A Scoping Review of Studies Using Artificial Intelligence Identifying Optimal Practice Patterns for Inpatients With Type 2 Diabetes That Lead to Positive Healthcare Outcomes.

The objective of this scoping review was to survey the literature on the use of AI/ML applications in analyzing inpatient EHR data to identify bundles of care (groupings of interventions). If evidence suggested AI/ML models could determine bundles, the review aimed to explore whether implementing these interventions as bundles reduced practice pattern variance and positively impacted patient care outcomes for inpatients with T2DM. Six databases were searched for articles published from January 1, 2000, to January 1, 2024. Nine studies met criteria and were summarized by aims, outcome measures, clinical or practice implications, AI/ML model types, study variables, and AI/ML model outcomes. A variety of AI/ML models were used. Multiple data sources were leveraged to train the models, resulting in varying impacts on practice patterns and outcomes. Studies included aims across 4 thematic areas to address: therapeutic patterns of care, analysis of treatment pathways and their constraints, dashboard development for clinical decision support, and medication optimization and prescription pattern mining. Multiple disparate data sources (i.e., prescription payment data) were leveraged outside of those traditionally available within EHR databases. Notably missing was the use of holistic multidisciplinary data (i.e., nursing and ancillary) to train AI/ML models. AI/ML can assist in identifying the appropriateness of specific interventions to manage diabetic care and support adherence to efficacious treatment pathways if the appropriate data are incorporated into AI/ML design. Additional data sources beyond the EHR are needed to provide more complete data to develop AI/ML models that effectively discern meaningful clinical patterns. Further study is needed to better address nursing care using AI/ML to support effective inpatient diabetes management.

Mothers' Internet Journeys Through Social, Health Care, and Virtual Systems When Congenital Anomalies Are Diagnosed In Utero.

OBJECTIVE: To examine mothers' internet usage, in conjunction with social, health care, and virtual peer support navigations, when congenital anomalies were diagnosed in utero. DESIGN: Qualitative descriptive, consisting of semistructured interviews. SETTING: Interview data were collected over Zoom; mothers participated from locations of their choosing. PARTICIPANTS: Mothers of neonates discharged postoperatively from NICUs for uterine-diagnosed congenital anomalies. The sample was purposefully recruited from private Facebook groups for parents of children with congenital anomalies. INTERVENTION/MEASUREMENTS: Analysis was done with deductive coding using concepts from the third iteration of the systems engineering initiative for patient safety theory. The a priori codes were health care, social, journey-benefit, journey-risk, task, and technology. RESULTS: Twenty-two mothers signed up for an interview; 12 completed an interview, and 10 did not. The majority (n = 8, 66%) were White, had a bachelor's or graduate degree (n = 7, 58%) and were between 24 and 33 years of age (n = 8, 66%). Nine themes emerged: (a) Providers cautioned searching for diagnosis information but encouraged private Facebook groups for peer support, (b) Mothers' inquiries for their own care are lacking, (c) Search for information while recognizing parent-partner's coping differences, (d) Pace information from friends and family with patience and appreciation, (e) Manage inquiries from friends and family with group sharing, (f) Private Facebook groups provide a means of receiving and giving peer support, (g) Exposure to difficult stories on Facebook is a risk of stress, (h) Select a NICU, learn about their children's diagnoses, participate in virtual peer support, and (i) Device features frame search strategies. CONCLUSION: Mothers reflected on the internet as a burden and a source of support in their health care journeys. The ubiquity of internet access calls for mothers to include in their health care journeys the complexities of managing time spent on the internet.

A virtual dissemination framework to inform and evaluate a neonatal project ECHO (NeoECHO).

AIM: To present the development, implementation and evaluation of a theoretically grounded novel virtual dissemination evaluation (VDE) framework. BACKGROUND: Care of intensive care unit patients requires access to the most up-to-date knowledge and best practices. To address this challenge, we present the development, implementation and evaluation of a theoretically grounded novel VDE framework. This framework is applied to a dissemination strategy, NeoECHO, in neonatal intensive care units. Evidence-based virtual education is implemented to prevent, detect and treat necrotizing enterocolitis in neonates. DESIGN: Research Methodology: Discussion Paper-Methodology. METHODS: The virtual dissemination evaluation framework is a sequential combination of Integration of Integrated-Promoting Action on Research Implementation in Health Services and Moore's Expanded Outcomes frameworks. The framework's conceptual determinants, virtual facilitators and implementation evaluations were operationalized in the NeoECHO dissemination strategy and evaluated for feasibility. The virtual dissemination evaluation framework was conceptually mapped, and operational activities were examined including theoretical constructs drawing on insights of nursing theorists, especially Fawcett's criteria (2005) for frameworks with practical application (significance, internal consistency, parsimony, testability and design fit). The NeoECHO strategy was evaluated for virtual dissemination evaluation adherence, operationalization and feasibility of implementation evaluation. RESULTS: The virtual dissemination evaluation framework meets the criteria for a practical application and demonstrates feasibility for adherence and operationalization consistency. The implementation evaluation was usable in the virtual dissemination of best practices for neonatal care for necrotizing enterocolitis and healthcare providers were actively engaged in using NeoECHO as an implementation strategy. CONCLUSION: This examination of the foundational aspects of the framework underscores the rigour required for generalization of practical application. Effective virtual dissemination of evidence-based practices to hospital units requires structured delivery and evaluation, enabling engaged healthcare providers to actualize education rapidly. The virtual dissemination evaluation frameworks' potential for narrowing the evidence-based practice gap in neonatal care showcases its wider significance and applicability. IMPLICATIONS: Care of neonates in NICUs requires a multidisciplinary approach and necessitates access to the most up-to-date knowledge and best practices. More than traditional dissemination methods are required to bridge the implementation gap. IMPACT: The effective use of the VDE framework can enhance the design, implementation and evaluation of knowledge dissemination, ultimately elevating neonatal care quality. CLINICAL RELEVANCE: This paper introduces the VDE framework, a sequential combination of the iPARIHS and Moore's EO frameworks-as a methodological tool for designing, implementing and evaluating a neonatal strategy (NeoECHO) for virtual dissemination of education in NICUs. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Barriers to Adoption of Tailored Drug-Drug Interaction Clinical Decision Support.

OBJECTIVE: Despite the benefits of the tailored drug-drug interaction (DDI) alerts and the broad dissemination strategy, the uptake of our tailored DDI alert algorithms that are enhanced with patient-specific and context-specific factors has been limited. The goal of the study was to examine barriers and health care system dynamics related to implementing tailored DDI alerts and identify the factors that would drive optimization and improvement of DDI alerts. METHODS: We employed a qualitative research approach, conducting interviews with a participant interview guide framed based on Proctor's taxonomy of implementation outcomes and informed by the Theoretical Domains Framework. Participants included pharmacists with informatics roles within hospitals, chief medical informatics officers, and associate medical informatics directors/officers. Our data analysis was informed by the technique used in grounded theory analysis, and the reporting of open coding results was based on a modified version of the Safety-Related Electronic Health Record Research Reporting Framework. RESULTS: Our analysis generated 15 barriers, and we mapped the interconnections of these barriers, which clustered around three entities (i.e., users, organizations, and technical stakeholders). Our findings revealed that misaligned interests regarding DDI alert performance and misaligned expectations regarding DDI alert optimizations among these entities within health care organizations could result in system inertia in implementing tailored DDI alerts. CONCLUSION: Health care organizations primarily determine the implementation and optimization of DDI alerts, and it is essential to identify and demonstrate value metrics that health care organizations prioritize to enable tailored DDI alert implementation. This could be achieved via a multifaceted approach, such as partnering with health care organizations that have the capacity to adopt tailored DDI alerts and identifying specialists who know users' needs, liaise with organizations and vendors, and facilitate technical stakeholders' work. In the future, researchers can adopt the systematic approach to study tailored DDI implementation problems from other system perspectives (e.g., the vendors' system).

Unintended consequences of the electronic health record and cognitive load in emergency department nurses.

AIM: The study aimed to explore the relationship between the unintended consequences of the electronic health record and cognitive load in emergency department nurses. METHODS: The study utilized a correlational quantitative design with a survey method approach. This study had a 30.4 % response rate for a total of 304 ED nurse participants who were members of a national ED nursing organization. Data analysis included descriptive and correlational measurements of two instruments. RESULTS: In this study, there was a statistically significant, weak negative relationship between CL and UC-EHR in ED nurses, rs (264) = -0.154, p 0.002. Although a significant weak relationship was identified in this study, the study variables, subscales, and demographic data groupings presented moderate-to-strong positive, statistically significant correlations. Descriptive frequency data unveiled EHR stimulated patient safety threats occurring once a week to monthly. CONCLUSIONS: The novelty of this research study provided profound implications for the future of nursing practice, policy, and nursing science. EHR optimization to minimize patient safety risks is recommended with the inclusion of end-users from this study's identified subgroups. The researchers propose a reduction of EHR burden in nursing practice.

Prevalence and Characteristics of Hospital Nurse Leaders' Turnover Intention.

OBJECTIVE: This project aims to identify the prevalence of acute care nurse leader turnover intention and the contributing factors. BACKGROUND: Previous research has identified that nurse leaders often quit around 1 year after stepping into a leadership position. More in-depth investigations of the phenomenon are needed. METHODS: The 2018 National Sample Survey of Registered Nurses data were used in this quantitative, cross-sectional study. The sample of nurse leaders was drawn from survey participants. Characteristics of interest in this study were listed in the survey questionnaire and divided into 5 categories: education, primary nursing employment, race, marital status, and age. RESULTS: A total of 50 273 participants completed the survey. The final sample size of nurse leaders was 1310 based on the eligibility criteria. The characteristics of the nurse leaders with turnover intention were reported in the 5 previously identified categories. Age, federally assisted student loans, and hours worked in a typical week predicted turnover intention. Low dissatisfaction and ability to practice to the full extent of knowledge, education, and training were strongly associated with nurse leader turnover intention. CONCLUSIONS: The study findings contribute to a more in-depth discovery of the causes of nurse leader turnover and future interventional research.

Prediction of GutCheck NEC and Its Relation to Severity of Illness and Measures of Deterioration in Necrotizing Enterocolitis.

BACKGROUND: Necrotizing enterocolitis (NEC) risk has been shown to arise from multiple sources and risk awareness may be supported using bedside tools. PURPOSE: The purpose of this research was to examine the extent to which GutCheck NEC was associated with scores for clinical deterioration, severity of illness, and clinical outcome, and further to examine how scores might improve NEC prediction. METHODS: A retrospective, correlational case-control study with infant data from 3 affiliated neonatal intensive care units was conducted. RESULTS: Of 132 infants (44 cases, 88 controls), most were 28 weeks of gestation at birth and less (74%). Median age at NEC onset was 18 days (range: 6-34 days), with two-thirds diagnosed before 21 days. At 68 hours of life, higher GutCheck NEC scores were associated with NEC requiring surgery or resulting in death (relative risk ratio [RRR] = 1.06, P = .036), associations that persisted at 24 hours prior to diagnosis (RRR = 1.05, P = .046), and at the time of diagnosis (RRR = 1.05, P = .022) but showed no associations for medical NEC. GutCheck NEC scores were significantly correlated with pediatric early warning scores (PEWS) ( r > 0.30; P < .005) and SNAPPE-II scores ( r > 0.44, P < .0001). Increasing numbers of clinical signs and symptoms were positively associated with GutCheck NEC and PEWS at the time of diagnosis ( r = 0.19, P = .026; and r = 0.25, P = .005, respectively). IMPLICATIONS FOR PRACTICE AND RESEARCH: GutCheck NEC provides structure to streamline assessment and communication about NEC risk. Yet, it is not intended to be diagnostic. Research is needed on how GutCheck NEC impacts timely recognition and treatment.

Developing a Preclinical Nurse-Nurse Communication Framework for Clinical Trial Patient-Related Safety Information.

Clinical trial trials have become increasingly complex in their design and implementation. Investigational safety profiles are not easily accessed by clinical nurses and providers when trial participants present for clinical care, such as in emergency or urgent care. Wearable devices are now commonly used as bridging technologies to obtain participant data and house investigational product safety information. Clinical nurse identification and communication of safety information are critical to dissuade adverse events, patient injury, and trial withdrawal, which may occur when clinical care is misaligned to a research protocol. Based on a feasibility study and follow-up wearable device prototype study, this preclinical nurse-nurse communication framework guides clinical nurse verbal and nonverbal communication of safety-related trial information to direct patient care activities in the clinical setting. Communication and information theories are incorporated with Carrington's Nurse-to-Nurse Communication Framework to encompass key components of a clinical nurse's management of a trial participant safety event when a clinical trial wearable device is encountered during initial assessment. Use of the preclinical nurse-nurse communication framework may support clinical nurse awareness of trial-related wearable devices. The framework may further emphasize the importance of engaging with research nurses, patients, and caregivers to acquire trial safety details impacting clinical care decision-making.

Scoping Review of Biological and Behavioral Effects of Babywearing on Mothers and Infants.

OBJECTIVE: To synthesize the evidence on the biological and behavioral effects of babywearing on mothers and infants. DATA SOURCES: We searched PubMed, CINAHL, Embase, PsycINFO, Sociological Abstracts, SCOPUS, and Google Scholar for peer-reviewed, full-text research articles published in English in which researchers reported on the biological or behavioral effects of babywearing on mothers or infants. STUDY SELECTION: We reviewed the titles and abstracts of 200 records and abstracted 80 for full-text review. Of these, 29 studies met the eligibility criteria and were included in the review. DATA EXTRACTION: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) and extracted the following data from the included articles: author(s), year of publication, setting, aim/purpose, design, description, sample, results/outcomes, and implications to practice. DATA SYNTHESIS: We synthesized data from the included studies into the following eight themes: Increased Contact, Responsiveness, and Secure Attachment; Physiologic Effects; Biomechanics and Positioning; Facilitating and Empowering; Comfort; Maternal Benefits; Speech, Vocalizations, and Tempo; and Beliefs and Perceptions About Babywearing. CONCLUSION: Babywearing may have a range of beneficial biological and behavioral effects on mothers and infants. The evidence, however, is insufficient to inform practice recommendations, and additional research is warranted.

Relationship between a risk score for QT interval prolongation and mortality across rural and urban inpatient facilities.

OBJECTIVES: To evaluate the relationship between a modified Tisdale QTc-risk score (QTc-RS) and inpatient mortality and length of stay in a broad inpatient population with an order for a medication with a known risk of torsades de pointes (TdP). BACKGROUND: Managing the risk of TdP is challenging due to the number of medications with known risk of TdP and the complexity of precipitating factors. A model to predict risk of mortality may be useful to guide treatment decisions. METHODS: This was a retrospective observational study using inpatient data from 28 healthcare facilities in the western United States. This risk score ranges from zero to 23 with weights applied to each risk factor based on a previous validation study. Logistic regression and a generalized linear model were performed to assess the relationship between QTc-RS and mortality and length of stay. RESULTS: Between April and December 2020, a QTc-RS was calculated for 92,383 hospitalized patients. Common risk factors were female (55.0%); age > 67 years (32.1%); and receiving a medication with known risk of TdP (24.5%). A total of 2770 (3%) patients died during their hospitalization. Relative to patients with QTc-RS < 7, the odds ratio for mortality was 4.80 (95%CI:4.42-5.21) for patients with QTc-RS = 7-10 and 11.51 (95%CI:10.23-12.94) for those with QTc-RS ≥ 11. Length of hospital stay increased by 0.7 day for every unit increase in the risk score (p < 0.0001). CONCLUSION: There is a strong relationship between increased mortality as well as longer duration of hospitalization with an increasing QTc-RS.

Neonatal Intensive Care Workflow Analysis Informing NEC-Zero Clinical Decision Support Design.

Decision support in neonatal ICUs is needed, especially for prevention and risk awareness of the devastating complication of necrotizing enterocolitis, a major cause of emergency surgery among fragile infants. The purpose of this study was to describe the current clinical workflow and sociotechnical processes among clinicians for necrotizing enterocolitis risk awareness, timely recognition of symptoms, and treatment to inform decision support design. A qualitative descriptive study was conducted. Focus groups were held in two neonatal ICUs (five groups in Unit A and six in Unit B). Transcripts were analyzed using content analysis and compared with field notes. Clinicians (N = 27) included nurses (37%), physicians (30%), neonatal nurse practitioners (19%), and other staff (16%). Workflow processes differed for nurses (who see necrotizing enterocolitis signs and notify providers to order diagnostic tests and treatments) and providers (who receive notification of necrotizing enterocolitis concern and then decide how to act). Clinicians desired (1) a necrotizing enterocolitis-relevant dashboard to support nutrition tracking and necrotizing enterocolitis recognition; (2) features to support decision-making (eg, necrotizing enterocolitis risk and adherence scoring); (3) breast milk tracking and feeding clinical decision support; (4) tools for necrotizing enterocolitis surveillance and quality reporting; and (5) general EHR optimizations to improve user experience.

Clinician Responses to a Clinical Decision Support Advisory for High Risk of Torsades de Pointes.

Background Torsade de pointes (TdP) is a potentially fatal cardiac arrhythmia that is often drug induced. Clinical decision support (CDS) may help minimize TdP risk by guiding decision making in patients at risk. CDS has been shown to decrease prescribing of high-risk medications in patients at risk of TdP, but alerts are often ignored. Other risk-management options can potentially be incorporated in TdP risk CDS. Our goal was to evaluate actions clinicians take in response to a CDS advisory that uses a modified Tisdale QT risk score and presents management options that are easily selected (eg, single click). Methods and Results We implemented an inpatient TdP risk advisory systemwide across a large health care system comprising 30 hospitals. This CDS was programmed to appear when prescribers attempted ordering medications with a known risk of TdP in a patient with a QT risk score ≥12. The CDS displayed patient-specific information and offered relevant management options including canceling offending medications and ordering electrolyte replacement protocols or ECGs. We retrospectively studied the actions clinicians took within the advisory and separated by drug class. During an 8-month period, 7794 TdP risk advisories were issued. Antibiotics were the most frequent trigger of the advisory (n=2578, 33.1%). At least 1 action was taken within the advisory window for 2700 (34.6%) of the advisories. The most frequent action taken was ordering an ECG (n=1584, 20.3%). Incoming medication orders were canceled in 793 (10.2%) of the advisories. The frequency of each action taken varied by drug class (P<0.05 for all actions). Conclusions A modified Tisdale QT risk score-based CDS that offered relevant single-click management options yielded a high action/response rate. Actions taken by clinicians varied depending on the class of the medication that evoked the TdP risk advisory, but the most frequent was ordering an ECG.

QTc Prolongation with the Use of Hydroxychloroquine and Concomitant Arrhythmogenic Medications: A Retrospective Study Using Electronic Health Records Data.

INTRODUCTION: Hydroxychloroquine can induce QT/QTc interval prolongation for some patients; however, little is known about its interactions with other QT-prolonging drugs. OBJECTIVE: The purpose of this retrospective electronic health records study was to evaluate changes in the QTc interval in patients taking hydroxychloroquine with or without concomitant QT-prolonging medications. METHODS: De-identified health records were obtained from the Cerner Health Facts® database. Variables of interest included demographics, diagnoses, clinical procedures, laboratory tests, and medications. Patients were categorized into six cohorts based on exposure to hydroxychloroquine, methotrexate, or sulfasalazine alone, or the combination of any those drugs with any concomitant drug known to prolong the QT interval. Tisdale QTc risk score was calculated for each patient cohort. Two-sample paired t-tests were used to test differences between the mean before and after QTc measurements within each group and ANOVA was used to test for significant differences across the cohort means. RESULTS: A statistically significant increase in QTc interval from the last measurement prior to concomitant exposure of 18.0 ms (95% CI 3.5-32.5; p < 0.05) was found in the hydroxychloroquine monotherapy cohort. QTc changes varied considerably across cohorts, with standard deviations ranging from 40.9 (hydroxychloroquine monotherapy) to 57.8 (hydroxychloroquine + sulfasalazine). There was no difference in QTc measurements among cohorts. The hydroxychloroquine + QTc-prolonging agent cohort had the highest average Tisdale Risk Score compared with those without concomitant exposure (p < 0.05). CONCLUSION: Our analysis of retrospective electronic health records found hydroxychloroquine to be associated with a moderate increase in the QTc interval compared with sulfasalazine or methotrexate. However, the QTc was not significantly increased with concomitant exposure to other drugs known to increase QTc interval.

Overriding Drug-Drug Interaction Alerts in Clinical Decision Support Systems: A Scoping Review.

Ineffective computerized alerts for potential Drug-Drug Interactions (DDI) is a longstanding informatics issue. Prescribing clinicians often ignore or override such alerts due to lack of context and clinical relevance, among various other reasons. In this study, we reveiwed published data on the rate of DDI alert overrides and medications involved in the overrides. We identified 34 eligible studies from sites across Asia, Europe, the United States, and the United Kingdom. The override rate of DDI alerts ranged from 55% to 98%, with more than half of the studies reporting the most common drug pairs or medications involved in acceptance or overriding of alerts. The high prevalance of alert overrides highlights the need for decision support systems that take user, drug, and institutional factors into consideration, as well as actionable metrics to better characterize harm associated with overrides.

Placement disruption of children with disabilities in foster care.

PURPOSE: To investigate and describe available data on children with disabilities in the United States foster care system and examine placement disruptions. DESIGN: This quantitative descriptive study was a secondary data analysis of the Adoption and Foster Care Analysis and Reporting System (AFCARS) and included 680,611 children. METHODS: Descriptive and regression analyses were conducted. FINDINGS: Of 680,611 children in the U.S. foster care system in 2017, 22% had a medical or disability diagnosis, requiring additional or specialized care. Children with disabilities in foster care (CDFC) had a mean of 4.0 disruptions-significantly higher than the mean 2.37 disruptions among those without a disability (p < .001, d = 0.51). CDFC spent an average of 915 days in foster care compared to 514 days for children without a disability (p < .001, d = 0.59). Predictive risk factors for disruptions were increased child age, race (American Indian or Black), and increased foster parent age. Protective factors against disruptions included married foster parents and a child being placed outside of the child's initial state of residence. CONCLUSIONS: CDFC have significantly more disruptions and longer stays in foster care. While risk and protective factors affect all foster children similarly, they have significantly greater effect on foster children with disabilities. PRACTICE IMPLICATIONS: Increased disruptions compound the vulnerability of CDFC as relationships and support systems are broken. Understanding the extent to which childhood disabilities play a role allows school nurses, healthcare providers, and child advocates to better design interventions to improve lifelong health outcomes.

Engaging Parents of Fragile Infants in the Design and Appraisal of Health Literature: An Español Toolkit for Necrotizing Enterocolitis.

WHAT WAS OBSERVED OR INVESTIGATED: The increased morbidity of diverse infants is unacceptable, and methods to reduce necrotizing enterocolitis (NEC) in their communities are needed. This article discusses the importance of the Español toolkit; provides a backstory of how the Español toolkit came about and how it was verified and validated; and concludes with impressions from involving parents in the research process. SUBJECTS AND METHODS: After research evidence was translated from English into Spanish, a cross-sectional exploratory, descriptive, mixed-methods study was conducted, guided by the knowledge translation into practice (Translating Research Into Practice [TRIP]) framework. Twenty bilingual English-Spanish parents of fragile infants evaluated the NEC-Zero Español toolkit from a single neonatal intensive care unit. RESULTS AND CONCLUSIONS: The NEC-Zero Español toolkit was found to be easy-to-use and useful and provided information that can be used to augment information sharing. Having access to health information offers a meaningful way to start a conversation and may even impact positive behaviors such as breastfeeding promotion. To lessen Spanish speakers' linguistic barriers, providing materials in Spanish can help meet their information needs and initiate conversations with healthcare providers. This is particularly important because Hispanic infants are at high risk for NEC.

Clinician Satisfaction With Advanced Clinical Decision Support to Reduce the Risk of Torsades de Pointes.

OBJECTIVES: Clinical decision support (CDS) can potentially help clinicians identify and manage patients who are at risk for torsades de pointes (TdP). However, computer alerts are often ignored and might contribute to alert fatigue. The goals of this project were to create an advanced TdP CDS advisory that presents patient-specific, relevant information, including 1-click management options, and to determine clinician satisfaction with the CDS. METHODS: The advanced TdP CDS was developed and implemented across a health system comprising 29 hospitals. The advisory presents patient-specific information including relevant risk factors, laboratory values, and 1-click options to help manage the condition in high-risk patients. A short electronic survey was created to gather clinician feedback on the advisory. RESULTS: After implementation, an email invitation to complete the anonymous advisory-related survey was sent to 442 clinicians who received the advisory. Among the 38 respondents, feedback was generally positive, with 79% of respondents reporting that the advisory helps them care for their patients and 87% responding that alternative actions for them to consider were clearly specified. However, 46% of respondents indicated the alert appeared too frequently. CONCLUSIONS: Advanced TdP risk CDS that provides relevant, patient-specific information and 1-click management options can be generally viewed favorably by clinicians who receive the advisory.

Exploring Greater Rates of Breastfeeding Among Civilian Military Wives.

OBJECTIVE: To explore factors contributing to the greater rates of breastfeeding initiation and duration among civilian military wives (e.g., legally married to an active-duty spouse) and to determine what might be learned from these factors for intervention design for the broader population of women in the postpartum period. DESIGN: The study was conducted online using a concurrent mixed-methods design. SETTING: National and International U.S. military bases. PARTICIPANTS: The sample consisted of 28 civilian military wives whose ages ranged from 18 to 45 years. INTERVENTIONS/MEASUREMENTS: The Breastfeeding Self-Efficacy Scale-Short Form and semistructured interviews. RESULTS: Breastfeeding self-efficacy was high among civilian military wives. Seven main themes with 16 subthemes emerged from the descriptions of the semistructured interviews. The results of the integrative analysis showed that factors within the military environment influence a sense of community and that there were supportive and pro-breastfeeding health care facilitators (especially lactation consultants). CONCLUSION: Civilian military wives described breastfeeding facilitators who they believed promote their greater rates of breastfeeding initiation and continuation, quantified their high level of breastfeeding self-efficacy, and identified descriptive factors that contributed to both areas, topics that are lacking in the literature among this population.

Evidentiary and theoretical foundations for virtual simulation in nursing education.

Virtual simulation has been used extensively in nursing education since the beginning of the COVID-19 pandemic due to the unavailability of clinical sites. Extant research supports substitution of up to 50% of nursing clinical hours with simulation. However, in many nursing programs virtual simulation is currently substituting more than half of traditional clinical hours, and the knowledge gaps and limitations surrounding virtual simulation exist. The purpose of this paper is to describe the evidentiary and theoretical foundations for virtual simulation. Through examination of adult learning theories, learning styles and Bloom's Revised Taxonomy, recommendations for maximizing the use of virtual simulation in the current clinical learning environment are outlined. Debriefing is a vital component of virtual simulation. Synchronous debriefing with nursing students, faculty, preceptors, and peers provides the opportunity for scaffolding to support students' learning needs and foster reflection and evaluation to mitigate shortcomings of virtual simulation in the current clinical learning environment.

Exploring Internal Facilitators' Experience With NeoECHO to Foster NEC Prevention and Timely Recognition Through the iPARIHS Lens.

BACKGROUND: Necrotizing enterocolitis (NEC) remains a major complication in the neonatal population. Standard practices regarding the care of premature infants and attitudes toward NEC prevention strategies vary across neonatal intensive care units (NICUs). Evidence-based best practice dissemination was presented through the NEC-Zero bundle. To close gaps between evidence and practice, a telehealth-delivered intervention (ie, NeoECHO) was provided to NICUs. PURPOSE: The purpose of this study was to enable adoption of best practice for NEC prevention using NeoECHO through describing the local volunteer unit leaders', or internal facilitators' (IFs'), experiences in participating in NeoECHO and identifying the extent to which the facilitation activities within the NeoECHO experience were consistent with constructs from the integrated Promoting Action on Research Implementation in Health Services (iPARHIS) framework. METHODS: The design of this study was qualitative descriptive. Six IFs were recruited in the Southwest. After 6 NeoECHO sessions, individual interviews were conducted and transcribed verbatim. Content analysis was applied. Codes were informed by the iPARIHS framework. RESULTS: Major themes were (1) Innovation: Quality Improvement Projects, Bundles of Care, and Huddle; (2) Recipient: Reluctant Stakeholders and Technical Modalities; (3) Context: Buy-In, Timing, Resources, Leadership, and Blame; (4) Facilitation: Betterment, Buddy System, Passionate Care, and Empowerment; and (5) Adoption: Continuous Quality Improvement, Evidence-Based Practice, and Honest Discussions. IMPLICATIONS FOR PRACTICE AND RESEARCH: NeoECHO fostered a learning community to share current practices, policies, and strategies for NEC prevention, but the IFs were essential to foster local participation. The long-term impacts of NeoECHO are the focus of current research.Video Abstract available athttps://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.