Midwestern Community Hospital Research Articles

Universal genetic counseling in breast cancer patients significantly improves overall testing rates and improves completion rates in subpopulations.

The NCCN guidelines recommend genetic testing in those patients at increased risk of breast cancer in order to identify candidates for increased frequency of screening or prophylactic mastectomy. However, genetic testing may now identify patients who may benefit from recently developed targeted breast cancer therapy. In order to more widely identify these patients, we implemented genetic counseling for all patients diagnosed with breast cancer. In 2021, all patients evaluated within a Midwestern community hospital system diagnosed with breast cancer were offered genetic counseling. This group of patients was compared to a cohort of patients in 2021 who were offered genetic counseling based on NCCN guidelines. With Pearson's chi square, Fisher's Exact test, Mann-Whitney U, and multivariate regression as appropriate, individual demographic data and genetic testing completion between 2019 and 2021 were evaluated. A total of 973 patients were reviewed. 439 were diagnosed with breast cancer in 2019 and 534 in 2021. Demographics and stage at diagnosis (p = 0.194) were similar between years. Completion of genetic testing increased from 204 (46.5%) in 2019 to 338 (63.3%) in 2021 (p < 0.01) with the universal counseling protocol. Specifically, genetic testing completion increased significantly in older patients (p = 0.041) and patients receiving Medicare benefits (p = 0.005). The overall pathogenic variants found increased from 32 to 39 with the most common including BRCA2 (n = 11), CFTR (n = 9), CHEK2 (n = 8), BRCA1 (n = 6). Universal genetic counseling was related to a significant increase in genetic testing completion and an increase in pathogenic variants found among breast cancer patients, specifically in subpopulations which may have been previously excluded by traditional NCCN genetic testing screening guidelines.

Medical-surgical nurse leaders' experiences with safety culture: An inductive qualitative descriptive study.

The aim of this study is to describe safety culture as experienced by medical-surgical nurse leaders. Safety culture remains a barrier in safer patient care. Nurse leaders play an important role in creating and supporting a safety culture. We used an inductive qualitative descriptive study using semistructured interviews, document review and observations in a Midwestern community hospital in the United States. Results of the study are as follows: making sure nurses are keeping patients safe, making sure nurses have nursing interventions in place, expecting nurses to stop unsafe acts or escalate when they feel uncomfortable, making sure nurses have what they need to provide safe care, organization prioritizes patient safety and making sure nurses are learning and growing emerged as themes describing safety culture. Nurse leaders made sure patients were safe by making sure everyone was doing their best to provide safe care. Insufficient time, too many priorities, insufficient resources, poor physician behaviours and lack of respect for their role emerged as barriers to leading a safety culture. Organizations must remove barriers for nurse leaders to develop and lead a safety culture. Nurse leaders must learn to advocate successfully for safe nursing care and professional work environments.

Preoperative Cryoneurolysis for Total Knee Arthroplasty: A Case Series

PurposeThe purpose of this pilot project case series is to describe the use of preoperative cryoneurolysis for 10 patients presenting for total knee arthroplasty (TKA). DesignDescriptive research design. MethodsBilling codes were used to identify 10 patients who had previously undergone TKA, preoperative cryoneurolysis and physical therapy (PT) at a Midwestern community hospital. Data collected included anesthetic management strategies, multimodal analgesic therapies, postanesthesia care unit pain scores (PACU), pain scores during physical therapy, and achievement of a range of motion during physical therapy. FindingsNine of 10 patients who received preoperative cryoneurolysis had PACU pain scores of 0 (0-10 scale) up to 90 minutes postoperatively. Pain scores immediately following cryoneurolysis therapy were reduced in all patients reporting pain greater than 0 (1-10 pain scale) before their treatment. Increased active range of motion trends were noted with reports of decreased pain scores during postoperative physical therapy sessions. ConclusionsThis pilot project case series demonstrates potential benefits of using preoperative cryoneurolysis to provide postoperative pain control and aid with physical therapy recovery following TKA.

Reducing 30-Day All-Cause Acute Exacerbation of Chronic Obstructive Pulmonary Disease Readmission Rate With a Multidisciplinary Quality Improvement Project.

Our objective was to implement a comprehensive quality improvement project to decrease the 30-day readmission rate for all-cause acute exacerbation of chronic obstructive pulmonary disease (AECOPD) at a rural Midwestern community hospital in the United States. Prospective data were collected from January 1 to December 31, 2017. A total of 77 patients met the study criteria and were included for analysis. Baseline data analysis involved data for 72 patients from September 1, 2015, to October 1, 2016, and showed a 30.6% all-cause 30-day AECOPD readmission rate. The Define, Measure, Analyze, Improve, and Control (DMAIC) model was used for this quality improvement project. All aspects of this project were successfully implemented, and the resulting 30-day all-cause AECOPD readmission rate decreased to 16.9% during the study time frame. Through this comprehensive quality improvement project, the 30-day all-cause AECOPD readmission rate was reduced by 23.7%.

Escape the Womb: A Maternal Emergency

Background. Due to advanced maternal age, obesity, drug use, and other comorbidities, the frequency of maternal cardiac arrest continues to rise nationally and in our Midwestern community hospital. While still a relatively rare occurrence, the national rise in maternal mortality rates has created a need for population-specific resuscitation education for caregivers of obstetric patients. Educators are challenged with creating engaging, meaningful education that is inexpensive and effective. Educational escape rooms challenge participants to discover clues, solve puzzles, progress through the game and ultimately escape the room. The format offers team problem-solving and experiential learning with immediate feedback in an enjoyable atmosphere. Aim. In order to provide an interprofessional and economical educational intervention for labor and delivery teams, the authors created an escape room focused on principles of effective maternal resuscitation. Method. Participants completed an evaluation tool measuring perceptions of content clarity and confidence, and an author created pre-test and post-test to measure knowledge of cardiopulmonary resuscitation medications and interventions for the obstetric patient. Results and Conclusions. Comparison of aggregated pre- and post-test showed an 11% increase in knowledge scores. All participants self-evaluation showed improved clarity and confidence and described the activity as a fun way to learn and reinforce knowledge.

Escape Room Blueprint: Central Orientation Contagion Crisis

Background: Turnover rate for new graduate nurses at a midwestern community hospital was 30% for the first two years. Central clinical orientation for new hire registered nurses and care assistants was heavily executed via didactic format. Feedback from instructors suggested boredom and disengagement of learners during these sessions. Post central orientation evaluations resulted in 49% of attendees feeling not “very confident” to apply skills in clinical practice. Methods: Clinical educators created an escape room to improve learner satisfaction, interprofessional communication, and confidence in applying skills in practice. A convenience sample of twenty-three (23) registered nurses and care assistants participated in an escape room, Contagion Crisis, covering basic knowledge of infection control, emergency response, restraints, and drug calculation. Results: Average Likert scores on the post survey for satisfaction and communication were 4.67 and 4.0 respectively. Confidence in applying skills to practice averaged 4.72. Subjective feedback from participants included enjoyment of a fun, non-pressure environment. Conclusion: Multiple clinical disciplines can use this escape room, as it covers topics from central hospital orientation. Learners preferred the escape room format versus a high-fidelity simulation, due to it being less “high stakes” and not a judgement of individual performance.

Operation Outbreak: A Periop 101 Exam Review Escape Room

Background: Perioperative nursing is expected to see a 20% reduction in the workforce due to retirement within five (5) years. To recruit and retain nurses within this specialty, the Association of Operating Room Nurses (AORN) Periop 101: Core Curriculum™ OR was added to an existing nurse residency program. Periop 101 is an online learning program providing evidence-based guidelines for practice and requires the learner to pass a final exam with a score of 80% or higher. Following a didactic final exam review session, most nurse residents at a midwestern community hospital failed to pass the final exam on their first attempt. Aim: To address this knowledge gap, the clinical educators decided to create a more interactive review session by creating an escape room. Current literature supports the use of escape rooms to increase knowledge and learner engagement. Method: Nurse residents participate in Operation Outbreak during the exam review session. A convenience sample of twenty-two (22) registered nurses were included in the quality improvement project. Group one consisted of 18 participants who received only the didactic review session. Group two had four participants who participated in the didactic review session as well as the Operation Outbreak escape room. Results/Conclusion: Overall, there was improvement in the average final exam scores and average percentage of residents to pass the exam on the first attempt after the addition of the escape room. Statistical analysis was not performed due to sample limitations.

Self-Management Toolkit for High-Risk Patients With Type 2 Diabetes and the Effect on Nurses' Confidence.

A quality improvement project at a small midwestern community hospital assessed current education for adult patients with type 2 diabetes and nurses' knowledge and confidence in providing diabetes education. The intervention targeted staff nurses on a medical-surgical floor and included a revised diabetes toolkit, development of an education process for patients with diabetes, and multimodality delivery of education about diabetes care. Evaluation of the intervention was accomplished through a pre- and postsurvey measuring nurses' confidence. Nurses' confidence improved postintervention (S = 26, p = .04). The project outcome aligned with similar diabetes education projects in the literature that reflected an increase in nurse confidence following an educational intervention. Leadership support of ongoing educational experiences for nurses is necessary to address gaps in knowledge and changes in clinical standards. Patient outcomes may be positively affected if nurses are confident teaching patients how to effectively manage their diabetes. [J Contin Educ Nurs. 2020;51(6):287-292.].

Realistic Evaluation of a Rapid Response System: Context, Mechanisms, and Outcomes.

The purpose of this study was to describe and explore differences between rapid response system events in a Midwestern community hospital through context, mechanism, and outcome factors. The design was a retrospective review of 1,939 adult inpatient events that occurred on medical (62.8%) and surgical units (37.2%) over 92 months. The immediate outcomes of the events were stabilization (59.0%), transfer to a higher level of care (39%), and cardiopulmonary arrest (2%). Nurses activated 94% of all rapid response events; respiratory (38.8%) and cardiac (29.2%) symptoms were the most common triggers, and worry alone triggered 23% of all events. Medical and surgical events were significantly different with regard to antecedents to unit arrival, most common triggers, immediate clinical outcomes, and occurrence during resource-limited times. Understanding rapid response events and differences between medical and surgical units is important to improve early identification of deterioration and thus intervention for vulnerable patients.

59: Differences in apical repair at time of hysterectomy for patients with pelvic organ prolapse at a Midwestern community hospital

59: Differences in apical repair at time of hysterectomy for patients with pelvic organ prolapse at a Midwestern community hospital

Abstract WP370: Breaking Barriers for Fast Acute Stroke Treatment

Background: Timeliness of acute stroke treatment is imperative. Our 384 bed, Midwestern community hospital seeks to treat ischemic stroke tPA patients within 45 minutes of arrival. However, individual staff attitudes toward use of tPA, early treatment and teamwork appeared to be barriers to timely treatment. Purpose: To understand what the barriers are for fast treatment and to give staff tools to overcome. Methods: A carefully designed, but brief, set of survey questions concerning individual views and attitudes toward the timeliness and smooth treatment between EDP/ED nurses/Neurology was completed by EDP’s, ED Nurses and Neurologists. The data from this survey was analyzed and provided information to implement changes: 1] Immediate and collaborative feedback reporting timing and outcomes; 2] Provision of a stroke-alert algorithm attached to tPA; and, 3] Accessible education information for patients and family. Results: 56 staff completed the survey pre intervention (PRE) and 72 post intervention (POST). In most cases the barriers were reduced POST. Top barriers identified were: Slow ED to Neurology Contact time PRE 38% and POST 21%; EDP reluctance to treat PRE 32% and POST 18%; Difficulty identifying stroke patients PRE 30% and POST 26%; Losing track of time PRE 29% and POST 19%; Delay due to time to educate patients PRE 18% and POST 19%. Treatment times PRE were an average of 52 minutes door to needle and POST an average of 45 minutes. Door to neurology contact was PRE an average 20 minutes and POST an average of 11 minutes. There was a shift of the EDP’s attitude towards tPA use for acute stroke. PRE 50% answered that tPA use for stroke is not based on existing science. POST this was reduced to 20%. Conclusions: While treatment time, neurology contact time, and reported barriers were improved, the clear shift in EDP collective attitude toward tPA was most important. Keeping stroke at the forefront by communicating through collaborative feedback reports appeared to keep staff engaged and accountable. Keeping algorithms and tPA education material immediately available also assisted in our treatment goals.

What’s Ideal? A case study exploring handoff routines in practice

BackgroundHandoffs of care in the healthcare system between responsible providers have traditionally been conceptualized and studied at the point of patient transfer. Thus, clinical practice and associated information systems are designed with the concept of the handoff as a solitary event. This viewpoint does not consider the routine activities necessary for a successful handoff. We propose expanding the analysis of the handoff beyond the single point of transfer to include a routine of interrelated activities leading up to the transfer of responsibility. We used this expanded definition of handoffs to identify exceptions from standard practice as identified by ideal-type handoff routines. MethodWe used an ethnographic case method to study handoffs in an interventional cardiology unit in a Midwestern community hospital. This involved examining handoffs and their supporting routines. We conducted thematic analysis of the handoffs using NVivo, a qualitative software analysis program. These analyses include categorization of the types and causes of differences in practice and exceptions from ideal-type handoffs. ResultsObserved handoffs that took place within the clinical unit did not consistently align with the ideal-type routine, yet this variation did not necessarily lead to exceptions. However, for handoffs between clinical units, although more likely to follow the ideal-type routine, differences from the standardized routine more often led to exceptions. We found that problems with performing the routine activities leading up to the handoff and the context in which the handoff occurred affected whether the handoff was successful. ConclusionsConsidering the handoff as a routine rather than simply the point of transition gives broader insight about how care transitions function. Such consideration helps clinicians better understand how variations occur and how differences from ideal-type handoffs can lead to potential exceptions such as missing information. This analysis can be used to develop information systems that better support handoffs.

Capturing Key NANDA-I Nursing Diagnoses From Actual Clinical Data for Patients With Heart Failure.

The purpose of the study was to identify key nursing diagnoses with related factors and signs/symptoms using NANDA-I for patients with heart failure (HF). A retrospective descriptive design was used to address the research questions. Data were obtained from the records of patients discharged for 1 year with the medical diagnoses of HF from a Midwestern community hospital. A total of 272 inpatient records were analyzed to describe the frequency and percentage of NANDA-I diagnosis with related factors and signs/symptoms. The top 10 NANDA-I diagnoses associated with related factors and signs/symptoms were identified. Further research related to standardized nursing terminologies such as NANDA-I using large clinical databases from health information systems is needed to support evidence-based nursing diagnosis decision making.

Advanced Practice Nurse-managed Heart Failure Clinic Benefits Patient’s Quality of Life and Limits Readmissions

Background: Heart failure (HF) is the primary cause of hospitalizations and readmissions to a hospital within 30 days of initial discharge. In 2010 HF cost an estimated $39.2 billion in health care services, lost productivity and medications. Optimizing outpatient care is vital to effectively manage this patient population. Objective: The purpose of this paper is to describe and evaluate the effectiveness of an optimized outpatient HF clinic. Patient outcomes from a Midwestern community hospital were based on quality of life (QOL) and readmission rates. Methods: A retrospective chart audit was conducted on a random sample of patients enrolled in the Heart Failure Recovery Center (HFRC). The QOL outcomes were measured using the Minnesota Living with Heart Failure® Questionnaire. Results: Enrolled patients demonstrated improvement in their QOL in the emotional, physical, and overall scores across the first 6 months of care. In addition, there were significantly fewer 30-day all-cause readmissions when compared to non-Clinic patients. Conclusion: Utilization of an APN-managed multidisciplinary HF clinic improved patient's QOL and contributed to one hospital's decreased all-cause readmission rates for the HF population.

The Need for Nursing Education in the Care of Adults With Congenital Heart Defects

The population of adults with congenital heart defects is rapidly expanding. Formal and informal nursing education offers little if any training in the care of adults with congenital heart defects, creating a disparity between the growing need for care for these patients and the availability of knowledgeable providers. A needs assessment survey was conducted to assess educational needs, use of available resources, and learning method preferences of nurses within a Midwestern community hospital (N = 800). The convenience sample included 269 responses (n = 269). A pilot survey was conducted with a subset of the population (n = 18). The results showed a poor understanding of adults with congenital heart defects, with findings similar to those of previous studies. Providing education may help to prepare nurses to care for adults with congenital heart defects as these patients are seen in increasing numbers in all areas of health care.

Nurses' Beliefs and Self-Reported Practices Related to Pain Assessment in Nonverbal Patients

This study explored the beliefs and self-reported practices of nurses related to pain assessment in nonverbal patients. A convenience sample of 74 nurses from one Midwestern community hospital responded to a researcher-developed questionnaire based on established pain standards and clinical practice recommendations. Areas of nonverbal pain assessment beliefs and practices with low scores were identified. One-way analysis of variance with Tukey post hoc tests showed a significant difference in belief scores based on unit worked. No significant differences in beliefs or practices were found based on age, years of experience, or degree. Paired t tests showed significant differences between general pain beliefs and nonverbal pain beliefs, between general pain beliefs and practices, and between nonverbal pain beliefs and practices. Additional testing using Pearson correlation coefficients demonstrated that only three out of seven questions relating to beliefs were significantly correlated with similar questions related to practices. Good reliability of the instrument was demonstrated by Cronbach alpha coefficient α = 0.82. Recommendations include further education for hospital nurses related to pain assessment standards in nonverbal patients, as well as utilization of techniques to integrate this knowledge into nurses' belief systems and practice environment.

Post-thrombotic Syndrome Patient Education Based on the Health Belief Model

This study was designed to evaluate patient responses to a patient education handout on post-thrombotic syndrome prevention based on the Health Belief Model. This quasi-experimental pilot study involved a patient survey to be completed after reviewing a patient education handout. A convenience sample of 25 patients with deep vein thrombosis confirmed by venous Doppler assessment with a lower extremity deep vein thrombosis admitted to a Midwestern community hospital was identified. Seven patients were excluded and 5 declined participation; 13 completed the survey patients. Subjects were older than 18 years and able to read and understand English. Patients with hospice or palliative care service or life expectancy less than 6 months were excluded. Subjects were provided with the post-thrombotic syndrome (PTS), patient education handout, and the PTS patient education survey. The PTS patient education handout consisted of a 1-page informational sheet based on PTS and Health Belief Model literature. The 24-item PTS Patient Education Survey required approximately 15 minutes to complete; items included demographic information, questions regarding previous deep vein thrombosis and Likert scale opinion statements regarding PTS based on Health Belief Model components. Patients meeting inclusion criteria were approached by the investigator, invited to participate in the study, and offered the option of having the investigator collect the survey or return in an addressed, stamped envelope. Respondents tended to agree that PTS was a serious condition and that it would negatively affect their life, primarily in relation to comfort and the ability to engage in leisure activities. Ten participants (76.9%) acknowledged that they were susceptible to PTS, and that elastic graduated compression stockings were effective. The most commonly cited barrier to wearing the stockings was difficulty with application. Five patients (38.5%) agreed that they had the ability to prevent PTS and 9 (69.2%) indicated that they intended to wear the stockings. Patient education for post-thrombotic syndrome prevention based on the Health Belief Model resulted in self-reported intention to comply with recommendations to wear graduated elastic compression stockings. Compliance may be enhanced by specifically addressing individual risk factors and barriers to stocking application.

Barbed Sutures Are a Safe Alternative to Polyglycolic Acid Sutures for Closure of the Vaginal Cuff at the Time of Robotic Hysterectomy

To determine the safety of barbed suture use in the robotic closure of vaginal cuffs. Retrospective medical records review at least 90 days post-operative. Vaginal cuff healing complication (further referred to as “cuff complication”) was defined as cellulitis, abscess, cuff separation, complete dehiscence, or evisceration. Midwestern community hospital. 220 patients who underwent robotically assisted laparoscopic hysterectomy for benign indications from September 2009 through December 2010. Vaginal cuff closure with barbed suture or polyglycolic acid (PGA). Barbed suture was used for vaginal cuff closure in 166 procedures- 145 Quill™ SRS (Angiotech Pharmaceuticals, Inc., San Angelo, TX) and 21 V-Loc™ 180 (Covidien, Mansfield, MA). PGA was utilized in 54 procedures- 32 interrupted, 18 running, 2 locked, and 2 unknown. Mean procedure time for barbed suture was 162 minutes, compared with 185 for PGA (p=0.037). Five cuff complications (3.0%) occurred with the use of barbed suture (4 Quill™ SRS and 1 V-Loc™ 180) compared with one cuff complication (1.9%) with the use of PGA (See Tables 1 & 2). This difference was not significant. All four cuff complications in the Quill™ SRS group occurred in the first four months following its introduction. Further analysis revealed that all four of these complications occurred within the first ten cases in which barbed suture was utilized by the operating surgeon. The single cuff complication in the PGA group occurred in one of the two procedures in which a running locked method was employed. No cuff complications occurred with either an interrupted or continuously run PGA suture.Table 1Vaginal Cuff Complications by Suture TypeCases (n)Cuff Complications (n)Cuff Complications (%)SignificanceBarted SutureQuil SRS14542.8NSV-Lock2114.8NSTotal16653.0NSCases (n)Cuff Complications (n)Cuff Complications (%)Polyglycollic AcidInterrupted3200NSContinuous1800NSLocked2150NSUndocumented200NSTotal5411.9NS Open table in a new tab Table 2Characteristics of Vaginal Cuff ComplicationsComplicationSuture MaterialClosure MethodTime CoursePresentationRepeat SurgeryBMIConcurrent Risk FactorsPartial Cuff SeparationQuil™RunningPoD 25Vaginal bleedingVaginal repair41ObesityPartial Cuff SeparationQuil™RunningPoD 17Vaginal bleedingVaginal repair39Obesity, Diabetes, CAD, HypertensionCuff AbscessQuil™RunningPoD 5Fever, PainVaginal I&D25noneCuff AbscessQuil™RunningPoD 5Fever, Painnone23Diabetes, HypertensionCuff AbscessV-Loc™RunningPoD 4Fever, PainVaginal I&DnoneComplete Dehiscence without EviscerationPGALockedPoD 138Pain with IntercourseVaginal repair x221None Open table in a new tab Barbed suture provides safe and reliable results when utilized for vaginal cuff closure at the time of robotic hysterectomy. The clustering of cuff complications early in our experience is suggestive of a learning curve for the effective use of barbed suture.

Excessive Weight Loss in Breastfed Infants During the Postpartum Hospitalization

To examine differences in breastfeeding frequency, voids, and stools in infants with weight losses < or > or =7% during the postpartum hospitalization. Secondary analysis of data from a primary psychometric study examining the Mother Infant Breastfeeding Progress Tool (MIBPT). A midwestern community hospital in a multicultural racially diverse community. Convenience sample of 53 breastfeeding women and infants hospitalized after birth. Data were collected during a chart review; infants were divided into < or > or =7% weight loss groups at 2 days postpartum, and breastfeeding frequency, voiding, and stooling were examined between groups and used to predict a > or =7% weight loss at 2 days postpartum. Of the 53 infants, 20.8% lost > or =7% of their birth weight. Infants who lost > or =7% of their birth weight had significantly more total voids and a higher breastfeeding frequency on the day of birth than infants who lost <7% of their birth weight. A logistic regression analysis resulted in total voids being the only significant predictor of a > or =7% weight loss, with an odds ratio of 1.74 (95% CI=1.09, 2.75, p <; .05). In the absence of other indicators of ineffective breastfeeding, breastfeeding infants who lose > or =7% of their birth weight during the first 2 days postpartum might be experiencing a physiologic diuresis after birth, unrelated to their breastfeeding behaviors. More research is necessary to determine the cause of a > or =7% weight loss in newborns during the first 48 hours after birth.

Detecting Potential Pathogens on Hospital Surfaces: An Assessment of Carpet Tile Flooring in the Hospital Patient Environment

The type of flooring in hospitals has long been scrutinized in terms of its potential role in nosocomial (hospital-acquired) infections. This study was conducted for the purpose of detecting potential pathogens on tiled carpets, nontiled carpets, and vinyl flooring, all used in a Midwestern community hospital. A swab sampling protocol conducted over a 5-month period, coupled with denaturing gradient gel electrophoresis-16S rDNA molecular analysis, allowed for greater than 93% of the major components in the flooring samples to be identified at the genus and species level. This study evaluates the impact of floor finish materials as potential sources of microbial-related hospital-acquired infections.