Barriers encountered by nurses in the care of walk-in international patients in an emergency department in Japan.

BACKGROUND: An increasing number of international patients continue to visit emergency departments (EDs) in Japanese hospitals. However, nurses in Japan perceive challenges when caring for patients from other countries. This study explored ED nurses' perceptions of barriers when caring for walk-in international patients. METHODS: Five semi-structured online focus group interviews involving 15 registered nurses with experience in caring for patients in an ED at a university referral hospital located in the center of Tokyo were conducted. Thematic analysis was used to identify patterns from the interviews. RESULTS: The themes that emerged were as follows: (1) hesitation to engage with patients due to ambiguity, (2) loss of harmony in the ED, (3) difficulty with mutual goal settings, and (4) decreased professional self-efficacy. CONCLUSION: The findings provide an understanding of the challenges faced when caring for walk-in international patients. Educational interventions for ED nurses and other strategies, such as the use of interpreters, can enhance nurses' abilities to improve patient safety and maintain equality.

Evaluation of nursing process competencies, nursing quality, and patient safety using virtual simulation with debriefing: A quasi-experimental study.

Background: Investing in clinical education is important for adult urgent and emergency surgery and traumatology as it promotes registered nurses' competencies by providing professional development training to respond to urgent or emergency surgeries. Objective: To examine registered nurses' self-assessment of the effects of virtual video simulation with an immediate debriefing approach on nursing process competencies, nursing care quality, incomplete care, and patient safety in surgical units. Methods: This study used a quasi-experimental two-group pre- and post-test design. The study was conducted at two provincial hospitals in Cambodia. Participants included registered nurses employed in surgical units. The experimental group (n = 46) completed a virtual video simulation and immediate debriefing. The control group (n = 35) completed virtual training on the nursing process. Data were collected two months after a successful second-week follow-up using Competency of Nursing Process, Cambodian Nursing Care Quality, Care Left Undone, and Patient Safety scales. Wilcoxon signed-rank test and Mann-Whitney U test were used to evaluate the differences before and after the sessions. Generalized linear model was used to compare the differences between the two groups. Results: The results showed statistically significant improvements in the experimental group on competency, nursing care quality, patient safety, and reducing care left undone after the intervention. However, the control group revealed statistically insignificant differences. In addition, the experimental group provided positive feedback, such as experiencing a real patient scenario, developing critical-thinking, improving communication skills, and having an opportunity to ask questions. Conclusion: Our study showed that VVS and immediate debriefing have the potential to support in-service training of RNs from diverse backgrounds. Particularly, integrating virtual video simulation and immediate debriefing may to promote competency in the nursing process and improve care outcomes.

Development and psychometric testing of a competency of nursing process questionnaire.

Objectives: This study aimed to develop and evaluate a competency of nursing process questionnaire (CNPQ) for registered nurses in Cambodia. Methods: Guided by the nursing process, an initial questionnaire was generated through focus group discussion, literature review, and the expert consultation. Finally, the validity and reliability of the questionnaire were validated through a questionnaire survey online of 260 registered nurses selected from Complimentary Package Activities 1, 2, 3, and national hospitals from January to February 2022 in five geographic areas of Cambodia. Results: The content validity index was 1.00. The Cronbach's α coefficient for the whole questionnaire was 0.963, and the range for the five dimensions was 0.963-0.964, which shows that the questions were consistent. The test-retest reliability was 0.769. The exploratory factor analysis led to a list of 24 items that were grouped into five dimensions: assessment, diagnosis, planning, implementation, and evaluation. The cumulative variance contribution rate was 70.08%. Conclusions: The CNPQ developed in this study showed good reliability and validity and can be used to assess the competency of registered nurses by themselves and help nursing managers to develop the relevant policies.

Efficacy of modified team-based learning in a flipped classroom for an acute-care nursing course: A mixed-methods study.

AIM: To test a modified team-based learning approach on undergraduate learning outcomes in an acute-care nursing course in Japan. DESIGN: Mixed-methods. METHODS: Students worked on three simulated cases, engaged in pre-class preparation, completed a quiz and engaged in group work. We collected data on team approach, critical-thinking disposition and time spent in self-learning at four time-points: before the intervention and after each simulated case. Data were analysed using a linear mixed model, a Kruskal-Wallis test and a content analysis. DATA SOURCES: We recruited nursing students attending a mandatory course in acute-care nursing at University A. Data were collected at four time-points between April and July 2018. Data from 73 of 93 respondents were analysed. RESULTS: Team approach, critical thinking and self-learning all increased significantly across the time-points. Four categories emerged from students' comments: 'achievement of teamwork', 'sense of learning efficacy', 'satisfaction with course approach' and 'issues related to course approach'. The modified team-based learning approach led to improvements in team approach and critical-thinking disposition across the course. CONCLUSION: Incorporating team-based learning into the curriculum not only contributes to team building but is also effective as a teaching method to improve student learning. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: The intervention led to improvements in team approach and critical-thinking disposition across the course. The educational intervention also led to more time for self-learning. Future studies should include participants from various universities and evaluate the outcomes over a longer period.

Nursing workforce characteristics and effect on life expectancy and under-five mortality in the ASEAN.

AIM: To assess the effects of the nursing workforce and advanced nursing practice on the outcomes of patients and life expectancy, including mortality rates of under-five children in Cambodia, and to develop policy recommendations to increase the influence of the nursing workforce. BACKGROUND: In low-middle-income nations, life expectancy and under-five mortality are important measures of public health. However, there is still a dearth of literature related to the nursing workforce in Southeast Asia. METHOD: The authors retrieved the data from the World Nursing Report produced by the World Health Organization 2020 for 10 member states. The transparent reporting of a multivariable prediction model for individual prognosis or diagnosis checklist has guided this study. The univariate linear regression model was applied to categorize the potential predictors for each outcome assessment. In addition, the Spearman rank correlation test was selected to assess the potential predictors, and a multivariate statistical analysis was carried out for each of the five outcomes. RESULTS: According to the study's findings, nurse density and advanced practice nursing improve both female and male life expectancy. The existence of advanced nursing roles is associated with decreased under-five mortality. CONCLUSIONS: There are great opportunities to improve the nursing workforce within Cambodia and other Association of Southeast Asian Nations member states to increase patient outcomes. Investment in nursing is essential for improved patient outcomes. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Health policy investments in these projects and future initiatives intended to advance nurse density, education, and practice are based on this study's results. Policy initiatives should focus on increasing density because nursing appears to impact life expectancy and other outcomes.

Perioperative management of obstructive sleep apnea in lower extremity orthopedic procedures: A review of evidence to inform the development of a clinical pathway.

Obstructive sleep apnea (OSA) is unrecognized in as high as 80% of patients before surgery. When untreated, OSA increases a surgical patient's propensity for airway collapse and sleep deprivation lending to a higher risk for emergent re-intubation, prolonged recovery time, escalation of care, hospital readmission, and longer length of stay. We have reviewed the evidence regarding diagnostic performance of OSA screening methods and the impact of perioperative management strategies on postoperative complications among patients with diagnosed or suspected OSA who are undergoing orthopedic surgery. We then integrated the data and recommendations from professional society guidelines to develop an evidence-based clinical care pathway to optimize the perioperative management of this surgical population. Successful management of patients with diagnosed or suspected OSA encompass five facets of care: screening, education, airway management, medications, and monitoring. This narrative review revealed two gaps in the evidence to inform management of patients undergoing orthopedic surgery 1) during the perioperative setting to include evidence-based interventions that reduce postoperative complications and 2) after discharge to an unmonitored environment. The clinical care pathway as well as perspectives for future research are discussed.

Donating Dantrolene: Development and Implementation of a Malignant Hyperthermia Program in a Scarce Resource Setting.

Intravenous dantrolene is the first-line treatment of malignant hyperthermia (MH), however, it is not always accessible in lower-middle income countries (LMICs). Facilities in the United States are in a transition period where dantrolene is being replaced with Ryanodex, therefore, there is an opportunity for excess dantrolene to be utilized in LMICs where neither dantrolene nor Ryanodex exist. Thirty-six vials of recently expired, unused dantrolene were obtained for a hospital in a LMIC and an MH program was developed in conjunction with the Lao Friends Hospital for Children (LFHC) anesthesia providers, LFHC liaison, LFHC leadership team, and an expert in the field of MH. Components of the MH program included developing a facility-specific protocol, treatment guidelines, supply list, and educational tools. A designated MH drawer was also created in preparation for an MH event. By procuring dantrolene and implementing an MH program in a facility where no MH protocol, treatment guidelines, supply list, or educational tools existed, LFHC is better equipped to handle a potentially lethal scenario.

Decreasing the Incidence of Hypoxia and Airway Maneuvers During GI Procedures.

Many outpatient gastrointestinal procedures are completed with propofol anesthesia. A side effect of propofol is airway obstruction and subsequent hypoxia. This study was designed to determine whether the use of a high-flow nasal cannula is associated with a decreased incidence of hypoxia or airway obstruction in patients undergoing propofol sedation in the gastrointestinal laboratory with a STOP-BANG score ≥5. High-flow nasal cannula was administered at 70 L/min on 27 patients with a STOP-BANG score ≥5 receiving monitored anesthesia care sedation for an esophagogastroduodenoscopy, endoscopic ultrasound, or colonoscopy procedure. Patients were compared to a group from a previous project without the use of high-flow nasal cannula assessing whether hypoxia, apnea, or the need for airway maneuvers occurred. The non-high-flow nasal cannula group required an airway maneuver 53.3% (n = 8) whereas the high-flow nasal cannula group required an airway maneuver 18.5% (n = 5) (p = .021). High-flow nasal cannula was associated with a reduced need for airway maneuvers in patients with a high risk of obstructive sleep apnea undergoing propofol-assisted procedures.

Perspectives of Parents/Legal Guardians of Children With Down Syndrome Requiring Anesthesia: Concerns and Sources of Information.

This descriptive exploratory study sought to gain insight about where caregivers of children with Down syndrome find information regarding anesthesia and the experiences of these caregivers when their child had to receive an anesthetic. We hypothesized that the Internet and social media were major sources of information. We recruited parents/caregivers via Down syndrome organizational websites and social media. A total of 515 participants completed a 24-question survey. Descriptive analysis and content analysis were used to analyze the data. Nearly all participants (96%) indicated their child had received an anesthetic. Reportedly, 41.2% had never searched the Internet about anesthesia. Responses indicated that caregivers obtained information mostly from Facebook groups and local websites and groups. Respondents believed the information was helpful (88.2%) but considered it to be only somewhat trustworthy (73.3%). Most (82%) indicated they would prefer a face-to-face conversation with the anesthesia provider. Among participants, 45% reported having a positive experience with anesthesia, 25% reported a negative experience, and 30% responded neither. Negative experiences involved children who had symptoms of emergence delirium and regression or when the caregiver perceived there were unexpected complications. These results are intended to be used to develop a checklist for caregivers when speaking to anesthesia providers.

Certified registered nurse anesthetist and anesthesiologist assistant education programs in the United States.

In Japan, a relative shortage of practicing anesthesiologists continues to be a national issue. To address this issue, some Japanese medical institutions have started developing curriculums to train non-physician perioperative anesthesia personnel, including nurse practitioners and perianesthesia nurses. We urgently need to establish a national standard for the education programs that train these extended non-physician anesthesia care providers. A certified registered nurse anesthetist educational program at a large academic medical center in the United States is described in detail as a reference. Highly systematic educational programs using simulation, didactics, and full clinical subspecialty rotations are ideal if not easily achievable in many current training institutions in Japan. Anesthesia assistant education programs in the United States can be used as an additional reference to create a national educational program in Japan.

Predictors of severe postoperative pain after orthopedic surgery in the immediate postoperative period.

AIM: Severe pain in the immediate postoperative period can negatively affect patients' quality of recovery, prolong hospital stay, and increase the risk of developing persistent pain. This study aimed to examine the predictors of severe postoperative pain in the immediate postoperative period among orthopedic trauma patients. METHODS: A prospective observational study design was used. Data were collected from 153 patients that underwent orthopedic surgery procedures. Pain scores were assessed by a numeric pain scale at 45 min in the Post Anesthesia Care Unit. Physical health status was measured by the American Society of Anesthesiologists Status Classification System, and total dose of opioids (converted to morphine equivalents) and other demographic and clinical characteristics were recorded from medical records. RESULTS: Preoperative smoking and physical health status were statistically significant predictors of severe postoperative pain in the immediate postoperative period. The odds of severe postoperative pain for smokers were 2.42 times the odds of nonsmokers. Patients with severe systemic disease showed 4.27 times lower odds of severe pain than more healthy patients. CONCLUSION: Preoperative predictors of severe postoperative pain should be considered when assessing and treating orthopedic patients postoperatively to assure adequate pain relief.

STOP-BANG as a Pre-procedure Risk Assessment Tool to Predict Intraprocedure Airway Maneuvers and Adverse Events in a Gastrointestinal Laboratory.

A high prevalence of undiagnosed obstructive sleep apnea (OSA) exists in patients receiving sedation for gastrointestinal laboratory (GI lab) procedures, with potentially serious adverse events associated with untreated OSA. This quality improvement project aimed to identify patients at high risk of OSA and evaluate their risk of intraprocedure airway maneuvers and adverse events in a GI lab. In the GI lab, nurses administered and documented the STOP-BANG questionnaire as part of their pre-procedure assessment of 80 patients presenting for elective procedures. The occurrence of airway maneuvers and adverse events during the procedures was measured using a checklist given to nurse anesthetists as they brought patients to the postprocedure area. Patients with STOP-BANG scores below 5 and with scores of 5 and above were compared. Descriptive and inferential statistics were used to analyze differences in patient outcomes. Patients with high STOP-BANG scores had an increased need for airway maneuvers and higher occurrence of adverse events (P=.05). These results support the use of STOP-BANG as a pre-procedure risk assessment tool. Anesthesia professionals can anticipate intraprocedure airway interventions, consider preemptive interventions in a GI lab, and be more vigilant when caring for patients with high STOP-BANG scores at high risk of undiagnosed OSA.

The impact of preoperative pain-related psychological factors on pain intensity post-surgery in Jordan.

This study aimed to investigate the impact of preoperative psychological factors on postoperative pain. We included 300 postoperative patients who underwent open reduction and internal fixation surgery. Pain Scale, Pain Catastrophizing Scale, and Depression, Anxiety, and Stress Scale were completed by patients preoperatively and at 24 hours after surgery. Clinical characteristics were obtained from medical records. Data were analyzed using multiple linear regression. Postoperative pain was predicted by pain catastrophizing and anxiety symptoms. High preoperative catastrophizing and anxiety levels were associated with increased pain postoperatively. However, the relationships between preoperative depressive and stress symptoms and postoperative pain were not significant.

Bayesian modeling to predict malignant hyperthermia susceptibility and pathogenicity of RYR1, CACNA1S and STAC3 variants.

Aim: Identify variants in RYR1, CACNA1S and STAC3, and predict malignant hyperthermia (MH) pathogenicity using Bayesian statistics in individuals clinically treated as MH susceptible (MHS). Materials & methods: Whole exome sequencing including RYR1, CACNA1S and STAC3 performed on 64 subjects with: MHS; suspected MH event or first-degree relative; and MH negative. Variant pathogenicity was estimated using in silico analysis, allele frequency and prior data to calculate Bayesian posterior probabilities. Results: Bayesian statistics predicted CACNA1S variant p.Thr1009Lys and RYR1 variants p.Ser1728Phe and p.Leu4824Pro are likely pathogenic, and novel STAC3 variant p.Met187Thr has uncertain significance. Nearly a third of MHS subjects had only benign variants. Conclusion: Bayesian method provides new approach to predict MH pathogenicity of genetic variants.

The Japanese version of the Richards-Campbell Sleep Questionnaire: Reliability and validity assessment.

AIMS: The purpose of this study was to determine the reliability and validity of the Japanese version of the Richards-Campbell Sleep Questionnaire as a measure of sleep among intensive care unit patients in a Japanese hospital. DESIGN: Cross-sectional survey. METHODS: The Richards-Campbell Sleep Questionnaire was initially translated into Japanese using the back-translation method. Validity was evaluated by determining the association between sleep efficiency, measured using simplified polysomnography, and the total score on the Japanese version of the Richards-Campbell Sleep Questionnaire. Adult non-intubated intensive care unit patients who completed the five-item visual analogue scale underwent polysomnography for one night. Reliability was tested using Cronbach's alpha coefficient. RESULTS: Thirty-three patients were included in the analysis. After excluding four patients with subsyndromal delirium, the Pearson correlation coefficient was 0.602 (p = 0.001). Cronbach's alpha coefficient was 0.911. CONCLUSION: The Japanese version of the Richards-Campbell Sleep Questionnaire could be used as an alternative to polysomnography when assessing sleep quality in lucid intensive care unit patients.

Perianesthesia Measurement During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Procedure: A Case Report and Review of the Literature.

PURPOSE: This purpose of this case study and review was to understand perianesthesia care of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy surgery (CRS+HIPEC). DESIGN: Case study. METHODS: The perianesthesiaa medical record of a patient under CRS+HIPEC was analyzed to study the characteristics of perianestheia care for CRS+HIPEC. The literature of perianestheisa care for CRS+HIPEC was reviewed. FINDINGS: The challenges that perianesthesia care for CRS+HIPEC include-but are not limited to-electrolyte abnormalities, hemodynamic instabilities, and temperature fluctuation. Optimal perianesthesia management of a patient treated with CRS+HIPEC requires control of a complex interplay of physiologic mechanisms. CONCLUSIONS: Besides maintenance of clinical and laboratory parameters, and recognition and treatment of any changes, evidenced-based guidelines are needed, not only for the optimal perianesthesia management of these patients, but also to avoid potential life threatening intraoperative and postoperative complications. The standardization of perianesthesia management for CRS+HIPEC is a necessary step in meeting these goals.

Accuracy of Temporal Artery Thermometry as an Indicator of Core Body Temperature in Patients Receiving General Anesthesia.

PURPOSE: To evaluate the agreement of temporal artery temperature (Tat) with esophageal temperature (Tes) and oral temperature (Tor), and explore potential factors associated with the level of agreement between the thermometry methods in different clinical settings. DESIGN: A prospective repeated measures (induction, emergence, and postanesthesia care unit) design was used. METHODS: Temperature data were collected for 54 patients receiving general anesthesia. Analyses included descriptive statistics, paired t tests for the within-patient comparison of temperature methods, Bland-Altman plots to examine agreement between methods, and multiple linear regression to identify factors associated with the agreement between methods. FINDINGS: Tat was significantly higher compared with Tes and Tor (P < .05) and was poor at detecting hypothermia. The use of a muscle relaxant and surgical site were suggested to be associated with the difference between Tat and Tes at emergence. CONCLUSIONS: Tat is more convenient, but less accurate, than other thermometry methods. These inaccuracies are exacerbated by common anesthetic medications.

Crisis Team Management in a Scarce Resource Setting: Angkor Hospital for Children in Siem Reap, Cambodia.

INTRODUCTION: A crisis team management (CTM) simulation course was developed by volunteers from Health Volunteers Overseas for physicians and nurses at Angkor Hospital for Children (AHC) in Siem Reap, Cambodia. The framework for the course was adapted from crisis resource management (1, 2), crisis team training (3), and TeamSTEPPs© models (4). The CTM course focused on teaching physicians and nurses on the development of team performance knowledge, skills, and attitudes. Challenges to providing this course at AHC included availability of simulation equipment, cultural differences in learning, and language barriers. The purpose of this project was to evaluate the impact of a CTM simulation course at AHC on attitudes and perceptions of participants on concepts related to team performance. METHODS: Each of the CTM courses consisted of three lectures, including team performance concepts, communication, and debriefing followed by rotation through four simulation scenarios. The evaluation instrument used to evaluate the AHC CTM course was developed for Cambodian staff at AHC based on TeamSTEPPs© instruments evaluating attitude and perceptions of team performance (5). CTM team performance concepts included in lectures, debriefing sessions, and the evaluation instrument were: team structure, leadership, situation monitoring, mutual support, and communication. The Wilcoxon signed-rank test was used to analyze pre- and post-test paired data from participants in the course. RESULTS: Of the 54 participants completing the three CTM courses at AHC, 27 were nurses, 6 were anesthetists, and 21 were physicians. Attitude and perception scores were found to significantly improve (p < 0.05) for team structure, leadership, situation monitoring, and communication. Team performance areas that improved the most were: discussion of team performance, communication, and exchange of information. CONCLUSION: Teaching of non-technical skills can be effective in a setting with scarce resources in a Southeastern Asian country.

Development of a Unifying Target and Consensus Indicators for Global Surgical Systems Strengthening: Proposed by the Global Alliance for Surgery, Obstetric, Trauma, and Anaesthesia Care (The G4 Alliance).

After decades on the margins of primary health care, surgical and anaesthesia care is gaining increasing priority within the global development arena. The 2015 publications of the Disease Control Priorities third edition on Essential Surgery and the Lancet Commission on Global Surgery created a compelling evidenced-based argument for the fundamental role of surgery and anaesthesia within cost-effective health systems strengthening global strategy. The launch of the Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care in 2015 has further coordinated efforts to build priority for surgical care and anaesthesia. These combined efforts culminated in the approval of a World Health Assembly resolution recognizing the role of surgical care and anaesthesia as part of universal health coverage. Momentum gained from these milestones highlights the need to identify consensus goals, targets and indicators to guide policy implementation and track progress at the national level. Through an open consultative process that incorporated input from stakeholders from around the globe, a global target calling for safe surgical and anaesthesia care for 80% of the world by 2030 was proposed. In order to achieve this target, we also propose 15 consensus indicators that build on existing surgical systems metrics and expand the ability to prioritize surgical systems strengthening around the world.