Hospital-Based Nursing Research: Clinical and Economic Outcomes.

We surveyed 181 nursing research leaders from Magnet® hospitals, using mixed methods with the online Hospital-Based Nursing Research Clinical and Economic Outcomes survey, to describe the clinical and economic outcomes of nursing research conducted in hospital settings. We used descriptive statistics to analyze the quantitative findings and a qualitative descriptive approach to study the open-ended responses. Most respondents reported that findings from their hospital-based studies were implemented on their units (88.2%), improved health care processes (88.2%), and reduced hospital costs (79%). Over 50% reported positive impacts on core quality measures, including improving patient/family satisfaction (76.8%), nurse satisfaction (65%), length of stay (59.1%), and infection rates (56.5%). Four themes were identified: study evaluation, improvements in care delivery/clinical outcomes, economic impact, and intrinsic and extrinsic rewards. Much of the research reported by respondents focused on quality measures with findings that resulted in improved clinical and economic outcomes.

Reducing Unnecessary Phlebotomy Testing Using a Clinical Decision Support System.

INTRODUCTION: Reducing unnecessary tests reduces costs without compromising quality. We report here the effectiveness of a clinical decision support system (CDSS) on reducing unnecessary type and screen tests and describe, estimated costs, and unnecessary provider ordering. METHODS: We used a pretest posttest design to examine unnecessary type and screen tests 3 months before and after CDSS implementation in a large academic medical center. The clinical decision support system appears when the test order is initiated and indicates when the last test was ordered and expires. Cost savings was estimated using time-driven activity-based costing. Provider ordering before and after the CDSS was described. RESULTS: There were 26,206 preintervention and 25,053 postintervention specimens. Significantly fewer unnecessary type and screen tests were ordered after the intervention (12.3%, n = 3,073) than before (14.1%, n = 3,691; p < .001) representing a 12.8% overall reduction and producing an estimated yearly savings of $142,612. Physicians had the largest weighted percentage of unnecessary orders (31.5%) followed by physician assistants (28.5%) and advanced practice nurses (11.9%). CONCLUSIONS: The CDSS reduced unnecessary type and screen tests and annual costs. Additional interventions directed at providers are recommended. The clinical decision support system can be used to guide all providers to make judicious decisions at the time of care.

Establishing an Open Access Repository for Doctor of Nursing Practice Projects.

The Doctor of Nursing Practice (DNP) faculty at the George Washington University (GW) decided to create a digital DNP Project Repository for our students in 2016 based on the American Association of Colleges of Nursing (AACN) 2015 recommendations to do so. We describe the two-year process during which the DNP faculty and the GW librarians at our Health Sciences Library collaborated to create the DNP project repository. This article contains important information that was learned about digital institutional repositories, the criteria used in deciding to make the GW library's Health Sciences Research Commons the home for the repository, along with questions and concerns that arose during the process. Our library internally collaborated to customize the digital collection to meet the needs of DNP students and their project teams. Development included creating the URL for the collection, customizing digital metadata fields, developing submission forms and guidelines, and adding embargo options for projects. A pilot collection of six DNP projects was completed in 2017; and in 2018, the first cohort of 34 students submitted their projects to our repository. Outcomes are reported of the repository launch, lessons learned, and repository submission experiences of two DNP students. We believe our journey may guide others.

National Study of Nursing Research Characteristics at Magnet®-Designated Hospitals.

OBJECTIVE: To describe the research infrastructure, culture, and characteristics of building a nursing research program in Magnet®-designated hospitals. BACKGROUND: Magnet recognition requires hospitals to conduct research and implement evidence-based practice (EBP). Yet, the essential characteristics of productive nursing research programs are not well described. METHODS: We surveyed 181 nursing research leaders at Magnet-designated hospitals to assess the characteristics in their hospitals associated with research infrastructure, research culture, and building a nursing research program. RESULTS: Magnet hospitals provide most of the needed research infrastructure and have a culture that support nursing research. Higher scores for the 3 categories were found when hospitals had a nursing research director, a research department, and more than 10 nurse-led research studies in the past 5 years. CONCLUSIONS: While some respondents indicated their nurse executives and leaders support the enculturation of EBP and research, there continue to be barriers to full implementation of these characteristics in practice.

Family Presence During Trauma Resuscitation: Family Members' Attitudes, Behaviors, and Experiences.

BACKGROUND: The paradigm is shifting from separating family members from their children during resuscitation to one of patient- and family-centered care. However, widespread acceptance is still lacking. OBJECTIVE: To measure attitudes, behaviors, and experiences of family members of pediatric patients during the resuscitation phase of trauma care, including family members who were present and those who were not. METHODS: An observational mixed-methods study using structured interviews and focus groups was conducted at 3 level 1 pediatric trauma centers. Family members of children who met trauma team activation criteria (N = 126; 99 present, 27 not present) were interviewed; 25 also participated in focus groups. RESULTS: Mean attitude scores indicated a positive attitude about being present during the resuscitation phase of trauma care (3.65; SD, 0.37) or wanting to be present (3.2; SD, 0.60). Families present reported providing emotional support (94%) for their child and health care information (92%) to the medical team. Being present allowed them to advocate for their child, understand their child's condition, and provide comfort. Families in both groups felt strongly that the choice was their right but was contingent upon their bedside behavior. CONCLUSIONS: Study findings demonstrated compelling family benefits for presence during pediatric trauma care. This study is one of the first to report on family members who were not present. The practice of family presence should be made a priority at pediatric trauma centers.

Perioperative hypothermia in NICU infants: its occurrence and impact on infant outcomes.

Infants admitted to the neonatal intensive care unit (NICU) often require surgical intervention and maintaining normothermia perioperatively is a major concern. In our preliminary study of 31 normothermic infants undergoing operative procedures in the operating room (OR), 58% (N = 18) returned hypothermic while all 5 undergoing procedures in the NICU remained normothermic (P = .001). To describe perioperative thermal instability (temperatures lower than 36.0°C) and frequency of associated adverse events, support interventions, and diagnostic tests in infants undergoing operative procedures in the OR and the NICU. This prospective, case-control study included 108 infants admitted to the NICU who were sequentially scheduled for an operative procedure in the OR (50.93%; N = 55) or the NICU (49.07%; N = 53). Existing data from the medical record were collected about temperatures and frequency of adverse cardiovascular, respiratory, and metabolic events, associated support interventions, and diagnostic tests during the perioperative period. Analyses examined the relative risks and proportional differences in rates of hypothermia between the OR group and the NICU group and associated adverse events, support interventions, and diagnostic tests between hypothermic and normothermic infants. Hypothermia developed in 40% (N = 43) of infants during the perioperative period. The OR group had a higher rate of perioperative hypothermia (65.45%, N = 36; P < .001) and were 7 times more likely to develop perioperative hypothermia (P = .008) than the NICU group (13.21%, N = 7). Likewise, infants in the OR group were 10 times more likely to develop hypothermia during the intra- and postoperative periods than those in the NICU group (P = .001). The hypothermic group had significantly more respiratory adverse events (P = .025), were 6 times more likely to require thermoregulatory interventions (P < .001), 5 times more likely to require cardiac support interventions (P < .006), and 3 times more likely to require respiratory interventions (P = .02) than normothermic infants. Although infants undergoing operative procedures in the OR experienced significantly higher rates of hypothermia than those undergoing procedures in the NICU, both groups experienced unacceptable rates of clinical hypothermia. Hypothermic infants experienced more adverse events and required more support interventions during the intra- and postoperative periods than normothermic infants, thereby demonstrating the negative sequelae associated with thermal instability. As a result, a translational team of key stakeholders has been created to explore multifaceted strategies based on translation science to implement, embed, and sustain perioperative thermoregulation best practices for the infant, regardless of the operative setting.

Pediatric fasting times before surgical and radiologic procedures: benchmarking institutional practices against national standards.

Prolonged preoperative fasting can be associated with adverse outcomes, particularly in children. Our aims were to assess the time pediatric patients fasted prior to surgical or radiologic procedures and evaluate whether fasting (NPO) orders complied with national guidelines. We measured NPO start time, time of last intake, and time test or surgery was scheduled, took place, or was cancelled in 219 pediatric patients. Findings demonstrate that pediatric patients experienced prolonged fasting before procedures and that the majority of NPO orders were non-compliant with national guidelines. We have developed strategies to reduce fasting times and ensure compliance with recommended national fasting standards.

National survey of hospital nursing research, part 2: facilitators and hindrances.

OBJECTIVE: The aim of this study was to describe the facilitators and hindrances associated with the conduct of registered nurse-led research in US hospitals. BACKGROUND: Hospital-based nursing research programs are growing in response to increasing emphasis on evidence-based practice. Concerns existed about institutional regulations prohibiting staff nurses' ability to be principal investigators of their research studies. METHODS: Comments from the Hospital-Based Nursing Research Requirements and Outcomes national survey regarding facilitators and hindrances of conducting nursing research in hospitals were analyzed using content analysis. RESULTS: Comments from 95% of surveys were classified into 24 facilitator and hindrance codes. Both Magnet and non-Magnet hospitals identified the presence of a research mentor as the top facilitator. In non-Magnet hospitals, the top hindrance was a lack of a research mentor as compared with Magnet hospitals, which reported lack of time. CONCLUSIONS: The presence of a research mentor is the most important facilitator for hospital nursing research. Findings provide data to inform research program development.

National survey of hospital nursing research, part 1: research requirements and outcomes.

OBJECTIVE: The aim of this study was to describe program requirements and scholarly outcomes for registered nurse (RN)-led research in US hospitals. BACKGROUND: Magnet recognition emphasis on evidence-based practice and research has stimulated the growth of hospital-based nursing research programs. Hospital policies stipulating whether RNs can lead studies as principal investigators (PIs) varied among members of a regional nursing research consortium. METHODS: Members of the consortium conducted a national survey of hospitals regarding their requirements for RN-led research and associated scholarly outcomes. RESULTS: Most (87.1%) of the hospitals (N = 160) reported no minimum educational requirements for nurses to be PIs. Mentoring, training, and peer review/approval requirements differed between Magnet and non-Magnet hospitals. On average, hospitals reported an annual total of 4 studies initiated, 4 disseminated via podium or poster presentation, 1 published, and 2 funded. CONCLUSIONS: Findings from this study provide a prototype and benchmark information for nursing administrators planning to establish, evaluate, and/or expand nursing research programs.

Outcomes of implementing rapid triage in the pediatric emergency department.

INTRODUCTION: Efficiency and effectiveness are often used as quality indicators in emergency departments. With an aim to improve patient throughput and departmental efficiency while decreasing left-without-being-seen (LWBS) rates, this two-group, pre-intervention, post-intervention study in a pediatric emergency department evaluated the outcomes of implementing rapid triage on arrival-to-triage time, fast track utilization, and LWBS. METHODS: We implemented rapid triage assessment integrating the Emergency Severity Index and fast track guidelines in our pediatric emergency department. Arrival-to-triage times were tracked for 1 month before and after the intervention (N = 13,910 patient visits) by recording the time the patient arrived in the department and time triage assessment was complete. Fast track utilization and LWBS rates were measured for all patients sequentially included in pre-intervention (n = 60,373) and post-intervention (n = 67,939) groups for 10 months. RESULTS: After the intervention, patients experienced a significant decrease in arrival-to-triage times compared with the pre-intervention group (P < .001), with most patients (88.3%) being triaged in less than 10 minutes after the intervention. Following implementation of fast track guidelines, patients were 14% more likely to be triaged to fast track compared with pre-intervention patients (odds ratio [OR] = 1.14, 95% confidence interval [CI] = 1.11-1.67). Additionally, patients with the lowest acuity were nearly 50% more likely to be triaged to fast track compared with pre-intervention patients (OR = 1.48, 95% CI = 1.35-1.63). Although LWBS rates were insignificant, overall acuity level of this group was lower in the post-intervention group. DISCUSSION: Although LWBS rates did not decrease with the intervention, implementation of a rapid triage system and fast track guidelines reduced arrival-to-triage times and decreased acuity in the LWBS population. Implementing rapid triage and fast track guidelines can affect nurse-sensitive patient outcomes related to safety and care delivery in a pediatric emergency department.

Advancing evidence-based nursing practice in a children's hospital using competitive awards.

When creating an evidence-based practice (EBP) nursing environment became an organizational mandate for the authors' tertiary care pediatric hospital, they assessed the state of EBP at their hospital. Findings revealed inconsistent use of EBP principles by the nursing staff. Nurses routinely cited literature to inform practice guidelines and performance improvement initiatives, but they lacked skills to comprehensively search available literature and critically appraise evidence for its quality. In addition, evaluating practice changes was not universally used. To stimulate the consistent use of the full scope of EBP, we created a call for competitive awards for EBP projects. Three teams (Of eight proposals submitted) each received $5,000 to implement their projects. Teams also received comprehensive education and were assigned EBP experts to help them implement and evaluate their EBP projects. We report the steps taken to implement and evaluate this approach to stimulating nurses' interest in and use of EBP.

Family presence during trauma activations and medical resuscitations in a pediatric emergency department: an evidence-based practice project.

INTRODUCTION: The existing family presence literature indicates that implementation of a family presence policy can result in positive outcomes. The purpose of our evidence-based practice project was to evaluate a family presence intervention using the 6 A's of the evidence cycle (ask, acquire, appraise, apply, analyze, and adopt/adapt). For step 1 (ask), we propose the following question: Is it feasible to implement a family presence intervention during trauma team activations and medical resuscitations in a pediatric emergency department using national guidelines to ensure appropriate family member behavior and uninterrupted patient care? METHODS: Regarding steps 2 through 4 (acquire, appraise, and apply), our demonstration project was conducted in a pediatric emergency department during the implementation of a new family presence policy. Our family presence intervention incorporated current appraisal of literature and national guidelines including family screening, family preparation, and use of family presence facilitators. We evaluated whether it was feasible to implement the steps of our intervention and whether the intervention was safe in ensuring uninterrupted patient care. RESULTS: With regard to step 5 (analyze), family presence was evaluated in 106 events, in which 96 families were deemed appropriate and chose to be present. Nearly all families (96%) were screened before entering the room, and all were deemed appropriate candidates. Facilitators guided the family during all events. One family presence event was terminated. In all cases patient care was not interrupted. DISCUSSION: Regarding step 6 (adopt/adapt), our findings document the feasibility of implementing a family presence intervention in a pediatric emergency department while ensuring uninterrupted patient care. We have adopted family presence as a standard practice. This project can serve as the prototype for others.

Development and psychometric testing of the Attitudes Toward Mental Illness in Pediatric Patients Scale.

PROBLEM: To develop the Attitudes toward Mental Illness in Pediatric Patients (ATMIPP) Scale measuring nonpsychiatric provider attitudes toward pediatric patients with mental illness. METHODS: Responses from 492 nonpsychiatric and 30 psychiatric providers were evaluated for reliability and validity. Cronbach's alpha was used for reliability while factor analysis and known-groups technique were used for validity. FINDINGS: The scale's internal consistency was 0.85. Factor analysis revealed three factors (Comfort, Tolerance, and Unbiasness) accounting for 74.5% of the variance. Compared to nonpsychiatric providers, psychiatric providers had significantly more positive attitudes on the ATMIPP (p < 0.001). CONCLUSIONS: The ATMIPP has evidence of reliability and validity for the sampled population.

Development, testing, and national evaluation of a pediatric Patient-Family-Centered Care benchmarking survey.

This study provides evidence for reliability (the Cronbach alpha of .76-.94) and construct validity of the Patient-Family-Centered Care Survey developed by the researchers in collaboration with FKP Architects, used to measure and benchmark practice within pediatric institutions. The survey evaluates progress of integrating patient-family-centered care over time and can be triangulated with measurements of desired patient and institutional outcomes.

Perianesthesia nurses' pain management after tonsillectomy and adenoidectomy: pediatric patient outcomes.

Tonsillectomy and adenoidectomy (T and A) is a common, painful surgical procedure. The purpose of this descriptive-comparative study was to evaluate the effects of postanesthesia analgesic treatments on self-reported pain intensity, incidence of nausea and vomiting, and amount of oral fluid intake among pediatric patients after T and A. A total of 92 patients, 3 to 18 years old, received one of five analgesic treatments during their postoperative recovery: (1) intravenous fentanyl alone, (2) intravenous fentanyl in combination with an oral analgesic, (3) intravenous morphine alone, (4) intravenous morphine in combination with an oral analgesic, or (5) oral analgesics alone. Although significant differences were found in mg/kg morphine equivalents among the five analgesic groups (P < .0001), there were no differences in pain scores, incidence of nausea and vomiting, or amount of oral intake among the groups. Overall 29% of patients had nausea and vomiting, but all ingested oral fluids before discharge home. Nurses gave significantly more mg/kg morphine equivalents to patients who reported any pain while in the PACU (Phase I recovery) than patients who reported no pain (P = .046). All patient groups reported low pain scores upon discharge from Phase I and Phase II recovery. Nurses, however, reported difficulty obtaining pain-intensity scores for many patients, especially in Phase I. These findings suggest that despite variations in analgesics and the amount of analgesics administered, patients received adequate pain control. The findings also support the need for pain medication titration and validate that the amount required to relieve pain differs from child to child.