Serious Illness Conversations: A Case Management Quality Improvement Project.

PURPOSE/OBJECTIVES: The purpose of this project was to develop, implement, and evaluate an educational program and a serious illness (SI) protocol for a case management team of nurses and social workers to achieve the following: (1) utilize an SI protocol to identify patients with SI; (2) utilize a Serious Illness Structured Communication Guide to elicit these patients' goals and preferences for SI care; and (3) document in the electronic medical record the patients' elicited values and goals using a structured SI documentation template. PRIMARY PRACTICE SETTING AND SAMPLE: Seventeen nurse and 3 social work case managers in an Accountable Care Organization (ACO) in a large health system in a western suburb of Chicago participated in this project. The practice setting was the primary care clinics associated with the health system. Patients eligible for the project met the SI criteria and were part of the organization's ACO or Bundle Payment for Care Improvement program. METHODOLOGY: Twenty members of the case management staff participated in a 4-hr face-to-face educational program, based in part on review of best practices related to SI care and communication. Participants completed a pre- and posttest survey of knowledge; self-rated their confidence in conducting SI conversations; and evaluated the educational program. Participants then engaged in the established protocol inclusive of the following: (1) identify patients appropriate for an SI conversation; (2) initiate the SI conversation; and (3) document components of the SI in the electronic medical record. FINDINGS/CONCLUSIONS: Educational Program: Ninety-five percent of the RN and SW case managers reported that that the educational module objectives were met to a moderate or great extent. One hundred percent of the participants reported that the format to deliver the program was effective, the content of the program was directly relevant to their clinical practice, and they would change their practice because of learning/understanding the content in the program. Educational program pretest scores ranged from 46.2% to 84.6%, with posttest scores ranging from 69.2% to 100%. A paired-samples t test demonstrated a statistically significant increase in posttest scores. Baseline confidence scores ranged from 1 to 4, with postproject confidence scores ranging from 2 to 4. A paired-samples t test demonstrated a statistically significant increase in confidence.Serious Illness Protocol: The case managers correctly identified 92% of patients who met the established SI identification criteria for this project. In 91.8% of cases, the case managers conducted an SI conversation in adherence to the protocol. In 76% of the cases, documentation about the SI conversation was completed in accordance with the protocol. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: .

The Management of Nausea at the End of Life.

The evaluation and management of nausea in patients near the end of life can be more challenging than that of nausea in patients undergoing antineoplastic therapies. Unlike in the oncology setting in which nausea is primarily managed using antiemetic regimens that have been developed with the neuropharmacology and emetogenic potentials of chemotherapy agents in mind, many patients receiving end-of-life care have nausea of multifactorial etiology. Patients also may be older with reduced physiologic ability to metabolize and clear drugs. Therefore, typical antiemetics in regimens initially selected for oncology patients may be ineffective. In this article, the prevalence, manifestation, and pathophysiology of nausea experienced by patients near and at the end of life will be reviewed, with a focus on pharmacological and nonpharmacological interventions that have been found to effectively manage this symptom in this patient population.

Implementing Interprofessional Alcohol Screening, Brief Intervention, and Referral to Treatment in the Emergency Department: An Evidence-Based Quality Improvement Initiative.

Alcohol misuse is one of the leading causes of illness, disease, injury, and death in the Unites States. For many patients, the emergency department (ED) visit may provide the only therapeutic opportunity to influence problematic drinking behavior. Screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based approach that may reduce alcohol-related morbidity and mortality and improve health outcomes and quality of life. Developing and implementing an alcohol SBIRT educational module for ED nurses and social workers is an efficient and effective mechanism to provide education about alcohol SBIRT, and revising the electronic health record to include an alcohol SBIRT protocol provides a standard mechanism for documentation by the interprofessional team of ED nurses and social workers. By integrating SBIRT knowledge as standard of practice in the ED setting, providers can positively impact the health and well-being of patients.

Pediatric Pain Assessment In the Emergency Department: A Nursing Evidence-Based Practice Protocol.

BACKGROUND: Many children present to the emergency department (ED) in pain and/or experience pain as a result of interventions necessary to manage their illness. Pediatric pain assessment and management is complex and challenging. Despite the presence of published standards of care specific to pain assessment and management, nurses in the ED may not know about and/or consistently use these evidence-based practices. In particular, pediatric patients are inconsistently and/or inappropriately assessed for pain in the ED. METHODS: The aim of this project was to make standard the utilization of evidence-based practices regarding pediatric pain assessment in the ED at a community hospital. The purpose of this project was to develop, implement, and evaluate a pediatric pain education program and pain assessment protocol to improve nurses' knowledge and standardize care in a community hospital emergency department. RESULTS: Seventy-eight ED nurses completed the education program, consisting of an online module with content addressing pediatric pain assessment and management, and then used the protocol. Education program evaluations were very positive. A statistically significant difference in the mean pre- and post-test scores indicated significant learning gains among participants; strong reliability of this test was demonstrated. Sixty patient medical records were reviewed two weeks after the educational program. Pain assessment at triage and use of an appropriate pain scale for all assessments were the most consistently used components of the protocol. A low percentage of protocol adherence was found regarding assessment of pain characteristics. CONCLUSION: Significant improvements in nurses' pain knowledge are demonstrated via an education program. Implementation of a pain assessment protocol is one mechanism to standardize nursing practice with pediatric patients in the ED setting.

Providing palliative care to seriously ill patients with nonhealing wounds.

Patients may experience wounds at or near the end of life that are difficult to treat and may not be amenable to healing. In these cases, hospice and palliative care may be considered. Palliative care approaches include stabilization of existing wounds, prevention of new wounds, and symptom management with a focus on quality of life. Treatment goals for nonhealing wounds at the end of life include managing exudate, controlling odor, maximizing mobility and function, preventing infection, and controlling pain and other symptoms. Complementary components of palliative care are also instituted including communication and psychosocial support for patients and families.

Clostridium difficile infection: essential information for nurses.

Clostridium difficile (C. difficile) infection is a challenging problem in the acute care setting. Staff nurses are important in the early recognition, diagnosis, and prompt treatment of patients with this bacterial infection. Essential information regarding C. difficile, including pathogenesis, risk factors, patient presentation, diagnosis, and treatment approaches, is reviewed.

Quality of life in caregivers providing care for lung transplant candidates.

CONTEXT: Caregivers are essential members of the health care team who provide care, valued at more than $250 billion each year, to millions of persons who require assistance with health and daily care. Patients with respiratory diseases who are waiting for a lung transplant are required to have an identified caregiver. The caregivers are rarely studied. OBJECTIVE: To explore the relationships among the health status of caregivers of lung transplant candidates, caregivers' reaction to caregiving, and caregivers' perceived quality of life. DESIGN: This descriptive study examined the quality of life of lung transplant caregivers from a multidimensional perspective. SETTING AND PARTICIPANTS: Twenty-nine dyads of lung transplant candidates and their caregivers were recruited from a Midwestern medical center. MEASURES: Data were collected by self-report: caregivers completed the Quality of Life Index, SF-12 health survey, Profile of Mood States-Short Form, and the Caregiver Reaction Assessment. RESULTS: Caregivers reported favorable levels of quality of life, physical health, and mood during the pretransplant waiting phase. However, problem areas for caregivers during this time included fatigue, depression, and the financial impact of the transplant. Data analyses indicated that depression, caregiver general health, impact on finances, and lack of family support had the greatest effect on caregivers' quality of life. Nurses are urged to recognize the role of caregivers in the transplant process, ask about and listen to caregivers' needs, and include caregivers in the plan of care.

Understanding and responding to the death rattle in dying patients.

Medical-surgical nurses in inpatient settings may encounter dying patients who exhibit a number of symptoms during the end of life. One symptom, the death rattle, refers to the noise of excessive secretions present during the inspiratory and expiratory phases of respiration. Symptom improvement can be obtained with pharmacologic and non-pharmacological measures. Empathic communication with the patient's significant others also is an important component of care.

Kyphoplasty. A treatment for osteoporotic vertebral compression fractures.

Patients experience more than 700,000 osteoporotic vertebral compression fractures each year in the United States, primarily because of bone brittleness and the inability of the vertebrae to resist increased forces applied to them. Patients diagnosed with this type of fracture are given the option of conservative or operative treatment approaches. Although a typical compression fracture generally heals in 6 to 12 weeks, patients may be offered the kyphoplasty procedure, which reduces the fracture and stabilizes it with cement. Although this procedure is not without risk, it is deemed a safe and effective treatment option. This article reviews the indications, implications, and care provided to patients pursuing kyphoplasty after osteoporotic vertebral compression fracture.

Community-acquired methicillin-resistant Staphylococcus aureus: considerations for school nurses.

Methicillin-resistant Staphylococcus aureus (MRSA) is a disease-causing organism that has been present in hospital settings since the 1960s. However, a genetically distinct strain of MRSA, called community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), has emerged in recent years in community settings among healthy individuals. While this organism has been found to be less resistant to antibiotics, it is also more virulent and capable of causing a spectrum of illnesses. School nurses must be aware of the risk factors for this infection and understand its signs, symptoms, diagnostic testing, and management. With this knowledge, school nurses can help protect students, staff, and community members from this increasingly prevalent pathogen.

Using the Roy Adaptation Model to explore the dynamics of quality of life and the relationship between lung transplant candidates and their caregivers.

Using theory to support nursing research may be considered superfluous by some authors, yet a theoretical framework provides structure and consistency to a research study. This article presents the use of the Roy Adaptation Model within the theoretical framework underpinning an investigation of quality of life as perceived by lung transplant candidates and their caregivers. Each step of the research process is identified in this article and the link to the theoretical framework is demonstrated. The use of nursing frameworks to guide research strengthens the theoretical framework itself and also adds another dimension to the body of nursing knowledge.

Identifying and managing acute alcohol withdrawal in the elderly.

In the elderly population, alcohol-related problems may be misinterpreted as normal consequences of aging. However, alcohol is a commonly abused substance among older adults, and age-related changes predispose these patients to a greater sensitivity to its effects. All older patients should be screened for alcohol dependence and abuse on admission to an acute care facility. If identified, the plan of care must include close observation for acute alcohol withdrawal and prompt intervention if it occurs.

Barriers to caregiver administration of pain medication in hospice care.

Barriers to adequate pain management in hospice and palliative care settings are an important area of investigation. In this study, a Caregiver Pain Medicine Questionnaire (CPMQ) was developed and psychometrically tested. The CPMQ is a 22-item self-report instrument that measures concern about reporting pain, concern about administering analgesics, and difficulty administering analgesics. One hundred fifty-one caregivers of patients admitted to three Chicagoland hospice agencies participated; these individuals were family members, hired caregivers in the home, or staff nurses in skilled care facilities. While only a small percentage of the caregivers expressed concern about communicating information about the patient's pain, more than a quarter were concerned about addiction, tolerance, and side effects from medications. A fourth of the caregivers had difficulty administering medications because of fear of doing something wrong and difficulty deciding which or what amount of medications to give. Male caregivers and hired caregivers had greater concerns, both about reporting information about the patient's pain and administering medications. Greater concerns were also evident among less educated caregivers, caregivers who worked in blue-collar jobs, and caregivers who were homemakers or retired. Concerns of caregivers in the home were significantly greater than staff nurse caregivers in skilled care facilities only in the belief that pain could not be controlled and concern about addiction. Caregivers who had greater concern about addiction and tolerance, and more difficulty administering medications, rated the patient's pain as less completely controlled. These findings remind hospice staff members of the importance of assessing specific caregiver concerns about medication administration and devising appropriate strategies to address them.

Repeating the call for restraint reduction.

Over the past 2 decades, great advances have been made in reducing the use of physical restraints in health care facilities. In this article, misconceptions and facts related to restraint use are reviewed and restraint reduction strategies are presented. Although all those involved in health care are called to carefully evaluate restraint use, medical-surgical nurses can take the lead in changing restraint practices in the acute care workplace.

Laryngeal edema: perioperative nursing considerations.

Laryngeal edema is a relatively rare yet serious postoperative complication for those patients undergoing general anesthesia. Maintenance of airway and breathing are always the first priority of perioperative patient care. Medical-surgical nurses working in postoperative settings must be familiar with the signs, symptoms, and necessary prompt treatment for this life-threatening condition.