Electronic Health Record Usability and Postsurgical Outcomes Among Older Adults With Dementia.

INTRODUCTION: Electronic health record (EHR) usability, defined as the extent to which the system can be used to complete tasks, can influence patient outcomes. The aim of this study is to assess the relationship between EHR usability and postsurgical outcomes of older adults with dementia including 30-day readmission, 30-day mortality, and length of stay (LOS). METHODS: A cross-sectional analysis of linked American Hospital Association, Medicare claims data, and nurse survey data was conducted using logistic regression and negative binominal models. RESULTS: The dementia population who received care in hospitals with better EHR usability were less likely to die within 30 days of their admission following surgery compared to hospitals with poorer EHR usability (OR: 0.79, 95% CI: 0.68-0.91, p = 0.001). EHR usability was not associated with readmission or LOS. DISCUSSION: Better nurse reported EHR usability has the potential to reduce mortality rates among older adults with dementia in hospitals.

Using Family Narrative Reports to Identify Practices for Improving End-of-Life Care Quality.

CONTEXT: Patient experiences should be considered by healthcare systems when implementing care practices to improve quality of end-of-life care. Families and caregivers of recent in-patient decedents may be best positioned to recommend practices for quality improvement. OBJECTIVES: To identify actionable practices that bereaved families highlight as contributing to high quality end-of-life care. METHODS: We conducted qualitative content analysis of narrative responses to the Bereaved Family Surveys Veterans Health Administration inpatient decedents. Out of 5964 completed surveys in 2017, 4604 (77%) contained at least one word in response to the open-ended questions. For feasibility, 1500/4604 responses were randomly selected for analysis. An additional 300 randomly selected responses were analyzed to confirm saturation. RESULTS: Over 23% percent (355/1500) of the initially analyzed narrative responses contained actionable practices. By synthesizing narrative responses to the BFS in a national healthcare system, we identified 98 actionable practices reported by the bereaved families that have potential for implementation in QI efforts. Specifically, we identified 67 end-of-life practices and 31 practices in patient-centered care domains of physical environment, food, staffing, coordination, technology and transportation. The 67 cluster into domains including respectful care and communication, emotional and spiritual support, death benefits, symptom management. Sorting these practices by target levels for organizational change illuminated opportunities for implementation. CONCLUSION: Narrative responses from bereaved family members can yield approaches for systematic quality improvement. These approaches can serve as a menu in diverse contexts looking for approaches to improve patient quality of death in in-patient settings.

Palliative Care and Documented Suicide: Association Among Veterans With High Mortality Risk.

CONTEXT: Palliative care consultations (PCCs) are associated with reduced physical and psychological symptoms that are related to suicide risk. Little is known, however, about the association between PCCs and death from suicide among patients at high risk of short-term mortality. OBJECTIVE: To examine the association between the number of PCCs and documentation of suicide in a cohort of Veterans at high risk of short-term mortality, before and after accounting for Veterans' sociodemographic characteristics and clinical conditions. METHODS: An observational cohort study was conducted using linked Veterans Affairs clinical and administrative databases for 580,620 decedents with high risk of one-year mortality. Logistic regression models were used to examine the association between number of PCCs and documentation of suicide. RESULTS: Higher percentages of Veterans who died by suicide were diagnosed with chronic pulmonary disease as well as mental health/substance use conditions compared with Veterans who died from other causes. In adjusted models, one PCC in the 90 days prior to death was significantly associated with a 71% decrease in the odds of suicide (OR = 0.29, 95% CI = 0.23-0.37, P < 0.001) and two or more PCCs were associated with a 78% decrease (OR = 0.22, 95% CI = 0.15-0.33, P < 0.001). Associated "number needed to be exposed" estimates suggest that 421 Veterans in this population would need to receive at least one PCC to prevent one suicide. CONCLUSION: While acknowledging the importance of specialized mental health care in reducing suicide among high-risk patients, interventions delivered in the context of PCCs may also play a role.

The Association Between Hospital End-of-Life Care Quality and the Care Received Among Patients With Heart Failure.

CONTEXT: Improving end-of-life care (EOLC) quality among heart failure patients is imperative. Data are limited as to the hospital processes of care that facilitate this goal. OBJECTIVES: To determine associations between hospital-level EOLC quality ratings and the EOLC delivered to heart failure patients. METHODS: Retrospective analysis of the Veterans Health Administration (VA) and the Bereaved Family Survey data of heart failure patients from 2013 to 2015 who died in 107 VA hospitals. We calculated hospital-level observed-to-expected casemix-adjusted ratios of family reported excellent EOLC, dividing hospitals into quintiles. Using logistic regression, we examined associations between quintiles and palliative care consultation, receipt of chaplain and bereavement services, inpatient hospice, and intensive care unit death. RESULTS: Of 6256 patients, mean age was 77.4 (SD = 11.1), 98.3% were male, 75.7% were white, and 18.2% were black. Median hospital scores of "excellent" EOLC ranged from 41.3% (interquartile range 37.0%-44.8%) in the lowest quintile to 76.4% (interquartile range 72.9%-80.3%) in the highest quintile. Patients who died in hospitals in the highest quintile, relative to the lowest, were slightly although not significantly more likely to receive a palliative care consultation (adjusted proportions 57.6% vs. 51.2%; P = 0.32) but were more likely to receive chaplaincy (92.6% vs. 81.2%), bereavement (86.0% vs. 72.2%), and hospice (59.7% vs. 35.9%) and were less likely to die in the intensive care unit (15.9% vs. 31.0%; P < 0.05 for all). CONCLUSION: Patients with heart failure who die in VA hospitals with higher overall EOLC quality receive more supportive EOLC. Research is needed that integrates care processes and develops scalable best practices in EOLC across health care systems.

Case-Mix Adjustment of the Bereaved Family Survey.

Surveys of bereaved family members are increasingly being used to evaluate end-of-life (EOL) care and to measure organizational performance in EOL care quality. The Bereaved Family Survey (BFS) is used to monitor EOL care quality and benchmark performance in the Veterans Affairs (VA) health-care system. The objective of this study was to develop a case-mix adjustment model for the BFS and to examine changes in facility-level scores following adjustment, in order to provide fair comparisons across facilities. We conducted a cross-sectional secondary analysis of medical record and survey data from veterans and their family members across 146 VA medical centers. Following adjustment using model-based propensity weighting, the mean change in the BFS-Performance Measure score across facilities was -0.6 with a range of -2.6 to 0.6. Fifty-five (38%) facilities changed within ±0.5 percentage points of their unadjusted score. On average, facilities that benefited most from adjustment cared for patients with greater comorbidity burden and were located in urban areas in the Northwest and Midwestern regions of the country. Case-mix adjustment results in minor changes to facility-level BFS scores but allows for fairer comparisons of EOL care quality. Case-mix adjustment of the BFS positions this National Quality Forum-endorsed measure for use in public reporting and internal quality dashboards for VA leadership and may inform the development and refinement of case-mix adjustment models for other surveys of bereaved family members.

Geriatric Oncology Program Development and Gero-Oncology Nursing.

OBJECTIVES: To provide a critical analysis of current approaches to the care of older adults with cancer, outline priority areas for geriatric oncology program development, and recommend strategies for improvement. DATA SOURCES: Published articles and reports between 1999 and 2015. CONCLUSION: Providing an interdisciplinary model that incorporates a holistic geriatric assessment will ensure the delivery of patient-centered care that is responsive to the comprehensive needs of older patients. IMPLICATIONS FOR NURSING PRACTICE: Nursing administrators and leaders have both an opportunity and responsibility to shape the future of geriatric oncology. Preparations include workforce development and the creation of programs that are designed to meet the complex needs of this population.

Changes in patient and nurse outcomes associated with magnet hospital recognition.

BACKGROUND: Research has documented an association between Magnet hospitals and better outcomes for nurses and patients. However, little longitudinal evidence exists to support a causal link between Magnet recognition and outcomes. OBJECTIVE: To compare changes over time in surgical patient outcomes, nurse-reported quality, and nurse outcomes in a sample of hospitals that attained Magnet recognition between 1999 and 2007 with hospitals that remained non-Magnet. RESEARCH DESIGN: Retrospective, 2-stage panel design using 4 secondary data sources. SUBJECTS: One hundred thirty-six Pennsylvania hospitals (11 emerging Magnets and 125 non-Magnets). MEASURES: American Nurses Credentialing Center Magnet recognition; risk-adjusted rates of surgical 30-day mortality and failure-to-rescue, nurse-reported quality measures, and nurse outcomes; the Practice Environment Scale of the Nursing Work Index. METHODS: Fixed-effects difference models were used to compare changes in outcomes between emerging Magnet hospitals and hospitals that remained non-Magnet. RESULTS: Emerging Magnet hospitals demonstrated markedly greater improvements in their work environments than other hospitals. On average, the changes in 30-day surgical mortality and failure-to-rescue rates over the study period were more pronounced in emerging Magnet hospitals than in non-Magnet hospitals, by 2.4 fewer deaths per 1000 patients (P<0.01) and 6.1 fewer deaths per 1000 patients (P=0.02), respectively. Similar differences in the changes for emerging Magnet hospitals and non-Magnet hospitals were observed in nurse-reported quality of care and nurse outcomes. CONCLUSIONS: In general, Magnet recognition is associated with significant improvements over time in the quality of the work environment, and in patient and nurse outcomes that exceed those of non-Magnet hospitals.

Variations in postoperative complications according to race, ethnicity, and sex in older adults.

OBJECTIVES: To explore differences in the incidence of postoperative complications between three racial and ethnic groups (white, black, Hispanic) before and after taking into account potentially confounding patient and hospital characteristics. DESIGN: Cross-sectional study using 2006 to 2007 administrative discharge data from hospitals in four states (CA, PA, NJ, FL) linked to American Hospital Association Annual Survey data and data from the U.S. Census. Risk-adjusted logistic regression models were used in the analyses. SETTING: Six hundred U.S. adult nonfederal acute care hospitals. PARTICIPANTS: Individuals aged 65 and older undergoing general, orthopedic, or vascular surgery (N = 587,314; 86% white, 6% black, 8% Hispanic). MEASUREMENTS: Thirteen frequent postoperative complications. RESULTS: When considered without controls, black patients had significantly greater odds than white patients of developing 12 of the 13 complications, by factors (ORs) ranging from 1.09 to 2.69. Hispanic patients had significantly greater odds than white patients in nine of the 13 complications (ORs = 1.11-1.82) and significantly lower odds than white patients on two of the other four (ORs both = 0.84). The fully adjusted models that accounted for hospital and especially patient characteristics substantially diminished the number of complications for which black and Hispanic patients had significantly greater odds than white patients. Many of the significant differences between black, Hispanic, and white patients that persisted after controls were different for men and women. CONCLUSION: Older black and Hispanic individuals have greater odds than white individuals of developing a vast majority of postoperative complications. Procedure type and health status largely explained differences in postoperative complication risk, which are frequently conditional on sex.

An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality.

An Institute of Medicine report has called for registered nurses to achieve higher levels of education, but health care policy makers and others have limited evidence to support a substantial increase in the number of nurses with baccalaureate degrees. Using Pennsylvania nurse survey and patient discharge data from 1999 and 2006, we found that a ten-point increase in the percentage of nurses holding a baccalaureate degree in nursing within a hospital was associated with an average reduction of 2.12 deaths for every 1,000 patients--and for a subset of patients with complications, an average reduction of 7.47 deaths per 1,000 patients. We estimate that if all 134 hospitals in our study had increased the percentage of their nurses with baccalaureates by ten points during our study's time period, some 500 deaths among general, orthopedic, and vascular surgery patients might have been prevented. The findings provide support for efforts to increase the production and employment of baccalaureate nurses.

Nurse staffing and postsurgical outcomes in black adults.

OBJECTIVES: To determine the association between nurse staffing and postsurgical outcomes for older black adults, including 30-day mortality and failure to rescue. DESIGN: A cross-sectional study of University of Pennsylvania Multi-State Nursing Care and Patient Safety Survey data, linked to 2006-2007 administrative patient discharge data from four states (CA, PA, NJ, FL), American Hospital Association Annual Survey data, and a U.S. Census-derived measure of socioeconomic status (SES). Risk-adjusted logistic regression models with correction for clustering were used for the analysis. SETTING: Five hundred ninety-nine adult nonfederal acute care hospitals in California, Pennsylvania, New Jersey, and Florida PARTICIPANTS: Five hundred forty-eight thousand three hundred ninety-seven individuals ages 65 and older undergoing general, orthopedic, or vascular surgery (94% white, 6% black). MEASUREMENTS: Thirty-day mortality and failure to rescue (death after a complication). RESULTS: In models adjusting for sex and age, 30-day mortality was significantly higher for black than white participants (odds ratio (OR) = 1.42, 95% confidence interval (CI) = 1.32-1.52). In fully adjusted models that accounted for SES, surgery type, and comorbidities, as well as hospital characteristics, including nurse staffing, the odds of 30-day mortality were not significantly different for black and white participants. In the fully adjusted models, one additional patient in the average nurse's workload was associated with higher odds of 30-day mortality for all patients (OR = 1.03, 95% CI = 1.01-1.05). A significant interaction was found between race and nurse staffing for 30-day mortality, such that blacks experienced higher odds of death with each additional patient per nurse (OR = 1.10, 95% CI = 1.03-1.18) compared to whites (OR = 1.03, 95% CI = 1.01-1.06). Similar patterns were detected in failure-to-rescue models. CONCLUSION: Older surgical patients experience poorer postsurgical outcomes, including mortality and failure to rescue, when cared for by nurses with higher workloads. The effect of nurse staffing inadequacies is more significant in older black individuals.

Effect of nurse staffing and education on the outcomes of surgical patients with comorbid serious mental illness.

OBJECTIVE: This study of surgical patients compared outcomes of those with and those without serious mental illness and examined effects of patient-to-nurse ratios and nurses' education levels on outcomes, including death within 30 days of admission, failure to rescue (death resulting from surgery complication), and length of stay. METHODS: Cross-sectional data from a nurse survey and from patient and administrative records were linked. Data for 9,989 nurses and 228,433 surgical patients discharged from 157 Pennsylvania hospitals were analyzed by using generalized estimating equations. RESULTS: Records indicated that 4.7% (N=10,666) of the sample had a diagnosis of serious mental illness. A higher level of nurse staffing had a stronger effect on prevention of death among patients with serious mental illness than among those without it. Length of stay for patients with serious mental illness was shorter in hospitals with higher proportions of baccalaureate-prepared nurses. CONCLUSIONS: Better nurse staffing and higher education level mitigated poor patient outcomes among highly vulnerable patients with serious mental illness.