Organizational learning in hospitals: A realist review.

AIM: To establish a middle-range theory of organizational learning in hospitals. DESIGN: A realist review of the literature, conducted according to established standards for realist and meta-narrative evidence syntheses. Middle-range theory development was performed according to Smith and Liehr's recommendations. DATA SOURCES: Two comprehensive scientific databases and six discipline-focused databases spanning health care, life sciences, business, sociology, and psychology were searched from inception to 12 May 2016. REVIEW METHODS: Citations meeting the inclusion criteria were appraised using the Mixed Methods Appraisal Tool. Data extraction was guided by a focus on the contextual factors, mechanisms, and outcomes associated with organizational learning. RESULTS: The initial search yielded 2,332 citations, 147 of which were ultimately included in the review. The included citations were generally of high quality. Reviewed evidence indicates certain aspects of organizational context can be conducive to mechanisms of organizational learning, leading to a range of positive organizational outcomes. CONCLUSION: This review updates and expands on a previous review of the literature on organizational learning in hospitals, refines the concept of organizational learning in hospitals, and provides a middle-range theory of organizational learning in hospitals. IMPACT: This updated review provides a strong evidence base for future work on the topic of organizational learning in hospitals. The refined concept of organizational learning makes it possible to develop reliable, valid research instruments that better reflect of the full scope of organizational learning. Finally, the middle-range theory guides researchers and clinical leaders as they advance the science and practice of organizational learning.

Organizational Learning in a Cardiac Intensive Care Unit: A Learning History.

INTRODUCTION: Providing high-quality care to every patient is challenging, particularly in critical care units (CCUs). However, this standard can be achieved through organizational learning. Unfortunately, the process of organizational learning in CCUs is not well understood. OBJECTIVE: The objective of this study is to describe the developmental progression of a cardiac intensive care unit (CICU) to reach its current state of reliably excellent clinical performance. METHODS: The method selected for this study was a learning history. A total of 43 individuals with experience working on the CICU participated in small group interviews. Participants included nurses, surgeons, unit clerks, administrators, nursing assistants, a pharmacist, a respiratory therapist, and an administrative assistant. Relevant artifacts, including unit performance data, were also gathered to complement interview data. RESULTS: The CICU progressed through 4 distinct developmental stages to reach its current state. The CICU's early development involved establishing psychological safety on the unit, which prepared the unit for increased accountability, improved performance, and the pursuit of reliability. DISCUSSION/CONCLUSION: The findings validate the relationship between psychological safety and organizational learning, offer insight into how CCUs become high-reliability organizations, and provide clinical leaders with guidance for achieving high reliability in their organizations. The findings also help validate the American Association of Critical-Care Nurses position that a healthy work environment is essential to achieving clinical excellence. Critical care unit teams should use these findings as a framework for collective reflection and planning to achieve their desired future. Further research is needed to validate the applicability of these findings and to continue building the evidence base for organizational learning in hospital units.

Noninvasive hemoglobin measurement in pediatric trauma patients.

INTRODUCTION: Hemorrhage is a major cause of preventable death secondary to traumatic injury. Diagnosis often requires multiple blood draws, which are psychologically stressful in pediatric patients. The Pronto device is a pulse co-oximeter that measures the total hemoglobin level using multiple wavelengths of light. The purpose of this study was to evaluate the accuracy of the noninvasive hemoglobin measurements relative to current invasive and point of care testing methods in pediatric trauma patients. METHODS: We performed a prospective observational trial involving patients younger than 17 years presenting to a Level I pediatric trauma center. Following admission, blood was sampled from each patient for testing using an i-Stat device (point-of-care hemoglobin) and a complete blood count within our core laboratory (invasive hemoglobin). Noninvasive hemoglobin analysis was performed within 15 minutes of phlebotomy. Data were evaluated using Spearman correlation and Bland-Altman analysis. RESULTS: Over 2 years, 114 patients had attempted noninvasive hemoglobin measurements, with a success rate of 89%. Mean ± SD age was 9.2 ± 5.1 years. Ninety percent of admissions were for blunt injury, 3% penetrating, 5% near drowning, and 1% burns. Mean invasive hemoglobin was 12.6 ± 1.9 g/dL, mean point-of-care hemoglobin was 12.2 ± 2.0 g/dL, and mean noninvasive hemoglobin was 12.3 ± 1.6 g/dL. Noninvasive hemoglobin values were strongly correlated with both invasive and point of care measurements (R = 0.672 and R = 0.645, respectively; p < 0.001). Bland-Altman analysis comparing noninvasive to point-of-care and invasive hemoglobin levels resulted in an estimated bias of -0.39 and -0.49, respectively. CONCLUSION: Noninvasive hemoglobin values had excellent correlation with both invasive and point-of-care hemoglobin measurements, although the device was not successful for all patients. Given the rapid availability of results and the lack of requirement of venipuncture, noninvasive hemoglobin monitoring may be a valuable adjunct in the initial evaluation and monitoring of pediatric trauma patients. LEVEL OF EVIDENCE: Diagnostic test study, level II.

7% Hypertonic saline in acute bronchiolitis: a randomized controlled trial.

BACKGROUND: Research suggests that hypertonic saline (HS) may improve mucous flow in infants with acute bronchiolitis. Data suggest a trend favoring reduced length of hospital stay and improved pulmonary scores with increasing concentration of nebulized solution to 3% and 5% saline as compared with 0.9% saline mixed with epinephrine. To our knowledge, 7% HS has not been previously investigated. METHODS: We conducted a prospective, double-blind, randomized controlled trial in 101 infants presenting with moderate to severe acute bronchiolitis. Subjects received either 7% saline or 0.9% saline, both with epinephrine. Our primary outcome was a change in bronchiolitis severity score (BSS), obtained before and after treatment, and at the time of disposition from the emergency department (ED). Secondary outcomes measured were hospitalization rate, proportion of admitted patients discharged at 23 hours, and ED and inpatient length of stay. RESULTS: At baseline, study groups were similar in demographic and clinical characteristics. The decrease in mean BSS was not statistically significant between groups (2.6 vs 2.4 for HS and control groups, respectively). The difference between the groups in proportion of admitted patients (42% in HS versus 49% in normal saline), ED or inpatient length of stay, and proportion of admitted patients discharged at 23 hours was not statistically significant. CONCLUSIONS: In moderate to severe acute bronchiolitis, inhalation of 7% HS with epinephrine does not appear to confer any clinically significant decrease in BSS when compared with 0.9% saline with epinephrine.

Interaction of myeloperoxidase with vascular NAD(P)H oxidase-derived reactive oxygen species in vasculature: implications for vascular diseases.

Vascular NAD(P)H oxidase-derived reactive oxygen species (ROS) such as hydrogen peroxide (H2O2) have emerged as important molecules in the pathogenesis of atherosclerosis, hypertension, and diabetic vascular complications. Additionally, myeloperoxidase (MPO), a transcytosable heme protein that is derived from leukocytes, is also believed to play important roles in the above-mentioned inflammatory vascular diseases. Previous studies have shown that MPO-induced vascular injury responses are H2O2 dependent. It is well known that MPO can use leukocyte-derived H2O2; however, it is unknown whether the vascular-bound MPO can use vascular nonleukocyte oxidase-derived H2O2 to induce vascular injury. In the present study, ANG II was used to stimulate vascular NAD(P)H oxidases and increase their H2O2 production in the vascular wall, and vascular dysfunction was used as the vascular injury parameter. We demonstrated that vascular-bound MPO has sustained activity in the vasculature. MPO could use the vascular NAD(P)H oxidase-derived H2O2 to produce hypochlorus acid (HOCl) and its chlorinating species. More importantly, MPO derived HOCl and chlorinating species amplified the H2O2-induced vascular injury by additional impairment of endothelium-dependent relaxation. HOCl-modified low-density lipoprotein protein (LDL), a specific biomarker for the MPO-HOCl-chlorinating species pathway, was expressed in LDL and MPO-bound vessels with vascular NAD(P)H oxidase-derived H2O2. MPO-vascular NAD(P)H oxidase-HOCl-chlorinating species may represent a common pathogenic pathway in vascular diseases and a new mechanism involved in exacerbation of vascular diseases under inflammatory conditions.

Chinese hamster ovary cell motility to fibronectin is modulated by the second extracellular loop of CD9. Identification of a putative fibronectin binding site.

CD9, a member of the tetraspanin family of proteins, is characterized by four transmembrane domains and two extracellular loops. Surface expression of CD9 on Chinese hamster ovary (CHO) cells dramatically enhances spreading and motility on fibronectin. To elucidate the mechanistic basis of CD9-fibronectin interaction, binding to fibronectin was investigated using purified and recombinant forms of CD9. The affinity of fibronectin for CD9 in enzyme-linked immunosorbent assay was 81 +/- 25 nm. The binding of fibronectin to immobilized CD9 was enhanced by Ca(2+) ions. Protein binding and peptide competition studies demonstrated that peptide 6 derived from CD9 extracellular loop 2 (amino acids 168-192) contained part of the fibronectin-binding domain. Additionally, enhanced adhesion of CD9-CHO-B2 cells to fibronectin was significantly reduced by peptide 6. CD9-CHO cells had a 5-fold increase in motility to fibronectin as compared with mock-transfected controls, an effect that correlated with CD9 cell surface density. Truncation of CD9 extracellular loop 2 and peptide 6 caused inhibition of CD9-CHO cell motility to fibronectin. Deletion of CD9 extracellular loop 1 had no significant effect on CHO cell motility. These findings demonstrate a critical role for CD9 extracellular loop 2 in cell motility to fibronectin and clarify the mechanism by which CD9-fibronectin interaction modulates cell adhesion and motility.