Trauma Patient Transitions From Critical Care: A Survey of U.S. Trauma Centers.

BACKGROUND: Transitions between clinical units are vulnerable periods for patients. A significant body of evidence describes the importance of structured transitions, but there is limited reporting of what happens. Describing transitions within a conceptual model will characterize the salient forces that interact during a patient transition and, perhaps, lead to improved outcomes. OBJECTIVE: To describe the processes and resources that trauma centers use to transition patients from critical care to nonintensive care units. METHODS: This cross-sectional study surveyed all Level I and II trauma centers listed in the American Trauma Society database from September 2020 to November 2020. Data were merged from the American Hospital Association 2018 Hospital Survey. RESULTS: A total of 567 surveys were distributed, of which 152 responded for a (27%) response rate. Results were organized in categories: capital input, organizational facets, employee behavior, employee terms/scope, and labor inputs. Resources and processes varied; the most important opportunities for transition improvement included: (1) handoff instruments were only reported at 36% (n = 27) of trauma centers, (2) mandatory resident education about transitions was only reported at 70% (n = 16) of trauma centers, and (3) only 6% (n = 4) of trauma centers reported electronic medical record applications that enact features to influence employee behavior. CONCLUSIONS: After years of focusing on transitions as a high-stake period, there remain many opportunities to develop resources and enact effective processes to address the variability in transition practice across trauma centers.

Reports of three organizations' members about doctor of nursing practice project experiences and outcomes.

BACKGROUND: Holders of the Doctor of Nursing Practice (DNP) degree were envisioned to improve health and health care outcomes by implementing quality improvement initiatives, applying evidence-based practice changes (EBP), and influencing policy. Little is known about the nature of the DNP project experience and its relationship with subsequent experiences of graduates. Filling these knowledge gaps is important because of the investment of time, faculty and student effort, expense, and the projects' potential long-term effects on the organizations in which they were conducted. PURPOSE: (1) Describe the impetus for foci, outcomes and activities of DNP projects and (2) determine the extent to which project foci are a part of post-graduation experiences. METHODS: A cross-sectional descriptive survey design was used and a via mailed paper and online version was sent with return options to graduates of Doctor of Nursing Practice program. The sampling technique was designed to maximize the capture of DNP graduates. Three mailings were sent to 5,830 nurse members of three national organizations with memberships that included advanced practice registered nurses, nurse administrators and nurse educators. The 1,308 DNP prepared respondents were demographically and geographically representative of organizational members. FINDINGS: Most (65.2%) reported the topic of the project was their own idea and they sought out an organization in which to conduct it. Twenty-five percent indicated not all aspects of the reorganization/initiative/policy change were completed by graduation. Five project foci emerged with the majority reporting an EBP initiative or an EBP project involving reorganization in the setting (57.7%) There was also a wide variation in the number, types and combinations of activities reported to be a part of the project. There was wide variation in the relationship of project foci and activities with reports of post-graduation experience by position title. DISCUSSION/CONCLUSION: Findings suggest potential avenues for innovations during the DNP project experience innovations. Long term effects of projects on organizations in which they were conducted and the relationship of project activities with post-graduation roles should be considered.

Providers' Reports of Environmental Conditions and Resources at Births in the United States.

Environmental conditions and resources that may influence provider's behaviors have been investigated in birth environments focusing on location rather than conditions and available resources. Using a descriptive, cross sectional design, we surveyed a random sample of certified nurse-midwives (CNMs), obstetricians, family practice physicians, and certified professional midwives (CPMs) to describe conditions, resources, and workforce present during U.S. births. In all, 1,243 midwives and physicians reported most environmental resources were present at almost 100% of births they attended. Conditions varied: room noise acceptability restriction of phone calls/texts from any source and lighting kept to a minimum. Trainees were present at most births regardless of setting and provider type. The impact of room noise, phone calls/texting, and lighting on outcomes should be determined. The roles and impact of personnel, including trainees, should be described. The extent to which clusters of resources are associated with outcomes might provide new directions for interventions that improve care.

DNPs' labor participation, activities, and reports of degree contributions.

BACKGROUND: There is limited information about the careers, roles and views of doctor of nursing practice (DNP) graduates. METHOD: This study describes the labor participation, post-graduation work activities, and perceptions of 1,308 DNP members of three professional nursing organizations who completed a 2017 survey (32% response rate). FINDINGS: More than 70% of respondents reported substantial improvements in quality improvement, evidenced based practice and leadership abilities. Twenty-two percent of respondents noted the degree was required by their employer and most of these held educational positions. Postgraduate participation in activities associated with DNP education, assessment of personal impact and degree necessity varied by position title and organization membership. DISCUSSION: These differences have implications for nursing associations and professional solidarity.

Nurse Practitioners and Interdisciplinary Teams in Pediatric Critical Care.

OBJECTIVE: To describe the members of pediatric intensive care unit interdisciplinary provider teams and labor inputs, working conditions, and clinical practice of pediatric intensive care unit nurse practitioners. METHODS: A national, quantitative, crosssectional, descriptive postal survey of pediatric intensive care unit medical directors and nurse practitioners was administered to gather information about provider-team members, pediatric intensive care unit nurse practitioner labor inputs, working conditions, and clinical practice. Descriptive statistics, cross-tabulations, and χ2 tests were used. RESULTS: Responses from 97 pediatric intensive care unit medical directors and 59 pediatric intensive care unit nurse practitioners representing 126 institutions were received. Provider-team composition varied between institutions with and without nurse practitioners. Pediatric intensive care units employed an average of 3 full-time nurse practitioners; the average nurse practitioner-to-patient ratio was 1 to 5. The clinical practice reported by medical directors was consistent with practice reported by nurse practitioners. CONCLUSION: Nurse practitioners are integrated into interdisciplinary pediatric intensive care unit teams, but institutional variation in team composition exists. Investigating models of care contributes to the understanding of how models influence positive patient and organizational outcomes and may change future role implementation.

PICU Provider Supply and Demand: A National Survey.

OBJECTIVES: To describe physicians' and nurse practitioners' perceptions of the national and local PICU physician and other provider supply in institutions that employ PICU nurse practitioners, assess for differences in perceptions of supply, and evaluate the intent of institutions to hire additional nurse practitioners to work in PICUs. DESIGN: National, quantitative, cross-sectional descriptive study via a postal mail survey from October 2016 to January 2017. SETTING: Institutions (n = 140) identified in the 2015 American Hospital Association Annual Survey with a PICU who employ PICU nurse practitioners. SUBJECTS: PICU physician medical directors and nurse practitioners. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 119 respondents, representing 93 institutions. Responses were received from 60 PICU medical directors (43%) and 59 lead nurse practitioners (42%). More than half (58%) of all respondents reported the national supply of PICU physicians is less than demand and 61% reported the local supply of PICU providers (physicians in all stages of training, nurse practitioners, and physician assistants) is less than demand. Of the respondents from institutions that self-reported a local provider shortage (n = 54), three fourths (78%) reported plans to increase the number of PICU nurse practitioners in the next 3 years and 40% were likely to expand the nurse practitioner's role in patient care. CONCLUSIONS: Most PICU medical directors and lead nurse practitioners in institutions that employ PICU nurse practitioners perceived that national and local supply of providers to be less than the demand. Nurse practitioners are employed in PICUs as part of interdisciplinary models of care being used to address provider demand. The demand for more PICU nurse practitioners with expanded roles in care delivery was reported. Further evaluation of models of care and provider roles in care delivery can contribute to aligning provider supply with demand for care delivery.

Regulation of pediatric intensive care unit nurse practitioner practice: A national survey.

PURPOSE: To describe the extent to which organizational regulation of pediatric intensive care unit (PICU) nurse practitioner (NP) practice and prescriptive authority aligns with state scope-of-practice (SSOP) regulations, to examine differences between PICU medical directors' and NPs' report of regulation, and to describe organizational-level restriction of PICU NP practice. METHODS: A 34-item national, quantitative cross-sectional descriptive survey of US PICU medical directors and NPs included demographic, institutional characteristics, and PICU NP regulation and role-related questions. Invitations to participate were sent between October 2016 and January 2017. RESULTS: Respondents (n = 121, 60 PICU NPs and 61 PICU medical directors) reported that 30% of PICU NPs have additional organizational restrictions beyond their SSOP practice authority and 11% have prescriptive authority regulations that exceed those required by the SSOP regulations. Medical directors and lead NPs showed agreement in reports of NP practice regulation. Variation in organizational-level restrictions of privileging, billing, and reporting structure practices were identified. IMPLICATIONS FOR PRACTICE: As more states move to full SSOP regulatory environments, organizational regulation of NP practice can impede attainment of full practice authority. Future research is needed to determine whether variations in regulation of PICU NP practice influence patient outcomes, interdisciplinary collaboration, and NP role actualization.

Nurses' responses to interruptions during medication tasks: A time and motion study.

BACKGROUND: The majority of interruption research has focused on the undesirable effects of interruptions, especially related to errors during medication tasks. However, there may be times when interruptions result in positive effects by providing new information to a situation or preventing an error. The study of nurses' responses to interruptions is limited. Since interruptions cannot (and possibly should not) be avoided, a reasonable method for handling interruptions might be to learn how best to prepare for and manage interruption-prone situations. OBJECTIVES: The purpose of this study was to examine nurses' responses to interruptions and explore contextual factors that influence interruption management during medication tasks. This is a secondary analysis of an original study aimed at describing interruptions and nurses' responses to interruptions during routine nursing work on medical-surgical units. DESIGN AND SETTING: This descriptive study was conducted in 5 medical and/or surgical units at 2 acute care facilities in the southern United States, during weekday shifts. PARTICIPANTS: Twenty registered nurses participated in the study. METHODS: The researcher observed nurse participants for at least 4.5 h during routine nursing work. Observation data were collected using time and motion software. Questionnaires were used to collect organizational, unit, and nurse level data. Interruptions during medication tasks were isolated and described as a secondary analysis. RESULTS: Approximately 39% of medication tasks were interrupted. Following an interruption, nurses were more likely to suspend the medication task to attend to the interruption task (51.1%) or multitask (40.3%) than delay responding to the interruption until the medication task was complete (12.6%). Several characteristics of the interruption task, including task type, source, method, and communication intent were associated with nurses' responses at the level of statistical significance. CONCLUSIONS: The findings of this study reveal that nurses are interrupted frequently during medication tasks. The range of nurses' responses to interruptions was surprising in relation to the frequency with which nurses accepted the interruption task and the infrequency of delay responses. Additional study of nurses' responses to interruptions during medication tasks and the effect of different responses on patient safety outcomes is indicated.

The Effects of Social Influence on Nurses' Hand Hygiene Behaviors.

OBJECTIVE: The aim of this article is to describe the associations of nurses' hand hygiene (HH) attitudes, subjective norms, and perceived behavioral control with observed and self-reported HH behavior. BACKGROUND: Hand hygiene is an essential strategy to prevent healthcare-associated infections. Despite tremendous efforts, nurses' HH adherence rates remain suboptimal. METHODS: This quantitative descriptive study of ICU nurses in the southeastern United States was guided by the theory of planned behavior. The self-administered Patient Safety Opinion Survey and iScrub application, which facilitates observation, comprised the data set. RESULTS: Nurses' observed HH median was 55%; tendency to self-report was a much higher 90%. Subjective norm and perceived control scores were associated with observed and self-reported HH (P < .05) but not attitude scores or reports of intention. CONCLUSIONS: Nurses' subjective norm and perceived control are associated with observed and self-reported HH performance. Healthcare workers overestimate their HH performance. Findings suggest future research to explore manipulators of these variables to change nurses' HH behavior.

Promoting Faculty Scholarship: A Clinical Faculty Scholars Program.

BACKGROUND: The importance of supporting and promoting faculty scholarship in nursing is acknowledged, but the reality of scholarship for faculty engaged in clinical teaching can be challenging. METHOD: The article describes the development and initial results of the scholarly practice program. Mentorship, time, and limited funding are essentials for the program. RESULTS: After submitting detailed proposals, 15 faculty were chosen to be project leaders in the first 2 years of the program, resulting in 15 presentations, three posters, 19 publications, and a webinar, to date. External continuing funding has been secured by three projects. Additional dissemination efforts are awaiting peer review. CONCLUSION: The program has successfully increased the level of scholarship among clinical teaching faculty and contributed to the faculty's professional satisfaction. Faculty have increased experience and ability to conduct clinical quality improvement. Experience supports targeted, substantial support for projects, rather than a general average faculty allocation strategy to promote scholarship. [J Nurs Educ. 2018;57(2):121-125.].

Variables That Influence US Midwife and Physician Management of the Third Stage of Labor.

INTRODUCTION: Midwives and physicians incorporate their knowledge, experiences, and other variables in making clinical decisions. Variations in the management of the third stage of labor may be a result of variables that influence providers' decision making. The purpose of this study was to describe variables that influence US midwives' and physicians' management of the third stage of labor. METHODS: A randomly selected national sample of certified nurse-midwives and certified midwives, certified professional midwives, obstetricians, and family physicians was surveyed about the extent to which maternal characteristics, maternal history, and current birth characteristics influence their third-stage management. The extent of influence was defined in terms of always to never altering management. Descriptive summaries, group comparisons, and partial correlations were used to determine differences in influences between midwives and physicians. One free-text question was analyzed using qualitative methods. RESULTS: A total of 1243 clinicians responded. There was considerable variability in the response patterns in that the same variable was reported to always alter management during the third stage of labor for some participants yet did not influence the management practices of others at all. Differences between responses from midwives and physicians were explored as a possible explanation for some of the variability. In response to the free-text inquiry about variables that most influenced changes in participants' usual management of the third stage, the participants most often included active bleeding, current recommendations or guidelines, and maternal or family preferences. DISCUSSION: This study identifies variables reported as influencing clinical decision making during the third stage of labor. Therefore, these variables are important to consider when evaluating interventions and outcomes related to management of the third stage of labor and any attempts to design new interventions. The findings are descriptive of practice; they are not intended to guide changes in practice.

An elicitation study of critical care nurses' salient hand hygiene beliefs.

AIM: To describe critical care nurses' hand hygiene attitudinal, normative referent, and control beliefs. BACKGROUND: Hand hygiene is the primary strategy to prevent healthcare-associated infections. Social influence is an underdeveloped hand hygiene strategy. METHODS: This qualitative descriptive study was conducted with 25 ICU nurses in the southeastern United States. Data were collected using the Nurses' Salient Belief Instrument. RESULTS: Thematic analysis generated four themes: Hand Hygiene is Protective; Nurses look to Nurses; Time-related Concerns; and Convenience is Essential. CONCLUSION: Nurses look to nurses as hand hygiene referents and believe hand hygiene is a protective behaviour that requires time and functional equipment.

US Physician and Midwife Adherence to Active Management of the Third Stage of Labor International Recommendations.

INTRODUCTION: The prevalence of postpartum hemorrhage has increased in the United States despite the international promotion of active management of the third stage of labor. Adherence to the international recommendations in the United States is unclear. It is also not known how the components of active management are related to other practices that may be used during the third stage of labor. The purpose of this study was to determine routine practice patterns for managing the third stage of labor in the United States. METHODS: A randomized national survey was conducted of certified nurse-midwives/certified midwives, certified professional midwives, obstetricians, and family physicians who self-reported third-stage practices. Descriptive analyses and partial correlations were used to determine differences in practice patterns between midwives and physicians. A 2-step clustering algorithm was used to identify clusters of third-stage practices. RESULTS: A total of 1243 clinicians responded. Uterine massage after placenta expulsion was reportedly used at almost every birth by all provider types. Median use of cord traction and oxytocin administration by all provider types was 80% and 90% of births, respectively. Cluster analysis of these and other interventions used during the third stage of labor revealed 4 distinct clusters of practices ranging from primarily a hands-off at one extreme to high-intervention approaches at the other extreme. The other 2 clusters were defined by practices that fell between those extremes. DISCUSSION: Determination of how, and under what conditions, clinicians decide when to use particular techniques to manage the third stage of labor and how these techniques influence the incidence of postpartum hemorrhage, is necessary. The clusters of practice combinations that emerged in this study suggest that there are extreme variations in clinician practices during management of the third stage of labor.

Junior research track faculty in U.S. schools of nursing: Resources and expectations.

BACKGROUND: Concerns about U.S. nursing research workforce preparation and success in the research arena require information about support mechanisms and readiness because the first research position is key to researcher retention and success. PURPOSE: The purpose was to describe the state of junior nursing research faculty recruitment terms, nursing programs' support during the first 2 years of employment, and administrators' views about strengths and weaknesses of the junior nursing research faculty pool and adequacy of the support provided. METHODS: Survey administrators in all U.S. nursing programs offering research doctorates (n = 125; response rate: 52%). DISCUSSION: Resource availability varied widely across institutions. Most respondents reported resources were adequate regardless of the actual level provided. Administrators' teaching and research expectations of these faculty also varied widely. Administrators identified readiness to perform as an issue of concern. CONCLUSION: As consumers of nursing research program graduates and as administrators responsible for the nursing research enterprise, deans need to take collective as well as individual actions.

Preinjury physical frailty and cognitive impairment among geriatric trauma patients determine postinjury functional recovery and survival.

BACKGROUND: Injury is an external stressor that often initiates a cycle of decline in many older adults. The influence of physical frailty and cognitive decline on 6-month and 1-year outcomes after injury is unreported. We hypothesized that physical frailty and cognitive impairment would be predictive of 6-month and 1-year postinjury function and overall mortality. METHODS: The sample involved patients who are 65 years or older admitted to a Level I trauma center between October 2013 and March 2014 with a primary injury diagnosis. Surrogates of 188 patients were interviewed within 48 hours of hospital admission to determine preinjury cognitive and physical frailty impairments using brief screening instruments. Follow-up was completed on 172 patients at 6 months and 176 patients at 1 year to determine posthospitalization status and outcomes. Data analysis involved frequencies, measures of central tendency, χ analyses, linear and logistic regression. RESULTS: The mean age of the patients was 77 years. The median Injury Severity Score (ISS) was 10. The mechanism of injury involved falls from standing (n = 101, 54%). Preinjury vulnerabilities included cognitive impairment (AD8 Dementia Screen [AD8] score ≥ 2, n = 93, 50%) and physical frailty (Vulnerable Elders Survey [VES-13] score ≥ 4, n = 94, 50%). Overall, median physical frailty scores did not return to baseline in the majority of survivors at 1 year. Multivariate regression analysis revealed that preinjury cognitive impairment (6 months, AD8, ß = -0.20, p = 0.002) and preinjury physical frailty (6 months, Barthel Index, ß = 0.60, p < 0.001; 1 year, Barthel Index, ß = 0.52, p < 0.001) are independently associated with physical function (frailty). Multivariate logistic regression analysis revealed that age (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.04-1.14), injury severity (OR, 1.07; 95% CI, 1.02-1.12), and preinjury physical frailty (OR, 1.28; 95% CI, 1.14-1.47) are independently associated with overall mortality at 1 year. CONCLUSION: Preinjury physical frailty is the predominant predictor of postinjury functional status and mortality in geriatric trauma patients. Identification of frailty and appropriate follow-up are crucial for decision making by providers, patients, and family caregivers. LEVEL OF EVIDENCE: Prognostic study, level II.

Relationships of Maternal Stress with Milk Immune Components in African American Mothers of Healthy Term Infants.

BACKGROUND: In the United States, African American infants experience the highest mortality, and their mothers report the lowest breastfeeding rates. Science reports decreased infant mortality among breastfed infants and suggests that milk immune component (MIC) levels are associated with maternal stressors. Little is known about these relationships among African Americans; therefore the aim was to explore the relationships of African American mothers' stressors and MICs 1-14 days postdelivery. MATERIALS AND METHODS: Mothers meeting eligibility requirements were approached for consent 48-72 hours postdelivery of a healthy term infant and given instructions to collect milk (Days 3, 9, and 14) and saliva (Day 9), as well as complete three Perceived Stress Scale questionnaires (Days 3, 9, and 14) and a survey of pregnancy stressors experiences. Pearson correlations and linear regressions were performed to assess the relationships of maternal stressors with MICs. RESULTS: There was at least one statistically significant correlation of a maternal stressor with nine of the 10 MICs (effect sizes ranging from r = 0.22 to 0.38) on Days 3 and 9. Of all MICs, epidermal growth factor had the most associations with maternal stress indicators. No mediational relationship of cortisol with MICs was observed. CONCLUSIONS: Many of the MIC changes observed could potentially impact the health of term and preterm infants. Further research is warranted.

Preinjury Physical Function and Frailty in Injured Older Adults: Self- Versus Proxy Responses.

OBJECTIVES: To determine the extent to which proxy respondents can provide reliable reports. DESIGN: Prospective cohort study. SETTING: Level I trauma center. PARTICIPANTS: Seventy-seven older adults (≥65, median 73.0, interquartile range 67-80; 53% female) admitted to three services (trauma, geriatrics, orthopedics) with primary injury diagnoses over a 6-month period and their proxies (43% spouses, 44% children, 5% siblings, 8% friends or other relatives). MEASUREMENTS: Three brief screening instruments (Vulnerable Elders Survey-13 (VES-13), modified Barthel Index (mBI), Life Space Assessment (LSA)) for physical function and frailty were administered to older adults and their proxies within 48 hours of admission. Data analysis included frequencies, percentages, intraclass correlations, and Kappa statistics. RESULTS: Approximately 47% (n = 36) of the proxies lived with the older adults. Perfect agreement and 90% agreement between older adults and proxies: There was perfect agreement for 39 (51%) dyads and a difference of 1 or less (range 1-10) for 66 (86%) on the VES-13, perfect agreement for 48 (62%) and a difference of two or less (range 0-20) for 69 (89%) on the mBI, and perfect agreement for 27 (35%) and a difference of 12 or less (range 0-120) for 55 (71%) on the LSA. CONCLUSION: Proxy reports of older adults' preinjury physical function and frailty are in an acceptable range of agreement with those of the older adults. Using proxy reports when people cannot provide information on themselves may facilitate care management and goal setting.

The aging of America: a comprehensive look at over 25,000 geriatric trauma admissions to United States hospitals.

A 2001 study on geriatric trauma by trauma center (TC) status was based on 1989 Medicare data. The purpose of this study was to compare 1989 findings with a 2009 sample, and to examine patient characteristics and outcomes by TC status. From 2009 Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS) data, we examined a geographically representative sample (n = 25,512) of injured older adults (>/= age 65) admitted to 127 TCs and non-TCs in 24 states. Data analysis included descriptive statistics for eight patient characteristics and four outcome variables (mortality, discharge disposition, length of stay, and total charges). χ(2) tests were conducted to examine differences between 1989 and 2009 for age groups, gender, and mortality. Higher percentages of patients were in older age groups in 2009, however mortality declined overall (4.8% vs 3.4%, P < .001). Consistent incremental patterns of differences were observed among TC levels for all patient characteristics and outcomes. Level I TCs admitted highest percentages of: lower age groups, males, nonwhite race, motor-vehicle related trauma, and intracranial injuries. Non-TCs admitted highest percentages of oldest age groups, comorbidities, falls, femur neck fractures, and patients requiring OR procedures. Although Level I TCs had higher lengths of stay and total charges, a higher percentage of patients were discharged home. Despite a growing number of patients in older age groups, inpatient mortality declined over two decades. Level I TCs are managing patients at highest risk for decompensation and mortality; a significant percentage of patients are going to non-TCs.

Feasibility of screening for preinjury frailty in hospitalized injured older adults.

BACKGROUND: Frailty assessment of injured older adults (IOAs) is important for clinical management; however, the feasibility of screening for preinjury frailty has not been established in a Level I trauma center. The aims of our study were to assess enrollment rates of IOAs and their surrogates as well as completion rates of selected brief frailty screening instruments. METHODS: We conducted a prospective cohort study on patients, age 65 years and older with a primary injury diagnosis. Patients and/or surrogates were interviewed within 48 hours of admission using the Vulnerable Elders Survey (VES-13), Barthel Index (BI), and the Life Space Assessment (LSA). Data analysis included frequency distributions, χ statistics, Mann-Whitney and Kruskal-Wallis tests, and general linear modeling (analysis of variance). RESULTS: Of 395 admitted patients, 188 were enrolled with subsequent surrogate screening. Corresponding patient interviews were conducted for 77 patients (41%). Screening time was less than 5 minutes for each instrument, and item completion was 100%. Forty-two enrolled patients (22%) had nurse-reported delirium, and 69 (37%) patients either did not feel like answering questions or were unable to be interviewed secondary to their medical condition. The median score of surrogate responses for the VES-13 was 3.5 (interquartile range, 2-7), with 64% of the sample having a score of 3 or greater, indicating vulnerability or frailty. Median scores for the BI (19.0) and LSA (56.0) indicated high numbers with limitations in activities of daily living and limitations in mobilization. CONCLUSION: Screening for preinjury frailty in IOAs is feasible yet highly dependent on the presence of a surrogate respondent. A clinically significant percentage of patients have functional deficits consistent with frailty, dependence in activities of daily living, and limitations in mobilization. Implementation of validated brief screening instruments to identify frailty in clinical settings is warranted for targeting timely, efficient, and effective care interventions. LEVEL OF EVIDENCE: Epidemiologic study, level II.

An exploration of how midwives and physicians manage the third stage of labor in the United States.

INTRODUCTION: Care of the woman during the third stage of labor is a critical component of good patient outcomes. The type and extent of activities used in the United States, including those suggested for active management of the third stage of labor, are unknown. This study obtained preliminary data for the development of a national study of interventions used by US birth attendants during the third stage of labor, work that will ultimately lead to a study examining links between activities and outcomes. The specific aims were to identify provider-reported assessments and interventions used during the third stage of labor and to examine which management steps or interventions providers believe should always be used during the third stage of labor. METHODS: Four provider-specific focus groups (certified nurse-midwives, certified professional midwives, obstetricians, and family practice physicians) were held using a nominal group technique. Two researchers analyzed audio-recorded transcriptions independently. RESULTS: More than 100 assessments, 110 interventions, and 65 "always used" activities were identified. There was variation within and across groups. Midwife groups were more likely to specify maternal preference activities, and physician groups were more likely to specify drug-related actions. DISCUSSION: Surveys of third-stage labor practices must include large numbers of actions to represent what may be the state of US practices. Survey design may need to include a multiple-forms approach to avoid participant burden. Designs should include the exploration of differences by provider type as well as within provider variation.