CDC STEADI : Best practices for developing an inpatient program to prevent older adult falls after discharge

Each year more than one quarter of Americans aged 65 and older (older adults) report a fall.1 While not all falls result in injury, fall injuries can result in functional decline, decreased quality of life, and even death.2 The risk of a fall among recently hospitalized older adults is substantially increased in the first 30 days after discharge.3The Centers for Disease Control and Prevention\u2019s (CDC) STEADI (Stopping Elderly Accidents, Deaths, and Injuries) initiative was developed for clinicians in outpatient care settings. STEADI provides tools to screen older adultsfor fall risk, assess fall risk factors, and intervene to reduce fall risk. Combining components of STEADI with early mobilization of older adults in an inpatient setting may reduce the risk of falls in hospitalized older adults during and after their hospital stay.The STEADI Algorithm for Fall Risk Screening, Assessment, and Intervention outlines steps to implement the three core elements of the initiative (screen, assess, and intervene) and can be adapted for different clinical practice settings. Clinicians in an inpatient setting at University of California San Francisco (UCSF) adapted STEADI for patient care to reduce falls during and after a hospital stay. This guide, CDC STEADI: Best Practices for Developing an Inpatient Program to Prevent Older Adult Falls after Discharge, highlights 10 steps used by UCSF to integrate a STEADI safe mobility and fall prevention program into their inpatient workflow and clinical practice. The goal was to prevent falls during hospitalization, set the stage for better collaboration with external providers for post-discharge care, and reduce risk of falls after hospital stays.SUGGESTED CITATION: Rogers S., Haddad Y.K., Legha J.K., Stannard D., Auerbach A., Eckstrom E. CDC STEADI: Best Practices for Developing an Inpatient Program to Prevent Older Adult Falls after Discharge. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2021.STEADI-inpatient-guide-508.pdf?ACSTrackingID=DM63048&ACSTrackingLabel=New%20CDC%20Fall%20Prevention%20Resources_DM63048&deliveryName=DM6304820211006

Support for improving the clinical judgment of novice nurses in fall prevention : A multi-phase study

13301甲第5473号博士(保健学)金沢大学博士論文本文Ful

Identification of Posttraumatic Stress Disorder Symptoms in Post-ICU Patients

Background: Patients receiving critical care are experiencing post-traumatic stress syndrome (PTSS) as a result of life-saving interventions received in the intensive care unit (ICU). PTSS is associated with poor patient outcomes and decreased quality of life compared to post-ICU patients without PTSS. Personal and clinical characteristics that place patients at higher risk for PTSS are still being examined. It is also unknown to what extent patients are being screened for ICU-induced PTSS. Objectives: This body of work aims to examine the risk factors associated with ICU-related PTSS and describe the screening experiences of patients who recently received care in an ICU. The work will be presented in three manuscripts. Methods: A single-center, descriptive, correlational design was used. Personal and clinical characteristics were obtained from medical records on a sample of 41 patients recently transferred out of the ICU. Two to 4 weeks after hospital discharge, patients completed the PTSS-14 and a Screening Experience Questionnaire via telephone. Screening experiences and the feasibility of the PTSS-14 in this population was described and associations between the personal and clinical characteristics and PTSS-14 scores were examined. Results: The first manuscript titled ICU-related PTSD; The Importance of Nurse Involvement is under review at Critical Care Nurse. The purpose of this manuscript is to examine current literature addressing risk factors, negative health outcomes, and nursing roles in identifying patients at risk for PTSS. The second manuscript titled A Concept Analysis of ICU-related PTSD is under review at Journal of Advanced Nursing. The purpose of this manuscript is to report a concept analysis of ICU-related PTSD. Manuscript three is titled Identification of Posttraumatic Stress Disorder Symptoms in Post-ICU Patients and is being submitted to American Journal of Critical Care. The purpose of this manuscript is to report the study\u27s results. It was found that the majority of patients were not screened, and none received education about the risk of PTSS after ICU care. The PTSS-14 was found to be an acceptable and feasible way to identify at risk patients and higher PTSS-14 scores were correlated with depression, moderate levels of sedation, number of days sedated, and delirium. Further research is needed to address strategies in implementing early screening for PTSS, and to determine if early identification and referral of at-risk patients can reduce the incidence of PTSD in this population

Substance Use Related Postoperative Delirium: A Classification, Clinical and Comparative Analysis

Advances in medical science and technology enable more Veterans of all ages to choose surgical interventions to treat diseases, relieve pain, regain physical functionality, and to enrich their quality of life. Surgery, however, brings the risk of postoperative delirium, a common complication of surgery. Postoperative delirium is a multifactorial syndrome that appears to be transient but sustains deleterious effects long after its resolution. Much work has been done to understand the pathophysiology of this syndrome and to find efficacious means of prevention and management. This dissertation presents a compendium of three manuscripts related to the recognition, documentation and the association of postoperative delirium with poor outcomes among Veterans, with a particular interest in those with a substance use disorder and the use of psychotropic medications. The first manuscript is a review of systematic reviews, seeking consensus on the prevention of postoperative delirium. A consensus message is challenging for a syndrome with an unresolved pathophysiology. The second manuscript is a qualitative study, exploring the perspectives of stakeholder providers, regarding the documentation of postoperative delirium in the electronic medical records. The non-recognition and under-documentation of POD present a significant barrier to establishing a baseline for the at-risk population. The third manuscript reports the results of a classification and clinical analysis of substance use related postoperative delirium. Using chart reviews to establish a baseline of incidence for postoperative delirium in our local VA, and explored the associations that might be contributory to the poor outcomes attendant to this syndrome. These investigations are preliminary to proposing hypotheses for future research to investigate interventions for the prevention, management, and treatment of postoperative delirium

Patients, carers and nurses : collaborators in development of a new model of nursing care for older persons in the acute care setting

Globally the population is ageing and as a consequence people are living longer with multiple chronic conditions. A range of factors, including decreased lengths of hospital stay and a greater focus on community based care, has led to an increasing acuity of patients admitted to acute care settings, many with complex care needs. To date, models of nursing care in acute settings have been configured to focus on acute, procedural care and do not meet the unique needs of the older person. In order to ensure optimal health outcomes of older hospitalised people, nursing care needs to be responsive to the priorities and needs of patients and their families. This study sought to collaboratively develop a model of nursing care with nurse clinicians to improve the care of older people in the acute care setting. Model development was driven by an action research framework, using evidence-based principles and a comprehensive needs assessment. A three phased, mixed method design was embedded within the overarching conceptual and philosophical framework of action research. The first phase of the study comprised a needs assessment and allowed appraisal of the needs of patients as perceived by patients, carer’s and nurses, this was performed using the Caring Activity Scale [CAS]. Qualitative data and semi-structured interviews added depth to the survey data and qualified responses by confirming that patients thought that nurses did the best they could within a culture of busyness, while patients strived to maintain and sustain their own independence. Managing the discharge process and carer burden arose mainly from the carer semi-structured interviews only. Data revealed significant differences between patients, carer’s and nurses in relation to priority and satisfaction with care. Patients did not place a large importance on discharge care which contrasted with the focus of nursing initiatives. During the subsequent phases of the study a collaborative approach, using action research principles, was used to develop and implement a model of nursing care. A key feature of this model was the introduction of a team structure with a focus on patient centred care. Significant differences were identified in the pre model and post model patient groups in relation to satisfaction with care, with the post model group more satisfied than the pre group model group. Further, improvements in functional status and medication knowledge were demonstrated among patients cared for under the new model. This study has demonstrated that developing a model of care appropriate to the needs of patients, carer’s and nurses can be achieved through the use of action research principles. Study data illustrates the importance of collaboration, empowerment and change management principles in driving clinical improvement and patient satisfaction with care. The findings also underscore the importance of promoting and educating patients and carers as well as nurses about the importance of discharge planning to optimise post-discharge health outcomes

Hearing the Child\u27s Voice: Their Lived Experience in the Pediatric Intensive Care Unit

Background: More than 200,000 children are admitted annually to Pediatric Intensive Care Units (PICUs) in the US. Research has shown young children can provide insight into their hospitalization experiences; child reports rather than parental reports are critical to understanding the child’s experience. Information relating to children’s perceptions while still in the PICU is scarce. Aims: The purpose of this qualitative study was to investigate school age children’s and adolescents’ perceptions of PICU while in the PICU; changes in perceptions after transfer to the General Care Unit (GCU); differences in perceptions of school age children/adolescents and those with more invasive procedures. Methods: Interviews were conducted in PICU within 24-48 hours of admission and 24-48 hours after transfer to GCU. Data on demographics, clinical care and number/types of procedures were obtained. Results: Participants were 7 school age children, 13 adolescents; 10 Hispanic; 13 males. Five overarching themes: Coping Strategies, Environmental Factors, Stressors, Procedures/Medications, and Information. Children emphasized the importance of peer support and visitation; adolescents relied strongly on social media and texting. Parent visits sometimes were more stressful than peer visits. Video games, TV, visitors, and eating were diversional activities. In the PICU, they wanted windows to see outside and interesting things to see on the ceiling above them. Children expressed anticipatory fear of shots and procedures, frustration with lab work, and overwhelming PICU equipment. Number of child responses was higher in PICU (927) than GCU (593); the largest difference was in Environmental Factors. Variations between school age children and adolescents were primarily in Coping Strategies, especially in social support. Number of GCU procedures were the same (8 children) or greater (2 children) than PICU procedures. Discussion: Admission to PICU is a very stressful event. Perceptions from children while still in PICU found information not previously found in the literature. Longitudinal studies to identify children’s perceptions regarding PICU hospitalization and post-discharge outcomes are needed

Interaction Behaviors Effects on Nursing Care Quality of Older Adults in the ICU

Background: Approximately 2.8 million people require mechanical ventilation (MV) in intensive care units (ICU) each year and, therefore, are unable to communicate using vocal speech. ICU nurses are positioned to mitigate the detrimental effects of communication difficulties during care interactions. Objectives: The specific aims included: 1a) identify and describe communication interaction behaviors that nurses and nonspeaking, critically ill older adults use during communication interactions; 1b) describe the frequency of augmentative and alternative communication (AAC) use with critically ill older adults; 1c) evaluate the relationship between individual interaction behaviors and individual AAC strategies; 2) explore the association between interaction behaviors and nursing care quality indicators (NCQI), and 3) psychometrically evaluate an interaction behavior instrument derived from prior observational research in ICU. Methods: The sample included patients > 60 years of age (N=38) and their nurses (N=24) who participated in the Study of Patient-Nurse Effectiveness with Communication Strategies (SPEACS) (R01-HD043988). Interaction behaviors were measured by rating videotaped interactions. Participant characteristics and NCQI were obtained from the SPEACS dataset and medical chart review. Descriptive statistics were used to describe the nurse and patient interaction behaviors and AAC use. Group comparative statistics were used to examine the differences between interaction behaviors and use of AAC. The association between interaction behaviors and NCQI was explored through repeated measures analysis. Reliability and validity of the instrument were determined by inter-rater agreement, and expert review. Results: All positive behaviors were observed, whereas negative behaviors were rare. Significant (p<.05) associations were observed between: 1) positive nurse and patient behaviors, 2) patient unaided communication strategies and positive nurse behaviors, 3) individual unaided strategies and individual nurse positive behaviors and 4) nurse and patient behaviors and pain management and sedation level, respectively. Using the revised instrument, percent agreements were better for nurse behaviors (73-100%) than patient behaviors (68-100%). Kappa coefficients ranged from 0.13-1.00; lower coefficients occurred for patient behaviors. Conclusion: Findings provide evidence that nurse behaviors affect communication tone and suggest an association between nurse-patient interaction behaviors and NCQI. Preliminary results suggest that the revised interaction behavior instrument has good reliability and face validity in MV, non-speaking older adult patients

Measuring and Improving the Safety and Quality of Care in Older Medical Inpatients

Older people, often frail with multiple co-morbidities, constitute the largest proportion of hospital inpatient populations. Yet existing ways of measuring the quality and safety of care that they receive are not usually designed with the unique problems encountered by this vulnerable population in mind. The aims of the work presented in this thesis were to investigate what is known about the types, incidence and causes of safety and quality issues in older medical inpatients, to develop and test novel tools to measure the safety and quality of care that they receive and finally to design and test interventions to improve care. In Section 1 of the thesis (Chapters 1 and 2), an introduction of patient safety and quality in older people is presented, with an overview of current strategies for measurement and improvement, and the rationale for undertaking this research. Section 2 (Chapters 3 - 5) contains three exploratory studies in which different approaches (a systematic review of the literature and re-analysis of the major adverse event studies, a qualitative study involving staff who are involved in the care of older people, and an exploratory retrospective case record review) were used to produce an overall picture of safety and quality issues in older medical inpatients. This information was used to develop two novel case record review tools (the “Long tool” and “COMPACT”) to measure the quality and safety of care in older medical inpatients, using a combination of outcome and process measures. Section 3 (Chapters 6 and 7) describes the development and testing of these tools. Next, Section 4 (Chapters 8 and 9) of the thesis consists of two studies which were designed to provide the basis for further safety and quality improvement work in older medical inpatients. In Chapter 8, an investigation of the importance and trainability of safety skills (attributes of the safe practitioner) that may form the basis of a template for future patient safety curricula is described. In Chapter 9, a different improvement approach is described - the development and use of a multidisciplinary goal sheet on a medicine for the elderly ward, its effect on quality of care as measured by COMPACT, on staff perceptions of the incidence of adverse events, teamwork and communication, and on goal understanding. Finally, the discussion (Section 5, Chapter 10) reflects on the overall findings, strengths and weaknesses of the studies, and implications for clinical practice and future research

The International Collaboration of Orthopaedic Nursing (ICON): Best practice nursing care standards for older adults with fragility hip fracture

© 2018 Elsevier Ltd. This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/ This author accepted manuscript is made available following 12 month embargo from date of publication (November 2018) in accordance with the publisher’s archiving policyThe purpose of this document is to provide nurses who care for older adults with fragility hip fracture with a framework to promote safe and optimal care for this vulnerable population. The successful application of the standards of care contained in this document requires clinical expertise and evidence-supported decision-making in order to maximize patient outcomes. In 2012, 2013 a two part consensus document published in the International Journal of Orthopaedic and Trauma Nursing entitled “Acute nursing care of the older adult with fragility hip fracture: an international perspective” was developed by nursing leaders from seven countries across 3 continents who delineated the recommended care standards for this group of patients (Maher et al., 2012; Maher et al., 2013)

Post-Intensive Care Syndrome: Comparison of Educational Interventions to Educate Parents of Children Hospitalized in the Pediatric Intensive Care Unit at St. Louis Children’s Hospital

Background: Family members of children hospitalized in the pediatric intensive care unit (PICU) can develop cognitive, psychological, and physical manifestations of post-intensive care syndrome (PICS). Targeted education to help parents/caregivers recognize the signs and symptoms of PICS may result in better awareness of the syndrome and greater willingness to seek and receive support during their child’s PICU admission. Objective: to evaluate three targeted PICS educational interventions to increase PICS awareness among parents/caregivers in the St. Louis Children’s Hospital (SLCH) PICU. Results: A total of 62 parents/caregivers received one of three educational interventions: informational brochures (n=22), scripted informational conversation (n=20), or three-minute educational video (n=20). An additional 19 bedside nurses completed surveys to describe how each educational intervention affected daily work flow. Changes in parental/caregiver PICS fund of knowledge was evaluated using Fischer’s exact test. All three educational interventions were associated with a significant improvement in understanding of PICS, with no single intervention being superior. Nursing surveys indicated that work flow was minimally disrupted using PICS education and that all interventions were perceived to be important and useful. Conclusions: Targeted educational interventions led to improvement in knowledge about PICS among parents/caregivers and were well supported by PICU nursing staff. Thus, providing support for a sustainable implementation of PICS education in the SLCH PICU