Outcomes-Based Standardization: A New Approach to An Old Problem.

The COVID-19 pandemic has significantly strained care delivery, reduced available resources, and further destabilized health care finances. As health care organizations emerge from a pandemic that has worsened uncontrolled health care spending, while greatly reducing patient volumes and revenue, reactive cost cutting with little regard for the people at the end of those decisions quickly emerged as the standard approach. Historically, limiting cost decisions to product selection was a common, yet minimally effective, strategy for controlling health care spending. In the post-COVID health care environment, where clinical and financial challenges are greater than ever, a new approach to reducing health care spending offers promise. Outcomes-based standardization is an approach that begins with the end in mind, incorporating lean concepts to alleviate redundant or ineffective products and practice, while prioritizing value added activities to catalyze the greatest reduction of harm, time, and money spent. Outcomes-based standardization is a framework for change that balances clinical and financial decisions to ensure high value care across the continuum. This new approach has been employed across the country to help health care organizations reduce health care spending. This article explains what it is, why it works, and how the reader can successfully deploy it across the health care spectrum to achieve better clinical outcomes, alleviate waste, and reduce unnecessary health care spending.

Evaluation of a Modified Version of the Norton Scale for Use as a Pressure Injury Risk Assessment Instrument in Critical Care: A Quality Improvement Project.

PURPOSE: No risk assessment scale exists in the United States specifically designed for use among patients with critical illness. The aim of this project was to modify the Norton Scale for Pressure Sore Risk to improve its predictive power when used in the critical care setting. PARTICIPANTS AND SETTING: The setting for this quality improvement project was a 1157-bed academic medical center in the Southeast United States. Data were collected from 114 clinicians; 111 were critical care nurses and 3 were certified wound care nurses. METHODS: Participants assessed the pressure injury risks of a video-simulated critical care patient using the optimized Norton Scale (oNS); this instrument was modified from the Norton Scale. Data were collected on reliability, validity, usability, and preference. OUTCOMES: All 114 participants accurately predicted a patient's severe high risk for pressure injury using the oNS. Predictive validity and reliability of the oNS were excellent based on a correlation coefficient of more than 0.6 and a Cronbach α = 0.944, respectively. The intraclass correlation coefficient (ICC) was 0.933 (95% confidence interval, 0.911-0.950). From 71.2% to 84.9% of the participants agreed that the oNS represented the desired characteristics for optimal usability in the critical-care setting. Preference for the oNS was associated with perceptions that it was easier, quicker, and more critical-care-specific than the Braden Scale for Pressure Sore Risk currently used in critical care units in the project facility. IMPLICATIONS FOR PRACTICE: The oNS offered critical care nurses in our facility a quick, easy-to-use, critical care- specific risk assessment tool that focused on the unique vulnerabilities of patients with critical illness.

Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis.

Anaphylaxis is an acute, potential life-threatening systemic allergic reaction that may have a wide range of clinical manifestations. Severe anaphylaxis and/or the need for repeated doses of epinephrine to treat anaphylaxis are risk factors for biphasic anaphylaxis. Antihistamines and/or glucocorticoids are not reliable interventions to prevent biphasic anaphylaxis, although evidence supports a role for antihistamine and/or glucocorticoid premedication in specific chemotherapy protocols and rush aeroallergen immunotherapy. Evidence is lacking to support the role of antihistamines and/or glucocorticoid routine premedication in patients receiving low- or iso-osmolar contrast material to prevent recurrent radiocontrast media anaphylaxis. Epinephrine is the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis. After diagnosis and treatment of anaphylaxis, all patients should be kept under observation until symptoms have fully resolved. All patients with anaphylaxis should receive education on anaphylaxis and risk of recurrence, trigger avoidance, self-injectable epinephrine education, referral to an allergist, and be educated about thresholds for further care.

Evaluating Mid-Upper Arm Circumference Z-Score as a Determinant of Nutrition Status.

BACKGROUND: Mid-upper arm circumference (MUAC) z-score, has recently been listed as an independent indicator for pediatric malnutrition. This investigation examined the relationship between MUAC z-score and the z-scores for conventional indicators (ie, weight-for-length and body mass index) to expand the available evidence for nutrition classification z-score threshold ranges in U.S. practice settings. METHODS: This was a single-center study of children through 18 years of age seen between October 2015 and September 2016. Height and weight were obtained on intake. MUAC was measured at midpoint of the humerus, between the acromion and olecranon. Age-specific and gender-specific z-score values were calculated using published λ, µ, and σ values derived from Centers for Disease Control and Prevention reference data. Nutrition status was determined from biochemical data; prior history; anthropometrics; weight gain velocity; weight loss, if present; and nutrient intake. RESULTS: 5,004 children (7.5 ± 5.7 years, 53% boys) were evaluated. As expected, MUAC z-scores were significantly correlated with body mass index (r = 0.789, P < .01) and weight-for-length (r = 0.638, P < .01) z-scores. There was a large degree of overlap in z-scores for all indicators between nutrition status groups; however, MUAC z-scores spanned a narrower range of values such that mean MUAC z-scores are lower in children classified as overweight/obese and higher in children who were severely malnourished than the corresponding body mass index or weight-for-length z-scores. CONCLUSION: These data are the first to suggest that the z-score ranges used to define various stages of malnutrition may not be the same for all indicators.

Use of a Soft Silicone Foam Dressing to Change the Trajectory of Destruction Associated with Suspected Deep Tissue Pressure Ulcers.

PURPOSE: To explore the evolution of suspected deep tissue injury (sDTI) pressure ulcers and identify the role of early identification and intervention in hindering tissue destruction. In contrast to previously published evidence, the foundational research identified a significant trend of sDTI recovery which warranted further analysis. SUBJECTS AND SETTINGS: A single-site, 24-month retrospective, IRB-approved study evaluated 77 adult (age 18 or older) hospitalized subjects with 128 wound care nurse-identified sDTIs over the course of 1 day to 14 weeks for 377 encounters. METHODS: Data from a 24-month period (2010-2012) were analyzed during the primary study. In addition to demographics, the evolution process including site, initial presentation, measurements, tissue consistency, and treatment, were assessed. In response to findings of significant sDTI recovery, a secondary in-depth analysis focused on commonalities and variables for clarity of their contribution to the isolated improved patient outcomes. RESULTS: In addition to clearer delineation of demographics, co-morbid conditions, and evolutionary patterns, the researcher identified patient outcomes in stark contrast to those previously published in the literature. A significant outcome of resolution of sDTI pressure ulcers was observed. Upon further review, the role of absorbent soft silicone, multi-layer, self-adherent bordered foam (Mepilex) in these outcomes was elucidated clearly.

A 5-year retrospective study of descriptors associated with identification of stage I and suspected deep tissue pressure ulcers in persons with darkly pigmented skin.

BACKGROUND: As skin assessment is critical to pressure ulcer prevention, it is essential that practitioners performing skin assessments understand individuals with dark skin tones may represent at-risk persons. In addition, visual cues commonly associated with the identification of stage I and suspected deep tissue injury (sDTI) pressure ulcers may not be sufficient in persons with darkly pigmented skin. OBJECTIVE: The purpose of this study was to identify common descriptors associated with stage I and sDTI pressure ulcers in persons with darkly pigmented skin, to determine whether the National Pressure Ulcer Advisory Panel (NPUAP) definitions are adequate, and to identify additional descriptors that might aid practitioners in identifying pressure ulcers in this at-risk population. METHODS: A 5-year retrospective review of 96 subjects with 274 stage I or sDTI pressure ulcers was conducted at an acute care facility. A literature search aided in identifying descriptors associated with pressure ulcers in persons with darkly pigmented skin. Computer-queried records targeted subjects matching the descriptors of "African American," "Asian," "Hispanic," "American Indian," "Alaskan Native,""Native Hawaiian," or "Pacific Islander" descent; with a "stage I or sDTI" and a "WOCN consult" from "March-2008 through March-2013." The pressure ulcer documentation of 9 wound, ostomy, and continence nurses (WOCNs) was analyzed. RESULTS: Stage I and sDTIs presentations were varied. However, the majority of pressure ulcers were associated with descriptors consistent with NPUAP staging guidelines. For stage I pressure ulcers, the prevailing presentation was nonblanchable erythema in 66 (75%) cases and intact skin in all 88 (100%) cases. Contrary to NPUAP guidelines, the blanching effect was commonly present. Stage I pressure ulcers also presented with normal color in 17 (11.4%) instances and were accompanied by bogginess, pain, and induration. For sDTI pressure ulcers, the prevailing color presentation was purple discoloration in 130 (70%) of the 186 cases. Intact skin was observed in 140 (75.3%) cases of the 186 cases. CONCLUSION: Contrary to NPUAP guidelines, this study showed sDTIs can have a break in the skin, with 26 (14%) ulcers demonstrating this. This suggests the NPUAP definition may benefit from revision to improve the accuracy of sDTI identification among persons with darkly pigmented skin.

A two-year retrospective review of suspected deep tissue injury evolution in adult acute care patients.

Suspected deep tissue injury (sDTI) was recently defined as a pressure ulcer category, and knowledge about the evolution of these ulcers is limited. The purpose of this single-site, 2-year, retrospective, IRB-approved study was to increase understanding of the evolution and outcomes of sDTI. Inclusion criteria were hospitalized patients, 18 years or older, with a sDTI confirmed by a wound care nurse. Patient charts and WOC nurse notes were examined and patient demographics and DTI variables abstracted. All patients received standardized, comprehensive care for pressure ulcer prevention and treatment. Seventy-seven (77) patients, average age 67.5 years (range 32-91 years), with 128 sDTIs were identified and included in the study. The majority were men (52, 67.5%) and non-Hispanic Caucasian (68, 88.3%). Twenty-three (23, 31%) were overweight. The most common comorbidities were coronary artery disease (38, 50%) and diabetes mellitus (33, 43%), and the vast majority (67, 88.1%) had altered mobility (67, 88.1%), spent time in the intensive care unit (64, 84.2%), and were incontinent (64, 84.2%). The most common areas involved were the sacrum (51, 39.8%) and the heel/Achilles region (37, 28.9%). Maroon-purple discoloration of intact skin was the most commonly documented presentation (115 ulcers, 89.9%). Average length of follow-up was 6 days (range 1 day to 14 weeks). At the final assessment, 85 sDTIs (66.4%) completely resolved or were progressing toward resolution, 31 remained unchanged and were still documented as purple-maroon discoloration or a blood-filled blister, and deterioration to full-thickness tissue loss occurredin 12 (9.3%). These observations may offer important insights into the evolution of sDTIs. Research is needed to identify sDTI risk factors and most effective protocols of care.