Contributors to Hospitalized Infective Endocarditis Outcomes Among Patients With Substance Use.

Background: Patients with substance use (SU) diagnosed with infective endocarditis (IE) have high rates of discharge against medical advice (DAMA) and 30-day readmission. Objective: Evaluate contributors associated with DAMA and 30-day readmission among patients with SU and IE. Methods: This retrospective chart review included patients >18 years, admitted to one hospital in the Northeastern, United States for SU and IE from January 2018 to December 2020. Patient demographic and clinical characteristics and their association with DAMA and 30-day readmission were summarized using descriptive statistics and Logistic Regression. Results: Of the 144 patients, 60.4% used more than one substance, 38.2% experienced DAMA, and 61.1% were readmitted within 30 days. Age (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.92-0.98), Length of stay (LOS) (OR, 0.95; 95% CI, 0.93-0.98), Medicaid (OR, 2.98; 95% CI, 1.45-6.16), Medicare (OR, 0.29; 95% CI, 0.10-0.81), opioid usage (OR, 2.29; 95% CI, 1.01-5.16), and stimulant usage (OR, 2.89; 95% CI, 1.43-5.84) were all significantly associated with DAMA but not with 30-day readmission. Conclusions: Additional investigations of factors associated with DAMA and 30-day readmission are needed to help improve practices and reduce negative outcomes. Implications for Nursing: Multiple factors can affect patient adherence to treatment in this high-risk population. Nursing directly impacts the identification and addressing of unique SU IE patient needs to optimize treatment goals.

Exploring the Clinical Outcomes of Implementing Diabetes Self-Management Education and Support in a Primary Care Practice: A Quality Improvement Project.

Introduction/Purpose: Diabetes self-management education and support (DSMES) can be a very valuable service for many patients with diabetes. Unfortunately, despite its expected benefits, many patients do not receive DSMES through a quality, structured program. The purpose of this quality improvement project was to determine if integrating a diabetes education program utilizing the Association of Diabetes Care and Education Specialists (ADCES)7 Self-Care Behaviors into diabetes care in a primary care clinic could improve glycemic control and body mass index (BMI). Methods: The DSMES services provided were in accordance with the ADCES and the American Diabetes Association National Standards. The program included a 1-hour face-to-face service incorporating the ADCES7 Self-Care behaviors. A retrospective chart review was conducted to extract outcome data from N = 54 random medical records. This data was then analyzed to evaluate the program's effectiveness. Pre- and postintervention data from medical records were analyzed for eligible patients who participated in the DSMES service (ages 18-75 with type 2 diabetes, hemoglobin A1c [A1c] >8%). Results: Paired t tests were used to determine significant changes in BMI and A1c parameters pre- and postintervention. Preintervention A1c (M = 9.5, SD = 1.7) and BMI (M = 33.2, SD = 7.8) and postintervention A1c (M = 7.8, SD = 1.5) and BMI (M = 32.2, SD = 7.9) indicate that DSMES significantly reduced A1c, t(53) = 8.1, p = <.001, and BMI, t(53) = 4.4, p = <.001. Models were then adjusted for pretest measures, age, gender, and time since diagnosis in a regression analysis. In models adjusted for pretest measures, age, gender, and time since diagnosis was significantly predictive of the postmeasure of BMI (B = .41, p = .01, R2 = .96) and postmeasure of A1c (B = .28, p = .04, R2 =.41). Discussion: This project demonstrated that integrating a simple, cost-effective diabetes education service consisting of ADCES7 Self-Care Behaviors in a primary care practice could bridge gaps in diabetes management and significantly improve patients' BMI and A1c. Long-term utilization of this service may also enhance patient satisfaction, improve the patient's health, and reduce healthcare costs related to diabetes.

Direct Yet Opposite Effects of Stress-related and Mindful Eating on Diet Quality.

OBJECTIVE: Examine the relationships among dietary quality, mindful eating, and constructs of the Transactional Model of Stress and Coping. METHODS: In this cross-sectional study, women (n = 67) aged 25-50 years, with a body mass index of 25-40 kg/m2 completed 3 days of 24-hour recalls and a survey that included the Perceived Stress Scale, Eating and Appraisal Due to Emotions and Stress Questionnaire, and the Mindful Eating Questionnaire. Structural equation modeling assessed relationships among all constructs with the dependent variable, the Healthy Eating Index-2015. RESULTS: Mindful Eating Questionnaire (ß = 0.60, P = 0.001) and Emotion and Stress-related Eating scores from Eating and Appraisal Due to Emotions and Stress Questionnaire (ß = -0.69, P < 0.001) (r2 = 0.50) were directly associated with Healthy Eating Index-2015, but no indirect effects were identified. CONCLUSIONS AND IMPLICATIONS: Overall dietary quality is associated with greater mindful eating but more emotion and stress-related eating scores among women who were overweight or obese. Future studies could assess model constructs using other diet quality scores and including additional coping mechanisms such as substance use, physical activity, and meditation.

Management of Diabetes During a Dual Pandemic.

The dual pandemics of coronavirus disease-19 (COVID-19) and diabetes among patients are associated with 2- to 3-times higher intensive care admissions and higher mortality rates. Whether sheltering at home, quarantined with a positive COVID-19 test, or hospitalized, the person living with diabetes needs special considerations for successful management. Having diabetes and being COVID-19-positive increases the risk of poor outcomes and death. Providers need to give anticipatory pharmacologic guidance to patients with diabetes during COVID-19 lockdown. Patients with diabetes need to be more observant than others and to use self-protective actions. This review (1) discusses the clinical observations of COVID-19, diabetes and underlying mechanisms, (2) describes special considerations in caring for patients with diabetes in a COVID-19 environment, and (3) reviews clinical implications for the health care provider. This review highlights current evidenced-based knowledge. Additional research regarding clinical management is warranted.

Risk Reduction Interventions for Human Papillomavirus in Rural Maryland.

BACKGROUND: Human papillomavirus (HPV) is largely vaccine preventable. The Healthy People 2020 target goal for vaccine administration is 80%. Current United States (U. S.) rates are far lower primarily because of vaccine hesitancy and lack of provider recommendation. OBJECTIVE: Implement a risk reduction initiative to increase HPV vaccine rates in females aged 12-26 in five rural counties in Maryland. METHODS: A convenience sample from a rural community screened an HPV documentary movie, Questionnaire responses pre- and postscreening were surveyed for impact on vaccine readiness. Postscreening focus group comments were analyzed for common themes. Females aged 12-26 from a University Medical Group Women's Health Center located in rural Maryland were targeted. Chart review of immunization records 90 days pre- and postprovider vaccine recommendation demonstrated impact. RESULTS: Public awareness events have the potential to impact HPV vaccine hesitancy, but this research did not achieve statistical significance. Direct provider to patient recommendations resulted in a 15% increase in HPV immunizations. CONCLUSIONS: Education of vaccine-eligible individuals should be undertaken. IMPLICATIONS FOR NURSING: Providers who recommend administration of the vaccine significantly increase immunization rates.

Comparisons of Trauma Outcomes and Injury Severity Score.

Trauma is a global health problem and a leading cause of mortality. One of the major predictors of trauma mortality is the Injury Severity Score (ISS). Theoretically, as the ISS increases, the probability of survival decreases; ISS = 75 is considered to be not survivable. Studies have shown that some deaths are preventable and some potentially preventable. Hemorrhagic shock is a potentially preventable cause of trauma mortality. A retrospective database review was conducted of the Mississippi Trauma Registry and point-by-serial correlational analyses were conducted to determine the direction of any significant relations between blood product usage, traditional vital signs, and shock index. Pearson correlation, logistic regressions, and odds ratio calculation results revealed that shock index can signal impending hemorrhagic compromise better than traditional vital signs; thus, facilitating early intervention, specifically, as heart rate and shock index increase, the use of blood products increases, and as blood pressure increases, the use of blood products decreases. Independent t tests for shock index and ISS revealed significant differences in the means with relationship to the subgroups "Dead" and "Alive." Higher ISS were found to correlate with higher shock indices. Evaluation of ISS and survivability demonstrates that ISS = 75 is survivable and should not lead one to reflexively assume otherwise. A total mortality finding of only 1.58% (n = 2,010) was unexpected but very encouraging.

2015 Beers criteria medication review in assisted living facilities.

BACKGROUND AND PURPOSE: The elderly population is expected to double by 2050 with falls and hospitalizations due to adverse drug events having a major effect on health and quality of life. With the release of the revised 2015 American Geriatrics Society (AGS) Beers criteria, usage of potentially inappropriate medications (PIMs) should be studied to determine their effect on falls and hospitalizations in frail populations such as those in assisted living facilities. METHODS: This quality improvement project used a retrospective chart review on residents from a purposive sample of two assisted living facilities in Northern Virginia. Residents were aged ≥65 and lived at the facility for at least 6 months and were not enrolled in hospice and/or palliative care or living in the dementia unit. The 2015 AGS Beers criteria were used to evaluate the effect of PIMs on falls and hospitalization rates. CONCLUSIONS: This project did not find statistical significance between PIMs and falls (p = .276). A favorable, but not statistically significant trend, was noted between PIMs and hospitalizations (p = .079). IMPLICATIONS FOR PRACTICE: Understanding the effect of PIMs on falls and hospitalizations could help providers improve prescribing practices for the elderly population who are at the greatest risk for potential adverse effects from polypharmacy.

Simulation With Advanced Care Providers in a Nurse Residency Program.

As many hospitals are implementing residency programs for new graduate nurses, the utilization of high-fidelity simulation has become common. This pilot program compared simulation with participation of only new graduate nurses and new graduates with advanced care providers. Results found a statistically significant increase in knowledge of differing roles and skills in simulations that included both groups. Nursing professional development practitioners will find this helpful in designing residency programs for new graduate nurses.

Improving HPV vaccination rates among young males in rural areas of the United States.

Human papillomavirus (HPV) vaccination occurs more frequently among females ages 11 to 18 than their male counterparts. The purpose of this quality improvement project is to identify reasons why parents/guardians either choose or decline HPV immunization and increase rates of vaccination among males ages 11 to 18 in rural areas of the United States.

Diabetes Self-Management Education and Self-Efficacy Among African American Women Living With Type 2 Diabetes in Rural Primary Care.

African American women suffer the highest prevalence of type 2 diabetes (T2D). Self-efficacy is important for optimal diabetes self-management (DSM). Purpose: To evaluate DSM by comparing pre- and postintervention responses to a diabetes self-efficacy scale. Design: Descriptive pilot study. Sample: Participants for this study were N = 15 African American women aged 25-65 years (M = 47.4 years) and recruited from a rural health clinic in the Southeastern United States, who received a 4-hr DSM class. Method: Data were collected using the Stanford Self-Efficacy for Diabetes (SED). Results: The increase in the pre- and posttest SED scores were statistically significant, (p < .001). Implications for Nursing: Health care providers should tailor a diabetes education program for these individuals living with T2D. Through a collaborative patient-provider relationship to care, individuals may ultimately experience increased self-efficacy leading to improved DSM.

Effectiveness of Interventions to Increase Provider Monitoring of Endotracheal Tube and Laryngeal Mask Airway Cuff Pressures.

Previous research demonstrates that monitoring and adjusting pressures in endotracheal (ET) tubes 30 cm H2O or less and laryngeal mask airways (LMAs) 60 cm H2O or less decrease rates of postoperative pharyngolaryngeal complications. In this evidencebased practice project we examined whether a multistep intervention (departmental education plus reference cards in operating rooms plus addition of cuff pressure documentation variable in electronic anesthesia record) would increase the frequency of providers monitoring intracuff pressures and decrease the rate of high intracuff pressures. Before and after the intervention, we recorded intracuff pressures of 51 ET tubes and 51 LMAs in surgical patients, as well as providers' self-reported incidence of monitoring and adjusting intracuff pressures. Our multistep intervention increased provider monitoring of intracuff pressures in ET tubes (77% pre- vs 94% postintervention, P = .025) and LMAs (37% pre- vs 94% postintervention, P < .001). Mean ET tube and LMA cuff pressures were significantly lower postintervention: ET tube: pre = 34 ± 16 cm H2O vs post = 29 ± 12 cm H2O (P = .045), LMA: pre = 73 ± 30 cm H2O vs post = 49 ± 15 cm H2O (P < .001). Our multistep intervention improved compliance with intracuff pressure recommendations.

Strategies to Alleviate Anxiety Before the Placement of a Stereotactic Radiosurgery Frame.

BACKGROUND: Patients scheduled for stereotactic radiosurgery (SRS) need the placement of a head frame for accurate treatment of brain metastases and other abnormalities in the brain. These patients frequently experience anxiety before frame placement. Although there is evidence that preprocedure education can alleviate anxiety, less is known about education for patients undergoing head frame placement. OBJECTIVE: The aim of this study was to determine whether a preprocedure educational intervention can reduce/alleviate anxiety for patients undergoing head frame placement for SRS. METHODS: This study was a practice improvement project using a nonrandomized controlled design to evaluate patients (N = 28) diagnosed with metastasized brain cancer or other abnormalities in the brain. Patients aged ≥19 and <75 years were recruited, and all participants had been radiographically diagnosed and were dispositioned for SRS. The control group (n = 14) received the standard preprocedure teaching, and the intervention group (n = 14) received both the standard preprocedure teaching and an additional educational intervention. Data collecting tools included the Hospital Anxiety and Depression Scale and a visual analog scale to measure the patient's anxiety. RESULTS: It was found that, on average, anxiety levels were lower in the intervention group on both the visual analog scale and Hospital Anxiety and Depression Scale. However, the findings did not reach statistical significance, p < .05. CONCLUSION: On the basis of existing literature, preprocedure education has been shown to decrease patient anxiety. This study aimed to determine whether an additional educational intervention impacted anxiety in patients undergoing SRS for metastatic cancer. Although we found that anxiety levels were decreased in the intervention group, this finding did not reach statistical significance. A larger randomized study is needed to confirm the efficacy of such an intervention in this unique patient population.

Identifying early signs of peripheral neuropathy among patients with diabetes mellitus.

This article aims to help nurse practitioners develop a best practice algorithm to identify the early signs of peripheral neuropathy (PNP) among individuals living with diabetes mellitus. This literature review also seeks to determine if there are better clinical testing methods than the Semmes-Weinstein monofilament examination to detect diabetes-related PNP.

Group Conference Call Diabetes Educational Support Sessions: A Pilot Study.

The aim of this study was to determine the acceptability of group-conference-call diabetes educational support sessions for rural dwelling southern African-American women and to describe the impact on diabetes distress. Pre- post-test design was utilized to determine any change in scores on questionnaires. Qualitative techniques were utilized to determine the acceptability of the conference callformat. Participants recruited (N = 3) manifested either dysglycemia or frank type 2 diabetes. Diabetes distress and knowledge tools, demographics, baseline laboratory data, and measures of body habitus were obtained. An adapted version of the American Association of Diabetes Educator's Association diabetes education curriculum was used to provide the classes. The conference call intervention was found to be convenient, informative, and it removed the hassle of needing to be in one location to receive education. Diabetes distress was reduced (p = 0.005) in the sub-scale related regimen management. Offering alternatives to in-person diabetes education classes has the potential to reduce levels of opportunity costs and include a larger number of individuals living chaotic lives due to the demands of chronic illness and extended family needs.

Expedited diagnosis and management of inpatient hyperosmolar hyperglycemic nonketotic syndrome.

PURPOSE: This practice improvement project was formulated to determine accuracy rate in differentiating between two hyperglycemic crises (diabetes ketoacidosis [DKA] and hyperosmolar hyperglycemic nonketotic syndrome [HHNKS]) in a clinical population of individuals who manifested hyperglycemia and diabetes mellitus (DM). We hypothesized that HHNKS was commonly misdiagnosed as DKA. Our primary aim was to determine frequency of correct HHNKS diagnoses. A second aim was to review the literature and present an evidence-based protocol to assist providers with the differential diagnosis of HHNKS from DKA. DATA SOURCES: Electronic health records (N = 911) were selected by ICD-9 codes for hyperglycemia, DKA, and HHNKS. A retrospective record review indicated n = 436 met the blood glucose level depicting HHNKS. Additional laboratory findings were compared with diagnostic criteria from the literature. CONCLUSIONS: HHNKS was commonly misdiagnosed and mismanaged as DKA. Only n = 9 (5%) patients with type 2 DM were correctly diagnosed and managed as having HHNKS. Of the records misdiagnosed with DKA, 74 (39%) actually manifested HHNKS clinical features. Of these, n = 24 (36%) were readmitted within 2 weeks. IMPLICATIONS FOR PRACTICE: Early recognition of HHNKS is essential for appropriate condition management. HHNKS-specific algorithms are essential for expediting accurate diagnosis, managing appropriately, minimizing mortality, reducing stay length, and avoiding readmissions.

Identifying Women at Risk for Hereditary Breast and Ovarian Cancer Syndrome Utilizing Breast Care Nurse Navigation at Mammography and Imaging Centers.

Approximately 5-10% of breast cancer cases appear in families at a higher rate and at an earlier onset than in the average population. Two known gene defects, BRCA1 and BRCA2, account for the majority of these hereditary related breast cancers. Additionally, BRCA1 and BRCA2 are related to the Hereditary Breast and Ovarian Cancer syndrome (HBOC), where risk for other related cancers are increased. Various health-care professional organizations provide guidelines that speak to the need for conducting risk assessments, but little research has been conducted focusing on the initial screening for this syndrome. This quality improvement project attempts to determine if Nurse Navigators can effectively perform the initial education and screening for HBOC syndrome within a mammography and women's breast imaging setting using a simplified patient history tool. E. M. Rodgers' Diffusion of Innovation model, a map of how new ideas and programs have become adopted and accepted, guided this project's development and implementation. Over the course of 8 weeks, 1,420 women seeking service at 3 mammography and imaging sites were given a new risk assessment tool for HBOC. Additionally, the use of Nurse Navigation to identify women who may be at risk for HBOC was implemented. Two populations seeking service at the study sites were evaluated: (1) women obtaining breast screening/imaging services and (2) women receiving breast biopsy results. Patients identified as "at-risk" were defined by evidence-based practice guidelines from the National Comprehensive Cancer Network and were referred for further genetic evaluation by a genetic professional. During this initial implementation of the HBOC risk assessment program, low participation of screening/imaging patients requesting HBOC education and evaluation occurred (129 screening patients or 9%). High rates of positive biopsy patients (5 patients or 34.7%) werefound to be at risk for HBOC compared to similar studies. Identifying HBOC risk at the time of breast biopsy results gave the opportunity to impact the timing and kind of surgical management of patients at risk for this syndrome.The Commission on Cancer (CoC), an arm of the American College of Surgeons, provides practice guideline standards and accreditation for cancer programs. Patients will become more familiar with being assessed for HBOC and other hereditary cancers during their annual health-care visits and more identification of patients at riskfor HBOC should occur as new CoC 2012 standards requiring hereditary cancer risk assessments for a cancer program's certification are enacted.

Substantive review of the literature of medication treatment of chronic low back pain among adults.

PURPOSE: Pain can be debilitating, and it is often inadequately treated, particularly among patients with chronic low back pain (CLBP). CLBP has a substantial economic impact, as it affects an individual's ability to perform activities of daily living and maintain employment. This study aims to review original studies related to the evidence-based management of patients with CLBP to develop an algorithm for prescribing medications and recommending other treatment modalities for patients with CLBP. DATA SOURCES: An electronic search of PubMed, CINAHL, and the Cochrane Database was conducted to identify studies related to the evidence-based management of CLBP that were performed between 2003 and 2012. The following keywords were used: low back pain, back pain, chronic back pain, medication management, and adjunct therapy. The selected articles were specific to CLBP, medication-based management, and additional treatment options, such as adjunct therapies. CONCLUSIONS: The collected data revealed that there are a number of approaches to the management of CLBP. Medication regimens are frequently used and widely available, but alternative treatment modalities can also be effective. IMPLICATIONS FOR PRACTICE: Providers should encourage patients to explore a variety of treatment modalities that can provide pain relief and improve functionality and overall well-being.

The synergistic effects of HIV, diabetes, and aging on cognition: implications for practice and research.

Thanks to highly active antiretroviral therapy, many people infected with HIV will likely live into old age. Although this is a welcome prognosis, new issues are emerging that may complicate the ability to successfully age in this clinical population. HIV and aging independently are related to cognitive impairments, so there are concerns that those aging with HIV may be more at risk of such cognitive impairments. Moreover, highly active antiretroviral therapy itself can create metabolic disorders, such as prediabetes and/or frank type 2 diabetes, which have also been linked to poorer cognitive functioning. Thus, concerns increase that, as people age with HIV and develop comorbid metabolic disorders that may lead to type 2 diabetes, they will be at triple risk of developing cognitive impairments that can impair everyday functioning and reduce quality of life. This article explores these issues and provides implications for practice and research.