Increasing Activities of Daily Living Is as Easy as 1-2-3

Abstract

Background: Human flora are the most common cause of bacteremia in immunocompromised patients. Activities of daily living (ADL), including oral care and daily chlorhexidine gluconate bathing, can lower the risk of infection. Methods: To address ADL compliance in our pediatric oncology and bone marrow transplant patients, we adopted the ADL 1-2-3 initiative: daily chlorhexidine gluconate bath and linen change, at least 2 activities per day, and oral care 3 times per day. Using the Model for Improvement we created a standardized ADL process that involved all providers. Interventions included addressing ADL 1-2-3 compliance during rounds, establishing accountability in care delivery, an oral care order set and algorithm, daily text message reminders, and physician intervention with noncompliant and high-risk patients. Results: With our interventions, we increased our median compliance with the all-or-none ADL 1-2-3 initiative from 25% to 66% in 90 days. We have sustained our median compliance to 75% sixteen months after implementation. The greatest impact on compliance was seen with text message reminders to staff to complete and document the ADL 1-2-3 components, designated roles and responsibilities, and physician discussion with noncompliant and high-risk patients. Discussion: Oral care algorithm and order set, daily text message reminders, and physician intervention with noncompliant and high-risk patients has improved our compliance. Units where compliance with ADL participation is low can benefit from incorporating elements from this ADL 1-2-3 initiative.

Keywords

blood stream infection activities of daily living compliance chlorhexidine bathing pediatric oncology pediatric bone marrow transplantation quality improvement

Background

Patients receiving radiation and chemotherapy for cancer, or undergoing bone marrow transplantation (BMT), are at increased risk of blood stream infections (BSIs; Ibrahim et al., 2013). Bacterial and fungal BSIs are among the most serious complications in children receiving chemotherapy and undergoing BMT (R. C. Allen et al., 2008). BSIs lead to prolonged hospitalization, intensive care admissions, extensive antibiotic treatment, and increased mortality (Cecinati, Brescia, Tagliaferri, Giordano, & Esposito, 2012; Wilson, Rafferty, Deeter, Comito, & Hollenbeak, 2014).

Daily chlorhexidine gluconate (CHG) bathing has been shown to decrease BSI rates by 40% in hospitalized patients, and are well tolerated (Chen, Li, Li, Wu, & Zhang, 2013; Milstone et al., 2013). The oral flora is a common cause of infection in immunocompromised patients, in particular those with mucositis, warranting the need for oral care (Bergmann, 1989; Harris, Eilers, Harriman, Cashavelly, & Maxwell, 2008; Scully & Epstein, 1996). Hospital physical inactivity can lead to pressure ulcers, deconditioning, gastrointestinal issues, and infection and is associated with extended hospital stays (C. Allen, Glasziou, & Del Mar, 1999; Drolet et al., 2013). Interventions to increase physical activity during hospitalization can provide both physical and psychological benefits (Mishra et al., 2012; Mishra, Scherer, Snyder, Geigle, & Gotay, 2015; Tonosaki, 2012; Wiskemann & Huber, 2008).

This quality improvement project was performed in the Cancer and Blood Diseases Institute (CBDI) at Cincinnati Children’s Hospital Medical Center. Daily bathing, oral care 2 to 4 times per day, and twice daily activity is recommended for all patients receiving therapy for cancer and undergoing BMT (Rinke et al., 2013). We analyzed our compliance with patients obtaining daily baths, oral care 3 times daily, and twice daily activity and identified a low compliance rate in the inpatient setting. The aim of this quality improvement project was to create and implement a standardized process for activities of daily living (ADL) compliance.

Methods

A multidisciplinary team of both oncology and BMT units consisting of patient care assistants (PCAs), registered nurses (RNs), nursing leadership, and physicians was created to address ADL compliance. The team reviewed the current ADL practices and published recommendations. We identified gaps between our practice and current recommendations, and identified areas of improvement. Using the Model for Improvement, we identified a reliable mechanism to implement the specific processes and tested hypotheses by using Plan-Do-Study-Act measures (Berwick, 1996; P. J. Pronovost et al., 2006; Varkey, Reller, & Resar, 2007).

ADL 1-2-3 Initiative

To track and encourage compliance with ADLs, the team adopted the ADL 1-2-3 initiative:

Once daily CHG bath with impregnated cloths and daily linen change

Activity at least 2 times per day

Oral care at least 3 times per day

We measured compliance using an “all or none” measurement for each component of the ADL 1-2-3 initiative. A CHG bath and linen change (or bath and linen change if there are CHG bath contraindications) must be completed 1 time a day, out of bed activity must be completed 2 times a day, and oral care must be completed 3 times a day. Each patient has 3 opportunities per day for each component of the ADL 1-2-3 initiative. For example, if the patient only participated in 1 oral care instead of 3 times then the patient was measured as noncomplaint for oral care. If the patient completed 2 out of bed activities and received a CHG bath with linen change then the patient was compliant for 2 of 3 ADL 1-2-3 components.

Patients with skin graft versus host disease, a CHG allergy, or those without central lines were exempt from CHG bathing; however, they did require daily bath as well as linen change to meet compliance for daily bathing. Oral care consisted of brushing teeth, nystatin mouth rinse, and/or CHG mouth rinse 3 times daily. Baseline analysis revealed a 25% compliance with the ADL 1-2-3 initiative.

Context

The CBDI consists of 68 patient beds throughout the Hematology/Oncology and BMT Units. The BMT program performs 95 to 110 transplants annually, with a majority being allogeneic. The Hematology/Oncology program cares for over 300 new and relapsed oncology patients per year, along with hundreds of children and young adults with hematologic disorders. The CBDI consists of 45 attending physicians, 35 nurse practitioners, 12 hospitalists, and 8 dedicated pharmacists who participate in family-centered rounds. The nursing team consists of 270+ RNs and 60 PCAs. Family members can take an active role in the care of patients by participating in the Family Advisory Council and through daily family-centered rounds (Muething, Kotagal, Schoettker, Gonzalez del Rey, & DeWitt, 2007).

Improvement

Prior to any intervention, we analyzed the ADL compliance process in the CBDI through patient, family, and clinical staff interviews. Root cause analysis revealed (1) an incomplete and nonstandardized ADL documentation process; (2) no processes to ensure patient compliance with daily ADLs; (3) little staff accountability for completion of ADLs; (4) poor engagement and enforcement of ADLs with family and staff; (5) causes for CHG bathing and linen change noncompliance were patient discomfort during the bath, and family and staff unaware of importance of daily bathing; (6) patients were found to be noncompliant with oral care due to nausea, severe mucositis, pain during oral care, poor taste, variable ordering of oral care on admission, inadequate pain, and nausea control; and (7) activity compliance was low due to patient’s comfort level with new medical devices (lines, poles, etc; Figure 1).

Interventions: Documentation

Documentation barriers were addressed through the following mechanisms: implementation of a standardized process to document ADL 1-2-3 compliance in the electronic medical record (EMR), mechanism to document refusals and reason for refusal, and mechanism to communicate ADL timing preferences to bedside caregivers.

Automated Reminder of ADLs

An automated text message reminder was sent out 4 times in 24 hours reminding staff to complete and document ADL 1-2-3 compliance in the EMR. The times were chosen to capture staff during all shifts and were sent on the hospital-provided staff cell phones.

Bathing-Specific Interventions

Practice was standardized by the addition of a “bath PCA” role, which was assigned daily. The “bath PCA” was responsible for ensuring the patient received a CHG bath and linen change daily. Additionally, patient bath preferences were documented in an ongoing spreadsheet that was used as a reference by all the PCAs on the unit. The PCA bath spreadsheet contains the type of bath the patient prefers, what time they usually prefer their bath, and who performs the bath daily (patient, staff member, or family member). This spreadsheet is updated in real time so that any member of the health care team can access it and obtain information about the patients’ bath compliance.

Oral Care–Specific Interventions

The EMR admission order set for CBDI patients contains specific oral care orders. Prior to intervention, 30% to 40% of patients who should have oral care ordered did not. Most orders were discontinued secondary to noncompliance (painful mucositis, nausea, pain, etc). Once the symptoms of nausea/pain resolved, the orders rarely were reentered.

We developed 3 interventions to improve oral care compliance: (1) an oral care algorithm to address pain/nausea. Standard orders include nystatin and CHG mouth rinses; however, these interventions can be deescalated to sterile water and/or saline 3 times daily (Figure 2). (2) The pharmacy staff evaluates and discusses oral care orders and compliance weekly during family-centered rounds. (3) Oral care compliance is discussed during daily family-centered rounds between the nursing staff and the provider team.

Activity-Specific Interventions

To improve twice daily activity compliance, nursing staff, along with the physical therapy and occupational therapy team, planned the timing and activity that would be performed for the day. Twice daily activity was discussed during daily family-centered rounds and barriers to compliance were addressed.

Clearly Defined Roles and Responsibilities

In order to standardize practice, processes such as daily discussion of ADLs in family-centered rounds, weekly pharmacist review of mouth care orders on all inpatients, inclusion of ADL 1-2-3 compliance with PCA and RN shift sign out, and scheduling a “bath PCA” to ensure CHG bath completion were implemented. Additionally, a mouth care algorithm was developed.

Awareness of ADL 1-2-3 Initiative With Patients, Families, and Staff

All staff received education through a mandatory computer module and with direct interaction with designated champion team members. Physicians, hospitalists, and nurse practitioners were also educated on the ADL 1-2-3 initiative. Additionally, ADL 1-2-3 signs were placed inside patients’ rooms as a reminder for staff and families. Education surrounding the ADL 1-2-3 initiative was given to families’ early on in treatment as well as included in the family education binders. Compliance with ADL 1-2-3 initiative was discussed with the families on admission, and then reviewed daily on family-centered rounds. Daily discussion during family-centered rounds included development and distribution of the oral care algorithm with a mitigation plan for patient barriers with oral care compliance.

Physician Engagement

Poor compliance with the ADL 1-2-3 initiative was discussed with the physician on service. One physician sent an e-mail at the beginning of the week to the BMT and Hematology/Oncology physicians on service with the patients that were noncompliant with CHG bathing. The e-mail was standardized stating the reasons to enforce CHG bathing and describing the intervention. The physician on service then discussed how the CHG baths were going, what barriers existed to completing the CHG baths, and provided additional education on CHG bathing.

Quality Assurance

Regular auditing and reviewing of roles, responsibilities, and compliance were performed. These audits were designed as a learning opportunity for staff to understand barriers to noncompliance.

Human Subjects Protection

This initiative fell within the Cincinnati Children’s Hospital Medical Center Institutional Review Board’s guidance for quality improvement projects that did not constitute human subjects research.

Study of the Improvement

We analyzed the process through a quantitative time series study design and measured compliance using an “all or none” measurement for each component of the ADL 1-2-3 initiative. CHG/bathing compliance, oral care compliance, and daily activity compliance were documented in a standardized process in the EMR. Weekly compliance reports were generated from the EMR and assessed weekly by the oversight team.

Additionally, BSIs were measured during this time as the number of BSIs per 1000 inpatient central venous catheter days (P. Pronovost et al., 2006). BSIs were defined by the National Healthcare Safety Network criteria 2014 criteria (Centers for Disease Control and Prevention, 2014).

Analysis

Statistical process control methods were used to monitor changes in care processes and health outcomes. Annotated run charts with overall compliance were developed and updated weekly. We established a median, illustrated as the centerline on all control charts. Standard industry criteria were used to determine if observed changes in measures were chance random variation (common cause variation) or due to a specific assignable cause, in this case the intervention (special cause variation; Amin, 2001; Benneyan, Lloyd, & Plsek, 2003).

Results

The study period was from April 2014 through May 2015. Initial median compliance through CBDI for the ADL 1-2-3 process was 25% in April 2014. By August 2014, the median compliance increased to 66% (BMT = 65%, Hematology/Oncology = 68%). The median compliance has increased and sustained at 75% through September 2015 (Figure 3).

CHG Bathing Compliance

Bathing compliance in the CBDI increased from a median of 25% in April 2014 to 65% in July 2014. Standardization of documentation increased the median to 45% (May 2014), which increased to 70% with implementation of automated ADL 1-2-3 text message reminders, physician engagement with noncompliant patients, as well as a dedicated “bath PCA.” The median bathing compliance has been sustained through September of 2015.

Oral Care Compliance

Baseline oral care compliance was 20%. This median increased to 65% in August 2014 through implementation of the oral care algorithm to address pain/nausea, pharmacy staff weekly evaluation of oral care orders, and daily discussion on rounds. Through standardization of practice, and family engagement in oral care, the median has been sustained at 75% through September 2015. The majority of oral care compliance failures are from patients performing oral care once or twice per day instead of 3 times. Over 95% of patients perform oral care at least once daily.

Twice Daily Activity

The median baseline activity compliance in patients admitted to the CBDI was 70%. The median percentage of patients compliant with daily activities increased during June 2014 with implementation of the ADL 1-2-3 initiative to 85%, and has been sustained through September 2015.

Finally, we followed BSI trends throughout implementation of the ADL 1-2-3 process. Baseline data from July 2013 to May 2014 showed the BSI rate of 2.01 CLABSIs/1000 line days. After initiation of the ADL 1-2-3 initiative, as well as multiple other improvement practices, we saw a significant decrease in the CLABSI rate to 0.6 CLABSIs/1000 line days (June 2014 to September 2015).

Discussion and Implications

We describe a standardized, multidiscipline approach to improve compliance with ADLs in our pediatric hematology/oncology and BMT population. Our compliance with the ADL 1-2-3 initiative improved from 25% in April 2014 to a median of 75%. Currently, ADL 1-2-3 compliance is embedded in the culture of the CBDI.

Initial barriers we encountered to daily ADL compliance included incomplete documentation, little oversight and accountability for ADL compliance, poor understanding of the importance of ADLs, and patient discomfort. We addressed these barriers in many ways; however, we found the most impactful results with assigning accountability of the ADL 1-2-3 process. Early education on the importance of the ADL 1-2-3 initiative, and staff engagement, improved the culture of ADL 1-2-3 throughout the CBDI. Identification of noncompliant patients, and mitigating these barriers on rounds with the providing physician, helped with ADL 1-2-3 acquiescence. With redundancy in the system, we maintained a high degree of reliability in the ADL 1-2-3 process. This reliability was accomplished with accountability of ADL 1-2-3 in the PCAs and RNs, and daily discussion of ADL 1-2-3 compliance in rounds. Furthermore, pharmacy evaluation of oral care compliance (from the EMR) added additional provider oversight.

During the implementation process of ADL 1-2-3 into the CBDI our BSI rate decreased by nearly 75%. It is impossible to know the impact of ADL 1-2-3 on the decreased BSI rate secondary to various processes that were implemented in April and May 2014 to decrease our CLABSI rate; however, we believe implementation of the ADL 1-2-3 initiative was instrumental in decreasing our CLABSI rates. To further increase ADL 1-2-3 initiative compliance, our current Plan-Do-Study-Act testing is focused on early identification of noncompliant patients, oral pain management in patients with mucositis, and improved family engagement in adolescent patient families.

Units where compliance with ADL participation is low would be an ideal environment to incorporate the ADL 1-2-3 initiative. Utilization of the oral care algorithm and order set, daily text message reminders, assignment of accountability, and physician intervention with noncompliant and high-risk patients could all be adaptive to other units.

This report employed the Standards for QUality Improvement Reporting Excellence (SQUIRE) publication guidelines for reporting health care quality improvement research, which were developed for scholarly reports of health care improvement and to increase the completeness, precision, and transparency of those reports (Davidoff, Batalden, Stevens, Ogrinc, & Mooney, 2009).

Footnotes

Acknowledgements

The authors wish to thank the physicians, nurses, patient care assistants, nurse practitioners, hospitalists, fellows, unit health coordinators, environmental coordinators, pharmacists, and staff at Cincinnati Children’s Hospital Medical Center, and especially the patients and their families. We thank Carolyn Luzader, Melody Siska, and the Rapid Cycle Improvement Collaborative staff for their guidance, education, and support of this work. Finally, we wish to thank Tammy Otis, Dr Beverly Connelly, Connie Koons, Brenda Mott, Melissa Hayward, and Jackie Hausfeld for their assistance in this quality improvement initiative.

Authors’ Note

Deanna Best and Erin Osterkamp are co–first authors.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Deanna Best, BSN, RN, is a registered nurse in the Division of Bone Marrow Transplantation and Immune Deficiency and is a quality outcomes manager with the James M Anderson Center at Cincinnati Children’s Hospital Medical Center.

Erin Osterkamp, MSN, RN, is a registered nurse and nursing clinical manager in the Division of Oncology at Cincinnati Children’s Hospital Medical Center.

Kathleen Demmel, MHA, RN, is a quality outcomes manager with the James M Anderson Center at Cincinnati Children’s Hospital Medical Center.

Shivonne Kiniyalocts, BSN, RN, is a registered nurse in the Division of Bone Marrow Transplantation and Immune Deficiency at Cincinnati Children’s Hospital Medical Center.

Shawn Mock, BSN, RN, is a registered nurse in the Division of Bone Marrow Transplantation and Immune Deficiency at Cincinnati Children’s Hospital Medical Center.

Kelly Mulligan, BSN, RN, is a registered nurse in the Division of Oncology at Cincinnati Children’s Hospital Medical Center.

Angela Bell, BSN, RN, is a registered nurse in the Division of Oncology at Cincinnati Children’s Hospital Medical Center.

Crystal Doughman is a patient care attendant in the Division of Oncology at Cincinnati Children’s Hospital Medical Center.

Miranda Flemming is a patient care attendant in the Division of Oncology at Cincinnati Children’s Hospital Medical Center.

Laura Flesch, MSN, APRN, CFNP, is the director of the Bone Marrow Transplant Unit at Cincinnati Children’s Hospital Medical Center.

Deanna Hawkins, MSN, RN, is the director of the Hematology Oncology Unit at Cincinnati Children’s Hospital Medical Center.

Abigail Pate is a clinical research coordinator in the Division of Bone Marrow Transplantation and Immune Deficiency at Cincinnati Children’s Hospital Medical Center.

Ashley Bedel, PharmD, is a clinical pharmacist in the Cancer and Blood Disease Institute at Cincinnati Children’s Hospital Medical Center.

Lori Ann McKenna, MSN, APRN, CPNP; is a pediatric nurse practitioner in the Department of Anesthesia at Cincinnati Children’s Hospital Medical Center.

Ashley Teusink, PharmD, is a clinical pharmacist in the Cancer and Blood Disease Institute at Cincinnati Children’s Hospital Medical Center.

Sonata Jodele, MD, is the clinical director of the Division of Bone Marrow Transplantation and Immune Deficiency at Cincinnati Children’s Hospital Medical Center.

Rajaram Nagarajan, MD, MS, is the clinical director of the Division of Hematology Oncology at Cincinnati Children’s Hospital Medical Center.

John Perentesis, MD, FAAP, is the division director of the Division of Oncology at Cincinnati Children’s Hospital Medical Center.

Stella M. Davies, MBBS, PhD, is the division director of the Division of Bone Marrow Transplantation and Immune Deficiency at Cincinnati Children’s Hospital Medical Center.

Christopher E. Dandoy, MD, MSc, is a bone marrow transplant attending in the Division of Bone Marrow Transplantation and Immune Deficiency at Cincinnati Children’s Hospital Medical Center.

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