Evaluation of health alerts from an early illness warning system in independent living.

Passive sensor networks were deployed in independent living apartments to monitor older adults in their home environments to detect signs of impending illness and alert clinicians so they can intervene and prevent or delay significant changes in health or functional status. A retrospective qualitative deductive content analysis was undertaken to refine health alerts to improve clinical relevance to clinicians as they use alerts in their normal workflow of routine care delivery to older adults. Clinicians completed written free-text boxes to describe actions taken (or not) as a result of each alert; they also rated the clinical significance (relevance) of each health alert on a scale of 1 to 5. Two samples of the clinician's written responses to the health alerts were analyzed after alert algorithms had been adjusted based on results of a pilot study using health alerts to enhance clinical decision-making. In the first sample, a total of 663 comments were generated by seven clinicians in response to 385 unique alerts; there are more comments than alerts because more than one clinician rated the same alert. The second sample had a total of 142 comments produced by three clinicians in response to 88 distinct alerts. The overall clinical relevance of the alerts, as judged by the content of the qualitative comments by clinicians for each alert, improved from 33.3% of the alerts in the first sample classified as clinically relevant to 43.2% in the second. The goal is to produce clinically relevant alerts that clinicians find useful in daily practice. The evaluation methods used are described to assist others as they consider building and iteratively refining health alerts to enhance clinical decision making.

Future advancement of health care through standardized nursing terminologies: reflections from a Friends of the National Library of Medicine workshop honoring Virginia K. Saba.

OBJECTIVE: To honor the legacy of nursing informatics pioneer and visionary, Dr. Virginia Saba, the Friends of the National Library of Medicine convened a group of international experts to reflect on Dr. Saba's contributions to nursing standardized nursing terminologies. PROCESS: Experts led a day-and-a-half virtual update on nursing's sustained and rigorous efforts to develop and use valid, reliable, and computable standardized nursing terminologies over the past 5 decades. Over the course of the workshop, policymakers, industry leaders, and scholars discussed the successful use of standardized nursing terminologies, the potential for expanded use of these vetted tools to advance healthcare, and future needs and opportunities. In this article, we elaborate on this vision and key recommendations for continued and expanded adoption and use of standardized nursing terminologies across settings and systems with the goal of generating new knowledge that improves health. CONCLUSION: Much of the promise that the original creators of standardized nursing terminologies envisioned has been achieved. Secondary analysis of clinical data using these terminologies has repeatedly demonstrated the value of nursing and nursing's data. With increased and widespread adoption, these achievements can be replicated across settings and systems.

The use of bedside electronic medical record to improve quality of care in nursing facilities: a qualitative analysis.

It appears that the implementation and use of a bedside electronic medical record in nursing homes can be a strategy to improve quality of care. Staff like using the bedside electronic medical record and believe it is beneficial. Information gleaned from this qualitative evaluation of four nursing homes that implemented complete electronic medical records and participated in a larger evaluation of the use of an electronic medical record will be useful to other nursing homes as they consider implementing bedside computing technology. Nursing home owners and administrators must be prepared to undertake a major change requiring many months of planning to successfully implement. Direct care staff will need support as they learn to use the equipment, especially for the first 6 to 12 months after implementation. There should be a careful plan for continuing education opportunities so that staff learn to properly use the software and can benefit from the technology. After 12 to 24 months, almost no one wants to return to the era of paper charting.

Improving nurse care coordination with technology.

Technology offers potential solutions to the pending crisis of healthcare for older adults, while healthcare workers are in short supply. Technology can enable remote monitoring of individuals and early detection of potential problems, so that early interventions can help older adults remain as healthy and independent as possible. Research is under way with passive monitoring technology in senior housing that is finding patterns in the data that can enhance nurse care coordination through early illness detection. With early detection, interventions can be more effective and reduce hospitalization and other healthcare expenses. Case studies are presented, and implications are discussed.

Developing a comprehensive electronic health record to enhance nursing care coordination, use of technology, and research.

As in acute care, use of health information technology in long-term care holds promise for increased efficiency, better accuracy, reduced costs, and improved outcomes. A comprehensive electronic health record (EHR), which encompasses all health care measures that clinicians want to use-both standard health care assessments and those acquired through emerging technology-is the key to improved, efficient clinical decision making. New technologies using sensors to passively monitor older adults at home are being developed and are commercially available. However, integrating the clinical information systems with passive monitoring data so that clinical decision making is enhanced and patient records are complete is challenging. Researchers at the University of Missouri (MU) are developing a comprehensive EHR to: (a) enhance nursing care coordination at TigerPlace, independent senior housing that helps residents age in place; (b) integrate clinical data and data from new technology; and (c) advance technology and clinical research.

Extrauterine neuromaturation of low risk preterm infants.

The objective of the study was to follow neuromaturation in preterm infants. From serial exams in 90 low risk very low birthweight infants, each infant's Maturity Scores (the sum of tone, reflex, and response items) were plotted against postmenstrual age (PMA) when examined. Each infant's estimated line of best fit provides two descriptors of that infant's neuromaturation: slope (Individual Maturity Slope) and y-value (Predicted Maturity Score at 32-wk PMA). We found that Maturity Scores increased with PMA; 96% had correlation coefficients >0.8. Mean Actual and Predicted Maturity Scores at 32-wk PMA were 60 and 58, respectively, in 65 infants. When stratified by gestational age, Mean Actual Maturity Score at 30-wk PMA were 50 whether infants were 1 or several weeks old when examined. Therefore, low risk preterm infants demonstrated individual variability in rate of neuromaturation. Tone, reflexes, and responses nonetheless emerged in a predictable pattern, whether neuromaturation was intrauterine or extrauterine. This unique tool that measures preterm neuromaturation requires expertise but no technology. It has an exciting potential for providing insight into how emerging central nervous system function and structure influence each other, as well as how the central nervous system recovers from injury.

Pregnancy spacing among women delaying initiation of childbearing.

INTRODUCTION: An increasing proportion of women in the US and other countries delay initiation of childbearing until their thirties. Little is known about their subsequent pregnancies, particularly with regard to pregnancy spacing. OBJECTIVES: To determine interpregnancy interval (IPI) patterns, factors associated with IPI among women delaying initiation of childbearing until their thirties, and ascertain if delay in initiation of childbearing is associated with increased likelihood for short interpregnancy interval of less than 6 months. METHODS: A retrospective cohort study was performed using the Missouri maternal linked file for 1978-1997, inclusive. Analysis was limited to mothers aged 20-50 years at first pregnancy, having a first and second pregnancy during the study period; the sample size included 242,559 mother-infant pairs. Analysis strategies included stratified analysis, and multivariable logistic regression. Interpregnancy interval was main outcome variable, and was grouped in seven categories: 0-5, 6-11, 12-17, 18-23, 24-59, 60-119, >or=120 months. RESULTS: The mean interpregnancy interval was significantly shorter for women delaying start of childbearing (>or=30 years) compared to 20-29 year olds. Observed intervals are 31 (+/-24) months for mothers aged 20-29 years, 25 (+/-17) months for mothers aged 30-34 years, 21 (+/- 14) for 35-39 year olds, and 19 (+/-16) for 40-50 year olds (P < 0.0001). A significant trend for shorter intervals was noted as maternal age at first pregnancy increased (P < 0.0001). Factors associated with interpregnancy interval for women delaying initiation of childbearing included adverse outcome in preceding pregnancy, and low educational status. Mothers aged 35 and above at first pregnancy had increased odds for a second pregnancy following short IPI <6 months; (35-39 years OR = 1.26 95% CI 1.11-1.44; 40-50 OR = 1.91 95% CI 1.13-3.24). Mothers aged 30-34 years have lower odds for short IPI (OR = 0.93 95% CI 0.87-0.99). CONCLUSION: First time mothers aged 35 and above have higher odds of having a second pregnancy shortly after their first pregnancy. Given the increasing number of first time mothers aged 35 and above, these findings are of relevance for preconception counseling for this unique population of women.

Helping nursing homes "at risk" for quality problems: a statewide evaluation.

The Quality Improvement Program for Missouri (QIPMO), a state school of nursing project to improve quality of care and resident outcomes in nursing homes, has a special focus to help nursing homes identified as "at risk" for quality concerns. In fiscal year 2006, 92 of 492 Medicaid-certified facilities were identified as "at risk" using quality indicators (QIs) derived from Minimum Data Set (MDS) data. Sixty of the 92 facilities accepted offered on-site clinical consultations by gerontological expert nurses with graduate nursing education. Content of consultations include quality improvement, MDS, care planning, evidence-based practice, and effective teamwork. The 60 "at-risk" facilities improved scores 4%-41% for 5 QIs: pressure ulcers (overall and high risk), weight loss, bedfast residents, and falls; other facilities in the state did not. Estimated cost savings (based on prior cost research) for 444 residents who avoided developing these clinical problems in participating "at-risk" facilities was more than $1.5 million for fiscal year 2006. These are similar to estimated savings of $1.6 million for fiscal year 2005 when 439 residents in "at-risk" facilities avoided clinical problems. Estimated savings exceed the total program cost by more than $1 million annually. QI improvements demonstrate the clinical effectiveness of on-site clinical consultation by gerontological expert nurses with graduate nursing education.

Analyzing Hospital Transfers Using INTERACT Acute Care Transfer Tools: Lessons from MOQI.

OBJECTIVES: We explored the differences in potentially avoidable/unavoidable hospital transfers in a retrospective analysis of Interventions to Reduce Acute Care Transfers (INTERACT) Acute Transfer Tools (ACTs) completed by advanced practice registered nurses (APRNs) working in the Missouri Quality Improvement (QI) Initiative (MOQI). DESIGN: Cross-sectional descriptive study of 3996 ACTs for 32.5 calendar months from 2014 to 2016. Univariate analyses examined differences between potentially avoidable vs unavoidable transfers. Multivariate logistic regression analysis of candidate factors identified those contributing to avoidable transfers. SETTING: Sixteen nursing homes (NHs), ranging from 120 to 321 beds, in urban, metro, and rural communities within 80 miles of a large midwestern city. PARTICIPANTS: A total of 5168 residents with a median age of 82 years. MEASUREMENTS: Data from 3946 MOQI-adapted ACTs. RESULTS: A total of 54% of hospital transfers were identified as avoidable. QI opportunities related to avoidable transfers were earlier detection of new signs/symptoms (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 1.61-3.42; P < .001); discussions of resident/family preference (OR = 2.12; 95% CI = 1.38-3.25; P < .001); advance directive/hospice care (OR = 2.25; 95% CI = 1.33-3.82; P = .003); better communication about condition (OR = 4.93; 95% CI = 3.17-7.68; P < .001); and condition could have been managed in the NH (OR = 16.63; 95% CI = 10.9-25.37; P < .001). Three factors related to unavoidable transfers were bleeding (OR = .59; 95% CI = .46-.77; P < .001), nausea/vomiting (OR = .7; 95% CI = .54-.91; P = .007), and resident/family preference for hospitalization (OR = .79; 95% CI = .68-.93; P = .003). CONCLUSION: Reducing avoidable hospital transfers in NHs requires challenging assumptions about what is avoidable so QI efforts can be directed to improving NH capacity to manage ill residents. The APRNs served as the onsite coaches in the use and adoption of INTERACT. Changes in health policy would provide a revenue stream to support APRN presence in NH, a role that is critical to improving resident outcomes by increasing staff capacity to identify illness and guide system change. J Am Geriatr Soc 67:1953-1959, 2019.

Obesity and extreme obesity: new insights into the black-white disparity in neonatal mortality.

OBJECTIVE: To estimate whether the preponderance of obesity among black women could explain the black-white disparity in neonatal mortality. METHODS: This is a population-based study using longitudinally collected data among pregnant women from the state of Missouri spanning almost two decades (1978-1997). Obesity is defined in this study as body mass index (BMI) of at least 30 and further categorized into the typically reported three subclasses: class I (BMI 30.0-34.9), class II (BMI 35.0-39.9), and extreme/morbid obesity (BMI at least 40). The main outcome measures were neonatal mortality, early neonatal mortality, and late neonatal mortality. RESULTS: Overall, neonatal mortality and early neonatal mortality but not late neonatal mortality increased with higher obesity subclass, with the greatest risk registered among morbidly obese mothers (hazards ratio for neonatal mortality 1.3; 95% confidence interval [CI] 1.1-1.5; hazards ratio for early neonatal mortality 1.3; 95% CI 1.1-1.5). Among blacks, the risk for neonatal, early, and late neonatal mortality increased significantly with rising BMI (50-100% increments). However, offspring of obese white mothers had no elevated risks for any of the three indices of mortality regardless of maternal obesity subclass. CONCLUSION: Neonates of obese black mothers have an elevated risk of mortality throughout the neonatal period, whereas those of obese white mothers do not. Obesity among black mothers may contribute to the persistent black-white disparity in infant survival in the United States and could provide an avenue for narrowing the black-white gap in infant mortality. LEVEL OF EVIDENCE: II.

The increasing racial disparity in infant mortality rates: composition and contributors to recent US trends.

OBJECTIVES: We examined trends in birthweight-gestational age distributions and related infant mortality for African American and white women and calculated the estimated excess annual number of African American infant deaths. STUDY DESIGN: Live births to US-resident mothers with a maternal race of white or African American were selected from the National Center for Health Statistics' linked live birth-infant death cohort files (1985-1988 and 1995-2000). RESULTS: The racial disparity in infant mortality widened despite an increasing rate of white low-birthweight infants. White preterm infants had relatively greater gains in survival and the white advantage in survival at term increased. Annually, African American women experience approximately 3300 more infant deaths than would be expected. CONCLUSION: The increasing US racial disparity in infant mortality is largely influenced by changes in birthweight-gestational age-specific mortality, rather than the birthweight-gestational age distribution. Improvement in the survival of white preterm and low-birthweight infants, probably reflecting advances in and changing access to medical technology, contributed appreciably to this trend.

Pregnancy outcomes of American Indians: contrasts among regions and with other ethnic groups.

OBJECTIVES: The two-fold purpose of this analysis is first to contrast the maternal risk factors and birth outcomes of American Indians (AIs) with other race/ethnic groups and to compare the maternal risk factors and birth outcomes of AIs by region to assess whether there are geographic variations in the adverse outcomes that might suggest intervention strategies. STUDY DESIGN: This study used the National Center for Health Statistics live birth infant death cohort files from 1995-2001. Singleton live births to U.S. resident mothers were selected. The analyses were limited to non-Hispanic American Indians, including Aleuts and Eskimos (n = 239,494), Non-Hispanic White (n = 15,488,133), and Hispanic births (n = 5,284,978). RESULTS: This comparison of birth characteristics and outcomes by ethnic group revealed that AIs have more adverse maternal risk factors (e.g., unmarried and <18 years of age) than Whites and Hispanics. After adjustment for these factors, AIs have higher risks of low birth weight and preterm birth and elevated risks of postneonatal and infant mortality. Their cause-specific rates for perinatal, SIDS, injury and infection are also higher. The regional analysis indicated the South/Northeast have more low birth weight and preterm problems, but the Mid-West has the highest risks of infant mortality among LBW infants gestational age-specific mortality rates, and mortality from SIDS. CONCLUSIONS: These data show that AIs are not a homogenous group as evinced by distinct regional differences. SIDS is mainly a problem in the Mid-West, suggesting the involvement of environmental factors in that region. Further investigation is needed to examine the current AI perinatal health concerns.

APRN-Conducted Medication Reviews for Long-Stay Nursing Home Residents.

OBJECTIVE: As part of the Missouri Quality Initiative (MOQI) to reduce hospitalizations for long-stay nursing home residents, this article describes reasons MOQI advanced practice registered nurses (APRNs) recommended medication order changes as part of their medication review process as well as the outcomes of their recommendations. DESIGN: Cross-sectional descriptive study of MOQI APRN-conducted medication reviews. SETTING: Long-stay nursing homes participating in the MOQI project. PARTICIPANTS: Seventeen MOQI APRNs recorded medication reviews for 3314 long-stay residents residing in 16 Midwestern nursing homes over a 2-year period. INTERVENTION: APRNs conducted medication reviews and made recommendations for medication order changes to residents' medical providers. MEASUREMENTS: The MOQI medication review database was used to abstract data. RESULTS: There were 19,629 medication reviews recorded for 3314 residents during the 2-year period. Of the 19,629 reviews, 50% (n = 9841) resulted in recommended order changes of which 82% (n = 8037) of order changes occurred. More than two-thirds of recommendations were because of changes in the residents' plans of care. Other recommendations included adjusting and/or discontinuing medications that had the potential for harm. CONCLUSION: Resident care needs are dynamic, resulting in the need for frequent medication order changes. MOQI APRNs, because of their advanced pharmacological education and daily presence in the nursing home, are uniquely positioned to ensure residents' medications aligned with their overall goals of care while minimizing risk of harm.

Impact of Advanced Practice Registered Nurses on Quality Measures: The Missouri Quality Initiative Experience.

PURPOSE: The purpose of this article is to review the impact of advanced practice registered nurses (APRNs) on the quality measure (QM) scores of the 16 participating nursing homes of the Missouri Quality Initiative (MOQI) intervention. The MOQI was one of 7 program sites in the US, with specific interventions unique to each site tested for the Centers for Medicaid and Medicare Services Innovations Center. While the goals of the MOQI for long-stay nursing home residents did not specifically include improvement of the QM scores, it was anticipated that improvement most likely would occur. Primary goals of the MOQI were to reduce the frequency of avoidable hospital admissions and readmissions; improve resident health outcomes; improve the process of transitioning between inpatient hospitals and nursing facilities; and reduce overall healthcare spending without restricting access to care or choice of providers. METHODS: A 2-group comparison analysis was conducted using statewide QMs; a matched comparison group was selected from facilities in the same counties as the intervention homes, similar baseline QM scores, similar size and ownership. MOQI nursing homes each had an APRN embedded full-time to improve care and help the facility achieve MOQI goals. Part of their clinical work with residents and staff was to focus on quality improvement strategies with potential to influence healthcare outcomes. Trajectories of QM scores for the MOQI intervention nursing homes and matched comparison group homes were tested with nonparametric tests to examine for change in the desired direction between the 2 groups from baseline to 36 months. A composite QM score for each facility was constructed, and baseline to 36-month average change scores were examined using nonparametric tests. Then, adjusting for baseline, a repeated measures analysis using analysis of covariance as conducted. RESULTS: Composite QM scores of the APRN intervention group were significantly better (P = .025) than the comparison group. The repeated measures analysis identified statistically significant group by time interaction (P = .012). Then group comparisons were made at each of the 6-month intervals and statistically significant differences were found at 24 months (P = .042) and 36 months (P = .002), and nearly significant at 30 months (P = .11). IMPLICATIONS: APRNs working full time in nursing homes can positively influence quality of care, and their impact can be measured on improving QMs. As more emphasis is placed on quality and outcomes for nursing home services, providers need to find successful strategies to improve their QMs. Results of these analyses reveal the positive impact on QM outcomes for the majority of the MOQI nursing homes, indicating budgeting for APRN services can be a successful strategy.