Documented Penicillin Allergies on Antibiotic Selection at Pediatric Emergency Department Visits.

BACKGROUND: Penicillin or amoxicillin are the recommended treatments for the most common pediatric bacterial illnesses. Allergies to penicillin are commonly reported among children but rarely true. We evaluated the impact of reported penicillin allergies on broad-spectrum antibiotic use overall and for the treatment of common respiratory infections among treat-and-release pediatric emergency department (ED) visits. METHODS: Retrospective cohort study of pediatric patients receiving antibiotics during a treat-and-release visit at a large, pediatric ED in the northeast from 2014 to 2016. Study exposure was a reported allergy to penicillin in the electronic medical record. Study outcomes were the selection of broad-spectrum antibiotics and alternative (second-line) antibiotic therapy for the treatment of acute otitis media (AOM) and group A streptococcus (GAS) pharyngitis. We used unadjusted and adjusted generalized estimating equation models to analyze the impact of reported penicillin allergies on the selection of broad-spectrum antibiotics. We used unadjusted and adjusted logistic regression models to determine the probability of children with a documented penicillin allergy receiving alternative antibiotic treatments for AOM and GAS. RESULTS: Among 12,987 pediatric patients, 810 (6.2%) had a documented penicillin allergy. Penicillin allergies increased the odds of children receiving a broad spectrum versus narrow spectrum antibiotic (adjusted odds ratio, 13.55; 95% confidence interval (CI), 11.34-16.18). In our adjusted logistic regression model, the probability of children with a documented penicillin allergy receiving alternative antibiotic treatment for AOM was 0.97 (95% CI, 0.94-0.99) and for GAS was 0.97 (95% CI, 0.92-0.99). CONCLUSIONS: Antibiotic stewardship efforts in pediatric EDs may consider the delabeling of penicillin allergies particularly among children receiving antibiotics for an acute respiratory infection as a target for intervention.

Differentiating research and quality improvement activities: A scoping review and implications for clinical scholarship.

BACKGROUND: Differentiating activities that are research or quality improvement (QI) is challenging. PURPOSE: Compare tools that distinguish research from QI and evaluate the utility of tools to determine whether institutional review board (IRB) approval is required for a test-project. METHODS: Scoping review of the literature to identify tools that distinguish QI from research. Two reviewers independently screened records in PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Google Scholar and extracted information from tools. Inclusion criteria were English language peer-reviewed publications or publicly available tools with scoring systems to differentiate between research and QI. The reporting of this review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We then applied a test-project to evaluate the utility of the tools. FINDINGS: One-hundred forty sources were reviewed; 13 met inclusion criteria. Tools consistently used project intent/purpose, design and intervention as differentiating criteria; additional criteria varied. Five studies described tool development, and one reported that the tool had been tested. Our application of a test-project proved challenging as tools commonly presented research and QI as discrete activities. DISCUSSION: Based on the core criteria common across tools to distinguish research from QI, we propose a simple four-criteria decision tool for assessing the need for IRB submission.

Programmatic details and outcomes of an Academic-Practice Research Fellowship for clinical nurses.

AIM: Describe the programmatic details and outcomes of a competitive, two-year Academic-Practice Research Fellowship for clinical nurses. BACKGROUND: Numerous barriers challenge clinical nurses in their ability to conduct and disseminate research. We describe and evaluate a competitive, semi-structured, two-year Academic-Practice Research Fellowship in which clinical nurse 'fellows' accepted into the program are paired with a faculty mentor at a school of nursing to conduct and disseminate a research study that addresses a clinical problem identified by the fellow. The fellowship is facilitated by the Director of Academic-Practice Partnerships jointly appointed between a school of nursing and affiliated acute care hospitals, and with resources provided by both. The vast majority of didactic training is provided outside the classroom. METHODS: We reviewed administrative records to describe the programmatic details and outcomes of the program. RESULTS: Thirteen nurses were accepted into the first three cohorts of the Academic-Practice Research Fellowship. Among the five fellows in the graduating first cohort, all successfully completed their research, presented their findings at national or international conference(s) and four have submitted manuscripts for publication, with two being accepted for publication. The eight current fellows are meeting all delineated milestones and timelines. Evaluations demonstrate the effectiveness of the fellowship in enhancing the professional development and research capacity of clinical nurses. CONCLUSIONS: The Academic-Practice Research Fellowship program integrates expertise and resources across academia and practice and has resulted in the successful conduct and dissemination of clinically relevant research by fulltime practicing nurses in the acute care setting.

The Jonas Scholars Program-Evaluation of a decade-long program to advance doctoral-prepared nurses.

BACKGROUND: The Jonas Scholars Program of Jonas Nursing & Veterans Healthcare aims to advance the pipeline of doctoral-prepared, research-focused, and practice-focused faculty via student financial support and leadership training. PURPOSE: Program evaluation of the Jonas Scholars Program. We describe the reach of the program over time, scholar characteristics, and report on graduated scholars that are currently employed in faculty and clinical positions. METHOD: Retrospective analysis of administrative records from the Jonas Scholars Program spanning 2008 to 2016. FINDINGS: The Jonas Scholars Program has grown substantially since its inception. From 2008 to 2016, a total of 1,032 doctoral students at 174 universities across the United States have received financial support through the program. Scholars have a mean age of 38 and nearly two-thirds are enrolled in a research-focused PhD program. Most graduated scholars for which data are available are primarily faculty in nursing schools 185 (30.7%), providing direct patient care 171 (28.4%), or conducting research 118 (19.8%). DISCUSSION: The Jonas Scholars Program supports the pipeline of a younger generation of doctoral-prepared nurses that are faculty in schools of nursing, providing direct patient care and conducting research.

Evaluation of the joint nurse scientist role across academia and practice.

BACKGROUND: Mapped with the guiding principles of academic-practice partnerships (APPs) outlined by the American Association of Colleges of Nursing and the American Organization for Nursing Leadership, a joint nurse scientist role between a nursing school and acute care facility at a large academic health center was developed and characterized by a PhD-prepared nurse appointed in a research role across organizations. To date, eight faculty are now appointed across the School and four health systems. PURPOSE: Describe outcomes, facilitators and vulnerabilities of the joint nurse scientist role. METHODS: Review of administrative records. DISCUSSION: Outcomes include the 1) conduct and dissemination of joint research, 2) translation of evidence into practice, 3) development of educational programs for health system nurses, 4) scholarly activities among health system nurses, and 5) improved visibility and valuation of the PhD-prepared nurse. Role facilitators include those previously reported for APPs, the joint nurse scientists' ability to broker opportunities across settings, and the evolving nature of the role. Role vulnerabilities pertain to the negotiation of workload, promotion, and institutional priorities. CONCLUSION: The joint nurse scientist role fosters shared scholarly successes across academia and service.

Clinical Nurse Preparation and Partnership in Antibiotic Stewardship Programs: National Survey Findings Are a Call to Action for Nurse Leaders.

OBJECTIVE: Describe clinical nurse involvement in antibiotic stewardship programs (ASPs). BACKGROUND: The extent to which clinical nurses are supported and integrated into ASPs is unknown. METHODS: Electronic survey of infection preventionists (IPs) working in acute care hospitals. RESULTS: A total of 207 IPs nationwide reported on clinical nurses' involvement in their hospital's ASP. Among respondents, 42% reported the presence of a designated nurse executive that championed nurses' involvement in ASPs; 33% reported that the hospital provides antibiotic stewardship education and training to clinical nurses, and only 14% believed that clinical nurses have adequate stewardship knowledge to participate in ASP activities. CONCLUSIONS: Study findings indicate the need for nurse leaders to improve the preparation and integration of clinical nurses in ASPs. While clinical nurses routinely perform activities that contribute to optimal antibiotic use, the knowledge and competency of clinical nurses in these activities and their formal integration in ASPs are minimal.

Linking to Improve Nursing Care and Knowledge: Evaluation of an Initiative to Provide Research Support to Clinical Nurses.

OBJECTIVES: The aim of this study is to describe and evaluate the impact of the Linking to Improve Nursing Care and Knowledge (LINK) project on increasing nurse-led clinical research. BACKGROUND: Nurse-generated research is the cornerstone of evidence-based practice and continues to be a marker of nursing excellence. However, the dearth of PhD-prepared nurses creates a challenge for creating an environment to promote clinical nursing research. We evaluated the LINK project, an academic-clinical partnership, to assess its impact and feasibility, for fostering nurse-led clinical research. METHODS: The LINK project created a formal command and control structure bringing together existing academic resources, including a PhD-prepared nurse researcher, a biostatistician, and a development of a formal research consultation request process. Measures tracked over a 12-month period included average response time, request volume, client satisfaction, institutional review board (IRB)-submitted protocols, and work products. RESULTS: All measures exceeded expectations with an average 1-day request response time, 35 requests, 98% client satisfaction, a 367% increase in nurse-led IRB approved protocols from the previous 12-month period, and 2 publications in peer-reviewed journals. CONCLUSIONS: The process and outcome measures indicate that the LINK project is feasible, sustainable, and reproducible. We were able to meet and, in many cases, exceed measurement goals. In addition, implementation science literature indicates that the most valid measure of a successful project rollout is user satisfaction and usefulness. The LINK project received consistently positive feedback.

The Expanding Role of Antimicrobial Stewardship Programs in Hospitals in the United States: Lessons Learned from a Multisite Qualitative Study.

BACKGROUND: Misuse of antibiotics can lead to the development of antibiotic resistance, which adversely affects morbidity, mortality, length of stay, and cost. To combat the threat of antimicrobial resistance, The Joint Commission and the Centers for Medicare & Medicaid Services have initiated or proposed requirements for hospitals to have antimicrobial stewardship programs (ASPs), but implementation remains challenging. A key-informant interview study was conducted to describe the characteristics and innovative strategies of leading ASPs. METHODS: Semistructured interviews were conducted with 12 program leaders at four ASPs in the United States, chosen by purposive sampling on the basis of national reputation, scholarship, and geography. Questions focused on ASP implementation, program structure, strengths, weaknesses, lessons learned, and future directions. Content analysis was used to identify dominant themes. RESULTS: Three major themes were identified. The first was evolution of ASPs from a top-down structure to a more diffuse approach involving unit-based pharmacists, multidisciplinary staff, and shared responsibility for antimicrobial prescribing under the ASPs' leadership. The second theme was integration of information technology (IT) systems, which enabled real-time interventions to optimize antimicrobial therapy and patient management. The third was barriers to technology integration, including limited resources for data analysis and poor interoperability between software systems. CONCLUSION: The study provides valuable insights on program implementation at a sample of leading ASPs across the United States. These ASPs used expansion of personnel to amplify the ASP's impact and integrated IT resources into daily work flow to improve efficiency. These findings can be used to guide implementation at other hospitals and aid in future policy development.

Targeted Interventions to Advance a Culture of Inquiry at a Large, Multicampus Hospital Among Nurses.

OBJECTIVES: The aim of this study is to assist nurse leaders in developing innovative structures to foster a culture of inquiry among professional nurses. BACKGROUND: Critical to nurse's engagement in evidence-based practice (EBP) is a culture of inquiry, in which nurses critically evaluate patient care activities and actively review existing evidence to address identified clinical issues. A bundle of structural interventions was implemented across a large, multisite hospital to advance a culture of inquiry. We measured the impact of these interventions on nurses' library use and on nurses' knowledge, attitudes, and practices towards EBP. METHODS: Structural interventions included: 1) EBP and Research Committee meetings, in which nurses were educated on how to formulate a clinical question and critically appraise a research article; 2) Academic Partners Program, in which nurse academicians provided scholarly mentorship and guidance during monthly committee meetings; 3) hiring of clinical nurse scientists who provided 1-on-1 education and mentorship to clinical nurses in EBP and research; and 4) a Nurse Residency Program partnership, in which newly graduated nurses were required to complete an EBP project. We examined the impact of these structural interventions on nurses' use of library resources and nurses' knowledge, attitudes, and practices toward EBP. RESULTS: The implementation of structural interventions to support nurses' engagement in EBP was associated with a significant increase in the number of nurse-generated library consultative requests over time. Results showed high levels of nurse knowledge, attitudes, and practices in EBP. CONCLUSIONS: Nurse leaders may advance a culture of inquiry by providing the infrastructure to support EBP activities and by empowering nurses to question and seek answer to identified practice questions. Infrastructures should include access to scientific articles and partnerships with schools of nursing. Additional research is needed to validate nurse library use as a measure of nurse engagement in EBP.

Driven to distraction: The nature and apparent purpose of interruptions in critical care and implications for HIT.

OBJECTIVES: To examine the apparent purpose of interruptions in a Pediatric Intensive Care Unit and opportunities to reduce their burden with informatics solutions. MATERIALS AND METHODS: In this prospective observational study, researchers shadowed clinicians in the unit for one hour at a time, recording all interruptions participating clinicians experienced or initiated, their starting time, duration, and a short description that could help to infer their apparent purpose. All captured interruptions were classified inductively on their source and apparent purpose and on the optimal representational media for fulfilling their apparent purpose. RESULTS: The researchers observed thirty-four one-hour sessions with clinicians in the unit, including 21 nurses and 13 residents and house physicians. The physicians were interrupted on average 11.9 times per hour and interrupted others 8.8 times per hour. Nurses were interrupted 8.6 times per hour and interrupted others 5.1 times per hour. The apparent purpose of interruptions included Information Seeking and Sharing (n=259, 46.3%), Directives and Requests (n=70, 12%), Shared Decision-Making (n=49, 8.8%), Direct Patient Care (n=36, 6.4%), Social (n=71, 12.7%), Device Alarms (n=28, 5%), and Non-Clinical (n=10, 1.8%); 6.6% were not classified due to insufficient description. Of all captured interruptions, 29.5% were classified as being better served with informational displays or computer-mediated communication. CONCLUSIONS: Deeper understanding of the purpose of interruptions in critical care can help to distinguish between interruptions that require face-to-face conversation and those that can be eliminated with informatics solutions. The proposed taxonomy of interruptions and representational analysis can be used to further advance the science of interruptions in clinical care.

Clarifying the Conundrum: Evidence-Based Practice, Quality Improvement, or Research?: The Clinical Scholarship Continuum.

Nurses' active involvement in clinical scholarship is necessary to advance the nursing profession and improve patient outcomes. Yet, definitional confusion and numerous barriers exist to clinical scholarship in and across academic and patient care settings. We discuss factors that pose barriers to the continuum of clinical scholarship and suggest opportunities for clinician-researcher collaborations that promote nurses' engagement in evidence-based practice, quality improvement, and research.

A Qualitative Study of Factors Facilitating Clinical Nurse Engagement in Emergency Department Catheter-Associated Urinary Tract Infection Prevention.

OBJECTIVE: The aim of this study was to explore the actions of nurse leaders that facilitated clinical nurses' active involvement in emergency department (ED) catheter-associated urinary tract infection (CAUTI) prevention programs. BACKGROUND: Hospitals face increasing financial pressures to reduce CAUTI. Urinary catheters, often inserted in the ED, expose patients to CAUTI risk. Nurses are the principal champions of ED CAUTI prevention programs. METHODS: This was a qualitative analysis from a multisite, comparative case study project. A total of 52 interviews and 9 focus groups were analyzed across 6 enrolled EDs. Using a conventional content analysis, members of the research team coded data and developed site summaries to describe themes that had emerged across transcripts. Subsequently, all codes and site summaries were reviewed to identify the actions of nurse leaders that facilitated clinical nurses' engagement in CAUTI prevention efforts. RESULTS: Nurse leaders were the principal champions of CAUTI prevention programs and successfully engaged clinical nurses in CAUTI prevention efforts by (1) reframing urinary catheters as a source of potential patient harm; (2) empowering clinical nurses to identify and address CAUTI improvement opportunities; (3) fostering a culture of teamwork, which facilitated interdisciplinary communication around urinary catheter appropriateness and alternatives; and (4) holding clinical nurses accountable for CAUTI process and outcome measures. CONCLUSIONS: The prevention of CAUTI is an important opportunity for nurse leaders to engage clinical nurses in meaningful improvement efforts. Clinical nurses are best positioned to examine urinary catheter insertion workflow and to suggest improvements in avoiding use and improving placement and maintenance. To engage clinical nurses in CAUTI prevention, nurse leaders should focus on how urinary catheters expose patients to potential harm, involve nurses in designing and implementing practice changes, and provide local data to show the impact of nursing practices on patient outcomes.

Using Workflow Diagrams to Address Hand Hygiene in Pediatric Long-Term Care Facilities.

Hand hygiene (HH) in pediatric long-term care settings has been found to be sub-optimal. Multidisciplinary teams at three pediatric long-term care facilities developed step-by-step workflow diagrams of commonly performed tasks highlighting HH opportunities. Diagrams were validated through observation of tasks and concurrent diagram assessment. Facility teams developed six workflow diagrams that underwent 22 validation observations. Four main themes emerged: 1) diagram specificity, 2) wording and layout, 3) timing of HH indications, and 4) environmental hygiene. The development of workflow diagrams is an opportunity to identify and address the complexity of HH in pediatric long-term care facilities.

Risk Factors for Nosocomial Bacteremia Secondary to Urinary Catheter-Associated Bacteriuria: A Systematic Review.

A systematic appraisal of evidence suggests that male patients in hospital may be at higher risk for bacteremia following urinary catheter-associated bacteriuria than females. Other risk factors include immunosuppressant medication, red blood cell transfusion, neutropenia, malignancy, and liver disease.

The relationship between emergency department crowding and patient outcomes: a systematic review.

PURPOSE: Emergency department (ED) crowding is a significant patient safety concern associated with poor quality of care. The purpose of this systematic review is to assess the relationship between ED crowding and patient outcomes. DESIGN: We searched the Medline search engine and relevant emergency medicine and nursing journals for studies published in the past decade that pertained to ED crowding and the following patient outcome measures: mortality, morbidity, patient satisfaction, and leaving the ED without being seen. All articles were appraised for study quality. FINDINGS: A total of 196 abstracts were screened and 11 articles met inclusion criteria. Three of the eleven studies reported a significant positive relationship between ED crowding and mortality either among patients admitted to the hospital or discharged home. Five studies reported that ED crowding is associated with higher rates of patients leaving the ED without being seen. Measures of ED crowding varied across studies. CONCLUSIONS: ED crowding is a major patient safety concern associated with poor patient outcomes. Interventions and policies are needed to address this significant problem. CLINICAL RELEVANCE: This review details the negative patient outcomes associated with ED crowding. Study results are relevant to medical professionals and those that seek care in the ED.

Nursing home residents' experiences and perceptions of antibiotic use: A qualitative descriptive study.

BACKGROUND: Antibiotics are commonly used in the nursing home (NH) setting. Little is known of NH residents' perceptions and experiences regarding antibiotic use. METHODS: This was a qualitative descriptive study. We conducted individual, semi-structured interviews with NH residents. Interview transcripts were analyzed using conventional content analysis. RESULTS: Twenty-six residents were interviewed. Four themes emerged: (1) perceived benefits and risks to antibiotics; (2) information needs regarding antibiotic treatment; (3) approaches to address information needs; and (4) resident involvement in antibiotic treatment decisions. The perceived benefits of antibiotics were described as symptom-relief and cure; risks included gastrointestinal symptoms and antibiotic resistance. Informational needs included the indication for antibiotics, risks and side-effects of antibiotics, and potential interactions between antibiotic treatments and medication regimens. Residents performed information seeking behaviors to address informational needs but described difficulty obtaining and recalling desired information. Diverse involvement in antibiotic treatment decisions were described, in which a subset of participants reported seeking antibiotics from their prescriber. CONCLUSIONS: Future efforts aiming to improve collaborative decision making and antibiotic use in the NH setting should address the unmet information needs of NH residents regarding their antibiotic treatment plans.

Perceived usefulness of a mnemonic to improve nurses' evaluation of reported penicillin allergies.

We surveyed clinicians to evaluate the perceived usefulness of a mnemonic, STORY, to improve penicillin allergy evaluation. Survey responses indicated that the perceived usefulness of STORY was high, and support for nurses' involvement in penicillin allergy assessment was high. Future research may evaluate the feasibility of STORY implementation in clinical care.

Parent-reported penicillin allergies in children: A qualitative study.

BACKGROUND: Penicillin allergies are commonly reported in children. Most reported penicillin allergies are false, resulting in the unnecessary selection of alternative antibiotic treatments that promote antibiotic resistance. While formal allergy testing is encouraged to establish a diagnosis of penicillin allergy, children are rarely referred for allergy testing, and study of parents' experiences and perceptions of their child's reported penicillin allergy is limited. We aimed to describe parents' experiences and perceptions of their child's penicillin allergy and attitudes towards penicillin allergy testing to identify opportunities to engage parents in antimicrobial stewardship efforts. METHODS: This was a qualitative descriptive study. RESULTS: Eighteen parents participated in this study. Parents' children were on average 2 years old when the index reaction occurred, and 7 years had passed since the reaction. Transcripts revealed that participants were receptive to penicillin allergy testing for their child after learning the consequences of penicillin allergy and availability of allergy testing. Four major themes emerged from data (1) parents' making sense of allergy; (2) parents' impressions of allergy label, (3) parents' attitudes towards allergy testing, and (4) parents' desire to be informed of testing availability. CONCLUSIONS: Efforts are needed to engage parents in addressing spuriously reported penicillin allergies.

Development and Validation of a Fall Prevention Efficiency Scale.

OBJECTIVES: Fall TIPS (Tailoring Interventions for Patient Safety) is an evidence-based fall prevention program that led to a 25% reduction in falls in hospitalized adults. Because it would be helpful to assess nurses' perceptions of burdens imposed on them by using Fall TIPS or other fall prevention program, we conducted a study to learn benefits and burdens. METHODS: A 3-phase mixed-method study was conducted at 3 hospitals in Massachusetts and 3 in New York: (1) initial qualitative, elicited and categorized nurses' views of time spent implementing Fall TIPS; (2) second qualitative, used nurses' quotes to develop items, research team inputs for refinement and organization, and clinical nurses' evaluation and suggestions to develop the prototype scale; and (3) quantitative, evaluated psychometric properties. RESULTS: Four "time" themes emerged: (1) efficiency, (2) inefficiency, (3) balances out, and (4) valued. A 20-item prototype Fall Prevention Efficiency Scale was developed, administered to 383 clinical nurses, and reduced to 13 items. Individual items demonstrated robust stability with Pearson correlations of 0.349 to 0.550 and paired t tests of 0.155 to 1.636. Four factors explained 74.3% variance and provided empirical support for the scale's conceptual basis. The scale achieved excellent internal consistency values (0.82-0.92) when examined with the test, validation, and paired (both test and retest) samples. CONCLUSIONS: This new scale assess nurses' perceptions of how a fall prevention program affects their efficiency, which impacts the likelihood of use. Learning nurses' beliefs about time wasted when implementing new programs allows hospitals to correct problems that squander time.

Infection preventionists role in antimicrobial stewardship: Survey of APIC members.

The primary job responsibility of infection preventionists (IPs) is to lead organizational initiatives that prevent and control health care-associated infections. Increasingly, IPs are participating in activities that support antimicrobial stewardship programs (ASPs). We conducted a survey of Association of Professionals in Infection Control and Epidemiology members practicing in acute care facilities to determine the degree of their involvement in ASP activities.