Improving Case History
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This document describes a quality improvement project to improve case history documentation for undergraduate medical students. The project aimed to ensure students were achieving structured case history taking and receiving feedback. Students were introduced to a standardized clerking proforma and asked to submit two case histories per week of their rotations. Their case submissions and feedback were kept in individual files to track their progress and identify underperforming students. This provided evidence of student engagement for quality assurance visits. The changes improved documentation of student learning objectives and skills development.
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Journal of Perioperative Nursing in Australia Volume 29 Number 1 Autumn 2016 acorn.org.au30
Peer-reviewed article
Handover between anaesthetists
and post-anaesthetic care
unit nursing staff using
ISBAR principles: A quality
improvement study
Authors
Patricia Kitney
RN, BAppSc-Nsg, DAppSc-Nsg Ed, MEd
(Research), GradCert LdrshipEdTrng,
GradCertPeriop
Western Health, Sunshine, Vic
Raymond Tam
MBBS FANZCA
Western Health, Sunshine, Vic
Paul Bennett
RN BN GradCertSc (App Stats) MHSM PhD
Deakin University, Geelong, Victoria,
Western Health – Nursing Research
Centre, Sunshine, Vic
Dianne Buttigieg
RN, BHSc (Nursing), Grad Cert Periop Nsg,
DipMgt
Western Health, Sunshine, Vic
David Bramley
MBBS MPH FANZCA
Western Health, Sunshine, Vic
Wei Wang
Msc (Stats) GdipSci (Stats) MD PhD
Deakin University, Geelong, Vic
Corresponding author
Patricia Kitney
Clinical Nurse Educator - Perioperative
Services
Western Health, Gordon Street, Footscray
VIC 3011
Tel. 03 8345 0506
[email protected]
Abstract
A structured approach to communication between health care
professionals contains introduction/identification; situation;
background; assessment and request/recommendation (ISBAR).
ISBAR was introduced into the post-anaesthetic care unit (PACU)
of a large Victorian health service in 2013. The aim of this study
was to measure the effect of an education program on ISBAR
compliance.
Method: A pre/post-test design using a 14-item audit tool was used to
measure compliance to ISBAR before and after an education intervention in
two acute hospitals in Melbourne, Victoria. The intervention consisted of one
30-minute education session to anaesthetists, and two 30-minute education
sessions to PACU nurses, combined with visual cues using ISBAR wall posters.
Results: In Hospital A, significant improvement from pre- to post-audit
was found in the items of cardiovascular assessment (χ2 (1) = 4.06, p < .05),
respiratory assessment (χ2 (1) = 12.85, p < .01), analgesia assessment and
actions (Fisher’s exact test p < .05) and responsibility + referral (χ2 (1) = 4.44,
p < .05). For Hospital B significant improvement was found in communication
difficulties (χ2 (2) = 13.55, p < .01) and significant decreased performance was
found in respiratory assessment (χ2 (1) = 8.98, p < .01) and responsibility +
referral (χ2 (1) = 13.26, p < .01).
Implication for practice: The results from this study cohort suggest an
augmented education program may produce mixed results for ISBAR
compliance. More than education and visual tools may be required to improve
PACU ISBAR compli ...
02
1) The Transition Program was designed to help medical students smoothly transition from clinical skills training in a simulation lab to applying those skills with real patients in clinical settings.
2) It recruited clinical skills tutors and medical staff to supervise students during supervised practice sessions in hospital departments. Tutors were trained on the simulation lab's teaching methods.
3) Students who completed the simulation lab course could book supervised sessions through an online system to practice skills like examinations, procedures, and communication with patients under expert supervision.
4) Initial feedback from students has been positive, finding value in gaining experience with real patients under supervision to bridge the gap between simulation and clinical practice. Further evaluation of the program's effectiveness is still
MDT round protocol of yekatit 12 Hospital medical college.pdf
This document outlines protocols for multidisciplinary team (MDT) rounds at Yekatit 12 Hospital Medical College. Key points include:
1. MDT rounds involve multiple care team members like doctors, nurses, pharmacists discussing patient care in real-time to coordinate care, establish goals, and plan discharge.
2. MDT rounds are done twice daily at the hospital to review all patients, evaluate new/critical cases, and ensure quality of care.
3. The rounds are led by senior consultants and include evaluating clinical status, nursing care, medication practices, and patient/family engagement.
4. Data from the rounds is documented and used for daily clinical audits to improve departmental
Clinical Practicum CPCU at Tanner Medical Center Reflection Paper.pdf
The document is a reflection paper from a nursing student about their clinical practicum experiences at an intensive care unit and emergency department. It discusses four key themes: 1) The experience involved intense emotions for students, both positive feelings from patient improvements and negative feelings from serious situations and death. 2) Attitudes are important over techniques in caring for critically ill patients. 3) Students identified with nurses who could manage complex environments and provide close care to patients. 4) Students reflected on how to improve care for critically ill patients and their families.
Clasbi poster 6 2014 final
This document summarizes a project to reduce central line-associated bloodstream infections (CLABSIs) in non-intensive care unit settings. The hospital conducted education and training for nurses on appropriate central line care and maintenance. This included videos, demonstrations and skills assessments. They also implemented chlorhexidine bathing and daily line audits. Following these interventions between January 2012 and July 2013, they observed a 67% reduction in CLABSIs in non-ICU patients. The conclusion is that standardizing education and care practices can help reduce infections from central lines outside the ICU.
1 Quantitative Syno
1
Quantitative Synopsis and Appraisal
Studentfirstname Studentlastname, Studentfirstname Studentlastname, Studentfirstname
Studentlastname, Studentfirstname Studentlastname
College of Nursing, Resurrection University
NUR4440: Research in Nursing
Professor Carina Piccinini
February 14, 2020
2
Quantitative Appraisal and Synopsis
The purpose of this paper is to summarize and appraise a research study testing the use of
disinfectant caps on intravenous (IV lines) to reduce the rate of hospital associated bloodstream
infections (BSI). The Centers for Disease Control and Prevention (CDC, 2019) reports that
central line associated bloodstream infections (CLABSI) remain a major concern in hospital
settings causing fatalities, increased length of stay, and increased costs. The CDC (2019)
recommends proper maintenance of intravenous lines to reduce the risk of infection. Current
research is still looking to define what proper maintenance should be, including whether
disinfectant caps influence rates of infection for intravenous (IV) lines.
Summary of the Study
The CDC recommends that healthcare workers disinfect all needleless connectors for
peripheral and central IVs prior to connection to reduce the risk of CLABSIs without further
recommendation on the type or length of disinfections. The authors of this study note other
studies have tested disinfecting caps and sought to confirm those results.
Merrill et al. (2014) conducted a quasi-experimental study to identify if disinfectant caps
reduce CLABSI incidence and the relationship between nursing compliance with the caps and
CLABSI rates. This study was held in a single Trauma 1 hospital with 430 beds in the United
States.
The researchers obtained their sample through nonrandom convenience sampling by
including all patients meeting inclusion criteria at the hospital starting January 2012. Participants
were included if they had a central or peripheral intravenous line, of any age, and were admitted
to 13 specific hospital floors. Subjects were excluded if they were on the following floors:
emergency department; labor, delivery or post-partum; ambulatory care, surgical services; and
3
well-baby nursery. The study did not report any demographic information about participants, the
number of participants, or attrition or loss to follow up.
The intervention involved applying a Curos brand disinfectant cap to all ports on
peripheral lines, central lines, and IV tubing when not in use on patients. The nurses on the
involved units were trained on the use of the disinfectant caps with a 1:1 follow up by the
researchers. Nurses were then responsible for placing caps. The researchers intermittently
observing nurses for compliance to the intervention and reporting compliance to nursing
departments twice a week.
CLABSIs were defined as a positive blood culture drawn within 48 hours symptom onset,
and C ...
1 Quantitative Syno
The document summarizes a study that tested the use of disinfectant caps on intravenous (IV) lines to reduce the rate of hospital-associated bloodstream infections (BSIs). The study found that using disinfectant caps on IV ports decreased the mean rate of central line-associated BSIs from 1.5 infections per month before the intervention to 0.88 infections after. However, the study had limitations such as lack of statistical significance testing for the pre-post infection rates and not accounting for other infection prevention practices. Therefore, more research is needed to fully understand the impact of disinfectant caps on reducing BSIs.
ISBARR The purpose of this project is to practice formulat.docx
ISBARR
The purpose of this project is to practice formulating and delivering patient report to other health professionals using the ISBARR format
Instructions:
1. Find an article on ISBARR (SBAR), summarize, and reflect on how it can be used in communicating assessment findings. Summarize your research on ISBARR/SBAR and cite your reference/s in no less than 500 words
Journal of Perioperative Nursing in Australia Volume 29 Number 1 Autumn 2016 acorn.org.au30
Peer-reviewed article
Handover between anaesthetists
and post-anaesthetic care
unit nursing staff using
ISBAR principles: A quality
improvement study
Authors
Patricia Kitney
RN, BAppSc-Nsg, DAppSc-Nsg Ed, MEd
(Research), GradCert LdrshipEdTrng,
GradCertPeriop
Western Health, Sunshine, Vic
Raymond Tam
MBBS FANZCA
Western Health, Sunshine, Vic
Paul Bennett
RN BN GradCertSc (App Stats) MHSM PhD
Deakin University, Geelong, Victoria,
Western Health – Nursing Research
Centre, Sunshine, Vic
Dianne Buttigieg
RN, BHSc (Nursing), Grad Cert Periop Nsg,
DipMgt
Western Health, Sunshine, Vic
David Bramley
MBBS MPH FANZCA
Western Health, Sunshine, Vic
Wei Wang
Msc (Stats) GdipSci (Stats) MD PhD
Deakin University, Geelong, Vic
Corresponding author
Patricia Kitney
Clinical Nurse Educator - Perioperative
Services
Western Health, Gordon Street, Footscray
VIC 3011
Tel. 03 8345 0506
[email protected]
Abstract
A structured approach to communication between health care
professionals contains introduction/identification; situation;
background; assessment and request/recommendation (ISBAR).
ISBAR was introduced into the post-anaesthetic care unit (PACU)
of a large Victorian health service in 2013. The aim of this study
was to measure the effect of an education program on ISBAR
compliance.
Method: A pre/post-test design using a 14-item audit tool was used to
measure compliance to ISBAR before and after an education intervention in
two acute hospitals in Melbourne, Victoria. The intervention consisted of one
30-minute education session to anaesthetists, and two 30-minute education
sessions to PACU nurses, combined with visual cues using ISBAR wall posters.
Results: In Hospital A, significant improvement from pre- to post-audit
was found in the items of cardiovascular assessment (χ2 (1) = 4.06, p < .05),
respiratory assessment (χ2 (1) = 12.85, p < .01), analgesia assessment and
actions (Fisher’s exact test p < .05) and responsibility + referral (χ2 (1) = 4.44,
p < .05). For Hospital B significant improvement was found in communication
difficulties (χ2 (2) = 13.55, p < .01) and significant decreased performance was
found in respiratory assessment (χ2 (1) = 8.98, p < .01) and responsibility +
referral (χ2 (1) = 13.26, p < .01).
Implication for practice: The results from this study cohort suggest an
augmented education program may produce mixed results for ISBAR
compliance. More than education and visual tools may be required to improve
PACU ISBAR compli ...
ISBARR The purpose of this project is to practice formulat.docx
ISBARR
The purpose of this project is to practice formulating and delivering patient report to other health professionals using the ISBARR format
Instructions:
1. Find an article on ISBARR (SBAR), summarize, and reflect on how it can be used in communicating assessment findings. Summarize your research on ISBARR/SBAR and cite your reference/s in no less than 500 words
Journal of Perioperative Nursing in Australia Volume 29 Number 1 Autumn 2016 acorn.org.au30
Peer-reviewed article
Handover between anaesthetists
and post-anaesthetic care
unit nursing staff using
ISBAR principles: A quality
improvement study
Authors
Patricia Kitney
RN, BAppSc-Nsg, DAppSc-Nsg Ed, MEd
(Research), GradCert LdrshipEdTrng,
GradCertPeriop
Western Health, Sunshine, Vic
Raymond Tam
MBBS FANZCA
Western Health, Sunshine, Vic
Paul Bennett
RN BN GradCertSc (App Stats) MHSM PhD
Deakin University, Geelong, Victoria,
Western Health – Nursing Research
Centre, Sunshine, Vic
Dianne Buttigieg
RN, BHSc (Nursing), Grad Cert Periop Nsg,
DipMgt
Western Health, Sunshine, Vic
David Bramley
MBBS MPH FANZCA
Western Health, Sunshine, Vic
Wei Wang
Msc (Stats) GdipSci (Stats) MD PhD
Deakin University, Geelong, Vic
Corresponding author
Patricia Kitney
Clinical Nurse Educator - Perioperative
Services
Western Health, Gordon Street, Footscray
VIC 3011
Tel. 03 8345 0506
[email protected]
Abstract
A structured approach to communication between health care
professionals contains introduction/identification; situation;
background; assessment and request/recommendation (ISBAR).
ISBAR was introduced into the post-anaesthetic care unit (PACU)
of a large Victorian health service in 2013. The aim of this study
was to measure the effect of an education program on ISBAR
compliance.
Method: A pre/post-test design using a 14-item audit tool was used to
measure compliance to ISBAR before and after an education intervention in
two acute hospitals in Melbourne, Victoria. The intervention consisted of one
30-minute education session to anaesthetists, and two 30-minute education
sessions to PACU nurses, combined with visual cues using ISBAR wall posters.
Results: In Hospital A, significant improvement from pre- to post-audit
was found in the items of cardiovascular assessment (χ2 (1) = 4.06, p < .05),
respiratory assessment (χ2 (1) = 12.85, p < .01), analgesia assessment and
actions (Fisher’s exact test p < .05) and responsibility + referral (χ2 (1) = 4.44,
p < .05). For Hospital B significant improvement was found in communication
difficulties (χ2 (2) = 13.55, p < .01) and significant decreased performance was
found in respiratory assessment (χ2 (1) = 8.98, p < .01) and responsibility +
referral (χ2 (1) = 13.26, p < .01).
Implication for practice: The results from this study cohort suggest an
augmented education program may produce mixed results for ISBAR
compliance. More than education and visual tools may be required to improve
PACU ISBAR compli ...
Obtaining Patient Information and Anxiety in Novice Nursing Students ,Article...
Novice nursing students experience high anxiety levels during their first clinical rotation due to a lack of experience in unfamiliar clinical environments. This study assessed anxiety levels and the ability of novice nursing students to obtain essential patient information from the previous shift at the beginning, middle, and end of their first clinical rotation. The study found that students' anxiety levels decreased significantly over the course of the rotation as they gained experience. While students improved at obtaining some information like vital signs and lab results, less than half obtained pain levels at any point. The study recommends providing clearer guidance to students on essential information to obtain from shift reports.
Running head INDIVIDUAL SUCCESS PLAN1INDIVIDUAL SUCCESS PLAN.docx
Running head: INDIVIDUAL SUCCESS PLAN1
INDIVIDUAL SUCCESS PLAN2
NRS 490: Self-Assessment and Individual Success Plan
Name: Nanah Kamara
Institution: GCU
Application-based Learning Course Assignments
List of Current Course Objectives
Number of Clock Hours Associated with Each Assignment
Assignment
Date Due
Self-Assessment:
GCU RN-to-BSN
University Mission Critical Competencies and
Programmatic Domains & Competencies
(see Appendix A)
Date
Assignment
Completed
Week 1
· My professional capstone & documentation of the practicum process
· My personal success Strategy
· My professional capstone & a reflective journal of the practicum process, among other scholarly/ academic activities
i. Acknowledging of the issues, along with determining of the opportunities for providing and improving patient care, the care outcome, and clinical procedures.
ii. Examine likely and existent clinical and healthcare problems and their implication in the practice.
iii. Come up with some evidence-based solutions for leveraging the quality of patient care and address care problems.
iv. Use PICOT process to investigate the clinical care problems.
v. Exemplify knowledge and skills valued in care delivery that are consistent with the professional role of nursing (Gemuenden & Lechler, 2014).
10
1/13/2020
The Effective Communication (MCI): Therapeutic communication is central to baccalaureate nursing practice. Students gain an understanding of their ethical responsibility and how verbal and written communication affects others intellectually and emotionally. Students begin to use nursing terminology and taxonomies within the practice of professional and therapeutic communication. Courses require students to write scholarly papers, prepare presentations, develop persuasive arguments, and engage in discussion that is clear, assertive, and respectful (GCU, 2015).
1/19/2020
Week 2
· Selecting the topic for my capstone project and forwarding for approval
· clarifying the statement for my topic II, practicing, and assigning of time for its completion
i. Identification of the issues, along with determining of the opportunities for providing and improving patient care, the care outcome, and clinical procedures.
ii. Examine likely and existent clinical and healthcare problems and their implication in the practice.
iii. Come up with some evidence-based solutions for leveraging the quality of patient care and address care problems.
iv. Use PICOT process to investigate the clinical care problems.
v. Exemplify knowledge and skills valued in care delivery that are consistent with the professional role of nursing (Gemuenden & Lechler, 2014).
10
1/20/2020
MC2: Critical Thinking: Courses require students to use critical thinking skills by analyzing, synthesizing, and evaluating scientific evidence needed to improve patient outcomes and professional practice (GCU, 2015).
MC4:Global Awareness, Perspectives, and Ethics: The concept of global citizenship is introduced to bac.
Running head INDIVIDUAL SUCCESS PLAN1INDIVIDUAL SUCCESS PLAN.docx
Running head: INDIVIDUAL SUCCESS PLAN1
INDIVIDUAL SUCCESS PLAN2
NRS 490: Self-Assessment and Individual Success Plan
Name: Nanah Kamara
Institution: GCU
Application-based Learning Course Assignments
List of Current Course Objectives
Number of Clock Hours Associated with Each Assignment
Assignment
Date Due
Self-Assessment:
GCU RN-to-BSN
University Mission Critical Competencies and
Programmatic Domains & Competencies
(see Appendix A)
Date
Assignment
Completed
Week 1
· My professional capstone & documentation of the practicum process
· My personal success Strategy
· My professional capstone & a reflective journal of the practicum process, among other scholarly/ academic activities
i. Acknowledging of the issues, along with determining of the opportunities for providing and improving patient care, the care outcome, and clinical procedures.
ii. Examine likely and existent clinical and healthcare problems and their implication in the practice.
iii. Come up with some evidence-based solutions for leveraging the quality of patient care and address care problems.
iv. Use PICOT process to investigate the clinical care problems.
v. Exemplify knowledge and skills valued in care delivery that are consistent with the professional role of nursing (Gemuenden & Lechler, 2014).
10
1/13/2020
The Effective Communication (MCI): Therapeutic communication is central to baccalaureate nursing practice. Students gain an understanding of their ethical responsibility and how verbal and written communication affects others intellectually and emotionally. Students begin to use nursing terminology and taxonomies within the practice of professional and therapeutic communication. Courses require students to write scholarly papers, prepare presentations, develop persuasive arguments, and engage in discussion that is clear, assertive, and respectful (GCU, 2015).
1/19/2020
Week 2
· Selecting the topic for my capstone project and forwarding for approval
· clarifying the statement for my topic II, practicing, and assigning of time for its completion
i. Identification of the issues, along with determining of the opportunities for providing and improving patient care, the care outcome, and clinical procedures.
ii. Examine likely and existent clinical and healthcare problems and their implication in the practice.
iii. Come up with some evidence-based solutions for leveraging the quality of patient care and address care problems.
iv. Use PICOT process to investigate the clinical care problems.
v. Exemplify knowledge and skills valued in care delivery that are consistent with the professional role of nursing (Gemuenden & Lechler, 2014).
10
1/20/2020
MC2: Critical Thinking: Courses require students to use critical thinking skills by analyzing, synthesizing, and evaluating scientific evidence needed to improve patient outcomes and professional practice (GCU, 2015).
MC4:Global Awareness, Perspectives, and Ethics: The concept of global citizenship is introduced to bac ...
Similar to Improving Case History (20)
Using Data to Overcome Recruitment and Retention Issues for Stroke Patients
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ISBARR The purpose of this project is to practice formulat
ISBARR The purpose of this project is to practice formulat
MDT round protocol of yekatit 12 Hospital medical college.pdf
MDT round protocol of yekatit 12 Hospital medical college.pdf
Clinical Practicum CPCU at Tanner Medical Center Reflection Paper.pdf
Clinical Practicum CPCU at Tanner Medical Center Reflection Paper.pdf
ISBARR The purpose of this project is to practice formulat.docx
ISBARR The purpose of this project is to practice formulat.docx
ISBARR The purpose of this project is to practice formulat.docx
ISBARR The purpose of this project is to practice formulat.docx
Obtaining Patient Information and Anxiety in Novice Nursing Students ,Article...
Obtaining Patient Information and Anxiety in Novice Nursing Students ,Article...
Running head INDIVIDUAL SUCCESS PLAN1INDIVIDUAL SUCCESS PLAN.docx
Running head INDIVIDUAL SUCCESS PLAN1INDIVIDUAL SUCCESS PLAN.docx
Running head INDIVIDUAL SUCCESS PLAN1INDIVIDUAL SUCCESS PLAN.docx
Running head INDIVIDUAL SUCCESS PLAN1INDIVIDUAL SUCCESS PLAN.docx
Improving Case History
- 1. Improving “Case History” clerking for Undergraduate Medical students (Clinical Phase 1) : Project 2014. K Jacob 1 , R M Koshy 2 , A Rizvi 1 Affiations:- 1. Pilgrim Hospital, Boston, ULHT, Lincolnshire. 2. Kings College, London 1. Why did a QI project need to be done? Every year, 14 Clinical Phase 1 undergraduate students (3rd year) from Nottingham university are posted to Pilgrim Hospital, Boston from March until June. They have a common, initial 2 weeks of induction followed by half the students posted in Medicine and the other half in Surgery. Midcourse both batches rotate to opposite discipline. Whilst in Medicine, the major aim is taking clinical case history, examination and note keeping. Currently there is no effective way to demonstrate students were achieving training in structured case history taking, exposure to all systems as well as feedback or reflection. During a Quality assurance visit from the deanery there was a paucity of records to demonstrate student engagement in the learning objectives. 2. What did you do to address the issue? We discussed the issue and decided to use the “SMART” goal setting to achieve our objective in 2014. 3. What is the outcome from your intervention? Each student had a named file where all their submitted case histories were kept. Feedback and reflection occurred. Each file demonstrated the studentʼs progress and also doubled as evidence towards Deanery Quality Control visit. The module lead was able to identify less performing students, investigate and organise support effectively. 4. What lessons have been learnt & how have you shared them? I have continued with this project for CP1 students in 2015. Changes were made to further improve the training. Whilst posted to acute medicine unit, a case demonstrating SEPSIS 6 usage and a reflection on DNAR is required. The Undergraduate co-ordinator monitors compliance and provides reminders to students in a timely fashion Improving Case History taking CP1 Medicine Procedure SPECIFIC Improving case history writing by using standardised Trust clerking proforma. Exposure to system specific history taking and examination by rotation in subspecialty wards like CCU, Respiratory, stroke etc. Understanding usage of risk scoring, note keeping and patient confidentiality. During Induction, students were introduced to the Trust medical clerking Proforma and were asked to use them for writing patient case history and examination. The proforma has incorporated risk assessment scoring like AMTS, CURB65, and ABCD2. Introduced to medical record keeping and patient confidentiality. Comments MEASURABLE During each subspecialty week, a minimum of 2 clinical cases had to be completed. Review of clerking helps in identifying the underperforming student. ASSIGNABLE Students rotated through subspecialty according to rota and were required to take case history in that particular system. Both cases had to be completed by the end of the week and following student reflection and feedback was filed in their individual file kept at the postgraduate centre. Feedback was provided either by educational supervisor or clinical teaching fellow Students have access to their files and could refer to them and learn from their mistakes. Files were routinely inspected by module lead for monitoring progress of student. Evidence for Deanery during Quality Control Visit. REALISTIC The minimum requirement of two cases per week was achievable. Progressive improvement was noticeable TIME RELATED Two cases had to be completed by the end of the week. Students didnʼt find the task oner- ous and enjoyed doing it.