Opioid and Nerve Block Administration in Knee Arthroplasty: An Observational Retrospective Evaluation.

AIMS: Increasing opioid-related adverse events and deaths have amplified interest in non-opioid analgesic options. Peripheral nerve blocks (PNBs) are useful in pain management, especially in minimally invasive day surgeries. This evaluation sought to examine patterns of opioid use among adult patients undergoing total knee arthroplasty, stratified by use of PNBs. DESIGN: A retrospective, observational design. SETTINGS: A large tertiary medical center and community hospital in the Inland Northwest. PARTICIPANTS/SUBJECTS: A dataset of 8,493 adult patients undergoing elective total knee arthroplasty, 3,432 of which received a PNB while 5,061 did not. METHODS: A deidentified dataset was obtained to evaluate: (a) opioid use frequency, (b) average morphine milligram equivalents (MMEs) administered, (c) independent factors associated with opioid administration, and (d) time to first opioid administered in adults undergoing total knee arthroplasty while in the recovery room, stratified by use of PNBs. RESULTS: When controlling for general anesthesia, opioid use frequency was reduced when PNBs were administered (p < .05). The amount of MMEs consumed was 15 mg less in the group receiving a PNB (p < .001). In a linear regression model, PNBs reduced the MMEs consumed by 5 mg (p = .014). Time-to-first opioid was increased in patients receiving general anesthesia and PNBs with a hazards ratio of 0.70 (p < .001). CONCLUSIONS: Peripheral nerve blocks are an opioid-sparing technique in adult patients undergoing total knee arthroplasty. CLINICAL IMPLICATIONS: The results confirm best practices regarding opioid-sparing PNBs. Postoperative opioids are appropriate, but regimens incorporating PNB administration for total knee arthroplasty help reduce opioid use.

Relationships Between Perceived Importance of Chaplain Presence and Health Professionals' Emotional Well-Being in the United States.

Hospital-based chaplains receive specialized training to provide spiritual support to patients and healthcare staff during difficult health transitions. However, the impact of perceived chaplain importance on healthcare staff's emotional and professional well-being is unclear. Healthcare staff (n = 1471) caring for patients in an acute care setting within a large health system answered demographic and emotional health questions in Research Electronic Data Capture (REDCap). Findings suggest that as perceived levels of chaplain importance increase, burnout may decrease and compassion satisfaction may improve. Chaplain presence in the hospital setting may support healthcare staff emotional and professional well-being following occupational stressors including COVID-19-related surges.

Improving Pneumococcal Vaccination Rates among Rural Older Adults through Academic Detailing: Medicine, Nursing and Pharmacy Partnership.

Academic detailing is an educational approach involving provision of evidence-based information by healthcare providers for healthcare providers with the goal of improving clinical decision-making. An interprofessional academic detailing initiative was developed to encourage rural providers to utilize guidelines when deciding which patients to vaccinate against pneumonia. This study utilized a quasi-experimental, single-group, pre-post observational design with physicians, nurses, and staff at two rural medical clinics. The 12-month academic detailing intervention included a needs assessment, workflow assessment of practice-based health information technology, vaccination training for providers and staff, and creation of exam-room posters encouraging patients to discuss vaccination with their provider. Six visits were made to deliver education, discuss needs, select priorities, and develop action plans from recommendations. Data were collected from each site for three years prior to the intervention year and for one year following the intervention. The annual rate of patients vaccinated increased during the five-year study. The cumulative proportion of the sample population that received vaccination also increased over time. Interprofessional academic detailing was well received and increased pneumococcal vaccination rates among rural-dwelling older adults. Given the alarming disparities in health outcomes for rural patients, educational outreach is needed to improve healthcare access and outcomes.

Engagement With the Plan of Care Among Older Adults With Multiple Cardiac Diagnoses.

Aging adults depend on complex treatment plans to manage chronic conditions, yet little is known about their ability to perform the sophisticated behaviors required of technologically engaged patients. This qualitative descriptive study describes engagement with the plan of care. Forty chronically ill adults participated in this study, which involved an observation of the clinical encounter and an interview. Data were collected and analyzed simultaneously in keeping with principles of qualitative research. Multiple techniques were used to test conclusions and findings were constructed as thematic sentences, including the following: I act in ways that support my health, I manage my health-related information, I make visits with my doctor part of my routine, I participate in treatment planning. Older adults work to achieve self-management to the best of their ability, shunning the use of health information technology (HIT) and demonstrating a preference for provider-created treatment plans.

Disability stories: personal perspectives of people with disabilities on navigating the U.S. health system.

Americans with disabilities and chronic illness or injury tend to be in poorer health, use more health services, and pay more for healthcare than those without disabilities. Consequently, their lives can be profoundly affected by federal and state health policies. The concerns of this population do not figure prominently in national health policy discourse and related public health and health services research efforts. This study sought to give voice to the lived experiences of people with disabilities as they navigate a fragmented U.S. healthcare system. We interviewed 30 adults who self-identified as having a disability and spoke or otherwise communicated in the English language. Directed content analysis was used to examine words and phrases in professionally transcribed documents by experienced qualitative researchers. We report and discuss four themes from the perspective of the participant, presented in thematic statements, related to vocation, finances, stressors, and advocacy.

Perspectives of Aging Adults Who Frequently Seek Emergency Department Care.

BACKGROUND: The number of people managing chronic conditions is growing with the rapidly aging population. Visits to the emergency department are steadily rising, but little is known about the rationale of those seeking emergent care. AIMS: The goal of this study was to better understand, from the patients' perspective, the reasons for seeking care in an emergency department setting. DESIGN: A qualitative descriptive design was used to interview aging adults with at least two chronic conditions who made three or more visits to the emergency department within a year. PARTICIPANTS/SUBJECTS: The eight-person sample was 88% female and 75% white, with an average age of 54 years. METHODS: Participant interviews were conducted with a semistructured interview guide. Conventional content analysis was used to examine words and phrases in professionally transcribed documents. Qualitative methods for testing and confirming conclusions were performed. RESULTS: We discovered that aging adults visit the emergency department to seek relief from unrelenting pain and to overcome barriers to receiving treatment for pain in ambulatory settings. Participants reported feeling judged when seeking emergency department care for pain management. CONCLUSIONS: Participants described emergency department care as the only option in response to several barriers to healthcare access. Most commonly, emergency department care was sought when relief from persistent or acute pain was required. One way to reduce strain on EDs from pain-related visits is to manage patients with persistent pain more proactively in their community environment.

Study Behaviors Associated with Student Pharmacists' Academic Success in an Active Classroom Pharmacy Curriculum.

Objective. To identify the specific study behaviors that promoted student pharmacists' success in an active-learning pharmacy curriculum. Methods. The Washington State University College of Pharmacy and Pharmaceutical Sciences implemented an active-learning, flipped classroom model for instruction to equitably deliver course content to Doctor of Pharmacy students on both its main and extended campuses. Students' ability to adapt to the new model and its impact on their study behaviors were unknown. A qualitative descriptive design that included semi-structured interviews was applied to evaluate the study behaviors of high-performing students. The study sample included 13 third and fourth professional year pharmacy students in the top 20% of their respective classes. Results. Interview responses were unaffected by baseline demographics such as gender and year of graduation. Content analysis generated five primary themes related to the behavioral strategies used by high performers: preparing for class, preparing for testing, seeking help, knowing yourself, and building on strengths. These were mapped to the four tenants of Wenger's social learning theory in the representation of findings: learning as doing, learning as belonging, learning as becoming, and learning as experience. Conclusion. High-performing students demonstrated a refined ability to select and modify study behaviors that aided in their academic success, demonstrating a high degree of metacognition. The results of this research may assist pharmacy faculty members in identifying critical elements for success of students enrolled in pharmacy programs using an active learning model.

Influencing outcomes with automated time zero for sepsis through statistical validation and process improvement.

BACKGROUND: Sepsis is a life threating complication of infection acquired by more than 1.5 million people in the United State annually. Each year, sepsis claims the lives of at least 250,000 people. Real-time, automated surveillance for sepsis among hospitalized patients is of critical importance, given that one in three people who die in hospitals have sepsis. The early identification and treatment of sepsis is associated with reduced mortality and costly intensive care bed days. The objective of this analysis was to improve the performance of an electronic medical record based sepsis algorithm (early identification) and improve evidence based bundle compliance (early intervention) with the addition of a real-time, automated time zero calculation. METHODS: Data from our enterprise-wide health information systems were landed in a data lake platform and was used to statistically validate existing sepsis algorithms. An additional algorithm calculating time zero was introduced and a post-hoc comparison of measures of test performance, alert timing, bundle compliance, ICU length of stay, and all-hospital mortality were performed. RESULTS: A total of 55,918 alerts for sepsis were generated over the one-year study period across 30 inpatient facilities. The addition of an automated time zero algorithm improved several key indicators including superior positive predictive value (37% to 52%), enhanced timing of the alert (79% occurred within six hours, 77% within the critical 180-minute SEP-1 window, 47% within an hour of time zero), a 14% increase in bundle compliance, a 10% reduction in ICU length of stay, and a decrease in mortality from sepsis. CONCLUSIONS: The addition of a real-time, automated sepsis time zero calculation improved the performance and timeliness of a predictive sepsis alert provided through a system developed mobile application for clinicians and administrators. KEYWORDS: Sepsis; validation studies; decision making; computer assisted.

Provider Education About Pneumococcal Vaccination Practices for Older Adults.

OBJECTIVE: To describe an interdisciplinary academic detailing project implemented to address low pneumococcal immunization rates. SETTING: Two medical clinics and four community pharmacies in rural Washington state. PRACTICE DESCRIPTION: The two medical clinics and four community pharmacies were all located in two rural counties and serve geographically large rural areas. PRACTICE INNOVATION: Academic detailing is an evidence-based approach designed to change clinical practice and improve decision-making. Our team utilized the academic detailing model to provide educational outreach to local rural health care providers. The detailing team visited each clinic and pharmacy on a defined schedule and provided information to physicians, clinic administrators, nurses, pharmacists, pharmacy technicians, medical assistants, and clinic front-end staff. MAIN OUTCOME MEASUREMENTS: The project team maintained detailed field notes from each academic detailing the visit and met to debrief about each encounter. From the field notes, through the process of thematic analysis and analytic memoing, the project team produced a list of "lessons learned" that could be used to guide other interprofessional teams wishing to embark on an academic detailing project. RESULTS: We have identified four key "lessons learned": Interprofessional team members bring different strengths to the project; using same-discipline team members paved the way for success; involving students aids in educating future practitioners in interprofessional practice; and scheduling meetings in advance is important. CONCLUSION: We described an approach to enhanced academic detailing using interprofessional team delivery, bringing interprofessional practice into the real-world practice setting.

The Impact of Communication Surrounding Intrauterine Congenital Anomaly Diagnoses: An Integrative Review.

Congenital anomalies are the leading cause of infant death in the United States, accounting for 20% of the annual infant mortality. Advancements in ultrasound diagnostic technology allow practitioners to diagnose fetal anomalies as early as 11 weeks' gestational age, 75% of which are detected in low-risk pregnancies. Communicating a fetal anomaly diagnosis to parents and initiating perinatal end-of-life discussions are difficult for healthcare providers and parents alike. Furthermore, poorly communicated diagnoses have had long-term negative impacts on perinatal grief intensity, which can manifest into lifelong symptoms of adverse psychosocial outcomes such as anxiety, depression, substance abuse, and suicidal ideation. The purpose of this integrative review is to examine the impact of communication in discussing an intrauterine diagnosis of a fetal congenital anomaly on perinatal grief. An integrative review was conducted following the distinct 5-stage process of problem identification, searching the literature, evaluating data, analyzing, and presenting findings. A systematic literature review using the PICO model (Population, Intervention, Comparison, Outcome) and structured after the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). This framework was completed between November 2017 and May 2018 using PubMed, CINAHL, and PsycINFO databases. Of the 931 article results, 15 satisfied search criteria. Emerging themes included parental need for appropriate time to assimilate and understand the diagnosis, freedom to explore options and alternatives, and the need for clinicians with expert communication skills. The initial conversation communicating the diagnosis of a congenital anomaly impacts expectant parents for the remainder of their lives. Healthcare professionals are in a unique position to either positively or negatively impact the intensity of perinatal grieving reactions. The application of empathetic, sensitive communication may offer solace and promote healing surrounding perinatal end-of-life discussions.

Assessing Pneumococcal Vaccination Availability in Under-Vaccinated Rural Counties: A Pharmacy Perspective.

OBJECTIVE: Vaccines are a low-cost, high-impact interventions that effectively and efficiently reduce the burden of infectious diseases. Many rural populations have vaccination rates well below nationally recommended levels. Community pharmacies may offer a solution to this problem. Under a collaborative drug therapy agreement (CDTA), pharmacists can prescribe and administer immunizations. The purpose of this study was to examine pneumococcal vaccine access in rural pharmacies in Eastern Washington state. DESIGN: A qualitative descriptive design was utilized in this study. The sample included all pharmacies located in two rural Washington state counties. Interviews were conducted with pharmacy staff. Every pharmacy in the two counties was surveyed over the telephone. Data analysis included directed content analysis and descriptive statistics. FINDINGS: Each of the 10 pharmacies identified participated. Pharmacy volume varied (weekly prescription counts of 300 to 2,500). Sixty percent of pharmacies currently provide vaccines. Quoted prices of the PCV13 varied between $65 and $228. Quoted prices of the PPSV23 varied between $64 and $120. Pharmacies that vaccinated made it convenient with "walk-in" scheduling practices. Some pharmacies required a prescription from a separate provider while others could prescribe on-site through CDTA. Pharmacies that chose not to vaccinate did so for a variety of reasons. CONCLUSIONS: Access to pneumococcal vaccines will be enhanced by pharmacist administration, resulting in improved availability, accessibility, accommodation, affordability, and acceptability for patients in rural Washington.

Preferences of older adults and their families for Meaningful Use clinical summaries.

BACKGROUND: This study assessed the perceptions of older adults regarding the plan of care (POC) contained in the clinical summary mandated by the Electronic Health Records (EHR) Incentive Program. METHODS: A qualitative descriptive design was selected for this study. Older adults (≥65) with chronic cardiac diagnoses were invited to participate. The investigator shadowed the physician during the patient encounter, interviewed the patients following their encounter, and asked patients to complete standard health literacy and cognitive screening tools and the Patient Activation Measure. Directed content analysis was used to analyze transcripts. RESULTS: Patients (n=40) found the clinical summary useful for sharing information with family members and other physicians, reminding and informing, and for engaging in behavior change. Seventy-six percent reported that they would not go online to access the clinical summary for multiple reasons, including not being "computer savvy" and privacy concerns. Participant recommendations for a re-designed, improved clinical summary are included. The clinical summary helps patients and families communicate among health care professionals in a complex, disjointed health care system that often burdens patients with that responsibility. The majority of participants were happy with the paper version and offered multiple reasons for not wanting online access that may help us to focus on more compelling reasons for patient portal use. CONCLUSIONS: Qualitatively, it appears that the clinical summary is a useful tool for engaging people with chronic disease in self-management. The participants in this study told us what many of us already know to be true; that the documentation we provide patients and families is less than ideal.

The Reliability of Electronic Health Record Data Used for Obstetrical Research.

BACKGROUND: Hospital electronic health record (EHR) data are increasingly being called upon for research purposes, yet only recently has it been tested to examine its reliability. Studies that have examined reliability of EHR data for research purposes have varied widely in methods used and field of inquiry, with little reporting of the reliability of perinatal and obstetric variables in the current literature. OBJECTIVE: To assess the reliability of data extracted from a commercially available inpatient EHR as compared with manually abstracted data for common attributes used in obstetrical research. METHODS: Data extracted through automated EHR reports for 3,250 women who delivered a live infant at a large hospital in the Pacific Northwest were compared with manual chart abstraction for the following perinatal measures: delivery method, labor induction, labor augmentation, cervical ripening, vertex presentation, and postpartum hemorrhage. RESULTS: Almost perfect agreement was observed for all four modes of delivery (vacuum assisted: kappa = 0.92; 95% confidence interval [CI] = 0.88-0.95, forceps assisted: kappa = 0.90; 95%CI = 0.76-1.00, cesarean delivery: kappa = 0.91; 95%CI = 0.90-0.93, and spontaneous vaginal delivery: kappa = 0.91; 95%CI = 0.90-0.93). Cervical ripening demonstrated substantial agreement (kappa = 0.77; 95%CI = 0.73-0.80); labor induction (kappa = 0.65; 95%CI = 0.62-0.68) and augmentation (kappa = 0.54; 95%CI = 0.49-0.58) demonstrated moderate agreement between the two data sources. Vertex presentation (kappa = 0.35; 95%CI = 0.31-0.40) and post-partum hemorrhage (kappa = 0.21; 95%CI = 0.13-0.28) demonstrated fair agreement. CONCLUSION: Our study demonstrates variability in the reliability of obstetrical data collected and reported through the EHR. While delivery method was satisfactorily reliable in our sample, other examined perinatal measures were less so when compared with manual chart abstraction. The use of multiple modalities for assessing reliability presents a more consistent and rigorous approach for assessing reliability of data from EHR systems and underscores the importance of requiring validation of automated EHR data for research purposes.

Assessing the value of the Meaningful Use Clinical Summary for patients and families with pediatric asthma.

Electronic clinical summaries are innovations supported by the Electronic Health Record Incentive Program, known as "Meaningful Use" (MU). The MU clinical summary documents the shared understanding of the plan of care for patients and assists families in managing asthma-related health care. The purpose of this analysis was to identify the communicative value of the summaries to patients and families. Readability measurements, content analysis, and descriptive statistics were employed in a review of twenty clinical summaries and compared with provider encounter notes. The average age of the patients from whom we collected clinical summaries was six years old. The average reading level of the summaries was ninth grade. Neither summaries nor health education contained visual images. There was a total of nine different asthma diagnoses. A full list of diagnoses was present in 45% of summaries. The average medications per patient was 5.75, and there were multiple medication changes noted (dosage adjustment, add, discontinued). Allergies, vital signs, and smoking status were reliably reported (99-100%). Provider orders present included medication, follow up, and return to the clinic instructions. The plan of care was replicated on 45% of summaries. There was variable reporting of various asthma guidelines. Opportunities to improve the clinical summary include using plain language to promote readability, action, understanding, and health literacy, training providers to standardize their documentation and include asthma action plans, and configuring EHR settings to ensure diagnoses and plan of care is carried over from provider notes to the summary.

It's Time for Innovation in the Health Insurance Portability and Accountability Act (HIPAA).

Whether it is the result of a tragic news story, a thoughtful commentary, or a segment on the entertainment networks, patient privacy rights are never far from the top of our minds. The Privacy and Security Rules contained in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) represent a concerted effort to protect the privacy and security of the volumes of patient data generated by the health care system. However, the last twenty years has seen innovations and advancements in health information technology that were unimaginable at that time. It is time for innovation to the Privacy and Security Rules. We offer a common and relatable scenario as proof that certain Privacy and Security Rules can tie the hands of educators and innovators and need to be transformed.

Qualitative Descriptive Methods in Health Science Research.

OBJECTIVE: The purpose of this methodology paper is to describe an approach to qualitative design known as qualitative descriptive that is well suited to junior health sciences researchers because it can be used with a variety of theoretical approaches, sampling techniques, and data collection strategies. BACKGROUND: It is often difficult for junior qualitative researchers to pull together the tools and resources they need to embark on a high-quality qualitative research study and to manage the volumes of data they collect during qualitative studies. This paper seeks to pull together much needed resources and provide an overview of methods. METHODS: A step-by-step guide to planning a qualitative descriptive study and analyzing the data is provided, utilizing exemplars from the authors' research. RESULTS: This paper presents steps to conducting a qualitative descriptive study under the following headings: describing the qualitative descriptive approach, designing a qualitative descriptive study, steps to data analysis, and ensuring rigor of findings. CONCLUSIONS: The qualitative descriptive approach results in a summary in everyday, factual language that facilitates understanding of a selected phenomenon across disciplines of health science researchers.

Connected health: a review of the literature.

The presence of social support, and more recently, connection, has been linked to multiple health benefits and longevity measures and the lack of connection is associated with premature morbidity and mortality. Connected health is a growing industry, and we were interested in determining whether or not scholars in the field have established the ways in which technology could facilitate or promote connection between patients and healthcare providers. This integrative literature review sought to collect and analyze research studies addressing social support or connection in a sample of patients with diabetes to evaluate the social support or connection metrics in use, the type of technology deployed by researchers to achieve connection, and to assess the state of the science in this area. We hypothesized that being connected to someone who cares is good for your health. We believe this holds true even when connection is accomplished with mobile technologies. Thirty five studies were included in this review, 21 utilized technology to enhance patient-provider connection. The articles included in this review were from a total of more than nine countries and took place in hospital, physician office, and community settings. They represented people from childhood through to old age. Technologies evaluated include: telephone interventions, email, text messaging, interactive voice response (IVR), video blogs, apps, websites, and social media. There were multiple operational definitions of social support and self-management used as variables within the studies. Findings from this review suggest that being connected does matter to patients with diabetes, and being connected to family matters the most, even though the associations are complex and not always predictable. Furthermore, patients with diabetes will utilize a variety of technologies to connect with healthcare providers, team members, and even other people with the same disease. The use of technology with diabetes patients positively impacts a variety of health outcomes, such as HbA1c, weight, physical activity, healthy eating, cholesterol and frequency of glycemic monitoring.

Cost analysis of a home-based nurse care coordination program.

OBJECTIVES: To determine whether a home-based care coordination program focused on medication self-management would affect the cost of care to the Medicare program and whether the addition of technology, a medication-dispensing machine, would further reduce cost. DESIGN: Randomized, controlled, three-arm longitudinal study. SETTING: Participant homes in a large Midwestern urban area. PARTICIPANTS: Older adults identified as having difficulty managing their medications at discharge from Medicare Home Health Care (N = 414). INTERVENTION: A team consisting of advanced practice nurses (APNs) and registered nurses (RNs) coordinated care for two groups: home-based nurse care coordination (NCC) plus a pill organizer group and NCC plus a medication-dispensing machine group. MEASUREMENTS: To measure cost, participant claims data from 2005 to 2011 were retrieved from Medicare Part A and B Standard Analytical Files. RESULTS: Ordinary least squares regression with covariate adjustment was used to estimate monthly dollar savings. Total Medicare costs were $447 per month lower in the NCC plus pill organizer group (P = .11) than in a control group that received usual care. For participants in the study at least 3 months, total Medicare costs were $491 lower per month in the NCC plus pill organizer group (P = .06) than in the control group. The cost of the NCC plus pill organizer intervention was $151 per month, yielding a net savings of $296 per month or $3,552 per year. The cost of the NCC plus medication-dispensing machine intervention was $251 per month, and total Medicare costs were $409 higher per month than in the NCC plus pill organizer group. CONCLUSION: Nurse care coordination plus a pill organizer is a cost-effective intervention for frail elderly Medicare beneficiaries. The addition of the medication machine did not enhance the cost effectiveness of the intervention.