sentinel
events and electronic
hospital occurrences
reports.
Create awareness and
highlight importance
of proper handover
techniques
Appoint a time keeper
During the clinical
handover rounds, a
nurse sitting in would be
appointed as the time
keeper. This ensured
that each case took
a maximum of 2-3
minutes.
Misuse of time10,13
Increase abidance to the
use of the standardised
tool for handover.
The duration of
handovers was reduced
due to the appointment
of a time keeper.
Appendix 2
165
166
JBI Fellows Monographs 2011-2012 Jill Parke
Capillary blood glucose monitoring by registered
and enrolled nurses among older persons
in a tertiary hospital setting. a best practice
Jill Parke
Marian van Meurs CNC
Project Officer
Research Centre for Nursing and Midwifery Practice
ACT Directorate – Health
Vascular and Urology Ward (9A)
Ward Canberra Hospital
David Larkin
Research Nurse
Research Centre for Nursing and Midwifery Practice
ACT Directorate – Health
Dr Imke Fischer
Senior Lecturer
Australian Catholic University
North Sydney Campus NSW
Dr Cindy Leigh
Sandra Hives CNC
Hospital in the Home (HITH)
Canberra Hospital
Ellen Scanes and Michelle Warnock
Registered Nurses
General Outpatients Department (OPD)
Canberra Hospital
Libby Bancroft CDE
Diabetes Education Unit
Directorate – Health
Senior Lecturer
Australian Catholic University
North Sydney Campus NSW
Maria Trudinger CNC
Acute Care of the Elderly (ACU)
Canberra Hospital
Abstract
Background
Capillary Blood Glucose Monitoring (CBGM) is a procedure undertaken by hospital nurses on patients with diabetes
types 1 and 2. CBGM is considered a routine management tool for monitoring blood glucose levels. Due to this,
and that CBGM is undertaken from the most senior to the most junior clinical nurses, there is limited reviewing of
the nurses’ knowledge and skills about the best-available evidence for this procedure.
Aim
The aim of this project was to ensure the practice of capillary blood glucose testing on older persons by nurses in
the tertiary hospital setting was practised according to the best-available evidence.
Methods
A pre- and post implementation audit was conducted. The tools included two surveys based on JBI audit criteria,
an information sheet and a consent form. The first of the two surveys gathered information about knowledge of and
interventions for CBGM.The second of the two survey forms had individual nurses being observed undertaking a
CBGM procedure. An education program was distributed immediately after the pre-audit for four weeks and then
withdrawn for eight weeks prior to the post audit.
Results
The post audit results showed increased compliance to the four audited criteria. For criterion 1 and 2, it was from
51% and 52% to 91% and 93% respectively. For criterion 3 and 4, it was from 68% and 82% to 96% and 93%
respectively.
167
Discussion
The difficulties nurses faced with this project included difficulty accessing rooms and computers for in-service,
competing educational priorities, audit fatigue, workloads and CBGM not being an education essential. These
longstanding barriers reduced nurses’ interest in participating in the projects.
Conclusion
These results demonstrate that Best Practice education interventions in the workplace do make practice change
happen. Without the support of senior nurses it is difficult for the nurses to achieve change within the workplace.
Keywords: aged, audit, clinical, diabetes, education
Background
The earliest known writings that mention symptoms of diabetes are about 3000 years old. A papyrus written
by Hesy-Ra an Egyptian physician to King Amenophis 1 (1536 BC) was found in a tomb at Thebes, where the
papyrus mentions polyuria as a common symptom of the “sugar disease”1 Hindu scholars at around the same
time described diabetes as “a mysterious disease causing thirst, enormous urine output and wasting away of the
body with flies and ants attracted to the urine of people”2 The word “diabetes” was given to the above symptoms
in 250 AD by the early Greeks and it means to “siphon” or to “go through”3, mellitus’s was added 200 years later
to describe the “honey” the physicians tester tasted in the urine of people with the collections of these symptoms.1
Since then, an evolution in diabetes mellitus’s management has occurred and a lucky part of it is that tasting of urine
is no longer used as a diabetes diagnostic or management tool. In the 1960s Capillary Blood Glucose Monitoring
(CBGM) became a routine procedure undertaken by nurses to patients with types 1 and 2 diabetes in hospital
settings to ascertain their capillary blood glucose levels.4 These results give an indication of a patient’s blood
glucose control and are influential in the decision making by clinicians for immediate and ongoing management
of diabetes.
CBGM for inpatients in this organisation is undertaken prior to meals, administering diabetic medications and
before settling for the night. Patients whose diabetes is being managed (eg post surgery) by insulin infusion require
hourly to second hourly CPGM5 Patients using multiple insulin injections daily will also require frequent CBGM.6.
In outpatient clinics, CBGM is undertaken as part of a patient’s clinical review for their initial and subsequent followup consultations by either one or all of the following: endocrinologist, diabetes educator, dietician and podiatrist.5
An organisation has the responsibility to develop and implement an accessible, ongoing education program for
all staff members who perform CBGM.8,9 This will improve compliance with evidence-based clinical practice and
knowledge of legal accountability as patients’ medication and dietary changes can be based on the CBGM results.6
It is difficult to assess if evidence-based practice for CBGM is undertaken by the nurses doing the procedure
and teaching the technique of CBGM to patients and their carers if the procedure for CPGM is not included in an
orientation program for new nurses or in the organisation’s recognised ‘Education Essentials’.7 A review of the available literature showed a consensus for organisations to develop a protocol for capillary blood
glucose testing and to regularly review the protocol.8 The protocol should aim to standardise diabetes management
parameters and ensure education of staff who undertake CBGM.. The outcomes from this should be: improved
diabetes management and reduced length of time the patient stays in hospital.9
Aim
The aim of this project was to ensure the practice of capillary blood glucose testing on older persons by nurses in
the tertiary hospital setting in the Australian Capital Territory (ACT) was performed according to the best available
evidence.6 The specific objectives were to:
• Conduct a pre- and post audit of nursing staff skills and
• Develop an evidence-based education program using protocols and procedures demonstrating skills and
techniques for nurses who undertake CBGM
• Improve nurses understanding of the use of evidence-based practices when undertaking CBGM.
168
Methods
A pre- and post implementation clinical audit was conducted using the Joanna Briggs Institute Practical Application
Clinical Evidence System (JBI-PACES). The audit tools consisted of two surveys, an information sheet and a
consent form (Appendix 1, 2, 3 and 4). The surveys contained the JBI audit criteria. These tools were approved by
the ACT Human Research Ethics Committee. The project was conducted from June to December 2011consisting
of the three phases as follows:
The pre- and post audits included gathering information from nurses by using two different survey forms. The
first of the two survey forms gathered information about individual nurses’ knowledge of policy/procedure and
interventions for CBGM. The second of the two survey forms gained information about individual nurse’s compliance
to policy/procedure and interventions needed if the result of the CBGM procedure was outside normally accepted
parameters. This was achieved by nurses observing nurses undertaking a capillary blood glucose test on a patient.
Signed consent was obtained from nurses being observed before undertaking this procedure. Both surveys for
the pre- and post audits were undertaken over a two-week timeframe to allow nurses working on all shifts and all
days the opportunity to participate.
The clinical areas and the potential number of nurses involved in this audit included the Acute Care of the Elderly
(34 nurses), a vascular and urology surgical ward (32 nurses), Hospital in the Home, which is a unit that has mainly
older patients with co-morbidities (22 nurses) and the Diabetes Clinic of the General Outpatients Department (16
nurses). This gave a potential sample size of 104 nurses.
A concise, comprehensive interactive evidence-based education program on a DVD with PowerPoint slides was
developed and included a video clip with a Diabetes Educator undertaking a capillary blood glucose test on
a patient using equipment available throughout the hospital. The PowerPoint slides discussed critical thinking
skills required to ensure compliance with the organisation’s evidence-based policies and protocols to ensure the
procedure was undertaken using the correct CBGM technique and to accurately interpret and act on the results.
It also prompted nurses to consider their responsibility to remain up to date with current research. Multiple copies
of the DVD education program were distributed to the clinical areas immediately after the completion of the first
audit and were freely available for four weeks to all nurses including those who were casual, on call, agency and
students. The education program was then withdrawn from the clinical areas, to allow time for the effects of the
education program to dissipate and measure the nurses’ retention of evidence-based practice.
Each clinical area nominated two to three staff members to facilitate this project through its three phases. They
included senior clinical nurse such as a Clinical Development Nurse and involved Enrolled Nurses. These facilitators
encouraged nurses to complete both surveys, sign the consent form for the observational survey, view the DVD
and sign an attendance sheet once this had been finished.
Data analysis
Data was analysed by entering the results into JBI-PACES to compare nurses’ skills, knowledge and compliance
with four of the five audit criteria.
Results
Pre-implementation results
During the pre-audit (baseline cycle) 79 nurses consented to participate in the skills and knowledge and
observational surveys. They included Registered and Enrolled Nurses (RN, EN ) from various classification levels
( L): RN L3 x 0 , RN L 2 x 20, RN L1 x 36, EN L 2 x 2 , EN L1 x 9 and unknown x 8 (n=79)
Table 1: Pre-audit participating Registered and Enrolled Nurses by classification and clinical areas
OPD
11A
HITH
9A
RN L3
0
0
0
0
RN L2
3
2
11
4
RN L1
4
7
10
15
EN L2
1
0
1
0
EN L1
2
5
0
2
Unknown
1
5
2
4
The highest compliance was in criteria 3 and 4 at 68% and 82% respectively; the lowest rate of compliance was
criteria 1 at 51% followed by criteria 2 at 52%.
169
Post implementation results
In the post audit (follow-up cycle) 56 of a possible 104 nurses participated in the skills and knowledge and
observational surveys. The breakdown of the participating nurses for the post audit is as follows: RN L3 x 1 , RN
L2 x 12, RN L1 x 29, EN L2 x 2, EN L1 x 9 and unknown x 3 (n=56). This was 23 fewer nurses than for the pre-audit.
Table 2: Post audit participating Registered and Enrolled Nurses by classification level
and clinical areas
OPD
11A
HITH
9A
RN L3
0
0
0
1
RN L2
1
0
6
5
RN L1
4
8
8
8
EN L2
1
0
1
0
EN L1
2
6
1
2
Unknown
0
1
0
1
However the post audit results showed increased compliance in all four audit criteria as demonstrated by the
increasing compliance in criteria 1 and 2 from 51% and 52% to 91% and 93% respectively. The increase in
compliance for criteria 3 and 4 was from 68% and 82% to 96% and 93% respectively.
Criteria legend
1. Organisation policy and/or procedure manual is available for blood glucose monitoring procedure.
2. Health care staff ensures that expiry date of test strips are checked before use.
3. Health care staff checks that test strips are compatible with blood glucose monitor.
4. Health care staff checks that the patient’s chosen hand is washed with soap and water prior to finger pricking.
5. Health care staff has undertaken a diabetes education program.
Figure 1: Comparison between pre and post audit compliance to JBI clinical audit criteria
Criteria 5 was excluded from this clinical audit primarily because attending a diabetes education program is not a
clinical necessity in the Health Directorate’s Essential Education Policy and Framework. This policy and framework
outlines the essential training and education the Directorate requires for different classifications of nursing staff.
Secondly the Directorate through its Diabetes Education Service Clinical Unit, and facilitated by Staff Development
Unit provides two education modules each year for 20-30 clinicians per module (60 per year). The Directorate
employs approximately 2000 Full Time Equivalent nurses. Thus it is readily seen the accessibility to these modules
cannot give nurses an evidence-based diabetes education including skills, knowledge and procedural adeptness
of CBGM. Therefore innovative education processes need to be developed to assist the organisation and staff to
undertake evidence-based practice of CBGM.
170
Implementation
Table 3: Getting Research into Practice(GRIP): the barriers, strategies , resources and outcome from
CGBM clinical audit
GRIP: CBGM clinical audit on older persons in the Canberra Hospital
Barriers
Strategies
Resources
1. Nurses do not receive
ongoing formal education
on diabetes and are not
observed undertaking
CBGM procedure.
Involve Clinical
Development Nurses
(CDNs) and other
audit staff members to
facilitate education and
observation of ward
based nurses in order
they are able to undertake
Improved compliance
CDNs and other audit
staff members. Room for from all clinical areas with
all audited criteria.
teaching.
2. Competition within
each clinical area for
access to computers
for staff to view
or undertake online
education in the clinical
areas.
Book a time slot to use a CDNs and other audit
computer in each clinical staff members.
area for staff to view
interactive educational
DVDs or undertake online
education program
3. Competing education
priorities in the clinical
areas.
Prioritise with Clinical
Nurse Consultant (CNC)
educational in-services.
Allocate time for nurses
during handover to attend
the CBGM in-service.
CNC and CDNs
Clinical area staff
understood that
education/revision of
CBGM was a priority.
4. Access to organisation
policies and procedure.
Include whereabouts of
24 hour access to policy
and procedure register.
Provide staff with
Intranet site address of
Directorate’s policy and
procedure register.
Clinical area staff became
aware of the Directorate’s
intranet site and the
address of the policy and
procedure register.
5. Lack of knowledge
of all aspects of CBGM
from technique to clinical
interventions.
Clinical area nurses to
view interactive DVD.
Multiple copies of DVD
distributed within each
clinical area to provide
ease of access for staff
for the program outside of
scheduled in-services.
Clinical area nurses’,
especially those working
Night Duty and weekends
viewed the DVD outside
of scheduled in-services.
6. Audit fatigue of the
nurses in the clinical
areas, who can view
outside requests as an
imposition.
Sufficient notice to
nurses of audit, and
encouragement from their
colleagues and peers to
participate.
Project leaders, CNCs.
CDNs and other project
facilitators
Pre-audit had a response
rate of nearly 70%. Post
audit had a response rate
of over 50%.
7. Management and
clinical leaders of the
Directorate appear
unaware that
CBGM
procedure is not being
carried out according to
Provide feedback of the
results of this audit to
clinical areas and their
management and clinical
leaders.
Project leaders.
This is still under
discussion as results are
yet to be comprehensively
distributed with
recommendations.
Allocated time for
in-services to view
the evidence-based
interactive education
DVD.
Outcomes
Observational CBGM
procedure improved
nurses’ compliance
to evidence-based
technique.
Clinical area staff aware
of accessibility of
computer to view DVD
or undertake online
educational program.
171
Discussion
The aim of this project was to ensure the practice of capillary blood glucose testing on older persons by nurses
in the tertiary hospital setting in the ACT was performed according to the best available evidence. The pre-audit
results showed that nurses did not always practice or understand the skills and knowledge required to carry
out CBGM procedure. The nurses were also unaware of where to access the organisations Policy and Standard
Operating Procedure for Blood Glucose and Ketone testing. The post audit results following intensive evidencebased education in each clinical area, showed an improvement in compliance varying from 11% to 40% for the
four criteria audited in this project.
This project results demonstrate interventions such as education packages in the workplace based on the best
current practice can, and do, make clinical practice change happen. The major intervention strategy to achieve
practice change was the viewing of the educational DVD; however it is difficult to pinpoint if this was the only factor
in achieving compliance change. There is a possibility the project itself raised the nurses awareness of CBGM, and
thus this may have impacted on the improvement in the post audit compliance.
Although the project time frame was limited, a number of barriers that impact on nurses’ ability to utilise evidencebased practices were identified. Some of these are anecdotal to the clinical area, and they included patient acuity,
nursing skill mix and nursing numbers. Others included nurses being able to access computers for viewing the
educational DVD, and knowing where to access the policy and procedures for CBGM. Throughout the project with
the assistance of the CNC and CDNs, strategies addressing these barriers were implemented and provided the
nurses with resources so they could participate in the project.
This project focussed on CBGM procedures being undertaken by nurses on older persons; however due to the
worldwide epidemic of type 2 diabetes of persons across the age spectrum,10 the need for evidenced-based
practice of CBGM is essential for nurses to ensure their clinical practice for these people is evidence-based.
Literature review has not provided projects with comparable aims and objectives of this project to ensure capillary
blood glucose testing on older persons by nurses is undertaken according to evidence-based practice.
To achieve nursing practice change for diabetes management including CBGM, it will be necessary for senior
nurses in management, clinical and education positions to be involved and supportive of their nurses’ to achieve
practice change. The results of this small project are heartening and could provide impetus for the organisation
to build on the existing DVD to develop, with input from the Diabetes Educators and Staff Development Unit, an
online diabetes education module. This would provide easily accessible evidence-based education to all clinical
staff.
The results from this project will be disseminated to each clinical area for the nurses to be aware of the improvements
they made in delivering evidence-based practice to their patients. Each area’s Directors of Nursing will be provided
with the results of this project which clearly demonstrates interventions improve the delivery of evidence-based
patient care.
Conclusions
This project provided evidence that by implementing evidence-based education intervention strategies within
the clinical areas, practice change can be achieved. To achieve nursing practice change it is essential to have
the collaboration and support of recognised nurse leaders from the most senior positions to the nurses who hold
key clinical positions. These people are the ones able to motivate nurses to be involved in projects that measure
current nursing practices against the most recent available clinical research evidence. The involvement of these
clinical leaders allows a nursing service to sustain a nursing practice culture based on evidence and driven to
provide the best patient outcomes.
172
Acknowledgements
The Nursing and Midwifery Office, Health Directorate ACT Government has provided the funding for this project.
For this I thank the Chief Nurse ACT, Ms Veronica Croome, who believes in and wholeheartedly supports her
nursing staff to undertake such projects as JBI Clinical Fellowships.
I also thank Professor Violeta Lopez, Director of the Research Centre for Nursing and Midwifery Practice (RCNMP)
and the Australian Capital Regional Research Centre for Evidence-based Nursing and Midwifery Research
Practice: an affiliated centre of Joanna Briggs Institute, because without her support none of this would have been
possible. Thanks to my colleagues David Larkin for his patience and friendship throughout this process, Libby Bancroft CDE
for her expert opinions, and Drs Cindy Leigh and Imke Fischer.
I offer my profound thanks to the four clinical areas and their nurses who participated in this clinical audit even
when patient acuity was high, nurses’ skill mix less than optimal and nursing numbers below what they believed
they needed.
My grateful thanks also to the wonderful JBI staff and JBI mentor Alexa McArthur who has so kindly persevered
with me throughout this project.
References
1. K
ing KM, Rubin G. A history of diabetes: from antiquity to discovering insulin. Br J Nurs. 2003; Oct 9-Oct
22,12,18. pg 1091
2. Das AK, Shah S. History of diabetes: from ants to analogs. Supplement to JAPI. 2011; 59 pg 6
3.Aronson SM. The many words of diabetes mellitus. Med Health R I. 2005 Provided by ProQuest Information
and Learning Company
4.Dufaitre-Patouraux L, Vague P, Lassman-Vague V. History accuracy and precision of SMBG devices. Diabetes
and Metabolism. 2003; 29(2 pt 2): S7 -14
5.Canberra Hospital: Standard operating procedure; blood glucose and ketone point-of-care testing. Issued
15/2/2011
6.The Joanna Briggs Institute. Blood glucose monitoring, Recommended Practice, JBI COnNECT+, 2010. http://
connect.jbiconnectplus.org/ViewDocument.aspx?0=4972
7. Essential Education Policy , ACT Health. Issued March 2011
8. Wallymahmed M. Capillary blood glucose monitoring. Nurs Stand. 2007; 21, 38,35-38
9. Gill EA, Corwin PA , Mangin DA, Sutherland MG. Diabetes UK. Diabetic Medicine. 2006; 23, 1252-1256 10.Sonsksen, P, Fox C, Judd S, with Diabetes Australia. Diabetes at your fingertips. 4th ed; 2003. 244- 245.
Appendix 1
173
174
Appendix 2
Appendix 2 (con’t)
175
176
Appendix 3
Appendix 3 (con’t)
177
178
Appendix 4
JBI Fellows Monographs 2011-2012 Kristian Sanchez
179
Preoperative fasting times among emergency
orthopaedic patients in an acute hospital setting:
a best practice implementation project
Kristian Sanchez
Acting Clinical Services Coordinator
Ward S3
Anita Taylor
Orthopaedic Nurse Practitioner
Orthopaedic and Trauma Unit
Abstract
Background
There is a need to establish how long patients awaiting emergency surgery are currently being fasted for
preoperatively, so that strategies can be explored to reduce preoperative fasting times.
Aims
This project aims to establish how long emergency patient fast for, and to set up a working party to discuss the
reasons why emergency patients fast for an excessive amount of time.
Method
Phase 1:
Conducted a baseline audit and used the Joanna Briggs Institute Practical Application of Clinical Evidence
Systems (JBI-PACES) to measure the percentage compliance against specific audit criteria.
Phase 2:
Met with stakeholders and utilised the Getting Research into Practice (GRIP) program to assist with identifying
barriers and recording strategies that were implemented.
Phase 3:
A post implementation audit was conducted using the same criteria as phase 1.
Results
The majority of patients awaiting emergency theatre fasted from midnight and for an excessive amount of time.
There was a decrease in the number of patients who fasted from midnight in the follow-up audit. However patients
continued to fast for an excessive amount of time. There was an increase in the number of nurses who received
education on preoperative fasting in the follow-up audit; however, documented actions to prevent periods of
prolonged fasting had low percentage compliance in the baseline audit with a slight improvement in the follow-up
audit.
Conclusion
This project has confirmed that patients awaiting emergency orthopaedic surgery do fast for an excessive amount
of time, and that barriers, although easily identified, are difficult to overcome. This project has not achieved all of
its aims at this stage; however it has enabled discussion around the topic of preoperative fasting to take place that
may lead to changes in the future.
Keywords: Emergency, fasting, orthopaedic, preoperative, surgery
180
Background
This project took place on the Orthopaedic Unit of a large metropolitan hospital and included all orthopaedic
patients awaiting emergency surgery. Preoperative fasting was chosen as the topic for this project as patients
waiting for emergency surgery can often be fasting for four or five days due to cancellations,1 and fasting appears
to often commence from midnight although there is no evidence in recent literature to support this practice.
Patients awaiting emergency orthopaedic surgery will only increase, as the population grows and ages there will
certainly be a rise in fragility fractures. Patients are fasted preoperatively so that their stomach contents are empty,
therefore reducing the risk of aspiration whilst under anaesthetic.2 A systematic review carried out by Bray, Kinn,
Stuart and Ness3 involved 22 trails, made 38 random comparisons and involved studies from across the world
from 1978-2003. This review considered many different variables to ascertain whether preoperative complications
arose with a shortening of fasting times preoperatively. The paper found that no increase in complications such
as aspiration were observed when patients were given clear oral fluids two to three hours prior to surgery, and
found that patients who received a drink two hours preoperatively had a beneficial experience with regard to their
thirst. The review therefore recommended following the ASA guidelines4 which recommends that patients should
fast from solids for six hours and clear fluids for two hours prior to surgery. These recommendations are widely
accepted around the world. Although these guidelines are internationally accepted it has been shown in some
studies that patient’s still fast for an excessive amount of time.5 It is important to audit this topic as excessive
preoperative fasting may have several detrimental effects such as confusion, irritability, dehydration, headaches,
hypoglycaemia and nausea.6 This Best Practice implementation project aims to improve patient outcomes through
ensuring service delivery is evidence based.
Aims
The aims of this project were to:
• Establish how long preoperative orthopaedic patients are fasted for preoperatively.
• Establish a working party to look at the barriers that prevent appropriate fasting from taking place.
• Increase nursing knowledge on the current evidence with regard to preoperative fasting.
• Improve communication between the ward, theatre and medical staff.
• Instigate discussion around the topic of preoperative fasting.
Methods:
Ethical consideration
Ethical approval was not sought for this project as it concentrates on clinical practice and will not compromise
patient confidentiality; however, general approval for the project was sought from the Nursing Director of the
orthopaedic area, Ms Amanda Biddle.
Phase 1:
Audit criteria
Audit criteria for this project was challenging as although there is evidence to suggest a minimum fasting time there
were no Best Practice guidelines regarding maximum fasting times. Therefore it was decided that audit criteria
would concentrate on measures taken to prevent extended periods of preoperative fasting; therefore the audit
criteria were:
• Documented actions were taken to prevent periods of prolonged fasting.
• Members of staff had attended education sessions on reducing preoperative fasting.
An audit team was set up consisting of one volunteer level 2 nursing staff from each of the three orthopaedic
wards; Kristian Sanchez (project lead) was the primary contact. The role of the other members of the audit team
was to ensure that all emergency patients fasting in their ward area were included in the audit and that data
collection sheets were completed and returned to the project team leader.
A baseline audit was collected using a data collection sheet (see Appendix 1) and this information was then
inputted into the Joanna Briggs Institutes Practical Application of Clinical Evidence Systems (JBI-PACES).
Patients who were on an orthopaedic ward and were awaiting emergency orthopaedic surgery over two weeks
(12-25 April 2011) were included in the clinical audit. The achievement of the audit criteria was determined by any
181
documentation to prevent prolonged fasting periods being recorded in the patient’s case notes.
The second audit criteria was measured by asking 30 members of staff in the area on 12 April whether they had
received any education on preoperative fasting.
The audit also collected information on:
• The average preoperative fasting times from fluids and food.
• Whether patients had been fasted from midnight or not.
• Patient demographics: including type of injury.
• If any actions were taken to reduce the risk dehydration.
Following the baseline audit, results were fed back to members of the audit team and to senior nurses at a local
quality meeting.
Phase 2: Implementation of Best Practice.
The JBI-PACES ‘Getting Research into Practice’ program (GRIP) was utilised to identify barriers and record
strategies and resources needed to overcome these barriers. Barriers were identified by discussing issues with
members of the project team, anaesthetics, dieticians, theatre nurses and orthopaedic medical staff.
Barriers
Strategies
Resources
Outcome
Lack of collaboration
between nursing, medical
and theatre staff.
Arrange a meeting and
set up a working party.
Project lead to discuss
with Nursing Director
appropriate contacts
Several meetings set
up; however unable to
get everyone together
at same time due to
excessive workloads,
etc. Therefore met with
members individually.
Lack of nursing
knowledge on
preoperative fasting.
Develop education
session on preoperative
fasting.
Project lead to develop
and deliver education
session.
Education session
developed and delivered
to nursing staff.
Poor communication
between the ward and
theatre.
Arrange a meeting with
theatre staff to discuss
issues.
Project team met with
theatre staff.
Agreed that ward staff
could call theatre T/L to
check patients on list.
Lack of protocols
for fasting times of
emergency patients.
Meet with anaesthetic
and orthopaedic medical
staff to discuss.
Project team met with
anaesthetic fellow and
orthopaedic registrar to
discuss.
Anaesthetic fellow stated
at meeting that patients
should be allowed clear
fluid up until 05:00am and
that he would discuss
other parameters with
colleagues (awaiting
response).
Anaesthetic fellow
and orthopaedic
registrar acknowledged
preoperative fasting was
a problem. Anaesthetic
registrar will discuss issue
with colleagues at their
quality meeting.
Orthopaedic registrar
would write in treatment
orders of patients
awaiting emergency
surgery that they could
have clear fluids until
05:00 am.
The above strategies took a few months to implement. Meetings with key stakeholders presented many challenges
due to excessive workloads and several meetings were cancelled. Nursing education was delivered over a twomonth period, and four sessions were delivered in total, with 53 nursing staff attending.
Phase 3
A post implementation audit was completed in August 2011. The amount of fasting cases in the baseline audit was
84 over a two-week period, and in the follow-up cycle audit there were only 70 also fasting cases. The same data
collection techniques as in phase 1 were used and over the same period of time, and this was then inputted into
JBI-PACES. The same audit criteria were used to ascertain the success of the implementation strategies.
182
Results
The baseline audit demonstrates low percentage compliance in documented actions to prevent periods of
prolonged fasting. The follow-up cycle audit also reflected low percentage compliance to this audit criterion.
The baseline audit revealed that no members (0% compliance) in the baseline audit had attended education on
preoperative fasting. The follow-up cycle audit displayed a 53% compliance (16 staff out of 30 asked on a single
day had attended an education session). In total 53 staff members received preoperative fasting education.
183
Other data collected included whether patients were being fasted from fluids at midnight or not. The baseline
audit illustrated that although no evidence exists to support this prolonged period of fasting, 93% of patients were
fasted from midnight. The follow-up cycle audit displayed improvement; however 61% of patients still fasted from
fluids from midnight.
Patients in the baseline audit fasted from fluid and food for 13hrs on average. In the follow-up cycle audit the
average fasting from fluids was 11.94hrs and from food it was 13.73hrs.
Discussion
The baseline audit illustrated that patients awaiting emergency orthopaedic surgery are fasted for an excessive
amount of time and were usually fasted from both food and fluids from midnight. The baseline audit confirmed that
nursing staff in the area had not received any education on preoperative fasting and that documented actions to
prevent prolonged periods of preoperative fasting were also poor.
Actions implemented following the baseline audit included in-service education sessions given to nursing staff. In
the education sessions, many nurses admitted to being unaware of the minimum recommended fasting times and
the potential complications associated with prolonged fasting. The nursing staff also cited poor communication
between the wards and theatre as a major barrier that affected the length of time patients fast for. Throughout
the implementation stage the project team attempted to set up a working party of nursing, medical, theatre and
anaesthetic staff; however this proved difficult and all were eventually seen on an individual basis. All stakeholders
seemed aware that patients were fasting for excessive amounts of time, but offered little solutions to the problem.
In fact all stakeholders cited the need for an emergency list to be flexible as the major barrier to shortening
preoperative fasting times. This barrier seems consistent with the findings of other audits in the literature.5 Patients
can often be delayed going to theatre on medical grounds and therefore theatre lists are often overbooked so that
if a cancellation occurs a replacement case is already fasted and ready for surgery.
The anaesthetic medical staff stated that patients should be allowed clear fluids until 05:00am and that he would
discuss other parameters with anaesthetic colleagues, for example if the order of a theatre list was established
early it may be possible for some patients to have an early breakfast. Therefore it was suggested that orthopaedic
registrars should write the time to commence fasting from fluids and food separately in the treatment orders.
Throughout the implementation stage it appeared that staff were enthusiastic about the project and wanted to
improve preoperative fasting times. Nursing staff responded well to the education sessions and were calling
theatres regularly to check patients were on lists; however, they reported that they were often told to keep patients
fasted and that patients were still being cancelled late. The medical officers were prescribing a separate time for
fluids in the treatment order. During the implementation stage, only one meeting took place with anaesthetics, and
the project team is awaiting feedback from a meeting between anaesthetists.
The follow-up audit cycle only showed a small improvement in documented actions to prevent preoperative fasting,
although this number could have been higher as not all actions may have been documented in the case notes. The
percentage of nurses who have received education on preoperative fasting has improved from the baseline audit
and this can only have a positive effect on patient outcomes. Since the project commenced and education has
been given, nursing staff have begun to report excessive fasting times as clinical incidents.
Although education on preoperative fasting in the area has improved since the baseline audit, this has only had
little effect on the average preoperative fasting times and many patients are still fasting from midnight. There
are many possible reasons for this such as a recent change in orthopaedic interns and registrars. Ward nurses
currently have no access to theatre lists and have to follow fasting orders as prescribed by the medical officer.
This project has had limited impact on fasting times and has highlighted the need for a discussion involving all the
key stakeholders to take place. This barrier was identified in the GRIP stage but was not overcome and therefore
major barriers were not discussed between all the stakeholders at the same time. Meeting all the stakeholders
together would have enabled solutions to be sought and parameters agreed upon. Another limitation of the project
was the short timeframe which only allowed for a short implementation stage.
The JBI clinical fellowship program has had a positive impact on the author’s practice. The author had many
barriers to overcome in the audit process and although at times the process was frustrating, the author enjoyed
working through the barriers and developing strategies with other members of the project. The author also learnt
to accept that changing practice takes time and persistence.
184
Recommendations
1. A meeting between all of the senior key stakeholders.
2.Organisational wide approach to patient fasting awaiting emergency surgery and the development of a hospital
protocol.
3. Education sessions for medical staff.
4. Continue regular education for nursing staff.
Conclusion
This project has confirmed that patients awaiting emergency orthopaedic surgery do fast for an excessive amount
of time and that barriers, although easily identified, are difficult to overcome. These barriers will only be overcome
if there is an organisational willingness to change current practice.
The implementation of education sessions for nurses on preoperative fasting has had a positive impact on the
orthopaedic area as nursing staff now have an improved understanding of why patients are fasted preoperatively
and the minimum length of time recommended for fasting. This project has generated discussion on the subject
of preoperative fasting and highlighted the need for change. The major barrier to change appears to be the need
for an emergency theatre list to be flexible; however, it could be argued that the current practice is too flexible
and many patients are cancelled after fasting for an excessive amount of time only to be told they need to fast
again from midnight and that they could get cancelled again. The answer of how to fix this dilemma will not be
easy but this project will create discussions that could lead to practice improvement in the future. The JBI clinical
fellowship program has developed the author’s clinical leadership and audit skills. This program has illustrated the
importance of clinical audit and Best Practice implementation. The author hopes to be involved with the JBI and
continue to lead evidence-based practice.
Acknowledgements
The orthopaedic and trauma service: Royal Adelaide Hospital
Alexa McArthur: JBI
References
1. Millar E. Reducing the impact of preoperative fasting on patients. Nurs NZ 2009, 15(5): 16-18.
2. Baril P, Portman H. Preoperative Fasting: Knowledge and Perceptions. AORN J 2007, 86(4): 609-617. 3. B
rady MC, Kinn S, Stuart P, Ness V. Preoperative fasting for adults to prevent perioperative complications’.
Cochrane Database Syst Rev 2003; 4.
4.
American Society of Anesthesiologists. Practice guidelines for preoperative fasting and the use of
pharmacological agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing
elective procedures. Anesthesiology 1999, 90: 896-905.
5. Bothanmley J, Mardell A. Preoperative fasting revisited. Br J Perioper Nurs. 2005, 15(9): 370-374.
6.Jester R, Williams S. Preoperative fasting: putting research into practice Nurs Stand. 1999, 13(39): 33-35.
185
Appendix 1
Patient details
Time
Commenced
fasting from
fluids.
Time
Commenced
fasting from
food.
Time went
to theatre or
ceased fasting.
Time IVT
commenced.
Were any action
taken to prevent
long period of
fasting (tick one)
Affix label
Yes
No
Affix label
Yes
No
Affix label
Yes
No
Affix label
Yes
No
Affix label
Yes
No
Affix label
Yes
No
Affix label
Yes
No
Affix label
Yes
No
Affix label
Yes
No
186
JBI Fellows Monographs 2011-2012 Jovy Tesani
Implementing evidence-based practice for falls
prevention among residents in a dementia specific
aged care facility
Jovy Tesani
Registered Nurse
Kensington Park Nursing Home
Perth, Western Australia
Abstract
Keywords: falls, aged care, dementia, implementation, evidence-based practice
Background
In 1987, the Kellogg International Working Group on the Prevention of Falls in the Elderly defined a fall as
‘unintentionally coming to the ground or some lower level and other than as a consequence of sustaining a violent
blow, loss of consciousness, sudden onset of paralysis as in stroke or an epileptic seizure’.1
Nursing home residents with dementia were nearly twice as likely to fall as those without dementia even when
other important risk factors were controlled for. Although residents with dementia were not more likely to injure
themselves once they fell, they did have significantly higher injurious fall rates because they experienced more
falls.10
Prevention of falls is a vital matter in maintaining the quality of life among residents in a dementia specific aged
care facility and therefore implementing strategies for falls prevention plays a major role in this setting.
It is for this reason that I chose this topic for the JBI Evidence-Based Clinical Fellowship Program among 48
dementia specific residents of Kensington Park Nursing Home (KPNH) in Kensington, Perth, Western Australia,
where the study was conducted.
Falls represent a major source of death and disability in older people, posing a serious threat to their physical health
and psychological well-being. The consequences of falls are not solely confined to the older person themselves.
They place a burden on family members, make demands on healthcare professionals, and strain the economic
resources of healthcare institutions as well.3
A fall can be defined as any event in which a person inadvertently or intentionally comes to rest on the ground or
another low level such as a chair, toilet or bed. As an initial step in designing any intervention to reduce falls, it is
essential to know why falls occur and under what circumstances they take place. The risk of falling occurs when a
person engages in an activity that results in a loss of balance, a displacement of the body beyond its base support.
Loss of balance may occur while one is carrying out everyday activities such as walking; transferring on or off
chairs, wheelchairs, beds, and toilets; and reaching up or bending to retrieve or place objects. A fall is also likely to
follow an episode of balance loss if the neuromuscular systems responsible for balance stability fail to recognise
and correct the displacement of the body in time to avert fall.2
Falls in older people are often precipitated by a number of factors. These factors include intrinsic factors (eg agerelated physiological changes, disease states, medications) and extrinsic factors (eg hazardous environmental
conditions, faulty devices, footwear). In addition, several situational circumstances, such as length of stay in
institutional settings, time of day when falls take place, and staff characteristics influence the occurrence of falls.2
Consequently, falls and fall related injuries are among the most serious and common medical problems experienced
by older persons.4
Physiotherapists and occupational therapists are identified as essential members of specialised falls prevention
teams. The remit of physiotherapists working with older people according to the National Service Framework for
older people is to be part of this falls prevention team (Department of Health, 2001).9 The physiotherapist’s role
in assessing the mobility of each resident, providing physiotherapy programs/activities to be implemented by
the Physiotherapy Assistant and prescribing mobility aids like zimmer frames and four wheel walkers are vital in
falls prevention. In addition the occupational therapist’s role is to assess residents who may need hip protectors
as part of their personal garment, matt alarms, proper footwear as well as creation of programs/activities to be
implemented by the occupational therapy assistant, all of which may reduce the frequency of falls in a residential
aged care facility.
187
The benefit to the individual resident in an aged care facility who is able to participate in a falls prevention program
can be significant. For a resident to be able to maintain a level of independence without fear in relation to falls is
vital to any aged care facility. The significance of the project would be improved client outcomes including a better
quality of life, long term independence, self assurance in mobilising, reduced risk of injuries associated with falls
and a healthier and happier life.4
In consultation with the Director of Nursing and staff from Kensington Park Nursing Home, research into clinical
practice on falls prevention was conducted at Kensington Park Nursing Home, a high care dementia specific
facility located in Kensington, South Perth, Western Australia.
Audit question
Is Kensington Park Nursing Home implementing evidence based practice for falls prevention among residents with
dementia?
Aims and objectives
While all residents at Kensington Park Nursing Home are required to have a Falls Risk Assessment, a form
developed by Hall and Prior to be completed on admission, there is no evidence that a falls risk program has been
effectively implemented or have resulted in improved outcome for the residents. The statistics in the resident’s
incident/accident monthly register on falls in the facility continue to indicate that Best Practice procedures have
not been implemented or maintained at the facility.
This project aims to achieve the following objectives in the area of falls prevention:
1. To review current falls risk assessment being used to identify residents who are at risk of falls.
2. To evaluate falls risk preventative interventions implemented in the facility.
3. To ensure falls risk strategies are implemented according to evidence-based practice.
4. To reduce the incidence of falls among residents with dementia.
Methods
The privacy and confidentiality of all the 46 residents participating in the study was maintained. Throughout the
data collection process there had been no information that could identify any of the residents during the audit. In
as much as this audit has been implemented in the age care facility as a continuous quality improvement project,
Kensington Park Nursing Home did not require ethical consent to complete the study.
Phase 1:
The Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES), an audit criteria
developed by the Joanna Briggs Institute, was utilised to conduct the audits. After the barriers were identified in the
audit process, the Getting Research into Practice (GRIP) method was utilised to develop actions to overcome the
barriers. A follow-up audit was carried out and this assessed the effectiveness of the strategies being implemented
using the same audit criteria used in the baseline audit.
The project on Implementing Evidence-Based Practice for Falls Prevention among Residents in a Dementia
Specific Aged Care Facility was started on August 2011 at Kensington Park Nursing Home. Information and
dissemination through staff meetings to eight registered nurses, one enrolled nurse, one occupational therapist,
one occupational therapy assistant, one physiotherapist, one physiotherapy assistant, three student nurses and
19 care staff with Certificate III was held to inform them of the background and aims of the project that was to be
conducted. Minutes of the meetings were made available for staff who were unable to attend.
The facility is set in the suburb of Kensington, South Perth, Western Australia, under the organisation of Hall and
Prior. It is a 48-bed high care dementia specific facility which has two sections with both sections having moderate
to severe dementia residents. The majority of the residents had been living in the facility for an average of one to
three years. At implementation of the project, only 46 residents were available; therefore, all residents were the
target population for the study.
Documentations at the facility to determine the compliance of the six criteria were audited in each resident’s file,
care plan, incident and accident forms, information from policies and procedures manual and falls assessment tool
developed by Hall and Prior used at KPNH.
188
Phase 2:
A situational analysis was conducted to identify barriers to achieving compliance in the GRIP process. Five
potential barriers were identified by auditing residents’ files and care plans, through feedback from trained staff
and by observing and constant monitoring of staff on duty in implementing Best Practice for falls prevention and
resident compliance.
Table 1:
Illustration of the barriers identified and the strategies that were undertaken during the GRIP process within
Kensington Park Nursing Home Aged Care Facility as well as the resources used to overcome the barriers.
Barriers
Strategies undertaken
Resources
1. Trained staff’s knowledge/skills
in completing falls risk assessment
One-on-one sessions with all
trained staff on how to complete
falls risk assessment
Falls Risk Assessment Tool
2. Staff’s knowledge on falls
prevention
Education sessions with all care
staff on Best Practice for falls
prevention
JBI Best Practice for falls
prevention
3. Staff’s attitude/compliance in
implementing falls preventative
measures
Constant monitoring of care staff
CNM/trained staff
4. Residents’ compliance on falls
preventative interventions
Continuous observation and
monitoring of residents eg
constantly using their zimmer
frame or not removing their hip
protectors
Zimmer frame and hip protectors
5. Lack of personal garment
to minimise hip fracture and
equipment to prevent falls
Purchased more hip protectors
for residents with recent falls
history and obtained additional
mat alarms for residents who were
assessed to use one
Funds obtained from management
Phase 3:
The data collected from the pre-audit based on the 46 residents’ files, care plans, incident and accident forms,
information from the policies and procedures manual and falls assessment tool used at KPNH were analysed. The
results were presented to staff through staff meetings and the minutes of the meeting were posted in the 24/7 diary
for staff to read especially those not able to attend.
Results
Pre-audit
Graph 1: Pre-audit at the Kensington Park Nursing Home Aged Care Facility of 46 residents measuring the
compliance of falls assessments, interventions and appropriate documentation of risks by trained and care staff.
189
Criteria legend
1. Fall risk assessment is done accurately using a falls assessment tool.
2. Fall risk assessment is done on admission.
3. Fall risk preventative interventions are evaluated.
4. Patients who have experienced a fall are considered at high risk for future falls.
5. Reassessment occurs when there is a change in condition or following a fall.
6. Targeted interventions are implemented according to risk factors.
Criterion 1
The initial audit at the facility indicated 87% compliance in criterion 1. The facility has an outlined falls assessment
tool. Falls risk assessment was to be done by a trained staff to identify residents who were at risk of falls. All risk
assessment scores were to be documented on the falls risk assessment tool and with the assessment score,
residents were identified as at being low, medium or high risk of falls.
Criterion 2
Criterion 2 showed 87% compliance on the initial audit conducted in the facility. It is a policy of the organisation that
a falls risk assessment was to be conducted by a trained staff on admission, annually and as clinically indicated to
assess the actual falls risk of each resident.
Criterion 3
The initial audit rated 100% compliance to criterion 3. After identifying residents as falls risk, a care plan was
generated for each resident wherein individualised falls risk preventative measures were indicated or provided.
Criterion 4
Criterion 4 revealed 78% compliance on the initial audit conducted. When a resident was assessed following a
fall due to various risk factors, that resident was considered as high risk for future falls. It was then required that
an individualised care plan be developed by a registered nurse to prevent future falls or injuries by that resident.
Criterion 5
Out of 46 residents participating in the audit, only 36 (78%) were reassessed when there was a change in condition
following a fall. The falls risk assessment tool was to be completed on admission and updated or reviewed regularly
based on the resident’s condition and following a fall. A revised care plan is required to be generated with the
updated preventative measures.
Criterion 6
Criterion 6 illustrated 65% compliance in the initial audit conducted at KPNH. Individualised care plans were to be
produced for each resident identified as at risk of falls. Interventions used were obtained from JBI Evidence Based
Practice Information Sheets based on each resident risk factor.
Post audit
The post audit revealed significant improvement in compliance for critera 1, 2. 4 and 5. There was 100% compliance
for criterion 3 in both pre- and post audit which meant that falls risk preventative interventions were evaluated
correctly. Criterion 6 increased by 20% from 65% to 85% compliance implying that targeted interventions were
not implemented according to risk factors in the initial audit. The table below shows the comparator graph of the
pre- and post audit of the study conducted.
190
Graph 2: Post audit at the Kensington Park Nursing Home Aged Care Facility of 46 residents measuring the
compliance of falls assessments, interventions and appropriate documentation of risks by care staff after training
and supervision had been implemented.
Criteria legend
1. Fall risk assessment is done accurately using a falls assessment tool. (46 of 46 samples taken)
2. Fall risk assessment is done on admission. (46 of 46 samples taken)
3. Fall risk preventative interventions are evaluated. (46 of 46 samples taken)
4 .Patients who have experienced a fall are considered at high risk for future falls. (46 of 46 samples taken)
5. Reassessment occurs when there is a change in condition or following a fall. (46 of 46 samples taken)
6. Targeted interventions are implemented according to risk factors. (46 of 46 samples taken)
After the pre-audit and the GRIP process was implemented, a dramatic change of outcome in criterion 1, 2, 4 and
5 was achieved with assessment for those residents considered to be at risk and/or having a change in condition
reaching 100% compliance. Criterion 6 obtained an increase of 18% which means that compliance with regards
to the implementation of targeted interventions according to risk factors still needed to be improved. However,
the strategy of monitoring and supervising staff members on duty by trained staff will be continuously observed in
order to achieve better outcomes in the future.
Discussion
The project conducted at Kensington Park Nursing Home contributed to the continuous quality improvement in
reducing the incidence of falls. It also met the aims and objectives in all areas and continues to shape and influence
practice in the future.
The current risk falls assessment tool used in the facility was effective. It encompassed all categories that are vital
in falls risk assessment. Trained staff’s accurate assessment contributed as well in identifying residents who were
at medium and high risk of falls.
The Physiotherapy and Occupational Therapy activities and programs as documented in each resident’s care plan
and implemented by the PTA and OTA reduced the frequency of falls. It was also evident through observation
and feedback from staff that the hip protector as part of the resident personal garment prevented further hip
injuries. Hip protectors were referred to the OT as part for care planning. Proper footwear of residents and the
use of mat alarms are also very effective in the prevention of falls. Mobility aids like zimmer frames and four wheel
walkers being used by residents are referred to the PT for care planning and have proven to be useful in the
reduction in the incidence of falls. Education and toolbox sessions, monitoring and supervision of staff on duty
were very instrumental in minimising incidence of falls in the Residential Age Care Facility, which means that falls
risk strategies were implemented according to evidence-based practice during the GRIP process.
191
Clinical audit is a process initiated and pursued by clinicians which seeks to improve the quality of care through
structured peer review. The process involves clinicians examining their practices against agreed standards and
changing practice when this is indicated. Essentially, ‘Best Practice’ is identified and current practice is then
surveyed and compared to agreed Best Practice. The results of the audit are then used to process change.8
However, the change that I have documented is less than what I expected. KPNH is already equipped with necessary
documents and interventions to prevent incidence of falls. The major issues for Best Practice implementation is set
on the barriers identified and that strategies should be undertaken in order to comply with Best Practice.
The impact of this study to the individual resident was very significant including a better quality of life, self assurance
in mobilising, reduced risk of injuries associated with falls and a healthier and happier life.4
The initial audit revealed below 100% compliance for criterions 1, 2, 4, 5 and 6 whilst criterion 3 had 100%
compliance. However, the proponent of this project and all staff at KPNH tried to work harder in order to attain
100% compliance in the other criteria.
Some of the challenges faced in establishing the project were initially the compliance of residents on the assessed
interventions due to cognitive impairment. Falls are an extremely common problem among older persons with
dementia. Within the institutional setting, several researchers have found that older persons suffering from
dementia tend to fall more often than those without cognitive impairment (Morse et al., 1987).3 In addition staff
attitudes (Harris, 1989) and competence levels (Tutuarima, deHann, & Limburg, 1993) toward assisting patients at
falls risk, and applying safety procedures was found to be a barrier to implementation, ie negative attitudes and
poor knowledge may lead to acts of omission (eg failure to assess risk and implement preventative strategies),
and thus to increased falls3 whereas positive staff attitudes and increased knowledge with respect to caring for
older residents at risk, especially the dementia residents may decrease the frequency of falls.3 Also, education is a
crucial part of any falls prevention program.1, 5, 6 Patients/residents, family members and staff should be informed
if an individual is at an increased risk of falls, and the particular activities that they should avoid attempting
unassisted or unsupervised. Systems are required to ensure that specific patient information is conveyed from
each nursing shift to the next and that no lapses in vigilance occur during staff changeovers.1, 7 Due to staff and
resident changes, education sessions should also be held regularly.
Conclusion
The incidence of falls at KPNH was reduced during the implementation of the GRIP process despite criterion
6 obtaining below 100% compliance to evidence-based practice. The need for continuous education sessions
both for trained and care staff on falls prevention is vital to achieving better outcomes. However, supervision
and monitoring has proven to be effective in this study, especially in the implementation of the interventions with
residents with dementia.
The implementation of falls prevention at KPNH through evidence-based practice paved the way in reducing the
incidence of residents’ falls. Staff became more aware of how to manage the individual needs of the residents
because of their enhanced knowledge in falls prevention. Moreover, the proponent of this project developed her
skill in identifying barriers and strategies to be undertaken in the prevention of falls. The impact of this study to
the individual resident was significant including a better quality of life, self assurance in mobilising, reduced risk
of injuries associated with falls and a healthier and happier life4 as a measured outcome and also pointed out in
the previous study conducted by Tanya Martin on Preventing and Managing Falls in Aged Care Facilities. Further,
the outcome of this study could be used as a guide for other nursing homes within the Hall and Prior Organisation
aside from its contribution to continuous quality improvement in the facility where this project was conducted.
192
Acknowledgements
I would like to acknowledge and express my gratitude to Hall and Prior and Tena for giving me the opportunity
and providing the funding for my attendance in the Clinical Fellowship Program. To Joanna Briggs Institute for the
training and support during the fellowship I thank you. To Cate Barlow, the Director of Nursing, for her untiring
support and to all staff at the Kensington Park Nursing Home for their valued contributions to the project. Without
all of you this endeavour will never be successful.
References
1. L
ord S, Sherrington C, Menz H, Close J. Falls in Older People. 2nd ed. United Kingdom: Cambridge University
Press; 2007.
2.Tideiksaar R. Falls in Older People Prevention and Management. 4th ed. Baltimore, United States of America:
Health Profession Press; 2010.
3.Tideiksaar R. Falling in Old Age Prevention and Management. 2nded. New York, NY: Springer Publishing
Company, Inc.; 1997
4. Martin T. Improving Practice JBI Fellow Reports 2005-2008. Australia: Griffin Press; 2010
5.Shanley C. Putting Your Best Foot Forward: Preventing and Managing Falls in Aged Care Facilities. Sydney:
The Centre for Education and Research on Ageing; 1998.
6.Jensen J. Lundin-Olsson L. Nyberg L. Gustafson Y. Fall and Injury Prevention in older people living in residential
care facilities: a cluster randomized trial. Annals of Internal Medicine, 136(10) (2002), 733-41.
7. R
ubenstein L. Josephson K. Osterweil D. Falls and fall prevention in the nursing home. Clinics in Geriatric
Medicine, 12(4) (1991), M114-22.
8.The Joanna Briggs Institute. Clinical Fellowship Program-Study Guide. Adelaide, South Australia, Australia:
The Joanna Briggs Institute; 2010
9.The Chartered Society of Physiotherapy. Effectiveness of falls prevention and rehabilitation strategies in older
people: implications for physiotherapy. London: The Chartered Society of Physiotherapy, 2001. (available:
www.csp.org.uk, Ref: EB01)
10.Van Doorn C, Gruber-Baldini A, Zimmerman S, Hebel R, Port C, Baumgarten M, Quinn C, Taler G, May C,
Magaziner J. Dementia as a Risk Factor for Falls and Fall Injuries: Discussion [internet]. J Am Geriatr Soc.
2003;51(9). Available from www.medscape.com/viewarticle/460913_5.
JBI Fellows Monographs 2011-2012 Judith Vercoe
193
Documentation of medication and food allergies
on clinical records: a best practice project
Judith Vercoe
Quality Co-ordinator
Mercy Hospital
Dunedin
New Zealand
Philippa Pringle
Director of Nursing
Mercy Hospital
Dunedin
New Zealand
Abstract
Background
The Health Quality Safety Commission (HQSC) has highlighted the cost of adverse drug reactions (ADRs) which
affect between 2% and 13% of patients admitted to a hospital each year in New Zealand. Studies have reported
inaccurate or absent data on patients’ clinical records as contributing to ADRs.
Whilst there have been no reportable ADRs at Mercy Hospital, a clinical record audit in June 2011 revealed
evidence of documentation errors especially relating to alerts against the National Health Index (NHI) number. The
audit provided an excellent impetus to consider participating in the Joanna Briggs Institute Clinical Fellowship
Program to advance clinical audit skills and address a potential patient safety problem.
Aims/objectives
The objectives of the program were:
• T
o ensure patients admitted for surgery at Mercy Hospital have their specific alert details accurately documented
on their clinical record
• T
o demonstrate specific improvement possibilities in documenting alert information on clinical records through
clinical audit
• To improve accuracy in the documentation of medication and food alerts on clinical records
• To reduce the likelihood of adverse drug or food reactions suffered by patients in hospital care.
Method
The process involved four phases.
A baseline audit was conducted to examine current alert documentation practices in patients admitted for surgery.
The Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES) was utilised to assist
with data collection and the Getting Research into Practice (GRIP) tool was used to identify barriers to change.
Changes to the administration of alert data entry were implemented which subsequently required a review of the
clinical record policy. A further audit was conducted to examine the effectiveness of the changes.
Results
A gap between current practice/policy and evidence-based guidelines was identified in two criteria. An additional
gap was noted in one criterion of interest not included in the JBI-PACES analysis. Following the implementation
of strategies an improvement ranging between 9 to 27% in the three criteria was achieved. The further two criteria
identified high compliance between evidence-based guidelines and audit results.
An improvement in the documentation of alert information on patients’ clinical records was achieved, although there
remains opportunity for improvement. A patient education strategy is yet to be developed but once implemented a
further audit will be undertaken. The key improvements noted were due to system changes and expected barriers
to their implementation did not arise. Improved alert documentation on patient records will reduce the risk of ADRs
and ultimately reduce the burden on the healthcare system.
194
Keywords: evidence-based practice, implementation, accurate documentation, admission documentation,
patient safety, allergy
Background
The Health Quality Safety Commission (HQSC) has highlighted the cost of adverse drug reactions (ADRs) which
affect between 2% and 13% of patients admitted to a hospital each year in New Zealand.1 According to a recently
published report from the New Zealand Pharmacovigilance Centre, the groups of medication most often cited in
preventable adverse drug events (ADEs) are systemic antibacterials and anti-inflammatory agents, with the most
common adverse events reported being gastrointestinal and respiratory system disorders. Most errors included in
the preventable ADEs and ‘no harm’ events relate to incorrect dose and drug therapy monitoring problems. This
report also makes specific mention of failures in detection of significant drug interactions, past allergies or lack of
necessary clinical monitoring in reported ADEs.2
It is routine practice to ask patients admitted to hospital to give a history of their medication and food alerts
(encompasses allergy, intolerance, sensitivity and medication side effects) but evidence suggests that there is poor
correlation between perception and knowledge of these terms by both nurses and patients.3,4
Errors found in documentation in clinical files in one research project included a lack of drug allergy information
which contributed to preventable medical errors.3 Assertions from researchers and clinicians alike emphasise that
health professionals need to be more pro-active in determining the manner of any drug allergy or ADR along with
the extent of the reaction.1,3,4,5,7,8
Information relating to medication alerts is documented in many healthcare facilities on the front cover of a clinical
file, often with an easily identifiable label. At Mercy Hospital, the large label contains the symbol of a red exclamation
mark. Information relating to alerts is replicated on the nursing assessment form, consent form, surgical safety
checklist, intra-operative form, post anaesthetic care form and patient medication record by different people at
different times. Farooq et al. conducted a study in 2008 which demonstrated 30% of charts had no entry in the
specific area requiring allergy documentation.6 Highlighted was the importance of always documenting the section
with ‘no known allergies’ (NKA) if there was no allergy history to report. Other studies have demonstrated that a
systems approach to standardising the collection of information from patients by nurses, along with education,
can support changes in practice to minimise ADRs.1,5,6,7 Health information stored on a national database in New
Zealand is searchable by the patient National Health Index (NHI) number. The NHI is a system used by public
hospitals and other health and disability support services in New Zealand to assign an alpha-numeric identifier
(the NHI number) to people who use their services. The NHI holds information on names and addresses, ethnicity,
gender, date of birth and New Zealand resident status along with specific information relating to medical alerts.
A clinical record audit conducted at Mercy Hospital in June 2011 identified inaccuracies in documentation on the
clinical record by nursing staff, which reinforced the need to investigate opportunities for improvement. Historically
at Mercy Hospital, an administration clerk has accessed and had the responsibility to add or change alerts on
the NHI database according to information supplied by each patient on their admission form. The risk of errors
in reporting medication allergy has been noted in the transference of clinical information from paper to electronic
patient record.4 However, previous clinical record audits at Mercy Hospital had demonstrated a number of data
entry errors. These were often found to be the result of lack of professional verification of the information supplied
by the patient and one memorable entry cited “morphine causes sore tummy” which was documented as a drug
allergy on the NHI and on the same record “swell up and can’t breathe when eat nuts” was absent. For these
reasons, amongst others, a clinical audit was proposed to be conducted at Mercy Hospital to evaluate current
practice in terms of medication and food alert documentation.
Audit Question
Can the accuracy of medication and food alert documentation in clinical records be improved at Mercy Hospital?
Aims
To ensure patients admitted for surgery at Mercy Hospital have their specific alert details accurately documented
on their clinical record.
To demonstrate specific improvement possibilities in documenting alert information on clinical records through
clinical audit
To improve accuracy in the documentation of medication and food alerts on clinical records
To reduce the likelihood of adverse drug or food reactions suffered by patients in hospital care.
195
Audit criteria
The audit criteria for the documentation alerts were created in JBI-PACES by Joanna Briggs Institute staff. Four
criteria formed the basis for the audit and these were:
1. Full history of drug allergy is obtained at admission:
This criterion was deemed to be met if the nursing assessment documentation had been accurately completed on
the Nursing Assessment form.
2. Self reported history of drug allergy and record from previous admissions are validated during
admission:
This criterion was deemed to be met if there is documented evidence that any inaccurate or conflicting data had
been noted and action taken to correct it during admission.
3. Allergy and intolerance are documented separately on the front page of the patient’s chart:
This criterion was deemed to be met if the procedure relating to the Clinical Record Documentation Policy had
been followed with the appropriate sticker fixed to the front of the patient’s record.
4. Nurses have received education on documentation of drug allergy and reaction, use of the
appropriate terminologies, correct spelling and legible hand writing:
This criterion was deemed to be met if there is documented evidence that the admitting nurses had received
education relating to correct documentation of allergies, intolerances and sensitivities within the last twelve months.
Setting and sample
Mercy Hospital is a private not-for-profit organisation with charitable status.
The organisation is owned by Nga Whaea Atawhai o Aotearoa Sisters of Mercy New Zealand and the focus is
private elective surgery. Six theatres, a two-bed ICU facility, 41 inpatient beds, 18 day surgery beds, six day
surgery chairs along with a Cardiac Catheterisation Lab and a Cancer Care Unit outline the physical capability of
the services offered.
During 2010, 6,135 patients were admitted for an elective surgical procedure with the majority being admitted
through the Day Surgery Unit.
A random sample of 100 patient National Health Index (NHI) numbers was generated using Trendcare12 (identified
from a computerised list of patients having had a procedure completed at Mercy Hospital between 1 January
and 30 June 2011). The number of clinical records reviewed was based on the amount of time available to the
reviewers to undertake the pre- and post audit, whilst understanding that there would be clinical records with no
alert details to consider.
Nurses responsible for admitting patients were asked if they had received education concerning documentation of
drug and food allergy, along with the use of appropriate terminologies within the last 12 months.
Methods
The project was conducted in four phases over a four-month period. Discussion with staff at the commencement
of the project demonstrated an interest by those involved in the admission of patients. However the audits were
conducted by the project leader and the Director of Nursing (DON). The project leader and the DON collected the
baseline and follow up audit data.
To formalise the audit process, the Joanna Briggs Institute software program JBI-PACES,9 was utilised. The use of
JBI-PACES9 provided a framework to utilise the cycles of audit, feedback and re-audit.
Phase 1: Evidence-based standards and ethical approval
Whilst there were no names or identifying information collected, stored or reported on in this project, clinical files
were accessed for the purpose of comparing information documented on admission, with evidenced-based Best
Practice criteria.
In view of the potential for publishing the results of this project, ethical approval was sought and subsequently
granted from the Ethics Committee Mercy Hospital.
Errors noted on the patient NHI during both audits were verified and corrected.
In order to consider the project within an evidence-based framework, the best available evidence in relation to the
documentation of allergies and alerts was established, which would then translate into auditable criteria. There
were no audit criteria relating to allergies and alerts on JBI-PACES9 so following a literature review conducted with
the support of JBI staff, the four criteria were established.
196
Phase 2: Audit
A baseline audit was conducted during August 2011 to ascertain the current level of practice relating to the
recording of alert information on patient clinical records. One hundred clinical records from patients identified as
having been admitted over the period January to June 2011 were audited and data were entered into the JBIPACES9 program. In terms of the audit data relating to staff education, each staff member was asked if they had
received education during the last 12 months relating to the identification of alert information.
Because of concerns raised during the clinical record audit conducted in June, data was collected relating to a
further three specific criteria which included:
• Accurate information relating to alerts transferred onto the electronic record (TRAK11)
• Accurate information relating to alerts recorded on the pre-operative checklist
• Accurate information relating to alerts recorded on the medication chart
Following the data entry process, audit criteria not showing 100% compliance were identified as requiring
strategies for change in the next phase.
Phase 3: Strategies for Getting Research into Action (GRIP)10
The findings of the baseline audit were discussed with the DON and Senior Nurses responsible for patient
admissions. The GRIP10 component of the JBI-PACES9 program was used to strategically develop a plan to address
the areas for improvement. The baseline audit identified three major areas including administration staff having
access to add/change information on the NHI, one ‘alert’ sticker applied to the front of the clinical record covered
allergies, intolerances, sensitivities and side effects and a differing interpretation of the alert terms between staff
and patients (Table 1).
The report generated by the GRIP10 program was disseminated and discussed. Day surgery unit staff were
pleased to see the excellent compliance in their nursing assessment documentation and were supportive in their
improvement suggestion with regards to a plan for developing patient education.
The post implementation audit was conducted in mid November 2011 following an implementation phase of
approximately four months. The same methods used in the pre-implementation audit were applied to the post
implementation audit, with no variations to the topic, the criteria or the sample size. The NHI numbers were
generated this time for clinical records of patients who had been admitted between 1 August and 15 November
2011. As in the first audit phase, the findings of the post implementation audit were reported back to key staff.
Results
As outlined previously, a four-phase approach was employed for this project in order to implement change in
the documentation of data relating to patient alerts. GRIP10 analysis proved a useful tool to strategically plan for
improvement in accurate patient alert documentation by complying with Best Practice evidence.
197
The following is a summary of the barriers, strategies, resources and outcomes:
Table 1: GRIP implementation
Mercy Hospital – Day Stay unit
Barriers
Strategies
Resources
Outcome
Administration staff
have authority to add
information to the NHI
Discuss the ramifications
of an incorrect alert with
Allocated time for staff to
meet Director of Nursing
Director of Nursing took
the lead on implementing
changes to the entering
of alerts on NHI –
no longer have access
to adding/changing
information to the NHI
Clinical record policy
does not reflect proposed
changes to administration
changes
Recommend changes to
the clinical record policy
Time required for writing/
consultation re changes
to clinical record policy
Clinical record
Policy considered at
Policy meeting and
recommended changes
accepted.
Staff received education
about the changes
One type of sticker on the
front cover indicates all
allergies, sensitivities and
intolerances
Investigate options to
provide different stickers
to denote each alert
problem OR
Money to develop
stickers – not in current
budget allocation
This has not been
resolved but is under
discussion with Senior
Nurses responsible.
Budget allocation has
been secured for next
year’s plan
JBI-PACES Patient
Brochure
Staff felt there was too
much written material
already given to patients
on admission. They have
suggested utilising ‘cue’
cards to validate the
terminology used. This is
an initiative to be trialled
in early 2012
Use the current sticker for
just one identified alert
eg: allergies
Different interpretations
of allergy, sensitivity, side
effect and intolerance
between nursing staff and
patients
Develop education
resources for patients/
family/carers
Education for staff
following change to the
administration of alert
data entry
Audit results
Initial audit
The baseline audit conducted in August 2011 identified two areas which did not meet Best Practice standards
relating to criteria 2 (self reported history of drug allergy and record from previous admissions are validated during
admission) and criteria 4 (allergy and intolerance are documented separately on the front page of the patient’s
chart). However 97% compliance was achieved in relation to criteria 1 (full history of drug allergy is obtained at
admission) and 100% compliance for criteria 3 (nurses have received education on documentation of drug allergy
and reaction, use of appropriate terminologies, correct spelling and legible hand writing)(Table 2).
The three additional criteria of interest identified specifically a lack of compliance in the transference of information
from the hard copy clinical record to the electronic record (Table 4).
Post implementation audit
Following the initial audit in August and implementation of one key strategy to overcome practice deficit, the post
implementation audit was completed in mid November 2011 to determine any changes in compliance.
Although the percentages indicate a noteworthy improvement of 27% achieved in criteria 4 and 9% in criteria 2,
the actual numbers represented are small. The following table (Table 2) shows a comparison of the results of the
pre and post implementation audit:
198
Table 2: Summary of the pre- and post implementation audits
Criteria Legend
1. Full history of drug allergy is obtained at admission. (100 of 100 samples taken)
2. Self-reported history of drug allergy and record from previous admissions are validated (check for inaccurate of
conflicting data) during admission. (100 of 100 samples taken)
3. Nurses have received education on documentation of drug allergy and reaction, use of appropriate terminologies,
correct spelling and legible hand writing. (9 of 9 samples taken)
4. Allergy and intolerance are documented separately on the front page of the patient’ chart. (100 of 100 samples
taken)
Table 3: Raw numbers contributing to the baseline and post audit results
Baseline Audit
Audit Criteria
Follow up Audit
n
N/A
%y
y
n
N/A
%y
Full history of drug allergy is obtained on 97
admission
3
0
97%
98
2
0
98%
Self reported history of drug allergy and record 29
from previous admissions are validated during
admission
6
65
85%
32
4
64
94%
Nurses
have
received
education
on 9
documentation of drug allergy and reaction,
use of appropriate terminologies, correct
spelling and legible hand writing.
0
0
100% 9
0
0
100%
Allergy and intolerance are documented 26
separately on the front page of the patient’s
record
15
59
63%
2
77
90%
y
21
Summary of the additional criteria audited during the project highlighted a concern in the transferring of patient
information from the clinical file to the electronic record (Table 4).
Table 4: Raw numbers contributing to the baseline and post audit results
Baseline Audit
Follow up Audit
n
N/A
%y
y
n
N/A
%y
Accurate information relating to alerts was 24
transferred onto the electronic record (TRAK)10
14
62
63%
26
8
66
77%
recorded on the pre-operative checklist
2
68
94%
32
0
68
100%
recorded on the medication chart
1
68
97%
25
3
82
89%
Audit Criteria
y
199
Discussion
As with any improvement project, demonstrating and evaluating change in clinical practice can be challenging.
Despite the fact that some improvement in practice was achieved within the four month time frame, there remains
opportunity for further gain with a further audit planned during April 2012.
The four audit criteria relating to the documentation of alert (allergies, intolerances, medication side effects
and sensitivities) developed by the Joanna Briggs Institute and based on the best currently available research
evidence, served as the benchmark for the success of the project. While it is noted that the audit criteria are
regarded as evidence of Best Practice, the practicalities of achieving compliance as measured against them can
be challenging. For example, the separate documentation of each specific alert on the front of the clinical record is
without doubt an excellent approach, but a change in such a protocol would require more extensive consultation
with medical and nursing staff than time allowed in this instance. Despite this, a small improvement was noted
between baseline and follow-up audit. This was likely to be due to the change in the clinical record policy requiring
a Senior Registered Nurse to be responsible for any addition or changes to the patient data recorded against the
NHI.
This illustrates one of the challenges in that while practice must be embedded in best available evidence, it is not
always achievable (at least in the first instance) for a particular setting.
The audit criteria for the validation of the self reported history of drug allergy and record from previous admissions,
however, generated the recognition that patient’s perception of the alert terms (allergy, intolerance, sensitivity and
drug side effect) was, at times, different from that of the admitting nurses. Now identified, a plan is underway to
trial cue cards for clarification of alert terms when the nursing assessment is being undertaken.
One area that had been identified as requiring improvement prior to the project was education for staff. During the
baseline audit, all staff indicated they had undertaken education in relation to alerts and had confidence in their
understanding of the specified terms. This was all due to timing. The baseline clinical record audit was undertaken
retrospectively (ie based on patient admissions during the six month period prior to the audit), and whilst the
criterion question was asked of staff during the same time as the baseline audit was completed, there had been
very recent changes (following the June 2011 clinical record audit) made to both the NHI data administration
system and to the clinical record policy requiring staff to update their knowledge.
The review of the clinical records policy and administrative changes to the entering of data onto the NHI have
been shown to be the key to improvements demonstrated. Whilst both these issues had been identified prior to
the commencement of the project, two expected barriers did not materialise. Administrative staff embraced the
change in documentation procedure and nursing staff readily adapted to the requirements of the reviewed clinical
record policy. Nursing staff who admit patients were shown to be achieving excellent compliance in their nursing
assessment documentation at both baseline and follow up audit.
An area proving difficult to address has arisen from the extra data set relating to the transference of information
from the clinical record to the electronic record (TRAK).
With only 63% compliance in the baseline audit and 77% in the follow up, improvement is required to ensure safer
care for patients.
The options being considered at present include the printing of specific stickers to note at a glance allergy,
sensitivity, side effect or intolerance or the use of the current alert sticker for allergy only. Whatever decision is
made, there will be necessity for a multidisciplinary approach and this will form the next phase of the project.
Overall some of the findings of this implementation project are reflective of the findings of the Health Quality Safety
Commission investigation into medication errors.1 Specifically, unless changes are made to a system, errors will
inevitably continue. The major gains have been as a result of a change in administration of the documentation
against the NHI and in the review of the clinical record policy. Education provided has obviously supported the
gains in knowledge by the admitting nursing staff but because the training occurred prior to the undertaking of the
baseline audit, this improvement has not been reflected in the results.
Patient education has also been shown to be essential in increasing accuracy of alert documentation.3,4 Whilst
the patient education improvements have not been implemented to date, plans are underway for cue cards to be
created to support a common understanding of alert terms between the assessing nurse and the patient being
admitted.
200
Conclusions
This project has emphasised how important it is to critically assess the systems involved in care delivery and not
just focus on behaviour or clinical process. Two changes to the system of documentation of alerts on the NHI and
review of the clinical record policy and process led to improvement gains in the accuracy of alert documentation.
Relevant education leading to a good understanding of alert terminology for nurses was paramount but had
already taken place prior to the baseline audit. Of equal importance, education for patients will hopefully support
further improvement.
Acknowledgements
This project has been generously supported by the Executive Team at Mercy Hospital Dunedin and particularly by
Philippa Pringle. The staff from Mercy Hospital who have contributed to the project are thanked for their effort. I
would personally like to thank my facilitator Zachary Munn, the other Fellows taking part in the program and staff
contributing to the JBI Fellowship program for the support and guidance with this project.
References
1Health Safety Quality Commission (HSQC): Factsheet has focus on medication safety. 2011: www.hsqc.govt.
nz Accessed November 2011
2 K
unac DL, Tatley MV. Detecting medication errors in the New Zealand pharmacovigilance database: a
retrospective analysis. Drug Saf.2011;34(1):59-71
3 K
halil H, Leversha A, Khalil V. Drug allergy documentation – time for a change?
Int J Clin Pharm.2011; May: 26
4Forjuoh SN, Pohl S, Reis MD. Medication allergy documentation in ambulatory care: A case report of errors
and missed opportunities quantified during the unique transition from paper records to electronic records.
Internet J Family Practice. 2010; 8(1)
5 V
alente S, Murray LP. Creative strategies to improve patient safety – allergies and adverse drug reactions. J
Nurses Staff Dev. 2011; 27(1):E1-E5
6 F
arooq M, Kirke C, Foley K. Documentation of drug allergy on drug charts in patients presenting for surgery.
Ir J Med Sci. 2008;177(1):243–5
7Valente S, Murray LP,Fisher D. Nurses improve medication safety with medication allergy and adverse drug
reports. J Nurs Care Qual. 2007;22(4):322-327
8 O’Dell K. Allergy Documentation: Strategies for Patient Safety. The Oklahoma Nurse. 2006;June-August:16
9The Joanna Briggs Institute. Practical Application of Clinical Evidence System. The Joanna Briggs
Institute;2009. http://paces.jbiconnectplus.org/AuditHome.aspx. Accessed November 2011
10The Joanna Briggs Institute. Getting Research Into Practice. The Joanna Briggs Institute;2009. http://paces.
jbiconnectplus.org/AuditHome.aspx. Accessed November 2011
11InterSystems TrakCare. InterSystems; V6.9.90003. Mercy Hospital Dunedin. Accessed November 2011
12Trend Care Systems Pty Ltd. Trendcare; V3.4: 2010. Mercy Hospital Dunedin. Accessed November 2011
JBI Fellows Monographs 2011-2012 Loendi van der Westhuizen
201
Clinical handover among nursing staff in an
acute care setting: a best practice implementation
project
Anne Blunden
Director of Nursing (Children’s Hospital)
King Fahad Medical City
Loendi van der Westhuizen (author)
Nurse Educator (Nursing Research and Evidence-based Practice)
Maria Holswilder
Director of Nursing (National Neuroscience Institute)
Salma Yasmeen
Nurse Manager Projects
Nurse Manager (Nursing Services – Projects)
Abstract
Aims and objectives
To improve the nursing bedside handover process and ensure safe and continuity of care using a best practice
approach.
Background
Bedside handover is based on patient-centered care, where patients participate in communicating relevant and
timely information for care planning. Patient input reduces care fragmentation as well as duplication of services and
enhances satisfaction and continuity of care. “Clinical handover is one of the most important issues to consider
when ensuring the continuity of patient care”.2
Method
Data collection included the observation of 25 handovers. The information gathered during the handover process
was entered into the Joanna Briggs Institute Practical Application of Clinical Evidence (JBI-PACES) audit tool. This
took place over a five-month period in a multi-entity tertiary care hospital in Saudi Arabia. A baseline audit was
carried out on10 August 2011 and a final audit was performed on 29 January 2012.
Results and conclusion
The data was analysed and a significant improvement was seen in the introduced process, where the current
handover away from the bedside was altered to a structured, standardised bedside handover.
Relevance to clinical practice
Recently, bedside handover has emerged as a method to improve the accuracy of handover communication. It
promotes a patient-centered approach to care and with patient contribution, it can improve patient safety and
increase both patient and health professional satisfaction. “Streamlining the nursing handover may improve the
quality of the information presented and reduce the amount of time spent in handover”.8
Key words: acute care setting, clinical handover, evidence based practice, Saudi Arabia.
202
Background
Saudi Arabia (population 27 million) has the largest health care market in the Gulf Cooperation Council, boasting
the region’s most technologically-advanced infrastructure, and state-of-the-art facilities and medical equipment.
The Saudi Ministry of Health continues to be the main financier for the healthcare market. By the end of 2009, there
were 408 operating hospitals, and 2,037 primary health care centres. Outpatient visits amounted to 131 million
Saudi Rials and inpatient admissions to three million Saudi Rials in 2009. The demand for health care services
will continue to rise in the upcoming five years, due to rapid population growth, a larger ageing segment, and the
prevalence of long-term non-communicable diseases.
The Kingdom of Saudi Arabia (KSA) has transformed a primitive healthcare system into one that is seen as achieving
universally acceptable standards. Significant metamorphosis has been achieved through the allocation of vast
amounts of funding from the Ministry of Health, the adoption of more conventional management systems and the
recognition of the rights of the citizens and the responsibilities of the regime regarding the health of the population.
The World Health Organization (WHO) listed “Communication during Patient Care Handovers’’ as one of its ‘High
5s initiative’.5 The primary objective of a ‘handover’ is to provide accurate information concerning a patient’s care,
treatment and services, current condition and any recent or anticipated changes. Interest in implementation of
effective handovers has grown over the past decade as researchers, hospital administrators, educators, and policy
makers have determined that current handover processes are highly variable and potentially unreliable.
“During an episode of disease or period of care, a patient can potentially be treated by a number of healthcare
practitioners, nurses and specialists in multiple settings”.5 Additionally, patients will move between areas of
diagnoses, treatment and care on a regular basis and may encounter three shifts of staff each day, introducing
a safety risk to the patient at each interval. Improving effective communication throughout the hospital is a lead
patient safety goal. Problems with patient handovers are an international concern: Australia, United Kingdom
and North Ireland have recently reviewed this issue and developed risk reduction recommendations.8 In addition,
patient handovers have seldom been studied systematically and studies describing handover practice show
significant variation within and across health care settings. “Although it is widely recognised that handovers
influence morbidity and mortality of patients, the extent of this problem is still unclear and best practice has not
been accepted nor exchanged on a larger scale”.7
The aim of clinical handover is to ensure that following handover all members of the team will have the same
understanding and set of priorities. “The handover is a two-way process to provide and receive information, gives
an opportunity to ask questions and for health professionals to make each other aware of relevant issues”.3
“The problem with transfer of patient care is that it is not a clear pathway”.9 We must understand that we cannot
simply “improve handoffs”9 with a checklist or some training. We must review our handoff process and make
changes were most lasting improvements aut to be made.”There are a variety of handover techniques that have
been used by health professionals, such as taped and verbal reports given in staff rooms or at a nursing station”.3
Recently, bedside handover has emerged as a method that improves the accuracy of handover communication.
“It promotes a patient-centered approach to care and with patient contribution, it can improve patient safety and
increase both patient and health professional satisfaction”.3
This Clinical Handover Project was conducted in a Joint Commission International (JCI) accredited, 1094-bed
multi-facility, multi-entity tertiary care hospital, which also promotes medical research and education programs,
including postgraduate education training, as well as a focus on disease prevention. The evidence used in the
project was based on a structured search of the literature and selected evidence-based healthcare databases. In
order to develop a clinical handover project that had a meaningful impact on improving patient safety, we need to
look at all aspects involved in the handover process.
Handover practices in King Fahad Medical City (KFMC) before the structured, evidence-based handover process
was implemented in the institution were:
• Handovers occurred at the duty station/conference room, away from the patient
• The amount of time allocated for handover was excessive (staff left long after shift completion)
• No standardised guidelines or form for safe nursing handover
• Continuity of care not apparent in the handover process
• T
ype and level of handover differed according to distractions, time of day, day of week, level of stress and
acuity of patients, and workflow.
203
Audit questions
Was the existing handover practice and information communicated away from the bedside consistent, accurate,
timely, patient centered and based on best available evidence?
Aims:
• D
evelop and implement a policy, guidelines and forms to ensure nursing handovers comply with the latest
evidence-based clinical practice.
• Ensure standardisation of the clinical nursing handover process in the institution
• To improve patient outcomes by ensuring that handover is comprehensive, accurate and safe.
• To implement handover at the bedside with the following three elements:
-- Charge Nurse to Charge Nurse comprehensive handover of all patients
-- Primary Nurse to Primary Nurse handover at the bedside
-- Group handover/group huddle
• T
o improve nurses’ communication, understanding and use of evidence-based practices during nursing
handover.
• To ensure 80% nursing staff compliance with the implementation of an effective clinical handover.
• To conduct a pre- and post implementation audit of nursing handovers based on best practice.
Method/data collection
Phase 1
The development and approval of the project’s standardised handover form (Appendix A) was done according to
the organisational policy, evidence-based practice and all relevant stakeholders were involved. A policy on safe
nursing handovers was developed and applied to all nursing staff working at the institution. Training and education
of staff on the use of the new form was completed during a Gold Standard Event. The new form was implemented
in all units in the institution, to ensure consistency when clinical handovers was performed.
Audit criteria:
JBI-PACES, an audit criteria developed by the Joanna Briggs Institute, was utilised to conduct the baseline audit,
as well as cycle 1 and cycle 2 audits. The use of the JBI-PACES evidence-based criteria was presented to the
project team for approval before it was used.
The audit tool included the following criteria as per JBI-PACES:
1. Verbal (face to face) communication has occurred.
2. Standardized documentation has been used.
3. The patient has been identified correctly.
4. Relevant history of the patient has been stated.
5. Detailed observations of the patient have been stated.
6. The handover process includes an agreed plan of care for the patient.
7. Transfer of responsibility of the patient from one nurse/shift to another nurse/shift occurred.
This project did not require ethics approval as it was conducted in accordance with the clinical quality improvement
policy and was in accordance with all of the by-laws of the institution. It did not infringe on patients’ confidentiality
and care in any manner. However, confidentiality of all audits was maintained at all times.
Participants and sampling frame
The new handover process was implemented in the entire hospital, which consists of four hospitals and three
centres. Considering the size of the institution, only three areas in each hospital/centre were chosen for this study,
and four other areas were randomly selected,by the author; thus 25 units in the institution were part of the study.
The staff of the chosen units were oblivious to the fact that they were chosen, as audits were conducted in other
units, which were not part of the study, to ensure compliance to the handover policy and practice. The operating
room was excluded from this study as this area uses a different handover process.
204
Data collection
A baseline audit was completed on 10 August 2011, using the JBI-PACES audit tool (Attachment B). When
observing the clinical handover process, the information was charted on the tool in a ‘yes’ or ‘no’ format and
later entered into JBI-PACES. To ensure the validity and reliability of the audit, most nurses from the hospitals and
centres did participate in this project although, as stated previously, not all areas were included in the study.
Baseline audit results were disseminated to the project team members who reviewed and analysed the results to
determine the direction of more education and training, and how to further facilitate the evidence-based process
of change.
Phase 2:
Implementation of best practice
Implementation of best practice regarding clinical handover occurred in all areas in the institution, but only 25
units were included as part of the study. Areas where compliance was not achieved were identified. Following the
baseline audit, analysis and identification of gaps in the current practice, and in-service sessions were conducted
in the units.
An action plan was developed using the JBI Getting Research into Practice (GRIP) program based on results of the
baseline audit and project member analysis. Potential barriers were identified and target implementation strategies
for Phase 2 was planned (Table 1).
Table 1: List of potential barriers to the implementation of effective clinical handover
and the perceived outcomes, once strategies and resources have been put in place
Potential barriers
Barriers
Strategies
Resources
Outcome
Lack of training in effective Provide training through Project team leader and Knowledgeable staff
clinical handover
the Gold Standard Event members
and
unit
in-service
sessions
Lack of time to prepare, Prioritise time to prepare Project team leader and Detailed handover
responsible staff
provide
detailed members
provide or receive a and
handover
detailed handover
to
Changing
workplace Target all nursing staff to Project team and Nursing All nurses complying to
handover policy
practice
to
facilitate ensure that handovers are Education Department
done with each change or
increased handovers
period of care
Reluctance to change Target all staff to accept Project team and Nursing Smooth facilitation of “
change”
among nursing staff
change and the positive Education Department
impact it will have on
patient care
Insufficient
time
and
resources for the training
and education of new
guidelines and handover
form
of
Prioritise areas of greatest Project leader and team Implementation
guidelines and handover
weakness
that
need members
form
training and schedule unit
in-service
Although education was given to all staff, some areas still needed reassurance that they were using the form
correctly. In the specialty areas (Woman Specialized Hospital, National Neuroscience Institute, Cancer Center and
Rehabilitation Hospital) the staff developed their own form with the necessary information. The staff highlighted
that the forms were lacking specialty information. The project team approved this until the revision of the handoff
form in February 2012, when missing information was added.
A follow-up audit cycle 1 was performed (10 November 2011) to track the process and to ensure that the nursing
staff were complying with the new handover process. Follow-up sessions were held with the staff to disseminate
the data feedback and to focus on areas that showed a poor outcome from the baseline data.
Staff received feedback at regular intervals throughout the implementation phase to facilitate compliance. Any
barriers that arose during the project were resolved in consultation with the project team.
205
Phase 3:
A post implementation audit was undertaken (29 January 2012). Data was entered using JBI-PACES and the
evidence based criteria that were used in the previous two audits. The same checklist and the same units were
used to ensure reliability and validity of the results.
Graph 1.
Baseline data:
Although handovers in the units were not done at the bedside, most of the criteria were met, but improvement
needs to be seen to ensure patient safety and quality of care.
Baseline results:
1. Verbal (face to face) communication occurred (76%).
2. Standardized documentation was used (72%).
3. The patient was identified correctly (84%). As patient identification is one of the 6 international patient safety
goals, this criteria needs to be nearer 100%, as mistakes must not occur regarding identification of patients.
4. Relevant history of the patient was stated (80%). The remaining 20% of patients will not receive adequate quality
of care.
5. Detailed observations of the patient were stated (80%).
6. The handover process included an agreed plan of care for the patient(92%). All patients need a plan of care
regardless of their illness.
7. Transfer of responsibility of the patient from one nurse/shift to another nurse/shift occurred (100%).
Graph 2.
206
Post implementation audit data:
Although the handover in the units were not done at the bedside, most of the criteria were met, but improvement
needs to be seen to ensure patient safety and quality of care.
Baseline and Cycle 2 results with improvement percentage:
1. Verbal (face to face) communication occurred (92%), an improvement of 16%.
2. Standardized documentation was used (80%). This was an improvement of 8%. It was mostly the specialty
areas that did not use the new form; however the specialty areas developed their own handover forms specific
to their area and changes will be implemented on the new form.
3. The patient was identified correctly (92%) an improvement of 8%. This area still needs to be addresses as all
patients should be identified.
4. Relevant history of the patient was stated (92%). This was an improvement of 12% but significant improvements
still need to be achieved.
5. Detailed observations of the patient were stated (96%). This was significant improvement of 16%.
6. The handover process included an agreed plan of care for the patient in 100% of patients.
7. Transfer of responsibility of the patient from one nurse/shift to another nurse/shift occurred 100%.
Continued re-enforcement and educational sessions will be conducted on a two-monthly basis to ensure
compliance and to further improve upon the implemented handover project. In addition the handover policy,
forms and guidelines will continue to be modified in consultation with key stakeholders especially those being
implemented in specialty areas.
Discussion
The implementation of the updated, evidence-based form for clinical handover in the units of an acute care tertiary
hospital in KSA was a success as deemed by the following outcomes.
All units changed the process of handing over patient information from one shift to another shift in a positive way.
Most units used the standardised form to handover and continue to do so. Bedside handover by the primary nurse
to the primary nurse is occurring and the medical file is used for transfer of information. All seven of the criteria that
were audited showed improvement in the handover process with some areas showing more improvement than
others for example criterion 5 where a 16% improvement was observed.
However, the developed form is not appropriate for some of the specialty areas and consequently it is recognised
that the form will need adjustments to ensure compliance to the handover process in these specialty areas. Nursing
staff within these units have provided feedback and where applicable these suggestions will be implemented with
the revision of the form in February 2012.
Conclusion
Although this handover audit was done in only 25 units in the hospital there were positive results to show that
implementation of the handover process was beneficial to the patients and the staff. As stated previously the
handover form will be modified at the next review to ensure that all units will be able to use the form. The form
would need further trialing in the various specialty areas over a longer period of time to ensure that it will be totally
usable.
Within this project the Executive Nursing Director and all other nursing directors were thoroughly involved,
which enabled the change process to occur and the outcome to be positive. This shows that when the relevant
organisational stakeholders are engaged in the project, positive outcomes can be ensured. “With involvement
comes understanding; with understanding comes support and commitment”.1 Organising a team and including the
right people on a process improvement project is critical to a successful improvement effort. This requires more
than buy-in or passive agreement that the direction of changes is acceptable. It demands ownership by leaders
willing to accept responsibility for making change happen in all areas they influence or control. Top management
commitment is always considered as the first requirement for implementing projects in the institute.
The project findings were reported to the applicable stakeholders.
207
Acknowledgements
The author would like to thank Jane Wilshaw, Executive Director of Nursing Affairs; Donna Hilliard, Director Nursing
Education; and Salma Yasmeen, Project Nurse Manager; for their support in making this project an integral part
of the ongoing drive to improve the quality of service provided to KFMC patients; all the Nursing Directors\Nurse
Managers and staff nurse undertaking the implementation and maintenance of this project.
Appreciation also goes to the Joanna Briggs Institute staff, for their support throughout the time of the program,
and KFMC-Riyadh for funding this Evidence Based Clinical Fellowship program.
References
1.Australian Commission on Safety and Quality in Health Care. The OSSIE guide to clinical handover
improvement. Sydney, ACSQHC. 2010.
2.Australian Medical Association. (2006) Safe handover: Safe Patients. Guidance on clinical handover for
clinicians and managers. AMA; [Available online http://www.ama.com.au/web.nsf/doc/WEEN-6XFDKN]
3.Bhabra G, Mackeith S, Monteiro P, Pothier DD. (2007) An experimental comparison of handover methods.
Ann R CollSurgEngl; 89(3): 298-300.
4. K
assean HK, Jaggo ZB. Managing change in the nursing handover from traditional to bedside handover—A
case study from Mauritius. BMC Nursing. 2005 4(1).
5.Memoire A, (2007) Communication during patient hand-overs. Joint Commision Journal on Patient Safety
Solutions, Volume 1, Solution 3.
6.Patterson. ES. and Wears RL. Patient Handoffs: Standardized and reliable measurement tools remain elusive.
Joint Commission Journal on Quality and Patient Safety, 2010.
7.Patterson. ES. and Wears RL. Understanding and improving patient handoffs. Joint Commission Journal on
Quality and Patient Safety, 2010
8.Sexton A, Chan C, Elliott M, Stuart J, Jayasuriya R, Crookes P. Nursing handovers: do we really need them?
J NursManag. 2004;12(1):37-42.
9.Van Eaton E, Handoff Improvement: We need to understand what we are trying to fix. Joint Commission
Journal on Quality and Patient Safety, Feb 2010
208
JBI Fellows Monographs 2011-2012 Caroline Whiteford
Administration of BCG for cancer in situ of the
bladder: a best practice implementation project
Caroline Whiteford
Clinical Service Coordinator
Surgical Specialties Outpatients
Julie Aldridge
Enrolled Nurse (Advanced Diploma)
Cassandra Haynes
Enrolled Nurse (Advanced Diploma)
Abstract
Background
Immucyst-BCG Immunotherapeutic (Bacillus Calmette-Guerin/Connaught) is a drug administered for the treatment
of cancer in situ of the bladder. At the Royal Adelaide Hospital, a large tertiary public hospital comprising 623 acute
beds, BCG treatment is administered to outpatients once weekly for six weeks.
This paper reports on a four-month implementation project, which formed part of the Joanna Briggs Institute
Clinical fellowship program. The aim of the Clinical Fellowship program is to develop clinical leaders, examine and
analyse clinical practice and develop Best Practice within health services.
Aims/Objectives
The aims and objectives of this project were to critically examine our processes surrounding Administration of
BCG to patients with cancer in situ of the bladder and implement changes to practice.
Methods
A team was established comprising a team leader and two team members (Clinical Service Coordinator and two
Enrolled Nurses). Our aim was to perform a three phase project- a baseline audit with specific criteria on a sample
group of ten patients, then examine results and findings of the audit in phase two and make changes to practice
based on these results. The Joanna Briggs Institute Practical Application of Clinical Evidence System ((JBI-PACES)
and Getting Research into Practice (GRIP) programs were used to conduct this body of work. We then undertook
a follow-up audit to review whether the changes to practice we had implemented had any benefit to patient care.
Results
Our results were excellent within a very short space of time, and improvements had excellent outcomes and
demonstrated a gap in the education of treatment for patients and staff. The team was able to seek information
and resources from other health sources to improve information and education within the BCG clinics thereby
improving practice significantly.
Conclusion
The project results have also assisted in initiating dialogues with the governing body of our health services, SA
Health, and Country Health SA to create a statewide guideline, standardise protocols and improve education for
health workers across the state regarding the administration of BCG to patients in metropolitan and rural centres.
Keywords
BCG, Bladder, Cancer, education
209
Background
Bladder cancer is a chronic illness and many patients require surveillance programs for many years following
treatment. The exact cause of bladder cancer is unknown but some known risk factors are smoking, exposure to
chemicals used in the manufacture of plastics and dyes, insecticides, chronic inflammation and calculi. Tumours
develop in the epithelial lining of the bladder and can often start as papillary growths. The majority of these growths
are transitional cell carcinomas but without treatment they can invade by stages into superficial muscle layers,
then progress into deep muscle layers and then into surrounding tissues. Stages of tumour aggressiveness can be
classified as G1 (least aggressive), G2 (moderately aggressive) and G3 (most aggressive). Treatment is dependent
on the stage of the disease. Patients are classified as having non-muscle invasive disease – cancer in situ, (CIS)
or muscle invasive disease. The primary treatment is a transurethral resection of the bladder (TURBT) which
enables the determination of the grade of the cancer. Once the exact extent of the cancer is known then treatment
is decided. For CIS a common treatment is BCG and surveillance/maintenance therapy.1 Treatment for muscle
invasive cancer might involve surgical intervention or radiotherapy or a combination of both.
The purpose of this implementation project was to investigate the current clinical practice of administration of BCG
for cancer in situ at the Royal Adelaide Hospital in the outpatient setting. BCG is an immunotherapeutic freeze
dried preparation of a living bovine tubercule bacillus, Mycobacterium bovis.2 The bacilli is viable on reconstitution.
When the drug is instilled/administered into the bladder as a cancer therapy, BCG promotes an inflammatory
process which eliminates or reduces non-muscle invasive cancerous lesions of the urinary bladder. The exact
way this drug works is still not completely known. Patients are currently treated with a six-week course of BCG
during which the patient is monitored closely during a two-hour visit once a week when the drug is reconstituted
with normal saline and instilled into the bladder via a urinary catheter. The patient is then instructed to retain the
fluid for a period of two hours and then monitored closely for the presence of symptoms and signs of toxicity after
each intravesical treatment. Patients also return for surveillance cystoscopy at intervals of three, six, nine,12 and18
months, and six monthly maintenance courses of BCG, which involves a three-week course of treatment. This may
occur for a period of up to five years. Whilst there is a lot of clinical information and results of clinical trials and
studies involving BCG,1 there is scant information about administration of BCG for health professionals.3 At the
Royal Adelaide Hospital, the number of patients accessing this treatment is reasonably consistent (six per month,
90% male, 10% female), the vast majority with a history of smoking. Nursing staff have developed guidelines and
protocols for safe administration, handling and disposal of the drug by following manufacturer guidelines of BCG
Immucyst®.
This topic was chosen to improve staff education and set benchmarks for the administration of BCG for patients
with cancer in situ. Patient safety and improving patient outcomes was also an aim. The topic was chosen as
it was identified as a treatment that is being offered to large numbers of patients and it was felt that more data
and benchmarking needed to be collected to assist in developing some statewide standardisation policies and
procedures for health workers handling and administering BCG both in the metropolitan and rural areas.
Setting and sample
The site for this project is a 623-bed acute care public hospital located in the city of Adelaide in South Australia.
The Royal Adelaide Hospital services a large multicultural and Indigenous population from areas as far away as
Northern Territory and vast rural areas of the whole of Australia. The Surgical Specialties Outpatient department
was chosen as the clinical area where the audit was conducted as this is the area where patients attend to
receive their BCG treatment on a weekly basis. The data collected in the audits (baseline and secondary) was
observational and by case note review. The audits were conducted by a team of three nurses; myself, a Clinical
Service Coordinator and two Enrolled Nurses with Advanced Diplomas. The patients were all ambulant outpatients
who were compliant to the treatment. The sample size was 10 patients . The audits were conducted over a sixweek period with each criteria being audited therefore a total of 60 responses per question for criteria B, D, E,
F, G, H , I, J and K by direct observation or checking documentation. Criteria A required one response by direct
observation and criteria C required 10 responses by checking documentation The audits were confidential and no
personal data was collected.
210
Aims
• To ensure all nursing/medical staff were compliant with protocols and procedures developed with Best
Practice guidelines
• To create an organisational wide instruction for administration of BCG
• To improve education for nursing/medical staff
• To ensure patient safety and improve patient outcomes.
Method
The project was conducted in three phases over a four month period (November 2011 – February 2012). At the
commencement of the project, discussion and education about the project was conducted and team members
involved in the BCG clinics were identified. These included two Enrolled Nurses working in the BCG clinic and
myself as the project leader. We were all responsible for collecting data for the baseline and follow-up audits
using JBI-PACES. The three phase process undertaken was a literature search and baseline audit, GRIP and post
implementation audit.
Phase 1: Literature search and baseline audit
To establish current practices regarding administration of BCG including education, protocols and guidelines a
literature search was undertaken by the project leader. As a result a large amount of information was discovered
on the internet under the Western Australian Government Department of Health website4 and the New South
Wales Cancer Council education website EVIQ.5 These were compared to the unit’s current protocol and education
packages. In addition to this literature search the Team leader also contacted peers via telephone or email in order
to establish other practices used in the administration of BCG in other metropolitan and rural facilities.
A baseline audit was established and conducted using JBi-PACES in November 2011. Ten patients were selected
and the members of the project team collected the data by direct observation. The team leader entered the data
into the JBI-PACES audit program.
Audit criteria:
The audit criteria for the project are below:
A. A protocol is in place for organisations administering BCG.
B. Urinalysis is performed prior to BCG administration.
C. Patients have received education regarding BCG treatment.
D. Before administering BCG, contraindications to therapy have been assessed.
E. BCG is administered weekly for at least six weeks initially.
F. BCG remains in the bladder for up to 2 hours, and at least 1 hour.
G. BCG is stored at 4 degrees Celsius until use.
H. BCG is administered immediately following reconstitution or within 2 hours.
I. When reconstituting and diluting BCG, personal protective equipment is worn.
J. When administrating and disposing of BCG, personal protective equipment is worn.
K. Materials used to administer BCG are disposed of in a biohazard container.
The sample size for each criteria and how they were measured is below:
Direct observation was by Project Leader (Clinical Service Coordinator) and Team Members (Enrolled Nurses)
and was completed by answering the criteria with a yes, no and percentage expressed response which was then
tabulated and entered into JBI-PACES audit format by the project leader.
Criteria A will be 1- by direct observation in the treatment room
Criteria B will be 60- by checking documentation in patient case files
Criteria C will be 10- by checking documentation in patient case files
Criteria D will be 60- by checking documentation in patient case files
Criteria E will be 60- by checking documentation in patient case files
Criteria F will be 60- by checking documentation in patient case files
Criteria G will be 60- by direct observation/ checking thermometer in fridge in drug room
211
Criteria H will be 60- by direct observation in treatment room
Criteria I will be 60- by direct observation in treatment room
Criteria J will be 60- by direct observation in treatment room
Criteria K will be 60- by direct observation in treatment room and then in contaminated clean up room
Phase 2: Strategies for Getting Research into Practice (GRIP)
The team leader met with team members, medical and nursing staff to report back the findings of the baseline
audit and discussed time frames and implementation strategies for phase 2. The GRIP tool was used to identify
barriers and create targeted implementation strategies based on the results of the phase 1 audit.
The baseline audit identified one major area for improvement and this was the issue of patient education. Following
discussion, the group decided to begin to utilise the Western Australian Education Package and improve our
education handouts6 and commence an education session for patients prior to their treatment to improve
understanding of their treatment. Table 1 outlines a summary of the barriers, strategies, resources and outcomes
Implementation:
Public Hospital, Surgical Specialties Outpatients department:
Barriers
Strategies
Resources
Outcome
Less than ten patients
attending BCG clinics for
treatment
Extend the baseline audit
for a period longer than
four months
Direct discussion with
Urology Consultants
to refer patients for
treatment to Outpatients
No issues with number of
patients attending BCG
clinic. Patient numbers
increasing
Patients becoming
unwell whilst receiving
treatment which altered
administration timeline,
patients having a lack
of knowledge regarding
BCG
Improve staff education
to ensure procedure is
performed to meet Best
Practice (sterile set up,
safe administration)
and improve patient
education to more rapidly
identify symptomatic
complications
Educational handouts
– Western Australian
Government, rewritten
protocols and guidelines,
education sessions
prior to treatment, pre
treatment checklist
developed
Education sessions for
patients run prior to
treatment, pre procedure
checklist stamp
developed for patient
case notes, ongoing
staff education via staff
education sessions
Lack of Nursing Staff
to be allocated to BCG
clinic- staffing clinics with
relieving staff
To establish a ‘core
group’ of Nurses to
run the BCG clinic with
specialised knowledge
and skills of BCG
Nurse Manager and
Nursing Director involved
in discussions to
ensure clinic is staffed
appropriately and
specialised staff available
and back filled if on leave
or sick
Clinics have a stable ‘core
group’ of Nurses running
the clinic who roster
themselves to adequately
cover the clinics at all
times
Lack of knowledge
regarding administration
of BCG amongst staff
Education sessions to
improve knowledge of
Best Practice guidelines
for administration of BCG
Allocation of staff
education time
Better understanding of
BCG treatment by all staff
Improving resources and
access to resources for
all staff involved in BCG
clinics
The post implementation audit was conducted in February 2012 following an implementation phase of approximately
two months. The same methods used in the baseline audit were applied to the post implementation audit. No
variations to the criteria, sample size, topic or location were made. As was the case with the baseline audit all
results were discussed with the project team and all nursing and medical staff.
212
Results
Baseline audit
Audit criteria
Post
implementation
audit
The following table provides a summary of the pre- and post implementation audits:
Observations
yes
no
%
Observations
A.A protocol is in place for
organisations administering BCG
1
1
0
yes
no
%
100%
1
1
0
100%
B. urinalysis is performed prior to BCG
administration
60
60
0
100%
60
60
0
100%
C.Patients have received education
regarding BCG treatment
10
6
4
60%
60
60
0
100%
60
D. Before administering BCG
contraindications to therapy have been
assessed
58
2
97%
60
60
0
100%
E. BCG is administered weekly for at
least six weeks initially
60
58
2
97%
60
58
2
97%
F. BCG remains in the bladder for up to 60
2 hours and at least one hour
58
2
97%
60
60
0
100%
G.BCG is stored at 4 degrees celsius
until use
60
60
0
100%
60
60
0
100%
H. BCG is administered immediately
following reconstitution or within 2
hours
60
60
0
100%
60
60
0
100%
i.When reconstituting and diluting
BCG, personal protective equipment
is worn
60
60
0
100%
60
60
0
100%
60
J. When administering and disposing
of BCG, personal protective equipment
is worn
60
0
100%
60
60
0
100%
60
60
0
100%
60
60
0
100%
K. Materials used to administer
BCG are disposed of in a biohazard
container
213
Discussion
This project was undertaken at the Royal Adelaide Hospital in the Surgical Specialties Outpatients unit. The project
consisted of a baseline audit, conducted in November 2011, a post implementation strategies phase and then a
follow-up audit in February 2012. Compliance with the audit criteria was good on the first audit and improved on
the second audit.
Undertaking this project was a challenging yet rewarding exercise for all members of the team involved. Locally
we hoped to gain some knowledge of what our ‘gaps in practice’ were but on a larger scale we hoped to use the
information discovered to benchmark our practice and introduce a statewide standard policy and procedure for
the administration of BCG. The team leader of the project has taken the results of this project to the Outpatient
Reform group in SA Health who have now committed a working party to develop these policies and procedures.
One of the main findings of the project was that education surrounding BCG administration was an area that
needed significant improvement. It was discovered that education has been occurring on an ‘ad hoc’ fashion
depending on time, resources available and staff knowledge of the administration process and drug knowledge.
It was also discovered that patient understanding of the procedure was also a factor in the type and quality of the
information given. One of the strategies developed following the baseline audit was to source some clear, concise,
accurate information to use as a tool with every patient which we feel was achieved successfully with the discovery
of online guidelines and information from Western Australia and updating our local policies and procedures. As
a result of our improvements in education surrounding administration of BCG a marked improvement was noted
from baseline audit to post implementation audit (60% baseline audit to 100% post implementation audit).
The impact of these changes has been significant for patients with the outcome being better understanding of
the treatment by patients causing less anxiety and fear and more confidence towards the nursing staff caring for
them. It also gave the patients a better understanding of any side effects or complications of the treatment should
they need to seek medical advice when they were not in hospital undergoing treatment. This information also has
assisted the team involved in the project to demonstrate the positive results to their peers, the advantages of
benchmarking information to the wider medical community and a feeling of ‘leading the way’ in excellence of care/
Best Practice.
214
The audit highlighted some variances in treatment that were out of the staff’s control. Two of those were that the
patient’s treatment schedule was longer than six weeks (normal duration of course of BCG) and that the BCG
treatment could not be held in the bladder for up to two hours and at least one hour.
These variances can be explained simply. Sometimes the duration of the course of BCG can extend longer than
six weeks due to complications such as infection, ill health or personal reasons, hence the treatment may be seven
or eight weeks. The audits (both baseline and post implementation) demonstrated that this situation occurred on
more than one occasion within the sample group. The other variance in the audit (BCG treatment could not be held
in the bladder for up to two hours and at least one hour) can be explained by the fact that as treatment progresses
the patient can experience some localised bladder symptoms such as irritability and inability to hold large volumes
of urine causing the patient to be unable to hold on to the treatment for a long time period. This is an expected
symptom of the treatment and patients are advised in their education program to consume additional water and
use urinary alkaline preparations to assist in diluting and calming the bladder throughout treatment. They are also
advised as part of the education program to minimise bladder stimulant fluids such as drinks containing caffeine.
While the staff all embraced the changes to clinical practice made as a result of the baseline audits, there were
barriers identified that involved negotiation with Nursing Management. One of those were ensuring that the
BCG clinics were staffed with an adequate number of nurses who were experienced in handling, administering
and disposing of the drug and also had received appropriate training to educate patients. This involved some
meetings with a ‘core group’ of interested nurses and an establishment of a BCG Nurses group who all underwent
specialised education and training and were able to self roster to ensure consistency of care for the patients over
the six-week period of treatment. This had a positive outcome for patients as they were rostered the same nurse
for their six weeks of treatment and developed a very close relationship with ‘their’ nurse which led to confidence
and trust between them – a very important factor when the patient was in an exposed position undergoing an
invasive procedure involving body exposure and catheterisation .
One barrier we identified that we are continuing to work on is that we would like to widen the education and
standardise the procedure and protocol for administration of BCG across the state. This is by no means a small
project and will require nurses, medical staff, pharmacists and governing bodies in SA Health and Country Health
SA to roll out these guidelines in a safe, supported manner. The great advantage to developing a statewide
guideline/information pack/protocol for use in all areas and centres identified as capable of caring for patients
undergoing BCG treatment is that patients who travel long distances for BCG treatment currently may be able
to access and undergo their treatment closer to home in smaller regional hospitals supported by larger tertiary
facilities with a ‘shared care’ arrangement. This would be a real advantage to patients whose lives now are quite
disrupted for long periods during each treatment cycle (may be up to every six months).
Throughout the project the team did not encounter any other similar projects and through discussions with other
peers in initial conversations regarding the project, it became very obvious that far more research and education
are required in this area. There was a great deal of enthusiasm from those contacted to be involved in developing
a statewide protocol and some structured education courses regarding administration of BCG. The team involved
in this project are currently hoping to lead this working party through implementing this change in practice on a
large scale. The benefit for patients and staff would be remarkable and would contribute to ongoing research and
benchmarking.
The project contributed to my personal development by providing me with the resources and tools (JBI-PACES and
GRIP) to gather data and to display my findings in a clear, concise fashion in order to facilitate change in clinical
practice. It also gave me the ability to add to data by performing auditing on an ongoing basis to benchmark
improvement and change in practice.
215
Conclusion:
In conclusion, at present, administration of BCG for cancer in situ of the bladder is a procedure performed on
outpatients with no statewide standardised protocols. This project was initiated by nursing staff recognising that
their practice needed improving and this implementation project has shown itself to have great value in identifying
gaps in practice and ways to address them. Excellent outcomes have resulted in the short time frame of the
project and it is envisaged that the data and information already collected can be utilised and developed further to
establish statewide guidelines and protocols for this treatment.
This project highlighted the importance of research and education for medical treatments and defined the need
for ongoing evaluation of clinical practice. By using tools such as PACES and GRIP the changes to practice were
obvious and could be demonstrated clearly and accurately.
In order for change to occur and to demonstrate a professional, transparent approach to change, activities such
as this project are necessary to create benchmarks and Best Practice. It also generated interest in evaluating our
practice so as to deliver better quality care and satisfaction to our patients.
Acknowledgements
This project has been supported by the Joanna Briggs Institute Evidence-based Clinical Fellowship Program. All
staff from the BCG clinic at the Royal Adelaide Hospital, Surgical Specialties Outpatients unit are to be commended
for their effort and contribution to this project. I would personally like to thank my facilitator, Zachary Munn, the
other Fellows taking part in the program and all staff contributing to the JBI Fellowship Program for their support
and guidance.
References
1.Joanna Briggs Institute. Evidence Summary: Bladder cancer: Bacillus Calmette- Guerin Effectiveness. JBICOnNect+, accessed online 27/10/11
2. Sanofi Aventis Immucyst product information leaflet. Feb 2010
3.Joanna Briggs Institute. Evidence Summary: Bladder cancer: Bacillus Calmette- Guerin Effectiveness. JBICOnNect+, accessed online 27/10/11
4. G
overnment of Western Australia. Intravesical BCG treatment – Patient information. Department of Health. 2011. Accessed online: 18 April 2012. www.healthnetworks.health.wa.gov.au/cancer/docs/BCG_treatment.
pdf
5.EviQ. Bladder intravesical BCG (ImmuCyst). Cancer Institute NSW, 17 Feb 2012. Accessed online 18 April
2012. https://www.eviq.org.au/Protocol/tabid/66/id/313/Default.aspx
6.Royal Adelaide Hospital, Surgical Specialties Outpatients unit protocol, Administration and Safe Handling of
BCG, July 2011. Caroline Whiteford CSC.
216
JBI Fellows Monographs 2011-2012 Xu Yan
Implementation of best practice in nasogastric
tube feeding of critically-ill patients in a
neurosurgical intensive care unit
Xu Yan
Registered Nurse
Neurosurgical Intensive Care Unit
Huashan Hospital
Shi Weilin
Head Nurse
Huashan Hospital
Jin Yufeng
Registered Nurse
Huashan Hospital
Yang Yu
Registered Nurse
Huashan Hospital
Abstract
Background: Nasogastric tube feeding is a frequent nursing practice to prevent malnutrition in neurosurgical
intensive care units for the critically-ill patients with unconsciousness, swallowing dysfunction or artificial
airways. However, poor management of tube feeding can also lead to or aggravate several complications, such
as pulmonary aspiration, intolerance of feeding, mechanical blocking, inadvertent respiratory placement and
infection.4 To ensure nutrition intakes and to avoid the above complications, an evidence-based management of
nasogastric tube feeding was conducted in the Neurosurgical Intensive Care Unit.
Objectives: This project was designed to implement best practice in nasogastric tube feeding of critically-ill
patients in Neurosurgical Intensive Care Unit.
Methods: A clinical audit software program, the Joanna Briggs Institute Practical Application of Clinical Evidence
System (JBI PACES) and Getting Research Into Practice (GRIP) was used in the project. A baseline audit, feedback
and follow-up audit cycle was followed. The audit team analysed the results of the baseline audit, conducted a
situational analysis and formulated and implemented a strategic plan to improve the nasogastric tube care.
Results: The results revealed disparity between current practice and best practice recommendations. The nurses’
compliance with each criterion improved through the process of auditing.
Conclusion: The project had some successes in improving the practice of nasogastric tube feeding. Collaboration,
education, monitoring and a reward system were the key factors that contributed to the success of the project.
Further actions and changes are still expected.
Keywords: nasogastric tube feeding, evidence-based practice
Background:
Nasogastric tube feeding is defined as the delivery of nutrients or medications by a tube inserted from the nasal
cavity, along with the esophagus and finally into the stomach.1 Since conscious disturbance or swallowing
dysfunction is a common condition in patients after neurosurgical operations, mouth feeding is not possible.2
217
And malnutrition contributes to an increase in mortality and enhances the risk of complications or infection.
Good nutrition is vital to the treatment of these postoperative patients. Consequently, nasogastric tube feeding is
frequently used to ensure the nutrition and medication intake.3
Management of nasogastric procedures, starting at the moment of insertion, requires skills and evidence-based
standards.4 Poor management may lead to or aggravate several complications, including pulmonary aspiration
(which could further induce pneumonia and apnea), intolerance of feeding (such as high residual volumes,
regurgitation, vomiting and diarrhea), mechanical blocking, inadvertent respiratory placement and infection.4 The
reported incidence rate of pulmonary aspiration ranges from 1% to 77%, the intolerance of feeding up to 63% and
the mechanical blocking up to 14%4. Lower rates of respiratory placement were reported, 10 cases in two years
in the nearest report.4 The management of the gastric tube feeding is directly associated to patients’ safety and
outcomes.5
To minimise these risks, the safe application of nasogastric tube feeding has been researched in the last 20
years. The researchers together recommend that quality management of nasogastric tube feeding consists of the
following four critical aspects: tube placement (especially the verification of the tube position), tube patency, feeds
administration and prevention of contamination.1,4,5,6 The Joanna Briggs Institute has developed eight criteria for
nasogastric tube feeding from these researchers, which are recommended as best practice.
Nursing management of nasogastric tube feeding was chosen as the topic because it was a frequent and
complicated nursing practice in ICUs. Our current policies for the procedure are based on experiences and expert
opinions. Some of the best practice criteria have not been introduced in our hospital. The program sought to
implement evidence-based practice in our daily care of nasogastric tube feeding. It was a big challenge and
improvement because of the gaps between local policies and evidence-based practice. This report outlines
the process of implementing evidence-based practice in nursing management of nasogastric tube feeding in a
neurosurgical ICU.
Aims:
Specific aims of this project are:
• To improve local practice in nasogastric tube feeding of critically-ill patients in a neurosurgical ICU.
• To promote the compliance with best practice by staff.
Ethical Considerations
This project was conducted in accordance with the principles of clinical audit and quality improvement and did
not require direct interaction with the client group. The tools that were utilised to aid this process included the JBIPACES and GRIP programs.
Methods:
A clinical audit software program of the Joanna Briggs Institute, Practical Application of Clinical Evidence System
(JBI PACES) and Getting Research Into Practice GRIP) were used in the project, which included a baseline audit,
feedback and follow-up audit cycle. The project was implemented over a five-month period, from November 2011
to March 2012.
Setting and sample
Setting
The project was conducted in the Neurosurgical ICU of Huashan Hospital in Shanghai, China. Huashan Hospital is
a teaching hospital affiliated to Fudan University, with a total of 1200 beds. The Neurosurgical Department is the
largest department of Huashan Hospital and plays a leading role in speciality services nationally. It consists of four
wards, one brain trauma centre and one neurosurgical intensive care unit. The Neurosurgical ICU was established
for serving patients after neurosurgical surgery (mainly tumor resection) for initial 24-hour stays (about 15) and the
critically-ill patients before or after neurosurgical surgery (about 14). Most of the critically-ill patients totally rely on
nasogastric tube feeding for unconsciousness or swallowing impairment or artificial airway. There are 29 patient
beds and 54 nurses working in the Neurosurgical ICU. The reason why we chose the Neurosurgical ICU as the
audit setting was the frequent use of nasogastric tube feeding and the risks for serious complications.
Population and amount measurement
Patients: Because one of the criteria refers to the management of the airway cuff pressure, we discussed and
decided to choose patients on nasogatric tubes and tracheal tubes as the target population. All patients in
the Neurosurgical ICU who were on the nasogastric tube and tracheal tube (with or without a ventilator) were
218
enrolled in the audit program. The number of such patients in the Neurosurgical ICU is estimated to be five
to eight per day. The patients are meant to be transferred out of the ICU when their conscious and physical
conditions stablises. The average duration of their stay in the ICU is five days.
Nurses: The 54 nurses working in the Neurosurgical ICU were involved in this project. All of them might provide
nasogastric tube care.
Workload: There are three shifts, with eight hours for each shift. On weekdays, one nurse takes care of two patients
in day shift and six patients in evening shift and night shift. The volume of feeding ranges from 1000 to 3000 ml per
patient per day according to medical orders. The nurses deliver the intermittent feeding every two hours (less than
300ml for each feeding). The intermittent feeding procedure is estimated as 10 times for one patient per day. The
continuous feeding requires the nurses to monitor the equipment every two hours.
Timeframe: The whole project took five months. Both of baseline and follow-up observations took around four
weeks. Weekends were excluded.
Because the management of nasogastric tube feeding is an everyday task, we chose patient-day as a sample unit.
Based on the conditions above, we decided on a timeframe of 150 patient-days for the baseline and follow-up
audits.
Phase 1: Baseline audit
Establishing the team:
An audit team was established at the first week, including three registered nurses and one head nurse in the
Neurosurgical ICU. After introducing the project to team members, we defined the role for each member. I was the
project coordinator, responsible for organising team meetings, staff education and data collection. The head nurse
was responsible for supervising the implementation of practice criteria and improving the compliance. The other
two nurses were responsible for communicating with the nurses and doctors and then giving feedback to them.
Identifying audit criteria
The audit criteria are evidence-based and derived from theJBI-PACES audit program. After getting permission
from nurse managers and discussing the details with the team members, we excluded the criterion of mouth
care as it conflicted with our mouth care plan. We highlighted the main item that needed improvement mostly for
position checking and infection control policies. Subsequently we determined the site-specific requirement and
established the observation standard to demonstrate compliance with each criterion. The details are described
as follows:
Criterion 1: The position of the nasogastric tube is checked at the commencement of each shift along with other
safety checks and when the tube is inserted prior to feeding.
(The criterion about checking the position at the initial insertion was excluded as its compliance had already been
100% because the nurses knew the adverse consequence of misplacing in tracheal and they are highly alert to it.)
• Nurses were required to check the tube position at the commencement of each shift.
• The data collector observed the nurse’s procedure at the beginning of the night-day shift or day-evening shift
once for each patient.
• This criterion was met if the nurses checked the position at the commencement of shifts through at least two
of the following ways:
• air auscultation aspiration of fluid
• visual inspection of the aspirates
• putting the tip of the tube in the water to see if there are bubbles coming out which means the tube is
probably in the tracheal.
Criterion 2: The gastric residual volume (GRV) and the gastric aspirate is assessed at every shift.
• It required tests and recording of the GRV on nursing sheets at every shift.
• The data collector checked if there were three full records of each shift on the nursing sheet for each patient.
• The criterion wass met if there were three records on the sheet; less than three wss considered a ‘no’.
Criterion 3: The patient is nursed in a semi-recumbent position (30° to 45°).
• The bedhead of patients’ beds needed to be elevated above 30° except when there was a contraindication.
• The data collector randomly checked the angle of each patient’s bedhead with a conimeter once a day.
• The criterion was met if the angle was above 30°.
219
Criterion 4: Flushing of the nasogastric tube is conducted before and after feeds.
• The data collector randomly observed the tube on each patient once a day.
• The criterion was met if the tube was clean and was without any feeds in it. (The tubes were transparent and
the criterion could be easily observed.)
Criterion 5: Airway cuff pressure is maintained at 20-25 cm H2O and oropharyngeal suctioning is performed every
shift as clinically needed.
(Suctioning for the patients with tracheal tube occurred far more frequently than at every shift, so the oropharyngeal
suctioning was excluded.)
• Nurses adjusted the cuff pressure at every shift and recorded the data.
• The data collector checked if there were a three full records on the nursing sheet and checked if the cuff is full
by touching it once a day at random times.
• The criterion was met if there were three records of each shift on the sheet and the cuff was full. Less than
three records or the cuff being flat was considered a ’no’.
Criterion 6: Mouth care is performed after every feed.
(This criterion was excluded by the audit team because we had our own mouth care plan.)
Criterion 7: Local infection control policies are adhered to prevent bacterial contamination of feeds and equipments.
(The specific policies about preventing contamination consist of the following aspects:
(1)Proper storage of food: for intermittent feeding, the diet worker delivers food every four hours in the day
time and the nurses administer the tube feeding every two hours. For continuous feeding, a bag of 500ml is
administered less than eight hours according to the product information, and the equipment is changed every day.
Hence this was not an audit item in this project.
(2)Hand hygiene: the nurses wear single-use gloves while feeding and we already have a hand hygiene
improvement plan. Hence it was not an audit item in this project.
(3) Good manipulation of feeding equipment: Compliance for washing of the syringe was very low, and the nurses
changed the syringe when it was obviously dirty or could not be used. Hence this was an audit item.)
• The syringe for each patient was washed after each feeding and changed everyday.
• The data collector checked if the syringe for each patient was clean once a day at random times.
• The criterion was met if the syringe used for administering was clean without any feeds left on it.
Criterion 8: Continuous feeding is used over intermittent feeding except where clinically indicated.
(There are two types of feeds, the fresh formula which is delivered intermittently via the syringe and the commercial
product which is administered continuously by closed equipment).
• The volume of commercial product and the total volume of the feed and of each patient was calculated.
• Compliance was shown as the proportion of the two.
Conducting baseline audit
The baseline audit was conducted in November 2011 to ascertain compliance with the criteria in the neurosurgical
intensive care unit (ICU). A data collecting form was created and assigned to each patient enrolled, in which
the criteria and the standards for ‘yes’ and ‘no’ were clearly listed. We stopped collecting when the sample size
reached 150 patient days. The data was then entered manually into JBI-PACES and the results were represented
in a bar graph. The baseline audit took about four weeks (excluding the weekends).
Phase 2: Joanna Briggs Institute Getting Research into Practice (JBI-GRIP):
The JBI-GRIP phase was conducted over three months, from December 2011 to February 2012. The team met
to discuss the findings of the first audit and identified gaps between local polices and best practice criteria. The
team identified issues that they considered to bebarriers to achieving 100% compliance, and strategies were then
developed and resources utilized.
In December 2011, all the criteria and collected evidence were shown to the nurses through a tailored training held
in a seminar room during the morning shift. A printed handout was handed to each nurse in the ward. A printed
sheet listing the requirements under eachcriteria was put on the message board. The sheet had a a signature list to
keep track of who had read the list. The equipment for measuring the cuff pressure was applied by the department
manager. The team members discussed with the physician about the two criteria that involved their decisions. At
the same time, the team members observed the performance and collected feedback from the nurses.
In January and February 2012, the team members continued to observe performance and collect feedback. A
team meeting was conducted monthly to discuss this. Subsequently, strategies were developed.
220
Phase 3: Follow-up audit
After implementation of the strategies to improve evidence based practice, a follow-up audit was conducted in
March 2012. This was a replication of the baseline audit process. The sample size and the data collecting method
were same to baseline audit.
Results
Baseline audit
The sample size of baseline audit was 150 patient-days. The team observed the criteria randomly once per day
for each patient. The results were transcribed into the JBI-PACES (see Figure 1). The compliance of patients’
semi-recumbent position and tube flushing was relatively high (68% and 87%), because the two criteria had
been a requirement under local policies in our hospital. Tube position checking and infection control are also
local policies. But compliance for the two criteria was lower (43% and 47%) because they may be adhered in
busy working environment. GRV measurement and continuous feeding were not included in thelocal policies, and
involved in the physicians’ decisions, so the compliance was very low (9% and 11%). Measuring the cuff pressure
was completely new criterion for us and there was no unavailable measurement equipment, so the result was 0.
Figure 1: Baseline audit result and criteria legend
Barriers to compliance
The results of baseline audit showed varying compliance of the criteria. The barriers and actions for each criterion
are identified and listed below:
safety checks.
Barrier: The nurses often overlooked the fact that the tube could be displaced by coughing, vomiting or movement.
Action: The danger of tube displacement was emphasised by the head nurse repeatedly at the morning meetings.
Criterion 2: The gastric residual volume (GRV) and the gastric aspirate is assessed at every shift.
Barriers:
(1) Assessing GRV is not a nursing-related activity but a doctor’s decision based on the individual condition.
(2) The nurses were against the criterion because they thought it was unnecessary and complained about the
increased workload.
221
Actions:
(1) The audit team discussed the issues with the doctors. They agreed on their importance, but they did not think
it was necessary for patients who had no gastrointestinal dysfunction.
(2) The team members reminded the doctors to give GRV measurement orders to patients in danger of excessive
GRV or aspiration.
(3) The team added measuring of GRV to the workload record which was matched to the reward.
Barrier: The angle did not meet the criterion because it was checked by eye.
Action: A conimeter is bought in for measuring the angle.
This was performed quite well with a compliance of 87%. Further monitoring was made by the head nurse.
Barriers:
(1) As this criterion involved a new nursing practice, the nurses were apprehensive about its necessity and
complained about the extra workload.
(2) There were no instruments needed for this criterion and they were expensive
Action:
(1) A course was designed to explain the function of preventing aspiration.
(2) A written application was made to the department manager for the purchase of the instrument and this was
subsequently approved.
(3) This procedure was added to the workload record which was matched to the reward.
Barrier: Nurses complained that it was troublesome to wash the syringe in the diet room every two hours.
Actions:
(1) The head nurse the nurses informed about the criterion during the morning meetings.
(2) The head nurse informed the nurses about the policy of washing the syringe after every feed and changing it
at the beginning of the day shift at the morning meetings and a written notice with a signature list was put on the
message board as well.
(3) The head nurse monitored this procedure randomly.
Criterion 8: Continuous feeding is used over intermittent feeding except where clinically indicated
Barriers:
(1) The type of feeds (commercial product for continuous feeding and fresh formula for intermittent feeding) was
decided by the doctors.
(2) The commercial product was much more expensive than the fresh formula.
Action: The audit team discussed with the doctors and gave them suggestions. They chose the mixture of two
types.
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Follow-up audit
The sample size of the follow-up audit was still 150 patient-days and we observed the criteria randomly once per
day for each patient. The results were transcribed into JBI-PACES (see Figure 2).
Figure 2: Follow-up audit results and criteria legend
Compliance for the tube positioning was 43% in the baseline audit. Compliance went up to 76% in the follow-up
audit.
Criterion 2: The gastric residual volume and the gastric aspirate is assessed at every shift.
The compliance in the baseline audit was as low as 9% due to the fact that it was not a nursing-related activity but
a doctor’s medical order. The compliance in the follow-up audit was still low (33%).
This criterion got a relatively high compliance of 68% as it had been a PDCA (Plan Do Check Act) project in the
ward before the project. It did not achieve 100% because the staff checked the angle by eye. In the follow-up audit
compliance went up to 95%.
This is a local policy in our hospital. It has been performed for a long time and can be easily supervised. The
compliance was 87% in baseline audit. There was a slight increase of 6% in follow-up audit.
Suctioning for the patients with tracheal tube is done far more frequently than at every shift, so the oropharyngeal
suctioning was excluded. The compliance was 0% in the baseline audit because measuring cuff pressure was not
part of the local nursing practice and we had no measurement tools. This criterion saw a great improvement from
0 to 79%.
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The main issue with the criterion was the syringe management. Compliance in the baseline audit was 47%, but
increased to 72% in the follow-up audit.
Criterion 8: Continuous feeding is used over intermittent feeding except where clinically indicated.
This criterion was incumbent upon the physician’s decision. 11% of the total feeds was continuously delivered in
the baseline audit. Thiswent up to 52% in the follow-up audit.
Discussion
Nasogastric tube feeding is an ordinary procedure in the ICU. Poor management may lead to serious complications
that may aggravate the patient’ condition, including pulmonary aspiration (further induced pneumonia and apnea),
intolerance of feeding (such as high residual volumes, regurgitation, vomiting and diarrhea), and inadvertent
respiratory placement and infection.4 There are local policies regarding practices in our hospital for a long time,
such as rechecking the position of tube, elevating the patients’ bed, flushing the tube and preventing infection.
These policies are mostly based on experience and experts’ opinions. Compliance to these local policies which
are encompassed in the audit criteria ranged from 43% to 87% in the baseline audit. GRV measurement is not a
routine practice in our hospital and the nurses do it according to a medical order. The cuff pressure management
is a new procedure. The decision for conducting continuous or intermittent feeding is made based on the type of
formula assigned by the doctors. The detail of each criterion is discussed below:
A misplacement of the nasogastric tube into the trachea can induce sudden apnea and bad pneumonia.5 Although
radiography is considered as the gold standard, it cannot be used generally because of the exposure of frequent
radiation, the economic cost and inconvenience.5 Thus, a variety of bedside methods were developed, such as air
auscultation aspiration of fluid, visual inspection of the aspirates, testing the PH of aspirates, altered phonation,
and so on.5,6,7 As none of them is completely reliable and there is no evidence for preference of one over the other,5,
two or more methods together is recommended. Compliance for checking the position after initial insertion is
100% because all the nurses knew the adverse consequences of misplacing the nasogastric tube in the trachea
and they are highly vigilant with this practice. And possible displacements may also be caused by accident pulling,
coughing, vomiting or movement.1,6 The compliance of rechecking the tube position was just 43% because some
of the nurses were unaware of the risks. Thus, the head nurse emphasised the rechecking of tube position in the
morning meeting and monitored the practice. There was an improvement after auditing from 43% to 76%.
Criterion 2: The gastric residual volume and the gastric aspirate is assessed at every shift.
Excessive gastric residual may induce aspiration, thus the measurement of GRV is recommended in acute
care settings.4 The recommended frequency of GVR measurement is every four to eight hours and before each
intermittent feeding as suggested by the experts.1 The compliance in our setting was only 9% in the baseline
audit because assessing GRV is a doctor’s decision based on the individual condition. The audit team discussed
with the doctors about the necessity of GRV measurement. They agreed on its importance, but they did not think
it was necessary for all the patients who might have no gastrointestinal dysfunction. The nurses refused to do
it without a medical order because they thought it was unnecessary and did not want to undertake this extra
workload. Hence compliance was still low after auditing. The improvement from 9% to 33% was attributable to the
audit team members reminding the doctors to give GRV orders to patients in danger of excessive gastric residual
or aspiration, such as patients with a history of gastrointestinal diseases, belly expansion, overt regurgitation
and vomiting. The above indicators of measuring GRV are based on our experience and there is no available
good evidence regarding this. However, the definition of excessive GRV has not been determined and further
studies are needed.4 A multi-centre random control trail showed 500ml of GRV was a safe borderline.8 Despite few
randomised controlled trials being conducted regarding the management of GRV, it has been recommended that
feeding should be withheld if the aspirates exceed 500 ml, and careful bedside assessment of enteral nutrition
delivery is recommended if the aspirate is 200-500 ml4.
The semi-recumbent position of patients and regular assessment of residual gastric volumes has been approved
as effective measures to reduce aspiration when administrating feeds.4 The criterion got a higher compliance of
68% because the 30°-45° position had been a PDCA project in the ward. It is required not just for nasogastric tube
feeding, but also for decreasing the intracranial pressure of patients after neurosurgical surgery and for preventing
ventilator associated pneumonia.9 It has been highly supervised by the managers and physicians. However, the
compliance of the baseline audit did not get 100% because the angles varied and some of us were ‘cheated’ by
our eyes. Hence a conimeter was used and the compliance went up to 95%.
224
This practice was performed well in both the baseline and follow-up audits because it is much easier to flush a
tube than replace a blocked one.
A high cuff pressure (﹥25-35 cmH2O) that exceeds the capillary pressure may cause tissue ischemia and pressure
damage to the trachea while a low cuff pressure (﹤18 cmH2O) can lead the aspiration of secretions to the lungs
which is associated to pneumonia.10 One study suggested that continuous measurement of cuff pressure is more
effective than intermittent monitoring.11 And an evidence summary suggested that cuff pressure should be measured
and adjusted at least once during each shift.12 We had no continuous or intermittent measurement instrument and
no clear requirement on this procedure was stated in local policies. The nurses suspected it was necessity at
first. Therefore, a course was designed to explain its function in preventing aspiration which is directly associated
to pneumonia. It made sense to all staff. The department manager, the nurse manager and the physicians also
approved it as they had been frequently highlighting the prevention of hospital acquired pneumonia and ventilator
associated pneumonia. We received funding support to buy the equipment. The criterion was the most successful
one in terms of compliance because it received the most support. The compliance went up to 79%. It is hope that
over time we will be able to achieve 100% compliance.
Criterion 6: This criterion was excluded because we have our own mouth care plan based on the individual mouth
conditions, implemented usually four times a day.
An exogenous contamination of feeds and equipments may be caused by non-sterile ingredients, poorly designed
systems, faulty handling procedures and manipulation of the tube feeding system.5 The specific local policies on
preventing contamination include food storage, hand hygiene and good manipulation of feeding equipment. The
former two aspects are performed well by the nurses. We chose the management of feeding syringe to illustrate
this criterion. The requirement of washing the syringe after every feeding and changing it at the beginning of the
day shift was informed by the head nurse. A written notice was shown as well. The improvement was mainly
attributable to changes in supervision.
Criteria 8: Continuous feeding is used over intermittent feeding except where clinically indicated
As minimal handling of feed and feed equipment is also recommended to reduce contamination, a closed and
continuous feeding system is preferred to intermittent delivery.6 We have two types of the feeds, the fresh formula
which is delivered intermittently by syringe and the commercial product which is administrated continuously
by closed equipment. The type of liquid is decided by the physicians. The audit team gave suggestion to the
physicians. More and more physicians chose the mixture of the two types. This accounted for the post-audit
compliance of 52%. We could not achieve 100% compliance because the commercial product is much more
expensive than the fresh formula, so that the patients can not totally rely on commercial product.
Conclusion
The project had some successes in improving nursing management of nasogastric tube feeding in the neurosurgical
ICU. Quality monitoring of nursing practice contributed to the increased compliance of rechecking the position
of the tube, elevating the patient’s bed, flushing the tube and preventing infection. Tailored education improved
nurses’ knowledge and attitudes regarding cuff pressure measurement. Active communication with doctors
facilitated GRV measurement and the use of continuous feeding. In all, collaboration, education, quality monitoring
and a reward system were the key factors behind the success of the the project. The results demonstrated the
effectiveness of the strategies used. The compliance of all the criteria was improved, but none met the target of
100%. However further action and changes are still expected. Moreover, the outcomes for patients arising from
best practice could contribute towards future research.
Reporting
The results and outcomes of the project will be disseminated to key stakeholders within the Huashan Hospital via
an in-service presentation. The project findings and impact will be distributed more widely via publications and
possible conference presentations.
225
Table 1: JBI-GRIP implementation
Barriers
Actions
Resources
Outcomes
Conflict with local
standards
Identify gaps between
local standards and best
practice criteria
Information about JBI
Relative literature Best
practice evidence
Get permission of new
criteria
New equipment
Funding support
successful
Meet with the nurse
managers to show them
evidence of best practice
criteria
Exclude the criterion
of mouth care and still
proceed local mouth care
plan
Communicate with the
nurse managers
Cuff pressure measuring
equipment needed
Application for it to the
department manager
Purchased equipment
Training arranged to
Measuring cuff pressure
procedures by nurses that show the evidence of
do not meet best practice measuring cuff pressure
Monitor performance and
collect feedback
Literature on evidence
Training time
Knowledge and
awareness of the criteria
A vacant multimedia room increased among nurses
Increased compliance.
Random monitoring of
performance by the head
nurse
Extra workload
Incorporate a reward
system to the additional
workload
A reward system based
on workload and
performance
Good performance was
rewarded accordingly.
Two criteria that involve
physicians’ decisions
Discussion with the
doctorsFollowing the
doctors during the
morning rounds and
making suggestions;
Literature showing the
evidence
Ssupport and cooperation
from physicians
Getting the involvement
of nurses with adequate
experiences
Increased rate of GRV
measurement
Increased use of
continuous feeding
Acknowledgement
I would like to express my appreciation to the Joanna Briggs Institute for providing us with the opportunity and
support for this Clinical Fellowship.
Thanks to Dr Yifan Xue, our JBI facilitator in this project, for his time, patience, support and guidance.
Thanks to Fudan University for funding the project, especially to Professor Hu Yan for her support and guidance.
Thanks to the Manager of the Neurosurgical Department, Professor Mao Ying, for providing funding to us for
purchasing the instruments.
Thanks to the Manager of the Nursing Department, Jiang Hong, for giving me the opportunity to attend this Clinical
Fellowship and supporting the project.
Many thanks to the audit team members who conducted this project – Shi Weilin, Jin Yufeng, Yang Yu.
I wish to show my appreciation to the nurses in the Neurosurgical ICU for their coordination and hard work, as well
as the physicians for their kind support by accepting our suggestions.
226
Reference
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Singapore: MOH nursing clinical practice guidelines. 2010; page 7.
(2)Zhou Liangfu. Neurosurgery. Fudan University Press. 2001.
(3)Hansson Annette BSN RN, et al. Implementing clinical guidelines for nutrition in a neurosurgical intensive
care unit. Nurs Health Sci. 2005, 7: 266-272.
(4)Teresa A. Williams, et al. A review of the nursing care of enteral feeding tubes in critically ill adults: part I.
Intensive Crit Care Nurs. 2004; 20: 330-343.
(5) Ann-Marie Cannaby, et al. Nursing care of patients with nasogastric feeding tubes. BJN. 2002; 11: 366-372.
(6)Teresa A. Williams, et al. A review of the nursing care of enteral feeding tubes in critically ill adults: part II.
Intensive Crit Care Nurs. 2005; 21: 5-15.
(7)Methods for determining the correct nasogastric tube placement after insertion in adults. Adelaide: Joanna
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