Comparison of Aerodigestive and Nonaerodigestive Provider Responses to Clinical Case Vignettes.

OBJECTIVE: To evaluate differences in practice patterns between aerodigestive and nonaerodigestive providers in pediatric gastroenterology when diagnosing and treating common aerodigestive complaints. STUDY DESIGN: A questionnaire comprised of clinical vignettes with multiple-choice questions was distributed to both aerodigestive and nonaerodigestive pediatric gastroenterologists. Vignettes focused on management of commonly encountered general gastroenterology and aerodigestive issues, such as gastroesophageal (GE) reflux, aspiration, and feeding difficulties. Tests of equal proportions were used to compare rates of testing and empiric therapy within and across groups. Multivariate analysis was used to assess differences in response rates between aerodigestive and nonaerodigestive providers. RESULTS: A total of 88 pediatric gastroenterologists from 18 institutions completed the questionnaire. There were 35 aerodigestive gastroenterology providers and 53 nonaerodigestive gastroenterology providers. The nonaerodigestive group included 31 general gastroenterologists and 22 providers with self-identified subspecialty gastroenterology expertise. Aerodigestive specialists were more likely than nonaerodigestive gastroenterologists to pursue testing over empiric therapy in cases involving isolated respiratory symptoms (P < .05); aerodigestive providers were more likely to recommend pH-impedance testing, videofluoroscopic swallow studies, and upper gastrointestinal barium study (P < .05 for each test) depending on the referring physician. For vignettes involving infant GE reflux, both groups chose empiric treatments more frequently than testing (P < .001), although aerodigestive providers were more likely than nonaerodigestive providers to pursue testing like upper gastrointestinal barium studies (P < .05). CONCLUSIONS: Although some practice patterns were similar between groups, aerodigestive providers pursued more testing than nonaerodigestive providers in several clinical scenarios including infants with respiratory symptoms and GE reflux.

Clinician Perception of a Machine Learning-Based Early Warning System Designed to Predict Severe Sepsis and Septic Shock.

OBJECTIVE: To assess clinician perceptions of a machine learning-based early warning system to predict severe sepsis and septic shock (Early Warning System 2.0). DESIGN: Prospective observational study. SETTING: Tertiary teaching hospital in Philadelphia, PA. PATIENTS: Non-ICU admissions November-December 2016. INTERVENTIONS: During a 6-week study period conducted 5 months after Early Warning System 2.0 alert implementation, nurses and providers were surveyed twice about their perceptions of the alert's helpfulness and impact on care, first within 6 hours of the alert, and again 48 hours after the alert. MEASUREMENTS AND MAIN RESULTS: For the 362 alerts triggered, 180 nurses (50% response rate) and 107 providers (30% response rate) completed the first survey. Of these, 43 nurses (24% response rate) and 44 providers (41% response rate) completed the second survey. Few (24% nurses, 13% providers) identified new clinical findings after responding to the alert. Perceptions of the presence of sepsis at the time of alert were discrepant between nurses (13%) and providers (40%). The majority of clinicians reported no change in perception of the patient's risk for sepsis (55% nurses, 62% providers). A third of nurses (30%) but few providers (9%) reported the alert changed management. Almost half of nurses (42%) but less than a fifth of providers (16%) found the alert helpful at 6 hours. CONCLUSIONS: In general, clinical perceptions of Early Warning System 2.0 were poor. Nurses and providers differed in their perceptions of sepsis and alert benefits. These findings highlight the challenges of achieving acceptance of predictive and machine learning-based sepsis alerts.

Variability in Antibiotic Prescribing for Upper Respiratory Illnesses by Provider Specialty.

OBJECTIVE: To evaluate variation in antibiotic prescribing between pediatric and nonpediatric providers for common upper respiratory illnesses. STUDY DESIGN: Patient encounters for children aged <18 years from a regional health care system were identified. Electronic medical records from 2011 to 2016 were extracted for diagnoses of upper respiratory infection, pharyngitis, acute otitis media, and sinusitis. Encounters with competing medical diagnoses, recent hospitalization, and antibiotic prescriptions within 30 days were excluded. Adherence to antibiotic guidelines was assessed by provider training (pediatric, nonpediatric physicians, and advance practice providers). Additional factors assessed were calendar year, and patient's age, sex, insurance status, and number of sick visits in the prior year. RESULTS: Across 6 years, 141 361 visits were examined: 43 914 for upper respiratory infection, 43 701 for pharyngitis, 43 925 for acute otitis media, and 9821 for sinusitis. Pediatricians were more likely than Advanced practice providers (APP) and nonpediatric providers to have guideline-concordant prescribing for pharyngitis (pediatricians, 66.7% [95% CI, 54.5-77.0]; nonpediatricians, 49.1% [95% CI, 36.3-62.0], APPs, 52.2% [95% CI, 39.4-64.7]; P < .0001) and sinusitis (pediatricians, 70.8% [95% CI, 53.8-83.4], nonpediatricians, 63.3% [95% CI, 46.8-77.2], APPs, 62.1% [95% CI, 45.1-76.5]; P = .48) and to withhold antibiotics for upper respiratory infection than APPs and nonpediatric providers (pediatricians, 86.6% [95% CI, 81.2-90.6], nonpediatricians, 80.8% [95% CI, 73.0-86.8], APPs, 76.8% [95% CI, 68.4-83.5]; P < .0001). Pediatricians were less likely to prescribe antibiotics for pharyngitis without a positive test for group A Streptococcus than APPs and nonpediatric providers (pediatricians, 15.1% [95% CI, 10.4-21.6], nonpediatricians, 29.4% [95% CI, 20.8-39.6], APPs, 27.2% [95% CI, 19.3-36.9]; P < .0001). First-line antibiotic prescribing for acute otitis media did not differ between provider specialties. A trend toward more guideline-concordant prescribing was seen for pharyngitis and sinusitis over the study period. CONCLUSIONS: Pediatricians were more likely to adhere to guidelines for management of pediatric acute respiratory infections. Pediatric antibiotic stewardship efforts should also target nonpediatricians.

Assessing gastric residual volume: a description of nurses' clinical practice. / Aferição do volume residual gástrico: retrato da prática clínica de enfermeiros.

OBJECTIVE: To analyze the differences in nurses' clinical practice for assessing residual gastric volume and identifying the theoretical framework which supports their practice. METHOD: A cross-sectional study carried out by sending an online questionnaire by e-mail to nurses registered at the Regional Nursing Council of the State of São Paulo. RESULTS: This study included 598 nursing professionals, with 484 only providing care to adults and 114 exclusively to children. The gastric residual volume test is performed by 83.4% of nursing professionals; in most cases the suspension and prescription of enteral nutritional therapy are performed by the physician. Suspension of enteral nutritional therapy among adults predominantly occurs when the gastric residual volume is equal to 200 ml, and in children when values are less than 100 ml. Procedure after diet suspension involves the return of aspirated gastric contents and maintaining the catheter closed until the next hour in 48.3% of the procedures among adults, and 68.4% among children. 42.9% of the participants in this study were not aware of the theoretical basis that supports the test performance. CONCLUSION: We can highlight the need for nurses' training and further studies focused on the practice for assessing gastric residual volume.

Indian nurses' Knowledge, Attitude and Practice towards use of physical restraints in psychiatric patients.

OBJECTIVES: To assess nurses' knowledge, attitude and practice towards using physical restraints among psychiatric patients. METHODS: A descriptive cross sectional survey was carried out among conveniently selected sample of nurses working in psychiatry departments at a tertiary care center. The data was collected using self reported questionnaires of Suen. RESULTS: The findings revealed that nurses had good knowledge (7.2±1.7, maximum posible=11), favorable attitudes 30.8± 3.3 (maximum posible=48) and good practice 31.2±6.2 (maximun posible=42) about use of physical restraints in psychiatric patients. Females had better knowledge (p<0.001), attitudes (p<0.05) than males towards use of physical restraints. Nurses those had more than ten years of experience found to have more favorable attitudes towards using physical restraints than nurses with less experience (p<0.05) and nurses with higher education differed significantly on practice score than nurses with basic education in nursing (p<0.05). CONCLUSIONS: This study revealed good knowledge, positive attitudes and good practices among nurses about using physical restraints in mental health services. However there is need to improve even more nurses practice through continuing education programs on this topic.

Implementation of care practices to prevent and repair perineal trauma in childbirth. / Implementação de práticas assistenciais para prevenção e reparo do trauma perineal no parto.

OBJECTIVE: To implement care practices for perineal trauma prevention and repairing in normal birth. METHOD: Quasi-experimental study conducted at Hospital da Mulher Mãe-Luzia, in Macapá, AP, Brazil. Seventy-four (74) nurses and obstetricians and 70 post-partum women were interviewed and the records of 555 patients were analyzed. The study was conducted in three stages: pre-audit and baseline audit (phase 1); educational intervention and implementation of best practices (phase 2); post-implementation audit (phase 3). Data was analyzed by comparison of the results of phases 1 and 3. RESULTS: Following the educational intervention, a lower number of health professionals encouraged directed pushing, performed episiotomies and repaired first-degree lacerations; more women reported lithotomy position; more patient records indicated the use of Vicryl™ to suture the perineal mucosa and skin. CONCLUSION: The educational intervention improved birth care and perineal outcomes. Nevertheless, gaps were identified in the implementation of evidence, as well as inappropriate perineal care management.

Evaluating the Feasibility of Using Mobile Devices for Nurse Documentation.

The use of electronic health records (EHR) has changed the quality of clinical documentation and improved quality of patient assistance, allowing better communication between health professionals and increased data recording that helps the nursing assistance process. The use of mobile devices for compiling data at the assistance moment has increased, and more studies have demonstrated its usefulness. The aim of this study was to evaluate the use of mobile devices in the nursing staff of the Hospital Italiano de Buenos Aires, in a pilot test to measure their use and user satisfaction.

Nursing Activities Score: Cloud Computerized Structure.

This study objective to describe the cloud Nursing Activities Score implementation process in the Intensive Care Unit of the Post-Anesthesia Recovery Room. It is a case study. The tools used were the Google applications with high productivity interconnecting the topic knowledge on behalf of the nursing professionals and information technology professionals. As partial results, it was determined that the average nursing staff workload in the ICU/PARR during the first 24 hours, according to the score on the scale, was 91.75 ± 18.2. Each point of NAS is converted into 14.4 minutes, which is equivalent to an average of 22 working hours. Currently the instrument is implemented in the institution, reinforcing the need to update and raise awareness concerning the need to maintain the new routine.

A Nursing Survey on Nutritional Care Practices in French-Speaking Pediatric Intensive Care Units: NutriRéa-Ped 2014.

OBJECTIVES: Malnutrition in critically ill children contributes to morbidity and mortality. The French-speaking pediatric intensive care nutrition group (NutriSIP) aims to promote optimal nutrition through education and research. METHODS: The NutriSIP-designed NutriRéa-Ped study included a cross-sectional survey. This 62-item survey was sent to the nursing teams of all of the French-speaking pediatric intensive care units (PICUs) to evaluate nurses' nutrition knowledge and practices. One nurse per PICU was asked to answer and describe the practices of their team. RESULTS: Of 44 PICUs, 40 responded in Algeria, Belgium, Canada, France, Lebanon, Luxemburg, and Switzerland. The majority considered nutrition as a priority care but only 12 of the 40 (30%) had a nutrition support team, 26 of the 40 (65%) had written nutrition protocols, and 19 of 39 (49%) nursing teams felt confident with the nutrition goals. Nursing staff generally did not know how to determine nutritional requirements or to interpret malnutrition indices. They were also unaware of reduced preoperative fasting times and fast-track concepts. In 17 of 35 (49%) PICUs, the target start time for enteral feeding was within the first 24 hours; however, frequent interruptions occurred because of neuromuscular blockade, fasting for extubation or surgery, and high gastric residual volumes. Combined pediatric neonatal intensive care units were less likely to perform systematic nutritional assessment and to start enteral nutrition rapidly. CONCLUSIONS: We found a large variation in nursing practices around nutrition, exacerbated by the lack of nutritional guidelines but also because of the inadequate nursing knowledge around nutritional factors. These findings encourage the NutriSIP to improve nutrition through focused education programs and research.

Implementação de práticas assistenciais para prevenção e reparo do trauma perineal no parto / Implementación de prácticas asistenciales para la prevención y reparación de trauma perineal en el parto / Implementation of care practices to prevent and repair perineal trauma in childbirth

RESUMO Objetivos Implementar práticas assistenciais para prevenção e reparo do trauma perineal no parto normal. Métodos Estudo quase-experimental, realizado no Hospital da Mulher Mãe-Luzia, Macapá, AP. Realizaram-se 74 entrevistas com enfermeiros e médicos e 70 com puérperas, e analisaram-se dados de prontuários (n=555). O desenvolvimento da pesquisa se deu em três fases: pré-auditoria e auditoria de base (fase 1); intervenção educativa e implementação de boas práticas assistenciais (fase 2); auditoria pós-implementação (fase 3); a análise foi pela comparação das fases 1 e 3. Resultados Após a intervenção educativa, menos profissionais incentivavam puxos dirigidos, realizavam episiotomia e suturavam lacerações de primeiro grau; mais mulheres informaram que o parto foi em posição litotômica; mais registros nos prontuários indicaram o uso de Vicryl® na sutura da mucosa e pele. Conclusões A intervenção educativa melhorou os cuidados e os desfechos perineais, porém há lacunas na implementação das evidências e inadequações no manejo do cuidado perineal.

RESUMEN Objetivo Implementar prácticas asistenciales para la prevención y reparación del trauma perineal en el parto. Método Estudio casi experimental, conducido en el Hospital da Mulher Mãe-Luzia, Macapá, AP. Se realizaron 74 entrevistas con médicos y enfermeras y 70 con puérperas y se analizaron los datos de registros médicos (n=555). La investigación se desarrolló en tres fases: preauditoría y auditoría de base (fase 1); intervención educativa e implementación de buenas prácticas asistenciales (fase 2); auditoría posimplementación (fase 3); el análisis fue comparando las fases 1 y 3. Resultados Después de la intervención educativa, menos profesionales incentivaban pujo dirigido, realizaban episiotomía y suturaban desgarros de primer grado; más mujeres tuvieron el parto en posición litotomía; más registros indicaban uso de Vicryl® para suturar la mucosa y piel. Conclusión La intervención educativa ha mejorado el cuidado y los resultados perineales, pero hay lagunas en la implementación de evidencias y deficiencias en el cuidado perineal.

ABSTRACT Objective To implement care practices for perineal trauma prevention and repairing in normal birth. Method Quasi-experimental study conducted at Hospital da Mulher Mãe-Luzia, in Macapá, AP, Brazil. Seventy-four (74) nurses and obstetricians and 70 post-partum women were interviewed and the records of 555 patients were analyzed. The study was conducted in three stages: pre-audit and baseline audit (phase 1); educational intervention and implementation of best practices (phase 2); post-implementation audit (phase 3). Data was analyzed by comparison of the results of phases 1 and 3. Results Following the educational intervention, a lower number of health professionals encouraged directed pushing, performed episiotomies and repaired first-degree lacerations; more women reported lithotomy position; more patient records indicated the use of Vicryl™ to suture the perineal mucosa and skin. Conclusion The educational intervention improved birth care and perineal outcomes. Nevertheless, gaps were identified in the implementation of evidence, as well as inappropriate perineal care management

Impact of a mobile health aplication in the nursing care plan compliance of a home care service in Belo Horizonte, Minas Gerais, Brazil.

OBJECTIVE: To assess impact of a mobile health solution in the nursing care plan compliance of a home care service. METHODS: A retrospective cohort study was performed with 3,036 patients. Compliance rates before and after the implementation were compared. RESULTS: After the implementation of a mobile health aplication, compliance with the nursing care plan increased from 53% to 94%. The system reduced IT spending, increased the nursing team efficiency and prevented planned hiring. CONCLUSION: The use of a mobile health solution with geolocating feature by a nursing home care team increased compliance to the care plan.

Autonomy and empowerment in advanced practice registered nurses: lessons from New Mexico.

PURPOSE: The purpose of this study was to determine the association between autonomy and empowerment of advanced practice registered nurses (APRNs) and predictor variables of physician oversight, geographical location, and practice setting. As the Patient Protection and Affordable Care Act (PPACA) is implemented, these characteristics are vital to understanding how APRNs practice and the relationship of APRNs to other healthcare team members, including physicians. DATA SOURCES: This was a descriptive, correlational survey of APRNs in New Mexico exploring autonomy and empowerment in relation to variables of physician oversight, geographical location, and practice setting. CONCLUSIONS: New Mexico's APRN Nurse Practice Act supports independent practice and prescriptive authority. Results indicated that APRNs are highly empowered and autonomous. However, nearly 40% of respondents identified practicing with physician oversight. Further investigation of subscales of empowerment also provided insight of relationships among healthcare team members, particularly physicians. IMPLICATIONS FOR PRACTICE: This research provides additional knowledge for policy changes that support APRNs assuming more responsibility for primary care. However, understanding the APRN role within the healthcare team is necessary for effective implementation of primary care in New Mexico.

Implementation of lipid screening guidelines in children by primary pediatric providers.

OBJECTIVE: To assess the awareness and implementation of lipid guidelines among primary pediatric providers. STUDY DESIGN: An online survey was administered to primary pediatric providers (n = 1488): pediatricians, family medicine/general practitioners, and advanced practitioners (nurse practitioners/physician assistants) in Minnesota. The survey was conducted over 12 weeks in 2012-2013. A multiple-choice questionnaire was used to evaluate the participants' knowledge, screening, and management attitudes regarding pediatric lipid guidelines. RESULTS: The overall response rate was 39% (n = 548 of 1402 successful e-mails). Respondents were primarily pediatricians and family medicine practitioners (37% each), followed by general practitioners (11%) and advanced practitioners (nurse practitioners, 5.5%; physician assistants, 1.6%). Although 74% of providers reportedly believed that lipid screening and treatment would reduce future cardiovascular risk, 34% performed no screening, 50% screened selectively, and only 16% performed universal screening. Pediatricians were more likely to screen, with 30% performing universal screening and 41% performing selective screening. Among perceived barriers to screening, providers reported uneasiness addressing lipid disorders (43%), and unfamiliarity with screening guidelines (31%). The majority (83%) were uncomfortable managing lipid disorders, and 57% were opposed to the use of lipid-lowering medications in children. CONCLUSION: These findings underscore the need to further educate providers and supply easily accessible information on the screening and treatment of childhood lipid disorders.

Políticas de distribución del RR HH de Enfermería, Según sus nivel de formación, en relación a las Leyes vigentes del ejercicio profesional de Enfermería del Hospital Interzonal San Juan Bautista de la Provincia de CATAMARCA ûa±o 2012 / Distribution policies Nursing HR, according to their level of training, in relation to current practice Laws Interzonal Nursing Hospital San Juan Bautista of the Province of Catamarca -year 2012

El presente trabajo tiene la finalidad reflexionar sobre el uso de las teorías de Enfermería en la prßctica. A pesar de los esfuerzos de los profesionales de Enfermería en construir conocimiento a través de las teorías y modelos y del alto nivel alcanzado en la formación de Enfermería, aún no se evidencia en la prßctica la implementación de las teorías y odelos que fundamenten la misma. Por el contrario se ha considerado que la prßctica de Enfermería se ha basado en la técnica y el cumplimiento de las Leyes vigentes sobre los procedimientos rutinarios Se utilizó un abordaje Cuali-Cuantitativo-Descriptivo, interpretativo, estratificado por servicio, de corte transversal, en un universo de 165 enfermeros del Hospital Interzonal San Juan Bautista de la Provincia de Catamarca, cuya muestra seleccionada fue de 41 enfermeros de los servicios de Clínica, Terapia y Cirugía, seleccionada en forma estratificada por servicio en forma aleatoria...

The present work aims to reflect on the use of nursing theories in practice. Despite the efforts of professionals from nursing to build knowledge through the theories and models and the high level achieved in the training of nursing, still not evident in practice implementation of the theories and models that support the same. On the other hand has been considerednursing practice is based on the technique and the enforcement of existing laws on procedures routine was used an approach qualitative-quantitative-descriptive, interpretive, stratified by service, cross section, in a universe of 165 nurses of the Hospital Interzonal San Juan Bautista of the province of Catamarca, whose sample was 41 nursing of clinic services Therapy and surgery, selected as stratified by randomly service...