Sue & Bill Gross School of Nursing

Background: A national intravenous fluid (IV) shortage prompted our institution to implement fluid conservation measures in the perioperative setting. Results from a preliminary survey conducted during the restriction period revealed that most anesthesia providers did not adhere to the restriction guideline, with nearly half opposing its implementation. There was a noticeable increase in anecdotal reports of postoperative nausea and vomiting (PONV) and hypotension in the postoperative anesthesia care unit (PACU). A multidisciplinary anesthesia team subsequently developed and implemented an updated preoperative IV fluid guideline concurrent with the replenishment of IV fluid supplies. This is particularly relevant given persistent gaps in national and local preparedness for supply chain disruptions driven by escalating natural disaster events. Objective: This QI project sought to evaluate improvements in provider reported adherence, workflow efficiency, and perceived utilization following the implementation of an updated, evidence-based guideline, with the goal of informing future planning in the event of an IV fluid shortage without compromising postoperative outcomes. Methods: This QI initiative was conducted within an urban anesthesia department at an academic Level I trauma center. A survey was distributed to 209 anesthesia providers within the department to evaluate an updated guideline, assess adherence, and examine provider perceptions. The Logic Model framework was employed to systematically identify and assess short and long term outcomes related to the guideline implementation. Results: A follow-up survey showed that while most providers reported low to moderate adherence, nearly twice as many providers chose to follow the updated guideline compared to the original (55% vs. 26%). Provider perceptions were more positive overall, with fewer expressing opposition. More providers felt that fluid waste was no longer a concern and believed the guideline did not cause delays or alterations in treatments or surgical start times. Although self reported on-time case rates did not improve, many providers reported increased satisfaction with having fluids prepared preoperatively. Sixty percent of respondents felt that 500 mL was sufficient for cases under two hours. The survey results identified certain procedural and surgical locations where reducing volumes to 250 mL was considered safe, as well as there was strong provider opposition to such reductions. The site of anesthesia delivery, patient acuity, and duration were identified as significant factors influencing providers’ perceptions of a safe initial IV fluid volume. Conclusion: When facing externally imposed fluid restrictions, a clear gap in practice was identified, in which no guidelines existed to drive clinical decision making. While provider acceptance improved, an adherence paradox emerged - support for the guideline increased, yet the proportion of providers who reported not following it rose, suggesting acceptance does not guarantee compliance. Additionally, under-resuscitation carries meaningful patient safety risks including PONV, hypotension, acute kidney injury, and myocardial infarction, reinforcing that fluid volumes must be tailored to patient acuity, surgical location, and case duration. There is a gap in the literature regarding fluid shortages and patient outcomes. Future studies should expand data collection to include patient outcomes, develop guidelines through expert feedback, and establish organizational policies to address IV supply chain disruptions, so that facilities have a clear basis for decision making.

Purpose: To improve daily chlorhexidine gluconate (CHG) bathing rates among hospitalized adults with central venous catheters (CVCs) by implementing a standardized patient education pamphlet and education process. Background: Hospital-acquired infections (HAIs), including central line-associated bloodstream infections (CLABSIs), contribute to increased morbidity, length of stay, and healthcare costs. Daily CHG bathing is an evidence-based strategy for CLABSI prevention; however, patient refusal remains a major barrier to adherence. Engaging patients and families through standardized education may improve compliance with CHG bathing protocols. Methods: This project was conducted on a post-surgical acute care unit at an academic hospital in Northern California. The intervention consisted of (1) a standardized patient education toolkit (handout, self-bathing instructional diagram, and wall signage) and (2) a structured education process delivered by trained champions. Patients appropriate for self-bathing were observed during their initial bath, while others received assisted bathing at arranged times. Weekly reinforcement was provided for patients with a CVC’s length of stay greater than 7 days. Champions documented interventions using standardized templates, and data were securely stored and analyzed using a project site-approved Excel tool. Central line maintenance bundle (CLMB) audits were used to collect data on CHG bathing compliance. Descriptive statistics were used to analyze CVC types, patient mobility level, education length, and self-bathing eligibility. Results: A total of 32 eligible patients were included over the 9-week implementation period. Monthly CLMB audits demonstrated a marked improvement in daily CHG bathing rates in which pre-intervention rates were 57% and 54% in the two months prior, compared to 90% and 72% during the two-month intervention period. Implementation outcomes included participation from 9 project champions and 100% adherence to the presence of wall signage and education pamphlets in all patient rooms. Implications and Conclusion: A structured CHG education process with standardized materials is a feasible and effective strategy to enhance bathing compliance and support infection prevention efforts. Engaging patients and families as active participants in care, alongside targeted workflow adaptations, can improve implementation success. Future efforts should expand family involvement, extend device-specific education to other high-risk populations, and evaluate patient-driven engagement measures to further strengthen outcomes.

Background: Heart failure (HF) readmissions remain a significant healthcare challenge, often driven by medication nonadherence. A needs assessment in a transitional care clinic identified diuretic nonadherence as a key contributor to 30-day HF readmissions. The Teach-Back Method (TBM), a structured communication strategy, has been shown to improve patient understanding and adherence. Purposes/Aims: This DNP quality improvement project aimed to increase provider utilization of TBM through structured training and electronic medical record (EMR) integration to support diuretic adherence and reduce 30‑day HF readmissions. Methods: A pre–post intervention quality improvement project was implemented in a heart failure transitional care clinic in Southern California using the Johns Hopkins Evidence-Based Practice model. Providers completed a 30-minute TBM training, and TBM and diuretic adherence SmartPhrases were integrated into the EMR. Provider confidence was assessed pre-intervention, immediately post-intervention, and at 30 days. TBM adherence was evaluated through chart audit and provider self-report due to EMR data limitations. Diuretic adherence was tracked using EMR-documented SmartPhrase data over two months, and 30-day HF readmissions were obtained from regional reports. Data were analyzed using descriptive statistics and chi-square testing. Findings: Provider confidence increased from 9.5 pre-intervention to 9.8 immediately post-intervention and 10 at one month. A 26.9% chart audit showed 70% TBM adherence, consistent with provider self-report. Diuretic adherence remained low (21.2% and 20.6%) and was limited by inconsistent documentation. Thirty-day HF readmission decreased slightly from 22% to 20.3%, but this change was not statistically significant (χ² = 0.17, p = 0.68). Conclusions: Structured TBM training with EMR integration improved provider confidence but did not meaningfully change patient outcomes. Findings highlight the need for consistent implementation, reliable documentation, and system-level support. Future efforts should optimize EMR workflows, improve data capture, and evaluate long-term impact.

Background: Based on the BOOST II study and Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC) guidelines, evidence indicates that brain tissue oxygen (PbtO₂) monitoring in severe traumatic brain injury (TBI) patients results in lower mortality and improved Glasgow Outcome Scale-Extended Scores. A large academic hospital's neurocritical care unit lacks standardized PbtO₂ monitoring protocols for TBI patients despite clinical recommendations for invasive intraparenchymal catheter monitoring. Purpose: This project aimed to implement PbtO₂ monitoring in severe TBI patients and assess its impact on mortality, Glasgow Coma Scale (GCS), hospital, and ICU length of stay. Additional goals included promoting provider and nursing knowledge of PbtO2 monitoring and ensuring sustainability through policy development. Methods: This evidence-based practice project was a pre- and post-intervention design which included the implementation of a brain tissue oxygen (PbtO₂) monitoring protocol adapted from the BOOST III trial in adult severe traumatic brain injury patients. Inclusion criteria included patients with a GCS <8 admitted to the neurocritical care unit with staff education tailored by role. Outcomes including mortality rates, length of stay, and GCS scores were compared between pre- and post-implementation cohorts using retrospective chart review and non-paired t-tests over an 8–12-week period. Results: No statistically significant differences were found between the pre and post groups on any outcome measure. The study was substantially underpowered across all variables, warranting further investigation with adequately powered samples. Conclusions: This evidence-based practice project examined outcomes before and after implementation of PbtO₂ brain tissue oxygen monitoring across two independent patient cohorts (PRE, n=20; POST, n=7). Although descriptive trends favored the POST group — including lower mortality (42.9% vs. 50.0%), shorter lengths of stay among survivors, and higher GCS on arrival — no statistically significant differences were found on any outcome measure. These null findings are largely attributable to the small number of participants in the POST group. Additionally, baseline differences in injury severity between groups introduce potential confounding that limits direct comparison. These results should not be interpreted as evidence against the utility of PbtO₂ monitoring, but rather highlight the need for larger, prospective studies.

Delayed recognition of patient deterioration in acute care settings is associated with increased morbidity, mortality, unplanned transfers to higher levels of care, and failure to rescue. Early warning systems, such as the Modified Early Warning Score (MEWS), provide standardized criteria to identify at-risk patients and facilitate earlier escalation of care, including activation of the Rapid Response Team (RRT). Despite evidence supporting MEWS, staff awareness and consistent utilization remain variable, highlighting the need for targeted education and structured implementation. This quality improvement project aimed to enhance early recognition of patient deterioration and improve outcomes in a Level II trauma center observation unit in Southern California. The intervention included standardized staff education on MEWS scoring and escalation protocols, reinforcement of MEWS use and RRT activation, and provision of MEWS reference tools. During the 7-week implementation period, MEWS use and adherence were evaluated through periodic audits to ensure accurate scoring and appropriate RRT activation. Primary outcomes, including RRT activations, code blue events, and transfers to higher levels of care, were collected from the electronic medical record. Nurse confidence in recognizing and escalating patient deterioration was assessed using pre- and post-intervention surveys. Implementation fidelity was monitored through periodic chart audits. Post-intervention survey results are pending. Anticipated outcomes include increased RRT activation, improved nurse confidence, and a reduction in adverse events. Findings from this quality improvement project support ongoing implementation, with integration of MEWS into the electronic medical record currently in progress and expected to be implemented hospital wide.

Background: Diabetic kidney disease (DKD) is the leading cause of end stage renal disease (ESRD) in the United States and affects one-third of adults with diabetes. Albuminuria is a critical biomarker of renal and cardiovascular morbidity, including coronary artery disease, stroke, heart failure, arrhythmias, and microvascular complications. Early detection through estimated glomerular filtration rate (eGFR) and urine albumin–creatinine ratio (uACR) testing enables timely interventions, improved chronic disease management, and better long-term outcomes. Local Problem: At the project site, only 80% of eligible adults with diabetes completed annual kidney health evaluations, below the NCQA HEDIS KED national benchmark of 90%. Contributing barriers included inconsistent ordering practices, workflow inefficiencies, and underutilized point-of-care testing. The absence of a standardized system-based process limited screening consistency and early disease identification. Objective: This quality improvement initiative’s objective was to evaluate how the implementation of a standardized electronic health records (EHR) “Diabetes Workup” order set, adopting a new office workflow, and use of a provider decision-support flowchart versus standard practice had effect on uACR screening compliance rates over 16 weeks for adult patients with diabetes mellitus in an outpatient clinic. The primary goal was to achieve a 10% increase in KED HEDIS screening compliance compared to the previous year. Methods: This 16-week pre-post albuminuria quality improvement project was conducted in a primary care clinic in Orange County, California. Participants included three primary care providers and an interprofessional team of nurses, medical assistants, and quality staff. Data was collected tracked and collected by the organization’s quality team using COZEVA quality reports. Results: After the 13-week implementation period, KED performance rates improved from 80.24% in 2024 to 87.43% in 2025, nearly reaching the project goal of a 10% increase. uACR screening rates among 250 eligible patients showed an upward trend, particularly in December 2025 and January 2026 of 90.74% and 92.50% respectively. The provider knowledge of frequency of screening and antiproteinuric therapy remained unchanged in pre-and-post intervention, with baseline at 100%. Conclusion: This DNP-led quality improvement initiative demonstrated that small, scalable interventions are effective in improving evidence-based DKD screening practices.

Critical care nurses are exposed to high-acuity, emotionally demanding environments that contribute to elevated stress and burnout. Burnout is associated with emotional exhaustion, decreased job satisfaction, increased turnover, and potential negative impacts on patient safety and quality of care. Although mindfulness-based interventions (MBIs) have demonstrated effectiveness in reducing stress and improving resilience, their implementation in inpatient critical care settings remains limited. The purpose of this Doctor of Nursing Practice (DNP) quality improvement (QI) project was to implement and evaluate an 8-week MBI to reduce stress and burnout while improving Keyword: mindfulness among critical care nurses in an intensive care unit (ICU), and to assess feasibility and acceptability, poster, DNP Scholarly Project Poster 2026 This project utilized a pre- and post-intervention QI design guided by the Johns Hopkins Nursing Evidence-Based Practice Model. The intervention consisted of an 8-week mindfulness-based stress reduction program (MBSR), delivered via weekly 5–10 minute guided electronic sessions (e.g., diaphragmatic breathing, mindful movement, gratitude reflection, and visualization). Participants were encouraged to practice mindfulness independently two to three times weekly. Outcome measures included burnout, perceived stress, and mindfulness, assessed using the Modified Maslach Burnout Inventory (MBI), Perceived Stress Scale (PSS), and Mindful Attention Awareness Scale (MAAS) at baseline, Week 4, and Week 8. Feasibility was evaluated using recruitment, retention, attendance, time burden, and participant feedback. Data were analyzed using descriptive statistics and non-paired samples t-tests. A total of 63 critical nurses enrolled, with 47 completing the intervention (74% retention). Burnout decreased from moderate at baseline to low levels post-intervention. Perceived stress declined from moderate (M = 20.1) at baseline to low levels (M = 7.5) at Week 8. Mindfulness increased from moderate (M = 3.16) at baseline to high levels (M = 5.26) post-intervention. Feasibility outcomes demonstrated strong engagement, high completion rates, and positive participant feedback, supporting acceptability within a high-acuity environment. Findings suggest that a brief MBI is both feasible and effective in reducing burnout and stress while enhancing mindfulness among critical care nurses. The findings support the integration of low-burden mindfulness strategies into nursing workflows as a scalable, evidence-based intervention to improve nurse well-being, reduce burnout in critical care settings, and guide broader organizational wellness initiatives.

Background: Chemotherapy-Induced Nausea and Vomiting (CINV) affects over 60% of oncology patients, and can cause dehydration, treatment disruption, and life-threatening emergencies. Current CINV guidelines recommend pharm & non-pharmacological methods to relieve CINV, however, multiple factors may impair self-management.

Objective: This project aimed to improve CINV self-management in a Southern Californian outpatient breast cancer clinic by integrating nurse-led written education, telephone follow-up, and a standardized CINV assessment tool into the existing practice flow.

Interventions/ Methods: The project was a pre/post quality improvement (QI) initiative. Baseline data were obtained via EHR chart review to evaluate CINV symptoms and antiemetic use in breast cancer patients receiving highly emetogenic chemotherapy (HEC). The intervention consisted of a nurse-led CINV patient education handout & antiemetic review, post-chemotherapy follow-up at 24 hrs and 96 hrs (acute & delayed CINV) with education reinforcement, and standardized CINV assessment using the Multinational Association of Supportive Care in Cancer (MASCC) Antiemesis Tool (MAT). Primary outcomes were CINV symptoms and antiemetic use.

Results: Antiemetic usage increased for initial encounters, all encounters, and first use patients post-intervention. Overall, CINV symptoms reduced from (94.7% to 41.7%) pre to post-intervention. 100% antiemetic adherence was seen in initial encounter and first use patients experiencing CINV. Prophylactic antiemetic use in all categories increased post-intervention.

Conclusions: This QI project demonstrated benefits of nurse-led written education, post-chemo follow-up, and a standardized CINV assessment tool. Outcomes included improved adherence to abortive and prophylactic antiemetic regimens and reduced CINV symptoms.

Implications for Oncology Nursing Practice: The QI project success and future expansion across oncology specialties ensures health equity, clinical consistency, and improved patient outcomes. Addressing CINV self-management improves hydration, nutrition, and experience promoting treatment adherence, quality of life, and, ideally, disease remission. Utilization of standardized materials and evidence-based assessment tools serve as a scalable framework for enhancing interprofessional collaboration, patient monitoring, and patient-provider communication.

Purpose: To develop and implement a Structured Handoff from the operating room (OR) to pediatric cardiovascular intensive care unit (CVICU) to improve interdisciplinary team participation, completeness and timeliness of handoff information, and team satisfaction at a Southern California Children’s Hospital. Background: Ineffective handoffs have been identified as the 3rd most common cause of medical error and posing a significant threat to patient safety. Hand-offs from the OR to the pediatric CVICU represent one of the most demanding care transfers and, if inadequate, may result in loss or unreliable information and adverse events. Despite the Joint Commission recognition as an important patient safety goal, some centers have not incorporated handoff standards among their interdisciplinary teams. Methods: An Evidence Based Practice (EBP) methodology guided development of the handoff tool using current literature and unit-specific workflows. The tool was refined through staff and provider feedback and implemented over 14 weeks. Data collection occurred across three phases: pre-intervention, intervention, and post-intervention. Each phase included a minimum of 4 direct handoff observations assessing the outcome measures of timeliness of report, team member presence, and completeness of information. Staff satisfaction surveys were administered both pre- and post-intervention to evaluate satisfaction with the handoff report. Outcomes: Out of 33 surgical cases during 14-week implementation, 30 Handoff Forms were completed reporting a 91% utilization. Use of the form improved team participation (pre-85.7 vs. post-92.7%; 7.2% ↑), documentation accuracy (pre-83.5% vs. post-87.4%; 3.9% ↑) and staff satisfaction (pre-67% to post-80%; 13% ↑) with current handoff procedure. However, timeliness of report was longer (pre-12.3 minutes vs. post-25.5 minutes; 13.2 minutes↓). Ongoing challenges reported qualitatively in the post-survey were distractions in post-operative tasks and variability in adherence to handoff report process. Conclusions: This project demonstrated successful use of a EBP standardized handoff report form for patients transferred from the OR to the pediatric CVICU. Use of the form improved team participation, documentation accuracy, and staff satisfaction. While implementation resulted in longer report times, this was likely due to higher surgical complexity. Clinical Implications: This form can be adapted for other surgical units to drive system-wide, sustainable, interdisciplinary tracking.

Background and Significance

Vietnamese Americans experience disproportionately high rates of T2DM. Diabetic patients experience healthcare costs 2.6 times higher than healthy patients, as it leads to complications such as heart disease, stroke, kidney failure, and amputations. Culturally appropriate health education has been shown to significantly improve glycemic control and diabetes knowledge among ethnic minorities. The purpose of this quality improvement project is to enhance type 2 diabetes mellitus (T2DM) education for Vietnamese-speaking patients by integrating culturally and linguistically tailored education materials into a digital platform and handouts within a busy clinic workflow.

Method

This project was implemented at an endocrinology clinic for 10 weeks. All providers (3 nurse practitioners) and medical assistants (4 MAs) were invited. The intervention included a bilingual diabetes education website and bilingual handouts covering key diabetes self-management information. Educational content was written at a fifth to sixth-grade reading level and includes visuals, case examples, and videos. These resources were part of the new clinic workflow where bilingual educational handouts and website flyers are handed out by MAs upon check in and providers encourage patients to review the available materials. All MAs and providers receive training on the new workflow and educational materials prior to implementation.

MA’s consistency was measured weekly by the percentage of patients receiving educational materials. Providers’ consistency was measured weekly by their self-report percentage of patients receiving recommendation to review educational materials. Patient engagement was defined as reading handouts, reviewing the website, and willingness to follow the recommendations, and was measured through surveys embedded in the website. The project lead conducted site visits to monitor progress and ensure consistent implementation. Data was analyzed using descriptive statistics, with all information de-identified and securely stored in accordance with institutional and clinic policies.

Results

All 4 MAs and 3 NPs participated. Total 72 patients had clinical encounters during implementation (n=72). MA’s consistency was 41.7% (n=30). It varied significantly from 0% to 100%. Provider consistency was initially low (0–25%), improved during Weeks 6–7 (76–100%), declined again during Weeks 8–9, and partially improved in Week 10 (51–100%).

Of 30 Vietnamese patients receiving materials, 16.7% accessed the website (n=5), with highest views in community resources, diet, and exercise content. Video engagement could not be tracked due to technical difficulty. No blog comments were left. Only one patient completed the survey, limiting evaluation of willingness to follow recommendations.

Despite having reported barriers of time constraints (71.4%) and forgetfulness (28.6%) from participants (n=7), 85.8 % participants rated the workflow as easy to neutral.

Conclusions

The project demonstrated that culturally and linguistically tailored materials like online materials can be successfully integrated into routine clinical workflows and delivered to patients.