Individuals Who Developed Delirium While Enrolled in the Hospital Elder Life Program: An Exploratory Study.

Delirium prevention in hospitalized older adults is important due to delirium's high prevalence and negative impact on outcomes. Today, there are evidence-based programs with well-documented effectiveness aimed at preventing delirium, such as the Hospital Elder Life Program (HELP); however, approximately 4% to 5% of patients develop delirium regardless of implemented prevention interventions. It remains unknown why some patients develop delirium. The current retrospective exploratory chart review analyzed 98 records for clinical risk factors and outcomes of patients who developed delirium while enrolled in the HELP. On admission, immobility (86.7%) was the most common risk factor. Patients developed delirium approximately 70 hours after admission. Average length of stay was 8 days. Approximately one half (44.9%) of patients died within 1 year. Immobility (97.7% vs. 77.8%, p = 0.005) and renal disease (52.3% vs. 24.1%, p = 0.008) were more often found in patients who died. This study identifies risk factors that seem to require heightened attention during hospitalization to prevent the negative outcomes associated with delirium in older adults. [Journal of Gerontological Nursing, 49(5), 19-29.].

Impact of supplemental thiamin on lactate levels in adults with septic shock.

BACKGROUND: Elevated lactate levels at 24 h are highly predictive of in-hospital mortality in adults with septic shock. Thiamin is closely involved in carbohydrate metabolism, and in thiamin-deficient states, increased lactic acid levels can be found, exacerbated by critical illness. This integrative literature review focused on the relationship between supplemental thiamin, lactate clearance, and impact on mortality in sepsis. METHODS: A search in PubMed, Embase, and CINAHL was conducted for literature published between January 2016 and January 2021. We included observational studies and clinical trials with ≥10 participants. We excluded studies involving pediatric (<18 years old) populations, animal studies, case studies, dropout rate of >20%, nonhospitalized patients, or patients receiving comfort measures only. RESULTS: A total of 48 full-text articles were assessed for eligibility, with 15 evaluated for this integrative review. Included were five retrospective, two prospective observational, and eight randomized controlled trials. In almost all retrospective studies, thiamin administration was associated with decreased mortality, and in observational studies, with decreased lactate and improved clinical outcomes. In clinical trials, thiamin with or without vitamin C/hydrocortisone did not impact clinical outcomes or mortality. However, four trials testing intravenous thiamin 200-500 mg two to three times daily for up to 3 days reported improved lactate clearance. CONCLUSIONS: Thiamin supplementation may improve lactate clearance when administered in the first 24 h. Those deficient in thiamin may benefit more from supplementation. The combination of thiamin, vitamin C, and/or hydrocortisone may not be advantageous. Lactate reduction in response to thiamin needs further rigorous research.

Moral distress and spiritual/religious orientation: Moral agency, norms and resilience.

BACKGROUND: Nurses tasked with providing care which they perceive as increasing suffering often experience moral distress. Response to moral distress in nurse wellbeing has been widely studied. Less research exists that probes practicing nurses' foundations of moral beliefs. AIMS: The purpose of this phenomenological study was to gain understanding of nurse meaning-making of morally distressing situations, with particular attention to ethical norms, moral agency and resiliency, and nurse religious/spiritual orientation. DESIGN: This exploratory study employed semi-structured interviews using open-ended questions. Qualitative data analysis was assisted by MAXQDA software. PARTICIPANTS AND RESEARCH CONTEXT: Nine pulmonary care nurses during COVID-19 in a tertiary care teaching hospital in the northeastern United States. ETHICAL CONSIDERATIONS: The study was approved by the IRB. Participants were consented before the study and confidentiality was preserved. FINDINGS/RESULTS: The study revealed three main themes of meaning-making, rooted in the identity of the "good nurse": Being true to one's own values, pursuing ideal patient care ("doing good"), and conforming to/challenging values of the system and culture. Tensions were found between (a) nurse's own values (b) duty to institutional norms and duty to nurse's personal code of ethics, and (c) perceptions of institutional support in response to nurse moral distress. Religion was described as a remote source of nurse moral values, among other sources. Spiritual practices were not experienced as sufficient in coping with moral distress at the bedside. CONCLUSIONS: The study suggests nurses need more opportunities to engage in reflection on their practice and values. The findings also indicate need for accessible institutional supports for nurses experiencing moral distress and strategic use of chaplains in helping with moral distress. Further research is needed on the interplay of nurse spirituality, moral agency, and reflective practice in the face of morally challenging situations.

End-of-Life Care: Improving Communication and Reducing Stress.

This quality improvement initiative originated in the cardiac intensive care unit (CICU) at a 637-bed licensed Magnet teaching hospital with the rating of level 1 trauma center. The CICU has 12 beds, with a staff of 59 nurses (RNs). The nursing staff expressed increased stress and discomfort when communicating with patients and their families when providing end-of-life care. Selected evidence-based techniques for stress reduction and active listening skills were taught in 4- to 5-minute mini sessions during the morning huddle 3 days per week for 4 weeks. The program was evaluated using pretest, posttest, and 2 follow-up surveys composed of 5 statements and 2 open-ended questions. The survey tool was developed by researchers in accordance with the relevant literature. The results showed improved communication as demonstrated by the surveys. Nurses also reported feeling more supported by their colleagues and supervisors. The project was conducted in 1 CICU, therefore limiting the generalizability of the results.

Case Report of Cardiopulmonary Arrest During Pregnancy due to Opioid Overdose.

In the United States, the number of deaths related to overdose of heroin and other opioids, specifically among women of reproductive age, has been rising. This case report adds new knowledge to the limited scientific literature currently available. We describe the care of a 30-year-old pregnant (31.4 weeks gestation) woman who was found unresponsive from a suspected opioid overdose in a friend's home. In response to an unwitnessed cardiopulmonary arrest, the team initiated therapeutic hypothermia 12 hours after the event. Multiple interdisciplinary teams came together to care for this woman and fetus. Information sharing among care providers from multiple disciplines is needed to build expertise in managing the care of pregnant women who experience opioid overdose.

New Graduate Orientation Evaluation: Are There Any Best Practices Out There?: A Scoping Review.

Efficient, cost-effective, and safe orientations with clear expectations are necessary for new graduates in their transition from student to practicing nurse. In the current nursing shortage, healthcare needs to invest more in retaining new graduates. Orientation can be a factor in decisions to leave. This scoping review revealed that strong evidence is lacking regarding best practices during orientation for evaluating new graduate nurses' readiness to practice on their own. More resources, research, and tools are needed.

Evidence-Based Education for Perianesthesia RNs to Increase Knowledge and Change Attitudes of Electroconvulsive Therapy.

PURPOSE: To increase perianesthesia registered nurses (RNs') knowledge and change attitudes of electroconvulsive therapy (ECT). DESIGN: A pretest/post-test design was used. METHODS: An interprofessional team collaborated in the development of a 1-hour teaching session, which included PowerPoint presentation, case studies, and online resources. The education was offered four times from December 2017 to April 2018. Data were collected on self-reported learning outcomes and the Questionnaire on Attitudes and Knowledge of ECT. FINDINGS: After the education, increased knowledge was reported. RNs (n = 25) were more likely to recommend ECT as a treatment option (P = .013) and believed that psychiatrists take other health care providers' views into account (P = .023). They were also more likely to believe that ECT should not be used as a last resort (P = .022) and should not be banned (P = .025). CONCLUSIONS: Self-reported knowledge increased, and some of the RNs' attitudes toward ECT changed after education.

Teaching-learning partnership between nurses and long-term patients undergoing peritoneal dialysis: A qualitative study.

BACKGROUND: People with end-stage kidney disease (ESKD) receiving peritoneal dialysis (PD) have been found to alter their adherence to the renal therapeutic regimen following their initial teaching by PD nurses. Since alterations of adherence have been associated with poor health outcomes, this study focuses on persons receiving PD who rely on support and re-education from their nurses. OBJECTIVES: To explore the teaching-learning partnership between people receiving PD and PD nurses, and to compare and contrast shared perspectives. DESIGN: The study consisted of individual semi-structured interviews of four people receiving PD and three PD nurses, using qualitative content analysis. FINDINGS: Four shared themes and nine sub-themes emerged: "motivation" was characterised by perceptions of "staying healthy to avoid peritonitis pain and to qualify for a transplant". One sub-theme emerged exclusively in the interviewed people receiving PD: "motivation" to initiate PD through "finding meaning in life and situation". The theme "acceptance" was comprised "of diagnosis and choosing to initiate PD" and the "modification and integration into daily life". The presence of "support" arose from "personal support from family and friends", "professional care and understanding of the individual" and "professional customised and re-iterative education". The evolving "partnership" was comprised of "exposure", "personal rapport", and the "necessity of working together" in order to maintain positive health outcomes. CONCLUSION: The partnership between the PD nurse and people receiving PD for ESKD is crucial for successful health outcomes. Each partnership is unique and evolves over time. A successful partnership requires nurses to modify the educational content and teaching style to best meet the needs of people receiving PD and, most importantly, allow them to feel cared for and supported.

Missing pieces of the retention puzzle.

Identifying pragmatic aspects for succession planning needs.

Quantitative Analysis of Surgical Residency Reform: Using Case-Logs to Evaluate Resident Experience.

BACKGROUND: Curricular changes at a mid-sized surgical training program were developed to rebalance clinical rotations, optimize education over service, decrease the size of service teams, and integrate apprenticeship-type experiences. This study quantifies the operative experience before and after implementation as part of a mixed-methods program evaluation. STUDY DESIGN: Retrospective review of case-log data and data from the Accreditation Council for Graduate Medical Education (ACGME) and the American College of Surgeons National Surgical Quality Improvement Program: quality in-training initiative to evaluate case volume pre- and postintervention. RESULTS: 11,365 cases, excluding "first-assistant" and "endoscopic" cases, were logged for an average of 291 and 263 cases/resident pre- and postintervention, respectively. Average case volume increased significantly for postgraduate year (PGY) 3 residents and decreased significantly for PGY 4 residents between the two time periods. Variability was observed among residents at the same PGY level both pre- and postintervention, with coefficients of variation of 6.0% to 34.1% in 2014 to 2015 and 11.2% to 66.8% in 2015 to 2016. Inter-resident variability persisted when comparing a specific procedure between ACGME case-log and quality in-training initiative data sets. CONCLUSION: The data suggest that inter-resident variability in case load is not an artifact of case logging behavior alone, but may reflect personal preferences and choices in case selection that are not impacted by curriculum change. Logging behavior and accuracy of case-logs may contribute to variability. The shift in case load from PGY 4 to PGY 3 after curriculum implementation requires validation by ongoing analysis of ACGME case-log data.

Mobilizing older adults: A multi-site, exploratory and observational study on patients enrolled in the Hospital Elder Life Program (HELP).

The aim of this study was to explore and describe the characteristics of the Hospital Elder Life Program (HELP) sites and how they mobilize patients with volunteers in the United States and other countries. The purpose was to describe: the number of enrollments, modalities, fall and injury rates, and to identify barriers to mobilization. A survey was distributed to 228 international sites. The responding sites enrolled an average of 53.9 (SD 35.3) patients per month. The majority (76%) reported that mobilization included 'active range of motion exercises' and 'ambulation'. Eighteen percent identified volunteer training, safety and liability concerns as barriers. Falls with injury on HELP units was 0-3%, with an average rate of 0.46 per 1,000 patient days. No patient falls while ambulating with the HELP team and/or volunteers were reported. More research and evidence are needed to further determine barriers and safety of mobilization with the HELP during hospitalization.

Stress and Symptoms of Depression in Fathers of Infants Admitted to the NICU.

OBJECTIVE: To describe perceived stress and symptoms of depression in fathers of infants admitted to the NICU through 2 months after discharge and to explore associations between fathers' childhood and current relationships with their own parents and their stress and symptoms of depression. DESIGN: Observational, longitudinal. SETTING: Tertiary care center in northeastern United States. PARTICIPANTS: English-speaking fathers of newborns admitted to the NICU. METHODS: Fathers completed the Parental Stress Scale and the Edinburgh Postnatal Depression Scale (EPDS) at infants' NICU admissions (Time [T] 1), 3 weeks (T2), discharge (T3), and 2 months after discharge (T4). RESULTS: A total of 146 fathers were enrolled between March 2013 and February 2016. Infants' mean gestational age at birth was 31.9 weeks, and 88% remained in the NICU for 3 weeks or longer. We found that 12% of fathers reported high stress levels at T1, 8% at T3, and 13% at T4. Overall EPDS scores improved over time (p < .001). From T1 to T4, the proportion of fathers with distress/minor symptoms of depression decreased from 41% to 10% and with symptoms of major depression from 16% to 2%. Statistically significant positive associations were found between fathers' EPDS scores and the quality of relationships with their fathers (at T1, T2, and T3) and with their mothers (across all time points). CONCLUSION: From admission to 2 months after discharge, stress and symptoms of depression persisted for some fathers of infants admitted to the NICU. Evidence-based strategies to support fathers during and after their infants' NICU hospitalizations need to be further developed, implemented, and evaluated.

Physicians' Perceptions of Hope and How Hope Informs Interactions With Patients: A Qualitative, Exploratory Study.

OBJECTIVES: Today some studies of physicians' perceptions of hope are available, but not studies of how hope informs patient care. The objectives of this qualitative study were to describe the ways physicians conceptualize hope and how these may inform interactions with their patients. METHODS: Ten physicians working in a large tertiary care teaching hospital were interviewed. They represented palliative care, oncology, and 7 other specialties. Minimal amount of background information was collected. In-depth interviews were conducted during spring of 2016. Open coding and the constant comparison method were used to identify emerging themes from the transcribed data. Validation method included member checking. RESULTS: Hope was defined as an abstract, evolving concept characterized by future-oriented wishes; offering possibilities for reframing and shaping new meaning; an attitude of positivity or optimism; an attribute of the human condition with emotional and relational roots; and as a response to the existential inevitability of suffering and death. Three themes describing hope emerged: "assessing hope," "fostering and sustaining hope," and "attributes and outcomes of hope." CONCLUSIONS: The findings show how physicians conceptualize hope and how these conceptions differ in the empirical light of the study. Physicians' perceptions of "hope" may evolve when entering into a therapeutic relationship exploring the needs and desires of patients. Physicians' perspectives about "hope" may at times not be solely their own but are those of their patients and thus resulting in an amalgamation, or a rebuilding/rekindling of hope amidst hopelessness, that suits a particular relationship.

Falls and delirium in an acute care setting: A retrospective chart review before and after an organisation-wide interprofessional education.

AIM AND OBJECTIVES: To describe and compare identification of delirium, length of stay and discharge locations in two patient samples of falls, before and after an organisation-wide interprofessional delirium education and practice change along with implementation of a policy. BACKGROUND: Delirium is a common and severe problem for hospitalised patients, with occurrence ranging from 14%-56%, morbidity and mortality from 25%-33%. Recent studies report that 73%-96% of patients who fell during a hospital stay had symptoms of delirium; however, the delirium went undiagnosed and untreated in 75% of the cases. DESIGN: A descriptive, retrospective observational study using a pre/postdesign. METHODS: Two chart reviews were performed on patient falls as identified in the hospital safety reporting system in 2009-2010 (98 fallers) and 2012 (108 fallers). An organisation-wide education was planned and implemented with monitoring of policy compliance. RESULTS: After the education, documentation of the "diagnosis of delirium" and "no evidence of delirium" increased from 14.3%-29.5% and from 27.6%-44.4%. The documentation of "evidence of delirium" decreased significantly from 58.2%-25.9% (p < .001). The confusion assessment method (CAM) identified the diagnosis of delirium at 76% accuracy. The length of stay decreased by 7.3 days. The fall rates in 2011 and 2012 were 3.01 and 2.82 falls per 1,000 patient days and in 2013 decreased to 2.16. CONCLUSION: The results indicate that improving delirium recognition and treatment through interprofessional education can reduce falls and length of stay. RELEVANCE TO CLINICAL PRACTICE: The results demonstrate that when staff learn to prevent, identify, manage and document delirium more accurately the fall rate decreases. The practice change, including the use of CAM, was sustained by continuous auditing including re-education, and the re-enforcement of learning along with the implementation of a policy.

Geographic access to interventional cardiology services in one rural state.

OBJECTIVES: Explore (1) the characteristics of the Maine population with delayed geographic access to interventional cardiology (IC) services and (2) the effect of delayed geographic IC access on coronary mortality. BACKGROUND: Acute coronary syndrome (ACS), ST-segment elevated myocardial infarction (STEMI), and non-ST segment elevated myocardial infarction (NSTEMI) are highly prevalent. Coronary mortality is minimized when victims have prompt IC access. METHODS: The study design was (1) an exploration of census data to investigate disparities in geographic IC access and (2) a secondary analysis of administrative claims data to investigate coronary mortality relative to delayed geographic IC access. RESULTS: Delayed access was associated in the Maine population with rural residence, advanced age, high school education, and lack of health insurance. Delayed access was associated with increased unadjusted coronary mortality, but not age-adjusted coronary mortality. CONCLUSION: Delayed geographic IC access was associated with disparity but not with increased age-adjusted coronary mortality.

Falls in A Tertiary Care Hospital-Association With Delirium: A Replication Study.

BACKGROUND: Delirium has been previously implicated as a risk factor for patient falls. This is a replication study of a 2009 investigation examining the prevalence of diagnosed and undiagnosed delirium in patients who fell during their hospital stay. OBJECTIVE: To determine the prevalence of delirium at our institution and to examine the relationship of falls with delirium, advanced age, and hospital procedures. METHOD: Using the data collection tool developed for the 2009 study, the authors performed a retrospective review of records of 99 patients who fell during their inpatient stay. Similar information was gathered on patient demographics, fall date, fall location, hospital service type, discharge disposition, diagnosis of delirium (DD), synonyms used to describe delirium, metabolic derangements, and surgeries or procedures performed. Data were collected on the day of admission, day of the fall, and 2 days before the fall. RESULTS: Falls in the general hospital were associated with delirium (73% of subjects had evidence or a DD at the time of their fall), advanced age (64.5% were older than 70 years), and specific procedures and surgeries. CONCLUSION: As identified in the previous study, improving delirium recognition and treatment may reduce the number of patient falls and promote more favorable outcomes such as reduced length of stay, fewer discharges to intermediate care facilities, and prevention of fall injuries. A comprehensive fall risk assessment that includes a delirium detection tool would improve the sensitivity and specificity of these instruments to detect those at greatest risk.

Effectiveness of regionalized systems for stroke and myocardial infarction.

BACKGROUND: Acute ischemic stroke (AIS) and ST-segment elevation myocardial infarction (STEMI) are ischemic emergencies. Guidelines recommend care delivery within formally regionalized systems of care at designated centers, with bypass of nearby centers of lesser or no designation. We review the evidence of the effectiveness of regionalized systems in AIS and STEMI. METHODS: Literature was searched using terms corresponding to designation of AIS and STEMI systems and from 2010 to the present. Inclusion criteria included report of an outcome on any dependent variable mentioned in the rationale for regionalization in the guidelines and an independent variable comparing care to a non- or pre-regionalized system. Designation was defined in the AIS case as certification by the Joint Commission as either a primary (PSC) or comprehensive (CSC) stroke center. In the STEMI case, the search was conducted linking "regionalization" and "myocardial infarction" or citation as a model system by any American Heart Association statement. RESULTS: For AIS, 17 publications met these criteria and were selected for review. In the STEMI case, four publications met these criteria; the search was therefore expanded by relaxing the criteria to include any historical or anecdotal comparison to a pre- or nonregionalized state. The final yield was nine papers from six systems. CONCLUSION: Although regionalized care results in enhanced process and reduced unadjusted rates of disparity in access and adverse outcomes, these differences tend to become nonsignificant when adjusted for delayed presentation and hospital arrival by means other than emergency medical services. The benefits of regionalized care occur along with a temporal trend of improvement due to uptake of quality initiatives and guideline recommendations by all systems regardless of designation. Further research is justified with a randomized registry or cluster randomized design to support or refute recommendations that regionalization should be the standard of care.

A comparison of usual care, a patient-centred education intervention and motivational interviewing to improve medication adherence and readmissions of adults in an acute-care setting.

AIM: To compare medication adherence and readmissions in patients who received usual care vs. patient-centred interventions. BACKGROUND: Medication adherence is a complex behaviour that may be improved with patient-centred strategies. METHOD: A non-concurrent convenience sample of 303 hospitalised patients received either usual care (n = 98) or patient-centred interventions (n = 205). Intervention patients received teach-back and medication tools (n = 137) or motivational interviewing (n = 68). Data were collected at discharge (T1), at 48-72 hours (T2) and 30 days after discharge (T3). RESULTS: No significant differences were found in medication adherence, therapeutic alliance, patients' experience and readmissions between groups. Patients in the motivational interview group reported lower confidence with medication adherence at T1 (P = 0.01) and T2 (P = 0.00) than the patient-centred intervention group. Motivational interviewing was a significant predictor (ß = -1.55, P = 0.01, OR 0.21, 95% CI 0.06, 0.72) of fewer readmissions. CONCLUSION: Overall, patients reported very low levels of non-adherence and very high levels of confidence and importance of medication adherence. IMPLICATIONS FOR NURSING MANAGEMENT: Medication adherence continues to be an important area for clinical inquiry. For those patients who lack confidence for medication adherence, comprehensive patient-centred strategies such as motivational interviewing may improve treatment outcomes.