Increasing Competence in Pressure Injury Prevention Using Competency-Based Education in Adult Intensive Care Unit.

BACKGROUND: There is a significant focus on pressure injury prevention to promote better patient outcomes and control health care cost. LOCAL PROBLEM: In 2016, the institution's pressure injury quarterly prevalence survey showed that two-thirds of the patients surveyed who developed unit-acquired pressure injury stage 2 and greater were in the adult intensive care units. METHODS: The quality improvement project used a pre- and postintervention design. INTERVENTIONS: The adult medical intensive care unit (MICU) executed a competency-based education project to increase staff implementation of pressure injury prevention. RESULTS: Following initiation of competency-based education, staff documentation of pressure injury prevention implementation increased, and unit-acquired pressure injury stage 2 and greater rates were reduced. CONCLUSIONS: The use of a competency-based education program may be effective in increasing pressure injury prevention in the intensive care unit.

The Johns Hopkins Fall Risk Assessment Tool: A Study of Reliability and Validity.

Patient falls and fall-related injury remain a safety concern. The Johns Hopkins Fall Risk Assessment Tool (JHFRAT) was developed to facilitate early detection of risk for anticipated physiologic falls in adult inpatients. Psychometric properties in acute care settings have not yet been fully established; this study sought to fill that gap. Results indicate that the JHFRAT is reliable, with high sensitivity and negative predictive validity. Specificity and positive predictive validity were lower than expected.

Nurse-pharmacist collaboration on medication reconciliation prevents potential harm.

BACKGROUND: Medication reconciliation can prevent some adverse drug events (ADEs). Our prospective study explored whether an easily replicable nurse-pharmacist led medication reconciliation process could efficiently and inexpensively prevent potential ADEs. METHODS: Nurses at a 1000 bed urban, tertiary care hospital developed the home medication list (HML) through patient interview. If a patient was not able to provide a written HML or recall medications, the nurses reviewed the electronic record along with other sources. The nurses then compared the HML to the patient's active inpatient medications and judged whether the discrepancies were intentional or potentially unintentional. This was repeated at discharge as well. If the prescriber changed the order when contacted about a potential unintentional discrepancy, it was categorized as unintentional and rated on a 1-3 potential harm scale. RESULTS: The study included 563 patients. HML information gathering averaged 29 minutes. Two hundred twenty-five patients (40%; 95% confidence interval [CI], 36%-44%) had at least 1 unintended discrepancy on admission or discharge. One hundred sixty-two of the 225 patients had an unintended discrepancy ranked 2 or 3 on the harm scale. It cost $113.64 to find 1 potentially harmful discrepancy. Based on the 2008 cost of an ADE, preventing 1 discrepancy in every 290 patient encounters would offset the intervention costs. We potentially averted 81 ADEs for every 290 patients. CONCLUSION: Potentially harmful medication discrepancies occurred frequently at both admission and discharge. A nurse-pharmacist collaboration allowed many discrepancies to be reconciled before causing harm. The collaboration was efficient and cost-effective, and the process potentially improves patient safety.

Lung myeloid-derived suppressor cells and regulation of inflammation.

Myeloid-derived suppressor cells (MDSCs) have been investigated largely in the context of tumor progression. In contrast to the negative connotation of MDSCs in cancer immunity, our laboratory has recently reported on the development and role of pulmonary MDSC-like cells (CD11b(+)Gr1(int)F4/80(+)) in the regulation of allergic airway inflammation. These regulatory cells were expanded in a TLR4/MyD88-dependent manner and were both phenotypically and morphologically similar to those described in the tumor microenvironment. Although bacterial lipopolysaccharide (LPS) was initially described as an adjuvant in the development of allergic inflammation, subsequent studies showed that this is true only at relatively low doses of LPS. A high dose of LPS was shown to actually suppress eosinophilic airway inflammation. In our efforts to understand the mechanism underlying LPS-mediated suppression of allergic airway disease, we recently showed that LPS induces MDSC-like cells in the lung tissue in a dose-dependent manner, with increased accumulation of the cells at high doses of LPS. In contrast to lung dendritic cells (DCs), the MDSC-like cells did not traffic to the lung-draining lymph nodes, allowing them to act in a dominant fashion over DCs in the regulation of Th2 responses. The MDSC-like cells were found to blunt the ability of the lung DCs to upregulate GATA-3 or to promote STAT5 activation in primed Th2 cells, both transcription factors having critical roles in Th2 effector function. Thus, a complete understanding of the generation and regulation of the lung MDSCs would provide novel options for therapeutic interventions.

LPS-induced CD11b+Gr1(int)F4/80+ regulatory myeloid cells suppress allergen-induced airway inflammation.

In humans, the bacterial product lipopolysaccharide (LPS) has been associated with protection from allergic diseases such us asthma. However, in mouse models of allergic asthma, differential effects of LPS have been noted based on the dose. A low dose of LPS promotes Th2 responses and allergic disease but a high dose has been associated with suppression of allergic airway inflammation. Our recent work has described the ability of LPS to increase the frequency of CD11b+Gr1(int)F4/80+(abbreviated as Gr1(int) cells) cells in the lung tissue of mice in a dose-dependent fashion that is dependent on TLR4 and the TLR adaptor protein, MyD88. Both phenotypically and morphologically, the cells were found to have similarities with mycloid-derived suppressor cells. Adoptive transfer of LPS-induced Gr1(int) cells suppressed allergen-induced airway inflammation suggesting regulatory functions of the cells in allergic asthma. Although the Gr1(int) cells are detectable in the lung tissue of LPS-treated mice, they are barely detectable in the lung-draining lymph nodes (Lns) or in the airway lumen. This causes selective enrichment of these cells over dendritic cells (Dcs) in the tissue which upon LPS stimulation migrate to lung-draining LNs. The Gr1(int) cells were found to blunt the ability of the lung DCs to upregulate GATA-3 or to promote STAT5 activation in primed Th2 cells, both transcription factors having critical roles in TH2 effector function. Thus, a complete understanding of the generation and regulation of the Gr1(int) cells would provide new avenues to either promote or delete these cells for disease-specific immunoregulation.

Challenges in posthospital care: nurses as coaches for medication management.

The purpose of this study was to evaluate a transitional care intervention posthospital discharge for chronically ill medical patients managing complex medication regimens. This descriptive pilot study tested 2 interventions: telephone follow-up and a home visit. Registered nurses delivered the interventions with consulting pharmacist support. Findings included 62% more medication discrepancies discovered during home visit than detected by telephone interview. This brief intervention identified significant knowledge gaps in self-management of discharge medications in the inner city population.

Building nursing intellectual capital for safe use of information technology: a before-after study to test an evidence-based peer coach intervention.

Use of peer coaches may be effective in building and maintaining competencies bedside nurses need to safely use electronic health records (EHRs). A nonexperimental design with before-after measures was used to evaluate the effectiveness of peer coaches in increasing learner satisfaction and confidence in EHR use on 9 units at an academic medical center. Survey findings suggested that nurses experienced higher than expected satisfaction with training and increased self-confidence in the EHR use following program implementation.

Building nursing intellectual capital for safe use of information technology: a systematic review.

Information technology is integral to health care delivery. Nurse leaders recognize the need to build intellectual capital (knowledge, skills, and experience) in use and oversight of electronic health records despite financial constraints on indirect care time. A systematic literature review was conducted to answer the question, "What are the best practices to build nursing intellectual capital for use of IT for safe clinical care?" Evidence was translated to support a planned electronic health record rollout.

Educational strategies to develop evidence-based practice mentors.

Basing practice decisions on sound scientific research and best available evidence is an optimal approach for making practice changes. A five-member team of nursing leaders formed an evidence-based practice (EBP) steering committee and developed an EBP model and process. This article describes the educational approaches and the development of mentors used to provide the staff nurse with the necessary knowledge and skills to use EBP successfully.

Organizational change strategies for evidence-based practice.

Evidence-based practice, a crucial competency for healthcare providers and a basic force in Magnet hospitals, results in better patient outcomes. The authors describe the strategic approach to support the maturation of The Johns Hopkins Nursing evidence-based practice model through providing leadership, setting expectations, establishing structure, building skills, and allocating human and material resources as well as incorporating the model and tools into undergraduate and graduate education at the affiliated university.

Use of the ABC care bundle to standardize guideline implementation in a cardiac surgical population: a pilot study.

A cardiac surgical progressive care unit implemented the ABC's of Cardiovascular Risk Reduction Care Bundle to determine whether the use of a packaged approach to medication prescription and lifestyle counseling would improve adherence to secondary risk-reduction guidelines in postcoronary artery bypass graft patients. A pilot study was carried out to assess changes in adherence to guideline recommendations post-Care Bundle implementation. Findings support using a systematic strategy to improve guideline adherence in this population.

The slippery slope: differentiating between quality improvement and research.

As hospitals strive to create strong work environments for nurses, many use the core requirements for Magnet designation to enhance and build new programs in research and evidence-based practice into patient care and operational processes. The problem is the use of quality improvement projects in these efforts as evidence of a healthy "research" program. This confusion can lead to 3 major consequences: (1) poorly designed and interpreted studies; (2) lack of consideration of subject rights; and (3) Institutional Review Board or other regulatory sanctions for noncompliance with federal, state, and local law and institutional policies. The purpose of this article is to differentiate between research and quality improvement, explore the potential risks of confusing quality improvement with research, and suggest criteria by which to determine the difference.

An evidence-based approach to fall risk assessment, prevention, and management: lessons learned.

Nurses at an academic medical institution undertook a fall safety initiative. Using an evidence-based approach, they created a risk stratification tool, developed a comprehensive protocol, investigated fall-prevention products and technologies, and piloted the protocol and products/technologies before the full implementation. This article describes their journey and lessons learned along the way, the most compelling of which is the need for a simple, guided, and time-efficient approach to implementing the best practices into clinical care.

Evidence-based practice: a practical approach to implementation.

Organizations often do not have processes in place to support nurses through a systematic approach for developing and evaluating nursing interventions, protocols, critical pathways, and policies that are derived from scientific evidence. The development of a framework to guide inquiry will have a positive impact on patients. This process may foster a higher level of professional engagement by nurses that may, in the long-term, help improve nurse retention and recruitment. The authors discuss a nursing evidence-based practice model and guidelines that were developed by a team of hospital and academic nurse leaders and is practical and easy to use. This model has been successfully implemented across the department of nursing as a strategic initiative. Results of the implementation have shown that staff nurses can effectively use this model with the help of knowledgeable mentors.