24-hour Coverage Research Articles

Rotigotine transdermal system and evaluation of pain in patients with Parkinson’s disease: a post hocanalysis of the RECOVER study

BackgroundPain is a troublesome non-motor symptom of Parkinson’s disease (PD). The RECOVER (Randomized Evaluation of the 24-hour Coverage: Efficacy of Rotigotine; Clintrials.gov: NCT00474058) study demonstrated significant improvements in early-morning motor function (UPDRS III) and sleep disturbances (PDSS-2) with rotigotine transdermal system. Improvements were also reported on a Likert pain scale (measuring any type of pain). This post hoc analysis of RECOVER further evaluates the effect of rotigotine on pain, and whether improvements in pain may be attributable to benefits in motor function or sleep disturbance.MethodsPD patients with unsatisfactory early-morning motor impairment were randomized to optimal-dose (up to 16 mg/24 h) rotigotine or placebo, maintained for 4 weeks. Pain was assessed in the early-morning using an 11-point Likert pain scale (rated average severity of pain (of any type) over the preceding 12 hours from 0 [no pain] to 10 [worst pain ever experienced]). Post hoc analyses for patients reporting ‘any’ pain (pain score ≥1) at baseline, and subgroups reporting ‘mild’ (score 1–3), and ‘moderate-to-severe’ pain (score ≥4) were performed. Likert pain scale change from baseline in rotigotine-treated patients was further analyzed based on a UPDRS III/PDSS-2 responder analysis (a responder defined as showing a ≥30% reduction in early morning UPDRS III total score or PDSS-2 total score). As post hoc analyses, all p values presented are exploratory.ResultsOf 267 patients with Likert pain data (178 rotigotine, 89 placebo), 187 (70%) reported ‘any’ pain; of these 87 (33%) reported ‘mild’, and 100 (37%) ‘moderate-to-severe’ pain. Change from baseline pain scores decreased with rotigotine compared with placebo in patients with ‘any’ pain (-0.88 [95% CI: -1.56, -0.19], p = 0.013), and in the subgroup with ‘moderate-to-severe’ pain (-1.38 [-2.44, -0.31], p = 0.012). UPDRS III or PDSS-2 responders showed greater improvement in pain than non-responders.ConclusionsThe results from this post hoc analysis of the RECOVER study suggest that pain was improved in patients with PD treated with rotigotine; this may be partly attributable to benefits in motor function and sleep disturbances. Prospective studies are warranted to investigate this potential benefit and the clinical relevance of these findings.

Successful placement of intracranial pressure monitors by trauma surgeons

The Brain Trauma Foundation guidelines advocate for the use of intracranial pressure (ICP) monitoring following traumatic brain injury (TBI) in patients with a Glasgow Coma Scale (GCS) score of 8 or less and an abnormal computed tomographic scan finding. The absence of 24-hour in-house neurosurgery coverage can negatively impact timely monitor placement. We reviewed the safety profile of ICP monitor placement by trauma surgeons trained and credentialed in their insertion by neurosurgeons. In 2005, the in-house trauma surgeons at a Level I trauma center were trained and credentialed in the placement of ICP parenchymal monitors by the neurosurgeons. We abstracted all TBI patients who had ICP monitors placed during a 6-year period. Demographic information, Injury Severity Score (ISS), outcome, and monitor placement by neurosurgery or trauma surgery were identified. Misplacement, hemorrhage, infections, malfunctions, and dislodgement were considered complications. Comparisons were performed by χ testing and Student's t tests. During the 6-year period, 410 ICP monitors were placed for TBI. The mean (SD) patient age was 40.9 (18.9) years, 73.7% were male, mean (SD) ISS was 28.3 (9.4), mean (SD) length of stay was 19 (16) days, and mortality was 36.1%. Motor vehicle collisions and falls were the most common mechanisms of injury (35.2% and 28.7%, respectively). The trauma surgeons placed 71.7 % of the ICP monitors and neurosurgeons for the remainder. The neurosurgeons placed most of their ICP monitors (71.8%) in the operating room during craniotomy. The overall complication rate was 2.4%. There was no significant difference in complications between the trauma surgeons and neurosurgeons (3% vs. 0.8%, p = 0.2951). After appropriate training, ICP monitors can be safely placed by trauma surgeons with minimal adverse effects. With current and expected specialty shortages, acute care surgeons can successfully adopt procedures such as ICP monitor placement with minimal complications. Therapeutic/care management study, level IV.

The Effect of Organizational Structure and Processes of Care on ICU Mortality as Revealed by the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study*

The Effect of Organizational Structure and Processes of Care on ICU Mortality as Revealed by the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study*

Structure, Process, and Annual ICU Mortality Across 69 Centers

Hospital-level variations in structure and process may affect clinical outcomes in ICUs. We sought to characterize the organizational structure, processes of care, use of protocols, and standardized outcomes in a large sample of U.S. ICUs. We surveyed 69 ICUs about organization, size, volume, staffing, processes of care, use of protocols, and annual ICU mortality. ICUs participating in the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. Sixty-nine intensivists completed the survey. We characterized structure and process variables across ICUs, investigated relationships between these variables and annual ICU mortality, and adjusted for illness severity using Acute Physiology and Chronic Health Evaluation II. Ninety-four ICU directors were invited to participate in the study and 69 ICUs (73%) were enrolled, of which 25 (36%) were medical, 24 (35%) were surgical, and 20 (29%) were of mixed type, and 64 (93%) were located in teaching hospitals with a median number of five trainees per ICU. Average annual ICU mortality was 10.8%, average Acute Physiology and Chronic Health Evaluation II score was 19.3, 58% were closed units, and 41% had a 24-hour in-house intensivist. In multivariable linear regression adjusted for Acute Physiology and Chronic Health Evaluation II and multiple ICU structure and process factors, annual ICU mortality was lower in surgical ICUs than in medical ICUs (5.6% lower [95% CI, 2.4-8.8%]) or mixed ICUs (4.5% lower [95% CI, 0.4-8.7%]). We also found a lower annual ICU mortality among ICUs that had a daily plan of care review (5.8% lower [95% CI, 1.6-10.0%]) and a lower bed-to-nurse ratio (1.8% lower when the ratio decreased from 2:1 to 1.5:1 [95% CI, 0.25-3.4%]). In contrast, 24-hour intensivist coverage (p = 0.89) and closed ICU status (p = 0.16) were not associated with a lower annual ICU mortality. In a sample of 69 ICUs, a daily plan of care review and a lower bed-to-nurse ratio were both associated with a lower annual ICU mortality. In contrast to 24-hour intensivist staffing, improvement in team communication is a low-cost, process-targeted intervention strategy that may improve clinical outcomes in ICU patients.

Survey of Anesthesiologists Practicing in American Neurointensive Care Units as Neurointensivists

A group of anesthesiologists practice as intensivists in neurointensive care units (NeuroICU). The current nature and implications of the role of anesthesiology-based neurointensivist remain unclear. The purpose of this survey was to assess today's practice environment of anesthesiology-based neurointensivists as a framework for future study. During the period between January 2011 and March 2011, we identified anesthesiologists who provide patient care in specialized NeuroICUs in the United States. We used an online, 15-question survey to gauge the environment and their role in the delivery of care to critically ill patients admitted to NeuroICUs. Of the 104 NeuroICUs in the United States, 22 institutions include anesthesiology-based neurointensivists (n=41). With a response from 33 of 41 requested surveys, anesthesiology-based neurointensivists reported that background training and roles for providing patient care in the NeuroICU setting varied widely between institutions. In contrast, these practices were similar in providing 24-hour coverage (76%), working with neurosurgical (88%) and anesthesiology residents (85%), and having critical-care fellowship training (97%). Almost all surveyed individuals practice both neurocritical care and anesthesia in the operating room, and 76% reported satisfaction with their working environment in the NeuroICU relative to other responsibilities. Anesthesiology-based neurointensivists currently represent a small subgroup within the rapidly growing neurointensivist workforce in the United States and consider neurocritical care a valuable aspect of their career. Promoting subspecialty training in neurocritical care among anesthesiologists may provide an opportunity for new patient-care frontiers and address the increasing need for NeuroICU physicians.

Do Intensivist Staffing Patterns Influence Hospital Mortality Following ICU Admission? A Systematic Review and Meta-Analyses*

To determine the effect of different intensivist staffing models on clinical outcomes for critically ill patients. A sensitive search of electronic databases and hand-search of major critical care journals and conference proceedings was completed in October 2012. Comparative observational studies examining intensivist staffing patterns and reporting hospital or ICU mortality were included. Of 16,774 citations, 52 studies met the inclusion criteria. We used random-effects meta-analytic models unadjusted for case-mix or cluster effects and quantified between-study heterogeneity using I. Study quality was assessed using the Newcastle-Ottawa Score for cohort studies. High-intensity staffing (i.e., transfer of care to an intensivist-led team or mandatory consultation of an intensivist), compared to low-intensity staffing, was associated with lower hospital mortality (risk ratio, 0.83; 95% CI, 0.70-0.99) and ICU mortality (pooled risk ratio, 0.81; 95% CI, 0.68-0.96). Significant reductions in hospital and ICU length of stay were seen (-0.17 d, 95% CI, -0.31 to -0.03 d and -0.38 d, 95% CI, -0.55 to -0.20 d, respectively). Within high-intensity staffing models, 24-hour in-hospital intensivist coverage, compared to daytime only coverage, did not improved hospital or ICU mortality (risk ratio, 0.97; 95% CI, 0.89-1.1 and risk ratio, 0.88; 95% CI, 0.70-1.1). The benefit of high-intensity staffing was concentrated in surgical (risk ratio, 0.84; 95% CI, 0.44-1.6) and combined medical-surgical (risk ratio, 0.76; 95% CI, 0.66-0.83) ICUs, as compared to medical (risk ratio, 1.1; 95% CI, 0.83-1.5) ICUs. The effect on hospital mortality varied throughout different decades; pooled risk ratios were 0.74 (95% CI, 0.63-0.87) from 1980 to 1989, 0.96 (95% CI, 0.69-1.3) from 1990 to 1999, 0.70 (95% CI, 0.54-0.90) from 2000 to 2009, and 1.2 (95% CI, 0.84-1.8) from 2010 to 2012. These findings were similar for ICU mortality. High-intensity staffing is associated with reduced ICU and hospital mortality. Within a high-intensity model, 24-hour in-hospital intensivist coverage did not reduce hospital, or ICU, mortality. Benefits seen in mortality were dependent on the type of ICU and decade of publication.

A comparison between GPS-only and combined GPS+GLONASS Precise Point Positioning

The benefits and challenges of a combined GPS and GLONASS Precise Point Positioning (PPP) system in post-processed static and kinematic modes are analysed and identified. Different elevation cut-off angles are applied to simulate satellites' availability in different sky view conditions. The results show that for kinematic PPP, the addition of GLONASS observations could speed up the solution convergence time and improve the accuracy and precision of the position estimates. However, for daily static PPP, the benefits of integrating GLONASS to the current GPS-only PPP system are marginal as the 24-hour cumulative satellite coverage is near-optimal with the current GPS constellation.

Evaluation and Development of an ED Management Model: An Effort to Optimize Patient-Centered Care

In 2008, the emergency department at Mary Washington Hospital was in the midst of a crisis marked by increasing volumes, increasing numbers of left without being seen (LWBS) patients, falling patient satisfaction numbers and a staff dissatisfied with ED leadership. The existing ED model of charge nurses, a nurse manager, and an administrative director was not working. The single nurse manager could not effectively manage the over 200 staff members he/she was assigned. Based upon the findings from the employee satisfaction survey the inability of the nurse managers to properly manage such large numbers of employees was at the core of the issue. Through benchmarking with a similar healthcare system, an evidence based leadership model was identified, developed, and implemented. The model included the addition of six patient care managers with 24-hour coverage in the department, led to a reduced number of direct reports per manager, and an increased connection with employees. The goal was to engage employees in the effort to provide patient centered, quality care. Residual benefits of our change effort improved the patient satisfaction scores as evidenced by meeting organizational goals within 12 months; goal was exceeded in the following year. Additionally, the walk out rate was reduced 75% over 18 months. The correlation between satisfied employees, patient satisfaction, and reduced walk-outs cannot be ignored. Engaged employees positively impact service and quality.

Self-Assessed Fidelity: Proceed With Caution: In Reply

Back to table of contents Previous article Next article LettersFull AccessSelf-Assessed Fidelity: Proceed With Caution: In ReplyJohn H. McGrew, Ph.D., Laura M. White, M.S., and Laura G. Stull, Ph.D.John H. McGrewSearch for more papers by this author, Ph.D., Laura M. WhiteSearch for more papers by this author, M.S., and Laura G. StullSearch for more papers by this author, Ph.D.Published Online:1 Apr 2013https://doi.org/10.1176/appi.ps.640419AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In Reply: We appreciate the opportunity to respond to Bond’s thoughtful commentary on our brief report. It is important to contextualize this discussion. The evidence-based practice “movement” is sweeping public mental health. Proponents largely agree that these practices should be widely disseminated, that fidelity assessment is needed to ensure high-quality implementation, and that assessments are most valid when conducted by independent assessors. But there is a problem. The “need” for independent assessment far outstrips the capacity to provide it. This problem is exacerbated by increases in the numbers of interventions classified as evidence-based practices (now exceeding 100 [1]) and of sites implementing them and is particularly acute for onsite assessment, which requires up to three days of assessor time. Thus there is a need to identify alternate, less burdensome, yet valid assessment methods, such as self-report.Although we agree with Bond’s cautions concerning self-assessment for fidelity ratings as usually conducted, we believe that these concerns are most relevant for self-rated fidelity and that carefully collected self-reported data can be a valid and sole source for independent fidelity raters. Moreover, because all fidelity assessment methods use some self-reported data, differences are a matter of degree. Our approach assumes that the chief source of self-report invalidity is subjectivity in defining items and data needed to make ratings and that most people will report accurately when asked directly and clearly. To establish more objective procedures, we created a detailed protocol to gather data to score scale items, piloting and revising it over several years. For example, instead of asking, “Do you provide 24-hour coverage?” we ask, “What percentage of clients in crisis directly talk to staff after hours?” Instead of asking, “Are you involved with 95% of admissions?” we ask, “Describe team involvement with the past ten admissions.” In addition, we use independent raters to score the self-reported data and do not permit self-scoring of items. We believe that self-presentation biases are most problematic when self-scoring is used. In our study, for example, self-reported fidelity generally produced lower scores than phone fidelity.As detailed in our report, self-report can be reliable and valid when this approach is used. Moreover, in contrast to Bond’s generalizability concerns, preliminary results from an ongoing study support the validity of our self-report approach for teams naïve to fidelity assessment and for those with moderate experience. Also, we disagree with and are confused by Bond’s assertion that we endorse replacing onsite assessment with self-reported assessment. In fact, we proposed a stepped approach in which phone and self-reported assessment complement and supplement onsite assessment. Nevertheless, we agree that self-report should be reserved for evidence-based practices with well-articulated fidelity scales, that auditing procedures are needed to ensure accuracy, and that, to date, the advantage of self-reported over phone assessment appears minimal (2). We also agree that integrating self-report fidelity data into electronic records is a useful next step. However, the current state of the science is preliminary, and further research is needed to more carefully examine each of these important questions.References1 Chambless DL, Ollendick TH: Empirically supported psychological interventions: controversies and evidence. Annual Review of Psychology 52:685–716, 2001Crossref, Medline, Google Scholar2 McGrew JH, Stull LG, Rollins AL, et al.: A comparison of phone-based and on-site assessment of fidelity for assertive community treatment in Indiana. Psychiatric Services 62:670–674, 2011Link, Google Scholar FiguresReferencesCited byDetailsCited ByThe Relationship Between Suicidal Behaviors and Zero Suicide Organizational Best Practices in Outpatient Mental Health ClinicsDeborah M. Layman, M.A., Jamie Kammer, Ph.D., Emily Leckman-Westin, Ph.D., Mike Hogan, Ph.D., Julie Goldstein Grumet, Ph.D., Christa D. Labouliere, Ph.D., Barbara Stanley, Ph.D., Jay Carruthers, M.D., Molly Finnerty, M.D.18 March 2021 | Psychiatric Services, Vol. 72, No. 10Comparing fidelity monitoring methods in an evidence-based parenting intervention11 February 2021 | Journal of Children's Services, Vol. 16, No. 2Is There a Role for Fidelity Self-Assessment in the Individual Placement and Support Model of Supported Employment?Paul J. Margolies, Ph.D., Jennifer L. Humensky, Ph.D., I-Chin Chiang, M.S., Nancy H. Covell, Ph.D., Karen Broadway-Wilson, B.S., Raymond Gregory, B.S., Thomas C. Jewell, Ph.D., Gary ScannevinJr., M.P.S., C.P.R.P., Stephen Baker, B.A., B.S., Lisa B. Dixon, M.D., M.P.H.17 April 2017 | Psychiatric Services, Vol. 68, No. 9Administration and Policy in Mental Health and Mental Health Services Research, Vol. 43, No. 2 Volume 64Issue 4 April 2013Pages 394-394 Metrics PDF download History Published online 1 April 2013 Published in print 1 April 2013

Reduction in Observation Unit Length of Stay With Coronary Computed Tomography Angiography Depends on Time of Emergency Department Presentation

Prior studies demonstrating shorter length of stay (LOS) from coronary computed tomography angiography (CCTA) relative to stress testing in emergency department (ED) patients have not considered time of patient presentation. The objectives of this study were to determine whether low-risk chest pain patients receiving stress testing or CCTA have differences in ED plus observation unit (OU) LOS and if there are disparities in testing modality use, based on the time of patient presentation to the ED. The authors examined a cohort of low-risk chest pain patients evaluated in an ED-based OU using prospective and retrospective OU registry data. During the study period, stress testing and CCTA were both available from 08:00 to 17:00 hours. CCTA was not available on weekends, and therefore only subjects presenting on weekdays were included. Cox regression analysis was used to model the effect of testing modality (stress testing vs. CCTA) on OU LOS. Separate models were fit based on time of patient presentation to the ED using 4-hour blocks beginning at midnight. The primary independent variable was testing modality: stress testing or CCTA. Age, sex, and race were included as covariates. Logistic regression was used to model testing modality choice by time period adjusted for age, sex, and race. Over the study period, 841 subjects presented Monday through Friday. Median LOS was 18.0 hours (interquartile range [IQR] = 11.7 to 22.9 hours). Objective cardiac testing was completed in 788 of 841 (94%) patients, with 496 (63%) receiving stress testing and 292 (37%) receiving CCTA. After age, race, and sex were adjusted for, patients presenting between 08:00 and 11:59 hours not only had a shorter LOS associated with CCTA (p < 0.0001), but also had a greater likelihood of being tested by CCTA (p = 0.001). None of the other time periods had significant differences in LOS or testing modality choice for CCTA relative to stress testing. In an OU setting with weekday and standard business hours CCTA availability, CCTA testing was associated with shorter LOS among low-risk chest pain patients only in patients presenting to the ED between 08:00 and 11:59 hours. That time period was also associated with a greater likelihood of being tested by CCTA, suggesting that ED providers may have intuited the inability of CCTA to shorten LOS during other times.

Nighttime Intensivist Staffing: Is There Evidence for a Need?

Postoperative critical care provided by critical care specialists, or intensivists, improves outcomes after surgery. Although there are data supporting daytime intensivist coverage in the intensive care unit, it is not clear how nighttime specialist coverage impacts the quality of care or outcomes. Many surgical intensive care units have adopted continuous 24-hour critical care coverage. Here, we highlight an important study by Wallace and colleagues that reports the impact of nighttime intensivist staffing on outcomes in critically ill patients.

There Is No News Like Bad News: Women Are More Remembering and Stress Reactive after Reading Real Negative News than Men

With the advent of specialized television channels offering 24-hour coverage, Internet and smart phones, the possibility to be constantly in contact with the media has increased dramatically in the last decades. Despite this higher access to knowledge, the impact media exposure has on healthy individuals remains poorly studied. Given that most information conveyed in the media is negative and that upon perception of threat, the brain activates the stress system, which leads to cortisol secretion, we decided to determine how healthy individuals react to media information. Accordingly, we investigated whether reading real negative news (1) is physiologically stressful, (2) modulates one’s propensity to be stress reactive to a subsequent stressor and (3) modulates remembrance for these news. Sixty participants (30 women, 30 men) were randomly assigned to either twenty-four real neutral news excerpts or to twenty-four real negative excerpts for 10 minutes. They were then all exposed to a well-validated psychosocial stressor, the Trier Social Stress Test (TSST), which consists of an anticipation phase of 10 minutes and a test phase of 10 minutes. A total of eight salivary cortisol samples were collected, at 10-minutes intervals, throughout the experimental procedure. One day later, a free recall of the news was performed. Results showed that although reading negative news did not lead to change in cortisol levels (p>0.05), it led to a significant increase in cortisol to a subsequent stressor in women only (p<0.001). Also, women in the negative news condition experienced better memory for these news excerpts compared to men (p<0.01). These results suggest a potential mechanism by which media exposure could increase stress reactivity and memory for negative news in women.

Evolution of Critical Care Cardiology: Transformation of the Cardiovascular Intensive Care Unit and the Emerging Need for New Medical Staffing and Training Models

Critical care, defined as the diagnosis and management of life-threatening conditions that require close or constant attention by a group of specially trained health professionals, is inherent to the practice of cardiovascular medicine. The demand for cardiovascular critical care is increasing with the aging of the population and is reflected by trends in the use of critical care in general.1 Between 2000 and 2005, although the total number of hospital beds in the United States declined by 4.2%, the number of critical care beds increased by 6.5% and the annual costs attributed to critical care increased by 44%, representing 13.4% of hospital costs.2 Projections for the next 15 years suggest that the need for critical care will increase markedly in the United States and globally.1,3–5 For example, in Canada, a 57% increase in the need for critical care beds is anticipated during that period.5 Concurrent with increases in demand, the medical demographics of general and cardiac critical care have evolved toward a patient population with an increasing number of comorbid medical conditions who require more prolonged and more technologically sophisticated invasive support. As a result, the delivery of critical care is advancing substantially in its complexity. Moreover, accumulating evidence has indicated that outcomes are better when critical care is provided by specially trained providers in a dedicated intensive care unit (ICU).6–9 In the context of this evolution, provision of optimal care in the contemporary cardiac ICU (CICU) presents a different set of challenges and requires an expanded set of skills compared with 10 years ago. Cardiovascular medicine has lagged behind other medical disciplines that have met the “critical care crisis”4 with ICU-focused innovations in organization, training, and quality improvement. Therefore, the American Heart Association Council on Cardiopulmonary, Critical …

Sleep Deprivation in Resident Physicians, Work Hour Limitations, and Related Outcomes: A Systematic Review of the Literature

Extended work hours, interrupted sleep, and shift work are integral parts of medical training among all specialties. The need for 24-hour patient care coverage and economic factors have resulted in prolonged work hours for resident physicians. This has traditionally been thought to enhance medical educational experience. These long and erratic work hours lead to acute and chronic sleep deprivation and poor sleep quality, resulting in numerous adverse consequences. Impairments may occur in several domains, including attention, cognition, motor skills, and mood. Resident performance, professionalism, safety, and well–being are affected by sleep deprivation, causing potentially adverse implications for patient care. Studies have shown adverse health consequences, motor vehicle accidents, increased alcohol and medication use, and serious medical errors to occur in association with both sleep deprivation and shift work. Resident work hour limitations have been mandated by the Accreditation Council for Graduate Medical Education in response to patient safety concerns. Studies evaluating the impact of these regulations on resident physicians have generated conflicting reports on patient outcomes, demonstrating only a modest increase in sleep duration for resident physicians, along with negative perceptions regarding their education. This literature review summarizes research on the effects of sleep deprivation and shift work, and examines current literature on the impact of recent work hour limitations on resident physicians and patient–related outcomes.

The Role of the Neonatal Nurse Practitioner in the Community Hospital Level I Nursery

Neonatal nurse practitioners (NNPs) have played a significant role in providing medical coverage to many of the country's Level III neonatal intensive care units (NICUs). Extensive education and experience are required for a nurse practitioner (NP) to become competent in caring for these critically ill newborns. The NNP can take this competence and experience and expand her role out into the community Level I nurseries. Clinical care of the infants and close communication with parents, pediatricians, and the area tertiary center provide a community service with the goal of keeping parents and babies together in the community hospital without compromising the health of the baby. The NNP service, with 24-hour nursery and delivery coverage, supports an ongoing obstetric service to the community hospital. The NNP's experience enables her to provide a neonatal service that encompasses a multitude of advanced practice nursing roles.

The Relationship Between Shift Work, Sleep, and Cognition in Career Emergency Physicians

The 24-hour physician coverage of the emergency department (ED) requires shift work, which can result in desynchronosis and cognitive decline. We measured changes in cognition and sleep disturbance in attending emergency physicians (EPs) before and after day and overnight shifts. Thirteen EPs were tested before and after day and overnight shifts using the Paced Auditory Serial Addition Test (PASAT), the University of Southern California Repeatable Episodic Memory Test (REMT), the Trail Making Test (TMT), and the Stroop Color-Word Test. Sleep quality and fatigue were assessed using the Pittsburgh Sleep Quality Index (PSQI) and Chalder Fatigue Questionnaire (CFQ). Saliva samples were collected from each physician immediately before and after day shifts and night shifts for neurohormonal assays. Significantly fewer words were recalled on the REMT after both day (-2.4, 95% confidence interval [CI] = -4.4 to -0.4) and overnight shifts (-4.6, 95% CI = -6.4 to -2.8). There was a significant postshift increase in words recalled from the last third of the REMT list after overnight shifts (6.6, 95% CI = 2.8 to 10.4). Sleep quality was worse in EPs (mean PSQI = 4.8, SD ± 2.5) compared to the normal population, with 31% of subjects reporting poor sleep quality. Postshift fatigue was correlated with the perceived difficulty of the shift. Salivary cortisol and melatonin demonstrated diurnal variation consistent with normal circadian rhythms. Morning cortisol peak was decreased or delayed in samples from physicians after a night shift. These data indicate that short-term memory appears to decline after day and overnight shifts and confirms the high incidence of disturbed sleep in this population.

Effect of 24-hour mandatory vs on-demand critical care specialist presence on long-term survival and quality of life of critically ill patients in the intensive care unit of a teaching hospital

BackgroundMandatory compared with on-demand intensivist presence improves processes of care and decreases intensive care unit (ICU) complication rate and hospital length of stay. The effect of continuous mandatory intensivist coverage on long-term patient mortality and quality of life (QOL) is not known. MethodsWe compared the long-term survival before (year 2005) and after (year 2006) the intervention when the staffing model changed from on-demand presence to mandatory 24-hour staff-critical care specialist presence in the medical ICU. Baseline and 6-month QOL surveys (SF-36 [short form 36 health survey]) were compared in subgroups of patients admitted before and after the staffing change. Cox proportional hazard and paired statistical analyses were used for survival and QOL comparisons. ResultsThe baseline characteristics did not differ significantly between the 2 groups except for race and Acute Physiology and Chronic Health Evaluation III score (median, 30 vs 37; P < .001 before and after the staffing model change). Long-term survival was not significantly different before and after the staffing change—adjusted hazard ratio, 1.05; 95% confidence interval, 0.95 to 1.16; P = .3. In a subset of ICU survivors, SF-36 physical component score improved significantly at 6 months compared with baseline after the staffing model change—Δ mean (SD) 8 (14) vs 2 (11), P = .03. However, there was no difference in the Δ mean mental component score of the SF-36 between the 2 groups (P = .77). ConclusionsIntroduction of an additional night shift to provide mandatory as opposed to on-demand 24-hour staff critical care specialist coverage did not affect long-term survival of medical ICU patients.

The Use of Nonphysician Providers in Adult Intensive Care Units

In the United States there are not currently enough critical care-trained practitioners to provide care to all critically ill patients. With calls for "high-intensity" staffing and 24-hour coverage of our intensive care units, the board-certified intensivists we do have are being stretched ever more thin. Nonphysician providers (physician assistants and nurse practitioners) are being used with increasing frequency in critical care settings to provide care to critically ill patients. In this review, we explore the impact of introducing nonphysician providers into the adult intensive care unit.

Inpatient staffing within pediatric residency programs: Work hour restrictions and the evolving role of the pediatric hospitalist

In October 2010, the Accreditation Council for Graduate Medical Education (ACGME) mandated new standards that will further restrict resident work hours. There is growing concern surrounding the impact these restrictions will have on the staffing of inpatient services. The objective of this study was to survey the landscape of pediatric resident coverage of noncritical care inpatient teaching services prior to the implementation of these guidelines. In addition, we sought to explore how changes in work hour restrictions might affect the role of pediatric hospitalists in training programs. In January 2010, an institutional review board (IRB)-approved electronic survey was sent to 196 US residency training programs via the Association of Pediatric Program Directors (APPD) listserve. One hundred twenty responses were received representing 5201 pediatric residents. Of the programs that responded, 84% have hospitalists. At programs with hospitalists (n = 97), 24% have pediatric hospitalist attendings in-house at night. Nearly a quarter of responding programs (22%) reported having no attending physicians in-house at night. At the time of our survey, 31% of programs anticipated the addition of 24-hour in-house hospitalist coverage within the next 5 years. When the additional work hour restrictions are implemented, 70% of programs anticipated the need to add additional hospitalist coverage at night. Significant variation exists in how pediatric teaching services provide overnight coverage. While hospitalists are prevalent in pediatric training programs (84% overall, 67% day only), their role in direct patient care during the overnight hours has been limited thus far. New work hour restrictions will promote the need for more hospitalists.

Hacia un uso adecuado de la telerradiología

Teleradiology involves much more than merely transmitting images and information between two points: teleradiology consists of sharing knowledge and working together in a network. It facilitates rapid access to radiological reports and second opinions, remote consulting among physicians, improved patient care, access to complex tools for postprocessing and computer-aided diagnosis, support for research and training projects, ties between isolated healthcare providers and busier or more experienced providers, 24-hour coverage, and competition among radiology departments. A close relation with the radiologist leads to better care. However, teleradiology should not have negative effects on the efficacy of the clinical radiology service that is closest to the patient. This article focuses on the legal requirements of teleradiology services and on the clinical problems that can arise in teleradiology settings, with the ultimate aim of ensuring the appropriate use of teleradiology to improve healthcare.