The CAUTI Prevention Tool Kit: A Professional Practice and Collaborative Project of the Wound, Ostomy and Continence Nurses Society.

In order to address the need for a tool to support hospital-based nurses in catheter-associated urinary tract infection (CAUTI) prevention, the American Nurses Association (ANA) was asked to convene a Technical Expert Panel of stakeholders in CAUTI prevention. The Technical Expert Panel was chaired by the ANA's Senior Policy Fellow, a certified wound, ostomy and continence (WOC) nurse. The panel comprised 23 representatives, including nurses from specialty practice organizations, nursing affiliated with the ANA, infection control specialists, patient safety authorities, award-winning hospitals using the National Database of Nursing Quality Indicators, and content experts. The Wound, Ostomy and Continence Society appointed 2 representatives to this panel, a key nurse researcher with expertise in this area of care and a former Society President. The CAUTI Prevention Tool Kit, combined with supplemental guidance documents developed, supports WOC nurses and Society members in achieving quality clinical outcomes for their patients.

Achieving Outcomes With Innovative Smart Pump Technology: Partnership, Planning, and Quality Improvement.

BACKGROUND: A 5-time designated Magnet academic medical center partnered with its infusion systems supplier to successfully integrate 1327 smart pumps across 45 departments with an aggressive 3-month timeline. The team also achieved quality improvement (QI) outcomes through increased drug library compliance and decreased alerts with their new technology. PROBLEM: This large academic medical center needed to implement innovative wireless infusion pump technology in a short time frame. APPROACH: The approach involved a strong partnership from the medical center and the supplier, with extensive planning and collaboration among the clinical nurse specialists and consultants from both organizations to accomplish QI goals. Lean principles were also followed to enhance efficiency and accountability. OUTCOMES: Quality improvement outcomes included 100% drug library compliance across all 6 intensive care units, a decrease in pump alert rates from 4.18% to 0.79%, and a decrease in pump programming correction rate from 0.36% to 0.06%. CONCLUSIONS: A partnership led to a large implementation being completed efficiently across an academic medical center. Through these joint efforts, quality of care was improved within a short period of time.

Probable drug-drug interaction between dabigatran and quinidine resulting in thrombin time rebound despite multiple idarucizumab doses.

: Dabigatran is a direct thrombin inhibitor that was approved as an alternative to warfarin because it offers the benefit of predictable pharmacokinetic properties, favorable safety profile and ease of administration. Despite the improved safety profile, dabigatran use can lead to bleeding events. The bleeding risk associated with dabigatran is higher in the setting of renal impairment or drug-drug interactions resulting in supratherapeutic serum concentrations. Unfortunately, clinically significant interactions are not always identified by providers, especially in the case of infrequent drug-drug combinations. Dabigatran-related coagulopathy can be effectively reversed by idarucizumab. However, high dabigatran serum concentrations can lead to increased tissue distribution resulting in decreased idarucizumab efficacy and repeat idarucizumab doses may be warranted. This case describes a patient presenting with uncontrolled bleeding due to a significant drug-drug interaction between quinidine and dabigatran resulting in acute kidney injury and persistent coagulopathy despite multiple idarucizumab doses and transfusion measures.

Nursing Morbidity and Mortality: The Clinical Nurse Specialist Role in Improving Patient Outcomes.

PURPOSE: The purpose of this article is to discuss the development and implementation of a nursing morbidity and mortality (M&M) monthly conference at an academic medical center. Nursing M&M was developed as a peer review process in which cases where clinical errors or misjudgments that have occurred are reviewed in a nonpunitive setting. The cases are selected based on the National Database for Nursing Quality Indicators and the implications they have for the quality of nursing practice. BACKGROUND/RATIONALE: Morbidity and mortality conferences are well documented in the physician arena as an avenue to review and discuss adverse events. There is little published in the literature related to nursing using this peer review format and what impact this forum can have on clinical outcomes. Clinical nurse specialists and clinical nurse educators are oftentimes positioned to help implement this type of forum and evaluate the impact that it has for the staff and patients that they work with. DESCRIPTION: The clinical nurse specialists/clinical nurse educators at this fourth-time designated Magnet® academic medical center facilitate the monthly M&M and select 4 to 5 cases to present. At the end of each brief presentation, the outcome is determined to be either preventable or unpreventable. Action items for educational needs are also identified. OUTCOMES: Nursing M&M has been well attended over the past year. Since its inception, multiple practice changes have been implemented. Based on the positive feedback from the evaluations, this monthly conference has become standing practice in the institution.

The VCU Pressure Ulcer Summit-Developing Centers of Pressure Ulcer Prevention Excellence: A Framework for Sustainability.

Hospital-acquired pressure ulcer occurrences have declined over the past decade as reimbursement policies have changed, evidence-based practice guidelines have been implemented, and quality improvement initiatives have been launched. However, the 2006-2008 Institute for Healthcare Improvement goal of zero pressure ulcers remains difficult to achieve and even more challenging to sustain. Magnet hospitals tend to have lower hospital-acquired pressure ulcer rates than non-Magnet hospitals, yet many non-Magnet hospitals also have robust pressure ulcer prevention programs. Successful programs share commonalities in structure, processes, and outcomes. A national summit of 55 pressure ulcer experts was convened at the Virginia Commonwealth University Medical Center in March 2014. The group was divided into 3 focus groups; each was assigned a task to develop a framework describing components of a proposed Magnet-designated Center of Pressure Ulcer Prevention Excellence. Systematic literature reviews, analysis of exemplars, and nominal group process techniques were used to create the framework. This article presents a framework describing the proposed Magnet-designated Centers of Pressure Ulcer Prevention Excellence. Critical attributes of Centers of Excellence are identified and organized according to the 4 domains of the ANCC model for the Magnet Recognition Program: transformational leadership; structural empowerment; exemplary professional practice; and new knowledge innovation and improvements. The structures, processes, and outcome measures necessary to become a proposed Center of Pressure Ulcer Prevention Excellence are discussed.

The effects of music on pain and anxiety during screening mammography.

One in four women who are diagnosed with breast cancer die annually, and the single most important way to prevent this is early detection; therefore, women older than 40 years should have an annual screening mammography. Many barriers have been reported that prevent compliance with this recommendation, including lack of insurance, fear, anxiety, pain, worry, and mistrust of the medical community. Nurses are in a position to use creative interventions, such as music therapy, to help minimize barriers. Although this study did not show that music therapy during screening mammograms decreased the amount of pain that the participants experienced, it did suggest that music therapy has the potential to decrease the amount of anxiety. Assisting patients in decreasing anxiety reduces barriers for screening mammography. The literature does suggest that music is a distraction for many populations of patients; however, when patients are faced with the possible diagnosis of breast cancer, it may be difficult to find an intervention to distract a woman's mind, which was supported by the findings of this study.

Interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures.

BACKGROUND: Achieving informed consent is a core clinical procedure and is required before any surgical or invasive procedure is undertaken.  However, it is a complex process which requires patients be provided with information which they can understand and retain, opportunity to consider their options, and to be able to express their opinions and ask questions.  There is evidence that at present some patients undergo procedures without informed consent being achieved. OBJECTIVES: To assess the effects on patients, clinicians and the healthcare system of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare treatments and procedures. SEARCH METHODS: We searched the following databases using keywords and medical subject headings: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 5, 2012), MEDLINE (OvidSP) (1950 to July 2011), EMBASE (OvidSP) (1980 to July 2011) and PsycINFO (OvidSP) (1806 to July 2011). We applied no language or date restrictions within the search. We also searched reference lists of included studies. SELECTION CRITERIA: Randomised controlled trials and cluster randomised trials of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures. We considered an intervention to be intended to promote informed consent when information delivery about the procedure was enhanced (either by providing more information or through, for example, using new written materials), or if more opportunity to consider or deliberate on the information was provided. DATA COLLECTION AND ANALYSIS: Two authors assessed the search output independently to identify potentially-relevant studies, selected studies for inclusion, and extracted data. We conducted a narrative synthesis of the included trials, and meta-analyses of outcomes where there were sufficient data. MAIN RESULTS: We included 65 randomised controlled trials from 12 countries involving patients undergoing a variety of procedures in hospitals. Nine thousand and twenty one patients were randomised and entered into these studies. Interventions used various designs and formats but the main data for results were from studies using written materials, audio-visual materials and decision aids. Some interventions were delivered before admission to hospital for the procedure while others were delivered on admission.Only one study attempted to measure the primary outcome, which was informed consent as a unified concept, but this study was at high risk of bias.  More commonly, studies measured secondary outcomes which were individual components of informed consent such as knowledge, anxiety, and satisfaction with the consent process.  Important but less commonly-measured outcomes were deliberation, decisional conflict, uptake of procedures and length of consultation.Meta-analyses showed statistically-significant improvements in knowledge when measured immediately after interventions (SMD 0.53 (95% CI 0.37 to 0.69) I(2) 73%), shortly afterwards (between 24 hours and 14 days) (SMD 0.68 (95% CI 0.42 to 0.93) I(2) 85%) and at a later date (15 days or more) (SMD 0.78 (95% CI 0.50 to 1.06) I(2) 82%). Satisfaction with decision making was also increased (SMD 2.25 (95% CI 1.36 to 3.15) I(2) 99%) and decisional conflict was reduced (SMD -1.80 (95% CI -3.46 to -0.14) I(2) 99%). No statistically-significant differences were found for generalised anxiety (SMD -0.11 (95% CI -0.35 to 0.13) I(2) 82%), anxiety with the consent process (SMD 0.01 (95% CI -0.21 to 0.23) I(2) 70%) and satisfaction with the consent process (SMD 0.12 (95% CI -0.09 to 0.32) I(2) 76%). Consultation length was increased in those studies with continuous data (mean increase 1.66 minutes (95% CI 0.82 to 2.50) I(2) 0%) and in the one study with non-parametric data (control 8.0 minutes versus intervention 11.9 minutes, interquartile range (IQR) of 4 to 11.9 and 7.2 to 15.0 respectively). There were limited data for other outcomes.In general, sensitivity analyses removing studies at high risk of bias made little difference to the overall results.  AUTHORS' CONCLUSIONS: Informed consent is an important ethical and practical part of patient care.  We have identified efforts by researchers to investigate interventions which seek to improve information delivery and consideration of information to enhance informed consent.  The interventions used consistently improve patient knowledge, an important prerequisite for informed consent.  This is encouraging and these measures could be widely employed although we are not able to say with confidence which types of interventions are preferable. Our results should be interpreted with caution due to the high levels of heterogeneity associated with many of the main analyses although we believe there is broad evidence of beneficial outcomes for patients with the pragmatic application of interventions. Only one study attempted to measure informed consent as a unified concept.

Inhibition, ADHD, and computer games: the inhibitory performance of children with ADHD on computerized tasks and games.

Contrary to empirical reports of inhibitory dysfunction in ADHD, parental reports suggest that when playing computer games, the inhibitory abilities of children with ADHD are unimpaired. This small-scale preliminary investigation into this phenomenon looks at inhibition of an ongoing response and activity exhibited by children with ADHD between 6 and 14 years old on two commercially available games, on the Conners's Continuous Performance Test II (CPT II), and on a more game-like version of the same task that incorporates characteristics commonly found in commercially available computer games. The performance of participants with ADHD on commercially available games is equivalent to that of typically developing participants and is significantly better on the more game-like version of the CPT II.

Play and language in children with autism.

It is well established that the play and language skills of children with autism are impaired. The article considers the relationship between these developments in typically developing children and children with autism. First, the evidence for a relationship between these two areas in typically developing children is reviewed. Despite many methodological differences between studies, this evidence supports a relationship, with specific developments emerging first in play and subsequently in language. Second, evidence for a relationship between play and language in children with autism is reviewed. From published and some previously unpublished data it is concluded that if there is a relationship between play and language in children with autism it is weak, if it exists at all. Finally, the implications of these findings are discussed and it is suggested that any relationship between play and language may be mediated by how children and their parents interact when they are playing.

Estimating pediatric primary care provider visits in a capitated environment: encounter vs. claims databases.

PURPOSE: To evaluate the accuracy of insurance claims data indicating underutilization of primary care visits by children with special health care needs (CSHCN). DESIGN: The study was a retrospective comparison of primary care provider (PCP) utilization by 1,131 CSHCN, using secondary data from electronic claims-and-encounters databases in a Medicaid health maintenance organization (HMO) and a commercial HMO. METHODOLOGY: The study was conducted at the Children's Clinics for Rehabilitative Services (Children's Clinics) in Tucson, Ariz., a provider of specialty care to CSHCN. All the children in the study were eligible for specialty services under Arizona's statewide program for CSHCN and were simultaneously enrolled, from Oct. 1, 1995 through Sept. 30, 1996, in either one or both of the managed care plans for their primary care. Identical PCP-visit information for the same 1-year period was collected from the plans' claims-and-encounters databases, and the number of primary care visits as computed from both databases was compared. PRINCIPAL FINDINGS: Health plan claims data show that only 14 percent of the patients visited a PCP during the course of a year. The encounter data indicate that 59 percent of the same cohort had PCP visits. CONCLUSIONS: Encounter databases capture more information about PCP visits than insurance claims databases in capitated environments.