Large Acute Care Hospital Research Articles

Learning needs assessment for registered nurses in two large acute care hospitals in Urban New Zealand

Ongoing education for the nursing workforce is necessary to ensure currency of knowledge in order to enable evidence based client care. The cost of education is high to the organisation and the individual, and must therefore be cost-effective, relevant and appropriate. According to research, education for nurses is not always systematically planned and developed and often relies on the interest area and assessment of the nurse educators. To survey the learning needs of clinically based registered nurses within an acute care setting. An anonymous questionnaire was used to collect the data. Two groups completed the questionnaire: all eligible registered nurses in two acute care hospitals located in urban New Zealand and their senior nurses such as clinical nurse managers, specialists and educators. The study found agreement on learning needs and also noted differing opinions between the Registered Nurses (RNs), and their senior RNs, RNs initially registered overseas and between levels of practice, on selection and ranking of learning needs. This survey identified a number of high learning needs for RNs working within acute care settings. Differences in perception of learning needs for RNs, between the nurses themselves and the Senior RNs exist, as well as among sub groups of RNs. As a result, educators and managers are encouraged to collaborate to realise the opportunity which exists for the provision of education across specialty areas and to work with the different groups and the individual to ensure unique learning needs are met.

Rapid Assessment and Disposition: Applying LEAN in the Emergency Department

The nation's emergency rooms are overflowing with patients who endure increasingly long waits to be examined and treated. When our large metropolitan adult acute care hospital adopted LEAN as its standard operating procedure, we began to examine our processes from the customers' perspective and identified a significant opportunity to reduce the emergency department length of stay. Using LEAN tools we designed and implemented a Rapid Assessment and Disposition process to decrease the amount of time patients waited in the emergency department, reduce diversion time, and reduce the number of patients who left without being seen. We have succeeded in reducing the average length of stay for all emergency department patients by 45 minutes, diversion by 55%, and patients who left without being seen by 28%.

Nephrogenic Systemic Fibrosis: Incidence, Associations, and Effect of Risk Factor Assessment—Report of 33 Cases

To describe the presentation and clinical course of patients with nephrogenic systemic fibrosis (NSF) at a large acute-care hospital, to evaluate the overall incidence of NSF, and to assess the effect of a hospital-wide policy regarding gadolinium-based contrast agent (GBCA) use on NSF incidence. A review of all cases of NSF observed at an institution from 2003 to 2008 was conducted. This HIPAA-compliant study was approved by the institutional review board. The informed consent requirement was waived. Demographics, medical history, and associated conditions were recorded. Radiologic procedures were evaluated if they were performed within 1 year prior to NSF onset. GBCA use was assessed by checking the electronic database for each procedure. The incidence of NSF was compared before and after implementation of an institutional policy designed to assess risk of NSF prior to GBCA use. All 33 patients with NSF (mean age, 49 years; age range, 15-78 years) had advanced renal failure (estimated glomerular filtration rate < 15 mL/min/1.73 m(2)) when the GBCA was injected. Twenty-six patients had severe chronic or end-stage renal disease, and seven had acute renal failure. The mean interval between contrast material injection and NSF onset was 29 days +/- 25 (standard deviation) (range, 4-112 days). The overall incidence of NSF was 36.5 cases per 100,000 gadolinium-enhanced magnetic resonance (MR) examinations between 2003 and 2006 and four cases per 100,000 gadolinium-enhanced MR examinations between 2007 and 2008 after screening for NSF risk was instituted (Fisher exact test, P = .001). Five patients developed NSF in the peritransplant period, and four underwent a catheter-based radiographic procedure with administration of a GBCA. Common associations of GBCA MR imaging and NSF were acute and severe chronic renal failure and liver or renal transplantation. Screening procedures performed before MR imaging to determine which patients were at risk of developing NSF appear to reduce the incidence of this complication and further support the belief that NSF is associated with GBCA administration.

Descriptive Study of a Novel OXA-23 Carbapenemase Strain of Acinetobacter baumanii in a Large Acute Care Hospital in Southeastern Michigan

Descriptive Study of a Novel OXA-23 Carbapenemase Strain of Acinetobacter baumanii in a Large Acute Care Hospital in Southeastern Michigan

Change process during redesign of a model of nursing practice in a surgical ward

This paper reports a case study of nursing practice model redesign in a surgical ward at a large metropolitan acute care hospital in Sydney, Australia. Literature suggests that factors such as financial restraints and shortage of nurses necessitate redesign of nursing care. A descriptive case study design was used. The nursing practice model was changed from a patient allocation model to a team-nursing model and a new role of Clinical Activities Coordinator was introduced. This study has confirmed that people need to be able to empower themselves to ensure an effective change process. It was also apparent in the case study that the staff were resistant to the redesign. Change is a difficult process, which needs to involve all stakeholders. The planning process needs to consider the characteristics of the context such as workload and skill required, and the measures such as patient and staff satisfaction and health outcomes.

Physicians' resistance toward healthcare information technology: a theoretical model and empirical test

This paper presents a theoretical model of physician resistance of healthcare information technology (HIT) usage by integrating the technology acceptance and resistance to change literatures, using a dual-factor model of technology usage. This model elaborates the interdependent and asymmetric effects of inhibiting usage perceptions, such as resistance, on HIT usage intentions relative to enabling perceptions, such as perceived usefulness and perceived ease of use. It also proposes perceived threat as a predictor of resistance, perceived compatibility as predicting perceived usefulness, and related knowledge as predicting perceived ease of use. The resulting model is empirically supported using a field survey of a computerized physician order entry system among 129 practicing physicians at a large acute-care hospital. Our study illustrates the importance of incorporating user resistance in technology usage studies in general and HIT usage studies in particular, grounds resistance research within extant theories of technology usage, and provides a preliminary model of resistance that can serve as the starting point for future research in this relatively unexplored yet potentially fertile area of research.

Discharge Knowledge and Concerns of Patients Going Home With a Wound

To examine patients' wound care knowledge and concerns prior to discharge from an acute care hospital. Comparative descriptive study of patients with wounds. Participants (N = 76) included 17 men and 59 women who were African American (n = 33, 43.4%) or Caucasian (n = 43, 56.6%) and ranged in age from 20 to 83 years (M = 48, SD = 13). There were 67 persons with acute wounds and 9 with chronic wounds. All were scheduled to be discharged home from a large urban acute care hospital. The questionnaire for this study included the following sections: Demographic, Admission and Discharge, Health, Wound Care, Beliefs about Wounds and their Care, Pain and Wounds, Literacy and Learning, and Discharge Concerns. Participants' greatest concerns about going home were: (1) how active to be at home, (2) wound pain, (3) looking for wound complications, and (4) watching for wound infection. Many participants did not know the dressing (38.2%) or solution to cleanse the wound (58.7%) at home. Most had taken care of a wound before (67.1%), could see (68.4%) and reach (69.7%) the wound, and had looked at it (64.5%) during the hospitalization. Patients with acute and chronic wounds did not differ significantly in their concerns about their wound or their fear of taking care of their wound. Participants generally had appropriate knowledge about wounds and hand washing, nutrition, going out of the home, and cigarette smoking. They had incorrect information about drying out wounds and leaving them open to breathe the air. The majority of patients with chronic wounds preferred getting answers to questions about their wound and its care from their physician followed by their clinic and family/friends. Patients with acute wounds overwhelmingly chose their physician as a source of information about their wound and its care, followed by calling a nurse at the hospital and using the Internet. Patients were able to verbalize their concerns about going home with a wound. Concerns about discharge may help to direct patient teaching in preparation for discharge. Teaching literature could include the most common concerns, as well as ways to avoid misinformation about wound care. Discharge teaching needs to begin early so that patients feel they have adequate time to learn and ask questions. Further research is needed about patients' wound care knowledge and discharge concerns.

Interpreting rehabilitation outcome measurements

With the increased use of standardized outcome instruments in rehabilitation, questions frequently arise as to how to interpret the scores that are derived from these standardized outcome instruments. This article uses examples drawn from the Activity Measure for Post Acute Care to illustrate 4 different data analysis and presentation strategies that can be used to yield meaningful outcome data for use in rehabilitation research and practice. A prospective cohort study in patients recruited at the point of discharge from a large acute care hospital or on admission to 1 of 2 rehabilitation hospitals after discharge from an acute care hospital in the greater Boston, MA region. A total of 516 subjects in the Rehabilitation Outcome Study. Four distinct approaches to analyzing and reporting outcome data are described to derive more meaningful outcome measurements: interpreting a single scale score; interpreting clinical significance of score changes; a percentile ranking method; and a functional staging approach. The first 3 methods focus on interpreting the numeric property of individual measurements and are best suited to assess individual outcomes and for detecting change. The fourth, a functional staging approach, provides an attractive feature of interpreting the clinical meaning provided by a particular quantitative score without sacrificing the inherent value of a quantitative scale for tracking change over time. Users are encouraged to consider the range of analysis and presentation strategies available to them to evaluate a standardized scale score, both from a quantitative and a content perspective.

Use of a Violence Risk Assessment Tool in an Acute Care Hospital

This study examined the use and effectiveness of the Alert assessment form. The form is part of the Alert system, used by one large acute care hospital to identify patients with a propensity for violence. All reported incidents of patient violence from August 1, 2003, through December 31, 2004, were included in patient charts. One hundred seventeen violent patient charts were reviewed and compared with 161 non-violent patient charts, randomly chosen from the same time period. Overall use of the Alert assessment form for violent and non-violent patients was 75.7% and 35.4%, respectively. The assessment form was found to have moderate sensitivity (71%) and high specificity (94%). It is reasonably effective in identifying potentially violent or aggressive patients when it is used according to protocol. Efforts to improve the tool are warranted, as is evaluation of its benefit in settings with low prevalence of violence. Also, greater effort must be taken to prevent violence once an aggressive patient has been identified.

Control of an Outbreak of Burkholderia cepacia at a Large Acute Care Hospital

BACKGROUND/OBJECTIVES: In May 2005, an increase in the organism <i>Burkholderia cepacia</i> was noted at a 903-bed urban hospital. A similar increase was later noted at a second 302-bed facility that is part of the same hospital system. Control of this outbreak and identification of its source were the main objectives. <i>B. cepacia</i> is a gram negative organism that is similar to Pseudomonas, and is commonly found in soil and water. Though relatively rare in the hospital setting, it is an important pathogen in immunocompromised patients, especially those with Cystic Fibrosis. Hospital outbreaks have often been linked to common contaminated sources, such as disinfectants, IV solutions, nebulizer solutions, and medical devices. METHODS: All patients found positive for <i>B. cepacia</i> were placed into Contact Precautions with dedicated staff for the duration of admission, as well as any subsequent admissions. Hand hygiene and compliance with isolation practices were reinforced through in-person in services. Surveillance cultures were performed on two separate occasions to identify and isolate previously unidentified cases. A common source for the outbreak was sought by culturing available lots of common fluid-based products. Respiratory Therapy policies and procedures were also reviewed. All available isolates were saved, and compared using Pulse-Field Gel Electrophoresis (PFGE). RESULTS: Between May and October of 2005, 40 patients with <i>B. cepacia</i> were identified. No further cases were identified over the next two-month period. PFGE results confirmed 37 of the 40 patients to have a single, outbreak-related strain. Positive specimens included 9 respiratory, 8 blood, 24 urine, 3 intravascular catheter tips, and 1 bone marrow. No commonalities in terms of specific location, diagnosis, medications, or procedures were identified. Isolates from patients in the smaller facility were also typed using PFGE, and were found to be identical. All surveillance cultures of fluids-based products were negative. However, a recall notice in late August 2005 of a non-alcohol mouthwash contaminated with <i>B. cepacia</i> linked this outbreak to a larger national outbreak. This link was confirmed by showing the outbreak strain was identical to isolates from the contaminated mouthwash as confirmed by the Centers for Disease Control and Prevention using PFGE. Contaminated lots were not identified by either facility at the time of the recall, and additional cases of <i>B. cepacia</i> were felt to be due to cross-transmission between patients. CONCLUSIONS: Although introduction of <i>B. cepacia</i> into the hospital was by a common source, interruption of secondary transmission is needed. In these instances, implementation of comprehensive infection control measures, with multi-disciplinary cooperation, is essential.

Reduction of Skin Flora in Blood Cultures from Patients on an Oncology Unit in a Large Acute Care Hospital

BACKGROUND/OBJECTIVES: Electronic surveillance capabilites began at our 453 bed acute care hospital in June of 2005. The availability of searchable laboratory and census data allowed us to aggregate data by specific source, organism and location of collection. METHODS: A house-wide search for isolates from all patients with a length of stay of three days or longer was performed for June through August 2005. We found that the third highest incidence was blood isolates. When we aggregated blood sources separately we noted that the unit with the highest incidence was our Hematology/Oncology unit. Additionally we noted that 68% of the blood isolates were probable skin flora. We then directed interventions to this group of organisms. Visits to the Oncology unit revealed a lack of uniform practices for prepping prior to blood draws, and inconsistencies in accessing IV lines. The unit nurse manager instructed staff in blood culture prep technique. The practitioner responsible for PICC line insertion was enlisted to assist in policy revision and staff education. RESULTS: After interventions, subsequent results during the months of October through December 2005 demonstrated a 50% decrease in the overall number of isolates from patients on Oncology with a 26% decrease in isolates of skin flora. Patient days remained unchanged over the entire period. CONCLUSIONS: The ability to conduct surveillance beyond those units included in conventional surveillance models allows for prompt identification of areas where basic interventions can improve the quality of patient care. The presence of a positive blood culture in this very high risk population mandates antibiotic treatment. Many organisms generally regarded as evidence of contamination may actually be an infection in extremely compromised individuals, therefore improved techniques for acquiring blood specimens for culture will reduce antibiotic exposure for this population.

Collective soul: The spirituality of an interdisciplinary palliative care team

Although spirituality as it relates to patients is gaining increasing attention, less is known about how health care professionals (HCP) experience spirituality personally or collectively in the workplace. This study explores the collective spirituality of an interdisciplinary palliative care team, by studying how individuals felt about their own spirituality, whether there was a shared sense of a team spirituality, how spirituality related to the care the team provided to patients and whether they felt that they provided spiritual care. A qualitative autoethnographic approach was used. The study was conducted in a 10-bed Tertiary Palliative Care Unit (TPCU) in a large acute-care referral hospital and cancer center. Interdisciplinary team members of the TPCU were invited to participate in one-to-one interviews and/or focus groups. Five interviews and three focus groups were conducted with a total of 20 participants. Initially participants struggled to define spirituality. Concepts of spirituality relating to integrity, wholeness, meaning, and personal journeying emerged. For many, spirituality is inherently relational. Others acknowledged transcendence as an element of spirituality. Spirituality was described as being wrapped in caring and often manifests in small daily acts of kindness and of love, embedded within routine acts of caring. Palliative care served as a catalyst for team members' own spiritual journeys. For some participants, palliative care represented a spiritual calling. A collective spirituality stemming from common goals, values, and belonging surfaced. This was the first known study that focused specifically on the exploration of a collective spirituality. The culture of palliative care seems to foster spiritual reflection among health care professionals both as individuals and as a whole. While spirituality was difficult to describe, it was a shared experience often tangibly present in the provision of care on all levels.

Antibiotic Use in Non–University Regional Acute Care General Hospitals in Southwestern Germany, 2001–2002

A previous study from Germany showed high antibiotic use in university hospitals, particularly in intensive care units (ICU) and hematology-oncology services, but there has been no information about recent antibiotic use in non-university hospitals. In the present study, we collected data from 40 non-university regional general hospitals located in the southwestern part of the country, and analyzed use density in the medical and surgical services of these hospitals. Hospital pharmacy records for the calendar years 2001 and 2002 were evaluated. The number of defined daily doses (DDD, definition according to the WHO/ATC 2001 index) and prescribed daily doses (PDD) per 100 patient days (DDD/100 or PDD/100, respectively) were calculated to compare antibiotic use densities in medical and surgical services. Data for surgery included various subspecialties and gynecology. Antibiotic use in the participating hospitals increased minimally between 2001 and 2002 both in medicine as well as in surgery. Use density in internal medicine (ICU areas excluded) in the year 2002 ranged between 13.5 and 93.7 DDD/100 with a weighted mean of 49.9 DDD/100 (corresponding to 28.6 PDD/100, respectively). Values for surgery were lower with a weighted mean of 43.4 DDD/100 (corresponding to 26.1 PDD/100, range, 10 to 65.4 DDD/100), respectively. Hospital size was not a strong predictor of use density, while large differences were observed between intensive care areas and normal wards. Mean use densities in intensive care areas in 2002 were 105.6 DDD/100 (or 49.7 PDD/100) in medical intensive care units, 116.9 DDD/100 (or 61.2 PDD/100) in surgical intensive care units, and 112.7 DDD/100 (or 66.7 PDD/100) in mixed, interdisciplinary intensive care units. Betalactams made up > 50% of all PDDs, while fluoroquinolones were the second most frequently prescribed drugs (15% of all PDDs). Fluoroquinolones were usually given orally. Overall glycopeptide and aminoglycoside use was < 1 PDD/100. This recent data from a large regional nonuniversity acute care hospital sample confirms that hospital antibiotic use density largely depends on patient care areas and less on hospital size. Surprisingly low use was observed for glycopeptides and aminoglycosides. The data may be useful as a benchmark for further pharmaco-epidemiologic evaluation and focused drug use control interventions.

The effects of preparatory sensory information on ICU patients.

Preparatory sensory information (PSI) has been found to have significant effects in reducing distress, tension, restlessness, negative moods, and anxiety, and also in reducing length of postoperative hospitalization during various threatening medical events, but no evidence has demonstrated the effect of PSI on a patient during ICU hospitalization. On the basis of Lazarus' theory, a structural equation model was developed to examine the role of the nursing intervention, PSI, as a significant factor influencing patients' processes of cognitive appraisals and coping, adaptational responses, and patient care outcomes during ICU hospitalization. The analytical model examined the net effect of PSI on outcomes, controlling for the effects of mastery, interpersonal trust, social support, socioeconomic status, severity of illness, age, and gender. A quasi-experiment was executed in four large acute care hospitals. Data were collected from 41 subjects in the control group and from 42 in the treatment group receiving PSI before ICU admission. Structural equation modeling was employed to test the proposed analytic model. The initial tests of model fit indicate that the original model did not fit the data well with GFI = 0.85, AGFI = 0.76, RMSEA = 0.059, p_close = 0.28, and critical N = 78. A revised model was developed, and the fit indices suggested an adequate fit with GFI = 0.90, AGFI = 0.84, RMSEA = 0.00, p_close = 0.89, and critical N = 109. These findings provide empirical support for Lazarus' theory on stress, appraisal, and coping. The findings also verify the beneficial effects of the nursing intervention of PSI on ICU patients.

OPINIONS OF HEALTHCARE PROFESSIONALS REGARDING THE MATERNITY EXPERIENCES OF INDIGENOUS WOMEN IN AN ACUTE CARE SETTING

ABSTRACT: This is the report of stage three of a three stage project. The aims of the overall project were to seek advice from expert Indigenous women on how to gather information from birthing Indigenous women while in hospital. Information was gathered from Indigenous women who gave birth in hospital or were admitted after the birth of their baby. The opinions of healthcare professionals on the care of these women were investigated. This paper describes the opinions and concerns of healthcare professionals regarding identified cultural, social and economical issues for Indigenous women at a large acute care hospital in the Northern Territory, Australia. The opinions of healthcare professionals are vital if the needs and concerns of Indigenous women are to be considered within the hospital setting.Stages one and two of this project have been presented previously. Stage three, reported here, describes a survey of 18 non‐Indigenous and one Indigenous healthcare professionals regarding their opinions of the maternity experiences of Indigenous women admitted to an acute care setting. The consultative process for designing the questionnaire and reflections on issues raised by Indigenous women during their interviews in the previous two stages is presented. The methodology of the survey, demographics and perceptions of healthcare professionals who participated in the project are examined and the similarities and differences between the issues raised by the healthcare professionals and the Indigenous women in stage two of the project are discussed. Suggestions made by the healthcare professionals regarding improving quality of care for Indigenous women when admitted to an acute healthcare setting are presented.

Developing strategies to gather information about the maternity experiences of indigenous women in an acute care setting.

This project emerged from the concerns of health care professionals at a large acute care hospital in the Northern Territory of Australia. The aim of the project was to develop educational resources through information and experiences provided by Aboriginal and Torres Strait Islander women and health care professionals. The objectives are to optimise collaboration and participation by Indigenous and Torres Strait Islander women in sharing their maternity experiences about the birthing of their baby either in hospital, or out of hospital before arrival. Stage one of a three stage project is reported here. In stage one a modified Delphi method was used to interview ten purposefully chosen professional Indigenous women with insight into the research process and changing social arrangements. Stage two involved the development of an interview schedule and face-to-face interviews. Stage three includes the development of a questionnaire to be answered by health care professionals. Discussion of the background to the study, reviewed literature and issues identified from interviews with the professional Indigenous women regarding best methods and appropriate data collection processes is presented. Research described here explores issues of concern for Indigenous women from the Northern Territory around their child birthing experiences in an acute care setting.

Opinions of healthcare professionals regarding the maternity experiences of indigenous women in an acute care setting

This is the report of stage three of a three stage project. The aims of the overall project were to seek advice from expert Indigenous women on how to gather information from birthing Indigenous women while in hospital. Information was gathered from Indigenous women who gave birth in hospital or were admitted after the birth of their baby. The opinions of healthcare professionals on the care of these women were investigated. This paper describes the opinions and concerns of healthcare professionals regarding identified cultural, social and economical issues for Indigenous women at a large acute care hospital in the Northern Territory, Australia. The opinions of healthcare professionals are vital if the needs and concerns of Indigenous women are to be considered within the hospital setting. Stages one and two of this project have been presented previously. Stage three, reported here, describes a survey of 18 non-Indigenous and one Indigenous healthcare professionals regarding their opinions of the maternity experiences of Indigenous women admitted to an acute care setting. The consultative process for designing the questionnaire and reflections on issues raised by Indigenous women during their interviews in the previous two stages is presented. The methodology of the survey, demographics and perceptions of healthcare professionals who participated in the project are examined and the similarities and differences between the issues raised by the healthcare professionals and the Indigenous women in stage two of the project are discussed. Suggestions made by the healthcare professionals regarding improving quality of care for Indigenous women when admitted to an acute healthcare setting are presented.

Best care for the elderly at Forsyth Medical Center.

Health care organizations are very interested in the unique needs and resource utilization the aging population will create. This article describes the commitment of a large acute-care hospital to create a senior-friendly environment. The care of hospitalized elders has become a central focus to identify and prioritize improvement opportunities. An interdisciplinary team of professionals passionate about the care of the elder population was developed to champion the efforts, and the NICHE project was their starting point. This article describes the team and the methods they used to modify models and design processes to meet the needs of the organization and this patient population. Successes and opportunities for continued improvement also are identified.

Skin only or silo closure in the critically ill patient with an open abdomen

Background: The morbidity and mortality of various open abdominal techniques remains unclear. Methods: A retrospective review was made of all trauma or general surgery patients who underwent an open abdominal closure from January 1997 to December 2000, at a large urban acute care hospital. Data are mean ± SD. Results: From 1997 to 2000, 181 patients (aged 39.8 ± 16.5 years) had an open abdomen for abdominal infection, planned reexploration, abdominal compartment syndrome, inability to reapproximate fascia, or as part of a “damage control” procedure. Twenty-three patients went on to develop an abdominal compartment syndrome. Gastrointestinal fistulas occurred in 26 patients, and 9 patients had a dehiscence. The overall mortality was 44.7%. Of the survivors, 52% went on to fascial closure, requiring 1 to 7 additional abdominal operations. Conclusions: The morbidity of the open abdomen varies with the particular indication. Gastrointestinal fistulas are the most common acute complication and an abdominal wall hernia, the most common chronic complication.

Predicting Length of Stay in an Acute Care Hospital

ABSTRACT In an acute care hospital, a major performance indicator is patient length of stay. This study, in a large university teaching acute care hospital in Canada, examined the effect of psychosocial problems on length of stay, controlling for patient demographics and medical condition. Average days stay for Diagnostic Related Groups (DRGs) was used as a proxy variable for severity of medical condition, and the Person-in-Environment (PIE) classification system was used to measure psychosocial problems. Data were collected on a sample of 160 patients; 78 in psychiatry and 82 in medical/surgical wards. In a regression analysis, the severity of the patient's psychosocial problem was a more significant predictor of length of stay than the DRG variable. The identification of psychosocial problems and their severity add an important and complementary dimension to research into the effectiveness of social workers in reducing length of stay. Workers found clients had significantly more problems related to their social role functioning than problems in the environment.