Impact of an institution-designed algorithm for the management of dislodged gastrostomy tubes.

BACKGROUND: Gastrostomy tube (GT) dislodgement is a common reason for emergency department (ED) visits. We aim to assess the efficacy of our institution's algorithm in reducing surgical consultation and GT contrast studies for replacement of dislodged GT and to examine the need for operation before and after algorithm implementation. METHODS: A retrospective review was performed between March 2017-February 2018 (prealgorithm) and March 2018-December 2018 (postalgorithm) for patients <18 years presenting to the ED with GT dislodgement. Demographics and outcomes were analyzed. RESULTS: A total of 433 visits among 279 patients were included, 200 (46.2%) pre and 233 (53.8%) postalgorithm implementation. Median ED LOS was 2.1 h (IQR 1.4, 3.0). Surgery was consulted in 92 visits (21.3%) and a contrast study obtained in 287 (66.3%). The GT was replaced by ED providers in 363 visits (83.8%) and by surgery in 70 (16.2%). Surgical consultation increased postalgorithm (16.5% vs. 25.3%; p = 0.03). Six (1.4%) patients required reoperation, with 5 occurring postalgorithm, p = 0.22. For GTs placed < 8 weeks prior to the dislodgment, there were no differences in surgical consultations, contrast studies performed, or need for reoperation pre and postalgorithm. CONCLUSION: An algorithm for replacement of dislodged GT is usable, effective, and increased surgical team involvement without significant changes in patient outcomes. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: Level III.

Evaluating the Impact of Implementing a Clinical Practice Guideline for Febrile Infants With Positive Respiratory Syncytial Virus or Enterovirus Testing.

OBJECTIVES: To evaluate clinical practice patterns and patient outcomes among febrile low-risk infants with respiratory syncytial virus (RSV) infection or enterovirus (EV) meningitis after implementing a clinical practice guideline (CPG) that provides recommendations for managing febrile infants with RSV infection and EV meningitis. METHODS: Our institution implemented a CPG for febrile infants, which gives explicit recommendations for managing both RSV-positive and EV-positive infants in 2011. We retrospectively analyzed medical records of febrile infants ≤60 days old from June 2008 to January 2013. Among 134 low-risk RSV-positive infants, we compared the proportion of infants who underwent lumbar puncture (LP), the proportion of infants who received antibiotics, antibiotic hours of therapy (HOT), and length of stay (LOS) pre- and post-CPG implementation. Among 274 low-risk infants with EV meningitis, we compared HOT and LOS pre- and post-CPG implementation. RESULTS: Among low-risk RSV-positive patients, the proportion of infants undergoing LP, the proportion of infants receiving antibiotics, HOT, and LOS were unchanged post-CPG. Among low-risk infants with EV meningitis, HOT (79 hours pre-CPG implementation versus 46 hours post-CPG implementation, P < .001) and LOS (47 hours pre-CPG implementation versus 43 hours post-CPG implementation, P = .01) both decreased post-CPG. CONCLUSIONS: CPG implementation is associated with decreased antibiotic exposure and hospital LOS among low-risk infants with EV meningitis; however, there were no associated changes in the proportion of infants undergoing LP, antibiotic exposure, or LOS among low-risk infants with RSV. Further studies are needed to determine specific barriers and facilitators to effectively incorporate diagnostic viral testing into medical decision-making for these infants.

Development of an Instrument to Measure Civil and Uncivil Behaviors in the Hospital Clinical Environment: Implications for Nurse Leaders.

OBJECTIVE: The purpose of this study is to develop a valid and reliable instrument to measure nursing students' (NSs') perceptions of civil and uncivil behaviors displayed by direct care nurses in the hospital clinical environment. BACKGROUND: Incivility in nursing has been well documented. However, little is known about perceptions of incivility by NSs in the hospital clinical environment and its effects on NSs' transition to professional practice. METHODS: A 13-item instrument was developed using literature, faculty feedback, and a semistructured focus group. The instrument was administered to convenience samples of NSs at a Midwest, Magnet-designated pediatric hospital (N = 496). RESULTS: Findings indicated high reliability and validity of the instrument, with a Cronbach's α of .930. CONCLUSIONS: This study has produced a valid and reliable survey instrument to measure the perception of civil and noncivil behaviors on the part of clinical nurses as rated by NSs in hospital clinical settings. The use of this instrument will be beneficial to nurse executives in measuring these perceptions in their clinical settings.

Nasogastric tube placement and verification in children: review of the current literature.

Placement of a nasogastric enteral access device (NG-EAD), often referred to as a nasogastric tube, is a common practice and largely in the domain of nursing care. Most often an NG-EAD is placed at the bedside without radiographic assistance. Correct initial placement and ongoing location verification are the primary challenges surrounding NG-EAD use and have implications for patient safety. Although considered an innocuous procedure, placement of an NG-EAD carries risk of serious and potentially lethal complications. Despite acknowledgment that an abdominal radiograph is the gold standard, other methods of verifying placement location are widely used and have success rates from 80% to 85%. The long-standing challenges surrounding bedside placement of NG-EADs and a practice alert issued by the Child Health Patient Safety Organization on this issue were the stimuli for the conception of The New Opportunities for Verification of Enteral Tube Location Project sponsored by the American Society for Parenteral and Enteral Nutrition. Its mission is to identify and promote best practices with the potential of technology development that will enable accurate determination of NG-EAD placement for both the inpatient and outpatient pediatric populations. This article presents the challenges of bedside NG-EAD placement and ongoing location verification in children through an overview of the current state of the science. It is important for all healthcare professionals to be knowledgeable about the current literature, to be vigilant for possible complications, and to avoid complacency with NG-EAD placement and ongoing verification of tube location.

Nasogastric tube placement and verification in children: review of the current literature.

Placement of a nasogastric enteral access device (NG-EAD), often referred to as a nasogastric tube, is common practice and largely in the domain of nursing care. Most often an NG-EAD is placed at the bedside without radiographic assistance. Correct initial placement and ongoing location verification are the primary challenges surrounding NG-EAD use and have implications for patient safety. Although considered an innocuous procedure, placement of an NG-EAD carries risk of serious and potentially lethal complications. Despite acknowledgment that an abdominal radiograph is the gold standard, other methods of verifying placement location are widely used and have success rates from 80% to 85%. The long-standing challenges surrounding bedside placement of NG-EADs and a practice alert issued by the Child Health Patient Safety Organization on this issue were the stimuli for the conception of The New Opportunities for Verification of Enteral Tube Location Project sponsored by the American Society for Parenteral and Enteral Nutrition. Its mission is to identify and promote best practices with the potential of technology development that will enable accurate determination of NG-EAD placement for both the inpatient and outpatient pediatric populations. This article presents the challenges of bedside NG-EAD placement and ongoing location verification in children through an overview of the current state of the science. It is important for all health care professionals to be knowledgeable about the current literature, to be vigilant for possible complications, and to avoid complacency with NG-EAD placement and ongoing verification of tube location.

Psychometric evaluation of the Shared Decision-Making Instrument--Revised.

The purpose of this study was to evaluate the psychometric properties of the Shared Decision-Making Inventory-Revised (SDMI-R) to measure four constructs (knowledge, attitudes, self-efficacy, and intent) theoretically defined as vital in discussing the human papillomavirus (HPV) disease and vaccine with clients. The SDMI-R was distributed to a sample (N = 1,525) of school nurses. Correlational matrixes denoted moderate to strong correlations, indicating adequate internal reliability. Reliability for the total instrument was satisfactory (α = .874) along with Attitude, Self-Efficacy and Intent subscales .828, .917, .891, respectively. Exploratory factor analysis revealed five components that explained 75.96% of the variance.

The uptake of Human Papillomavirus (HPV) vaccine among adolescent females in the United States: a review of the literature.

A comprehensive review of literature was conducted to identify the barriers and facilitators, from the parents'/guardians' and primary care providers' (PCPs) perspective, that are associated with the uptake of Human Papillomavirus (HPV) vaccine among adolescent females. Findings from 14 peer-reviewed articles indicate that 37% of adolescent females, 9 to 17 years of age, initiated the HPV vaccine, compared to the national average of 13- to 15-years-olds, which is 50%. The overall uptake and completion rates of the vaccine were low across all racial and ethnic groups. Barriers included parents'/guardians' knowledge, perceptions, and attitudes toward the HPV disease and the vaccine, along with the convenience in receiving the vaccine. Six studies reported that HPV vaccine initiation was highly likely if the parents/guardians had received a doctor's recommendation. Learning what interventions school nurses currently utilize could positively affect the HPV vaccine uptake and completion rates by other nursing disciplines realizing this ongoing effort.

Panic disorder and immunity: few effects on circulating lymphocytes, mitogen response, and NK cell activity.

Altered immune measures are commonly found in major depression (MD), however, less is known about the immune system in anxiety disorders. We examined quantitative and functional in vitro immune measures in patients with panic disorder (PD), which is often comorbid with MD. Fourteen otherwise healthy medication-free adults (ages 23-49; 11 female) meeting SCID-UP DSM-IIIR criteria for PD with agoraphobia and without current MD, were compared with 14 subjects free of PD, MD, or other major psychiatric disorders, matched by gender, age, and racial background. PD was associated with decreased percentage (p<.03) and total (p<.03) circulating CD19+ B lymphocytes, but no differences in other enumerative lymphocyte measures. Mitogen responses (Con A, PHA, PWM) did not differ except for possibly decreased PHA in PD (p<.06). NK cell activity did not differ between PD and control subjects. The few immune measure changes in PD contrast with those found in MD, providing further evidence for the specificity of immune changes in psychiatric disorders.

Immunity in adolescents with major depression.

OBJECTIVE: The association between major depression (MD) and altered immunity appears to be age-related, with differing immune changes found in prepubertal children, young adults, and older adults. There is limited information concerning immunity in adolescents with MD. METHOD: Thirty-six otherwise healthy medication-free adolescents (aged 14-20; 23 female) from a community sample, meeting Diagnostic Interview Schedule for Children DSM-III-R criteria for unipolar MD, were compared with 36 nondepressed adolescents matched by gender, age, and racial background. A battery of quantitative and functional immune measures was obtained. RESULTS: MD adolescents had increased (p < .05) circulating lymphocytes and lymphocyte subsets; however, altered distribution of lymphocyte subsets was found only for activated T (HLA-DR+) cells (p < .004) and, possibly, natural killer (NK) (CD56+) cells (p < .06), each showing lower percentages in the MD adolescents. Concanavalin A (but not phytohemagglutinin or pokeweed mitogen) mitogen response was lower in the MD adolescents (p < .02). NK cell activity was elevated at higher effector-target ratios (p < .001), an effect not associated with the number of circulating CD56+ (NK) cells. CONCLUSIONS: Depressed adolescents showed changes in immune measures that have been found to be altered in other MD groups, although the pattern of effects differs.