Academic-Practice Partnerships: Building a sustainable model for Doctor of Nursing Practice (DNP) projects

BackgroundDNP programs should follow the Academic-Practice Partnership guiding principles developed by the AACN-AONE Task Force of Academic Practice Partnerships (2012) to support students educational and practice experiences. This paper outlines the collaboration between a college of nursing (CON) and academic medical center in establishing a formal process for identification and vetting of student DNP projects.MethodsA collaborative committee called DNP Project Oversight Committee (DNPPOC) was formed. DNPPOC members outlined a number of processes to facilitate DNP project review, key stakeholder input, and developed several tools to accomplish the committee's goals. A survey was sent to DNPPOC members to solicit their feedback on meeting the committees overall goals.ResultsMedical center leadership reported improvements in the collection of key DNP project information and the distribution of DNP projects across facilitators and geographic locations. There was also report of perceived improvement in the overall quality of student learning opportunities, strategic direction of DNP projects, and alignment between CON and healthcare system goals.ConclusionsProcesses developed by the DNPPOC have allowed the organization to handle the increase in DNP projects and maximize organizational resources. The DNPPOC structure has ensured high-quality DNP projects and that DNP students are prepared to be leaders in quality improvement.     

Curricular Revision to Increase Use of Quality Improvement Principles in Doctor of Nursing Practice Projects

BackgroundA gap was identified related to students’ use of quality improvement (QI) methodologies in their final project, so a curricular change was made to incorporate a health care QI methods course in the curriculum.MethodsWe compared the use of SMART (specific, measurable, achievable, relevant, and time-bound) aims and QI evaluation methodologies in doctor of nursing practice (DNP) project proposals in 2 cohorts before and after the curriculum change.ResultsA total of 88 DNP proposals were evaluated.ConclusionIncluding a QI course increased the use of SMART aims but did not influence the use of QI methodologies. Future interventions will target faculty development related to QI.     

Development of a DNP measurement grid to increase the rigor of doctor of nursing practice students' data collection and analysis methods

A key component of the DNP project rigor is the collection and analysis of data or measurement. A Steering Committee at the University of Maryland formed to improve the quality of DNP projects established a workgroup to evaluate the current measurement content in four DNP core courses with the goal of establishing DNP project measurement criteria across the curriculum. The steps included: Step 1: Identify QI Measurement Methods and Tools. Identify the essential QI measurement methods and tools recommended by national organizations. Step 2: Create a DNP Measurement Grid. Define main data methods topics with subtopics. Step 3: Map the DNP core courses. Using the DNP Measurement Grid criteria determine the measurement content included in each course and student mastery level. The level of mastery was ranked from introduced (awareness), to reinforced (knowledge), to demonstrated (application). Step 4: Evaluate and Refine the DNP Measurement Grid Criteria. Adjustments were made in the DNP curriculum to include topics and subtopics at the desired mastery level. The rigor of data measurement and analysis will be evaluated in future DNP projects. The workgroup's four-step process provides a path that facilitated improving curriculum measurement content. This process may provide guidance for others undertaking similar work.     

CTSA Consortium Consensus Scientific Review Committee (SRC) Working Group Report on the SRC Processes

Human research projects must have a scientifically valid study design, analytic plan, and be operationally feasible in order to be successfully completed and thus to have translational impact. To ensure this, institutions that conduct clinical research should have a scientific review process prior to submission to the Institutional Review Committee (IRB). This paper reports the Clinical and Translational Science Award (CTSA) Consortium Scientific Review Committee (SRC) Consensus Working Group''s proposed framework for a SRC process. Recommendations are provided for institutional support and roles of CTSAs, multisite research, criteria for selection of protocols that should be reviewed, roles of committee members, application process, and committee process. Additionally, to support the SCR process effectively, and to ensure efficiency, the Working Group recommends information technology infrastructures and evaluation metrics to determine outcomes are provided.     

Maximizing benefits and minimizing risks in health services research near the end of life

This article explores the ethical issues specific to Health Services Research (HSR) in palliative care, with particular attention to similarities and differences between HSR and institutional quality improvement (QI) initiatives. We focus on the challenges of determining what level of protection is warranted by investigations of health services and programs of care, in contrast to the traditional randomized clinical trial design, and how best to assure subject protection. A decision algorithm regarding the requirements for full IRB review and informed consent is proposed as a mechanism to assure that the level of protection is commensurate with the level of risk.     

Variation in Institutional Review Board Responses to a Standard, Observational, Pediatric Research Protocol

Background: Multicenter studies are becoming more common, and variability in local institutional review board (IRB) assessments can be problematic.
Objective: To investigate the variability of IRB responses to a multicenter observational study of children presenting to emergency departments.
Methods: The authors collected the original IRB applications, subsequent correspondence, and a survey assessing submission timing and response and the nature of IRB queries. The study was conducted as part of the Emergency Medicine Network http://www.emnet-usa.org
Results: Of 37 sites initiating the IRB process, 34 (92%) participated in this IRB-approved study. Institutional review boards returned initial applications in a median of 19 days (IQR, 11–34 d), and 91% considered the protocol to be minimal risk. Of 34 submissions, 13 required no changes, 18 received conditional approvals, and 3 were deferred. The median time from initial submission to final approval was 42 days (IQR, 27–61 d). Seven sites did not participate in patient recruitment: two had institutional issues, one obtained IRB approval too late for participation, and four sites (12%) reported that IRB hurdles contributed to their lack of participation. Nonetheless, 68% of sites that recruited patients reported that the overall experience made them more likely to participate in future multicenter research.
Conclusions: There was substantial variation in IRB assessment of a standard protocol in this study. The burden of the application process contributed to some investigators not participating, but the majority of investigators remain enthusiastic about multicenter research. A national IRB may streamline the review process and facilitate multicenter clinical research.     

The Pulmonary Embolism Rule-Out Criteria rule in a community hospital ED: a retrospective study of its potential utility

Background

The Pulmonary Embolism Rule-Out Criteria (PERC) rule identifies patients who can be safely discharged from the emergency department (ED) without undergoing laboratory or radiological investigation for possible pulmonary embolism (PE). It was shown to be 99% sensitive in a large validation series. Our objective was to assess the PERC rule's performance in a representative US community hospital.

Methods

A chart review of ED patients receiving computed tomographic scans (CTS) for possible PE during a 4-month study period was performed. The PERC rule was applied to this cohort, and its sensitivity and negative predictive value were determined.

Results

Two hundred thirteen patients underwent chest CTS to “rule out” PE. Forty-eight patients met PERC rule criteria, and all had negative CTS. Of the remaining 165 patients, 18 patients (11%) had scans positive for PE. The overall prevalence of PE was 8.45% (95% CI, 5.22-13.24%). The PERC rule's sensitivity was 100% (95% CI, 78.12-100%), with a negative predictive value of 100% (95% CI, 90.80-100%). Application of the PERC rule at the point-of-care would have reduced CTS by 23%.

Conclusions

In our community hospital, the PERC rule successfully identified ED patients who did not require CTS evaluation for PE. Had the PERC rule been applied, nearly one-quarter of all CTS performed to “rule out PE” could have been avoided.     

Quality Indicators (QI) of Acute Pain after Surgery in European Countries

ObjectivesIt is common practice to use pain quality indicators (QI) to accurately assess the medical care situation of patients. This literature review identifies the status quo of acute pain QI among adult inpatients.Data SourcesStudies published in English or German were identified using a systematic search on CINAHL, Cochrane Library, PubMed, Web of Science, and Google Scholar from 01/2007 to 02/2018. Additional pain management journals, conference proceedings, and websites of health organizations and pain societies were manually screened. Studies about postoperative pain in adults (≥18 years) during inpatient stay after all types of surgery in Europe were included in this review.Review/Analysis MethodsThe identified study results were categorized into structural, process, and outcome indicators based on Donabedian's framework of evaluating care quality.ResultsThe search identified 319 citations, of which 20 studies used structure, process, and outcome data including 180,988 patients and 1,970 health care professionals to gain insight into the quality of acute pain management. Overall, 80% used patient surveys to collect data. National data on pain management are reported in five European studies (France [2], the Netherlands, Spain, and Austria).ConclusionsEuropean studies comprehensively comparing acute pain management results are currently missing. Thus, this report highlights the need to develop consensus-based quality indicators in management of acute pain, which take into account both the methodologic quality and the relevance to clinical practice.     

Recruitment of minority and underserved populations in the United States: the Centers for Population Health and Health Disparities experience

ObjectiveThe recruitment of minority and underserved individuals to research studies is often problematic. The purpose of this study was to describe the recruitment experiences of projects that actively recruited minority and underserved populations as part of The Centers for Population Health and Health Disparities (CPHHD) initiative.MethodsPrincipal investigators and research staff from 17 research projects at eight institutions across the United States were surveyed about their recruitment experiences. Investigators reported the study purpose and design, recruitment methods employed, recruitment progress, problems or challenges to recruitment, strategies used to address these problems, and difficulties resulting from Institutional Review Board (IRB) or Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements. Additionally, information was collected about participant burden and compensation. Burden was classified on a three-level scale. Recruitment results were reported as of March 31, 2007.ResultsRecruitment attainment ranged from 52% to 184% of the participant recruitment goals. Commonly reported recruitment problems included administrative issues, and difficulties with establishing community partnerships and contacting potential participants. Long study questionnaires, extended follow-up, and narrow eligibility criteria were also problematic. The majority of projects reported difficulties with IRB approvals, though few reported issues related to HIPAA requirements. Attempted solutions to recruitment problems varied across Centers and included using multiple recruitment sites and sources and culturally appropriate invitations to participate. Participant burden and compensation varied widely across the projects, however, accrual appeared to be inversely associated with the amount of participant burden for each project.ConclusionRecruitment of minority and underserved populations to clinical trials is necessary to increase study generalizbility and reduce health disparities. Our results demonstrate the importance of flexible study designs which allow adaptation to recruitment challenges. These experiences also highlight the importance of involving community members and reducing participant burden to achieve success in recruiting individuals from minority and underserved populations.     

Improving On-Time First Case Starts: An Integrative Review and Quality Improvement Project Plan

PurposeSurgeon late arrival is the major cause of delays in first case starts. The estimated cost of these delays can reach $800,000 a year. The purpose of this integrative review and proposed quality improvement (QI) project plan was to increase the first case on-time starts through surgeon behavior modification.DesignAn integrative literature review and creation of a QI project plan.MethodsThe literature review included an independent electronic literature search between the years of 2011 and 2020 through CINAHL PLUS, PubMed, and Medline OVID databases. The search was limited to scholarly peer-reviewed journal articles in the English language, and search terms included: “operating rooms,” “delay first cases start,” “first case tardiness,” and “operating room efficiency.” The QI project plan was a three-phase process based on surgeon behavioral modification using educational material, visual reminders, and individualized e-mail notifications of habitually late surgeons.FindingsA synthesis of articles reported proper site marking and surgical consent 15 to 30 minutes before surgery increased first case on-time starts from 55.90% to 66.60% and a mean delay decrease of 9.67 minutes to 7.17 minutes. Visual cues significantly enhanced memory, 64% versus 50%, and e-mail reminders increased compliance, 77% to 86.1%.ConclusionAs the need for hospital revenue dependency grows, so will the need for more efficient operating rooms. The evidence shows a positive correlation between early arrival by surgeons to the preoperative area and increased on-time first case starts.     

Impact of Quality Improvement (QI) Program on 5-Year Risk of Diabetes-Related Complications: A Simulation Study

OBJECTIVEWe successfully implemented the American Diabetes Association’s (ADA) Diabetes INSIDE (INspiring System Improvement with Data-Driven Excellence) quality improvement (QI) program at a university hospital and safety-net health system (Tulane and Parkland), focused on system-wide improvement in poorly controlled type 2 diabetes (HbA_1c >8.0% [64 mmol/mol]). In this study, we estimated the 5-year risk reduction in complications and mortality associated with the QI program.RESEARCH DESIGN AND METHODSThe QI implementation period was 1 year, followed by the postintervention period of 6 months to evaluate the impact of QI on clinical measures. We measured the differences between the baseline and postintervention clinical outcomes in 2,429 individuals with HbA_1c >8% (64 mmol/mol) at baseline and used the Building, Relating, Assessing, and Validating Outcomes (BRAVO) diabetes model to project the 5-year risk reduction of diabetes-related complications under the assumption that intervention benefits persist over time. An alternative assumption that intervention benefits diminish by 30% every year was also tested.RESULTSThe QI program was associated with reductions in HbA_1c (−0.84%) and LDL cholesterol (LDL-C) (−5.94 mg/dL) among individuals with HbA_1c level >8.0% (64 mmol/mol), with greater reduction in HbA_1c (−1.67%) and LDL-C (−6.81 mg/dL) among those with HbA_1c level >9.5% at baseline (all P < 0.05). The implementation of the Diabetes INSIDE QI program was associated with 5-year risk reductions in major adverse cardiovascular events (MACE) (relative risk [RR] 0.78 [95% CI 0.75–0.81]) and all-cause mortality (RR 0.83 [95% CI 0.82–0.85]) among individuals with baseline HbA_1c level >8.0% (64 mmol/mol), and MACE (RR 0.60 [95% CI 0.56–0.65]) and all-cause mortality (RR 0.61 [95% CI 0.59–0.64]) among individuals with baseline HbA_1c level >9.5% (80 mmol/mol). Sensitivity analysis also identified a substantially lower risk of diabetes-related complications and mortality associated with the QI program.CONCLUSIONSOur modeling results suggest that the ADA’s Diabetes INSIDE QI program would benefit the patients and population by substantially reducing the 5-year risk of complications and mortality in individuals with diabetes.     

Institutional Review Boards: What Clinician Researchers Need to Know

The institutional review board (IRB) is a group federally mandated to review and monitor research involving humans to ensure protection of their rights and welfare as research participants. Clinicians engaged in research require IRB approval for all research involving human participants, whether living individuals, data, or specimens. The process for obtaining IRB approval may seem like a daunting task. However, it is critical for clinical researchers to conduct research in a manner that protects human participants, and it is the mission of the IRB to help researchers accomplish this task. The purpose of this article is to review the role and purpose of the IRB, highlight federal and regulatory standards in human research participants protection, and help clinical researchers have a broader understanding of IRB functions that will help them conduct high-quality research with human participants.     

Dry Needling and Photobiomodulation Decreases Myofascial Pain in Trapezius of Women: Randomized Blind Clinical Trial

ObjectiveThe purpose of this study was to assess whether dry needling (DN) added to photobiomodulation (PBM) has effects on the treatment of active myofascial trigger points in the upper trapezius.MethodsThis study was a randomized clinical trial, with 43 participants divided into 3 groups: DN and PBM (DNP), DN, and DN outside of the trigger point (DNout). Each group received 1 session of DN followed by PBM therapy with the machine turned on or off. Pain, disability, pain pressure threshold, and muscle activity were assessed before the intervention and afterward at intervals of 10 minutes, 30 minutes, 1 week, and 1 month.ResultsPain decreased after intervention in the DNP and DNout groups, with mean differences, respectively, of 1.33 cm (95% confidence interval [CI], 0.019-2.647) and 2.78 cm (95% CI, 1.170-2.973). Scores for the disability questionnaire decreased in all groups after intervention (F = 36.53, P < .0001) after the intervention, with mean differences of 3.8 points in the DNP group (95% CI, 1.082-5.518), 3.57 in the DN group (95% CI, 0.994-6.149), and 5.43 in the DNout group (95% CI, 3.101-7.756). There were no significant differences between or within groups in pain pressure threshold (F = 2.14, P = .139), with mean differences after 30 minutes of 0.139 kgf for the DNP group (95% CI, ?0.343 to 0.622), 0.273 for the DN group (95% CI, ?0.661 to 1.209), and ?0.07 for the DNout group (95% CI, ?0.465 to 0.324). Muscle activation for the DN group increased 8.49% after the intervention, where for the DNP group it decreased 11.5%, with a significant difference between groups.ConclusionDN added to PBM presented similar results compared to DNout and DN. In this sample, the effects of the application of DN outside of the trigger point had better effects on pain and disability scores than DN applied directly on the trigger point.