Adult Inpatient Units Research Articles

COVID-19 Pandemic Increases in Nursing-Sensitive Quality Indicators.

The pandemic profoundly stressed practicing nurses and could have thereby affected trends in nursing-sensitive quality indicators (NSIs), measures that detect changes in patient health status directly affected by nursing care. The aim of the study was to determine if NSIs have worsened in response to the pandemic and then returned to prepandemic levels using data from 2019 through 2022. We conducted a cross-sectional descriptive study of annual trends, examining unit data from the National Database of Nursing Quality Indicators (NDNQI) from 2019 through 2022 for five indicators: rates of falls, central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), hospital-acquired pressure injuries (HAPI), and ventilator-associated events (VAE). The NDNQI is the largest repository of nursing quality indicators, which are derived from patient-level events, reported at the nursing unit level, and submitted quarterly by over 2,000 member hospitals. Adult medical-surgical or critical care inpatient nursing units with complete data for the 4 years were included, with samples ranging from 456 to 5,818 nursing units in 2,346 hospitals. Analysis of variance was conducted by comparing the 2019 rates to each subsequent year. In decreasing order of prevalence, the mean prepandemic rates were 6.58 VAE per 1,000 ventilator days (critical care only), 2.41 HAPI per 1,000 device days, 2.20 falls per 1,000 patient days, 0.96 CAUTI per 1,000 catheter days, and 0.68 CLABSI per 1,000 central line days for medical-surgical and critical care units combined. The rates for all five nurse-sensitive indicators increased significantly beginning in 2020 and have begun to decline but have not returned to baseline by 2022. The maximum rate was observed in 2020 for falls and 2021 for the remaining indicators. These increases to the maximum ranged from a 12% increase in CAUTI to 49% for CLABSI. NSIs increased during the pandemic and are now returning to baseline. The pandemic underscored the importance of nursing practice. The pandemic's enduring negative effects on the nursing workforce must be addressed to preserve patient safety.

Family resilience experiences of individuals with schizophrenia-family caregivers dyads: Qualitative study.

INTRODUCTION: Family resilience is one of the important concepts that should be addressed in chronic mental illnesses. This study was aimed at investigating family resilience experiences from the perspective of individuals diagnosed with schizophrenia-family caregiver dyads. The study was conducted in the Adult Psychiatry inpatient and outpatient unit of a university hospital in a province in western Turkey using the phenomenological method. By using the purposeful sampling method, 20 participants were selected in the study. Of them, 10 were family caregivers and 10 were patients diagnosed with schizophrenia. The results of the study were analysed with a dyadic approach within the framework of key processes of Walsh family resilience model. The directed content analysis method was used to analyse the data obtained from the study. COREQ checklist was used to report the research. After the analysis, the following five main themes emerged: positive cognitions, routines, family support, intra-family communication and love as a healing force. Family resilience is a structure shaped by the relationship between family members. The factors that contribute to the individual diagnosed with schizophrenia-caregiver dyads' ability to overcome difficulties in family resilience are discussed in line with the relevant literature. Intervention programs should be implemented to create an environment of love by improving relationships and communication in the family, improving problem solving and increasing support resources.

Comparison of intramuscular haloperidol and other short-acting injectable antipsychotics for management of acute agitation in an adult inpatient psychiatry unit.

There is no consensus on the optimal antipsychotic for acute agitation. Whereas haloperidol is frequently used and has proven efficacy, second generation antipsychotics show similar efficacy and improved safety and tolerability. This study aimed to determine the effectiveness of short-acting intramuscular (IM) haloperidol versus other IM antipsychotics for acute agitation in adults admitted to an inpatient psychiatry unit. This was a retrospective medical record review of patients who received 1 or more doses of a short-acting IM antipsychotic, including chlorpromazine, haloperidol, olanzapine, or ziprasidone. The primary endpoint was the need for subsequent IM antipsychotic(s) or physical restraint within 2 hours of the initial IM antipsychotic. Secondary endpoints assessed outcomes at 24 hours and adverse events. One hundred six patients were included. Four patients in the haloperidol group and 0 patients in the other antipsychotic group received an additional IM antipsychotic or required physical restraints within 2 hours (5.3% versus 0%, p = .319). More patients in the other antipsychotic group required an additional dose of IM antipsychotic within 24 hours compared with the haloperidol group (p = .0096). More adverse events were seen in patients who received haloperidol. Haloperidol was used more frequently than other short-acting IM antipsychotics. Whereas the effectiveness at 2 hours was not significantly different between groups, patients who received haloperidol were more likely to experience adverse events and were more often subjected to polypharmacy with benzodiazepines and/or diphenhydramine. This study further supports the use of olanzapine and ziprasidone for acute agitation in patients hospitalized in inpatient psychiatry.

Variations in definitions used for describing restrictive care practices (seclusion and restraint) in adult mental health inpatient units: a systematic review and content analysis.

The main purpose of this review was to (1) identify thematic elements within definitions used by recently published literature to describe the constructs of physical/mechanical restraint, seclusion and chemical restraint in adult mental health inpatient units. We conducted a comprehensive literature search of six databases (Scopus, MEDLINE, PsycINFO, Web of Science, Embase, and CINAHL-Plus). In this review, we conducted content analysis to synthesize evidence to understand and compare the commonalities and discrepancies in conceptual elements that were incorporated within the definitions of different forms of restrictive care practices. A total of 95 studies that provided definitions for different forms of restrictive care practices [physical/mechanical restraint (n = 72), seclusion (n = 65) and chemical restraint (n = 19)] were included in this review. Significant variations existed in the conceptual domains presented within the applied definitions of physical/mechanical restraint, seclusion, and chemical restraint. Conceptual themes identified in this review were methods of restrictive care practice, reasons and desired outcomes, the extent of patient restriction during restrictive care practice episodes, timing (duration, frequency, and time of the day), the level of patient autonomy, and the personnel implementing these practices. Inconsistencies in the terminologies and conceptual boundaries used to describe the constructs of different forms of restrictive care practices underscore the need to move forward in endorsing consensus definitions that reflect the diverse perspectives, ensuring clarity and consistency in practice and research. This will assist in validly measuring and comparing the actual trends of restrictive care practice use across different healthcare institutions and jurisdictions.

Decreasing Premedication for Blood Transfusions: A Quality Improvement Project.

Premedication administration to patients who are to receive blood transfusions continues despite evidence of a lack of benefit when given to prevent febrile nonhemolytic or mild allergic transfusion reactions. Reviews of ordering practices and staff surveys on an adult inpatient hematology-oncology unit in our multisite oncology medical center indicated a lack of standardization and overuse of premedication in blood transfusions and a lack of knowledge of when it was appropriate to use premedication. A literature search was performed, and the evidence led to a proposal for a quality improvement (QI) project focused on development of an evidence-based algorithm to guide clinicians in when to administer which premedication, development of clear documentation for premedication plans, integration of the documented premedication plans into electronic orders for blood products, and staff education. Interventions included a hospital-wide algorithm and an electronic order to be integrated with a premedication plan for each patient on the adult hematology-oncology unit. Seven months after implementation of the intervention, premedication use among patients decreased by 57.6%, and the transfusion reaction rate decreased from 1% to 0.8%. Staff knowledge as measured by responses to pre- and postintervention surveys on the appropriate use of premedication also improved. Evidence-based interventions can reduce the incidence of premedication use in patients receiving blood transfusions.

QAPI 113 - A Comprehensive infection control response to a norovirus outbreak on an adult inpatient hematologic oncology and clinical trials unit

QAPI 113 - A Comprehensive infection control response to a norovirus outbreak on an adult inpatient hematologic oncology and clinical trials unit

‘Walk a Mile in My Shoes’: stories of recovery in art therapy

ABSTRACT Background The ‘Walk a Mile in My Shoes’ (Shoes) art therapy approach was developed as part of substance use treatment during the COVID-19 pandemic to give patients a platform where their stories could be told and shared. This paper describes this directive approach. Case examples explore the importance of addressing loneliness, acceptance and attachment, while fostering connection to a supportive community. Context Shoes was facilitated at an adult inpatient substance use rehabilitation unit and was available to all patients, upon request. Approach The Shoes approach is underpinned by a theoretical framework including attachment theory alongside theories relating touch and trauma recovery in art therapy. Outcomes The people who used the Shoes service fed back that they experienced a sense of acceptance and support and connection to a supportive community. Conclusions The Shoes project goals and outcomes align with similar treatment perspectives, focusing on self-acceptance and connection to a supportive community. Attachment, empathy and acceptance were expressed between the therapist and client, through the use of touch, proximity, and co-creation. Peers on the unit reinforced and validated connection and acceptance by interacting with Shoes. Implications for research Further research warranted includes: impact of touch and proximity in art therapy across cultures; long-term outcomes on motivation and connection; impact of therapist–client demographics on attachment and treatment outcomes; adaptability of project.

143. Self-Reported Quality of Interpersonal Relationships and Its Overlap With Psychopathology in Adult Inpatient Psychiatric Units

143. Self-Reported Quality of Interpersonal Relationships and Its Overlap With Psychopathology in Adult Inpatient Psychiatric Units

Implementing an Evidence-Based Functional Pain Assessment Scale in an Adult Inpatient Unit

BackgroundThe focus on pain assessment using a single, one-dimension pain assessment scale can be problematic. Locally, challenges we faced with this were; a) pain was percieved as not being effectively managed, b) patients with chronic pain were not having their pain adequately controlled, and c) misconceptions and subsequent confusion between health care teams and patients related to what pain intensity scores mean to each individual. AimsThe purpose of this paper is to describe an evidence-based practice project aiming at improving pain assessment through the implementation of a Functional Pain Scale (FPS) on an adult inpatient cardiothoracic unit. DesignThe Iowa Model-Revised and the Implementation Strategies for Evidence- Based Practice Guide served as the framework for this project. SettingOver an 18-month period at a academic tertiary medical center in the midwest. Participants/SubjectsStaff and patients on an adult inpatient 48-bed medical and surgical cardiothoracic unit. MethodsFollowing a synthesis of the evidence, implementation of the FPS required various strategies, such as, individualized patient and staff education, audit and feedback, a pain policy revision, and creating documentation in the electronic medical record. Evaluation of the FPS consisted of patient and staff surveys pre- and postimplementation to assess knowledge, attitudes, and behaviors. ResultsAfter the pilot period, over 75% of the patients preferred to use the FPS and almost all the patients found the scale easy to use. Nurses reported an increase in perception that pain documentation was complete, that the FPS allowed them to accurately document their patients’ pain experience, and that their patients were well informed of their pain management plan. ConclusionsThis project supports successful implementation of the FPS within nursing workflow. The goal of using the FPS is to change pain management discussions from an intensity reduction to meeting goals of care, aligning expectations, and creating common language among patients and providers.

Pediatric Antimicrobial Stewardship Programs Reduce Antibiotic Use at Combined Adult-Pediatric Hospitals.

Implementation of dedicated pediatric antimicrobial stewardship programs (ASPs) at 2 combined adult-pediatric hospitals with existing ASPs was associated with sustained decreases in pediatric antibiotic use out of proportion to declines seen in adult inpatient units. ASPs in combined hospitals may not detect excessive pediatric antibiotic use without incorporating pediatric expertise.

Physician and nurse well-being, patient safety and recommendations for interventions: cross-sectional survey in hospitals in six European countries

ObjectivesTo determine the well-being of physicians and nurses in hospital practice in Europe, and to identify interventions that hold promise for reducing adverse clinician outcomes and improving patient safety.DesignBaseline cross-sectional...

Evidence-Based Pain Assessment in Nonverbal Palliative Care Patients

BackgroundCentral to palliative care is the early assessment and treatment of pain, whether physical, psychosocial, or spiritual. Nonverbal palliative care patients are at risk for inadequate pain assessment leading to prolonged suffering. AimsThe purpose of this project was to implement and evaluate an evidence-based pain assessment tool for nonverbal palliative care patients. DesignThe Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Healthcare and the Implementation Strategies for Evidence-Based Practice Guide provided the guiding frameworks. SettingsOn a six-bed adult inpatient Palliative Care Unit (PCU). Participants/SubjectsNonverbal palliative care patients. MethodsEvidence supported use of the Multidimensional Objective Pain Assessment Tool (MOPAT) for nonverbal patients receiving palliative care. During an eight-week pilot, nurses recorded pain assessments on a paper form and trended pain scores over a 24-hour period. Evaluation included knowledge, attitudes, and behaviors pre- and post-pilot and was subsequently used in a Precision Implementation Approach to promote adoption. ResultsNurses’ attitudes toward palliative care pain assessment improved in all items on the evaluation tools. Pain was assessed using MOPAT for 74% of nonverbal palliative care patients and 88% of patients had linked pain interventions to MOPAT scores. ConclusionsMOPAT is the only valid evidence-based pain assessment tool for nonverbal patients receiving palliative care. This project led to successful adoption of the MOPAT within the PCU.

The risk assessment of imminent inpatient aggression: A cross-cultural validation study of the dynamic appraisal of situational aggression in Estonia.

The reason for this study was void of a data-driven imminent risk assessment instrument for aggression in psychiatry clinics in Estonia. The predictive accuracy of the observer-rated Dynamic Assessment of Situational Aggression (DASA) has been repeatedly demonstrated. However, the research gap remains regarding a deeper conceptual understanding of the underlying latent structure of the DASA. Comprehensively evaluate the psychometric properties of the Estonian DASA version for cross-cultural clinical use. We used a prospective repeated measure design and collected 6097 risk evaluations from 381 adult inpatients, 151 of whom committed 1013 aggressive incidents during the study. The Estonian DASA version has acceptable inter-rater reliability (Kendall's τ = 0.74) and is a useful instrument with excellent predictive validity (AUC = 0.86) for identifying potentially aggressive inpatients. In our sample, the DASA has a bi-factorial structure which explains 83% of the total variance. The adapted DASA has acceptable validity and reliability indices for measuring imminent aggression risk in adult inpatient units. Evidence-based risk assessment of aggression in psychiatric clinics enhances recognition of the signs of potentially aggressive behaviour in order to apply preventive actions and reduce aggression, thereby improving the quality of the care provided.

Implementing a Fall Prevention Protocol to Reduce Fall Rates Among Inpatients With Cancer.

Globally in healthcare delivery, inpatient falls and fall-related injuries contribute to unsafe patient care environments. On two inpatient oncology units, the frequency of patient falls had increased, despite the use of a fall screening tool. This project aimed to determine whether implementing the Agency for Healthcare Research and Quality (AHRQ) 3B Scheduled Rounding Protocol would reduce the average daily fall rate and number of fall-related injuries on two adult inpatient oncology units. This quantitative, quasi-experimental quality improvement project evaluated the implementation of the AHRQ protocol to reduce the average fall rate and number of fall-related injuries for adult patients with cancer. The average daily fall rate decreased following implementation of the AHRQ protocol, indicating clinical significance. This project's results suggest that implementing a standard fall prevention protocol can reduce the rate of patient falls.

Patient and family perceptions of a discharge bedside board

ObjectiveTo explore patient and family perspectives of a discharge bedside board for supporting engagement in patient care and discharge planning to inform tool revision. MethodsThis qualitative descriptive study included 45 semi-structured interviews with a purposeful sample of English-speaking patients (n = 44; mean age 58.5 years) and their family members (n = 5) across seven adult inpatient units at a tertiary acute care hospital in mid-western Canada. Thematic (interviews), content (board, organization procedure document), and framework-guided integrated (all data) analyses were performed. ResultsFour themes were generated from interview data: understanding the board, included essential information to guide care, balancing information on the board, and maintaining a sense of connection. Despite application inconsistencies, documented standard procedures aligned with recommended board (re)orientation, timely patient-friendly content, attention to privacy, and patient-provider engagement strategies. ConclusionFindings indicate the tool supported consultation and some involvement level engagement in patient care and discharge. Board information was usually valued, however, perceived procedural gaps in tool education, privacy, and the quality of tool-related communication offer opportunities to strengthen patients' and families' tool experience. InnovationNovel application of a continuum engagement framework in the exploration of multiple data sources generated significant insights to guide tool revision.

Treatment without consent in adult psychiatry inpatient units: a retrospective study on predictive factors.

Coercion is one of the most important challenges in mental health. In Switzerland, forced medication can be applied during an emergency (Art. 435 of the Civil Code) or over a longer period in case of endangerment of others or oneself (Art. 434). We aimed to analyze the predictors of this specific treatment without consent. Forced medication prescriptions in the Division of Adult Psychiatry of the Geneva University Hospitals between 2018 and 2021 were retrospectively analyzed. Medication under Article 434 was the main outcome variable. Age, gender, admission mode, main diagnosis, and the Health of the Nation Outcome Scales (HoNOS) score at admission were considered as potential predictors. T-test and Pearson's chi-square test were used to compare continuous and categorical variables. A logistic regression was performed to find significant predictors of forced medication. Seventy-one out of 4,326 inpatients were subjected to forced medication under Art. 434. HoNOS global scores at admission were not significantly different in the forced medication group compared to the control group. Aggressive behavior was lower in the former at the univariate level. Forced medication was associated at the multivariate level with female gender, involuntary admission, and psychosis. Women suffering from psychosis are more at risk of receiving involuntary and repeated medication. The risk of deterioration in psychosocial functioning or behavioral disorganization seems to be the main argument for this coercive measure. Future studies should focus on the patient's perception of this coercion to prevent it and improve adherence to care. Follow-up after discharge might be useful to evaluate a long-term benefit.

Work-schedule management in psychiatric hospitals and its associations with nurses' emotional exhaustion and intention to leave: A cross-sectional multicenter study

BackgroundManaging nurses' work schedules in hospitals is challenging because employer needs, like shift changes at short notice and overtime, may conflict with nurses' desires for a predictable and stable schedule. Nurses should have a certain degree of control over their work schedules, and their supervisors should support their needs in scheduling. How perceived control over work schedules, perceived support from supervisors in scheduling, shift changes at short notice, and overtime affect nurses' emotional exhaustion and intentions to leave has not been studied. ObjectivesThe aims are (1) to describe perceived control, perceived supervisor support, shift changes at short notice, and overtime among nurses in psychiatric hospitals; (2) to assess the variation of these four factors between units at psychiatric hospitals; and (3) to investigate the association between these factors with nurses' emotional exhaustion and intentions to leave. DesignCross-sectional survey study. Setting(s)Swiss psychiatric hospitals with 24-hour services. ParticipantsRegistered nurses (N = 994) from 114 adult-inpatient units. MethodsTo describe perceived control, perceived supervisor support, shift changes at short notice, and overtime among nurses, we calculated frequencies, percentages, means, and standard deviations of their responses to the survey. To assess the variation between units, we computed intraclass correlations for the four factors. We constructed random-effects models accounting for the clustering of nurses in units for emotional exhaustion and intentions to leave separately. ResultsPerception of work-schedule control was 3.32 (SD 1.39, range 0–5); perception of supervisor work-schedule support was 3.28 (SD 1.14, range 0–4). On average, 9 % of the nurses had to take over a shift at short notice at least three times per month, and 40 % worked at least 15 minute overtime on their most recent shift. Intraclass correlation for all four factors was higher than 0.05. Emotional exhaustion was significantly associated with supervisor support and overtime, and leaving intentions were significantly associated with perceived control, supervisor support and overtime. ConclusionPerceived control, perceived supervisor support, shift changes at short notice, and overtime are promising factors for interventions to prevent nurses' emotional exhaustion and allay their intentions to leave. Unit managers should provide nurses with increased predictability and influence on their work schedules. This could reduce early career endings and early retirement and counteract nurse shortages.

Decreasing Pressure Injuries on an Adult Inpatient Unit through Implementation of a Nutrition Assessment and Management Process.

To lower the rate of hospital-acquired pressure injuries (HAPIs) by identifying at-risk patients based on the Braden Scale score, evaluating nutrition using a Mini Nutrition Assessment (MNA) tool, and implementing nutrition improvement measures. There were three steps in this intervention. First, patients with a Braden Scale score of 18 or lower were identified as being at risk for HAPI. Next, the MNA screening tool was implemented to identify nutrition deficiencies. The MNA screening tool can predict malnutrition, HAPI development, and/or additional complications. It is validated, cost-effective, and easy to administer to patients who are hospitalized with HAPI complications. In the final step, the author implemented a multicomponent nutrition intervention to improve the nutrition status of patients at risk for developing HAPI. Included patients (N = 205) were hospitalized in the intermediate ICU, had a Braden Scale score of 18 or lower, and had poor nutrition status. There was a 74% decrease in HAPI rate following the MNA nutrition screening and management, with HAPI incidence decreasing from 1.9% preintervention to 0.5% postintervention. Categorizing patients who are at risk for developing HAPI, assessing for nutrition deficiency, and then implementing a multicomponent nutrition intervention considerably reduced the rate of HAPIs per number of patients admitted to the unit.

Do they cross the bridge when they come to it? Young adult's engagement in attachment‐based family therapy as part of inpatient care

AbstractAlthough attachment seems to be ‘in fashion’ when it comes to discussing mental health issues, there are few evidence‐based therapy models treating attachment issues related to psychopathology. In this paper, we will briefly introduce Attachment‐Based Family Therapy (ABFT) as an evidence‐based intervention for depressed and suicidal adolescents, and its first‐time large‐scale application and implementation in a young adult inpatient care unit. We present our clinical data showing that 98% of the young adults who were proposed ABFT engage into this therapy. In our discussion we briefly describe accommodations to the young adult (YA) age and the inpatient setting and discuss hypotheses about which characteristics of young adulthood, the ABFT core interventions and the residential setting play a role in this high engagement. We discuss how adopting a shared clinical attachment‐based framework as a team might broaden the impact.

Relating clustered noise data to hospital patient satisfaction.

Hospital noise can be problematic for both patients and staff and consistently is rated poorly on national patient satisfaction surveys. A surge of research in the last two decades highlights the challenges of healthcare acoustic environments. However, existing research commonly relies on conventional noise metrics such as equivalent sound pressure level, which may be insufficient to fully characterize the fluctuating and complex nature of the hospital acoustic environments experienced by occupants. In this study, unsupervised machine learning clustering techniques were used to extract patterns of activity in noise and the relationship to patient perception. Specifically, nine patient rooms in three adult inpatient hospital units were acoustically measured for 24 h and unsupervised machine learning clustering techniques were applied to provide a more detailed statistical analysis of the acoustic environment. Validation results of five different clustering models found two clusters, labeled active and non-active, using k-means. Additional insight from this analysis includes the ability to calculate how often a room is active or non-active during the measurement period. While conventional LAeq was not significantly related to patient perception, novel metrics calculated from clustered data were significant. Specifically, lower patient satisfaction was correlated with higher Active Sound Levels, higher Total Percent Active, and lower Percent Quiet at Night metrics. Overall, applying statistical clustering to the hospital acoustic environment offers new insights into how patterns of background noise over time are relevant to occupant perception.