Development and Implementation of an Escalation Protocol for Internal Medicine Trainees.

Background: Overnight, physicians in training receive less direct supervision. Decreased direct supervision requires trainees to appropriately assess patients at risk of clinical deterioration and escalate to supervising physicians. Failure of trainees to escalate contributes to adverse patient safety events. Objective: To standardize the evaluation of patients at risk of deterioration overnight by internal medicine residents, increase communication between residents and supervising physicians, and improve perceptions of patient safety at a tertiary academic medical center. Methods: A multidisciplinary stakeholder team developed an overnight escalation-of-care protocol for residents. The protocol was implemented with badge buddies and an educational campaign targeted at residents, supervising physicians, and nursing staff. Residents and supervising physicians completed anonymous surveys to assess the use of the protocol; the frequency of overnight communication between residents and supervising physicians; and perceptions of escalation and patient safety before, immediately after ("early postintervention"), and 8 months after ("delayed postintervention") the intervention. Results: Seventy-five (100%) residents participated in the intervention, and 57-89% of those invited to complete surveys at the various time points responded. After the intervention, 82% of residents reported using the protocol, though no change was observed in the frequency of communication between residents and supervising physicians. After the implementation, residents perceived that patient care was safer (early postintervention, 47%; delayed postintervention, 72%; P = 0.02), and interns expressed decreased fear of waking and being criticized by supervising physicians. Conclusion: An escalation-of-care protocol was developed and successfully implemented using a multimodal approach. The implementation and dissemination of the protocol standardized resident escalation overnight and improved resident-perceived patient safety and interns' comfort with escalation.

Percutaneous Decommissioning of a Left Ventricular Assist Device in a Patient With Myocardial Recovery.

A 37-year-old man was referred for consideration of percutaneous decommissioning of a left ventricular assist device (LVAD). Following careful hemodynamic monitoring during pump turn-down and temporary outflow graft occlusion, the LVAD was permanently decommissioned by using a vascular plug to induce thrombosis of the outflow graft. (Level of Difficulty: Advanced.).

Nursing Management of Patients Requiring Acute Mechanical Circulatory Support Devices.

TOPIC: The growing use of acute mechanical circulatory support devices to provide hemodynamic support that has accompanied the increasing prevalence of heart failure and cardiogenic shock, despite significant improvement in the treatment of acute myocardial infarction. CLINICAL RELEVANCE: The critical care nurse plays a crucial role in managing patients receiving acute mechanical circulatory support devices and monitoring for potential complications. PURPOSE: To review the anatomical placement and mechanics of each type of device so that nurses can anticipate patients' hemodynamic responses and avoid complications whenever possible, thereby improving patients' clinical outcomes. CONTENT COVERED: Nursing considerations regarding the intra-aortic balloon pump, the TandemHeart, the Impella, and extracorporeal membrane oxygenation.

Retention Outcomes of New Graduate Nurse Residency Programs: An Integrative Review.

OBJECTIVE: The purpose of this integrative literature review is to examine the effects that nurse residency programs (NRPs) have on the retention of new graduates. BACKGROUND: The Institute of Medicine recommends implementing NRPs and evaluating their effectiveness. Nursing leaders need to understand if an investment in a residency program is beneficial to their organization. METHODS: A database search was performed for research from 2010 to 2016 reporting outcomes of new graduate NRPs relating to retention. RESULTS: In the articles reviewed, the 1-year retention was higher than the national average for new graduate nurses ranging from 74% to 100%. Higher rates were associated with national programs such as the University Hospital Consortium/American Association of Colleges of Nursing or Versant compared with organization-based programs. CONCLUSIONS: NRPs can increase 1-year retention of new graduate nurses. More controlled and comparative studies are needed to evaluate program differences. Nurse leaders need evidence to ascertain which programs are the most effective in supporting retention and return on investment.