Improving efficiency within a trauma nurse practitioner team.

BACKGROUND: Clinicians, including nurse practitioners (NPs), face a number of challenges in delivering high-quality care including frequent interruptions that can potentially compromise patient safety and job satisfaction. LOCAL PROBLEM: Trauma NPs voiced frustration with their efforts to provide efficient, high-quality care with frequent interruptions, most commonly pager alerts. The purpose of this quality improvement (QI) initiative was to increase trauma NPs' perceptions of patient safety and improve NPs' job satisfaction by reducing workflow interruptions. METHODS: The Model for Improvement guided this initiative. INTERVENTIONS: The aims of this initiative were to reduce the percentage of nonurgent workflow interruptions via pager alerts by 20% and to increase the utilization of a standardized trauma NP patient rounding process from 0% to 50%. RESULTS: Use of the standardized rounding process improved from 0% to 87%. Interruptions via pager alerts decreased by 36.2%. All nine (100%) trauma NP survey responses revealed an improvement in NP perception of patient safety and job satisfaction. CONCLUSION: The QI initiative found that increasing communication during rounds by using a standardized rounding process involving the bedside registered nurse can minimize interruptions and improve the efficiency of a trauma NP team. The key to the success of the QI initiative was the implementation of a standardized rounding process.

Outcomes of adding acute care nurse practitioners to a Level I trauma service with the goal of decreased length of stay and improved physician and nursing satisfaction.

BACKGROUND: The trauma service experienced preventable delays caused by an Accreditation Council for Graduate Medical Education work restrictions and a 16% increase in patient census. Furthermore, nurses needed a consistently accessible provider for the coordination of care. We hypothesized that using experienced acute care nurse practitioners (ACNPs) on the stepdown unit would improve throughput and decrease length of stay (LOS) and hospital charges. Moreover, we hypothesized that adding ACNPs would improve staff satisfaction. On December 1, 2011, the Vanderbilt University Medical Center Division of Trauma reassigned ACNPs to the stepdown area 5 days a week for a pilot program. METHODS: LOS data from December 1, 2011 through December 1, 2012 was compared with data from the same months from the previous two years and estimated hospital charges and patient days were extrapolated. Physician and nursing surveys were performed. Data from 2010 (n = 2,559) and 2011 (n= 2,671) were averaged and the mean LOS for the entire trauma service was 7.2 days. After adding an experienced ACNP, the average LOS decreased to 6.4 days, a 0.8 day reduction. Per patient, there was a $ 9,111.50 savings in hospital charges, for a reduction of $27.8 million dollars in hospital charges over the 12 month pilot program. RESULTS: A confidential survey administered to attending physicians showed that 100% agreed that a nurse practitioner in the stepdown area was beneficial and helped throughput. Dayshift nurses were surveyed, and 100% agreed or strongly agreed that the ACNPs were knowledgeable about the patient's plan of care, experienced in the care of trauma patients, and improved patient care overall. CONCLUSION: The addition of experienced ACNPs resulted in the decrease of overall trauma service LOS, saving almost $9 million in hospital charges. LEVEL OF EVIDENCE: Economic/decision study, level III.

Early gene expression profile in mouse brain after exposure to ionizing radiation.

Acute changes in the gene expression profile in mouse brain after exposure to ionizing radiation were studied using microarray analysis. RNA was isolated at 0.25, 1, 5 and 24 h after exposure to 20 Gy and at 5 h after exposure of the whole brain of adult mice to 2 or 10 Gy. RNA was hybridized onto 15K cDNA microarrays, and data were analyzed using GeneSpring and Significant Analysis of Microarray. Radiation modulated the expression of 128, 334, 325 and 155 genes and ESTs at 0.25, 1, 5 and 24 h after 20 Gy and 60 and 168 at 5 h after 2 and 10 Gy, respectively. The expression profiles showed dose- and time-dependent changes in both expression levels and numbers of differentially modulated genes and ESTs. Seventy-eight genes were modulated at two or more times. Differentially modulated genes were associated with 12 different classes of molecular function and 24 different biological pathways and showed time- and dose-dependent changes. The change in expression of four genes (Jak3, Dffb, Nsep1 and Terf1) after irradiation was validated using quantitative real-time PCR. Up-regulation of Jak3 was observed in another mouse strain. In mouse brain, there was an increase of Jak3 immunoreactivity after irradiation. In conclusion, changes in the gene profile in the brain after irradiation are complex and are dependent on time and dose, and genes with diverse functions and pathways are modulated.

Apoptosis and proliferation of oligodendrocyte progenitor cells in the irradiated rodent spinal cord.

PURPOSE: Oligodendrocytes undergo early apoptosis after irradiation. The aim of this study was to determine the relationship between oligodendroglial apoptosis and proliferation of oligodendrocyte progenitor cells (OPC) in the irradiated central nervous system. METHODS AND MATERIALS: Adult rats and p53 transgenic mice were given single doses of 2 Gy, 8 Gy, or 22 Gy to the cervical spinal cord. Apoptosis was assessed using TUNEL (Tdt-mediated dUTP terminal nick-end labeling) staining or by examining nuclear morphology. Oligodendrocyte progenitor cells were identified with an NG2 antibody or by in situ hybridization for platelet-derived growth factor receptor alpha. Proliferation of OPC was assessed by in vivo bromodeoxyuridine (BrdU) labeling and subsequent immunohistochemistry. Because radiation-induced apoptosis of oligodendroglial cells is p53 dependent, p53 transgenic mice were used to study the relationship between apoptosis and cell proliferation. RESULTS: Oligodendrocyte progenitor cells underwent apoptosis within 24 h of irradiation in the rat. That did not result in a change in OPC density at 24 h. Oligodendrocyte progenitor cell density was significantly reduced by 2-4 weeks, but showed recovery by 6 weeks after irradiation. An increase in BrdU-labeled cells was observed at 2 weeks after 8 Gy or 22 Gy, and proliferating cells in the rat spinal cord were immunoreactive for NG2. The mouse spinal cord showed a similar early cell proliferation after irradiation. No difference was observed in the proliferation response in the spinal cord of p53 -/- mice compared with wild type animals. CONCLUSIONS: Oligodendroglial cells undergo early apoptosis and OPC undergo early proliferation after ionizing radiation. However, apoptosis is not likely to be the trigger for early proliferation of OPC in the irradiated central nervous system.

Changes in oligodendrocytes and myelin gene expression after radiation in the rodent spinal cord.

PURPOSE: The aim of this study was to assess changes in oligodendrocytes (OL), myelin gene expression, and their relationships with late demyelination after irradiation. METHODS AND MATERIALS: Adult rats were given single doses of 8 or 22 Gy to the cervical spinal cord. Immunohistochemistry for APC or GST-pi was used to identify OL. Changes in myelin gene expression were assessed using RT-PCR for proteolipid protein (PLP). Luxol fast blue staining was used to assess demyelination. CNP-(beta)geo transgenic mice were used to confirm some of the results of the rat model. Cells of the oligodendroglial lineage in these animals express beta-galactosidase (beta-gal). RESULTS: Early apoptosis of APC, GST-pi, and beta-galactosidase positive cells was observed in the spinal cord of rats and CNP-(beta)geo mice. At 24 h after 22 Gy, there was a significant decrease in OL density. Cell density continued to decline thereafter after both 8 and 22 Gy, and a reduction in PLP expression was observed at 4-5 weeks. A further decrease in PLP expression was seen beginning at 18 weeks after 22 Gy only. Demyelination was observed at 19 weeks after 22 Gy. CONCLUSIONS: Apoptosis of OL and changes in OL density and PLP gene expression were observed early after both 8 and 22 Gy. This suggests that these early changes are unlikely to be directly related to the late demyelination observed.

Mapping of determinants required for the function of the HIV-1 env nuclear retention sequence.

Control of HIV-1 RNA processing and transport are critical to the successful replication of the virus. In previous work, we identified a region within the HIV-1 env that is involved in mediating nuclear retention of unspliced viral RNA. To define this sequence further and identify elements required for function, deletion mutagenesis was carried out. Progressive 5' and 3' deletions map the nuclear retention sequence (NRS) within the intron between nts 8281 and 8381. While deletion of sequences comprising the 3'ss had no effect, removal of the 5'ss resulted in cytoplasmic accumulation of unspliced RNA. Sequence analysis determined that the region corresponding to the NRS is highly conserved among HIV-1 strains. To evaluate whether this NRS interacts with cellular factors, RNA electrophoretic mobility shift assays (REMSA) were performed. We show that the NRS specifically interacts with cellular factors present in HeLa nuclear extracts, and, by UV crosslinking, correlates with the binding of a 49-kDa protein. Immunoprecipitation of the UV crosslinked products determined that this 49-kDa protein corresponds to hnRNP C.