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Diabetic Kidney Disease
Radica Alicic, Emily J Johnson, and Katherine Tuttle
From the Publisher: From basic science to practical clinical tools, Chronic Kidney Disease, Dialysis, and Transplantation, 4th Edition provides you with the up-to-date, authoritative guidance you need to safely and effectively manage patients with chronic renal disease. Covering all relevant clinical management issues, this companion volume to Brenner and Rector’s The Kidney presents the knowledge and expertise of renowned researchers and clinicians in the fields of hemodialysis, peritoneal dialysis, critical care nephrology, and transplantation – for an all-in-one, indispensable guide to every aspect of this fast-changing field.
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Anticoagulation optimization: Capturing triple aim value in percutaneous coronary intervention within a large health system
Braden Batkoff, P Casterella, Tyler J Gluckman, and A Lee
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Improving the Value of Transcather Aortic Valve Replacement (TAVR)
Braden Batkoff, Tyler J Gluckman, Robert Hunter, Michael Ring, Leland Siwek, Branden Reynolds, Matthew Forrester, and Steven Thew
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Inverted L Osteotomy for Management of Severe Mandibular Deficiency with Short Posterior Face Height
R. Bryan Bell and Andrew Weeks
From the Publisher:
This trusted, three-volume resource covers the full scope of the field with up-to-date, evidence-based coverage of surgical procedures performed today - including cleft and craniofacial surgeries, oral surgery, oncologic surgery, orthognathic surgery, trauma surgery, surgical pathology, surgery of TMJ disorders, dental implants, dentoalveolar surgery, cosmetic surgery, and reconstructive surgery. More than 4,800 full-color images and illustrations serve as valuable visual references. You'll also find complete guidelines for a wide range of practice issues such as anesthesia, diagnostic imaging, treatment planning, , psychological considerations, office design and ergonomics, plus new information on implants and orthognathic surgery. It's all the information you need to perfect your oral and maxillofacial surgical techniques and provide state-of-the-art care for your patients.
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CLABSI Rangers: A Team Approach to Extinguishing CLABSI
Alisa Bowman, Christine Bartlett, Sarah Gattis, Staci Hartmann, Eddie LeSage, Heidi Mosher, Joya Picket, and Sarah Potts
Purpose: Decrease incidence of Central line Associated Bloodstream Infection (CLABSI) in the ICU/IMCU at Swedish Medical Center by August 31st 2018, with the overall goal of zero CLABSI stemming from the ICU’s.
Synthesis of Evidence: A review of CLABSI costs, the problem as a whole, and products that help decrease CLABSI was completed. Swedish’s current CLABSI state was discussed and ways to improve existing practices investigated. Ideas to engage and educate patients, family and staff in order to bolster infection prevention practices was reviewed.
Change in practice: Based on the evidence and our protocols we began reviewing patient charts for the existence of central line flush orders and discovered they were not being ordered as they should be. We developed a way to catch missing orders by discussing saline flushes during Medical Directed Rounds (MDR’s) and later adopted the intervention. We developed a central line order-set to streamline central line orders. We trialed products making dialysis lines a closed system and educated staff regarding its use. We switched the practice of accessing dialysis catheters using betadine to utilizing alcohol due to its similar efficacy and faster dry time. Many of these changes not only effected ICU practice but the entire First Hill campus.
Implementation: Staff were educated extensively on new products brought in to create a closed dialysis system, products available for patient/family education and documentation in EPIC. We also filmed a series of four short educational videos designed to engage and educate staff. Saline flushes were added to daily rounds sheets to insure they were flushed per protocol and lastly, we required that 1:1 return demonstrations occur for nurses who access dialysis lines.
Evaluation: At nine months post implementation, the Surgical Intensive Care Unit (SICU) had incurred two CLABSI, the Medical ICU (MICU) and Intermediate Care Unit (IMCU) have remained CLABSI free. This is equivalent to an 80% reduction in CLABSI when compared to the same time period the year prior. 93% of RN’s who access dialysis lines were educated and audits of charts show an increase in patient central line education from 41-71%. Target Standardized Infection Ratio (SIR) of < 1 has been met or exceeded and the number of champions recruited has been exceeded as well. Target Standardized Utilization Ratio (SUR) has not been impacted as we had hoped.
Conclusion: Implementing a group of 4 bedside RN’s interested in improving CLABSI rates in the ICU has been effective in decreasing the incidence of CLABSI on the units. Change was affected by educating staff via short videos, posting scrub the hub signage and central line education in patient rooms, implementing saline flush orders during MDRs, the addition of new products keeping the dialysis catheter a closed system and requiring return demonstrations of proper dialysis access. Use of incentives helped to bring about compliance and rewards staff for their excellent work.
Presenting Author: Alisa Bowman RN, CCRN, Nurse Quality Leader for Infection Prevention, Swedish Medical Center, FH ICU
References
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What Health Care Leaders Can Learn From Amazon
Amy Compton-Phillips and Goran Henricks
Leading change in the internet economy takes different thinking and skills then those that got us the healthcare miracles we have today. Tech companies learned they needed to perfect the product, get serious about costs, remove friction, control the last mile, and accelerate careers to disrupt their industry. Healthcare leaders, and the systems they run, can use the same concepts to re-think our entrenched care models of today. Design thinking coupled with a scrupulous focus on value can help create the nimble systems we all want to work (and receive care) in. Learn how to go from idea to action in this interactive, energizing session.
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Teamwork, Communication, and Data: 3 Keys to Large- Scale Practice Change in Opioid Prescribing
Linda Cruz and Ryan Dix
This session will share lessons learned from the four-year implementation of a pain-care pathway across 45 patient-centered medical home (PCMH) clinics in Oregon. Leveraging the PCMH team, communication, and data to improve pain management and reduce risk, Providence Medical Group was able to realize a 68% reduction of patients on high-dose opioids. After this presentation you will be able to:
- Explain a scalable approach, using CDC guidelines, to implement a pathway to reduce opioid prescribing in primary care
- Discuss three key principles of implementing a pain-care pathway in a team-based care environment
- Develop an opioid care pathway action plan at an organization.
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Hospital Libraries: A Path Forward
Basia Delawska-Elliott and Wm. Brian Elliot
Program Description: Despite our profession’s constant evolution to address the changing needs of our users, many health sciences libraries, particularly hospital libraries, are under scrutiny by their institutions. Many of these libraries are facing closure. In fact, a recent study of health sciences library closings [Schwartz, Elkin 2017] found that from 1989-2006 approximately 23-34% of US health sciences libraries closed. Furthermore, between 2011 and 2015, 613 libraries closed, for an average of 115 closings per year [Thibodeau, Funk 2009]. But why? What was the rationale for these closings? Was the decision based solely on economic reasons, or were there other underlying motives? How will providers who lack library services fill their information needs? How can we prevent the closing of additional libraries? This Special Content Session will focus on the ongoing challenges faced by health sciences libraries to remain relevant in an ever-changing world. A panel of speakers will share their experiences with library closures and strategies and best practices for remaining vigilant and promoting library staff, resources, and services effectively. The panel will be followed by an open forum discussion of health sciences library closings in general.
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250 Miles Apart, Saving Lives Together: Stop Sepsis
Ann C. Eells, Christiana Paul, Caroline Williams, Robert Fitting, Mauren Disbot, Bradley Shroeder, Jenifer Rofkahr, and Amy Samolis
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High Reliability + Value Improvement = Learning Organization
Sheri Feeney, Liga Mezaraups, Douglas Meyer, Glenda Battey, and Linda Severs
Experience how the 3rd largest nonprofit health-system is becoming a learning organization. Engaging frontline staff in high reliability and improvement skills is critical to a High Reliability Learning Organization (HRLO). Leaders and staff pursuing daily improvement deliver greater value to patients, each other, business operations, and their communities. Participants will learn how to combine HRO and improvement science so everyone has the skills, will, and freedom to provide more affordable care and attain zero harm.
Objectives:
- Identify successful elements and challenges of implementation and spread of our high reliability behaviors.
- Demonstrate how HRO behaviors are the foundation for daily improvement across a large organization.
- Apply Clinical Value Improvement to empower employees to improve their job, quality, and affordability.
- Learn how HRO and CVI are integral to PSJH’s strategic plan and leadership development.
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Caring for Newborns With Transitional Hypoglycemia: Best Practices for Education Healthcare Providers and Families
Emelia C. Garcia, JoAnn D. Long, and Monica T. Foster
A number of fetal-maternal conditions predispose infants to hypoglycemia. Consensus on postnatal glucose screening and management is mixed contributing to ineffective communication during level of care transition. This project presents evidence informing best practices in how to educate healthcare providers and families of newborns with hypoglycemia.
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Moving Slow to Move Fast-Nursing Handovers-Implementing Electronic to ED Report to Improve Throughput
Dawn Gilbert, Roni Lyons, Patrick Mugrage, and Linda Severs
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Integrate Behavioral Health in the ED and Upstream
Katie Gilligan and Heidi Beazizo
This interactive session will describe the changes being tested by 10 hospitals in the Integrating Behavioral Health in the ED and Upstream Learning Community, convened by IHI and Well Being Trust, to achieve meaningful improvements for patients with mental health and substance abuse conditions, their families, and ED staff. Participants will learn from experts and participating team members, share learning with other participants, and develop action plans for bringing this critical work to their organizations.
After this presentation you will be able to:
- Describe a theory of change and set of core measures to improve patient outcomes, experience, and staff safety while reducing avoidable ED re-visits
- Explain key changes tested by a range of health care organizations and results that can be achieved
- Identify strategies and ideas to test at any organization
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Implementation of an EMR-based continuous electrocardiographic monitoring (CEM) order to reduce inappropriate utilization
Ty J. Gluckman, Maulin P. Shah, Nicole E. Ondoworth, Stephanie C. Fine, Jonathan V. Laius, Wendy W. Yu, Janelle D. Stevens, Shelley L. Schoepflin Sanders, Ruben O. Halperin, Braden W. Batkoff, Robert M. Dressler, and Mark L. Sanz
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Implementation of an EMR-based cardiovascular discharge checklist to close gaps in care
Tyler J Gluckman, Maulin P. Shah, Elizabeth A. Widhalm, Daniel J. Weidert, Stephanie C. Fine, Jonathan V. Laius, Braden Batkoff, and Mark L. Sanz
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Where's the Money? Revenues associated with 3000 Lung Cancer Screens
John Handy Jr., Courtney Wood, Erika Rauch, Kevin Olson, Roshanthi Weerasinghe, Rachel Sanborn, and Micheal Skokan
Objective: Since the National Lung Screening Trial (NLST), lung cancer screening (LCS) has been widely implemented but little is known about LCS finances. We describe revenues associated with screening and immediate downstream clinical activity.
Methods: A lung cancer screening (LCS) program began in November 2013 incorporating 7 hospitals (2 non-university tertiary and 5 community medical centers) and 3 free standing imaging centers. Candidates were referred by primary care providers (PCP). LCS was carried out using the Center for Medicare & Medicaid Services modified NLST eligibility criteria. Dedicated radiologists at the tertiary centers interpreted all LCS, assigning Lung RADS categories. Every Lung RADS 4 LCS was reviewed by the multidisciplinary thoracic disease conference, generating management recommendations. The program coordinator recorded all imaging, procedures, adverse events, pathology, staging and ensured follow up LCS. Clinical and administrative data bases were combined, examining 2013 - May 2017. Weighted average payment (to account for payer differences) and average total costs (direct + indirect) were analyzed. Downstream clinical activity was identified from the index event (LCS) and examining subsequent clinical encounters using relevant ICD10 codes (neoplasm, tobacco use, oncology, etc).
Results: 1950 people underwent initial CT screening, 1160 underwent follow up LCS, totaling 3110 scans. Payers comprised Medicare-65%, commercial-20% and Medicaid-14%. 55 cancers were diagnosed, including 40 non-small cell (stage I-26; stage II-5; stage III- 4 and stage IV-5), 6 small cell and 9 extra-thoracic cancers. Lung cancer detection rate was 2.3%. Intervention included additional imaging (CT, XR, PET, US, MRI, bone scan, mammogram) in 483 (15.5%) and 111 procedures (5.6%). Invasive diagnostic procedures included bronchoscopy (27), CT-guided biopsy (19) and ultrasound guided biopsy (18). 47 surgeries were performed (1.5%). Thoracic surgeries included thoracoscopic lobectomy (21), thoracoscopic wedge resection (6), thoracoscopic anatomic segmentectomy (4) and thoracoscopic pneumonectomy (1). Adverse event rate for procedures was 10.8% (0.6% of all screened patients). One lobectomy patient died, yielding a 2.1% surgical mortality. LCS Revenues Events Average Total Cost Average Total Payment Net Margin LCS 2781 $357,493 $393,491 9.1% Additional imaging resulting from LCS 483 $129,492 $187,138 30.8% Downstream clinical activity 263 $654,340 $703,448 7%
Of the downstream clinical activity, thoracic surgery contributed 34%, medical oncology 21%, general surgery 19%, and pulmonology 14%.Conclusion: Beyond the substantial human and financial benefits of identifying curable early stage lung cancer, a low dose CT lung cancer screening program is profitable. 55% of payment results from downstream clinical activity while the LCS itself and additionally generated imaging generated 45%. This information can be used to allocate costs of a LCS program to clinical services and radiology.
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#Work2BeWell Powered by Providence Health & Services
Robin Henderson and Mary Renouf-Hanson
Improving mental health and emotional well-being is the focus of many community health assessments and prevention efforts. This session will focus on innovative ideas that engage youth and their families where they are—in schools, communities and while seeking healthcare. Learn from healthcare leaders at Bellin Health, Cincinnati Children’s, Providence St Joseph Health and East London NHS Foundation Trust and their community partners as they share their successful efforts to change the conversation with today’s youth.
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Changing Culture One PDSA at a Time: The Creation of an Innovation Unit
Jennifer Hoople, Gale Arnold, Jennifer Bletscher, Shawna Bolgen, Andy Branca, Tana Case, Matthew Dietz, Jennifer Ferenczy, Heather Haake, Janine Holbrook, Ingrid Jonely, Liga Mezaraups, Jessica Osantowski, Jessica Sehorn, Linda Severs, and Dina Shepelyuk
An inpatient unit in an acute care hospital was designated as an Innovation Unit. This unit was challenged with the creation of culture change in regards to process improvement. The team learned to use Improvement Science to facilitate rapid and innovative process improvements. These changes have enhanced the quality of healthcare provided while decreasing cost. The poster highlights some of the Improvement Science processes, forms, and roles of the team as well as some of the projects and successes.
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A Systematic Review and Meta-Analysis of Dual Antiplatelet Therapy Versus Antiplatelet Monotherapy After Coronary Artery Bypass Graft Surgery
Leonardo Knijnik, Rhanderson Cardoso, Manuel Rivera, Gilson Costa Fernandes Filho, Amanda Fernandes, John McEvoy, Seamus Whelton, Tyler J Gluckman, and Roger Blumenthal
Background
The role of dual antiplatelet therapy (DAPT) after coronary artery bypass grafting (CABG) is controversial, particularly among patients with stable ischemic heart disease (IHD).
Methods
We performed a systematic review and meta-analysis comparing DAPT to antiplatelet monotherapy following CABG. Subgroup analyses were performed in randomized trials (RCTs), stable IHD, extended duration DAPT (≥ 6 months), and long-term follow-up (≥ 2 years).
Results
Twenty studies and 19,795 patients were included, of which 7301 (37%) received DAPT after CABG. Overall, DAPT was associated with a significant reduction in cardiovascular (CV) mortality (OR 0.66; p=0.01; Fig 1A) and a trend towards lower all-cause mortality (0.78; p=0.08). There were no between group differences in total mortality, CV mortality, myocardial infarction, or stroke in thesubanalyses of RCTs, stable IHD, extended DAPT, and long-term follow-up. Vein graft occlusion up to 1 year after CABG was significantly lower with DAPT in the overall analysis (OR 0.64; p=0.01; Fig 1B) and in RCTs (OR 0.58; P
Conclusion
Although DAPT is associated with a lower CV mortality in an unselected population after CABG, our findings suggest that routine DAPT after CABG does not improve clinical endpoints when evaluated in RCTs or in patients with stable IHD, but does reduce rates of early vein graft occlusion.
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Bridging the Gap: An Innovative Web-Based Approach for Evaluating EBP Readiness in Direct Care Nurses
JoAnn D. Long, Stacey L. Spradling, Karen Baggerly, Nikki L. Galaviz, and Jamie Roney
The provision of universal and equitable access to safe and effective healthcare emphasized in The 2012 World Health Report, 'no health without research': The endpoint needs to go beyond publication outputs, has forwarded the global evidence-based practice (EBP) movement (Zachariah et al., 2011). Notably, Lindeman (1975) identified research utilization and quality improvement as nursing priorities over forty years ago. Yet, current literature suggests research findings may take seventeen years to reach practice integration (Morris et al., 2011). Notably another dilemma added to the challenge is approximately 80% of current nursing practice does not reflect evidence-based nursing decisions (Conner, Dwyer, and Oliveria, 2016). Peer reviewed literature report direct care nurses self-identify lack of resources, time, and critical appraisal skills to navigate current literature (Yoder et al., 2014). Proficient skills of direct care nurses to acquire and appraise existing studies can be the catalyst translating scientific knowledge to the bedside; however, an understanding of the baseline knowledge and readiness of front-line providers is limited. Organizations worldwide are challenged to overcome these self-reported barriers to implementing and adopting research findings into clinical nursing practice. The purpose of this research study was to determine the self-perceived online research and critical appraisal skills and the EBP readiness and knowledge of front-line nurses from three care facilities in the southwest United States.
Methods: A cross-sectional exploratory descriptive design was used in this study. The Stevens EBP Readiness Inventory and EBP Knowledge Assessment questionnaires were used to assess direct care nurses’ self-reported evidenced-based readiness and baseline EBP knowledge. Research skill was measured using four questions adapted from the Research Readiness Self-Assessment tool. Informed consent was obtained from (N=49) Registered Nurses volunteering to participate. The survey questionnaires were administered online to nurses volunteering to participate from 22 nursing units during a 3-week period in May 2017.
Results: Demographic, descriptive, and frequency distributions were examined.Front-line nurses expressed the highest level of self-confidence in four questions pertaining to the area of use and implementation of clinical practice guidelines. The study data were analyzed using SPSS version 25. The highest area of perceived evidence-based practice readiness was ability to “deliver care using evidence-based clinical practice guidelines” with a mean 4.5, SD, 1.55; “use of agency-adopted clinical practice guidelines”, mean, 4.29, SD, 1.60; “choose evidence-based approaches over routine as a base for own clinical decision making”, mean 4.2, SD, 1.60; and “participate in evidence-based quality improvement processes to evaluate outcomes of practice changes”, mean, 4.02, SD, 1.49. In comparison, the lowest areas of self-confidence for evidence-based practice centered on a range of topics reflected in three questions reflecting the ability to assess the “major facets to be assessed when using clinical practice guidelines”, mean, 2.77, SD, 1.18; “ability to identify statistics commonly used in evidence summaries”, mean, 2.96, SD, 1.18; and “ability to conduct expert search strategies using pre-constructed strategies in major databases”, mean, 2.67, SD, 1.21. The remaining 14 questions assessing evidence-based practice readiness ranged from a low mean score of 3.02 – 3.69, reflecting scores falling approximately half-way between having “very little” to having a “great deal” of evidence-based readiness.
Conclusion: While front-line nurses reported high levels of self-confidence for using EBP to implement and deliver care using clinical practice guidelines, they also expressed lower knowledge and self-efficacy with use of more advanced EBP skills. Strengthening nurse online search skills was identified as the most important learning deficit in this sample of Registered Nurses. Limitations of this study included a voluntary and relatively small sample size and cross-sectional design. Findings from this study helped identify objective data to guide focused organizational education efforts to improve direct care nurses’ use of EBP and research concepts necessary to integrate research into clinical practice.
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Medication Safety Zone to Promote Uninterrupted Medication Administration
Sandy Martir and Trisha Saul
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Improving Engagement in an Emergency Department: A Quality Improvement Project
Roxanne McGray, Mary Waldo, and Catherine Van Son
Purpose: This quality improvement, doctorate of nursing practice (DNP) project assesses the need for and evaluates the impact of an engagement intervention focused on improving nurse, physician, and emergency department technician (EDT) engagement within an emergency department.
Background: Engagement is defined as an energetic state of involvement with personally fulfilling activities that enhance one’s sense of professional efficacy and is characterized by vigor, dedication, and absorption. While a significant amount of research exists that correlates the relationship between low nurse engagement levels with high turnover rates, there is little known about the effectiveness of interventions aimed at improving nurse engagement. Therefore, a project evaluating the impact of an engagement intervention on increasing engagement levels for all staff was piloted in an emergency department.
Methods: In September 2017 staff (physicians, nurses and EDTs) who work in the emergency department (N=69) completed a pre-intervention survey to assess baseline engagement levels, using the Utrecht Work Engagement Scale (UWES). The preintervention survey included open-ended questions developed by the project team to solicit qualitative information regarding engagement, as well as demographic questions. The preintervention data revealed overall low engagement levels of participants (m = 2.10, sd = 1.63, n=40). The dedication subscale had the lowest mean (m = 1.30, sd = 1.49), while the absorption subscale had the highest mean (m = 2.53, sd = 1.78); the vigor subscale fell between these two means (m = 2.33, sd = 1.59). The open-ended pre-intervention survey results, along with recommendations from the literature and guided by the six areas of worklife framework, were used to guide the design of the unit-based engagement intervention. Some of the interventions will include enhanced staff recognition, activities to improve the sense of community within the department, increased accountability of staff members, augmented shared governance structures, and improved follow-through by the leadership team when staff suggestions are presented. The post-intervention survey will be administered in March 2018 following the intervention phase of the project. Pre- and postintervention survey results and the intervention will be presented.
Outcomes: The level of staff engagement is the primary outcome of this quality improvement project. Pre- and post-intervention survey data will be compared to understand the effectiveness of the intervention designed to increase engagement in the emergency department. The outcomes of this project will help to inform future interventions focused on supporting and maintaining high levels of staff engagement.
Conclusion: Staff engagement is integral to the vitality of the healthcare workforce. A onesize- fits-all approach is not enough to keep staff engaged, excited to come to work, and able to provide the best care for their patients. Listening to staff suggestions and creating an individualized approach for each unit is essential to keep the workforce engaged.
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