Small Community Hospital Research Articles

The Impact of Shared Governance Over Time in a Small Community Hospital.

This study examined the impact of shared governance (SG) on the professional nursing practice environment of a small community hospital over time. Shared governance has been shown to empower nurses in direct patient care to make decisions about their practice and improve job satisfaction. No research has been found that examined the progression of SG over time in a small community hospital. Questionnaires pertaining to the professional practice environment, perception of nursing leadership, nurse empowerment, nurse satisfaction, risk of practice errors, and comfort with evidence-based practice were administered to all nurses employed at a 149-bed community hospital in central North Carolina for 5 consecutive years. Results showed that nursing leadership and SG explained 90% of the variance in the nursing professional practice environment. This relationship held true for 5 years. All variables showed continued improvement for 4 years, until year 5 when the organization experienced disruptive change. Even during this year, the results did not return to baseline. In order to improve the professional practice environment of nurses, hospitals should focus on strong nursing leadership and a sound SG infrastructure.

Economic and patient satisfaction outcomes of a layered learning model in a small community hospital.

Results of a study of economic and patient satisfaction outcomes of implementing a "layered learning model" (LLM) in a community hospital are presented. An LLM consisting of a clinical pharmacist, two postgraduate year 1 pharmacy residents, and pharmacy students participating in rounds and providing patient education was implemented at a small community hospital. The primary endpoint was the difference in mean total drug cost per discharge in cases managed by physicians who rounded with pharmacy representatives (the intervention group) and cases managed by physicians who rounded with no pharmacist present (the control group). Secondary outcomes were drug expenditures associated with eight common diagnoses and patient satisfaction scores in medication education domains of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Statistical analysis was performed using Student's t test and chi-square tests. The intervention-group data comprised 2737 hospital discharges, as compared with 3983 discharges for the control group. The geometric mean total drug cost per discharge was $161.52 for the intervention group, as compared with $210.15 for the control group (difference, $48.63; p < 0.001); drug costs for pneumonia and urinary tract infection were significantly lower for the intervention group. Patient satisfaction scores were significantly improved in the intervention group relative to baseline scores (8th percentile versus 39th percentile, p < 0.001). Implementation of the LLM in a small community hospital reduced medication costs and improved HCAHPS patient satisfaction scores.

Comparison of Intraoperative Periarticular Injections Versus Liposomal Bupivacaine as Part of a Multimodal Approach to Pain Management in Total Knee Arthroplasty.

Total knee arthroplasty (TKA) has been shown to restore mobility, return an individual to activities of daily living, and improve quality of life. Nearly 80% of patients undergoing TKA report moderate to severe pain in the first 2 weeks following surgery. A retrospective study was conducted in 103 patients who underwent TKA between October 12, 2014 and May 30, 2015 by a single surgeon at a small community hospital. During this period, data were analyzed for differences in outcomes with a change from intraoperative periarticular (IOPA) injections containing an anesthetic/analgesic mixture of ropivacaine, epinephrine, ketorolac, and clonidine to liposomal bupivacaine. Patient records were reviewed to extract study data including postoperative opioid use, length of stay (LOS), opioid-associated adverse events, and non-opioid analgesic use. No statistical differences were determined between groups for mean postoperative opiate usage in morphine equivalences during any time frame or for total opiate usage (79.4 vs 89.2 mg; P = .259) during the first 72 postoperative hours. Patients who received a liposomal bupivacaine injection did have a statistically significant increase in hospital LOS (70.0 vs 75.5 hours; P = .013) when compared to patients who received an IOPA injection. The incidence of nausea or vomiting, pruritus, or oversedation did not differ between groups. Pain control in TKA with a multimodal pain management protocol was not improved with the addition of liposomal bupivacaine compared to the IOPA injection at a community hospital.

Validation of the Critical Care Pain Observation Tool (CPOT) in a Small Community Hospital Setting

This IRB approved quantitative validation study utilized a repeated measure design to determine if the CPOT tool is a valid and reliable tool to detect pain for non-verbal critical care patients in our small community hospital setting. Our study utilized a convenience sample of 52 critical care patients who were considered for inclusion if they were >18 y/o and were unable to communicate the presence or absence of pain verbally or through gestures. Recruitment of eligible patients was done through daily rounds by the PI and/or the staff nurse. Consent was not required by the IRB. Each patient received a study folder containing 3 sets of 2 CPOT scoring tools. Patients were assessed with the current method of pain assessment - Assume Pain Present (+/− APP) and the CPOT tool. Both assessments were completed by two RNs at the bedside on three separate occasions. At the conclusion of the study, results were tabulated by a statistician. Interrater reliability was found to be acceptable with a weighted kappa coefficient of 0.950. There was a statistically significant high correlation between the CPOT and APP, indicating good convergent validity at 0.98. Our research demonstrated the CPOT to be a valid and reliable tool to detect the presence of pain in our hospital setting. Future research will focus on the use of the CPOT to increase the confidence of the RN in both assessment of pain for this patient population and collaboration with other members of the health care team to provide safe and appropriate intervention related to pain for this vulnerable patient population.

Antimicrobial Stewardship Knowledge, Attitudes, and Practices among Health Care Professionals at Small Community Hospitals.

Very little is known about antimicrobial stewardship knowledge, attitudes, and practices (KAP) among health care practitioners in small, community hospitals (SCHs) compared to large community hospitals (LCHs). To compare infectious diseases (ID) clinical resources and describe KAP pertaining to antimicrobial stewardship among prescribers, pharmacists, and administrators from a large hospital network including a comparison between SCHs and LCHs. An anonymous 48-item antimicrobial stewardship KAP survey was administered to pharmacists, prescribers, and administrators at 15 SCH (<200 beds) and 5 LCHs (>200 beds) within an integrated health care network. In total, 588 (14%) completed the survey: 198 from SCHs and 390 from LCHs. Most respondents were familiar or very familiar with the term antimicrobial stewardship and felt that antimicrobial stewardship was necessary. Most pharmacists and prescribers agreed that antimicrobials were overused at their hospital. However, SCH pharmacists and prescribers were more likely to disagree that antibiotic resistance is a significant problem locally. Pharmacists saw restrictions as a reasonable method of controlling antibiotic use more than prescribers. SCH practitioners were less familiar with IDSA guidelines and less likely to rely on ID specialists to a greater extent than LCH practitioners. Most respondents strongly agreed they would like more antimicrobial education. SCH and LCH pharmacists, prescribers, and administrators are aware of antimicrobial resistance and overuse and agree that antimicrobial stewardship programs are necessary. SCHs are less likely to contact ID for information. These results support the development of antimicrobial stewardship programs at SCHs, while recognizing the significant differences in availability and utilization of resources.

Abstract 25: Evidence Based Aspiration Risk Tool: Improving Stroke Care

Introduction: According to the American Heart Association, approximately 65 percent of stroke patients will have swallowing impairment that needs evaluation prior to oral intake or medications. Per the Joint Commission Guidelines, all stroke patients must be screened for aspiration risk using an evidence-based tool prior oral intake. Hypothesis: We hypothesized that combining the MetroHealth dysphagia screen and 3 oz. water test as a 2-tiered evidence-based screening tool will properly identify stroke patients at risk for aspiration pneumonia. Method: A retrospective cohort analysis of 266 patients was conducted of transient ischemic attack, ischemic, and hemorrhagic stroke patients admitted to a small community hospital from July 2014-June 2015. The hospital implemented a 2-tiered aspiration risk screen (ARS), in addition to standard ARS. Inclusion criteria: stroke patients discharged with additional diagnosis of pneumonitis due to inhalation of food or vomitus (ICD9 507.0). Exclusion criteria: all stroke patients that were discharged without discharge diagnosis of ICD9 507.0. Results: Of the 266 patients, 11 (4.1%) were diagnosed with pneumonitis. Eight patients (72%) were screened for aspiration utilizing both screens. Three of the 8 patients (37.5%) passed the hospital’s standard ARS tool, but were identified to have aspiration risk utilizing the 2-tiered screen. Three of the 11 patients (27%) were identified at risk for aspiration utilizing the 2-tiered ARS only. Two patients were found to have questionable infiltrates on admission. The other patient passed the ARS on admission, and later failed upon rescreen for change in mental status. All patients were evaluated by speech prior to oral intake. Conclusion: This study reveals that the 2-tiered ARS can be utilized to identify stroke patients at risk for aspiration. Despite proper recognition of aspiration risk upon admission, a small number of patients, 4% in our study, will go on to aspirate. An opportunity exists for closer collaboration between nursing, speech language pathology, and medical staff to streamline processes to encourage screening of all patients admitted for stroke in an effort to reduce occurrence of pneumonitis for high risk stroke patients.

Radioactive Seed Localization for Nonpalpable Breast Lesions in a Community Hospital Setting

Purpose: To compare the positive margin rates for women with nonpalpable breast tumors whom had wire localization compared to radioactive seed localization in a small community hospital.Introduction: Wire localized (WL) breast biopsies have been performed on patients with nonpalpable breast lesions for many years. Radioactive seed localization (RSL) offers advantages of patient comfort and scheduling convenience.There is an extensive literature from large centers regarding the RSL technique. Little is known whether physicians performing these procedures in smaller community hospitals can achieve comparable negative margin rates as those performed with wire localization.Methods: The thirty-six patients who underwent wire localized breast conserving surgery between September 18, 2013 and December 10, 2014, were compared to the 48 radioactive seed localization patients resected between February 12, 2014 and December 18, 2014. The primary objective was to determine if the introduction of the radioactive seed localization technique significantly changed the positive margin rate.Results: Two of 36 wire localized breast biopsied patients had positive margins, compared to 5 of 48 radioactive seed localization patients, a difference which is not statistically different. The specimen weight was larger for the patients treated with the RSL technique. There was a trend toward a higher positive margin rate with older patients.Conclusion: The positive margin rate was similar between the wire localized and radioactive seed localized patients, and comparable to those in the published literature.

First 101 Robotic General Surgery Cases in a Community Hospital.

Background and Objectives:The general surgeon's robotic learning curve may improve if the experience is classified into categories based on the complexity of the procedures in a small community hospital. The intraoperative time should decrease and the incidence of complications should be comparable to conventional laparoscopy. The learning curve of a single robotic general surgeon in a small community hospital using the da Vinci S platform was analyzed.Methods:Measured parameters were operative time, console time, conversion rates, complications, surgical site infections (SSIs), surgical site occurrences (SSOs), length of stay, and patient demographics.Results:Between March 2014 and August 2015, 101 robotic general surgery cases were performed by a single surgeon in a 266-bed community hospital, including laparoscopic cholecystectomies, inguinal hernia repairs; ventral, incisional, and umbilical hernia repairs; and colorectal, foregut, bariatric, and miscellaneous procedures. Ninety-nine of the cases were completed robotically. Seven patients were readmitted within 30 days. There were 8 complications (7.92%). There were no mortalities and all complications were resolved with good outcomes. The mean operative time was 233.0 minutes. The mean console operative time was 117.6 minutes.Conclusion:A robotic general surgery program can be safely implemented in a small community hospital with extensive training of the surgical team through basic robotic skills courses as well as supplemental educational experiences. Although the use of the robotic platform in general surgery could be limited to complex procedures such as foregut and colorectal surgery, it can also be safely used in a large variety of operations with results similar to those of conventional laparoscopy.

Linking Community Hospital Initiatives With Osteopathic Medical Students' Quality Improvement Training: A Pilot Program.

Quality improvement (QI) continues to be a health care challenge, and the literature indicates that osteopathic medical students need more training. To qualify for portions of managed care reimbursement, hospitals are required to meet measures intended to improve quality of care and patient satisfaction, which may be challenging for small community hospitals with limited resources. Because osteopathic medical training is grounded on community hospital experiences, an opportunity exists to align the outcomes needs of hospitals and QI training needs of students. In this pilot program, 3 sponsoring hospitals recruited and mentored 1 osteopathic medical student each through a QI project. A mentor at each hospital identified a project that was important to the hospital's patient care QI goals. This pilot program provided osteopathic medical students with hands-on QI training, created opportunities for interprofessional collaboration, and contributed to hospital initiatives to improve patient outcomes.

An Interhospital, Interdisciplinary Needs Assessment of Palliative Care in a Community Critical Care Context.

There is a paucity of data on the provision of palliative care in the critical care settings of smaller community hospitals. This study aimed to identify the gaps that affect the provision of palliative care in a community critical care setting. The study was set in a 10-bed, open intensive care unit and emergency department at a community hospital. Mixed methods were used. Quantitative data included those drawn from databases and surveys; qualitative data included those collected from interviews, focus groups, and onsite walk-throughs and were analyzed with inductive coding techniques. Gaps were identified in palliative care, goals of care and end-of-life discussions, and resources. Community hospital healthcare professionals did not fully appreciate their essential contribution to the provision of palliative care in the intensive care unit. In addition, there was a lack of expertise, and a lack of interest in gaining expertise, in palliative/end-of-life care. Interrelated needs in a complex interprofessional, interhospital context were captured. Further studies are required to obtain data on palliative practice in the care of critically ill patients in various community hospital contexts.

Development of a Hospital Standardized Mortality Ratio for Emergency Department Care

Experts have recommended including measures of mortality in emergency department (ED) performance evaluation frameworks. This study aims to develop a hospital standardized mortality ratio (HSMR) for patients admitted to the hospital with conditions for which ED care may reduce mortality (emergency-sensitive conditions). Data were extracted from Canadian hospital discharge databases from April 1, 2009, to March 31, 2012. The ED HSMR is the ratio of the observed deaths among patients with emergency-sensitive conditions in a hospital during a year to the expected deaths for the same patients during the reference year (2009-2010). The expected deaths were estimated with predictive models fitted for different hospital peer groups (teaching hospitals and large, medium, and small community hospitals). The data set included 1,770,809 admissions (9.2% deaths). The ED HSMR was calculated for 47% (294/629) of all Canadian hospitals. The majority of exclusions (98%) were for small community hospitals with fewer than 20 expected deaths. Predictive models had good calibration and discrimination, with areas under the curve ranging from 0.80 to 0.81. In comparisons of 2010-2011 and 2011-2012, the classification of hospitals by ED HSMR quartile was stable, with the majority remaining within the same quartile (43.5%) or moving up or down a single quartile (40.2%). Peer-group-level comparisons between ED HSMR measured at different points after admission (2, 7, and 30 days, and hospital discharge) did not demonstrate any significant differences. The ED HSMR appears to be a reliable measure with high discrimination, calibration, and forecasting properties that can be used to guide assessment of ED performance.

Thrombolysis in small community hospitals: Comparable results?

Thrombolysis in small community hospitals: Comparable results?

Reasons for Encounters and Diagnoses of New Outpatients at a Small Community Hospital in Japan: an Observational Study.

Reasons for Encounters and Diagnoses of New Outpatients at a Small Community Hospital in Japan: an Observational Study.

Jacob Chose Hospice: A Critique of Invasive End-of-Life Care

Jacob Chose Hospice: A Critique of Invasive End-of-Life Care

Development and Validation of an Algorithm to Identify Planned Readmissions From Claims Data.

It is desirable not to include planned readmissions in readmission measures because they represent deliberate, scheduled care. To develop an algorithm to identify planned readmissions, describe its performance characteristics, and identify improvements. Consensus-driven algorithm development and chart review validation study at 7 acute-care hospitals in 2 health systems. For development, all discharges qualifying for the publicly reported hospital-wide readmission measure. For validation, all qualifying same-hospital readmissions that were characterized by the algorithm as planned, and a random sampling of same-hospital readmissions that were characterized as unplanned. We calculated weighted sensitivity and specificity, and positive and negative predictive values of the algorithm (version 2.1), compared to gold standard chart review. In consultation with 27 experts, we developed an algorithm that characterizes 7.8% of readmissions as planned. For validation we reviewed 634 readmissions. The weighted sensitivity of the algorithm was 45.1% overall, 50.9% in large teaching centers and 40.2% in smaller community hospitals. The weighted specificity was 95.9%, positive predictive value was 51.6%, and negative predictive value was 94.7%. We identified 4 minor changes to improve algorithm performance. The revised algorithm had a weighted sensitivity 49.8% (57.1% at large hospitals), weighted specificity 96.5%, positive predictive value 58.7%, and negative predictive value 94.5%. Positive predictive value was poor for the 2 most common potentially planned procedures: diagnostic cardiac catheterization (25%) and procedures involving cardiac devices (33%). An administrative claims-based algorithm to identify planned readmissions is feasible and can facilitate public reporting of primarily unplanned readmissions.

At Risk Care Plans: a way to reduce readmissions and adverse events.

The purpose of this article is to describe an "At Risk Care Plan." The goal of an At Risk Care Plan is to improve safety and quality care by proactively anticipating individual safety and care needs of patients at risk and to communicate those needs to the health care team. This innovative intervention has dramatically reduced hospital readmissions, costs, and adverse events for high-risk adult inpatients in a small community hospital.

Feasibility of applying data mining techniques for predicting technical difficulties during laparoscopic cholecystectomy based on routine patient work-up in a small community hospital.

Predicting technical difficulties in laparoscopic cholecystectomy (LC) in a small regional hospital increases efficacy, cost-benefit and safety of the procedure. The aim of the study was to assess whether it is possible to accurately predict a difficult LC (DLC) in a small regional hospital based only on the routine available clinical work-up parameters (patient history, ultrasound examination and blood chemistry) and their combinations. A prospective, cohort, of 369 consecutive patients operated by the same surgeon was analyzed. Conversion rate was 10 (2.7%). DLC was registered in 55 (14.90%). Various data mining techniques were applied and assessed. Seven significant predictors of DLC were identified: i) shrunken (fibrotic) gallbladder (GB); ii) ultrasound (US) GB wall thickness >4 mm; iii) >5 attacks of pain lasting >5 hours; iv) WBC >10x109 g/L; v) pericholecystic fluid; vi) urine amylase >380 IU/L, and vii) BMI >30kg/m2. Bayesian network was selected as the best classifier with accuracy of 94.57, specificity 0.98, sensitivity 0.77, AUC 0.96 and F-measure 0.81. It is possible to predict a DLC with high accuracy using data mining techniques, based on routine preoperative clinical parameters and their combinations. Use of sophisticated diagnostic equipment is not necessary.

Using an Acuity Tool to Maintain Productivity While Adhering to AWHONN's Perinatal Nurse Staffing Guidelines

Poster Presentation Purpose for the Program The art of scheduling perinatal nursing staff in a small community hospital is challenging in a specialty where census and acuity are highly unpredictable. This challenge on a women and children's (WMCH) unit is particularly complex because of five specialties: labor and delivery, postpartum/newborn, pediatrics, Level‐II nursery, and cesarean birth operating room. The hospital was facing decreasing revenue, increased cost because of health care reform, fluctuations in volume, and uncompensated costs. The hospital took this opportunity to reevaluate productivity and used a health care analytics company to adopt a new productivity benchmark for all departments. Proposed Change The hospital's operations excellence process utilized the Lean and Six Sigma methods to improve performance, which required that frontline staff of all levels creatively develop solutions. The WMCH department used the Lean and Six Sigma methods to determine a plan to meet this goal while maintaining quality care and patient satisfaction. Previously the staffing assignments were done every shift based on charge nurse predictions not on evidence. This method was unreliable and generated frustration when there were discrepancies. To staff for patient census, varying acuity levels, and maintain staffing ratios recommended by AWHONN, the department incorporated an acuity tool into the daily nursing assignment sheet. Implementation, Outcomes, and Evaluation The sheet yielded a productivity standard that clearly demonstrated whether each nurse assignment was appropriate and the unit was staffed safely every 2 hours. Charge nurses were able to make staffing decisions based on real‐time data. Department leaders could look at retrospective long‐range acuity and productivity data that allowed them to analyze trends and make departmental decisions. The staffing decisions were based on the acuity tool were clearly and objectively displayed to staff nurses, which allowed the nurses to feel confident with their assignments because of the alignment with AWHONN guidelines. After 6 months of utilizing the acuity tool, the department reduced the hours worked per equivalent patient days from 23 hours to 18.7 hours. This reduction was projected to save $800,000 a year, although it actually resulted in hospital savings of $1,300,000. Implications for Nursing Practice These metrics demonstrate the benefits of an acuity tool in a daily nursing assignment sheet for safe patient care, improved nursing satisfaction, increased productivity, and financial savings.

Imparting Knowledge, Skill, and Confidence to Rural Nurses

Poster Presentation Purpose for the Program The labor and delivery (L&D) nurse manager of a small community hospital contacted our academic medical center and requested assistance to train two medical/surgical nurses who float to the hospital's L&D unit for the occasional birth. Located in a remote area of Northern California with a low volume of births, the hospital setting is not conducive to providing adequate L&D experience for the nurses. A partnership was proposed to better prepare these nurses to care for L&D patients. Proposed Change Information provided by the community hospital indicated an extreme lack of resources for nurses who needed training in specialty areas. As a facility with less than 100 births per year located hours from the nearest city or major medical center, the hospital was not equipped to keep nurses current in L&D skills, knowledge, and practice. We were requested to provide a training opportunity incorporating 240 hours of didactic and practical instruction. Implementation, Outcomes, and Evaluation A contract was secured, and a training outline was developed and submitted for approval. Per UC Davis Medical Center (UCDMC) requirements, a day of hospital orientation preceded the nurses' L&D training. This included mandatory safety training and the signing of a confidentiality agreement. When the nurses arrived on L&D, the Association of Women's Health, Obstetric and Neonatal Nurses' (AWHONN) Perinatal Orientation and Education Program (POEP) testing was utilized as a baseline assessment of knowledge. Each nurse was assigned a master's‐prepared preceptor. The nurses received reference binders containing publications on fetal monitoring, labor and birth, postpartum care, newborn assessment, high‐risk obstetrics, obstetric emergencies, and operating room procedures, as well as journal articles. They attended lectures given by the perinatal nurse educator incorporating the POEP material. An AWHONN's Intermediate Fetal Monitoring Course (IFMC) was scheduled and conducted. Upon completion of the program, the nurses expressed tremendous gratitude to the staff and reported feeling much better prepared to care for perinatal patients. Scores on the POEP posttests increased by 32% and 44%, respectively, with an overall average score of 98.5% at the conclusion of the training. Implications for Nursing Practice The collaboration of hospitals from two very different milieus resulted in an unprecedented training opportunity for nurses caring infrequently for perinatal patients. The nurses reported an overwhelmingly positive experience. Other academic medical centers may consider developing similar programs to assist smaller hospitals in isolated areas with a lack of resources for nurse specialty training.

Supporting Rural nurses: Skills and Knowledge to Practice in Ontario, Canada

Background: Nursing in rural settings requires the skill set of a multi-specialist who is adaptable to change and different ways of working. Maintaining skills needed for emergency management of complex health issues is difficult, and retention is affected by the paucity of further education opportunities and mentors. Purpose : In collaboration with five small community hospitals in southern Ontario that experience challenges in recruiting and retaining sufficient nursing staff, this project used critical ethnography to ascertain appropriate retention strategies. Methods : Data collection included environmental scans, interviews with 45 rural nurses, and completion of 156 surveys from nurses on rural nursing careers. During the project, staff-identified, educational strategies were implemented in 3 of the 5 community hospitals. Findings : Seven themes emerged from the data. Overall, rural nurses identified that they were content to stay, as long as there was sufficient work. Conclusion : Retention interventions that are locally constructed with attention to community factors have the greatest likelihood of succeeding. DOI : http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 Keywords: rural nursing, nurse retention, critical ethnography, retention strategies