Lori A. Loan

Medication Administration Variances Before and After Implementation of Computerized Physician Order Entry in a Neonatal Intensive Care Unit

OBJECTIVE. The goal was to determine whether implementation of a computerized physician order entry system was associated with a decrease in medication administration variances in a NICU. METHODS. A prospective observational study was conducted. Research nurses recorded details of medication administrations for patients in a NICU during standardized observation periods. Details of each administration were compared with the medication order; a variance was defined as a discrepancy between the order and the medication administration. Rates of variances before and after implementation of computerized physician order entry in the NICU were compared. Specific types of and reasons for variances were also compared. RESULTS. Data on 526 medication administrations, including 254 during the pre-computerized physician order entry period and 272 after implementation of computerized physician order entry, were collected. Medication variances were detected for 19.8% of administrations during the pre-computerized physician order entry period, compared with 11.6% with computerized physician order entry (rate ratio: 0.53). Overall, administration mistakes, prescribing problems, and pharmacy problems accounted for 74% of medication variances; there were no statistically significant differences in rates for any of these specific reasons before versus after introduction of computerized physician order entry. Administration of a medication at the wrong time accounted for 53.1% of all variances. Variance rates related to giving a drug at the wrong time were significantly lower in the computerized physician order entry period than in the pre-computerized physician order entry period (rates: 6.7% and 9.9%, respectively; rate ratio: 0.53). CONCLUSIONS. Implementation of computerized physician order entry in a NICU was associated with a significant decrease in the rate of medication administration variances. However, even with the use of computerized physician order entry, variances were noted for >11% of all medication administrations, which suggests that additional methods may be needed to improve neonatal patient safety.

The association of shift-level nurse staffing with adverse patient events

Objective: The objective of this study was to demonstrate the association between nurse staffing and adverse events at the shift level. Background: Despite a growing body of research linking nurse staffing and patient outcomes, the relationship of staffing to patient falls and medication errors remains equivocal, possibly due to dependence on aggregated data. Methods: Thirteen military hospitals participated in creating a longitudinal nursing outcomes database to monitor nurse staffing, patient falls and medication errors, and other outcomes. Unit types were analyzed separately to stratify patient and nurse staffing characteristics. Bayesian hierarchical logistic regression modeling was used to examine associations between staffing and adverse events. Results: RN skill mix, total nursing care hours, and experience, measured by a proxy variable, were associated with shift-level adverse events. Conclusions: Consideration must be given to nurse staffing and experience levels on every shift.

What Really Matters to Healthcare Consumers

Consumer satisfaction with healthcare is an important quality and outcome indicator. Satisfaction may be at the crux of survival for healthcare delivery systems because it creates the competitive edge in healthcare. To better understand patient satisfaction by examining consumer healthcare experiences and expectations, a study was conducted. An important concept identified in the data, MY CARE, refers to a constellation of quality healthcare features that were wished for by all participants and realized by only some of them. The features of MY CARE offer lessons for all healthcare leaders to use when making improvements in care delivery systems—improvements that could create a more patient-centered healthcare system and boost patient satisfaction.

Towards Evidence-based Management: Creating an Informative Database of Nursing-Sensitive Indicators

PURPOSE The purpose of this paper is to describe the creation, evolution, and implementation of a database of nursing-sensitive and potentially nursing-sensitive indicators, the Military Nursing Outcomes Database (MilNOD). It discusses data quality, utility, and lessons learned. DESIGN/METHODS Prospective data collected each shift include direct staff hours by levels (i.e., registered nurse, other licensed and unlicensed providers), staff categories (i.e., military, civilian, contract, and reservist), patient census, acuity, and admissions, discharges, and transfers. Retrospective adverse event data (falls, medication errors, and needle-stick injuries) were collected from existing records. Annual patient satisfaction, nurse work environment, and pressure ulcer and restraint prevalence surveys were conducted. FINDINGS AND CONCLUSIONS The MilNOD contains shift level data from 56 units in 13 military hospitals and is used to target areas for managerial and clinical performance improvement. This methodology can be modified for use in other healthcare systems. CLINICAL RELEVANCE As standard tools for evidence-based management, databases such as MilNOD allow nurse leaders to track the status of nursing and adverse events in their facilities.

Exploring factors associated with pressure ulcers: A data mining approach

BACKGROUND Pressure ulcers are associated with a nearly three-fold increase in in-hospital mortality. It is essential to investigate how other factors besides the Braden scale could enhance the prediction of pressure ulcers. Data mining modeling techniques can be beneficial to conduct this type of analysis. Data mining techniques have been applied extensively in health care, but are not widely used in nursing research. PURPOSE To remedy this methodological gap, this paper will review, explain, and compare several data mining models to examine patient level factors associated with pressure ulcers based on a four year study from military hospitals in the United States. METHODS The variables included in the analysis are easily accessible demographic information and medical measurements. Logistic regression, decision trees, random forests, and multivariate adaptive regression splines were compared based on their performance and interpretability. RESULTS The random forests model had the highest accuracy (C-statistic) with the following variables, in order of importance, ranked highest in predicting pressure ulcers: days in the hospital, serum albumin, age, blood urea nitrogen, and total Braden score. CONCLUSION Data mining, particularly, random forests are useful in predictive modeling. It is important for hospitals and health care systems to use their own data over time for pressure ulcer risk prediction, to develop risk models based upon more than the total Braden score, and specific to their patient population.

Tracheobronchial Trauma Associated With Airway Management in Neonates

Airway management procedures are an integral part of caring for the newborn infant with respiratory compromise. Concomitant with these interventions are latrogenic consequences that result in varying degrees of trauma to the tracheobronchial tree. Common interventions such as intubation, mechanical ventilation, use of heated and humidified gases, and endotracheal suctioning are discussed using research-based literature that evaluates the injury to the trachea and the mucociliary transport system.

Needlestick injuries among nursing staff: Association with shift-level staffing

BACKGROUND Despite the advent of safety measures to protect the health care workforce from contracting blood-borne diseases, nurses still sustain percutaneous injuries. We investigated the association between shift-level staffing and needlestick injuries. METHODS Shift-level staffing, patient occupancy, and acuity data were collected between 2003 and 2006 for the Military Nursing Outcomes Database (MilNOD), a multisite project that examined nurse staffing and adverse patient and nurse events. Data on needlestick injuries were obtained from occupational health/risk management reports and merged with MilNOD specific shift data. Hierarchical logistic regression, with Bayesian modeling, was used to analyze shift-level staffing, patient acuity, and workload as associated with needlestick injuries among nursing staff. RESULTS Of 108,000 shifts, 80 (<0.1%) had at least one needlestick injury occurrence, with 62 (78%) involving a contaminated needle. There was no difference in rate by unit type. Factors associated with needlestick occurrences on shifts were lower RN skill mix, a lower percentage of experienced staff, and fewer nursing care hours per patient per shift. CONCLUSION Needlestick injuries continue to occur. An organizational culture of safety should emphasize the need for adequate staffing on every shift and extra vigilance during periods of high workload.

Participation in a national nursing outcomes database: monitoring outcomes over time.

The current and future climates in health care require increased accountability of health care organizations for the quality of the care they provide. Never before in the history of health care in America has this focus on quality been so critical. The imperative to measure nursings impact without fully developed and tested monitoring systems is a critical issue for nurse executives and managers alike. This article describes a project to measure nursing structure, process, and outcomes in the military health system, the Military Nursing Outcomes Database project. Here we review the effectiveness of this project in monitoring changes over time, in satisfying expectations of nurse leaders in participating hospitals, and evaluate the potential budgetary impacts of such a system. We conclude that the Military Nursing Outcomes Database did meet the needs of a monitoring system that is sensitive to changes over time in outcomes, provides interpretable data for nurse leaders, and could result in cost benefits and patient care improvements in organizations.

Neonatal thermal care, part III: The effect of infant position and temperature probe placement.

Purpose: Accurate management of infant temperature requires appropriate placement of temperature monitoring probes. Currently, there is a lack of consensus regarding placement of skin temperature probes and the effect on temperature monitoring of the infant’s lying on the probe. The objective of this study was to compare abdomen and back skin temperatures when infants were positioned supine and prone. Design: A quasi-experimental design was used to randomize infants to prone or supine position. Infant back, abdomen, and axillary temperatures were measured at oneminute intervals with small disposable thermocouples over a one-hour period. Sample: Twenty-three infants, weight 820–2,400 gm, gestational age 27–37 weeks, postnatal age three to ten days. Main Outcome Variable: Gradient between abdomen and back temperature. Results: Both mean abdomen and mean back temperatures differed significantly by position (t-test, p = .003 and .028, respectively). Weight and postnatal age did not have an effect on the mean difference between abdomen and back temperature. Results indicate that probe placement and infant positioning are important factors altering measurement of skin temperature.

The Practice Environment Scale of the Nursing Work Index: An updated review and recommendations for use

OBJECTIVES The Practice Environment Scale of the Nursing Work Index (PES-NWI) is an instrument, which measures the nursing practice environment - defined as factors that enhance or attenuate a nurses ability to practice nursing skillfully and deliver high quality care. The purpose of this paper is to provide an updated review of the Practice Environment Scale of the Nursing Work Indexs use to date and provide recommendations that may be helpful to nursing leaders and researchers who plan to use this instrument. DESIGN A narrative review of quantitative studies. DATA SOURCES PubMed, EMBASE, and the Cumulative Index to Nursing & Allied Health Literature were searched to identify relevant literature using the search terms, Practice Environment Scale of the Nursing Work Index and PES-NWI. REVIEW METHODS Studies were included if they were published in English between 2010 and 2016 and focused on the relationship between the Practice Environment Scale of the Nursing Work Index and patient, nurse, or organizational outcomes. Data extraction focused on the reported survey scores and the significance and strength of the reported associations. RESULTS Forty-six articles, from 28 countries, were included in this review. The majority reported significant findings between the nursing practice environment and outcomes. Although some modifications have been made, the instrument has remained primarily unchanged since its development. Most often, the scores regarding staffing and resource adequacy remained the lowest. CONCLUSION The frequency of use of this instrument has remained high. Many researchers advocate for a move beyond the study of the connection between the Practice Environment Scale and nurse, patient, and organizational outcomes. Research should shift toward identifying interventions that improve the environment in which nurses practice and determining if changing the environment results in improved care quality.