The use of national collaborative to promote advanced practice registered nurse-led high-value care initiatives.

BACKGROUND: High-value healthcare focuses on improving healthcare to produce cost effective care, however limited information on the role of advanced practice registered nurses (APRNs) exists. PURPOSE: This descriptive report describes APRN-led initiatives implemented as part of a national collaborative promoting the Choosing Wisely® campaign and high-value care measures. METHOD: An APRN national collaborative focuses on developing and implementing high-value care initiatives. Monthly calls, podcasts, and a file sharing platform are used to facilitate the work of the national collaborative. FINDINGS: A total of 16 APRN teams from 14 states are participating and have implemented a number of initiatives to reduce unnecessary testing and treatments, promote appropriate antibiotic use, and promote optimal clinical practices such as mobility for hospitalized elderly patients, among others. DISCUSSION: A national collaborative has proven to be a successful way to engage APRN teams to focus on targeting high-value care and promoting evidence-based practices in clinical care.

Deimplementation of Routine Chest X-rays in Adult Intensive Care Units.

BACKGROUND: Choosing Wisely® is a national initiative to deimplement or reduce low-value care. However, there is limited evidence on the effectiveness of strategies to influence ordering patterns. OBJECTIVE: We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies. DESIGN: We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies. SETTING: The study was performed in the medical intensive care unit (MICU) and cardiovascular intensive care unit (CVICU) of an academic medical center in the United States from October 2015 to June 2016. PARTICIPANTS: The initiative included the staff of the MICU and CVICU (physicians, surgeons, nurse practitioners, fellows, residents, medical students, and X-ray technologists). INTERVENTION COMPONENTS: We utilized provider education, peer champions, and weekly data feedback of CXR ordering rates. MEASUREMENTS: We analyzed the CXR ordering rates and factors facilitating or inhibiting deimplementation. RESULTS: Segmented linear time-series analysis suggested a small but statistically significant decrease in CXR ordering rates in the CVICU (P < .001) but not in the MICU. Facilitators of deimplementation, which were more prominent in the CVICU, included engagement of peer champions, stable staffing, and regular data feedback. Barriers included the need to establish goal CXR ordering rates, insufficient intervention visibility, and waning investment among medical residents in the MICU due to frequent rotation and competing priorities. CONCLUSIONS: Intervention modestly reduced CXRs ordered in one of two ICUs evaluated. Understanding why adoption differed between the two units may inform future interventions to deimplement low-value diagnostic tests.