Don't interrupt me! development of a handoff education bundle to simulate the real world.

OBJECTIVES: Ineffective nurse-to-nurse handoff communication is associated with information omissions, diagnostic errors, treatment errors, and delays. New nurses report a lack of confidence and ability in handoff communication, which may stem from inadequate training in prelicensure nursing programs. Our objective was to introduce prelicensure nursing students to a standardized, theory-based method for handoff, including behavioral strategies employed by nurses during interrupted handoff. METHODS: A handoff education bundle (HEB) was developed. Kern's six-step curriculum model was utilized to design, implement, and evaluate the handoff curriculum. RESULTS: Student feedback highlighted the importance of integrating multiple, varying distractors during learning cycles and recognition of the impact of distractors on handoff. CONCLUSIONS: Implementing a HEB at the prelicensure nursing level could promote competency in handoff communication for new graduate nurses. IMPLICATIONS FOR INTERNATIONAL AUDIENCE: Handoff is an international patient safety priority, as inadequate communication has been linked to adverse patient events.

Bloom's Taxonomy: Framing Virtual Simulations During the COVID-19 Pandemic.

The COVID-19 pandemic required a significant pivot in nursing education, whereby in-person simulations moved to an online format. Kaplan's i-Human Patients was a virtual simulation platform utilized at a large Midwestern university for student nurses. This online virtual simulation platform helped evaluate students' clinical knowledge and understanding using the Bloom's taxonomy framework to scaffold cases. In addition, the five phases of professional development was incorporated to aid faculty instruction.

Nurse-to-nurse handoff with distractors and interruptions: An integrative review.

AIM: An integrative review of the literature was conducted to explore perceptions of distractors and interruptions during nurse-to-nurse handoff. BACKGROUND: Handoff distractors and interruptions are recognized as barriers to effective nurse handoff and may lead to preventable and costly medical errors. However, little is known about the perception of these barriers to nurses and strategies to mitigate distractors and interruptions during nurse-to-nurse handoff. METHODS: Using the framework of Whittemore and Knafl, four electronic databases were searched for articles written in English and published in the last five years. Inclusion criteria included: qualitative, quantitative, mixed-methods or quality improvement papers focused on distractors/interruptions during nurse handoff. A multi-author independent review of articles was completed with a rigorous process of data extraction and quality assessment. RESULTS: A total of 17 articles were reviewed with findings categorized into the following themes: perceptions of handoff, characteristics of handoff, or logistics of handoff. Nurses reported that interruptions and distractions were a limitation in handoff quality and handoff efficiency, occurring during inter-shift and unit-to-unit handoff. The two most common types of interruptions and distractions were people (patient, family) and environmental factors (equipment alarms). An organized and standardized approach to handoff was recommended, but few specific examples were reported. CONCLUSION: Despite recent research related to interruptions and distractions in nurse handoff, few evidence-based strategies have been identified that effectively mitigate these patient safety problems. More evidence is needed to determine best practice methods for handoff training for nurses and nursing students.

Identifying contributing factors influencing pediatric nurses' and health professionals' self-reported collaborative practice behaviors.

PURPOSE: In this study, we examined the influence of interprofessional American Heart Association (AHA) resuscitation courses on pediatric health care professionals' (N = 218) self- reported collaborative practice behaviors (CPBs) and examined differences in CPBs between nursing, medicine, and respiratory therapy. DESIGN AND METHODS: A mixed methods explanatory design was utilized with a sample of pediatric nurses, nurse practitioners, physicians, and respiratory therapists. Data were collected using the Interprofessional Collaborative Competency Attainment Survey (ICCAS) and two open-ended questions. Data analysis included: exploratory factor analysis, paired t-tests, mixed effects modeling and directed content analysis. Inferences were made across quantitative and qualitative data. RESULTS: Statistically significant improvement in mean CPB scores was demonstrated by all professions (t (208) = -12.76; ρ < 0.001) immediately after the AHA courses. Qualitative responses indicated physicians identified roles and responsibilities (94%, n = 17) as the most important CPB. Communication was identified by nurses (78%, n = 76), nurse practitioners (100%, n = 11) and respiratory therapists (71%, n = 5) as most important. CONCLUSIONS: Participation in an interprofessional AHA course significantly increased mean self-reported CPB scores. Changes in mean CPB scores were sustained over 6 weeks upon return to clinical practice. PRACTICE IMPLICATIONS: Future research focused on CPBs of front-line health care professionals can provide an accurate portrayal of an interprofessional team and can inform how collaborative practice is established in everyday clinical practice.

Development of a Multisite Nursing Simulation Work Group Focusing on the International Nursing Association for Clinical Simulation and Learning Standards.

BACKGROUND: Simulation faculty development refers to the education of faculty in preparation and facilitation of simulation-based experiences. A college of nursing with six campuses implemented a simulation work group to ensure consistent simulation faculty development across six campuses. METHOD: The simulation work group was formed in four stages and used the International Nursing Association for Clinical Simulation and Learning Standards as a framework for standardizing simulation. The work group consisted of 14 faculty from five nursing campuses. Members were recruited via email, telephone call, or a simulation newsletter. RESULTS: Challenges were identified and addressed. Work group implementation has provided the simulation program with new initiatives and a unified scheduling system, budget, standardized debriefing, and student evaluation method. CONCLUSION: With the greater dependence on simulation as an educational modality, implementation of a simulation work group may enable collaboration and growth across campuses while decreasing the disparity of simulation experiences. [J Nurs Educ. 2021;60(3):165-168.].

Redesigning the Patient Observer Model to Achieve Increased Efficiency and Staff Engagement on a Surgical Trauma Inpatient Unit.

BACKGROUND: Provision of safe and efficient observer care to inpatients whose behavior puts them at risk for injury is a clinically challenging and costly endeavor for hospitals. At Massachusetts General Hospital (MGH; Boston), process improvement strategies were deployed to provide staff with an improved clinical model for patient observation, unit-based responsibility for allocating resources, and strategies to maintain a safer environment. METHODS: In a surgical trauma unit at MGH, a team of nursing leaders and clinicians created an innovative process to identify, assess, and develop best practices for ensuring patient safety in the hospital environment. Patients with delirium were identified as the most prevalent and concerning patient group, and specific interventions were developed to address their unique needs. From December 2012 through June 2014, the team successfully piloted the best practices (July 16, 2013-September 30, 2013) and implemented them. RESULTS: The baseline outcome metric of patient observer direct-care hours decreased from a median of 208 hours/week (January 1, 2012-July 13, 2013) to a median of 112 hours/week (July 14, 2013-June 28, 2014); a 46% decrease in utilization. Fall rate (falls per 1,000 patient-days) remained unchanged postimplementation, and staff satisfaction with the patient observer model increased from 9% to 72%, while costs associated with providing observer care remained stable. CONCLUSIONS: Providing the inpatient unit staff with the knowledge and tools needed to optimally manage patients with at-risk behaviors, including delirium, significantly decreased the number of staff hours spent at the bedside providing observation, did not negatively affect the unit fall rate, and increased staff engagement at no additional expense to the unit.

Outcomes of a clinical nurse specialist-initiated wound care education program: using the promoting action on research implementation in health services framework.

Consistent with the sphere of clinical nurse specialist (CNS) practice related to advancing nursing practice and patient outcomes, a CNS task force of 20 of the 60 CNSs in our large teaching hospital was convened to plan, implement and evaluate a comprehensive wound care education program. The purpose of the program was to ensure the 24-7 hospital-wide availability of nurses with evidenced-based wound care knowledge and skills. The facilitative environment, in which the program was developed and operates, is analyzed using the Promoting Action on Research Implementation in Health Services framework. Outcomes of the CNS task force include (1) designation of unit-based CNS as the first line resources for wound care at the unit level, (2) education of almost 10% of the 3,800 nurses at Massachusetts General Hospital as staff nurse resources, and (3) a shift in the nature of CNS wound care consultations from prescription to validation of the staff nurse-initiated wound care plan.

Falls in the general hospital: association with delirium, advanced age, and specific surgical procedures.

BACKGROUND: Falls and delirium in general-hospital inpatients are related to increases in morbidity, mortality, and healthcare costs. Patients fall despite safeguards and programs to reduce falling. OBJECTIVE: The authors sought to determine the prevalence of diagnosed and undiagnosed delirium in patients who fell during their hospital stay. METHOD: The authors performed a retrospective electronic chart review of 252 patients who fell during their hospital stay. Falls were categorized by their severity (i.e., minor, moderate, and major). Demographic information, patient outcomes, and diagnostic criteria for delirium (per DSM-IV) were collected on the day of admission, the day of the fall, and the 2 days preceding the patient's fall. RESULTS: Falls in the general hospital were associated with delirium (both diagnosed and undiagnosed), advanced age, and specific surgical procedures. CONCLUSION: Improving the recognition of undiagnosed delirium may lead to sustainable and successful fall prevention programs. Detection of impairments in mental status can assist staff to create individualized patient care plans. Knowledge about which patients are at risk for injury from delirium and falls can lead to improvements in patient safety, functioning, and quality of life.

Tumor-specific urinary matrix metalloproteinase fingerprinting: identification of high molecular weight urinary matrix metalloproteinase species.

PURPOSE: We have previously reported that matrix metalloproteinases MMP-2, MMP-9, and the complex MMP-9/NGAL can be detected in urine of patients with a variety of cancers including prostate and bladder carcinoma. In addition, we also detected several unidentified urinary gelatinase activities with molecular weights >125 kDa. The objective of the current study was to identify these high molecular weight (HMW) species, determine their potential as predictors of disease status, and ask whether a tumor-specific pattern existed based on urinary MMP analysis. EXPERIMENTAL DESIGN: Chromatography, zymography, and mass spectrometry was used to identify HMW gelatinase species of approximately 140, 190, and >220 kDa in urine of cancer patients. To determine whether a tumor-specific pattern of appearance existed among the MMPs detected, we analyzed the urine of 189 patients with prostate or bladder cancer and controls. RESULTS: The approximately 140, >220 kDa, and approximately 190 HMW gelatinase species were identified as MMP-9/tissue inhibitor of metalloproteinase 1 complex, MMP-9 dimer, and ADAMTS-7, respectively. The frequency of detection of any MMP species was significantly higher in urine from prostate and bladder cancer groups than controls. MMP-9 dimer and MMP-9 were independent predictors for distinguishing between patients with prostate and bladder cancer (P < 0.001 for each) by multivariable analysis. CONCLUSIONS: This study is the first to identify a tumor-specific urinary MMP fingerprint that may noninvasively facilitate identification of cancer presence and type. This information may be of diagnostic and prognostic value in the detection and/or clinical monitoring of disease progression and therapeutic efficacy in patients with bladder or prostate cancer.

Establishment and biochemical characterization of primary cells of the upper aerodigestive tract.

The upper aerodigestive tract, composed of the oral cavity, the pharynx and the esophagus, is a complex system whose components function in both organ-specific ways as well in serving as a protective barrier against the enzymes which initiate digestion as well as against the mechanical functions which serve to ensure movement of food through the upper aerodigestive tract. Given these diverse functional requirements, the study of the anatomy and physiology of this region are uniquely complex and significantly understudied. The goal of the current study was to develop a simple and reproducible method for the isolation, growth, and maintenance of primary epithelial cells from the oral cavity, the pharynx and the esophagus. In addition, given the increased interest in diseases characterized by a loss of mucosal integrity in these areas which is often accompanied by a diminished wound healing capability, these cells were biochemically characterized with a focus on the components of the extracellular matrix remodeling axis including the activity and inhibition of the matrix metalloproteinases (MMPs).

The feasibility of digital pen and paper technology for vital sign data capture in acute care settings.

The transition from paper to electronic documentation systems in acute care settings is often gradual and characterized by a period in which paper and electronic processes coexist. Intermediate technologies are needed to "bridge" the gap between paper and electronic systems as a means to improve work flow efficiency through data acquisition at the point of care in structured formats to inform decision support and facilitate reuse. The purpose of this paper is to report on the findings of a study conducted on three acute care units at Brigham and Women's Hospital and Massachusetts General Hospital in Boston, MA to evaluate the feasibility of digital pen and paper technology as a means to capture vital sign data in the context of acute care workflows and to make data available in a flow sheet in the electronic medical record.

Increased expression of urinary matrix metalloproteinases parallels the extent and activity of vascular anomalies.

OBJECTIVE: Matrix metalloproteinases (MMPs) and the angiogenic proteins basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) have been implicated in mechanisms of human cancer and metastasis. Assays were conducted on the urine of patients with vascular anomalies (tumors and malformations), relatively common and occasionally life-threatening disorders for which few therapies exist. We sought to determine whether these angiogenesis modulators are present in the urine and whether their expression is associated with the extent and clinical course of the vascular lesion. METHODS: A total of 217 patients with vascular anomalies and 74 age-matched control subjects participated. Urinary MMP expression was determined by substrate gel electrophoresis. Urinary bFGF and VEGF levels were measured by enzyme-linked immunosorbent assay. Each patient was assigned to 1 of 2 categories (tumor or malformation) and 1 of 9 specific groups. Extent of the vascular lesion and activity were scored by a blinded clinician. RESULTS: Urinary high molecular weight (hMW) MMPs and bFGF were significantly increased in patients with vascular tumors (53%) and vascular malformations (41%), compared with control subjects (22%). These percentages increased as a function of extent of the lesion and disease activity. hMW MMPs were increased in 4 groups: infantile hemangioma, other vascular neoplasms, lymphatic malformation and capillary-lymphaticovenous malformations, and extensive and unremitting capillary malformation and arteriovenous malformation. No significant differences among the groups were detected for low molecular weight MMPs or VEGF. CONCLUSIONS: Expression patterns of hMW MMPs and bFGF in the urine of patients with tumors and malformations are consistent with their different clinical behavior. These data represent the first evidence that MMPs are elevated in the urine of children with vascular anomalies. These data also suggest that the increased expression of urinary MMPs parallels the extent and activity of vascular anomalies in children. In addition to tumors, vascular malformations are angiogenesis dependent, suggesting that progression of a vascular malformation might be suppressed by angiogenic inhibitors, which would target bFGF and MMPs.

Urinary matrix metalloproteinases and their endogenous inhibitors predict hepatic regeneration after murine partial hepatectomy.

BACKGROUND: Matrix metalloproteinases (MMPs) play a key role in extracellular matrix remodeling events associated with hepatic regeneration after partial hepatectomy. We therefore hypothesized that urinary MMPs and their endogenous tissue inhibitors of matrix metalloproteinases (TIMPs) might also provide important information regarding initiation and progression of liver regeneration. METHODS: Groups of 20 mice underwent sham operations, two-thirds hepatectomy, or treatment with the angiogenesis inhibitor, AGM-1470,O-chloroacetyl-carbamoyl-fumagillol (TNP-470), after two-thirds hepatectomy to prevent hepatic regeneration. Urine was collected preoperatively and for 24 days after surgery and tested for MMP-2, MMP-9, TIMP-1, and TIMP-2 using substrate gel electrophoresis (zymography) and Western blot analysis. RESULTS: During hepatic regeneration, MMP-9 was detected in the urine at significantly lower levels on postoperative day 8 when the liver returned to its preoperative mass. In contrast, urine from mice whose livers were inhibited from regenerating (TNP-treated groups) contained increased levels of the gelatinases MMP-2 and MMP-9. The MMP inhibitors, TIMP-1 and TIMP-2, were significantly reduced in the urine of mice with normally regenerating livers but were increased in the urine of mice treated with TNP-470 on day 8. CONCLUSIONS: We demonstrate that (1) urinary MMPs and their cognate inhibitors, the TIMPs, can be detected in the urine of mice undergoing partial hepatectomy, (2) the presence of these remodeling proteins in the urine may predict the progressive return of the partially resected liver to its preoperative mass, and (3) analysis of urinary MMPs and TIMPs may someday provide a noninvasive means of monitoring the status of patients undergoing hepatic resection and transplantation.

Malignant transformation of melanocytes to melanoma by constitutive activation of mitogen-activated protein kinase kinase (MAPKK) signaling.

Malignant melanoma is the cancer with the most rapid increase in incidence in the United States. Ultraviolet light and deficiency of the p16ink4a gene are known factors that predispose one to the development of malignant melanoma. The signal transduction pathways that underlie the progression of melanoma from their precursors, atypical nevi, are not well understood. We examined activation of the MAP kinase pathway in atypical nevi and melanoma cells and found that this pathway is activated in melanomas. To determine the functional significance of this activation, we introduced constitutively active MAP kinase kinase (MAPKK) into immortalized melanocytes. The introduction of this gene into melanocytes leads to tumorigenesis in nude mice, activation of the angiogenic switch, and increased production of the proangiogenic factor, vascular endothelial growth factor (VEGF), and matrix metalloproteinases (MMPs). Activation of MAP kinase signaling may be an important pathway involved in melanoma transformation. Inhibition of MAP kinase signaling may be useful in the prevention and treatment of melanoma.

Weight loss-induced calciphylaxis: potential role of matrix metalloproteinases.

Calciphylaxis is an uncommon and often devastating syndrome of calcification of small vessels, leading to tissue infarction. The mechanism of how calcium deposits on small vessels is unknown. Recently, metalloproteinase digestion of elastin has been shown to enhance deposition of calcium, suggesting a possible mechanism of calciphylaxis. We describe a case of a patient who developed calciphylaxis after rapid weight loss, but had normocalcemia and normal renal function. She was found to have high levels of matrix metalloproteinases, which may have chemically altered elastin, allowing deposition of calcium on small vessels. Inhibitors of matrix metalloproteinases may be useful in the prevention and treatment of calciphylaxis.

PPARgamma ligands inhibit primary tumor growth and metastasis by inhibiting angiogenesis.

Several drugs approved for a variety of indications have been shown to exhibit antiangiogenic effects. Our study focuses on the PPARgamma ligand rosiglitazone, a compound widely used in the treatment of type 2 diabetes. We demonstrate, for the first time to our knowledge, that PPARgamma is highly expressed in tumor endothelium and is activated by rosiglitazone in cultured endothelial cells. Furthermore, we show that rosiglitazone suppresses primary tumor growth and metastasis by both direct and indirect antiangiogenic effects. Rosiglitazone inhibits bovine capillary endothelial cell but not tumor cell proliferation at low doses in vitro and decreases VEGF production by tumor cells. In our in vivo studies, rosiglitazone suppresses angiogenesis in the chick chorioallantoic membrane, in the avascular cornea, and in a variety of primary tumors. These results suggest that PPARgamma ligands may be useful in treating angiogenic diseases such as cancer by inhibiting angiogenesis.

Reactive oxygen generated by Nox1 triggers the angiogenic switch.

The reactive oxygen-generating enzyme Nox1 transforms NIH 3T3 cells, rendering them highly tumorigenic and, as shown herein, also increases tumorigenicity of DU-145 prostate epithelial cells. Although Nox1 modestly stimulates cell division in both fibroblasts and epithelial cells, an increased mitogenic rate alone did not account fully for the marked tumorigenicity. Herein, we show that Nox1 is a potent trigger of the angiogenic switch, increasing the vascularity of tumors and inducing molecular markers of angiogenesis. Vascular endothelial growth factor (VEGF) mRNA becomes markedly up-regulated by Nox1 both in cultured cells and in tumors, and VEGF receptors (VEGFR1 and VEGFR2) are highly induced in vascular cells in Nox1-expressing tumors. Matrix metalloproteinase activity, another marker of the angiogenic switch, also is induced by Nox1. Nox1 induction of VEGF is eliminated by coexpression of catalase, indicating that hydrogen peroxide signals part of the switch to the angiogenic phenotype.