Hospital Readmission and Costs of Total Knee Replacement Surgery in 2009 and 2014: Potential Implications for Health Care Managers.

The purpose of this article is to describe changes in hospital readmissions and costs for US hospital patients who underwent total knee replacement (TKR) in 2009 and 2014. Data came from the Healthcare Cost and Utilization Project net-Nationwide Readmissions Database. Compared with 2009, overall 30-day rates of readmissions after TKR decreased by 15% in 2014. Rates varied by demographics: readmission rates were lower for younger patients, males, Medicare recipients, and those with higher incomes. Overall, costs rose 20% across TKR groups. This report is among the first to describe changes in hospital readmissions and costs for TKR patients in a national sample of US acute care hospitals. Findings offer hospital managers a mechanism to benchmark their facilities' performances.

Reducing RN Vacancy Rate: A Nursing Recruitment Office Process Improvement Project.

OBJECTIVE: The aim of this study was to reduce the RN vacancy rate at an academic medical center by improving the hiring process in the Nursing Recruitment Office. BACKGROUND: Inability to fill RN positions can lead to higher vacancy rates and negatively impact staff and patient satisfaction, quality outcomes, and the organization's bottom line. METHODS: The Model for Improvement was used to design and implement a process improvement project to improve the hiring process from time of interview through the position being filled. RESULTS: Number of days to interview and check references decreased significantly, but no change in overall time to hire and time to fill positions was noted. RN vacancy rate also decreased significantly. Nurse manager satisfaction with the hiring process increased significantly. CONCLUSION: Redesigning the recruitment process supported operational efficiencies of the organization related to RN recruitment.

Hospital Readmission in Total Hip Replacement Patients in 2009 and 2014.

OBJECTIVE: To document changes in 30-day hospital readmission rates and causes for returning to the hospital for care in THR patients. DESIGN: Retrospective cross-sectional descriptive design. SETTING: Community-based acute care hospitals. PARTICIPANTS: Total sample size (N=142,022) included THR patients (identified as ICD-9-CM procedure code 81.51) in 2009 (n=31,232) and (n=32,863) in 2014. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: 30-Day hospital readmission. RESULTS: The overall readmission rate decreased by 1.3% from 2009 to 2014. The decrease in readmission rates varied by groups, with lesser improvements seen in THR patients who were younger, with private insurance, and residing in lower-income and rural communities. Device complications were the leading cause of readmission in THR patients, increasing from 19.8% in 2009 to 23.9% in 2014. CONCLUSIONS: There has been little decrease in hospital 30-day readmission rates for US community hospitals between 2009 and 2014. Findings from this brief report indicate patient groups at greater risk for 30-day hospital readmission as well as leading causes for readmission in THR patients which can inform the development of tailored interventions for reduction.

Improving Quality and Safety Through Use of Secondary Data: Methods Case Study.

Researchers need to evaluate the strengths and weaknesses of data sets to choose a secondary data set to use for a health care study. This research method review informs the reader of the major issues necessary for investigators to consider while incorporating secondary data into their repertoire of potential research designs and shows the range of approaches the investigators may take to answer nursing research questions in a variety of context areas. The researcher requires expertise in locating and judging data sets and in the development of complex data management skills for managing large numbers of records. There are important considerations such as firm knowledge of the research question supported by the conceptual framework and the selection of appropriate databases, which guide the researcher in delineating the unit of analysis. Other more complex issues for researchers to consider when conducting secondary data research methods include data access, management and security, and complex variable construction.

Intrahospital Transport of the Critically Ill Adult: A Standardized Evaluation Plan.

BACKGROUND: Intrahospital transport of the critically ill adult carries inherent risks that can be manifested as unexpected events. OBJECTIVE: The aim of this study is to evaluate the implementation of a standardized evaluation plan for intrahospital transports to/from adult intensive care units. METHODS: Nurses at a level I trauma/academic center captured clinical data throughout transport. Outcome measures included compliance with the organization's transport policy and unexpected events. RESULTS: There were 502 transports audited. Most nurses were compliant with the policy, except for the stabilization process (n = 174, 34.7%). Forty-one transports (8.2%) had an unexpected event, and 11 of these transports (26.8%) were aborted. Most of the events were hemodynamic (12), sedation (11), respiratory (10), and gastrointestinal (5). Fewer events occurred with the transport team (P = .036) and among nurses with a bachelor of science in nursing or higher degree (P = .002). Events were higher among transporting nurses with only 0 to 2 years of intensive care unit experience (P = .002), "stabilized" transports (P = .022), and patients with higher Acute Physiology and Chronic Health Evaluation scores (P = .009). CONCLUSIONS: Health care organizations should have a policy that includes both transport and evaluation plans for intrahospital transport. Guidelines should be revised with specific criteria for the stabilization process and unexpected events. Revision should also have a standardized evaluation plan that includes an audit tool to measure incidence of unexpected events and a rapid change quality improvement method.

Design and evaluation of a prelicensure interprofessional course on improving care transitions.

Effective management of care transitions for older adults require the coordinated expertise of an interprofessional team. Unfortunately, different health care professions are rarely educated together or trained in teamwork skills. To address this issue, a team of professionally diverse faculty from the Duke University Geriatric Education Center designed an interprofessional course focused on improving transitions of care for older adults. This innovative prelicensure course provided interactive teaching sessions designed to promote critical thinking and foster effective communication among health care professionals, caregivers, and patients. Students were assessed by in-class and online participation, performance on individual assignments, and team-based proposals to improve care transitions for older patients with congestive heart failure. Twenty students representing six professions completed the course; 18 completed all self-efficacy and course evaluation surveys. Students rated their self-efficacy in several domains before and after the course and reported gains in teamwork skills (p < .001), transitions of care (p < .001), quality improvement (p < .001) and cultural competence (p < .001). Learner feedback emphasized the importance of enthusiastic and well-prepared faculty, interactive learning experiences, and engagement in relevant work. This course offers a promising approach to shifting the paradigm of health professions education to empower graduates to promote quality improvement through team-based care.

Cascade iatrogenesis: a case-control study to detect postoperative respiratory failure in hospitalized older adults.

During hospitalization, older adults are at high risk for cascade iatrogenesis, the serial development of complications. In this retrospective, descriptive, case-control pilot study, 28 patients (cases) who developed respiratory failure after an elective surgical procedure were compared to 28 matched controls who did not develop postoperative respiratory failure. The type, frequency, and timing of events that preceded the development of postoperative respiratory failure in hospitalized older adults (age 65 and older) and the presence and timing of similar events for matched controls during a postoperative period of the same length were recorded. Cases experienced certain trigger events, including atelectasis and fluid overload, at significantly higher rates than controls. Cases and controls experienced similar rates of oversedation and delirium, yet controls were less likely to aspirate following these episodes. Patients who developed postoperative respiratory failure were less likely to ambulate early and experienced more calls to rapid response or code teams, more transfers to higher levels of care, longer lengths of stay, and more deaths than matched controls.

Implementation of the Josie King Care Journal in a pediatric intensive care unit: a quality improvement project.

The Care Journal is a tool developed by the Josie King Foundation to promote interactive exchange among providers and patients/families. The Care Journal was implemented in a pediatric intensive care unit, and surveys were administered to assess perceptions about use. Parents who used the Care Journal and nursing staff found it to be a useful tool that improved communication, made parents feel more knowledgeable and empowered, and improved parents' overall perception of the hospital stay.

Can we make postoperative patient handovers safer? A systematic review of the literature.

Postoperative patient handovers are fraught with technical and communication errors and may negatively impact patient safety. We systematically reviewed the literature on handover of care from the operating room to postanesthesia or intensive care units and summarized process and communication recommendations based on these findings. From >500 papers, we identified 31 dealing with postoperative handovers. Twenty-four included recommendations for structuring the handover process or information transfer. Several recommendations were broadly supported, including (1) standardize processes (e.g., through the use of checklists and protocols); (2) complete urgent clinical tasks before the information transfer; (3) allow only patient-specific discussions during verbal handovers; (4) require that all relevant team members be present; and (5) provide training in team skills and communication. Only 4 of the studies developed an intervention and formally assessed its impact on different process measures. All 4 interventions improved metrics of effectiveness, efficiency, and perceived teamwork. Most of the papers were cross-sectional studies that identified barriers to safe, effective postoperative handovers including the incomplete transfer of information and other communication issues, inconsistent or incomplete teams, absent or inefficient execution of clinical tasks, and poor standardization. An association between poor-quality handovers and adverse events was also demonstrated. More innovative research is needed to define optimal patient handovers and to determine the effect of handover quality on patient outcomes.

Use of a Clinical Decision Support Tool to improve guideline adherence for the treatment of methicillin-resistant Staphylococcus aureus: Skin and Soft Tissue Infections.

Skin and Soft Tissue Infections (SSTI's) with abscess are commonly seen in the Emergency Department (ED) setting. Given the increasing prevalence of methicillin-resistant Staphylococcus-aureus (MRSA)-related abscesses, appropriate evidence-based decisions are essential in assuring successful treatment. Provider adherence to clinical guidelines for the treatment of SSTI's with presumed MRSA remains inconsistent in terms of prescriptive practice related to antibiotic selection, culturing wounds, and patient discharge recommendations regarding the use of infection control techniques. Evidence indicates that the use of Clinical Decision Support (CDS) tools is valuable in improving provider awareness and adherence to clinical guidelines. This study was conducted to examine whether the development of a CDS tool to guide order entry for the treatment of MRSA-related SSTI's and embed it into the electronic medical record program would improve provider adherence to the North Carolina Consensus Guideline for Management of Suspected Commmunity-Acquired MRSA Skin and Soft Tissue.

Design, implementation, and evaluation of population-specific telehealth nursing services.

An implementation project was conducted to introduce a structure for telehealth nursing practice (TNP) which would address the specific needs of complex endocrinology patients in a hospital-based clinic. Outcomes of the pilot study include analysis of 727 advice calls, survey responses from a sample of 101 patients, and feedback from 9 providers. Results support current evidence that disease management needs of chronically ill patients include prescription refills, medication and symptom management, lab results, and patient education. 81.2% of patients rated satisfaction with telehealth nursing services as very high or high. A statistically significant relationship was found between timeliness of response and patient satisfaction. A focus on care coordination provided through telehealth nursing services may emerge as an important element in the care of chronically ill patient populations.

Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units.

Catheter-associated urinary tract infections account for 40% of all health care-associated infections. An evidence-based, nurse-driven daily checklist for initiation and continuance of urinary catheters was implemented in 5 adult intensive care units. Measures of compliance, provider satisfaction, and clinical outcomes were recorded. Compliance with the checklist was 50 to 100%: catheter-associated urinary tract infections decreased from 2.88 to 1.46 per 1000 catheter days and catheter days decreased in 2 intensive care units.

What does quality care mean to nurses in rural hospitals?

AIM: This paper is a report of a study conducted to answer the question: 'How do rural nurses and their chief nursing officers define quality care?' BACKGROUND: Established indicators of quality care were developed primarily in urban hospitals. Rural hospitals and their environments differ from urban settings, suggesting that there might be differences in how quality care is defined. This has measurement implications. METHODS: Focus groups with staff nurses and interviews with chief nursing officers were conducted in 2006 at four rural hospitals in the South-Eastern United States of America. Data were analysed using conventional content analysis. FINDINGS: The staff nurse and chief nursing officer data were analysed separately and then compared, exposing two major themes: 'Patients are what matter most' and 'Community connectedness is both a help and a hindrance'. Along with conveying that patients were the utmost priority and all care was patient-focused, the first theme included established indicators of quality such as falls, pressure ulcers, infection rates, readmission rates, and lengths of stay. A new discovery in this theme was a need for an indicator relevant for rural settings: transfer time to larger hospitals. The second theme, Community Connectedness, is unique to rural settings, exemplifying the rural culture. The community and hospital converge into a family of sorts, creating expectations for quality care by both patients and staff that are not typically found in urban settings and larger hospitals. CONCLUSION: Established quality indicators are appropriate for rural hospitals, but additional indicators need to be developed. These must include transfer times to larger facilities and the culture of the community.

A necessary sea change for nurse faculty development: spotlight on quality and safety.

More than 10 years have passed since the publication of the Institute of Medicine's report, To Err is Human: Building a Safer Health Care System, yet recent reports indicate that significant strides toward transformational improvement in quality and patient safety are still necessary. Real progress toward superior health care quality requires foundational enhancements in health care education. An urgent need exists for undergraduate nursing programs to strengthen quality and safety knowledge in their curricula. A first step in attaining this goal is to equip baccalaureate nursing faculty with the knowledge, skills, and abilities needed to teach these concepts. The first part of this article provides a compelling case for new graduate nurses to have a comprehensive understanding of how quality and safety issues affect patient outcomes. The second part highlights the specific faculty competencies required to teach quality and safety to undergraduate nursing students and offers a framework that faculty can use for professional development in this area. This article is by no means exhaustive but provides a starting point for providing undergraduate nursing faculty with the knowledge, skills, and attitudes necessary to assist students to achieve quality and safety competencies in their curricula.

Increased risk for patient safety incidents in hospitalized older adults.

2004 HCUPnet data indicated that hospitalized patients age 65 and older experience higher rates of patient safety incidents than younger adults for 11 of 13 indicators analyzed; patients over age 85 in particular were susceptible to certain adverse events. In this article, rates of patient safety incidents for hospitalized older adults are described and adverse events for which older adults might be at particular risk are identified.

Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults.

Older adults are at particular risk for injuries associated with hospitalization and the rate of adverse events increases significantly with age. The purpose of this paper is to review factors associated with the development of adverse events in hospitalized older adults, especially those factors that contribute to cascade iatrogenesis. Cascade iatrogenesis is the serial development of multiple medical complications that can be set in motion by a seemingly innocuous first event [Rothschild, J.M., Bates, D.W., Leape, L.L., 2000. Preventable medical injuries in older patients. Archieves of Internal Medicine 160 (October), 2717-2728]. Research has examined how patient characteristics may lead to cascade iatrogenesis, but existing conceptual models and research have not considered the role of nursing care. Using the outcome postoperative respiratory failure as an example, we expand on existing knowledge about factors associated with older adults' risk for developing this complication by presenting a conceptual model of events that may trigger the initial cascade and the nursing care variables that may prevent or mitigate these risks. We believe that this model will help guide research in this area and enable clinicians to identify systemic failures and develop targeted interventions to prevent their occurrence.

Managing to improve quality: the relationship between accreditation standards, safety practices, and patient outcomes.

BACKGROUND: Given the trend toward eliminating reimbursement for "never events," hospital administrators are challenged to implement practices designed to prevent their occurrence. Little evidence exists, however, that patient safety practices, as evaluated using accreditation criteria, are related to the achievement of patient safety outcomes. PURPOSE: The aim of this study was to examine the relationship between patient safety practices, as measured by accreditation standards, and patient safety outcomes as measured by hospital rates of infections, decubitus ulcers, postoperative respiratory failure, and failure to rescue. METHODOLOGY: Secondary data were used to examine relationships between patient-safety-related accreditation standards and patient outcomes in U.S. acute care hospitals. Accreditation performance areas were reduced into subscores to represent patient safety practices. Outcome rates were calculated using the Agency for Healthcare Research and Quality Patient Safety Indicator software. Multivariate regression was performed to determine the significance of the relationships. FINDINGS: Three of four multivariate models significantly explained variance in hospital patient safety indicator rates. Accreditation standards reflecting patient safety practices were related to some outcomes but not others. Rates of infections and decubitus ulcers occurred more frequently in hospitals with poorer performance in utilizing patient safety practices, but no differences were noted in rates of postoperative respiratory failure or failure to rescue. PRACTICE IMPLICATIONS: Certain adverse events, such as infections and decubiti, may be reduced by preventive protocols that are reflected in accreditation standards, whereas other events, such as failure to rescue and postoperative respiratory failure, may require multifaceted strategies that are less easily translated into protocols. Our approach may have influenced the observed associations yet represents progress toward assessing whether safety practices, as measured by accreditation standards, are related to patient outcomes.