Decreasing Pediatric PACU Noise Level and Alarm Fatigue: A Quality Improvement Initiative to Improve Safety and Satisfaction.

PURPOSE: To describe how a pediatric postanesthesia care unit used a two-phased approach of bundled interventions to reduce unit noise levels and improve staff perceptions of their work environment. DESIGN: Pre/post design. METHODS: Postanesthesia care unit sound levels and monitor alarms were measured at baseline and after implementing both project phases. Nursing staff members were surveyed at baseline and after completion of the project. FINDINGS: Monitor alarms were reduced by more than 50% after Phase I. However, noise measurement data did not reflect a difference in sound levels between baseline and intervention phases. Despite this, staff perceived the unit as much quieter. CONCLUSIONS: The reduction in monitor alarms did not cause an appreciable change in sound levels as measured by noise dosimeters in either intervention phase. Despite these findings, nurses perceived a quieter and more pleasant workplace. These impressions might have resulted from subjective expectations versus actual volume levels, or they might owe to the reduction in incidence of alarms themselves, which they had viewed as nuisance sounds.

Intravenous Versus Oral Acetaminophen in Ambulatory Surgical Center Laparoscopic Cholecystectomies: A Retrospective Analysis.

STUDY OBJECTIVE: The primary aim was to compare postoperative pain scores in patients undergoing laparoscopic cholecystectomy and receiving intravenous (IV) or oral (PO) acetaminophen (APAP) as part of a multimodal analgesic regimen to examine whether PO APAP is non-inferior to IV APAP. DESIGN: Retrospective analysis. SETTING: Ambulatory surgical center (ASC) in an academic setting. PATIENTS: 579 patients (18-70 years old), American Society of Anesthesiologists physical status I-III, undergoing laparoscopic cholecystectomy. INTERVENTIONS: Patients received 1,000 mg IV APAP intraoperatively (n = 319) or 1,000 mg PO APAP preoperatively (n = 260). MEASUREMENTS: The primary outcome was the median difference in post-anesthesia care unit (PACU) end-pain scores between the groups. Median pain scores were also compared on PACU admission, and at 15, 30, 45, and 60 minutes. Additional measures include PACU rescue-analgesia consumption, time to first PACU rescue analgesia, intraoperative use of opioid and nonopioid analgesics, PACU length of stay, and PACU rescue nausea and vomiting therapy. MAIN RESULTS: In both groups, the PACU median end-pain score was 2. The 90% confidence interval (CI) for difference in median pain scores between groups was [0, 0]; the CI upper limit was below the non-inferior margin of 1 pain-score point, indicating PO APAP's non-inferiority to IV APAP. There were no statistically significant differences in the percentages of patients receiving PACU hydromorphone equivalents between the IV and PO groups (75% vs. 77%, P = 0.72) or in the mean dose received (0.5 mg vs. 0.5 mg, P = 0.66). CONCLUSION: Single-dose PO APAP is non-inferior to IV APAP for postoperative analgesia in ASC laparoscopic cholecystectomy patients. The value of single-dose IV APAP in this population should be further explored.

Data-Driven Implementation of Alarm Reduction Interventions in a Cardiovascular Surgical ICU.

BACKGROUND: Alarm fatigue in the ICU setting has been well documented in the literature. The ICU's high-intensity environment requires staff's vigilant attention, and distraction from false and non-actionable alarms pulls staff away from important tasks, creates dissatisfaction, and is a potential patient safety risk if alarms are missed or ignored. This project was intended to improve patient safety by optimizing alarm systems in a cardiovascular surgical intensive care unit (CVSICU). Specific aims were to examine nurses' attitudes toward clinical alarm signals, assess nurses' ability to discriminate audible alarm signals, and implement a bundled set of best practices for monitor alarm reduction without undermining patient safety. METHODS: CVSICU nurses completed an alarm perception survey and participated in alarm discriminability testing. Nurse survey data and baseline monitor alarm data were used to select targeted alarm reduction interventions, which were progressively phased in. Monitor alarm data and cardiorespiratory event data were trended over one year. RESULTS: Five of the most frequent CVSICU monitor alarm types-pulse oximetry, heart rate, systolic and diastolic blood pressure, pulse oximetry sensor, and ventricular tachycardia > 2-were targeted. After implementation, there was a 61% reduction in average alarms per monitored bed and a downward trend in cardiorespiratory events. CONCLUSION: To reduce alarm fatigue it is important to decrease alarm burden through targeted interventions. Methods to reduce non-actionable alarms include adding short delays to allow alarm self-correction, adjusting default alarm threshold limits, providing alarm notification through a secondary device, and teaching staff to optimize alarm settings for individual patients.

The Eating Disorders Examination in adolescent males with anorexia nervosa: how does it compare to adolescent females?

OBJECTIVE: The study aimed to explore the Eating Disorder Examination (EDE) for adolescent males with eating disorders (EDs) compared with adolescent females with EDs. METHOD: Data were collected from 48 males and matched on percent median body weight (MBW) and age to 48 females at two sites. RESULTS: Adolescent males with anorexia nervosa-type presentation scored significantly lower than matched females on Shape Concern, Weight Concern, and Global score. They also scored lower on a number of individual items. DISCUSSION: The EDE has clinical utility with adolescent males with anorexic-type presentation although males' scoring ranges are consistently lower than those from adolescent females with similar clinical presentations. Males scored significantly lower on a number of items representing core symptoms such as desire to lose weight. More research is needed to gain a better understanding of the experience of adolescent males with EDs, particularly in relation to the nature of shape concern.

Patient safety reporting systems: sustained quality improvement using a multidisciplinary team and "good catch" awards.

BACKGROUND: Since 1999, hospitals have made substantial commitments to health care quality and patient safety through individual initiatives of executive leadership involvement in quality, investments in safety culture, education and training for medical students and residents in quality and safety, the creation of patient safety committees, and implementation of patient safety reporting systems. At the Weinberg Surgical Suite at The Johns Hopkins Hospital (Baltimore), a 16-operating-room inpatient/outpatient cancer center, a patient safety reporting process was developed to maximize the usefulness of the reports and the long-term sustainability of quality improvements arising from them. METHODS: A six-phase framework was created incorporating UHC's Patient Safety Net (PSN): Identify, report, analyze, mitigate, reward, and follow up. Unique features of this process included a multidisciplinary team to review reports, mitigate hazards, educate and empower providers, recognize the identifying/reporting individuals or groups with "Good Catch" awards, and follow up to determine if quality improvements were sustained over time. RESULTS: Good Catch awards have been given in recognition of 29 patient safety hazards identified since 2008; in each of these cases, an initiative was developed to mitigate the original hazard. Twenty-five (86%) of the associated quality improvements have been sustained. Two Good Catch award-winning projects--vials of heparin with an unusually high concentration of the drug that posed a potential overdose hazard and a rapid infusion device that resisted practitioner control--are described in detail. CONCLUSION: A multidisciplinary team's analysis and mitigation of hazards identified in a patient safety reporting process entailed positive recognition with a Good Catch award, education of practitioners, and long-term follow-up.

Emotional intelligence and selection to administrative chief residency.

OBJECTIVE: The authors sought to determine whether emotional intelligence, as measured by the BarOn emotional quotient inventory (EQ-i), is associated with selection to administrative chief resident. METHOD: Authors invited senior-year residents at the University of Texas Health Science Center at Houston to participate in an observational cross-sectional study using the BarOn EQ-i. In October 2009 they sent an invitation e-mail to 66 senior residents, with a reminder e-mail 1 month later. The study was designed to detect a 15-point difference in EQ-i scores with 80% power. RESULTS: Of the 66 invited residents, 69.6% participated in the study. Average total EQ-I score was 104.9. Among senior-year residents, there were no statistically significant differences in EQ-i scores between administrative chief residents (at 109) and non-administrative chief residents (at 103.2). CONCLUSION: Administrative chief residents do not demonstrate higher Emotional Intelligence, as measured by the EQ-i, than other senior-year residents.

Static foot posture associated with dynamic plantar pressure parameters.

STUDY DESIGN: Controlled laboratory study. OBJECTIVE: To explore potential associations between foot posture index (FPI-6) composite scores and dynamic plantar pressure measurements, and to describe each of the 6 subscales and the FPI-6 composite scores across our sample. BACKGROUND: The FPI-6 is a static foot posture assessment comprised of 6 observations. Extreme scores have been associated with increased injury risk. However, knowledge describing the relationship between FPI-6 scores and plantar pressure distributions during gait is limited. METHODS: Participants (n = 1000; 566 males, 434 females) were predominantly active adults (mean ± SD age, 30.6 ± 8.0 years; body mass index, 26.2 ± 3.7 kg/m²), who ran 3.1 ± 1.4 d/wk. Static and dynamic foot characteristics were compared using the FPI-6 and a capacitance-based pressure platform. Correlation and hierarchical stepwise regression analyses were performed to determine the most parsimonious set of dynamic pressure data associated with FPI-6 scores. RESULTS: The mean ± SD FPI-6 score was 3.4 ± 2.9 (range, -6.0 to 11.0). Only 31 participants received a score of -2 (supinated foot) on any FPI-6 subscale. Classification of a pronated foot was 2.4 times more likely than a supinated foot. A 5-variable model (R = 0.57, R2 = 0.32) was developed to describe the association between dynamic plantar pressures and FPI-6 scores. CONCLUSION: The multivariate model associated with FPI-6 scores comprised clinically plausible variables which inform the association between static and dynamic foot postures. Different cutoff values may be required when using the FPI-6 to screen for individuals with supinated feet, given the limited number of high-arched participants identified by FPI-6 classifications.

Effect of Post-Grazing Sward Height, Sire Genotype and Indoor Finishing Diet on Steer Intake, Growth and Production in Grass-Based Suckler Weanling-to-Beef Systems.

This study evaluated the effects of post-grazing sward height (PGSH, 4 or 6 cm) on herbage production, its nutritive value, dry matter (DM) intake, grazing behaviour and growth of early- (EM) and late-maturing (LM) breed suckler steers (n = 72), and the subsequent effect of indoor finishing diet (grass silage + 3.8 kg concentrate DM/head daily (SC), or grass silage only (SO)) on performance and carcass traits. Animals rotationally grazed pasture for 196 days, followed by indoor finishing for 119 days. At pasture, daily live-weight gain (LWG) was 0.10 kg greater for PGSH-6 than PGSH-4, resulting in a tendency for carcass weight to be 11 kg heavier. Although EM had a 0.10 kg greater daily LWG at pasture than LM, carcass weight did not differ between the genotypes. There was a genotype × PGSH interaction for carcass fat score, whereby there was no difference between EM-4 (8.83, 15-point scale) and EM-6 (8.17), but LM-6 (7.28) was greater than LM-4 (6.33). Although concentrate supplementation during indoor finishing increased carcass weight (+37 kg) and fat score (1.75 units), the majority of steers (83% of EM and 78% of LM) achieved a commercially-acceptable carcass fat score (6.78) at slaughter in the grass-forage-only system.

Early response to family-based treatment for adolescent anorexia nervosa.

OBJECTIVE: The purpose of this study was to determine if early weight gain predicted remission at the end of treatment in a clinic sample of adolescents with anorexia nervosa (AN). METHOD: Sixty five adolescents with AN (mean age = 14.9 years, SD = 2.1), from two sites (Chicago n = 45; Columbia n = 20) received a course of manualized family-based treatment (FBT). Response to treatment was assessed using percent ideal body weight (IBW) with remission defined as having achieved ≥ 95% IBW at end of treatment (Session 20). RESULTS: Receiver operating characteristic analyses showed that a gain of at least 2.88% in ideal body weight by Session 4 best predicted remission at end of treatment (AUC = 0.674; p = 0.024). DISCUSSION: Results suggest that adolescents with AN, receiving FBT, who do not show early weight gain are unlikely to remit at end of treatment.

Python script for homogeneous aqueous chemical reaction analysis and associated data related to radiolysis simulations.

A script was developed to perform homogenous radiolysis calculations. It was used specifically to calculate radiolysis products under various neutron and gamma flux environments [1]. The routine may be used to calculate a single radiolysis condition, multiple independent conditions, or multiple conditions computed in series (the final concentration set of run i is the initial concentration of run i+1). While designed for radiolysis of water, the routine is easily adapted to a variety of aqueous reaction systems and may even be altered with minimal effort for more general homogenous chemical analysis. In the present article, the Python routine is explained along with various outputs and inputs. It and the relevant input and output text files are included as supplementary materials. They are the raw data used for calculation of figures in the associated journal article.

Body mass index as a predictor of 1-year outcome in gastric bypass surgery.

BACKGROUND: The aim of this study was to determine if presurgery (T1), post-surgery (T2), or the change in body mass index (BMI) between these time points are useful predictors for predicting longer-term (T3) outcome in gastric bypass surgery. METHODS: The sample consisted of 72 gastric bypass surgery patients with an average age of 40.5. The mean presurgery BMI was 54.7 (SD = 8.6). T2 assessments (BMI, depressed mood, binge eating status) occurred on average 21 weeks (SD = 19) after surgery and T3 assessments occurred on average 63 weeks (SD = 34) after surgery. RESULTS: Three separate hierarchical linear regressions were performed to assess the predictive value of (1) BMI at T1, (2) BMI at T2, and (3) change in BMI from T1 to T2 on the dependent variable, BMI at T3, when age, sex, ethnicity, education status, age of overweight, binge eating status, depressed mood, and number of weeks after surgery were controlled for. When these demographic and psychological variables were controlled for, lower BMI at T1 and lower BMI at T2 predicted lower BMI at T3. However, change in BMI from T1 to T2, did not significantly predict BMI at T3 (p < .001). CONCLUSIONS: Higher presurgery BMI and post-surgery BMI predict poorer 1-year follow-up BMI in gastric bypass surgery, and these measures can be used as easy "rules of thumb" for predicting longer term outcome.

Caffeine, artificial sweetener, and fluid intake in anorexia nervosa.

OBJECTIVE: This article provides an analysis of the use of artificial sweeteners, caffeine, and excess fluids in patients diagnosed with anorexia nervosa (AN). METHOD: Seventy participants with AN were recruited to participate in an ecologic momentary assessment study which included nutritional analysis using the Nutrition Data Systems for Research, a computer based dietary recall system. RESULTS: When subtypes were compared, participants with AN-restricting subtype (AN-R) and participants with AN-Binge-Purge (AN-B/P) did not differ in quantity of aspartame, caffeine, or water consumed. Daily water consumption was related to daily vomiting frequency in AN-B/P but not to daily exercise frequency in either participants with AN-R or AN-B/P. DISCUSSION: Caffeine, water, and aspartame consumption can be variable in patients with AN and the consumption of these substances seems to be only modestly related to purging behavior.

A practical framework for patient care teams to prospectively identify and mitigate clinical hazards.

BACKGROUND: One of the greatest challenges facing both practitioners and risk managers is the identification of previously unknown clinical hazards and defects. With the rapid proliferation of new health care services, unknown hazards may propagate as new therapies are integrated into the existing health care system. The main goal of risk analysis is to make these hazards visible by proactively searching and probing the system. Yet, a comprehensive approach by which to safely integrate new therapies into the existing clinical environment has yet to be clearly articulated. Patient care teams can use the proposed framework when introducing new therapies. A PRACTICAL FRAMEWORK: The framework includes a background investigation and literature search; an in situ simulation (in the actual clinical setting used for patients); a Failure Mode and Effects Analysis to determine the severity, probability, and risk of the potential hazards; and a multidisciplinary protocol and safety checklist to standardize practice and ensure provider accountability. CASE EXAMPLES: Application of this framework to three operative scenarios--intraoperative radiation therapy (IORT), hyperthermic intraperitoneal chemotherapy (HIPEC), and an interventional pulmonology program--demonstrates its flexibility. Its use prospectively identified and mitigated 20 IORT, 5 HIPEC, and 18 interventional pulmonology hazards/defects. Subsequent patient cases were largely uneventful. All cases and patient safety reporting systems are monitored to identify any new defects in an effort to continuously improve patient care. CONCLUSION: The use of a comprehensive framework to identify and mitigate hazards in an on-site simulated environment promotes safer care for target patient populations; results in familiarity with procedures, amelioration of staff concerns, and standardization of practice; and facilitates teamwork and communication.

Early response to treatment in adolescent bulimia nervosa.

OBJECTIVE: The purpose of this study was to determine if early response predicted remission at the end of a controlled trial. METHOD: Eighty adolescents with bulimia nervosa participated in an RCT comparing family-based treatment and individual supportive psychotherapy. Response to treatment was assessed via self-report of bingeing and purging. Remission was defined as abstinence from bingeing and purging for the last 28 days and measured by investigator-based interview, that is, the Eating Disorder Examination. RESULTS: Receiver-operating characteristic analyses showed that, regardless of treatment, symptom reduction at session six predicted remission at posttreatment (AUC = 0.814 (p < .001)) and 6-month follow-up (AUC = 0.811 (p < .001)). CONCLUSION: Results suggest that adolescents with BN who do not show early reductions in bulimic symptoms are unlikely to remit at posttreatment or follow-up.

Palatal implants are a good alternative to headgear: a randomized trial.

INTRODUCTION: The objective of this study was to compare the effectiveness of midpalatal implants with that of headgear as methods of supplementing anchorage during orthodontic treatment. This was a randomized, clinical trial at the Chesterfield and North Derbyshire Royal Hospital NHS Trust and the Charles Clifford Dental Hospital, Sheffield, United Kingdom. METHODS: Fifty-one orthodontic patients between the ages of 12 and 39 with absolute anchorage requirements were randomly allocated to receive either a midpalatal implant or headgear to reinforce orthodontic anchorage. The outcome measures of the trial were the surgical and orthodontic success rates of the implants, the number of visits, and the length of treatment time, and the success of treatment as judged by the peer assessment rating (PAR) score reductions and the patients' attitudes to implant placement. RESULTS: The surgical success rate of the implants was 75%, and the orthodontic success rate was more than 90%. Both implants and headgear proved to be effective methods of reinforcing anchorage. The total number of visits was greater in the implant group, but the overall treatment times were almost identical. There were no statistically significant differences between the 2 groups in PAR scores either at the start or the end of treatment, and the percentages of PAR score reductions were almost identical. The patients had no problems accepting midpalatal implants as a method of reinforcing anchorage. CONCLUSIONS: Midpalatal implants are an acceptable technique for reinforcing anchorage in orthodontic patients and a good alternative for patients who do not wish to wear headgear.

A set of MATLAB routines and associated files for prediction of radiation-enhanced diffusion in ion irradiated materials.

This article presents MATLAB routines that may be used to evaluate radiation-enhanced diffusion (RED) in ion irradiation materials. Four routines are included: Main, DataCollect, Diffuse, and Directory. A sample input file and README are also included. The input may be directly modified as provided and used as an input to the routines. Data from Stopping Range of Ions in Matter (SRIM) is also required as an input. A stream of data files at different damage conditions is created by the routines.

Midpalatal implants vs headgear for orthodontic anchorage--a randomized clinical trial: cephalometric results.

INTRODUCTION: The purpose of this study was to compare the clinical effectiveness of the midpalatal implant as a method of reinforcing anchorage during orthodontic treatment with that of conventional extraoral anchorage. This was a prospective, randomized, clinical trial at Chesterfield and North Derbyshire Royal Hospital NHS Trust and the Charles Clifford Dental Hospital, Sheffield, in the United Kingdom. METHODS: Fifty-one orthodontic patients between the ages of 12 and 39, with Class II Division 1 malocclusion and absolute anchorage requirements, were randomly allocated to receive either a midpalatal implant or headgear to reinforce orthodontic anchorage. The main outcome was to compare the mesial movement of the molars and the incisors of the 2 treatment groups between the start and the end of anchorage reinforcement as measured from cephalometric radiographs. RESULTS: The reproducibility of the measuring technique was acceptable. There were significant differences between T1 and T2 in the implant group for the positions of the maxillary central incisor (P <.001), the maxillary molar (P = .009), and the mandibular molar (P <.001). There were significant differences between T1 and T2 in the headgear group for the positions of the mandibular central incisor (P <.045), the maxillary molar (P <.001), and the mandibular molar (P <.001). All skeletal and dental points moved mesially more in the headgear group during treatment than in the implant group. These ranged from an average of 0.5 mm more mesially for the mandibular permanent molar to 1.5 mm more mesially for the maxillary molar and the mandibular base. No treatment changes between the groups were statistically significant. CONCLUSIONS: Midpalatal implants are an acceptable technique for reinforcing anchorage in orthodontic patients.