Relationship Quality and Sexuality: A Latent Profile Analysis of Long-term Heterosexual and LGB Long-term Partnerships.

Purpose: Drawing on survey data (N = 7,826) collected in the United Kingdom, Australia, and the United States, this paper examines whether sexual orientation is a differentiating factor in explaining relationship quality and maintenance. Previous research suggests that sexual orientation is not significant in determining relationship satisfaction; however, these analyses have used traditional variable driven approaches, which do not provide an holistic view of the relationship by considering the unique combination of characteristics.Method: In this study, latent profile analyses were used, which is a person-centered approach that allows for identification of different types of long-term relationships.Results: Data suggested that LGB individuals had marginally higher levels of relationship quality compared to their heterosexual counterparts, and sexual orientation was also associated with differing types of long-term relationships.Discussion: These findings are interrogated in more detail, in particular, how sexual orientation is associated with types of long-term relationships and how everyday practices are associated with relationship quality.

Tumefactive synovial thickening mimicking synovial chondromatosis in the setting of oligoarticular juvenile idiopathic arthritis in a toddler.

Juvenile idiopathic arthritis (JIA) is the most common cause of arthritis in children. It is characterized by inflammatory cell infiltration of synovial membranes leading to synovitis and synovial membrane thickening. Synovial chondromatosis is rare sequela of synovitis in which foci of cartilage develop within the synovial membrane of a joint capsule. We report a case of a 35-month old boy who developed tumefactive synovial hypertrophy and hyperplasia that mimicked synovial chondromatosis on MRI. The reactive synovium was arthroscopically excised and the patient's arthritis improved. Tumefactive synovial hypertrophy and hyperplasia mimicking synovial chondromatosis on MRI in the setting of JIA, has not been reported in this young of a patient in the literature to date. A discussion on imaging in oligoarticular JIA and synovial chondromatosis is presented herein.

Subacute Osteomyelitis of the Pediatric Talus: A First Report of Brodie's Abscess from Morganella morganii.

Brodie's abscess is a subacute form of osteomyelitis which generally occurs in the metaphysis of the femur and tibia in the pediatric population. Pathogens are most commonly Gram-positive bacteria, notably Staphylococcus and Streptococcus. In this article, we describe a young pediatric patient presenting with subacute ankle pain with a subsequent diagnosis of Brodie's abscess of the talus secondary to Morganella morganii. We review the presentation, diagnosis, and treatment of this unique patient. To our knowledge, this is the first report of Morganella morganii as a cause of Brodie's abscess.

Measuring Relationship Quality in an International Study: Exploratory and Confirmatory Factor Validity.

OBJECTIVE: This study reports on the operationalization and testing of the newly developed Relationship Quality (RQ) scale, designed to assess an individual's perception of his or her RQ in their current partnership. METHODS: Data were generated through extended sampling from an original U.K.-based research project, Enduring Love? Couple relationships in the 21st century. This mixed methods study was designed to investigate how couples experience, understand, and sustain their long-term relationships. This article utilizes the cross-sectional, community sample (N = 8,132) from this combined data set, drawn primarily from the United Kingdom, United States, and Australia. A two-part approach to scale development was employed. An initial 15-item pool was subjected to exploratory factor analysis leading into confirmatory factor analysis using structural equation modeling. RESULTS: The final 9-item scale evidenced convergent construct validity and known-groups validity along with strong reliability. CONCLUSION: Implications for future research and professional practice are discussed.

Improving patient safety and optimizing nursing teamwork using crew resource management techniques.

OBJECTIVE: This project describes the application of the "sterile cockpit rule," a crew resource management (CRM) technique, targeted to improve efficacy and safety for nursing assistants in the performance of patient care duties. BACKGROUND: Crew resource management techniques have been successfully implemented in the aviation industry to improve flight safety. Application of these techniques can improve patient safety in medical settings. METHODS: The Veterans Affairs (VA) National Center for Patient Safety conducted a CRM training program in select VA nursing units. One unit developed a novel application of the sterile cockpit rule to create protected time for certified nursing assistants (CNAs) while they collected vital signs and blood glucose data at the beginning of each shift. RESULTS: The typical nursing authority structure was reversed, with senior nurses protecting CNAs from distractions. This process led to improvements in efficiency and communication among nurses, with the added benefit of increased staff morale. CONCLUSION: Crew resource management techniques can be used to improve efficiency, morale, and patient safety in the healthcare setting.

Association between implementation of a medical team training program and surgical morbidity.

OBJECTIVE: To determine whether there is an association between the Veterans Health Administration Medical Team Training (MTT) program and surgical morbidity. DESIGN, SETTING, AND PARTICIPANTS: A retrospective health services study was conducted with a contemporaneous control group. Outcome data were obtained from the Veterans Health Administration Surgical Quality Improvement Program. The analysis included aggregated measures representing 119,383 sampled procedures from 74 Veterans Health Administration facilities that provide care to veterans. MAIN OUTCOME MEASURES: The primary outcome measure was the rate of change in annual surgical morbidity rate 1 year after facilities enrolled in the MTT program as compared with 1 year before and compared with the non-MTT program sites. RESULTS: Facilities in the MTT program (n = 42) had a significant decrease of 17% in observed annual surgical morbidity rate (rate ratio, 0.83; 95% CI, 0.79-0.88; P = .01). Facilities not trained (n = 32) had an insignificant decrease of 6% in observed morbidity (rate ratio, 0.94; 95% CI, 0.86-1.05; P = .11). After adjusting for surgical risk, we found a decrease of 15% in morbidity rate for facilities in the MTT program and a decrease of 10% for those not yet in the program. The risk-adjusted annual surgical morbidity rate declined in both groups, and the decline was 20% steeper in the MTT program group (P = .001) after propensity-score matching. The steeper decline in annual surgical morbidity rates was also observed in specific morbidity outcomes, such as surgical infection. CONCLUSION: The Veterans Health Administration MTT program is associated with decreased surgical morbidity.

Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program.

There are differences between nurse and physician perceptions of teamwork. The purpose of this study was to determine whether these differences would be reduced with medical team training (MTT). The Safety Attitudes Questionnaire was administered to nurses and physicians working in the operating rooms of 101 consecutive hospitals before and at the completion of an MTT program. Responses to the 6 teamwork climate items on the Safety Attitudes Questionnaire were analyzed using nonparametric testing. At baseline, physicians had more favorable perceptions on teamwork climate items than nurses. Physicians demonstrated improvement on all 6 teamwork climate items. Nurses demonstrated improvement in perceptions on all teamwork climate items except "Nurse input is well received." Physicians still had a more favorable perception than nurses on all 6 teamwork climate items at follow-up. Despite an improvement in perceptions by physicians and nurses, baseline nurse-physician differences persisted at completion of the Veterans Health Administration MTT Program.

Changing perceptions of safety climate in the operating room with the Veterans Health Administration medical team training program.

Perceptions of organizational commitment to safety differ between the operating rooms in high- and medium-complexity facilities of the Veterans Health Administration (VHA). The purpose of this study was to see whether medical team training (MTT) reduced this difference. The Safety Attitudes Questionnaire was administered before and at the completion of a MTT program. The study population consisted of respondents working in the operating room. Responses to the 7 safety climate items were analyzed using nonparametric tests. Before MTT, respondents working at medium-complexity facilities had more favorable perceptions of knowledge of proper channels and encouragement by colleagues to report safety concerns than respondents who work at high-complexity facilities. At completion, there was no difference in perceptions between respondents working at high- and medium-complexity facilities for these items. The VHA MTT program improved perceptions at both high- and medium-complexity facilities and eliminated differences present at baseline.

Association between implementation of a medical team training program and surgical mortality.

CONTEXT: There is insufficient information about the effectiveness of medical team training on surgical outcomes. The Veterans Health Administration (VHA) implemented a formalized medical team training program for operating room personnel on a national level. OBJECTIVE: To determine whether an association existed between the VHA Medical Team Training program and surgical outcomes. DESIGN, SETTING, AND PARTICIPANTS: A retrospective health services study with a contemporaneous control group was conducted. Outcome data were obtained from the VHA Surgical Quality Improvement Program (VASQIP) and from structured interviews in fiscal years 2006 to 2008. The analysis included 182,409 sampled procedures from 108 VHA facilities that provided care to veterans. The VHA's nationwide training program required briefings and debriefings in the operating room and included checklists as an integral part of this process. The training included 2 months of preparation, a 1-day conference, and 1 year of quarterly coaching interviews MAIN OUTCOME MEASURE: The rate of change in the mortality rate 1 year after facilities enrolled in the training program compared with the year before and with nontraining sites. RESULTS: The 74 facilities in the training program experienced an 18% reduction in annual mortality (rate ratio [RR], 0.82; 95% confidence interval [CI], 0.76-0.91; P = .01) compared with a 7% decrease among the 34 facilities that had not yet undergone training (RR, 0.93; 95% CI, 0.80-1.06; P = .59). The risk-adjusted mortality rates at baseline were 17 per 1000 procedures per year for the trained facilities and 15 per 1000 procedures per year for the nontrained facilities. At the end of the study, the rates were 14 per 1000 procedures per year for both groups. Propensity matching of the trained and nontrained groups demonstrated that the decline in the risk-adjusted surgical mortality rate was about 50% greater in the training group (RR,1.49; 95% CI, 1.10-2.07; P = .01) than in the nontraining group. A dose-response relationship for additional quarters of the training program was also demonstrated: for every quarter of the training program, a reduction of 0.5 deaths per 1000 procedures occurred (95% CI, 0.2-1.0; P = .001). CONCLUSION: Participation in the VHA Medical Team Training program was associated with lower surgical mortality.

Medical team training and coaching in the Veterans Health Administration; assessment and impact on the first 32 facilities in the programme.

BACKGROUND: Communication is problematic in healthcare. The Veterans Health Administration is implementing Medical Team Training. The authors describe results of the first 32 of 130 sites to undergo the programme. This report is unique; it provides aggregate results of a crew resource-management programme for numerous facilities. METHODS: Facilities were taught medical team training and implemented briefings, debriefings and other projects. The authors coached teams through consultative phone interviews over a year. Implementation teams self-reported implementation and rated programme impact: 1='no impact' and 5='significant impact.' We used logistic regression to examine implementation of briefing/debriefing. RESULTS: Ninety-seven per cent of facilities implemented briefings and debriefings, and all implemented an additional project. As of the final interview, 73% of OR and 67% of ICU implementation teams self-reported and rated staff impact 4-5. Eighty-six per cent of OR and 82% of ICU implementation teams self-reported and rated patient impact 4-5. Improved teamwork was reported by 84% of OR and 75% of ICU implementation teams. Efficiency improvements were reported by 94% of OR implementation teams. Almost all facilities (97%) reported a success story or avoiding an undesirable event. Sites with lower volume were more likely to conduct briefings/debriefings in all cases for all surgical services (p=0.03). CONCLUSIONS: Sites are implementing the programme with a positive impact on patients and staff, and improving teamwork, efficiency and safety. A unique feature of the programme is that implementation was facilitated through follow-up support. This may have contributed to the early success of the programme.

Rural veteran access to healthcare services: investigating the role of information and communication technologies in overcoming spatial barriers.

This multimethod pilot study examined patient and practitioner perspectives on the influence of spatial barriers to healthcare access and the role of health information technology in overcoming these barriers. The study included a survey administered to patients attending a Department of Veterans Affairs (VA) health visit, and a focus group with VA care providers. Descriptive results and focus group findings are presented. Spatial distance is a significant factor for many rural veterans when seeking healthcare. For this sample of rural veterans, a range of telephone, computer, and Internet technologies may become more important for accessing care as Internet access becomes more ubiquitous and as younger veterans begin using the VA health system. The focus group highlighted the negative impact of distance, economic considerations, geographic barriers, and specific medical conditions on access to care. Lack of adequate technology infrastructure was seen as an obstacle to utilization. This study discusses the need to consider distance, travel modes, age, and information technology infrastructure and adoption when designing health information technology to care for rural patients.

Differences in nurse and surgeon perceptions of teamwork: implications for use of a briefing checklist in the OR.

The quality of teamwork among health care professionals is known to affect patient outcomes. In the OR, surgeons report more favorable perceptions of communication during procedures and of teamwork effectiveness than do nurses. We undertook a quality improvement project in the Veterans Health Administration to confirm reported teamwork differences between perioperative nurses and surgeons and to examine the implications of these differences for improving practice patterns in the OR. The Safety Attitudes Questionnaire, which measures safety culture, including the quality of communication and collaboration among health care providers who routinely work together, was administered in 34 hospitals. Perioperative nurses who participated in the survey rated teamwork higher with other nurses than with surgeons, but surgeons rated teamwork high with each other and with nurses. On five of six communication and collaboration items, surgeons had a significantly more favorable perception than did perioperative nurses. To increase the likelihood of success when implementing the use of checklist-based crew resource management tools, such as the World Health Organization's Surgical Safety Checklist, project leaders should anticipate differences in perception between members of the different professions that must be overcome if teamwork is to be improved.

The effect of facility complexity on perceptions of safety climate in the operating room: size matters.

This study explores the effect of facility complexity on operating room (OR) caregiver perceptions of safety climate in the Veterans Health Administration (VHA). Facility complexity is a standardized score based on volume, risk, teaching, research, and intensive care unit capability. The Safety Attitudes Questionnaire was administered at 34 VHA hospitals. The authors performed analysis of variance on safety climate item scores by facility complexity and Bonferroni post hoc probes. Caregivers at high-complexity facilities were significantly less likely to agree that "Medical errors are handled appropriately in this hospital" than caregivers at medium-complexity facilities. Caregivers at high-complexity facilities were significantly more likely to agree that "I know the proper channels to direct questions regarding patient safety in the ORs here" than caregivers at medium-complexity facilities. Differences in caregiver perceptions of safety climate by facility complexity are present. Awareness of these differences can help when facilities implement surgical safety procedures.

Use of the Safety Attitudes Questionnaire as a measure in patient safety improvement.

BACKGROUND: There is widespread interest in improving safety for patients receiving medical care, yet direct measurement of harm has been elusive. The Safety Attitudes Questionnaire is a validated measure of patient safety culture that has been associated with improved patient outcomes. We report on an attempt to use the Safety Attitude Questionnaire as an outcome measure for a patient safety implementation project. METHODS: Operating room staffs at 63 Veterans Affairs Medical Centers were surveyed using the Safety Attitude Questionnaire before and after a medical team training (MTT) program focused on improving staff communication. Survey results before and after MTT within medical centers were compared using nonparametric statistical testing. RESULTS: Of the 63 VA hospitals that received medical team training, 26 showed changes in the staff's attitude as measured by the Safety Attitudes Questionnaire. Improvement was most common in the "perceptions of management" domain. There was no correlation between survey response rate and measured improvement. CONCLUSIONS: The Safety Attitudes Questionnaire demonstrated good utility as a possible proxy measure of patient safety in the implementation study of MTT. Health care organizations may consider using it to measure effectiveness of safety improvement activities.

Interosseous nerve transfers for tibialis anterior muscle paralysis (foot drop): a human cadaver-based feasibility study.

This study explored the anatomical feasibility of using an interosseous nerve transfer (routed between the tibia and fibula) to restore motor function to the tibialis anterior (TA) muscle, following injury to the common peroneal nerve (resulting in a foot drop). The specific nerve branches evaluated as possible donor nerves included the nerves to the medial gastrocnemius, the lateral gastrocnemius, and the soleus muscles. All nerve transfers were accomplished using a direct interosseous route and a direct repair (one medial gastrocnemius transfer did require interpositional grafting). The distance from the repair site to the TA muscle was shortest for the transfer using the nerve branch to the soleus. Histologically, the nerve branch to the soleus was most similar to the branch to the TA for both axonal count and cross-sectional area. A two-incision surgical approach using a fibular window (mobilizing a fibular segment after double osteotomy) and interosseous routing of the transfer is proposed.