Effect of Vancomycin Loading Doses on the Attainment of Target Trough Concentrations in Hospitalized Children.

OBJECTIVE: Subtherapeutic vancomycin trough concentrations are common in children and may be associated with suboptimal therapeutic response. Our objective was to determine if vancomycin loading doses safely increase the frequency of target trough attainment in hospitalized children. METHODS: Patients (≥6 months and <18-years-old) who received a vancomycin loading dose between February 1, 2018, and January 30, 2019, were retrospectively enrolled. These patients were compared to a convenience cohort of patients hospitalized between January 1, 2015, and December 31, 2015, who received vancomycin without a loading dose. Target trough concentrations were defined as >15 mg/dL for invasive infections and >10 mg/dL for non-invasive infections. RESULTS: A total of 151 patients were enrolled, with 77 in the control arm and 74 in the loading dose arm. There was no significant difference in the frequency of comorbidities or need for intensive care unit admission between the two arms. Those receiving a vancomycin loading dose were older (mean age 9.1 vs 5.2 years, p < 0.0001). Patients given a loading dose achieved higher mean initial trough values (13.0 mg/dL vs 9.2 mg/dL, p < 0.0001), were more likely to have an initial trough at or above target (37.0% vs 10.4%, p = 0.0001), were more likely to reach target trough values at any point during therapy (52.1% vs 32.9%, p = 0.0081), and attained a target trough concentration more quickly (mean 41.1 hours vs 58.8 hours, p = 0.0118). There were no significant differences in the frequency of serum creatinine elevation or oliguria at the end of therapy. CONCLUSIONS: Vancomycin loading doses may improve the ability to safely obtain target trough values in hospitalized children.

Understanding the Impact of Bullying in a Unionized U.S. Public Sector Workforce.

Background: Workplace Bullying (WPB) can have a tremendous, negative impact on the victims and the organization as a whole. The purpose of this study was to examine individual and organizational impact associated with exposure to bullying in a large U.S. unionized public sector workforce. Methods: A cross-sectional Web-based survey was conducted among 16,492 U.S. state government workers. Survey domains included demographics, negative acts (NAs) and bullying, supportiveness of the organizational climate, and individual and organizational impacts of bullying. Multinomial logistic regression was used to assess the impact among respondents who reported exposure to bullying. Findings: A total of 72% participants responded to the survey (n = 11,874), with 43.7% (n = 5,181) reporting exposure to NAs and bullying. A total of 40% (n = 4,711) participants who experienced WPB reported individual impact(s) while 42% (n = 4,969) reported organization impact(s). Regular NA was associated with high individual impact (negatively impacted them personally; odds ratio [OR] = 5.03) when controlling for other covariates including: female gender (OR =1.89) and job tenure of 6 to 10 years (OR = 1.95); working in a supportive organizational climate and membership in a supportive bargaining unit were protective of high impact (OR = 0.04 and OR = 0.59, respectively). High organizational impact (transferring to another position) was associated with regular NA and bullying (OR = 16.26), female gender (OR = 1.55), providing health care and field service (OR = 1.68), and protective effect of organizational climate (OR = 0.39). We found a dose-response relationship between bullying and both individual and organizational-level impact. Conclusion/Application to Practice: Understanding the impacts of WPB should serve to motivate more workplaces and unions to implement effective interventions to ameliorate the problem by enhancing the organizational climate, as well as management and employee training on the nature of WPB and guidance on reporting.

Comparative psychometric review of the Negative Acts Questionnaire-Revised in a unionized U.S. public sector workforce.

BACKGROUND: Workplace violence is a global problem that includes actions collectively defined as bullying as perpetrated by a work colleague. PURPOSE: Two distinct studies were conducted to assess the feasibility of using an abridged 6-item scale within the 21- item Negative Acts Questionnaire-Revised (NAQ-R) designed to assess workplace bullying. METHODS: The pilot study was a psychometric review of the 21-item NAQ-R, and the main study was conducted to determine the reliability and the validity of using a 6-item version. Cronbach's alpha assessed the internal consistency of the two versions of the NAQ-R. Validity was assessed using logistic regression with theoretically related constructs with a pilot study (n = 420) using the 21-item scale, followed by the main study (n = 11,874) using the 6-item version. RESULTS: Both the pilot study (21-item)and the main study (6-item) versions of the NAQ-R demonstrated high internal consistency (Cronbach's alpha 0.93-0.86, respectively). Similar to the 21-item, the 6-item version had a significant impact on the intent to remain on the job, being personally affected, and supported the protective role of the organizational climate against exposure to negative acts. CONCLUSION: This study supports using the 6-item NAQ-R, which can reduce respondent burden and streamline data gathering and analysis.

A framework for translating workplace violence intervention research into evidence-based programs.

Workplace violence, a dangerous and complex occupational hazard in the modern health care work environment, presents challenges for nurses, other health care employees, management, labor unions, and regulators. Violence from patients, visitors, and coworkers is often tolerated and explained as part of the job in the fast-paced, stressful health care delivery workplace. Addressing violence in health care requires very purposeful organizational processes conducted by very specific organizational structures. The strength of the scientific evidence for workplace violence prevention strategies is well past the "emerging" evidence stage but has not achieved the "unequivocal" stage. It is unlikely that workplace violence interventions will be tested using randomized controlled experimental conditions. Consequently, educated and aware nurses often provide key leadership for organizations undertaking the development of workplace violence prevention programs, but must do so using local evidence generated at the facility level. In some cases, tools such as state regulations and federal workplace safety policies provide important impetus and support for nurses and hospitals undertaking these transformational programs. This article provides background information about workplace violence and offers a framework for developing comprehensive workplace violence prevention programs built on the existing scientific evidence, regulatory guidance, and locally generated practice evidence.

Impact of pharmacist discharge medication therapy counseling and disease state education: Pharmacist Assisting at Routine Medical Discharge (project PhARMD).

Many patients experience adverse events after discharge; numerous are medication related and preventable. The objective of this study is to evaluate the impact of pharmacist medication counseling and disease education at discharge. Pharmacist Assisting at Routine Medical Discharge is a prospective study of English- or Spanish-speaking adults discharged from internal medicine. Control patients received usual hospital discharge care; intervention patients received usual care with discharge counseling and a follow-up phone call. Evaluated outcomes included the following: 30-day hospital reutilization (combined readmissions/emergency department visits), pharmacist interventions, predictors for hospital utilization, patient satisfaction, and primary medication adherence. In all, 279 patients were enrolled: 139 in the control and 140 in the intervention group. Pharmacists made 198 interventions. The rate of hospital reutilization was 20.7% and similar between the intervention and control groups. Patients receiving the pharmacist intervention demonstrated improved primary medication adherence and increased patient satisfaction. Pharmacist-provided discharge counseling resulted in medication interventions, improved patient satisfaction, and increased medication adherence.

Environmental evaluation for workplace violence in healthcare and social services.

PROBLEM: Federal policy recommends environmental strategies as part of a comprehensive workplace violence program in healthcare and social services. The purpose of this project was to contribute specific, evidence-based guidance to the healthcare and social services employer communities regarding the use of environmental design to prevent violence. METHOD: A retrospective record review was conducted of environmental evaluations that were performed by an architect in two Participatory Action Research (PAR) projects for workplace violence prevention in 2000 and, in the second project in 2005. Ten facility environmental evaluation reports along with staff focus group reports from these facilities were analyzed to categorize environmental risk factors for Type II workplace violence. RESULTS: Findings were grouped according to their impact on access control, the ability to observe patients (natural surveillance), patient and worker safety (territoriality), and activity support. DISCUSSION: The environmental assessment findings reveal design and security issues that, if corrected, would improve safety and security of staff, patients, and visitors and reduce fear and unpredictability. IMPACT ON INDUSTRY: Healthcare and social assistance employers can improve the effectiveness of violence prevention efforts by including an environmental assessment with complementary hazard controls.

Characteristics of patients with work-related asthma seen in the New York State Occupational Health Clinics.

OBJECTIVE: The objective of this study was to characterize the work-related asthma population seen by the New York State Occupational Health Clinic Network (OHCN) to determine which industries, occupations, and causal agents are associated with work-related asthma in New York State (NYS). METHODS: The OHCN patient database was analyzed to identify those patients with a diagnosis of work-related asthma and medical charts were then abstracted for data on demographics, clinical history, disease severity, industry, occupation, and putative agent. RESULTS: The OHCN patients with work-related asthma were most commonly employed in the service and manufacturing industries. Common occupations included teachers, farm operators/managers, and construction trades. The most frequently reported putative agents associated with work-related asthma were dust, indoor air, mold, and solvents. CONCLUSIONS: Our findings suggest the potential importance of prevention of workplace exposure in reducing adult asthma in NYS.

A simple and inexpensive method for determining the effective ventilation rate in a negatively pressurized room using airborne particles as a tracer.

The ventilation rate within a negatively pressurized room is usually determined by measuring the exhaust air flow rate. This method does not account for air mixing factors and gives limited information on ventilation efficiency within the room. Effective ventilation rates have been determined using tracer gases such as sulfur hexafluoride (SF6). The objective of this study was to determine whether artificially generated airborne particles could be used as a tracer to directly measure ventilation efficiency. We monitored the decay of artificially generated particles within negatively pressurized rooms. Separate trials were conducted at air exhaust rates ranging from about 6 to 20 room air changes per hour. Particles were generated to a minimum of 20 times the ambient concentration using a simple ventilation smoke bottle and measured with handheld light-scattering airborne particle counters. Data were obtained for aerodynamic particle size ranges of: 0.5 micron (microM) and larger, and 1.0 microM and larger. The time rate of decay of particles was plotted after subtracting the background concentrations. Results were compared with simultaneously conducted tracer gas decay analyses (ASTM method E741-95) using SF6. Particle concentrations followed an exponential decay (R2 = 0.98-0.99+) and mirrored the decay curve of the tracer gas. The air change rates predicted by the particle count procedure differed from the tracer gas results by a mean of 4.0 percent (range 0%-12%). The particle count procedure was substantially simpler and less expensive than the SF6 tracer gas method. Additional studies are needed to further refine this procedure and to explore its range of applicability.