Transformational Leadership Meets Innovative Strategy: How Nurse Leaders and Clinical Nurses Redesigned Bedside Handover to Improve Nursing Practice.

In 2000, the Institute of Medicine (IOM) published To Err Is Human: Building a Safer Health System, highlighting medical errors resulting from failure in perception, assumption, and communication. The handover process is a high-risk activity prone to the communication vulnerabilities described in the IOM report. The handover project started as a 3-month pilot with plans to expand to the entire facility. The handover education had 4 elements: questionnaire, presentation, video, and simulation. Compliance with the new process was measured using audits completed by the unit managers. Sixty-four registered nurses on 2 acute units were educated by nurse champions. After a successful implementation, the surge of COVID-19 patients in spring of 2020 required us to adjust expectations regarding bedside handover. As the number of hospitalized COVID patients began to decrease, we reinvigorated the project and re-established the expectation that handover be performed at the bedside. A post-questionnaire was completed after implementation and revealed more favorable responses toward bedside handover. We also saw improvements in our patient satisfaction scores (Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS]). With direct observation and a checklist, we were able to return to the practice of bedside handover following the surge of COVID-19 patients. As a direct result of the bedside RN involvement, we created and implemented a handover process that prioritized nursing needs and concerns. Our implementation of this evidence-based practice enhanced patient experience and improved safety. Through education, observational audits, and use of a checklist, we were able to re-establish the expectation and practice of handover being completed at the bedside.

Assessing Evidence-Based Practice Knowledge: An Innovative Approach by a Nursing Research Council.

OBJECTIVE: The aim of this study was to describe the structure and processes implemented by nursing research councils to conduct a nurse-led research study at an urban community teaching hospital. BACKGROUND: We assessed nurses' knowledge, skills, and attitudes toward evidence-based practice (EBP) to inform development plans. METHODS: This is an institutional review board-approved single-site cross-sectional anonymous online survey (Evidence-Based Practice Questionnaire [EBPQ]) emailed to 850 participants. Data were analyzed using SPSS v25 (Armonk, New York). RESULTS: Initial response rate was 11%. Deployment of new strategies achieved an overall response rate of 57.5%. EBPQ subscale scores were highest for "attitude," followed by "knowledge/skills," and "practice." Lowest-scoring items included critical appraisal of literature, converting information needs into a question, time for new evidence, information technology, and research skills. CONCLUSIONS: Our EBPQ scores were consistent with prior findings. Our strategies provide a framework for other institutions in similar stages of implementing EBP and nurse-led research initiatives.

Interfacility Transfer is Associated With Lower Mortality in Undertriaged Gunshot Wound Patients.

BACKGROUND: Treatment at a Level I trauma center yields better outcomes for patients with moderate-to-severe injury as compared with treatment in nontrauma centers. We examined the association between interfacility transfer to a level I or II trauma center and mortality for gunshot wound patients, among patients initially transported to a lower level or undesignated facility. MATERIALS AND METHODS: This retrospective cohort study included all patients from the National Trauma Data Bank (2010-2015) with firearm as the external cause of injury, who met CDC criteria for emergency medical services triage to a higher level (American College of Surgeons [ACS] Level II or above) trauma center. We compared outcomes between patients (a) treated in an ACS level III or below facility and not transferred versus (b) transferred to an ACS level II or above facility, adjusting for confounders using inverse probability of treatment weights. RESULTS: Of the total 62,277 patients, 10,968 (17.6%) were transferred to a level II center or above, and 51,309 (82.4%) were treated at a level III or below or undesignated center. In adjusted analysis comparing transferred versus not transferred patients, risk was lower for mortality (risk ratio [RR] 0.81, 95% confidence interval [CI] 0.70 to 0.95 P = 0.011) but similar for any complication (RR 1.02, 95% CI 0.83 to 1.25 P = 0.87) and the five most common complications. Results were consistent when accounting for data missing at random, and when including state trauma center designations in the definition of Level II or greater versus III and below. CONCLUSIONS: Our study found lower mortality but similar complication risk associated with interfacility transfer for undertriaged gunshot wound patients. This suggests that transfer to a higher level center is warranted among these patients, with improved care potentially outweighing potential harms because of transfer.

Differences in trauma mortality between ACS-verified and state-designated trauma centers in the US.

BACKGROUND: Traumatic injury is a leading cause of deaths worldwide, and designated trauma centers are crucial to preventing these. In the US, trauma centers can be designated as level I-IV by states and/or the American College of Surgeons (ACS), reflecting the resources available for care. We examined whether state- and ACS-verified facilities of the same level (I-IV) had differences in mortality, complications, and disposition, and whether differences varied by center level. MATERIALS AND METHODS: Using all admissions reported to the National Trauma Data Bank 2010-2015, we estimated risk ratios for the association between current ACS verification (vs. state designation) and patient mortality and complications, adjusting for trauma level and facility, injury, and demographic characteristics. We tested the interaction between trauma level and ACS verification, stratifying by trauma level in the presence of significant statistical interaction. RESULTS: Overall, patients admitted to ACS-verified vs state-designated facilities had similar adjusted mortality risk [RR 1.00; 95% CI 0.91-1.03] and lower risk of discharge to intermediate care facilities [RR 0.58; 95% CI 0.44 to 0.78]. However, Level III and IV facilities had lower adjusted mortality risk when ACS-verified, with much lower mortality risk in ACS-verified Level IV facilities [RR 0.25; 95% CI 0.12 to 0.54]. DISCUSSION: Findings suggest that while outcomes are similar between ACS-verified and state-designated Level I and II centers, state-designated Level III and particularly Level IV centers show poorer outcomes relative to their ACS-verified counterparts. Further research could explore mechanisms for these differences, or inform potential changes to state designation processes for lower-level centers.

Feasibility of referral of patients with elevated blood pressure from the Emergency Department.

Recent studies suggest that patients' elevated blood pressure (BP) readings in the Emergency Department (ED) may be due to hypertension (HTN) rather than pain and anxiety. Identifying BP patterns suggestive of HTN in the ED presents an opportunity for referral. The purpose of this prospective cohort study was to assess the feasibility of referral of ED patients with elevated BP readings suggestive of HTN. Adults with elevated BP suggestive of HTN and no history of HTN were tracked as to referral status using an actively monitored ED referral system. Patients referred to a community clinic network were tracked regarding clinic visits, subsequent BP, and diagnosis of HTN. Of 662 patients with elevated BP in the ED at triage, 197 (29.8%) had a pattern of blood pressure readings that were suggestive of HTN. Of these, 63 (32.0%) were referred to in-network clinics, 5 (2.5%) were referred out of network, and 129 (65.5%) were not referred. Of the 63 referred to network clinics, 17 (27.0%) kept their appointments and of those, 5 (29.4%) were diagnosed with HTN. Elevated BP was not mentioned in any ED physician referral notes as a reason for referral and the number of appointments kept among patients who were referred was low. Referral to outpatient clinics based on BP levels suggestive of HTN may not be feasible despite active referral systems.