Inpatient Medical-surgical Unit Research Articles

Reduction of Very Rapid Emergency Transfers to the Pediatric Intensive Care Unit.

Emergency transfers are associated with increased inpatient pediatric mortality. Therefore, interventions to improve system-level situational awareness were utilized to decrease a subset of emergency transfers that occurred within four hours of admission to an inpatient medical-surgical unit called very rapid emergency transfers (VRET). Specifically, we aimed to increase the days between VRET from non-ICU inpatient units from every 10 days to every 25 days over 1 year. Using the Model for Improvement, we developed an interdisciplinary team to reduce VRET. The key drivers targeted were the admission process from the emergency department and ambulatory clinics, sepsis recognition and communication, and expansion of our situational awareness framework. Days between VRET defined the primary outcome metric for this improvement project. After six months of interventions, our baseline improved from a VRET every 10 days to every 79 days, followed by another shift to 177 days, which we sustained for 3 years peaking at 468 days between events. Interventions targeting multiple admission sources to improve early recognition and communication of potential clinical deterioration effectively reduced and nearly eliminated VRET at our organization.

An interprofessional discharge planning curriculum in the clinical learning environment

Evidence suggests that medical errors are most likely to occur during care transitions, i.e., handoffs from unit to unit or discharge home. Lapses in coordination and communication, poorly delineated professional roles and responsibilities, and lack of patient/family engagement are often associated with resulting patient harm. This manuscript describes a small sample interprofessional learning experience executed within the acute care setting, with the goal of positively affecting Interprofessional Education Collaborative (IPEC) competencies, attitudes toward teamwork, and professional role development among nursing and medical students. Nursing and medical students engaged in a 4-week learning activity centered on discharge planning of patients on an inpatient medical-surgical unit. Our project demonstrated not only positive shifts in understanding and attitudes toward teamwork, but also the feasibility of implementing an interprofessional learning activity in the clinical environment.

Stewardship Nightmare: Ceftolozane/Tazobactam–Resistant Pseudomonas aeruginosa Infections Accelerated by the COVID-19 Pandemic

Background: The Centers for Disease Control and Prevention reported 32,600 cases, 2,700 deaths, and healthcare costs of 767 million dollars attributed to multidrug-resistant Pseudomonas aeruginosa. A recent study of 128 patients with nosocomial pneumonia due to P. aeruginosa showed the noninferiority of ceftolozane-tazobactam compared to meropenem. However, the resistance of ceftolozane-tazobactam due to AmpC mutations has been described. Compared with 2019, we observed an increase from 2 to 13 cases of ceftolozane-tazobactam–resistant P. aeruginosa (CRPA) during the COVID-19 pandemic at our institution in the Bronx, New York. Methods: A report of patients with CRPA between March and August 2020 was obtained. Data collected included demographics, hospitalization/IV antibiotic use in prior 90 days, SARS-CoV-2 PCR result, ICU admission, length of stay, antibiotic days of therapy, mortality, etc. Results: In total, 13 patients with CRPA infection were reviewed (Table 1). Among them, 2 patients were on the same inpatient medical-surgical unit but separated by 5 months. Also, 11 patients were from different medical-surgical units or ICUs. In addition, 5 patients (38%) were SARS-CoV-2 PCR positive. None of these COVID-19 patients were cohorted on the same unit, making horizontal spread of CRPA or COVID-19 unlikely. Finally, 8 of these patients died while hospitalized (4 were COVID-19 patients). Conclusions: We found a high incidence of mortality in patients with CRPA infection. Many patients had prolonged hospital stay and required ICU admission. Few patients were from long-term care facilities. Given the associated morbidity and mortality, increased surveillance and intensified antimicrobial stewardship efforts are needed to mitigate the impact of CRPA during the COVID-19 pandemic.Funding: NoDisclosures: None

Signal Detection to Measure Allostatic Load.

To illustrate a means to calculate allostatic load in hospitalized patients using big data from the electronic medical record (EMR). To describe the development of the Troubled Outcome Risk (TOR) scale using signal detection in big data. Using both retrospective and prospective observational studies, I describe a mechanism to determine meaning from retrospective data then use the results to improve nursing surveillance to reduce length of stay (LOS) and nursing sensitive indicators on an inpatient medical surgical unit. Results from the retrospective study contained over 290,000 individual data points and established an interpretation standard for the TOR score using an algorithm to detect signals. The prospective observational study used the TOR scale and developed an interpretation standard to assist unit charge nurses in assigning staff to patients based on a fully objective measure of patient allostatic load. The TOR scale in conjunction with existing nurse staffing methodology reduced inpatient LOS by 0.3 days, reduced allostatic load as measured by the TOR scale, and changed staffing patterns from purely geographic to patient-need based. The TOR scale demonstrates that careful evidence-based criteria can be easily gathered from the EMR and used to positively impact nursing practice and patient outcomes.

3. BRINGING RESIDENTS BACK TO BEDSIDE THROUGH TRADING CARDS

Background Physician burnout is well documented in residents. In response to these concerns, the ACGME launched the Back to Bedside initiative and sponsored projects that encouraged residents to engage with patients on a deeper level. The Resident Trading Card Program was created by pediatric residents as part of this movement. Objective To evaluate the impact of a patient-centered communication program on the physician-patient relationship, as perceived by first year pediatric residents over 12 months at a large tertiary care children's hospital. Methods Each first year resident received their own “trading cards” which contained a photograph of the resident with interesting biographical facts. Residents used their cards as an introduction to patients and families on two inpatient medical-surgical units. Patients were then invited to create their own cards, which were shared with residents. Following participation in the program, residents were asked to describe a meaningful interaction between themselves and their patient. Inductive qualitative methods were used to identify common themes. Questions adopted from a validated survey tool were used to elicit resident perceptions. Results 34 first year residents participated. Over 200 provider-patient interactions took place. The most common themes in the qualitative analysis of resident responses were: 1) Strengthening of the physician-patient relationship; 2) Influence of patient centered wellness on communication; 3) Impact of a nonclinical interaction on patient wellness; and 4) Improving ability to provide care. Residents felt the program increased feelings of connectedness with families (mean response score: 6.9) and improved communication (mean: 6.3). They reported the trading cards were useful from the perspectives of the provider (mean: 6.6), the patient (mean: 7.1), and the patients family (mean: 7.1). Residents did not feel the program's activities were intrusive to their work (mean: 4.0). Conclusion The Resident Trading Card Program is a novel initiative to bring residents back to their patients’ bedside and engage more deeply with both patients and family members.

Exploring nurses' perceptions of nurse managers' communicative relationships that encourage nurses' decisions to buy-in to initiatives that enhance patients' experiences with care.

To explore nurses' perceptions of nurse managers' (NMs') communicative relationships that encourage nurses' decisions to buy-in to organisational initiatives to enhance patients' experiences with care (PEC). The role of the nurse to patient experience is well established, yet little is known about how the communicative relationship between manager and nurse relates to nurse buy-in to PEC initiatives. An exploratory qualitative descriptive study was conducted with 15 nurses from two inpatient medical-surgical units in a large acute care hospital using semi-structured interviews. Three themes were identified. The communicative relationship was developed and strengthened through the manager's: (a) multimodal approach to communicating and influencing, (b) engaging and supporting staff and (c) promoting staff-led decision-making. Nurses in our study who reported having a strong communicative relationship with their NM perceived that this relationship encouraged their buy-in and engagement in PEC initiatives. An assessment of the communication between the frontline NM and his or her team is important for understanding why initiatives to support PEC are or are not yielding desired results.

Comprehensive nursing peer review: Our voice, our practice, our growth.

A hallmark of professional practice, nursing peer review is the process by which practicing RNs systematically assess, monitor, and give feedback to peers about the quality of nursing care measured against professional standards of practice.1 Nursing peer review supports self-regulation of clinical

What’s Old Is New Again: Psychosomatic Medicine Renamed C-L Psychiatry

Back to table of contents Previous article Next article Professional NewsFull AccessWhat’s Old Is New Again: Psychosomatic Medicine Renamed C-L PsychiatryJames Rundell,M.D.James Rundell,Search for more papers by this authorM.D.Published Online:27 Apr 2018https://doi.org/10.1176/appi.pn.2018.5a5AbstractThe new name better reflects the type and scope of the work done by psychiatrists in this subspecialty.The Academy of Psychosomatic Medicine (APM) has changed its name to the Academy of Consultation-Liaison Psychiatry. This follows an October 2017 action by the American Board of Medical Specialties (ABMS), acting on recommendations by the American Board of Psychiatry and Neurology (ABPN), APA, and APM. In November 2017, APM then voted to change its name to the Academy of Consultation-Liaison Psychiatry. The academy’s name change became effective on April 16.James R. Rundell, M.D., is president of the Academy of Consultation-Liaison Psychiatry.The name “psychosomatic medicine” had been selected by ABMS as the subspecialty’s board-certification name during deliberations conducted between 2000 and 2003. From the beginning, there was controversy and general dissatisfaction with the name. For many years APM’s council heard concerns from members that “psychosomatic medicine” was problematic; the primary concerns were that “psychosomatic medicine” had a pejorative connotation, had a negative impact on recruitment, and was not widely used by clinicians and academic departments. APM conducted several surveys to determine whether there was a consensus for a name change. In early 2016, a majority of APM members responded to an initial member survey; 68 percent supported a name change, 16 percent disagreed, and 16 percent were neutral. A second survey focused on how APM members were currently describing their field. The majority (55 percent) said they were using the name “consultation-liaison psychiatry”; only 17 percent said they used the term “psychosomatic medicine.” Finally, late in 2016, APM members were asked: “If other key national organizations were in favor, would you support changing the name of the field to consultation-liaison psychiatry, which would include also changing the name of the academy to mirror that term?” Of the 668 respondents, representing more than half of APM’s membership, 81 percent endorsed the name change.With robust support from APM members documented, APM then requested and received the support of the APA Board of Trustees for a name change for the field in December 2016. The next step was to petition the ABPN, the organization within ABMS that oversees accreditation in psychiatry. In February 2017, the ABPN Board of Directors voted to support the name change. The ABPN then took this request to the ABMS, which gave its approval at its annual meeting in October 2017. Finally, APM’s council recommended that academy members support changing APM’s name to the Academy of Consultation-Liaison Psychiatry, and at the academy’s annual meeting the following month, the members voted in favor of the change.The new name for the subspecialty is actually the old name. Consultation-liaison psychiatry developed several decades ago at a time when most of the clinical work was in inpatient medical-surgical units. Much has changed since then, and the council is focused on finding ways to market an expanded brand that captures a broad and deep set of practice settings. The word “liaison” will be branded by the academy to mean integrated care in primary care and specialty care outpatient settings, in addition to the important work done integrating psychiatric care into inpatient medical-surgical, critical care, and rehabilitation units.The academy will use the expansive stage of APA’s 2018 Annual Meeting to begin the process of educating psychiatrists and other physicians and the public about the name change. For example, APA TV is producing a video that will be widely seen during the meeting. APA’s Council on Psychosomatic Medicine (which also underwent a name change to the Council on Consultation-Liaison Psychiatry) will continue to work with APM after the meeting to further support the name-change process.The theme of the Academy of Consultation-Liaison Psychiatry’s 2018 annual meeting, which is being held in Orlando November 13 to 17, is “Branding C-L Psychiatry: Defining the Breadth and Depth of Our Subspecialty.” The meeting will highlight the clinical, academic, and research work done in outpatient and inpatient clinical settings. The plenary sessions will be presented by the academy’s 14 Special Interest Groups (SIGs), who represent the field’s areas of expertise. Information about the academy, its SIGs, and the annual meeting is posted on the academy’s webpage—now www.clpsychiatry.org! ■The Academy of Consultation-Liaison Psychiatry is presenting the session “Mythbusters: Consultation-Liaison Doctors Separate Medical Fact From Fiction” at APA’s 2018 Annual Meet-ing on Wednesday, May 9, from 8 a.m. to 11 a.m. in Room 1E07 at the Javits Center. ISSUES NewArchived

A systematic approach for studying the signs and symptoms of fever in adult patients: the fever assessment tool (FAST)

BackgroundAlthough body temperature is one of four key vital signs routinely monitored and treated in clinical practice, relatively little is known about the symptoms associated with febrile states. The purpose of this study was to assess the validity, reliability and feasibility of the Fever Assessment Tool (FAST) in an acute care research setting.MethodsQualitative: To assess content validity and finalize the FAST instrument, 12 adults from an inpatient medical-surgical unit at the National Institutes of Health (NIH) Clinical Center participated in cognitive interviews within approximately 12 h of a febrile state (tympanic temperature ≥ 38° Celsius). Quantitative: To test reliability, validity and feasibility, 56 new adult inpatients completed the 21-item FAST.ResultsThe cognitive interviews clarified and validated the content of the final 21-item FAST. Fifty-six patients completed the FAST from two to 133 times during routine vital sign assessment, yielding 1,699 temperature time points. Thirty-four percent of the patients (N = 19) experienced fever at one or more time points, with a total of 125 febrile time points. Kuder-Richardson 20 (KR-20) reliability of the FAST was 0.70. Four nonspecific symptom categories, Tired or Run-Down (12), Sleepy (13), Weak or Lacking Energy (11), and Thirsty (9) were among the most frequently reported symptoms in all participants. Using Generalized Estimating Equations (GEE), the odds of reporting eight symptoms, Warm (4), Sweating (5), Thirsty (9), General Body Aches (10), Weak or Lacking Energy (11), Tired or Run Down (12) and Difficulty Breathing (17), were increased when patients had a fever (Fever Now), compared to the two other subgroups—patients who had a fever, but not at that particular time point, (Fever Not Now) and patients who never had a fever (Fever Never). Many, but not all, of the comparisons were significant in both groups.ConclusionResults suggest the FAST is reliable, valid and easy to administer. In addition to symptoms usually associated with fever (e.g. feeling warm), symptoms such as Difficulty Breathing (17) were identified with fever. Further study in a larger, more diverse patient population is warranted.Trial RegistrationClinical Trials Number: NCT01287143 (January 2011)

Embedded, In Situ Simulation Improves Ability to Rescue

BackgroundA gap exists in providing simulation that incorporates the complexity of a typical work day and its effect on patient safety. MethodsAs part of a quality improvement project for the education of all nurses on a regular inpatient medical-surgical unit, nursing education facilitators embedded a standardized patient scenario into the typical work environment to help nurses understand how to safely prioritize a difficult care situation while managing their entire workload during a full shift. ResultsUsing this embedded real-time simulation, nurse educators were able to determine nurses did not consistently recognize subtle signs of clinical deterioration in a patient with a spinal cord injury. Nursing staff reported an increase in knowledge and comfort with spinal cord injury and activation of rapid response at the end of the simulation. ConclusionClinical decision-making appears to be less effective when subtle patient-assessment findings are collected and interpreted over time in the presence of a full patient assignment being cared for by a variety of caregivers. Understanding how nurses work within their typical environment opens the door for innovative approaches to designing future simulation education and hospital-based process changes that create safer environments for patients.

4-140 - Observer Role Impacts Directly Observed Hand Hygiene Compliance on Medical-Surgical Units

BACKGROUND: In our 713-bed academic tertiary care center, hand hygiene (HH) measurement was previously calculated by product usage corrected for patient census, validated by direct observation data by independent observers from Infection Control/Hospital Epidemiology (ICHE). In 2014, product usage estimates on inpatient medical-surgical units were replaced by direct observations performed by unit-based observers from Patient Care Services (PCS). We sought to compare HH compliance between ICHE and PCS observers to ensure accuracy of PCS-collected data.

Reducing Falls and Fall-Related Injuries in Medical-Surgical Units: One-Year Multihospital Falls Collaborative.

On the basis of fall injury program characteristics across multiple inpatient medical-surgical units from 6 medical centers, we developed and implemented an operational strategic plan to address fall and injury prevention program attributes and enhance program infrastructure and capacity. Expert faculty provided lectures and served as coaches and mentors through triweekly conference calls and collaborative e-mail exchange. Statistically significant findings support improved fall and injury prevention program components and processes at the organizational and unit levels.

Turning electronic health record data into meaningful information using SQL and nursing informatics.

The combination of nursing informatics knowledge with SQL code writing in an electronic health record is a powerful partnership to obtain meaningful information and improve healthcare. The purpose of this project is to use SQL and nursing informatics to identify the underpinnings and scope of present-on-patient-admission pressure ulcer documentation incongruence within the inpatient medical-surgical unit of a rural hospital. Project results reveal a 76% incidence rate of incongruent nurse and physician documentation of pressure ulcers as present on admission. However, the scope of such incongruence affects only 3% for the inpatient population. The high incidence rate of nurse-documented present-on-admission pressure ulcers without a physician diagnoses indicates a potential for lost rural hospital reimbursement and risk to patient care.

The Use of Multiple Qualitative Methods to Characterize Communication Events Between Physicians and Nurses

Despite the importance of communication to patient safety in hospital settings, we know surprisingly little about communication patterns between physicians and nurses, particularly on general medical–surgical units. Poor communication is the leading cause of preventable adverse events in hospitals, as well as a major root cause of sentinel events. The literature provides little guidance on what qualitative methods are best for capturing different types of communication events and patterns. The purpose of this study was to develop a methodology for identifying and characterizing communication events between physicians and nurses to better understand communication patterns on general medical–surgical units. We used a sequential qualitative mixed method design beginning with general observation, progressing to shadowing and focus groups of physicians and nurses who worked on two medical–surgical units at one academically affiliated U.S. Department of Veterans Affairs (VA) hospital. Each data collection method (observation, shadowing, and focus groups) had its own advantages and disadvantages for capturing communication events and patterns. Through observation we were able to see the “what”: communication activities. Shadowing was most useful for understanding “how” physicians and nurses communicated. Focus groups helped answer “why” certain patterns emerged and allowed us to further explore communication events within a group setting. By using all three methods we were able to more thoroughly characterize communication events than by using a single method alone, providing a more holistic picture of how communication occurs on an inpatient medical–surgical unit.

Continuous Monitoring in an Inpatient Medical-Surgical Unit: A Controlled Clinical Trial

BackgroundFor hospitalized patients with unexpected clinical deterioration, delayed or suboptimal intervention is associated with increased morbidity and mortality. Lack of continuous monitoring for average-risk patients has been suggested as a contributing factor for unexpected in-hospital mortality. Our objective was to assess the effects of continuous heart rate and respiration rate monitoring in a medical-surgical unit on unplanned transfers and length of stay in the intensive care unit and length of stay in the medical-surgical unit. MethodsIn a controlled study, we have compared a 33-bed medical-surgical unit (intervention unit) to a “sister” control unit for a 9-month preimplementation and a 9-month postimplementation period. Following the intervention, all beds in the intervention unit were equipped with monitors that allowed for continuous assessment of heart and respiration rate. ResultsWe reviewed 7643 patient charts: 2314 that were continuously monitored in the intervention arm and 5329 in the control arms. Comparing the average length of stay of patients hospitalized in the intervention unit following the implementation of the monitors to that before the implementation and to that in the control unit, we observed a significant decrease (from 4.0 to 3.6 and 3.6 days, respectively; P <.05). Total intensive care unit days were significantly lower in the intervention unit postimplementation (63.5 vs 120.1 and 85.36 days/1000 patients, respectively; P = .04). The rate of transfer to the intensive care unit did not change, comparing before and after implementation and to the control unit (P = .19). Rate of code blue events decreased following the intervention from 6.3 to 0.9 and 2.1, respectively, per 1000 patients (P = .02). ConclusionsContinuous monitoring on a medical-surgical unit was associated with a significant decrease in total length of stay in the hospital and in intensive care unit days for transferred patients, as well as lower code blue rates.

Oncology patients’ and nurses’ perceptions of caring

The concept of caring is central to the practice of nursing. Recent focus on patient-centred care highlights the importance of viewing caring from the patient's perspective. A comparative descriptive cross-sectional study was conducted to determine if there was a difference in oncology patients' and nurses' perceptions of caring. The Caring Behaviors Inventory-Elders (CBI-E) directly derived from Watson's Theory of Human Caring was administered to patients and nurses from in-patient medical-surgical units. This paper reports on a subset of 19 patients and 15 nurses from the oncology unit. There were significant differences between patients' and nurses' perceptions on overall caring and on several individual behaviours. In order to provide true patient-centred care, innovative approaches to addressing these differences are needed.

Reducing restraint use in the acute care setting.

A Massachusetts hospital with a significant geriatric population initiated a pilot program to reduce use of restraints on an inpatient medical-surgical unit. A task force developed and implemented a successful program that included identification of alternatives to restraint use, policy and procedure development, staff education and evaluation.