Heather L. Tubbs-Cooley

Testing a post-discharge nurse-led transitional home visit in acute care pediatrics: the Hospital-To-Home Outcomes (H2O) study protocol.

AIMS The aims of this study were: (1) to explore the family perspective on pediatric hospital-to-home transitions; (2) to modify an existing nurse-delivered transitional home visit to better meet family needs; (3) to study the effectiveness of the modified visit for reducing healthcare re-use and improving patient- and family-centered outcomes in a randomized controlled trial. BACKGROUND The transition from impatient hospitalization to outpatient care is a vulnerable time for children and their families; children are at risk for poor outcomes that may be mitigated by interventions to address transition difficulties. It is unknown if an effective adult transition intervention, a nurse home visit, improves postdischarge outcomes for children hospitalized with common conditions. DESIGN (1) Descriptive qualitative; (2) Quality improvement; (3) Randomized controlled trial. METHODS Aim 1 will use qualitative methods, through focus groups, to understand the family perspective of hospital-to-home transitions. Aim 2 will use quality improvement methods to modify the content and processes associated with nurse home visits. Modifications to visits will be made based on parent and stakeholder input obtained during Aims 1 & 2. The effectiveness of the modified visit will be evaluated in Aim 3 through a randomized controlled trial. DISCUSSION We are undertaking the study to modify and evaluate a nurse home visit as an effective acute care pediatric transition intervention. We expect the results will be of interest to administrators, policy makers and clinicians interested in improving pediatric care transitions and associated postdischarge outcomes, in the light of impending bundled payment initiatives in pediatric care.

Development of a Regional Nursing Research Partnership for Academic and Practice Collaborations

Background. Collaborative nursing research across academic and practice settings is imperative to generate knowledge to improve patient care. Models of academic/practice partnerships for nursing research are lacking. This paper reports data collected before and during a one-day retreat for nurse researchers and administrators from local universities and health care organizations designed to establish a regional nursing research partnership. Methods. Quantitative and qualitative methods were used to address the study aims: (1) to assess research involvement and institutional research resources; (2) to assess interest in and concerns regarding cross-institutional collaborations; and (3) to describe perceptions of the purpose of a partnership and resources needed to ensure success. Results. Participants (n = 49) had differing perceptions of accessibility to resources; participants in practice settings reported less accessibility to resources, notably grant development, informatics, and research assistant support. Participants were interested in collaboration although concerns about conflict of interest were expressed. Four themes related to partnering were identified: harnessing our nursing voice and identity; developing as researchers; staying connected; and positioning for a collaborative project. Conclusion. Academic-practice research collaborations will become increasingly important with health care system changes. Strategies to develop and sustain productive partnerships should be supported.

Effects of the neonatal intensive care unit environment on preterm infant oral feeding.

OBJECTIVE To examine the effect of neonatal intensive care unit environmental characteristics (perceived levels of light and sound, and time of day) in open unit wards and single-family rooms (SFRs) on oral feeding outcomes in preterm infants. DESIGN Data were collected at each scheduled oral feeding for 87 preterm infants from the first oral feeding until discharge. Data included the prescribed volume of feeding and the volume consumed, the infants level of wakefulness before feeding, and the nurses perception of light and sound. RESULTS Data were collected on 5111 feedings in the ward unit and 5802 in the SFR unit from feedings involving 87 preterm infants. Light and sound were rated significantly lower in the SFR (χ2 = 139 and 1654.8, respectively). Feeding times of 9 am, 12 noon, and 3 pm were associated with the highest perceived levels of light and sound, regardless of unit design (P < 0.0001). Moderate light levels and feeding times of 12, 3, and 6 am were associated with improved feeding outcomes. Infants consumed a greater proportion of their prescribed feeding volume when fed in the open ward and when awake before feeding. CONCLUSION Further study on the clinical effects of unit design is needed, as is study on the effects of environmental stimuli, so that interventions can be appropriately developed and tailored for infants needing the most support for optimal development.

Improving Recruitment and Retention Rates in a Randomized Controlled Trial

Quality improvement methods can be used within the scope of a large research study to achieve and sustain high recruitment and retention rates. High recruitment and retention rates in randomized controlled trials are essential to ensure validity and broad generalizability. We used quality improvement methods, including run charts and intervention cycles, to achieve and sustain high recruitment and retention rates during the Hospital-To-Home Outcomes randomized controlled trial. This study is examining the effects of a single nurse–led home health care visit after discharge for an acute pediatric hospitalization. A total of 1500 participants were enrolled in the 15-month study period. For study recruitment, we assessed the percentage of patients who enrolled in the study among those randomly selected to approach (goal ≥50%) and the percentage of patients who refused to enroll from those randomly selected to approach (goal ≤30%). For intervention completion, we examined the percentage of patients who completed the home visit intervention among those randomized to receive the intervention (goal ≥95%) were examined. Follow-up rates were tracked as the percentage of patients who completed the 14-day follow-up telephone survey (goal ≥95%). The study goals for 2 of the 4 metrics were met and sustained, with statistically significant improvements over time in 3 metrics. The median enrollment rate increased from 50% to 59%, and the median refusal rate decreased from 37% to 32%. The median intervention completion rate remained unchanged at 88%. The 14-day follow-up completion median rate increased from 94% to 96%. These results indicate that quality improvement methods can be used within the scope of a large research study to achieve and sustain high recruitment and retention rates.

Using Health Information Technology to Improve Safety in Neonatal Care: A Systematic Review of the Literature

Health information technology (HIT) interventions may improve neonatal patient safety but may also introduce new errors. The objective of this review was to evaluate the evidence for use of HIT interventions to improve safety in neonatal care. Evidence for improvement exists for interventions like computerized provider order entry in the neonatal population, but is lacking for several other interventions. Many unique applications of HIT are emerging as technology and use of the electronic health record expands. Future research should focus on the impact of these interventions in the neonatal population.

Patient-Centered Outcomes Research: A “New” Research Agenda

There is a new player among funders of health care research—the Patient Centered Outcomes Research Institute (PCORI). PCORI was established by Congress as part of the Patient Protection and Affordable Care Act of 2010. Through the Patient-Centered Outcomes Research Trust Fund (PCORTF) established at that time, PCORI receives funding from two sources: the general fund of the Treasury and a fee assessed on Medicare, private health insurance, and self-insured plans. PCORI is expected to receive an estimated

Issues in Research Integrity: Deciding What Is Mine, Yours, and Ours

3.5 billion from the

From research to policy: enhancing uptake of quality improvement methods in government contracts

370 Volume 26 Number 5 methods in proposing, performing, and evaluating research; reporting research results with particular attention to adherence to rules, regulations, and guidelines; and following commonly accepted professional codes or norms.’’ So important is this content to the National Institutes of Health that in 2009 it began specifying the scope of instruction in research integrity that institutions receiving federal funds are required to provide. Such instruction is required to be given in both formal (classroom) and informal (practical and experiential) ways throughout any research training program that is funded by the DHHS. Although the content for the training is not prescriptive, several topics are noted to be included in most plans deemed acceptable to the DHHS and its funding agencies (Box). Clearly, research integrity encompasses a vast array of topics, and the full scope ofwhat constitutes research integrity is too broad a topic for this column. This article will focus on several areas of closely related topics that are addressed less frequently in contemporary writing on research integrity: ownership of ideas, misuse of privileged information, and collaborative research efforts, including those of trainee/faculty and research networks. Because of space limitations, we have included links to a number of resources to aid the reader in the further consideration of these topics.

A descriptive study of nurse-reported missed care in neonatal intensive care units

Presentation The Centers for Medicare and Medicaid Services (CMS) provide healthcare coverage for 100 million people and, particularly through provisions of the Affordable Care Act, the agency strives to improve care and to ensure coverage for all Americans. Government agencies like CMS need processes that encourage improvements in value and outcomes and reduce variation in quality, and yet have been slow to embrace quality improvement (QI) methods. With QI, the agency could be more effective in partnering with providers to achieve “triple aim” outcomes of improving patient experiences with health care, improving population health, and reducing percapita health care costs [1]. Most CMS work proceeds through contracts that specify actions and on-time deliverables (such as supplies or helpdesk services). Similarly, contracts to “Quality Improvement Organizations” (QIOs) typically require that an “evidence-based” intervention be applied in a certain number of clinical settings – not that the intervention be tested further and adapted to the local context, or even that a particular outcome be achieved. Such contracts are eminently auditable, an important fact in the scrutiny of government contracting by CMS, Congress, the press, and others. Translating efficacious interventions into effective health care processes and outcomes at a local level ordinarily requires iterative, exploratory testing and adaptation, which is the core of QI. CMS’s traditional purpose has been to pay the bills and uphold the “standard of care”; it generally does not issue research grants that allow exploration of novel implementation approaches. Although CMS has not historically been at the forefront of QI methods, the agency’s position is simultaneously changing to adopt QI and encountering challenges along the way. Key points: • Implementation of evidence-based interventions with strict fidelity to the research protocol is often an ineffective strategy; testing and adaptation are usually necessary for optimal implementation and for scaling up. • Quality improvement methods such as statistical process control (SPC), frequent and repeated measurement, rapid-cycle testing of interventions and strategies, and qualitative insights about causal chains and effectiveness are powerful implementation tools that could work better to achieve program goals than implementation of rigidly specified interventions. • Writing an auditable contract for these approaches poses challenges. • Strategic partnerships between QI researchers, QI leaders, and government staffers/officials might be effective in promoting familiarity with QI methods and structuring contracts to allow for integration of QI methods while meeting audit and evaluation needs.