Journal of the American Association of Nurse Practitioners最新文献

Background: Cervical cancer is the fourth most common cancer in women. Early detection with screening methods can help to prevent mortality.

Local problem: Cervical cancer screening is below national standards at a Midwest Federally Qualified Health Center and may compromise future funding. A manual chart review of cervical cancer screening was compared with an electronic health record-generated report and found results from outside facilities accounted for 27% of the metric's underperformance. This quality improvement project aimed to improve the Uniform Data System performance for cervical cancer screening at a specific health center from 46.3% to 79.2% by July 2024.

Methods: Implementation, guided by the Improvement Model and Lewin's Change Theory, included (1) analysis of cervical cancer screening underperformance, (2) sharing data with key stakeholders, and (3) creating tip sheets for chart reconciliation.

Interventions: Interventions consisted of (1) auditing and reconciling charts from Epic's generated reports, (2) modifying the frequency of or discontinuing Pap smears, (3) updating surgical history to reflect hysterectomy type, and (4) sending scheduling outreach messages.

Results: As of March 2024, cervical cancer screening 2023 percentages increased by ≥9% for each quarter and by 8.7% for year-to-date at the Midwest health center. The quality metric's quarter 1 and 2, 2024 data increased by 4% and 3% as of July 2024.

Conclusions: Although the target goal was not reached in the designated time frame, the percentage increase proves that implementation of a chart reconciliation workflow can improve rates for cervical cancer screening at a Federally Qualified Health Center.

Background: Hepatic encephalopathy (HE) is a common neurocognitive cirrhosis-related complication with a broad range of symptoms. Timely recognition and treatment of HE, including identifying precipitating factors, when possible, is critical for improving outcomes in patients with cirrhosis. Lactulose and rifaximin therapies, as appropriate, are recommended for patients with cirrhosis and a history of HE episode(s) to reduce risk of HE recurrence.

Objectives: To provide clinical considerations for nurse practitioners and physician assistants (PAs) on the diagnosis and management of patients with cirrhosis.

Data sources: A PubMed search of English-language articles published between January 1, 2008, and March 13, 2024, was performed to identify publications on the diagnosis and treatment of HE.

Results: Important topics to address when discussing care with patients with cirrhosis and their caregivers include concomitant medication use, recent infection history, comorbid conditions (e.g., diabetes), fall and frailty risks, and sleep quality. In addition, ensuring treatment adherence is important for reducing the risk of future HE episodes and HE-related hospitalizations. Engaging and empowering caregivers helps reinforce the need for patient adherence to treatment and facilitates earlier identification of HE symptoms.

Conclusions: Early recognition of HE, treatment, and reduction in risk of recurrence are imperative to minimize patient morbidity and mortality.

Implications for practice: Nurse practitioners and PAs play an important role in supporting patients with cirrhosis who are at risk for developing HE, as well as their caregivers. Understanding and recognizing precipitating factors and clinical symptoms of HE and treating and preventing HE recurrence can improve patient outcomes.

Background: Oral health screening and access to dental care in adults with diabetes lead to improved health outcomes and quality of life. Patients with barriers to accessing health services have a greater risk of poor medical and dental outcomes. People with diabetes are more likely to have periodontal disease and less likely to visit a dentist.

Local problem: Oral screening and dental referrals were not being done at a community health clinic in Plano, Texas.

Methods: The aim of this 6-month quality-improvement project was to increase oral health screenings in adults with diabetes from 0% to 80%; subaim was to increase access to dental services by increasing referrals from 0% to 50%. Adults with diabetes without insurance or dental care in the past 12 months were eligible for the project ( n = 263). Outcome measures were tracked using a longitudinal chart.

Interventions: Eligible patients were screened and referred to a dental office with an income-based financial assistance program using Plan-Do-Study-Act methodology. Staff education, referral order set, and follow-up calls were additional processes implemented.

Results: Fifty-two percent of eligible patients were screened, 35.9% were referred to dental services, and 17.7% of those referred established care with dental clinic.

Conclusions: Interventions were successful in improving access to dental care, although target goal was not met. Creating systems that facilitate interdisciplinary care improved health equity and standards of health in chronic disease.

Background: Diabetes management is challenged by the complexity of treatment regimens and the need for frequent injections, affecting patient adherence and quality of life. Insulin icodec, a once-weekly basal insulin analog, represents a significant innovation, potentially simplifying diabetes care and improving outcomes.

Objectives: This review aims to evaluate the safety, efficacy, and clinical implications of insulin icodec for individuals with type 1 and type 2 diabetes, highlighting its potential to affect current treatment paradigms.

Data sources: A review was conducted comparing once-weekly insulin icodec with daily basal insulin analogs using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to ensure transparent reporting of systematic reviews. A search was performed in the following databases: PubMed, Google Scholar, Embase, and ClinicalTrials.gov , focusing on efficacy and safety outcomes.

Conclusions: Insulin icodec has demonstrated effective glycemic management and a safety profile comparable to daily basal insulins. Its extended half-life and steady-state glucose-lowering effect have the potential to reduce the burden of daily injections and improve patient adherence.

Implications for practice: The introduction of once-weekly insulin icodec represents an advancement in diabetes care. For front-line clinicians, this innovation aligns with the need for more straightforward medication regimens. Coupled with continuous glucose monitoring systems, it enables a more personalized and efficient approach to diabetes management, with the potential to improve patient satisfaction and clinical outcomes. This underscores the impact of integrating such advancements into practice, highlighting the role of nurse practitioners and physician assistants in adopting these innovations to optimize patient care.

Abstract: Hypophosphatasia (HPP) is a rare genetic metabolic bone disorder that is underdiagnosed. Although there are many forms of this disease, based on age of onset, symptoms, and severity, HPP is characterized by low serum alkaline phosphatase levels, bone fractures, and dental complications. Diagnosis of HPP is made from clinical, laboratory, and radiologic findings. Genetic testing for an ALPL gene variant responsible for causing HPP confirms a molecular diagnosis. Distinguishing HPP from other more common bone disorders, such as osteoporosis, is important as the treatment for these diseases differs greatly. Although there is no known cure for HPP, treatment should be holistic and multidisciplinary.

Background: An individual's inability to self-identify or refusal to acknowledge an analgesic adverse drug event (ADE) lengthens the time to ADE treatment and resolution and may worsen the outcome.

Purpose: The purpose was to describe how people who experienced an analgesic ADE during pain self-management respond to the event and to identify predictors of serious analgesic ADEs.

Methodology: The design was a secondary data analysis. The sample consisted of 599 adult cases that had an analgesic ADE during pain self-management and reported their response to the ADE, the analgesic, a description of the ADE, demographic, and health data. Logistic regression was used to test predictors of serious versus nonserious analgesic ADEs.

Results: Three-fourth (75.5%) of cases indicated the ADE was easy to connect to the analgesic. The majority (72.6%) stopped the medication. Most (71.9%) talked with their provider. Serious ADEs such as gastrointestinal bleeding occurred in 16.2% of cases. Significant predictors of serious analgesic ADEs included less than a baccalaureate degree, male gender, and a higher Analgesic Adverse Drug Event Measure score.

Conclusions: Adults who experience an analgesic ADE generally respond in an injury prevention way. A smaller group of individuals who experienced a serious analgesic ADE did not seem to differentiate between serious and nonserious ADEs.

Implications: To promote safe pain management when prescribing new analgesics, providers should highlight common serious ADEs and instruct patients to contact them if an ADE emerges and to seek immediate care if they suspect a serious ADE.

Abstract: Increased complexity of the health care system has led to challenges of vital communications, such as a current and accurate patient medication list. Medication reconciliation aims to create the most comprehensive and accurate list of a patient's current medications by comparing it with their electronic health record. However, effectively gathering, organizing, and communicating this medication information across different stages of care is often complex and challenging. Fragmented provider groups and incompatible software systems can also lead to breaks in communication and contribute to medication discrepancies. Medication reconciliation is an evidence-based safety intervention that can decrease medication errors and patient harm. Primary care providers play a critical role in ensuring a patient's medication list is current and accurate.

Background: Pediatric nurse practitioners (NPs) play an essential role in achieving optimal child health. However, few studies have examined barriers to implementing pediatric NP roles.

Purpose: The purpose of this study was to identify challenges in pediatric NPs' practice that limit their ability to provide care.

Methodology: The authors conducted a secondary, qualitative analysis of survey data collected by the National Association of Pediatric Nurse Practitioners. The authors analyzed data from one open-ended question, "What is the biggest challenge to the pediatric-focused NP role?" An inductive thematic analysis resulted in discovery of 18 themes.

Results: A total of 980 pediatric NPs responded, most (67.9%) were primary care pediatric NPs, and 15.2% were acute care pediatric NPs. Challenges aligned with four megathemes: who we are, what we can do, what we need, and what our patients need.

Conclusions: Pediatric NPs identified barriers to role recognition that align with improving professional identity.

Implications: Future research should address barriers to role recognition that can increase the ability of pediatric NPs to provide child health care.

Abstract: Human trafficking is a proliferating abuse within the United States in which persons who are victimized frequently interface with clinical environments across the care continuum with a variety of presentations for health needs. However, in the absence of uniform standards for evidence-based training among the health professions, recognition and response in these scenarios remains low. This case study presents a young adolescent female accessing primary care with a chief complaint of commercial sexual exploitation. The Core Competencies for Human Trafficking Response in Health Systems is used as a guiding lens for practical applications in clinical practice in provision of pediatric primary care. Health care providers in a direct service role should be prepared to respond with evidence-based, trauma-informed, culturally responsive procedures and protocols used within their scope of practice.

Background: The COVID-19 pandemic has exacerbated already existing stressors within health care. In August 2020, a campus-wide COVID-19 well-being survey indicated high levels of burnout, stress, and mental health concerns among certified nurse practitioners (CNPs), clinical nurse specialists (CNSs), and physician assistants (PAs) within our Department of Medicine.

Purpose: In response to this survey, an interdisciplinary task force was formed by CNPs, CNSs, and PAs across departmental specialty divisions to conduct focus groups to gain a deeper understanding of workplace experience both prepandemic and during the COVID-19 pandemic.

Methodology: As part of a quality-improvement project, 14 focus groups involving 34 CNPs, CNSs, and PAs within our department were conducted to better understand their experiences before and during the COVID-19 pandemic. A rapid qualitative analysis was used to identify themes and subthemes. In this article, we explore these themes and review potential solutions solicited from the focus groups.

Results: The following themes were identified: (1) the importance of being valued; (2) the need for career development opportunities; and (3) the significance of professional fulfillment.

Conclusions: Each of these themes existed before, but was exacerbated by, the ongoing COVID-19 pandemic. The manifestation of these stressors is unique to the CNPs, CNSs, and PAs experience, although the larger themes may overlap with physician colleagues.

Implications: To improve the professional experience and well-being of CNPs, CNSs, and PAs at our institution, it will be critical for leadership to acknowledge these differences and develop specific initiatives to address these concerns.