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  Enhancing Diabetes Self-Management and Nutrition Literacy in South Stockton, California

  Yessenia Bejarano, Carissa Chothia, Madisyn Widmer, and Angela Lim

  Diabetes mellitus and food insecurity contribute to poor health outcomes among underserved adults participating in the Healthy Food Rx program at the Stockton Emergency Food Bank in South Stockton, California. Limited access to culturally relevant diabetes education and ongoing self-management resources may hinder effective diabetes management among food-insecure adults. This quality improvement project evaluated a four-week culturally responsive diabetes education program consisting of weekly education sessions, hands-on blood pressure and blood glucose monitoring, and a QR code-enabled Linktree resource platform. The intervention included weekly diabetes education sessions, hands-on monitoring of blood pressure and blood glucose, and access to bilingual digital educational materials. Data were collected using pre- and post-intervention Likert-scale surveys and weekly blood pressure and blood glucose measurements and analyzed using descriptive statistics. Participants demonstrated improved confidence in checking blood glucose and blood pressure and recognizing abnormal blood glucose values, while diabetes knowledge scores remained relatively stable. Mean blood glucose values showed an overall downward trend throughout the four-week intervention. Participants reported positive perceptions of the program, and all post-survey respondents indicated they would recommend it to others. Community-based, culturally responsive diabetes education, combined with accessible digital resources, may strengthen confidence in diabetes self-management among food-insecure adults. Future quality improvement efforts should evaluate longer intervention periods, implement strategies to improve participant retention and attendance throughout the program, increase engagement with digital resources, and assess long-term clinical outcomes.

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  Patient-centered Education in Fall Risk and Prevention Decreases the Number of Falls on the Orthopedic Unit

  Kaitlyn Chan, Amparo Guzman Garcia, and Tran Huynh

  Inpatient falls are a major patient safety concern, particularly in orthopedic units where mobility limitations, comorbidities, and postoperative factors elevate risk and contribute to preventable injury, longer hospital stays, and increased costs. At Sutter Medical Center Sacramento’s orthopedic unit, an annual rate of 16 falls and persistent gaps in patient and staff education highlight the need for a targeted quality improvement initiative despite use of an EPIC predictive fall-risk model. Guided by the Plan-Do-Study-Act framework, this project implements a comprehensive fall-prevention education program modeled on the Fall T.I.P.S. toolkit, including a standardized bedside brochure, visual cues (wristbands, door signage, bedside cards), and structured nursing workflows to enhance individualized risk communication and shared responsibility among staff, patients, and families. The primary aim is to reduce inpatient falls by 15–20% (2–4 fewer falls per year) by August 2026 through improved fall-prevention knowledge, consistent documentation, and stronger engagement of nursing staff, charge nurses, leaders, and caregivers in safety practices. Process and outcome measures will include fall incidence, staff compliance with fall-risk assessments and education checklists, documentation of patient and family teaching in the electronic health record, and staff surveys on perceived barriers and brochure effectiveness to inform iterative PDSA cycles and sustain improvements in fall prevention on the orthopedic unit.

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  Improving Mobility Awareness and JH-AMP Tool Utilization on a Cardiac Care Unit

  Courtney Joe, Clarissa Chaires, Jocelyn Martin, and Eunice Sanchez

  The quality improvement project evaluated the impact of staff education and a unit-wide mobility awareness campaign on the use of the Johns Hopkins Activity and Mobility Promotion tools and patient mobilization in a 48-bed Cardiac Care Unit (CCU). The project involved registered nurses, nursing assistants, unit leaders, and adult cardiac patients represented by aggregate mobility data. A preliminary survey completed by 42 CCU staff members, CCU Partnership Council focus group, meetings with clinical nurse specialists, and a baseline unit audit identified inconsistent mobility practices, uncertainty regarding Johns Hopkins Highest Level of Mobility tool, and limited completion of in-room mobility signs. The intervention included three 10-minute staff education sessions with interactive case studies, the “Movement is Medicine” awareness campaign, a month-long unit challenge to improve mobility tool use complete with leaderboards, periodic audits, and recognition prizes. Patient mobility key performance indicators (KPI) were compiled throughout the process and monitored for trends. Staff feedback was obtained post-implementation through a survey and repeat CCU Partnership council focus group. Quantitative data were analyzed using compliance percentages, mobilization averages, trend comparisons, and a run chart. Qualitative data were analyzed for recurring themes. Average daily patient mobilizations increased from 1.5 times in February to 1.7 times in April. Baseline data indicated unit compliance of in-room tool completion was 0% in February and peaked at 13.5% during the March Movement Challenge, ultimately not meeting the 50% unit compliance goal. The percentage of patients mobilizing at least three times per day also increased from 37.3% in March to a maximum of 39.8% in April. Findings suggested the education and awareness strategies were successful but insufficient to create long-term change without reinforcement. Future quality improvement projects should address perceived barriers including workflow integration, double documentation, sign fatigue, role uncertainty, and ongoing sustainability measures.

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  Improving Clostridioides difficile Prevention Practices Through Standardized Stool Collection and Hand Hygiene

  Dunya Khateeb, Laura Martin, and Jessica Zhang

  Healthcare-associated Clostridioides difficile (C. diff) infections increase patient morbidity, length of stay, and healthcare costs (Simor, 2010). Our quality improvement project seeks to reduce C. diff infection rates and enhance prevention practices on the Med-Acute Unit at Sutter Medical Center Sacramento (SMCS) by utilizing the Plan-Do-Study-Act (PDSA) framework. Interventions will be implemented between March 2026 and July 2026. The project examined whether introducing a standardized stool collection tote and improving hand hygiene compliance would reduce C. diff infection rates. Participants included all nursing staff on the unit. Data is being collected through observational hand hygiene audits, collaboration with the SMCS Infection Prevention Team to track hospital-associated C. diff infections, and pre- and -post intervention staff surveys. Findings currently indicate that an intervention bundle may improve infection prevention practices by improving workflow efficiency and supporting reductions in hospital-acquired C. diff infections. Future work should focus on sustaining the intervention and expanding it to other units.

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  Improving Adolescent Sexual Health Education Through a Gamified Quality Improvement Initiative in Kenya: Game on for Safe Choices

  Alyssa Kashia Lee, Isabel Diazdeleon, and Ilyana Karkar

  Adolescent sexual health remains a significant public health concern in rural Kenya because of the limited access to comprehensive sexuality education; therefore, contributing to high rates of sexually transmitted infections (STIs), HIV, unintended pregnancy, and gender-based violence. This quality improvement project evaluated the implementation of the Game On for Safe Choices, a culturally responsive, game-based sexual health education intervention designed to improve adolescents' sexual health knowledge and confidence. The project was conducted at ByKay Hotel in Sega, Siaya County, Kenya, and included 25 adolescents aged 15–17 years. Guided by the Plan-Do-Study-Act framework, participants completed three interactive educational stations focused on consent, HIV/sexually transmitted infection prevention, pregnancy prevention, healthy relationships, and communication skills. Pre- and post-intervention surveys measured changes in knowledge and confidence, and quantitative data were analyzed using descriptive statistics and paired comparisons, while qualitative participant feedback was analyzed for common themes. Mean knowledge scores increased from 70.2% to 80.4%, exceeding the project's SMART objective, and confidence scores increased by 17.6% following the intervention. Participants also reported that the interactive, game-based activities enhanced engagement, teamwork, and learning. These findings suggested that culturally responsive, game-based sexual health education can improve adolescents' sexual health knowledge and confidence in resource-limited community settings. The project demonstrated the feasibility of implementing low-cost, community-based sexual health education through collaborative partnerships and supports future evaluation of long-term knowledge retention, behavioral outcomes, and implementation in larger and more diverse populations.

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  Know Your Birth

  Jasmine McKelvey, Reagan L. Hunt, and Michaela M. David

  Maternal mortality remains a significant public health concern in rural Kenya because of limited healthcare resources, inadequate emergency obstetric training, and barriers to accessing timely, high-quality maternal care. This quality improvement project evaluated the implementation of the Know Your Birth educational intervention, a culturally responsive, simulation-based training program designed to improve healthcare providers' knowledge, confidence, and competency in evidence-based maternal and newborn care. The project was conducted at Sega Dispensary in Sega, Siaya County, Kenya, and included 26 healthcare staff members. Guided by the Plan-Do-Study-Act framework, participants completed a brief educational presentation followed by three interactive skills stations focused on respectful maternity care, postpartum hemorrhage recognition and response, breastfeeding support, safe newborn swaddling, and evidence-based labor positioning using peanut balls. Pre- and post-intervention surveys measured changes in knowledge and confidence, and quantitative data were analyzed using descriptive statistics and paired-samples t tests. Confidence scores demonstrated a statistically significant improvement following the intervention (M = 4.86 vs. 4.93, p = .029). Knowledge scores increased from 5.04 to 5.35, but did not reach statistical significance (p = .188). Participants demonstrated high engagement throughout the simulation-based educational activities and demonstrated increased confidence in providing evidence-based maternal and newborn care. These findings suggest that brief, low-cost, simulation-based education is a feasible and sustainable strategy for strengthening provider confidence and supporting evidence-based maternity care in low-resource settings. Future quality improvement initiatives should evaluate long-term knowledge retention, changes in clinical practice, and maternal and neonatal outcomes to determine the sustained impact of the intervention.

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  Improving Knowledge of Obesity-Related Risks and Healthy Lifestyle Behaviors in Adolescents

  Tehroop Notra, Samreet Kaur, and Karina Heredia

  This quality improvement project evaluated the effectiveness of a school-based educational intervention aimed at improving ninth-grade students’ knowledge and understanding of obesity prevention, nutrition, and physical activity. Adolescent obesity remains a significant public health concern, showcasing the need for early, evidence-based education. A total of 57 students participated in the two classroom sessions. Of these students, 49 completed the pre-intervention survey, and 48 completed the post-intervention survey. The intervention included an interactive presentation, group discussions, and educational materials. Student knowledge was assessed using a six-item survey administered before and after the session. The results demonstrated improvements across multiple knowledge areas, with the largest growth seen in understanding recommended fruit and vegetable intake (+46.4 percentage points) and factors that contribute to obesity (+36.2 percentage points). Mean knowledge scores increased from 4.12 (SD = 1.17) pre-intervention to 5.23 (SD = 0.99) post-intervention. This difference was statistically significant, t(95) = 5.025, p < .001, representing a large effect size (Cohen’s d = 1.02). The number of students achieving high scores (5-6 correct) increased, while low scores decreased. These findings indicate that a brief, school-based educational intervention can significantly improve adolescent health knowledge. Future efforts should evaluate long-term knowledge retention and expansion in further school settings

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  Reducing Falls in the Cardiac Care Unit: An Improvement Project

  Andrea Otero, Aryanna Campa, and Nia Butac

  Abstract

  Background: Patient falls persist as a leading cause of preventable harm in hospitals, particularly among cardiac care patients who are at increased risk because of medication effects and mobility limitations. Despite existing fall `prevention measures in the Cardiac Care Unit (CCU) at Sutter Medical Center, Sacramento, 43 falls occurred, highlighting the need for improved patient education and consistent staff communication.

  Purpose: This quality improvement project evaluated the effectiveness of implementing a standardized fall prevention communication script to reduce the average monthly fall rate in the CCU from 3.583 to fewer than 2 falls per month.

  Methods: Using the Plan-Do-Study-Act (PDSA) framework, a standardized communication script was integrated into ambulation assistance and patient education over a six-week implementation period (May-June 2026). The script was provided to staff through pre-shift huddles, staff meetings, unit emails, and one-on-one rounding. Outcome measures included total monthly falls and falls per 1,000 patient days, using de-identified incident report data.

  Results: Before the implementation period (January 1-May 19, 2026), the CCU recorded 18 falls, with an average of 3.16 falls per 1,000 patient days. Following implementation (May 19-June 30, 2026), the fall rate decreased to 1.82 falls per 1,000 patient-days, representing an approximate 42% reduction. June recorded only one patient fall, meeting the project’s goal of reducing monthly falls to fewer than two.

  Conclusion: The standardized fall prevention communication script was a practical, low-cost intervention that integrated easily into existing nursing workflows and was associated with improved fall outcomes. Continued leadership support, staff education, and ongoing monitoring may improve sustainability, while future quality improvement efforts should evaluate the intervention over longer implementation periods.

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  ​​Hospital-Acquired Pressure Injury Prevention in the Sutter Sacramento Cardiac Care Unit ​QI Proposal

  Amy Roderick

  Background: Hospital-acquired pressure injuries (HAPIs) remain a significant source of preventable patient harm despite established prevention protocols. In the Cardiac Care Unit (CCU) at Sutter Medical Center Sacramento, inconsistent patient education and limited patient engagement were identified as potential contributors to ongoing HAPI occurrence. This quality improvement (QI) project evaluated whether implementing structured, individualized patient education could strengthen existing pressure injury prevention efforts.

  Methods: A seven-week QI project was conducted in the CCU using the Plan-Do-Study-Act (PDSA) framework. The intervention consisted of nurse-led, individualized pressure injury prevention (PIP) education supported by a standardized patient handout tailored to each patient's risk factors. Education was provided to all adult CCU patients, reinforced throughout hospitalization, documented in the electronic health record (EHR), and supported through staff communication and QI team rounding. The primary outcome measure was average monthly HAPI occurrence, while the primary process measure was compliance with documentation of individualized education and bedside handout placement.

  Results: Thirty patient audits were completed during the implementation period. Overall compliance with the education and handout workflow was 10%. One HAPI occurred during the seven-week implementation period. Average monthly HAPI occurrence decreased from 0.83 during the 2025 baseline period to an estimated 0.62 during implementation, representing a 25.3% reduction. Although the outcome objective was achieved, the process objective of 90% compliance was not met.

  Conclusions: Individualized patient education was feasible to implement within the CCU but was not consistently integrated into routine nursing practice. While HAPI occurrence decreased during the implementation period, low intervention fidelity prevented attribution of the improvement to the educational intervention. Future efforts should strengthen implementation strategies through leadership support, unit champions, standardized documentation, and ongoing reinforcement to improve sustainability and evaluate long-term effectiveness.

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  From Birth to Better Health: Educating Mothers with Gestational Diabetes on Breastfeeding Benefits and Glucose Management

  Jesse A. Soria Jr, Sarah Smith, Audrey Nolan Smith, and Keeley Kosier

  Gestational diabetes mellitus (GDM) increases a mother's risk of developing type 2 diabetes after pregnancy. Breastfeeding provides many health benefits for both mothers and babies and may help lower the mother's future risk of diabetes. However, many mothers with GDM do not receive enough education about breastfeeding and diabetes prevention before leaving the hospital. The purpose of this quality improvement project was to improve breastfeeding knowledge and diabetes prevention among postpartum mothers with GDM through a standardized education program.

  This project was completed at the Family Birthing Center at St. Joseph's Medical Center in Stockton, California. Twenty mothers were invited to participate, and 14 enrolled in the project. Participants completed a pre-survey, received a 10- to 15-minute education session using an educational pamphlet, completed a post-survey, and participated in follow-up phone calls. The project was guided by the Johns Hopkins Evidence-Based Practice Model.

  After the education session, participants showed improved knowledge about GDM, breastfeeding, and available breastfeeding resources. Mothers also reported feeling more confident asking healthcare providers questions about breastfeeding. At the time of data analysis, follow-up calls had been completed with seven participants. Many participants reported remembering the education and continued using the educational pamphlet after leaving the hospital.

  This project showed that a brief, standardized education program can improve breastfeeding knowledge and increase awareness of diabetes prevention among mothers with GDM. The intervention was easy to implement, required minimal resources, and can continue to be used as part of routine postpartum education.gestational diabetes mellitus, breastfeeding, postpartum education, diabetes prevention, quality improvement

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  Mind Over Scrubs – A Peer-Led Anxiety Reduction Program

  Nhi T. Tran, Angelica Dirige, and Adeleke Fashola

  Nursing students experience elevated anxiety during the transition into accelerated programs, which can negatively affect academic performance, well-being, and retention. This quality improvement project evaluated Mind Over Scrubs, a peer-led anxiety reduction program for incoming Entry-Level Master of Science in Nursing students at the University of the Pacific, consisting of four 45-minute sessions on evidence-based coping strategies. Generalized Anxiety Disorder-7 surveys were administered at baseline, before and after each session, and at two- and four-week follow-ups; Wilcoxon signed-rank tests evaluated matched changes. Thirty-one of 62 enrolled students (50%) attended at least one session. Post-session scores fell below individual baselines for 69–92% of matched respondents, exceeding the 30% improvement target at every session, and baseline-to-post reductions were statistically significant at three of four sessions (p = .033, .013, and .001). Mean scores declined from 10.61 at baseline to 5.67–5.80 at follow-up; reductions were sustained among matched follow-up respondents, and no adverse events were identified; a temporary increase at Session 2 coincided with a cohort examination, and attrition limited follow-up samples. Findings support peer-led wellness programming as a feasible, low-cost, and effective approach to supporting anxiety reduction in graduate nursing education, with future cycles recommended to expand recruitment, improve follow-up completion, and schedule sessions away from examinations.

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  Camino a la Salud: Culturally Tailored Diabetes Education for Hispanic Older Adults in Stockton, California

  Alondra Aldaba, Alexis Irvine, Jazmyn Monares, and Marissa Doblados-Wood

  AIM: Camino a la Salud addresses diabetes in one of the most affected populations in San Joaquin County, older Hispanic adults and their caregivers. This project aims to increase diabetes knowledge, confidence, and self-management among older adults in Stockton through culturally tailored education and hands-on learning. The project also provided glucometers and visual teaching tools to support skill development and improve diabetes awareness and prevention in this community.

  METHODS: This project included three weekly bilingual diabetes education sessions held at El Concilio during their senior food distribution program. Each session covered a different topic: diabetes risks and complications, understanding glucose and blood pressure numbers, and lifestyle changes for prevention and management. Education was delivered through short presentations, teach-back techniques, and culturally relevant examples. Participants completed pre- and post-surveys, including Likert-scale questions to measure changes in knowledge and confidence. The ADA diabetes risk test, printed materials, and live demonstrations supported learning. Surveys and observations were analyzed using SQUIRE guidelines.

  RESULTS: Across the project, there were 66 total session encounters (23 in Session 1, 23 in Session 2, and 20 in Session 3), with 19 participants completing demographic intake forms. Participants were mostly older adults with a mean age of 70.8 years, and the majority identified as Hispanic or Latino. Knowledge and confidence improved following the educational sessions, with survey scores increasing by at least 20 percent across all sessions. Confidence in understanding glucose and blood pressure values increased to a mean of 4.17 (≈30 percent improvement). In the final session, participants reported the highest overall outcome, with a mean score of 4.77, and the majority indicated they planned to adopt at least one healthy lifestyle change, such as improving their diet or incorporating gentle physical activity. These findings show meaningful increases in diabetes literacy and self‑management readiness.

  CONCLUSION: Camino a la Salud demonstrated improved diabetes knowledge, confidence, and intention to practice healthier behaviors among older Hispanic adults in Stockton, California. Delivering education in a trusted community setting with bilingual materials and culturally tailored content supported engagement and understanding. Participants showed improved awareness of diabetes risks, greater confidence with glucometer use and interpretation of numbers, and strong motivation to adopt healthier practices. Continued access to culturally relevant education and community partnerships may strengthen long-term health outcomes and reduce disparities for Hispanic older adults living with or at risk for diabetes.

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  Reducing Opioid Overdose Harm Through Narcan Access and Education

  Shane Alexander Role Alihan, Jared Timothy Chua, Siwapond (Taylor) Yuen, and Matthew Reynon

  Background: The overuse of opioids has led to an epidemic that affects the health of young adults in Sacramento, CA. Social and economic factors have influenced the use of opioids which has led those individuals to acquire an addiction and dependency to such drugs. This age group is typically engaged in college and career-minded endeavors. Thus, the impact on this age group is substantial, requiring impactful interventions.

  Aim: The purpose of this intervention is to provide a foundation for educating those affected by opioid overdose. This strategic goal is to equip students at the University of the Pacific’s Entry-Level Master of Science in Nursing program with ways to improve outcomes and prevent deaths. Students should be educated and informed on how to respond to opioid overdose and the proper use of Narcan.

  Methods: Surveys using the Likert-scale questionnaire were developed to determine whether the pre and post-interventions were impactful. The data from the 50 participants were collected anonymously via Google Forms and analyzed using Intellectus.

  Results: Results showed significant improvements, including improvement from 63% to 81% in the total correct of knowledge questions. The result of the two-tailed independent samples t-test was significant based on an alpha value of .05, (t80) = -5.75, p < .001, indicating the null hypothesis can be rejected. This finding suggests the mean of Knowledge survey was significantly different between the pre and post categories.

  Conclusion: Implementing opioid educational interventions and emphasizing training in a university setting with a focus on healthcare professionals is highly impactful. Understanding causation and remedies in a university setting helps build the foundation for addressing concerns and providing a basis for meaningful interventions.

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  The Sweet Solution Project - Improving Gestational Diabetes Management of the Mothers in Stockton, California

  Joelynn Ali, Cayla Cook, Jessica Frey, Hector Rizo, and Teresa Serna

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  Overdose Watch: Educate, Prevent, & Respond

  Linsey Atis, Jared Burton, Madison Meade, and Elizabeth Oliveira

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  Empower Birth: Black Maternal Health Project Improving Health Literacy and Health Management in Black Pregnant Women

  Harman Aujla, Carsyn Hoogendoorn, Blair Price, and Morgan Rohmann

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  The Safe Steps Project: Fall Prevention Amongst Older Adults in a Skilled Nursing Facility

  Maiana Cabrera, Nicole Le, Yen Tran, and Madeline Turcotte

  BACKGROUND: The Safe Steps Project aimed to reduce falls at Pine Creek Care Center, a skilled nursing facility located in Roseville, CA. Before this intervention, the fall rate at Pine Creek Care Center had been rising above their 15% goal in the first few months of 2025. Through an in-service education, this project has helped educate and increase nursing staff knowledge on fall prevention, such as intentional rounding with the 4 Ps (pain, position, potty, and possessions).

  AIM: The Safe Steps Project addresses a major cause of injury in older adults, falls. The aim of this project was to improve knowledge regarding fall prevention to nursing staff at Pine Creek Care Center through an education in-service, ultimately reducing fall rates.

  METHODS: This project was conducted through planned education in-services with a pre- and post-questionnaire, along with an interactive activity. Utilizing this method was aimed at increasing knowledge on fall prevention through a concise in-service that staff were already accustomed to this education format. The interactive activity provided the opportunity for staff to recall their knowledge prior to taking the post-survey. Data was collected from 56 participants via these questionnaires and analyzed using SQUIRE.

  RESULTS: Results from 45 participants with completed surveys showed an improvement in knowledge regarding intentional rounding and the 4 Ps. Certified nursing assistants (CNAs) represented the largest group of participants. The mean participant age was 33.8 years old. The mean survey score increased from the pre-survey to the post-survey.

  CONCLUSIONS: The Safe Steps Project was conducted at Pine Creek Care Center, where participating nursing staff exhibited improvement in knowledge of fall prevention education related to intentional rounding and the implementation of 4 Ps. The provision of continued education opportunities for facility nursing staff on fall prevention and access to educational materials is essential to improve and sustain positive outcomes in older adults in SNFs who are at higher risk of experiencing falls and fall injuries.

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  Hygiene Heroes: Strengthening Oral Hygiene to Reduce Central Line-Associated Bloodstream Infections in Pediatric Hematology/Oncology Patients

  Sidney Clymer-Engelhart and Kirstie Shulman

  Background: Central line-associated bloodstream infections (CLABSIs) impact pediatric patient outcomes, increasing mortality, hospital stays, and healthcare costs. At Sutter Medical Center Sacramento (SMCS), the CLABSI prevention bundle includes proper line care, dressing assessments, and hygiene practices, including twice-daily oral care, daily linen changes, and chlorhexidine gluconate (CHG) bathing. Sutter found their CLABSI bundle compliance at approximately 76–78%, with oral hygiene identified as the most frequent gap in care.

  Aim: This quality improvement project, partnered with SMCS, targeted oral care compliance to enhance overall bundle adherence, strengthen staff-leadership communication, and ultimately reduce CLABSI rates in the hematology/oncology units. In a wider perspective, this project sought to support Sutter’s broader commitment to preventing hospital-acquired infections through evidence-based care.

  Methods: Targeting all 80 registered nurses and 9 technicians working on the pediatric and hematology/oncology units at SMCS, staff education was delivered through Tuesday Teaching Tip (“T3”) emails, huddle reminders, and weekly patient rounds, focusing on proper oral hygiene practices for patients with central lines. Educational hygiene flyers were provided to patients and families during weekly oncology rounding to deliver individualized education and assess oral care practices. Kamishibai cards (K-card) audits tracked pre- and post-intervention bundle adherence to evaluate the effectiveness in improving oral care compliance and decreasing CLABSI rates.

  Results: Mean oral care compliance improved from 71% (SD = 0.30) during the pre-intervention phase to 91% (SD = 0.06) in phase 1 and 87% (SD = 0.03) in phase 2. The difference between the pre-intervention phase and phase 1 was statistically significant (p = .043). The rolling 12- month CLABSI rate decreased from 0.87 (SD = 0.40) to 0.61 (SD = 0.24) per 1,000 catheter days by phase 2, though changes were not statistically significant (p > .05). Overall, the intervention was associated with improved oral care compliance and a downward trend in CLABSI rates.

  Conclusion: This project was used to enhance and improve oral hygiene compliance in hematology/oncology pediatric patients with central lines at SMCS as a strategy to reduce CLABSIs. This supported an existing quality improvement project at SMCS and aimed to reinforce best practices through two primary interventions: nurse education through “T3” email updates and huddle reminders, as well as the implementation of an educational hygiene flyer for patients and their families. Through these interventions, oral care compliance increased within the unit, ranging between 80% and 90%, and is expected to continue improving over the next several months.

  
  

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  Wound Care 101

  Kristen DeLaRosa, Katelyn Moore, Lauren Rossi, and Marissa Yorita

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  Enhancing Empathetic Dementia Care Through Cognitive Training: A Holistic Approach to Improving Patient Outcomes

  Truyen Do, Yasmin Khouri, Millie Patel, and Levan Petrossian

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  The Artful Aging Project

  Maria Carmelita Fernandez, Sah'Neya Fryer, Kathleen Morris, and Maya Price

  As the older adult population in Sacramento County continues to expand, addressing age-related declines in fine motor function, cognition, and social well-being has become increasingly critical. Such declines can compromise activities of daily living, reduce independence, and exacerbate risks associated with social isolation. Evidence suggests that art-based interventions may mitigate these effects by enhancing motor coordination, promoting social engagement, and stimulating cognitive processes. The Artful Aging Project was designed to evaluate the effectiveness of structured art activities in improving fine motor skills and social wellness among older adults served by the Stanford Settlement Neighborhood Center (SSNC). Grounded in community-based participatory principles, the project involved strong collaboration with SSNC leadership to develop culturally inclusive programming for a diverse and multilingual senior population. Participants engaged in four weekly sessions featuring origami, calligraphy, mosaic, and collage between July and August 2025. Pre- and post-intervention assessments utilized adapted versions of the Manual Ability Measure (MAM-36) and the Functional Status Questionnaire (FSQ) to evaluate fine motor function and social well-being, respectively.

  Seven participants completed both MAM-36 surveys, demonstrating an average improvement of 1.8 points, with 85.7% showing maintained or enhanced scores. Six participants completed both FSQ surveys, with 66.7% exhibiting improved post-intervention scores and an average increase of 4.2 points.

  These findings indicate that structured, culturally responsive art interventions can effectively preserve or enhance fine motor abilities and social wellness in older adults, supporting the integration of art-based programming within community health initiatives for aging populations.

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  Mindful Aging Project Mental Wellness Education in Partnership with Older Adults in Sacramento County

  Yesica Garcia, Sarah Molla, Kristin Provencher, and Sharon Yeong

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  The Bonding Project: Addressing Mental Health Issues in the Older LGBTQ+ Community in Sacramento

  Jose A. Gonzalez-Villasenor, Morgan Taniguchi, Claire Tousley, Jessica Landmark, and Jacqueline Paine

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  Improving Maternal Mental Health Awareness and Support in Perinatal Black and Latina Women

  Jasman Hans, Lesly Carrillo, Kayla Huynh, and Brianna Harrison

  Background: Black and Latina women in California experience disproportionately high rates of perinatal mental health disorders due to limited access to care, stigma, and systemic inequities.

  Aim: In collaboration with BeMomAware, this Quality Improvement project aimed to enhance maternal mental health literacy among Black and Latino individuals in the Oak Park community of Sacramento. The project sought to increase awareness, knowledge, and access to culturally appropriate mental health resources through an educational video and community session.

  Methods: Interventions included a short educational video and an in-person community session providing culturally relevant information about perinatal depression and anxiety disorders, available resources, and strategies for seeking help. Participants completed pre- and post- surveys to assess knowledge and attitudes before and after the intervention.

  Results: Results from a two-tailed independent samples t-test indicated a statistically significant improvement in post-survey knowledge scores (p < 0.05). Participants also reported greater confidence in identifying perinatal mental health symptoms (p = .005).

  Conclusion: This Quality Improvement project demonstrated that culturally sensitive education can effectively improve maternal mental health literacy within underserved communities. By promoting awareness and reducing stigma, the project supports the integration of nursing practice and public health efforts to advance health equity. Sustained collaboration with community organizations such as BeMomAware will further strengthen maternal mental health education and support for communities of color in Sacramento.

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  Staying Ahead of the Pressure: A Multimodal Intensive Care Unit Hospital-Acquired Pressure Injury Quality Improvement Project at Sutter Medical Center, Sacramento

  Mijung Lim, Daniela Tobler, and Raquel Youkhana

  Background: Hospital-acquired pressure injuries (HAPIs) are a major quality and safety concern, particularly in the intensive care units (ICUs) where critically ill and immobile patients face elevated risk. At Sutter Medical Center Sacramento (SMCS), nine confirmed HAPIs and two under investigation were reported within the medical ICU, cardiac ICU, and neurosurgical ICU by May 2025, exceeding the hospital’s target and prompting a system-wide quality improvement initiative.

  Aim: The aim of this project was to: (a) reduce ICU-acquired HAPIs to fewer than four cases per quarter by December 2025 and (b) increase nursing compliance with early and ongoing prevention strategies, including repositioning, nutrition optimization, and risk assessment accuracy.

  Methods: Guided by the Iowa Model Revised, this quality improvement project was implemented across the Cardiac (CICU), Medical (MICU), and Neurosurgical (NSSICU) ICUs. Interventions included: (1) staff education, (2) Wound Champion designation, (3) wound care supply room reorganization, (4) nutritional supplementation with Juven and enteral feeding catch-up protocols, (5) wedge repositioning trials that led to full implementation, and (5) beta testing of the Braden and Cubbin–Jackson (CJ) scales for enhanced risk identification. In addition, beta-test data from the Leaf and Atlas mobility monitoring systems were collected to assess repositioning adherence but not adopted for routine use. Enteral feeding data was verified through EPIC chart audits and bedside rate checks, documented in Excel for trend analysis.

  Results: Among 22 ICU patients assessed, the CJ scale identified 55% as moderate to high risk compared with 18% using the Braden scale, suggesting improved sensitivity for critically ill patients. Leaf system data showed high repositioning adherence (87% and 84.7%), while nutrition audits revealed declining compliance with Juven implementation and documentation (58.8% → 20% → 0%) and enteral feeding catch-up goals. As of October, a total of twenty-one HAPIs were reported across three ICUs, with an estimated 33.6 HAPIs prevented during the reporting period.

  Conclusion: Integrating evidence-based interventions strengthened prevention practices and early risk recognition. Sustained progress will require leadership engagement, standardized audit tools, and policy integration of nutritional and positioning protocols to maintain improvements in patient safety.