Aligning Organizational Culture and Infrastructure to Support Evidence-Based Practice.

Standardized nursing practice based on the foundations of evidence-based practice leads to high-quality patient care and optimal outcomes. Despite knowing the benefits of evidence-based practice, health care organizations do not consistently make it the standard of care; thus, implementation of evidence-based practice at the system level continues to be challenging. This article describes the process adopted by a facility in the Southwest that took on the challenge of changing the organizational culture to incorporate evidence-based practice. The organization met the challenges by identifying perceived and actual barriers to successful implementation of evidence-based practice. The lack of standardized practice was addressed by developing a group of stakeholders including organizational leaders, clinical experts, and bedside providers. Changing the culture required a comprehensive process of document selection and development, education, and outcome evaluation. The ultimate aim was to implement an integrated system to develop practices and documents based on the best evidence to support patient outcomes.

Survivorship Data Coordinator: Successful Exemplar of a New Survivorship Care Plan Role.

Survivorship care and survivorship care plans have become integral components of comprehensive cancer care and national accreditation. An academic and community cancer network successfully pilot tested a new non-nursing role to support efficiency in case finding, staffing, and tracking patients throughout care delivery: the survivorship data coordinator (SDC). Key functions of the SDC role include abstracting data into survivorship care plans, scheduling survivorship visits, and tracking the number of completed survivorship care plans shared with patients. This pivotal role improved organizational processes and facilitated achievement of accreditation standards around survivorship care.

SerpinB3, a new prognostic tool in breast cancer patients treated with neoadjuvant chemotherapy.

It is unclear which patients with breast cancer benefit from anthracycline-based neoadjuvant chemotherapy and whether taxanes increase survival. Hsp70 and serpinB3 inhibit a lysosomal cell death pathway induced in anthracycline and taxane treated cells, which may be critical for breast cancer cell survival. Thus we evaluated serpinB3 and Hsp70 as putative prognostic biomarkers in breast cancer patients treated with neoadjuvant chemotherapy. SerpinB3 and Hsp70 were measured by immunohistochemistry in residual breast tumours of patients without a complete pathological response [pCR] (n = 250), from a retrospective cohort of 296 patients treated with anthracycline-based chemotherapy with or without sequential docetaxel prior to surgical resection. SerpinB3 (P = 0.02) and Hsp70 (P = 0.008) positivity in residual tumour were associated with a poor pathological response and serpinB3 was an independent prognostic biomarker (HR 2.1 (95% CI 1.2-3.8), P = 0.02). Docetaxel significantly improved overall survival of breast cancer patients treated with neoadjuvant chemotherapy. Furthermore, serpinB3 positivity predicted poor survival in patients treated with anthracycline-based chemotherapy alone (P = 0.02), but those with serpinB3 negative tumours had as equally good survival as those also treated with docetaxel (P = 0.7). Survival was independent of serpinB3 expression in patients who received sequential docetaxel. The Nottingham prognostic index (NPI), calculated at surgical resection, predicted overall survival in these neoadjuvantly treated patients (P < 0.001) and serpinB3 status segregated patients with a moderate NPI into distinct prognostic subgroups. The use of clinical (NPI) and molecular (serpinB3) biomarkers measured at surgical resection to provide accurate prognostication in patients who do not achieve a pCR following neoadjuvant chemotherapy could facilitate optimal post-operative clinical management of these patients and is of significant clinical value. Furthermore, serpinB3 status in residual tumour is a biomarker of neoadjuvant docetaxel benefit in patients not achieving a pCR and use of serpinB3 molecular subtyping for adjuvant docetaxel treatment planning warrants further investigation.

Passport to health: an innovative tool to enhance healthy lifestyle choices.

Obesity in children and adolescents has become an epidemic in the United States. The ramifications of obesity at a young age are longstanding and affect physical health, emotional health, and the economics of the health care industry. The Strong Pediatric Practice at Golisano Children's Hospital is a large inner-city practice serving more than 14,000 urban children and adolescents, the majority living below the poverty level. The Obesity Task Force, which comprises four nurse practitioners, two nurses, a nutritionist, and one physician, developed and implemented the "Passport to Health" tool in an attempt to encourage providers to assess and work with families around the issues of weight and activity, a need that was identified through chart audits. The Passport to Health supports the policy statements on prevention of overweight and obesity by the Centers for Disease Control and Prevention, National Association of Pediatric Nurse Practitioners, and American Academy of Pediatrics. Quality assurance standards for managed care that mandate body mass index (BMI) assessment and nutrition counseling in all children and adolescents also is supported by this tool. The Passport to Health also provides the same message as a current community initiative in the Rochester area that has received widespread media coverage. This tool includes a visual color-coded indicator of the child's BMI status and a synopsis of specific healthy eating and activity goals, and it permits an individualized goal to be established. The Passport to Health translates information that the provider knows about the BMI status into information that the family and child can embrace and understand. Chart audits as well as exit interviews have demonstrated that use of the Passport to Health has increased the assessment, identification, and counseling by providers in relation to healthy eating and activity. Chart audits found that nurse practitioners embraced this practice change more readily than did other providers. We also found that the use of the Passport to Health has increased the involvement of the child and adolescent in discussions about weight and activity status. Recommendations to encourage future practice changes have been established and will be implemented. The changes include intensive education with providers who were less likely to utilize the Passport to Health tool. The Passport to Health could be implemented easily in any pediatric practice setting.

The effect of family routines on care for inner city children with asthma.

This article provides the results of a study utilizing baseline data from the School-Based Asthma Therapy Trial, an ongoing comprehensive school-based intervention for urban children. We examined the effect of family routines as measured by the Asthma Routines Questionnaire on asthma care measures of trigger control and medication adherence, as well as on parental quality of life. We found that families with more asthma routines had better adherence with preventive medications (r = .36) and less exposure to environmental triggers (r = -.22). These findings suggest that assisting families in developing routines around asthma care might improve preventive care for urban youth.

Optimizing the health of infants and children: their oral health counts!

Tooth decay and poor oral health are the most common chronic health conditions in children in the United States today. This article discusses the significance of dental caries in children, the importance of oral health promotion, barriers to providing and obtaining oral health care, and current recommendations for practice. This article also recommends strategies for the promotion of optimal oral health in children and adolescents through screening, triaging, education, and tracking.

The relationship of household routines to morbidity outcomes in childhood asthma.

PURPOSE: The major purpose of this study was to explore the effect of routines on asthma management and morbidity outcomes for children with asthma and their parents. DESIGN AND METHODS: This study is a secondary data analysis in a sample of 150 children, which was originally used for an intervention study. RESULTS: Parents who had fewer routines in their homes had lower quality-of-life scores and higher burden of asthma scores when compared to parents in households with more routines. More routines were associated with improved asthma morbidity outcomes as measured by nurse rankings of routines. PRACTICE IMPLICATIONS: Assisting families to establish routines may result in improved asthma morbidity outcomes.

Infant-feeding practices of low-income Vietnamese American women.

Healthy People 2010 breastfeeding goals include 50% exclusive breastfeeding at 6 months. In California, US, Santa Clara County Women, Infants, and Children (SCCWIC) data indicated Asian participants had low (5.6%) 6-month breastfeeding rates. To examine infant-feeding practices, Vietnamese breastfeeding peer counselors surveyed 133 Vietnamese SCCWIC participants (> or= 18 years old, nonpregnant, < 28 months postpartum) using a structured questionnaire regarding intentions, attitudes, and subjective norms toward breastfeeding. Results indicated that 75% initiated breastfeeding in the hospital (33% exclusively, 42% partially), and 25% exclusively formula fed. At survey time, 49% had terminated breastfeeding (average duration 4.4 months). Feeding intentions during pregnancy predicted feeding method used (P < .001). Most prenatal advice was from SCCWIC employees, friends, and doctors who supported breastfeeding. Most postnatal advice was from nurses who supported breastfeeding and bottle-feeding equally. Stronger control beliefs, peer counseling, and education were correlated with breastfeeding (P < .001). Improved postdelivery hospital advice may further increase breastfeeding initiation and duration.

Impact of asthma education received from health care providers on parental illness representation in childhood asthma.

The burden of asthma has increased dramatically despite increased understanding of asthma and new medication regimens. Data reported here are part of a larger study investigating factors that influence parental asthma illness representation and the impact of this representation on treatment outcomes, including the parent/health care provider relationship. We investigated the influence of asthma related education provided by health care providers on these outcomes. After interviewing 228 parents of children with asthma, we found that asthma education received from the child's health care providers positively influenced parental belief systems, especially attitudes towards anti-inflammatory medications and facts about asthma. Parents who reported receiving more education also reported stronger partnerships with their child's health care provider.

The use of focus groups in pediatric and adolescent research.

Through this past decade, health care research has focused on clinical trials and establishing intervention versus control group research to improve the health of children and adolescents. Many of these clinical intervention trials have not demonstrated significantly improved health for these persons. One possible reason for the failure to demonstrate improved health is that the young persons' perspective is lacking. Focus group method of data collection is an excellent vehicle to help gain the young person's perspective on a variety of issues related to health and wellness. Including the young person's perspective when designing a program may encourage this person to participate in the new initiative, which would ultimately improve the health of children and adolescents to a greater degree than when their perspective is not taken into account. This article discusses the use of focus groups as an important part of the research process in pediatric and adolescent populations.

Parental perceptions of their child's asthma: management and medication use.

INTRODUCTION: Adequate treatment for asthma depends on accurate assessment and intervention by the parent and child and timely communication with the provider. These actions by the parent may be affected by their understanding of asthma management and their concerns about medications being prescribed. This research reports parental experiences with their children with asthma, specifically their beliefs, knowledge, and attitudes about asthma management, including medication use. METHODS: Data reported are from a study investigating parental attitudes and beliefs affecting antiinflammatory medication use in childhood asthma. These qualitative findings emerged from one-on-one semistructured qualitative interviews with 18 parents of children 2 to 18 years of age who were from diverse racial and socioeconomic backgrounds and who represented the spectrum of illness severity. RESULTS: Eight main themes within the domain of asthma management and medication use were identified: "I know my child," "trial and error," "partnership," "need for education," "negotiating responsibility," "hassles with medication administration," "preferences," and "the benefits outweigh the risks of side effects." DISCUSSION: These themes emphasize parents' need to partner with providers in their child's asthma management, as well as their need for ongoing asthma education. Parents also expressed concern about adverse effects of antiinflammatory medication but acknowledged the importance of controlling asthma symptoms. Based on these findings, systematic practice changes are recommended that provide regular opportunities for parent and child asthma education in a structured asthma wellness or "tune-up" visit.

Therapeutic Magnets Do Not Affect Tissue Temperatures.

OBJECTIVE: Manufacturers of commercially available "therapeutic" magnets claim that these magnets cause physiologic thermal effects that promote tissue healing. We conducted this study to determine if skin or intramuscular temperatures differed among magnet, sham, and control treatments during 60 minutes of application to the quadriceps muscle. DESIGN AND SETTING: A 3 x 3 mixed-model, factorial design with repeated measures on both independent variables was used. The first independent variable, application duration, had 3 random levels (20, 40, and 60 minutes). The second independent variable, treatment, had 3 fixed levels (magnet, sham, and control). The dependent variable was tissue temperature ( degrees C). Measurement depth served as a control variable, with 2 levels: skin and 1 cm below the fat layer. Data were collected in a thermoneutral laboratory setting and analyzed using a repeated-measures analysis of variance. SUBJECTS: The study included 13 healthy student volunteers (8 men, 5 women; age, 20.5 +/- 0.9 years; height, 176.8 +/- 10.4 cm; weight, 73.8 +/- 11.8 kg; anterior thigh skinfold thickness, 16.9 +/- 6.5 mm). MEASUREMENTS: Temperatures were measured at 30-second intervals using surface and implantable thermocouples. Temperature data at 20, 40, and 60 minutes were used for analysis. Each subject received all 3 treatments on different days. RESULTS: Neither skin nor intramuscular temperatures were different across the 3 treatments at any time. For both skin and intramuscular temperatures, a statistically significant but not clinically meaningful temperature increase (less than 1 degrees C), was observed over time within treatments, but this increase was similar in all treatment groups. CONCLUSIONS: No meaningful thermal effect was observed with any treatment over time, and treatments did not differ from each other. We conclude that flexible therapeutic magnets were not effective for increasing skin or deep temperatures, contradicting one of the fundamental claims made by magnet distributors.