Mary Terhaar

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

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.

The Preparation–Practice Gap: An Integrative Literature Review

BACKGROUND The purpose of this integrative literature review was to evaluate and synthesize the evidence regarding the existence, extent, and significance of a preparation-practice gap-namely, the deficits in knowledge and skills that novice nurses may demonstrate on entry into the clinical setting and the identified best practices to narrow this gap. METHOD An integrative literature review was performed. RESULTS A final set of 50 articles were included in the review. Three main themes permeate the evidence: a preparation-practice gap exists; this gap is costly; and closing the preparation-practice gap will likely rely on changes in undergraduate education and on-the-job remediation (i.e., nurse residency or preceptor programs). CONCLUSIONS The preparation-practice gap is a challenge that has faced the nursing profession for years. Efforts to close this gap can be justified on the hopes of decreasing turnover (and its attendant costs), boosting morale of novice nurses and their preceptors, decreasing stress among the novice nurses, and improving patient safety.

Scholarly work products of the doctor of nursing practice: one approach to evaluating scholarship, rigour, impact and quality

AIMS AND OBJECTIVES The aim of this investigation was to evaluate, monitor and manage the quality of projects conducted and work produced as evidence of scholarship upon completion of Doctor of Nursing Practice education. BACKGROUND The Doctor of Nursing Practice is a relatively new degree which prepares nurses for high impact careers in diverse practice settings around the globe. Considerable variation characterises curricula across schools preparing Doctors of Nursing Practice. Accreditation assures curricula are focused on attainment of the Doctor of Nursing Practice essentials, yet outcomes have not been reported to help educators engage in programme improvement. This work has implications for nursing globally because translating strong evidence into practice is key to improving outcomes in direct care, leadership, management and education. The Doctor of Nursing Practice student learns to accomplish translation through the conduct of projects. Evaluating the rigour and results of these projects is essential to improving the quality, safety and efficacy of translation, improvements in care and overall system performance. DESIGN A descriptive study was conducted to evaluate the scholarly products of Doctor of Nursing Practice education in one programme across four graduating classes. METHODS A total of 80 projects, conducted across the USA and around the globe, are described using a modification of the Uncertainty, Pace, Complexity Model. RESULTS The per cent of students considered to have produced high quality work in relation to target expectations as well as the per cent that conducted means testing increased over the four study years. CONCLUSIONS Evaluation of scope, complexity and rigour of scholarly work products has driven improvements in the curriculum and informed the work of faculty and advisors. RELEVANCE TO CLINICAL PRACTICE Methods, evaluation and outcomes conformed around a set of expectations for scholarship and rigour have resulted in measurable outcomes, and quality publications have increased over time.

A systematic approach incorporating family history improves identification of cardiovascular disease risk.

Background:Although family history (FH) is an independent predictor of cardiovascular disease (CVD) risk, traditional risk scores do not incorporate FH. Nurse practitioners routinely solicit FH but have no mechanism to incorporate the information into risk estimation. Underestimation of risk leaves clinicians misinformed and patients vulnerable to the CVD epidemic. Objective:We examined a systematic approach incorporating FH in CVD risk assessment, validating risk reclassification using carotid intima-media thickness (CIMT), a surrogate measure of atherosclerosis. Methods:Of 413 consecutive patients prospectively enrolled in the Integrative Cardiac Health Project Registry, a subgroup of 239 was low or intermediate risk by the Framingham Risk Score. A systematic approach for the assessment of FH was applied to this subgroup of the registry. A positive FH for premature CVD, defined as a first-degree relative having a CVD event before the age of 55 years in men and 65 years in women, conferred reclassification to high risk. Reclassification was validated with CIMT results. Results:Chart audits revealed adherence to the systematic approach for FH assessment in 100% of cases. This systematic approach identified 115 of 239 (48%) patients as high risk because of positive FH. Of the reclassified patients, 75% had evidence of subclinical atherosclerosis by CIMT versus 55% in the patients not reclassified, P < 0.001. Logistic regression identified positive FH for premature CVD (odds ratio, 2.6; P = 0.001) among all variables, as the most significant predictor of abnormal CIMT, thus increasing risk for CVD. Conclusions:The Integrative Cardiac Health Project systematic approach incorporating FH into risk stratification enhances CVD risk assessment by identifying previously unrecognized high-risk patients, reduces variability in practice, and appropriately targets more stringent therapeutic goals for prevention.

Using dashboard technology and clinical decision support systems to improve heart team efficiency and accuracy: Review of the literature

AIM This review aimed to provide a comprehensive overview of the current state of evidence for the use of clinical dashboards and clinical decision support systems (CDSS) in multidisciplinary teams. METHODS A literature search was performed for the dates 2004-2014 on CINAHL, Medline, Embase, and Cochrane Library. A citation search and a hand search of relevant papers were also conducted. RESULTS (One hundred and twelve full text papers were retrieved of which 22 were included in the review.) There was considerable heterogeneity in setting, users, and indicators utilized. Information on usability and human-computer interaction was thoroughly reviewed. There was evidence that dashboards were associated with improved care processes when end-user input was incorporated and information was concurrent, pertinent and intuitive. CONCLUSION There is some evidence that implementing clinical dashboards and/or CDSS that provide immediate access to current patient information for clinicians can improve processes and patient outcomes.

The Doctor of Nursing Practice: From Start-Up to Impact

AIMThis article reflects on the progress of the doctor of nursing practice (DNP) degree and its place in health care. BACKGROUNDThe DNP originated over 10 years ago, long enough for a comprehensive evaluation. METHODRogers’ Diffusion of Innovation Theory is used to trace the history of the DNP. Nurse leaders from service and academia (n = 120) share strategies and innovations, and evaluate DNP education with a focus on outcomes and impact. RESULTSAs schools of nursing target DNPs to become faculty to mitigate the shortage, participants agreed it is time to focus on graduating strong leaders prepared to transform health care. CONCLUSIONA growing number of nurses practicing in diverse roles have earned the DNP from programs that vary considerably in rigor. Demand for the competencies, skills, and experience which DNPs bring to practice is high as organizations adapt to the accountable care environment.

Flying Lessons for Clinicians: Developing System 2 Practice

There is a long history of adopting lessons learned from aviation to improve health care practice. Two of the major practices that have successfully transferred include using a checklist and simulation. Training and simulation technology is currently underdeveloped for nurses and health care providers entering critical care transport. This article describes a pedagogical approach adopted from aviation to develop a new simulation platform and program of research to develop the science of critical care transport nursing education.

Using clinical decision support and dashboard technology to improve heart team efficiency and accuracy in a transcatheter aortic valve implantation (TAVI) program

Heart Team meetings are becoming the model of care for patients undergoing transcatheter aortic valve implantations (TAVI) worldwide. While Heart Teams have potential to improve the quality of patient care, the volume of patient data processed during the meeting is large, variable, and comes from different sources. Thus, consolidation is difficult. Also, meetings impose substantial time constraints on the members and financial pressure on the institution. We describe a clinical decision support system (CDSS) designed to assist the experts in treatment selection decisions in the Heart Team. Development of the algorithms and visualization strategy required a multifaceted approach and end-user involvement. An innovative feature is its ability to utilize algorithms to consolidate data and provide clinically useful information to inform the treatment decision. The data are integrated using algorithms and rule-based alert systems to improve efficiency, accuracy, and usability. Future research should focus on determining if this CDSS improves patient selection and patient outcomes.