Strategies for Strengthening Quality Improvement Projects in a Doctor of Nursing Practice Program.

BACKGROUND: Doctor of Nursing Practice (DNP) programs must assure that attention to safe quality healthcare is threaded throughout the curriculum and prepare students to lead quality improvement (QI) initiatives in healthcare systems. OBJECTIVE: This article illustrates the integration of implementation science, QI methods, process and evaluation tools, and faculty enrichment as strategies to strengthen QI projects in a DNP program. METHODS: A three-phased approach to implement strategies to strengthen QI projects in a DNP program and to enhance faculty engagement was undertaken. A needs assessment drove the development of strategies to strengthen QI in a DNP program. RESULTS: Outcomes of implementing strategies to strengthen QI in a DNP program showed rapid uptake of the concepts of QI process models into course content within the DNP curriculum. CONCLUSIONS: Strategies consisted of assessment of courses for gaps in QI content, faculty enrichment sessions on implementation science, QI processes and models, QI metrics and data analytics, embedding new content in the DNP program courses and the use of a rigorous evaluation tool for QI projects. IMPLICATIONS FOR NURSING: When provided with QI mentors and tools, DNP students are prepared to lead QI initiatives in healthcare systems to improve the safety and quality of healthcare.

CE: Original Research: Recognizing Delirium in Hospitalized Children: A Systematic Review of the Evidence on Risk Factors and Characteristics.

: Purpose: The purpose of this study was to examine the evidence regarding the risk factors for and characteristics of acute pediatric delirium in hospitalized children. METHODS: The systematic review method within an epidemiological framework of person, place, and time was used. Fifty-two studies were selected for initial retrieval. Of these, after assessment for methodological quality, 21 studies involving 2,616 subjects were included in the review. RESULTS: Findings revealed five primary characteristics seen in children experiencing delirium: agitation, disorientation, hallucinations, inattention, and sleep-wake cycle disturbances. Children who were more seriously ill, such as those in a pediatric ICU (PICU) and those with a high Pediatric Risk of Mortality II (PRISM II) score, and children who were mechanically ventilated were at greater risk for development of delirium. Those with a developmental delay or a preexisting anxiety disorder were also more prone to delirium. Although delirium symptoms fluctuate, most episodes occurred at night. Boys were slightly more susceptible than girls, though this difference was not significant. A key finding of this review was that delirium is multifactorial, related to treatment (mechanical ventilation, for example) and to a hospital environment (such as a PICU) that deprives patients of normal sleep-wake cycles and familiar routines. CONCLUSION: These findings will be useful in efforts to achieve earlier recognition and better management or prevention of pediatric delirium. This may also help to prevent unnecessary laboratory testing and imaging studies, which can cause children and parents unnecessary pain and anxiety and increase hospital costs.

Factors influencing utilization of hospital services by adult sickle cell disease patients: a systematic review.

BACKGROUND: Painful vaso-occlusive crisis is a hallmark of sickle cell disease (SCD) that commonly results in utilization of hospital services. Recurrent use of hospital services by SCD patients is associated with high healthcare costs and adverse clinical outcomes. Understanding the factors influencing the pattern of utilization is a first step in improving medical care of this patient population while reducing healthcare expenditures. OBJECTIVES: The primary objective of this systematic review was to determine what modifiable and non-modifiable factors influence utilization of hospital services by adult SCD patients. INCLUSION CRITERIA TYPES OF PARTICIPANTS: Adult SCD patients of both sexes who utilized hospital services for acute or emergency care. TYPES OF FACTORS/EXPOSURE: Non-modifiable and modifiable factors influencing utilization of hospital services. TYPES OF STUDIES: Prospective and retrospective cohort studies, case-control and analytical cross-sectional studies. OUTCOMES: The primary outcome of interest was high utilization of hospital services by adult SCD patients based on non-modifiable and modifiable factors measured as an odds ratio (analytical outcome). The secondary outcome was the prevalence of non-modifiable and modifiable factors among SCD patients who utilized hospital services measured as an event rate (descriptive outcome). SEARCH STRATEGY: A comprehensive multi-step search was undertaken to find both published and unpublished studies. Only studies published in the English language were included. The search was not limited by year of publication. METHODOLOGICAL QUALITY: Retrieved papers were assessed for methodological quality using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument. DATA EXTRACTION: Data were extracted using a researcher-developed tool. DATA SYNTHESIS: Included studies were combined in a statistical meta-analysis. The meta-analysis was based on a random effect model. For studies that did not allow statistical pooling, the findings have been presented in a narrative form. RESULTS: Fourteen studies were included in this review. The analysis demonstrated that male patients accounted for 40.8% (95% confidence interval [CI] 0.370-0.447) of all utilizing patients. Sickle cell disease patients who were publically insured accounted for 76.5% (95% CI 0.632-0.861) of all patients who had hospital encounters. Patients aged 25-35 years had the highest rate of utilization, and the rate of utilization declined in patients older than 50 years. High utilizing patients had more diagnoses of acute chest syndrome and sepsis than patients who were moderate or low utilizers. CONCLUSION: The majority of SCD patients who utilized hospital services were women, young people and publically insured individuals. Patients with particularly high level of utilization had more frequent diagnoses of acute chest syndrome and sepsis.

Healthcare Transformation and Changing Roles for Nursing.

Factors driving healthcare transformation include fragmentation, access problems, unsustainable costs, suboptimal outcomes, and disparities. Cost and quality concerns along with changing social and disease-type demographics created the greatest urgency for the need for change. Caring for and paying for medical treatments for patients suffering from chronic health conditions are a significant concern. The Affordable Care Act includes programs now led by the Centers for Medicare & Medicaid Services aiming to improve quality and control cost. Greater coordination of care-across providers and across settings-will improve quality care, improve outcomes, and reduce spending, especially attributed to unnecessary hospitalization, unnecessary emergency department utilization, repeated diagnostic testing, repeated medical histories, multiple prescriptions, and adverse drug interactions. As a nation, we have taken incremental steps toward achieving better quality and lower costs for decades. Nurses are positioned to contribute to and lead the transformative changes that are occurring in healthcare by being a fully contributing member of the interprofessional team as we shift from episodic, provider-based, fee-for-service care to team-based, patient-centered care across the continuum that provides seamless, affordable, and quality care. These shifts require a new or an enhanced set of knowledge, skills, and attitudes around wellness and population care with a renewed focus on patient-centered care, care coordination, data analytics, and quality improvement.

Care Bundles: Increasing Consistency of Care.

Care bundling is a strategy for reliably delivering quality, evidence-based care for patients undergoing treatments known to be accompanied by potential risks. This article reviews the purpose, types, and components of care bundles, as well as the process for development and implementation.

Translating Knowledge Into Practice Through an Academic-Practice Partnership for Exploring Barriers That Impact Management of Homebound Patients With Heart Failure.

A knowledge translation project involving an academic-practice partnership and guided by action-oriented research was used for exploring barriers that impact management of homebound heart failure patients. The intervention process followed an action research model of interaction, self-reflection, response, and change in direction. External facilitators (academia) and internal facilitators (practice) worked with clinicians to identify a topic for improvement, explore barriers, locate the evidence compare current practice against evidence-based practice recommendations, introduce strategies to "close the gap" between actual practice and the desired practice, develop audit criteria, and reevaluate the impact.

Infants with Delirium: A Primer on Prevention, Recognition, and Management.

Delirium is a serious neuropsychiatric condition that emerges acutely in all age groups, including infants, children, and adolescents. Delirium serves as an urgent signal of distress that a young child's brain is in trouble. Prevention, recognition, and management of infants with delirium is often especially challenging due to their pre-verbal status and still immature cognitive development. This article presents an overview of delirium in infants, offers details regarding the presentation of delirium in infants, discusses the challenges to screening and identification of infants with delirium, and provides evidence-based suggestions for pediatric nurses to optimize nursing care for infants at risk for or exhibiting delirium.

Moving evidence to practice: reflections on a multisite academic-practice partnership.

This paper describes the challenges encountered by an academic team when working with clinical teams to translated knowledge for the purposes of quality improvement in multiple sites. The sites were four differing health care settings in a Northeastern US state: two acute care hospital sites (one rural, one urban), one visiting nurse service and one psychiatric specialty hospital were purposively chosen for the action research study. In conducting this study at these diverse sites the importance of developing relationships and trust, understanding the context and dealing with real world complexities were evident. We conclude with observations and recommendations on important elements for effective knowledge translation work.