Splint Quality Assessment and Improvement Among Emergency Department Staff.

The purpose of this quality improvement project is to assess and improve the quality of splint application in the emergency department (ED), as well as the splint application confidence level of the ED staff. Consistent and high-quality splint application is critical in fracture stabilization and prevention of further injury. Significantly high turnover and a lack of formal training of ED staff has led to poor splint application, and in some cases, patient injuries related to the splints themselves. These injuries include pain, edema, and skin complications (A. P. Carino, 2017). A random, Likert-based analysis was performed on 20 ED-applied splints. Once analysis was complete, training courses were implemented to improve splint application techniques. Using the same Likert-based tool, applications of 20 posttraining splints were analyzed. In addition, ED staff confidence levels were scored before and after the training courses. Overall, statistically significant improvement was achieved in splint application quality and staff confidence. Correct splint applications increased from 50% to 95% after the educational sessions. Staff confidence in splint application also increased, from 35% to 77.1%. Quality splint application affects all patients. The higher risk population is more likely to suffer the consequences of poor splint application. This project had a positive impact on the region's marginalized patient population. These patients have limited resources, including lack of transportation, financial limitations, and typically are at higher risk for complications due to comorbidities.

The Role of Patient and Parent Education in Pediatric Cast Complications.

Cast immobilization remains the standard of care in managing pediatric fractures. Cast complications often result in emergency department visits, office calls and visits, or lasting patient morbidities that burden the healthcare institution from a time and economic standpoint. The purpose of this quality improvement project was to create a multimodal cast care education protocol with an aim of decreasing cast complications over a 6-week period. Qualified patients (0-18) placed in cast immobilization received a quick response (QR) code sticker on their casts linked to a custom cast care website with text, pictures, and video instructions. Incidence of cast complications, complication type, effect(s) on workflow, and patient demographics were recorded. The complication rate declined 7.6%, but it was not statistically significant. Continuous access to clinic-specific cast instructions demonstrates decreased cast complications in pediatric populations, and this approach to patient education can be easily utilized across all medical specialties.

Meeting the complex healthcare needs of veterans.

ABSTRACT: More than half of US veterans seek care outside of the Veterans Health Administration. Physical and mental healthcare needs can be complicated by experiences during military service. Community clinicians can deliver more holistic and comprehensive care to veterans through understanding the unique needs of the veteran population.

Implementation of a standardized robotic assistant surgical training curriculum.

Since 2000, robotic-assisted surgery has rapidly expanded into almost every surgical sub-specialty. Despite the popularity of robotic surgery across the United States, a national consensus for standardized training and education of robotic surgeons or surgical teams remains absent. In this quality improvement initiative, a novel, stepwise iterative Robotic Assistant Surgical Training (RAST) curriculum was developed to broaden and standardize robotic bedside assistant training. Thirteen voluntary participants, capable of fulfilling the bedside assistant role, were evaluated to determine if RAST enhanced the learner's self-perceived level of confidence and comfort in their role as bedside assistant. A pre- and post-RAST training survey and a between-stages repeated-measures survey were conducted. All learner participants reported statistically significant increases in confidence and comfort after RAST training, (p = < 0.001), and between each stage, F (2, 24 = 60.47, p < .001; [Formula: see text] = 0.834). Participant feedback regarding curriculum improvement was obtained, suggesting the desire for more training and practice, in smaller groups of 2-3 participants. One hundred percent of participants felt RAST was beneficial and that it should be implemented as standardized training during onboarding for all robotic bedside assistants. Thus, a standardized, stepwise iterative robotic bedside assistant curriculum increases learner preparedness, comfort, and confidence, safely away from the patient bedside.

A Day in the Life: Advanced Practice Nurses Providing Care to Patients with Musculoskeletal Conditions: Preparation, Role, and Impact.

Nurse practitioners (NPs) play an increasingly greater role in the delivery of orthopedic patient care. NPs practice in a wide variety of orthopedic settings having a significant positive impact on orthopedic care delivery. Few formal educational outlets exist for training NPs for orthopedic care. Many new orthopedic NPs rely on continuing education and an apprenticeship model of learning "on the job" with their surgeon counterparts. This article describes the preparation, role, and impact that today's NPs have on orthopedic care delivery.

Implementation and Evaluation of Tactical Combat Casualty Care for Army Aviators.

INTRODUCTION: The importance of developing military strategies to decrease preventable death by mitigating hemorrhage and reducing time between the point of injury and surgical intervention on the battlefield is highlighted in previous studies. Successful implementation of Tactical Combat Casualty Care (TCCC) throughout elements of the USA and allied militaries begins to address this need. However, TCCC implementation is neither even nor complete in the larger, conventional force. Army Aviators are at risk for preventable death as they do not receive prehospital care training and are challenged to render prehospital care in the austere environment of helicopter operations. Army aviators are at risk for preventable death due to the challenges to render prehospital care in the austere environment of helicopter operations. Helicopters often fly at low altitudes, engage in direct action in support of ground troops, operate at a great distance from medical facilities, typically do not have medical personnel onboard, and can have long wait times for medical evacuation services due to the far forward nature of helicopter operations. MATERIALS AND METHODS: This is a quality improvement pre-post-intervention design study evaluating the implementation of a combat casualty care training program for Army aviators using well-established evidence-based guidelines for providing care to casualties on the battlefield. The evaluation consisted of participants' self-perceived confidence in providing care to a casualty and change in knowledge level in combat casualty care in a pre/post-intervention design. Clinical skills of tourniquet application, nasopharyngeal airway placement, and needle chest decompression were assessed on a pass/fail grading standard. RESULTS: A total of 18 participants completed the pre- and post-education surveys. A paired t-test showed a statistically significant increase in total composite scores from pre (M = 24.67, SD = 5.06) to post-education self-efficacy (M = 37.94, SD = 2.10), t (17) = -11.29, p < 0.001. A paired t-test revealed a significant increase in exam scores from pre (M = 70.22, SD = 9.43) to post (M = 87.78, SD = 7.19), t (17) = -7.31, p < 0.001. There was no pre-intervention skills assessment, however, all participants (n = 18, 100%) passed the tourniquet application, needle chest compression, and insertion of nasopharyngeal airway. CONCLUSION: TCCC for Army Aviators is easily implemented, demonstrates an increase in knowledge and confidence in providing prehospital care, and provides effective scenario-based training of necessary psychomotor skills needed to reduce preventable death on the battlefield. TCCC for Army Aviators effectively takes the TCCC for All Combatants curriculum and modifies it to address the unique considerations in treating wounded aviators and passengers, both in flight and after crashes. This project demonstrates on a small scale how TCCC can be tailored to specific military jobs in order to successfully meet the intent of the upcoming All Service Member TCCC course mandated in DoD 1322.24. Beyond Army aviation, this program is easily modifiable for aviators throughout the military and civilian sector.

Clinical pathways on a mobile device.

Clinical pathways have been successfully implemented in the primary care setting in New Zealand, Australia and the UK. Despite wide adoption and decreased costs, these pathways have yet to translate evidence into clinical practice while also saving providers time-an important barrier for the translation of evidence at the point of care. The goal of this project was to determine if future development of a point-of-care mobile application should be undertaken with design principles using the theoretical framework of Hick's law. Three new-to-practice providers participated in three plan-do-study-act cycles using these pathways installed on mobile devices to determine if they were a feasible, efficient and useful method to implement evidence. The project was a success with all three participants wishing to continue using the pathways after project completion. Participants felt the digital clinical pathways were the next evolution of the popular UpToDate software platform and helped them apply the latest evidence better than other available tools. While these results are promising, there were also limitations. Participants felt the lack of chart integration coupled with time constraints made full integration challenging and suggested launching the platform using a variety of delivery systems. The project's findings suggest that future application development using the developed design principles would be worth further consideration. If this mobile application ultimately proved successful, the application framework could be implemented on a larger scale, thus improving patient outcomes and saving providers time.

A call to action: Building evidence for use of simulation in nurse practitioner education.

Leaders from national nursing organizations, nursing schools, and health care simulation vendors convened in early 2019 to discuss simulation in nurse practitioner (NP) education. Nurse practitioner clinical education needs a more standardized, efficient, and sustainable model to prepare NPs to provide quality care in complex health care systems. Currently, a major shortage of clinical sites and preceptors to educate students creates challenges for NP programs and nursing faculty. One strategy used by nursing programs to overcome this challenge is using simulation to provide clinical training for NP students in a safe, controlled environment. There remains, however, a lack of evidence linking these simulation experiences with clinical skills acquisition and program outcomes. Implementing competency-based education through standardized simulations has the potential to demonstrate quality, safety, and accountability across NP education programs. Ultimately, the expansion and acceptance of simulation hours in NP education is dependent on strong and favorable evidence from rigorous, high-quality studies.

Multimodal Pain Management for Major Joint Replacement Surgery.

Effective pain management for orthopaedic major joint replacement is key to achieving earlier recovery, better functioning, and high rates of patient satisfaction. In an effort to decrease opioid dependency, practitioners are turning to multimodal pain management, which involves the use of multiple analgesic agents and techniques. To utilize this technique, a patient's history of and preoperative consumption of medications to treat pain impacts the success of this regimen. Multimodal pain management involves the use of nonsteroidal anti-inflammatory drugs, acetaminophen, N-methyl-D-aspartate antagonists, gabapentin, serotonin inhibitors, regional techniques, and opioids as needed. It is necessary for the nurse to understand the mechanism of pain and how the multimodal adjuncts target the pain response to benefit the patient's perioperative course as well as his or her postoperative and discharge management.

Joint Clinical Consensus Statement of the American College of Foot and Ankle Surgeons® and the American Association of Nurse Practitioners®: Etiology, Diagnosis, and Treatment Consensus for Gouty Arthritis of the Foot and Ankle.

Gout is a condition that commonly affects the foot and ankle, and practitioners who treat these structures should be aware of the methods to diagnose and treat this form of arthritis. Practitioners also need to recognize extra-articular manifestations of the disease. Although the acutely red, hot, swollen joint is a common presentation, chronic tophaceous gout can be associated with pain, nodule formation, and cutaneous compromise. Since the underlying causes that lead to excessive monosodium urate deposition may be treatable, early and accurate diagnosis can be very beneficial and may even prevent articular degeneration.

Multimodal Perioperative Analgesia Regimen to Improve Patient Outcomes After Total Knee Arthroplasty: A Multidisciplinary Quality Improvement Project.

PURPOSE: The primary aim of this quality improvement project was to improve mobilization for patients after total knee arthroscopy by developing and implementing a standardized, evidence-based, multimodal analgesia regimen and patient-educational video. Secondary outcomes included opioid consumption, pain, and length of stay. DESIGN: A pre-post implementation design was used to compare two independent samples. METHODS: Patients were screened based on inclusion and exclusion criteria 1-2 weeks before surgery. The anesthesia provider made the final determination for inclusion. Data were collected by retrospective chart review. FINDINGS: Following implementation, patients displayed significantly improved mobilization, reduced opioid consumption, and reduced length of stay. Patient-reported pain scores were similar or significantly lower in the postimplementation group. CONCLUSIONS: Variability of patient outcomes was reduced, and quality of care was improved by standardizing care and incorporating the best available evidence, consistent with organization's resources in the nonacademic-affiliated, community hospital setting.

Increasing Influenza Immunization Rates Among Retail Employees: An Evidence-Based Approach.

Influenza has a significant impact on the health of Americans and the U.S. economy. Annual influenza immunization can decrease the burden of influenza-related illnesses for both employees and employers. This project evaluated a nurse practitioner-led intervention to increase influenza immunization rates among retail employees from August through December of the 2015-2016 influenza season. The sample included employees from retail locations with on-site convenience care clinics staffed by nurse practitioners. This quality improvement project used a pre-post implementation evaluation design and compared influenza immunization rates of employees, before and after an intervention, at one worksite, and influenza immunization rates of employees, who did not receive the same intervention, at a comparison site. The intervention site employees were immunized at a higher rate than employees at the comparison site. Interventions, including health care professional-led education, program promotion, on-site access to and no-cost immunizations, choice of immunization delivery, and incentives, should be considered to increase immunization rates among employees.

Intrahospital Transport of the Critically Ill Adult: A Standardized Evaluation Plan.

BACKGROUND: Intrahospital transport of the critically ill adult carries inherent risks that can be manifested as unexpected events. OBJECTIVE: The aim of this study is to evaluate the implementation of a standardized evaluation plan for intrahospital transports to/from adult intensive care units. METHODS: Nurses at a level I trauma/academic center captured clinical data throughout transport. Outcome measures included compliance with the organization's transport policy and unexpected events. RESULTS: There were 502 transports audited. Most nurses were compliant with the policy, except for the stabilization process (n = 174, 34.7%). Forty-one transports (8.2%) had an unexpected event, and 11 of these transports (26.8%) were aborted. Most of the events were hemodynamic (12), sedation (11), respiratory (10), and gastrointestinal (5). Fewer events occurred with the transport team (P = .036) and among nurses with a bachelor of science in nursing or higher degree (P = .002). Events were higher among transporting nurses with only 0 to 2 years of intensive care unit experience (P = .002), "stabilized" transports (P = .022), and patients with higher Acute Physiology and Chronic Health Evaluation scores (P = .009). CONCLUSIONS: Health care organizations should have a policy that includes both transport and evaluation plans for intrahospital transport. Guidelines should be revised with specific criteria for the stabilization process and unexpected events. Revision should also have a standardized evaluation plan that includes an audit tool to measure incidence of unexpected events and a rapid change quality improvement method.

Improving the management of tibia stress fractures: a collaborative, outpatient clinic-based quality improvement project.

PURPOSE: Implement and evaluate the effectiveness of the Leg Pain Screening and Referral Tool (LPS&RT) for patients presenting with lower extremity leg pain in an outpatient clinic. SAMPLE: A total of 46 patients diagnosed with tibia stress fractures. METHODS: The study employed a pre-/postintervention design. Retrospective and prospective information was collected from an electronic health record to obtain patient data. The pre- and postintervention groups were compared on the number of patients diagnosed with tibia stress fractures. Provider adherence to the treatments recommended by the algorithm was assessed by chart audits postintervention. RESULTS: There was a significant increase (87.5%) in tibia stress fracture diagnosis, from 16 preintervention to 30 postintervention. Provider adherence to the LPS&RT was 93.3% postintervention. Common treatments were activity restriction, oral medication, and/or specialty referrals. CONCLUSION: The LPS&RT was an effective, uniform measure to standardize the plan of care for tibia stress fractures in one outpatient clinic.

Viscosupplementation for knee osteoarthritis.

PURPOSE: To provide an overview of the diagnosis and pathophysiology of osteoarthritis (OA), and to describe appropriate treatments for knee OA, with a focus on the efficacy and safety of viscosupplementation. Because nurse practitioners (NPs) can inject viscosupplements, a section on injection technique is included. DATA SOURCES: Manuscripts were identified using PubMed and EMBASE with a review of the reference lists from retrieved articles. CONCLUSIONS: Viscosupplements are safe and effective at improving function and alleviating knee pain from OA for up to 26 weeks. IMPLICATIONS FOR PRACTICE: As the number of patients with OA is increasing, NPs need to be prepared to prescribe various treatment options to alleviate osteoarthritic knee pain, including viscosupplementation.

Pathophysiology of heterotopic ossification.

Heterotopic ossification (HO) is a pathologic condition that leads to the development of bone within nonosseous soft tissues. A common site for HO development is at the hip. The bone that forms is believed to develop through stimulation by cellular mediators and altered neurovascular signaling. Heterotopic ossification can be a debilitating disease leading to pain, edema, and stiffness. This only compounds already-debilitating comorbid conditions such as a spinal cord injury, head injury, or trauma. Several factors, including prostaglandin E2, bone morphogenetic protein, and the inflammatory process, are believed to contribute to the development of HO. The full scope of pathophysiology contributing to HO is not fully understood.

A closer look at hand and wrist complaints.

Hand or wrist pain is a common complaint in primary care. This pain can be very disabling and can significantly impair a person's quality of life. With the appropriate clinical knowledge and skills, nurse practitioners can effectively evaluate, diagnose, and treat many of the common hand and wrist complaints seen in primary care.

Pre-participation physical evaluations for athletes.

The pre-participation physical evaluation helps keep athletes safe. This article discusses the essential components of the PPE history and physical. Findings that should prompt further evaluation of the athlete, including those consistent with risk for sudden cardiac death, are discussed.