Importance: Transitional care for elderly patients who suffer from multiple chronic medical conditions is essential to reduce the length of and improve the quality of care. According to the 2010 census, older adults accounted for 13 % of the United States population. There were 58 million Medicare enrollees with approximately $ 135 billion in expenditures for Medicare beneficiaries’ inpatient hospital costs in 2017. The average length of stay (LOS) in the acute care setting for ages 65 to 84 was 5.2 days with a mean cost of $ 11,300 per stay nationwide in 2016.

Methodology: The study was designed as a descriptive statistic through a retrospective chart review in a teaching hospital in northern New Jersey. The study sample of 102 charts randomly selected. The study sample consisted of Medicare patients 65 years and older who were diagnosed with sepsis which includes severe sepsis and septic shock ranging from the beginning of the third quarter of 2018 to the end of the second quarter in 2019.

Analysis: The variables of the study were age, gender, ethnicity, number of chronic medical conditions, mortality, diagnosis, 30-day readmission, patient’s support system in the community, transitional care, and discharged to. This study used descriptive statistics and a Kruskal-Wallis or Wilcoxon-Rank Sum test to assess the differences in LOS.

Results: There were 57 females (55.9%) and 45 males (44.1%) in the study. 50.0% of cases were 79 years and older. Sepsis were 44 cases (43.1%), severe sepsis 44 cases (43.1%), and septic shock 18 cases (17.6%). The majority of ethnicity was white with 65 cases (63%), followed by black or African-American (22.5%). 27 (24.9 %) out of 81 cases (excluded 21 deaths as an inpatient from the total 102 cases) were readmitted within 30 days after discharge. 24 (23.5 %) cases had 5 chronic medical conditions, followed by 23 (22.5%) of cases who had 4 chronic medical conditions. 99% (101 cases) had a community support system, and 3 cases (2.9 %) had transitional care APN involvement during the hospitalization. The mortality of this sample population was 20.6% (21 cases), 24.5% (25 cases) discharged to skilled nursing facilities, 17.6% (18 cases) to home with visiting nurse services, and 17.6% (18 cases) to home with family care. The mean LOS for sepsis was 9.2, severe sepsis 9.8, and septic shock 19.4. This study did not find a statistically significant factor that impacted LOS. Yet, the p-value of age was 0.149 followed by the p-value of 0.163 for comorbidity. 

Background: As part of the American College of Cardiology (ACC) patient navigator program (PNP) phase II focus MI, we continued risk-specific interventions implemented in phase I to reduce AMI readmissions. Concentration was placed on identifying strategies most impactful on increasing early post-discharge follow-up as it has been promoted as a method of reducing 30-day readmission rates.2

Methods: A multidisciplinary approach was implemented to include the cardiologist, transition nurse, inpatient pharmacist, patient navigator, and the ambulatory care clinic nurse. Special needs were identified during discussions at the team’s daily multidisciplinary rounds. AMI patients received disease-specific education by the transition nurse and pharmacist prior to discharge. The patient navigator scheduled a 7-day follow-up appointment with a cardiology or outside provider based on the patient’s individualized needs prior to discharge. Follow-up phone calls were made 72 hours post-discharge by the transition nurse, and, at a minimum, 30- and 90-day calls were made by the ambulatory care clinic nurse. Each call was structured to solicit specific information regarding cardiac specific medications and symptom management and encourage follow-up appointment compliance and cardiac rehab participation.

Results: Data was collected January 2018 through September 2019. A total of 135 AMI patients were included in the National Cardiovascular Data Registry (NCDR®) Chest Pain-MI Registry™. 60% completed at least one appointment within 30 days post- discharge and 32% completed an appointment within 7 days. Follow-up calls were made within 72 hours; however, very few patients answered the call. requiring a message to be left with the nurse call-back information and appointment details. A total of 15 patients (11%) readmitted within 30 days, with 8 not having a follow-up call or completed appointment. Follow-up calls at 30-days post-discharge averaged a 77% success rate, and 90-day calls averaged 65%. A total of 16 patients (12%) readmitted within 90 days, with 8 not receiving a 30-day follow-up call. Those readmitted had one or more high risk factors including insurance limitations or unfunded status; discharge to assisted living; special caregiver requirements; active transplant evaluation; or having multiple co-morbidities, including cancer, which effected their compliance with cardiology follow-up.

Conclusions: The data reveals that in addition to inpatient interventions, telephonic nurse outreach, and early follow-up can help to reduce readmissions. Increased patient compliance with follow-up was noted in one large internal medicine practice with dedicated ambulatory care nursing staff to conduct post-hospitalization follow-up calls and ensuring a visit was completed within 7-14 days post-discharge.

References
1. Pandey A, Golwala H, Hall HM, et al. Association of US Centers for Medicare and Medicaid Services Hospital 30-Day Risk-Standardized Readmission Metric With Care Quality and Outcomes After Acute Myocardial Infarction. Findings from the National Cardiovascular Data Registry/Acute Coronary Treatment and Intervention Outcomes Network Registry–Get with the Guidelines. JAMA Cardiol. 2017;2(7):723–731. doi:10.1001/jamacardio.2017.1143
2. Tung YC, Chang GM, Chang HY, Yu TH. Relationship between Early Physician Follow-Up and 30-Day Readmission after Acute Myocardial Infarction and Heart Failure. PLoS One. 2017;12(1):e0170061. Published 2017 Jan 27. doi:10.1371/journal.pone.0170061

Surgical outcomes have impact on both patient health and CMS reimbursement. Preventing poor outcomes such as surgical site infections (SSIs) and readmissions are important tasks that do not only occur in the operating room. The general OBGYN department implemented the enhanced recovery after surgery (ERAS) best practice guidelines and utilized nursing care coordinators (CCs) in the clinic to impact patient outcomes. A pre-op education program was developed by GYN Nurse CCs based on best practice and hospital guidelines to prepare patients for surgery. The education is provided by a CC via a 30-minute telehealth or in-person appointment and includes what to expect with their procedure, pre-op instructions, and post-op mobility. As part of the education, the patient is encouraged to participate in a rehabilitation program. They are also introduced to pre-op nutrition and CHG bathing which are key elements of ERAS.

Several PDCA cycles have been completed to get to current state. Current state: once the surgery is deemed necessary, the provider places the case request. The patient is automatically added to a report that the GYN CCs manage. The report is pulled daily. The GYN CC places the pre-procedure orders and ERAS pathway. Once the surgery is scheduled, the GYN CC is notified to contact the patient and schedule their pre-op, pre-op education, post-op, and COVID testing appointments.

Initially, the patient was immediately called by the CC to set up their education appointment and then later called by the surgery scheduling team. The physician’s nurse would be notified to schedule the pre-op, post-op, and COVID testing. After this process had occurred for several patients, a better process was identified. The process was updated to the current state where the CC calls the patient to schedule their appointments all at once. This simple change improved patient experience and alleviated work from the nurse team that could easily be absorbed by the CC. We found that multiple calls to the patient from different people led to fatigue, frustration, and a sense of being overwhelmed for the patient; this simple change alleviated that.
Some patients provided immediate feedback regarding their pre-operative education appointment. One patient stated, “this education was very helpful and helped me to feel prepared.” Another stated, “Usually when you decide to have surgery, you walk out of the doctor’s office feeling nervous and unsure and like you are just floating…The education [the CC] provided helped me to feel self-assured and knowledgeable.” In addition to providing education and setting up appointments, the CC has become the primary source of contact for the patient as they prepare for their surgery which allows each patient to become familiar and comfortable with a trusted member of their health care team.

Future state will include post-op follow up calls. Data is being collected regarding readmissions and surgical site infections and will be analyzed monthly. The ERAS program started in August of 2020, and to date we have provided care to over 100 patients.

Background of the problem: Well-managed oral anticoagulant (OAC) therapy can reduce the risk of adverse events, including excessive bleeding or venous thromboembolism. The percentage of international normalized ratio (INR) values in therapeutic range for active chronic care clinic patients taking OACs, averaged 52.9% in 2018. Routine follow-up for INR checks is crucial and often challenging.

Objectives/purpose: The goal is to increase the percentage of active oral anticoagulant therapy patients in the chronic care clinic having an INR value in their recommended targeted range.

Literature review: Repeatedly missing INR value check has been associated with an increases risk for thromboembolic complications during warfarin therapy. Most patients treated with OACs spend the majority of their time with their INR values out of their recommended target range. Improving INR values within the recommended therapeutic range can reduce major adverse events. A systematic process for tracking patients should be used to minimize the possibility that a patient on warfarin therapy is lost to follow-up. Improving care coordination and the appropriate length of time between follow-up INR testing is critical to achieve the INR therapy goal.

Methods: The chronic care clinic implemented usage of an Epic tool, the INR reminder list, for all active clinic patients on OACs. Patients who are overdue for their INR check will show up in the INR reminder list. This list is reviewed daily by the LPN to make sure the patients have a follow-up appointment. The LPN reports to the RN with any patient having barriers to attending their appointment. The RN will coordinate their care based on the patients need. Coordination of care includes, but not limited to, transportation arrangements, pill box fill, and social worker consult.

Outcomes: Since initiating the project, the percentage of INR values in the targeted range improved from the average 52.9% to 56-57 % most months. Improving the process over time helped to sustain the percentage of INR values in target range. Nurses and support staff must work together to ensure that patients do not get lost in follow-up.

Conclusion: Maintaining INR values within therapeutic range is associated with better outcomes. Patients with multiple comorbidities are particularly challenging. Engaging in a patient-focused quality improvement project, with care coordination as an intervention, helps manage the OAC patient population and reduces their risk for adverse events.

Implications for nursing practice: Ambulatory care RNs provide leadership in coordination of services and collaborative efforts. The INR reminder list is a systematic process for tracking patients to minimize the lost to follow-up appointments. The INR reminder list helps to improve care coordination and the appropriate length of time between follow-up INR testing to help manage the OAC patients and reduce the risk of major adverse events while on anticoagulant therapy. Sustaining the process can be challenging; utilizing the plan/do/adjust/check cycle will assist in the progression of continual improvement.

Purpose: A quality improvement (QI) project implemented on an inpatient cardiac unit evaluated the effectiveness of standardized bedside shift report (BSR) on patient-nurse communication scores as measured by CMS HCAHPS, which is part of the national public system reporting patient perceptions of hospital care1. Because communication for ambulatory care transitions begins at the patient’s bedside, the QI project encompassed this foundational setting to improve patient safety and satisfaction.

Review of literature: Improving nurse-patient communication can improve patient outcomes and satisfaction. Miscommunication between nurses and patients has contributed to ongoing patient safety issues in both the inpatient and ambulatory care settings. The Joint Commission (TJC) reported the most common cause of sentinel events is handoff communication failure2. Communication breakdown contributes to countless patient deaths. The Institute of Medicine reported between 44,000 and 98,000 patients die annually from preventable medical errors3. Nurses report difficulty with effective communication secondary to frequent interruptions, complex tasks, and inconsistencies with staffing and time limitations4. These factors can lead to omission of pertinent patient information and flawed transfers, ultimately compromising patient safety4. Effective and efficient communication is essential to provide quality patient care4. In accordance with TJC, standardized BSR is an evidence-based approach to improve inconsistencies and efficiency in patient handoff2. Evidence-based toolkits were used in the development of this project to directly engage nurses and patients in the education and implementation of standardizing patient handoff through BSR. Research shows involving patients during handoff decreases communication failures and duplication of care, thus improving patient outcomes and safety2. In addition to inpatient communication, primary care physicians are concerned with the transitions from inpatient to the ambulatory care citing omissions and delays leading to the potential of patient harm6.

Methodology: Patient handoff is an opportune time to improve nurse-patient communication, thereby contributing to positive patient outcomes. The QI project integrated the knowledge that communication directly affects patient safety and sentinel events. Using the Agency for Healthcare Research Quality bedside shift report toolkit and a five-step cyclic process, this QI project directly engaged both nurses and patients in the education and implementation processes to standardizing patient handoff through bedside shift report. The project also addressed potential barriers to bedside shift report and how to overcome these conflicts.

Analysis: Results were collected and analyzed through the CMS HCAHPS score reporting system. This system is a part of the national, standardized public reporting system that credibly and confidentially reports patient perceptions of hospital care.1 HCAHPs scores are sent to randomized patients regardless of insurance or reimbursement method.1

Results: Three months of post-data were collected and compared to pre-implementation scores (n=16). Post-data results showed an increase in nurse-patient communication scores with implementation of BSR. Results will be discussed.

Learning outcomes: Nurse leaders have a responsibility to continue identifying evidence-based strategies to optimize patient safety and quality care. Implications for practice stem from the use of toolkits to assist with development of efficient, sustainable, and quality handoff reports that establish effective communication between nurses and patients in all settings5.

Transgender/gender non-binary (TGNB) individuals experience health disparities such as gaps in knowledge amongst providers and health care organizations.

To understand the level of knowledge and self-efficacy at an organizational level when providing health care related services to the TGNB population within Eastern Riverside County, an evidence-based practice (EBP) project was created using Brown and Ecoff’s EBP Institute Model. The study was a prospective cohort study that recruited a sample of 150 employees and community partners to participate in a two-hour TGNB intervention. The participants that were recruited consisted of various socio-demographic such as age, sex, sexual orientation, and gender identity backgrounds.

The data was collected using a pre-test and post-test instrument that captured information assessing the overall knowledge and level of self-efficacy of the individuals participating in the intervention. Questions consisted of: 1) how confident are you with working with the transgender/gender non-binary community, 2) how confident are you in applying your knowledge into your daily practice? Rate your knowledge in best-practices when working with the transgender community.

Data was analyzed using SPSS version 25, and responses were compared using a non-parametric Wilcox-Sign Ranks Test. Based on the findings, there is an increase in knowledge and self-efficacy after the intervention was conducted. When comparing the results on “how knowledgeable are you of the transgender community,” 28% responded very little knowledge for the pre-test while 63% responded knowledgeable/very knowledgeable on the post-test. When comparing “how confident are you working with the TGNB community,” 46% responded that they had very little confidence/somewhat confident on the pre-test, whereas 83% responded confident/very confident on the post-test. In addition, questions such as “please rate your knowledge of the transgender community, please rate your knowledge of the gender non-binary community, best practices involving the transgender community, confidence in working with the TGNB community, and confidence in applying your knowledge into your daily practice” illustrated normal distribution with (P=0.02) making the intervention significant.

As a result of the intervention and the preparation leading up to it, it was identified that the employees and community partners in attendance were receptive in more education towards culturally competent care for TGNB individuals. In addition, a shift in knowledge and self-efficacy can have a positive impact in patient care delivery at all levels of the organization. Based on the findings, the organization will implement a condensed 30-minute presentation from a subject matter expert that will cover best practices when working with the TGNB patients and/or community. Furthermore, the data that was collected will be utilized to develop and/or update future organizational health policies, program development, and additional resources needed to better improve care delivery. Overall, the findings from the intervention were beneficial and similar interventions could be applied for continuous development of trainings to address health disparities in other marginalized communities. 

Purpose/significance: The incidence of patients with multiple complex chronic conditions is rising.1 Patients with chronic conditions often need additional support to identify and understand personal barriers, engage in healthy lifestyle choices for physical and mental health, manage symptoms, and navigate the health care system. In our family practice care team panel, 58% of patients are over 60 years of age. Providers have limited time to spend with patients. Collaboration with the RN care coordinator bridges that gap through understanding a patient’s capacity to care for themselves in regard to resources, support systems, and burdens of illness and treatment. Chronic care management (CCM) and the utilization of the Instrument for patient capacity assessment (ICAN) tool enhance the RN care coordinator’s ability to understand the needs and concerns of the patient. It is imperative to consider the distinct challenges that a patient faces in order to provide individualized care for patients with chronic conditions. The ICAN tool focuses on the patient’s life situation and the potential burdens of treatment. Identification of burdens provides insight into the patient’s challenges and helps the RN care coordinator formulate a contextualized plan of care.2

Methods: Parameters for inclusion: CCM is offered to patients with two or more chronic conditions expected to last twelve months or until the death of the patient. All patients in the CCM program will complete the ICAN tool at initial enrollment and then at all subsequent visits with the RN care coordinator.

Results/evaluation: A retrospective review of patient self-assessed burdens will be done at enrollment and then at each subsequent visit over a period of one year. Data will be analyzed by number and type of burdens, chronic conditions, age, and gender as well as trends over time while patients are enrolled in CCM.

Implications for practice/learning outcome: Connecting with patients; establishing trusting relationships; meeting them where they are at; and understanding patients’ needs, barriers, and values is advantageous to improving patient self-management and health care outcomes.3

References
1. Leppin, A.L, Montori, V.M & Gionfriddo, M.R. (2015). Minimally disruptive medicine: a pragmatically comprehensive model for delivering care to patients with multiple chronic conditions. Healthcare, 3(1), 50 -63.
2. Boehmer, K.R., Hargraves, I.G., Allen, S.V. et al. Meaningful conversations in living with and treating chronic conditions: development of the ICAN discussion aid. BMC Health Serv Res 16, 514 (2016). https://doi.org/10.1186/s12913-016-1742-6
3. Vanderboom, C.E., Thackery, N. L., & Rhudy, L. M., (2015). Key factors in patient-centered care. Nurse care coordinators’ perspectives. Applied Nursing Research, 28(1), 18-24. https://doi.org/10.1016/j.apnr.2014.03.004 

Purpose: To understand the experiences of front-line nurses during the COVID-19 outbreak in Hubei and investigate their views on the role of ambulatory care in the management of COVID-19 and future infectious disease outbreaks.

Background: The emergence of the novel coronavirus disease (COVID-19) continues to stretch the capacity of health care systems worldwide. High hospitalization rates for infected patients have put immense strain on health care workers who tirelessly exert themselves to deliver quality inpatient care amidst critical resources shortages. Exploring their experiences may identify ways in which ambulatory health care can be incorporated into infection control and prevention responses and ease the pressure on hospital resources during future pandemics.

Methods: Purposive, convenience, and snowball sampling were used to recruit 60 registered nurses who provided inpatient care during the COVID-19 outbreak in Hubei. Semi-structured interviews were conducted. Participants were asked to share their work experiences during the pandemic, including challenges faced in patient care, related coping strategies, and suggested improvements for future pandemic responses. Interviews were audio recorded and transcribed verbatim. Resulting data was coded and analyzed thematically according to Braun and Clarke’s (2006) framework.

Results: Participants reported multiple challenges in their experiences of delivering patient care during the COVID-19 outbreak. Due to high caseloads, nurses worked lengthier shifts and took on additional responsibilities in order to make up for shortages in hospital staff, leading to an increase in psychological and physical distress. Support came in the form of fever clinics which reduced nurses’ burden by screening patients for COVID-19 in the community and freeing up valuable hospital resources. Suggestions to improve future epidemic responses and prevent the overburdening of hospital staff included the installation of additional fever clinics and the delivery of reliable public health education in primary care settings, which may raise awareness on infection prevention and control measures and potentially lower overall infection rates.

Conclusions: Nurses in hospital settings have been overstretched due to an unprecedented surge in patients requiring hospitalization. Psychological and physical stress were frequently reported, with a potential reduction in the quality of inpatient care. To protect and reduce strain on hospital staff, ambulatory health care may be explored as a solution to increase community capacity in responding to future infectious disease outbreaks, thus allowing hospital resources to be directed towards the most serious patients and further optimizing pandemic control efforts.

Purpose: Digital communication is rapidly evolving in community care practices. With 85% of our primary care paneled patients utilizing portal accounts, patient online portal messages to team pools and prescription refill requests increased 272% over a five-year period. Nursing and allied health staff support the practice with episodic patient care in addition to tasks such as prescription refills, pre-visit work, patient education, and reviewing and completing messages in message center. Messages were not addressed in a timely manner due to competing priorities. The additional non-visit care and clerical burden required a change to team workflows. an electronic medical assistant (EMA) role was developed to shift messages from nursing and provider in-baskets. The clinical background of an EMA adds value to message review and handling. Initial trial results showed that an EMA was able to manage 82% of patient medical advice requests and 47% of messages to patients.

Description: Results from the EMA trial helped to secure funding for a 12-month pilot to restyle two full-time medical assistants as EMAs. Goals were to reduce message volume downstream by capturing certain message types, increase efficiency and order by routing messages strategically, and have care team members work to their highest scope of practice. Each EMA was assigned to 11 providers. Two new in-baskets were created: one to address patient advice requests and one for prescription refills. In the 2-month training period, EMAs completed direct portal messages and provider requests to call results. A suite of smart phrases was created to provide language and tone consistency when communicating with patients. In addition, EMAs responded to incoming patient calls and assisted with prescription refills. Team member assignments were adjusted on high-volume message days. Data on in-basket total message volumes and number of refill messages for EMAs and providers was collected at pre-pilot, training, and post-implementation intervals.

Evaluation/outcome: Total in-basket message volumes increased for physicians and EMAs from pre-pilot levels to training and post-implementation intervals. However, the number of in-basket messages by user type indicated that physician patient advice messages decreased from 98% pre-pilot to 64% during implementation. Physician refill messages decreased from 100% pre-pilot to 69% during implementation. EMAs managed 28% of patient advice messages during training and maintained at 27% during implementation. EMA refill messages increased from 19% during training to 36% during implementation. EMAs had a sense of ownership, developed competence, and focused on message completion. The smaller feedback loop showed an increase in efficiencies while providing shorter message response times, which increased patient satisfaction. Smart phrases were well received by patients and the practice. The greatest impact to the practice will come from task shifting among remaining nursing and allied health staff. With the EMA managing patient messages, other team members can focus on clinical tasks nearer to the limit of their licensure such as pre-visit planning, wellness services, or procedures. This task shifting has potential for a greater impact to providers than patient message volume reduction alone.

Purpose: The purpose of our contribution is to demonstrate the opportunity for improved patient care and nurse satisfaction by expediting clinical assessments and disposition during quick response (QR) calls.

Description: While rapid response teams (RRT) have been identified as best practice in hospital settings, there is a paucity in the literature regarding emergency medical response in ambulatory care patients, particularly in an outlying, stand-alone clinics with limited staff support (Rojas et al., 2017).

The quick response team (QRT) at this clinic is responsible for reporting to all QR calls within a 300,000 square foot building which encompasses approximately 50,000 square feet of medical space. This clinic is the largest outlying independent ambulatory care clinic within the local network with approximately 22,000 enrolled patients. The QRT consisted of two registered nurses (RN) and was responding in a “ramp up” model. This “ramp up” methodology is described as being nurse-led and does not include a provider responding simultaneously. In contrast, a “ramp down” approach consists of a provider concomitantly responding to all QR calls.

Growing frustration motivated a team of clinic nurses to evaluate nursing staff’s perception of the QRT process and perceived barriers. A layout analysis was completed and demonstrated multiple decision points resulting in time wasted in locating a provider. A similar circumstance was also found in the literature, where it was noted that “awaiting the physician arrival from the ICU further delayed necessary transitions to the ED” (Dechert et al., 2013). We found this “ramp up” phenomenon was also present in our outlying clinic setting where nurses were responding alone. Implementation of a “ramp down” approach in our clinic included executing a “doc of the day” plan where a provider is assigned to respond (with the RNs) to all QR calls for the day. Doc of the day was implemented in October 2019.

Evaluation and outcome: “Time spent” data was collected for all quick response calls 180 days prior (99 calls) and 180 post-implementations (54 calls) of doc of the day. The average time spent on QR calls was 48 minutes prior to “doc of the day” in comparison to 30 minutes post-implementation. Nursing staff surveys were also completed 180 days prior and 150 days post-implementation. In May 2019, 75% of surveyed primary care nurses reported frustration in finding a provider, and 57% of nurses indicated they would hesitate in initiating an intervention without a provider present. These values decreased by 58% and 27%, respectively.

Implementing a “ramp down” approach in responding to emergency situations in an ambulatory care clinic decreased the mean duration of QR calls by 18 minutes over a six-month period. The learning outcome and conclusion is that simultaneous provider response expedites the dispositioning of patients requiring evacuation to a higher level of care, decreasing the potential for poor patient outcomes. This “ramp down” approach and process improvement scenario may be implemented in other similar outpatient settings to improve efficiency, patient safety, and staff satisfaction.