The impact of a high dependency unit continuing education program on nursing practice and patient outcomes

Most evaluation studies of continuing education (CE) programs have concentrated on the assessment of learner knowledge and satisfaction and/or learner perceptions of change in professional competence and patient care, rather than on actual changes in nursing practice and patient outcomes. This study aimed to measure and compare frequency of nursing interventions and patient outcomes before and after a high-dependency (HD) CE program. A retrospective review of all HD patient records (n = 92) over the same 2-month periods in 1994 (n = 39) and 1995 (n = 53) was undertaken. Outcome variables were measured by assessing the incidence of cardiorespiratory complications, HD patient admission rates to critical care areas and process measures of nursing interventions with predetermined practice patterns. The before and after groups of patients were similar in age (mean 69 years), severity of illness (mean APACHE II = .12) and HD length of stay (mean 2.6 days). While the average number of critical events per patient was similar in both groups (before 2.03; after 1.96), complications resulting from critical events were 8 per cent fewer in the after group. The implementation and documentation of appropriate nursing interventions improved by 30 per cent following the introduction of the CE program (chi 2 = 25.53, df = 1, p < 0.001, 95 per cent CI 0.1804 to 0.4196, point estimate 0.3). The study revealed that there was a strong association between implementing the HD CE program and improved nursing practice. This may be related to the observed improvement in patient outcomes.     

The impact of a high-dependency unit on the workload of an intensive care unit

While there has been recent support for high-dependency unit development, there are few data reporting the impact of such development on existing critical care facilities. Therefore the aim of this study was to examine the workload and capacity constraints of an adult general intensive care unit before and after the development of an adjacent high-dependency unit. Following the opening of the high-dependency unit, the total number of patients admitted increased by 49%. On the high-dependency unit, more elderly patients were admitted for longer and more frequently following midweek elective surgery. On the intensive care unit, patients' initial severity of illness was lower and their duration of admission decreased; fewer patients were admitted directly from the general wards. The financial benefits of high dependency care may be eroded by the increased use of the critical care services.     

Intermediate care, possibilities, requirements and solutions

The inadequate supply of intensive care facilities has focused interest on intermediate care as a means of bridging the gulf between the level of support available in the intensive care unit and the general ward. However, few hospitals have developed intermediate care, in the form of high-dependency care units, and little information exists concerning the use or potential of such areas. Therefore, this review proposes to cover the definition of intermediate care and to discuss some of the possible reasons why intermediate care is now believed necessary. The capabilities of intermediate care for selected groups of patients and the treatment modalities offered are described. The present provision of high-dependency care in the United Kingdom is discussed and the methods for estimating the required size of a high-dependency unit are outlined. The impact of a high-dependency unit on the workload of the intensive care unit and the potential cost saving of managing such patients in an intermediate care area are illustrated.     

The intermediate care unit as a cost-effective option for the treatment of medical patients in critical condition

Since the limited accessibility of general intensive care units creates a situation in which medical patients in critical condition continue to be cared for in the regular wards, we conducted a retrospective cohort study to assess the treatment outcomes in such patients referred to the medical intermediate care unit (MICU). At the Soroka Medical Center, a facility with 810 beds, of which 170 beds are in medical wards, including an 8-bed intensive cardiac care unit and a 5-bed general intensive care unit, 119 patients were referred to the MICU, directly from the emergency room or from medical wards, during the first half of 1994. Eighty percent of the patients were admitted to the MICU directly from the emergency room. The mean disease severity, as measured by the APACHE II score, was 12.9, and the mean intensity of care for these patients, as measured by the TISS scale, was 12.6. Twenty-one of the 119 patients died during hospitalization (17.6%). This mortality rate conformed to the mortality risk of 15.5%, which was calculated using prognostic formulae. The ratio of nursing staff to patient in the MICU was approximately 1:3, compared to 2:3 in the general intensive care unit and 1:12 in the wards. The mean cost of one day of hospitalization in the MICU was one-third that in the general intensive care unit and double the cost in a ward. Medical patients in critical condition can be treated in an MICU, with a savings in expenses and without impairing the patient's chances for survival.     

Developing a CQI program in a family medicine department

BACKGROUND: Efforts to implement continuous quality improvement (CQI) principles in ambulatory or primary care settings still lag behind efforts in the hospital setting. Many physicians view the concept of CQI with unconcealed skepticism; the process of ambulatory care is very different from that of hospital-based care; and the data necessary to guide CQI efforts are often either missing or inaccurate in the outpatient setting. Since fall 1995, the Department of Family Medicine (DFM) at the University of Michigan (Ann Arbor), including approximately 35 faculty members at seven family practice sites, has been engaged in CQI projects. PLANNING AND IMPLEMENTATION: The CQI committee had a six-month deadline to lay out a plan for educating all faculty and staff in the importance of the CQI approach to problems; design methods for all faculty and staff to buy in to the concepts; and develop a plan to address basic clinical CQI activities, administrative systems change and work environment improvement, and larger ad hoc projects in clinical care, educational programs, and research programs. IMPLEMENTATION: CQI activities were incorporated into the routine monthly business agendas at each clinical site, each of which had a functioning local committee and had begun development of at least one CQI project. PROJECTING INTO THE FUTURE AND CONCLUSIONS: Cost cutting has further moved CQI from the sideline to center stage in the DFM's activities. An effective CQI program can be a major asset in the current competitive health care market, but designing and implementing an outpatient CQI program is a difficult and complex process. Three major problems--the ongoing resistance to change, the slow pace of adding CQI projects to already overburdened work schedules, and the need to conduct the program with ever-decreasing resources available-persist.     

The cost of caring for end-stage kidney disease patients: an analysis based on hospital financial transaction records

The costs of care for end-stage renal disease patients continue to rise because of increased numbers of patients. Efforts to contain these costs have focused on the development of capitated payment schemes, in which all costs for the care of these patients are covered in a single payment. To determine the effect of a capitated reimbursement scheme on care of dialysis patients (both hemodialysis [HD] and peritoneal dialysis [PD]), complete financial records (all reimbursements for inpatient and outpatient care, as well as physician collections) of dialysis patients at a single medical center over 1 year were analyzed. For the period from July 1994 to July 1995, annualized cost per dialysis patient-year averaged $63,340, or 9.8% higher than the corrected estimate from the U.S. Renal Data Service (USRDS; $57,660). The "most expensive" 25% of patients engendered 44 to 48% of the total costs, and inpatient costs accounted for 37 to 40% of total costs. Nearly half of the inpatient costs resulted from only two categories (room charges and inpatient dialysis), whereas other categories each made up a small fraction of the inpatient costs. PD patients were far less expensive to care for than HD patients, due to reduced hospital days and lower cost of outpatient dialysis. Care for a university-based dialysis population was only slightly more expensive than estimates predicted from the USRDS. These results validate the USRDS spending data and suggest that they can be used effectively for setting capitated rates. Efforts to control costs without sacrificing quality of care must center on reducing inpatient costs, particularly room charges and the cost of inpatient dialysis.     

Reperfusion injury delays healing of intestinal anastomosis in a rat

This SAEM position paper clarifies the role of emergency medicine in health care delivery. It builds upon the working definition of emergency medicine developed by the American College of Emergency Physicians in 1994 by describing the health care role of emergency physicians (EPs). EPs are first-contact providers who care for all patients regardless of age, gender, time of presentation, or ability to pay. They remain the only continuously accessible specialty for patients seeking help and solace in the health care system. They are an essential link in the health care continuum between primary care physicians, specialists, the out-of-hospital system, the patient, inpatient services, and communication services. The EP's role is in organizing and monitoring the emergency care delivery system. Part of this role is to better align the health care provider training and ability with the specific medical needs of a patient. The emergency health care system remains the essential medical safety net for all individuals needing care in this country.     

Increasing clinical prevention efforts in a family practice residency program through CQI methods

BACKGROUND: As primary care physicians develop ongoing relationships with their patients, each contact provides another opportunity for primary, secondary, or tertiary prevention activities. In 1991 an interdisciplinary prevention project team using continuous quality improvement (CQI) principles was established to improve family practice residents' provision of such services. DIAGNOSTIC JOURNEY: For a random sample of 60 patient charts, abstractors looked for documentation of 23 clinical preventive services, including nursing screens, physician on-site and off-site implemented services, lifestyle education (diet, tobacco use), and self-screening education. After the chart review, the physicians, nurses, residents, and clinical staff used a fishbone analysis to identify physician-, clinic system-, and patient-centered factors contributing to the lack of conformance with clinical prevention guidelines. REMADIAL JOURNEY: The residency program began a series of didactic sessions on clinical prevention and instituted a procedures rotation to teach prevention procedure skills such as flexible sigmoidoscopy, stress testing, and colposcopy. On the CQI team's recommendation, a checklist developed by physicians and staff which itemized age- and gender-specific clinical prevention services was placed at the front of all patient charts. Clinic-system and patient factors were also addressed. HOLDING THE GAINS--MONITORING PERFORMANCE: The 1993 postintervention chart review showed significant improvements for 17 (81%) of the 21 targeted services. DISCUSSION: Providing educational sessions on prevention, permitting residents to select the areas of prevention on which to focus, and giving feedback on resident and staff performance through ongoing, nonpunitive monitoring resulted in increased provision of clinical prevention services in a family practice residency training center.     

Integrating feminist theory and women''s studies into the women''s health nursing curriculum: special topics in women''s health

The elements of the Nursing Minimum Data Set (NMDS) were collected manually from 188 medical records in eight acute care facilities. These eight facilities represent 54 per cent of the beds in South Dakota. The purpose of the study was to describe discharge destination, nursing diagnoses, nursing interventions, and nursing resource utilization for patients with fractured femur with pinning. The sample was primarily female (69.1 per cent), with a mean age of 78.5 years. Most (84.0 per cent) patients were transferred to another facility, with 46.2 per cent going to extended care facilities. The most frequent nursing diagnoses were comfort (89.9 per cent) and physical mobility (59.6 per cent). Interventions were classified using the 16-category classification scheme developed by Werley and Lang. The most frequently recorded types of interventions were in the category of monitoring and/or surveillance (16.7 per cent of 7,555 interventions), whereas emotional support and/or counseling was much less frequent (3.0 per cent of 7,555). Discharge planning was the most frequent nursing intervention in the category of coordination and collaboration of care (54.8 per cent of 188 patients). Documentation systems have been structured to accommodate technical tasks on flow sheets, for example. Nursing resource utilization was the most difficult, and also presently the least meaningful, NMDS element to collect because each facility has different staffing, different patient classification systems, and no prescribed method for collecting these data. Manual data collection is time-consuming and expensive and therefore not recommended.     

Teaching medical faculty how to apply continuous quality improvement to medical education

BACKGROUND: An eight-hour workshop was conducted at a professional meeting in 1996 to introduce medical faculty to the principles of continuous quality improvement (CQI) as they relate to change in medical education and to provide participants with opportunities to use specific tools for applications to education. Four two-hour sessions focused on an introduction to CQI, understanding and mapping processes, identifying change ideas, and testing a change for improvement. TESTING A CHANGE FOR IMPROVEMENT: The goals of the final session were to plan a pilot test of an improvement, identify the steps of the plan-do-study-act (PDSA) cycle, and consider change for improvement in the context of one's own organization. Working in small groups, participants chose a specific change one might try in the following example: improving student performance in a neuroscience course. POSTSESSION EVALUATION AND FOLLOW-UP: Immediately following the workshop sessions, participants represented by administrators in medical education and clinical and basic science teaching faculty completed evaluations on the usefulness and likelihood of their using CQI tools. One year later, of the 32 workshop registrants who were mailed surveys, 15 respondents rated their change in understanding of CQI and their use of CQI techniques. More than 60% of the respondents reported application of CQI principles at their organizations. CQI methods used most frequently included structured team meetings, prioritizing opportunities, and brainstorming. CONCLUSION: The significant application of CQI principles and methods reported by participants one year after a brief intervention supports a need and utility for CQI principles and tools in medical education.     

Medical scheme expenditure on dental care--a smaller slice of the pie

Medical schemes play an important part in financing dental care in the private sector and provide many dental practitioners with a substantial source of income. Data on medical scheme expenditure indicates a steady decline in their proportional pay-out for dental care during the period 1985 to 1994. In 1985 more than 12 per cent of total medical scheme expenditure was spent on dental care. In 1994 this had reduced to 8.37 per cent. In the present study, the historical trend (1985-1994) of medical scheme expenditure on dental care is analysed. By using the least squares method, the annual medical scheme expenditure on dental care is computed for the next eleven years (1995-2005). If the secular trend continues, less than 4 per cent of medical scheme expenditure will be paid for dental care by the year 2005.     

CQI and anemia management: maximizing positive outcomes. Case study of the anemic patient

Quality improvement techniques provide a scientific approach that allows nurses and other health care professionals to improve patient satisfaction and outcomes. Continuous quality improvement (CQI) encourages the health care team to move beyond minimum standards of care and create an environment in which all team members are continuously working to improve services. This article reviews the principles of CQI and discusses the nurses' role in implementing and maintaining a successful CQI program. Anemia management is used as an example to illustrate how CQI principles and tools can lead to improvements in patient outcomes.     

Understanding Huntington's disease: an overview of symptomatology and nursing care. Nurses must balance safety, quality-of-life issues, the need for personal choice, and the meaning of human dignity when caring for patients with Huntington's disease

Patients and families who have been affected by HD deserve high-quality and dignified nursing care. The complexity and extent of losses and uncertainties imposed by this illness challenge nursing. We have briefly reviewed the current state of knowledge regarding the illness and the nursing interventions appropriate for working with people with HD. What is missing is an empirically validated body of interventions to guide nursing practice. Nursing research is needed to validate existing care practices, generate new interventions, and to begin to build theoretical explanations that assist nurses in providing care to people with Huntington's disease.     

Satisfaction with inpatient acquired immunodeficiency syndrome care. A national comparison of dedicated and scattered-bed units

OBJECTIVES: This study sought to determine whether there were differences in acquired immunodeficiency syndrome (AIDS) patients' satisfaction with inpatient nursing care on dedicated AIDS units compared with conventional, multidiagnosis medical units. METHODS: Interview data were collected from more than 600 consecutive AIDS admissions in 40 patient care units in 20 hospitals in 11 high AIDS incidence cities. Ten hospitals with dedicated AIDS units were matched with comparable hospitals treating AIDS patients on multidiagnosis medical units. AIDS patients' satisfaction with nursing care on dedicated AIDS units was compared with AIDS patients' satisfaction with care on scattered-bed units in the same hospital and with AIDS patients' satisfaction on scattered-bed units in different, matched hospitals without dedicated units. Interhospital differences that were not controlled by design were controlled statistically, as were differences in patient characteristics and illness severity. RESULTS: Acquired immunodeficiency syndrome patients receiving care on dedicated AIDS units were significantly more satisfied with their nursing care. In hospitals with units of both types, dedicated AIDS units had a higher proportion of white patients, men, and homosexuals, whereas scattered-bed units had more minority patients and intravenous drug users. Controlling for these factors as well as for differences in illness severity and interhospital differences in patient satisfaction did not diminish the positive AIDS unit effect on patient satisfaction. CONCLUSIONS: Dedicated AIDS units achieve higher levels of satisfaction among patients with AIDS than general medical units. There is no evidence that patients feel isolated or stigmatized on dedicated AIDS units compared with patients on general units, and many patients have a clear preference for dedicated units.     

The clinical relevance of the Waterlow pressure sore risk scale in the ICU

OBJECTIVE: To evaluate whether the Waterlow pressure sore risk (PSR) scale has prognostic significance for intensive care patients. DESIGN: A prospective study. SETTING: The surgical intensive care unit (ICU) of the University Hospital Rotterdam. PATIENTS: Data were evaluated from 594 patients who had been admitted to the ICU during the year 1994. METHODS AND RESULTS: Each patient was assessed daily with respect to their Waterlow PSR score and the development of pressure sores in the sacral region. Actuarial statistical methods were used to analyse the predictive value of the risk score. When a patient had a Waterlow PSR score > 25 on admission, the risk of developing a pressure sore was significantly increased compared to patients with a PSR score < 25. After admission, the daily Waterlow PSR scores obtained were significantly associated with the risk of developing a pressure sore. For each additional point this risk increased by 23% (95% confidence interval 17 to 28%). CONCLUSIONS: The Waterlow PSR scale provides the medical and nursing staff at an early stage with reliable information about the risk patients have in developing a pressure sore.     

The validity of a nursing assessment and monitoring of signs and symptoms scale in ICU and non-ICU patients

PURPOSE: This study examined the validity of medical-record-based nursing assessment and monitoring of signs and symptoms (nursing surveillance) in predicting patients who were admitted to ICUs and those admitted to non-ICUs. The association of this assessment and monitoring with differences in an intermediate patient outcome, instability at discharge, was also explored. Patients admitted to either setting with a diagnosis of acute myocardial infarction, cerebrovascular accident, congestive heart failure, or pneumonia, were included in the study. METHOD: A secondary analysis was carried out using a subset of data originally collected for a quality-of-care study. Data from the medical records of 11,246 patients (52% female, 48% male) with a mean age of 76.4 years were used in the present study. RESULTS: ICU patients (n = 3969) were found to have a longer length of stay and to be sicker on admission than non-ICU patients (n = 7277). Overall, patients in the ICU received significantly higher nursing assessment and monitoring of signs and symptoms scores than non-ICU patients. Nursing assessment and monitoring of signs and symptoms scores were lower for patients discharged with greater instability for three of the four diseases (cerebrovascular accidents, congestive heart failure, and pneumonia).     

Comparison of long-term care in an acute care institution and in a long-term care institution

BACKGROUND: Acute care hospitals in Quebec are required to reserve 10% of their beds for patients receiving long-term care while awaiting transfer to a long-term care facility. It is widely believed that this is inefficient because it is more costly to provide long-term care in an acute care hospital than in one dedicated to long-term care. The purpose of this study was to compare the quality and cost of long-term care in an acute care hospital and in a long-term care facility. METHODS: A concurrent cross-sectional study was conducted of 101 patients at the acute care hospital and 102 patients at the long-term care hospital. The 2 groups were closely matched in terms of age, sex, nursing care requirements and major diagnoses. Several indicators were used to assess the quality of care: the number of medical specialist consultations, drugs, biochemical tests and radiographic examinations; the number of adverse events (reportable incidents, nosocomial infections and pressure ulcers); and anthropometric and biochemical indicators of nutritional status. Costs were determined for nursing personnel, drugs and biochemical tests. A longitudinal study was conducted of 45 patients who had been receiving long-term care at the acute care hospital for at least 5 months and were then transferred to the long-term care facility where they remained for at least 6 months. For each patient, the number of adverse events, the number of medical specialist consultations and the changes in activities of daily living status were assessed at the 2 institutions. RESULTS: In the concurrent study, no differences in the number of adverse events were observed; however, patients at the acute care hospital received more drugs (5.9 v. 4.7 for each patient, p < 0.01) and underwent more tests (299 v. 79 laboratory units/year for each patient, p < 0.001) and radiographic examinations (64 v. 46 per 1000 patient-weeks, p < 0.05). At both institutions, 36% of the patients showed anthropometric and biochemical evidence of protein-calorie undernutrition; 28% at the acute care hospital and 27% at the long-term care hospital had low serum iron and low transferrin saturation, compatible with iron deficiency. The longitudinal study showed that there were more consultations (61 v. 37 per 1000 patient-weeks, p < 0.02) and fewer pressure ulcers (18 v. 34 per 1000 patient-weeks, p < 0.05) at the acute care hospital than at the long-term care facility; other measures did not differ. The cost per patient-year was $7580 higher at the acute care hospital, attributable to the higher cost of drugs ($42), the greater use of laboratory tests ($189) and, primarily, the higher cost of nursing ($7349). For patients requiring 3.00 nursing hours/day, the acute care hospital provided more hours than the long-term care facility (3.59 v. 3.03 hours), with a higher percentage of hours from professional nurses rather than auxiliary nurses or nursing aides (62% v. 28%). The nurse staffing pattern at the acute care hospital was characteristic of university-affiliated acute care hospitals. INTERPRETATION: The long-term care provided in the acute care hospital involved a more interventionist medical approach and greater use of professional nurses (at a significantly higher cost) but without any overall difference in the quality of care.     

Organizational stages and processes of change for continuous quality improvement in health care.

This article provides an overview of the transtheoretical model of change (TTM, or stage model) and how it can guide the development of stage-matched interventions to increase physicians' readiness for continuous quality improvement (CQI) in health care. In addition, this article describes the development and initial validation of two TTM measures—stages and processes of change—designed to assess the extent to which hospitals are engaging in activities that can facilitate individual providers' movement through the stages of change for CQI. 299 Ss participated in the study. A majority (57%) of informants reported that their organizations were in the maintenance stage for CQI. Organizational-level processes of change differed significantly across the stages: Hospitals in the precontemplation stage tended to use the processes least, and hospitals in the maintenance stage tended to use them most. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A collaborative approach to standards, practices. Setting the stage for continuous quality improvement

In retrospect, the most important thing we did was work together. We analyzed, refined, and validated our philosophical approach to patient care. We provided an information data base that is readily available for on-the-job reference and serves as a starting point for CQI activities. The very act of joint documentation of practices encourages open discussions about improvements to patient care. One physician states, We know that flaws in the process through which we produce care are everywhere--waste, duplication of effort, unnecessary complexity, and unpredictability . . . I believe that modern total quality management offers enormous hope to a medical care field that is rather desperate. . . . Collaborative practice and CQI activities are one hope. The scope of what nurses and physicians traditionally consider when discussing standards and practices must widen. We should no longer look only at patient care. We must simultaneously focus on how the management of total systems influences quality care for all patients. The CQI process, a proactive method, requires an accurate data base of information that is easily retrieved when looking for systems and individual patient care improvements. Our Computerized Collaborative Standards and Practices Manual is the reservoir for documenting practice plans developed and approved by all the disciplines involved. The process described here began with two closely knit operating room disciplines; this framework, however, offers the potential for expansion into a hospital-wide system of information organization and use.