RESUMO
BACKGROUND: Provision of safe and efficient observer care to inpatients whose behavior puts them at risk for injury is a clinically challenging and costly endeavor for hospitals. At Massachusetts General Hospital (MGH; Boston), process improvement strategies were deployed to provide staff with an improved clinical model for patient observation, unit-based responsibility for allocating resources, and strategies to maintain a safer environment. METHODS: In a surgical trauma unit at MGH, a team of nursing leaders and clinicians created an innovative process to identify, assess, and develop best practices for ensuring patient safety in the hospital environment. Patients with delirium were identified as the most prevalent and concerning patient group, and specific interventions were developed to address their unique needs. From December 2012 through June 2014, the team successfully piloted the best practices (July 16, 2013-September 30, 2013) and implemented them. RESULTS: The baseline outcome metric of patient observer direct-care hours decreased from a median of 208 hours/week (January 1, 2012-July 13, 2013) to a median of 112 hours/week (July 14, 2013-June 28, 2014); a 46% decrease in utilization. Fall rate (falls per 1,000 patient-days) remained unchanged postimplementation, and staff satisfaction with the patient observer model increased from 9% to 72%, while costs associated with providing observer care remained stable. CONCLUSIONS: Providing the inpatient unit staff with the knowledge and tools needed to optimally manage patients with at-risk behaviors, including delirium, significantly decreased the number of staff hours spent at the bedside providing observation, did not negatively affect the unit fall rate, and increased staff engagement at no additional expense to the unit.
Assuntos
Delírio/fisiopatologia , Eficiência Organizacional , Assistentes de Enfermagem/organização & administração , Recursos Humanos de Enfermagem Hospitalar/organização & administração , Qualidade da Assistência à Saúde/organização & administração , Feminino , Humanos , Pacientes Internados , Capacitação em Serviço , Masculino , Segurança do Paciente , Projetos Piloto , Avaliação de Processos em Cuidados de Saúde , Medição de Risco , Prevenção do SuicídioRESUMO
BACKGROUND: Falls and delirium in general-hospital inpatients are related to increases in morbidity, mortality, and healthcare costs. Patients fall despite safeguards and programs to reduce falling. OBJECTIVE: The authors sought to determine the prevalence of diagnosed and undiagnosed delirium in patients who fell during their hospital stay. METHOD: The authors performed a retrospective electronic chart review of 252 patients who fell during their hospital stay. Falls were categorized by their severity (i.e., minor, moderate, and major). Demographic information, patient outcomes, and diagnostic criteria for delirium (per DSM-IV) were collected on the day of admission, the day of the fall, and the 2 days preceding the patient's fall. RESULTS: Falls in the general hospital were associated with delirium (both diagnosed and undiagnosed), advanced age, and specific surgical procedures. CONCLUSION: Improving the recognition of undiagnosed delirium may lead to sustainable and successful fall prevention programs. Detection of impairments in mental status can assist staff to create individualized patient care plans. Knowledge about which patients are at risk for injury from delirium and falls can lead to improvements in patient safety, functioning, and quality of life.
Assuntos
Acidentes por Quedas/estatística & dados numéricos , Delírio/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Acidentes por Quedas/prevenção & controle , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Delírio/diagnóstico , Diagnóstico Diferencial , Feminino , Hospitais Gerais/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Masculino , Massachusetts , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Estudos Retrospectivos , Fatores de Risco , Prevenção Secundária , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/prevenção & controleRESUMO
PURPOSE/OBJECTIVES: To reduce workplace stress by developing a brief psychological skills training for nurses and to evaluate program feasibility, acceptability, and preliminary efficacy in decreasing burnout and stress. DESIGN: Intervention development and evaluation. SETTING: Outpatient chemotherapy unit at a comprehensive cancer center. SAMPLE: 26 infusion nurses and oncology social workers. METHODS: Focus groups were conducted with nurses. Results informed the development and evaluation of training for nurses. Participants completed the Maslach Burnout Inventory and Perceived Stress Scale post-training. MAIN RESEARCH VARIABLES: Burnout and stress. FINDINGS: Focus groups indicated strong commitment among nurses to psychosocial care and supported the idea that relationships with patients and families were sources of reward and stress. Stressors included factors that interfered with psychosocial care such as difficult family dynamics, patient behaviors and end-of-life care issues. Psychological skills training was developed to address these stressors. Evaluations suggested that the program was feasible and acceptable to nurses. At two months, participants showed reductions in emotional exhaustion (p = 0.02) and stress (p = 0.04). CONCLUSIONS: Psychological skills training for managing difficult encounters showed feasibility, acceptability, and potential benefit in reducing emotional exhaustion and stress. IMPLICATIONS FOR NURSING: Brief training that targets sources of clinical stress may be useful for nurses in outpatient chemotherapy units. KNOWLEDGE TRANSLATION: Specific stressors in relationships with patients and families present challenges to nurses' therapeutic use of self. Targeted psychological skills training may help nurses problem-solve difficult encounters while taking care of themselves. System-level strategies are needed to support and promote training participation.
Assuntos
Esgotamento Profissional/psicologia , Recursos Humanos de Enfermagem Hospitalar/educação , Enfermagem Oncológica/educação , Desenvolvimento de Pessoal/organização & administração , Adulto , Institutos de Câncer , Estudos de Viabilidade , Feminino , Hidratação/enfermagem , Grupos Focais , Humanos , Masculino , Pessoa de Meia-Idade , Pesquisa em Avaliação de Enfermagem , Ambulatório Hospitalar , Desenvolvimento de Programas , Pesquisa Qualitativa , Serviço SocialAssuntos
Relações Enfermeiro-Paciente , Enfermeiras e Enfermeiros/psicologia , Equipe de Assistência ao Paciente , Estresse Psicológico/etiologia , Assistência Terminal , Recusa do Paciente ao Tratamento , Adulto , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Ira , Empatia , Ética em Enfermagem , Feminino , Frustração , Humanos , Relações Enfermeiro-Paciente/ética , Dor/tratamento farmacológico , Equipe de Assistência ao Paciente/ética , Enfermagem Psiquiátrica/ética , Assistência Terminal/ética , Assistência Terminal/psicologia , Recusa do Paciente ao Tratamento/ética , Recusa do Paciente ao Tratamento/psicologiaRESUMO
BACKGROUND: Although alcohol use and abuse are common among general-hospital inpatients, many patients are inadequately assessed and treated for alcohol withdrawal. OBJECTIVE: The purpose of this study was to determine whether the implementation of a clinical pathway for the treatment of alcohol withdrawal in medical inpatients would result in improvements in clinical practice and patient outcomes. METHOD: Authors retrospectively reviewed 80 patient records (including 40 of those treated before the implementation of a pathway and 40 of those treated after pathway implementation). RESULTS: Assessment procedures and ordering patterns of physicians (medical house staff and staff physicians) shifted in a fashion consistent with the new treatment guidelines. Patient outcomes (e.g., length of stay and the incidence of delirium) improved for those patients who received benzodiazepines within the range of the pathway guidelines. CONCLUSIONS: Timely assessment and staff education can shift prescription patterns, increase patient monitoring, and reduce costs associated with alcohol withdrawal.
Assuntos
Alcoolismo/reabilitação , Etanol/efeitos adversos , Hospitais Gerais , Síndrome de Abstinência a Substâncias/etiologia , Síndrome de Abstinência a Substâncias/reabilitação , Ansiolíticos/uso terapêutico , Benzodiazepinas/uso terapêutico , Feminino , Nível de Saúde , Hospitalização , Humanos , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Estudos Retrospectivos , Síndrome de Abstinência a Substâncias/tratamento farmacológicoRESUMO
Look beyond the stereotype. Any hospitalized patient could be dependent on alcohol-and at risk for alcohol withdrawal syndrome.