Identification of Acute Kidney Injury Subphenotypes with Differing Molecular Signatures and Responses to Vasopressin Therapy.

RATIONALE: Currently, no safe and effective pharmacologic interventions exist for acute kidney injury (AKI). One reason may be that heterogeneity exists within the AKI population, thereby hampering the identification of specific pathophysiologic pathways and therapeutic targets. OBJECTIVE: The aim of this study was to identify and test whether AKI subphenotypes have prognostic and therapeutic implications. METHODS: First, latent class analysis methodology was applied independently in two critically ill populations (discovery [n = 794] and replication [n = 425]) with AKI. Second, a parsimonious classification model was developed to identify AKI subphenotypes. Third, the classification model was applied to patients with AKI in VASST (Vasopressin and Septic Shock Trial; n = 271), and differences in treatment response were determined. In all three populations, AKI was defined using serum creatinine and urine output. MEASUREMENTS AND MAIN RESULTS: A two-subphenotype latent class analysis model had the best fit in both the discovery (P = 0.004) and replication (P = 0.004) AKI groups. The risk of 7-day renal nonrecovery and 28-day mortality was greater with AKI subphenotype 2 (AKI-SP2) relative to AKI subphenotype 1 (AKI-SP1). The AKI subphenotypes discriminated risk for poor clinical outcomes better than the Kidney Disease: Improving Global Outcomes stages of AKI. A three-variable model that included markers of endothelial dysfunction and inflammation accurately determined subphenotype membership (C-statistic 0.92). In VASST, vasopressin compared with norepinephrine was associated with improved 90-day mortality in AKI-SP1 (27% vs. 46%, respectively; P = 0.02), but no significant difference was observed in AKI-SP2 (45% vs. 49%, respectively; P = 0.99) and the P value for interaction was 0.05. CONCLUSIONS: This analysis identified two molecularly distinct AKI subphenotypes with different clinical outcomes and responses to vasopressin therapy. Identification of AKI subphenotypes could improve risk prognostication and may be useful for predictive enrichment in clinical trials.

Worksite Walkthrough Intervention: Data-driven Prevention of Workplace Violence on Hospital Units.

OBJECTIVE: The aim of this study was to describe the implementation of a data-driven, unit-based walkthrough intervention shown to be effective in reducing the risk of workplace violence in hospitals. METHODS: A structured worksite walkthrough was conducted on 21 hospital units. Unit-level workplace violence data were reviewed and a checklist of possible prevention strategies and an Action Plan form guided development of unit-specific intervention. Unit supervisor perceptions of the walkthrough and implemented prevention strategies were reported via questionnaires. Prevention strategies were categorized as environmental, behavioral, or administrative. RESULTS: A majority of units implemented strategies within 12 months' postintervention. Participants found the walkthrough useful, practical, and worthy of continued use. CONCLUSIONS: Structured worksite walkthroughs provide a feasible method for workplace violence reduction in hospitals. Core elements are standardized yet flexible, promoting fidelity and transferability of this intervention.

Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention.

OBJECTIVE: To evaluate the effects of a randomized controlled intervention on the incidence of patient-to-worker (Type II) violence and related injury in hospitals. METHODS: Forty-one units across seven hospitals were randomized into intervention (n = 21) and control (n = 20) groups. Intervention units received unit-level violence data to facilitate development of an action plan for violence prevention; no data were presented to control units. Main outcomes were rates of violent events and injuries across study groups over time. RESULTS: Six months post-intervention, incident rate ratios of violent events were significantly lower on intervention units compared with controls (incident rate ratio [IRR] 0.48, 95% confidence interval [CI] 0.29 to 0.80). At 24 months, the risk for violence-related injury was lower on intervention units, compared with controls (IRR 0.37, 95% CI 0.17 to 0.83). CONCLUSIONS: This data-driven, worksite-based intervention was effective in decreasing risks of patient-to-worker violence and related injury.

Worker-to-Worker Violence in Hospitals: Perpetrator Characteristics and Common Dyads.

Worker-to-worker (Type III) violence is prevalent in health care settings and has potential adverse consequences for employees and organizations. Little research has examined perpetrator characteristics of this type of violence. The current study is a descriptive examination of the common demographic and work-related characteristics of perpetrators of Type III workplace violence among hospital workers. Analysis was based on documented incidents of Type III violence reported within a large hospital system from 2010 to 2012. Nurses were involved as either the perpetrator or target in the five most common perpetrator-target dyads. Incidence rate ratios revealed that patient care associates and nurses were significantly more likely to be perpetrators than other job titles. By examining characteristics of perpetrators and common worker dyads involved in Type III workplace violence, hospital stakeholders and unit supervisors have a starting point to develop strategies for reducing conflict between workers.

Underreporting of Workplace Violence: Comparison of Self-Report and Actual Documentation of Hospital Incidents.

This study examined differences between self-report and actual documentation of workplace violence (WPV) incidents in a cohort of health care workers. The study was conducted in an American hospital system with a central electronic database for reporting WPV events. In 2013, employees (n = 2010) were surveyed by mail about their experience of WPV in the previous year. Survey responses were compared with actual events entered into the electronic system. Of questionnaire respondents who self-reported a violent event in the past year, 88% had not documented an incident in the electronic system. However, more than 45% had reported violence informally, for example, to their supervisors. The researchers found that if employees were injured or lost time from work, they were more likely to formally report a violent event. Understanding the magnitude of underreporting and characteristics of health care workers who are less likely to report may assist hospitals in determining where to focus violence education and prevention efforts.

Catalysts of worker-to-worker violence and incivility in hospitals.

AIMS AND OBJECTIVES: To identify common catalysts of worker-to-worker violence and incivility in hospital settings. BACKGROUND: Worker-to-worker violence and incivility are prevalent forms of mistreatment in healthcare workplaces. These are forms of counterproductive work behaviour that can lead to negative outcomes for employees, patients and the organisation overall. Identifying the factors that lead to co-worker mistreatment is a critical first step in the development of interventions targeting these behaviours. DESIGN: Retrospective descriptive study. METHODS: Qualitative content analysis was conducted on the total sample (n = 141) of employee incident reports of worker-to-worker violence and incivility that were documented in 2011 at a large American hospital system. RESULTS: More than 50% of the incidents involved nurses, and the majority of incidents did not involve physical violence. Two primary themes emerged from the analysis: Work Behaviour and Work Organisation. Incidents in the Work Behaviour category were often sparked by unprofessional behaviour, disagreement over responsibilities for work tasks or methods of patient care, and dissatisfaction with a co-worker's performance. Incidents in the Work Organisation category involved conflicts or aggression arising from failure to following protocol, patient assignments, limited resources and high workload. CONCLUSION: Incidents of worker-to-worker violence and incivility stemmed from dissatisfaction with employee behaviour or from organisational practices or work constraints. These incident descriptions reflect worker dissatisfaction and frustration, resulting from poor communication and collaboration between employees, all of which threaten work productivity. RELEVANCE TO CLINICAL PRACTICE: Violence and incivility between hospital employees can contribute to turnover of top performers, hinder effective teamwork and jeopardise the quality of patient care. Identification of common catalysts for worker-to-worker violence and incivility informs the development of mistreatment prevention programmes that can be used to educate hospital staff.

Application and implementation of the hazard risk matrix to identify hospital workplaces at risk for violence.

BACKGROUND: A key barrier to preventing workplace violence injury is the lack of methodology for prioritizing the allocation of limited prevention resources. The hazard risk matrix was used to categorize the probability and severity of violence in hospitals to enable prioritization of units for safety intervention. METHODS: Probability of violence was based on violence incidence rates; severity was based on lost time management claims for violence-related injuries. Cells of the hazard risk matrix were populated with hospital units categorized as low, medium, or high probability and severity. Hospital stakeholders reviewed the matrix after categorization to address the possible confounding of underreporting. RESULTS: Forty-one hospital units were categorized as medium or high on both severity and probability and were prioritized for forthcoming interventions. Probability and severity were highest in psychiatric care units. CONCLUSIONS: This risk analysis tool may be useful for hospital administrators in prioritizing units for violence injury prevention efforts.

Understanding health care personnel's attitudes toward mandatory influenza vaccination.

BACKGROUND: This study investigated the factors influencing influenza vaccination rates among health care personnel (HCP) and explored HCP's attitudes toward a policy of mandatory vaccination. METHODS: In September 2012, a 33-item Web-based questionnaire was administered to 3,054 HCP employed at a tertiary care hospital in metropolitan Detroit. RESULTS: There was a significant increase in the rate of influenza vaccination, from 80% in the 2010-2011 influenza season (before the mandated influenza vaccine) to 93% in 2011-2012 (after the mandate) (P < .0001). Logistic regression showed that HCP with a history of previous influenza vaccination were 7 times more likely than their peers without this history to receive the vaccine in 2011-2012. A pro-mandate attitude toward influenza vaccination was a significant predictor of receiving the vaccine after adjusting for demographics, history of previous vaccination, awareness of the hospital's mandatory vaccination policy, and patient contact while providing care (P = .01). CONCLUSIONS: The increased rate of influenza vaccination among HCP was driven by both an awareness of the mandatory policy and a pro-mandate attitude toward vaccination. The findings of this study call for better education of HCP on the influenza vaccine along with enforcement of a mandatory vaccination policy.

A unique rodent model of cardiometabolic risk associated with the metabolic syndrome and polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is characterized by hyperandrogenism, oligo-/anovulation, and polycystic ovarian morphology and is a complex endocrine disorder that also presents with features of the metabolic syndrome, including obesity, insulin resistance, and dyslipidemia. These latter symptoms form cardiometabolic risk factors predisposing individuals to the development of type 2 diabetes and cardiovascular disease (CVD). To date, animal models to study PCOS in the context of the metabolic syndrome and CVD risk have been lacking. The aim of this study was to investigate the JCR:LA-cp rodent as an animal model of PCOS associated with the metabolic syndrome. Metabolic indices were measured at 6 and 12 wk, and reproductive parameters including ovarian morphology and estrous cyclicity were assessed at 12 wk or adulthood. At 6 wk of age, the cp/cp genotype of the JCR:LA-cp strain developed visceral obesity, insulin resistance, and dyslipidemia (hypertriglyceridemia and hypercholesterolemia) compared with control animals. Serum testosterone concentrations were not significantly different between groups at 6 wk of age. However, at 12 wk, the cp/cp genotype had higher serum testosterone concentrations, compared with control animals, and presented with oligoovulation, a decreased number of corpora lutea, and an increased number of total follicles, in particular atretic and cystic follicles. The cardiometabolic risk factors in the cp/cp animals were exacerbated at 12 wk including obesity, insulin resistance, and dyslipidemia. The results of this study demonstrate that the JCR:LA-cp rodent may be a useful PCOS-like model to study early mechanisms involved in the etiology of cardiometabolic risk factors in the context of both PCOS and the metabolic syndrome.