Physical activity, sleep and cardiovascular health data for 50,000 individuals from the MyHeart Counts Study.

Studies have established the importance of physical activity and fitness for long-term cardiovascular health, yet limited data exist on the association between objective, real-world large-scale physical activity patterns, fitness, sleep, and cardiovascular health primarily due to difficulties in collecting such datasets. We present data from the MyHeart Counts Cardiovascular Health Study, wherein participants contributed data via an iPhone application built using Apple's ResearchKit framework and consented to make this data available freely for further research applications. In this smartphone-based study of cardiovascular health, participants recorded daily physical activity, completed health questionnaires, and performed a 6-minute walk fitness test. Data from English-speaking participants aged 18 years or older with a US-registered iPhone who agreed to share their data broadly and who enrolled between the study's launch and the time of the data freeze for this data release (March 10 2015-October 28 2015) are now available for further research. It is anticipated that releasing this large-scale collection of real-world physical activity, fitness, sleep, and cardiovascular health data will enable the research community to work collaboratively towards improving our understanding of the relationship between cardiovascular indicators, lifestyle, and overall health, as well as inform mobile health research best practices.

Assessing Insomnia in Active-Duty Service Members in a Military Primary Care Clinic.

BACKGROUND: Insomnia is a significant problem in the U.S. military, affecting the health, resiliency, and readiness of service members (Seelig et al., 2016). Although insomnia is a common sleep disorder among active-duty personnel (Mysliwiec et al., 2013), it often goes unrecognized and untreated because sleep disturbances are not routinely assessed during military primary care visits (U.S. Navy Medicine, 2014). OBJECTIVE: To introduce an evidence-based assessment for insomnia-the Insomnia Severity Index (ISI)-into a military primary care setting to increase the number of service members assessed for insomnia. METHODS: The ISI was integrated into the patient intake process at a military primary care clinic serving active-duty service members exclusively. Data were collected from 180 patients before implementation and 164 patients after implementation to compare the number of sleep assessments conducted. An independent samples t-test and Fisher's exact test were used to examine whether the ISI intervention led to an increase in insomnia assessment. RESULTS: A significant increase was found in patients who were evaluated for insomnia from pre-implementation (13.9%, n = 25/180) to post-implementation (90.3%, n = 148/164), p < .0001. CONCLUSIONS: A sleep screening process can be effectively implemented at a military primary care facility to increase the number of active-duty service members assessed for insomnia. IMPLICATIONS FOR NURSING: Sleep assessment is critically needed to identify service members with sleep disorders that may negatively impact their physical and mental health. An evidence-based screening tool is an important preventive measure that can be integrated into primary care visits to ensure routine evaluation of sleep.

High-Dose Interleukin-2: Evaluation of a Standardized Order Set for Biotherapy in an Intensive Care Unit
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BACKGROUND: Life-threatening toxicity may result from administration of high-dose (HD) interleukin-2 (IL-2). Patients receiving HD IL-2 treatment often experience severe adverse side effects, which result in the interruption of treatment. 
. OBJECTIVES: A standardized order set (SOS) was developed for patients with melanoma or renal cell carcinoma receiving HD IL-2. The aims of the study were to determine compliance of clinicians to the SOS, report the completed doses and major side effects of HD IL-2, and document the satisfaction level of clinicians.
. METHODS: A retrospective chart review of 40 health records of patients with melanoma or renal cell carcinoma who were treated with HD IL-2 was conducted to determine compliance to the SOS. Staff satisfaction with the SOS was surveyed.
. FINDINGS: The SOS was successfully implemented with a provider compliance rate of 90%. Cardiovascular side effects were the most common. Clinicians found the SOS very satisfactory or superior in guiding care and treatment of side effects.

Feasibility of Obtaining Measures of Lifestyle From a Smartphone App: The MyHeart Counts Cardiovascular Health Study.

Importance: Studies have established the importance of physical activity and fitness, yet limited data exist on the associations between objective, real-world physical activity patterns, fitness, sleep, and cardiovascular health. Objectives: To assess the feasibility of obtaining measures of physical activity, fitness, and sleep from smartphones and to gain insights into activity patterns associated with life satisfaction and self-reported disease. Design, Setting, and Participants: The MyHeart Counts smartphone app was made available in March 2015, and prospective participants downloaded the free app between March and October 2015. In this smartphone-based study of cardiovascular health, participants recorded physical activity, filled out health questionnaires, and completed a 6-minute walk test. The app was available to download within the United States. Main Outcomes and Measures: The feasibility of consent and data collection entirely on a smartphone, the use of machine learning to cluster participants, and the associations between activity patterns, life satisfaction, and self-reported disease. Results: From the launch to the time of the data freeze for this study (March to October 2015), the number of individuals (self-selected) who consented to participate was 48 968, representing all 50 states and the District of Columbia. Their median age was 36 years (interquartile range, 27-50 years), and 82.2% (30 338 male, 6556 female, 10 other, and 3115 unknown) were male. In total, 40 017 (81.7% of those who consented) uploaded data. Among those who consented, 20 345 individuals (41.5%) completed 4 of the 7 days of motion data collection, and 4552 individuals (9.3%) completed all 7 days. Among those who consented, 40 017 (81.7%) filled out some portion of the questionnaires, and 4990 (10.2%) completed the 6-minute walk test, made available only at the end of 7 days. The Heart Age Questionnaire, also available after 7 days, required entering lipid values and age 40 to 79 years (among 17 245 individuals, 43.1% of participants). Consequently, 1334 (2.7%) of those who consented completed all fields needed to compute heart age and a 10-year risk score. Physical activity was detected for a mean (SD) of 14.5% (8.0%) of individuals' total recorded time. Physical activity patterns were identified by cluster analysis. A pattern of lower overall activity but more frequent transitions between active and inactive states was associated with equivalent self-reported cardiovascular disease as a pattern of higher overall activity with fewer transitions. Individuals' perception of their activity and risk bore little relation to sensor-estimated activity or calculated cardiovascular risk. Conclusions and Relevance: A smartphone-based study of cardiovascular health is feasible, and improvements in participant diversity and engagement will maximize yield from consented participants. Large-scale, real-world assessment of physical activity, fitness, and sleep using mobile devices may be a useful addition to future population health studies.

Intrahospital Transport of the Critically Ill Adult: A Standardized Evaluation Plan.

BACKGROUND: Intrahospital transport of the critically ill adult carries inherent risks that can be manifested as unexpected events. OBJECTIVE: The aim of this study is to evaluate the implementation of a standardized evaluation plan for intrahospital transports to/from adult intensive care units. METHODS: Nurses at a level I trauma/academic center captured clinical data throughout transport. Outcome measures included compliance with the organization's transport policy and unexpected events. RESULTS: There were 502 transports audited. Most nurses were compliant with the policy, except for the stabilization process (n = 174, 34.7%). Forty-one transports (8.2%) had an unexpected event, and 11 of these transports (26.8%) were aborted. Most of the events were hemodynamic (12), sedation (11), respiratory (10), and gastrointestinal (5). Fewer events occurred with the transport team (P = .036) and among nurses with a bachelor of science in nursing or higher degree (P = .002). Events were higher among transporting nurses with only 0 to 2 years of intensive care unit experience (P = .002), "stabilized" transports (P = .022), and patients with higher Acute Physiology and Chronic Health Evaluation scores (P = .009). CONCLUSIONS: Health care organizations should have a policy that includes both transport and evaluation plans for intrahospital transport. Guidelines should be revised with specific criteria for the stabilization process and unexpected events. Revision should also have a standardized evaluation plan that includes an audit tool to measure incidence of unexpected events and a rapid change quality improvement method.

Operating Room Delays: Meaningful Use in Electronic Health Record.

Perioperative areas are the most costly to operate and account for more than 40% of expenses. The high costs prompted one organization to analyze surgical delays through a retrospective review of their new electronic health record. Electronic health records have made it easier to access and aggregate clinical data; 2123 operating room cases were analyzed. Implementing a new electronic health record system is complex; inaccurate data and poor implementation can introduce new problems. Validating the electronic health record development processes determines the ease of use and the user interface, specifically related to user compliance with the intent of the electronic health record development. The revalidation process after implementation determines if the intent of the design was fulfilled and data can be meaningfully used. In this organization, the data fields completed through automation provided quantifiable, meaningful data. However, data fields completed by staff that required subjective decision making resulted in incomplete data nearly 24% of the time. The ease of use was further complicated by 490 permutations (combinations of delay types and reasons) that were built into the electronic health record. Operating room delay themes emerged notwithstanding the significant complexity of the electronic health record build; however, improved accuracy could improve meaningful data collection and a more accurate root cause analysis of operating room delays. Accurate and meaningful use of data affords a more reliable approach in quality, safety, and cost-effective initiatives.

Coalition Building for Health: A Community Garden Pilot Project with Apartment Dwelling Refugees.

Refugees often experience compromised health from both pre- and post-migration stressors. Coalition theory has helped guide the development of targeted programs to address the health care needs of vulnerable populations. Using the Community Coalition Action Theory as a framework, a coalition was formed to implement a community garden with apartment-dwelling refugees. Outcomes included successful coalition formation, a community garden, reported satisfaction from all gardeners with increased vegetable intake, access to culturally meaningful foods, and evidence of increased community engagement. The opportunity for community health nurses to convene a coalition to affect positive health for refugees is demonstrated.

Transformation of Care: Integrating the Registered Nurse Care Coordinator into the Patient-Centered Medical Home.

The purpose of this quality improvement project was to implement and evaluate a care delivery model integrating the registered nurse care coordinator (RNCC) into a family practice that is certified as a patient-centered medical home (PCMH) by the National Committee for Quality Assurance. The initial target population was the 937 patients with diabetes in the family practice. A pre-post design was used to assess changes in patients' diabetic quality indicators after integrating the role of RNCC using existing staff. This 6-month project compared the following diabetic quality indicators: blood pressure < 140/90 mm Hg, hemoglobin A1c ≤ 7, low-density lipoprotein cholesterol < 100 mg/dL, documentation of smoking cessation counseling, and aspirin prescription if existing vascular disease. Yearly documentation of microalbuminurea level, and filament foot and retinal examination was assessed. Patient and health care team satisfaction also was measured. Care coordination interventions included: telehealth, group visits, standardized individual patient education, as well as creative uses of the electronic medical record for workflow changes, daily huddles, and monthly meetings. The results were positive, statistically significant differences in the pre and post scores for A1c (P = .001, n = 790), foot exam (P = .001, n = 850), and microalbumin (P = .01, n = 850). Post intervention, patient and health care team satisfaction with the RNCC role was high (mean scores ≥3 on a 5-point Likert scale). Integrating the RNCC within a multidisciplinary team in the PCMH had a significant positive impact on diabetic quality indicators. Patient and health care team satisfaction with the RNCC role was high.

Policy to practice: increased family presence and the impact on patient- and family-centered care adoption.

OBJECTIVE: This quality improvement study introduced 24/7 family presence and measured its impact in 3 categories; perceptions, complaints, and patient experience scores. This article offers insight for leaders into the 1st phase of patient- and family-centered care (PFCC) adoption. BACKGROUND: Family presence improves patient safety and satisfaction; however, 70% of US healthcare organizations maintain restrictive visitation policies. METHODS: We surveyed nursing staff 6 months postinnovation to determine staff knowledge, implementation practices, and perceived challenges to implementation. We surveyed system leaders regarding PFCC transformation and trended formal complaints and patient experience scores after family presence innovation. RESULTS: Findings provide insight for leaders into family presence policy adherence challenges experienced by staff. Leaders perceived significant transformation toward PFCC adoption postinnovation. Complaints increased postinnovation, and patient experience scores demonstrated positive trends. CONCLUSIONS: We gained insight regarding challenges to policy adherence and identified next steps for leaders in the transformation toward PFCC adoption.

Implementing evidence-based medication safety interventions on a progressive care unit.

While preparing medications in complex health care environments, nurses are frequently distracted or interrupted, which can lead to medication errors that may adversely affect patient outcomes. This pilot quality improvement project, which took place in a 32-bed surgical progressive care unit in an academic medical center, implemented five medication safety interventions designed to decrease distractions and interruptions during medication preparation: nursing staff education, use of a medication safety vest, delineation of a no-interruption zone, signage, and a card instructing nurses how to respond to interruptions. Four types of distractions and interruptions decreased significantly between the two-month preimplementation and two-month postimplementation periods: those caused by a physician, NP, or physician assistant; those caused by other personnel; phone calls and pages placed or received by the nurse during medication administration; and conversation unrelated to medication administration that involved the nurse or loud nearby conversation that distracted the nurse. The total number of reported adverse drug events also decreased from 10 to four, or by 60%. Thus, medication safety interventions may help decrease distractions and interruptions in high-acuity settings.

The language of data: tools to translate evidence for nurses in clinical practice.

In clinical practice, nurses are expected to understand and implement the science that supports patient care, yet they fall short of goals to implement evidence in practice. One reason is difficulty in interpreting research results. Interpretation requires an ability to read and speak a language that many nurses have never mastered-the language of data. This article presents a skill-based solution for use in nursing professional development to improve nurses' understanding of statistics as a language.

Implementation of the Josie King Care Journal in a pediatric intensive care unit: a quality improvement project.

The Care Journal is a tool developed by the Josie King Foundation to promote interactive exchange among providers and patients/families. The Care Journal was implemented in a pediatric intensive care unit, and surveys were administered to assess perceptions about use. Parents who used the Care Journal and nursing staff found it to be a useful tool that improved communication, made parents feel more knowledgeable and empowered, and improved parents' overall perception of the hospital stay.

Evaluation of a nurse-led safety program in a critical care unit.

This implementation of a formalized safety program in a critical care unit highlights the importance of the "voice of the caregiver," as it relates to patient safety. This nurse-led program featured executive walkrounds and a multidisciplinary core team whose goal was to prioritize and resolve safety issues identified during the 6-month study period. Unit nurses' scores on the Safety Attitudes Questionnaire remained stable from July 2011 to February 2012. Staff identified 77 safety issues during executive walkrounds; 57% were resolved during the study period. Results indicate the clinical significance of nurse-led patient safety programs.

Focused anesthesia interview resource to improve efficiency and quality.

In an effort to reduce costs, many hospitals may use registered nurses (RNs) with little to no formal education or training in anesthetic or surgical risk to perform anesthesia preoperative interviews (APIs). This lack of education and training can result in day of surgery delays and cancellations because of suboptimal preparation of patients for anesthesia and surgery. The Focused Anesthesia Interview Resource (FAIR) establishes minimum educational preparation for conducting APIs through educational modules and electronic triggers that prompt further questions and consultation flags or comorbidities for which an anesthesia provider is consulted. The goal of this process improvement project was to determine if fidelity to the FAIR tool enhanced the ability of RNs to perform preoperative anesthesia interviews and, if so, did this result in decreased surgical cancellations and delays? Retrospectively, we assessed completion rates of the training modules and anesthesia preoperative records as well as day of surgery cancellation and delay rates before and after the implementation of the FAIR tool. All RNs who might rotate to the API clinic (n=33) were included in the sample. Nurse fidelity to completion of the training modules was high (91%). Five hundred anesthesia interview records were randomly selected, reviewed, and completion rates scored. Our pre-/post-quasi-experimental design compared record completion rates. After the implementation of FAIR, significant improvement in identification of patients with hypertension (P<.01) and cardiac disease (P<.05) was noted. In addition, cancellation rates declined from 3.33% to 2.31% (P<.05) and first case delays decreased from 7.54% to 6.99%, although this was not statistically significant. FAIR improved preoperative record completion rates and decreased surgical cancellations, which improved perioperative quality and efficiency.

Diffusion of innovations in long-term care measurement battery.

Poor understanding of factors influencing integration of new practices into long-term care (LTC) hinders timely implementation of evidence-based practices (EBPs). Using the Diffusion of Innovations (DOI) framework, a new instrument measuring staff perceptions of an EBP was developed as part of a DOI-LTC measurement battery and tested in a cross-sectional survey of North Carolina LTC nursing personnel. Valid questionnaires were received from 95 licensed nurses and 102 certified nursing assistants (CNAs). Internal consistency reliability for five of seven subscales was acceptable (Cronbach's alpha coefficient = 0.77 to 0.95). Perception of innovation attributes was associated with intention to adopt the new practice (Spearman rho correlation: licensed nurses = 0.41 to 0.68, p < 0.0001; CNAs = 0.26 to 0.54, p = 0.05 to <0.0001). The DOI-LTC measurement battery represents a promising new approach to studying implementation of EBPs in LTC. Future work should examine its responsiveness to interventions that facilitate implementation of EBPs in LTC.

Utilizing a diabetic registry to manage diabetes in a low-income Asian American population.

Racial and income disparities persist in diabetes management in America. One third of African and Hispanic Americans with diabetes receive the recommended diabetes services (hemoglobin A1c [A1c] testing, retinal and foot examinations) shown to reduce diabetes complications and mortality, compared to half of whites with diabetes. National data for Asian Americans are limited, but studies suggest that those with language and cultural barriers have difficulty accessing health services. A diabetic registry has been shown to improve process and clinical outcomes in a population with diabetes. This study examined whether a community center that serves primarily low-income Asian American immigrants in Santa Clara County, California, could improve diabetes care and outcomes by implementing a diabetic registry. The registry was built using the Access 2007 software program. A total of 580 patients with diabetes were identified by reviewing charts, the appointment database, and reimbursement records from Medicaid, Medicare, and private insurance companies. Utilizing the registry, medical assistants contacted patients for follow-up appointments, and medical providers checked and tracked the patients' A1c results. Among the 431 patients who returned for treatment, the mean A1c was reduced from 7.27% to 6.97% over 8 months (P<0.001). Although 10.8% of the patients changed from controlled to uncontrolled diabetes post intervention, 32.6% of patients with uncontrolled diabetes converted to controlled diabetes (P<0.001). The diabetes control rate improved from 47% to 59% at the end of the study. This study demonstrated that a diabetic registry is an effective tool to manage an underserved population with diabetes, thereby reducing disparities in diabetes management.

Implementation of condition help: family teaching and evaluation of family understanding.

Partnering with families to deliver safe care includes teaching how to activate the rapid response team (RRT) if their hospitalized child's condition worsens. Condition Help (Condition H) is how families call the RRT. Pediatric nurses used scripted Condition H teaching and follow-up surveys to evaluate family understanding about Condition H. Although there were only 2 Condition H calls during the study period, 53% to 90% of families received Condition H teaching, and family understanding was greater than 75%.