Informatics Tools in Deprescribing and Medication Optimization in Older Adults: Development and Dissemination of VIONE Methodology in a High Reliability Organization.

PURPOSE: Polypharmacy is common in older adults, with almost 20% of older adults taking ≥10 medications. They are at great risk for adverse events related to potentially inappropriate medications (PIMs). Although evidence-based methods for deprescribing have been successful at reducing polypharmacy and improving quality of medication use, there are several challenges to implementing these methods on a large scale. VIONE, a medication deprescribing methodology, was developed to reduce polypharmacy and PIMs across the Veterans Health Administration (VHA). (VIONE stands for Vital, Important, Optional, Not indicated, and Every medication has an indication.) This study describes the tools created for implementation of VIONE and the dashboards used to track VIONE implementation and subsequent deprescribing across the VHA; their use and sustainment are examined in a health system-wide adoption of this deprescribing practice in a high reliability organization (HRO). METHODS: VIONE was disseminated by the VHA via the Diffusion of Excellence Initiative. Dissemination included an implementation toolkit and four dashboards that collect and display data from the electronic medical record to monitor utilization of VIONE, track medication discontinuations, and prospectively identify veterans who may be candidates for deprescribing. FINDINGS: Between 2016 and the present, VIONE has been adopted at >130 medical centers and influenced almost 700,000 unique patients. In addition, a total of >1.6 million medication orders have been discontinued by >15,000 providers. IMPLICATIONS: The VIONE methodology and informatics tools were widely disseminated and successfully adopted and sustained nationally in a high reliability organization, leading to a reduction in PIM use by older adults and improved quality and patient safety. Future efforts should continue to consider ways to leverage electronic medical record data and other relevant informatics tools to provide customized clinical decision support to further medication optimization and deprescribing efforts.

Developing best practices for PPE Portraits across 25 sites: a systematic assessment of implementation and spread of adaptations using FRAME.

BACKGROUND: Adaptation, a form of modification that aims to improve an intervention's acceptability and sustainability in each context, is essential to successful implementation in some settings. Due to the COVID-19 pandemic, clinicians have rapidly adapted how they deliver patient care. PPE Portraits are a form of adaptation, whereby health workers affix a postcard size portrait of themselves to the front of their personal protective equipment (PPE) to foster human connection during COVID-19. METHODS: We used the expanded framework for reporting adaptations and modifications to evidence-based interventions (FRAME) method to better understand the reasoning behind and results of each adaptation. We hypothesized that using the FRAME in conjunction with design-thinking would lead to emerging best practices and that we would find adaptation similarities across sites. Throughout multiple implementations across 25 institutions, we piloted, tracked, and analyzed adaptations using FRAME and design thinking. For each adaptation, we assessed the stage of implementation, whether the change was planned, decision makers involved, level of delivery impacted, fidelity to original intervention, and the goal and reasoning for adaptation. We added three crucial components to the FRAME: original purpose of the adaptation, unintended consequences, and alternative adaptations. RESULTS: When implementing PPE Portraits across settings, from a local assisted living center's memory unit to a pediatric emergency department, several requests for adaptations arose during early development stages before implementation. Adaptations primarily related to (1) provider convenience and comfort, (2) patient populations, and (3) scale. Providers preferred smaller portraits and rounded (rather than square) laminated edges that could potentially injure a patient. Affixing the portrait with a magnet was rejected given the potential choking hazard the magnetic strip presented for children. Other adaptations, related to ease of dissemination, included slowing the process down during early development and providing buttons, which could be produced easily at scale. CONCLUSIONS: The FRAME was used to curate the reasoning for each adaptation and to inform future dissemination. We look forward to utilizing FRAME including our additions and design thinking, to build out a range of PPE Portrait best practices with accompanying costs and benefits.

The effect of data aggregation on estimations of nurse staffing and patient outcomes.

OBJECTIVE: To examine how estimates of the association between nurse staffing and patient length of stay (LOS) change with data aggregation over varying time periods and settings, and statistical controls for unobserved heterogeneity. DATA SOURCES/STUDY SETTING: Longitudinal secondary data from October 2002 to September 2006 for 215 intensive care units and 438 general acute care units at 143 facilities in the Veterans Affairs (VA) health care system. RESEARCH DESIGN: This retrospective observational study used unit-level panel data to analyze the association between nurse staffing and LOS. This association was measured over both a month-long and a year-long period, with and without fixed effects. DATA COLLECTION: We used VA administrative data to obtain patient data on the severity of illness and LOS, as well as labor hours and wages for each unit by month. PRINCIPAL FINDINGS: Overall, shorter LOS was associated with higher nurse staffing hours and lower proportions of hours provided by licensed professional nurses (LPNs), unlicensed personnel, and contract staff. Estimates of the association between nurse staffing and LOS changed in magnitude when aggregating data over years instead of months, in different settings, and when controlling for unobserved heterogeneity. CONCLUSIONS: Estimating the association between nurse staffing and LOS is contingent on the time period of analysis and specific methodology. In future studies, researchers should be aware of these differences when exploring nurse staffing and patient outcomes.

Quantifying paediatric intensive care unit staffing levels at a paediatric academic medical centre: A mixed-methods approach.

AIM: To identify, simulate and evaluate the formal and informal patient-level and unit-level factors that nurse managers use to determine the number of nurses for each shift. BACKGROUND: Nurse staffing schedules are commonly set based on metrics such as midnight census that do not account for seasonality or midday turnover, resulting in last-minute adjustments or inappropriate staffing levels. METHODS: Staffing schedules at a paediatric intensive care unit (PICU) were simulated based on nurse-to-patient assignment rules from interviews with nursing management. Multivariate regression modelled the discrepancies between scheduled and historical staffing levels and constructed rules to reduce these discrepancies. The primary outcome was the median difference between simulated and historical staffing levels. RESULTS: Nurse-to-patient ratios underestimated staffing by a median of 1.5 nurses per shift. Multivariate regression identified patient turnover as the primary factor accounting for this difference and subgroup analysis revealed that patient age and weight were also important. New rules reduced the difference to a median of 0.07 nurses per shift. CONCLUSION: Measurable, predictable indicators of patient acuity and historical trends may allow for schedules that better match demand. IMPLICATIONS FOR NURSING MANAGEMENT: Data-driven methods can quantify what drives unit demand and generate nurse schedules that require fewer last-minute adjustments.

Enablers, Barriers, and Contributions of Pediatric Nurse Practitioners to Ambulatory Specialty Care.

INTRODUCTION: The objective of this study was to explore the enablers of and barriers to the contribution of nurse practitioners (NPs) in pediatric specialty care. METHOD: A total of 11 NPs in pediatric medical specialties were interviewed regarding teamwork, communication, documentation, satisfaction, overall role, and perception of the value they contribute to care. RESULTS: Themes were identified related to structural and organizational enablers and barriers that facilitate or hinder the NPs' contribution to pediatric specialty care. DISCUSSION: The findings of this study can provide a better understanding of the role of NPs caring for pediatric patients in the specialty setting and can also help guide organizational environments to maximize the potential of pediatric NPs to positively affect patient care.

Service Value Activities by Nurse Practitioners in Ambulatory Specialty Care.

The increase in nurse practitioners (NPs) in ambulatory medical and surgical specialty settings has prompted inquiry into their role and contribution to patient care. We explored the role and contribution of NPs in ambulatory specialty care through their activities outside of direct care and billable visits (referred to as service value activities), and how NPs perceive these activities enhance quality and efficiency of care, for both patients and the health care institution. This qualitative thematic analysis examined interviews from 16 NPs at a large academic medical center about their role and contribution to patient care quality and departmental efficiency beyond billable visits. Five categories of NP contribution were identified: promoting patient care continuity, promoting departmental continuity, promoting institutional historical and insider knowledge, addressing time-sensitive issues, and participating in leadership and quality improvement activities. As the role of NPs in specialty care grows and health care systems emphasize quality of care, it is appropriate to explore the quality- and efficiency-enhancing activities NPs perform in specialty care beyond direct patient care.

Review of Use of Standardized Patients in Psychiatric Nursing Education.

BACKGROUND: Simulations using standardized patients (SPs) are increasingly used to teach and assess competencies in psychiatric/mental health (PMH) nursing education. To advance the field, it is important to identify current knowledge, practice, and evidence. OBJECTIVE: To determine the current knowledge, evidence, and practice of using SPs in PMH nursing education by conducting an integrative review of the empirical research on the use of SPs in PMH nursing education, and by providing a supplementary descriptive review of non-research articles on PMH simulations using SPs. DESIGN: A comprehensive search using electronic databases was conducted to identify both research and simulation description papers meeting inclusion criteria. The research literature was reviewed using an integrative review approach and a simple descriptive review of the non-research simulation literature was also conducted. RESULTS: Six research studies and 18 simulation description articles were included in the review. Although there are several PMH SP simulation descriptions in the literature, and anecdotal indications that they are a valuable educational tool, there is insufficient research evidence regarding their effectiveness as a method in psychiatric nursing education due to few published studies and methodological limitations of existing studies. CONCLUSIONS: Well-designed research studies are needed to develop an evidence base for this promising and increasingly employed teaching method.