Appropriate Plan Of Care Research Articles

Use of machine learning to identify prognostic variables for outcomes in chronic low back pain treatment: a retrospective analysis

ABSTRACT Objectives Most patients seen in physical therapy (PT) clinics for low back pain (LBP) are treated for chronic low back pain (CLBP), yet PT interventions suggest minimal effectiveness. The Cochrane Back Review Group proposed ‘Holy Grail’ questions, one being: ‘What are the most important (preventable) predictors of chronicity’ for patients with LBP? Subsequently, prognostic factors influencing outcomes for CLBP have been described, however results remain conflicting due to methodological weaknesses. Methods This retrospective observational cohort study examined prognostic risk factors for PT outcomes in CLBP treatment using a sub-type of AI. Bootstrap random forest supervised machine learning analysis was employed to identify the outcomes-associated variables. Results The top variables identified as predictive were: FOTO™ predicted functional status (FS) change score; FOTO™ predicted number of visits; initial FS score, age; history of jogging/walking, obesity, and previous treatments; provider education level; medication use; gender. Conclusion This article presents how AI can be used to predict risk prognostic factors in healthcare research. Improving predictive accuracy helps clinicians predict outcomes and determine most appropriate plans of care and may impact research attrition rates.

Traumatic hyphema

A nurse’s triage skills result in the appropriate plan of care.

CHALLENGES AND STRATEGIES TO IMPLEMENTING THE TRANSITIONAL CARE MODEL: LESSONS LEARNED FROM THE MIRROR-TCM TRIAL

Abstract The Transitional Care Model (TCM) is an advanced practice registered nurse-led, team-based, care management strategy which has repeatedly been shown to improve outcomes for older adults transitioning from hospital to home. The MIRROR-TCM randomized controlled trial was implemented at three healthcare systems (7 hospitals) in four states. Older adults, hospitalized with heart failure, chronic obstructive pulmonary disease, or pneumonia, were enrolled between September 2020 and January 2023. A parallel evaluation study of “what it takes” to implement the TCM was launched to explore the challenges and strategies necessary to implement the Model’s 10 components, especially in the context of COVID-19. A qualitative descriptive analysis of 167 meetings (clinical, community, leadership) from June 2020 (Pre-Implementation) through January 2023 (implementation/evaluation) was conducted. Codes were developed inductively over the first year of the study. The most common challenges were patient and caregiver factors (e.g., engagement, preferences, medical complexity), staffing coverage (e.g., time off, absences), and collaboration with multidisciplinary teams (e.g., poor or reluctant collaboration/communication). Common strategies to address challenges included: clarifying and adapting TCM processes, establishing an appropriate plan of care, building and engaging networks and relationships across healthcare and community settings, and trialing alternative strategies (e.g., telehealth in place of in-person visits). While some challenges were more common across sites such as patients refusing visits or no weekend coverage, strategies to resolve them tended to be site-specific. Findings provide important insights into what it takes to successfully implement complex evidence-based interventions such as the TCM.

Assessments of Aphasia: Practices and Challenges faced by Malaysian Speech-Language Therapists

Aphasia assessment is crucial in diagnosing aphasia, determining the extent of language impairment, and identifying factors that may support or restrict aphasia recovery to design an appropriate plan of care for people with aphasia. Speech-language therapists (SLTs) play a major role in conducting aphasia assessments. Little is known about the practices of SLTs in assessing aphasia in low-resource regions. The present study aims to identify aphasia assessment practices among Malaysian SLTs and related challenges, as well as strategies for improving aphasia assessments from SLTs’ perspectives. A total of 32 SLT participants who have been practicing in Malaysia completed an online survey to gather their background information, data pertaining to practices and challenges in conducting aphasia assessments, and suggestions for improving aphasia assessments. Descriptive analyses were conducted for all numerical data. Suggestions for improving aphasia assessment practices were analysed qualitatively using the thematic content analysis approach. SLT practices in aphasia assessment were found to be consistent in certain aspects, but not all. Two major challenges were identified: (a) linguistic barriers between clinicians and clients/caregivers, and (b) a lack of standardized assessment tools for aphasia evaluations. Participants suggested “Internal Strategies” and “External Strategies” for improving aphasia assessment practices. Keywords:aphasia; clinical practices; Malaysia; speech-language therapists

Effects of telehealth-assisted interventions for secondary prevention of cardiovascular disease: A systematic review and meta-analysis.

Telehealth-assisted interventions have been used as secondary prevention measures in cardiac rehabilitation, especially for the delivery of information between healthcare service providers and patients. However, as the application of this intervention modality broadens, investigation of its effects in secondary prevention of cardiovascular disease (CVD) is necessary. To identify the effectiveness of telehealth-assisted interventions for secondary prevention of CVD. Systematic review and meta-analysis. The PRISMA protocol was used to conduct a systematic review and meta-analysis of randomised controlled trials. The full text of articles was obtained from six databases for the period from database establishment to 25 November 2021. To assess the methodological quality of the studies reviewed, the updated Cochrane risk-of-bias checklist for randomised trials was employed. A meta-analysis was performed using a random-effects model to calculate the pooled effects of telehealth-assisted interventions for secondary CVD prevention. The final analysis included 4012 individuals from 18 different trials. Telehealth-assisted interventions were shown to improve medication adherence (standardised mean difference [SMD]: 0.31; 95% confidence interval [CI]: 0.33-0.59) and reduce depression (SMD: -0.28; 95% CI: -0.46 to -0.10). Telehealth-assisted interventions appear to improve adherence to medication and reduce depression of individuals with CVD. These intervention strategies could be offered to both healthcare providers and individuals with CVD as an option in delivering and facilitating the use of health services to improve health behaviours and overall outcomes. Furthermore, this study may be used as guidance for future research to provide an appropriate plan of care for this population. The findings imply that the delivery of care remotely via telehealth-assisted interventions for secondary prevention of CVD is beneficial in improving CVD survivors' health and access to healthcare services. The International Prospective Register of Systematic Review: (PROSPERO): CRD 42021290111.

Development and validation of the ABC2-SPH risk score for in-hospital mortality in COVID-19 patients

Abstract Introduction Fast and efficient assessment of prognosis of coronavirus disease 19 (COVID-19) is needed to optimize the allocation of health care and human resources, to empower early identification and intervention of patients at higher risk of poor outcome. A proper assessment tool may guide decision making, to develop an appropriate plan of care for each patient. Although different scores have been proposed, the majority of them are limited due to high risk of bias, and there is a lack of reliable prognostic prediction models. Purpose To develop and validate an easy applicable rapid scoring system that employs routinely available clinical and laboratory data at hospital presentation, to predict in-hospital mortality in patients with COVID-19, able to discriminate high vs non-high risk patients. Additionally, we aimed to compare this score with other existing ones. Method Cohort study, conducted in 36 Brazilian hospitals in 17 cities. Consecutive symptomatic patients (≥18 years old) with laboratory confirmed COVID-19 admitted to participating hospitals. Primary outcome was in-hospital mortality. Logistic regression analysis was performed to develop a prediction model for in-hospital mortality, based on the 3978 patients that were admitted between March-July, 2020. The model was then validated in the 1054 patients admitted during August-September, as well as in an external cohort of 474 Spanish patients. Results Median (25th-75th percentile) age of the model-derivation cohort was 60 (48–72) years, 53.8% were men, in-hospital mortality was 20.3%. The validation cohorts had similar age distribution and in-hospital mortality. From 20 potential predictors, seven significant variables were included in the in-hospital mortality risk score: age, blood urea nitrogen, number of comorbidities, C-reactive protein, SpO2/FiO2 ratio, platelet count and heart rate. The model had high discriminatory value (AUROC 0.844, 95% CI 0.829 to 0.859), which was confirmed in the Brazilian (0.859) and Spanish (0.899) validation cohorts. Our ABC2-SPH score showed good calibration in both Brazilian cohorts, but, in the Spanish cohort, mortality was somewhat underestimated in patients with very high (>25%) risk. The ABC2-SPH score is implemented in a freely available online risk calculator. Conclusions We designed and validated an easy-to-use rapid scoring system based on characteristics of COVID-19 patients commonly available at hospital presentation, for early stratification for in-hospital mortality risk of patients with COVID-19. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Minas Gerais State Agency for Research and Development (Fundação de Amparo à Pesquisa do Estado de Minas Gerais - FAPEMIG) [grant number APQ-00208-20], National Institute of Science and Technology for Health Technology Assessment (Instituto de Avaliação de Tecnologias em Saúde – IATS)/ National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnolόgico - CNPq) [grant number 465518/2014-1]

Virtual Evaluation of Clinical Competence in Nurse Practitioner Students.

All in-person nurse practitioner (NP) student clinical activities were suspended in the spring of 2020 due to COVID-19. This posed a unique summer semester challenge, as students needed to complete an objective structured clinical examination (OSCE). The traditional face-to-face OSCE was revised into a virtual format using a teleconferencing platform and included the following learning objectives: obtain the medical history, describe a focused physical examination, formulate differential diagnoses, and develop an appropriate plan of care. Together with the Health Education Center, students met with a standardized patient (SP) virtually. All elements of the virtual OSCE were the same as the traditional OSCE, except students were required to demonstrate their clinical assessment skills by verbalizing to faculty what they would examine if the visit were in-person. When finished, all participants were invited to complete a survey about their experience. Survey findings revealed that most faculty and students considered the interactive virtual OSCE an extremely effective tool for assessing communication and history taking skills, differential diagnosis, and management of patients. All SPs felt comfortable communicating with the students and felt that the virtual OSCE was a very effective way to assess their interpersonal skills of students. The virtual OSCE also served as an opportunity to incorporate telehealth competencies into a simulation experience for students. This innovative distance learning activity facilitated effective virtual evaluation of clinical competence in NP students and all stakeholders expressed satisfaction with the experience. Most faculty and students strongly agreed that they wanted to continue using the virtual OSCE platform.

Use of the Clinical Examination in the Diagnosis of Cardiac Syncope.

Patient history: Age at first syncopal episode older than 35 years = 3.3 History of atrial fibrillation or flutter = 7.3 Known severe structural heart disease = 3.3 to 4.8 Dyspnea prior to syncope = 3.5 Chest pain/angina prior to syncope = 3.4 to 3.8 Cyanotic during syncope = 6.2 Diagnostic tests: High-sensitivity cardiac troponin T > 42 pg/mL = 5.1 High-sensitivity cardiac troponin I > 31.3 pg/mL = 5.4 NT-proBNP ≥ 210.5 pg/mL = 47 NT-proBNP > 1966 pg/mL = 5.8 BNP > 302 pg/mL = 6.3 Multivariable evaluation: Heart disease, abnormal ECG, or both = 2.3 EGSYS score 3 or more = 2.8 to 3.3 Vasovagal score less than −2 = 1.7 to 8.6 Patient history: Age at first syncopal episode 35 years or younger = 0.13 Diagnostic tests: Normal cardiac troponin T or I = 0.15 to 0.39 Normal BNP level = 0.16 to 0.21 Multivariable evaluation: EGSYS score less than 3 = 0.12–0.17 Absence of heart disease, abnormal ECG or both = 0.20 Vasovagal score −2 or more = 0.10–0.84 Syncope or transient loss of consciousness is a common problem seen in the emergency department (ED), accounting for 1% to 1.5% of ED visits annually.1 Cardiac syncope caused by cerebral hypoperfusion secondary to cardiopulmonary events such as arrhythmia or structural heart disease, accounts for 5% to 21% of syncope events.2 Cardiac syncope is associated with an increased risk of premature death and cardiac events.3, 4 It is therefore important for emergency providers to differentiate cardiac syncope from other causes. This systematic review by Albassam et al.5 evaluated patient characteristics, physical examination findings, and diagnostic tests to identify cardiac causes of syncope. The authors searched the MEDLINE, Embase, CINAHL, and Cochrane databases, selecting 11 studies that met inclusion and exclusion criteria. Each study included at least 10 subjects aged 12 years or older, for a total of 4,317 patients. Studies were assigned levels of evidence developed for the Rational Clinical Examination series.6 Several historical factors were associated with an increased likelihood of cardiac syncope including age at first syncopal episode 35 years or older; history of atrial fibrillation or flutter; known severe structural heart disease; dyspnea or chest pain prior to syncope; and witnessed cyanosis during syncope. An elevated cardiac troponin T or I and an elevated B-type natriuretic peptide (BNP) both modestly increased the probability of cardiac syncope. Factors that decreased the probability included age less than 35 years at first syncopal episode; normal cardiac troponin T or I; and normal BNP. Combinations of findings such as Evaluation of Guidelines in Syncope Study (EGSYS) score ≥ 3; vasovagal score < −2; and abnormal electrocardiogram, heart disease, or both were more useful when absent than when present. The results of this review should be interpreted cautiously. Included studies generally defined cardiac syncope based on cardiologist judgment. Five of 11 studies included specialty referral populations or inpatients, leading to the potential for spectrum bias. Applying these results to a general ED population might lead to additional testing or interventions in patients who have lower risk of cardiac syncope than the studied population. Misclassification may have further skewed the results as patients with unexplained syncope were excluded from several studies. Many of the clinical findings resulted from single studies. Studies often included a wide age range of patients despite the incidence of syncope, related ED visits, and serious outcomes increasing sharply after the age of 60.7 Cardiac biomarkers such as troponin or BNP testing appear to be an attractive diagnostic option, however, they did not rule in or rule out cardiac syncope. Moreover, these cardiac biomarkers were likely used to diagnose cardiac syncope leading to incorporation bias. ACEP clinical policy, appreciating these limitations, suggests a risk stratification approach focusing on patient history and physical examination to avoid unnecessary testing and hospital admissions.1 In summary, the accurate diagnosis of cardiac syncope is helpful in determining an appropriate plan of care. While no single variable can independently diagnose or exclude cardiac syncope, several clinical findings may be used cohesively to help guide health care providers.

Fatigue and Functional Outcomes in Cancer Rehabilitation

Abstract Date Presented 4/20/2018 The purpose of this study was to determine whether fatigue severity on admission influenced functional outcomes in an inpatient oncology rehabilitation population. Results can help guide practitioners to develop appropriate plans of care for this population. Primary Author and Speaker: Karla Garrity Additional Authors and Speakers: Twyla Fink, Monica Arrigo Contributing Authors: Lisa Wood, Lynne Brady-Wagner

20 Comparison of Admission Rates Among Patients Treated by Male and Female Emergency Physicians

The volume of emergency department (ED) visits has been steadily increasing over the past decade. Also, in parallel, the number of board certified emergency medicine (EM) physicians has been growing. One of the most important decisions made in a patient’s course in the ED is the development of a disposition plan by the physician provider. Many factors influence the development of an appropriate plan of care, such as, patient medical and social needs. Literature from other specialties such as internal medicine and general surgery have shows us that practice patterns and outcomes differ at times by non-patient factors, more specifically, by physician sex bias. Studies in EM have shown non-patient variables that potentially have an influence such as ED crowding and years of physician experience. No paper to date has looked at sex of EM providers in the United States as a function of adult admission rates. The current study seeks to investigate admission rates of adult patients who are treated by male versus female emergency physicians, in order to identify whether or not a practice pattern bias exists. This was a multi-center retrospective cross-sectional study of one health care system in the Midwest. All patient encounters by EM-trained physicians in the emergency department of 4 hospitals over the academic year, July 1, 2016 to June 30, 2017 were analyzed. The primary outcome was admission rate of each physician with admission rate defined as the percentage of encounters that resulted in admission to the hospital as a portion of all encounters. Admission defined by patients who were admitted to observation, inpatient or emergent surgery from the ED. Any physician with less than 100 patient encounters was excluded. Secondary analysis assessed physician metrics and benchmarks with potential confounding effects: patient acuity, average length of stay, return visits, patient age and years of practice by physician, using independent samples t-tests. 110,230 patient encounters were analyzed, treated by 80 emergency physicians; 49 male, 31 female. The average admission rates were male 28%, female 29%, t = .504 with equal variances assumed. Acuity of patients seen by providers: male .741, female .763, t = -2.862. Average length of stay in minutes: male 264, female 292, t = -2.158. Average returns visits per 1,000: male 8.24, female 8.37, t = -.222. Patient age: male 49.74, female 51.12, t = -1.439. Years of practice: male 20.24, female 15.77, t = 2.097. In this analytic retrospective observational study, we found that the difference of admission rates of male and female EM providers was not statistically significant. We did find significance between the average length of stay, patient acuity seen and years of practice. The etiology of these significances can be postulated to be interrelated. Further studies are needed with a greater sample size of physicians to potentially find sex bias practice patterns and differences.Table 1Descriptive statistics with independent samples t-testsAdmission RatePatient Acuity (0-1)Average LOS (minutes)Returns per 1,000Patient AgeYears of PracticeMale28%0.7412648.2449.7420.24Female29%0.7632928.3751.1215.77T value0.504-2.862-2.158-0.222-1.4392.097 Open table in a new tab

FROM DYSTOPIA TO UTOPIA: THE PERCEPTIONS OF OSTOMY CLIENTS

Following ostomy surgery, patients experience overwhelming changes which often affect their overall well-being (Ito et al., 2012). Surprisingly, there is paucity on the perceptions and views of clients with an ostomy in a Filipino understanding. A phenomenological lens anchored on the philosophy of Husserl was used to discover and describe the lived experience of clients with ostomy. Purposive-Snowball sampling was utilized in the study. Conversational, formal and semi-structured interviews were the methods used as means to unravel the experience of the participants. Data analysis was based on Colaizzi’s methodology. The whole process was based on the data, transcribed interviews, sorting, categorizations (cool analysis), categories as thematized (warm analysis) and a repertory grid or a dendrogram that paved the way to discovering the value of the lived experiences of clients with ostomy. The description of the experience revealed two major themes namely, the Dystopia experience that emanate from the participants’ negative perceptions of alienation, desolation and desperation. Moreover, the second theme is the Utopia experience that derives from the participants’ understanding of acceptance, gratitude, and enlightenment. It is imperative that there is a need to understand the perceptions of clients with ostomy to devise an appropriate plan of care that addresses the main goal of a healthy transition.

An Actual Advance in Advance Directives: Moving from Patient Choices to Patient Voices in Advance Care Planning.

Since the concept of the living wills emerged nearly 50years ago, there have been practical challenges in translating the concept of an advance directive (AD) into documents that are clinically useful across various healthcare settings and among different patient populations and cultures. Especially, challenging has been the reliance in most ADs on pre-selected "choices" about specific interventions which either revolve around broad themes (e.g., "prolong life / do not prolong life") or whether or not to utilize particular interventions (e.g., CPR, mechanical ventilation), both of which about most laypersons know little and, more importantly, lacking context, prove to be of limited meaningfulness. Moreover, whether by foundational frame, decade-long misunderstanding in medicine and bioethics, or different societal customs, these ADs present decision-making responsibility for initiating, continuing, or withdrawing medical interventions as a patient responsibility-creating a burden for which most patients are unprepared-and hence reducing healthcare providers' responsibility to mere technical application or customer service. At our institution, significant efforts have focused on embracing the unique and complementary responsibilities of patients (articulating their goals, values, and preferences) and physicians (using medical expertise to reach patient goals) for enabling appropriate plans of care. This includes re-structuring our AD form to more accurately represent patient's values as the frame within which physicians are responsible for determining appropriate care. Rather than specifying interventions, the AD makes patients responsible for specifying what matters to them as well as what they value in terms of function, interaction, and level of acceptable burden, thus providing clear goals for clinicians to pursue-or when goals are not reachable by available medical interventions, to acknowledge and allow for logical shifts to what may be achieved, including, in end of life contexts, care focused on respect and dignity.

The Fontan Procedure for Single-Ventricle Physiology.

The Fontan procedure is the final procedure in staged palliation for patients with functional single-ventricle physiology. The goal of the procedure is to separate systemic and pulmonary blood flow by directing systemic venous return through the Fontan connection to the pulmonary arteries and the lungs without ventricular contribution. Following the procedure, pulmonary blood flow is completely passive and dependent on pressure gradients, resulting in complex postoperative cardiopulmonary interactions. Understanding the physiology is essential to effectively manage these patients. Critical care nurses caring for patients after a Fontan procedure must understand preoperative data, risk factors, and unique postoperative physiology so they can anticipate specific postoperative problems, recognize trends in clinical status, and develop an appropriate plan of care. This paper reviews the first 2 stages of single-ventricle palliation, relevant modifications to the Fontan procedure, important preoperative cardiac catheterization data, common postoperative problems, and outcomes after the Fontan procedure.

Management of Rotator Cuff Injuries in the Elite Athlete.

Rotator cuff injuries are a common cause of pain and dysfunction for the elite athlete and can result in time loss from participation. This review highlights the current management of these injuries. Conservative management of rotator cuff injuries continues to be the "gold standard" in the elite athlete. This includes a comprehensive rehabilitation program, anti-inflammatories, and corticosteroid injections. Newer treatment techniques such as intramuscular dry needling and the use of biologics such as platelet-rich plasma and stem cells demonstrate early promising results; however, these modalities require further investigation to determine their effectiveness. Rotator cuff injuries can range from contusions and tendinopathy to full-thickness tears. A comprehensive evaluation is needed to determine the extent of injury and appropriate plan of care. Management strategies can range from rehabilitation to operative intervention and are guided by the size of the tear, time of season, sport, performance limitations, and presence of concomitant pathology.

Learning Implicit Tasks for Patient-Specific Risk Modeling in ICU

Accurate assessment of the severity of a patient’s condition plays a fundamental role in acute hospital care such as that provided in an intensive care unit (ICU). ICU clinicians are required to make sense of a large amount of clinical data in a limited time to estimate the severity of a patient’s condition, which ultimately leads to the planning of appropriate care. The ICU is an especially demanding environment for clinicians because of the diversity of patients who mostly suffer from multiple diseases of various types. In this paper, we propose a mortality risk prediction method for ICU patients. The method is intended to enhance the severity assessment by considering the diversity of patients. Our method produces patient-specific risk models that reflect the collection of diseases associated with the patient. Specifically, we assume a small number of latent basis tasks, where each latent task is associated with its own parameter vector; a parameter vector for a specific patient is constructed as a linear combination of these. The latent representation of a patient, namely, the coefficients of the combination, is learned based on the collection of diseases associated with the patient. Our method could be considered a multi-task learning method where latent tasks are learned based on the collection of diseases. We demonstrate the effectiveness of our proposed method using a dataset collected from a hospital. Our method achieved higher predictive performance compared with a single-task learning method, the “de facto standard,” and several multi-task learning methods including a recently proposed method for ICU mortality risk prediction. Furthermore, our proposed method could be used not only for predictions but also for uncovering patient-specificity from different viewpoints.

Telenutrition in oncology: A novel model of care in a geographically diverse network.

43 Background: Telehealth is growing as a way for qualified providers to reach patients closer to home. Dietitians have been using telephone counseling to support cancer patients for years, but recently consults via videoconference have emerged to better duplicate in office, face-to-face service. Telenutritionallows Registered Dietitians (RDs)who are also Certified Oncology Specialists in Nutrition (CSOs) to provide patients consults at their regular medical oncologist’s office. As part of its goal to provide expert care to oncology patients in regional settings, genetics counselors, social workers, and Palliative Care providers at Levine Cancer Institute (LCI) are currently using a telehealth model to provide services traditionally available only in metro areas. Methods: RDs located within the LCI Network receive consults from regional sites in NC based on established criteria. LCI RDs use Vidyo to teleconference between LCI locations to meet with patients, caregivers, and the healthcare team to establish an appropriate plan of care. Appointments are scheduled directly on the virtual schedule by the referring office. Consents are signed and scanned into the chart. Assessment is completed using the same protocol and policy as face-to-face consults, and follow up can conducted via teleconference or phone, based on patient preference and the clinical judgement of the RD. Patient satisfaction surveys are completed at the end of each telenutritionsession and sent to the RD. Results: LCI initially started telenutritionwith one regional site in 2014, completing 3 consults with one RD housed at its main location. In 2015, three additional sites were added, as well as an additional RD housed regionally, and 22 consults were completed. 22 consults have been completed year to date in 2016. Conclusions: Early feedback from patients and providers suggest telenutrition may be an effective method to deliver quality nutritional interventions to patients in the comfort of their regular oncology office. Formal study is needed to explore patient barriers to care, reimbursement for services, expense of equipment, and feasibility of program expansion.

Should Tomorrow Be? Ethical and Medical Challenges of Spinal Cord Injury Patients and the Need for Multidisciplinary Palliative Medicine Support (SA536)

Participants will be able to describe appropriate assessment components and frequency of assessment after an opioid dosage error and develop an appropriate plan of care based on the type and amount of opioid involved in the error. Describe the components of a protocol outlining the safe and appropriate use of narcan in opioid tolerant patients with pain along with the risks of using narcan for full reversal of opioids in opioid tolerant patients with pain. Despite robust teaching, opioid dosage errors occur in the hospice and palliative care setting. This presentation will explore the components of a robust opioid teaching plan, including patient teaching tools. We will review the risks associated with opioid dosage errors based on the type of opioid (short or long acting) and the patient’s history of opioid use and discuss appropriate follow up for each type of dosage error. Narcan is not always the answer. We will share the protocol we developed in response to a methadone dosage error.

“They Got How Much Methadone?” What We Learned About How to Best Respond to Opioid Dosage Errors (SA535)

•Describe the risks associated with dosage errors for both long-acting opioids such as methadone and short-acting opioids such as morphine. Participants will be able to describe appropriate assessment components and frequency of assessment after an opioid dosage error and develop an appropriate plan of care based on the type and amount of opioid involved in the error.•Describe the components of a protocol outlining the safe and appropriate use of narcan in opioid tolerant patients with pain along with the risks of using narcan for full reversal of opioids in opioid tolerant patients with pain. Despite robust teaching, opioid dosage errors occur in the hospice and palliative care setting. This presentation will explore the components of a robust opioid teaching plan, including patient teaching tools. We will review the risks associated with opioid dosage errors based on the type of opioid (short or long acting) and the patient’s history of opioid use and discuss appropriate follow up for each type of dosage error. Narcan is not always the answer. We will share the protocol we developed in response to a methadone dosage error.

Sickle cell disease in adults: developing an appropriate care plan.

Sickle cell disease (SCD) is primarily characterized by pain. This chronic pain with acute exacerbations is the most common reason for hospital visits, admissions, and readmissions, particularly in young adults (aged 18–39 years). People who present to the hospital for pain crises often report that nurses lack knowledge of SCD and, consequently, they do not provide appropriate, timely care. Because pain episodes often result in hospital admissions, this article highlights prominent issues that staff nurses need to know. Using a review of the literature and case studies, the authors provide recommendations to improve care of adults with SCD. No objective signs of a sickle cell pain crisis exist. Patients react to pain in different ways and use various coping mechanisms in response. Suspected opioid addiction should not affect the provision of nursing care. Pain must be treated appropriately to decrease the potential for prolonged admissions and/or readmissions. Patients are to be acknowledged as experts and collaborated with in developing an appropriate plan of care. Advocacy on behalf of the patient is important for better communication with providers. With this knowledge, nurses will be better equipped to provide the appropriate and timely care required to manage pain crises experienced by individuals living with SCD.

Diagnosing Child Abuse: The Role of the Nurse Practitioner

Child abuse is a major epidemic within the United States, affecting over 3 million children in 2011. Although specific children may be at increased risk, child abuse can affect anyone, at any time. To provide care, a nurse practitioner must be know the clinical manifestations, differential diagnoses, and epidemiology to accurately rule-out other disorders and develop an appropriate plan of care.