The Trach Trail: A Systems-Based Pathway to Improve Quality of Tracheostomy Care and Interdisciplinary Collaboration.

OBJECTIVE: To implement a standardized tracheostomy pathway that reduces length of stay through tracheostomy education, coordinated care protocols, and tracking patient outcomes. METHODS: The project design involved retrospective analysis of a baseline state, followed by a multimodal intervention (Trach Trail) and prospective comparison against synchronous controls. Patients undergoing tracheostomy from 2015 to 2016 (n = 60) were analyzed for demographics and outcomes. Trach Trail, a standardized care pathway, was developed with the Iowa Model of Evidence-Based Practice. Trach Trail implementation entailed monthly tracheostomy champion training at 8-hour duration and staff nurse didactics, written materials, and experiential learning. Trach Trail enrollment occurred from 2018 to 2019. Data on demographics, length of stay, and care outcomes were collected from patients in the Trach Trail group (n = 21) and a synchronous tracheostomy control group (n = 117). RESULTS: Fifty-five nurses completed Trach Trail training, providing care for 21 patients placed on the Trach Trail and for synchronous control patients with tracheostomy who received routine tracheostomy care. Patients on the Trach Trail and controls had similar demographic characteristics, diagnoses, and indications for tracheostomy. In the Trach Trail group, intensive care unit length of stay was significantly reduced as compared with the control group, decreasing from a mean 21 days to 10 (P < .05). The incidence of adverse events was unchanged. DISCUSSION: Introduction of the Trach Trail was associated with a reduction in length of stay in the intensive care unit. Realizing broader patient-centered improvement likely requires engaging respiratory therapists, speech language pathologists, and social workers to maximize patient/caregiver engagement. IMPLICATIONS FOR PRACTICE: Standardized tracheostomy care with interdisciplinary collaboration may reduce length of stay and improve patient outcomes.

Comparing inpatient versus emergency department clinician perceptions of personal protective equipment for different isolation precautions.

Adherence to isolation precaution practices, including use of personal protective equipment (PPE), remains a challenge in most hospitals. We surveyed inpatient and emergency department clinicians about their experiences and opinions of various isolation policies, specifically those related to wearing PPE. Our findings show several differences between inpatient and emergency department clinicians involving perceptions related to safety, and the difficulty associated with using PPE for certain types of organisms.

Quality Improvement Initiative to Reduce Pediatric Intensive Care Unit Noise Pollution With the Use of a Pediatric Delirium Bundle.

OBJECTIVES:: Noise pollution in pediatric intensive care units (PICU) contributes to poor sleep and may increase risk of developing delirium. The Environmental Protection Agency (EPA) recommends <45 decibels (dB) in hospital environments. The objectives are to assess the degree of PICU noise pollution, to develop a delirium bundle targeted at reducing noise, and to assess the effect of the bundle on nocturnal noise pollution. METHODS:: This is a QI initiative at an academic PICU. Thirty-five sound sensors were installed in patient bed spaces, hallways, and common areas. The pediatric delirium bundle was implemented in 8 pilot patients (40 patient ICU days) while 108 non-pilot patients received usual care over a 28-day period. RESULTS:: A total of 20,609 hourly dB readings were collected. Hourly minimum, average, and maximum dB of all occupied bed spaces demonstrated medians [interquartile range] of 48.0 [39.0-53.0], 52.8 [48.1-56.2] and 67.0 [63.5-70.5] dB, respectively. Bed spaces were louder during the day (10AM to 4PM) than at night (11PM to 5AM) (53.5 [49.0-56.8] vs. 51.3 [46.0-55.3] dB, P < 0.01). Pilot patient rooms were significantly quieter than non-pilot patient rooms at night (n=210, 45.3 [39.7-55.9]) vs. n=1841, 51.2 [46.9-54.8] dB, P < 0.01). The pilot rooms compliant with the bundle had the lowest hourly nighttime average dB (44.1 [38.5-55.5]). CONCLUSIONS:: Substantial noise pollution exists in our PICU, and utilizing the pediatric delirium bundle led to a significant noise reduction that can be perceived as half the loudness with hourly nighttime average dB meeting the EPA standards when compliant with the bundle.

Implementing a Daily Maintenance Care Bundle to Prevent Central Line-Associated Bloodstream Infections in Pediatric Oncology Patients.

Eliminating central line-associated bloodstream infection (CLABSI) is a national priority. Central venous catheter (CVC) care bundles are composed of a series of interventions that, when used together, are effective in preventing CLABSI. A CVC daily maintenance care bundle includes procedural guidelines for hygiene, dressing changes, and access as well as specific timeframes. Failure to complete one of the components of the care bundle predisposes the patient to a bloodstream infection. A nurse-led multidisciplinary team implemented and, for six months, sustained a daily maintenance care bundle for pediatric oncology patients. This quality improvement project focused on nursing staffs' implementation of the daily maintenance care bundle and the sustainment of the intervention. The project used a pre-post program design to evaluate outcomes of CVC daily maintenance care bundle compliancy and CLABSI. A statistically significant increase between the pre- and post-assessments of the compliance was noted with the CVC daily maintenance care bundle. CLABSI infection rates decreased during the intervention. Strategies to implement practice change and promote sustainability are discussed.

Facilitating the implementation of evidence- based practice through contextual support and nursing leadership.

BACKGROUND/PURPOSE: Nurse managers (NMs) play an important role promoting evidence-based practice (EBP) on clinical units within hospitals. However, there is a dearth of research focused on NM perspectives about institutional contextual factors to support the goal of EBP on the clinical unit. The purpose of this article is to identify contextual factors described by NMs to drive change and facilitate EBP at the unit level, comparing and contrasting these perspectives across nursing units. METHODS: This study employed a qualitative descriptive design using interviews with nine NMs who were participating in a large effectiveness study. To stratify the sample, NMs were selected from nursing units designated as high or low performing based on implementation of EBP interventions, scores on the Meyer and Goes research use scale, and fall rates. Descriptive content analysis was used to identify themes that reflect the complex nature of infrastructure described by NMs and contextual influences that supported or hindered their promotion of EBP on the clinical unit. RESULTS: NMs perceived workplace culture, structure, and resources as facilitators or barriers to empowering nurses under their supervision to use EBP and drive change. A workplace culture that provides clear communication of EBP goals or regulatory changes, direct contact with CEOs, and clear expectations supported NMs in their promotion of EBP on their units. High-performing unit NMs described a structure that included nursing-specific committees, allowing nurses to drive change and EBP from within the unit. NMs from high-performing units were more likely to articulate internal resources, such as quality-monitoring departments, as critical to the implementation of EBP on their units. This study contributes to a deeper understanding of institutional contextual factors that can be used to support NMs in their efforts to drive EBP changes at the unit level.

A Cost-Benefit Analysis: Electronic Clinical Procedural Resource Supporting Evidence-Based Practice.

There are many benefits of having an electronic reference at the patient bedside. Because of the significant costs involved, it is important to first understand if staff will utilize the system. A cost-benefit analysis of such an electronic clinical procedural resource at one large, academic health system showed a significant savings of $360,899. Having an electronic reference system at the patient bedside increased standardization throughout the organization. Additionally, clinical and instructional experts are not needed to write standard policies and procedures. Ongoing education was needed to increase utilization of the system within the organization.

Dissemination and implementation: INQRI's potential impact.

BACKGROUND: Application of research evidence in care delivery improves patient outcomes. Large gaps still exist, however, between recommended care and that used in practice. To increase the understanding of implementation studies, and dissemination of research findings, we present the perspective of investigators from seven Interdisciplinary Nursing Quality Research Initiative (INQRI)-funded studies. OBJECTIVE: To describe implementation strategies, challenges, and lessons learned from conducting 5 INQRI-funded implementation studies, and present 2 case examples of other INQRI studies to illustrate dissemination strategies. Potential impact of study findings are set forth. RESEARCH DESIGN: Qualitative descriptive methods were used for the implementation studies. Case examples were set forth by investigators using reflection questions. RESULTS: Four of the 5 implementation studies focused on clinical topics and 1 on professional development of nurse managers, 4 were multisite studies. Common implementation strategies used across studies addressed education, ongoing interaction with sites, use of implementation tools, and visibility of the projects on the study units. Major challenges were the Institutional Review Board approval process and the short length of time allocated for implementation. Successes and lessons learned included creating excitement about research, packaging of study tools and resources for use by other organizations, and understanding the importance of context when conducting this type of research. Case examples revealed that study findings have been disseminated to study sites and to the health care community through publications and presentations. The potential impact of all 7 studies is far reaching. CONCLUSIONS: This study captures several nuanced perspectives from 5 Principal Investigators, who were completing INQRI-funded implementation studies. These nuanced perspectives are important lessons for other scientists embarking on implementation studies. The INQRI case examples illustrate important dissemination strategies and impact of findings on quality of care.

Can the use of an early mobility program reduce the incidence of pressure ulcers in a surgical critical care unit?

UNLABELLED: The Agency for Healthcare Research and Quality has defined pressure ulcers (PUs) an important patient safety indicator (#3). Despite the existence of evidence-based guidelines for PU prevention and treatment from the United States Department of Health and Human Services, the sustained success in reducing the development of PUs is elusive in many acute care hospitals. PURPOSE: The specific aim of the study was to determine whether the implementation of an early standardized process for mobility could reduce or eliminate the development of PUs in a surgical intensive care unit. METHODS: Patient data were collected pre- and postimplementation of the early mobility protocol. RESULTS: The mobility compliance for patients postimplementation was 71.30% (SD = 12.73), with a range of 25% to 100%. A χ² test for independence (with Yates continuity correction) indicated a significant association between unit-acquired PUs and the pre- and postimplementation mobility groups (χ²(1,1051) = 6.86, P = .009). Specifically, patients in the intervention group had significantly more unit-acquired PUs than the control group. No significant differences were identified between the 2 groups. IMPLICATIONS/CONCLUSIONS: Despite implementation of the early mobility protocol, we did not see an improvement in the PU rate overall or with time as protocol compliance improved.

Multidisciplinary treatments, patient characteristics, context of care, and adverse incidents in older, hospitalized adults.

The purpose of this study was to examine factors that contribute to adverse incidents by creating a model that included patient characteristics, clinical conditions, nursing unit context of care variables, medical treatments, pharmaceutical treatments, and nursing treatments. Data were abstracted from electronic, administrative, and clinical data repositories. The sample included older adults hospitalized during a four-year period at one, academic medical facility in the Midwestern United States who were at risk for falling. Relational databases were built and a multistep, statistical model building analytic process was used. Total registered nurse (RN) hours per patient day (HPPD) and HPPDs dropping below the nursing unit average were significant explanatory variables for experiencing an adverse incident. The number of medical and pharmaceutical treatments that a patient received during hospitalization as well as many specific nursing treatments (e.g., restraint use, neurological monitoring) were also contributors to experiencing an adverse incident.

Reliability of pressure ulcer staging: a review of literature and 1 institution's strategy.

Pressure ulcers are an increasing health care problem. Accurate identification and classification of pressure ulcers impacts patient outcomes, health care costs, and quality initiatives.To identify existing evidence related to answering the question "Does bedside nursing staff accurately and reliably stage pressure ulcers as evidenced in their documentation?" Further evidence from one large tertiary care center with pressure ulcer identification and staging by nurses is also reported. Cumulative Index to Nursing and Allied Health Literature and MEDLINE databases were searched to identify existing evidence on the accuracy and reliability of pressure ulcer classification by nurses. Two reviewers independently screened results. A total of 54 full-text articles were obtained for review and 10 were included for final review. In addition, the accuracy and consistency of pressure ulcer identification and staging were examined at one large tertiary health system by extracting data from electronic health records for 1488 patient visits and assessments for 1499 patients. Comparisons were done for pressure ulcer documentation from 1 nurse's assessment to the following shift nurse's assessment and from the bedside nurse's assessment to assessments done by pressure ulcer experts.Review of the literature revealed that the reliability of pressure ulcer identification and classification is limited and highly variable. Some reports in the literature suggested nurses had difficulty distinguishing a pressure ulcer from other types of wounds. In addition, inaccuracies in pressure ulcer documentation were also identified. Further analysis of data within one large tertiary health care system revealed unreliable pressure ulcer documentation.

The impact of nursing surveillance on failure to rescue.

Greater amounts of nursing surveillance is thought to decrease failure to rescue but studies to date have used nurse staffing levels as a proxy for nursing surveillance. The purpose of this nursing effectiveness study was to examine the unique treatment effect of nursing surveillance on failure to rescue. Data were abstracted from 9 electronic clinical data repositories including the nursing documentation system that used the Nursing Interventions Classification (NIC) to record nursing care. Nursing surveillance was quantified as "high use" when the subjects received it an average of 12 times per day or more. Propensity scores were used to match subjects who had received high-dose nursing surveillance with subjects who received low-dose nursing surveillance (average of less than 12 times a day). The results indicate that when nursing surveillance is performed an average of 12 times a day or greater, there is a significant (p = .0058) decrease in the odds of experiencing failure to rescue (odds ratio [OR] = 0.52) compared to when surveillance was delivered an average of less than 12 times a day. Additional unique variables included in this study are robust levels of nurse staffing based on hourly data, medical treatments, pharmaceutical treatments, and nursing treatments. The use of propensity scores helped determine the unique contribution of nursing surveillance on failure to rescue in this observational study.

Factors associated with falls during hospitalization in an older adult population.

BACKGROUND: Falls of hospitalized older adults are of concern for patients, family members, third-party payers, and caregivers. Falls are the most common safety incident among hospitalized patients with fall rates from 2.9-13 per 1,000 patient days. Little effectiveness research has been conducted on nursing interventions and other variables associated with falls of older adults during hospitalization. PURPOSE: The purpose of this exploratory outcomes effectiveness study was to examine variables associated with falls during hospitalization of older adults. METHOD: An effectiveness research model composed of patient characteristics, clinical conditions, nursing unit characteristics, medical, pharmacy, and nursing interventions was tested using generalized estimating equations (GEE) analysis. The sample consisted of 10,187 hospitalizations of 7,851 patients, aged 60 or older, admitted for acute care services over a 4-year period. Those included in the sample either had received the Nursing Interventions Classification (NIC) intervention of Fall Prevention (defined as "instituting special precautions with patient at risk for injury from falling" [Dochterman & Bulechek, 2004, p. 363]) or were at risk for falling as defined by a fall risk assessment scale. Data were obtained retrospectively from 9 clinical and administrative data repositories from 1 tertiary care hospital. DISCUSSION: Variables that were positively associated with falls, after controlling for other variables in the model, included several medical and nursing treatments; several types of medications including antidepressants, benzodiazepines, antipsychotic, and psychotropic agents; and several types of nursing treatments including restraints and neurologic monitoring (at low use rates of < 2 times a day). Variables inversely associated with falls included registered nurse (RN) skill mix, pressure ulcer care, pain management, and tube care. CONCLUSIONS: The study demonstrates the importance of conducting interdisciplinary effectiveness research that includes nursing care. Most of the variables associated with falls were interventions (medical, pharmacy, and nursing). Dose of nursing treatments and RN skill mix were also associated with falls.

Fall prevention practices in adult medical-surgical nursing units described by nurse managers.

The purpose of this article was to describe nursing practices (e.g., assessment, interventions) around fall prevention, as perceived by nurse managers in adult, medical-surgical nursing units. One hundred forty nurse managers from 51 hospitals from across the United States participated. Descriptive frequencies are used to describe nurse manager responses. The most commonly used fall risk assessment tool was the Morse Fall Risk Assessment Tool (40%). The most common fall prevention interventions included bed alarms (90%), rounds (70%), sitters (68%), and relocating the patient closer to the nurses' station (56%). Twenty-nine percent of nurse managers identified physical restraints as an intervention to prevent falls whereas only 10% mentioned ambulation. No nurse manager identified that RN hours per patient-day were adjusted to prevent falls or fall-related injuries. More work is needed to build systems that ensure evidence-based nursing interventions are consistently applied in acute care.

Estimating effects of nursing intervention via propensity score analysis.

BACKGROUND: Lack of randomization of nursing intervention in outcome effectiveness studies may lead to imbalanced covariates. Consequently, estimation of nursing intervention effect can be biased as in other observational studies. Propensity score analysis is an effective statistical method to reduce such bias and further derive causal effects in observational studies. OBJECTIVES: The objective of this study was to illustrate the use of propensity score analysis in quantitative nursing research through an example of pain management effect on length of hospital stay. METHODS: Propensity scores are generated through a regression model treating the nursing intervention as the dependent variable and all confounding covariates as predictor variables. Then, propensity scores are used to adjust for this nonrandomized assignment of nursing intervention through three approaches: regression covariance adjustment, stratification, and matching in the predictive outcome model for nursing intervention. RESULTS: Propensity score analysis reduces the confounding covariates into a single variable of propensity score. After stratification and matching on propensity scores, observed covariates between nursing intervention groups are more balanced within each stratum or in the matched samples. The likelihood of receiving pain management is accounted for in the outcome model through the propensity scores. Both regression covariance adjustment and matching methods report a significant pain management effect on length of hospital stay in this example. The pain management effect can be regarded as causal when the strongly ignorable treatment assignment assumption holds. DISCUSSION: Propensity score analysis provides an alternative statistical approach to the classical multivariate regression, stratification, and matching techniques for examining the effects of nursing intervention with a large number of confounding covariates in the background. It can be used to derive causal effects of nursing intervention in observational studies under certain circumstances.

The effect of high nursing surveillance on hospital cost.

PURPOSE: The purpose of this study was to determine the cost of one nursing treatment, surveillance, for older, hospitalized adults at risk for falling. DESIGN: An observational study using information from data repositories at one Midwestern tertiary hospital. The inclusion criteria included patients age>60 years, admitted to the hospital between July 1, 1998 and June 31, 2002, at risk for falls or received the nursing treatment of fall prevention. METHODS: Data came from clinical and administrative data repositories that included Nursing Interventions Classification (NIC). The nursing treatment of interest was surveillance and total hospital cost associated with surveillance was the dependent variable. Propensity-score analysis and generalized estimating equations (GEE) were used as methods to analyze the data. Independent variables related to patient characteristics, clinical conditions, nurse staffing, medical treatments, pharmaceutical treatments, and other nursing treatments were controlled for statistically. FINDINGS: The total median cost per hospitalization was $9,274 for this sample. The median cost was different (p=0.050) for patients who received high versus low surveillance. High surveillance delivery cost $191 more per hospitalization than did low surveillance delivery. CONCLUSION: Propensity scores were applied to determine the cost of surveillance among hospitalized adults at risk for falls in this observational study. The findings show the effect of high surveillance delivery on total hospital cost compared to low surveillance delivery and provides an example of a useful method of determining cost of nursing care rather than including it in the room rate. More studies are needed to determine the effects of nursing treatments on cost and other patient outcomes in order for nurses to provide cost-effective care. Propensity scores were a useful method for determining the effect of nursing surveillance on hospital cost in this observational study. CLINICAL RELEVANCE: The results of this study along with possible clinical benefits would indicate that frequent nursing surveillance is important and might support the need for additional nursing staff to deliver frequent surveillance.

Cost of hospital care for older adults with heart failure: medical, pharmaceutical, and nursing costs.

OBJECTIVE: To determine the impact of patient characteristics, clinical conditions, hospital unit characteristics, and health care interventions on hospital cost of patients with heart failure. DATA SOURCES/STUDY SETTING: Data for this study were part of a larger study that used electronic clinical data repositories from an 843-bed, academic medical center in the Midwest. STUDY DESIGN: This retrospective, exploratory study used existing administrative and clinical data from 1,435 hospitalizations of 1,075 patients 60 years of age or older. A cost model was tested using generalized estimating equations (GEE) analysis. DATA COLLECTION/EXTRACTION METHODS: Electronic databases used in this study were the medical record abstract, the financial data repository, the pharmacy repository; and the Nursing Information System repository. Data repositories were merged at the patient level into a relational database and housed on an SQL server. PRINCIPAL FINDINGS: The model accounted for 88 percent of the variability in hospital costs for heart failure patients 60 years of age and older. The majority of variables that were associated with hospital cost were provider interventions. Each medical procedure increased cost by $623, each unique medication increased cost by $179, and the addition of each nursing intervention increased cost by $289. One medication and several nursing interventions were associated with lower cost. Nurse staffing below the average and residing on 2-4 units increased hospital cost. CONCLUSIONS: The model and data analysis techniques used here provide an innovative and useful methodology to describe and quantify significant health care processes and their impact on cost per hospitalization. The findings indicate the importance of conducting research using existing clinical data in health care.

Measuring the dose of nursing intervention.

PURPOSE: To increase awareness of the many issues involved in measuring the dose of nursing intervention in nursing interventions effectiveness research. METHODS: Identify critical issues in measurement of the dose of nursing intervention and discuss decisions regarding dosage measurement made in a study of the effectiveness of nursing interventions. FINDINGS: A single method can be applied to resolve two critical issues in intervention dosage measurement. CONCLUSIONS: Those conducting nursing interventions effectiveness research must think explicitly about how intervention dosage will be measured and reported so that dosage can be replicated in research and practice. PRACTICE IMPLICATIONS: Measuring and reporting the dose of nursing intervention in research is essential to the development of an evidence base adequate to support practice.