Prediction of parturition in Holstein dairy cattle using electronic data loggers.

The objective of the present study was to assess the effect of parturition on behavioral activity [steps, standing time, lying time, lying bouts (LB), and duration of LB] 4 d before calving using electronic data loggers. Animals (n=132) from 3 herds were housed in similar freestall barns using a prepartum pen 21 d before the expected calving date and were moved into a contiguous individual maternity pen for parturition. Electronic data loggers were placed on a hind leg of prepartum heifers (heifers, n=33) and cows (cows, n=99) at 7±3 d before the expected calving date and removed at 14±3 d in milk. Calving ease (scale 1-4), parity, calving date and time, and stillbirth (born dead or died within 24h) were recorded. The number of steps (no./d), standing time (min/d), lying time (min/d), number of LB (no./d), and duration of LB (min/b) were recorded. Data were analyzed using MIXED procedures of SAS, adjusting for the herd effect. Only cows experiencing unassisted births (calving ease=1) were included in the study. An activity index was developed to predict calving time. Heifers and cows with unassisted births had significantly higher number of steps and longer standing time, decreased lying time, and more LB of shorter duration 24h before calving compared with d -4, -3, and -2. Additionally, the number of LB increased as both heifers and cows approached labor starting on d -2 and peaked at the day of calving. The time since the activity index increased over 50% to parturition did not differ between heifers and cows, and the activity index revealed the shift in activity on average 6h 14min (range from 2h to 14h 15min) before calf birth. This study provided evidence that heifers and cows approaching parturition showed a similar, but distinct, behavioral pattern that can be observed on average 6h before calf birth. The potential benefits of electronic data loggers as predictors of parturition along with proactive management practices should improve the overall survival and welfare of both the dam and calf.

Effect of intrauterine administration of gonadotropin releasing hormone with glycerol on serum LH concentrations in lactating dairy cows.

The objectives of the study were to assess: (1) preovulatory serum LH concentrations and (2) synchrony of ovulation after im or iu administration of GnRH with or without the addition of glycerol. Cows were presynchronized with 2 injections of PGF2α given 14d apart (starting at 26±3DIM) followed by Ovsynch (OV; GnRH-7d-PGF2α-48h-GnRH) 12d later. At the time of the second GnRH of OV (GnRH2), cows were blocked by parity and randomly allocated to 1 of 4 treatments: (1) control (CON; n=8) received 2mL of sterile water im; (2) im (IM; n=8) received 100µg of GnRH im; (3) cows were infused with 200µg GnRH into the uterus (IU; n=9); and (4) iu administration of 200µg GnRH plus glycerol 7% v/v (IUG; n=8). Serum circulating progesterone concentrations at hour 0 did not differ (P>0.05) among groups. Concentrations of LH were greater (P<0.05) in IM than IU, IUG, and CON cows at hours 1, 1.5, 2, and 3. All cows ovulated within 48h in the IM (8/8) group followed by IU (6/9) and IUG (4/8) groups, and only two out of eight cows ovulated in the CON group. Although iu administration of GnRH in the IU and IUG groups resulted in lower serum concentrations of LH than IM cows, IU or IUG cows were able to ovulate within 48h after GnRH2 administration.

Pain management in the culture of critical care.

Pain of critically ill patients is undertreated. Undertreatment of pain may be related, in part, to the culture of critical care practice, where nurses are challenged to meet competing patient demands. Implementation of appropriate pain management strategies is within the critical care nurse's scope of practice and must be a priority when delivering patient care. Although the multidisciplinary team can make the best holistic pain management plan, nurses have extensive independence and latitude in administration of pharmacologic and nonpharmacologic interventions. It is, in fact, "primarily the nurses' responsibility to administer the proper drug and dose at the proper time". Fostering a culture within critical care units that promotes optimal pain management is influenced by unit leadership, the values held by the staff, nurse competency, and an effective quality program that includes process and outcome indicators of pain management.

Nonpharmacologic treatment of pain.

Nonpharmacologic interventions for pain treatment are important complementary therapies but are not substitutes for pharmacologic management of pain. Use of nonpharmacologic pain treatments in critical care settings is helpful to decrease pain, but the challenge remains for nurses to have the knowledge, time, and skill to use these interventions in a busy daily practice with severely ill patients. Although numerous studies testing the effectiveness of nonpharmacologic interventions for pain management are available, the varying methods and interventions used in these studies make it difficult to draw conclusions. Further research on the use of these interventions for pain reduction is necessary to determine the most effective treatments and the conditions under which they should be used.

The Iowa Model of Evidence-Based Practice to Promote Quality Care.

The UIHC Department of Nursing is nationally known for its work on use of research to improve patient care. This reputation is attributable to staff members who continue to question "how can we improve practice?" or "what does the latest evidence tell us about this patient problem?" and to administrators who support, value, and reward EBP. The revisions made in the original Iowa Model are based on suggestions from staff at UIHC and other practitioners across the country who have implemented the model. We value their feedback and have set forth this revised model for evaluation and adoption by others.

Translating research into practice. Considerations for critical care investigators.

Experimental multisite studies are needed to test adoption interventions that promote use of evidence-based guidelines in critical care practice. A research model (see Fig. 2) based on Rogers' diffusion of innovation model provides a conceptual guide for selecting interventions to test in translational research studies. Studies should address the four major areas of innovation adoption: (1) characteristics of the guideline, (2) users of the guideline, (3) methods of communicating the guideline, and (4) the social system in which it is being adopted. It is imperative that researchers study which interventions are most effective in promoting use of critical care evidence-based practices by nurses and physicians and how the social system of critical care environments affects adoption of such practices. Without this empiric knowledge, health care systems have little guidance in how to most effectively promote adoption of scientific evidence to improve care of critically ill patients.

Acute confusion/delirium protocol.

This abbreviated version of the Acute Confusion/Delirium Research-Based protocol provides clinical guidelines for the assessment and management of acute confusion/delirium in the elderly individual. A screening and ongoing surveillance program that is based on identified risk factors is recommended to prevent or minimize episodes of acute confusion in this age group. This protocol is part of a series of protocols developed to help clinicians use the best evidence available in the care of older adults.

From book to bedside: putting evidence to use in the care of the elderly.

BACKGROUND: Infusion of research findings into clinical practice is a challenging part of the research process. Because the length of time between discovery and use of knowledge averages 20 years, methods are needed to speed translation of research findings into practice. Few efforts have been made to coordinate the generation of new knowledge with the dissemination of findings from research to improve care of the elderly. RESEARCH-BASED PRACTICE PROTOCOLS: The Research Development and Dissemination Core (RDDC) of the Gerontological Nursing Interventions Research Center (GNIRC) at the University of Iowa emphasizes development of research-based (RB) protocols, which requires collecting relevant literature, critiquing studies, and synthesizing research findings for practice. GNIRC-generated research is disseminated to nurses in practice, and the RDDC links nurses who identify clinical problems in care of the elderly with GNIRC scientists. Currently, 19 RB protocols are offered for dissemination through the RDDC, and 5 protocols are under development. Implementation and evaluation of research-based practices on "Split Thickness Skin Graft Donor Site Care" and "Nasogastric/Nasointestinal Tube Placement" are described. CONCLUSIONS: Lessons learned on the basis of experience in disseminating and implementing research-based practices include the necessity of tailoring them to the local needs of various clinical settings in which they are used, reinfusing them periodically to keep staff motivated, and making them consumer friendly. The challenge remains to integrate these practices into the fiber of organizations and to keep staff educated and motivated to carry out research-based practices to improve the care of the elderly.

University of Iowa Hospital and Clinics: outcomes management.

Delivery of quality patient care and management of patient outcomes is critical to the success of academic medical centers in the ever-changing health care market. The University of Iowa Hospitals and Clinics (UIHC) promotes quality care through the provision of organizational structures and processes that are described in this article. In addition, quality of care and outcomes management are described by members in various roles within the UIHC health care system. It is the authors' belief that understanding quality from these various perspectives helps UIHC work across departments to achieve excellence in patient care.

Cost-identification analysis in oral cavity cancer management.

The objectives of this study were to investigate potential relationships between pretreatment patient-mix characteristics, treatment modalities, and costs generated during the pretreatment work-up, treatment, and 1-year follow-up periods for patients with oral cavity cancer (OCC). Another objective was to identify potential areas for cost reduction and improved resource allocation in the management of OCC patients. Using a retrospective cohort of 73 patients with OCC, pretreatment patient-mix characteristics and treatment modalities were evaluated in relation to university-based charges incurred during the pretreatment evaluation, treatment, and 1-year follow-up periods. Simple regression and stepwise multiple regression analyses were used to develop predictive models for cost based on independent variables, including age, AJCC TNM clinical stage, smoking history, American Society of Anesthesiologists (ASA) class, comorbidity as defined by the Kaplan-Feinstein grade and treatment modality. The dependent measurements included all physician, office, and hospital charges incurred at the University of Iowa Hospitals and Clinics during the pretreatment evaluation, treatment, and follow-up periods, as well as the total pretreatment through 1-year follow-up management costs. Independent variables that were identified as being significantly associated with treatment costs included T classification, N classification, TNM stage, unimodality versus multimodality treatment, and the Kaplan-Feinstein comorbidity grade. Age, smoking status, and ASA class were not significantly associated with costs. The majority of the OCC management costs were incurred during the treatment period. The most substantial decreases in management costs for OCC will be realized through measures that allow identification and treatment of disease at an early stage, in which single-modality treatment may effectively be used. Resource allocation for OCC should support the investigation of measures through which the diagnosis and treatment of OCC at the earliest possible stage is facilitated. The presence of comorbid illness is a significant component in the determination of management costs for OCC and should be included in analyses of resource allocation for OCC. The singular diagnosis of OCC encompasses a wide range of patient illness severity, and diagnosis-related reimbursement schemes for OCC treatment should optimally differentiate between early and advanced stage disease.

Issues in the development and implementation of clinical pathways.

Issues related to the development and implementation of clinical pathways require thoughtful planning, collaborative teamwork, and an understanding of the evolutionary nature of this work. Creating an understanding of the purpose behind the development of these guidelines often is only the first issue to be considered. Other common issues include physician involvement, documentation, pathway development, variance data analysis and feedback, and integration with outcomes management activities. Successfully addressing these issues is an ongoing component of a clinical pathway program.

Use of the nursing interventions classification by critical care nurses.

A survey of 111 critical care nurses was carried out to determine the frequency with which they perform each of the 336 interventions in the NIC. Forty-nine interventions were used at least daily, indicating a set of core interventions unique to critical care practice. These findings have implications for critical care practice, education, and research.

Restructuring the clinical nurse specialist position to a unit-based role.

Role restructuring can be the key to maximizing efficiency, productivity, and operational effectiveness. The clinical nurse specialist role was restructured from a divisional project focus to a unit-based design to enhance the care of specific patient populations. The authors describe the process used to make this change, the outcomes achieved, and the lessons learned.