Quality and Safety in Nursing: Recommendations From a Systematic Review.

ABSTRACT: As a consistent 24-hour presence in hospitals, nurses play a pivotal role in ensuring the quality and safety (Q&S) of patient care. However, a comprehensive review of evidence-based recommendations to guide nursing interventions that enhance the Q&S of patient care is lacking. Therefore, the purpose of our systematic review was to create evidence-based recommendations for the Q&S component of a nursing professional practice model for military hospitals. To accomplish this, a triservice military nursing team used Covidence software to conduct a systematic review of the literature across five databases. Two hundred forty-nine articles met inclusion criteria. From these articles, we created 94 recommendations for practice and identified eight focus areas from the literature: (1) communication; (2) adverse events; (3) leadership; (4) patient experience; (5) quality improvement; (6) safety culture/committees; (7) staffing/workload/work environment; and (8) technology/electronic health record. These findings provide suggestions for implementing Q&S practices that could be adapted to many healthcare delivery systems.

Healthy work environment: A systematic review informing a nursing professional practice model in the US Military Health System.

AIM: The aim of the study was to develop recommendations for creating a healthy work environment based on current literature for nurses working within the US Military Health System (MHS). However, our findings would likely benefit other nursing populations and environments as well. DESIGN: Systematic literature review. DATA SOURCES: We conducted a systematic literature search for articles published between January 2010 until January 2024 from five databases: PubMed, Joanna Briggs, Embase, CINAHL and Scopus. METHODS: Articles were screened, selected and extracted using Covidence software. Article findings were synthesized to create recommendations for the development, implementation and measurement of healthy work environments. RESULTS: Ultimately, a total of 110 articles met the criteria for inclusion in this review. The articles informed 13 recommendations for creating a healthy work environment. The recommendations included ensuring teamwork, mentorship, job satisfaction, supportive leadership, nurse recognition and adequate staffing and resources. Additionally, we identified strategies for implementing and measuring these recommendations. CONCLUSIONS: This thorough systematic review created actionable recommendations for the creation of a healthy work environment. Based on available evidence, implementation of these recommendations could improve nursing work environments. IMPACT: This study identifies methods for implementing and measuring aspects of a healthy work environment. Nurse leaders or others can implement the recommendations provided here to develop healthy work environments in their hospitals, clinics or other facilities where nurses practice. REPORTING METHOD: PRISMA 2020 guidelines. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Evolution of an Instrument: Measuring the Nursing Work Environment: A Scoping Review.

Background and Purpose: The Nursing Work Index (NWI) was developed in the 1980s to measure the nursing work environment (NWE). Instruments descended from the NWI continue to measure the NWE today. The purpose of this review was to identify instruments derived from the NWI, examine how they have been used and revised, and evaluate their ability to capture elements of the current work environment. Methods: A scoping literature review. Results: Forty articles were included. Instruments developed from the NWI have been translated into numerous languages and administered to hundreds of thousands of nurses globally. Conclusions: The study of the NWE remains extensive throughout the world. Future research should examine the factorial structure of instrument adaptions and ensure that items are relevant to contemporary nursing practice.

Recommendations From a Systematic Review of Leadership Development to Support a New Nursing Practice Model.

OBJECTIVE: To develop a new nursing practice model for use within the US military, researchers aimed to create evidence-based recommendations for nursing leadership development based on current literature. BACKGROUND: The role of nursing leadership has many implications, including better nurse and patient outcomes. Therefore, an actionable compilation of recommendations informing how to develop effective nurse leaders could be helpful for current and aspiring nurse leaders. METHODS: Researchers conducted a systematic literature review of 5 databases searching for relevant articles published from 2001 to 2020. RESULTS: Seventy-eight articles were synthesized to develop a list of 5 broad yet actionable recommendations for leadership development. CONCLUSIONS: Leadership development is essential for current and future nurse leaders. The recommendations identified from this review can assist in developing leaders. Leaders can use these recommendations to guide leadership training initiatives, engage in self-development, or begin succession planning.

Modernizing Measure of the Nurse Work Environment.

BACKGROUND: Research has established a relationship between favorable nurse work environments and better nurse, patient, and organizational outcomes. However, the instrument most frequently used to measure the nurse work environment, the Practice Environment Scale of the Nursing Work Index (PES-NWI), has not had its items significantly re-evaluated since the 1980s. OBJECTIVE: We sought to examine the psychometric properties of an updated PES-NWI and create an instrument suitable for further testing and refinement to measure the present-day nurse work environment. Specifically, we sought to establish construct, structural, discriminative, and concurrent validity. For reliability, we desired to establish interrater reliability and internal consistency reliability. METHODS: We administered a modified PES-NWI to a national sample of direct-care hospital nurses (n = 818) in the United States. We then assessed the psychometric properties of the instrument. RESULTS: While the modified PES-NWI displayed adequate validity and reliability properties, further testing and refinement of the instrument is necessary. CONCLUSIONS: With this updated measure of the nurse work environment, researchers and hospital leaders can identify modifiable opportunities for improvement in contemporary hospital nurse work environments which may enhance nurse and patient outcomes.

Uniting Experiments and Big Data to advance ecology and conservation.

Many ecologists increasingly advocate for research frameworks centered on the use of 'big data' to address anthropogenic impacts on ecosystems. Yet, experiments are often considered essential for identifying mechanisms and informing conservation interventions. We highlight the complementarity of these research frameworks and expose largely untapped opportunities for combining them to speed advancements in ecology and conservation. With nascent but increasing application of model integration, we argue that there is an urgent need to unite experimental and big data frameworks throughout the scientific process. Such an integrated framework offers potential for capitalizing on the benefits of both frameworks to gain rapid and reliable answers to ecological challenges.

Using item response theory to develop a shortened practice environment scale of the nursing work index.

The 31-item Practice Environment Scale of the Nursing Work Index (PES-NWI) has been frequently used globally to measure the nurse work environment. However, due to its length and subsequent respondent burden, a more parsimonious version of the PES-NWI may be desirable. Item response theory (IRT) is a statistical technique that assists in decreasing the number of items in an instrument without sacrificing reliability and validity. Two separate samples of nurses in the United States (one called the "internal data source" and the other called "external data source"; sample sizes = 843 and 722, respectively) were analyzed. The internal data source was randomly split into training (n = 531) and validating data sets (n = 312), while a separate whole external data source was used as the final validating data set. Using IRT with training data, we removed nine items; two additional items were removed based on recommendations from a previous study. Confirmatory factor analyses supported the validity of the measurement model with the 20-item of PES-NWI in both internal and external validation data sources. The correlations among subscales between 31- and 20-item versions were high magnitude for five subscales in both validation data sets (τ = 0.84-0.89). Ultimately, we identified a 20-item version of the PES-NWI which demonstrated adequate validity and reliability properties while decreasing data collection burden yet maintaining a similar factor structure to the original instrument. Additional research may be necessary to update the items themselves on the PES-NWI.

Development of a Joint Professional Practice Model for the Total Nursing Force of the United States Military: Describing an Evidence-Based Process Across Multiple Entities.

Professional practice models are a hallmark of professional organizations. Creating a model that can apply across contexts, however, can be a challenge. This article describes the process that a team of nurse leaders and researchers used to create a professional practice model that would serve active-duty and civilian nurses working in military treatment facilities.

Measuring the Work Environment: The Voice of the Staff Nurse.

OBJECTIVE: The aims of this study were to obtain direct care hospital nurse input on the relevance of the Practice Environment Scale of the Nursing Work Index (PES-NWI) and to determine whether additional items are needed to measure the contemporary nursing work environment (NWE). BACKGROUND: Instruments accurately measuring the NWE are essential due to the NWE's association with nurse, patient, and organizational outcomes. However, the most frequently used instrument for measuring the NWE has not been scrutinized by today's practicing direct care nurses to ensure its current relevancy. METHODS: Researchers administered a survey with a modified PES-NWI and open-ended questions to a national sample of direct care hospital nurses. RESULTS: Three items from the PES-NWI may be suitable for removal, and additional items may be added to accurately measure the current NWE. CONCLUSION: Most PES-NWI items remain relevant for modern nursing practice. However, some revisions could enable greater precision in measuring the current NWE.

Findings from the development of a nursing joint professional practice model for the U.S. military.

BACKGROUND: By 2022 the Defense Health Agency became responsible for administration of all military treatment facilities (MTFs), which were previously managed by their respective military services. However, three different service-specific nursing professional practice models currently govern nursing practice in MTFs. PURPOSE: To describe the literature search, review, and synthesis of evidence which informed the JPPM and provide some of the most actionable findings. METHODS: A team of tri-service nurses developed the JPPM by conducting six rigorous systematic reviews to synthesize evidence pertaining to relevant model components. DISCUSSION: A total of 51,360 titles and abstracts were initially screened. Data were extracted from 540 included articles. The team then developed standards for five JPPM components: evidence-based practice, safety and quality, leadership development, healthy work environment, and operational readiness. CONCLUSION: The JPPM is a meaningful framework that will help create a mutual professional identity and shared vision to promote a unified nursing force in U.S. military settings.

Provider Perspectives on Fertility and Fertility Preservation Discussions Among Women With Cystic Fibrosis.

Cystic Fibrosis (CF) is a genetic disorder that primarily impacts the respiratory and gastrointestinal systems. With advances in treatment and medications, the life expectancy of people with CF is continuing to increase with current life expectancy at 47 years of age. Given the increased life expectancy, people with CF are interested in childbearing but may have CF specific fertility issues that should be addressed by their CF healthcare provider. Currently, these conversations are not occurring or are suboptimal. This study aimed to investigate the practices of cystic fibrosis (CF) healthcare providers regarding fertility and fertility preservation (FP) discussions among women with CF. This was a qualitative, descriptive study. Twenty CF healthcare providers were interviewed including nurses, nurse practitioners, social workers, and dieticians among other disciplines. The semi-structured interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis. Four themes emerged from the provider interviews about their fertility and FP discussion practices: (1) Change over Time; (2) CF Team Provides Primary Care including Reproductive Health Care; (3) Patient Support and Advocacy; and (4) Barriers and Facilitators to FP Discussions. The results of this study demonstrate an opportunity for CF healthcare providers to deliver patient-centered care. However, CF providers need to be educated on fertility and FP options. Additionally, there is a need for a more standardized structure of care to address the reproductive health of women with CF. The findings from this study may also be useful to non-CF providers who deliver care to women whose chronic illnesses impact their reproductive health.

Components, Implementation, and Outcomes of a Nursing Professional Practice Model: A Systematic Review.

Nursing professional practice models (PPMs) are known to have beneficial effects on nurse and patient outcomes. Determining what components should be present in a PPM, how to implement a PPM, and evaluating the outcomes associated with a PPM is less certain. Therefore, as part of a larger project to develop a nursing PPM for use within the United States Military Health System, this study aimed to conduct a systematic literature review on nursing PPMs. Specifically, the review sought to investigate components, implementation, and outcomes of PPMs in current literature. A total of 37 articles were included in the review. The literature supported the development of 12 recommendations for creating, implementing, and evaluating a nursing PPM. As health care facilities develop their own PPMs or reassess their current PPMs, findings from this review may assist hospital leadership by providing the most recent evidence on the strategic value of nursing PPMs in contemporary health care.

Transitioning to telehealth during the coronavirus disease 2019 pandemic: Perspectives from partners of women with cystic fibrosis and healthcare providers.

OBJECTIVES: Cystic fibrosis is a chronic, genetic disease that primarily affects the respiratory system. The coronavirus disease 2019 pandemic has altered how people with cystic fibrosis receive healthcare. This paper explores the perceptions of cystic fibrosis healthcare providers and partners of women with cystic fibrosis regarding the use of telehealth in routine cystic fibrosis healthcare in the US. METHODS: As part of a larger study examining fertility counseling for women with cystic fibrosis, we conducted qualitative, semi-structured interviews. Participants included partners of women with cystic fibrosis (n = 20) and cystic fibrosis healthcare providers (n = 20). We completed the interviews before and during the global coronavirus disease 2019 pandemic. We analyzed the data using thematic analysis. RESULTS: When in-person healthcare could not be achieved safely, partners and healthcare providers found new value in telehealth. Three themes emerged: (1) increased connection between healthcare team and family, (2) increased efficiency of healthcare appointments, and (3) improved interdisciplinary collaboration. Partners found that telehealth allowed for more engagement in their significant others' healthcare. Providers reported enhanced efficiency and opportunities for collaboration across specialties that improved healthcare delivery and care coordination. DISCUSSION: Results from this study highlighted the positive value of telehealth. Telehealth presents as a potential alternative to delivering outpatient care for people with chronic illnesses beyond the pandemic.

Tricolored bats at a southern range edge exhibit partial migration northward in autumn.

BACKGROUND: Animal migration is a widespread global adaptation by which individuals move in response to environmental conditions to reach more favorable conditions. For bats in temperate climates, migration and hibernation are often associated with each other when these bats must migrate to reach suitable overwintering sites. However, differences in movement across the geographical range of a species and the degree to which hibernation drives migratory behavior of bats in subtropical climates, where conditions may remain warm with available prey year-round, remains incomplete. Understanding the migratory strategies of subtropical bats during winter is of increasing importance as they are threatened by stressors such as disease and environmental change. METHODS: We evaluated migration patterns of tricolored bats (Perimyotis subflavus) in Florida, USA, through analysis of stable hydrogen isotope ratios of the fur. We inferred the summer geographic origins of the fur samples and estimated the minimum distance and likely direction traveled by hibernating individuals. We used linear models to examine whether hibernation region, colony size, and an individual's sex affected the distance traveled. RESULTS: We sampled 111 bats hibernating at 40 sites and found that more than half (54.1%) of individuals were residents of the area in which they hibernated. We found that almost half of the sampled bats (43.2%) traveled from southern Florida to overwinter in North Florida. We also documented three individuals that traveled > 100 km from northerly origins, one of which had traveled an estimated minimum distance of 1382 km. We also found that tricolored bats moved farther to reach hibernacula in Northwest Florida and hibernacula with more populous colonies, with no difference in movement between sexes. CONCLUSIONS: Our results indicate a pattern of northward autumnal movements of tricolored bats in the subtropical southeastern portion of their range. We suggest that bats are differentially constrained at the edge of their geographical range, resulting in movement contrary to what is expected. Even though we found that few (2.7%) bats moved into Florida from farther north, those migrants can potentially transfer the fungus that causes the deadly white-nose syndrome, which does not currently occur in the state. Our results support the characterization of tricolored bats as flexible partial migrators, with a rarely exercised capacity for long-distance movements.

Performance of 5-Strand Hamstring Autograft Anterior Cruciate Ligament Reconstruction in the STABILITY Study: A Subgroup Analysis.

BACKGROUND: Anterior cruciate ligament (ACL) reconstructions (ACLRs) with graft diameters <8mm have been shown to have higher revision rates. The 5-strand (5S) hamstring autograft configuration is a proposed option to increase graft diameter. PURPOSE: To investigate the differences in clinical outcomes between 4-strand (4S) and 5S hamstring autografts for ACLR in patients who underwent ACLR alone or concomitantly with a lateral extra-articular tenodesis (LET) procedure. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Data from the STABILITY study were analyzed to compare a subgroup of patients undergoing ACLR alone or with a concomitant LET procedure (ACLR + LET) with a minimum graft diameter of 8mm that had either a 4S or 5S hamstring autograft configuration. The primary outcome was clinical failure, a composite of rotatory laxity and/or graft failure. The secondary outcome measures consisted of 2 patient-reported outcome scores (PROs)-namely, the ACL Quality of Life Questionnaire (ACL-QoL) and the International Knee Documentation Committee (IKDC) score at 24 months postoperatively. RESULTS: Of the 618 patients randomized in the STABILITY study, 399 (228 male; 57%) fit the inclusion criteria for this study. Of these, 191 and 208 patients underwent 4S and 5S configurations of hamstring ACLR, respectively, with a minimum graft diameter of 8mm. Both groups had similar characteristics other than differences in anthropometric factors-namely, sex, height, and weight, and Beighton scores. The primary outcomes revealed no difference between the 2 groups in rotatory stability (odds ratio [OR], 1.19; 95% CI, 0.77-1.84; P = .42) or graft failure (OR, 1.13; 95% CI, 0.51-2.50; P = .76). There was no significant difference between the groups in Lachman (P = .46) and pivot-shift (P = .53) test results at 24 months postoperatively. The secondary outcomes revealed no differences in the ACL-QoL (P = .67) and IKDC (P = .83) scores between the 2 subgroups. CONCLUSION: At the 24-month follow-up, there were no significant differences in clinical failure rates and PROs in an analysis of patients with 4S and 5S hamstring autografts of ≥8mm diameter for ACLR or ACLR + LET. The 5S hamstring graft configuration is a viable option to produce larger-diameter ACL grafts.

Pediatric Ventilation Liberation: A Survey of International Practice Among 555 Pediatric Intensivists.

Pediatric ventilation liberation has limited evidence, likely resulting in wide practice variation. To inform future work, practice patterns must first be described. OBJECTIVES: Describe international pediatric ventilation liberation practices and regional practice variation. DESIGN SETTING AND PARTICIPANTS: International cross-sectional electronic survey. Nontrainee pediatric medical and cardiac critical care physicians. MAIN OUTCOMES AND MEASURES: Practices focusing on spontaneous breathing trial (SBT) eligibility, SBT practice, non-SBT extubation readiness bundle elements, and post-extubation respiratory support. RESULTS: Five-hundred fifty-five responses representing 47 countries were analyzed. Most respondents reported weaning followed by an SBT (86.4%). The top SBT eligibility variables reported were positive end-expiratory pressure (95%), Fio2 (93.4%), and peak inspiratory pressure (73.9%). Most reported use of standardized pressure support regardless of endotracheal tube size (40.4%) with +10 cm H2O predominating (38.6%). SBT durations included less than or equal to 30 minutes (34.8%), 31 minutes to 1 hour (39.3%), and greater than 1 hours (26%). In assigning an SBT result, top variables were respiratory rate (94%), oxygen saturation (89.3%), and subjective work of breathing (79.8%). Most reported frequent consideration of endotracheal secretion burden (81.3%), standardized pain/sedation measurement (72.8%), fluid balance (83%), and the endotracheal air leak test as a part of extubation readiness bundles. Most reported using planned high flow nasal cannula in less than or equal to 50% of extubations (83.2%). Top subpopulations supported with planned HFNC were those with chronic lung disease (67.3%), exposed to invasive ventilation greater than 14 days (66.6%), and chronic critical illness (44.9%). Most reported using planned noninvasive ventilation (NIV) following less than or equal to 20% of extubations (79.9%). Top subpopulations supported with planned NIV were those with neuromuscular disease (72.8%), chronic lung disease (66.7%), and chronic NIV use for any reason (61.6%). Regional variation was high for most practices studied. CONCLUSION AND RELEVANCE: International pediatric ventilation liberation practices are heterogeneous. Future study is needed to address key evidence gaps. Many practice differences were associated with respondent region, which must be considered in international study design.

Ventilation Liberation Practices Among 380 International PICUs.

1) Characterize the prevalence of ventilator liberation protocol use in international PICUs, 2) identify the most commonly used protocol elements, and 3) estimate an international extubation failure rate and use of postextubation noninvasive respiratory support modes. DESIGN: International cross-sectional study. SUBJECTS: Nontrainee pediatric medical and cardiac critical care physicians. SETTING: Electronic survey. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Responses represented 380 unique PICUs from 47 different countries. Protocols for Spontaneous Breathing Trial (SBT) practice (50%) and endotracheal tube cuff management (55.8%) were the only protocols used by greater than or equal to 50% of PICUs. Among PICUs screening for SBT eligibility, physicians were most commonly screened (62.7%) with daily frequency (64.2%). Among those with an SBT practice protocol, SBTs were most commonly performed by respiratory therapists/physiotherapists (49.2%) and least commonly by nurses (4.9%). Postextubation respiratory support protocols were not prevalent (28.7%). International practice variation was significant for most practices surveyed. The estimated median international extubation failure was 5% (interquartile range, 2.3-10%). A majority of respondents self-reported use of planned high-flow nasal cannula in less than or equal to 50% (84.2%) and planned noninvasive ventilation in less than or equal to 20% of extubations (81.6%). CONCLUSIONS: Variability in international pediatric ventilation liberation practice is high, and prevalence of protocol implementation is generally low. There is a need to better understand elements that drive clinical outcomes and opportunity to work on standardizing pediatric ventilation liberation practices worldwide.

White-Nose Syndrome Pathogen Pseudogymnoascus destructans Detected in Migratory Tree-Roosting Bats.

White-nose syndrome (WNS) is an emerging fungal epizootic disease that has caused large-scale mortality in several species of North American bats. The fungus that causes WNS, Pseudogymnoascus destructans (Pd), has also been detected in bat species without diagnostic signs of WNS. Although these species could play a role in WNS spread, understanding of the spatial and temporal extents of Pd occurrence on WNS-resistant species is limited. This study evaluated the presence of Pd on 272 individuals of three species of migratory tree-roosting bats: hoary (Lasiurus cinereus), eastern red (Lasiurus borealis), and silver-haired (Lasionycteris noctivagans) bats, obtained opportunistically during summer and autumn from throughout much of their ranges in North America. We also compared tissue sampling protocols (i.e., tissue swabbing, fur swabbing, and DNA extraction of excised wing tissue). We detected Pd on three eastern red bats from Illinois and Ohio, US, one silver-haired bat from West Virginia, US, and one hoary bat from New York, US, all via DNA extracted from wing tissue of carcasses. These results document the first publicly reported detections of Pd on a hoary bat and on migratory bats during the autumn migratory period, and demonstrate the potential for using carcasses salvaged at wind-energy facilities to monitor for Pd.

Paths to Motherhood for Women with Cystic Fibrosis.

PURPOSE: Cystic fibrosis (CF) is no longer a disease limited to childhood. With medical advancements, many of those with CF live into adulthood and have similar life goals as their non-CF peers. Most women with CF want to become mothers. However, available options and the related decision-making process is not well understood. The purpose of this study was to explore the decision-making framework of women with CF to better understand the factors they consider when deciding on a path to motherhood. STUDY DESIGN AND METHODS: Qualitative interviews were performed using a grounded theory approach. Inclusion criteria were women with CF who became mothers through biological pregnancy, adoption, or gestational surrogacy. Results: Twenty-five mothers with CF were interviewed. A distinct decision-making process was identified through which women started with a desire for motherhood, assessed several factors, then eventually took the path they felt was right for them and their family. CLINICAL IMPLICATIONS: Our findings provide women with CF a framework that other women with CF have used to assist in making decisions about their reproductive options. Conversations about family planning should occur early and regularly between women with CF and their health care providers. The decision-making process to achieve motherhood for women with a chronic illness, such as CF, includes consideration of unique factors that should be included in clinical conversations.

Predictors of Graft Failure in Young Active Patients Undergoing Hamstring Autograft Anterior Cruciate Ligament Reconstruction With or Without a Lateral Extra-articular Tenodesis: The Stability Experience.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction (ACLR) has higher failure rates in young active patients returning to sports as compared with older, less active individuals. Augmentation of ACLR with an anterolateral procedure has been shown to reduce failure rates; however, indications for this procedure have yet to be clearly defined. PURPOSE/HYPOTHESIS: The purpose of this study was to identify predictors of ACL graft failure in high-risk patients and determine key indications for when hamstring ACLR should be augmented by a lateral extra-articular tenodesis (LET). We hypothesized that different preoperative characteristics and surgical variables may be associated with graft failure characterized by asymmetric pivot shift and graft rupture. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Data were obtained from the Stability 1 Study, a multicenter randomized controlled trial of young active patients undergoing autologous hamstring ACLR with or without a LET. We performed 2 multivariable logistic regression analyses, with asymmetric pivot shift and graft rupture as the dependent variables. The following were included as predictors: LET, age, sex, graft diameter, tear chronicity, preoperative high-grade knee laxity, preoperative hyperextension on the contralateral side, medial meniscal repair/excision, lateral meniscal repair/excision, posterior tibial slope angle, and return-to-sports exposure time and level. RESULTS: Of the 618 patients in the Stability 1 Study, 568 with a mean age of 18.8 years (292 female; 51.4%) were included in this analysis. Asymmetric pivot shift occurred in 152 (26.8%) and graft rupture in 43 (7.6%). The addition of a LET (odds ratio [OR], 0.56; 95% CI, 0.37-0.83) and increased graft diameter (OR, 0.62; 95% CI, 0.44-0.87) were significantly associated with lower odds of asymmetric pivot shift. The addition of a LET (OR, 0.40; 95% CI, 0.18-0.91) and older age (OR, 0.83; 95% CI, 0.72-0.96) significantly reduced the odds of graft rupture, while greater tibial slope (OR, 1.15; 95% CI, 1.01-1.32), preoperative high-grade knee laxity (OR, 3.27; 95% CI, 1.45-7.41), and greater exposure time to sport (ie, earlier return to sport) (OR, 1.18; 95% CI, 1.08-1.29) were significantly associated with greater odds of rupture. CONCLUSION: The addition of a LET and larger graft diameter were significantly associated with reduced odds of asymmetric pivot shift. Adding a LET was protective of graft rupture, while younger age, greater posterior tibial slope, high-grade knee laxity, and earlier return to sport were associated with increased odds of graft rupture. Orthopaedic surgeons should consider supplementing hamstring autograft ACLR with a LET in young active patients with morphological characteristics that make them at high risk of reinjury.