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Increasing Awareness and Consult Rates of Palliative Care for Bone Marrow Transplant (BMT) Patients
No full textBone marrow transplant (BMT) patients often experience complex, high-burden symptoms, including pain, fatigue, and emotional distress, which can significantly impact their quality of life. Palliative care, provided by Supportive Oncology Services (SOS), is specialized medical care that focuses on improving symptom management, enhancing patient and family support, and facilitating goals-of-care discussions alongside curative treatments. Despite its well-documented benefits in oncology, BMT patients receive palliative care at significantly lower rates than those with solid tumors, often due to provider misconceptions that it is only for end-of-life care. Enhancing BMT provider awareness of SOS and its role in comprehensive patient management is essential to ensuring timely and appropriate consults, improving patient outcomes, reducing unnecessary suffering, and fostering better communication between patients, families, and their care teams. Local Problem: Before the intervention, registered nurses (RNs) and advanced practice clinicians (APCs) demonstrated limited awareness and confidence in initiating SOS consults and recognizing patients who could benefit from SOS involvement. Additionally, there was minimal engagement from physicians and challenges in implementing an IT-driven trigger tool further complicated comprehensive screening efforts. Guided by the PDSA cycle and the Johns Hopkins Evidence-Based Practice Model, the project used an iterative process to improve awareness of SOS and increase consults. A pre-and post intervention survey design was utilized to assess changes in RN/APC awareness, confidence, and consult behaviors related to SOS. The study measured outcomes, including the rate of initiating palliative care consults, the confidence in identifying suitable patients for SOS consults, and the overall belief in the benefits of enhanced SOS involvement. Interventions: A structured education session focusing on the role of SOS in managing BMT patients across various stages of disease was developed and delivered to RNs/APCs. Although an IT-driven trigger tool was planned to automate screening and trigger consults, its deployment was delayed due to interdepartmental and IT-related challenges. The education session was designed to empower frontline providers with the knowledge and skills to integrate SOS involvement more effectively into their practice. Post-intervention survey results indicated a 16.4% increase in the RN/APC self-reported initiation of SOS consults, a 19.8% increase in confidence in recognizing patients who might benefit from SOS consults, and a 2.5% increase in the belief that patients would benefit from enhanced SOS involvement. These improvements highlight the positive impact of the educational intervention on RN/APC practices. However, the project faced challenges, including the non-implementation of the IT tool and limited physician engagement, which suggests that further refinement and targeted strategies are necessary to achieve broader implementation. The structured education session enhanced RN/APC awareness and confidence in utilizing SOS services for BMT patient care, leading to measurable improvement in consult behaviors. While the intervention shows promise in improving patient management, addressing IT integration challenges and increasing physician engagement will be critical for sustainable impact and broader applicability. Future initiatives should focus on these areas to optimize provider workflows and extend the benefits of the intervention across diverse clinical settings
Examination of the Diagnosis and Management of Urinary Tract Infections in the Neonatal Intensive Care Unit: A Needs Assessment
No full textUrinary tract infections (UTIs) are one of the most common bacterial infections seen in the neonatal intensive care unit (NICU). Widely used laboratory diagnostic criteria stem from recommendations made by the American Academy of Pediatrics (AAP) in their clinical practice guideline for UTI management in infants and children between two and 24 months of age (2016). This criterion includes the presence of at least 50,000 colony forming units (CFUs) per milliliter of a single uropathogen from the quantitative culture of a properly collected urine specimen in conjunction with pyuria on urinalysis (UA). More recent studies question the use of these standards, particularly in the setting of prematurity, where there may be unmeasurable signs of inflammation at the time of evaluation (Lasry et al., 2024; Shaikh et al., 2024). Despite national guidelines, there is no standardized process for UTI diagnosis for clinicians in two NICUs within an integrated hospital system. As a result, infants in the NICU may be getting over- or under- treated with antibiotics. A needs assessment was conducted to examine the diagnosis and management of UTIs in infants between two and 24 months of age, determine the need for a guideline, and make evidence-based recommendations. Key stakeholders were engaged in planning and designing the needs assessment. A Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was performed to summarize findings and identify barriers to implementation. A SWOT analysis was conducted, summarized, and presented to key stakeholders. Providers were surveyed on practices surrounding UTI management and diagnosis. Patient charts were retrospectively reviewed. Discussions were held with nurses regarding barriers and/or facilitators to the specimen collection process. A self-report survey was sent to 122 providers with a response rate of 29% (N=35). Most providers described themselves as "somewhat confident" (n=17, 48.6%) or "not at all confident" (n=2, 5.7%) regarding UTI management and report lack of clinical practice guideline as a barrier (n=19, 54.3%). Of 214 instances of urine culture collection, 52% (N=110) were treated as a UTI. Of these, 44% (n=48) had pyuria and 16% (n=18) met AAP criteria. Qualitative analysis of feedback from bedside nurses (N=27) identified several themes including confusion regarding interpretation of results (n=10, 37%) and how they change the plan of care (n=7, 26%). Clinicians in the NICU are not using AAP guidance to diagnose UTI and have differing opinions on minimal diagnostic laboratory criteria needed to define UTI. Standardizing the diagnosis of UTI in the NICU would be helpful for clinicians and may result in decreased antibiotic use. It is recommended to follow AAP guidance with the following evidence-based considerations: it may be reasonable to consider UTI diagnosis in the absence of pyuria on UA. For premature infants, it may be reasonable to consider a diagnostic threshold of as low as 10,000 CFUs per milliliter of a single uropathogen on a catheterized urine specimen when other signs, such as pyuria or fever, are also present
Improving the Education Process for Pediatric Patients with Diabetes Prior to their Transition to Adult Care: A Quality Improvement Project
No full textYoung adults with diabetes report that it is difficult to navigate healthcare, and studies show that there is often a delay in the transition from pediatric to adult care. This delay leads to poor patient outcomes, such as increased emergency department visits and hospitalizations. The American Diabetes Association recommends clinics provide transition programs early in adolescence, and support and resources prior to transition. Patients at a pediatric diabetes clinic affiliated with an academic medical center experienced delays in transitioning from pediatric to adult care. The clinic provided transition education that addressed navigating healthcare and encouraged independence, but it was not consistently implemented and standardized amongst staff. Patients, families, and medical staff expressed dissatisfaction with the transition education. A quality improvement (QI) project to improve education for the transition from pediatric to adult diabetes care was conducted at the urban pediatric diabetes clinic associated with an academic medical center in the Intermountain West. Multiple Plan-Do-Study-Act (PDSA) cycles were used for rapid change and improvement of the new education process. A retrospective chart review and brief interviews were used to assess the usability, feasibility, and satisfaction of the education process pre- and post-implementation. A new workflow process was created for the education for transition to adult care. The education material was reviewed, updated, and condensed by the QI team. An education toolkit for transition to adult diabetes care was created that consisted of a workflow chart, education outline, patient checklist, folder with the updated patient education materials, and auto text for charting. The toolkit was piloted by a small group of diabetes educators and then rolled out to all diabetes educators at the main clinic site. The intervention was received by patients 15-18 years old. The small pilot group saw 33 qualifying patients. They documented giving the transition packet 16 times (48.5%), discussing it 19 times (57.6%), specifying which topics they taught 19 times (57.6%), and using the auto text 17 times (51.5%). The clinic site saw 103 qualifying patients and documented giving the transition packet to the patient 70 times (67.9%), discussing transition with them 66 times (64.1%), and specifying which topics they taught 59 times (57.3%). Auto text use increased from 11 times (47.8%) in the first week of full clinic implementation to 17 times (85%) in the last week. Results showed that the new transition process and materials were overall feasible, usable and satisfactory for diabetes educators and adolescent patients. The results also demonstrated that more PDSA cycles may be needed to improve the usability as demonstrated by only 40% of diabetes educators using the transition education auto texts. Because diabetes educators express concern about not having enough time to complete the education, the clinic should consider offering transition-specific education appointments
The Implementation of Fecal Sample Collection Workflow: An Evidence-Based Practice Quality Improvement Project
No full textBackground: Stool sample collection represents a critical diagnostic tool for identifying gastrointestinal: disorders. However, family practice clinics serving refugee communities face unique challenges with incomplete stool samples due to language barriers, varying literacy levels, and cultural differences. These challenges may contribute to delayed diagnoses, repeated visits, and health inequities. At a family practice clinic serving a diverse refugee population, patients were experiencing difficulties completing stool collections due to inadequate multilingual instructions, while staff lacked standardized workflow protocols. This quality improvement project addressed these challenges by implementing standardized processes and developing culturally appropriate patient education materials. Methods: This three-month evidence-based quality improvement project utilized the Johns Hopkins Nursing Evidence-Based Practice Model and Plan-Do-Study-Act cycles. Interventions included (1) developing a standardized workflow protocol for clinic staff through comprehensive training sessions and quick reference materials; (2) creating simplified, multilingual patient education materials in English, Spanish, and Arabic; and (3) producing a wordless instructional video accessible via QR code to overcome language and literacy barriers. Pre- and postimplementation surveys (N=17, N=14) measured staff knowledge and confidence regarding stool collection procedures. Qualitative data analysis identified key themes in staff feedback. Chart reviews assessed specimen completion rates before (N=7) and after (N=11) implementation. Results: Statistically significant improvements were observed in staff confidence across all communication contexts (p<0.05), particularly with non-English speaking patients (W=165, p=0.048) and those with low literacy (W=167, p=0.043). Knowledge of test-specific requirements improved, with the greatest gains in FOBT sample requirements (23.53% to 64.29%, p=0.021). Staff reported high satisfaction with the new process (92.86%), particularly valuing quick reference materials and visual aids. Qualitative feedback revealed that visual aids and clear, simplified instructions were most beneficial for patient education. Ova and parasite specimen completion rates increased from 42.86% to 54.55% for one or more specimens, with full three-specimen completion rates rising substantially from 14.29% to 36.36%. The instructional video was viewed 39 times during the implementation period. Conclusions: This quality improvement initiative demonstrated that addressing social determinants of health through tailored educational approaches can significantly improve diagnostic testing compliance in diverse patient populations. The comprehensive approach of standardizing workflows while enhancing patient education materials effectively overcame language and literacy barriers. The statistically significant improvements in staff confidence across communication contexts and increased specimen completion rates suggest that the dual focus on staff training and patient education materials can successfully reduce health inequities in diagnostic testing. These findings highlight the importance of culturally sensitive, accessible healthcare communication in promoting equitable healthcare delivery. Future investigations should explore additional barriers beyond knowledge deficits and evaluate the economic impact of enhanced educational materials versus reduced repeated testing in diverse healthcare settings
Streamlining Obstetric Emergency Admissions: A Quality Improvement Initiative for Pregnancy-Induced Hypertension Protocol Implementation
No full textHypertension in pregnancy (PIH) is a complex medical condition that significantly increases the risk of maternal and fetal mortality and morbidity. Early recognition and intervention are essential to avoid poor outcomes. Without appropriate treatment, hypertensive patients are at heightened risk for cardiovascular events, organ failure, stroke, and death. Medical providers must be proficient in early detection, appropriate intervention, and evidence-based delivery planning to avoid these adverse events. A prominent academic hospital in the Salt Lake Valley, serving a diverse population that includes urban, rural, and high-risk pregnancies, lacked a standardized admission protocol for PIH patients. The obstetric-based emergency department followed a first-come, first-served admission system, which introduced variability in patient triage and opened opportunities for inconsistent care. The perceived barriers to effective care were primarily attributed to insufficient education and training for medical assistants (MAs) and hospital unit coordinators (HUACs), contributing to the inefficient management of high-risk patients. A Quality Improvement initiative aimed to develop and implement a pregnancy-induced hypertension triage and standardized workflow in the obstetric-based emergency department (OBED) unit and assess the feasibility, usability, and satisfaction of the workflow changes. Interventions: Key stakeholders were identified from a multidisciplinary staff team, including APRNs, RNs, MAs, and HUACs. The initial phase of the QI project began with a review of the unit\u27s current practices, and an in-depth literature review was conducted. Recommendations from current governing bodies of obstetrics medicine guided the creation of the PIH admission protocol, flowsheet, and intake form. Role-specific education sessions were provided. A PDSA model guided rapid cycle changes throughout the initiative. Of the 145 staff members, 42 (29%) completed the pre-intervention surveys. Nine hundred eighty total patients were admitted to the unit during the project, with 152 patients presenting with a chief complaint of hypertension (15.5%), and 55 (36%) were evaluated using the PIH intake form. Priority of patients was assigned 9% of the time (n=5 out of the 55 forms). However, PIH-specific questions were used 100% of the time (n=55). Fewer staff completed the post-intervention survey (n=15). Most staff reported being very satisfied with the protocol (n=10, 67%). The OBED multi-disciplinary unit demonstrated satisfaction with a hypertension-specific admission protocol and expressed interest in its continued use. The pre-intervention survey highlighted the need for further education and training, particularly for MAs. The lack of MA participation was present in the survey responses and in-patient surveys. The post-intervention survey showed a strong interest in future utilization, indicating long-term clinical use potential. In the future, long-term standardization of admission protocols could improve staff satisfaction with work responsibilities
Improving Clinician Satisfaction Through Improved Care Coordination for New American and Patients with Low English Proficiency Populations at an Urgent Care Clinic: A Quality Improvement Project
No full textLanguage concordance significantly impacts the continuity of care for new Americans and patients with low English proficiency (LEP) by affecting health literacy, patient education, and healthcare system navigation. These populations frequently use emergency departments (EDs) or urgent care (UC) facilities inappropriately due to healthcare system unfamiliarity and appointment scheduling challenges. Utah hosts over 85,000 refugees, with approximately 75% (n = 63,750) served by a large academic healthcare institution in Utah, yet only 10% (n = 6,000) are registered as established patients. Since 2019, daily patient volume at the affected clinic has doubled from approximately 50 to more than 100 patients, creating an urgent need for more efficient processes to improve continuity of care. This project aimed to increase successful primary care follow-up appointments for new Americans and LEP patients following UC visits. We used the Johns Hopkins Evidence-Based Practice Model and the Plan-Do-Study-Act (PDSA) framework, to conduct a 12-week mixed-methods analysis of clinic staff. Data collection assessed the frequency of interactions with target populations, primary care referral needs, common presentations requiring referral, and perceived barriers to successful follow-up. Weekly site visits and meetings with content experts facilitated rapid-cycle changes. Pre- and post-intervention surveys measured usability, feasibility, and satisfaction, and gathered recommendations for future applications. We implemented a new standard practice flowchart at the affected clinic, where UC providers identified patients requiring primary care providers, while nurses, medical assistants, and patient registration staff facilitated immediate appointment scheduling before discharge. Of 213 clinicians invited, 30 completed the pre-intervention survey, and 13 completed the post-intervention survey. Primary referral reasons included hypertension (20.3%) and type 2 diabetes mellitus (15.9%). Most participants rated the intervention as very usable (53.8%), very feasible (61.5%), and very sustainable (53.8%). Financial analysis revealed annual implementation costs of approximately 42,834 to 156,000 annually. Further evaluation is needed to assess the intervention\u27s effectiveness in reducing the ‘no-show\u27 rate and identify underlying barriers to workflow adherence to optimize implementation
Improving Nutritional Screening and Education in an Outpatient Mental Health Clinic: A Quality Improvement Project
No full textNutrition plays a crucial role in mental health, yet nutritional screening and education are often underutilized in outpatient mental health settings. Poor nutrition is associated with worsened psychiatric symptoms, while improved dietary habits can enhance overall mental well-being. Clinicians frequently face barriers to integrating nutritional guidance into patient care, including limited knowledge, time constraints, and a lack of standardized tools and resources. An outpatient mental health clinic in suburban Utah lacked a structured protocol for assessing and addressing patients\u27 nutritional health. Clinicians expressed interest in integrating nutritional healthcare into their mental health practice but named several barriers, including limited education in nutrition, uncertainty about proper recommendations, and a lack of accessible resources. This Doctor of Nursing Practice (DNP) quality improvement project sought to implement and evaluate a nutritional screening and education toolkit designed to support clinicians in routinely addressing patients\u27 nutritional needs as an essential part of comprehensive mental healthcare. By integrating evidence-based resources into clinical practice, the project aimed to enhance the quality of care and promote better health outcomes for individuals receiving mental health services. The project lead implemented a quality improvement initiative using the Johns Hopkins Evidence-Based Practice model and Plan-Do-Study-Act (PDSA) cycles. A pre-implementation survey assessed clinicians\u27 knowledge, attitudes, and barriers to nutritional interventions. The project lead then integrated a nutritional toolkit-including a screening tool, a QR-accessible patient education document, and a listing of local registered dietitians-into the electronic health record (EHR). A post-intervention survey evaluated the feasibility and usability of the toolkit, as well as clinician satisfaction with the new workflow. This iterative process allowed for ongoing evaluation and refinement of the intervention to optimize its integration into clinical practice. Interventions: The project followed four phases: (1) conducting a pre-implementation survey and engaging stakeholders, (2) developing and integrating the nutritional toolkit, (3) refining the toolkit through iterative PDSA cycles, and (4) evaluating outcomes post-implementation. Clinicians received education during monthly staff meetings and through email updates. The toolkit emphasized practicality, requiring minimal additional appointment time while encouraging patient engagement with nutrition-related resources. Of the 18 clinicians and staff at the clinic, 89% (n = 16) completed the pre-survey and 75% (n = 12) completed the post-survey. The pre-implementation survey showed that 90% (n = 14) of respondents recognized the impact of nutrition on mental health, yet only 46% (n = 6) frequently recommended nutritional changes to patients. Following the intervention, 56% of clinicians reported using the nutritional screening tool at least some of the time. Similarly, 56% discussed nutrition education materials with clients occasionally, 22% did so rarely, and 11% always engaged in this practice. Feasibility ratings were high, with 83% of respondents finding the screening tool somewhat to very feasible. All participants rated the toolkit\u27s usability as fair to excellent, and 75% agreed that the intervention was acceptable. Clinicians in the outpatient mental health clinic found the nutritional screening and education toolkit to be feasible, acceptable, and usable. The intervention increased clinician confidence and engagement in addressing nutrition as part of holistic mental health care. These findings suggest similar strategies could be implemented in other outpatient settings to promote interdisciplinary collaboration and improve patient outcomes. Future projects should identify the long-term effects, address ongoing barriers, and evaluate the toolkit\u27s effectiveness across diverse clinical environments
Infantile nystagmus syndrome with latent nystagmus
No full textThis patient developed infantile nystagmus in early infancy due to retinopathy of prematurity. In addition to a continuous torsional pendular nystagmus, latent nystagmus was apparent with either eye covered (e.g., right-beating with right eye viewing and left-beating with left eye viewing) and was associated with esotropia. Mixed pendular and jerk waveforms are common in infantile nystagmus, oscillopsia was absent, and all classes of eye movements (e.g., saccades, pursuit, vestibulo-ocular reflex, etc) were normal. While infantile nystagmus is usually predominantly horizontal, torsional and/or vertical vectors can be seen depending on the etiology and other factors. This patient\u27s nystagmus was well documented and unchanged over several decades
Oral history interview with Jorge Fierro, conducted by Marylinda Gonzalez (video)
No full textJorge Fierro discusses his childhood growing up in Mexico and his family. Fierro is an entrepreneur and owner of Rico Brands, which distributes ready to eat Mexican food for supermarkets. He mentions that he was considered the "black sheep" of his family because his life did not revolve around Catholic traditions. Fierro talks about his struggles going to school and learning later in life that he had a learning disability. He moved to America after deciding to quit his schooling, and started doing manual labor and worked as a sheep herder in Wyoming. Fierro talks about his determination to become successful and learn English. He was homeless for a time in Salt Lake City and was aided by programs at the Rescue Mission in 1985. Fierro details his philosophy of developing natural food products with no preservatives, and his approach to building his company and developing it over time. He discusses his feelings about the benefits of immigration, and immigrants being able to build opportunities for themselves and other people
