Implementing Oral Care as a Nursing Intervention to Reduce Hospital-Acquired Pneumonia Across the United States Department of Veterans Affairs Healthcare System.

Hospital-acquired pneumonia is a preventable complication. The primary source of pneumonia among hospitalized and long-term care residents is aspiration of bacteria present in the oral biofilm. Reducing the bacterial burden in the mouth through consistent oral care is associated with a reduction in the incidence of hospital-acquired pneumonia. Following a significant reduction in pneumonia among non-ventilated patients in the research pilots, the Veterans Health Administration deployed the evidence-based, nurse-led oral care intervention called Hospital Acquired Pneumonia Prevention by Engaging Nurses as quality improvement nationwide. In this article, nursing informatics experts on the team describe the design and implementation of process and outcome measures of Hospital-Acquired Pneumonia Prevention by Engaging Nurses and outline lessons learned. The team used standardized terms and observations embedded within the EHR documentation templates to measure the oral care intervention in acute care areas. They also developed a tracking system for hospital-acquired pneumonia cases among non-ventilated patients. In addition to improving patient safety and care quality, Hospital-Acquired Pneumonia Prevention by Engaging Nurses links evidence-based practice with nursing informatics principles to generate numerous opportunities to measure the value of nursing at the point of care. This initiative was reported using SQUIRE 2.0: Standards for QUality Improvement Reporting Excellence.

Nonventilator hospital-acquired pneumonia: A call to action.

In 2020 a group of U.S. healthcare leaders formed the National Organization to Prevent Hospital-Acquired Pneumonia (NOHAP) to issue a call to action to address non-ventilator-associated hospital-acquired pneumonia (NVHAP). NVHAP is one of the most common and morbid healthcare-associated infections, but it is not tracked, reported, or actively prevented by most hospitals. This national call to action includes (1) launching a national healthcare conversation about NVHAP prevention; (2) adding NVHAP prevention measures to education for patients, healthcare professionals, and students; (3) challenging healthcare systems and insurers to implement and support NVHAP prevention; and (4) encouraging researchers to develop new strategies for NVHAP surveillance and prevention. The purpose of this document is to outline research needs to support the NVHAP call to action. Primary needs include the development of better models to estimate the economic cost of NVHAP, to elucidate the pathophysiology of NVHAP and identify the most promising pathways for prevention, to develop objective and efficient surveillance methods to track NVHAP, to rigorously test the impact of prevention strategies proposed to prevent NVHAP, and to identify the policy levers that will best engage hospitals in NVHAP surveillance and prevention. A joint task force developed this document including stakeholders from the Veterans' Health Administration (VHA), the U.S. Centers for Disease Control and Prevention (CDC), The Joint Commission, the American Dental Association, the Patient Safety Movement Foundation, Oral Health Nursing Education and Practice (OHNEP), Teaching Oral-Systemic Health (TOSH), industry partners and academia.

Nurse practitioner productivity measurement: An organizational focus and lessons learned.

Nurse practitioners (NPs) are valued members of the health care team, and their numbers are growing each year. The volume of literature demonstrating the impact on quality, safety, patient satisfaction, and access measures is substantial and growing. There is a significant lack of measurement methods and outcomes related to NP contributions to organizational productivity. The construction of strategy for measurement of NP productivity is a prerequisite for studies focusing on impact. Models that are being used to measure physician productivity are available to be examined in terms of their applicability to the NP work force. In 2005, the Deputy Under Secretary for Health for Operations and Management directed Veterans Healthcare Administration (VHA) to develop a productivity-based model for physicians using the Medicare Resource-Based Relative Value Scale, which was created in 1992 to provide guidance on determining payment for physician services. In 2015, the VHA set out to set standards for productivity measurements for NPs, physician assistants, and clinical nurse specialists, and in doing so, the physician productivity model was adapted for the NP workforce. The work of adapting the model will be presented in this article. The specific steps in the process of measurement, operational definitions for work activities, and calculations are provided. The article concludes with a discussion of lessons learned and next steps.

Incorporating Theory into Practice: Reconceptualizing Exemplary Care Coordination Initiatives from the US Veterans Health Delivery System.

This perspective paper seeks to lay out an efficient approach for health care providers, researchers, and other stakeholders involved in interventions aimed at improving care coordination to partner in locating and using applicable care coordination theory. The objective is to learn from relevant theory-based literature about fit between intervention options and coordination needs, thereby bringing insights from theory to enhance intervention design, implementation, and troubleshooting. To take this idea from an abstract notion to tangible application, our workgroup on models and measures from the Veterans Health Administration (VA) State of the Art (SOTA) conference on care coordination first summarizes our distillation of care coordination theoretical frameworks (models) into three common conceptual domains-context of an intervention, locus in which an intervention is applied, and specific design features of the intervention. Then we apply these three conceptual domains to four cases of care coordination interventions ("use cases") chosen to represent various scopes and stages of interventions to improve care coordination for veterans. Taken together, these examples make theory more accessible and practical by demonstrating how it can be applied to specific cases. Drawing from theory offers one method to anticipate which intervention options match a particular coordination situation.

Registered Nurses as Professionals, Advocates, Innovators, and Collaborative Leaders: Executive Summary

This article concludes a series that described work completed by the American Nurses Association (ANA) Barriers to RN Scope of Practice Professional Issues Panel (Panel). The Panel has summarized the roles of the registered nurse (RN) as professional, advocate, innovator, and collaborative leader. As professionals, RNs are accountable for their own educational development, growth of their own practice, and execution of their own professional role. As advocates, RNs provide direct and indirect care focused on the achievement of optimal health. As innovators, RNs act as agents of change in driving processes and policy and leveraging technology. As collaborative leaders, RNs lead within the professional practice setting with state-specific nurse practice acts, a defined scope of practice, and nurse-led initiatives. In this article, Panel members describe their methodology, offer role definitions and recommendations, and provide individual recommendations for RNs to remove barriers and practice to the full extent of their scope of practice. We conclude with some future considerations.

Registered Nurses as Caregivers: Influencing the System as Patient Advocates

Registered Nurses (RNs) influence the health of individual patients and populations. RNs provide the most value for the healthcare system when they work collaboratively with other healthcare team members, work to their full scope of practice, and when they are engaged and accountable. In 2011, the Institute of Medicine report on the future of nursing made the call to achieve the full value of nursing care. Creation of this future state requires both a vision of the "to be" as well as removal of existing barriers. In this article, we present a description of this future state in the context of a team based culture that utilizes collaboration to achieve the full scope of practice, accountability to deliver healthcare based on a discrete body of knowledge, and accountability to provide value and measure effectiveness of nursing care. This proposed future vision focuses on patient advocacy for nurses working in healthcare systems. Barriers that currently exist, such as overlaps in professional scopes of practice, organizational policy and structure, and a lack of the ability to grant privileges to nurses based upon their education and skills are discussed. We offer recommendations to remove barriers and contribute to creation of a new future state of nursing, and conclude that the removal of barriers to inhibit the fullest scope of nursing practice will continue to require focus in purpose and persistence in action.

The Veterans Health Administration's proposal for APRN full-practice authority.

The Veterans Health Administration (VHA) is proposing full-practice authority for advanced practice registered nurses (APRNs) to improve access, care delivery, and patient choice, as well as reduce costs. The authors performed a mixed-methods assessment to obtain the perspectives of administrators and APRNs on the characterization of the APRN workforce and their present practice in the VHA.

Impacting the Trajectory of Chronic Kidney Disease With ARPN-Led Renal Teams.

Health care reform demands improvements in population health and the patient experience while reducing costs. This demand is referred to as The Triple Aim of Improvement. A sense of urgency must be created for development of new models of care that impact outcomes earlier in the disease process. One new model of care addressing the triple aim is the Advanced Practice Registered Nurse (APRN)-Led Specialty Care Team. APRN-Led Specialty Care Team members engage patients and implement evidence at a point in the disease trajectory that is most likely to influence population outcomes, resources, and cost. In the pilot described in this article, a nurse practitioner, a registered nurse, a licensed practice nurse, a registered nurse certified diabetes educator, a registered dietitian, and a clinical pharmacist provided care to 20 patients with diabetes and chronic kidney disease, using the chronic disease trajectory model. The team was trained and supported through virtual technology and chronic kidney disease clinical decision-making tools. This APRN-Led Renal Specialty Care Team was embedded into primary care, using group appointments with nephrology support. Lessons learned regarding implementation, with a focus on the role of the nursing executive, are presented along with recommendations for future implementation.

RN Diabetes Virtual Case Management: A New Model for Providing Chronic Care Management.

The U.S. chronic disease health care system has substantial gaps in delivery of services. New models of care change traditional delivery of care and explore new settings for care. This article describes a new model of diabetes chronic care delivery: nurse-delivered care that includes protocol-based insulin titration and patient education delivered solely in a virtual environment. In phase 1, the clinical outcome of time to achievement of glycated hemoglobin (A(1C)) goals (P < .001; 95% confidence interval, 1.68-2.24) was significantly improved by registered nurse (RN) standing order intervention (n = 24) as compared with historical controls (n = 28). In phase 2, patients who were referred to an RN-managed insulin titration protocol with individualized A(1C) goals had a significant (P < .001; 95% confidence interval, 1.680-2.242) reduction in results from a mean of 9.6% at baseline to 7.7% at completion. Average patient age was 66 years, with a mean duration of 11 years diagnosed with diabetes. Safety was demonstrated by the absence of hypoglycemia related to RN protocol adjustment. There were no admissions or emergency room (ER) visits for hypoglycemia. This study demonstrates safety and efficacy of RN virtual chronic disease management for an older population of patients with long-standing diabetes.

Care coordination between specialty care and primary care: a focus group study of provider perspectives on strong practices and improvement opportunities.

Care coordination between the specialty care provider (SCP) and the primary care provider (PCP) is a critical component of safe, efficient, and patient-centered care. Veterans Health Administration conducted a series of focus groups of providers, from specialty care and primary care clinics at VA Medical Centers nationally, to assess 1) what SCPs and PCPs perceive to be current practices that enable or hinder effective care coordination with one another and 2) how these perceptions differ between the two groups of providers. A qualitative thematic analysis of the gathered data validates previous studies that identify communication as being an important enabler of coordination, and uncovers relationship building between specialty care and primary care (particularly through both formal and informal relationship-building opportunities such as collaborative seminars and shared lunch space, respectively) to be the most notable facilitator of effective communication between the two sides. Results from this study suggest concrete next steps that medical facilities can take to improve care coordination, using as their basis the mutual understanding and respect developed between SCPs and PCPs through relationship-building efforts.

A review of recent literature - nurse case managers in diabetes care: equivalent or better outcomes compared to primary care providers.

Primary care has changed remarkably with chronic disease burden growth. Nurse case managers assist with this chronic disease by providing if not significantly better care, than equivalent care to that provided by usual primary care providers. Chronic disease management requires patient-centered skills and tools, such as registries, panel management, review of home data, communicating with patients outside of face-to-face care, and coordinating multiple services. Evidence reviewed in this article demonstrates that registered nurse care managers (RNCM) perform many actions required for diabetes chronic disease management including initiation and titration of medications with similar or improved physiologic and patient satisfaction outcomes over usual care providers. Selection and training of the nurse case managers is of utmost importance for implementation of a successful chronic disease management program. Evidence based guidelines, algorithms, protocols, and adequate ongoing education and mentoring are generally cited as necessary support tools for the nurse case managers.

Assessing appropriateness of lipid management among patients with diabetes mellitus: moving from target to treatment.

BACKGROUND: Performance measures that emphasize only a treat-to-target approach may motivate overtreatment with high-dose statins, potentially leading to adverse events and unnecessary costs. We developed a clinical action performance measure for lipid management in patients with diabetes mellitus that is designed to encourage appropriate treatment with moderate-dose statins while minimizing overtreatment. METHODS AND RESULTS: We examined data from July 2010 to June 2011 for 964 818 active Veterans Affairs primary care patients ≥18 years of age with diabetes mellitus. We defined 3 conditions as successfully meeting the clinical action measure for patients 50 to 75 years old: (1) having a low-density lipoprotein (LDL) <100 mg/dL, (2) taking a moderate-dose statin regardless of LDL level or measurement, or (3) receiving appropriate clinical action (starting, switching, or intensifying statin therapy) if LDL is ≥100 mg/dL. We examined possible overtreatment for patients ≥18 years of age by examining the proportion of patients without ischemic heart disease who were on a high-dose statin. We then examined variability in measure attainment across 881 facilities using 2-level hierarchical multivariable logistic models. Of 668 209 patients with diabetes mellitus who were 50 to 75 years of age, 84.6% passed the clinical action measure: 67.2% with LDL <100 mg/dL, 13.0% with LDL ≥100 mg/dL and either on a moderate-dose statin (7.5%) or with appropriate clinical action (5.5%), and 4.4% with no index LDL on at least a moderate-dose statin. Of the entire cohort ≥18 years of age, 13.7% were potentially overtreated. Facilities with higher rates of meeting the current threshold measure (LDL <100 mg/dL) had higher rates of potential overtreatment (P<0.001). CONCLUSIONS: Use of a performance measure that credits appropriate clinical action indicates that almost 85% of diabetic veterans 50 to 75 years of age are receiving appropriate dyslipidemia management. However, many patients are potentially overtreated with high-dose statins.

Monitoring performance for blood pressure management among patients with diabetes mellitus: too much of a good thing?

BACKGROUND: Performance measures that reward achieving blood pressure (BP) thresholds may contribute to overtreatment. We developed a tightly linked clinical action measure designed to encourage appropriate medical management and a marker of potential overtreatment, designed to monitor overly aggressive treatment of hypertension in the face of low diastolic BP. METHODS: We conducted a retrospective cohort study in 879 Department of Veterans Affairs (VA) medical centers and smaller community-based outpatient clinics. The clinical action measure for hypertension was met if the patient had a passing index BP at the visit or had an appropriate action. We examined the rate of passing the action measure and of potential overtreatment in the Veterans Health Administration during 2009-2010. RESULTS: There were 977,282 established VA patients, 18 years and older, with diabetes mellitus (DM). A total of 713,790 patients were eligible for the action measure; 94% passed the measure (82% because they had a BP <140/90 mm Hg at the visit and an additional 12% with a BP ≥140/90 mm Hg and appropriate clinical actions). Facility pass rates varied from 77% to 99% (P < .001). Among all patients with DM, 197,291 (20%) had a BP lower than 130/65 mm Hg; of these, 80 903 (8% of all patients with DM) had potential overtreatment. Facility rates of potential overtreatment varied from 3% to 20% (P < .001). Facilities with higher rates of meeting the current threshold measure (<140/90 mm Hg) had higher rates of potential overtreatment (P < .001). CONCLUSIONS: While 94% of diabetic veterans met the action measure, rates of potential overtreatment are currently approaching the rate of undertreatment, and high rates of achieving current threshold measures are directly associated with overtreatment. Implementing a clinical action measure for hypertension management, as the Veterans Health Administration is planning to do, may result in more appropriate care and less overtreatment.

Validation of a medical record-based delirium risk assessment.

OBJECTIVES: To improve identification of patients at high risk for delirium, this study developed a chart abstraction tool for delirium risk and validated the tool against clinical expert diagnosis of delirium. DESIGN: Prospective cohort study. SETTING: Tertiary Veterans Affairs hospital in New England. PARTICIPANTS: One hundred veterans admitted to the medical service. MEASUREMENTS: While admitted, each participant underwent serial assessments for delirium by a clinical expert. Using the four criteria of a validated delirium prediction rule (cognitive impairment, sensory deficit, severe illness, and dehydration), chart review terms were selected for each criterion, and delirium risk was the sum of criteria present (range: 0-4; 4 = worst). After discharge, a nurse blinded to the expert's diagnosis completed the chart tool. RESULTS: The participants were mostly male (94%) and older (mean age 81 ± 7), and 23% developed overall delirium (14% incident). The rate of overall delirium was 11% in participants with zero risk factors, 18% in those with one or two, and 50% in those with three or four (P = .01; c-statistic 0.65, 95% confidence interval (CI) = 0.54-0.76). For incident delirium, the rates were 11%, 13%, and 25%, respectively (P = .53; c-statistic 0.56, 95% CI = 0.42-0.74). Discharge to a rehabilitation center or nursing home increased with increasing delirium risk (0%, 18%, 60%, P = .02). CONCLUSION: A chart abstraction tool was effective at identifying overall delirium risk but not incident delirium risk. Although the tool cannot replace clinical assessment and diagnosis of delirium, the use of this tool as an educational, clinical, or quality measurement aid warrants additional study.