Retrospective analysis of HEART Score results in cost saving.

BACKGROUND AND PURPOSE: Chest pain (CP) is one of the most frequent chief complaints of patients presenting to the emergency department (ED). Diagnoses range from life-threatening acute coronary syndrome (ACS) to less concerning musculoskeletal injury. Patients are frequently admitted for comprehensive cardiac evaluation. However, it is estimated that <10% are diagnosed with ACS. Identifying low-risk patients who can be safely discharged from the ED results in lower cost burden and less patient days. The HEART Score is a recently validated tool for undifferentiated CP in the ED used to identify low-risk patients. The purpose of this project was to ascertain if the HEART Score could be utilized in the Veteran population for the evaluation of undifferentiated chest pain. LOCAL PROBLEM: There is no standard assessment tool used in the ED at the Veterans Administration Pittsburgh Healthcare System (VAPHS) to evaluate CP in low-risk patents. METHODS: As part of a quality improvement initiative, a retrospective analysis was performed on patients presenting to the ED with CP over a 6-month period. A total of 197 VAPHS patients were identified through the computerized medical record system. HEART Scores were calculated for each patient. Patients scored as low risk (score of 0-3) were further evaluated for major adverse cardiac events (MACE) and cost saving. CONCLUSIONS: Approximately 28% (56) of the patients presenting to the ED with CP were at low risk based on the HEART Score. There were no MACE. There were cost savings compared with usual care ($1,145 vs. $4,700). IMPLICATIONS FOR PRACTICE: The HEART Score can be safely used to identify low-risk patients and result in cost savings for Veteran population.

Improving Knowledge, Comfort, and Confidence of Nurses Providing End-of-Life Care in the Hospital Setting Through Use of the CARES Tools.

Although most individuals prefer to die at home, approximately 60% of Americans die in the hospital setting. Nurses are inadequately prepared to provide end-of-life (EOL) care because of cure-focused education. Friends and family of dying patients report poor quality of death largely as a result of inadequate communication from health care professionals about the dying process. The purpose of this project was to improve nursing knowledge and comfort related to EOL care through use of the CARES tool and to improve the EOL experience of families of dying patients in the hospital setting through use of Final Journey. These acronym organized tools were developed based upon the common symptom management needs of the dying including Comfort, Airway, Restlessness and delirium, Emotional and spiritual support, and Self-care. The CARES tool for nurses improved nursing knowledge and comfort related to EOL care and common symptom management needs of the dying and also enhanced nurses' confidence in communicating about the dying process with friends and family. Final Journey, the friends and family version of the CARES tool, reinforced EOL information for friends and family, helped nurses answer difficult questions, and promoted and enhanced communication between health care professionals and friends and family of the dying.

Implementation of pulmonary ultrasound training for critical care advanced practice providers.

BACKGROUND AND PURPOSE: The use of pulmonary ultrasound (US) in the critical care setting has been increasing over the past 2 decades. The use of advanced practice providers (APPs) in the critical care setting is also increasing. Limited data exist regarding the clinical and educational impact of a formal pulmonary US training course for APPs working in critical care settings. METHODS: A preimplementation and postimplementation comparative design focused on the development and implementation of a formal pulmonary US course for novice critical care APPs. CONCLUSIONS: Eleven APPs underwent formal pulmonary US training. There was a significant increase in pulmonary US knowledge after the course, with pretest median of 13 and posttest median of 22 (p < .001; maximum score = 23). Presurvey and postsurvey comparison showed overall increase in skill and clinical use of pulmonary US. After the course, participating APPs reported a greater frequency of clinical decision-making based on US examination as measured by presurvey and postsurvey results. IMPLICATIONS FOR PRACTICE: Implementation of a formal pulmonary US course for critical care APPs improved pulmonary US knowledge, skill, and utilization, and impacted clinical decision-making and should be a highly recommended addition to the practice setting.

Development of a Home Health-Based Palliative Care Program for Patients With Heart Failure.

Heart failure is a significant burden to the healthcare system. Approximately 5.7 million adults in the United States were diagnosed with heart failure between 2009 and 2012 (). The American Heart Association projects that direct costs for heart failure may be as high as $77.7 billion by 2030 (). Technological and pharmaceutical advancements have delayed the progression of the disease; however, it is predicted that close to half of individuals with heart failure will die within 5 years of the initial diagnosis (; ). Current research suggests that the utilization of palliative care and an interdisciplinary team approach to the care of patients with heart failure improves the quality of life and decreases utilization of healthcare resources at the end of life (). This performance improvement project examined the knowledge of a home healthcare interdisciplinary team's knowledge about palliative care in patients with heart failure, the 30-day readmission rate for patients enrolled in a home-based palliative care program, and documentation of advanced directives in a home healthcare organization.

Paroxysmal Supraventricular Tachycardia: Pathophysiology, Diagnosis, and Management.

Paroxysmal supraventricular tachycardia (PSVT) is a well-known and thoroughly studied clinical syndrome, characterized by regular tachycardia rhythm with sudden onset and abrupt termination. Most patients present with palpitations and dizziness, and their electrocardiogram demonstrates a narrow QRS complex and regular tachycardia with hidden or inverted P waves. PSVT is caused by re-entry due to the presence of inhomogeneous, accessory, or concealed conducting pathways. Hemodynamically stable patients are treated by vagal maneuvers, intravenous adenosine, diltiazem, or verapamil, hemodynamically unstable patients are treated by cardioversion. Patients with symptomatic and recurrent PSVT can be treated with long-term drug treatment or catheter ablation.

Chest pain: a time for concern?

When a patient complains of chest pain, the first priority is to establish whether the situation is life threatening. Life-threatening differential diagnoses that clinicians must consider include acute coronary syndrome, cardiac tamponade, pulmonary embolus, aortic dissection, and tension pneumothorax. Nonthreatening causes of chest pain that should be considered include spontaneous pneumothorax, pleural effusion, pneumonia, valvular diseases, gastric reflux, and costochondritis. The challenge for clinicians is not to be limited by "satisfaction of search" and fail to consider important differential diagnoses. The challenge, however, can be met by developing a systematic method to assess chest pain that will lead to the appropriate diagnosis and appropriate treatment plan.

Defining NP scope of practice and associated regulations: focus on acute care.

PURPOSE: Although the nurse practitioner (NP) role has been in existence for over 40 years, there continues to be uncertainty about the essential components that define NP scope of practice. The purpose of this article is to review definitions and concepts related to NP scope of practice with an emphasis on NPs working in acute care. DATA SOURCES: A synthesis literature review was conducted on defining NP scope of practice. Simultaneous review of authoritative resources including National Council of State Board of Nursing, individual state board of nursing language, and NP scope and standards of practice documents was conducted. CONCLUSIONS: Scope of practice is a legal term used by states to define what activities an individual professional can undertake. The Consensus Model for Advanced Practice Registered Nurse (APRN) Regulation outlines that licensure and scope of practice are based on graduate education within a defined patient population for the APRN role. The APRN Consensus Model further identifies that the services provided by APRNs are not defined or limited by setting but rather by patient care needs. For the acute care NP, this is especially significant, as patient acuity and care requirements can vary across settings. When implemented, the Consensus Model will help to standardize regulation for APRNs as well as ensure congruence between licensure, accreditation, certification, and education. IMPLICATIONS FOR PRACTICE: Providing clarification of the NP scope of practice, especially as it pertains to NPs working in acute care settings, remains needed to support practice based on educational preparation, licensure, certification, and focus of practice.

Patient communication simulation laboratory for students in an acute care nurse practitioner program.

BACKGROUND: Effective communication skills for clinical practice are essential for all advanced practice nurses. However, competence in these skills is not necessarily intuitive. Advanced communication skills should be taught in a way that is similar to the way other psychomotor skills in advanced nursing practice programs are taught. OBJECTIVES: To develop a patient communication simulation laboratory for the acute care nurse practitioner program at a major university and to evaluate students' perceived confidence and communication effectiveness before and immediately as well as 4 months after completion of the laboratory. METHODS: The communication simulation laboratory was developed in collaboration with faculty from the schools of nursing and medicine. Students participated in a didactic session and then completed a 2-hour communication simulation in the laboratory. Content and simulation concentrated on breaking "bad news," empathetic communication, motivational interviewing, and the "angry" patient. Students' self-reported confidence and perceived skill in communication were measured via a Likert scale before, immediately after, and 4 months after completion of the laboratory simulation. Students also evaluated the experience by responding to open-ended questions. RESULTS: Compared with baseline findings (before the lecture and simulation), students' confidence in initiating difficult conversations increased significantly both immediately (P<.001) and 4 months after (P=.001) the laboratory simulation. Students' self-ratings of overall ability to communicate were also significantly greater immediately (P<.001) and 4 months (P=.001) after the simulation. Overall, students rated the laboratory simulation experience highly beneficial. CONCLUSIONS: The content and methods used for the simulation improved students' confidence and perceived skill in communication in potentially difficult acute care situations.

Credentialing for nurse practitioners: an update.

The public has the right to safe, quality healthcare delivered by professionals with the appropriate education, training, and experience. The Joint Commission on Accreditation of Healthcare Organizations, the Accreditation Association for Ambulatory Healthcare, and managed care organizations take this commitment very seriously. One mechanism required by these agencies to ensure patient safety is the process of credentialing and delineation of clinical privileges for medical staff and allied health professionals, such as Acute Care Nurse Practitioners. This commitment extends to patients receiving healthcare through the technology of telemedicine and to those requiring emergency care resulting from trauma, disasters, and varying forms of terrorism. In addition, safeguards must be in place to prevent identity theft of healthcare providers, including Acute Care Nurse Practitioners. It is essential that Acute Care Nurse Practitioners be familiar with the regulations that impact and guide the process of credentialing and obtaining clinical privileges in a variety of venues.