Nursing overtime: why, how much, and under what working conditions?

To provide the best care to patients, the physical wellness of nursing staff is essential. Current evidence indicates long work hours can lead to adverse nurse and patient outcomes. To provide quality and safe patient care, both staff nurses and nurse managers need to recognize the adverse effects of overtime, whether it is mandatory or voluntary. Results of this study showed overtime was not used more when there was an increase in nursing shortages. Further, overtime was not used to control shortages; rather, understaffing was an underlying condition of the nursing practice, at least in the study sample. Thus, efforts must be made not only to prevent nurses from working long hours, but also to resolve the problem of understaffing in order to retain qualified nurses in hospitals.     

比伐卢定联合挽救性经皮冠状动脉介入治疗急性心肌梗死溶栓失败患者的疗效及安全性

目的探讨比伐卢定联合挽救性经皮冠状动脉介入治疗(PCI)治疗急性心肌梗死(ACI)溶栓失败患者的疗效及安全性。方法选取2017年9月至2020年6月辽宁省人民医院收治的98例ACI患者作为研究对象,按随机数字表法分为对照组与观察组,各49例。对照组接受肝素+挽救性PCI治疗,观察组采用比伐卢定+挽救性PCI治疗。比较两组血管再通率、血清心肌损伤标志物肌酸激酶同工酶(CK-MB)、肌钙蛋白T(cTnT)、肌钙蛋白Ⅰ(cTnⅠ)、超声心动图心功能参数左室射血分数(LVEF)、每搏输出量(SV)、左室舒张功能比值(E/A),随访并记录主要不良心血管事件发生情况。结果治疗后,两组患者的血管再通率差异无统计学意义(χ²=1.010,P=0.315);PCI术后,两组血清CK-MB、cTn T、cTnⅠ水平及超声LVEF、SV、E/A水平差异无统计学意义(t=1.283、1.163、0.795、0.351、0.309、0.471,P=0.101、0.124、0.214、0.363、0.379、0.319)。随访期间,观察组主要不良心血管事件发生率低于对照组患者(χ²=4.009,P=0.045)。结论伐卢定联合挽救性PCI用于急性心肌梗死溶栓失败患者的治疗,疗效与普通肝素相当,但在治疗安全性方面具有一定优势。     

Economic modelling of costs associated with outcomes reported for type 2 diabetes mellitus (T2DM) patients in the CANVAS and EMPA-REG cardiovascular outcomes trials

Aims: To model direct medical costs associated with reductions in cardiovascular disease (CVD) events in T2DM patients reported in the CANVAS and EMPA-REG trials, which assessed the cardiovascular safety of canagliflozin and empagliflozin, respectively.

Materials and methods: Costs were modeled from a US managed care organization (MCO) perspective for the CVD outcomes included in both trials: three-point major adverse cardiovascular event (MACE) and its components (cardiovascular-related death, nonfatal myocardial infarction, nonfatal stroke), as well as heart failure requiring hospitalization. The rate of CVD events averted (difference between study drug and placebo) was projected to the portion of an MCO T2DM population matching the respective trial’s inclusion criteria. A targeted literature search for paid amounts directly associated with each CVD event provided the unit costs, which were applied to the projected number of events averted, to calculate costs avoided per member per year (PMPY). One-way sensitivity analyses were performed on events averted, unit costs, and percentages of trial-applicable patients.

Results: Based on three-point MACE events averted, costs avoided PMPY of $6.17 (range: $1.27–$10.94) for CANVAS and $2.75 ($0.19–$4.83) for EMPA-REG were estimated. Costs avoided for individual components of MACE ranged from $0.77 to $3.84 PMPY for CANVAS and from -$0.97 (additional costs) to $1.54 for EMPA-REG. PMPY costs avoided for heart failure were $2.72 for CANVAS and $1.32 for EMPA-REG.

Limitations and conclusions: Models assumed independent, non-recurrent outcomes and were restricted to medical costs directly associated with the trial-reported events. The reductions in CVD events in T2DM patients reported for both CANVAS and EMPA-REG project to a positive cost avoidance for these events in an MCO population. The analysis did not include an assessment of the impact on total cost, as the costs associated with adverse events, drug utilization or other clinical outcomes were not examined.     

Patients' perceptions of nurse staffing, nursing care, adverse events, and overall satisfaction with the hospital experience

Noticeably absent in the discussions surrounding nurse staffing and adverse events is the patients' perspective, except for their satisfaction with various aspects of their hospitalization experience. The results of a study undertaken to test a theoretical model of patients' perceptions of nurse staffing, the nursing care they receive, self-reported adverse events, and overall satisfaction with the hospital experience are presented. Perception of nurse staffing only weakly predicted the number of adverse events reported by patients, but was a strong predictor of the perception of nursing care received, and the perception of nursing care received was the only significant predictor of overall satisfaction with the hospital experience.     

The impact of nurse staffing on hospital costs and patient length of stay: a systematic review

Research examining the relationships between nurse staffing, hospital costs, and length of stay is varied using a range of methods and definitions. This lack of coherence in definitions and measurement tools for cost and length of stay makes it difficult to conclude with certainty the results of nurse staffing on hospital cost and length of stay. However, the evidence reflected that significant reductions in cost and length of stay may be possible with higher ratios of nursing personnel in hospital settings. Sufficient numbers of RNs may prevent patient adverse events that cause patients to stay longer than necessary. Patient costs were also reduced with greater RN staffing as RNs have higher knowledge and skill levels to provide more effective nursing care as well as reduce patient resource consumption. Hospital administrators are encouraged to use higher ratios of RNs to non-licensed personnel to achieve their objectives of quality patient outcomes and cost containment.     

Evaluation of a client care delivery model, Part 2: Variability in client outcomes in community home nursing

Using similar variables, Part II explores variation in client outcomes such as OMAHA knowledge, behavior, and SF-36 scores. Medical and nursing diagnoses explained large variations in client outcomes. Clients cared for by degree-prepared nurses improved knowledge and behavior scores. Unanticipated case complexity was negatively associated with client outcome even with nursing intervention. The study revealed that "for every unit increase in assignment of baccalaureate-prepared nurses, clients will on average demonstrate an 80% greater likelihood of improvement in knowledge scores and a 120% greater likelihood of improvement in behavior scores in relation to their health condition at discharge." This two-part study has offered insight into the controllable variables influencing the cost and quality of home care services.     

Economic burden of contrast-induced nephropathy: implications for prevention strategies

SUMMARY

Contrast-induced nephropathy (CIN) is the third most common cause of hospital-acquired acute renal failure. There is increasing evidence that CIN has a significant adverse impact on patient morbidity and mortality. The objective of this study was to estimate the in-hospital and 1-year direct healthcare costs related to CIN. Using the values obtained from the literature review, a decision analytic model was developed to estimate the in-hospital and 1-year costs of CIN. Patients who develop CIN are more likely to experience adverse events, to undergo prolonged dialysis, to have longer hospital and intensive care unit stays and to have higher mortality rates. The average in-hospital cost of CIN is $10,345. The 1-year cost of treating a patient with CIN is $11,812. Overall, the economic burden associated with CIN is high. Adopting targeted interventions will reduce the incidence of CIN and its overall economic burden.     

Leadership-organizational culture relationship in nursing units of acute care hospitals

The phenomena of leadership and organizational culture (OC) has been defined as the driving forces in the success or failure of an organization. Today, nurse managers must demonstrate leadership behaviors or styles that are appropriate for the constantly changing, complex, and turbulent health care delivery system. In this study, researchers explored the relationship between nurse managers' leadership styles and OC of nursing units within an acute care hospital that had achieved excellent organizational performance as demonstrated by a consistent increase in patient satisfaction ratings. The data from this study support that transformational and transactional contingent reward leaderships as nurse manager leadership styles that are associated with nursing unit OC that have the ability to balance the dynamics of flexibility and stability within their nursing units and are essential for maintaining organizational effectiveness. It is essential for first-line nursing leaders to acquire knowledge and skills on organizational cultural competence.     

基于科学的创新失败挽救：扩展适应视角

基于科学的创新具有失败率极高的特点，对其失败（项目）进行挽救可减少创新资源浪费，提升相关产业创新绩效，具有可观的经济价值和社会意义。采用多案例方法，从扩展适应视角研究发现，基于科学的创新失败挽救过程由新功能意义建构、基于扩展适应的商业化实现及持续扩展适应3个阶段构成；在基于科学的创新领域，扩展适应是一种重要的失败挽救机制；机缘巧合触发基于扩展适应的挽救机会形成，已存在扩展适应的创新生态系统是挽救创新失败的实现条件，多次、持续的扩展适应可不断挖掘和释放失败项目的创新价值。结论可丰富基于科学的创新和创新失败挽救相关理论研究，为创新管理实践、政策制定等提供理论参考。     

Healthcare resource utilization among patients with relapsed multiple myeloma in the UK,France, and Italy

Aims: To assess the real-world healthcare resource utilization (HRU) and costs associated with different treatment regimens used in the management of patients with relapsed multiple myeloma in the UK, France, and Italy.

Methods: Retrospective medical chart review of characteristics, time to progression, level of response, HRU during treatment, and adverse events (AEs). Data collection started on June 1, 2015 and was completed on July 15, 2015. In the 3 months before record abstraction, eligible patients had either disease progression after receiving one of their country’s most commonly prescribed regimens or had received the best supportive care and died. Costs were calculated based on HRU and country-specific diagnosis-related group and/or unit reference costs, amongst other standard resources.

Results: Physicians provided data for 1,282 patients (387 in the UK, 502 in France, 393 in Italy) who met the inclusion criteria. Mean [median] total healthcare costs associated with a single line of treatment were €51,717 [35,951] in the UK, €37,009 [32,538] for France, and €34,496 [42,342] for Italy, driven largely by anti-myeloma medications costs (contributing 95.0%, 90.0%, and 94.2% of total cost, respectively). During active treatment, the highest costs were associated with lenalidomide- and pomalidomide-based regimens. Mean cost per month was lowest for patients achieving a very good partial response or better. Unscheduled events (i.e. not considered part of routine management, whether or not related to multiple myeloma, such as unscheduled hospitalization, AEs, fractures) accounted for 1–9% of total costs and were highest for bendamustine.

Limitations: The use of retrospective data means that clinical practice (e.g. use of medical procedures, evaluation of treatment response) is not standardized across participating countries/centers, and some data (e.g. low-grade AEs) may be incomplete or differently adjudicated/reported. The centers involved may not be fully representative of national practice.

Conclusions: Drug costs are the main contributor to total HRU costs associated with multiple myeloma. The duration of active treatment may influence the average total costs, as well as response, associated with a single line of therapy. Improved treatment outcomes, and reductions in unscheduled events and concomitant medication use may, therefore, reduce the overall HRU and related costs of care in multiple myeloma.     

Professional role clarity and competency in health care staffing--the missing pieces

Professional role clarity and role competency are the missing pieces to achieving staffing excellence. The relationships among professional practice models, professional role competency, professional role clarity, patient safety, data, and staffing effectiveness build a solid equation, which supports improved patient outcomes. An essential variable binding these elements is housed in the patient handover conversation. Ensuring this handover is an evidence-based, data-driven conversation which contains both the medical and nursing plans of care provides standardization in nursing practice and improves patient safety. This powerful equation resets the nursing standard of practice and identifies the missing pieces to staffing excellence, namely, the integration of professional role clarity and professional role competency.     

Ambulatory care registered nurse performance measurement

On March 1-2, 2010, a state-of-the-science invitational conference titled "Ambulatory Care Registered Nurse Performance Measurement" was held to focus on measuring quality at the RN provider level in ambulatory care. The conference was devoted to ambulatory care RN performance measurement and quality of health care. The specific emphasis was on formulating a research agenda and developing a strategy to study the testable components of the RN role related to care coordination and care transitions, improving patient outcomes, decreasing health care costs, and promoting sustainable system change. The objectives were achieved through presentations and discussion among expert inter-professional participants from nursing, public health, managed care, research, practice, and policy. Conference speakers identified priority areas for a unified practice, policy, and research agenda. Crucial elements of the strategic dialogue focused on issues and implications for nursing and inter-professional practice, quality, and pay-for-performance.     

Developing a tool to measure pharmacoeconomic outcomes of post-surgical pain management interventions

Background:

Financial pressures have limited the ability of providers to use medication that may improve clinical outcomes and patient satisfaction. New interventions are often fraught with resistance from individual cost centers. A value realization tool (VRT) is essential for separate cost centers to communicate and comprehend the overall financial and clinical implications of post-surgical pain management medication interventions (PSMI). The goal was to describe development of a VRT.

Methods:

An evaluation of common in-patient PSMI approaches, impacts, and costs was performed. A multidisciplinary task force guided development of the VRT to ensure appropriate representation and relevance to clinical practice. The main outcome was an Excel-based tool that communicates the overall cost/benefit of PSMI for the post-operative patient encounter.

Results:

The VRT aggregated input data on costs, clinical impact, and nursing burden of PSMI assessment and monitoring into two high-level outcome reports: Overall Cost Impact and Nurse & Patient Impact. Costs included PSMI specific medication, equipment, professional placement, labor, overall/opioid-related adverse events, re-admissions, and length of stay. Nursing impact included level of practice interference, job satisfaction, and patient care metrics. Patient impact included pain scores, opioid use, PACU time, and satisfaction. Reference data was provided for individual institutions that may not collect all variables included in the VRT.

Conclusions:

The VRT is a valuable way for administrators to assess PSMI cost/benefits and for individual cost centers to see the overall value of individual interventions. The user-friendly, decision-support tool allows the end-user to use built-in referenced or personalized outcome data, increasing relevance to their institutions. This broad picture could facilitate communication across cost centers and evidence-based decisions for appropriate use and impacts of PSMI.     

Costs associated with adverse events in patients with metastatic renal cell carcinoma

Objective:

To estimate adverse event (AE) costs in patients receiving targeted therapies for the first line treatment of metastatic renal cell carcinoma (mRCC).

Methods:

Retrospective study based on healthcare claims data for patients with mRCC, aged ≥18 years, receiving first-line treatment with targeted therapies. AEs of interest comprised of abdominal pain, back pain, diarrhea, dyspnea, extremity pain, fatigue/asthenia, hand-foot syndrome, hypertension, lymphopenia, nausea/vomiting, neutropenia, proteinuria, and thrombocytopenia. Healthcare encounters for AEs were based on ICD-9-CM diagnosis/procedure codes on healthcare claims. AE costs were examined over a 30-day period, beginning with the date of first mention of AE, and were estimated based on the difference in total costs between patients with and without events. Drug costs of targeted agents were excluded from the analysis. Multivariate generalized linear models with a log-link function and gamma response probability distribution were utilized to control for differences in baseline characteristics between patients with and without evidence of AEs.

Results:

A total of 533 patients were included in this analysis: 418 patients with AE and 115 patients without AE. Baseline characteristics were generally similar between patients in the two groups. The GLM-based estimate of incremental 30-day post-event costs among patients with evidence of any adverse events was $9807 (95% CI?=?$4386–$22,947). For all types of adverse events examined, the estimated difference in costs between evented and non-evented patients was positive; the 95% CI did not include zero for all of the adverse events considered, except hypertension and proteinurea. Study limitations include errors of commission/omission, especially as they may affect case-finding methods that rely on ICD-9-CM diagnosis and procedure codes, as was the case in the current study.

Conclusion:

Costs associated with AEs of first-line targeted therapies are substantial in patients with mRCC. Efforts to prevent and/or better manage these events may reduce overall healthcare costs.     

On leadership organizational intelligence/organizational stupidity: the leader's challenge

Creating organizations with a high IQ or creating organizations without the necessary intelligence guarantees success or failure of the organization. Without structures such as shared leadership and other forms of participative management, the organization or unit cannot access and use the available information and wisdom in the organization. When nurses and other health care professionals do not feel like they have a shared stake and do not feel like citizens of the organization, they lack passion for the organization's work. When nurses feel a sense of share ownnership and autonomy for the clinical practice, terrific outcomes are achieved. Leaders must accept the challenge to build the infrastructure that leads to excellence in organizational IQ.     

The AACN Synergy Model for Patient Care: a nursing model as a Force of Magnetism

One of the 14 Forces of Magnetism requires a health care organization to have a professional model of care. The eligibility requirements stipulate that this model must be utilized throughout the health care system and that the same philosophy must be used throughout the system. The American Association of Critical-Care Nurses Synergy Model for Patient Care describes nursing practice based on eight patient characteristics, and also describes eight nurse competencies. The core concept of the model is that the needs or characteristics of patients and families influence and drive the characteristics or competencies of nurses. Synergy results when the needs and characteristics of a patient, clinical unit, or system are matched with a nurse's competencies. The synergy model is an excellent framework to organize the work of patient care throughout the health care system. It can be used and applied in various ways and provides a comprehensive framework for assuring success in building a philosophy that supports the Forces of Magnetism.     

Clinical trials with multiple endpoints can establish a correlation,but not (yet) causality,between dietary supplementation with omega-3 fatty acids and keratoconjunctivitis sicca

Aim: We review clinical evidence of therapeutic efficacy and effectiveness of omega-3 fatty acids (omega-3s) in keratoconjunctivitis sicca, colloquially known as dry eye disease. In doing so, we identify relevant literature to address the following questions: (1) What definitive guidance can clinical evidence offer eye physicians and their patients? (2) What aspects of omega-3 supplementation lack definitive evidence, and how might economic assessments help?

Methods: A targeted and systematic search strategy based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) was designed in this study for refereed clinical trials of omega-3s in dry eye treatment. Four key databases were accessed. Records were filtered through a three-step process using predetermined inclusion criteria. Data was extracted for experimental design, sample population characteristics, content of test and control groups, symptoms and associated opthalmologic conditions, diagnostic measures, patient health outcomes, adverse events, and model time horizon.

Results: A total of 219 records were initially identified, of which 21 prospective clinical trials, with a total of 2,973 participants, were admitted for review. Clinical evidence indicates that daily oral supplementation with omega-3s statistically correlates with dry eye treatment in the general symptomatic population as well as induced sub-populations. Reported adverse events are minimal. These trials nonetheless exhibit considerable heterogeneity in clinical endpoints, particularly as a result of the multi-factorial character of dry eye as well as continuous advances in scientific knowledge and technology. Their findings and recommendations appear to be of limited external validity. And causal inferences are needed, but difficult to establish. These have encouraged and sustained wide variations in ophthalmologic practice and normative decision-making.

Conclusions: Comparability of omega-3 therapeutic efficacy and effectiveness remains a major challenge in dry eye disease management. Notwithstanding its multi-factorial character, addressing prevailing methodological and empirical issues in clinical trials will help reduce knowledge gaps and normative choices among eye physicians and patients alike. In this regard, pharmacoeconomics offers a useful and robust toolset through which analysis of cost-minimization, cost-effectiveness, and cost-utility as well as meta-analysis can be comparatively pursued. Blending measures of costs and outcomes puts in perspective the heterogeneity of clinical endpoints in keratoconjunctivitis sicca.     

A systematic review of cost-effectiveness modeling of pharmaceutical therapies in neuropathic pain: variation in practice,key challenges,and recommendations for the future

Objectives: Complexities in the neuropathic-pain care pathway make the condition difficult to manage and difficult to capture in cost-effectiveness models. The aim of this study is to understand, through a systematic review of previous cost-effectiveness studies, some of the key strengths and limitations in data and modeling practices in neuropathic pain. Thus, the aim is to guide future research and practice to improve resource allocation decisions and encourage continued investment to find novel and effective treatments for patients with neuropathic pain.

Methods: The search strategy was designed to identify peer-reviewed cost-effectiveness evaluations of non-surgical, pharmaceutical therapies for neuropathic pain published since January 2000, accessing five key databases. All identified publications were reviewed and screened according to pre-defined eligibility criteria. Data extraction was designed to reflect key data challenges and approaches to modeling in neuropathic pain and based on published guidelines.

Results: The search strategy identified 20 cost-effectiveness analyses meeting the inclusion criteria, of which 14 had original model structures. Cost-effectiveness modeling in neuropathic pain is established and increasing across multiple jurisdictions; however, amongst these studies, there is substantial variation in modeling approach, and there are common limitations. Capturing the effect of treatments upon health outcomes, particularly health-related quality-of-life, is challenging, and the health effects of multiple lines of ineffective treatment, common for patients with neuropathic pain, have not been consistently or robustly modeled.

Conclusions: To improve future economic modeling in neuropathic pain, further research is suggested into the effect of multiple lines of treatment and treatment failure upon patient outcomes and subsequent treatment effectiveness; the impact of treatment-emergent adverse events upon patient outcomes; and consistent and appropriate pain measures to inform models. The authors further encourage transparent reporting of inputs used to inform cost-effectiveness models, with robust, comprehensive and clear uncertainty analysis and, where feasible, open-source modeling is encouraged.     

基于创新失败情境的情绪智力结构关系研究

基于情绪事件理论，利用收集的298份正式调研样本进行实证分析，探究创新失败情境下情绪智力的内部结构关系。结果发现：①在创新失败情境下，情绪智力4个维度在发挥作用时存在先后次序；②自我和他人情绪评价、情绪控制对失败学习存在显著正向影响；③情绪控制在两种情绪评价与失败学习关系中起中介作用；④与自我情绪评价相比，他人情绪评价对失败学习的作用效果更佳。研究结论有助于廓清创新失败情境下情绪智力结构，明晰情绪智力4个维度间的内部关系，打破以往学者对情绪智力这一构念的固化认知，同时也为中国企业创新失败后的情绪管理实践提供参考。     

生物制药创新失败的挽救过程 ——偶然事件、社会资本与整合能力

运用多维度的数据来源构造案例,通过典型案例剖析发现,转化科学家是生物制药创新失败挽救的动力来源,挽救过程包括价值暴露、能力吸纳、路径转换和常规创新4个主要阶段,在挽救过程中发挥关键推动作用的因素主要是幸运的偶然事件、特定性社会资本和整合能力,创新主体对挽救过程具有权变调节作用.在此基础上提炼升华得到技术创新失败挽救的过程模型,并对企业挽救技术创新失败项目提出管理启示.