RESEARCH
Nursing Care Patterns for Patients Receiving Total Hip Replacements Mikyoung Lee ▼ Sue Moorhead
Successful recovery from total hip replacement requires not only proper surgical technique but also appropriate nursing care during the immediate recovery period. PURPOSE: The study focused on (1) describing nursing interventions for inpatients who underwent total hip replacement; (2) depicting the patterns of nursing interventions over the hospital stay; and (3) examining relationships among patient characteristics, nursing interventions, and complication rates. METHODS: With retrospective data, the types, numbers, and time required for nursing interventions were identified by descriptive statistics. Using a cross-tabulation table and a graph, the patterns of nursing interventions were depicted by day. A correlation analysis was conducted to examine relationships among variables. RESULTS: On the first day of admission, the 5 most frequent nursing interventions were intravascular administration, care plan, orthotics management, teaching/emotional support, and elimination care. However, when frequencies and time required for nursing interventions were considered together, the rank order was different. Furthermore, complications had significant relationships with age, comorbidity, severity of illness, length of stay, and some nursing interventions at the significant level (p ≤ .05). CONCLUSION: The description and review of nursing interventions being provided in a hospital are necessary to delineate nursing work and improve nursing practice. The significant relationships among nursing interventions, comorbidities, and complications found in this study suggest that nurses should consider comorbidities in their care planning, monitoring, and documenting of nursing interventions and outcomes along with the onset of complications. BACKGROUND:
T
otal hip replacement (THR) is a common reconstructive surgical treatment to alleviate pain and preserve physical independence and function in patients suffering from arthritis and chronic joint symptoms (Montin, Leino-Kilpi, Suominen, & Lepisto, 2008; Parsons & Sonnabend, 2004). More than 285,000 THRs are performed each year in the United States (American Academy of Orthopaedic Surgeons, 2011) and make up the largest dollar volume within the Medicare Program in the United States (Bozic, 2006). © 2014 by National Association of Orthopaedic Nurses
With advances in surgical care, there has been a decrease in hospital length of stay (LOS) for primary THR from 9.1 days to 3.7 days between 1991 and 2008 (Cram et al., 2011). However, during the same period, there was an increase in the rates of 30-day readmission from 5.9% in 1991 to 8.5% in 2008 (Cram et al., 2011). Reasons for readmissions include dislocation of joint, fracture of bone, and other mechanical complications; signs and symptoms related to joints (pain, swelling, stiffness, etc.); postoperative infection; and postoperative thromboembolism (Cullen, Johnson, & Cook, 2006; Mnatzaganian, Ryan, Norman, Davidson, & Hiller, 2012). Readmission was associated with comorbidity and inhospital complications (Mnatzaganian et al., 2012). Depending on the study sample and country, there is wide variation in complication rates following THR. In the United States, the rates have ranged from approximately 3.8% to 7% (Cushner, Agnelli, FitzGerald, & Warwick, 2010; SooHoo, Farng, Lieberman, Chambers, & Zingmond, 2010). Although these rates seem low, readmissions and complications are costly. A hip revision due to dislocation or infection costs 1.5 to 3.6 times more than an uncomplicated primary THR (De Palma, Procaccini, Soccetti, & Marinelli, 2012; Klouche, Sariali, & Mamoudy, 2010; Sanchez-Sotelo, Haidukewych, & Boberg, 2006). The extra costs are due to the extension in operation time, hospital stay, nursing care, and rehabilitation (Bozic, Rubash, Sculco, & Berry, 2008; Klouche et al., 2010; Sanchez-Sotelo et al., 2006; Vanhegan, Malik, Jayakumar, Islam, & Haddad, 2012). As Medicare, which is the biggest payer for the procedure, will reduce payments for readmissions through the value-based purchasing program in 2015 (Centers for Medicare & Medicaid Services, 2013), readmissions may place an increased financial burden on hospitals. The most common complications following THR are Mikyoung Lee, PhD, RN, Assistant Professor, Indiana University School of Nursing, Indianapolis, Indiana. Sue Moorhead, PhD, RN, Associate Professor, Director, Center for Nursing Classification & Clinical Effectiveness, The University of Iowa College of Nursing, Iowa City. The authors have no conflicts of interest directly relevant to the content of this study. No funding has been received for this study. DOI: 10.1097/NOR.0000000000000047 Orthopaedic Nursing
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myocardial infarction, pulmonary embolism, deep vein thrombosis, pneumonia, dislocation, and surgical site infection (Cushner et al., 2010; Mahomed et al., 2003; Mantilla, Horlocker, Schroeder, Berry, & Brown, 2002; Memtsoudis et al., 2010). Other recognized perioperative complications include excessive bleeding, decubitus ulcer, delirium, neurovascular injuries, compartment syndrome, and ileus, just to mention a few. These serious complications after THR occur in the early postoperative course (Parvizi et al., 2007). Successful recovery from THR requires appropriate nursing care during the immediate recovery period. Perioperative assessments, education, pain management, ambulation, and rehabilitation have a significant impact on treatment effectiveness and patient satisfaction (Lubbeke, Suva, Perneger, & Hoffmeyer, 2009; Mauer, Abrahams, Arslanian, Schoenly, & Taggart, 2002; O’Sullivan & Savage, 2008; Parsons & Sonnabend, 2004). However, the effects of each of these interventions have been individually examined in single studies. Providing these interventions during the hospital stay is important for successful recovery and complication prevention. Nursing care for this patient group has not been studied using actual clinical data. In addition, the time required for these interventions has not been determined through previous research. Nurses have increasingly focused on translating research findings into routine clinical practice. Before translating interventions into practice, it is important to clearly describe current nursing interventions and practice patterns for patients in specific contexts during hospitalization. Subsequently, the extent of quality improvement in nursing care can be clearly identified when nursing practice is changed considering patient outcomes and costs.
Purpose The purpose of the study was to (1) describe nursing interventions for patients who underwent THR at a hospital; (2) depict the patterns of nursing interventions over the hospital stay; and (3) examine relationships among patient characteristics, nursing interventions, and complication rates.
Methods This study was based on retrospective data collection and analysis and was approved by the institutional review board. The data were retrieved from medical discharge records and the nursing workload system at a 218-bed, not-for-profit community hospital in the Midwest.
SAMPLE A total of 254 patients who were admitted to the orthopaedic unit for THR between January 2006 and December 2007 were included in the sample. Data from only one admission for each patient were collected.
DATA COLLECTION Patient variables included age, gender, marital status, and comorbidities. Comorbidities were defined as a
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patient’s other illnesses on admission, but not the principal reason for admission. Comorbidities were extracted from a list of secondary diagnoses, using the 30-comorbidity identification method by Elixhauser, Steiner, Harris, and Coffey (1998) and the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) comorbidity codes identified by Agabiti et al. (2007) specific to patients undergoing hip replacements. Nursing intervention data were obtained from the GRASP ® System (GRASP Systems International Companies, Fort Collins, CO), which is a nursing workload system and has been implemented for 20 years in the study hospital. The GRASP System views nursing as a series of tasks performed in a sequence (Hernandez & O’Brien-Pallas, 1996a, 1996b) and consists of comprehensive lists of direct and indirect nursing interventions with associated durations. Direct nursing intervention is defined as “hands-on” care provided directly to the patient by nurses, whereas indirect nursing interventions are “hands-off” activities supporting direct nursing interventions. Each nursing intervention label has a group of relevant activities in steps involved from the beginning to the end. For example, Apply/Remove Orthotics is categorized as taking 4.4 minutes, based on eight relevant sequential activities beginning with “Assemble/prepare equipment, cleanse if applicable” through “Explain procedure, application adjustment, and removal,” “Apply orthotic device and adjust it as needed,” and ending with “Document.” The GRASP System has allowed the nursing interventions to be specified according to the priorities and convenience preferred by an individual unit or a hospital. Thus, the nursing intervention labels specific to an individual unit have been developed through a consensus process unit-by-unit and then put into each unit’s interface screen. Therefore, the total list of nursing interventions in this study includes the nursing interventions considered as important and necessary to the orthopaedic unit of the study hospital. The type and the time value of a specific nursing intervention were determined by a combination of time studies and the consensus method. The validity and reliability of the list of nursing interventions/activities and corresponding time values have been repeatedly tested on the study unit with nurses by three different methods: interrater reliability, content validity, and predictive validity. In particular, the interrater reliability of the system has been assessed on a weekly basis on the study unit. During the time period of this study, the average interrater reliability score for the unit was 91.5%. Severity of illness was defined as the extent of organ system loss of function or physiologic decompensation, and was measured by the All Patient Refined Diagnosis Related Group (APR-DRG) Severity of Illness Scale (3M Health Information Systems, 2003). Severity of illness was graded sequentially from 1 to 4, corresponding to minor, moderate, major, and extreme severity. Complications were defined as additional medical problems that arose after a procedure or treatment during the patient’s hospitalization. Complications were extracted from the list of secondary diagnoses using the
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Complications Screening Programme (Iezzoni et al., 1994, 1999; Weingart et al., 2000), the Agency for Healthcare Research and Quality (AHRQ, 2007) Patient Safety Indicators, and the complication codes for THR identified by Agabiti et al. (2007). Length of stay was calculated as the number of days from the first shift at admission to the shift at discharge, based on the nursing documents in the GRASP System. For example, a patient who was admitted during the evening shift on March 21 and discharged during the day shift on March 25 was considered to have an LOS of 3.67 days.
DATA ANALYSIS Data analyses were performed using SPSS 19.0. The types, numbers, and time required for nursing interventions were identified by descriptive statistics. Using cross-tabulations, the frequency distributions of nursing interventions were compared with each other over the hospital stay. In addition, the combination of the frequency and time required per nursing intervention was depicted by days in a graph. The graph provided visual cues to quickly understand nursing intervention patterns over the hospital stay. Correlation analysis was conducted to examine relationships among patient characteristics, nursing interventions, and complication rates, with p values of < .05 and < .001 considered to be significant and highly significant, respectively.
Results PATIENTS The average patient age was 66 years, with ages ranging from 27 to 93 years; the elderly—65 years or older— made up 62.6% of the sample. Slightly more than half of the subjects were female (53.5%), and the majority were married (68.9%). The dominant primary medical diagnosis was osteoarthrosis, localized, not specified whether primary or secondary on pelvic region and thigh (ICD-9-CM Code, 71535) (88.2%). On average, patients had five comorbidities; only 10 of 254 patients (3.9%) had none. A total of 1,198 comorbid conditions under 44 different categories were identified. Common comorbid conditions with the study subjects were diseases of the musculoskeletal system and connective tissue (n = 191; 15.9%), uncomplicated hypertension (n = 144; 12%), and ischemic heart disease (n = 86; 7.2%). Most (65%) of the patients were at Stage 3 on the severity of illness scale, which indicates major severity as rated by the APR-DRG Severity of Illness Scale. The rest of the patients (35%) were at Stage 2, which is the moderately severe stage of illness. The mean number of complications per patient was 1.18 ± 1.30. Ninety-six patients (37.8%) did not have any complication; 31.1% of the patients had one complication, 16.1% had two complications, 8.7% had three, 4.3% had four, three patients had five, and two patients had six or seven complications. Complications in this study ranged from life-threatening outcomes (e.g., cardiac arrest, pulmonary embolism, and infarction) to
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negative orthopaedic outcomes (e.g., a fracture of the femur neck and unequal leg length), to minor symptoms that necessitated additional observation or treatment such as blood transfusion or antibiotics (e.g., irritable bowel syndrome and iatrogenic hypotension). Common complications were related to the digestive (32.8%), metabolic and immune (19.1%), urinary (10%), or nervous/musculoskeletal systems (7%) or were general symptoms (8%). There was no perioperative thromboembolism. Other notable complications experienced by patients were anemia (four cases), iatrogenic hypotension (four), irritable bowel syndrome (three), hemorrhages (two), falls (two), urinary infection (two), and cardiac arrest (one). The mean LOS was 3.84 ± 1.08 days, ranging from 1.33 days to 8.67 days. Most patients (n = 206; 81.1%) stayed 2 to 4 days in the hospital. The next most common LOS was between 4 and 6 days (n = 39; 15.4%).
THE DOSAGE OF NURSING INTERVENTIONS The mean total nursing hours per patient during hospitalization was 30. The majority of patients (n = 140; 55.1%) received 20 to 30 total nursing hours. Patients who received 30 to 40 nursing hours in total care comprised the second largest proportion (n = 77; 30.3%). The average total nursing hours per day was 7.78; 93.3% of the patients received nursing care, including direct and indirect nursing interventions, for 7–9 hours every day. Based on the original database of the GRASP System, 57 direct nursing interventions were provided at least once for a patient. However, some nursing interventions could be grouped into broader labels for definitional purposes. For example, intravascular (IV) 1–4 medications and IV 5–8 medications were merged into IV administration. In addition, some nursing interventions could be grouped according to the similarity of roles and activities. For example, Bathes with Assistance, Bathed by Staff, and Bathes Self were grouped under the label “Bathing.” With the relabeled interventions, Table 1 presents the average durations of all nursing interventions. On average, nurses spent the greatest number of hours for the intervention “Care Plan” (3.6032 ± 1.0571 hours) (see Table 1), which includes shift assessment on behavioral, skin, respiratory, gastrointestinal, incisional, pain, and neurological conditions, as well as review and evaluation of care and the patient’s response. During the entire hospital stay, patients received an average of 3.33 hours of mobility care and 1.94 hours of nutrition care. Other interventions on which nurses spent more than 1 hour per patient included IV administration, elimination care, oral medication, intensive monitoring, fall intervention, and bathing. A total of 36 indirect nursing interventions were categorized into six broader concepts (i.e., administrative/ clerical, housekeeping, admission/discharge/transfer, communication, transportation, and personal time) for the category “Indirect Nursing Interventions” in the GRASP System. The mean of total nursing hours for the indirect nursing interventions was 8.24 during hospitalization.
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TABLE 1. THE TYPES OF AND TIME REQUIRED FOR NURSING INTERVENTIONS Total Hours During Hospitalization Nursing Interventions
Mean
SD
Care plan
3.6032
1.0571
Mobility care
3.3288
0.8646
Nutrition care
1.9394
0.5470
IV administration
1.7422
0.4715
Elimination care
1.4687
0.5835
Oral medication
1.3442
0.5217
Intensive monitoring
1.3381
0.6744
Fall intervention
1.2779
0.4079
Bathing
1.0735
0.2963
Teaching/emotional support
0.8780
0.3088
1:1 care
0.7367
8.2918
Orthotics management
0.7026
0.2744
V/S check
0.6394
0.1872
Pain management
0.5968
0.2185
Incentive spirometry
0.5908
0.4110
IM/SQ administration
0.3873
0.3139
Blood transfusion
0.3862
0.7437
Wound care
0.2513
0.1182
Blood draw
0.1617
0.3505
Incontinence care
0.1104
0.4777
Drain management
0.0758
0.0456
Dementia management
0.0025
0.0309
Delirium management
0.0022
0.0244
Isolation/chemo/latex precautions
0.0004
0.0068
Indirect nursing interventions
8.2426
2.4181
Note. IM = intramuscular; IV = intravascular; SQ = subcutaneous; V/S = vital sign.
THE PATTERNS OF NURSING INTERVENTIONS OVER HOSPITAL STAY The cross-tabulations in Table 2 show the frequency distributions of the direct nursing interventions during hospitalization. Although some interventions were provided less often when patients neared discharge, substantial time in nursing interventions was being used right up to the time of discharge. Care plan, orthotics management, bathing, oral medication, elimination care, and pain management were implemented most frequently on the first day and intensively provided on the 1st, 2nd, and 3rd days. Mobility care, teaching/emotional support, fall intervention, nutrition, vital sign (V/S) check, incentive spirometry, and blood draw were provided more on the 2nd, 3rd, and 4th days than the 1st day. Intravascular administration was predominantly provided on the 1st (n = 2,439) and 2nd days (n = 1,593) and then dramatically decreased in use on the 3rd day (n = 422). IM/SQ administration was provided in a similar pattern. Intensive monitoring 152
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was provided primarily on the 1st day (n = 359; 98.9%). Drain management, including external drain management and nasogastric suction, was implemented mostly on the 1st and 2nd days (99.8%) and rarely provided after the 3rd day. Blood transfusion also was provided primarily on the 1st and 2nd days (83.5%). Wound care was provided more often on the 3rd day. The interventions of incontinence care, 1:1 care, dementia management, delirium management, and isolation/chemo/latex precautions were rarely provided to the patients. Figure 1 shows the patterns of the direct nursing interventions, considering both frequency and time for providing each intervention. Because of the limited graphical display with too many interventions, Figure 1 presents the top 10 common interventions only. On the first day the top five most frequently provided direct nursing interventions were IV administration (n = 2,439), care plan (n = 1,524), orthotics management (n = 1,031), teaching/emotional support (n = 764), and elimination care (n = 759) (see Table 2). However, when the frequency and the time consumption of nursing interventions are considered together, the rank was different as shown in Figure 1. The top five direct nursing interventions that consumed the most time on the first day included IV administration (2,534.12 hours = 1.039 hours per intervention [H] × 2,439 frequency [F]), mobility care (771.78 hours = 1.5313 H × 504 F), nutrition care (503.53 hours = 0.6687 H × 753 F), care plan (473.51 hours = 0.3107 H × 1524 F), and elimination care (404.02 hours = 0.5323 H × 759 F). On the 2nd day, fall intervention (n = 756), bathing (n = 756), and oral medication (n = 755) were more frequently provided than elimination care (n = 749); however, the rank was similar to the first day when the frequency and the time consumption of nursing interventions are considered together. On the 3rd day, the top five frequent nursing interventions were care plan (n = 1,476), teaching/emotional support (n = 745), fall intervention (n = 733), bathing (n = 733), and V/S check (n = 733). On the same day, the top five most timeconsuming nursing interventions were mobility care (1,120.91 hours), nutrition care (488.15 hours), care plan (458.59 hours), IV administration (438.46 hours), and elimination care (379.53 hours).
Correlation Comorbidity had significant positive associations with age (r = .39), severity of illness (r = .34), complications (r = .27), and LOS (r = .18) at the significant level, p ≤ .001, and with the majority of nursing interventions at the significant level, p ≤ .05. Older patients were likely to have comorbid conditions on admission. Patients with more comorbidity conditions on admission were likely to have a higher “severity of illness” score, more complications, and a longer hospital stay, and to need more nursing interventions. Complications had significant relationships with age (r = .13, p ≤ .05), comorbidity (r = .27, p ≤ .001), severity of illness (r = .18, p ≤ .05), and LOS (r = .18, p ≤ .05). The interventions—care plan, teaching/emotional support, oral medication, wound care, bathing, mobility care, fall intervention, nutrition care, and elimination care—were positively correlated © 2014 by National Association of Orthopaedic Nurses
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TABLE 2. THE PATTERNS OF DIRECT NURSING INTERVENTIONS OVER THE HOSPITAL STAY (FREQUENCY) Day 1
2
3
4
5
6
7
8
9
Total
Care plan
1,524
1,520
1,476
841
278
120
52
18
4
5,833
IV administration
2,439
1,593
422
79
16
1
0
0
0
4,550
Orthotics management
Interventions
1,031
923
638
309
89
34
5
2
0
3,031
Teaching/emotional support
764
770
745
420
139
60
26
9
2
2,935
Fall intervention
754
756
733
411
131
57
20
5
2
2,869
Bathing
758
756
733
410
129
57
18
5
2
2,868
Nutrition
753
756
730
411
133
57
20
5
2
2,867
Oral medication
757
755
729
412
135
57
22
6
2
2,875
Elimination care
759
749
713
400
126
48
12
4
2
2,813
Mobility care
504
752
732
410
132
56
21
5
2
2,614
V/S check
400
753
733
413
133
57
22
6
2
2,519
Pain management
675
636
620
345
114
49
18
3
2
2,462
Wound care
272
492
724
407
132
57
18
5
2
2,109
Incentive spirometry
427
494
441
212
71
27
5
2
0
1,679
IM/SQ administration
575
256
127
64
27
17
0
0
0
1,066
Drain management
557
328
1
1
0
0
0
0
0
887
Blood draw
95
130
120
66
34
16
2
0
0
463
Intensive monitoring
359
4
0
0
0
0
0
0
0
363
Blood transfusion
45
31
11
4
0
0
0
0
0
91
Incontinent care
1
6
16
11
5
8
9
2
0
58
1:1 care
3
4
5
3
3
3
3
3
0
27
Delirium management
0
3
1
2
0
0
0
0
0
6
Dementia management
2
0
1
2
1
1
0
0
0
7
Precautions Total
0
0
1
0
0
0
0
0
0
1
14,215
13,228
11,189
6,054
1,967
842
299
89
26
47,909
Note. IM = intramuscular; IV = intravascular; SQ = subcutaneous; V/S = vital sign.
with complications at the significant level (p ≤ .05). The older patients with more comorbid conditions were likely to have more complications. Patients who had more complications tended to stay longer at the hospital and to have higher severity of illness scores (see Table 3).
Discussion Information on the types and patterns of nursing interventions during hospitalization for patients receiving THR provides insight into what nurses are doing for patients and what opportunities exist for improving patient conditions. This information can help nurses redesign the range of nursing interventions or alternative nursing care toward efficient and cost-effective care delivery. Examination of the time required for accomplishing nursing interventions will assist nurse managers and administrators in evaluating nursing resource use including staffing and costing out nursing care for this patient population. On average, total nursing hours per day for THR patients were 7.78. This means that the patients spent a © 2014 by National Association of Orthopaedic Nurses
large portion of their time receiving nursing care during their hospital stay, which is about 32.5% of 24 hours and 48.7% of the day excluding sleeping time. This finding supports the idea that nurses are the closest to the patient and important health care providers in acute care hospitals and therefore their contributions should be delineated by research describing the results of nursing interventions. If the average nursing hours per day (7.78 hours) are simply divided by 3 for 8-hour shifts, a patient receiving THR on average may require 2 hours and 36 minutes of nursing time in a shift. Given a shift, a staff nurse can, therefore, care for up to three patients with THR; this calculation suggests that, on average, a nurse-to-patient staffing ratio of 1:3 would be desirable for this population, although different skill-mix options can dictate different staffing ratios. Because it was presumed in this study that nursing interventions were provided by RNs only, repeated studies with different skill mixes in different settings will be necessary. From the accumulated findings of these studies, then, if there is consensus on the nursing intensity or the minimum nurse-to-patient staffing ratio required for this THR population across Orthopaedic Nursing
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FIGURE 1. The patterns of direct nursing interventions over hospital stay (Frequency × Time).
settings, such information could be used to reflect nursing resource weight in calibrating the payment for THR. This kind of information would be a solution to overcoming the difficulty of calculating relative weights of nursing care in specific diagnosis-related groups (DRGs) and address policy makers’ hesitation to isolate nursing resource weight from the room-and-board portion per DRG. Regarding nursing practice pattern for THR patients, Mauer et al. (2002) identified national nursing practice pattern via a survey with orthopaedic nurses across the country. Although they highlighted key nursing interventions in preoperative, intraoperative, and postoperative practices, our study identified the patterns of dosage of nursing interventions day by day during hospitalization, naming such nursing interventions in a standard and predetermined manner. In a report by Mauer et al., the postoperative practices, the similar period that the nursing interventions were provided in our study, focused on pain management, nausea/vomiting control, bowel regimen, turning, positioning, transfer, and ambulation. All of these nursing practices were embraced in the nursing intervention list identified in this study. 154
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Pain management via IV patient-controlled analgesia and IM morphine and meperidine was a focus for most of the orthopaedic nurses during the first 48 hours postoperatively (Mauer et al., 2002). The patients in our study also received a great deal of pain management and IM/SQ administration on the 1st and 2nd days of the hospital stay. Most THR patients were transferred to a chair or ambulated initially on the 1st postoperative day, turned on the nonoperative side, and instructed about mobilization and relevant precautions (Mauer et al., 2002). Our study revealed that mobility care began on the 1st day (19.3%), was provided primarily on the 2nd and 3rd days (56.8%), and was delivered right up to the time of discharge for the patients. Because dislocation is the most common serious complication after THR (Cram et al., 2011; Lubbeke et al., 2009; SooHoo et al., 2010), it is very important to educate and assist patients in their mobility progress to prevent dislocation. With the GRASP System, nurses differentiated the activities of mobility care postoperatively day by day. For example, on the 1st postoperative day, nurses assist patients to a seated position in a chair, protecting alignment of the extremity and realigning tubes. On the 2nd day, nurses moved patients © 2014 by National Association of Orthopaedic Nurses
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TABLE 3. THE RELATIONSHIPS BETWEEN PATIENT CHARACTERISTICS, NURSING INTERVENTIONS, AND COMPLICATIONS Age Marital status Comorbidity
Marital Status
Comorbidity
Severity of Illness
Complications
.21** .39**
.1
Severity of illness
.11
−.01
.34**
Complication
.13*
−.01
.27**
.18*
Length of stay
.16*
.19**
.18**
.16*
.18*
Care plan
.11
.14*
.17*
.14*
.19**
−.02
0
.07
.01
.04
0
.11
.01
0
.07
Drain management Orthotics management V/S check
.09
.1
.1
.13*
.11
Wound care
.15*
.15*
.13*
.07
.15*
Blood transfusion
.19**
.06
.12
.07
.08
Bathing
.11
.16*
.19**
.14*
.14*
Blood draw
.04
.04
.32**
.08
.05
Mobility care
.07
.12
.13*
.12
.14*
Fall intervention
.12
.16*
.16*
.14*
.13*
Nutrition care
.08
.15*
.15*
.11
.14*
Incentive spirometry
.02
.06
.16*
.11
.08
0
.16*
.13*
.1
.1
.14*
.13*
.15*
Pain management Elimination care
−.01
.06
Teaching/emotional support
.07
.12*
.18**
.16*
.21**
Oral medication
.11
.16*
.2**
.12*
.19**
IM/SQ administration
.05
.02
.32**
.17*
.06
.05
.07
−.02
.11
IV administration
−.03
−.02
.08
Intensive monitoring
−.02
.09
.07
Note. IM = intramuscular; IV = intravascular; SQ = subcutaneous; V/S = vital sign. *p < .05; **p < .001.
to the edge of the bed and elevated the head on the bed; on the 3rd and 4th days, nurses assisted patients to move to a chair and, if possible, to ambulate; from the 5th day to discharge nurses assisted patients to ambulate with leg support, ensuring alignment and safety. In addition to the phased mobility care, the instruction on the correct use of the toilet seat is important to prevent dislocation. This importance was well reflected with the finding that elimination care including toilet use assistance and education was one of the top five frequent and timeconsuming nursing interventions in this study. The fact that intensive monitoring was provided on the 1st day (98.9%) indicates that the operation was performed on admission day. Intensive monitoring includes intensive circulatory-vascular checks, motor-sensory checks, and every-2-hour clinical parameter checks immediately after surgery. Although the use of drains and blood loss replacement was described as intraoperative nursing practice in the report by Mauer et al., nurses in this study still administered blood transfusions and conducted drain management (including care for external drains and nasogastric tubes) on the 1st and 2nd days of hospitalization in the postoperative unit. This objectively measured view of nursing interventions provided routinely is critical to determine implications © 2014 by National Association of Orthopaedic Nurses
of treatment alternatives (Feinstein & Horwitz, 1997). The findings help clinicians evaluate current practices and use the results to develop fact-based improvements to the care process rather than clinical opinion-based modifications (Horn, 2001). Variations from this comparison can be monitored with the measurement of their effects on patient outcomes. Dochterman et al. (2005) stated that determining the interventions used most frequently on a specific type of unit or in a certain type of agency helps determine interventions that should be on that facility’s nursing information system, selection of personnel to staff that unit, and structure for the orientation and continuing education needed by care providers. Furthermore, Dochterman et al. stated that the retrospective review of nursing interventions routinely delivered is also helpful in constructing critical paths, determining costs of services, and planning for resource allocation. Along with the review of nursing practice patterns for THR patients by frequency, a notable finding in this study was the different ranks of nursing interventions by time consumption. In the first day of hospitalization, the top five most frequently provided were IV administration, care plan, orthotics management, teaching/ emotional support, and elimination care. However, Orthopaedic Nursing
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when the frequency and the time requirements of nursing interventions were considered together, IV administration consumed the largest amount of nursing time. Mobility care consumed the second largest amount of nursing time, followed by nutrition care, care plan, and elimination care. Although orthotics management was the third most frequently provided intervention, it took only a small amount of the time (237.44 hours) and ranked 10th. Pain management (n = 675) also was frequently provided for patients on the 1st day, and this intervention consumed 41.18 hours of nursing care (rank = 15th). The results imply that the different intensity of each intervention affects nurses’ time consumption. More reliable measures for evaluating nursing interventions would be to consider both frequency and time required, and then these measures of nursing interventions should be used to evaluate the effects of nursing interventions on outcomes as well as to manage for nurse staffing. This study identified significant relationships among patient characteristics, nursing interventions, and complications. Not surprisingly, older patients were likely to have more comorbidities on admission. Patients with more comorbidities on admission were likely to have higher severity of illness scores, more complications, and longer hospital stays. This finding is consistent with the previous reports that advanced age and comorbid diseases have been associated with an increased risk of complications (McDonald & Huo, 2008; Shebubakar, Hutagalung, Sapardan, & Sutrisna, 2009; SooHoo et al., 2010). Comorbidity also significantly affected the dose of nursing interventions. Patients who had more comorbid conditions were likely to receive more nursing interventions. So it is important to consider comorbidities in nursing care planning and staffing. Research is needed to track comorbidities and corresponding nursing interventions to build system support as a feature of the hospital information system to guide nurses in care planning along with different types of comorbid conditions to decrease risks of complications. For example, patients with diabetes might need more frequent blood draws. Patients who smoke or patients with lung diseases might need more use of an incentive spirometer to prevent pneumonia or other respiratory complications because they are at risk of having airway or breathing problems after the surgery. This area needs further exploration in future studies. This study found significant relationships between nursing interventions and complication rates. This finding implies that nurses should be able to provide appropriate nursing interventions and monitor changes of patient conditions to prevent and treat complications if they develop. It is remarkable that teaching/emotional support and care plan showed stronger correlations with complication rates than other nursing interventions. Teaching/emotional support encompassed routine conversational education/emotional support and ongoing reinforcement as well as extensive reassurance per patients’/families’ requests; Care plan included head-to-toe assessments and review/evaluation of care delivered and patient responses. These two interven-
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tions can be characterized as nursing surveillance, which have been found to be effective on early detection of adverse patient outcomes (Henneman, Gawlinski, & Giuliano, 2012; Shever, 2011). The significant relationships between these nursing interventions and complication rates reinforced the importance of nursing surveillance for preventing complications. It is also possible to link the nursing interventions showing significant relationships with some complications identified in this study. For example, nutrition care might be associated with 32% of the complications related to digestive system. Mobility care and fall interventions might be related to complications of nervous/musculoskeletal system (7%) and two fall incidents. Elimination care might be needed to care for urinary complications (10%) and two urinary infections. It should be noted that the definition of complications in this study was very broad, from severe and common complications to minor complications rarely reported. Therefore, many of them were not comparable to common quality indicators such as AHRQ’s Patient Safety Indicators. The common quality indicators include falls, pneumonia, urinary infections, and medication errors; only a few of these complications were found in this study. Minor complications identified in the study included fatigue, fever, sleep disturbances, chest pain, palpitations, urinary incontinence, nausea, and vomiting. Although these minor complications are not included in AHRQ quality indicators, they are important cues for indicating patients’ conditions. Although the current DRG system does not count nursing care with specific codes as a source for reimbursement, the nursing document is often used when the coders in clinics look for evidence to justify reimbursement. Thus, it is essential to document and create nursing outcomes data. This study could not review the link between each nursing intervention and the onset time of each complication because this information could not be retrieved from the hospital discharge record. It is important to have nursing outcomes documentation along with nursing interventions meant to reduce complications risks. In future research, the relationships between complication onsets and nursing interventions should be identified. The great majority (>90%) of complications, including pulmonary embolism, typically occur within 4 days after a standard elective joint replacement (Mantilla et al., 2002; Parvizi et al., 2007). If studies are able to link nursing interventions to time-flagged complication data, the findings can be used to build a clinical decision support system to alert nurses to pay attention to the high risk of complications on particular days of hospitalization and to provide appropriate interventions in a timely manner. This would be an important quality improvement process. The hospital information system needs to have features to help nurses monitor and document this information. Electronic nursing information systems are becoming more prevalent; however, the availability of standardized nursing interventions and outcomes measurements is still limited in practice settings. Rare documentation of the time spent for each nursing intervention and the nursing outcomes (changes in patient conditions as a
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result of nursing interventions) makes it difficult to accurately measure the nursing dose and the effectiveness of nursing interventions. Creating a nursing database including both nursing interventions and outcomes is a prerequisite of nursing research to verify nursing contributions to patient and health care outcomes. As Dochterman et al. (2005) stated, the link between science and practice is strengthened when clinical information systems include meaningful data.
Conclusion This study identified patterns of nursing interventions by day for THR patients in one Midwestern community hospital over the course of a year. The description and review of nursing interventions currently being provided are necessary for delineating nursing work and improving hospital nursing practice. To develop accurate, reliable, and valid measures of nurses’ work, more studies are needed to get consensus on the activities, time estimates, and skill levels required per intervention with patient populations in different settings. This will help management plan the most appropriate staff-mix and also determine the effect of nursing interventions on patient outcomes. The significant relationships among nursing interventions, comorbidities, and complications found in this study put high importance on nurses’ accounting for comorbidities in their care planning, monitoring, and documentation of nursing interventions and outcomes along with the onset of the complications. To do this, nursing information systems in hospitals need to have the features for nurses to document, archive, retrieve, and guide nursing interventions and nurse-sensitive outcomes.
REFERENCES 3M Health Information Systems. (2003). All patient refined diagnosis related groups (APR-DRGs) Version 20.0: Methodology Overview. Wallingford, CT: Author. Agabiti, N., Picciotto, S., Cesaroni, G., Bisanti, L., Forastiere, F., Onorati, R., … Perucci, C. A. (2007). The influence of socioeconomic status on utilization and outcomes of elective total hip replacement: A multicity population-based longitudinal study. International Journal for Quality in Health Care, 19(1), 37–44. Agency for Healthcare Research and Quality. (2007). Guide to patient safety indicators. Retrieved from http://www .qualityindicators.ahrq.gov American Academy of Orthopaedic Surgeons. (2011). Total hip replacement. Retrieved from http://orthroinfo.aaos .org/topic.cfm?topic=a00377 Bozic, K. J. (2006). Hospital profitability on the decline for joint replacement service lines. Orthopedics Today, 26(11), 20. Bozic, K. J., Rubash, H. E., Sculco, T. P., & Berry, D. J. (2008). An analysis of Medicare payment policy for total joint arthroplasty. The Journal of Arthroplasty, 23(6, Suppl. 1), 133–138. Centers for Medicare & Medicaid Services. (2013). Readmissions reduction program. Retrieved from http://www.cms.gov/Medicare/medicare-fee-forservice-payment/acuteinpatientPPS/readmissionsreduction-program.html Cram, P., Lu, X., Kaboli, P. J., Vaughan-Sarrazin, M. S., Cai, X., Wolf, B. R., & Li, Y. (2011). Clinical characteristics © 2014 by National Association of Orthopaedic Nurses
and outcomes of Medicare Patients undergoing total hip arthroplasty, 1991–2008. JAMA, 305(15), 1560–1567. Cullen, C., Johnson, D. S., & Cook, G. (2006). Re-admission rates within 28 days of total hip replacement. Annals of the Royal College of Surgeons of England, 88, 475–478. Cushner, F., Agnelli, G., FitzGerald, G., & Warwick, D. (2010). Complications and functional outcomes after total hip arthroplasty and total knee arthroplasty: Results from the Global Orthopaedic Registry (GLORY). American Journal of Orthopedics, 39(9, Suppl.), 22–28. De Palma, L., Procaccini, R., Soccetti, A., & Marinelli, M. (2012). Hospital cost of treating early dislocation following hip arthroplasty. Hip International, 22(1), 62–67. Dochterman, J., Titler, M., Wang, J., Reed, D., Pettit, D., Mathew-Wilson, M., … Kanak, M. (2005). Describing use of nursing interventions for three groups of patients. Journal of Nursing Scholarship , 37(1), 57–66. Elixhauser, A., Steiner, C., Harris, D. R., & Coffey, R. M. (1998). Comorbidity measures for use with administrative data. Medical Care, 36(1), 8–27. Feinstein, A. R., & Horwitz, R. I. (1997). Problems in the evidence of evidence-based medicine. American Journal of Medicine, 103, 529–535. Henneman, E. A., Gawlinski, A., & Giuliano, K. K. (2012). Surveillance: A strategy for improving patient safety in acute and critical care units. Critical Care Nurse, 32(2), e9–e18. Hernandez, C. A., & O’Brien-Pallas, L. L. (1996a). Validity and reliability of nursing workload measurement systems: review of validity and reliability theory. Canadian Journal of Nursing Administration, 9(3), 32–50. Hernandez, C. A., & O’Brien-Pallas, L. L. (1996b). Validity and reliability of nursing workload measurement systems: Strategies for nursing administrators. Canadian Journal of Nursing Administration, 9(4), 33–52. Horn, S. D. (2001). Quality, clinical practice improvement, and the episode of care. Managed Care Quarterly, 9(3), 10–24. Iezzoni, L. I., Daley, J., Heeren, T., Foley, S. M., Fisher, E. S., Duncan, C., … Coffman, G. A. (1994). Identifying complications of care using administrative data. Medical Care, 32(7), 700–715. Iezzoni, L. I., Davis, R. B., Palmer, R. H., Cahalane, M., Hamel, M. B., Mukamal, K., … Davis, D. T., Jr. (1999). Does the complications screening program flag cases with process of care problems? Using explicit criteria to judge processes. International Journal for Quality in Health Care, 11(2), 107–118. Klouche, S., Sariali, E., & Mamoudy, P. (2010). Total hip arthroplasty revision due to infection: A cost analysis approach. Orthopaedics & Traumatology: Surgery & Research, 96, 124–132. Lubbeke, A. L., Suva, D., Perneger, T., & Hoffmeyer, P. (2009). Influence of preoperative patient education on the risk of dislocation after primary total hip arthroplasty. Arthritis & Rheumatism, 61(4), 552–558. Mahomed, N. N., Barrett, J. A., Katz, J. N., Phillips, C. B., Losina, E., Lew, R. A., & Baron, J. A. (2003). Rates and outcomes of primary and revision total hip replacement in the United States Medicare population. Journal of Bone & Joint Surgery, 85-A(1), 27–32. Mantilla, C. B., Horlocker, T. T., Schroeder, D. R., Berry, D. J., & Brown, D. L. (2002). Frequency of myocardial infarction, pulmonary embolism, deep venous thrombosis, and death following primary hip or knee arthroplasty. Anesthesiology, 96(5), 1140–1146. Orthopaedic Nursing
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Mauer, K. A., Abrahams, E. B., Arslanian, C., Schoenly, L., & Taggart, H. M. (2002). National practice patterns for the care of the patient with total joint replacement. Orthopaedic Nursing, 21(3), 37–44. McDonald, J. E., & Huo, M. H. (2008). Total hip replacement: Unique challenges in the obese and geriatric populations. Current Opinion in Orthopaedics, 19(2), 33–36. Memtsoudis, S. G., Ma, Y., Gonzalez Della Valle, A., Besculides, M. C., Gaber, L. K., Koulouvaris, P., … Liu, S. S. (2010). Demographics, outcomes, and risk factors for adverse events associated with primary and revision total hip arthroplasties in the United States. American Journal of Orthopedics, 39(8), E72–E77. Mnatzaganian, G., Ryan, P., Norman, P. E., Davidson, D. C., & Hiller, J. E. (2012). Length of stay in hospital and all-cause readmission following elective total joint replacement in elderly men. Orthopedic Research and Reviews, 4, 43–51. Montin, L., Leino-Kilpi, H., Suominen, T., & Lepisto, J. (2008). A systematic review of empirical studies between 1966 and 2005 patient outcomes of total hip arthroplasty and related factors. Journal of Clinical Nursing, 17(1), 40–45. O’Sullivan, M., & Savage, E. (2008). Nursing contributions to mobilizing older adults following total hip replacement in Ireland. Journal of Orthopaedic Nursing, 12(3/4), 181–186. Parsons, I. M., & Sonnabend, D. H. (2004). What is the role of joint replacement surgery? Best Practice & Research in Clinical Rheumatology, 18(4), 557–572.
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Parvizi, J., Mui, A., Purtill, J. J., Sharkey, P. F., Hozack, W. J., & Rothman, R. H. (2007). Total joint arthroplasty: When do fatal or near-fatal complications occur? Journal of Bone & Joint Surgery, 89, 27–32. Sanchez-Sotelo, J., Haidukewych, G. J., & Boberg, C. J. (2006). Hospital cost of dislocation after primary total hip arthroplasty. The Journal of Bone & Joint Surgery, 88-A(2), 290–294. Shebubakar, L., Hutagalung, E., Sapardan, S., & Sutrisna, B. (2009). Effects of older age and multiple comorbidities on functional outcome after partial hip replacement surgery for hip fractures. Acta Medical Indonesia, 41(4), 195–199. Shever, L. (2011). The impact of nursing surveillance on failure to rescue. Research & Theory for Nursing Practice, 25(2), 107–126. SooHoo, N. F., Farng, E., Lieberman, J. R., Chambers, L., & Zingmond, D. S. (2010). Factors that predict shortterm complication rates after total hip arthroplasty. Clinical Orthopaedics and Related Research, 468(9), 2363–2371. Vanhegan, I. S., Malik, A. K., Jayakumar, P., Islam, S. U. I., & Haddad, F. S. (2012). A financial analysis of revision hip arthroplasty: The economic burden in relation to the national tariff. The Bone & Joint Journal, 94-B(5), 619–623. Weingart, S. N., Iezzoni, L. I., Davis, R. B., Palmer, R. H., Cahalane, M., Hamel, M. B., … Banks, N. J. (2000), Use of administrative data to find substandard care: Validation of the complications screening program. Medical Care, 38(8), 796–806.
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Nursing Care Patterns for Patients Receiving Total Hip Replacements Mikyoung Lee ▼ Sue Moorhead
Successful recovery from total hip replacement requires not only proper surgical technique but also appropriate nursing care during the immediate recovery period. PURPOSE: The study focused on (1) describing nursing interventions for inpatients who underwent total hip replacement; (2) depicting the patterns of nursing interventions over the hospital stay; and (3) examining relationships among patient characteristics, nursing interventions, and complication rates. METHODS: With retrospective data, the types, numbers, and time required for nursing interventions were identified by descriptive statistics. Using a cross-tabulation table and a graph, the patterns of nursing interventions were depicted by day. A correlation analysis was conducted to examine relationships among variables. RESULTS: On the first day of admission, the 5 most frequent nursing interventions were intravascular administration, care plan, orthotics management, teaching/emotional support, and elimination care. However, when frequencies and time required for nursing interventions were considered together, the rank order was different. Furthermore, complications had significant relationships with age, comorbidity, severity of illness, length of stay, and some nursing interventions at the significant level (p ≤ .05). CONCLUSION: The description and review of nursing interventions being provided in a hospital are necessary to delineate nursing work and improve nursing practice. The significant relationships among nursing interventions, comorbidities, and complications found in this study suggest that nurses should consider comorbidities in their care planning, monitoring, and documenting of nursing interventions and outcomes along with the onset of complications. BACKGROUND:
T
otal hip replacement (THR) is a common reconstructive surgical treatment to alleviate pain and preserve physical independence and function in patients suffering from arthritis and chronic joint symptoms (Montin, Leino-Kilpi, Suominen, & Lepisto, 2008; Parsons & Sonnabend, 2004). More than 285,000 THRs are performed each year in the United States (American Academy of Orthopaedic Surgeons, 2011) and make up the largest dollar volume within the Medicare Program in the United States (Bozic, 2006). © 2014 by National Association of Orthopaedic Nurses
With advances in surgical care, there has been a decrease in hospital length of stay (LOS) for primary THR from 9.1 days to 3.7 days between 1991 and 2008 (Cram et al., 2011). However, during the same period, there was an increase in the rates of 30-day readmission from 5.9% in 1991 to 8.5% in 2008 (Cram et al., 2011). Reasons for readmissions include dislocation of joint, fracture of bone, and other mechanical complications; signs and symptoms related to joints (pain, swelling, stiffness, etc.); postoperative infection; and postoperative thromboembolism (Cullen, Johnson, & Cook, 2006; Mnatzaganian, Ryan, Norman, Davidson, & Hiller, 2012). Readmission was associated with comorbidity and inhospital complications (Mnatzaganian et al., 2012). Depending on the study sample and country, there is wide variation in complication rates following THR. In the United States, the rates have ranged from approximately 3.8% to 7% (Cushner, Agnelli, FitzGerald, & Warwick, 2010; SooHoo, Farng, Lieberman, Chambers, & Zingmond, 2010). Although these rates seem low, readmissions and complications are costly. A hip revision due to dislocation or infection costs 1.5 to 3.6 times more than an uncomplicated primary THR (De Palma, Procaccini, Soccetti, & Marinelli, 2012; Klouche, Sariali, & Mamoudy, 2010; Sanchez-Sotelo, Haidukewych, & Boberg, 2006). The extra costs are due to the extension in operation time, hospital stay, nursing care, and rehabilitation (Bozic, Rubash, Sculco, & Berry, 2008; Klouche et al., 2010; Sanchez-Sotelo et al., 2006; Vanhegan, Malik, Jayakumar, Islam, & Haddad, 2012). As Medicare, which is the biggest payer for the procedure, will reduce payments for readmissions through the value-based purchasing program in 2015 (Centers for Medicare & Medicaid Services, 2013), readmissions may place an increased financial burden on hospitals. The most common complications following THR are Mikyoung Lee, PhD, RN, Assistant Professor, Indiana University School of Nursing, Indianapolis, Indiana. Sue Moorhead, PhD, RN, Associate Professor, Director, Center for Nursing Classification & Clinical Effectiveness, The University of Iowa College of Nursing, Iowa City. The authors have no conflicts of interest directly relevant to the content of this study. No funding has been received for this study. DOI: 10.1097/NOR.0000000000000047 Orthopaedic Nursing
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myocardial infarction, pulmonary embolism, deep vein thrombosis, pneumonia, dislocation, and surgical site infection (Cushner et al., 2010; Mahomed et al., 2003; Mantilla, Horlocker, Schroeder, Berry, & Brown, 2002; Memtsoudis et al., 2010). Other recognized perioperative complications include excessive bleeding, decubitus ulcer, delirium, neurovascular injuries, compartment syndrome, and ileus, just to mention a few. These serious complications after THR occur in the early postoperative course (Parvizi et al., 2007). Successful recovery from THR requires appropriate nursing care during the immediate recovery period. Perioperative assessments, education, pain management, ambulation, and rehabilitation have a significant impact on treatment effectiveness and patient satisfaction (Lubbeke, Suva, Perneger, & Hoffmeyer, 2009; Mauer, Abrahams, Arslanian, Schoenly, & Taggart, 2002; O’Sullivan & Savage, 2008; Parsons & Sonnabend, 2004). However, the effects of each of these interventions have been individually examined in single studies. Providing these interventions during the hospital stay is important for successful recovery and complication prevention. Nursing care for this patient group has not been studied using actual clinical data. In addition, the time required for these interventions has not been determined through previous research. Nurses have increasingly focused on translating research findings into routine clinical practice. Before translating interventions into practice, it is important to clearly describe current nursing interventions and practice patterns for patients in specific contexts during hospitalization. Subsequently, the extent of quality improvement in nursing care can be clearly identified when nursing practice is changed considering patient outcomes and costs.
Purpose The purpose of the study was to (1) describe nursing interventions for patients who underwent THR at a hospital; (2) depict the patterns of nursing interventions over the hospital stay; and (3) examine relationships among patient characteristics, nursing interventions, and complication rates.
Methods This study was based on retrospective data collection and analysis and was approved by the institutional review board. The data were retrieved from medical discharge records and the nursing workload system at a 218-bed, not-for-profit community hospital in the Midwest.
SAMPLE A total of 254 patients who were admitted to the orthopaedic unit for THR between January 2006 and December 2007 were included in the sample. Data from only one admission for each patient were collected.
DATA COLLECTION Patient variables included age, gender, marital status, and comorbidities. Comorbidities were defined as a
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patient’s other illnesses on admission, but not the principal reason for admission. Comorbidities were extracted from a list of secondary diagnoses, using the 30-comorbidity identification method by Elixhauser, Steiner, Harris, and Coffey (1998) and the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) comorbidity codes identified by Agabiti et al. (2007) specific to patients undergoing hip replacements. Nursing intervention data were obtained from the GRASP ® System (GRASP Systems International Companies, Fort Collins, CO), which is a nursing workload system and has been implemented for 20 years in the study hospital. The GRASP System views nursing as a series of tasks performed in a sequence (Hernandez & O’Brien-Pallas, 1996a, 1996b) and consists of comprehensive lists of direct and indirect nursing interventions with associated durations. Direct nursing intervention is defined as “hands-on” care provided directly to the patient by nurses, whereas indirect nursing interventions are “hands-off” activities supporting direct nursing interventions. Each nursing intervention label has a group of relevant activities in steps involved from the beginning to the end. For example, Apply/Remove Orthotics is categorized as taking 4.4 minutes, based on eight relevant sequential activities beginning with “Assemble/prepare equipment, cleanse if applicable” through “Explain procedure, application adjustment, and removal,” “Apply orthotic device and adjust it as needed,” and ending with “Document.” The GRASP System has allowed the nursing interventions to be specified according to the priorities and convenience preferred by an individual unit or a hospital. Thus, the nursing intervention labels specific to an individual unit have been developed through a consensus process unit-by-unit and then put into each unit’s interface screen. Therefore, the total list of nursing interventions in this study includes the nursing interventions considered as important and necessary to the orthopaedic unit of the study hospital. The type and the time value of a specific nursing intervention were determined by a combination of time studies and the consensus method. The validity and reliability of the list of nursing interventions/activities and corresponding time values have been repeatedly tested on the study unit with nurses by three different methods: interrater reliability, content validity, and predictive validity. In particular, the interrater reliability of the system has been assessed on a weekly basis on the study unit. During the time period of this study, the average interrater reliability score for the unit was 91.5%. Severity of illness was defined as the extent of organ system loss of function or physiologic decompensation, and was measured by the All Patient Refined Diagnosis Related Group (APR-DRG) Severity of Illness Scale (3M Health Information Systems, 2003). Severity of illness was graded sequentially from 1 to 4, corresponding to minor, moderate, major, and extreme severity. Complications were defined as additional medical problems that arose after a procedure or treatment during the patient’s hospitalization. Complications were extracted from the list of secondary diagnoses using the
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Complications Screening Programme (Iezzoni et al., 1994, 1999; Weingart et al., 2000), the Agency for Healthcare Research and Quality (AHRQ, 2007) Patient Safety Indicators, and the complication codes for THR identified by Agabiti et al. (2007). Length of stay was calculated as the number of days from the first shift at admission to the shift at discharge, based on the nursing documents in the GRASP System. For example, a patient who was admitted during the evening shift on March 21 and discharged during the day shift on March 25 was considered to have an LOS of 3.67 days.
DATA ANALYSIS Data analyses were performed using SPSS 19.0. The types, numbers, and time required for nursing interventions were identified by descriptive statistics. Using cross-tabulations, the frequency distributions of nursing interventions were compared with each other over the hospital stay. In addition, the combination of the frequency and time required per nursing intervention was depicted by days in a graph. The graph provided visual cues to quickly understand nursing intervention patterns over the hospital stay. Correlation analysis was conducted to examine relationships among patient characteristics, nursing interventions, and complication rates, with p values of < .05 and < .001 considered to be significant and highly significant, respectively.
Results PATIENTS The average patient age was 66 years, with ages ranging from 27 to 93 years; the elderly—65 years or older— made up 62.6% of the sample. Slightly more than half of the subjects were female (53.5%), and the majority were married (68.9%). The dominant primary medical diagnosis was osteoarthrosis, localized, not specified whether primary or secondary on pelvic region and thigh (ICD-9-CM Code, 71535) (88.2%). On average, patients had five comorbidities; only 10 of 254 patients (3.9%) had none. A total of 1,198 comorbid conditions under 44 different categories were identified. Common comorbid conditions with the study subjects were diseases of the musculoskeletal system and connective tissue (n = 191; 15.9%), uncomplicated hypertension (n = 144; 12%), and ischemic heart disease (n = 86; 7.2%). Most (65%) of the patients were at Stage 3 on the severity of illness scale, which indicates major severity as rated by the APR-DRG Severity of Illness Scale. The rest of the patients (35%) were at Stage 2, which is the moderately severe stage of illness. The mean number of complications per patient was 1.18 ± 1.30. Ninety-six patients (37.8%) did not have any complication; 31.1% of the patients had one complication, 16.1% had two complications, 8.7% had three, 4.3% had four, three patients had five, and two patients had six or seven complications. Complications in this study ranged from life-threatening outcomes (e.g., cardiac arrest, pulmonary embolism, and infarction) to
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negative orthopaedic outcomes (e.g., a fracture of the femur neck and unequal leg length), to minor symptoms that necessitated additional observation or treatment such as blood transfusion or antibiotics (e.g., irritable bowel syndrome and iatrogenic hypotension). Common complications were related to the digestive (32.8%), metabolic and immune (19.1%), urinary (10%), or nervous/musculoskeletal systems (7%) or were general symptoms (8%). There was no perioperative thromboembolism. Other notable complications experienced by patients were anemia (four cases), iatrogenic hypotension (four), irritable bowel syndrome (three), hemorrhages (two), falls (two), urinary infection (two), and cardiac arrest (one). The mean LOS was 3.84 ± 1.08 days, ranging from 1.33 days to 8.67 days. Most patients (n = 206; 81.1%) stayed 2 to 4 days in the hospital. The next most common LOS was between 4 and 6 days (n = 39; 15.4%).
THE DOSAGE OF NURSING INTERVENTIONS The mean total nursing hours per patient during hospitalization was 30. The majority of patients (n = 140; 55.1%) received 20 to 30 total nursing hours. Patients who received 30 to 40 nursing hours in total care comprised the second largest proportion (n = 77; 30.3%). The average total nursing hours per day was 7.78; 93.3% of the patients received nursing care, including direct and indirect nursing interventions, for 7–9 hours every day. Based on the original database of the GRASP System, 57 direct nursing interventions were provided at least once for a patient. However, some nursing interventions could be grouped into broader labels for definitional purposes. For example, intravascular (IV) 1–4 medications and IV 5–8 medications were merged into IV administration. In addition, some nursing interventions could be grouped according to the similarity of roles and activities. For example, Bathes with Assistance, Bathed by Staff, and Bathes Self were grouped under the label “Bathing.” With the relabeled interventions, Table 1 presents the average durations of all nursing interventions. On average, nurses spent the greatest number of hours for the intervention “Care Plan” (3.6032 ± 1.0571 hours) (see Table 1), which includes shift assessment on behavioral, skin, respiratory, gastrointestinal, incisional, pain, and neurological conditions, as well as review and evaluation of care and the patient’s response. During the entire hospital stay, patients received an average of 3.33 hours of mobility care and 1.94 hours of nutrition care. Other interventions on which nurses spent more than 1 hour per patient included IV administration, elimination care, oral medication, intensive monitoring, fall intervention, and bathing. A total of 36 indirect nursing interventions were categorized into six broader concepts (i.e., administrative/ clerical, housekeeping, admission/discharge/transfer, communication, transportation, and personal time) for the category “Indirect Nursing Interventions” in the GRASP System. The mean of total nursing hours for the indirect nursing interventions was 8.24 during hospitalization.
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TABLE 1. THE TYPES OF AND TIME REQUIRED FOR NURSING INTERVENTIONS Total Hours During Hospitalization Nursing Interventions
Mean
SD
Care plan
3.6032
1.0571
Mobility care
3.3288
0.8646
Nutrition care
1.9394
0.5470
IV administration
1.7422
0.4715
Elimination care
1.4687
0.5835
Oral medication
1.3442
0.5217
Intensive monitoring
1.3381
0.6744
Fall intervention
1.2779
0.4079
Bathing
1.0735
0.2963
Teaching/emotional support
0.8780
0.3088
1:1 care
0.7367
8.2918
Orthotics management
0.7026
0.2744
V/S check
0.6394
0.1872
Pain management
0.5968
0.2185
Incentive spirometry
0.5908
0.4110
IM/SQ administration
0.3873
0.3139
Blood transfusion
0.3862
0.7437
Wound care
0.2513
0.1182
Blood draw
0.1617
0.3505
Incontinence care
0.1104
0.4777
Drain management
0.0758
0.0456
Dementia management
0.0025
0.0309
Delirium management
0.0022
0.0244
Isolation/chemo/latex precautions
0.0004
0.0068
Indirect nursing interventions
8.2426
2.4181
Note. IM = intramuscular; IV = intravascular; SQ = subcutaneous; V/S = vital sign.
THE PATTERNS OF NURSING INTERVENTIONS OVER HOSPITAL STAY The cross-tabulations in Table 2 show the frequency distributions of the direct nursing interventions during hospitalization. Although some interventions were provided less often when patients neared discharge, substantial time in nursing interventions was being used right up to the time of discharge. Care plan, orthotics management, bathing, oral medication, elimination care, and pain management were implemented most frequently on the first day and intensively provided on the 1st, 2nd, and 3rd days. Mobility care, teaching/emotional support, fall intervention, nutrition, vital sign (V/S) check, incentive spirometry, and blood draw were provided more on the 2nd, 3rd, and 4th days than the 1st day. Intravascular administration was predominantly provided on the 1st (n = 2,439) and 2nd days (n = 1,593) and then dramatically decreased in use on the 3rd day (n = 422). IM/SQ administration was provided in a similar pattern. Intensive monitoring 152
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was provided primarily on the 1st day (n = 359; 98.9%). Drain management, including external drain management and nasogastric suction, was implemented mostly on the 1st and 2nd days (99.8%) and rarely provided after the 3rd day. Blood transfusion also was provided primarily on the 1st and 2nd days (83.5%). Wound care was provided more often on the 3rd day. The interventions of incontinence care, 1:1 care, dementia management, delirium management, and isolation/chemo/latex precautions were rarely provided to the patients. Figure 1 shows the patterns of the direct nursing interventions, considering both frequency and time for providing each intervention. Because of the limited graphical display with too many interventions, Figure 1 presents the top 10 common interventions only. On the first day the top five most frequently provided direct nursing interventions were IV administration (n = 2,439), care plan (n = 1,524), orthotics management (n = 1,031), teaching/emotional support (n = 764), and elimination care (n = 759) (see Table 2). However, when the frequency and the time consumption of nursing interventions are considered together, the rank was different as shown in Figure 1. The top five direct nursing interventions that consumed the most time on the first day included IV administration (2,534.12 hours = 1.039 hours per intervention [H] × 2,439 frequency [F]), mobility care (771.78 hours = 1.5313 H × 504 F), nutrition care (503.53 hours = 0.6687 H × 753 F), care plan (473.51 hours = 0.3107 H × 1524 F), and elimination care (404.02 hours = 0.5323 H × 759 F). On the 2nd day, fall intervention (n = 756), bathing (n = 756), and oral medication (n = 755) were more frequently provided than elimination care (n = 749); however, the rank was similar to the first day when the frequency and the time consumption of nursing interventions are considered together. On the 3rd day, the top five frequent nursing interventions were care plan (n = 1,476), teaching/emotional support (n = 745), fall intervention (n = 733), bathing (n = 733), and V/S check (n = 733). On the same day, the top five most timeconsuming nursing interventions were mobility care (1,120.91 hours), nutrition care (488.15 hours), care plan (458.59 hours), IV administration (438.46 hours), and elimination care (379.53 hours).
Correlation Comorbidity had significant positive associations with age (r = .39), severity of illness (r = .34), complications (r = .27), and LOS (r = .18) at the significant level, p ≤ .001, and with the majority of nursing interventions at the significant level, p ≤ .05. Older patients were likely to have comorbid conditions on admission. Patients with more comorbidity conditions on admission were likely to have a higher “severity of illness” score, more complications, and a longer hospital stay, and to need more nursing interventions. Complications had significant relationships with age (r = .13, p ≤ .05), comorbidity (r = .27, p ≤ .001), severity of illness (r = .18, p ≤ .05), and LOS (r = .18, p ≤ .05). The interventions—care plan, teaching/emotional support, oral medication, wound care, bathing, mobility care, fall intervention, nutrition care, and elimination care—were positively correlated © 2014 by National Association of Orthopaedic Nurses
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TABLE 2. THE PATTERNS OF DIRECT NURSING INTERVENTIONS OVER THE HOSPITAL STAY (FREQUENCY) Day 1
2
3
4
5
6
7
8
9
Total
Care plan
1,524
1,520
1,476
841
278
120
52
18
4
5,833
IV administration
2,439
1,593
422
79
16
1
0
0
0
4,550
Orthotics management
Interventions
1,031
923
638
309
89
34
5
2
0
3,031
Teaching/emotional support
764
770
745
420
139
60
26
9
2
2,935
Fall intervention
754
756
733
411
131
57
20
5
2
2,869
Bathing
758
756
733
410
129
57
18
5
2
2,868
Nutrition
753
756
730
411
133
57
20
5
2
2,867
Oral medication
757
755
729
412
135
57
22
6
2
2,875
Elimination care
759
749
713
400
126
48
12
4
2
2,813
Mobility care
504
752
732
410
132
56
21
5
2
2,614
V/S check
400
753
733
413
133
57
22
6
2
2,519
Pain management
675
636
620
345
114
49
18
3
2
2,462
Wound care
272
492
724
407
132
57
18
5
2
2,109
Incentive spirometry
427
494
441
212
71
27
5
2
0
1,679
IM/SQ administration
575
256
127
64
27
17
0
0
0
1,066
Drain management
557
328
1
1
0
0
0
0
0
887
Blood draw
95
130
120
66
34
16
2
0
0
463
Intensive monitoring
359
4
0
0
0
0
0
0
0
363
Blood transfusion
45
31
11
4
0
0
0
0
0
91
Incontinent care
1
6
16
11
5
8
9
2
0
58
1:1 care
3
4
5
3
3
3
3
3
0
27
Delirium management
0
3
1
2
0
0
0
0
0
6
Dementia management
2
0
1
2
1
1
0
0
0
7
Precautions Total
0
0
1
0
0
0
0
0
0
1
14,215
13,228
11,189
6,054
1,967
842
299
89
26
47,909
Note. IM = intramuscular; IV = intravascular; SQ = subcutaneous; V/S = vital sign.
with complications at the significant level (p ≤ .05). The older patients with more comorbid conditions were likely to have more complications. Patients who had more complications tended to stay longer at the hospital and to have higher severity of illness scores (see Table 3).
Discussion Information on the types and patterns of nursing interventions during hospitalization for patients receiving THR provides insight into what nurses are doing for patients and what opportunities exist for improving patient conditions. This information can help nurses redesign the range of nursing interventions or alternative nursing care toward efficient and cost-effective care delivery. Examination of the time required for accomplishing nursing interventions will assist nurse managers and administrators in evaluating nursing resource use including staffing and costing out nursing care for this patient population. On average, total nursing hours per day for THR patients were 7.78. This means that the patients spent a © 2014 by National Association of Orthopaedic Nurses
large portion of their time receiving nursing care during their hospital stay, which is about 32.5% of 24 hours and 48.7% of the day excluding sleeping time. This finding supports the idea that nurses are the closest to the patient and important health care providers in acute care hospitals and therefore their contributions should be delineated by research describing the results of nursing interventions. If the average nursing hours per day (7.78 hours) are simply divided by 3 for 8-hour shifts, a patient receiving THR on average may require 2 hours and 36 minutes of nursing time in a shift. Given a shift, a staff nurse can, therefore, care for up to three patients with THR; this calculation suggests that, on average, a nurse-to-patient staffing ratio of 1:3 would be desirable for this population, although different skill-mix options can dictate different staffing ratios. Because it was presumed in this study that nursing interventions were provided by RNs only, repeated studies with different skill mixes in different settings will be necessary. From the accumulated findings of these studies, then, if there is consensus on the nursing intensity or the minimum nurse-to-patient staffing ratio required for this THR population across Orthopaedic Nursing
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FIGURE 1. The patterns of direct nursing interventions over hospital stay (Frequency × Time).
settings, such information could be used to reflect nursing resource weight in calibrating the payment for THR. This kind of information would be a solution to overcoming the difficulty of calculating relative weights of nursing care in specific diagnosis-related groups (DRGs) and address policy makers’ hesitation to isolate nursing resource weight from the room-and-board portion per DRG. Regarding nursing practice pattern for THR patients, Mauer et al. (2002) identified national nursing practice pattern via a survey with orthopaedic nurses across the country. Although they highlighted key nursing interventions in preoperative, intraoperative, and postoperative practices, our study identified the patterns of dosage of nursing interventions day by day during hospitalization, naming such nursing interventions in a standard and predetermined manner. In a report by Mauer et al., the postoperative practices, the similar period that the nursing interventions were provided in our study, focused on pain management, nausea/vomiting control, bowel regimen, turning, positioning, transfer, and ambulation. All of these nursing practices were embraced in the nursing intervention list identified in this study. 154
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Pain management via IV patient-controlled analgesia and IM morphine and meperidine was a focus for most of the orthopaedic nurses during the first 48 hours postoperatively (Mauer et al., 2002). The patients in our study also received a great deal of pain management and IM/SQ administration on the 1st and 2nd days of the hospital stay. Most THR patients were transferred to a chair or ambulated initially on the 1st postoperative day, turned on the nonoperative side, and instructed about mobilization and relevant precautions (Mauer et al., 2002). Our study revealed that mobility care began on the 1st day (19.3%), was provided primarily on the 2nd and 3rd days (56.8%), and was delivered right up to the time of discharge for the patients. Because dislocation is the most common serious complication after THR (Cram et al., 2011; Lubbeke et al., 2009; SooHoo et al., 2010), it is very important to educate and assist patients in their mobility progress to prevent dislocation. With the GRASP System, nurses differentiated the activities of mobility care postoperatively day by day. For example, on the 1st postoperative day, nurses assist patients to a seated position in a chair, protecting alignment of the extremity and realigning tubes. On the 2nd day, nurses moved patients © 2014 by National Association of Orthopaedic Nurses
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TABLE 3. THE RELATIONSHIPS BETWEEN PATIENT CHARACTERISTICS, NURSING INTERVENTIONS, AND COMPLICATIONS Age Marital status Comorbidity
Marital Status
Comorbidity
Severity of Illness
Complications
.21** .39**
.1
Severity of illness
.11
−.01
.34**
Complication
.13*
−.01
.27**
.18*
Length of stay
.16*
.19**
.18**
.16*
.18*
Care plan
.11
.14*
.17*
.14*
.19**
−.02
0
.07
.01
.04
0
.11
.01
0
.07
Drain management Orthotics management V/S check
.09
.1
.1
.13*
.11
Wound care
.15*
.15*
.13*
.07
.15*
Blood transfusion
.19**
.06
.12
.07
.08
Bathing
.11
.16*
.19**
.14*
.14*
Blood draw
.04
.04
.32**
.08
.05
Mobility care
.07
.12
.13*
.12
.14*
Fall intervention
.12
.16*
.16*
.14*
.13*
Nutrition care
.08
.15*
.15*
.11
.14*
Incentive spirometry
.02
.06
.16*
.11
.08
0
.16*
.13*
.1
.1
.14*
.13*
.15*
Pain management Elimination care
−.01
.06
Teaching/emotional support
.07
.12*
.18**
.16*
.21**
Oral medication
.11
.16*
.2**
.12*
.19**
IM/SQ administration
.05
.02
.32**
.17*
.06
.05
.07
−.02
.11
IV administration
−.03
−.02
.08
Intensive monitoring
−.02
.09
.07
Note. IM = intramuscular; IV = intravascular; SQ = subcutaneous; V/S = vital sign. *p < .05; **p < .001.
to the edge of the bed and elevated the head on the bed; on the 3rd and 4th days, nurses assisted patients to move to a chair and, if possible, to ambulate; from the 5th day to discharge nurses assisted patients to ambulate with leg support, ensuring alignment and safety. In addition to the phased mobility care, the instruction on the correct use of the toilet seat is important to prevent dislocation. This importance was well reflected with the finding that elimination care including toilet use assistance and education was one of the top five frequent and timeconsuming nursing interventions in this study. The fact that intensive monitoring was provided on the 1st day (98.9%) indicates that the operation was performed on admission day. Intensive monitoring includes intensive circulatory-vascular checks, motor-sensory checks, and every-2-hour clinical parameter checks immediately after surgery. Although the use of drains and blood loss replacement was described as intraoperative nursing practice in the report by Mauer et al., nurses in this study still administered blood transfusions and conducted drain management (including care for external drains and nasogastric tubes) on the 1st and 2nd days of hospitalization in the postoperative unit. This objectively measured view of nursing interventions provided routinely is critical to determine implications © 2014 by National Association of Orthopaedic Nurses
of treatment alternatives (Feinstein & Horwitz, 1997). The findings help clinicians evaluate current practices and use the results to develop fact-based improvements to the care process rather than clinical opinion-based modifications (Horn, 2001). Variations from this comparison can be monitored with the measurement of their effects on patient outcomes. Dochterman et al. (2005) stated that determining the interventions used most frequently on a specific type of unit or in a certain type of agency helps determine interventions that should be on that facility’s nursing information system, selection of personnel to staff that unit, and structure for the orientation and continuing education needed by care providers. Furthermore, Dochterman et al. stated that the retrospective review of nursing interventions routinely delivered is also helpful in constructing critical paths, determining costs of services, and planning for resource allocation. Along with the review of nursing practice patterns for THR patients by frequency, a notable finding in this study was the different ranks of nursing interventions by time consumption. In the first day of hospitalization, the top five most frequently provided were IV administration, care plan, orthotics management, teaching/ emotional support, and elimination care. However, Orthopaedic Nursing
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when the frequency and the time requirements of nursing interventions were considered together, IV administration consumed the largest amount of nursing time. Mobility care consumed the second largest amount of nursing time, followed by nutrition care, care plan, and elimination care. Although orthotics management was the third most frequently provided intervention, it took only a small amount of the time (237.44 hours) and ranked 10th. Pain management (n = 675) also was frequently provided for patients on the 1st day, and this intervention consumed 41.18 hours of nursing care (rank = 15th). The results imply that the different intensity of each intervention affects nurses’ time consumption. More reliable measures for evaluating nursing interventions would be to consider both frequency and time required, and then these measures of nursing interventions should be used to evaluate the effects of nursing interventions on outcomes as well as to manage for nurse staffing. This study identified significant relationships among patient characteristics, nursing interventions, and complications. Not surprisingly, older patients were likely to have more comorbidities on admission. Patients with more comorbidities on admission were likely to have higher severity of illness scores, more complications, and longer hospital stays. This finding is consistent with the previous reports that advanced age and comorbid diseases have been associated with an increased risk of complications (McDonald & Huo, 2008; Shebubakar, Hutagalung, Sapardan, & Sutrisna, 2009; SooHoo et al., 2010). Comorbidity also significantly affected the dose of nursing interventions. Patients who had more comorbid conditions were likely to receive more nursing interventions. So it is important to consider comorbidities in nursing care planning and staffing. Research is needed to track comorbidities and corresponding nursing interventions to build system support as a feature of the hospital information system to guide nurses in care planning along with different types of comorbid conditions to decrease risks of complications. For example, patients with diabetes might need more frequent blood draws. Patients who smoke or patients with lung diseases might need more use of an incentive spirometer to prevent pneumonia or other respiratory complications because they are at risk of having airway or breathing problems after the surgery. This area needs further exploration in future studies. This study found significant relationships between nursing interventions and complication rates. This finding implies that nurses should be able to provide appropriate nursing interventions and monitor changes of patient conditions to prevent and treat complications if they develop. It is remarkable that teaching/emotional support and care plan showed stronger correlations with complication rates than other nursing interventions. Teaching/emotional support encompassed routine conversational education/emotional support and ongoing reinforcement as well as extensive reassurance per patients’/families’ requests; Care plan included head-to-toe assessments and review/evaluation of care delivered and patient responses. These two interven-
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tions can be characterized as nursing surveillance, which have been found to be effective on early detection of adverse patient outcomes (Henneman, Gawlinski, & Giuliano, 2012; Shever, 2011). The significant relationships between these nursing interventions and complication rates reinforced the importance of nursing surveillance for preventing complications. It is also possible to link the nursing interventions showing significant relationships with some complications identified in this study. For example, nutrition care might be associated with 32% of the complications related to digestive system. Mobility care and fall interventions might be related to complications of nervous/musculoskeletal system (7%) and two fall incidents. Elimination care might be needed to care for urinary complications (10%) and two urinary infections. It should be noted that the definition of complications in this study was very broad, from severe and common complications to minor complications rarely reported. Therefore, many of them were not comparable to common quality indicators such as AHRQ’s Patient Safety Indicators. The common quality indicators include falls, pneumonia, urinary infections, and medication errors; only a few of these complications were found in this study. Minor complications identified in the study included fatigue, fever, sleep disturbances, chest pain, palpitations, urinary incontinence, nausea, and vomiting. Although these minor complications are not included in AHRQ quality indicators, they are important cues for indicating patients’ conditions. Although the current DRG system does not count nursing care with specific codes as a source for reimbursement, the nursing document is often used when the coders in clinics look for evidence to justify reimbursement. Thus, it is essential to document and create nursing outcomes data. This study could not review the link between each nursing intervention and the onset time of each complication because this information could not be retrieved from the hospital discharge record. It is important to have nursing outcomes documentation along with nursing interventions meant to reduce complications risks. In future research, the relationships between complication onsets and nursing interventions should be identified. The great majority (>90%) of complications, including pulmonary embolism, typically occur within 4 days after a standard elective joint replacement (Mantilla et al., 2002; Parvizi et al., 2007). If studies are able to link nursing interventions to time-flagged complication data, the findings can be used to build a clinical decision support system to alert nurses to pay attention to the high risk of complications on particular days of hospitalization and to provide appropriate interventions in a timely manner. This would be an important quality improvement process. The hospital information system needs to have features to help nurses monitor and document this information. Electronic nursing information systems are becoming more prevalent; however, the availability of standardized nursing interventions and outcomes measurements is still limited in practice settings. Rare documentation of the time spent for each nursing intervention and the nursing outcomes (changes in patient conditions as a
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result of nursing interventions) makes it difficult to accurately measure the nursing dose and the effectiveness of nursing interventions. Creating a nursing database including both nursing interventions and outcomes is a prerequisite of nursing research to verify nursing contributions to patient and health care outcomes. As Dochterman et al. (2005) stated, the link between science and practice is strengthened when clinical information systems include meaningful data.
Conclusion This study identified patterns of nursing interventions by day for THR patients in one Midwestern community hospital over the course of a year. The description and review of nursing interventions currently being provided are necessary for delineating nursing work and improving hospital nursing practice. To develop accurate, reliable, and valid measures of nurses’ work, more studies are needed to get consensus on the activities, time estimates, and skill levels required per intervention with patient populations in different settings. This will help management plan the most appropriate staff-mix and also determine the effect of nursing interventions on patient outcomes. The significant relationships among nursing interventions, comorbidities, and complications found in this study put high importance on nurses’ accounting for comorbidities in their care planning, monitoring, and documentation of nursing interventions and outcomes along with the onset of the complications. To do this, nursing information systems in hospitals need to have the features for nurses to document, archive, retrieve, and guide nursing interventions and nurse-sensitive outcomes.
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