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BACKGROUND: Randomized controlled trials typically require study-specific visits, which can burden participants and sites. Remote follow-up, such as centralized call centers for participant-reported or site-reported, holds promise for reducing costs and enhancing the pragmatism of trials. In this secondary analysis of the CONNECT-HF (Care Optimization Through Patient and Hospital Engagement For HF) trial, we aimed to evaluate the completeness and validity of the remote follow-up process. METHODS AND RESULTS: The CONNECT-HF trial evaluated the effect of a post-discharge quality-improvement intervention for heart failure compared to usual care for up to 1 year. Suspected events were reported either by participants or by health care proxies through a centralized call center or by sites through medical-record queries. When potential hospitalization events were suspected, additional medical records were collected and adjudicated. Among 5942 potential hospitalizations, 18% were only participant-reported, 28% were reported by both participants and sites, and 50% were only site-reported. Concordance rates between the participant/site reports and adjudication for hospitalization were high: 87% participant-reported, 86% both, and 86% site-reported. Rates of adjudicated heart failure hospitalization events among adjudicated all-cause hospitalization were lower but also consistent: 45% participant-reported, 50% both, and 50% site-reported. CONCLUSIONS: Participant-only and site-only reports missed a substantial number of hospitalization events. We observed similar concordance between participant/site reports and adjudication for hospitalizations. Combining participant-reported and site-reported outcomes data is important to capture and validate hospitalizations effectively in pragmatic heart failure trials.
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Anticoagulantes , Fibrilación Atrial , Hemorragia , Humanos , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/complicaciones , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Hemorragia/inducido químicamente , Administración Oral , Femenino , Masculino , Anciano , Medición de Riesgo , Accidente Cerebrovascular/prevención & control , Persona de Mediana Edad , ComunicaciónRESUMEN
BACKGROUND: Nearly half of American adults have hypertension (HTN), and non-Hispanic Black patients are diagnosed at a higher rate than others. LOCAL PROBLEM: Our local clinic population reflected disproportionate rates of uncontrolled HTN among Black patients. METHODS: A quality improvement pre-/postintervention design was used to evaluate an educational intervention to reduce blood pressure (BP) and improve self-monitoring of BP in Black patients using the Chronic Care Model. INTERVENTIONS: A team-based approach was used to redesign clinic workflows and patient education, prescribe self-paced videos from an electronic health record (EHR) patient portal, and provide home BP cuffs. RESULTS: Black participants (n = 79) improved viewing of prescribed videos (7.9% to 68.5%), knowledge scores (67.9 to 75.2), and mean systolic BP (-20.3 mm Hg; P > .001). CONCLUSIONS: This team-based approach enhanced patient engagement, self-monitoring skills, EHR-reported BP, and overall BP control for a cohort of Black patients with uncontrolled BP.
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Registros Electrónicos de Salud , Hipertensión , Adulto , Humanos , Mejoramiento de la Calidad , Flujo de Trabajo , Negro o Afroamericano , Hipertensión/prevención & control , Hipertensión/diagnósticoRESUMEN
OBJECTIVES: To use the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to evaluate an educational model addressing self-management of uncontrolled hypertension. METHODS: We used a pre-post single cohort design to identify minoritized patients with uncontrolled hypertension (systolic > 160 mmHg and/or diastolic > 100 mmHg). Trained Ambassadors provided telephone outreach, skill-based blood pressure (BP) monitoring, and goal-setting for 4 months. Follow-up occurred at 7 months. We evaluated the initiative using the RE-AIM framework and quantitative analysis for process and outcome measures post-intervention. RESULTS: Among Black patients (n = 345), the average age was 55.4 years (8.7), half identified as male (n = 173, 50.1 %); many were uninsured (n = 159, 46.1 %). Engagement in calls occurred for 67.8 % (n = 234) of the cohort; monitor distribution was 22.9 % (n = 79); and goal setting occurred for 64 patients. BP improved for 40 % of the cohort (mean pre: 168/98 mmHg, mean post: 150/89 mmHg; p < 0.0001) and 40 % of patients' last known BP was < 140/90. CONCLUSIONS: RE-AIM evaluation of the Closing the Gap initiative suggests that the model is associated with BP reduction in high-risk Black patients. PRACTICE IMPLICATIONS: An educational model for patient-centered hypertension management in low-income populations is feasible and addresses self-monitoring barriers.
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Equidad en Salud , Hipertensión , Humanos , Masculino , Persona de Mediana Edad , Antihipertensivos/uso terapéutico , Presión Sanguínea , Determinación de la Presión Sanguínea , Hipertensión/tratamiento farmacológico , Modelos Educacionales , Femenino , Negro o AfroamericanoRESUMEN
AIMS: To evaluate the impact of a lay health worker support role in the inpatient setting. BACKGROUND: Healthcare systems are facing critical nursing and nurse assistant staffing shortages. These disciplines can be challenging to recruit and retain, leading healthcare leaders to identify innovative staffing models. Whereas lay health workers have been used in the community and low-income setting, there is scant evidence of their use in the inpatient setting. We implemented a lay health worker role, called Patient Attendant Service Aides (PASAs), on two medical/surgical units at a community hospital. METHODS: A pre/post-implementation design was used for this study. An online survey was provided to nurses, nursing assistants, and PASAs on the two medical/surgical units to assess their satisfaction and perceptions of the role. Nursing quality metrics, patient satisfaction, and nursing and nursing assistant turnover were evaluated before and after implementing the role. RESULTS: The online survey showed that nurses and nursing assistants felt that PASAs helped offload their workload, allowing them to focus on nursing-related tasks. PASAs felt supported by the team and believed they were making a meaningful contribution to the unit. There were slight improvements in patient satisfaction, although not significant. There was a significant improvement in nursing turnover on Unit A, from 71.1% to 21.6% (p = 0.009). CONCLUSIONS: This is one of the first studies to evaluate the use of lay health workers in the inpatient setting; we found this role to be a feasible way to offload tasks from clinical staff. This role may serve as a pathway for workforce development, as several PASAs are now enrolled in nursing assistant training. Nurse managers may consider using lay health workers in the inpatient setting as they face severe clinical staff shortages.
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Pacientes Internos , Personal de Enfermería en Hospital , Humanos , Carga de Trabajo , Fuerza Laboral en Salud , Recursos Humanos , Calidad de la Atención de Salud , Admisión y Programación de PersonalRESUMEN
Cardiovascular disease remains the leading cause of death and disability in the United States and globally. Disease burden continues to escalate despite technological advances associated with improved life expectancy and quality of life. As a result, longer life is associated with multiple chronic cardiovascular conditions. Clinical guidelines provide recommendations without considering prevalent scenarios of multimorbidity and health system complexities that affect practical adoption. The diversity of personal preferences, cultures, and lifestyles that make up one's social and environmental context is often overlooked in ongoing care planning for symptom management and health behavior support, hindering adoption and compromising patient outcomes, particularly in groups at high risk. The purpose of this scientific statement was to describe the characteristics and reported outcomes in existing person-centered care delivery models for selected cardiovascular conditions. We conducted a scoping review using Ovid MEDLINE, Embase.com, Web of Science, CINAHL Complete, Cochrane Central Register of Controlled Trials through Ovid, and ClinicalTrials.gov from 2010 to 2022. A range of study designs with a defined aim to systematically evaluate care delivery models for selected cardiovascular conditions were included. Models were selected on the basis of their stated use of evidence-based guidelines, clinical decision support tools, systematic evaluation processes, and inclusion of the patient's perspective in defining the plan of care. Findings reflected variation in methodological approach, outcome measures, and care processes used across models. Evidence to support optimal care delivery models remains limited by inconsistencies in approach, variation in reimbursement, and inability of health systems to meet the needs of patients with chronic, complex cardiovascular conditions.
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Enfermedades Cardiovasculares , Calidad de Vida , Humanos , Estados Unidos/epidemiología , American Heart Association , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/terapia , Atención a la Salud , Cuidados PaliativosRESUMEN
BACKGROUND: Invasive cardiac catheterization (CC) temporarily increases pain, discomfort, and anxiety. Procedural sedation is deployed to mitigate these symptoms, though practice varies. Research evaluating peri-procedural patient-reported outcomes is lacking. METHODS AND RESULTS: We randomized 175 patients undergoing CC to short interval ([SI] group, <6 min) or long interval ([LI] group, ≥6 min) time intervals between initial intravenous sedation and local anesthetic administration. Outcomes included: (1) total pain medication use, (2) patient-reported and behaviorally assessed pain and (3) patient satisfaction during outpatient CC. Generalized linear mixed effect models were used to evaluate the impact of treatment time interval on total medication utilization, pain, and satisfaction. Among enrollees the mean age was 62 (standard deviation [SD] = 13.4), a majority were male (66%), white (74%), and overweight (mean body mass index = 28.5 [SD = 5.6]). Total pain medication use did not vary between treatment groups (p = 0.257), with no difference in total fentanyl (p = 0.288) or midazolam (p = 0.292). Post-treatment pain levels and nurse-observed pain were not statistically significant between groups (p = 0.324 & p = 0.656, respectively. No significant differences with satisfaction with sedation were found between the groups (p = 0.95) Patient-reported pain, satisfaction and nurse-observed measures of pain did not differ, after adjustment for demographic and procedural factors. Analyses of treatment effect modification revealed that postprocedure self-reported pain levels varied systematically between individuals undergoing percutaneous coronary intervention (PCI) (SI = 2.2 [0.8, 3.6] vs. LI = 0.7 [-0.6, 2.0]) compared with participants not undergoing PCI (SI = 0.4 [-0.8, 1.7] vs. LI = 0.7 [-0.3, 1.6]) (p = 0.043 for interaction). CONCLUSION: No consistent treatment differences were found for total medication dose, pain, or satisfaction regardless of timing between sedation and local anesthetic. Treatment moderations were seen for patients undergoing PCI. Further investigation of how procedural and individual factors impact the patient experience during CC is needed.
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BACKGROUND: Clinicians are often familiar with quality improvement (QI) and evidence-based practice (EBP) processes, which provides guidance into what evidence should be implemented; however, these processes do not address how to successfully implement evidence. OBJECTIVE: Clinicians would benefit from a deeper understanding of implementation science, along with practical tools for how to use these principles in QI and EBP projects. METHODS: We provide a brief background of the principles of implementation science, an overview of current implementation science models and a toolkit to facilitate choosing and using common implementation science strategies. In addition, the toolkit provides guidance for measuring the success of an implementation science project and a case study showing how implementation science strategies can be used successfully in clinical practice. CONCLUSIONS: Using an implementation science toolkit for designing, conducting, and evaluating a QI or EBP project improves the quality and generalizability of results.
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Ciencia de la Implementación , Mejoramiento de la Calidad , HumanosRESUMEN
BACKGROUND AND OBJECTIVES: Central line-associated bloodstream infections (CLABSIs) are a common, preventable healthcare-associated infection. In our 3-hospital health system, CLABSI rates in non-intensive care unit (ICU) settings were above the internal target rate of zero. A robust quality improvement (QI) project to reduce non-ICU CLABSIs was undertaken by a team of Doctor of Nursing Practice (DNP)-prepared nurse leaders enrolled in a post-DNP Quality Implementation Scholars program and 2 QI experts. Based on a review of the literature and local root cause analyses, the QI team implemented the evidence-based practice of using 2% chlorhexidine gluconate (CHG) cloths for daily bathing for non-ICU patients with a central line. METHODS: A pre-post-design was used for this QI study. CHG bathing was implemented using multifaceted educational strategies that included an e-learning module, printed educational materials, educational outreach, engagement of unit-based CLABSI champions, and an electronic reminder in the electronic health record. Generalized linear mixed-effects models were used to assess the change in CLABSI rates before and after implementation of CHG bathing. CLABSI rates were also tracked using statistical process control (SPC) charts to monitor stability over time. CHG bathing documentation compliance was audited as a process measure. These audit data were provided to unit-based leadership (nurse managers and clinical team leaders) on a monthly basis. A Qualtrics survey was also disseminated to nursing leadership to evaluate their satisfaction with the CHG bathing implementation processes. RESULTS: Thirty-four non-ICU settings participated in the QI study, including general medical/surgical units and specialty areas (oncology, neurosciences, cardiac, orthopedic, and pediatrics). While the change in CLABSI rates after the intervention was not statistically significant ( b = -0.35, P = .15), there was a clinically significant CLABSI rate reduction of 22.8%. Monitoring the SPC charts demonstrated that CLABSI rates remained stable after the intervention at all 3 hospitals as well as the health system. CHG bathing documentation compliance increased system-wide from 77% (January 2020) to 94% (February 2021). Overall, nurse leaders were satisfied with the CHG bathing implementation process. CONCLUSIONS: To sustain this practice change in non-ICU settings, booster sessions will be completed at least on an annual basis. This study provides further support for using CHG cloths for daily patient bathing in the non-ICU setting.
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Antiinfecciosos Locales , Infecciones Relacionadas con Catéteres , Infección Hospitalaria , Humanos , Niño , Mejoramiento de la Calidad , Unidades de Cuidados Intensivos , Clorhexidina , Infección Hospitalaria/prevención & control , Infecciones Relacionadas con Catéteres/epidemiología , Infecciones Relacionadas con Catéteres/prevención & controlRESUMEN
OBJECTIVE: To examine factors contributing to racial differences in 30-day readmission in patients with cardiovascular disease (CVD). DESIGN: Patients were enrolled from 1 January 2015 to 31 August 2017 and data were collected from electronic health records and a standardised interview administered prior to discharge. SETTING: Duke Heart Center in the Duke University Health System. PARTICIPANTS: Patients aged 18 and older admitted for the treatment of cardiovascular-related conditions (n=734). MAIN OUTCOME AND MEASURES: All-cause readmission within 30 days was the main outcome. Multivariate logistic regression models were used to examine whether and to what extent socioeconomic, psychosocial, behavioural and healthcare-related factors contributed to 30-day readmissions in Black and White CVD patients. RESULTS: The median age of patients was 66 years and 18.1% (n=133) were readmitted within 30 days after discharge. Black patients were more likely than White patients to be readmitted (OR 1.62; 95% CI 1.18 to 2.23) and the racial difference in readmissions was largely reduced after taking into account differences in a wide range of clinical and non-clinical factors (OR 1.37; 95% CI 0.98 to 1.91). In Black patients, readmission risks were especially high in those who were retired (OR 3.71; 95% CI 1.71 to 8.07), never married (OR 2.21; 95% CI 1.21 to 4.05), had difficulty accessing their routine care (OR 2.88; 95% CI 1.70 to 4.88) or had been hospitalised in the prior year (OR 1.97; 95% CI 1.16 to 3.37). In White patients, being widowed (OR 2.39; 95% CI 1.41 to 4.07) and reporting a higher number of depressive symptoms (OR 1.07; 95% CI 1.00 to 1.13) were the key factors associated with higher risks of readmission. CONCLUSIONS AND RELEVANCE: Black patients were more likely than White patients to be readmitted within 30 days after hospitalisation for CVD. The factors contributing to readmission differed by race and offer important clues for identifying patients at high risk of readmission and tailoring interventions to reduce these risks.
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Enfermedades Cardiovasculares , Readmisión del Paciente , Adulto , Humanos , Anciano , Factores Raciales , Estudios Retrospectivos , Disparidades en Atención de SaludRESUMEN
INTRODUCTION: Using evidence-based teaching approaches can improve nursing students' learning. However, variation in how - or if - these approaches are implemented by faculty and nursing educators is prevalent. A thorough, applied understanding of how evidence-based teaching approaches can best be implemented in the educational setting is lacking. OBJECTIVES: The purpose of this project was to use an implementation science framework to implement and evaluate the quality of a doctor of nursing practice (DNP) course before and after implementing evidence-based revisions to course delivery and composition. DESIGN: A pre/post design was used to evaluate course outcomes following implementation of evidence-based teaching approaches. SETTING: A small, private university in the southeastern United States. PARTICIPANTS: Students who enrolled in a DNP healthcare quality improvement course. METHODS: An implementation science framework for integrating evidence-based teaching approaches was used to guide this project. Revisions were made to a DNP course, with evidence-based teaching approaches implemented using strategies including a dedicated course facilitator, faculty education, interactive assistance to course faculty, and detailed rubrics to ensure consistency in grading between sections. Outcomes included course evaluation scores, qualitative student comments, and student engagement measured via the average number of discussion board posts authored and read. RESULTS: After using the implementation science framework to translate evidence-based teaching approaches, there was a statistically significant improvement in three course evaluation questions and the overall course mean. Qualitative comments showed that students found the revisions beneficial to their learning. There was no change in student engagement. CONCLUSIONS: Using a structured implementation science framework and plan to translate and evaluate evidence-based teaching approaches resulted in significant improvements in course outcomes. Nurse educators should consider using an implementation framework to guide course revisions.
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Curriculum , Estudiantes de Enfermería , Humanos , Investigación en Educación de Enfermería , Ciencia de la Implementación , AprendizajeAsunto(s)
Baños , Clorhexidina , Clorhexidina/análogos & derivados , Humanos , Unidades de Cuidados IntensivosRESUMEN
ABSTRACT: BACKGROUND: Ischemic stroke continues to be a leading cause of serious disability within the United States, affecting 795 000 people annually. Approximately 12% to 21% of post-ischemic stroke patients will be readmitted to the hospital within 30 days of discharge. Studies suggest that implementation of a follow-up appointment within 7 to 14 days of discharge improves 30-day readmission rates; however, implementation of these guidelines is uncommon, and follow-up visits within the recommended window are not often achieved. The purpose of this project was to evaluate the impact of an advanced practice registered nurse (APRN)-led stroke clinic on follow-up care for post-ischemic stroke patients. The aims were to improve time to follow-up visit and reduce 30-day unplanned readmissions. METHODS: A pre/post intervention design was used to evaluate the impact of a process to access the APRN-led stroke clinic. The intervention included a scheduling process redesign, and subsequent APRN and scheduler education. RESULTS: The time to clinic follow-up preintervention averaged 116.9 days, which significantly reduced to 33.6 days post intervention, P = .0001. Unplanned readmissions within 30 days declined from 11.5% to 9.9%; however, it was not statistically significant, P = .149. Age was not statistically different between preintervention and postintervention groups, P = .092, and other demographics were similar between the groups. CONCLUSION: An APRN-led clinic can improve follow-up care and may reduce unplanned 30-day readmissions for post-ischemic stroke patients. Further work is needed to determine the impact of alternative approaches such as telehealth.
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Enfermería de Práctica Avanzada , Accidente Cerebrovascular Isquémico , Pautas de la Práctica en Enfermería , Cuidados Posteriores , Humanos , Alta del Paciente , Readmisión del Paciente , Estados UnidosRESUMEN
BACKGROUND: Mobile health (mHealth) platforms can affect health behaviors but have not been rigorously tested in randomized trials. OBJECTIVES: We sought to evaluate the effectiveness of a pragmatic mHealth intervention in patients with heart failure (HF) and diabetes (DM). METHODS: We conducted a multicenter randomized trial in 187 patients with both HF and DM to assess an mHealth intervention to improve physical activity and medication adherence compared to usual care. The primary endpoint was change in mean daily step count from baseline through 3 months. Other outcomes included medication adherence, health-related quality of life and metabolomic profiling. RESULTS: The mHealth group had an increase in daily step count of 151 steps/day at 3 months, whereas the usual-care group had a decline of 162 steps/day (least squares mean between-group differenceâ¯=â¯313 steps/day; 95% CI: 8 619; Pâ¯=â¯0.044). Medication adherence, measured using the Voils Adherence Questionnaire, did not change from baseline to 3 months (LS-mean change -0.08 in mHealth vs -0.15 in usual care; Pâ¯=â¯0.47). The mHealth group had an improvement in Kansas City Cardiomyopathy Questionnaire Overall Summary Score compared to the usual-care group (LS-mean differenceâ¯=â¯5.5 points, 95% CI: 1.4, 9.6; Pâ¯=â¯0.009). Thirteen metabolites, primarily medium- and long-chain acylcarnitines, changed differently between treatment groups from baseline to 3 months (P < 0.05). CONCLUSIONS: In patients with HF and DM, a 3-month mHealth intervention significantly improved daily physical activity, health-related quality of life and metabolomic markers of cardiovascular health but not medication adherence. CONDENSED ABSTRACT: Heart failure (HF) and diabetes (DM) have overlapping biological and behavioral risk factors. We conducted a multicenter randomized, clinical trial in 187 patients with both HF (regardless of ejection fraction) and DM to assess whether an mHealth intervention could improve physical activity and medication adherence. The mHealth group had an increase in mean daily step count and quality of life but not in medication adherence. Medium- and long-chain acylcarnitines changed differently in treatment groups from baseline to 3 months (P < 0.05). These data have important implications for designing effective lifestyle interventions in HF and DM.