Round 2 Grants
The Robert Wood Johnson Foundation (RWJF) awarded the second round of grants through its Interdisciplinary Nursing Quality Research Initiative (INQRI) program on September 1, 2007. Twelve teams of nurse scholars and scholars from other disciplines were selected to conduct two-year research projects to examine the link between nurses' contributions and the safety and quality of patient care.
Round 2 Grants
Translating Fall Risk Status into Interventions to Prevent Patient Falls
Brigham & Woman's Hospital
Dr. Patricia Dykes
Dr. Blackford Middleton
A team led by Patti Dykes and Blackford Middleton has created a tool designed to prevent patient falls by translating an individual patient's fall risk assessment into a decision support intervention that communicates fall risk status, and creates a tailored plan that is accessible to care team members (including patients and family members) to prevent falls. The team constructed the Fall Prevention Toolkit (FPTK), and conducted a randomized controlled trial to examine whether the FPTK led to a decrease in the incidence of patient falls and a decrease in the incidence of patient falls with injury. The use of their toolkit did significantly lower the incidence of falls in the intervention units and several units wished to continue using the tool after the conclusion of the study. By establishing links between nursing fall risk assessment, risk communication and tailored interventions to prevent falls, Dykes and Middleton hope to raise awareness of fall risks for patients , nurses and other providers and to lower mortality and morbidity for potential fall victims.
Rural Hospital Quality Collaborative on Evidence-Based Nursing
University of Maryland
Dr. Robin Newhouse
Dr. Laura Morlock
Researchers at the University of Maryland and Johns Hopkins University, led by Robin Newhouse and Laura Morlock, recently concluded a study which identified the linkages between processes of nursing care and the quality of patient outcomes, while also addressing the pressing need for mentorship in implementing evidence-based heart failure (HF) care in rural hospitals. The team conducted a randomized control trial with twenty three rural hospitals from five states in the eastern United States. In the course of their project, the team found that heart failure core measures improved significantly between 2007 and 2009, but that nursing support and staffing does not predict core measure improvement. Heart failure core measures are reported by acute care hospitals as a measure of quality care for HF patients. They found that there is no relationship between the smoking cessation core measure, nursing smoking cessation counseling activity, and patient intent to quit smoking. Finally, they found that nurses in better practice environments use more evidence-based smoking cessation interventions. This study is one of the first to focus on linkages between rural nursing and patient outcomes, and has affected the engagement of nurses in 23 rural hospitals in improvements in heart failure care. Qualitative evidence suggests profound changes in the uptake of evidence and the formation of multidisciplinary teams.
Nursing Workforce Impact on Performance Improvement in the CMS/Premier Hospital Quality Incentive Demonstration Project [HQID]
University of Minnesota
Dr. Ira Moscovice
Dr. Mary Wakefield
The Deficit Reduction Act of 2005 directs the Secretary of Health and Human Services to implement a nationwide value-based purchasing program for all PPS hospitals beginning in fiscal year 2009. This interdisciplinary team examined the impact of nurse staffing and nurses' work environment on hospital performance improvement in the CMS/Premier Inc. Hospital Quality Incentive Demonstration (HQID) project. HQID is the first CMS demonstration on the impact of hospital pay-for-performance.
Quality of Pediatric Nursing Care from the Children's Perspective
Columbus Children's Hospital
Dr. Nancy Ryan-Wenger
Dr. William Gardner
This interdisciplinary research team identified hospitalized children's perceptions of the linkages between the quality of nursing care and outcomes. This study identified the nursing care processes and outcomes that matter most to children during their hospitalization, and estimated the extent to which disparities exist in the quality of their care and outcomes. The results of this study have value in themselves, but also provide valid content for new age-appropriate patient satisfaction scales for hospitalized children.
Quality and Cost Outcomes of Hospital Supplemental Nurse Staffing
University of Rochester
Dr. Ying Xue
Dr. Deborah Freund
A team of researchers at the University of Rochester, led by Ying Xue and Deborah Freund, conducted a study to better understand one hospital's use of supplemental registered nurses (SRNs) and examine its impact on patient and nurse outcomes and cost. Using focus groups, interviews, mail surveys, chart reviews and reviewing hospital administration data, the team found that use of SRNs varied greatly by unit and that typically permanent RNs have similar experience and more education (BSN or higher degree). Although, the use of supplemental nurses occurred more frequently in units that were rated as having poor working environments, the team did not find that their use had any negative impact on patient or nurse outcomes. The findings of this project will further understanding of the impact of SRNs on quality and cost outcomes and help hospital administrators make evidence-based strategic plan for nurse staffing.
Examining the Impact of Nursing Structures and Processes on Medication Errors
Rutgers University
Dr. Linda Flynn
Dr. Dong Suh
A multi-disciplinary team at Rutgers University, led by Linda Flynn and Dong Suh, has identified changes in nursing care processes needed to prevent medication errors as well as adjustments in nurse staffing and the practice environment that can facilitate interception of such errors. This is the first study of its kind to show how predictive practice environments and nurse staffing levels are when it comes to medication errors. Preliminary findings reveal that there is a foundational nurse safety processes that are significantly associated with fewer medication errors. These include critical thinking and questioning, such as asking physicians to clarify or rewrite unclear orders, as well as independently reconciling patient medications and educating patients and families. This team also found that hospitals with supportive practice environments including having front-line managers, allowing nurses to participate in organizational decisions, and nurses having good collaborative relationships with physicians were key quality indicators. Finally, hospitals that had more RNs per patient were found to be places where nurses were more likely to engage in safer practices. The study also looked at the role of computerized physician order entry (CPOE). Findings reveal that full implementation of CPOE reduced medication errors significantly.
A Quality and Cost Analysis of Nurse Practice Predictors of Readiness for Hospital Discharge and Post-Discharge Outcomes
Marquette University
Dr. Marianne Weiss
Dr. Olga Yakusheva
Improving how patients are discharged from the hospital to reduce unnecessary readmissions is a critical issue now being debated at the national level. With one in five elderly readmitted to the hospital within 30 days at an annual cost to Medicare of $17 billion, policymakers are seeking cost-effective solutions to better transition patients from hospital to home. Researchers at Marquette University, led by Marianne Weiss and Olga Yakusheva, have been studying what hospital-based nurses do to influence outcomes after a patient is discharged from a hospital. Specifically, they identified the contributions that nursing staff make to the quality of discharge teaching and the impact of that teaching on patient outcomes, readiness and readmission rates of patients who are discharged home. They have found that when units had more RN hours per patient day, fewer overtime hours and fewer vacancies, the discharge teaching was of higher quality, patients reported greater readiness for hospital discharge, and post-discharge utilization of readmission and emergency room visits was lower.
Linking Processes of Nursing Care and Patient Safety Outcomes: An Analysis of the Cause and Effect of Safe Practice
Medical University of South Carolina
Dr. Richard Lindrooth
Dr. John Welton
This interdisciplinary team examined how adoption of the National Quality Forum (NQF) safe practices affects nursing sensitive patient safety outcomes. Barriers to adoption of these practices were also explored. This team took a step beyond existing literature by testing whether the implementation of safe practices leads to more effective use of nurses, and whether this leads to better performance on patient safety outcomes.
Acuity-adjusted Staffing, Nurse Practice Environments and NICU Outcomes
University of Pennsylvania
Dr. Eileen Lake
Dr. Jeannette Rogowski
Large variations in outcomes exist across neonatal intensive care units (NICUs) that cannot be explained by patient or NICU differences. This interdisciplinary team examined acuity-adjusted nurse staffing levels and nursing practice environments in the NICU and their effects on very low birth weight (VLBW) infant mortality, morbidity, failure-to-rescue and length of stay. While VLBW infants account for only 1% of births, half of infant deaths each year occur within this population. Since NICU cases are among the most nurse-intensive hospitalizations, nursing holds promise for explaining the variations and for improving the outcomes of these high-risk infants.
Nursing Care Quality in Acute Care Hospitals: New Linkages to Patient Outcomes
University of California
Dr. Arlyss Anderson Rothman
Dr. R. Adams Dudley
Led by Arlyss Anderson Rothman and R. Adams Dudley, a team at the University of California, San Francisco examined whether increases in nurse staffing and skill mix improve hospital performance on a subset of Joint Commission core measures, enhance patient perceptions of nursing performance, and improve overall nursing performance as measured by composite indicators that capture patients' perceptions of care and other selected outcomes of care such as complication rates. Researchers found that, for measures in which nurses were dependent on the actions of others (such as pneumonia vaccination screening and the delivery of beta-blockers on arrival for acute myocardial infarction patients) or shared responsibility with others (such as pressure ulcer prevalence) the impact of nurse staffing on performance was mixed. However, when patients were asked about aspects of care in which nurses functioned independently, there were more consistent, statistically significant correlations between patients' assessments of the quality of their hospital care and nurse staffing. This work comes at an important time as increased public reporting of hospital performance and the emergence of hospital pay-for-performance initiatives provide new impetus to define all aspects of hospital care.
Impact of System-Centered Factors, and Processes of Nursing Care on Fall Prevalence and Injuries from Falls
University of Iowa
Dr. Marita Titler
Dr. Gary Rosenthal
Patient falls represent the largest category of hospital incident reports (70%-80%) and are among the most common adverse events. This interdisciplinary team examined linkages among selected NQF nurse-sensitive measures and processes of care to prevent falls. Specifically, the team investigated linkages between level of professional nursing practice and adoption of evidence-base practices, fall prevalence and injury from falls.
Nursing-Pharmacy Collaboration on Medication Reconciliation: A Novel Approach to Information Management
Johns Hopkins Hospital
Dr. Linda Costa
Dr. Robert Feroli
About 400,000 patients are affected by adverse drug events (ADEs) each year at a national cost of approximately $3.5 billion. Johns Hopkins Hospital researchers, led by Linda Costa and Bob Feroli, have evaluated the effectiveness of a nurse-pharmacist clinical information coordination team in improving medication reconciliation management on admission and discharge, quantified potential harm due to reconciliation failures and determined the cost-benefit related to averted harm. Preliminary findings quantify how much each adverse drug event costs based on the literature, the cost of the nurse-pharmacist intervention and how many ADEs could be avoided with appropriate intervention. Elements of the intervention include having nurses obtain home medication lists from patients, using a set of criteria to involve the pharmacist, and accessing multiple sources including community pharmacists and primary care physicians to complete the list. Discrepancies between the admission and discharge medication orders were resolved by consultation with the hospital provider. Thus far, their work suggests that medication reconciliation at the time of admission and at discharge is important in avoiding ADEs, improving patient safety and reducing healthcare costs.