The Use of the Acute Stroke Management Questionnaire to Measure Acute Care Nurses' Stroke Knowledge.

ABSTRACT: BACKGROUND: Nurses are key in identifying and treating in-hospital strokes (IHSs). Delayed treatment times and poor patient outcomes are associated with IHSs. Information is needed on nurses' stroke knowledge and the objective measurement of stroke knowledge using a validated tool. The Acute Stroke Management Questionnaire (ASMaQ) was recently developed to test stroke knowledge of healthcare professionals but has not been used on a nursing-specific population. METHODS: Through online surveying and use of ASMaQ, we will measure stroke knowledge of nurses caring for adult, hospitalized patients in an urban, southeast US health system. RESULTS: Total N is 196. Most participants (74.5%, n = 146) never worked on a stroke floor; however, almost all (95.9%, n = 188) cared for a stroke patient in the past. Most participants (65.3%, n = 128) reported receiving prelicensure stroke education, and 98.5% (n = 193) received postlicensure stroke education. Acute Stroke Management Questionnaire total scores ranged from 93 to 133 (mean [SD], 117.35 [8.15]). Most participants scored in the good stroke knowledge range for all 3 ASMaQ domains and total ASMaQ score. CONCLUSION: The online delivery of the ASMaQ was successful in testing nurses' stroke knowledge, and nurses were shown to have good stroke knowledge. Future initiatives should focus on discerning whether certain nurse characteristics predict higher or lower levels of stroke knowledge to help inform educational initiatives to improve IHS outcomes.

Reducing Catheter-Associated Urinary Tract Infections Across a Hospital System Through Urine Culture Stewardship.

Objective: To evaluate the effectiveness and safety of an evidence-based urine culture stewardship program in reducing hospital catheter-associated urinary tract infections (CAUTIs) and the rate of CAUTIs across a 3-hospital system. Patients and Methods: This is a prospective, 2-year quality improvement program conducted from October 1, 2018, to September 30, 2020. An evidence-based urine culture stewardship program was designed, which consisted of the following: criteria for allowing or restricting urine cultures from catheterized patients, a best practice advisory integrated into the ordering system of an electronic medical record, and a systematic provider education and feedback program to ensure compliance. The system-wide rates of CAUTIs (total CAUTIs/catheter days×1000), changes in intercepts, trends, mortality, length of stay, rates of device utilization, and rates of hospital-onset sepsis were compared for 3 years before and 2 years after the launch of the program. Results: Catheter-associated urinary tract infections progressively decreased after the initiation of the program (B=-0.21, P=.001). When the trends before and after the initiation of the program were compared, there were no statistically significant increases in the ratio of actual to predicted hospital length of stay, intensive care unit length of stay, system-wide mortality, and intensive care unit mortality. Although the rates of hospital-acquired sepsis remained consistent after the implementation of the stewardship program through the first quarter of 2020, the rates showed an increase in the second and third quarters of 2020. However, hospital-onset sepsis events associated with the diagnosis of a urinary tract infection did not increase after the intervention. Conclusion: Urine culture stewardship is a safe and effective way to reduce CAUTIs among patients in a large multihospital health care system. Patient safety indicators appeared unchanged after the implementation of the program, and ongoing follow-up will improve confidence in the long-term sustainability of this strategy.

Program Evaluation of Implementation Science Outcomes From an Intervention to Improve Compliance With Chlorhexidine Gluconate Bathing: A Qualitative Study.

BACKGROUND AND OBJECTIVES: Evaluation of implementation science research is warranted to better understand and determine the success of translating evidence-based infection prevention practices at the bedside. The purpose of this program evaluation was to evaluate implementation outcomes from the perspectives of nurses and nursing leaders regarding a previously conducted chlorhexidine gluconate (CHG) bathing implementation science study among 14 critical care units. METHODS: Focus groups and interviews, using semistructured interview questions, were conducted to examine the perceptions of nurses who participated in a CHG bathing implementation science study. A deductive qualitative analysis using Proctor and colleagues' implementation outcomes framework was used. Transcripts were analyzed and categorized using the framework as a predetermined code list to structure the implementation outcomes of acceptability, appropriateness, adoption, feasibility, and sustainability. FINDINGS: A total of 19 nurses and nurse leaders participated in a focus group or interview. Participants noted that both implementation strategies used in the initial study (educational outreach and audit and feedback) were acceptable and appropriate and expressed that the evidence-based CHG bathing practice was feasible to integrate into practice and was being adopted. DISCUSSION: The program evaluation identified strengths and opportunities for improvement related to the implementation strategies and evidence-based CHG bathing protocol. Findings can inform future studies that seek to implement CHG bathing protocols in the critical care setting using audit and feedback and educational outreach strategies.

An Innovative Nurse Staffing Model: Nurses Are Happy2Help and Strike the Right Balance.

OBJECTIVE: The aim of this study was to develop a flexible nurse reallocation solution. BACKGROUND: Successful nurse reallocation supports appropriate staffing and may enhance workforce flexibility. METHODS: An innovative program incentivizing regular nursing staff to volunteer for extra shifts systemwide was implemented at a large healthcare organization. RESULTS: Nurses' perceptions of appropriate staffing improved, and nursing care quality was not compromised. The program primed the organization to respond to the pandemic. CONCLUSIONS: The staffing model has been sustained for 3+ years.

Results of the CHlorhexidine Gluconate Bathing implementation intervention to improve evidence-based nursing practices for prevention of central line associated bloodstream infections Study (CHanGing BathS): a stepped wedge cluster randomized trial.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) result in approximately 28,000 deaths and approximately $2.3 billion in added costs to the U.S. healthcare system each year, and yet, many of these infections are preventable. At two large health systems in the southeast United States, CLABSIs continue to be an area of opportunity. Despite strong evidence for interventions to prevent CLABSI and reduce associated patient harm, such as use of chlorhexidine gluconate (CHG) bathing, the adoption of these interventions in practice is poor. The primary objective of this study was to assess the effect of a tailored, multifaceted implementation program on nursing staff's compliance with the CHG bathing process and electronic health record (EHR) documentation in critically ill patients. The secondary objectives were to examine the (1) moderating effect of unit characteristics and cultural context, (2) intervention effect on nursing staff's knowledge and perceptions of CHG bathing, and (3) intervention effect on CLABSI rates. METHODS: A stepped wedged cluster-randomized design was used with units clustered into 4 sequences; each sequence consecutively began the intervention over the course of 4 months. The Grol and Wensing Model of Implementation helped guide selection of the implementation strategies, which included educational outreach visits and audit and feedback. Compliance with the appropriate CHG bathing process and daily CHG bathing documentation were assessed. Outcomes were assessed 12 months after the intervention to assess for sustainability. RESULTS: Among the 14 clinical units participating, 8 were in a university hospital setting and 6 were in community hospital settings. CHG bathing process compliance and nursing staff's knowledge and perceptions of CHG bathing significantly improved after the intervention (p = .009, p = .002, and p = .01, respectively). CHG bathing documentation compliance and CLABSI rates did not significantly improve; however, there was a clinically significant 27.4% decrease in CLABSI rates. CONCLUSIONS: Using educational outreach visits and audit and feedback implementation strategies can improve adoption of evidence-based CHG bathing practices. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03898115 , Registered 28 March 2019.

One-year results from the first US-based enhanced recovery after cardiac surgery (ERAS Cardiac) program.

OBJECTIVE: Our enhanced recovery after cardiac surgery (ERAS Cardiac) program is an evidence-based interdisciplinary process, which has not previously been systematically applied to cardiac surgery in the United States. METHODS: The Knowledge-to-Action Framework synthesized evidence-based enhanced recovery interventions and implementation of a designated ERAS Cardiac program. Standardized processes included (1) preoperative patient education, (2) carbohydrate loading 2 hours before general anesthesia, (3) multimodal opioid-sparing analgesia, (4) goal-directed perioperative insulin infusion, and (5) a rigorous bowel regimen. All cardiac anesthesiologists and surgeons agreed to follow the standardized pathway for adult cardiac surgery cases. The 1-year outcomes were compared between the 9 months pre- and post-ERAS Cardiac implementation using prospectively collected, retrospectively reviewed data. RESULTS: Comparing the pre- (N = 489) with the post- (N = 443) ERAS Cardiac groups, median postoperative length of stay was decreased from 7 to 6 days (P < .01). Total intensive care unit hours were decreased from a mean of 43 to 28 hours (P < .01). The incidence of gastrointestinal complications was 6.8% pre-ERAS versus 3.6% post-ERAS implementation (P < .05). Opioid use was reduced by a mean of 8 mg of morphine equivalents per patient in the first 24 hours postoperatively (P < .01). Reintubation rate and intensive care unit readmission rate were reduced by 1.2% and 1.5%, respectively (P = not significant). The incidence of hyperglycemic episodes was no different after ERAS Cardiac initiation. Patient satisfaction was 86.3% pre-ERAS versus 91.8% post-ERAS Cardiac implementation and work culture domain scores revealed increases in satisfaction across all measured indices, including patient focus, culture, and engagement. CONCLUSIONS: Initial clinical and survey data after the first year of a system-wide ERAS Cardiac program were associated with significantly improved perioperative outcomes. We believe this value-based approach to cardiac surgery can consistently result in earlier recovery, cost reductions, and increased patient/staff satisfaction.

Enhanced recovery after cardiac surgery program to improve patient outcomes.

This article details the obstacles of implementing a cardiac-specific enhanced recovery after surgery (ERAS) program in a 919-bed not-for-profit community-based health system and the benefits of ERAS programs for different patient populations.

Pathophysiological relationships between heart failure and depression and anxiety.

Depression and anxiety are common comorbid conditions in patients with heart failure. Patients with heart failure and depression have increased mortality. The association of anxiety with increased mortality in patients with heart failure is not established. The purpose of this article is to illustrate the similarities of the underlying pathophysiology of heart failure, depression, and anxiety by using the Biopsychosocial Holistic Model of Cardiovascular Health. Depression and anxiety affect biological processes of cardiovascular function in patients with heart failure by altering neurohormonal function via activation of the hypothalamic-pituitary-adrenal axis, autonomic dysregulation, and activation of cytokine cascades and platelets. Patients with heart failure and depression or anxiety may exhibit a continued cycle of heart failure progression, increased depression, and increased anxiety. Understanding the underlying pathophysiological relationships in patients with heart failure who experience comorbid depression and/or anxiety is critical in order to implement appropriate treatments, educate patients and caregivers, and educate other health professionals.

Effects of interventions on depression in heart failure: a systematic review.

OBJECTIVE: We sought to conduct a systematic review to evaluate the effects of interventions on depression in adults with heart failure (HF). METHODS: Published, peer-reviewed, English-language, prospective interventional studies were identified in a search of Medline, CINAHL, PsychINFO, and the Cochrane Libraries of Systematic Reviews and Clinical Trials from 1996 through August 2011 and relevant bibliographies. Eligible studies included patients with New York Heart Association functional class II and III HF with experimental or quasiexperimental designs and preintervention and postintervention measures of depression. Ineligible studies were nonpharmacologic with a sample size <50, and drug studies without a comparison group. RESULTS: Twenty-three experimental and quasiexperimental studies that enrolled a total of 3564 persons with HF contributed evidence about 6 types of interventions: selective serotonin reuptake inhibitors (SSRIs), an erythropoiesis-stimulating agent, exercise, disease management programs, complementary and alternative medicine (CAM), and a multimodal intervention of cognitive behavioral therapy and exercise. Studies with SSRIs examined effects of sertraline, paroxetine, and citalopram. The CAM interventions included tai chi, progressive muscle relaxation therapy, and mindfulness-based stress reduction. CONCLUSIONS: Evidence is strong that pharmacology and CAM may improve depression. Moderate evidence supports the use of exercise. A strong body of evidence indicates that disease management programs do not improve depression. This review does not support the development of guidelines for treatment of depression in persons with HF because evidence is insufficient and, at times, contradictory.

Oral mucositis-related oropharyngeal pain and correlative tumor necrosis factor-alpha expression in adult oncology patients undergoing hematopoietic stem cell transplantation.

BACKGROUND: Oral mucositis is the most common sequela of conditioning chemotherapy (CT) for hematopoietic stem cell transplantation (HSCT) and is the principal cause of most of the associated pain. Tumor necrosis factor-alpha (TNF-alpha) is a key pathogenic component of oral mucositis. OBJECTIVES: The primary purpose of this study was to describe oral mucositis-related oropharyngeal pain in the setting of HSCT. A secondary purpose was to assess the effectiveness of molecular biology methods for measuring TNF-alpha concentrations in plasma, saliva, and buccal epithelial cells in patients with oral mucositis undergoing HSCT. METHODS: This descriptive, correlative study recruited subjects aged >or= 18 years who were scheduled to receive HSCT with CT. Subjects assessed their pain at baseline and 9 days (+/-24 hours) after CT using a pain visual analog scale (VAS) from 0=no pain to 10=worst possible pain, as well as word descriptors of sensory and affective pain. The extent and severity of oral mucositis were evaluated using the Oral Mucositis Assessment Scale. Saliva and blood samples and buccal brush biopsies were obtained at the same time points. Salivary and plasma TNF-alpha concentrations were measured using an enzyme-linked immunosorbent assay. Quantitative real-time polymerase chain reaction testing was used to measure buccal TNF-alpha gene expression. To determine the optimal method of RNA isolation, samples were extracted using 3 different methods: TRIzol, RNeasy, and RLT/TRIzol. RESULTS: Twenty-five adult men and women (mean age, 46 years; age range, 32-68 years; 64% white) underwent HSCT with CT. Significant differences from baseline to day 9 were observed in the severity of oral mucositis (P<0.001), the overall intensity of oral pain (P<0.05), the overall intensity of oral pain with swallowing (P<0.01), the sensory dimension of oral pain with swallowing (P<0.05), and the sensory and affective dimension of oral pain with swallowing (P<0.05). The severity of oral mucositis was significantly associated with the overall intensity of oral pain (P<0.05). Although mean scores for oral pain were low, 8 subjects had clinically unacceptable pain VAS scores (>3) while receiving opioids. Fourteen subjects had measurable increases in buccal TNF-alpha RNA expression at day 9 (P=0.027 vs baseline), as measured using the TRIzol method, which was found to be the best method for measuring this variable. TNF-alpha RNA content in buccal samples was significantly associated with the worst intensity of oral pain with swallowing (partial R(2)=0.19; P<0.05). CONCLUSIONS: Despite the use of opioids, oropharyngeal pain remained a treatment challenge in approximately one third of these subjects after CT with HSCT. The sensitive assay used to measure TNF-alpha gene expression in buccal cells may be useful in investigating molecular events in oral mucositis-related pain, as well as in evaluating the therapeutic response to investigational agents.

Care for patients undergoing extracorporeal photopheresis to treat chronic graft-versus-host disease: review of the evidence.

Late immune dysregulation following allogeneic hematopoietic cell transplantation (HCT) is known as chronic graft-versus-host disease (GVHD), which is a major cause of mortality and morbidity after HCT, and a rise in its incidence is predicted. Better therapies are being sought to manage chronic GVHD and limit patients' exposure to corticosteroids. Extracorporeal photopheresis (ECP), an immune-modulating therapy, has shown preliminary safety and efficacy in treating chronic GVHD. However, access to ECP is limited, care is costly, and the optimal frequency, duration, and durability of response are unknown. Although nurses who care for patients with chronic GVHD recognize its adverse impact on patients' quality of life, limited evidence exists about the selection of patients most likely to benefit from ECP therapy and from the supportive care provided to them. A multidisciplinary approach is needed to define the desired outcomes of ECP therapy and to determine the evidence base for nursing management approaches.

Severe chronic graft-versus-host disease is characterized by a preponderance of CD4(+) effector memory cells relative to central memory cells.

Donor alloreactive CD4(+) T cells are important to the pathogenesis of chronic graft-versus-host disease (cGVHD), but specific subsets of CD4(+) T cells responsible for GVHD have not been defined. We hypothesized that cGVHD might be associated with a preponderance of CD4(+) effector memory cells (CCR7(-)/CD62L(low), CD4(EM)). We analyzed CCR7 and CD62L expression on CD4(+) T cells from stem cell transplantation patients, who did or did not develop cGVHD, and healthy donors. Patients with cGVHD had a higher percentage of CD4(EM) cells (35.5% +/- 2.9%) than healthy donors (13.8% +/- 0.7%; P <.0001) or patients without cGVHD that received a transplant (21.7% +/- 2.1%; P <.01). Using corticosteroid dose as a surrogate marker for cGVHD severity, severe cGVHD was associated with a higher percentage of CD4(EM) cells. The proportion of CD4(EM) cells in corticosteroid-dependent patients with systemic lupus erythematosis or Wegener granulomatosis did not differ from patients without cGVHD that received a transplant. This finding implies that overrepresentation of CD4(EM) cells is a unique feature of cGVHD.