The CNO US Healthcare Immersion Program, Part 1: A Transformational Leadership Model.

As a result of recent global health events, US health care leaders are strengthening international relationships to share best practices, health research, and support of workforce capacity. The Institute for Healthcare Improvement, the National Academies of Sciences, Engineering, and Medicine, the American Nurses Credentialing Center, and the Joint Commission International have all committed to expanding their vision and mission to improve health and health care globally. To support excellence in international health care delivery, the authors embarked on a Chief Nursing Officer (CNO) US Healthcare Immersion Program. The purpose of the program is to introduce the US nursing leadership competences to China CNO colleagues in preparation for their future role with health care reform.

MotivATE: A Pretreatment Web-Based Program to Improve Attendance at UK Outpatient Services Among Adults With Eating Disorders.

BACKGROUND: In the UK, eating disorders affect upward of 725,000 people per year, and early assessment and treatment are important for patient outcomes. Around a third of adult outpatients in the UK who are referred to specialist eating disorder services do not attend, which could be related to patient factors related to ambivalence, fear, and a lack of confidence about change. This lack of engagement has a negative impact on the quality of life of patients and has implications for service costs. OBJECTIVE: To describe the development of a Web-based program ("MotivATE") designed for delivery at the point of referral to an eating disorder service, with the aim of increasing service attendance. METHODS: We used intervention mapping and a person-based approach to design the MotivATE program and conducted a needs assessment to determine the current impact of service nonattendance on patients (via a review of the qualitative evidence) and services (through a service provision survey to understand current issues in UK services). Following the needs assessment, we followed the five steps of program development outlined by Bartholomew et al (1998): (1) creating a matrix of proximal program objectives; (2) selecting theory-based intervention methods and strategies; (3) designing and organizing the program; (4) specifying adoption and implementation plans; and (5) generating program evaluation plans. RESULTS: The needs assessment identified current nonattendance rates of 10%-32%. We defined the objective of MotivATE as increasing attendance rates at an eating disorder service and considered four key determinants of poor attendance: patient ambivalence about change, low patient self-efficacy, recognition of the need to change, and expectations about assessment. We chose aspects of motivational interviewing, self-determination theory, and the use of patient stories as the most appropriate ways to enable change. Think-aloud piloting with people with lived experience of an eating disorder resulted in positive feedback on the MotivATE program. Participants related well to the stories used. Nonetheless, because of feedback, we further modified the program in line with patients' stage of change and addressed issues with the language used. A consultation with service staff meant that we could make clear implementation plans. Finally, a randomized controlled trial is currently underway to evaluate the MotivATE program. CONCLUSIONS: Using intervention mapping, we have developed a novel pretreatment Web-based program that is acceptable to people with eating disorders. To our knowledge, this is the first such program. The model of development described here could be a useful template for designing further programs for other difficult-to-engage populations.

Timely delivery of hip fracture care: a Middlemore Hospital audit.

INTRODUCTION: New Zealand (NZ) hospitals lack a centralised audit process to evaluate hip fracture care whereas UK hospitals audit hip fracture care in relation to best practice guidelines. This study sought to evaluate multiple factors in hip fracture care at Middlemore Hospital (MMH). Comparisons were made with an audit from MMH in 2008 and a multicentre UK audit. METHOD: A retrospective audit of patients with hip fractures was carried out at MMH between January and June 2012. RESULTS: 120 patient charts were reviewed. In 2012, 14.2% of patients were admitted from ED within the guideline recommended period of four hours compared to 5.6% of patients in 2008. 72.5% received operative management within the guideline suggested period of 48 hours in comparison to 51% in 2008. Lack of available theatre space accounted for 51% of delays in 2008. CONCLUSION: There have been considerable improvements to timely delivery of hip fracture care at MMH between 2008 and 2012. However, there are ongoing delays to ward admission and operative management at our institution resulting in care that falls beyond the times recommended by international guidelines. The lack of available theatre space remains a major cause of delayed surgery. We advocate the development of a multicentre audit in NZ hospitals.

Formal ventilation patient education for ALS predicts real-life choices.

Our objective was to evaluate a single-session, hands-on education programme on mechanical ventilation for ALS patients and caregivers in terms of knowledge, change in affect and to determine whether ventilator decisions made after the education sessions predict those made later in life. Questionnaires were administered to 26 patients and 26 caregivers on four separate occasions. The questionnaires assessed knowledge of ventilatory support, feedback on the nature of the education programme, as well as self-reported emotional well-being. All patients were followed until their death or until initiation of invasive ventilation. Both groups demonstrated significant improvements in knowledge as a result of the education session which was retained after one month. There was no change in patient or caregiver reports' self-reported emotional well-being. The choices of ventilatory support expressed at one month (T4) accurately predicted the real-life clinical choices made by 76% of patients. Any difference resulted from choosing palliative care. Hands-on patient and caregiver education results in improved knowledge, assists in decision-making with respect to ventilatory support, and is not associated with a worsening of affect. It also provides for an accurate prediction of real-life choices and avoids undesired life support interventions and critical care admissions.

Implementing smokeless tobacco instruction into medical student education: addressing the gap.

BACKGROUND: Despite the unique health and epidemiological aspects of smokeless tobacco use, medical education regarding this topic is virtually lacking. DESCRIPTION: The purpose of this study is to develop a comprehensive tobacco curriculum that includes smokeless tobacco education. A thorough review of the literature was carried out to develop includes 8 modules in basic and clinical sciences that are evaluated by pretest/posttest increases in knowledge as well as standardized patient encounters and process evaluation. EVALUATION: Pretest/posttest data indicate that students increased knowledge on specific smokeless tobacco questions. Students also scored well on interactions with standardized patients using the Tobacco Intervention Risk Factor Interview Scale, a validated instrument to assess medical students' tobacco counseling skills. Process evaluation data indicate that modules were generally well received. CONCLUSIONS: This Web-based, comprehensive curriculum-the only curriculum we are aware of treating the topic of smokeless tobacco use-appears to be effective and well received. Smokeless tobacco should be included in medical education.

Comparison and verification of bacterial water quality indicator measurement methods using ambient coastal water samples.

More than 30 laboratories routinely monitor water along southern California's beaches for bacterial indicators of fecal contamination. Data from these efforts frequently are combined and compared even though three different methods (membrane filtration (MF), multiple tube fermentation (MTF), and chromogenic substrate (CS) methods) are used. To assess data comparability and quantify variability within method and across laboratories, 26 laboratories participated in an intercalibration exercise. Each laboratory processed three replicates from eight ambient water samples employing the method or methods they routinely use for water quality monitoring. Verification analyses also were conducted on a subset of wells from the CS analysis to confirm or exclude the presence of the target organism. Enterococci results were generally comparable across methods. Confirmation revealed a 9% false positive rate and a 4% false negative rate in the CS method for enterococci, though these errors were small in the context of within- and among-laboratory variability. Fecal coliforms also were comparable across all methods, though CS underestimated the other methods by about 10%, probably because it measures only E. coli, rather than the larger fecal coliform group measured by MF and MTF. CS overestimated total coliforms relative to the other methods by several fold and was found to have a 40% false positive rate in verification. Across-laboratory variability was small relative to within- and among-method variability, but only after data entry errors were corrected. One fifth of the laboratories committed data entry errors that were much larger than any method-related errors. These errors are particularly significant because these data were submitted in a test situation where laboratories were aware they would be under increased scrutiny. Under normal circumstances, it is unlikely that these errors would have been detected and managers would have been obliged to issue beach water quality warnings.

Training and evaluating tobacco-specific standardized patient instructors.

BACKGROUND AND OBJECTIVES: A comprehensive training program to develop tobacco-specific standardized patient instructors (SPIs) was implemented and evaluated at Wake Forest University. METHODS: Descriptive statistics were used to assess SPIs' experience with the training program and medical students' perceptions of the SPI-student interaction. Two standardized scales, used to assess student performance on counseling (Tobacco Intervention Risk Factor Interview Scale [TIRFIS]) and cultural competency (Tobacco Beliefs Management Scale-Tobacco Cultural Concerns Scale [TBMS-TCCS]), were tested for internal and interrater reliability and sensitivity to varied student performance. Costs of the program were measured. RESULTS: SPIs highly rated the content, organization, and presenters of the training program. Medical students positively evaluated their experience with the SPIs. The TIRFIS and TBMS-TCCS subscales demonstrated good internal reliability, and inconsistencies in ratings by different SPIs were minimal. In addition, a range of scores on both measures attest to the sensitivity of the instruments to assess variations in student performance. Significant start-up costs are associated with developing this training program, although costs decline when SPIs are retained long term. CONCLUSIONS: The SPI training program was effective in developing a cohort of knowledgeable and reliable SPIs to train medical students in ways to improve their tobacco intervention counseling skills. Retaining SPIs long term should be a primary goal of implementing a cost-effective, successful training program.

Comparison of beach bacterial water quality indicator measurement methods.

Three methods (membrane filtration, multiple tube fermentation, and chromogenic substrate technology kits manufactured by IDEXX Laboratories, Inc.) are routinely used to measure indicator bacteria for beach water quality. To assess comparability of these methods, quantify within-laboratory variability for each method, and place that variability into context of variability among laboratories using the same method, 22 southern California laboratories participated in a series of intercalibration exercises. Each laboratory processed three to five replicates from thirteen samples, with total coliforms, fecal coliforms or enterococci measured depending on the sample. Results were generally comparable among methods, though membrane filtration appeared to underestimate the other two methods for fecal coliforms, possibly due to clumping. Variability was greatest for the multiple tube fermentation method. For all three methods, within laboratory variability was greater than among laboratories variability.