A randomized trial of early discharge and nurse specialist transitional follow-up care of high-risk childbearing women

A systematic review on outcome reporting in randomised controlled trials assessing treatment interventions in pregnant women with pregestational diabetes

BACKGROUND

Pregestational diabetes mellitus (PGDM) is associated with adverse pregnancy outcomes. Studies assessing interventions to improve maternal and infant outcomes have increased exponentially over recent years. Several outcomes in this field of maternal diabetes are rare, making it difficult to synthesise evidence.

OBJECTIVES

To collect outcomes reported in studies assessing treatment interventions in pregnant women with PGDM.

SEARCH STRATEGY

CENTRAL, Web of Science, Medline, CINAHL, Embase and ClinicalTrials.gov from their inception until 27 January 2020.

SELECTION CRITERIA

Any randomised controlled trial assessing treatment interventions in pregnant women with PGDM reported in English.

DATA COLLECTION AND ANALYSIS

Two independent reviewers assessed the suitability of articles and retrieved the data. Outcomes extracted from the literature were broadly categorised into maternal, fetal/infant or other outcomes by the study advisory group.

MAIN RESULTS

Sixty-seven of the 1475 studies identified fulfilled the inclusion criteria. The median number of outcomes reported per study was 15 (range 1-46). The majority of studies were from North America and Europe. Insulin and metformin were the most commonly investigated pharmacological interventions. Glucose monitoring was the most assessed technological intervention. In all, 131 unique outcomes were extracted: maternal (n = 69), fetal/infant (n = 61) and other (n = 1).

CONCLUSIONS

Outcome reporting in treatment interventions trials of pregnant women with PGDM is varied, making it difficult to synthesise evidence, especially for rare outcomes. Systems are needed to standardise outcome reporting in future clinical trials and so facilitate evidence synthesis in this area of maternal diabetes.

REGISTRATION

The systematic review was registered prospectively with the International Prospective Register of Systematic Reviews (PROSPERO) database (Registration number CRD42020173549).

TWEETABLE ABSTRACT

Outcome reporting is heterogeneous in intervention trials of pregnant women with diabetes existing before pregnancy.

A core outcome set for the treatment of pregnant women with pregestational diabetes: an international consensus study

Objective

To develop a core outcome set (COS) for randomised controlled trials (RCTs) evaluating the effectiveness of interventions for the treatment of pregnant women with pregestational diabetes mellitus (PGDM).

Design

A consensus developmental study.

Setting

International.

Population

Two hundred and five stakeholders completed the first round.

Methods

The study consisted of three components. (1) A systematic review of the literature to produce a list of outcomes reported in RCTs assessing the effectiveness of interventions for the treatment of pregnant women with PGDM. (2) A three-round, online eDelphi survey to prioritise these outcomes by international stakeholders (including healthcare professionals, researchers and women with PGDM). (3) A consensus meeting where stakeholders from each group decided on the final COS.

Main outcome measures

All outcomes were extracted from the literature.

Results

We extracted 131 unique outcomes from 67 records meeting the full inclusion criteria. Of the 205 stakeholders who completed the first round, 174/205 (85%) and 165/174 (95%) completed rounds 2 and 3, respectively. Participants at the subsequent consensus meeting chose 19 outcomes for inclusion into the COS: trimester-specific haemoglobin A1c, maternal weight gain during pregnancy, severe maternal hypoglycaemia, diabetic ketoacidosis, miscarriage, pregnancy-induced hypertension, pre-eclampsia, maternal death, birthweight, large for gestational age, small for gestational age, gestational age at birth, preterm birth, mode of birth, shoulder dystocia, neonatal hypoglycaemia, congenital malformations, stillbirth and neonatal death.

Conclusions

This COS will enable better comparison between RCTs to produce robust evidence synthesis, improve trial reporting and optimise research efficiency in studies assessing treatment of pregnant women with PGDM.

165 key stakeholders have developed #Treatment #CoreOutcomes in pregnant women with #diabetes existing before pregnancy.

Unbiasing costs? An appraisal of economic assessment alongside randomized trials in neonatology

Economic evaluations performed alongside randomized controlled trials benefit from the protections against bias inherent in randomization. In this systematic review, we assessed the frequency and quality of economic assessments alongside randomized controlled trials of interventions in neonates published between 1990 and 2016. Over that period, 58 economic assessments were published, corresponding to approximately 2% of RCTs. We noted significant methodological limitations of these studies, including limitation of included costs to the health sector or payer rather than broader categories such as family or community expenditures (81%), short time horizon for cost measurement (less than one year in 60%), lack of reporting of uncertainty (26%), and infrequent analysis of costs and effects in a single metric (combined in 45%). Strategies for improving the quality and frequency of economic evaluations in neonatology are discussed, including selection of appropriate trials, funding, and peer review.

Postpartum management of hypertensive disorders of pregnancy: a systematic review

OBJECTIVES

Hypertensive disorders of pregnancy (HDP) affect one in ten pregnancies and often persist postpartum when complications can occur. We aimed to determine the effectiveness and safety of pharmacological interventions, other interventions and different care models for postpartum hypertension management.

DESIGN

A systematic review was undertaken. Nine electronic databases, including Medline, were searched from inception to 16 March 2017. After duplicate removal, 4561 records were screened. Two authors independently selected studies, extracted study characteristics and data, and assessed methodological quality.

SETTING

Randomised controlled trials, case-control studies and cohort studies from any country and healthcare setting.

PARTICIPANTS

Postnatal women with HDP.

INTERVENTIONS

Therapeutic intervention for management of hypertension, compared with another intervention, placebo or no intervention.

PRIMARY AND SECONDARY OUTCOME MEASURES

Outcome data were collected for maternal mortality and severe morbidity; systolic, diastolic and mean arterial blood pressure (BP) control; and safety data. Secondary outcome data collected included the length of postnatal hospital stay and laboratory values.

RESULTS

39 studies were included (n=2901). Results were heterogeneous in terms of intervention, comparison and outcome requiring a narrative approach. There were insufficient data to recommend any single pharmacological intervention. 18 studies reported calcium-channel blockers, vasodilators and beta-blockers lowered BP postpartum. 12 of these reported safety data. Limited data existed regarding management in the weeks following hospital discharge. Neither loop diuretics (three studies) nor corticosteroids (one study) produced clinical benefit. Uterine curettage significantly reduced BP over the first 48 hours postpartum (range 6-13 mm Hg) compared with standard care (eight studies), with safety data only reported by four of eight studies.

CONCLUSION

There was insufficient evidence to recommend a particular BP threshold, agent or model of care, but three classes of antihypertensive appeared variably effective. Further comparative research, including robust safety data, is required. Curettage reduced BP, but without adequate reporting of harms, so it cannot currently be recommended.

Graduate Nursing Education as a Conduit to Embed Evidence-Based Practice in Home Health Care

Historically, nurses have relied on traditions, clinical expertise, and expert opinion as a foundation for practice. Although these sources of knowledge are important and valued in nursing, the approach is unsystematic and not always based on scientific evidence. Although medicine used evidence-based practice (EBP) guidelines in their practice for decades, nurses have only recently embraced this concept. The purpose of this article is to describe the implementation of an EBP clinical practicum for graduate nursing students designed to (a) engage graduate nursing students in a collaborative relationship with a clinical nurse specialist (CNS) who is practicing in the home health care arenas, (b) provide CNS students with a framework for translating research to effect advanced clinical practice, and (c) provide opportunities for CNS students to critically evaluate the applicability and adaptability of evidence for the specific needs of the patient and the home health agency.

The clinical effectiveness and cost-effectiveness of clinical nurse specialist-led hospital to home transitional care: a systematic review

RATIONALE, AIMS AND OBJECTIVES

Clinical nurse specialists (CNSs) are major providers of transitional care. This paper describes a systematic review of randomized controlled trials (RCTs) evaluating the clinical effectiveness and cost-effectiveness of CNS transitional care.

METHODS

We searched 10 electronic databases, 1980 to July 2013, and hand-searched reference lists and key journals for RCTs that evaluated health system outcomes of CNS transitional care. Study quality was assessed using the Cochrane Risk of Bias and Quality of Health Economic Studies tools. The quality of evidence for individual outcomes was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool. We pooled data for similar outcomes.

RESULTS

Thirteen RCTs of CNS transitional care were identified (n = 2463 participants). The studies had low (n = 3), moderate (n = 8) and high (n = 2) risk of bias and weak economic analyses. Post-cancer surgery, CNS care was superior in reducing patient mortality. For patients with heart failure, CNS care delayed time to and reduced death or re-hospitalization, improved treatment adherence and patient satisfaction, and reduced costs and length of re-hospitalization stay. For elderly patients and caregivers, CNS care improved caregiver depression and reduced re-hospitalization, re-hospitalization length of stay and costs. For high-risk pregnant women and very low birthweight infants, CNS care improved infant immunization rates and maternal satisfaction with care and reduced maternal and infant length of hospital stay and costs.

CONCLUSIONS

There is low-quality evidence that CNS transitional care improves patient health outcomes, delays re-hospitalization and reduces hospital length of stay, re-hospitalization rates and costs. Further research incorporating robust economic evaluation is needed.

A systematic review of the cost-effectiveness of nurse practitioners and clinical nurse specialists: what is the quality of the evidence?

Background. Improved quality of care and control of healthcare costs are important factors influencing decisions to implement nurse practitioner (NP) and clinical nurse specialist (CNS) roles. Objective. To assess the quality of randomized controlled trials (RCTs) evaluating NP and CNS cost-effectiveness (defined broadly to also include studies measuring health resource utilization). Design. Systematic review of RCTs of NP and CNS cost-effectiveness reported between 1980 and July 2012. Results. 4,397 unique records were reviewed. We included 43 RCTs in six groupings, NP-outpatient (n = 11), NP-transition (n = 5), NP-inpatient (n = 2), CNS-outpatient (n = 11), CNS-transition (n = 13), and CNS-inpatient (n = 1). Internal validity was assessed using the Cochrane risk of bias tool; 18 (42%) studies were at low, 17 (39%) were at moderate, and eight (19%) at high risk of bias. Few studies included detailed descriptions of the education, experience, or role of the NPs or CNSs, affecting external validity. Conclusions. We identified 43 RCTs evaluating the cost-effectiveness of NPs and CNSs using criteria that meet current definitions of the roles. Almost half the RCTs were at low risk of bias. Incomplete reporting of study methods and lack of details about NP or CNS education, experience, and role create challenges in consolidating the evidence of the cost-effectiveness of these roles.

Adapting and testing telephone-based depression care management intervention for adolescent mothers

This phase 1 clinical trial combined qualitative and quantitative methods to modify a collaborative care, telephone-based, depression care management intervention for adolescent mothers and to determine the acceptability, feasibility, and initial efficacy of the intervention in a sample of adolescent mothers (n = 97) who were recruited from a Teen Parent Program. Outcomes included measures of depressive symptoms, functioning, and use of mental health services. Acceptability of the intervention was demonstrated, but feasibility issues related to the complex life challenges confronting the adolescent mother. Although only four adolescent mothers received mental health treatment, there was a trend for improved depressive symptoms over time. Results of the study provide data for the need of further refinement of the intervention before a large clinical trial is conducted for adolescent mothers with symptoms of depression.

Women with high-risk pregnancies, problems, and APN interventions

PURPOSE

To (a) describe women's prenatal and postpartum problems and advanced practice nurses (APN) interventions; and (b) determine if problems and APN interventions differed by women's medical diagnosis (diabetes, hypertension, preterm labor).

DESIGN AND METHODS

Content analysis of 85 interaction logs created by APNs during a randomized clinical trial in which half of physician-provided prenatal care was substituted with APN-provided prenatal care in the women's homes. Patients' problems and APN interventions were classified with the Omaha Classification System.

FINDINGS

A total of 212,835 health problems and 212,835 APN interventions were identified. The dominant antenatal problems were physiologic (59.2%) and health-related behaviors (33.3%); postpartum were physiologic (44.0%) and psychosocial problems (31.6%). Antenatally, women with diabetes had significantly more health-related behavior problems; women with preterm labor had more physiologic problems. APN surveillance interventions predominated antenatally (65.6%) and postpartum (66.0%), followed by health teaching, guidance, and counseling both antenatally (25.4%) and postpartum (28.1%). Women with chronic hypertension required significantly more case-management interventions.

CONCLUSIONS

The categories of women's problems were largely similar across medical diagnostic groups. Interventions to address women's problems ranged from assessing maternal and fetal physiologic states to teaching interpersonal relationships and self-care management to assisting with transportation and housing. Data show the range of APN knowledge and skills needed to improve maternal and infant outcomes and ultimately reduce healthcare costs in women with high-risk pregnancies.

Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home

BACKGROUND

It is known that many patients encounter a variety of problems in the first weeks after they have been discharged from hospital to home. In recent years many projects have addressed discharge planning, with the aim of reducing problems after discharge. Telephone follow-up (TFU) is seen as a good means of exchanging information, providing health education and advice, managing symptoms, recognising complications early, giving reassurance and providing quality aftercare service. Some research has shown that telephone follow-up is feasible, and that patients appreciate such calls. However, at present it is not clear whether TFU is also effective in reducing postdischarge problems.

OBJECTIVES

To assess the effects of follow-up telephone calls in the first month post discharge, initiated by hospital-based health professionals, to patients discharged from hospital to home.

SEARCH STRATEGY

We searched the following databases from their start date to July 2003, without limits as to date of publication or language: the Cochrane Consumers and Communication Review Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), PubMed, EMBASE (OVID), BiomedCentral, CINAHL, ERIC (OVID), INVERT (Dutch nursing literature index), LILACS, Picarta (Dutch library system), PsycINFO/PsycLIT (OVID), the Combined Social and Science Citation Index Expanded (SCI-E), SOCIOFILE. We searched for ongoing research in the following databases: National Research Register (http://www.update-software.com/nrr/); Controlled Clinical Trials (http://www.controlled-trials.com/); and Clinical Trials (http://clinicaltrials.gov/). We searched the reference lists of included studies and contacted researchers active in this area.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of TFU initiated by a hospital-based health professional, for patients discharged home from an acute hospital setting. The intervention was delivered within the first month after discharge; outcomes were measured within 3 months after discharge, and either the TFU was the only intervention, or its effect could be analysed separately.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and for methodological quality. The methodological quality of included studies was assessed using the criteria from the Cochrane Effective Practice and Organisation of Care Review Group. The data-extraction form was based on the template developed by the Cochrane Consumers and Communication Review Group. Data was extracted by one review author and checked by a second author. For as far it was considered that there was enough clinical homogeneity with regard to patient groups and measured outcomes, statistical pooling was planned using a random effects model and standardised mean differences for continuous scales and relative risks for dichotomous data, and tests for statistical heterogeneity were performed.

MAIN RESULTS

We included 33 studies involving 5110 patients. Predominantly, the studies were of low methodological quality. TFU has been applied in many patient groups. There is a large variety in the ways the TFU was performed (the health professionals who undertook the TFU, frequency, structure, duration, etc.). Many different outcomes have been measured, but only a few were measured across more than one study. Effects are not constant across studies, nor within patient groups. Due to methodological and clinical diversity, quantitative pooling could only be performed for a few outcomes. Of the eight meta-analyses in this review, five showed considerable statistical heterogeneity. Overall, there was inconclusive evidence about the effects of TFU.

AUTHORS' CONCLUSIONS

The low methodological quality of the included studies means that results must be considered with caution. No adverse effects were reported. Nevertheless, although some studies find that the intervention had favourable effects for some outcomes, overall the studies show clinically-equivalent results between TFU and control groups. In summary, we cannot conclude that TFU is an effective intervention.

Advanced Practice Nursing: Unification Through a Common Identity

Despite the wide variety of advanced practice roles in nursing and the well-documented differences among them [Hamric, A. (2000). A definition of advanced nursing practice. In A. Hamric, J. Spross, & C. Hanson (Eds.), Advanced nursing practice: An integrative approach (pp. 53-73). Philadelphia, PA: W. B. Saunders], the authors suggest that nurses in these roles should adopt a common identity, that of an "advanced practice nurse" (APN). The authors outline the development of advanced practice nursing in Canada and the United States, tracking historical influences and highlighting current issues facing APNs. The authors explore elements that constitute the definable and describable core of advanced practice nursing-knowledge, education, scope of practice, regulatory issues, and outcomes. They conclude that adoption of a common identity for all advanced practice nursing roles may clarify role confusion (which is currently experienced within and outside the profession), reinforce links between knowledge development and nursing practice, and ensure that advanced nursing practice is responsive to the needs of society.

Nurse Dose as a Concept

PURPOSE

To describe the concept of Nurse Dose.

METHODS

The concept of nurse dose has been identified from decades of clinical research as a concept essential in the delivery of safe and high quality health care. The components of nurse dose were conceptualized through review of the literature from nursing, medicine, and health services research.

FINDINGS

Nurse dose is conceptualized as having three equally essential components: dose, nurse, and host and host response. Dose in the macro view includes the number of nurses per patient or per population in cities, states, regions, or countries. Dose in a micro view includes the amount of nurse time and the number of contacts. The nurse component consists of the education, expertise, and experience of the nurse. Host is represented by an organization and its characteristics (culture, autonomy, practice control) in a macro view and by the patient and characteristics (beliefs, values, culture) in a micro view. Host response includes response to the autonomy and acceptability of the nurse.

CONCLUSIONS

Greater nurse dose has been associated with decreases in patient mortality, morbidity, and healthcare costs.

The effect of a multidisciplinary hospitalist/physician and advanced practice nurse collaboration on hospital costs

OBJECTIVE

To compare nurse practitioner/physician management of hospital care, multidisciplinary team-based planning, expedited discharge, and assessment after discharge to usual management.

BACKGROUND

In the context of managed care, the goal of academic medical centers is to provide quality care at the lowest cost and minimize length of stay (LOS) while not compromising quality.

METHODS

Comparative, 2-group, quasiexperimental design was used; 1,207 general medicine patients (n=581 in the experimental group and n=626 in the control group) were enrolled. The control unit provided usual care. The care management in the experimental unit had 3 different components: an advanced practice nurse who followed the patients during hospitalization and 30 days after discharge, a hospitalist medical director and another hospitalist, and daily multidisciplinary rounds. LOS, hospital costs, mortality, and readmission 4 months after discharge were measured.

RESULTS

Average LOS was significantly lower for patients in the experimental group than the control group (5 vs. 6 days, P<.0001). The "backfill profit" to the hospital was US$1591 per patient in the experimental group (SE, US$639). There were no significant group differences in mortality or readmissions.

CONCLUSIONS

Collaborative physician/nurse practitioner multidisciplinary care management of hospitalized medical patients reduced LOS and improved hospital profit without altering readmissions or mortality.

Nurses', midwives' and health visitors' involvement in cross-boundary working within child health services

BACKGROUND

Cross-boundary working is a key policy objective. Cross-boundary working provides the foundation for high quality provision across child health services and is imperative for an effective child protection system and the support of children and young people with health needs.

METHODS

Two participative conferences were attended by 113 stakeholders utilizing the World Café focus group method. Most (87%) of the sample were nurses, midwives or health visitors.

RESULTS

Many examples of cross-boundary working were identified across the different areas of practice. Remarkably few transdisciplinary examples were identified in contrast to the number of inter-agency examples. Intra-organizational boundaries across the health service were also noted.

CONCLUSIONS

Considerable cross-boundary working was reported but transdisciplinary working is not yet well established across all areas of child health provision.

APN-physician collaboration in caring for women with high-risk pregnancies

PURPOSE

To examine: (a) frequency and focus of APN-physician collaborations in a clinical trial in which half of physician prenatal care for women with high-risk pregnancies was substituted with APN prenatal care delivered in women's homes; and (b) characteristics of women requiring greater numbers of collaborations.

DESIGN AND METHODS

Descriptive study with secondary analysis of data from 83 of the original trial's 85 intervention participants followed by APNs prenatally through 8 weeks postpartum. APN practices, recorded in logs, included APN interactions with the women and the physician, and type of APN contact (e.g., home visit, telephone call). Each APN-physician collaboration was coded for type, timing, and focus.

FINDINGS

Total number of APN-physician collaboration contacts was 351, with a mean of 4.5 and a range of 1 to 16 per woman. Focus of collaborations was: status updates (59%), new physical findings (21%), change in treatment (8%), patient concerns (7%) and medication adjustment (5%). No significant differences in numbers of collaborations were found according to age, primary diagnosis, marital status, type of health insurance, race, or income. Women with high school education received more collaborations than did those not completing high school or those with some postsecondary education. Prenatally, women with a first pregnancy required more collaborations than did multipara participants.

CONCLUSIONS

Most APN-physician collaborative contacts were focused on monitoring women's physical and emotional status and discussing new physical findings. These collaborations were important in the original trial's successful pregnancy and infant outcomes and savings in health care dollars.

Economic evaluation of specialist cancer and palliative nursing: a literature review

Little progress has been made in economic evaluation of specialist cancer and palliative care nursing. A literature review of economic studies of clinical nurse specialists (CNSs) was undertaken to assess how the measurement of economic outcomes has been tackled in the literature to date. The initial search found 400 studies. Abstracts from all the studies were reviewed but only 17 studies met the basic criteria for inclusion, reporting primary cost and outcomes data, and clearly specifying the role of a CNS. All of the studies but one focused on direct patient care rather than other CNS roles and were undertaken alongside effectiveness studies. The economic evaluations considered only a narrow range of costs, but a wide range of outcomes. Specific nursing outcomes were only reported in a minority of studies. None of the studies reported cost-effectiveness ratios. However, CNS interventions were reported to be both less costly and more effective than alternative forms of care, negating the need for further cost-effectiveness analysis. Overall, the papers were not of good quality, reducing the validity of the findings. Robust economic evaluations of the CNS role need to be undertaken. These should involve nursing researchers and practitioners so that evaluations reflect the complex and multidimensional nature of CNS care and meet the required standard of evidence to influence practice.

Lay Home Visiting May Improve Pregnancy Outcomes

Home visiting may be a promising strategy to improve pregnancy outcomes, and home visiting by lay workers may be more accepted by pregnant women. Lay workers may impact on social and environmental risk factors as well as on health care utilization. As with any primary prevention strategy, these programs may be more successful if implemented with responsibility shared between the health care system and the community. This article reviews the state of the science related to lay home visiting during pregnancy in the United States. Using a variety of search terms, an exhaustive review of the literature was conducted using several large electronic databases. Studies of lay home visiting during pregnancy have documented mixed results. Many weaknesses exist in the studies available, including use of descriptive or quasi-experimental designs in most of the studies, absence of a clearly specified set of interventions, and lack of cost analysis. Gaps in our knowledge of the impact of lay home visitors on pregnancy outcomes persist.

APN-directed transitional home care model: achieving positive outcomes for patients with COPD

Advanced practice nurses (APNs) have not been widely used in home care, despite evidence of their effectiveness with a variety of patient groups. This study examined the use of the transitional model for home care patients with chronic obstructive pulmonary disease. The study found patients cared for by an APN-directed visit team had fewer nursing visits, rehospitalizations, and acute care visits. Depressive symptoms were also less, and functional abilities increased compared with patients cared for by a usual care model.

Health disparities among vulnerable populations: evolution of knowledge over five decades in Nursing Research publications

BACKGROUND

Considerable attention has been focused recently on conducting research on the health disparities experienced by some Americans as the result of poverty, ethnicity, and/or marginalized social status. Nursing research has a major role to play in developing this body of knowledge.

PURPOSE

The purpose of this paper is to review the contributions that Nursing Research made through its publications over the last five decades in developing the body of tested knowledge about health disparities in vulnerable groups and to analyze the progress made.

METHODS

Criteria for reviewing the literature were established. All Nursing Research publications between 1952 and 2000 were searched manually, indexes of each year's bound volumes were reviewed, and computer searches were conducted. Included in the review were research reports, research briefs, and methodology articles.

RESULTS

Seventy-nine papers were found that met basic criteria for inclusion. The number of relevant publications increased each decade, with a sizable increase in numbers since 1990, and may be related to the social, political, and economic climate of each decade. The research questions asked and the methods used became more complex over time.

CONCLUSIONS

Nursing Research has made a significant contribution in disseminating the body of tested knowledge related to the health disparities experienced by vulnerable populations and the methodologies associated with vulnerable populations research. Areas for future research are community-based studies, intervention studies that provide tangible resources, and methodologic approaches that involve participants in the research process.

Development of a program to manage costly outliers

The advanced practice nurse group devised a method to identify clinical variables of the elderly patients with multisystem failure requiring complex nursing care referred to as outlier. Outliers in this program were defined as patients whose hospital charges were greater than $50,000 with a length of stay greater than the primary diagnostic related group designated. Once criteria were identified, nursing strategies were developed to monitor the elderly patient, implement interventions, and evaluate patient outcomes. The goals of this program were to identify who the outliers might be prior to becoming outliers and to manage their nursing care early in their hospital course, attempting to match resource requirements with resource availability.

Returning to our roots: 25 years of maternal/child nursing in the community

In many ways the past 25 years in maternal/child nursing have brought us back to community roots. Components of community care in maternal/child nursing include self-care; prevention; family, culture, and community; and collaboration. These components are reviewed through a retrospective look at community maternal/child nursing activities during the past 25 years. In addition, maternal/child nursing for the future is examined by thinking expansively in five areas: childbirth education, community-based interventions for better health behavior, community-based interventions to meet 2010 objectives, family forms, and definitions of women's health in the United States and beyond. We are birthing a new vision of maternal/child health and wellness. Central to that birthing is an awakening of the still, small, wise intuitive voice in all of us.

The CNS's impact on process and outcome of patients with total knee replacement

This study was designed to determine whether differences exist between patients with total knee replacement on hospital units with or without clinical nurse specialists (CNSs) in terms of selected process and outcome variables. The charts of 128 randomly chosen patients who had undergone total knee replacement were reviewed. Sixty-four patients were from orthopedic units with CNSs and 64 were from orthopedic units without CNSs. This study was based on Donabedian's framework for assessment of quality of care using structure, process, and outcome variables. Structural variables were collected on institutional and unit demographics. Data were gathered on nursing care interventions (process variables) using process instruments designed by the investigator. Length of stay, total length of stay, which included rehabilitation length of stay, and complications were the outcome variables used. Patients on units with CNSs had significantly higher process scores, shorter total length of stay, and fewer complications than patients on units without CNSs. In addition, significant negative correlations were found between process instrument scores and total length of stay. Higher scores on the process instruments (with CNS units) were correlated with shorter total length of stay. The number of complications was also negatively correlated to the process instrument scores.

A public health nursing early intervention program for adolescent mothers: outcomes from pregnancy through 6 weeks postpartum

BACKGROUND

Adolescent pregnancy and parenting remain a major public concern because of their impact on maternal-child health and on the social and economic well-being of the nation. Federal welfare reform legislation has created an urgent need for community-based nursing intervention programs to improve health and social outcomes for disadvantaged adolescent mothers and to promote their self-sufficiency.

OBJECTIVE

To evaluate the effects of an early intervention program (EIP) that uses a public health nursing model on health and social outcomes of adolescent mothers and their children and on the quality of mother-child interaction.

METHODS

Pregnant adolescents referred to a county health department were randomly assigned to an experimental (EIP) or control (traditional public health nursing [TPHN]) group. The sample included 121 adolescents from predominantly minority and impoverished backgrounds who were followed from pregnancy through 6 weeks postpartum. Intense and comprehensive home visitation by public health nurses and preparation-for-motherhood classes were provided to adolescents in the EIP. Health outcomes were determined on the basis of medical record data. Other measures included maternal self-report on selected behaviors, nurse interviews, and the Nursing Child Assessment Teaching Scale (NCATS).

RESULTS

Early findings indicate reduced premature birth and low-birth-weight (LBW) rates for young mothers receiving both forms of public health nursing care. No significant differences between groups were found for infant birth weight or type of delivery. Infants in the EIP had significantly fewer total days of birth-related hospitalization and rehospitalization than those in the TPHN group during the first 6 weeks of life (chi2(1) = 6.41; p = 0.01). Adolescents in the EIP demonstrated significantly more positive educational outcomes (e.g., lower school dropout rates) than those in the TPHN group (chi2(1) = 6.76; p < 0.009).

CONCLUSIONS

The early findings of this study demonstrate that pregnant adolescents benefit from both traditional and more intense public health nursing care in terms of prenatal and perinatal outcomes. The EIP was associated with decreased infant morbidity during the first 6 weeks of life and decreased maternal school dropout. Long-term outcomes for the EIP are being evaluated.

Patient problems and advanced practice nurse interventions during transitional care

This study is a secondary analysis of patient records written by advanced practice nurses (APNs) as they provided discharge planning and 4 weeks of home follow-up to elderly patients hospitalized with common medical and surgical conditions. The purposes of this study were to examine the problems experienced by elders who were hospitalized and discharged to home, the interventions used by APNs as they cared for these patients, and the linkages between patient problems and APN interventions. Care logs written by the APNs to document the patient problems and nursing interventions were content analyzed and coded using the Problem Classification Scheme and Intervention Scheme of the Omaha System. The results provided a description of the 10 most frequent problems experienced by the patients linked with the APN's interventions. The study provides a description of the nature and complexity of patient problems as they transition from hospital to home and increases our understanding of the contribution of APNs to the care of elders.

Employment patterns and timing of birth in women with high-risk pregnancies

OBJECTIVE

To describe the characteristics of employed women with high-risk pregnancies, their pattern of employment prenatally and postpartum, and the relationship of prenatal employment to preterm or full-term birth.

DESIGN

Secondary analysis with a sample of 171 women with high-risk pregnancies.

SETTING

Women's homes and a tertiary care hospital.

PARTICIPANTS

Women who were primarily single, African American, and poor; 33% worked or attended school during their pregnancies.

MAIN OUTCOME MEASURES

Gestational age at birth, employment, and school attendance.

RESULTS

Preterm delivery was not related to when the women stopped working or attending school or were prescribed bed rest. Women employed prenatally were older, had higher incomes, and were more likely to be white or of ethnicity other than African American. Fifty-seven percent of women with a history of prenatal employment and 85% of the women who intended to work after delivery returned to work during the first postpartum year.

CONCLUSIONS

Women employed during high-risk pregnancies are similar demographically to women with low-risk pregnancies in other studies. Most of the women stopped working or attending school because of prescribed bed rest. Bed rest, however, was not related to preterm delivery. Most women who planned to return to work did so. Factors other than the women's high-risk pregnancies, such as attitudes toward employment, employability, and family circumstances, most likely influenced their employment status. Current welfare reform initiatives will increase the number of women working while pregnant. This article provides pre-welfare-reform baseline data concerning patterns and effects of employment for women with high-risk pregnancies. These data will enable nurses to examine the effects of welfare reform on employment during pregnancy and preterm birth.

Outcome evaluation: an essential component for CNS practice

Tumultuous changes in healthcare costs, delivery, and service are requiring revolutionary new approaches by healthcare professionals to meet current and future needs. Multidisciplinary teams are creating many innovative care delivery models. It is essential that healthcare professionals evaluate the cost effectiveness and impact of their care and service on both patient and system outcomes. Clinical nurse specialists (CNSs) are an integral component in these models and are uniquely qualified both to implement and to evaluate care delivery and systems changes. The purpose of this article is to describe the role of the CNS in outcomes evaluation. Specifically, various types of outcomes are delineated, with a differentiation between nurse-sensitive and medical and collaborative care outcomes. Examples of valid and reliable measurement tools that are easy to use and have wide comparability are described, and implications for CNS practice are posed.

Antepartum home care for high-risk pregnant women

Home care for women experiencing complications of pregnancy is a rapidly growing specialty. A variety of models of antepartum home care have emerged. Provision of effective antepartum home care requires knowledge and clinical skills in perinatal and home health nursing and an understanding of the structure and function of the home health care system. Nursing care in the home encompasses case coordination, maternal and fetal assessment, maternal education regarding the woman's risk situation and self-monitoring requirements, and provision of support. Antepartum home care for conditions such as hypertension in pregnancy, preterm labor, and hyperemesis gravidarum is discussed.

Role of the clinical nurse specialist: an integrative review of the literature

This review of the literature related to the role of the clinical nurse specialist was commissioned by the AACN in order to provide a comprehensive resource for advanced practice nurses. This review provides a historical overview of clinical nurse specialists and some of the gaps or barriers to practice that have been experienced. A summary of these gaps shows that many have repeated themselves over the years. Also provided are potential solutions to facilitate the progression of this role in the future.