Hospital Nurses' Work Activity in a Technology-Rich Environment: A Triangulated Quality Improvement Assessment.

The aim of this project was to describe hospital nurses' work activity through observations, nurses' perceptions of time spent on tasks, and electronic health record time stamps. Nurses' attitudes toward technology and patients' perceptions and satisfaction with nurses' time at the bedside were also examined. Activities most frequently observed included documenting in and reviewing the electronic health record. Nurses' perceptions of time differed significantly from observations, and most patients rated their satisfaction with nursing time as excellent or good.

Impact of nurse-led remote screening and prompting for evidence-based practices in the ICU*.

OBJECTIVES: Evidence-based practices are not consistently applied in the ICU. We sought to determine if nurse-led remote screening and prompting for evidence-based practices using an electronic health record could impact ICU care delivery and outcomes in an academic medical center. DESIGN: Single-center, before-after evaluation of a quality improvement project. SETTING: Urban, academic medical center in the mid-Atlantic United States with eight subspecialty ICUs and 156 ICU beds. PATIENTS: Adult patients admitted to the ICU between January 1, 2011, and August 31, 2012. INTERVENTIONS: Beginning on July 25, 2011, trained ICU nurses screened all ICU patients for selected evidence-based practices on a daily basis. The screening was conducted from a remote office, facilitated by the electronic health record. Selected practices included compliance with a ventilator care bundle, assessment of appropriateness of indwelling venous and urinary catheters, and concordance between sedation orders and documented level of sedation. When gaps were observed, they were communicated to the point-of-care bedside nurse via telephone, page, or facsimile. MEASUREMENTS AND MAIN RESULTS: Fourteen thousand eight hundred twenty-three unique patients were admitted during the study period. We excluded 1,546 patients during a 2-month run-in period from July 1, 2011, to August 31, 2011, resulting in 4,339 patients in the 6-month preintervention period and 8,938 patients in the 12-month postintervention period. Compared with patients admitted in the preintervention period, patients admitted in the postintervention period were more likely to receive sedation interruption (incidence rate ratio, 1.57; 95% CI, 1.45-1.71) and a spontaneous breathing trial (incidence rate ratio, 1.24; 95% CI, 1.20-1.29). Hospital-acquired infection rates were not different between the two periods. Adjusting for patient characteristics and illness severity, patients in the postintervention period experienced shorter duration of mechanical ventilation (adjusted reduction, 0.61 d; 95% CI, 0.27-0.96; p < 0.001), shorter ICU length of stay (adjusted reduction, 0.22 d; 95% CI, 0.04-0.41; p = 0.02), and shorter hospital length of stay (adjusted reduction, 0.55 d; 95% CI, 0.15-0.93; p = 0.006). In-hospital mortality was unchanged (adjusted odds ratio, 0.96; 95% CI, 0.84-1.09; p = 0.54). The results were robust to tests for concurrent temporal trends and coincident interventions. CONCLUSIONS: A program by which nurses screened ICU patients for best practices from a remote location was associated with improvements in the quality of care and reductions in duration of mechanical ventilation and length of stay, but had no impact on mortality.

Utilizing bedside shift report to improve the effectiveness of shift handoff.

Handoff of patient information during shift report between nurses is a time of risk and liability. A quality improvement project was conducted on a 23-bed inpatient unit to measure the value of a bedside change-of-shift report in improving the effectiveness of shift report. Indicators including end-of-shift overtime, call light usage, nurse perceptions, and patient satisfaction were impacted by the change in process.

Good care, good science: leveraging frontline staff for quality.

Health care is changing by moving from volume-based care to quality-based care according to the US Department of Health and Human Services. Although hospitals have been required to report data and the results have been publically reported for some time, the frontline nurse was not aware of the impact of the federal government regulations and how this would refocus and re-center care that is provided. Nursing leaders need to provide the context for this culture shift and support the efforts of the frontline nurses by connecting the evidence of the quality indicators to quality care they provide. Linking good care and good science provides the vehicle for setting this stage.

A relational leadership perspective on unit-level safety climate.

OBJECTIVE: This study compared nursing staff perceptions of safety climate in clinical units characterized by high and low ratings of leader-member exchange (LMX) and explored characteristics that might account for differences. BACKGROUND: Frontline nursing leaders' actions are critical to ensure patient safety. Specific leadership behaviors to achieve this goal are underexamined. The LMX perspective has shown promise in nonhealthcare settings as a means to explain safety climate perceptions. METHODS: Cross-sectional survey of staff (n = 711) and unit directors from 34 inpatient units in an academic medical center was conducted. RESULTS: Significant differences were found between high and low LMX scoring units on supervisor safety expectations, organizational learning-continuous improvement, total communication, feedback and communication about errors, and nonpunitive response to errors. CONCLUSION: The LMX perspective can be used to identify differences in perceptions of safety climate among nursing staff. Future studies are needed to identify strategies to improve staff safety attitudes and behaviors.

A patient-centered model to improve metrics without cost increase: viewing all care through the eyes of patients and families.

The need for patient-centeredness in care delivery has been articulated for decades, yet meaningful progress toward patient-centered healthcare has been hobbled by the lack of a replicable patient-centered care model and method. The authors describe the patient- and family-centered care method, built around viewing every care experience through the eyes of the patient and family, and its outcomes proving the approach is replicable and sustainable while improving outcomes without additional cost. A follow-up article on patient and family shadowing will be published in the January 2011 issue.

Transforming care at the bedside: an ambulatory model for improving the patient experience.

Transforming Care at the Bedside is a nationwide effort to design a model for improving care to hospitalized patients. With the projected growth of ambulatory services, it is increasingly important to focus on potential methods to increase patient satisfaction and care delivery improvement in the outpatient setting, as well. The authors describe the University of Pittsburgh Medical Center Hillman Cancer Center's adaptation of the Transforming Care at the Bedside care delivery improvement model to its ambulatory services arena and its promising results.