Association between advanced practice nursing and 30-day mortality in mechanically ventilated critically ill patients: A retrospective cohort study

Impact of professional nursing interventions on clinical outcomes in patients with acute gastric bleeding: a retrospective analysis

Acute gastric bleeding (AGB) is a common and potentially serious complication in patients with gastrointestinal disorders. Nursing interventions play a critical role in the management of acute gastric bleeding, but their impact on clinical outcomes is not well understood. The aim of this retrospective analysis was to evaluate the impact of nursing interventions on clinical outcomes in patients with acute gastric bleeding. A retrospective review of medical records was conducted for 220 patients with acute gastric bleeding who were admitted to the hospital between February 2022 and February 2023. Patients were divided into two groups based on whether or not they received nursing interventions during their hospital stay. Clinical outcomes, including length of hospital stay, blood transfusion requirements, and mortality rates, were compared between the two groups using descriptive statistics and logistic regression analysis. Of the 220 patients included in the study, 168 (76.4%) received nursing interventions during their hospital stay. Patients who received nursing interventions had a significantly shorter length of hospital stay (mean = 7.2 days, SD = 2.1) compared to those who did not receive nursing interventions (mean = 10.5 days, SD = 3.4, p < 0.001). Additionally, the 90-day mortality rate was lower in the group receiving professional nursing interventions (4.2% vs. 15.4%, p = 0.010). Fewer patients who received nursing interventions required blood transfusions (33.3% vs. 65.2%, p < 0.001) and mortality rates were lower (6.7% vs. 20.8%, p = 0.04). Multivariate logistic regression analysis suggested that professional nursing intervention was a protective factor for postoperative rebleeding in patients with gastric hemorrhage (OR 0.727, 95% CI 0.497-0.901, P < 0.001). The results of this retrospective analysis suggest that nursing interventions are associated with improved clinical outcomes in patients with acute gastric bleeding. The implementation of nursing interventions, such as individualized care plans, monitoring and evaluation, and patient education, should be encouraged to optimize patient outcomes in this population. Further research is needed to identify the most effective nursing interventions and to evaluate their cost-effectiveness.

Exploring the influence of a financial incentive scheme on early mobilization and rehabilitation in ICU patients: an interrupted time-series analysis

BACKGROUND

Clinical guidelines recommend early mobilization and rehabilitation (EMR) for patients who are critically ill. However, various barriers impede its implementation in real-world clinical settings. In 2018, the Japanese universal healthcare coverage system announced a unique financial incentive scheme to facilitate EMR for patients in intensive care units (ICU). This study evaluated whether such an incentive improved patients' activities of daily living (ADL) and reduced their hospital length of stay (LOS).

METHODS

Using the national inpatient database in Japan, we identified patients admitted to the ICU, who stayed over 48 hours between April 2017 and March 2019. The financial incentive required medical institutions to form a multidisciplinary team approach for EMR, development and periodic review of the standardized rehabilitation protocol, starting rehabilitation within 2 days of ICU admission. The incentive amounted to 34.6 United States Dollars per patient per day with limit 14 days, structured as a per diem payment. Hospitals were not mandated to provide detailed information on individual rehabilitation for government, and the insurer made payments directly to the hospitals based on their claims. Exposure was the introduction of the financial incentive defined as the first day of claim by each hospital. We conducted an interrupted time-series analysis to assess the impact of the financial incentive scheme. Multivariable radon-effects regression and Tobit regression analysis were performed with random intercept for the hospital of admission.

RESULTS

A total of 33,568 patients were deemed eligible. We confirmed that the basic assumption of ITS was fulfilled. The financial incentive was associated with an improvement in the Barthel index at discharge (0.44 points change in trend per month; 95% confidence interval = 0.20-0.68) and shorter hospital LOS (- 0.66 days change in trend per month; 95% confidence interval = - 0.88 - -0.44). The sensitivity and subgroup analyses showed consistent results.

CONCLUSIONS

The study suggests a potential association between the financial incentive for EMR in ICU patients and improved outcomes. This incentive scheme may provide a unique solution to EMR barrier in practice, however, caution is warranted in interpreting these findings due to recent changes in ICU care practices.

Implementierung einer „Nurse Practitioner“-Rolle in der stationären Chirurgie

Zusammenfassung. Hintergrund: Die Studie beschreibt die Einführung und Erprobung einer Nurse-Practitioner-Rolle in der akutstationären Chirurgie in einem schweizerischen Krankenhaus über ein Jahr. Der Einsatz Nurse Practitioner kann die Kontinuität in der Betreuung, die Versorgungsqualität und die Patientensicherheit verbessern. Ziel: Aufgezeigt werden die kurzfristigen Ergebnisse einer solchen Rolle im stationär chirurgischen Bereich nach einem Jahr Laufzeit. Die Zielgrößen umfassten neun Messkriterien. Methode: Die Evaluation erfolgte mittels eines Mixed-Methods-Ansatzes, teilweise im Prä-post-Vergleich. Quantitativ wurden Anzahl betreute Patient_innen, Austrittszeit, interprofessionelle Zusammenarbeit, Liegedauer, Störungen im Alltag und die Verfügbarkeit der Austrittsdokumente erfasst. Die qualitative Erfassung beinhaltete das Erleben der Beteiligten. Ergebnisse: Die Ergebnisse der Evaluation weisen auf einen Mehrwert durch die neue Rolle hin. Hinweise finden sich in der Betreuungskontinuität und Zugänglichkeit in medizinischen Fragen der Beteiligten sowie in der Optimierung der Patient_innenprozesse. Erschwerend erwies sich die gesetzlich ungeklärte Situation in der Schweiz. Schlussfolgerungen: Die Stärke dieser Rolle lag in der Erhöhung der Betreuungskontinuität, der Verbesserung der Ansprechbarkeit in medizinischen Fragen für Patient_innen und Pflegende sowie in der Optimierung der Patientenprozesse und damit auch der Patientensicherheit. Die gesetzlichen Vorgaben bezüglich der Kompetenzen erschweren derzeit den Einsatz von Nurse Practitioner im stationären Bereich.

Development of a quality indicator set to measure and improve quality of ICU care in low- and middle-income countries

PURPOSE

To develop a set of actionable quality indicators for critical care suitable for use in low- or middle-income countries (LMICs).

METHODS

A list of 84 candidate indicators compiled from a previous literature review and stakeholder recommendations were categorised into three domains (foundation, process, and quality impact). An expert panel (EP) representing stakeholders from critical care and allied specialties in multiple low-, middle-, and high-income countries was convened. In rounds one and two of the Delphi exercise, the EP appraised (Likert scale 1-5) each indicator for validity, feasibility; in round three sensitivity to change, and reliability were additionally appraised. Potential barriers and facilitators to implementation of the quality indicators were also reported in this round. Median score and interquartile range (IQR) were used to determine consensus; indicators with consensus disagreement (median < 4, IQR ≤ 1) were removed, and indicators with consensus agreement (median ≥ 4, IQR ≤ 1) or no consensus were retained. In round four, indicators were prioritised based on their ability to impact cost of care to the provider and recipient, staff well-being, patient safety, and patient-centred outcomes.

RESULTS

Seventy-one experts from 30 countries (n = 45, 63%, representing critical care) selected 57 indicators to assess quality of care in intensive care unit (ICU) in LMICs: 16 foundation, 27 process, and 14 quality impact indicators after round three. Round 4 resulted in 14 prioritised indicators. Fifty-seven respondents reported barriers and facilitators, of which electronic registry-embedded data collection was the biggest perceived facilitator to implementation (n = 54/57, 95%) Concerns over burden of data collection (n = 53/57, 93%) and variations in definition (n = 45/57, 79%) were perceived as the greatest barrier to implementation.

CONCLUSION

This consensus exercise provides a common set of indicators to support benchmarking and quality improvement programs for critical care populations in LMICs.

Dose-response association between nurse staffing and patient outcomes following major cancer surgeries using a nationwide inpatient database in Japan

AIMS AND OBJECTIVES

To examine the non-linear dose-response associations between nurse staffing levels and patient outcomes using a nationwide inpatient database in Japan.

BACKGROUND

Previous studies showed that higher nurse staffing levels were associated with better patient outcomes. However, it remains unclear whether there are thresholds for the associations between higher nurse staffing levels and improved patient outcomes.

DESIGNS

Retrospective observational study design following the STROBE guideline.

METHODS

We identified all patients aged ≥20 years who underwent one of six major cancer surgeries between July 2010 and March 2018 using data from the Diagnosis Procedure Combination database, a nationwide database for acute-care inpatients in Japan. Restricted cubic spline regression analyses, the statistical method that allows non-linear functional form, were performed with several scenarios of cut-off points to examine the dose-response associations between patient-to-nurse ratio per shift and failure to rescue, 30-day in-hospital mortality and postoperative complications.

RESULTS

Among 645,687 patients, restricted cubic spline regression analyses showed insignificant associations of patient-to-nurse ratio with failure to rescue and 30-day in-hospital mortality with no threshold, but a reverse J-shaped association with postoperative complications with a threshold of patient-to-nurse ratio per shift of 5.4.

CONCLUSIONS

In terms of postoperative complications, additional registered nurses were associated with decreased postoperative complications. However, this incremental benefit of additional registered nurses may disappear if hospitals allocate five to six number of registered nurses in general wards.

RELEVANCE TO CLINICAL PRACTICE

This study suggested that additional registered nurses over one per five to six patients may not bring the incremental benefit to decrease postoperative complications.

A scoping review of registry captured indicators for evaluating quality of critical care in ICU

BACKGROUND

Excess morbidity and mortality following critical illness is increasingly attributed to potentially avoidable complications occurring as a result of complex ICU management (Berenholtz et al., J Crit Care 17:1-2, 2002; De Vos et al., J Crit Care 22:267-74, 2007; Zimmerman J Crit Care 1:12-5, 2002). Routine measurement of quality indicators (QIs) through an Electronic Health Record (EHR) or registries are increasingly used to benchmark care and evaluate improvement interventions. However, existing indicators of quality for intensive care are derived almost exclusively from relatively narrow subsets of ICU patients from high-income healthcare systems. The aim of this scoping review is to systematically review the literature on QIs for evaluating critical care, identify QIs, map their definitions, evidence base, and describe the variances in measurement, and both the reported advantages and challenges of implementation.

METHOD

We searched MEDLINE, EMBASE, CINAHL, and the Cochrane libraries from the earliest available date through to January 2019. To increase the sensitivity of the search, grey literature and reference lists were reviewed. Minimum inclusion criteria were a description of one or more QIs designed to evaluate care for patients in ICU captured through a registry platform or EHR adapted for quality of care surveillance.

RESULTS

The search identified 4780 citations. Review of abstracts led to retrieval of 276 full-text articles, of which 123 articles were accepted. Fifty-one unique QIs in ICU were classified using the three components of health care quality proposed by the High Quality Health Systems (HQSS) framework. Adverse events including hospital acquired infections (13.7%), hospital processes (54.9%), and outcomes (31.4%) were the most common QIs identified. Patient reported outcome QIs accounted for less than 6%. Barriers to the implementation of QIs were described in 35.7% of articles and divided into operational barriers (51%) and acceptability barriers (49%).

CONCLUSIONS

Despite the complexity and risk associated with ICU care, there are only a small number of operational indicators used. Future selection of QIs would benefit from a stakeholder-driven approach, whereby the values of patients and communities and the priorities for actionable improvement as perceived by healthcare providers are prioritized and include greater focus on measuring discriminable processes of care.

Communication Skills, Problem-Solving Ability, Understanding of Patients' Conditions, and Nurse's Perception of Professionalism among Clinical Nurses: A Structural Equation Model Analysis

This study was intended to confirm the structural relationship between clinical nurse communication skills, problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism. Due to changes in the healthcare environment, it is becoming difficult to meet the needs of patients, and it is becoming very important to improve the ability to perform professional nursing jobs to meet expectations. In this study method, structural model analysis was applied to identify factors influencing the perception of professionalism in nurses. The subjects of this study were 171 nurses working at general hospitals in city of Se, Ga, and Geu. Data analysis included frequency analysis, identification factor analysis, reliability analysis, measurement model analysis, model fit, and intervention effects. In the results of the study, nurse’s perception of professionalism was influenced by factors of communication skills and understanding of the patient’s condition, but not by their ability to solve problems. Understanding of patient’s condition had a mediating effect on communication skills and nursing awareness. Communication skills and understanding of the patient’s condition greatly influenced the nurse’s perception of professionalism. To improve the professionalism of clinical nurses, nursing managers need to emphasize communication skills and understanding of the patient’s condition. The purpose of this study was to provide a rationale for developing a program to improve job skills by strengthening the awareness of professional positions of clinical nurses to develop nursing quality of community.

Efforts to reduce the length of stay in a low-intensity ICU: Changes in the ICU brought about by collaboration between Certified Nurse Specialists as head nurses and intensivists

Certified Nurse Specialists (CNS) are advanced practice nurses that often play a role in management. This study aims to investigate whether cooperation between CNSs in the position of Intensive Care Unit (ICU) head nurse and intensivists change the length of stay for ICU patients. A single centered retrospective cohort study design was followed. A multivariable regression analysis was performed to determine whether there is a difference in patients’ length of ICU stay for two years before and after CNS as ICU head nurse and an intensivist started collaborating. The patients’ diagnosis, age, gender, scheduled/emergency admission, surgical history, length of ICU stay, usage of ventilator, and details of ICU treatment were collected from the institution’s electronic medical records. During the study period (April 2015 to March 2019), 3,135 patients were admitted to ICU, with 1,471 in the before collaboration group and 1,664 in the after-collaboration group. Collaboration between the CNS as head nurse and intensivists was significantly associated with shorter length of ICU stay (coefficient -0.03 [95% CI, -0.05–0.01], p < 0.001, t-statistic -3.29). Our main finding illustrates that in low-intensity ICUs, collaboration between CNSs as head nurses and intensivists may reduce patients’ length of ICU stay.

Association between nursing care delivery models and patients' health outcomes in a university hospital: A retrospective cohort study based on the Diagnostic Procedure Combination database

AIM

This study aims to examine the association between nursing delivery models (fixed-team nursing model and Partnership Nursing System® [PNS®]) and patients' health outcomes (30-day in-hospital mortality and functional decline, indicated by a decline in Barthel Index or in-hospital mortality).

METHODS

This study used a retrospective cohort design based on the data from the Diagnostic Procedure Combination database, which included routinely collected health data for Japanese administrative claims. Participants were inpatients aged 20-99 years admitted between July 2010 and August 2012 (fixed-team nursing period) and July 2014 and August 2017 (PNS® period) to an academic teaching hospital in Japan. Odds ratios and 95% confidence intervals were estimated using multivariable logistic models.

RESULTS

We included 24,108 and 23,872 patients for the analyses of 30-day in-hospital mortality and functional decline, respectively (median age: 62 years; 52% women). The 30-day mortalities in both fixed-team nursing and PNS® groups were 0.5%. There was no significant association between the nursing delivery models and 30-day in-hospital mortality (adjusted odds ratio = 1.15, 95% confidence interval = 0.78-1.70). However, the PNS® group was found to have a higher proportion of patients with functional decline (2.7%) than the fixed-team nursing group (2.2%; p = .030). The adjusted odds ratio of declined function in the PNS® group, compared to the fixed-team nursing group, was 1.40 (95% confidence interval = 1.17-1.68, p < .001).

CONCLUSIONS

Further studies are needed to examine how the PNS® model influences patient outcomes, especially nurse-sensitive patient outcomes.

Impact of having a certified nurse specialist in critical care nursing as head nurse on ICU patient outcomes

Objectives

This study evaluated the impact of the presence of a certified nurse specialist in critical care (CNS) as ICU head nurse in an open ICU on clinical outcomes.

Methods

The presence of a CNS as ICU head nurse was implemented in practice in April 2017. To evaluate the impact on patient outcomes before and after the implementation, patients were divided into two groups: before (April 2014 to March 2017; 1988 patients) and after (April 2017 to March 2019; 1664 patients). Patients’ demographic data were collected from the ICU database.

Results

Multivariable logistic regression analysis revealed that the presence of a CNS as ICU head nurse was associated with lower ICU mortality (odds ratio (OR): 0.52, 95% CI: 0.36–0.73, p < .001) and fewer patients receiving mechanical ventilation in the ICU (OR: 0.20, 95% CI: 0.15–0.26, p < .001).

Conclusion

CNSs are defined as one type of advanced practice nurses. Having a CNS as a head nurse in the ICU may have helped improve patient outcomes by leveraging these practical skills in nursing management.

What nursing sensitive outcomes have been studied to-date among patients cared for in intensive care units? Findings from a scoping review

BACKGROUND

Although many studies have considered mortality and adverse effects as outcomes sensitive to nursing practice, it seems that other outcomes of nursing care in intensive care units have been explored less commonly.

OBJECTIVES

To describe the state-of-science in research in the field of nursing sensitive outcomes in intensive care units and to synthesize outcomes that have been documented to date as being influenced by nursing care.

DESIGN

A scoping review study based on the framework proposed by Arksey and O'Malley, further refined by the Levac and Joanna Briggs Institute was performed in 2019.

DATA SOURCES

The Medline, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Scopus, and Google Scholar electronic databases were searched. In addition, the reference list of included articles was screened.

REVIEW METHODS

Two researchers independently identified publications on the basis of the following criteria: (a) articles that reported nursing sensitive outcomes on critically-ill adult patients admitted to the intensive care unit, (b) as primary and secondary studies, (c) written in English, and (d) without any time frame limitation.

RESULTS

Of the 4,231 records, 112 fully met the inclusion criteria and were included. Publications were mainly authored in the US and Canada (n = 44, 39.2%), and the majority (n = 62, 55.3%) had an observational design. A total of 233 nursing sensitive outcomes emerged, categorized in 35 outcomes, with, on average, two per study included. The most often measured outcomes were pressure ulcers (20 studies) and ventilator-associated pneumonias (19 studies); the less studied outcomes were quality of life, secretion clearance, patient-ventilator dysynchrony, and post-extubation dysphagia. When categorizing outcomes, the ones concerning safety (n = 77, 33.1%) were represented the most, followed by those concerning the clinical (n = 72, 30.9%), functional (n = 70, 30.0%), and perceptual (n = 14, 6.0%) domains. The interdependent outcomes linked to multi-professional interventions (e.g., ventilator-associated pneumonias) were the most frequently studied nursing sensitive outcomes (n = 20, 57.1%), while independent outcomes resulting from autonomous interventions performed by nurses were less often studied (n = 8, 22.9%).

CONCLUSIONS

From a clinical point of view, a large heterogeneity of outcomes influenced by nursing care emerged. However, identified outcomes have been studied with different approaches and metrics, so that future efforts will need to establish homogeneous conceptual and operative definitions. Moreover, increasing efforts in establishing perceptual outcomes, or those close to the fundamentals of nursing care, are suggested in order to better depict the contribution of critical care nurses in the field.