Integrating Nurse Practitioners Into Long-term Care: A Call for Action.

The coronavirus disease 2019 pandemic exposed the devastating effects of inadequate primary care in long-term care (LTC) settings, both nationally and internationally. Deaths in LTC were compounded by the global shortage of physicians and limitations in existing funding models for these facilities. Nurse practitioners (NPs) can provide similar services as general practice physicians in LTC while meeting residents' needs in a more timely, cost-effective manner. It is critical that NPs be integrated into LTC, particularly in the wake of the coronavirus disease 2019 pandemic. This article provides relevant literature and evidence to substantiate the effectiveness of integrating NPs into the Canadian LTC and highlights the urgent need for improved funding models and policy reform.

Acute Fulminant Cerebral Edema: A Newly Recognized Phenotype in Children With Suspected Encephalitis.

BACKGROUND: Encephalitis is a severe neurological syndrome associated with significant morbidity and mortality. The California Encephalitis Project (CEP) enrolled patients for more than a decade. A subset of patients with acute and fulminant cerebral edema was noted. METHODS: All pediatric encephalitis patients with cerebral edema referred to the CEP between 1998 and 2012 were reviewed. A case definition was developed for acute fulminant cerebral edema (AFCE) that included the CEP case definition for encephalitis and progression to diffuse cerebral edema on neuroimaging and/or autopsy, and no other recognized etiology for cerebral edema (eg, organic, metabolic, toxin). Prodromic features, demographic and laboratory data, neuroimaging, and outcomes were compared with non-AFCE encephalitis cases. RESULTS: Of 1955 pediatric cases referred to the CEP, 30 (1.5%) patients met the AFCE case definition. The median age for AFCE and non-AFCE cases was similar: 8.2 years (1-18 years) and 8.0 years (0.5-18 years), respectively. Asian-Pacific Islanders comprised a larger proportion of AFCE cases (44%) compared with non-AFCE cases (14%, P < .01). AFCE cases often had a prodrome of high fever, vomiting, and profound headache. Mortality among AFCE patients was significantly higher than among non-AFCE patients (80% vs 13%, P < .01). A confirmed etiology was identified in only 2 cases (enterovirus, human herpes virus type 6), while 10 others had evidence of a respiratory pathogen.Thirty pediatric patients referred to the California Encephalitis Project with a unique, and often fatal, form of encephalitis are reported. Demographic and clinical characteristics, possible etiologies and a proposed case definition for acute fulminant cerebral edema (AFCE) are described. CONCLUSIONS: AFCE is a recently recognized phenotype of encephalitis with a high mortality. AFCE may be triggered by common pediatric infections. Here, we propose a case definition.

When and how to use factorial design in nursing research.

BACKGROUND: Quantitative research designs are broadly classified as being either experimental or quasi-experimental. Factorial designs are a form of experimental design and enable researchers to examine the main effects of two or more independent variables simultaneously. They also enable researchers to detect interactions among variables. AIM: To present the features of factorial designs. DISCUSSION: This article provides an overview of the factorial design in terms of its applications, design features and statistical analysis, as well as its advantages and disadvantages. CONCLUSION: Factorial designs are highly efficient for simultaneously evaluating multiple interventions and present the opportunity to detect interactions amongst interventions. Such advantages have led researchers to advocate for the greater use of factorial designs in research when participants are scarce and difficult to recruit. IMPLICATIONS FOR PRACTICE: A factorial design is a cost-effective way to determine the effects of combinations of interventions in clinical research, but it poses challenges that need to be addressed in determining appropriate sample size and statistical analysis.

A review of the non-equivalent control group post-test-only design.

BACKGROUND: Quantitative research designs are broadly classified as either experimental or quasi-experimental. The main distinguishing feature of the quasi-experiment is the manipulation of the independent variable without randomisation. When randomisation or use of a control group is unfeasible, a researcher can choose from a range of quasi-experimental designs. AIM: To present the features of the quasi-experimental 'non-equivalent control group post-test-only' design, which aims to demonstrate causality between an intervention and an outcome. DISCUSSION: This paper provides an overview of the non-equivalent control group post-test-only design in terms of its design features, applications and statistical analysis, as well as its advantages and disadvantages. CONCLUSION: The non-equivalent control group post-test-only design can be used in natural settings, where randomisation cannot be conducted for ethical or practical reasons. Although the design is less complex than some other designs, with low error propagation, it is vulnerable to threats to internal validity.

A Philosophical Analysis of Clinical Decision Making in Nursing.

BACKGROUND: Clinical decision making is a fundamental aspect of nurses' clinical practice and has a direct impact on the health and well-being of each patient. METHOD: An exploratory analysis of the concept of clinical decision making in nursing will be provided from the two predominant theoretical perspectives: the systematic-positivist model and the intuitive-humanistic model. The origin, aim, value, ontology and epistemology, assumptions, communicability, and context specificity of these two models are discussed. RESULTS: As nurses work in ever-changing health care environments, either the positivist model or the intuitive model is adequate to describe the dynamic processes nurses use in clinical decision making. Therefore, it was suggested that the cognitive processes used in decision making were neither completely analytical nor completely intuitive. CONCLUSION: Clinical decision making is complex. A combination of scientific evidence-based knowledge in conjunction with intuition and contextual factors could enable nurses to utilize excellent clinical decision making. [J Nurs Educ. 2018;57(2):73-78.].

Predicting hospital transfers among nursing home residents in the last months of life.

BACKGROUND: Concerns have been raised over the practice of transferring nursing home residents to hospital at their end of life. OBJECTIVE: To examine the family and facility factors that may influence the decision to transfer nursing home residents to hospital in the last month of life. RESEARCH DESIGN: Secondary data analysis includes a sample of 119 bereaved family members from 21 nursing homes located in Central Canada. METHOD: A binary logistic regression analysis was conducted to explore the predictors for hospital transfers. RESULTS: Terminal hospital transfers were common: 70% of nursing home residents were sent to hospitals in the last month of their life, and the likelihood of terminal hospital transfers increased by having an adult child as decision-maker (odds ratio (OR) = 5.03; 95% confidence interval (CI) = 1.6, 16; significance level/probability value (p) = 0.007) or having a lower family income (OR = 2.9; 95% CI =1.1, 2.9; p = 0.027). Discussion and implications: The identified predictors for terminal hospital transfers are helpful in targeting and developing interventions to improve end-of-life care. Particular emphasis should therefore be placed on targeting families with low income and children of the nursing home residents for educational initiatives such as advance care planning awareness, in order to prevent terminal hospital transfers. It is hoped that policy-makers and practitioners can start addressing the findings of this study to reduce terminal hospital transfers at end of life and promote quality end-of-life care in nursing homes.

Minimizing variance in Care of Pediatric Blunt Solid Organ Injury through Utilization of a hemodynamic-driven protocol: a multi-institution study.

BACKGROUND: An expedited recovery protocol for management of pediatric blunt solid organ injury (spleen, liver, and kidney) was instituted across two Level 1 Trauma Centers, managed by nine pediatric surgeons within three hospital systems. METHODS: Data were collected for 18months on consecutive patients after protocol implementation. Patient demographics (including grade of injury), surgeon compliance, National Surgical Quality Improvement Program (NSQIP) complications, direct hospital cost, length of stay, time in the ICU, phlebotomy, and re-admission were compared to an 18-month control period immediately preceding study initiation. RESULTS: A total of 106 patients were treated (control=55, protocol=51). Demographics were similar among groups, and compliance was 78%. Hospital stay (4.6 vs. 3.5days, p=0.04), ICU stay (1.9 vs. 1.0days, p=0.02), and total phlebotomy (7.7 vs. 5.3 draws, p=0.007) were significantly less in the protocol group. A decrease in direct hospital costs was also observed ($11,965 vs. $8795, p=0.09). Complication rates (1.8% vs. 3.9%, p=0.86, no deaths) were similar. CONCLUSIONS: An expedited, hemodynamic-driven, pediatric solid organ injury protocol is achievable across hospital systems and surgeons. Through implementation we maintained quality while impacting length of stay, ICU utilization, phlebotomy, and cost. Future protocols should work to further limit resource utilization. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: Level II.

Emergency department interventions for persons with dementia presenting with ambulatory care-sensitive conditions: a scoping review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this scoping review is to examine and map, within existing literature, the characteristics of emergency department/urgent care interventions, strategies or contextual factors, implemented to reduce unnecessary hospitalization of people with dementia (PWD) presenting at the emergency department/urgent care with ambulatory care-sensitive conditions (ACSC).More specifically, the review questions are.

Concept analysis of good death in long term care residents.

The purpose of this concept analysis paper is to delineate the meaning of good death in long term care (LTC) settings and examine its implications for nursing. The Walker and Avant (2011) method was chosen for this analysis. An in depth literature review identifies uses of the concept and determines the defining attributes of the good death. This paper also illustrates case presentations, antecedents, consequences, empirical referents and implications for clinical practice to clarify the concept of 'good death' in this population. In LTC, death is experienced frequently and is considered the ultimate outcome for most admissions. Much of the existing research on end-of-life care has focused on community dwelling cancer patients whose death trajectory is predictable and who may remain cognitively intact until actively dying. In contrast, the LTC population is older and more likely to suffer from dementia and experience chronic illness for long periods prior to death, and they follow a less predictable death trajectory. In this century, death became the province of older people and the assurance of a good death became the responsibility of those caring for them.

Setting a new standard of care in nursing homes.

The Winnipeg Regional Health Authority's introduction of a full-time nurse practitioner in a 116-bed non-profit nursing home provided an opportunity to explore a collaborative relationship between an NP acting as the primary care provider and a single physician serving as the consultant for complex care and after-hours care. The outcomes were measured in terms of resident and family satisfaction, quality of care indicators and cost effectiveness. Data were collected from pre-existing quality indicators, including a resident/family satisfaction survey, transfers to acute care, and medication use statistics. Unstructured interviews were also conducted with nursing staff and members of the interdisciplinary team. Dramatic improvements in medication use were observed, including a 17 per cent reduction in overall drug costs, a 55 per cent decrease in polypharmacy rates and a 63 per cent reduction in antipsychotic drug use. Transfers to emergency decreased by 20 per cent. Family satisfaction with the quality of health care provided to residents increased by 24 per cent. The collaborative practice of an NP with physician consultation is an effective way of delivering quality care to nursing home residents.

Diagnosis and management of geriatric insomnia: a guide for nurse practitioners.

PURPOSE: To discuss the assessment, diagnosis, and management of geriatric insomnia, a challenging clinical condition of older adults frequently seen by primary care providers. DATA SOURCES: Extensive literature review of the published research articles and textbooks. CONCLUSIONS: Complaints of insomnia among older adults are frequently ignored, considered a part of the normal aging process or viewed as a difficult to treat condition. Geriatric insomnia remains a challenge for primary care providers because of the lack of evidence-based clinical guidelines and limited treatment options available. Effective management of this condition is necessary for improved quality of life, which is a primary issue for the elderly and their families. Therefore, geriatric insomnia warrants thorough attention from the nurse practitioners (NPs) who provide care for older adults. IMPLICATIONS FOR PRACTICE: Undiagnosed or under treated insomnia can cause increased risk for falls, motor vehicle accidents, depression, and shorter survival. Insomniacs double their risk for cardiovascular disease, stroke, cancer, and suicide compared to their counterparts. Insomnia is also associated with increased healthcare utilization and institutionalization. NPs could play a central role in reducing the negative consequences of insomnia through a systematic approach for diagnosis, evaluation, and management.