Journal of the American Association of Nurse Practitioners最新文献

Abstract: This case report presents a 34-year-old Middle Eastern woman with atypical symptoms of Type II Necrotizing Soft Tissue Infection (NSTI). Due to the difficulty in diagnosing Type II NSTI, the patient experienced protracted illness. Once diagnosed, the patient underwent multiple surgical debridement procedures requiring antibiotic and pain management therapy before being successfully discharged home. Initial diagnosis of Type II NSTI is challenging to the provider due to vague symptoms and late occurrence of cutaneous changes. When cutaneous lesions are identified, rapid surgical evaluation is imperative to minimize morbidity and mortality. This paper emphasizes the complexity of diagnosing Type II NSTI and the need for a comprehensive history and frequent physical examinations.

Background: Chronic obstructive pulmonary disease (COPD) is a costly chronic disease affecting more than 15 million Americans. The prevalence among US veterans is 3 times higher than the general population.

Local problem: The Veteran Health Administration developed a standardized, evidence-based COPD educational tool called Green Light to Go (GLTG) designed to educate patients on managing their COPD symptoms at home. Despite the availability of this resource, inpatient education on COPD self-management practices is highly variable across different medical teams. This quality improvement (QI) initiative sought to standardize inpatient COPD patient education using the GLTG tool. This initiative also assessed whether patients receiving standardized patient education during their index hospitalization had lower COPD 30-day readmission rates.

Method: The QI initiative followed the LEAN methodology and the A3 framework. The team performed rapid tests of change (plan-do-study-act cycles) to increase the percentage of veterans receiving COPD education.

Interventions: The interventions implemented for this QI initiative focused on clinical, patient, and system improvements.

Results: This initiative standardized COPD patient education and increased the percentage of veterans receiving (a) daily COPD education from 0% to 66%, (b) verbal COPD education on discharge from a baseline of 20% to 100%, (c) receipt of written educational material on discharge from 20% to 100%, and (d) the cohort all-cause 30-day readmission rate declined from 19.3% to 14.3%.

Conclusions: Given the substantial economic burden of COPD readmissions on the health care system and patients, evidence-based educational interventions may potentially improve outcomes and reduce hospital readmissions in this veteran population.

Abstract: Men's mental health is an important topic for nurse practitioners (NPs) because men and women have different epidemiological profiles and clinical presentations when it comes to behavioral health. As clinicians, we must be aware of these differences to better serve diverse patient populations. In this article, four key issues to men's mental health will be discussed in relationship to masculinities: suicide; depression; stigma; and engagement with mental health services. A case study of a male patient is presented, and the article concludes with clinical implications for NPs.

Abstract: Depression is a leading cause of disability worldwide, with treatment-resistant depression (TRD) affecting approximately 30% of patients who do not respond to standard antidepressants. In underserved and uninsured communities, where Nurse Practitioners (NPs) often provide essential mental health care, the challenges of managing TRD are compounded by limited access to specialized services. Pharmacogenomic testing offers a promising approach to overcoming these barriers by providing personalized medication recommendations based on a patient's genetic profile. This brief report examines the medical records of 46 patients from underserved communities who underwent genetic testing for TRD. Of the patients reviewed, 31 achieved remission within 2 months of receiving genetically guided treatment, resulting in a remission rate of 67.39%. Patients with specific genetic markers, such as poor metabolizers for CYP2D6 or CYP2C19, experienced the most significant benefits. These findings suggest that pharmacogenomic testing can significantly improve treatment outcomes for TRD in underserved populations, enabling NPs to provide more personalized, effective care. Further research is necessary to explore the long-term benefits and cost-effectiveness of integrating pharmacogenomic testing into NP-led practices, particularly in resource-limited settings.

Background: The practice of patient self-collected swab specimens for Neisseria gonorrhoeae and Chlamydia trachomatis is supported in the literature.

Local problem: Health care providers observed that patients sometimes performed their self-swabs incorrectly resulting in cancelled or invalid specimens.

Methods: The clinic's outdated visual aids were replaced with new visual aids. The goal was to improve health care provider proficiency in providing the health teaching and to reduce the clinic's number of cancelled or invalid swab specimens. Staff evaluated the visual aids using an online pretest and post-test survey. The percentage of invalid swabs was calculated before and after project implementation.

Intervention: The posters were designed and printed. In-person teaching on the project and using the new visual aids was provided.

Results: There was no change in the reported proficiency of staff in providing health teaching for self-collected swab specimens. There was a reduction in staff observed self-swabbing errors. Three percent of rectal swabs were reported as invalid in the 2 weeks before project implementation, and 1.4% of rectal swabs were invalid in the 2 weeks after.

Conclusions: Providing patient health teaching using verbal instructions combined with visual diagrams can improve patients' ability to retain health information.

Background: The Neonatal Eating Assessment Tool-Mixed Breastfeeding and Bottle-feeding (NeoEAT-Mixed Feeding) is a parent-report assessment of symptoms of problematic feeding in infants who are feeding by both breast and bottle.

Purpose: To establish reference values for the NeoEAT-Mixed Feeding and evaluate factors that contribute to symptoms of problematic feeding in healthy, full-term infants.

Methodology: Parents of 409 infants less than 7 months old completed an online survey. Median and percentile scores are presented for infants aged 0-2, 2-4, 4-6, and 6-7 months old.

Results: Neonatal Eating Assessment Tool-Mixed Feeding total score and scores for the Gastrointestinal Tract Function and Energy & Physiologic Stability subscales decreased with increasing infant age. Infant Regulation and Feeding Flexibility subscale scores remained stable over time, whereas Sensory Responsiveness subscale scores increased with increasing infant age. Infants with more gastrointestinal and gastroesophageal symptoms had higher NeoEAT-Mixed Feeding total scores.

Conclusions: In healthy, full-term infants, symptoms of problematic feeding generally improve over the first 7 months, with the exception of symptoms related to sensory responsiveness. Gastrointestinal and gastroesophageal reflux symptoms are related to symptoms of problematic feeding.

Implications: The reported reference values may be used to identify infants in need of further assessment, referral, and intervention. In healthy, full-term infants with concurrent gastrointestinal symptoms and problematic feeding, interventions targeted at gastrointestinal symptoms may help to improve symptoms of problematic feeding as well.

Background: This was an ongoing quality-improvement (QI) project that aimed to assess the quality of nurse practitioner (NP)-driven diabetes care based on the 2023 American Diabetes Association (ADA) Standards of Care (SOC) at a NP-owned primary care practice. In addition, a more recent focus was the assessment of and intervention on social determinants of health (SDOH). Nationally, 47.4% of people with diabetes mellitus (DM) have an HbA1C of >7.0%. Adherence to ADA SOC for DM management minimizes the risk of diabetes-associated complications.

Local problem: At a NP-owned clinic, within one year, the average A1Cs improved in all patients except those with positive SDOH despite receiving similar care. SDOH predicts DM prevalence and severity of progression, yet screening is not consistently performed or documented.

Methods: An ongoing retrospective chart review since 2013 has assessed adherence to ADA SOC among adult patients with type 2 DM at an NP-owned practice. Multiple Plan-Do-Study-Act (PDSA) cycles have resulted in new recommendations that have promoted adherence to diabetes metrics and improvement in overall mean A1C.

Interventions: The current PDSA cycle emphasizes the creation and implementation of evidence-based interventions to assist NPs in addressing social needs at a NP-owned practice.

Results: Recent data collection has included frequency of SDOH screening, identifying social needs, gaps in SDOH documentation, and has found overall higher A1Cs in patients with positive screens.

Conclusions: Project intervention of social workers collaboration with NPs resulted in improvement in addressing social needs in patients with type 2 diabetes mellitus.

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: Nurse practitioners (NPs) provide high-quality, comprehensive health care at Veterans Health Administration (VHA) medical centers in various practice settings. Accurately determining the productivity of NPs is essential to understanding their overall contribution to veteran care. There is a lack of understanding of the contributors to the variability among VHA medical centers regarding their processes for capturing these data. Using benchmark data from the VHA Support Service Center Capital Assets application, this quality improvement (QI) initiative implemented a series of plan-do-study-act (PDSA) cycles to determine whether increased education regarding billing and coding, along with person classification and labor mapping accuracy, could increase NP productivity.

Local problem: The problem identified through an analysis of NP productivity revealed variability across multiple VHA facilities.

Methods: The PDSA method was employed in this QI project. The QI team compared the total workload relative value units (wRVU) for NPs in each participating facility pre and post a three-phase intervention.

Interventions: Nurse practitioners' person classification and labor mapping accuracy was evaluated at each site. An educational program regarding billing and coding was developed and delivered to the NP frontline staff. The QI team compared the total wRVUs for the NPs at each facility pre- and postintervention.

Results: An increase in the wRVUs was observed following the intervention across six facilities. Five of the seven facilities displayed stability in relative value unit improvement postintervention.

Conclusion: Educating frontline NPs on billing, coding, person classification, and labor mapping can improve NP productivity.

Abstract: Preclinical simulation is an evidence-based method for nurse practitioner (NP) students to improve clinical communication and disease management competency. During simulation, students may receive feedback from multiple sources, including standardized patients (SPs), faculty, peers, and themselves. Although evidence supports simulation with multisource feedback, its impact on clinical knowledge and communication has yet to be evaluated among NP students. We designed, implemented, and evaluated a preclinical simulation program with structured multisource feedback integrated into a disease management course within a Doctor of Nursing Practice curriculum. Differences in communication self-efficacy and disease management knowledge before and after participation, as well as perceptions of learning and importance of varying feedback sources, were evaluated using a single group pre-post mixed-methods design. On average, clinical communication self-efficacy was significantly higher, and disease management knowledge scores were significantly higher after participation. Learners rated feedback sources as important or very important and described varying feedback sources as complementary. Feedback from SPs, peers, learners themselves, and faculty was complementary and important to learning. This preclinical simulation program with purposeful integration of multisource feedback provides an evidence-based foundation for scaffolding multidomain competency development into curriculums to meet updated standards of advanced nursing education.