NR 451 Week 2 Discussion The Clinical Question

NR 451 Week 2 Discussion The Clinical Question

NR 451 Week 2 Discussion The Clinical Question

My systemic review is Effectiveness of early discharge planning in acutely ill or injured hospitalized older adult; a systematic review and meta-analysis.

My clinical question is: Are acute cardiac and/or vascular patients, age 65 or greater who have early discharge planning compared to those without early or any discharge planning at risk for readmissions over 30 days?

This question was formatted using the PICOT etiology method.

In my current position of case manager, the highest priority is always discharge planning or DCP. Effective DCP usually includes researching diagnosis, test/procedures, communicate with nurses and doctors for prognosis and potential medical needs, performing an initial assessment with the patient and family to assess for home/social needs and communicate with physical therapy for any safety needs. All this is to help the patient become more aware of needs and provide disease management education to prevent exacerbations and readmissions.

“The Institute of Medicine (IOM), in its landmark book Crossing the Quality Chasm (2001), defined patient-centered as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” (Sherwood and barnsteiner, 2012, p. 68) Preventing exacerbation is self explanatory. AS healthcare professionals we want people to improve and manage their health. But what is the big deal about readmissions anyway? Basically it boils down to a single question—Is this readmission AVOIDABLE? Repeat admission cost more because the treatment can get more involved, length of stay can be longer and hospitals can get penalized on reimbursement from payers like Medicare and Medicaid.

For example a 68M is admitted to a Cardiac Step-down Unit for SOB, Dyspnea and bilateral lower extremity edema. The patient is diagnosed and treated for CHF. He is given Beta-blockers and diuretics and recovers quickly. He is discharged on day 3. The nurses and MD briefly discuss importance of nutrition and medication management, briefly mentioning monitoring weight before he leaves. The patient returns to his life as normal and within 2-3 weeks he returns to the ER with same symptoms, but much worse. Now he requires oxygen supplementation, plus IV diuretics and spends 5 days in the hospital. Could this exacerbation and readmission have been avoided? The scenario represents a fragmented health care system, and patient can leave feeling confused about their disease and how to manage it.

What if at the first admission when it was a new diagnosis, there was a patient educator who started educating the patient on disease process, medication and diet management, importance and rationale of daily weights, follow up appointments, early signs and symptoms of CHF exacerbation and when to contact the MD/cardiologist? What if the nurses and MD’s all stressed these important points every time they met with the patient? What if the case manager arranged for a HHC nurse to provide 3-6 weeks of focused education and monitoring in the patient home, along with a discharge follow-up nurse who makes first follow up appointments for patients and calls patients 24-48 post discharge to see how the patient is doing at home? These interventions significantly decrease the likelihood the patient will be readmitted in 30 days. This scenario is more representative of a quality health care system that care for not only the acute issues of their patients but the long-term, life time care of patients too.

“Research gaps prevent systematic reviewers from making conclusions and, ultimately, limit our ability to make informed health care decisions.” (Robinson, K et al, 2013) But a research gap may not necessarily be a bad thing, because we can form new research questions from them.

Reference

Fox, M. T., Persaud, M., Maimets, I., Brooks, D., O’Brien, K., & Tregunno, D. (2013). Effectiveness of early discharge planning in acutely ill or injured hospitalized older adults: A systematic review and meta-analysis. BMC Geriatrics, 13(1), 1. doi:10.1186/1471-2318-13-70

Sherwood, G., Jane Barnsteiner. (May-12). Quality and Safety in Nursing: A Competency Approach to Improving Outcomes, 1st Edition.

Robinson KA, Akinyede O, Dutta T, et al. Framework for Determining Research Gaps During Systematic Review: Evaluation [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Feb. Available from: https://www.ncbi.nlm.nih.gov/books/NBK126708/

The Clinical Question

Your capstone change project begins this week when you identify a problem that you judge needs to experience a change in order to produce better patient outcomes

• Formulate a significant clinical question that will be the basis for your capstone change project

• Relate how you developed the question

• Describe the importance of this question to your clinical practice

• Define meta-analysis.and explain how this relates to evidence -based practice (EBP)
• Describe what a research-practice gap is

Week 2: The Clinical Question 

Your capstone change project begins this week when you identify a practice issue that you believe needs to change. The practice issue must pertain to a systematic review that you must choose from a List of Approved Systematic Reviews (Links to an external site.)Links to an external site. for the capstone project. 

• Choose a systematic review from the list of approved reviews based on your interests or your practice situation. 
• Formulate a significant clinical question related to the topic of the systematic review that will be the basis for your capstone change project. 
• Relate how you developed the question. 
• Describe the importance of this question to your clinical practice previously, currently, or in the future. 
• Describe what a research-practice gap is.

I think all of us at one time or another has certainly asked our selves…There has to be a better way of doing this.  In this discussion you need to choose a systematic review from the topics provided in the class resources that is pertinent to your current or past practice.  Remember you will not really be expected to implement the practice, just how you would start the process.  For instance, CAUTI or catheter associated urinary tract infections are a major problem in the hospital.  In surgical patients especially.  When I worked on the surgical floor years ago, I was made aware of the non sterile catheter insertion procedure done in pre-op. The staff would just pour a little water over the peri area and insert.  We had some raging post op UTIs needless to say even when the Foley was removed on day one. 

Follow the steps above in your discussion question and tell us some of your stories of research-practice gaps.  Your capstone project one is fill out the Practice Issue and Evidence Summary Worksheet on your chosen systematic review.  Please review your posting requirements You should have one initial post and 2 posts to 2 different class mates. 

I encourage all of you to use one of the systematic reviews provided in the class resources section, this is a starting point and not the only reference you should use, it is just a start your research.  If there is another topic you would like to use, you must have a systematic review that covers that topic.  The systematic review must be used as one of your references but other references will certainly be necessary.    

Also, please come to the questions and answer web-ex I’m having next week.  It is posted in the announcements. 

The systematic review that I chose was obstetrics with a focus on skin to skin care.  I currently work on a pediatric unit where NAS babies are transferred after they are stable following birth.  I have seen many children sit on this unit for a month too two months going through withdrawal.  These children have myoclonic tremors, increased muscle tone, inconsolable irritability, and an overall rough start in life.  Most of these children don’t have a high parental involvement; but I was wondering what the affects would be on their weaning process if they had daily skin to skin. I want to know if their negative symptoms would dissipate faster, would they come off the drugs faster, and would their overall health improve quicker allowing them to either go home or be placed in foster care.

 I believe it is important to my current practice because we have a large population of mothers that go through the methadone clinic in town.  If we found a way to improve family centered care while simultaneously shortening the weaning process for the infant and minimizing withdrawal symptoms it could mean the difference between these babies staying with us for a few weeks compared to a few months. “:Newborns with moderate to severe NAS are typically treated with oral opioids, and then weaned over days to weeks.  Pharmacologically treated NAS is prolonged and costly, with lengths of stay of 2 to 12 weeks and estimated charges of $90 000 per admission (Holmes et al).” Research practice gap is when there is evidence based research supporting a specific practice but it hasn’t been implemented into actual patient care.  

  Holmes, A. V., Atwood, E. C., Whalen, B., Beliveau, J., Jarvis, J. D., Matulis, J. C., & Ralston, S. L. (2016). Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower Cost. Pediatrics,137(6). doi:10.1542/peds.2015-2929  

I’m not pediatric or OB oriented but the theory of “healing touch” is one that I am familiar with.  This is such a sad situation for both baby and parents and I have heard that it is getting worse all over the country with the epidemic of inappropriate opioid use.  I nursing self would say that yes skin to skin contact would help these babies recover faster and at least comfort them in their struggle to withdraw.  According to Artigas, V. 2015, supportive care such as aromatherapy massage therapy, music therapy as well as skin-to-skin contact have been shown to promote weight gain and feeding tolerance, increased sleep cycles and decreased neurologic symptoms. It make sense that healing touch and providing a sense of security for the infant would decrease the affects of NAS especially considering Erickson’s stages of psychosocial  development- an infant would be at the stage of Trust vs. Mistrust.  Feeling safe and protected at the infant stage would promote trust. 

Artigas, V. (2014). Clinical Practice: Management of Neonatal Abstinence Syndrome in the Newborn Nursery. Nursing For Women’S Health, 18509-514. doi:10.1111/1751-486X.12163  

Above is what happens when you copy and paste a reference.  Copy and paste is no longer an option in the discussions so be aware.   

Professor, I usually type my threads in word and copy and paste it over. Is this still ok? or are we needing to type everything directly in the reply box?  In the last course, we were not able to “edit” in the reply box, so I would type it up in “word” to make corrections, go in and add or take things out before submitting it as an actual post. Are we able to edit if we post then need to go back in a add or change something in the post? Thank you for your assistance in this area.  

You know Julie, I’m not sure, I was told in our meeting that copy and paste was going away, but It seems that we should be able to copy and past in word I’ll try it.  

this is what copy and paste looks like from word, if it looks ok, and correct, then as far as I’m concerned you can do it that way.  

Very interesting, at our facility we manage these infants in NICU setting. I will say that our NAS taskforce have recently researched infant massage in NAS infants to use as non pharmaceutical approach for these infants. We are also looking to see if this could in conjunction with music therapy, cuddling, and possible aroma therapy may decrease the initiation of meds and aid in the weaning process to get these infants home sooner. These are actually my “niche” patients, I enjoy caring for NAS infants and their families, although as you know, it can be challenging. In addition, look into the “ESC” model. This is a new approach to care that replacing the Finnegan scoring model and simply evaluates if the infant can eat a minimal amount, sleep at least one hour at a time, and be consoled within a 15 minute period medications are withheld. Enjoy the research process! I look forward to following your progress as this is a subject of great interest to me as well.         

I think one of the main reasons it is difficult for some people to really embrace active parental involvement with these types of patients is because the child is in this predicament due to the poor choices of the parent.  I try to have an open mind when interacting with these families and I always have hope that the parent(s) will turn their lives around for their child.  I have noticed that seasoned nurses lose this optimism.  I am still a new nurse and still have a bleeding heart that I wear on my sleeve.    

If you read up on this, even mothers who are taking SSRIs for depression may have an infant with withdrawal symptoms.  For these mothers, SSRIs are not a choice it is a necessity.  I have dealt with patients with chronic depression and is debilitating and dangerous to the mother if she does not continue the medication .  Most OB and psychiatrist instruct patients to avoid the SSRI for the first trimester if possible and then restart to prevent any possible birth defects.  They have not determined if SSRI cause any permanent disabilities for the fetus other than a period of withdraw after birth. 

Professor, this is true in many cases. What we are seeing is that most of these parents have not been educated on what to expect after delivery for the infant. They have no idea that a prescribed medication they are taking and the physician is aware of, leads to a 6-8 week hospitalization for the baby. They feel very uninformed and lots of guilt. 

Our taskforce has suggested a “referral” for these patients taking SSRI to talk with NICU personnel about the process before delivery, as well as receive brochure about NAS and what they can do to help the process. For many, rooming in would be possible if they have time to make arrangement for children, talk to close family members that may be willing to assist. When they are unprepared, and family are questioning why the infant is in hospital , it often leads to feeling that it needs to be a “secret” . These families shun their support system, instead of being able to utilize them, because of feelings of shame and guilt. This is why educating this patient population is vital.  

I honestly did not know this about SSRIs until I looked it up.  My daughter is pregnant and taking SSRIs but she is planning on tapering them in the last month of pregnancy so she can try to breast feed.  Both her GYN and Psychiatrist knows, and neither one has given her this information that the infant may experience withdrawal symptoms if she doesn’t taper the drug prior to delivery.  I told her the other night when I did some research.  You guys teach me something every session! 

 I haven’t worked on a pediatric unit for over 20 years now, I can’t imagine how such a rough start in life these little ones endures.  During the years I worked in neonatal care, we were just learning how to treat these baby as they when through withdrawal.  The drug of choice was “crack”. The hospital allowed volunteers mostly elderly ladies from the churches to visit the unit and they would sit and hold the infants in a quiet room to help soothe them.  The tremors were lesser and the babies were much calmer while being held.  However, most of these infants went into foster care when they were stabilized and therefore I can’t tell what happened after they left the hospitals.  

Thanks for the post. 

I found your post to be interesting. When I initially decided to go into the field of nursing, my plan was to be a neonatal nurse. I thought that my love for babies would make it the perfect career for me. I would get paid to “play” with babies all day. I soon found that I was not able to handle neonatal nursing. I could not separate myself from the children when I walked out of the doors of the hospital. My heart bled for the children, especially those who had no parental involvement. 

I can’t imagine working with infants who have Neonatal Abstinence Syndrome. “It is estimated that 5% to 10% of pregnant women abuse drugs during pregnancy, not including alcohol” (Maguire & Passmore, 2012). These statistics are astounding. One out of ten to one out of twenty babies are born to women abusing drugs, with most neonates beginning to showing withdrawal symptoms within the first two to three days. It is hard to imagine the ethical issues surrounding sending these infants home to known drug abusers. 

Thank you for caring for these little ones. 

Reference: 

Maguire, D., & Passmore, D. (2012). NICU Nurses’ Lived Experience Caring for Infants With Neonatal Abstinence Syndrome. Retrieved September 8, 2017, from https://wwwLinks to an external site..researchgate.net/profile/Denise_Maguire/publication/230829215_NICU_Nurses%27_Lived_Experience_Caring_for_Infants_With_Neonatal_Abstinence_Syndrome/links/00b49533479ca8d38c000000.pdfLinks to an external site. 

We actually have a huge Methadone clinic here due to the high abuse.  It is extremely hard to get into the program, but if you are pregnant you go to the front of the line. After looking at a few studies it looks like this is common practice. “Women who sought out methadone maintenance treatment when they were pregnant had no difficulty enrolling in a clinic. Women who were not pregnant when seeking treatment were not so successful (Stone).”

So essentially we aren’t necessarily willing to treat an addict but if they are carrying a baby why not.  I guess that a huge part of me wants to believe that people can be better and we should give them the benefit of the doubt, which can be very hard when you’re watching an innocent baby seizing multiple times a day.  I just think that if we try to treat the moms as moms and integrate them into the treatment of their newborns we might have a better chance of healing both of them.