Implications For Nurses Research Articles

Aromatherapy to The Rescue for Postoperative Nausea and Vomiting

<h3>Introduction</h3> Post- operative nausea and vomiting (PONV) occurs in in approximately 30 to 37 % of patients. It is one of the most common complaints after surgery. A modality of pre-and post- operative antiemetics are routinely used, however PONV persists. The literature indicates that patients have reported significantly lower levels of PONV with aromatherapy. Inhaled aromatherapy that consists of a blend of essential oils such as spearmint, peppermint, lavender and ginger have been shown to decrease and eliminate PONV. Aromatherapy can be initiated as a nursing measure immediately upon patient complaint of symptoms. The patients can be instructed to self-administer the product upon discharge. <h3>Identification of the problem</h3> PONV can lead to delays in discharge, increased healthcare cost, undue stress, pain and discomfort at the surgical site, and electrolyte imbalance. All these lead to patient dissatisfaction with the surgical experience. <h3>EBP Question/Purpose</h3> For the adult ambulatory surgery patient, is the use of an inhaled aromatherapy product effective for the relief of PONV in the Phase I and Phase II PACU setting prior to discharge? Data bases utilized for the project include, PubMed, Ovid and CINAHL. <h3>Methods/Evidence</h3> Patients were assessed for risk factors of PONV in the pre-operative area and received preliminary education regarding use of the product. The aromatherapy was used as a first line defense against PONV. Patients were not denied refusal or use of standard antiemetics. Nurses assessed the effectiveness of the product prior to patient discharge by completing the data collection sheet. Follow up phone calls inquired about the use of the product at home as well as overall satisfaction. <h3>Significance of Findings/Outcomes</h3> 38 patients used the product, with 81% reporting improved or total relief of PONV. A total of 47.4% had total relief. Only 7.89% stated they had minor or no relief. Nurses expressed 100% satisfaction with ease and use. <h3>Implications for perianesthesia nurses and future research</h3> Use of aromatherapy provides the perianesthesia nurse with greater autonomy and satisfaction. The use of aromatherapy can only increase the patient's overall satisfaction. Further research can be done by comparing actual length of stays for patients with and without the use of aromatherapy.

Enhancing the Use of Opioid Sparing Protocol in the PACU

<h3>Introduction</h3> Opioids serve as the cornerstone for severe acute post-operative pain management in the PACU. Opioids have been used for their quick onset and efficacy without analgesic ceiling yet have significant side effects. The Opioid Sparing Protocol was developed to provide pain relief to post knee and hip arthroplasty while minimizing narcotics and allowing rapid rehabilitation and faster discharge. <h3>Identification of the problem</h3> Acute post-operative pain remains a major problem, resulting in the multiple undesirable outcomes if inadequately controlled. In the PACU setting, opioid use is common as the primary treatment for post-operative pain. <h3>Purpose of the study</h3> The purpose of the study is to assess the impact of the Opioid Sparing Protocol on opioid-naive patients in the PACU post knee and hip arthroplasty. <h3>Methods</h3> Retrospective analysis by chart review of 200 comparable cases, from each period, for implementation of the Opioid Sparing Protocol pre-intervention (Q2, 2018) and post-intervention (Q2, 2019). <h3>Outcomes/Results</h3> Significant increase in the use of Tramadol (+242.86%), along with reduction in the use of Percocet (-44.44%) and Oxycodone (-56.52%) have shown to be effective in providing analgesia and improved patient outcomes. <h3>Discussion</h3> There is an ongoing effort to develop strategies for safe and effective alleviation of post-operative pain. This analysis of comparable cases shows that changes in pain management methodologies can lead to positive results for the patient's surgical experience and post-operative clinical outcome. <h3>Conclusion</h3> Utilizing the multimodal approach outlined in the Opioid Sparing Protocol provides consistent pain relief while reducing opioid requirements and opioid related events. Effective management of acute pain in the PACU results in reduced PACU length of stay and improved patient outcomes. <h3>Implications for perianesthesia nurses and future research</h3> As health care professionals, it is our responsibility to provide safe and effective pain management. Considering the heavy societal cost of the opioid crisis, enhanced pain management addresses opioid misuse. The challenge for the healthcare workforce is to develop new, effective and non-addictive approaches to pain management.

Discharge Instructions - Who, What, When and Where: The Development of a Discharge Liaison Role to Improve the Patient Experience and Discharge Planning Process Post-operatively

<h3>Introduction</h3> Ambulatory Surgery Patient Experience Scores related to post-operative discharge instructions for FY19 were at the 38^th percentile, well below the institutional goal of the 50^th percentile. <h3>Identification of the problem</h3> Team dissatisfaction with the inconsistency and unavailability of discharge instructions post-operatively along with low patient experience scores related to discharge instructions led to the development of a dedicated position and process to coordinate communication with the surgeon and parents post-operatively prior to discharge. <h3>QI question/Purpose of the study</h3> The goal of the project was to improve the discharge process and communication of discharge instructions with parents/caregivers resulting in improved patient experience scores, improved team member and surgeon satisfaction and decreased discharge delays. <h3>Methods</h3> After development of a Process Improvement (PI) Team, the Discharge Liaison Role and responsibilities were established. The Pilot was presented to the peri-operative teams and surgeons, and a time frame was identified. An initial survey was sent to the surgeons to gauge their satisfaction with the current discharge process. <h3>Outcomes/Results</h3> By developing and implementing a dedicated Discharge Liaison Role we improved our patient experience scores specific to the question "instructions nurses gave you about caring for your child at home" from the 38^th percentile in FY19 to the 90^th percentile in FY20. <h3>Discussion</h3> Implementing the Discharge Liaison Role allowed for consistent and thorough post-operative discharge instructions and provided the opportunity for clarification and coordination of any prescriptions or equipment that may be needed. <h3>Conclusion</h3> By developing the Discharge Liaison Role our patients, the team, and the surgeons responded positively, and we realized a significant improvement in our Patient Experience Scores. <h3>Implications for perianesthesia nurses and future research</h3> The development of a dedicated Discharge Liaison was essential to the improvement of our patient experience scores and the coordination of timely discharge planning for our post-operative patients. Future research is needed to evaluate of the impact on readmission rates, post-operative complications and decreased discharge delays.

Implementing Perioperative Evidence-Based Interventions for OSA: Increasing Risk Awareness, Enhancing Patient Care

<h3>Introduction</h3> The majority of Obstructive Sleep Apnea (OSA) cases are reported to be undiagnosed, including surgery patients. Perioperative nurses are in a unique position to recognize OSA not diagnosed in the perianesthesia period. <h3>Identification of the problem</h3> OSA has been identified as a factor for prolonging PACU stays and, more importantly, a contributing factor to respiratory compromise for those receiving opioids postoperatively. This population has an increased risk for adverse respiratory events once discharged. Implementing and sustaining interventions to safely discharge the patient can be a challenge. <h3>EBP Question/Purpose</h3> . <h3>PICO question. Databases utilized</h3> Can increasing nursing knowledge of OSA risk and perioperative nursing interventions optimize perioperative care for surgical patients with diagnosed and undiagnosed OSA? The American Society of Anesthesiologist published guidelines for perioperative management of patients with OSA in 2006. Since then, the ASPM published guidelines for monitoring opioid induced sedation in 2011 and in 2012 ASPAN published practice recommendation for obstructive sleep apnea in the adult patient. Various literature has been published on implementing these guidelines. <h3>Methods/Evidence</h3> Initial data showed patients with oxygen desaturation less than 92%, had STOPBANG scores of 4-8 52%. A pre-survey was distributed to nurses working in the pre-op and post-op area to assess their knowledge of OSA, OSA risk identification, and interventions to initiate with OSA and at-risk populations. Education was then given regarding identification of undiagnosed sleep apnea, recognition of post-operative hypoventilation and apneic events, and implementation of enhanced monitoring and nursing interventions. OSA screening information was added to electronic documentation, including assessments of at home CPAP/BiPAP use. A literature review identified post-anesthesia patient education points for patient diagnosed with or at risk for OSA. Educational points were incorporated into discharge teaching and discharge documents. A post survey was completed. <h3>Significance of Findings/Outcomes</h3> The initial desaturation data was thought to be skewed as nurses were unwilling to document low saturations on their patients, waiting to document until the patient was encouraged to take deep breaths, repositioned the airway, or provided other interventions. <h3>Implications for perianesthesia nurses and future research</h3> Encourage frontline nurses to recognize the significance of respiratory compromise and improve quality of care with resources and increased knowledge of interventions.

The Johns Hopkins Evidence-Based Practice (EBP) Model: Weinberg Perianesthesia Interventions for a Healing Environment

<h3>Introduction</h3> Weinberg Perianesthesia Unit has 28 Prep/PACU bays divided by curtains. In this unit, diverse surgical patients are prepared/recovered from anesthesia and surgery. Patients/families described the unit as congested, cluttered, dim, noisy, and unfriendly. This Prep/PACU is the busiest adult unit in this Mid-Atlantic academic medical center and has been compared to "Grand Central Station." <h3>Identification of the problem</h3> After participating in the Weinberg EBP Competency Program in 2017, the staff identified the need to conduct EBP Healing Environment Project that focused on therapeutic nursing interventions. <h3>EBP Question/Purpose: PICO question. Databases utilized</h3> What are the best therapeutic nursing interventions to create a safe, caring, healing environment for perianesthesia patients being prepared and recovered from their surgeries? P = Prep/PACU patients having surgery; I – Therapeutic healing nursing interventions; C = Compared to standard Prep/PACU nursing care; and O = Safe, caring, and healing environment. PubMed, CINAHL, and Scopus databases identified 43 key articles relating to complementary techniques to promote relaxation, music therapy, guided imagery, massage therapy, noise reduction, light therapy, aromatherapy, and clean, uncluttered environment. <h3>Methods/Evidence</h3> Nineteen articles were appraised and leveled using Johns Hopkins Nursing EBP Model that revealed: 8 Level I's, 6 Level III's, and 5 Level IVs with a 19 Quality "A" rating for strength of the evidence. <h3>Significance of Findings/Outcomes</h3> Evidence revealed: Promoting filtering light correlates with higher satisfaction, decreased opioid use; decreasing noise during agitated emergence reduces anxiety; providing music listening reduces anxiety, improves pain management and easy to administer; offering relaxation therapy with guided imagery decreases anxiety and reduces pain; providing massage therapy and therapeutic touch are beneficial for relieving pain and anxiety. <h3>Implications for perianesthesia nurses and future research</h3> Increased lighting, decreased noise, relaxation techniques, guided imagery and music therapy improved the perianesthesia healing environment as well as patient care outcomes. The project raised staff awareness of the importance of using EBP to change practice by motivating staff to use complimentary techniques to improve the healing environment of the PACU. Currently, the PACU nurses are conducting randomized comparative clinical research study with music listening interventions to determine if patients' anxiety and pain are alleviated.

An Evidence-Based Approach to Nursing Recognition and Management of Early Sepsis in Percutaneous Transhepatic Biliary Drainage (PTBD)

<h3>Introduction</h3> Percutaneous Transhepatic Biliary Drainage (PTBD) is an interventional radiology (IR) procedure indicated for relief of biliary obstructive symptoms: pruritus, jaundice ang cholangitis cause by benign or malignant conditions. Gallstones, cholangiocarcinoma and hepatobiliary malignancy are frequently seen to cause sepsis. <h3>Identification of the Problem</h3> Although PTBD is generally a safe procedure, significant complications manifest as systemic inflammatory response syndrome (SIRS) that leads to mortality. Early post anesthesia care unit (PACU) nursing recognition is critical in effectively managing these high risk patients. <h3>EBP Question/Purpose: PICO question. Databases utilized</h3> What is the best practice for patients post biliary drain placement presenting symptoms of systemic inflammatory response syndrome (SIRS)? (P) Patients post PTBD; (I) Early recognition of SIRS; (C) Prompt/early management of SIRS compare to standard care in alleviating sepsis (O). The evidence-based practice (EBP) searches were conducted using PUBMED/CINAHL databases. <h3>Methods/Evidence</h3> The evidence reviewed from PUBMED/CINAHL ranged from 2013 to 2019. Mesh terms were: interventional, biliary drainage, PTBD, pathophysiology, cholangitis, symptoms, complications, sepsis and SIRS. The first search yielded eight out of 36 articles that met PICO criteria. The second and final search included eight additional articles with terms of mortality and patient outcomes. <h3>Significance of Findings/Outcomes</h3> EBP appraisal revealed compelling science for recognizing and managing early SIRS in PTBD patients. Team created an EBP algorithm (see poster) that was effective for PACU nurses in early recognition of SIRS and prompt PACU nursing management to mitigate deteriorating symptoms of increased heart rates and rigors followed by fevers to improve quality patient care. <h3>Implications for perianesthesia nurses and future research</h3> Post PTBD SIRS can be challenging for PACU nurses to manage life-threatening complications. Evidence supports the development of an algorithm tool that focuses on recognition, assessment, and appropriate management of SIRS in this population. The science recommends easy accessibility of standing physician order sets, including medications, such as intravenous (IV) fluids, IV antibiotics, and acetaminophen as SIRS management in PACU strategies to facilitate positive patient outcomes.

Comparative Study on Intravenous Catheter Insertion Pain control, Anxiety, and Satisfaction in Adult Same Day Surgery Patient; Using a Vibrating, Cold Device or Traditional Local Anesthetics Intradermal Injection

<h3>Introduction</h3> Intradermal local anesthetic injection has been shown to be effective in decreasing pain during peripheral intravenous placement compared with other interventions. Current research has identified that distraction techniques and topical anesthetics are effective in decreasing pain and anxiety during painful procedures. Vibration, cold and other tactile stimulation are also mechanisms for reducing the pain sensation <h3>Identification of the problem</h3> Pain from intravenous placement is one of the most frequent, painful, anxiety provoking events experienced by patients in the hospital. Current popular method to decrease pain during venipuncture is intradermal local anesthetic injection which is not within nursing scope of practice. Alternatives that may be used, such as the vibrating cold device should be explored. <h3>Purpose of the Study</h3> To determine if there is a difference between intravenous insertion techniques used to manage pain, anxiety and patient experience in adult pre-operative patients. Techniques compared are intradermal local anesthetic injection and an external vibrating/cold device. <h3>Methodology</h3> Experimental, Randomized Controlled Trial. Subjects approached through face to face invitation to participate and consent to be in the study. A coin was flipped to determine if they will receive vibrating/cold device or intradermal lidocaine injection as means of venipuncture comfort measure. Members of the research team utilized a de-identified data collection tool and subjects were asked to complete surveys after the intervention; pain score, anxiety rating, and satisfaction rating based on a Likert scale. <h3>Results</h3> 1.00=Vibrating Cold Device 2.00=Local Anesthetic Intradermal <h3>Discussion</h3> Vibrating cold device (VCD) mean pain score of 3.1 is considered mild pain intensity. Use of VCD yielded lower levels of anxiety and comparable satisfaction scores when comparted to Local anesthetic intradermal. <h3>Conclusion</h3> Vibrating cold device may be used, within the scope of nursing practice, to provide pain control during IV insertion. This intervention also has a positive effect on the anxiety level experienced by patients during IV insertion and offers a high level of patient satisfaction. <h3>Implications for perianesthesia nurses and future research</h3> Use of Vibration, cold and other tactile stimulation as mechanisms for reducing pain sensation experienced by patients post procedure.

Perianesthesia Nurses’ Knowledge, Attitude, and Intention to Promote Safe Use, Storage, and Disposal of Opioids

<h3>Introduction</h3> Opioid overdose deaths and opioid use disorders are a crisis in the United States. Perianesthesia nurses have an excellent opportunity to educate patients and families who are discharged to home after surgery. <h3>Identification of the problem</h3> In a prior study, the authors found that nurses and other providers do not routinely discuss safe use, storage, or disposal of medications; perianesthesia nurses are more likely to discuss side effects of opioids. <h3>Purpose of the Study</h3> The purpose of this study is to determine if a web-based educational intervention increases knowledge, attitude, and intention of perianesthesia nurses to promote safe use, storage and disposal of opioids. <h3>Methodology</h3> A one group pre-test, post-test interventional study was conducted using a survey of ASPAN nurses. The intervention was a web-based voiceover module with patient education scenarios focused on information for patients before discharge. Responses to the pre-survey and 2 post surveys were collected. Data analysis included descriptive summary and evaluation of changes in knowledge and domains of Theory of Planned Behavior using repeated measures mixed modeling. <h3>Results</h3> The participants included pre-test survey (n = 678), the immediate post-test (n = 247), and the 4-week post-test (n = 171). The analysis presented is limited to 247 who completed at least the first post-survey. For all outcomes, there was an immediate increase in the measure following the intervention; this pairwise difference (between pretest and the immediate post-test) was significant in each model. The immediate and 4-week post-test scores exceeded the corresponding pre-test score, though for perceived behavioral control, attitude, and intention, the difference between baseline and week 4 was not significant. <h3>Discussion</h3> These findings suggest a more intensive intervention with possibly the inclusion of booster sessions, particularly for the outcomes of perceived behavioral control and subjective norms may be needed. <h3>Conclusion</h3> This educational intervention can be implemented at the national level for optimum impact. <h3>Implications for perianesthesia nurses and future research</h3> Perianesthesia nurses are well-positioned to teach patients about the risks of diversion, nonmedical use, and proper disposal of opioids. Research to develop safe postdischarge prescription practices and encourage safe opioid practices after surgery is needed.

“BLOCKED” Sign to Prevent Patient Falls Due to Peripheral Nerve Blocks

<h3>Introduction</h3> Multimodal analgesia is a practice used at the Kaiser Permanente Ambulatory Surgical Units (ASU). Preoperatively, patients are given different types of analgesic medications such as acetaminophen, gabapentin, NSAIDS plus a peripheral nerve block, and the like. This practice decreases post-operative opioid use and shortens the PACU length of stay. <h3>Identification of the problem</h3> The increase of the use of peripheral nerve blocks in an ASU increases the risk of a patient fall. There have been 2 falls, and 1 near-miss at the Kaiser Permanente Otay Mesa ASU in 2016 and 2018 due to peripheral nerve blocks such as femoral, and interscalene nerve blocks. The PACU staff work as a team, that although there is one primary nurse for a patient, all staff are there to help any patient in need. The danger of this is that the staff helping might not know that the patient is a fall risk due to the block and that led to the patient's falling. <h3>QI question/Purpose of the study</h3> What can be done to alert the perioperative/perianesthesia staff that the patient is a fall risk due to a peripheral nerve block? <h3>Methods</h3> Placing a bright "BLOCKED" sign on the gurney's IV pole on every patient that received a peripheral nerve block. The sign will only be removed after the patient has been discharged. <h3>Outcomes/Results</h3> Since implementation of the "BLOCKED" sign in September 2018, there have been no patient falls due to peripheral nerve blocks at the Kaiser Permanente Otay Mesa ASU. <h3>Discussion</h3> This simple sign alerted the perioperative staff that a patient is a fall risk due to the block and to take special care to prevent a patient fall. <h3>Conclusion</h3> The "BLOCKED" sign implementation alerts the staff that a patient is a fall risk due to the block. <h3>Implications for perianesthesia nurses and future research</h3> Spreading this QI project to the other Kaiser ASU's in San Diego will help with its sustainability. In fact, one of the ASU's has already adopted this practice with the same results.

Improving Discharge Phone Call Compliance

<h3>Introduction</h3> The immediate period following a hospitalization is a vulnerable time for patients. Discharge phone calls are an outlet for post-operative patients to express concerns related to their hospitalization and care. <h3>Identification of the problem</h3> An area of opportunity was identified with discharge phone call compliance. A singular nurse had been designated to complete discharge phone calls but was often reassigned to provide patient care. Discharge phone call compliance was low and/or made several days following discharge. Post-operative patients were asking, "Why were they receiving a follow up call so many days later?" <h3>QI question/Purpose of the study</h3> To improve overall patient satisfaction and experience resulting in the ability to address immediate post-operative concerns. <h3>Methods</h3> Every nurse was asked to complete three discharge phone calls per shift. Daily broadcasts via inter-hospital communication were used as a reminder. Weekly data was posted for the team showing our unit compliance and individual's compliance in completing their three calls. During our daily huddles, shout outs were made for individuals who completed the most phone calls. <h3>Outcomes/Results</h3> Nurses were observed being proactive in completing discharge phone calls every shift. Team leaders were reminding staff to complete their discharge phone calls instead of reminders from management. The completion rate of discharge phone calls have increased following implementation resulting in a 100% attempt rate of calls to patients in comparison to the 64% attempt rate pre-intervention. Secondly, our patient experience was improved, evident by our Outpatient and Ambulatory Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) scores for "information regarding recovery". Pre-intervention results were 78% and post intervention results were 87%. <h3>Discussion</h3> Providing staff with caller statistics during daily team huddles contributed to overall success. Limitations included the workflow of the PACU such as patient flow, number of cases per day, staffing, and unpredictable factors relating to patient care. <h3>Conclusion</h3> It was founded that by providing staff education and daily reminders, this greatly improved staff compliance. Ultimately, patient overall satisfaction and experience scores improved. <h3>Implications for perianesthesia nurses and future research</h3> The ability to address concerns is vital in overall patient care and well-being. Interacting with patients post-operatively is essential and should continue to be assessed and evaluated for areas of opportunity for improvement.

The Effects of Music Intervention on Pain and Anxiety in the Immediate Postoperative Period in Adults Undergoing Total Knee Arthroplasty and Total Hip Arthroplasty

<h3>Introduction</h3> This study evaluated the effect of music on acute and/or acute on chronic pain and anxiety during the immediate postoperative period. A standardized music intervention (Music Care) was used with patients who had undergone elective joint replacement. <h3>Identification of the problem</h3> The current opioid crisis has led us to examine adjunct therapies for pain control in postoperative care. One such therapy, music, has demonstrated value in the treatment of pain and anxiety in multiple clinical settings. Patients who receive fewer opioid analgesics postoperatively have shown fewer respiratory events and a decreased length of stay. <h3>EBP Question/Purpose</h3> PICO question. Databases utilized: Does the addition of music reduce postoperative pain, anxiety and analgesia during the initial recovery phase of orthopedic surgery patients? <h3>Methods/Evidence</h3> Study participants included patients of who underwent elective joint replacement in 2019 and early 2020. Historical data was gathered from the electronic health record (EHR) of patients January to April 2019 (n=50). From December 2019 to March 2020, the music intervention was initiated upon admission to the PACU (Phase 1 of recovery) and discontinued when patients entered Phase 2 of recovery (n=50) Perioperative data collected from EHR of all patients included: vital signs, Pasero Opioid Induced Sedation Scale (POSS), narcotics and benzodiazepines administered and pain ratings. Significance of the findings/Outcomes: There was a statistically significant decrease in the amount of Dilaudid administered in the study participants, with a p value of 0.03, as well as statistically significant decrease in heart rate (p value 0.006), respiratory rate (p value 0.05) and POSS (p value 0.05). <h3>Implications for perianesthesia nurses and future research</h3> These findings are important in supporting the use of adjunct therapies for pain control thus decreasing the use of narcotics and their untoward side effects and related sequelae. A lower POSS and decreased narcotic use may promote early mobility and discharge. Further research in the use of music throughout the entire operative experience, and beyond, may be of interest.

Multidisciplinary Approach to Reduce OR Delay and Cancellations Due to Covid-19 Testing

Background informationThe COVID-19 pandemic has influenced the global health care system. The institutional guidelines indicate that all surgical procedures require a negative COVID test within four days of surgery. Operating room (OR) delays/cancellations related to pending COVID results can lead to unnecessary waste of PPE resources. Additionally, it can cause undue emotional distress for the patient and family, which affects the patient experience.Objectives of ProjectThe objective of this project was to reduce OR delays/cancellations related to COVID-19 testing.Process of implementationPerioperative guidelines and workflow on testing for COVID-19 prior to surgery was developed utilizing the institutional guidelines, based on Centers for Disease Control and Prevention (CDC) recommendations. A tracking tool was created to enter COVID-19 test information, starting from 6/15/2020. This data included information regarding test status, delays and cancellations. Testing appointments and pending results were reviewed throughout the day to ensure timely identification and interventions if the patients fell outside the COVID testing criteria. Communication to surgical and leadership teams were also completed to ensure proper follow up and escalation of processes.Statement of Successful PracticeThe development of a COVID-19 test tracking tool data indicates significant reduction of OR delay or cancellation.The overall data from June to August 2020 shows that COVID-19 pending tests have improved significantly from 6.8% to 0.2%. Of the pending results, the delay of surgical cases improved from 2.9% to 0.2%; and the cancellations of cases improved from 0.7% to 0.07%.Implications for perianesthesia nurses and future researchHaving a tracking tool provides perianesthesia nurses an opportunity to quickly identify COVID testing needs. This can have a positive impact on the patient experience during a pandemic and eliminate the waste of PPE, helping the organization to be financially responsible. The development of the perioperative guidelines is important in managing practice changes during a global pandemic.

Implementation of Strategies to Reduce Improper Disposal of Opioids Following Orthopedic Surgery: A Pilot Study

<h3>Introduction</h3> The opioid epidemic remains a challenging problem currently facing healthcare systems. As opioids are often prescribed in greater quantities than patients consume, proper disposal of unused medications is crucial. <h3>Identification of the problem</h3> Literature suggests many patients who are prescribed opioids share medications with another person and that there is a lack of patient education regarding safe disposal of opioids. <h3>Purpose of the Study</h3> To analyze how the implementation of the Deterra® Disposal Pouch (DDP), and education regarding its use, may reduce the percentage of improper disposals of opioids following orthopedic surgery. Secondly, the study examined the patient utilization rate of the DDP after implementation. <h3>Methodology</h3> All patients undergoing elective orthopedic surgery at a single ambulatory surgery center noted their opioid disposal technique via an automated survey 2-weeks post-operatively. Pre-implementation (12/2018-02/2019) versus post-implementation (12/2019-02/2020) of the DDP were compared for improper disposal (storing prescription, flushing down the toilet, etc.) versus proper disposal (DDP, dropped at police station/pharmacy/city-hall, etc.). Patients not prescribed opioids, still taking opioids, or who had finished their opioid prescription at the time of the survey were excluded. <h3>Results</h3> Prior to implementation of the DDP, 54.2% (n=39) of patients disposed of their opioids improperly versus 45.8% (n=33) properly. Following implementation, 49.1% (n=53) disposed of their opioids improperly versus 50.9% (n=55) properly. Importantly, post-implementation, 21.3% (n=23) of patients disposed of their opioids using the DDP. This difference between 54.2% and 49.1% was not statistically significant, yet may be deemed clinically relevant (p=.502). <h3>Discussion</h3> The results suggest the effectiveness of implementing strategies to encourage proper disposal of unused opioids following orthopedic surgery, with important implications for reducing the negative, secondary effects of improperly storing and disposing of opioids. <h3>Conclusion</h3> Comprehensive implementation and education regarding proper use of the DDP led to decreases in improper opioid disposal, with over 1 in 5 patients utilizing the new disposal method. <h3>Implications for perianesthesia nurses and future research</h3> Perianesthesia nurses play an important role in educating patients about correct use and reasoning behind proper disposal of opioids. The authors recognize this data is preliminary, but further large-scale studies are warranted to study effective opioid disposal.

Parent Acceptability and Use of Complementary and Alternative Medicine to Manage Children's Post-Tonsillectomy Pain

<h3>Introduction</h3> Complementary and Alternative Medicine (CAM) interventions, such as honey, have been well-documented in reducing pain following tonsillectomy procedures. <h3>Identification of the problem</h3> CAM is oftentimes overlooked when it comes to the treatment of pain, particularly when it comes to children. With the new restrictions placed on opioid prescribing, more research is needed to find alternative ways to manage children's pain. <h3>Purpose of the Study</h3> Our study aimed to assess parents' CAM use for their own health and their child's health. Further, we assessed parents' willingness to use various forms of CAM for their child's health in the future. <h3>Methodology</h3> Parents (n = 64) were recruited by a nurse at the time of their child's tonsillectomy procedure to participate in a study on CAM and children's postoperative pain. Following informed consent, parents completed online surveys through REDCap about their use of CAM, CAM beliefs, and willingness to use CAM for their child's health. <h3>Results</h3> Over half of parents (62.5%) reported using CAM for their own health. Parents had tried an average of 3.2 (SD = 3.38) forms of CAM (most common: natural supplements, chiropractic or massage, and relaxation strategies). Similarly, parents had tried an average of 2.12 (SD = 2.60) forms of CAM for their child's health with 59.4% of parents trying at least one form of CAM for their child. Most commonly used forms of CAM for children were honey of bee products (37.5%), aromatherapy (34.3%), and natural supplements (26.5%). <h3>Discussion</h3> The majority of parents had some experience with CAM interventions and had tried CAM for their child's health. However, a significant minority of parents had never tried CAM interventions. <h3>Conclusion</h3> CAM interventions could be acceptable to parents for use in managing children's pain. Honey appears to be the most commonly tried form of CAM for children and could have potential utility for use following tonsillectomy procedures. <h3>Implications for perianesthesia nurses and future research</h3> Families overall are open to CAM and could use further education regarding how to best use CAM to manage children's postoperative pain. Future research will evaluate the efficacy of honey for controlling postoperative pain and reducing need for opioids following tonsillectomy.

“Who wants to be a CERTIFIED Millionaire?” A Multifaceted Approach to Increasing Certification

<h3>Introduction</h3> Post Anesthesia Care Unit (PACU) certification is important because it shows a strength in knowledge and a drive for continual learning in this specialty nursing. <h3>Identification of the problem</h3> The number of certified nurses in the PACU has declined and nurses qualified to take the certification exam express concern due to the financial burden and concern of failing the exam. <h3>QI question/Purpose of the study</h3> The goal is to increase perianesthesia nurse certification through education and financial incentives. <h3>Methods</h3> In 2019, an educational initiative was launched to increase staff awareness of importance, benefits and support available for certification. Education on certification was provided at unit meetings, in an American Society Perianesthesia Nurses (ASPAN) formal webinar review, availability of a library of study resources and in creating an interactive game show study review. A three-part education series provided benefits of certification, test taking strategies and test questions in a game show format known as, "Who wants to be a Certified Millionaire." The leadership provided financial support with a class day for the webinar review, purchasing unit study resources and trialing a voucher program to discount the cost to retake the test if needed. <h3>Outcomes/Results</h3> The anticipated projected outcome of the financial and educational interventions is that perianesthesia nursing certification rates will increase in the PACU. Already 20 nurses have purchased vouchers and plan to take the exam within the next 12 months. Dual certification is being sought for the first time within perioperative services by at least 5 nurses. <h3>Discussion</h3> Nurses have stated they have learned a lot and understand more about the complex PACU patients. As individuals pass or fail, we can identify knowledge gaps that we can than focus interactive educational offerings towards. <h3>Conclusion</h3> Advocating for certification has increased interest and commitment to take the exam. <h3>Implications for perianesthesia nurses and future research</h3> The educational certification initiative has increased staff engagement, satisfaction and interest in becoming certified.

Implementing an Enhanced Recovery After Surgery Joint Replacement Program in a Small Acute Hospital Using a Multi-Disciplinary Approach

<h3>Introduction</h3> The facility began doing elective surgeries in 2017 without a standard joint program to regulate practice. To deliver highest standard of care, the need to systematize the process and develop a program was identified. This can only be done with the support of leadership while using a multi-disciplinary approach, implementing a program using the latest evidenced based practice (EBP) and clinical practice guidelines (CPGS). A joint program was created to initiate an Enhanced Recovery after Surgery (ERAS) program in a small acute care setting. <h3>Identification of the problem</h3> Without the structure of a formal joint program, several orthopedic surgeons were not standardizing their practices when it came to optimization of patients, spinal anesthesia, or ERAS medications. The program identifies these barriers that promote the need for change. <h3>EBP Question/Purpose: PICO question. Databases utilized</h3> In patients undergoing joint surgery, what is the effect of implementing ERAS in reducing length of stay visits, reducing post- operative complications? Research began using EBSCO host to find articles no later than 2010 for ERAS implementation and EBP. Current guidelines referenced from the American Academy of Orthopedic Surgeons, National Association of Orthopaedic Nursing, American Society of PeriAnesthesia Nurses, and the Association of periOperative Registered Nursing were used. Guidelines for the hospital program were created based on research findings. <h3>Methods/Evidence</h3> To initiate the program, EBP and CPGs were first used to support the rationale for the program. Key stakeholders and leadership used a multi-disciplinary approach to develop the program and explain the rationale for the program with each surgeon. Key stakeholders decided to then create a pre-admission testing clinic to screen patients appropriately. Education for hospital-wide staff for joint specific patients was implemented. <h3>Significance of Findings/Outcomes</h3> After three years, of implementing the joint program, the program has had 92% discharges on postoperative day one along with reduction in post-operative complications. <h3>Implications for perianesthesia nurses and future research</h3> Using EBP and CPG to standardize care ensure best practices, in which a majority of the ERAS bundle happens within the perianesthesia department. As ERAS is the gold standard, the next step is Advanced Certification.

Leveraging Community Partnerships and Education to Improve the Safe Use, Storage and Disposal of Opioids

<h3>Introduction</h3> Literature suggests patients often have leftover opioids after surgery. It has also been reported that opioids are frequently not stored in a safe place at home. With the assistance of a community program, this hospital system received a donation of items to safely store and/or dispose of opioids to give to patients being discharged with an opioid prescription. <h3>Identification of the problem</h3> Utilizing the Instrument developed by Odem-Forren (Odom-Forren, Brady, Rayens, & Sloan, 2019), nurses were assessed for their knowledge and practice on safe opioids use, storage and disposal education. Gaps were identified across a community based hospital system with four hospitals and two outpatient surgery centers. <h3>EBP Question/Purpose: PICO question. Databases utilized</h3> For Perianesthesia nurses, will education and the availability of disposal and storage of opioid options for patients over standard of care, improve discharge teaching practice of safe use, storage and disposal of opioids and patient satisfaction scores? <h3>Methods/Evidence</h3> Education is key to increasing the patient's likelihood of disposal of opioids. To ensure proper education is being provided, nurses need to be knowledgeable about misuse of opioids in the community and the importance of storing or disposing of opioids safely. Champions were identified at each hospital in the system to ensure adoption. Disposal and storage items were compiled and "DASH" (Disposal And Storage at Home) bins were created for each unit that discharges outpatient surgery patients. The education plan was developed based on gaps in knowledge and practice from survey. Education is currently in progress with post-survey to follow. <h3>Significance of Findings/Outcomes</h3> Monitoring for improved patient satisfaction scores, increase in documentation of education, disposal and storage items given and improved post implementation survey results will occur. Results will be analyzed in December 2020. <h3>Implications for perianesthesia nurses and future research</h3> Perianesthesia nurses play a critical role educating patients. Because of this, it is crucial we as nurses are knowledgeable and aware of the safe use, storage and disposal practices that are recommended. Being able to supply patients with the needed items to safely store and dispose of opioids is an added benefit that should be considered whenever possible.

The Rolling Refresher Cart (RRC): Improving the Level of Preparedness in PACU Nurses in Caring for Patients and their Specialized Surgical Drains

<h3>Introduction</h3> Patients with specialized surgical drains can be a high-risk occurrence in the post anesthesia care unit (PACU) if PACU nurses (RNs) mishandle these drains. Disproportionate opportunities to care for particular patient drains have contributed to RNs feeling unprepared. Research studies have shown that frequent education has a positive impact on RN's performance and preparedness level. <h3>Identification of the problem</h3> Absence of frequent education sessions have negatively impacted PACU RNs' level of preparedness to care for patients and their specialized drains. <h3>QI Question/Purpose of Study</h3> Will using a mobile teaching cart (aka RRC) that provides monthly in situ "refresher" sessions increase the level of preparedness in PACU RNs by 15% after each session? <h3>Methods</h3> PACU RNs were selected to participate in monthly 20-minute RRC sessions in their unit for 11 months. A needs assessment questionnaire was used to identify the 3 surgical drains for this project. One drain was reviewed per month and repeated quarterly. The hospital's policies and subject matter experts were consulted for the teaching points. A re-purposed utility cart was used during RRC sessions to store, transport, and display teaching materials. During each session, participants were provided a quick lecture and hands-on practice. Pre and post data for the nurses' preparedness level were collected immediately before and after each session via questionnaires. <h3>Outcomes/Results</h3> The goal was met. Self-reported data from PACU nurses show that monthly RRC sessions have increased the RNs' preparedness level to manage specialized surgical drains by at least 15%. 98% of the participants agreed to participate in future RRC sessions. <h3>Discussion</h3> Monthly RRC sessions were successful in improving the level of preparedness in PACU RNs. Buy-in from these RNs ensured future opportunities to use the RRC again for in-situ training. <h3>Conclusion</h3> Results from this project highlight the promising role of RRC in improving and maintaining knowledge, preparedness level, and skills set in PACU nurses. The absence of a control group in this project limits the generalizations that can be made. <h3>Implications for perianesthesia nurses and future research</h3> The RRC is optimal for in-situ training because it is easily accessible, readily available, uses minimal space, and can be used for just-in-time training. The RRC should be considered for use in other departments for RN training.

Optimizing Thymoglobulin Administration: A Care Bundle Approach

<h3>Introduction</h3> Smart infusion pumps, and information systems have enhanced nursing practice, but awareness of our overreliance on technology must be considered to prevent adverse events. Infusion pumps are required to achieve optimal dosage and timing of Thymoglobulin infusion. This project addressed safety measures in daily nursing practice, including medication administration, documentation, and clinical alarm management. <h3>Identification of the problem</h3> IV Infusion pump assigned to administer Thymoglobulin to a kidney transplant recipient did not function appropriately, failing to deliver any medication, and failing to alarm, leading to subsequent adverse reactions. Nursing documentation reflected Thymoglobulin had been actively infusing on that failed pump. Inability to trace the infusion pump was also present in the event. <h3>Purpose of the study</h3> Our aim is to optimize care processes related to the administration of Thymoglobulin in kidney transplant recipients by using a care bundle approach. <h3>Methods</h3> Nursing staff in-services were provided on the Thymoglobulin care bundle interventions. Staff compliance with care bundle was reviewed through direct observation, surveys and patient chart audits: (1) Standard cell documenting Thymoglobulin and pump asset tag number, (2) ‘Bag details' on the I&O Flowsheet, (3) ‘Thymoglobulin Administration Note' when infusing a new IV bag, (4) Pump drug library selecting Thymoglobulin, and (5) Infusion pump alarm checks. <h3>Outcomes/Results</h3> Patients' charts were reviewed prior to in-service (n=20), and post in-service (n=32), for the presence of documentation elements of the care bundle. Prior to in-service, 80% of the charts demonstrated some elements of the care bundle. Post in-service, 91% demonstrated all the documentation elements of the care bundle. Post in-service Survey results revealed 80% of RNs were performing infusion pump alarm checks, versus 20% pre in-service survey results. Direct observations revealed 90% of staff used infusion pump drug library. <h3>Discussion</h3> Infusion pumps carry certain degree of risk of not working correctly, and nurses must mitigate this risk by ensuring the safety and effective performance of these devices. <h3>Conclusion</h3> The care bundle significantly improved documentation on Thymoglobulin administration, including management of Infusion pump alarms. <h3>Implications for perianesthesia nurses and future research</h3> RNs must rely on their expert monitoring of the patient and his/her environment to ensure patient safety. Continuous assessment of infusion practices is required to enable us to identify opportunities for process improvements.

#KnockTheNausea: Use of Aromatherapy in the Pediatric Perianesthesia Care Unit

<h3>Introduction</h3> Post-operative nausea and vomiting (PONV) is a major cause of distress in the PACU (Post-anesthesia Care Unit). It is associated with an increased risk of potential complications, patient dissatisfaction, and delayed discharge. The prolonged stay in PACU directly affects the efficiency of our patient throughput. Nonpharmaceutical therapies offer an alternative to antiemetic therapies with benefits in being noninvasive and inexpensive. <h3>Identification of the problem</h3> PONV in the PACU setting is an important cause of morbidity in children. This puts patients at risk for complications including but not limited to dehydration, aspiration, wound dehiscence, and bleeding post operatively. <h3>EBP Question/Purpose: PICO question. Databases utilized</h3> In pediatric postoperative patients ages 5-18, does aromatherapy reduce the incidence of postoperative nausea and vomiting (PONV) and therefore improve patient/family satisfaction when used adjunctively with current practice? P - Pediatric postoperative patients I - Aromatherapy C - Current state/practice O - Reduced PONV and improved patient/family satisfaction Databases utilized were PubMed, Google Scholar, and CINAHL <h3>Methods/Evidence</h3> • The IOWA model was followed • Education for staff and families was created • Utilized validated pediatric nausea/vomiting tools for patients/families in PACU • Choice of ginger or peppermint offered to patient/family with PONV • A survey was developed for nurses and patients/parents to document effectiveness of aromatherapy • Inclusion criteria: ○ Patients undergoing the following surgical procedures: ■ Orchidopexy, testicular/ovarian torsion, inguinal hernia, hydrocelectomy, tympanoplasty/mastoidectomy, and eye muscle correction ○ Patients age 5-18 •Exclusion Criteria: ○ All other surgical procedures <h3>Significance of Findings/Outcomes</h3> Pre-implementation: 3-month period of pharmacological and non-pharmaceutical interventions. Post-implementation data: 3-month period pharmacological, non-pharmaceutical interventions, Pre/post implementation PONV scores, and patient satisfaction scores post implementation. Post-implementation findings: • 150 patients met inclusion criteria ○ 100 patients eliminated due to not completing survey ○ 50 surveys completed ■ 20 completed correctly ■ 12 surveys eliminated due to denying nausea pre intervention ■ Total sample size of 8 • 6 reported reduction in PONV • 2 reported no change or reduction in PONV Regarding patient satisfaction data: • 20 completed surveys ○ 7 completed satisfaction survey, therefore sample size of 7 ○ 3 rated their experience "neutral" ○ 4 rated their experience "satisfied/extremely satisfied" <h3>Implications for perianesthesia nurses and future research</h3> The use of aromatherapy is an integrative and holistic approach to help minimize PONV in post-operative patients. Patients achieved relief which aids in decreasing the chance of potential complications. Patients also had an increase in satisfaction post-operatively in the PACU. Future goals: Integrate BARF tool/Likert scale into current electronic medical charting as an objective way to assess and document PONV within the institution.