Purpose: Falls are a common occurrence in the ambulatory care setting and can lead to unintended patient harm and work-related injury. Fall rates at the site remained a concern. An evidence-based approach was sought. The purpose of this quantitative, quasi-experimental quality improvement project in two ambulatory care departments was to determine if or to what degree the bedside mobility assessment tool (BMAT) used in conjunction with current fall practices would impact fall rates in the ambulatory setting in Southern California over four weeks.
Description: The safety of patients is threatened by the possibility of falls when receiving ambulatory care services. This issue impacts patients’ health and outcomes, but there is also a substantial financial impact on the healthcare community. This project used nursing mobility assessment and safe patient handling and mobilization (SPHM) technology based on the patient’s mobility level. The BMAT instructs nurses to guide patients through a four-step functional task list to identify the level of mobility patients can successfully perform. The tool takes both patient and the nursing staff to determine mobility level based on a pass or fail score. The nurses use the patient’s level of mobility and the unique technology needed to lift safely, transfer, and mobilize the patient.
Evaluation/outcome: Emergency department results: The total sample population of N=10,469, n= 5,456 in the comparative group, and n= 5,013 in the implementation group. The fall rate in the comparison group was 0.05% (n=3), and .02% (n=1) in the implementation group. The p-value of .359 showed no statistically significant difference in fall rates. There was, however, a clinical significance as the fall rate was reduced by 0.3% over the project timeline.
Gastroenterology department results: A chi-square test showed a clinical and statistically significant improvement in fall rates X 2 (1, N= 90) = 8.39, p = .004. The results indicate that implementing the BMAT and current fall practices may reduce fall rates in this population and setting.
Summary statistics on the number of work-related injuries were collected. There were four injuries during the comparative period and no injuries during the implementation period. Summary statistics were computed for SPHM technology use within the comparative and implementation group. There was an increase of 10% use of the SPHM technology in the implementation group. Summary statistics were computed for the use of BMAT. Of the 45 patients, 43 (93.3%) were assessed using the BMAT.

Background: CDC reports hypertension (HTN) is the leading risk factor for CVD, which is the leading cause of death in the U.S. Ambulatory blood pressure management (ABPM) is a useful diagnostic tool for the management of HTN. Research found targeted strategies involve intervention to increase awareness, treatment, and control in individuals. White coat effect can be a limitation in blood pressure (BP) results. We examined ABPM with specific format that gives a better picture of the normal fluctuation in BP levels in office and in nurse visits. We examined how provider and nursing intervention can directly affect BP. The plan was to discover if collaboration of nurses and providers could influence adherence, compliance, lifestyle, exercise efforts, and diet. We determined improved clinical outcome as a result of APBM.
Methods: The research involved ABPM during office and nurse visits. We utilized the hypertension dashboard to track patient's with BP over 140/90 and called them to schedule a nurse visit appointment after they were seen by their provider for HTN follow-up. The population studied was those age over 18 years old with BP greater than 140/90. Research methods included observation and interviews with individual patients during office visits with providers and nurse. The study duration was for one year. Intervention involved comprehensive care strategy on lifestyle and adherence to treatment. Home BP readings were also taken under consideration. Patients were encouraged to bring their home BP equipment to their appointments to assure they were well calibrated in comparison to the office equipment. Patients were educated on correct BP monitoring procedure.
Results: Main findings using data: Participants showed improvement in BP after office visit goal setting and nurse visits. ABPM results show importance of education by providers and nurses. The results showed a steady improvement per quarter of BP. The 4th quarter of 2021 showed 75.5% improvement in BP readings. The 1st quarter of 2022 showed 76%, the 2nd quarter of 2022 showed 80.5%, and the 3rd quarter of 2022 showed an 82% improvement in BP readings.
Conclusions/discussion: Findings determined the APBM intervention was successful in demonstrating focused intervention and education with providers and nurses. Results were particularly striking for the approach as it capitalizes on existing patient interest and participation by patient, providers, and nurse. This is significant because it demonstrates provider- and nurse-focused expertise in ABPM. It is a low cost, sustainable strategy for effectively managing HTN in ambulatory care settings. We were able to assess patient's response to antihypertensive therapy. Many patients reported increased stress, decrease in exercise, and increased eating at home related to COVID-19 pandemic. There was an increase in patient follow-up and nurse visit for BP check. Patients had improved experience, improved BP results, increase in satisfaction, and increase in safety and patient health. Providers had improved job satisfaction, improved work life balance, decreased burnout, and decreased turnover. Staff had improved job satisfaction, increased opportunity for growth, and improved team culture.

HEDIS is a performance improvement tool that compare the health care quality with regional and national performance benchmark. According to National Committee for Quality Assurance’s (NCQA) website, “more than 200 million people are enrolled in plans that report HEDIS.” (HEDIS Measures and Technical Resources, 2022). HEDIS measures are used widely due to important implications in health care industries’ performance measures. Although NCQA established many HEDIS measures for 2023, currently our nursing care services report on eleven measures which are considered equally important to improve quality of patient care in outpatient setting: alcohol, positive alcohol follow-ups, cervical cancer, colon cancer, depression, hypertension, influenza, mammogram, pneumococcal vaccine, PTSD, and tobacco screening.
HEDIS measures are calculated as the division of weighted denominator and weighted numerator scored in percentile. In the electronic health record in our primary care clinics, we have a clinical reminder system which nurses access during the clinical encounter to document assessment data tracked as HEDIS measures. Nursing leadership set a goal to improve performance measures using HEDIS data and dedicated time to identify incomplete clinical reminders through weekly reminders to each primary care team. Primary nurses collaboratively worked together on documenting assessment data through the clinical reminder system which translated to higher performance measures and improved patient outcomes. At the end of the month, HEDIS reports are submitted to the nursing executive leadership for recognition and recommendation on strategic plan for improvement. Comparing the initial data of HEDIS measure established in FY19 to current data of FY22, current data shows significant improvement on public health issues such as alcohol, positive alcohol follow-up, tobacco, depression, PTSD, and hypertension. Evidence-based practice research done by the Substance Abuse and Mental Health Services Administration (SAMHSA) correlation on HEDIS measure and substance abuse. Result indicated HEDIS measures can be used as empirical evidence on effective treatment plan to reduce overdose risk for substance abuse patient (Williams and et.al, 2022).
Nursing team have been analyzing HEDIS data focusing on patient’s health care to optimize quality care in outpatient services. Nursing service took ownership over five composites (alcohol, positive alcohol follow-up, tobacco, depression, and PTSD) of HEDIS measures and continuously meeting the target goal among all outpatient settings under our service in FY22. Collaboration of nursing leadership and front-line nursing staff created a target BP workgroup to meet the AHA EBP target BP since FY19. Nursing leadership had been providing the HEDIS data on BP to identify opportunities for improvement and tracking quality improvement set by AHA EBP target BP (< 149/90). The American Heart Association (AHA) recognized our organization on meeting the AHA EBP target blood pressure criteria for the GOLD+ recognition for the 4th year in a row.
References
1) Williams, A. R., Mauro, C. M., Feng, T., Wilson, A., Cruz, A., Olfson, M., Crystal, S., Samples, H., & Chiodo, L. (2022). Performance measurement for opioid use disorder medication treatment and care retention. American Journal of Psychiatry. https://doi.org/10.1176/appi.a...
2) HEDIS Measures and Technical Resources. (2022). NCQA.org. https://www.ncqa.org/hedis/mea...

Importance: Medical assistants are a crucial integrant in the ambulatory care setting. With duties ranging from administrative tasks to complex clinical skills, medical assistants support the flow of the ambulatory care clinic while delivering compassionate care. According to the US Department of Labor, the profession of medical assisting is expected to grow by 29% by 2026. In 2021, amid a global pandemic, many healthcare systems experienced a need for medical assistants. Faced with 87 openings and a 33% turnover rate, it was difficult to keep positions filled. Without candidates available in the hiring pool a workforce development strategy was proposed in the form of a professional apprenticeship.
Methodology: A collaborative approach was taken by clinical education specialists to develop an evidence-based curriculum for medical assistant apprenticeship. It was determined that candidates would be required to meet the criteria for employment and have a high school diploma or GED. Apprentices were interviewed and selected by their hiring clinic. The program was determined to be five weeks of classroom-based learning followed by a three-week period of clinicals in which apprentices were paired with a medical assistant mentor. Following those three weeks, the apprentice had two weeks of orientation and on-the-job training in their hiring clinic. Classroom curriculum was developed to include all cognitive, psychomotor, and affective skills along with didactic lecture and tactile skills practice with evaluation. The clinical period offered learning experiences in both ambulatory primary care and specialty clinics.
Analysis: Effectiveness of the program was assessed through participant and clinical manager evaluation. Metrics monitored included enrollment rate, completion of the program, and employee retention at 90 days, six months, and one year.
Results: Between the dates of 6/7/2021 and 7/15/2022, 66 medical assistants were enrolled and 65 completed the program. The 90-day retention rate was 98% (49/50). The six-month retention rate was 97% (34/35). The one-year retention rate was 73% (11/15). In 2022, there are 21 current openings with an 18% turnover rate. Manager feedback commented on apprentices being positive and flexible and serving as assets to their team. Apprentice feedback noted feeling confident and prepared for the work they complete in their ambulatory care clinics. Apprenticeship offers the potential for career advancement and increased job satisfaction while addressing vacant positions and increased employee retention.

Purpose: The purpose of this project was to implement a behavioral emergency response team (BERT) within ambulatory care (AC) to address aggressive or other behavioral health crises. BERT works to de-escalate situations and minimize patient, visitor, and employee exposure and prevent or mitigate workplace violence. As one of the top four key risks in AC, workplace violence is especially dangerous due to AC’s increased patient volume, isolation from resources, and minimal structured organizational support during aggressive events. Implementing BERT in AC became a priority due to its noted success in inpatient with efficacy at decreasing assaults by 90% and security responses by 93%. With the rise of workplace violence in healthcare as well as the organization’s increased episodes of verbal and aggressive behaviors from patients/visitors in AC, BERT was identified as a strategic goal and priority.
Strategy/implementation/methods:
An interdisciplinary team of nurses, nurse leaders, and a Licensed Clinical Social Worker (LCSW) were tasked with implementing BERT in AC, with nurse leadership oversight. It was determined a BERT would augment nursing interventions during behavioral and aggressive events and a BERT response consisted of LCSW, Security, and AC leadership to ensure nursing and clinic support. Before implementation, policies and operational workflows were updated, staff educated, and an after-incident debriefing process created. Documentation and reporting were initiated to mirror the inpatient process to maintain system alignment while allowing for differences in practice settings.
Evaluation/Outcomes/Results: Prior to BERT, there were 108 security calls made by AC the previous year. Fees for security responses totaled $286,000, ranging from $150-$3500/hour, depending upon resources needed. As part of BERT, 2.4 FTE LCSWs were hired costing $257,000, a savings of nearly $30,000. After implementation, there were 80 BERT responses in the ten-month post-COVID window. LCSW responded to de-escalate difficult events in real time, either in-person or remotely. The type of response was determined by the distance to the AC site and the needed response time, the location of the LCSW, and the intensity of the situation. The LCSW worked with nurses, nurse leaders, and security to address events and assess the resources needed to de-escalate the situation. After BERT became more socialized across AC, nurses requested preventative BERT responses. Preventative BERTs were called prior to the arrival of a patient or visitor who had previously threatened or had a recent aggressive event in-person, on the phone, or in email. The BERT team arrived onsite before the patient appointment prepared to mitigate an escalation, de-escalate if needed, and promote safety for nurses and other patients. There were 42 preventative BERT visits in AC which proactively addressed workplace violence in addition to the 80 real-time BERT calls.
Conclusions/implications for practice: A BERT team response is a cost-effective and proactive approach to reducing workplace violence in AC. AC workplace violence events require dynamic resources to address behavioral and aggressive issues from patients/visitors and BERT provides a resource for AC’s unique practice environments.

Purpose and background: Patients with end-stage liver disease are frequently admitted to the hospital due to the complex nature of the disease process. This places them at risk for hospital-acquired complications and injuries which include pressure injuries, deep vein thrombosis, and falls. Inadequate communication about fall risk factors between the nurses and the patient care associates (PCAs) can put the patients in harm's way and potentially lead to falls. Creating a communication tool that addresses specific fall risk factors can increase awareness and bridge the communication gap among the nursing team.
Project design/methods: The project team was led by the unit educator and consisted of shared governance council members. The plan, do, study, act (PDSA) methodology was utilized for this quality improvement initiative. The goal of this project was to reduce the number of falls from 1.58 to one or less per month. Lewis’ Change Theory and Roy’s Adaptation Model were used to identify interventions and drive change.
Thorough chart reviews and root cause analyses identified hemodynamic changes such as low blood pressure, hyponatremia, and ascites as predisposing risk factors for falls. These findings were incorporated into a new pre-liver transplant fall risk bundle which included an updated communication tool that incorporated predisposing fall risk factors. Education was provided to staff, and fall rates pre- and post-intervention were monitored. Due to the novel coronavirus (COVID-19) pandemic, several PDSA cycles were implemented to meet the challenges and restrictions posed by the pandemic, such as staffing, patient acuity, and patient volume.
Results and outcomes: The quality improvement initiative was piloted in December 2020. Education on the fall risk bundle and the communication tool was completed by 85% of the nursing staff. The total number of falls decreased from 19 in 2020 to 9 in 2021, showing a 53% reduction in falls. As of July 2022, there have been five falls.
Implications on practice: This communication tool, specifically addressing hemodynamic changes and fall risks, bridges the communication gap between the nurses and the PCAs. The tool can be redesigned to meet the needs of specific patient populations that experience hemodynamic changes and other factors to help prevent falls.
References
1) Yildirim, M. (2017). Falls in patients with liver cirrhosis. Gastroenterology Nursing, 40(4), 306-310.
Román, E., Córdoba, J., Torrens, M., Guarner, C., & Soriano, G. (2013). Falls and cognitive dysfunction impair health-related quality of life in patients with cirrhosis. 2) European Journal of Gastroenterology & Hepatology, 25(1), 77–84.
3) Soriano, G., Román, E., Córdoba, J., Torrens, M., Poca, M., Torras, X., Villanueva, C., Gich, I. J., Vargas, V., & Guarner, C. (2012). Cognitive dysfunction in cirrhosis is associated with falls: A prospective study. Hepatology, 55(6), 1922–1930.
4) Tapper, E. B., Nikirk, S., Parikh, N. D., & Zhao, L. (2021). Falls are common, morbid, and predictable in patients with cirrhosis. Journal of Hepatology, 75(3), 582–588.

Background: Workplace violence in healthcare is a growing and global problem with verbal violence as the most prevalent form of workplace violence experienced by nurses. For ambulatory care nurses, verbal violence may also occur over the telephone while triaging and providing patient care. Calls may manifest as yelling, cursing, and threatening (reactive expressive) but may also be comprised of snide remarks, personally or professionally attacks, and language containing sexual or racial slurs (passive aggressive). To de-escalate and manage these violent calls real time in a professional manner can be challenging. The purpose of this program was to establish organizationally approved de-escalation scripting tools, develop support structures to terminate a call if necessary, and expand documentation procedures to include verbally violent telephonic events.
Methods: Development of scripting phrases, call termination procedures, and documentation were created with support from ambulatory care leaders, patient experience, behavioral health, patient and family advisors, security, and risk and legal consults. The scripting and the decision algorithm were trialed and revised several times over the course of a year. Algorithm starts with service recovery (addressing the problem), de-escalation attempts, back-to-service recovery OR call termination, post-event documentation, and staff support. Process includes management of threats, those which are categorized as “imminent danger” requiring emergency response or “non-imminent” addressed by organizational security. Nurses were extensively involved and contributed to the final scripting product, development of electronic documentation, and reporting. Post-event self-care was built into the process for nurses to recover after these difficult calls.
Results: Initially, nurses were reluctant to set limits with verbally violent callers and would “just take it,” or they transferred to a clinic leader who was, in turn, exposed to the verbal violence. Nurses needed reassurance and empowerment to manage the calls professionally and terminate the call if necessary. A third of the nurses reported they received one to four verbally violent calls per week to more than three a day. 88% of nurses reported being emotionally impacted by these calls with more than a third reporting being upset more than an hour, affecting their productivity. However, nurses rarely terminated calls; three calls were terminated in three months with more than 100 nurses using the algorithm. Post-event documentation included call content, call outcome, and event reporting, which increased by 33% from before the process was initiated. Self-care after verbally violent events allowed for debriefs, peer support, a break for breathing, taking short walks, or chair yoga.
Discussion: Verbal violence, even verbal violence over the telephone, is negatively impactful on nurses and nursing care. Considering verbal violence is a precursor to physical forms of violence, managing and de-escalating telephone verbal violence is essential for proactive management of workplace violence. Providing nurses the structure to de-escalate and manage verbally violent calls in a professional manner allows for individual critical thinking and empowerment without exposing others, such as leaders, who are transferred angry callers, to the violent events. This type of structure and process is integral to a culture of zero tolerance within ambulatory care when addressing workplace violence.

Our expansive pediatric primary care network includes 31 offices serving over 250,00 patients across Pennsylvania and New Jersey. Telephone nurse triage services are provided 24 hours per day. A centralized call center provides nurse triage services whenever network offices are closed. In contrast, a decentralized model of registered nurses working within the individual offices provides triage services during the daytime hours when offices are open. In fiscal year 2022, approximately 400 triage nurses spread throughout the primary care network managed over 400,000 triage calls. Previous work found that our decentralized model of daytime triage resulted in considerable variability in the way services were being delivered across the network. A telephone triage training class was developed as one intervention aimed at decreasing variability and standardizing nurse triage practice across the network.
At its inception in 2016, the triage training class was offered quarterly and consisted of two full classroom days at a central urban location. The class design was approximately 75% lecture and 25% active learning. Post-class surveys consistently cited the need for more hands-on activity and access to the lecture content outside of class. The considerable time out of the office had been cited as a barrier to attendance, and the cadence of the class resulted in those in attendance being at varying stages of triage training. Identifying these opportunities for improvement led to a redesigned “office hours telephone triage training program,” a formalized approach to triage training implemented in April 2022.
The program redesign aims to provide training in a format that meets the needs of the learner and the offices while ensuring consistency. The training occurs in four phases, with the cadence of the training class now occurring bimonthly. The content and structure are standardized and coordinated by program leaders. The two-day classroom training session has been replaced with a hybrid training course steeped in adult learning theory. The evidence-based flipped classroom was implemented to provide knowledge-based lecture content as pre-work. Students receive a “triage training workbook,” an online notebook designed to encourage student engagement and collaboration. Classroom time has been reduced to one full day and reserved exclusively for engaging, student-centered learning activities such as simulations, role play and scenario practice, and group discussion. Post-class evaluations have yielded positive feedback for this new model of triage training. Comparison of pre- and post-test scores indicate that our learning objectives are being met.
After attending this poster presentation, the audience will understand how to use their organization’s existing technology and resources and apply it to the design of their own "flipped Classroom." They will be able to describe how to use readily available online collaboration tools to provide a shared learning space and centralized location for course materials. Participants will also understand how incorporating the principles of adult learning theory in class design can improve learner engagement and satisfaction with their training experience, and result in improved outcomes for their learners and their training programs.

Problem statement: Patients calling to schedule appointments often speak to non-clinical personnel unqualified to offer medical advice. At this call center, there was not an efficient method to transfer callers with designated high-risk symptoms to a registered nurse. Patients were placed on hold and transferred to a registered nurse in the order calls were placed regardless of symptomology. This led to a delay in high-risk patients being triaged and the possibility of patients hanging up prior to speaking with a registered nurse, missing an opportunity to address immediate health needs.
Project intent: The intent of this project was to improve the process at a call center for non-clinical staff to connect patients with high-risk symptoms to a registered nurse.
Methodology: The nursing triage team collaborated with telecom to develop a priority queue within the current telephone software. The priority queue was built to move patients to the front of the wait list based upon high-risk symptoms rather than call order. The priority queue was assigned a dedicated phone number only provided to the non-clinical call center staff to utilize when high-risk symptoms are identified.
Results: Prior to implementation of a priority queue, the estimated average wait time was five to ten minutes. Three months after implementation, identified high-risk patients are speaking to a registered nurse in an average of 39 seconds with a maximum wait time of four minutes and 16 seconds. This is below the Schmitt-Thompson recommendation of high-risk patients speaking to a registered nurse in under five minutes.
Conclusions/implications for nursing: Time can mean the difference between positive or negative patient outcomes, and even life or death in certain situations. This quality improvement project demonstrates how nurses, in collaboration with other disciplines, can work to identify and implement novel technologic solutions to decrease time patients with high-risk symptoms must wait to speak to a registered nurse.

At a large academic medical center with 80+ clinics dispersed throughout a large urban area, multiple new clinic locations have opened in the past five years. With this constant expansion, the demand for direct patient care staff including nurses and medical assistants has grown to match. Each clinic has its own geographic location and unique onboarding requirements associated with the clinical specialties housed there. To address this staffing need, the ambulatory care float pool (AFP) stepped up to the plate to deliver staff that were ready to respond in multiple physical locations and clinical specialties. Pre-intervention request-to-fill rate was at 48% and current request-to-fill rate is 68.5%, an increase of 20.5%.
In May 2021, the recruiting and hiring process was modified to target candidates that could service various regional sites. The goal of this intervention was to maximize the flexibility of staff by tailoring the hiring and training processes within the department to support specific groupings of locations and specialties. One of the greatest challenges to the implementation of this plan was the increased demand for trained personnel, both locally and nationally, created by the recent COVID-19 pandemic. Burnout, early retirement, and travel opportunities have also contributed to the reduction in the availability of qualified applicants.
To optimize the available staff, the AFP divided the service area into separate “regions” to provide a geographical visualization on where staff was in highest demand. Coverage was then grouped and prioritized based on the team member’s geographical location. This allowed the team to tailor onboarding and training to maximize coverage in the most specialized clinics within each assigned region.
By using this hiring process and the associated geographical location map to guide the allocation of direct patient care staff to various requesting clinics, the AFP was able to substantially increase the amount of assistance provided to the satellite areas. This model has improved direct patient care staff coverage of satellite clinic locations by 20% for fiscal year 2022 as compared to fiscal year 2021. With multiple new clinic locations projected to open over the upcoming fiscal year 2023, the need for the regional recruiting and staffing model has become more important than ever. As a next step, the AFP will analyze historical request volumes to project future staffing needs by region. Based on this data, the AFP will then slow recruiting in lower-demand geographical areas and focus recruiting on high-demand regions of care.
By dividing AFP staff into geographical regions, the institution can be ready to respond to future staffing needs in each physical location.