An evidence-based oxytocin protocol for the third stage of labor to improve hemorrhage outcomes.

OBJECTIVE: To assess the use of an evidence-based oxytocin protocol for management of the third stage of labor to decrease non-beneficial clinical variation and improve clinical outcomes. DESIGN: This is a cohort study of pregnant patients delivering before implementation of an evidence-based oxytocin protocol compared to patients delivering after implementation of an evidence-based oxytocin protocol. SETTING: A level III maternal care referral hospital with an average delivery volume of approximately 3000 deliveries. PARTICIPANTS: Pregnant patients delivering over a 60-month period from January 2013 to December 2017. INTERVENTION: An evidence-based oxytocin protocol: 3 units of oxytocin administered over 3 minutes, with a second 3-unit bolus if inadequate tone, then oxytocin infusion at 18 units/hour × 1 hour and then 3.6 units/hour for 3 hours. MAIN OUTCOME MEASURES: Postpartum hemorrhage (PPH) rate (EBL ≥500 ml for vaginal and ≥1000 ml for cesarean). RESULTS: Data from 14 603 deliveries were analyzed, 8408 pre-protocol and 6195 post-protocol. We demonstrated a significant decrease in PPH from 5.2% to 2.9% (P < 0.001) and a small but non-significant increase in the transfusion rate from 1.8% to 2.3% (P = 0.11). CONCLUSION: A standardized oxytocin infusion protocol in the third stage of labor resulted in a significant decrease in PPH for both vaginal and cesarean deliveries.

Implementation of a standardized nurse initiated protocol to manage severe hypertension in pregnancy.

Objectives: Hypertensive disorders of pregnancy are a leading cause of maternal morbidity and mortality, studies have shown that standardized protocols for treating severe hypertension improves outcomes. Our goal was to examine the effects of a protocol for treating severe hypertension.Methods: Using quality improvement methodology, we developed an evidence-based nurse-initiated protocol for management of severe hypertension. We used a before and after study design, with the primary outcome of time to administration of antihypertensive medications and time to achieve blood pressure control. Secondary outcomes included medication usage, time to repeat blood pressure, and proportion of women receiving appropriate treatment. Statistical analysis was completed with Stata, using data medians, 95% confidence intervals and a rank-sum test.Results: Data was collected for 5 months before and 5 months after protocol implementation, with 67 patients included before and 125 patients after implementation. The median time to treatment of severe range blood pressure decreased from 25 min before to 11 min after protocol implementation, p <.001. Twenty-four% of women were treated within 15 min before and 60.6% were treated within 15 min after protocol implementation. Median time required to regain sustained mild range blood pressure was reduced from 45 min before to 41 min after protocol implementation, p = .004. 67.5% of women regained mild range blood pressure within 60 min before and 81.9% achieved blood pressure control within 60 min after protocol implementation. These improved outcomes were evident within the first month after protocol implementation and remained stable throughout the follow-up period.Discussion: Implementation of an evidence-based nurse-initiated protocol for the treatment of severe hypertension in pregnancy decreases the time required to administer antihypertensive medication, time required to regain blood pressure control and nonbeneficial clinical variation. In addition, these benefits were achieved rapidly within a large hospital setting.

Uncertainties in data and models to describe event dynamics of agricultural sediment and phosphorus transfer.

Mathematical models help to quantify agricultural sediment and phosphorus transfers and to simulate mitigation of pollution. This paper develops empirical models of the dominant sediment and phosphorus event dynamics observed at high resolution in a drained and undrained, intensive grassland field-scale lysimeter (1 ha) experiment. The uncertainties in model development and simulation are addressed using Generalized Likelihood Uncertainty Estimation. A comparison of suspended solids (SS) and total phosphorus (TP) samples with a limited number of manual repeats indicates larger data variability at low flows. Quantitative uncertainty estimates for discharge (Q) are available from another study. Suspended solids-discharge (SS-Q) hysteresis is analyzed for four events and two drained and two undrained fields. Hysteresis loops differ spatially and temporally, and exhaustion is apparent between sequential hydrograph peaks. A coherent empirical model framework for hysteresis, where SS is a function of Q and rate of change of Q, is proposed. This is evaluated taking the Q uncertainty into account, which can contribute substantially to the overall uncertainty of model simulations. The model simulates small hysteresis loops well but fails to simulate exhaustion of SS sources and flushing at the onset of events. Analysis of the TP-SS relationship reveals that most of the variability occurs at low flows, and a power-law relationship can explain the dominant behavior at higher flows, which is consistent across events, fields, and pathways. The need for further field experiments to test hypotheses of sediment mobilization and to quantify data uncertainties is identified.

A review of portfolio use in residency programs and considerations before implementation.

BACKGROUND: Portfolios, often described as collections of evidence, are discussed as a means of teaching or assessing the Accreditation Council for Graduate Medical Education competencies. Yet, it is unclear how many residency programs utilize portfolios. The purpose of this article is to (a) review the literature on portfolio use in graduate medical education; (b) examine efficacy of portfolio use, based upon studies in the field; and (c) offer a discussion of considerations for implementing portfolios. SUMMARY: Two searches of PubMed, OVID, JSTOR, SCOPUS, and FirstSearch Wilson Select were conducted between October 2006 and April 2007 to identify studies and articles related to portfolio usage. Thirty-nine articles met criteria and were reviewed. CONCLUSIONS: There is wide variation in how portfolios are utilized within U.S. residency programs. The challenge for graduate medical education is to create consensus on the definition and purpose of portfolios, such that best practices in portfolio implementation and assessment can be achieved.

Using delta15N and delta18O to evaluate the sources and pathways of NO3- in rainfall event discharge from drained agricultural grassland lysimeters at high temporal resolutions.

The origin of NO(3) (-) yielded in drainage from agricultural grasslands is of environmental significance and has three potential sources; (i) soil organic mater (SOM), (ii) recent agricultural amendments, and (iii) atmospheric inputs. The variation in delta(15)N-NO(3) (-) and delta(18)O-NO(3) (-) was measured from the 'inter-flow' and 'drain-flow' of two 1 ha drained lysimeter plots, one of which had received an application of 21 m(3) of NH(4) (+)-N-rich agricultural slurry, during two rainfall events. Drainage started to occur 1 month after the application of slurry. The concentrations of NO(3) (-)-N from the two lysimeters were comparable; an initial flush of NO(3) (-)-N occurred at the onset of drainage from both lysimeters before levels quickly dropped to <1 mg NO(3) (-)-N L(-1). The isotopic signature of the delta(15)N-NO(3) (-) and delta(18)O-NO(3) (-) during the first two rainfall events showed a great deal of variation over short time-periods from both lysimeters. Isotopic variation of delta(15)N-NO(3) (-) during rainfall events ranged between -1.6 to +5.2 per thousand and +0.4 to +11.1 per thousand from the inter-flow and drain-flow, respectively. Variation in the delta(18)O-NO(3) (-) ranged from +2.0 to +7.8 per thousand and from +3.3 to +8.4 per thousand. No significant relationships between the delta(15)N-NO(3) (-) or delta(18)O-NO(3) (-) and flow rate were observed in most cases although delta(18)O-NO(3) (-) values indicated a positive relationship and delta(15)N-NO(3) (-) values a negative relationship with flow during event 2. Data from a bulked rainfall sample when compared with the theoretical delta(18)O-NO(3) (-) for soil microbial NO(3) (-) indicated that the contribution of rainfall NO(3) (-) accounted for 8% of the NO(3) (-) in the lysimeter drainage at most. The calculated contribution of rainfall NO(3) (-) was not enough to account for the depletion in delta(15)N-NO(3) (-) values observed during the duration of the rainfall event 2. The relationship between delta(15)N-NO(3) (-) and delta(18)O-NO(3) (-) from the drain-flow indicated that denitrification was causing enrichment in the isotopes from this pathway. The presence of slurry seemed to cause a relative depletion in delta(18)O-NO(3) (-) in the inter-flow and delta(15)N-NO(3) (-) in the drain-flow compared with the zero-slurry lysimeter. This may have been caused by increased microbial nitrification stimulated by the presence of increased NH(4) (+)-N.

A study of certified diabetes educators: influences and barriers.

PURPOSE: There were 2 related goals for this study. The first purpose was to describe the structure (type, staffing, and number of educational sessions provided), process (preferred learning approaches), and outcome measures commonly used to provide patient education. The second purpose was to identify the influences, resources, and constraints that affect and alter the attitudes and practices of diabetes educators. METHODS: A 30-item questionnaire that addressed 4 areas--demographics, practice characteristics, education program structure, and educational processes--was mailed to a sample of American Association of Diabetes Educators members. Three hundred sixty-one registered nurse and registered dietician certified diabetes educators completed the questionnaire and were included in the final analysis. RESULTS: This survey indicated that this group of certified diabetes educators has incorporated new research findings and innovative teaching methods into their practices. They experience few barriers and tend to make changes in their attitudes and practices based on scientific and experiential evidence. The 3 most highly rated influences on these changes were related to patient responses to their teaching, followed by continuing education conferences and new research findings. CONCLUSIONS: Based on these findings, providing continuing education that first and foremost incorporates experience-based examples of effective strategies supported by research published in professional journals appears to have the most influence on the practice of educators.

The impact of preclinical preceptorships on learning the fundamentals of clinical medicine and physical diagnosis skills.

PURPOSE: To learn whether preclinical primary care preceptorships resulted in demonstrable clinical performance benefits to medical students. METHOD: This was a retrospective cohort study of 267 medical students who elected and 310 students who did not elect to take a four-week primary care preceptorship following the first year of training at the University of Texas Medical School at Houston in 2001-2003. Outcome variables were the students' performances on a written examination testing their integration of basic science and fundamentals of clinical medicine and performances on a comprehensive objective structured clinical examination (OSCE). After adjusting for factors that might have explained differences in the students' performances, logistic regression models were used to assess the association of the outcome variables with participation in a preceptorship. RESULTS: Students who participated in any one of the preceptorships performed better on the OSCE and on the fundamentals of clinical medicine examination than students who did not participate (p < .01). Students who participated in the family medicine or pediatric preceptorship scored higher on an OSCE (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.01-2.78 and OR, 2.26; 95% CI, 1.18-4.36, respectively) than those students who did not participate in a preceptorship. Students who participated in the internal medicine preceptorship scored higher on the fundamentals of clinical medicine examination (OR, 3.18; 95% CI, 1.92-5.23). CONCLUSIONS: Preliminary evidence indicates that a short preclinical primary care preceptorship can help medical students to consolidate and integrate the fundamental cognitive and clinical skills they will apply during the clinical years of medical training.

Evaluating colloidal phosphorus delivery to surface waters from diffuse agricultural sources.

Colloid-facilitated phosphorus (P) delivery from agricultural soils in different hydrological pathways was investigated using a series of laboratory and field experiments. A soil colloidal P test was developed that yields information on the propensity of different soils to release P attached to soil colloids. The relationship between turbidity of soil extracts and total phosphorus (TP) was significant (r2 = 0.996, p < 0.001) across a range of agricultural soils, and a strong positive relationship (r2 = 0.86, p < 0.001) was found between "colloidal P" (H2O-CaCl2 extracts) and turbidity. Linear regression of the proportion of fine clay (<2 microm) for each soil type evaluated against the (H2O-CaCl2) colloidal P fraction gave a weak but positive relationship (r2 = 0.38, p = 0.082). The relative contribution of different particle-size fractions in transporting P in agricultural runoff from grassland soils was evaluated using a randomized plot experiment. A significant difference (p = 0.05) in both TP and reactive phosphorus (RP) in subsurface flow was recorded for different particle-size fractions, with most TP transferred either in association with the 2-microm fraction or with the 0.001-microm or smaller fractions. Total P concentrations in runoff were higher from plots receiving P amendments compared with the zero-P plots; however, these differences were only significant for the >0.45-microm particle-size fractions (p = 0.05), and may be evidence of surface applications of organic and inorganic fertilizers being transferred through the soil either as intact organic colloids or attached to mineral particles. Our results highlight the potential for drainage water to mobilize colloids and associated P during rainfall events.

ERISA update: the Supreme Court Texas decision and other recent developments.

This issue brief is part of a continuing series of policy papers published by The Robert Wood Johnson Foundation's State Coverage Initiatives program, housed at AcademyHealth, and the National Academy for State Health Policy on the state health policy implications of ERISA's preemption clause.1 The purpose of the brief is to explore the U.S. Supreme Court's June 2004 decision that ERISA preempts the Texas HMO liability law and its effects on other state health plan liability laws. The brief also examines implications of ERISA preemption for state health insurance regulation, "pay or play" health coverage laws, and premium assistance programs.