Implementing Prone Positioning for COVID-19 Patients Outside the Intensive Care Unit

BACKGROUND

Proning intubated intensive care unit patients for the management of acute respiratory distress syndrome is an accepted standard of practice. We examined the nursing climate in 4 units and its impact on implementing a novel self-proning protocol to treat COVID-19 patients outside the intensive care unit.

LOCAL PROBLEM

Nursing units previously designated for medical/surgical populations had to adjust quickly to provide evidence-based care for COVID-19 patients attempting self-proning.

METHODS

Nurses from 4 nursing units were surveyed about the implementation process on the self-proning protocol. Their perception of unit implementation was assessed via the Implementation Climate Scale.

INTERVENTIONS

A new self-proning nursing protocol was implemented outside the intensive care unit.

RESULTS

Consistent education on the protocol, belief in the effectiveness of the intervention, and a strong unit-based climate of evidence-based practice contributed to greater implementation of the protocol.

CONCLUSIONS

Implementation of a new nursing protocol is possible with strong unit-based support, even during a pandemic.

Turning education into action: Impact of a collective social education approach to improve nurses' ability to recognize and accurately assess delirium in hospitalized older patients

BACKGROUND

Although cognitive impairment including dementia and delirium is common in older hospital patients, it is not well recognized or managed by hospital staff, potentially resulting in adverse events. This paper describes, and reports on the impact of a collective social education approach to improving both nurses' knowledge of, and screening for delirium.

METHODS

Thirty-four experienced nurses from six hospital wards, became Cognition Champions (CogChamps) to lead their wards in a collective social education process about cognitive impairment and the assessment of delirium. At the outset, the CogChamps were provided with comprehensive education about dementia and delirium from a multidisciplinary team of clinicians. Their knowledge was assessed to ascertain they had the requisite understanding to engage in education as a collective social process, namely, with each other and their local teams. Following this, they developed ward specific Action Plans in collaboration with their teams aimed at educating and evaluating ward nurses' ability to accurately assess and care for patients for delirium. The plans were implemented over five months. The broader nursing teams' knowledge was assessed, together with their ability to accurately assess patients for delirium.

RESULTS

Each ward implemented their Action Plan to varying degrees and key achievements included the education of a majority of ward nurses about delirium and the certification of the majority as competent to assess patients for delirium using the Confusion Assessment Method. Two wards collected pre-and post-audit data that demonstrated a substantial improvement in delirium screening rates.

CONCLUSION

The education process led by CogChamps and supported by educators and clinical experts provides an example of successfully educating nurses about delirium and improving screening rates of patients for delirium.

TRIAL REGISTRATION

ACTRN 12617000563369.

Improving Patient Safety through the Use of Nursing Surveillance

Surveillance and monitoring each represent a distinct process in patient care. Monitoring involves observation, measurement, and recording of physiological parameters, while surveillance is a systematic, goal-directed process based on early detection of signs of change, interpretation of the clinical implications of such changes, and initiation of rapid, appropriate interventions. Through use of an illustrative clinical example based on Early Warning System scoring and rapid response teams, this article seeks to distinguish between nurse monitoring and surveillance to demonstrate the impact of surveillance on improving both care processes and patient care. Using a clinical example, differences between surveillance and monitoring as a trigger for deployment of the rapid response team were reviewed. The use of surveillance versus monitoring resulted in a mean reduction in rapid response team deployment time of 291 minutes. The median hospital length of stay for patients whose clinical care included using surveillance to initiate the deployment of the rapid response team was reduced by 4 days. Monitoring relies on observation and assessment while nursing surveillance incorporates monitoring with recognition and interpretation of the clinical implications of changes to guide decisions about subsequent actions. The clinical example described here supports that the use of an automated surveillance system versus monitoring had a measurable impact on clinical care.

Zero Lift Programs in Small Rural Hospitals in Washington State

In Washington State, health care workers have the highest rate of compensable back injuries. Washington Hospital Services, a self-insured workers' compensation program, implemented a zero lift program in 31 of its 38 hospitals. Zero lift was defined as replacing manual lifting, transferring, and re-positioning of patients with mechanical lifting or use of other patient assist devices. This program included two trusts, two pools of hospitals that self-insure workers' compensation. The pools are governed by elected boards of trustees from the pool memberships and regulated by the State Department of Labor and Industries. This pretest–posttest descriptive study compared patient-handling injury data prior to program implementation with those after program implementation. Patient-handling injury claims decreased by 43% in the participating hospitals from 2000 to 2004 (i.e., from 3.51 to 2.23). The time lost frequency rate decreased by 50% (i.e., from 1.91 to 1.03).

Pregnant Women in the Workplace

The Bureau of Labor Statistics reported in 2001 that 51% of married women return to the work force before their children are 1 year old (Rojjanasrirat, 2004). Women's roles in the United States are rapidly changing, and the workplace environment is also changing to meet the added demands of women in the work force. Many women assimilate the multiple roles of wife, mother, and working professional into a cohesive unit; however, this is often difficult. Occupational health nurses play a vital role advocating for women in the work force. A critical area of advocacy (and education) focuses on providing necessary support to pregnant employees.

Standardization of Telephone Triage in Pediatric Oncology

Nurses in pediatric oncology are often the main resource for overwhelmed parents and deal with complex patient issues over the telephone but often not without concerns about best patient care, liability, and accountability for the advice given. The question is whether using standardization of telephone triage practices can provide opportunities for improvement in the care of pediatric oncology patients. A review of the literature pertaining to telephone triage, standardization of practice, and the practice in outpatient oncology was conducted. The utilization of easy-to-use, accessible yet nonrestrictive resources and a well-designed documentation tool can help guide the decision-making process while addressing legal concerns and ensuring best possible patient care. An advantage that nurses in outpatient oncology settings have in performing telephone triage is the knowledge they have of their patient population and the disease process and treatments. Using a balanced approach to standardization of telephone triage practices can provide opportunities for improvements in care while still capitalizing on the intuitive knowledge and experience of the nurses involved.

Conditions for Patient Participation and Non-Participation in Health Care

This study explored patients' experiences of participation and non-participation in their health care. A questionnaire-based survey method was used. Content analysis showed that conditions for patient participation occurred when information was provided not by using standard procedures but based on individual needs and accompanied by explanations, when the patient was regarded as an individual, when the patient's knowledge was recognized by staff, and when the patient made decisions based on knowledge and needs, or performed self-care. Thus, to provide conditions for true patient participation, professionals need to recognize each patient's unique knowledge and respect the individual's description of his or her situation rather than just inviting the person to participate in decision making.

Research Priorities for Family Assessment and Intervention in Pediatric Oncology

Four broad areas of research priority related to family assessment and intervention in pediatric oncology are outlined. The importance of a contextual, systemic approach is highlighted along with the value of systematic empirical assessment of psychosocial risk at diagnosis. Research to advance the development and application of standards of care during treatment is also advocated. The chapter concludes with opportunities for family-oriented research related to survivorship and end-of-life care.

Mind-Body Therapies for the Pediatric Oncology Patient: Matching the Right Therapy With the Right Patient

Pediatric oncology nurses provide care for children across a continuum from the point of diagnostic evaluation through treatments and cure or a peaceful, dignified death. Nurses provide this care in a wide variety of settings such as the home, hospital, clinics, schools, camps, and residential facilities. Mind-body therapies are being used more frequently in the care of children receiving treatment for cancer. Matching the right therapy with the right patient is an important component of care.

Setting up and Auditing Guideline- and Evidence-Based Cardiac Rehabilitation

Background: Rehabilitation is available to only a minority of post-myocardial infarction (MI) patients and is of variable quality. Guidelines now recommend individualised care delivered by hospital, primary care and community services, but there is little evidence of the feasibility, acceptability or effectiveness of this approach.

Aims: To demonstrate the feasibility of guideline-based rehabilitation, to audit delivery and outcome and to identify problems.

Methods: A four-phase stepped programme for post-MI patients was developed based on individualised in-hospital care and aftercare from a menu of options. Delivery involved co-ordination between hospital services, primary care and community services. Self-report audit data were collected in hospital and at 3 months post-discharge by postal questionnaire and telephone calls. Clinical information was recorded from hospital, telephone and outpatient contacts. Delivery of care to patients receiving interventions was recorded.

Results: It was possible to negotiate individualized plans for all patients and to monitor progress for 3 months after discharge. The rehabilitation team achieved high rates of delivery of agreed interventions, considerably better than delivery by primary care. Problems largely related to difficulties and failures in communication. Patients with major social or psychological difficulties were the most difficult to treat.

Conclusion: Guideline-based rehabilitation is feasible, but there is a need to improve the coordination of delivery of later steps of care and also to refine specialist interventions.

The Role of Nurses in a Chest Pain Unit

The chest pain unit (CPU) provides a service for patients at moderate-to-low risk for acute coronary syndrome (ACS). Although the number of CPUs has continued to grow worldwide, little has been written on the specific role and contribution of nursing in CPUs. The stay of patients in the CPU can be divided into six stages: triage, diagnosis, treatment, observation/monitoring, discharge, and follow-up. CPU nurses are in a unique position to promote evidence-based practice during all of these stages. Deeper insight into the unique role of nurses in CPUs will promote understanding of what type of knowledge, skills, and attitudes are required to provide the services that will contribute to improved quality of care for chest pain patients.

Development of a Multimedia Dysphagia Assessment Learning System Using Responsive Web Design: From e-Learning to m-Learning

Swallowing problems have significant affect the health outcome of some residents in long-term care facilities. Nursing staff who care these residents should have the ability of assessing dysphagia. However, nursing continued education to improve the performance of dysphagia assessment is still challenged. To enhance nurses' capability of dysphagia assessment, a Multimedia Dysphagia Assessment learning System was developed for nursing staff in long-term care institutions. This system was evaluated by performing a user usability test.

Triage nurse's assessment of a child with a fever

Fever in children is a common presentation to the emergency department and in most instances has no adverse consequences. The role of the triage nurse is to have thorough knowledge of up to date practices in caring for the child with fever, and to accurately assess and manage the child. Using evidence based practice to apply appropriate triage categories, effective care including accurate and informed education of parents. Every nurse working on triage should maintain current knowledge and have continuous education concerning the child with fever and the unwell child to promote best patient outcomes and maintain best practice standards.

[For discussion: Quality assurance in medical care - is PKMS the right way to go?]

Hospitals are legally obliged to take part in external comparative quality assurance programs. Quality indicators for pressure ulcer prevention are among the most widely used for geriatric clinical institutions. To enable more precise risk adjustment established risk factors are employed in conjunction with the OPS 9-200. Using a PKMS case to produce an OPS 9-200 is far too heterogeneous, sketchy and vague to create an accurate and satisfactory pressure ulcer risk assessment for patients with varied and individual case factors. Therefore we propose to include risk factors which, according to experts, are clearly and specifically related to pressure ulcers (e.g. immobility and incontinence) and matched by unique ICD codes.

Is It PANS, CANS, or PANDAS? Neuropsychiatric Pediatric Disorders That Are Not Black and White--Implications for the School Nurse

The terms pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), pediatric acute-onset neuropsychiatric syndrome (PANS), and childhood acute neuropsychiatric symptoms (CANS) have all been used to describe certain acute onset neuropsychiatric pediatric disorders. Additionally, controversy is ongoing concerning the diagnosis and etiology of the disorders. The school nurse, as a member of a multidisciplinary team, benefits from an awareness of these disorders, the resulting impact on school performance, and the recommended treatment. The school nurse assists the team through the development of an Individualized Healthcare Plan to help the student to achieve success in school.

Use of an electronic patient-reported outcome measurement system to improve distress management in oncology

OBJECTIVE

Management of patient distress is a critical task in cancer nursing and cancer practice. Here we describe two examples of how an electronic patient-reported outcome (ePRO) measurement system implemented into routine oncology care can practically aid clinical and research tasks related to distress management.

METHODS

Tablet personal computers were used to routinely complete a standardized ePRO review of systems surveys at point of care during every encounter in the Duke Oncology outpatient clinics. Two cases of use implementation are explored: (1) triaging distressed patients for optimal care, and (2) psychosocial program evaluation research.

RESULTS

Between 2009 and 2011, the ePRO system was used to collect information during 17,338 Duke Oncology patient encounters. The system was used to monitor patients for psychosocial distress employing an electronic clinical decision support algorithm, with 1,952 (11.3%) referrals generated for supportive services. The system was utilized to examine the efficacy of a psychosocial care intervention documenting statistically significant improvements in distress, despair, fatigue, and quality of life (QOL) in 50 breast cancer patients.

SIGNIFICANCE OF RESULTS

ePRO solutions can guide best practice management of cancer patient distress. Nurses play a key role in implementation and utilization.

[CLIC and mental healthcare]

The Gagny local centre for information and coordination in gerontology (CLIC) became officially accredited in December 2004. Located within the town hall, it consists of an adviser in social and family economics who acts as the centre's manager, coordinator and assessor, as well as an assessment nurse.

Pressure ulcers and prevention among acute care hospitals in the United States

BACKGROUND

Most pressure ulcers can be prevented with evidence-based practice. Many studies describe the implementation of a pressure ulcer prevention program but few report the effect on outcomes across acute care facilities.

METHODS

Data on hospital-acquired pressure ulcers and prevention from the National Database of Nursing Quality Indicators 2010 Pressure Ulcer Surveys were linked to hospital characteristics and nurse staffing measures within the data set. The sample consisted of 1,419 hospitals from across the United States and 710,626 patients who had been surveyed for pressure ulcers in adult critical care, step-down, medical, surgical, and medical/surgical units. Hierarchical logistic regression analysis was performed to identify study variables associated with hospital-acquired pressure ulcers among patients at risk for these ulcers.

RESULTS

The rate of hospital-acquired pressure ulcers was 3.6% across all surveyed patients and 7.9% among those at risk. Patients who received a skin and pressure ulcer risk assessment on admission were less likely to develop a pressure ulcer. Additional study variables associated with lower hospital-acquired pressure ulcer rates included a recent reassessment of pressure ulcer risk, higher Braden Scale scores, a recent skin assessment, routine repositioning, and Magnet or Magnet-applicant designation. Variables associated with a higher likelihood of hospital-acquired pressure ulcers included nutritional support, moisture management, larger hospital size, and academic medical center status.

CONCLUSIONS

Results provide empirical support for pressure ulcer prevention guideline recommendations on skin assessment, pressure ulcer risk assessment, and routine repositioning, but the 7.9% rate of hospital-acquired pressure ulcers among at-risk patients suggests room for improvement in pressure ulcer prevention practice.

Implementing an evidence-based detoxification protocol for alcoholism in a residential addictions treatment facility

Chemical dependency, commonly known as substance abuse and use disorders, continues to plague residents of the United States. Because treatment has expanded beyond the walls of the acute care hospital, advanced practice nurses play a pivotal role in caring for clients addicted to various substances. This article describes how an advanced practice nurse in collaboration with the medical director and a director of nursing at a residential treatment center in southern New Jersey oversaw the development of an evidence-based detoxification treatment protocol for alcohol dependency, emphasizing the critical role of nurses in assuring that clinical practice is rooted in current evidence.

CURRENT PRACTICE IN RENAL ANAEMIA MANAGEMENT: TWO MULTINATIONAL SURVEYS

The European Best Practice Guidelines recommend that 85% of patients with standard causes of chronic renal failure should achieve a target haemoglobin concentration of > or = 11 g/dL. However, patient outcomes need to be improved as many patients respond suboptimally to treatment and fail to reach these targets. Two multinational surveys of nursing practice in the management of renal anaemia in northern (with comparative data from Australia) and southern Europe were conducted. The aim was to assess variations in the role and amount of responsibility delegated to nurses in renal units throughout Europe and Australia. Patient care could be optimised by developing formal training and educational programmes for nephrology nurses and this has already occurred in many units in the UK.

Postpartum anaemia. Are we vigilant enough?

Anaemia in the immediate postnatal period can manifest itself physically in a number of ways. Amongst these are pallor, tiredness, dizziness, loss of appetite and oedema (Bewley 2004), all of which could be mistaken for commonly observed benign symptoms of the immediate postnatal period. However, left untreated, anaemia can severely impact on both the physical and emotional wellbeing of a woman and dramatically slow down her recovery (Bewley 2004). This altered state of health can also have a detrimental effect on a woman's ability to bond with her new child (Abbott et al 1997) and has been identified as a contributory factor in the initiation of postnatal depression (Corwin et al 2003). It is therefore imperative that, as midwives and student midwives, we take every opportunity to closely monitor the wellbeing of women in our care in order to facilitate their return to a normal haemoglobin level, promote infant bonding and reduce the risk of postnatal depression.

Taking a patient history: the role of the nurse

History taking is a key component of patient assessment, enabling the delivery of high-quality care. Understanding the complexity and processes involved in history taking allows nurses to gain a better understanding of patients' problems. Care priorities can be identified and the most appropriate interventions commenced to optimise patient outcomes.

Advanced physical assessment skills: implementation of a module

This article aims to explore and examine advanced physical assessment skills and the role of the district nurse. It will particularly highlight district nurses' perceptions of how they may implement skills learnt on a new module introduced into the Community Health Care Nursing degree at a university in London. Physical assessment skills have traditionally been viewed as part of a doctor's role; however, with the advancement of nursing roles, it is argued that it has become a key nursing skill. As Government policy continues to expect health professionals to keep patients in the community who have complex health and social care needs, the role of the district nurse presents as 'best placed' to take on this challenge (Department of Health (DH), 2005a; 2005b). Evaluation of the district nurses' perceptions of their practice is shared here, highlighting some of the challenges that they face. The article will address the complexity of developing a curriculum in response to the DH initiatives and the importance of listening to students on courses.

Cardiac surgery discharge questionnaires: meeting information needs of patients and families

Tailoring discharge teaching information to the unique learning needs of cardiac surgery patients and their caregivers may improve information acquisition and retention and positively influence the transition home for these individuals. Two questionnaires were developed, one for adult cardiac surgery patients, and one for their caregivers, to explore their self-identified information needs regarding discharge teaching information. The questionnaires were adapted from the Patient Learning Needs Scale of Bubela et al. (1990). The content of the questionnaires was based on informal discussions with patients and their caregivers and nurses of the cardiac surgery department of a university teaching hospital. In addition, previous research exploring discharge teaching content post cardiac surgery and perceived discharge information needs of this population was reviewed. Preliminary testing of the tools indicated content validity. The questionnaires may enhance the efficiency and quality of discharge teaching, as they enable nurses to address the unique information needs of patients and caregivers. This, in turn, may assist patients and caregivers to cope with the transition home. Formal piloting and evaluation of the tools with all stakeholder groups is indicated, in order to determine the effectiveness of the questionnaires and to evaluate and validate their content and format.

Secure mother-infant attachment and the ABC programme: a case history

This case history describes the first application of the Attachment and Bio-behavioural Catch-up (ABC) programme in the UK. It illustrates the key role and value of primary care clinicians in early infancy. The health visitor's careful and reflective observations, and her close links with a GP who shared her understanding of why these were significant, were the only means for this family to access help. The need for interventions in attachment is only likely to be identified by health visitors, with their unique opportunities to see families in their own homes.

Pre-assessment for children scheduled for day surgery

This article reports on an evaluation of a established pre-assessment clinic for children scheduled for day surgery. The results suggest that the pre-assessment clinic increases the efficiency and effectiveness of the admissions process for children. The authors discuss the results in detail and make recommendations for further research and nursing practice. They suggest, for example, that evaluative research can provide a framework for assessing new services.

Nocturnal enuresis: assessing and treating children and young people

Bedwetting (nocturnal enuresis) is a common and distressing condition, both for children and young people and their families, and the National Institute for Health and Clinical Excellence (NICE) has produced its first guidelines for its assessment and treatment in those aged up to 19 years. This paper, by two NICE guideline development group members, provides an update on the new guidance. Treatment options include the provision of advice, use of a reward system and/or alarm, and desmopressin medication. These should be considered carefully depending on individual needs. Treatment for most children is effective and successful. Where necessary, referrals may be made to a specialist enuresis practitioner.

Nursing recognition and response to signs of clinical deterioration

The suboptimal assessment of patients for signs of clinical deterioration and the subsequent response has led to the development of national guidelines and tools for tracking and responding to these situations. Such tools can provide guidance but ultimately the clinical skill, decision making and collaboration of professional practitioners determine optimal care. The use of track-and-trigger tools is insufficient to provide optimal care due to the many factors that affect patient journeys. The clinical knowledge and skill of nurses are important to this process and in achieving safe patient care. This article focuses on the clinical implications of the knowledge and experience of nurses, as well as their role in team working when recognising and responding to clinical deterioration.

[The Nidcap, care centred on the newborn]

The Nidcap (Newborn individualised developmental care and assessment programme) sets out a well-thought-out framework of care centred on the infant. Body temperature, nutritional and hormonal regulation is close to that observed in utero and individual stimulation is adapted to the cerebral capacities of the newborn. It thereby favours the harmonious development of the infant.

Consent and capacity: a guide for district nurses

The Mental Capacity Act 2005, which came into force in 2007, sought to provide a statutory framework to facilitate empowerment and provide protection to individuals who lack capacity. District nurses must be aware of the legislation regarding mental capacity (Nursing and Midwifery Council, 2008) and understand how and when they may need to assess decision-making capacity. The article explores the legal and ethical issues surrounding consent, and seeks to inform district nurses as to the guidelines used in assessing a person's capacity to consent, along with best interests policy.

Observation assistants: sitter effectiveness and industry measures

Patient safety remains a strategic goal and of societal importance for better health care. Direct observation remains an ineffective and expensive means of providing for patient safety. The nursing quality team found that using assessment tools helped to objectively categorize which patients are at risk. Defining patient volume, actual productive sitter usage, and assessing demand for patients in psychiatric crisis and patients at high risk to fall in the form of average daily census provided an easy-to-translate, familiar unit of measure to compare patient volume to demand and utilization. The sitter utilization case was unable to provide correlation of sitter use to decreased fall rates, elopement, or assault behaviors. Currently, there is no research to suggest the use of constant observation reduces the risk of patient harm related to their risk for falling or harming themselves.

The 'five rights' of clinical reasoning: an educational model to enhance nursing students' ability to identify and manage clinically 'at risk' patients

Acute care settings are characterised by patients with complex health problems who are more likely to be or become seriously ill during their hospital stay. Although warning signs often precede serious adverse events there is consistent evidence that 'at risk' patients are not always identified or managed appropriately. 'Failure to rescue', with rescue being the ability to recognise deteriorating patients and to intervene appropriately, is related to poor clinical reasoning skills. These factors provided the impetus for the development of an educational model that has the potential to enhance nursing students' clinical reasoning skills and consequently their ability to manage 'at risk' patients. Clinical reasoning is the process by which nurses collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process. Effective clinical reasoning depends upon the nurse's ability to collect the right cues and to take the right action for the right patient at the right time and for the right reason. This paper provides an overview of a clinical reasoning model and the literature underpinning the 'five rights' of clinical reasoning.