Sexual Assault Nurse Examiner programs in the United States

STUDY OBJECTIVE

We sought to provide a descriptive study of the Sexual Assault Nurse Examiner (SANE) programs and their characteristics in the United States.

METHODS

A confidential survey addressing patient and staff demographics, administration attributes, examination procedures, and medical and legal issues was mailed to SANE programs in the United States.

RESULTS

Sixty-one (66%) of 92 programs responded. More than half of the programs (32/58 [55%]) had been in operation for less than 5 years. Thirty (52%) of the 58 programs performed the initial sexual assault examination in hospital emergency departments. Written consent (57/59 [97%]) was obtained for the initial examination, and most (51/59 [86%]) programs used preprepared commercial sexual assault kits. Program directors were predominately registered nurses. All but one program mandated specific training requirements for their staff, with a median requirement of 80 hours. Procedures used for initial examinations varied; most offered pregnancy testing (56/58 [97%]), pregnancy prophylaxis (57/59 [97%]), and sexually transmitted disease (STD) prophylaxis (53/59 [90%]). HIV testing was not offered in 32 (54%) of 59 programs. Almost all programs used Wood's lamp (51/59 [86%]), colposcopes (42/59 [71%]), and photographs (46/59 [78%]) for documentation. Median time required per patient for initial examination and evidence collection was 3 hours (range, 1 to 8 hours). Follow-up is consistently offered to the survivor. Most programs (45/61 [74%]) could report the number of survivors treated, but few could provide information on survivor medical follow-up or the number of prosecutions by survivors and their outcomes.

CONCLUSION

This survey provided an overview of SANE programs. SANE programs are similar across the country with regard to staffing, training, STD and pregnancy prophylaxis, and documentation techniques. They are inconsistent in the use of STD cultures, HIV testing, and alcohol and drug screening. SANE programs were unable to provide data regarding survivor follow-up and legal outcomes. This information is essential to evaluate the programs' effectiveness and to improve performance. The need for better outcome data should be addressed to define success or failure of SANE programs.

[Client categorization: a tool to assess nursing workload]

BACKGROUND

Client categorization is a management tool that allows an objective and structured assessment of the care demands imposed by patients and nursing workloads.

AIM

To characterize the need for direct nursing care of patients admitted to a university hospital.

PATIENTS AND METHODS

During two months, all patients admitted to intensive, intermediate care units and general services were categorized, their need for nursing care and the time invested by nurses in their care was registered. All patients were classified as maximal, high, median or low risk and as independent, totally or partially dependent on nursing care. Considering four degrees of risk and three degrees of dependency, 12 categories of patients were defined.

RESULTS

Patients admitted to intensive care units were of maximal risk and totally dependent and required 1 nurse per 2.2 patients. Those admitted in intermediate care units required 1 nurse per 3.8 patients and those in general services, 1 nurse per 11.5 patients.

CONCLUSIONS

Client categorization is a reproducible method that determines a standard measuring unit to define nursing needs. This allows the comparison of workloads between different services within a hospital or between hospitals.

Reducing hospital inpatient lengths of stay

This article describes the importance of hospital length of stay as an indicator of health care efficiency and provides guidance concerning the development of data for length of stay reduction. It identifies variables involved in length of stay evaluation including the mean stay, median stay, and length of stay standard deviation. It describes how consistent length of stay data can be generated and analyzed for local populations and benchmark communities.

Longitudinal evaluation of professional nursing practice redesign

OBJECTIVES

The authors describe a 5-year study at a western university teaching hospital that evaluated the effect of organizational redesign on nurse job satisfaction, autonomy, and patient satisfaction.

BACKGROUND

Change in institutional status from public to private authority stimulated this hospital to map a new direction for professional nursing practice, to strengthen autonomy and job satisfaction while improving quality care outcomes. Evaluating redesign changes systematically provided significant longitudinal trended data to guide nurse executive actions.

METHODS

Phase-I evaluation, from 1992 to 1995, was a quasi-experimental design comparing pre- and poststudy outcomes of facilitator-led activities on units receiving interventions compared with control units. Of 12 outcome variables measured, 3 were sustained longitudinally into Phase II: nursing job satisfaction using the McCloskey Mueller Satisfaction Scale (MMSS), autonomy using Schutzenhofer's Scale, and patient satisfaction using the Picker Institute survey. Data were trended across units and departments over a 5-year period.

RESULTS

Phase-I results reported that control units held higher nursing documentation scores than the experimental units. There were no significant differences in aggregate nurse job satisfaction scores. Nurse autonomy scores significantly improved. Other results are reported descriptively. Phase II continued the evaluation, reporting no differences in nurse job satisfaction aggregate scores a decline in autonomy, and decreased patient satisfaction scores. There were significant differences by units and across departments.

CONCLUSIONS

Longitudinal evaluation provides significant data to guide nurse executives in an uncertain healthcare environment. Of theoretical interest is the absence of congruence in nurse job satisfaction and autonomy scores, suggesting more independence between these variables than previously reported.

Influences on nursing care volume

This study explores influences on nursing care volume per case in four DRGs and five hospitals. After accounting for the effects of length of stay, patient characteristics, and severity of illness, the direct effect of factors describing the nursing staff and hospital was assessed. Skill mix and standing orders each were significant in one or more DRGs, but there was no significant association between the volume of nursing care and occupancy or staff availability. The management and research implications of the findings are discussed.

Automation of patient dependency systems

One of the most challenging decisions in resource allocations in hospitals is: how to allocate nursing duties on the basis of patients' needs? Patient Dependency Systems, in different forms, can be used to provide information for staffing decisions and budgetary developments. That is why Patient Dependency Systems are emerging as powerful tools in hospital management. It is anticipated that their use will grow, as hospitals everywhere come under pressure to reduce cost and improve the delivery and quality of health care to patients. Experience has shown that manual Patient Dependency Systems lack the ability to process and provide information fast enough to handle crisis situations. In addition, manual calculations are inefficient and are not free from human errors. However, the utilization of current advances in computing technology can overcome these disadvantages. Patient Dependency Systems are suitable for automation since their essence is too complex to handle manually. Furthermore, it is essential to automate the Patient Dependency Systems because of their critical role and their inherent complexity. In this paper, the automation of Patient Dependency Systems is presented. The development of Patient Dependency Automated Systems is shown to provide reliable and valid methods for evaluating the needs of patients in terms of the nursing effort required.

The effectiveness of 'nursing beds': a review of the literature

A literature search was conducted to identify 'nursing led in-patient units' where the nurse is the designated leader of the clinical team. The review concentrates on studies which have attempted to measure the impact of nursing-led in-patient units and reviews both the methodology and outcomes. Three major bodies of work were identified. Lydia Hall's evaluation of the Loeb Center for Nursing and Rehabilitation (USA) is reviewed in some detail. This work was the model for 'nursing beds' at the two Oxfordshire Nursing Development Units (UK) in the 1980s. Studies evaluating these centres are reviewed and reports of similar UK units discussed. A third body of work evaluates a nurse-managed critical care environment. Common features include a case mix based on nursing need with nurses having authority to admit and discharge patients. While results are generally favourable, with improved patient independence, fewer readmissions, lower mortality and cost savings reported in some or all of the studies, all studies reviewed demonstrate the difficulties of applying an experimental model to real life clinical services. Methodological limitations render firm conclusions difficult. Techniques adopted from studies in field settings, the so-called 'quasi-experiment', are advocated as a remedy, as is further study of the process of care in investigating this model of care delivery.

Survey and critique of studies related to unlicensed assistive personnel from 1975 to 1997, Part 2

This article is part 2 of a descriptive integrated review of research on the use of unlicensed assistive personnel in nursing. Part 1, published last month, described the methods used to find and to critique 29 research articles; it included the conceptual model and the variables identified in the studies. Part 2 presents a synthesis of the 29 studies data conclusions, implications and recommendations.

Survey and critique of studies related to unlicensed assistive personnel from 1975 to 1997, Part 1

This descriptive integrated review of research on the use of unlicensed assistive personnel in nursing is presented in two parts. In this issue, part 1 describes the methods used to find and critique research related to unlicensed assistive personnel in nursing. It includes the conceptual model and findings related to the variables studied. Part 2 of this review, which is scheduled for publication in the next issue, will present research findings, conclusions, and recommendations.

Hospital activity. Barred facts

Barcode technology is applicable to a number of crucial management issues in the NHS, including internal efficiency, contract pricing and the effectiveness of care. Its enormous potential lies in the ability to record in detail over a number of dimensions such as time, staff group, patient type, and cost. But the effort involved is considerable. Projects have to be actively managed, users have to be willing participants and data has to be analysed. Where short cuts have been sought, projects have failed to deliver their full potential. The data is merely a means to an end, but a very powerful one. It brings together people who may normally work independently, and the process of collecting barcode data is a perfect mechanism for bringing together the patient, the professional and the purse strings.

Study provides comparative targets to help reduce costs of surgical procedures

Data Benchmarks: Cost and LOS benchmarks can help your organization target and reduce costs of surgical procedures. Setting up clinical pathways to improve quality and reduce costs requires good benchmarking data to zero in on the appropriate clinical services or procedures. This month's Data Benchmarks offers good comparative data on the most cost-intensive surgical procedures performed at U.S. hospitals.

South Dakota statewide Nursing Minimum Data Set Project

The elements of the Nursing Minimum Data Set (NMDS) were collected manually from 188 medical records in eight acute care facilities. These eight facilities represent 54 per cent of the beds in South Dakota. The purpose of the study was to describe discharge destination, nursing diagnoses, nursing interventions, and nursing resource utilization for patients with fractured femur with pinning. The sample was primarily female (69.1 per cent), with a mean age of 78.5 years. Most (84.0 per cent) patients were transferred to another facility, with 46.2 per cent going to extended care facilities. The most frequent nursing diagnoses were comfort (89.9 per cent) and physical mobility (59.6 per cent). Interventions were classified using the 16-category classification scheme developed by Werley and Lang. The most frequently recorded types of interventions were in the category of monitoring and/or surveillance (16.7 per cent of 7,555 interventions), whereas emotional support and/or counseling was much less frequent (3.0 per cent of 7,555). Discharge planning was the most frequent nursing intervention in the category of coordination and collaboration of care (54.8 per cent of 188 patients). Documentation systems have been structured to accommodate technical tasks on flow sheets, for example. Nursing resource utilization was the most difficult, and also presently the least meaningful, NMDS element to collect because each facility has different staffing, different patient classification systems, and no prescribed method for collecting these data. Manual data collection is time-consuming and expensive and therefore not recommended.

Survey of current practice patterns for percutaneous transluminal coronary angioplasty. SANDBAG Nursing Coordinators

BACKGROUND

The increasing complexity of coronary intervention has led to variations in current patterns of nursing practice for patients undergoing routine percutaneous transluminal coronary angioplasty. In preparation for a large study examining the effects of specific nursing practices on complications at the site of vascular access, we surveyed institutions participating in a randomized phase III trial involving 4010 patients to determine current patterns of practice.

OBJECTIVE

The purpose of this study was to determine the current patterns of nursing practice for patients undergoing percutaneous transluminal coronary angioplasty.

METHODS

An eight-page questionnaire was completed by 70 hospitals participating in the study titled Integrelin to Manage Platelet Aggregation to Prevent Coronary Thrombosis (IMPACT II).

RESULTS

The hospitals participating in this study have an average of 500 beds; 34% of the institutions do 500 to 1000 angioplasty procedures annually. At many sites (39%), heparin is infused for 12 to 18 hours after the intervention, but heparin is not infused at all in 31% of the hospitals studied. At 27% of the hospitals, arterial sheaths are removed 12 to 18 hours after angioplasty, and at 15% of the hospitals, sheaths are removed more than 18 hours after the procedure. Typically after angioplasty (36%), patients are transferred to an ICU, with a nurse-patient ratio of 1:2. Eighty-three percent of the hospitals use CareMAPs or care plans for standardization of care. Most hospitals (83%) require complete bed rest for patients who have had angioplasty, with the affected leg restrained to prevent mobility. Ninety-one percent of the hospitals reported continuing to treat the patient with bed rest for an additional 6 hours after the sheath is removed.

CONCLUSION

Comprehensive nursing standards of care based on well-designed clinical trials for patients after angioplasty are not available. In the second phase of our study, we hope to correlate nursing practices with clinical outcome data to improve further the care of patients who have had angioplasty.

Changes related to care delivery patterns

Nurse administrators, faced with a need to increase productivity and reduce costs in response to lower inpatient volumes and increased competition, are restructuring systems of care delivery. A survey of acute care hospitals was conducted to determine the extent of changes in nursing care delivery models, skill mix, assignment of non-nursing personnel to the nursing department, use of unlicensed assistive personnel, and registered nurse role changes in healthcare delivery systems employing unlicensed personnel.

Changing the admission process for elective surgery: an economic analysis

This study compared the costs of an inpatient elective surgical admission process with an outpatient based same day admission programme in patients undergoing laparoscopic cholecystectomy. The effect of this process change on annual surgical volume and case flow (number of procedures performed per surgical bed) in the year before the initiation of same-day method (1989/90) and subsequent to the widespread use of the process (1992/93), was also assessed. Costs incurred by 53 patients who underwent preoperative anaesthetic and surgical assessment as outpatients and were admitted as an outpatient on the day of surgery (SD Group) were compared with those incurred by 11 patients who entered hospital on the day before surgery and underwent anaesthetic and other assessments as inpatients (IP Group). Nursing, radiology, laboratory, operating room, rehabilitation and clinic costs were obtained for each patient. The remaining costs were not amenable to individual attribution and were assigned to each group as a percentage of the allocated costs. The cost per case in the SD Group was $360 less than in the IP Group, reflecting decreased nursing costs incurred by the SD Group. Between the period 1989/90 and 1992/93, the number of surgical beds declined 15.7%; however, surgical volume decreased by only 5.4%. Total case flow improved by 12.2%, that for elective and non-elective surgery increasing by 14.1% and 9.5%, respectively. Elective surgery, where same day admission was used, showed the greatest improvement in case flow. We conclude that a same day admission process reduces cost and serves to enhance hospital productivity.

Measurement of patient outcomes: data availability and consistency across hospitals

In a random sample of 20 hospitals, the availability and consistency of five patient outcome indicators were examined, including medication administration errors, patient falls, occurrence of new decubitus ulcers, nosocomial infections, and unplanned readmission to the hospital. The results indicate that information about only two outcome indicators--medication errors and patient falls--were collected consistently by the sampled hospitals. The findings are discussed in the context of implications for the study of patient outcomes research.

Requirement for nursing care services and associated costs in acute spinal cord injury

The purpose of this study was to analyze the requirement for professional nursing care and the nursing care costs for patients with acute spinal cord injury. This descriptive study used a convenience sample of 50 consecutively admitted spinal cord-injured (SCI) patients who agreed to participate. Trained data collectors interviewed patients daily, reviewed the chart and spoke with the patient's nurses, after which nursing diagnoses were determined and acuity calculated. The sample consisted of 26 quadriplegic (Q), 5 ventilator-dependent quadriplegic (V) and 19 paraplegic (P) SCI subjects. The median length of stay (LOS) was 16 days with an intensive care unit (ICU) LOS of 4 days. LOS in the intermediate unit was 11 days. Median hours of nursing care was 143 (translating to $2458) for the entire acute care hospitalization. Specific hours of care and consequent costs were determined for all three groups through both phases of care. Significant differences were found in the hours of nursing care required among the three groups (X2 7.18, df = 2, p < .03), even though no difference was found in the LOS. A nursing consumption ratio (hours of nursing care/hours of LOS) demonstrated that ventilator-dependent SCI patients required the greatest number of nursing care hours.

Managing with precision. A budgetary decision support model

In this era of intense competition for restrained healthcare resources, a sound financial system can provide the foundation for evaluating care requirements while balancing allocation and deployment of resources. The authors describe one nursing division's comprehensive budgetary decision support model. This model has enabled achievement of rigorous budgetary goals while maintaining high standards of quality. The budgetary decision support model was internally created; however, it is applicable and easily adaptable to any healthcare organization.