Search

Background: To the best of our knowledge, no prospective research studies have compared clinical practice to the American Heart Association (AHA) updated practice standards for in-hospital telemetry monitoring., Objectives: Our aims were therefore (1) to investigate how patients were assigned to telemetry monitoring in accordance with the AHA's updated practice standards, (2) to determine the number and type of arrhythmic events, and (3) to describe subsequent changes in clinical management., Methods: This prospective multicenter study included 1154 patients at three university hospitals in Norway. Data were collected 24/7 over a four-week period, with follow-up measurements from telemetry admission until hospital discharge., Results: Of patients assigned to telemetry, 67 % (n = 767) met practice standards, corresponding to AHA Class I or II. Patients were predominantly men (65 %, n = 748), and the mean age was 65 years (SD ±16). The study included both patients with cardiac and non-cardiac diagnoses from various medical and surgical departments throughout the hospitals. Ninety-one percent of the patients in Class III were monitored based on indications that were reclassified from Class II to Class III (not indicated) in the updated practice standards (patients admitted with chest pain or post-percutaneous coronary intervention (PCI) without complications). Overall, arrhythmic events occurred in 37 % (n = 424) of patients, and they occurred in all classes. Eighteen percent (n = 59) of arrhythmic events occurred in Class III. Of all arrhythmias, 3 % (n = 14) were life threatening, and all of them occurring within Class I. Telemetry monitoring led to changes in clinical management in 22 % (n = 257) of patients due to clinical alarms, of which 71 % (n = 182) were related to medication management., Conclusions: Most patients were appropriately monitored according to the AHA practice standards, meeting Class I and II. Arrhythmias occurred in all classes, but life-threatening arrhythmias only occurred in patients in Class I. However, a daily re-assessment of each patient's telemetry indication is warranted., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: General patient acuity is increasing in the United States, with more patients having multiple comorbidities and acute-on-chronic conditions. Hospitalizations may also be complicated by serious adverse events, often unrelated to the admitting medical diagnosis. In our facility, the late detection of patient deterioration on general medical units often resulted in increased length of stay (LOS) in the ICU and poor patient outcomes., Purpose: The purpose of this project was to improve patient surveillance and better identify early signs of patient deterioration through the use of continuous vital sign monitoring technology., Methods: To improve detection of patient deterioration, a nurse-led monitoring and response system was developed using a wearable, wireless device for continuous vital sign surveillance. The patient data the device provided was used with early warning scores and sepsis screening protocols for timely goal-directed interventions., Results: Ninety-seven percent of patient deterioration events were recognized and treated as a result of this continuous monitoring and response system. Rapid response team activations decreased by 53% between baseline and the intervention period. LOS among patients transferred to the ICU decreased from 2.82 to 2.19 days. Nurse satisfaction with use of the continuous monitoring device was positive, with 74% of nurses surveyed reporting that information provided by the device enhanced decision-making., Conclusions: New technology for patient surveillance, in this case a nurse-led monitoring and response system, can be successfully integrated into general care practice. Use of the nurse-led response system helped nurses recognize early signs of deterioration and continue meaningful patient interactions., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Development of personalized, stratified follow-up care pathways where care intensity and setting vary with needs could improve cancer survivor outcomes and efficiency of health-care delivery. Advancing such an approach in the United States requires identification and prioritization of the most pressing research and data needed to create and implement personalized care pathway models. Cancer survivorship research and care experts (n = 39) participated in an in-person workshop on this topic in 2018. Using a modified Delphi technique-a structured, validated system for identifying consensus-an expert panel identified critical research questions related to operationalizing personalized, stratified follow-up care pathways for individuals diagnosed with cancer. Consensus for the top priority research questions was achieved iteratively through 3 rounds: item generation, item consolidation, and selection of the final list of priority research questions. From the 28 research questions that were generated, 11 research priority questions were identified. The questions were categorized into 4 priority themes: determining outcome measures for new care pathways, developing and evaluating new care pathways, incentivizing new care pathway delivery, and providing technology and infrastructure to support self-management. Existing data sources to begin answering questions were also identified. Although existing data sources, including cancer registry, electronic medical record, and health insurance claims data, can be enhanced to begin addressing some questions, additional research resources are needed to address these priority questions., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Measuring and documenting accurate data from pulmonary artery and central venous pressure catheters is an important responsibility of critical care nurses. The American Association of Critical-Care Nurses Practice Alert titled Pulmonary Artery/Central Venous Pressure Monitoring in Adults provides evidence-based standards against which nurses can compare their practice related to obtaining valid hemodynamic data. Identifying and acting on improvement opportunities is also a nursing responsibility and helps to ensure that patients with pulmonary artery or central venous pressure catheters receive high-quality care. This article reviews various strategies to compare nursing practice to the Pulmonary Artery/Central Venous Pressure Monitoring in Adults Practice Alert and to close identified gaps in clinical practice., (©2020 American Association of Critical-Care Nurses.)

Risk for complications and even death is inherent to anesthesia. However, the use of guidelines, checklists, and training can decrease the risk of anesthesia-related adverse events. These tools should be used not only during the time the patient is unconscious but also before and after this phase. The framework for safe anesthesia delivered as a continuum of care from home to hospital and back to home is presented in these guidelines. The critical importance of client communication and staff training have been highlighted. The role of perioperative analgesia, anxiolytics, and proper handling of fractious/fearful/aggressive patients as components of anesthetic safety are stressed. Anesthesia equipment selection and care is detailed. The objective of these guidelines is to make the anesthesia period as safe as possible for dogs and cats while providing a practical framework for delivering anesthesia care. To meet this goal, tables, algorithms, figures, and "tip" boxes with critical information are included in the manuscript and an in-depth online resource center is available at aaha.org/anesthesia.

Digital health technology, especially digital and health applications ("apps"), have been developing rapidly to help people manage their diabetes. Numerous health-related apps provided on smartphones and other wireless devices are available to support people with diabetes who need to adopt either lifestyle interventions or medication adjustments in response to glucose-monitoring data. However, regulations and guidelines have not caught up with the burgeoning field to standardize how mobile health apps are reviewed and monitored for patient safety and clinical validity. The available evidence on the safety and effectiveness of mobile health apps, especially for diabetes, remains limited. The European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) have therefore conducted a joint review of the current landscape of available diabetes digital health technology (only stand-alone diabetes apps, as opposed to those that are integral to a regulated medical device, such as insulin pumps, continuous glucose monitoring systems, and automated insulin delivery systems) and practices of regulatory authorities and organizations. We found that, across the U.S. and Europe, mobile apps intended to manage health and wellness are largely unregulated unless they meet the definition of medical devices for therapeutic and/or diagnostic purposes. International organizations, including the International Medical Device Regulators Forum and the World Health Organization, have made strides in classifying different types of digital health technology and integrating digital health technology into the field of medical devices. As the diabetes digital health field continues to develop and become more fully integrated into everyday life, we wish to ensure that it is based on the best evidence for safety and efficacy. As a result, we bring to light several issues that the diabetes community, including regulatory authorities, policy makers, professional organizations, researchers, people with diabetes, and health care professionals, needs to address to ensure that diabetes health technology can meet its full potential. These issues range from inadequate evidence on app accuracy and clinical validity to lack of training provision, poor interoperability and standardization, and insufficient data security. We conclude with a series of recommended actions to resolve some of these shortcomings., (© 2019 by the American Diabetes Association.)

Postpartum hemorrhage causes approximately 11% of maternal deaths in the United States and is the leading cause of death that occurs on the day of birth. Importantly, 54-93% of maternal deaths due to obstetric hemorrhage may be preventable. Studies that have evaluated factors associated with identification and treatment of postpartum hemorrhage have found that imprecise health care provider estimation of actual blood loss during birth and the immediate postpartum period is a leading cause of delayed response to hemorrhage. Although current data do not support any one method of quantifying blood loss as superior to another, quantification of blood loss, such as using graduated drapes or weighing, provides a more accurate assessment of actual blood loss than visual estimation; however, the effectiveness of quantitative blood loss measurement on clinical outcomes has not been demonstrated. Successful obstetric hemorrhage bundle implementation is associated with improved outcome measures related to obstetric hemorrhage. However, further research is necessary to better evaluate the particular effect of quantitative blood loss measurement in reducing maternal hemorrhage- associated morbidity in the United States.

Postpartum hemorrhage causes approximately 11% of maternal deaths in the United States and is the leading cause of death that occurs on the day of birth. Importantly, 54-93% of maternal deaths due to obstetric hemorrhage may be preventable. Studies that have evaluated factors associated with identification and treatment of postpartum hemorrhage have found that imprecise health care provider estimation of actual blood loss during birth and the immediate postpartum period is a leading cause of delayed response to hemorrhage. Although current data do not support any one method of quantifying blood loss as superior to another, quantification of blood loss, such as using graduated drapes or weighing, provides a more accurate assessment of actual blood loss than visual estimation; however, the effectiveness of quantitative blood loss measurement on clinical outcomes has not been demonstrated. Successful obstetric hemorrhage bundle implementation is associated with improved outcome measures related to obstetric hemorrhage. However, further research is necessary to better evaluate the particular effect of quantitative blood loss measurement in reducing maternal hemorrhage- associated morbidity in the United States.

Inappropriate daily lab testing can have adverse effects on patients, including anemia, pain, and interruption of sleep. We implemented a student-led, multifaceted intervention featuring clinician education, publicity campaign, gamification, and system changes, including a novel nurse-driven protocol to reduce unnecessary daily lab testing in a teaching hospital. We applied a quasi-experimental interrupted time series design with a segmented regression analysis to estimate changes before and after our 14-month intervention with a comparison to a control surgical unit. There was an increasing trend in the baseline period, which was mitigated by the intervention (postintervention effect estimate -0.04 labs per patient day/month, p < .05), which was not seen in the control unit. Estimated cost savings was $94,269 ($6,734/month). A student-led, multidisciplinary campaign involving nurse-driven pathway, education, publicity, gamification, and system changes was effective in reducing daily lab testing.

Background: Remote monitoring technologies are positioned to mitigate the problem of a dwindling care workforce and disparities in access to care for the growing older immigrant population in the United States. To achieve these ends, designers and providers need to understand how these supports can be best provided in the context of various sociocultural environments that shape older adults' expectations and care relationships, yet few studies have examined how the same remote monitoring technologies may produce different effects and uses depending on what population is using them in a particular context., Objective: This study aimed to examine the experiences and insights of low-income, immigrant senior residents, family contacts, and staff of housing that offered a sensor-based passive monitoring system designed to track changes in movement around the home and trigger alerts for caregivers. The senior housing organization had been offering the QuietCare sensor system to its residents for 6 years at the time of the study. We are interested in adoption and discontinuation decisions and use over time, rather than projected acceptance. Our research question is how do cultural differences influence use and experiences with this remote monitoring technology? The study does not draw generalizable conclusions about how cultural groups interact with a given technology, but rather, it examines how values are made visible in elder care technology interactions., Methods: A total of 41 participants (residents, family, and staff) from 6 large senior housing independent living apartment buildings were interviewed. Interviews were conducted in English and Korean with these participants who collectively had immigrated to the United States from 10 countries., Results: The reactions of immigrant older adults to the passive monitoring system reveal that this tool offered to them was often mismatched with their values, needs, and expectations. Asian elders accepted the intervention social workers offered largely to appease them, but unlike their US-born counterparts, they adopted reluctantly without hope that it would ameliorate their situation. Asian immigrants discontinued use at the highest rate of all residents, and intergenerational family cultural conflict contributed to this termination. Social workers reported that none of the large population of Russian-speaking residents agreed to use QuietCare. Bilingual and bicultural social workers played significant roles as cultural navigators in the promotion of QuietCare to residents., Conclusions: This research into the interactions of culturally diverse people with the same monitoring technology reveals the significant role that social values and context play in shaping how people and families interact with and experience elder care interventions. If technology-based care services are to reach their full potential, it will be important to identify the ways in which cultural values produce different uses and responses to technologies intended to help older adults live independently., (©Clara Berridge, Keith T Chan, Youngjun Choi. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 25.03.2019.)

Fifteen years have elapsed since a report was released by the National Academy of Sciences (NAS) on the scientific status of polygraph testing. The NAS report concluded that the scientific basis of the comparison question technique (CQT) was weak, the extant research was of low quality, the polygraph profession's claims for the high accuracy of the CQT were unfounded, and, although the CQT has greater than chance accuracy, its error rate is unknown. Polygraph proponents argue that current research indicates that the CQT has 90% or better accuracy, the National Research Council of the National Academy of Sciences' (2003) analysis supports this accuracy claim, and the CQT qualifies as legally admissible scientific evidence. We review the scientific literature that has appeared since the appearance of the NAS publication, including a new method for estimating polygraph accuracy. We show that the NAS report has been misrepresented and misinterpreted by those who support use of the CQT in forensic settings. We conclude that the quality of research has changed little in the years elapsing since the release of the NAS report, and that the report's landmark conclusions still stand. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Neuromonitoring is important for patients with acute brain injury. The bedside neurologic examination is standard for neurologic monitoring; however, a clinical examination may not reliably detect subtle changes in intracranial physiology. Changes found during neurologic examinations are often late signs. The assessment of multiple physiological variables in real time can provide new clinical insights into treatment decisions. No single monitoring modality is ideal for all patients. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism, such as in multimodal monitoring, allows an innovative approach to individualized patient care., (©2018 American Association of Critical-Care Nurses.)

Objective: The objective was to implement the evidence-based Spinal Cord Impairment Pressure Ulcer Monitoring Tool (SCI-PUMT) in 23 Spinal Cord Injury/Disorders Centers (SCI/D) in the Veterans Health Administration (VHA)., Setting: A collaborative was held in Minnesota that was attended by key personnel from SCI/D Centers in the VHA., Methods: This initiative was based on a 3-year longitudinal study that established the validity and reliability of a novel pressure ulcer monitoring tool for persons with spinal cord impairment. A multifaceted evidence-based strategy was used to implement the Institute for Healthcare Improvement's framework of Plan-Do-Study-Act. The plan was executed by clinical champions who implemented the tool in their respective SCI/D Centers following a conference that used both didactic and practicum approaches., Outcomes: A 15-item toolkit was developed to educate clinicians and patients regarding use of the SCI-PUMT. Toolkit elements were frequently accessed over the VA intranet (n = 3254). The 1.5-day national conference rolled out the new tool to the SCI/D Centers. Pre/post SCI-PUMT knowledge of the SCI-PUMT improved by 78% during the conference. Following the conference, periodic conference calls cemented the implementation efforts of the SCI-PUMT clinical champions and barriers were mitigated.

The goal of asthma treatment is to obtain clinical control and reduce future risks to the patient. To reach this goal in children with asthma, ongoing monitoring is essential. While all components of asthma, such as symptoms, lung function, bronchial hyperresponsiveness and inflammation, may exist in various combinations in different individuals, to date there is limited evidence on how to integrate these for optimal monitoring of children with asthma. The aims of this ERS Task Force were to describe the current practise and give an overview of the best available evidence on how to monitor children with asthma. 22 clinical and research experts reviewed the literature. A modified Delphi method and four Task Force meetings were used to reach a consensus. This statement summarises the literature on monitoring children with asthma. Available tools for monitoring children with asthma, such as clinical tools, lung function, bronchial responsiveness and inflammatory markers, are described as are the ways in which they may be used in children with asthma. Management-related issues, comorbidities and environmental factors are summarised. Despite considerable interest in monitoring asthma in children, for many aspects of monitoring asthma in children there is a substantial lack of evidence., (Copyright ©ERS 2015.)

Importance: Surgical site infection (SSI) has emerged as the leading publicly reported surgical outcome and is tied to payment determinations. Many hospitals monitor SSIs using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), in addition to mandatory participation (for most states) in the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN), which has resulted in duplication of effort and incongruent data., Objective: To identify discrepancies in the implementation of the NHSN and the ACS NSQIP at hospitals that may be affecting the respective SSI rates., Design, Setting, and Participants: A pilot sample of hospitals that participate in both the NHSN and the ACS NSQIP., Interventions: For each hospital, observed rates and risk-adjusted observed to expected ratios for year 2012 colon SSIs were collected from both programs. The implementation methods of both programs were identified, including telephone interviews with infection preventionists who collect data for the NHSN at each hospital., Main Outcomes and Measures: Collection methods and colon SSI rates for the NHSN at each hospital were compared with those of the ACS NSQIP., Results: Of 16 hospitals, 11 were teaching hospitals with at least 500 beds. The mean observed colon SSI rates were dissimilar between the 2 programs, 5.7% (range, 2.0%-14.5%) for the NHSN vs 13.5% (range, 4.6%-26.7%) for the ACS NSQIP. The mean difference between the NHSN and the ACS NSQIP was 8.3% (range, 1.6%-18.8%), with the ACS NSQIP rate always higher. The correlation between the observed to expected ratios for the 2 programs was nonsignificant (Pearson product moment correlation, ρ = 0.4465; P = .08). The NHSN collection methods were dissimilar among interviewed hospitals. An SSI managed as an outpatient case would usually be missed under the current NHSN practices., Conclusions and Relevance: Colon SSI rates from the NHSN and the ACS NSQIP cannot be used interchangeably to evaluate hospital performance and determine reimbursement. Hospitals should not use the ACS NSQIP colon SSI rates for the NHSN reports because that would likely result in the hospital being an outlier for performance. It is imperative to reconcile SSI monitoring, develop consistent definitions, and establish one reliable method. The current state hinders hospital improvement efforts by adding unnecessary confusion to the already complex arena of perioperative improvement.

Objectives: (1) To determine the percentage of otherwise healthy patients achieving "graduation," or postoperative compliance achieving complete problem resolution and discharge from the otolaryngologist's care, after tympanostomy tube placement. (2) To analyze follow-up behaviors and patient characteristics influencing the likelihood of graduation., Study Design: Retrospective cohort study., Setting: Tertiary care hospital., Subjects and Methods: Analysis of details of tympanostomy tube placements performed from 2004 to 2011 by 2 pediatric otolaryngologists for children aged 0 to 18 years. Exclusion criteria were clearly defined craniofacial anomalies, cleft palates, and other ongoing postoperative care. The remaining study subjects were categorized into 3 groups. Graduation (GRAD) subjects achieved discharge from care with "follow-up pro re nata" status. LOST<2Y subjects had not attended scheduled follow-up in <2 years. LOST≥2Y subjects had no follow-up in ≥2 years., Results: A total of 1454 pediatric subjects were included. GRADs constituted only 25.6% of the subject pool; 22.1% were LOST<2Y, and 52.3% were LOST≥2Y. Statistically significant factors in achieving graduation were total number of follow-up visits, total duration of follow-up, compliance with first postoperative visit, patient age, insurance type, and distance between home and practice., Conclusion: Rate of graduation, or postoperative compliance achieving complete problem resolution, of otherwise healthy tympanostomy tube patients is low despite perioperative discussions of the importance of proper follow-up. Higher graduation rates are associated with increasing number of follow-up visits and duration, younger patient age, private insurance, and proximity to the practice. Compliance with attending the first postoperative visit may be an early marker for increased likelihood of graduation., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.)

Objectives: Surveillance after radical cystectomy is recommended to detect tumor recurrence and treatment complications. We evaluated adherence to National Comprehensive Cancer Network (NCCN) guidelines using a large population-based database., Methods and Materials: The Surveillance, Epidemiology, and End Results-Medicare database was used to identify patients aged ≥66 years diagnosed with nonmetastatic bladder cancer who had undergone radical cystectomy between 2000 and 2007. Medicare claims information identified recommended surveillance tests for 2 years after cystectomy as outlined in the NCCN guidelines. Adherence was defined as receipt of urine cytology and imaging of the chest, abdomen, and pelvis in each year. We evaluated the effect of patient and provider characteristics on adherence, controlling for demographic and disease characteristics., Results: Of 3,757 patients who had undergone radical cystectomy, 2,990 (80%) were alive after 2 years. Adherence to all recommended investigations was 17% for the first and the second years following surgery. Among patients surviving 2 years, only 9% had complete surveillance in both years. In either year, adherence was less likely in patients with advanced pathologic stage (III/IV) (adjusted odds ratio [AOR] = 0.74, 95% CI: 0.60-0.91) and unmarried patients (AOR = 0.82, 95% CI: 0.68-0.99). Adherence was more likely in patients treated by high-volume surgeons (AOR = 2.00, 95% CI: 1.70-2.36) and those who saw a medical oncologist (AOR = 1.52, 95% CI: 1.27-1.82). We also observed significant geographic variability in adherence., Conclusion: Patterns of surveillance after radical cystectomy deviate considerably from NCCN recommendations. Despite increased utilization of radiographic imaging investigations, the omission of urine cytology significantly contributed to the low rate of overall adherence to surveillance guidelines. Uniform adherence to surveillance guidelines was observed in patients treated by high-volume surgeons. This suggests an important opportunity for quality improvement in bladder cancer care., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Telecare is often regarded as a win/win solution to the growing problem of meeting the care needs of an ageing population. In this paper we call attention to some of the ways in which telecare is not a win/win solution but rather aggravates many of the long-standing ethical tensions that surround the care of the elderly. It may reduce the call on carers' time and energy by automating some aspects of care, particularly daily monitoring. This can release carers for other caring activities. On the other hand, remote and impersonal monitoring seems to fall short of providing care. Monitoring may be used to help elderly users retain independence. But it may also increase the amount of information which flows from users to carers, which can result in a form of function-creep that actually undermines independence., (© 2012 John Wiley & Sons Ltd.)

Purpose: The purpose of this study was to describe nursing practice in the care of patients with intracranial pressure monitoring. Although standards for care of such patients have been established, there continue to be variations in the nursing practice., Methods: This was an observational study in which data were collected from 28 nurse-patient dyads at 16 different hospitals across the United States. Each dyad was observed for 2 hours; nursing actions and patient responses including intracranial pressure readings were documented., Results: Differences in the care of patients with intracranial pressure monitoring were prevalent. Variations in practice were prompted by healthcare provider prescriptions as well as nursing decisions. Prescriptions and interventions were often not supported by the available scientific evidence., Video Abstract: For more insights from the authors, see Supplemental Digital Content 1, at http://links.lww.com/JNN/A7.

The American Society for Pain Management Nursing convened a taskforce to develop guidelines on monitoring for opioid-induced sedation and respiratory depression. Part of the guideline development was the determination of nursing practice patterns related to monitoring and preventing respiratory depression during the administration of analgesics for pain. One hundred and forty-seven responses were received from 90 unique institutions across the United States. Monitoring adults with intermittent pulse oximetry while using intravenous patient-controlled analgesia (IV PCA) was 58%. Adults were monitored with continuous pulse oximetry by 25% of respondents. When using continuous epidural analgesia, 56% of patients were monitored intermittently, and 40% were monitored continuously. The use of end tidal CO2 (ETCO2) monitoring was much less, with 2.2% patients on epidural therapy, and 1.5% of institutions were using ETCO2 with IV PCA. The survey also included the location of the alarm, respiratory parameters for alarms, changes in procedures reported by institutions, and definitions of high-risk patients., (Copyright © 2013 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

Objective: Therapeutic hypothermia (TH) for neonatal encephalopathy is becoming widely available in clinical practice. The goal of this collaborative was to create and implement an evidence-based standard-of-care approach to neonatal encephalopathy, deliver consistent care, and optimize outcomes., Methods: The quality improvement process identified and used the Model for Improvement as a framework for improvement efforts. This was a Vermont Oxford Network Collaborative focused on optimizing TH in the treatment of neonatal encephalopathy. By using an evidence-based approach, Potentially Better Practices were developed by the topic expert, modified by the collaborative, and implemented at each hospital. These included the following: timely identification of at-risk infants, coordination with referring hospitals to ensure TH was available within 6 hours after birth, staff education for both local and referring hospitals, nonsedated MRI, incorporating amplitude-integrated EEG into a TH protocol, and ensuring standard neurodevelopmental follow-up of infants. Each center used these practices to develop a matrix for implementation., Results: Local self-assessments directed the implementation and adaptation of the Potentially Better Practices at each center. Resources, based on common identified barriers, were developed and shared among the group., Conclusions: The implementation of a TH program to improve the consistency of care for patients in NICUs is feasible using standard-quality improvement methodology. The successful introduction of new interventions such as TH to the NICU culture requires a collaborative multidisciplinary team, use of a systematic quality improvement process, and perseverance.

Objectives: Standard metrics for evaluating rapid response systems (RRSs) include cardiac and respiratory arrest rates. These events are rare in children; therefore, years of data are needed to evaluate the impact of RRSs with sufficient statistical power. We aimed to develop a valid, pragmatic measure for evaluating and optimizing RRSs over shorter periods of time., Methods: We reviewed 724 medical emergency team and 56 code-blue team activations in a children's hospital between February 2010 and February 2011. We defined events resulting in ICU transfer and noninvasive ventilation, intubation, or vasopressor infusion within 12 hours as "critical deterioration." By using in-hospital mortality as the gold standard, we evaluated the test characteristics and validity of this proximate outcome metric compared with a national benchmark for cardiac and respiratory arrest rates, the Child Health Corporation of America Codes Outside the ICU Whole System Measure., Results: Critical deterioration (1.52 per 1000 non-ICU patient-days) was more than eightfold more common than the Child Health Corporation of America measure of cardiac and respiratory arrests (0.18 per 1000 non-ICU patient-days) and was associated with >13-fold increased risk of in-hospital death. The critical deterioration metric demonstrated both criterion and construct validity., Conclusions: The critical deterioration rate is a valid, pragmatic proximate outcome associated with in-hospital mortality. It has great potential for complementing existing patient safety measures for evaluating RRS performance.

Objectives: Existing cross-sectional quality measures for colorectal cancer (CRC) screening do not assess longitudinal adherence and thus may overestimate the quality of care. Our goal was to evaluate the adherence to repeated yearly fecal occult blood tests (FOBTs) in order to better understand the extent to which longitudinal adherence may impact screening quality., Methods: This was a retrospective cohort analysis of 1,122,645 patients aged 50-75 years seen at any of the 136 Department of Veterans Affairs medical centers across the United States in 2000 and followed through 2005. The primary outcome was receipt of adequate CRC screening as defined by receipt of FOBTs in at least 4 out of 5 years or receipt of any number of FOBTs in addition to at least one colonoscopy, flexible sigmoidoscopy, or double-contrast barium enema. In a predefined subset of patients receiving exclusively FOBT, adherence with repeated testing was determined over the 5-year study period., Results: Only 41.1% of men and 43.6% of women received adequate screening. Of the 384,527 men who received exclusively FOBT, 42.1% received a single FOBT, 26.0% received 2 tests, 17.8% received 3 tests, and only 14.1% were documented to have received at least 4 tests during the study period. Among the 10,469 female veterans receiving FOBT alone, rates were similar with only 13.7% completing at least 4 FOBTs in the 5-year study period., Conclusions: Adherence to repeated FOBT is low, suggesting that cross-sectional measurements of quality may overestimate the programmatic success of CRC screening.

Because of the number and complexity of issues addressed, this manuscript is divided into two major sections. The first section focuses on how new technology can transform vitamin K antagonist therapy. Specifically, evidence suggest that combining INR self testing with online automated management (STOAM) can greatly reduce the time, expense, and hassle of managing VKA therapy; improve the quality of INR control to a degree that, in large studies, has been associated with a 50% or more reduction in major events (such as stroke, myocardial infarction, major hemorrhage, and death); reduce health care costs by an estimated $4 million per 1,000 patients per year; and improve quality of life and patient satisfaction. Such improved VKA therapy should be safer, more effective, and more cost-effective than the new oral anticoagulants. The improved efficiency and outcomes also should prompt reconsideration of indications in which VKA therapy may not be the current standard of care. Although new reimbursement models are clearly needed for STOAM, the current Medicare reimbursement model for patient self testing can be utilized to make VKA management financially viable and sustainable. The second section of this article focuses on additional considerations that may be important in optimizing VKA therapy and/or selecting an online management system. A brief review is provided to examine why a recent meta analysis and a large randomized trial of self testing did not find the same degree of improvement as reported in the four STOAM trials described in the first section of this article.

Great variability exists in microsurgical postoperative care in the United States. Lack of standardized postoperative monitoring protocols and appropriate training of monitoring personnel leads to inefficiency and increased cost of providing microsurgical postoperative care. A 45-question survey was sent to all plastic surgery and plastic surgery-based microsurgery program directors in the United States. Questions focused on the number and type of flaps performed, length of stay, complications, postoperative monitoring setting, training provided to monitoring personnel, and limitations in flap monitoring. The response rate was 31% with 3407 microvascular free flaps performed annually at 26 centers. A total of 1533 flaps were monitored in the intensive care unit (ICU) for an average of 3.1 days. In 45% of responding centers patients were cared for in an ICU secondary to a lack of adequately trained nurses at alternative sites. Printed postoperative protocols were provided to nurses in 39% of centers. With a comparative increase cost of $2878 to $3345 per day for ICU care, this translates into an annual increased cost of $13.7 to $15.9 million to the responding centers. Improved nursing training and the use of standardized postoperative protocols may allow patients to be monitored in non-ICU settings postoperatively, thereby reducing the costs associated with providing postoperative microsurgical care., ((c) Thieme Medical Publishers.)

In response to recently published KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for the care of kidney transplant recipients (KTRs), the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) organized a working group of transplant nephrologists and surgeons to review these guidelines and comment on their relevance and applicability for US KTRs. The following commentaries on the KDIGO guidelines represent the consensus of our work group. The KDIGO transplant guidelines concentrated on aspects of transplant care most important to this population in the posttransplant period, such as immunosuppression, infection, malignancy, and cardiovascular care. Our KDOQI work group concurred with many of the KDIGO recommendations except in some important areas related to immunosuppression, in which decisions in the United States are largely made by transplant centers and are dependent in part on the specific patient population served. Most, but not all, KDIGO guidelines are relevant to US patients. However, implementation of many may remain a major challenge because of issues of limitation in resources needed to assist in the tasks of educating, counseling, and implementing and maintaining lifestyle changes. Although very few of the guidelines are based on evidence that is strong enough to justify their being used as the basis of policy or performance measures, they offer an excellent road map to navigate the complex care of KTRs., (Copyright (c) 2010 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Continuous ST-segment monitoring can be used to detect early and transient cardiac ischemia. The American Heart Association and American Association of Critical-Care Nurses recommend its use among specific patients, but such monitoring is routine practice in only about half of US hospitals., Objective: To determine cardiologists' awareness and practice standards regarding continuous ST-segment monitoring and the physicians' perceptions of appropriate patient selection, benefits and barriers, and usefulness of this technology., Methods: An electronic survey was sent to a random sample of 915 US cardiologists from a pool of 4985 certified cardiologists., Results: Of 200 responding cardiologists, 55% were unaware of the consensus guidelines. Of hospitals where respondents admitted patients, 49% had a standard of practice for using continuous ST-segment monitoring for cardiac patients. Most cardiologists agreed or strongly agreed that patients in the cardiovascular laboratory (87.5%) and intensive care unit (80.5%) should have such monitoring. Cardiologists routinely ordered ST monitoring for patients with acute coronary syndrome (67%) and after percutaneous coronary intervention (60%). The primary factor associated with higher perceptions for benefits, clinical usefulness, and past use of continuous ST-segment monitoring was whether or not hospitals in which cardiologists practiced had a standard of practice for using this monitoring. A secondary factor was awareness of published consensus guidelines for such monitoring., Conclusion: Respondents (55%) were unaware of published monitoring guidelines. Hospital leaders could raise awareness by multidisciplinary review of evidence and possibly incorporating continuous ST-segment monitoring into hospitals' standards of practice.

Miniature sensors that could measure forces applied by the fingers and hand without interfering with manual dexterity or range of motion would have considerable practical value in ergonomics and rehabilitation. In this study, techniques have been developed to use inexpensive pressure-sensing resistors (FSRs) to accurately measure compression force. The FSRs are converted from pressure-sensing to force-sensing devices. The effects of nonlinear response properties and dependence on loading history are compensated by signal conditioning and calibration. A fourth-order polynomial relating the applied force to the current voltage output and a linearly weighted sum of prior outputs corrects for sensor hysteresis and drift. It was found that prolonged (>20h) shear force loading caused sensor gain to change by approximately 100%. Shear loading also had the effect of eliminating shear force effects on sensor output, albeit only in the direction of shear loading. By applying prolonged shear loading in two orthogonal directions, the sensors were converted into pure compression sensors. Such preloading of the sensor is, therefore, required prior to calibration. The error in compression force after prolonged shear loading and calibration was consistently <5% from 0 to 30N and <10% from 30 to 40N. This novel method of calibrating FSRs for measuring compression force provides an inexpensive tool for biomedical and industrial design applications where measurements of finger and hand force are needed.

Objective: In low- and middle-income countries, methods for clinicians to address difficulties in language, social-emotional, cognitive, behavioral, or neuromotor development during early childhood are lacking. To fill this gap, we designed, in Turkey, the Guide for Monitoring Child Development, which aims to aid clinicians in monitoring and supporting child development and the early detection and management of developmental difficulties. The Guide for Monitoring Child Development monitoring component is a practical, open-ended interview that catalyzes communication between clinicians and caregivers and obtains a portrayal of the child's development. We report on the development and psychometric properties of the Guide for Monitoring Child Development monitoring component for children aged 0 to 24 months., Methods: We examined the ages of attainment of Guide for Monitoring Child Development milestones and internal consistency in a cross-sectional study of healthy children receiving well-child care (study 1). In 2 clinical samples, we studied the interrater reliability between medical students and a child development specialist administering the guide (study 2), as well as the concurrent validity of the guide administered during a health visit and a comprehensive developmental assessment (study 3)., Results: In study 1 (N = 510), item-total scale correlations ranged from 0.28 to 0.91. An age-dependent attainment pattern was seen in all of the milestones. In study 2 (N = 92), interrater reliability between medical-student pairs and between the child development specialist and students was high (kappa scores were 0.83-0.88). In study 3 (N = 79), the sensitivity, specificity, and positive and negative predictive values were 0.88, 0.93, 0.84, and 0.94, respectively., Conclusions: The Guide for Monitoring Child Development is an innovative method for monitoring child development that is designed specifically for use by health care providers in low- and middle-income countries. Studies in Turkey provide preliminary evidence for its reliability and validity.

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the pharmacokinetic and pharmacodynamic effects of the medications used for sedation as well as an appreciation for drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of people to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to presedation level of consciousness before discharge from medical supervision, and appropriate discharge instructions.

Objectives: To develop an algorithm to standardize capillary blood glucose (CBG) testing in nursing home and rehabilitation patients., Design: Descriptive study in which an interdisciplinary team from a nursing home, a rehabilitation center, and a diabetes mellitus care program developed and tested a protocol to standardize diabetes management parameters and CBG testing frequency., Setting: Department of Veterans Affairs nursing home and rehabilitation unit., Participants: One hundred one patients admitted to the units during the 6-month study period who had orders for CBG testing., Intervention: Use of a standardized CBG testing protocol., Measurements: Use of management goal, use of CBG testing protocol, total CBG tests/month., Results: One hundred one subjects received orders for CBG testing; 72 (72%) received orders for a management goal, and 69 (69%) received orders to use the CBG protocol. Of these 69 patients, 22 met their CBG goals and were advanced to less-frequent CBG testing using the protocol, and 15 did not meet their CBG goals and were not advanced. An additional 15 patients were advanced to less-frequent CBG testing but not using the protocol. In all, 54 of 69 patients (78%) were advanced or could have been advanced by protocol to less-frequent CBG testing. Total CBG testing per month did not change before, during, or after the study period., Conclusion: This protocol would be useful in long-term care facilities and in other congregate living settings where patients with diabetes mellitus have staff assisting with their diabetes management. Barriers to successful implementation are discussed.

Anesthesiology has served as a model for patient safety in health care and was the first medical profession to treat patient safety as an independent problem. Anesthesiology has implemented widely accepted guidelines on basic monitoring, conducted long-term analyses of closed malpractice claims, developed patient simulators as meaningful training tools, and addressed problems of human error. The National Surgical Quality Improvement Program is the first national, validated, and peer-controlled program that uses risk-adjusted outcomes for the comparative assessment and improvement of the quality of surgical care. The program has reduced postoperative complications in the Veterans Administration, at both national and local levels. It is becoming more evident that processes and events during surgery can be important determinants of long-term outcomes after anesthesia and surgery.

The American Society of Neurophysiological Monitoring (ASNM) is developing position statements aimed at assisting practitioners and others in making decisions regarding neurophysiological monitoring practice. This paper describes the procedures used in drafting these documents.

The goals of electrocardiographic (ECG) monitoring in hospital settings have expanded from simple heart rate and basic rhythm determination to the diagnosis of complex arrhythmias, myocardial ischemia, and prolonged QT interval. Whereas Computerized arrhythmia analysis is automatic in cardiac monitoring systems, computerized ST-segment ischemia analysis is available only in newer-generation monitors, and computerized QT-interval monitoring is currently unavailable. Even in hospitals with ST-monitoring capability, ischemia monitoring is vastly underutilized by healthcare professionals. Moreover, because no computerized analysis is available for QT monitoring, healthcare professionals must determine when it is appropriate to manually measure QT intervals (eg, when a patient is started on a potentially proarrhythmic drug). The purpose of the present review is to provide "best practices" for hospital ECG monitoring. Randomized clinical trials in this area are almost nonexistent; therefore, expert opinions are based upon clinical experience and related research in the field of electrocardiography. This consensus document encompasses all areas of hospital cardiac monitoring in both children and adults. The emphasis is on information clinicians need to know to monitor patients safely and effectively. Recommendations are made with regard to indications, time frames, and strategies to improve the diagnostic accuracy of cardiac arrhythmia, ischemia, and QT-interval monitoring. Currently available ECG lead systems are described, and recommendations related to staffing, training, and methods to improve quality are provided.