Quality Improvement on the Long-term Care Ventilator Unit: Interventions to Increase Patient Safety and Prevent Patient Harm

BACKGROUND: Tracheostomy patients are susceptible to life-threatening emergencies when their airways are compromised. Epidemiologic data suggests that 3.2% to 30% of tracheostomy patents have a complication. The long-term care ventilator unit (LTCVU) is a 25-bed unit in a nursing home. It has noted that 40% of patients have a complication. A group of hospitals demonstrated a 90% reduction in complications through five interventions. METHODS: The Johns Hopkins Nursing Evidence-Based Practice model was utilized to take the Global Tracheostomy Collaborative interventions and apply them to the LTCVU with the aim of reducing the number of airway complications on the unit by 50%. INTERVENTIONS: Five interventions were implemented for this quality improvement project: Bedside multidisciplinary team rounds, nursing in-services, continued protocolization of care, tracking complication rates and active prevention measures. Pre- and post-education surveys were distributed to nurses. Pre-education surveys averaged a 49% score, while the post-education average was 98%. RESULTS: Complications per patient per day were tracked pre- and post-intervention and a control chart compared pre- and post-intervention rates. Pre-implementation there were 0.00655 complications per patient per day over 22-weeks. Post-implementation there were 0.01012 complications per patient per day over 6-weeks. CONCLUSIONS: While complication rates seem to have increased following implementation, there are many reasons that an increase may have been noted. During implementation, census increased while staffing did not. Additionally, the project was implemented during the winter season, when dry air often causes increased mucous plugging. Finally, the post-implementation period has only covered six weeks. Perhaps with extended monitoring, rates would decrease

Oregon: Round 1 - State-Level Field Network Study of the Implementation of the Affordable Care Act

This report is part of a series of 21 state and regional studies examining the rollout of the ACA. The national network ---- with 36 states and 61 researchers ---- is led by the Rockefeller Institute of Government, the public policy research arm of the State University of New York, the Brookings Institution, and the Fels Institute of Government at the University of Pennsylvania.Oregon has taken an overwhelmingly affirmative response to the ACA, as evidenced by its enthusiastic development and implementation of Cover Oregon and its decision to expand Medicaid. In fact, it is one of six states to receive a Model Testing award from the Centers for Medicare & Medicaid Services, which will support continuing efforts to transform its health care delivery system through innovative methods

Prevalence of \u3cem\u3eMyxobolus cerebralis\u3c/em\u3e Infections Among Genetic Lineages of \u3cem\u3eTubifex tubifex\u3c/em\u3e at Three Locations in the Madison River, Montana

Host biodiversity can impact disease risk and influence the transmission of parasitic disease. Stream sediment–dwelling worms, Tubifex tubifex (Clitellata: Oligochaeta), are the definitive host of the parasite Myxobolus cerebralis (Myxozoa: Myxosporea), which causes whirling disease in salmonid fishes. Genetic diversity of T. tubifex is correlated with host susceptibility to M. cerebralis, and mitochondrial Lineage III is generally shown to be more likely to be infected and produce the triactinomyxon (TAM) spores than other lineages. We determined the mitochondrial lineage, relative abundance, and prevalence of infection of T. tubifex collected at 3 sites in the Madison River, Montana, where previous study had shown variation in whirling disease prevalence and severity in caged trout fry. We also compared visual identification of TAMs released from cultured worms with a molecular genetic assay (diagnostic polymerase chain reaction [PCR]) for parasite detection of both infected and uninfected worms. We estimated that mitochondrial Lineage III was most abundant at the site previously shown to have high fish disease and was also most likely to be infected. The 2 techniques for detecting parasite infection did not always agree, and the likelihood of PCR (+) and spore (−) was not significantly different from PCR (−) and spore (+). Differences in the relative infection prevalence for these 2 lineages may explain the wide range of infection in natural streams

Experimental Testing Program in Elementary Chemistry: A Preliminary Report

An experimental testing program is described which utilizes questions that are partly computer composed, in addition to a section composed by the instructor, and a retesting option to the student. Results from a trial of the program for one term indicate that (1) course grades were improved, (2) the student withdrawal failure rate was unaffected, and (3) the employed students took greater advantage of the retest than did the unemployed students

Māori farming trusts - A preliminary scoping investigation into the governance and management of large dairy farm businesses.

This preliminary scoping study investigates areas for possible improvement in the governance and management of large Māori dairy farm businesses. Building on the innovative practices of their tūpuna – including Rawiri Taiwhanga, the country’s first commercial dairy farmer – Māori are defining their own aspirations, realities and goals in the dairy farming world (Durie 1998, 2000). This report outlines these, and their accompanying challenges, as expressed by individuals and collectives currently engaged in Māori Dairy farm businesses. The Māori way of doing business is described in this study as having a ‘Quadruple Bottom Line of Profit, People, Environment and Community’ business objectives. More specifically, ‘Māori farms often have an inverted Quadruple Bottom Line. People, Environment and their Community often come before Profit….but without Profit none of it happens.’ Māori strategic plans and business values place emphasis on relationships, responsibilities, reciprocity and respect. These are exemplars of a Māori world-view, which explicitly acknowledges particular historic and cultural contexts (Tapsell and Woods 2010). The strategic management plans of the Māori Farming Trusts illustrate the spiral or matrix of values ‘He korunga o nga tikanga’ envisaged by Nicholson, Hēnare and Woods (2012). They prioritise the development of social capital to create competitive advantage. Such strategic plans reflect Māori vision and aspirations. These are to sustain and grow the land base; to provide leadership and guidance for the whānau; to develop capacity and resources within the Trusts and to perform better as businesses.DairyNZ Ltd, Ministry for Primary Industries (NZ

The Parasite that Causes Whirling Disease, \u3cem\u3eMyxobolus cerebralis\u3c/em\u3e, is Genetically Variable Within and Across Spatial Scales

Understanding the genetic structure of parasite populations on the natural landscape can reveal important aspects of disease ecology and epidemiology and can indicate parasite dispersal across the landscape. Myxobolus cerebralis (Myxozoa: Myxosporea), the causative agent of whirling disease in the definitive host Tubifex tubifex, is native to Eurasia and has spread to more than 25 states in the USA. The small amounts of data available to date suggest that M. cerebralis has little genetic variability. We examined the genetic variability of parasites infecting the definitive host T. tubifex in the Madison River, MT, and also from other parts of North America and Europe. We cloned and sequenced 18S ribosomal DNA and the internal transcribed spacer-1 (ITS-1) gene. Five oligochaetes were examined for 18S and five for ITS-1, only one individual was examined for both genes. We found two different 18S rRNA haplotypes of M. cerebralis from five worms and both intra- and interworm genetic variation for ITS-1, which showed 16 different haplotypes from among 20 clones. Comparison of our sequences with those from other studies revealed M. cerebralis from MT was similar to the parasite collected from Alaska, Oregon, California, and Virginia in the USA and from Munich, Germany, based on 18S, whereas parasite sequences from West Virginia were very different. Combined with the high haplotype diversity of ITS-1 and uniqueness of ITS-1 haplotypes, our results show that M. cerebralis is more variable than previously thought and raises the possibility of multiple introductions of the parasite into North America

My Future

The drama of the future becomes ourselves. A part of us is already dead, gone, and no longer existing anywhere. From the beginning of our existence we have left behind a part of us each day, a portion of burned energy which will never return