AkkeNeel Talsma

An anesthesia information system designed to provide physician-specific feedback improves timely administration of prophylactic antibiotics.

Surgical site infections are a frequent cause of morbidity and mortality and add significantly to the cost of care. One component of the national Surgical Infection Prevention (SIP) program is to ensure timely administration of prophylactic antibiotics, a key factor to reduce postoperative infection. Our anesthesia department decided to assume the responsibility for timing and administration of antibiotic prophylaxis and we initiated a multitiered approach to remind the anesthesiologist to administer the prophylactic antibiotics. We used our anesthesia clinical information system to implement practice guidelines for timely antibiotic administration and to generate reports from the database to provide specific feedback to individual care providers with the goal of ensuring that patients receive antibiotic prophylaxis within 1 h of incision. Before the initiation of this project, 69% of eligible patients received antibiotics within 60 min of the incision. After the program began, there was a steady increase in compliance to 92% 1 yr later. Provider-specific feedback increases compliance with practice guidelines related to timely administration of prophylactic antibiotics. Anesthesia information systems hold promise for implementing and monitoring new practice guidelines and the anesthesiologist may play a key role in influencing surgical outcomes by ensuring appropriate therapy that may not be directly related to anesthesia care.

Development and testing of the barriers to cessation scale

The purpose of this research was to develop and test a measure of barriers to smoking cessation. Barriers, reconceptualized within the Transactional Model of Stress (Lazarus, 1966), reflect specific stressors associated with smoking cessation. The measure consists of a 19-item scale, which has been tested in three studies. Cronbachs alpha coefficients ranged from .81 to .87. Construct validity was demonstrated by correlations between barrier scores and scores on the Daily Hassles Scale (DeLongis, Folkman, & Lazarus, 1988). Predictive validity was demonstrated by findings that barriers scows significantly contributed to classification of abstainers versus relapsers 8 weeks after smoking cessation group participants quit smoking.

Effectiveness of the surgical safety checklist in correcting errors: A literature review applying reason's Swiss cheese model

Approximately 2,700 patients are harmed by wrong-site surgery each year. The World Health Organization created the surgical safety checklist to reduce the incidence of wrong-site surgery. A project team conducted a narrative review of the literature to determine the effectiveness of the surgical safety checklist in correcting and preventing errors in the OR. Team members used Swiss cheese model of error by Reason to analyze the findings. Analysis of results indicated the effectiveness of the surgical checklist in reducing the incidence of wrong-site surgeries and other medical errors; however, checklists alone will not prevent all errors. Successful implementation requires perioperative stakeholders to understand the nature of errors, recognize the complex dynamic between systems and individuals, and create a just culture that encourages a shared vision of patient safety.

Identifying nursing processes to reduce failure to rescue.

The authors explore the meaning of failure to rescue and highlight empirical links between processes of care and failure to rescue that arise through a critique of nursing literature. They provide an example of one approach where administrative billing data were used to better understand healthcare system issues and practice patterns influencing failure to rescue.

Intraoperative Risk Factors Associated With Postoperative Pressure Ulcers in Critically Ill Patients: A Retrospective Observational Study*

Objective:The risk for pressure ulcers is rarely identified in the perioperative period, and the influence of this period on risk factors has not been as rigorously studied as the postoperative period. We hypothesized that intraoperative risk factors exist, which increase the likelihood of a postoperative new-onset pressure ulcer. Design:A retrospective observational study. Setting:A large midwestern U.S. quaternary care institution. Patients:A total of 2,695 adult surgical patients underwent operative procedures and received care in one of three ICUs using an electronic documentation application. Interventions:None. Measurements and Main Results:The primary outcome was hospital-acquired pressure ulcer categorized as stages II, III, and IV; deep tissue injury; or unstageable. Univariate analyses comparing patients with and without the outcome of pressure ulcers were conducted for each preoperative characteristic or comorbidity. Patients were matched using the logit of the propensity score based solely on their preoperative comorbidities. Adjusted associations between development of pressure ulcers and intraoperative characteristics were determined in the postmatch cohort. We identified seven independent preoperative patients’ characteristics and comorbidities in our adult surgical patient sample: American Society of Anesthesiologists risk classification 4 or 5, underweight body mass index, noncardiac surgery, history of congestive heart failure, renal disease, existing airway present prior to arrival in the operating room, and age. The only significant association in the matched dataset accounting for patient preoperative variability is the use of intraoperative blood products. Conclusion:Postoperative pressure ulcers developed in 10.7% of critically ill patients in our study. Only intraoperative use of blood products, not operative case length, hypotension, or vasopressor use, was associated with postoperative pressure ulcer development on adjusted analysis.

Characterizing the Structure of Operating Room Staffing Using Social Network Analysis

Background:Very little research has been focused on the interdisciplinary staffing characteristics of the operating room team, an essential component of providing safe patient care in a high-risk setting. Objectives:The aim of this study was to determine how the operating room staffing of two surgical specialties compares in terms of social network variables. Methods:Staffing data from all general and neurosurgical procedures performed at a large Midwestern hospital were analyzed using Social Network Analysis methods. Network variables include centrality, team coreness, and the core/periphery network structure. Multidimensional scaling, correlation, and descriptive statistics were used for the analysis. Results:The core/periphery network structure was characteristic of both surgical services. Team coreness, a measure of how often the team worked together, was associated with the length of the case (p < .001). Procedure start time predicts the team coreness measure, with cases starting later in the day less likely to be staffed with a high core team (p < .001). Registered nurses constitute the majority of core interdisciplinary team members in both groups. Discussion:Analysis of the core/periphery structure of specialty team staffing networks indicates that many procedures are staffed with individuals who are associated peripherally with the specialty. Registered nurses as core group members are in a position to take a leadership role in the communication of norms and process variations to noncore members. The effect of having late starting cases staffed with a lower core team should be studied further because it pertains to patient outcomes. Future work should strive to account for the complex and dynamic nature of team development.

Nursing surveillance moderates the relationship between staffing levels and pediatric postoperative serious adverse events: A nested case-control study

BACKGROUND Insufficient monitoring, surveillance, and nurse staffing levels are system factors that may contribute to serious adverse events and deterioration in hospitalized patients. Limited data have examined the relationship between these factors and postoperative outcomes, particularly in the pediatric setting. OBJECTIVES This retrospective, case-control study examined the relationship between surveillance, staffing, and serious adverse events in children on general care postoperative units. The following hypotheses were tested: (1) the relationship between patient factors and surveillance would be moderated by staffing (i.e., registered nurse hours per patient per shift), and (2) the relationship between staffing and serious adverse events would be mediated by surveillance. METHODS With institutional review board approval, children with serious adverse events on a general care unit were identified from institutional event databases, and procedure-matched controls were randomly selected from surgical lists. Demographics, co-morbidities, perioperative information, frequency of postoperative monitoring and assessments (i.e., surveillance), and registered nurse hours per patient per shift (i.e., staffing) were recorded. Regression models were used to test the hypotheses. RESULTS The Event Group included 98 children and the Control Group, 158. Registered nurse hours per patient per shift were lower for the Event Group (2.99 ± 0.59) compared to Controls (3.38 ± 1.23, p=0.002). The number of assessments/shift was higher for the Event Group (4.27 ± 2.8) compared to Controls (2.85 ± 1.9; p<0.001), as was use of continuous pulse oximetry (78% vs. 58%, respectively; p=0.001). Staffing moderated the relationship between comorbidity and surveillance (r(2)=0.192, p<0.001) revealing a significant relationship at lower staffing but not higher. Surveillance did not mediate the relationship between staffing and events, but moderated it (r(2)=0.435; p<0.001) showing no relationship at lower surveillance levels. CONCLUSIONS Nurse staffing levels moderated the relationship between patient factors and surveillance demonstrating that this association is dependent on staffing levels. The association between staffing and adverse outcomes was dependent on the level of surveillance. Increased surveillance based on recognition of deterioration may have facilitated rescue of children in this setting, even during times of lower staffing.

Early adjuvant use of nonopioids associated with reduced odds of serious postoperative opioid adverse events and need for rescue in children

Examine factors associated with opioid adverse drug events (ADE) in children.

Exploratory analyses of the "failure to rescue" measure: evaluation through medical record review.

Clinicians and hospital leaders are interested in assessing the degree to which the failure-to-rescue indicator identifies true problems in processes of care at the individual or system level. Failure-to-rescue complications are flagged through administrative data, and the clinical course of events is evaluated. The review suggests that many factors influence whether a case is included in the measure, such as existing health problems, the presence of complex comorbidities, and variation in clinical documentation and coding practices.

Nursing medication administration and workflow using computerized physician order entry.

The benefits of computerized physician order entry systems have been described widely; however, the impact of computerized physician order entry on nursing workflow and its potential for error are unclear. The purpose of this study was to determine the impact of a computerized physician order entry system on nursing workflow. Using an exploratory design, nurses employed on an adult ICU (n = 36) and a general pediatric unit (n = 50) involved in computerized physician order entry-based medication delivery were observed. Nurses were also asked questions regarding the impact of computerized physician order entry on nursing workflow. Observations revealed total time required for administering medications averaged 8.45 minutes in the ICU and 9.93 minutes in the pediatric unit. Several additional steps were required in the process for pediatric patients, including preparing the medications and communicating with patients and family, which resulted in greater time associated with the delivery of medications. Frequent barriers to workflow were noted by nurses across settings, including system issues (ie, inefficient medication reconciliation processes, long order sets requiring more time to determine medication dosage), less frequent interaction between the healthcare team, and greater use of informal communication modes. Areas for nursing workflow improvement include (1) medication reconciliation/order duplication, (2) strategies to improve communication, and (3) evaluation of the impact of computerized physician order entry on practice standards.