While developing a standardized approach to orient new staff in the U.S. Army Institute of Surgical Research Burn Center at Fort Sam Houston in Texas, nurse leaders identified the need to also standardize preceptor selection and instruction. A multidisciplinary research team conducted a two-year pilot project based on the evidence-based Vermont Nurses in Partnership Clinical Transition Framework, which provides a structured method for preceptor selection, development, and evaluation. Minimum preceptor qualifications; preceptor validation processes; and modifiable, unit-specific coaching tools were established. The authors previously published a description of the preceptor program implementation process and their findings. In this article, they discuss lessons learned during the project, highlighting the challenges and obstacles encountered when implementing this preceptorship program.
Introduction Timely rehabilitation is vital to the functional outcomes of burn patients. The rehabilitation department at our ABA certified Burn Center determined there was a need for a more effective method to coordinate daily care in the Burn Progressive Care Unit (BPCU). The purpose of this performance improvement project was to evaluate whether our Burn Center had a problem with delays in rehabilitation and if so, develop a plan to reduce disruptions. Methods Lean Six Sigma Process Improvement Methodology guided the team in this project. A 5-question needs assessment Pre-Rehabilitation Worksheet (Pre-RW) was used to evaluate the problem. The Pre-RW asked if there was a delay; reason for delay; length of delay; communication between services; body region, and the number of cutaneous functional units (CFUs) involved. The team then analyzed data from the Pre-RWs using descriptive statistics and a Pareto chart. Results from the Pre-RWs were used to prioritize changes that would mitigate delays. Rehabilitation staff then completed Post-RWs. Pre- and Post-RW results were compared to determine if the changes decreased delays in rehabilitative care. Results From April 24 to August 5, 2018, 140 Pre-RWs were completed in the BPCU; 24 were incomplete/omitted. Rehabilitation encounters that were delayed or canceled were 37.9% (n=53). Of these, 64% were delayed but eventually completed. The top 3 reasons for delay were: dressings down for morning rounds (DFR, 26%); wound care in progress (19%); patient refusal (16%). In 47% of the encounter delays the patients had over 15 CFUs involved. Improvements were made as follows: DFR assessment became part of the bedside rounds process; wound care orders were placed prior to 9 a.m.; patients were offered evening wound care. Communication improved through the use of a whiteboard, hands-free voice-call badges, and a time frame for coordinating the plan of the day. Following the improvements, Post-RWs (n=131) were collected from May 1 to July 30, 2019. 23.8% of all encounters were delayed or canceled. Of these, 51% were delayed but performed. The 3 chief reasons for delay were patient refusal, 38%; untimely dressing changes, 19%; and medical issues, 13%. In 84% of the deficit encounters 0–15 CFUs were involved. Conclusions Our burn center was able to define a problem with delays in rehabilitation and mitigate delays. This project demonstrates that deliberate changes decrease delays in rehabilitation. Applicability of Research to Practice Care of the burn patient requires a structured interdisciplinary, systems approach. Burn centers can improve outcomes by adopting a plan to improve coordination of services.
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