Capturing Functional Independence Measure (FIM®) Ratings.

PURPOSE: The aim of the study was to identify interventions to capture admission functional independence measure (FIM®) ratings on the day of admission to an inpatient rehabilitation facility. DESIGN: A quantitative evidence-based practice quality improvement study utilizing descriptive statistics. METHODS: Admission FIM® ratings from patients discharged in June 2012 (retrospective review) were compared to admission FIM® ratings from patients discharged in June 2014 (prospective review). The logic model was utilized to determine the project inputs, outputs, and outcomes. FINDINGS: Interventions to capture admission FIM® ratings on the day of admission are essential to accurately predict the patient's burden of care, length of stay, and reimbursement. Waiting until Day 2 or Day 3 after admission to capture the admission FIM® assessment resulted in inflated admission FIM® ratings and suboptimal quality outcomes. CONCLUSION/CLINICAL RELEVANCE: Interventions to capture admission FIM® ratings on the day of admission were successful at improving the quality of care, length of stay efficiency, and accurately recording admission FIM® ratings to determine the patient's burden of care.

Shared governance: a way to improve the care in an inpatient rehabilitation facility.

BACKGROUND: Rehabilitation care is specialized and individualized requiring effective and efficient communication to achieve optimal patient outcomes. PURPOSE: To examine how effective implementation of shared governance could improve care delivery, promote patient-centered care, and improve patient outcomes. DESIGN: The shared governance approach included all members of the rehabilitation team (i.e., physical therapist, occupational therapist, speech therapist, registered nurse and nurse aide) and was implemented over 6 months. FINDINGS/CONCLUSIONS: The major end products of this shared governance effort were improved staff communication, problem solving, patient outcomes, and staff satisfaction on our stroke and brain injury unit. CLINICAL RELEVANCE: When effectively implemented and sustained, shared governance between all rehabilitation team stakeholders can increase the effectiveness of communication along with more positive patient and staff outcomes.

Milk yield and somatic cell count during the following lactation after selective treatment of cows at dry-off.

Selective dry cow therapy (SDCT) has received increasing attention in recent years owing to global concerns over agricultural use of antimicrobial drugs and development of antimicrobial resistance. The objective of this study was to evaluate the effect of SDCT on milk yield and somatic cell count (SCC) in dairy herds in the USA. Cows in four Ohio dairy herds were categorized into two groups (low-SCC and high-SCC) at dry-off based on their SCC and clinical mastitis (CM) history during the lactation preceding the dry-off. Low-SCC cows were randomly assigned to receive or not to receive intramammary antibiotics at dry-off. Milk yield and SCC of these cows during the following lactation were compared using linear mixed effects models, adjusting for parity, calving season, stage of lactation, previous lactation milk yield and herd. Milk yield of untreated and treated low-SCC cows at dry-off did not differ significantly during the following lactation. Overall, treated low-SCC cows had 16% lower SCC (approximately 35 000 cells/ml, P = 0·0267) than the untreated cows during the following lactation; however, the effect was variable in different herds. Moreover the impact of treatment, or the lack thereof, on milk yield varied considerably between herds. The results suggested that in some herds treating all cows at dry-off may be beneficial while in other herds leaving healthy cows without antibiotic dry cow treatment has no negative impact on milk yield or milk quality (SCC), and in fact, may be beneficial. Further studies are needed to identify characteristics of herds where treating all cows routinely at dry-off may be needed for maintaining good udder health and where switching to selective treatment of cows at dry-off would be the optimal approach to achieve best results.

Perfil epidemiológico dos recém-nascidos admitidos na unidade neonatal de uma maternidade pública do município de Caruaru, PE / Epidemiological profile of newborns admitted to the neonatal unit of a public hospital in the municipal district of Caruaru, PE

Objetivo: identificar perfil epidemiológico dos recém-nascidos admitidos na unidade neonatal de uma maternidadepública no município de Caruaru/PE, em 2008. Método: estudo descritivo, exploratório, retrospectivo, transversal equantitativo. Composto por prontuários das crianças nascidas na maternidade e admitidas na unidade neonatal,constituindo 515 prontuários. Na coleta, utilizou-se formulário contendo as variáveis: peso ao nascer, Apgar, idadegestacional, tipo de parto, motivo da internação e alta, além da idade e grau de instrução materna. Os dados foramtabulados no software EPI-INFO 6.04d e analisados estatisticamente. O estudo teve aprovação do Comitê de Ética emPesquisa da Associação Caruaruense de Ensino Superior, protocolo 136/09. Resultados: das gestantes, 60% estavam entre20 e 34 anos e 68,7% não concluíram o ensino fundamental. O número de partos cesáreos (45,2%) foi superior aos 15%preconizado pela OMS. A maioria das gestações (51,1%) não atingiu o termo e 48,8% nasceram com baixo peso, o principalmotivo de internação foi a prematuridade, associada ao baixo peso e síndrome do desconforto respiratório (17,3%) e ocoeficiente de mortalidade neonatal foi de 7,7%. Conclusão: um adequado pré-natal, uma assistência sistematizada deenfermagem e uma boa estruturação do serviço são fundamentais para redução desses índices.

Diagnosis of intramammary infections at dry-off based on sampling strategy, epidemiology of pathogens, and agreement beyond chance.

Isolation of pathogens from duplicate or multiple milk samples is currently considered the gold standard in diagnosis of bovine intramammary infections (IMI). However, in large field studies and especially in normal dairy production conditions, collection of single samples is often the most practical option to determine the causal agents of mastitis in a herd. The objective of the present study was to determine how well results between the first and the second sample in pairs of duplicate and successive quarter milk samples agree, using 5 different IMI definitions, based on the number of colony forming units (CFU) per milliliter of milk and epidemiology of the pathogens isolated. Agreement between microbiologic results from the first and the second sample of a pair was assessed by calculating the percentage of agreement and kappa coefficient. Milk samples collected at dry-off from 561 Holstein cows in 4 Ohio dairy herds were included in the analyses. Results of the study indicate that the agreement between the first and the second sample of a duplicate pair was high when criteria to call a sample positive was adjusted for the number of CFU/ml of milk by considering the epidemiology of different mastitis organisms. This finding suggests that an IMI can be accurately diagnosed with single samples. For contagious pathogens (Staphylococcus aureus) a cutoff of 100 CFU/ml and a cutoff of 1,000 CFU/ml for major environmental and minor pathogens will serve as a sensible approach to diagnose bovine IMI with single milk samples.

Using dairy herd improvement records and clinical mastitis history to identify subclinical mastitis infections at dry-off.

Interest in selective dry cow therapy (SDCT) has been increasing owing to concerns over development of antimicrobial resistance. Implementation of SDCT, however, requires a quick and cost-effective on-farm method for identifying cows for treatment and cows that can be left without treatment. The objective of the present study was to evaluate the use of clinical mastitis (CM) history and somatic cell counts (SCC) from monthly Dairy Herd Improvement (DHI) records in identification of infected and uninfected cows at dry-off. A total of 647 Holstein cows were classified as uninfected or infected at dry-off based on CM history and varying number of monthly SCC records (with three different SCC cut-offs). Cows were considered uninfected based on the following criteria: (1) SCC <100,000 cells/ml and no CM during the lactation; (2) SCC <200,000 cells/ml and no CM during the lactation; (3) as criterion two, but additionally a cow was also considered uninfected if it experienced a case of CM during the first 3 months of the lactation and the SCC was <100,000 cells/ml for the rest of the lactation; (4) SCC <300,000 cells/ml and no CM during the lactation; otherwise they were considered infected. Infected and uninfected cows at dry-off were most efficiently identified using three months' SCC records with a threshold of 200,000 cells/ml for cows without CM during the lactation and a threshold of 100,000 cells/ml during the rest of lactation for cows with CM during the first 90 days in milk. Moreover, this criterion also most efficiently identified cows infected with major pathogens only at dry-off. The success of the criteria used for identifying infected and uninfected cows will, however, depend on herd characteristics, such as prevalence of infection and type of pathogens present in the herd.

Postoperative atrial fibrillation following coronary artery bypass graft: clinical factors associated with in-hospital death.

OBJECTIVE: To identify factors associated with a higher likelihood of in-hospital death in patients submitted to coronary artery bypass graft surgery (CABG) who developed atrial fibrillation (AF) postoperatively. METHODS: The authors analyzed data from 397 consecutive patients submitted to CABG that developed AF postoperatively between 2000 and 2003. The patients were divided into 2 groups: group 1 (G1) comprised patients who survived (n=369); and group 2 (G2) comprised patients who died during hospital stay (n=28). Statistical analysis was performed using Student's t test and chi-square test, and p values < 0.05 were considered significant. RESULTS: A comparative analysis between G1 and G2 showed that there was no difference between the groups as regards age (67.3 +/- 8.4 versus 69.3 +/- 9.6; p = 0.4), male gender (75.9% versus 64.3%; p = 0.1), systemic arterial hypertension (75.3% versus 85.7%; p = 0.2) and congestive heart failure (17% versus 17%; p = 1). Group 2 presented higher rates for previous acute myocardial infarction (14.6% versus 28.6%; p = 0.05), left ventricular ejection fraction < 40% (12.2% versus 32.1%; p = 0.003), previous cerebrovascular accident (0.8% versus 17.9%; p = 0.03), previous percutaneous coronary intervention (19.5% versus 39.3%; p = 0.01) and previous CABG (19.3% versus 35.7%; p = 0.03). CONCLUSION: Clinical history of acute myocardial infarction, CABG, percutaneous coronary intervention, cerebrovascular accident and severe ventricular dysfunction were significantly more frequent in the group that died during hospital stay, which suggests a possible association of these factors with a higher likelihood of death following CABG.

Fibrilação atrial no pós-operatório de cirurgia de revascularização do miocárdio: características do perfil clínico associadas a óbitos hospitalares / Postoperative atrial fibrillation following coronary artery bypass graft: clinical factors associated with in-hospital death

OBJETIVO: Identificar fatores associados à maior chance de óbitos hospitalares em pacientes submetidos a revascularização cirúrgica do miocárdio (RM), que tenham apresentado fibrilação atrial (FA) no pós-operatório. MÉTODOS: No período de 2000 a 2003, foi analisada uma série consecutiva de 397 pacientes submetidos a RM que desenvolveram FA no pós-operatório. Esses pacientes foram divididos em dois grupos (G), sendo o G1 formado pelos pacientes que sobreviveram (n=369) e o G2, por aqueles que faleceram na fase hospitalar (n=28). Foram realizados os testes t de Student e do qui-quadrado, sendo p significativo quando < 0,05. RESULTADOS: A análise comparativa entre o G1 e o G2 demonstrou não haver diferença entre os grupos quanto a idade (67,3 ± 8,4 anos vs 69,3 ± 9,6 anos; p = 0,4), sexo masculino (75,9 por cento vs 64,3 por cento; p = 0,1), hipertensão arterial sistêmica (75,3 por cento vs 85,7 por cento; p = 0,2) e insuficiência cardíaca congestiva (17 por cento vs 17 por cento; p = 1). O G2 apresentou maiores taxas de infarto agudo do miocárdio prévio (14,6 por cento vs 28,6 por cento; p = 0,05), fração de ejeção do ventrículo esquerdo < 40 por cento (12,2 por cento vs 32,1 por cento; p = 0,003), acidente vascular encefálico prévio (0,8 por cento vs 17,9 por cento; p = 0,03), intervenção coronariana percutânea prévia (19,5 por cento vs 39,3 por cento; p = 0,01), e revascularização cirúrgica do miocárdio prévia (19,3 por cento vs 35,7 por cento; p = 0,03). CONCLUSÃO: Antecedentes de infarto agudo do miocárdio, RM, intervenção coronariana percutânea, acidente vascular encefálico e déficit ventricular grave foram mais freqüentes no grupo que faleceu na fase hospitalar, sugerindo possível associação entre esses fatores e maior chance de óbito no pós-operatório de RM.

OBJECTIVE: To identify factors associated with a higher likelihood of in-hospital death in patients submitted to coronary artery bypass graft surgery (CABG) who developed atrial fibrillation (AF) postoperatively. METHODS: The authors analyzed data from 397 consecutive patients submitted to CABG that developed AF postoperatively between 2000 and 2003. The patients were divided into 2 groups: group 1 (G1) comprised patients who survived (n=369); and group 2 (G2) comprised patients who died during hospital stay (n=28). Statistical analysis was performed using Student's t test and chi-square test, and p values < 0.05 were considered significant. RESULTS: A comparative analysis between G1 and G2 showed that there was no difference between the groups as regards age (67.3 ± 8.4 versus 69.3 ± 9.6; p = 0.4), male gender (75.9 percent versus 64.3 percent; p = 0.1), systemic arterial hypertension (75.3 percent versus 85.7 percent; p = 0.2) and congestive heart failure (17 percent versus 17 percent; p = 1). Group 2 presented higher rates for previous acute myocardial infarction (14.6 percent versus 28.6 percent; p = 0.05), left ventricular ejection fraction < 40 percent (12.2 percent versus 32.1 percent; p = 0.003), previous cerebrovascular accident (0.8 percent versus 17.9 percent; p = 0.03), previous percutaneous coronary intervention (19.5 percent versus 39.3 percent; p = 0.01) and previous CABG (19.3 percent versus 35.7 percent; p = 0.03). CONCLUSION: Clinical history of acute myocardial infarction, CABG, percutaneous coronary intervention, cerebrovascular accident and severe ventricular dysfunction were significantly more frequent in the group that died during hospital stay, which suggests a possible association of these factors with a higher likelihood of death following CABG.

In vitro activity of an ear rinse containing tromethamine, EDTA, benzyl alcohol and 0.1% ketoconazole on Malassezia organisms from dogs with otitis externa.

The purpose of this study was to evaluate the in vitro activity of an ear rinse containing tromethamine, EDTA, benzyl alcohol and 0.1% ketoconazole in purified water on Malassezia organisms from dogs with otitis externa. Malassezia organisms were collected from ear swab samples from the external ear canal of 19 dogs with otitis externa plus one control strain of Malassezia pachydermatis. Three test solutions were evaluated: ER (EDTA, tromethamine, benzyl alcohol), ER + keto (EDTA, tromethamine, benzyl alcohol, ketoconazole), and H2O (purified water). Ten-millilitre aliquots of each test solution was transferred into 20 tubes and inoculated with one of the isolates (1 tube per isolate: 19 clinical and 1 control strain). Samples were retrieved from each tube at five time points (0, 15, 30, 45 and 60 min), transferred to Petri dishes, mixed with Sabouraud dextrose agar supplemented with 0.5% Tween 80 and incubated. Following incubation, the plates were examined for growth and colonies counted as colony-forming units per millilitre. The data were analysed using a repeated measures analysis, with pair-wise comparisons of solution-time combinations. There was a significant reduction in Malassezia growth in ER + keto at all time points (P < 0.0001) compared to time zero. Neither ER nor H2O had any effect on the growth of Malassezia. ER + keto was significantly more effective in reducing Malassezia growth (P < 0.0001) at all time points compared to both ER and H2O. ER + keto may be useful in the treatment of Malassezia otitis externa. Future studies should be performed to evaluate the in vivo efficacy of ER + keto as treatment for otic infections caused by Malassezia.

In vitro activity of an ear rinse containing tromethamine, EDTA, and benzyl alcohol on bacterial pathogens from dogs with otitis.

OBJECTIVE: To evaluate the in vitro activity of an ear rinse (ER) containing tromethamine, EDTA, and benzyl alcohol on bacterial pathogens from dogs with otitis. SAMPLE POPULATION: Organisms were collected from ear swab specimens from the external and middle ear and included Staphylococcus spp (n = 11; Staphylococcus intermedius [7] and Staphylococcus spp [4]), Pseudomonas aeruginosa (5), Proteus spp (5), beta-hemolytic streptococcus (11), and 1 control strain of each organism. PROCEDURES: 3 test solutions were evaluated including EDTA, tromethamine, and benzyl alcohol (ER); EDTA and tromethamine (ER without benzyl alcohol [ER - BA]); and purified water. Ten-milliliter aliquots of each test solution were transferred into 36 tubes and inoculated with one of the organisms. Samples were retrieved from each tube at 0, 15, 30, 45, and 60 minutes, transferred to Petri dishes, mixed with soybean-casein digest agar, and incubated. After incubation, plates were examined for growth, and the number of colonies was expressed as CFU per milliliter. RESULTS: ER significantly decreased bacterial growth in vitro of P aeruginosa and beta-hemolytic streptococcal organisms within 15 minutes, Proteus spp within 30 minutes, and Staphylococcus spp within 60 minutes. Comparatively, the presence of benzyl alcohol in ER significantly decreased bacterial growth of beta-hemolytic streptococcus and Proteus spp. CONCLUSIONS AND CLINICAL RELEVANCE: On the basis of results of this study, future studies should be performed to evaluate the in vivo efficacy of ER alone as a treatment for otic infections caused by beta-hemolytic streptococcus, P aeruginosa, and Proteus spp and of ER combined with an antimicrobial agent for otic infections caused by Staphylococcus spp.