Implementation of a Pediatric Post-Operative Hand-Off Tool: A Patient Safety Project

Abstract Problem: The clinical nurse leader (CNL) performed a microsystem assessment using the Dartmouth assessment tool to evaluate the microsystem’s readiness to provide safe care for pediatric post-operative cardiovascular patients. The microsystem is a 12-bed unit caring for critically ill pediatric patients requiring intensive monitoring and therapy. The microsystem’s interdisciplinary team is comprised of medical doctors, nurses, respiratory therapists, social workers, nutritionists, child life specialists, and pharmacists. During assessment and gap analysis, the CNL identified gaps in nursing knowledge and skills to deliver safe care for this patient population during the immediate post-operative phase of recovery. There is a concern for patient safety and poor quality outcomes due to these gaps. Since it is a new patient population for the microsystem, there are no protocols nor tools in place for nurses to feel confident in their ability to safely and effectively care for these patients. Context: As part of the organization’s integration efforts, the pediatric cardiovascular surgical service will be offered to its members beginning August 2018. This service will be piloted in a 12-bed microsystem, where the care of the patients post-operatively will occur. The microsystem interdisciplinary team has never cared for these patients in their immediate post-operative phase of recovery. Approximately 40% of the nurses in the microsystem are master’s prepared, and 85% of the nurses in the microsystem have over 5 years of experience in the pediatric intensive care unit (PICU). Because this is a new patient population for the microsystem, a nursing knowledge and skills gap was identified. Nurses are not confident and competent to care for these patients in the current state. To address this, prior to the first surgical date of August 15, 2018, the organization partnered with a neighboring organization with extensive experience in caring for congenital heart disease patients for training and education. Thirty-five out of 70 nurses in the microsystem, who volunteered to be part of the core group of cardiothoracic (CT) surgery trained nurses, were sent to that organization for training and education. Each nurse received 32 hours of didactic classes and 36 hours of hands-on precepted training in the other organization. The microsystem also provided 8 hours of further education and training of equipment and simulation. After training and education, the CNL collaborated with the nurse manager and frontline interdisciplinary team to create a hand-off tool and to define nurse roles during post-operative take back to ensure safety and quality outcomes during the most critical phase of the patient’s recovery. Intervention: The interdisciplinary team created a post-operative hand-off tool for a safe hand off at the PICU. The tool includes basic patient information, weight, diagnosis, surgical procedure, intraoperative information such as anesthesia and sedation used, blood products and medications administered during the procedure, and events such as arrhythmia and bleeding. The tool also has information pertinent to post-operative care, such as vital signs parameters, pain and sedation plan, medications, laboratory monitoring, and other details important for the nurse to monitor. The frontline nurses also created defined nursing roles during the post-operative take back to help ensure that all necessary care and tasks are safely accomplished in a timely and effective manner. Measures: Direct observation was done during the hand-off process to evaluate completion of all items in the hand-off tool at the PICU during hand off. Direct observation was done on the execution of the RN1 and RN2 roles. The goal is 100% utilization of the tool and the defined RN roles every post-operative take back. Results: Four surgical cases were performed since August 15, 2018. The hand-off tool and RN1 and RN2 roles have been utilized 100%, with no variances and barriers. Conclusion: The immediate post-operative phase of recovery for a pediatric cardiovascular patient is the most critical and intense period. Attention to detail and timely delivery of care are very important; hence, clear communication is vital during the hand-off process. In an effort to achieve a safe hand-off process and meet the patient’s care demands, the interdisciplinary team created the tool and the roles. Based on the results to date, these tools are effective interventions to ensure delivery of safe quality care to acutely ill pediatric patients after CT surgery in the immediate post-operative period

Beyond the Spitfire: Re-visioning Latinas in Sylvia Morales’ A Crushing Love

From Dolores del Río to Salma Hayek and from Lupe Vélez to Eva Longoria, the portrayal of Latinas in the United States has provoked debate, criticism and controversy. Since the era of silent movies, Hollywood’s depiction of the Latina has been rigidly prescribed and reductive, while Latinos and Latinas themselves have contested these problematic portrayals in more nuanced and multifaceted visions of their communities. Sylvia Morales’s documentary A Crushing Love: Chicanas, Motherhood and Activism (2009) presents a vision of activists and mothers that is radically at odds with the stereotypes of Latinas in Hollywood film and in the US media more generally.1 This chapter examines the film against the context of persistently problematic representation of Latinas in the media and the ways in which Morales’ film counters demeaning images of Chicanas through a multilayered examination of different experiences of motherhood by politically radical women

EMSA probe sequences.

<p>EMSA probe sequences.</p

CLAMP binds to similar <i>in vivo</i> X-enriched binding sites in <i>D</i>. <i>miranda</i> and <i>D</i>. <i>melanogaster</i>.

<p><b>A)</b> The ratio of <i>in vitro</i> CLAMP binding site density (number of CLAMP binding sequence hits per Mb) for X versus autosomes is plotted for <i>D</i>. <i>miranda</i>, <i>D</i>. <i>melanogaster</i> and <i>A</i>. <i>gambiae</i>. Autosomes of <i>D</i>. <i>melanogaster</i> are chromosomes 2L (Muller-B), 2R (Muller-C), 3L (Muller-D), 3R (Muller-E) and 4 (Muller-F); autosomes of <i>D</i>.<i>miranda</i> are chromosomes 2 (Muller-E), 4 (Muller-B) and 5 (Muller-F); and autosomes of <i>A</i>. <i>gambiae</i> are chromosomes 2L (Muller-D), 2R (Muller-E), 3L (Muller-C), and 3R (Muller-B). <b>B)</b> The density ratios of GA-repeats on individual X-chromosome(s) vs. autosomes for different repeat lengths in the <i>D</i>. <i>melanogaster</i>, <i>D</i>. <i>miranda</i> and <i>A</i>. <i>gambiae</i> genomes are plotted. Any value above 1 indicates a higher repeat density on the X-chromosome compared to autosomes. <b>C)</b> CLAMP ChIP-seq motifs are shown for <i>D</i>. <i>melanogaster</i> and <i>D</i>. <i>Miranda</i> larval ChIP-seq data. Motifs are found using MEME-ChIP for the peak regions (peak centers +/-100bp).</p

Increasing the number of GA-dinucleotide repeats increases CLAMP occupancy.

<p><b>A)</b> A multiple linear regression to test contribution of sequence length (k-mer) and shape to overall binding. Adding dinucleotide (2mer) features to the sequence-only (1mer) model increases the performance more than adding DNA shape features, indicating the importance of dinucleotides in CLAMP-DNA recognition. Adding trinucleotide (3mer) features further increases the performance marginally. <b>B)</b> CLAMP PBM binding for GA-dinucleotide repeats of different lengths is plotted as box plot distributions. The y-axis is the PBM intensity score for each number of GA-repeats, which are plotted along the x-axis, e.g. 1 = GA, 2 = GAGA. <b>C)</b> An electrophoretic mobility shift assay to test MBP-CLAMP binding to increasing numbers of GA-repeats. The labeled probes contain GA-repeats of 4 (8-bp), 8 (16-bp), 10 (20-bp) and 15 (30-bp) centered within a 60-bp sequence. The first four lanes are reactions containing MBP control protein with DNA, and the next four are MBP-CLAMP with DNA. <b>D)</b> Input-normalized CLAMP ChIP-seq signal enrichments at GA-repeats of different lengths are given for the X-chromosome (red) and autosomes (blue) from male S2 (top) and female Kc cells (bottom). The x-axis shows the number of GA-repeats e.g. 1 = GA, 2 = GAGA.</p

A long 15-bp motif increases CLAMP binding to DNA.

<p><b>A)</b> Motifs obtained from the custom gcPBMs are shown: I) The PBM+ChIP+ motif represents the sequences that CLAMP binds both <i>in vivo</i> and <i>in vitro</i>. II) The PBM-ChIP- motif represents the sequences that are on the array but not bound by CLAMP <i>in vivo</i> or <i>in vitro</i>. The most conserved 8-bp core element is indicated by vertical dashed lines. <b>B)</b> A representation of the methodology to define the minimal CLAMP-bound motif by scanning both 5’ and 3’ of the core motif. The table shows the percentage of PBM+ChIP+ (CLAMP binding both <i>in vitro</i> and <i>in vivo</i>) sequences that overlap with PBM-ChIP- sequences (CLAMP binding neither <i>in vitro</i> nor <i>in vivo</i>) at the specified motif size. The y-axis shows the nucleotides 5’ of the 8-bp core motif and the x-axis shows the nucleotides 3’. The scale ranges from green for the maximal values to red for the minimal values. Values show the percentage of PBM+ChIP+ sequences shared with PBM-ChIP- sequences for the length window selected. A value of zero overlapping sequences represents complete separation between PBM+ChIP+ and PBM-ChIP- sequences and is obtained at 4-bp 5’ and 3-bp 3’ of the core motif. <b>C)</b> CLAMP and MSL ChIP-seq enrichments are shown for sequences containing the 8-bp core with and without additional flanking sequence matching the motif. Motif hits were found using the FIMO tool (p < E-4). All 8-bp core hits were found first and the ones overlapping with the full 15-bp motif were separated as ‘8bp + matched endogenous flank’ and the rest were grouped as ‘8bp + unmatched endogenous flank’. Since the ‘8bp + unmatched endogenous flank’ group has ~10,000 sites, the top 10,000 enrichments are shown in the CLAMP enrichment plot. Since there are ~300 CES, the top 300 enrichments are shown in the MSL enrichment plot. <b>D)</b> Binding intensities are shown for the following classes of probes: 1) probes with the optimal motif (8-bp + matched endogenous flank, red); 2) probes that have matching 8-bp core regions but the endogenous flanks do not match the motif (8-bp + unmatched endogenous flanks, blue); 3) probes that have 8-bp cores with synthetic constant flanking sequences (8-bp + unmatched synthetic flank, cyan); 4) probes that do not have the 8-bp core motif (without 8-bp, brown); 5) Intensities for C-terminal 4 zinc finger GST fusion proteins are shown for probes containing the 15-bp CLAMP motif (15–bp, 4ZF, orange). <b>E)</b> CLAMP binds to DNA containing a high affinity, 8 bp + matched flank motif in an electrophoretic mobility shift assay. Biotin-labeled DNA alone (lane 1) and DNA with MBP (lane 2) do not shift, while MBP-CLAMP forms a complex with DNA to shift the signal. This was competed away with specific (high affinity) competitor but not a non-specific competitor that contains the 8-bp core but lacks endogenous flanking sequences (8-bp + unmatched synthetic flank).</p

CLAMP directly binds to a long GA-rich motif that is enriched at <i>in vivo</i> targets.

<p><b>A)</b> The following motifs are shown: I) MRE motif [<a href="http://www.plosgenetics.org/article/info:doi/10.1371/journal.pgen.1006120#pgen.1006120.ref013" target="_blank">13</a>]. II) CLAMP <i>in vivo</i> motif derived from ChIP-seq data from S2 cells [<a href="http://www.plosgenetics.org/article/info:doi/10.1371/journal.pgen.1006120#pgen.1006120.ref020" target="_blank">20</a>]; III) CLAMP <i>in vitro</i> motif derived from the uPBM [<a href="http://www.plosgenetics.org/article/info:doi/10.1371/journal.pgen.1006120#pgen.1006120.ref020" target="_blank">20</a>] and IV) CLAMP <i>in vitro</i> motif that we derived from the custom gcPBM. The most conserved part of the motifs, their 8-bp core, is highlighted between two dashed lines. <b>B)</b> gcPBM intensities (intensity from genomic context PBM) (top) and CLAMP ChIP signal (input normalized RPKM: Reads per Kb per Million) for S2 (middle) and Kc (bottom) cells are plotted for 800 bp windows centered at each of two MSL complex CES (<i>roX1</i>, left, and <i>roX2</i>, <i>right</i>). MRE sequences are shown as blue dashes on each profile. <b>C)</b> A histogram of intensities from the gcPBM experiment. The intensity of 6500, between the two peaks of the bimodal distribution, is indicated with a dashed line. Probes with intensities higher than 6500 are designated PBM+ and those that are lower than 6500 are considered PBM-. <b>D)</b> Box plots are used to compare the intensities for probes sorted by whether they contain sequences that are bound or unbound from <i>in vivo</i> ChIP-seq data (ChIP +/-) and whether or not they conform to the previously characterized MRE motif (MRE+/-). In the right half of the panel, probes were resorted to add the category of bound or unbound on the PBM (PBM+/-). p-values for comparisons between categories are displayed above the relevant boxes, and the number of probes for each category are listed for each group. For each box plot used throughout this study, the collared box indicates that 95% percent confidence interval. If the notches at the center of the box are not overlapping, it indicates that two samples are statistically different from each other.</p