Cerner Millennium's Care Pathways for Specialty Care Referrals: Provider and Nurse Experiences, Perceptions, and Recommendations for Improvements.

BACKGROUND: Using structured templates to guide providers in communicating key information in electronic referrals is an evidence-based practice for improving care quality. To facilitate referrals in Veterans Health Administration's (VA) Cerner Millennium electronic health record, VA and Cerner have created "Care Pathways"-templated electronic forms, capturing needed information and prompting ordering of appropriate pre-referral tests. OBJECTIVE: To inform their iterative improvement, we sought to elicit experiences, perceptions, and recommendations regarding Care Pathways from frontline clinicians and staff in the first VA site to deploy Cerner Millennium. DESIGN: Qualitative interviews, conducted 12-20 months after Cerner Millennium deployment. PARTICIPANTS: We conducted interviews with primary care providers, primary care registered nurses, and specialty providers requesting and/or receiving referrals. APPROACH: We used rapid qualitative analysis. Two researchers independently summarized interview transcripts with bullet points; summaries were merged by consensus. Constant comparison was used to sort bullet points into themes. A matrix was used to view bullet points by theme and participant. RESULTS: Some interviewees liked aspects of the Care Pathways, expressing appreciation of their premise and logic. However, interviewees commonly expressed frustration with their poor usability across multiple attributes. Care Pathways were reported as being inefficient; lacking simplicity, naturalness, consistency, and effective use of language; imposing an unacceptable cognitive load; and not employing forgiveness and feedback for errors. Specialists reported not receiving the information needed for referral triaging. CONCLUSIONS: Cerner Millennium's Care Pathways, and their associated organizational policies and processes, need substantial revision across several usability attributes. Problems with design and technical limitations are compounding challenges in using standardized templates nationally, across VA sites having diverse organizational and contextual characteristics. VA is actively working to make improvements; however, significant additional investments are needed for Care Pathways to achieve their intended purpose of optimizing specialty care referrals for Veterans.

Compressed 4-day workweek for dental faculty retention and recruitment.

Faculty recruitment and retention are major concerns faced by dental schools across the country. This increase in faculty shortage impacts training the next generation of clinicians and oral health care delivery in dental institutions, which together will exacerbate challenges related to access to dental care. The objective of this paper is to propose a compressed workweek as an incentive to improve recruitment, retention, and faculty well-being. There are several well-documented benefits of the 4-day workweek which include employee wellness, increased job satisfaction, happiness, and improved perception of personal worth. Cost savings may be also realized with this schedule, as expenses related to transportation and dependent care costs could potentially decrease. Altogether, these benefits have been shown to lead to reduced absenteeism, anxiety, stress, and burnout. This perspective piece will discuss how the 4-day workweek could be implemented in dental institutions, along with the benefits and challenges. Given the shortage of clinical faculty throughout the United States, we recommend this approach not only as a means to attract recent graduates to academia but also to ensure the retention of those who provide clinical instruction.

Leveraging Shared Governance to Build a Healthier Work Environment in a NICU.

PURPOSE: A unit-shared governance model was established in the NICU at Tampa General Hospital to enhance nursing autonomy and improve job satisfaction, teamwork, and patient outcomes. SIGNIFICANCE: Shared governance models have been introduced within health systems to shape healthy work environments. STRATEGY AND IMPLEMENTATION: The NICU experienced an extended hiring freeze that led to a significant nursing shortage and staff dissatisfaction. A unit-shared governance model was established to address key areas of concern. This led to the development of the new employee orientation committee. Their goal was to make significant changes in the onboarding and precepting process, including: (1) revising the Registered Nurse Competency-Based Orientation tool to align with a 3-phased orientation process, (2) incorporating a systems approach throughout the orientation period, (3) embedding references to best practices and policies, (4) creating a reference list of recommended reading materials, and (5) developing a skills checklist to guide in selection of patient assignments. The final step was developing a NICU preceptor course to increase consistency between preceptors and standardize orientation. OUTCOMES: Recent engagement survey results revealed significant improvements in employee satisfaction, validating key improvements made in the onboarding process.

Association between second stage of labour length and risk of obstetrical anal sphincter injury in nulliparous women: a population-based retrospective cohort study.

INTRODUCTION AND HYPOTHESIS: Obstetrical anal sphincter injury (OASIS) is a common consequence of vaginal delivery in nulliparas and carries the risk of short- and long-term morbidity. The objective of this study was to estimate the association between the duration of the second stage of labour and OASIS risk. METHODS: A population-based, retrospective cohort of nulliparas delivering singleton, vertex, non-anomalous fetuses at term in Nova Scotia, Canada, from 2005 to 2019, were identified using the Nova Scotia Atlee Perinatal Database. Poisson regression models were used to estimate risk ratios (RR) with robust 95% confidence intervals (CI) adjusting for confounding variables to investigate the association between the length of the second stage and OASIS in the entire cohort and in operative vaginal deliveries. RESULTS: Of 36,662 participants, 7.6% sustained an OASIS (6.8% third-degree, 0.8% fourth-degree tear). The proportion of participants who sustained an OASIS increased over the study period. For each 30-min increase in the length of second stage, the OASIS risk increased by 11% (RR 1.11, 95% CI 1.10-1.12). When stratified by mode of delivery, second stage length ≥ 90 min was associated with an increased OASIS risk in spontaneous (RR 1.35, 95% CI 1.15-1.58) and vacuum-assisted vaginal deliveries (RR 1.42, 95% CI 1.11-1.81). In forceps-assisted vaginal deliveries, OASIS risk was increased, with shorter and longer durations of the second stage. CONCLUSION: Increasing length of the second stage of labour was associated with increasing risk of OASIS overall, but the association was heterogeneous between modes of delivery. Length of the second stage should be considered in counseling about OASIS risk.

Cross-sectional survey describing general practitioners' absolute cardiovascular disease risk assessment practices and their relationship to knowledge, attitudes and beliefs about cardiovascular disease risk in Queensland, Australia.

OBJECTIVES: To describe general practitioners' (GPs') absolute cardiovascular disease risk (ACVDR) self-reported assessment practices and their relationship to knowledge, attitudes and beliefs about ACVDR. DESIGN: Cross-sectional survey with opportunistic sampling (October-December 2017). SETTING: Sunshine Coast region, Queensland, Australia. PARTICIPANTS: 111 GPs responded to the survey. PRIMARY AND SECONDARY OUTCOME MEASURES: Proportion of GPs reporting a high (≥80%) versus moderate (60%-79%)/low (<60%) percentage of eligible patients receiving ACVDR assessment; proportion agreeing with statements pertaining to knowledge, attitudes and beliefs about ACVDR and associations between these factors. RESULTS: Of the 111 respondents, 78% reported using the Australian ACVDR calculator; 45% reported high, 25% moderate and 30% low ACVDR assessment rates; >85% reported knowing how to use ACVDR assessment tools, believed assessment valuable and were comfortable with providing guideline-recommended treatment. Around half believed patients understood the concept of high risk and were willing to adopt recommendations. High assessment rates (vs moderate/low) were less likely among older GPs (≥45 vs ≤34 years, age-adjusted and sex-adjusted OR (aOR) 0.36, 95% CI 0.12 to 0.97). Those who answered knowledge-based questions about the guidelines incorrectly had lower assessment rates, including those who answered questions on patient eligibility (aOR 0.13, 95% CI 0.02 to 1.11). A high assessment rate was more likely among GPs who believed there was sufficient time to do the assessment (aOR 3.79, 95% CI 1.23 to 11.61) and that their patients were willing to undertake lifestyle modification (aOR 2.29, 95% CI 1.02 to 5.15). Over 75% of GPs agreed better patient education, nurse-led assessment and computer-reminder prompts would enable higher assessment rates. CONCLUSIONS: Although the majority of GPs report using the ACVDR calculator when undertaking a CVD risk assessment, there is a need to increase the actual proportion of eligible patients undergoing ACVDR assessment. This may be achieved by improving GP assessment practices such as GP and patient knowledge of CVD risk, providing sufficient time and nurse-led assessment.

High-Intensity Bowel Protocol for Trauma Patients.

BACKGROUND: Internal performance improvement data showed extended length of stay (LOS) in addition to an increased number of patients with constipation. This study was designed to evaluate the number of hospital days a trauma patient with opioid use had a bowel movement (BM) utilizing a high-intensity bowel protocol compared with the standard hospital bowel protocol. METHODS: This was a retrospective analysis of the trauma registry at a Level I trauma center from 2 different time periods to assess the number of hospital days that patients had a BM. These patients had a traumatic mechanism of injury that required admission to the hospital with a LOS equivalent to 3 or more days. Other data analyzed included age, gender, injury severity score (ISS), morphine equivalents (ME), and hospital days with a BM. RESULTS: A total of 282 patients were included in the final analysis. Group 1 represented the standard hospital bowel protocol (n = 166), and Group 2 represented the high-intensity bowel protocol (n = 116). No significant difference was calculated between age, gender, ISS, or ME per day. A significant difference was observed with the number of hospital days with a BM between these 2 groups. The group with the high-intensity bowel protocol exhibited more days with a BM than the standard bowel protocol group (p < .05). CONCLUSION: The high-intensity bowel protocol averaged 1 BM every 2 days, whereas the standard hospital bowel protocol averaged 1 BM every 3 days. There was no significant change in LOS.

The Impact of a Brief Embedded Mindfulness-Based Program for Veterinary Students.

Veterinary medical students, like other university students, are likely to experience elevated levels of stress, anxiety, and depression over the course of their studies. Mindfulness-based interventions have previously been effective for university students in reducing stress, depression, and anxiety. In this study, a mindfulness-based intervention was embedded in a core (compulsory) unit of a veterinary science course, in part with the aim of improving student well-being. Preliminary results suggest that, despite the mindfulness intervention, overall symptoms of stress, depression, and anxiety among participants (n=64) increased between the start and end of the semester. However, further analysis showed that most of this longitudinal increase was attributable to individuals who scored above the normal range (i.e., at least mild level of symptoms) in one or more measures at the beginning of the semester. Within this subset, individuals who regularly engaged in mindfulness practice once a week or more throughout the semester reported significantly lower depression and anxiety symptoms than those who practiced less than once a week (i.e., who had long periods without practice). Results suggest that engaging regularly in mindfulness practice potentially acted as a protective factor for students already experiencing at least a mild range of symptoms of anxiety and depression at the beginning of the semester. While not all veterinary students may derive significant benefit immediately, providing access to an embedded mindfulness program early in their program may facilitate the development of adaptive coping mechanisms, which may be engaged to increase resilience across their academic and professional life.

Is Preterm Premature Rupture of Membranes Latency Influenced by Single Versus Multiple Agent Antibiotic Prophylaxis in Group B Streptococcus Positive Women Delivering Preterm?

OBJECTIVE: To evaluate the influence of antibiotic regimen on the duration of latency (time from preterm pre-labour rupture of membranes [PPROM] to delivery) and significant infectious neonatal morbidity from rupture of membranes to delivery < 37 weeks' gestational age in women known to be group B Streptococcus (GBS) positive. METHODS: We obtained data from the Nova Scotia Atlee Perinatal Database. In a retrospective, cohort, population-based study, we included pregnancies complicated by PPROM but excluded pregnancies in this group requiring immediate delivery. The cohort was categorized by antibiotic regimen (single vs. multiple agents) and we compared latency and adverse neonatal outcomes according to antibiotic regimen used. Summary characteristics were compared using chi-square analysis with significance < 0.05. Logistic regression was used to estimate adjusted odds ratios, 95% confidence intervals, and mean differences for all outcomes and to account for confounding variables. RESULTS: From 1988 to 2011, the potential study population was 119 158 pregnancies. In total, 3435 deliveries were identified to be PPROM (3%). Of these, 303 mother-baby pairs (9%) were known to be GBS positive by urine or swab culture. Adjusted comparisons of latency and neonatal sepsis showed no difference according to antibiotic regimen (P > 0.05). CONCLUSION: The 2013 SOGC guideline on GBS prophylaxis recommends antibiotic therapy in women with PPROM for both latency and prevention of GBS-related neonatal sepsis. This clinically relevant evaluation in a select preterm group demonstrated that type of antibiotic regimen did not influence either latency with PPROM and GBS positive culture or rates of neonatal sepsis. Ongoing evaluation of serious neonatal outcomes is essential in view of this new recommendation.

Objectif : Évaluer l'influence d'un schéma antibiotique sur la durée de la latence (période séparant la rupture prématurée des membranes préterme [RPMP] et l'accouchement) et la présence d'une morbidité infectieuse néonatale considérable, entre la rupture des membranes et l'accouchement à < 37 semaines d'âge gestationnel, chez des femmes ayant obtenu des résultats positifs au dépistage des streptocoques du groupe B (SGB). Méthodes : Nous avons tiré des données de la Nova Scotia Atlee Perinatal Database. Dans le cadre d'une étude populationnelle de cohorte rétrospective, nous avons inclus les grossesses compliquées par la RPMP, mais nous avons exclu les grossesses de ce groupe qui nécessitaient un accouchement immédiat. La cohorte a été catégorisée en fonction du schéma antibiotique (un seul agent vs de multiples agents) et nous avons comparé la latence et les issues néonatales indésirables en fonction du schéma antibiotique utilisé. Les caractéristiques sommaires ont été comparées au moyen d'une analyse du chi carré (signification < 0,05). Une régression logistique a été utilisée pour estimer les rapports de cotes corrigés, les intervalles de confiance à 95 % et les différences moyennes pour toutes les issues et pour tenir compte des variables parasites. Résultats : Entre 1988 et 2011, la population d'étude potentielle s'élevait à 119 158 grossesses. Au total, 3 435 accouchements ont été identifiés comme présentant une RPMP (3 %). La présence de SGB avait été déterminée par uroculture ou par mise en culture d'écouvillonnages chez 303 paires mère-enfant (9 %) de ce groupe. Les comparaisons corrigées de la latence et de la septicémie néonatale n'ont indiqué aucune différence en fonction du schéma antibiotique (P > 0,05). Conclusion : La directive de 2013 de la SOGC sur la prophylaxie anti-SGB recommande la mise en œuvre d'une antibiothérapie chez les femmes qui présentent une RPMP, et ce, tant pour la latence que pour la prévention de la septicémie néonatale attribuable aux SGB. Cette évaluation pertinente sur le plan clinique auprès d'un groupe sélectionné d'accouchements prétermes a démontré que le type de schéma antibiotique n'influençait ni la latence (en présence d'une RPMP et de résultats positifs à la suite de la mise en culture des SGB) ni les taux de septicémie néonatale. La poursuite de l'évaluation des issues néonatales graves s'avère essentielle à la lumière de cette nouvelle recommandation.

Relative contribution of stoichiometry and mean coordination to the fragility of Ge-As-Se glass forming liquids.

The structural relaxation properties of 34 compositions of Ge-As-Se glass forming liquids are investigated by differential scanning calorimetry (DSC). The fragility index (m) and activation energies for enthalpy relaxation (Ea) exhibit universal trends with respect to stoichiometry and mean coordination (⟨r⟩), respectively. The liquid fragility which defines the full temperature dependence of the relaxation processes shows no well defined trend with respect to ⟨r⟩ but instead is found to be closely determined by the excess or deficiency in selenium with respect to stoichiometry. The mean coordination on the other hand appears to be an accurate predictor of the activation energy near the glass transition where most constraints are still intact. No intermediate phase is observed in either case. These results emphasize that chemical effects rather than topological effects appear to control the wide ranging structural mobility of these glass forming liquids. The consequences of these findings in terms of the thermal stability of the corresponding glasses are discussed. It is similarly found that sub-Tg relaxation is controlled by stoichiometry rather than topology.

Structural variation in ethylenediamine and -diphosphine adducts of (2,6-Me2C6H3S)2Pb: a single crystal X-ray diffraction and 207Pb solid-state NMR spectroscopy study.

Coordination complexes of (2,6-Me2C6H3S)2Pb (1) with flexible bidentate ligands have been prepared to explore new bonding environments for Pb(II) thiolates. The reaction of 1 with a series of ethylenediamine and ethylenediphosphine ligands resulted in isolation of the adducts [(2,6-Me2C6H3S)2Pb]2(tmeda) (9), [(2,6-Me2C6H3S)2Pb]3(dmpe) (10) and [(2,6-Me2C6H3S)2Pb]2(dppe) (11) [tmeda = N,N,N',N'-tetramethylethylenediamine; dmpe = bis(dimethylphosphino)ethane; dppe = bis(diphenylphosphino)ethane]. The X-ray crystal structure of 9 shows a dinuclear species in which tmeda is chelating a ψ-trigonal bipyramidal S2N2 Pb centre via axial and equatorial sites. The structure of 10 displays a trinuclear structural unit in which dmpe is chelating a ψ-trigonal bipyramidal S2P2 Pb centre via equatorial sites. Compounds 9 and 10 also contain a second unique metal centre with ψ-tetrahedral S3Pb bonding motifs. The structure of 11 shows the dppe ligand bridging two Pb ψ-tetrahedral S2P metal bonding environments. Static (207)Pb solid-state NMR (SSNMR) spectra of 9-11 and [Ph4As][(PhS)3Pb] (12) were acquired with cross polarization (CP)-CPMG and frequency swept pulse (WURST)-CPMG pulse sequences, and the efficiencies of these pulse sequences are compared. The (207)Pb SSNMR spectra reveal that the lead chemical shift anisotropies (CSA) vary greatly between the different Pb sites, and are generally large in magnitude. DFT calculations are utilized to relate the orientations of the (207)Pb nuclear magnetic shielding tensors to the molecular structures, and to aid in spectral assignment where multiple Pb centres are present. The combination of X-ray diffraction, (207)Pb SSNMR and DFT is shown to be invaluable for the structural characterization of these important structural motifs, and should find wide-ranging application to numerous lead coordination compounds.

Using a theory to understand triage decision making.

The purpose of this discussion is to present triage decision making research within the context of the Revised Cognitive Continuum Theory. Triage is an essential clinical skill in emergency nursing. Understanding the best way to facilitate this skill is vital when educating new nurses or providing continuing education to practicing nurses. Delineating research evidence within a theory allows clinical educators to understand practices that foster successful triage skills and permits the grounding of educational strategies within a theoretical framework.

Use of multiple pedagogies to promote confidence in triage decision making: a pilot study.

BACKGROUND: The purpose of this pilot study was to determine whether the addition of educational interventions to required clinical hours promotes confidence in triage decision making among nursing students enrolled in a final capstone course. METHODS: An experimental design was implemented with randomization of students (n = 14) to 1 of 3 intervention groups or the control group. The Triage Decision Making Inventory was used as a pretest-posttest. Educational strategies implemented included an Advanced Cardiac Life Support course and simulations with debriefing. Interventions were in addition to required clinical hours. RESULTS: A mixed analysis of variance was used to examine the 4 groups by time, with all groups exhibiting higher scores on the Triage Decision Making Inventory from the pretest to the posttest (F (3, 10) = 4.51, P = .03 (η(2) = .575). Students who received both the simulations and the Advanced Cardiac Life Support course demonstrated a significant difference across time. CONCLUSIONS: As nursing education evolves with the integration of technology, the combination of multiple pedagogies also can enhance confidence in triage decision making among experienced and novice nurses in emergency settings.

A new ball game: the United Nations Convention on the Rights of Persons with Disabilities and assumptions in care for people with dementia.

The United Nations Convention on the Rights of Persons with Disabilities is a powerful international instrument which imposes significant responsibilities on signatories. This column discusses changes in the definition of legal capacity which will have significant impacts on decision-making related to people with dementia. Various restrictions and limitations on personal freedoms are discussed in light of the Convention. The main focus is on challenges to existing paradigms of substitute decision-making, which are in wide use through a guardianship model. Under Art 12 of the Convention, moves to supported decision-making will result in significant changes in ensuring the rights of people with dementia. There are challenges ahead in implementing supported decision-making schemes, not only due to tension with existing practices and legislation, but also the difficulty of developing and resourcing workable schemes. This is particularly so with advanced dementia, which is acknowledged as a pressing issue for Australia due to effective health care, an ageing population and changing expectations.

Assessing confidence in triage decision making: evaluation of an inventory in a sample of navy and civilian nurses.

Triage decision making and prioritizing nursing care are essential nursing skills in all clinical settings. The purpose of this study was to evaluate the psychometric properties of the Triage Decision Making Inventory in a sample of Navy and civilian nurses with diverse clinical specialties and years of clinical experience. Establishing reliability and validity allows staff development educators to evaluate training strategies that promote confidence in decision making among nurses of all specialty practices.

Signs of aging or the vague symptoms of ovarian cancer?

PURPOSE/OBJECTIVES: To explore the feelings that occurred at the same time as the vague physical symptoms of ovarian cancer. RESEARCH APPROACH: Qualitative, descriptive methodology. SETTING: University cancer institute in southeastern United States. PARTICIPANTS: 24 women (ages 39-78) diagnosed with ovarian cancer. Most were Caucasian, were diagnosed at stage II-III, had a college-level education, and had health insurance. Eighty-three percent did not know the signs and symptoms of ovarian cancer prior to diagnosis, and 91% had no family history of the cancer. METHODOLOGIC APPROACH: SPSS (version 18.0) was used to summarize the demographic characteristics and qualitative descriptive content analysis to identify and summarize themes in the narrative data. FINDINGS: Two themes were noted in the handwritten answers provided by the women: (a) "thought symptoms were aging" and (b) "felt or knew something was not right." CONCLUSIONS: Findings demonstrate and reinforce that a need exists for education regarding signs and symptoms of ovarian cancer among the general population as well as the common providers of women's health care. INTERPRETATION: Education campaigns on signs and symptoms of ovarian cancer and normal aging are necessary so women are empowered with knowledge and healthcare providers can suspect and evaluate the symptoms.

catena-Poly[[bis(pyridine)-lead(II)]bis(µ-penta-fluoro-benzene-thiol-ato)].

The title compound, [Pb(C(6)F(5)S)(2)(C(5)H(5)N)(2)](n), shows the Pb(II) atom in a ψ-trigonal bipyramidal S(2)N(2) bonding environment. Pyridine N atoms occupy axial sites, while thiol-ate S atoms and a stereochemically active lone pair occupy equatorial sites. Very long inter-molecular Pb⋯S inter-actions [3.618 (4) and 3.614 (4) Å] yield a weakly associated one-dimensional polymeric structure extending parallel to [010].