Friday, April 18, 2014

Nurses' Experience and Teamwork Contribute to Better Patient Care

A new study partially funded through the INQRI program reveals that nurse tenure and good team work improve the quality of hospital care and reduce costs. The research team, led by INQRI grantee Patricia Stone, found that patients received the best care when treated by nurses who have extensive experience in their current job. The study is in the current issue of the American Economics Journal: Applied Economics.

Stone and her team reviewed more than 900,000 patient admissions over four years at Veterans Administration Healthcare System hospitals. It is the largest study of its kind to link nurse staffing to patient outcomes, according to a statement by Columbia University Medical Center. Stone, centennial professor of health policy at Columbia Nursing, and her co-authors analyzed payroll records for individual nurses and medical records for individual patients to examine how changes in nurse staffing impacted length of stay.

"Reducing length of stay is the holy grail of hospital management because it means patients are getting higher quality, more cost-effective care," Stone said in the statement. "When the same team of nurses works together over the years, the nurses develop a rhythm and routines that lead to more efficient care. Hospitals need to keep this in mind when making staffing decisions–disrupting the balance of a team can make quality go down and costs go up."

Stone’s earlier INQRI-funded project: “The Impacts of Nurse Staffing, Skill Mix, and Experience on Quality and Costs in Long-Term Care” examined whether there is a causal relationship between nursing input and patient outcomes in long-term care facilities.

Wednesday, April 16, 2014

Dedicated “Sleep Time” in ICUs May Prevent Delirium, Shorten Hospital Stays

Patients who had a four-and-a-half hour window of uninterrupted sleep experienced less delirium and shorter hospitalizations during a protocol study conducted at a Philadelphia-area hospital intensive care unit (ICU).

An interprofessional team, including a nurse, pharmacist, dietitian, and respiratory therapist, developed the protocol. The team was led by Critical Care Director Dominic Valentino at Mercy Fitzgerald Hospital, the Philadelphia Inquirer reports. 

During the study, ICU room lights were turned off and loud talking was prohibited from midnight until 4:30am to protect patients' sleep. During those hours, nurses monitored patients remotely and all routine bloodwork, medications, and exams were halted, unless a patient's medical condition required immediate intervention.

One hundred twenty-five patients were put on the protocol during January and February of 2013. Patients who had uninterrupted nightly sleep for more than half of their time in the ICU shortened their stays there by approximately four-and-a-half days. Researchers also found that these patients averaged two days of delirium, compared with three–and-a-half days for patients who got uninterrupted nightly sleep for less than half of their stays.

The successful protocol has now been adopted at other Mercy Health System hospitals in West Philadelphia, East Norriton, and Northeast Philadelphia. Hospitals are particularly open to it because it is effective and there is no cost to implementing the protocol, Valentino told the Inquirer.

A recent study funded by INQRI and published in Critical Care Medicine found that implementing a set of practices to encourage patients’ mobility and reduce sedation effectively reduces delirium and the need for a ventilator, and increases patients’ mobility during hospitalization. This, in turn, decreases weakness.

The INQRI study tested the effectiveness and safety of implementing a bundled set of evidence-based practices into everyday practice in the ICU. It is called the ABCDE bundle, for Awakening and Breathing Coordination, Delirium monitoring and management, and Early mobility.

The research team, led by Michele Balas and William Burke, examined the results of having a nurse-led interdisciplinary team use the bundle with roughly 150 patients in five adult ICUs, one step-down unit, and an oncology/special care unit in a medical center; researchers compared their outcomes with those of a similar group of patients in the same setting prior to implementation of the bundle.

Thursday, April 10, 2014

Increasing Both Nurse and Doctor Staffing Levels Can Reduce Patient Mortality in ICUs – but Nurses Are Key

A new study in the International Journal of Nursing Studies finds that higher staffing levels for doctors and nurses in intensive care units (ICUs) are associated with higher survival rates for patients at high risk for death. The report, titled “Nurse staffing, medical staffing and mortality in Intensive Care: an observational study,” examines whether the number of nurses, doctors, and support staff affected the survival chances of critically ill patients in both the ICU and the hospital, HealthCanal reports.

Researchers reviewed information on nearly 40,000 patients from 65 ICUs in the United Kingdom. Among the findings, higher numbers of nurses per bed were associated with higher survival rates, and the number of nurses had the greatest impact on patients at a high risk of death when compared to other medical staffing levels.

An INQRI-funded study on the impact of nursing staffing on hospital performance revealed that increasing the number of registered nurse (RN) hours per patient day increased the quality of patient care. The study looked in particular at patients who were being treated for acute myocardial infarction, pneumonia or heart failure.) For all three conditions, increasing the number of RN hours increased the quality of care. This did not hold true for increasing the number of licensed practical nurse or nursing assistant hours.

The study's authors—Gestur Davidson, Ira Moscovice, and Kathy Belk—posited that RNs are involved in and directly affect procedures, practices and processes that directly influence patient outcomes. This was the first study into how nurse staffing affects hospital performance on quality metrics used in the Premier Hospital Quality Demonstration project. It is reviewed in a research brief on the Robert Wood Johnson Foundation website.

Monday, April 7, 2014

Infections Drop by nearly 20 Percent with Reduced Blood Transfusions

Reducing the amount of red blood cell (RBC) transfusions performed in hospitals can also reduce infection rates, according to a new study published in the Journal of the American Medical Association.

Researchers from the University of Michigan and the University of Rochester School of Medicine and Dentistry studied 18 clinical trials, comparing those which restricted use of blood transfusions with a more liberal transfusion strategy. They found that incidence of health care-associated infections was 11.8 percent in the restrictive group and 16.9 percent in the liberal group.

The study shows that RBCs can be a more costly and dangerous treatment method than previously believed, according to the researchers.

"Many people are beginning to accept that we can make a difference--despite being taught in medical school that blood transfusions 'might help and can't hurt,'" Neil Blumberg, professor at the University of Rochester School of Medicine and Dentistry tells HealthCanal. "What we've found is actually the opposite, that it can hurt and it rarely helps."

An INQRI-funded study published last year in Critical Care Medicine found that a nurse-led intervention combining a “bundle” of evidence-based practices with a comprehensive safety program dramatically reduced the mean rate of infections. The study was conducted by David Thompson and Jill Marsteller associate professors at Johns Hopkins University in the School of Medicine and Bloomberg School of Public Health, respectively, and by J. Bryan Sexton now at the Duke University Health System Patient Safety Center.

Thursday, April 3, 2014

Stroke Survivors Need Team Approach to Palliative Care

A new scientific statement from the American Heart Association (AHA) recommends that people recovering from a stroke should have a well-coordinated medical team, working in collaboration with the patients and their families, to personalize care, optimize quality of life, and minimize suffering.

The statement provides guidance on how patients and families should work with the stroke team and providers, including nurses, neurologists, neurosurgeons, primary care providers, and therapists, Nurse.com reports.

“The stroke team and its members can manage many of the palliative care problems themselves. It encourages patient independence and informed choices,” Robert Holloway, lead author of the statement, said in a news release

AHA states that stroke survivors and family members should expect health care providers to:

  • Discuss preferences, needs, and values as a guide to medical decisions;
  • Discuss which aspects of recovery are most important to them;
  • Have effective, sensitive discussions about the prognosis, how to deal with physical or mental losses from a stroke and, if necessary, about dying, among other serious topics;
  • Provide guidance regarding life-sustaining treatment options. Providers should address pros and cons of CPR, ventilators, feeding tubes, surgery, do-not-resuscitate orders, do-not-intubate orders, and natural feeding;
  • Know the best treatment options for common post-stroke symptoms, including pain, other physical symptoms and psychological problems such as depression and anxiety;
  • Engage a palliative care specialist if complex issues arise; and
  • Help preserve dignity and maximize comfort throughout the course of a stroke, including during the dying process and when nearing death.
Nearly 800,000 stroke and 130,000 stroke-related deaths occur in the U.S. each year, according to the AHA and up to 30 percent of all survivors are permanently disabled. The AHA’s scientific statement is available here.

The INQRI-funded “Nursing's Specific Contributions to Quality Palliative Care within the Context of Interdisciplinary Intensive Care Practice” explores the relationships between quality palliative nursing care delivered in intensive care units (ICUs) and patient and family outcomes and on how to measure and to improve these outcomes. The purpose of this investigator-initiated study was to examine nursing's specific contributions to quality palliative care provided to patients and their families in the ICU. This interdisciplinary team was led by Lissi Hansen and Richard Mularski.

Wednesday, April 2, 2014

Evidence-Based Practice, Nurse-led Research Key to Patient Outcomes

In a two-part series, Nurse.com provides first-hand feedback from nurses presenting posters at the Oncology Nursing Society national conference, who share guidance for other nurses interested in research practice.

One of the researchers quoted, Nalo Hamilton, a Robert Wood Johnson Foundation Nurse Faculty Scholar, advises nurses to recognize the contributions they can make to research practice and to realize that all research, whether small or large, makes a difference in nursing knowledge and patient care.

“As nurses, we can examine how we can improve our nursing interventions and showcase what we do in our research,” Hamilton tells Nurse.com. “For example, we are great at health care prevention and can demonstrate through our research how, for example, patient education improves medication compliance and patient outcomes.”

All of the nurses interviewed noted that evidence-based practice projects and research in oncology nursing help nurses determine their role in improving patient care and outcomes.

Part I is available here
Part II is available here.  

Thursday, March 27, 2014

One in Five Health Care Facilities Falling Short on Hand Sanitizer


In a time of progress against hospital-acquired infections, a new nurse-led study offers a reminder of the work that remains to be done. The study finds that approximately one in five U.S. health care facilities fails to place alcohol-based hand sanitizer at every point of care, missing an opportunity to prevent the spread of infectious diseases.

A research team jointly led by Laurie Conway, RN, MS, CIC, a PhD student at the Columbia University School of Nursing, and Benedetta Allegranzi, MD, of the World Health Organization (WHO), surveyed compliance with WHO hand-hygiene guidelines at 168 facilities in 42 states and Puerto Rico. Just over 77 percent reported that alcohol-based sanitizer was continuously available at every point of care. They also found that only about half of the hospitals, ambulatory care, and long-term care facilities had allocated funds for hand-hygiene training.

“When hospitals don’t focus heavily on hand hygiene, that puts patients at unnecessary risk for preventable health care-associated infections,” Conway said in a news release. “The tone for compliance with infection control guidelines is set at the highest levels of management, and our study also found that executives aren’t always doing all that they can to send a clear message that preventing infections is a priority.”

Read the study in the American Journal of Infection Control.