Nurses caring for patients undergoing treatment in an inpatient setting can face a number of challenges that include keeping patients safe from infections or other injuries, such as falls, and ensuring patients are supported in the necessary ways to ensure positive outcomes.
Infections—such as hospital-acquired pneumonia (HAP)—contracted during hospital stays is perhaps one of the more frustrating complications for patients and nurses, and this is especially true of oncology patients who are more “susceptible to critical illness due to an already immunocompromised state,” said Cheryl Clements, BSN, RN, PCCN, in her presentation, “Taking HAP off the Map with a Routine Screen.” HAP is the leading cause of prolonged hospitalization in patients. To evaluate how to better prevent the occurrence of HAP for the oncology patients at Eastern Regional Medical Center, Philadelphia, PA, Clements and colleagues wanted to evaluate if implementing the Massey Bedside Swallowing Screen when patients were admitted to the oncology telemetry unit could help to detect any deficits that could potentially lead to HAP, in conjunction with strict oral care for identified high-risk patients.
In their institution, nursing staff received education through lecture format on the utilization of the Massey Bedside Swallowing Screen to help them identify which patients were high-risk and should be placed on nothing-by-mouth (NPO) precautions; nurses were also instructed to order a speech and swallow evaluation to further evaluate these patients. Each patient admitted to the oncology treatment unit was screened in this way. Patients were also given a role as they were asked to perform their own mouth care and were provided with a simple oral care regimen. Patients with cancer who were too ill to perform their own oral care were placed on a strict oral care regimen performed by the nursing staff, with the charge nurse overseeing compliance with this protocol.
Ultimately, “Implementation of the Massey Bedside Swallowing Screen for each admission and strict oral care regimen for high risk patients [decreased] the incidence of HAP [by] 50%” during their study period of May 2015–August 2015, Clements said. Moreover, with continued education and compliance, follow-up data collection from September 2015–March 2016 revealed no additional cases of HAP in the unit. And although RN compliance of screening was 65.5% during the study period, the follow-up period up to March 2016 showed an improved compliance rate of 94.4%, with the charge RN playing a critical role in ensuring the full implementation.
“Patients assessed with the Massey Bedside Swallowing Screen upon admission to the oncology telemetry unit were noted to have improved outcomes and lower rates of HAP,” said Clements. “Early detection of patients at high-risk for aspiration and implementation of interventions to improve oral care in high-risk patients leads to improved patient outcomes through lower incidence of HAP in the acute care setting,” with education and compliance being key to decreasing rates of this infection.
Inpatient settings can present additional potential threats, such as falls, to patient well-being. In their presentation “A Nurse-Driven Strategy to Reduce Falls in the Inpatient Malignant Hematology Population,” Joel Stettler, BSN, RN, OCN®, and Megan Hoffman, MSN, RN, CMSRN, AOCNS®, of the Moffitt Cancer Center in Tampa, FL, explained how medications for oncology—in this case, hematology—can lead to increased falls. “Falls in the malignant hematology population are a major concern due to prolonged side effects related to treatment and disease process,” said presenters. Patients with hematology diagnosis are at an especially high risk at the end of their treatment cycles because of impaired levels of physical function and physiological changes causes by polypharmacy. And although the Morse Fall Scale exists to help nurses evaluate falls for such patients, it does not reflect, according to Hoffman and Stettler, potential complications from medications used to alleviate treatment-related side effects, including
- History of falling
- Secondary diagnosis
- Ambulatory aid
- IV access
- Mental status.
As a means of intervention, presenters explained that their institution created a quality improvement committee to determine that any patient receiving high-risk medications (lorazepam, furosemide, and first-time sleeping aids) would be placed on a bed or chair alarm for the duration of the drug effect. Moreover, an emphasis was placed on communication between the RN and oncology technician to evaluate when patients met the criteria for the bed or chair alarm protocol.
Further interventions included laying floor mats, offering hip protectors and protective caps to patients, providing bed and chair alarms, and installing the AvaSys® TeleSitter® system—16 remotely observed cameras.
The new protocol had positive results (FIGURE 1), showing a 60% decline in falls. Stettler and Clements stressed that falls in malignant hematology populations are a major concern and that additional protocols and communications may be needed to supplement the Morse Fall Scale as it does not reflect the potential complications from medications.