Mortality of Mechanically Ventilated COVID-19 Patients in Traditional versus Expanded Intensive Care Units in New York.

Rationale: During the first wave of the coronavirus disease (COVID-19) pandemic in New York City, the number of mechanically ventilated COVID-19 patients rapidly surpassed the capacity of traditional intensive care units (ICUs), resulting in health systems utilizing other areas as expanded ICUs to provide critical care. Objectives: To evaluate the mortality of patients admitted to expanded ICUs compared with those admitted to traditional ICUs. Methods: Multicenter, retrospective, cohort study of mechanically ventilated patients with COVID-19 admitted to the ICUs at 11 Northwell Health hospitals in the greater New York City area between March 1, 2020 and April 30, 2020. Primary outcome was in-hospital mortality up to 28 days after intubation of COVID-19 patients. Results: Among 1,966 mechanically ventilated patients with COVID-19, 1,198 (61%) died within 28 days after intubation, 46 (2%) were transferred to other hospitals outside of the Northwell Health system, 722 (37%) survived in the hospital until 28 days or were discharged after recovery. The risk of mortality of mechanically ventilated patients admitted to expanded ICUs was not different from those admitted to traditional ICUs (hazard ratio [HR], 1.07; 95% confidence interval [CI], 0.95-1.20; P = 0.28), while hospital occupancy for critically ill patients itself was associated with increased risk of mortality (HR, 1.28; 95% CI, 1.12-1.45; P < 0.001). Conclusions: Although increased hospital occupancy for critically ill patients itself was associated with increased mortality, the risk of 28-day in-hospital mortality of mechanically ventilated patients with COVID-19 who were admitted to expanded ICUs was not different from those admitted to traditional ICUs.

Providing postpartum care with limited resources: Experiences of nurse-midwives and obstetricians in urban Tanzania.

BACKGROUND: Tanzania has high maternal and neonatal mortality rates. Comprehensive guidelines for postpartum care have been developed by the government as a means to improve health outcomes during the perinatal period. Despite the creation of these guidelines and the government's commitment to universal perinatal care for women and neonates, there is concern that the delivery of postpartum services may not be meeting the needs of mothers and neonates. AIM: The purpose of this feminist poststructuralist study was to explore nurse-midwives' and obstetricians' experiences of providing postpartum care in Tanzania. METHODS: This qualitative study used feminist poststructuralism to explore the personal, social, and institutional discourses of postpartum care. We individually interviewed ten nurse-midwives and three obstetricians in Dar es Salaam, Tanzania. Feminist poststructuralist discourse analysis was used to analyze the transcribed interviews after their translation from Kiswahili to English. FINDINGS: Four main themes were identified. In this paper, we present the main theme of availability of resources, and its four corresponding subthemes; (1) space, (2) equipment, (3) staffing, and (4) government responsibility. DISCUSSION: The findings from our study illustrate the need for health workforce planning to be addressed in a comprehensive manner that accounts for context, required resources and systemic challenges. These findings are consistent with findings from other studies. CONCLUSION: Understanding the resource challenges that nurse-midwives and obstetricians are facing in one low-and-middle-income-country will assist researchers, decision makers, and politicians as they address issues of mortality, morbidity, and disrespectful maternity care.

Saving lives with caring assessments: How Tanzanian nurse-midwives and obstetricians negotiate postpartum practices.

AIMS AND OBJECTIVES: To explore the nurse-midwives' and obstetricians' experiences delivering postpartum care assessments and how it was constructed through personal, social and institutional discourses. INTRODUCTION: The Tanzanian Government has prioritised maternal and child health as an urgent healthcare issue. Nurse-midwives and obstetricians are the two main providers of care throughout the prenatal and postpartum periods. DESIGN: A qualitative design guided by a feminist poststructuralist methodology. METHODS: Ten nurse-midwives and three obstetricians from three Regional Hospitals in Dar es Salaam participated in individual semi-structured in-depth interviews. RESULTS: Assessment emerged as a significant theme with three subthemes. Nurse-midwives shared their beliefs and values about assessments that focused on the safety of mothers and babies. They felt proud working with mothers and babies and shared their frustrations having to deal with inadequate working conditions. Guidelines and practices were part of the institutional discourse that impacted the day-to-day experiences of nurse-midwives and obstetricians. The nurse-midwives held the belief that it was vital to complete a comprehensive assessment to identify danger signs, keep mothers and babies safe and look for any abnormalities. They were concerned that mothers were being sent home too early. CONCLUSIONS: Nurse-midwives' experiences in the provision of postpartum care portray that these health providers work heartedly to make sure that the mothers and their newborns receive the best care they can provide. The health system is challenged to address the needed supplies and equipment for reproductive health in particular postpartum care services. RELEVANCE TO CLINICAL PRACTICE: Institutional health discourses significantly affect the practice of nurse-midwives and obstetricians to deliver timely and effective postpartum assessments. Immediate and ongoing postpartum assessments conducted by nurse-midwives and obstetricians can save lives. This study presents the first theme of the study: Caring assessments save lives.

The Challenges of Providing Postpartum Education in Dar es Salaam, Tanzania: Narratives of Nurse-Midwives and Obstetricians.

Postpartum education can save lives of mothers and babies in developing countries, and the World Health Organization recommends all mothers receive three postpartum consultations. More information is needed to better understand how postpartum education is delivered and ultimately improves postpartum health outcomes. The purpose of this qualitative study was to examine how postpartum care was delivered in three postnatal hospital clinics in Dar es Salaam, Tanzania. Semistructured interviews with 10 nurse-midwives and three obstetricians were conducted. Feminist poststructuralism guided the research process. Postpartum education was seen to be an urgent matter; there was a lack of supportive resources and infrastructure in the hospital clinics, and nurse-midwives and obstetricians had to negotiate conflicting health and traditional discourses using various strategies. Nurse-midwives and obstetricians are well positioned to deliver life-saving postpartum education; however, improvements are required including increased number of nurse-midwives and obstetricians.

Structural empowerment of clinical nurse managers.

OBJECTIVE: The purpose of this study was to describe perceptions of structural empowerment of clinical nurse managers (CNMs) in 1 large healthcare system. BACKGROUND: The recruitment and retention of CNMs are crucial to the future of healthcare institutions. Understanding the extent to which CNMs feel supported in the work environment and have access to resources, information, support, and opportunities to learn and develop will be beneficial to organizational effectiveness. METHODS: The sample included 140 CNMs from 1 large healthcare system in the northeastern United States. RESULTS: Consistent with previous research, CNMs in the present study had moderate levels of empowerment. They had lower than expected subscale scores on the resources subscale and acceptable scores on the subscales of support, formal power, and informal power. CONCLUSIONS: In the current changing healthcare environment, it is important to gain more understanding of the role of CNMs who are crucial to quality care and patient and nurse satisfaction. This study provides important baseline information about perceptions of structural empowerment among CNMs. Interventions that can be initiated to enhance the CNM empowerment are presented.

The Interprofessional Psychosocial Oncology Distance Education (IPODE) project: perceived outcomes of an approach to healthcare professional education.

The Interprofessional Psychosocial Oncology Distance Education (IPODE) project was designed as an approach to the problems of feasibility and accessibility in specialty health professional education, in this case, psychosocial oncology (PSO). In this article, we report the evaluation findings from the first three years of the project in relation to one IPODE course, which was offered as a graduate level university elective in nine Canadian universities and as a continuing education (CE) option to health professionals between January 2008 and May 2010. The evaluation included a pre and post questionnaire that explored how an interprofessional (IP), web-based, PSO course influenced participants' knowledge, attitudes and beliefs about IP, person-centered PSO care. It also examined what attributes of a web-based platform were most effective in delivering an IP PSO course. The study yielded two key findings. First, web-based learning in a pan-Canadian and cross-university collaboration is a viable alternative to providing specialty education and significantly improves knowledge, attitudes and beliefs about IP, person-centered PSO care. Second, a web-based platform with real-time seminars, discussion boards and multiple audio visual resources that privilege first person illness narratives were important elements in expanding knowledge and shifting attitudes about IP practice and person-centered care in regards to PSO. In their evaluation, course participants highlighted a variety of ways in which the course expanded their vision about what constitutes an IP team and increased their confidence in interacting with healthcare professionals from professions other than their own.

Preparing for the future: what nurses need to know.

This column outlines some of the challenges and opportunities for nurses in the coming years. Implications for nursing practice and education are highlighted.

Potential mechanism for recruitment and migration of CD133 positive cells to areas of vascular inflammation.

OBJECTIVE: Mast cells are found in large numbers in atherosclerotic plaques. The present study was conducted to determine whether tryptase stimulation of human coronary artery endothelial cells (HCAEC) would lead to an increase in transmigration of CD133 positive cells (CD133+). In vitro these cells can differentiate into mast cells under the influence of specific cytokines and growth factors. METHODS AND RESULTS: CD133+ cells were isolated from umbilical cord blood. They express mRNA for several adhesion molecules that are also utilized in neutrophil migration and can migrate across an HCAEC monolayer. Migration increased significantly when HCAEC were stimulated with tryptase and decreased when CD133+ cells were pretreated with CV3988, a platelet activating factor receptor (PTAFR) antagonist. Following long-term cell culture, these cells stained positively for the presence of tryptase, a mast cell enzyme. CONCLUSION: CD133+ cells can be utilized as a mast cell precursor population. The transendothelial migration is facilitated by the presence of tryptase and may utilize the PAF/PTAFR interaction in a manner similar to that involved in neutrophil transmigration. Following transmigration, a subset of these progenitor cells may mature into mast cells in the subendothelial space and play a role in propagation of the inflammatory process in atherosclerosis.

Lysoplasmenylcholine increases neutrophil adherence to human coronary artery endothelial cells.

We demonstrated previously that thrombin stimulation of human coronary artery endothelial cells (HCAEC) results in release of choline lysophospholipids [lysophosphatidylcholine (lysoPtdCho) and lysoplasmenylcholine (lysoPlsCho)]. These amphiphilic metabolites have been implicated in arrhythmogenesis following the onset of myocardial ischemia, but studies examining their direct effects on the vasculature remain limited. We and others have shown that thrombin and lysoPtdCho can increase cell surface adhesion molecules and adherence of circulating inflammatory cells to the endothelium. This study supports our hypothesis that these changes may be mediated, at least in part, by lysoPlsCho, thus implicating this metabolite as an inflammatory mediator in the coronary vasculature and a modulator of the progression of atherosclerosis. Apical stimulation of HCAEC with thrombin resulted in the production and release of choline lysophospholipids from the apical surface of the HCAEC monolayer. Basolateral stimulation had no effect on choline lysophospholipid production or release from either the apical or basolateral surface of the HCAEC monolayer. Incubation of HCAEC with lysoPlsCho or lysoPtdCho resulted in similar increases in HCAEC surface expression of P-selectin and E-selectin. Furthermore, lysoPlsCho increased cell surface expression of P-selectin, E-selectin, vascular cell adhesion molecule-1, and intercellular adhesion molecule-1 with a time course similar to that of thrombin stimulation. Increased presence of cell surface adhesion molecules may contribute to the significant increase in adherence of neutrophils to either thrombin- or lysoPlsCho-stimulated HCAEC. These results demonstrate that the presence of thrombin at sites of vascular injury in the coronary circulation, resulting in increased choline lysophospholipid release from the HCAEC apical surface, has the potential to propagate vascular inflammation by upregulation of adhesion molecules and recruitment of circulating inflammatory cells to the endothelium.

Cultural competence among staff nurses who participated in a family-centered geriatric care program.

The purpose of this training program was to prepare nursing staff in family-centered geriatric care that emphasizes providing culturally competent care to hospitalized elders at two major tertiary hospitals in New York. This research report corresponds to the first phase of a 3-year project. In this research project, a descriptive exploratory design was used to identify the levels of cultural awareness and cultural competence of nursing staff who participated in a family-centered geriatric care training program.

Protease activation of calcium-independent phospholipase A2 leads to neutrophil recruitment to coronary artery endothelial cells.

INTRODUCTION: Thrombin or tryptase cleavage of protease-activated receptors (PAR) on human coronary artery endothelial cells (HCAEC) results in activation of a membrane-associated, calcium-independent phospholipase A2 (iPLA2) that selectively hydrolyzes plasmalogen phospholipids. Atherosclerotic plaque rupture results in a coronary ischemic event in which HCAEC in the ischemic area would be exposed to increased thrombin concentrations in addition to tryptase released by activated mast cells present in the plaque. MATERIALS AND METHODS: HCAEC were stimulated with thrombin or tryptase in the absence or presence of bromoenol lactone (BEL), a selective iPLA2 inhibitor, and iPLA2 activation, accumulation of biologically active membrane phospholipid-derived metabolites, upregulation of cell surface P-selectin expression and neutrophil adherence were measured. RESULTS: HCAEC exposed to thrombin or tryptase stimulation demonstrated an increase in iPLA2 activity and arachidonic acid release. Additionally, stimulated HCAEC demonstrated increased platelet-activating factor (PAF) production and cell surface P-selectin expression, resulting in increased adhesion of neutrophils to HCAEC monolayers. Pretreatment with bromoenol lactone to inhibit iPLA2, blocked membrane phospholipid-derived metabolite production, increased cell surface P-selectin expression and neutrophil adherence. CONCLUSIONS: The similar biochemical and cellular responses in HCAEC exposed to thrombin or tryptase stimulation suggest that the cleavage of two separate PAR serve to extend the range of proteases to which the cells respond rather than resulting in separate intracellular events. This suggests that in conditions such as thrombosis and atherosclerosis that multiple mechanisms can activate the inflammatory response.

Strategic positioning for nursing excellence in health systems: insights from chief nursing executives.

The emergence of health systems as a dominant structure for organizing healthcare has stimulated the development of health system chief nursing executive (CNE) positions. These positions have large spans of control, requiring CNEs to balance a wide range of responsibilities, making them accountable for fiscal management, quality of care, compliance, and contributing to organizational growth. As such the CNE is required to use principles of distributive justice to guide priority setting and decision making. This review addresses important questions about CNE system integration strategies, strategic priorities, and organizational positioning as they attempt to fulfill their ethical responsibilities to patients and the nurses they serve.

Nursing care quality initiative for care of hospitalized elders and their families.

This report describes a Nursing Care Quality Initiative (NCQI) through which a new model of care for hospitalized older adults and their families, the Family-Centered Geriatric Resource Nurse (FCGRN) model, was introduced. Eighteen units in 10 hospitals participated in the NCQI Project. Educational, clinical, and evaluation components of the NCQI Project are described.

Hospitalized elders: changes in functional and mental status.

This article describes outcomes of a new model of care for hospitalized elders and their families. Patient functional and cognitive status on admission and discharge were evaluated for changes as a result of an educational program for preparing family-centered geriatric resource nurses. Patients in the intervention group (n = 173) demonstrated significant improvements in outcome measures (functional and cognitive status) from admission to discharge. A subset (n = 50) was selected from the 173 subjects who comprised the intervention group; this subset was compared with control subjects (n = 44); no statistically significant differences were noted between the 2 groups. Suggestions for future research are presented.

Reinforcing organizationwide pressure ulcer reduction on high-risk geriatric inpatient units.

Skin care and pressure ulcer prevention programs abound, although their content varies and their outcomes are often difficult to quantify. This article describes 2 complementary programs, their quality improvement processes, and a variety of ways of measuring their success. The first program was broad in scope, emphasizing system-wide changes in administration and coordination of resources, while the second focused on nursing education on high-risk units. These 2 approaches could be adapted for use in any health care setting.