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Perioperative areas are the most costly to operate and account for more than 40% of expenses. The high costs prompted one organization to analyze surgical delays through a retrospective review of their new electronic health record. Electronic health records have made it easier to access and aggregate clinical data; 2123 operating room cases were analyzed. Implementing a new electronic health record system is complex; inaccurate data and poor implementation can introduce new problems. Validating the electronic health record development processes determines the ease of use and the user interface, specifically related to user compliance with the intent of the electronic health record development. The revalidation process after implementation determines if the intent of the design was fulfilled and data can be meaningfully used. In this organization, the data fields completed through automation provided quantifiable, meaningful data. However, data fields completed by staff that required subjective decision making resulted in incomplete data nearly 24% of the time. The ease of use was further complicated by 490 permutations (combinations of delay types and reasons) that were built into the electronic health record. Operating room delay themes emerged notwithstanding the significant complexity of the electronic health record build; however, improved accuracy could improve meaningful data collection and a more accurate root cause analysis of operating room delays. Accurate and meaningful use of data affords a more reliable approach in quality, safety, and cost-effective initiatives.

The purpose of this quality improvement project was to implement and evaluate a care delivery model integrating the registered nurse care coordinator (RNCC) into a family practice that is certified as a patient-centered medical home (PCMH) by the National Committee for Quality Assurance. The initial target population was the 937 patients with diabetes in the family practice. A pre-post design was used to assess changes in patients' diabetic quality indicators after integrating the role of RNCC using existing staff. This 6-month project compared the following diabetic quality indicators: blood pressure < 140/90 mm Hg, hemoglobin A1c ≤ 7, low-density lipoprotein cholesterol < 100 mg/dL, documentation of smoking cessation counseling, and aspirin prescription if existing vascular disease. Yearly documentation of microalbuminurea level, and filament foot and retinal examination was assessed. Patient and health care team satisfaction also was measured. Care coordination interventions included: telehealth, group visits, standardized individual patient education, as well as creative uses of the electronic medical record for workflow changes, daily huddles, and monthly meetings. The results were positive, statistically significant differences in the pre and post scores for A1c (P = .001, n = 790), foot exam (P = .001, n = 850), and microalbumin (P = .01, n = 850). Post intervention, patient and health care team satisfaction with the RNCC role was high (mean scores ≥3 on a 5-point Likert scale). Integrating the RNCC within a multidisciplinary team in the PCMH had a significant positive impact on diabetic quality indicators. Patient and health care team satisfaction with the RNCC role was high.

While preparing medications in complex health care environments, nurses are frequently distracted or interrupted, which can lead to medication errors that may adversely affect patient outcomes. This pilot quality improvement project, which took place in a 32-bed surgical progressive care unit in an academic medical center, implemented five medication safety interventions designed to decrease distractions and interruptions during medication preparation: nursing staff education, use of a medication safety vest, delineation of a no-interruption zone, signage, and a card instructing nurses how to respond to interruptions. Four types of distractions and interruptions decreased significantly between the two-month preimplementation and two-month postimplementation periods: those caused by a physician, NP, or physician assistant; those caused by other personnel; phone calls and pages placed or received by the nurse during medication administration; and conversation unrelated to medication administration that involved the nurse or loud nearby conversation that distracted the nurse. The total number of reported adverse drug events also decreased from 10 to four, or by 60%. Thus, medication safety interventions may help decrease distractions and interruptions in high-acuity settings.

The Care Journal is a tool developed by the Josie King Foundation to promote interactive exchange among providers and patients/families. The Care Journal was implemented in a pediatric intensive care unit, and surveys were administered to assess perceptions about use. Parents who used the Care Journal and nursing staff found it to be a useful tool that improved communication, made parents feel more knowledgeable and empowered, and improved parents' overall perception of the hospital stay.

This implementation of a formalized safety program in a critical care unit highlights the importance of the "voice of the caregiver," as it relates to patient safety. This nurse-led program featured executive walkrounds and a multidisciplinary core team whose goal was to prioritize and resolve safety issues identified during the 6-month study period. Unit nurses' scores on the Safety Attitudes Questionnaire remained stable from July 2011 to February 2012. Staff identified 77 safety issues during executive walkrounds; 57% were resolved during the study period. Results indicate the clinical significance of nurse-led patient safety programs.

In an effort to reduce costs, many hospitals may use registered nurses (RNs) with little to no formal education or training in anesthetic or surgical risk to perform anesthesia preoperative interviews (APIs). This lack of education and training can result in day of surgery delays and cancellations because of suboptimal preparation of patients for anesthesia and surgery. The Focused Anesthesia Interview Resource (FAIR) establishes minimum educational preparation for conducting APIs through educational modules and electronic triggers that prompt further questions and consultation flags or comorbidities for which an anesthesia provider is consulted. The goal of this process improvement project was to determine if fidelity to the FAIR tool enhanced the ability of RNs to perform preoperative anesthesia interviews and, if so, did this result in decreased surgical cancellations and delays? Retrospectively, we assessed completion rates of the training modules and anesthesia preoperative records as well as day of surgery cancellation and delay rates before and after the implementation of the FAIR tool. All RNs who might rotate to the API clinic (n=33) were included in the sample. Nurse fidelity to completion of the training modules was high (91%). Five hundred anesthesia interview records were randomly selected, reviewed, and completion rates scored. Our pre-/post-quasi-experimental design compared record completion rates. After the implementation of FAIR, significant improvement in identification of patients with hypertension (P<.01) and cardiac disease (P<.05) was noted. In addition, cancellation rates declined from 3.33% to 2.31% (P<.05) and first case delays decreased from 7.54% to 6.99%, although this was not statistically significant. FAIR improved preoperative record completion rates and decreased surgical cancellations, which improved perioperative quality and efficiency., (Copyright © 2012 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.)

Racial and income disparities persist in diabetes management in America. One third of African and Hispanic Americans with diabetes receive the recommended diabetes services (hemoglobin A1c [A1c] testing, retinal and foot examinations) shown to reduce diabetes complications and mortality, compared to half of whites with diabetes. National data for Asian Americans are limited, but studies suggest that those with language and cultural barriers have difficulty accessing health services. A diabetic registry has been shown to improve process and clinical outcomes in a population with diabetes. This study examined whether a community center that serves primarily low-income Asian American immigrants in Santa Clara County, California, could improve diabetes care and outcomes by implementing a diabetic registry. The registry was built using the Access 2007 software program. A total of 580 patients with diabetes were identified by reviewing charts, the appointment database, and reimbursement records from Medicaid, Medicare, and private insurance companies. Utilizing the registry, medical assistants contacted patients for follow-up appointments, and medical providers checked and tracked the patients' A1c results. Among the 431 patients who returned for treatment, the mean A1c was reduced from 7.27% to 6.97% over 8 months (P<0.001). Although 10.8% of the patients changed from controlled to uncontrolled diabetes post intervention, 32.6% of patients with uncontrolled diabetes converted to controlled diabetes (P<0.001). The diabetes control rate improved from 47% to 59% at the end of the study. This study demonstrated that a diabetic registry is an effective tool to manage an underserved population with diabetes, thereby reducing disparities in diabetes management.

Partnering with families to deliver safe care includes teaching how to activate the rapid response team (RRT) if their hospitalized child's condition worsens. Condition Help (Condition H) is how families call the RRT. Pediatric nurses used scripted Condition H teaching and follow-up surveys to evaluate family understanding about Condition H. Although there were only 2 Condition H calls during the study period, 53% to 90% of families received Condition H teaching, and family understanding was greater than 75%.

Poor understanding of factors influencing integration of new practices into long-term care (LTC) hinders timely implementation of evidence-based practices (EBPs). Using the Diffusion of Innovations (DOI) framework, a new instrument measuring staff perceptions of an EBP was developed as part of a DOI-LTC measurement battery and tested in a cross-sectional survey of North Carolina LTC nursing personnel. Valid questionnaires were received from 95 licensed nurses and 102 certified nursing assistants (CNAs). Internal consistency reliability for five of seven subscales was acceptable (Cronbach's alpha coefficient = 0.77 to 0.95). Perception of innovation attributes was associated with intention to adopt the new practice (Spearman rho correlation: licensed nurses = 0.41 to 0.68, p < 0.0001; CNAs = 0.26 to 0.54, p = 0.05 to <0.0001). The DOI-LTC measurement battery represents a promising new approach to studying implementation of EBPs in LTC. Future work should examine its responsiveness to interventions that facilitate implementation of EBPs in LTC., (Copyright 2012, SLACK Incorporated.)

An implementation project was conducted to introduce a structure for telehealth nursing practice (TNP) which would address the specific needs of complex endocrinology patients in a hospital-based clinic. Outcomes of the pilot study include analysis of 727 advice calls, survey responses from a sample of 101 patients, and feedback from 9 providers. Results support current evidence that disease management needs of chronically ill patients include prescription refills, medication and symptom management, lab results, and patient education. 81.2% of patients rated satisfaction with telehealth nursing services as very high or high. A statistically significant relationship was found between timeliness of response and patient satisfaction. A focus on care coordination provided through telehealth nursing services may emerge as an important element in the care of chronically ill patient populations.

Catheter-associated urinary tract infections account for 40% of all health care-associated infections. An evidence-based, nurse-driven daily checklist for initiation and continuance of urinary catheters was implemented in 5 adult intensive care units. Measures of compliance, provider satisfaction, and clinical outcomes were recorded. Compliance with the checklist was 50 to 100%: catheter-associated urinary tract infections decreased from 2.88 to 1.46 per 1000 catheter days and catheter days decreased in 2 intensive care units.

Academic medical centers (AMCs) have traditionally provided primary care for low-income and other underserved populations. However, they have had difficulty developing lasting partnerships with other organizations serving the same populations. This article describes an exception to the rule, in which an academic division was created at Duke University Medical Center to develop effective collaborations with health care and social service providers in Durham, North Carolina, including both public agencies and private organizations. Together, the division and its partners have created and operate programs that improve health outcomes and access to care for those at risk. These programs share a number of characteristics: they are designed to meet the needs of the patient, not the provider; they are based in the community, not in the AMC; they bring services to people's homes, schools, and neighborhoods; they are multidisciplinary, combining health, social, and even mental health services; and, once established, they are revenue-generating and can be made self-supporting when grant funding ends. These programs are also innovative. They are designed to model and test new ways of organizing and delivering care. Preliminary indications suggest that they also strengthen the AMC's relationships with the surrounding community.

For over 20 years, nursing literature has discussed the gap between the conduct of research and the use of its findings to improve practice. Factors relating to the nurse, the setting, the research, and the way research is presented have been identified as barriers to research utilization. A combined approach that includes specialty organizations that take the lead in knowledge synthesis and dissemination, the creation of national on-line databases, and enhanced institutional supports and educational efforts is recommended.

Barriers to the use of research in practice include problems with the availability of research, the manner in which it is presented, and the use of the research. They also include barriers in the setting and "shortcomings" of individual nurses. Most approaches to increasing research utilization have focused on the "shortcomings" of clinicians. A more useful approach is to make changes in both education and practice to rejoin researchers and clinicians and to reconnect the conduct and use of research.

This article describes a learning module for teaching heart sound recognition and summarizes results of two studies testing the learning module. The module, built around a heart sound simulator, was effective with both graduate nursing students (n = 37) and experienced critical care nurses (n = 40). In each study, recognition of heart sounds improved significantly, and the knowledge gained was retained for at least 2 weeks.

Forty critical care nurses participated in a 2-hour teaching program using a heart sound simulator to increase skill in recognition of heart sounds. Mean test scores increased 10 points from the pretest to the first posttest (t = 11.9, p = 0.0001), and this increase was maintained on the second posttest 3 weeks later. Medical intensive care unit and coronary care nurses scored higher than the other critical care nurses. There was a low correlation between recognition of sounds and years of critical care experience. The correlation between the subjects' self-rating of knowledge of heart sounds and their actual skills was also low. These findings suggest that a similar teaching program might be useful for critical care nurses.

Optimal recovery of the critically ill elderly patient depends on an adequate nutritional state. Preventing and treating malnutrition is fundamental to the provision of good patient care, yet providing nutritional support to the critically ill elderly is challenging. Health care has not reached the state of sophistication in which a few simple rules suffice. Many of the current assessment techniques, diagnostic standards, and guides for intervention are based on studies of the young and middle aged. As the critically ill elderly population continues to grow, more specific assessment parameters need to be identified so that the elderly person's response to different nutritional therapies will be understood better. Carefully documented and published case studies will enrich the understanding of nutritional support in this vulnerable group of patients.

The use of a heart sound simulator in teaching recognition of heart sounds was tested in 37 graduate students. Subjects were randomly divided into two groups; one group received both auditory and tactile cues and the other group received only auditory cues. Students were tested at three times: (1) before use of the simulator, (2) after a short teaching session using the simulator, and (3) 2 weeks later. Recognition of heart sounds increased significantly after the teaching session with the simulator, and this knowledge was retained. There was no difference in sound recognition between the two groups.