Category Archives: Patient safety and outcomes
SreyRam Kuy, MD, MHS, is an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, and a vascular surgery fellow at the Medical College of Wisconsin.
Gallbladder disease, and specifically gallstones, can present as pain in the upper abdomen, usually after eating fatty foods. More severely, gallstones can progress to an inflammation and infection called cholecystitis or cholangitis, both of which require prompt surgical treatment. Gallbladder disease is an important medical problem as it accounts for $650 billion in health care costs annually in the United States[i], making it the second most costly digestive disease in the country.[ii] With more than 700,000 cholecystectomies (surgeries to remove the gallbladder) performed annually in the United States, gallbladder disease is the number one reason for abdominal surgery in the nation.[i] Cholecystectomies can be done with traditional surgery (open cholecystectomy) or performed minimally invasively (laparoscopic cholecystectomy).
The National Health and Nutrition Examination Survey estimates 6.3 million men and 14.2 million women in the United States have gallbladder disease.[iii] It occurs two times more frequently in women than in men.[i][iv] However, during the reproductive years, women have a four-fold higher prevalence of gallstones than men.[iii] As a result of its disproportionate burden on women, gallbladder disease is a critically important topic in women’s health.
There is currently a lack of consensus on whether a patient’s gender affects how soon they get surgery for cholecystitis, what type of surgery they get (open versus laparoscopic cholecystectomy), and how they do after surgery. My prior work and that of my colleagues has clearly shown that older age negatively impacts how patients do following cholecystectomy.[v] Therefore, to determine whether gender, independent of other factors, affects outcome, we examined a national group of patients hospitalized with cholecystitis over an eight-year period, age-matched to account for the effect of age, and identified gender-based differences in patients hospitalized with cholecystitis. We measured outcomes of women compared with men who underwent cholecystectomy during that admission for cholecystitis, and identified factors associated with outcome.
Promoting Rigorous Interdisciplinary Research and Building an Evidence Base to Inform Health Care Learning, Practice, and Policy
By Mary D. Naylor, PhD, RN, FAAN, Marian S. Ware Professor in Gerontology, director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, and co-director of the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative. This commentary originally appeared on the Institute of Medicine website.
The Institute of Medicine (IOM) established the Roundtable on Value & Science-Driven Health Care to accelerate the advancement and application of science to achieve the best possible health and health care outcomes and value for Americans. The work of the roundtable is predicated on the notion that our health care system must continuously learn from rigorous evidence in order to innovate and improve. To that end, it acknowledges and promotes the importance of identifying best practices in health and health care, developing and testing innovations, and—most importantly— promoting collaborative efforts.
This vision for improving health and health care is shared by the Robert Wood Johnson Foundation, which funds an innovative and unique initiative to improve patient care by examining the role nurses play in improving care quality: the Interdisciplinary Nursing Quality Research Initiative (INQRI). Mark Pauly of the University of Pennsylvania and I have had the great privilege of serving as co-directors of this program since its inception in 2005.
This is part of the August 2013 issue of Sharing Nursing's Knowledge.
Nurse Manager Turnover Associated with Poorer Patient Outcomes
High turnover among hospital nurse managers can have negative effects on patient outcomes, according to a new study by a group of scholars that includes Robert Wood Johnson Foundation Executive Nurse Fellows alumna Karen Stefaniak, PhD, RN.
Stefaniak and colleagues used 27 months of data from 23 critical care and medical/surgical nursing units in two U.S. hospitals. Of the 23 nursing units in the study, 13 experienced "interim nurse management" during the period of the study, meaning that a nurse manager had recently left and an acting nurse manager was fulfilling his or her duties. Ten of the units had stable management. The data also included information on patient fall rates and pressure ulcer rates; these items were studied because they were deemed to be particularly "nurse-sensitive" indicators.
The results favored nursing units with stable management. Patients in medical/surgical units with nurse manager turnover were more likely to suffer falls, and patients in intensive care units with turnover were more likely to have pressure ulcers.
The authors conclude that nurse manager turnover "may negatively impact patient outcomes." They write: "One reason for this may be because nurse managers enable the flow of information between the broader organization and their patient care areas. When practice changes are made, nurse managers are often the primary conduit to ensure that their staffs are aware of and comply with the practice change. Equally important, when nursing staff develop innovative process improvements, nurse managers often facilitate the spread of the innovation from the nursing unit out to the broader organization."
This is part of the July 2013 issue of Sharing Nursing's Knowledge.
NP-Doctor Co-Management of Geriatric Cases Leads to Improved Outcomes
New research finds that geriatric patients with chronic conditions may have better outcomes if their cases are co-managed by a nurse practitioner (NP) and a physician than by a physician alone.
David Reuben, MD, chief of the Geriatrics Division in the Department of Medicine at the David Geffen School of Medicine at the University of California, Los Angeles, reports on the research leading to that conclusion in the June 2013 issue of the Journal of the American Geriatrics Society. Reuben and colleagues studied the cases of 485 patients who had one of four chronic conditions: falls; urinary incontinence (UI); dementia/Alzheimer's disease; or depression. Some of their cases were managed by doctors alone, and others were co-managed by doctors and NPs.
The researchers then examined individual patients' charts, assessing the quality of their care using several specific quality indicators. They found that patients whose cases were co-managed generally had better care, and significantly better care for some conditions. "Quality scores for all conditions (falls, 80 percent vs. 34 percent; UI, 66 percent vs. 19 percent; dementia, 59 percent vs. 38 percent) except depression (63 percent vs. 60 percent) were higher for individuals who saw a NP," they wrote.
Tracey L. Yap, PhD, RN, CNE, WCC, is an assistant professor at the Duke University School of Nursing, a John A. Hartford Foundation Claire M. Fagin Fellow, and a senior fellow at the Duke University Center for Aging and Human Development. With funding from the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI), Yap and her co-investigators developed a cost-effective, nurse-led intervention that aimed to reduce the prevalence of pressure ulcers in long-term care facilities by increasing resident mobility through a musical prompting system specifically tailored to each facility. This is part of a series of posts for National Nurses Week, highlighting how nurses are driving quality and innovation in patient care.
It started with a boombox and the Byrds.
Those are hardly the first things that come to mind when you think about pressure ulcers, also referred to as bed sores—the wounds that are caused by continuous, unrelieved pressure on the skin and that often develop in people who have impaired mobility. Yet that’s just how my husband, a physician who has a large population of patients in long-term care, inspired this research by suggesting that I pursue a grant related to this serious issue.
At one long-term care facility, my husband had a maintenance person use a boombox over the public address system to play “Turn, Turn, Turn” at two-hour intervals. It was a creative, simple, and fun way to remind staff to move patients, and it appeared to be effective in preventing pressure ulcers.
We were in Kentucky at the time, and I was teaching at the University of Cincinnati College of Nursing. When I took my husband’s suggestion and applied for an INQRI grant, it radically changed my life—and the lives of many long-term care residents—for good. In my PhD studies, I’d focused on occupational health, and the INQRI grant helped me apply that knowledge in a new way and ultimately led to my current work at Duke University.
This is part of the April 2013 issue of Sharing Nursing's Knowledge.
Survey of Nurses: Hospitals’ Patient Safety Programs Lacking
A new survey of hospital nurses in the United States, the United Kingdom, and China finds that nurses lack confidence in their hospitals’ safety programs.
The online survey, conducted by a research firm for the American Nurses Association (ANA) and GE Healthcare, included 500 respondents from the United States and 200 each from the United Kingdom and China. Each country's responses were given equal weight in the final results. Among the findings:
- Ninety-four percent of nurses report that their hospitals have programs in place that promote patient safety, but only 57 percent believe those programs are effective.
- Just 41 percent describe their hospital as “safe.”
- Ninety percent of nurses believe it is important that nurses not be penalized for reporting errors or near misses, but 59 percent agree that nurses often hold back in reporting patient errors in fear of punishment (67 percent in the United States, 62 percent in the United Kingdom, and 49 percent in China). Sixty-two percent agree that nurses often hold back in reporting near misses for the same reason (69 percent in the United States, 65 percent in the United Kingdom, and 54 percent in China).
- Thirty-three percent of nurses said that "poor communication among nurses at handoff" has increased the risk of patient safety incidents in their hospitals in the past 12 months. Thirty-one percent said "poor communication with doctors" has also increased the risk of patient safety incidents.
This is part of the March 2013 issue of Sharing Nursing's Knowledge.
“[W]e continue to be stretched in terms of being able to fill the demand… I know, particularly in the Dayton area, there is a need for mental health nurse practitioners. We have recently partnered with the Veterans Administration to develop a pysch mental health practitioner program that will help meet the need of all our returning veterans, many of whom have depression, post-traumatic stress disorder and other problems related to having served in a particular conflict and who are trying to re-integrate into society.”
-- Rosalie Mainous, PhD, APRN, NNP-BC, dean, School of Nursing, Wright State University and RWJF Executive Nurse Fellow, Wanted: Specialty Nurses, Springfield News-Sun, February 22, 2013
“We need to be keeping more data, recording our expertise and speaking up for ourselves so when people say quality of care, they will also say, quality of nursing.”
-- Susan B. Hassmiller, PhD, RN, FAAN, RWJF senior adviser for nursing, Nurses Need to Pull Up a Seat at the Table, Hassmiller Says, Lund Report, February 20, 2013
The Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI) will host the next webinar in its “Translating Research Into Practice” series on February 14, 2013.
INQRI investigators Linda Flynn, PhD, RN, FAAN, and Joel Cantor, ScD, will discuss their research and the intervention they designed to increase patient safety by enhancing the leadership and team building skills of nurse managers.
The webinar will be held from 3-4 p.m. EST.
Michael D. Cohen, PhD, is the recipient of a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research, and the William D. Hamilton Professor of Complex Systems, Information and Public Policy at the University of Michigan School of Information.
Handoffs are a critical link in maintaining continuity of care during a hospital stay. Whenever there is a shift change, or when a patient moves between departments (such as from an Emergency Room to an inpatient unit), there should be communication between the personnel who have been caring for the patient, and those who are to assume responsibility. These handoffs have to be done effectively. Root cause analyses of sentinel events find communication breakdowns to be major contributing factors nearly two-thirds of the time, and a large fraction of those problems occur during handoffs.
It seems logical that nurses and doctors should receive some training in how to conduct these vital conversations, but in interviews during my research on handoffs, it has been rare to find a practitioner who learned anything in nursing or medical school about how to hand off effectively.
The Robert Wood Johnson Foundation (RWJF) Human Capital Blog is asking diverse experts: What is and isn’t working in health professions education today, and what changes are needed to prepare a high-functioning health and health care workforce that can meet the country’s current and emerging needs? This post is by RWJF Investigator Award in Health Policy Research recipients Robert L. Wears, MD, PhD, a professor in the Department of Emergency Medicine at the University of Florida, and Kathleen M. Sutcliffe, PhD, The Gilbert and Ruth Whitaker Professor of Business Administration at the University of Michigan’s Ross School of Business.
There are many aspects to the problem of what is or is not working in health professionals’ education today, and the changes needed to address them. From our view as researchers studying issues of safety, resilience, and managing for the unexpected, some of the more important are that health professionals’ education is seriously deficient in the social sciences; is limited almost exclusively to largely positivist ideas about what counts as scientific activity; and is almost totally devoid of the humanities.
None of these deficiencies are new, and that is what concerns us. The lack of engagement with the sciences of safety, and of human and organizational performance, has implications for practice, for safety, and for understanding and creating actionable knowledge.
With respect to practice, for example, without sufficient exposure to humanities and social sciences we risk socializing people to become authoritative but inhuman techno-nerds, even if they didn’t start out that way.
With respect to safety, we risk training people in positivistic methods and research approaches that oversimplify and even miss local contextual specifics that create real threats to safety.
With respect to understanding and knowledge creation, we risk training people to revere scientific and technical rationality and ‘objectivity’ at the expense or even denial of any sort of constructivist or interpretive understanding.