Coding for Physical Restraint Status Among Hospitalized Patients: a 2019 National Inpatient Sample Analysis.

BACKGROUND: The reduction of physical restraint utilization in the hospital setting is a key goal of high-quality care, but little is known about the rate of restraint use in general hospitals in the USA. OBJECTIVE: This study reports the rate of physical restraint coding among acute care hospital discharges in the USA and explores associated demographic and diagnostic factors. DESIGN: The National Inpatient Sample, a de-identified all-payors database of acute care hospital discharges in the USA, was queried for patients aged 18 and older with a diagnosis code for physical restraint status in 2019. PARTICIPANTS: Hospitalized patients aged 18 and older. MAIN MEASURES: Demographics, discharge diagnoses, in-hospital mortality, length of stay, total hospital charges. KEY RESULTS: In total, 220,470 (95% CI: 208,114 to 232,826) hospitalizations, or 0.7% of overall hospitalizations, included a discharge code for physical restraint status. There was a 700-fold difference in coding for restraint utilization based on diagnosis, with 7.4% of patients with encephalitis receiving restraint diagnosis codes compared to < 0.01% of patients with uncomplicated diabetes. In an adjusted model, male sex was associated with an odds ratio of 1.4 (95% CI: 1.4 to 1.5) for restraint utilization coding, and Black race was associated with an odds ratio of 1.3 (95% CI: 1.2 to 1.4) relative to white race. CONCLUSIONS: In the general hospital setting, there is variability in physical restraint coding by sex, race, and clinical diagnosis. More research is needed into the appropriate utilization of restraints in the hospital setting and possible inequities in restraint utilization.

Experiences of moral distress in a COVID-19 intensive care unit: A qualitative study of nurses and respiratory therapists in the United States.

The COVID-19 pandemic has placed extraordinary stress on frontline healthcare providers as they encounter significant challenges and risks while caring for patients at the bedside. This study used qualitative research methods to explore nurses and respiratory therapists' experiences providing direct care to COVID-19 patients during the first surge of the pandemic at a large academic medical center in the Northeastern United States. The purpose of this study was to explore their experiences as related to changes in staffing models and to consider needs for additional support. Twenty semi-structured interviews were conducted with sixteen nurses and four respiratory therapists via Zoom or by telephone. Interviews were transcribed verbatim, identifiers were removed, and data was coded and analyzed thematically. Five major themes characterize providers' experiences: a fear of the unknown, concerns about infection, perceived professional unpreparedness, isolation and alienation, and inescapable stress and distress. This manuscript analyzes the relationship between these themes and the concept of moral distress and finds that some, but not all, of the challenges that providers faced during this time align with previous definitions of the concept. This points to the possibility of broadening the conceptual parameters of moral distress to account for providers' experiences of treating patients with novel illnesses while encountering institutional and clinical challenges.

Pressure Injury Development, Mitigation, and Outcomes of Patients Proned for Acute Respiratory Distress Syndrome.

OBJECTIVE: To describe trends and risk factors for pressure injuries (PIs) in adult critical care patients proned to alleviate acute respiratory distress syndrome secondary to COVID-19 and examine the effectiveness of products and strategies used to mitigate PIs. METHODS: The authors conducted a retrospective chart review between April 9 and June 8, 2020. Demographic data were analyzed using descriptive statistics. Differences between groups with and without PIs were analyzed. RESULTS: Among 147 patients, significant PI risk factors included male sex (P = .019), high body mass index (>40 kg/m2; P = .020), low Braden Scale score (<12; P = .018), and low-dose vasopressor therapy (P = .020). Taping endotracheal tubes (ETTs) caused significantly fewer facial PIs than commercial ETT holders (P < .0001). Maximum prone duration/session was a significant risk factor for anterior PIs (P = .016), which dropped 71% with newer pressure redistribution products. d-Dimer greater than 3,200 µg/mL (P = .042) was a significant risk factor for sacrococcygeal PIs while supine. Mortality was 30%; significant risk factors included age older than 60 years (P = .005), Sequential Organ Failure Assessment score greater than 11 (P = .003), and comorbid congestive heart failure (P = .016). CONCLUSIONS: Taping the ETT, limiting the maximum duration of prone positioning to less than 32 hours, and frequent repositioning while supine may reduce the number of modifiable risk factors for PIs. Standardized methods for testing products for PI prevention will inform individualized patient care.

Encountering the social determinants of health on a COVID-19 ICU: Frontline providers' perspectives on inequality in a time of pandemic.

Efforts to improve health equity may be advanced by understanding health care providers' perceptions of the causes of health inequalities. Drawing on data from in-depth interviews with nurses and registered respiratory therapists (RRTs) who served on intensive care units (ICUs) during the first surge of the pandemic, this paper examines how frontline providers perceive and attribute the unequal impacts of COVID-19. It shows that nurses and RRTs quickly perceived the pandemic's disproportionate burden on Black and Latinx individuals and families. Providers attribute these inequalities to the social determinants of health, and also raise questions about how barriers to healthcare access may have made some patients more vulnerable to the worst consequences of COVID-19. Providers' perceptions of inequality and its consequences on COVID-19 ICUs were emotionally impactful and distressing, suggesting that this is a critical moment for offering clinicians practical strategies for understanding and addressing the persistent structural inequities that cause racial inequalities in health.

Nursing Attitudes and Practices in Code Documentation Employing a New Electronic Health Record.

OBJECTIVE: Based on feedback from nurses regarding the challenges of code documentation following the implementation of a new electronic health record (EHR), we sought to better understand inpatient nurse attitudes and practices in code documentation and to identify opportunities for improvement. METHODS: An anonymous electronic survey was distributed to all inpatient nurses working at a single, 999-bed, university-based, and quaternary care hospital. Participation in the study was voluntary and consent was implied by survey completion. RESULTS: Overall, 432 (14%) of 3,121 inpatient nurses completed the survey. While nearly 80% of respondents indicated feeling very comfortable using computers for personal use, only 5% felt very comfortable navigating the EHR to document codes in real time. While 53% had documented codes in the new EHR, most admitted to documenting on paper with retroactive entry into the EHR. About 25% reported having participated in a code that was not accurately documented in the new EHR. All respondents provided specific suggestions for improving the EHR interface, and over 90% expressed interest in having opportunities to practice code documentation using simulated code events. CONCLUSION: Despite completion of training modules in code documentation in a new EHR, many inpatient nurses in a single institution feel uncomfortable documenting codes directly into the EHR, and some question the accuracy of this documentation. Improving EHR functionality based on specific recommendations from end-users coupled with more practice documenting simulated codes may ease EHR navigation, leading to nurses' acceptance of the EHR tool, more accurate and efficient documentation, greater nurse satisfaction and more appropriate quality improvement measures.

Intensive care unit nurses living through COVID-19: A qualitative study.

AIMS: To understand how nurses experience providing care for patients hospitalized with COVID-19 in intensive care units. BACKGROUND: As hospitals adjust staffing patterns to meet the demands of the pandemic, nurses have direct physical contact with ill patients, placing themselves and their families at physical and emotional risk. METHODS: From June to August 2020, semi-structured interviews were conducted. Sixteen nurses caring for COVID-19 patients during the first surge of the pandemic were selected via purposive sampling. Participants worked in ICUs of a quaternary 1,000-bed hospital in the Northeast United States. Interviews were transcribed verbatim, identifiers were removed, and data were coded thematically. RESULTS: Our exploratory study identified four themes that describe the experiences of nurses providing care to patients in COVID-19 ICUs during the first surge: (a) challenges of working with new co-workers and teams, (b) challenges of maintaining existing working relationships, (c) role of nursing leadership in providing information and maintaining morale and (d) the importance of institutional-level acknowledgement of their work. CONCLUSIONS: As the pandemic continues, hospitals should implement nursing staffing models that maintain and strengthen existing relationships to minimize exhaustion and burnout. IMPLICATIONS FOR NURSING MANAGEMENT: To better support nurses, hospital leaders need to account for their experiences caring for COVID-19 patients when making staffing decisions.

Development of a Prone Team and Exploration of Staff Perceptions During COVID-19.

OBJECTIVE: As intensive care unit bed capacity doubled because of COVID-19 cases, nursing leaders created a prone team to support labor-intensive prone positioning of patients with COVID-related acute respiratory distress syndrome. The goal of the prone team was to reduce workload on intensive care teams, standardize the proning process, mitigate pressure injuries and turning-related adverse events, and ensure prone team safety. METHODS: Staff were trained using a hybrid learning model focused on prone-positioning techniques, pressure injury prevention, and turning-related adverse events. RESULTS: No adverse events occurred to patients or members of the prone team. The prone team mitigated pressure injuries using prevention strategies. The prone team and intensive care unit staff were highly satisfied with their experience. CONCLUSION: The prone team provided support for critically ill patients, and team members reported feeling supported and empowered. Intensive care unit staff were highly satisfied with the prone team.

Interdisciplinary Patient Tracers: Routine, Systematic Safety Surveillance.

Patient tracers and leadership WalkRounds proactively identify quality and safety issues. However, these programs have been inconsistent in application, results, and sustainability. The goal was to identify a more consistent and efficient approach to survey health care facilities. The authors developed a Peer-to-Peer Interdisciplinary Patient Tracer program to assess compliance with National Patient Safety Goals and to proactively identify areas of inpatient, ambulatory, and procedural risk. The program has been operational for more than 5 years, with continued expansion annually. In all, 96% of frontline leadership reported satisfaction; 100% reported that they would recommend the program to others (Kirkpatrick level 1 results). Mean absolute change in performance scores from 2014 to 2018 was 15%. All survey findings triggered the development of an improvement project. This novel integrated program advanced institutional improvement by strengthening internal peer-to-peer surveillance, engaging leadership, and creating an accountability structure for internal improvement efforts.

Association of Hospital Characteristics With Early SEP-1 Performance.

A variety of hospital characteristics, including teaching status, ownership, location, and size, have been shown to be associated with quality measure performance. The association of hospital characteristics, including teaching intensity, with performance on the Centers for Medicare & Medicaid Services (CMS) SEP-1 sepsis measure has not been well studied. Utilizing a statewide, all-payer database and the CMS Hospital Compare database, this study investigated the association of various hospital characteristics with early SEP-1 performance in 48 acute hospitals in Massachusetts. Hospital teaching intensity and Magnet designation did not have a statistically significant association with SEP-1 performance in multivariable linear modeling. However, SEP-1 performance was higher in smaller, for-profit hospitals with higher case mix index. This finding suggests that emergency department activity, hospital ownership, and patient complexity should be studied further across a larger geographic spectrum and longitudinally as hospitals implement efforts to reduce morbidity associated with sepsis.

Development and Implementation of a Suicide Prevention Checklist to Create a Safe Environment.

BACKGROUND: An increasing number of patients are admitted to general hospitals for injuries sustained in suicide attempts and for assessment of their ongoing risk for suicide. However, clinical staff may lack knowledge and expertise in the provision of a safe environment for potentially suicidal patients. OBJECTIVE: In an effort to follow the Joint Commission's recommendations on the care of suicidal patients, a Suicide Prevention Interdisciplinary Task Force was created. The task force sought to design and implement a suicide checklist that would facilitate creation of a safe environment for potentially suicidal inpatients on nonpsychiatric units in a general hospital. METHODS: We describe the development and implementation of a Care of the Suicide and Self-Injury Patient Checklist and report on data derived from incident reports related to self-harm/suicide attempts over a 4-year period. We also report results of a Research Electronic Data Capture survey of nurses' feedback on the checklist. RESULTS: After implementation of the Care of the Suicide and Self-Injury Patient Checklist, a total of 47 incidents of patient self-injury were reported over 4 years on nonpsychiatric inpatient units at a large general hospital; only three sustained permanent or serious harm. The Research Electronic Data Capture survey revealed that 88% of responding nurses believed that the Care of the Suicide and Self-Injury Patient Checklist guided creation of a safe environment and 90% believed that it supported consistent practice. CONCLUSIONS: The Care of the Suicide and Self-Injury Patient Checklist contributed to the creation of a safe environment while caring for potentially suicidal patients on nonpsychiatric inpatient units and guided clinicians on the management of potentially self-injurious individuals.

Meta-Analysis of Clinical Trials That Evaluate the Effectiveness of Hospital-Initiated Postdischarge Interventions on Hospital Readmission.

Under pressure to avoid readmissions, hospitals are increasingly employing hospital-initiated postdischarge interventions (HiPDI), such as home visits and follow-up phone calls, to help patients after discharge. This study was conducted to assess the effectiveness of HiPDI on reducing hospital readmissions using a systematic review of clinical trials published between 1990 and 2014. We analyzed twenty articles on HiPDI (from 503 reviewed abstracts) containing 7,952 index hospitalizations followed for a median 3 months (range 1-24) after discharge for readmission. The two most common HiPDI included follow-up phone calls (n = 14, 70%) or home visits (n = 11, 55%); eighty-five percent (n = 17) of studies had multiple HiPDI. In meta-analysis, exposure to HiPDI was associated with a lower likelihood of readmission (odds ratio [OR], 0.8 [95% CI, 0.7-0.9]). Patients receiving ≥2 postdischarge home visits or ≥2 follow-up phone calls had the lowest likelihood of readmission (OR, 0.5 [95% CI, 0.4-0.8]). Hospital-initiated postdischarge interventions seem to have an effect on reducing hospital readmissions. Together, multiple home visits and follow-up phone calls may be the most effective HiPDI to reduce hospital readmission.

Feasibility and safety of combined percutaneous coronary intervention and therapeutic hypothermia following cardiac arrest.

REVIEW: Mild therapeautic hypothermia (MTH) has been associated with cardiac dysrhythmias, coagulopathy and infection. After restoration of spontaneous circulation (ROSC), many cardiac arrest patients undergo percutaneous coronary intervention (PCI). The safety and feasibility of combined MTH and PCI remains unclear. This is the first study to evaluate whether PCI increases cardiac risk or compromises functional outcomes in comatose cardiac arrest patients who undergo MTH. METHODS: Ninety patients within a 6-h window following cardiac arrest and ROSC were included. Twenty subjects (23%) who underwent PCI following MTH induction were compared to 70 control patients who underwent MTH without PCI. The primary endpoint was the rate of dysrhythmias; secondary endpoints were time-to-MTH induction, rates of adverse events (dysrhythmia, coagulopathy, hypotension and infection) and mortality. RESULTS: Patients who underwent PCI plus MTH suffered no statistical increase in adverse events (P=.054). No significant difference was found in the rates of dysrhythmias (P=.27), infection (P=.90), coagulopathy (P=.90) or hypotension (P=.08). The PCI plus MTH group achieved similar neurological outcomes (modified Rankin Scale (mRS)

A model of recovering medical errors in the coronary care unit.

OBJECTIVE: The purpose of this study was to explore the thoughts, interpersonal processes, and actions used by nurses who had recently intervened to protect coronary care unit (CCU) patients from potential medical errors. METHODS: The study used semistructured interviews conducted with 18 very experienced CCU nurses in two academic medical centers. Content analysis was used to code and analyze text segments. Core codes were used for developing an empirically derived model. RESULTS: There were more than 1000 data bits of accounts of involvement in the near-miss events, thought processes and actions surrounding the events, communication strategies used, feelings, outcomes, reflection about the event and consequences, and environment/context in which the events occurred. A three-stage temporally ordered model illustrates the process of recovering medical errors. In stage one, the presence of the evolving clinical scenario and nursing knowledge and expertise plus the CCU context are the antecedents that lead to processes and actions of identification, interruption, and correction of the error in stage two. Outcomes of whether or not the near miss was recovered lead to an adverse event (or not), and reflections on the process and outcome lead to the nurse's feelings about the event in stage three. CONCLUSIONS: The model can guide nursing administration, practice, education, and research to recognize and value this responsibility, to teach others, and to test strategies to enhance the vital nursing role of recovering near-miss events that leads to safer and better patient care.