Management of Do Not Resuscitate Orders Before Invasive Procedures.

BACKGROUND: In 2017, the US Department of Veterans Affairs (VA) implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI), which created a portable and durable code status for use across its health care system. Patients who now have a durable do not resuscitate (DNR) status may undergo invasive procedures. Few studies have examined whether proceduralists discuss DNR status and document changes before procedures. OBJECTIVE: To assess baseline percentage of suspension of DNR before nonsurgical invasive procedures and determine whether an academic detailing intervention consisting of training proceduralists in the use of a template that allows rapid suspension of DNR status increases percentage of DNR acknowledgments. METHODS: Single-center, quasi-experimental pre- and postassessments were done in high-volume, procedural areas, including gastroenterology, cardiology, and interventional radiology, in a VA medical center. The primary outcome was the proceduralists' documentation of DNR status acknowledgment before a nonsurgical invasive procedure at baseline and after the intervention. Logistic regression was used to compare percentage of DNR acknowledgment with time (before, after) and procedural area and assessing their interaction in the model. RESULTS: The interaction between department and time revealed wide variation in documentation of DNR acknowledgment. Examining the model predicted percentages from the interaction, preintervention percentages for gastroenterology, cardiology and interventional radiology were 46%, 75.6%, and 7.5%, respectively, and postintervention model predicted percentages were 53.5%, 91.7%, and 26.3%, respectively. Only the before vs after contrast for interventional radiology was significantly different. When all procedural areas were combined, the percentage of DNR acknowledgment significantly improved from 38.6% to 61.1% (P = .01). CONCLUSIONS: Before nonsurgical invasive procedures, the percentage of DNR acknowledgment was low but after, the intervention significantly improved. Further research is needed to assess its impact on patient-centered outcomes.

Quality of Chronic Obstructive Pulmonary Disease-Related Health Care in Rural and Urban Veterans Affairs Clinics.

Only minor disparities were found between patients at rural and urban clinics in this examination of the differences in the quality of health care for patients with COPD.

Versatile control of metal-assisted chemical etching for vertical silicon microwire arrays and their photovoltaic applications.

A systematic study was conducted into the use of metal-assisted chemical etching (MacEtch) to fabricate vertical Si microwire arrays, with several models being studied for the efficient redox reaction of reactants with silicon through a metal catalyst by varying such parameters as the thickness and morphology of the metal film. By optimizing the MacEtch conditions, high-quality vertical Si microwires were successfully fabricated with lengths of up to 23.2 µm, which, when applied in a solar cell, achieved a conversion efficiency of up to 13.0%. These solar cells also exhibited an open-circuit voltage of 547.7 mV, a short-circuit current density of 33.2 mA/cm(2), and a fill factor of 71.3% by virtue of the enhanced light absorption and effective carrier collection provided by the Si microwires. The use of MacEtch to fabricate high-quality Si microwires therefore presents a unique opportunity to develop cost-effective and highly efficient solar cells.

Filter-free image sensor pixels comprising silicon nanowires with selective color absorption.

The organic dye filters of conventional color image sensors achieve the red/green/blue response needed for color imaging, but have disadvantages related to durability, low absorption coefficient, and fabrication complexity. Here, we report a new paradigm for color imaging based on all-silicon nanowire devices and no filters. We fabricate pixels consisting of vertical silicon nanowires with integrated photodetectors, demonstrate that their spectral sensitivities are governed by nanowire radius, and perform color imaging. Our approach is conceptually different from filter-based methods, as absorbed light is converted to photocurrent, ultimately presenting the opportunity for very high photon efficiency.

Si microwire solar cells: improved efficiency with a conformal SiO2 layer.

Silicon microwire arrays have attracted considerable attention recently due to the opportunity they present as highly efficient and cost-effective solar cells. In this study, we report on efficient Si microwire array solar cells with areas of 1 cm(2) and Air Mass 1.5 Global conversion efficiencies of up to 10.6%. These solar cells show an open-circuit voltage of 0.56 V, a short-circuit current density of 25.2 mA/cm(2), and a fill factor of 75.2%, with a silicon absorption region that is only 25 µm thick. In particular, the maximum overall efficiency of the champion device is improved from 8.71% to 10.6% by conformally coating the wires with a 200 nm thick SiO2 layer. Optical measurements reveal that the layer reduces reflection significantly over the entire visible range.

Inaccuracy in patient handoffs: discrepancies between resident-generated reports and the medical record.

A handoff is the transfer of a patient's care from one provider to another. It usually involves both a verbal and written exchange of information. Although written handoff sheets are critical to good patient care, there is little data on the quality of information they contain. We conducted a study to assess the accuracy of handoff sheets used in one Minneapolis internal medicine residency program. We compared the accuracy of information about code status, medication allergies, medications, and problems recorded on the handoff sheet with that in the patient's medical record. We found errors were common in resident handoff sheets. Only 83 (19%) of 428 handoff sheets contained no errors. The most common error was one of omission on the medication list (69% of the handoff sheets contained a medication omission). The percentage of patient handoff sheets with code-status errors was 5.7%, and the percentage with medication allergy errors was 2.8%. Important problems were omitted from the problem list in 22% of cases.

An innovative approach to teaching resuscitation skills.

We report the impact of a monthly educational exercise for residents that emphasized practical skills and equipment usage rather than knowledge of advanced cardiac life support (ACLS) protocols. Residents were divided into groups of approximately four that rotated through three stations. Each station included several objectives, most of which related to specific types of equipment. The exercise was held six times from July 2003 to June of 2004. Sixty-seven residents participated and completed a questionnaire prior to and following the exercise. The questionnaire elicited comfort level with basic tasks including using an automated external defibrillator (AED), attaching leads and paddles to read a cardiac rhythm, delivering unsynchronized shocks with monophasic and biphasic defibrillators and implementing the pacing function on a defibrillator. There were significant differences in the pre- and post-answers to each question. The largest difference was found in the question asking how comfortable participants were delivering unsynchronized shocks with a defibrillator. Importantly, responses for the question 'How comfortable are you being a code leader?' showed significant improvement. Simple skills such as attaching tubing to the oxygen tank, turning on the defibrillator and entering appropriate charge, or positioning paddles and monitor leads properly often caused significant difficulty. Cardiopulmonary arrests tend to generate anxiety among house staff, despite certification in ACLS and adequate knowledge of protocols. Exercises, such as the one presented here, will reduce anxiety by specifically addressing this skill. We conclude that residents benefit from additional teaching and practice in actual performance of basic skills used during cardiac arrests. Furthermore, our data demonstrate that comfort levels among house officers increase when they are given the opportunity to practice these skills.