Adult Acute Care Research Articles

Impact of multiplex respiratory virus testing on antimicrobial consumption in adults in acute care: a randomized clinical trial

ObjectivesInappropriate use of antibiotics is associated with development of antimicrobial resistance. In respiratory infections it is often difficult to differentiate between viral and bacterial infections, and empirical treatment is common. Enhanced viral testing is expected to clarify clinical decision-making and reduce the prescription of antibacterial agents, but the impact of such information on patient care is unclear. MethodsWe conducted a (1:1) randomized controlled clinical trial involving 998 adults with respiratory symptoms, fever, chest pain or poor general condition in the emergency unit of a tertiary hospital. Multiplex PCR results for 496 patients were available in 24 hours (intervention group) and those for the remaining 502 patients were available in 7 days (control group). Our primary outcome measures were the duration of hospitalization and the consumption of antibiotics within 30 days of enrolment. ResultsIn all, 841 of 998 (84%) patients had respiratory symptoms at study entry. A respiratory virus was detected in 175 (17.5%). The mean duration of hospitalization was 4.2 days (SD 5.4) in the intervention group and 4.1 days (SD 4.9) in the control group (difference 0.1, 95% CI –0.5 to 0.6, p 0.810). The mean days on antibiotics were 11.3 days (SD 12.6) in the intervention group and 10.4 days (SD 11.4) in the control group (difference 0.9, 95% CI –0.6 to 2.4, p 0.235). ConclusionsMultiplex PCR testing for respiratory viruses with results available within 24 hours did not reduce the consumption of bacterial antibiotics or the length of hospital stay in adults presenting with respiratory symptoms, fever, chest pain or reduced general condition in acute care.

Does Simulation Training for Acute Care Nurses Improve Patient Safety Outcomes: A Systematic Review to Inform Evidence-Based Practice.

Simulation is increasingly used as a training tool for acute care medical-surgical nurses to improve patient safety outcomes. A synthesis of the evidence is needed to describe the characteristics of research studies about acute care nurse simulation trainings and patient safety. An additional purpose is to examine the effects of acute care registered nurse (RN) simulation trainings on patient safety outcomes. Five Internet databases were searched for articles published on any date through October 2018 examining the effect of RN simulation trainings on patient safety outcomes in the adult acute care setting. N=12 articles represented 844 RNs of varying experience levels and 271 interprofessional participants. Nine studies (75%) used high-fidelity scenarios developed locally about high risk but infrequent events. Five studies (42%) incorporated interdisciplinary team members in the scenarios and/or outcome evaluations. Outcome measures were self-reported, direct observation, or clinical indicators. All studies in this review achieved improved patient safety outcomes. It is unknown how outcomes vary for different groups of RNs because of insufficient gender, ethnicity/race, and age reporting. Findings support the design of simulation training research studies for patient safety outcomes and use of simulation training and research in acute care RNs. Additional high-quality research is needed to support this field. Future studies should include descriptors that characterize the sample (i.e., age, gender, education level, type of nursing degree, ethnicity or race, or years of experience); incorporate interdisciplinary teams; evaluate a combination of outcome measure types (i.e., self-report, direct observation, and clinical outcomes) both proximal and distal to the simulation; and that utilize standardized scenarios, validated outcome measure instruments, and standardized debriefing tools.

Validation of the Presence of Nursing Scale Using Data Triangulation.

Nursing presence has been developed as a distinct concept with identifiable behaviors but remains only partially defined as a quantifiable construct. This study asked if the Presence of Nursing Scale (PONS) is a reliable and valid instrument to measure nursing presence from the patient's perspective. A convenience sample of 75 adult acute care inpatients were verbally administered the 25-item PONS considering the registered nurse taking care of them on the day of data collection. Open-ended questions elicited the patients' explanations of their ratings. They also rated their overall satisfaction with the nursing care provided by the subject nurse using a 5-point scale. The mean PONS score was 104.5 (SD = 17.26) on the 25-125 scale. Instrument reliability reported as a Cronbach's alpha coefficient of .95 was .94 in this study. Instrument validity was tested correlating PONS scores to the satisfaction rating. The Spearman's rho correlation was large and statistically significant, r (73) = .708. The higher the PONS score, the more satisfied the patient was with care from that nurse. Nineteen narratives selected from the lower quartile PONS scores (PONS < 99) and 11 from the upper quartile (PONS > 116) were thematically analyzed. Lower PONS scores corresponded with themes of patients being objectified as the work of the nurse without a respectful and caring nurse-patient relationship. Higher PONS scores coincided with patients' perceptions of enhanced nurse-patient rapport, feelings of better coping, and decreased anxiety. These results demonstrate reliability and validity of the PONS and add to the body of evidence about nurse behaviors exhibited in the nurse-patient relationship, which influence patients' feelings of being cared for and satisfied with nursing care. These findings may be useful in the development of educational materials aimed at the advancement of nursing presence competency.

The Restrictive IV Fluid Trial in Severe Sepsis and Septic Shock (RIFTS): A Randomized Pilot Study.

It is unclear if a low- or high-volume IV fluid resuscitation strategy is better for patients with severe sepsis and septic shock. Prospective randomized controlled trial. Two adult acute care hospitals within a single academic system. Patients with severe sepsis and septic shock admitted from the emergency department to the ICU from November 2016 to February 2018. Patients were randomly assigned to a restrictive IV fluid resuscitation strategy (≤ 60 mL/kg of IV fluid) or usual care for the first 72 hours of care. We enrolled 109 patients, of whom 55 were assigned to the restrictive resuscitation group and 54 to the usual care group. The restrictive group received significantly less resuscitative IV fluid than the usual care group (47.1 vs 61.1 mL/kg; p = 0.01) over 72 hours. By 30 days, there were 12 deaths (21.8%) in the restrictive group and 12 deaths (22.2%) in the usual care group (odds ratio, 1.02; 95% CI, 0.41-2.53). There were no differences between groups in the rate of new organ failure, hospital or ICU length of stay, or serious adverse events. This pilot study demonstrates that a restrictive resuscitation strategy can successfully reduce the amount of IV fluid administered to patients with severe sepsis and septic shock compared with usual care. Although limited by the sample size, we observed no increase in mortality, organ failure, or adverse events. These findings further support that a restrictive IV fluid strategy should be explored in a larger multicenter trial.

Student perceptions of the value they bring to APPE sites

IntroductionPartner institutions invest much time and effort into educating pharmacy students, and ideally students should be viewed as valuable to those sites. Prior studies have demonstrated the perceptions that preceptors and administrators have about the value of students at their sites. However, students' perceptions of their own value at practice sites have not been described. Students do have perceptions about their own value to sites, and such information could be useful in learning about potential areas in which students perceive they are making an impact on patient care. MethodsFive hundred qualitative student responses to an evaluation question regarding perceived value were analyzed from a United States pharmacy school. Nineteen categories of value were extracted. Responses fit into multiple categories, resulting in 783 data points for analysis. The categories were analyzed overall and with respect to advanced pharmacy practice experience (APPE) type (acute care, community, hospital, ambulatory care, and elective). Descriptive statistics were used. ResultsProviding patient counseling (15.7%) and therapeutic recommendations (14.7%) were the highest perceived values. In adult acute care and hospital APPEs, “providing therapeutic recommendations” (24.4% and 19.1% respectively) were rated highest. In community, ambulatory care, and elective APPEs, “providing patient counseling” (25%, 23%, and 13.8%, respectively) was highest rated. ConclusionsStudents perceive they are valuable to practice sites in several ways. These results demonstrate that students' self-reported perceptions of the value they bring to their sites are consistent with other literature reports based on perception of preceptors regarding student value to patient care.

Forecasting hospital pneumonia admissions using influenza surveillance, climate and community data

ObjectiveUsing the information that we have available, our primary objective is to explore if there was any cross-correlation between pneumonia admissions and hospital influenza positivity. We then aim to develop a data driven approach to forecast pneumonia admissions using data from our hospital’s weekly surveillance. We also attempted using external sources of information such as national infectious diseases notifications and climate data to see if they were useful for our model.IntroductionInfluenza peaks around June and December in Singapore every year. Facing an ageing population, hospitals in Singapore have been constantly reaching maximum bed occupancy. The ability to be able to make early decisions during peak periods is important. Tan Tock Seng Hospital is the second largest adult acute care general hospital in Singapore. Pneumonia-related emergency department (ED) admissions are a huge burden to the hospital's resources. The number of cases vary year on year as it depends on seasonal vaccine effectiveness and the population’s immunity to the circulating strain. While many pneumonia cases are of unknown origin, they tend to mirror the influenza seasons very closely.MethodsWe used data from epidemiological week (e-week) 1 of 2013 to e-week 34 of August 2017 to train our model, with the next 52 weeks (e-week of 35 of 2017 to e-week 34 of 2018 ) being used as validation cohort. Pneumonia and influenza data were obtained from our hospital’s weekly surveillance. National level acute upper respiratory illness (AURI) was obtained from Ministry of Health’s (MOH) weekly infectious diseases bulletin. Climate data were obtained from the National Environment Agency’s website. Daily rainfall, temperature and wind data from the S20 satellite station were used. Automatic autoregressive (A-ARIMA), non-seasonal and seasonal vector autoregressive models (VAR) were used to either analyse the univariate pneumonia trends or simultaneously model pneumonia, influenza, AURI notification and climatic data. Granger-causality tests were performed to check if these variables were causal of pneumonia admissions. As most of the seasonal variation are seen in older patients, stratified analysis were performed on those that were below and above 65 years old. Forecasts were calculated up to 3 weeks in advance. Mean absolute error (MAE), mean absolute percentage error (MAPE), and root mean squared error (RMSE) were used to validate the model performance. These performance metrics were applied on 3-week ahead forecasts comparing A-ARIMA, VAR, and seasonal-adjusted VAR.ResultsFigure 1 shows that both influenza and pneumonia admissions follow similar trends. We see that the number of influenza cases have reduced as compared to the previous years. The number hospital influenza cases and the number of AURI cases nationwide are strongly cross-correlated with pneumonia admissions. Granger-causality tests confirmed the directionality of the relationships (p &lt;0.01). Climate factors do not strongly affect the number of pneumonia admissions. (Fig 2) Unsurprisingly, the A-ARIMA model showed that the 1-day forecasts were most accurate (MAE: 7.0; MAPE: 12.7; RMSE: 8.7 for elderly subgroup). However, the 3-day ahead forecasts were only slightly less precise (MAE: 7.2 ; MAPE: 13.2; RMSE: 9 for elderly subgroup). Testing for significant lags using the various information criteria suggested that a lag3 model should be used. The non-seasonal and seasonal VAR models showed that historical pneumonia admissions and influenza positivity was the best model. The MAPE for all 3 models hovered between 12-13%, with the A-ARIMA model performing slightly better. This is not surprising as the A-ARIMA takes the latest information at hand to derive the best model. Accounting for seasonality allowed better precision as compared to the non-seasonal VAR but was not better as compared to the A-ARIMA model.ConclusionsHospital surveillance data are the most useful for developing forecast models for hospital pneumonia admissions. Climate data were likely not to be useful as Singapore does not experience much variaton in weather throughout the year. Pneumonia peaks do not follow necessarily fall on the same week every season. Therefore, both the autoregressive and seasonal-adjusted vector autoregressive models can be useful complements to each other for forecasting pneumonia admissions.

Ventilators for Noninvasive Ventilation in Adult Acute Care.

The use of noninvasive ventilation (NIV) is common in adult acute care. As evidence to support the use of NIV has developed, there has been a concurrent proliferation of NIV technology. Efforts have been made to improve patient-ventilator synchrony, monitoring capabilities, and portability of devices used to deliver NIV. The technological enhancements provide clinicians with myriad modes, settings, and capabilities designed to improve patient adherence with NIV. Although this technology is generally superior to that of the past, a great deal of variation exists between devices. Clinicians need to be accustomed to the devices available to them to maximize the potential for clinical improvement and patient tolerance. The purpose of this paper is to review current technology, current literature comparing devices, and various clinical considerations associated with NIV use in adult acute care.

Validation of Early Warning Scores at Two Long-Term Acute Care Hospitals

Early warning scores were developed to identify high-risk patients on the hospital wards. Research on early warning scores has focused on patients in short-term acute care hospitals, but there are other settings, such as long-term acute care hospitals, where these tools could be useful. However, the accuracy of early warning scores in long-term acute care hospitals is unknown. Observational cohort study. Two long-term acute care hospitals in Illinois from January 2002 to September 2017. Admitted adult long-term acute care hospital patients. None. Demographic characteristics, vital signs, laboratory values, nursing flowsheet data, and outcomes data were collected from the electronic health record. The accuracy of individual variables, the Modified Early Warning Score, the National Early Warning Score version 2, and our previously developed electronic Cardiac Arrest Risk Triage score were compared for predicting the need for acute hospital transfer or death using the area under the receiver operating characteristic curve. A total of 12,497 patient admissions were included, with 3,550 experiencing the composite outcome. The median age was 65 (interquartile range, 54-74), 46% were female, and the median length of stay in the long-term acute care hospital was 27 days (interquartile range, 17-40 d), with an 8% in-hospital mortality. Laboratory values were the best predictors, with blood urea nitrogen being the most accurate (area under the receiver operating characteristic curve, 0.63) followed by albumin, bilirubin, and WBC count (area under the receiver operating characteristic curve, 0.61). Systolic blood pressure was the most accurate vital sign (area under the receiver operating characteristic curve, 0.60). Electronic Cardiac Arrest Risk Triage (area under the receiver operating characteristic curve, 0.72) was significantly more accurate than National Early Warning Score version 2 (area under the receiver operating characteristic curve, 0.66) and Modified Early Warning Score (area under the receiver operating characteristic curve, 0.65; p < 0.01 for all pairwise comparisons). In this retrospective cohort study, we found that the electronic Cardiac Arrest Risk Triage score was significantly more accurate than Modified Early Warning Score and National Early Warning Score version 2 for predicting acute hospital transfer and mortality. Because laboratory values were more predictive than vital signs and the average length of stay in an long-term acute care hospital is much longer than short-term acute hospitals, developing a score specific to the long-term acute care hospital population would likely further improve accuracy, thus allowing earlier identification of high-risk patients for potentially life-saving interventions.

Nasal high flow: physiology, efficacy and safety in the acute care setting, a narrative review.

Nasal high flow (NHF) is a promising novel oxygen delivery device, whose mechanisms of action offer some beneficial effects over conventional oxygen systems. It is considered to have a number of physiological effects: it improves oxygenation, dynamic lung compliance, homogeneity and end expiratory lung volume; it decreases anatomical dead space and generates a positive airway pressure that can reduce respiratory rate, the work of breathing, and enhance patient comfort. NHF has been used as a prophylactic tool or as a treatment device mostly in patients with acute hypoxemic respiratory failure such as pre-oxygenation before intubation, immunocompromised patients and acute heart failure. Moreover, there is some evidence that NHF could be used during procedural sedation. Finally, NHF was deemed to be effective in chronic obstructive pulmonary disease patients with its positive end expiratory pressure effects and dead-space washout. However, careful monitoring is crucial to maximize NHF settings aimed at maximizing patient comfort while limiting the risk of delayed intubation. The present review presents the most updated evidence for NHF use in the adult acute care setting with the goal of providing clinicians with useful insights on the physiologic effects, main clinical indications, and safety issues of NHF treatment.

Nursing Education Program for Hospital-Acquired Pressure Injury Prevention in Adult Acute Care Setting: A Quality Improvement Project.

The purpose of this Quality Improvement project was to develop a multimedia hospital-acquired pressure injury (HAPI) prevention education program. The project setting was 3 adult critical care units plus a step-down unit located in the Mid-Atlantic region of the United States. A multimedia educational intervention was developed, which comprised 4 modules designed to improve nursing knowledge and competency in HAPI prevention. A posteducation program staff survey was also administered to evaluate nurse satisfaction with the program. Nurse knowledge of HAPI prevention was measured before and following implementation of the educational intervention. One hundred twenty-nine participants completed the education program, and 117 completed the satisfaction survey. Analysis revealed a statistically significant increase in knowledge after the education course (P < .05). Findings also indicated participants were satisfied that the program met stated aims.

The experience of person‐centred practice in a 100% single‐room environment in acute care settings—A narrative literature review

To review published research into the staff and adult patient experience of person-centred practice in a 100% single-room environment in acute care. There has been a significant move towards the 100% single-room environment within healthcare systems. Furthermore, there has been a global move for developing person-centred practice in a range of healthcare settings. Some studies have linked the role of the physical environment to patient outcomes and improved patient satisfaction; however, these are limited. Overall, there is little evidence in the international literature of the experience of care in single rooms in adult, acute care settings. A narrative description was developed using the major constructs of the person-centred practice framework (PcPF). The PRISMA checklist provided additional rigour. Problems, Exposure, Outcomes (PEO) refined the search terms to: person-centred, adult acute care, single room, staff experience and patient experience. CINAHL, Medline Ovid, Psycinfo, Embase, Web of Science and Scopus were searched for full-text English language papers of empirical studies published between 2012-2017. PRISMA illustrated final paper determination, and the CASP/EPHPP frameworks were used for a critical appraisal of the 12 selected papers. The literature recognises the increasing complexity of health care in the acute care environment globally. The international literature available identifies staffs' desire to practise person-centredness, but much of the evidence is focused on care delivery. The impact of the single-room environment on person-centred practice links mainly to the constructs of the care environment and person-centred processes within the PcPF. This review focuses on empirical studies relating to person-centred practice in the single-room environment published in the last 5years. While there is a significant body of work relating to person-centredness and the delivery of person-centred practice, and the impact of the environment on care delivery, there appears to limited evidence linking person-centred practice, staff and patient experience and the single-room environment. By understanding the context in which care is delivered, multiprofessional teams can explore how the delivery of person-centred practice may be influenced by the physical environment and what changes to culture, systems and processes may be required to enhance the experience of care for patients and the delivery of care for staff.

Incidence and Current Treatment Gaps in Pediatric Stroke and TIA: An Ontario-Wide Population-Based Study

Background: Reported incidence rates of pediatric stroke and transient ischemic attack (TIA) range widely. Treatment gaps are poorly characterized. We sought to evaluate in ­Ontario, the incidence and characteristics of pediatric stroke and TIA including care gaps and the predictive value of International Classification of Diseases (ICD) codes. Methods: A retrospective chart review was conducted at 147 Ontario pediatric and adult acute care hospitals. Pediatric stroke and TIA cases (age < 18 years) were identified using ICD-10 code searches in the 2010/11 Canadian Institute for Health Information’s Discharge Database (CIHI-DAD) and National Ambulatory Care Reporting System (NACRS) databases in the Ontario Stroke Audit. Results: Among 478 potential pediatric stroke and TIA cases identified in the CIHI-DAD and NACRS databases, 163 were confirmed as cases of stroke and TIA during the 1-year study period. The Ontario stroke and TIA incidence rate was 5.9 per 100,000 children (3.3 ischemic, 1.8 hemorrhagic and 0.8 TIA). Mean age was 6.4 years (16% neonate). Nearly half were not imaged within 24 h of arrival in emergency and only 56% were given antithrombotic treatment. At discharge, 83 out of 121 (69%) required health care services post-discharge. Overall positive predictive value (PPV) of ICD-10 stroke and TIA codes was 31% (range 5–74%) and yield ranged from 2.4 to 29% for acute stroke or TIA event; code I63 achieved maximal PPV and yield. Conclusion: Our population-based study yielded a higher incidence rate than prior North-American studies. Important care gaps exist including delayed diagnosis, lack of expert care, and departure from published treatment guidelines. Variability in ICD PPV and yield underlines the need for prospective data collection and for improving the pediatric stroke and TIA coding processes.

"That Can't Be!": Perceptions of HIV and Hepatitis C Screening during Admission to an Acute Care Surgery Service.

Background:A large number of patients live with undiagnosed HIV and/or hepatitis C despite broadened national screening guidelines. European studies, however, suggest many patients falsely believe they have been screened during a prior hospitalization. This study aims to define current perceptions among trauma and emergency general surgery (EGS) patients regarding HIV and hepatitis C screening practices.Methods:Prospective survey administered to adult (>18 years old) acute care surgery service (trauma and EGS) patients at a Level 1 academic trauma center. The survey consisted of 13 multiple choice questions: demographics, whether admission tests included HIV and hepatitis C at index and prior hospital visits and whether receiving no result indicated a negative result, prior primary care screening. Response percentages calculated in standard fashion.Results:One hundred and twenty-five patients were surveyed: 80 trauma and 45 EGS patients. Overall, 32% and 29.6% of patients believed they were screened for HIV and hepatitis C at admission. There was no significant difference in beliefs between trauma and EGS. Sixty-eight percent of patients had a hospital visit within 10 years of these, 49.3% and 44.1% believe they had been screened for HIV and hepatitis C. More EGS patients believed they had a prior screen for both conditions. Among patients who believed they had a prior screen and did not receive any results, 75.9% (HIV) and 80.8% (hepatitis C) believed a lack of results meant they were negative. Only 28.9% and 23.6% of patients had ever been offered outpatient HIV and hepatitis C screening.Conclusions:A large portion of patients believe they received admission or prior hospitalization HIV and/or hepatitis C screening and the majority interpreted a lack of results as a negative diagnosis. Due to these factors, routine screening of trauma/EGS patients should be considered to conform to patient expectations and national guidelines, increase diagnosis and referral for medical management, and decrease disease transmission.

Patient and family members' perceptions of family participation in care on acute care wards.

Hospital leaders, policymakers and healthcare professionals are realising the benefits of delivering care that promotes family participation because it is known to enhance the quality of care, and improve patient satisfaction. The aim of this study was to explore, from the perspective of patients and family members within an adult acute care ward: (a) their beliefs and attitudes towards family participation in patient care and (b) staff behaviours that support or hinder family participation in patient care. A naturalistic approach with an exploratory sequential design was used in a medical assessment and planning unit of a regional referral hospital in Australia. Purposeful maximum variation sampling was used to recruit patients and family members who differed in age, ethnicity, relationship to patient and gender. Observer-as-participant observation data and semi-structured interviews were undertaken. Following separate inductive content analysis, data were triangulated. Thirty-two patients and 26 family members were recruited. Thirty hours of observational data were gathered. Eighteen patients and 15 family members were interviewed. Analysis uncovered two contrasting categories: (a) disconnected communication and (b) family influence quality. The findings of our study demonstrated that most patients and families perceived staff communication as disconnected and inadequate, which constrained them from engaging in care processes or decision-making. However, when family felt empowered and participated in patient care, the quality of health care was enhanced. Healthcare professionals can use these findings to make informed evidence-based changes to the way they practice and communicate to ensure family participation in patient care is optimised in the acute care setting.

Quantitative comparison of group-based music therapy experiences in an acute care adult mental health setting: A four-group cluster-randomized study

ABSTRACTIntroduction: Acute care mental health inpatients have the expertise to evaluate different group-based music therapy interventions. Moreover, from an objectivist worldview, there is a need for data concerning non-symptom measures that are specific to group-based music therapy experiences using randomized designs. The purpose of this posttest-only study is to compare how adult acute care mental health inpatients rated group experiences of three different types of educational music therapy for illness management and recovery (EMT-IMR) interventions and a recreational music therapy (RMT) intervention.Methods: Participants (N = 91) were cluster-randomized to one of four single-session group-based conditions: EMT-IMR-songwriting, EMT-IMR-lyric analysis, EMT-IMR-social story, or RMT-music therapy game.Results: There were significant between-group differences concerning RMT and EMT-IMR (both lyric analysis and songwriting conditions) in the sharing of emotions and experiences subscale. Participants in the EMT-IMR conditions rated this subscale higher than participants in the RMT condition. Although no other difference was significant, descriptive statistics tended to favor the three EMT-IMR conditions. Group experiences descriptive data from people in community mental health services from a previous study were also compared with data collected in the current study. Results indicated tendencies for the three EMT-IMR conditions to have slightly higher mean group experiences scores across all subscales than participants in the non-music therapy community mental health services condition.Discussion: Specifically targeting illness management and recovery via EMT-IMR may be practical, effective, and constitute an ideal model within acute care mental health facilities. Limitations, suggestions for future inquiry, and implications for clinical practice are provided.

Case-Based PowerPoint to Improve Knowledge and Comfort of Having Code Status Discussions by Physician Assistant and Nurse Practitioner Students.

Little is known about how certain educational interventions may improve informed code status discussions by physician assistant (PA) and nurse practitioner students. This is a prospective, prospective, single academic center pilot study utilizing a short case-based PowerPoint that reviewed the differences between code status choices and the likelihood of survival to hospital discharge of attempted resuscitation after a cardiac arrest. Training occurred between September 1, 2017, and May 31, 2018. The study population included PA and adult gerontology acute care nurse practitioner (AGACNP) students during their inpatient internal medicine rotation (n = 9) and preclinical PA students (n = 5). After training, there was a significant increase in knowledge in the likelihood of survival to hospital discharge (P = .01) and comfort level in having an informed code status discussion (3.36 ± 0.81 vs 4.10 ± 0.80, P = .02). For questions related to identification of the correct code status, there were no significant differences before and after the intervention. A short case-based PowerPoint viewed by PA and AGACNP students increased the knowledge about the likelihood of survival to hospital discharge of attempted resuscitation after a cardiac arrest and increased the comfort level of having code status discussions with patients by PA and AGACNP students.

Adult Gerontology Acute Care Nurse Practitioner Student and Prelicensure Registered Nurse Student Perceptions of Intradisciplinary, High-Fidelity Rapid Response Team Simulations

BackgroundAdult gerontology acute care nurse practitioner (AGACNP) students and prelicensure registered nurse (RN) students rarely have the opportunity to actively participate in the management of acutely decompensating patients during inpatient clinical rotations. However, upon completion of their academic programs, these two groups will frequently interact in the hospital setting when managing acutely ill patients. This combined lack of hands-on experience and failure to practice team interactions may contribute to impaired intradisciplinary collaboration, delayed utilization of the organizational rapid response team (RRT), and adverse patient outcomes. MethodsAGACNP and RN students were presented with high-fidelity simulation experiences in which they worked collaboratively to stabilize and manage acutely ill patients after RRT activation. Following debriefing after the simulation experience, AGACNP and RN students were provided with an optional pen and paper survey that measured their perceptions of the experience on a five-point Likert scale. ResultsThe survey data support that the RRT simulation experience provided AGACNP students with the opportunity to lead and collaborate with intradisciplinary team members in stressful situations and reinforced their views that detailed communication and a cohesive team is critical in the management of acutely ill patients. The experience assisted RN students in identifying criteria for RRT activation, practicing communication skills with intradisciplinary health care team members, working collaboratively as part of an intradisciplinary team, and recognizing areas for improvement in communication. ConclusionsAGACNP and RN students perceive intradisciplinary, high-fidelity simulation to be a valuable form of preparation in the management of acutely ill patients requiring RRT activation.

Evaluating Prescribing Competence in Nurse Practitioner Fellowship and Residency Programs

A prepiloted electronic survey sent to all nurse practitioner postgraduate residency/fellowship programs in Washington State asked participants to identify how practicums evaluate prescribing-specific functions. Of the 8 respondents (66.7% response rate), most accept new or recent graduates without the need for reentry or remediation of their license. Clinical focus for participants includes family practice (62%), adult internal medicine (37%), pediatrics (25%), or acute care inpatient (25%). Most do not use competency-based assessment. No program offers current content in authorizing medical marijuana. Additional content is advised to align with national recommendations regarding routine screening for drug and alcohol misuse.

Family Caregivers' Experiences of Within-Hospital Handoffs for Older Adults in Acute Care.

Family caregivers' experiences during within-hospital handoffs between acute care units are not well understood. Qualitative description methodology was employed to describe family caregivers' experiences during their loved ones' handoffs. Semistructured interviews were conducted with 10 caregivers of hospitalized older adults. Three themes emerged: Lack of care coordination, Muddling through handoffs alone, and Wariness toward the care delivery system. Findings can help clinicians shape their interactions with caregivers to maximize their involvement in post-hospital care.

Pilot Study to Evaluate the Safety, Feasibility, and Financial Implications of a Postoperative Telemedicine Program.

Telemedicine in surgery holds promise for improving access and decreasing costs, but its role remains ill-defined. This pilot study was performed to investigate the safety, feasibility, and financial implications of providing postoperative care using an electronic clinic (eClinic) at a university hospital. An easy-to-use and secure eClinic platform was constructed in Epic (Epic Systems Corporation, Verona, WA). Patients undergoing laparoscopic cholecystectomy, appendectomy, and hernia repairs on an adult acute care surgery service were enrolled in this program over an 11-month period (March 2017 to January 2018). Patients with prolonged hospitalizations (greater than 4 nights), perioperative complications, drains, and open wounds were excluded. Demographics, clinical outcomes, encounter time, patient satisfaction survey results, and cost analysis were compared with the traditional clinic (tClinic) patient population. Two hundred thirty-three eligible patients (61% female; mean age 41 ± 16 years) were enrolled in this program. Their demographics were no different than the tClinic. Frequencies of readmission, reoperation, and emergency department visits (2.7%, 0%, and 4.2%, respectively) in the eClinic group were also similar to the tClinic group. However, total visit time was significantly shorter in the eClinic group (14 vs 145 minutes, P < 0.01). Anonymous surveys demonstrated a high degree of satisfaction, with 85% of patients expressing desire to utilize the eClinic again. This program enhanced the capacity for new visits to tClinic, with a resultant projected increase in additional operative cases and revenue for the health care system. A safe and efficient postoperative telemedicine program can be constructed utilizing a widely available electronic medical record system, which can improve patient satisfaction, optimize throughput, and increase gross charges for the healthcare system.