The fluid dynamics of barnacle feeding.

Sessile barnacles feed by sweeping their basket-like cirral fan through the water, intercepting suspended prey. A primary component of the diet of adult barnacles is copepods that are sensitive to fluid disturbances and capable of escaping. How do barnacles manage to capture copepods despite the fluid disturbances they generate? We examined this question by describing the feeding current architecture of 1 cm sized Balanus crenatus using particle image velocimetry, and by studying the trajectories of captured copepods and the escapes of evading copepods. We found that barnacles produce a feeding current that arrives both from behind and the sides of the barnacle. The flow from the sides represents quiescent corridors of low fluid deformation and uninterrupted by the beating cirral fan. Potential prey arriving from behind are likely to encounter the cirral fan and, hence, capture here is highly unlikely. Accordingly, most captured copepods arrived through the quiet corridors, while most copepods arriving from behind managed to escape. Thus, it is the unique feeding flow architecture that allows feeding on evasive prey. We used the Landau-Squire jet as a simple model of the feeding current. For the Reynolds number of our experiments, the model reproduces the main features of the feeding current, including the lateral feeding corridors. Furthermore, the model suggests that smaller barnacle specimens, operating at lower Reynolds numbers, will produce a fore-aft symmetric feeding current without the lateral corridors. This suggests an ontogenetic diet shift from non-evasive prey to inclusion of evasive prey as the barnacle grows.

Trauma-Informed Psychosocial Screening and Care Planning: A Patient-Centered Improvement Project in a Midwife Clinic.

INTRODUCTION: Traumatic stress is associated with increases in preterm birth, low birth weight, and other perinatal complications. Yet the identification of patients with traumatic stress and intervention for traumatic stress prevention or treatment remain low. Locally in this university hospital-based midwife clinic, a health records review found that trauma exposure was documented in 5% of patient records, and no records had a diagnosis of posttraumatic stress disorder (PTSD). This is lower than research-based population estimates of 25% to 50% for trauma exposure and 8% for PTSD during pregnancy. The clinic staff did not screen for posttraumatic stress, and exposure screening was limited to intimate personal violence. Staff had not been trained in trauma-informed care (TIC) as defined by the Substance Abuse and Mental Health Services Administration. The aim for this improvement project was to provide trauma screening and trauma-related care planning, collectively referred to as trauma-informed psychosocial care, to midwifery patients 85% of the time. PROCESS: Interventions were implemented over 4 plan-do-study-act (PDSA) cycles. These included staff training in TIC; written screening at the new prenatal, third trimester, and postpartum visits; verbal broad inquiry at every visit; and bidirectional trauma-specific care planning emphasizing patient and provider input into treatment choice. The clinic flow was changed to create privacy for patient-staff interaction at every visit. Field notes and data were analyzed every 2 weeks and iterative changes applied. OUTCOMES: Trauma disclosure increased from 5% to 30% and identification of PTSD from 0% to 7%. Bidirectional care plan documentation increased from 8% to 67%. Staff rated the workload as reasonable. DISCUSSION: Redesigning psychosocial screening to align with TIC principles increased the discovery of trauma to levels consistent with research-based population estimates. Gains were made in bidirectional care planning. This project illustrates practical methods of implementing TIC principles.

Novel Shared Decision-Making Tool Improves Contraceptive Screening and Right Care during Pregnancy in a Military Hospital: A Quality Improvement Report.

INTRODUCTION: Unintended pregnancy rates in the military remain high compared with rates outside of the military in the United States (54%-60% vs 45%-50%, respectively). Contraceptive counseling in conjunction with shared decision-making is recommended to improve military unintended pregnancy rates. Best counseling practices and decision aids for contraceptive counseling are unknown in military and nonmilitary populations. Pregnancy may be an opportune time to complete contraceptive counseling because of regularly scheduled prenatal visits, and counseling during pregnancy is associated with higher postpartum contraception use. A quality initiative was implemented to improve contraceptive screening and counseling during pregnancy for servicewomen and nonservicewomen in a clinic setting. PROCESS: The initiative included 4 patient-centered core interventions: a patient screening, a shared decision-making tool, a right care checklist, and a team engagement plan, across 4 rapid plan-do-study-act cycles. OUTCOMES: Contraceptive screening rates and delivery of right care improved from 37% to 79% in the pregnant patients over 90 days; 81% of patients screened positive for contraception needs; 89% of patients made a same-day decision about their contraception plan after completing the tool; and 92% of patients had a contraception plan documented in the electronic health record by the health care provider prior to birth. DISCUSSION: Results demonstrated that contraception screening rates and right care improved with initiative interventions for servicewomen and nonservicewomen. A novel shared decision-making tool presented 18 contraception methods, risks and benefits, and tiered effectiveness that aided the majority of patients in a same-day decision with high patient satisfaction. Provider counseling was also simplified without delay in clinic time. Contraceptive counseling completed with a shared decision-making tool may benefit military and civilian populations during pregnancy. Additional research is needed to examine the best time to conduct counseling during pregnancy and the long-term rates of contraceptive use or unplanned pregnancy following counseling events.

Quality Improvement Methodology.

Patient Safety and Quality Improvement as a formal discipline has become widely established, with hospitals and health systems dedicating significant resources to improvement science. Physicians have leadership potential in quality and safety due to their clinical expertise and influence with both patients and hospital leadership. Success in such a leadership role, however, requires knowledge of the fundamentals of how to navigate an improvement endeavor from inception through implementation, analysis, and sustainment. Herein, the authors introduce the formal process of improvement science, discuss basic principles of change management, and provide a summary of the elements of scholarly writing to facilitate dissemination of knowledge across institutions.

Improving Timeliness of Obstetrical Triage Throughput in an Urban Tertiary Care Hospital.

BACKGROUND: Obstetrical triage units function like emergency departments with unpredictable volumes that affect the timely evaluation and treatment of patients and lead to longer wait times, delays in care, and longer length of stay (LOS). OBJECTIVE: The aim of this quality improvement initiative was to decrease the length of stay (LOS) of obstetrical triage patients by 20% through the utilization of nurse-driven orders, improved communication, and patient engagement. METHODS: Rapid cycle quality improvement using four plan-do-study-act cycles was utilized. Primary interventions were a patient decision tool, nurse-driven orders, a hypertension care algorithm, and team huddles. Data were analyzed using run charts to evaluate the impact of interventions on outcomes. RESULTS: Overall mean LOS for all patients (N = 654) was decreased by 26%. Most patients were satisfied with the patient decision tool (M = 4.45 on a 5-point Likert scale). The utilization of nurse-driven orders facilitated a decrease in mean LOS for hypertensive patients (N = 59) of 12%. CONCLUSIONS: Throughput in obstetrical triage is affected by many factors including availability of test results, practice styles of providers, and availability of beds. IMPLICATIONS FOR NURSING: Nurses can influence the length of time a patient remains in triage through the use of nurse-driven orders and improved communication with providers.

Improving equitable access to inclusive sexual healthcare in a small urban college health setting.

BACKGROUND: Sexual and gender minorities (SGM) experience many disparities in sexual health. College health centers must address early inequities for this population. LOCAL PROBLEM: Significant access disparity was noted for SGM students at a small urban college health center. The aim of this quality initiative was to increase equitable access by 20% over 90 days. METHODS: A rapid-cycle quality improvement project was initiated using a Plan-Do-Study-Act model. INTERVENTIONS: Templated nurse-led visits, a discussion starter tool, and an inclusive care checklist were introduced, with assurance of equity for each metric, and a focus on team collaboration. RESULTS: Access to sexual health services increased by 22.6% over 8 weeks with SGM utilization increasing 2.7-fold. Guideline-concordant care improved by 94% for all students. Student comfort scores (Likert range 1-5) also improved, from a baseline of 3.53 to a project mean of 4.62. CONCLUSIONS: This project addressed equity in a college health setting through improved student engagement, targeted workflow innovation, and enhanced team collaboration. Application of key findings to other health topics will continue to mitigate disparities in college health centers. Tools may also be applied to adolescent and adult primary care settings to improve patient comfort and SGM-inclusive sexual health service delivery.

Coercive pressure as a moderator of organizational structure and risk management: Empirical evidence from Malaysian construction industry.

INTRODUCTION: The construction industry in Malaysia has been bedevilled by myriads of risk issues that have hampered its smooth operations in recent times. This paper is an empirical assessment that aims to examine the effect of coercive pressure on the relationship between organizational structure and construction risk management among construction industry in Malaysia. METHOD: Based on the proposed model, a quantitative method was employed to obtain data from G7 construction industry operating within the peninsular Malaysia. Out of the 180 copies of questionnaire, 165 copies were properly filled, returned, and used for the analysis. PLS-SEM was used to analyze the obtained data. RESULTS: The findings of the study affirmed that specialization, centralization, and management of risk by the construction industry had positive correlation. CONCLUSIONS: As anticipated, coercive pressure had positive moderating correlation with both formalization and the management of risk by the construction industry. Similarly, it was also found that in the course of carrying out construction activities, coercive pressure made significant interactive influence on formalization, specialization, and centralization. Practical Applications: Coercive pressure reduced the frequency of accidents among workers in the process of carrying out construction works.

Nursing rounds: A quality improvement project to improve outpatient satisfaction.

AIM: To implement the nursing rounds to improve the quality and patient satisfaction of the outpatient department. BACKGROUND: Patient satisfaction is one of the most critical standards for judging the quality of hospitals. Clinical daily nursing rounds significantly increase patient satisfaction and influence safety. METHOD: SQUIRE guidelines directed the execution of a quality improvement project, which used the Driver Model to improve patient satisfaction in a Chinese outpatient department with 15,000 visits per day (4 million/year). Patient satisfaction based on questionnaires (1,541), pre-intervention and (1,219) post-intervention provided increased satisfaction (p < .05). RESULTS: Improvements validated were satisfaction with outpatient services from patients, effective nurse-patient communications, an increase in the quality of nursing care, doctors' satisfaction with the outpatient department operations, reduced wait time and more efficient management, all impact safety. CONCLUSIONS: The institution of daily nursing rounds made an overall improvement in the operations of the outpatient department, which increased patient satisfaction, quality of care and safety. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing rounds promote patient satisfaction through assessment of operations, addressing patient and staff needs, and appropriate interventions to rectify issues and reduce adverse outcomes. Patient satisfaction impacts quality, outcomes and safety in clinical settings.

Quality improvement in pediatric urology-a historical perspective on street pumps, puerperal fever, surgical infection, and contemporary methodology.

Quality improvement and patient safety (QIPS) can trace its origin back to the court of Hammurabi (circa 1700BC). However, it did not begin its evolution into its present methodology until the mid-19th century. It was through the application of quantitative parameters around the time of World War I that the field of QIPS has matured and gained a significant presence in the practice of medicine. Herein, the authors present a historical overview of this increasingly important field and correlate the current pediatric urology literature that has arisen from it. Because QIPS research is likely to contribute to efficient, streamlined health care through rapid changes to routine clinical practices, it would behoove pediatric urologists to familiarize themselves with its history and fundamental concepts.

Necitumumab for the treatment of advanced non-small-cell lung cancer.

Personalized patient-precise medicine is being gradually incorporated into clinical practice for the treatment of non-small-cell lung cancer (NSCLC). The EGFR pathway has been explored as a druggable target with monoclonal antibodies such as cetuximab or necitumumab. Necitumumab is a humanized IgG1 anti-EGFR. In the Phase III SQUIRE trial, necitumumab used as first-line therapy in combination with cisplatin and gemcitabine showed a reduction in risk-of-death and a better disease control rate in advanced squamous NSCLC. Thus, necitumumab is now a new first-line treatment option in squamous NSCLC. However, further biomarker research is needed to improve patient selection. Moreover, necitumumab associated with other immunotherapy and targeted agents is currently an important area of research that may yield better outcomes for NSCLC patients.

Correlation of EGFR-expression with safety and efficacy outcomes in SQUIRE: a randomized, multicenter, open-label, phase III study of gemcitabine-cisplatin plus necitumumab versus gemcitabine-cisplatin alone in the first-line treatment of patients with stage IV squamous non-small-cell lung cancer.

BACKGROUND: SQUIRE demonstrated addition of necitumumab to gemcitabine and cisplatin significantly improved survival in patients with stage IV sq-NSCLC. Here, we report additional outcomes for the subpopulation of patients with tumor epidermal growth factor receptor (EGFR) protein expression. PATIENTS AND METHODS: Patients with pathologically confirmed stage IV sq-NSCLC were randomized 1:1 to receive a maximum of six 3-week cycles of gemcitabine (1250 mg/m(2) i.v., days 1 and 8) and cisplatin (75 mg/m(2) i.v., day 1) chemotherapy with or without necitumumab (800 mg i.v., days 1 and 8). Patients in the chemotherapy plus necitumumab group with no progression continued on necitumumab alone until disease progression or intolerable toxicity. SQUIRE included mandatory tissue collection. EGFR protein expression was detected by immunohistochemistry (IHC) in a central laboratory. Exploratory analyses were pre-specified for patients with EGFR protein expressing (EGFR > 0) and non-expressing (EGFR = 0) tumors. RESULTS: A total of 982 patients [90% of intention-to-treat (ITT)] had evaluable IHC results. The large majority of these patients (95%) had tumor samples expressing EGFR protein; only 5% had tumors without detectable EGFR protein. Overall survival (OS) for EGFR > 0 patients was significantly longer in the necitumumab plus gemcitabine-cisplatin group than in the gemcitabine-cisplatin group {stratified hazard ratio (HR) 0.79 [95% confidence interval (CI) 0.69, 0.92; P = 0.002]; median 11.7 months (95% CI 10.7, 12.9) versus 10.0 months (8.9, 11.4)}. Additionally, an OS benefit was seen in all pre-specified subgroups in EGFR > 0 patients. However, OS HR for EGFR = 0 was 1.52. Adverse events of interest with the largest difference between treatment groups in EGFR > 0 patients (Grade ≥3) were hypomagnesemia (10% versus <1%) and skin rash (6% versus <1%). CONCLUSIONS: In line with SQUIRE ITT, addition of necitumumab to gemcitabine-cisplatin significantly prolonged OS and was generally well tolerated in the subpopulation of patients with EGFR-expressing advanced sq-NSCLC. The benefit from addition of necitumumab to chemotherapy was not apparent in this analysis for the small subgroup of patients with non-EGFR-expressing tumors. CLINICAL TRIAL: NCT00981058.

What is the quality of reporting of studies of interventions to increase compliance with antibiotic prophylaxis?

BACKGROUND: Despite studies reporting successful interventions to increase antibiotic prophylaxis compliance, surgical site infections remain a significant problem. The reasons for this lack of improvement are unknown. This review evaluates the internal and external validity of quality improvement studies of interventions to increase surgical antibiotic prophylaxis compliance. STUDY DESIGN: Three investigators independently performed systematic literature searches and selected eligible studies that evaluated interventions to improve perioperative antibiotic prophylaxis timing, type, and/or discontinuation. Studies published before the Surgical Infection Prevention project inception in 2002 were excluded. Each study was assessed based on modified criteria for evaluating quality improvement studies (Standards for Quality Improvement Reporting Excellence) and for facilitating implementation of evidence into practice (Reach-Efficacy-Adoption-Implementation-Maintenance). RESULTS: Forty-six articles met inclusion criteria; 93% reported improvement in antibiotic prophylaxis compliance. Surgical site infections were evaluated in 50% of studies and 65% reported an improvement. Less than 5% of studies used randomization, allocation concealment, or blinding. Nine percent of studies described efforts to minimize bias in the design results and analysis and 13% described a sample size calculation. Approximately one-third of studies described participant adoption of the intervention (26%), factors affecting generalizability (33%), or implementation barriers (37%). Most studies (80%) used multiple interventions; no single intervention was associated with change in compliance. Studies with the lowest baseline compliance showed the greatest improvement, regardless of the intervention(s). CONCLUSIONS: The methodology and reporting of quality improvement studies on perioperative antibiotic prophylaxis is suboptimal, and factors that would improve generalizability of successful intervention implementation are infrequently reported. Clinicians should use caution in applying the results of these studies to their general practice.