Nursing Policies and Protocols: Do Nurses Really Use Them?

BACKGROUND: Nursing policies and protocols exist to promote high-quality, safe, and effective nursing practice; however, there is little evidence demonstrating how nurses actually use them to inform their everyday, routine practice. PURPOSE: The purposes were to explore the extent to which nurses use nursing policies and protocols to guide their routine practice, and identify barriers and facilitators affecting the frequency with which nurses use nursing policies and protocols. METHODS: Licensed nurses (N = 235) providing direct care to inpatients and outpatients in a large medical center participated in an 18-question online survey. RESULTS: Most nurses access policies and protocols once a month or more; the greatest barrier to more frequent access was length of the policy or protocol. CONCLUSIONS: Organizations should make policies and protocols succinct, current, and easily accessible. Studies are needed to determine how policies and procedures can best meet the needs of stakeholders, including health care organizations, staff, and patients.

Methodology for sampling women at high maternal risk in administrative data.

BACKGROUND: In population level studies, the conventional practice of categorizing women into low and high maternal risk samples relies upon ascertaining the presence of various comorbid conditions in administrative data. Two problems with the conventional method include variability in the recommended comorbidities to consider and inability to distinguish between maternal and fetal risks. High maternal risk sample selection may be improved by using the Obstetric Comorbidity Index (OCI), a system of risk scoring based on weighting comorbidities associated with maternal end organ damage. The purpose of this study was to compare the net benefit of using OCI risk scoring vs the conventional risk identification method to identify a sample of women at high maternal risk in administrative data. METHODS: This was a net benefit analysis using linked delivery hospitalization discharge and vital records data for women experiencing singleton births in Georgia from 2008 to 2012. We compared the value identifying a sample of women at high maternal risk using the OCI score to the conventional method of dichotomous identification of any comorbidities. Value was measured by the ability to select a sample of women designated as high maternal risk who experienced severe maternal morbidity or mortality. RESULTS: The high maternal risk sample created with the OCI had a small but positive net benefit (+ 0.6), while the conventionally derived sample had a negative net benefit indicating the sample selection performed worse than identifying no woman as high maternal risk. CONCLUSIONS: The OCI can be used to select women at high maternal risk in administrative data. The OCI provides a consistent method of identification for women at risk of maternal morbidity and mortality and avoids confounding all obstetric risk factors with specific maternal risk factors. Using the OCI may help reduce misclassification as high maternal risk and improve the consistency in identifying women at high maternal risk in administrative data.

Growing a Robust Academic Practice Partnership in an Academic Health System.

Schools of nursing located within academic health centers have embraced expanded opportunities to lead in this era of rapid change and considerable uncertainty in US health care. These schools bear a unique responsibility to work with their clinical nursing partners to advance the care of patients, improve the health of communities and populations, and help steward the nation's health care resources. This article describes how the Emory University Nell Hodgson Woodruff School of Nursing has formed and sustained academic-practice partnerships in response to these imperatives. The structures and processes that have supported the partnerships are shared, as are the keys to success in a true partnership. The authors describe the work required to achieve mutually agreed-upon goals, along with the challenges that faculty and health care leaders have faced in their journey to system partnerships.

Accountable Care Units: A Disruptive Innovation in Acute Care Delivery.

Accountable Care Units are a disruptive innovation that has moved care on acute care units from a traditional silo model, in which each discipline works separately from all others, to one in which multiple disciplines work together with patients and their families to move patients safely through their hospital stay. This article describes the "what," "how," and "why" of the Accountable Care Units model as it has evolved in different locations across a single health system and includes the lessons learned as different units and hospitals continue working to implement the model in their complex care environments.

The intentional development of nurses as leaders: a proposed framework.

In their 2010 report on The Future of Nursing, the Institute of Medicine called for nurses to be prepared to lead in all areas of healthcare. However, the nursing profession lacks consensus on a framework to guide the development of nurses as leaders and has yet to define essential leader competencies. This article reviews the Army's intentional, sequential, and progressive leader development program that is grounded in essential leader competencies. The applicability of this model to nursing is discussed, and examples of how it could be applied are highlighted. This article proposes the use of the military framework as a successful model for the intentional development of nurses as leaders to meet the triple aims of better care for patients, better health for populations, and reduced costs of care through more efficient use of resources.

Blood Glucose Levels of Patients With Diabetes in the Immediate Post-Acute Hemodialysis Period: An Exploratory Study.

UNLABELLED: PROBLEM/PURPOSE: To establish the evidence on which to base a protocol for monitoring capillary blood glucose in hospitalized patients with diabetes mellitus in the immediate post-acute hemodialysis period. SAMPLE: Hospitalized, non-critically ill, adult patients (n = 68) with diabetes undergoing acute hemodialysis treatments. METHODS: Capillary blood glucose was tested 30 minutes prior to the end of the hemodialysis treatment, at the end of the treatment, and 30 minutes and 60 minutes post-treatment. Data were analyzed to determine both within and between patient variability. RESULTS: Glucose levels varied widely before, during, and after hemodialysis, with greatest variability at 60 minutes post-hemodialysis. Levels did not vary based on diabetes type or admitting diagnosis. Possible relationships were identified with length of treatment, insulin administration prior to treatment, and food consumed within an hour after treatment. CONCLUSIONS/NURSING IMPLICATIONS: Testing post-dialysis glucose levels earlier than 60 minutes post-treatment may miss the need for additional medication.

Clinical phenotype, laboratory features and genotype of 35 patients with heritable dysfibrinogenaemia.

Heritable dysfibrinogenaemia (HD) is a rare qualitative disorder of fibrinogen (FGN). To better describe the clinical, laboratory and genotypic spectrum of HD, we evaluated 35 subjects identified at two UK centres using laboratory criteria. 12/35(34%) subjects with HD experienced bleeding (bleeding score >1 at any site), 3/35(9%) thrombosis and 20/35(57%) were asymptomatic. Amongst subjects with bleeding, symptoms were typically mild, at one anatomical site and seldom occurred after invasive procedures. All subject showed dry clot weight within or above laboratory reference interval (median 3·2 g/l; range 1·9-5·1), reduced Clauss fibrinogen (median 0·52 g/l; range 0·21-1·3), and prolonged thrombin (median 30·7 s; range 21·3-45·7) and reptilase (median 42·0 s; range 20·0-68·0) times. In all subjects, the prothrombin time ratio (PTR), determined by Sysmex CA-1500 coagulometer and Innovin activator, was abnormal (median 1·42; range 1·22-1·61). The activated partial thromboplastin time ratio and PTR with other coagulometers and activators were comparatively insensitive to HD. All subjects with HD harboured heterozygous candidate nucleotide variations within known hotspots in the FGN genes. The HD variants identified in this cross-sectional study seldom have significant clinical manifestations and show similar laboratory features irrespective of genotype. Selection of coagulometer and PT activator may markedly affect the detection of new HD cases using coagulation screening tests.

Risk of thrombosis with thrombocytopenia syndrome after COVID-19 vaccination prior to the recognition of vaccine-induced thrombocytopenia and thrombosis: A self-controlled case series study in England.

Background: Several studies have found increased risks of thrombosis with thrombocytopenia syndrome (TTS) following the ChAdOx1 vaccination. However, case ascertainment is often incomplete in large electronic health record (EHR)-based studies. Objectives: To assess for an association between clinically validated TTS and COVID-19 vaccination. Methods: We used the self-controlled case series method to assess the risks of clinically validated acute TTS after a first COVID-19 vaccine dose (BNT162b2 or ChAdOx1) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Case ascertainment was performed uninformed of vaccination status via a retrospective clinical review of hospital EHR systems, including active ascertainment of thrombocytopenia. Results: One hundred seventy individuals were admitted to the hospital for a TTS event at the study sites between January 1 and March 31, 2021. A significant increased risk (relative incidence [RI], 5.67; 95% confidence interval [CI], 1.02-31.38) of TTS 4 to 27 days after ChAdOx1 was observed in the youngest age group (18- to 39-year-olds). No other period had a significant increase, although for ChAdOx1 for all ages combined the RI was >1 in the 4- to 27- and 28- to 41-day periods (RI, 1.52; 95% CI, 0.88-2.63; and (RI, 1.70; 95% CI, 0.73-3.8, respectively). There was no significant increased risk of TTS after BNT162b2 in any period. Increased risks of TTS following a positive SARS-CoV-2 test occurred across all age groups and exposure periods. Conclusions: We demonstrate an increased risk of TTS in the 4 to 27 days following COVID-19 vaccination, particularly for ChAdOx1. These risks were lower than following SARS-CoV-2 infection. An alternative vaccine may be preferable in younger age groups in whom the risk of postvaccine TTS is greatest.

Implementing a conceptually based training program to increase nurses' effectiveness in securing patient rescue.

In this article, the authors describe a conceptually based training program designed to improve staff nurses' ability to successfully rescue patients. The 4-hour program includes both didactic material and a minimum of 1-hour skills' sessions. It was taught entirely by senior staff nurses skilled in crisis communications. Components of this successful program have been included in new employee orientation, and the entire program continues to be taught twice a year.

Associations Between Hospital Maternal Service Level and Delivery Outcomes.

OBJECTIVE: This study explored the associations between delivery hospital self-reported level of maternal service, as defined by the American Hospital Association, and both maternal and neonatal outcomes among women at high maternal risk, as defined by the Obstetric Comorbidity Index. METHODS: This was a secondary analysis of linked delivery hospitalization discharge and vital records data for women experiencing singleton births in Georgia from 2008 to 2012. The need for maternal transfer was defined using a sample-specific cut-off of the risk score calculated using the Obstetric Comorbidity Index. Outcomes included poor maternal outcome (severe maternal morbidity or death), maternal length of stay, preterm delivery, low birth weight, and perinatal death. The analysis was completed using hierarchical logistic regression with a two-level model considering hospital level of maternal service and controlling for maternal race and transfer status. RESULTS: In these data, there was no difference in the odds of a poor maternal or neonatal outcome according to delivery hospital level of maternal care; however, delivery at a hospital with maternal service level III was associated with a higher odds of an extended length of stay. CONCLUSIONS: For this group of pregnant women in need of maternal transfer, delivery hospital self-reported level of maternal care was not associated with the odds of poor maternal or neonatal outcomes. This study supports the need for improved definitions of hospital level of maternal services.

Measuring Organizational Capacity to Accelerate Health Care Innovation in Academic Health Centers.

In an era of rising clinical costs and shrinking federal research dollars, the survival of the academic health center may depend on its capacity to cultivate high-impact innovations in care delivery on an accelerated basis. Yet, the health sciences literature offers little guidance regarding the key organizational determinants most likely to facilitate such innovation. We report on the conceptualization, development, and preliminary testing of a new 21-item Accelerated Healthcare Innovation Capacity scale for addressing that knowledge gap. Instrument development followed a standardized process, including expert panel testing of the new scale's content relevance validity. A sample (N = 53) of academic health center administrators, clinicians, and faculty affiliated with a single organization volunteered to complete the Accelerated Healthcare Innovation Capacity scale in survey form. Data were analyzed to evaluate scale reliability, internal consistency, and construct validity. High-expert agreement (overall S-CVI of 0.91) was obtained on content relevance validity. Cronbach α for the scale was 0.941. Exploratory factor analysis confirmed the theoretical soundness of the scale's conceptual framework, which showed high-impact health care innovation support to be a complex, multidimensional concept involving key facilitating factors across 3 major constructs-that is, Culture, Structure, and Policy-with implications for future research and managerial practice, particularly for staff development educators engaged in evaluating quality management and organizational change strategies.

Post thrombotic syndrome following deep vein thrombosis in paediatric patients.

Background Although well characterised in adults, less is known about post-thrombotic syndrome in children. In this review, current knowledge regarding paediatric post-thrombotic syndrome is summarised, with particular emphasis on pathophysiology, aetiology, diagnosis and management. Methods A Medline literature review was performed using search terms 'post thrombotic syndrome', 'post phlebitic syndrome', paediatric and children. Relevant articles were identified and included for summation analysis. Results The incident of paediatric venous thromboembolism is rising. Deep vein thrombosis can cause venous hypertension through a combination of venous reflux, venous obstruction and impairment of the calf muscle pump, leading to development of post-thrombotic syndrome. In children, this is more likely to occur if deep vein thrombosis diagnosis and treatment are delayed, if a higher number of vessels are involved, and if factors such as D-dimer are elevated at diagnosis and throughout treatment. Post-thrombotic syndrome occurs in about 26% of paediatric deep vein thrombosis, though the results of individual studies vary widely. A number of tools exist to diagnose paediatric post-thrombotic syndrome, including the modified Villalta scale and Manco-Johnson instrument. Once post-thrombotic syndrome develops, the mainstay of treatment remains supportive, with little evidence of benefit from pharmacological measures. Conclusion Surgical or interventional treatment is not advised except in exceptional cirumstances, due to variable prognosis of PTS in paediatric populations with rising incidence of paediatric venous thromboembolism, it follows that the prevalence of post-thrombotic syndrome in children may also increase. Evidence-based venous thromboembolism prevention strategies need to be implemented for prevention of deep vein thrombosis, but when it does occur, deep vein thrombosis requires prompt and effective treatment to prevent post-thrombotic syndrome. Optimum treatment strategies for post-thrombotic syndrome require further investigation.

Predicting patient follow-through on telephone nursing advice.

Although use of telephone advice nursing services continues to grow, little research has addressed factors that affect crucial call outcomes like follow-through on the advice given. This article describes aspects of the advice call process and examines predictors of caller follow-through, using a conceptual model derived from the literature and the authors' preliminary work. Calls to call centers and medical offices of a large health maintenance organization were taped, then content was coded and matched with caller questionnaire (CQ) data. Out of 1,863 participants, 1,489 reported following all the advice. In the final multivariate predictive model, statistically significant predictors of follow-through were patient health status, caller's rating of nurse helpfulness, and the extent to which caller expectations for collaboration were met and the caller understood the advice given. Results suggest that nurses should receive continuous training on effective communication techniques, and advice nurse performance standards that create barriers to communication should be modified.

Predictors of patient satisfaction with telephone nursing services.

Patient satisfaction has been shown to be a factor in clinical outcomes, health care quality, and patient follow-through. Thus, a high level of satisfaction is a desired outcome of patient care. This article examines predictors of patient satisfaction with telephone nursing services among a sample of 1,939 respondents, using a conceptual model derived from the literature and preliminary work. The study was conducted in medical offices and call centers of a large national health maintenance organization. Calls were taped and content coded and then matched with caller questionnaire data. In the final multivariate predictive models, patient health status; caller ratings of expectations met by the nurse for listening, clarity, and collaboration; and nurse competence were the strongest predictors of satisfaction. Consistent with the literature, findings suggest that nurses should expand interpersonal communication skills, and systems should reduce barriers to effective listening, clarity, and collaboration with callers.

Caring for Young Children Exposed to Marijuana.

This article reviews the research report, Marijuana Exposure Among Children Younger Than Six Years in the United States (), and, using a case study approach, applies the findings to advanced practice registered nurses. B. extracted data from the National Poison Data System showing an increasing trend in marijuana exposure in children, especially in states where marijuana has been legalized for either medicinal use or recreational use. Advanced practice registered nurses need to be comfortable recognizing and managing marijuana intoxication in the pediatric population, as well as educating parents in providing safe environments for their children.

Guidelines for developing and testing clinical decision rules.

Clinical decision rules (CDRs) are decision support tools that synthesize evidence for use in bedside practice. They differ from other decision support tools in the methodological rigor with which they are developed. This article describes the important considerations in developing a CDR, including identifying the need for the rule, carefully defining the outcome variable, identifying and selecting the possible predictor variables, and guidelines for initial testing of the CDR. The process of developing and testing CDRs is best undertaken by teams of researchers, with clinical nurses providing important input in both the development and testing. It's important that clinical nurses understand both the contributions of CDRs and their inherent limitations, as appropriate use of well-developed, well-validated CDRs will become more and more a necessity in evidence-based nursing.

Suicidality Risk Assessment in Adolescents and Young Adults.

The Research to Practice column is intended to improve the research critique skills of the advanced practice registered nurse (APRN) and the emergency nurse (RN) and to assist with the translation of research into practice. This column focuses on assessing risks of suicide in adolescents and young adults, using as a basis for the discussion a recently developed suicidality screening tool (L. M. ).