Exploring the relationship between AM-PAC scores and mobility components in falls and pressure injury risk assessment tools: A pathway to improve nursing clinical efficiency.

BACKGROUND: Nurses routinely perform multiple risk assessments related to patient mobility in the hospital. Use of a single mobility assessment for multiple risk assessment tools could improve clinical documentation efficiency, accuracy and lay the groundwork for automated risk evaluation tools. PURPOSE: We tested how accurately Activity Measure for Post-Acute Care (AM-PAC) mobility scores predicted the mobility components of various fall and pressure injury risk assessment tools. METHOD: AM-PAC scores along with mobility and physical activity components on risk assessments (Braden Scale, Get Up and Go used within the Hendrich II Fall Risk Model®, Johns Hopkins Fall Risk Assessment Tool (JHFRAT) and Morse Fall Scale) were collected on a cohort of hospitalised patients. We predicted scores of risk assessments based on AM-PAC scores by fitting of ordinal logistic regressions between AM-PAC scores and risk assessments. STROBE checklist was used to report the present study. FINDINGS: AM-PAC scores predicted the observed mobility components of Braden, Get Up and Go and JHFRAT with high accuracy (≥85%), but with lower accuracy for the Morse Fall Scale (40%). DISCUSSION: These findings suggest that a single mobility assessment has the potential to be a good solution for the mobility components of several fall and pressure injury risk assessments.

Validation of the Hendrich II Fall Risk Model: The imperative to reduce modifiable risk factors.

AIM: To validate the psychometrics of the Hendrich II Fall Risk Model (HIIFRM) and identify the prevalence of intrinsic fall risk factors in a diverse, multisite population. BACKGROUND: Injurious inpatient falls are common events, and hospitals have implemented programs to achieve "zero" inpatient falls. METHODS: Retrospective analysis of patient data from electronic health records at nine hospitals that are part of Ascension. Participants were adult inpatients (N = 214,358) consecutively admitted to the study hospitals from January 2016 through December 2018. Fall risk was assessed using the HIIFRM on admission and one time or more per nursing shift. RESULTS: Overall fall rate was 0.29%. At the standard threshold of HIIFRM score ≥ 5, 492 falls and 76,800 non-falls were identified (fall rate 0.36%; HIIFRM specificity 64.07%, sensitivity 78.72%). Area under the receiver operating characteristic curve was 0.765 (standard error 0.008; 95% confidence interval 0.748, 0.781; p < 0.001), indicating moderate accuracy of the HIIFRM to predict falls. At a lower cut-off score of ≥4, an additional 74 falls could have been identified, with an improvement in sensitivity (90.56%) and reduction in specificity (44.43%). CONCLUSION: Analysis of this very large inpatient sample confirmed the strong psychometric characteristics of the HIIFRM. The study also identified a large number of inpatients with multiple fall risk factors (n = 77,292), which are typically not actively managed during hospitalization, leaving patients at risk in the hospital and after discharge. This finding represents an opportunity to reduce injurious falls through the active management of modifiable risk factors.

Consent and enrollment process: achieving high enrollment rates for obstetric research.

AIM: The aim was to study the development, design, and implementation of a patient consent and enrollment initiative to identify strategies that enhanced participation. BACKGROUND: Consent and enrollment of patients, especially pregnant women, remains a challenge in healthcare research. Although many barriers have been identified, strategies to consistently improve consent and enrollment are less defined. METHODS: A case study was conducted on a consent and enrollment approach aimed at optimizing participation of mothers who delivered their infants from July 1, 2010 through June 30, 2013. Data were gathered through practitioner interviews, focus groups, and documentation review for each year of the study. RESULTS: A total of 19,236 mothers enrolled, representing an 85% enrollment rate at the five study sites. Enrollment rates improved over time with increased nursing engagement in patient recruitment, site specific adaptations and patient education strategies. CONCLUSIONS: Nursing's active role in implementation and rapid feedback loop of a multifaceted consent and enrollment program showed promise.

Avoiding potential harm by improving appropriateness of urinary catheter use in 18 emergency departments.

STUDY OBJECTIVE: Urinary catheters are often placed in the emergency department (ED) and are associated with an increased safety risk for hospitalized patients. We evaluate the effect of an intervention to reduce unnecessary placement of urinary catheters in the ED. METHODS: Eighteen EDs from 1 health system underwent the intervention and established institutional guidelines for urinary catheter placement, provided education, and identified physician and nurse champions to lead the work. The project included baseline (7 days), implementation (14 days), and postimplementation (6 months, data sampled 1 day per month). Changes in urinary catheter use, indications for use, and presence of physician order were evaluated, comparing the 3 periods. RESULTS: Sampled patients (13,215) admitted through the ED were evaluated, with 891 (6.7%; 95% confidence interval [CI] 6.3% to 7.2%) having a catheter placed. Newly placed catheters decreased from 309 of 3,381 (9.1%) baseline compared with 424 of 6,896 (6.1%) implementation (Δ 3.0%; 95% CI 1.9% to 4.1%), and 158 of 2,938 (5.4%) postimplementation periods (Δ 3.8%; 95% CI 2.5% to 5.0%). The appropriateness of newly placed urinary catheters improved from baseline (228/308; 74%) compared with implementation (385/421; 91.4%; Δ 17.4%; 95% CI 11.9% to 23.1%) and postimplementation periods (145/158; 91.8%; Δ 23.9%; 95% CI 18% to 29.3%). Physician order documentation in the presence of the urinary catheter was 785 of 889 (88.3%), with no visible change over time. Improvements were noted for different-size hospitals and were more pronounced for hospitals with higher urinary catheter placement baseline. CONCLUSION: The implementation of institutional guidelines for urinary catheter placement in the ED, coupled with the support of clearly identified physician and nurse champions, is associated with a reduction in unnecessary urinary catheter placement. The effort has a substantial potential of reducing patient harm hospital-wide.

The ascension health experience: maximizing the chief nursing officer role in a large, multihospital system to advance patient care quality and safety.

Ascension Health is the largest Catholic and nonprofit health system in the United States, encompassing 70 acute care hospitals organized into 34 health ministries. Consistent with its distributed leadership model, Ascension Health has created a Chief Nursing Officer (CNO) Advisory Council to provide strategic direction and thought leadership on major system-level initiatives that impact quality, safety, operational performance, nursing leadership, and patient care delivery. The council fosters systemwide CNO engagement and dialogue through a unique structure of regional CNO work teams called "pods," each of which is chaired by a member of the council. This communication structure has facilitated consensus on major system initiatives at Ascension Health related to clinical goals, patient safety, nursing leadership, and systemwide capital investments. This article describes the history, structure, goals, processes, and successes of the CNO Advisory Council shared governance model.

CE: Reimagining Injurious Falls and Safe Mobility.

ABSTRACT: Injurious falls remain among the most common, dangerous, and costly adverse events in hospitals, despite the widespread implementation of fall prevention programs. Many current health care system policies and nursing practices oversimplify fall prevention by focusing on limiting the person's mobility and making the environment safer, or simply documenting a fall risk score. But most falls are caused by factors intrinsic to that individual; merely limiting their mobility can increase preventable hospital complications and readmissions, and still leaves them at risk for falls. This article proposes a new approach to reducing injurious falls in older adults-one grounded in evidence-based protocols known to positively impact the health of older adults. The approach, called by the acronym ERA-Electronic health record integration, Risk factors that matter, Assessment and care plans-allows nurses to use a validated fall risk assessment tool to reframe fall risk factors as part of the comprehensive care plan, and to map modifiable risk factors to interventions that address the underlying causes of falls and promote safer mobility. The ERA approach can help nurses use their time more effectively by focusing on targeted actions that improve patient outcomes, working in coordination with an interprofessional, cross-continuum care team.

Disproportionate Preterm Delivery Among Black Women: a State-Level Analysis.

Preterm delivery occurs at extraordinarily higher rates among Black women than among women of any other race or ethnicity. For those children who survive, many face a lifetime of health and developmental challenges as well as difficulties in school and life. Previous studies have provided substantive evidence that the preterm delivery disparity experienced by Black women is associated with ongoing distress caused by racism. Our study examines rates of preterm delivery for Black women in the USA to determine the level of risk associated with living in specific states. Using a logistic regression model, we examined the impact of the delivery state, controlling for known clinical, economic, and demographic risk factors. We found that 32 of the 35 states included in our analysis were associated with a statistically significantly increased risk of preterm delivery among Black women, as compared to the state with the lowest preterm delivery rate for Black women. These findings allowed us to organize states into a continuum of preterm delivery risk. Because of the harmful effects of preterm delivery and its disproportionate impact among Black women and infants, we recommend that a measure of preterm delivery be included in any state plan to assess, intervene in, and monitor racial disparities.

A proclamation for change: transforming the hospital patient care environment.

Mounting evidence describes inefficiencies in the hospital work environment that threaten the safety and sustainability of care. In response to these concerns, diverse experts convened to create a set of evidence-based recommendations for the transformation of the hospital work environment. The resulting Proclamation for Change, now endorsed by multiple health systems and professional and consumer organizations, cites patient-centered design, systemwide integrated technology, seamless workplace environments, and vendor partnerships as the cornerstones of transformational change.

Sustaining and spreading quality improvement: Decreasing intrapartum malpractice risk.

BACKGROUND: Malpractice liability is an ongoing problem in obstetrics. However, developing, sustaining, and spreading effective interventions is challenging. The aim of this study is to examine the spread and sustainability of a multilevel integrated practice and coordinated communication model 66 months after its original implementation. METHODS: Data on labor and delivery patients from 37 hospitals (5 beta sites and 32 expansion sites) were analyzed for the 81-month time period from January 2010 through September 2016. RESULTS: High-risk occurrence rates per 1000 live births decreased by over 70% at both beta and expansion sites. The likelihood of a high-risk occurrence was statistically significantly lower during the final study period than in the preintervention period at both beta sites (odds ratio [OR] = 0.218; p < .0001) and expansion sites (OR = 0.288; p < .001). CONCLUSION: The multilevel integrated practice and coordinated communication model was successfully spread and sustained. Key elements contributing to this success included developing and maintaining evidence-based guidelines, ensuring leadership buy-in and support, collecting and reporting performance measures, holding teams accountable, providing training, and ensuring transparent communication.

The case for a population standardized infection ratio (SIR): A metric that marries the device SIR to the standardized utilization ratio (SUR).

BACKGROUND: The device standardized infection ratio (SIR) is used to compare unit and hospital performance for different publicly reported infections. Interventions to reduce unnecessary device use may select a higher-risk population, leading to a paradoxical increase in SIR for some high-performing facilities. The standardized utilization ratio (SUR) adjusts for device use for different units and facilities. METHODS: We calculated the device SIR (calculated based on actual device days) and population SIR (defined as Σ observed events divided by Σ predicted events based on predicted device days), adjusting for the facility SUR for both central-line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) in 84 hospitals from a single system for calendar years 2016 and 2017. RESULTS: The central-line SUR was 1.02 for 801,172 central-line days, with a device SIR of 0.76 and a population SIR of 0.78, a 1.6% relative increase. On the other hand, the urinary catheter SUR was 0.90 for 757,504 urinary catheter days, with a device SIR of 0.84 and a population SIR of 0.76, a 10.0% relative decrease. The cumulative attributable difference for CAUTI to a target SIR of 1 was -135.4 for the device SIR compared to -203.66 for the population SIR, a 50.8% increase in prevented events. CONCLUSION: Population SIR accounts for predicted device utilization; thus, it is an attractive metric with which to address overall risk of infection or harm to a patient population. It also reduces the risk of selection bias that may impact the device SIR with interventions to reduce device use.

Risk Factors for Shoulder Dystocia: the Impact of Mother's Race and Ethnicity.

Shoulder dystocia is a rare but severe birth trauma where the neonate's shoulders fail to deliver after delivery of the head. Failure to deliver the shoulders quickly can lead to severe, long-term injury to the infant, including nerve injury, skeletal fractures, and potentially death. This observational study examined shoulder dystocia risk factors by race and ethnicity using a sample of 19,236 pregnant women who presented for labor and delivery from July 1, 2010 until June 30, 2013 at five locations. Multivariate analyses were used to identify risk factors associated with shoulder dystocia occurrence in racial/ethnic groups with high incidence rates. For White non-Hispanic mothers, the strongest risk factors were delivering past 40 weeks' gestation (odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.5, 3.9; p < .01) and use of epidural anesthesia during delivery (OR = 4.4; 95% CI = 3.0, 6.4; p < .01). Among Black non-Hispanic mothers, the risk factors with the greatest impact were use of epidural (OR = 5.3; 95% CI = 3.2, 8.7; p < .01) and having gestational diabetes and controlling the condition with insulin (OR = 4.6; 95% CI = 1.5, 13.8; p < .01). Additionally, among Hispanic mothers, having Spanish as primary language increased shoulder dystocia likelihood compared to those who did not cite it as their primary language (OR = 2.3; 95% CI = 1.1, 4.6; p < .05). This study provides evidence that risk factors for a labor and delivery condition can vary significantly across racial and ethnic subgroups. These differences emphasize the importance of evaluating risk by population subgroups and might provide a basis for labor and delivery clinicians to enhance personalized medicine to reduce adverse events.

Population-Based Risk Factors for Shoulder Dystocia.

OBJECTIVE: To re-examine the risk factors for shoulder dystocia given the increasing rates of obesity and diabetes in pregnant women. DESIGN: Retrospective observational study. SETTING: Five hospitals located in Wisconsin, Florida, Maryland, Michigan, and Alabama. PARTICIPANTS: We evaluated 19,236 births that occurred between April 1, 2011, and July 25, 2013. METHODS: Data were collected from electronic medical records and used to evaluate the risk of shoulder dystocia. Data were analyzed using a generalized linear mixed model, which controlled for clustering due to site. RESULTS: When insulin was prescribed, gestational diabetes was associated with an increased risk of shoulder dystocia (odds ratio = 2.10, 95% confidence interval [1.01, 4.37]); however, no similar association was found with regard to gestational diabetes treated with glycemic agents or through diet. Use of epidural anesthesia was associated with an increased risk for shoulder dystocia (odds ratio = 3.47, 95% confidence interval [2.72, 4.42]). Being Black or Hispanic, being covered by Medicaid or having no insurance, infant gestational age of 41 weeks or greater, and chronic diabetes were other significant risk factors. CONCLUSION: With the changing characteristics of pregnant women, labor and birth clinicians care for more pregnant women who have an increased risk for shoulder dystocia. Our findings may help prospectively identify women with the greatest risk.

Hospital-Onset Staphylococcus aureus Bacteremia Is A Better Measure Than MRSA Bacteremia for Assessing Infection Prevention: Evaluation of 50 US Hospitals.

Of 500 hospital-onset Staphylococcus aureus bacteremia events (58% methicillin-susceptible S. aureus [MSSA]; 42% methicillin-resistant S. aureus [MRSA]), we found no significant differences in S. aureus bacteremia rates between medium-sized and large hospitals. However, the proportion of S. aureus bacteremia caused by MSSA was greater in medium-sized hospitals and did not correlate with MRSA bacteremia. Infect Control Hosp Epidemiol 2018;39:476-478.

The Ascension Health journey to zero: lessons learned and leadership.

BACKGROUND: In 2002, Ascension Health, a 65-hospital nonprofit health care system, articulated a call to action to provide Healthcare That Works, Healthcare That Is Safe, and Healthcare That Leaves No One Behind. The goal is to provide excellent clinical care with no preventable injuries or deaths by July 2008. Just months from this target date, substantial reductions in events related to eight priorities for action have been documented, and at the current rate more than 2,000 lives a year are being saved compared to the baseline mortality rate. BUILDING THE AGENDA FOR CHANGE: Progress toward the goal of zero preventable injuries or deaths required transformational change. Key steps toward this change included establishing a sense of urgency, creating a guiding coalition (the clinical excellence team), and developing the Destination Statement II. Other key factors in our early success included methods of process and outcomes measurement, the formation of appropriate and diverse leadership groups comprised of primary stakeholders, methods of knowledge transfer, and the involvement and leadership of the Ascension Health Quality Committee and individual health ministry Boards. THE JOURNEY CONTINUES: An ongoing discussion of what "zero preventable deaths and injuries" really means has led to the identification of additional interventions to further reduce preventable injuries and deaths.

Definitional Change in NHSN CAUTI Was Associated with an Increase in CLABSI Events: Evaluation of a Large Health System.

BACKGROUND The National Healthcare Safety Network (NHSN) catheter-associated urinary tract infection (CAUTI) definition was revised as of January 2015 to exclude funguria and lower bacteriuria levels. We evaluated the effect of the CAUTI definition change on NHSN-defined central-line-associated bloodstream infection (CLABSI) outcomes. METHODS We compared CAUTI and CLABSI NHSN-defined outcomes for calendar years 2014 and 2015 in the adult intensive care units (ICUs) of a single large health system. Changes in the event rates, the associated organisms, and the standardized infection ratio (SIR) were evaluated. RESULTS The study included 137 adult ICUs from 65 hospitals. The CAUTI SIR dropped from 1.04 in 2014 to 0.58 in 2015 (-44.2%), while the CLABSI SIR increased from 0.36 in 2014 to 0.47 in 2015 (+30.6%). CAUTI rates dropped 44.8% from 2.09 to 1.15 events per 1,000 device days (P<.001). Gram-positive-associated CAUTI rates dropped 36.7% from 0.34 to 0.22 per 1,000 device days (P=.007). CLABSI rates increased 27.1% from 0.71 to 0.90 per 1,000 device days (P=.027). Candida-associated CLABSI increased by 91.1% from 0.104 to 0.198 per 1,000 device days (P=.012), and Enterococcus-associated CLABSI increased by 121.6% from 0.071 to 0.16 per 1,000 device days (P=.008). CONCLUSIONS The revised CAUTI definition led to a large reduction in CAUTI rates and, in turn, an increase in candidemia and enterococcemia cases classified as CLABSI events. These findings have important implications on the perceived successes or failures to eliminate both infections. Infect Control Hosp Epidemiol 2017;38:685-689.

The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths.

BACKGROUND: In 2002 Ascension Health, a 67-hospital not-for-profit health care system, articulated a call to action to provide excellent clinical care with no preventable injuries or deaths by July 2008. It embarked on a journey of clinical transformation. Transformational change implies a much greater pace of change than that reflected in traditional, incremental change processes. THE JOURNEY BEGINS: Progressing from vision to action plan required setting the clinical transformation agenda, identifying challenges to this agenda, and establishing measurements of progress. Environmental changes that must be addressed to successfully implement a transformational change process include culture, making the business case, infrastructure investments, standardization, and how we work together. TAKING ACTION: Improvement activities focused on eight priorities for action, including preventable mortality and areas such as adverse drug events, falls, and surgical complications. "Alpha" sites would develop the best clinical and implementation practices for eliminating the preventable adverse events related to these areas. EARLY RESULTS: The observed decrease in the mortality rate among non-end-of-life-care patients was 21% (p < .001), exceeding the 15% goal set for July 2008 and corresponding to 1,200 deaths prevented across the system. The alpha sites reported initial results in June 2004, with more than 50% reductions in adverse events for all the priorities for action areas.

Taking advantage of public reporting: An infection composite score to assist evaluating hospital performance for infection prevention efforts.

BACKGROUND: The standardized infection ratio (SIR) evaluates individual publicly reported health care-associated infections, but it may not assess overall performance. METHODS: We piloted an infection composite score (ICS) in 82 hospitals of a single health system. The ICS is a combined score for central line-associated bloodstream infections, catheter-associated urinary tract infections, colon and abdominal hysterectomy surgical site infections, and hospital-onset methicillin-resistant Staphylococcus aureus bacteremia and Clostridium difficile infections. Individual facility ICSs were calculated by normalizing each of the 6 SIR events to the system SIR for baseline and performance periods (ICSib and ICSip, respectively). A hospital ICSib reflected its baseline performance compared with system baseline, whereas a ICSip provided information of its outcome changes compared with system baseline. RESULTS: Both the ICSib (baseline 2013) and ICSip (performance 2014) were calculated for 63 hospitals (reporting at least 4 of the 6 event types). The ICSip improved in 36 of 63 (57.1%) hospitals in 2014 when compared with the ICSib in 2013. The ICSib 2013 median was 0.96 (range, 0.13-2.94) versus the 2014 ICSip median of 0.92 (range, 0-6.55). Variation was more evident in hospitals with ≤100 beds. The system performance score (ICSsp) in 2014 was 0.95, a 5% improvement compared with 2013. CONCLUSIONS: The proposed ICS may help large health systems and state hospital associations better evaluate key infectious outcomes, comparing them with historic and concurrent performance of peers.