Improving Nursing Staffing Methodology and Nursing Sensitive Outcomes with the Addition of a Patient Centered Acuity Measure

Background: Assigning the correct nursing resources to hospitalized patients positively impacts patient outcomes. The current process for matching nurses to patients is highly variable and involves a combination of simple ratios, historical workload data, and expert opinion but lacks objective measurement of the patient’s condition. Objectives: This project evaluated change in selected quality indicators and the daily unit-level management of nursing resources after implementing the Troubled Outcome Risk (TOR) into existing nursing staffing methodology in a Department of Veterans Affairs hospital. Methods: TOR provides objective measurement of individual patient allostatic load. Daily calculation of TOR scores for each patient on the study unit and nursing staffing methodology were used by charge nurses to determine assignments. Nursing sensitive indicators including length of stay, transfers to intensive care unit, hospital acquired pressure ulcer (HAPU), 30-day readmissions, and nursing surveillance indicators including rapid response team activation and cardiac arrests were compared before and after implementing TOR. Results: There was a reduction of HAPU rates that exceeded the stated goal after implementation of TOR. Other indicators did not meet project goals. Prior to implementation of TOR, nurse assignments clustered in specific locations; after implementation 16.7% were without regard to location. None of the results were statistically significant; yet we observed a small-medium effect size between intervention and assignment change. Conclusions: The implementation of TOR did not result in significant differences in nursing sensitive outcomes, however charge nurses appear to have changed staff nurse assignments using TOR as an addition to existing methodology. Future study with a larger sample over a longer period of time may yield different results

Policy Options for Improving the Resilience of US Transportation Infrastructure

Despite the vulnerability of America’s aging infrastructure to costly disruptions from man-made and natural disasters, infrastructure insurance under-utilized. On average, only 30% of catastrophic losses in the past 10 years have been covered by insurance. Most infrastructure project managers have relied instead on taxpayer-funded federal aid when disaster strikes. But it doesn’t need to be this way. In this brief, Gina Tonn, Jeffrey Czajkowski, and Howard Kunreuther use technical reports and input from infrastructure managers to outline steps that policymakers can take to help maximize the use of infrastructure insurance for providing financial protection, encouraging investment in loss mitigation measures, and limiting the current reliance on taxpayer dollars.https://repository.upenn.edu/pennwhartonppi/1058/thumbnail.jp

Expression of G-protein inwardly rectifying potassium channels (GIRKs) in lung cancer cell lines

BACKGROUND: Previous data from our laboratory has indicated that there is a functional link between the beta-adrenergic receptor signaling pathway and the G-protein inwardly rectifying potassium channel (GIRK1) in human breast cancer cell lines. We wanted to determine if GIRK channels were expressed in lung cancers and if a similar link exists in lung cancer. METHODS: GIRK1-4 expression and levels were determined by reverse transcription polymerase chain reaction (RT-PCR) and real-time PCR. GIRK protein levels were determined by western blots and cell proliferation was determined by a 5-bromo-2\u27-deoxyuridine (BrdU) assay. RESULTS: GIRK1 mRNA was expressed in three of six small cell lung cancer (SCLC) cell lines, and either GIRK2, 3 or 4 mRNA expression was detected in all six SCLC cell lines. Treatment of NCI-H69 with beta2-adrenergic antagonist ICI 118,551 (100 microM) daily for seven days led to slight decreases of GIRK1 mRNA expression levels. Treatment of NCI-H69 with the beta-adrenergic agonist isoproterenol (10 microM) decreased growth rates in these cells. The GIRK inhibitor U50488H (2 microM) also inhibited proliferation, and this decrease was potentiated by isoproterenol. In the SCLC cell lines that demonstrated GIRK1 mRNA expression, we also saw GIRK1 protein expression. We feel these may be important regulatory pathways since no expression of mRNA of the GIRK channels (1 & 2) was found in hamster pulmonary neuroendocrine cells, a suggested cell of origin for SCLC, nor was GIRK1 or 2 expression found in human small airway epithelial cells. GIRK (1,2,3,4) mRNA expression was also seen in A549 adenocarcinoma and NCI-H727 carcinoid cell lines. GIRK1 mRNA expression was not found in tissue samples from adenocarcinoma or squamous cancer patients, nor was it found in NCI-H322 or NCI-H441 adenocarcinoma cell lines. GIRK (1,3,4) mRNA expression was seen in three squamous cell lines, GIRK2 was only expressed in one squamous cell line. However, GIRK1 protein expression was not seen in any non-SCLC cells. CONCLUSION: We feel that this data may indicate that stimulation of GIRK1 or GIRK2 channels may be important in lung cancer. Stimulation of GIRK channels and beta-adrenergic signaling may activate similar signaling pathways in both SCLC and breast cancer, but lead to different results

Transitioning from Episodic to Sustained Care in Humanitarian Service

Background: Humanitarian missions serve populations needing care and usually provide short term interventions. Traditionally, care provided through humanitarian agencies like VOSH International has been episodic, consisting of a short-term mission placing a team in country for several days. There have been discussions that episodic care is a short term measure which impedes the systematic development of a long term solution to providing the necessary health care. The move toward sustained care is a step in the direction of improving the public health in developing countries. Method: A survey instrument was mailed to the 26 VOSH chapters in the United States and Canada. Results were tabulated and analyzed. Results: Sixteen completed surveys were returned for a response rate of 62%. In a one-year period, missions were carried out in 13 countries. There is a strong tendency toward continuity of care with 81% of respondents returning to locations of previous missions and 69% targeting the same population base. There is also a trend toward providing sustained care (such as establishment of a fixed clinical facility) with half responding affirmatively. Nineteen percent of chapters have been involved in the development or enhancement of departments, schools or colleges of optometry in the developing world. Conclusion: It is exhibited in this study that most teams return to the same areas for future missions and collaborate with other partners with different expertise to create an ongoing presence. This model provides acute care for those needing immediate attention but also enhances the local infrastructure to develop a plan for long term care of this population. This allows for the opportunity to address immediate concerns, build rapport with the community, and use that goodwill and expertise to create long term change. While episodic humanitarian missions have made a profound impact, transitioning from episodic to sustained care improves overall quality of care, expanded services and long-term impact

The Role of Relationships in the Professional Formation of Physicians

BACKGROUND: Studies of the professional development of physicians highlight the important effect that the learning environment, or \ hidden curriculum,\ has in shaping student attitudes, behaviors, and values. We conducted this study to better understand the role that relationships have in mediating these effects of the hidden curriculum. [See PDF for complete abstract

Health literacy, health status, and healthcare utilization of Taiwanese adults: results from a national survey

Abstract Background Low health literacy is considered a worldwide health threat. The purpose of this study is to assess the prevalence and socio-demographic covariates of low health literacy in Taiwanese adults and to investigate the relationships between health literacy and health status and health care utilization. Methods A national survey of 1493 adults was conducted in 2008. Health literacy was measured using the Mandarin Health Literacy Scale. Health status was measured based on self-rated physical and mental health. Health care utilization was measured based on self-reported outpatient clinic visits, emergency room visits, and hospitalizations. Results Approximately thirty percent of adults were found to have low (inadequate or marginal) health literacy. They tended to be older, have fewer years of schooling, lower household income, and reside in less populated areas. Inadequate health literacy was associated with poorer mental health (OR, 0.57; 95% CI, 0.35-0.91). No association was found between health literacy and health care utilization even after adjusting for other covariates. Conclusions Low (inadequate and marginal) health literacy is prevalent in Taiwan. High prevalence of low health literacy is not necessarily indicative of the need for interventions. Systematic efforts to evaluate the impact of low health literacy on health outcomes in other countries would help to illuminate features of health care delivery and financing systems that may mitigate the adverse health effects of low health literacy.http://deepblue.lib.umich.edu/bitstream/2027.42/78252/1/1471-2458-10-614.xmlhttp://deepblue.lib.umich.edu/bitstream/2027.42/78252/2/1471-2458-10-614.pdfPeer Reviewe

Intractable Alcoholism in a Patient with a Levine Shunt

Ellen Shaw. M.D., Fellow in Hepatology: Mr. J is a forty-six-year-old white male who was initially seen on the medical service in July 1982. At that time he presented with hepatic encephalopathy, jaundice, and ascites. A liver biopsy was performed, confirming the clinical diagnosis of alcoholic hepatitis superimposed on cirrhosis. Following discharge it was difficult to maintain Mr. J as an outpatient. He did not follow dietary restrictions or take diuretics as prescribed. Additionally he was unable to control his drinking. Finally about a year ago a Levine shunt was implanted in an effort to control his ascites. Subsequently he did well for a period of several months. He was able to abstain from alcohol with a resulting decrease in his ascites and jaundice. Recently he has resumed drinking, with a return of his symptoms. He has missed his last several appointments in the clinic. Control of his medical problems remains problematic unless his alcohol abuse can be better controlled

Looking, seeing and believing in autism: Eye movements reveal how subtle cognitive processing differences impact in the social domain

Adults with High Functioning Autism Spectrum Disorders (ASD) viewed scenes with people in them, while having their eye movements recorded. The task was to indicate, using a button press, whether the pictures were normal, or in some way weird or odd. Oddities in the pictures were categorized as violations of either perceptual or social norms. Compared to a Typically Developed (TD) control group, the ASD participants were equally able to categorize the scenes as odd or normal, but they took longer to respond. The eye movement patterns showed that the ASD group made more fixations and revisits to the target areas in the odd scenes compared with the TD group. Additionally, when the ASD group first fixated the target areas in the scenes, they failed to initially detect the social oddities. These two findings have clear implications for processing difficulties in ASD for the social domain, where it is important to detect social cues on‐line, and where there is little opportunity to go back and recheck possible cues in fast dynamic interactions

Sequence Skill Acquisition and Off-Line Learning in Normal Aging

It is well known that certain cognitive abilities decline with age. The ability to form certain new declarative memories, particularly memories for facts and events, has been widely shown to decline with advancing age. In contrast, the effects of aging on the ability to form new procedural memories such as skills are less well known, though it appears that older adults are able to acquire some new procedural skills over practice. The current study examines the effects of normal aging on procedural memory more closely by comparing the effects of aging on the encoding or acquisition stage of procedural learning versus its effects on the consolidation, or between-session stage of procedural learning. Twelve older and 14 young participants completed a sequence-learning task (the Serial Reaction Time Task) over a practice session and at a re-test session 24 hours later. Older participants actually demonstrated more sequence skill during acquisition than the young. However, older participants failed to show skill improvement at re-test as the young participants did. Age thus appears to have a differential effect upon procedural learning stages such that older adults' skill acquisition remains relatively intact, in some cases even superior, compared to that of young adults, while their skill consolidation may be poorer than that of young adults. Although the effect of normal aging on procedural consolidation remains unclear, aging may actually enhance skill acquisition on some procedural tasks

Ellipsoidal analysis of coordination polyhedra

The idea of the coordination polyhedron is essential to understanding chemical structure. Simple polyhedra in crystalline compounds are often deformed due to structural complexity or electronic instabilities so distortion analysis methods are useful. Here we demonstrate that analysis of the minimum bounding ellipsoid of a coordination polyhedron provides a general method for studying distortion, yielding parameters that are sensitive to various orders in metal oxide examples. Ellipsoidal analysis leads to discovery of a general switching of polyhedral distortions at symmetry-disallowed transitions in perovskites that may evidence underlying coordination bistability, and reveals a weak off-centre ‘d(5) effect' for Fe(3+) ions that could be exploited in multiferroics. Separating electronic distortions from intrinsic deformations within the low temperature superstructure of magnetite provides new insights into the charge and trimeron orders. Ellipsoidal analysis can be useful for exploring local structure in many materials such as coordination complexes and frameworks, organometallics and organic molecules