Linda L. Costa

Nurse‐pharmacist collaboration on medication reconciliation prevents potential harm

BACKGROUND Medication reconciliation can prevent some adverse drug events (ADEs). Our prospective study explored whether an easily replicable nurse-pharmacist led medication reconciliation process could efficiently and inexpensively prevent potential ADEs. METHODS Nurses at a 1000 bed urban, tertiary care hospital developed the home medication list (HML) through patient interview. If a patient was not able to provide a written HML or recall medications, the nurses reviewed the electronic record along with other sources. The nurses then compared the HML to the patients active inpatient medications and judged whether the discrepancies were intentional or potentially unintentional. This was repeated at discharge as well. If the prescriber changed the order when contacted about a potential unintentional discrepancy, it was categorized as unintentional and rated on a 1-3 potential harm scale. RESULTS The study included 563 patients. HML information gathering averaged 29 minutes. Two hundred twenty-five patients (40%; 95% confidence interval [CI], 36%-44%) had at least 1 unintended discrepancy on admission or discharge. One hundred sixty-two of the 225 patients had an unintended discrepancy ranked 2 or 3 on the harm scale. It cost

Validation of Patient and Nurse Short Forms of the Readiness for Hospital Discharge Scale and Their Relationship to Return to the Hospital

113.64 to find 1 potentially harmful discrepancy. Based on the 2008 cost of an ADE, preventing 1 discrepancy in every 290 patient encounters would offset the intervention costs. We potentially averted 81 ADEs for every 290 patients. CONCLUSION Potentially harmful medication discrepancies occurred frequently at both admission and discharge. A nurse-pharmacist collaboration allowed many discrepancies to be reconciled before causing harm. The collaboration was efficient and cost-effective, and the process potentially improves patient safety.

Improving Assessment of Cardiovascular Disease Risk by Using Family History An Integrative Literature Review

OBJECTIVE To validate patient and nurse short forms for discharge readiness assessment and their associations with 30-day readmissions and emergency department (ED) visits. DATA SOURCES/STUDY SETTING A total of 254 adult medical-surgical patients and their discharging nurses from an Eastern US tertiary hospital between May and November, 2011. STUDY DESIGN Prospective longitudinal design, multinomial logistic regression analysis. DATA COLLECTION/EXTRACTION METHODS Nurses and patients independently completed an eight-item Readiness for Hospital Discharge Scale on the day of discharge. Patient characteristics, readmissions, and ED visits were electronically abstracted. PRINCIPAL FINDINGS Nurse assessment of low discharge readiness was associated with a six- to nine-fold increase in readmission risk. Patient self-assessment was not associated with readmission; neither was associated with ED visits. CONCLUSIONS Nurse discharge readiness assessment should be added to existing strategies for identifying readmission risk.

Challenges in posthospital care: nurses as coaches for medication management.

Background:Cardiovascular disease (CVD) is the number one killer in the United States. Although the causes of CVD are multifactorial, including genetic and environmental influences, it is largely a preventable disease. The cornerstone of CVD prevention is accuracy in risk prediction to identify patients who will benefit from interventions aimed at reducing risk. Nurse practitioners commonly perform CVD risk assessments and are well positioned to impact preventive therapy. Cardiovascular disease risk scoring systems currently in use substantially underestimate risk in large part because these do not include family history of premature CVD as a high-risk factor. Purpose:We sought to examine the state of evidence for the use of family history as a predictor in CVD risk stratification. Conclusions:A comprehensive literature search using the Medical Subject Headings terms of family history of CVD, family history of premature CVD, risk assessment, and risk estimation displayed 416 articles; a review of the titles and subsequent evaluation of the articles eliminated 392 references, leaving 24 for review. By incorporating family history in risk assessment, categorization of CVD risk improves substantially. The evidence demonstrates that family history is an independent contributor to risk appraisal and unequivocally supports its incorporation to improve accuracy in global CVD risk estimation. Clinical Implications:Underestimation of CVD risk leaves patients and providers misinformed, promoting the ongoing epidemic of chronic disease. Translating this evidence into practice by establishing a clinical algorithm that incorporates family history into risk prediction will standardize CVD risk assessment, improve the identification of high-risk patients, and provide the indicated aggressive care to prevent CVD.

Succession Management: A Model for Developing Nursing Leaders

The purpose of this study was to evaluate a transitional care intervention posthospital discharge for chronically ill medical patients managing complex medication regimens. This descriptive pilot study tested 2 interventions: telephone follow-up and a home visit. Registered nurses delivered the interventions with consulting pharmacist support. Findings included 62% more medication discrepancies discovered during home visit than detected by telephone interview. This brief intervention identified significant knowledge gaps in self-management of discharge medications in the inner city population.

A Model for Hospital Discharge Preparation: From Case Management to Care Transition

Succession management is critical to all healthcare organizations as they respond to the cost-cutting initiatives brought about by the prospective payment era. This personnel management system ensures that motivated individuals enter and ascend the management hierarchy consistently. Such stabilization is reflected in turnover vacancy rates of < 12 percent and < 9 percent, respectively, at a time of unprecedented competition for professional nurses. This provides not only greater professional advancement but also stability for patient care delivery.

Facilitators and challenges to conducting interdisciplinary research.

There has been a proliferation of initiatives to improve discharge processes and outcomes for the transition from hospital to home and community-based care. Operationalization of these processes has varied widely as hospitals have customized discharge care into innovative roles and functions. This article presents a model for conceptualizing the components of hospital discharge preparation to ensure attention to the full range of processes needed for a comprehensive strategy for hospital discharge.

Cause Celebre: Georgetown University Hospital’s Journey to Magnet

Background:Complex, interconnected issues challenge the United States health care system and the patients and families it serves. System fragmentation, limited resources, rigid disciplinary boundaries, institutional culture, ineffective communication, and uncertainty surrounding health policy legislation are contributing to suboptimal care delivery and patient outcomes. Methods:These problems are too complex to be solved by a single discipline. Interdisciplinary research affords the opportunity to examine and solve some of these problems from a more integrative perspective using innovative and rigorous methodological designs. Results:In this paper, we explore lessons learned from exemplars funded by the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative. Discussion:The discussion is framed using an adaptation of the Interdisciplinary Research Model to evaluate improvements in individual health outcomes, health systems, and health policy. Barriers and facilitators to designing, conducting, and translating interdisciplinary research are discussed. Implications for health system and policy changes, including the need to provide funding mechanisms to implement interdisciplinary processes in both research and clinical practice, are provided.

Models of Discharge Care in Magnet® Hospitals

Designation as a magnet organization by the American Nurses Credentialing Center is a coveted distinction for health care organizations. These organizations experience fewer problems with nurse recruitment and retention because they have been found to be good places to practice professional nursing. Better patient outcomes have also been documented in these organizations. In this article, the authors recount their 3-year experience leading an organization successfully to become the first magnet organization in the nation’s capitol. The magnet application and review process is linked to the core principles of organization development. The authors conclude with policy recommendations for other organizations that are just beginning their journey to achieving magnet status and with reflections on leadership and the value created by participating in the magnet program.

Using appreciative inquiry during care transitions: an exploratory study.

OBJECTIVE: The aim of this article is to describe how the discharge preparation process is operationalized in Magnet® hospitals. BACKGROUND: Nationally, there are intensive efforts toward improving discharge transitions and reducing readmissions. Discharge preparation is a core hospital function, yet there are few reports of operational models. METHODS: This was a descriptive, Web-based survey of 32 Magnet hospitals (64 units) participating in the Readiness Evaluation and Discharge Interventions study. RESULTS: Most hospitals have adopted 1 or more national readmission reduction initiatives. Most unit models include several discharge preparation roles; RN case managers, and discharging RNs lead the process. Nearly one-half of units actively screen for readmission risk. More than three-fourths report daily discharge rounds, but less than one-third include the patient and family. More than two-thirds report a follow-up phone call, mostly to assess patient satisfaction. CONCLUSIONS: Magnet hospitals operationalize discharge preparation differently. Recommended practices from national discharge initiatives are inconsistently used. RNs play a central role in discharge planning, coordination, and teaching.