REadmission PREvention in SepSis: Development and Validation of a Prediction Model.

ABSTRACT: Hospital 30-day readmissions remain a major quality and cost indicator. Traditional readmission risk scores, such as LACE (length of stay, acuity of admission, Charlson comorbidity index, and emergency department visits), may be suboptimal in special patient populations, such as those with sepsis. As sepsis survivorship improves, there is a need to determine which variables might be associated with a decrease in 30-day readmission. We completed a retrospective analysis reviewing patients with sepsis who had unplanned 30-day readmissions. Multivariate regression analysis was performed for the REadmission PREvention in SepSis (REPRESS) model, which evaluated age, length of stay, Charlson disease count, Richmond Agitation-Sedation Scale score, discharge to a skilled nursing facility, and mobility for predictive significance in hospital readmission. Our REPRESS model performed better when compared with LACE for predicting readmission risk in a sepsis population.

Navigating the Doctor of Nursing Practice project within an academic practice partnership.

ABSTRACT: The Doctor of Nursing Practice (DNP) curriculum was initially developed in 2004. The DNP degree is a practice doctorate, which educates nurses to the highest level of clinical nursing practice. DNP students must complete a scholarly project in accordance with the American Association of Colleges of Nursing (AACN) guidelines. The project is an opportunity for the student to integrate skills into practice and demonstrate principles of advanced nursing practice. The AACN provides recommendations for the DNP project, but much confusion regarding the context and implementation of the project still exists. At one academic health sciences center, DNP project students often complete their projects within academic practice partnerships. Such partnerships are encouraged by the AACN. Several DNP quality improvement (QI) projects were submitted a hospital's interdisciplinary quality week event. Upon review, some of the abstracts were found to contain aspects of research. This finding prompted the review of all DNP project processes to standardize methods for faculty, students, the University, and the academic practice partner.

Minimally Invasive Surgical Options with Valvular Heart Disease.

The incidence and prevalence of structural heart disease has risen due to the longevity of the population, placing an economic burden on society. Over the past 20 years, treatment options for structural heart disease has significantly evolved. Advances in technology and interventional techniques have now shifted therapeutic options to include minimally invasive approaches to correct valvular heart disease. Patients with congenital heart defects are candidates for minimally invasive approaches to correct valvular heart disease. An interdisciplinary team approach using a fusion of multimodal imaging is the best approach for the treatment of this complex patient population.

Answering the question: Is the Doctor of Philosophy or Doctor of Nursing Practice right for me?

Over the past decade, leading health care organizations have recommended doubling the number of doctorally prepared nurses to meet the future demands of health care. In 2018, the National Organization of Nurse Practitioner Faculties committed to move all nurse practitioner degree programs to the Doctor of Nursing Practice degree by 2025. As more and more doctorally prepared nurses enter the workforce, other nurses are considering returning to school for a terminal degree. This column will review options for doctoral education in nursing and the strength, focus, and program requirements for PhD and DNP degrees.

Academic nursing scholarship redefined.

The American Association of Colleges of Nursing (AACN) last defined academic nursing scholarship in 1999. The AACN recognized faculty scholarship must align with the increasingly complex and dynamic health care environment to prepare nurses for an ever-changing future. The new, broader definition recognizes multiple ways of knowing and values all scholarly contributions, which affect nursing science and the health care system. The alignment of faculty scholarship to the practice of nursing will ensure high-quality education, influencing the next generation of nurses. This new position statement also provides clarity as to valued activities within the faculty role, which will assist administrative faculty who struggle with appointment, tenure, and promotion criteria. This column will provide a summary of the new position statement and exemplars of activities within the faculty role of research, practice, and teaching.

Sleep Deprivation in Neurointensive Care Unit Patients From Serial Neurological Checks: How Much Is Too Much?

OBJECTIVE: Hourly neurological examinations are frequently performed in the neurointensive care unit (NICU) to quickly detect neurological deterioration. These examinations require the patient to be awakened hourly for days disrupting the sleep cycle and potentially causing neurological deterioration through sleep deprivation and the development of delirium. This pilot study's aim was to describe the prevalence of neurologic deterioration and delirium in patients receiving hourly neuro checks. DESIGN: A 6-month prospective observational cohort study was conducted within the NICU at Mayo Clinic Florida. Twenty subjects were enrolled between July 24, 2016, and January 30, 2017. RESULTS: Neurological deterioration as defined as a decrease in Glasgow Coma Scale score of 2 or more, an increase in National Institute of Health Stroke Scale score by 4 or more, or a change in Confusion Assessment Method score for use in intensive care unit patients from negative to positive occurred in 19 of 20 patients (95%) for a total of 67 events, with most patients having multiple events. Seventy-five percent of the subjects experienced a decrease in Glasgow Coma Scale score of 2 or more at least once during the study period. The largest number of events occurred within the first 24 hours (39%). Surprisingly, 75% of the subjects also developed delirium. Forty percent of the subjects demonstrating neurological deterioration received computed tomography imaging to evaluate the change. Sixty-seven percent lacked deterioration evident on computed tomography imaging, and the deterioration was not attributed to medication effect or seizure by an experienced provider. CONCLUSIONS: Neurological deterioration is prevalent in the NICU population. Although hourly neurological examinations may be beneficial in the acute phase of neurological injury, prolonged use may be paradoxically harmful due to sleep deprivation.

CE: Assessing and Managing Pain, Agitation, and Delirium in Hospitalized Older Adults.

: In the acute care setting, pain, agitation, and delirium (PAD) often occur as interrelated parts of a syndrome rather than as separate entities. Because the three facets of PAD may be similar in presentation, it is often difficult for clinicians to recognize the syndrome and to assess and treat it. The challenge is particularly great in older patients, who are more likely than their younger counterparts to have such comorbid conditions as dementia, which may impair the ability to report pain, or age-related physiologic changes that may affect the metabolism and clearance of certain medications. This article provides an overview of each aspect of PAD, discusses clinical considerations related to the assessment and treatment of the syndrome in older adults receiving acute care, and illustrates the application of published PAD guidelines through the use of a hypothetical patient scenario.

Making the Case for Palliative Care in Critical Care.

The United States has a changing populace with an increasing number of vulnerable, diverse, and older adults. Of people aged 65 and older, nearly two-thirds suffer from serious comorbidities. Costs associated with chronic illness increase with age and number of conditions. More than 25% of older adults do not have advanced care planning. The current model of health care cannot meet these needs. The initiation of palliative care in the ICU will capture many patients who meet the criteria for palliative care and improve their QOL by management their end-of-life symptoms and reduce unnecessary utilization of health care resources.

Predicting Which Patients Will Benefit From Palliative Care: Use of Bundles, Triggers, and Protocols.

Intensive care units provide a wide range of care to patients with serious or life-threatening conditions. This care provides excellent state-of-the-art interventions, often concentrated on meeting national health priorities and performance measures. Overall patient care and the resultant outcomes in the intensive care unit are superb. However, one area that needs improvement is the provision of high-quality palliative care (PC) and end-of-life care. Many providers and administrators now realize implementing PC in the critical care setting is vital to optimal patient outcomes. PC improves patient and family satisfaction and quality of life, reduces length of stay and 30-day readmission rates, and patients can live longer with PC.