Keep the Beat with Heart Failure Education: A Quality Improvement Project

Abstract Problem: Heart failure (HF), also known as congestive heart failure (CHF), is the number one diagnosis-related group (DRG) for people 65 years of age and older in the United States. This disease group is complicated and debilitating, requiring frequent hospitalizations with high mortality rates. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has identified CHF as an area for improvement in hospitals. Context: This was a quality improvement project for an integrated medical center in the Central Valley, California with over 19,000 HF patients. In 2018, for patients 65 years and older, HF is the third-most admitted DRG in the hospital, with an average length of stay of 4.3 days. Interventions: A multifaceted educational model was developed with many interventions: 1) Patient educational handout for HF, 2) Patient teach-back discharge education, 3) RN staff education for HF, 4) RN checklist for HF, 5) HF web page, and 6) Referral workflow of HF patient to the chronic care department for follow-up after discharge. Measures: The aim of the project is to reduce HF 30-day post-discharge re-admission rates from 6.8% to 4% by December 2018, by focusing on the discharge education to the patients and caregivers. Using 2017 as a baseline, with 311 discharges and 21 (6.8%) re-admissions, the goal for 2018 would be 12 re-admissions, a reduction of 8.7 patients. Results: There is consistency by the nursing staff in educating a discharging HF patients. Patients state that the discharge instructions for HF are beneficial. Attendance to the heart failure basic class after patient discharge has improved. Due to time constraints with the project deadlines, the patient re-admission rates have not improved as projected since the implementation of the model. The results are expected to improve over the next few months. Conclusion: There are some important implications for nursing practice from this HF quality improvement project. Nurses require education to give education. Discharge instructions are imperative. Patients need discharge instructions written at a reading level that is easy to understand. Teach-back is a technique in education that improves the patient’s comprehension. Checklists provide consistency in nursing practice to ensure all steps are followed in fast-paced hospital discharges. Follow-up for a patient within a short time from discharge is well received by the patient. The educational model design can be transferable for other commonly admitted chronic conditions. Patients being readmitted routinely for HF generally have been in the later stages of the disease process. Few patients are not involved with the palliative care team. Many of the patients and their families have not considered end-of-life decisions, including code status for admissions. The next phase of this project will involve palliative care intervening in the plan of care for the chronic HF/CHF patient. Sustainability is a process and competing priorities make it difficult to achieve improvements as expected in the planned timeline. Quality improvement projects evolve over the process, and new insights are gleaned and can change the focus or aim of the project

Women\u27s Choir presents Hearts All Whole with special guest, Boss.Quartet

Kennesaw State University School of Music Women\u27s Choir presents Hearts All Whole with special guest, Boss.Quartet.https://digitalcommons.kennesaw.edu/musicprograms/1911/thumbnail.jp

A First Look at the Auriga-California Giant Molecular Cloud With Herschel and the CSO: Census of the Young Stellar Objects and the Dense Gas

We have mapped the Auriga/California molecular cloud with the Herschel PACS and SPIRE cameras and the Bolocam 1.1 mm camera on the Caltech Submillimeter Observatory (CSO) with the eventual goal of quantifying the star formation and cloud structure in this Giant Molecular Cloud (GMC) that is comparable in size and mass to the Orion GMC, but which appears to be forming far fewer stars. We have tabulated 60 compact 70/160um sources that are likely pre-main-sequence objects and correlated those with Spitzer and WISE mid-IR sources. At 1.1 mm we find 18 cold, compact sources and discuss their properties. The most important result from this part of our study is that we find a modest number of additional compact young objects beyond those identified at shorter wavelengths with Spitzer. We also describe the dust column density and temperature structure derived from our photometric maps. The column density peaks at a few x 10^22 cm^-2 (N_H2) and is distributed in a clear filamentary structure along which nearly all the pre-main-sequence objects are found. We compare the YSO surface density to the gas column density and find a strong non-linear correlation between them. The dust temperature in the densest parts of the filaments drops to ~10K from values ~ 14--15K in the low density parts of the cloud. We also derive the cumulative mass fraction and probability density function of material in the cloud which we compare with similar data on other star-forming clouds.Comment: in press Astrophysical Journal, 201

Plant stem cell maintenance by transcriptional cross-regulation of related receptor kinases

The CLAVATA3 (CLV3)-CLAVATA1 (CLV1) ligand-receptor kinase pair negatively regulates shoot stem cell proliferation in plants. clv1 null mutants are weaker in phenotype than clv3 mutants, but the clv1 null phenotype is enhanced by mutations in the related receptor kinases BARELY ANY MERISTEM 1, 2 and 3 (BAM1, 2 and 3). The basis of this genetic redundancy is unknown. Here, we demonstrate that the apparent redundancy in the CLV1 clade is in fact due to the transcriptional repression of BAM genes by CLV1 signaling. CLV1 signaling in the rib meristem (RM) of the shoot apical meristem is necessary and sufficient for stem cell regulation. CLV3-CLV1 signaling in the RM represses BAM expression in wild-type Arabidopsis plants. In clv1 mutants, ectopic BAM expression in the RM partially complements the loss of CLV1. BAM regulation by CLV1 is distinct from CLV1 regulation of WUSCHEL, a proposed CLV1 target gene. In addition, quadruple receptor mutants are stronger in phenotype than clv3, pointing to the existence of additional CLV1/BAM ligands. These data provide an explanation for the genetic redundancy seen in the CLV1 clade and reveal a novel feedback operating in the control of plant stem cells

Development of an Objective Structured Clinical Examination as a Component of Assessment for Initial Board Certification in Anesthesiology.

With its first administration of an Objective Structured Clinical Examination (OSCE) in 2018, the American Board of Anesthesiology (ABA) became the first US medical specialty certifying board to incorporate this type of assessment into its high-stakes certification examination system. The fundamental rationale for the ABA's introduction of the OSCE is to include an assessment that allows candidates for board certification to demonstrate what they actually "do" in domains relevant to clinical practice. Inherent in this rationale is that the OSCE will capture competencies not well assessed in the current written and oral examinations-competencies that will allow the ABA to judge whether a candidate meets the standards expected for board certification more properly. This special article describes the ABA's journey from initial conceptualization through first administration of the OSCE, including the format of the OSCE, the process for scenario development, the standardized patient program that supports OSCE administration, examiner training, scoring, and future assessment of reliability, validity, and impact of the OSCE. This information will be beneficial to both those involved in the initial certification process, such as residency graduate candidates and program directors, and others contemplating the use of high-stakes summative OSCE assessments

GOLVEN peptide signalling through RGI receptors and MPK6 restricts asymmetric cell division during lateral root initiation

During lateral root initiation, lateral root founder cells undergo asymmetric cell divisions that generate daughter cells with different sizes and fates, a prerequisite for correct primordium organogenesis. An excess of the GLV6/RGF8 peptide disrupts these initial asymmetric cell divisions, resulting in more symmetric divisions and the failure to achieve lateral root organogenesis. Here, we show that loss-of-function GLV6 and its homologue GLV10 increase asymmetric cell divisions during lateral root initiation, and we identified three members of the RGF1 INSENSITIVE/RGF1 receptor subfamily as likely GLV receptors in this process. Through a suppressor screen, we found that MITOGEN-ACTIVATED PROTEIN KINASE6 is a downstream regulator of the GLV pathway. Our data indicate that GLV6 and GLV10 act as inhibitors of asymmetric cell divisions and signal through RGF1 INSENSITIVE receptors and MITOGEN-ACTIVATED PROTEIN KINASE6 to restrict the number of initial asymmetric cell divisions that take place during lateral root initiation. The authors demonstrate the negative role of GOLVEN peptides during lateral root initiation in Arabidopsis, at the very early stage of the first asymmetric cell division of lateral root founder cells, and identify the receptors for these peptides

The Luminosities of Protostars in the Spitzer c2d and Gould Belt Legacy Clouds

Motivated by the long-standing "luminosity problem" in low-mass star formation whereby protostars are underluminous compared to theoretical expectations, we identify 230 protostars in 18 molecular clouds observed by two Spitzer Space Telescope Legacy surveys of nearby star-forming regions. We compile complete spectral energy distributions, calculate Lbol for each source, and study the protostellar luminosity distribution. This distribution extends over three orders of magnitude, from 0.01 Lsun - 69 Lsun, and has a mean and median of 4.3 Lsun and 1.3 Lsun, respectively. The distributions are very similar for Class 0 and Class I sources except for an excess of low luminosity (Lbol < 0.5 Lsun) Class I sources compared to Class 0. 100 out of the 230 protostars (43%) lack any available data in the far-infrared and submillimeter (70 um < wavelength < 850 um) and have Lbol underestimated by factors of 2.5 on average, and up to factors of 8-10 in extreme cases. Correcting these underestimates for each source individually once additional data becomes available will likely increase both the mean and median of the sample by 35% - 40%. We discuss and compare our results to several recent theoretical studies of protostellar luminosities and show that our new results do not invalidate the conclusions of any of these studies. As these studies demonstrate that there is more than one plausible accretion scenario that can match observations, future attention is clearly needed. The better statistics provided by our increased dataset should aid such future work.Comment: Accepted for publication in AJ. 21 pages, 10 figures, 4 table