Design and Implementation of Hospital Automatic Nursing Management Information System Based on Computer Information Technology.

Clinical nursing work fails to integrate various nursing tasks such as basic care, observation of patients' conditions, medication, treatment, communication, and health guidance to provide continuous and full nursing care for patients. Based on this, this paper uses the Internet of Things (IoT) technology to optimize the infusion process and achieve closed-loop management of medications and improve the efficiency and safety of infusion and medication administration by using a rational and effective outpatient and emergency infusion and medication management system. The system was built by applying wireless network, barcode technology, RFID, infrared tube sensing, and other technologies and was combined with actual nursing work to summarize application techniques and precautions. The application of this system will become a new highlight of medical informatization, improve patient experience, monitor infusion safety, enhance nursing care, reduce emergency medical disputes, improve patient satisfaction, and will create good social and economic benefits for the hospital.

Cost-effectiveness of point-of-care testing with task-shifting for HIV care in South Africa: a modelling study.

BACKGROUND: The number of people on antiretroviral therapy (ART) requiring treatment monitoring in low-resource settings is rapidly increasing. Point-of-care (POC) testing for ART monitoring might alleviate burden on centralised laboratories and improve clinical outcomes, but its cost-effectiveness is unknown. METHODS: We used cost and effectiveness data from the STREAM trial in South Africa (February, 2017-October, 2018), which evaluated POC testing for viral load, CD4 count, and creatinine, with task shifting from professional to lower-cadre registered nurses compared with laboratory-based testing without task shifting (standard of care). We parameterised an agent-based network model, EMOD-HIV, to project the impact of implementing this intervention in South Africa over 20 years, simulating approximately 175 000 individuals per run. We assumed POC monitoring increased viral suppression by 9 percentage points, enrolment into community-based ART delivery by 25 percentage points, and switching to second-line ART by 1 percentage point compared with standard of care, as reported in the STREAM trial. We evaluated POC implementation in varying clinic sizes (10-50 patient initiating ART per month). We calculated incremental cost-effectiveness ratios (ICERs) and report the mean and 90% model variability of 250 runs, using a cost-effectiveness threshold of US$500 per disability-adjusted life-year (DALY) averted for our main analysis. FINDINGS: POC testing at 70% coverage of patients on ART was projected to reduce HIV infections by 4·5% (90% model variability 1·6 to 7·6) and HIV-related deaths by 3·9% (2·0 to 6·0). In clinics with 30 ART initiations per month, the intervention had an ICER of $197 (90% model variability -27 to 863) per DALY averted; results remained cost-effective when varying background viral suppression, ART dropout, intervention effectiveness, and reduction in HIV transmissibility. At higher clinic volumes (≥40 ART initiations per month), POC testing was cost-saving and at lower clinic volumes (20 ART initiations per month) the ICER was $734 (93 to 2569). A scenario that assumed POC testing did not increase enrolment into community ART delivery produced ICERs that exceeded the cost-effectiveness threshold for all clinic volumes. INTERPRETATION: POC testing is a promising strategy to cost-effectively improve patient outcomes in moderately sized clinics in South Africa. Results are most sensitive to changes in intervention impact on enrolment into community-based ART delivery. FUNDING: National Institutes of Health.

Task Shifting for Initiation and Monitoring of Antiretroviral Therapy for HIV-Infected Adults in Uganda: The SHARE Trial.

BACKGROUND: With countries moving toward the World Health Organization's "Treat All" recommendation, there is a need to initiate more HIV-infected persons into antiretroviral therapy (ART). In resource-limited settings, task shifting is 1 approach that can address clinician shortages. SETTING: Uganda. METHODS: We conducted a randomized controlled trial to test if nurse-initiated and monitored ART (NIMART) is noninferior to clinician-initiated and monitored ART in HIV-infected adults in Uganda. Study participants were HIV-infected, ART-naive, and clinically stable adults. The primary outcome was a composite end point of any of the following: all-cause mortality, virological failure, toxicity, and loss to follow-up at 12 months post-ART initiation. RESULTS: Over half of the study cohort (1,760) was women (54.9%). The mean age was 35.1 years (SD 9.51). Five hundred thirty-three (31.6%) participants experienced the composite end point. At 12 months post-ART initiation, nurse-initiated and monitored ART was noninferior to clinician-initiated and monitored ART. The intention-to-treat site-adjusted risk differences for the composite end point were -4.1 [97.5% confidence interval (CI): = -9.8 to 0.2] with complete case analysis and -3.4 (97.5% CI: = -9.1 to 2.5) with multiple imputation analysis. Per-protocol site-adjusted risk differences were -3.6 (97.5% CI: = -10.5 to 0.6) for complete case analysis and -3.1 (-8.8 to 2.8) for multiple imputation analysis. This difference was within hypothesized margins (6%) for noninferiority. CONCLUSIONS: Nurses were noninferior to clinicians for initiation and monitoring of ART. Task shifting to trained nurses is a viable means to increase access to ART. Future studies should evaluate NIMART for other groups (e.g., children, adolescents, and unstable patients).

Medication Safety: What Nurses Should Know About Black Box Warnings.

"Safety first" has always been a nursing priority-just as medication education has been an essential nursing function. Approximately 79 million individuals of all ages, birth-to-death, were prescribed psychotropic medications in 2013. Nurses of all disciplines and who work in all practice settings must be aware of the potential safety concerns related to medications patients may be taking. Black Box Warnings (BBWs) are the strictest labeling requirements that the U.S. Food and Drug Administration can mandate. Risks of increased suicidality, mortality in older adults, potential for abuse and drug dependence, and life-threatening hepatic failure are among the most significant BBWs attributed to psychotropic medications. As such, nurses must be aware of not only how medications will benefit patients in relieving symptoms of or preventing their disease but also the potential risks, adverse reactions, and BBWs. [Journal of Psychosocial Nursing and Mental Health Services, 55(6), 11-15.].

The Impact of Liver and Renal Dysfunction on the Pharmacokinetics and Pharmacodynamics of Sedative and Analgesic Drugs in Critically Ill Adult Patients.

The use of sedative and analgesic drug therapy is often necessary for the care of critically ill patients. Renal and hepatic dysfunction, which occurs frequently in this patient population, can significantly alter drugs' pharmacokinetic and pharmacodynamics properties. By anticipating how these medications may be affected by liver or kidney dysfunction, health care practitioners may be able to provide tailored dosing regimens that ensure optimal comfort while minimizing the risk of adverse events.

Toward Solving the Sedation-Assessment Conundrum: Neurofunction Monitoring.

The sedation-assessment conundrum is the struggle to balance the need for sedation against the need to awaken the patient and perform a neurologic examination. This article discusses the nuances of the sedation-assessment conundrum as well as approaches to resolve this and reduce the negative impact of abruptly stopping sedative infusions. Both oversedation and undersedation affect critically ill patients. This article discusses methods of assessing sedation and interpreting individualized patient responses to sedation. The use of neurofunction monitors and periods of sedation interruption are discussed within the context of addressing the sedation-assessment conundrum.

Nurse-led titration of angiotensin converting enzyme inhibitors, beta-adrenergic blocking agents, and angiotensin receptor blockers for people with heart failure with reduced ejection fraction.

BACKGROUND: Heart failure is associated with high mortality and hospital readmissions. Beta-adrenergic blocking agents, angiotensin converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) can improve survival and reduce hospital readmissions and are recommended as first-line therapy in the treatment of heart failure. Evidence has also shown that there is a dose-dependent relationship of these medications with patient outcomes. Despite this evidence, primary care physicians are reluctant to up-titrate these medications. New strategies aimed at facilitating this up-titration are warranted. Nurse-led titration (NLT) is one such strategy. OBJECTIVES: To assess the effects of NLT of beta-adrenergic blocking agents, ACEIs, and ARBs in patients with heart failure with reduced ejection fraction (HFrEF) in terms of safety and patient outcomes. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL Issue 11 of 12, 19/12/2014), MEDLINE OVID (1946 to November week 3 2014), and EMBASE Classic and EMBASE OVID (1947 to 2014 week 50). We also searched reference lists of relevant primary studies, systematic reviews, clinical trial registries, and unpublished theses sources. We used no language restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing NLT of beta-adrenergic blocking agents, ACEIs, and/or ARBs comparing the optimisation of these medications by a nurse to optimisation by another health professional in patients with HFrEF. DATA COLLECTION AND ANALYSIS: Two review authors (AD & JC) independently assessed studies for eligibility and risk of bias. We contacted primary authors if we required additional information. We examined quality of evidence using the GRADE rating tool for RCTs. We analysed extracted data by risk ratio (RR) with 95% confidence interval (CI) for dichotomous data to measure effect sizes of intervention group compared with usual-care group. Meta-analyses used the fixed-effect Mantel-Haenszel method. We assessed heterogeneity between studies by Chi(2) and I(2). MAIN RESULTS: We included seven studies (1684 participants) in the review. One study enrolled participants from a residential care facility, and the other six studies from primary care and outpatient clinics. All-cause hospital admission data was available in four studies (556 participants). Participants in the NLT group experienced a lower rate of all-cause hospital admissions (RR 0.80, 95% CI 0.72 to 0.88, high-quality evidence) and fewer hospital admissions related to heart failure (RR 0.51, 95% CI 0.36 to 0.72, moderate-quality evidence) compared to the usual-care group. Six studies (902 participants) examined all-cause mortality. All-cause mortality was also lower in the NLT group (RR 0.66, 95% CI 0.48 to 0.92, moderate-quality evidence) compared to usual care. Approximately 27 deaths could be avoided for every 1000 people receiving NLT of beta-adrenergic blocking agents, ACEIs, and ARBs. Only three studies (370 participants) reported outcomes on all-cause and heart failure-related event-free survival. Participants in the NLT group were more likely to remain event free compared to participants in the usual-care group (RR 0.60, 95% CI 0.46 to 0.77, moderate-quality evidence). Five studies (966 participants) reported on the number of participants reaching target dose of beta-adrenergic blocking agents. This was also higher in the NLT group compared to usual care (RR 1.99, 95% CI 1.61 to 2.47, low-quality evidence). However, there was a substantial degree of heterogeneity in this pooled analysis. We rated the risk of bias in these studies as high mainly due to a lack of clarity regarding incomplete outcome data, lack of reporting on adverse events associated with the intervention, and the inability to blind participants and personnel. Participants in the NLT group reached maximal dose of beta-adrenergic blocking agents in half the time compared with participants in usual care. Two studies reported on adverse events; one of these studies stated there were no adverse events, and the other study found one adverse event but did not specify the type or severity of the adverse event. AUTHORS' CONCLUSIONS: Participants in the NLT group experienced fewer hospital admissions for any cause and an increase in survival and number of participants reaching target dose within a shorter time period. However, the quality of evidence regarding the proportion of participants reaching target dose was low and should be interpreted with caution. We found high-quality evidence supporting NLT as one strategy that may improve the optimisation of beta-adrenergic blocking agents resulting in a reduction in hospital admissions. Despite evidence of a dose-dependent relationship of beta-adrenergic blocking agents, ACEIs, and ARBs with improving outcomes in patients with HFrEF, the translation of this evidence into clinical practice is poor. NLT is one strategy that facilitates the implementation of this evidence into practice.

Prescription drug monitoring programs: Combating prescription drug misuse.

To help combat prescription drug misuse, most states have implemented Prescription Drug Monitoring Programs (PDMPs)-electronic databases that collect and track prescription data and flag suspected diversion activities. Equipped with expanding prescriptive authority, NPs are now poised to become vital change agents in expanding the potential effectiveness of PDMPs.

Anticoagulation clinic versus a traditional warfarin management model.

Warfarin is the most commonly prescribed oral anticoagulant. The management of warfarin is challenging, and current guidelines fail to include a model to assist practitioners in optimizing therapeutic dosing. The traditional model and the anticoagulation clinic (AC) model of warfarin management were compared and results found the AC model optimum.

Identification and management of bipolar disorder.

Bipolar disorder is a complex and chronic mental illness. Individuals with this disorder usually have medical comorbidities needing management in primary care. This article focuses on bipolar disorder identification and medication management concerns for primary care nurse practitioners.

Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting.

BACKGROUND: Nurses are frequently interrupted during medication verification and administration; however, few interventions exist to mitigate resulting errors, and the impact of these interventions on medication safety is poorly understood. OBJECTIVE: The study objectives were to (A) assess the effects of interruptions on medication verification and administration errors, and (B) design and test the effectiveness of targeted interventions at reducing these errors. METHODS: The study focused on medication verification and administration in an ambulatory chemotherapy setting. A simulation laboratory experiment was conducted to determine interruption-related error rates during specific medication verification and administration tasks. Interventions to reduce these errors were developed through a participatory design process, and their error reduction effectiveness was assessed through a postintervention experiment. RESULTS: Significantly more nurses committed medication errors when interrupted than when uninterrupted. With use of interventions when interrupted, significantly fewer nurses made errors in verifying medication volumes contained in syringes (16/18; 89% preintervention error rate vs 11/19; 58% postintervention error rate; p=0.038; Fisher's exact test) and programmed in ambulatory pumps (17/18; 94% preintervention vs 11/19; 58% postintervention; p=0.012). The rate of error commission significantly decreased with use of interventions when interrupted during intravenous push (16/18; 89% preintervention vs 6/19; 32% postintervention; p=0.017) and pump programming (7/18; 39% preintervention vs 1/19; 5% postintervention; p=0.017). No statistically significant differences were observed for other medication verification tasks. CONCLUSIONS: Interruptions can lead to medication verification and administration errors. Interventions were highly effective at reducing unanticipated errors of commission in medication administration tasks, but showed mixed effectiveness at reducing predictable errors of detection in medication verification tasks. These findings can be generalised and adapted to mitigate interruption-related errors in other settings where medication verification and administration are required.

Therapeutic education to cancer patients: experiences of Italian nurses.

INTRODUCTION: Therapeutic patient' education is a complex process requiring a proper level of communication between the patient and the healthcare professional. Nurses play a key role in providing the patients and their families with educational activities. OBJECTIVE: This paper is the report of a study which investigates the experiences of some Italian nurses with regards to their role in therapeutic education to cancer patients. METHODS: Qualitative research. Semi-structured interviews were carried out with 52 nurses working in different Local Health Service Units of two northern Italy regions: Piedmont and Valle d'Aosta. To identify categories and items arising from the data, the researchers used a qualitative content analysis. RESULTS: The interview format was classified into six main categories: a) Patient education as daily care activity; b) Relevance of communication and dialogue for educational purposes; c) Relative usefulness of written information; d) Therapeutic education recording; e) Patients' feedbacks as a tool for assessing therapeutic education; and f) Difficult communication. CONCLUSIONS: The experience of nurses in terms of their professional role in therapeutic education for cancer patients shows the steady presence of educational activities carried out in a non-planned way. This research confirms the need to launch educational interventions for nurses. IMPLICATIONS FOR PRACTICE: It is essential to implement an action plan to promote opportunities of professional training in the field since among the most frequent reasons for project failure in therapeutic education is the lack of expert human resources.

Sedation practice in Nordic and non-Nordic ICUs: a European survey.

BACKGROUND AND AIMS: A trend towards lighter sedation has been evident in many intensive care units (ICUs). The aims of the survey were to describe sedation practice in European ICUs and to compare sedation practice in Nordic and non-Nordic countries. DESIGN AND METHODS: A cross-sectional survey of ICU nurses attending the fourth European federation of Critical Care Nursing associations (EfCCNa) in Denmark, 2011. Data included use of protocols; sedation, pain and delirium assessment tools; collaborative decision-making; sedation and analgesic medications; and educational preparation related to sedation. RESULTS: Response rate was 42% (n = 291) from 22 countries where 53% (n = 148) used sedation protocols. Nordic nurses reported greater use of sedation (91% versus 67%, p < 0·01) and pain (91% versus 69%, p < 0·01) assessment tools than non-Nordic nurses. Decision-making on sedation was more inter-professionally collaborative in Nordic ICUs (83% versus 61%, p < 0·01), units were smaller (10 versus 15 beds, p < 0·01) and nurse-patient ratio was higher (1:1, 75% versus 26%, p < 0·01). Nordic nurses reported greater consistency in maintaining circadian rhythm (66% versus 49%, p < 0·01), less use of physical restraints (14% versus 36%, p < 0·01), less use of neuromuscular blocking agents (3% versus 16%, p < 0·01), and received more sedation education (92% versus 76%, p < 0·01). Delirium assessment was not performed systematically in most settings. CONCLUSIONS: Organizational and contextual factors, such as ICU size, staffing ratio and inter-professional collaboration, are contributing factors to sedation management in European ICUs. The Nordic context might be more germane to the goal of lighter sedation and better pain management. RELEVANCE TO CLINICAL PRACTICE: Our study raises awareness of current sedation practice, paving the way towards optimized ICU sedation management.

PCA by proxy: taking the patient out of patient-controlled analgesia: this controversial practice can be done safely in carefully controlled circumstances.

Among the questions raised about patient-controlled analgesia (PCA) by proxy are as follows: What are the safety issues related to PCA by proxy? Should another type of pain management be used for patients who can not activate the PCA button? This article focuses on safe PCA use and authorized agent-controlled analgesia (AACA).

Monitoring of international normalized ratios: comparison of community nurses with family physicians.

OBJECTIVE: To determine whether community-based, nurse-led monitoring of the international normalized ratio (INR) in patients requiring long-term warfarin therapy was comparable to traditional physician monitoring. DESIGN: A retrospective cohort analysis of patients taking long-term warfarin therapy. SETTING: The study used data gathered from 3 family medicine clinics in a primary care network in Edmonton, Alta. PARTICIPANTS: Medical records of patients currently taking warfarin were examined. INTERVENTION: Implementation of nurse-led monitoring in a primary care network in place of standard family physician INR monitoring. MAIN OUTCOME MEASURES: The degree of INR control before and after the implementation of nurse-run INR monitoring was assessed. The average proportion of time spent outside of therapeutic INR ranges, as well as the average number of days between successive INR readings, was calculated and compared. The degree of control placed patients into either a good-control group (out of range ≤ 25% of the time) or a moderate-control group (out of range > 25% of the time) and these groups were compared. RESULTS: Before nurse monitoring, INR values were out of range 20.4% of the time; after nurse monitoring they were out of range 19.2% of the time (P = .115); the time between sequential INR readings also did not differ before and after implementation of nurse monitoring (23.9 vs 21.6 days, P = .789). CONCLUSION: Nurse-led monitoring of INR is as effective as traditional physician monitoring. Advantages of nurse-led monitoring might include freeing family physicians to see more patients or to spend less time at work. It might also represent potential cost savings.

Improving adherence to safe prescription guidelines for Dapsone: harnessing an enhanced electronic medical records system and a team approach.

BACKGROUND: Dapsone is a commonly prescribed medication in dermatological practice. Its use is associated with a broad spectrum of adverse effects. Careful selection and monitoring of patients on dapsone are paramount in the prevention and early recognition of adverse effects. OBJECTIVE AND METHODS: We designed a risk-management program for dapsone at National Skin Centre, Singapore, enhancing an existing electronic medical records system and harnessing a team approach involving the nurses. This includes the performance of key laboratory tests before and after starting dapsone, ensuring adequate counseling before starting dapsone and screening for adverse effects using a questionnaire every visit. RESULTS: This system of dapsone prescription efficiently improved the adherence to safe prescription and monitoring guidelines. Average adherence rates for key safety parameters improved from 61.4% pre-implementation to 95.3% at six months and were sustained at 12 months at 91.3%. Percentage of follow-up cases in which all three key monitoring parameters were fulfilled increased from 9.5% to 79.6% (p=0.0001) after 12months. The percentage of new patients in which all four key monitoring parameters were met increased from 50% to 80%. It was not statistically significant possibly because of small patient numbers. This project has also translated into enhanced patient safety with dapsone dosages adjusted in 17 patients who experienced mild adverse effects. No severe adverse effects to dapsone were observed in the 12-month period. CONCLUSION: This example of risk management for dapsone may serve as a model for institutions looking at harnessing information technology and a team approach for safer prescription of high-alert medications.