Risk factors for readmission after sepsis and its association with mortality.

BACKGROUND: Sepsis is associated with an approximately 20 % 30-day readmission rate and with subsequent mortality. OBJECTIVES: To determine the demographics, comorbidities that had been documented prior to sepsis onset, processes of care, commonly administered laboratory tests measured near discharge, and post-sepsis infections that may be associated with readmission and, secondarily, whether readmission is an independent risk factor for 90-day mortality. METHODS: Using a database of patients who met Sepsis-3 criteria divided into Construction and Validation groups, we used logistic regression to estimate the factors independently associated with readmission within 30 days after discharge and proportional hazard regression to estimate the factors independently associated with 90-day mortality. RESULTS: Of the 30,798 patients ≥ 18 years at our combined referral and community hospital and were discharged alive who met Sepsis-3 criteria between July 10, 2009 and September 7, 2019, 5943 (19 %) were readmitted within 30 days. Thirteen thousand, four hundred forty-four (44 %) of the patients were female, 25,293 (82 %) White, 3523 (11 %) Black, and the mean age was 59 ± 17 years. Among the readmitted patients, 894 (15 %) died within 90 days from the original discharge compared to 11 % (p < 0.001) who had not been readmitted. Seven comorbidities, five processes of care (presepsis platelet transfusion, postsepsis platelet transfusion, operation, ICU length of stay, and hospital length of stay), five culture results, two discharge laboratory values, and discharge location were associated with readmission. The model had good discrimination, 0.770 ± 0.004 (Construction Group) and 0.748 ± 0.006 (Validation Group) and good relevancy (area under the precision recall curve), 0.390 ± 0.004 (Construction group) and 0.476 ± 0.005 (Validation group). Readmission within 30 days was independently associated with a 56 % higher risk of death (HR=1.562, 95 % CI=1.434, 1.703, p < 0.001) within 90 days from discharge. CONCLUSIONS: Comorbidities, abnormal laboratory values, processes of care, and post-sepsis onset culture results, but not demographic characteristics, were associated with 30-day readmission. Readmission was associated with 90-day mortality.

Adapting user-centered design principles to improve communication of peer parent narratives on pediatric tracheostomy.

BACKGROUND: Parents who have to make tracheostomy decisions for their critically ill child may face forecasting errors and wish to learn from peer parents. We sought to develop an intervention with peer parent narratives to help parents anticipate and prepare for future challenges before making a decision. METHODS: To ensure that the intervention reflects parents' needs (rather than experts' opinions), we adapted a user-centered design (UCD) process to identify decision-critical information and refine the presentation format by interviewing parents who had tracheostomy decision making experience. Phase 1 (n = 10) presented 15 possible forecasting errors and asked participants to prioritize and justify the problematic ones. It also asked participants to comment on the draft narratives and preferred delivery mode and time of the intervention. Phase 2 (n = 9 additional parents and 1 previous parent) iteratively collected feedback over four waves of user interviews to guide revisions to the informational booklet. RESULTS: Phase 1 revealed that parents wanted information to address all forecasting errors as soon as tracheostomy becomes an option. They also highlighted diverse family situations and the importance of offering management strategies. The resulting prototype booklet contained five sections: introduction, child's quality of life, home care, practical challenges, and resources. Feedback from Phase 2 focused on emphasizing individualized situations, personal choice, seriousness of the decision, and caregiver health as well as presenting concrete illustrations of future challenges with acknowledgement of positive outcomes and advice. We also learned that parents preferred to use the booklet with support from the care team rather than read it alone. CONCLUSIONS: A UCD process enabled inclusion of parental perspectives that were initially overlooked and tailoring of the intervention to meet parental expectations. Similar UCD-based approaches may be valuable in the design of other types of patient communications (e.g., decision aids).

How can the nursing profession help reduce sexual and gender minority related health disparities: Recommendations from the National Nursing LGBTQ Health Summit.

BACKGROUND: Lesbian, gay, bisexual, transgender and queer (LGBTQ) people, also commonly referred to as sexual and gender minorities (SGMs), live in every part of the United States and encompass all races and/or ethnicities, religions, and social classes. Major reports from various sources document higher rates of health issues (e.g., substance abuse, depression, suicidality, cardiovascular disease) among SGMs than heterosexuals. Chronic stress related to marginalization and discrimination is a key contributor to these disparities. The nursing profession has paid relatively little attention to SGM health issues. PURPOSE AND METHODS: To address these gaps, the first National Nursing LGBTQ Health Summit brought together nursing deans, leaders of national nursing organizations, and other participants from across the United States. FINDINGS: Participants agreed that increasing SGM-specific content in nursing curricula, practice guidelines, faculty development, and research is necessary to improve the health of SGM people. DISCUSSION: The Summit ended with a call to action for the nursing profession to prioritize SGM health through innovations in education, research, and practice.

Improving hypertension control and cardiovascular health: An urgent call to action for nursing.

BACKGROUND: Hypertension is a leading cause of cardiovascular disease (CVD) and affects nearly one in two adults in the United States when defined as a blood pressure of at least 130/80 mm Hg or on antihypertensive medication (Virani et al., 2021, Circulation, 143, e254). Long-standing disparities in hypertension awareness, treatment, and control among racial and ethnic populations exist in the United States. High-quality evidence exists for how to prevent and control hypertension and for the role nurses can play in this effort. In response to the 2020 Surgeon General's Call to Action to Control Hypertension, nursing leaders from 11 national organizations identified the critical roles and actions of nursing in improving hypertension control and cardiovascular health, focusing on evidence-based nursing interventions and available resources. AIMS: To develop a unified "Call to Action for Nurses" to improve control of hypertension and cardiovascular health and provide information and resources to execute this call. METHODS: This paper outlines roles that registered nurses, advanced practice nurses, schools of nursing, professional nursing organizations, quality improvement nurses, and nursing researchers can play to control hypertension and prevent CVD in the United States. It describes evidence-based interventions to improve cardiovascular health and outlines actions to bring hypertension and CVD to the forefront as a national priority for nursing. LINKING EVIDENCE TO ACTION: Evidence-based interventions exist for nurses to lead efforts to prevent and control hypertension, thus preventing much CVD. Nurses can take actions in their communities, their healthcare setting, and their organization to translate these interventions into real-world practice settings.

Race and sex based disparities in sepsis.

BACKGROUND: Studies of sepsis evaluating sex- and race-related disparities in treatment and outcome have been limited by using administrative databases, which may not adequately capture sepsis diagnosis, used limited number and types of races, or not included both sex and race in the analyses. OBJECTIVE: To determine if patients of different races and sexes with sepsis have different mortality, receipt of mechanical ventilation or renal replacement therapy, or time to antibiotics? METHODS: We retrospectively analyzed clinical data from 34,999 patients with sepsis, defined by Sepsis-3 criteria, using logistic regression and linear regression. RESULTS: After adjustments for confounders, Asian females had the lowest adjusted 90-day mortality (OR=0.656, 95% CI=0.385-1.118, p<0.001 compared to White males). Similarly, compared to White males, African-American males had a lower adjusted mortality (OR=0.790, 95% CI=0.648-0.963, p = 0.019), while Asian males (OR=1.185, 95% CI=0. 828-1.696, p = 0.354) and both African-American (OR=0.972, 95% CI=0.800-1.182, p = 0.779) and Caucasian (OR=1.054, 95% CI=0.960-1.158, p = 0.270) females had similar mortality. Both male and female patients with Other/unknown race had higher mortality (OR=1.776, 95% CI=1.395-2.261, p<0.001 and OR=1.658, 95% CI=1.359-2.021, p<0.001), respectively. In the secondary analyses for new-onset mechanical ventilation and new-onset renal replacement therapy post-sepsis, we found no association between any of the race-sex groups and receipt of these therapies. CONCLUSION: We found that Asian females had the lowest adjusted 90-day mortality for patients with sepsis. Understanding the reasons for disparities in outcome after sepsis may improve care and outcomes in diverse populations.

Experience of African American Surrogate Decision Makers of Patients With Dementia.

Dementia cases are expected to grow for African Americans and surrogate decision makers (SDMs) will have a significant role at the end of life (EOL). This qualitative exploratory case study used Cognitive Task Analysis and an integrated conceptual framework to understand the EOL decision experience of African American SDMs for patients with advanced dementia. Using a holistic multiple-case design, 8 African American SDMs were interviewed about their experiences with the decision-making process, including role acceptance, role enactment, and emotional outcomes of decision making. Thirteen themes germane to understanding the EOL decision experience of African American SDMs were identified. Findings suggest African American SDMs often lack sufficient knowledge of disease prognosis and intervention options to make informed treatment choices at EOL. In particular, African Americans extend the caregiver role to SDM for patients with dementia at EOL without being fully aware of the role and decision-making responsibilities. Surrogates lacked a general understanding of EOL options resulting in underutilization of hospice and palliative care and subsequent regret, and few interventions exist to improve the uptake of EOL care services. There is a need to develop culturally appropriate role preparation, education, and decision support to improve EOL treatment decisions and emotional adjustment of surrogates of patients with advanced dementia, which should be rendered early and throughout the illness trajectory.

Critical Care Nurses' Physical and Mental Health, Worksite Wellness Support, and Medical Errors.

BACKGROUND: Critical care nurses experience higher rates of mental distress and poor health than other nurses, adversely affecting health care quality and safety. It is not known, however, how critical care nurses' overall health affects the occurrence of medical errors. OBJECTIVE: To examine the associations among critical care nurses' physical and mental health, perception of workplace wellness support, and self-reported medical errors. METHODS: This survey-based study used a cross-sectional, descriptive correlational design. A random sample of 2500 members of the American Association of Critical-Care Nurses was recruited to participate in the study. The outcomes of interest were level of overall health, symptoms of depression and anxiety, stress, burnout, perceived worksite wellness support, and medical errors. RESULTS: A total of 771 critical care nurses participated in the study. Nurses in poor physical and mental health reported significantly more medical errors than nurses in better health (odds ratio [95% CI]: 1.31 [0.96-1.78] for physical health, 1.62 [1.17-2.29] for depressive symptoms). Nurses who perceived that their worksite was very supportive of their well-being were twice as likely to have better physical health (odds ratio [95% CI], 2.16 [1.33-3.52]; 55.8%). CONCLUSION: Hospital leaders and health care systems need to prioritize the health of their nurses by resolving system issues, building wellness cultures, and providing evidence-based wellness support and programming, which will ultimately increase the quality of patient care and reduce the incidence of preventable medical errors.

Women's Choices Regarding Use of Their Newborns' Residual Dried Blood Samples in Research.

OBJECTIVE: To determine the proportion of informed choices women made about donating their newborns' blood samples for research. DESIGN: A quantitative analysis of informed choice using data on women's knowledge and attitudes from a descriptive, cross-sectional survey. SETTING: The state of Michigan. PARTICIPANTS: Women (N = 69, ≥18 years old) who had (a) newborns 0 to 3 months of age, (b) yes or no decisions regarding use of the blood sample for research on file, (c) no evidence of an infant death in the state database, (d) completed the knowledge scale, (e) completed the attitude scale, and (f) recalled the decision (i.e., yes or no) about donating blood samples. METHODS: We used the multidimensional measure of informed choice to calculate the proportion of informed choices in data on women's knowledge, attitudes, and decisions about biospecimen research. RESULTS: Fifty-five percent (38/69) of participants made informed choices about donating newborn blood samples for research, and 45% made uninformed choices (31/69). Inadequate knowledge about biospecimen research contributed to 87% of uniformed choices (27/31). Participants who declined to donate their newborns' blood samples struggled with making decisions consistent with their values. CONCLUSION: Nearly half of the participants made uninformed choices about donating the blood samples of their newborns for research. Women need more information about genetics and the storage and research use of newborns' blood samples to make informed choices. Nurses need to be made aware of the ethical, legal, and social implications of such research because they are primary sources of advocacy, information, and support for childbearing women and may be charged with overseeing or obtaining informed consent. Additional research with larger, more diverse samples is needed.

Using Narratives to Correct Forecasting Errors in Pediatric Tracheostomy Decision Making.

PURPOSE: Parents who face goals-of-care tracheostomy decisions may lack an understanding of challenges affecting their child's and family's long-term quality of life (QOL) to accurately forecast possible outcomes for decision making. We sought to examine whether and how parents' narratives of the child's and family's long-term QOL influence parental tracheostomy decisions and forecasting. METHOD: We recruited US adult Amazon Mechanical Turk participants (N = 1966) who self-reported having a child (<6 y old) or planning a pregnancy within 5 y. Participants read a vignette about making a tracheostomy decision for their hypothetical neurologically impaired baby. They were randomized to 1 of the following 4 conditions: 1) Baby QOL narratives, 2) Family QOL narratives, 3) Baby QOL + Family QOL narratives, and 4) control: no narratives. They then made a decision about whether or not to pursue tracheostomy, forecasted their concerns about the baby's and family's QOL, reported their values and social norm beliefs about tracheostomy, comfort care, and parental medical decision making, and completed individual differences scales and demographics. RESULTS: Controlling for individual characteristics, participants in the Baby QOL and Baby QOL + Family QOL conditions were less likely to choose tracheostomy as compared with the control (odds ratio [OR] = 0.38 and 0.25, respectively, P < 0.001). Fewer participants in the Family QOL condition chose tracheostomy compared with the control, but this difference was not statistically significant (OR = 0.70, P = 0.11). Moreover, narratives increased pessimistic forecasting, which was associated with less interest in tracheostomy. CONCLUSION: Narratives clarifying long-term implications of pursuing tracheostomy have the potential to influence forecasting and decisions. Narrative-based interventions may be valuable in other situations in which forecasting errors are common.

Nurse competencies for transitions of care: Implications for education and practice.

Although there are a number of transitions of care initiatives that address specific needs as patients move across healthcare settings, adverse events still occur during handoffs. Transitions of care create periods of vulnerability for populations with complex needs that include communication gaps, medication changes, and poorly coordinated treatment plans, often without involving patients and their families. This paper outlines what nurses need to know to provide for safe transitions of care across the healthcare continuum. The theoretical basis for transitions of care at the macro level, examples of nurse-led models for transitions of care, and key activities and implications for nursing education and practice are described. A holistic framework for effective transitions of care across healthcare settings can guide nursing educators in the development of specific nursing competencies for transitions of care.

A Pilot Study to Evaluate a Computer-Based Intervention to Improve Self-care in Patients With Heart Failure.

BACKGROUND: Cognitive dysfunction contributes to poor learning and impaired self-care (SC) for patients with heart failure. OBJECTIVES: The aims of this study were to (1) evaluate the feasibility and acceptability of a nurse-led, virtual home-based cognitive training and SC education intervention to support SC and (2) evaluate the relationship between improvements in SC and cognitive change and examine 30-day readmission rates. METHODS: In this 2-phase pilot study, we used a prospective, exploratory design. In phase 1, recruitment criteria and retention issues threatened feasibility and acceptance. Significant modifications were made and evaluated in phase 2. RESULTS: In phase 2, 12 participants were recruited (7 women and 5 men). Feasibility was supported. All participants and the study nurse positively evaluated acceptability of the intervention. Median SC scores improved over time. Thirty-day hospital readmission rates were 25%. CONCLUSION: Phase 1 indicates the intervention as originally designed was not feasible or acceptable. Phase 2 supports the feasibility and acceptability of the modified intervention. Further testing is warranted.

An eye toward the future: Pressing questions for our discipline in today's academic and research climate.

This paper seeks to open a dialogue concerning the current trend in hiring non-nurse faculty (NNF) to tenure track positions in schools/colleges of nursing. The evolution of non-nurses as faculty, including a review of contemporary papers in affecting this trend, is offered. Three means of involving non-nurses in advancing our discipline are presented. The impact of the growing trend of NNF is discussed relative to the integrity of our discipline and effects on education. We conclude by suggesting a manner of proceeding and raise questions for furthering dialogue.

Prevention of Complications in the Cardiac Intensive Care Unit: A Scientific Statement From the American Heart Association.

Contemporary cardiac intensive care units (CICUs) have an increasing prevalence of noncardiovascular comorbidities and multisystem organ dysfunction. However, little guidance exists to support the development of best-practice principles specific to the CICU. This scientific statement evaluates strategies to avoid the potentially preventable complications encountered within contemporary CICUs, focusing on those that are most applicable to the CICU environment. This scientific statement reviews evidence-based practices derived in non-CICU populations, assesses their relevance to CICU practice, and highlights key knowledge gaps warranting further investigation to attenuate patient risk.

Improving the care and health of populations through optimal use of clinical nurse specialists.

Patients with complex and chronic illnesses and those who have significant needs related to care coordination and transitions of care are dependent on access to healthcare providers who are skilled at meeting the distinct needs of these populations and are current in the latest evidence-based practices and guidelines. Clinical nurse specialists (CNSs) are uniquely qualified to care for patients with complex illnesses as well as having the skills to optimize care for entire populations with complex needs. The absence of consistent legislative advanced practice registered nurse recognition of CNSs prevents health care systems from optimal use of this advanced practice registered nurse role to improve and provide safe and quality care for these patients. Additional barriers in optimal utilization of CNSs include lack of consistency: in title protection and licensing from state to state; ensuring patient access through identification and tracking of CNS numbers across the United States in order to determine workforce and educational program requirements; and ensuring appropriate reimbursement for care provided by CNSs. Therefore, it is the position of the American Academy of Nursing that addressing public and private sector regulatory, legislative, and policy concerns related to CNSs is essential to achieving optimal population health outcomes across the nation.

Development and usability testing of Understanding Stroke, a tailored life-sustaining treatment decision support tool for stroke surrogate decision makers.

BACKGROUND: Surrogate decision makers of stroke patients are often unprepared to make critical decisions on life-sustaining treatments. We describe the development process and key features for the Understanding Stroke web-based decision support tool. METHODS: We used multiple strategies to develop a patient-centered, tailored decision aid. We began by forming a Patient and Family Advisory Council to provide continuous input to our multidisciplinary team on the development of the tool. Additionally, focus groups consisting of nurses, therapists, social workers, physicians, stroke survivors, and family members reviewed key elements of the tool, including prognostic information, graphical displays, and values clarification exercise. To design the values clarification exercise, we asked focus groups to provide feedback on a list of important activities of daily living. An ordinal prognostic model was developed for ischemic stroke and intracerebral hemorrhage using data taken from the Virtual International Stroke Trials Archive Plus, and incorporated into the tool. RESULTS: Focus group participants recommended making numeric prognostic information optional due to possible emotional distress. Pie charts were generally favored by participants for graphical presentation of prognostic information, though a horizontal stacked bar chart was also added due to its prevalence in stroke literature. Plain language descriptions of the modified Rankin Scale were created to accompany the prognostic information. A values clarification exercise was developed consisting of a list of 13 situations that may make an individual consider comfort measures only. The final version of the web based tool (which can be viewed on tablets) included the following sections: general introduction to stroke, outcomes (prognostic information and recovery), in-hospital and life-sustaining treatments, decision making and values clarification, post-hospital care, tips for talking to the health care team, and a summary report. Preliminary usability testing received generally favorable feedback. CONCLUSION: We developed Understanding Stroke, a tailored decision support tool for surrogate decision makers of stroke patients. The tool was well received and will be formally pilot tested in a group of stroke surrogate decision makers. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT03427645 ).

Sexual Orientation and Hypertension Risk Reduction Behaviors Among Adults with High Blood Pressure.

INTRODUCTION: Hypertension is a significant modifiable risk factor for cardiovascular disease (CVD), the leading cause of death in the U.S. Evidence is emerging showing disparities in CVD risk between sexual minorities and heterosexuals. Engagement in CVD risk reduction behaviors may account for differences. We examined CVD risk reduction for hypertension between sexual minorities and heterosexuals using data from the 2017 Behavioral Risk Factor Surveillance System. METHODS: Using bivariate and multivariable logistic regression analyses, we compared medical advice and actions taken (taking medicine, changing eating habits, cutting down on sale, reducing alcohol and exercising) to control blood pressure in sexual minority and heterosexual respondents. Analyses were conducted in 2019. RESULTS: Approximately 35% of the sample indicated being told by a health professional they had high blood pressure. Sexual minorities were less likely to report reduced alcohol intake to lower their blood pressure (AOR=.515, 95% CI=.300, .883). One sex specific difference between sexual minority women and heterosexual women was found; sexual minority women were less likely to indicate being advised by a health professional to take medications to lower blood pressure when compared to heterosexual women. CONCLUSIONS: Strategies are needed to reduce alcohol consumption in sexual minority individuals. Uncovering the reasons for the lack of adherence by both sexual minority patients and health care providers can guide future interventions to improve adherence and reduce hypertension as a CVD risk.

Yoga for Cancer-Related Fatigue in Survivors of Hematopoietic Cell Transplantation: A Feasibility Study.

CONTEXT: Cancer-related fatigue (CRF) is one of the most common symptoms experienced by cancer patients after hematopoietic cell transplantation (HCT). Yoga is an approach with supportive evidence to improve CRF in different cancer populations, but to our knowledge, it has not been tested in an adult HCT population. OBJECTIVES: The aim of this study was to evaluate the feasibility of a yoga intervention offered to adult HCT survivors with moderate-to-severe CRF. METHODS: This feasibility study used a single-arm, pretest-posttest design. Adult HCT survivors were enrolled in a six-week restorative yoga intervention that consisted of a one-hour once-weekly class with twice-weekly home practice using a DVD. RESULTS: Twenty participants (13 women and seven men) enrolled in this study with a mean age of 51 years (SD = 12.5). The sample consisted of 19 allogeneic HCT survivors, seven of whom had a history of acute graft-vs.-host disease (GVHD), six with active, extensive chronic GVHD, and one autologous HCT survivor. The accrual acceptance rate was 23.2% (20/86 HCT survivors) and retention rate was 60% (12/20). Overall adherence was 45.4%. No adverse events were reported. CONCLUSION: The results of this study suggest that a restorative yoga intervention in adult HCT survivors is safe and feasible. The incidence of GVHD may have impacted adherence. Strategies to improve accrual acceptance, retention, and adherence are needed.