Development, Implementation, and Evaluation of an Early Mobility Protocol in a Regional Level II Trauma Center.

The purpose of this project was to develop and evaluate a collaborative nursing/therapist protocol for early mobility in a medical-surgical intensive care unit (MICU) in a regional level II trauma center. Data for patients in the MICU were compared for the periods August 3, 2015-August 2, 2016, and August 3, 2014-August 2, 2015. Semistructured interviews were conducted with 10 nurses and 1 therapist. Average MICU length of stay decreased from 3.81 to 3.50 days (P = .057). Mean time in mobility chairs did not change (0.12 days vs 0.11 days, P = .389). Mean number of days to first documented level 2-5 activity decreased significantly, from 1.81 to 1.51 days (P = .036). The percentage of hospitalizations with any documented level 3 or 4 activity increased significantly (from 3.8% to 7.4% and from 61.5% to 66.7%, P = .003 and P = .031, respectively). Barriers/challenges to implementation included having enough people to assist, space, documentation, having to coax the physician to place order for upright mobility, availability of therapists for later stages of protocol, patient variability, fear of patient falls, availability of therapy chairs, staff changes, time, and patient refusal. A multidisciplinary approach to protocol development for early mobility in an intensive care unit was successfully implemented at a regional level II trauma center.

Public Attitudes toward Consent and Data Sharing in Biobank Research: A Large Multi-site Experimental Survey in the US.

Individuals participating in biobanks and other large research projects are increasingly asked to provide broad consent for open-ended research use and widespread sharing of their biosamples and data. We assessed willingness to participate in a biobank using different consent and data sharing models, hypothesizing that willingness would be higher under more restrictive scenarios. Perceived benefits, concerns, and information needs were also assessed. In this experimental survey, individuals from 11 US healthcare systems in the Electronic Medical Records and Genomics (eMERGE) Network were randomly allocated to one of three hypothetical scenarios: tiered consent and controlled data sharing; broad consent and controlled data sharing; or broad consent and open data sharing. Of 82,328 eligible individuals, exactly 13,000 (15.8%) completed the survey. Overall, 66% (95% CI: 63%-69%) of population-weighted respondents stated they would be willing to participate in a biobank; willingness and attitudes did not differ between respondents in the three scenarios. Willingness to participate was associated with self-identified white race, higher educational attainment, lower religiosity, perceiving more research benefits, fewer concerns, and fewer information needs. Most (86%, CI: 84%-87%) participants would want to know what would happen if a researcher misused their health information; fewer (51%, CI: 47%-55%) would worry about their privacy. The concern that the use of broad consent and open data sharing could adversely affect participant recruitment is not supported by these findings. Addressing potential participants' concerns and information needs and building trust and relationships with communities may increase acceptance of broad consent and wide data sharing in biobank research.

How Do Patients Respond to Genetic Testing for Age-related Macular Degeneration?

SIGNIFICANCE: The American Academy of Ophthalmology currently recommends against routine genetic testing for complex diseases such as age-related macular degeneration (AMD). The results of this study demonstrate that patients are very interested in predictive genetic testing for AMD, find the information useful, and make behavioral changes as a result of the information. PURPOSE: The goal of this project was to conduct a pilot AMD genomic medicine study. METHODS: Eligible patients were aged 50 to 65 years with no personal history of AMD. DNA samples were genotyped for five single-nucleotide polymorphisms (SNPs) in the CFH gene, one SNP in the ARMS-2 gene, one SNP in the C3 gene, and one SNP in the mitochondrial ND2 gene. A risk score was calculated utilizing a model based on odds ratios, lifetime risk of advanced AMD and known population prevalence of genotype, haplotype, and smoking risk. The study optometrist provided the patient's risk score and counseling for personal protective behaviors. Telephone interviews were conducted 1 to 3 months after the counseling visit. RESULTS: One hundred one subjects (85%) participated in the genetic testing; 78 (77.2%) were female. Follow-up interviews were conducted with 94 participants (93.1%). More than half (n = 48) of the participants said that they were motivated to participate in the study because they had a family member with AMD or another eye or genetic disorder. Despite low risk levels, many participants reported making changes as a result of the genetic testing. Twenty-seven people reported making specific changes, including wearing sunglasses and brimmed hat and taking vitamin supplements. Another 16 people said that they were already doing the recommended activities, including wearing glasses, quitting smoking, and/or taking vitamins. CONCLUSIONS: Interest in genetic testing for future risk of AMD was high in this population and resulted in support to continue current health behaviors or incentive to improve behaviors related to eye health.

An IDeA for enhancing undergraduate research at rural primarily undergraduate institutions.

This study documents the efforts of the North Dakota (ND) IDeA Networks of Biomedical Research Excellence (INBRE) program to assist in the development of undergraduate research programs at four state-supported primarily undergraduate institutions (PUIs) in ND. The study was initiated in the 2004-2005 academic year and continues to the present. The study shows that gaining initial institutional support for undergraduate research was assisted by providing salary support for faculty involved in undergraduate research. Once research was ongoing, each institution evolved their own unique plan for the use of support from the ND INBRE. Undergraduate student researchers have prepared, presented, and defended their research results on 188 unique posters since initiation of the program, with many posters being presented at more than one meeting. PUI faculty have authored 35 peer-reviewed manuscripts. Evaluation has shown that over 95% of the undergraduate students performing research matriculated with their bachelor's degree. Career choices of 77.2% of these graduates was determined, and 37% pursued a career in the health professions. Of the students not pursuing a post-baccalaureate degree, 81.2% chose careers directly linked to science. The study reinforces the concept that undergraduate research can be performed directly on the PUI campus and be of value in preparing the next generation of health professionals in research, service, and teaching.

Alcohol Use at the Time of Traumatic Brain Injury: Screening and Brief Intervention in a Community Hospital.

The use of screening and brief interventions (SBI) has been proposed to reduce future alcohol misuse and injury in traumatic brain injury (TBI) patients. As a result a SBI protocol for TBI patients was introduced with nursing training at a community hospital. In the 2 years following the implementation of a SBI protocol and nursing training, the number of patients with positive alcohol results decreased. The number of brief interventions increased to 83 (40.1%, 95% confidence limit [CL] = 33.4, 46.8), and CAGE questionnaire screenings decreased to 88 (42.5%, 95% CL = 35.8, 49.2), with 31 (35.2%) having positive results. These results highlight the need to assess processes and training in the emergency department to ensure that SBIs occur.

Rural definition of health: a systematic literature review.

BACKGROUND: The advent of patient-centered care challenges policy makers, health care administrators, clinicians, and patient advocates to understand the factors that contribute to effective patient activation. Improved understanding of how patients think about and define their health is needed to more effectively "activate" patients, and to nurture and support patients' efforts to improve their health. Researchers have intimated for over 25 years that rural populations approach health in a distinct fashion that may differ from their non-rural counterparts. METHODS: We conducted a systematic review of the literature to assess the extent and strength of evidence for rural definition of health. Studies were eligible for inclusion if they were published in English, reported on original research and presented findings or commentary relevant to rural definition of health, were published over the last 40 years, and were based on observations of rural U.S., Canadian, or Australian populations. Two reviewers were assigned to each selected article and blinded to the other reviewer's comments. For discordant reviews, a third blinded review was performed. RESULTS: Of the 125 published articles identified from the literature, 34 included commentary or findings relevant to a rural definition of health. Of these studies, 6 included an urban comparison group. Few studies compared rural and urban definitions of health directly. Findings relevant to rural definition of health covered a broad range; however, good health was commonly characterized as being able to work, reciprocate in social relationships, and maintain independence. This review largely confirmed many general characteristics on rural views of health, but also documented the extensive methodological limitations, both in terms of quantity and quality, of studies that empirically compare rural vs. urban samples. Most notably, the evidence base in this area is weakened by the frequent absence of parallel comparison groups and standardized assessment tools. CONCLUSIONS: To engage and activate rural patients in their own healthcare, a better understanding of the health beliefs in rural populations is needed. This review suggests that rural residents may indeed hold distinct views on how to define health, but more rigorous studies are needed to confirm these findings.

Implementing Healing Touch Pilot in an Inpatient Rehabilitation Unit: Reductions in Pain and Anxiety.

Energy-based therapies (EBT) are increasingly being used as comfort measures for hospitalized patients. This article describes the background and process of implementing an EBT healing touch (HT) pilot program in an inpatient rehabilitation unit. The pilot built on knowledge gained in a preliminary EBT pilot in two hospital units to improve rehabilitation patient outcomes and gather additional information to support a fully funded, sustainable rehabilitation EBT program. Thirty-five percent of the rehabilitation patients received HT, most commonly for pain and anxiety, by experienced HT practitioners over the 9-month pilot period. Both HT practitioners' and patients' ratings showed that patients' level of pain and anxiety decreased by approximately two points after the HT experience. Documented patient comments confirmed their positive experience, including comments describing a reduction in anxiety and increased sense of calm.

Observational Study: Predictors of a Successful Functional Outcome in Persons Who Receive Physical Therapy for Knee Osteoarthritis.

A retrospective design was employed to determine what factors are predictive of achieving a successful outcome for individuals with knee osteoarthritis following an episode of physical therapy. Success was defined as achieving the minimum clinically important difference with the change in the lower extremity functional scale (LEFS). Receiving guideline adherent care was hypothesized to increase odds of success. Data for treatment interventions, health care utilization, patient characteristics, and LEFS scores were collected from electronic health records from 2014-2018 across 34 outpatient clinics. The sample (N = 706) was primarily female, White, and older adults. Receiving guideline adherent care did not predict odds of achieving success. Patient age, initial LEFS score, opioid prescription, number of visits, and Medicare/Medicaid insurance were predictive of the outcome. Increasing age after 65 years predicted decreased odds of success. Older adults showed improved odds with an opioid prescription and with increased number of visits from two through 18 therapy sessions. Opportunities exist for further health services research on optimal management of knee OA, including underutilization of physical therapy (only 6% in this study), measuring adherence to CPGs, determining recommended intensity for interventions, and the effects of non-physical therapy interventions such as opioid use on outcomes.

Evaluation of a protocol for early detection of delayed brain hemorrhage in head injured patients on warfarin.

PURPOSE: In 2007, Essentia Health St. Mary's Medical Center (SMMC), a Level II trauma center in northeastern Minnesota, implemented a protocol for patients who presented with blunt head trauma and were receiving warfarin for anticoagulation. The purpose of this study was to determine the incidence and risk factors of early delayed, warfarin-associated intracranial hemorrhage (ICH). METHODS: Adult patients with signs and symptoms of head injury on warfarin who were admitted by protocol to SMMC between March 2007 and June 2015 were included. Patients were observed for neurologic change and received a follow-up head CT scan within 24 h after an initial negative scan. RESULTS: Among the 232 episodes of care studied, there were 204 patients. The average age was 71; 51% of patients were female. Most patients presented with Glasgow Coma Scale score of 15 and had signs of head trauma. The majority of patients (63%) had a therapeutic International Normalized Ratio (INR) for their indicated condition, but 19% of patients had a supratherapeutic INR and 19% had a subtherapeutic INR. The incidence of early delayed ICH was 1.7%; none of these cases required operative intervention or were fatal. CONCLUSIONS: For patients who were anticoagulated with warfarin and had sustained minor traumatic brain injury, implementation of our protocol showed low incidence of early delayed ICH in the first 24 h. We believe withholding warfarin for several days and careful follow-up regarding its resumption is warranted, especially in the setting of supratherapeutic INR.

Parents' attitudes toward consent and data sharing in biobanks: A multisite experimental survey.

BACKGROUND: The factors influencing parents' willingness to enroll their children in biobanks are poorly understood. This study sought to assess parents' willingness to enroll their children, and their perceived benefits, concerns, and information needs under different consent and data-sharing scenarios, and to identify factors associated with willingness. METHODS: This large, experimental survey of patients at the 11 eMERGE Network sites used a disproportionate stratified sampling scheme to enrich the sample with historically underrepresented groups. Participants were randomized to receive one of three consent and data-sharing scenarios. RESULTS: In total, 90,000 surveys were mailed and 13,000 individuals responded (15.8% response rate). 5737 respondents were parents of minor children. Overall, 55% (95% confidence interval 50-59%) of parents were willing to enroll their youngest minor child in a hypothetical biobank; willingness did not differ between consent and data-sharing scenarios. Lower educational attainment, higher religiosity, lower trust, worries about privacy, and attitudes about benefits, concerns, and information needs were independently associated with less willingness to allow their child to participate. Of parents who were willing to participate themselves, 25% were not willing to allow their child to participate. Being willing to participate but not willing to allow one's child to participate was independently associated with multiple factors, including race, lower educational attainment, lower annual household income, public health care insurance, and higher religiosity. CONCLUSIONS: Fifty-five percent of parents were willing to allow their youngest minor child to participate in a hypothetical biobank. Building trust, protecting privacy, and addressing attitudes may increase enrollment and diversity in pediatric biobanks.

STEERing an IDeA in Undergraduate Research at a Rural Research Intensive University.

This study documents outcomes, including student career choices, of the North Dakota Institutional Development Award Networks of Biomedical Research Excellence program that provides 10-week, summer undergraduate research experiences at the University of North Dakota School of Medicine and Health Sciences. Program evaluation initiated in 2008 and, to date, 335 students have completed the program. Of the 335, 214 students have successfully completed their bachelor's degree, 102 are still undergraduates, and 19 either did not complete a bachelor's degree or were lost to follow-up. The program was able to track 200 of the 214 students for education and career choices following graduation. Of these 200, 76% continued in postgraduate health-related education; 34.0% and 20.5% are enrolled in or have completed MD or PhD programs, respectively. Other postbaccalaureate pursuits included careers in pharmacy, optometry, dentistry, public health, physical therapy, nurse practitioner, and physician's assistant, accounting for an additional 21.5%. Most students electing to stop formal education at the bachelor's degree also entered fields related to health care or science, technology, engineering, and mathematics (19.5%), with only a small number of the 200 students tracked going into service or industries which lacked an association with the health-care workforce (4.5%). These student outcomes support the concept that participation in summer undergraduate research boosts efforts to populate the pipeline of future researchers and health professionals. It is also an indication that future researchers and health professionals will be able to communicate the value of research in their professional and social associations. The report also discusses best practices and issues in summer undergraduate research for students originating from rural environments.

Rural Health Networks and Care Coordination: Health Care Innovation in Frontier Communities to Improve Patient Outcomes and Reduce Health Care Costs.

Rural residents' health is challenged by high health care costs, chronic diseases, and policy decisions affecting rural health care. This single-case, embedded design study, guided by community-based participatory research principles and using mixed methods, describes outcomes of implementation of a community care team (CCT) and care coordination to improve outcomes of patients living in a frontier community. Seventeen organizations and 165 adults identified as potential care coordination candidates constituted the target populations. Following CCT development, collaboration and cohesion increased among organizations. Patients who participated in care coordination reported similar physical and lower emotional health quality of life than national counterparts; emergency department use decreased following care coordination. Key components identified as successful in urban settings seem applicable in rural settings, with emphasis on the key role of team facilitators; need for intense care coordination for people with complex health needs, especially behavioral health needs; and access to specialty care through technology.

Using PhenX toolkit measures and other tools to assess urban/rural differences in health behaviors: recruitment methods and outcomes.

BACKGROUND: The overall study was designed to examine how vacation behavior affects rural and urban Minnesotans and North Dakotans. The purpose of this substudy was to describe the method for sampling, follow-up and response rate by gender and urban/rural location to help inform future studies in this population. METHODS: Essentia health primary care patients (n=1344) were sent a 21-page self-administered questionnaire. The questionnaire included questions on demographics, work history, perceived stress, work productivity, depression and mania screeners, tobacco use, dietary information, vacation habits, and technology use. Participants were offered $10 to complete the questionnaire. RESULTS: The overall response to the three mailings to 1344 adults aged 25-64 was 38.8% for a final sample size of 522 completed surveys. Despite the oversampling of males, the total number of responses from males was lower than for females. The response rates between urban and rural locations were nearly identical for the males (33.3% and 33.0% respectively) but higher for rural females than urban females (47.2% and 42.6% respectively). Seventy-eight percent were currently employed. Sixty-nine percent of the participants reported being married, 5.4% were living with a partner, 14% were divorced widowed or separated and 11% were never married. Forty-seven percent of our population had an associate degree or some college, 29% had a Bachelor's degree or higher, 17% had their diploma or equivalent and 2% had not completed high school. CONCLUSIONS: The goal of the sampling frame and recruitment strategy for this study was to assemble a cohort of approximately 1000 working adults, represented equally by age, gender and rural location. We ended up with a smaller cohort than desired. The law of diminishing returns was observed, although the third mailing was more effective for men than women.

Protecting fragile skin: nursing interventions to decrease development of pressure ulcers in pediatric intensive care.

BACKGROUND: The reported incidence of pressure ulcers in critically ill infants and children is 18% to 27%. Patients at risk for pressure ulcers and nursing interventions to prevent the development of the ulcers have not been established. OBJECTIVES: To determine the incidence of pressure ulcers in critically ill children, to compare the characteristics of patients in whom pressure ulcers do and do not develop, and to identify prevention strategies associated with less frequent development of pressure ulcers. METHODS: Characteristics of 5346 patients in pediatric intensive care units in whom pressure ulcers did and did not develop were compared. Multiple logistic regression was used to determine which prevention strategies were associated with less frequent development of pressure ulcers. RESULTS: The overall incidence of pressure ulcers was 10.2%. Patients at greatest risk were those who were more than 2 years old; who were in the intensive care unit 4 days or longer; or who required mechanical ventilation, noninvasive ventilation, or extracorporeal membrane oxygenation. Strategies associated with less frequent development of pressure ulcers included use of specialty beds, egg crates, foam overlays, gel pads, dry-weave diapers, urinary catheters, disposable under-pads, body lotion, nutrition consultations, change in body position every 2 to 4 hours, blanket rolls, foam wedges, pillows, and draw sheets. CONCLUSIONS: The overall incidence of pressure ulcers among critically ill infants and children is greater than 10%. Nursing interventions play an important role in the prevention of pressure ulcers.