Evidence-based Care Plans Research Articles

Increased postoperative day one discharges after implementation of a hysterectomy enhanced recovery pathway: a retrospective cohort study.

In 2011, the hysterectomy enhanced recovery (HER) pathway, a multi-disciplinary, evidence-based care plan designed to improve recovery after open gynecologic surgery for non-malignant lesions, was introduced at The Ottawa Hospital (TOH). This before-and-after study examined the impact of the HER pathway on postoperative day (POD) 1 hospital discharge. Ethical approval was obtained. This retrospective cohort study included patients who had undergone open abdominal gynecologic surgery for non-malignant lesions at TOH Civic Campus between July 2010 and September 2012 (the year before and year after HER implementation). Patients were analyzed in either a pre-HER or post-HER group depending on their surgery date. Patients with chronic pain and emergent surgery were excluded. Data were obtained via medical chart review. Our primary outcome was the percentage of POD 1 discharges before and after HER implementation. Secondary outcomes included return to hospital within 30 days of discharge, median length of stay (LOS), clinician compliance with HER, and an exploratory analysis with multivariable modelling to evaluate which aspects of the HER independently predicted POD 1 discharge. Variables used included American Society of Anesthesiologists physical status (≥ II), prior abdominal surgery, body mass index, use of transversus abdominis plane blocks, and anesthetic type. Among the 223 patients, significantly more POD 1 discharges occurred for post-HER compared to pre-HER patients (34% vs 7%, respectively; adjusted odds ratio [OR] = 7.33; 95% confidence interval [CI] = 3.05 to 17.62). Rates of return to hospital at 30 days were similar between the groups (10% post-HER and 13% pre-HER; adjusted OR = 0.74; 95% CI = 0.32 to 1.74). The median length of stay was two days in the post-HER group and three days in the pre-HER group (P < 0.0001). Only inhalational general anesthesia was independently associated with decreased odds of POD 1 discharge (adjusted OR = 0.16, 95% CI = 0.04 to 0.65). For patients undergoing abdominal hysterectomy, implementation of a HER pathway is associated with a higher POD 1 discharge rate, with no increase in the early return to hospital rate.

Palliative Care at the End of Life

To describe the process of symptom management in the care of oncology patients with advanced cancer. Journal articles, evidence-based reviews, textbooks, and clinical guidelines. Symptom management is an essential component of oncology nursing practice that improves quality of life for patients and families throughout the cancer trajectory. Effective symptom management requires that oncology nurses holistically assess the patient's symptom experience and goals of care, formulate specific symptom diagnoses, and develop, implement, and evaluate the outcomes of an evidence-based plan of care that is individualized and acceptable to the patient.

Simulated Electronic Health Record (Sim-EHR) Curriculum

Electronic health records (EHRs) can improve many aspects of patient care, yet few formal EHR curricula exist to teach optimal use to students and other trainees. The Simulated EHR (Sim-EHR) curriculum was introduced in January 2011 at Oregon Health & Science University (OHSU) to provide learners with a safe hands-on environment in which to apply evidence-based guidelines while learning EHR skills. Using an EHR training platform identical to the OHSU EHR system, learners review and correct a simulated medical chart for a complex virtual patient with chronic diseases and years of fragmented care. They write orders and prescriptions, create an evidence-based plan of care for indicated disease prevention and management, and review their work in a small-group setting. Third-year students complete the Sim-EHR curriculum as part of the required family medicine clerkship; their chart work is assessed using a rubric tied to the curriculum's general and specific objectives. As of January 2014, 406 third-year OHSU medical students, on campus or at remote clerkship sites, and 21 OHSU internal medicine interns had completed simulated charts.In this article, the authors describe the development and implementation of the Sim-EHR curriculum, with a focus on use of the curriculum in the family medicine clerkship. They also share preliminary findings and lessons learned. They suggest that the Sim-EHR curriculum is an effective, interactive method for providing learners with EHR skills education while demonstrating how a well-organized chart helps ensure safe, efficient, and quality patient care.

Evidence-Based Solution-Focused Care for School-Age Children Experiencing Cyberbullying: Using the Omaha System to Guide and Document Psychiatric Nursing Interventions

Cyberbullying is a global phenomenon. The experiences of bullied children are the same across cultures and languages, and psychiatric nursing interventions are known to be effective. It is critical to widely disseminate effective interventions to identify and address cyberbullying. Therefore, evidence-based care plans addressing cyberbullying at the individual and community levels were developed using the Omaha System, a terminology that is used internationally to guide and document care. This article presents a case study in which an evidence-based intervention was used to help a bullied child arrive at a solution, and demonstrates the use of the Omaha System to document evidence-based cyberbullying interventions with individuals and communities.

From Door to Recovery: A Collaborative Approach to the Development of a Post–Cardiac Arrest Center

Out-of-hospital cardiac arrest remains common and, despite advances in resuscitation practices, continues to carry a high mortality that may be influenced by several factors, including where a patient is cared for after the cardiac arrest. Implementing a post-cardiac arrest care guideline for survivors of out-of-hospital and in-hospital cardiac arrest involves a multidisciplinary approach with short-term and long-term strategies. Physician and nursing leaders must work in synergy to guide the implementation of an evidence-based plan of care. A collaborative approach was used at a hospital to develop processes, build consensus for protocols, and provide support to staff and teams. A joint approach has allowed the hospital to move from traditional silos of individual departmental care to a continuum of patient-focused management after cardiac arrest. This care coordination is initiated in the emergency department and follows the patient through to discharge.

PC-FACS

PC-FACS

The Evidence against Prophylactic Nasogastric Intubation and Oral Restriction

Evidence-based perioperative care plans after colorectal surgery serve to improve quality outcome, decrease complications, and reduce medical cost. The benefits of routine nasogastric decompression and prolonged enteral restriction after bowel resection are not supported in this new era of evidence-based surgical care. Prophylactic nasogastric decompression fails to improve bowel function, length of stay, and prevent anastomotic leak, wound complications (infection, fascial dehiscence, incisional hernia), pulmonary complications (atelectasis, aspiration, pneumonia, fever, pharyngolaryngitis), and abdominal discomfort (distension, nausea, vomiting). Patients have earlier return of bowel function without the use of a nasogastric tube (NGT). Early refeeding within 24 hours after bowel resection is well tolerated in 80 to 90% of patients, and associated with earlier hospital discharge, decreased risk of infection, and improved postoperative hyperglycemic control. Abdominal discomfort is the most common complication observed in patients treated with early feeding and without a NGT, but does not result in higher therapeutic nasogastric intubation, postoperative ileus, aspiration, or other complications. The use of multimodal adjuncts in combination with these guidelines should be considered to improve outcome. The current literature is reviewed with suggestions for achieving better outcomes after colorectal resection.

Management of delirium on acute geriatric wards: A survey in Belgian hospitals

BackgroundDelirium often occurs among hospitalized older patients and is associated with high rates of mortality and morbidity, institutionalization and increased length of stay. Despite its clinical importance, delirium is frequently not recognized and poorly managed in acute care settings. A clear policy or guideline can be of help in the early detection and management of patients with delirium. ObjectivesGain insight into the existence and use of structured delirium management protocols on geriatric wards of Belgian hospitals. MethodsThis study involved 110 hospitals with an acute geriatric ward. A questionnaire was developed by a multidisciplinary panel of experts (geriatricians and nurses) and sent to the medical head of the geriatric department. The response rate was 59.1%. ResultsOnly one quarter (n=17; 26.2%) of the Belgian hospitals have a written delirium policy at the geriatric department level. At hospital level, the presence of a policy is even less frequent (n=10; 15.4%). Although the majority (n=36; 72%) state to have an oral or written arrangement for delirium prevention, only few have a written protocol to identify the cause (n=10; 15.4%) and to manage (n=9; 13.8%) delirium. Furthermore, only 22.6% (n=14.5) have an information leaflet available for patients and/or family. ConclusionGiven the high rates and complexity of delirium management in geriatric wards, hospitals need to further implement evidence-based prevention, screening and standard intervention care plans to maintain uniformity and quality of care in delirium management.

Estimating population size, HIV prevalence and HIV incidence among men who have sex with men: a case example of synthesising multiple empirical data sources and methods in San Francisco

ObjectiveThe number of persons living with HIV/AIDS, the number of new infections and the number of persons at risk for HIV infection are the foundations of evidence-based prevention, treatment and...

Development of a Proactive Care Program (U‐CARE) to Preserve Physical Functioning of Frail Older People in Primary Care

Care for older patients in primary care is currently reactive, fragmented, and time consuming. An innovative structured and proactive primary care program (U-CARE) has been developed to preserve physical functioning and enhance quality of life of frail older people. This study describes in detail the development process of the U-CARE program to allow its replication. The framework of the Medical Research Council (MRC) for the development and evaluation of complex interventions was used as a theoretical guide for the design of the U-CARE program. An extended stepwise multimethod procedure was used to develop U-CARE. A team of researchers, general practitioners, registered practice nurses, experts, and an independent panel of older persons was involved in the development process to increase its feasibility in clinical practice. A systematic review of the literature and of relevant guidelines, combined with clinical practice experience and expert opinion, was used for the development of the intervention. Based on predefined potentially effective guiding components, the U-CARE program comprises three steps: a frailty assessment, a comprehensive geriatric assessment at home followed by a tailor-made care plan, and multiple follow-up visits. Evidence-based care plans were developed for 11 geriatric conditions. The feasibility in clinical practice was tested and approved by experienced registered practice nurses. Using the MRC Framework, a detailed description of the development process of the innovative U-CARE program is provided, which is often missing in reports of complex intervention trials. Based on our feasibility-pilot study, the general practitioners and the registered practice nurses indicated that the U-CARE intervention is feasible in clinical practice. The U-CARE program consists of promising components and has the potential to improve the care of older patients.

A matched-pair cluster-randomized trial of guided care for high-risk older patients.

Patients at risk for generating high health care expenditures often receive fragmented, low-quality, inefficient health care. Guided Care is designed to provide proactive, coordinated, comprehensive care for such patients. We hypothesized that Guided Care, compared to usual care, produces better functional health and quality of care, while reducing the use of expensive health services. 32-month, single-blind, matched-pair, cluster-randomized controlled trial of Guided Care, conducted in eight community-based primary care practices. The "Hierarchical Condition Category" (HCC) predictive model was used to identify high-risk older patients who were insured by fee-for-service Medicare, a Medicare Advantage plan or Tricare. Patients with HCC scores in the highest quartile (at risk for generating high health care expenditures during the coming year) were eligible to participate. A registered nurse collaborated with two to five primary care physicians in providing eight services to participants: comprehensive assessment, evidence-based care planning, proactive monitoring, care coordination, transitional care, coaching for self-management, caregiver support, and access to community-based services. Functional health was measured using the Short Form-36. Quality of care and health services utilization were measured using the Patient Assessment of Chronic Illness Care and health insurance claims, respectively. Of the eligible patients, 904 (37.8 %) gave written consent to participate; of these, 477 (52.8 %) completed the final interview, and 848 (93.8 %) provided complete claims data. In intention-to-treat analyses, Guided Care did not significantly improve participants' functional health, but it was associated with significantly higher participant ratings of the quality of care (difference = 0.27, 95 % CI = 0.08-0.45) and 29 % lower use of home care (95 % CI = 3-48 %). Guided Care improves high-risk older patients' ratings of the quality of their care, and it reduces their use of home care, but it does not appear to improve their functional health.

Application of the NICU Practice Guidelines to Treat an Infant in a Level III NICU

The purpose of this case report was to determine how current physical therapy (PT) practice in the neonatal intensive care unit (NICU), with 1 infant, adhered to the neonatal PT decision-making framework that was developed as part of the NICU practice guidelines for clinical care. Most PT interventions implemented in this NICU were supported by the algorithm, with some steps more readily implemented than others. This case report highlights the utility of the NICU clinical decision-making algorithm for not only assisting with developing an evidence-based PT plan of care for an infant at high risk but also its usefulness in revealing NICU programmatic and policy strengths and areas for improvement. The NICU developmental and therapeutic teams are encouraged to conduct similar endeavors to assess the quality of PT care in their NICUs.

Firefighter hearing health: An informatics approach to screening, measurement, and research

Objective: The purpose of this study was to evaluate the use of a standardized interface terminology, the Omaha System, with respect to noise-induced hearing loss (NIHL). Design: A descriptive, correlational design was employed for this secondary analysis with the data from an ongoing hearing protection intervention study. Study sample: A total of 346 firefighters were included. Results: First, an evidence-based standardized care plan (EB-SCP) for hearing screening was developed and validated by clinical experts. Second, occupational health records were used to compute Omaha System Knowledge, Behavior, and Status outcomes. Third, research data were mapped to Omaha System rating scales. For Knowledge, the mean score was close to ‘adequate’ (3.7). For Behavior, the mean score was close to ‘rarely appropriate’ (2.2). For Status, the mean score was close to ‘minimal sign/symptom’ (4.4). Significant positive relationships were found between Knowledge and Behavior (Spearman's rho =.13, p =.01), and between Behavior and hearing Status (Spearman's rho =.12, p =.02). Conclusions: Findings support the validity of the new Knowledge, Behavior, and hearing Status. Informatics methods such as the standardized NIHL EB-SCP and outcome data sets will create opportunities for clinical decision support and data exchange across various health care settings, thus supporting population-based hearing health assessments and outcomes.

Developing a Personal Health Record for Community-Dwelling Older Adults and Clinicians: Technology and Content

To empower older consumers and improve health outcomes, a consumer-friendly personal health record (PHR) is needed. The purpose of this article was to evaluate PHR technology and content for older community-dwelling consumers. Specific aims were to: (a) develop a secure, web-based application for a PHR to enable interoperable exchanges of data between consumers and clinicians; (b) develop structured, evidence-based shared care plan content for the PHR using an interface terminology standard; and (c) validate the shared care plans with consumers. An interoperable web-based form was developed. The standardized PHR content was developed by expert panel consensus using the Omaha System problem list and care plans, and validated by consumer interviews. Evidence-based shared care plans for 21 problems common among community-dwelling older adults were developed and encoded with Omaha System terms for data capture in the PHR. An additional problem, Neighborhood-workplace safety, was identified by consumers and will be added to the care plans.

PS2-20: The Development of Educational Materials to Assist Family and Friend Caregivers and Healthcare Providers in Caring For Persons with Incontinence and Dementia

Jody Jackson, RN, BSN1, Donna Bliss, PhD, RN2, Kenneth Hepburn, PhD3, Casey Arntson2, Jean Mullins2 and Sharon Rolnick, PhD, MPH1 1HealthPartners 2University of Minnesota 3Emory University

Managing dementia agitation in residential aged care

Agitation is a widespread and challenging problem among aged care residents with dementia. This article draws on empirical and theoretical literature to propose a model for preventing and treating agitation non-pharmacologically. A literature review finds agreed, coherent definition and measurement of agitation to be absent despite numerous agitation remedies having been suggested, yet sufficient material to support evidence-based care planning. Agitation is revealed as resulting from a resident’s interactions with the environment or their internal state, giving rise to unmet needs that attentive care can treat. Agitation treatments are reviewed to find no single effective remedy and a lack of quality evaluation. A higher-order, problem-solving approach is proposed. The described system consists of sequential diagnosis, decision making and treatment options, commencing with individualized and institutional preventative measures removing environmental triggers, followed by individual remediation, with residents’ unmet needs receiving priority consistent with patient-centred care.

Methods to improve effectiveness and retention of asthma education for children: a pilot project with 1 year follow-up

The Centers for Disease Control and Prevention reports that 7.5% of children under the age of 18 in the United States have an asthma diagnosis. Nurse practitioners will manage asthma for pediatric patients in well and acute primary care clinic visits. In both types of visits, nurse practitioner students must be able to assess the child and develop a treatment plan. When presented with a patient case, learners must have opportunities to demonstrate clinical reasoning progress through appropriate assessment and the ability to develop an evidence-based intervention or plan of care. This article describes an interactive, online, self-paced learning activity delivered via an online format designed to challenge learners to build these skills via an interactive, nonlinear, simulated patient visit.

The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial.

The effect of interdisciplinary primary care teams on the use of health services by patients with multiple chronic conditions is uncertain. This study aimed to measure the effect of guided care teams on multimorbid older patients' use of health services. Eligible patients from 3 health care systems in the Baltimore, Maryland-Washington, DC, area were cluster-randomized to receive guided care or usual care for 20 months between November 1, 2006, and June 30, 2008. Eight services of a guided care nurse working in partnership with patients' primary care physicians were provided: comprehensive assessment, evidence-based care planning, monthly monitoring of symptoms and adherence, transitional care, coordination of health care professionals, support for self-management, support for family caregivers, and enhanced access to community services. Outcome measures were frequency of use of emergency departments, hospitals, skilled nursing facilities, home health agencies, primary care physician services, and specialty physician services. The study included 850 older patients at high risk for using health care heavily in the future. The only statistically significant overall effect of guided care in the whole sample was a reduction in episodes of home health care (odds ratio, 0.70; 95% confidence interval, 0.53-0.93). In a preplanned analysis, guided care also reduced skilled nursing facility admissions (odds ratio, 0.53; 95% confidence interval, 0.31-0.89) and days (0.48; 0.28-0.84) among Kaiser-Permanente patients. Guided care reduces the use of home health care but has little effect on the use of other health services in the short run. Its positive effect on Kaiser-Permanente patients' use of skilled nursing facilities and other health services is intriguing. Trial Registration clinicaltrials.gov Identifier: NCT00121940.

Tailored Prevention of Inpatient Falls

Patient falls and fall-related injuries are serious problems in hospitals. The Fall TIPS application aims to prevent patient falls by translating routine nursing fall risk assessment into a decision support intervention that communicates fall risk status and creates a tailored evidence-based plan of care that is accessible to the care team, patients, and family members. In our design and implementation of the Fall TIPS toolkit, we used the Spiral Software Development Life Cycle model. Three output tools available to be generated from the toolkit are bed poster, plan of care, and patient education handout. A preliminary design of the application was based on initial requirements defined by project leaders and informed by focus groups with end users. Preliminary design partially simulated the paper version of the Morse Fall Scale currently used in hospitals involved in the research study. Strengths and weaknesses of the first prototype were identified by heuristic evaluation. Usability testing was performed at sites where research study is implemented. Suggestions mentioned by end users participating in usability studies were either directly incorporated into the toolkit and output tools, were slightly modified, or will be addressed during training. The next step is implementation of the fall prevention toolkit on the pilot testing units.

Tailored Prevention of Inpatient Falls

Patient falls and fall-related injuries are serious problems in hospitals. The Fall TIPS application aims to prevent patient falls by translating routine nursing fall risk assessment into a decision support intervention that communicates fall risk status and creates a tailored evidence-based plan of care that is accessible to the care team, patients, and family members. In our design and implementation of the Fall TIPS toolkit, we used the Spiral Software Development Life Cycle model. Three output tools available to be generated from the toolkit are bed poster, plan of care, and patient education handout. A preliminary design of the application was based on initial requirements defined by project leaders and informed by focus groups with end users. Preliminary design partially simulated the paper version of the Morse Fall Scale currently used in hospitals involved in the research study. Strengths and weaknesses of the first prototype were identified by heuristic evaluation. Usability testing was performed at sites where research study is implemented. Suggestions mentioned by end users participating in usability studies were either directly incorporated into the toolkit and output tools, were slightly modified, or will be addressed during training. The next step is implementation of the fall prevention toolkit on the pilot testing units.