Thursday, December 11, 2014

Nurse-led Study Provides First Ever Real-World Data on Hospital Alarm Noise

More than 2.5 million alarms were triggered on bedside monitors in a single month, according to the first study on hospital alarms conducted in a real-world setting. An article about the study in Medical Express notes that excessive alarm noise can lead to alarm fatigue among nurses and other clinicians and negative outcomes for patients.

The study was conducted by Jessica Zègre-Hemsey, assistant professor at the University of North Carolina - Chapel Hill School of Nursing and a cardiac monitoring expert, and University of California, San Francisco (UCSF) School of Nursing Professor Barbara Drew, along with her UCSF colleagues. The study also found that 88.8 percent of the alarms for abnormal cardiac conditions were false.

"Current technologies have been instrumental in saving lives but they can be improved," Zègre-Hemsey tells Medical Xpress. "For example, current monitoring systems do not take into account differences among patients. If alarm settings were tailored more specifically to individuals that could go a long way in reducing the number of alarms health care providers respond to."

Zègre-Hemsey and her colleagues recommend that clinicians, engineers, and administrators collaborate to develop monitors that can be configured to individual patients and create a "gold standard" database of annotated alarms to reduce false alarms.

"Alarm fatigue is a large and complex problem," she said. "Yet the implications are far-reaching since sentinel events like patient death have been reported. This is a current patient safety crisis."

The full study is available on PLOS ONE.

In a related story, the Columbus Dispatch (Columbus, Ohio) looks at what local hospitals are doing to reduce alarm fatigue. For example, the Ohio State University’s Wexner Medical Center recently moved to a system in which some patient alarms go directly to a nurse’s phone, thereby decreasing alarm noise by approximately 20 percent.

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.

Wednesday, November 26, 2014

Patient Satisfaction, Outcomes Could Improve with Use of Nursing Quality Analytics Data

Having access to a quality analytics database that measures clinical data specific to the role of nurses as well as data about the nursing environment, could help improve patient satisfaction and outcomes nationwide, according to Christina Dempsey, chief nursing officer at Press Ganey.

Press Ganey, an organization that works to help hospitals and other medical facilities improve patient experiences, recently acquired the National Database of Nursing Quality Indicators (NDNQI) from the American Nursing Association (ANA). NDNQI includes clinical quality measures and corresponding information on nurse engagement and the nursing environment. Press Ganey is distilling the data into four areas that affect the patient experience. They believe this approach will ultimately help their clients decide where to invest in improvements.

“Nurse-sensitive indicators reflect the structure, the process and the outcomes of nursing care,” Dempsey told HealthITAnalytics. “The structure of nursing care is indicated by the supply of the nursing staff, the skill level of the nursing staff, and the education of the nursing staff.  Process indicators measure things like assessments, intervention, and job satisfaction.  And then outcomes are those things that improve if there’s a greater quantity or quality of nursing care, such as pressure ulcers and falls.”

“… Being able to bring some of that data together will allow managers, clinicians, and nurses at the bedside better understand what they need to do for which population of patients to get the highest and best return,” Dempsey said.

Friday, November 14, 2014

Misfortune at Birth

This blog post originally appeared on the RWJF Human Capital Blog.


Eileen Lake, PhD, RN, FAAN, and Jeannette Rogowski, PhD, are co-principal investigators of a study, supported by the Robert Wood Johnson Foundation (RWJF) Interdisciplinary Nursing Quality Research Initiative, that generated evidence linking nurse staffing and work environments to infant outcomes in a national sample of neonatal intensive care units.* A new documentary, “Surviving Year One,” examines infant mortality in Rochester, N.Y. and nationwide. It is being shown on PBS and World Channel stations (check local listings). Read more about it on the RWJF Culture of Health Blog here and here.

Are some premature babies simply born in the wrong place? Premature babies are fragile at birth and most infant deaths in this country are due to prematurity.  It is well established that blacks have poorer health than whites in our country, but the origin of these disparities is still a mystery.  It’s possible that the hospital in which a child is born may tell us why certain population groups have poorer health.

A new study by University of Pennsylvania and Rutgers investigators that I led shows that seven out of ten black infants with very low birth weights (less than 3.2 lbs.) in the United States have the simple misfortune of being born in inferior hospitals. What makes these hospitals inferior?  A big component is lower nurse staffing ratios and work environments that are less supportive of excellent nursing practice than other hospitals.  Our study, which was funded by the RWJF Interdisciplinary Nursing Quality Research Initiative, indicates that the hospitals in which infants are born can affect their health all their lives. 

A Brighter Future

What can be done to make these hospitals better?  A first step would be to include nurses in decisions at all levels of the hospital, as recommended by the Institute of Medicine to position nursing to lead change and advance health. Laws in seven states require hospitals to have staff nurses participate in developing plans for safe staffing levels on all units.

Another solution would be to require hospitals to publicly report their neonatal unit staffing levels or work environment ratings (which are determined from a standard survey of nurses about features of their job, such as whether there is teamwork between nurses and doctors) so that pregnant women can make informed decisions about birth options in their communities. Five states require staffing levels to be displayed on nursing units.  Colorado already publicly reports work environment ratings on all hospitals with more than 100 beds.

It would also be a good idea to require the use of a patient acuity tool in staffing plans. We developed a five-level acuity tool for critically ill babies that is ready for use.  Our research using this acuity tool revealed substantial understaffing in neonatal intensive care nursing units was related to higher infection rates.

Previously, there was very little research evidence about the role of nurses in improving outcomes for premature babies, despite nurses being the main caregivers for infants in hospitals.  Our work filled in these gaps. We showed that in hospitals recognized for excellent nursing standards, premature infants have lower rates of death, infection, and severe brain hemorrhage. These standards include the active participation of nurses in hospital policies and decision making.

Among the premature infants who are fortunate enough to survive, the birth hospital is where they receive their first nutrition. Nurses are the principal caregivers and assist new mothers in developing supplies of breast milk, which the U.S. Surgeon General recommends for all newborns. Breast milk is particularly beneficial for premature infants because their immune systems are not completely developed, and it provides both nutrition and immunity protection. In hospitals where disproportionately more black infants are born, 47 percent more infants were discharged without receiving breast milk than in hospitals where the proportion was low. Nurses also play a great role in supporting and guiding mothers through breast-feeding. They commit a large amount of time to instructing and encouraging breast-feeding mothers, but if a neonatal intensive care unit (NICU) is understaffed, nurses have less time to devote to these activities. This in turn may affect infants’ access to breast milk.

Premature newborns often require life-saving interventions and central venous catheters.  Especially in a unit as nurse-intensive as a NICU, nurses play a significant role in preventing infection. They must remember to carefully use sterile techniques while performing procedures and be diligent about detecting early signs of infection. Although these tasks are crucial, they can also be time consuming. They may also be unintentionally overlooked in an understaffed unit. In hospitals where disproportionately more black infants are born, infections were 29 percent more frequent.

Improving Quality

These two perinatal care standards, breast milk and infection prevention, build a foundation for an infant’s lifelong health. Infections can affect neurological development and growth during childhood. In addition, the optimal nutrition provided by breast milk has a lasting impact on a person’s health. Breast-feeding is particularly important for premature infants because it reduces the chance an infant will develop a potentially fatal condition known as necrotizing enterocolitis, in which part of the bowel dies.  The study showed that one-third to one-half of the poorer health outcomes suffered by these premature infants were related to a lack of nursing resources.

Most importantly, if safe staffing helps to improve nurses’ resources in the NICU, the outcomes of those seven of ten black very low birth weight infants may be improved.  Health as a newborn builds a foundation for a healthier life.

*Lake is the Jessie M. Scott Term Chair in Nursing and Health Policy at the University of Pennsylvania School of Nursing and associate director of the Center for Health Outcomes & Policy Research. She leads a program of research on the contributions of the nurse's work environment and clinical nursing expertise to patient outcomes. She has developed an instrument to measure the work environment that is endorsed by the National Quality Forum as a nursing care performance standard that is used internationally.

Rogowski is the University Professor in Health Economics at the Rutgers School of Public Health. For more than two decades, her research has focused on access to care, quality and treatment costs for infants with very low birth weights. Rogowski has served as a member of the Institute of Medicine Committee on Understanding Premature Birth and Assuring Healthy Outcomes and is currently a member of the National Advisory Committee for the RWJF Investigator Awards in Health Policy Research.

Monday, November 3, 2014

Incorporating Patient-Reported Outcomes in Care Plans Beneficial

Improving two-way communication between patients and caregivers can improve outcomes for cancer patients in palliative care, particularly in the area of patient-reporting, according to an oncology nurse specialist and nurse scientist Jeannine M. Brant of the Billings Clinic in Montana.

During the American Society of Clinical Oncology’s inaugural Palliative Care Symposium Brant told participants “we really have a propensity to underestimate symptoms – not only the incidence, but also the severity of the symptom, and also what type of distress that symptom is causing for that individual patient. We need to incorporate patient-reported outcomes [PROs] into our clinical practice,” according to an article in The Oncology Report.

There are numerous reasons for a breakdown in communication between a care provider and patient, including patients’ embarrassment to disclose certain symptoms, the article notes. Physicians and nurses may not ask about specific symptoms due to gaps in their knowledge or time constraints.

Brant presented findings from a pilot study with the semi-automated care planning system On Q that uses both patient-reported and clinical data to generate a customized draft patient care plan. More than 90% of patients in the pilot reported being satisfied with the system and said they would recommend it to others, with one participant commenting that it provided a reminder to bring up issues they were dealing with.

An INQRI study, Nursing's Specific Contributions to Quality Palliative Care within the Context of Interdisciplinary Intensive Care Practice, explored the relationships between quality palliative nursing care delivered in intensive care units and patient and family outcomes. The study also explored how to measure and to improve these outcomes. This interdisciplinary team was led by Lissi Hansen and Richard Mularski.

Tuesday, October 21, 2014

Patient Sensor Improves Pressure-Ulcer Prevention Compliance

A three month study of a wearable ulcer prevention technology showed that it was effective in preventing the occurrence of pressure ulcers by increasing adherence to established protocols, according to Leaf Healthcare, Inc., the company that developed the device.

The Leaf system is a wearable sensor that electronically monitors a patient's position and movements and then wirelessly communicates the data collected to central monitoring stations or mobile devices so that nurses and other caregivers can check on patient position and movement. The Leaf sensor also will sound alerts when necessary to ensure that all patients are repositioned according to established turning schedules, to reduce the incidence of pressure ulcers.

Results of the clinical trial were presented this month at the American Nurses Credential Center National Magnet Conference in Dallas. The trial found that use of the monitoring device increased compliance with hospital turn protocols from a baseline of 64 percent at the start of the trial, to 98 percent after the system was implemented.

The INQRI funded project “Interdisciplinary Mobility Team Approach to Reduction of Facility-Acquired Pressure Ulcers” developed a sustainable, system-wide program for pressure ulcer prevention that enhances mobility of long-term care (LTC) residents. The primary goal, under nursing's leadership, was to reduce LTC facility-acquired pressure ulcer incidence by 50 percent using a cost-effective innovative program to increase resident active or passive movement. The team, which developed and implemented a program that involved using musical cues to remind residents to move or staff to help residents move, was led by Tracey Yap, a nurse researcher, and Jay Kim, an engineer.

Monday, October 20, 2014

Supreme Court Ruling in Federal Trade Commission Case Will Have Broad Implications for Scope of Practice Regulations

By Joanne Spetz, PhD

Last week, the U.S. Supreme Court heard arguments in North Carolina State Board of Dental Examiners v. Federal Trade Commission (FTC), a case that will have significant implications for scope of practice regulations across the country.   At the center of this case is the “state-action doctrine,” which provides immunity from federal antitrust liability for certain state-mandated activities. In this case, the FTC had filed a complaint regarding the Board’s efforts to stop non-dentists from offering teeth whitening services. The North Carolina Dental Board asserted state-action as a defense. The case centers on how the Board operates and whether its operations fall under the state-action doctrine. The FTC believes that the board, which is comprised mainly of practicing dentists, exceeded its authority and its actions were a private effort to eliminate competition from non-dentists – a violation of anti-trust law. The Board believes it is acting as a regulatory body to ensure consumer safety.

Last spring, the 4th Circuit Court of Appeals agreed with the FTC; the Board appealed to the Supreme Court. This case gives the Supreme Court an opportunity to decide whether health professions boards in general, which are usually established by state legislatures but whose members are private actors, fall under the state-action doctrine. If the Supreme Court sides with the FTC, it could have a significant impact on the capacity of dental, medical, nursing, and other boards to regulate health care services, especially when a compelling public safety argument cannot be made.  The Supreme Court’s decision also could provide clear guidance to states in how their boards can be appointed and function in order to adhere to anti-trust law. To follow the case’s history, look here

This same issue was addressed last June at an FTC public workshop in Washington, DC, titled, “Examining Health Care Competition. The workshop topics included professional regulation of health care providers, health care delivery innovations such as retail clinics, health information technology, health care quality, and price transparency. The meeting room was full for most of the two-day event, but attendance appeared greatest for the first session, “Professional Regulation of Health Care Providers,” for which I was one of the presenters. 

The session did not address any specific legal action related to health professions regulation, focusing instead on providing an overview of several important aspects of health professions regulation.  Barbara J. Safriet, JD, LLM, a Visiting Professor of Health Law and Lewis and Clark Law School, discussed the history of health professions regulation and the potential for legal collusion and hindrance of competition. Morris Kleiner, PhD, from the University of Minnesota, discussed health professions regulation in the context of professional regulation in general. He noted that health professions boards are often based at the same agencies as many other professions’ boards, so a single organization is charged with overseeing physicians, nurses, cosmetologists, pet groomers, and myriad other professions. Gail Finley of the Colorado Hospital Association discussed particular challenges that state faced regulating nurse anesthetists, and the battle between physicians and nurses regarding safe anesthesia care in rural communities. I discussed the impact of scope of practice regulations for licensed practical/vocational nurses on the demand by hospitals and nursing homes – we found that in states with stricter regulations, there is lower demand.

The FTC published a Policy Perspective paper in March 2014 on “Competition and the Regulation of Advanced Practice Nurses.”  The paper’s authors reviewed the rationale for establishing scope of practice regulations, noting that there are valid reasons to control scope of practice, even if it might reduce competition. However, they wrote: “…the FTC staff has consistently urged state legislators to avoid imposing restrictions on APRN scope of practice unless those restrictions are necessary to address well-founded patient safety concerns. Based on substantial evidence and experience, expert bodies have concluded that ARPNs are safe and effective as independent providers of many health care services within the scope of their training, licensure, certification, and current practice. Therefore, new or extended layers of mandatory physician supervision may not be justified.”

Unsurprisingly, there is great interest in the Supreme Court case throughout the health care industry. Among the entities that have filed amici briefs, are the American Dental Association, Federation of State Boards of Physical Therapy, American Association of Nurse Anesthetists, Association of Dental Support Organizations, Cato Institute, Pacific Legal Foundation, National Governors Association, California Optometric Association, and Public Citizen, and 23 states.  A decision is expected next year.

Joanne Spetz is a professor at the Philip R. Lee Institute for Health Policy Studies and associate director of research strategy for the Center for the Health Professions at the University of California, San Francisco.

Friday, October 3, 2014

Carrots and Sticks to Reduce Readmissions and Improve Home Health Care

Olga Jarrín, PhD, RN @OJ_RN
National Hartford Center of Gerontological Nursing Excellence, Claire M. Fagin Fellow Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing

The Affordable Care Act has generated carrots and sticks for hospitals to reduce readmissions. With the goal of achieving the Triple Aim (improving quality of patient care, improving population health, and reducing overall cost of care), innovative care delivery models are being tested locally and nationally, including the roll-out of Accountable Care Organizations and bundled payment programs. These programs create incentives in terms of shared savings for health care systems that provide high quality, coordinated care.
Olga Jarrín is a National Hartford Center of Gerontological Nursing Excellence, Claire M. Fagin Fellow at the Center for Health Outcomes and Policy Research.
Meanwhile, a readmission penalty has taken effect, and hit safety net and teaching hospitals hard. While increased referrals to home health care from hospitals might lower readmission, there is wide variation in home health agencies’ ability to keep patients safely in their homes, and out of the hospital.
Institute of Medicine Workshop on the Future of Home Health Care
Health services researchers, home health agency executives, other industry representatives, and stakeholders including patients and patient advocates met at the Institute of Medicine for a 2 day workshop on the Future of Home Health Care #FutureofHH September 30-October 1, 2014. Major challenges for home health include reduced/insufficient payment for home health care, misaligned regulatory requirements and statutes, and the image of the home health care industry, that has been tainted with fraud, abuse, and sub-optimal patient care. Core issues discussed at the meeting included the use of technology to enhance care, the need for interoperable health records, the need for statutory changes at the federal level to allow advanced practice nurses to sign orders for home health care, and new models of care.
In contrast, the existing way that home health care is provided to Medicare beneficiaries was criticized as fragmented, uncoordinated, siloed, slow, and unable to meet the functional or clinical needs of today’s population. The desire to scrap the entire system and start over was balanced by a call for action “Let's work to improve, not diminish our existing home health care system” from keynote Steve Landers, MD, President and CEO of VNA Health Group. Reminding the audience of the Jimmo v. Sebelius Settlement Agreement, Judith Stein, JD, founder and Executive Director of the Center for Medicare Advocacy, pointed out the discrepancy between how home health care has been provided to Medicare beneficiaries, and how it should be provided.
Home Health Agency Work Environment Study
Using publicly reported CMS Home Health Compare data linked with nurse-reported ratings of the home health agency work environment, researchers from the Center for Health Outcomes and Policy Research have established a mechanism for why some home health agencies have better outcomes. Hospitalizations, including both acute and long-term stays, were lowest for patients receiving services from home health agencies where nurses reported excellent working conditions. Nurses working in home health agencies with poor working conditions were much more likely to report being unable to complete necessary care coordination and patient teaching due to time constraints. These findings are published open access in the October issue of the journal Medical Care.
These findings have implications for hospital and home health administrators, as well as policymakers. Hospitals should consider partnering with home health agencies that have better nurse work environments as a strategy to improve their patient outcomes, and bottom line. Home health agencies should work towards creating optimal conditions for nurses to care for patients. Policymakers should remove barriers to full scope of practice for Advanced Practice Nurses (APNs) and Registered Nurses (RNs) working in home health care, especially the requirement for physician co-signatures of APN orders for changes to the home health plan of care, including medication changes. The federal statute restricting APN authority supersedes state laws, and provides a disincentive for home health agencies to hire and collaborate with expert nurse clinicians.
Some of the “new” care models highlighted at the IOM Workshop: The Future of Home Health Care were strikingly similar to old models of home health care provided by public health district nurses and community-based family practice doctors who made both house-calls and hospital-rounds. Removing barriers to practice in home health care for APNs to direct care and directly order services is a small but important step towards raising the quality, responsiveness, and cost-effectiveness of home health care.
 This post first appeared on the Leonard Davis Institute of Health Economics Blog (LDI Blog) of the University of Pennsylvania.