The effect of high nursing surveillance on hospital cost

Future advancement of health care through standardized nursing terminologies: reflections from a Friends of the National Library of Medicine workshop honoring Virginia K. Saba

OBJECTIVE

To honor the legacy of nursing informatics pioneer and visionary, Dr. Virginia Saba, the Friends of the National Library of Medicine convened a group of international experts to reflect on Dr. Saba's contributions to nursing standardized nursing terminologies.

PROCESS

Experts led a day-and-a-half virtual update on nursing's sustained and rigorous efforts to develop and use valid, reliable, and computable standardized nursing terminologies over the past 5 decades. Over the course of the workshop, policymakers, industry leaders, and scholars discussed the successful use of standardized nursing terminologies, the potential for expanded use of these vetted tools to advance healthcare, and future needs and opportunities. In this article, we elaborate on this vision and key recommendations for continued and expanded adoption and use of standardized nursing terminologies across settings and systems with the goal of generating new knowledge that improves health.

CONCLUSION

Much of the promise that the original creators of standardized nursing terminologies envisioned has been achieved. Secondary analysis of clinical data using these terminologies has repeatedly demonstrated the value of nursing and nursing's data. With increased and widespread adoption, these achievements can be replicated across settings and systems.

Factors Affecting Nursing Surveillance Activity among Clinical Nurses

Nursing surveillance is a defense mechanism that protects patients from adverse events, as it is a systematic process that contributes to nurses' detection of and intervention in dangerous situations. This descriptive cross-sectional study examined the degree of nursing surveillance activity performed by clinical nurses, nurses' perceived importance of nursing surveillance, and their perception of patient safety culture. The study aimed to identify the predictors of nursing surveillance activity. Participants included 205 clinical nurses from two secondary hospitals and two tertiary hospitals in Changwon-si and Cheongju-si, South Korea, who had at least one year of clinical experience. Nursing surveillance activity was high among nurses who were assigned fewer than 1.88 patients, who worked in a tertiary hospital, and those who scored 7.0 or higher in nurses' perceived expertise. Nursing surveillance activity was significantly positively correlated with nurses' perceived importance of nursing surveillance and patient safety culture. A hierarchical multiple regression analysis was performed to identify the predictors of nursing surveillance activity. Nurses' perceived expertise, perceived importance of nursing surveillance, patient safety culture, and type of hospital explained 65.3% of the variance of nursing surveillance activity. This study is significant as it provides an assessment of the extent and key predictors of nursing surveillance activity.

Secondary use of standardized nursing care data for advancing nursing science and practice: a systematic review

OBJECTIVE

The study sought to present the findings of a systematic review of studies involving secondary analyses of data coded with standardized nursing terminologies (SNTs) retrieved from electronic health records (EHRs).

MATERIALS AND METHODS

We identified studies that performed secondary analysis of SNT-coded nursing EHR data from PubMed, CINAHL, and Google Scholar. We screened 2570 unique records and identified 44 articles of interest. We extracted research questions, nursing terminologies, sample characteristics, variables, and statistical techniques used from these articles. An adapted STROBE (Strengthening The Reporting of OBservational Studies in Epidemiology) Statement checklist for observational studies was used for reproducibility assessment.

RESULTS

Forty-four articles were identified. Their study foci were grouped into 3 categories: (1) potential uses of SNT-coded nursing data or challenges associated with this type of data (feasibility of standardizing nursing data), (2) analysis of SNT-coded nursing data to describe the characteristics of nursing care (characterization of nursing care), and (3) analysis of SNT-coded nursing data to understand the impact or effectiveness of nursing care (impact of nursing care). The analytical techniques varied including bivariate analysis, data mining, and predictive modeling.

DISCUSSION

SNT-coded nursing data extracted from EHRs is useful in characterizing nursing practice and offers the potential for demonstrating its impact on patient outcomes.

CONCLUSIONS

Our study provides evidence of the value of SNT-coded nursing data in EHRs. Future studies are needed to identify additional useful methods of analyzing SNT-coded nursing data and to combine nursing data with other data elements in EHRs to fully characterize the patient's health care experience.

Women and In-hospital Stroke Code Activation: Age, Ethnicity, and Unique Symptoms Matter

BACKGROUND

Women have worse stroke outcomes than men, and almost 17% of all stroke cases have symptom onset when admitted to the hospital for a separate condition.

OBJECTIVE

The aim of this study was to investigate the distinctive factors that impact the activation of an in-hospital stroke code and outcomes in women who have a stroke while admitted to the hospital for a separate condition.

METHODS

A retrospective observational propensity score study guided by the model for nursing effectiveness was used.

RESULTS

In-hospital stroke code was activated in 46 of 149 or 30.9% of women and 15 of 149 or 10.1% of women received thrombolytic therapy. Activation of an in-hospital stroke code was significant (P < .001) for women receiving thrombolytic therapy and significant to a home discharge status (P = .014). Age (P < .001), ethnicity (P < .001), common (P ≤ .001) and unique (P = .012) stroke symptoms, stroke risk factors (P < .001), comorbid conditions (P < .001), time last known well (P = .041), and diagnostic imaging (P < .001) were all significantly related to activation of an in-hospital stroke code.

CONCLUSIONS

Activation of an in-hospital stroke is a key indicator for women to receive thrombolytic therapy and be discharged to home. Younger married women from non-Caucasian ethnic groups and women with stroke risk factors and comorbid conditions are at a greater risk for delayed stroke symptom detection and not having an in-hospital stroke code activated. Awareness of these factors that hinder early stroke detection in women is crucial to improving stroke treatment and outcomes in women.

Design and validation of the INICIARE instrument, for the assessment of dependency level in acutely ill hospitalised patients

AIMS AND OBJECTIVES

The aim of this study was to establish the validity and reliability of an instrument (Inventario del NIvel de Cuidados mediante IndicAdores de clasificación de Resultados de Enfermería) used to assess the dependency level in acutely hospitalised patients. This instrument is novel, and it is based on the Nursing Outcomes Classification.

BACKGROUND

Multiple existing instruments for needs assessment have been poorly validated and based predominately on interventions. Standardised Nursing Languages offer an ideal framework to develop nursing sensitive instruments.

DESIGN

A cross-sectional validation study in two acute care hospitals in Spain.

METHODS

This study was implemented in two phases. First, the research team developed the instrument to be validated. In the second phase, the validation process was performed by experts, and the data analysis was conducted to establish the psychometric properties of the instrument.

RESULTS

Seven hundred and sixty-one patient ratings performed by nurses were collected during the course of the research study. Data analysis yielded a Cronbach's alpha of 0·91. An exploratory factorial analysis identified three factors (Physiological, Instrumental and Cognitive-behavioural), which explained 74% of the variance.

CONCLUSIONS

Inventario del NIvel de Cuidados mediante IndicAdores de clasificación de Resultados de Enfermería was demonstrated to be a valid and reliable instrument based on its use in acutely hospitalised patients to assess the level of dependency.

RELEVANCE TO CLINICAL PRACTICE

Inventario del NIvel de Cuidados mediante IndicAdores de clasificación de Resultados de Enfermería can be used as an assessment tool in hospitalised patients during the nursing process throughout the entire hospitalisation period. It contributes information to support decisions on nursing diagnoses, interventions and outcomes. It also enables data codification in large databases.

Development and Psychometric Assessment of the Presence of Nursing Scale

Nursing presence has been conceptualized in the literature. However, no instrument has been developed to measure it. The purpose of this study was to develop a scale to measure patients’ perceptions of nursing presence and to examine its psychometric properties. A conceptual definition of nursing presence was operationalized and integrated into the 25-item Presence of Nursing Scale and tested on 330 hospitalized patients. Reliability and validity of the Presence of Nursing Scale were supported when tested with this sample. The study represents the first time the phenomenon of nursing presence has been measured.

Twelve-month fall outcomes among delirium subtypes

PURPOSE

The purpose of this study was to examine falls as an outcome measure at 12 months for two-group comparison (delirium cases and noncases) and five-group comparison (noncases, hypoactive, hyperactive, mixed delirium cases, and subsyndromal delirium cases).

DESIGN

Three hundred and twenty patients enrolled in the Delirium in Rural Long-Term Care Facilities Study, which examined subjects for delirium during a 28-day surveillance period, were followed longitudinally for fall events for 12 months. Fall events were recorded and data analyzed using date of "first fall" as the referent for statistical analysis.

METHODS

Fall reports were completed for all subjects for 12 months following delirium surveillance. Fall records were reviewed and the number of days until the first fall event was calculated. Data were censored for deaths that occurred during the 12-month period.

FINDINGS

Five group analysis of variance (noncases, hyperactive delirium, hypoactive delirium, mixed delirium, and subsyndromal delirium) showed significant differences in Functional Independence Measure scores (p = .001) and number of medications (p = .001). The percentage of patients who fell was higher in all delirium subtypes than in noncases at 12 months and was statistically significant for subsyndromal subjects. Two patients, one each from the subsyndromal and mixed delirium subtypes, died from injuries sustained during falls.

CONCLUSIONS

Delirium appears to increase the risk for falls.

CLINICAL RELEVANCE

Increased surveillance and fall prevention strategies are needed for patients who experience transient cognitive changes such as delirium and subsyndromal delirium, even after delirium resolution.

Twelve-month mortality among delirium subtypes

This study used data from the Delirium Among the Elderly in Rural Long-Term Care Facilities Study and data from the National Death Index (NDI) to examine mortality among 320 individuals. Individuals were grouped into noncases, subsyndromal cases, hypoactive delirium, hyperactive delirium, and mixed delirium on the basis of scoring using the Confusion Assessment Method (CAM), NEECHAM Scale, Mini-Mental State Examination (MMSE), Clinical Assessment of Confusion-A (CAC-A), and Vigilance A instruments. Risk ratios of mortality using "days of survival" did not reach statistical significance (α = .05) for any subgroup. Underlying cause of death (UCD) using International Classification of Disease, 10th version (ICD-10), showed typical UCD among older adults. There appeared to be clinical differences in UCD between delirium subgroups. Findings supported the conclusion that careful monitoring of patients with delirium and subsyndromal delirium is needed to avoid complications and injuries that could increase mortality.

Off-peak nurse staffing: critical-care nurses speak

The off-peak work environment is important to understand because the risk for mortality increases for patients at night and on the weekend in hospitals. Because critical-care nurses are on duty in hospitals 24 hours a day, 7 days a week, they are excellent sources of information regarding what happens on a unit during off-peak times. Inadequate nurse staffing on off-peak shifts was described as a major problem by the nurses we interviewed. The study reported here contributes the type of information needed to better understand the organization of nursing units and nurse staffing on outcomes.

The costs and outcomes of falls: what's a nursing administrator to do?

Falls affect older people in every healthcare setting, causing significant morbidity and mortality. With the aging population, we can expect rates of falling to increase. Nurses and nursing administrators are challenged to prevent injuries and address this multifactorial problem, and nurses are on the front lines of care and in a position to make a difference. Evidence-based measures have been identified, but implementation and management of falls continue to be difficult. Nursing administrators need a clear understanding of the dynamics of falling and the current evidence for their particular setting to ensure that their nurses have the tools to implement appropriate programs and interventions.

The dimensions of nursing surveillance: a concept analysis

AIM

This paper is a report of an analysis of the concept of nursing surveillance.

BACKGROUND

Nursing surveillance, a primary function of acute care nurses, is critical to patient safety and outcomes. Although it has been associated with patient outcomes and organizational context of care, little knowledge has been generated about the conceptual and operational process of surveillance.

DATA SOURCES

A search using the CINAHL, Medline and PubMed databases was used to compile an international data set of 18 papers and 4 book chapters published from 1985 to 2009.

REVIEW METHODS

Rodger's evolutionary concept analysis techniques were used to analyse surveillance in a systems framework. This method focused the search to nursing surveillance (as opposed to other medical uses of the term) and used a theoretical framework to guide the analysis.

RESULTS

The examination of the literature clarifies the multifaceted nature of nursing surveillance in the acute care setting. Surveillance involves purposeful and ongoing acquisition, interpretation and synthesis of patient data for clinical decision-making. Behavioural activities and multiple cognitive processes are used in surveillance in order for the nurse to make decisions for patient safety and health maintenance. A systems approach to the analysis also demonstrates how organizational characteristics and contextual factors influence the process in the acute care environment.

CONCLUSION

This conceptual analysis describes the nature of the surveillance process and clarifies the concept for effective communication and future use in health services research.

Medical errors recovered by critical care nurses

OBJECTIVE

: The frequency and types of medical errors are well documented, but less is known about potential errors that were intercepted by nurses. We studied the type, frequency, and potential harm of recovered medical errors reported by critical care registered nurses (CCRNs) during the previous year.

BACKGROUND

: Nurses are known to protect patients from harm. Several studies on medical errors found that there would have been more medical errors reaching the patient had not potential errors been caught earlier by nurses.

METHODS

: The Recovered Medical Error Inventory, a 25-item empirically derived and internally consistent (alpha =.90) list of medical errors, was posted on the Internet. Participants were recruited via e-mail and healthcare-related listservs using a nonprobability snowball sampling technique. Investigators e-mailed contacts working in hospitals or who managed healthcare-related listservs and asked the contacts to pass the link on to others with contacts in acute care settings.

RESULTS

: During 1 year, 345 CCRNs reported that they recovered 18,578 medical errors, of which they rated 4,183 as potentially lethal.

CONCLUSION

: Surveillance, clinical judgment, and interventions by CCRNs to identify, interrupt, and correct medical errors protected seriously ill patients from harm.

Screening and Surveillance for Promoting Population Health

After completing this chapter, you will be able to:

Distinguish between screening and surveillance activities.

Interpret the accuracy of a screening test.

Identify limitations associated with screening for a health problem.

Plan a surveillance system based upon known risk factors for a health problem.

Identify limitations of a surveillance system.

Estimating effects of nursing intervention via propensity score analysis

BACKGROUND

Lack of randomization of nursing intervention in outcome effectiveness studies may lead to imbalanced covariates. Consequently, estimation of nursing intervention effect can be biased as in other observational studies. Propensity score analysis is an effective statistical method to reduce such bias and further derive causal effects in observational studies.

OBJECTIVES

The objective of this study was to illustrate the use of propensity score analysis in quantitative nursing research through an example of pain management effect on length of hospital stay.

METHODS

Propensity scores are generated through a regression model treating the nursing intervention as the dependent variable and all confounding covariates as predictor variables. Then, propensity scores are used to adjust for this nonrandomized assignment of nursing intervention through three approaches: regression covariance adjustment, stratification, and matching in the predictive outcome model for nursing intervention.

RESULTS

Propensity score analysis reduces the confounding covariates into a single variable of propensity score. After stratification and matching on propensity scores, observed covariates between nursing intervention groups are more balanced within each stratum or in the matched samples. The likelihood of receiving pain management is accounted for in the outcome model through the propensity scores. Both regression covariance adjustment and matching methods report a significant pain management effect on length of hospital stay in this example. The pain management effect can be regarded as causal when the strongly ignorable treatment assignment assumption holds.

DISCUSSION

Propensity score analysis provides an alternative statistical approach to the classical multivariate regression, stratification, and matching techniques for examining the effects of nursing intervention with a large number of confounding covariates in the background. It can be used to derive causal effects of nursing intervention in observational studies under certain circumstances.