Angela A. Richard

Delineation of Self‐Care and Associated Concepts

PURPOSE The purpose of this paper is to delineate five concepts that are often used synonymously in the nursing and related literature: self-care, self-management, self-monitoring, symptom management, and self-efficacy for self-care. METHOD Concepts were delineated based on a review of literature, identification of relationships, and examination of commonalities and differences. FINDINGS More commonalities than differences exist among self-care, self-management, and self-monitoring. Symptom management extends beyond the self-care concepts to include healthcare provider activities. Self-efficacy can mediate or moderate the four other concepts. Relationships among the concepts are depicted in a model. CONCLUSIONS A clearer understanding of the overlap, differences, and relationships among the five concepts can provide clarity, direction and specificity to nurse researchers, policy makers, and clinicians in addressing their goals for health delivery. CLINICAL RELEVANCE Concept clarity enables nurses to use evidence that targets specific interventions to individualize care toward achieving the most relevant goals.

Improving Patient Outcomes of Home Health Care: Findings from Two Demonstration Trials of Outcome-Based Quality Improvement

OBJECTIVES: To evaluate effects on patient outcomes of Outcome‐Based Quality Improvement (OBQI), a continuous quality improvement methodology for home health care (HHC).

Indwelling urinary catheter management and catheter-associated urinary tract infection prevention practices in Nurses Improving Care for Healthsystem Elders hospitals

BACKGROUND Indwelling urinary catheters (IUCs) are commonly used in hospitalized patients, especially elders. Catheter-associated urinary tract infections (CAUTIs) account for 34% of all health care associated infections in the United States, associated with excess morbidity and health care costs. Adherence to CAUTI prevention practices has not been well described. METHODS This study used an electronic survey to examine IUC care practices for CAUTI prevention in 3 areas-(1) equipment and alternatives and insertion and maintenance techniques; (2) personnel, policies, training, and education; and (3) documentation, surveillance, and removal reminders-at 75 acute care hospitals in the Nurses Improving the Care of Healthsystem Elders (NICHE) system. RESULTS CAUTI prevention practices commonly followed included wearing gloves (97%), handwashing (89%), maintaining a sterile barrier (81%), and using a no-touch insertion technique (73%). Silver-coated catheters were used to varying degrees in 59% of the hospitals; 4% reported never using a catheter-securing device. Urethral meatal care was provided daily by 43% of hospitals and more frequently that that by 41% of hospitals. Nurses were the most frequently reported IUC inserters. Training in aseptic technique and CAUTI prevention at the time of initial nursing hire was provided by 64% of hospitals; however, only 47% annually validated competency in IUC insertion. Systems for IUC removal were implemented in 56% of hospitals. IUC documentation and routine CAUTI surveillance practices varied widely. CONCLUSIONS Although many CAUTI prevention practices at NICHE hospitals are in alignment with evidence-based guidelines, there is room for improvement. Further research is needed to identify the effect of enhanced compliance with CAUTI prevention practices on the prevalence of CAUTI in NICHE hospitals.

A study of reliability and burden of home health assessment using OASIS.

ABSTRACT The Outcome and Assessment Information Set (OASIS) is used for outcome reporting, quality improvement, and case mix adjustment of per-episode payment for home health care. The research described here addresses interrater reliability of OASIS items and compares clinician time required to complete patient assessment with and without OASIS. Interrater reliability for OASIS data items was estimated using independent assessments by two clinicians for a sample of 66 patients. Incremental assessment time due to OASIS was estimated using interview data from two agency-matched groups of clinical care providers-one group who used OASIS in the assessment and a second group whose assessment did not include OASIS items. Interrater reliability is excellent (kappa > .80) for many OASIS items and substantial (kappa > 0.60) for most items. The reported time required to complete an assessment with OASIS did not differ from the time required for a comparable assessment without OASIS. The results of this study are being used to guide developmental efforts to improve OASIS items. They can also be informative to home health care agencies when interpreting OASIS-based outcome and case mix reports.

Chief nursing officers' perspectives on Medicare's hospital-acquired conditions non-payment policy: implications for policy design and implementation

BackgroundPreventable adverse events from hospital care are a common patient safety problem, often resulting in medical complications and additional costs. In 2008, Center for Medicare and Medicaid Services (CMS) implemented a policy, mandated by the Deficit Reduction Act of 2005, targeting a list of these ‘reasonably’ preventable hospital-acquired conditions (HACs) for reduced reimbursement. Extensive debate ensued about the potential adverse effects of the policy, but there was little discussion of its impact on hospitals’ quality improvement (QI) activities. This study’s goals were to understand organizational responses to the HAC policy, including internal and external influences that moderated the success or failure of QI efforts.MethodsWe employed a qualitative descriptive design. Representatives from 14 Nurses Improving Care of Health System Elders (NICHE) hospitals participated in semi-structured interviews addressing the impact of the HAC policy generally, and for two indicator conditions: central-line associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). Within-case analysis identified the key components of each institution’s response to the policy; across-case analysis identified themes. Exemplar cases were used to explicate findings.ResultsInterviewees reported that the HAC policy is one of many internal and external factors motivating hospitals to address HACs. They agreed the policy focused attention on prevention of HACs that had previously received fewer dedicated resources. The impact of the policy on prevention activities, barriers, and facilitators was condition-specific. CLABSI efforts were in place prior to the policy, whereas CAUTI efforts were less mature. Nearly all respondents noted that pressure ulcer detection and documentation became a larger focus stemming from the policy change. A major challenge was the determination of which conditions were ‘hospital-acquired.’ One opportunity arising from the policy has been the focus on nursing leadership in patient safety efforts.ConclusionsWhile the CMS’s HAC policy was just one of many factors influencing QI efforts, it may have served the important role of drawing attention and resources to the targeted conditions—particularly those not previously in the spotlight. The translational research paradigm is helpful in the interpretation of the findings, illustrating how the policy can advance prevention efforts for HACs at earlier phases of research translation as well as pitfalls associated with earlier phase implementation. To maximize their impact, such policies should consider condition-specific contextual factors influencing policy uptake and provide condition-specific implementation support.

Accuracy of Electronic Surveillance of Catheter-Associated Urinary Tract Infection at an Academic Medical Center

OBJECTIVE To develop and validate a methodology for electronic surveillance of catheter-associated urinary tract infections (CAUTIs). DESIGN Diagnostic accuracy study. SETTING A 425-bed university hospital. SUBJECTS A total of 1,695 unique inpatient encounters from November 2009 through November 2010 with a high clinical suspicion of CAUTI. METHODS An algorithm was developed to identify incident CAUTIs from electronic health records (EHRs) on the basis of the Centers for Disease Control and Prevention (CDC) surveillance definition. CAUTIs identified by electronic surveillance were compared with the reference standard of manual surveillance by infection preventionists. To determine diagnostic accuracy, we created 2 × 2 tables, one unadjusted and one adjusted for misclassification using chart review and case adjudication. Unadjusted and adjusted test statistics (percent agreement, sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], and κ) were calculated. RESULTS Electronic surveillance identified 64 CAUTIs compared with manual surveillance, which identified 19 CAUTIs for 97% agreement, 79% sensitivity, 97% sensitivity, 23% PPV, 100% NPV, and κ of .33. Compared with the reference standard adjusted for misclassification, which identified 55 CAUTIs, electronic surveillance had 98% agreement, 80% sensitivity, 99% specificity, 69% PPV, 99% NPV, and κ of .71. CONCLUSION The electronic surveillance methodology had a high NPV and a low PPV compared with the reference standard, indicating a role of the electronic algorithm in screening data sets to exclude cases. However, the PPV markedly improved compared with the reference standard adjusted for misclassification, suggesting a future role in surveillance with improvements in EHRs.

Using case mix and adverse event outcome reports for outcome-based quality monitoring.

The OBQM process is similar to many of the QI/PI processes that agencies have used in the past. The Adverse Event Outcome and Cse Mix Reports, based on OASIS data, provide agencies with clinical out come data that can be used to improve quality of care. The reposts are a first step in the effort to bring the home care industry to a new era of using patient-centered data as the basis for improving services.

Implementation of electronic surveillance of catheter use and catheter-associated urinary tract infection at Nurses Improving Care for Healthsystem Elders (NICHE) hospitals

BACKGROUND Manual surveillance of indwelling urinary catheters (IUCs) and catheter-associated urinary tract infections (CAUTIs) is resource intense. METHODS We implemented electronic surveillance in nonintensive care units of Nurses Improving Care for Healthsystem Elders (NICHE) hospitals. Capacity was created centrally to analyze data collected electronically or manually at each site. We measured the average IUC duration and proportion of patients with IUC duration <3 days. CAUTIs were identified using a validated algorithm based on the Centers for Disease Control and Prevention definition and used to calculate rates and standardized incidence ratios (SIRs). RESULTS Electronic surveillance was implemented in 25 units at 20 NICHE hospitals. Full automation was achieved at 15 of 16 sites with electronic health records (EHRs). Electronic surveillance challenges included EHR data element formats and IUC documentation. Study units reported on 4,574 patients for 16,105 IUC days over a 6-month period. The mean of the unit-level average IUC duration was 3.2 ± 2.6 days, mean proportion of patients with IUC duration <3 days was 52.4% ± 50%, and mean CAUTI SIR was 0.14 ± 0.31. CONCLUSION A centralized electronic surveillance strategy for CAUTI is feasible and sustainable. Baseline performance of participating sites was exemplary, with very low SIRs at baseline.

Measuring healthcare outcomes to improve quality of care across post--acute care provider settings.

Post-acute care (PAC) occurs in a variety of settings—skilled nursing facilities (nursing homes), rehabilitation facilities, and home health agencies. To evaluate the impact of care processes on clinical outcomes and implement changes designed to improve outcomes, one must begin by measuring outcomes in a valid, reliable manner that allows for comparisons to reference or benchmarking data. Currently, several data sets exist in PAC settings for the purpose of outcome measurement. However, there is a need for comparable information across settings to ensure the quality and continuity of care. This article reviews various existing data sets used in PAC settings, examines ongoing projects to create a single set of measures, and suggests some directions for future research.

Using OASIS for outcome-based quality improvement.

OASIS was developed for the purpose of measuring and enhancing outcomes of patients receiving home health services. OASIS-derived outcome reports provide a foundation of Outcome-Based Quality Improvement (OBQI). This article describes the OBQI process and provides two case studies to illustrate how agencies can use OBQI to enhance patient care.