Workforce Engagement for Compassionate Advocacy, Resilience, and Empowerment (WE CARE): An Evidence-Based Wellness Program.

Poor well-being and burnout among the nursing workforce were heightened by the COVID-19 pandemic. The purpose of this study was to deliver, spread, and sustain an evidence-based wellness program, Workforce Engagement for Compassionate Advocacy, Resilience, and Empowerment (WE CARE), for nurse leaders, staff registered nurses (RNs), and patient care technicians (PCTs) to ameliorate or prevent burnout, promote resilience, and improve the work environment. The program included Community Resiliency Model (CRM) training provided by a certified 6-member wellness team. A baseline and 6-month follow-up survey included measures of well-being, moral distress, burnout, resilience, perceived organizational support (POS), job satisfaction, intent to leave (ITL), and work environment. A total of 4900 inpatient RNs, PCTs, and leaders of a 1207-bed academic medical center in the southeastern United States were analyzed. From baseline (n = 1533) to 6-month follow-up (n = 1457), well-being, moral distress, burnout, job satisfaction, and work environment improved; however, resilience, POS, and ITL did not. Although we have seen some improvements in well-being and mental health indicators, it is still early in the intervention period to have reached a critical mass with the training and other interventions. The mental health and work environment issues among nurses are so complex, no one-size-fits-all intervention can resolve.

Reducing hospital acquired pressure injury in a learning health center: Making the case for quality.

Introduction: The purpose of this descriptive study is to examine a learning health system (LHS) continuous improvement and learning approach as a case for increased quality, standardized processes, redesigned workflows, and better resource utilization. Hospital acquired pressure injuries (HAPI) commonly occur in the hospitalized patient and are costly and preventable. This study examines the effect of a LHS approach to reducing HAPI within a large academic medical center. Methods: Our learning health center implemented a 6-year series of iterative improvements that included both process and technology changes, with robust data and analytical reforms. In this descriptive, observational study, we retrospectively examined longitudinal data from April 1, 2018 to March 31, 2022, examining the variables of total number of all-stage HAPI counts and average length of stay (ALOS). We also analyzed patient characteristics observed/expected mortality ratios, as well as total patient days, and the case-mix index to determine whether these factors varied over the study period. We used the Agency for Healthcare Research and Quality cost estimates to identify the estimated financial benefit of HAPI reductions on an annualized basis. Results: HAPI per 1000 patient days for FY 20 (October 1-September 30) and FY 21, decreased from 2.30 to 1.30 and annualized event AHRQ cost estimates for HAPI decreased by $4 786 980 from FY 20 to FY 21. A strong, statistically significant, negative and seemingly counterintuitive correlation was found (r = -.524, P = .003) between HAPI and ALOS. Conclusions: The LHS efforts directed toward HAPI reduction led to sustained improvements during the study period. These results demonstrate the benefits of a holistic approach to quality improvement offered by the LHS model. The LHS model goes beyond a problem-based approach to process improvement. Rather than targeting a specific problem to solve, the LHS system creates structures that yield process improvement benefits over a continued time period.

Value of Using a Structured Improvement Approach: A Dedicated Education Unit Exemplar.

ABSTRACT: Using a structured approach to improvement that integrates methodological frameworks and commonly used improvement tools and techniques allows an improvement team to systematically implement and evaluate an intervention. Authors from one academic medical center will describe our four-step structured improvement approach in the design of a dedicated education unit (DEU) pilot to potentially meet a critical post-COVID-19 workforce need. Using our structured improvement approach, we successfully piloted a DEU with a unit-based clinical educator and 16 nursing students over 26 clinical days and received 13 preintervention surveys from participants. Although the DEU pilot was small with limited data, the structured improvement approach resulted in an organized and systematic way of designing, implementing, and evaluating improvement.

Academic Practice Partnerships: Improving Doctor of Nursing Practice Project Quality.

ABSTRACT: Doctor of nursing practice (DNP) projects with impactful health system outcomes can be a challenge for graduate students and graduate program faculty to develop. Rigorous DNP projects address patient and health system needs, meet programmatic requirements, and result in a portfolio of sustainable scholarship for DNP graduates. A strong academic-practice partnership may result in a greater likelihood of successful and impactful DNP projects. Our academic-practice partnership leaders developed a strategic approach to align health system priorities with DNP student project needs. This partnership has resulted in project innovation, increased clinical application, improved outcomes within the community, and enhanced project quality.

Quality Matters: Examining the Impact of Nurse Staffing Challenges on Clinical Outcomes.

GOAL: The purpose of this study was to examine nurse staffing while describing the relationships that exist in staffing and quality associated with nursing care during the COVID-19 pandemic, a significantly challenging time for nurse staffing. We examined the relationship between permanent registered nurse (RN) and travel RN staffing during the pandemic and the nursing-sensitive outcomes of catheter-associated urinary tract infections (CAUTIs), central line-associated bloodstream infections (CLABSIs), falls, and hospital-acquired pressure injuries (HAPIs) and length of stay and compared the cost of CAUTIs, CLABSIs, falls, and HAPIs in fiscal years 2021 and 2022. METHODS: We used a descriptive, observational design to retrospectively examine permanent nurse staffing volume and CAUTI, CLABSI, HAPI, and fall counts from October 1, 2019, to February 28, 2022, and travel nurse volume for the most current 12 months, April 1, 2021, to March 31, 2022. Descriptive statistics, Pearson correlation, and statistical process control analyses were completed. PRINCIPAL FINDINGS: Pearson correlation showed a statistically significant, moderately strong negative correlation (r = -0.568, p = .001) between the active registered nurse full-time equivalents (RN FTEs) and average length of stay (ALOS), and a moderately strong positive correlation (r = 0.688, p = .013) between the travel RN FTEs and ALOS. Pearson correlations were not statistically significant, with low to moderate negative correlations for CAUTIs (r = -0.052, p = .786), CLABSIs (r = -0.207, p = .273), and falls (r = -0.056, p = .769). Pearson correlation for active RN and HAPI showed a moderately strong, statistically significant positive correlation (r = 0.499, p = .003). We observed common cause variation in CAUTIs and CLABSIs, with HAPIs and falls showing special cause variation via statistical process control. PRACTICAL APPLICATIONS: Despite the challenges associated with the lack of available nurse staffing accompanied by increasing responsibilities including unlicensed tasks, positive clinical outcomes can be maintained by staff adherence to evidence-based quality improvement.

Antipsychotics and obsessive-compulsive disorder/obsessive-compulsive symptoms: A pharmacovigilance study of the FDA adverse event reporting system.

OBJECTIVE: Antipsychotics have conflicting data with respect to obsessive-compulsive disorder/symptoms (OCD/OCS), with some reporting causality and some reporting treatment benefits. This pharmacovigilance study aimed to investigate reporting of OCD/OCS in association with the use of antipsychotics in comparison to one another, as well as treatment failure using data derived from the FDA Adverse Event Reporting System (FAERS). METHODS: Data from January 1st, 2010 to December 31st, 2020 on suspected adverse drug reactions (ADRs) including OCD/OCS was obtained. The information component (IC) was used to determine a disproportionality signal, and reporting odds ratio (ROR) calculations were performed via intra-class analyses to discern differences between the evaluated antipsychotics. RESULTS: A total of 1454 OCD/OCS cases were utilized in IC and ROR calculations and 385,972 suspected ADRs were used as non-cases. A significant disproportionality signal was seen with all second generation antipsychotics. Relative to other antipsychotics, only aripiprazole had a significant ROR of 23.87 (95% CI: 21.01-27.13; p < 0.0001). The ROR for antipsychotic treatment failure in those with OCD/OCS was highest with aripiprazole, and lowest with risperidone and quetiapine. Sensitivity analyses were largely in favor of the primary findings. Our analysis appears to implicate the 5-HT1A receptor or an imbalance between this receptor and the D2 -receptor in antipsychotic treatment-emergent OCD/OCS. CONCLUSIONS: In contrast to prior reports noting clozapine as the antipsychotic most commonly associated with de novo or exacerbated OCD/OCS, this pharmacovigilance study found aripiprazole was most frequently reported for this adverse effect. While these findings from FAERS offer a unique perspective on OCD/OCS with different antipsychotic agents, due to the inherent limitations of pharmacovigilance studies they should ideally be validated through alternative prospective research studies involving direct comparisons of antipsychotic agents.

Nurse Anesthesia Diversion Prevention: A Knowledge and Needs Gap Analysis.

BACKGROUND: Substance misuse is an occupational health problem for anesthesia providers (APs). More than 10% of nurse anesthetists misuse and divert medications. No standard exists for addressing AP drug diversion. The purpose of this quality improvement project was to evaluate the use of a knowledge and needs assessment to inform the development of a successful drug diversion prevention program for certified registered nurse anesthetists (CRNAs) and student registered nurse anesthetists (SRNAs). METHODS: A 28-item questionnaire, using the health belief model (HBM) and the risk perception attitude (RPA) framework, was developed to assess knowledge, beliefs, and practices of substance misuse and diversion. RPA groups were determined by level of belief in self-risk and perceived efficacy of prevention strategies. The survey was emailed to 100 CRNAs and over 100 SRNAs. Survey results were organized using the RPA framework. FINDINGS: One hundred twelve surveys were completed. The RPA avoidant category (high-risk belief and low perceived efficacy of preventive interventions) comprised 52.5% of CRNAs; SRNAs were divided primarily among the RPA responsive category with high perceived risk and high-efficacy beliefs (38.9%) and the indifferent category of low-risk beliefs and low perceived efficacy (31.9%). CONCLUSIONS/APPLICATIONS TO PRACTICE: Anesthesia providers have varying beliefs regarding drug misuse and diversion risks and perceptions of their ability to be successful with preventive strategies. Failure to address nurse anesthesia needs-based diversion prevention may result in missed opportunities to educate this group. Implementation of RPA-tailored interventions by health care organizations may produce effective, long-term outcomes for drug diversion within the profession.

Use of a Novel Standardized Administration Protocol Reduces Agitation Pro Re Nata (PRN) Medication Requirements: The Birmingham Agitation Management (BAM) Initiative.

BACKGROUND: Agitation management is a principal challenge on inpatient psychiatric units. Overreliance on common prescribing strategies of pro re nata (PRN) medication administration is problematic, given the tendencies to have overlapping or unclear indications. OBJECTIVE: Piloted project to determine whether a standardized protocol for agitation intervention may reduce PRN medication administration. METHODS: The Birmingham Agitation Management (BAM) interdisciplinary team uniquely connected the Brøset Violence Checklist (BVC) for assessment of agitation severity to a standardized PRN medication order set. Nurses on the piloted unit were trained on how to score the BVC and administer medications. Patients were assessed by the BVC every 4 hours and, based on their score, would receive no medication, low-dose benzodiazepine, high-dose benzodiazepine, or high-dose benzodiazepine plus antipsychotic. The primary end point compared the number of PRNs administered after novel protocol implementation with a retrospective cohort. Secondary measures included analysis of medication-related effects, seclusion, and physical restraint rates. RESULTS: 377 patients were included in the final analyses (184 pre-BAM, 193 BAM intervention group). No significant differences were seen in patient characteristics between groups. The total number of PRNs administered decreased by 42.5%, with both the mean and median number of administrations decreasing significantly (95% confidence interval [CI] = [1.68-5.75]; P < 0.001). A trend was noted between the number of PRNs administered and seclusion rates, but did not reach statistical significance (95% CI = [-7.28 to 60.31]; P = 0.124). CONCLUSIONS: In seemingly the first initiative of its kind, we found that a standardized agitation management protocol can help decrease the total number of PRN administrations for agitation without worsening of restraint rates and may possibly reduce the risk of adverse effects. These results require validation in specific, larger populations.

Modeling Patient Risk for Hospital-Acquired Pressure Injuries During COVID-19: A Retrospective Study.

BACKGROUND: COVID-19 negatively impacts many organ systems including the skin. One of the most significant skin-associated adverse events related to hospitalization are pressure injuries. PURPOSE: The aim of this study was to determine 8 risk factors that would place hospitalized patients at a higher risk for hospital-acquired pressure injuries (HAPIs) during the COVID-19 pandemic. METHODS: A retrospective, descriptive analysis was conducted in an urban academic health science center located in the southeastern United States. RESULTS: There were 247 of 23 093 patients who had pressure injuries and 1053 patients who had a positive COVID-19 diagnosis. Based on the generalized estimating equation model, diagnosis of COVID-19, age, male gender, risk of mortality, severity of illness, and length of stay are statistically significant factors associated with the development of HAPIs. CONCLUSIONS: Further study should explore pathology of COVID-19 skin changes and what interventions are effective against HAPIs in the COVID-19 population taking into consideration current treatments.

Unexpected COVID-19 Opportunity: Applied Experience for the Nurse Educator Student.

BACKGROUND: Lack of experiential learning in nurse educator (NE) programs may result in students completing didactic coursework with limited or no opportunities to supervise nursing students in a clinical environment. During the coronavirus disease 2019 pandemic, one organization transformed an educational challenge into an opportunity for NE students. METHOD: Programmatic evaluation, using a 10-item Likert scale evaluation tool, was used to obtain feedback from 15 NE students regarding their perceived value of an experiential learning activity. RESULTS: Aggregate mean evaluation scores ranged from 2.7 to 4.3. An aggregate mean of 4.3 was attributed by the NE students to the possibility of spending additional clinical hours providing oversight to nursing students participating in this process. CONCLUSION: Applied experiential learning may enhance the quality of NE students' educational experience, provide needed opportunity for developing critical expertise as a NE, and create a window of opportunity for future application of NE students' experiential learning. [J Nurs Educ. 2021;60(11):642-645.].

Learning During Crisis: The Impact of COVID-19 on Hospital-Acquired Pressure Injury Incidence.

ABSTRACT: The impact of COVID-19, on the health and safety of patients, staff, and healthcare organizations, has yet to be fully uncovered. Patient adverse events, such as hospital-acquired pressure injuries (HAPIs), have been problematic for decades. The introduction of a pandemic to an environment that is potentially at-risk for adverse events may result in unintended patient safety and quality concerns. We use the learning health system framework to motivate our understanding of the impact of the COVID-19 pandemic on the incidence of HAPIs within our health system. Using a retrospective, observational design, we used descriptive statistics to evaluate trends in HAPI from March to July 2020. Hospital-acquired pressure injury numbers have fluctuated from a steady increase from March-May 2020, hitting a peak high of 90 cases in the month of May. However, the trend in the total all stage HAPIs began to decline in June 2020, with a low of 51 in July, the lowest number since March 2020. Patients evaluated in this study did not have a longitudinal increase in HAPIs from March-July 2020 during the COVID-19 pandemic, despite similarities in illness severity between the two time points. Our experience has demonstrated the ability of our organizational leaders to learn quickly during crisis.

Innovations in Evaluating Nursing Academic Practice Partnerships.

Academic-practice partnerships are formalized relationships encouraged by the American Association of Colleges of Nursing to meet healthcare and societal needs. While Academic-practice partnerships have existed for decades, the process for evaluating their outcomes often lacks a robust, standardized structure. The purpose of this article is to describe one organization's process for developing and implementing an evaluation blueprint for appraising an Academic-practice partnership.

The Heart Failure Journey Board to Discharge.

BACKGROUND: Patients with heart failure (HF) require lifestyle changes to improve functional status and health outcomes. LOCAL PROBLEM: Heart failure was the most common readmitting diagnosis, with costs per patient of $5332, length of stay (LOS) of 5.9 days, and readmission rate of more than 30%. IMPLEMENTATION: The purpose was to adapt and implement a journey board discharge tool for adults with HF. METHODS: A journey board was created, piloted, and trialed on 1 nursing unit. Large journey boards were attached to communication boards in patient rooms for nurses to mark off topics, listed in the form of a tile (n = 19), as complete following education sessions. RESULTS: Nurses reported the tool helped them know what educational topics were covered by previous shifts. Following implementation, the average LOS was 5.3 days, patient cost per patient was $4848, and readmission rate was 28%. CONCLUSIONS: Utilizing journey board discharge education tools with patients can improve communication and evidence-based self-care instruction.

Cost of Quality Pilot: A Systematic Methodology for Examining the Cost of Pressure Injury.

Health care costs in the United States are considerable, and total national cost of preventable adverse events in the United States ranges from billions to trillions of dollars annually. Achieving the highest quality of health services requires delivering care that mitigates the risk of patient adverse events. Pressure injuries are a significant and costly adverse event. Mitigating or eliminating harm from pressure injuries not only improves quality and increases patient safety but also decreases costs of care. The purpose of this article is to pilot a systematic methodology for examining the differences in the cost of care for a subset of patients with and without hospital-acquired pressure injuries in an acute care setting.

Using Simulation and Competency Assessment to Decrease Inappropriate Referrals to a Comprehensive Vascular Access Team.

This department column highlights translation of research into health care quality practice. Achieving the highest quality of health care requires attention to creating and sustaining process efficiencies through the development of bedside provider competencies that result in workflow improvements and positive patient outcomes. An improvement intervention aimed at decreasing unnecessary referrals to a comprehensive vascular access team (CVAT) resulted in a 21% reduction in inappropriate consults to the team in approximately 6 weeks. The purpose of this article is to describe a simulation and competency assessment intervention aimed at increasing staff nurse proficiency in the emergency department for placing ultrasound-guided intravascular catheters, thereby reducing the number of inappropriate referrals to a CVAT team.

Workforce Competencies for Healthcare Quality Professionals: Leading Quality-Driven Healthcare.

As healthcare delivery systems increasingly adopt models designed to reward cost-efficient and high-quality care, the demand for expertise in healthcare quality continues to grow. There has been wide variation and limited conformity in the definition of the quality competencies that are essential for healthcare professionals. To address the need for a standard, widely accepted, comprehensive definition of the competencies required for healthcare quality, the National Association for Healthcare Quality (NAHQ) made a strategic commitment to develop a comprehensive healthcare quality competency framework applicable to all practice settings across the care continuum. In this article, the authors describe the development of NAHQ's Healthcare Quality Competency Framework depicting eight competency dimensions required for success in current and future healthcare quality positions. In addition, they discuss a self-assessment survey tool to identify individual and organizational gaps in the workforce competencies of Healthcare Quality Professionals.

Innovations in Pressure Injury Reporting: Creating Actionable Data for Improvement.

This department column highlights translation of research into health care quality practice. Achieving the highest quality of health care requires attention to developing and sustaining process efficiencies, and a thorough understanding of data and reporting. Mitigating or eliminating harm from pressure injuries may be more quickly achieved when accurate and consistent data are available for creating actionable interventions. The three aims of this project were to (1) confirm internally reported hospital acquired pressure injury data, (2) identify opportunities for improving the accuracy of internal reports, and (3) design and implement innovative quality informatics solutions for pressure injury reporting.

The Application of the Toyota Production System LEAN 5S Methodology in the Operating Room Setting.

The purpose of the Toyota Production System (TPS) Lean 5S methodology project is to improve the efficiency and effectiveness in a process by eliminating identified process waste of (1) defects (errors), (2) overproduction, (3) waiting, (4) confusion, (5) motion/travel, (6) excess inventory, (7) overprocessing, and (8) human potential. The specific aim of this quality improvement project was to evaluate the impact of the TPS 5S tool process, a problem-solving, space-organizing tool, on distractions and interruptions in the neurosurgery operating room (OR) workflow with a goal to decrease neurosurgery craniotomy infection rates in a neurosurgery OR suite within a 3-month period.

Preventing Central Line-Associated Bloodstream Infections in the Intensive Care Unit: Application of High-Reliability Principles.

This department column highlights translation of research into healthcare quality practice. Achieving the highest quality in healthcare requires organizations to understand care delivery and to proactively mitigate risks in care delivery processes. The purpose of this article is to describe a quality initiative that used principles of high reliability to develop a zero tolerance culture for central line-associated bloodstream infections in an intensive care unit at an independent, nonprofit acute care community hospital.

Designing Large-Scale Improvement: Using an Academic-Practice Partnership to Enhance Care Transitions.

This department column highlights translation of research into healthcare quality practice. Achieving the highest quality in healthcare requires organizations to understand care delivery and to develop and design process efficiencies. The improvement process may be enhanced through a partnership between the healthcare facility and an affiliated school of nursing. The purpose of this article was to describe the process for developing a large-scale improvement project focused on enhancing care transitions within an academic medical center using an academic-practice partnership model.