Application of the Plan-Do-Study-Act method to optimize the ordering and administration of dexmedetomidine for sleep hygiene in the intensive care unit.

PURPOSE: To describe the Plan-Do-Study-Act (PDSA) methodology utilized by a multidisciplinary team to address the discordance between ordering and administration of dexmedetomidine for sleep hygiene in the intensive care unit (ICU). SUMMARY: The addition of sleep hygiene as an indication for the use of dexmedetomidine at University of Virginia (UVA) Health led to discordance between the medication orders in the electronic medical record and the subsequent administration of dexmedetomidine. A multidisciplinary team implemented interventions that included modifying the order panel, streamlining the institutional formulary, developing institutional practice guidelines, and providing education to healthcare team members. After completion of the first PDSA cycle, the mean number of discordant order elements decreased to 1.96 out of 5 possible order elements from an initial 2.5 out of 5 elements before the interventions, meeting the aim to reduce the mean to less than 2. There was a significant decrease in the discordance in the duration of infusion (discordant for 14 of 30 orders before the interventions vs 1 of 28 orders after the interventions, P = 0.0002) but a significant increase in the discordance in the titration dose (discordant for 13 of 30 orders before the interventions vs 24 of 28 orders after the interventions, P < 0.0001). Other discordant order elements including the starting dose, maximum rate, and titration interval time decreased in frequency after the interventions, although the differences were not statistically significant. The interventions made during the first PDSA cycle are anticipated to lead to an estimated cost savings of up to $180,000 per year within the UVA Health system. CONCLUSION: The multidisciplinary team utilizing a PDSA method to modify the order panel, streamline the institutional formulary, develop institutional practice guidelines, and provide education to healthcare team members was effective at reducing overall discordance between order intent and administration of dexmedetomidine for sleep hygiene in the ICU.

Resource competition explains rare cannibalism in the wild in livebearing fishes.

Cannibalism, the act of preying on and consuming a conspecific, is taxonomically widespread, and putatively important in the wild, particularly in teleost fishes. Nonetheless, most studies of cannibalism in fishes have been performed in the laboratory. Here, we test four predictions for the evolution of cannibalism by conducting one of the largest assessments of cannibalism in the wild to date coupled with a mesocosm experiment. Focusing on mosquitofishes and guppies, we examined 17 species (11,946 individuals) across 189 populations in the wild, spanning both native and invasive ranges and including disparate types of habitats. We found cannibalism to be quite rare in the wild: most populations and species showed no evidence of cannibalism, and the prevalence of cannibalism was typically less than 5% within populations when it occurred. Most victims were juveniles (94%; only half of these appeared to have been newborn offspring), with the remaining 6% of victims being adult males. Females exhibited more cannibalism than males, but this was only partially explained by their larger body size, suggesting greater energetic requirements of reproduction likely play a role as well. We found no evidence that dispersal-limited environments had a lower prevalence of cannibalism, but prevalence was greater in populations with higher conspecific densities, suggesting that more intense resource competition drives cannibalistic behavior. Supporting this conclusion, our mesocosm experiment revealed that cannibalism prevalence increased with higher conspecific density and lower resource levels but was not associated with juvenile density or strongly influenced by predation risk. We suggest that cannibalism in livebearing fishes is rare in the wild because preying on conspecifics is energetically costly and only becomes worth the effort when competition for other food is intense. Due to the artificially reduced cost of capturing conspecifics within confined spaces, cannibalism in captive settings can be much more frequent.