Indicators used in the inpatient setting such as fall rates and pressure ulcer prevention rates are preventative in nature and are inappropriate for the ambulatory care setting because of the timeframe of action between patient and nurse. In the ambulatory care setting, interactions with patients are time sensitive and sporadic in nature. For example, a patient may visit an ambulatory setting only once a year for his/her primary care provider visit, or for a time limiting visit to his specialist. The limited amount of time during these interactions causes ambulatory indicators, and their respective interventions, to be generally related to health promoting. Thus, ambulatory nurse interventions should be examined from two perspectives:

• The potential influence on the patient’s health the nurse may have through counseling or education.
• The immediate impact of an intervention by a nurse.

Nurse sensitive indicators are powerful measurement tools that help nursing teams monitor the elements of patient care that are directly affected by nursing care. In general, indicators monitor the three key aspects of nursing care: Structure, Process, and Outcomes.

Structure:

• Structural indicators measure the supply of nursing staff, the skill level of the nursing staff, and the education and certification levels of the nursing staff. These indicators are deemed “structural” in that they reflect the make-up of the nursing team that is providing patient care.

• Potential measurements here are: (number of RN hours per patient day) or the (number of unlicensed assistive hours per patient day).

Process:

• Process indicators measure various methods of patient assessment and nursing interventions. Successful data collection for these indicators often requires an augmentation of the current operational process. These indicators are deemed “Procedural” in that they are components of nurse’s job duties and descriptions.

• Potential measurements here are: (smoking cessation intervention rate) or the (weight management intervention rate).

Outcomes:

• Outcome indicators measure specific patient outcomes that are nursing sensitive because they rely on the quantity or quality of nursing care.
• Potential measurements here are: (Patient satisfaction with educational information) or (Patient satisfaction with pain management).

Healthcare is increasingly being driven by performance based pay. That is, providers, and healthcare facilities are financially rewarded for producing better healthcare outcomes. The Affordable Care Act has specific programs targeting specific populations in order to encourage health programs to be as efficient as possible. In the ambulatory care setting, the healthcare effectiveness data and information set (HEDIS) is a tool used by major healthcare plans to measure performance on particular dimensions. Among the HEDIS measures, there are specific dimensions of care that are nurse sensitive.

A Sample Case:

In one ambulatory setting, nurse sensitive indicators were reviewed and developed as part of the journey towards becoming a Magnet facility in ambulatory care. A literature review was conducted in order to find nurse sensitive indicators in the ambulatory care setting. A cross examination of the American Nurses Association indicators, the National Quality Forum indicators and the Physician Quality Reporting Initiative (PQRI) led to the selection of 3 applicable nurse sensitive indicators. Smoking cessation was the only indicator that could be traced among all three indicator organization groups. Weight management and hypertension are inter related, thus weight management was selected as the second indicator. From a risk reduction perspective, intravenous extravasation rates were selected for the infusion center clinic.

• Patient education related to smoking cessation. The goal was to increase the rate of patients educated about smoking cessation, and therefore increase the amount of smoking cessation interventions. The benchmark that was used was derived from HEDIS.
• Patient education related to weight management. Goal was to increase the rate of patients educated about weight management, and therefore increase the amount of weight management interventions. The benchmark was derived from HEDIS.
• Tissue salvage related to prevention of extravasation of vesicant solutions. Goal was to increase the rate of early extravasation identification, and to document the rate of successful nursing interventions. The goal was internal and the Infusion Nursing Society goal was adapted.

To date, tobacco use remains the single largest preventable cause of disease; however 43.8 million Americans still smoke cigarettes.

• Nearly 1 in every 5 adults smokes cigarettes.
• According to the American Lung association as of 2010, there were also 13.2 million cigar smokers in the US, and 2.2 million who smoke tobacco in pipes.

The Cochrane collaborative reviewed over forty seven studies related to nursing interventions and smoking cessation. Among ambulatory patients, nine studies showed evidence of benefit comparing different nurse delivered interventions.

Interventions were defined as advice, counseling and or strategies provided to assist patients in quitting. In the studies reviewed by the Cochrane collaborative, interventions were divided into low and high intensity.

• Low intensity consultation - less than 10 minutes of advice (with or without written material) with one follow up visit.
• High intensity consultation - more than 10 minutes of advice and with additional materials provided.
• Advice was defined as verbal instructions from the nurse.

The studies conducted on outpatients noted that when a health care provider gives smoking cessation advice, there is a two percent chance the patient will quit.

• However, when the Nurse also provides smoking cessation the percent increases to 4 percent.

Although this number appears small, given the large audience that a nurse can potentially counsel throughout a career, smoking cessation interventions performed by a nurse are extremely important. Accordingly, smoking cessation may be a nurse sensitive indicator appropriate for the ambulatory care setting.

According to the US Surgeon general, two thirds of Americans are overweight or obese. Obesity contributes to risk of stroke, diabetes, coronary heart disease and cancer.

• Over the last four decades body mass index (BMI) has increased from 13% to 31% in adults (McTigue, et al. 2002).
• Counseling is aimed to promote change in diet and or exercise (McTigue, 2002).

As early as 1979, the United States Preventive Health Services Task Force made the recommendation that counseling be offered to all patients to promote regular physical activity for all children and adults based on the evidence of the benefits.

• Surveys of patients report less than 45% received this type of preventive education from their providers.
• A review of 15 studies done between 1979 and 1999 reveal that counseling was moderately effective (Ieakin, Glasgow, & Riley, 2000).

Thus the nurse is in a key position to identify obesity, counsel patients and make additional recommendations and referrals to intensive counseling and other health care professionals. The National Heart Lung Blood Institute has also endorsed the appropriate assessment of BMI in adult patients.

• Compared to smoking cessation programs, health care providers have different capabilities with regards to advising about diet.

Counseling about physical activity is preferred due to the fact that health providers clearly understand what exercise recommendations should be. It is advised that all persons participate in 20 minutes of activity four times a week.

Extravasation refers to a solution that is given intravenously and that moved outside the vein. A vesicant solution is a solution that has a pH of either < 5 or > 9. This type of solution, when outside the vein, is capable of serious tissue damage to the site and to the overall health of the patient. The earlier signs and symptoms of the extravasation are found, the better for the overall health of the patient. Several examples of vesicant solutions include:

• (Antibiotics) Penicillin, Vancomycin, Gentamycin and Naficillin
• (Vasocompressive Agents) dobutamine, dopamine and epinephrine
• (Cytotoxic Agents) Vinblastine and vinristine
• Most chemotherapy

Several circumstances can cause extravasation:

• Previous Venipuncture - blood was drawn for a previous lab test prior to current therapy.
• Leakage – Caused by brittle veins in very elderly patients.
• Direct leakage – Incorrectly positioned venous access devices.

In the ambulatory care setting, where infusions may be given, the nurse's vigilance and early intervention can be tissue saving. Early signs and symptoms of extravasation include:

• A feeling of cooling at the site
• Swelling and discomfort
• A change in the quality of the flow
• Burning and stinging
• Blistering

Ambulatory nurse sensitive indicators differ from inpatient indicators due to the amount of time that the nurse has direct interaction with a patient. Given only a 15 to 20 minute visit, it is important for the ambulatory care nurse to assess and identify tobacco use habits or obesity and to counsel the patient appropriately. If needed, the nurse can facilitate additional resources in order to assist the patient in achieving a healthier lifestyle. When the patient and the nurse will be interacting for slightly longer periods of time, such as during intravenous infusions, the nurse's keen assessment during an infusion can help prevent potentially life threatening complications associated with vesicant solutions. For the ambulatory care setting, and its limited nursing interaction timeframes, it is crucial that nursing interventions be focused on the potential impact that they may have towards a patient’s level of health.

The three indicators listed above are in no way all inclusive. There are many more potential indicators that could be valuable measurement tools for your organization. The National Database for Nursing Quality Indicators (NDNQI), The Centers for Medicare and Medicaid, or your State Nursing Association can be excellent resources for identifying potential indicators and for measuring your unit’s performance against the national benchmarks.

American Nurses Association. (2000). Nursing Quality Indicators beyond acute care: Measurement instruments. American Nurses Publishing. Washington, DC. ISBN: 1558101500.

Centers for Disease Control and Prevention. (2000-2004) Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States. Morbidity and Mortality Weekly Report 2008;57(45):1226–8. [Accessed Dec. 20, 2013]

Centers for Medicare and Medicaid (2014). Physician Quality Reporting System Formerly known as Physician Quality Reporting Initiative (Assessed March 9, 2015). http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS/

Eakin, E.G., Glasgow, R.E., & Riley, K.M. (2000) Review of Primary Care-Based Physical Activity Intervention Studies: Effectiveness and Implications for Practice and Future Research. AMC Cancer Research Center, Center for Community Studies. Denver, Colorado, USA.

Infusion Nurses Society. Infusion Nursing Standards. J Infus Nurs. 2006 Jan-Feb; 29 (1 Suppl):S1-9

McTigue, KM, Harris, R, Hemphill, B, Lux, L, Sutton, S, Bunton, AJ, & Lohr, KN. (2003). Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force.Ann Intern Med.

National Heart, Lung, and Blood Institute. (2012) Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. [Accessed Dec. 19, 2012] www.nhlbi.nih.gov/health/public/heart/obesity/wecan/healthy-weight-basics/body-mass-index.htm

Pearson, Steven D., Eric C. Schneider, Ken P. Kleinman, Kathryn L. Coltin, and Janice A. Singer. (2003). The Impact of Pay-for-Performance on Health Care Quality in Massachusetts, 2001-2003. Health Affairs. 27, no. 4 (2008): 1167-76.

Schulmeister, Lisa (2008) Managing Vesicant Extravasations. The Oncologist. [Accessed Dec. 15, 2012]. www.theoncologist.com.

Stead, LF, & Lancaster, T. (Dec. 12, 2012) Does a combination of Smoking Cessation medication and behavioral support help smokers to stop?. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD008286

U.S. Department of Health and Human Services. (2010) How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA.