REadmission PREvention in SepSis: Development and Validation of a Prediction Model.

ABSTRACT: Hospital 30-day readmissions remain a major quality and cost indicator. Traditional readmission risk scores, such as LACE (length of stay, acuity of admission, Charlson comorbidity index, and emergency department visits), may be suboptimal in special patient populations, such as those with sepsis. As sepsis survivorship improves, there is a need to determine which variables might be associated with a decrease in 30-day readmission. We completed a retrospective analysis reviewing patients with sepsis who had unplanned 30-day readmissions. Multivariate regression analysis was performed for the REadmission PREvention in SepSis (REPRESS) model, which evaluated age, length of stay, Charlson disease count, Richmond Agitation-Sedation Scale score, discharge to a skilled nursing facility, and mobility for predictive significance in hospital readmission. Our REPRESS model performed better when compared with LACE for predicting readmission risk in a sepsis population.

Development of paediatric critical care in northwestern Nigeria: Initial implementation with a needs assessment model.

INTRODUCTION: There is high paediatric morbidity and mortality in northwestern Nigeria, attributable in part to vaccine-preventable illnesses and lack of comprehensive training of medical and nursing staff in the healthcare delivery of paediatric critical care. Pediatric Universal Life-Saving Effort Inc. (PULSE), a New York-based nonprofit organisation with a mission to develop paediatric critical care in resource-limited settings, collaborated with Aminu Kano University Teaching Hospital to decrease the gaps in knowledge and skills of medical and nursing personnel. The joint effort also aims to address and remove barriers to the delivery of paediatric critical care in northwestern Nigeria. The primary objective was to perform a needs assessment for paediatric intensive care resources in northwestern Nigeria, identify barriers to delivering these services, and designate a hub for the development of paediatric critical care educational programs for healthcare professionals. METHODS: An anonymous survey was designed and distributed using SurveyMonkey® online software to medical and nursing staff from nine healthcare institutions in northwestern Nigeria. RESULTS: Analysis from 67 responses revealed that care delivered to critically ill paediatric patients was by anaesthesiologists (77%), pediatricians (26%), and adult intensive care specialists (10%). The acquisition of clinical skills was perceived to be an essential need (65%), followed by adequate staffing of critical care units (19%), continuing medical and nursing education (13%), and availability of medical equipment (3%). DISCUSSION: There is an identified need for paediatric critical care training and resources in northwestern Nigeria. CONCLUSION: The needs assessment conducted has provided important results that will form the basis for building staff capacity and training programs for paediatric critical care in northwestern Nigeria.

Navigating the Doctor of Nursing Practice project within an academic practice partnership.

ABSTRACT: The Doctor of Nursing Practice (DNP) curriculum was initially developed in 2004. The DNP degree is a practice doctorate, which educates nurses to the highest level of clinical nursing practice. DNP students must complete a scholarly project in accordance with the American Association of Colleges of Nursing (AACN) guidelines. The project is an opportunity for the student to integrate skills into practice and demonstrate principles of advanced nursing practice. The AACN provides recommendations for the DNP project, but much confusion regarding the context and implementation of the project still exists. At one academic health sciences center, DNP project students often complete their projects within academic practice partnerships. Such partnerships are encouraged by the AACN. Several DNP quality improvement (QI) projects were submitted a hospital's interdisciplinary quality week event. Upon review, some of the abstracts were found to contain aspects of research. This finding prompted the review of all DNP project processes to standardize methods for faculty, students, the University, and the academic practice partner.

Neuro R2 score: Predicting high-risk neurologic readmissions within 30 days.

OBJECTIVE: To evaluate clinical and demographic factors of patients with neurologic disorders to determine which patient characteristics are significant for predicting 30-day hospital readmissions to develop a readmission risk predictor specific to patients with neurologic disorders. METHODS: We performed a retrospective single-center chart review for all patients admitted to the Department of Neurology or neurologic intensive care unit from January 1, 2013, to December 31, 2017. Clinical and demographic factors were analyzed to determine the association with readmission. Multivariable logistic regression analysis was performed and validated to develop a simple tool (Neuro R2 score) for predicting patients with neurologic disorders at high risk for hospital readmission. RESULTS: After removal of planned readmissions and patients who died in the hospital, the records of 4,876 patients with 314 (6.4%) readmission events were analyzed. The strongest predictors for readmission were Charlson disease count (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.06-1.35, p = 0.005), urgent or emergent admission (OR 1.50, 95% CI 1.04-2.17, p = 0.031), discharge to rehabilitation (OR 1.66, 95% CI 1.16-2.35, p = 0.005), cancer (OR 1.70, 95% CI 1.15-2.50, p = 0.007), brain tumor (OR 1.82, 95% CI 1.08-3.09, p < 0.03), cerebrovascular disease (OR 2.18, 95% CI 1.53-3.11, p < 0.001), and discharge to skilled nursing facility (OR 2.43, 95% CI 1.65-3.57, p < 0.001). CONCLUSIONS: The Neuro R2 score was developed to predict readmission risk, specifically in patients with neurologic disorders. Future research could include further validation of this readmission risk tool and strategies to reduce readmission in patients with the highest risk.

Implementing primary palliative care best practices in critical care with the Care and Communication Bundle.

BACKGROUND: Clinician-family communication is a central component of medical decision-making in the intensive care unit (ICU) and the quality of this communication has a direct impact on decisions made regarding care for patients who are critically ill. AIM: The purpose of the project was to emphasise the need for quality improvement in the medical ICU at the University of Florida Health Hospital in regard to communication between the patients, families and providers. METHOD: Interventions included development of a more systemic approach to primary palliative care by using the nationally recognised and published Care and Communication Bundle tool. The Bundle is a standardised clinical pathway of palliative care best practices. RESULTS: During the project period, staff satisfaction/engagement increased from tier 3 to tier 1 level, the medical ICU length of stay decreased from 4.97 days in fiscal year (FY) 2016 to 4.22 days in FY2017. Moreover, the number of patients discharged directly to hospice increased from 21 in FY2016 to 42 in FY2017, representing a 100% increase. Additionally, palliative care consults decreased in the medical ICU (FY2016=108, FY2017=82), as a result of an increase in daily primary palliative care interventions. The findings demonstrate an improvement in outcome measures during the project.

Minimally Invasive Surgical Options with Valvular Heart Disease.

The incidence and prevalence of structural heart disease has risen due to the longevity of the population, placing an economic burden on society. Over the past 20 years, treatment options for structural heart disease has significantly evolved. Advances in technology and interventional techniques have now shifted therapeutic options to include minimally invasive approaches to correct valvular heart disease. Patients with congenital heart defects are candidates for minimally invasive approaches to correct valvular heart disease. An interdisciplinary team approach using a fusion of multimodal imaging is the best approach for the treatment of this complex patient population.

Answering the question: Is the Doctor of Philosophy or Doctor of Nursing Practice right for me?

Over the past decade, leading health care organizations have recommended doubling the number of doctorally prepared nurses to meet the future demands of health care. In 2018, the National Organization of Nurse Practitioner Faculties committed to move all nurse practitioner degree programs to the Doctor of Nursing Practice degree by 2025. As more and more doctorally prepared nurses enter the workforce, other nurses are considering returning to school for a terminal degree. This column will review options for doctoral education in nursing and the strength, focus, and program requirements for PhD and DNP degrees.

Early mobilisation in intensive care during renal replacement therapy: A quality improvement project.

OBJECTIVE: To improve mobility for patients undergoing renal replacement therapy within intensive care. DESIGN: A quality improvement study utilising a step-wise mobility protocol within a before-and-after audit design. SETTING: Twenty-four bed Trauma/Surgical intensive care unit within a level one trauma and academic centre. MAIN OUTCOME: Improvement of compliance to the mobility plan following introduction of a step-wise mobility protocol. RESULTS: A total of fifty-six renal replacement therapy patients were measured on a randomly selected day each week during the nine month before-and-after protocol audit period. Before introducing the protocol, compliance to mobility was 12.5%, compared to 62.5% after the protocol was introduced. There were no identified negative outcomes, such as catheter loss, filter loss or bleeding, associated with mobilising these patients following implementation of the protocol. CONCLUSION: The use of a step-wise mobility protocol was effective and safe strategy to increase mobility in the renal replacement therapy patient population.

A model of successful DNP and PhD collaboration.

BACKGROUND AND PURPOSE: Within nursing education, the existence of two graduate-level programs has created some challenges. Role confusion between the practice-focused Doctor of Nursing Practice (DNP) and the research-focused Doctor of Philosophy (PhD) is compounded by competition for similar positions. Collaboration between DNP and PhD nurses, however, benefits the health care system and patients. METHODS: The complementary skills of these two groups of nurses are detailed, and a model for building PhD-DNP partnerships is presented based on a collaborative PhD-DNP project that resolved a negative trend in outcomes from cardiac surgery. The clinical pathway created by the project met national benchmarks, improved interprofessional staff communication, and resulted in uniform and improved patient care. CONCLUSIONS: Although role differentiation for doctoral nurses can be challenging, role integration is critical. Building collaborative partnerships between these groups of nurses benefits the health care system, as well as patients, and this partnership is sustainable through successful collaborative projects. IMPLICATIONS FOR PRACTICE: Doctoral-prepared nurses must understand each other's background and education and focus on what each can contribute. In the beginning, as with any collaborative relationship, collaborators must discuss and agree on ground rules, team roles, responsibilities, and time line for projects.

Academic nursing scholarship redefined.

The American Association of Colleges of Nursing (AACN) last defined academic nursing scholarship in 1999. The AACN recognized faculty scholarship must align with the increasingly complex and dynamic health care environment to prepare nurses for an ever-changing future. The new, broader definition recognizes multiple ways of knowing and values all scholarly contributions, which affect nursing science and the health care system. The alignment of faculty scholarship to the practice of nursing will ensure high-quality education, influencing the next generation of nurses. This new position statement also provides clarity as to valued activities within the faculty role, which will assist administrative faculty who struggle with appointment, tenure, and promotion criteria. This column will provide a summary of the new position statement and exemplars of activities within the faculty role of research, practice, and teaching.

Improving Cardiac Surgery Outcomes by Using an Interdisciplinary Clinical Pathway.

A cardiothoracic intensive care unit (CTICU) team evaluated preoperative and postoperative processes to improve outcomes for cardiac surgery patients. The primary aim of this project was to streamline and improve care in the CTICU by implementing a new clinical pathway for patients undergoing coronary artery bypass graft or valve replacement procedures. We analyzed processes, communication, ventilator days, respiratory complications, patient mobility, presence of invasive catheters and lines, CTICU length of stay, and hospital-adjusted length of stay before and after we implemented the clinical pathway. This article outlines the methods we used to plan, implement, and assess the clinical pathway. Implementation of the clinical pathway successfully streamlined care, reduced variations in care, and improved health care quality and resource use.

CE: A Review of the Revised Sepsis Care Bundles.

: Sepsis is an extreme response to infection that can cause tissue damage, organ failure, and death if not treated promptly and appropriately. Each year in the United States, sepsis affects more than 1.5 million people and kills roughly 250,000. Prompt recognition and treatment of sepsis are essential to saving lives, and nurses play a critical role in the early detection of sepsis, as they are often first to recognize the signs and symptoms of infection. Here, the authors review recent revisions to the sepsis care bundles and discuss screening and assessment tools nurses can use to identify sepsis in the ICU, in the ED, on the medical-surgical unit, and outside the hospital.

Sleep Deprivation in Neurointensive Care Unit Patients From Serial Neurological Checks: How Much Is Too Much?

OBJECTIVE: Hourly neurological examinations are frequently performed in the neurointensive care unit (NICU) to quickly detect neurological deterioration. These examinations require the patient to be awakened hourly for days disrupting the sleep cycle and potentially causing neurological deterioration through sleep deprivation and the development of delirium. This pilot study's aim was to describe the prevalence of neurologic deterioration and delirium in patients receiving hourly neuro checks. DESIGN: A 6-month prospective observational cohort study was conducted within the NICU at Mayo Clinic Florida. Twenty subjects were enrolled between July 24, 2016, and January 30, 2017. RESULTS: Neurological deterioration as defined as a decrease in Glasgow Coma Scale score of 2 or more, an increase in National Institute of Health Stroke Scale score by 4 or more, or a change in Confusion Assessment Method score for use in intensive care unit patients from negative to positive occurred in 19 of 20 patients (95%) for a total of 67 events, with most patients having multiple events. Seventy-five percent of the subjects experienced a decrease in Glasgow Coma Scale score of 2 or more at least once during the study period. The largest number of events occurred within the first 24 hours (39%). Surprisingly, 75% of the subjects also developed delirium. Forty percent of the subjects demonstrating neurological deterioration received computed tomography imaging to evaluate the change. Sixty-seven percent lacked deterioration evident on computed tomography imaging, and the deterioration was not attributed to medication effect or seizure by an experienced provider. CONCLUSIONS: Neurological deterioration is prevalent in the NICU population. Although hourly neurological examinations may be beneficial in the acute phase of neurological injury, prolonged use may be paradoxically harmful due to sleep deprivation.

CE: Assessing and Managing Pain, Agitation, and Delirium in Hospitalized Older Adults.

: In the acute care setting, pain, agitation, and delirium (PAD) often occur as interrelated parts of a syndrome rather than as separate entities. Because the three facets of PAD may be similar in presentation, it is often difficult for clinicians to recognize the syndrome and to assess and treat it. The challenge is particularly great in older patients, who are more likely than their younger counterparts to have such comorbid conditions as dementia, which may impair the ability to report pain, or age-related physiologic changes that may affect the metabolism and clearance of certain medications. This article provides an overview of each aspect of PAD, discusses clinical considerations related to the assessment and treatment of the syndrome in older adults receiving acute care, and illustrates the application of published PAD guidelines through the use of a hypothetical patient scenario.

Making the Case for Palliative Care in Critical Care.

The United States has a changing populace with an increasing number of vulnerable, diverse, and older adults. Of people aged 65 and older, nearly two-thirds suffer from serious comorbidities. Costs associated with chronic illness increase with age and number of conditions. More than 25% of older adults do not have advanced care planning. The current model of health care cannot meet these needs. The initiation of palliative care in the ICU will capture many patients who meet the criteria for palliative care and improve their QOL by management their end-of-life symptoms and reduce unnecessary utilization of health care resources.

Predicting Which Patients Will Benefit From Palliative Care: Use of Bundles, Triggers, and Protocols.

Intensive care units provide a wide range of care to patients with serious or life-threatening conditions. This care provides excellent state-of-the-art interventions, often concentrated on meeting national health priorities and performance measures. Overall patient care and the resultant outcomes in the intensive care unit are superb. However, one area that needs improvement is the provision of high-quality palliative care (PC) and end-of-life care. Many providers and administrators now realize implementing PC in the critical care setting is vital to optimal patient outcomes. PC improves patient and family satisfaction and quality of life, reduces length of stay and 30-day readmission rates, and patients can live longer with PC.