Strengthening New Nurse Manager Leadership Skills Through a Transition-to-Practice Program.

The nurse manager role is increasingly complex, and oftentimes, leadership competencies are learned through experience rather than an effective role transition. The need for a transition-to-practice program for new nurse managers is frequently cited in the literature. This evidence-based practice project resulted in significant improvement in leadership competencies and was used in the development of an American Organization for Nursing Leadership nurse manager transition-to-practice program to be offered in 2021.

["Alternanza scuola lavoro": an observational study of the experience in Italy in upper secondary school in the years 2016-2018.] / Alternanza Scuola Lavoro: uno studio osservazionale dell'esperienza in Italia nella scuola secondaria di secondo grado negli anni 2016-2018.

SUMMARY: Objectives. To assess the results of the national survey published by skuola.net addressed to students involved in the "Alternanza Scuola-Lavoro"(ASL) project in the years 2016-2018. Methods. An anonymous online survey was employed to gather information on students' experiences during the ASL project. Chi-squared test was performed for the univariate analysis. Results. A total of 8695 questionnaires were included in the analysis. The results of the descriptive and univariate analysis showed that a large number of students, especially those living in Northern Italy, performed more than 15 days of ASL during the year. In addition, students belonging to technical and professional institutes spent more hours compared to classical and scientific high schools ones. Employment in private companies was greater in the North than in the Center and South (54.9% vs 47.7% vs 47.7%, p minor than 0.001). In classical and scientific institutes, on the other hand, there were more students who replied that they had received a theoretical training at work (23% vs. 19.7 p minor than 0.001) or that they had carried out "outline tasks such as making photocopies, cleaning etc.". (19.6 vs 11.5, p mionr than 0.001). Another aspect investigated what kind of training they had had about safety at the workplace before starting the experience in the company: among the students resident in the South and in the Islands there was the highest number of negative responses, in fact 30.8% answered "No, by no one", compared to 15.2% in the North and 17.6% in the Center (p minor than 0.001). Conclusions. The ASL represented a concrete attempt to overcome the distinction between the world of education and the world of work within the Italian educational system. There were also some critical issues in its implementation, such as the lower involvement of classical and scientific high school students in projects consistent with their studies and their future prospects, compared to those of technical and commercial institutes. There was also a lack of homogeneity in the quality of the experiences lived between geographical macro areas, which reflects the diversity of employment opportunities present on the national territory.

Market competition and demand for skills in a credence goods market: Evidence from face-to-face and web-based non-physician clinician training in rural China.

BACKGROUND: Non-physician clinicians (NPCs) providing services in functionally private markets account for a large share of the workforce in the primary care system in many low-income and middle-income countries. Although regular in-service training is believed to be crucial to updating NPCs' professional knowledge, skills, and practices, participation rates are often low. Low participation may result from the "credence good" nature of the market for primary care: if patients are unable to observe quality improvements from training, NPCs have weaker incentives to participate. Empirical evidence is limited on the relationship between market competition and NPC participation in-service training as well as how participation varies with the type of training available. METHODS: The study uses a dataset of 301 NPCs from three prefectures in Yunnan, a province in southwest China, collected in July 2017. Logistic regression is used to estimate the relationship between competition and NPC's participation in in-service training. We assess the relationship between participation and both the quantity of competition (number of competitors in the same village and surrounding villages) and the quality of competition (proxied using characteristics of competing clinicians). RESULTS: In 2016, nearly two thirds of NPCs participated in face-to-face or web-based in-service trainings at least once. Specifically, 58 percent of NPCs participated in face-to-face in-service trainings, and 24 percent of NPCs participated in web-based in-service trainings. The quantity of competitors is unrelated to participation in in-service training. The quality of competition is not related to face-to-face training but has a significant positive relationship with participation in web-based training. CONCLUSIONS: Web-based trainings may be a better approach to increase NPC skills in developing country primary care markets.

Site preparedness and quality of HIV sentinel surveillance at antenatal care clinic sites in India, 2019.

BACKGROUND: Quality of HIV sentinel surveillance (HSS) depends on preparedness of the site and adherence to the standard operating procedures (SOPs) for HSS. A designated sentinel site is considered prepared for the round of sentinel surveillance based on the availability of infrastructure, human resource, and consumables. OBJECTIVES: The study objectives were to describe the site level preparedness and adherence to SOP of antenatal care clinic (ANC) sites during the 16th round of HSS in India. METHODS: This was a cross-sectional study based on the findings of the supervisory visits conducted by public health specialists in ANC sites during the 16th round of HSS from January to March 2019. Semi-structured checklists were used to assess site-preparedness and adherence to the SOP for HSS. All supervisors were expected to upload the filled pro forma to the HSS management information system (MIS). We present here a descriptive analysis of the uploaded visit reports. RESULTS: Of 870 HSS sites, 783 (90%) were visited, and 479 (61.2%) reports were uploaded to MIS. Preround HSS training was not attended by one-fifth (22.6%) of the site in-charges; 35.8% of them had never received any HSS training. SOP was followed at most (94%) of the sites. The most frequently reported problem at the sites was inadequate or delayed availability of consumables. CONCLUSION: The overall quality of site-level preparedness at antenatal clinic sites in India was good. Attention needs to be given to timely and adequate availability of consumables at sentinel sites along with proper administrative support and preround training of site in-charges.

New Graduate Nurse Transition Into the Intensive Care Unit: Qualitative Insights From a Longitudinal Study-Part 1.

BACKGROUND AND PURPOSE: Patients admitted to intensive care units (ICUs) are critically ill and suffer from life-threatening sickness of injury. To work in ICU, registered nurses require additional knowledge and skills. While practices regarding the hire of new graduate nurses (NGNs) into settings such as the ICU vary, it is common that NGNs are being hired. However, NGNs in general, are at a higher risk for turnover within the profession as compared to their more experienced colleagues. NGNs in ICU settings may be at higher risk of turnover due to the complexity of the care context. It is of particular importance that the experiences of NGNs in ICU be explored with the intent of identifying what these nurses experience but also to consider how they can be best supported during a period of transition. This manuscript reports the findings from a mixed design study that sought to understand the transition of a cohort of NGNs over a period of 2 years. METHODS: This study used both a purposive and convenience sample of NGNs. The qualitative component incorporated Thorne's (2016) interpretive description. Face-to-faceinterviews were completed. RESULTS: Five themes were identified: an emotional transition, a social transition, a transitioning mindset, transitioning through firsts, and transitioning with confidence. Within each theme, there is a distinct difference and elements of transition were evident. Findings demonstrate that the NGNs appeared to be more confident in their skills and in their nursing practice over time. Findings from this study provide important insight into the experiences of NGNs in ICUs.

An environmental scan of quality improvement and patient safety activities in emergency medicine in Canada.

OBJECTIVE: We conducted an environmental scan of quality improvement and patient safety (QIPS) infrastructure and activities in academic emergency medicine (EM) programs and departments across Canada. METHODS: We developed 2 electronic surveys through expert panel consensus to assess important themes identified by the CAEP QIPS Committee. "Survey 1" was sent by email to all 17 Canadian medical school affiliated EM department Chairs and Academic Hospitals department Chiefs; "Survey 2" to 12 identified QIPS leads in these hospitals. This was followed by 2 monthly email reminders to participate in the survey. RESULTS: 22/70 (31.4%) Department Chairs/Chiefs completed Survey 1. Most (81.8%) reported formal positions dedicated to QIPS activities within their groups, with a mixed funding model. Less than half of these positions have dedicated logistical support. 11/12 (91.7%) local QIPS leads completed Survey 2. Two-thirds (63.6%) reported explicit QIPS topics within residency curricula, but only 9.1% described QIPS training for staff physicians. Many described successful academic scholarship output, with the total number of peer-reviewed QIPS-related publications per centre ranging from 1-10 over the past 5 years. Few respondents reported access to academic supports: methodologists (27.3%), administrative personnel (27.3%), and statisticians (9.1%). CONCLUSION: This environmental scan provides a snapshot of QIPS activities in EM across academic centres in Canada. We found significant local educational and academic efforts, although there is a discrepancy between the level of formal support/infrastructure and such activities. There remains opportunity to further advance QIPS efforts on a national level, as well as advocating and supporting local QIPS activities.

OBJECTIF: L'étude visait à réaliser une analyse environnementale des activités d'amélioration de la qualité de la pratique clinique et de la sécurité des patients (AQSP) ainsi que de l'infrastructure afférente dans les programmes de médecine d'urgence (MU) et dans les services des urgences des hôpitaux d'enseignement partout au Canada. MÉTHODE: Deux questionnaires d'enquête électroniques ont été élaborés par un groupe d'experts après l'atteinte d'un consensus dans le but d'évaluer des thèmes jugés importants par le comité de l'AQSP de l'Association canadienne des médecins d'urgence. Le premier questionnaire a été envoyé par courriel aux directeurs de département de MU et aux chefs de service des hôpitaux d'enseignement rattachés aux 17 écoles de médecine au Canada; le deuxième, à 12 responsables des activités d'AQSP, désignés comme tels, dans ces hôpitaux. Ont suivi deux rappels envoyés par courriel, à un mois d'intervalle, aux participants concernés. RÉSULTATS: Au total, 22 directeurs de département ou chefs de service sur 70 (31,4%) ont répondu au premier questionnaire. La grande majorité d'entre eux (81,8%) ont fait état de postes officiels réservés aux activités d'AQSP dans leur groupe, soutenus selon un modèle de financement mixte. Toutefois, moins de la moitié des postes en question disposent d'un soutien logistique particulier. Quant au deuxième questionnaire, 11 responsables locaux des activités d'AQSP sur 12 (91,7%) y ont répondu. Environ les deux tiers (63,6%) ont indiqué que des sujets explicites d'AQSP étaient inclus dans les programmes de résidence, mais seulement 9,1% des responsables ont décrit la formation en matière d'AQSP donnée aux médecins membres du personnel hospitalier. Par ailleurs, bon nombre de répondants ont fait état de travaux d'érudition couronnés de succès; ainsi, le nombre total de publications évaluées par les pairs en lien avec l'AQSP variait de 1 à 10 par centre, au cours des 5 dernières années. Enfin, peu de répondants ont indiqué bénéficier du soutien de ressources universitaires : spécialistes de la méthodologie (27,3%), personnel administratif (27,3%) et statisticiens (9,1%). CONCLUSION: Cette analyse environnementale a dressé le portrait des activités d'AQSP menées dans les services de MU dans les hôpitaux d'enseignement au Canada. Les efforts fournis sur les plans de la formation et du soutien universitaire à l'échelle locale sont importants, mais il y a un déséquilibre entre le degré de soutien structuré ou d'infrastructure disponible et la réalisation de ces activités. Aussi y a-t-il lieu d'accroître les efforts d'AQSP à l'échelle nationale, en plus de soutenir ces activités à l'échelle locale et d'en faire la promotion.

Simulation-based training is associated with lower risk-adjusted mortality in ACS pediatric TQIP centers.

BACKGROUND: Although use of simulation-based team training for pediatric trauma resuscitation has increased, its impact on patient outcomes has not yet been shown. The purpose of this study was to determine the association between simulation use and patient outcomes. METHODS: Trauma centers that participate in the American College of Surgeons (ACS) Pediatric Trauma Quality Improvement Program (TQIP) were surveyed to determine frequency of simulation use in 2014 and 2015. Center-specific clinical data for 2016 and 2017 were abstracted from the ACS TQIP registry (n = 57,916 patients) and linked to survey responses. Center-specific risk-adjusted mortality was estimated using multivariable hierarchical logistic regression and compared across four levels of simulation-based training use: no training, low-volume training, high-volume training, and survey nonresponders (unknown training use). RESULTS: Survey response rate was 75% (94/125 centers) with 78% of the responding centers (73/94) reporting simulation use. The average risk-adjusted odds of mortality was lower in centers with a high volume of training compared with centers not using simulation (odds ratio, 0.58; 95% confidence interval, 0.37-0.92). The times required for resuscitation processes, evaluations, and critical procedures (endotracheal intubation, head computed tomography, craniotomy, and surgery for hemorrhage control) were not different between centers based on levels of simulation use. CONCLUSION: Risk-adjusted mortality is lower in TQIP-Pediatric centers using simulation-based training, but this improvement in mortality may not be mediated by a reduction in time to critical procedures. Further investigation into alternative mediators of improved mortality associated with simulation use is warranted, including assessment of resuscitation quality, improved communication, enhanced teamwork skills, and decreased errors. LEVEL OF EVIDENCE: Therapeutic/care management, Level III.

AGSM Proficiency and Depression Are Associated With Success of High-G Training in Trainee Pilots.

INTRODUCTION: High-gravity (G) training is used to educate trainee pilots about anti-G straining maneuvers (AGSM) in an environment similar to that of a real fighter aircraft, and to enhance their G tolerance. The success or failure of high-G training could be multifactorial, but most previous studies have only focused on the effect of pilots' physical condition.METHODS: A total of 138 male trainee pilots participated in this study. All trainee pilots had received AGSM training from experienced instructors and then underwent centrifuge high-G training. Participants completed questionnaire surveys about body size, lifestyle, self-reported AGSM proficiency, resilience (Connor-Davidson Resilience Scale, CD-RISC), and depression level (Center for Epidemiologic Studies Depression Scale, CES-D).RESULTS: Of the 138 subjects, 100 (72.5%) successfully completed high-G training without experiencing G-induced loss of consciousness (G-LOC) within two trials; these were allocated to the success group. The remaining 38 (27.5%) subjects who completed the training after three or more attempts, or who failed to complete the training at all, were allocated to the failure group. Multivariate analyses revealed that the success of centrifuge training was positively associated with age and self-reported AGSM proficiency, and negatively associated with depression level.DISCUSSION: The success of high-G training was significantly associated with self-reported AGSM proficiency and depression level. Instructors should emphasize the importance of AGSM proficiency and offer practice-based learning to trainee pilots. In addition, they should pay attention to not only trainee pilots' physical condition, but also their psychological status.Yun C, Oh S, Shin YH. AGSM proficiency and depression are associated with success of high-G training in trainee pilots. Aerosp Med Hum Perform. 2019; 90(7):613-617.

Nationwide survey of neonatal transportation practices in Italy.

BACKGROUND: Despite regionalization of perinatal care provides for the "in utero" transfer of high-risk pregnancies, there will always be a number of neonates who undergo acute inter-facility transport. The presence of a well-organized Neonatal Emergency Transport Service (NETS) can prevent and reduce risks of transportation, especially for very preterm infants, and is therefore mandatory for any program of regionalization of perinatal care. Italian National Health System is highly decentralized and Regions are autonomous to structure, plan and delivery their regional health services. Consequently, organization models and resources available vary widely and significant regional differences in access and quality of health services have been reported in the past years. A national survey was conducted in 2015 by the neonatal transport study group of the Italian Society of Neonatology with the aim to describe neonatal transfer practices and to assess the Neonatal Emergency Transport Services (NETS) status in the 20 Italian regions. METHODS: A questionnaire regarding neonatal transfer practices and NETS activity for the previous year (2014) was sent to the 44 NETS operating in the 20 Italian regions. Demographic data were obtained from the Italian National Statistical Institute (ISTAT). RESULTS: The overall survey response rate was 100%. In 2014, only 12 (60%) of the 20 Italian regions were fully covered by NETS, 3 (15%) regions were partially covered, while neonatal transport was not available in 5 (25%) regions. Overall, in 2014, the 44 NETS operating in Italy transported a total of 6387 infants, including 522 (8.17%) having a gestational age < 28 weeks. CONCLUSIONS: The organization of NETS in Italy is devolved on a regional basis, resulting in a large heterogeneity of access and quality to services across the country. Where available, NETS are generally well-equipped and organized but limited volume of activities often cannot guarantee adequate levels of skills of personnel or an appropriate cost-efficiency ratio. The regions reported with lack of NETS have managed, or are trying, to fill the gap, but continuing efforts to reduce regional differences in the availability and quality of services are still needed.

Effect of team training and monitoring on the rate of failed mid and low cavity vacuum extraction: a hospital based intervention study.

BACKGROUND: Clinical team training has been advocated as a means to improve delivery care, and failed extractions is a suggested variable for clinical audit in instrumental vaginal delivery. Other activities may also have intended or unintended effects on care processes or outcomes. METHODS: We retrospectively observed 1074 mid and low vacuum extraction deliveries during three time periods (prevalence periods): Baseline (period 0), implemented team training (period 1 and 2) and monitoring of traction force during vacuum extraction (period 2). Our primary outcome was failed extraction followed by emergency cesarean section or obstetric forceps delivery. RESULTS: The prevalence proportion (relative risk) of failed extraction decreased significantly after implementation of team training, from 19% (period 0) to 8 % (period 1), corresponding to a relative risk of 0.48 [0.26-0.87]. The secondary procedural outcome complicated delivery (duration > 15 min or number of pulls > 6, or cup detachment > 1) was decreased in period 2 compared to period 1, RR 0.42 [0.23-0.76]. Secondary clinical (neonatal) outcome were not affected. CONCLUSION: Clinically based educational efforts and increased monitoring improved procedural outcome without improving neonatal outcome. The study design has inherent limitations in making causal inference.

Hospitals with more-active participation in conducting standardized in-situ mock codes have improved survival after in-hospital cardiopulmonary arrest.

AIM: The American Heart Association (AHA) and the Institute of Medicine have published a national "call-to-action" to improve survival from in-hospital cardiopulmonary arrest (IHCA). Our aim was to determine if more-active hospital participation in standardized in-situ mock code (ISMC) training is associated with increased IHCA survival. METHODS: We performed an ecological study across a multi-state healthcare system comprising 26 hospitals. Hospital-level ISMC performance was measured during 2016-2017 and IHCA hospital discharge survival rates in 2017. We performed univariate and multivariate analysis of the hospital-level association between more-active ISCM participation and IHCA survival, with adjustment for hospital expected mortality as determined by a commercial severity scoring system. Other potential confounders were analyzed using univariate statistics. RESULTS: Hospitals with more-active ISMC participation conducted a median of 17.6 ISMCs/100 beds/year (vs 3.2/100 beds/year in less-active hospitals, p = 0.001) in 2016-2017. 220,379 patients were admitted and 3289 experienced IHCA in study hospitals in 2017, with an overall survival rate of 37.4%. Hospitals with more-active ISMC participation had a mean IHCA survival rate of 42.8% vs. 31.8% in hospitals with less-active ISMC participation (p < 0.0001), and a significantly reduced odds ratio (OR) of 0.62 for IHCA mortality (95% CI: 0.54-0.72; p < 0.0001) which was unchanged after adjustment for hospital-level expected mortality (adjusted OR: 0.62; 95% CI: 0.54-0.71; p < 0.001). CONCLUSIONS: Hospitals in our healthcare system with more-active ISMC participation have higher IHCA survival. Prospective trials are needed to establish the efficacy of standardized ISMC training programs in improving patient survival after cardiac arrest.

Curriculum and training needs of mid-level health workers in Africa: a situational review from Kenya, Nigeria, South Africa and Uganda.

BACKGROUND: Africa's health systems rely on services provided by mid-level health workers (MLWs). Investment in their training is worthwhile since they are more likely to be retained in underserved areas, require shorter training courses and are less dependent on technology and investigations in their clinical practice than physicians. Their training programs and curricula need up-dating to be relevant to their practice and to reflect advances in health professional education. This study was conducted to review the training and curricula of MLWs in Kenya, Nigeria, South Africa and Uganda, to ascertain areas for improvement. METHODS: Key informants from professional associations, regulatory bodies, training institutions, labour organisations and government ministries were interviewed in each country. Policy documents and training curricula were reviewed for relevant content. Feedback was provided through stakeholder and participant meetings and comments recorded. 421 District managers and 975 MLWs from urban and rural government district health facilities completed self-administered questionnaires regarding MLW training and performance. RESULTS: Qualitative data indicated commonalities in scope of practice and in training programs across the four countries, with a focus on basic diagnosis and medical treatment. Older programs tended to be more didactic in their training approach and were often lacking in resources. Significant concerns regarding skills gaps and quality of training were raised. Nevertheless, quantitative data showed that most MLWs felt their basic training was adequate for the work they do. MLWs and district managers indicated that training methods needed updating with additional skills offered. MLWs wanted their training to include more problem-solving approaches and practical procedures that could be life-saving. CONCLUSIONS: MLWs are essential frontline workers in health services, not just a stop-gap. In Kenya, Nigeria and Uganda, their important role is appreciated by health service managers. At the same time, significant deficiencies in training program content and educational methodologies exist in these countries, whereas programs in South Africa appear to have benefited from their more recent origin. Improvements to training and curricula, based on international educational developments as well as the local burden of disease, will enable them to function with greater effectiveness and contribute to better quality care and outcomes.

Assessing the predictors for training in management amongst hospital managers and chief executive officers: a cross-sectional study of hospitals in Abuja, Nigeria.

BACKGROUND: There is a compelling need for management training amongst hospital managers in Nigeria mostly because management was never a part of the curricula in medical schools and this has resulted in their deficiencies in effective policymaking, planning and bottom line management. There has been no study to the best of our knowledge on the need and likely factors that may influence the acquisition of such training by hospital managers and this in effect was the reason for this study. METHODS: Data for this study came from a cross-sectional survey distributed amongst management staff in twenty five (25) hospitals that were purposively selected. One hundred and twenty five (125) questionnaires were distributed, out of which one hundred and four (104) were answered and returned giving a response rate of 83.2%. Descriptive and Inferential statistics were used to summarize the results. Decisions were made at 5% level of significance. A binary logistic regression was performed on the data to predict the logit of being formally and informally trained in health management. These statistical techniques were done using the IBM SPSS version 20. RESULTS: The result revealed a high level of formal and informal trainings amongst the respondent managers. In formal management training, only few had no training (27.9%) while in informal management training, all had obtained a form of training of which in-service training predominates (84.6%). Most of the administrators/managers also had the intention of attending healthcare management programme within the next five years (62.5%). Socio-demographically, age (p = .032) and academic qualification (p < .001) had significant influence on training. Number of hospital beds (p < .001) and number of staff (p < .001) including managers' current designation (p < .001) also had significant influence on training. CONCLUSION: Our work did establish the critical need for both formal and informal trainings in health management for health care managers. Emphasis on training should be directed at younger managers who are the least likely to acquire such trainings, the smaller and private hospitals who are less likely to encourage such trainings amongst their staff and the least educated amongst health managers.

The Impact of New Graduate Nurse Transition Programs on Competency Development and Patient Safety: An Integrative Review.

Stronger evidence on the value of new graduate nurse transition programs is needed to justify the cost and warrant expansion of these programs to more health systems. The aim of this integrative review was to critically analyze published research on the relationship between new graduate nurse transition programs and patient safety outcomes. Limited evidence was found on actual safety improvement; rather, transition programs have predominately measured the development of competency as a process outcome variable for improving patient safety. A systems model is proposed to guide future research examining structure, process, and outcome variables, linking transition programs with patient outcomes.

Training in youth-friendly service provision improves nurses' competency level in the Great Lakes Region.

OBJECTIVES: This survey investigates whether relevant training and availability of guidelines improve self-reported competencies of nurses in the provision of youth-friendly sexual and reproductive health services in South-Kivu Province in the Democratic Republic of the Congo, Burundi, and Rwanda. METHODS: A quantitative baseline survey was conducted among nurses in randomly selected health facilities. Nurses providing youth-friendly sexual and reproductive health services were asked to self-rate their competencies with regards to technical knowledge, clinical, and communication skills. In South-Kivu, Burundi, and Rwanda, 135, 131, and 99 nurses were interviewed, respectively. RESULTS: Overall differences of service and guideline availability and self-rated competencies can be observed between the three countries. In two countries, more than one in five nurses considered themselves to be only somewhat or not confident to counsel young people. Nurses from Rwanda showed the highest level of competencies followed by Burundi and South-Kivu. Lack of training in youth-friendly health services or family planning showed significant associations with reporting feeling somehow or not competent. CONCLUSIONS: The lack of training, supervision, and guidelines expressed by the nurses is of great concern. Competency-based training in youth-friendly health services is an important approach in improving nurses' competency level.

Physicians' Views on Advance Care Planning and End-of-Life Care Conversations.

OBJECTIVES: To evaluate physicians' views on advance care planning, goals of care, and end-of-life conversations. DESIGN: Random sample telephone survey. SETTING: United States. PARTICIPANTS: Physicians (primary care specialists; pulmonology, cardiology, oncology subspecialists) actively practicing medicine and regularly seeing patients aged 65 and older (N=736; 81% male, 75% white, 66% aged ≥50. MEASUREMENTS: A 37-item telephone survey constructed by a professional polling group with national expert oversight measured attitudes and perceptions of barriers and facilitators to advance care planning. Summative data are presented here. RESULTS: Ninety-nine percent of participants agreed that it is important to have end-of-life conversations, yet only 29% reported that they have formal training for such conversations. Those most likely to have training included younger physicians and those caring for a racially and ethnically diverse population. Patient values and preferences were the strongest motivating factors in having advance care planning conversations, with 92% of participants rating it extremely important. Ninety-five percent of participants reported that they supported a new Medicare fee-for-service benefit reimbursing advance care planning. The biggest barrier mentioned was time availability. Other barriers included not wanting a patient to give up hope and feeling uncomfortable. CONCLUSION: With more than half of physicians reporting that they feel educationally unprepared, there medical school curricula need to be strengthened to ensure readiness for end-of-life conversations. Clinician barriers need to be addressed to meet the needs of older adults and families. Policies that focus on payment for quality should be evaluated at regular intervals to monitor their effect on advance care planning.

Phosphine Exposure Among Emergency Responders - Amarillo, Texas, January 2017.

Phosphine is a highly toxic gas that forms when aluminum phosphide, a restricted-use pesticide* typically used in agricultural settings, reacts with water. Acute exposure can lead to a wide range of respiratory, cardiovascular, and gastrointestinal symptoms, and can be fatal (1). On January 2, 2017, the Texas Department of State Health Services (DSHS) was notified by the Texas Panhandle Poison Center of an acute phosphine exposure incident in Amarillo, Texas. DSHS investigated potential occupational phosphine exposures among the 51 on-scene emergency responders; 40 (78.4%) did not use respiratory protection during response operations. Fifteen (37.5%) of these 40 responders received medical care for symptoms or as a precaution after the incident, and seven (17.5%) reported new or worsening symptoms consistent with phosphine exposure within 24 hours of the incident. Emergency response organizations should ensure that appropriate personal protective equipment (PPE) is used during all incidents when an unknown hazardous substance is suspected. Additional evaluation is needed to identify targeted interventions that increase emergency responder PPE use during this type of incident.

Implementation and outcomes of hospital-wide computerized antimicrobial approval system and on-the-spot education in a traumatic intensive care unit in Taiwan.

BACKGROUND/PURPOSE: Inappropriate prescribing of antibiotics is a major health-care problem in intensive care units (ICUs). This study evaluates the impact of a direct hospital-wide computerized antimicrobial approval system (HCAAS) and on-the-spot education for practitioners in a neurosurgical ICU in Taiwan. METHODS: We retrospectively analyzed the medical records monthly of patients who were admitted to the neurosurgical ICU during a period of 7 years and 7 months. A pretest-post-test time series analysis, comparing the three periods: period I (no infectious disease (ID) physician), period II (part-time ID physicians), and period III (full-time ID physician). Antimicrobial consumption and expenditure, incidence of hospital-associated infections, prevalence of healthcare-associated bacterial isolates, in-hospital mortality rates, and indication of antibiotics usage were analyzed. RESULTS: Full-time ID physician can increase the consumption of narrow-spectrum antimicrobials (cefazolin, and cefuroxime), and decrease the consumptions of broad-spectrum antimicrobials (ceftazidime, cefepime, and vancomycin) compared to part-time ID physicians. From period I to period III, the expenditure of antimicrobials, incidence of hospital-associated pneumonia, and the in-hospital mortality rates (crude, sepsis-related, and overall infection-related mortality) decreased statistically. The prevalence of extended-spectrum ß-lactamase-producing Escherichia coli and Klebsiella pneumoniae, and Carbapenems-resistant Pseudomonas aeruginosa remained at low level after HCAAS implementation. From 2007 to 2009, the rational antibiotics usage continued to increase, resulting from to more prophylaxis and appropriate microbiologic proof, but less empiric antimicrobial therapy. CONCLUSION: Implementation of HCAAS and long-term on-the-spot education by full-time ID physician can reduce antimicrobial consumption, cost, and improve inappropriate antibiotic usage whilst not compromising healthcare quality.

Evaluating the Training, Responsibilities, and Practices of P&T Committee Members and Nonmember Contributors.

BACKGROUND: Pharmacy and therapeutics (P&T) committees are responsible for managing drug formularies in numerous health care settings. Although pharmacy practice and health care organizations provide general recommendations of responsibilities and skills for members and nonmember contributors of P&T committees, the study investigators hypothesized that there is diversity in the training, responsibilities, and practices of these members and contributors. OBJECTIVE: To describe the training, responsibilities, and practices of members and nonmember contributors of P&T committees in a variety of health care settings, using an online survey. METHODS: In December 2015, an online survey was delivered to clinicians who were considered likely to be involved in P&T committee service from hospitals ranked by U.S. News & World Report and a convenience sample of clinicians practicing in managed care settings. The survey instrument was designed to assess various domains and perceptions of P&T committee processes. RESULTS: Sixty-nine respondents representing various health care delivery settings in the United States were eligible for and completed the survey. The majority of the respondents were pharmacists (94.2%), and 72.5% of the respondents were P&T committee members. The remainder of the respondents were nonmember P&T committee contributors. Approximately 60% of the respondents had served in P&T committee roles for ≥ 10 years. Specialized postgraduate training incorporating literature evaluation and formulary management was possessed by 21.7% and 17.4% of the respondents, respectively; however, most of the respondents received on-the-job training. Approximately half of the respondents were responsible for preparation of P&T committee documents, and 58% reported that nonmember contributors typically write and prepare these documents. Skill in literature evaluation was the most important criterion in selecting authors of P&T committee documents, while 10.1% of the respondents indicated that their committees did not use any criteria for author selection. When authoring documents, primary literature was routinely consulted by 89.5% of the respondents. Most of the respondents (84.1%) used an organization-specific document template, while 5.8% of the respondents indicated that they prepared documents with no defined process. The most highly ranked factor that could have a perceived beneficial effect on P&T committee functions were guidelines on the authoring and reviewing of P&T committee documents. CONCLUSIONS: The survey of P&T committee members and nonmember contributors used in this study identified current training, responsibilities, and practices that can inform recommendations for standards in these domains. Findings suggest opportunities for improvement in achieving best practice recommendations to ensure evidence-based decision making by P&T committees. DISCLOSURES: No outside funding supported this study. At the time of this study, Kelly was employed by Global Account Management Group (GAMG), which provides consulting services to the hospital and health services industry. As an employee of GAMG, Kelly has served on various advisory boards. All fees for consulting work were paid to GAMG and were primarily related to training or the federal market (e.g., Department of Defense or the Department of Veterans Affairs) and have no association with this study. Rodriguez and Moody report no conflicts of interest. All authors contributed to study concept and design. Rodriguez took the lead in data collection, assisted by the other authors. Data interpretation was performed by Rodriguez, along with Kelly and Moody. The manuscript was written and revised primarily by Rodriguez, along with the other authors.