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Hospital Consult - October 2015

Hospital Access Management - Hospital Case Management - Hospital Employee Health
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Influx of Younger RNs Help to Moderate Nursing Shortage

BOZEMAN, MT – A decade ago, about 20,000 baby boomer RNs left the workforce each year. In the next decade, that number is expected to increase to 80,000.

With more than a million RNs already older than 50, does that mean an even more devastating nurse shortage is on the horizon?

Not really, according to a new study published in the journal Medical Care. In fact, researchers from Montana State University, have some reassuring information.

“We project that this outflow will be more than offset by continued strong entry of new RNs into the workforce,” they write, although still warning of a shortage of nurses as the number of baby boomer patients increase.

"Overall, we project that the registered nursing workforce will increase from roughly 2.7 million full-time equivalent registered nurses in 2013 to 3.3 million in 2030," said lead author David I. Auerbach, PhD, a healthcare economist. "However, this is contingent on people still entering the nursing profession at the current rate – which is higher than anyone anticipated."

The researchers credit national initiatives to make nursing a more attractive profession as well as the recession of 2008, when students entered nursing school for a more stable career, for creating a better outlook. In fact, they report, nursing school enrollments – and the number of young RNs in the workforce – doubled over the first decade of the 2000s.

"It's important to keep in mind that this doesn't get us out of the woods, the woods just are not as dark and scary as they appeared,” emphasized Peter I.Buerhaus, PhD, RN, director of Center for Interdisciplinary Health Workforce Studies. “We still project the nation will have a shortage of around 130,000 nurses by 2025, which is by no means a small number, but not the overwhelming shortage that we had once anticipated.”

For the retrospective cohort analysis of employment trends by birth year and age, the researchers looked at data on employed RNs from the United States Bureau of the Census Current Population Survey, 1979-2000, and the American Community Survey, 2001-13.

The study projects that the RN workforce should reach its peak average age of 44.4 this year.

“This increase in workforce size, which was not expected in forecasts made a decade ago, is contingent on new entry into nursing continuing at its current rate,” the researchers write. “Even then, supply would still fall short of demand as recently projected by the Health Resources and Services Agency in the year 2025 by 128,000 RNs (4%).”

Related [Live Webinar]: The Latest and Greatest CMS Nursing CoPs

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Most Cardiac Arrest Inpatients with Poor Prognosis Don’t Opt for DNRs

KANSAS CITY – Do-not-resuscitate (DNR) orders are designed for use by patients with a poor prognosis for favorable neurological survival, such as being revived without severe cognitive disability.

In fact, that’s the way it generally works for those who survive an in-hospital cardiac arrest: The presence of a DNR typically is in line with their prognosis, according to a study published recently in the Journal of the American Medical Association.

Yet the study led by researchers from Saint Luke's Mid America Heart Institute in Kansas City also found that nearly two-thirds of patients least likely to have a favorable neurological survival did not have DNR orders.

"Among patients with a low likelihood of favorable neurological survival after in-hospital cardiac arrest, our findings highlight the potential to improve DNR decision making,” the authors write.

Background information in the article notes that in-hospital cardiac arrest affects nearly 200,000 patients in the United States annually, with fewer than 20% having favorable neurological survival.

Using the Get With The Guidelines-Resuscitation registry, the research team identified 26,327 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest between April 2006 and September 2012 at 406 U.S. hospitals. Each patient's likelihood of favorable neurological survival was calculated, and the proportion of patients with DNR orders within each prognosis score group and the association between DNR status and actual favorable neurological survival were examined.

Results indicate that 23% of the patients had DNR orders within 12 hours of ROSC, usually older patients with a high rate of comorbidities. While 7% of patients with the best prognosis had DNR orders, even though their predicted rate of favorable neurological survival was 65%, 36% of the patients with the worst expected outcomes opted against resuscitation, despite an expected favorable neurological survival rate of just 4%. That pattern continued after 24 hours, 72 hours, and five days past ROSC, according to the study.

Study authors also point out that “patients who had DNR orders despite a good prognosis had significantly lower survival and less resource use than patients without DNR orders who had a similar prognosis after ROSC.”

In an accompanying editorial, JAMA associate editor Derek C. Angus, MD, MPH, of the University of Pittsburgh, notes, "In summary, when a cardiac arrest occurs in hospital, healthcare teams are good at rushing in to provide robust resuscitative effort.

"However, after successful ROSC, just as after the initial response to any disaster, it is clear the work has only just begun. Hopefully in the future, standardized delivery of high-quality evidence-based resuscitation guidelines for cardiac arrest will be followed by equally high-quality standard approaches to ensure patients and families are supported optimally, regardless of prognosis."

Related [Live Webinar]: Advance Directives Update: What Every Healthcare Provider Should Know


HRM horizonal


Lapses in Nursing Care Can Have Detrimental Effect on Patient Surveys

PHILADELPHIA – As hospital managers well know, overworked nurses often are unable to tick off every task on their list before a shift ends. The question is how that failure to complete nursing care affects the patient experience.

A study published recently in BMJ Quality & Safety sought to quantify the answer by describing the prevalence and patterns of missed nursing care and looking at the impact on patient satisfaction.

The study team, led by researchers from the University of Pennsylvania and McKinsey & Company, suggests, “As nurses are the principal care provider in the hospital setting, the completion or omission of nursing care is likely to have a sizable impact on the patient care experience. However, this relationship has not been explored empirically.”

Using secondary nurse and patient survey data from 409 adult non-federal acute care U.S. hospitals in four states, the researchers found that, in an average hospital, nurses missed 2.7 of 12 required care activities per shift.

In fact, 73.4% of nurses reported missing at least one activity on their last shift. The percentage ranged from 25 to 100 across hospitals. Most commonly, nurses reported they had been unable to comfort or talk with patients, 47.6%, or plan care, 38.5%.

At the same time, 6 out of 10 patients rated hospitals highly, ranging from 33% to 90% across the facilities, according to the report.

Yet, at hospitals where nurses missed more care, 2.2% fewer patients rated the hospital highly, according to the report.

That’s especially important, the researchers note, now that CMS is tying reimbursements to scores on instruments such as the Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS).

“Patients have poorer care experiences in hospitals where more nurses miss required nursing care,” the authors write. “Supporting nurses’ ability to complete required care may optimize the patient care experience. As hospitals face changing reimbursement landscapes, ensuring adequate nursing resources should be a top priority.”

With HCAHPS, patients rate their inpatient stay in 27 categories, including communication with nurses and nursing care. The scores factor into whether hospitals gain or lose up to 1.5% of their Medicare payments in fiscal year 2015, rising to 2% by fiscal year 2017.

Related [On-Demand Webinar]: Admission and Discharge Time Outs: Tools for Effective Gap Elimination


Rapid Assessment Can Detect Delirium in Hospital Patients in Seconds

UNIVERSITY PARK, PA – In less than a minute, hospital clinicians can determine with a high rate of accuracy whether an older patient is suffering from delirium.

So says a study published recently in the Journal of Hospital Medicine. The assessment instrument consists of just two questions, according to the study team.

"Delirium can be very costly and deadly – and with high-risk patients, time matters," said lead author Donna M. Fick, PhD, of Penn State. "Our ultra-brief two-item bedside test for delirium takes an average of 36 seconds to perform and has a sensitivity of 93%."

Co-author Edward R. Marcantonio, MD, of the Harvard Medical School, recently developed the 3D-CAM, a 3-minute confusion assessment method, to help quickly identify patients with delirium. In developing the new, more concise instrument, Fick said she and Marcantonio wanted to develop an assessment that would be easier to use at the bedside and take less time for a busy nurse or hospitalist.

"We started by looking for one question that could detect delirium, but we could only get 83% sensitivity, which is not good enough," Fick said.

Eventually, the study team settled on two questions that proved to have 93% sensitivity in identifying delirium: Asking what day of the week it was and to recite the months of the year backwards.

If a patient failed to answer those two questions correctly – indicating a strong possibility of delirium – the 3D-CAM was administered.

The 201 study participants, 62% female, were patients at an academic medical center with a mean age of 84. Of those, 21% patients were found to have delirium based on the assessment. The two-item test identified 48 as possibly delirious – 42 were identified correctly, with six false positives.

Researchers note that the item with the best test characteristics was the “months of the year backwards” question with a sensitivity of 83% and specificity of 69%.

Before the test can be widely recommended, however, "These results still need to be validated, with a very large sample,” Fick said.


CMA horizonal


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