Enforcement of Hospital Nurse Staffing Regulations Across the United States: Progress or Stalemate?

Enactment of hospital nurse staffing regulations was brought about by changes in the U.S. health care system that resulted in large-scale reductions in nurse staffing. These reductions came at a time when studies were highlighting inadequacies in care that caused negative patient outcomes and raised questions about the safety of hospitalized patients. Nurse staffing regulations were enacted to ensure that adequate numbers of nurses were available to provide high-quality and safe care. Although these regulations represent progress toward addressing staffing inadequacies, enforcement language is absent or weak and compliance data are either not collected or difficult to access. Explicit and funded enforcement measures need to be included in staffing regulations. Additionally, compliance monitoring and reporting are necessary to evaluate these types of staffing regulations and to determine if they actually achieve the goal of appropriate nurse staffing.

Use of three computer training methods in elderly underserved rural patients enrolled in a diabetes telemedicine program.

A telephone survey of Medicare beneficiaries with diabetes living in rural underserved areas and enrolled in the Informatics for Diabetes Education and Telemedicine project identified 109 subjects who requested further training in functions of the home telemedicine unit after initial in-home training by regional nurse installers. The initial training provided the skills needed to videoconferences with nurse case managers and to transmit blood glucose and blood pressure readings, but further instruction was needed for access to Web-based education features and messaging. This study evaluated these elderly patients' perceptions of the helpfulness of three additional telemedicine training methods:in-home visit with an regional nurse installer referencing a user's manual, unassisted patient use of the user's manual, and telephone-based training not using regional nurse installers reinforcing the user's manual. Eligible subjects rated the helpfulness of the three computer training methods on a five-point Likert scale (1 = "not helpful at all," 5 = "very helpful"). Participants rated "in-home" training with an regional nurse installer significantly higher than they did for the user's manual alone (P < .01). In response to this finding and other companion usability studies, Informatics for Diabetes Education and Telemedicine deployed home telemedicine units with enhanced remote training capabilities to better emulate characteristics of in-person training.

School-centered telemedicine for children with type 1 diabetes mellitus.

OBJECTIVES: To test the feasibility and effectiveness of telemedicine to improve care of children with type 1 diabetes in schools. STUDY DESIGN: Subjects, ages 5 to 14 years (grades kindergarten through eighth) were randomized to usual care (18 students; 13 schools) or intervention (23 students; 12 schools). Usual care included medical visits every 3 months and communication between school nurse and diabetes team as needed by phone. The intervention group received usual care plus a telemedicine unit in the school nurse office to videoconference between the school nurse, child, and diabetes team every month. Hemoglobin A1c and pediatric quality of life were measured every 3 months for 1 year. Analyses used multilevel modeling. RESULTS: A1c values increased from baseline to 6 months for students in the usual care group and decreased in the telemedicine cohort (P < .02). Lower A1c levels in the telemedicine group were maintained over the next several months, and significant improvements in several subscales of the Pediatric Diabetes Quality of Life questionnaire were observed. In the telemedicine group, urgent diabetes-related calls initiated by the school nurse were significantly reduced, and there were fewer hospitalizations and emergency department visits. CONCLUSIONS: A school telemedicine program can improve diabetes care in grades kindergarten through eighth.

A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.

BACKGROUND: Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions who experience barriers to access to care or a high burden of illness. METHODS: The authors conducted a randomized, controlled trial comparing telemedicine case management to usual care, with blinding of those obtaining outcome data, in 1,665 Medicare recipients with diabetes, aged 55 years or greater, and living in federally designated medically underserved areas of New York State. The primary endpoints were HgbA1c, blood pressure, and low-density lipoprotein (LDL) cholesterol levels. RESULTS: In the intervention group (n = 844), mean HgbA1c improved over one year from 7.35% to 6.97% and from 8.35% to 7.42% in the subgroup with baseline HgbA1c > or =7% (n = 353). In the usual care group (n = 821) mean HgbA1c improved over one year from 7.42% to 7.17%. Adjusted net reductions (one-year minus baseline mean values in each group, compared between groups) favoring the intervention were as follows: HgbA1c, 0.18% (p = 0.006), systolic and diastolic blood pressure, 3.4 (p = 0.001) and 1.9 mm Hg (p < 0.001), and LDL cholesterol, 9.5 mg/dL (p < 0.001). In the subgroup with baseline HgbA1c > or =7%, net adjusted reduction in HgbA1c favoring the intervention group was 0.32% (p = 0.002). Mean LDL cholesterol level in the intervention group at one year was 95.7 mg/dL. The intervention effects were similar in magnitude in the subgroups living in New York City and upstate New York. CONCLUSION: Telemedicine case management improved glycemic control, blood pressure levels, and total and LDL cholesterol levels at one year of follow-up.

A comparison of diabetes education administered through telemedicine versus in person.

OBJECTIVE: To determine whether diabetes education can be provided as effectively through telemedicine technology as through in-person encounters with diabetes nurse and nutrition educators. RESEARCH DESIGN AND METHODS: A total of 56 adults with diabetes were randomized to receive diabetes education in person (control group) or via telemedicine (telemedicine group) and were followed prospectively. The education consisted of three consultative visits with diabetes nurse and nutrition educators. The in-person and telemedicine groups were compared using measures of glycemic control (HbA(1c)) and questionnaires to assess patient satisfaction and psychosocial functioning as related to diabetes. Outcome measures were obtained at baseline, immediately after the completion of diabetes education, and 3 months after the third educational visit. RESULTS: Patient satisfaction was high in the telemedicine group. Problem Areas in Diabetes scale scores improved significantly with diabetes education (adjusted P < 0.05, before vs. immediately after education and 3 months after education), and the attainment of behavior-change goals did not differ between groups. With diabetes education, HbA(1c) improved from 8.6 +/- 1.8% at baseline to 7.8 +/- 1.5% immediately after education and 7.8 +/- 1.8% 3 months after the third educational visit (unadjusted P < 0.001, P = 0.089 adjusted for BMI and age), with similar changes observed in the telemedicine and in-person groups. CONCLUSIONS: Diabetes education via telemedicine and in person was equally effective in improving glycemic control, and both methods were well accepted by patients. Reduced diabetes-related stress was observed in both groups. These data suggest that telemedicine can be successfully used to provide diabetes education to patients.

Telemedicine intervention effects on waist circumference and body mass index in the IDEATel project.

BACKGROUND: We examine the changes in waist circumference (WC) and body mass index (BMI) in older adults enrolled in a diabetes telemedicine program. The subjects were elderly Medicare beneficiaries participating in the rural (upstate New York) cohort of Informatics and Diabetes Education and Telemedicine, a randomized, controlled trial using telemedicine to improve diabetes care in which the primary outcome was glycemic control. METHODS: Ninety-two percent of the subjects had BMI >25 kg/m(2), and 65.8% had a BMI > or =30 kg/m(2). Intervention subjects received home televisits with a dietitian or nurse educator every 4-6 weeks. Blood glucose and blood pressure values were reviewed, and lifestyle and medication changes were recommended. Non-intervention subjects received usual care through their primary care physicians. Change in WC, BMI, diet, and exercise behaviors and knowledge were examined at baseline and 12 and 24 months. A mixed-effects path analysis was performed to examine direct and indirect effects. RESULTS: The telemedicine participants increased diet and exercise knowledge over time (P < 0.001). It was estimated that women in the telemedicine group reduced their WC over the 2 years by 1.2 cm, whereas women in the usual care group increased their WC by almost 1 cm (P = 0.02). Path analysis demonstrated that the intervention, through improved diet and exercise knowledge, was related to the decrease in WC (P = 0.006) and BMI (P = 0.004). CONCLUSIONS: Diabetes case management using telemedicine improved self-reported diet and exercise knowledge, practices, and behaviors, which in turn was associated with reductions in WC and BMI at 2 years.

Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus.

INTRODUCTION: Detection and response to medically urgent situations in patients with diabetes mellitus can improve the process and outcomes of care and potentially decrease morbidity and mortality. We examined the detection and remediation of medically urgent situations among older patients receiving telemedicine case management for diabetes. METHODS: In the setting of a randomized trial, 338 patients in the intervention group and living in upstate New York received a home telemedicine unit to transmit blood glucose and blood pressure values to a nurse case manager, videoconference with a nurse or dietitian every 4-6 weeks and access educational websites. The educators met with a supervising endocrinologist 4-5 times weekly and clinical recommendations were proposed to the primary care providers via mail, fax, or phone. RESULTS: Over a 36 month period, 67 medically urgent situations were identified and addressed (1.9 events/month). Some of these situations were potentially life-threatening, including major drug contraindications (N = 24), other medically urgent situations (N = 19), and medical urgent conditions (ie, unstable angina) (N = 24). CONCLUSION: The interaction via telemedicine in rural upstate New York between patients with diabetes mellitus, a diabetes care team, and primary care providers can successfully identify and remediate medically urgent situations.

Age affects ERK1/2 and NRF2 signaling in the regulation of GCLC expression.

We previously reported that activator protein-1 (AP-1) DNA binding activity was increased in vascular smooth muscle cells (VSMC) from old rats when exposed to high glucose or tumor necrosis factor (TNF-alpha) (Li et al., 2003. J Cell Physiol 197:418-425). We have now examined the relationship between the age-dependent activation of the ERK1/2-AP-1 pathway and modulation of constitutive gene expression of the catalytic subunit of glutamate-cysteine ligase (GCLC) in response to high glucose and TNF-alpha. GCLC mRNA levels were higher in VSMC from old rats compared to young, a pattern consistent with its protein levels. To determine whether age-related activation of ERK1/2-AP-1 signaling is responsible for the up-regulation of GCLC, the MEK inhibitors, PD98059 and U0126, were used to block ERK1/2 in VSMC from old rats. An increase in GCLC with inhibitors was observed, diminishing the likelihood of ERK1/2-AP-1 activation as the up-regulating signal for GCLC. However, the transcription factor Nrf2 was higher in nuclei and accompanied by increased Nrf2-ARE binding in VSMC from old rats. Furthermore, MEK inhibitors increased nuclear Nrf2 and Nrf2/ARE binding. These data suggest opposing effects of Nrf2 and ERK1/2 signaling in the modulation of GCLC expression in old animals.