Assessing dosing errors in legacy and low dose tip ENFit® syringes.

WHAT IS KNOWN AND OBJECTIVE: To avoid misconnections between different medical devices, a unique standardized design of connectors (ENFit® ) for enteral medical devices has been developed. It was expected that the syringes with these connectors will replace the pre-existing syringes, henceforth referred to as legacy syringes. However, the changes in the connector's design led to concerns regarding dosing errors for low volume syringes (≤2 ml). Therefore, novel low dose tip (LDT) syringes were designed to address these concerns. These LDT syringes can connect with the standardized ENFit® male connectors. Only a few studies have investigated dosing errors, and findings have largely been mixed. The objective of this report was to calculate the contributions of unavoidable dosing errors for LDT syringes, compare with legacy syringes and to suggest strategies to optimize dose accuracy for enteral applications. METHODS: Studies performed with a limited number of syringes to date may not reflect the actual diversity of dosing error that can occur across syringe orientations, batches, manufacturers, medications, etc. A computer-aided design software SolidWorks® was used to calculate the dosing errors in 0.5 and 1.0 ml legacy syringe connectors and were compared with dosing errors in LDT syringe connectors with the same nominal volume. Influence of orientation during delivery, spillage and flushing on dosing error was also investigated. RESULTS AND DISCUSSION: For 0.5 and 1.0 ml LDT syringes, in absence of medication in the moat area, the maximum dosing error will be ±5% when delivering 100% of nominal volume, which is also equal to the dosing error in 0.5 and 1.0 ml slip tip legacy syringes. However, with medication present in moat area, and with syringe reused during flushing, the LDT dosing error can range from 1% to 18% and 28% to 35% for 1.0 and 0.5 ml syringes, respectively. The corresponding dosing error for legacy syringes would be when the same syringe is used for flushing or when syringe disengages pointing vertically up. The corresponding dosing errors for legacy syringes could range from -7 to 12% and -9% to 19% for 1.0 and 0.5 ml syringes, respectively. Dosing errors for legacy and LDT syringes increase as the nominal capacity of syringe reduces, or when the dose delivered is lower than the nominal capacity of the syringe. WHAT IS NEW AND CONCLUSION: For LDT syringes, dosing errors can be reduced by clearing the moat area of the syringe and by using a new syringe for flushing post-delivery of medication. For legacy syringes, dosing errors can be minimized by ensuring the female connector points up during disengagement from the syringe post-medication administration, and by using a new syringe for flushing.

Rising Sea Levels: Helping Decision-Makers Confront the Inevitable.

Sea-level rise (SLR) is not just a future trend; it is occurring now in most coastal regions across the globe. It thus impacts not only long-range planning in coastal environments, but also emergency preparedness. Its inevitability and irreversibility on long time scales, in addition to its spatial non-uniformity, uncertain magnitude and timing, and capacity to drive non-stationarity in coastal flooding on planning and engineering timescales, create unique challenges for coastal risk-management decision processes. This review assesses past United States federal efforts to synthesize evolving SLR science in support of coastal risk management. In particular, it outlines the: (1) evolution in global SLR scenarios to those using a risk-based perspective that also considers low-probability but high-consequence outcomes, (2) regionalization of the global scenarios, and (3) use of probabilistic approaches. It also describes efforts to further contextualize regional scenarios by combining local mean sea-level changes with extreme water level projections. Finally, it offers perspectives on key issues relevant to the future uptake, interpretation, and application of sea-level change scenarios in decision-making. These perspectives have utility for efforts to craft standards and guidance for preparedness and resilience measures to reduce the risk of coastal flooding and other impacts related to SLR.

Quality Measures: A Stakeholder Analysis.

For quality measures, confusion and discontentment have increased, as availability of electronic data and data collection tools has expanded. We examined current issues with quality measures across 4 stakeholder groups: developers, regulators/endorsers, data collectors, and consumer advocates. There are missing quality measures, issues with data quality and purpose, questionable usability of electronic health records, and an increased measurement burden and cost. Policymakers, administrators, health care professionals, and consumers need to collaborate on measure development and selection.

Revising the Scope and Standards for Nurse Administrators.

In the fall of 2013, the American Nurses Association began the process of redesigning the scope and standards for the nurse administrator. This article provides a synthesis of the top 10 changes in the new Scope and Standards for Nurse Administrators that are being reviewed for approval. These changes reflect the continuing evolution of practice for nurses serving as leaders across the United States.

Anterior cruciate ligament- specialized post-operative return-to-sports (ACL-SPORTS) training: a randomized control trial.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) is standard practice for athletes that wish to return to high-level activities; however functional outcomes after ACLR are poor. Quadriceps strength weakness, abnormal movement patterns and below normal knee function is reported in the months and years after ACLR. Second ACL injuries are common with even worse outcomes than primary ACLR. Modifiable limb-to-limb asymmetries have been identified in individuals who re-injure after primary ACLR, suggesting a neuromuscular training program is needed to improve post-operative outcomes. Pre-operative perturbation training, a neuromuscular training program, has been successful at improving limb symmetry prior to surgery, though benefits are not lasting after surgery. Implementing perturbation training after surgery may be successful in addressing post-operative deficits that contribute to poor functional outcomes and second ACL injury risk. METHODS/DESIGN: 80 athletes that have undergone a unilateral ACLR and wish to return to level 1 or 2 activities will be recruited for this study and randomized to one of two treatment groups. A standard care group will receive prevention exercises, quadriceps strengthening and agility exercises, while the perturbation group will receive the same exercise program with the addition of perturbation training. The primary outcomes measures will include gait biomechanics, clinical and functional measures, and knee joint loading. Return to sport rates, return to pre-injury level of activity rates, and second injury rates will be secondary measures. DISCUSSION: The results of this ACL-Specialized Post-Operative Return To Sports (ACL-SPORTS) Training program will help clinicians to better determine an effective post-operative treatment program that will improve modifiable impairments that influence outcomes after ACLR. TRIAL REGISTRATION: Randomized Control Trial NIH 5R01AR048212-07. ClinicalTrials.gov: NCT01773317.

Policy implications for optimizing advanced practice registered nurse use nationally.

This article examines the potential benefits of enhanced use of advanced practice registered nurses (APRNs) given health care workforce projections that predict an inadequate supply of certain types of providers. The conclusions of a systematic review comparing the effectiveness of care provided by APRNs with that of physicians alone or teams without APRNs indicate the viability of this approach. Allowing APRNs to assume roles that take full advantage of their educational preparation could mitigate the shortage of primary care physicians and improve care processes. The development of health care policy should be guided by patient-centric evidence rather than how care has been delivered in the past.

The Effect of Burnout on Quality of Care Using Donabedian's Framework.

Donabedian's framework offers a model to evaluate the relationship between patient outcomes, influenced by clinical care delivery structures and processes. Applying this model proposes that adequate and appropriate structures and processes within organizations are necessary to realize optimal outcomes; it is imperative that leadership focuses on those structures and processes to reduce the risk of burnout. Current research cannot determine whether burnout causes decreased quality or working in a setting with decreased quality causes burnout. The follow-up question is whether curtailing burnout will improve quality or whether improving quality of care will reduce provider burnout?

The Influence of Leadership Style and Nurse Empowerment on Burnout.

The levels of burnout nurses experience continue to increase with resultant negative impacts on the nursing work environment, patient outcomes, and the retention of qualified nurses. Nurse leaders are essential in developing and fostering positive work environments that retain an empowered and motivated workforce. Research indicates that positive and relational leadership styles can improve nurses' job satisfaction, organizational commitment, and retention while concurrently reducing emotional exhaustion and burnout.

Factors Associated with Burnout in the United States Versus International Nurses.

Nurse burnout is a serious global problem that is associated with adverse job factors. In this article, research on burnout as measured by the Maslach Burnout Inventory is reviewed from 2000 to 2019, specifically analyzing job factors associated with nurse burnout and comparing US with international findings. Most of the reviewed articles found a significant relationship between nurse burnout and a nurse's intention to leave their job, job stress, nurse satisfaction, and workplace violence. There were very few articles reporting on research done in the United States, whereas most of them described international research. Recommendations on how to decrease the risk of nurse burnout are summarized.

Systematic Review of Burnout in US Nurses.

Nurses experience high levels of burnout, and this has become a major factor in recruitment and retention of nurses. Several factors have been associated with burnout, but it is not clear which factors are the most significant predictors. Understanding the most prevalent factors that are associated with burnout will allow for the development and implementation of interventions to ameliorate and/or reduce burnout in the nursing workforce.

Guiding implementation: frameworks and resources for evidence translation.

In this department, Dr Newhouse highlights hot topics in nursing outcomes, research, and evidence-based practice relevant to the nurse administrator. The goal is to discuss practical implications for nurse leaders in diverse healthcare settings. Content includes evidence-based projects and decision making, identifying measurement tools for quality improvement and safety projects, using outcome measures to evaluate quality, practice implications of administrative research, and exemplars of projects that demonstrate innovative approaches to organizational problems. In this article, the authors discuss the need for knowledge translation to leverage improvements in healthcare quality and describe 3 frameworks that can be used to plan and implement translation of evidence to practice.

Advanced practice nurse outcomes 1990-2008: a systematic review.

Advanced practice registered nurses have assumed an increasing role as providers in the health care system, particularly for underserved populations. The aim of this systematic review was to answer the following question: Compared to other providers (physicians or teams without APRNs) are APRN patient outcomes of care similar? This systematic review of published literature between 1990 and 2008 on care provided by APRNs indicates patient outcomes of care provided by nurse practitioners and certified nurse midwives in collaboration with physicians are similar to and in some ways better than care provided by physicians alone for the populations and in the settings included. Use of clinical nurse specialists in acute care settings can reduce length of stay and cost of care for hospitalized patients. These results extend what is known about APRN outcomes from previous reviews by assessing all types of APRNs over a span of 18 years, using a systematic process with intentionally broad inclusion of outcomes, patient populations, and settings. The results indicate APRNs provide effective and high-quality patient care, have an important role in improving the quality of patient care in the United States, and could help to address concerns about whether care provided by APRNs can safely augment the physician supply to support reform efforts aimed at expanding access to care.

A placebo-controlled trial of atomoxetine in marijuana-dependent individuals with attention deficit hyperactivity disorder.

This study evaluated the effects of atomoxetine on the symptoms of attention deficit hyperactivity disorder (ADHD) and marijuana use in marijuana-dependent adults. In conjunction with motivational interviewing, participants received either atomoxetine (n = 19) or matching placebo (n = 19) for 12 weeks. Participants randomized to atomoxetine had greater improvement in ADHD on the Clinical Global Impression-Improvement scale than participants treated with placebo. No treatment group differences in self-rated ADHD symptoms, overall Wender-Reimherr Adult Attention Deficit Disorder Scale scores, or marijuana use outcomes were noted. These results suggest that atomoxetine may improve some ADHD symptoms but does not reduce marijuana use in this population.

Managing common foot problems in older adults.

Foot problems related to aging or disease processes such as nail fungus or arthritis often go unrecognized and untreated, and can lead to considerable dysfunction. Multiple contributing factors, such as repetitive stress and structural changes in the foot, further compromise function. Effective topical management approaches for xerosis, fissures, hyperkeratotic lesions, and fungal infections can lessen the severity of symptoms. However, when recalcitrant, such as long-standing onychomycosis, prescription medications may be warranted. These medications are not without serious side effects and should be used with caution in older adults. New methods that pose fewer risks, such as film-forming solutions and photodynamic therapy, are emerging to treat skin and toenail infections. Several nonpharmacological and pharmacological treatment approaches are presented in this article.

Endometriosis: An Unusual Cause of Bilateral Pneumothoraces.

A 27-year-old female presented to the emergency department with sudden onset shortness of breath. A diagnosis of bilateral catamenial pneumothoraces was made following chest radiograph. Catamenial pneumothorax is a recurrent spontaneous pneumothorax that occurs in 90% of affected women 24-48 hours after the onset of their menstruation; 30-50% of cases have associated pelvic endometriosis. Symptoms can be as simple as chest pain or as severe as the presentation of this patient who was initially found to be in significant respiratory distress.

Human-centered design strategies in family and staff preparation for neonatal care.

OBJECTIVE: This paper describes human-centered design strategies used to develop solutions for neonatal intensive care unit (NICU) patients, families, and staff in preparation for transition from an open bay (OB) NICU to a single-family room (SFR) NICU. HUMAN-CENTERED DESIGN: Through a series of user group meetings, an interdisciplinary team of NICU families, administrators, providers, nurses, and other care team members (CTMs) collaborated with design professionals to create and carry out their vision for the new NICU. This process, which spanned the design, construction, and transition planning phases of the project, enabled stakeholders at the Medical University of South Carolina in Charleston, South Carolina (USA) to seek solutions for integrating patient and family-centered care into the fabric of its new facility and to redesign the care experience. RESULT: From this work, new opportunities for family and staff engagement emerged. CONCLUSIONS: Continuous end-user involvement led to targeted preparation for neonatal care.

Is the Medicines and Healthcare products Regulator Agency (MHRA) guidance on sodium valproate acceptable to women of childbearing age?

BACKGROUND: The UK Medicines and Healthcare products Regulatory Agency (MHRA) published guidelines restricting the use of sodium valproate in women of childbearing age unless they consented to the pregnancy prevention programme (PPP), receiving counselling by an epilepsy specialist, or meeting exclusion criteria. METHODS: We contacted every woman of childbearing age on valproate for epilepsy in NHS Tayside (122). RESULTS: Seventeen out of 122 (13.9%) responded to the initial invitation to attend, and 25 out of 122 (20.4%) responded to a letter sent to their GP. Twenty-five attended, 21 completed a consent form, seven switched to another drug and three attended to express dissatisfaction with the MHRA guidance. There were 53 patients identified with learning difficulties. Consent was only taken from three patients, with carers declining to sign consent because the patient was not sexually active. CONCLUSION: Our study suggests that patients and carers do not wish to stop valproate or engage in PPP despite being made aware of MHRA guidance.

Keeping It Contemporary: Ensuring Dynamism in an Online Population Health Course.

BACKGROUND: Population health is a dynamic area that nurses must grasp to meet the demands of the evolving health care system. Staying current on public health priorities, health policies, and population health analytic approaches poses a challenge for nurse educators. METHOD: This article describes strategies used by nurse educators in a prelicen-sure population health course for student engagement on contemporary population health issues and highlights opportunities to develop skills and build competencies to lead population health initiatives. RESULTS: Innovations in course content, assignments, and evaluation strategies are useful in training nurses to thrive in health care systems addressing population health. Strategies to remain current on developments in the field promote population health competencies. CONCLUSION: Prelicensure nursing students can attain knowledge and skills in population health to prepare them to lead population health initiatives, analyze population-level data, provide care coordination, support complex patient groups, and optimize the use of research to promote evidence-based care. [J Nurs Educ. 2019;58(1):53-56.].

N-Methyl-N-Nitrosourea (MNU): A positive control chemical for p53+/- mouse carcinogenicity studies.

This study evaluated the effects of a single intraperitoneal injection of N-methyl-N-nitrosourea (MNU) in citrate buffer (pH 4.5) at a dose of 75 mg/kg in thirty male and thirty female p53+/- mice followed by a six-month observation period. Fifteen control mice per sex received a single intraperitoneal injection of citrate buffer. Fifty-six of sixty mice treated with MNU died or were sacrificed before the end of the observation period. Twenty-four males and twenty-seven females treated with MNU developed malignant lymphoma of the thymus; of these, twenty-three males and twenty-seven females had corresponding enlargement or masses in the thymus at necropsy. Lymphoblasts in thymic lymphomas stained positively for mouse CD3 antigen, indicating a T-cell lineage. One control female mouse had malignant lymphoma of the spleen that did not involve the thymus. Nine males and five females treated with MNU had adenomas or adenocarcinomas of the small intestine, whereas no intestinal neoplasms were observed in control mice. These findings support the use of a single dose of MNU as a positive control chemical in six-month p53+/- mouse carcinogenicity studies and suggest that examination of the thymus alone is sufficient to evaluate the validity of the model system.

Educational strategies to develop evidence-based practice mentors.

Basing practice decisions on sound scientific research and best available evidence is an optimal approach for making practice changes. A five-member team of nursing leaders formed an evidence-based practice (EBP) steering committee and developed an EBP model and process. This article describes the educational approaches and the development of mentors used to provide the staff nurse with the necessary knowledge and skills to use EBP successfully.