Ancillary Staff Research Articles

The Effect of Primary Care Team Realignment on Point-of-Care Screening.

Reporting primary care quality measures is an essential component of value-based care delivery and is part of the strategy to bend the health care cost curve. As primary care physicians are increasingly pressed for time, incorporating ancillary staff screening into pre-visit workflows can increase screening rates, but can pose a challenge in large practice settings. The objective was to improve screening rates for depression and falls risk at a large, urban primary care practice. Jefferson Family Medicine Associates is a practice in downtown Philadelphia that serves 35,000 patients and provides approximately 80,000 visits annually. The majority of patients are African American. Screening responsibilities were realigned within medical assistant workflows, and a training program was designed and implemented to ensure its success and sustainability. Monthly Group Practice Reporting Option data on depression screening and falls risk screening was collected from January 1, 2015, to October 31, 2016. The primary outcome measures were the rate of depression screening and falls risk screening performed for patients who had a visit during the study period. The average monthly depression screening rate changed from 1.41% pre intervention to 49.77% post intervention (z = -100.65; P < .001). The average monthly falls screening rate changed from 19.23% pre intervention to 61.33% post intervention (z = -77.97, P < .001). This workflow redesign, training model, and implementation was successful at increasing screening rates for depression and falls risk, and may benefit other practices that hope to accomplish similar quality measure improvements.

Initiating a women's health physician–run rehabilitation clinic in the United States

Pelvic dysfunction can lead to persistent impairment and disability when left untreated. While some diagnoses overlap with those seen in a general Physical Medicine and Rehabilitation (PM&R) outpatient setting and Obstetrics/Gynecology (Ob/Gyn), management varies with changes in biomechanics and function in contexts of fecundity, gravidity, post-partum status, post-menopause, history of surgical intervention, or history of sexual trauma. PM&R initiated a collaboration with Ob/Gyn to create a physician-run Women's Health Rehabilitation specialty clinic embedded within an established Ob/Gyn clinic at an academic university hospital in the United States. The clinic focuses on pelvic floor disorders and musculoskeletal issues associated with pregnant or post-partum women. Over 50 referrals were made from Ob/Gyn in the initial months of clinic launch. Diagnoses included low back pain and sacroiliac joint dysfunction related to pregnancy, pelvic floor instability, dyspareunia, post-partum thoracic back pain, and coccydynia. Management included education of biomechanics, referral to Pelvic Floor-specialized Physical Therapy (PFPT), medications, referral to Psychology, and injections. Despite significant enthusiasm from Ob/Gyn and the patients, initial referrals were delayed due misunderstanding regarding difference between PM&R and PT, failure to recall initiation of clinic, and flawed protocol with ancillary staff on scheduling process. Despite infrastructure of a large academic institution in a metropolitan area, there was a paucity of availability of PFPT multiple sites within the academic affiliation or the metropolitan area. Comprehensive Women's Health Rehabilitation lead by physiatrists can address biomechanical issues, treat pain, perform interventional procedures, and coordinate care with PFPT and other professionals to address contributing factors, like mood disturbances and life situations. Our clinic aim is to expand collaborations with increased marketing, face-to-face interaction, and visibility at multidisciplinary events. We expect to increase referral sources and numbers as well as educate more of the medical community about our specialty.

Cost and Revenue Relationship in Orthopaedic and Trauma Surgery Patients in Relation to Body Mass Index

Growing numbers of patients in orthopaedic and trauma surgery are obese. The risks involved are e.g. surgical complications, higher costs for longer hospital stays or special operating tables. It is a moot point whether revenues in the German DRG system cover the individual costs in relation to patients' body mass index (BMI) and in which area of hospital care potentially higher costs occur. Data related to BMI, individual costs and revenues were extracted from the hospital information system for 13,833 patients of a large hospital who were operated in 2007 to 2010 on their upper or lower extremities. We analysed differences in cost revenue relations dependent on patients' BMI and surgical site, and differences in the distribution of hospital cost areas in relation to patients' BMI by t and U tests. Individual costs of morbidly obese (BMI ≥ 40) and underweight patients (BMI < 18.5) significantly (p < 0.05) exceeded individual DRG revenues. Significantly higher cost revenue relations were detected for all operations on the lower and upper extremities except for ankle joint surgeries in which arthroscopical procedures predominate. Most of the incremental costs resulted from higher spending for nursing care, medication and special appliances. Costs for doctors and medical ancillary staff did not increase in relation to patients' BMI. To avoid BMI related patient discrimination, supplementary fees to cover extra costs for morbidly obese or underweight patients with upper or lower extremities operations should raise DRG revenues. Moreover, hospitals should be organisationally prepared for these patients.

Integrating childhood obesity resources into the patient-centered medical home: Provider perspectives in the United States.

Pediatric primary care providers play a critical role in managing obesity yet often lack the resources and support systems to provide effective care to children with obesity. The objective of this study was to identify system-level barriers to managing obesity and resources desired to better managing obesity from the perspective of pediatric primary care providers. A 64-item survey was electronically administered to 159 primary care providers from 26 practices within a large pediatric primary care network. Bivariate analyses were performed to compare survey responses based on provider and practice characteristics. Also factor analysis was conducted to determine key constructs that effect pediatric interventions for obesity. Survey response rate was 69% ( n = 109), with the majority of respondents being female (77%), physicians (67%), and without prior training in obesity management (74%). Time constraints during well visits (86%) and lack of ancillary staff (82%) were the most frequently reported barriers to obesity management. Information on community resources (99%), an on-site dietitian (96%), and patient educational materials (94%) were most frequently identified as potentially helpful for management of obesity in the primary care setting. Providers who desired more ancillary staff were significantly more likely to practice in clinics with a higher percentage of obese, Medicaid, and Hispanic patients. Integrating ancillary lifestyle expert support into primary care practices and connecting primary care practices to community organizations may be a successful strategy for assisting primary care providers with managing childhood obesity, especially among vulnerable populations.

Young children’s agency: exploring children’s interactions with practitioners and ancillary staff members in Greek early childhood education and care settings

ABSTRACTMost research in early childhood education and care (ECEC) settings, in Greece and internationally, focuses on children’s relationships with their early years practitioners, but evidence regarding young children’s role in the formation of these relationships is limited. This paper focuses on 10 children, under the age of three, recognizing children’s agency and their significant contribution to the formation of interpersonal relationships with practitioners and ancillary staff members. The paper draws on findings from an ethnographic case study, conducted in two Greek day-care settings over the course of six months, which used an adaptation of the Mosaic Approach. The analysis suggests that children’s relationships with significant adults beyond the home are paramount for children and influence and shape the way they perceive and experience the settings.

Physicians' Perspectives Regarding Prescription Drug Monitoring Program Use Within the Department of Veterans Affairs: a Multi-State Qualitative Study.

The Department of Veterans Affairs (VA) has implemented robust strategies to monitor prescription opioid dispensing, but these strategies have not accounted for opioids prescribed by non-VA providers. State-based prescription drug monitoring programs (PDMPs) are a potential tool to identify VA patients' receipt of opioids from non-VA prescribers, and recent legislation requires their use within VA. To evaluate VA physicians' perspectives and experiences regarding use of PDMPs to monitor Veterans' receipt of opioids from non-VA prescribers. Qualitative study using semi-structured interviews. Forty-two VA primary care physicians who prescribed opioids to 15 or more Veterans in 2015. We sampled physicians from two states with PDMPs (Massachusetts and Illinois) and one without prescriber access to a PDMP at the time of the interviews (Pennsylvania). From February to August 2016, we conducted semi-structured telephone interviews that addressed the following topics regarding PDMPs: overall experiences, barriers to optimal use, and facilitators to improve use. VA physicians broadly supported use of PDMPs or desired access to one, while exhibiting varying patterns of PDMP use dictated by state laws and their clinical judgment. Physicians noted administrative burdens and incomplete or unavailable prescribing data as key barriers to PDMP use. To facilitate use, physicians endorsed (1) linking PDMPs with the VA electronic health record, (2) using templated notes to document PDMP use, and (3) delegating routine PDMP queries to ancillary staff. Despite the time and administrative burdens associated with their use, VA physicians in our study broadly supported PDMPs. The application of our findings to ongoing PDMP implementation efforts may strengthen PDMP use both within and outside VA and improve the safe prescribing of opioids.

“I wouldn’t really believe statistics” – Challenges with influenza vaccine acceptance among healthcare workers in Singapore

BackgroundInfluenza vaccine acceptance among healthcare workers (HCWs) is a worldwide problem, but relatively little research has focussed on Asia, including Singapore. Despite widespread access and recommendations from public health authorities, influenza vaccine uptake remains suboptimal among HCWs. MethodsOur qualitative study used focus group discussions to identify and explain factors limiting influenza vaccine acceptance among HCWs in Singapore. A total of 73 doctors, nurses, allied health and ancillary staff across three public hospitals were included. ResultsChallenges identified include a fear of contracting influenza from vaccination exacerbated by negative anecdotes regarding vaccine safety and efficacy, distrust of published efficacy data, uncertainty regarding relevance of existing data for Singapore, reluctance to introduce chemicals or overmedicate, pain from injection, low risk attributed to influenza and limited awareness of influenza transmission with a preference for alternatives in patient protection. Differences in attitudes were observed across vocational groups. Lack of overt promotion by hospital leadership in some institutions, perceived vaccine hesitancy among doctors, access, and work culture that implicitly encourages working through illness were further barriers. ConclusionOur findings highlight a combination of misperceptions about influenza vaccination and cognitive biases at the individual level, and challenges at the institutional level limiting uptake. Findings indicate an urgent need to provide targeted education and communication. Rather than providing more data, we recommend a widely-disseminated, locally-compiled synthesis addressing specific concerns of hesitant HCWs. Tailoring interventions to specific vocational groups should be considered. Institutional norms and culture may have a powerful influence in setting default behaviours: more effort is needed in improving influenza vaccine promotion and priority at some institutions, integrating vaccine-related communication with other infection control communication and addressing influenza vaccine hesitancy among doctors as a priority. Finally, further study of strategies to address cognitive biases affecting influenza vaccine acceptance in Singapore is desirable.

Use of a Novel Memory Aid to Educate Perioperative Team Members on Proper Patient Positioning Technique.

Interdisciplinary collaboration is key to safe surgical positioning. Although the surgical procedure dictates the patient's position, surgeons, anesthesia care providers, intraoperative nurses, and ancillary staff members must work together to achieve the goal of safe positioning. Correct patient positioning includes the provision of adequate access to the surgical site for the surgeon and surgical assistants. Surgical positions may put the patient at risk of injury. Understanding human anatomy, including the nerves commonly affected by each surgical position, can help the surgical team prevent accidental and irreversible patient injury. A lack of knowledge of proper positioning practices can result in serious patient injury, such as permanent paralysis, blindness, tissue necrosis, burns, bone fracture, and even death. This article reviews surgical positioning and introduces a learning module that involves the use of mnemonics as memory aids for perioperative team members who are learning proper positioning techniques.

Abstract TP8: Process Modification to Reduce Door to Puncture Time for Patients With Large Vessel Ischemic Stroke

Numerous studies have demonstrated the paramount importance of rapid treatment of large vessel occlusion ischemic stroke. We sought to improve our door to reperfusion times (DTRt) so as to ensure we complied with the Joint Commission CSC measure of 90 minutes. We theorized that by reducing the Door To Puncture time (DTPt), we would promote rapid revascularization and improved clinical outcomes. Our goal was to reduce the DTPt to be consistently less than 75 minutes by ensuring rapid identification, streamlining the activation of the neuroendovascular team and providing education to the providers and ancillary staff. We had two scheduled systems evaluations; Pre-intervention (01/15 to 06/16), and post-intervention (01/17 to 07/17). A total of 82 patients were reviewed, 45 pre-intervention, and 37 post-intervention. During the pre-intervention period, the median DTPt was 98 minutes with an intraquartile range of 75 to 127. In the post-intervention phase the median DTPt was 49 minutes with an intraquartile range of 40 to 82. The p value comparing pre-intervention to post-intervention DTPt was 0.000042. In conclusion, we found that the implementation of rapid identification, streamlined activation and education resulted in a statistically significant decrease in Door To Puncture times from a median of 98 minutes to 49 minutes (p=0.000042). This allowed for a decrease in median Door To Reperfusion time from 130 minutes pre-intervention to 66 minutes post-intervention.

Abstract TP273: Stroke Pit Stop Decreases Door to Needle Time

Background: The American Stroke association has set targets for certified stroke centers achieving door to needle times within 60 minutes for 75% of cases, and less than 45 minutes for half of the cases. For each 15 minute reduction in delay, an estimated 4% improvement is realized in clinical outcomes. However, many barriers interfere with the hospital’s ability to attain a reduction both in clinical decision making and treatment times. Purpose: This quality improvement project examined the impact of a work flow re-design using a Stroke "Pit Stop" protocol. The project was designed to improve patient care and determine appropriate institutional practices at our hospital by evaluating patient outcomes. Methods: A protocol was developed where stroke code patients was rapidly evaluated for tPA candidacy and tasks were simultaneously completed by physicians, nurses, and ancillary staff prior to CT imaging. All code stroke cases from a single hospital were evaluated 6 month pre (2016 July-December), and 6 months post (2017 January - June) intervention. Average door to needle, proportion of cases below 60 minutes and 45 minutes were compared between the two time periods. Results: Mean door to needle time statistically significantly decreased from 63 ± 33 minutes to 46 ± 13 minutes (p= 0.044). Furthermore, the percentage of patients receiving tPA under 60 minutes and under 45 minutes increased from 63% to 79% and from 29% to 47% respectively. Conclusion: Instituting the Stroke "Pit Stop" statistically significant decreased door to needle times helping the hospital meet national guidelines.

Tenure-track Faculty Determine the Success of Online Graduate Education

Tenure-track Faculty Determine the Success of Online Graduate Education Carmen King de Ramírez Keywords courses/cursos, faculty/profesoriado, graduate/graduado, language/lenguas, online/en línea Response 1 to "Meeting Twenty-First-Century Needs: Spanish for the Professions as the Future of Spanish Graduate Education?" "Meeting Twenty-First-Century Needs: Spanish for the Professions as the Future of Spanish Graduate Education?" provides insights to how one particular university is confronting the decreased student enrollments seen across foreign language (FL) graduate programs in the United States. The author discusses the importance of online post-graduate language courses through examples of how such courses would meet a variety of working professionals' needs as well as increase languishing enrollments in post-graduate FL programs. This argument is followed by an overview of an existing online Spanish for the Professions Master of Science degree (SPMS). While the SPMS clearly fills a gap in FL education, the widespread skepticism that many language educators harbor regarding online language courses may impede the quality, vitality, and implementation of such programs (Blake 2007). Elizabeth Harsma (2017) briefly alludes to and refutes common objections to online FL language education but admits that faculty interest continues to be an issue since two faculty members primarily teach the courses. While the programmatic structure is innovative and promising, the reader is left to question the longevity and quality of the program as the author fails to mention strategies for training and recruiting tenured and tenure-track faculty who are qualified to teach at the post-graduate level. The lack of tenured and tenure-track faculty interest in online education (Allen and Seaman 2010; Kim and Bonk 2006) is illustrated by the numerous studies on non-tenured online faculty in comparison to limited publications regarding online tenured and tenure-track faculty (Drewelow 2013; LoBasso 2013). One factor that may contribute to this phenomenon is that tenured and tenure-track positions are evaluated largely on research production with little incentive for undertaking new pedagogical endeavors (Zhao and Cziko 2001). The lack of incentive that the tenure track system places on pedagogical innovation is compounded by the fact that novice online instructors must invest a considerable amount of time in familiarizing themselves with course materials, digital platforms, and resources provided by ancillary staff such as instructional designers and web programmers (Bartolic-Zlomislic and Bates 1999; Stone and Perumean-Chaney 2011). Such distractions from academic research may explain why part- time and adjunct faculty are more frequently assigned online teaching assignments than full-time faculty (Seaman 2009). Despite the aforementioned challenges in recruiting tenured and tenure-track faculty to teach online, experienced online professors reported an increase in productivity as the flexibility of online instruction allowed them to spend more time on service or research (Meyer 2012). In order to help T/TT faculty reconceptualize online teaching, departmental training and faculty [End Page 153] mentorship programs are an indispensable means of helping faculty integrate technology in a way that presents minimal disturbances to their established academic routine (Gabriel and Kaufield 2008; Zhao and Cziko 2001). In conclusion, the future of online graduate programs such as SPMS does not depend on the clever creation of online courses but the department's commitment to training/incentivizing tenured and tenure-track faculty members to teach online. Carmen King de Ramírez University of Arizona WORKS CITED Allen, I. Elaine, and Jeff Seaman. (2010). "Class Differences: Online Education in the United States, 2010." Sloan Consortium. Print. Google Scholar Bartolic-Zlomislic, Silvia, and AW Tony Bates. (1999). "Investing in On-line Learning: Potential Benefits and Limitations." Canadian Journal of Communication 24.3. n.p. Print. Google Scholar Blake, Robert J. (2007). "New Trends in Using Technology in the Language Curriculum." Annual Review of Applied Linguistics 27: 76–97. Print. Google Scholar Drewelow, Isabelle. (2013). "Exploring Graduate Teaching Assistants' Perspectives on their Roles in a Foreign Language Hybrid Course." System 41.4: 1006–22. Print. Google Scholar Gabriel, Martha A., and Kandra J. Kaufield. (2008). "Reciprocal Mentorship: An Effective Support for Online Instructors." Mentoring and Tutoring: Partnership in Learning 16.3: 311–27. Print. Google Scholar Harsma, Elizabeth. (2017). "Meeting Twenty-First-Century Needs: Spanish for the Professions as the...

Novel use of interventional radiology in trauma

Trauma is one of the leading causes of mortality in the United States. There is a need for effective and efficient delivery of care that can improve survival and reduce morbidity as much as possible. Due to technological advances in interventional radiology (IR); there has been an expanding role for IR in hemodynamically stable and unstable patients. Various tools, such as micro catheters, stent grafts, digital subtraction angiography (DSA), and cone beam angiography have expanded the ability of the IR physician in reducing mortality and morbidity in patients who have suffered traumatic injuries. However, for the best possible patient care to be administered there must be two important resources readily available: the ability to triage before or quickly upon presentation to the hospital and a multidisciplinary trauma team which includes physicians and well trained ancillary staff. Here we describe the critical role IR plays in the trauma setting and its evolution and future growth, given the advances in technology.

Interdisciplinary Skills Review Program to Improve Team Responses During Postpartum Hemorrhage

ObjectiveTo develop an interdisciplinary, interactive, skills review program to improve team responses during a postpartum hemorrhage (PPH). DesignOnline didactic modules in combination with an interdisciplinary skills program consisting of seven hemorrhage-related stations. Setting/Local ProblemThe project was conducted in the Women’s Health Department in a quaternary-care Magnet- and Baby Friendly–designated academic medical center in Philadelphia, Pennsylvania. Women cared for at this center have comorbidities that place them at greater risk for PPH. A need was identified to implement a multidisciplinary and comprehensive program to assess hemorrhage risk and appropriately recognize and intervene with all PPHs in this setting. ParticipantsThe 276 participants, including registered nurses, obstetric and family medicine attending physicians and residents, advanced practice nurses, and ancillary staff in the hospital’s Women’s Health Department, completed the initial obstetric hemorrhage program. Intervention/MeasurementsThe program included online didactic modules, seven interdisciplinary skills stations led by trained nurses and providers, and an in situ simulation. Successful completion of the online modules was a prerequisite for participation in the skills stations. All participants completed a written program evaluation at the conclusion of the program. ResultsResults of the postassessment survey indicated that participants rated the program 3.94 of 4.00 for overall effectiveness to improve interdisciplinary team responses to PPH. Comments were overwhelmingly positive, and participants expressed increased confidence and knowledge related to PPH after completion of the program. ConclusionAn interdisciplinary program that included online didactic modules, interactive skills stations, and simulation improved team confidence and responses to PPH.

Acupuncture-Associated Vasovagal Response: Revised Terminology and Hospital Experience.

Background: Vasovagal responses associated with acupuncture therapy are relatively uncommon adverse events, occurring in ∼0.02%-7% of treatments. The complex neurocardiovascular reflexes involved in vasovagal responses can induce a range of symptoms such as dizziness, nausea, sweating, bradycardia, hypotension, and, in some cases, syncope or convulsions. Although patients typically recover quickly with proper support, these events may be of concern and anxiety-producing for both patient and provider. Providers need to be well-versed in methods for prevention and treatment of acupuncture-associated vasovagal responses to promote safe practice environments, patient satisfaction and comfort, and cost-effectiveness. Objectives: To examine the biomedical and Traditional Chinese Medicine mechanisms of vasovagal responses, propose updated terminology, and outline steps for prevention and treatment. Methods: During an 18-month period, 281 community-style acupuncture treatments were performed on family members of admitted patients and hospital staff members at the University of Minnesota Masonic Children's Hospital. Five (1.8%) treatments resulted in documented acupuncture-associated vasovagal response (AAVR) symptoms. Results: All 5 patients recovered from their AAVR symptoms after treatment interventions. After recovery, 3 patients reported reductions in their main complaint symptoms; main complaint symptom outcomes were not recorded for the other 2 patients. Conclusions: As integrative practices become more prevalent in academic institutions and primary care environments, clear communication about, as well as prevention treatment, documentation and reporting of acupuncture-associated adverse events will become increasingly valuable. The authors recommend that clinicians in integrative practice clinical environments consider developing formal AAVR response plans as well as training students, supervising and attending providers, and ancillary staff members to ensure rapid, prepared handling and documentation of AAVR incidents.

Use of a Hands Free, Instantaneous, Closed-Loop Communication Device Improves Perception of Communication and Workflow Integration in an Academic Teaching Hospital: A Pilot Study.

Efficient and effective communication between providers is critical to quality patient care within a hospital system. Hands free communication devices (HFCD) allow instantaneous, closed-loop communication between physicians and other members of a multidisciplinary team, providing a communication advantage over traditional pager systems. HFCD have been shown to decrease emergency room interruptions, improve nursing communication, improve speed of information flow, and eliminate health care waste. We evaluated the integration of an HFCD with an existing alphanumeric paging system on an acute inpatient medicine service. We conducted a prospective, observational, survey-based study over twenty-four weeks in an academic tertiary care center with attending physicians and residents. Our intervention involved the implementation of an HFCD alongside the existing paging system. Fifty-six pre and post surveys evaluated the perception of improvement in communication and the integration of the HFCD into existing workflow. We saw significant improvements in the ability of an HFCD to help physicians communicate thoughts clearly, communicate thoughts effectively, reach team members, reach ancillary staff, and stay informed about patients. Physicians also reported better workflow integration during admissions, rounds, discharge, and teaching sessions. Qualitative data from post surveys demonstrated that the greatest strengths of the HFCD included the ability to reach colleagues and staff quickly, provide instant access to individuals of the care team, and improve overall communication. Integration of an instantaneous, hands free, closed loop communication system alongside the existing pager system can provide improvements in the perceptions of communication and workflow integration in an academic medicine service. Future studies are needed to correlate these subjective findings with objective measures of quality and safety.

Caracterización del funcionamiento de la unidad de cuidados postanestésicos a partir de la percepción del personal de enfermería profesional

IntroductionThe post-anesthesia care unit has been identified as a vulnerable area for the occurrence of adverse events. Here, the nursing staff is responsible for managing and taking care of patients. ObjectiveTo explore the perception of the professional nursing staff about the performance of the post-anesthesia care unit, and portray certain aspects of its operations. Materials and methodsThis is a mixed sequential study including an observational, descriptive and quantitative cross section phase and a qualitative, descriptive, interpretative phase, using grounded theory. ResultsNurses perceive the PACU as “a place for care” with weak processes such as patient handover and monitoring, communications among care providers, lack of specific skills of the ancillary staff and lack of team work. Work overload, extended administrative tasks that take away focus from patient care, in addition to a lack of compliance with protocols, are all conducive to the occurrence of adverse events. ConclusionsNurses perceive the unit as a place of complex processes and particular characteristics that make the unit prone to adverse events. Institutional factors, work team and professional-related aspects become threats that undermine the safety environment that should always prevail in every PACU. Specific strategies are discussed to turn the recovery unit into a safe care service for the surgical patient.

Portrayal of the performance of the post-anesthesia care unit, based on the perception of the professional nursing staff

IntroductionThe post-anesthesia care unit has been identified as a vulnerable area for the occurrence of adverse events. Here, the nursing staff is responsible for managing and taking care of patients. ObjectiveTo explore the perception of the professional nursing staff about the performance of the post-anesthesia care unit, and portray certain aspects of its operations. Materials and methodsThis is a mixed sequential study including an observational, descriptive and quantitative cross section phase and a qualitative, descriptive, interpretative phase, using grounded theory. ResultsNurses perceive the PACU as “a place for care” with weak processes such as patient handover and monitoring, communications among care providers, lack of specific skills of the ancillary staff and lack of team work. Work overload, extended administrative tasks that take away focus from patient care, in addition to a lack of compliance with protocols, are all conducive to the occurrence of adverse events. ConclusionsNurses perceive the unit as a place of complex processes and particular characteristics that make the unit prone to adverse events. Institutional factors, work team and professional-related aspects become threats that undermine the safety environment that should always prevail in every PACU. Specific strategies are discussed to turn the recovery unit into a safe care service for the surgical patient.

Emergency Department Staff Beliefs About Self-Harm: A Thematic Framework Analysis.

To explore the beliefs and attitudes of emergency department staff about self-harm behaviour. Existing studies looking at views regarding self-harm rely solely on the information provided by medical and nursing staff using a questionnaire format. No studies currently consider ancillary staff members' beliefs about self-harm, even though they also work with these patients. A thematic framework analysis of interview transcriptswas carried out. Individual semi-structured interviews were conducted from December 2015 to February 2016. Fifteen medical, nursing, and ancillary staff members from a large, tertiary emergency department participated. There were 5 major themes identified-causes of self-harm are multifactorial; beliefs about self-harm can change over time; emergency departments should only focus on the physical; self-harm occurs on a spectrum; and the system has failed. The results suggest participants felt ill-prepared and lacking in appropriate training to help patients that self-harm, and furthermore they have little faith in the mental health system. Staff beliefs and attitudes may change over time with exposure to patients who self-harm, possibly becoming more positive in response to a greater understanding of why the self-harm behaviour is occurring.

Alterations in Spanish Language Interpretation During Pediatric Critical Care Family Meetings.

To characterize alterations in Spanish language medical interpretation during pediatric critical care family meetings. Descriptive, observational study using verbatim transcripts of nine PICU family meetings conducted with in-person, hospital-employed interpreters. A single, university-based, tertiary children's hospital. Medical staff, family members, ancillary staff, and interpreters. None. Interpreted speech was compared with original clinician or family speech using the qualitative research methods of directed content analysis and thematic analysis. Alterations occurred in 56% of interpreted utterances and included additions, omissions, substitutions, editorializations, answering for the patient/clinician, confessions, and patient advocacy. Longer utterances were associated with more alterations. To minimize interpreter alterations during family meetings, physicians should speak in short utterances (fewer than 20 words) and ask interpreters to interrupt in order to facilitate accurate interpretation. Because alterations occur, physicians may also regularly attempt to assess the family's understanding.

Curriculum Using the In-Situ Operating Room Setting

The American College of Surgeons/Association of Program Directors in Surgery is a comprehensive, simulation-based curriculum for General Surgery residents which exists in 3 phases. While phases 1 and 2 deal with core skills and advanced procedures respectively, phase 3 targets team-based skills. To date, the 3rd phase of this curriculum has not seen wide scale implementation. This is a pilot study to verify the feasibility of implementing the phase 3 curriculum in the in-situ setting. In our initial attempt to implement Phase 3 at our institution, we chose to perform the training in an in-situ setting within an operating room (OR) at our main hospital, despite our having a separate simulation center. By choosing the in-situ OR environment for this training we were able to minimize concerns regarding resident and faculty availability and able to successfully complete 8 separate sessions during the academic year. During 7 sessions, 2 separate scenarios were performed while a single scenario was performed in 1 session. This single session was excluded from analysis, leaving a total of 14 scenarios to evaluate. The unique scenarios included laparoscopic crisis, postoperative myocardial infarction, anaphylaxis, and postoperative hypotension. All sessions were audiovisually recorded. In order to evaluate the effect of the training, the videos were viewed by 3 independent reviewers and all surgery, anesthesia and nursing participants were rated using the NOTECHs II scale. Degree of inter-rater agreement was established. The difference between the first and second simulations on the same day was then assessed. In addition, participant opinions of the simulations were assessed through electronic surveys following the training. Tertiary Care University Hospital. We performed a total of 8 sessions, for a total of 15 scenarios. Eight surgery residents at the postgraduate year 1 (PGY1)-PGY3 level, 16 anesthesia residents at the PGY3-PGY4 level, 16 nurses and 13 ancillary staff participated. From the first to the second scenario, the total team NOTECHs II score increased from 69.4 ± 1.4 to 77.3 ± 0.5 (p = 0.007). The NOTECHs II scores for each subteam also improved, from 24.2 ± 0.6 to 26.4 ± 0.5 (p = 0.007) for surgery residents, 23.7 ± 0.9 to 26.7 ± 0.4 (p = 0.03) for anesthesia, and 21.6 ± 0.3 to 24.3 ± 0.5 (p = 0.01) for nursing. The inter-rater reliability as measured by Kendall's coefficient of concordance was modest for the whole team score. Most of the participant responses were either favorable or strongly favorable. The in-situ OR environment is both a unique and effective setting to perform team-based training. Furthermore, training in the in-situ setting minimizes or removes many of the logistic issues involved in designing and implementing team-based training curricula for general surgery residency programs. However, we found that administrative and departmental (surgery, anesthesia, and nursing) "buy in" as well as protected faculty time for education were all necessary for in-situ training to be successful. NOTECHs II is an established scale for the evaluation of teams in this simulation setting and appears to be a valid tool based on the results of this study. However, further assessment of inter-rater reliability as well as improved training of evaluators are necessary to determine if inter-rater reliability can improve.