Low complication rates for procedures performed by advanced practice providers
Advanced practice providers (APPs) performed office-based neonatal circumcisions with results comparable to those of physicians, according to two studies reported here.
A circumcision clinic led by nurse practitioners (NPs) had a 5-year complication rate of 4.1% as compared with 3.4% for circumcisions performed by physicians. Neither the overall rate nor any of the rates for specific types of complications differed significantly between NPs and MDs, reported Jonathan A. Gerber, MD, of Texas Children’s Hospital (TCH) in Houston, at the American Urological Association annual meeting.
The second study showed a 3-year complication rate of about 5% for circumcisions performed by a specially trained physician assistant (PA). That compared with complication rates of 4%-5% in published reviews of physician-performed circumcisions. The PA-performed circumcisions also generated substantial revenue for the urology practice, said Kaity Colon-Sanchez, PA-C, of Nemours Children’s Hospital in Orlando.
“We felt that utilization of advanced practice providers in our newborn services clinic has allowed pediatric urologists to focus their attention on the most complicated cases in the practice, while the more simple newborn circumcisions are being performed safely and effectively by advanced practice providers,” said Gerber. “Additionally, the results suggest that the longstanding age and weight cutoffs for newborn circumcisions need to be reconsidered, because our study shows similar outcomes in older and heavier children.”
About 70%-80% of newborn male infants undergo circumcision, making it the most common urologic procedure. An ongoing shortage of pediatric urologists has created a significant imbalance between the need for circumcision and the resources to provide the service. To address the problem, TCH established an APP-led newborn circumcision clinic, said Gerber.
One previous study documented results of a service wherein NPs performed minor urologic procedures, but the procedures all occurred in an operating room. The TCH service is provided in an outpatient setting.
Pediatric urologists trained APPs to perform Gomco clamp circumcisions. The training consisted of observing 10 newborn circumcisions, assisting in 10 procedures, and then performing 10 circumcisions under direct supervision of a pediatric urologist. Thereafter, a pediatric urologist was on call for all APP-performed circumcisions. APPs were limited to performing circumcisions for infants <30 days old and weighing <10 lbs.
Investigators retrospectively reviewed records for circumcisions performed over a 5-year period, which allowed for comparison of outcomes before and after implementation of the APP-led clinic.
Gerber reported data for 314 APP-performed circumcisions and 237 performed by pediatric urologists. The analysis focused primarily on complications. The study population had a mean age of 23.8 days and mean weight of 8.6 pounds. Physicians performed circumcisions on older (28.4 vs 20.3 days, P<0.0001) and heavier (8.9 vs 8.4 lb, P<0.0063) infants and used more lidocaine per procedure (0.96 vs 0.8 mL).
Overall, 21 complications occurred, with no significant differences between the APP and physician procedures:
- Total: 13 (4.1%) vs 8 (3.4%)
- Revision circumcision: 1 each
- 30-day return to emergency department (ED): 2 vs 0
- Other penile surgery: 2 vs 4
- Intraprocedure bleeding: 11 vs 4
The data showed no difference in outcomes for patients <30 vs ≥30 days or weight <10 vs ≥10 lbs, the traditional age and weight cutoffs for uncomplicated circumcision.
Colon-Sanchez reported her 3-year experience performing clinic-based circumcision in a pediatric urology service. She evaluated 371 infants for neonatal circumcision. They had a mean age of 7.8 weeks (range of 1 to 13 weeks) and weighed an average of 5.2 kg (11.4 lbs) and had a weight range of 3.2-7.5 kg. Subsequently, 95 infants did not undergo circumcision, 91 because of an abnormal genital exam. Colon-Sanchez performed 272 circumcisions with the Plastibell device and four with the Gomco device.
The clinic charged $366 for families that paid for the procedures themselves, and billed $722 when procedures were covered by insurance. Colon-Sanchez noted that the 95 patients excluded from the analysis did not represent lost revenue, as the office visit was considered billable and many of the patients required additional surgery.
Records revealed a complication rate of 6.43%, consisting of retained Plastibell device in 1.80% of cases, swelling in 1.40%, adhesions in 1.10%, cosmesis issues in 0.73%, and ED visits for bleeding in 1.40%.
The results compared favorably with those from studies of circumcisions performed by physicians, said Colon-Sanchez. A study of more than 1,000 circumcisions performed by pediatricians and ob/gyns showed an acute complication rate of 3.9%, all involving bleeding. A study of 9,000 surgeries at a pediatric urology service showed that 4.7% of the procedures involved late complications of circumcisions. Additionally, 7.4% of visits to the pediatric urology outpatient clinic during a 1-year period involved concerns related to newborn circumcisions.
“Well-trained physician urology physician assistants can perform neonatal circumcisions,” said Colon-Sanchez. “The data support low complication rates with well-trained PA providers. Urologist back-up is readily available. Office-based neonatal circumcisions provides an additional revenue stream.”
In response to a question, she described a training program similar to the one the APPs in Gerber’s study completed. She said she felt comfortable with her abilities after about 30 procedures.
Gerber and Colon-Sanchez disclosed no relevant relationships with industry.
This story was originally posted on MedPage Today.
You entered the field of psychiatric nursing because you wanted to make a difference in the lives of patients. As a psychiatric nurse with VHA, you’ll do that and more. Not only will you play a critical role in changing the lives of Veterans, often in the most challenging stage of their life, but you’ll work with their network of family and friends to provide whole healing and a successful outcome. Learn more about the specific Veteran populations you’ll be working with and the opportunities for making an impact.
1. The families of Veterans
VA offers a range of family services for Veterans and their family members, including family education, brief problem-focused consultation, family psychoeducation, and marriage and family counseling. Our psychiatric nurses play an integral part in facilitating these services, working with all members of the family to provide holistic solutions.
2. Homeless Veterans
VA is the only Federal agency that provides substantial hands-on assistance directly to homeless Veterans. As a VHA psychiatric nurse, you’ll have the unique opportunity to step outside the hospital walls and treat Veterans who would not otherwise seek help. Additional VA assistance programs where you can make an impact include:
- Drop-in centers where Veterans who are homeless can shower, get a meal, and get help with a job or getting back into society
- Transitional housing in community-based programs
- Long-term assistance, case management and rehabilitation
3. Veterans with Serious Mental Illness
Veterans diagnosed with Schizophrenia, Schizoaffective Disorder and Bipolar Disorder work with VHA psychiatric nurses on a variety of treatment plans, including psychosocial rehabilitation and recovery services to optimize functioning. In addition, you’ll be a part of our Mental Health Intensive Case Management team. The team of mental health physicians, nurses, psychologists and social workers helps Veterans experiencing symptoms of severe mental illness cope with their symptoms and live more successfully at home and in the community.
4. Veterans adjusting to civilian life
The transition process from military to civilian life is a challenging one, and our psychiatric nurses are there from the beginning to provide crucial support. At our 300 community-based Vet Centers, our staff provides adjustment counseling and outreach services to all Veterans who served in any combat zone. Services are also available for family members for military-related issues, and bereavement counseling is offered for parents, spouses and children of Armed Forces, National Guard and Reserve personnel who died in the service of their country.
5. Older Veterans
To provide specialized care for our older Veterans, we’ve developed VA Community Living Centers (CLCs). Here, you will treat older Veterans needing temporary assisted care until they can return home or find placement in a nursing home. Our staff also works on ensuring that Veterans can safely live independently by screening for dementia and general assessments that help us decide whether the Veteran can make informed medical decisions.
As a psychiatric nurse at VHA, the work you do will deeply affect the Veteran, their family and generations of families to come. View our Nursing positions or, Join VA in making a difference in one of the many other health care fields available.
This story was originally posted on VAntage Point.
But low-ranking hospitals had nearly double the risk
The estimated number of avoidable deaths in U.S. hospitals each year has dropped, according to updated analysis prepared for The Leapfrog Group by Johns Hopkins University School of Medicine researchers.
Matt Austin, PhD, an assistant professor in the school’s Armstrong Institute for Patient Safety and Quality, and Jordan Derk, MPH, used the latest data from Leapfrog’s semiannual hospital safety grades to estimate that there are 161,250 such deaths each year, down from the 206,000 deaths they estimated three years prior, according to their report.
Austin and Derk said they used 16 measures from Leapfrog’s 2019 data to identify deaths that could clearly be attributed to a patient safety event or closely related prevention process. The reduction is the result of two main factors, they wrote: One, hospitals have made some improvement on the performance measures included in Leapfrog’s safety grades. And, two, some of the measures “have been re-defined and rebaselined” in the past three years, they wrote.
Furthermore, these data likely represent an undercount, Austin and Derk wrote, noting that other studies have estimated anywhere from 44,000 to 440,000 deaths due to medical errors.
“The measures included in this analysis reflect a subset of all potential harms that patients may encounter in U.S. hospitals, and as such, these results likely reflect an underestimation of the avoidable deaths in U.S. hospitals,” they wrote.
“Also, we have only estimated the deaths from patient safety events and have not captured other morbidities that may be equally important,” they added.
The updated analysis was released to coincide with the latest release of Leapfrog’s controversial scores, which assessed quality data from more than 2,600 hospitals and assigned each an “A” through “F” letter grade.
“The good news is that tens of thousands of lives have been saved because of progress on patient safety. The bad news is that there’s still a lot of needless death and harm in American hospitals,” Leapfrog Group President and CEO Leah Binder said in a statement.
Less than one-third (32%) of hospitals secured an “A” grade. More than a quarter (26%) earned a “B.” The group gave a “C” to another 36%, a “D” to 6%, and an “F” to less than 1% of hospitals.
The analysis from Austin and Derk found that the rate of avoidable deaths per 1,000 admissions was 3.24 at “A” hospitals, 4.37 at “B” hospitals, 6.08 at “C” hospitals, and 6.21 and “D” and “F” hospitals combined. That means patients admitted to a “D” or “F” hospital face nearly double the risk of those admitted to an “A” hospital, the Leapfrog group said.
This story was originally posted on MedPage Today.
Work-life balance is a hot concept in the nursing profession. We hear we need it. We want to achieve it. But does it really exist?
That question has piqued the interest of Adele A. Webb, PhD, RN, FNAP, FAAN, senior academic director of workforce solutions at Capella University in Minneapolis.
“People think they need it,” she said. “But do they? Can you ever have it? Or are people chronically dissatisfied because it’s like a unicorn … they’re chasing something that doesn’t exist.”
Balance Vs Satisfaction
Webb plans to study and delve into the concept of work-life balance and nurses. She said recent conversations with nurse executives, including those at HealthLeaders Media 2017 CNO Exchange, left her realizing that the idea needs to be better defined.
“Years ago, I read an article called Balance is Bunk!, and [the point] was you never have 50% this and 50% that. Sometimes work takes more, sometimes family takes more,” she recalled.
For example, if a nurse must take off from work to stay home with a sick child, on that day, family needs more focus than work. And there are times, especially for those who work weekends or holidays, where work will eclipse family.
Still, Webb said she understands the desire behind the idea of work-life balance.
“What does work-life balance really mean? It means you’re happy. Well, what does happy mean? Happy means you’re satisfied with what you’re doing,” she said. “I think what people really want is life satisfaction. They can be satisfied at home and satisfied at work even if it’s not balanced.”
Another question Webb said she is pondering is, “How then do we address or encourage satisfaction and what does that mean?”
She said she has noticed, even among her own family, that different generations of nurses crave different things.
“I have a daughter and a granddaughter who are nurses. My granddaughter is definitely a Millennial. She’s 24, new in her career, and what she wants is opportunity,” Webb said. “She’s always reading, trying to better her skills, and to learn something new.”
This drive to further their skills and their careers is a trait often tied to the Millennial generation. However, it can also be a factor that contributes to their workplace turnover. According to the RN Work Project, almost 18% of newly licensed RNs leave their first employer within the first year.
“We have the job to educate these younger nurses on opportunities to find satisfaction in the job they’re in. So when you want more, you can sign up for a committee. You can look at policy in your community or state. There are opportunities outside of leaving your unit that can meet your needs,” Webb said.
“How exciting it would be for a young nurse to have the opportunity to be on the quality committee at a hospital. Or to have the opportunity to contribute to care algorithms or standards or care or policies?” she added. “They would learn [so much] from it [and] they could contribute so much.”
While baby boomers are more likely to stay in their positions, they, too, have a need for life satisfaction and often value time and self-fulfillment, said Webb.
For example, offering tuition assistance to pursue a master’s degree may give this generation a sense of satisfaction. Or they may find fulfillment in sharing the knowledge they’ve garnered over their years of experience.
“[Give them] the opportunity to be involved, and be on a budget committee at the hospital and understand the finances and the contributions they make,” Webb suggested. “Train them to be preceptors. Let them share that knowledge with the younger generation.”
Webb is in the early stages of reviewing published literature for existing information on work-life balance and satisfaction, and plans to interview nurses about their insights. Once she has a working thesis, she plans to connect with nursing professionals through presentations and conferences to see whether her definition and evaluation of work-life balance or work-life satisfaction rings true.
This story was originally posted on MedPage Today.
CPR in a restaurant on a woman not breathing
Here is just one story about how VA nurses excel in their occupation, on and off duty.
VA Nurse Karen Brodlo sat in a restaurant enjoying her dinner when she heard someone yell to call 911.
She looked up to see an elderly woman had collapsed and was not breathing. The woman was having dinner with her husband when the night took a turn for the worst.
Brodlo quickly jumped in action. As a VA nurse for 23 years and in the nursing field since 1969, it was second nature. She identified herself to the crowd as a nurse and assessed the situation. Right away she noticed that the woman was positioned incorrectly. She quickly made the adjustments and started to administer CPR.
She continued manual CPR process until the rescue team arrived. She then turned her focus to the husband who was nervous and scared for his wife’s well-being. She tried to calm him down as the rescue team continued to work to save the woman’s life.
She remembers the worst part being, not having the equipment she needed. She suggested to the restaurant after the incident that a general-use defibrillator would be a useful addition. Just as most businesses have fire extinguishers, a defibrillator should also be a requirement. Just as easy to use, it’s better to have and not need it than to need it and not have it.
After much praise came her way for saving a life, Brodlo said, “I just did what was right. No accolades are needed for doing my job.”
The restaurant now gives her star treatment. The daughter of the woman she saved sent a bouquet of flowers along with a heartfelt thank you card calling Brodlo her mom’s “Guardian Angel.”
Brodlo is a nurse at the Captain James A. Lovell Federal Health Care Center in North Chicago.
As a caring nurse who adores her job, she followed up on the status of her honorary patient. Sadly, a couple of weeks after the incident, the woman passed away from further complications, but the family was overwhelmingly grateful.
The last days with any family member or loved one is crucial. If it wasn’t for the quick actions of nurse Karen Brodlo, they would have missed out on the opportunity to say their last goodbye.
This story was originally posted on VAntage Point.