Enteral nutrition: An underappreciated source of patient safety events.

Enteral nutrition (EN) therapies are prescribed for patients not able to maintain adequate nutrition through the oral route. Medical errors and close calls associated with the provision of EN therapy leading to actual and potential patient harm have been reported. The purpose of this study was to determine the number, type, and severity of safety events related to the provision of EN therapies reported to a national database and provide workable recommendations from the literature to improve safety. An interdisciplinary team queried the National Center for Patient Safety (NCPS) Joint Patient Safety Reporting (JPSR) system using keywords related to EN therapy use. The team reviewed the number, type, and severity of reported events and safety codes as categorized by the NCPS and then thematically classified the narratives using the Medication Use Process (MUP). Our query revealed 1227 safety events related to the EN keywords. Thematic analysis of the top five event subtypes (n = 1030) revealed that there were 691 EN safety reports directly related to an MUP step, and the majority fell into the steps of administering (31%), followed by monitoring (28%), dispensing (26%), prescribing (11%), and transcription (4%), with many events involving more than one MUP step. Safety events associated with the provision of EN therapies leading to patient harm have been reported to the JPSR system. To improve safety related to EN use, modifications to prescribing, transcribing/documenting, dispensing, administering, and monitoring of prescribed EN therapies are needed.

Guiding Post-Hospital Recovery by 'What Matters:' Implementation of Patient Priorities Identification in a VA Community Living Center.

BACKGROUND: Patient priorities care (PPC) is an effective age-friendly health systems (AFHS) approach to aligning care with goals derived from 'what matters'. The purpose of this quality improvement program was to evaluate the fidelity and feasibility of the health priorities identification (HPI) process in VA Community Living Centers (CLC). METHODS: PPC experts worked with local CLC staff to guide the integration of HPI into the CLC and utilized a Plan-Do-Study-Act (PDSA) model for this quality improvement project. PPC experts reviewed health priorities identification (HPI) encounters and interdisciplinary team (IDT) meetings for fidelity to the HPI process of PPC. Qualitative interviews with local CLC staff determined the appropriateness of the health priorities identification process in the CLC. RESULTS: Over 8 months, nine facilitators completed twenty HPI encounters. Development of a Patient Health Priorities note template, staff education and PPC facilitator training improved fidelity and documentation of HPI encounters in the electronic health record. Facilitator interviews suggested that PPC is appropriate in this setting, not burdensome to staff and fostered a person-centered approach to AFHS. CONCLUSIONS: The HPI process is an acceptable and feasible approach to ask the 'what matters' component of AFHS in a CLC setting.

Improving Administration and Documentation of Enteral Nutrition Support Therapy in a Veteran Affairs Health Care System: Use of Medication Administration Record and Bar Code Scanning Technology.

OBJECTIVES: The goal of this project was to evaluate and improve the ordering, administration, documentation, and monitoring of enteral nutrition therapies within the inpatient setting in a Veteran's Health Administration system. METHODS: An interdisciplinary team of clinicians reviewed the literature for best practices and revised the process for enteral nutrition support for hospitalized veterans. Interventions included training staff, revising workflows to include scanning patients and products, including enteral nutrition orders within the medication administration record (MAR), and using the existing bar code medication administration system for administration, documentation, and monitoring. Baseline and postprocess improvement outcomes over a year period were collected and analyzed for quality improvement opportunities. RESULTS: Before process change, only 60% (33/55) of reviewed enteral nutrition orders were documented and 40% (22/55) were not documented in the intake flowsheet of the electronic health record. In the year after adding enteral nutrition therapies to the MAR and using bar code scanning, a total of 3807 enteral nutrition products were evaluated. One hundred percent of patients were bar code scanned, 3106/3807 (82%) products were documented as given, 447/3807 (12%) were documented as held (with comments), 12/3807 (<1%) were documented as missing/unavailable, and 242/3807 (6%) were documented as refused. CONCLUSIONS: Inclusion of enteral nutrition order sets on the MAR and using bar code scanning technology resulted in sustained improvements in safety, administration, and documentation of enteral therapies for hospitalized veterans.

Importance of public-private partnerships for nutrition support research: An ASPEN Position Paper.

Parenteral and enteral nutrition support are key components of care for various medical and physiological conditions in infants, children, and adults. Nutrition support practices have advanced over time, driven by the goals of safe and sufficient delivery of needed nutrients and improved patient outcomes. These advances have been, and continue to be, dependent on research and development studies. Such studies address aspects of enteral and parenteral nutrition support: formulations, delivery devices, health outcomes, cost-effectiveness, and related metabolism. The studies are supported by public funding from the government and by private funding from foundations and from the nutrition support industry. To build public trust in nutrition support research findings, it is important to underscore ethical research conduct and reporting of results for all studies, including those with industry sponsors. In 2019, American Society for Parenteral and Enteral Nutrition's (ASPEN's) Board of Directors established a task force to ensure integrity in nutrition support research that is done as collaborative partnerships between the public (government and individuals) and private groups (foundations, academia, and industry). In this ASPEN Position Paper, the Task Force presents principles of ethical research to guide administrators, researchers, and funders. The Task Force identifies ways to curtail bias and to minimize actual or perceived conflict of interests, as related to funding sources and research conduct. Notably, this paper includes a Position Statement to describe the Task Force's guidance on Public-Private Partnerships for research and funding. This paper has been approved by the ASPEN Board of Directors.

Enteral Nutrition Administration Record Prescribing Process Using Computerized Order Entry: A New Paradigm and Opportunities to Improve Outcomes in Critically Ill Patients.

BACKGROUND: Prevalence of malnutrition has been reported in 60% of hospitalized and up to 78% of patients admitted to intensive care units. Malnutrition has been associated with complications, such as infection, increased hospital length of stay, morbidity, and mortality. Nutritional support has been shown to reduce avoidable readmissions, pressure ulcers, malpractice claims, and hospital costs. Creating a new electronic nutrition administration record (ENAR) with a linked nutrition tab within the electronic health record (EHR) would promote enhanced patient outcomes by improving adherence to established institutional enteral nutrition (EN) protocols and achieving early energy goals. Additionally, it would enable a clear and standardized method for documentation and administration of EN therapy. METHODS: The multidisciplinary nutrition support team was established and met on a weekly basis to discuss strategies and barriers, identify stakeholders, evaluate the current state, and establish a process and workflow from the point of order entry, delivery, administration, and electronic documentation of orders of EN supplements. The aim of this article is to describe a systematic approach and process of creating a new ENAR with a linked nutrition tab in the EHR, and to illustrate the order panel built and lessons learned from the process. RESULTS: A separate nutrition tab was created in the EHR with minimal disruption in patient care and end-users' positive feedback for the new order panel. CONCLUSION: ENAR allows for easier data collection and promotes nutrition-related research that may result in enhanced patient care. Utilizing technology to build a full ENAR would result in optimized patient care and safety.

Nutrition Support Therapies on the Medication Administration Record: Impacts on Staff Perception of Nutrition Care.

BACKGROUND: It has been reported that many hospitals in the United States have fragmented and ineffective ordering, administration, documentation, and evaluation/monitoring of nutrition therapies. This paper reports on a project to investigate if perceived hospital staff awareness and documentation of nutrition support therapies (NSTs) improves by including them as part of the medication administration record (MAR). METHODS: Surveys were conducted with nursing staff, physicians, and dietitians before and after adding NSTs to the MAR to evaluate the perceived impact on the outcome of interest. The outcomes of interest include nurses' perception of ease of finding information, awareness of an order, and ability to assess administration and documentation and dietitian, nurse, and physician staff perceptions of impact of intervention on aspects of the nutrition care process. RESULTS: After adding NST to the MAR, nursing staff perceived improvement in knowing that their patient had an oral nutritional supplement (ONS) order (P = .01), when and how much product was last administered (P = .01), and documentation of the type of product consumed (P = .01) and volume of product consumed (P = .01). The majority of dietitian and nurses surveyed reported perceived improvement in placing and finding ONS orders, in administration of ONS, in ability to evaluate patient nutrition status, and in ONS intake and a positive impact on clinical practice. CONCLUSION: Inclusion of NST in the MAR presents an innovative solution to enhance staff awareness of ordered therapies and perception of improved documentation of nutrition interventions for hospitalized patients.

ASPEN Consensus Recommendations for Refeeding Syndrome.

INTRODUCTION: In the spring of 2017, the American Society for Parenteral and Enteral Nutrition (ASPEN) Parenteral Nutrition Safety Committee and the Clinical Practice Committee convened an interprofessional task force to develop consensus recommendations for identifying patients with or at risk for refeeding syndrome (RS) and for avoiding and managing the condition. This report provides narrative review and consensus recommendations in hospitalized adult and pediatric populations. METHODS: Because of the variation in definitions and methods reported in the literature, a consensus process was developed. Subgroups of authors investigated specific issues through literature review. Summaries were presented to the entire group for discussion via email and teleconferences. Each section was then compiled into a master document, several revisions of which were reviewed by the committee. FINDINGS/RECOMMENDATIONS: This group proposes a new clinical definition, and criteria for stratifying risk with treatment and screening strategies. The authors propose that RS diagnostic criteria be stratified as follows: a decrease in any 1, 2, or 3 of serum phosphorus, potassium, and/or magnesium levels by 10%-20% (mild), 20%-30% (moderate), or >30% and/or organ dysfunction resulting from a decrease in any of these and/or due to thiamin deficiency (severe), occurring within 5 days of reintroduction of calories. CONCLUSIONS: These consensus recommendations are intended to provide guidance regarding recognizing risk and identifying, stratifying, avoiding and managing RS. This consensus definition is additionally intended to be used as a basis for further research into the incidence, consequences, pathophysiology, avoidance, and treatment of RS.

Impact of Telephone Follow-Up on Patient Satisfaction in a Pediatric Neurosurgery Clinic.

Patient satisfaction is a key metric used to measure quality in health care. However, patient satisfaction measures in the pediatric population are less studied and understood than in the adult population. The purpose of this study was to evaluate the impact of telephone follow-up on patient satisfaction in an outpatient pediatric neurosurgery clinic. A standardized telephone follow-up call was performed within 1 week of a child's clinic visit. Pearson's χ2 or Fisher's exact tests were used to assess changes in patient satisfaction measures after implementation of the telephone follow-up call initiative. The proportion of overall "top-box" physician rating significantly increased from 85.5% in 2017 to 95.6% in 2018 (P = .04). There was also a nonsignificant upward trend in the proportion of respondents noting that they would recommend this provider, as well as in all measures of physician communication quality and office staff quality. A simple telephone call to new patients after an outpatient pediatric neurosurgery clinic visit resulted in statistically significant and clinically meaningful changes in patient satisfaction scores.

Towards implementing SNOMED CT in nursing practice: A scoping review.

BACKGROUND: Currently, it is rare for nursing data to be available in data repositories due to the quality of nursing data collected in clinical practice. To improve the quality of nursing data, the American Nurses Association recommends the use of Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) for coding nursing problems, interventions, and observations in electronic health records. OBJECTIVE: To determine "what is known about the use of SNOMED terminology (Pre-SNOMED CT and SNOMED CT) in nursing". METHODS: We searched four databases and two search engines. We identified 29 articles for review. A modified version of System Development Life Cycle (SDLC), and Mapping Evaluation Assessment (MEA), created by the authors were used for quality assessment. RESULTS: All 29 studies mapped standardized (n = 19) or local nursing terms (n = 10) to the SNOMED terminology. MEA scores ranged from 2-8 (range 0-11) with 25 receiving scores from 5-8. On the modified SDLC (range 0-5), all studies exhibited activities of stage 0 (pre-application integration), with two studies describing integration and preliminary testing of SNOMED CT coded nursing content in applications (stage 2). CONCLUSION: Though efforts are underway to ensure adequate coverage of nursing in SNOMED CT, there were no studies indicating use in nursing practice. The authors offer recommendations for achieving the widespread collection of interoperable SNOMED CT coded nursing data in clinical applications to evaluate nursing's impact on patient outcomes. These include creating a clear professional vision and path to our data goals that builds on sound rationale and evidence, abundant stakeholder engagement, and sufficient resources.

Optimizing Nutrition Care for Pressure Injuries in Hospitalized Patients.

Significance: It is estimated that up to 50% of hospitalized patients are malnourished. Malnutrition can lead to longer hospital stays, altered immune function, and impaired skin integrity and wound healing. Malnutrition has been found to be a significant factor influencing pressure injury (PI) risk and wound healing. While PI prevention requires multidimensional complex care using a variety of evidence-based strategies, hospitalized patients benefit from interventions that focus on improving oral nutrition to reduce PI risk and enhance wound healing. Unfortunately, malnutrition is often under-recognized and inadequately managed in hospitalized patients and this can lead to higher rates of complications such as PI. Recent Advances: Recent studies suggest that nutritional care has a major impact in PI prevention and management. Strategies, including early identification and management of malnutrition and provision of specially-formulated oral nutritional interventions to at-risk patients, optimization of electronic health record systems to allow for enhanced administration, monitoring, and evaluation of nutritional therapies, and implementation of protocol-based computerized decision support systems, have been reported to improve outcomes. Critical Issues: Unfortunately, there are gaps in the implementation of nutritional care in hospitals. Timely identification and management of malnutrition is needed to advance quality care for hospitalized patients and reduce malnutrition and associated PI. Future Directions: Further research on effective, evidence-based strategies for implementation of all stages of the nutrition care process is needed to reduce pressure injuries and malnutrition in hospitalized patients.

The Use of Simulation to Teach Nursing Students and Clinicians Palliative Care and End-of-Life Communication: A Systematic Review.

OBJECTIVES: To present the findings of a systematic review on the use of simulation-based learning experiences (SBLEs) to teach communication skills to nursing students and clinicians who provide palliative and end-of-life care to patients and their families. BACKGROUND: Palliative care communication skills are fundamental to providing holistic patient care. Since nurses have the greatest amount of direct exposure to patients, building such communication competencies is essential. However, exposure to patients and families receiving palliative and end-of-life care is often limited, resulting in few opportunities to learn these skills in the clinical setting. Simulation-based learning experiences can be used to supplement didactic teaching and clinical experiences to build the requisite communication skills. METHODS: Searches of CINAHL, MEDLINE, PsychINFO, ERIC, and Web of Science electronic databases and Grey Literature returned 442 unique records. Thirty articles met the established criteria, including the SBLE must contain a nursing role. RESULTS: Simulation-based learning experience are being used to teach palliative and end-of-life communication skills to nursing students and clinicians. Lack of standardization, poor evaluation methods, and limited exposure to the entire interprofessional team makes it difficult to identify and disseminate validated best practices. CONCLUSION: While the need for further research is acknowledged, we recommend this evidence be augmented by training programs that utilize SBLEs through (1) applying standards, (2) clearly specifying goals and objectives, (3) integrating externally validated scenarios, and (4) employing rigorous evaluation methods and measures that link the SBLE to the training objectives and desired clinician practice behaviors and patient outcomes.

Optimizing the electronic health record to standardize administration and documentation of nutritional supplements.

Malnutrition in hospitalized patients is a major cause for hospital re-admission, pressure ulcers and increased hospital costs. Methods to improve the administration and documentation of nutritional supplements for hospitalized patients are needed to improve patient care, outcomes and resource utilization. Staff at a medium-sized academic health science center hospital in the southeastern United States noted that nutritional supplements ordered for patients at high risk for malnutrition were not offered or administered to patients in a standardized manner and/or not documented clearly in the electronic health record as per prescription. This paper reports on a process improvement project that redesigned the ordering, administration and documentation process of oral nutritional supplements in the electronic health record. By adding nutritional products to the medication order sets and adding an electronic nutrition administration record (ENAR) tab, the multidisciplinary team sought to standardize nutritional supplement ordering, documentation and administration at prescribed intervals. This process improvement project used a triangulated approach to evaluating pre- and post-process change including: medical record reviews, patient interviews, and nutrition formula room log reports. Staff education and training was carried out prior to initiation of the system changes. This process change resulted in an average decrease in the return of unused nutritional formula from 76% returned at baseline to 54% post-process change. The process change resulted in 100% of nutritional supplement orders having documentation about nutritional medication administration and/or reason for non-administration. Documentation in the ENAR showed that 41% of ONS orders were given and 59% were not given. Significantly more patients reported being offered the ONS product (p=0.0001) after process redesign and more patients (5% before ENAR and 86% after ENAR reported being offered the correct type, amount and frequency of nutritional products (p=0.0001). ENAR represented an effective strategy to improve administration and documentation of nutritional supplements for hospitalized patients.

Improving End-of-Life Care Knowledge Among Senior Baccalaureate Nursing Students.

OBJECTIVE: It is imperative that nurses are proficient and comfortable providing care to patients at the end of life. Recent studies show that nurses' knowledge of end-of-life care is less than optimal. Effective, evidence-based methods to infuse palliative and end-of-life care education into the undergraduate nursing curriculum are needed. METHODS: A descriptive pre- and postassessment evaluating senior nursing students' acquisition of knowledge on end-of-life care after attending the End-of-Life Nursing Education Consortium (ELNEC) core course was conducted. The course evaluation included qualitative statements. RESULTS: Before the ELNEC course, one-third of the students had cared for a dying patient during clinical rotations, yet 85% reported they had not received adequate training in end-of-life care. Posttest questions related to palliative care, symptom management, communication, and grief indicated that students acquired significant knowledge after participating in the ELNEC course ( P < .05). CONCLUSION: The ELNEC core course is an effective way to improve nursing students' knowledge of palliative and end-of-life care.

Improving Insulin Administration Through Redesigning Processes of Care: A Multidisciplinary Team Approach.

OBJECTIVES: This article describes a quality improvement project using a multidisciplinary team approach to improve the rate of errors of omission of preprandial subcutaneous coverage insulin orders. METHODS: A Diabetic Management Work Group was created to evaluate the system processes that affect success and failure of timely administration and documentation of preprandial coverage insulin, commonly referred to as sliding scale coverage. Data before and after the project were collected to evaluate the effectiveness of a process change through the bar code medication administration system, in which preprandial coverage insulin order sets were changed to eliminate errors of omission and improve documentation. RESULTS: A review of 833 random blood glucose measurements with corresponding short- or rapid-acting insulin coverage orders was conducted. A mean error of omission rate of 23.4% was identified with respect to coverage insulin that was clinically indicated by provider-ordered insulin set but not administered or documented in the electronic medication record. After process redesign and implementation, 951 blood glucose measurements with corresponding insulin coverage orders were randomly reviewed, and a mean of 10.7% of omission rate for coverage insulin administration was identified. This represented a decrease in omission of coverage insulin by 54% compared with preprocess improvement. CONCLUSIONS: Decreased errors of omission as well as improved administration and documentation of coverage insulin were demonstrated by this multimodal process change. Scheduled standardized order sets, extensive nursing staff education, and enhanced efficiency of the existing process led to improved outcomes.

The VA nursing academy embedded clinical education model.

The Veterans Health System (VHS) implemented a new program, the Veterans Affairs Nursing Academy, to promote partnerships between the VHS and schools of nursing to supplement faculty resources to educate more nurses and to increase recruitment of nurses in the VHS. The partnership at the University of Florida College of Nursing and the Malcolm Randall Veterans Affairs Medical Center, Gainesville, Florida, has been successful in increasing student enrollment, improving nursing care of veterans, and increasing recruitment of new graduate nurses. The partnership implemented a new model of clinical education called the embedded faculty model. The authors describe the embedded faculty model and the goals and outcomes of the partnership program.