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CLINICAL ROUNDS

doi: 10.1097/01.NURSE.0000446638.57252.f2
Department: CLINICAL ROUNDS
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PATIENT OUTCOMES

Longer RN tenures improve quality of care

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A 4-year study of over 900,000 patient admissions at hospitals in the Veterans Administration Healthcare System shows that a 1-year increase in the average tenure of RNs on a hospital unit was associated with a 1.3% decrease in length of stay. According to one of the study's authors, Patricia Stone, PhD, RN, FAAN, “reducing length of stay is the holy grail of hospital management because it means patients are getting higher quality, more cost-effective care.”

The study found that compared with hiring temporary RN staff to fill vacancies, paying staff RNs to work overtime on their usual unit was not only more cost-effective, but also resulted in shorter lengths of stay. Length of stay also decreased in relation to RN staffing versus staffing by unlicensed assistive personnel. Lengths of stay increased when a unit's team was disrupted by the absence of an experienced member or the addition of a new nurse.

This is the largest study of its kind linking nurse staffing to patient outcomes.

Sources: Bartel AP, Beaulieu NC, Phibbs CS, Stone PW. Human capital and productivity in a team environment: evidence from the healthcare sector. Am Econom J: Applied Economics. 2014;6(2):231–259. Columbia University School of Nursing. Longer nurse tenure on hospital units leads to higher quality care. News release. April 14, 2014.

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ORAL INTUBATION

Simple device restores “the gift of speech”

The electrolarynx, a small oscillating device that produces vibrations, is used primarily to help postlaryngectomy patients speak without the passage of air through the vocal cords. Dutch physicians report that the device was surprisingly successful at restoring “the gift of speech” to a patient with an oral endotracheal tube receiving mechanical ventilation. They believe this is the first report of the device being used to restore speech in an orally intubated patient.

The patient was receiving mechanical ventilation following right bilobectomy complicated by a bronchopleural fistula. When the patient's wife told his physicians that he was frustrated by his inability to speak, they obtained his consent to try the device. The patient was able to speak intelligibly immediately after device placement.

The most effective location for the device was between the upper trachea and the sternocleidomastoid muscle. Nurses learned to place the device after only 2 minutes of instruction.

Noting that the ability to speak decreases anxiety in ICU patients, the authors hypothesize that “the selected use of an electrolarynx may be helpful in preventing or reducing stress and delirium in these patients.”

Source: Girbes AR, Elbers PW. Speech in an orally intubated patient. N Engl J Med. 2014;370(12):1172–1173.

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HCAHPS SCORES

Is pain control the key to patient satisfaction?

Patient reports about postoperative pain and how it was addressed strongly correlate with overall patient satisfaction scores, according to new findings presented at the 30th Annual Meeting of the American Academy of Pain Medicine.

Under the Affordable Care Act, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a factor in value-based incentive payments. Scores are based on patients' responses to a 27-question survey at discharge.

For this study, researchers analyzed data from 2,933 surgical patients who were hospitalized at an academic level 1 trauma center between March 2012 and February 2013. The patient responses to two questions addressing in-hospital pain management and two questions addressing general satisfaction were compared with the postanesthesia care unit (PACU) visual analog scale pain scores. Researchers then categorized patients based on type of surgery.

In all patients, researchers found “a statistically robust relationship” between HCAHPS responses and PACU pain scores. PACU pain scores following surgery involving the spine, nonspine orthopedics, and obstetrics/gynecology were more significantly related to satisfaction responses than scores related to other procedures. Researchers concluded that preadmission, preoperative, and intraoperative interventions and improvements in PACU patient care could strongly influence HCAHPS scores.

Source: Maher D, Babu V, Mullen D, et al. Post-operative PACU pain score is related to post discharge HCAHPS scores: a retrospective analysis of 2933 surgical patients. Presented at the 2014 Annual Meeting of the American Academy of Pain Medicine, Phoenix, Arizona, March 2014. http://www.painmed.org/annualmeeting/.

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INFECTION CONTROL

Nurse liaisons help reduce MRSA rates

An interdisciplinary program was initiated to reduce healthcare-acquired (HCA) methicillin-resistant Staphylococcus aureus (MRSA) infection in a university hospital. Participating in ongoing monthly education, staff nurses were trained to be liaisons, or “links,” with infection prevention (IP) personnel and given clearly defined goals. The incidence of HCA-MRSA per 1,000 patient-days was compared between the baseline period (January 2006 to March 2008) and the intervention period (April 2008 to September 2009). Researchers also tracked total and non-HCA-MRSA, HCA and non-HCA-MRSA bacteremia, and hand hygiene compliance.

Findings included the following:

  • HCA-MRSA decreased by 28%.
  • HCA-MRSA bacteremia decreased by 41%.
  • Use of hand soaps/sanitizer and hand hygiene compliance increased “significantly.”

Researchers concluded that the “link nurse program effectively reduced HCA-MRSA. Goal-defined metrics with ongoing re-education for the nurses by IP personnel helped drive these results.”

Source: Sopirala MM, Yahle-Dunbar L, Smyer J, et al. Infection control link nurse program: an interdisciplinary approach in targeting health care-acquired infection. Am J Infect Control. 2014;42(4):353–359.

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CONTINUITY OF CARE

Benefits offer career opportunities for RNs

To quantify the costs and benefits of care continuity, researchers conducted a retrospective cohort study of insurance claims data for a sample of Medicare patients experiencing a 12-month episode of care for congestive heart failure, chronic obstructive pulmonary disease, or type 2 diabetes in 2008 and 2009. Care was considered better coordinated when patients saw fewer healthcare providers or when visits were concentrated among fewer providers.

The researchers found that even modest improvements in care continuity were associated with “sizable differences in costs, use, and complications.” For example, across all three chronic disorders, higher levels of care continuity were associated with lower odds of inpatient hospitalization, lower odds of ED visits, and lower odds of complications.

Recognizing that care coordination is a significant growth area for nursing practice, the American Academy of Ambulatory Care Nursing (AAACN) has recently developed a Care Coordination and Transition Management (CCTM) Core Curriculum. It's available on AAACN's website at http://www.aaacn.org/practice-resources/cctm.

Sources: Hussey PS, Schneider EC, Rudin RS, Fox DS, Lai J, Pollack CE. Continuity and the costs of care for chronic disease. JAMA Intern Med. [e-pub Mar. 17, 2014]. Rand Corporation. “Improving Continuity of Care for Elderly Patients with Chronic Diseases Cuts Costs and Complications.” News release. March 17, 2014.

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In June, celebrate

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PEDIATRIC ADMISSIONS

Mental health disorders under scrutiny

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Although inpatient pediatric mental health is a priority for national quality improvement, little data about pediatric patients and their mental health diagnoses are available. In a study designed to address this shortcoming, researchers used two large national databases to examine all discharges in 2009 for patients ages 3 to 20 years. They found that nearly 10% of pediatric hospitalizations in the United States were due to primary mental health disorders. The most common conditions were depression (44% of all pediatric admissions for mental health), bipolar disorder (18%), and psychosis (12%). The cost associated with depression diagnoses was estimated at $1.33 billion. Predictors of hospitalization for a primary mental health issue were older age, male gender, White race, and insurance type. Substance abuse was an important comorbid diagnosis.

Researchers based their findings on data from the nationally representative Kids' Inpatient Database and the Pediatric Health Information System, which captures data from free-standing children's hospitals.

Source: Bardach NS, Coker TR, Zima BT, et al. Common and costly hospitalizations for pediatric mental health disorders. Pediatrics. 2014;133(4):602–609.

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OLDER ADULTS

Muscle up for longer life

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Muscle mass outweighs body mass index and body weight as a predictor of death risk, according to new research. The study involved 3,659 older adults (men age 55 and older and women age 65 and older) participating in the U.S. National Health and Nutrition Examination Survey between 1988 and 1994. As part of the survey, they were tested to determine their muscle mass index (amount of muscle relative to height). In a 2004 follow-up survey, researchers determined how many had died and how muscle mass correlated to all-cause death risk. (Underweight adults and those who died in the first 2 years of follow up were excluded from the sample, and the analysis was adjusted for central obesity and other significant variables.) They found that participants with the highest levels of muscle mass were significantly less likely to have died from any cause. Researchers say their study “highlights the need to look beyond total body mass in assessing the health of older adults.”

Sources: Srikanthan P, Karlamangla AS. Muscle mass index as a predictor of longevity in older-adults. Am J Med. [e-pub Feb. 18, 2014]. Preidt R. More muscles linked to longer life, research suggests. HealthDay News. March 18, 2014.

© 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins.