Adult Acute Care Research Articles

The relationship between the nursing practice environment and five nursing-sensitive patient outcomes in acute care hospitals: A systematic review.

AimTo synthesize the available evidence on the relationship between the nursing practice environment in acute care hospitals and five selected nursing‐sensitive patient outcomes (mortality, medication error, pressure injury, hospital‐acquired infection and patient fall).DesignA quantitative systematic review of literature was conducted using the PRISMA reporting guidelines (PROSPERO: CRD42020143104).MethodsA systematic review was undertaken up to October 2020 using: CINAHL, MEDLINE and Scopus. The review included studies exploring the relationship between the nursing practice environment in adult acute care settings and one of five selected patient outcomes using administrative data sources. Studies were published in English since 2000.ResultsTen studies were included. Seven studies reported that a favourable nursing practice environment reduced the likelihood of mortality in acute care hospitals, but estimates of the effect size varied. Evidence on the association between the nursing practice environment and medication administration error, pressure injury and hospital‐acquired infection was mixed.

Fever Associated With Dexmedetomidine in Adult Acute Care Patients: A Systematic Review of the Literature.

Dexmedetomidine-associated fever has been reported in the literature and can lead to lengthy workups and unnecessary antibiotic exposure. We conducted a systematic review to evaluate and describe the evidence of fever or hyperthermia caused by dexmedetomidine in adult patients. Data sources included PubMed/MEDLINE, EMBASE, CINAHL, and Web of Sciences. English-language studies of any design published from inception through April 2020 including conference abstracts were included. The target population was hospitalized adult patients. Quality of evidence was determined based on GRADE recommendations and risk of bias assessed using the Evidence Project Risk of Bias tool. Naranjo scores were assessed to determine the likeliness of adverse event being caused by dexmedetomidine. All data were extracted independently and with the guidance of a medical librarian. Four hundred and eighty-eight total citations were found on formal search, with 329 left after removal of duplicates. Independent record screening was performed, leaving 17 citations including 4 retrospective cohort studies, 1 case series, and 12 case reports. Quality of evidence ranged from very low to low for identified analyses. Evidence with patient-level data (case reports and series) were combined to establish a cohort for descriptive results. The median Naranjo score was 4 (range, 3 to 8), and dexmedetomidine doses ranged from 0.1 to 2 μg·h/kg. Obesity and cardiac surgery appear to be significant risk factors. Dexmedetomidine-associated fever appears uncommon, but the true incidence is unknown. Clinicians should keep dexmedetomidine-associated fever in their differential, and stewardship programs should consider assessing for this adverse effect in their patient monitoring.

Gaps in Emergency General Surgery Coverage in the United States.

Despite three million adults in the United States (US) being admitted annually for emergency general surgery (EGS) conditions, which disproportionately affect vulnerable populations, we lack an understanding of the barriers to round-the-clock EGS care. Our objective was to measure gaps in round-the-clock EGS care. From August 2015 to December 2015, we surveyed all US-based, adult acute care general hospitals that have an emergency room and ≥1 operating room and provide EGS care, utilizing paper and electronic methods. Surgeons or chief medical officers were queried regarding EGS practices. Of 2,811 hospitals, 1,634 (58.1%) responded; 279 (17.1%) were unable to always provide round-the-clock EGS care. Rural location, smaller bed size, and non-teaching status were associated with lack of round-the-clock care. Inconsistent surgeon coverage was the primary reason for lacking round-the-clock EGS care (n=162; 58.1%). However, lack of a tiered system for booking emergency cases, no anesthesia availability overnight, and no stipend for EGS call were also associated with the inability to provide round-the-clock EGS care. We found significant gaps in access to EGS care, often attributable to workforce deficiencies.

Resilience and Burnout Resources in Respiratory Care Departments.

Burnout is a major problem in health care, with rates of approximately 33% and 50% in nurses and physicians, respectively, prior to the COVID-19 pandemic. Respiratory therapist (RT) burnout rates and drivers have not been specifically examined. The purpose of this project was to determine resilience and burnout resources available within respiratory care departments and to provide an estimate of pre- and post-COVID-19 RT burnout rates. A survey was developed to evaluate resilience and burnout resources in respiratory care departments. The survey was posted online to the AARConnect management, education, adult acute care, neonatal/pediatrics, COVID-19, and help line communities. Data analysis was descriptive. Key drivers of burnout among RTs were identified from qualitative answers. There were 221 responses, and 72% reported experiencing burnout. Ten percent of the departments that responded measured burnout; 36% utilized resilience tools, and 83% offered free employee assistance for those struggling with burnout. In January 2020, 30% of departments reported an estimated burnout rate > 40%, which increased to 44% of departments (P = .007) in the COVID-19 pandemic period. The most common drivers reported were poor leadership (32%), high work load (31%), and staffing (29%); 93% of respondents agreed that burnout is a major problem in health care, 33% agreed that burnout is primarily driven by external factors, 92% agreed that RTs have a similar risk of burnout as other health care professionals, 73% agreed that they were comfortable discussing challenging situations with colleagues, 32% agreed that their leadership provided adequate support for those suffering from burnout, and 79% agreed that they would be open to utilizing resilience tools from the AARC or other professional organizations. Most respondents experienced burnout and few respiratory care departments measured burnout. Resilience resources were not commonly used but employee assistance and wellness programs were common. Key drivers of burnout identified were poor leadership, staffing, and high workloads.

Rallying All Resources: A Multidisciplinary Innovation to Plan for the Projected COVID-19 Inpatient Surge.

The COVID-19 pandemic resulted in the need for hospitals to plan for a potential "surge" of COVID-19 patients. Prior to the onset of the COVID-19 pandemic, our hospital adult acute care capacity ranged 90% to 100%, and a potential hospital surge was projected for Oregon that would exceed existing capacity. A multidisciplinary team with stakeholders from nursing leadership, nursing units, nurse-led case management, and physicians from hospital medicine was convened to explore the conversion of an ambulatory surgical center to overflow patient acute care capacity. A protocol was rapidly created and implemented, ultimately transferring 12 patients to an ambulatory surgery unit. This project highlighted the ability for stakeholders and innovators to work together in an interprofessional, multidisciplinary way to rapidly create an overflow unit. While this innovation was designed to address COVID-19, the lessons learned can be applied to any other emerging infectious disease or acute care capacity crisis.

Delirium in Geriatric Trauma Patients

This review focuses on exploring the most recent literature on delirium among older adult trauma and acute care surgery patients. There are numerous scientific advances in the understanding and management of delirium among geriatric trauma patients (GTP). In terms of prevention, most of these advances are focused on non-pharmacological interventions. There are several studies exploring biomarkers for the objective assessment of delirium. Current recommendations for the pharmacologic treatment of delirium suggest reserving the use of antipsychotics and other sedating medications for the treatment of severe agitation that poses a risk to the patient. Despite extensive strides in the prevention and treatment of delirium, there is still a paucity of data in GTPs. Our review shows that GTPs benefit from multi-faceted interventions that serve primarily as preventive measures, and there is evidence that some novel pharmacological interventions may help in the treatment of GTPs.

Structured Mentorship and the Nursing Clinical Ladder.

The evidence-based practice (EBP) project's aim was to determine whether a short-term structured mentorship program led by a clinical nurse specialist increased work engagement among staff nurses within 8 to 10 weeks. The EBP project was implemented on 2 adult acute care inpatient units. Using Wagner's caring mentorship model, a mentorship program using the organization's clinical ladder criteria was established where nurses were able to participate and complete selected professional development activities based on personal interests and perceived strengths. The clinical nurse specialist provided guidance and advice based each participant's identified activity. Since the completion of the initial pilot, the organization has expanded the mentorship program to include mentorship of nursing leaders as well as staff on the clinical units. With this expansion, the organization has trained an additional 167 mentors and has a consistent 27% overall advancement of nurses on the clinical ladder. In addition, advanced practice registered nurses have implemented mentorship as part of their onboarding practice for advanced practice nursing. The EBP project demonstrated that a mentorship program using an established clinical ladder can increase elements of work engagement and satisfaction with the mentor and program among hospital nursing staff. Sustaining and expanding the program can facilitate with increased nursing job satisfaction and employee retention.

Partnering with Central Sterile Processing Department Experts to Advance Infection Prevention Competency

<h3>Background</h3> The Central Sterile Processing Department (CSPD) manages the cleaning, disinfection, and sterilization of reprocessed devices and instruments. Infection Preventionists (IP) work closely with CSPD to ensure devices and instruments are reprocessed and stored according to the recommendations of manufacturer, regulatory, and expert guidelines. A large healthcare system surveyed their IP and identified opportunities related to the updated Association for Professionals in Infection Control and Epidemiology (APIC) Competency Model (2019) domains. Cleaning, Disinfection and Sterilization falls under the Operations domain and was identified as an area in which IP wanted to enhance their expertise. <h3>Methods</h3> IP partnered with CSPD experts throughout the healthcare system to provide an in-depth education workshop to grow IP competency in CSPD. IP within our system are responsible for CSPD in a range of settings, including adult and pediatric acute care, critical access hospitals, ambulatory surgery centers, and over 120 physician offices or outpatient care areas. The workshop was divided into 4 sessions that consisted of oral presentations, hands-on learning, and discussion of examples and real-life scenarios. Manufacturer instructions for use (MIFU) were addressed, and a review of standard work and best practices due to sterilization failures were discussed. <h3>Results</h3> 32 attendees from 12 settings participated in the workshop, including Infectious Diseases (ID) physicians, IP, Occupational Health (OH) practitioners, and CSPD technicians. Attendees were asked to evaluate the quality of the educational sessions. 20 attendees completed their evaluations. The 4 sessions each received either an Agree (12) or a Strongly Agree (68) approval rating. The overall quality of the program received an Excellent (16) or a Good (4). <h3>Conclusions</h3> By partnering with CSPD subject matter experts (SME) from their healthcare facilities, IP, ID Physicians and OH Specialists increased their knowledge about the cleaning, disinfection, and sterilization of reusable devices and instruments and enhanced their professional relationships with their CSPD team.

The Provision of Acute Pediatric Surgical Care by Adult Acute Care General Surgeons : Is There a Learning Curve?

At our hospital, acute surgical care of children aged 6 and older is managed by adult acute care surgeons. Previously published data from a 10-year experience with this model demonstrated no differences in outcomes when compared with pediatric surgical benchmark data. This study assesses for the effects of a learning curve in the care of pediatric patients by comparing outcomes of patients treated in the first three years with those treated in the last 3 years during a 10-year experience with this model. This was a retrospective study of pediatric patients aged 6 and older who underwent an emergent or urgent, nontrauma surgical procedure by a general surgeon. Data was obtained via chart review and descriptive statistics were compared between patients operated on between January 1, 2009-January 1, 2012 and January 1, 2016-January 1, 2019. In all, 208 cases were performed in the early cohort and 192 cases in the late cohort. Appendectomy was the most common procedure in both intervals (88% early, 94.8% late). Although there was a significant decrease in open procedures in the later cohort (22.6% vs 4.7%, P < .001), there was no significant change in disease-specific complications or negative appendectomies. No consults to a fellowship-trained pediatric surgeon were required during either time period, although one was available if needed. Our data demonstrated a decrease in the number of open procedures in the later cohort. This may be due to an increased comfort level with pediatric laparoscopy over time. However, no significant changes in outcomes were observed. This study supports that acute care general surgeons can provide comparable care to pediatric patients within this age demographic and that although a learning curve, appears to exist with respect to pediatric laparoscopy, it is insignificant in terms of its effect on overall outcomes.

Urinary tract infection prevention: evaluating Scotland's national hydration campaign.

Urinary tract infection (UTI) is a prevalent healthcare-associated infection in adult acute and long-term care facilities in Scotland. To convey the public health benefits of optimal hydration to support UTI prevention, the Scottish UTI Network, coordinated by Health Protection Scotland, launched a national hydration campaign in 2018. The benefits of hydration were promoted using a range of materials displayed in a variety of settings, including community pharmacies, inpatient hospital wards, care homes and community settings such as GP surgeries and district nursing hubs. The campaign consisted of three stages, of which the first two stages were aimed at adults. The first two stages were evaluated using online surveys, which were completed by a total of 153 respondents. This article puts the hydration campaign in the context of UTI prevention in Scotland, describes the first two stages of the campaign and provides an overview of the evaluation findings, which suggest that the campaign was received positively.

Using Functional Ability Measures to Assess Fall Risk in Acute Care.

Currently, it is not known whether integration of functional performance measures is sensitive and feasible for use in acute care settings. This cross-sectional study explored the subjective and objective measures of the risks of falling, falls efficacy, and functional abilities for inpatients in an adult acute care unit. The Morse Fall Scale (n = 30) and Timed Up and Go (TUG; n = 10) had excellent sensitivity (100%) for identifying participants with prior fall histories, while the St. Thomas Risk Assessment Tool in Falling Elderly Inpatients only had good sensitivity (87.5%). Study findings suggest that implementation of feasible functional ability measures in conjunction with subjective fall risk measures could enhance accuracy and performance in identifying inpatient risks of falling in acute care settings.

Implementing daily chlorhexidine gluconate treatment for the prevention of healthcare-associated infections in non-intensive care settings: A multiple case analysis.

IntroductionDaily bathing with chlorhexidine gluconate (CHG) in hospitalized patients reduces healthcare-associated bloodstream infections and colonization by multidrug-resistant organisms. Achieving compliance with bathing protocols is challenging. This non-intensive care unit multicenter project evaluated the impact of organizational context on implementation of CHG and assessed compliance with and healthcare workers’ perceptions of the intervention.Materials and methodsThis was a multiple case study based on the SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety. The four sites included an adult cardiovascular unit in a community hospital, a medical-surgical unit in an academic teaching pediatric hospital, an adult medical-surgical acute care unit and an adult neuroscience acute care unit in another academic teaching hospital. Complementary data collection methods included focus groups and interviews with healthcare workers (HCWs) and leaders, and direct observations of the CHG treatment process and skin swabs.ResultsWe collected 389 bathing observations and 110 skin swabs, conducted four focus groups with frontline workers and interviewed leaders. We found variation across cases in CHG compliance, skin swab data and implementation practices. Mean compliance with the bathing process ranged from 64% to 83%. Low detectable CHG on the skin was related to immediate rinsing of CHG from the skin. Variation in the implementation of CHG treatments was related to differences in organizational education and training practices, feedback and monitoring practices, patient education or information about CHG treatments, patient preferences and general unit patient population differences.ConclusionOrganizations planning to implement CHG treatments in non-ICU settings should ensure organizational readiness and buy-in and consider delivering systematic and ongoing training. Clear and systematic implementation policies across patients and units may help reduce potential confusion about treatment practices and variation across HCWs. Patient populations and unit factors need to be carefully considered and procedures developed to manage unique challenges.

A model of the multidimensional nature of experienced dietitian clinical decision-making in the acute care setting.

Clinical decision-making (CDM) is an essential component of dietetic practice that can significantly affect the quality of patient care. Research around CDM in clinical dietetics is scarce, with research in other healthcare professions offering limited insight into dietitian CDM in the specific setting of the acute care hospitals. The aim of this qualitative research was to deepen our understanding of the nature of the CDM of experienced dietitians in the acute care setting. The present study employed philosophical hermeneutics to guide methods situated within the interpretative paradigm. This study invited dietitians currently practising in adult acute care hospitals with at least 3years of experience to be involved two in-depth semi-structured interviews using the principles of hermeneutics. A reference focus group session was then used to provide rigour and further interpretation of the findings. Ten dietitians participated in the interviews and five of these same participants in the reference focus group. The findings have informed the development of A Model of the Multidimensional Nature of Dietitian CDM in the Acute Care Setting, which reflects the nature of making decisions for patient care through the synergistic relationship between five key dimensions: (i) tasks; (ii) interactions; (iii) reasoning; (iv) practitioner factors; and (v) context, all of which are managed and monitored by the higher- order reasoning process of the dietitian's clinical judgement. Because there is scarcity of research on the CDM of dietitians in acute care settings, the present study can provide training and professional development insights to managers, educators and supervisors.

Psychometric testing of perceived implicit rationing of nursing care (PIRNCA).

To evaluate the psychometric properties of the Perceived Implicit Rationing of Nursing Care (PIRNCA) instrument and to report the prevalence of rationed care at university and faculty hospitals. A cross-sectional study. The study was carried out at two university and five faculty hospitals in the Slovak Republic. Participants were 895 Registered Nurses recruited by the purposive sampling method between December 2017-July 2018. Data were collected using the PIRNCA instrument. Construct validity and reliability of the instrument were tested. The prevalence of rationed care at university and faculty hospitals was identified as being 42.1%. Furthermore, 87.6% of nurses reported rationing one or more nursing care activities. Using both statistical methods when evaluating the PIRNCA resulted in the confirmation that the tool is valid and reliable. Rationed care is a common phenomenon at university and faculty hospitals. The PIRNCA is a suitable instrument to measure the phenomenon in adult acute care units because of its high reliability and validity. We recommend using the instrument in different contexts, not only for specific conditions that were presented for this study. Rationed care at university and faculty hospitals has never been reported. Psychometric properties of the instrument that measures nurses´ perception of rationed care have never been evaluated by using different approaches. The most frequently rationed nursing care activities are those that nurses are competent to initiate on the basis of their knowledge and skills - the independent ones. The PIRNCA is a valid and reliable instrument. Hospital management can use the instrument to explore the prevalence of rationed care, followed by the application of prevention strategies. Our findings represent the base for further exploration of rationed care using the PIRNCA.

Teaching Versus Learning

Teaching Versus Learning

Integration of Adult Acute Care Surgeons into Pediatric Surgical Care Models—Results of a 10-Year Experience with a Novel Approach to the Pediatric Surgical Workforce Shortage

Integration of Adult Acute Care Surgeons into Pediatric Surgical Care Models—Results of a 10-Year Experience with a Novel Approach to the Pediatric Surgical Workforce Shortage

Rebleeding in Variceal and Nonvariceal Gastrointestinal Bleeds in Cirrhotic Patients Using Vitamin K1: The LIVER-K Study

Gastroesophageal varices are the most common cause of upper gastrointestinal bleeding (UGIB) in patients with cirrhosis. Vitamin K1 is commonly administered to patients presenting with UGIB and elevated international normalized ratio, despite limited evidence to support this practice. The primary objective was to describe the incidence of rebleeding within 30 days after vitamin K1 administration in patients with cirrhosis and UGIB. The secondary objective was to describe prescribing patterns for vitamin K1. This retrospective, descriptive multicentre study involved patients with cirrhosis and UGIB who were admitted to any of the 4 adult acute care hospitals in Calgary, Alberta, from January 1, 2014, to December 31, 2016. Patients were divided into 2 groups: those who received vitamin K1 and those who did not. A total of 370 patients met the inclusion criteria, of whom 243 received vitamin K1 and 127 did not. Baseline characteristics were similar between the groups. Greater proportions of patients in the vitamin K1 group received transfusions of packed red blood cells, fresh frozen plasma, platelets, cryoprecipitate, or prothrombin concentrate during their admissions. There was no significant difference in the duration of octreotide and pantoprazole infusions. Among patients in the vitamin K1 group, there were more admissions to the intensive care unit and longer lengths of stay. More patients in the no vitamin K1 group had esophageal varices evident on endoscopy that required endoscopic treatment. Forty of the patients (16.5%) in the vitamin K1 group and 7 (5.5%) in the no vitamin K1 group had rebleeding within 30 days of the initial bleed. The median total vitamin K1 dose administered was 25 mg. The study results suggest that vitamin K1 does not reduce the incidence of rebleeding within 30 days of the initial bleed in patients with cirrhosis and UGIB.

On-call simulation for adult gerontology acute care nurse practitioner students: A comparative descriptive study.

It is now commonplace for acute care nurse practitioners (ACNPs) to work in positions that include an on-call component or management of emergent concerns through telephone. There are no published reports on the inclusion of an on-call component in ACNP clinical preparation of students; novice ACNPs feel unprepared to competently and confidently manage emergent patient situations and on-call responsibilities. To examine ACNP student perception of stress, necessary skills, confidence, and benefit of participating in a simulated on-call experience. Using simulated faculty callers as nurses, ACNP students participated in a simulated on-call experience that included receiving two calls, eliciting key information from the nurse, diagnosing and managing the patient, and submitting documentation of the encounter. Students completed preparticipation and postparticipation perception surveys, and they were evaluated by the simulated nurse (faculty) using standardized evaluation tools. Acute care nurse practitioner students rated the simulated on-call experience as educationally valuable. High levels of anxiety before participation were notably improved after participation. Students identified critical thinking, clear communication, and knowledge with the specific disease as the most important skills needed to manage nurse calls successfully. Students reported marked improvement in their confidence and were receptive to accepting an nurse practitioner position with call/triage responsibilities after their on-call experience. Inclusion of a simulated on-call experience in the final semester of an ACNP program is both feasible and relevant to ACNP student development. On-call exposure within the clinical practicum is inconsistent and, therefore, should be added through simulation.

Lack of effect of a poster-based intervention to reduce the number of blood culture samples collected

ObjectiveTo reduce the number of blood culture samples collected. Patients and methodWe performed a cluster randomized controlled trial in adult acute care, and subacute care and rehabilitation wards in a university hospital in France. A poster associating an image of eyes looking at the reader with a summary of blood culture sampling guidelines was displayed in hospital wards in the intervention group. The incidence rate of blood cultures per 1000 days during pre- and post-intervention periods was calculated. ResultsThirty-one wards participated in the study. The median difference in blood cultures/1000 days between periods was −1.863 [−11.941; 1.007] in the intervention group and −5.824 [−14.763; −2.217] in the control group (P=0.27). ConclusionThe intervention did not show the expected effect, possibly due to the choice of blood cultures as a target of good practice, but also to confounding factors such as the stringent policy of decreasing unnecessary costly testing.

The effect of volunteers' care and support on the health outcomes of older adults in acute care: A systematic scoping review.

AimTo examine the available evidence on the effects of care and support provided by volunteers on the health outcomes of older adults in acute care services.BackgroundAcute hospital inpatient populations are becoming older, and this presents the potential for poorer health outcomes. Factors such as chronic health conditions, polypharmacy and cognitive and functional decline are associated with increased risk of health care‐related harm, such as falls, delirium and poor nutrition. To minimise the risk of health care‐related harm, volunteer programmes to support patient care have been established in many hospitals worldwide.DesignA systematic scoping review.MethodsThe review followed the PRISMA Extension for Scoping Reviews (PRISMA‐ScR) (File S1). Nine databases were searched (CINAHL, MEDLINE, EMBASE, Cochrane, Scopus, Web of Science, PubMed, ScienceDirect and JBI) using the following key terms: ‘hospital’, ‘volunteer’, ‘sitter’, ‘acute care’, ‘older adults’, ‘confusion’, ‘dementia’ and ‘frail’. The search was limited to papers written in English and published from 2002–2017. Inclusion criteria were studies involving the use of hospital volunteers in the care or support of older adult patients aged ≥ 65 years, or ≥ 50 years for Indigenous peoples, with chronic health conditions, cognitive impairment and/or physical decline or frailty, within the acute inpatient settings.ResultsOf the 199 articles identified, 17 articles that met the inclusion criteria were critically appraised for quality, and 12 articles were included in the final review.ConclusionsThere is evidence that the provision of volunteer care and support with eating and drinking, mobilising and therapeutic activities can impact positively upon patient health outcomes related to nutrition, falls and delirium. Further robust research is needed to determine the impact of volunteers in acute care and the specific care activities that can contribute to the best outcomes for older adults.Relevance to clinical practiceVolunteers can play a valuable role in supporting care delivery by nurses and other health professionals in acute care services, and their contribution can improve health outcomes for older adults in this setting.