RESUMEN
PURPOSE: The purpose of this quality improvement (QI) project was to develop and implement an interactive, evidence-based pressure injury (PI) education program and evaluate the impact on frontline hospice nursing staff knowledge and practice. PARTICIPANTS AND SETTING: The QI setting was a 12-bed inpatient hospice unit in a tertiary care Veterans Affairs (VA) Medical Center in Cleveland, Ohio. Nineteen licensed and unlicensed hospice nursing staff participated in this pre-/postworkshop project. APPROACH: Chart audit determined baseline PI incidence and prevalence on the inpatient hospice unit. Interviews with key leaders informed the need to develop and implement innovative PI education opportunities. A literature review determined existing standards regarding the benefits of PI education for nursing staff but did not reveal measurable targets in hospice settings. We developed a PI education intervention based on Kolcaba's Theory of Comfort framework and a Plan-Do-Study-Act (PDSA) performance improvement model. Education was delivered in 7 workshops, lasting 2 hours each. Knowledge, practice, and comfort for inpatient hospice nursing staff were evaluated at baseline and 8 weeks following the final refresher visit. Workshop satisfaction was collected once using standard program evaluation forms after final workshop delivery. OUTCOMES: We observed a significant improvement in staff PI knowledge (P = .001) and practice (P = .001) after initial workshop attendance and repeat engagement (P = .001). There was a large magnitude of effect for overall knowledge change (d = 1.04); similarly PI care planning and practice showed a large magnitude of effect and significant improvement (P = .001, d = 2.64). Staff comfort with job duties was stable with low effect size (mean 4.52, d = 0.04), and satisfaction with the workshop education was high (100% agreement with trainer effectiveness). IMPLICATIONS FOR PRACTICE: We found that frontline hospice nursing staff knowledge and practice improved after attendance at our evidence-based PI education program. Results of this QI project have stimulated ongoing discussion on how to sustain this program in our hospice setting.
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Enfermería de Cuidados Paliativos al Final de la Vida , Personal de Enfermería , Entrenamiento Simulado , Humanos , Conocimiento , Mejoramiento de la Calidad , Úlcera por PresiónRESUMEN
BACKGROUND: Pressure injuries (PrI) are serious complications for many with spinal cord injury (SCI), significantly burdening health care systems, in particular the Veterans Health Administration. Clinical practice guidelines (CPG) provide recommendations. However, many risk factors span multiple domains. Effective prioritization of CPG recommendations has been identified as a need. Bioinformatics facilitates clinical decision support for complex challenges. The Veteran's Administration Informatics and Computing Infrastructure provides access to electronic health record (EHR) data for all Veterans Health Administration health care encounters. The overall study objective was to expand our prototype structural model of environmental, social, and clinical factors and develop the foundation for resource which will provide weighted systemic insight into PrI risk in veterans with SCI. METHODS: The SCI PrI Resource (SCI-PIR) includes three integrated modules: (1) the SCIPUDSphere multidomain database of veterans' EHR data extracted from October 2010 to September 2015 for ICD-9-CM coding consistency together with tissue health profiles, (2) the Spinal Cord Injury Pressure Ulcer and Deep Tissue Injury Ontology (SCIPUDO) developed from the cohort's free text clinical note (Text Integration Utility) notes, and (3) the clinical user interface for direct SCI-PIR query. RESULTS: The SCI-PIR contains relevant EHR data for a study cohort of 36,626 veterans with SCI, representing 10% to 14% of the U.S. population with SCI. Extracted datasets include SCI diagnostics, demographics, comorbidities, rurality, medications, and laboratory tests. Many terminology variations for non-coded input data were found. SCIPUDO facilitates robust information extraction from over six million Text Integration Utility notes annually for the study cohort. Visual widgets in the clinical user interface can be directly populated with SCIPUDO terms, allowing patient-specific query construction. CONCLUSION: The SCI-PIR contains valuable clinical data based on CPG-identified risk factors, providing a basis for personalized PrI risk management following SCI. Understanding the relative impact of risk factors supports PrI management for veterans with SCI. Personalized interactive programs can enhance best practices by decreasing both initial PrI formation and readmission rates due to PrI recurrence for veterans with SCI.
Asunto(s)
Traumatismos de la Médula Espinal , Comportamiento del Uso de la Herramienta , Veteranos , Registros Electrónicos de Salud , Humanos , Úlcera por Presión/epidemiología , Úlcera por Presión/terapia , Traumatismos de la Médula Espinal/complicaciones , Traumatismos de la Médula Espinal/epidemiología , Traumatismos de la Médula Espinal/terapiaRESUMEN
Objective: To investigate potential linkages between pressure injury (PrI) recurrence following spinal cord injury (SCI) and muscle-based and circulatory biomarkers, specifically fatty metabolites and inflammatory cytokines. Design: Observational study. Setting: Tertiary Care Center. Participants: 30 individuals with complete or incomplete SCI. Study participants either had never developed a PrI (Group I) or had a history of recurrent PrI (Group II). Interventions: Not applicable. Outcome Measures: Gluteal muscle histology, immunohistochemistry, muscle-based and circulatory fatty metabolites and inflammatory cytokines. Results: Gluteal intramuscular adipose tissue (IMAT) was greater than 15% in most Group II (83%) individuals. Muscle tissue histology confirmed intramuscular structural differences. Fatty acid binding protein 4 (FABP4) and fatty acid binding protein 3 (FABP3) were reliably detected in muscle and blood and significantly correlated with IMAT (P < 0.001). FABP4 was significantly higher in Group II muscle and blood (P < 0.05). FABP3 was significantly higher in Group I muscle (P < 0.05). Circulatory FABP3 levels were lower for Group I. Inflammatory biomarkers were more reliably detected in blood. Colony-Stimulating Factor-1 was slightly higher in Group II muscle. Circulatory interleukin-13 was significantly higher (P < 0.01) in Group I. Vascular endothelial growth factor (VEGF-A) was significantly increased (P < 0.05) in Group I muscle and blood. Conclusion: Identifying individuals with SCI at highest risk for recurrent PrI may impact patient management. IMAT content evaluation illustrates that muscle quality is a key biomarker. Low circulatory inflammatory biomarker expression potentially limits clinical significance for between group differences. Circulatory levels of FABP4 hold great potential as a recurrent PrI risk biomarker.
Asunto(s)
Úlcera por Presión , Traumatismos de la Médula Espinal , Factor A de Crecimiento Endotelial Vascular , Humanos , Tejido Adiposo , Biomarcadores/sangre , Proteína 3 de Unión a Ácidos Grasos/sangre , Proteínas de Unión a Ácidos Grasos/sangre , Interleucina-13/sangre , Recurrencia , Factores de Riesgo , Médula Espinal , Traumatismos de la Médula Espinal/complicaciones , Factor A de Crecimiento Endotelial Vascular/sangre , Úlcera por Presión/diagnóstico , Úlcera por Presión/etiologíaRESUMEN
OBJECTIVE: This study was undertaken to determine if ALS patients evaluated via telemedicine received the same quality of care as patients evaluated by traditional face-to-face encounters. METHODS: A retrospective cohort study design was used. Participants were patients diagnosed with ALS that received multidisciplinary care at the tertiary Cleveland VA ALS Centre between 1 March 2008- and 31 anuary 2015. Participants were not randomised, but chose telemedicine based on preference, disability level or distance from the clinic. Telemedicine in this study consisted of a video conferencing platform enabling remote rather than face-to-face encounters with participants. RESULTS: There was no significant association between receiving quality ALS care and the mode of care. There was a trend for telemedicine patients to utilise home health care less often than those that received clinic care (AOR 0.50; 95% CI 0.16-1.59). There was no significant difference in survival time between the two groups (log-rank test χ2 = 3.62, df = 1, p = 0.05). Patients receiving telemedicine had a higher probability of remaining stable or having <30% decrease in ALSFRS-R over time (log-rank test χ2 = 4.46, df = 1, p = 0.03). There was a significantly lower risk of disease progression for patients receiving telemedicine (HR = 0.39, 95% CI = 0.16-0.93). CONCLUSIONS: Patients managed by telemedicine received the same quality of care and had similar outcomes to those patients seen via traditional face-to-face encounters. Telemedicine is an effective platform for delivering high quality tertiary ALS care.
Asunto(s)
Esclerosis Amiotrófica Lateral/terapia , Atención a la Salud/métodos , Calidad de la Atención de Salud , Telemedicina/métodos , Centros de Atención Terciaria , Anciano , Esclerosis Amiotrófica Lateral/diagnóstico , Estudios de Cohortes , Atención a la Salud/normas , Femenino , Estudios de Seguimiento , Humanos , Masculino , Medicina/métodos , Medicina/normas , Persona de Mediana Edad , Calidad de la Atención de Salud/normas , Estudios Retrospectivos , Telemedicina/normas , Centros de Atención Terciaria/normasRESUMEN
BACKGROUND: A spinal cord injury disease management protocol (SCI DMP) was developed to address the unique medical, physical, functional, and psychosocial needs of those living with spinal cord injuries and disorders (SCI/D). The SCI DMP was piloted to evaluate DMP clinical content and to identify issues for broader implementation across the Veterans Affairs (VA) SCI System of Care. METHODS: Thirty-three patients with SCI/D from four VA SCI centers participated in a 6-month pilot. Patients received customized SCI DMP questions through a data messaging device (DMD). Nurse home telehealth care coordinators (HTCC) monitored responses and addressed clinical alerts daily. One site administered the Duke Severity of Illness (DUSOI) Checklist and Short Form-8 (SF-8™) to evaluate the changes in comorbidity severity and health-related quality of life while on the SCI DMP. RESULTS: Patients remained enrolled an average of 116 days, with a mean response rate of 56%. The average distance between patient's home and their VA SCI center was 59 miles. Feedback on SCI DMP content and the DMD included requests for additional clinical topics, changes in administration frequency, and adapting the DMD for functional impairments. Improvement in clinical outcomes was seen in a subset of patients enrolled on the SCI DMP. CONCLUSION: SCI HTCCs and patients reported that the program was most beneficial for newly injured patients recently discharged from acute rehabilitation that live far from specialty SCI care facilities. SCI DMP content changes and broader implementation strategies are currently being evaluated based on lessons learned from the pilot.