Inspiring Writing in Nursing: A Clinical Nurse Specialist-Led Program.

BACKGROUND: Hospitals are constantly involved in quality improvement and research projects investing considerable money, time, and effort in supporting these projects; however, there is not always a strong enough focus on publishing the results. The challenge lies in engaging clinicians to publish their work. One of the hallmarks of the clinical nurse specialist is mentoring, and this has led to the creation of our Inspiring Writing in Nursing (IWIN) program. PURPOSE: The goal of IWIN cohort was to engage and promote publication submissions from frontline clinicians. The 18-member Nursing Research and Evidence-Driven Practice Council (NR-EDPC) supports more than 3000 nurses in quality and research projects. Two senior librarians support our council and staff. In 2014, we launched our first IWIN cohort to mentor nurses in writing and submitting for publication. EVALUATION: The NR-EDPC motto "meet them where they are" applies to both location and level of research/EDPC knowledge and skill. An Annual Nursing Research Conference showcases the products of nursing science. The first cohort of IWIN enrolled 11 mentees, and after a yearlong journey, we submitted 5 of 11 manuscripts, 3 withdrew, and 3 are still under revisions. From the 5 submissions, 3 were published, 1 was rejected, and 1 is currently under revision. DISCUSSION: With support and the infrastructure of our NR-EDPC, we are launching our second IWIN cohort.

Systems Addressing Frail Elders (SAFE) Care: Description of Successful Partnerships Across Hospitals.

Systems Addressing Frail Elders (SAFE) Care is an interprofessional team-based program, which was developed and evaluated in a cluster randomized controlled trial. Results of this trial included reduced length of stay and complications for patients. This article describes a successful partnership across 4 Magnet hospitals in the dissemination of the model. A 2-year sequential implementation process was completed, with an approach of adoption, adaptation, and abandonment. The model was successfully implemented at each participating Magnet hospital. Implementation included capacity building, organizational change, and process implementation.

Frailty in a Post-Acute Care Population: A Scoping Review.

Frailty is a complex and growing phenomenon facing health care providers throughout the continuum of care. Frailty is not well understood in post-acute care (PAC) settings. The purpose of this scoping review was to summarize current evidence of frailty impact on outcomes and frailty mitigation initiatives in PAC. Three major publication databases were searched from January 2000 to June 2017 that identified 18 articles specifically addressing frailty in PAC. Three themes were identified: scales used to measure frailty, factors that led to an adverse outcome or diagnosis of frailty, and interventions to address frailty in PAC. Scales used to measure frailty were dominated by physical factors and scarce on nutrition and social support. Functional decline, grip strength, gait speed, polypharmacy, and nutrition were identified in the studies as factors that identify frailty and are associated with poor outcomes. All these frailty characteristics compromise patients' ability to benefit from rehabilitation, which further establishes the importance of PAC providers to identify, prevent, and treat frailty. Intervention studies had mixed outcomes, suggesting a need for further development in this area. The findings of this scoping review highlight the need for a comprehensive multidimensional assessment of frailty risks in PAC. LEVEL OF EVIDENCE: IV.

Systems Addressing Frail Elder Care: Description of a Successful Model.

OBJECTIVE: The aim of this article is to describe the Systems Addressing Frail Elder (SAFE) Care model, features of the interprofessional team and reengineered workflow, and details of the intervention. BACKGROUND: Older inpatients are vulnerable to adverse events related to frailty. SAFE Care, an interprofessional team-based program, was developed and evaluated in a cluster randomized controlled trial (C-RCT). Results found reduced length of stay and complications. The purpose of this article is to support and encourage the replication of this innovation or to help facilitate implementation of a similar process of organizational change. METHODS: This was a review of model features and intervention data abstracted from electronic health records. RESULTS: Salient features of team composition, training, and workflow are presented. The C-RCT intention-to-treat sample included 792 patients, of whom 307 received the SAFE Care huddle intervention. The most frequent problem was mobility (85.7%), and most frequent recommendation was fall precautions protocol (83.1%). CONCLUSIONS: The SAFE Care model may provide a standardized framework to approach, assess, and address the risks of hospitalized older adults.

Ambulatory Care Nurse-Sensitive Indicators Series: Reaching for the Tipping Point in Measuring Nurse-Sensitive Quality in the Ambulatory Surgical and Procedure Environments.

The value of the ambulatory care nurse remains undocumented from a quality and patient safety measurement perspective and the practice is at risk of being highly variable and of unknown quality. The American Academy of Ambulatory Care Nursing and the Collaborative Alliance for Nursing Outcomes propose nurse leaders create a tipping point to measure the value of nursing across the continuum of nursing care, moving from inpatient to ambulatory care. As care continues to shift into the ambulatory care environment, the quality imperative must also shift to assure highly reliable, safe, and effective health care.

Identification and team-based interprofessional management of hospitalized vulnerable older adults.

BACKGROUND: Extended hospital stays and complications are common among older adults and may lead to morbidity and loss of independence. Specialized geriatric units have been shown to improve outcomes but, with the growing numbers of older adults, may be difficult to scale to meet needs. PURPOSE: The purpose was to evaluate a quality improvement initiative that redesigned unit-based workflow and trained interprofessional teams on general medical/surgical units to create care plans for vulnerable older adults using principles of comprehensive geriatric assessment and team management. METHOD: The evaluation included a cluster randomized controlled trial of 10 medical/surgical units and intention-to-treat analysis of all patients meeting risk screening criteria. RESULTS: N = 1,384, median age = 80.9 years, and 53.5% female. Mean difference in observed vs. expected length of stay was 1.03 days shorter (p = .006); incidence of complications (odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.21-0.98) and transfer to intensive care (OR = 0.45; 95% CI = 0.25-0.79) lower among patients admitted to intervention units; incidence of discharge to institutional care was higher (OR = 1.43; 95% CI = 1.06-1.93). Mortality during hospitalization (OR = 0.64; 95% CI = 0.37-1.11) did not differ between groups. CONCLUSION: Reorganizing general medical/surgical units to provide team-based interprofessional care can improve outcomes among hospitalized older adults.

Improving hospital patient falls: leveraging staffing characteristics and processes of care.

OBJECTIVE: Predictive models for falls, injury falls, and restraint prevalence were explored within nursing unit structures and processes of care. BACKGROUND: The patient care team is responsible for patient safety, and improving practice models may prevent injuries and improve patient safety. METHODS: Using unit-level self-reported data from 215 hospitals, falls, injury falls, and restraint prevalence were modeled with significant covariates as predictors. RESULTS: Fewer falls/injury falls were predicted by populations with fewer frail and at-risk patients, more unlicensed care hours, and prevention protocol implementation, but not staffing per se, restraint use, or RN expertise. Lower restraint use was predicted by fewer frail patients, shorter length of stay, more RN hours, more certified RNs, and implementation of fall prevention protocols. CONCLUSION: In the presence of risk, patient injuries and safety were improved by optimizing staffing skill mix and use of prevention protocols.

Validating SPICES as a Screening Tool for Frailty Risks among Hospitalized Older Adults.

Older patients are vulnerable to adverse hospital events related to frailty. SPICES, a common screening protocol to identify risk factors in older patients, alerts nurses to initiate care plans to reduce the probability of patient harm. However, there is little published validating the association between SPICES and measures of frailty and adverse outcomes. This paper used data from a prospective cohort study on frailty among 174 older adult inpatients to validate SPICES. Almost all patients met one or more SPICES criteria. The sum of SPICES was significantly correlated with age and other well-validated assessments for vulnerability, comorbid conditions, and depression. Individuals meeting two or more SPICES criteria had a risk of adverse hospital events three times greater than individuals with either no or one criterion. Results suggest that as a screening tool used within 24 hours of admission, SPICES is both valid and predictive of adverse events.

Early recognition of risk factors for adverse outcomes during hospitalization among Medicare patients: a prospective cohort study.

BACKGROUND: There is a persistently high incidence of adverse events during hospitalization among Medicare beneficiaries. Attributes of vulnerability are prevalent, readily apparent, and therefore potentially useful for recognizing those at greatest risk for hospital adverse events who may benefit most from preventive measures. We sought to identify patient characteristics associated with adverse events that are present early in a hospital stay. METHODS: An interprofessional panel selected characteristics thought to confer risk of hospital adverse events and measurable within the setting of acute illness. A convenience sample of 214 Medicare beneficiaries admitted to a large, academic medical center were included in a quality improvement project to develop risk assessment protocols. The data were subsequently analyzed as a prospective cohort study to test the association of risk factors, assessed within 24 hours of hospital admission, with falls, hospital-acquired pressure ulcers (HAPU) and infections (HAI), adverse drug reactions (ADE) and 30-day readmissions. RESULTS: Mean age = 75(±13.4) years. Risk factors with highest prevalence included >4 active comorbidities (73.8%), polypharmacy (51.7%), and anemia (48.1%). One or more adverse hospital outcomes occurred in 46 patients (21.5%); 56 patients (26.2%) were readmitted within 30 days. Cluster analysis described three adverse outcomes: 30-day readmission, and two groups of in-hospital outcomes. Distinct regression models were identified: Weight loss (OR = 3.83; 95% CI = 1.46, 10.08) and potentially inappropriate medications (OR = 3.05; 95% CI = 1.19, 7.83) were associated with falls, HAPU, procedural complications, or transfer to intensive care; cognitive impairment (OR = 2.32; 95% CI = 1.24, 4.37), anemia (OR = 1.87; 95% CI = 1.00, 3.51) and weight loss (OR = 2.89; 95% CI = 1.38, 6.07) were associated with HAI, ADE, or length of stay >7 days; hyponatremia (OR = 3.49; 95% CI = 1.30, 9.35), prior hospitalization within 30 days (OR = 2.66; 95% CI = 1.31, 5.43) and functional impairment (OR = 2.05; 95% CI = 1.02, 4.13) were associated with 30-day readmission. CONCLUSIONS: Patient characteristics recognizable within 24 hours of admission can be used to identify increased risk for adverse events and 30-day readmission.

Multidimensional health risk appraisal among adults aging with acquired disabilities.

BACKGROUND: The increasing older adult population includes people with disabilities facing added challenges of aging. The Affordable Care Act Section 4103 calls for an annual health risk appraisal (HRA) to be administered with older adults. HRAs show promise when used with older adults, yet little is known about their use with adults aging with acquired disabilities. OBJECTIVES: 1) Explore psychometrics of the multidimensional Stay Well and Healthy! Health Risk Appraisal tool (SWH-HRA) among persons aging with disabilities acquired in early or mid-life, and 2) Assess SWH-HRA application to characterize disability subgroup differences. METHODS: Psychometric analysis conducted on SWH-HRA interview data collected with 93 participants with an acquired disability of at least five years or more post-onset. ANOVA and Chi-square to explore differences in risks by subgroups identified by etiology (traumatic brain injury, stroke, spinal cord injury, and movement disorders). RESULTS: A high prevalence of health risks was noted. Risks were associated with health, participation and quality of life outcomes. With the exception of independence in basic activities of daily living and incontinence, few statistically significant differences were noted among disability subgroups. Patterns of risk clusters and prevalence within disability subgroup were consistent with findings in the literature. CONCLUSION: The SWH-HRA provides a valid and comprehensive health risk assessment. When used in annual wellness visits among persons with disabilities, it has the potential to inform the partnership between health providers and individuals with disabilities as they collaborate to promote healthy aging.

Mandated nurse staffing ratios in California: a comparison of staffing and nursing-sensitive outcomes pre- and postregulation.

This article examines the impact of mandated nursing ratios in California on key measures of nursing quality among adults in acute care hospitals. This study is a follow-up and extension of our first analysis exploring nurse staffing and nursing-sensitive outcomes comparing 2002 pre-ratios regulation data to 2004 postratios regulation data. For the current study we used postregulation ratios data from 2004 and 2006 to assess trends in staffing and outcomes. Findings for nurse staffing affirmed the trends noted in 2005 and indicated that changes in nurse staffing were consistent with expected increases in the proportion of licensed staff per patient. This report includes an exploratory examination of the relationship between staffing and nursing-sensitive patient outcomes. However anticipated improvements in nursing-sensitive patient outcomes were not observed. This report contributes to the growing understanding of the impacts of regulatory staffing mandates on hospital operations and patient outcomes.