Licensed Practical Nurses Working To Maximum Scope of Practice

BACKGROUND: Nurses on 4800, a medical-surgical unit, were feeling overwhelmed by an increasing patient load due to Registered Nurse (RN) vacancies. No not only was staff morale at a low, but the staff was concerned about the impact on patient care. Nursing staff on 4800 consists of RNs as well as Licensed Practical Nurses (LPNs). As the team contemplated the high nurse:patient ratio, they identified that LPNs were not working to the full scope of their practice. The team began to wonder if ensuring that LPNs could work at the highest level of their scope of practice if this would help mitigate some of the stress experience by RNs. A literature search was completed and while there is evidence to support improved patient ratios can lead to a decrease in length of stay and improved patient outcomes, there was not much that discussed LPNs working at their fullest scope of practice in the hospital setting. On 4800, LPNs were not working to their fullest scope. This was due in part to system-wide and EPIC barriers. The EPIC barriers include the verbiage found within the program. There were some modifications made to EPIC, such as the change from “Pain Assessment” to “Pain Observation;” however, EPIC was unable to change the “Head to Toe Assessment” flowsheet. The hospital was able to modify their policy to ensure LPNs were practicing within their scope and documenting “Head to Toe Observations.” PLANNING: After having reviewed the literature, the leadership team, comprised of the Nurse Manager, Assistant Nurse Manager, Clinical Resource Team, and Lindsey Sippel LPN, felt the next step was to design a new care delivery model that would incorporate LPNs working to their full potential. The team began to work closely with the Clinical Nurse Specialist to learn system and state policies regarding LPNs to create a care delivery model that complied with state and local policies. To compensate for what LPNs are not able to document, a Free Charge RN (FCRN) position was developed. The FCRN’s role consists of acknowledging orders, administering medications outside of the LPNs scope, and completing documentation outside of the LPN’s scope. After identifying key stakeholders and drafting a rollout plan, the team identified measures that could be used to evaluate this QI project’s success. INTERVENTION: The leadership team designated a Head to Toe competency as the primary focus of the project. Leadership created a PowerPoint designed to educate LPNs on Head to Toe observations and specific observations for each body system. Completing the Head to Toe competency ensured that the LPNs knew how to properly observe their patients and document it accurately. This meant the LPN no longer had to be paired and supervised by a RN, instead the LPN is now able to independently take their own five patient assignment. The FCRN was there to provide supervision and the necessary care that the LPN is unable to provide due the scope of their practice. In addition, the unit RNs were provided education on what is within the LPN’s scope of practice and the FCRN role. RESULTS: The new care delivery model is still being evaluated; however so far there has been an improvement in nurse to patient ratios. DISCUSSION: Since introducing this care delivery model, staff cohesiveness has improved when utilizing a FCRN. Since nurse satisfaction was not measured prior to the initiation of this care delivery model, this should be studied in the future if expanded to other units. This care delivery model might be applicable in other medical-surgical units across the system and we encourage other units to consider adopting this care delivery model. The barrier that has been identified since starting the care delivery model is the lack of provider knowledge on the LPN scope of practice. To combat this providers should be educated on what LPNs can and cannot do within their scope, and how 4800 is able to coordinate care that is outside of the LPNs scope, through the use of a FCRN.https://scholar.rochesterregional.org/nursingresearchday/1013/thumbnail.jp

Multifocality in sporadic medullary thyroid carcinoma: An international multicenter study

Background: Current surgical standard of care in sporadic medullary thyroid carcinoma (sMTC) consists of a minimum of total thyroidectomy with central neck dissection. Some have suggested thyroid lobectomy with isthmusectomy and central neck dissection for patients with sMTC, given their lower frequency of bilateral disease, although this topic has not been thoroughly studied. This study assessed the prevalence of multifocality in sMTC via a large international multi-institutional retrospective review to quantify this prevalence, including the impact of geography, to assess more accurately the risks associated with alternative surgical approaches. Methods: A retrospective chart review of sMTC patients from 11 institutions over 29 years (1983-2011) was undertaken. Data regarding focality, extent of disease, RET germline analysis plus family and clinical history for multiple endocrine neoplasia type 2 (MEN2), and demographic data were collected and analyzed. Results: Patients from four continents and seven countries were included in the sample. Data for 313 patients with documented sMTC were collected. Of these, 81.2% were confirmed with negative RET germline testing, while the remaining 18.8%demonstrated a negative family history and nomanifestations ofMEN2 syndromes other thanMTC. Bilateral disease was identified in 17/306 (5.6%) patients, while multifocal disease was noted in 50/312 (16.0%) sMTC patients. When only accounting for germline negative patients, these rates were not significantly different (5.6% and 17%, respectively). Among them, when disease was unifocal in the ipsilateral lobe and isthmus, bilateral disease was present in 6/212 (2.8%) cases. When disease was multifocal in the ipsilateral lobe or isthmus, then bilateral disease was present in 8/37 (21.6%) cases ( p < 0.001). No geographic differences in focality were identified. Conclusions: The 5.6% prevalence of bilateral foci in sMTC suggests that total thyroidectomy should remain the standard of care for initial surgery, as less complete thyroid surgery may fail to address fully the primary site of disease. Whether ipsilateral tumor focality should be an independent factor determining the need for completion thyroidectomy when sMTC is diagnosed after hemithyroidectomy remains to be determined

Fine needle aspiration and medulla

Objectives: To evaluate the diagnostic accuracy of fine-needle aspiration biopsy (FNAB) to preoperatively diagnose medullary thyroid cancer (MTC) among multiple international centers and evaluate how the cytological diagnosis alone could impact patient management.Methods: We performed a retrospective chart review of sporadic MTC (sMTC) patients from 12 institutions over the last 29 years. FNAB cytology results were compared to final pathologic diagnoses to calculate FNAB sensitivity. To evaluate the impact of cytology sensitivity for MTC according to current practice and to avoid confounding results by local treatment protocols, changes in treatment patterns over time, and the influence of ancillary findings (e.g., serum calcitonin), therapeutic interventions based on FNAB cytology alone were projected into 1 of 4 treatment categories: total thyroidectomy (TT) and central neck dissection (CND), TT without CND, diagnostic hemithyroidectomy, or observation.Results: A total of 313 patients from 4 continents and 7 countries were included, 245 of whom underwent FNAB. FNAB cytology revealed MTC in 43.7% and possible MTC in an additional 2.4%. A total of 113 (46.1%) patients with surgical pathology revealing sMTC had FNAB findings that supported TT with CND, while 37 (15.1%) supported TT alone. In the remaining cases, diagnostic hemithyroidectomy and observation were projected in 32.7% and 6.1%, respectively.Conclusion: FNAB is an important diagnostic tool in the evaluation of thyroid nodules, but the low sensitivity of cytological evaluation alone in sMTC limits its ability to command an optimal preoperative evaluation and initial surgery in over half of affected patients. © 2013 AACE

Multifocality in Sporadic Medullary Thyroid Carcinoma: An International Multicenter Study.

BACKGROUND: Current surgical standard of care in sporadic medullary thyroid carcinoma (sMTC) consists of a minimum of total thyroidectomy with central neck dissection. Some have suggested thyroid lobectomy with isthmusectomy and central neck dissection for patients with sMTC, given their lower frequency of bilateral disease, although this topic has not been thoroughly studied. This study assessed the prevalence of multifocality in sMTC via a large international multi-institutional retrospective review to quantify this prevalence, including the impact of geography, to assess more accurately the risks associated with alternative surgical approaches. METHODS: A retrospective chart review of sMTC patients from 11 institutions over 29 years (1983-2011) was undertaken. Data regarding focality, extent of disease, RET germline analysis plus family and clinical history for multiple endocrine neoplasia type 2 (MEN2), and demographic data were collected and analyzed. RESULTS: Patients from four continents and seven countries were included in the sample. Data for 313 patients with documented sMTC were collected. Of these, 81.2% were confirmed with negative RET germline testing, while the remaining 18.8% demonstrated a negative family history and no manifestations of MEN2 syndromes other than MTC. Bilateral disease was identified in 17/306 (5.6%) patients, while multifocal disease was noted in 50/312 (16.0%) sMTC patients. When only accounting for germline negative patients, these rates were not significantly different (5.6% and 17%, respectively). Among them, when disease was unifocal in the ipsilateral lobe and isthmus, bilateral disease was present in 6/212 (2.8%) cases. When disease was multifocal in the ipsilateral lobe or isthmus, then bilateral disease was present in 8/37 (21.6%) cases (p < 0.001). No geographic differences in focality were identified. CONCLUSIONS: The 5.6% prevalence of bilateral foci in sMTC suggests that total thyroidectomy should remain the standard of care for initial surgery, as less complete thyroid surgery may fail to address fully the primary site of disease. Whether ipsilateral tumor focality should be an independent factor determining the need for completion thyroidectomy when sMTC is diagnosed after hemithyroidectomy remains to be determined

Multifocality in Sporadic Medullary Thyroid Carcinoma:An International Multicenter Study

Background: Current surgical standard of care in sporadic medullary thyroid carcinoma (sMTC) consists of a minimum of total thyroidectomy with central neck dissection. Some have suggested thyroid lobectomy with isthmusectomy and central neck dissection for patients with sMTC, given their lower frequency of bilateral disease, although this topic has not been thoroughly studied. This study assessed the prevalence of multifocality in sMTC via a large international multi-institutional retrospective review to quantify this prevalence, including the impact of geography, to assess more accurately the risks associated with alternative surgical approaches. Methods: A retrospective chart review of sMTC patients from 11 institutions over 29 years (1983-2011) was undertaken. Data regarding focality, extent of disease, RET germline analysis plus family and clinical history for multiple endocrine neoplasia type 2 (MEN2), and demographic data were collected and analyzed. Results: Patients from four continents and seven countries were included in the sample. Data for 313 patients with documented sMTC were collected. Of these, 81.2% were confirmed with negative RET germline testing, while the remaining 18.8% demonstrated a negative family history and nomanifestations ofMEN2 syndromes other thanMTC. Bilateral disease was identified in 17/306 (5.6%) patients, while multifocal disease was noted in 50/312 (16.0%) sMTC patients. When only accounting for germline negative patients, these rates were not significantly different (5.6% and 17%, respectively). Among them, when disease was unifocal in the ipsilateral lobe and isthmus, bilateral disease was present in 6/212 (2.8%) cases. When disease was multifocal in the ipsilateral lobe or isthmus, then bilateral disease was present in 8/37 (21.6%) cases (p < 0.001). No geographic differences in focality were identified. Conclusions: The 5.6% prevalence of bilateral foci in sMTC suggests that total thyroidectomy should remain the standard of care for initial surgery, as less complete thyroid surgery may fail to address fully the primary site of disease. Whether ipsilateral tumor focality should be an independent factor determining the need for completion thyroidectomy when sMTC is diagnosed after hemithyroidectomy remains to be determined.National Cancer Institute (NCI) National Institutes of Health (NIH) Health and Human Services (HHS)Medical Research CouncilOhio State Univ, Wexner Med Ctr, Dept Otolaryngology Head & Neck Surg, Columbus, OH 43210 USAOhio State Univ, Wexner Med Ctr, Ctr Biostat, Columbus, OH 43210 USAUniv Wisconsin, Sch Med & Publ Hlth, Sect Endocrine Surg, Madison, WI USAUniv Naples Federico II, Dept Clin Med & Surg, Naples, ItalyUniv Fed Sao Paulo, Dept Med, Lab Mol & Translat Endocrinol, Div Endocrinol, Sao Paulo, BrazilUniv Siena, Sect Endocrinol & Metab, Dept Med Surg & Neurol Sci, Siena, ItalyMonash Univ, Alfred Hlth, Dept Endocrinol & Diabet, Melbourne, Vic, AustraliaPierre Oudot Hosp, Dept Endocrinol & Nephrol, Bourgoin Jallieu, FranceUniv Birmingham, Sch Clin & Expt Med, Ctr Endocrinol Diabet & Metab, Inst Biomed Res, Birmingham, W Midlands, EnglandUniv Birmingham, Inst Head & Neck Studies & Educ, Birmingham, W Midlands, EnglandRadboud Univ Nijmegen, Med Ctr, Dept Internal Med, Nijmegen, NetherlandsAlbert Schweitzer Hosp, Dept Internal Med, Dordrecht, NetherlandsUniv Athens, Evgenid Hosp, Thyroid Sect, Unit Endocrinol Diabet & Metab, Athens, GreeceInst Jules Bordet, Dept Med, Brussels, BelgiumUniv Roma La Sapienza, Dipartimento Med Interna, Rome, ItalyVeracyte Inc, 6000 Shoreline Court,Suite 300, San Francisco, CA 94080 USAOhio State Univ, Wexner Med Ctr, Div Endocrinol Diabet & Metab, Columbus, OH 43210 USAOhio State Univ, Wexner Med Ctr, Div Nucl Med, Columbus, OH 43210 USADivision of Endocrinology, Laboratory of Molecular and Translational Endocrinology, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, BrazilNCI NIH HHS: P50 CA168505Medical Research Council: MR/J001414/1Medical Research Council: G0601811Web of Scienc

Fine Needle Aspiration and Medullary Thyroid Carcinoma: The Risk of Inadequate Preoperative Evaluation and Initial Surgery When Relying Upon FNAB Cytology Alone

Item does not contain fulltextObjectives: To evaluate the diagnostic accuracy of fine-needle aspiration biopsy (FNAB) to preoperatively diagnose medullary thyroid cancer (MTC) among multiple international centers and evaluate how the cytological diagnosis alone could impact patient management.Methods: We performed a retrospective chart review of sporadic MTC (sMTC) patients from 12 institutions over the last 29 years. FNAB cytology results were compared to final pathologic diagnoses to calculate FNAB sensitivity. To evaluate the impact of cytology sensitivity for MTC according to current practice and to avoid confounding results by local treatment protocols, changes in treatment patterns over time, and the influence of ancillary findings (e.g., serum calcitonin), therapeutic interventions based on FNAB cytology alone were projected into 1 of 4 treatment categories: total thyroidectomy (TT) and central neck dissection (CND), TT without CND, diagnostic hemithyroidectomy, or observation.Results: A total of 313 patients from 4 continents and 7 countries were included, 245 of whom underwent FNAB. FNAB cytology revealed MTC in 43.7% and possible MTC in an additional 2.4%. A total of 113 (46.1%) patients with surgical pathology revealing sMTC had FNAB findings that supported TT with CND, while 37 (15.1%) supported TT alone. In the remaining cases, diagnostic hemithyroidectomy and observation were projected in 32.7% and 6.1%, respectively.Conclusion: FNAB is an important diagnostic tool in the evaluation of thyroid nodules, but the low sensitivity of cytological evaluation alone in sMTC limits its ability to command an optimal preoperative evaluation and initial surgery in over half of affected patients