bluuebunny/crossref_metadata_2025 huggingface dataset:
Prevalence of hepatitis B surface antigen and hepatitis B core antibody among adults with latent tuberculosis infection
Authors: Hubbard Ashley , Hirode Grishma , Chitnis Amit , Wong Robert
Published: May 2021

Objective

To evaluate the prevalence of hepatitis B surface antigen (HBsAg) positive or hepatitis B core antibody total (anti-HBc) among adults with latent tuberculosis infection (LTBI) in the USA.

Methods

Using data from the National Health and Nutrition Examination Survey 1999–2000 and 2011–2012 cycles, US adults with LTBI (identified by positive tuberculin skin test or positive QuantiFERON-TB Gold In-Tube test) were evaluated to determine prevalence HBsAg and anti-HBc. Survey-weighted data was used to determine prevalence estimates of HBsAg or anti-HBc, which were further stratified by sex, race/ethnicity, country of birth and age. Trends were analyzed by regressing the outcome over time. Between-group comparisons used chi-squared testing.

Results

Overall prevalence of LTBI was 4.2% [95% confidence interval (CI), 3.5–5.1]. Among individuals with LTBI, HBsAg prevalence was 0.9% (95% CI, 0.4–2.1) and anti-HBc prevalence was 12.9% (95% CI, 9.8–16.8), both of which remained stable between 1999–2000 and 2011–2012. While no significant differences in HBsAg prevalence were observed by sex, race/ethnicity, country of birth, age, anti-HBc prevalence was significantly higher in men vs. women (16.8 vs. 7.9%, P < 0.05), blacks vs. non-Hispanic whites (22.9 vs. 5.9%, P < 0.05), non-US born vs. US-born (15.9 vs. 7.2%, P = 0.01) and highest in the oldest age group (age ≥65 years: 17.5%, 95% CI, 10.5–27.8).

Conclusion

Among US adults with LTBI, overall prevalence of HBsAg was 0.9%. One in eight individuals with LTBI had prior HBV exposure. Effective HBV screening among individuals with LTBI may allow changes in clinical practice to prevent drug-induced liver injury from anti-TB therapies.
The role of mean platelet volume in nonalcoholic fatty liver disease without cardiovascular comorbidities, obesity and diabetes mellitus
Authors: Tuzer Can , Sertbas Yasar , Duman Emrah , Komoglu Sabiha , Kan Omer , Ay Seval , Yigit Abdurrahman , Sertbas Meltem , Okuroglu Nalan , Ozen Birgul , Dalbeler Aysegul , Ozdemir Ali
Published: May 2021

Background

While the relation of mean platelet volume (MPV) with inflammatory diseases is obvious, its role in nonalcoholic fatty liver disease (NAFLD) without cardiovascular comorbidities, obesity and diabetes mellitus is not clear.

Methods

A total of 249 patients (nonobese, nondiabetic and not having cardiac diseases) who underwent an abdominal ultrasonography assessment were enrolled. They were divided according to the absence (group 1) or presence (group 2) of hepatic steatosis. The patients with steatosis were further divided according to the severity of steatosis as group 2a (grade 1), 2b (grade 2) and 2c (grade 3). The demographic and laboratory features were compared between groups.

Results

Hepatic steatosis was absent in 120 patients and detected in 129 patients (grade 1, 2, 3 hepatic steatosis in 75, 49 and 5 patients, respectively). BMI, aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio and serum AST, ALT, triglyceride levels were significantly higher in group 2 than in group 1 (P < 0.001, P < 0.001, P < 0.001, P = 0.005, P < 0.001, respectively). BMI, serum AST and triglyceride levels were significant factors for NAFLD (P < 0.001, P = 0.018, P = 0.001). MPV was neither different between groups (P > 0.05) nor a predictor factor for NAFLD (P > 0.05).

Conclusion

MPV is a useless parameter to detect NAFLD without cardiovascular comorbidities, obesity and diabetes mellitus.
Production of copper-64 using a hospital cyclotron: targetry, purification and quality analysis
Authors: Jauregui-Osoro Maite , De Robertis Simona , Halsted Philip , Gould Sarah-May , Yu Zilin , Paul Rowena L , Marsden Paul K , Gee Antony D , Fenwick Andrew , Blower Philip J.
Published: May 2021

Objectives

To construct and evaluate a 64Cu production system that minimises the amount of costly 64Ni, radionuclidic impurities and nonradioactive metal contamination and maximises radiochemical and radionuclidic purity and molar activity; and to report analytical and quality control methods that can be used within typical PET radiochemistry production facilities to measure metal ion concentrations and radiometal molar activities.

Methods

Low volume was ensured by dissolving the irradiated nickel in a low volume of hydrochloric acid (<1 mL) using the concave gold target backing as a reaction vessel in a custom-built target holder. Removal of contaminating 55Co and nonradioactive trace metals was ensured by adding an intermediate hydrochloric acid concentration step during the conventional ion-exchange elution process. The radionuclidic purity of the product was determined by half-life measurements, gamma spectroscopy and ion radiochromatography. Trace metal contamination and molar activity were determined by ion chromatography.

Results and conclusions

On a small scale, suitable for preclinical research, the process produced typically 3.2 GBq 64Cu in 2 mL solution from 9.4 ± 2.1 mg nickel-64 electroplated onto a gold target backing. The product had high molar activity (121.5 GBq/µmol), was free of trace metal contamination detectable by ion chromatography and has been used for many preclinical and clinical PET imaging applications.
Peptide-based 68Ga-PET radiotracer for imaging CD133 expression in colorectal cancer
Authors: Liu Yu , Yao Xiaobo , Wang Changxin , Wang Minrui , Wang Ying , Ye Mingshan , Liu Ying
Published: May 2021

Objective:

CD133 is a demonstrated cancer stem cell marker. A small peptide LS7, screened by a phage display technique, was identified to specifically target CD133. The purpose of this study was to develop a novel and specific peptide-based PET imaging agent for CD133 imaging in colorectal cancer.

Methods:

The peptide LS7 was conjugated with 1,4,7,20-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) and radiolabeled with 68Ga. The cellular uptake was assessed in vitro. In vivo small-animal PET/CT and ex vivo biodistribution evaluations were performed in mice bearing CD133-positive HCT116 and Lovo cell-derived tumors as well as CD133-negative DLD1 cell-derived tumors. Nonspecific uptake of the tracer in HCT116 cell-derived tumor cells and tumor models was determined by coincubation or coinjection with an excess of unlabeled DOTA-LS7 along with radiolabeled tracers.

Results:

68Ga-DOTA-LS7 was produced with 80.0% yield and the radiochemical purity was greater than 95.0%. In vitro, 68Ga-DOTA-LS7 was selectively taken up by HCT116 and Lovo cells but not by DLD1 cells. Small-animal PET/CT clearly revealed deposition of 68Ga-DOTA-LS7 in HCT116 and Lovo cell-derived tumors with excellent contrast. Biodistribution demonstrated that the tumor uptakes were 2.24 ± 0.16, 1.76 ± 0.42, and 0.69 ± 0.28% ID/g in HCT116, Lovo and DLD1 cell-derived tumors, respectively, at 90 min post-injection. Uptake of 68Ga-DOTA-LS7 in HCT116 tumors was significantly inhibited by coinjection of excess DOTA-LS7.

Conclusion:

Rapid tumor CD133 detection and selectivity were demonstrated in vitro and in vivo with PET using the specific CD133 binding peptide 68Ga-DOTA-LS7. A robust correlation was detected in vivo between tumor signals from mouse xenograft models with different cell lines and CD133 expression. The favorable characteristics of 68Ga-DOTA-LS7, such as convenient synthesis and specific uptake, warrant its further investigation for CD133 expression imaging.
A Study of Home Healthcare Nursing Outcomes Quality Indicators for Older People in Thailand Using Delphi Technique
Authors: Srithumsuk Werayuth , Prachusilpa Gunyadar , Thummapol Onouma , Kasemsuk Weha
Published: May 2021

Nurses are the primary health professionals who provide home healthcare (HHC) for older people. Measurements of nursing outcomes and quality of care are needed to ensure that older people receive quality nursing care. The objective of this study was to identify HHC nursing outcomes and quality indicators for older people in Thailand. The participants included 22 experts and professional caregivers of older adult HHC patients (i.e., geriatric and HHC policy makers, family physicians, nursing faculty, advanced practice nurses, and registered nurses). The Delphi technique was deployed. Final medians and interquartile ranges were calculated. Five components with 47 nursing outcomes and quality indicators for older people in Thailand were developed, including: 1) functional health and physiological status (13 indicators); 2) perception and behavior in health (6 indicators); 3) psychosocial response needs (8 indicators); 4) caregiver and family (16 indicators); and 5) satisfaction of older people, caregivers, and family (4 indicators). The findings demonstrate a need for further research to test the feasibility of the established criteria, including tests of content validity, construct validity, and instrument reliability. The outcome from the established indicators requires a high consistency. The analysis of the correlation between indicators scores obtained by the trial of indicators implementation can strengthen the validity of the indicators.
Patient Safety and Satisfaction in Home Chemotherapy
Authors: Sanguinetti José María , Martínez Daniel , Dimase Federico , Streich Guillermo , Castro Paola , Vega Victoria , Batagelj Emilio
Published: May 2021

Chemotherapy is increasingly being administered in patients' homes, improving quality of life and patient comfort as well as reducing use of inpatient facilities and costs. This article describes outcomes of home chemotherapy administered by trained nurses to adult patients with solid tumors or hematological diseases. This descriptive study was conducted between February 2018 and May 2020. Variables examined included age, sex, diagnosis, routes of administration, adverse effects, tolerance, and patient satisfaction. One hundred forty-seven patients (57.14% male) with an average age of 67.8 years agreed to participate. A total of 1018 chemotherapy sessions were examined. The most common diagnoses were prostate cancer, colon cancer, and high-risk myelodysplastic syndromes. Thirty-five percent (n = 356) of the sessions were conducted with: Azacytidine, 5-Fluoruracil, Oxaliplatin + Docetaxel + Leucovorin + Fluorouracil, and Leuprolide Acetate. The routes of administration included: intravenous (69.25%), intramuscular (13.75%), subcutaneous (15.32%), and intravesical (1.66%). Very good tolerance was reported after 87.81% of sessions and good after 8.45%. Adverse events during administration occurred in 7 sessions (0.7%); all were considered minor events. In the 24 hours following administration, 62 adverse events (6.1%) were reported, again all considered minor. All patients reported feeling just as safe as in the hospital. Our results contribute to the feasibility and safety of home chemotherapy.
The Journey of Web-Based Education for Caregivers of Persons With Dementia
Authors: Gies Cheryl E. , Pierce Linda L.
Published: May 2021

Family caregivers provide long-term, complex care in home settings where most persons with dementia (PWD) live. These men/women caregivers differ in responses and approaches to caring problems. Following our review of the research literature and needs assessment from caregivers of PWD (group 1), a comparison revealed key caregiver gender differences in caring problems and approaches. We developed and implemented a Web-based Educational Modules (WBEMs) project focused on gender-based differences to offer unique support for men/women caregivers who face these problems. Other caregiver evaluators (group 2) agreed the WBEMs were well designed with clear, credible, informative content. Evaluators' suggestions for larger font size and navigation directions were incorporated in module improvements. Six modules were eventually placed on an established university-sponsored caregivers' website. WBEMs have potential to reestablish well-being for caregivers of PWD. Home healthcare nurses and other healthcare providers can use, adapt, or create additional modules to meet the needs of and support for caregivers and patients living in community settings.
Self-Injury Is My Drug
Authors: Pritchard Tyler R. , Fedchenko Chelsey A. , Lewis Stephen P.
Published: May 2021

Adolescents and emerging adults who engage in nonsuicidal self-injury (NSSI) often participate in online activity regarding their self-injury. Of particular importance are the potential benefits and risks associated with online NSSI activity, including how individuals describe their NSSI experiences. One way that individuals describe these experiences is by discussing NSSI as an addiction. Accordingly, we used thematic analysis to explore why individuals may use addiction references to describe their NSSI experiences. To do this, we examined 71 posts from a popular NSSI social network. Four themes emerged: difficulty inherent in stopping, authentication, warn others, and communicate the plight of the behavior. Findings highlight a number of avenues for research as well as implications for clinicians working with clients who self-injure perceive NSSI as an addiction. Mental health professionals can leverage their understanding of clients' perceptions of NSSI to better serve this population.
The Development of Posttraumatic Stress Disorder and Depression Symptoms in Iraqi Refugees
Authors: Yamin Jolin B. , Sudan Sukhesh , Lumley Mark A. , Dhalimi Abir , Arnetz Judith E. , Stemmer Paul M. , Burghardt Paul R. , Jamil Hikmet , Arnetz Bengt B.
Published: May 2021

Refugees experience distress from premigration trauma, often exacerbated by postmigration difficulties. To develop effective interventions, risk factors for mental health symptoms need to be determined. Male Iraqi refugees (N = 53) to the United States provided background information and reported predisplacement trauma and psychological health within 1 month of their arrival. An inflammatory biomarker—C-reactive protein (CRP) was assessed approximately 1.5 years after arrival, and a contextual factor—acculturation—and psychological health were assessed 2 years after arrival. We tested whether acculturation and CRP were associated with posttraumatic stress disorder (PTSD) and depression symptoms at the 2-year follow-up, controlling for baseline symptoms, age, body mass index, and predisplacement trauma. Acculturation was inversely related to depression, and CRP was positively related to both PTSD and depression at the 2-year follow-up. Interventions targeting acculturation could help reduce the development of depression symptoms in refugees. The role of CRP in the development of PTSD and depression symptoms warrants further research.
Sensitive Situations in a Nurse Residency Program
Authors: Blackburn Brianna N.
Published: May 2021

Nurse residency programs are designed to be a safe, supportive learning environment for newly licensed nurses. Topics such as horizontal violence, ethical dilemmas, and patient safety are often addressed throughout the course of the program. Confidentiality is key to maintaining trust in these discussions, but what do we do when confidentiality feels wrong or sometimes unethical? After being faced with this question, a “sensitive situations” algorithm was designed to guide others through the same challenges. This tool provides a framework for nursing professional development practitioners to strategically and consistently approach these sensitive situations.
The Nursing Professional Development Practitioner During a Pandemic
Authors: Fox Naomi M. , Richter Stephanie M.
Published: May 2021

The nursing professional development practitioner’s call to action at a large, acute care academic facility during the novel coronavirus pandemic required adaptability and resiliency. When rapid, unprecedented challenges altered nursing professional development workflow, a department of 16 practitioners split into three teams. The teams achieved goals by meeting the demand for education and training of frontline staff during the surge in novel coronavirus patients.
Informing the Nursing Professional Development Scope and Standards
Authors: Maloney Patsy , Harper Mary G.
Published: May 2021

A two-phase research study was conducted to inform the upcoming fourth edition of Nursing Professional Development: Scope and Standards of Practice. This column describes Phase 1, which used a virtual world café methodology to gather qualitative data from 32 nursing professional development experts. Eighteen themes emerged from the data supporting the six responsibilities of the nursing professional development practitioner. Researchers found the virtual world café to be a useful technique for eliciting expert opinions.
Analysis of Content Gaps in Prelicensure Nursing Textbooks to Meet Veteran Care Competencies
Authors: Chargualaf Katie A. , Patterson Barbara , Elliott Brenda
Published: May 2021

Background

Despite the Joining Forces initiative and recently published veteran care competencies, nursing students and graduates are often unprepared to care for veterans who have unique service-connected illnesses and injuries.

Purpose

The purpose was to evaluate identified content gaps in prelicensure nursing textbooks with the veteran care competencies knowledge, skills, and attitude (KSA) domains.

Methods

A secondary qualitative analysis was conducted of veteran content in prelicensure nursing textbooks.

Results

The skills and attitude domains of veteran care competencies were poorly addressed in nursing textbooks. Overall, the knowledge domain was adequately covered; however, most had limited connection with veterans and veteran care. Competency-focused recommendations for expanding and enhancing veteran content, KSAs, and teaching strategies are offered.

Conclusions

Prelicensure textbooks met the knowledge domain for each veteran competency. Overcoming content gaps needed to achieve requisite skills and attitudes requires interaction with veterans through clinical immersion experiences in various care settings.
Use of Exam Wrapper Metacognitive Strategy to Promote Student Self-assessment of Learning
Authors: Sethares Kristen A. , Asselin Marilyn E.
Published: May 2021

Background

Metacognitive knowledge and regulation are critical to nursing students who must apply knowledge to rapidly changing and complex conditions. Exam wrappers assist learners to consider past study habits with the goal of improving future exam preparation. However, little is known about use of exam wrappers in nursing education.

Purpose

The purpose of this integrative review was to describe the disciplines, populations, courses, specific strategies, and outcomes of the exam wrapper strategy.

Methods

A systematic literature search of peer-reviewed publications was completed in any discipline using exam wrappers.

Results

Ten academic disciplines of primarily introductory students completed exam wrappers with positive effects on course and exam grades, as well as metacognition, and noted changes in future study habits.

Conclusions

The exam wrapper strategy has been successfully implemented with improvements in course and exam grades, levels of metacognition, and changes in future study habits.
Script Concordance Approach in Nursing Education
Authors: Deschênes Marie-France , Létourneau Dimitri , Goudreau Johanne
Published: May 2021

Background

The script concordance approach aims at triggering judgments in simulated contexts of uncertainty.

Problem

Nursing students need to be prepared to manage the uncertainty of clinical practice.

Approach

The purpose of this article is to describe the theoretical foundation and the pedagogical use of the script concordance approach, as well as to present the current state of nursing evidence on the subject. The script concordance approach includes (1) script concordance testing, which is a quantitative examination that evaluates clinical reasoning; (2) a face-to-face script concordance activity; and (3) a digital educational strategy based on script concordance delivered via an online teaching/learning platform that aims to support clinical reasoning development.

Conclusions

Relying on questioning and experts' modeling, the script concordance offers an innovative pedagogical approach that approximates the uncertainty of clinical practice.
Promoting Inclusion of Disabled Nursing Faculty
Authors: Hassouneh Dena , Mood Laura
Published: May 2021

Background

Disabled nursing faculty make important contributions, yet little information is available about this group.

Problem

Although information specifically about disabled nursing faculty is limited, available evidence and related literature point to a need for disability inclusive policy and practice in nursing academe.

Approach

The authors gathered available information to inform development of 10 recommendations for change using universal design as a guiding framework. Universal design is development of an environment usable by all people to the greatest extent possible.

Outcomes

The article includes 10 recommendations to promote inclusion of disabled faculty in nursing academe. Although disabled faculty are the focus, these recommendations have the potential to benefit all faculty.

Conclusions

Implementing the recommendations may be challenging and will look different across schools. Nevertheless, such change is necessary to counteract exclusionary practices that impact disabled nursing faculty and promote inclusion of this important and underrepresented group.
Intrawound Liposomal Bupivacaine in Pediatric Chiari Decompression: A Retrospective Study
Authors: LoPresti Melissa A. , Harrell B. Nathan , Goethe Eric , McClugage Samuel , Wyatt Karla , Lam Sandi K.
Published: May 2021

Introduction:

Intrawound liposomal bupivacaine is a long-acting local anesthetic used to decrease postoperative pain in various procedures. Although it is used in posterior cervical and suboccipital approaches in the adult population, it is currently off-label for pediatrics. This quality improvement (QI) project examines intrawound liposomal bupivacaine for pediatric Chiari decompression and evaluates its role in postoperative opioid consumption.

Methods:

We retrospectively analyzed all patients 0–18 years old of age who underwent Chiari decompression from January 2017 to July 2019 at our tertiary care hospital. Demographic and clinical data regarding postoperative opioid use, subjective and objective pain control, length of stay, discharge medications, and comorbid conditions were collected.

Results:

We included 30 patients in this study: 19 females and 11 males. Of these, 6 received an intrawound injection of liposomal bupivacaine.

Patients

treated with liposomal bupivacaine require fewer opioids while admitted. There was no apparent difference in pain control immediately postoperatively, pain control at clinical follow-up, or inpatient length of stay between each group. Patients who received liposomal bupivacaine did not require opioid analgesics at the time of discharge from the hospital.

Conclusion:

The use of intrawound liposomal bupivacaine may decrease inpatient and outpatient postoperative opioid consumption amongst pediatric patients following Chiari decompression while providing adequate pain control. We investigate liposomal bupivacaine perioperative blockade in this QI project as a viable option for opioid-sparing pain control in the postoperative setting for the pediatric population. Future investigation via clinical trials and more extensive prospective studies may glean further insights into efficacy.
Implementing Volume-targeted Ventilation to Decrease Hypocarbia in Extremely Low Birth Weight Infants during the First Week of Life: A Quality Improvement Project
Authors: Akpan Uduak S. , Patel Sunny , Driver Paige , Tumin Dmitry
Published: May 2021

Introduction:

Hypocarbia in neonates increases the risk of poor neurodevelopmental outcomes. Volume-targeted ventilation (VTV) is associated with decreased hypocarbia and other respiratory morbidities. We noticed a high incidence of hypocarbia in extremely low birth weight (ELBW; <1,000 g) neonates in our Neonatal Intensive Care Unit. Thus, we undertook a quality improvement project to decrease the incidence of hypocarbia (the occurrence of PCO2 < 35 mm Hg) in ELBW neonates during the first week of life by 50% over 1 year.

Methods:

Our major interventions were employing VTV as the primary mode of mechanical ventilation in neonates less than 28 weeks of gestation or ELBW at birth and increasing staff knowledge regarding hypocarbia. The baseline period spanned May–August 2016. We implemented the interventions in October 2016 and tracked the use of VTV and the incidence of hypocarbia during the first week of life for 12 months.

Results:

We analyzed data on 28 and 77 patients in the baseline and postintervention periods, respectively. The use of VTV increased from 39% to 65%. However, the incidence of hypocarbia was not reduced (57% preintervention vs. 64% postintervention). In the postintervention cohort, the incidence of hypocarbia was comparable between VTV and other modes (60% vs. 70%; 95% confidence interval: −32%, 12%; P = 0.367), but we noted decreased blood gas sampling and earlier extubation in the VTV group (P = 0.002 and P = 0.046, respectively).

Conclusions:

Successfully increasing VTV in our Neonatal Intensive Care Unit did not decrease hypocarbia during the first week of life. However, we observed the safety of VTV and obtained other desirable results.
Quality Improvement Methodology Optimizes Infliximab Levels in Pediatric Patients with Inflammatory Bowel Disease
Authors: Hellmann Jennifer , Etter Renee K. , Denson Lee A. , Minar Phillip , Hill Denise , Dykes Dana M. , Rosen Michael J.
Published: May 2021

Introduction:

Achieving and maintaining target serum trough infliximab levels improves outcomes in children and young adults with inflammatory bowel disease. Our goal was to improve adherence to an infliximab therapy guideline. The primary aim was to increase the percentage of patients with infliximab levels ≥5 μg/mL and results checked in the last 12 months from 73% to ≥80% from July 2017 to January 2018.

Methods:

We participated in Intermediate Improvement Science Series, a course at Cincinnati Children’s Hospital Medical Center designed to catalyze change using quality improvement methodology. We implemented interventions through plan-do-study-act cycles. Our outcome measure was balanced by 2 process measures to determine what actions impacted improvement. These measures included the percentage of infusion plans revised in response to a drug level <5 μg/mL and the proportion of plans for which a follow-up drug level was ordered.

Results:

We increased the percentage of infusion plans revised before the next infusion from 63% to 87% and the percentage of plans that had an appropriate drug level recheck from 61% to 83% from July 2017 to January 2018. We increased the percentage of patients with an infliximab level >5 μg/mL, and results checked in the last 12 months, from 73% to 80%.

Conclusions:

Quality improvement methodology was effective in improving provider adherence to infliximab therapeutic drug monitoring guidelines. Improvement in adherence to guidelines directly improved the percentage of patients achieving target infliximab levels at any time during infliximab therapy.
Managing the COVID-19 Pandemic Using Quality Improvement Principles: A New York City Pediatric Primary Care Experience
Authors: Friedman Suzanne , Krause Margaret C. , Pethe Kalpana , Caddle Steve , Finkel Morgan , Glassman Melissa E. , Kostacos Connie , Robbins-Milne Laura , Bracho-Sanchez Edith , Soren Karen , Stockwell Melissa , Lane Mariellen
Published: May 2021

Introduction:

In the setting of COVID-19, pediatric primary care in New York City faced multiple challenges, requiring large-scale practice reorganization. We used quality improvement principles to implement changes to care delivery rapidly.

Methods:

Plan-do-study-act cycles were used, based on primary drivers of consolidation, reorganization of in-person and urgent care, telehealth expansion, patient outreach, mental health linkages, team communication, and safety.

Results:

The average visit volume in pediatrics decreased from 662 per week to 370. Telehealth visits increased from 2 to 140 per week, whereas urgent in-person visits decreased from 350 to 8 per week. Adolescent visits decreased from 57 to 46 per week. Newborn Clinic visits increased from 37 per week to 54. Show rates increased significantly for pediatrics and adolescent (P = 0.003 and P = 0.038, respectively).

Conclusions:

Quality improvement methodology allowed for the consolidation of pediatric primary care practices during the first wave of the COVID-19 pandemic, ensuring care for patients while prioritizing safety, evidence-based practices, and available resources.
Sleeping Safely! A Quality Improvement Project to Minimize Nighttime Interruptions without Compromising Patient Care
Authors: Lee Clifton C. , Savage Nastassia M. , Wilson Emily K. , Brigle Jennifer , Poliakoff Daniel , Shah Rozana , Lowerre Tracy
Published: May 2021

Introduction:

Sleep is crucial for patients’ health but is often disrupted, slowing recovery and resulting in adverse health effects. This study identified whether passive vital sign checks (heart rate, respiratory rate, and pulse oximetry) and delayed routine morning laboratories in clinically stable pediatric patients minimized nighttime interruptions without compromising patient safety.

Methods:

After developing the inclusion criteria using the Pediatric Early Warning Score, we enrolled eligible patients for the intervention. We assessed physician compliance through order entry and nursing compliance through recorded vital signs and timing of blood draws. Eligible patients received passive vital sign checks at 4 am with routine morning laboratories drawn at midnight or 6 am, instead of 4 am, to minimize patients’ nighttime interruptions. All other nursing duties continued with the institution’s patient care policies. Finally, retrospective chart reviews were performed to determine whether the intervention resulted in the escalation of care, our primary outcome.

Results:

We collected 2,138 individual data points, which represented approximately 420 patients. Over the intervention period, high compliance rates with physician order placement, nurse performing passive vital signs, and delayed blood draws were maintained. On eligible patients, there was no escalation of care or rapid response team involvement.

Conclusions:

The use of passive vital sign checks on eligible pediatric patients was generally well-received and had high compliance during the intervention period. There were no negative patient care consequences, supporting the feasibility of this program. Further studies are needed to determine sleep quality and patient satisfaction.
Impact of Eliminating Local Anesthesia on Immediate Postoperative Analgesia in Pediatric Ambulatory Adenotonsillectomy
Authors: Loy Kelsey A , Lam Austin S , Franz Amber M , Martin Lynn D , Manning Scott C , Ou Henry C , Perkins Jonathan A , Parikh Sanjay R , Low Daniel K-W , Dahl John P
Published: May 2021

Introduction:

Our goal was to standardize intraoperative analgesic regimens for pediatric ambulatory tonsillectomy by eliminating local anesthetic use and to determine its impact on postoperative pain measures, while controlling for other factors.

Methods:

We assembled a quality improvement team at an ambulatory surgery center. They introduced a standardized anesthetic protocol, involving American Society of Anesthesiologists Classification 1 and 2 patients undergoing adenotonsillectomy. Local anesthesia elimination was the project’s single intervention. We collected pre-intervention data (79 cases) from July 5 to September 17, 2019 and post-intervention data (59 cases) from September 25 to December 17, 2019. The intervention requested that surgeons eliminate the use of local anesthetics. The following outcomes measures were evaluated using statistical process control charts and Shewhart’s theory of variation: (1) maximum pain score in the post-anesthesia care unit, (2) total post-anesthesia care unit minutes, and (3) postoperative opioid rescue rate.

Results:

No special cause variation signal was detected in any of the measures following the intervention.

Conclusions:

Our data suggest that eliminating intraoperative local anesthetic use does not worsen postoperative pain control at our facility. The intervention eliminated the added expenses and possible risks associated with local anesthetic use. This series is unique in its standardization of anesthetic regimen in a high-volume ambulatory surgery center with the exception of local anesthesia practices. The study results may impact the standardized clinical protocol for pediatric ambulatory adenotonsillectomy at our institution and may hold relevance for other centers.
Reducing Time to First Dose of Antibiotic: The Example of Asymptomatic Neonates Exposed to Chorioamnionitis
Authors: Ajayi Samuel , Kehinde Folasade , Cooperberg David , Touch Suzanne M.
Published: May 2021

Introduction:

Time of medication delivery from the onset of illness is one factor that determines disease outcomes. In this study, we aimed to reduce the average time from admission to the first dose of antibiotic by at least 30% and increase the percentage of neonates receiving the first antibiotic dose within 1 hour of neonatal intensive care unit arrival to 50% over 12 months in asymptomatic neonates 34 weeks and older estimated gestational age with exposure to maternal chorioamnionitis as a sample population.

Method:

This study involved 135 infants 34 weeks and older gestational age exposed to chorioamnionitis. We documented the demographic characteristics of mothers and infants. We monitored time to the administration of the first dose of antibiotics through multiple plan-do-study-act cycles. We identified barriers to timely antibiotic administration and targeted them with multipronged interventions in plan-do-study-act cycles. Process measures were displayed monthly using X-bar/S control charts and P charts. We applied established rules for detecting a special cause.

Results:

We reduced the meantime to the first dose of antibiotics from 130 to 78 minutes (40% reduction). The percentage of infants who received the first antibiotic dose within 60 minutes rose from 5.8% to 36.3% during the study period. Special cause improvement was seen in all process measures. The most significant improvement seen was in the time to obtain a blood culture and the interval between intravenous access placement and antibiotic delivery.

Conclusion:

Multipronged interventions can help improve timely medication delivery to neonates in the neonatal intensive care unit in this example of infants exposed to chorioamnionitis.
Can Emergency Department Wait Times Predict Rates of Hospital-Acquired Clostridioides difficile Infection? A Study of Acute Care Facilities in New York State
Authors: Durant Danielle J. , Young Claudia Guerrazzi
Published: May 2021

Objective

Clostridioides difficile is the most common hospital-acquired pathogen and persists in the environment for extended periods. As a common entry point for patients with diarrhea, and a setting providing fast-paced, high-volume care, emergency departments (EDs) are often sites of C. difficile contamination. This study examined the relationship between average patient wait times in the ED before admission and overall hospital-acquired C. difficile infection (HA-CDI) rates in New York State acute care hospitals.

Methods

A random-effects regression analysis compared each facility’s annual average ED wait time for admitted patients with that facility’s average (HA-CDI) rates for patients entering through the ED. This model controlled for known clinical and nonclinical predictors of HA-CDI: average length of stay; case mix index; total discharges, a measure of hospital size; and percent Medicare discharges, a proxy for advanced age.

Results

Emergency department wait times had a significant and positive relationship with HA-CDI rates. Facilities experience an additional 0.002 cases of HA-CDI per 1000 patient discharges with every additional minute patients spend in the ED (P = 0.003), on average. Emergency department wait times also had the largest effect size (0.210), indicating that they explain more of the variance in HA-CDI rates for patients entering through the ED than some of the best-known predictors of HA-CDI.

Conclusions

The relationship between ED wait times and eventual HA-CDI warrants further exploration. These findings suggest efforts to reduce ED wait times for admitted patients or more rigorous environmental cleanliness strategies in the ED, as possible avenues for HA-CDI prevention.
Occupational Therapy Utilization in Veterans With Dementia: A Retrospective Review of Root Cause Analyses of Falls Leading to Adverse Events
Authors: Rhodus Elizabeth K. , Lancaster Elizabeth A. , Hunter Elizabeth G. , Nudell Tina , Humphrey Casey , Duke Mary , Harris Andrew M.
Published: May 2021

Introduction

Falls in persons with dementia are associated with increased mortality. Occupational therapy (OT) is a rehabilitation discipline, which has, among its goals, the promotion of safety and fall prevention in older adults and those with dementia. The purpose of this study was to evaluate root cause analysis (RCA) data to identify causes of falls with adverse events in patients with dementia who were referred to or receiving OT services within the Veterans Health Administration (VHA).

Methods

This study used retrospective review of RCAs within the National Center for Patient Safety database for the VHA. The RCA database was searched using these terms: falls with adverse events, dementia, and OT. Descriptive statistical analysis of demographic information, location, occurrence of orthopedic fracture, and mortality was used. All root causes were qualitatively categorized using thematic analysis of determined causes.

Results

Eighty RCAs were included in analysis. Mean age of veterans included was 80 years; 96% were male; 76% resulted in hip fracture; and 20% died as a result of the fall. Occupational therapy evaluations occurred within 7 days of admission to VHA and falls most frequently occurred within 4 days of OT evaluation. Most common causes included inappropriate or lack of equipment (21%), need for falls/rehabilitation assessment (20%), compliance/training to fall protocol of all staff (19%), and behavior/medical status (17%).

Conclusions

Earlier identification for OT evaluation need may improve access to services, and use of proper equipment to decrease frequency of falls may improve patient safety for older adults with dementia.
Perspectives of Dental Patients About Safety Incident Reporting: A Qualitative Pilot Study
Authors: Obadan-Udoh Enihomo M. , Gharpure Arti , Lee Joo Hyun , Pang Jason , Nayudu Anuradha
Published: May 2021

Objectives

Patient reporting of safety incidents is one of the hallmarks of an effective patient safety protocol in any health care setting. However, very little is known about safety reporting among dental patients or effective strategies for engaging them in activities that promote safety. The goal of this study was to understand the perceptions of dental patients about the barriers and benefits of reporting safety incidents. We also sought to identify strategies for improving patient reporting of safety incidents in the dental care setting.

Methods

We conducted 3 focus group sessions with adult dental patients (n = 16) attending an academic dental center from November 2017 to February 2018. Audio recordings were transcribed and analyzed using a hybrid thematic analysis approach with NVivo software.

Results

Dental patients mainly attributed safety incidents to provider-related and systemic factors. They were most concerned about the financial implications, inconvenience of multiple visits, and the absence of an apology when an incident occurred. The major recommended strategies for engaging patients in safety-related activities included the following: proactive solicitation of patient feedback, what-to-expect checklists, continuous communication during visits/procedures, after-visit summary reports, clear incident reporting protocols, use of technology, independent third-party safety incident reporting platforms, and a closed feedback loop.

Conclusions

This study offers a roadmap for proactively working with dental patients as vigilant partners in promoting quality and safety. If properly engaged, dental patients are prepared to work with dental professionals to identify threats to safety and reduce the occurrence of harm.
Identifying Health Information Technology Usability Issues Contributing to Medication Errors Across Medication Process Stages
Authors: Adams Katharine T. , Pruitt Zoe , Kazi Sadaf , Hettinger Aaron Z. , Howe Jessica L. , Fong Allan , Ratwani Raj M.
Published: May 2021

Objective

Different health information technology (health IT) systems are intended to support medication ordering, reviewing, and administration. We sought to identify the types of medication errors associated with health IT use, whether they reached the patient, where in the medication process those errors occurred, and the specific usability issues contributing to those errors.

Methods

Patient safety event reports from more than 595 healthcare facilities entered between January 2013 and September 2018 were analyzed. We computationally identified reports associated with health IT intended to support the medication process, including computerized provider order entry, electronic medication administration record, and barcode medication administration. From these, 2700 reports were manually reviewed to determine the type of medication error, medication process stage, and health IT usability issue.

Results

Of the 2700 manually reviewed reports, 1508 (55.9%) described a medication error that was associated with health IT use and 750 (49.7%) reached the patient. Improper dose errors were frequent (1214 of 1508, 80.5%) with most errors during ordering (673 of 1508, 44.6%) and reviewing medications (639 of 1508, 42.4%). Most health IT–associated medication error reports described usability issues (n = 1468 of 1508, 97.3%) including data entry, workflow support, and alerting. Data entry usability issues impacted few medication process stages, whereas workflow support and alerting impacted several stages.

Conclusions

Health IT usability issues are a prevalent contributing factor to medication errors, many of which reach the patient. Data entry, workflow support, and alerting should be prioritized during usability and safety optimization efforts.
Microvascular Dysfunction in Patients with Critical Covid-19, a Pilot Study
Authors: Tehrani Sara , Gille-Johnson Patrik
Published: May 2021

Background:

Endothelial and microvascular dysfunction may be a key pathogenic feature of severe COVID-19. The aim of this study was to investigate endothelial-dependent and endothelial-independent skin microvascular reactivity in patients with critical COVID-19.

Methods:

Twelve patients with COVID-19 treated with non-invasive or invasive mechanical ventilation were included in the study. We investigated skin microvascular reactivity on 2 separate days during hospitalization (study day 1 and 2) and at least 3 months after disease onset (study day 3). Twelve controls with no confirmed or suspected COVID-19 infection during 2020 were also examined. Skin perfusion was investigated through Laser Speckle Contrast Imaging before and after iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP) to determine the endothelial-dependent and the endothelial-independent vasodilation, respectively.

Results:

Compared to controls, patients with critical COVID-19 had higher basal skin perfusion and reduced responses to endothelial-dependent (ACh, P = 0.002) and endothelial-independent (SNP, P = 0.01) vasodilator drugs on study day 1. In addition, the ACh/SNP ratio was significantly reduced in patients (0.50 ± 0.36 vs. 0.91 ± 0.49 in controls, P = 0.02). Three months after disease onset, surviving patients tended to have reduced ACh-mediated vasodilation compared to controls (P = 0.08).

Conclusions:

This small-sized pilot study demonstrates that critical COVID-19 infection is associated with microvascular impairment and, in particular, a markedly reduced endothelial function. Our results also suggest that microvascular function may not be fully recovered 3 months after disease onset.
Multimodal Evoked Potentials as Candidate Prognostic and Response Biomarkers in Clinical Trials of Multiple Sclerosis
Authors: Hardmeier Martin , Fuhr Peter
Published: May 2021

Evoked potentials (EPs) measure quantitatively and objectively the alterations of central signal propagation in multiple sclerosis and have long been used for diagnosis. More recently, their utility for prognosis has been demonstrated in several studies, summarizing multiple EP modalities in a single score. In particular, visual, somatosensory, and motor EPs are useful because of their sensitivity to pathology in the frequently affected optic nerve, somatosensory tract, and pyramidal system. Quantitative EP scores show higher sensitivity to change than clinical assessment and may be used to monitor disease progression. Visual EP and the visual system have served as a model to study remyelinating therapies in the setting of acute and chronic optic neuritis. This review presents rationale and evidence for using multimodal EP as prognostic and response biomarkers in clinical trials, targeting remyelination or halting disease progression in multiple sclerosis.
Biomarkers and Surrogate End points in Multiple Sclerosis Trials: Regulatory Issues
Authors: Skeen Mark B. , Pani Luca
Published: May 2021

Evoked potentials have assisted in the diagnosis of multiple sclerosis for years, but the potential to demonstrate pathophysiologic change has prompted a reconsideration of their potential role as outcome measures in clinical trials of multiple sclerosis. The use of any surrogate end point or biomarker in clinical trials requires a thorough understanding of that end point's performance characteristics and utility in a particular setting. This article explores regulatory issues regarding the use of biomarkers and surrogate end points in clinical trials of multiple sclerosis with particular emphasis on challenges faced by evoked potential studies.
Changing Paradigms and Unmet Needs in Multiple Sclerosis: The Role of Clinical Neurophysiology
Authors: Skeen Mark B.
Published: May 2021

Our increasing understanding of the immunopathogenesis of multiple sclerosis has led to the development of many disease-modifying therapies that have revolutionized the care of patients with relapsing forms of the disease. Our understanding of the pathophysiologic basis of progressive forms of the disease is much more limited but has dramatically changed over the past several decades. We are now on the verge of developing therapies that promote remyelination, reduce axonal loss, and restore axonal function. This progress is challenged by inadequate animal models of progressive disease and incomplete biomarkers of progression. In measuring central nervous system function, evoked potentials may have an advantage over biomarkers, which measure only pathologic change. Monitoring multifocal visual evoked potential amplitude may be one possible means of monitoring disease progression in multiple sclerosis. Additional clinical studies are required to document whether evoked potentials can adequately serve as effective biomarkers of progression.