"Don't Drop the Baton: Transitioning Change of Shift Report to the Bedside"
Ngozi Akubuilo, Salve Arriola, Erin Castle, Nickey Gregorio, Tammy Huang, Schana Kim, Tina Morrison,
and Agnes Tan
Over a year ago, our practice involved exchanging handoff report at the nurses’ station, reviewing the chart,
and performing walking rounds with the oncoming nurse and patients. We pursued a way to increase patient
satisfaction scores and communication with patients, families, and caregivers. In October- December 2011, our
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores for communication with
nurses were 53.1%. This includes three specific questions: “Did nurses treat you with courtesy and respect?”,
“How well did nurses listen to you?”, and “How often did nurses explain things in a way you can understand?”
We asked the question: “Will bedside report improve patient safety, patient satisfaction, accuracy of patient
status, and nurse accountability?”
The 5NW Geriatrics Unit Practice Council (UPC) decided to implement bedside report to ensure patient
safety, enhance professional care, improve nurse accountability, and increase communication between nurses
and patients, families, and caregivers.
Research supports bedside report implementation being linked to positive results. For example, Anderson &
Mangino (2006)1 highlight that bedside report contributes to reducing patient anxiety, increasing patient
collaboration with nursing staff regarding plan of care, and increasing nurse accountability. In addition,
Chaboyer, McMurray, Johnson, et al (2009)2 discuss improvement of patient safety by both nurses performing
an environmental check.
We collaborated with the intermediate care unit at Santa Monica and 7West at Ronald Reagan to form an
action plan. The first step to kick off bedside report was a survey sent to nurses via E-mail prior to
implementation. Then, we educated staff members in January and February through huddle messages; one on
one education to staff members by UPC members, our unit director, and unit CNS; E-mails of articles on bedside
report; and a YouTube video created by 7west Ronald Reagan demonstrating bedside report. Next, we
implemented bedside report on February 27th 2012 at 0700 shift change. UPC members and unit administration
were available during each change of shift for the first two weeks as resources and observers. This was a smooth
transition and feedback from staff was conducted through personal conversations and a survey. We also
rounded with CCPs an hour before change of shift to maintain a smooth transition, educate patient about
report, and address their needs for toileting, placement of items, fall prevention, pain control, position changes,
and IV pump maintenance (6Ps). Our goal was also to reduce the amount of call lights going off at change of
shift and increase patient safety by checking the 6Ps during report. Unit administrators and UPC members
observed each staff member and completed a competency a month later to give real time feedback.
After bedside report implementation, our HCAHPS scores for nurse communication in April-June 2012
increased to 67.5% from 53.1%. UPC sent a follow up nurse survey after three months, which displays that
nurses perceive an improvement in patient safety, increased accountability, decreased unmet needs at change
of shift, decreased anxiety from nurses and patients, and decreased amount of missed information from report.
We believe the improvement of our HCAHPS scores and nurse survey results depict that bedside report is
effective in enhancing patients’ health care, staff team building, and patient safety. We will continue practicing
bedside report despite any challenges we encounter, which we will improve based on staff and patient
feedback. This year, we observed each staff member again and completed the competency for sustainability.
Our goal is to have 100% of staff giving report at the bedside and performing thorough environmental checks.
We plan on adapting bedside report to CareConnect by staff education and cheat sheets on each computer
listing the screens to review for chart checks and patient care. We also have an open space on our UPC board in
the staff lounge for staff to write issues and suggestions. Our vision is to provide patient safety; develop efficient
communication; and enrich nurse, patient, family, and caregiver communication to deliver high quality care. We
continue to cultivate ways to connect with patients and make their hospital stay a positive one.
1. Anderson, C., & Mangino, R. (2006). Nurse Shift Report: Who says you can’t talk in front of the patient? Nursing Administration
Quarterly, 30 (2), 112-122.
2. Chaboyer, W., McMurray, A., Johnson, J., et al. (2009). Bedside Handover: Quality Improvement Strategy to “Transform Care at the
Bedside.” Journal of Nursing Care Quality, 24 (2), 136-14
New Grad Retention in SM-UCLA Critical Care Unit
By
Somyah Ibrahim, RN, PCCN; Imelda Zaragoza, RN CCRN; Margarete Moore, RN
Problem Statement: Currently, the new graduate retention rate in the critical care unit at Santa Monica
UCLA and Orthopeadic Hospital has consecutively been 30 to 50% over the past 5 classes.
Innovative Plan: The goal is to improve the new grad retention rate to 75% or greater, by implementing
a project called Preceptor Champions.
Action: Preceptor Champions is a taskforce of experienced RNs in the critical care unit at SM-UCLA who
have at least three years precepting experience who aim to work with the unit management team,
preceptors, and new grads to improve the retention rate. The action plan consists of five steps.
1. Preceptors were recruited on a volunteer basis
2. All preceptors completed the preceptor development course offered at UCLA
3. Preceptor champions provided additional hands on clinical support for both preceptors and
new grads
4. Pre and post surveys given to preceptors and new grads to assess their knowledge and
expectations prior to implementation
5. Development of a communication tool to monitor the progress of the new grad and assess for
areas of improvement
Change Achieved: Our most recent new grad class has a retention rate of 75%
Implications: Increased nursing retention can improve the quality of care, cohesiveness within the unit,
and improve nursing satisfaction overall. Additionally, monatary benefits exist for the institution as the
data shows estimated costs of 100,000 dollars or more to train one new grad RN.
Looking toward the future:
Implementing tools and simulation teaching labs shown effective at other institutions noted in some of
the research on this topic. Continued preceptor training facilitated by preceptor champions.
Mentorship of new grads for the next three monthsby either their assigned preceptor or preceptor
champion.
Child Maltreatment Victim’s Attitudes about Appearing in Dependency and Criminal Courts
Diane Oran MN, RN, PMHCNS-BC, PMHNP-BC, Sue. D Hobbs, MA, Gail Goodman, Ph.D.
Stephanie D Block, Ph.D Jodi A. Quas, Avery Park, Keith Widamen, Nikki Baumrind Ph.D,
Problem Statement/ Purpose
The purpose of the study was to investigate children’s attitudes after appearing in dependency court compared to
criminal court in child maltreatment cases. Several hypotheses were advanced: 1) Testifying in criminal court will
be associated with more negativity about seeing the defendant in the courtroom relative to testifying in dependency
court. Being older, female, or a minority, having experienced longer or more severe abuse and having parents as
defendants will be associated with greater negativity about seeing the defendant in the courtroom for both
dependency and criminal cases; 2) Answering questions in criminal court will be associated with more negativity
relative to answering questions in dependency court, being older, female, or a minority, having experienced longer
or more severe abuse, and having parents as defendants will be associated with greater negativity about answering
questions in the courtroom for both dependency and criminal cases; 3) Answering defense attorney questions in
criminal court will be associated with more negativity relative to answering defense attorney questions in
dependency court. Being older, female, or a minority having experienced longer or more severe abuse, and having
parents as defendants will be associated with greater negativity toward the defense attorney for both dependency and
criminal cases.
Background
Each year, millions of children are involved in legal actions, including in criminal and dependency courts. There is
a growing movement to increase children’s participation in court proceedings. Article 12 of the United Nations
Convention on the Rights of the Child explicitly states “The child has a right to be heard in any judicial and
administrative hearing affecting the child.” Yet debate continues as to whether children should participate in their
court hearings.
Methods: design, sample, procedure
Participants
Dependency court. For the dependency court sample, 85 children ages 7 to 10 were recruited over a period of 1.5
years as they awaited their court hearings.
Criminal court. The criminal court sample (n=52) was a subset of children (N=218) who participated in Goodman
et al. (1992) research. The 52 children were selected for the current study because they testified in their court cases.
The children ranged in age from 4-16 years.
Procedure
Because the children from the dependency court sample were deemed wards of the court, consent to participate
was obtained from the presiding judge of the Juvenile Court. A children’s assistant from the Child Advocates Office
approached each child before the court appearance and asked “There is someone from UCLA who would like to ask
you some questions and play some games to find out what children think about coming to court. Would you be
interested in talking with them?” If the child assented, they were introduced to one of the two interviewers (a child
psychiatric nurse or a psychology Ph.D student) Participants for the criminal court sample were solicited though the
district attorney’s office. Victim advocates mentioned the study during their routine calls to families. The
researchers then contacted interested families and obtained informed consent from the child’s primary
(nonoffending) caretaker). Assent was later obtained from the child. Most of the children were from low
socioeconomic status backgrounds. Additional information, such as type, severity, and duration of alleged abuse,
along with child and defendant demographic factors, was obtained from court files.
Instrument and analysis
Measures
Children’s Court Questionnaire (CCQ; Oran, 1990). For the dependency court sample, a structured interview
was created to assess children’s attitudes, and perceived legal participation. It was developed by a panel of court
experts. After-Court Questionnaire (Goodman et. al., 1992). For the criminal court sample, the After-Court
Questionnaire was used to assess children’s feelings about experiences in the courtroom. It contained open-ended
questions to be answered verbally and with a series of “faces” scales that were adaptations of Andrews and Withey
(1976) happiness scale. Demographic and case information forms. Demographic and case information
questionnaires were constructed to gather specific demographic and case information from each child’s confidential
court file. From these files, information, such as child age, child gender, main abuse type (in dependency court),
victim-defendant relationship, abuse duration, abuse severity, and number of previous times the child appeared at
the courthouse, was derived.
Analysis
Our analysis plan relied primarily on multiple linear regression. The dependent variables (i.e feelings about
answering questions in court, feelings about answering questions asked by the defense attorney, and feelings abou
seeing the defendants in the courtroom) were separately regressed on abuse factors (i.e duration of abuse and
severity of abuse) in the first models. Then in subsequent models, child factors (i.e. number of court appearances,
defendant relationship to victim [parent or nonparent], victim age [mean centered], victim gender, victim minority
status, and the three type of court/type of abuse dummy variables with criminal court/sexual abuse as the reference
were added.
Results
Regression analysis indicated that our predictions were partially confirmed. Sexually abuse children in criminal
court system, b =2.80 (SE=0.45), p <.001, and female children, b = 0.90, (SE=0.27) , p =.001, β =.25, conveyed
the most negativity about seeing defendants in the courtroom, whereas the most positivity about seeing defendants in
the courtroom was expressed by physically abused children in the dependency court system, b =2.32 (SE=0.50),
p<.001, β =.54. Severity of abuse was negatively related to how children felt about answering questions in the
courtroom, b = -.50, (SE=0.20) p =.01, β =-.25. There were no significant predictors pertaining to children’s
feelings about answering questions posed by the defense attorney. A meditational analysis was conducted to
determine if relationship to perpetrator mediated the effect of child-sexual-abuse criminal-court involvement on
attitudes toward seeing the defendant in the court. However, relationship to perpetrator did not mediate the effect.
Discussion
The results suggest that specific factors, such as type of court and severity of abuse, play a role in how children feel
about their court experiences in court. It is therefore imperative to evaluate children’s reactions to legal proceedings
separately for each type of court and for various types of abuse.
Implications for Practice
Every nurse who works with children has the potential of trying to meet the needs of an abused or neglected child.
Unfortunately abused and neglected children are seen in every setting: outpatient, inpatient, the emergency room,
the ICU, medical floors and in psychiatric facilities. Understanding the impact of proceedings for children has
important implications for procedural justice and for nurses to help in the development of and implementation of
preparation and support programs to better assist children who must interact with our court systems. Understanding
the factors related to adverse or positive attitudes for child victims will help nurses to empower children to be a part
of decisions that affect their lives and also protect them from further trauma and victimization from lega l
proceedings and to promote child wellbeing.
IMPROVING TURNAROUND TIME FOR THE FIRST-DOSE OF AN ANTIBIOTIC IN
THE NICU
By C. Cheng RN, CCRN, D. Dolliole RN, MSN, CCRN, B. Heliker RNC, MN, CNS, A.
Kaur RN, T. Kuge RN, G. Manlapaz RN, L. Miyamoto RN
Clinical issue: There is a wide variation in timing of when NICU patients receive the first-dose
of an antibiotic.
Evidence: Studies show that patient outcomes are improved and hospital stays are shortened
when the first-dose of an antibiotic is administered within one hour of order/admission time.
Question: Will the introduction of a collaboration process between multidisciplinary healthcare
team members decrease turnaround time for the first-dose of an antibiotic?
Interventions: After a retrospective chart review, a step-by-step flowchart with prospective
interventions was created, outlining a process to decrease turnaround time. Doctors/NNPs wrote
“first-dose stat” on orders. Administrative care partners/nurses followed-up with pharmacy to
inform and confirm order receipt. A team member retrieved medication from pharmacy. All
members were educated on respective responsibilities.
Outcomes: The percentage of patients receiving the first-dose of an antibiotic within one hour
will be examined. Descriptive statistics will be used to describe the time lapse before
administration.
Results: Patients receiving their first-dose of an antibiotic within an hour increased from 6% to
53% after implementation. The median time between order/admission and administration
decreased from 3-4 hours to less than 1 hour. Of the 15 orders with “first-dose stat” written on
them, 11 were given within 1 hour with an average time of 54 minutes.
Conclusions: Improving awareness of the importance of administering a first-dose antibiotic
within an hour is positively correlated with decreasing administration lag time. Bedside nurses
are able to shorten turnaround time between order/admission and administration by being
proactive about obtaining the first dose. Implementing a flowchart process for the NICU staff to
follow, with emphasis on writing “first-dose stat”, significantly improves the likelihood that a
patient will receive their first-dose antibiotic in a timely manner.
Improving Clinical Quality with the Use of a Mandatory Computerized Ordering Tool (MCOT) for the Prevention
of Premature Peripherally Inserted Central Catheter (PICC) Removals
Sue-Kim-Saechao, RN, MSN, NP, Earl Almario, RN, BSN
Problem Statement:
therapy.
At UCLA, an estimated 20% of PICCs are removed prematurely prior to completion of
Background: Possibly due to increased vigilance for BSIs, PICCs are being removed prematurely for
complications unrelated to systemic infection such as mechanical phlebitis, local cellulitis, catheter malpositions,
and fever, without removal assessment by the PICC team.
The literature provides strong evidence-based initiatives for: 1) the use of a specialized team for the maintenance
of intravascular catheters and educational needs; 2) an interdisciplinary, collaborative approach; and 3) early
communication to decrease complications and prevent premature removal of PICCs.
Methods:
Design: Historical cohort study (12-months separating data collected from Cohort 1 and Cohort 2).
IRB approved SM-UCLA pilot 09/22/12. Study started 09/26/2012. Sample size: 200/group for a 50% decrease
from 20% to 10% in premature PICC removals with a type 1 error of 0.05 and 80% power. Procedure: 1)
Retrospective data collection for the first cohort of 200 consecutive PICCs inserted in SM-UCLA adult inpatients in
2011. 2) Post-intervention data collection for 200 consecutive PICCs inserted in SM-UCLA adult inpatients starting
09/26/12, although the intervention was provided to all SM-UCLA adult in-patients.
Instruments: Early communication and specialty evaluation utilizing a mandatory computerized ordering tool
(Forms Portal PICC Referrals) and daily paging for all UCLA PICCs.
Analysis:
Chi square testing for desired outcomes including a 50% decrease in premature PICC removal
rates and 25% decrease in complications and costs from baseline.
Results:
84% reduction in premature PICC removal rates, zero provider led removals && zero central-line
associated blood stream infection (CLABSI). A 25% reduction in complications and 34% reduction in radiology
costs with greater cost implications.
Discussion:
In a pilot study at SM-UCLA, early communication and specialty evaluation utilizing a mandatory
computerized ordering tool (MCOT) statistically decreased premature PICC removals, as well as associated
complications and costs.
Implications for practice:
Early communication and specialty evaluation utilizing a MCOT may help decrease
complications and costs for all specialty catheters throughout the UCLA Health System. MCOT also meets
Electronic Health Record ‘meaningful use’ objectives.
A3: Reducing Lab Errors in the ICUs
Authors: Maureen Keckeisen, Sarah Lloyd-Kolkin, Liza Galicia-Canete, Deanna Felix, Terry Siegel, Annie
Whitworth, Nadine Neri, Rosalie Garcia, Leslie Denogean, Charlene Earnhardt, Shannon McCarville
Problem Statement: The ICUs have an overall laboratory error rate of 24.5 mislabeled, unlabeled, and
specimen/requisition mismatches per month.
Current State: Procedures for specimen collection and labeling vary for each ICU unit because there is
no standardized specimen collection/labeling procedures.
Goals and Metrics:
1. Reduce frequency of requisition/specimen mismatches (average error is 14.2/month and target is
7.1 within 1 month, 0 within 3 months)
2. Reduce frequency of unlabeled specimen (average error is 8.3/month and target is 4.15 within 1
month, 0 within 3 months)
3. Reduce frequency of mislabeled specimen (average error is 0.3/month and target is .15 within 1
month, 0 within 3 months)
Analysis of Current State: After a 5Y root cause analysis, the following 4 root causes were identified:
1) Difficult for staff to find name quickly on requisition, 2) RN may use labels that are left in room after
patient is transferred or discharged, 3) No established process for ACP/RN to verify requisition is
matched to the correct patient, and 4) Staff are frequently multi-tasking
Potential Solutions: The workgroup brainstormed several solutions, including:
 Highlight name and MRN # on requisition
 Develop instructions (checklist) on clearing PHI from rooms
 Read back requisition and confirm name and test
 RN legibly prints first initial and last name on each requisition
 Re-educate RNs on critical points of policy HS1328 to RNs and do one-on-one education
 Use consistent progressive discipline
 Implement "Right Blood, Right Name. One Patient at a Time" Campaign
Action Plan: The workgroup implemented the following solutions via “class in the box” education:
 Remove Old PHI
 Highlight Name
 Read Back Requisition
 Remember Policy
 Legibly Print First Initial, Last Name on Requisition
 Slow Down! Campaign
Next Steps and Results:
 Complete pilot testing
 Send out weekly lab error reports to unit leadership
 Complete revised lab error self-assessment, when necessary
 Report out to Quality Outcomes Council and HOT Meeting
 Monitor results (currently: 85% decrease in errors after first month of implementation)