Hands Off Research Articles

375 Improving Interdepartmental Trauma Evaluation and Resuscitation Through Mock In Situ Trauma Review and Debriefing

Effective trauma resuscitation is essential to providing patients with an optimal outcome. We implemented a curriculum to review interdepartmental, interdisciplinary mock in situ traumas from the moment EMS calls our code line all the way through the patient’s disposition. Our primary goal is to streamline and standardize the evaluation and resuscitation of our trauma patients by improving interdepartmental communication skills, identifying and reviewing each member's role, reviewing the clinical management of ATLS algorithms, and reviewing ATLS procedural skills. Design: We created a curriculum to enhance the communication and skills of all members of our trauma team. The curriculum has two components: 1. The first component is an online PowerPoint module. All members of the trauma team are required to review. 2. The second component involves monthly unannounced mock in situ trauma codes. The trauma team's response to a trauma code is reviewed through focused debriefing with a team, strategically selected for their expertise. Our debriefing process occurs immediately after the conclusion of the case. Content experts have a checklist and focus on one of six critical actions. Each of these debriefers also has an opportunity to mention one other observation for improvement within their area of expertise. Our mock in situ traumas occur in the trauma bays in our emergency department. From August 2013- February 2017, we have had 32 mock in situ traumas. In total, we had 477 participants across 7 departments (emergency medicine, trauma surgery, respiratory therapy, radiology, EMS, orthopedic surgery and anesthesia) and across 9 professions (attending, physician assistant, resident, registered nurse, patient care assistant, certified registered nurse assistant, radiology technician, emergency medicine service, respiratory therapy). We tracked and classified most of our data throughout our mock in situ traumas into three categories. In the category of Leadership, we tracked: 1.The time taken for Verbal Identification of a team leader and 2. The team member’s awareness of who is the leader. In the Category of Team work and communication, we tracked: 1. Verbal role assignment to team members by the team leader, 2. The number of “thin air” commands and the total number of recaps, and 3. The Number of people in trauma box and nursing documentation. In the category of Clinical Outcomes, we tracked: 1. Room preparedness prior to patient arrival: a. Time to first set of Vitals, b. Time to primary assessment and c.Time to secondary assessment, 2. Number of critical actions completed and number of critical actions missed, 3. Formal hand off from ED to trauma team. We recognize limitations in this study: 1. Trauma codes are only run once a month.2. We did not assess any direct correlation with patient outcomes as we do not measure patient outcomes. 3. We only had one observer who consistently collected all data for every trauma. 4. We modified our checklist as we determined what was most relevant. Our online instructional course and mock in situ trauma codes are demonstrating improvement in mock in situ trauma evaluation and resuscitation. While medical proficiency is vital, teamwork and communication are the cornerstone of effective resuscitation. Our curriculum reinforces the tools that create a culture of teamwork and communication.

Do manual therapies to the perineum during the second stage of labor reduce the incidence of genital tract trauma during vaginal deliveries?

EVIDENCE-BASED ANSWER Warm compresses and perineal massage in the second stage of labor each reduce incidence of third- and fourthdegree lacerations compared with usual care (SOR: A, systematic review of RCTs). “Hands off” reduces the incidence of episiotomy (SOR: B, systematic review and single RCT). Perineal massage does not reduce the incidence of postpartum perineal pain (SOR: B, single RCT). The modified Ritgen maneuver does not reduce perineal trauma (SOR: B, systematic review containing a single RCT).

Long term evolution of distant retrograde orbits in the Earth-Moon system

This work studies the evolution of several Distant Retrograde Orbits (DROs) of varying size in the Earth-Moon system over durations up to tens of millennia. This analysis is relevant for missions requiring a completely hands off, long duration quarantine orbit, such as a Mars Sample Return mission or the Asteroid Redirect Mission. Four DROs are selected from four stable size regions and are propagated for up to 30,000 years with an integrator that uses extended precision arithmetic techniques and a high fidelity dynamical model. The evolution of the orbit’s size, shape, orientation, period, out-of-plane amplitude, and Jacobi constant are tracked. It has been found that small DROs, with minor axis amplitudes of approximately 45,000 km or less decay in size and period largely due to the Moon’s solid tides. Larger DROs (62,000 km and up) are more influenced by the gravity of bodies external to the Earth-Moon system, and remain bound to the Moon for significantly less time.

All Hands Off Deck? The Legal Barriers to Autonomous Ships

Disruptive technology is affecting all industries and shipping is no exception. Commercial autonomous ships are soon to be realised but before they can operate internationally, there are significant legal hurdles to overcome. This article considers some of these hurdles from a common law perspective. First, the lack of human presence on-board may render the proposed autonomous ships unseaworthy thereby removing the benefit of the exclusions in the Hague and Hague-Visby Rules and potentially voiding marine insurance policies. Second, these ships may not be able to comply with COLREGs. Third, the traditional role of the shipmaster will disappear and the associated legal duties and liabilities will disperse to other actors. Finally, compulsory pilotage laws vary not only from country to country, but also from port to port meaning that autonomous ships may not be permitted to berth in some ports. Thus, their usefulness as cargo-carrying vessels will be limited unless these issues are resolved at an international level.

Understanding the potential of eco-certification in salmon and shrimp aquaculture value chains

This paper examines how value chain coordination affects the ability of aquaculture producers to engage in eco-certification. Through a comparison of global salmon and shrimp value chains, it is argued that production risks and producer capacity are key determinants in the type of chain coordination adopted by lead firms. The results challenge global value chain governance theory by indicating that it is hierarchical (or vertically integrated) forms of coordination that are associated with high capabilities and low risk rather than market forms of coordination. It is also shown that eco-certification is more likely to be adopted in value chains with more engaged forms of coordination. This in turn means that eco-certification is a far less ‘hands off’ form of regulation than widely thought. The paper concludes that for certification to engage producers operating under market forms of chain coordination new arrangements are needed that can respond to challenges of improving producer capability and production risk. Statement of relevanceBy understanding the role of risk and producer capability this paper contributes to improving the application and impact of eco-certification in global aquaculture production.

A Joint CAC and Dynamic Bandwidth Allocation Technique for Capacity and QoS Analysis in Heterogeneous LTE based BWA Network: Few Case Studies

Broadband Wireless Access (BWA) network such as LTE brings heterogeneity in terms of different radio access technologies, multi-tier architectures and co-implementation of various protocols to support various types of services with desired Quality of Service (QoS) for the subscribers. However, due to limited bandwidth and high demand of LTE-BWA networks, effective network planning is required to utilize the available radio resources in an efficient way. To achieve this target, this paper aims to implement a unique Radio Resource Management scheme for a heterogeneous LTE based BWA network (BWA Het-Nets) which consists of Small cells along with Macro cells. The proposed analysis has two components: (1) Received Signal Strength (RSS) based CAC policy; and (2) Dynamic Bandwidth Allocation (DBA) scheme for QoS provisioning. The novelty of this work lies on the integration of the RSS based CAC policy with DBA scheme for improved performance in terms of different QoS parameters like New Call Blocking Probability (NCBP), Hand off Call Dropping Probability (HCDP) and Bandwidth Utilization (BU). A Continuous Time Markov Chain based mathematical model is also developed for the realistic analysis of those QoS parameters. The Joint CAC and DBA scheme (JCAC-DBA) in two-tier LTE BWA Het-Nets significantly improves NCBP, HCDP, BU and overall capacity of the network under different combinations of macro/small cells for heterogeneous multimedia services.

Any questions? Yes, do pharmacists monitor medications at refill?

ObjectivesTo describe pharmacists' self-reported refill monitoring activities and test for demographic and work setting differences that contribute to variation. MethodsThis study used a cross-sectional survey design. A 4-contact survey was mailed to 599 community pharmacists randomly selected from a list provided by the state board of pharmacy. Surveys were mailed in June and July 2013. Descriptive statistics and analysis of variance were used to characterize these data. ResultsOf the 599 surveys mailed, 269 complete responses were received for a 44.9% response rate. Pharmacists reported reviewing the patient's medication profile for 40% of refills. Of the 29% of refills handed off, pharmacists asked 70% of patients if they had any questions and 23% a specific question about drug therapy. Pharmacists at mass merchandisers and those in smaller towns were least likely to examine the profile, whereas pharmacists working at independent stores, owners, and pharmacists with a BS Pharm degree were most likely to hand off refills to patients. Demographic and work-setting characteristics factors were not associated with the rate of asking specific questions about the patient's drug therapy, although pharmacists with a BS Pharm, at an independent store, or working in the smallest towns were least likely to ask “Any questions?” when handing off the prescription. ConclusionPharmacists reported reviewing patient profiles, handing off prescriptions, and asking medication-specific questions to fewer than one-half of patients picking up refills. Pharmacists were more likely to inquire if patients had any questions than to ask specific questions, and other researchers have reported that the former phrasing may inadvertently serve to reduce patient engagement.

Development of a New Care Model for Hospitalized Children With Medical Complexity.

Children with medical complexity are a rapidly growing inpatient population with frequent, lengthy, and costly hospitalizations. During hospitalization, these patients require care coordination among multiple subspecialties and their outpatient medical homes. At a large freestanding children's hospital, a new inpatient model of care was developed in an effort to consistently provide coordinated, family-centered, and efficient care. In addition to expanding the multidisciplinary team to include a pharmacist, dietician, and social worker, the team redesign included: (1) medication reconciliation rounds, (2) care coordination rounds, and (3) multidisciplinary weekly handoff with outpatient providers. During weekly medication reconciliation rounds, the team pharmacist reviews each patient's current medications with the team. In care coordination rounds, the team collaborates with unit care managers to identify discharge needs and complete discharge tasks. Finally, at the end of the week, the outgoing hospital medicine attending physician hands off patient care to the incoming attending with input from the team's pharmacist, dietician, and social worker. Families and providers noted improvements in care coordination with the new care model. Remaining challenges include balancing resident autonomy and attending supervision, as well as supporting providers in delivering care that can be emotionally challenging. Aspects of this care model could be tested and adapted at other hospitals that care for children with medical complexity. Additionally, future work should study the impact of inpatient complex care models on patient health outcomes and experience.

Perineal techniques during the second stage of labour for reducing perineal trauma.

Perineal techniques during the second stage of labour for reducing perineal trauma.

Gail E. Latimer, MSN, RN, FACHE, FAAN

Gail E. Latimer, MSN, RN, FACHE, FAAN

Performance evaluation of wide-spread assignment schemes in a vehicular cloud

A parking lot based vehicular cloud is a cloud system where the resources are parked vehicles with onboard computing units. The dynamic and random process of vehicles joining and leaving a vehicular cloud results in a randomly changing number of available resources. This dynamic nature results in tasks assigned to departing resources to fail which reduces system efficiency. In this paper, we introduce a vehicular cloud model that considers multiple task request types and multiple resource capability types. We studied the performance of each type of user task request in tour model when using classical assignment policies, i.e. First Fit, Best Fit, and Last Fit. We also propose and investigate two techniques, task handoff and queueing, to increase the efficiency of the system and reduce the failure rate in the cloud. System simulation results show that the Last-Fit technique having the lowest task completion failure, while Best-Fit having the lowest task assignment failure. Simulations also show that hand off and queueing are very effective in increasing efficiency and reducing failure rates.

Optimizing postpartum care for the patient with gestational diabetes mellitus

Gestational diabetes mellitus poses well-established risks to both the mother and infant. As >50% of women with gestational diabetes mellitus will develop type 2 diabetes mellitus in their lifetime, performing postpartum oral glucose tolerance testing is paramount to initiation of appropriate lifestyle interventions and pharmacologic therapy. Nonetheless, test completion among women with gestational diabetes mellitus is estimated to be <50%, with particularly low rates in Latina patients, as well as patients with public insurance, low education levels, and low health literacy. Data suggest our current health services infrastructure loses patients in the postpartum gap between pregnancy-focused care and primary care. Previous studies have suggested strategies to promote oral glucose tolerance testing completion to identify type 2 diabetes mellitus. Based on existing evidence, we propose best practices for the postpartum care of women with gestational diabetes mellitus: (1) enhanced patient support for identifying long-term health care providers, (2) patient-centered medical home utilization when possible, (3) patient and provider test reminders, and (4) formalized obstetrician-primary care provider hand offs using the Situation Background Assessment Recommendation (SBAR) mnemonic. These strategies deserve future investigation to solidify a multilevel approach for identifying and preventing the continuum of diabetes.

Delegation in our Justice-Seeking Constitution

The place of the written Constitution in our constitutional practice is defined secondarily, from outside the text, not commanded by the text. Like moral readers of our constitutional practice, originalists of all stripes have to argue from outside the text. This makes the new originalist turn to the theory of language come too early; the place of such theory is necessarily subordinate to a convincing moral account of our practice as a whole. To lament the existence of constitutional provisions that do not provide legible descriptions of encompassing states of affairs —as the new originalists implicitly do— is to badly misunderstand a morally salient element of our constitutional practice. The non-encompassing provisions of the Constitution are not incomplete, and hence failed instructions; rather they are complete, successful delegations of authority to constitutionally responsible officials. A delegatory constitutional instruction hands off responsibility and authority; in order to do that, it must be non-encompassing. This is a virtue, not a liability of the written Constitution. The purpose of our constitutional practice is justice-seeking. It aims at better aligning our institutions, policies, laws and the political community as a whole, with the requirements of justice. It aims, that is, at our making moral progress as a political community. Delegations of constitutional authority and responsibility invite the partnership of contemporary constitutional actors, in the justice-seeking enterprise, including and especially courts. Our constitutional courts are common law courts; they are, that is, reason-giving and precedent- drawn, features that make them worthy partners in that enterprise.

Clinical Hand Off (Transfer of Care): A Plea for Human Factor Engineering

Clinical Hand Off (Transfer of Care): A Plea for Human Factor Engineering

U.S.-Taiwan Relations in the Trump Administration: No Big Fixes Needed

U.S.-Taiwan Relations in the Trump Administration:No Big Fixes Needed Richard C. Bush (bio) As the Obama administration officials hand off Asia policy to Donald Trump and his team, one success story is the relationship with Taiwan. Through concerted efforts and in spite of very occasional difficulties, Washington and Taipei have broadened and deepened their bilateral ties over the last eight years. The two governments are working, in the words of one U.S. official, “to build a comprehensive, durable, and mutually beneficial partnership.”1 Going forward, continuity, not reinvention, is the most sensible path. A rift is not impossible, but if it occurs, it will be because a deterioration in Taiwan-China relations drives a wedge between Washington and Taipei. That has happened before, but it need not happen again this time around. Based on current circumstances, a cross-strait downturn is more likely to disrupt U.S.-China relations than U.S.-Taiwan relations. This essay examines the ways in which the U.S.-Taiwan relationship is both normal and unique, the changes brought by the January 2016 election of Tsai Ing-wen, and U.S. policy going forward. A Unique Relationship In some ways, the U.S. relationship with Taiwan seems perfectly normal. Its economy is complementary to that of the United States, and with a population of only 23 million people, it is still the United States’ ninth-largest overall trading partner and seventh-largest destination for agricultural exports. In 2015, U.S. two-way trade in goods with Taiwan exceeded $66 billion, a 4.5% increase from 2013.2 In the last year, the United States became Taiwan’s second-largest trading partner after mainland China. Most significantly, Taiwan companies are the vital center of global supply chains that run from the United States through Taiwan to China [End Page 29] and to the world at large. Under a bilateral trade and investment framework agreement, the two governments are working to deepen economic ties and remove barriers. At Taiwan’s request, the United States has sought to find ways to expand Taiwan’s contributions to the international community, despite China’s persistent efforts to exclude it. Facilitating global training is a good example. In June 2015 the two sides signed a memorandum of understanding creating the Global Cooperation and Training Framework, whereby the United States and Taiwan agreed to conduct training programs for various Asian experts to assist their own countries in building capacities to tackle issues where Taiwan has proven experience and advantages. Counterterrorism is another example. In 2015, as a member of the coalition to counter the Islamic State of Iraq and Syria (ISIS), Taiwan worked together with the United States to deliver 350 prefabricated homes for displaced families in northern Iraq.3 Finally, as with many other places around the world, over several decades immigrants from Taiwan to the United States have created a human American stake in Taiwan’s future. A significant number of people, probably over one million, in the United States have connections to Taiwan and contribute to American life in myriad ways. In 2015, Taiwan was the United States’ seventh-largest source of international students, higher than the more populous Japan, United Kingdom, or Germany.4 It is when we move from economic, functional, and people-to-people areas to the diplomatic and security arenas that U.S.-Taiwan relations become “not so normal.” The United States does not recognize or have diplomatic relations with the Republic of China (ROC) government in Taipei but instead recognizes the People’s Republic of China (PRC) in Beijing. Washington has an embassy in Beijing and conducts its ties with Taiwan through a nominally private organization, the American Institute in Taiwan, which is staffed by U.S. government employees. This unique character applies to security as well, with the political and military threat from China perceived by Taiwan closely binding the island to the United States. The ROC fears that through force, coercion, or intimidation, Beijing will compel the island to be incorporated into the PRC. That fear only deepens as China’s military power and willingness to accept risk grow. Under the rubric of the 1979 Taiwan Relations Act...

A Location-Aware Service Deployment Algorithm Based on K-Means for Cloudlets

Cloudlet recently was proposed to push data centers towards network edges for reducing the network latency of delivering cloud services to mobile devices. For the sake of user mobility, it is necessary to deploy and hand off services anytime anywhere for achieving the minimal network latency for users’ service requests. However, the cost of this solution usually is too high for service providers and is not effective for resource exploitation. To resolve this problem, we propose a location-aware service deployment algorithm based on K-means for cloudlets in this paper. Simply speaking, the proposed algorithm divides mobile devices into a number of device clusters according to the geographical location of mobile devices and then deploys service instances onto the edge cloud servers nearest to the centers of device clusters. Our performance evaluation has shown that the proposed algorithm can effectively reduce not only the network latency of edge cloud services but also the number of service instances used for satisfying the condition of tolerable network latency.

Finance for All: The Success of the Market-Led Approach to Financial Development in the Developing World

Economists have long argued that inclusive and well-developed financial systems play a critical role in fostering economic growth and development. However, the question of what is the best means of achieving financial development has long remained a puzzle in the development finance literature. In this paper, I show that some of the greatest examples of financial development in modern times have not come from countries that have pursued a more top-down or state-led approach to financial development, which has been the dominant mode of promoting financial inclusion and development in the postwar era. Instead, they’ve come from countries that have taken a bottom-up or market-oriented approach. This hands-off approach has succeeded because it gives entrepreneurs the ability to utilize their knowledge of their local economy to discover innovative ways to access financially excluded segments of the population. Perhaps the greatest modern day example of market-led financial development is the mobile money revolution that has swept across Sub-Saharan Africa (SSA) over the past decade. In this paper, I argue that the key predictor of whether a country will reap the benefits of these transformative innovations is whether its government embraces a hands off, or “enabling,” regulatory environment that promotes entrepreneurship and experimentation.

Parabolic Path

Parabolic Path Bobby Mitchell (bio) When the bullet passed through the girl’s head, entering at the base of her neck and exiting through her forehead, it pulled behind it a trail of gray matter into the broken cranium. It restored the fractured skull, stitching together the delicate, dark skin between the girl’s eyebrows. When the bullet encased itself in its shell and spun and rushed and sped into the muzzle of Sergeant Sofie Afridi’s Beretta at a rate of 1,100 meters per second, as the shell came to rest in the chamber of her sidearm and the force of the bullet sent a shock through her rigid, outstretched arms, Sofie knew she’d become a mother. When she first saw the girl, blood smeared on her face and pooled on the suddenly wet earthen ground of a mud home in a small compound near the Khyber Pass, Sofie knew the girl would be born soon. She looked to the other soldiers in the room with her. Private Murphy. Specialist Granger. Sergeant Carter. One of these would be the girl’s father, she thought. There were other bodies in the room, too. Their pale, cold forms—dimly lit—cast small shadows on the ground where the dawn’s twilight had crept in through the west-facing windows. Sofie dusted her hands off and knelt beside the girl. She held two fingers to the girl’s carotid artery. She hoped for a pulse, for the first small beat. In some births, she knew, there could be a long, quiet period of a slow, weak pulse before the first painful and beautiful breath. For those born in war, and there were always so many born that way, birth involved a lot of blood. There was, of course, a variety of other and less violent ways to be born, but for those who had seen a war-birth, there was no arguing that it was one of nature’s most beautiful miracles. [End Page 72] Sofie stood up, buttoning the chin strap of her helmet into place. She stretched out her arm, pointing to the other bodies in the room. She called out to her fellow soldiers, asking for a status report. The other soldiers—Private Granger and Specialist Murphy were closest to her—shook their heads, meaning no one was breathing, not yet anyway. Specialist Murphy stood, his legs spread wide and slightly bent, his weapon drawn, standing next to the body of an unborn soldier he and Granger had carried with them to this home. His nametape said Ramirez, so that’s what they would call him. Somewhere on this compound, Murphy knew Ramirez had a father or a mother waiting for him. Murphy had said so on the way to the compound, he just knew it, why else would he be lugging the body around with him? Sofie looked back to the little girl on the ground, the wet blood all but gone, the last trails of it snaking its way across her face. She broke the holster strap on her sidearm, her weapon drawn and steady, waiting for the bullet which, a moment later, had ripped out of the girls head and traced its parabolic path into her gun. The girl screamed. She scooted across the floor, hands behind her bent back, her heels digging into the ground and pulling her small self towards Sofie. The girl’s eyes were wide and her chest rose and fell in massive heaves. She wanted to holster her weapon, to kneel back down in the dirt to comfort the girl, her daughter, her first child, but she knew she couldn’t. The compound was ringing with the hollow bangs of bullets coming loose from the secret places where they had been lodged, waiting for this moment when the soldiers would come along to collect them. The bullets pried loose from mud walls and feather bedding, from bookcases and hand-crank-radios, from livestock and people alike, and once a soldier drew their weapon they kept it out until the last bullet tore through the air. Nineteen rounds in all, that’s what she collected. She’d had to drop...

Law as an equalizer

Law as an equalizer

EFFECTIVENESS OF HANDS OFF VERSUS HANDS ON TECHNIQUES ON PERINEAL TRAUMA AND PERINEAL PAIN AMONG PARTURIENT MOTHERS

Background: Labor is the process by which the fetus and the placenta leave the uterus. Delivery can occur in two ways, vaginally or by a cesarean delivery. The majority of women who have a vaginal birth will sustain perineal trauma from a spontaneous perineal tear or episiotomy or both.Aim: This study aims to assess the effectiveness of hands off versus hands on techniques on perineal trauma and perineal pain among parturient mothers in selected hospitals, Kerala.Methods: The research design adopted in this study was true experimental post test only design. The study was conducted in 3 hospitals at Kerala such as Karothukuzhiyil hospital Pvt, Lakshmi hospital Pvt and Carmal hospital Pvt. Sample size was computed by power analysis based on the previous studies and it would be a total of 90 samples, with 30 parturient mothers in each groups. Simple random sampling technique (Lottery method) was adopted for the selection of parturient mothers into the study. Perineal trauma was assessed by the scale given by Royal College of Obstetrics and Gynaecology (RCOG), 2001, and visual analogue scale (Combined numerical and categorical pain scale) was used to assess the perineal pain of parturient mothers.Results: The results showed that, there was extremely significant difference found in perineal trauma and perineal pain of parturient mothers between study group I and study II at p=0.000 level. The mean scores of study group I was lesser than the mean scores of study group II. Conclusion: Different perineal techniques and interventions such as hands on technique, hands off technique, perineal massage, warm compresses etc can be widely used by midwives and birth attendants to prevent perineal trauma during labour. Key words: hands off technique, hands on technique, perineal trauma and perineal pain