Medication Safety Event Reporting: Factors That Contribute to Safety Events During Times of Organizational Stress.

BACKGROUND: Incident reports submitted during times of organizational stress may reveal unique insights. PURPOSE: To understand the insights conveyed in hospital incident reports about how work system factors affected medication safety during a coronavirus disease-2019 (COVID-19) surge. METHODS: We randomly selected 100 medication safety incident reports from an academic medical center (December 2020 to January 2021), identified near misses and errors, and classified contributing work system factors using the Human Factors Analysis and Classification System-Healthcare. RESULTS: Among 35 near misses/errors, incident reports described contributing factors (mean 1.3/report) involving skill-based errors (n = 20), communication (n = 8), and tools/technology (n = 4). Reporters linked 7 events to COVID-19. CONCLUSIONS: Skill-based errors were the most common contributing factors for medication safety events during a COVID-19 surge. Reporters rarely deemed events to be related to COVID-19, despite the tremendous strain of the surge on nurses. Future efforts to improve the utility of incident reports should emphasize the importance of describing work system factors.

An Organizational Commitment to Diversity, Equity, Inclusion, and Justice: A Multipronged Strategic Approach.

Cedars-Sinai is a sixth continuous Magnet organization in Southern California that embodies inclusive leadership in support of diversity, equity, inclusion, and justice (DEIJ) principles. The organization adheres to a strategic model prioritizing staff sense of belonging, empowerment, engagement, curiosity, and creativity. Employing inclusive leadership, we have implemented strong programs of professional development and continuous learning, innovation, and research. This leadership and these programs have fostered a culture of inquiry, support evidence-driven practice, quality improvement, and staff engagement. Our organization is committed to creating a caring and healing environment that promotes performance. We believe in practicing loving-kindness toward ourselves and others as a core value. Executive leadership support has been a key element in our successful implementation of DEIJ strategies, including employee resource groups, Shared Leadership Councils, transition to practice programs, health equity research, and innovative solutions. These strategies have been shown to yield a significant return on investment.

Seasonal COVID-19 surge related hospital volumes and case fatality rates.

BACKGROUND: Seasonal and regional surges in COVID-19 have imposed substantial strain on healthcare systems. Whereas sharp inclines in hospital volume were accompanied by overt increases in case fatality rates during the very early phases of the pandemic, the relative impact during later phases of the pandemic are less clear. We sought to characterize how the 2020 winter surge in COVID-19 volumes impacted case fatality in an adequately-resourced health system. METHODS: We performed a retrospective cohort study of all adult diagnosed with COVID-19 in a large academic healthcare system between August 25, 2020 to May 8, 2021, using multivariable logistic regression to examine case fatality rates across 3 sequential time periods around the 2020 winter surge: pre-surge, surge, and post-surge. Subgroup analyses of patients admitted to the hospital and those receiving ICU-level care were also performed. Additionally, we used multivariable logistic regression to examine risk factors for mortality during the surge period. RESULTS: We studied 7388 patients (aged 52.8 ± 19.6 years, 48% male) who received outpatient or inpatient care for COVID-19 during the study period. Patients treated during surge (N = 6372) compared to the pre-surge (N = 536) period had 2.64 greater odds (95% CI 1.46-5.27) of mortality after adjusting for sociodemographic and clinical factors. Adjusted mortality risk returned to pre-surge levels during the post-surge period. Notably, first-encounter patient-level measures of illness severity appeared higher during surge compared to non-surge periods. CONCLUSIONS: We observed excess mortality risk during a recent winter COVID-19 surge that was not explained by conventional risk factors or easily measurable variables, although recovered rapidly in the setting of targeted facility resources. These findings point to how complex interrelations of population- and patient-level pandemic factors can profoundly augment health system strain and drive dynamic, if short-lived, changes in outcomes.

Implementing a Departure Lounge: A Strategy to Improve Patient Flow and the Discharge Process.

This column presents the development of a Departure Lounge at Cedars Sinai Medical Center as a mechanism to assist in addressing capacity constraints. Departure lounges have been presented as an option to improve hospital throughput by providing a safe space for discharged patients to wait once medical and nursing care has been completed.

Symptomology following mRNA vaccination against SARS-CoV-2.

Despite demonstrated efficacy of vaccines against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the causative agent of coronavirus disease-2019 (COVID-19), widespread hesitancy to vaccination persists. Improved knowledge regarding frequency, severity, and duration of vaccine-associated symptoms may help reduce hesitancy. In this prospective observational study, we studied 1032 healthcare workers who received both doses of the Pfizer-BioNTech SARS-CoV-2 mRNA vaccine and completed post-vaccine symptom surveys both after dose 1 and after dose 2. We defined appreciable post-vaccine symptoms as those of at least moderate severity and lasting at least 2 days. We found that symptoms were more frequent following the second vaccine dose than the first (74% vs. 60%, P < 0.001), with >80% of all symptoms resolving within 2 days. The most common symptom was injection site pain, followed by fatigue and malaise. Overall, 20% of participants experienced appreciable symptoms after dose 1 and 30% after dose 2. In multivariable analyses, female sex was associated with greater odds of appreciable symptoms after both dose 1 (OR, 95% CI 1.73, 1.19-2.51) and dose 2 (1.76, 1.28-2.42). Prior COVID-19 was also associated with appreciable symptoms following dose 1, while younger age and history of hypertension were associated with appreciable symptoms after dose 2. We conclude that most post-vaccine symptoms are reportedly mild and last <2 days. Appreciable post-vaccine symptoms are associated with female sex, prior COVID-19, younger age, and hypertension. This information can aid clinicians in advising patients on the safety and expected symptomatology associated with vaccination.

Current status and future directions of U.S. genomic nursing health care policy.

BACKGROUND: As genomic science moves beyond government-academic collaborations into routine healthcare operations, nursing's holistic philosophy and evidence-based practice approach positions nurses as leaders to advance genomics and precision health care in routine patient care. PURPOSE: To examine the status of and identify gaps for U.S. genomic nursing health care policy and precision health clinical practice implementation. METHODS: We conducted a scoping review and policy priorities analysis to clarify key genomic policy concepts and definitions, and to examine trends and utilization of health care quality benchmarking used in precision health. FINDINGS: Genomic nursing health care policy is an emerging area. Educating and training the nursing workforce to achieve full dissemination and integration of precision health into clinical practice remains an ongoing challenge. Use of health care quality measurement principles and federal benchmarking performance evaluation criteria for precision health implementation are not developed. DISCUSSION: Nine recommendations were formed with calls to action across nursing practice workforce and education, nursing research, and health care policy arenas. CONCLUSIONS: To advance genomic nursing health care policy, it is imperative to develop genomic performance measurement tools for clinicians, purchasers, regulators and policymakers and to adequately prepare the nursing workforce.

Prophylactic Dressings for Maintaining Skin Integrity of Healthcare Workers When Using N95 Respirators While Preventing Contamination Due to the Novel Coronavirus: A Quality Improvement Project.

PURPOSE: Extended use of N95 respirator masks is far more prevalent during the coronavirus disease 2019 (COVID-19) pandemic. As WOC nurses, we were tasked with formulating procedures for protecting the facial skin integrity of healthcare workers (HCWs) using personal protective devices when caring for patients with suspected or active COVID-19, while avoiding contamination when the masks are donned or doffed. This quality improvement project describes how we approached this project within the limited time frame available as we cared for patients with established and suspected COVID-19. PARTICIPANTS AND SETTING: This project focused on HCW use of N95 respirator masks and dressings currently available in our facility. The 4 WOC nurses acted as quality improvement project directors and as participants. The setting for our project was our facility's simulation laboratory. APPROACH: We evaluated 6 topical products (an alcohol-free liquid acrylate, thin film dressing, thin hydrocolloid dressing, hydrocolloid blister care cushion, thin foam transfer dressing, and thick foam dressing) applied to skin in contact with 3 N95 respirators; all are available on our facility's formulary and all are in widespread clinical use. After the product was applied to the face and nose, the N95 respirator was donned and evaluated for fit. Participants then wore the devices for 10 hours and doffed the mask using established facility procedures. In order to evaluate for potential contamination including possible aerosolization, we applied a commercially available fluorescent lotion to simulate the presence of infectious particles. Contamination was assessed using an ultraviolet light for all dressings except for the alcohol-free liquid acrylate. We also evaluated cutaneous responses (skin integrity, irritation, comfort) during this period. OUTCOMES: We found that contamination of the simulated pathogen did not occur with removal of any of the protective products. No skin irritation was noted with any of the tested products after a 10-hour wear time underneath the N95 respirator masks, but mild discomfort was experienced with 3 of the dressings (thin film dressing and both hydrocolloid dressings). CONCLUSION: Based on these experiences, we recommend application of an alcohol-free liquid acrylate film to prevent facial skin injury associated with friction from the extended use of an N95 respirator mask. We further recommend performing a fit test and user-performed seal check with the use of any topical dressing and especially those that add cushion. For the duration of the COVID-19 pandemic, we recommend use of protective dressings to maintain skin integrity and protection from coronavirus infection as HCWs continue to provide care to all of patients under their care.

Chloroquine and Hydroxychloroquine for the Treatment of COVID-19: Review and Appraisal of Current Evidence.

Novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and associated coronavirus disease 19 (COVID-19) began ravaging most of the globe in November 2019. In the United States more than 25 million people have been infected with SARS-CoV-2. To date, COVID-19 has killed close to 400,000 U.S. citizens. In the face of limited pharmacotherapies, the current burden of SARS-CoV-2 and COVID-19 signals overwhelming sickness and trillions in healthcare costs ahead. The need to expeditiously identify safe and efficacious prophylaxis and treatment options is critical. Drug repositioning may be a promising strategy toward mitigating the impact of SARS-CoV-2 and COVID-19. This rapid review appraises available evidence on the viability of vintage antimalarial drugs chloroquine (CHQ) and its analog hydroxychloroquine (HCQ) repositioned for SARS-CoV-2 prophylaxis and COVID-19 treatment. Findings suggest neither the use of CHQ nor HCQ singularly, or concomitantly, with azithromycin and/or zinc provide definitive benefits for use against SARS-CoV-2 infection or COVID-19 illness. Moreover, administration of these medications was linked to significant and sometimes fatal complications.

Extracorporeal Membrane Oxygenation Appropriateness: An Interdisciplinary Consensus-Based Approach.

We describe a quality improvement initiative aimed at achieving interdisciplinary consensus about the appropriate delivery of extracorporeal membrane oxygenation (ECMO). Interdisciplinary rounds were implemented for all patients on ECMO and addressed whether care was consistent with a patient's minimally acceptable outcome, maximally acceptable burden, and relative likelihood of achieving either. The rounding process was associated with decreased days on venoarterial ECMO, from a median of 6 days in 2014 (first quartile [Q1]-third quartile [Q3], 3-10) to 5 days in 2015 (Q1-Q3, 2.5-8) and in 2016 (Q1-Q3, 1-8). Our statistical methods do not allow us to conclude that this change was due to our intervention, and it is possible that the observed decreases would have occurred whether or not the rounding process was implemented.

Establishing the Genomic Knowledge Matrix for Nursing Science.

PURPOSE: To establish the knowledge needed to integrate the multiple branches of omics into nursing research to accelerate achieving the research recommendations of the Genomic Nursing Science Blueprint. METHODS: The creation of the Genomic Knowledge Matrix occurred in three phases. In phase 1, the Omics Nursing Science and Education Network (ONSEN) Education Workgroup completed an evidence, bioinformatics, and technology review to inform the components of the Matrix. The ONSEN Advisory Panel then reviewed and integrated revisions. Phase 3 solicited targeted public comment focused on education and research experts, and applicable revisions were made. FINDINGS: The Genomic Knowledge Matrix establishes the following content areas: cellular and molecular biology, system physiology, microbiology, and translational bioinformatics as the minimum required preparation for nurse scientists to understand omics and to integrate this knowledge into research. The Matrix also establishes levels of understanding needed to function based on the role of the nurse scientist. CONCLUSIONS: The Genomic Knowledge Matrix addresses knowledge important for nurse scientists to integrate genomics into their research. Building on prior recommendations and existing genomic competencies, the Matrix was designed to present key knowledge elements critical to understand omics that underpin health and disease. Knowledge depth varies based on the research role. CLINICAL RELEVANCE: The Genomic Knowledge Matrix provides the vital guidance for training nurse scientists in the integration of genomics. The flexibility of the Matrix also provides guidance to inform fundamental genomic content needed in core science content in undergraduate and graduate level nursing curricula.

Advocacy and actions to address disparities in access to genomic health care: A report on a National Academies workshop.

BACKGROUND: In the United States, access to genomic risk assessment, testing, and follow up care is most easily obtained by those who have sufficient financial, educational, and social resources. Multiple barriers limit the ability of populations without those resources to benefit from health care that integrates genomics in assessment of disease risk, diagnosis, and targeted treatment. PURPOSE: To summarize barriers and potential actions to reduce genomic health care disparities. METHOD: Summarize authors' views on discussions at a workshop hosted by the National Academy of Medicine. DISCUSSION: Barriers include access to health care providers that utilize genomics, genetic literacy of providers and patients, and absence of evidence of gene variants importance in ancestrally diverse underserved populations. CONCLUSION: Engagement between underserved communities, health care providers, and policy makers is an essential component to raise awareness and seek solutions to barriers in access to genomic health care for all populations.

Systems Addressing Frail Elders (SAFE) Care: Description of Successful Partnerships Across Hospitals.

Systems Addressing Frail Elders (SAFE) Care is an interprofessional team-based program, which was developed and evaluated in a cluster randomized controlled trial. Results of this trial included reduced length of stay and complications for patients. This article describes a successful partnership across 4 Magnet hospitals in the dissemination of the model. A 2-year sequential implementation process was completed, with an approach of adoption, adaptation, and abandonment. The model was successfully implemented at each participating Magnet hospital. Implementation included capacity building, organizational change, and process implementation.

Exploration of African-American Nurses' Perceptions Toward Seeking and Utilizing Genetic Information.

Advances in genetics and genomics have revolutionized the treatment possibilities for common diseases. Many treatment prospects demonstrate promise for addressing population health disparities. African-American nurses have a crucial role in facilitating the translation of scientific discovery into real-world practice among at-risk populations. The primary aims of this pilot study were to gain insight into the contextual perspectives of African-American nurses' views about factors that impede, support, and/or promote genetics and genomics knowledge in practice and participation in research. Data were obtained from a focused discussion of N = 6 registered nurses who attended the 2011 National Black Nurses Association (NBNA) annual conference. Utilizing a grounded theory approach, themes extrapolated from the focused discussion included the need for genetic and genomic education, distrust, cultural competency in care interactions, and the role of the NBNA in providing education. Suggestions for explanatory relationships are also presented.

Improving Utilization of the Family History in the Electronic Health Record.

PURPOSE: The purpose of this article is to provide an overview of Family History in the Electronic Health Record and to identify opportunities to advance the contributions of nurses in obtaining, updating and assessing family history in order to improve the health of all individuals and populations. ORGANIZING CONSTRUCT: The article presents an overview of the obstacles to charting Family History within the Electronic Health Record and recommendations for using specific Family History tools and core Family History data sets. METHODS: Opportunities to advance nursing contributions in obtaining, updating, and assessing family history in order to improve the health of all individuals were identified. These opportunities are focused within the area of promoting the importance of communication within families and between healthcare providers to obtain, document, and update family histories. FINDINGS: Nurses can increase awareness of existing resources that can guide collection of a comprehensive and accurate family history and facilitate family discussions. In this paper, opportunities to advance nursing contributions in obtaining, updating, and assessing family history in order to improve the health of all individuals were identified. CONCLUSIONS: Aligned with the clinical preparation of nurses, family health should be used routinely by nurses for risk assessment and to help inform patient and family members on screening, health promotion, and disease prevention. The quality of family health information is critical in order to leverage the use of genomic healthcare information and derive new knowledge about disease biology, treatment efficacy, and drug safety. These actionable steps need to be performed in the context of promoting evidence-based applications of family history that will be essential for implementing personalized genomic healthcare approaches and disease prevention efforts. CLINICAL RELEVANCE: Family health history is one of the most important tools for identifying the risk of developing rare and chronic conditions, including cardiovascular disease, cancer, and diabetes, and represents an integration of disease risk from genetic, environmental, and behavioral/lifestyle factors. In fact, family history has long been recognized as a strong independent risk factor for disease and is the current best practice used in clinical practice to guide risk assessment.

Implementation science, genomic precision medicine, and improved health: A new path forward?

Implementation of genomic discoveries into health care optimally includes evaluation of outcomes for recipients of care, providers, payers, and health care systems. However, the influence of specific aspects of the implementation process on observed outcomes may be missed if assessment of implementation success is not built into the implementation design. The intersection of implementation science with genomics may provide new insights on how to maximize the benefits of emerging genomic technologies in health care. In this summary, members of the Roundtable on Genomics and Precision Health, formerly the Roundtable on Translating Genomic-Based Research for Health, of the National Academies of Sciences, Engineering, and Medicine and the American Academy of Nursing explore challenges and opportunities for nurses to participate in implementing genomic discoveries into their practice informed by the principles of implementation science. Implementation requires collaboration across disciplines. Nurses can take leadership roles in engaging key stakeholders in health care organizations, assuring that communications regarding implementation are consistent with genomic literacy for each group of stakeholders, and planning for evaluation of data to assess how each component of the implementation process affected the overall outcome for health care.

Advanced nursing practice and research contributions to precision medicine.

BACKGROUND: Genomic discoveries in the era of precision medicine hold the promise for tailoring healthcare, symptom management, and research efforts including targeting rare and common diseases through the identification and implementation of genomic-based risk assessment, treatment, and management. However, the translation of these discoveries into tangible benefits for the health of individuals, families, and the public is evolving. PURPOSE: In this article, members of the Genetics Expert Panel identify opportunities for action to increase advanced practice nursing and research contributions toward improving genomic health for all individuals and populations. DISCUSSION: Identified opportunities are within the areas of: bolstering genomic focused advanced practice registered nurse practice, research and education efforts; deriving new knowledge about disease biology, risk assessment, treatment efficacy, drug safety and self-management; improving resources and systems that combine genomic information with other healthcare data; and advocating for patient and family benefits and equitable access to genomic healthcare resources.

Multi-ethnic minority nurses' knowledge and practice of genetics and genomics.

PURPOSE: Exploratory studies establishing how well nurses have integrated genomics into practice have demonstrated there remains opportunity for education. However, little is known about educational gaps in multi-ethnic minority nurse populations. The purpose of this study was to determine minority nurses' beliefs, practices, and competency in integrating genetics-genomics information into practice using an online survey tool. DESIGN: A cross-sectional survey with registered nurses (RNs) from the participating National Coalition of Ethnic Minority Organizations (NCEMNA). Two phases were used: Phase one had a sample of 27 nurses who determined the feasibility of an online approach to survey completion and need for tool revision. Phase two was a main survey with 389 participants who completed the revised survey. The survey ascertained the genomic knowledge, beliefs, and practice of a sample of multi-ethnic minority nurses who were members of associations comprising the NCEMNA. METHODS: The survey was administered online. Descriptive survey responses were analyzed using frequencies and percentages. Categorical responses in which comparisons were analyzed used chi square tests. FINDINGS: About 40% of the respondents held a master's degree (39%) and 42% worked in direct patient care. The majority of respondents (79%) reported that education in genomics was important. Ninety-five percent agreed or strongly agreed that family health history could identify at-risk families, 85% reported knowing how to complete a second- and third-generation family history, and 63% felt family history was important to nursing. Conversely, 50% of the respondents felt that their understanding of the genetics of common disease was fair or poor, supported by 54% incorrectly reporting they thought heart disease and diabetes are caused by a single gene variant. Only 30% reported taking a genetics course since licensure, and 94% reported interest in learning more about genomics. Eighty-four percent believed that their ethnic minority nurses' organizations should have a visible role in genetics and genomics in their communities. CONCLUSIONS: Most respondents felt genomics is important to integrate into practice but demonstrated knowledge deficits. There was strong interest in the need for continuing education and the role of the ethnic minority organizations in facilitating the continuing education efforts. This study provides evidence of the need for targeted genomic education to prepare ethnic minority nurses to better translate genetics and genomics into practice. CLINICAL RELEVANCE: Genomics is critical to the practice of all nurses, most especially family health history assessment and the genomics of common complex diseases. There is a great opportunity and interest to address the genetic-genomic knowledge deficits in the nursing workforce as a strategy to impact patient outcomes.

Non-Biological (Fictive Kin and Othermothers): Embracing the Need for a Culturally Appropriate Pedigree Nomenclature in African-American Families.

Although the Family Health History (FHH) is the most cost-effective tool in the staratification of disense risk, it is not designed to collect information from non-biological family members (NBFM). Significant NBFM, defined as "fictive kin and othermothers," tend to play a major role in the transmission of culture, health promotion, and decision-making; yet, their influence cannot be captured using the standard FHH. Participants attending the National Black Nurses Association (NBNA) 2012 genetic workshop were divided into groups to role-play FHH. All participants (N = 50) indicated difficulties with the standard FHH, ranking collection of sensitive data as the number 1 challenge. Consequently, a new symbol was developed with support from NBNA genetics workshop participants. Having such a symbol afforts an apportunity for inclusion of all NBFM to help guide risk-specific recommendations for disense management, prevention, and health promotion of common chronic diseases. This report will describe the process, presentation, and adoption of the symbol.

Implications for Socio-environmental Determinants of Health-Informed Health Worker Wellness Programs: Findings from a Cross-Sectional Study.

PURPOSE: To explore how socio-environmental factors may potentially impact health outcomes across different groups of health workers (HW). METHOD: Data from the California Healthy Places Index (HPI) and administrative dataset including 12,715 HWs were analyzed using analysis of variance and two-step cluster analysis to evaluate variations in socio-environmental factors across 11 HW job categories. RESULTS: While physicians had the highest average HPI percentiles (69th percentile) across almost all HPI components, the lower-wage HWs consistently ranked below the state average (50th percentile). Overall, the HPI percentile was lowest for environmental living conditions and pollution for all HCWs (30th percentile). The education (52nd percentile) and economic components (59th percentile) were higher than the state average. CONCLUSIONS: The findings from this highlight the importance of socio-environmental determinants of health-informed employee wellness programs and research studies.