Danielle M. Olds

The Importance Of Transitional Care In Achieving Health Reform

Under the Affordable Care Act of 2010, a variety of transitional care programs and services have been established to improve quality and reduce costs. These programs help hospitalized patients with complex chronic conditions-often the most vulnerable-transfer in a safe and timely manner from one level of care to another or from one type of care setting to another. We conducted a systematic review of the research literature and summarized twenty-one randomized clinical trials of transitional care interventions targeting chronically ill adults. We identified nine interventions that demonstrated positive effects on measures related to hospital readmissions-a key focus of health reform. Most of the interventions led to reductions in readmissions through at least thirty days after discharge. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Based on these findings, we recommend several strategies to guide the implementation of transitional care under the Affordable Care Act, such as encouraging the adoption of the most effective interventions through such programs as the Community-Based Care Transitions Program and Medicare shared savings and payment bundling experiments.

Education Policy Initiatives To Address The Nurse Shortage In The United States

Employment opportunities are expected to grow much faster for registered nurses (RNs) than for most other occupations. Yet a major shortage of nurses is projected by 2020. A nurse faculty shortage and financially strapped colleges and universities are limiting the ability of U.S. nursing schools to take advantage of historically high numbers of qualified applicants. Increased public subsidies are needed to provide greater access to nursing education, with a priority on baccalaureate and graduate nursing education, where job growth is expected to be the greatest.

Effective Antimicrobial Stewardship in a Long-Term Care Facility through an Infectious Disease Consultation Service: Keeping a LID on Antibiotic Use

DESIGN We introduced a long-term care facility (LTCF) infectious disease (ID) consultation service (LID service) that provides on-site consultations to residents of a Veterans Affairs (VA) LTCF. We determined the impact of the LID service on antimicrobial use and Clostridium difficile infections at the LTCF. SETTING A 160-bed VA LTCF. METHODS Systemic antimicrobial use and positive C. difficile tests at the LTCF were compared for the 36 months before and the 18 months after the initiation of the ID consultation service through segmented regression analysis of an interrupted time series. RESULTS Relative to that in the preintervention period, total systemic antibiotic administration decreased by 30% (P<.001), with significant reductions in both oral (32%; P<.001) and intravenous (25%; P=.008) agents. The greatest reductions were seen for tetracyclines (64%; P<.001), clindamycin (61%; P<.001), sulfamethoxazole/trimethoprim (38%; P<.001), fluoroquinolones (38%; P<.001), and β-lactam/β-lactamase inhibitor combinations (28%; P<.001). The rate of positive C. difficile tests at the LTCF declined in the postintervention period relative to preintervention rates (P=.04). CONCLUSIONS Implementation of an LTCF ID service led to a significant reduction in total antimicrobial use. Bringing providers with ID expertise to the LTCF represents a new and effective means to achieve antimicrobial stewardship.

Learning by doing: observing an interprofessional process as an interprofessional team

Abstract New competencies exist for interprofessional education, which are centered on the goal of improving quality of care and patient safety through improved interprofessional collaboration. Interprofessional education and effective interprofessional collaboration are cornerstones of the Veterans Affairs Quality Scholars fellowship program. The purpose of this project was to evaluate an innovative interprofessional education strategy in which teams of physicians and nurses were “learning by doing” as they observed and analyzed the functioning of an interprofessional process, specifically, inpatient discharge. Fellows completed voluntary, anonymous surveys seeking their perspectives about the project. Fellows’ feedback revealed several themes, with both positive and negative characteristics related to team functioning, interprofessional understanding, microsystem knowledge, pooled knowledge and assignment challenges. The strength of this strategy is exemplified by the fact that fellows not only learned from each other’s separate professional observations, but also observed the emergence of a shared interprofessional perspective through working together.

Nurse work environment and quality of care by unit types: A cross-sectional study

BACKGROUND Nursing unit is the micro-organization in the hospital health care system in which integrated patient care is provided. Nursing units of different types serve patients with distinct care goals, clinical tasks, and social structures and norms. However, empirical evidence is sparse on unit type differences in quality of care and its relation with nurse work environment. Nurse work environment has been found as an important nursing factor predicting nurse and patient outcomes. OBJECTIVES To examine the unit type differences in nurse-reported quality of care, and to identify the association between unit work environment and quality of care by unit types. METHODS This is a cross-sectional study using nurse survey data (2012) from US hospitals nationwide. The nurse survey collected data on quality of care, nurse work environment, and other work related information from staff nurses working in units of various types. Unit types were systematically classified across hospitals. The unit of analysis was the nursing unit, and the final sample included 7677 units of 14 unit types from 577 hospitals in 49 states in the US. Multilevel regressions were used to assess the relationship between nurse work environment and quality of care across and by unit types. RESULTS On average, units had 58% of the nurses reporting excellent quality of care and 40% of the nurses reporting improved quality of care over the past year. Unit quality of care varied by unit types, from 43% of the nurses in adult medical units to 73% of the nurses in interventional units rating overall quality of care on unit as excellent, and from 35% of the nurses in adult critical care units to 44% of the nurses in adult medical units and medical-surgical combined units reporting improved quality of care. Estimates from regressions indicated that better unit work environments were associated with higher quality of care when controlling various hospital and unit covariates; and this association persisted among units of different types. CONCLUSIONS Unit type differences exist in the overall quality of care as well as achievement in improving quality of care. The low rates of nurses reporting improvement in the quality of nursing care to patients suggest that further interventions focusing at the unit-level are needed for achieving high care quality. Findings from our study also suggest that improving nurse work environments can be an effective strategy to improve quality of care.

Specialty Care Delivery: Bringing Infectious Disease Expertise to the Residents of a Veterans Affairs Long‐Term Care Facility

To initiate a long‐term care facility (LTCF) infectious disease (LID) service that provides on‐site consultations to LTCF residents to improve the care of residents with possible infections.

Association of nurse work environment and safety climate on patient mortality: A cross-sectional study

BACKGROUND There are two largely distinct research literatures on the association of the nurse work environment and the safety climate on patient outcomes. OBJECTIVE To determine whether hospital safety climate and work environment make comparable or distinct contributions to patient mortality. DESIGN Cross-sectional secondary analysis of linked datasets of Registered Nurse survey responses, adult acute care discharge records, and hospital characteristics. SETTING Acute care hospitals in California, Florida, New Jersey, and Pennsylvania. PARTICIPANTS The sample included 600 hospitals linked to 27,009 nurse survey respondents and 852,974 surgical patients. METHODS Nurse survey data included assessments of the nurse work environment and hospital safety climate. The outcome of interest was in-hospital mortality. Data analyses included descriptive statistics and multivariate random intercept logistic regression. RESULTS In a fully adjusted model, a one standard deviation increase in work environment score was associated with an 8.1% decrease in the odds of mortality (OR 0.919, p<0.001). A one-standard deviation increase in safety climate score was similarly associated with a 7.7% decrease in the odds of mortality (OR 0.923, p<0.001). However, when work environment and safety climate were modeled together, the effect of the work environment remained significant, while safety climate became a non-significant predictor of mortality odds (OR 0.940, p=0.035 vs. OR 0.971, p=0.316). CONCLUSIONS We found that safety climate perception is not predictive of patient mortality beyond the effect of the nurse work environment. To advance hospital safety and quality and improve patient outcomes, organizational interventions should be directed toward improving nurse work environments.

Differences in Pediatric Pain Management by Unit Types

PURPOSE The purpose of this study was to determine differences in pediatric pain management by unit type in hospitals across the United States. The aims were to (a) compare unit-type rates of assessment, intervention, and reassessment (AIR), and (b) describe differences in assessment tools and intervention use by unit type. DESIGN The study used a cross-sectional design. A secondary analysis of 2013 data from the National Database of Nursing Quality Indicators (NDNQI®) pain AIR cycle indicator was conducted. The sample included 984 pediatric units in 390 hospitals. METHODS Data were gathered via retrospective chart review on the pain assessment tool used, presence of pain, interventions, and reassessment. Descriptive statistics and the Kruskal-Wallis one-way analysis of variance test were conducted. Post-hoc analyses included the Wilcoxon-rank sum test with Bonferroni correction. FINDINGS Across all units the mean unit-level percentage of patients assessed for pain was 99.6%. Of those patients assessed, surgical units had the highest average unit-level percentage of patients with pain, while Level 4 neonatal intensive care units (NICUs) had the lowest. The most commonly used assessment tool among all units was the Faces, Legs, Activity, Crying, and Consolability (FLACC) Scale. The Neonatal Pain, Agitation, and Sedation Scale (N-PASS) and Neonatal Infant Pain Scale (NIPS) specifically developed for infants were more commonly used across NICU unit types. The mean unit-level percentage of patients with pain receiving an intervention was 89.4%, and reassessment was 83.6%. Overall, pharmacologic methods were the most common pain intervention, while music was the least common. CONCLUSIONS Assessments were performed routinely, yet interventions and reassessments were not. Pain AIR cycle completion varied by unit type. Pain was also widely present across many unit types, and pharmacologic methods were most frequently used. CLINICAL RELEVANCE Frontline nurses are instrumental to pain management and have the ability to improve patient care and outcomes by effectively managing pain. A comprehensive understanding of it provides valuable insight into improving our practice to produce the best outcomes for pediatric patients.

Results of a Veterans Affairs employee education program on antimicrobial stewardship for older adults

We describe a course in the Veterans Affairs (VA) Employee Education System designed to engage nursing staff working in VA long-term care facilities as partners in antimicrobial stewardship. We found that the course addressed an important knowledge gap. Our outcomes suggest opportunities to engage nursing staff in advancing antimicrobial stewardship, particularly in the long-term care setting.

Innovations in Quality Improvement Research for more useful answers to research users’ questions.

Presentation Quality Improvement Research (QIR) is any systematic inquiry that generates actionable knowledge, enables practitioners and patients to improve care and health, and reduces bias to maximize the validity and reliability of the knowledge gained. Some QIR evaluates complex healthcare innovations, such as bundled interventions to reduce infections. Such innovations often involve multiple components (e.g., hand hygiene, review of device necessity), may be directed at various levels of the system (e.g., practitioner, provider teams, hospital units), and may change in content or implementation strategy across time and context. Such innovations are affected by contextual factors emanating from different levels of the system. If QIR addresses practitioners’ questions, it is more likely to be used. There are seven questions relevant to quality improvement (QI) practice: 1) Efficacy: does it work in controlled situations? 2) Effectiveness: will the intervention work in a setting and with patients like the practitioner’s own?; 3) Implementation: what are successful ways to implement change?; 4) Sustainability: what is needed to sustain the change?; 5) Fidelity: should the intervention be copied exactly?; which parts can be adapted?; 6) Cost: what are the costs and savings of making and sustaining the change?; and 7) De-implementation: how are ineffective practices modified? Research designs and methods must be chosen to match research users’ needs. Designs frequently used in research, such as randomized controlled trials (RCTs), might not address questions of interest to stakeholders (e.g., clinicians, administrators, patients, payers). QIR can be broadened to include adherence studies and multi-morbidity studies, and to use budget impact analyses, action evaluation, research syntheses, and context-and-theory-informed program evaluations, as well as RCTs that incorporate process evaluations. Secondly, to be more relevant to current initiatives, such as Patient Centered Medical Homes, QIR could include estimates of costs and savings of improvements. Thirdly, QIR can be extended to non-hospital settings to study improvements that significantly affect patients’ health and cost. In these settings, QIR could be used to study epidemiology of adherence, conditions that facilitate or impede health behaviors, and interventions to improve selfcare and self-management. Finally, an important point raised during conference discussion is the need to understand how practitioners and administrators use QIR. Because the goal of QIR is to provide actionable knowledge, researchers need to know how and even if, their findings are being used.