The POPPY study: developing a model of family-centred care for neonatal units.

BACKGROUND: The concept of family-centred care in neonatal practice has become increasingly recognised internationally. The underlying philosophy puts parents and the family at the centre of health care and promotes "individualised, flexible care." AIMS: To develop the first international model of family-centred care based on strong parental collaboration in the synthesis of robust research evidence to generate the philosophy, principles, model, and indicators for implementation. METHODS AND SYNTHESIS: Seven key steps were followed to develop the POPPY model of care collaboratively with parents. Step 1 drew on the POPPY systematic review to identify effective interventions. Step 2 drew on the POPPY qualitative study to identify good parent experiences. Step 3 identified the philosophy and principles of the POPPY model of care. Step 4 identified the key stages of the POPPY model of care. Step 5 populated the POPPY model of care with data from steps 1 and 2. Step 6 developed the indicators of family-centred care; and Step 7 undertook some initial testing with parents and practitioners. RESULTS: Seven key stages of the parents' journey through their neonatal unit experience were identified and formed the architecture of the POPPY model of care. These include: before admission to the unit, admission, early days, growing and developing, transfers between units and between levels of care, preparing for discharge, and transition to home and at home. A philosophy, a set of principles to underpin the model, and a set of indicators to guide implementation in neonatal units were developed. CONCLUSION: The POPPY model of family-centred care provides the first robust, collaboratively developed, parent-centred model, which can be implemented to deliver high quality care to parents of preterm infants. IMPLICATIONS: Implementing the POPPY model could help neonatal units to develop parent-focused services which better meet parents' needs for information, communication and support, key elements of family-centred care.

New Canadian and Provincial Records of Coleoptera Resulting from Annual Canadian Food Inspection Agency Surveillance for Detection of Non-Native, Potentially Invasive Forest Insects.

The arrival and establishment of adventive, invasive forest insects are a threat to the health, diversity, and productivity of forests in Canada and the world at large, and their early detection is essential for successful eradication and management. For that reason, the Canadian Food Inspection Agency (CFIA) conducts annual surveys at high risk sites such as international ports and freight terminals, industrial zones, and disposal sites for solid wood packaging material using two methods: (1) semiochemical-baited traps deployed in a total of about 63-80 sites per year in British Columbia (BC), Ontario (ON), Quebec (QC), New Brunswick (NB), Nova Scotia (NS), and Newfoundland and Labrador (NL); and (2) rearing of insects from bolts collected from stressed trees and incubated in modified shipping containers in four cities (Vancouver, Toronto, Montreal, and Halifax). We report 31 new Canadian provincial records of Coleoptera from surveys conducted in 2011-2021, including 13 new records for Canada and 9 species adventive to North America (indicated by †). Nine of the new Canadian records were native North American species previously detected only south of the border. All but three species belong to the Curculionidae family and most of these were in the subfamily Scolytinae. The records include: Xenomelanophila miranda (LeConte) (Canada, BC) (Buprestidae: Buprestinae); Neoclytus mucronatus mucronatus (Fabricius) (BC) (Cerambycidae: Cerambycinae); Amphicerus cornutus (Pallas) (Canada, BC) (Bostrichidae: Bostrichinae); Mecinus janthinus (Germar)† (ON) (Curculionidae: Curculioninae); Aulacobaris lepidii (Germar)† (Canada, ON); Buchananius striatus (LeConte) (ON) (Curculionidae: Baridinae); Cylindrocopturus binotatus LeConte (Canada, ON) (Curculionidae: Conoderinae); Himatium errans LeConte (ON); Phloeophagus canadensis Van Dyke (ON); Rhyncolus spretus Casey (Canada, BC); Stenomimus pallidus (Boheman) (Canada, ON); Tomolips quercicola (Boheman) (Canada, ON) (Curculionidae: Cossoninae); Strophosoma melanogrammum (Forster)† (NB) (Curculionidae: Entiminae); Conotrachelus aratus (Germar) (ON) (Curculionidae: Molytinae); Anisandrus maiche Stark† (Canada, ON, QC); Cnesinus strigicollis LeConte (Canada, ON); Cyclorhipidion pelliculosum (Eichhoff)† (Canada, ON, QC); Hylesinus fasciatus LeConte (QC); Hylesinus pruinosus Eichhoff (QC); Hypothenemus interstitialis (Hopkins) (Canada, ON); Lymantor alaskanus Wood (BC); Pityogenes bidentatus (Herbst)† (Canada, ON); Scolytus mali (Bechstein)† (BC); Scolytus schevyrewi Semenov† (QC); Trypodendron scabricollis (LeConte) (Canada, ON); Trypophloeus populi Hopkins (QC); Xylechinus americanus Blackman (NFLB); and Xylosandrus crassiusculus (Motschulsky)† (BC, QC) (Curculionidae: Scolytinae). We also provide additional data confirming the presence of the adventive Hylastes opacus Erichson† in NS. Rearing of insects from bolts accounted for two new records (H. pruinosus, R. spretus) and trapping accounted for the remainder. These surveys not only assist our efforts to manage forest insects by documenting new species introductions and apparent range expansions but also increase our knowledge of biodiversity.

Culturally competent assessment and care of self-mutilation in urological nursing.

Use of self-mutilating behaviors as ineffective coping techniques is increasing, and it cuts across cultural and ethnic populations. With increasing immigration, the chance of facing both issues with a single patient is also increasing. Therefore, the need for assessment and care that is culturally sensitive is a necessity.

Nurse staffing in relation to risk-adjusted mortality in neonatal care.

OBJECTIVE: To assess whether risk-adjusted mortality in very low birthweight or preterm infants is associated with levels of nursing provision. DESIGN: Prospective study of risk-adjusted mortality in infants admitted to a random sample of neonatal units. SETTING: Fifty four UK neonatal intensive care units stratified by: patient volume; consultant availability; nurse:cot ratios. PATIENTS: A group of 2585 very low birthweight (birthweight <1500 g) or preterm (<31 weeks gestation) infants. MAIN OUTCOME MEASURE: Death before discharge or planned deaths at home, excluding lethal malformations, after adjusting for initial risk 12 hours after birth using gestation at birth and measures of illness severity in relation to nursing provision calculated for each baby's neonatal unit stay. RESULTS: A total of 57% of nursing shifts were understaffed, with greater shortages at weekends. Risk-adjusted mortality was inversely related to the provision of nurses with specialist neonatal qualifications (OR 0.67; 95% CI 0.42 to 0.97). Increasing the ratio of nurses with neonatal qualifications to intensive care and high dependency infants to 1:1 was associated with a decrease in risk-adjusted mortality of 48% (OR: 0.52, 95% CI: 0.33, 0.83). CONCLUSIONS: Risk-adjusted mortality did not differ across neonatal units. However, survival in neonatal care for very low birthweight or preterm infants was related to proportion of nurses with neonatal qualifications per shift. The findings could be used to support specific standards of specialist nursing provision in neonatal and other areas of intensive and high dependency care.

Teaching about the brain and reaching the community: undergraduates in the pipeline neuroscience program at the university of pennsylvania.

This article provides an overview of the University of Pennsylvania School of Medicine's Pipeline Neuroscience Program, a multi-tiered mentorship and education program for Philadelphia high school students in which University of Pennsylvania undergraduates are integrally involved. The Pipeline Neuroscience Program provides mentorship and education for students at all levels. High school students are taught by undergraduates, who learn from medical students who, in turn, are guided by neurology residents and fellows. Throughout a semester-long course, undergraduates receive instruction in neuroanatomy, neuroscience, and clinical neurology as part of the Pipeline's case-based curriculum. During weekly classes, undergraduates make the transition from students to community educators by integrating their new knowledge into lesson plans that they teach to small groups of medically and academically underrepresented Philadelphia high school students. The Pipeline program thus achieves the dual goals of educating undergraduates about neuroscience and providing them with an opportunity to perform community service.

Intracardiac fistula: an unusual complication of catheter-related blood stream infection.

In end stage renal disease patients on dialysis, the use of catheter as a vascular access is associated with a significant risk of sepsis compared to an arterio-venous fistula. Our case emphasizes the importance of having high index of suspicion for unusual complications in patients presenting with possible catheter-related blood stream infection and early use of complementary tools such as trans-oesophageal echocardiography whenever applicable.

beta-Adrenergic receptor polymorphisms and responses during titration of metoprolol controlled release/extended release in heart failure.

OBJECTIVE: beta-Blockers require careful initiation and titration when used in patients with heart failure. Some patients tolerate beta-blocker therapy initiation without difficulty, whereas in other patients this period presents clinical challenges. We tested the hypothesis that polymorphisms at codons 389 (Arg389Gly) and 49 (Ser49Gly) of the beta(1)-adrenergic receptor would be associated with differences in initial tolerability of beta-blocker therapy in patients with heart failure. We also tested whether polymorphisms in the beta(2)-adrenergic receptor, G-protein alpha s subunit (G(s)alpha), and cytochrome P450 (CYP) 2D6 genes or S-metoprolol plasma concentrations were associated with beta-blocker tolerability. METHODS: Sixty-one beta-blocker-naive patients with systolic heart failure were prospectively enrolled. Patients began taking 12.5 to 25 mg metoprolol controlled release/extended release with titration every 2 weeks (as tolerated) to 200 mg/d or the maximum tolerated dose over a period of 8 to 10 weeks. Decompensation was the composite of death, heart failure hospitalization, increase in other heart failure medications, or need to discontinue metoprolol. End points were assessed during the titration period. RESULTS: The overall rate of decompensation was not different between the codon 49 or 389 genotypes. However, a significantly greater percentage of patients with the Gly389 variant required increases in heart failure medications as compared with Arg389 homozygotes (48% versus 14%, respectively; P = .006). Similarly, patients with the Ser49 homozygous genotype were significantly more likely to require increases in concomitant heart failure therapy as compared with Gly49 carriers (41% versus 11%, respectively; P = .03). Neither CYP2D6 genotypes nor metoprolol pharmacokinetics differed between patients with and those without a decompensation event. There was no association between the beta(2)-adrenergic receptor or G(s)alpha polymorphisms with decompensated heart failure. CONCLUSIONS: Patients with the Gly389 variant and Ser49Ser genotype were significantly more likely to require increases in heart failure medications during beta-blocker titration and thus may require more frequent follow-up during titration.

Exploring the effect of at-risk case management compensation on hospital pay-for-performance outcomes: tools for change.

PURPOSE/OBJECTIVES: Acute care nurse case managers are charged with compliance oversight, managing throughput, and ensuring safe care transitions. Leveraging the roles of nurse case managers and social workers during care transitions translates into improved fiscal performance under the Affordable Care Act. This article aims to equip leaders in the field of case management with tools to facilitate the alignment of case management systems with hospital pay-for-performance measures. A quality improvement project was implemented at a hospital in south Alabama to examine the question: for acute care case managers, what is the effect of key performance indictors using an at-risk compensation model in comparison to past nonincentive models on hospital readmissions, lengths of stay, and patient satisfaction surrounding the discharge process. PRIMARY PRACTICE SETTING(S): Inpatient acute care hospital. FINDINGS/CONCLUSIONS: The implementation of an at-risk compensation model using key performance indicators, Lean Six Sigma methodology, and Creative Health Care Management's Relationship-Based Care framework demonstrated reduced length of stay, hospital readmissions, and improved patient experiences. IMPLICATIONS FOR CASE MANAGEMENT: Regulatory changes and new models of reimbursement in the acute care environment have created the perfect storm for case management leaders. Hospital fiscal performance is dependent on effective case management processes and the ability to optimize scarce resources. The quality improvement project aimed to further align case management systems and structures with hospital pay-for-performance measures. Tools for change were presented to assist leaders with the change acceleration process.

Influence of gender and race on hemodynamic response to dobutamine during dobutamine stress echocardiography.

This study sought to determine the influence of gender and/or race on the hemodynamic response to dobutamine during dobutamine stress echocardiography. Blood pressure response patterns differed by gender and race, and completion of testing was often limited because of adverse events, namely, hypertension. Gender and racial differences in blood pressure response merit consideration as potential contributors to the suboptimal response in dobutamine stress testing.

Total laparoscopic hysterectomy using multifunction grasping, coagulating, and cutting forceps.

We describe the use of multifunction grasping, coagulating, and cutting forceps in total laparoscopic hysterectomy (LH) and compare surgery time, estimated blood loss, and costs for a series of 123 LH performed by the principal author at one of two community hospitals in Seattle between January 2001 and July 2002. The first 73 were performed using bipolar Kleppinger forceps (Richard Wolf Instruments, Vernon Hills, Illinois), endoscopic scissors (Karl Storz Endovision, Charlton, Massachusetts), and a monopolar spatula electrode (Jarit Surgical Instruments, Hawthorne, New York); the last 50 cases were performed using the PlasmaKinetic (PK) (Gyrus Medical, Maple Grove, Minnesota) multifunction cutting forceps and the monopolar spatula electrode. We were able to compare patient data in two surgery categories: LH alone (43 patients, 26 using the Kleppinger forceps and endoscopic scissors, 17 using the PK system), and laparoscopic hysterectomy with bilateral salpingo-oopherectomy (30 patients, 20 using Kleppinger forceps and endoscopic scissors, 10 using the PK system). In the remaining 50 cases, the addition of other secondary procedures precluded effective statistical comparisons. We found significantly lower estimated blood loss in both surgery categories when using the PK cutting forceps, but no differences in mean surgery time. Costs for disposable instrumentation parts and handling were approximately 70 dollars greater per procedure with the PK system. Using the PK cutting forceps eliminated some instrument exchanges and the requirement for a third instrument cannula. We also noted significantly less plume, quicker coagulation, and less tissue char when coagulating with the PK forceps compared to the Kleppinger forceps.

Deployment of lean six sigma in care coordination: an improved discharge process.

PURPOSE/OBJECTIVES: This article presents a quality improvement project to reduce readmissions in the Medicare population related to heart failure, acute myocardial infarction, and pneumonia. The article describes a systematic approach to the discharge process aimed at improving transitions of care from hospital to post-acute care, utilizing Lean Six Sigma methodology. PRIMARY PRACTICE SETTING: Inpatient acute care hospital. FINDINGS/CONCLUSIONS: A coordinated discharge process, which includes postdischarge follow-up, can reduce avoidable readmissions. Implications for CASE MANAGEMENT: The quality improvement project demonstrated the significant role case management plays in preventing costly readmissions and improving outcomes for patients through better transitions of care from the hospital to the community. By utilizing Lean Six Sigma methodology, hospitals can focus on eliminating waste in their current processes and build more sustainable improvements to deliver a safe, quality, discharge process for their patients. Case managers are leading this effort to improve care transitions and assure a smoother transition into the community postdischarge..

Prevalence of pulmonary hypertension in end-stage cystic fibrosis and correlation with survival.

BACKGROUND: Limited information is available about the prevalence of pulmonary hypertension diagnosed by right heart catheterization (RHC) in patients with cystic fibrosis being evaluated for lung transplantation. It is unclear whether there are factors that can predict the presence of pulmonary hypertension and whether the presence of pulmonary hypertension influences patient outcomes. METHODS: The study included 57 unique and consecutive adult patients (33 women) with cystic fibrosis who underwent lung transplant evaluation at the University of Florida. RESULTS: The average age at evaluation was 31.8 +/- 10 years. All patients were in New York Heart Association class III. The median (interquartile range) of mean pulmonary artery pressure (PAP) was 26 (24-30) mm Hg. Thirty-six patients (63.2%) had pulmonary hypertension (mean PAP >or= 25 mm Hg) and had a significantly higher degree of hypoxemia and oxygen requirements. Echocardiography evidenced limitations for the diagnosis of pulmonary hypertension. The 5-year mortality rate was similar in patients with or without pulmonary hypertension; however, it was higher in 7 patients identified by cluster analysis and in patients with a left ventricular ejection fraction < 55%. CONCLUSIONS: More than half of our patients with cystic fibrosis and advanced lung disease have elevation of PAP, usually of mild degree. A lower left ventricular ejection fraction, but not the presence of pulmonary hypertension, was associated with worse outcomes.

Tricuspid annular motion as a predictor of severe right ventricular failure after left ventricular assist device implantation.

BACKGROUND: Right ventricular (RV) failure after left ventricular assist device (LVAD) implantation is associated with a high rate of morbidity and mortality. We sought to determine pre-operative right heart echocardiographic predictors of post-LVAD severe RV failure. METHODS: RV failure, defined as the need for inotropic support or pulmonary vasodilators for >or=14 days post-operatively, was evaluated in 33 patients (age 54 +/- 13 years) with LVADs. Preoperative RV systolic and diastolic echocardiographic parameters, including RV fractional area change, tricuspid annular motion, right atrial volume index, RV index of myocardial performance, hepatic vein Doppler velocities, tricuspid regurgitation severity, and RV systolic pressures (RVSPs) in patients with and without RV failure were compared. RESULTS: Of the 33 patients evaluated, 11 (33%) had post-LVAD RV failure (2 needed RVAD support). Patients with post-LVAD RV failure had significantly lower pre-operative tricuspid annular motion (8 +/- 4 vs 15 +/- 6 mm, p < 0.01) and higher RVSPs (60 +/- 14 vs 46 +/- 11 mm Hg, p = 0.02). In 13 patients (39%) with moderate tricuspid regurgitation, pre-operative tricuspid annular motion remained significantly reduced (6.0 +/- 0.5 vs 13.5 +/- 5.0 mm, p = 0.045). Other echocardiographic parameters were not significantly different between patients. Tricuspid annular motion of <7.5 mm provides 91% specificity and 46% sensitivity in predicting post-LVAD RV failure. CONCLUSION: Tricuspid annular motion is a predictor of post-LVAD RV failure. Using tricuspid annular motion in addition to conventional criteria may aid in early identification of patients with prolonged inotropic support or severe RV failure and allow for better pre-operative planning.

Performance assessment in health care providers: a critical review of evidence and current practice.

AIM: To evaluate methods of performance assessment through an international literature review and a survey of current practice. BACKGROUND: Over the past two decades health care organizations have focussed on promoting high quality care in conjunction with retaining motivated staff. Cognisant of such initiatives, we sought to evaluate assessment methods for qualified staff according to their utility in the working environment. METHODS: A systematic literature search was completed and each paper independently reviewed. All health care organizations in Northern Ireland submitted details of their performance assessments. Each was critically appraised using a utility index. RESULTS: Performance was not universally defined. A broad range of assessments were identified, each method had advantages and disadvantages. Although many lacked rigorous testing, areas of good practice were also noted. CONCLUSIONS: No single method is appropriate for assessing clinical performance. Rather, this study endorses proposals for a multi-method strategy to ensure that performance assessment demonstrates all attributes required for effective nursing and midwifery practice.

Synergistic polymorphisms of beta1 and alpha2C-adrenergic receptors and the influence on left ventricular ejection fraction response to beta-blocker therapy in heart failure.

OBJECTIVES: The Arg389Gly polymorphism (Arg389Gly) in the beta1-adrenergic receptor gene (ADRB1) has been associated with improvement in left-ventricular remodeling with beta-blocker treatment. One study of risk for heart failure suggested a synergistic effect of ADRB1 Arg389Gly with the insertion/deletion polymorphism in the alpha2C-adrenergic receptor gene (ADRA2C). We tested whether the ADRA2C insertion/deletion polymorphism was associated with beta-blocker response in heart failure, either alone or in combination with the ADRB1Arg389Gly polymorphism. METHODS: Fifty-four beta-blocker naive heart failure patients underwent echocardiography before and after 5-6 months of metoprolol CR/XL therapy. Multivariant linear regression modeling was performed to assess the impact of genotypes and other variables on changes in left-ventricular function in response to metoprolol therapy. RESULTS: Deletion carriers had a significantly greater negative chronotropic response. Predictors of the end of study ejection fraction were baseline ejection fraction, deletion carrier status and Arg389Arg genotype. Patients with Arg389Arg/Del-carrier status showed the greatest ejection fraction increase with metoprolol CR/XL. Adjusting for baseline ejection fraction, final S-metoprolol plasma concentration and race, final ejection fraction in patients with this genotype combination was significantly higher than all other genotype combination groups. CONCLUSION: ADRB1 and ADRA2C polymorphisms synergistically influence the ejection fraction response to beta-blocker therapy of heart failure patients.

A managed clinical network for cardiac services: set-up, operation and impact on patient care.

PURPOSE: To investigate the set up and operation of a Managed Clinical Network for cardiac services and assess its impact on patient care. METHODS: This single case study used process evaluation with observational before and after comparison of indicators of quality of care and costs. The study was conducted in Dumfries and Galloway, Scotland and used a three-level framework. Process evaluation of the network set-up and operation through a documentary review of minutes; guidelines and protocols; transcripts of fourteen semi-structured interviews with health service personnel including senior managers, general practitioners, nurses, cardiologists and members of the public. Outcome evaluation of the impact of the network through interrupted time series analysis of clinical data of 202 patients aged less than 76 years admitted to hospital with a confirmed myocardial infarction one-year pre and one-year post, the establishment of the network. The main outcome measures were differences between indicators of quality of care targeted by network protocols. Economic evaluation of the transaction costs of the set-up and operation of the network and the resource costs of the clinical care of the 202 myocardial infarction patients from the time of hospital admission to 6 months post discharge through interrupted time series analysis. The outcome measure was different in National Health Service resource use. RESULTS: Despite early difficulties, the network was successful in bringing together clinicians, patients and managers to redesign services, exhibiting most features of good network management. The role of the energetic lead clinician was crucial, but the network took time to develop and 'bed down'. Its primary "modus operand" was the development of a myocardial infarction pathway and associated protocols. Of sixteen clinical care indicators, two improved significantly following the launch of the network and nine showed improvements, which were not statistically significant. There was no difference in resource use. DISCUSSION AND CONCLUSIONS: The Managed Clinical Network made a difference to ways of working, particularly in breaching traditional boundaries and involving the public, and made modest changes in patient care. However, it required a two-year "set-up" period. Managed clinical networks are complex initiatives with an increasing profile in health care policy. This study suggests that they require energetic leadership and improvements are likely to be slow and incremental.

Beta1-adrenergic receptor polymorphisms and left ventricular remodeling changes in response to beta-blocker therapy.

OBJECTIVE: Large variability exists in the improvement in left ventricular (LV) function from beta-blocker treatment. We hypothesized that polymorphisms at codon 389 (Arg389Gly) and 49 (Ser49Gly) in the beta1-adrenergic receptor (AR) gene were associated with LV reverse remodeling changes in response to beta-blocker therapy among heart failure patients. METHODS: We prospectively enrolled 61 beta-blocker naive patients with systolic heart failure. Patients underwent baseline echocardiography followed by metoprolol CR/XL. The dose was doubled on a biweekly basis up to 200 mg/day or attainment of maximum tolerated dose. Echocardiography was repeated after the patient received the target or highest tolerated dose for 3 months. RESULTS: Among patients with the Arg389Arg genotype, ejection fraction (EF) increased from 23+/-5 to 29+/-10 (P=0.008). Gly389 carriers did not demonstrate any significant change in EF (22+/-9 to 23+/-11; P=0.45). There was a significant between-group difference in EF by genotype (P=0.04). The Arg389Arg genotype was also associated with significantly greater reductions in LV end-diastolic and end-systolic diameters compared to Gly389 carriers. Patients with the Gly49 variant also had a significantly greater reduction in LV end-diastolic diameter compared to Ser49 homozygotes. Multiple regression analysis modeling revealed that the codon 389 polymorphism was a significant predictor of an improvement in EF and both codon 49 and 389 polymorphisms were significant predictors of final LV end-diastolic diameter. CONCLUSIONS: Heart failure patients with the Arg389Arg genotype and Gly49 carriers had greater improvements in LV remodeling from beta-blocker treatment.