Toward Advanced Nursing Practice along with People-Centered Care Partnership Model for Sustainable Universal Health Coverage and Universal Access to Health.

Objective: this study developed a people-centered care (PCC) partnership model for the aging society to address the challenges of social changes affecting people's health and the new role of advanced practice nurses to sustain universal health coverage. Method: a people-centered care partnership model was developed on the basis of qualitative meta-synthesis of the literature and assessment of 14 related projects. The ongoing projects resulted in individual and social transformation by improving community health literacy and behaviors using people-centered care and enhancing partnership between healthcare providers and community members through advanced practice nurses. Results: people-centered care starts when community members and healthcare providers foreground health and social issues among community members and families. This model tackles these issues, creating new values concerning health and forming a social system that improves quality of life and social support to sustain universal health care through the process of building partnership with communities. Conclusion: a PCC partnership model addresses the challenges of social changes affecting general health and the new role of advanced practice nurses in sustaining UHC.

Toward Advanced Nursing Practice along with People-Centered Care Partnership Model for Sustainable Universal Health Coverage and Universal Access to Health / Prática Avançada de Enfermagem e a Parceria de Cuidados Centrados nas Pessoas para a Cobertura de Saúde Universal Sustentável e o Acesso Universal à Saúde / Por una enfermería de práctica avanzada y una alianza para la atención centrada en las personas, para la Cobertura Universal y Acceso Universal a la salud

ABSTRACT Objective: this study developed a people-centered care (PCC) partnership model for the aging society to address the challenges of social changes affecting people’s health and the new role of advanced practice nurses to sustain universal health coverage. Method: a people-centered care partnership model was developed on the basis of qualitative meta-synthesis of the literature and assessment of 14 related projects. The ongoing projects resulted in individual and social transformation by improving community health literacy and behaviors using people-centered care and enhancing partnership between healthcare providers and community members through advanced practice nurses. Results: people-centered care starts when community members and healthcare providers foreground health and social issues among community members and families. This model tackles these issues, creating new values concerning health and forming a social system that improves quality of life and social support to sustain universal health care through the process of building partnership with communities. Conclusion: a PCC partnership model addresses the challenges of social changes affecting general health and the new role of advanced practice nurses in sustaining UHC.

RESUMO Objetivo: o estudo desenvolveu um modelo de parceria de cuidados centrados nas pessoas (CCP) para uma sociedade que está envelhecendo, com o fim de enfrentar os desafios das mudanças sociais que afetam a saúde das pessoas e o novo papel da prática avançada de enfermagem para sustentar a cobertura universal de saúde. Método: um modelo de parceria de cuidados centrados nas pessoas foi desenvolvido com base na meta-síntese qualitativa da literatura e a avaliação de 14 projetos relacionados. Os projetos em curso resultaram na transformação individual e social, melhorando a alfabetização de saúde da comunidade e comportamentos que usam o cuidado centrado nas pessoas e aumentando a parceria entre os profissionais de saúde e membros da comunidade por meio da prática avançada de enfermagem. Resultados: o cuidado centrado nas pessoas começa quando os membros da comunidade e os profissionais de saúde colocam em primeiro plano as questões sociais entre os membros da comunidade e das famílias. Esse modelo aborda essas questões, a criação de novos valores relativos à saúde e forma um sistema social que melhora a qualidade de vida e dá apoio social para sustentar o sistema de saúde universal por meio da construção de parcerias com as comunidades. Conclusão: um modelo de parceria CCP aborda os desafios das mudanças sociais que afetam a saúde geral e o novo papel das enfermeiras de prática avançada em sustentar a UHC.

RESUMEN Objetivo: este estudio desarrolló un modelo de alianza para el cuidado centrado en las personas (CCP) para una sociedad envejecida, que haga frente a los retos de los cambios sociales que afectan a la salud de las personas y el nuevo papel de las enfermeras de práctica avanzada para apoyar la cobertura universal de salud. Método: un modelo de alianza para el cuidado centrado en las personas fue desarrollado sobre la base de la meta-síntesis cualitativa de la literatura y la evaluación de 14 proyectos relacionados. Los proyectos en curso dieron lugar a la transformación individual y social mejorando la “alfabetización sanitaria” de la comunidad y los comportamientos, utilizando los cuidados centrados en las personas y aumentando la colaboración entre los profesionales sanitarios y miembros de la comunidad a través de las enfermeras de práctica avanzada. Resultados: el cuidado centrado en las personas comienza cuando los miembros de la comunidad y los profesionales sanitarios ponen en primer plano a la salud y las cuestiones sociales entre los miembros de la comunidad y las familias. Este modelo aborda estas cuestiones, creando nuevos valores relativos a la salud y formando un sistema social que mejora la calidad de vida y el apoyo social para hacer sostenible la atención sanitaria universal a través del proceso de construcción de alianzas con las comunidades. Conclusión: un modelo de alianza para CCP responde a los desafíos de los cambios sociales que afectan a la salud en general y al nuevo papel de las enfermeras de práctica avanzada en el sostenimiento de la Cobertura Universal en Salud (CUS).

A web-based, patient-centered toolkit to engage patients and caregivers in the acute care setting: a preliminary evaluation.

We implemented a web-based, patient-centered toolkit that engages patients/caregivers in the hospital plan of care by facilitating education and patient-provider communication. Of the 585 eligible patients approached on medical intensive care and oncology units, 239 were enrolled (119 patients, 120 caregivers). The most common reason for not approaching the patient was our inability to identify a health care proxy when a patient was incapacitated. Significantly more caregivers were enrolled in medical intensive care units compared with oncology units (75% vs 32%; P < .01). Of the 239 patient/caregivers, 158 (66%) and 97 (41%) inputted a daily and overall goal, respectively. Use of educational content was highest for medications and test results and infrequent for problems. The most common clinical theme identified in 291 messages sent by 158 patients/caregivers was health concerns, needs, preferences, or questions (19%, 55 of 291). The average system usability scores and satisfaction ratings of a sample of surveyed enrollees were favorable. From analysis of feedback, we identified barriers to adoption and outlined strategies to promote use.

Benefits and risks of using smart pumps to reduce medication error rates: a systematic review.

BACKGROUND: Smart infusion pumps have been introduced to prevent medication errors and have been widely adopted nationally in the USA, though they are not always used in Europe or other regions. Despite widespread usage of smart pumps, intravenous medication errors have not been fully eliminated. OBJECTIVE: Through a systematic review of recent studies and reports regarding smart pump implementation and use, we aimed to identify the impact of smart pumps on error reduction and on the complex process of medication administration, and strategies to maximize the benefits of smart pumps. METHODS: The medical literature related to the effects of smart pumps for improving patient safety was searched in PUBMED, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) (2000-2014) and relevant papers were selected by two researchers. RESULTS: After the literature search, 231 papers were identified and the full texts of 138 articles were assessed for eligibility. Of these, 22 were included after removal of papers that did not meet the inclusion criteria. We assessed both the benefits and negative effects of smart pumps from these studies. One of the benefits of using smart pumps was intercepting errors such as the wrong rate, wrong dose, and pump setting errors. Other benefits include reduction of adverse drug event rates, practice improvements, and cost effectiveness. Meanwhile, the current issues or negative effects related to using smart pumps were lower compliance rates of using smart pumps, the overriding of soft alerts, non-intercepted errors, or the possibility of using the wrong drug library. CONCLUSION: The literature suggests that smart pumps reduce but do not eliminate programming errors. Although the hard limits of a drug library play a main role in intercepting medication errors, soft limits were still not as effective as hard limits because of high override rates. Compliance in using smart pumps is key towards effectively preventing errors. Opportunities for improvement include upgrading drug libraries, developing standardized drug libraries, decreasing the number of unnecessary warnings, and developing stronger approaches to minimize workarounds. Also, as with other clinical information systems, smart pumps should be implemented with the idea of using continuous quality improvement processes to iteratively improve their use.

Effects of early morning care, named "Comfort upon Rising" care, on postoperative orthopedic ambulation and morning activity.

AIM: To examine the effects of "Comfort upon Rising" care (CUR) as a new type of early morning care. METHODS: This was a quasi-experimental study using a convenience sampling and non-random assignment of 80 orthopedic postoperative inpatients needing ambulation assistance. The intervention group of 40 inpatients was given CUR designed to support the patients' needs. The control group of 40 inpatients was given conventional early morning care (CMC). Floor nurses conducted either CMC or CUR for subjects beginning the morning after surgery and continuing for 3 days. Mood was measured by the Wake-up Questionnaire (question I) and Profile of Mood States (POMS). Morning activities, which were daily living activities, breakfast behaviors including breakfast intake rate, were measured by Wake-up Questionnaire (question IV) and observation. RESULTS: Completing the study were 36 patients from the control group and 36 patients from the intervention group. Mood and activities in the morning were improved in the CUR group. CONCLUSION: CUR is a patient-centered care based on patients' individual needs and promotes self-care. CUR is more effective than CMC in promoting natural recovery after an operation.

Evaluation of use of electronic patient controlled analgesia pumps to improve patient safety in an academic medical center.

Patient controlled analgesia (PCA) and Patient-controlled epidural analgesia (PCEA) pumps are methods of pain control with complex smart infusion devices and are widely used in hospitals. Smart PCA/PCEA pumps can be programmed with the dose and rate of medications within pre-set ranges. However, adverse effects have been reported associated with these pumps' use. In this paper, we describe a prevalence observational study where observers used an electronic data collection tool to record pump settings and medications with PCA pumps, corresponding medication orders to identify errors. The results showed that there were many labeling and tubing change tag errors, which were a violation of hospital policy. A few potential harmful medication errors were identified but no critical errors. Study results suggest the importance of a standard process of PCA pump use. Next steps include implementing a safety bundle for improving PCA practice to support safe and effective pain management.

Clinical Workflow Observations to Identify Opportunities for Nurse, Physicians and Patients to Share a Patient-centered Plan of Care.

Patient- and Family-Centered Care (PFCC) is essential for high quality care in the critical and acute-specialty care hospital setting. Effective PFCC requires clinicians to form an integrated interprofessional team to collaboratively engage with the patient/family and contribute to a shared patient-centered plan of care. We conducted observations on a critical care and specialty unit to understand the plan of care activities and workflow documentation requirements for nurses and physicians to inform the development of a shared patient-centered plan of care to support patient engagement. We identified siloed plan of care documentation, with workflow opportunities to converge the nurses plan of care with the physician planned To-do lists and quality and safety checklists. Integration of nurses and physicians plan of care activities into a shared plan of care is a feasible and valuable step toward interprofessional teams that effectively engage patients in plan of care activities.

Participatory Design and Development of a Patient-centered Toolkit to Engage Hospitalized Patients and Care Partners in their Plan of Care.

Patient engagement has been identified as a key strategy for improving patient outcomes. In this paper, we describe the development and pilot testing of a web-based patient centered toolkit (PCTK) prototype to improve access to health information and to engage hospitalized patients and caregivers in the plan of care. Individual and group interviews were used to identify plan of care functional and workflow requirements and user interface design enhancements. Qualitative methods within a participatory design approach supported the development of a PCTK prototype that will be implemented on intensive care and oncology units to engage patients and professional care team members developing their plan of care during an acute hospitalization.

Development of a web-based observational tool for detecting intravenous medication errors with smart infusion pumps.

Computerized smart infusion pumps have been widely implemented to decrease the rate of intravenous (IV) medication errors in hospitals. However, these devices have not always achieved their potential, and important IV errors still persist. Findings from a previous study [1] that assessed the frequency of IV medication errors and the impact of smart infusion pumps identified major issues related to use of smart infusion pumps in a single facility, but generalizability of these results is uncertain. Additionally, lack of standardized methodology for measuring these errors remains an issue. In this study, we developed an observational tool to capture IV medication errors through iterative participatory design with interdisciplinary experts and then tested the tool by using incident cases regarding smart pump errors. We found that the tool could capture all smart infusion pump errors and is ready for testing for use as standard data collection tool in different hospital settings.

Evaluation of intravenous medication errors with smart infusion pumps in an academic medical center.

While some published research indicates a fairly high frequency of Intravenous (IV) medication errors associated with the use of smart infusion pumps, the generalizability of these results are uncertain. Additionally, the lack of a standardized methodology for measuring these errors is an issue. In this study we iteratively developed a web-based data collection tool to capture IV medication errors using a participatory design approach with interdisciplinary experts. Using the developed tool, a prevalence study was then conducted in an academic medical center. The results showed that the tool was easy to use and effectively captured all IV medication errors. Through the prevalence study, violation errors of hospital policy were found that could potentially place patients at risk, but no critical errors known to contribute to patient harm were noted.

An electronic patient risk communication board.

Communication failures have been identified as the root cause of the majority of medical malpractice claims and patient safety violations. We believe it is essential to share key patient risk information with healthcare team members at the patient's bedside. In this study, we developed an electronic Patient Risk Communication Board (ePRCB) to assist in bridging the communication gap between all health care team members. The goal of the ePRCB is to effectively communicate the patient's key risk factors, such as a fall risk or risk of aspiration, to the healthcare team and to reduce adverse events caused by communication failures. The ePRCB will transmit patient risk information and tailored interventions with easy-to-understand icons on an LCD screen at the point of care. A set of patient risk reminder icons was developed and validated by focus groups. We used the results of the evaluation to refine the icons for the ePRCB.

Leveraging standards to support patient-centric interdisciplinary plans of care.

As health care systems and providers move towards meaningful use of electronic health records, the once distant vision of collaborative patient-centric, interdisciplinary plans of care, generated and updated across organizations and levels of care, may soon become a reality. Effective care planning is included in the proposed Stages 2-3 Meaningful Use quality measures. To facilitate interoperability, standardization of plan of care messaging, content, information and terminology models are needed. This degree of standardization requires local and national coordination. The purpose of this paper is to review some existing standards that may be leveraged to support development of interdisciplinary patient-centric plans of care. Standards are then applied to a use case to demonstrate one method for achieving patient-centric and interoperable interdisciplinary plan of care documentation. Our pilot work suggests that existing standards provide a foundation for adoption and implementation of patient-centric plans of care that are consistent with federal requirements.

Smart medical environment at the point of care: auto-tracking clinical interventions at the bed side using RFID technology.

We developed a wireless auto-tracking system for tracking clinical intervention such as drug administrations and blood tests at the patient bedside. The system can not only authenticate patients and nurses, but also confirm medications and provide relevant information, depending on the clinical situation and personnel location. We conducted a feasibility experiment and examined whether or not the system could work as a patient safety measure in terms of reducing misidentifications of patients and medical errors including wrong medication type, dose, time, and route. Also, the duration of clinical interventions in the system were measured to compare with the BCMA system. Moreover, we conducted a qualitative evaluation with nurses and received feedback clarifying their perceptions of the system. The results showed that the system correctly recognized medical staff, patient ID, and medication data in real time. With regards to workflow time, a significant reduction of time of clinical interventions was observed, when compared to a bar-coding system. In addition, on the nurses' evaluation, we received mostly positive comments although they also clarified some issues to consider with regards to operability and privacy issues. We concluded that the system had great potential for reducing medical errors and nurse workload with high efficiency.

Comparison of RFID systems for tracking clinical interventions at the bedside.

In recent years, there have been high expectations for RFID technologies applied in the medical field, particularly for automatic identification and location of patients and medical supplies. However, few studies have measured the applicability of currently available RFID technologies in a medical environment. To determine the technical factors that affect the performance of RFID systems, we examined the performance of different types of tags for medications, medical equipment, nurses, and patients under different experimental conditions. Three kinds of passive RFID tags and one active RFID tag were used in our study. Passive tags were affected by materials such as liquid and metal. Tags based on 13.56MHz were most suited for identifying medications. Tag placement was one of the main factors involved in correct identification of nurses, patients, and medical equipment. The results of this study may help decision makers decide whether (which) RFID technologies are useful for tracking clinical workflow.

Safe patient transfer system with monitoring of location and vital signs.

In recent years, ubiquitous computing technologies have been applied in the field of medicine. Especially radio frequency identification (RFID) and small sensor networks could provide information about medical practices and patient status in order to prevent malpractices and improve the quality of medical care. As an example of this application, we developed a new system, named "a smart stretcher," which continuously monitors the patient's vital signs and detects apnea during transfer within a hospital. This system consists of a small air-mat type pressure sensor measuring both heart rate and respiration rate and a wireless network transmitting these vital data as well as patient ID to an alerting system to notify hospital staff of patient emergencies. Results of experiments in a clinical setting indicated that the system was reliable in continuous respiration monitoring and detection of apnea during patient transfer on the stretcher; however, detection of heartbeat rate was practically difficult because of the motion noises. Moreover patient ID and location were also correctly detected in real time. These results suggested the feasibility of our system for real clinical use.

Development of Secured Medical Network with TCP2 for Telemedicine.

We developed a secure medical image transmission system by using TCP2 which is a new technology that establishes secure communications in transport layer. Two experiments were conducted; TCP2 performance tests, and field tests that transmit real-time digital video image in domestic and international settings by equipping TCP2 with DVTS (Digital Video Transmission System). The results showed DVTS equipped with TCP2 has enough performance to send secure and high quality medical images. It was considered that medical network using TCP2 would contribute as an essential technology to telemedicine.