Exploring the complex interactions of baseline patient factors to improve nursing triage of acute coronary syndrome.

Emergency department (ED) nurses need to identify patients with potential acute coronary syndrome (ACS) rapidly because treatment delay could impact patient outcomes. Aims of this secondary analysis were to identify key patient factors that could be available at initial ED nurse triage that predict ACS. Consecutive patients with chest pain who called 9-1-1, received a 12-lead electrocardiogram in the prehospital setting, and were transported via emergency medical service were included in the study. A total of 750 patients were recruited. The sample had an average age of 59 years old, was 57% male, and 40% Black. One hundred and fifteen patients were diagnosed with ACS. Older age, non-Caucasian race, and faster respiratory rate were independent predictors of ACS. There was an interaction between heart rate by Type II diabetes receiving insulin in the context of ACS. Type II diabetics requiring insulin for better glycemic control manifested a faster heart rate. By identifying patient factors at ED nurse triage that could be predictive of ACS, accuracy rates of triage may improve, thus impacting patient outcomes.

Understanding Respiratory Rate Assessment by Emergency Nurses: A Health Care Improvement Project.

INTRODUCTION: Respiratory rate is the first sign of patient decline. Monitoring and recording respiratory rate are essential nursing competencies. However, health care system emergency nurses' ability to differentiate normal from abnormal respiratory rates was unknown. We conducted a health care improvement project to assess emergency nurses' accuracy in "spot" and "formal" assessments, understand assessment practices, and determine competency and training needs. METHODS: In an anonymous cross-sectional survey, 78 emergency nurses from 1 health care system viewed 3 "spot" and 3 "formal" mock patient videos and answered questions in REDCap (Vanderbilt University, Nashville, TN). Accuracy (abnormal/normal), systematic error (bias), and random error (imprecision) were assessed. Descriptive statistics, bivariate analyses, and qualitative content analysis of open-ended questions were reported. RESULTS: Most emergency nurses identified respiration as abnormal in spot and formal assessment videos. Accuracy was lowest for the video displaying 6 breaths per minute. Emergency nurses were more likely to identify abnormal breathing in all formal assessment videos (n = 59, 75.7%) than in all spot assessment videos (n = 41, 52.6%) (McNemar χ2 = 10.32, P = 0.001). Most emergency nurses reported a willingness to use formal assessments and thought that respiratory rate was a good indicator of a patient's condition. The barriers to accurate assessment included time limitations, prior training focusing on assessments lasting less than 30 seconds, and monitor and staff errors. DISCUSSION: Respiratory rate assessment may be best assessed formally, particularly for bradypnea, where formal checks may outperform spot checks. The results present areas for improving respiratory rate assessment training and clinical practice.

Improving Pain Reassessment and Documentation Rates: A Quality Improvement Project in a Teaching Hospital's Emergency Department.

INTRODUCTION: ED pain score reassessment and documentation rates were drastically low according to sampled data from the St. Margaret Hospital Emergency Department, leading to difficult pain management encounters for clinicians. The purpose of this project was to improve pain score reassessment rates in ED patients who were discharged with extremity pain. METHODS: This project was an 8-month, pre-postinterventional (preintervention: September-November 2018, intervention: December 2018-January 2019, and postintervention: February-April 2019) quality improvement project that took place in a community hospital emergency department. Emergency nurses participated in 6 focus groups, allowing for the creation of focus group-themed interventions at the request of the nursing staff. Daily audits of pain reassessment and documentation rates for individual nurses took place during the month of January 2019. In addition, a weekly newsletter was created and reported the ED pain reassessment and documentation rates. RESULTS: All patient encounters (581) were reviewed over the 8-month period. Baseline pain score reassessment and documentation rates were 36.2% (confidence interval, 30.3%-42.3%) in the emergency department. Pain reassessment and documentation rates increased to 62.3% (confidence interval, 56.8%-67.6%) during the 3-month postintervention period. DISCUSSION: Implementing daily audits and weekly newsletters that created transparency of individual and group performances increased pain score reassessment and documentation rates.

The Influence of Patient Safety Culture and Patient Safety Error Experience on Safety Nursing Activities of Emergency Nurses in South Korea.

INTRODUCTION: The unique nature of the space and environment of emergency departments is a threat to patient safety. Enhancing patient safety and minimizing safety-related issues are important tasks for ED health care staff. The purpose of this study was to examine the relationships among patient safety culture, patient safety error, and safety nursing activities of emergency nurses in South Korea. METHODS: A convenience sample of 200 emergency nurses working in 12 general hospitals in South Korea were surveyed for safety nursing activities using the Hospital Survey of Patients' Safety Culture, a 4-item questionnaire for patient safety error and ED safety management items in the Guidelines for Patient Safety (seventh revision). RESULTS: Hierarchical regression analysis revealed that the potential factors associated with safety nursing activities were safety training experience (ß = 0.180, P=.01), organizational learning-continuous improvement (ß = 0.170, P=.04), age (ß = 0.160, P=.02), and implementation of domestic and foreign accreditation (ß = 0.147, P=.03). DISCUSSION: To improve patient safety, it is essential to identify problems in medical institutions, determine areas of improvement, and improve the organization's patient safety activity system on the basis of patient safety error experience reports. After training the emergency nurses for continuous improvement, the effect of patient safety activities must be analyzed.

Development and Validation of the Ambulance Nurse Competence Scale.

INTRODUCTION: In recent decades, major competency shifts have taken place in prehospital care in Sweden because staffing ambulances with registered/specialized nurses has become a priority. The aim of this study was to develop and validate a new instrument to measure the self-reported professional competency of specialist ambulance nursing students and registered/specialist nurses working in prehospital care. METHODS: This study used a quantitative cross-sectional design to evaluate psychometric properties of a new instrument. The sample included 179 registered/specialist ambulance nurses and 34 specialist ambulance nursing students. RESULTS: The analyses resulted in the Ambulance Nurse Competence (ANC) scale, consisting of 43 items and covering 8 factors: Nursing Care (n = 8), Value-based Nursing Care (n = 5), Medical Technical Care (n = 5), Care Environment's Community (n = 4), Care Environment's Serious Events (n = 8), Leadership Management (n = 3), Supervision and Professional Conduct (n = 4), and Research and Development (n = 6). All factors except Leadership Management achieved a Cronbach's alpha value greater than 0.71, explaining 59.62% of the total variance. DISCUSSION: The ANC scale was systematically tested and showed satisfactory psychometrical properties. The ANC scale can be used in the education programs of future registered/specialist ambulance nurses as a tool for self-reflected learning and could also be of potential use in identifying competence gaps in registered/specialist ambulance nurses, which could direct the design of introductory programs. The scale could also be used as an outcome measure together with other instruments.

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.

Ethical sensitivity, burnout, and job satisfaction in emergency nurses.

BACKGROUND: Rising levels of burnout and decreasing job satisfaction can inhibit healthcare professionals from providing high-quality care due to a corresponding decrease in their ethical sensitivity. AIM: This study aimed to determine the relationship between the level of ethical sensitivity in emergency service nurses and their levels of burnout and job satisfaction. RESEARCH DESIGN: This research employed a descriptive and cross-sectional design. PARTICIPANTS AND RESEARCH CONTEXT: This study was conducted with a sample of 236 nurses, all of whom worked in emergency service between 24 July 2015 and 28 April 2016. Data were collected using the Moral Sensitivity Questionnaire, Maslach Burnout Inventory, and Minnesota Job Satisfaction Scale. ETHICAL CONSIDERATIONS: This study was approved by the Institutional Ethics Review Board of Ondokuz Mayis University. FINDINGS: There was a weak and negative correlation (r = -0.158, p = 0.015) between Moral Sensitivity Questionnaire and Maslach Burnout Inventory scores. There was also a weak and negative correlation (r = -0.335, p < 0.001) between the Maslach Burnout Inventory and Minnesota Job Satisfaction Scale scores. DISCUSSION AND CONCLUSION: Decreased job satisfaction and increased burnout levels among emergency service nurses might result in them indulging in improper practices, frequently facing ethical problems, and a decrease in the overall quality of service in hospitals. In order for emergency service nurses to recognize ethical problems and make the most accurate decisions, a high level of ethical sensitivity is critical. In this respect, it is suggested that continuing education after graduation and training programs should be organized.

Iranian pre-hospital emergency care nurses' strategies to manage workplace violence: A descriptive qualitative study.

AIM: To explore the experiences of Iranian nurses working in pre-hospital emergency care services and the strategies used to manage of workplace violence. BACKGROUND: Pre-hospital emergency nurses are subject to workplace violence; however, little research addresses their experiences, particularly related to their strategies in dealing with workplace violence. METHODS: A descriptive qualitative study that involved nineteen male nurses who were working in pre-hospital services collected data using semi-structured interviews and analysed it using qualitative content analysis. RESULTS: Data analysis yielded four descriptive categories including no reaction to violence (tolerance and acceptance as common workplace conflicts), situational management (patient and scene management), confrontation (direct and indirect) and escaping the scene. Patient management was the dominant strategy used and had the best outcomes related to both patient and personnel safety. CONCLUSION: This study showed that pre-hospital nurses use different strategies to manage violence and patient management was a common and useful strategy for managing workplace violence. However, the pre-hospital nurses have little training, insufficient support and are poorly prepared to manage workplace violence. IMPLICATIONS FOR NURSING MANAGEMENT: The development of context-based guidelines, continuing education, better-equipped ambulances that include medical and defence equipment, as well as better coordination of the police force in ambulance operations, can help to reduce workplace violence.

Emergency Nurses' Perception of Geriatric Readiness in the ED Setting: A Mixed-Methods Study.

INTRODUCTION: The Centers for Disease Control and Prevention (CDC) reports 136.9 million ED visits in 2015, of which 21.4 million (15.6%) were by patients who were 65 or older. This US population demographic is expected to grow by 112% over the next 40 years, becoming just below 25% of the total US population. Emergency nurses will play an increasingly important part in the development of nursing care for geriatric patients. The purpose of this study was to explore emergency nurses' perception of their ability to care for geriatric patients in the emergency setting. METHODS: This was a mixed-methods sequential design using quantitative survey data and qualitative focus group data, which were analyzed separately and then given equal priority during the data-interpretation phase. RESULTS: Less than 50% of survey respondents (N = 1,610) reported geriatric-specific screenings, accommodations, and communication with outside agencies as "always available" in their care settings. Qualitative analysis (N = 23) yielded the categories of Triage/Assessment, Care in the Emergency Environment, Discharge Planning, and Facilitators and Barriers, which generally reflected the trajectory of care for the older patient. The overarching concern was keeping patients safe in both the community and in the emergency department. DISCUSSION: Emergency departments should develop integrated systems to facilitate appropriate care of older patients. Identified barriers to improved care include a lack of integration between emergency care and community care, deficits in geriatric-specific education, inconsistent use of early screening for frailty, and lack of resources in the emergency care environment to intervene appropriately.

Accuracy and Reliability of Emergency Department Triage Using the Emergency Severity Index: An International Multicenter Assessment.

STUDY OBJECTIVE: We assess accuracy and variability of triage score assignment by emergency department (ED) nurses using the Emergency Severity Index (ESI) in 3 countries. In accordance with previous reports and clinical observation, we hypothesize low accuracy and high variability across all sites. METHODS: This cross-sectional multicenter study enrolled 87 ESI-trained nurses from EDs in Brazil, the United Arab Emirates, and the United States. Standardized triage scenarios published by the Agency for Healthcare Research and Quality (AHRQ) were used. Accuracy was defined by concordance with the AHRQ key and calculated as percentages. Accuracy comparisons were made with one-way ANOVA and paired t test. Interrater reliability was measured with Krippendorff's α. Subanalyses based on nursing experience and triage scenario type were also performed. RESULTS: Mean accuracy pooled across all sites and scenarios was 59.2% (95% confidence interval [CI] 56.4% to 62.0%) and interrater reliability was modest (α=.730; 95% CI .692 to .767). There was no difference in overall accuracy between sites or according to nurse experience. Medium-acuity scenarios were scored with greater accuracy (76.4%; 95% CI 72.6% to 80.3%) than high- or low-acuity cases (44.1%, 95% CI 39.3% to 49.0% and 54%, 95% CI 49.9% to 58.2%), and adult scenarios were scored with greater accuracy than pediatric ones (66.2%, 95% CI 62.9% to 69.7% versus 46.9%, 95% CI 43.4% to 50.3%). CONCLUSION: In this multinational study, concordance of nurse-assigned ESI score with reference standard was universally poor and variability was high. Although the ESI is the most popular ED triage tool in the United States and is increasingly used worldwide, our findings point to a need for more reliable ED triage tools.

A Randomized Controlled Trial on the Effect of a Double Check on the Detection of Medication Errors.

STUDY OBJECTIVE: The use of a double check by 2 nurses has been advocated as a key error-prevention strategy. This study aims to determine how often a double check is used for high-alert medications and whether it increases error detection. METHODS: Emergency department and ICU nurses worked in pairs to care for a simulated patient. Nurses were randomized into single- and double-check groups. Errors intentionally introduced into the simulation included weight-based dosage errors and wrong medication vial errors. The evaluator recorded whether a double check was used, whether errors were detected, and observational data about nurse behavior during the simulation. RESULTS: Forty-three pairs of nurses consented to enroll in the study. All nurses randomized to the double-check group used a double check. In the single-check group, 9% of nurses detected the weight-based dosage error compared with 33% of nurses in the double-check group (odds ratio 5.0; 95% confidence interval 0.90 to 27.74). Fifty-four percent of nurses in the single-check group detected the wrong vial error compared with 100% of nurses in the double-check group (odds ratio 19.9; 95% confidence interval 1.0 to 408.5). CONCLUSION: Our study demonstrates that nurses use double checks before administering high-alert medications. Use of a double check increases certain error detection rates in some circumstances, but not others. Both techniques missed many errors. In some cases, the second nurse actually dissuaded the first nurse from acting on the error.

A comparative study on the frequency of simulation-based training and assessment of non-technical skills in the Norwegian ground ambulance services and helicopter emergency medical services.

BACKGROUND: Inadequate non-technical skills (NTSs) among employees in the Norwegian prehospital emergency medical services (EMSs) are a risk for patient and operational safety. Simulation-based training and assessment is promising with respect to improving NTSs. The frequency of simulation-based training in and assessment of NTSs among crewmembers in the Norwegian helicopter emergency medical service (HEMS) has gained increased attention over recent years, whereas there has been much less focus on the Norwegian ground emergency medical service (GEMS). The aim of the study was to compare and document the frequencies of simulation-based training in and assessment of seven NTSs between the Norwegian HEMS and GEMS, conditional on workplace and occupation. METHOD: A comparative study of the results from cross-sectional questionnaires responded to by employees in the Norwegian prehospital EMSs in 2016 regarding training in and assessment of NTSs during 2015, with a focus on the Norwegian GEMS and HEMS. Professional groups of interest are: pilots, HEMS crew members (HCMs), physicians, paramedics, emergency medical technicians (EMTs), EMT apprentices, nurses and nurses with an EMT licence. RESULTS: The frequency of simulation-based training in and assessment of seven generic NTSs was statistically significantly greater for HEMS than for GEMS during 2015. Compared with pilots and HCMs, other health care providers in GEMS and HEMS undergo statistically significantly less frequent simulation-based training in and assessment of NTSs. Physicians working in the HEMS appear to be undergoing training and assessment more frequently than the rest of the health trust employees. The study indicates a tendency for lesser focus on the assessment of NTSs compared to simulation-based training. CONCLUSION: HEMS has become superior to GEMS, in terms of frequency of training in and assessment of NTSs. The low frequency of training in and assessment of NTSs in GEMS suggests that there is a great potential to learn from HEMS and to strengthen the focus on NTSs. Increased frequency of assessment of NTSs in both HEMS and GEMS is called for.

Intentional Clinical Process Design to Improve Outcomes for Patients Who Require Emergency Surgery.

Ruptured abdominal aortic aneurysms (AAAs) are associated with a 90% overall mortality and $150 000 cost of care per patient. Despite improvements in intensive care and surgical technology, morbidity and mortality remain unchanged over the past 20 years. The most significant predictor of survival is time from the door of the hospital to the operating room. To streamline operational efficiency, a team utilized Lean Six Sigma methodologies, team training, and intentional clinical process design to institute changes in our clinical processes, enhance care coordination, and improve communication. Changes led to a $1.8 million profit on operations, 10-day reduction in length of stay, and 89% survival rate among patients with ruptured AAA.

Development of evidence-based nursing-sensitive quality indicators for emergency nursing: A Delphi study.

AIMS AND OBJECTIVES: To establish evidence-based nursing-sensitive quality indicators for emergency nursing in China. BACKGROUND: China lacks nursing-sensitive quality indicators necessary for assessing the quality of emergency nursing and essential to nursing management. DESIGN: Prospective. METHODS: A literature search for relevant evidence-based studies was performed using several databases from January 2009-May 2014. Previously reported quality indicators were identified as appropriate for assessment by a panel of 40 experts in emergency medicine and nursing. Two successive rounds of Delphi surveys were conducted using questionnaires designed by the experts. Kendal's W coordination coefficients were calculated for indicator importance, rationality of calculation and feasibility of data collection. RESULTS: Thirty-three quality indicators were initially proposed for expert evaluation. After round 1 of expert discussion, Kendal's W coordination coefficients were .152 for importance, .092 for rationality and .141 for feasibility of data collection (all p < .001). Seven unsuitable items were discarded in round 1 and 11 discarded in round 2, which also added one new item. Finally, the experts reached consensus on 16 items established as appropriate nursing-sensitive quality indicators for emergency nursing care. CONCLUSION: Evidence-based nursing-sensitive quality indicators were established through a consensus of experts in emergency nursing and medicine. RELEVANCE TO CLINICAL PRACTICE: The current findings may provide a theoretical basis for establishing an emergency nursing quality database and improving the quality of emergency nursing care in China.

Pediatric triage education: An integrative literature review.

INTRODUCTION: The objective of this study was to review the currently published literature on the topic of pediatric triage education. METHOD: An integrative review of the literature was conducted using database searching and historical record review. RESULTS: A wide variety of pediatric triage educational methods exist, but studies with the highest-quality ratings most often used simulation programs or a standardized curriculum. Although there was a good deal of heterogeneity in terms of the outcomes measured, the accuracy of triage improved following educational interventions. DISCUSSION: Additional research is needed to compare different methods of pediatric triage education directly. Emergency nurses should be aware that pediatric triage is a high-risk event, and some educational methods may have advantages over others. In addition, although retention of pediatric triage skills is affected by the method and timing of pediatric triage education, emergency nurses should remain aware that improved pediatric triage skills could lead to improved pediatric outcomes, and target this as an area for further research.

Use of a Standardized Procedure to Improve Behavioral Health Patients' Care: A Quality Improvement Initiative.

PROBLEM: Meeting the complex needs of behavioral health (BH) patients in the emergency department is an ongoing challenge. Delays in care can have adverse consequences for patient and staff safety and delay transfer to specialized care. METHODS: A quality improvement, nurse-driven initiative using a standardized procedure (STP) was developed and implemented in our busy Southern California Emergency Department, which focused on improving time to first medication and reduction of restraints. The project used a multidisciplinary team to develop the STP scoring tool and corresponding medications. Improvement was seen in all quality metrics. Time to first medication decreased from 43 minutes to less than 5 minutes. Adopting the STP resulted in a 50% decrease in use of restraints and time in restraints. Staff injuries remained low, with less than 3.6% of staff sustaining physical injuries. DISCUSSION: The STP is an effective method to initiate immediate treatment of patients with signs of anxiety and aggression and thus reduce risk of violence. Additional benefits are reduced time to disposition and earlier initiation of specialized BH care. This process can be replicated in other emergency departments with similar clinical environments through the use of STPs or protocols based on state regulations. Contribution to Emergency Nursing Practice.

Improvement of Door-to-Electrocardiogram Time Using the First-Nurse Role in the ED Setting.

INTRODUCTION: This quality improvement project compared door-to-electrocardiogram (ECG) times for patients presenting with symptoms suggestive of acute coronary syndrome within a community hospital emergency department before and after first-nurse (emergency nurse stationed in the ED waiting room) training. METHOD: Door-to-ECG time was compared before and after the educational intervention using Acute Coronary Treatment and Intervention Outcomes Network (ACTION) registry data reported by the facility. RESULTS: Statistical significance was not achieved using a 2-group t-test. However, when comparing monthly means, data trend lines showed favorable improvement for door-to-ECG time after the intervention. DISCUSSION: Limitations included using only those patients in the ACTION registry and not accounting for RN turnover with first-nurse education. Future studies should focus on all patients presenting with symptoms of acute coronary syndrome as well as other patients presenting with time-sensitive needs to determine the efficacy of the first-nurse role.

Using the Evidence-Based Practice Service Nursing Bundle to Increase Patient Satisfaction.

ABSTRACTINTRODUCTION: Patient satisfaction and patient experience goals are often linked to financial consequences. Although the link does exist, the bottom line is not only about money; it's about providing a quality experience for ED patients and creating an environment that engages staff. Evidence-based practice (EBP) strategies that have positive impact on patient perceptions of their ED care and increased satisfaction ratings include AIDET, Hourly Rounding, and Bedside Shift Report, which incorporate updates of test results and explanations of events occurring during a patient's visit. In addition to these outcomes, Hourly Rounding and Bedside Shift Report have been linked to patient safety improvements. Combining these strategies, our team created and implemented the service nursing bundle as a quality improvement (QI) initiative, with the goal of having a positive effect on patient experiences in emergency departments, represented by at least a 5% increase in overall quality-of-care ranking and ratings. METHODS: This QI project involved comparing professional research consultant (PRC) patient- satisfaction phone survey ratings from patients before and after ED staff members completed a 1-hour service nursing bundle class. In addition to the patient-satisfaction ratings, 1,104 audits evaluating staff use of the service bundle implementation were collected over an 8-week period.reading document: RESULTS: The random observational audits showed the adoption of the service nursing bundle as staff compliance started at 65% in week 1 compared with 100% by week 8. Before intervention (July 2015): 50% of patients rated their overall quality of care as excellent, yielding a benchmark ranking of 42.5 percentile. Postservice bundle education implementation (September 2015): 60% of patients rated their overall quality of care as excellent, increasing our ranking to the 85.5 percentile. The postservice bundle group was 1.5 times more likely to respond "excellent" to all 5 survey questions, which was statistically significant (z =2.82, P = 0.004). The patients' perceptions of total time spent in the emergency department and ratings of "excellent" revealed a significant statistical difference (before: 35.0%, after: 49.5%, X2 (1) = 4.24, P < 0.05). DISCUSSION: With the implementation of the bundle, our emergency department experienced an 11.8% increase in the number of patients rating their overall quality of care as excellent. This upsurge resulted in a 40% increase in overall quality of care, propelling our emergency department's ranking to the 85th percentile.

Advanced nurse practitioner scheduled return clinic: a clinical audit of a quality initiative.

Emergency care settings in Ireland have struggled with a high volume of service users in recent years. This nationwide crisis led to the establishment of the National Emergency Medicine Programme Strategy in 2012, which identified two key performance indicators for efficiency in emergency care: the patient experience time, which should not exceed six hours from the time of registration to the time of discharge; and patients who do not wait for treatment (DNW) should make up less than 5% of those attending emergency care services. This article explores a quality initiative to improve DNW rates using scheduled return clinics, implemented by a group of advanced nurse practitioners in an emergency department in a Dublin hospital. It reviews the literature on scheduled return clinics and discusses the rationale for the initiative, its implementation, barriers to its introduction and an audit of its effectiveness.