Previous Research Initiatives

• Kay Burke, MBA, BSN, RN, NE-BC, Chief Nursing Informatics Officer, Co-PI
• Andy Auerbach, MD, Co-PI
• Stephanie Rogers, MD, Investigator
• Melissa Lee, MS, RN, CNS-BC, Investigator
• Laurie Kramer, PT, Investigator

The STEADI Implementation and Evaluation project at UCSF Medical Center is both a quality improvement initiative and a research project.  Sponsored by the Centers for Disease Control (CDC), the aim of this project is to implement and evaluate the effectiveness and feasibility of the CDC STEADI Algorithm in an inpatient hospital setting to reduce falls in the elderly population. 

Co-Authors: 

• Chad O'Lynn PhD, RN, CNE, ANEF
• Adam Cooper, MSN, RN-BC, NPD-BC
• Lisa Blackwell, MLS

The objective of this qualitative systematic review was to identify and synthesize findings on the perceptions, experiences, and preferences of patients receiving clinician’s touch during intimate care and procedures.  Seven findings were organized into three categories and one synthesized finding, “clinician respect”.  The finding suggests that clients prefer engaged and meaningful communication prior to and during an intimate touch encounter, expect autonomy over their bodies, and desire shared decision-making relative to how and by whom intimate touch would be provided.  The synthesized finding from this review suggests that:

• Health care educators introduce clinician respect as an approach to care activities that involve intimate touch
• Clinicians practice with overall respect toward their patients by communicating clearly, honoring patients’ concerns and preferences, and engaging patients in decision-making in order to improve patients’ comfort with intimate touch.

Principal Co-Investigators: 

• Robin Bisgaard, MSN, RN, CNIV, Benioff Children’s Hospital, Intensive Care Nursery
• Linda Franck, PhD, RN, FAAN, UCSF School of Nursing

UCSF will be the first US hospital to implement an innovative approach to Family Centered Care in the Intensive Care Nursery (ICN).

Our Canadian colleagues conducted a major clinical trial across every ICN in Canada studying Family Integrated Care (FiCare; O’Brien, 2013). Results are very promising and show improved breast feeding, earlier hospital discharge and reduced parents stress scores. “Research suggests that infants admitted to the Neonatal Intensive Care Unit (NICU) and cared for under the FICare model grow faster and have less stress, spend fewer days in the NICU, and are less likely to be readmitted to hospital after discharge, compared to infants cared for primarily by staff. These infants are also more likely to be breastfed and for a longer time, which provides a host of long-term health benefits. The improved confidence and skills of parents in FICare increases parental readiness for the transition from hospital to home, improves management abilities at home, and lowers parental anxiety. Finally, parental involvement helps staff feel more confident in the abilities of the parent, which will help facilitate getting everyone home as soon as possible” (www.familyintegratedcare.com). The model is based on parent engagement, education and support. Parent stress during and after having a child in the ICN is quite significant; PTSD symptoms are present in a large percentage of parents after an ICN stay. Long-term stress of this nature interferes with bonding, growth and development in the child, significant health related illness in parents and the highest divorce rate in couples after such experiences. Patient and family engagement improves many aspects of hospital performance, which includes safety, quality, financial performance, patient/parent reports on experience of care, patient outcomes, and employee satisfaction (AHRQ, n.d.). Our Canadian colleagues have challenged our team to bring this success and model/philosophy to the US. In bringing this to the UCSF BCH ICN, there are four major novel components of care to our ICN:

1. A new peer parent mentor program. This involves recruitment and training mentor parents to support current parents in the ICN as well as ongoing support for mentor parents.

2. Daily group parent education sessions related to the care and diagnosis of their child will be a new component. This will not only provide daily education for parents but potential peer group benefits.

3. Specialized Nursing training regarding Ficare philosophy and components of care.

4. We have developed a mobile app for parents that aims to support parent engagement, education and peer support. (We have very fortunate support from Wills Way Foundation, Intuit, PTBI)

After more than 2 years of planning, engagement with our alumni parents and innovation of the mobile app, we have started enrollment (baseline data collection) Nov 1, 2016. There are 4 other nurseries preparing to join the study (UCLA 2 campuses, UCSF Benioff Children’s Hospital Oakland, Community Regional Medical Center in Fresno, Kaiser Santa Clara). UCSF will be the pilot institution and our program and training information will be shared. It is critical that we assess the effectiveness and impact on parents, volunteers and staff well before our larger study results are available. There is no qualitative component to the study to date with potential for rich information unavailable through larger study aims.

Aims

Explore the challenges and successes in program implementation of Family Integrated Care (including mobile enhanced FiCare via app) for parents. Specifically:

1. What are the needs of parents who have infants in the Neonatal Intensive Care Unit?

2. What do parents perceive as supportive to their parenting role

3. What behaviors and programs support parents with an infant in the neonatal intensive care unit.

Potential Impact to UCSF Medical Center:

The UCSF Benioff Children’s Hospital Intensive Care Nursery is a 58 bed Regional Tertiary level 3 nursery with 950 infants seen each year. There are over 200 nurses. With our facility being the first training institute for a US study, we must be prepared for immediate evaluation of our training, tools and implementation plan.

Approach and Sample

Research design: Ethnographic qualitative approach primarily based on symbolic interaction
Data collection: In person (recorded) interviews, focus groups, observation and field notes.
Data analysis/interpretation: Semi structured interviews with parents will be analyzed after transcription for thematic interpretation. Observations will include parent education sessions, bedside education. Focus groups on program will be conducted with parents, in their education session. Ten parent interviews (including maternal and paternal interviews) and 2 focus groups will be conducted. Analysis will include assessment of the needs parents and perceived support and will include standard care and education in the ICN, mobile family integration care (MFICare) materials, observations and interviews with parents. Analysis will be based on a symbolic interaction framework (Blumer, 1969). This includes the assumptions that meaning arises from a social and self-reflective process, that informants and investigators jointly create knowledge and findings, and that investigators must enter into the world of the people being studied (Rehm, 2005).

Principal Co-Investigators: 

• Daphne Stannard, PhD, RN, CNS
• Carla Graf, PhD, MS, RN, CNS

Additional Investigator: 

• Sandra Ng, MSN, RN-BC, Informaticist

Research staff:

• Sherrie Christesen, RN, BSN, CN IV

This is a multisite study (including UCSF), cluster-randomized controlled trial of performance audit and feedback at NICHE hospitals. The University of Colorado is the prime grant holder of the coordinating center. The specific aims of the study are to implement and test a methodology for information technology supported surveillance of urinary catheter duration and CAUTIs. An audit and feedback intervention on catheter duration and CAUTIs will also be tested.

Principal Investigators 

• Barbara J. Drew, PhD, RN, FAAN, FAHA - Professor at UCSF School of Nursing
• Marjorie Funk, PhD, RN, FAHA, FAAN - Professor at Yale University School of Nursing (NHLBI Grant)

UCSF Site Coordinators

• Cass Piper, MS, RN, CCRN, CNS
• Elise Hazlewood, MS, RN, CNS
• Noraliza Salazar, MS, RN, CCNS

The PULSE Trial is a NIH-funded, 5-year (2008-2013), multi-site, randomized clinical trial about implementing practice standards for ECG monitoring and examining the effect on nurses’ knowledge and skills, quality of care and patient outcomes. The long-term aim is to improve nursing practices related to ECG monitoring in hospital settings for better detection and diagnosis of cardiac arrhythmias, myocardial ischemia and drug-induced prolonged QT syndrome.  Sixteen participating national / international hospitals (including UCSF Medical Center) are involved in this trial.

Despite advances in hospital electrocardiographic (ECG) monitoring technology, monitoring practices are inconsistent and often inadequate. Barbara Drew, RN, PhD from the UCSF School of Nursing spear-headed American Heart Association practice standards to improve hospital ECG monitoring. We are now implementing these practice standards in two units at UCSF (10ICC and 10CVT) in a study called the PULSE Trial (Practical Use of the Latest Standards for Electrocardiography). 

Nurses complete an education intervention that is web-based and unit “champions” assist in changing and improving practice. If implementation of the practice standards is associated with improvement in quality of care and patient outcomes, then there is the potential for improved care and outcomes for the millions of patients who require continuous ECG monitoring while hospitalized.

Principal Co-Investigators

• Ann Mayo, DNS, RN – University of San Diego
• Linda Searle Leach, PhD, RN – University of California Los Angeles
• Virginia Terra-Hodge, MS, RN – University of California San Francisco

This research study will determine if two new surveys are strong and refined enough to be used in future research.  The surveys measure a nurse leader's development based on specific important job functions.

One version of the survey will be given to nurse leaders in California and the other to her/his employer.  A California nursing organization, Association of California Nurse Leaders (ACNL), has been offering a nursing leader development course for over five years.  The researcher will ask those participants and their employers to complete the testing of these two surveys.

Statistical tests, such as factor analysis and reliability and validity testing, will determine which items we will retain on the survey and if additional work is needed to strengthen the two surveys.

• ​Funded by American Association of Nurse Executives Seed Grant

Principal Co-Investigators

• Susan Khan, RN
• Daphne Stannard, PhD, RN, FCCM

Co-Investigators

• Courtney Trump, RN
• Catherine Enriquez, RN
• Karen Chisholm, RN

The Glasgow Coma Scale (GCS) was introduced by Teasdale and Jennett in 1974 as a tool to aid in objectively measuring the neurological status of a patient.

The GCS has achieved international acceptance and continues to be widely used, although studies have shown that it can be used  inconsistently by HCWs and clinical data can be mis-interpreted (Edwards, 2001; Ingram, 1994; Waterhouse, 2009). There have been unsuccessful attempts to replace or supplement the GCS with alternative tools, such as the Full Outline of Unresponsiveness tool (FOUR) (Fischer, 2010). The GCS remains the gold standard for neurologic screening and is built into APEX, the new electronic health record for UCSF Medical Center. 

To ensure standardization of the use of this tool, the research team has created a pre- and post-survey to assess knowledge of the GCS and application of the GCS using clinical scenarios and an educational program that will be available to nurses who consent to be in the study. In addition, there is a brief demographic section to the survey on the pre-survey only.

Principal Investigator

• Daphne Stannard, PhD, RN, FCCM

Co-Investigators

• Maureen Buick, MS, RN
• Adam Cooper, MSN, RN
• Craig Johnson, MSN, RN, FNP
• Melissa Lee, MS, RN, GCNS-BC
• Sandy Ng, MSN, RN, RN-BC
• Kathy Lee, PhD, RN, FAAN – UCSF School of Nursing

It has been estimated that medical errors, including medication errors and adverse events, rank as the 8th leading cause of death in the United States (Hoyert et al., 1999). An error is defined as “an unintended act (either of omission or commission) or as an act that does not achieve its intended outcome” (Leape, 2007).

Medication administration is a complicated process involving many overlapping systems and complex human factors (San et al., 2012). A failure in any one system or point in the process can cause an error—and this error often happens during the drug administration process (Hicks et al., 2006; Stavroudis et al., 2010). While some errors are benign, others can cause patient harm and/or death. Fortunately, technological advances have enabled many healthcare facilities to institute bar-code medication administration (BCMA), which has been shown to reduce medication errors in various settings in  hospitals, including intensive care units, transitional care units, and acute care areas (DeYoung et al., 2009; Helmons et al., 2009; Paoletti et al., 2007). BCMA can prevent errors related to the timing of medications and has also been shown to reduce wrong-patient, wrong-drug, wrong technique and dose omission errors. However, BCMA as a safety technology is only as effective as its utilization. In other words, traditional medication administration practices must be altered in order to leverage the full safety benefit of BCMA. 

Changing practice is never easy. And while the actual act of administering medication may be similar across areas, the workflows surrounding medication administration—from order to patient administration—varies widely. Staffing, patient population, pharmacy support, and even the built environment all have a profound impact on the workflows surrounding medication administration. UCSF Medical Center has implemented BCMA as the new safe medication administration method for many inpatient areas starting in the Spring of 2012. Nurses, pharmacists, and respiratory therapists have been trained for BCMA using a three pronged approach: viewing an online orientation module; attending a training class; and participating in simulated patient scenarios that focused on BCMA and medication administration workflows.

Simulation is the cornerstone of training in organizations requiring high reliability, such as aviation, nuclear power, and the military (Frengley et al., 2011). The Institute of Medicine (2000) has advocated HPS as an effective way of training healthcare professionals. To reduce variation and to reinforce medication safety processes, UCSF Medical Center instituted a simulated experience, alongside more traditional training approaches, to prepare healthcare professionals for BCMA. It is expected that the results of this study will yield insights that will have great impact to UCSF Medical Center. For example, the Department of Nursing Education and members of the simulation training team can revise and adapt simulation scenarios in the future by better understanding how healthcare professionals perceived the usefulness of this initial simulation experience.

• ​Funded by UCSF 2012 Synergy Grant

Principal Co-Investigators

• Catherine Walsh, MSN, RN – UCLA Medical Center
• Teryl Nuckols, MD, MSHS – UCLA Medical Center
• Carla Graf, MD, RN, CNS-BC – UCSF Medical Center

Falls during hospitalization can lead to serious injuries and death. Consequently, policymakers have developed robust incentives for hospitals to reduce falls.

After UCLA’s Ronald Reagan Medical Center (RRMC) implemented a new innovation in 2010, the 5P Fall Prevention Method, falls declined by 30%.  The primary objective of this project is to have nurses at Santa Monica Medical Center (SMMC) and UCSF Moffitt-Long Hospital Complex (UCSF) critically and uniformly incorporate the fifth “P” (Preventing Falls) into their current hourly rounding practices, thereby assessing individual patients’ risks of falling and mitigating those risks on an ongoing basis during hospitalization. A secondary objective is to improve collaboration among providers with the ability to influence fall risk during hospitalization. 

Funded by University of California Office of the President Collaborative Research Grant

Project manager: 

• Elizabeth Sin, MS, BSN, CCRN, Unit Director, Centralized Telemetry/Vascular Access Team

Sponsors: 

• Sheila Antrum, MHSA, RN, President and Senior VP, UCSF Health – Adult Services

• Tina Mammone, PhD, RN, CENP, NEA-BC, Vice President and Chief Nursing Officer

Participants: 

Adult Vascular Access Team members:  Anna Liang, MS, RN, CPNP-AC, VA-BC; Lynne Tom, MSN, RN, VA-BC; Michele Nomura, MSN, RN, VA-BC;  Yunhee Lee, BSN, RN, VA-BC; Todd Dayton, BSN, RN; Vivian Phan, RN; Kenichi Uyeda, RN, VA-BC; Shannon Sutherland, RN, VA-BC

Summary:

Elimination of confirmatory chest x-ray in selected patient population for tip location of Peripherally Inserted Central Catheter (PICC) utilizing electrocardiogram (ECG) based technology. This methodology is endorsed by the Infusion Nurses Society as it allows greater accuracy, more rapid initiation of infusion therapies, and reduction of radiation exposure as well as reduces costs for patient care.  

Principal Investigator

• Margo Peterson, MS, RN, CNOR, Clinical Nurse Supervisor IV, Mt. Zion Operating Room

Medical errors related to interruption of critical tasks are well documented in the clinical setting including the operating room.  Numerous strategies have successfully reduced interruptions during medication administration including the use of attention attention-getting vests, lanyards, or sashes along with signage alerting those in close proximity to the critical nature of medication administration.

The surgical count is the front line of defense against retained surgical items (RSI).  The Count In Progress project adopted the concept of visible signage into the operating room in the form of a bright orange visual indicator with ‘Count In Progress’ boldly printed across it.  The sterile visual indicator announcing the surgical count process is placed directly on the surgical field during the final count thus alerting direct providers as well as charge nurses and ancillary staff of the count process. Limiting the detrimental effects of interruptions during the final surgical count improves the surgical count process making it more effective and efficient thus improving patient outcomes by preventing exposure to unintended radiation, avoiding extended anesthetic and operative times, and potentially averting retained surgical items.

The purpose of this innovation project was to improve counting performance by visually alerting the entire perioperative team when the final count process takes place.  Interruptions during critical tasks result in errors -- This fact has been repeatedly recognized during the task of medication administration in a variety of health care settings.  Medical literature reveals the implementation of an array of interruption management strategies have effectively reduced medication administration errors consequently enhancing the culture of safety. One strategy used in medication administration is a visual indicator alerting others to limit conversations and interruptions while the critical task is performed.

Liberally borrowed from the medication administration techniques, the sterile bright orange visual indicator provides a simple and consistent method to alert perioperative staff in real-time to the count process.  Placed directly onto the surgical field during the count, the visual indicator erases ambiguity by communicating to everyone in the perioperative setting the critical task of the surgical count is taking place.      

All surgical procedures performed at UCSF’s main operating rooms during the three-week trial period whether scheduled or emergent, adult or pediatric, were provided with the orange visual indicator and a data collection sheet in the surgical case cart.  As the trial was voluntary, and although encouraged to use the visual indicator on every surgical procedure, the perioperative staff elected when to display the visual indicator during the closing surgical count process.  The sterile visual indicator was to be opened up and spread upon the sterile field or Mayo stand during the closing count process.  At the conclusion of the count the visual indicator was to be moved away from the sterile field onto the backtable.  The visual indicator could also be displayed during the closure of a cavity within a cavity, during permanent relief counts, or for the skin count. This innovation sought to increase awareness of the count in progress.

Implementation of AvaSure and decision making regarding sitter use

AvaSys is a remote patient observation system that enables audio and visual monitoring of patients at risk for falls. It is the first line of defense for patients at risk, allowing staff to immediately and directly intervene when a patient is at risk of self-harm. The technology is deployed as a portable, wireless unit.

Project manager: :

Elizabeth Sin, MS, BSN, CCRN, Unit Director, Centralized Telemetry/Vascular Access Team

Participants:

• Florlina Agudelo, BSN, RN, BMTCN, Unit Director, Adult Hematology, Oncology and BMT
• Julie Anderson, RN, Clinical Nurse, Adult Hematology, Oncology and BMT
• Brett Austin, RN, Unit Director, Nursing Hospital Supervisors
• Karri Ballard, RN, Assistant Patient Care Manager, Adult Hematology, Oncology and BMT
• Lindsay Bolt, MS, RN, CMSRN, Clinical Nurse Educator, Adult Acute and Transitional Care
• Irish Criseno, BSN, RN, Unit Director, Central Resource Group
• Amy Dunne, MS, RN, ACCNS-AG, CCRN, Adult Critical Care Clinical Nurse Specialist
• Kiran Gupta, MD, MPH, Assistant Professor of Medicine
• Craig Johnson, MSN, RN-BC, FNP, Clinical Nurse Informaticist
• Sudha Lama, BSN, RN, Clinical Nurse, 8L Neurosciences Acute Care
• Melissa Lee, MS, RN, CNS, Adult Acute and Transitional Care Clinical Nurse Specialist
• Michelle Macal, MS, RN, CNS, Adult Acute and Transitional Care Clinical Nurse Specialist
• Carrie Meer, MS, RN, CNS, CPHQ, Interim Director, Nursing Performance Improvement
• Jennifer Miranda, MSN, MBA, RN, Unit Director, 15L Acute Medicine
• Mary Moore, MS, RN, CPHQ, Performance Improvement Nurse
• Annette Neill, BSN, RN, SCRN, Assistant Patient Care Manager, 8L Neurosciences Acute Care
• Andrea Plati MSN, RN, OCN, Unit Director, Adult Hematology, Oncology and BMT
• Mary Reid, BSN, RN, NE-BC, Unit Director, 6L Adult Neurological Transitional Care and 8L Neurosciences Acute Care
• Stephanie Rogers, MD, MPH, Assistant Professor of Medicine, Division of Geriatrics
• Krystle Rowlands, RN, Clinical Nurse, 8L Neurosciences Acute Care
• Katie Segev, MS, RN, OCN, Assistant Patient Care Manager, Adult Hematology, Oncology and BMT
• Marjorie Smallwood, MPH, Manager, Workplace Violence Prevention Program
• Julie Vavuris, BSN, CCRN, Assistant Unit Director, Central Resource Group

The UCSF Benioff Children’s Hospital simulation-based Mock Code Program provides invaluable training for staff. Simulation-based interprofessional team training is important to ensure high quality, safe patient care.

By Ho Lom Lee and Joyce Nacario, RN

Perioperative services developed a solution in-house to address the need for multiple disciplines to view surgical case information in real time.

The effective management of surgical operating rooms is crucial in ensuring safe, high quality and cost-effective patient care. However, such management can be very challenging due to the number of staff, patients and rooms involved, in addition to the necessary coordination of equipment, medications and supplies. To address this important issue, the UCSF operating room has developed a novel, easy-to-use tool to visualize and manage operating room use in real time. The purpose of this study was to examine cost effectiveness and efficiency levels resulting from the use of CaseView as a web-based resource to expedite patient care and cost-saving for an operating room in clinical practice. 
Resources collaborated to assess the needs of the teams that care for patients undergoing surgery. This spanned all areas from pre-op, through the operating room (OR) all the way to the patient floors that would eventually care for patients after surgery. 

Background

It takes a lot of coordination on the part of many individuals to effectively run an operating room. Surgeons, anesthesiologists, nurses and ancillary staff need to know anticipated case volumes, scheduled case times, complexity of cases, acuity of patients, staff availability with mixed skill levels, medications, supplies and equipment needed to deliver safe, high quality patient care.  As cases are added, rearranged and cancelled over the course of a day, providers and staff must have access to the latest information in order to plan their next actions.

Individuals outside the OR also have an interest in the status of surgical cases.  Staff at the surgical waiting area must provide updates to families of patients who are having surgery.  The clinics need to know the whereabouts of their surgeons. The Admitting department needs to verify that patients having surgery are properly admitted into the system.  Nurses in the units need to be able to anticipate when their patients are due back from surgery.

CaseView addresses these needs by providing a powerful yet intuitive visual interface to data that already exists in clinical databases, but which is otherwise difficult to obtain and interpret.  It allows interested individuals to make decisions based on the most up-to-date information, and promotes efficiency and situational awareness of what’s happening in the ORs.
When everyone is literally looking at the same display, decisions are made wisely and effectively with certainty.

Overview

• A visual representation of past, present, future operating room cases at UCSF locations: Moffitt / Long, Mount Zion, Ambulatory Surgery Center
• Real-time information – display is updated as cases progress; represented by a vertical line
• Users identified using network account
• Multiple views of cases
• Hovering mouse over case displays information about case
• Clicking on case opens popup window with more detailed information about case to enhance hand-offs including skin assessment, procedure names, drains, EBL, etc
• Cost-saving and “green” for the environment by eliminating hundreds of daily paper print-out

It has been proven that students who received simulation-based training show statistically significant improvement in cognitive knowledge, both in the clinical and non-clinical settings. The aviation industry is a classic example of a field where simulation has been used for many years.  Key to simulation is providing a realistic and safe environment for practice and to learn new procedures or to test new devices or workflows. The more realistic (or high fidelity) the scenario, the more the learner can immerse themselves into the situation. 

UCSF Medical Center Patient Care Services is in the process of training staff to prepare for the transition from a paper based Medication Administration Record (MAR) to an electronic MAR or eMAR with barcode scanning. This transition must not only be smooth, but also cannot compromise patient safety related to medication administration errors. To address this, traditional methods of online learning modules and classroom training have been supplemented with mandatory simulation learning. 
The simulation team has developed a simulation area with patient rooms, medication areas, and separate debriefing rooms. The curriculum and room set up, using high fidelity manikins, create a realistic -- yet safe environment -- for clinicians to simulate medication administration using eMAR and barcoding.

Simulation Team

• Craig Johnson, MSN, RN, FNP, Patient Care Services Clinical Information Coordinator
• Daphne Stannard, PhD, RN, CCRN, CCNS, FCCM, Associate Chief Nurse Researcher and Perianesthesia Clinical Nurse Specialist
• Adam Cooper, MSN, RN, Nurse Educator
• Melissa Lee, MS, RN, GCNS-BC, Med / Surg Clinical Nurse Specialist
• Nina Manke, MSN, RN, Simulation Lab Coordinator
• Sandy Ng, MSN, RN, RN-BC, Patient Care Services Clinical Information Coordinator
• Maureen Buick, MS, RN, Director of Nursing Education and Performance Improvement

Simulation Videos

• eMAR / BCMA Sim Lab Video
• Local news coverage of UCSF Sim Lab