Positive Patient Outcomes Research Articles

452. Correlation of Charleston Comorbidity Index Score as the COVID-19 Pandemic Surged Throughout HCA Healthcare Facilities and Patient Outcomes

BackgroundAs the COVID-19 pandemic raged throughout the United States, the healthcare system was strained due to a sudden increase in demand. Testing was initially limited, and the perception was that patients with high comorbidity burden were at higher risk for poor outcomes. The Charleston Comorbidity Index (CCI) is widely used as a predictor of prognosis and one-year mortality for a wide range of pathologies. This study aims to assess whether a correlation exists between CCI score, COVID-19 incidence throughout the pandemic and patient outcomes.Charleston Comorbidity Index Score Scoring system for Charleston Comorbidity Index (CCI). Plus 1 point for every decade age 50 years and over, maximum 4 points. Higher scores indicate a more severe condition and consequently, a worse prognosis.MethodsMulticenter, retrospective review of patients diagnosed with COVID-19 from January 2020 to September 2020 throughout the HCA Healthcare system. The percent of total encounters that were COVID-19 positive by state was calculated along with the average CCI score for COVID-19 patients in 2-month increments. Patient outcomes were obtained across the entire population. ResultsA clear surge of infected patients was seen in almost all states in the dataset from May 2020 onward except in Colorado and Louisiana where the percentage of COVID-19 positive encounters decreased until July 2020. As summer 2020 progressed, the highest percentage of COVID-19 positive encounters among HCA Healthcare facilities was in Florida and Texas. However, despite the fact that more patients were COVID-19 positive in these states, the CCI score was the lowest (Figure 1). The highest average CCI throughout the 9-month period was 7.66 in Colorado. In the first two months of the pandemic, patients who tested positive for COVID-19 had higher CCI scores on average than those who became COVID-19 positive later in the pandemic. Missouri had the lowest CCI average but the highest ICU admissions and in-hospital mortality. Indiana had the lowest average CCI score, and lowest admission rate (Figure 2).COVID-19 Encounters and Average CCI score by State from January 2020 to September 2020 Graph 1: Percentage of COVID-19 Encounters in 9 Months at an HCA Healthcare Facility by State: Graph presents data obtained for the total of 92,800 patient encounters from January to September 2020 and recorded in 2-month increments. The rate of positive encounters throughout 18 states increased on average from May to September. From January to March 2020, the facilities with the highest rate of COVID-19 encounters were in Colorado, Louisiana and Texas. The states with the highest increment increase of COVID-19 positive patients were Texas, Florida and South Carolina and were trending up as the pandemic wore on through the summer of 2020. Graph 2: Average Charleston Comorbidity Index of COVID-19 Patient Seen at an HCA Healthcare Facility by State in 9 Months: In winter 2020 (January to March 2020) the average CCI score for patients seen with COVDI-19 was higher than in the Spring and Summer 2020 in all states except in Montana and Kentucky. Summer 2020 (May to July 2020) demonstrated some of the lowest average CCI scores for COVID-19 positive patients seen at an HCA Healthcare Facility.Rate of Positive COVID-19, Patient Outcomes and Average Charleston Comorbidity Index Score by State Graph 3: Outcomes of COVID-19 Positive Patients Seen at an HCA Healthcare Facility: Mortality and ICU admission was the highest in Missouri, however, the state had the least COVID-19 patients admitted. The rate of positive test per encounter was the highest in Florida and Texas. Texas had a higher mortality among admitted COVID-19 patients than Florida, however, Florida had a higher percentage of COVID-19 patients admitted. Graph 4: Average Charleston Comorbidity Index Score of COVID-19 Positive Patients Seen at an HCA Healthcare Facility: Average CCI was the lowest in Missouri. The states with the highest CCI score were Indiana, California, New Hampshire and Nevada.ConclusionWe observed an inverse correlation between CCI score and COVID-19 incidence while seeing that, on average, COVID-19 positive patients had higher CCI score in the first few months of the pandemic when incidence rate was lower. CCI score did not correlate to ICU admission, but a higher CCI score correlated to higher admission rate.Disclosures All Authors: No reported disclosures

Implementation of Computerized Physician Order Entry in Primary Care: A Scoping Review.

PurposeThis scoping review aimed to assess the implementation and outcomes of computerized physician order entry (CPOE) in primary care.MethodsA scoping review was carried out in accordance with the Joanna Briggs Institute’s guidelines (JBI). The databases PubMed, CINAHL, Science Direct, and Google Scholar were all searched. The full text of each article was reviewed for eligibility after the title and abstract were evaluated. JBI data extraction were used to extract data. Donabedian’s framework served as the foundation for the data discussion.ResultsBased on the inclusion criteria, seven studies were included. The studies’ main goal in common was to analyze the outcome or impact of implementing CPOE systems in ambulatory or primary care settings. Several studies described the framework, current state of implementation, and evaluation or recommendation following CPOE system implementation. Many positive effects were felt by physicians or prescribers, pharmacists, patients, and primary care providers, with patient safety being the primary goal.ConclusionAlthough this study discovered some issues and factors associated with CPOE implementation and adoption, such as infrastructure, workflow, level of engagement, and safety culture, CPOE has many positive outcomes for patients, physicians, and primary care. To improve CPOE adoption in healthcare, particularly primary care, more research into the structure, framework, and components of CPOE deployment is required.

Clinical effects of cervical conization with positive margins in cervical cancer

Radical surgery after cervical conization is a common approach for the treatment of cervical cancer. In some cases, disease progression is observed after positive margins at conization, but the effect of conization on disease progression remains unclear. Thus, the aim of this study was to investigate the clinical outcomes of positive margins at conization in cervical cancer. A total of 101 patients who underwent cervical conization before radical hysterectomy and pelvic lymph node dissection were considered eligible by reviewing medical records. The association between the positive margins and patient outcomes, including subsequent lymph node metastasis, was evaluated. The rate of lymphovascular space invasion (LVSI) positivity at radical surgery was significantly higher in patients with positive margins (p = 0.017) than in those with negative margins, although there was no significant difference in the rate of pelvic lymph node metastasis (p = 0.155). Moreover, there was no significant difference in the overall survival or progression-free survival between the two groups (p = 0.332 and 0.200, respectively). A positive margin at conization presented no significant prognostic disadvantage; thus, diagnostic conization is one of the most suitable treatment options for early-stage cervical cancer that is difficult to accurately assess.

A systematic review of the impact of carer interventions on outcomes for patients with eating disorders.

PurposeEating disorder (ED) prevalence and illness severity is rapidly increasing. The complicated interplay of factors contributing to the maintenance of EDs, including family/carer influences, highlights the importance of carer interventions within ED treatment. Carer interventions demonstrate positive outcomes for carers themselves, though are also hypothesised to benefit the patient indirectly. A systematic review was conducted to greater understand the impact of carer interventions on ED patient outcomes.MethodsEight databases, including CINAHL, MEDLINE and PsychINFO, were systematically searched. Intervention studies for parent(s)/carer(s) of a patient with an ED were included, provided they reported outcomes for the patient. No publication date restrictions were set. Included studies were quality appraised.ResultsTwenty-eight studies met inclusion for the review; all of which varied in intervention type, duration, content and setting. Patient diagnosis and treatment setting were mixed across studies, though the majority focused on Anorexia Nervosa within outpatient settings. Intervention content broadly included consideration of relationship issues and interactional patterns, psychoeducation, skill development, behavioural management, and peer support. Therapeutic models utilised were diverse, including but not limited to: family, interpersonal, cognitive, and psychodynamic approaches.ConclusionSeveral carer interventions showed positive outcomes for patients with EDs, with small group treatment formats being commonly used and proving effective through intervention content alongside a peer support element. Separate family therapy was suggested to be of equal efficacy, if not better, than family therapy alongside the patient. Recommendations for clinical practice and future research are considered.Level of evidence 1. Systematic review, evidence mostly obtained from randomised controlled trials.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40519-021-01338-7.

Leveraging Magnet® principles: Leadership during the COVID-19 pandemic.

Read about how one nursing team utilized Magnet tenets in their daily operations to achieve not only positive patient outcomes, but also a resilient workforce.

Shared Decision-Making During Labor and Birth Among Low-Risk, Active Duty Women in the U.S. Military.

The cesarean birth rate of 24.7% in the Military Health System (MHS) is lower than the national rate of 31.7%. However, the MHS rate remains higher than the 15-19% threshold associated with optimal maternal and neonatal outcomes. For active duty servicewomen, increased morbidity associated with cesarean birth is likely to affect the ability to meet the demands of assigned missions. Several decision-points occur during pregnancy and after the onset of labor that can affect the likelihood of cesarean birth including choice of provider, choice of hospital, timing of admission, and type of fetal monitoring. Evidence suggests the overuse of labor interventions may be associated with cesarean birth. Shared decision-making (SDM) is a strategy that can be used to carefully consider the risks, benefits, and alternatives of each labor intervention and is shown to be associated with positive patient outcomes. Most existing evidence explores SDM as an interaction that occurs between women and their providers. Few studies have explored the role of stakeholders such as spouses, family members, friends, labor and delivery nurses, and doulas. Furthermore, little is known about the process of SDM during labor and childbirth in the hospital setting, particularly for active duty women in the U.S. military. The purpose of this study was to propose a framework that explains the process of SDM during labor and childbirth in the hospital setting for active duty women in the U.S. military. A qualitatively driven mixed-methods approach was conducted to propose a framework that explains the process of SDM during labor and childbirth in the hospital setting for active duty women in the U.S. military. Servicewomen were recruited from September 2019 to April 2020. Semi-structured interviews were analyzed using a constructivist grounded theory approach. Participants also completed the SDM Questionnaire (SDM-Q-9). Interviews were conducted with 14 participants. The sample included servicewomen from the Air Force (n = 7), Army (n = 4), and Navy (n = 3). Two participants were enlisted and the remainder were officers. Ten births occurred at military treatment facilities (MTFs) and four births took place at civilian facilities. The mean score on the SDM Questionnaire was 86.7 (±11.6), indicating a high level of SDM. Various stakeholders (e.g., providers, labor and delivery nurses, doulas, spouses, family members, and friends) were involved in SDM at different points during labor and birth. The four stages of SDM included gathering information, identifying preferences, discussing options, and making decisions. Events that most often involved SDM were deciding when to travel to the hospital, deciding when to be admitted, and selecting a strategy for pain management. Military factors involved in SDM included sources of information, selecting and working with civilian providers, and delaying labor interventions to allow time for an active duty spouse to travel to the hospital. SDM during labor and birth in the hospital setting is a multi-stage process that involves a variety of stakeholders, including the woman, members of her social and support network, and healthcare professionals. Future research is needed to explore perspectives of other stakeholders involved in SDM.

Health literacy of cardiology patients: determinants and effects on patient outcomes

ABSTRACT Health literacy is important for the management of chronic cardiovascular diseases. Comprehensive studies related to health literacy of cardiac patients are limited. The aims of this study were to determine the determinants of health literacy and its effects on patient outcomes in cardiology patients. The European Health Literacy Survey Questionnaire (HLS-EU-Q- 47 items) was applied to 530 patients who presented to cardiology polyclinics of a university hospital in Ankara. Correlation coefficients, univariate and multi-linear regression analyses were used in the study. Determinants of health literacy were sex, education level, place of residence and perception of social status (p < .05). Although adjustments were made based on relevant control variables in multivariate analyses, health literacy was found to affect 14 of 26 patient outcomes within the scope of the study (p < .05). Higher education level and perception of social status, residing in the city center and being female were among the determinants of high health literacy. Higher health literacy was associated with more positive patient outcomes. Health literacy affected health behaviors and risks, drug use habits, health status, use of preventive health services and patient satisfaction.

Adaptation and Validation of the Spanish Version of the Instrument to Evaluate Nurses' Attitudes Toward Communication With the Patient for Nursing Students.

Communication is essential to the quality of care and patient satisfaction. It has been linked to positive patient outcomes, increased engagement, improved health outcomes, and safe practices. Given these benefits and the association between attitudes and behaviors, as behaviors can be predicted by studying attitudes, assessing attitudes of nursing students toward patient communication is critical for future nursing professionals. For this purpose, the main aim of this study was to adapt and validate an instrument to measure nurses’ attitudes toward communication (ACO) for nursing students. The ACO with patients was analyzed. Then, differences in the dimensions of the instrument (ACO) for nursing students according to an academic course and the correlations were calculated. A cross-sectional study was carried out in a convenience sample of 1,417 nursing students from five universities in the Valencian Community (Spain) during the 2018/2019 academic year and 83.8% (1,187) were women. The reliability was analyzed by using Cronbach’s alpha and composite reliability (CR). Analysis of construct validity was performed with exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). The instrument adapted from nurses to nursing students was composed of 25 items grouped in three dimensions: affective, cognitive, and behavioral. The psychometric properties suggested that the instrument ACO for nursing students was reliable and valid. The ACO of nursing students was positive with high levels in cognitive and behavioral dimensions, while scores were worst in the affective component. The second-year nursing students showed more positive attitudes in the affective dimension, while in the cognitive and behavioral dimensions, the most positive attitudes were found in the first year. In the correlations, the behavioral and cognitive dimensions showed a significant, positive, and very high correlation. These findings should be considered in developing academic plans to improve the effectiveness of the communication education process of the students to increase the quality of patient care and well-being of nursing students.

132 GERIATRIC REHABILITATION IN THE COVID-19 ERA: SERVICE INNOVATION AND PATIENT OUTCOMES

BackgroundThe COVID-19 pandemic fundamentally changed the way rehabilitation services are delivered, with focus placed on individual in-room therapy and cessation of group sessions. Sparks Innovation and National Lottery funding was obtained to implement the ‘In-Room Rehabilitation and Well-being Initiative’. This provided patients with individual physiotherapy equipment to use in their room thus maximizing time spent active during periods of isolation. We aim to describe service innovation occurring in a post-acute geriatric rehabilitation hospital during the COVID-19 era, and the resultant patient outcomes.MethodsRehabilitation was provided to patients in-line with evidence-based practice and national infection prevention and control guidelines. Patients who were deemed appropriate by the multi-disciplinary team were provided with in-room therapy equipment. Prospective data was collected on service and patient outcomes. Functional outcome measurements were collected on admission and discharge and compared using a paired t-test.ResultsRehabilitation was provided to 260 patients, average age 80.5 years (range 63–98) with 46.5% male. The majority of patients were admitted with ortho-geriatric diagnoses or general deconditioning following illness (70%). The patients were complex with multiple medical, functional, and psychosocial care needs, as indicated by an average Rehabilitation Complexity Score of 11/20, with 100% of patients requiring daily therapy. Average length of stay (LOS) was 30.7 days (range 3–169), with 85% of patients discharged home. Performance in activities of daily living (Barthel Index: 62 vs 79, p < 0.0001), and mobility (Cumulative Ambulatory Score: 3.8 vs 5.3, p < 0.0001) significantly improved from admission to discharge.ConclusionDespite ward closures, disruption to rehabilitation due to COVID-19 illness, and limitations on group therapies, our service achieved positive patient outcomes through innovation and delivery of high-quality evidence-based rehabilitation. Compared to the past eight years, 2020 had the lowest LOS and highest number of patients discharged home.

151 THERAPY OUTCOME MEASURES IN AN OLDER PERSONS REHABILITATION UNIT

Abstract Background The mission of an older person’s sub-acute rehabilitation unit is to improve the individual’s function and quality of life. This is achieved through patient and multidisciplinary team (MDT) collaboration. The MDT collect Therapy Outcome Measure (TOM) (Enderby and John 2015) data to measure the effectiveness of rehabilitation and facilitate analysis of patient and service outcomes. This abstract will present 6 months of data collection with the aim of evaluating the impact of MDT intervention from January 2021. Methods The MDT meet weekly to jointly record patient TOM scores on admission and discharge. The TOM scales used are; multifactorial conditions, stroke and neurological disorder. The patient is scored from 0–5 in four domains; impairment, activity, participation and well-being. There are 11 parts to the scale with 0.5 scores permitted (Enderby and John 2015). Results Data was analysed on 62 patients. Across an episode of rehabilitation an increase of 0.5 or more on the TOM is a clinically significant (positive) change. 84% of patients had an overall improvement in the total TOM score. There was an average overall increase of 2.6 points on the scale which equates to a 25% overall change. 63% improved in the domain of impairment, 77% in activity, 73% in participation and 66% in wellbeing. 100% of patients post-stroke, 81% with multifactorial conditions and 75% with neurological conditions experienced an overall improvement. Conclusion The data objectively shows positive patient outcomes in older persons rehabilitation. Individuals experienced the most positive change in their activity and participation function and high levels of change are also evident in impairment levels and well-being. Overall, TOM is a very useful MDT outcome measure tool. It has been successfully implemented and maintained in the service and facilitates the ongoing analysis of individual and service outcomes to understand the impact of intervention.

Abstract 13250: Factors Associated With Improvement of Left Ventricular Function After Catheter Ablation for Atrial Fibrillation in Patients With Heart Failure

Introduction: Catheter ablation is a well-established therapy for atrial fibrillation (AF), and studies have shown positive outcomes in patients with heart failure (HF). We aimed to evaluate the impact of AF ablation on echocardiographic and clinical parameters in patients with HF in Brazil, and to assess factors associated with improvement of the left ventricular ejection fraction (LVEF). Methods: Consecutive patients diagnosed with HF and LVEF &lt;50%, who underwent successful radiofrequency AF ablation in 5 high-volume institutions, were prospectively included. All patients underwent standard transthoracic echocardiography before the procedure and during clinical follow-up, and the analysis by the examiner was considered. The primary outcome was LVEF normalization (LVEF ≥50%) at follow-up. Clinical, echocardiographic, and procedure-related variables associated with the primary outcome were assessed by univariate logistic regression. P-value &lt;0.05 was considered significant. Results: From 2018 to 2020, 44 patients were included, being 28 (64%) males, mean age 66±11 years. Of these, 12 were in NYHA functional class 3/4, 35 had persistent AF, and only 3 had previous ablations. Mean pre-procedural LVEF was 38±7%, with 13 (30%) having LVEF&lt;35%. Complications occurred in only 2 patients, with 1 case of arterial pseudoaneurysm. In the 8.0±7.6 month follow-up, there was a substantial improvement of the LVEF to 53±14% (p&lt;0.001), and 27 (61%) achieved the primary outcome of LVEF normalization. Thirty patients (68%) had LVEF improvement of ≥10%, only 5 remained in NYHA class 3/4, and recurrent AF occurred in 11 (25%). Predictors of LVEF normalization were: pre-ablation LVEF (OR: 1.32, 95%CI 1.13-1.54, p=0.001), baseline left atrial diameter (OR: 0.87, 95%CI 0.77-0.98, p=0.02), baseline NYHA functional class 1/2 (OR: 5.11, 95%CI 1.29-21.28, p=0.025) and the absence of indication of spironolactone (OR: 5.60, 95%CI 1.20-26.14). There were 3 deaths, and none of them had LVEF improvement in follow-up echo. Conclusion: AF ablation in patients with HF resulted in remarkable echocardiographic and functional improvement, with low complication rates. Less clinical severity and less morpho-functional impairment were associated with LVEF normalization.

Shaping and delivering services in primary care: benzodiazepine and opiate withdrawal service

This article looks at the development of the benzodiazepine and opiate withdrawal service (BOWS) based in addiction services in London. The service was created to implement a manageable and sustainable model that would treat patients with benzodiazepine and codeine-based dependencies. It was envisaged the service would effectively treat patients in GP practices in two boroughs in London. The article outlines what is possible in terms of treatment for patients with issues of opioid dependency, by examining two in-depth case studies. It also illustrates what is possible for nurses in the modern NHS and can be used as a resource to shape and deliver services with positive patient outcomes. Nurses should be seen as shaping and delivering care in the NHS. This is a role that should be promoted to a greater degree, wherever possible.

Uncovering key targets of success for immunotherapy in pancreatic cancer

ABSTRACT Introduction Despite available treatment options, pancreatic ductal adenocarcinoma (PDAC) is frequently lethal. Recent immunotherapy strategies have failed to yield any notable impact. Therefore, research is focussed on unearthing new drug targets and therapeutic strategies to tackle this malignancy and attain more positive outcomes for patients. Areas covered In this perspective article, we evaluate the main resistance mechanisms to immune checkpoint inhibitors (ICIs) and the approaches to circumvent them. We also offer an assessment of concluded and ongoing trials of PDAC immunotherapy. Literature research was performed on Pubmed accessible through keywords such as: ‘pancreatic ductal adenocarcinoma,’ ‘immunotherapy,’ ‘immunotherapy resistance,’ ‘immune escape,’ ‘biomarkers.’ Papers published between 2000 and 2021 were selected. Expert opinion The tumor microenvironment is a critical variable of treatment resistance because of its role as a physical barrier and inhibitory immune signaling. Promising therapeutic strategies appear to be a combination of immunotherapeutics with other targeted treatments. Going forward, predictive biomarkers are required to improve patient selection. Biomarker-driven trials could enhance approaches for assessing the role of immunotherapy in PDAC.

How we Provide Nutritional Treatment in Hospitalized Patients?

In this study, we aimed to evaluate enteral nutrition (EN), parenteral nutrition (PN) and supplemental parenteral nutrition (SPN) in terms of achieving nutritional goals.Patients receiving either EN, PN, or SPN treatment followed up by the clinical nutrition team between January and December 2017 at the university research and training hospital were included in the study. Daily nutritional requirements were calculated according to the recommendations. Total energy intake during nutritional treatment (NT) and all metabolic, mechanical, technical complications of NT were recorded.A total of 603 inpatients were included in the study. The nutritional goal was achieved in the majority of the SPN group patients (87.5%) statistically significant relation was found between the achievement of the target (or not) and PN access route (peripheral or central) (P < .001). However, none of the complications found statistically related to achieving the target, including gastrointestinal complications of EN (P = .46), metabolic complications of EN (P = .07), mechanical complications of EN (P = .79), metabolic complications of PN (P = .89), gastrointestinal complications in SPN group (P = .45), and metabolic complications in SPN group (P = .68).Nutritional goals could be achieved with SPN without increasing complications in the majority of patients. Commencement of SPN should be considered for positive outcomes in patients who failed to achieve desired nutritional outcomes.

Implementing AACN's Healthy Work Environment Framework in an Intensive Care Unit.

Bedside nurse turnover in the United States is 15.9%, representing a national challenge that has been attributed to poor work environments. Healthy work environments are associated with improved nurse satisfaction and retention as well as positive patient outcomes; unhealthy work environments have the opposite effects. To implement the American Association of Critical-Care Nurses (AACN) healthy work environment (HWE) framework in an intensive care unit and to evaluate staff satisfaction, turnover, and tenure 2 years later. A pre-post study design was used to evaluate implementation of the HWE framework in an intensive care unit in a large academic medical facility. Interventions for each of the 6 HWE standards were performed. The AACN HWE assessment survey was used to measure skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership in 2017 and in 2019. Nurse cohorts (n = 165 in 2017; n = 176 in 2019) had a mean age of 31 (median, 27; range, 23-63) years, were predominantly female (76%), and had a mean of 5 (median, 3) years of intensive care unit nursing experience. Statistically significant improvements were found in all standards except the skilled communication and overall measures. Registered nurse turnover remained stable and tenure increased by 79 days in this 2-year period. Findings from this study suggest that interventions addressing the HWE standards are associated with improved staff satisfaction, turnover, and average tenure, further demonstrating the value of the HWE framework in improving retention.

Athletic Training Educators' ConferenceApril 29–May 1, 2021

Athletic Training Educators' ConferenceApril 29–May 1, 2021

Quantifying Accuracy of Self-Tapping Screw Models.

Correct torquing of bone screws is important to prevent fixation failures and ensure positive patient outcomes. It has been proposed that an automatic model-based method may be able to determine the patient-specific material properties of bone, and provide objective and quantitative torquing recommendations. Models have been previously proposed for identifying the bone material properties, but have not been experimentally tested for accuracy. Here we used these models to perform parameter identification on experimental data using a variety of materials (rigid polyurethane foams) and screws. The identified values were then compared to the values from the datasheet, and matched with a reasonable accuracy for medium-density foam. It was found that for the lower-density foam, the model slightly under-predicted the strength, and for the highest density foam there was a large under-prediction. This suggests that with appropriate calibration, this method is good, but may only be applicable to lower-to-medium strength materials. More thorough testing is required to confirm this and determine the reliable density range.Clinical relevance: Accurate material property identification is required to provide effective torque recommendations for bone screws. This work quantifies the accuracy of two proposed models for material property identification.

Investigating Torque-Speed Relationship of Self-Tapping Screws.

Correctly torquing bone screws is important to prevent fixation failures and ensure positive patient outcomes. It has been proposed that an automatic model-based method may be able to determine the patient-specific material properties of bone, and provide objective and quantitative torquing recommendations. One major part of developing this system is the modelling of the bone-screwing process, and the self-tapping screwing process in general. In this paper, we investigate the relationship between screw insertion torque (Nm) and speed of insertion (RPM). A weak positive correlation was found below approximately 30 RPM. Further research should focus on increasing the precision of the methodology, and this testing must be extended to ex-vivo animal bone testing in addition to the polyurethane foam substitute used here.Clinical relevance: To maximise the accuracy of torque recommendations, the model should account for all important factors. This study investigates and attempts to quantify the relationship between screw insertion speed and torque for later inclusion in modelling if significant.

Integrating service learning into the RN to BSN curriculum with the application of QSEN competencies.

To accomplish the goal of a more highly educated nursing workforce, academic nursing has supported a significant increase in the number of RN to BSN programs. The focus of educating practicing registered nurses is moving toward revising and designing curriculum that promote positive patient outcomes and supports contemporary healthcare practices. Facilitating a service-learning model for RN to BSN curricula and applying the Quality and Safety Education in Nursing (QSEN) competencies are two effective methods for enhancing professional practice. The purpose of this article is to promote the concept of integrating service learning into the RN to BSN curriculum and applying the QSEN competencies to learning activities to achieve improved quality and patient safety.

"If You Built It, They Could Come": Opportunities to Expand Access to Palliative Care.

There are growing calls to broaden palliative care access to more populations, diseases, and care settings and to earlier in the disease process; yet, supply of specialty palliative care is not likely to keep pace with demand. This article discusses possible solutions by which to bridge the gap between limited palliative care supply and demand. The proposed solutions include: (1) specialist workforce development; (2) alternate models of care; (3) triaging systems; and (4) telemedicine. Education/training, research, and policy mechanisms could operationalize these solutions. With the solutions in hand, the field may be able to increase the reach, sustainability, and equity of palliative care, thereby improving access and enabling a multitude of positive patient, family, and health care system outcomes.