Improving hospital patient falls: leveraging staffing characteristics and processes of care.

OBJECTIVE: Predictive models for falls, injury falls, and restraint prevalence were explored within nursing unit structures and processes of care. BACKGROUND: The patient care team is responsible for patient safety, and improving practice models may prevent injuries and improve patient safety. METHODS: Using unit-level self-reported data from 215 hospitals, falls, injury falls, and restraint prevalence were modeled with significant covariates as predictors. RESULTS: Fewer falls/injury falls were predicted by populations with fewer frail and at-risk patients, more unlicensed care hours, and prevention protocol implementation, but not staffing per se, restraint use, or RN expertise. Lower restraint use was predicted by fewer frail patients, shorter length of stay, more RN hours, more certified RNs, and implementation of fall prevention protocols. CONCLUSION: In the presence of risk, patient injuries and safety were improved by optimizing staffing skill mix and use of prevention protocols.

Modeling hospital-acquired pressure ulcer prevalence on medical-surgical units: nurse workload, expertise, and clinical processes of care.

OBJECTIVE: This study modeled the predictive power of unit/patient characteristics, nurse workload, nurse expertise, and hospital-acquired pressure ulcer (HAPU) preventive clinical processes of care on unit-level prevalence of HAPUs. DATA SOURCES: Seven hundred and eighty-nine medical-surgical units (215 hospitals) in 2009. STUDY DESIGN: Using unit-level data, HAPUs were modeled with Poisson regression with zero-inflation (due to low prevalence of HAPUs) with significant covariates as predictors. DATA COLLECTION/EXTRACTION METHODS: Hospitals submitted data on NQF endorsed ongoing performance measures to CALNOC registry. PRINCIPAL FINDINGS: Fewer HAPUs were predicted by a combination of unit/patient characteristics (shorter length of stay, fewer patients at-risk, fewer male patients), RN workload (more hours of care, greater patient [bed] turnover), RN expertise (more years of experience, fewer contract staff hours), and processes of care (more risk assessment completed). CONCLUSIONS: Unit/patient characteristics were potent HAPU predictors yet generally are not modifiable. RN workload, nurse expertise, and processes of care (risk assessment/interventions) are significant predictors that can be addressed to reduce HAPU. Support strategies may be needed for units where experienced full-time nurses are not available for HAPU prevention. Further research is warranted to test these finding in the context of higher HAPU prevalence.

Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes.

PURPOSE: To present findings from the Collaborative Alliance for Nursing Outcomes' (CALNOC) hospital medication administration (MA) accuracy assessment in a sample of acute care hospitals. Aims were as follows: (1) to describe the CALNOC MA accuracy assessment, (2) to examine nurse adherence to six safe practices during MA, (3) to examine the prevalence of MA errors in adult acute care, and (4) to explore associations between safe practices and MA accuracy. METHODS: Using a cross-sectional design, point in time, and convenience sample, direct observation data were collected by 43 hospitals participating in CALNOC's benchmarking registry. Data included 33,425 doses from 333 observation studies on 157 adult acute care units. Results reveal that the most common MA safe practice deviations were distraction/interruption (22.89%), not explaining medication to patients (13.90%), and not checking two forms of ID (12.47%). The most common MA errors were drug not available (0.76%) and wrong dose (0.45%). The overall percentage of safe practice deviations per encounter was 11.40%, whereas the overall percentage of MA errors was 0.32%. CONCLUSIONS AND IMPLICATIONS: Findings predict that for 10,000 MA encounters, 27,630 safe practice deviations and 770 MA errors will occur. A 36% reduction in practice deviation per encounter prevents 4.4% MA errors. Ultimately, reliably performing safe practices improves MA accuracy.

Medication administration accuracy: using clinical observation and review of patient records to assess safety and guide performance improvement.

RATIONALE, AIMS AND OBJECTIVES: Medication-related errors are common and can occur at every step of the medication process. The aim was to explore (1) the extent to which nurses perform fundamental safe practices related to medication administration (MA); (2) the frequency and characteristics of MA errors; and (3) the clinical significance of medication types (classes) subject to error. METHODS: A descriptive, exploratory cross sectional design with point in time sampling was used combining direct observations, conducted by naïve observers, and medical record review. A convenience sample of three adult surgical units was drawn from a 1000-bed university hospital. Seventy-two patient-nurse MA encounters were observed including 306 MA doses based on a minimum sample of 100 doses per unit. The Medication Administration Accuracy Assessment developed by the Collaborative Alliance for Nursing Outcomes in the United States was used. RESULTS: Observed adherence to MA safe practices varied between units. Identity control (9%), explaining medication to patient (11%) and medication labelled throughout the process (25%) were found to be safe practices with greatest deviation. 18% of doses involved a MA error (n = 54). Wrong time (9%) was the most common MA error, typically involving analgesics. CONCLUSIONS: Given recent reports suggesting MA safe practices are strongly associated with MA errors, it is timely to strengthen RN awareness of the critical role of safe practices in MA safety. In nursing education, clinical examination using the six safe practices studied herein may enhance medication administration accuracy.

Predictors of unit-level medication administration accuracy: microsystem impacts on medication safety.

OBJECTIVE: This study tested multivariate models exploring unit-level predictors of medication administration (MA) accuracy. BACKGROUND: During MA, nurses are both the last line of defense from medication-related errors and a potential perpetrator of error. Direct observation reveals safe practices and the accuracy of medication delivery. METHODS: Using a direct-observation, cross-sectional design, data submitted by 124 adult patient care units for 15600 medication doses, from January 2009 to April 2010, were studied. RESULTS: Distractions and interruptions were the most common safe practice deviation. Characteristics of patient care units and RN hours of care affected nurses' safe practices and MA accuracy. Safe practices predict and mediate MA accuracy. A 5% decrease in safe practice deviations would reduce MA errors by 46% without any change in RN hours of care. CONCLUSION: Nurses' adherence to MA safe practices, combined with unit characteristics and staffing factors, has the potential to dramatically improve MA accuracy.

Measuring nurses' impact on health care quality: progress, challenges, and future directions.

BACKGROUND: Quality measurement is central in efforts to improve health care delivery and financing. The Interdisciplinary Nursing Quality Research Initiative supported interdisciplinary research teams to address gaps in measuring the contributions of nursing to quality care. OBJECTIVE: To summarize the research of 4 interdisciplinary teams funded by The Interdisciplinary Nursing Quality Research Initiative and reflect on challenges and future directions to improving quality measurement. METHODS: Each team summarized their work including the targeted gap in measurement, the methods used, key results, and next steps. The authors discussed key challenges and recommended future directions. RESULTS: These exemplar projects addressed cross-cutting issues related to quality; developed measures of patient experience; tested new ways to model the important relationships between structure, process, and outcome; measured care across the continuum; focused on positive aspects of care; examined the relationship of nursing care with outcomes; and measured both nursing and interdisciplinary care. DISCUSSION: Challenges include: measuring care delivery from multiple perspectives; determining the dose of care delivered; and measuring the entire care process. Meaningful measures that are simple, feasible, affordable, and integrated into the care delivery system and electronic health record are needed. Advances in health information systems create opportunities to advance quality measurement in innovative ways. CONCLUSIONS: These findings and products add to the robust set of measures needed to measure nurses' contributions to the care of hospitalized patients. The implementation of these projects has been rich with lessons about the ongoing challenges related to quality measurement.

The value of reducing hospital-acquired pressure ulcer prevalence: an illustrative analysis.

OBJECTIVE: The aim of this study was to assess the cost savings associated with implementing nursing approaches to prevent hospital-acquired pressure ulcers (HAPU). BACKGROUND: Hospitals face substantial costs associated with the treatment of HAPUs. Interventions have been demonstrated as effective for HAPU prevention and management, but it is widely perceived that preventative measures are expensive and, thus, may not be a good use of resources. METHODS: A return-on-investment (ROI) framework from the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators Toolkit was used for this study. The researchers identified achievable improvements in HAPU rates from data from the Collaborative Alliance for Nursing Outcomes and measured costs and savings associated with HAPU reduction from published literature. RESULTS: The analysis produced a baseline ROI ratio of 1.61 and net savings of $127.51 per patient. CONCLUSIONS: Hospital-acquired pressure ulcer surveillance and prevention can be cost saving for hospitals and should be considered by nurse executives as a strategy to support quality outcomes.

A blueprint for genomic nursing science.

PURPOSE: This article reports on recommendations arising from an invitational workshop series held at the National Institutes of Health for the purposes of identifying critical genomics problems important to the health of the public that can be addressed through nursing science. The overall purpose of the Genomic Nursing State of the Science Initiative is to establish a nursing research blueprint based on gaps in the evidence and expert evaluation of the current state of the science and through public comment. ORGANIZING CONSTRUCTS: A Genomic Nursing State of the Science Advisory Panel was convened in 2012 to develop the nursing research blueprint. The Advisory Panel, which met via two webinars and two in-person meetings, considered existing evidence from evidence reviews, testimony from key stakeholder groups, presentations from experts in research synthesis, and public comment. FINDINGS: The genomic nursing science blueprint arising from the Genomic Nursing State of Science Advisory Panel focuses on biologic plausibility studies as well as interventions likely to improve a variety of outcomes (e.g., clinical, economic, environmental). It also includes all care settings and diverse populations. The focus is on (a) the client, defined as person, family, community, or population; (b) the context, targeting informatics support systems, capacity building, education, and environmental influences; and (c) cross-cutting themes. It was agreed that building capacity to measure the impact of nursing actions on costs, quality, and outcomes of patient care is a strategic and scientific priority if findings are to be synthesized and aggregated to inform practice and policy. CONCLUSIONS: The genomic nursing science blueprint provides the framework for furthering genomic nursing science to improve health outcomes. This blueprint is an independent recommendation of the Advisory Panel with input from the public and is not a policy statement of the National Institutes of Health or the federal government. CLINICAL RELEVANCE: This genomic nursing science blueprint targets research to build the evidence base to inform integration of genomics into nursing practice and regulation (such as nursing licensure requirements, institutional accreditation, and academic nursing school accreditation).

Eliminating hospital-acquired pressure ulcers: within our reach.

Hospital-acquired pressure ulcers (HAPUs) are a serious nosocomial problem that has been viewed as a ubiquitous consequence of immobility. This article provides data from the Collaborative Alliance for Nursing Outcomes (CALNOC) that shows a significant reduction in HAPUs in adults from 78 acute care hospitals over 8 years (2003-2010).

Exploring variation in pressure ulcer prevalence in Sweden and the USA: benchmarking in action.

AIM: To compare overall unit-level pressure ulcer (PU) prevalence, hospital-acquired pressure ulcer (HAPU) prevalence and prevention strategies, as well as nurse staffing and workload in two hospitals in Sweden with data from the USA. METHODS: Medical and surgical units in a university hospital and a general hospital in Sweden were compared with 207 hospitals in the USA participating in the Collaborative Alliance for Nursing Outcomes (CALNOC) benchmarking registry. All adult inpatients in university hospital (n = 630), general hospital (n = 253) and CALNOC hospitals (n = 3506) were included in the study. Outcome indicators were pressure ulcer prevalence for all types (PU) and HAPU prevalence, specifically. Process indicators were risk assessment and PU prevention strategies. Structure indicators were nurse staffing (hours of care, and skill mix) and workload (admissions, discharges and transfers). RESULTS: The prevalence of PU (categories 1-4) was 17.6% (university hospital) and 9.5% (general hospital) compared with 6.3-6.7% in the CALNOC sample. The prevalence of full thickness HAPU (categories 3 and 4) was 2.7% (university hospital) and 2.0% (general hospital) compared with 0-0.5% in the CALNOC sample. Risk and skin assessment varied between 6% and 60% in the Swedish hospitals compared with 100% in the CALNOC sample. Total hours per patient day were 8.4 in both Swedish hospitals and 9.5 to 9.8 in the CALNOC hospitals CONCLUSIONS: The findings suggest a link between processes of care and outcomes that is exciting to observe internationally and suggest the opportunity to expedite performance improvement through global benchmarking. Using HAPU as a complement to point prevalence of PU in Sweden has revealed this indicator as a more valid measure for patient care quality.

The association of shift-level nurse staffing with adverse patient events.

OBJECTIVE: The objective of this study was to demonstrate the association between nurse staffing and adverse events at the shift level. BACKGROUND: Despite a growing body of research linking nurse staffing and patient outcomes, the relationship of staffing to patient falls and medication errors remains equivocal, possibly due to dependence on aggregated data. METHODS: Thirteen military hospitals participated in creating a longitudinal nursing outcomes database to monitor nurse staffing, patient falls and medication errors, and other outcomes. Unit types were analyzed separately to stratify patient and nurse staffing characteristics. Bayesian hierarchical logistic regression modeling was used to examine associations between staffing and adverse events. RESULTS: RN skill mix, total nursing care hours, and experience, measured by a proxy variable, were associated with shift-level adverse events. CONCLUSIONS: Consideration must be given to nurse staffing and experience levels on every shift.

Nursing-sensitive benchmarks for hospitals to gauge high-reliability performance.

Benchmarking expedites the quest for best practices and is crucial to hospitals' effective, reliable, and superior performance. Comparative performance data are used by accrediting and regulatory bodies to evaluate performance and by consumers in making decisions on where to seek healthcare. Nursing-sensitive quality measures affirmed by the National Quality Forum are now used in public reporting and pay-for-performance in addition to traditional medical outcome metrics. This report provides hospital nursing-sensitive benchmarks from medical/surgical, critical care, and step-down units drawn from 196 hospitals during six quarters in 2007 and 2008. Outcome measures include pressure ulcer prevalence rates and fall/falls with injury rates. Additional indicators that describe nursing care (nurse staffing care hours, skill mix, nurse/patient ratios, workload intensity, voluntary turnover, and use of sitters) and patient descriptors (age, gender, and diagnosis description) were also included. Specific benchmarks are provided using the 10th and the 90th percentiles, as well as quartiles to allow hospitals an opportunity to understand comparative performance with specificity. The purpose of this article is to provide hospitals not currently participating in comparative benchmarking databases with nursing-sensitive data from the Collaborative Alliance for Nursing Outcomes for use in performance improvement processes.

Benchmarking for small hospitals: size didn't matter!

Benchmarking is an indispensable tool as hospital leaders face challenges to balance efficiency with safe and effective care. Selection of appropriate "like" hospitals is critical to the benchmarking aim of understanding comparative performance. Based on 10 years of observed outcome differences between small and large hospitals, the Collaborative Alliance for Nursing Outcomes (CALNOC) sought to empirically define small hospitals, and to determine if there were statistical differences between small and large hospitals for selected nursing sensitive outcome indicators. This article reports the examination of hospital size as a proxy characteristic to define "like" hospitals for the purpose of benchmarking outcomes. Findings suggest that optimal classifications into small and large hospital size based on the outcome indicators of falls, falls with injury, and hospital-acquired pressure ulcers stage 2 or worse (HAPU 2+) were not consistent with historical administrative categories based on average daily census and not consistent by outcome. Statistical differences were only found with HAPU 2+ in critical care units, with no differences in the fall outcomes. These data did not support the use of size-based categories to define like hospitals for benchmark comparisons.

Rapid response teams seen through the eyes of the nurse.

OBJECTIVE: This article reports on the findings of an evaluation project that explored the impact of rapid response teams from the perspective of the nurses who use them-to give voice to the experience of nurses. METHODS: Interviews with 56 staff nurses were analyzed, using thematic analysis, to describe the impact of rapid response teams on staff nurses' practice; the nurses' perspectives on what constitutes a successful rapid response team; their experiences before, during, and after activating a rapid response team; and the challenges they encountered when rapid response teams were used. RESULTS: Nurses described rapid response teams as quickly bringing needed resources to patients and, when necessary, facilitating patients' transfer to ICUs. They especially appreciated the ability to gather these resources with a single phone call. Nurses also expressed profound relief that rapid response teams were available to expedite patient care; this was so important that some stated they wouldn't work in a facility that didn't have a rapid response team. Successful rapid response systems were described as those in which nurses activated the team without hesitation when they felt it was needed. Challenges to successful use of rapid response teams included mixed messages from leadership about when to activate the team and the need for nurses who were themselves on a rapid response team to leave their patients in order to respond to an activation. CONCLUSION: Despite some limitations, this evaluation provides much-needed insight into the effects of rapid response teams on nurses' work environment. Further research is needed to explicate how having a successful rapid response team influences nurse recruitment and retention, as well as how such teams affect patient outcomes.

Impact of California mandated acute care hospital nurse staffing ratios: a literature synthesis.

California is the first state to enact legislation mandating minimum nurse-to-patient ratios at all times in acute care hospitals. This synthesis examines 12 studies of the impact of California's ratios on patient care cost, quality, and outcomes in acute care hospitals. A key finding from this synthesis is that the implementation of minimum nurse-to-patient ratios reduced the number of patients per licensed nurse and increased the number of worked nursing hours per patient day in hospitals. Another finding is that there were no significant impacts of these improved staffing measures on measures of nursing quality and patient safety indicators across hospitals. A critical observation may be that adverse outcomes did not increase despite the increasing patient severity reflected in case mix index. We cautiously posit that this finding may actually suggest an impact of ratios in preventing adverse events in the presence of increased patient risk.

Leading successful rapid response teams: A multisite implementation evaluation.

The purpose of this article is to report findings from the preliminary evaluation of a major initiative to support the implementation of rapid response teams. From 2004 to 2006, the Robert Wood Johnson Foundation funded diverse learning collaboratives fostering the implementation of rapid response teams. The authors report preliminary evaluation findings exploring the impact of rapid response teams "through the eyes of the nurse." Results may be especially useful to clinical and administrative leaders who are either preparing to implement rapid response teams or considering how to strengthen rapid response team initiatives in their settings.

How many nurses per patient? Measurements of nurse staffing in health services research.

OBJECTIVE: To compare alternative measures of nurse staffing and assess the relative strengths and limitations of each measure. DATA SOURCES/STUDY SETTING: Primary and secondary data from 2000 and 2002 on hospital nurse staffing from the American Hospital Association, California Office of Statewide Health Planning and Development, California Nursing Outcomes Coalition, and the California Workforce Initiative Survey. STUDY DESIGN: Hospital-level and unit-level data were compared using summary statistics, t-tests, and correlations. DATA COLLECTION/EXTRACTION METHODS: Data sources were matched for each hospital. When possible, hospital units or types of units were matched within each hospital. Productive nursing hours and direct patient care hours were converted to full-time equivalent employment and to nurse-to-patient ratios to compare nurse staffing as measured by different surveys. PRINCIPAL FINDINGS: The greatest differences in staffing measurement arise when unit-level data are compared with hospital-level aggregated data reported in large administrative databases. There is greater dispersion in the data obtained from publicly available, administrative data sources than in unit-level data; however, the unit-level data sources are limited to a select set of hospitals and are not available to many researchers. CONCLUSIONS: Unit-level data collection may be more precise. Differences between databases may account for differences in research findings.

Quartile dashboards: translating large data sets into performance improvement priorities.

Quality professionals are the first to understand challenges of transforming data into meaningful information for frontline staff, operational managers, and governing bodies. To understand an individual facility, service, or patient care unit's comparative performance from within large data sets, prioritization and focused data presentation are needed. This article presents a methodology for translating data from large data sets into dashboards for setting performance improvement priorities, in a simple way that takes advantage of tools readily available and easily used by support staff. This methodology is illustrated with examples from a large nursing quality data set, the California Nursing Outcomes Coalition.

The impact of nursing interventions: overview of effective interventions, outcomes, measures, and priorities for future research.

The purpose of this article is to present findings from a review of published systematic/integrative reviews and meta-analyses on nursing interventions and patient outcomes in acute care settings. A literature search was conducted for the period 1999-2005, producing 4,000 systematic/integrative reviews and 500 meta-analyses covering seven topics selected by the authors: elder care, caregivers, developmental care of neonates and infants, symptom management, pressure ulcer prevention/treatment, incontinence, and staffing. The association between nursing care interventions/processes and patient outcomes in acute care settings was found to be limited in the articles reviewed. The strongest evidence was for the use of patient risk-assessment tools and interventions implemented by nurses to prevent patient harm. We observed significant variation in methods to measure the effect of independent variables (nursing interventions) on patient outcomes. Results indicate the need for more research measuring the effect of specific nursing interventions that may impact acute care patient outcomes.