The role of clinical nurse specialists in the implementation and sustainability of a practice change.

AIM: This project\u27s purpose was to promote and sustain a practice change focusing on delirium utilising the clinical nurse specialist (CNS) in a leadership role. BACKGROUND: Delirium is an altered state of consciousness accompanied by an acute change in cognition that tends to have a fluctuating course. Delirium is strongly associated with negative outcomes and is often unrecognised. METHOD: A policy was implemented stating that the RNs will screen patients for delirium with the confusion assessment method (CAM). Interdisciplinary delirium education was offered prior to the practice change and repeated at 3, 6 and 12 months after implementation. The documentation, completion and CAM accuracy screening were determined by the CNS. RESULTS: The CAM documentation and completion audit goal was met and sustained by week 21, and screenings were accurate 83% of the time. CONCLUSIONS: The CNS has an opportunity to take a leadership role when instituting an innovative practice change. Successful implementation of a new practice requires that patient care units are divided into cohorts with systematic roll-out of the initiative. IMPLICATIONS FOR NURSING MANAGEMENT: In addition to leadership, CNS availability on the patient care units is imperative to staff acceptance and sustainability of a practice change

The role of clinical nurse specialists in the implementation and sustainability of a practice change.

Aim This project\u27s purpose was to promote and sustain a practice change focusing on delirium utilising the clinical nurse specialist (CNS) in a leadership role. Background Delirium is an altered state of consciousness accompanied by an acute change in cognition that tends to have a fluctuating course. Delirium is strongly associated with negative outcomes and is often unrecognised. Method A policy was implemented stating that the RNs will screen patients for delirium with the confusion assessment method (CAM). Interdisciplinary delirium education was offered prior to the practice change and repeated at 3, 6 and 12 months after implementation. The documentation, completion and CAM accuracy screening were determined by the CNS. Results The CAM documentation and completion audit goal was met and sustained by week 21, and screenings were accurate 83% of the time. Conclusions The CNS has an opportunity to take a leadership role when instituting an innovative practice change. Successful implementation of a new practice requires that patient care units are divided into cohorts with systematic roll-out of the initiative. Implications for nursing management In addition to leadership, CNS availability on the patient care units is imperative to staff acceptance and sustainability of a practice change

Mobilizing older adults: A multi-site, exploratory and observational study on patients enrolled in the Hospital Elder Life Program (HELP).

The aim of this study was to explore and describe the characteristics of the Hospital Elder Life Program (HELP) sites and how they mobilize patients with volunteers in the United States and other countries. The purpose was to describe: the number of enrollments, modalities, fall and injury rates, and to identify barriers to mobilization. A survey was distributed to 228 international sites. The responding sites enrolled an average of 53.9 (SD 35.3) patients per month. The majority (76%) reported that mobilization included \u27active range of motion exercises\u27 and \u27ambulation\u27. Eighteen percent identified volunteer training, safety and liability concerns as barriers. Falls with injury on HELP units was 0–3%, with an average rate of 0.46 per 1,000 patient days. No patient falls while ambulating with the HELP team and/or volunteers were reported. More research and evidence are needed to further determine barriers and safety of mobilization with the HELP during hospitalization

Mobilizing older adults: A multi-site, exploratory and observational study on patients enrolled in the Hospital Elder Life Program (HELP).

The aim of this study was to explore and describe the characteristics of the Hospital Elder Life Program (HELP) sites and how they mobilize patients with volunteers in the United States and other countries. The purpose was to describe: the number of enrollments, modalities, fall and injury rates, and to identify barriers to mobilization. A survey was distributed to 228 international sites. The responding sites enrolled an average of 53.9 (SD 35.3) patients per month. The majority (76%) reported that mobilization included \u27active range of motion exercises\u27 and \u27ambulation\u27. Eighteen percent identified volunteer training, safety and liability concerns as barriers. Falls with injury on HELP units was 0-3%, with an average rate of 0.46 per 1,000 patient days. No patient falls while ambulating with the HELP team and/or volunteers were reported. More research and evidence are needed to further determine barriers and safety of mobilization with the HELP during hospitalization

Variations in hospice utilization and length of stay for Medicare patients with melanoma

CONTEXT: Timely hospice referral is an indicator of high-quality end-of-life care for cancer patients. Variations in patient characteristics associated with hospice utilization and length of stay have been demonstrated in studies of other malignancies but not melanoma. OBJECTIVES: We sought to understand hospice utilization and patient characteristics associated with variability in use for the older melanoma population. METHODS: We used the Surveillance, Epidemiology, and End Results-Medicare database to identify 13,393 melanoma patients aged 65+ years at time of diagnosis between 2000 and 2009, who died by 12/31/10. The primary outcome was enrollment in hospice with secondary outcome of hospice duration. Patient characteristics associated with variations in hospice enrollment were examined. RESULTS: Among 13,393 patients who died with melanoma, 5298 (40%) received hospice care. Of these, 17% were enrolled in hospice for three days or less, while 13% had ≥90 days of hospice care. Despite improvements over time in the proportion of patients who received hospice and those who received at least 90 days of hospice care, late hospice enrollments did not change. Multivariable analysis revealed that patients of older age, with distant disease at time of diagnosis, and residing in rural areas or in census tracts with higher rates of high school completion were more likely to enroll in hospice. CONCLUSION: Rates of hospice enrollment increased over time but remained under accepted quality benchmarks with variations evident in those who receive hospice services. Efforts to increase access to earlier hospice care for all patients dying with melanoma are essential

Decisions about medication use and cancer screening across age groups in the United States.

OBJECTIVE: To describe decision process and quality for common cancer screening and medication decisions by age group. METHODS: We included 2941 respondents to a national Internet survey who made at least one decision about colorectal, breast, and prostate cancer screening, blood pressure or cholesterol medications. Respondents were queried about decision processes. RESULTS: Across the five decisions considered, decision process scores were similar (and generally low) across age groups for medication and cancer screening, indicating that all groups had poor involvement in medical decision making. Overall knowledge scores were low across age groups, with elderly (75+) having slightly higher knowledge about medications vs. younger respondents. Elderly respondents reported similar goals and concerns when making decisions, though placed greater importance of having peace of mind from a normal result for cancer screening vs. younger respondents. CONCLUSION: Across age groups, respondents reported poor decision processes about common medications and cancer screening, despite little evidence of benefit for some interventions (cancer screening, cholesterol lowering medicines in low risk elderly) and possibility of harm in the elderly. PRACTICE IMPLICATIONS: Particular care should be taken to help patients understand both benefit and risk of screening tests and routine medications

Intraperitoneal chemotherapy among women in the Medicare population with epithelial ovarian cancer.

BACKGROUND: Intraperitoneal combined with intravenous chemotherapy (IV/IP) for primary treatment of epithelial ovarian cancer results in a substantial survival advantage for women who are optimally debulked surgically, compared with standard IV only therapy (IV). Little is known about the use of this therapy in the Medicare population. METHODS: We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify 4665 women aged 66 and older with epithelial ovarian cancer diagnosed between 2005-2009, with their Medicare claims. We defined receipt of any IV/IP chemotherapy when there was claims evidence of any receipt of such treatment within 12 months of the date of diagnosis. We used descriptive statistics to examine factors associated with treatment and health services use. RESULTS: Among 3561 women with Stage III or IV epithelial ovarian cancer who received any chemotherapy, only 124 (3.5%) received IV/IP chemotherapy. The use of IV/IP chemotherapy did not increase over the period of the study. In this cohort, younger women, those with fewer comorbidities, whites, and those living in Census tracts with higher income were more likely to receive IV/IP chemotherapy. Among women who received any IV/IP chemotherapy, we did not find an increase in acute care services (hospitalizations, emergency department visits, or ICU stays). CONCLUSION: During the period between 2005 and 2009, few women in the Medicare population living within observed SEER areas received IV/IP chemotherapy, and the use of this therapy did not increase. We observed marked racial and sociodemographic differences in access to this therapy

Falls and delirium in an acute care setting: A retrospective chart review before and after an organisation-wide interprofessional education.

AIM AND OBJECTIVES: To describe and compare identification of delirium, length of stay and discharge locations in two patient samples of falls, before and after an organisation-wide interprofessional delirium education and practice change along with implementation of a policy. BACKGROUND: Delirium is a common and severe problem for hospitalised patients, with occurrence ranging from 14%-56%, morbidity and mortality from 25%-33%. Recent studies report that 73%-96% of patients who fell during a hospital stay had symptoms of delirium; however, the delirium went undiagnosed and untreated in 75% of the cases. DESIGN: A descriptive, retrospective observational study using a pre/postdesign. METHODS: Two chart reviews were performed on patient falls as identified in the hospital safety reporting system in 2009-2010 (98 fallers) and 2012 (108 fallers). An organisation-wide education was planned and implemented with monitoring of policy compliance. RESULTS: After the education, documentation of the diagnosis of delirium and no evidence of delirium increased from 14.3%-29.5% and from 27.6%-44.4%. The documentation of evidence of delirium decreased significantly from 58.2%-25.9% (p \u3c .001). The confusion assessment method (CAM) identified the diagnosis of delirium at 76% accuracy. The length of stay decreased by 7.3 days. The fall rates in 2011 and 2012 were 3.01 and 2.82 falls per 1,000 patient days and in 2013 decreased to 2.16. CONCLUSION: The results indicate that improving delirium recognition and treatment through interprofessional education can reduce falls and length of stay. RELEVANCE TO CLINICAL PRACTICE: The results demonstrate that when staff learn to prevent, identify, manage and document delirium more accurately the fall rate decreases. The practice change, including the use of CAM, was sustained by continuous auditing including re-education, and the re-enforcement of learning along with the implementation of a policy

Falls and delirium in an acute care setting: A retrospective chart review before and after an organisation‐wide interprofessional education.

p \u3c .001). The confusion assessment method (CAM) identified the diagnosis of delirium at 76% accuracy. The length of stay decreased by 7.3 days. The fall rates in 2011 and 2012 were 3.01 and 2.82 falls per 1,000 patient days and in 2013 decreased to 2.16. Conclusion: The results indicate that improving delirium recognition and treatment through interprofessional education can reduce falls and length of stay. Relevance to clinical practice: The results demonstrate that when staff learn to prevent, identify, manage and document delirium more accurately the fall rate decreases. The practice change, including the use of CAM, was sustained by continuous auditing including re‐education, and the re‐enforcement of learning along with the implementation of a policy. } data-sheets-userformat= { 2 :33569153, 3 :{ 1 :0, 3 :1}, 10 :0, 11 :4, 14 :[null,2,0], 15 : Calibri , 16 :11, 28 :1} \u3eAim and objectives: To describe and compare identification of delirium, length of stay and discharge locations in two patient samples of falls, before and after an organisation‐wide interprofessional delirium education and practice change along with implementation of a policy. Background: Delirium is a common and severe problem for hospitalised patients, with occurrence ranging from 14%–56%, morbidity and mortality from 25%–33%. Recent studies report that 73%–96% of patients who fell during a hospital stay had symptoms of delirium; however, the delirium went undiagnosed and untreated in 75% of the cases. Design: A descriptive, retrospective observational study using a pre/postdesign. Methods: Two chart reviews were performed on patient falls as identified in the hospital safety reporting system in 2009–2010 (98 fallers) and 2012 (108 fallers). An organisation‐wide education was planned and implemented with monitoring of policy compliance. Results: After the education, documentation of the “diagnosis of delirium” and “no evidence of delirium” increased from 14.3%–29.5% and from 27.6%–44.4%. The documentation of “evidence of delirium” decreased significantly from 58.2%–25.9% (p \u3c .001). The confusion assessment method (CAM) identified the diagnosis of delirium at 76% accuracy. The length of stay decreased by 7.3 days. The fall rates in 2011 and 2012 were 3.01 and 2.82 falls per 1,000 patient days and in 2013 decreased to 2.16. Conclusion: The results indicate that improving delirium recognition and treatment through interprofessional education can reduce falls and length of stay. Relevance to clinical practice: The results demonstrate that when staff learn to prevent, identify, manage and document delirium more accurately the fall rate decreases. The practice change, including the use of CAM, was sustained by continuous auditing including re‐education, and the re‐enforcement of learning along with the implementation of a policy