Difficult Intravenous Access in Pediatrics: Improving First Attempt Success Rates

Abstract Problem: This project aims to improve the success rate of peripheral intravenous catheter insertion on the first attempt from 50% to 60% with the implementation of the Difficult Intravenous Access (DIVA) clinical assessment and escalation tool, developed by the Queensland Children’s Hospital of Australia. Context:[LB1] Inserting a peripheral intravenous catheter is the most common invasive procedure during hospitalization. Obtaining vascular access in children may require multiple attempts due to their anatomical variations, smaller caliber veins, and the child\u27s level of anxiety. Up to 69% of first-attempt insertions fail, leading to delays in medical treatment and extended hospitalizations. Early identification and management of a child with difficult intravenous access can ensure prompt escalation and management, improving the patient and family experience. Intervention: Implementing the Difficult Intravenous Access (DIVA) clinical assessment and escalation tool. Education on the use of the tool is the primary test of change for this quality work; establishing DIVA champions to support staff on the use of the tool; reinforce proper documentation of peripheral intravenous properties in Health Connect; educate and reinforce the use of analgesia/comfort measures for all peripheral intravenous starts on pediatric patients. Measures: Measures for the Difficult Intravenous Access in Pediatrics project were designed to capture all peripheral intravenous access placed on the inpatient pediatric unit. The outcome measure is the percentage of patients with the successful placement of a peripheral intravenous catheter on the first attempt at cannulation. Process measures included adherence to the DIVA clinical assessment and escalation tool and the use of analgesia/comfort measures during peripheral intravenous catheter placement. Results: The primary outcome measure target of a 60% success rate at first attempt/cannulation for peripheral intravenous access was not met. Fifteen out of forty-four peripheral intravenous access attempts were successfully placed on the first attempt, resulting in a success rate of 34%. There was 100% compliance with using the DIVA clinical assessment and escalation tool for all forty-four attempts captured. Analgesia or comfort measures during peripheral intravenous catheter placement were used 66%, just below the set target of 70%. Conclusions: The main goal of providing a clinical assessment and escalation tool to help determine difficult intravenous access in pediatrics was achieved through implementing the DIVA key. Although the DIVA tool alone was insufficient to improve the overall success rate of peripheral intravenous access on the first attempt, it did help staff escalate to a confident or advanced inserter if the patient presented as a difficult intravenous access patient. The consistent use of analgesia or comfort measures for peripheral intravenous placement was also encouraged using the DIVA key. Keywords: difficult IV access, DIVA, difficult stick, pediatrics, and peripheral intravenous access

Sea turtle nesting in the Ten Thousand Islands of Florida

Loggerhead sea turtles (Caretta caretta) nest in numerous substrate and beach types within the Ten Thousand Islands (TTl) of southwest Florida. Nesting beach selection was analyzed on 12 islands within this archipelago. Numerous physical characteristics were recorded to identify the relatedness of these variables and determine their importance for nesting beach selection in C. caretta. These variables were chosen after evaluating the islands, conducting literature searches and soliciting personal communications. Along transects, data were collected, on the following: height of canopy, beach width, overall slope (beach slope and slope of offshore approach) and sand samples analyzed for pH, percentage of water, percentage of organic content, percentage of carbonate and particle size (8 size classes). Data on ordinal aspect of beaches and beach length were also recorded and included in the analysis. All of the variables were analyzed by tree regression, incorporating the nesting data into the analysis. In the TTl, loggerheads appear to prefer wider beaches (p< 0.001; R2 = 0.56) that inherently have less slope, and secondarily, wider beaches that have low amounts of carbonate (p< O.00 1). In addition, C. caretta favors nest sites within or in close proximity to the supra-littoral vegetation zone of beaches in the TTl (p< 0.001). (86 page document

Noise dephasing in the edge states of the Integer Quantum Hall regime

An electronic Mach Zehnder interferometer is used in the integer quantum hall regime at filling factor 2, to study the dephasing of the interferences. This is found to be induced by the electrical noise existing in the edge states capacitively coupled to each others. Electrical shot noise created in one channel leads to phase randomization in the other, which destroys the interference pattern. These findings are extended to the dephasing induced by thermal noise instead of shot noise: it explains the underlying mechanism responsible for the finite temperature coherence time $\tau_\phi(T)$ of the edge states at filling factor 2, measured in a recent experiment. Finally, we present here a theory of the dephasing based on Gaussian noise, which is found in excellent agreement with our experimental results.Comment: ~4 pages, 4 figure

Tuning decoherence with a voltage probe

We present an experiment where we tune the decoherence in a quantum interferometer using one of the simplest object available in the physic of quantum conductors : an ohmic contact. For that purpose, we designed an electronic Mach-Zehnder interferometer which has one of its two arms connected to an ohmic contact through a quantum point contact. At low temperature, we observe quantum interference patterns with a visibility up to 57%. Increasing the connection between one arm of the interferometer to the floating ohmic contact, the voltage probe, reduces quantum interferences as it probes the electron trajectory. This unique experimental realization of a voltage probe works as a trivial which-path detector whose efficiency can be simply tuned by a gate voltage

Finite bias visibility of the electronic Mach-Zehnder interferometer

We present an original statistical method to measure the visibility of interferences in an electronic Mach-Zehnder interferometer in the presence of low frequency fluctuations. The visibility presents a single side lobe structure shown to result from a gaussian phase averaging whose variance is quadratic with the bias. To reinforce our approach and validate our statistical method, the same experiment is also realized with a stable sample. It exhibits the same visibility behavior as the fluctuating one, indicating the intrinsic character of finite bias phase averaging. In both samples, the dilution of the impinging current reduces the variance of the gaussian distribution.Comment: 4 pages, 5 figure

A NEW APPROACH TO TEACHING NATURAL RESOURCE SAMPLING

A basic undergraduate course in statistics is often not adequate for students in renewable natural resource programs such as wildlife, forestry, fisheries, and related subjects. A strong foundation in the basics of sampling in time and space of forest, vegetation, wildlife and fish populations is needed. A brief account of our experience in teaching such a course over the last three years along with progress on developing course-related material and activities is reported. This includes the development of: 1) computer-based simulations; 2) in-class participation simulations to illustrate the basic concepts of sampling in space and time; 3) exercises to introduce students to basic field sampling methods (quadrat, line and point sample units, mark/recapture, radio telemetry, etc.); and 4) an associated hypermedia text. From the beginning, emphasis is placed on cost-effectiveness and on the importance of sampling in the decision-making process. Students are required to develop their own sampling project, implement the project, present the results in an open forum, and prepare an associated report in the format of a scientific paper

The Bright Side of Coulomb Blockade

We explore the photonic (bright) side of dynamical Coulomb blockade (DCB) by measuring the radiation emitted by a dc voltage-biased Josephson junction embedded in a microwave resonator. In this regime Cooper pair tunneling is inelastic and associated to the transfer of an energy 2eV into the resonator modes. We have measured simultaneously the Cooper pair current and the photon emission rate at the resonance frequency of the resonator. Our results show two regimes, in which each tunneling Cooper pair emits either one or two photons into the resonator. The spectral properties of the emitted radiation are accounted for by an extension to DCB theory.Comment: 4 pages, 4 figures + 3 pages, 1 figure supplementary materia

Quantum coherence engineering in the integer quantum Hall regime

We present an experiment where the quantum coherence in the edge states of the integer quantum Hall regime is tuned with a decoupling gate. The coherence length is determined by measuring the visibility of quantum interferences in a Mach-Zehnder interferometer as a function of temperature, in the quantum Hall regime at filling factor two. The temperature dependence of the coherence length can be varied by a factor of two. The strengthening of the phase coherence at finite temperature is shown to arise from a reduction of the coupling between co-propagating edge states. This opens the way for a strong improvement of the phase coherence of Quantum Hall systems. The decoupling gate also allows us to investigate how inter-edge state coupling influence the quantum interferences' dependence on the injection bias. We find that the finite bias visibility can be decomposed into two contributions: a Gaussian envelop which is surprisingly insensitive to the coupling, and a beating component which, on the contrary, is strongly affected by the coupling.Comment: 4 pages, 5 figure