Point-of-Care Ultrasonography to Confirm Endotracheal Tube Placement: A Review for the Emergency Nurse Practitioner.

Ensuring correct placement of the endotracheal tube (ETT) during intubation is an important step to avoid complications. Appropriate placement of the ETT can be challenging and, if done incorrectly, can lead to complications such as hypoxemia, atelectasis, hyperinflation, barotrauma, cardiovascular instability, end organ damage, and even death. Although several procedures exist to help assess ETT confirmation, all have limitations, are not always reliable, and vary in their degree of accuracy. Point-of-care ultrasound (POCUS) has emerged as a useful tool in the emergency department for quick diagnosis and treatment of many emergency conditions (Gonzalez et al., 2020). The purpose of this paper is to describe a systematic approach for the emergency nurse practitioner to use POCUS to assess proper endotracheal placement and the positioning within the trachea based on prior studies that compare this modality to traditional ones.

Design and Validation of a Simulation Scenario and Assessment Tool: A Pilot Project.

In 2016, the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) launched a Continued Professional Certification (CPC) Program to promote lifelong learning and to facilitate ongoing professional competency checks for practicing certified registered nurse anesthesiologists (CRNA). The use of simulation-based assessment is currently being studied by the NBCRNA for potential use in the CPC Program. The aim of the pilot project was to create and validate simulation scenarios and assessment tools for potential incorporation into the CPC Program. Using the modified Delphi method, an expert panel of eight CRNAs evaluated the validity of four simulation scenarios and the content validity and reliability of four scenario-specific assessment tools. Each of the eight individual surveys assessing simulation scenario validity and assessment tool validity reached ≥ 75% agreement among the expert panelists. Overall content validity index values for the four assessment tools ranged from 0.960 to 0.993. There was a direct relationship between panelists' scores and level of performance on all returned assessment tools. The expert panel validated four simulation scenarios and four accompanying assessment tools. All scenarios and assessment tools were determined to have high content validity and reliability. Using these scenarios and assessment tools would provide unique advantages over standardized assessment methods.

Point-of-Care Lung Ultrasonography: A Clinical Update for the Emergency Nurse Practitioner.

Since the introduction of ultrasonography, clinicians have discovered different uses for embedding this technology in the clinical setting. The use of point-of-care ultrasonography has gained a lot of interest in the emergency department. It is a procedure that a clinician can rapidly utilize to triage, risk stratify, evaluate, and monitor the patient's condition. The COVID-19 pandemic has highlighted the significance and application of ultrasonography in identifying and managing patients presenting with lung pathology in the emergency setting.

Formulation, high throughput in vitro screening and in vivo functional characterization of nanoemulsion-based intranasal vaccine adjuvants.

Vaccine adjuvants have been reported to induce both mucosal and systemic immunity when applied to mucosal surfaces and this dual response appears important for protection against certain pathogens. Despite the potential advantages, however, no mucosal adjuvants are currently approved for human use. Evaluating compounds as mucosal adjuvants is a slow and costly process due to the need for lengthy animal immunogenicity studies. We have constructed a library of 112 intranasal adjuvant candidate formulations consisting of oil-in-water nanoemulsions that contain various cationic and nonionic surfactants. To facilitate adjuvant development we first evaluated this library in a series of high-throughput, in vitro assays for activities associated with innate and adaptive immune activation in vivo. These in vitro assays screened for the ability of the adjuvant to bind to mucin, induce cytotoxicity, facilitate antigen uptake in epithelial and dendritic cells, and activate cellular pathways. We then sought to determine how these parameters related to adjuvant activity in vivo. While the in vitro assays alone were not enough to predict the in vivo adjuvant activity completely, several interesting relationships were found with immune responses in mice. Furthermore, by varying the physicochemical properties of the surfactant components (charge, surfactant polar head size and hydrophobicity) and the surfactant blend ratio of the formulations, the strength and type of the immune response generated (TH1, TH2, TH17) could be modulated. These findings suggest the possibility of using high-throughput screens to aid in the design of custom adjuvants with unique immunological profiles to match specific mucosal vaccine applications.

Objective Structured Clinical Examination as an educational initiative for summative simulation competency evaluation of first-year student registered nurse anesthetists' clinical skills.

The use of simulation to imitate real-life scenarios reaches back many centuries. In the last decade, the use of simulation in healthcare has gained acceptance as a valuable tool for teaching and learning technical and nontechnical skills in healthcare. The use of simulation technology has moved medical education from the standard of pen and paper examinations to the assessment of clinical competency before caring for patients. The old thinking of "see one, do one, teach one" is behind us as healthcare works to create a culture of safety that holds healthcare personnel accountable. A current use of testing clinical competence is the use of Objective Structured Clinical Examination (OSCE) by physician training programs. As a testing tool, the OSCE has great potential to assess the clinical competence of students before they enter the clinical setting. The nurse anesthesia program at the authors' university has moved toward creating a formal assessment to ensure clinical competence of their student registered nurse anesthetists. In this article, we describe the development and implementation of an OSCE to ensure clinical competence of first-year student registered nurse anesthetists before they begin their clinical training.

Nanoemulsion mucosal adjuvant uniquely activates cytokine production by nasal ciliated epithelium and induces dendritic cell trafficking.

While the nasal mucosa is a potentially useful site for human immunization, toxin-based nasal adjuvants are generally unsafe and less effective in humans. Safe mucosal adjuvants that activate protective immunity via mucosal administration are highly dependent on barrier antigen sampling by epithelial and DCs. Here, we demonstrate that protein antigens formulated in unique oil-in-water nanoemulsions (NEs) result in distinctive transcellular antigen uptake in ciliated nasal epithelial cells, leading to delivery into nasal associated lymphoid tissue. NE formulation also enhances MHC class II expression in epithelial cells and DC activation/trafficking to regional lymphoid tissues in mice. These materials appear to induce local epithelial cell apoptosis and heterogeneous cytokine production by mucosal epithelial cells and mixed nasal tissues, including G-CSF, GM-CSF, IL-1a, IL-1b, IL-5, IL-6, IL-12, IP-10, KC, MIP-1a, TGF-ß, and TSLP. This is the first observation of a nasal adjuvant that activates calreticulin-associated apoptosis of ciliated nasal epithelial cells to generate broad cytokine/chemokine responses in mucosal tissue.

Multi-center development and testing of a simulation-based cardiovascular assessment curriculum for advanced practice nurses.

Cardiovascular assessment skills are deficient among advanced practice nursing students, and effective instructional methods to improve assessment skills are needed. The purpose of this study was to develop, implement, and evaluate outcomes of a cardiovascular assessment curriculum for advanced practice nurses at four institutions. Each institution used a one-group pre-to-post-intervention design. Educational interventions included faculty-led, simulation-based case presentations using the Harvey cardiopulmonary patient simulator (CPS), and independent learning sessions using the CPS and a multimedia, computer-based CD-ROM program. Outcome measures included a 31-item cognitive written exam, a 13-item skills checklist used in each of a three-station objective structured clinical exam, learner self-efficacy and satisfaction survey, instructor satisfaction and self-efficacy survey, and a participant logbook to record practice time using the self-learning materials. Thirty-six students who received the simulation-based training showed statistically significant pre-to-post-test improvement in cognitive knowledge and cardiovascular assessment skills.

Simulation for learning and teaching procedural skills: the state of the science.

INTRODUCTION: Simulation is increasingly used to support learning of procedural skills. Our panel was tasked with summarizing the "best evidence." We addressed the following question: To what extent does simulation support learning and teaching in procedural skills? METHODS: We conducted a literature search from 2000 to 2010 using Medline, CINAHL, ERIC, and PSYCHINFO databases. Inclusion criteria were established and then data extracted from abstracts according to several categories. Although secondary sources of literature were sourced from key informants and participants at the "Research Consensus Summit: State of the Science," they were not included in the data extraction process but were used to inform discussion. RESULTS: Eighty-one of 1,575 abstracts met inclusion criteria. The uses of simulation for learning and teaching procedural skills were diverse. The most commonly reported simulator type was manikins (n = 17), followed by simulated patients (n = 14), anatomic simulators (eg, part-task) (n = 12), and others. For research design, most abstracts (n = 52) were at Level IV of the National Health and Medical Research Council classification (ie, case series, posttest, or pretest/posttest, with no control group, narrative reviews, and editorials). The most frequent Best Evidence Medical Education ranking was for conclusions probable (n = 37). Using the modified Kirkpatrick scale for impact of educational intervention, the most frequent classification was for modification of knowledge and/or skills (Level 2b) (n = 52). Abstracts assessed skills (n = 47), knowledge (n = 32), and attitude (n = 15) with the majority demonstrating improvements after simulation-based interventions. Studies focused on immediate gains and skills assessments were usually conducted in simulation. DISCUSSION: The current state of the science finds that simulation usually leads to improved knowledge and skills. Learners and instructors express high levels of satisfaction with the method. While most studies focus on short-term gains attained in the simulation setting, a small number support the transfer of simulation learning to clinical practice. Further study is needed to optimize the alignment of learner, instructor, simulator, setting, and simulation for learning and teaching procedural skills. Instructional design and educational theory, contextualization, transferability, accessibility, and scalability must all be considered in simulation-based education programs. More consistently, robust research designs are required to strengthen the evidence.