Code Critical: Improving Care Delivery for Critically Ill Patients in the Emergency Department.

PROBLEM: Although certain critically ill patients in emergency departments-such as those experiencing trauma, stroke, and myocardial infarction-often receive care through coordinated team responses, resource allocation and care delivery can vary widely for other high-acuity patients. The absence of a well-defined response process for these patients may result in delays in care, suboptimal outcomes, and staff dissatisfaction. The purpose of this quality improvement project was to develop, implement, and evaluate an ED-specific alert team response for critically ill medical adult and pediatric patients not meeting criteria for other medical alerts. METHODS: Lean (Lean Enterprise Institute, Boston, MA) principles and processes were used to develop, implement, and evaluate an ED-specific response team and process for critically ill medical patients. Approximately 300 emergency nurses, providers, technicians, unit secretaries/nursing assistants, and ancillary team members were trained on the code critical process. Turnaround and throughput data was collected during the first 12 weeks of code critical activations (n = 153) and compared with historical controls (n = 168). RESULTS: After implementing the code critical process, the door-to-provider time decreased by 62%, door to laboratory draw by 76%, door-to-diagnostic imaging by 46%, and door-to-admission by 19%. A year later, data comparison demonstrated sustained improvement in all measures. DISCUSSION: Emergency nurses and providers see the value of coordinated team response in the delivery of patient care. Team responses to critical medical alerts can improve care delivery substantially and sustainably.

Improving the quality of primary care for adults with intellectual and developmental disabilities: Value of the periodic health examination.

OBJECTIVE: To implement a Health Check protocol for patients with intellectual and developmental disabilities (IDD) and assess outcomes. DESIGN: Retrospective chart review and staff survey. SETTING: Two Ontario family health teams. PARTICIPANTS: Of 276 patients with IDD identified, 139 received the Health Check (Health Check group). A convenience sample (N = 147) of clinical staff participated in the survey. MAIN OUTCOME MEASURES: The protocol included patient identification, invitation, and modified health examination. Chart review assessed completion of 8 preventive maneuvers, and clinical staff were surveyed on their comfort, knowledge, and skills in care of patients with IDD. Logistic regression analyses were used to compare outcomes for the Health Check and non-Health Check groups, adjusted for practice site. RESULTS: Documentation of blood pressure, weight, body mass index, and influenza vaccination was significantly higher (P < .001) in the Health Check group, exceeding 70% of patients. Screening rates were higher for mammograms (63% vs 54%), fecal occult blood testing (39% vs 23%), and diabetes testing (80% vs 61%), but not significantly so, and they were similar to general population rates. Papanicolaou test rates were low for both groups (34% vs 32%). Staff comfort and skills were rated significantly higher (P < .05) for those who performed the Health Check. Still, fewer than half thought they had the necessary skills and resources to care for patients with IDD. CONCLUSION: Performing the Health Check was associated with improved preventive care and staff experience. Wider implementation and evaluation is needed, along with protocol adjustments to provide more support to staff for this work.

Diving Into Blunt Aortic Injury: A Case Review.

Although many advances in trauma care have occurred, traumatic aortic injuries remain a leading cause of death in trauma patients. For those who survive long enough to receive treatment, rapid identification of injuries, surgical intervention, and definitive care are critical. Assessment findings and diagnostic imaging are both necessary to rapidly identify aortic injury and select the proper intervention. Surgical options are now available that, for the appropriate patient with aortic injury, can eliminate the need for invasive surgery, decrease complications, and decrease recovery time.

Teratogenic risk and contraceptive counselling in psychiatric practice: analysis of anticonvulsant therapy.

BACKGROUND: Anticonvulsants have been used to manage psychiatric conditions for over 50 years. It is recognised that some, particularly valproate, carbamazepine and lamotrigine, are human teratogens, while others including topiramate require further investigation. We aimed to appraise the documentation of this risk by psychiatrists and review discussion around contraceptive issues. METHODS: A retrospective review of prescribing patterns of four anticonvulsants (valproate, carbamazepine, lamotrigine and topiramate) in women of child bearing age was undertaken. Documented evidence of discussion surrounding teratogenicity and contraceptive issues was sought. RESULTS: Valproate was most commonly prescribed (n=67). Evidence of teratogenic risk counselling at medication initiation was sub-optimal--40% of individuals prescribed carbamazepine and 22% of valproate. Documentation surrounding contraceptive issues was also low- 17% of individuals prescribed carbamazepine and 13% of valproate. CONCLUSION: We found both low rates of teratogenic risk counselling and low rates of contraception advice in our cohort. Given the high rates of unplanned pregnancies combined with the relatively high risk of major congenital malformations, it is essential that a detailed appraisal of the risks and benefits associated with anticonvulsant medication occurs and is documented within patients' psychiatric notes.

Critical role of TRAF3 in the Toll-like receptor-dependent and -independent antiviral response.

Type I interferon (IFN) production is a critical component of the innate defence against viral infections. Viral products induce strong type I IFN responses through the activation of Toll-like receptors (TLRs) and intracellular cytoplasmic receptors such as protein kinase R (PKR). Here we demonstrate that cells lacking TRAF3, a member of the TNF receptor-associated factor family, are defective in type I IFN responses activated by several different TLRs. Furthermore, we show that TRAF3 associates with the TLR adaptors TRIF and IRAK1, as well as downstream IRF3/7 kinases TBK1 and IKK-epsilon, suggesting that TRAF3 serves as a critical link between TLR adaptors and downstream regulatory kinases important for IRF activation. In addition to TLR stimulation, we also show that TRAF3-deficient fibroblasts are defective in their type I IFN response to direct infection with vesicular stomatitis virus, indicating that TRAF3 is also an important component of TLR-independent viral recognition pathways. Our data demonstrate that TRAF3 is a major regulator of type I IFN production and the innate antiviral response.

Differential requirement for TANK-binding kinase-1 in type I interferon responses to toll-like receptor activation and viral infection.

TANK-binding kinase-1 (TBK1) and the inducible IkappaB kinase (IKK-i) have been shown recently to activate interferon (IFN) regulatory factor-3 (IRF3), the primary transcription factor regulating induction of type I IFNs. Here, we have compared the role and specificity of TBK1 in the type I IFN response to lipopolysaccharide (LPS), polyI:C, and viral challenge by examining IRF3 nuclear translocation, signal transducer and activator of transcription 1 phosphorylation, and induction of IFN-regulated genes. The LPS and polyI:C-induced IFN responses were abolished and delayed, respectively, in macrophages from mice with a targeted disruption of the TBK1 gene. When challenged with Sendai virus, the IFN response was normal in TBK1(-/-) macrophages, but defective in TBK1(-/-) embryonic fibroblasts. Although both TBK1 and IKK-i are expressed in macrophages, only TBK1 but not IKK-i was detected in embryonic fibroblasts by Northern blotting analysis. Furthermore, the IFN response in TBK1(-/-) embryonic fibroblasts can be restored by reconstitution with wild-type IKK-i but not a mutant IKK-i lacking kinase activity. Thus, our studies suggest that TBK1 plays an important role in the Toll-like receptor-mediated IFN response and is redundant with IKK-i in the response of certain cell types to viral infection.

Type I interferon production enhances susceptibility to Listeria monocytogenes infection.

Numerous bacterial products such as lipopolysaccharide potently induce type I interferons (IFNs); however, the contribution of this innate response to host defense against bacterial infection remains unclear. Although mice deficient in either IFN regulatory factor (IRF)3 or the type I IFN receptor (IFNAR)1 are highly susceptible to viral infection, we show that these mice exhibit a profound resistance to infection caused by the Gram-positive intracellular bacterium Listeria monocytogenes compared with wild-type controls. Furthermore, this enhanced bacterial clearance is accompanied by a block in L. monocytogenes-induced splenic apoptosis in IRF3- and IFNAR1-deficient mice. Thus, our results highlight the disparate roles of type I IFNs during bacterial versus viral infections and stress the importance of proper IFN modulation in host defense.

Direct laser writing of volumetric gradient index lenses and waveguides.

Direct laser writing (DLW) has been shown to render 3D polymeric optical components, including lenses, beam expanders, and mirrors, with submicrometer precision. However, these printed structures are limited to the refractive index and dispersive properties of the photopolymer. Here, we present the subsurface controllable refractive index via beam exposure (SCRIBE) method, a lithographic approach that enables the tuning of the refractive index over a range of greater than 0.3 by performing DLW inside photoresist-filled nanoporous silicon and silica scaffolds. Adjusting the laser exposure during printing enables 3D submicron control of the polymer infilling and thus the refractive index and chromatic dispersion. Combining SCRIBE's unprecedented index range and 3D writing accuracy has realized the world's smallest (15 µm diameter) spherical Luneburg lens operating at visible wavelengths. SCRIBE's ability to tune the chromatic dispersion alongside the refractive index was leveraged to render achromatic doublets in a single printing step, eliminating the need for multiple photoresins and writing sequences. SCRIBE also has the potential to form multicomponent optics by cascading optical elements within a scaffold. As a demonstration, stacked focusing structures that generate photonic nanojets were fabricated inside porous silicon. Finally, an all-pass ring resonator was coupled to a subsurface 3D waveguide. The measured quality factor of 4600 at 1550 nm suggests the possibility of compact photonic systems with optical interconnects that traverse multiple planes. SCRIBE is uniquely suited for constructing such photonic integrated circuits due to its ability to integrate multiple optical components, including lenses and waveguides, without additional printed supports.

Child abuse in the eyes of the beholder: lay perceptions of child sexual and physical abuse.

OBJECTIVE: The purpose was to explore the effects of victim and perpetrator gender, type of abuse, and victim-perpetrator relationship on university students' and non-students' perceptions of different kinds of child abuse. METHOD: One hundred and ninety-nine participants (including university students and non-student adults) evaluated each of 24 vignettes (within-subjects design) describing an abusive interaction between a child and an adult. The following four variables were manipulated: the victim's gender, the perpetrator's gender, the type of abuse (physical, relatively mild sexual, or relatively severe sexual), and the perpetrator's relationship to the victim (parent or babysitter). Participants rated each vignette on a number of dimensions: degree of trauma and severity, likelihood of general occurrence and reoccurrence, victim believability, and "repressibility" of the event. RESULTS: Significant interactions emerged on each dimension. For example, sexual abuse (whether mild or severe) was rated as being more traumatic and severe if perpetrated by a parent, but relationship type did not affect perceptions of physical abuse. In addition, significant perpetrator gender by victim gender interactions indicated that homosexual abuse was perceived as more traumatic and repressible than heterosexual abuse, but as less likely to occur; and male participants tended to be more affected by the gender of the perpetrator and abuse type than female participants. CONCLUSION: The results suggest that people have stereotypes about the circumstances and consequences of child abuse. These stereotypes are often, though not always, consistent with existing empirical findings.

Retrospective assessment of childhood sexual and physical abuse: a comparison of scaled and behaviorally specific approaches.

This study compared retrospective reports of childhood sexual and physical abuse as assessed by two measures: the Childhood Trauma Questionnaire (CTQ), which uses a Likert-type scaling approach, and the Computer Assisted Maltreatment Inventory (CAMI), which employs a behaviorally specific means of assessment. Participants included 1,195 undergraduate students recruited from three geographically diverse universities. Agreement was high across the two measures in the classification of victim status (92% and 80% for sexual and physical abuse, respectively). However, the CTQ classified more participants as sexually abused than did the CAMI, whereas the opposite trend was found for physical abuse. For child physical abuse, many participants reporting abusive acts on the CAMI scored below the cut-point for physical abuse on the CTQ. Classification differences for both types of abuse were largely unrelated to demographic factors, socially desirable responding, or self-reported withholding of information. The implications of these results are discussed in light of future research using retrospective methods of assessing childhood abuse.

Evaluating the Implementation of Health Checks for Adults With Intellectual and Developmental Disabilities in Primary Care: The Importance of Organizational Context.

Compared to other adults, those with intellectual and developmental disabilities have more health issues, yet are less likely to receive preventative care. One strategy that has shown success in increasing prevention activities and early detection of illness is the periodic comprehensive health assessment (the health check). Effectively moving evidence into practice is a complex process that often receives inadequate attention. This qualitative study evaluates the implementation of the health check at two primary-care clinics in Ontario, Canada, and the influence of the clinic context on implementation decisions. Each clinic implemented the same core components; however, due to contextual differences, some components were operationalized differently. Adapting to the setting context is important to ensuring successful and sustainable implementation.