The role of interventional patient hygiene in improving clinical and economic outcomes

Interventional patient hygiene: discussion of the issues and a proposed model for implementation of the nursing care basics

More than 140 years ago, Florence Nightingale wrote "It may seem a strange principal to enunciate as the very first requirement in a Hospital that it should do the sick no harm." Data suggests that 63% of all preventable errors are related to clinical problems that are within nursing's independent scope of practice. Many of these fall in the category of "interventional hygiene" activities and include prevention of skin injury, post-operative respiratory complications and failure to rescue. As nurses we are called upon to assure higher levels of safety and quality for our patients by our governments, professional organisations and hospital administrations. It is essential that we implement evidence based nursing care strategies to reduce avoidable errors in care so that clinical outcomes improve. The author of this paper, who coined the team "interventional patient hygiene", discusses the science related to many of these care issues and proposes an Interventional Care Model for use by nurses in redesigning how we approach nurse sensitive care practices in the future. Additionally, a change framework called "Sustaining Nursing Clinical Practice" is described to ensure reintroduction and valuing of evidence basic nursing care in conjunction with the right resources and systems to sustain the new practice.

APN-led nursing rounds: an emphasis on evidence-based nursing care

In today's healthcare environment, nursing staff are challenged to care for patients with increasingly complex needs in an ever-changing environment. Nurses are expected to stay up to date on a tremendous number of institutional initiatives, best practice guidelines, and policies and procedures. These practice imperatives are often disseminated through passive means of information-sharing such as staff meetings and electronic mail. In this setting, it is difficult for nurses to simultaneously focus on incorporating practice updates while continuing to value basic nursing functions such as oral care, skin care, and incontinence management. The concept of Interventional Patient Hygiene emphasises that basic nursing functions are not only tasks, but also important evidence-based interventions that contribute to improved health for the patient. Interventional Patient Hygiene facilitates the integration of science and practice. This article describes a quality improvement intervention, Advanced practice nurse-led nursing rounds, which supports Interventional Patient Hygiene and be used to help staff integrate best practices while balancing the multiple priorities inherent in nursing care.

Characteristics and effects of nurse dosing over-rides on computer-based intensive insulin therapy protocol performance

OBJECTIVE

To determine characteristics and effects of nurse dosing over-rides of a clinical decision support system (CDSS) for intensive insulin therapy (IIT) in critical care units.

DESIGN

Retrospective analysis of patient database records and ethnographic study of nurses using IIT CDSS.

MEASUREMENTS

The authors determined the frequency, direction-greater than recommended (GTR) and less than recommended (LTR)- and magnitude of over-rides, and then compared recommended and over-ride doses' blood glucose (BG) variability and insulin resistance, two measures of IIT CDSS associated with mortality. The authors hypothesized that rates of hypoglycemia and hyperglycemia would be greater for recommended than over-ride doses. Finally, the authors observed and interviewed nurse users.

RESULTS

5.1% (9075) of 179,452 IIT CDSS doses were over-rides. 83.4% of over-ride doses were LTR, and 45.5% of these were ≥ 50% lower than recommended. In contrast, 78.9% of GTR doses were ≤ 25% higher than recommended. When recommended doses were administered, the rate of hypoglycemia was higher than the rate for GTR (p = 0.257) and LTR (p = 0.033) doses. When recommended doses were administered, the rate of hyperglycemia was lower than the rate for GTR (p = 0.003) and LTR (p < 0.001) doses. Estimates of patients' insulin requirements were higher for LTR doses than recommended and GTR doses. Nurses reported trusting IIT CDSS overall but appeared concerned about recommendations when administering LTR doses.

CONCLUSION

When over-riding IIT CDSS recommendations, nurses overwhelmingly administered LTR doses, which emphasized prevention of hypoglycemia but interfered with hyperglycemia control, especially when BG was >150 mg/dl. Nurses appeared to consider the amount of a recommended insulin dose, not a patient's trend of insulin resistance, when administering LTR doses overall. Over-rides affected IIT CDSS protocol performance.