Preventing Pressure Injuries in Neonates Undergoing Therapeutic Hypothermia for Hypoxic-Ischemic Encephalopathy: An Interprofessional Quality Improvement Project.

BACKGROUND: Hospital-acquired pressure injuries (HAPIs) can be caused by multiple factors including pressure, shear, friction, moisture/incontinence, device-related pressure, immobility, inactivity, and nutritional deficits. Along with immobility, medical device-related (MDR) HAPIs are a primary cause of pressure injury in neonates, as the clinical practice setting has become increasingly technologically advanced. It is estimated that up to 50% of HAPIs are MDR in pediatric patients. Neonates are at particular risk for HAPI because of their specific anatomical, physiological, and developmental vulnerabilities. A specific example of confluent factors that may increase risk for HAPI is the application of therapeutic hypothermia (TH) and continuous electroencephalography monitoring for neonates with hypoxic-ischemic encephalopathy (HIE). INTERVENTIONS: An interprofessional team collaborated to expand upon existing evidence-based standards of care to address the needs of this specific population within the neonatal intensive care unit (NICU). Interventions centered on revision of current protocols, with efforts to optimize product selection, hardwire assessment practices, and refine documentation of patient care and outcomes. METHODS: The team primarily utilized plan-do-study-act (PDSA) cycles to test and refine specific methods and strategies to reduce HAPIs. Tested solutions were adopted, adapted, or abandoned. RESULTS: A sustained zero HAPI rate in the HIE population resulted. The team continues to collect, report, and utilize near-miss data to continue to refine the process as new risks are identified. IMPLICATIONS FOR PRACTICE: Recognizing the unique skin protection needs of special populations within the NICU, such as those undergoing TH, is crucial. When evidence-based standards of care fail to adequately meet such needs, a collaborative approach to identifying, testing, and implementing population-specific solutions is essential. IMPLICATIONS FOR RESEARCH: A paucity of literature regarding the unique skin protection needs for babies undergoing TH exists. Work should be done to better describe the influence of TH on skin integrity, with the goal of identifying population-specific protective measures.

The Journey to High Reliability in the NICU.

Neonatal intensive care units (NICUs) are at high risk for medical errors due to the population, setting, and complexity of care. Furthermore, "near misses" often precede actual errors yet are mostly underreported and unrecognized as safety concerns. There is a growing recognition that a systems approach to quality and safety is foundational to improving care at the bedside and patient outcomes. The High Reliability Organization model is one such approach. It recognizes the challenges of a highly complex system and combines this recognition with a continual emphasis on reducing errors. Although the principles of the High Reliability Organization hold promise in accelerating quality and safety in the NICU, it is imperative that nurses at the bedside as well as nurse leaders actually learn how to operationalize high reliability principles and strategies that lead to better outcomes. This article outlines the necessary principles, culture, strategies, and behaviors that NICU nurses and nurse leaders must adopt to achieve high reliability in their units.

The impact of training interventions on organizational readiness to support innovations in juvenile justice offices.

Clinical trials on technology transfer models are rare, even with the interest in advancing the uptake of evidence-based practices in social service agencies. This article presents the results from a trial examining different transfer strategies to assist juvenile justice caseworkers in using screening, assessment, and case planning practices to address mental health and substance use needs. Study findings examine factors that promote organizational readiness. A clinical trial was conducted examining the impact of three post-training strategies: an external coach to build the social network of the justice office (build social climate), an external coach to educate staff (build skills and knowledge), and a control condition consisting of traditional management directives (directives to staff of agency priorities). All groups were exposed to a 1 day refresher course in motivational interviewing. The social network and skill building groups also attended an intensive 3-day training followed by three on-site booster sessions over a 12 month period of time. Twelve juvenile justice offices (with their 231 juvenile justice staff) were assigned to one of three conditions. The study examined the impact of different transfer conditions on organizational readiness to implement the innovation of screening, assessment, and referral strategies. External coaching targeting the social climate of the justice office to support innovations improved organizational readiness to change, regardless of office size. Coaching that targeted either the social climate or staff knowledge and skills both improved organizational readiness for change compared to management directives, but social climate coaching resulted in greater improvements in receptivity to change. No individual level features of case workers (e.g., age, gender, years of experience) significantly predicted organizational readiness to change. Unexpectedly, the skill and knowledge building approach did not perform any better than management directives only (no post training) efforts. Organizational readiness has been found to be an important factor supporting agencies' adoption of evidence-based practices. Techniques devoted to attending to the social climate are critical to increasing organizational readiness. External coach facilitators can accomplish this through modest means (three post training booster sessions) that build internal expertise and resiliency in support of the change. This is a low cost method of preparing a low resourced environment such as juvenile justice agencies to use evidence-based practices.

Psychological Well-Being, Risk, and Resilience of Youth in Out-Of-Home Care and Former Foster Youth.

This study assesses psychological well-being, risk, and resilience of youth currently in-care and former foster youth and how preparation for independent living affects these factors. Findings suggest significant psychosocial distress for former foster youth. Youth currently in-care fared better but demonstrated high scores on measures suggesting risk and potential for future mental health challenges. For former foster youth, independent living preparation positively impacted well-being. The more preparation for independence a youth received, the lower the psychological challenges. Findings suggest the need for mental health support for transitioning youth as well as preparation for independent living as a way to improve the well-being of former foster youth.

Technology-Enabled Population Health Management: Two Communities' Use of an Electronic Care Alert System.

Population health management is an approach to improve the health outcomes of a specific group of people, such as frequent users of the emergency department or those at high-risk for hospital admissions. When combined with quality improvement strategies, the targeted application of health information exchange and health information technology (health IT) can swiftly move health care systems and providers from basic to advanced population health management. One such tool is an electronic alert system (alert system), which informs a provider or site about a patient's visit to the emergency department or hospital admission on a daily basis. This article highlights the use of such an alert system in 2 communities to help address gaps in population health management.

Associations among state and local organizational contexts: Use of evidence-based practices in the criminal justice system.

This study used hierarchical linear modeling (HLM) to examine the extent to which the organizational characteristics of state corrections agencies and local criminal justice facilities interacted in their associations with the extent to which local facilities are using evidence-based substance abuse treatment practices (EBPs). The study used data collected from two nationally representative surveys - one of state executives and the other of local prison wardens, justice administrators, and treatment directors - which were conducted as part of the National Criminal Justice Treatment Practices survey [NCJTP; Taxman, F.S., Young, D., Wiersema, B., Mitchell, S., Rhodes, A.G., 2007. The National Criminal Justice Treatment Practices Survey: Multi-level survey methods and procedures. J. Subst. Abuse Treat. 32, 225-238], and includes both adult criminal and juvenile justice samples. Results indicated that several state organizational characteristics were either associated with more EBP use or interacted with local organizational characteristics in associations with EBP use, including: (1) systems integration at the state level was associated with greater EBP use; (2) state staffing adequacy and stability accentuated the association between local training and resources for new programs and EBP use (i.e., in states with better staffing, the relationship between training/resources and EBP use in local facilities was stronger); and (3) state executives' attitudes regarding the missions and goals of corrections tended to diminish the extent to which corresponding local administrator attitudes were associated with EBP use. The study has implications for future research focused on EBP diffusion and implementation in correctional environments, particularly attempts to influence EBP use by working through state agencies.

Filling service gaps: Providing intensive treatment services for offenders.

Consistent with the few studies that have previously examined treatment prevalence and access in the adult and juvenile justice systems, the recent National Criminal Justice Treatment Practices (NCJTP) survey indicated that there is a particular need to expand intensive treatment modalities for offenders in both institutional and community corrections settings. Applying multilevel modeling techniques to NCJTP survey data, this study explores conditions and factors that may underlie the wide variation among states in the provision of intensive treatment for offenders. Results indicate that states' overall rates of substance abuse and dependence, funding resources, and the state governor's political party affiliation were significantly associated with intensive treatment provision. Numerous factors that have been implicated in recent studies of evidence-based practice adoption, including state agency executives' views regarding rehabilitation, agency culture and climate, and other state-level measures (e.g., household income, crime rates, expenditures on treatment for the general population) were not associated with treatment provision. Future research should examine further variations in offenders' service needs, the role of legislators' political affiliations, and how other factors may interact with administrator characteristics in the adoption and expansion of intensive treatment services for offenders.