Advocating for the Vulnerable: The Clinical Nurse Specialist and Nursing Home Reform.

INTRODUCTION: Nursing homes have been disproportionally affected by the COVID-19 pandemic, particularly because of resident vulnerability, inadequate staffing, and poor quality of care. CURRENT STATE: Despite billions of dollars in funding, nursing homes often do not meet minimum federal staffing requirements and are frequently cited for infection prevention and control deficiencies. These factors significantly contributed to resident and staff deaths. For-profit nursing homes were associated with more COVID-19 infections and deaths. Nearly 70% of US nursing homes are for-profit ownership, where quality measures and staffing levels are often lower than their nonprofit counterparts. Nursing home reform is urgently needed to improve staffing and care quality in these facilities. Some states, such as Massachusetts, New Jersey, and New York, have made legislative progress in establishing standards for nursing home spending. The Biden Administration has also announced initiatives, through the Special Focus Facilities Program, to improve nursing home quality and the safety of residents and staff. Concurrently, the "National Imperative to Improve Nursing Home Quality" report from the National Academies of Science, Engineering, and Medicine made specific staffing recommendations, including an increase in direct care registered nurse coverage. CONCLUSION: There is an urgent need to advocate for nursing home reform by partnering with congressional representatives or supporting nursing home legislation to improve care for this vulnerable patient population. Adult-gerontology clinical nurse specialists have an opportunity to leverage their advanced knowledge and unique skill set to lead and facilitate change to improve quality of care and patient outcomes.

Making the Transition: A Critical Care Skills Program to Support Newly Hired Nurses.

PURPOSE: This article describes the impact of a hands-on critical care skills day led by clinical nurse specialist (CNS) to enhance junior nurses' clinical skills. Program objectives included providing specialized skills training to meet the needs of high-acuity patient population and reviewing nurse-sensitive indicator-associated care bundles with the goal of increasing compliance. DESCRIPTION OF THE PROJECT: An 8-hour program of lecture and hands-on skills was developed. Curriculum included nursing-sensitive indicators, sepsis management, complex tubes and drains, airway management, and emergency response. Clinical nurse specialists mentored senior nurses to colead program planning and execution. The program has been offered 9 times. Qualitative and quantitative data were collected on attendees. OUTCOME: Quantitative data analysis showed that 89% of the assessed components were affected by the program. Medium effect was noted in defibrillator skills, retrieving items from code care, care of suicidal patient, and sepsis screening. Qualitative data based on attendee survey are also presented and analyzed. Decreases in indwelling catheter utilization on select units are discussed. CONCLUSION: The CNS has the responsibility to ensure nursing practice is reflective of hospital policy and current evidence. This program demonstrates the impact of CNSs in staff education, mentorship, and competency assessment.

Misery Loves Company: Presenting Symptom Clusters to Urgent Care by Patients Receiving Antineoplastic Therapy.

PURPOSE: The Centers for Medicare & Medicaid Services (CMS) identifies suboptimal management of treatment toxicities as a care gap and proposes the measurement of hospital performance on the basis of emergency department visits for 10 common symptoms. Current management strategies do not address symptom co-occurrence. METHODS: We evaluated symptom co-occurrence in three patient cohorts that presented to a cancer hospital urgent care center in 2016. We examined both the CMS-identified symptoms and an expanded clinician-identified set defined as symptoms that could be safely managed in the outpatient setting if identified early and managed proactively. The cohorts included patients who presented with a CMS-defined symptom within 30 days of treatment, patients who presented within 30 days of treatment with a symptom from the expanded set, and patients who presented with a symptom from the expanded set within 30 days of treatment start. Symptom co-occurrence was measured by Jaccard index. A community detection algorithm was used to identify symptom clusters on the basis of a random walk process, and network visualizations were used to illustrate symptom dynamics. RESULTS: There were 6,429 presentations in the CMS symptom-defined cohort. The network analysis identified two distinct symptom clusters centered around pain and fever. In the expanded symptom cohort, there were 5,731 visits and six symptom clusters centered around fever, emesis/nausea, fatigue, deep vein thrombosis, pain, and ascites. For patients who newly initiated treatment, there were 1,154 visits and four symptom clusters centered around fever, nausea/emesis, fatigue, and deep vein thrombosis. CONCLUSION: Uncontrolled symptoms are associated with unplanned acute care. Recognition of the complexity of symptom co-occurrence can drive improved management strategies.