Evaluating a Workplace Violence Management Program and Nurses' Confidence in Coping With Patient Aggression.

OBJECTIVE: The purpose of this study was to evaluate nurse confidence in coping with patient aggression after implementing a workplace violence prevention program that includes management and postevent support. BACKGROUND: Patient aggression toward nurses is increasing, leading many healthcare organizations to develop workplace violence prevention programs. METHODS: This cross-sectional study was conducted at a large healthcare system in the Midwestern United States. Clinical nurses caring for adult patients across the care continuum ≥51% of the time were invited to participate. RESULTS: In situ simulation plus standard training did not have a significant impact on confidence after controlling for the year education occurred; however, nurses completing training in 2022 had significantly higher confidence than nurses completing training in 2019. Use of the Violence Assessment Tool and participating in a post-control alert debriefing were also associated with significantly higher confidence. CONCLUSION: Factors other than education may influence nurses' confidence in coping with patient aggression.

Description and Validation of a Novel Score (Flow Index) as a Clinical Indicator of the Level of Respiratory Support to Children on High Flow Nasal Cannula.

This study's objective was to describe and validate flow index (flow rate × FiO 2 /weight) as a method to report the degree of respiratory support by high flow nasal cannula (HFNC) in children. We conducted a retrospective chart review of children managed with HFNC from January 1, 2015 to December 31, 2019. Variables included in the flow index (weight, fraction of inspired oxygen [FiO 2 ], flow rate) and outcomes (hospital and intensive care unit [ICU] length of stay [LOS], escalation to the ICU) were extracted from medical records. Max flow index was defined by the earliest timestamp when patients FiO 2 × flow rate was maximum. Step-wise regression was used to determine the relationship between outcome (LOS and escalation to ICU) and flow index. Fifteen hundred thirty-seven patients met the study criteria. The median first and maximum flow indexes of the population were 24.1 and 38.1. Both first and maximum flow indexes showed a significant correlation with the LOS ( r = 0.25 and 0.31, p < 0.001). Correlation for the index was stronger than that of the variables used to calculate them and remained significant after controlling for age, race, sex, and diagnoses. Mild, moderate, and severe categories of first and max flow index were derived using quartiles, and they showed significant age and diagnosis independent association with LOS. Patients with first flow index >20 and maximum flow index >59.5 had increased odds ratio of escalation to ICU (odds ratio: 2.39 and 8.08). The first flow index had a negative association with rapid response activation. Flow index is a valid measure for assessing the degree of respiratory support for children on HFNC.

Association of Early Steroid Administration With Outcomes of Children Hospitalized for COVID-19 Without Multisystem Inflammatory Syndrome in Children.

Importance: There is limited evidence for therapeutic options for pediatric COVID-19 outside of multisystem inflammatory syndrome in children (MIS-C). Objective: To determine whether the use of steroids within 2 days of admission for non-MIS-C COVID-19 in children is associated with hospital length of stay (LOS). The secondary objective was to determine their association with intensive care unit (ICU) LOS, inflammation, and fever defervescence. Design, Setting, and Participants: This cohort study analyzed data retrospectively for children (<18 years) who required hospitalization for non-MIS-C COVID-19. Data from March 2020 through September 2021 were provided by 58 hospitals in 7 countries who participate in the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 registry. Exposure: Administration of steroids within 2 days of admission. Main Outcomes and Measures: Length of stay in the hospital and ICU. Adjustment for confounders was done by mixed linear regression and propensity score matching. Results: A total of 1163 patients met inclusion criteria and had a median (IQR) age of 7 years (0.9-14.3). Almost half of all patients (601/1163, 51.7%) were male, 33.8% (392/1163) were non-Hispanic White, and 27.9% (324/1163) were Hispanic. Of the study population, 184 patients (15.8%) received steroids within 2 days of admission, and 979 (84.2%) did not receive steroids within the first 2 days. Among 1163 patients, 658 (56.5%) required respiratory support during hospitalization. Overall, patients in the steroids group were older and had greater severity of illness, and a larger proportion required respiratory and vasoactive support. On multivariable linear regression, after controlling for treatment with remdesivir within 2 days, country, race and ethnicity, obesity and comorbidity, number of abnormal inflammatory mediators, age, bacterial or viral coinfection, and disease severity according to ICU admission within first 2 days or World Health Organization ordinal scale of 4 or higher on admission, with a random intercept for the site, early steroid treatment was not significantly associated with hospital LOS (exponentiated coefficient, 0.94; 95% CI, 0.81-1.09; P = .42). Separate analyses for patients with an LOS of 2 days or longer (n = 729), those receiving respiratory support at admission (n = 286), and propensity score-matched patients also showed no significant association between steroids and LOS. Early steroid treatment was not associated with ICU LOS, fever defervescence by day 3, or normalization of inflammatory mediators. Conclusions and Relevance: Steroid treatment within 2 days of hospital admission in a heterogeneous cohort of pediatric patients hospitalized for COVID-19 without MIS-C did not have a statistically significant association with hospital LOS.

Early combination therapy with immunoglobulin and steroids is associated with shorter ICU length of stay in Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19: A retrospective cohort analysis from 28 U.S. Hospitals.

OBJECTIVES: Suggested therapeutic options for Multisystem Inflammatory Syndrome in Children (MIS-C) include intravenous immunoglobulins (IVIG) and steroids. Prior studies have shown the benefit of combination therapy with both agents on fever control or the resolution of organ dysfunction. The primary objective of this study was to analyze the impact of IVIG and steroids on hospital and ICU length of stay (LOS) in patients with MIS-C associated with Coronavirus Disease 2019 (COVID-19). STUDY DESIGN: This was a retrospective study on 356 hospitalized patients with MIS-C from March 2020 to September 2021 (28 sites in the United States) in the Society of Critical Care Medicine (SCCM) Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 Registry. The effect of IVIG and steroids initiated in the first 2 days of admission, alone or in combination, on LOS was analyzed. Adjustment for confounders was made by multivariable mixed regression with a random intercept for the site. RESULTS: The median age of the study population was 8.8 (Interquartile range (IQR) 4.0, 13) years. 247/356 (69%) patients required intensive care unit (ICU) admission during hospitalization. Overall hospital mortality was 2% (7/356). Of the total patients, 153 (43%) received IVIG and steroids, 33 (9%) received IVIG only, 43 (12%) received steroids only, and 127 (36%) received neither within 2 days of admission. After adjustment of confounders, only combination therapy showed a significant decrease of ICU LOS by 1.6 days compared to no therapy (exponentiated coefficient 0.71 [95% confidence interval 0.51, 0.97, p = 0.03]). No significant difference was observed in hospital LOS or the secondary outcome variable of the normalization of inflammatory mediators by Day 3. CONCLUSIONS: Combination therapy with IVIG and steroids initiated in the first 2 days of admission favorably impacts ICU but not the overall hospital LOS in children with MIS-C.

Risk Factors for Critical Coronavirus Disease 2019 and Mortality in Hospitalized Young Adults: An Analysis of the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) Coronavirus Disease 2019 Registry.

IMPORTANCE: Even with its proclivity for older age, coronavirus disease 2019 has been shown to affect all age groups. However, there remains a lack of research focused primarily on the young adult population. OBJECTIVES: To describe the epidemiology and outcomes of coronavirus disease 2019 and identify the risk factors associated with critical illness and mortality in hospitalized young adults. DESIGN SETTINGS AND PARTICIPANTS: A retrospective cohort study of the Society of Critical Care Medicine's Viral Infection and Respiratory Illness Universal Study registry. Patients 18-40 years old, hospitalized from coronavirus disease 2019 from March 2020 to April 2021, were included in the analysis. MAIN OUTCOMES AND MEASURES: Critical illness was defined as a composite of mortality and 21 predefined interventions and complications. Multivariable logistic regression was used to assess associations with critical illness and mortality. RESULTS: Data from 4,005 patients (152 centers, 19 countries, 18.6% non-U.S. patients) were analyzed. The median age was 32 years (interquartile range, 27-37 yr); 51% were female, 29.4% Hispanic, and 42.9% had obesity. Most patients (63.2%) had comorbidities, the most common being hypertension (14.5%) and diabetes (13.7%). Hospital and ICU mortality were 3.2% (129/4,005) and 8.3% (109/1,313), respectively. Critical illness occurred in 25% (n = 996), and 34.3% (n = 1,376) were admitted to the ICU. Older age (p = 0.03), male sex (adjusted odds ratio, 1.83 [95% CI, 1.2-2.6]), and obesity (adjusted odds ratio, 1.6 [95% CI, 1.1-2.4]) were associated with hospital mortality. In addition to the above factors, the presence of any comorbidity was associated with critical illness from coronavirus disease 2019. Multiple sensitivity analyses, including analysis with U.S. patients only and patients admitted to high-volume sites, showed similar risk factors. CONCLUSIONS: Among hospitalized young adults, obese males with comorbidities are at higher risk of developing critical illness or dying from coronavirus disease 2019.

A novel in situ simulation framework for introduction of a new technology: the 3-Act-3-Debrief model.

BACKGROUND: New technologies for clinical staff are typically introduced via an "in-service" that focuses on knowledge and technical skill. Successful adoption of new healthcare technologies is influenced by multiple other factors as described by the Consolidated Framework in Implementation Research (CFIR). A simulation-based introduction to new technologies provides opportunity to intentionally address specific factors that influence adoption. METHODS: The new technology proposed for adoption was a telehealth cart that provided direct video communication with electronic intensive care unit (eICU) staff for a rural Emergency Department (ED). A novel 3-Act-3-Debrief in situ simulation structure was created to target predictive constructs from the CFIR and connect debriefing to specific workflows. The structure and content of the simulation in relation to the framework is described. Participants completed surveys pre-simulation/post-simulation to measure change in their readiness to adopt the new technology. RESULTS: The scenario was designed and pilot tested before implementation at two rural EDs. There were 60 interprofessional participants across the 2 sites, with 58 pre-simulation and 59 post-simulation surveys completed. The post-simulation mean ratings for each readiness measure (feasibility, quality, resource availability, role clarity, staff receptiveness, and tech usability) increased significantly as a result of the simulation experience. CONCLUSIONS: A novel 3-stage simulation-debriefing structure positively targets factors influencing the adoption of new healthcare technologies.

Intramuscular Liposomal Bupivacaine Decreases Length of Stay and Opioid Usage Following Lumbar Spinal Fusion.

STUDY DESIGN: A retrospective cohort review. OBJECTIVES: The objective of this study was to investigate the efficacy of liposomal bupivacaine (LB) in patients undergoing lumbar spinal fusion. SUMMARY OF BACKGROUND DATA: Historically, posterior spinal fusion has been recognized as a particularly painful surgery. Postoperative pain limits early patient mobilization and discharge, and negatively impacts patient satisfaction. Local infiltration of anesthetic agents combined with postoperative multimodal pain management is common. On the basis of existing data, the liposomal formulation of bupivacaine might play a role in promoting faster recovery during the immediate postoperative period. The purpose of this study was to investigate the potential impact of LB on postoperative opioid requirements, ambulation, and duration of hospital stay, as well as potential health care cost savings. MATERIALS AND METHODS: A historical cohort of adult lumbar spinal fusion patients was retrospectively evaluated, in which 105 patients received nonliposomal anesthetic and 105 received LB. Both groups were managed with a standardized postoperative analgesia regimen. Demographic information, opioid consumption, length of stay, distance ambulated, and total cost of inpatient stay were collected. RESULTS: Although there was no difference in the pain scores between the 2 groups, the LB group was associated with significantly lower opioid usage throughout the postoperative period. More patients in the LB group were discharged within 2 days of surgery compared with the control group (88.6% vs. 38.1%, P<0.05). The control group was able to walk for a longer median distances (175 vs. 150 ft, P=0.02) on the first attempt, however, a significantly larger proportion of the LB group walked within the first 12 hours after surgery (61% vs. 3%, P<0.001). Also, LB usage was associated with $218 higher pharmacological cost compared with the control group but an overall $3035 lower cost for the entire hospitalization (P<0.001). CONCLUSION: Adjunctive usage of LB with lumbar fusion surgeries promotes earlier mobility, lower opioid consumption, and shorter length of stay resulting in overall lower health care cost. LEVEL OF EVIDENCE: Level III.

Impact of an Electronic App on Resident Responses to Simulated In-Flight Medical Emergencies: Randomized Controlled Trial.

BACKGROUND: Health care providers are often called to respond to in-flight medical emergencies, but lack familiarity with expected supplies, interventions, and ground medical control support. OBJECTIVE: The objective of this study was to determine whether a mobile phone app (airRx) improves responses to simulated in-flight medical emergencies. METHODS: This was a randomized study of volunteer, nonemergency resident physician participants who managed simulated in-flight medical emergencies with or without the app. Simulations took place in a mock-up cabin in the simulation center. Standardized participants played the patient, family member, and flight attendant roles. Live, nonblinded rating was used with occasional video review for data clarification. Participants participated in two simulated in-flight medical emergencies (shortness of breath and syncope) and were evaluated with checklists and global rating scales (GRS). Checklist item success rates, key critical action times, GRS, and pre-post simulation confidence in managing in-flight medical emergencies were compared. RESULTS: There were 29 participants in each arm (app vs control; N=58) of the study. Mean percentages of completed checklist items for the app versus control groups were mean 56.1 (SD 10.3) versus mean 49.4 (SD 7.4) for shortness of breath (P=.001) and mean 58 (SD 8.1) versus mean 49.8 (SD 7.0) for syncope (P<.001). The GRS improved with the app for the syncope case (mean 3.14, SD 0.89 versus control mean 2.6, SD 0.97; P=.003), but not the shortness of breath case (mean 2.90, SD 0.97 versus control mean 2.81, SD 0.80; P=.43). For timed checklist items, the app group contacted ground support faster for both cases, but the control group was faster to complete vitals and basic exam. Both groups indicated higher confidence in their postsimulation surveys, but the app group demonstrated a greater increase in this measure. CONCLUSIONS: Use of the airRx app prompted some actions, but delayed others. Simulated performance and feedback suggest the app is a useful adjunct for managing in-flight medical emergencies.

Virtual Standardized Patient Simulation: Case Development and Pilot Application to High-Value Care.

INTRODUCTION: High-value care (HVC) suggests that good history taking and physical examination should lead to risk stratification that drives the use or withholding of diagnostic testing. This study describes the development of a series of virtual standardized patient (VSP) cases and provides preliminary evidence that supports their ability to provide experiential learning in HVC. METHODS: This pilot study used VSPs, or natural language processing-based patient avatars, within the USC Standard Patient platform. Faculty consensus was used to develop the cases, including the optimal diagnostic testing strategies, treatment options, and scored content areas. First-year resident physician learners experienced two 90-minute didactic sessions before completing the cases in a computer laboratory, using typed text to interview the avatar for history taking, then completing physical examination, differential diagnosis, diagnostic testing, and treatment modules for each case. Learners chose a primary and 2 alternative "possible" diagnoses from a list of 6 to 7 choices, diagnostic testing options from an extensive list, and treatments from a brief list ranging from 6 to 9 choices. For the history-taking module, both faculty and the platform scored the learners, and faculty assessed the appropriateness of avatar responses. Four randomly selected learner-avatar interview transcripts for each case were double rated by faculty for interrater reliability calculations. Intraclass correlations were calculated for interrater reliability, and Spearman ρ was used to determine the correlation between the platform and faculty ranking of learners' history-taking scores. RESULTS: Eight VSP cases were experienced by 14 learners. Investigators reviewed 112 transcripts (4646 learner query-avatar responses). Interrater reliability means were 0.87 for learner query scoring and 0.83 for avatar response. Mean learner success for history taking was scored by the faculty at 57% and by the platform at 51% (ρ correlation of learner rankings = 0.80, P = 0.02). The mean avatar appropriate response rate was 85.6% for all cases. Learners chose the correct diagnosis within their 3 choices 82% of the time, ordered a median (interquartile range) of 2 (2) unnecessary tests and completed 56% of optimal treatments. CONCLUSIONS: Our avatar appropriate response rate was similar to past work using similar platforms. The simulations give detailed insights into the thoroughness of learner history taking and testing choices and with further refinement should support learning in HVC.

Strategically Applying New Criteria for Use Improves Management of Peripheral Intravenous Catheters.

Peripheral intravenous catheters (PIVCs) are common devices used across many healthcare settings. This quality improvement project aims to proactively remove PIVCs as soon as possible by empowering nurses and providers to clinically evaluate the necessity of every PIVC on a daily basis on a general hospital medical unit. Specific criteria were established to assess PIVC necessity. Cases of PIVCs not meeting established criteria are escalated to providers for a decision point. The PIVC removal times documented within the electronic medical record were analyzed to compare precriteria PIVC dwell times to postcriteria dwell times. The time between removal of a patient's last PIVC and patient discharge was analyzed to determine if more PIVCs are being removed sooner after becoming clinically unnecessary. Significantly fewer PIVCs (decrease of 14.4%) are being removed on the day of discharge in the postintervention time frame, whereas more PIVCs are being removed one (increase of 5.5%) or two (increase of 4.0%) days before the day of discharge. A strategic project to critically evaluate PIVCs on a daily basis and remove PIVCs not meeting criteria for use was successful in proactively removing PIVCs. Hospitals should evaluate PIVC practice, monitor daily usage, and strategically intervene to remove unneeded PIVCs.

Quality of Life and Compassion Satisfaction in Clinicians: A Pilot Intervention Study for Reducing Compassion Fatigue.

BACKGROUND: Compassion fatigue (CF) is prevalent in healthcare professionals, particularly in those caring for chronic, acutely ill, and/or those patients who might be moving toward comfort care. Over time, CF can lead to burnout (BO) and secondary traumatic stress and an overall decrease in professional quality of life. In this pilot study, participants completed a resiliency program focused on education about CF and self-awareness of its individualized impact and were expected to develop ongoing self-care practices to prevent/address the untoward effects. METHODS: Healthcare professionals ( N = 15) participated in a formalized educational program consisting of three 90-minute educational sessions held 2 weeks apart. Preassessment and postintervention data were collected electronically in survey format. A postprogram evaluation was also offered. RESULTS: Upon completion of the program, participants noted an increase in compassion satisfaction (CS) and a small reduction in BO. Secondary traumatic stress remained unchanged. Feedback about the program was positive, and participants reported the impact on their clinical practice and life to be moderately high. At 6 months, over half of the participants continued to report positive impact on their personal/professional lives. CONCLUSION: While the small sample size of this pilot study limits the generalizability of the findings, there were positive effects for CS and BO in participants over time, indicating possible benefits of providing self-care education to healthcare providers. Additional research with a larger sample size is needed to address how healthcare providers might further benefit from resiliency education and interventions to improve professional quality of life.

Deliberate Practice with Standardized Patient Actors and the Development of Formative Feedback for Advance Care Planning Facilitators.

OBJECTIVE: Multimodal curricular assessment after adding standardized patient (SP) actor-based simulation to an advance care planning (ACP) facilitator training course and development of a formative feedback tool. BACKGROUND: ACP represents a highly valued service requiring more and better trained facilitators. METHODS: Participants were primarily nurses and social workers in a large multisite health system. The course included a precourse video demonstration of ACP, traditional lectures, and four 30-minute simulations with SPs. Knowledge was tested with a multiple choice question (MCQ) test. In addition to standard postcourse/postsimulation evaluations, learners were surveyed pre/post/30-90 days delayed for self-perceived confidence. A linear mixed-effects model was used to analyze changes over time. Trained faculty rated performance in simulations with an observational mini-clinical examination (mini-CEX)-type rating form with a checklist, global competency, and global communication rating. Inter-rater reliability (IRR) was calculated on randomly selected paired ratings. RESULTS: Sixty-seven individuals consented to participate. MCQ scores improved from 83% ± 10% to 92% ± 8% (p < 0.001). Paired learner surveys of self-confidence across six domains were available for 65 pre, 65 post, and 40 delayed with a mean positive change on a 0 to 10 point scale from pre-post (2.32 ± 1.65; p < 0.001) and predelayed (2.34 ± 1.96; p < 0.001) time frames. For the faculty observation ratings of simulation performance, the average raw agreement for critical actions was 82% and IRR was 0.71. CONCLUSIONS: Learner feedback and self-assessment suggest that actor-based simulation contributed to improved confidence in conducting ACP. The mini-CEX observation form is adequate for formative feedback, with further testing needed to make judgments of competence.