Evaluating an Evidence-Based Practice Curriculum for Nurses Entering Clinical Practice in the Veterans Health Administration.

Introduction: The Veterans Health Administration (VHA) registered nurse (RN) Transition to Practice (TTP) program is a 1-year comprehensive, standardized curriculum taught for entry-level nurses to assist them in transitioning to VA-trained, competent, professional RNs. The TTP program includes revised modules on Evidence-Based Practice (EBP) clinical decision making. The revised curriculum emphasizes EBP as a problem-solving approach to clinical decision making rather than a project-based approach to implement practice changes. The goal of this quality improvement project was to evaluate the content, delivery, and outcomes of a revised Evidence-Based Practice Curriculum (EBPC) for use in the VHA RN TTP program. Methods: Focus groups were conducted with TTP coordinators, who teach the program and facility EBP content experts from 32 VHA Medical Centers. All attended a three-day face-to-face training at a central location. Qualitative data were managed and analyzed with a rapid assessment process. Discussion: Leaders within and outside of organizations are commonly believed to affect the success of implementing and sustaining any program or initiative through their influence on organizational climate, leadership processes, and leadership alignment across multiple levels of leadership. Our findings were in line with other research showing that leaders should prioritize EBP and fuel it with resources to create sustainable change. Conclusions: In conclusion, the EBPC was reviewed very favorably by all who planned to use it in their facilities in teaching the content to practicing registered nurses. Future evaluation will focus on the degree to which faculty use the program, how they use the modules, and what feedback nurses provide after exposure to EBPC.

BUN as an Independent Predictor of Post-Hospital-Discharge Mortality among Older Veterans.

BACKGROUND/OBJECTIVES: An elevated blood urea nitrogen (BUN) in known to be an important prognostic indicator in patients with end-stage heart or kidney disease or certain other life-threatening illnesses. However, it is less certain as to whether an elevated BUN is an independent predictor of long-term mortality risk in less seriously ill patients. To address this issue, we examined the relationship between BUN and long-term mortality after adjusting for potential confounders and other indicators of health status/disease severity, in a select population of older medically stable Veterans. DESIGN: Long-term prospective cohort study. SETTING: Outpatient follow-up of patients discharged from a recuperative care and rehabilitation unit (RCRU) of a Department of Veterans Affairs Community Living Center. PARTICIPANTS: 383 older Veterans (mean age = 78.6±7.6 years, 98% male, and 87% white) discharged alive and in stable medical condition. MEASUREMENTS: At discharge, each subject completed a comprehensive assessment and was then monitored as an outpatient for up to 9.3 years. Associations between blood urea nitrogen at RCRU discharge and mortality were identified utilizing Cox proportional hazards (PH) regression analyses adjusting for conditions known to confound this relationship. RESULTS: Within the follow-up period, 255 subjects (67%) died. In the unadjusted Cox PH model, a BUN ≥ 30 mg/dL was associated with a nearly 2-fold increased risk of mortality (hazard ratio 1.90, 95%CI 1.41 - 2.56). The association between BUN and long-term mortality remained highly significant after adjusting for potential confounders (hazard ratio 1.78, 95%CI 1.29 - 2.44). CONCLUSION: Our findings support BUN levels as an independent predictor of long-term mortality in older, medically stable Veterans. An elevated BUN may be reflective of global health status rather than solely an indicator of the severity of acute illness or unstable chronic disease.

Benign recurrent isolated VI nerve palsy of childhood.

Benign recurrent isolated VI nerve palsy of childhood is a rare condition. The diagnosis is essentially one of exclusion. The following case report is of a child with 11 recurrences between age 10 months and 11 years. The literature is reviewed.

The effect of individualized activities on the sleep of nursing home residents who are cognitively impaired: a pilot study.

This pilot study investigated a program of individualized activities designed to enhance nocturnal sleep in five cognitively impaired veterans residing in a dementia care unit. Actigraphy documented 24-hour sleep-wake patterns of the residents for 3 days. Those meeting the criteria for inclusion then participated in an Individualized Activity Intervention timed to occur during peak napping times for 14 days. During the 10th, 12th, and 14th days of intervention, actigraphy provided a repeat measure of sleep-wake patterns. The results indicated an increase in nocturnal sleep with increased efficiency, as well as a decrease in daytime napping. This pilot study encourages further investigation of this potential method for enhancing nocturnal sleep in cognitively impaired elderly adults.

Predictors of circadian sleep-wake rhythm maintenance in elders with dementia.

Minimal data exists to predict which elders with dementia in nursing homes will maintain circadian sleep-wake rhythms during senescence and which elders with dementia in nursing homes will experience sleep-wake rhythm deterioration. This circadian deterioration is one of the background factors identified in the Needs-driven Dementia-compromised Behavior Model. The objective of this study was to determine predictors of circadian sleep-wake rhythm maintenance in elders with dementia residing in nursing homes. This secondary analysis identifies predictors of maintaining circadian sleep-wake rhythm in a convenience sample of 171 elders with dementia residing in seven nursing homes in the Southern United States. An autocorrelogram of the circadian sleep-wake rhythm for each participant determined whether or not the rhythm had deteriorated. Using measures of depression, cognitive function, physical and psychosocial activity, medications, and sleep apnea, as well as demographic characteristics of the sample, logistic regression determined the best predictors of rhythm maintenance. The best predictors of circadian sleep-wake rhythm maintenance in elders with dementia residing in nursing homes were physical activity (p = 0.00) and psychosocial activity (p = 0.00). The interaction term between these variables was not significant (p = 0.24). These findings suggest that providing meaningful daytime physical and psychosocial activity may assist in maintaining circadian sleep-wake rhythmicity. Additional research is needed to determine if these interventions would improve circadian sleep-wake rhythm in elders with dementia residing in nursing homes.

Management of peri-ocular skin tumours by laissez-faire technique: analysis of functional and cosmetic results.

AIM: The role of wound healing by secondary intention in the treatment of peri-ocular skin tumours is not well established. The object of this retrospective analysis was to evaluate the functional and cosmetic outcome of patients treated by the Laissez-faire technique in situations where primary closure would not have been possible. METHODS: Skin defects following excision of lid and peri-ocular tumours in 24 Caucasian patients were allowed to heal by granulation. The locations included lower eyelid (n = 10), upper lid (n = 6), medial canthus (n = 5), nasojugal fold (n = 2), lateral canthus (n = 1) and brow (n = 1). Four patients had lid margin involvement. The size of the initial defect, time taken to heal, discomfort during healing, the functional and cosmetic results-both from the surgeon and patient perspective, complications, secondary intervention if any and patient satisfaction were studied. RESULTS: A good functional and cosmetic result was obtained in 23 of the 25 lesions (92%). Of these 23 patients, two patients had slightly hypertrophied scars, which responded well to massage and two patients had some degree of ectropion. Of the two patients who did not have a good cosmetic result, only one needed secondary intervention. One had an exuberant granulation tissue, which responded to topical steroids and massage, but left behind a distorted lateral canthus. CONCLUSION: Healing by secondary intention of large defects following excision of peri-ocular tumours is an effective alternative to primary or staged reconstruction in selected cases.

Visitation in critical care: processes and outcomes of a performance improvement initiative.

When family members became dissatisfied with a restrictive visiting policy in a combined coronary and medical intensive care unit, this situation was seen as an opportunity to better meet patient and family needs. A review of the literature indicated that open visitation policies enhance patient and family satisfaction, while a survey of patients, families, and health care team members revealed a desire for a more open visitation policy. Nursing staff, with input from other disciplines, developed and implemented a less restrictive visitation policy. Post-intervention surveys revealed higher patient and family satisfaction and a marked decrease in formal complaints.