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PublicationThe Individualized Multidisciplinary Immediate Fall Response Program(2021-07-20) Awotundun, Adenike YAbstract Falls are frequent in older residents in the United States. 800,000 falls occur yearly, one in three residents will fall again within a year (Agency for Healthcare Research and Quality [AHRQ], 2017). In Frey Village, about 25 falls occur monthly with annual fall-injuries of 1.9%. This project focused on the Individualized Multidisciplinary Immediate Fall Response Program (IMIFRP). PICOT Question: In the older adults in a long-term facility (P), does an implementation of the individualized multidisciplinary immediate fall response program (I), improve fall care processes, and reduce fall rate (O) within 2-months post-intervention (T), compared to 2-months pre-intervention (C)? Conceptual and Theoretical Model: The IHI Plan-Do-Study-Act cycle was the conceptual framework that directed IMIFRP. The Theory of Bureaucratic Caring reinforced the impacts of providing quality, ethical, legal, and compassionate care. Methods: This pre/post-design quality improvement project included residents in long-term units, ³ 65 years. The IMIFRP was initiated with each fall. Project outcomes: usage of the IMIFRP form ([TRIPS]— Tracking Record for Improving Patient Safety) for falls data documentation, number of falls and repeated falls. Data were analyzed, using descriptive statistics, and run chart. Result: Fall rate reduced from 41 falls pre-intervention to 30 falls during the intervention. 27% reduced fall rate, 90% compliance rate in utilization of the TRIPS form and creation of a fall management team. Conclusion: The IMIFRP was well supported by the stakeholders and the IMIFRP led to development of a multidisciplinary fall committee. PublicationPressure Injury Prevention in Cardiac Surgery Using Risk Factor Assessment and Standardization(2021-08-05) Madeira, Timothy HCardiac surgical patients are more susceptible to pressure injury (PI) than other surgical specialties, and little is known about PI prevention (PIP) in this population. How do PIP strategies, compared to standard care, affect the incidence of PI during the post-operative recovery among adult cardiac surgery patients? The aim was to reduce the incidence of UAPI in an adult CVSICU by 5% in six weeks. The conceptual framework chosen was The Iowa Model Revised, and the theoretical framework employed was the Theoretical Model for Lesion Development. Quality improvement, single-group pretest-posttest design. Sample consisted of 69 cardiac surgery, LVAD, ECMO patients at Johns Hopkins CVSICU. The intervention was a standardized PIP bundle provided to “highest risk” patients screened before surgery. Outcome measures were UAPI count and incidence rates. Process measures were percentage of patients screened, prophylactic sacral dressing, rental bed cost. Balancing measures were PI severity, anatomic location, and time between wounds. Baseline data consisted of historic data and intervention data consisted of weekly survey observations. Implementation consisted of staff education, daily preoperative screening, weekly wound rounds. 33% of patients screened as “highest risk” and received the PIP bundle. PI count decreased from 25 to 13 during implementation and wound stages improved. Chi Square test of 2-proportions showed a reduced PI incidence of 8.56% (Z=1.66, p= .048) and 2-sample Poisson rate showed significance in count (Z=1.95, p=.036). Location changed to nose, buttocks, and occipital locations. There was an overall cost savings of $78,660. Reducing PI lead to reduced morbidity and cost. PublicationWorld Health Organizations Surgical Safety Checklist Project(2018-12-02) Lyons, AmberMedical error, especially in the operating room, claims the lives of patients and contributes to complications. A project was conducted to investigate the effectiveness of the World Health Organizations Surgical Safety Checklist. Communication, teamwork, and the readiness of use by the operating room team was measured. The project design was descriptive utilizing the Surgical Safety Checklist and a modified version of the Safety Attitudes Questionnaire Operating Room. Post-implementation responses to the Safety Attitudes Questionnaire Operating Room survey revealed a significant improvement in the surgical teams’ perception of teamwork and communication. Results show the World Health Organizations Surgical Safety Checklist improves teamwork and communication, and improves awareness of patient safety factors when consistently implemented before each operation. PublicationIntroduction of the Tools for Economic Analysis of Patient Management Interventions in Heart Failure Costing Tool: A User-Friendly Spreadsheet Program to Estimate Costs of Providing Patient-Centered Interventions(2011-12-06) Reed, Shelby D; Li, Yanhong; Kamble, Shital; Polsky, Daniel; Graham, Felicia L; Bowers, Margaret T; Samsa, Gregory P; Paul, Sara; Schulman, Kevin A; Whellan, David J; Riegel, BarbaraBackground—Patient-centered health care interventions, such as heart failure disease management programs, are under increasing pressure to demonstrate good value. Variability in costing methods and assumptions in economic evaluations of such interventions limit the comparability of cost estimates across studies. Valid cost estimation is critical to conducting economic evaluations and for program budgeting and reimbursement negotiations. Methods and Results—Using sound economic principles, we developed the Tools for Economic Analysis of Patient Management Interventions in Heart Failure (TEAM-HF) Costing Tool, a spreadsheet program that can be used by researchers and health care managers to systematically generate cost estimates for economic evaluations and to inform budgetary decisions. The tool guides users on data collection and cost assignment for associated personnel, facilities, equipment, supplies, patient incentives, miscellaneous items, and start-up activities. The tool generates estimates of total program costs, cost per patient, and cost per week and presents results using both standardized and customized unit costs for side-by-side comparisons. Results from pilot testing indicated that the tool was well-formatted, easy to use, and followed a logical order. Cost estimates of a 12-week exercise training program in patients with heart failure were generated with the costing tool and were found to be consistent with estimates published in a recent study. Conclusions—The TEAM-HF Costing Tool could prove to be a valuable resource for researchers and health care managers to generate comprehensive cost estimates of patient-centered interventions in heart failure or other conditions for conducting high-quality economic evaluations and making well-informed health care management decisions. PublicationEstablishing a Pragmatic Framework to Optimise Health Outcomes in Heart Failure and Multimorbidity (ARISE-HF): A Multidisciplinary Position Statement(2016-06-01) Stewart, Simon; Riegel, Barbara; Boyd, Cynthia; Ahamed, Yasmin; Thompson, David R; Burrell, Louise M; Carrington, Melinda J; Coats, Andrew; Granger, Bradi B; Hides, Julie; Weintraub, William S; Moser, Debra K; Dickson, Victoria Vaughan; McDermott, Cressida J; Keates, Ashley K; Rich, Michael WBackground Multimorbidity in heart failure (HF), defined as HF of any aetiology and multiple concurrent conditions that require active management, represents an emerging problem within the ageing HF patient population worldwide. Methods To inform this position paper, we performed: 1) an initial review of the literature identifying the ten most common conditions, other than hypertension and ischaemic heart disease, complicating the management of HF (anaemia, arrhythmias, cognitive dysfunction, depression, diabetes, musculoskeletal disorders, renal dysfunction, respiratory disease, sleep disorders and thyroid disease) and then 2) a review of the published literature describing the association between HF with each of the ten conditions. From these data we describe a clinical framework, comprising five key steps, to potentially improve historically poor health outcomes in this patient population. Results We identified five key steps (ARISE-HF) that could potentially improve clinical outcomes if applied in a systematic manner: 1) Acknowledge multimorbidity as a clinical syndrome that is associated with poor health outcomes, 2) Routinely profile (using a standardised protocol — adapted to the local health care system) all patients hospitalised with HF to determine the extent of concurrent multimorbidity, 3) Identify individualised priorities and person-centred goals based on the extent and nature of multimorbidity, 4) Support individualised, home-based, multidisciplinary, case management to supplement standard HF management, and 5) Evaluate health outcomes well beyond acute hospitalisation and encompass all-cause events and a person-centred perspective in affected individuals. Conclusions We propose ARISE-HF as a framework for improving typically poor health outcomes in those affected by multimorbidity in HF. PublicationImplementing and Evaluating a Sepsis Algorithm to Mitigate Acute Care Readmissions in an Inpatient Rehabilitation Facility(2020-12-28) Lockett, Michelle LBACKGROUND: Readmissions from post-acute care to acute care hospitals is well documented in the literature. Inadequate management of infection is a top readmission diagnosis and is often preventable. Nurse driven, protocolized treatment is the gold standard for treating sepsis patients in post and acute care settings. A quality improvement (QI) project was implemented in a 58-bed inpatient rehabilitation facility (IRF) to determine if a nurse-driven sepsis algorithm would decrease readmission rates to acute care hospitals, increase nursing staff sepsis knowledge, clinical confidence and communication. METHODS: This QI project was performed during a 3-month period in 2020. Readmission findings were compared before and after the study intervention implementation. Changes overtime in sepsis frequency were assessed through run charts. Pre- and post- survey data of sepsis knowledge, clinical confidence caring for a sepsis patient and care provider and clinician communication was assessed using a Wilcoxon Signed Rank Test. INTERVENTION: By utilizing the Systemic Inflammatory Response (SIRs) criteria, the Situation, Background, Assessment and Recommendation (SBAR) tool and Surviving Sepsis Campaign guidelines, a nurse driven sepsis algorithm was created and implemented in the rehabilitation facility. Additionally, pre-and post-surveys were administered to assess nurses’ knowledge of sepsis, clinical confidence in caring for a patient with suspected sepsis and bedside clinician to provider communication. RESULTS: Results show a decrease in readmissions to acute care hospitals post intervention but no statistically significant change in pre-post survey of sepsis knowledge, confidence or communication. CONCLUSIONS: An additional PDSA cycle of this QI project is needed to determine a true sepsis decrease overtime using the sepsis algorithm. A sepsis pre and post-test, and role play simulations may be key to a change in sepsis knowledge, confidence and communication. Keywords: inpatient rehabilitation facility, IRF, readmissions, sepsis, infection, surviving sepsis campaign, algorithm PublicationA Model to Advance Nursing Science in Trauma Practice and Injury Outcomes Research(2011-01-01) Richmond, Therese S; Aitken, Leanne MAims: This discussion paper reports development of a model to advance nursing science and practice in trauma care based on an analysis of the literature and expert opinion. Background: The continuum of clinical care provided to trauma patients extends from the time of injury through to long-term recovery and final outcomes. Nurses bring a unique expertise to meet the complex physical and psychosocial needs of trauma patients and their families to influence outcomes across this entire continuum. Data Sources: Literature was obtained by searching CINAHL, PubMed and OvidMedline databases for 1990 – 2010. Search terms included trauma, nursing, scope of practice and role, with results restricted to those published in English. Manual searches of relevant journals and websites were undertaken. Discussion: Core concepts in this trauma outcomes model include environment, person/family, structured care settings, long term outcomes and nursing interventions. The relationships between each of these concepts extend across all phases of care. Intermediate outcomes are achieved in each phase of care and influence and have congruence with long term outcomes. Implications for Policy and Practice: This model is intended to provide a framework to assist trauma nurses and researchers to consider the injured person in the context of the social, economic, cultural and physical environment from which they come and the long term goals that each person has during recovery. The entire model requires testing in research and assessment of its practical contribution to practice. Conclusion: Planning and integrating care across the trauma continuum, as well as recognition of the role of the injured person’s background, family and resources, will lead to improved long term outcomes. PublicationPredictors of Medication Nonadherence Differ among Black and White Patients with Heart Failure(2015-05-11) Dickson, Victoria Vaughan; Knafl, George J; Riegel, BarbaraHeart failure (HF) is a global public health problem, and outcomes remain poor, especially among ethnic minority populations. Medication adherence can improve heart failure outcomes but is notoriously low. The purpose of this secondary analysis of data from a prospective cohort comparison study of adults with heart failure was to explore differences in predictors of medication nonadherence by racial group (Black vs. White) in 212 adults with heart failure. Adaptive modeling analytic methods were used to model HF patient medication nonadherence separately for Black (31.7%) and White (68.3%) participants in order to investigate differences between these two racial groups. Of the 63 Black participants, 33.3% had low medication adherence, compared to 27.5% of the 149 White participants. Among Blacks, 16 risk factors were related to adherence in bivariate analyses; four of these (more comorbidities, lower serum sodium, higher systolic blood pressure, and use of fewer activities compensating for forgetfulness) jointly predicted nonadherence. In the multiple risk factor model, the number of risk factors in Black patients ranged from 0 to 4, and 76.2% had at least one risk factor. The estimated odds ratio for medication nonadherence was increased 9.34 times with each additional risk factor. Among White participants, five risk factors were related to adherence in bivariate analyses; one of these (older age) explained the individual effects of the other four. Because Blacks with HF have different and more risk factors than Whites for low medication adherence, interventions are needed that address unique risk factors among Black patients with HF. PublicationIdentification of Symptom Clusters among Patients with Heart Failure: An International Observational Study(2014-10-01) Moser, Debra K; Lee, Kyoung Suk; Wu, Jia-Rong; Mudd-Martin, Gia; Jaarsma, Tiny; Huang, Tsuey-Yuan; Fan, Xui-Zhen; Strömberg, Anna; Lennie, Terry A; Riegel, BarbaraBACKGROUND: Virtually all patients with heart failure experience multiple symptoms simultaneously, yet clinicians and researchers usually consider symptoms in isolation. Recognizing and responding early to escalating symptoms is essential to preventing hospitalizations in heart failure, yet patients have considerable difficulty recognizing symptoms. Identification of symptom clusters could improve symptom recognition, but cultural differences may be present that must be considered. OBJECTIVES: To identify and compare symptom clusters in heart failure patients from the United States, Europe and Asia. DESIGN: Cross-sectional, observational study. SETTINGS: In- and out-patient settings in three regions of the world: Asia (i.e., China and Taiwan); Europe (i.e., the Netherlands and Sweden); and the United States. PARTICIPANTS: A total of 720 patients with confirmed heart failure. Propensity scoring using New York Heart Association Classification was used to match participants from each of the three regions. METHODS: Symptoms were identified using the Minnesota Living with Heart Failure Questionnaire. To identify symptom clusters we used cluster analysis with the hierarchical cluster agglomerative approach. We used the Euclidean distance to measure the similarity of variables. Proximity between groups of variables was measured using Ward's method. The resulting clusters were displayed with dendrograms, which show the proximity of variables to each other on the basis of semi-partial R-squared scores. RESULTS: There was a core group of symptoms that formed two comparable clusters across the countries. Dyspnea, difficulty in walking or climbing, fatigue/increased need to rest, and fatigue/low energy were grouped into a cluster, which was labeled as a physical capacity symptom cluster. Worrying, feeling depressed, and cognitive problems were grouped into a cluster, which was labeled as an emotional/cognitive symptom cluster. The symptoms of edema and trouble sleeping were variable among the countries and fell into different clusters. CONCLUSION: Despite the diversity in cultures studied, we found that symptoms clustered similarly among the cultural groups. Identification of similar symptoms clusters among patients with heart failure may improve symptom recognition in both patients and healthcare providers. PublicationMotivational Interviewing Tailored Interventions for Heart Failure (MITI-HF): Study Design and Methods(2015-03-01) Masterson-Creber, Ruth; Patey, Megan; Dickson, Victoria Vaughan; DeCesaris, Marissa; Riegel, BarbaraOBJECTIVE: Lack of engagement in self-care is common among patients needing to follow a complex treatment regimen, especially patients with heart failure who are affected by comorbidity, disability and side effects of poly-pharmacy. The purpose of Motivational Interviewing Tailored Interventions for Heart Failure (MITI-HF) is to test the feasibility and comparative efficacy of an MI intervention on self-care, acute heart failure physical symptoms and quality of life. METHODS: We are conducting a brief, nurse-led motivational interviewing randomized controlled trial to address behavioral and motivational issues related to heart failure self-care. Participants in the intervention group receive home and phone-based motivational interviewing sessions over 90-days and those in the control group receive care as usual. Participants in both groups receive patient education materials. The primary study outcome is change in self-care maintenance from baseline to 90-days. CONCLUSION: This article presents the study design, methods, plans for statistical analysis and descriptive characteristics of the study sample for MITI-HF. Study findings will contribute to the literature on the efficacy of motivational interviewing to promote heart failure self-care. PRACTICAL IMPLICATIONS: We anticipate that using an MI approach can help patients with heart failure focus on their internal motivation to change in a non-confrontational, patient-centered and collaborative way. It also affirms their ability to practice competent self-care relevant to their personal health goals.