Implementation of the Caprini risk assessment model (RAM) in surgical patients to decrease postsurgical venous thromboembolism and enoxaparin prescription at hospital discharge.

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), has been an increasingly common post-surgical complication for surgical patients. In the United States, VTE has become a leading cause of preventable hospital death with more than half occurring after discharge and are directly linked to a recent (within 30 days) hospitalization or surgery [1]. In large, hospital-associated/acquired VTE (HA-VTE) are preventable through measures such as the use of risk stratification tools and chemoprophylaxis. The project institution, a community, academic, medical center, for multiple years has consistently remained a high outlier for postoperative VTE. Also, the choice of VTE chemoprophylaxis in surgical patients at the time of discharge depended on, and varied between, the individual prescribing physician. The goal was to implement and determine the efficacy of a standardized intervention tool, the Caprini risk assessment model (RAM), for reducing postoperative VTE complications and its influence on the physician's prescription of enoxaparin at discharge. Results: Risk assessment scoring pre-operatively increased from 0% baseline to 26.3% at Plan-Do-Study-Act (PDSA) cycle 1 and demonstrated a statistically significant change (p-value = 0.006). Risk assessment scoring pre-operatively was 42.9% by PDSA cycle 2 but was not statistically significantly different from PDSA cycle 1. Risk assessment scoring post-operatively (for eligible patients) remained the same throughout all three cycles at 0%. Appropriate prescription of anticoagulation declined from baseline (12.5%) to PDSA cycle 1 (0%), and improved at PDSA cycle 2 (33.3%), however no differences were significant (p-value 0.302). The National Surgical Quality Improvement Project (NSQIP) database showed a decline in VTE occurrences at the projects institution from baseline (1.02%, 6 occurrences, 2021) to PDSA cycle 2 (0.92%, 4 occurrences, 2022) when compared to the national benchmark (1.0%) for the first time since 2018. Given the significant national problem HA-VTE pose to the public, and the rise in occurrences, this quality improvement (QI) project is clinically relevant.

Impact of Nursing Clinical Elective Courses on New Graduate Nurses' Clinical Practice: A Mixed-Methods Descriptive Study.

BACKGROUND: Clinical elective courses provide additional specialty knowledge for prelicensure nursing students; however, it is unknown how these courses impact nurses' clinical practice after graduation. PURPOSE: To describe how clinical nursing electives impact graduates' clinical practice. METHODS: A mixed-methods descriptive design was used. Students who graduated from a prelicensure nursing program were sent an electronic survey and participated in qualitative interviews. RESULTS: Thirty-three graduates completed the survey, with 9 participating in interviews. Sixteen graduates worked in clinical practice areas that were the same, or related to, the clinical elective they took. Many graduates felt that taking the elective course improved their confidence in the clinical setting and provided increased knowledge that put them at an advantage over their peers. CONCLUSION: Clinical electives may offer a means to meet health care system needs by preparing a more confident, knowledgeable new graduate in specialty areas in which nurses are needed most.

Implementation of an Evidence-Based Onboarding Program to Optimize Efficiency and Care Delivery in an Intensive Care Unit.

Nationally, nurse turnover is 18.7%, and 24.1% of nurses leave their organization within a year of hire. Onboarding is a key component of a nurse's intent to stay and job satisfaction. This article describes the implementation and results of an onboarding program in a large intensive care unit.

Professional Case Management in Outpatient Settings for Patients With Myeloproliferative Neoplasms.

PURPOSE AND OBJECTIVES: The purpose of this discussion is to review the management and symptomatic burden of patients with myeloproliferative neoplasms (MPNs). Patients with MPNs are at increased risk for thromboembolic events; thus, cardiovascular complications are not uncommon. Professional case managers can coordinate outpatient services with the health care team and assist patients to mitigate cardiovascular complications. PRIMARY PRACTICE SETTING: This discussion is relevant to professional case managers who manage patients with chronic conditions in outpatient settings. FINDINGS/CONCLUSIONS: Professional case managers can intervene for patients with MPNs to improve (a) coordination of scheduled therapeutic phlebotomy procedures, and (b) education about subcutaneous injections and frequent monitoring of laboratory reports. In the outpatient setting, professional case managers can improve health care utilization for patients with MPNs and promote high-quality self-care and symptom management to prevent adverse complications. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: As a member of the outpatient health care team, the professional case manager can serve as a key clinician with comprehensive knowledge of the patient's experience of living with an MPN, their usual state of health and symptoms, and the factors affecting their quality of life. This article explores the role of the professional case manager in the outpatient setting and suggests specific interventions to improve delivery of care and contribute to better self-care management. Professional case managers can assess and validate symptom burden, coordinate and manage routine laboratory testing, support careful medication adjustment, and contribute to improved health outcomes.

Nursing Students From China and the United States: Learning Together Through Virtual Simulation.

AIM: The purpose of this project was to connect nursing students from schools of nursing in China and the United States for colearning using virtual simulations. BACKGROUND: With technology and international partnerships, nursing programs can offer global education without students traveling to other countries. METHOD: Virtual simulations were produced by each school for the project. Students completed them in two synchronous 1.5-hour virtual sessions, one month apart. At the end of each session, students completed the Simulation Effectiveness Tool-Modified and the Nurses Clinical Reasoning Scale. RESULTS: Scores on the Simulation Effectiveness Tool-Modified ranged from 75.0 percent to 100 percent on Simulation 1 (video vignettes focused on prioritization) and 88.9 percent to 100 percent on Simulation 2 (computer-based obstetrics case). Most students strongly agreed or agreed that the simulation improved their clinical reasoning skills. CONCLUSION: Virtual simulations allowed students to learn together and develop an awareness of differences in nursing practices across countries.

Nursing Students' Perceptions about Effective Pedagogy: Netnographic Analysis.

BACKGROUND: Effective pedagogy that encourages high standards of excellence and commitment to lifelong learning is essential in health professions education to prepare students for real-life challenges such as health disparities and global health issues. Creative learning and innovative teaching strategies empower students with high-quality, practical, real-world knowledge and meaningful skills to reach their potential as future health care providers. OBJECTIVE: The aim of this study was to explore health profession students' perceptions of whether their learning experiences were associated with good or bad pedagogy during asynchronous discussion forums. The further objective of the study was to identify how perceptions of the best and worst pedagogical practices reflected the students' values, beliefs, and understanding about factors that made a pedagogy good during their learning history. METHODS: A netnographic qualitative design was employed in this study. The data were collected on February 3, 2020 by exporting archived data from multiple sessions of a graduate-level nursing course offered between the fall 2016 and spring 2020 semesters at a large private university in the southeast region of the United States. Each student was a data unit. As an immersive data operation, field notes were taken by all research members. Data management and analysis were performed with NVivo 12. RESULTS: A total of 634 posts were generated by 153 students identified in the dataset. Most of these students were female (88.9%). From the 97 categories identified, four themes emerged: (T) teacher presence built through relationship and communication, (E) environment conducive to affective and cognitive learning, (A) assessment and feedback processes that yield a growth mindset, and (M) mobilization of pedagogy through learner- and community-centeredness. CONCLUSIONS: The themes that emerged from our analysis confirm findings from previous studies and provide new insights. Our study highlights the value of technology as a tool for effective pedagogy. A resourceful teacher can use various communication techniques to develop meaningful connections between the learner and teacher. Styles of communication will vary according to the unique expectations and needs of learners with different learning preferences; however, the aim is to fully engage each learner, establish a rapport between and among students, and nurture an environment characterized by freedom of expression in which ideas flow freely. We suggest that future research continue to explore the influence of differing course formats and pedagogical modalities on student learning experiences.

Reducing Intubation Time in Adult Cardiothoracic Surgery Patients With a Fast-track Extubation Protocol.

BACKGROUND: Prolonged intubation after cardiac surgery increases the risk of morbidity and mortality and lengthens hospital stays. Factors that influence the ability to extubate patients with speed and efficiency include the operation, the patient's baseline physiological condition, workflow processes, and provider practice patterns. LOCAL PROBLEM: Progression to extubation lacked consistency and coordination across the team. The purpose of the project was to engage interprofessional stakeholders to reduce intubation times after cardiac surgery by implementing fast-track extubation and redesigned care processes. METHODS: This staged implementation study used the Define, Measure, Analyze, Improve, and Control approach to quality improvement. Barriers to extubation were identified and reduced through care redesign. A protocol-driven approach to extubation was also developed for the cardiothoracic intensive care unit. The team was engaged with clear goals and given progress updates. RESULTS: In the preimplementation cohort, early extubation was achieved in 48 of 101 patients (47.5%) who were designated for early extubation on admission to the cardiothoracic intensive care unit. Following implementation of a fast-track extubation protocol and improved care processes, 153 of 211 patients (72.5%) were extubated within 6 hours after cardiac surgery. Reintubation rate, length of stay, and 30-day mortality did not differ between cohorts. CONCLUSIONS: The number of early extubations following cardiac surgery was successfully increased. Faster progression to extubation did not increase risk of reintubation or other adverse events. Using a framework that integrated personal, social, and environmental influences helped increase the impact of this project.

Subsequent Pressure Injury Development in Mechanically Ventilated Critical Care Patients with Hospital-Acquired Pressure Injury: A Retrospective Cohort Study.

OBJECTIVE: To identify factors associated with subsequent hospital-acquired pressure injury (HAPrI) formation among patients in surgical and cardiovascular surgical ICUs with an initial HAPrI. METHODS: Patients admitted to a level 1 trauma center and academic medical center in the Western US between 2014 and 2018 were eligible for this retrospective cohort study. Inclusion criteria were development of an HAPrI stage 2 or above, age older than 18 years, the use of mechanical ventilation for at least 24 hours, and documentation of a risk-based HAPrI-prevention plan including repositioning at least every 2 hours. The primary outcome measure was development of a second, subsequent HAPrI stage 2 or higher. Potential predictor variables included demographic factors, shock, Charleston comorbidity score, blood gas and laboratory values, surgical factors, vasopressor infusions, levels of sedation or agitation, Braden Scale scores, and nursing skin assessment data. RESULTS: The final sample consisted of 226 patients. Among those, 77 (34%) developed a second HAPrI. Independent risk factors for subsequent HAPrI formation were decreased hemoglobin (odds ratio, 0.71; 95% confidence interval [CI], 0.53-0.92; P < .000), vasopressin infusion (odds ratio, 2.20; 95% CI, 1.17-4.26; P = .02), and longer length of stay in the ICU (odds ratio, 1.01; 95% CI, 1.00-1.02; P = .009). CONCLUSIONS: Patients with an HAPrI are at high risk of subsequent HAPrI development. Anemia, vasopressin infusion, and longer ICU stays are independent risk factors for repeat HAPrI formation.

Nurse Graduates' Perceived Educational Needs After the Death of a Patient: A Descriptive Qualitative Research Study.

BACKGROUND: Nurse graduates (NGs) are ill prepared when faced with patient death and dying, despite receiving educational preparation on end-of-life (EOL) care in their prelicensure nursing programs. METHOD: This qualitative descriptive study included a convenience sample of NGs (n = 20) who experienced a first adult patient death during their first 18 months of practice at a large teaching hospital with an extensive NG transition program, including preceptor-guided orientations, nurse internship programs, and nurse residency programs. RESULTS: Six major themes described the NG experience: Navigating the Process, Not Prepared, Support, Missed Opportunities, Preparing NGs for Death and Dying, and Guiding NGs Through Practice. Critical gaps in preparation were evident across all themes. CONCLUSION: Results of this study suggest specific opportunities for improvement of NGs' readiness to effectively care for patients and families in EOL situations by increasing their exposure to death and dying experiences before graduation and during their first year of practice. [J Contin Educ Nurs. 2020;50(6):267-273.].