Using Implementation Science to Improve Short Peripheral Intravenous Catheter Outcomes.

Short peripheral intravenous catheters (short PIVCs) are commonly used in acute care, guided by evidence-based policy with interventions to limit premature failure. Research on how nurses use evidence and change processes to optimize outcomes is needed. The study objective was to use a theory-based implementation science approach to evaluate and improve short PIVC insertion and care processes and reduce removals for adverse outcomes in acute care. This mixed-methods study was conducted with inpatient nursing units (n = 23) at a large urban quaternary medical center. Units identified and implemented one PIVC care intervention that could lower catheter removals for adverse outcomes over 3 months. Data from multiple sources were convergently analyzed to evaluate process and outcomes postintervention. Although overall frequency of PIVC removals for adverse outcomes was unchanged, several units improved their outcomes using implementation strategies. The determinant framework provides a plausible explanation for the study results. While adverse outcome rates remained below published rates, some units had limited success improving outcomes with traditional change strategies. Implementation strategies and readily accessible data can offer nursing units a new approach to effectively deploy, monitor, and maintain interventions to achieve improved outcomes.

Implementation of MOVIN by a Nurse-Led Clinical Team: A Multiple Methods Evaluation Using the RE-AIM Framework.

PURPOSE: To evaluate the implementation of MOVIN, a multicomponent mobility intervention, by a nurse-led team and measure the effectiveness on unit-level outcomes. METHOD: A pragmatic quasi-experimental study was conducted on an inpatient adult medical unit. Evaluation was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Interviews with 13 organizational partners were conducted to understand barriers and facilitators to adoption. Thematic analysis was used to analyze the data. Quantitative data to determine effectiveness on distance of patient ambulation and percent of patients ambulated by nursing staff were analyzed using an interrupted time series. RESULTS: A significant increase in total weekly distances for patient ambulation and percent of patients ambulated by nursing staff occurred between preintervention, intervention, and postintervention periods. Themes for adoption included: Value, Immediate Feedback, Inclusive Implementation, Resource Needs, and Lack of Organizational Evidence. The nurse-led team demonstrated high fidelity to maintaining the core components of MOVIN. CONCLUSION: A nurse-led team can successfully launch a multicomponent mobility intervention and sustain impact. RE-AIM supported assessments of key partners at multiple organizational levels, capturing critical unit level outcomes. Multiple methods for data collection and analysis yielded rich results to inform future dissemination of MOVIN. [Research in Gerontological Nursing, 17(4), 189-201.].

Lessons Learned From Ventilated and Proned Patients With COVID-19: A Multisite Retrospective Study to Identify Predictive Factors for Facial Pressure Injuries.

BACKGROUND: Many patients critically ill with COVID-19 develop acute respiratory distress syndrome (ARDS) necessitating mechanical ventilation and proning. Although proning is lifesaving, it has been linked to the occurrence of facial pressure injuries (PIs). OBJECTIVES: To evaluate the incidence and use of prevention strategies and identify predictors of facial PIs in patients who received ventilator and proning treatments in COVID-designated intensive care units at 2 large quaternary medical centers in the Midwest. METHOD: This was a retrospective cohort study using data extracted from an electronic health record between October 2020 and February 2022. Demographics, clinical and care variables, and PI outcomes were analyzed to identify predictors of PI using logistic and Cox regression. RESULTS: The cohort (N = 150) included patients from 2 units, unit a (n = 97) and unit b (n = 53) with a mean age of 60 years, with 68% identifying as male. Patients were vented for an average of 18 (SD, 16.2) days and proned for an average of 3 (SD, 2.5) days. Many (71%) died. Over half (56%) developed facial PI with a proning-exposure-adjusted incidence rate of 18.5%. Patients with PI were significantly different in several factors. Logistic regression showed predictors of PIs were duration of mechanical ventilation (in days; P = .02) and head turned (P = .01). Cox regression also identified head turn as predictive (P < .01), with Black/African American race as protective (P = .03). DISCUSSION: Critically ill patients with COVID-19 receiving ventilator and proning therapy developed facial PIs despite the use of recommended prevention practices. Further research on effective PI prevention strategies is needed.

Ambulatory Care Coordination Data Gathering and Use.

Care coordination is a crucial component of healthcare systems. However, little is known about data needs and uses in ambulatory care coordination practice. Therefore, the purpose of this study was to identify information gathered and used to support care coordination in ambulatory settings. Survey respondents (33) provided their demographics and practice patterns, including use of electronic health records, as well as data gathered and used. Most of the respondents were nurses, and they described varying practice settings and patterns. Although most described at least partial use of electronic health records, two respondents described paper documentation systems. More than 25% of respondents gathered and used most of the 72 data elements, with collection and use often occurring in multiple locations and contexts. This early study demonstrates significant heterogeneity in ambulatory care coordination data usage. Additional research is necessary to identify common data elements to support knowledge development in the context of a learning health system.

Building research infrastructure and multisite studies in merged health care settings: A framework for nurse scientists and health care leaders.

BACKGROUND: Merged healthcare settings, particularly those with Magnet designated sites, present distinct opportunities for PhD nurse scientists developing nursing research infrastructure. PURPOSE: This article aims to assist nurse scientists and healthcare leaders in defining nurse scientist roles, and in developing research infrastructure for conducting multi-site research in merged settings. METHOD: Practical strategies and a framework are provided to assist in building and navigating nurse scientist roles and research infrastructure development. DISCUSSION: Emphasizing the necessity of organizational support, the article underscores the importance of clear role delineation and leadership support. CONCLUSION: To optimize the contributions of nurse scientists in merged healthcare settings, especially in Magnet organizations, clear role definitions, robust research infrastructure, and strong organizational support are imperative.

Knowing the Patient: Understanding Readmission Reasons in Complex Heart Failure.

BACKGROUND: Heart failure (HF) is a complex problem characterized by frequent hospitalizations and high 30-day readmission rates. Researchers studying HF readmission report that patients and clinicians have different perspectives on readmission and preventability when unadjusted for disease severity. OBJECTIVE: The aim of this study was to gather patient, caregiver, nurse, and physician subjective reason(s) for 30-day HF readmission and perceptions of preventability with contextual factors to evaluate differences. METHODS: A convergent, parallel, mixed-methods design was used with interviews and chart reviews to evaluate contextual factors from the current and index hospital stay. Adults readmitted within 30 days of a previous inpatient stay with a coded HF diagnosis were enrolled and interviewed, followed by interviews with associated caregivers, attending physicians, and assigned nurses. RESULTS: Interviews were conducted with patients (n = 44), caregivers (n = 6), physicians (n = 24), and nurses (n = 44). Readmissions were emergent/urgent (95%) and occurred within 14.9 days (SD, 8.1; 2-28 days) on average after discharge. Index stay coding revealed that most patients (73%) had a high severity of illness (73%) and risk of mortality (68%). Heart failure stage was inconsistently documented. Patients reported acute symptomatic reasons, with only 32% describing readmission as preventable. Physicians reported diagnostic reasons, 38% of which were preventable. Nurses reported behavioral reasons, with 59% being preventable. Patient/clinician agreement on readmission reason was low (30%). CONCLUSIONS: Patient/clinician perspectives on readmission varied among the patients with complex HF. Care planning based on HF stage and other contextual factors is needed to ensure a shared understanding of disease severity and a tailored symptom management approach to prevent readmission.

Best Fit Orientation: An Innovative Strategy to Onboard Newly Licensed Nurses.

The premature turnover of newly licensed registered nurses is a costly problem prompting leaders to consider new orientation approaches. This article describes the "Best Fit Orientation"-an innovative approach for onboarding newly licensed registered nurses. It features centralized hiring, individualized orientation on diverse units, and realistic job preview tenets promoting self-evaluation, change management, relationship building, and "best fit" unit selection. Positive evaluations, high retention, and minimal added costs make this program very attractive.

Using Electronic Data and a Mixed-Methods Approach to Evaluate Short Peripheral Catheter Outcomes in Acute Care.

Short peripheral catheters (SPCs) are commonly used in hospitals, guided by evidence-based standards to optimize dwell time and limit adverse outcomes. Although SPC insertions are common, real-world evaluation is rare. A theory-based framework and mixed-methods design were used to analyze findings from a unit-level survey and electronic data to evaluate SPC care delivered on units at a large quaternary medical center over a 6-month period (quarters 1 and 2, 2017). Dissemination without adoption and maintenance may limit effectiveness. The convergent results confirmed the feasibility of extracting electronic data to be used by leaders to clinically evaluate staff knowledge and use behaviors to take action to improve outcomes.

Information Models Offer Value to Standardize Electronic Health Record Flowsheet Data: A Fall Prevention Exemplar.

PURPOSE: The rapid implementation of electronic health records (EHRs) resulted in a lack of data standardization and created considerable difficulty for secondary use of EHR documentation data within and between organizations. While EHRs contain documentation data (input), nurses and healthcare organizations rarely have useable documentation data (output). The purpose of this article is to describe a method of standardizing EHR flowsheet documentation data using information models (IMs) to support exchange, quality improvement, and big data research. As an exemplar, EHR flowsheet metadata (input) from multiple organizations was used to validate a fall prevention IM. DESIGN: A consensus-based, qualitative, descriptive approach was used to identify a minimum set of essential fall prevention data concepts documented by staff nurses in acute care. The goal was to increase generalizable and comparable nurse-sensitive data on the prevention of falls across organizations for big data research. METHODS: The research team conducted a retrospective, observational study using an iterative, consensus-based approach to map, analyze, and evaluate nursing flowsheet metadata contributed by eight health systems. The team used FloMap software to aggregate flowsheet data across organizations for mapping and comparison of data to a reference IM. The FloMap analysis was refined with input from staff nurse subject matter experts, review of published evidence, current documentation standards, Magnet Recognition nursing standards, and informal fall prevention nursing use cases. FINDINGS: Flowsheet metadata analyzed from the EHR systems represented 6.6 million patients, 27 million encounters, and 683 million observations. Compared to the original reference IM, five new IM classes were added, concepts were reduced by 14 (from 57 to 43), and 157 value set items were added. The final fall prevention IM incorporated 11 condition or age-specific fall risk screening tools and a fall event details class with 14 concepts. CONCLUSION: The iterative, consensus-based refinement and validation of the fall prevention IM from actual EHR fall prevention flowsheet documentation contributes to the ability to semantically exchange and compare fall prevention data across multiple health systems and organizations. This method and approach provides a process for standardizing flowsheet data as coded data for information exchange and use in big data research. CLINICAL RELEVANCE: Opportunities exist to work with EHR vendors and the Office of the National Coordinator for Health Information Technology to implement standardized IMs within EHRs to expand interoperability of nurse-sensitive data.

A refined methodology for validation of information models derived from flowsheet data and applied to a genitourinary case.

Use of electronic health record data is expanding to support quality improvement and research; however, this requires standardization of the data and validation within and across organizations. Information models (IMs) are created to standardize data elements into a logical organization that includes data elements, definitions, data types, values, and relationships. To be generalizable, these models need to be validated across organizations. The purpose of this case report is to describe a refined methodology for validation of flowsheet IMs and apply the revised process to a genitourinary IM created in one organization. The refined IM process, adding evidence and input from experts, produced a clinically relevant and evidence-based model of genitourinary care. The refined IM process provides a foundation for optimizing electronic health records with comparable nurse sensitive data that can add to common data models for continuity of care and ongoing use for quality improvement and research.

Validation and Refinement of a Pain Information Model from EHR Flowsheet Data.

BACKGROUND: Secondary use of electronic health record (EHR) data can reduce costs of research and quality reporting. However, EHR data must be consistent within and across organizations. Flowsheet data provide a rich source of interprofessional data and represents a high volume of documentation; however, content is not standardized. Health care organizations design and implement customized content for different care areas creating duplicative data that is noncomparable. In a prior study, 10 information models (IMs) were derived from an EHR that included 2.4 million patients. There was a need to evaluate the generalizability of the models across organizations. The pain IM was selected for evaluation and refinement because pain is a commonly occurring problem associated with high costs for pain management. OBJECTIVE: The purpose of our study was to validate and further refine a pain IM from EHR flowsheet data that standardizes pain concepts, definitions, and associated value sets for assessments, goals, interventions, and outcomes. METHODS: A retrospective observational study was conducted using an iterative consensus-based approach to map, analyze, and evaluate data from 10 organizations. RESULTS: The aggregated metadata from the EHRs of 8 large health care organizations and the design build in 2 additional organizations represented flowsheet data from 6.6 million patients, 27 million encounters, and 683 million observations. The final pain IM has 30 concepts, 4 panels (classes), and 396 value set items. Results are built on Logical Observation Identifiers Names and Codes (LOINC) pain assessment terms and extend the need for additional terms to support interoperability. CONCLUSION: The resulting pain IM is a consensus model based on actual EHR documentation in the participating health systems. The IM captures the most important concepts related to pain.

Validation of Stroke Network of Wisconsin Scale at Aurora Health Care System.

BACKGROUND: The Stroke Network of Wisconsin (SNOW) scale, previously called the Pomona scale, was developed to predict large-vessel occlusions (LVOs) in patients with acute ischemic stroke (AIS). The original study showed a high accuracy of this scale. We sought to externally validate the SNOW scale in an independent cohort. METHODS: We retrospectively reviewed and calculated the SNOW scale, the Vision Aphasia and Neglect Scale (VAN), the Cincinnati Prehospital Stroke Severity (CPSS), the Los Angeles Motor Scale (LAMS), and the Prehospital Acute Stroke Severity Scale (PASS) for all patients who were presented within 24 hours after onset at AHCS (14 hospitals) between January 2015 and December 2016. The predictive performance of all scales and several National Institute of Health Stroke Scale cutoffs (≥6) were determined and compared. LVO was defined by total occlusions involving the intracranial internal carotid artery, middle cerebral artery (MCA; M1), or basilar arteries. RESULTS: Among 2183 AIS patients, 1381 had vascular imaging and were included in the analysis. LVO was detected in 169 (12%). A positive SNOW scale had comparable accuracy to predict LVO and showed a sensitivity of 0.80, specificity of 0.76, the positive predictive value (PPV) of 0.31, and negative predictive value of 0.96 for the detection of LVO versus CPSS ≥ 2 of 0.64, 0.87, 0.41, and 0.95. A positive SNOW scale had higher accuracy than VAN, LAMS, and PASS. CONCLUSION: In our large stroke network cohort, the SNOW scale has promising sensitivity, specificity and accuracy to predict LVO. Future prospective studies in both prehospital and emergency room settings are warranted.

Puerto Rican-Born Women in the United States: Contextual Approach to Immigration Challenges.

This study focused on how acculturative stress and psychological distress affect Puerto Rican-born women residing in the United States. Mediation path analysis was used to estimate relationships between contextual factors, acculturative stress, and psychological distress. The fit of the data to the final model was adequate as estimated using chi-square analysis, comparative fit index, Tucker-Lewis Index, and root-mean-square error of approximation. Racial discrimination (b = 0.38, p = .01), difficulties visiting family abroad (b = 0.26, p = .03), and age at immigration (b = 0.19, p = .03) were positively associated with acculturative stress. The factor English skills (b = -0.31, p = .02) was negatively associated with acculturative stress. Racial discrimination had the strongest effect on acculturative stress, followed by English skills, difficulties visiting family abroad, and age at immigration. Racial discrimination (b = 0.39, p = .01) and financial constraints (b = 0.30, p = .01) were positively associated with psychological distress. Racial discrimination affected the women's psychological distress the most, followed by economic contexts (financial constraints). This study informs practitioners in considering the significant contextual factors relevant to the psychological distress of Puerto Rican-born women.

EHR Documentation: The Hype and the Hope for Improving Nursing Satisfaction and Quality Outcomes.

The phenomenon of "data rich, information poor" in today's electronic health records (EHRs) is too often the reality for nursing. This article proposes the redesign of nursing documentation to leverage EHR data and clinical intelligence tools to support evidence-based, personalized nursing care across the continuum. The principles consider the need to optimize nurses' documentation efficiency while contributing to knowledge generation. The nursing process must be supported by EHRs through integration of best care practices: seamless workflows that display the right tools, evidence-based content, and information at the right time for optimal clinical decision making. Design of EHR documentation must attain a balance that ensures the capture of nursing's impact on safety, quality, highly reliable care, patient engagement, and satisfaction, yet minimizes "death by data entry." In 2014, a group of diverse informatics leaders from practice, academia, and the vendor community formed to address how best to transform electronic documentation to provide knowledge at the point of care and to deliver value to front line nurses and nurse leaders. As our health care system moves toward reimbursement on the basis of quality outcomes and prevention, the value of nursing data in this business proposition will become a key differentiator for health care organizations' economic success.

Harmonizing and extending standards from a domain-specific and bottom-up approach: an example from development through use in clinical applications.

OBJECTIVE: Currently, the processes for harmonizing and extending standards by leveraging the knowledge within local documentation artifacts are not well described. We describe a collaborative project to develop common information models, terminology bindings, and term definitions based on nursing documentation systems, and carry the findings through to the adoption in standards development organizations (SDOs) and technical implementations in clinical applications. MATERIALS AND METHODS: Nursing flowsheet documents from six large organizations were analyzed to generate a common information model and terminologies that fully expressed documentation across all systems, and were sufficient for evidence-based decision support, reporting, and analysis. RESULTS: Significant gaps in existing standards were identified. The models and terminologies were submitted to and incorporated by SDOs, are published, implemented, and now serving as a foundation for an eMeasure. DISCUSSION: There are few examples in the literature of success working through the standards development process from a bottom-up perspective. Subsequently, standards do not yet fully address the need for detailed clinical data that enables, for example, decision support as well as a range of reporting and analytic requirements. Recommendations from this project include transparent processes within SDOs, registries that make models and associated terminologies freely available, and coordinated governance processes. CONCLUSION: We demonstrated the feasibility of using documentation artifacts in a bottom-up approach to develop common models and sets of terms that are complete from the perspective of clinical implementation. Importantly, we demonstrated a process by which a community of practice can contribute to closing gaps in existing standards using SDO processes.

Contextual Approach to Acculturative Stress Among Latina Immigrants in the U.S.

Based on Family Stress Management theory, we explored the contextual influence on acculturative stress and psychological distress. We included 639 Latinas from the National Latino Asian American Survey. We hypothesized that (a) impact of acculturative stress on psychological distress depends on specific contexts; (b) U.S. climate (i.e., perceived discrimination, happiness with U.S. move, years in the U.S.) impacts acculturative stress and psychological distress the most, and (c) contextual factors interact in impacting acculturative stress. Acculturative stress did not always lead to psychological distress. Perceived discrimination and difficulty visiting family abroad were positively associated with acculturative stress. Years in the U.S. and happiness with the U.S. move were negatively associated with acculturative stress. Years in the U.S. and perceived discrimination interacted in predicting acculturative stress. These results can aid formulation of effective interventions that target contexts likely to impact acculturative stress and psychological distress among Latinas.

An IT innovation for individualizing care: success with clinicians leading the way.

In 2004, the Knowledge-based Nursing Initiative (KBNI) began as a partnership between a university-based college of nursing, an informatics vendor, and a large, integrated health care system. The goal was to develop a process for translating evidence into actionable recommendations, embedding the recommendations into the computerized decision support and documentation systems, and supporting nurses' use of the nursing process to individualize care. This paper will describe the essential administrative, information technology (IT), educational and clinical support activities that were used to deploy this innovation into the electronic health record (EHR) and workflow of nurses on two acute care medical pilot units in July of 2008. The project supported every nurse to document their evidenced-based practice with each patient contact and populate the EHR database with rich, nursing sensitive, retrievable data for quality improvement and research. The results included verifying data reliability and validity, evaluating go-live preparation, and summarizing the qualitative and quantitative findings. Two critical factors that made this implementation a success were that the project had a transformational vision and that it was led by the clinical team and strongly supported by the IT team. The lessons learned in the adoption phase will be diffused to the rest of the health care system and beyond.

Trafficking of children in Albania: patterns of recruitment and reintegration.

PROBLEM: Many children in Albania and other countries of Eastern Europe are being trafficked as part of the global business of human trafficking. OBJECTIVES: The study sought to identify the patterns of child trafficking involving Albanian children, and especially children's views of the role of family issues and the nature of the trafficking experience. METHOD: The study included verbally administered questionnaires, semi-structured interviews, focus groups, and use of already existing reports. Study participants included 61 children who had escaped from trafficking, 22 children from similar at-risk groups who had not been trafficked, 15 parents of currently or previously trafficked children, 10 parents from similar groups whose children had not been trafficked, and 8 key informants. RESULTS: Children at greatest risk of trafficking had very limited education and frequently were working on the streets. Their families were poor with many interpersonal problems, including violence. They typically belonged to the Gypsy community. Trusted community members usually recruited the children by promising that the children would work to help the family financially. Once abroad, the children were harshly treated, forced to work long hours, physically abused, and isolated from family members. Families did not receive the promised payment. Once returned, children had a difficult time reentering due to family, educational, and economic issues. CONCLUSIONS: Contextual issues supporting child trafficking in Albania include poverty, major internal and external migrations, discrimination, and problems in the legal system. Poverty combined with family problems and membership in the marginalized Gypsy group places children at increased risk of trafficking into harsh labor conditions. PRACTICE IMPLICATIONS: The study of Albanian children who were trafficked suggests that dealing with trafficking of children requires addressing family problems and complex social issues that perpetuate poverty as well as the legal and social structures that place children at risk and continue to marginalize certain communities. As a result, changes in social policies that protect victims and punish traffickers and the development of programs that facilitate integration and promote the economic and interpersonal welfare of families whose children are at-risk have been established in Albania.