Improving Patient-Centered Care for End-Stage Renal Disease Patients at a Community Palliative Setting.

End-stage renal disease (ESRD) is a complex medical condition growing fastest in Americans 65 years and older. Despite its chronic nature, fewer than 10% of these patients have had advanced care planning. A chart audit (n = 20) of the palliative patients at a community palliative program revealed that no patient had a conversation about prognostication, 10% (n = 2) about the burden of kidney disease, 30% (n = 6) had coordination of care with the nephrologist, and 35% (n = 7) had engaged in end-of-life planning. This project aimed to increase patient-centered care for ESRD patients to 80% in 90 days. The project utilized the Plan-Do-Study-Act quality improvement model in four 2-week rapid cycles with 2 focus improvement areas. The 2 core interventions were patient screening for preferences and values and providing the right care for palliative management utilizing a checklist. At the end of the project, patient-centered right care for ESRD increased from a baseline of 24% to 94%. Patient engagement scores increased from a baseline of 3.2 to 4.9 on a 5-point Likert scale, with 5 being the highest supporting a shared decision model of care in improving patient-centered right care.

Trauma-Informed Psychosocial Screening and Care Planning: A Patient-Centered Improvement Project in a Midwife Clinic.

INTRODUCTION: Traumatic stress is associated with increases in preterm birth, low birth weight, and other perinatal complications. Yet the identification of patients with traumatic stress and intervention for traumatic stress prevention or treatment remain low. Locally in this university hospital-based midwife clinic, a health records review found that trauma exposure was documented in 5% of patient records, and no records had a diagnosis of posttraumatic stress disorder (PTSD). This is lower than research-based population estimates of 25% to 50% for trauma exposure and 8% for PTSD during pregnancy. The clinic staff did not screen for posttraumatic stress, and exposure screening was limited to intimate personal violence. Staff had not been trained in trauma-informed care (TIC) as defined by the Substance Abuse and Mental Health Services Administration. The aim for this improvement project was to provide trauma screening and trauma-related care planning, collectively referred to as trauma-informed psychosocial care, to midwifery patients 85% of the time. PROCESS: Interventions were implemented over 4 plan-do-study-act (PDSA) cycles. These included staff training in TIC; written screening at the new prenatal, third trimester, and postpartum visits; verbal broad inquiry at every visit; and bidirectional trauma-specific care planning emphasizing patient and provider input into treatment choice. The clinic flow was changed to create privacy for patient-staff interaction at every visit. Field notes and data were analyzed every 2 weeks and iterative changes applied. OUTCOMES: Trauma disclosure increased from 5% to 30% and identification of PTSD from 0% to 7%. Bidirectional care plan documentation increased from 8% to 67%. Staff rated the workload as reasonable. DISCUSSION: Redesigning psychosocial screening to align with TIC principles increased the discovery of trauma to levels consistent with research-based population estimates. Gains were made in bidirectional care planning. This project illustrates practical methods of implementing TIC principles.

Improving Timeliness of Obstetrical Triage Throughput in an Urban Tertiary Care Hospital.

BACKGROUND: Obstetrical triage units function like emergency departments with unpredictable volumes that affect the timely evaluation and treatment of patients and lead to longer wait times, delays in care, and longer length of stay (LOS). OBJECTIVE: The aim of this quality improvement initiative was to decrease the length of stay (LOS) of obstetrical triage patients by 20% through the utilization of nurse-driven orders, improved communication, and patient engagement. METHODS: Rapid cycle quality improvement using four plan-do-study-act cycles was utilized. Primary interventions were a patient decision tool, nurse-driven orders, a hypertension care algorithm, and team huddles. Data were analyzed using run charts to evaluate the impact of interventions on outcomes. RESULTS: Overall mean LOS for all patients (N = 654) was decreased by 26%. Most patients were satisfied with the patient decision tool (M = 4.45 on a 5-point Likert scale). The utilization of nurse-driven orders facilitated a decrease in mean LOS for hypertensive patients (N = 59) of 12%. CONCLUSIONS: Throughput in obstetrical triage is affected by many factors including availability of test results, practice styles of providers, and availability of beds. IMPLICATIONS FOR NURSING: Nurses can influence the length of time a patient remains in triage through the use of nurse-driven orders and improved communication with providers.

The American College of Nurse-Midwives' Benchmarking Project: A Demonstration of Professional Preservation and Improvement.

Maternal and newborn outcomes in the United States are suboptimal. Care provided by certified nurse-midwives and certified midwives is associated with improved health outcomes for mothers and newborns. Benchmarking is a process of continuous quality assurance providing opportunities for internal and external improvement. Continuous quality improvement is a professional standard and expectation for the profession of midwifery. The American College of Nurse-Midwives Benchmarking Project is an example of a long-standing, midwifery-led quality improvement program. The project demonstrates a program for midwifery practices to display and compare their midwifery processes and outcomes of care. Quality metrics in the project reflect national quality measures in maternal child health while intentionally showcasing the contributions of midwives. The origins of the project and the outcomes for data submitted for 2019 are described and compared with national rates. The American College of Nurse-Midwives Benchmarking Project provides participating midwifery practices with information for continuous improvement and documents the high quality of care provided by a sample of midwifery practices.

Prevalence of low vitamin D levels in an urban midwestern obstetric practice.

INTRODUCTION: This study describes the prevalence of low vitamin D levels in pregnancy in a diverse urban population. METHODS: This was a retrospective chart review of 2839 women who gave birth at a Michigan hospital between January 1, 2008 and December 31, 2009 and had at least 1 vitamin D (25-hydroxyvitamin D [25(OH)D]) measurement during their pregnancies. Race/ethnic group, wearing the hijab, and season of 25(OH)D sample collection were used in the descriptive analysis. RESULTS: Most women (92.5%) in this study had documented insufficient levels of 25(OH)D (defined as < 30 mL), and 71.7% of all women had deficient levels of 25(OH)D (defined as < 20 ng/mL). Subgroups with the highest percentage of women who were vitamin D deficient were: Middle Eastern (91.8%), African American (81.6%), and Asian (74.3%). Overall, women who wore the hijab were more likely to be deficient (89.5% vs 68.7; P < .0001) and insufficient (98.8% vs 91.4%; P < .0001) compared with women who did not wear the hijab. DISCUSSION: The data demonstrate the high rate of vitamin D deficiency and insufficiency in this white and nonwhite urban population in which samples were collected in both winter and nonwinter months. The percentage of woman who had 25(OH)D levels below 30 ng/mL was significantly higher than that reported in the National Health and Nutrition Examination Survey III (NHANES III) (92.5% compared to 69%), although NHANES did not sample women in northern climates in the winter months. Even using new diagnostic definitions for vitamin D deficiency from the Institute of Medicine, the proportion of women with vitamin D deficiency and insufficiency was 40% and 31.6%, respectively. Clinicians caring for women in northern climates as well as women who are Middle Eastern, African American, and Asian need to be aware of the risk for vitamin D deficiency and the potential health effects for the mother and infant.