Advocate Christ Medical Center (ACMC)

Presentation Notes

Quality Improvement poster presented at Nursing Passion: Re-Igniting the Art & Science, Advocate Aurora Health Nursing & Research Conference 2022; November 9, 2022; virtual.


Background: Opioids administered during recovery help patients with immediate post-operative pain, but the combination anesthesia plus opioids puts them at higher risk for opioid-induced sedation (American Society for Pain Management Nursing [ASPMN], 2020). Therefore, monitoring opioid-induced sedation should be done with a valid and reliable tool to ensure patient safety (ASPMN, 2020), such as the Pasero Opioid Sedation Scale (POSS; Davis et al., 2017).

Local Problem: Advocate Christ Medical Center (ACMC) experienced simultaneous high surgical demands and throughput issues creating a bottleneck where patients were ‘boarding’ in the post-anesthesia recovery unit (PACU). Having patients ‘boarding’ in the PACU required the PACU nurses to learn a new reassessment and documentation processes to follow the AAH Pain Management policy and procedure using the POSS. Initial education resulted in only 17% compliance. The goal of the project was to empower PACU clinical nurse “unit champions” to “own” the project with the goal of improving reassessment documentation compliance to meet the 90% requirement (Cullen, 2020).

Method: Unit champions created and submitted their action plan to unit leaders, which was approved and implemented. The plan included a bulletin board explaining the reasons reassessment and documentation were critical for patient safety, description of the goals, creation and dissemination of a job aid to help educate all PACU team members, adding a checkbox to the shift report form, and peer-to-peer coaching by the unit champions.

Results: In eight months, from May to December 2021, documentation compliance increased from 17% to 100% for sedation and from 23% to 90% for pain.

Implications for Practice: Opioid medications continue to be used in perioperative pain management. To provide safe and effective care, nurses need to be empowered and educated to perform assessment and reassessment to prevent opioid-induced sedation while managing pain.

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