Journal of the American Association of Nurse Practitioners最新文献

Background: The increased costs associated with the management of mild to moderate hyperglycemia in the hospital are unnecessary and can be decreased with treatment in an outpatient setting by a standardized treatment protocol.

Local problem: A nurse practitioner-led clinic provides care to patients with uncontrolled diabetes who are uninsured and often present in hyperglycemic states that could be managed outpatient to prevent hospital utilization. This quality improvement project focused on the initial implementation of an evidence-based protocol to help standardize management of mild-to-moderate hyperglycemic crisis.

Methods: An evidence-based protocol for treating critically high blood glucose (BG) values (≥350 mg/dl) for in-person visits was developed using incremental doses of rapid-acting insulin, monitoring of basic metabolic profile, and oral hydration.

Interventions: The protocol was presented to nurse practitioners and essential staff. Implementation of the protocol was evaluated with attention to provider adherence and patients' resulting BG values.

Results: A total of 39 patient cases were managed with the protocol: 12 were assessed to be adherent to the protocol and 27 were not. Overall, the BG levels in both groups decreased to safer levels after implementation of the protocol. Provider adherence to the protocol made a clinically relevant difference in BG levels, and patients' hyperglycemia was controlled more safely in the adherent group compared with the nonadherent group.

Conclusions: This protocol can help safely control high BG levels in an outpatient setting and prevent hospital visits to control hyperglycemic crises. Ensuring provider adherence to the protocol is essential for achieving these outcomes.

Background: Lung cancer has been the leading cause of cancer-related deaths among women in the United States since 1987, with many cases diagnosed at advanced stages, despite screening methods like low-dose CT scans. Although smoking remains the primary risk factor for lung cancer, nonsmoking women, who make up 20% of lung cancer cases in the United States, are also at risk. However, there are no established guidelines for screening nonsmoking women, even as lung cancer rates rise in this group.

Purpose: The study explores potential risk factors that may influence cancer staging and assesses the potential benefits of low-dose computed tomography (LDCT) screening for nonsmoking women.

Methodology: This retrospective chart review analyzed 300 female patients diagnosed with lung cancer between 2019 and 2023. Data collected included smoking status, age, risk factors like family history, secondhand smoke, pulmonary comorbidities, cancer stage, and histology.

Results: A logistic regression model found that pulmonary comorbidities, a history of another cancer, and smoking status significantly influenced the likelihood of being diagnosed with advanced-stage (III or IV) lung cancer. Nonsmoking women with history of a lung comorbidity or history of cancer were more likely to be diagnosed at an earlier stage (I or II).

Conclusion: The study suggests that lung cancer screening (with LDCT) could enhance early detection and staging in high-risk nonsmoking women, especially those with pulmonary comorbidities or history of other cancers.

Implications: The results underscore the importance of expanding lung cancer screening criteria to include high-risk nonsmoking women, particularly those with pulmonary comorbidities or prior cancer history.

Abstract: Postgraduate education for advanced practice team members has emerged as a viable way of gaining critical experience needed for specialty practice. Residency and fellowship training programs have been part of the landscape for medical education for decades but have only recently become available to advanced practice team members. Most programs provide a year of structured learning, but there are few published reports of their value. We provide a description and outcome data of our specialty practice fellowship at an academic medical center over a 5-year period. A fellowship advisory board with representation from numerous specialties defined entry criteria, curriculum, and clinical site placement. Participant and preceptor experience was measured monthly to optimize rapid acquisition of skills. The curriculum was modified through rapid cycle quality improvement in response to scores lower than 70%. In total, 30 fellows have participated in the advanced practice nurse practitioner and physician assistant fellowship program between 2019 and 2023, among 8 specialty tracks. Of the participants from 2019 to 2023, 28 fellows graduated with successful program completion. Ninety-six percent were employed in specialty care settings at the time of graduation or within six months post program completion. The overall postfellowship retention rate at the training site was 79%. This outcome data supported the return on investment. This article provides data and insight into postgraduate fellowship programs with 5 years of cohort data, long-term outcomes, retention rates, and return on investment. In addition, it informs educators and employers with insight into programmatic design, evaluation, and outcomes in transition to practice programs.

Background: Provider handoff communication is essential to the continuity of care and safety of patients. The illness severity, patient information, action list, situational awareness and contingency plans, and synthesis (I-PASS) tool is an evidence-based resource that has been effective in handoffs between providers in a variety of settings. The tool was selected to improve provide communication in efforts to reduce surgical interventions and procedures in a gastroenterology inpatient setting.

Local problem: In an inpatient gastroenterology unit, there was no standardized handoff in place between gastroenterologist and nurse practitioners (NPs). Therefore, there were gaps in patient information, which would further delay procedures.

Methods: Using a plan-do-study-act framework, a quality improvement project was implemented to evaluate the effectiveness of I-PASS handoff implementation among NPs serving in a busy inpatient gastrointestinal setting.

Intervention: The standardized I-PASS handoff was implemented between gastroenterologist and NPs in an inpatient gastroenterology setting in an effort to reduce same-day cancellations of gastroenterology procedures.

Results: More than half (60%) fully adopted the standardized I-PASS handoff tool. Some seasoned providers resisted adopting a new standardized handoff. Monthly gastroenterology procedural cancellation rates steadily declined after the implementation of the standardized handoff tool.

Conclusions: Standardized provider handoff tools are effective in reducing communication errors and improving health care efficiency. The I-PASS tool is a useful handoff tool for inpatient gastroenterology teams and should be considered for implementation among other health delivery teams that care for complex patients and those that use resources such as a surgical suite or procedural laboratory.

Background: Positive airway pressure (PAP) remains the gold standard therapy for obstructive sleep apnea. Mood state negatively affects PAP tolerance, adjustment, and adherence and subsequent health-related quality of life (HRQOL).

Purpose: This secondary analysis examined complex relationships among sleep, mood state, and HRQOL variables from the Apnea Positive Pressure Long-term Efficacy Study (APPLES) national data set.

Methodology: Using Amos, structural equation modeling was conducted to examine the mediating effect of mood state on HRQOL among PAP and sham (subtherapeutic) PAP users (N = 1,105).

Results: Mood significantly mediated the relationship between sleep variables and HRQOL, including sleepiness (β = -0.07, p < .01) and sleep efficiency (β = 0.05, p < .01). Mood was the strongest HRQOL predictor in the model (β = -0.40, p < .01). Mood also significantly mediated the relationship between age (β = 0.08, p < .01), gender (β = -0.04, p < .05), Black ethnicity (β = 0.04, p < .05), marital status single (β = -0.05, p < .05), and HRQOL.

Conclusions: Mood significantly mediated the effects of sleepiness and sleep efficiency on HRQOL. Additional findings indicated potential health disparities related to PAP use, underscoring the need for personalized intervention strategies. Insights from this study highlight the importance of addressing mood state to improve PAP-related outcomes.

Implications: Understanding the relationship between mood and HRQOL among PAP users is essential in improving management strategies, including successful approaches to promote PAP tolerance, adjustment, and adherence. Future research to explore the PAP use-mood-HRQOL triad is warranted.

Background: Chronic wounds represent a significant health care burden, particularly among under-resourced people, due to limited access to care, social determinants, and untreated comorbidities. These factors contribute to delayed healing, complications, reduced quality of life, and increased costs.

Purpose: This study examined the types of chronic wounds, barriers to care, and clinical outcomes among under-resourced individuals treated at a nurse practitioner-led (NP-led) wound care clinic, to inform targeted interventions for improving access and continuity.

Methodology: This retrospective cohort study analyzed medical records of 493 patients treated at a NP-led clinic on the west coast between 2020 and 2024, focusing on wound types, care barriers, and clinical outcomes.

Results: The most common diagnoses were nonpressure chronic ulcers (17.6%) and pressure injuries (16.6%), with lower extremities as the main location (20.49%). A strong correlation was found between number of appointments and follow-up (r = 1.0). No significant relationship was seen between referral source and clinic visit status (χ2 = 2.67, p = .26). Overall, 91.9% of wounds healed, whereas 16.8% of patients experienced persistent wound issues, reflecting barriers such as inaccessibility (17%) and refusal of care (5.7%).

Conclusions: NP-led wound clinics are essential for under-resourced populations but face systemic challenges in patient follow-up and engagement. Findings highlight the need for interventions, improved continuity, and strategies addressing health care and social determinants.

Implications: Enhancing continuity, fostering patient trust, and addressing social determinants through remote monitoring, community outreach, and tailored approaches are vital to optimize outcomes for under-resourced individuals with chronic wounds.

Background: The neonatal nurse practitioner (NNP) is a pivotal member of the neonatal intensive care unit (NICU) care team. To ensure 24-hour coverage in this high-acuity environment, NNPs often work shifts exceeding 16 hours. However, little is known about how prolonged shifts affect NNP fatigue, clinical performance, and overall well-being.

Methods: A mixed-methods survey was distributed via postcards containing a QR code to board-certified NNPs. The survey assessed demographics, shift practices, and perceptions of fatigue when working shifts greater than 16 hours.

Results: A total of 623 participants initiated the survey; 371 completed all items. Most were experienced NNPs working in level III NICUs. Preferred shift lengths included 24-hour and 12-hour day shifts. Awareness of the National Association of NNP position statement on shift length was high (73%), with 76% agreeing with its recommendations. Over half (51%) supported continuing 24-hour shifts. Eighty-five percent agreed that unit census/acuity contributes to fatigue. Nearly half (49%) reported feeling unsafe driving after shifts >16 hours; among those who did acknowledge feeling unsafe to drive, this occurred an average of 17% of the time. Sixty percent denied ever feeling unable to perform duties after extended shifts; among those who did, the average frequency was 17.4%.

Conclusions: Neonatal nurse practitioners report a preference for extended shifts despite acknowledging associated fatigue-related concerns. Although these findings provided valuable subjective insight, findings are limited by self-reporting and sample representation.

Implications: Additional objective data and qualitative analysis are needed to guide evidence-based strategies that prioritize both provider well-being and patient safety.

Background: Clinician turnover is costly for health care organizations.

Local problem: A retention strategy for newly hired nurse practitioners (NPs) and physician associates (PAs) was needed at our organization.

Methods: A quality improvement project was conducted to determine whether a mentorship program could improve retention and employment experiences of newly hired NPs and PAs.

Interventions: A one-to-one mentorship program was implemented for newly hired NPs and PAs. (a) Retention and productivity data were compared for mentee participants vs. nonparticipants. (b) Mentee and mentor participants completed two program evaluation surveys to examine the program's impact on their employment experiences.

Results: Sixty-eight mentee-mentor pairs completed their mentoring relationship during the first 3 years of the program. Retention was higher among mentee participants vs. nonparticipants during their first (96% vs. 85%, p = .0332) and second year of employment (83% vs. 65%, p = .0480). Productivity during the first year was similar for mentee participants and nonparticipants (38th percentile vs. 37th percentile, p = .84). Most participants (≥69%) believed the program improved onboarding, personal and professional growth, work environment, and NP and PA community connection.

Conclusions: The mentorship program improved first- and second-year retention of newly hired NPs and PAs and employment experiences of program participants. By our estimates, the program helped retain 15 NPs and PAs who would have otherwise left the organization, yielding potential organizational savings of $1.29M-$1.72M. A mentorship program can be an effective retention strategy for reducing health care turnover and related costs.

Abstract: Mobile health units (MHUs) in the United States have grown to over 3,000 nationwide, increasing health care access and equity to underserved communities. Although MHUs have demonstrated improved patient outcomes, there is a lack of literature on partnering with nursing colleges and their faculty. This report will share how a college of nursing and their office of faculty practice and partnerships in a large midwestern state university implemented a nurse-led MHU to deliver reproductive health care to rural communities in central Illinois, incorporating advanced practice registered nurses (APRNs) faculty and graduate nursing students. Point-of-care screening for sexually transmitted infections (STIs) was the focus due to Centers of Disease Control and Prevention reports of more than 2.5 million cases of chlamydia, gonorrhea, and syphilis threatening the health of women and babies. Central Illinois was the selected region due to high rates of poverty, teen pregnancy, crime, and incidence of STIs. With few reported MHUs in this region, there was a health care desert for reproductive care. This partnership between a college of nursing and their APRN faculty, graduate nursing students, and underserved patients offered a mutually beneficial opportunity for improved health equity and access to reproductive care.