Improving Communication in Nursing Homes Using Plan-Do-Study-Act Cycles of an SBAR Training Program.

BACKGROUND: Incomplete communication between staff and providers may cause adverse outcomes for nursing home residents. The Situation-Background-Assessment-Recommendation (SBAR) tool is designed to improve communication around changes in condition (CIC). An adapted SBAR was developed for the Centers for Medicare and Medicaid Services demonstration project, OPTIMISTIC, to increase its use during a resident CIC and to improve documentation. METHODS: Four Plan-Do-Study-Act (PDSA) cycles to develop and refine successive protocol implementation of the OPTIMISTIC SBAR were deployed in four Indiana nursing homes. Use of SBAR, documentation quality, and participant surveys were assessed pre- and post-intervention implementation. RESULTS: OPTIMISTIC SBAR use and documentation quality improved in three of the four buildings. Participants reported improved collaboration between nurses and providers after SBAR intervention. CONCLUSION: Successive PDSA cycles implementing changes in an OPTIMISTIC SBAR protocol for resident CIC led to an increase in SBAR use, improved documentation, and better collaboration between nursing staff and providers.

The Avoidable Transfer Scale: A New Tool for Identifying Potentially Avoidable Hospital Transfers of Nursing Home Residents.

Background and Objectives: Prior approaches to identifying potentially avoidable hospital transfers (PAHs) of nursing home residents have involved detailed root cause analyses that are difficult to implement and sustain due to time and resource constraints. They relied on the presence of certain conditions but did not identify the specific issues that contributed to avoidability. We developed and tested an instrument that can be implemented using review of the electronic medical record. Research Design and Methods: The OPTIMISTIC project was a Centers for Medicare and Medicaid Services demonstration to reduce avoidable hospital transfers of nursing home residents. The OPTIMISTIC team conducted a series of root cause analyses of transfer events, leading to development of a 27-item instrument to identify common characteristics of PAHs (Stage 1). To refine the instrument, project nurses used the electronic medical record (EMR) to score the avoidability of transfers to the hospital for 154 nursing home residents from 7 nursing homes from May 2019 through January 2020, including their overall impression of whether the transfer was avoidable (Stage 2). Each transfer was rated independently by 2 nurses and assessed for interrater reliability with a kappa statistic. Results: Kappa scores ranged from -0.045 to 0.556. After removing items based on our criteria, 12 final items constituted the Avoidable Transfer Scale. To assess validity, we compared the 12-item scale to nurses' overall judgment of avoidability of the transfer. The 12-item scale scores were significantly higher for submissions rated as avoidable than those rated unavoidable by the nurses (mean 5.3 vs 2.6, p < .001). Discussion and Implications: The 12-item Avoidable Transfer Scale provides an efficient approach to identify and characterize PAHs using available data from the EMR. Increased ability to quantitatively assess the avoidability of resident transfers can aid nursing homes in quality improvement initiatives to treat more acute changes in a resident's condition in place.

Willingness of Long-Term Care Staff to Receive a COVID-19 Vaccine: A Single State Survey.

OBJECTIVES: To plan for coronavirus infectious disease 2019 (COVID-19) vaccine distribution, the Indiana Department of Health surveyed nursing home and assisted living facility staff. DESIGN: Cross-sectional analysis of an anonymous survey sent via text message link to personal cell phones and emails. SETTING AND PARTICIPANTS: Nursing home and assisted living facility staff in Indiana. MEASURES: Staff characteristics including age, gender, race, ethnicity, role in the facility, experience in long-term care, and geographic location of facility were self-reported along with prior infection and willingness to receive an approved vaccine as soon as it is available. Responses were weighted to represent staff statewide. Weighted frequencies and logit regression estimated characteristics associated with vaccine willingness. RESULTS: There were 8,243 responses to the survey. For nursing home staff (survey delivered via 23,232 working phone numbers), there was a 33% response rate). There were 2,372 (29%) in nurse aide or similar roles and 1,602 nurses providing direct clinical care (19%). Overall, 45% of respondents indicated they would receive an approved COVID-19 vaccine as soon as available. Of those unwilling to take the vaccine when first available, 44% would consider in the future. Concerns about side effects was the primary reason for vaccine hesitancy (70%). Characteristics associated with increased willingness were age over 60, male, and white race (P < .0001). No statistically significant differences were observed among staff self-reporting prior SARS-CoV-2 infection. CONCLUSIONS AND IMPLICATIONS: The willingness to receive the COVID-19 vaccine immediately or in the future may be as high as 69%, but varies among subgroups of nursing home staff which has implications for distribution. Educating staff on the vaccine may be critical for increasing uptake. Widespread vaccination holds the promise of protection against serious illness and death and a return of visitors and activities that support improved quality of life. This promise will not be realized without strong uptake of the vaccines.

Improving Nursing Facility Care Through an Innovative Payment Demonstration Project: Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care Phase 2.

Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) is a 2-phase Center for Medicare and Medicaid Innovations demonstration project now testing a novel Medicare Part B payment model for nursing facilities and practitioners in 40 Indiana nursing facilities. The new payment codes are intended to promote high-quality care in place for acutely ill long-stay residents. The focus of the initiative is to reduce hospitalizations through the diagnosis and on-site management of 6 common acute clinical conditions (linked to a majority of potentially avoidable hospitalizations of nursing facility residents): pneumonia, urinary tract infection, skin infection, heart failure, chronic obstructive pulmonary disease or asthma, and dehydration. This article describes the OPTIMISTIC Phase 2 model design, nursing facility and practitioner recruitment and training, and early experiences implementing new Medicare payment codes for nursing facilities and practitioners. Lessons learned from the OPTIMISTIC experience may be useful to others engaged in multicomponent quality improvement initiatives.

Cloning, Expression, and Purification of Histidine-Tagged Escherichia coli Dihydrodipicolinate Reductase.

The enzyme dihydrodipicolinate reductase (DHDPR) is a component of the lysine biosynthetic pathway in bacteria and higher plants. DHDPR catalyzes the NAD(P)H dependent reduction of 2,3-dihydrodipicolinate to the cyclic imine L-2,3,4,5,-tetrahydropicolinic acid. The dapB gene that encodes dihydrodipicolinate reductase has previously been cloned, but the expression of the enzyme is low and the purification is time consuming. Therefore the E. coli dapB gene was cloned into the pET16b vector to improve the protein expression and simplify the purification. The dapB gene sequence was utilized to design forward and reverse oligonucleotide primers that were used to PCR the gene from Escherichia coli genomic DNA. The primers were designed with NdeI or BamHI restriction sites on the 5'and 3' terminus respectively. The PCR product was sequenced to confirm the identity of dapB. The gene was cloned into the expression vector pET16b through NdeI and BamHI restriction endonuclease sites. The resulting plasmid containing dapB was transformed into the bacterial strain BL21 (DE3). The transformed cells were utilized to grow and express the histidine-tagged reductase and the protein was purified using Ni-NTA affinity chromatography. SDS/PAGE gel analysis has shown that the protein was 95% pure and has approximate subunit molecular weight of 28 kDa. The protein purification is completed in one day and 3 liters of culture produced approximately 40-50 mgs of protein, an improvement on the previous protein expression and multistep purification.

Postoperative hypoalbuminemia following surgery related to craniosynostosis.

BACKGROUND: An episode of postoperative phenytoin toxicity in a patient undergoing surgery related to craniosynostosis highlighted the presence of hypoalbuminemia. We believe that hypoalbuminemia contributed to the altered pharmacokinetics of phenytoin in this case. OBJECTIVES: To establish the incidence of postoperative hypoalbuminemia in patients undergoing surgery related to craniosynostosis and to investigate the likely etiology. METHODS: Data on 114 patients undergoing surgery for craniosynostosis over a 2-year period at Oxford Children's Hospital, between May 2011 and May 2013, were retrospectively reviewed. Twenty-two patients were excluded due to incomplete data. This cohort represents the entire population for whom transfusion data had been formally collected at our institution. Preoperative and day 1 postoperative serum albumin levels were collected from the hospital laboratory database. Data regarding blood loss and intra-operative fluid management were reviewed from the anesthetic database. Linear regression analysis was used to establish the relationship between percentage drop in serum albumin with: (i) milliliters per kilogram (ml·kg(-1)) volume of albumin-poor fluids used intra-operatively and (ii) percentage estimated red cell mass loss. RESULTS: All patients experienced a statistically significant drop in serum albumin. The mean difference in albumin was 17.1 g·l(-1), 95% CI (16.1-18.0) (P < 0.001). Expressed as a percentage, the mean reduction was 37.9% (range 16-61%), SD 9.7. The decrease in albumin was associated with an increase in estimated red cell mass loss (P < 0.001) and an increased ml·kg(-1) volume of albumin-poor fluids given (P < 0.001). CONCLUSION: Hemodilution due to large volume blood loss and transfusion with albumin-poor fluids is strongly associated with postoperative hypoalbuminemia in patients undergoing surgery related to craniosynostosis. Practitioners should be aware of this risk and the implications of postoperative hypoalbuminemia in this population.

Best practice in early psychosis intervention for Australian indigenous communities: indigenous worker consultation and service model description.

OBJECTIVE: The aim of this study was to identify promising elements of best practice relevant to mainstream mental health service (MHS) delivery of early psychosis intervention (EPI) to Indigenous communities. In a companion paper, a comprehensive literature review identified a promising service model with potential for delivering EPI: an Indigenous sub-team embedded within a mainstream health service. METHOD: This paper describes a consultation process with Indigenous Mental Health Workers (IMHWs) in south eastern Queensland. A case study of the Sunshine Coast Cultural Healing Program (CHP-SC) was carried out during the consultation process. RESULTS: IMHWs agreed that the Australian clinical guidelines for early psychosis were relevant to improving outcomes for Indigenous patients. IMHWs unanimously identified the CHP-SC as a best practice mainstream MHS for delivering EPI. The CHP-SC, which represented an Indigenous sub-team model, was found to be associated with substantially improved engagement of Indigenous young people. CONCLUSIONS: We provisionally conclude that specialist EPI could be delivered by specialist Indigenous sub-teams (rather than specialist EPI teams) embedded in mainstream MHSs that incorporate culturally safe practice and are fully integrated with Indigenous primary care services, and recommend that the model be formally evaluated.

High-speed analog fiber-optic link for electromagnetic interference suppression in infrared power measurement.

Electromagnetic interference (EMI) is a common problem in a high-power pulsed infrared laser measurement. In order to eliminate susceptibility to radiated EMI, we developed, tested and implemented an infrared power measurement system using a high-speed analog fiber-optic link. Key components are commercially available parts designed for high-speed digital data transmission, but can be operated in analog mode. We successfully utilized the system for time-resolved measurements of high-power transversely-excited atmospheric-pressure CO(2) lasers in amplifier and oscillator configurations. This paper presents experimental setup, testing results, and the details of the laser power measurements results.

Clinical indicators for routine use in the evaluation of early psychosis intervention: development, training support and inter-rater reliability.

AIM: Clinical practice improvement carried out in a quality assurance framework relies on routinely collected data using clinical indicators. Herein we describe the development, minimum training requirements, and inter-rater agreement of indicators that were used in an Australian multi-site evaluation of the effectiveness of early psychosis (EP) teams. METHODS: Surveys of clinician opinion and face-to-face consensus-building meetings were used to select and conceptually define indicators. Operationalization of definitions was achieved by iterative refinement until clinicians could be quickly trained to code indicators reliably. Calculation of percentage agreement with expert consensus coding was based on ratings of paper-based clinical vignettes embedded in a 2-h clinician training package. RESULTS: Consensually agreed upon conceptual definitions for seven clinical indicators judged most relevant to evaluating EP teams were operationalized for ease-of-training. Brief training enabled typical clinicians to code indicators with acceptable percentage agreement (60% to 86%). For indicators of suicide risk, psychosocial function, and family functioning this level of agreement was only possible with less precise 'broad range' expert consensus scores. Estimated kappa values indicated fair to good inter-rater reliability (kappa > 0.65). Inspection of contingency tables (coding category by health service) and modal scores across services suggested consistent, unbiased coding across services. CONCLUSIONS: Clinicians are able to agree upon what information is essential to routinely evaluate clinical practice. Simple indicators of this information can be designed and coding rules can be reliably applied to written vignettes after brief training. The real world feasibility of the indicators remains to be tested in field trials.

Is a national framework for implementing early psychosis services necessary? Results of a survey of Australian mental health service directors.

AIM: Expert opinion holds that the rate of implementation of specialist services for first presentation psychosis in Australia is much too slow. We aimed to collect evidence regarding this view from the first national survey of adult public mental health services about their self-reported efforts to implement specialist early psychosis intervention (EPI). METHODS: Using a purpose-designed Census form for assessing EPI implementation, adult public mental health service directors throughout Australia were asked about EPI-relevant local service activities. RESULTS: Sixty Census forms were returned (response rate = 61%), representing a total catchment population of 12.5 million people. A minority of services reported high levels of EPI implementation, which varied widely between area services and across state and territory jurisdictions. Rural and remote services were overrepresented in the lowest levels of reported EPI implementation. Only one service characteristic, the value of identifiable funding committed specifically to EPI, was predictive of level of reported EPI implementation. CONCLUSIONS: The disturbingly high levels of variability in EPI implementation across jurisdictions suggest a pressing need for a set of nationally agreed uniform EPI implementation standards. Additional specific strategies for rural and remote mental health services may be needed for these services to implement EPI.

Appraising evidence for intervention effectiveness in early psychosis: conceptual framework and review of evaluation approaches.

The literature that is relevant to evaluation of treatment effectiveness is large, scattered and difficult to assemble for appraisal. This scoping review first develops a conceptual framework to help organize the field, and second, uses the framework to appraise early psychosis intervention (EPI) studies. Literature searches were used to identify representative study designs, which were then sorted according to evaluation approach. The groupings provided a conceptual framework upon which a map of the field could be drawn. Key words were cross-checked against definitions in dictionaries of scientific terms and the National Library of Medicine Medical Subject Headings (MeSH) browser. Using the final list of key words as search terms, the EPI evaluation literature was appraised. Experimental studies could be grouped into two classes: efficacy and effectiveness randomized controlled trials. Non-experimental studies could be subgrouped into at least four overlapping categories: clinical epidemiological; health service evaluations; quality assurance studies; and, quasi-experimental assessments of treatment effects. Applying this framework to appraise EPI studies indicated promising evidence for the effectiveness of EPI irrespective of study design type, and a clearer picture of where future evaluation efforts should be focused. Reliance on clinical trials alone will restrict the type of information that can inform clinical practice. There is convergent evidence for the benefits of specialized EPI service functions across a range of study designs. Greater investment in health services research and quality assurance approaches in evaluating EPI effectiveness should be made, which will involve scaling up of study sizes and development of an EPI programme fidelity rating template. The degree of complexity of the evaluation field suggests that greater focus on research methodology in the training of Australasian psychiatrists is urgently needed.

A kinetic study of the reaction between N,N-dimethyl-p-toluidine and its electrogenerated radical cation in a room temperature ionic liquid.

The reaction between N,N-dimethyl-p-toluidine (DMT) and the radical cation generated through its one-electron oxidation has been studied electrochemically in the room temperature ionic liquid N-methyl-N-butylpyrrolidinium bis(trifluoromethylsulfonyl)imide, [Py14][NTf2]. Kinetic information obtained as linear sweep and cyclic voltammetry collected at 5 microm, 10 microm and 0.3 mm diameter platinum disk electrodes over a range of initial substrate concentrations and scan rates spanning five orders of magnitude was complemented by chronoamperometric measurements designed to probe the rate of diffusion. At the fastest scan rates the homogeneous reactions following the initial electron transfer were effectively out-run, facilitating an assessment of the electrode kinetics using DIGISIM and a validated Nicholson's method. Through digital simulation the voltammetry was then shown to be consistent with a mechanism established for the same reaction in acetonitrile, involving dimerisation of the DMT radicals following an initial and rate-determining proton transfer step. After careful consideration of all parameters, a bimolecular rate constant of (3.4 +/- 1.1) x 10(2) dm3 mol(-1) s(-1) was deduced by fitting the data. This was compared to the equivalent value for acetonitrile and, in light of this, the implications on the viability of ionic liquids for use as alternative mainstream solvents briefly assessed.

A comparative electrochemical study of diffusion in room temperature ionic liquid solvents versus acetonitrile.

Measurements on the diffusion coefficient of the neutral molecule N,N,N',N'-tetramethyl-para-phenylenediamine and the radical cation and dication generated by its one- and two-electron oxidation, respectively, are reported over the range 298-348 K in both acetonitrile and four room temperature ionic liquids (RTILs). Data were collected using single and double potential step chronoamperometry at a gold disk electrode of micrometer dimension, and analysed via fitting to the appropriate analytical expression or, where necessary, to simulation. The variation of diffusion coefficient with temperature was found to occur in an Arrhenius-type manner for all combinations of solute and solvent. For a given ionic liquid, the diffusional activation energies of each species were not only closely equivalent to each other, but also to the RTIL's activation energy of viscous flow. In acetonitrile supported with 0.1 M tetrabutylammonium perchlorate, the ratio in diffusion coefficients of the radical cation and dication to the neutral molecule were calculated as 0.89 +/- 0.05 and 0.51 +/- 0.03, respectively. In contrast, amongst the ionic liquids the same ratios were determined to be on average 0.53 +/- 0.04 and 0.33 +/- 0.03. The consequences of this dissimilarity are considered in terms of the modelling of voltammetric data gathered within ionic liquid solvents.

Non-haloaluminate room-temperature ionic liquids in electrochemistry--a review.

Some twenty-five years after they first came to prominence as alternative electrochemical solvents, room temperature ionic liquids (RTILs) are currently being employed across an increasingly wide range of chemical fields. This review examines the current state of ionic liquid-based electrochemistry, with particular focus on the work of the last decade. Being composed entirely of ions and possesing wide electrochemical windows (often in excess of 5 volts), it is not difficult to see why these compounds are seen by electrochemists as attractive potential solvents. Accordingly, an examination of the pertinent properties of ionic liquids is presented, followed by an assessment of their application to date across the various electrochemical disciplines, concluding with an outlook viewing current problems and directions.

Amperometric detection of glucose using self-catalytic carbon paste electrodes.

The analytical detection of d-glucose by means of self-catalytic carbon paste electrodes is described. In the construction of these electrodes, carbon powder has been modified with the redox liquid n-butylferrocene, which simultaneously serves both to help bind the paste together whilst also acting as a mediator in the enzymatic oxidation of d-glucose by glucose oxidase. The sensor then functions by monitoring the electrochemical oxidation of the constituent n-butylferrocene itself. Through testing in model glucose solutions, the electrodes were found to yield a linear response over a d-glucose concentration range of 2-20 mM. They were also successfully employed in the determination of d-glucose levels in a spiked blood sample, giving a detection limit of 0.8 mM (based on the 3sigma criterion).

Effect of increasing depth of propofol anesthesia on upper airway configuration in children.

BACKGROUND: The upper airway tends to be obstructed during anesthesia in spontaneously breathing patients. The purpose of the current study was to determine the effect of increasing depth of propofol anesthesia on airway size and configuration in children. METHODS: Magnetic resonance images of the upper airway were obtained in 15 children, aged 2-6 yr. Cross-sectional area, anteroposterior dimension, and transverse dimension were measured at the level of the soft palate, dorsum of the tongue, and tip of the epiglottis. Images were obtained during infusion of propofol at a rate of 50-80 microg.kg-1.min-1 and after increasing the depth of anesthesia by administering a bolus dose of propofol and increasing the infusion rate to 240 microg.kg-1.min-1. RESULTS: Overall, the cross-sectional area of the entire pharyngeal airway decreased with increasing depth of anesthesia. The reduction in cross-sectional area was greatest at the level of the epiglottis (24.5 mm2, 95% confidence interval = 16.9-32.2 mm2; P < 0.0001), intermediate at the level of the tongue (19.3 mm2, 95% confidence interval = 9.2-29.3 mm2; P < 0.0001), and least at the level of the soft palate (12.6 mm2, 95% confidence interval = 2.7-22.6 mm2; P < 0.005) in expiration and resulted predominantly from a reduction in anteroposterior dimension. The airway cross-sectional area decreased further in inspiration at the level of the epiglottis. The narrowest portion of the airway resided at the level of the soft palate or epiglottis in the majority of children. CONCLUSION: Increasing depth of propofol anesthesia in children is associated with upper airway narrowing that occurs throughout the entire upper airway and is most pronounced in the hypopharynx at the level of the epiglottis.

Hanging, firearm, and non-domestic gas suicides among males: a comparative study.

OBJECTIVE: To identify characteristics that could distinguish males who completed suicide by hanging from males who completed suicide by firearms and non-domestic gas, and to suggest suicide prevention strategies targeted at hanging. METHOD: Using the psychological autopsy design, males who used hanging, firearms and non-domestic gas were compared on a range of variables covering social, psychological, and health related factors and aspects of the suicide incident. The sample consisted of 950 males who completed suicide in Queensland, Australia, between 1994 and 1996. RESULTS: Compared with males who used firearms and non-domestic gas, males who used hanging were significantly younger, less likely to have left a suicide note, and more likely to have been diagnosed with a psychotic disorder. Compared with males who used firearms, males who used hanging were significantly more likely to have made prior suicide attempts and have had no physical illness. Compared with males who used non-domestic gas, males who used hanging were significantly more likely to have lived with others, have had prior legal trouble, and have completed suicide at their residence. CONCLUSIONS: The results are discussed in terms of the availability and socio-cultural acceptability of methods. The authors suggest a possible relationship between impulsive traits and method choice. This proposition requires further investigation using alternative methodologies. Some suicide prevention measures targeting hanging suicides are discussed in light of the results.