Sue & Bill Gross School of Nursing

Purpose: Palliative care (PC) is a medical service that provides physical and emotional care to individuals living with a chronic disease such as cancer. Although PC can significantly improve quality of life, there are numerous barriers that negatively affect patient engagement with the service. One of the primary barriers that has been identified is lack of patient knowledge about PC. The purpose of this quality improvement (QI) project was to increase cancer patient engagement with PC services by implementing an educational intervention at the time of referral. Methods: The Johns Hopkins Evidenced-Based Practice (EBP) Model guided the development and implementation of the project. The intervention was an educational brochure about PC developed by the National Cancer Institute. A pre-post practice change design was utilized, with outcomes being collected from the electronic medical record pre- and post-intervention. Outcomes included the number of PC referrals made and the percentage of those referrals scheduled as appointments. Data regarding barriers and facilitators to project implementation by the 8 participating clinicians were collected via weekly and post-intervention surveys using electronic data capture. Results: Pre-data were collected over a 5-week period, during which time 13 patients received PC referrals and 9 (69%) scheduled their initial appointment. Throughout the course of the 6-week implementation period, 17 patients received PC referrals and 6 (35%) scheduled their initial appointment. Of the 8 clinician participants, 4 completed the post-intervention survey. Two respondents reported utilization of the intervention less than 25% of the time and the other two did not refer a patient to PC during the implementation period. Three clinicians who completed the post-intervention survey expressed a future desire to use the intervention in their practice. Common barriers to intervention utilization identified in the survey included limited time in appointments and heavy workloads. Conclusion: Findings reveal multiple barriers faced by the project site to PC provision and access. The PC clinic also experienced significant increases in patient volume during the implementation period, which impacted the ability of new referrals to be seen in a timely manner. Further exploration is needed to determine how clinicians, patients, and site leadership can best overcome these challenges.

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.

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.

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: A significant concern contributing to morbidity and mortality among perioperative population is Surgical Site Infections (SSIs) compromising patient safety, readmissions and healthcare cost. In Same Day Services (SDS), variation in preoperative hygiene education and documentation created opportunities to improve workflow, standardize nursing practice and support reliable patient optimization prior to surgery. Purpose/Aims: The purpose of the Doctor of Nursing Practice (DNP) quality improvement (QI) was to implement a nurse-driven preoperative optimization bundle to improve workflow consistency, strengthen chlorhexidine gluconate hygiene (CHG) education and promote standardized documentation among SDS nurses. Methods: The QI project was implemented over a four-week period at a Magnet designated hospital ambulatory SDS within the perioperative department in Orange County, California. The intervention consisted of staff education, laminated patient centered educational materials, a QR linked digital toolkit, nurse champion support and an Epic SmartPhrase utilization among eligible preoperative encounters along with a pre/post survey findings related to nurse confidence, workflow clarity and feasibility. Findings: A total of 34 of 42 preoperative nurses received education on the optimization bundle, achieving 80.9% staff education reach. SmartPhrase usage increased across the implementation phase, reflecting improved documentation consistency among preoperative encounters meeting inclusion criteria. Post-implementation survey findings demonstrated an increase perceived workflow clarity and viability of using the standardize bundle in practice from 42% at baseline to 80% after implementation. Improvement was also observed in nurse confidence and consistency of CHG education practices. Conclusion: A nurse-driven preoperative optimization bundle supported more consistent preoperative education and documentation practices in SDS. The QI initiative highlighted the role of nursing leadership in translating evidence-based perioperative practices into sustainable improved workflow processes. Continued reinforcement, electronic medical record (EMR) integration and leadership guidance may further strengthen adoption and long-term sustainability.