PASTRY: A nursing-developed quality improvement initiative to combat moral distress.

BACKGROUND: High levels of moral distress in nursing professionals, of which oncology nurses are particularly prone, can negatively impact patient care, job satisfaction, and retention. AIM: "Positive Attitudes Striving to Rejuvenate You: PASTRY" was developed at a tertiary cancer center to reduce the burden of moral distress among oncology nurses. RESEARCH DESIGN: A Quality Improvement (QI) initiative was conducted using a pre- and post-intervention design, to launch PASTRY and measure its impact on moral distress of the nursing unit, using Hamric's Moral Distress Scale-Revised (MDS-R.) This program consisted of monthly 60-minute sessions allowing nurses to address morally distressing events and themes, such as clinicians giving "false hope" to patients or families. The PASTRY program sessions were led by certified clinicians utilizing strategies of discussion and mind-body practices. PARTICIPANTS: Clinical nurses working on an adult leukemia/lymphoma unit. ETHICAL CONSIDERATIONS: This was a QI initiative, participation was voluntary, MDS-R responses were collected anonymously, and the institution's Ethics Committee oversaw PASTRY's implementation. FINDINGS: While improvement in moral distress findings were not statistically significant, the qualitative and quantitative findings demonstrated consistent themes. The PASTRY program received strong support from nurses and institutional leaders, lowered the nursing unit's moral distress, led to enhanced camaraderie, and improved nurses' coping skills. DISCUSSION: Measurement of moral distress is innately challenging due to its complexity. This study reinforces oncology nurses have measurable moral distress. Interventions should be implemented for a safe and healing environment to explore morally distressing clinical experiences. Poor communication among multidisciplinary team members is associated with moral distress among nurses. Programs like PASTRY may empower nurses to build support networks for change within themselves and institutions. CONCLUSION: This QI initiative shows further research on moral distress reduction should be conducted to verify findings for statistical significance and so that institutional programs, like PASTRY, can be created.

Low-fidelity hybrid sexual assault simulation training's effect on the comfort and competency of resident physicians.

BACKGROUND: Alternative training methods are needed for resident physicians to ensure that care is not compromised should they practice in settings without well-established Sexual Assault Nurse Examiner (SANE) programs. OBJECTIVE: The purpose of this study is to determine the effectiveness of a simulation-based sexual assault response course for resident physicians at an institution without an on-site SANE program. METHODS: Educational intervention study of 12 emergency medicine residents using a low-fidelity hybrid simulation model. The study was comprised of eight male and four female physicians at a military medical center in San Diego, CA. Assessment occurred using three separate metrics. The first was a written knowledge test. The second was a simulated interview and evidentiary examination. These metrics were given 1 month before and 3 months after an 8-h training course. The final metric was Likert-scale questionnaires surveying pre- and post-course feelings of competency and comfort. RESULTS: The emergency medicine residents showed a 13% improvement (95% confidence interval [CI] 7-20%) in written examination scores pre and post intervention. Post-course interview and examinations reflected a 44% improvement (95% CI 24-64%) in critical action completion. Pre-course comfort and competency questionnaires were a median of 2 (interquartile range [IQR] 1-3) on a Likert Scale. Post-course survey responses were a median of 4 (IQR 2-5). CONCLUSIONS: Low-fidelity hybrid simulation is a useful tool to train inexperienced physicians to perform evidentiary examinations and interviews without sacrificing the privacy and direct care of sexual assault victims.

Site and bond-specific dynamics of reactions at the gas-liquid interface.

The dynamics of the interfacial reactions of O((3)P) with the hydrocarbon liquids squalane (C30H62, 2,6,10,15,19,23-hexamethyltetracosane) and squalene (C30H50, trans-2,6,10,15,19,23-hexamethyltetracosa-2,6,10,14,18,22-hexaene) have been studied experimentally. Laser-induced fluorescence (LIF) was used to detect the nascent gas-phase OH products. The O((3)P) atoms are acutely sensitive to the chemical differences of the squalane and squalene surfaces. The larger exothermicity of abstraction from allylic C-H sites in squalene is reflected in markedly hotter OH rotational and vibrational distributions. There is a more modest increase in translational energy release. A larger fraction of the available energy is deposited in the liquid for squalene than for squalane, consistent with a more extensive geometry change on formation of the allylic radical co-product. Although the dominant reaction mechanism is direct, impulsive scattering, there is some evidence for OH being accommodated at both liquid surfaces, resulting in thermalised translation and rotational distributions. Despite the H-abstraction reaction being strongly favoured energetically for squalene, the yield of OH is substantially lower than for squalane. This is very likely due to competitive addition of O((3)P) to the unsaturated sites in squalene, implying that double bonds are extensively exposed at the liquid surface.

Decreasing Premedication for Blood Transfusions: A Quality Improvement Project.

BACKGROUND: Premedication administration to patients who are to receive blood transfusions continues despite evidence of a lack of benefit when given to prevent febrile nonhemolytic or mild allergic transfusion reactions. Reviews of ordering practices and staff surveys on an adult inpatient hematology-oncology unit in our multisite oncology medical center indicated a lack of standardization and overuse of premedication in blood transfusions and a lack of knowledge of when it was appropriate to use premedication. METHODS: A literature search was performed, and the evidence led to a proposal for a quality improvement (QI) project focused on development of an evidence-based algorithm to guide clinicians in when to administer which premedication, development of clear documentation for premedication plans, integration of the documented premedication plans into electronic orders for blood products, and staff education. Interventions included a hospital-wide algorithm and an electronic order to be integrated with a premedication plan for each patient on the adult hematology-oncology unit. RESULTS: Seven months after implementation of the intervention, premedication use among patients decreased by 57.6%, and the transfusion reaction rate decreased from 1% to 0.8%. Staff knowledge as measured by responses to pre- and postintervention surveys on the appropriate use of premedication also improved. CONCLUSION: Evidence-based interventions can reduce the incidence of premedication use in patients receiving blood transfusions.

Inelastic scattering of OH radicals from organic liquids: isolating the thermal desorption channel.

Inelastic scattering of OH radicals from liquid surfaces has been investigated experimentally. An initially translationally and rotationally hot distribution of OH was generated by 193 nm photolysis of allyl alcohol. These radicals were scattered from an inert reference liquid, perfluorinated polyether (PFPE), and from the potentially reactive hydrocarbon liquids squalane (C30H62, 2,6,10,15,19,23-hexamethyltetracosane) and squalene (C30H50, trans-2,6,10,15,19,23-hexamethyltetracosa-2,6,10,14,18,22-hexaene). The scattered OH v = 0 products were detected by laser-induced fluorescence. Strong correlations were observed between the translational and rotational energies of the products. The high-N levels are translationally hot, consistent with a predominantly direct, impulsive scattering mechanism. Impulsive scattering also populates the lower-N levels, but a component of translationally relaxed OH, with thermal-desorption characteristics, can also be seen clearly for all three liquids. More of this translationally and rotationally relaxed OH survives from squalane than from squalene. Realistic molecular dynamics simulations confirm that double-bond sites are accessible at the squalene surface. This supports the proposition that relaxed OH may be lost on squalene via an addition mechanism.

Collision dynamics and reactive uptake of OH radicals at liquid surfaces of atmospheric interest.

The inelastic scattering of OH radicals from the surfaces of a sequence of potentially reactive organic liquids: squalane (C(30)H(62), 2,6,10,15,19,23-hexamethyltetracosane); squalene (C(30)H(50), trans-2,6,10,15,19,23-hexamethyltetracosa-2,6,10,14,18,22-hexaene); and oleic acid (C(18)H(34)O(2), cis-9-octadecanoic acid) was studied experimentally. A liquid long-chain perfluorinated polyether (PFPE, Krytox® 1506) was compared as a chemically inert reference. Gas-phase OH with an average laboratory-frame kinetic energy of 54 kJ mol(-1) was generated by 355-nm photolysis of a low-pressure of HONO a short distance (9 mm) above the liquid surface. Scattered OH was detected at the same distance by laser-induced fluorescence (LIF). Appearance profiles as a function of photolysis-probe delay were recorded for selected OH v' = 0, N' rotational levels. The efficiency of momentum transfer to the surface is least for PFPE and highest for squalane, with squalene and oleic acid intermediate, but in all cases the speed distributions are markedly too hot to be consistent with a thermal accommodation mechanism. The rotational distribution is found to be a function of scattered OH speed. The generally high rotational temperatures implied by the relative fluxes for N' = 1 and 5 were confirmed by LIF excitation spectra at the peak of the profile for each liquid. The trends in translational-to-rotational energy transfer were broadly consistent with the sequence in surface stiffness inferred from the translational inelasticity. The non-statistical distribution of OH fine-structure and Λ-doublet states produced by HONO photolysis appears to be effectively completely scrambled in collisions with the liquid surfaces. With due account taken of the product rotational distributions, and assuming that 100% of the OH scatters from PFPE, the integrated OH survival probabilities were: squalane (0.70 ± 0.08), squalene (0.61 ± 0.07) and oleic acid (0.76 ± 0.10). The 'missing' OH is presumed to have reacted at the liquid surface. Detailed comparison of the appearance profiles suggests that the main difference between squalane and squalene is loss of slower-moving OH, consistent with an additional capture mechanism at the vinyl sites.

Dynamics of the gas-liquid interfacial reaction of O(1D) with a liquid hydrocarbon.

The dynamics of the gas-liquid interfacial reaction of the first electronically excited state of the oxygen atom, O((1)D), with the surface of a liquid hydrocarbon, squalane (C(30)H(62); 2,6,10,15,19,23-hexamethyltetracosane) has been studied experimentally. Translationally hot O((1)D) atoms were generated by 193 nm photolysis of a low pressure (nominally 1 mTorr) of N(2)O a short distance (mean = 6 mm) above a continually refreshed liquid squalane surface. Nascent OH (X(2)Π, v' = 0) reaction products were detected by laser-induced fluorescence (LIF) on the OH A(2)Σ(+)-X(2)Π (1,0) band at the same distance above the surface. The speed distribution of the recoiling OH was characterized by measuring the appearance profiles as a function of photolysis-probe delay for selected rotational levels, N'. The rotational (and, partially, fine-structure) state distributions were also measured by recording LIF excitation spectra at selected photolysis-probe delays. The OH v' = 0 rotational distribution is bimodal and can be empirically decomposed into near thermal (~300 K) and much hotter (~6000 K) Boltzmann-temperature components. There is a strong positive correlation between rotational excitation and translation energy. However, the colder rotational component still represents a significant fraction (~30%) of the fastest products, which have substantially superthermal speeds. We estimate an approximate upper limit of 3% for the quantum yield of OH per O((1)D) atom that collides with the surface. By comparison with established mechanisms for the corresponding reactions in the gas phase, we conclude that the rotationally and translationally hot products are formed via a nonstatistical insertion mechanism. The rotationally cold but translationally hot component is most likely produced by direct abstraction. Secondary collisions at the liquid surface of products of either of the previous two mechanisms are most likely responsible for the rotationally and translationally cold products. We do not think it likely, a priori, that they could be produced in the observed significant yield via a statistical insertion mechanism for a molecule the size of squalane embedded in a surrounding liquid surface.

Siblings' Perceptions of Their ADHD-Diagnosed Sibling's Impact on the Family System.

This qualitative study explored siblings' perceptions of the impact a sibling diagnosed with ADHD has within the family system. Specific focus was placed on the different ways these different sibling cohorts were parented. Participants constituted eight adult females with a mean age of 20 years from different cultural and socio-economic backgrounds in the province of Gauteng, South Africa. Data was collected using semi-structured interviews and was analysed thematically. The four themes that emerged from the interviews include differential parental treatment, rejection, discrepancy with discipline, and the parentified child. Specifically, the results of this study revealed feelings of differential parental treatment and discipline that took place in the home and rejection experienced by the non-ADHD sibling. There was also a common theme of a parentified child, who had to carry a burden of caring for their sibling with ADHD. The non-diagnosed siblings perceive themselves to be particularly negatively impacted. The results are discussed in light of the previous empirical studies, and recommendations are made.

Negative predictive value of acetaminophen concentrations within four hours of ingestion.

OBJECTIVES: The objective was to ascertain whether acetaminophen (APAP) concentrations less than 100 µg/mL obtained between 1 and 4 hours after acute ingestion accurately predict a nontoxic 4-hour concentration. METHODS: The authors performed a multicenter, prospective cohort study involving five emergency departments (EDs) participating in the ToxIC Research Network. Data were collected from May 2009 to December 2011. Patients with APAP concentrations <100 µg/mL drawn between 1 and 4 hours after acute ingestions, and concentrations drawn 4 or more hours after ingestions, were included in the study. Exclusion criteria included initial concentration >100 µg/mL, initial APAP concentration drawn prior to 1 hour, two undetectable APAP concentrations, the second concentration drawn prior to 4 hours, and unknown time of ingestion. Toxic concentrations 4 or more hours after ingestion were defined as concentrations that plotted above the 150 µg/mL line on the Rumack-Matthew nomogram. RESULTS: Data were collected on 83 patients who met inclusion criteria. Of the 83 patients with APAP concentrations <100 µg/mL between 1 and 4 hours, one patient (1.2%) had a ≥ 4-hour toxic concentration. Negative predictive value (NPV) for an APAP concentration <100 µg/mL obtained between 1 and 4 hours after an acute ingestion was 98.8% (95% confidence interval [CI] = 93.5% to 99.8%). CONCLUSIONS: An APAP concentration of <100 µg/mL obtained between 1 and 4 hours after ingestion has a high NPV for excluding toxic ingestion. We do not recommend reliance on concentrations obtained between 1 and 4 hours to exclude toxicity, because of a potential false-negative rate of 6.5%.

Serum progesterone testing to predict ectopic pregnancy in symptomatic first-trimester patients.

STUDY OBJECTIVE: This study was conducted to prospectively measure the accuracy of serum progesterone levels to detect ectopic pregnancy. METHODS: Seven hundred sixteen symptomatic first-trimester emergency department patients with abdominal pain or vaginal bleeding at a tertiary care military teaching hospital had progesterone levels measured by radioimmunoassay with results unavailable to the treating physician. All patients were monitored until a criterion standard diagnosis of intrauterine pregnancy or ectopic pregnancy was confirmed. RESULTS: A 14-month derivation phase (n=399) used receiver operating characteristic curve testing to select a cutoff value of progesterone less than 22 ng/mL. A 12-month validation phase (n=317) then retested this cutoff value. Combining both phases, there were 434 (61%) viable intrauterine pregnancies, 229 (32%) nonviable intrauterine pregnancies, and 52 (7. 3%) ectopic pregnancies, of which 17 were ruptured. Sensitivity, specificity, positive predictive values, and negative predictive values (95% confidence intervals) for progesterone levels less than 22 ng/mL to detect ectopic pregnancy were 100% (94% to 100%), 27% (23% to 30%), 10% (7% to 12%), and 100% (98% to 100%), respectively. CONCLUSION: Given similar disease prevalence, roughly one fourth (178/716) of symptomatic patients can be classified as low risk (0%, 95% confidence interval 0 to 2%) for having an ectopic pregnancy using a progesterone cutoff of 22 ng/mL. Whether implementation of rapid progesterone testing can safely expedite care and reduce the need for urgent diagnostic evaluation or admission remains to be determined.