COVID-19 and Nurse-Sensitive Indicators: Using Performance Improvement Teams to Address Quality Indicators During a Pandemic

BACKGROUND

Nurse-sensitive quality indicators have historically been used as a metric of nursing care quality in health care organizations.

PROBLEM

At our academic medical center, critically ill COVID-19 patients led to a dramatic change in the organizational standard of care resulting in an increase in nurse-sensitive health care-associated infections.

APPROACH

Nursing performance improvement teams provided the structure for development of innovative strategies implemented in real time by our frontline clinicians to address the quality and safety issues found with these elevated health care-associated infections.

OUTCOMES

A new COVID-19 CLABSI (central line-associated bloodstream infection) Tip Sheet and a Prone Positioning Kit for HAPI Prevention are strategies developed to address quality of care issues experienced with the COVID-19 patients.

CONCLUSIONS

Deployment of these innovative practice strategies has led to a decline in health care-associated infections and instituted a new care standard for the COVID-19 patients.

Excellence through evidence: structures enabling clinical autonomy

Autonomy is a multidimensional process. Clinical autonomy, the dimension in which patients are the primary beneficiaries, is the focus of this study. Despite high valuation and persistent challenges to nurses to function autonomously, the relationship between autonomous practice and patient outcomes has not been empirically established due, in large measure, to a lack of correspondence between concepts and measurement of autonomy and to a lack of knowledge of enabling structures. The purpose of the research reported here is to identify the structures, practices, elements in the environment, and interventions that nurses, nurse managers, and physicians identify as promoting staff nurse clinical autonomy. Implementation of these interventions would then enable clinical decision making at the frontline and would foster studies to determine whether the expected linkage between clinical autonomy and positive patient outcomes prevails.

Disordered T-cell development and T-cell malignancies in SCL LMO1 double-transgenic mice: parallels with E2A-deficient mice

The gene most commonly activated by chromosomal rearrangements in patients with T-cell acute lymphoblastic leukemia (T-ALL) is SCL/tal. In collaboration with LMO1 or LMO2, the thymic expression of SCL/tal leads to T-ALL at a young age with a high degree of penetrance in transgenic mice. We now show that SCL LMO1 double-transgenic mice display thymocyte developmental abnormalities in terms of proliferation, apoptosis, clonality, and immunophenotype prior to the onset of a frank malignancy. At 4 weeks of age, thymocytes from SCL LMO1 mice show 70% fewer total thymocytes, with increased rates of both proliferation and apoptosis, than control thymocytes. At this age, a clonal population of thymocytes begins to populate the thymus, as evidenced by oligoclonal T-cell-receptor gene rearrangements. Also, there is a dramatic increase in immature CD44(+) CD25(-) cells, a decrease in the more mature CD4(+) CD8(+) cells, and development of an abnormal CD44(+) CD8(+) population. An identical pattern of premalignant changes is seen with either a full-length SCL protein or an amino-terminal truncated protein which lacks the SCL transactivation domain, demonstrating that the amino-terminal portion of SCL is not important for leukemogenesis. Lastly, we show that the T-ALL which develop in the SCL LMO1 mice are strikingly similar to those which develop in E2A null mice, supporting the hypothesis that SCL exerts its oncogenic action through a functional inactivation of E proteins.

An scl gene product lacking the transactivation domain induces bony abnormalities and cooperates with LMO1 to generate T-cell malignancies in transgenic mice

The product of the scl (also called tal-1 or TCL5) gene is a basic domain, helix-loop-helix (bHLH) transcription factor required for the development of hematopoietic cells. Additionally, scl gene disruption and dysregulation, by either chromosomal translocations or a site-specific interstitial deletion whereby 5' regulatory elements of the sil gene become juxtaposed to the body of the scl gene, is associated with T-cell acute lymphoblastic leukemia (ALL) and T-cell lymphoblastic lymphoma. Here we show that an inappropriately expressed scl protein, driven by sil regulatory elements, can cause aggressive T-cell malignancies in collaboration with a misexpressed LMO1 protein, thus recapitulating the situation seen in a subset of human T-cell ALL. Moreover, we show that inappropriately expressed scl can interfere with the development of other tissues derived from mesoderm. Lastly, we show that an scl construct lacking the scl transactivation domain collaborates with misexpressed LMO1, demonstrating that the scl transactivation domain is dispensable for oncogenesis, and supporting the hypothesis that the scl gene product exerts its oncogenic action through a dominant-negative mechanism.