Onboarding advanced practice nurses: development of an orientation program in a cardiac center.

The advanced practice nurse (APN) is critical to continuity of patient care, particularly in an innovative and research-intensive environment. The intensity of the environment, steep learning curve, and lack of a structured orientation can lead to difficulties in role assimilation and feelings of disconnectedness. This led the authors to undertake an improvement project to develop an onboarding program for APNs and develop strategies to orient them to their role. The authors describe the program and discuss how it was perceived by the APNs. Program evaluation and suggestions for future nursing research are identified.

A large multicenter outcome study of female genital plastic surgery.

INTRODUCTION: Female Genital Plastic Surgery, a relatively new entry in the field of Cosmetic and Plastic Surgery, has promised sexual enhancement and functional and cosmetic improvement for women. Are the vulvovaginal aesthetic procedures of Labiaplasty, Vaginoplasty/Perineoplasty ("Vaginal Rejuvenation") and Clitoral Hood Reduction effective, and do they deliver on that promise? For what reason do women seek these procedures? What complications are evident, and what effects are noted regarding sexual function for women and their partners? Who should be performing these procedures, what training should they have, and what are the ethical considerations? AIM: This study was designed to produce objective, utilizable outcome data regarding FGPS. MAIN OUTCOME MEASURES: 1) Reasons for considering surgery from both patient's and physician's perspective; 2) Pre-operative sexual functioning per procedure; 3) Overall patient satisfaction per procedure; 4) Effect of procedure on patient's sexual enjoyment, per procedure; 5) Patient's perception of effect on her partner's sexual enjoyment, per procedure; 6) Complications. METHODS: This cross-sectional study, including 258 women and encompassing 341 separate procedures, comes from a group of twelve gynecologists, gynecologic urologists and plastic surgeons from ten centers in eight states nationwide. 104 labiaplasties, 24 clitoral hood reductions, 49 combined labiaplasty/clitoral hood reductions, 47 vaginoplasties and/or perineoplasties, and 34 combined labiaplasty and/or reduction of the clitoral hood plus vaginoplasty/perineoplasty procedures were studied retrospectively, analyzing both patient's and physician's perception of surgical rationale, pre-operative sexual function and several outcome criteria. RESULTS: Combining the three groups, 91.6% of patients were satisfied with the results of their surgery after a 6-42 month follow-up. Significant subjective enhancement in sexual functioning for both women and their sexual partners was noted (p = 0.0078), especially in patients undergoing vaginal tightening/perineal support procedures. Complications were acceptable and not of major consequence. CONCLUSIONS: While emphasizing that these female genital plastic procedures are not performed to correct "abnormalities," as there is a wide range of normality in the external and internal female genitalia, both parous and nulliparous, many women chose to modify their vulvas and vaginas. From the results of this large study pooling data from a diverse group of experienced genital plastic surgeons, outcome in both general and sexual satisfaction appear excellent.

Use of the mechanical in-exsufflator in pediatric patients with neuromuscular disease and impaired cough.

BACKGROUND: Impaired cough secondary to weakness from neuromuscular disease (NMD) can cause serious respiratory complications, including atelectasis, pneumonia, small airway obstruction, and acidosis. The mechanical in-exsufflator (MI-E) delivers a positive-pressure insufflation followed by an expulsive exsufflation, thereby simulating a normal cough. Use of the MI-E in adults with impaired cough results in improved cough flows and enhanced airway clearance. However, only limited reports of MI-E use in children exist. OBJECTIVE: To determine the safety, tolerance, and effectiveness of the MI-E in a pediatric population. METHOD: Retrospective medical record review. PARTICIPANTS: Sixty-two patients (34 male patients) observed in a pediatric pulmonary program with NMD and impaired cough in whom MI-E therapy was initiated. Median age at initiation of MI-E use was 11.3 years (range, 3 months to 28.6 years). Diagnoses included the following: Duchenne muscular dystrophy (17 patients); spinal muscular atrophy, types I and II (21 patients); myopathy (12 patients); other nonspecific NMD (12 patients). Mechanical ventilation via tracheostomy was used in 29 patients, and 25 patients used noninvasive ventilation. RESULTS: The median duration of use was 13.4 months (range, 0.5 to 45.5 months). One infant died before using MI-E at home. Five patients chose not to continue MI-E therapy. Complications were reported in two patients, but ultimately they used the MI-E device. Chronic atelectasis resolved in four patients after beginning MI-E therapy, and five patients experienced a reduction in the frequency of pneumonias. CONCLUSION: In 90% of our study population, the use of an MI-E was safe, well-tolerated, and effective in preventing pulmonary complications.

Pulmonary function in technology-dependent children 2 years and older with bronchopulmonary dysplasia.

Somatic and pulmonary growth coincide with resolution of hypoxemia by 2 years of age in most children with bronchopulmonary dysplasia (BPD). However, a distinct subgroup of children with BPD continue to require mechanical ventilation and/or supplemental oxygen beyond 2 years of age. This study tested the hypothesis that indices of pulmonary function would be significantly worse in children with BPD 2 years and older who remained technology-dependent secondary to hypoxemia, compared to those of age-matched children with BPD who were normoxemic. We measured pulmonary mechanics in 21 oxygen- or ventilator-dependent children with BPD 2 years and older (BPDO2 group; mean age+/-SD, 30.2+/-6.5 months) and in 19 children with BPD who had been weaned off mechanical ventilation and supplemental oxygen for at least 6 months (control group; mean age, 30.1+/-5.5 months). Respiratory rate and tidal volume were measured after sedation with chloral hydrate, and dynamic compliance and expiratory conductance were calculated using the esophageal catheter technique. Maximal flow at FRC (V'(maxFRC)) and ratio of forced-to-tidal flows at midtidal volume were obtained by the rapid thoracic compression technique. FRC was determined by nitrogen washout. There were no statistically significant differences in most measured indices of pulmonary mechanics between the BPDO2 and control groups. However, V'(maxFRC)/FRC was higher in controls compared to subjects in the BPDO2 group (0.81+/-0.40 sec(-1) vs. 0.34+/-0.21 sec(-1), P<0.003). We conclude that most indices of pulmonary function in children with BPD 2 years and older do not reflect the need for mechanical ventilation or supplemental oxygen. We speculate that measurements of lung elastic recoil and tests of distribution of ventilation and pulmonary perfusion may be more sensitive in differentiating normoxemic and hypoxemic children with BPD 2 years and older.

Front-line ordering clinicians: matching workforce to workload.

BACKGROUND: Matching workforce to workload is particularly important in healthcare delivery, where an excess of workload for the available workforce may negatively impact processes and outcomes of patient care and resident learning. Hospitals currently lack a means to measure and match dynamic workload and workforce factors. OBJECTIVES: This article describes our work to develop and obtain consensus for use of an objective tool to dynamically match the front-line ordering clinician (FLOC) workforce to clinical workload in a variety of inpatient settings. METHODS: We undertook development of a tool to represent hospital workload and workforce based on literature reviews, discussions with clinical leadership, and repeated validation sessions. We met with physicians and nurses from every clinical care area of our large, urban children's hospital at least twice. RESULTS: We successfully created a tool in a matrix format that is objective and flexible and can be applied to a variety of settings. We presented the tool in 14 hospital divisions and received widespread acceptance among physician, nursing, and administrative leadership. The hospital uses the tool to identify gaps in FLOC coverage and guide staffing decisions. DISCUSSION: Hospitals can better match workload to workforce if they can define and measure these elements. The Care Model Matrix is a flexible, objective tool that quantifies the multidimensional aspects of workload and workforce. The tool, which uses multiple variables that are easily modifiable, can be adapted to a variety of settings.