Crossmodal Congruency Between Background Music and the Online Store Environment: The Moderating Role of Shopping Goals.

Despite the robust evidence that congruent background music in the physical store environment positively affects consumer reactions, less is known about its effects in an online context. The present study aims (1) to examine whether congruency via multiple elicited crossmodal correspondences between background music and the online store environment (e.g., perceived lightness, loudness, and coldness of the cue/environment) leads to more positive affective, evaluative, and behavioral consumer reactions and (2) to investigate the moderating role of shopping goals on this crossmodal congruency effect. Previous research showed that low task-relevant atmospheric cues like music can have a negative effect on consumers when they visit a website with a purchase goal in mind. An online experiment was conducted with 239 respondents randomly assigned to a shopping goal (experiential browsing vs. goal-directed searching) and a music condition (no music, crossmodally congruent music, or crossmodally incongruent music). Our results show that crossmodally incongruent background music (vs. no music) leads to more positive consumer reactions for experiential browsers and more negative consumer reactions for goal-directed searchers. Conversely, crossmodally congruent background music (vs. no music) has a positive effect on experiential browsers and no adverse effect on goal-directed searchers. Additionally, the presence of crossmodally congruent background music leads to more positive consumer reactions than the presence of crossmodally incongruent background music, independent of the shopping goal. We extend previous research on multisensory congruency effects by showing the added value of establishing congruency between music and the store environment via multiple elicited crossmodal correspondences in the online environment, countering previously found negative effects of low-task relevant atmospheric cues for goal-directed searchers.

Incorporating an Early Detection System Into Routine Clinical Practice in Two Community Hospitals.

Efforts to improve outcomes of patients who deteriorate outside the intensive care unit have included the use of rapid response teams (RRTs) as well as manual and automated prognostic scores. Although automated early warning systems (EWSs) are starting to enter clinical practice, there are few reports describing implementation and the processes required to integrate early warning approaches into hospitalists' workflows. We describe the implementation process at 2 community hospitals that deployed an EWS. We employed the Institute for Healthcare Improvement's iterative Plan-Do-Study-Act approach. Our basic workflow, which relies on having an RRT nurse and the EWS's 12-hour outcome time frame, has been accepted by clinicians and has not been associated with patient complaints. Whereas our main objective was to develop a set of workflows for integrating the electronic medical record EWS into clinical practice, we also uncovered issues that must be addressed prior to disseminating this intervention to other hospitals. One problematic area is that of documentation following an alert. Other areas that must be addressed prior to disseminating the intervention include the need for educating clinicians on the rationale for deploying the EWS, careful consideration of interdepartment service agreements, clear definition of clinician responsibilities, pragmatic documentation standards, and how to communicate with patients. In addition to the deployment of the EWS to other hospitals, a future direction for our teams will be to characterize process-outcomes relationships in the clinical response itself. Journal of Hospital Medicine 2016;11:S25-S31. © 2016 Society of Hospital Medicine.

Multicenter Implementation of a Treatment Bundle for Patients with Sepsis and Intermediate Lactate Values.

RATIONALE: Treatments for patients with sepsis with intermediate lactate values (≥2 and <4 mmol/L) are poorly defined. OBJECTIVES: To evaluate multicenter implementation of a treatment bundle (including timed intervals for antibiotics, repeat lactate testing, and intravenous fluids) for hemodynamically stable patients with sepsis and intermediate lactate values in the emergency department. METHODS: We evaluated patients in annual intervals before and after bundle implementation in March 2013. We evaluated bundle compliance and compared outcome measures across groups with multivariable logistic regression. Because of their perceived risk for iatrogenic fluid overload, we also evaluated patients with a history of heart failure and/or chronic kidney disease. MEASUREMENTS AND MAIN RESULTS: We identified 18,122 patients with sepsis and intermediate lactate values, including 36.1% treated after implementation. Full bundle compliance increased from 32.2% in 2011 to 44.9% after bundle implementation (P < 0.01). Hospital mortality was 8.8% in 2011, 9.3% in 2012, and 7.9% in 2013 (P = 0.02). Treatment after bundle implementation was associated with an adjusted hospital mortality odds ratio of 0.81 (95% confidence interval, 0.66-0.99; P = 0.04). Decreased hospital mortality was observed primarily in patients with a heart failure and/or kidney disease history (P < 0.01) compared with patients without this history (P > 0.40). This corresponded to notable changes in the volume of fluid resuscitation in patients with heart failure and/or kidney disease after implementation. CONCLUSIONS: Multicenter implementation of a treatment bundle for patients with sepsis and intermediate lactate values improved bundle compliance and was associated with decreased hospital mortality. These decreases were mediated by improved mortality and increased fluid administration among patients with a history of heart failure and/or chronic kidney disease.

Implementing clinical practice guidelines for screening and detection of delirium in a 21-hospital system in northern California: real challenges in performance improvement.

PURPOSE: The purpose of this article was to describe a quality improvement process on a diverse adult intensive care unit (ICU) population for a large healthcare organization for early detection of delirium. BACKGROUND: Delirium is often considered a common unpreventable problem in the ICU. A process for early detection of delirium allows the critical care team to evaluate the patient and intervene to improve or reverse the delirium. DESCRIPTION: A business case was first developed, and then using performance improvement methodology combined with quality improvement methods and oversight from a Delirium/Sedation Workgroup, an implementation plan was developed. Intensive care clinical nurse specialists were educated; patients in the ICU were screened for delirium twice daily by bedside nurses using the Confusion Assessment Method. The clinical nurse specialist in each ICU was instrumental for driving the process of change and supporting the bedside nurse and physicians to discuss preventing, screening, and treating delirium. OUTCOME: System-wide process implementation was completed in 1 year, 2011. In 2012, all medical centers had a program in place to decrease the use of benzodiazepines and improve communication in the multidisciplinary teams during daily rounds about the treatment and prevention of delirium. The process of performance improvement is ongoing with continual reassessment and feedback required to ensure sustainability. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Performance improvement involving 21 medical centers is a large-scale undertaking by an organization. It requires a systematic approach with key stakeholders and advanced practice nurses as subject matter experts involved throughout all phases of the implementation. Bedside clinicians assessing the patient must feel supported and valued members of the process. Challenges of all care providers need to be acknowledged and addressed.

Transformational quality in Kaiser Permanente Northern California.

The evolving nature of health care related to optimizing the quality of patient care while increasing efficiencies presents an opportunity to redesign roles within hospital quality departments to meet these upcoming challenges. Specifically, passage of the Patient Protection and Affordable Care Act and creation of Accountable Care Organizations will require hospitals to carefully monitor patient care outcomes as well as continually seek to improve their processes. An approach used by the Kaiser Permanente Northern California Regional Quality and Regulatory Services Department assisted the 21 hospitals of Kaiser Permanente Northern California to improve quality-of-care outcomes, establish effective assessment teams, and create infrastructure for sustainability. Leadership by a centralized internal consulting group used a model that weighs risk and opportunity against cost and outcomes to support strategic planning as projects and initiatives developed, rather than after they were initiated. This model can assist other organizations in maximizing cost-efficient and -effective performance improvement approaches to clinical and operational excellence.

Kaiser Permanente's performance improvement system, part 3: multisite improvements in care for patients with sepsis.

BACKGROUND: In 2008, Kaiser Permanente Northern California implemented an initiative to improve sepsis care. Early detection and expedited implementation of sepsis treatment bundles that include early goal-directed therapy (EGDT) for patients with severe sepsis were implemented. METHODS: In a top-down, bottom-up approach to performance improvement, teams at 21 medical centers independently decided how to implement treatment bundles, using a "playbook" developed by rapid cycle pilot testing at two sites and endorsed by a sepsis steering committee of regional and medical center clinical leaders. The playbook contained treatment algorithms, standardized order sets and flow charts, best practice alerts, and chart abstraction tools. Regional mentors and improvement advisers within the medical centers supported team-building and rapid implementation. Timely and actionable data allowed ongoing identification of improvement opportunities. A consistent approach to performance improvement propelled local rapid improvement cycles and joint problem solving across facilities. RESULTS: The number of sepsis diagnoses per 1,000 admissions increased from a baseline value of 35.7 in July 2009 to 119.4 in May 2011. The percent of admitted patients who have blood cultures drawn who also have a serum lactate level drawn increased from a baseline of 27% to 97% in May 2011. The percent of patients receiving EGDT who had a second and lower lactate level within six hours increased from 52% at baseline to 92% in May 2011. CONCLUSION: Twenty-one cross-functional frontline teams redesigned processes of care to provide regionally standardized, evidence-based treatment algorithms for sepsis, substantially increasing the identification and risk stratification of patients with suspected sepsis and the provision of a sepsis care bundle that included EGDT.

Subunit stoichiometry of the Kir1.1 channel in proton-dependent gating.

Kir1.1 channel regulates membrane potential and K+ secretion in renal tubular cells. This channel is gated by intracellular protons, in which a lysine residue (Lys80) plays a critical role. Mutation of the Lys80 to a methionine (K80M) disrupts pH-dependent channel gating. To understand how an individual subunit in a tetrameric channel is involved in pH-dependent channel gating, we performed these studies by introducing K80M-disrupted subunits to tandem tetrameric channels. The pH sensitivity was studied in whole-cell voltage clamp and inside-out patches. Homomeric tetramers of the wild-type (wt) and K80M-disrupted channels showed a pH sensitivity almost identical to that of their monomeric counterparts. In heteromeric tetramers and dimers, pH sensitivity was a function of the number of wt subunits. Recruitment of the first single wt subunit shifts the pK(a) greatly, whereas additions of any extra wt subunit had smaller effects. Single-channel analysis revealed that the tetrameric channel with two or more wt subunits showed one substate conductance at approximately 40% of the full conductance, suggesting that four subunits act as two pairs. However, three and four substates of conductance were seen in the tetrameric wt-3K80M and 4K80M channels. Acidic pH increased long-time closures when there were two or more wt subunits. Disruption of more than two subunits led to flicking activity with appearance of a new opening event and loss of the long period of closures. Interestingly, the channel with two wt subunits at diagonal and adjacent configurations showed the same pH sensitivity, substate conductance, and long-time closure. These results thus suggest that one functional subunit is sufficient to act in the pH-dependent gating of the Kir1.1 channel, the channel sensitivity to pH increases with additional subunits, the full pH sensitivity requires contributions of all four subunits, and two subunits may be coordinated in functional dimers of either trans or cis configuration.

Lessons learned from urban Latinas with type 2 diabetes mellitus.

This study focused on Latinas (female Hispanics) with Type 2 diabetes because this disease has a high prevalence and incidence among this population and cultural norms may affect women's experiences with diabetes. The study used a descriptive phenomenology design with a purposive sample of 13 Latina volunteers recruited from a local community health center in southern New England. Data were collected via interviews in English or Spanish. Six themes emerged from the analysis: stress as a cause and effect; too little, too late; profound sadness, diabetic anger, and loss of control; obsession with diet; life under a magnifying glass; and religion as a lifeline. Further research should pursue development of a culturally relevant approach to the health care management of Latinos.