Joseph's Regional Medical Center Research Articles

Geriatric Emergency Department Innovations: The Impact of Transitional Care Nurses on 30-day Readmissions for Older Adults.

Transitional care nurse (TCN) care has been associated with decreased hospitalizations for older adults in the emergency department (ED). The objective of this study was to evaluate the association between TCN care and readmission for geriatric patients who visit the ED within 30days of a prior hospital discharge. We studied a prospective cohort of ED patients aged 65 and older with an ED visit within 30days of inpatient discharge. Patients with an Emergency Severity Index of 1 or prior TCN contact were excluded. Entropy balancing and logistic regression were used to estimate the average incremental effect of the TCN intervention on risk of admission during the index ED visit and within 30days of prior discharge. Of 6,838 visits, 608 included TCN care. TCN patients had lower risk of readmission during the index ED visit at Mount Sinai Medical Center (MSMC), -10.1 percentage points (95% confidence interval [CI]= -18.5 to -2.7), and Northwestern Memorial Hospital (NMH), -17.3 percentage points (95% CI= -23.1 to -11.5), but not St. Joseph's Regional Medical Center (SJRMC), -2.5 percentage points (95% CI= -10.5 to 5.5). TCN patients had fewer readmissions within 30days of prior hospital discharge at NMH, -16.2 percentage points (95% CI= -22.0 to -10.3), but not at MSMC, -5.6 percentage points (95% CI= -13.1 to 1.8), or at SJRMC, 0.5 percentage points (95% CI= -7.2 to 8.2). Transitional care nurse care in the ED after a prior hospitalization was associated with decreased readmission of older adults during the index ED visit at two of three hospitals, with sustained reduction for the entire 30-day readmission window at one hospital. TCN interventions in the ED may decrease readmissions for geriatric patients in the ED; however, these results may be dependent on implementation of the program and availability of ED, hospital, and local resources for older adults.

Music as a Postoperative Pain Management Intervention

PAIN IS A COMMON and frequently reported effect of surgical intervention. The World Health Organization estimates 266 to 360 million surgeries are performed yearly. 1 Kuhlmann A. de Rooij A. Kroese L. van Dijk M. Hunink M. Jeekel J. Meta-analysis evaluating music interventions for anxiety and pain in surgery. Br J Surg. 2018; 105: 773-783 Crossref PubMed Scopus (130) Google Scholar Studies have shown that 40% to 65% of postoperative patients report moderate to severe pain. 1 Kuhlmann A. de Rooij A. Kroese L. van Dijk M. Hunink M. Jeekel J. Meta-analysis evaluating music interventions for anxiety and pain in surgery. Br J Surg. 2018; 105: 773-783 Crossref PubMed Scopus (130) Google Scholar The most common treatment for moderate to severe pain continues to be opioid medications because of immediate effects, multiple delivery forms, and ease of administration. The US Department of Health and Human Services has concerns with increasing opioid-related deaths and opioid use disorder, causing the medical community to rethink the approach to pain management regarding the use of opioid medications. 2 Health and Human ServicesWhat is the opioid epidemic?. https://www.hhs.gov/opioids/about-the-epidemic/index.htmlDate: 2018 Date accessed: June 6, 2018 Google Scholar Michael J. Poulsen, DNP, RN, FNP-C, St. Joseph Regional Medical Center Mishawaka, IN Jeffrey Coto, DNP, MS-CNS, RN, CCRN, Valparaiso University, IN Maureen F. Cooney, DNP, FNP-BC, Pain Management, Westchester Medical Center, Valhalla, NY.

Pivot Nursing: An Alternative to Traditional ED Triage

ProblemA 7.2% increase in patient volume from 130,700 to 140,800 in 2012 prompted St Joseph's Regional Medical Center Emergency Department to review existing triage processes to decrease turnaround time. "Pivot triage" is a new, efficient intake process that entails use of 4 rather than 8 determinants to identify acuity levels. The purpose of this performance improvement project was to create alternatives to traditional triage to decrease ED length of stay and door-to-physician time. MethodsAfter education, the pivot process was implemented using 4 determinants established by a multidisciplinary team. The pivot process was slowly implemented for 6 hours over a 1-week period to work out processing issues. Arrival time, door-to-physician time, and departure time from the emergency department were elements used to calculate the patient's turnaround time. Length of ED stay was collected monthly beginning in the fourth quarter of 2011. Comparisons were made after Pivot implementation in the fourth quarter of 2012. ResultsDespite the increasing volume, the mean door-to-physician time decreased from 71 to 40 minutes, a 43.7% reduction. The overall turnaround time decreased from 220 to 181 minutes, representing approximately a 17.7% reduction. The percentage of patients who left without being seen decreased from 2.5% to 1.0%. The pivot process improved patient flow in the emergency department, reducing time spent by the patient in the department. Implications for PracticeThe pivot process is a viable alternative to traditional triage. Nurses are able to accurately pivot patients with a reduced amount of information.

Nissen fundoplication in severely ill infants: A STROBE compliant study

Aim: Anti-reflux surgery is offered to those who fail medical management for gastroesophageal reflux disease (GERD) in the pediatric population. A handful of studies show that those with neurologic impairment have benefited from these procedures; however, there are a few studies that document the indications and outcomes for infants < 6 months of age. Methods: A retrospective analysis of children < 6 months of age who underwent a Nissen fundoplication (NF) at St. Joseph's Regional Medical Center from December 2006 to June 2013 was performed. The following factors, such as surgical indications, comorbidities, hospital course data, weight gain, length of stay, and complications, were analyzed. Results: A total of 23 patients with the average age of 95.8 days were studied in this analysis. Presurgery, the average weight of these patients was 9.88 percentile (interquartile range: 5.85). A total of 65.2% patients were considered having failure to thrive (FTT) as they were under the 10th percentile and 78% patients had anatomic or genetic abnormalities. Nearly 47.8% patients underwent upper gastrointestinal studies that were positive for reflux. All patients had a concomitant gastrostomy tube (G-tube) placed during the NF. Diet was advanced on the average postoperative day of 2, and the patients tolerated the highest diet by the postoperative day of 6. Most patients saw a decrease in medications after the procedure. Moreover, 7 patients had complications related to the G-tube, with the main complication reported as leakage around the tube. There were two mortalities, both unrelated to the operation. Conclusion: Infants undergoing NF under the age of 6 months typically present with multiple comorbidities. NF in this population will not only lead to weight gain but also decrease in overall need for GERD-related medications. Early recognition of the failure of nasojejunal feeds will facilitate NF before significant FTT is present.

Aligning Documentation With Congenital Muscular Torticollis Clinical Practice Guidelines: Administrative Case Report.

A hospital-based pediatric outpatient center, wanting to weave evidence into practice, initiated an update of knowledge, skills, and documentation patterns with its staff physical therapists and occupational therapists who treat people with congenital muscular torticollis (CMT). This case report describes 2 cycles of implementation: (1) the facilitators and barriers to implementation and (2) selected quality improvement outcomes aligned with published clinical practice guidelines (CPGs). The Pediatric Therapy Services of St Joseph's Regional Medical Center in New Jersey has 4 full-time, 1 part-time, and 3 per diem staff. Chart audits in 2012 revealed variations in measurement, interventions, and documentation that led to quality improvement initiatives. An iterative process, loosely following the knowledge-to-action cycle, included a series of in-service training sessions to review the basic anatomy, pathokinesiology, and treatment strategies for CMT; reading assignments of the available CPGs; journal review; documentation revisions; and training on the recommended measurements to implement 2 published CPGs and measure outcomes. A previous 1-page generic narrative became a 3-page CMT-specific form aligned with the American Physical Therapy Association Section on Pediatrics CMT CPG recommendations. Staff training on the Face, Legs, Activity, Cry, Consolability (FLACC) pain scale, classification of severity, type of CMT, prognostication, measures of cervical range of motion, and developmental progression improved documentation consistency from 0% to 81.9% to 100%. Clinicians responded positively to using the longer initial evaluation form. Successful implementation of both clinical and documentation practices were facilitated by a multifaceted approach to knowledge translation that included a culture supportive of evidence-based practice, administrative support for training and documentation redesign, commitment by clinicians to embrace changes aimed at improved care, and clinical guidelines that provide implementable recommendations.

Abstract P306: Physician Directed Nurse Practioner Model of Care Using Get With The GuidelinesSM is Superior in Attaining Centers for Medicare and Medicaid Services Core Measure Compliance for Patients With Acute Myocardial Infarction Amongst Urban Hospitals With Large Minority Populations

The goal of the Centers for Medicare and Medicaid Services acute myocardial infarction core measure program (AMI-CM) is to provide standards of care at the point of service. The American Heart Association's Get With The Guidelines (AHA-GWTG) program has previously been shown to be independently associated with significantly improved adherence to AMI-CM. However, a physician directed nurse practioner managed GWTG model of care (PDNP-GWTG) in an urban hospital with a large minority population (UH-LMP) has not yet been compared to GWTG and non-GWTG hospitals with similar demographics for compliance to AMI-CM. St. Joseph's Regional Medical Center (SJRMC) is an UH-LMP located in Northern NJ with a diverse and large minority composition. The objective of this study was to compare SJRMC's PDNP-GWTG model of care to GWTG and non-GWTG UH-LMP for AMI-CM. Methods: All UH-LMP hospitals' AMI-CM with a percent white population within +/- 5% of SJRMC and a similar Urbanicity Ranking, n= 113, were compared to SJRMC's AMI-CM for 2008. Differences in compliance for each of the 8 AMI-CM and for the composite AMI-CM (8-CM) were assessed using the Chi Square test for contingencies. Results: SJRMC 8-CM compliance of 96% (1275 of 1329) was superior to UH-LMP of 94% (55270 of 58798), p=0.0007. For individual AMI-CM compliance SJRMC was superior to UH-LMP for: Aspirin at arrival (100% (260 of 260) vs. 97% (12060 of 12434), p=0.007); Beta-Blocker (BB) at arrival (99% (230 of 232) vs. 95% (9533 of 10035), p=0.003); BB at discharge (98% (308 of 314) vs. 96% (13279 of 13832), p=0.03); and tobacco counseling (100% (116 of 116) vs. 94% (3870 of 4117), p=0.004). UH-LMP was superior to SJRMC compliance for PCI within 90 minutes of arrival (PCI-AMI) (56% (605 of 1080) vs. 29% (11 of 38), p=0.001). Conclusion: SJRMC PDNP AMI-CM compliance for the composite and 4 of the core measures that are also GWTG performance measures is superior to UH-LMP. UH-LMP PCI-AMI-CM performance (not a GWTG performance measure) was superior to SJRMC.

Oxymetazoline Superior to Cocaine and Lidocaine for Nosebleeds

Oxymetazoline Superior to Cocaine and Lidocaine for Nosebleeds

Long-term effectiveness and safety of sirolimus drug-eluting stents

The root cause of coronary artery disease is atherosclerosis, ie, intraluminal narrowing (stenosis) of the arteries that supply blood to tissues of the heart. The introduction of the drug-eluting stent over the past decade has revolutionized the field of interventional cardiology. It is used extensively in clinical practice for the treatment of coronary artery disease. The first drug-eluting stent to receive US Food and Drug Administration approval was the sirolimus-eluting stent. Recently, two other stent analogs of sirolimus were approved, ie, the zotarolimus-eluting stent and the everolimus-eluting stent. However, concern has arisen in recent years about the long-term safety and efficacy of drug-eluting stents, due to the occurrence of late adverse clinical events, such as stent thrombosis. This review focuses on clinical studies that have been performed with the sirolimus-eluting stent or its analogs. We discuss the pharmacology, safety, and various therapeutic options that exist when choosing stents for coronary artery disease. Our aim is to provide a thorough review of the long-term efficacy and safety of sirolimus drug-eluting stents, and also to discuss currently approved and promising investigational drug-eluting stents, in an effort to provide insight into how these stents are currently evolving and generate further investigation in this area.

SPECIAL ARTICLE: A review of the International Brain Research Foundation novel approach to mild traumatic brain injury presented at the International Conference on Behavioral Health and Traumatic Brain Injury

"The International Conference on Behavioral Health and Traumatic Brain Injury" held at St. Joseph's Regional Medical Center in Paterson, NJ., from October 12 to 15, 2008, included a presentation on the novel assessment and treatment approach to mild traumatic brain injury (mTBI) by Philip A. DeFina, PhD, of the International Brain Research Foundation (IBRF). Because of the urgent need to treat a large number of our troops who are diagnosed with mTBI and post-traumatic stress disorder (PTSD), the conference was held to create a report for Congress titled "Recommendations to Improve the Care of Wounded Warriors NOW. March 12, 2009." This article summarizes and adds greater detail to Dr. DeFina's presentation on the current standard and novel ways to approach assessment and treatment of mTBI and PTSD. Pilot data derived from collaborative studies through the IBRF have led to the development of clinical and research protocols utilizing currently accepted, valid, and reliable neuroimaging technologies combined in novel ways to develop "neuromarkers." These neuromarkers are being evaluated in the context of an "Integrity-Deficit Matrix" model to demonstrate their ability to improve diagnostic accuracy, guide treatment programs, and possibly predict outcomes for patients suffering from traumatic brain injury.

Time = MUSCLE the case for STEMI care improvements

Maryanne Crowther is a cardiology nurse practitioner at Saint Joseph's Regional Medical Center, Paterson, N.J. The author has disclosed that she has no significant relationship with or financial interest in any commercial companies that pertain to this educational activity. A paradigm shift incorporating process change for both facility and personnel is necessary to minimize the extent of ST-elevation myocardial infarction (STEMI) and improve patient outcomes.

Personal Accounts: Sanity, Psychosis, and September 11, 2001

Personal Accounts: Sanity, Psychosis, and September 11, 2001

Racial Disparity, Location and Stage at Diagnosis of Colorectal Cancer in Patients above and below 50 Years of Age

Purpose: Incidence rates of Colorectal Cancer (CRC) are decreasing in the United States, possibly due to preventive screening. These programs target older populations and may not apply to younger patients. Our aim is to analyze racial disparity, stage at diagnosis, and location of CRC among patients below age 50 years compared to patients above age 50 years. Methods: Patients with CRC were identified retrospectively from tumor registries at St. Joseph's Regional Medical Center, NJ and California Pacific Medical Center, CA., for the period of 1992 to 2004. Statistical analysis was done by Chi-square test. Results: Overall number of patients diagnosed with CRC was 2723 [1963(72.1%) white, 287(10.5%) black, 473(17.4%) others]. We identified 279 (10.2%) less than 50 years of age. We found statistically significant increase in CRC prevalence in blacks compared to white below age 50 years (table 1). Blacks have approximately two (2.12) times greater odds of being diagnosed with CRC than whites below age 50 years (95% Confidence Interval (CI) 1.5–3.03). Regarding location of CRC, patients below 50 years have approximately two (1.75) times greater odds of having their lesion in the rectosigmoid than in the remaining colon (95% CI 1.35–2.27).(table 2) Regarding staging of CRC, patients below age 50 years have almost 2 times (1.85) greater odds of having advanced stage at the diagnosis as compared to above 50 (95% CI 1.43–1.85). (table 2)Table: Racial disparity in the diagnosis of CRC in individuals < 50yrsTable: Distal site distribution and Advanced stage at the diagnosis of CRC in individuals < 50yrsConclusions: In this study there is a significant increase in the diagnoses of CRC in black patients below the age of 50 years. Our study reinforced the new CRC screening recommendation by ACG for blacks to begin screening at the age of 45 years rather than at age 50 years. Also, CRC in younger populations is diagnosed at later stages and is frequently in distal locations.

Patient Knowledge About Human Papillomavirus and Abnormal Papanicolaou Smears

The Medical College of Wisconsin, Milwaukee, WI; St. Joseph Regional Medical Center, Milwaukee, WI; Columbia St Mary's Hospital, Milwaukee, WI.

Does time interval between antenatal steroid administration and delivery affect neonatal outcomes in very low birth weight neonates—A cohort study

DELIVERY AFFECT NEONATAL OUTCOMES IN VERY LOW BIRTH WEIGHT NEONATESDA COHORT STUDY ALLISON GOEDEN, JEFFERY GARLAND, GAIL PECKMAN, MARGARET CARR, RICHARD PIRCON, Medical College of Wisconsin Affiliated Hospitals, OB/GYN, Wauwatosa, Wisconsin, St. Joseph Regional Medical Center, Pediatrics, Milwaukee, Wisconsin, St. Joseph Regional Medical Center, Center for Obstetrical Research and Education, Milwaukee, Wisconsin, Perinatal Medicine, Ltd., Milwaukee, Wisconsin, St. Joseph Regional Medical Center, Director-Center for Obstetrical Research and Education, Milwaukee, Wisconsin OBJECTIVE: To determine whether the neonatal benefit of a single course of antenatal steroids diminishes beyond fourteen days from administration. STUDY DESIGN: This retrospective cohort study included all women who received a complete course of antenatal steroids and delivered a living singleton between 26 and 34 weeks’ gestation between January 1999 and December 2004. Maternal charts were reviewed to obtain histories and confirm treatment. Neonatal demographic data and outcomes were collected prospectively and retrospectively reviewed. Individuals reviewing maternal data were blinded to neonatal outcomes. Comparisons were made between those delivering within seven days of receiving antenatal steroids and those beyond fourteen days using Student’s t-test, chi-square analysis, Fisher’s exact test and regression analysis. RESULTS: Two hundred and fifty-one patients met inclusion criteria. Patients were grouped based upon time from administration of steroids to delivery. In univariate analysis, neonates delivering greater than 14 days from antenatal steroids had higher Scores for Acute Neonatal Physiology (SNAP) (measures the severity of illness at 24 hours of life) (9.7 G 5.6 vs 7.3 G 4.4, p = 0.001). This difference remained in regression models that controlled potential confounders [RR = 1.76 (95 percent CI = 1.2, 2.5), p=0.006]. Risk of death or chronic lung disease was statistically significant in univariate analysis (17% vs 10%, p = 0.02). When corrected for potential confounders in regression analysis, statistical significance was not achieved [RR = 2.1 (95 percent CI = 0.98, 6.2), p=0.054]. There was no difference in IVH risk in either univariate (11% vs 12%, p = 0.8) or regression analysis [RR = 0.88 (95 percent CI = 0.38, 2.0)]. S118 SMFM Abstracts

The organizational huddle process--optimum results through collaboration.

The St. Joseph's Regional Medical Center in Paterson, New Jersey, initiated a methodology called The Organizational Huddle Process in the fall of 1999. This communication vehicle enhances operational performance through a fast, focused, and highly collaborative process. The results of this initiative have been most impressive. Hundreds of problems have been resolved before escalating to crisis levels, with an increase in stakeholder satisfaction. This process is appropriate for all levels within an organization, is effective for both interdisciplinary and departmental groups, and has minimal associated implementation costs. This article reviews the rationale and benefits of The Organizational Huddle Process, a recommended implementation strategy, and a nurse manager's review on the application of this methodology.

A model to enhance staff response in cardiopulmonary arrest.

Dissatisfaction with doing a yearly written test to evaluate competency in the management of cardiopulmonary arrest led to our exploration of ways to change our processes at St. Joseph Regional Medical Center. Guided by our Mission, Vision, and Values, we strove to create a process that would deliver exceptional health care to our patients, while contributing to the personal and professional growth of our staff. Cardiopulmonary arrest is a low volume, high-risk occurrence, which is anxiety provoking for staff. Therefore, it is difficult for staff to feel comfortable and maintain competence in these situations. A process was implemented incorporating a hands-on approach to manage a simulated cardiopulmonary arrest on an annual basis for registered nurses (RNs) and assistive staff. The opportunity for hands-on practice and skill development has enhanced the confidence of RNs and assistive staff, affording them the ability to handle real emergencies.