Pilot Process Evaluation of the Supporting Older Adults at Risk Model: A RE-AIM Approach.

ABSTRACT: Despite evidence supporting transitional care models, hospitals report challenges implementing and sustaining them. The Discharge to Assess (D2A) Model is an innovative solution to this problem but required translation from a national health system context to an U.S.-based context. We translated the central tenets of the D2A model to establish the Supporting Older Adults at Risk (SOAR) Model, which unfolds in three phases: Prepare, Transition, and Support. The purpose of this project was to conduct a process evaluation of the SOAR Model in practice using the RE-AIM Framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). Forty patients completed all SOAR Model components for a Reach of 21%. Patients averaged 80 years of age, 53% were female, and 64% Black/AA. SOAR significantly improved discharge before noon, time to first home visit, and use of the in-house pharmacy. SOAR also improved length of hospital stay, emergency department visits, and readmissions. Twenty-one of the 26 Implementation measures unfolded with 75% or greater fidelity. Sixteen of the 24 Adoption measures unfolded with 75% or greater fidelity. COVID-19 limited Maintenance. Given the model unfolds across settings over time, requiring adoption from interprofessional team members, patients, and families, future work should focus on improving reach and adoption.

Nursing Strategic Imperatives: Engaging Nurses in Strategy Development and Execution to Drive Value.

Strategic plans provide a roadmap for value creation by outlining key priorities that, when executed successfully, enhance quality and efficiency. Nurses are uniquely positioned to inform strategic planning because of their understanding of clinical operations and consumer needs. This article describes a multiphase process for engaging nurses, at all levels, in developing, implementing, and revising a nursing strategic plan over a 5-year period.

Readmitted Patients With Heart Failure Sick, Tired, and Symptomatic: A Qualitative Descriptive Study From a Quaternary Academic Medical Center.

BACKGROUND AND OBJECTIVE: Heart failure (HF) readmissions will continue to grow unless we have a better understanding of why patients with HF are readmitted. Our purpose was to gain an understanding, from the patients' perspective, of how patients with HF viewed their discharge instructions and how they felt when they got home and were then readmitted in less than 30 days. METHODS AND RESULTS: We used a qualitative descriptive approach using semistructured interviews with 22 patients with HF. Most participants had multimorbidities, were classified as New York Heart Association class III (n = 13) with reduced ejection fraction (n = 20), and were on home inotrope therapy (n = 13). The overarching theme that emerged was that these participants were sick, tired, and symptomatic. Additional categories within this theme highlight discharge instructions as being clear and easily understood; rich descriptions of physical, emotional, and other symptoms leading up to readmission; and reports of daily activities including what "good" and "not good" days looked like. Moreover, when participants experienced an exacerbation of their HF symptoms, they were sick enough to be readmitted to the hospital. CONCLUSION: Our findings confirm ongoing challenges with a complex group of sick patients with HF, with the majority on home inotropes with reduced ejection fraction, who developed an unavoidable progression of their illness and subsequent hospital readmission.

Handoffs and transitions in critical care-understanding scalability: study protocol for a multicenter stepped wedge type 2 hybrid effectiveness-implementation trial.

BACKGROUND: The implementation of evidence-based practices in critical care faces specific challenges, including intense time pressure and patient acuity. These challenges result in evidence-to-practice gaps that diminish the impact of proven-effective interventions for patients requiring intensive care unit support. Research is needed to understand and address implementation determinants in critical care settings. METHODS: The Handoffs and Transitions in Critical Care-Understanding Scalability (HATRICC-US) study is a Type 2 hybrid effectiveness-implementation trial of standardized operating room (OR) to intensive care unit (ICU) handoffs. This mixed methods study will use a stepped wedge design with randomized roll out to test the effectiveness of a customized protocol for structuring communication between clinicians in the OR and the ICU. The study will be conducted in twelve ICUs (10 adult, 2 pediatric) based in five United States academic health systems. Contextual inquiry incorporating implementation science, systems engineering, and human factors engineering approaches will guide both protocol customization and identification of protocol implementation determinants. Implementation mapping will be used to select appropriate implementation strategies for each setting. Human-centered design will be used to create a digital toolkit for dissemination of study findings. The primary implementation outcome will be fidelity to the customized handoff protocol (unit of analysis: handoff). The primary effectiveness outcome will be a composite measure of new-onset organ failure cases (unit of analysis: ICU). DISCUSSION: The HATRICC-US study will customize, implement, and evaluate standardized procedures for OR to ICU handoffs in a heterogenous group of United States academic medical center intensive care units. Findings from this study have the potential to improve postsurgical communication, decrease adverse clinical outcomes, and inform the implementation of other evidence-based practices in critical care settings. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04571749 . Date of registration: October 1, 2020.

Effect of Behaviorally Designed Gamification With a Social Support Partner to Increase Mobility After Hospital Discharge: A Randomized Clinical Trial.

Importance: Hospitalization is associated with decreased mobility and functional decline. Behaviorally designed gamification can increase mobility in community settings but has not been tested among patients at risk for functional decline during a high-risk transition period after hospitalization. Objective: To test a behaviorally designed gamification intervention with a social support partner to increase patient mobility after hospital discharge. Design, Setting, and Participants: This study is a randomized clinical trial of a 12-week intervention without follow-up. Enrollment occurred from January 2018 to June 2019 at a referral hospital with a remote at-home monitoring intervention among patients living predominantly in 3 states (Pennsylvania, New Jersey, and Delaware). Participants included adult patients discharged from general medicine and oncology units to home. Data analysis was performed from October 2019 to March 2020. Interventions: All participants received a wearable device to track daily steps. The control group received feedback from the device but no other interventions. The intervention group entered into a 12-week game informed by behavioral economics to assign points and levels for achieving step goals and reinforced by a support partner who received updates on participant progress. Main Outcomes and Measures: The primary outcome was change in mean daily steps from baseline through the 12-week intervention. Secondary measures were change in functional status and urgent care utilization (ie, emergency department visits and hospital readmissions) within this period. Results: A total of 232 participants were enrolled in the study (118 randomized to control and 114 randomized to the intervention). Participants had a mean (SD) age of 40 (14) years, 141 (61%) were female, 101 (43%) were White, and 103 (44%) had an annual household income less than $50 000. Daily step counts increased from 3795 to 4652 steps (difference, 857 steps; 95% CI, 488 to 1224 steps) among intervention participants and increased from 3951 to 4499 steps (difference, 548 steps; 95% CI, 193 to 903 steps) among control participants. The change in mean daily step count from baseline was not significantly different for participants in the intervention group vs the control group (adjusted difference, 270 steps; 95% CI, -214 to 754 steps; P = .27). Among the subgroup of 76 participants with higher levels of social engagement, post hoc exploratory analyses showed a significant increase in mobility for intervention vs control (adjusted difference, 1125 steps; 95% CI, 409 to 1841 steps; P = .002). Fewer participants in this subgroup experienced functional decline (1 of 36 participants [4%] in the intervention group vs 5 of 40 participants [12%] in the control group) and hospital readmission at 30 days (3 of 36 participants [8%] in the intervention group vs 6 of 40 participants [15%] in the control group), but the differences were not statistically significant. There were no significant differences in these secondary outcomes for the overall sample. Conclusions and Relevance: Gamification with social incentives did not affect mobility or functional decline in all participants, but post hoc analysis suggests positive findings for both outcomes for patients with higher social engagement. Trial Registration: ClinicalTrials.gov Identifier: NCT03321279.

Secondary Traumatic Stress Among Labor and Delivery Nurses.

PURPOSE: To describe the prevalence and severity of secondary traumatic stress (STS) among labor and delivery nurses within a Northeastern United States academic health system. STUDY DESIGN AND METHODS: Using a cross-sectional, descriptive correlational design, a convenience sample of labor and delivery nurses (288 nurses) were invited to complete Secondary Traumatic Stress Scale (STSS), a 17-item Likert-type instrument, that measures intrusion, avoidance, and the arousal symptoms associated with indirect exposure to traumatic events. Five additional questions about potential consequences of STS were also asked. RESULTS: N = 144 completed the survey (50% response rate). Average STSS score was 33.74 (SD, 11.8), with 35% of respondents meeting symptom severity scores associated with STS. STSS Scores ≥ 38 were significantly correlated with nurses considering leaving their jobs, calling out sick, or requesting an assignment change after witnessing a traumatic birth (p < 0.001). The majority of respondents (84.7%) reported witnessing a traumatic birth. After witnessing a traumatic birth, respondents used co-workers, family, and friends as sources of support. CLINICAL IMPLICATIONS: This study offers insight into the frequency and severity of STS among labor and delivery nurses, as well as the potential workforce-related consequences and provides a foundation for future work aimed at developing interventions to prevent or alleviate STS.

Moving beyond the measure: Understanding patients' experiences of communication with nurses.

Under Medicare's Value-Based Purchasing Program, scores derived from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey are used in the determination of incentive payments and financial penalties for healthcare organizations. Organizations, therefore, invest in approaches to improve the likelihood of positive patient responses. Evidence suggests that nurse communication as measured by HCAHPS influences overall patient satisfaction, yet little is known regarding what patients believe constitutes effective communication with nurses. In this qualitative descriptive study, we conducted phone interviews with 49 recently hospitalized patients to better understand patients' perceptions of their communication with nurses. Our findings indicate that patients perceived their communication with nurses to unfold via nurses' behaviors. Namely, nurses' engagement with patients, anticipation of patients' needs, responsiveness to patients' concerns, and teaching practices positively influence patient satisfaction with communication with nurses. These behaviors resonated most strongly with patients during particularly memorable moments of uncertainty and vulnerability over the course of a hospital stay. These findings suggest that focusing on the development of nurses' behaviors, ensuring processes are in place to support positive behaviors and creating organizational environments that position nurses to consistently apply these behaviors, can improve patients' perceptions of their communication with nurses. These findings also provide a foundation for further research focused on developing and testing specific behavioral interventions and their effect on communication perception.

Moral Distress: Identification Among Inpatient Oncology Nurses in an Academic Health System.

BACKGROUND: Moral distress occurs when clinicians know the morally correct action to take but are unable to follow through because of internal and external constraints. It is associated with negative consequences, such as burnout, decreased job satisfaction, avoidance, and turnover. OBJECTIVES: The purpose of this study was to describe the frequency and level of moral distress among inpatient oncology nurses and to identify possible associations among nurses' demographic characteristics, work experience, and moral distress levels. METHODS: Ninety-three inpatient oncology nurses from a large academic health system completed the Moral Distress Scale-Revised (MDS-R). Additional questions included intent to leave and requests for changes in patient assignments because of moral distress. FINDINGS: Years as a nurse, changing or considering changing patient assignments, and changing care provided to a patient because of moral distress were statistically significantly associated with higher MDS-R scores. Participants reported using palliative care consultations, pastoral care, and social work to assist with their moral distress.

Views From Patients With Cancer in the Setting of Unplanned Acute Care: Informing Approaches to Reduce Health Care Utilization.

PURPOSE: New oncology care delivery models that avoid preventable acute care are needed, yet it is unclear which interventions best meet the needs of patients and caregivers. Perspectives from patients who experienced unplanned acute care events may inform the successful development and implementation of care delivery models. METHODS: We performed a qualitative interview study of patients with solid tumors on active treatment who experienced the following 3 types of unplanned acute care events: emergency department visits, first hospitalizations, and multiple hospitalizations. Patients were prospectively recruited within a large academic health system from August 2018 to January 2019. Interviews followed a semi-structured guide developed from the Consolidated Framework for Implementation Research. The constant comparative approach was used to identify themes. RESULTS: Forty-nine patients were interviewed; 51% were men, 75% were non-Hispanic White, and the mean age was 57.4 years (standard deviation, 1.9 years). Fifty-five percent of patients had metastatic disease, and 33% had an Eastern Cooperative Oncology Group performance status of 3-4. We identified the following key themes: drivers of the decision to seek acute care, patients' emotional concerns that influence interactions with the oncology team, and strategies used to avoid acute care. Patients' recommendations for interventions included anticipatory guidance, peer support, improved triage methods, and enhanced symptom management. Patients preferred options for virtual and home-based outpatient care. CONCLUSION: Patient-centered care models should focus on early delivery of supportive interventions that help patients and caregivers navigate the unexpected issues that come with cancer treatment. Patients advocate for proactive, multidisciplinary supportive interventions that enable home-based care and are led by the primary oncology team.

Improving Nonvocal Critical Care Patients' Ease of Communication Using a Modified SPEACS-2 Program.

OBJECTIVE: To evaluate the feasibility and impact of implementing the "study of patient-nurse effectiveness with assisted communication strategies-2" (SPEACS-2); a program to facilitate communication with nonvocal patients. STUDY DESIGN: The plan-do-study-act quality improvement methodology guided the implementation of a modified SPEACS-2 program within a pre and posttest design. The Ease of Communication Scale (ECS) measured patients' communication difficulty, and care processes measured the program's success. STUDY POPULATION: Nurses (N = 385) across 5 intensive care units were trained in SPEACS-2. We assessed 354 nonvocal patients (aged 18-95 years) requiring continued mechanical ventilation after withdrawal of heavy sedation. Patients were evaluated over one 2-week preintervention (n = 163) and two 3-week postintervention periods (n = 128; n = 63). A subsample of intervention patients (n = 204) completed the ECS. RESULTS: Ease of Communication Scale scores improved significantly (p = .027) from baseline (mean 25.86 ± 12.2, n = 71) to postintervention period 2 (21.22 ± 12.2, n = 63). Nurses' use of communication techniques and compliance with communication plans of care incrementally increased after training. CONCLUSIONS: Implementing SPEACS-2 demonstrated positive changes in patients' ease of communication and feasibility of incorporating evidence-based communication strategies into practice.

A Multivariate Analysis of Pain and Distress in Adults Undergoing BMAB.

Clinicians routinely perform bone marrow aspiration and biopsy (BMAB) to diagnose cancer and evaluate disease status; however, few studies address pain and distress with BMAB. A prospective descriptive-correlational design examined patients' (N = 152) ratings of pain intensity (numeric rating scale, 0-10) and distress (distress thermometer) at baseline and 5 min and 1 hr postprocedure. Data were analyzed using descriptive statistics, chi-square, and linear regression models. Mean postprocedure pain intensity at 5 min was moderate, 5.56 (SD = 3.03), and opioid use was associated with decreased pain at 1 hr (p < .001). Preprocedure administration of anxiolytics had no significant effect on distress reduction (p = .88). Being female, first-time biopsy, and increased preprocedure pain were significant predictors of postprocedure distress (p < .001). Treating anxiety alone may not be sufficient to lessen pain and distress. Individualized plans of care should be based on patient risk and response to procedure.

Improving Patients' Experiences Communicating With Nurses and Providers in the Emergency Department.

INTRODUCTION: As health care becomes increasingly patient centered, organizations strive to improve patients' ratings of satisfaction with care. Communication with nurses and providers drives overall satisfaction, yet little evidence exists to guide them in ensuring effective communication in the emergency department. METHODS: A semistructured interview guide based on the Hospital Consumer Assessment of Healthcare Providers survey was used to elicit qualitative data from 30 patients seen in the emergency department and fast track regarding communication with nurses and providers. Data were analyzed using content analysis methodology. RESULTS: Two types of overarching themes emerged. Foundational themes include behaviors that convey courtesy and respect and are required for participants to view their interactions with nurses and providers as positive. Interactive themes describe humanistic ways in which nurses and providers conveyed courtesy and respect, reassurance through careful listening, attentiveness, and explaining things in an understandable way. DISCUSSION: The findings underscore existing evidence regarding patients' perceptions of being treated with courtesy and respect via nurses' and providers' use of positive verbal phrasing and nonverbal body language. They reveal new insights into the importance of specific communication behaviors used by nurses and providers during interactions. Treating patients as individuals amidst a fast-paced care environment, proactively recognizing and responding to patients' fears and concerns, and explaining information clearly to ensure understanding were critical.

Development of a Comprehensive Geriatric Assessment Led by Geriatric Nurse Consultants: A Feasibility Study.

Hospitalized older adults are at high risk for complications, leading to negative outcomes such as longer lengths of stay, hospital readmissions, and functional and cognitive decline. Comprehensive Geriatric Assessment (CGA) models are effective in mitigating these syndromes but are not widespread. Nurses with expertise in gerontology who can provide consultation and care coordination can improve care processes and clinical outcomes. This pilot study capitalized on the role of the geriatric nurse consultant (GNC) to develop, implement, and test the feasibility, acceptability, and utility of a GNC-led CGA. Through repeated applications with hospitalized patients, this study demonstrated that GNCs could complete a CGA and identify clinically actionable findings. This study also uncovered clinical geriatric concerns that would not have otherwise been identified via traditional nursing assessments. The results highlight contribution of a GNC-led CGA as a mechanism to support care process improvements to address common geriatric concerns in the acute care setting. [Journal of Gerontological Nursing, 44(12), 25-34.].

Reducing disability via a family centered intervention for acutely ill persons with Alzheimer's disease and related dementias: protocol of a cluster-randomized controlled trial (Fam-FFC study).

BACKGROUND: Hospitalized older persons with Alzheimer's disease and related dementias are at greater risk for functional decline and increased care dependency after discharge due to a combination of intrinsic factors, environmental, policy, and care practices that restrict physical and cognitive activity, lack of family involvement and limited staff knowledge of dementia care. We have developed a theory-based intervention, Family centered Function-focused Care, that incorporates an educational empowerment model for family caregivers (FCGs) provided within a social-ecological framework to promote specialized care to patients with dementia during hospitalization and the 60-day post-acute period. Primary aims are to test the efficacy of the intervention in improving physical and cognitive recovery in hospitalized persons living with Alzheimer's disease and related dementias (ADRD) and improving FCG preparedness and experiences. METHOD: We will implement Family centered Function-focused Care in a cluster-randomized trial of 438 patient/FCG dyads in six hospital units randomized within three hospitals. We hypothesize that patients who receive the intervention will demonstrate better physical function, less delirium occurrence and severity, neuropsychiatric symptoms, and depression compared to those in the control condition (Education-only). We also hypothesize that FCGs enrolled in Family centered Function-focused Care will experience increased preparedness for caregiving, and less strain, burden, and desire to institutionalize, as compared to FCGs the control group. We will also examine the costs and relative cost savings associated with the intervention and will evaluate the cultural appropriateness of Family centered Function-focused Care for families from diverse backgrounds. DISCUSSION: Our theory-based intervention makes use of real-world applicable approaches in a novel and innovative way to change the paradigm of how we currently look at acute care and post-acute transitions in persons with ADRD. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03046121 . Registered on 8 February 2017.

Lower Postsurgical Mortality for Individuals with Dementia with Better-Educated Hospital Workforce.

OBJECTIVES: To investigate whether care in a hospital with more nurses holding at least a Bachelor of Science in Nursing (BSN) degree is associated with lower mortality for individuals with Alzheimer's disease and related dementias (ADRD) undergoing surgery ADRD. DESIGN: Cross-sectional data from 2006-07 Medicare claims were linked with the Multi-State Nursing Care and Patient Safety Survey of nurses in 4 states. SETTING: Adult, nonfederal, acute care hospitals in California, Florida, New Jersey, and Pennsylvania (N=531). PARTICIPANTS: Medicare beneficiaries aged 65 and older with and without ADRD undergoing general, orthopedic, or vascular surgery (N=353,333; ADRD, n=46,163; no ADRD, n=307,170). MEASUREMENTS: Thirty-day mortality and failure to rescue (death after a complication). RESULTS: Controlling for hospital, procedure, and individual characteristics, each 10% increase in the proportion of BSN nurses was associated with 4% lower odds of death (odds ratio (OR)=0.96, 95% confidence interval (CI)=0.93-0.98) for individuals without ADRD, but 10% lower odds of death (OR=0.90, 95% CI=0.87-0.94) for those with ADRD. Each 10% increase in the proportion of nurses holding a BSN degree or higher was associated with 5% lower odds of failure to rescue (OR=0.95, 95% CI=0.92-0.98) for individuals without ADRD but 10% lower odds of failure to rescue (OR=0.90, 95% CI=0.87-0.94) for those with ADRD. CONCLUSION: Individuals undergoing surgery who have coexisting ADRD are more likely to die within 30 days of admission and die after a complication than those without ADRD. Having more BSN nurses in the hospital improves the odds of good outcomes for all individuals and has a much greater effect in individuals with ADRD.

Project SITUP: An Interdisciplinary Quality Improvement Initiative to Reduce Aspiration Pneumonia.

The purpose of this quality improvement initiative was to improve oropharyngeal dysphagia screening and reduce aspiration pneumonia rates on 3 inpatient hospital medical units. Guided by a Plan-Do-Study-Act methodology, an interdisciplinary health team developed and implemented a systematic process for oropharyngeal dysphagia screening and management. As a result, use of the screening protocol increased, timely initiation of speech language pathology consultations increased, and aspiration pneumonia rates decreased.

Pre-admission functional decline in hospitalized persons with dementia: The influence of family caregiver factors.

Older adults with dementia are more likely than those who do not have dementia to be hospitalized. Admission functional (ADL) performance is a salient factor predicting functional performance in older adults at discharge. The days preceding hospitalization are often associated with functional loss related to the acute illness. An understanding of functional changes during this transition will inform interventions to prevent functional decline. This secondary analysis examined data from a study that evaluated a family educational empowerment model and included 136 dyads (persons with dementia and their family caregiver). AMOS structural equation modeling examined the effects of family caregiver factors upon change in patient ADL performance (Barthel Index) from baseline (two week prior to hospitalization) to the time of admission, controlling for patient characteristics. Eighty-two percent of the patients had decline prior to admission. Baseline function, depression, and dementia severity, as well as Family caregiver strain, were significantly associated with change in pre-admission ADL performance and explained 40% of the variance. There was a good fit of the model to the data (Χ2=12.9, p=0.305, CFI=0.97, TLI=0.90, RMSEA=0.05). Findings suggest the need for a function-focused approach when admitting patients with dementia to the hospital. FCG strain prior to hospitalization may be a factor impacting trajectory of functional changes in older person with dementia, especially in those with advanced dementia. FCG strain is an important assessment parameter in the risk assessment for functional decline, to be considered when engaging the FCG in the plan for functional recovery.

Challenges in recruiting subjects to a pilot trial of patient-managed in-hospital insulin.

BACKGROUND: To examine the feasibility of implementing clinician-supported inpatient self-managed insulin to aid in the planning of a randomized clinical trial. RESULTS: We conducted a proof-of-concept interventional study of inpatients with diabetes mellitus who had hospital orders for basal-bolus or sliding scale insulin. Patients meeting inclusion criteria were offered the opportunity to manage their own basal-bolus insulin with support from a diabetes nurse practitioner. Over a three-month screening period, we conducted 361 screens in 336 patients, only eleven of whom met all inclusion criteria. None of these eleven eligible patients elected to enroll. The most common reason for refusal was lack of interest in self-managing insulin while acutely ill (36 %). DISCUSSION: Future studies of patient-managed in-hospital insulin should consider enrolling less acutely ill patients with longer anticipated lengths of stay. TRIALS REGISTRATION: NCT02144441.

Hourly rounding to improve nursing responsiveness: a systematic review.

UNLABELLED: The aims of this study were to synthesize the evidence concerning the effect of hourly rounding programs on patient satisfaction with nursing care and discuss implications for nurse administrators. BACKGROUND: Patient satisfaction is a key metric that influences both hospital ratings and reimbursement. Studies have suggested that purposeful nursing rounds can improve patient satisfaction, but the evidence to date has not been systematically examined. METHODS: A systematic review of published literature and GRADE analysis of evidence regarding nursing rounds were conducted. RESULTS: There is little consistency in how results of hourly rounds were measured, precluding quantitative analysis. There is moderate-strength evidence that hourly rounding programs improve patients' perception of nursing responsiveness. There is also moderate-strength evidence that these programs reduce patient falls and call light use. CONCLUSIONS: Nurse administrators should consider implementing an hourly rounding program while controlled trials discern the most cost-effective approach.

Using process improvement methodology to address the complex issue of falls in the inpatient setting.

Falls in the acute care hospital are a significant patient safety issue. The purpose of this article was to describe the use of process improvement methodology to address inpatient falls on 5 units. This initiative focused on a proactive approach to falls, identification of high-risk patients, and a complete assessment of patients at risk. During the project timeframe, the mean total fall rate decreased from 3.7 to 2.8 total falls per 1000 patient days.