Multimodal Perioperative Analgesia Regimen to Improve Patient Outcomes After Total Knee Arthroplasty: A Multidisciplinary Quality Improvement Project.

PURPOSE: The primary aim of this quality improvement project was to improve mobilization for patients after total knee arthroscopy by developing and implementing a standardized, evidence-based, multimodal analgesia regimen and patient-educational video. Secondary outcomes included opioid consumption, pain, and length of stay. DESIGN: A pre-post implementation design was used to compare two independent samples. METHODS: Patients were screened based on inclusion and exclusion criteria 1-2 weeks before surgery. The anesthesia provider made the final determination for inclusion. Data were collected by retrospective chart review. FINDINGS: Following implementation, patients displayed significantly improved mobilization, reduced opioid consumption, and reduced length of stay. Patient-reported pain scores were similar or significantly lower in the postimplementation group. CONCLUSIONS: Variability of patient outcomes was reduced, and quality of care was improved by standardizing care and incorporating the best available evidence, consistent with organization's resources in the nonacademic-affiliated, community hospital setting.

Meeting the complex healthcare needs of veterans.

ABSTRACT: More than half of US veterans seek care outside of the Veterans Health Administration. Physical and mental healthcare needs can be complicated by experiences during military service. Community clinicians can deliver more holistic and comprehensive care to veterans through understanding the unique needs of the veteran population.

A Day in the Life: Advanced Practice Nurses Providing Care to Patients with Musculoskeletal Conditions: Preparation, Role, and Impact.

Nurse practitioners (NPs) play an increasingly greater role in the delivery of orthopedic patient care. NPs practice in a wide variety of orthopedic settings having a significant positive impact on orthopedic care delivery. Few formal educational outlets exist for training NPs for orthopedic care. Many new orthopedic NPs rely on continuing education and an apprenticeship model of learning "on the job" with their surgeon counterparts. This article describes the preparation, role, and impact that today's NPs have on orthopedic care delivery.

Implementation and Evaluation of Tactical Combat Casualty Care for Army Aviators.

INTRODUCTION: The importance of developing military strategies to decrease preventable death by mitigating hemorrhage and reducing time between the point of injury and surgical intervention on the battlefield is highlighted in previous studies. Successful implementation of Tactical Combat Casualty Care (TCCC) throughout elements of the USA and allied militaries begins to address this need. However, TCCC implementation is neither even nor complete in the larger, conventional force. Army Aviators are at risk for preventable death as they do not receive prehospital care training and are challenged to render prehospital care in the austere environment of helicopter operations. Army aviators are at risk for preventable death due to the challenges to render prehospital care in the austere environment of helicopter operations. Helicopters often fly at low altitudes, engage in direct action in support of ground troops, operate at a great distance from medical facilities, typically do not have medical personnel onboard, and can have long wait times for medical evacuation services due to the far forward nature of helicopter operations. MATERIALS AND METHODS: This is a quality improvement pre-post-intervention design study evaluating the implementation of a combat casualty care training program for Army aviators using well-established evidence-based guidelines for providing care to casualties on the battlefield. The evaluation consisted of participants' self-perceived confidence in providing care to a casualty and change in knowledge level in combat casualty care in a pre/post-intervention design. Clinical skills of tourniquet application, nasopharyngeal airway placement, and needle chest decompression were assessed on a pass/fail grading standard. RESULTS: A total of 18 participants completed the pre- and post-education surveys. A paired t-test showed a statistically significant increase in total composite scores from pre (M = 24.67, SD = 5.06) to post-education self-efficacy (M = 37.94, SD = 2.10), t (17) = -11.29, p < 0.001. A paired t-test revealed a significant increase in exam scores from pre (M = 70.22, SD = 9.43) to post (M = 87.78, SD = 7.19), t (17) = -7.31, p < 0.001. There was no pre-intervention skills assessment, however, all participants (n = 18, 100%) passed the tourniquet application, needle chest compression, and insertion of nasopharyngeal airway. CONCLUSION: TCCC for Army Aviators is easily implemented, demonstrates an increase in knowledge and confidence in providing prehospital care, and provides effective scenario-based training of necessary psychomotor skills needed to reduce preventable death on the battlefield. TCCC for Army Aviators effectively takes the TCCC for All Combatants curriculum and modifies it to address the unique considerations in treating wounded aviators and passengers, both in flight and after crashes. This project demonstrates on a small scale how TCCC can be tailored to specific military jobs in order to successfully meet the intent of the upcoming All Service Member TCCC course mandated in DoD 1322.24. Beyond Army aviation, this program is easily modifiable for aviators throughout the military and civilian sector.

A call to action: Building evidence for use of simulation in nurse practitioner education.

Leaders from national nursing organizations, nursing schools, and health care simulation vendors convened in early 2019 to discuss simulation in nurse practitioner (NP) education. Nurse practitioner clinical education needs a more standardized, efficient, and sustainable model to prepare NPs to provide quality care in complex health care systems. Currently, a major shortage of clinical sites and preceptors to educate students creates challenges for NP programs and nursing faculty. One strategy used by nursing programs to overcome this challenge is using simulation to provide clinical training for NP students in a safe, controlled environment. There remains, however, a lack of evidence linking these simulation experiences with clinical skills acquisition and program outcomes. Implementing competency-based education through standardized simulations has the potential to demonstrate quality, safety, and accountability across NP education programs. Ultimately, the expansion and acceptance of simulation hours in NP education is dependent on strong and favorable evidence from rigorous, high-quality studies.

Increasing Influenza Immunization Rates Among Retail Employees: An Evidence-Based Approach.

Influenza has a significant impact on the health of Americans and the U.S. economy. Annual influenza immunization can decrease the burden of influenza-related illnesses for both employees and employers. This project evaluated a nurse practitioner-led intervention to increase influenza immunization rates among retail employees from August through December of the 2015-2016 influenza season. The sample included employees from retail locations with on-site convenience care clinics staffed by nurse practitioners. This quality improvement project used a pre-post implementation evaluation design and compared influenza immunization rates of employees, before and after an intervention, at one worksite, and influenza immunization rates of employees, who did not receive the same intervention, at a comparison site. The intervention site employees were immunized at a higher rate than employees at the comparison site. Interventions, including health care professional-led education, program promotion, on-site access to and no-cost immunizations, choice of immunization delivery, and incentives, should be considered to increase immunization rates among employees.

Intrahospital Transport of the Critically Ill Adult: A Standardized Evaluation Plan.

BACKGROUND: Intrahospital transport of the critically ill adult carries inherent risks that can be manifested as unexpected events. OBJECTIVE: The aim of this study is to evaluate the implementation of a standardized evaluation plan for intrahospital transports to/from adult intensive care units. METHODS: Nurses at a level I trauma/academic center captured clinical data throughout transport. Outcome measures included compliance with the organization's transport policy and unexpected events. RESULTS: There were 502 transports audited. Most nurses were compliant with the policy, except for the stabilization process (n = 174, 34.7%). Forty-one transports (8.2%) had an unexpected event, and 11 of these transports (26.8%) were aborted. Most of the events were hemodynamic (12), sedation (11), respiratory (10), and gastrointestinal (5). Fewer events occurred with the transport team (P = .036) and among nurses with a bachelor of science in nursing or higher degree (P = .002). Events were higher among transporting nurses with only 0 to 2 years of intensive care unit experience (P = .002), "stabilized" transports (P = .022), and patients with higher Acute Physiology and Chronic Health Evaluation scores (P = .009). CONCLUSIONS: Health care organizations should have a policy that includes both transport and evaluation plans for intrahospital transport. Guidelines should be revised with specific criteria for the stabilization process and unexpected events. Revision should also have a standardized evaluation plan that includes an audit tool to measure incidence of unexpected events and a rapid change quality improvement method.

Viscosupplementation for knee osteoarthritis.

PURPOSE: To provide an overview of the diagnosis and pathophysiology of osteoarthritis (OA), and to describe appropriate treatments for knee OA, with a focus on the efficacy and safety of viscosupplementation. Because nurse practitioners (NPs) can inject viscosupplements, a section on injection technique is included. DATA SOURCES: Manuscripts were identified using PubMed and EMBASE with a review of the reference lists from retrieved articles. CONCLUSIONS: Viscosupplements are safe and effective at improving function and alleviating knee pain from OA for up to 26 weeks. IMPLICATIONS FOR PRACTICE: As the number of patients with OA is increasing, NPs need to be prepared to prescribe various treatment options to alleviate osteoarthritic knee pain, including viscosupplementation.

Improving the management of tibia stress fractures: a collaborative, outpatient clinic-based quality improvement project.

PURPOSE: Implement and evaluate the effectiveness of the Leg Pain Screening and Referral Tool (LPS&RT) for patients presenting with lower extremity leg pain in an outpatient clinic. SAMPLE: A total of 46 patients diagnosed with tibia stress fractures. METHODS: The study employed a pre-/postintervention design. Retrospective and prospective information was collected from an electronic health record to obtain patient data. The pre- and postintervention groups were compared on the number of patients diagnosed with tibia stress fractures. Provider adherence to the treatments recommended by the algorithm was assessed by chart audits postintervention. RESULTS: There was a significant increase (87.5%) in tibia stress fracture diagnosis, from 16 preintervention to 30 postintervention. Provider adherence to the LPS&RT was 93.3% postintervention. Common treatments were activity restriction, oral medication, and/or specialty referrals. CONCLUSION: The LPS&RT was an effective, uniform measure to standardize the plan of care for tibia stress fractures in one outpatient clinic.

A closer look at hand and wrist complaints.

Hand or wrist pain is a common complaint in primary care. This pain can be very disabling and can significantly impair a person's quality of life. With the appropriate clinical knowledge and skills, nurse practitioners can effectively evaluate, diagnose, and treat many of the common hand and wrist complaints seen in primary care.

Pathophysiology of heterotopic ossification.

Heterotopic ossification (HO) is a pathologic condition that leads to the development of bone within nonosseous soft tissues. A common site for HO development is at the hip. The bone that forms is believed to develop through stimulation by cellular mediators and altered neurovascular signaling. Heterotopic ossification can be a debilitating disease leading to pain, edema, and stiffness. This only compounds already-debilitating comorbid conditions such as a spinal cord injury, head injury, or trauma. Several factors, including prostaglandin E2, bone morphogenetic protein, and the inflammatory process, are believed to contribute to the development of HO. The full scope of pathophysiology contributing to HO is not fully understood.

Pre-participation physical evaluations for athletes.

The pre-participation physical evaluation helps keep athletes safe. This article discusses the essential components of the PPE history and physical. Findings that should prompt further evaluation of the athlete, including those consistent with risk for sudden cardiac death, are discussed.

Gout: no longer the disease of kings.

Once described as the disease of kings, gout has developed a much greater incidence and prevalence. The incidence of gout is on the rise predominantly in the elderly. There appears to be a greater risk of developing gout with hyperuricemia, hypertension, and renal disease. High fructose drinks, red meat, organ meats, fatty seafood, and beer or liquor also appear to increase the risk of developing gout. Gout can lead to inflammation and damage to cartilage, bone, bursa, tendons, heart, or kidneys. Patients with gout will have many years of asymptomatic hyperuricemia followed by episodes of acute gouty inflammation and asymptomatic periods. Some people with gout will progress to chronic gout with tophi deposits, pain, deformity, and bone and cartilage destruction.

The doctor of nursing practice and nursing education: highlights, potential, and promise.

The success of the doctor of nursing practice (DNP) programs have exceeded everyone's expectations and resulted in increased interest in doctoral education in nursing. A shortage of doctorally prepared nurse educators continues to plague the profession and has a severe impact on the ability of schools of nursing to educate future generations of nurses. As a terminal degree in nursing practice, there is little focus on DNP graduates who are prepared as educators. To remedy this deficit, this article will therefore discuss and highlight (a) the significant potential of the DNP to mitigate the current nursing faculty shortage and to close the practice-education gap, (b) the specialized role of DNP graduates as educators and leaders in nursing education, and (c) the implications of the DNP for nursing scholarship.

Osteoarticular manifestations of Mycobacterium tuberculosis infection.

Mycobacterium tuberculosis has affected humans for much of our existence. The incidence of global tuberculosis infection continues to rise, especially in concert with HIV coinfection. Many disease processes, such as diabetes, increase the likelihood of tuberculosis infection. Tuberculosis bacteria can infect any bone, joint, tendon, or bursa; however, the most common musculoskeletal site for infection includes the spine and weight-bearing joints of the hip and knee. Many patients who present with osteoarticular tuberculosis infection will have a gradual onset of pain at the site of infection. Many patients who develop a musculoskeletal tuberculosis infection will have no evidence of a pulmonary tuberculosis infection on x-ray film and many will have very mild symptoms with the initial infection. Healthcare providers must remember that many patients who develop tuberculosis infection do not progress to active tuberculosis disease; however, the latent infection may become active with immune compromise.

The current state of care in gout: Addressing the need for better understanding of an ancient disease.

PURPOSE: To enable clinicians to initiate appropriate steps for long-term management of gout, including controlling acute exacerbations and pain and sustaining target serum uric acid (SUA) levels to control hyperuricemia as the underlying metabolic disorder. DATA SOURCES: Incorporation of pertinent rheumatology and primary care literature seeking a comprehensive overview about the disease state of gout and its symptoms, comorbidities, and impact on quality of life, with a key focus on the role of serum uric acid, evidence-based approaches to long-term management of gout, and the importance of a functioning clinician-patient relationship. CONCLUSIONS: Gout is increasingly recognized as a prevalent chronic disease state requiring appropriate long-term management while controlling for risk factors and comorbid conditions. Effective treatment options can help gout patients achieve therapeutic SUA targets to control gout flares and prevent potentially destructive disease manifestations. Patient education is an important element in achieving treatment goals and ensuring adherence. IMPLICATIONS FOR PRACTICE: Effective treatment plans for any gout patient must be guided by a long-term approach that focuses on sustained control of hyperuricemia, while providing continuous control of chronic disease. Patient education can be a key element in this process.