Non-acute Settings Research Articles

Facilitators and Barriers to Antibiotic Stewardship: A Qualitative Study of Pharmacists' Perspectives.

Background: The Veterans Affairs (VA) is a leader in the implementation and advancement of antibiotic stewardship programs throughout the nation. The Centers for Disease Control and Prevention (CDC) has also led national antibiotic stewardship efforts and has outlined core elements to improve antibiotic use in hospitals, long-term care, and outpatient settings. Many facilities still face challenges to the implementation and maintenance of successful programs, particularly in nonacute care settings. The objective of this study was to identify barriers and facilitators to antibiotic stewardship within the VA medical centers through qualitative interviews with pharmacists. Methods: Eight semi-structured telephone interviews were conducted with pharmacists from 6 VA medical centers within VA New England Healthcare System. Pharmacist respondents were either pharmacy champions (for medical centers with established programs) or pharmacists with responsibilities in making antibiotic recommendations (locations without established programs). All interviews were audio recorded and transcribed verbatim. NVivo 8 was used for data coding and analysis. Results: Pharmacists from all 8 medical centers were contacted for interviews and pharmacists from 6 medical centers agreed to interviews (75% VA New England medical center participation). Three main themes regarding antibiotic stewardship were identified from the interviews with pharmacists. Respondents described the importance of (1) a supportive organizational culture, (2) protected time for antibiotic stewardship, and (3) a cohesive organizational structure in the success of antibiotic stewardship programs. Conclusions: Our findings support the CDC core elements for antibiotic stewardship, in particular the importance of leadership commitment in the creation of a culture that supports antibiotic stewardship and in ensuring staff are given sufficient time for antibiotic stewardship efforts. Although a strong supportive culture has been built, strategies focused on fostering increased protected time for antibiotic stewardship and a cohesive organizational structure may be helpful in advancing and sustaining successful antibiotic stewardship programs that improve patient outcomes.

Feasibility and implementation of CYP2C19 genotyping in patients using antiplatelet therapy.

A tailored antiplatelet strategy based on CYP2C19 genotype may reduce atherothrombotic and bleeding events. We describe our experience with CYP2C19 genotyping, using on-site TaqMan or Spartan genotyping or shipment to a central laboratory. Data from two ongoing projects were used: Popular Risk Score project (non-urgent percutaneous coronary intervention patients) and the Popular Genetics study (ST-segment elevation myocardial infarction patients). For both projects, the time to genotyping result was calculated. In the Popular Risk Score project (n=2556), median time from blood collection to genotyping result was 4:04h. In the Popular Genetics study (n=1038), median time from randomization to genotyping result was 2:24h. CYP2C19 genotyping is feasible in everyday clinical practice, both in the acute and non-acute settings.

A systematic review of team-building interventions in non-acute healthcare settings

BackgroundHealthcare is increasingly delivered in a team-based format emphasizing interdisciplinary coordination. While recent reviews have investigated team-building interventions primarily in acute healthcare settings (e.g. emergency or surgery departments), we aimed to systematically review the evidence base for team-building interventions in non-acute settings (e.g. primary care or rehabilitation clinics).MethodsWe conducted a systematic review in PubMed and Embase to identify team-building interventions, and conducted follow-up literature searches to identify articles describing empirical studies of those interventions. This process identified 14 team-building interventions for non-acute healthcare settings, and 25 manuscripts describing empirical studies of these interventions. We evaluated outcomes in four domains: trainee evaluations, teamwork attitudes/knowledge, team functioning, and patient impact.ResultsTrainee evaluations for team-building interventions were generally positive, but only one study associated team-building with statistically significant improvement in teamwork attitudes/knowledge. Similarly mixed results emerged for team functioning and patient impact.ConclusionsThe evidence base for healthcare team-building interventions in non-acute healthcare settings is much less developed than the parallel literature for short-term team function in acute care settings. Only one intervention we identified has been tested in multiple non-acute settings by distinct research teams. Positive findings regarding the utility of team-building interventions are tempered by a lack of control conditions, inconsistency in outcome measures, and high probability of bias. Considering these results alongside the well-recognized costs of poor healthcare teamwork suggests that additional research is sorely needed to develop the evidence base for team-building in non-acute settings.

Evaluation of a transitional care programme for frail older adults and the effectiveness for the oldest old

Introduction: Older adults with multimorbidity, aged 70 years and older, experience a complex of both medical and social problems and frequently require continuous care in multiple settings. They move between acute and non-acute care settings, such as hospitals, home, intermediate care unit, primary care center, nursing home and hospice. It is within that context, that the transitional care programme for this group has been developed in the IJsselland hospital in the Netherlands, and will be evaluated. In this programme the Transmural Care Bridge is incorporated. The programme: The identification of seniors at risk starts at the Emergency Department with the ISAR- HP, the identification of seniors at risk- hospitalized. Patients at high risk for functional decline will fill out a triage questionnaire with their informal caregivers developed by the Geriatricians of the hospital. In all cases a registered nurse on the ward were the patient is admitted will start with screening on delirium, malnutrition, ADL functions, mobility and fall risk. If nessecary the geriatric consultation team will visit the patient and a systematic comprehensive geriatric assessment (CGA) will be done. The geriatrician will develop a care plan. In the programme one day before discharge from hospital a community nurse (CN) visits the patient inside the hospital and within 48 hours after discharge from hospital and after 2, 6, 12 and 24 weeks. Main issues during these visits are medication safety, appropriateness of care arranged during hospital admission resources, social network and support for the informal caregiver. The CN will discuss the care plan with the General Practitioner (GP) of the patient. In a prospective cohort study 100 older patients, 50 patients before and 50 patients a after the start of this programme, are asked to fill out a questionnaire at the start of the program in het hospital, and after one and three months after discharge from hospital, to measure morbidity, functional limitations, cognitive functioning, social functioning, self-perceived health, self-perceived quality of life, experiences, GP visits and admissions. Also the effectiveness of the program on self-management abilities will be measured by the CN through the Self Sufficiency Matrix. 30 professionals inside and outside the hospital who provide care for this group of older adults, specialist, nurses, general practitioners and community nurses will be asked to provide their perspectives on the programme and on inter-professional collaboration. Effectiveness for the oldest old: Because preliminary research findings showed that many people aged 85 years and older, who we consider in this study as the oldest old, said they felt lonely, useless, lost spouses, friends and sometimes children and sometimes were waiting to die, an additional question arose about how the oldest old would percieve this care programme and if this would meet their needs. This question will be adressed by in depth interviews with the oldest old. Aim: This research project aims to contribute to changes in transitional care for older adults who are admitted to the hospital and add to the current body of knowledge of the perspectives of the oldest old on their care.

Overview of Home Parenteral Nutrition: An Update.

The trend in modern medicine is to transition care from the hospital to home or other nonacute settings as soon as possible. Increasingly, nutrition support professionals are being asked to help facilitate discharge and/or manage patients who require prolonged intravenous fluid and/or nutrition after having been stabilized during a hospitalization. This updated tutorial reviews many of the concepts and challenges that must be considered for successful care that helps to focus on the patients and their quality of life.

Pressure Injuries in Inpatient Care Facilities in the Czech Republic: Analysis of a National Electronic Database.

The purpose of this study was to analyze pressure injury (PI) occurrence upon admission and at any time during the hospital course inpatients care facilities in the Czech Republic. Secondary aims were to evaluate demographic and clinical data of patients with PI and the impact of a PI on length of stay (LOS) in the hospital. Retrospective, cross-sectional analysis. The sample comprised data of hospitalized patients entered into the National Register of Hospitalized Patients (NRHOSP) database of the Czech Republic between 2007 and 2014 with a diagnosis L89 (pressure ulcer of unspecified site based on the International Classification of Diseases, Tenth Revision, ICD-10). Electronic records of 17,762,854 hospitalizations were reviewed. Data from the NRHOSP from all acute and non-acute care hospitals in the Czech Republic were analyzed. Specifically, we analyzed patients admitted to acute and non-acute care facilities with a primary or secondary diagnosis of PI. The NRHOSP database included 17,762,854 cases, of which 46,224 cases (33,342 cases in acute care hospitals; 12,882 in non-acute care hospitals) had the L89 diagnosis (0.3%). The mean age of patients admitted with a PI was 73.8 ± 15.3 years (mean ± SD), and their average LOS was 33.2 ± 76.9 days. The mean LOS of patients hospitalized with L89 code as a primary diagnosis (n = 6877) was significantly longer compared to those patients for whom L89 code was a secondary diagnosis (25.8 vs 20.2 days, P < .001) in acute care facilities. In contrast, we found no difference in the mean LOS for patients hospitalized in non-acute care facility (58.7 days vs 65.1 days; P = .146) with ICD code L89. Pressure injuries were associated with significant LOS in both acute and non-acute care settings in the Czech Republic. Despite the valuable insights we obtained from the analysis of NRHOSP data, we advocate creation of a more valid and reliable electronic reporting system that enables policy makers to evaluate the quality and safety concerning PI and its impact on patients and the healthcare system.

Morphological and pharmacological determinants of peri-procedural myocardial infarction following elective stent implantation: Optical coherence tomography sub-analysis of the PRASFIT-Elective study

BackgroundPrevious studies have suggested that peri-procedural myocardial infarction (PMI) following percutaneous coronary intervention (PCI) is associated with adverse short- and long-term outcomes, and several morphological predictors of PMI have been studied. However, the determinants of PMI under novel anti-platelet therapy are not fully elucidated. Methods and resultsPRASFIT-Elective is a multicenter, parallel-group study of PCI patients in non-acute settings receiving either prasugrel or clopidogrel in addition to aspirin. Among 742 study patients, 94 (116 lesions) underwent optical coherence tomography (OCT) to evaluate the area of intra-stent tissue (IST, which comprises tissue protrusion and thrombus) after stenting in addition to standard parameters. We investigated the relationship between the peak creatine kinase (CK)-MB fraction levels after PCI and post-stent OCT findings, as well as on-treatment platelet reactivity determined by the P2Y12 reaction units (PRU) at PCI, in a post hoc manner. The multivariate linear analysis revealed that a larger total IST area (standardized coefficient: 0.370, p<0.001) and smaller minimal stent diameter (standardized coefficient: −0.242, p<0.014), but not the PRU value (p=0.988), were independently associated with CK-MB leakage. The IST area after stenting was mainly determined by the target lesion lipid index (averaged lipid arc×lipid length) (r=0.583, p<0.001). ConclusionFollowing elective PCI, a large IST area originating from a lipid-rich plaque and a smaller minimal stent diameter were associated with PMI.

Infection prevention outside of the acute care setting: Results from the MegaSurvey of infection preventionists

In recent years, there has been a significant shift of health care delivery to nonacute care settings. However, research on staffing and resources dedicated to infection prevention and control (IPC) in these settings is lacking. The data for this analysis come from the 2015 APIC MegaSurvey. Descriptive statistics were computed to describe infection preventionists (IPs) employed in nonacute care settings. Bivariate analyses were conducted to examine differences in facility and demographic characteristics by type of nonacute care setting. In total, 861 IPs represented ambulatory surgical centers (33%), long-term care facilities (23%), long-term acute care facilities (20%), inpatient behavioral or mental health care (12%), clinic or outpatient services (10%), and home health care (3%). Few (15%) were Certified in Infection Control. Most (58%) reported that less than half of their job was officially dedicated to IPC. On average, respondents reported spending the largest proportion of their time on surveillance and epidemiologic investigation (19%). IPs lacked support for secretarial functions (23%), data management (14%), and electronic medical records (32%). IPC activities, staffing, and resources differed significantly by type of nonacute care facility. This study indicates that resources directed to IPC in nonacute care settings may be lacking and identifies important areas for IPC education and program improvement. Research is needed to further examine staffing and IPC resources in these settings, which represent unique challenges to infection prevention and control.

High-sensitivity assays for troponin in patients with cardiac disease.

Troponin is a widely used biomarker in patients with cardiac disease. The use of troponin is well established in patients with suspected acute myocardial infarction (AMI), but troponin measurement is also used in other acute and nonacute settings. In patients with suspected AMI, early decision-making is crucial to allow rapid treatment and further diagnostic evaluation. Current guidelines recommend serial measurements of troponin with a cut-off concentration at the 99th percentile to triage patients in the emergency department. Newer, high-sensitivity assays for troponin enable the detection of distinctly lower concentrations. Using these assays and very low cut-off concentrations, several rapid diagnostic strategies have been reported to improve diagnosis in acute cardiac care. Furthermore, noncoronary and nonacute applications of troponin assays - for example as a biomarker in patients with heart failure, pulmonary embolism, or stable coronary artery disease - are on the horizon and might improve individual risk stratification. In this Review, we provide an overview on the development of high-sensitivity assays for troponin, and their application in patients with cardiac disease.

Application of appropriate use criteria for percutaneous coronary intervention in Japan.

The aim of this review was to summarize the concept of appropriate use criteria (AUC) regarding percutaneous coronary intervention (PCI) and document AUC use and impact on clinical practice in Japan, in comparison with its application in the United States. AUC were originally developed to subjectively evaluate the indications and performance of various diagnostic and therapeutic modalities, including revascularization techniques. Over the years, application of AUC has significantly impacted patient selection for PCI in the United States, particularly in non-acute settings. After the broad implementation of AUC in 2009, the rate of inappropriate PCI decreased by half by 2014. The effect was further accentuated by incorporation of financial incentives (e.g., restriction of reimbursement for inappropriate procedures). On the other hand, when the United States-derived AUC were applied to Japanese patients undergoing elective PCI from 2008 to 2013, about one-third were classified as inappropriate, largely due to the perception gap between American and Japanese experts. For example, PCI for low-risk non-left atrial ascending artery lesion was more likely to be classified as appropriate by Japanese standards, and anatomical imaging with coronary computed tomography angiography was used relatively frequently in Japan, but no scenario within the current AUC includes this modality. To extrapolate the current AUC to Japan or any other region outside of the United States, these local discrepancies must be taken into consideration, and scenarios should be revised to reflect contemporary practice. Understanding the concept of AUC as well as its perception gap between different counties will result in the broader implementation of AUC, and lead to the quality improvement of patients' care in the field of coronary intervention.

Registered nurses: the impact of wages on labour force participation and hours worked – are wages an effective mechanism for addressing RN shortages with evidence from 1960 to 2008?

ABSTRACTRegistered nurses (RNs) are critical producers and coordinators of patient care in acute and non-acute settings (Needleman et al. 2011). The Affordable Care Act coupled with an ageing population, are increasing demand for health care and, in turn, RNs. Numbering 3 million, RNs comprise the largest professional occupation in health care. Therefore, the labour force participation and hours worked are of keen interest to stakeholders and policymakers. Rising demand may exacerbate nursing shortages and have important effects on costs. We estimate the impact of wages on participation and hours worked as a possible policy tool to increase nursing supply. In 2008, the RN wage had a positive and significant effect on participation and a small positive but only marginally significant effect on hours worked given participation. The latter elasticity for married females (single females) was 0.11 (0.33). Therefore, the elasticity of hours worked with respect to the nurse wage is and unlikely to have an important effect on the participation rates or hours worked of currently trained female RNs. Consequently, wage increases are unlikely to be an effective policy to increase the labour supply among the currently licensed RNs and will not relieve any short-term nursing shortage.

The Where is Norovirus Control Lost (WINCL) Study: an enhanced surveillance project to identify norovirus index cases in care settings in the UK and Ireland.

Norovirus outbreaks have a significant impact on all care settings; little is known about the index cases from whom these outbreaks initiate. To identify and categorise norovirus outbreak index cases in care settings. A mixed-methods, multi-centre, prospective, enhanced surveillance study identified and categorised index cases in acute and non-acute care settings. From 54 participating centres, 537 outbreaks were reported (November 2013 to April 2014): 383 (71.3%) in acute care facilities (ACF); 115 (21.4%) in residential or care homes (RCH) and 39 (7.3%) in other care settings (OCS). Index cases were identified in 424 (79%) outbreaks. Of the 245 index cases who were asymptomatic on admission and not transferred within/into the care setting, 123 (50%) had been an inpatient/resident for 4 days. Four themes emerged: missing the diagnosis, care service under pressure, delay in outbreak control measures and patient/resident location and proximity. The true index case is commonly not identified as the cause of a norovirus outbreak with at least 50% of index cases being misclassified. Unrecognised norovirus cross-transmission occurs frequently suggesting that either Standard Infection Control Precautions (SICPs) are being insufficiently well applied, and or SICPs are themselves are insufficient to prevent outbreaks.

Usability of the Clinical Care Classification System for Representing Nursing Practice According to Specialty.

This study examined the ability of the Clinical Care Classification system to represent nursing record data across various nursing specialties. The data comprised nursing care plan records from December 1998 to October 2008 in a medical center. The total number of care plan documentation we analyzed was 2 060 178, and we used a process of knowledge discovery in datasets for data analysis. The results showed that 75.42% of the documented diagnosis terms could be mapped using the Clinical Care Classification system. However, a difference in nursing terminology emerged among various nursing specialties, ranging from 0.1% for otorhinolaryngology to 100% for colorectal surgery and plastic surgery. The top five nursing diagnoses were identified as knowledge deficit, acute pain, infection risk, falling risk, and bleeding risk, which were the most common health problems in an acute care setting but not in non-acute care settings. Overall, we identified a total of 21 established nursing diagnoses, which we recommend adding to the Clinical Care Classification system, most of which are applicable to emergency and intensive care specialties. Our results show that Clinical Care Classification is useful for documenting patient's problems in an acute setting, but we suggest adding new diagnoses to identify health problems in specialty settings.

Linda Q. Everett, PhD, RN, NEA-BC, FAAN

Nurse Leader 15 FAS: Please share about your decision to pursue a nursing career. LQE: Throughout high school, I had my sights set on becoming a history teacher. I was enrolled at The Ohio State University (OSU) as an education major. Over one summer, I joined a group of friends who sought employment at a local hospital as nursing assistants. I was given the “float” position on night shift. Over the next several months, I observed the nurses at work. I witnessed my first labor and delivery mother, battered and bleeding automobile accident victims in the ER [emergency room], and the dying and death of many patients. I developed a deep appreciation and respect for how the nurses responded to each situation. When I asked any nurse, “Why do you do what you do?” she or he responded, “Because I love my work.” That response oddly stuck with me—I had to reflect upon whether my career aspirations would be what I would “love to do.” I wasn’t certain. Long story short, I too fell in love with patient care. I actually enjoyed the work so much that I dropped my plans to attend OSU; instead, I ended up working a full year as a nursing assistant, then attended Riverside-White Cross School of Nursing in Columbus, Ohio the following fall. And I have never regretted that decision. FAS: As a nurse leader, what skill sets came naturally to you? Which qualities have you eventually developed throughout your leadership roles? LQE: I have always enjoyed reading and learning. I was an excellent student. I consumed books to the point that I was often accused by my family for being a “professional student.” So, I’d say the thirst for knowledge and lifelong learning has always been one of my innate skills. Listening to others is also a skill I would claim as a strength. I learned early in life from my mother—“Stop waiting to talk and listen to me!” The woman was wise beyond her own admission. A third skill I developed would be the ability to identify talent: assessing strengths and potential in others. This attribute has served me well in my leadership role to attract and hire the right people for the right position at the right time. Leader to Honor Linda Q. Everett, PhD, RN, NEA-BC, FAAN

Medication Assistant-Certification Program in Washington State: Barriers to implementation

Medication assistants (MAs) are a legal alternative that enables licensed nurses to safely delegate medication administration to stable residents in non-acute settings. The purpose of this study was to query the beliefs and understanding of skilled nursing facility staff regarding the Washington State Medication Assistant Endorsement Program (MAEP). A 15-item survey was developed and administered to a convenience sample of 218 nursing staff from five eastern Washington nursing homes. Most believed that MAs would not change the cost of care, nor would they enhance or reduce the quality of care provided to residents in skilled nursing facilities. The relatively few Licensed Practical Nurses surveyed (n = 19) were the least in favor of MAs, possibly fearing job loss with the addition of MAs to the staffing mix at their facilities. These factors in combination may reflect why MAEP has not yet been embraced by providers in Washington State.

Guideline update: The British Thoracic Society Guidelines on home oxygen use in adults

The 2015 British Thoracic Society (BTS) Home Oxygen Guidelines provides detailed evidence-based guidance for the use of oxygen by patients in their own homes or other non-acute hospital settings.

Academic-Practice Partnerships for Unemployed New Graduates in California.

In California, academic-practice partnerships offer innovative transition programs to new registered nurse (RN) graduates who have not yet found positions in nursing. This report describes the formation of 4 partnerships between 1 or more schools of nursing and clinical practice sites that included hospitals and nonacute care settings, such as hospice, clinics, school districts, and skilled nursing facilities. Factors facilitating the partnerships included relationships established as nurse leaders from practice and academia came together to address previous workforce issues, positive interpersonal experiences, an independent convening and coordinating organization, a shared understanding of the employment challenge faced by new RN graduates, and a shared vision for its solution. Partnerships face continuing challenges that include sustaining engagement, resource constraints, and insufficient nursing leadership succession planning. Partnership benefits include improved relationships between academia and practice, a forum to address contemporary issues in nursing education and practice advances, and stimulation of a reassessment of how to integrate ambulatory, transitional, and community-based nursing into prelicensure education.

A Team of Experts or an Expert Team: Interdisciplinary Teamwork and Perceptions of Palliative Care Quality (S742)

Objectives Identify potential IDT structures as targets for quality improvement (QI) programs. Identify potential IDT processes (e.g., leadership, communication) as targets for quality improvement (QI) programs. Original Research Background. The collaboration of multiple disciplines is required for optimal care of patients and families facing serious illness. While an interdisciplinary team (IDT) approach is widely recognized as important to the provision of palliative care (PC), less is known about how structures and processes of IDTs are associated with perceptions of PC quality. Research Objectives. This study examines how IDT structures (e.g., personnel, certification status, and organizational characteristics) and processes (e.g., leadership, communication) influence provider perceptions of PC quality. Methods. A cross-sectional survey design addressed the research objectives. PC providers completed an online survey from May 2013 to May 2014 which included demographic and organizational questions, and the subscales of the TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ). Results. Of the 372 respondents providing complete data on all variables, 81.4% were RNs and 18.6% were other disciplines. The quality of PC was rated as excellent by 51.3% of respondents (versus 48.7% for all other responses). In bivariate analysis, higher perceptions of PC quality were associated withmembership on a formal IDT (p1⁄40.002), male gender (p1⁄40.030), less than a masters level education (p1⁄40.014), collaboration with more disciplines (p1⁄40.002), employment in non-acute care settings (p1⁄40.040), and all T-TPQ subscales (leadership, mutual support, communication, team structure [p<0.000 respectively]). In the multivariate model, team structure and communication subscales (OR: 1.133, CI: 1.047-1.225, p1⁄40.002; and OR: 1.093, CI: 1.012-1.180, p1⁄40.023 respectively), collaboration with more disciplines (OR: 1.148, CI: 1.040-1.268, p1⁄40.006), employment in non-acute care settings (OR: 1.891, CI: 1.133-3.157, p1⁄40.015), andmale gender (OR: 2.544, CI: 1.073-6.034, p1⁄40.034) were independent predictors of perceptions of excellent PC quality. Conclusions. Perceptions of PC quality may be influenced by both the structures of IDTs as well as the processes associated with IDT functioning. Implications for Research, Policy, or Practice. This research suggests potential targets for quality improvement projects to transform an IDT of experts into an expert team for providing exceptional PC.

Board #143 - Research Abstract Simulated Patient as Co-facilitators

HypothesisThe quality of care for chronic patients depends on the collaborative skills of the healthcare providers.1,2 The literature lacks reports of the use of simulation to teach collaborative skills in non-acute care settings. We posit that simulation offers benefits for supporting the developme

Paramedic Specialization: A Strategy for Better Out-of-Hospital Care

Demographic, economic, and political forces are driving significant change in the US health care system. Paramedics are a health profession currently providing advanced emergency care and medical transportation throughout the United States. As the health care system demands more team-based care in nonacute, community, interfacility, and tactical response settings, specialized paramedic practitioners could be a valuable and well-positioned resource to meet these needs. Currently, there is limited support for specialty certifications that demand appropriate education, training, or experience standards before specialized practice by paramedics. A fragmented approach to specialty paramedic practice currently exists across our country in which states, regulators, nonprofit organizations, and other health care professions influence and regulate the practice of paramedicine. Multiple other medical professions, however, have already developed effective systems over the last century that can be easily adapted to the practice of paramedicine. Paramedicine practitioners need to organize a profession-based specialty board to organize and standardize a specialty certification system that can be used on a national level.