Criteria for clinical information technology device selection: what do nurse executives need to know?

Hospital and healthcare's "most wired" organizations were surveyed to determine the evaluative criteria in the selection of bedside devices for clinical documentation. Ranked results of the characteristics are presented. Results can be used to inform nurse executives about selection criteria to consider.

A guideline-based approach to asthma management.

The management of asthma has dramatically improved in recent years because of a better understanding of the disease and an organized approach to therapy. All of the various components and tools for evaluating individuals with asthma may be found in the Expert Panel Report Guidelines by the National Heart, Lung, and Blood Institute, initially published in 2007. These comprehensive guidelines help health care professionals care for individuals with asthma throughout their lifespan. This article will assist the health care provider to use these evidence-based guidelines.

Obesity and asthma morbidity in a community-based adult cohort in a large urban area: the Chicago Initiative to Raise Asthma Health Equity (CHIRAH).

BACKGROUND: Urban minority populations experience increased rates of obesity and increased asthma prevalence and severity. Objective. The authors sought to determine whether obesity, as measured by body mass index (BMI), was associated with asthma quality of life or asthma-related emergency department (ED)/urgent care utilization in an urban, community-based sample of adults. METHODS: This is a cross-sectional analysis of 352 adult subjects (age 30.9 +/- 6.1, 77.8% females, forced expiratory volume in one second (FEV(1))% predicted = 87.0% +/- 18.5%) with physician-diagnosed asthma from a community-based Chicago cohort. Outcome variables included the Juniper Asthma Quality of Life Questionnaire (AQLQ) scores and health care utilization in the previous 12 months. Bivariate tests were used as appropriate to assess the relationship between BMI or obesity status and asthma outcome variables. Multivariate regression analyses were performed to predict asthma outcomes, controlling for demographics, income, depression score, and beta-agonist use. RESULTS: One hundred ninety-one (54.3%) adults were obese (BMI > 30 kg/m(2)). Participants with a higher BMI were older (p = .008), African American (p < .001), female (p = .002), or from lower income households (p = .002). BMI was inversely related to overall AQLQ scores (r = -.174, p = .001) as well as to individual domains. In multivariate models, BMI remained an independent predictor of AQLQ. Obese participants were more likely to have received ED/urgent care for asthma than nonobese subjects (odds ratio [OR] = 1.8, p = .036). CONCLUSIONS: In a community-based sample of urban asthmatic adults, obesity was related to worse asthma-specific quality of life and increased ED/urgent care utilization. However, compared to other variables measured such as depression, the contribution of obesity to lower AQLQ scores was relatively modest.

Improving asthma self-efficacy: developing and testing a pilot community-based asthma intervention for African American adults.

BACKGROUND: Low-income African American adults in Chicago have disproportionately high asthma morbidity and mortality rates. Interventions that improve asthma self-efficacy for appropriate self-management behaviors might ultimately improve asthma control in this population. OBJECTIVE: We sought to pilot test an intervention to improve asthma self-efficacy for appropriate self-management behaviors. METHODS: Participants for this trial were recruited through 2 primary care clinics located in the largest African American community in Chicago. Participants were then randomized into one of 2 groups. The control group received mailed asthma education materials. The intervention group was offered 4 group sessions led by a community social worker and 6 home visits by community health workers. Telephone interviews were conducted at baseline (before intervention), 3 months (after intervention), and 6 months (maintenance). RESULTS: The 42 participants were predominantly African American and low income and had poorly controlled persistent asthma. The intervention group had significantly higher asthma self-efficacy at 3 months (P < .001) after the completion of the intervention. Asthma action plans were more common in the intervention group at 3 months (P = .06). At 6 months, the intervention group had improved asthma quality of life (P = .002) and improved coping (P = .01) compared with control subjects. Trends in behavioral and clinical outcomes favored the intervention group but were not statistically significant. CONCLUSIONS: This community-based asthma intervention improved asthma self-efficacy, self-perceived coping skills, and asthma quality of life for low-income African American adults. Larger trials are needed to test the efficacy of this intervention to reduce asthma morbidity in similar high-risk populations.

The asthma emergency department visit: treating a crisis in the midst of uncontrolled disease.

BACKGROUND: Patients with asthma who require emergency department (ED) care are burdened with asthma symptoms, are at risk for hospitalization, and use expensive resources. OBJECTIVE: To examine whether an ED-based surveillance system that characterized asthma symptoms and care before, during, and after an ED visit enhances our understanding of the natural history of asthma exacerbations. METHODS: This cross-sectional follow-up enrolled 225 adult patients who presented to 1 of 6 Illinois EDs for asthma care. Clinical characteristics before ED presentation, care provided in the EDs, and 1-month follow-up status were assessed by self-administered questionnaire, medical record review, and telephone interview, respectively. RESULTS: Persistent asthma symptoms were reported by 85.8% and 84.9% (P = .37) of patients before their ED visit and follow-up call, respectively. For patients with persistent symptoms before the ED visit and follow-up call, 54.4% and 73.8% (P = .02) reported using an inhaled corticosteroid, respectively. Inhaled corticosteroids were recommended for 49.4% of discharged patients with persistent symptoms. Relapse rates for return ED visits and return hospitalizations were 26.4% and 9.6%, respectively. Patients had low asthma-specific and general quality-of-life scores at follow-up. CONCLUSIONS: Patients with asthma exacerbations most often had uncontrolled asthma before the ED visit that subsequently deteriorated, temporarily improved with ED treatment, and continued as uncontrolled asthma after the ED visit. Although improvements in care were reported 1 month after the ED visit, opportunities for additional improvement were observed.

A nurse coach quality improvement intervention: feasibility and treatment fidelity.

As the U.S. population ages and chronic illness prevalence increases, new approaches to care are needed. Although large health systems have begun to respond to this challenge, most Americans seek care from practitioners functioning in small office settings. Implementing systematic sustainable changes for quality improvement in this setting remains an unresolved challenge. In this study, trained Nurse Coaches (NCs) were employed to assist practices in adopting a new model of patient care called Virtual Integrated Practice (VIP). The feasibility and treatment fidelity of this approach were assessed through process measures and interviews in three practices. Findings document high acceptance of the NC approach and consistent delivery of the intervention. Enactment of the VIP model took place across practices, although to a variable degree. The study suggests that NCs may be an effective delivery method for quality and organizational improvements in small primary care practices.

Patient-initiated device removal in intensive care units: a national prevalence study.

OBJECTIVE: Information is needed about patient-initiated device removal to guide quality initiatives addressing regulations aimed at minimizing physical restraint use. Research objectives were to determine the prevalence of device removal, describe patient contexts, examine unit-level adjusted risk factors, and describe consequences. DESIGN: Prospective prevalence. SETTING: Total of 49 adult intensive care units (ICUs) from a random sample of 39 hospitals in five states. METHODS: Data were collected daily for 49,482 patient-days by trained nurses and included unit census, ventilator days, restraint days, and days accounted for by men and by elderly. For each device removal episode, data were collected on demographic and clinical variables. RESULTS: Patients removed 1,623 devices on 1,097 occasions: overall rate, 22.1 episodes/1000 patient-days; range, 0-102.4. Surgical ICUs had lower rates (16.1 episodes) than general (23.6 episodes) and medical (23.4 episodes) ICUs. ICUs with fewer resources had fewer all-type device removal relative to ICUs with greater resources (relative risk, 0.76; 95% confidence interval, 0.66-0.87) but higher self-extubation rates (relative risk, 1.27; 95% confidence interval, 1.07-1.52). Men accounted for 57% of the episodes, 44% were restrained at the time, and 30% had not received any sedation, narcotic, or psychotropic drug in the previous 24 hrs. There was no association between rates of device removal with restraint rates, proportion of men, or elderly. Self-extubation rates were inversely associated with ventilator days (rs = -0.31, p = .03). Patient harm occurred in 250 (23%) episodes; ten incurred major harm. No deaths occurred. Reinsertion rates varied by device: 23.5% of surgical drains to 88.9% of monitor leads. Additional resources (e.g., radiography) were used in 58% of the episodes. CONCLUSION: Device removal by ICU patients is common, resulting in harm in one fourth of patients and significant resource expenditure. Further examination of patient-, unit-, and practitioner-level variables may help explain variation in rates and provide direction for further targeted interventions.

Targeting improvements in asthma morbidity in Chicago: a 10-year retrospective of community action.

Chicago has been described as "asthma ground zero" due to its disproportionately high rates of asthma-related hospitalization and mortality. Asthma prevalence rates in Chicago are higher for whites and African Americans than the national average. In an effort to address the asthma burden and disparities in Chicago, multiple initiatives throughout the city have been launched and continue due largely to the support of the Otho S.A. Sprague Memorial Institute. The purpose of this article is to describe the policy, advocacy, educational, surveillance, research, quality improvement, community, and consortia activities over the past 10 years and their impact on asthma morbidity and disparities in Chicago.

Improving pediatric asthma care through surveillance: the Illinois Emergency Department Asthma Collaborative.

OBJECTIVES: To better understand and improve the care of asthma patients who require emergency department (ED) care, the Illinois Emergency Department Asthma Collaborative (IEDAC) was created to develop, test, and disseminate an ED-based surveillance system. This report describes the development and testing of the pediatric IEDAC surveillance instruments and demonstrates how these instruments can be used to describe the health status, healthcare delivery, and outcome of children using ED services. METHODS: A convenience sample of 128 children presenting to 5 EDs in Illinois for asthma care was the study base. Data were collected on monthly samples of children aged 2 through 17 years who presented to these EDs from May to November 2003. Three instruments were used to collect data regarding the children's pre-ED, ED, and post-ED experience. RESULTS: At the ED visit, 73.4% of children met national guideline criteria for persistent-level asthma symptoms. Among this group, 53.2% were using inhaled corticosteroid (ICS) medications. At 1 month follow-up, 66.6% of the children met the criteria for persistent-level asthma symptoms, which was statistically unchanged from the ED visit. Among the latter group, 64.2% were using ICS medications, again statistically unchanged compared with the ED visit. At follow-up, 24.5% of children were reported to have returned to an ED or were subsequently hospitalized. The majority of children were noted at follow-up to have limitation of at least some activity. CONCLUSIONS: Children who presented to IEDAC EDs were found to have a high level of asthma burden that continued at follow-up despite treatment. Moreover, a substantial proportion of children had returned to an ED or were subsequently hospitalized. Encouraging trends in medication use were observed, although suboptimal medication use was also observed.

Adequacy of medical chart review to characterize emergency care for asthma: findings from the Illinois Emergency Department Asthma Collaborative.

OBJECTIVES: To assess the intermethod reliability of medical chart review compared with directly observed care in patients presenting to emergency departments (EDs) for asthma care. METHODS: ED care practices for persons with asthma were evaluated by comparing chart review with trained observers. Fifty-one patients from five EDs participating in the Illinois Emergency Department Asthma Collaborative were studied. Practices in assessment, treatment, education, and referral were measured. Eighteen elements of care were assessed. Concordance between chart and observation was measured by using the kappa statistic. RESULTS: Of 51 subjects studied, nine were children. Kappa values varied depending on content. Kappa values ranged from 0.22 to 0.91 for items reflecting asthma assessment. Good concordances (kappa = 0.50 to 0.82) were found for items reflecting treatment practices. The lowest concordances were for items assessing educational activities (kappa = 0.04 to 0.34). Referral practices had fair to moderate concordances (kappa = 0.21 to 0.45). CONCLUSIONS: Intermethod reliability of medical chart review and directly observed care varied depending on the element of care being measured. The use of chart review to measure quality of ED-based asthma care may only be appropriate for a limited number of care processes that are reliably and validly captured from chart review.