Serious bacterial infection risk in recently immunized febrile infants in the emergency department.

STUDY OBJECTIVES: Fever following immunizations is a common presenting chiefcomplaint among infants. The 2021 American Academy of Pediatrics (AAP) febrile infant clinical practice guidelines exclude recently immunized (RI) infants. This is a challenge for clinicians in the management of the febrile RI young infant. The objective of this study was to assess the prevalence of SBI in RI febrile young infants between 6 and 12 weeks of age. METHODS: This was a retrospective chart review of infants 6-12 weeks who presented with a fever ≥38 °C to two U.S. military academic Emergency Departments over a four-year period. Infants were considered recently immunized (RI) if they had received immunizations in the preceding 72 h prior to evaluation and not recently immunized (NRI) if they had not received immunizations during this time period. The primary outcome was prevalence of serious bacterial infection (SBI) further delineated into invasive-bacterial infection (IBI) and non-invasive bacterial infection (non-IBI) based on culture and/or radiograph reports. RESULTS: Of the 508 febrile infants identified, 114 had received recent immunizations in the preceding 72 h. The overall prevalence of SBI was 11.4% (95% CI = 8.9-14.6) in our study population. The prevalence of SBI in NRI infants was 13.7% (95% CI = 10.6-17.6) compared to 3.5% (95% CI = 1.1-9.3) in RI infants. The relative risk of SBI in the setting of recent immunizations was 0.3 (95% CI = 0.1-0.7). There were no cases of invasive-bacterial infections (IBI) in the RI group with all but one of the SBI being urinary tract infections (UTI). The single non-UTI was a case of pneumonia in an infant who presented with respiratory symptoms within 24 h of immunizations. CONCLUSION: The risk of IBI (meningitis or bacteremia) in RI infants aged 6 to 12 weeks is low. Non-IBI within the first 24 h following immunization was significantly lower than in febrile NRI infants. UTIs remain a risk in the RI population and investigation with urinalysis and urine culture should be encouraged. Shared decision making with families guide a less invasive approach to the care of these children. Future research utilizing a large prospective multi-center data registry would aid in further defining the risk of both IBI and non-IBI among RI infants.

Undergraduate nursing students' learning experiences using design thinking on a human development course: A phenomenological study.

AIM: To explore nursing students' perceptions of their design thinking learning experiences on a human development course. BACKGROUND: Design thinking is a person-centered analytic and creative learning process that promotes higher order thinking skills rather than knowledge retention alone. Currently, this is the first study that has investigated the use of the design thinking process for nursing students on a human development course. DESIGN: A phenomenological research design. METHODS: The participants were first-year nursing students enrolled on a human development course at a Taiwanese university. In-depth, semi-structured interviews were conducted in 2022 and sufficiently high information power was obtained after 15 participants were interviewed. Data were systematically analysed, summarized and decoded using Colaizzi's seven analysis steps. RESULTS: Three themes and twelve subthemes emerged from the data. (1) Challenges experienced with the design thinking learning process: participants experienced anxiety because of the unfamiliar assignments, and they found the assignments to be thought-consuming, time-consuming and energy-consuming, plus the students needed to adapt to working in teams with classmates. (2) Adjustment strategies employed by participants: participants highlighted the importance of teamwork during the design thinking learning process. They achieved consensus through communication and sought support from others to overcome challenges related to design thinking; however, they ultimately needed to engage in problem-solving by themselves. (3) Developing the diversity of academic capabilities: after the human development course, participants experienced enriched mindsets, cognitive abilities, problem-solving skills, interpersonal relationships and knowledge application. CONCLUSIONS: Design thinking provides creative teaching opportunities and encourages nursing students to engage in experimental and creative learning, which is a meaningful experience for them. Nurse educators could use the insights thus obtained to design a curriculum that sources design thinking as a learning process while facilitating the complexity and diversity of students' higher order thinking skills and not just repetitive learning.

Four psychological processes navigated by patients during their journey of healing and recovering from depression: a grounded theory study.

This study explored the psychological processes that patients navigated when healing and recovering from depression. A grounded theory approach was used. Twenty patients who had recovered from depression participated. Four categories emerged depicting the psychological processes navigated by the participants during the recovery process: (1) acceptance: acceptance of depression and agreement to treatment; (2) transformation: change of mindsets and behaviours; (3) adaptation: stress regulation and change of focus; (4) integration: progress of depressive symptoms and moving on with 'regular' life. Each phase is related to the other phases, mental health professionals could assist patients with depression achieve the integration phase.

An Emergent Theory Depicting Patients' Fortitude Through the Healing and Recovering Process of Depression.

BACKGROUND: Depression is a common mental disorder. Literature has explored patients' perspectives of the recovering process of depression. However, there is a lack of research to explore both patients' and caregivers' perspectives of the healing process and develop a theory to support patients with depression. AIMS: The purpose of this study is to develop a substantive theory that depicts patients with depression toward healing and recovering. METHODS: This study used a grounded theory approach and collected data between 2019 and 2020 in a medical center in Taiwan. A theoretical sampling was performed after interviewing 29 participants, including 20 patients who had recovered from depression and nine caregivers; data saturation was achieved. Data analysis was conducted with open, axial, and selective coding and used NVivo Version 11 to aid the process of coding. RESULTS: A substantive theory was developed and the core category was "Patients' fortitude through the healing and recovering process of depression." Other main categories interrelated in this core category were reframing negative thinking and cultivating positive thinking, rebuilding a positive self-worth by embracing self-compassion, and learning to cope with everyday stress. CONCLUSIONS: This theory could help health care professionals to work therapeutically with patients and commend their fortitude while experiencing depression and engaging them with the care they planned together; and find some joy in life. Educators and researchers could use this theory to advance nursing care.

Exploring Meaning of Life in Women With Breast Cancer in Taiwan: A Phenomenological Study.

BACKGROUND: Globally, breast cancer is the most common cancer type in terms of incidence for women. Women with breast cancer endure higher levels of psychological distress than other types of cancer because many lose their identity as a woman, which is an additional characteristic of their psychological distress. Research using phenomenology to explore "the meaning of life" is rare among women with breast cancer. PURPOSE: The purpose of this study was to explore the perspectives of women with breast cancer on "the meaning of life." METHODS: A phenomenological approach was used. Twenty-six women living with breast cancer drawn from a cancer treatment hospital in Taiwan participated in this study. A semistructured interview was utilized to collect the data, and Colaizzi's seven steps were used to analyze the data. RESULTS: Four themes emerged: (a) value of overcoming suffering, (b) value of reciprocal love, (c) value of self-transcendence, and (d) value of spiritual comfort. This means that the participants defined "the meaning of life" through the lens of suffering from cancer, reciprocal love from their families and friends, uncovering and discovering creative pathways that transformed their pain while searching for the value of their existence, and seeking spiritual guidance from religion. CONCLUSIONS: The participants identified the most pivotal aspect of healing as transforming their pain and accepting value for their suffering. They acknowledged they could not change the fact that they had cancer, but they could learn to accept it as part of their lived experience. Healthcare professionals may use these four themes at a clinically appropriate time on women's journeys toward healing to inspire women with breast cancer to process their own unique "meaning of life."

Tactical Combat Casualty Care Maritime Scenario: Shipboard Missile Strike.

The types of injuries seen in combat action on a naval surface ship may be similar in many respects to the injuries seen in ground combat, and the principles of care for those injuries remain in large part the same. However, some contradistinctions in the care of combat casualties on a ship at sea must be highlighted, since this care may entail a number of unique challenges and different wounding patterns. This paper presents a scenario in which a guided missile destroyer is struck by a missile fired from an unmanned aerial vehicle operated by an undetermined hostile entity. Despite the presence of casualties who require care, the primary focus of a naval vessel that has just been damaged by hostile action is to prevent the ship from sinking and to conserve the fighting force on board the ship to the greatest extent possible. The casualties in this scenario include sailors injured by both blast and burns, as well as a casualty with a non-fatal drowning episode. Several of the casualties have also suffered the effects of a nearby underwater explosion while immersed. Challenges in the care of these casualties include delays in evacuation, the logistics of obtaining whole blood for transfusion while at sea, and transporting the casualties to the next higher level of care aboard a Casualty Receiving and Treatment Ship. As the National Defense Strategy pivots to a focus on the potential for maritime combat, the medical community must continue to maintain readiness by preparing fo.

Exploring the meaning of life from the perspective of patients with depression: A phenomenological study.

This study explored the perceptions of meaning of life for patients with depression. A qualitative phenomenology approach was used. Patients with depression (n = 20) were recruited until data saturation occurred. Findings revealed four themes all related to their value of: (1) accepting depression; (2) appreciating work (paid and non-paid); (3) embodying love and taking on responsibilities; (4) receiving spiritual comfort. Healthcare professionals could facilitate patients with depression to explore their meaning of life while enduring and transforming the emotional pain that accompanies depression, hence, perhaps, decreasing their suicidal ideations.

Simulation-Based Education Enhances Patient Safety Behaviors During Central Venous Catheter Placement.

OBJECTIVE: We describe the effect of simulation-based education on residents' adherence to protocols for and performance of central venous access. METHODS: Internal medicine and emergency medicine residents underwent a central venous access course that included a lecture, video presentation, readings, and simulation demonstrations presented by faculty. Baseline data were collected before the course was initiated. After a skills session where they rehearsed their ultrasound-guided central venous access skills, residents were evaluated using a procedural checklist and written knowledge exam. Residents also completed questionnaires regarding confidence in performing ultrasound-guided central venous access and opinions about the training course. RESULTS: Residents demonstrated significant improvement on the written knowledge exam (P < 0.0001) and Standard Protocol Checklist (P < 0.0001) after the training course. Training improved a number of patient safety elements, including adherence to sterile technique, transparent dressing, discarding sharps, and ordering postprocedure x-rays. However, a number of residents failed to wash their hands, prepare with chlorhexidine, drape the patient using a sterile technique, anesthetize the site, and perform a preprocedure time-out. Significant improvement in procedural skills was also noted for reduction in skin-to-vein time (P < 0.003) as well as a reduction in number of residents who punctured the carotid artery (P < 0.02). CONCLUSIONS: Simulation-based education significantly improved residents' knowledge and procedural skills along with their confidence. Adherence to the protocol also improved. This study illustrates that simulation-based education can improve patient safety through training and protocols.

Spontaneous hemopneumothorax in a patient with COVID-19.

Coronavirus disease 2019 (COVID-19) is primarily a febrile respiratory illness that was first documented in China in December 2019 and shortly after declared a pandemic on March 11, 2020. The pathophysiology of the virus is still not completely understood and remains under investigation. Consequently, new symptomatic manifestations and complications of the disease continue to be discovered. Here we present the case of a spontaneous hemopneumothorax resulting in hemorrhagic shock in an adult male with PCR confirmed COVID-19.

The psychological processes voiced by nursing students when caring for suicidal patients during their psychiatric clinical practicum: A qualitative study.

AIMS AND OBJECTIVES: This study was designed to explore the psychological processes experienced by nursing students caring for suicidal patients during their first psychiatric clinical practicum. BACKGROUND: Nursing students expressed fear when caring for patients who presented with suicidal behaviours. Yet, there is a lack of research exploring nursing students' feelings and thoughts when caring for suicidal patients. DESIGN: A grounded theory study. METHODS: A theoretical sample of 22 undergraduate nursing students who had cared for suicidal patients for at least 5 days during their psychiatric clinical practicum. Data were collected from 2016-2017, in three universities in Taiwan, using a semi-structured interview and constant comparative analysis. COREQ reporting guidelines were utilised. RESULTS: Four categories emerged depicting the psychological processes and revealing that the student nurses navigated four phases when caring for patients exhibiting suicidal behaviours. The phases were as follows: (a) apprehension and fear: involving students being frightened about patients attempting suicide; (b) frustration and powerlessness: concerning students finding it challenging to focus on changing patients' suicidal ideations; (c) support and catharsis: covering the students having to ask for psychological support from other people and explore their painful emotions; (d) confidence and empathy: meaning that the students incorporated enhanced confidence and cultivated advanced empathy, leading to the integration of competent care competencies towards suicidal patients. CONCLUSIONS: Findings could help nursing teachers to understand students' psychological processes when caring for suicidal patients. Teachers could provide appropriate support to help reduce students' negative thoughts and feelings and increase their care competencies when nursing suicidal patients during their psychiatric clinical practicum. RELEVANCE TO CLINICAL PRACTICE: Clinical nurse teachers could support and facilitate students to develop their competencies and confidence as they negotiate the four phases and, actually, complete their internship goals on their clinical practicums.

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America.

Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia.Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations.Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions.Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.

Agreement With Consensus Statements on End-of-Life Care: A Description of Variability at the Level of the Provider, Hospital, and Country.

OBJECTIVES: To develop an enhanced understanding of factors that influence providers' views about end-of-life care, we examined the contributions of provider, hospital, and country to variability in agreement with consensus statements about end-of-life care. DESIGN AND SETTING: Data were drawn from a survey of providers' views on principles of end-of-life care obtained during the consensus process for the Worldwide End-of-Life Practice for Patients in ICUs study. SUBJECTS: Participants in Worldwide End-of-Life Practice for Patients in ICUs included physicians, nurses, and other providers. Our sample included 1,068 providers from 178 hospitals and 31 countries. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We examined views on cardiopulmonary resuscitation and withholding/withdrawing life-sustaining treatments, using a three-level linear mixed model of responses from providers within hospitals within countries. Of 1,068 providers from 178 hospitals and 31 countries, 1% strongly disagreed, 7% disagreed, 11% were neutral, 44% agreed, and 36% strongly agreed with declining to offer cardiopulmonary resuscitation when not indicated. Of the total variability in those responses, 98%, 0%, and 2% were explained by differences among providers, hospitals, and countries, respectively. After accounting for provider characteristics and hospital size, the variance partition was similar. Results were similar for withholding/withdrawing life-sustaining treatments. CONCLUSIONS: Variability in agreement with consensus statements about end-of-life care is related primarily to differences among providers. Acknowledging the primary source of variability may facilitate efforts to achieve consensus and improve decision-making for critically ill patients and their family members at the end of life.

A theory to guide nursing students caring for patients with suicidal tendencies on psychiatric clinical practicum.

Research concerning this issue demonstrates that nursing students initially feared interacting with and caring for patients with suicidal tendencies. However, there is a lack of research, which examines the care that is provided to patients that are suicidal, by nursing students. The aim of this study was to develop a theory to guide nursing students when caring for patients with suicidal tendencies on their psychiatric clinical practicum. A qualitative approach using Grounded Theory was used. A total of 22 nursing students who had provided care for suicidal patients were interviewed. The core category that emerged from the data was the 'changing of mindsets towards caring for suicidal patients and promotion of suicidal care competencies'. Other key categories linked to and enfolded within this core category were: suicidal risk assessment; protecting patients' safety; and, developing therapeutic communication competencies to advance suicidal care. This study could help fill a theory-practice gap for both psychiatric nursing teachers and students. Nurse teachers could use this theory as a map to help guide students caring for patients with suicidal tendencies and develop nursing students' suicidal care competencies.

Interprofessional Shared Decision-Making in the ICU: A Systematic Review and Recommendations From an Expert Panel.

OBJECTIVES: There is growing recognition that high-quality care for patients and families in the ICU requires exemplary interprofessional collaboration and communication. One important aspect is how the ICU team makes complex decisions. However, no recommendations have been published on interprofessional shared decision-making. The aim of this project is to use systematic review and normative analysis by experts to examine existing evidence regarding interprofessional shared decision-making, describe its principles and provide ICU clinicians with recommendations regarding its implementation. DATA SOURCES: We conducted a systematic review using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases and used normative analyses to formulate recommendations regarding interprofessional shared decision-making. STUDY SELECTION: Three authors screened titles and abstracts in duplicate. DATA SYNTHESIS: Four papers assessing the effect of interprofessional shared decision-making on quality of care were identified, suggesting that interprofessional shared decision-making is associated with improved processes and outcomes. Five recommendations, largely based on expert opinion, were developed: 1) interprofessional shared decision-making is a collaborative process among clinicians that allows for shared decisions regarding important treatment questions; 2) clinicians should consider engaging in interprofessional shared decision-making to promote the most appropriate and balanced decisions; 3) clinicians and hospitals should implement strategies to foster an ICU climate oriented toward interprofessional shared decision-making; 4) clinicians implementing interprofessional shared decision-making should consider incorporating a structured approach; and 5) further studies are needed to evaluate and improve the quality of interprofessional shared decision-making in ICUs. CONCLUSIONS: Clinicians should consider an interprofessional shared decision-making model that allows for the exchange of information, deliberation, and joint attainment of important treatment decisions.

Pragmatic methods to avoid intensive care unit admission when it does not align with patient and family goals.

For patients with chronic, life-limiting illnesses, admission to the intensive care unit (ICU) near the end of life might not improve patient outcomes or be consistent with patient and family values, goals, and preferences. In this context, advance care planning and palliative care interventions designed to clarify patients' values, goals, and preferences have the potential to reduce provision of high-intensity interventions that are unwanted or non-beneficial. In this Series paper, we have assessed interventions that are effective at helping patients with chronic, life-limiting illnesses to avoid an unwanted ICU admission. The evidence found was largely from observational studies, with considerable heterogeneity in populations, methods, and types of interventions. Results from randomised trials of interventions to improve communication about goals of care are scarce, of variable quality, and mixed. Although observational studies show that advance care planning and palliative care interventions are associated with a reduced number of ICU admissions at the end of life, causality has not been well established. Using the available evidence we suggest recommendations to help to avoid ICU admission when it does not align with patient and family values, goals, and preferences and conclude with future directions for research.

Rationale underpinning postgraduate student nurses' choice of research methods used for their masters' theses.

Many nurses in Taiwan use quantitative research for their master's thesis. However, qualitative research explores humankind in depth providing a more holistic approach relating to nursing. The purpose of this study was to explore the rationale postgraduate students used to choose the research methods for their masters' theses in Taiwan. A descriptive qualitative research design was used. Data were collected through semi-structured interviews of sixteen nursing students studying a master's from seven different Universities in Taiwan in 2016. Data were analyzed using thematic analysis. Finding revealed three themes (1) Students' personal and professional backgrounds; (2) Myths about quantitative research; (3) Misperceptions about qualitative research. Nurse educators could use these findings as a reference to design post-graduate nursing courses. It is essential to provide a balanced educative experience between delivering qualitative and quantitative modules to enhance respect of research method, knowledge and skills. Further, this could facilitate students' choice in research methods when designing their master's theses.

Residents' Preferences and Performance of Three Techniques for Ultrasound-Guided Central Venous Cannulation After Simulation Training.

BACKGROUND: Obtaining central venous cannulation of the internal jugular vein is an important skill for physicians to master. To our knowledge, no studies to date have examined residents' preferences or the safety of the oblique approach compared to other approaches. This study compared medical residents' preferences for and performance of ultrasound-guided central venous access using the transverse, longitudinal, and oblique approaches. METHODS: Emergency medicine and internal medicine residents (n = 72) at an urban community hospital participated in a central venous access course. To assess the residents' preferences, residents were asked to rank the transverse, longitudinal, and oblique approaches as first, second, or third. In addition to preference, skin-to-vein time, carotid artery puncture, and successful completion on the first attempt during a final skills analysis were measured. RESULTS: During the final skills analysis, the majority (87.5%) of residents preferred the transverse approach. The oblique approach had a significantly larger proportion of failures of technique than the transverse approach (P = 0.02). No significant differences in successful cannulation on the first attempt, skin-to-vein time, or carotid artery puncture among the 3 approaches were found during the final skills assessment. CONCLUSION: The majority of residents preferred the transverse approach to the longitudinal and oblique approaches. Although no significant differences among the 3 approaches were found in performance measures, more failures of technique occurred with the oblique approach. This study suggests that novices may require in-depth training and supervision to become proficient with the oblique approach.