Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data

Introduction: In electronic health records (EHRs), standardized nursing terminologies (SNTs), such as nursing diagnoses (NDs), are needed to demonstrate the impact of nursing care on patient outcomes. Unfortunately, the use of NDs is not common in clinical practice, especially in surgical settings, and is rarely included in EHRs. Objective(s): The aim of the study was to describe the prevalence and trend of NDs in a hospital surgical setting by also analyzing the relationship between NDs and hospital outcomes. Methods: A retrospective study was conducted. All adult inpatients consecutively admitted to one of the 15 surgical inpatient units of an Italian university hospital across 1 year were included. Data, including the Professional Assessment Instrument and the Hospital Discharge Register, were collected retrospectively from the hospital's EHRs. Results: The sample included 5,027 surgical inpatients. There was a mean of 6.3 ± 4.3 NDs per patient. The average distribution of NDs showed a stable trend throughout the year. The most representative NANDA-I ND domain was safety/protection. The total number of NDs on admission was significantly higher for patient whose length of stay was longer. A statistically significant correlation was observed between the number of NDs on admission and the number of intra-hospital patient transfers. Additionally, the mean number of NDs on admission was higher for patients who were later transferred to an intensive care unit compared to those who were not transferred. Conclusion: NDs represent the key to understanding the contribution of nurses in the surgical setting. NDs collected upon admission can represent a prognostic factor related to the hospital's key outcomes

Transcatheter Aortic Valve Replacement (TAVR): A Needs Assessment for Norton Healthcare

Purpose: The purpose of this study was to conduct an initial needs assessment on the TAVR program at Norton Healthcare (NHC). Baseline data were collected on patient quality of life as evidenced by Kansas City Cardiomyopathy Questionnaire (KCCQ) scores, frailty scores, Katz index, Lawton scale, Society of Thoracic Surgeons (STS) mortality score, and comorbidities. A secondary purpose was to identify trends in patient outcomes such as increased morbidity, mortality, readmission rates, complications, discharge disposition, and increased length of stay. Setting and Population: The population for this study was all patients at Norton Audubon Hospital (NAH) who underwent TAVR between October 1, 2014 and December 31, 2015. A total of 51 patients were included in the chart review. Procedures: This needs assessment utilized a retrospective electronic medical record review. The records were assigned a study number that was used on all electronic data collection forms. Data were collected using an investigator developed data collection instrument. The data were then directly entered into Data Analysis Statistical Package for the Social Sciences (SPSS) software for analysis. Results and Conclusions: A review of the patients’ health history and co-morbid burden was conducted. Forty-three patients (84.3%) had hypertension, 33 (64.7%) had coronary artery disease or a myocardial infarction, 37 (72.5%) had hyperlipidemia, nine (17.6%) had a permanent pacemaker and/or AICD, 14 (27.5%) had previous coronary artery bypass grafting (CABG), 24 (47.1%) had an arrhythmia such as atrial fibrillation, 11 (21.6%) had a previous stroke, 26 (51%) had some form of pulmonary disease, 16 (31.4%) had some form of renal disease, 12 (23.5%) had history of cancer, and 13 (25.5%) were diabetic. Pre-procedure quality of life metrics were examined using KCCQ scores, Katz index, Lawton scale, STS score, and frailty score were included. The mean pre-procedure KCCQ score (n=50) was 29.16 (SD=11.919), Katz index (n=35) was 5.26 (SD= 1.094), Lawton scale (n=35) was 4.71 (SD= 2.573), STS score (n=51) was 12.28535 (SD= 5.638508), and frailty score (n=19) was 5.11 (SD= 1.100). Post-procedure metrics included 30-day KCCQ score, length of stay, discharge disposition, and 30-day readmission. The mean 30-day KCCQ score (n= 27) was 47.96 (SD=10.886). The median length of stay was five days. Thirty-three (64.7%) were discharged home, 13 (25.5%) went to a sub-acute rehabilitation facility, one (2%) went to the Veterans Affairs Medical Center (VAMC), three (5.9%) died, and one (2%) went to a long-term acute care (LTAC) facility. Seven patients (13.7%) were readmitted to a Norton facility within thirty days of being discharged from the hospital

Improving Emergency Department Throughput: Using a Pull Method of Patient Flow

Practice Problem: Overcrowding in the emergency department (ED) has been shown to increase the length of hospital stay, adversely impact patient outcomes, and reduce patient satisfaction. Problems with overcrowding and throughput are often thought of as an ED-specific inefficiency; however, the issue is indicative of hospital-wide inefficiencies. PICOT: The PICOT question that guided this project was “For ED patients admitted to the medical-surgical unit at an acute medical center, will the implementation of a pull model for patient flow, when compared to the current push model, reduce admission delay and length of stay (LOS) within six weeks of implementation? Evidence: A total of 21 studies were identified in the literature that directly support the implementation of this project. Themes from the literature include delays adversely impact patients, ED throughput is directly affected by throughput of inpatient units, and bed ahead programs can improve throughput. Intervention: The primary intervention for this project was implementing a bed ahead process for the host facility. The nurse hand-off process was also altered to improve efficiency. Outcome: The project resulted in an improvement in the ED delay time. During the project, the mean admission delay time was reduced from 184 minutes to 112 minutes. Conclusion: Using a pull methodology effectively enhances ED throughput by reducing delays in the ED admission process

Addendum to Informatics for Health 2017: Advancing both science and practice

This article presents presentation and poster abstracts that were mistakenly omitted from the original publication

A Managerial Ecosystem for Excellence in Hospital Administration

Major healthcare systems and hospital organizations face a myriad of challenges in today’s business environment, having to provide very complex and more comprehensive medical care with fewer resources. In this study, we investigate determinants of hospital performance in critical dimensions and propose an information infrastructure intended to promote excellence in clinical performance while sustaining a solid financial footing. Senior executives must be knowledgeable in both business and clinical aspects of hospital administration because their decisions ultimately affect patient care and clinical outcomes. Key performance indicators (KPI) are necessary on both dimensions to inform their decisions. Financial and operational aspects of hospital performance are tied to physical resources, staffing and services rendered, development projects and growth of the institution. Clinical aspects pertain to the care provided to patients and are represented by metrics such as death rates, infection rates, readmission rates, and patient-satisfaction surveys. These measures are affected by patient characteristics as well as services rendered. A thorough understanding of KPIs and their potential roles in effecting change for excellence in organizational performance is vital for hospital administrators. We build multivariate statistical models to assess hospital performance considering institutional characteristics and the populations they serve. Deviations from “adjusted norms” derived from these models reveal areas where an institution’s performance exceeds or falls below expectation or national standards. In addition, it allows for true inter-hospital comparisons. Upper Echelons Theory states that, “organizational outcomes – strategic choices and performance levels – are partially predicted by managerial background characteristics.” To assess extant evidence of this, we identify high and low performing hospitals with our proposed metrics and investigate whether there is a difference between these groups with respect to the training of senior management and the composition of the executive suite. Using our proposed metrics, we are unable to conclude that the training of senior management or the composition of the executive suite affects hospital performance. To guide strategic initiatives and improve control, we develop an ecosystem using KPIs that align with spheres of managerial responsibility for hospitals and propose them as an alternative to published “hospital star ratings” reported by third parties

Positive Margins And Other Factors Associated With Survival In Early Stage Oral Cavity Squamous Cell Cancer: Prognostic Impact And Quality Measure

Objective: The aim of this work was to determine the prognostic impact of positive margins in early oral cavity squamous cell cancer and evaluate the utility of positive margin incidence as a surgical quality measure. Study design and setting: Retrospective analysis of the National Cancer Data Base Subjects and methods: Patients with oral cavity squamous cell cancer diagnosed between 1998 and 2011 who were treated with surgical resection were sampled. Univariate and multivariate analyses of overall survival and incidence of positive margins were performed. Results: A total of 6,830 patients were included in the survival analysis. Overall survival at 5-years was 69.7%. On multivariate analysis, neck dissection (HR 0.79, 95% CI 0.76-0.94) and treatment at academic/research institutions (HR 0.88, 95% CI 1.01-0.99) were associated with improved survival, while positive margins (HR 1.27, 95% CI 1.08-1.49), insurance through Medicare (HR 1.45, 95% CI 1.25-1.69) or Medicaid (HR 1.96, 95% CI 1.60-2.39), and adjuvant radiotherapy (HR 1.31, 95% CI 1.16-1.49), or adjuvant chemotherapy (HR 1.34, 95% CI 1.03-1.75) were associated with compromised survival. A total of 20,602 early oral cancer patients were identified for analysis of factors associated with positive margins. Margin status was reported in 94.8% of cases, and positive margins occurred in 7.5% of those cases. Incidence of positive margins by institution varied from 0% to 43.8%, with median incidence of 7.1%. Positive margins were associated with clinical factors including stage II disease (OR 1.75; 95% CI 1.55-1.98), intermediate grade (OR 1.20; 95% CI 1.04-1.37), high grade (OR 1.68; 95% CI 1.39-2.03), and floor of mouth (OR 1.78; 95% CI 1.52-2.08), buccal mucosa (OR 2.06 95% CI 1.59-2.68), and retromolar locations (OR 2.40, 95% CI 1.85-3.11). Positive margins were also associated with treatment at non-academic cancer centers (OR 1.23; 95% CI 1.04-1.44) and institutions with low oral cancer case volume (OR 1.45; 95% CI 1.23-1.69). Conclusion: Positive margins portend a poor prognosis in early oral squamous cell cancer. The incidence of positive margins is associated with clinicopathologic factors as well as treatment and institution factors and can serve as an effective surgical quality measure for early oral cavity squamous cell cancer

Molecular imaging of abdominal aortic aneurysms

Abdominal aortic aneurysm (AAA) disease is characterised by an asymptomatic, permanent, focal dilatation of the abdominal aorta progressing towards rupture, which confers significant mortality. Patient management and surgical decisions currently rely on aortic diameter measurements via abdominal ultrasound screening. However, AAA rupture can occur at small diameters or may never occur at large diameters. Therefore, there is a need to develop molecular imaging-based biomarkers independent of aneurysm diameter that may help stratify patients with early-stage AAA to reduced surveillance. AAA uptake of [18F]fluorodeoxyglucose on positron emission tomography (PET) has been demonstrated previously; however, its glucose-dependent uptake may overlook other key mechanisms. The cell proliferation marker [18F]fluorothymidine ([18F]FLT) is primarily used in tumour imaging. The aim of the overall study for this thesis was to explore the feasibility of [18F]FLT PET / computed tomography (CT) to visualise and quantify AAA in the angiotensin II (AngII)-infused mouse model. The experiments presented in this thesis revealed increased uptake of [18F]FLT in the 14-day AngII AAA model than in saline controls, followed by a decrease in this uptake at 28 days. Moreover, in line with the in vivo PET/CT findings, Western blotting of aortic tissue revealed increased levels of thymidine kinase-1 (the substrate of [18F]FLT) and nucleoside transporters in the 14-day AngII AAA model than in saline controls, followed by decreased expression levels at 28 days. A pilot experiment further demonstrated that [18F]FLT PET/CT could be used to detect an early therapeutic response to oral imatinib treatment in the AngII AAA model. Therefore, [18F]FLT PET/CT may be a feasible modality to detect and quantify cell proliferation in the AngII AAA murine model. The findings of this thesis are encouraging for the application of [18F]FLT PET/CT in patients with small AAA

A pragmatic multi-centre randomised controlled trial of fluid loading in high-risk surgical patients undergoing major elective surgery - the FOCCUS study

Peer reviewedPublisher PD

Integrated out-of-hours care arrangements in England: observational study of progress towards single call access via NHS Direct and impact on the wider health system

Objectives: To assess the extent of service integration achieved within general practice cooperatives and NHS Direct sites participating in the Department of Health’s national “Exemplar Programme” for single call access to out-of-hours care via NHS Direct. To assess the impact of integrated out-of-hours care arrangements upon general practice cooperatives and the wider health system (use of emergency departments, 999 ambulance services, and minor injuries units). Design: Observational before and after study of demand, activity, and trends in the use of other health services. Setting: Thirty four English general practice cooperatives with NHS Direct partners (“exemplars”) of which four acted as “case exemplars”. Also 10 control cooperatives for comparison. Main Outcome Measures: Extent of integration achieved (defined as the proportion of hours and the proportion of general practice patients covered by integrated arrangements), patterns of general practice cooperative demand and activity and trends in use of the wider health system in the first year. Results: Of 31 distinct exemplars 21 (68%) integrated all out-of-hours call management by March 2004. Nine (29%) established single call access for all patients. In the only case exemplar where direct comparison was possible, cooperative nurse telephone triage before integration completed a higher proportion of calls with telephone advice than did NHS Direct afterwards (39% v 30%; p<0.0001). The proportion of calls completed by NHS Direct telephone advice at other sites was lower. There is evidence for transfer of demand from case exemplars to 999 ambulance services. A downturn in overall demand for care seen in two case exemplars was also seen in control sites. Conclusion: The new model of out-of-hours care was implemented in a variety of settings across England by new partnerships between general practice cooperatives and NHS Direct. Single call access was not widely implemented and most patients needed to make at least two telephone calls to contact the service. In the first year, integration may have produced some reduction in total demand, but this may have been accompanied by shifts from one part of the local health system to another. NHS Direct demonstrated capability in handling calls but may not currently have sufficient capacity to support national implementation