Tuesday, September 23, 2014

INQRI Study Shows Nursing Improvements Could Boost Outcomes for 7 Out of 10 Critically Ill Black Babies



Identifying the reasons for racial health disparities and ways to address them is a significant, complex challenge in health care. A new INQRI-funded study led by Eileen T. Lake, PhD, RN, FAAN and Jeannette A. Rogowski, PhD, provides insight into the issue of very low birth weight (VLBW) infants, who are disproportionately black, and finds that it’s not just their race that’s a factor in their health outcomes, it’s the quality of care at the hospitals where they’re born. The study was published in the journal Health Services Research.

The research team examined data on 8,252 VLBW infants in 98 Vermont Oxford Network member neonatal intensive care units (NICUs) throughout the country and the results of a survey of 5,773 NICU nurses. They found that nurse understaffing and practice environments were worse at hospitals with higher concentrations of black patients, contributing to adverse outcomes for VLBW infants born in those facilities.

Since 7 out of 10 black VLBW infants are born in hospitals with a high concentration of black patients, researchers concluded that improvements in nursing at such hospitals have the potential to boost the quality of care for many black VLBW infants. The study looked at two nurse-sensitive perinatal quality standards—hospital-acquired infection and discharge without having started breast milk, which have long-term health implications for VLBW infants—and found higher rates of both in high-black-concentration hospitals. NICU nursing features ultimately accounted for one-third to one-half of hospital-level health disparities.

“Very low birth weight infants are at a high risk for a lifetime of health challenges,” said Lake. “The birth hospitalization is the starting point.  With a high number of black infants born in relatively few hospitals, tackling a previously unaddressed question—do infants cared for in hospitals with a high concentration of black infants have poorer perinatal quality outcomes?—gives us an opportunity to make a positive impact on population-level health disparities.”

The study highlights dramatic differences in the distribution of care for black infants, with nearly three-fourths of black VLBW infants born in a third of hospitals that care for critically ill newborns. Only 1 in 20 black infants are born in hospitals with better nursing characteristics, and odds of adverse outcomes related to nurse-sensitive perinatal quality standards are at least 60 percent higher for infants born in disproportionately black hospitals.

The team also included Jeffrey Horbar, MD, chief executive and scientific officer, Vermont Oxford Network and  professor of pediatrics, University of Vermont; Michael Kenny, MS, research biostatistician, University of Vermont; Thelma Patrick, PhD, RN, associate professor, the Ohio State University College of Nursing; and Douglas Staiger, PhD, professor of economics, Dartmouth College.

Thursday, September 18, 2014

RN Researching Communication Tool that could Reduce Readmissions

A nurse researcher is exploring whether or not hospital readmissions among elderly patients in assisted living could be reduced through improved communications between medical providers, the Lubbock Avalanche Journal reports.

Alyce Ashcraft, associate dean for research at the Texas Tech University School of Nursing, is conducting a study with a customized Situation, Background, Assessment and Recommendation (SBAR) tool that gathers additional patient information and forces more transparency in nurse-provider communication.

Over a 16 week-period, Ashcraft instructed nurses at a retirement community in Lubbock, Texas, to document all of their consultations with health care providers, including phone and fax communications, on SBAR forms. The intent is to eliminate repeats tests and create more efficient care by recording when nurses contact other providers about a patient’s condition, and the actions taken. The data is still be collected and analyzed.

“I don’t care if you’re here in long-term care, or the hospital or home health, it doesn’t matter,” Ashcraft, told the Journal. “Communicating the right information and getting the residents’, the patients’, the clients’ story right so that decisions can be made that are good for them; [t]hat’s what we hope to do.”

INQRI researchers at Marquette University, led by Marianne Weiss and Olga Yakusheva, studied what hospital-based nurses do to influence outcomes, including readmission rates, after a patient is discharged from a hospital. Specifically, they identified the contributions that nursing staff make to the quality of discharge teaching and the impact of that teaching on patient outcomes, readiness and readmission rates of patients who are discharged home. They found that when units had more RN hours per patient day, fewer overtime hours and fewer vacancies, the discharge teaching was of higher quality, patients reported greater readiness for hospital discharge, and post-discharge utilization of readmission and emergency room visits was lower.

Wednesday, September 3, 2014

Webinar to Help Nurses Manage Alarm Fatigue

Advance Healthcare Network for Nurses is hosting a webinar on the issue of nurses facing alarm fatigue. The webinar is scheduled for Thursday, October 16, 2014 from 3:00pm-4:00pm ET. The webinar will provide information about:
  • Current literature on alarm fatigue.
  • Systems and human issues that contribute to alarm fatigue.
  • A system wide approach that can be developed to address alarm fatigue.
The webinar will also feature a question and answer session. Registration is available here. The webinar is sponsored by Covidien.

An INQRI-funded study found a unique way to use different sounds to reduce alarm fatigue and help keep patients safe. Led by Tracey Yap and Jay Kim the team used music to reduce the incidence of pressure ulcers. The study used music to cue patients in long-term care facilities to move in order to avoid getting pressure ulcers. The music also cued staff to help to move those patients who could not move on their own.

Thursday, August 28, 2014

Team-Based Interdisciplinary Care

This blog post originally appeared on the RWJF Human Capital Blog


The Robert Wood Johnson Foundation’s (RWJF) LEAP National Program is working to create a culture of health by discovering, documenting and sharing innovations in the primary care workforce. To advance this goal, the program is holding a series of six webinars that highlight best practices. (Read a post summarizing the first of the six webinars.) The second of the webinars in the series focused on team-based care for complex cases. Presenters included leaders from four primary care sites around the country that the LEAP program has deemed exemplars.

Managing Care for the Most Complex Patients

Kathy Bragdon, RN, director of care management at Penobscot Community Health Center in Bangor, Maine, discussed the rapid growth of the health center, and went on to describe its system of care management for the most complex patients.

The center relies on a transitions care manager, who shares information back and forth with the hospital and with patients’ medical homes. In addition, the manager meets with patients when they are in the hospital, looking to identify potential barriers to recovery and to provide any needed referrals.

“One of the big roles—we didn’t realize how big—was that a tremendous number of patients had no primary care at the time of admission,” she said. “We worked really closely with the hospitals trying to provide those services and make that linkage to those patients who needed primary care providers.”

Bragdon explained that the center’s biggest initiative was to embed care management at its larger facilities, using nurses, medical assistants, health coaches and social workers focused on improving patients’ self-management skills, thus reducing the number of hospitalizations and readmissions, and improving the overall quality of care. The initiative is built around face-to-face visits, as well as phone calls with a focus on hospital follow-up. They try to reach every patient within 72 hours after they’ve been discharged from acute care.

Finally, the center uses a community care team (CCT) to work on its most complex cases. In addition to the supports provided via embedded care management, the CCT conducts a team visit that includes both a social worker and a nurse, meeting the patient where it is convenient for them—at a doughnut shop, a homeless shelter, or wherever else makes sense. “We do this because the RN and the social worker look at the situation through very different eyes in trying to see what is driving that person to the emergency room,” she explained, adding that the effort is “focused on the highest utilizers of health care dollars.”

The cost savings generated by the CCT program are significant, she said, cutting costs to the state in half.

The Integrated Care Team

From Daughters of Charity Health Centers in New Orleans, Roslyn Arnaud, RN, chief nursing officer, and Grace Mena, RN Care Manager, discussed the center’s Integrated Care Team. Arnaud began by sketching out the members of the team. They include:
  • An RN Care Manager, who identifies patients who are not being treated appropriately by a primary care provider, generally at-risk patients with comorbidities. The nurses respond to patients from local safety net hospitals and provide intense follow-up support for them after discharge. They help patients understand what took place and make sure they have medications, have a follow up appointment with their primary care provider and reconcile medications. The RN Care Manager is also responsible for monitoring and tracking patients on anticoagulation therapy.  Additionally, they are responsible for overseeing the tracking of abnormal cancer screens.
  • A Patient Care Coordinator, who provides administrative support, including making appointments for patients for services the Health Center does not have provide onsite. Coordinators also make sure patients know about their appointments and work to ensure that they go. They also ensure that preventive care is completed, including mammograms, colonoscopies, pap smears, and other cancer-tracking.
  •  A Behavior Health Social Worker, who serves as a consultant to the patient, helping them identify the need for change, and establishing goals that are appropriate for that patient.
The team members also collaborate with a local university to arrange for the services of a clinical pharmacist and a certified asthma educator.

Mena explained that the center is now testing a team model with a different composition, bringing together a physician, nurse practitioner, medical assistant and care coordinator, with social workers also available to patients. She noted that the nurse practitioner provides patient education and patient engagement.   “The key part of this work is communication between the nurse practitioner and RN care manager,” she said.

Continuity and Coordination of Care for Complex Patients

Larry Holly, MD, CEO of Southeast Texas Medical Associates, then discussed his six-site clinic’s efforts to care for complex patients as they transition from one setting to another.

He said that the care transition process begins at hospital admission, when the patient receives a care plan to transition from the ambulatory to in-patient setting. Then, at the end of their hospital care, the patient receives materials that detail necessary follow-up appointments and include a medication reconciliation plan. Associates follows that up with a “care coaching call,” and then the patient completes the process with a follow-up appointment at the clinic.

Associates also uses a Hospital Consumer Assessment Health Care Provider and Systems audit that assesses whether the care provided has been patient-centered and of sufficient quality. It asks whether the physician explained the care plan, answered all of patient’s questions without interrupting, inquired about whether care at home was adequate, and wrote down what potential symptoms would necessitate a return to the hospital. The clinic reviews results of the assessment with the hospital.

Associates also features a Care Coordination Department that identifies and tries to overcome barriers to care, Holly explained. So if patients lack transportation to appointments, can’t afford their medication, or are in need of dental care, the patient is referred to other resources.

Said Holly: “This system has integrated a number of complex problems that have befuddled physicians for years. Now we can easily provide those in the context of continuity of care and transitions of care for complex patients. These are critical parts of a medical home.”

Expanding the Team for Complex Cases

Craig Robinson, MPH, executive director of Cabin Creek Health Systems (CCHS), and Amber Crist, MS, CCHS director of education and program development described their efforts to treat patients with chronic pain using interdisciplinary teams.

CCHS has four sites in rural southern West Virginia, Robinson and Crist explained. The program began with an effort to identify older, frail patients in the area in need of care focused on reducing pain from chronic conditions.

“We quickly realized [such patients] increase the complexity of our system,” Crist said, going on to explain that the system needed to adapt. “We needed to expand our clinical team. It couldn’t just be the medical provider. Accordingly, the team grew to include the MD, a nurse practitioner, a physician assistant, a medical assistant, a behavioral health coach, a pharmacist, a health coach, and administrators.”

“If we can keep these patients out of the hospital, we save the system money. That’s where the suffering, is and that’s also what’s sometimes burning our staff out,” she said. “Our providers feel alone in the room. [Otherwise,] they feel they don’t have anyone else to turn to and are alone dealing with these complex patients.”

The RWJF Human Capital Blog will report on additional LEAP webinars in coming weeks.

Friday, August 22, 2014

More Nursing Schools Focus on Interdisciplinary Care

A number of the nation’s top nursing schools now require students to participate in at least one interprofessional education course or activity, according to a “dashboard” report recently released by the Future of Nursing: Campaign for Action, an initiative of RWJF and AARP.

Experts have been calling for interprofessional education for decades, but more schools are now responding because requirements are being written into health professions accreditation standards, Barbara Brandt tells RWJF’s Sharing Nursing’s Knowledge (SNK) newsletter. Brant is head of the National Center for Interprofessional Practice and Education, a public-private partnership supported by RWJF, the U.S. Health Resources and Services Administration, and other organizations. While there is not yet any comprehensive data quantifying the number of interprofessional activities and courses offered nationwide, Brandt said that there is “no question” the number of schools requiring these types of activities is growing rapidly.

INQRI is credited in the SNK article for helping to foster interdisciplinary research and collaborative practice. The ongoing impact can also be seen in health journals, where the number of articles in 10 of the top health services research journals co-authored by a registered nurse (RN) is increasing dramatically, according to a supplemental dashboard indicator, which shows that articles co-authored by RNs jumped from 80 to 145 from 2010 to 2012.

“For much of history, physicians made the major care decisions,” INQRI Grantee Joanne Spetz said. “We need to start teaching nursing students that they bring a set of skills to the table that are unique and distinct, and add value to the skills provided by other professionals. That will help them develop good, collaborative relationships over time.”

Monday, August 11, 2014

Hourly Rounds Schedules for Nurses Improve Patient Satisfaction

A nurse-led study at an acute-care hospital in Houston found that overall patient satisfaction may be improved when nurses adopt hourly rounds schedules, but more research is needed to clearly define the benefit of hourly rounds to patients. The study was conducted at St. Luke’s Episcopal Hospital, where nurses on one unit engaged in a standard hourly rounding process to see if it would improve efficiencies, patient satisfaction, and quality and safety metrics, reports EndoNurse.

The study, published in National Association for Healthcare Quality’s Journal for Healthcare Quality, is based on data collected over six months in two 32-bed cardiovascular surgery nursing units at the hospital. Nurses on the control unit proceeded with rounds as they had before. The research team was led by Rebecca Kreppler, a professor at the College of Nursing at Texas Women’s University in Houston.

The team examined weekly readmission rates, number of patient falls, patient satisfaction questionnaires, the number of steps nurses walked in a shift (to measure efficiency of care), total number of call lights used by patients, and a nursing staff survey.

The most significant difference between the two units was in how often patients used their call lights. Patients in the intervention unit used their call lights less than patients on the control unit, and also indicated in surveys that they were satisfied with how quickly call lights were answered. Kreppler noted however, that because hourly rounding was only one of several quality improvement strategies employed in the units, more research was needed to see the direct impact it may have on patient outcomes, according to Endo Nurse.

Thursday, July 31, 2014

INQRI’s Mark Pauly Co-Authors New Study on Dual MBA/MD Degrees

Physicians who have both doctor of medicine (MD) and master of business administration (MBA) degrees reported that their dual training had a positive professional impact, according to a new study co-authored by INQRI co-director Mark V. Pauly. The study was published online by Academic Medicine and is one of the first to assess MD/MBA graduates’ perceptions of how their training has affected their careers. It focuses on physician graduates from the MBA program in health care management at the University of Pennsylvania.

The MD was more often cited as conveying professional credibility, while 40 to 50 percent of respondents said the MBA conveyed leadership, management, and business skills. Respondents also cited multidisciplinary experience and improved communication between the medical and business worlds as benefits of the two degrees.

The study’s authors also include David A. Asch, co-director of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars Program at the University of Pennsylvania and Clinical Scholar Mitesh S. Patel, who was quoted in a statement:

“A study published in 2009 found that among 6,500 hospitals in the United States, only 235 were run by physicians. Moving forward, changing dynamics triggered by national health care reform will likely require leaders to have a better balance between clinical care and business savvy. Graduates with MD and MBA training could potentially fill this growing need within the sector.”

Read the study, “The Role of MD and MBA Training in the Professional Development of a Physician: A Survey of 30 Years of Graduates From the Wharton Health Care Management Program,” which will also be published in the September issue of Academic Medicine.

The study was also covered on the RWJF Human Capital Blog.