DiversityNursing Blog

Alexandra Wilson Pecci

www.healthleadersmedia.com 

Hospitals have a broader responsibility to elderly trauma patients than just the time spent within their walls, and should consider updating their strategies to ensure the best outcomes for these patients, research suggests.

Elderly trauma patients are increasingly likely to be discharged to skilled nursing facilities, rather than inpatient rehabilitation facilities (IRF), finds a study in The Journal of Trauma and Acute Care Surgery published in the April issue.

Discharge to skilled nursing facilities for trauma patients has, however, been associated with higher mortality compared with discharge to inpatient rehabilitation facilities or home.

Researchers wanted to "better characterize trends in trauma discharges and compare them with a population that is equally dependent on post-discharge rehabilitation." They not only examined trauma discharges, but also discharges of stroke patients, who have been taking up more inpatient rehabilitation facility beds.

Using data from 2003–2009 data from the National Trauma Data Bank and National Inpatient Sample, the retrospective cohort study found that elderly trauma patients were 34% more likely to be discharged to a skilled nursing facility and 36% less likely to be discharged to an inpatient rehabilitation facility. By comparison, stroke patients were 78% more likely to be discharged to an inpatient rehabilitation facility.

This is despite the findings of a 2011  JAMA study of patients in Washington State showing that "Discharge to a skilled nursing facility at any age following trauma admission was associated with a higher risk of subsequent mortality."

The Journal of Trauma and Acute Care Surgery study notes that "elderly trauma patients are the fastest-growing trauma population," which leads to the question: Where should hospitals be investing their money and time to ensure the best outcomes for these patients?

"I think hospitals should be investing in post-acute care discharge planning," says Patricia Ayoung-Chee, MD, MPH, Assistant Professor, Surgery, NYU School of Medicine, and lead author of the study. "What's the best post-acute care facility for patients? And it may end up needing to be individualized."

She says reimbursement and insurance factors have "played more of a role than anybody sort of thought about" in discharges, rather than what is always necessarily best for patients.

For example, to be classified for payment under Medicare's IRF prospective payment system, at least 60% of all cases at inpatient rehab facilities must have at least one of 13 conditions that CMS has determined typically require intensive rehabilitation therapy, such as stroke and hip fracture.

"I think the unintended consequence is that we may be discharging patients to the best post-acute care setting, but we also may not be," Ayoung-Chee said by email, and that question "is only now being looked at in-depth."

She says hospitals should think about truly appropriate discharge planning upfront.

Proactive Hospitals
For instance, at admission, hospitals can find out who the patient lives with, or what their social support system is like. If they have a broken dominant hand after a fall, will they be able to get help with their groceries? Do they live alone? Will they be able to use the bathroom?

Caring for patients also doesn't end when patients leave the hospital, she adds. Hence the study's title: "Beyond the Hospital Doors: Improving Long-term Outcomes for Elderly Trauma Patients."

Ayoung-Chee says the next step in her research is to look at a more longitudinal picture, following individual patients to see what factors play into their function or lack of function.

But hospitals can do some of that work on a smaller scale, with internal audits to determine which facilities have the best post-acute care outcomes. For instance, they could spend time examining which facilities had fewer readmissions compared to others, as well as how long it took patients to get home and their how satisfied they were with their care.

Other research is also trying to determine which facilities are best for elderly trauma patients. For instance, a second study, also published in The Journal of Trauma and Acute Care Surgery, shows that geriatric trauma patients have improved outcomes when they are treated at centers that manage a higher proportion of older patients.

One of the overarching takeaways from Ayoung-Chee's research is the idea that hospitals have a broader responsibility to patients than just the time spent within their walls.

"What we do doesn't just end upon patient discharge. If we truly want to get the biggest bang from our buck, we're going to have to think about the entire continuum," she says.

That could range from working to prevent falls that can cause elderly trauma, to seeing patients through all of the appropriate care needed to expect a good functional outcome. Good healthcare for elderly trauma patients should extend beyond the parameters of morbidity and mortality, and toward returning patients to their original functional status and, ultimately, independence, says Ayoung-Chee.

"Our long-lasting effect as healthcare providers isn't just what we do in the hospital," she says. "And we have to start thinking outside."

BY SEAN DENT

http://scrubsmag.com 

Pens that don’t work? Socks that cut off your circulation? Cheap key chains? Yep, those sound like some Nurses Week gift failures to me!

I have some suggestions for gifts I think every nurse would appreciate for Nurses Week. Here are two major ones (you can thank me later!):

A real lunch break

• You know, the kind of lunch break that involves leaving the nursing unit, or even leaving the premises all together. The kind where you actually taste your meal instead of inhaling it on the go. Maybe even a full hour-long lunch so we could enjoy the food we eat and take our time getting back on shift.

IOU: A time out

• A certificate that allows you the ability to just call a time out. I’m talking stopping everything, putting your hands in the air and taking a “Calgon moment.” No explanation necessary, just produce the IOU. We should be able to use this IOU whenever the need arises. You could even put an expiration date on it, although I doubt it would take long to use this one up.

Here are a few more random ideas for gifts:

• A valet ticket for parking
• A free lunch (or more than one)
• IOU: One time you get to leave work early
• IOU: One time you get to come to work late
• IOU: One request for a new pot of coffee be made (when the pot is empty)
• IOU: One admission paperwork completion
• IOU: A free breakfast

Don’t get me wrong, I’m always appreciative of the recognition, but I think if we’re going to celebrate all things nursing, then the gifts should be worth the year-long wait!!

Any other suggestions? What would be a great gift for you this Nurses Week?

http://news.nurse.com 

The award-winning documentary “The American Nurse” (DigiNext Films) will be shown at special screening engagements May 6 in honor of National Nurses Week. The film highlights the work and lives of five American nurses from diverse specialties and explores topics such as aging, war, poverty and prisons. 

“At some point in our life each of us will encounter a nurse, whether it’s as a patient or as a loved one,” Carolyn Jones, director and executive producer of the film, said in a news release. “And that one encounter can mean the difference between suffering and peace; between chaos and order. Nurses matter.” 

The American Academy of Nursing recognized Jones, an award-winning filmmaker and photographer, as the winner of its annual Johnson & Johnson Excellence in Media Award for the documentary. The award recognizes exemplary healthcare journalism that incorporates accurate inclusion of nurses’ contributions and perspectives. “I intended to make a film that celebrated nursing,” Jones said in the release. “I ended up gaining deeper insights into some of the social issues we face as a country, through the eyes of American nurses. I’ve grown to believe that nurses are a truly untapped and under-appreciated national resource.” 

The documentary also was awarded a Christopher Award in the feature film category, alongside films “Selma” and “St. Vincent.”

The film, which was made possible by a grant from Fresenius Kabi, is being presented locally through sponsorship by the Future of Nursing: Campaign for Action, a joint initiative of the Robert Wood Johnson Foundation and AARP, together with the American Nurses Foundation and Carmike Cinemas. 

The campaign’s state action coalitions and other campaign partners are expected to host at least 50 screenings of the film. Ten percent of the proceeds will go to help local efforts to advance nursing. A portion of all proceeds from the film will benefit the American Nurse Scholarship Fund.

To find a screening near you or to learn how to host a screening, go to http://americannurseproject.com/national-nurses-day-screenings.

http://myfox8.com

 If you ever needed any evidence that nurses care vastly about every single patient they encounter, this is it.

A video posted last week on Facebook shows a nurse reacting as one of her patients stands up for the first time in 11 days.

The story as, posted by Texas mom Becky Miller:

“Our daughter, Bailey, had complete paralysis from the waist down for 11 days with no explanation as to why. This video is one of her favorite nurses coming onto her shift and not knowing that Bailey had started walking this day.”

The nurse immediately bursts into tears upon seeing Bailey, screaming, “Thank you, Lord.”

Miller said Bailey had no feeling or movement in her legs the day before. Doctors did not know what caused Bailey to lose feeling in her legs.

Commenters on Reddit immediately took the opportunity to commend nurses, and all of the work and long hours they put in daily.

“Nurses are great people,” one commenter wrote. “You’d have to be humanitarian to be a nurse.”

www.sunnyskyz.com

The Giles family is celebrating two miracles after the 20 year-old mom opened her eyes and saw a picture of her newborn child.

Sharista Giles awakened this week from a four month coma that doctors had feared would be permanent and learned that she had given birth to a baby boy.

Sharista was four-months pregnant when she was involved in a car crash near Nashville, Tennessee. Doctors told her family she had a 10% chance of coming out of the coma.

"The doctors were telling us there was nothing else they could do," her aunt Beverly Giles, 49, told ABC News. "They already gave up hope. We never gave up. She's fought this hard."

The infant, who is being called "Baby L" until his mom is able to give him a proper name, weighed just over 1 pound when he was welcomed into the world a month after the accident.

But now he's healthy, weighing 6 pounds and 4 ounces, and proving he's as strong as his mother - who still hasn't spoken yet.

Sharista's father held up a picture of "Baby L" when she woke up, and she never took her eyes off the image, her aunt told ABC News. "When he turned around to put it back on the bulletin board, she turned her neck, her whole head trying to follow and find the picture again."

By Tracey Boyd

http://news.nurse.com

Informatics programs that allow med/surg nurses to cut down on documentation and increase patient safety at the touch of a button are becoming more essential in today’s fast-paced healthcare environment.

“Most all nurses use the electronic health record in their daily practice,” said Jill Arzouman, MSN, RN, ACNS-BC, CMSRN, president of the Academy of Medical-Surgical Nurses and clinical nurse specialist in surgical oncology at the University of Arizona Medical Center, Tucson. The university has computer stations inside each patient room for access to charting, she said, and some hospitals are investing in iPads to facilitate charting. Arzouman is a DNP candidate.

Med/surg nurses at New York’s Montefiore Health System in the Bronx use informatics throughout the day to document patients’ electronic medical records and provide direct care to patients, said Maureen Scanlan, MSN, RN-BC, vice president, nursing and patient care services and former director of informatics for the health system. “Electronic documentation has provided us the ability to track and trend patient outcomes data in a more efficient manner. We have the added benefit of decision support alerts to guide practice and documentation. We then can leverage information collected from the records to streamline workflows and improve patient safety.” 

According to a HealthIt.gov study “Benefits of EHRs,” (www.healthit.gov/providers-professionals/improved-diagnostics-patient-outcomes), having quick, up-to-date access to patients’ information can also reduce errors and support better patient outcomes by keeping a record of a patient’s medications or allergies, checking for problems whenever a new medication is prescribed and alerting the clinician to potential conflicts. 

“The ability to clearly read a medication order printed from a computer is vastly different than trying to decipher a handwritten order,” said Arzouman.

In addition, staff can revisit patient information at any time. 

“Many of the systems are very intuitive and allow the entire interdisciplinary team to document and communicate with precision and ease,” she said “A medical/surgical nurse may be busy with another patient but she or he can go back and read documentation from the dietitian who may have visited the patient at the same time.“

A reduction in medication errors was the catalyst for a project using computerized EHRs at Abington (Penn.) Health. When staff realized that patients with heart failure were being readmitted largely because of incorrect medication lists upon discharge, Diane Humbrecht, MSN, RN-BC, chief nursing informatics officer, devised a plan to evaluate the accuracy of such lists. 

Humbrecht, a DNP candidate who is also a chapter director for the American Nursing Informatics Association, has worked in both cardiac and home care during her career and said she had experienced heart failure patients going home with medication lists that were either incorrect or missing information. 

“It was very frustrating for both the patient and the nurse who is trying to follow up,” she said.

As part of her DNP program, Humbrecht decided to focus on transitions of care for this vulnerable population to help correct their discharge medication instructions and reduce their risk for readmission.

“As I began researching, I saw medication errors on medication discharge lists were the main reasons patients were readmitted to the hospital,” she said. •

Her findings were validated, she said, when the transition nurses who were involved in the postop discharge process informed her of problems with patients going home with incorrect medication lists. “Medication reconciliation and discharge instructions are done by the physician, but the nurses are the ones who review them and they were finding these errors after discharge,” she said. 

Humbrecht implemented three changes to remedy the situation. The first step was to bring the pharmacists in on the front end. Pharmacists already performed patient rounding on units, but they were not involved in medication reconciliation at all, she said. The new protocol called for pharmacists to come in within 24 hours of a patient’s admittance to review the co-medications. The input from the pharmacists on the front end was crucial. “The pharmacists had to change about 80% of the lists,” Humbrecht said.

Next, upon discharge, the nurses perform a thorough review of the co-medications list that was corrected by the pharmacist. “If anything needed to be corrected, the nurse then called the physician to tell them they need to change a medication,” Humbrecht said. “Once that was done, it caused the physician to perform medication reconciliation again, automatically updating the entire medication list.” 

The transition nurses were the final piece to the puzzle. Prior to the new protocol, upon calling the discharged patient and finding any errors, the nurse would make notations on paper. If the patient was readmitted, and the change was not transferred onto the patient’s EHR, the incorrect information was still in the system. Now, using the computerized medication list, any errors are updated immediately in the system. 

The changes worked. Since implementation last fall, the transition nurses have found one error on the medication list of a discharged patient, Humbrecht said. 

“We figured if we can get the home medication list correct on the front end by using the pharmacists and double-checked and changed as needed by the nurses on the back end, then the transition nurses should find less errors,” she said.

Besides documentation and patient safety, med/surg nurses are using informatics to enhance patient care. “Our staff nurses provide expert advice when we are defining a new process for delivering patient care,” said Scanlan, who holds board certification in nursing informatics. “A recent implementation of a new lab system that changed the way specimens are collected was successful due to workflow and hardware recommendations from the frontline staff.” 

Scanlan said staff nurses recently have contributed to revising the electronic skin assessment template as well. 

“Although not a clear time saver,” she said, “it has significantly improved the ability to track, trend and communicate hospital-acquired pressure ulcers [and] has supported performance improvement efforts that are led by the nursing staff.”

Arzouman also noted innovative uses. “For a postoperative patient who needs to continue to ambulate and exercise while at home, a medical/surgical nurse can teach the patient how to track his activity using a smart phone app,” she said. “I have had the opportunity to trial an app on my smart phone that translates basic medical information into many different languages without needing to use a translator. For something simple like ‘Hi, my name is Jill and I will be the nurse coordinating your care today,’ it is a very helpful tool.” 

http://news.nurse.com 

Surgeons are no longer removing most of the lymph nodes in the underarm area when a biopsy near the area shows cancer, a major change in breast cancer management, according to a study published in the Journal of the American College of Surgeons.
Researchers evaluated data from 2.7 million patients with breast cancer in the U.S. and learned to what extent surgeons were following recommendations from the American College of Surgeons Oncology Group Z0011, or ACOSOG Z-11 trial, published four years ago.

They reported that most early-stage breast cancer patients with tumors in their sentinel lymph node who undergo lumpectomy do not benefit from surgical removal of the remaining lymph nodes in the underarm area, called completion axillary lymph node dissection or ALND, according to a news release. They found no difference in cancer recurrence and five-year survival between patients who underwent ALND and those who did not.

Researchers found a dramatic increase in the proportion of lumpectomy patients who underwent only a sentinel lymph node biopsy — SNB — without an ALND. The SNB-alone rate more than doubled — from 23% in 2009 to 56% in 2011, according to the study.

“As far as I know, our study is the first to show that the findings from the ACOSOG Z-11 trial have changed clinical practice for breast cancer patients nationwide,” lead author Katharine Yao, MD, FACS, director of the Breast Surgical Program at NorthShore University HealthSystem in Evanston, Ill., and clinical associate professor of surgery at the University of Chicago Pritzker School of Medicine, said in the release. “The Z-11 trial has had a huge impact because of the lower risks for patients who undergo SNB alone.”

Investigators found that 74,309 patients (of the 2.72 million cases diagnosed between 1998 and 2011) met criteria for having SNB alone but underwent lumpectomy and radiation therapy to the whole breast, according to the press release.

The rate of SNB alone cases reportedly increased from 6.1% in 1998 to 56% in 2011. 
Yao said findings suggest that some practitioners may feel uncomfortable not performing ALND in high-risk patients, and called for more education for surgeons.

By Elizabeth Cohen and John Bonifield

www.cnn.com

Today, because of a CNN story and the generosity of donors from around the world, Kekula wears scrubs bearing the emblem of the Emory University Nell Hodgson Woodruff School of Nursing in Atlanta, where she's learning skills she can take back home to care for her fellow Liberians. 

"It's a surprise -- a young child like me who came from a very poor background coming to the U.S.," she said. "I'm thankful to CNN and I appreciate the people who made donations, and I'm thankful to Emory for accepting me to study."

At Emory, Kekula has asked for special training on certain skills, such as caring for burns, a common type of injury because children in Liberia sometimes fall into the open fires used for cooking. 

One of her instructors, Kelly Fullwood, said Kekula's an excellent student who has taught her teachers a thing or two about how to do procedures without costly equipment, as she's been forced to do in Liberia. 

"She fascinates me every day," Fullwood said. "She gets nursing. She gets what it's about."

Kekula, 23, was just a year away from finishing up her nursing degree in Liberia when Ebola struck and her mother, father, sister and cousin came down with the disease. Hospitals were full and no doctors would visit her home, so with just advice from a physician on the phone, Kekula took care of all four of her relatives at the same time. 

All but her cousin survived -- a high success rate considering that at the time, about 70% of Ebola patients were dying in Liberia.

Kekula couldn't continue her nursing education in Liberia, because the schools had closed. 

A CNN story about Kekula in September prompted donations from around the world to IAM, an organization that raises money to help African natives pay for education. 

David Smith, an associate dean at Emory's nursing school, said they accepted Kekula because they were struck by how both she and Emory each treated four Ebola patients at around the same time last year -- and Emory had dozens of doctors and nurses and millions of dollars in technology while Kekula had nobody and nearly no supplies.

"It was obvious to us that this woman was intelligent and strong and fearless," he said. 

Kekula is scheduled to return to Liberia in August. 

"These things that I have learned here I am going to take back to my fellow nurses," she said. "I love to care for people. I love to save lives."

By SYDNEY LUPKIN

abcnews.go.com

The Easter Bunny has some sweet competition in the form of two therapy rabbits at NYU Langone Medical Center in Manhattan.

Nutmeg and Clovis, both 5 years old, live on the 13th floor of the hospital, and this week, they visited patients for Bunny Day, the hospital's nondenominational springtime celebration. They wore rabbit ears (yes, really), a bonnet, and sat on a basket of eggs.

"The bunny cart is decorated to the hilt, and then we'll go and see patients and work with patients," said Gwenn Fried, manager of horticultural therapy services at NYU Langone. "The patients adore it."

As she travels the hospital with one rabbit at a time (Rabbits need breaks, too!), she said she hands patients a plastic Easter egg, and it contains either a sticker or a bunny treat.

"The bunny is very excited about the bunny treat," she laughed.

The bunnies visited 15 patients on Thursday and will visit more today and tomorrow, Fried said.

The rabbits are part of a therapy program that's been at the hospital for about 13 years. Sometimes, doctors recommend the bunny therapy, and sometimes patients request it, but Fried said she's seen them work magic on children and adults alike.

"One dad just said, 'I really think Clovis changed our lives,'" Fried told ABC News last year. "He's the most patient animal I've ever seen in my life."