Improving Nursing Staffing Methodology and Nursing Sensitive Outcomes with the Addition of a Patient Centered Acuity Measure

Background: Assigning the correct nursing resources to hospitalized patients positively impacts patient outcomes. The current process for matching nurses to patients is highly variable and involves a combination of simple ratios, historical workload data, and expert opinion but lacks objective measurement of the patient’s condition. Objectives: This project evaluated change in selected quality indicators and the daily unit-level management of nursing resources after implementing the Troubled Outcome Risk (TOR) into existing nursing staffing methodology in a Department of Veterans Affairs hospital. Methods: TOR provides objective measurement of individual patient allostatic load. Daily calculation of TOR scores for each patient on the study unit and nursing staffing methodology were used by charge nurses to determine assignments. Nursing sensitive indicators including length of stay, transfers to intensive care unit, hospital acquired pressure ulcer (HAPU), 30-day readmissions, and nursing surveillance indicators including rapid response team activation and cardiac arrests were compared before and after implementing TOR. Results: There was a reduction of HAPU rates that exceeded the stated goal after implementation of TOR. Other indicators did not meet project goals. Prior to implementation of TOR, nurse assignments clustered in specific locations; after implementation 16.7% were without regard to location. None of the results were statistically significant; yet we observed a small-medium effect size between intervention and assignment change. Conclusions: The implementation of TOR did not result in significant differences in nursing sensitive outcomes, however charge nurses appear to have changed staff nurse assignments using TOR as an addition to existing methodology. Future study with a larger sample over a longer period of time may yield different results

Multi-messenger observations of a binary neutron star merger

On 2017 August 17 a binary neutron star coalescence candidate (later designated GW170817) with merger time 12:41:04 UTC was observed through gravitational waves by the Advanced LIGO and Advanced Virgo detectors. The Fermi Gamma-ray Burst Monitor independently detected a gamma-ray burst (GRB 170817A) with a time delay of ~1.7 s with respect to the merger time. From the gravitational-wave signal, the source was initially localized to a sky region of 31 deg2 at a luminosity distance of 40+8-8 Mpc and with component masses consistent with neutron stars. The component masses were later measured to be in the range 0.86 to 2.26 Mo. An extensive observing campaign was launched across the electromagnetic spectrum leading to the discovery of a bright optical transient (SSS17a, now with the IAU identification of AT 2017gfo) in NGC 4993 (at ~40 Mpc) less than 11 hours after the merger by the One- Meter, Two Hemisphere (1M2H) team using the 1 m Swope Telescope. The optical transient was independently detected by multiple teams within an hour. Subsequent observations targeted the object and its environment. Early ultraviolet observations revealed a blue transient that faded within 48 hours. Optical and infrared observations showed a redward evolution over ~10 days. Following early non-detections, X-ray and radio emission were discovered at the transient’s position ~9 and ~16 days, respectively, after the merger. Both the X-ray and radio emission likely arise from a physical process that is distinct from the one that generates the UV/optical/near-infrared emission. No ultra-high-energy gamma-rays and no neutrino candidates consistent with the source were found in follow-up searches. These observations support the hypothesis that GW170817 was produced by the merger of two neutron stars in NGC4993 followed by a short gamma-ray burst (GRB 170817A) and a kilonova/macronova powered by the radioactive decay of r-process nuclei synthesized in the ejecta