The Significance of Timing of Patient Daily Weights and the Barriers

Background. Current unit practice is that patient daily weights are obtained in the afternoon or evenings. However, patient weights in the afternoon and evenings are not accurate dry weights. According to evidenced based research, to obtain an accurate patient daily weight, patients should be weighed every morning, after their first void and before they eat breakfast. Purpose. The focus of the study was to compare the current practices of obtaining daily weights in the afternoon and evenings, compared to the evidenced based practice recommended in the literature. Method. Through interviews and surveys with staff, the barriers to obtaining patient weights in the mornings, rather than that of the afternoon or evenings, were evaluated. Interviews with nursing staff and nursing assistants were conducted, discussing possible implementations to overcome the barriers discussed. Results. The proposed solutions were organized and addressed with management for possible implementation. TIMING OF PATIENT DAILY WEIGHTS 3 Statement of the Problem Currently, patient weights are obtained in the afternoon or evenings. However, patient weights in the afternoon and evenings are not accurate dry weights. According to evidenced based research, to obtain an accurate patient weight, patients should be weighed every morning, after their first void and before they eat breakfast. The focus of the study was to compare the current practices of obtaining daily weights in the afternoon and evenings, compared to the evidenced based practice recommended in the literature. The barriers to obtaining patient weights in the mornings, rather than that of the afternoon or evenings, were also evaluated. Rationale According to the current unit protocol, all patients are supposed to be weighed weekly, whereas, 1) preand postheart transplants, 2) heart failure patients, 3) patients receiving diuretic therapy, and 4) patients in renal failure or receiving dialysis are to be weighed daily (Stanford Hospital & Clinics, 2012). Per the manager, in practice, all patients were being weighed daily to avoid any confusion. Also, in order to accommodate all patient daily weights, the data was obtained in the afternoon due to staffing convenience and availability. However, this was not the recommended protocol shown in the literature. The current unit practice and evidenced based practice was compared. The barriers to performing evidenced based practice were also be assessed. Literature Review Curtis et al., in the article, “The importance of daily weight measurements in heart failure patients: a performance improvement project”, addressed the problem of lack of accurate daily weights by 0500 daily. Despite the policy and importance of daily patient weights, it was shown that accurate daily weights were still lacking. They discovered that the problem was the lack of TIMING OF PATIENT DAILY WEIGHTS 4 availability of standing scales and lack of nursing staff support (NSS) understanding of the importance of daily patient weights. They supplied the floor with an additional standing scale and educated the nursing staff and support on the importance of daily weights. With these implementations, accurate patient daily weights increased by 90% (Curtis et al., 2012). Sherer et al., in the article, “Weighing In on the facts: Best practices in daily weight monitoring for heart failure patients”, noted that although daily patient weights were critical data in managing heart failure patients on diuretic therapy, only 86% of patient weights were documented. It was found that the reason why patient daily weight were not being obtained was secondary to the lack of nurses understanding the evidenced based practice of how critical accurate daily weights were to the care plan of heart failure patients. After educating the nurses about the best practices for the patients, accurate daily weights increased to 93% (Sherer et al., 2012). In the journal, Nursing Management, an article called “Improving CHF Outcomes” addressed issues that were vital to the care of CHF patients to improve their outcomes. The authors emphasized consistency and continuation of patient care. Not only was continuous evidenced based practice patient education imperative, but daily processes and monitoring such as daily weights, diet, activity, medications, physician follow-up, and signs and symptoms of CHF exacerbation were also required elements of care. On the hospital unit, it was shown that there were many inconsistencies among the nursing staff in regards to daily activities and patient education. The authors found and addressed the barriers of leading to inconsistent practices, which led to improved patient outcomes. The hospital readmission rate declined by 37%, while the mortality rate decreased by 25%. In addition, 95% of CHF patients received appropriate CHF TIMING OF PATIENT DAILY WEIGHTS 5 education and follow up within a 12 month period after implementation (Howell & Kniceley, 2007). At Naval Hospital Pensacola, Florida, a study was conducted aiming to reduce readmissions of CHF patients. The article “Reducing Readmissions for Congestive Heart Failure” noted that hospital readmissions for CHF were frequently preventable. Multiple disease factors and treatments, such as new medications, therapies, exercise programs, and daily health monitoring and maintenance, contributed patient readmission rates. In addition to other therapies, one aspect of patient daily care was the consistency of obtaining daily body weight. Weight gains of 1.5 to 2.0 kg per week with new signs or symptoms may signal a need for a change in therapy. Making sure accurate diuresis being achieved was a vital portion of CHF patients’ plan of care (Hoyt & Bowling, 2001). The article by Hauptman et al, “The Heart Failure Clinic: A Consensus Statement of the Heart Failure Society of America”, stated an important aspect of heart failure management is the physiological daily data, including body weight, blood pressure, and heart rate. This data should be tracked by the patient and shared with the heart failure management team. Being able to track weight and body mass index on a regular basis is part of the nutritional assessment component of care. With the accurate tracking and measurement of daily weights, patients and providers will be able to track if patients are suffering from access fluid volume accumulation, which a crucial part of heart failure management (Hauptman et al., 2008). In the article, “Promoting Self-Care in Persons with Heart Failure”, Riegel et al. started accurate morning daily weights were essential in heart failure disease maintenance. Diuretic therapies and doses vary in response to changes in body weight. Considerable weight gain is a significant problem for heart failure patients. Unintentional weight change of 3 or more pounds TIMING OF PATIENT DAILY WEIGHTS 6 in addition to increased severity and frequency of chest pain indicate clinical deterioration of the patient’s disease process (Riegel et al., 2009). Cost Analysis After discovering the RN and NA barriers to having daily morning weights on patients, the author devised a unit implementation. The specific implementation determines costs. It was unnecessary to obtain additional resources, such as additional scales. Staff used existing resources currently available on the unit to implement the change. Methodology After noticing the lack of morning weights, the author wished to first examine the reason why the weights are being obtained in the afternoon or evenings rather than that of the morning. The author wanted to compare current patient care on this intermediate ICU versus that of evidence based practice. After reviewing evidenced based practice, a survey (Appendix B) was used to evaluate the staff’s understanding of patient daily weights. Barriers to obtaining patient weights in the morning were identified. Interviews were conducted to discuss potential ideas to overcome the barriers. These ideas were organized and addressed with management for possible implementation. Data Source To be able to obtain data about the barriers of obtaining morning weights, the author interviewed the RNs and NAs on the unit. Using a staff interview form, shown in Appendix B, the author addressed that major reasons as to why the weights are not being obtained in the morning. Proposed implementation addressed the barriers to increase the number of morning TIMING OF PATIENT DAILY WEIGHTS weights available for morning rounds. This implementations. Root Cause Analysis During interviews with nurses and nursing assistances on the unit, it was noted that patient daily weights are obtained in either the afternoon or evening. A root cause analysis was performed, assessing the barriers on the unit preventing daily morning weights of all patients with various diagnoses. The root cause analysis chart is shown in Appendix A. It addressed the issues as to why patient weights are obtained in the afternoons and evenings. The themes included timing, staffing, resource availability, and patient concerns. In orange, at the end, the chart displays solutions to the barriers that are identified. As shown in Figure 1, the survey was completed by 56% of the staff (42 out of 75). In the results, shown in Figure 2, 5 of the 42 surveys were completed by nursing assistances. The reminder of the surveys was completed by staff RNs. Figure 1. Staff members surveyed vs. non 42 or 56% 33 or 44% was discussed with the manager to provide