Post-intervention Time Periods Research Articles

A Framework for Synthetic Control Methods With High-Dimensional, Micro-Level Data: Evaluating a Neighborhood-Specific Crime Intervention

ABSTRACTThe synthetic control method is an increasingly popular tool for analysis of program efficacy. Here, it is applied to a neighborhood-specific crime intervention in Roanoke, VA, and several novel contributions are made to the synthetic control toolkit. We examine high-dimensional data at a granular level (the treated area has several cases, a large number of untreated comparison cases, and multiple outcome measures). Calibration is used to develop weights that exactly match the synthetic control to the treated region across several outcomes and time periods. Further, we illustrate the importance of adjusting the estimated effect of treatment for the design effect implicit within the weights. A permutation procedure is proposed wherein countless placebo areas can be constructed, enabling estimation of p-values under a robust set of assumptions. An omnibus statistic is introduced that is used to jointly test for the presence of an intervention effect across multiple outcomes and post-intervention time periods. Analyses indicate that the Roanoke crime intervention did decrease crime levels, but the estimated effect of the intervention is not as statistically significant as it would have been had less rigorous approaches been used. Supplementary materials for this article are available online.

A randomized clinical trial of a supportive versus a skill-based couple-focused group intervention for breast cancer patients.

The aims of this study were to evaluate the efficacy of the 2 types of couple-focused group interventions on couples' psychological and relationship functioning, and to examine possible moderators for each intervention. Three hundred and two women with early stage breast cancer who were recruited within 1 year of diagnosis and their spouses were randomly assigned to either an 8 session enhanced couple-focused group intervention (ECG) or a couples' support group (SG). Couples completed surveys at 4 time points: preintervention, 1 week postgroup, 6 months, and 1 year. Analyses indicated that anxiety, depressive symptoms, and cancer-specific distress declined and positive well-being improved for couples enrolled in both ECG and SG. Thus, neither treatment was superior in terms of reduction of distress or improvements in positive well-being. Moderator effects indicated that, among patients reporting higher levels of cancer-specific preintervention distress, anxiety, depression, and well-being over the 1-year postintervention time period were significantly lower among SG couples than ECG couples. When patient cancer-specific preintervention distress was low, these 3 outcomes were more positive in ECG relative to SG. A similar pattern with regard to anxiety was illustrated when the moderator effects for perceived partner unsupportive behavior was examined, and a similar pattern was seen for anxiety and well-being for preintervention marital satisfaction. A couple-focused supportive group therapy may be more effective for distressed patients, whereas a structured, skills-based couples' group therapy may be more effective for less distressed patients. (PsycINFO Database Record

Sinusitis Treatment Guideline Adherence in the E-Visit Setting: A Performance Improvement Project.

Studies demonstrate poor guideline adherence by health care providers for the treatment of upper respiratory infections, particularly acute bacterial rhinosinusitis (ABRS), in the appropriate prescribing of antibiotic medications. The purpose of this quality improvement project was to evaluate the effect of implementing interventions for improving adherence to a clinical practice guideline for the management of ABRS for patients treated in the e-visit setting. Interventions included: providing a report to providers of their adherence to the ABRS clinical guideline prior to the intervention, providing updated education on the ABRS guideline, and implementing a clinical decision support system reminder. A pre and post intervention evaluation design was used. Data were obtained from a retrospective electronic health record (EHR) data extract of all 316 diagnoses for ABRS in the pre-intervention 2-month time period and all 368 diagnoses of ABRS in the post-intervention 2-month time period. A review of the structured clinical data elements was performed to determine whether the provider adhered to the clinical guideline, meaning that only patients meeting the criteria for ABRS were to receive an antibiotic prescription. The interventions resulted in a 3.3% improvement in adherence to the ABRS clinical guideline from 95.25% adherence pre-intervention to 98.4% post-intervention. These results demonstrated that the use of an educational intervention and clinical decision support resulted in improved adherence to the ABRS clinical guideline in the e-visit setting. The implications for practice could be significant in that these quality improvement interventions improve guideline adherence and reduce unnecessary prescribing of antibiotics.

Successful Application of a Canadian Mental Health Curriculum Resource by Usual Classroom Teachers in Significantly and Sustainably Improving Student Mental Health Literacy.

To investigate whether the significant and substantive findings from a previous study of youth mental health literacy (MHL) could be replicated using the same methods in another population. We examined the impact of a curriculum resource, the Mental Health and High School Curriculum Guide (The Guide), taught by usual classroom teachers on students' knowledge and attitudes related to mental health and mental illness in Canadian secondary schools. Survey data were collected before, immediately after, and 2 months after implementation of The Guide by teachers in usual classroom teaching. We conducted paired-sample t tests and calculated the Cohen d value to determine outcomes and impact of the curriculum resource application. One hundred fourteen students were matched for analysis of knowledge data and 112 students were matched for analysis of attitude data at pre-intervention, post-intervention, and 2-month follow-up time periods. Following classroom exposure to the curriculum resource, students' knowledge scores increased significantly and substantively, compared with baseline (P < 0.001, d = 1.11), and this was maintained at 2-month follow-up (P < 0.001, d = 0.91). Similar findings for attitude improvement were found (P < 0.001, d = 0.66), and this improvement was maintained at 2-month follow-up (P < 0.001, d = 0.52). These findings corroborate those from a previous study conducted in a different location. Taken together these results suggest a simple but effective approach to improving MHL in young people by embedding a classroom resource, delivered by usual classroom teachers in usual school settings.

Ordering of the Serum Angiotensin-Converting Enzyme Test in Patients Receiving Angiotensin-Converting Enzyme Inhibitor Therapy: An Avoidable but Common Error

Serum angiotensin-converting enzyme (ACE) levels may be decreased by use of ACE inhibitor (ACEI) medication. In this study, we determined how often ACE levels were measured in patients receiving ACEI therapy. ACE levels analyzed over a 54-month preintervention time period at an academic medical center were reviewed retrospectively for tests performed during ACEI therapy. These data were compared with a large, deidentified dataset of ACE levels measured at a national reference laboratory; in vitro studies of ACEI inhibition; and liquid chromatography time-of-flight mass spectrometry detection of lisinopril in a subset of clinical specimens. Over a 54-month period, 1,292 patients had ACE levels measured, with 108 patients (8.4%) receiving ACEI therapy at the time of testing. ACE levels measured for patients receiving ACEI therapy were substantially lower. In general, clinical teams did not recognize a medication effect on ACE levels. Introduction of a warning prompt in the electronic health record reduced the ordering of ACE levels in patients receiving ACEIs by > 60% in a 17-month postintervention time period. The deidentified dataset of ACE levels at a reference laboratory showed a bimodal distribution, with a peak of very low ACE levels. Using liquid chromatography time-of-flight mass spectrometry, the presence of lisinopril was confirmed in a subset of specimens with low ACE activity. In vitro studies of two different ACE assays showed significant inhibition of activity at clinically relevant concentrations. Assessment of ACE activity is often measured for patients receiving ACEIs, potentially leading to low ACE concentrations and inaccurate interpretations.

Increasing postpartum rate of vaccination with tetanus, diphtheria, and acellular pertussis vaccine by incorporating pertussis cocooning information into prenatal education for group B streptococcus prevention

BackgroundTo evaluate whether incorporating pertussis cocooning information into prenatal education for group B streptococcus (GBS) prevention increased postpartum rate of vaccination with tetanus, diphtheria, and acellular pertussis (Tdap) vaccine. MethodsWe performed a retrospective pre-intervention/post-intervention study of postpartum women at a teaching hospital in Taiwan. We compared the frequency of Tdap vaccination during the pre-intervention (May 1, 2009 to December 31, 2010) and post-intervention (March 1, 2011–March 31, 2012) time periods. The clinical intervention was incorporation of pertussis cocooning information into prenatal education for GBS prevention to pregnant women presented during a prenatal visit at 35–37 weeks of gestation. Postpartum Tdap vaccination rate during the pre-intervention and post-intervention periods was compared. We also specifically examined group differences in the percentage of women who received postpartum Tdap vaccination to explore factors that influenced their decision regarding Tdap vaccine. ResultsTdap vaccination was more likely during the post-intervention period compared with the pre-intervention period (2268 of 3186 [71.2%] compared with 2556 of 5030 [55.6%]; p<.001). Comparisons between each subgroup of pre-intervention and post-intervention women showed that incorporating pertussis information into prenatal education for GBS prevention was beneficial except for women of maternal age 30–34 years and women living in rural areas. ConclusionsPrenatal GBS screening activities represent an opportunity for healthcare providers to offer pertussis cocooning information to eligible pregnant women to improve rates of postpartum Tdap vaccination.

Causal judgements about temporal sequences of events in single individuals.

Stimuli were presented in which values of an outcome variable for a single individual were recorded over 24 time periods, and an intervention was introduced at one of the time periods. Participants judged whether and how much the intervention affected the outcome. Judgements were affected by manipulations of the temporal relation between the intervention and a gradual increase in values on the outcome variable, by the size of the increase, by the time taken for the increase to occur, and by variance in the preincrease data. Most results were predicted by a simple model in which the mean outcome value for the preintervention time periods is subtracted from the mean outcome value for the postintervention time periods, though there was also an effect of temporal contiguity that is not predicted by the simple model. This form of information, which is a kind of quasiexperimental design, is more representative of the kind of information generally available for causal judgement than the more commonly investigated binary variables in which the cause is either present or absent, and the outcome either occurs or does not; as such, it is more revealing of how causal judgements are made under the conditions that prevail in the world.

Abstract W P226: Pre-Notification of Stroke Symptoms Reduces Decision Times in Acute Stroke

Introduction: Both the American Heart and American Stroke Associations recommend pre-notification of potential stroke patients to receiving facilities. Although Emergency Medical Services (EMS) may identify stroke symptoms in the field, initiation of the stroke code process is often postponed until after the patient arrives in the Emergency Department (ED). This could lead to unnecessary delays in assessment and intervention during an acute stroke. Hypothesis: We hypothesized that initiating a stroke code based on advanced notification of stroke symptoms via EMS and a Stroke Code Pit Stop (SCPS) would lead to decreased time of assessment, diagnosticssitics and IV tPA initiation. Methods: A pre- and post-intervention study of 733 patients presenting to 2 EDs in a 5 campus hospital system. Both EDs initiated a SCPS, with pre-notification of stroke symptoms via EMS and stroke code activation prior to patient arrival. Data were reviewed from January 2013-April 2014, comparing code stroke metrics pre- and post SCPS initiation. Inclusion criteria: patients with stroke code initiations in the ED. Exclusion criteria: patients with stroke code initiations after hospitalization. Results: 668 patients metpatients met inclusion and exclusion criteria. Assessment times decreased in all metrics post SCPS initiation. Median time of arrival to time of stroke code initiation decreased from 7 minutes to -11 minutes (39%). Median time from patient arrival to CT imaging and laboratory results both decreased by 12 minutes, from 23 to 11 (48%) and from 41 to 29 (71%) respectively. Median door to IV tPA initiation decreased by 24 minutes, from 73 to 49 (67%). Of the 368 patients in the post intervention time period, 192 patients (52%) arrived to the ED through the SCPS. IV tPA was initiated in 30 patients (16%) arriving to the ED through SCPS, versus 13 patients (7%) arriving to the ED without EMS pre-notification. Conclusions: ED pre-notification of stroke symptoms via EMS and a Stroke Code Pit Stop leads to more rapid assessment, CT imaging, laboratory results , and increased IV tPA usage.

Effectiveness of the Tobacco Tactics Program for Psychiatric Inpatient Veterans: An Implementation Study

BackgroundThe objective of this study was to evaluate the effectiveness of the inpatient, nurse-administered Tobacco Tactics program for patients admitted for psychiatric conditions in two Veterans Affairs (VA) hospitals compared to a control hospital. MethodsThis is a subgroup analysis of data from the inpatient tobacco tactics effectiveness trial, which was a longitudinal, pre- post-nonrandomized comparison design with 6-month follow-up in the three large Veterans Integrated Service Networks (VISN) 11 hospitals. ResultsSix-month self-reported quit rates for patients admitted for psychiatric conditions increased from 3.5% pre-intervention to 10.2% post-intervention compared to a decrease in self-reported quit rates in the control hospital (12% pre-intervention to 1.6% post-intervention). There was significant improvement in self-reported quit rates for the pre- versus post-intervention time periods in the Detroit and Ann Arbor intervention sites compared to the Indianapolis control site (P=0.01) and cotinine results were in the same direction. ConclusionThe implementation of the Tobacco Tactics intervention has the potential to significantly decrease smoking and smoking-related morbidity and mortality among smokers admitted to VA hospitals for psychiatric disorders.

Implementation of an extracorporeal cardiopulmonary resuscitation simulation program reduces extracorporeal cardiopulmonary resuscitation times in real patients.

To determine if development of an extracorporeal cardiopulmonary resuscitation simulation program reduced extracorporeal cardiopulmonary resuscitation times in real patients : Before-after study. Twenty-six bed pediatric cardiac ICU in a tertiary urban hospital. Forty-three cardiac patients (aged 1 d to 16 yr) who received extracorporeal cardiopulmonary resuscitation. An interdisciplinary team collaborated to define the roles and clarify responsibilities of each individual involved in extracorporeal cardiopulmonary resuscitation. An "ideal rapid deployment" was defined and tested using simulation sessions. This included a task analysis, role creation, and multidisciplinary simulations, including structured debriefings and video review and the creation of a master checklist. There were a total of 43 episodes of extracorporeal cardiopulmonary resuscitation during the study period, 16 (37%) of which occurred during the preintervention time period (from February 2009 to March 2010) and 27 (63%) during the postintervention time period (April 2010 to March 2013). The median deployment time in the preintervention time period was 51 minutes (interquartile range, 43-62 min), whereas the median deployment time in the postintervention time period was 40 minutes (interquartile range, 23-52 min) (p = 0.018). There are no standard guidelines of how a team should coordinate the efforts of nursing, physicians, extracorporeal membrane oxygenation specialists, surgeons, respiratory therapists, patient care technicians, and unit clerks to emergently execute this complex procedure. Because time is of the essence, it is essential to develop a highly functioning and well-coordinated team with a standardized method of the procedure, its documentation, and communication. Simulation accomplished this for our program. Following these simulation exercises, not only was there a subjectively observed improved coordination and smoother deployment of extracorporeal membrane oxygenation in real-life extracorporeal cardiopulmonary resuscitation, but we have also demonstrated a significantly faster deployment of extracorporeal membrane oxygenation as compared with the presimulation era.

Effectiveness of the Tobacco Tactics program in the Department of Veterans Affairs

The purpose was to determine the effectiveness of the Tobacco Tactics program in three Veterans Affairs hospitals. In this effectiveness trial, inpatient nurses were educated to provide the Tobacco Tactics intervention in Ann Arbor and Detroit, while Indianapolis was the control site (N = 1,070). Smokers were surveyed and given cotinine tests. The components of the intervention included nurse counseling, brochure, DVD, manual, pharmaceuticals, 1-800-QUIT-NOW card, and post-discharge telephone calls. There were significant improvements in 6-month quit rates in the pre- to post-intervention time periods in Ann Arbor (p = 0.004) and Detroit (p < 0.001) compared to Indianapolis. Pre- versus post-intervention quit rates were 4 % compared to 13 % in Detroit, were similar (6 %) pre- and post-intervention in Ann Arbor, and dropped from 26 % to 12 % in Indianapolis. The Tobacco Tactics program, which meets the Joint Commission standards that apply to all inpatient smokers, has the potential to significantly decrease smoking among Veterans.

Effectiveness of the Tobacco Tactics Program in the Department of Veterans Affairs

The purpose was to determine the effectiveness of the Tobacco Tactics program in three Veterans Affairs hospitals. In this effectiveness trial, inpatient nurses were educated to provide the Tobacco Tactics intervention in Ann Arbor and Detroit, while Indianapolis was the control site (N = 1,070). Smokers were surveyed and given cotinine tests. The components of the intervention included nurse counseling, brochure, DVD, manual, pharmaceuticals, 1-800-QUIT-NOW card, and post-discharge telephone calls. There were significant improvements in 6-month quit rates in the pre- to post-intervention time periods in Ann Arbor (p = 0.004) and Detroit (p < 0.001) compared to Indianapolis. Pre- versus post-intervention quit rates were 4% compared to 13% in Detroit, were similar (6%) pre- and post-intervention in Ann Arbor, and dropped from 26% to 12% in Indianapolis. The Tobacco Tactics program, which meets the Joint Commission standards that apply to all inpatient smokers, has the potential to significantly decrease smoking among Veterans.

Impact Of Use Of a Disease-Specific Patient Portal On Transition Readiness and Quality Of Life In Adolescents With Sickle Cell Disease

IntroductionDisease-specific patient portals use technology to provide patients with easy access to health information and have been shown to promote healthy behaviors, encourage self-care, and assist with informed decision-making. Most of the available studies, however, have failed to examine the feasibility of patient portals with adolescent/young adult, vulnerable or underrepresented populations. As a first step toward enhancing patient access to medical information and better understanding how to engage adolescent/ young adult, diverse and vulnerable populations in using a patient portal, we designed and refined a disease-specific version of an existing patient portal (MyChart) for use with adolescents and young adults with sickle cell disease (SCD). We then piloted the patient portal with the goal of understanding the impact of the intervention on quality of life and transition readiness outcomes. We hypothesized that the patient portal would be rated as feasible, accurate and useful, and that use of the patient portal would be positively associated with transition readiness and increased quality of life. MethodsPatients were recruited from a Comprehensive Sickle Cell Center at an urban pediatric medical center in the Midwest through letters, at clinic visits and at SCD-related events. The current study reports data from a sample of participants who have been followed 6 months post-intervention. At each time point (Baseline, Post, 3, 6 Months Post-Intervention), participants completed a series of measures including the Pediatric Quality of Life Inventory (PedsQLTM) and an item asking about their readiness to transition to the adult healthcare system. The patient portal intervention consisted of four assignments to facilitate familiarity with the portal (e.g. graphing a test result). All participants completed these assignments over the 6-week intervention. ResultsAll participants in the study were African American (N=20; 60% male) with a mean age of 19.4 years (SD = 2.08). Ninety percent had HbSS (5% HbSC; 5% HbSB+Thal). At the post-intervention time point, the portal was rated as feasible (M = 3.3/5) and useful (M = 4.3/5). Data indicated that participants viewed/used the following portal features most often: 1) Lab results, 2) Medications, 3) Messaging, and 4) Appointment Review. Patients logged in an average of 6.59 times over six months (range: 0-39). Portal use was analyzed categorically as non-users (with zero independent logins after the intervention period) and users (with one or more independent logins after the intervention period). Sixty percent (n=12) of participants were users, whereas 40% were non-users. Portal patients reported increasing readiness to transition over the follow-up period (Post M = 2.3/5; 3-month M = 3/5; 6-month M = 3.6/5). Finally, a repeated measures ANOVA determined that Total PedsQLTM scores increased significantly over time, (F(3) = 2.98, p = .05). Post hoc tests using Bonferroni correction revealed the largest increase in Total PedsQL scores between the post-intervention and 3-month time points. Although this increase was not statistically significant, there was a significant correlation between transition readiness and Total PedsQL scores at the 3-month time point. DiscussionStudy results suggest that participants found the disease-specific patient portal easy to use and beneficial to their overall health management. Participants also showed improvements in quality of life across the post-intervention time period, suggesting that use of a patient portal may have served to bolster quality of life in this sample. Study participants further reported increased readiness to transition, which was positively associated with quality of life at 3 months post- intervention. Despite the small sample size, results of this study help to increase our understanding of the relationship between portal use and health and transition outcomes. This intervention shows promise in engaging SCD adolescent/ young adult patients in clinical care and disease management that can ultimately be evaluated in a larger multi-site study.This study was funded in part by NHLBI Grant#: 1K07HL108720-03 and the Cincinnati Children's Hospital Medical Center Place Outcomes Award. Disclosures:No relevant conflicts of interest to declare.

Comparison of Complication Rates of Implantable Venous Access Devices: Percutaneous Versus Cephalic Vein Cut-down Techniques

abdominal vascular surgery. A total of 388 patients were identified in the year prior to (266) and the year after (122) the intervention was initiated. Thirty-day readmission rates, emergency department (ED) visit rates, and early clinic visit rates (defined as a clinic visit less than 14 days postdischarge) were calculated and compared between the preand postintervention periods. Major demographic and comorbidities were then used to create a risk-adjusted logistic regression model examining the effect of the interventions on the outcomes. Results: Preintervention 30-day readmission rates were 9.8%, compared to 9.0% after the intervention (P 1⁄4 .81). The most common reason for readmission were infectious/wound-related (40.5%), and the incidence did not differ between preand postintervention time periods; additionally, patients with a positive screen for wound concerns at discharge were more likely to be readmitted (P 1⁄4 .04). Postoperative ED visit rates were identical in the postintervention group as compared to the preintervention group, as were the reasons for presentation. Risk-adjusted logistic regression models bore these trends out, though none reached statistical significance. Conclusions: A callback program did not reduce readmissions or direct patients to clinic rather than the ED in a population of patients undergoing major vascular surgery. A focused process for postoperative wound management may yield the highest decrease in readmissions.

Embracing collaboration: A novel strategy for reducing bloodstream infections in outpatient hemodialysis centers

The incidence of access-related bloodstream infections (AR-BSIs) in US outpatient hemodialysis centers is unacceptably high. This paper presents the implementation and results achieved from a multi-pronged strategy to reduce AR-BSIs in 1 outpatient hemodialysis center. The intervention, which took place between 2009 and 2011, involved membership in the Centers for Disease Control and Prevention Hemodialysis Bloodstream Infection Prevention Collaborative, implementation of a panel of infection prevention interventions, and use of positive deviance (PD) to engage staff. Changes in the incidence of AR-BSIs and infection prevention process measures between the pre- and postintervention time periods, as well as alterations in the center's social networks, were examined to assess impact. The incidence of all AR-BSIs dropped from 2.04 per 100 patient-months preintervention to 0.75 (P = .03) after employing the Collaborative interventions and to 0.24 (P < .01) after augmenting the Collaborative interventions with PD. Adherence rates increased significantly in 4 of 5 infection prevention process measure categories. The dialysis center's social networks became more inclusive and connected after implementation of PD. Participating in a Collaborative, employing a panel of infection prevention strategies, and engaging employees through PD resulted in a significant decline in AR-BSIs in this facility. Other hemodialysis facilities should consider a similar approach.

Phosphorus and chlorophyll in the Bay of Quinte: A time-series/intervention analysis of 1972–2008 data

Three independent methods of time-series analysis were applied to a 37-year record of total phosphorus and chlorophyll-a data collected at four sampling stations representing the upper, middle and lower sections of the Bay of Quinte, NE Lake Ontario, Canada. The three methods were used to build consensus around the significance of the apparent declines in total phosphorus (TP) and chlorophyll-a (Chl-a) concentrations following two interventions: (1) point-source phosphorus loading reductions of about 50% to the upper bay in the winter of 1977–1978 and (2) the establishment of Zebra Mussels (Dreissena spp.) in the early to mid-1990's. The methods were applied to May to October monthly means and included: (1) nonparametric tests that accounted for persistence and seasonality and determined the statistical significance of step-trends, (2) ARIMA-Intervention modelling that produced forecasts into post-intervention time periods that were compared statistically to measured data and (3) regime shift detection for identifying the significance of persistent steps after removal of the seasonal components of the data series (modelled as periodic functions). Strong gradients in total phosphorus (TP) and Chl-a concentrations between the upper and lower Bay of Quinte still existed three decades after reductions in point-source loadings of TP to the upper bay, where, during 2000–2008, May-October average TP was 3.8 times higher and Chl-a, 2.9 times higher than in the lower bay. The Remedial Action Plan May-October TP objective of 0.030 mg l-1 for the upper Bay of Quinte was not achieved consistently in recent years. Concurrence among the data analysis methods suggests that the relative decreases in the upper bay TP (31%) and Chl-a (37%) after phosphorus loading reductions were greater than in the lower bay (0% and 10%, respectively). The relative decreases in the upper bay TP (0%) and Chl-a (29%) associated with Dreissena establishment were less than those measured in the lower bay (20% and 50%, respectively).

Multi‐institutional evaluation of a sinus surgery checklist

To examine the frequency of safe surgical practices specific to endoscopic sinus surgery (ESS) before and after implementation of a checklist at four institutions across North America. Prospective, multi-institutional, observational study. Consecutive surgeries were observed at four institutions before (n = 100) and after (n = 100) implementation of the ESS Checklist. A passive observer documented whether 10 specific tasks were performed by the surgical team during the course of each case. The frequency with which each item was performed was tabulated, and differences across institutions were evaluated using the Pearson χ(2) test. Improvement in the frequency of each single item between pre- and postintervention time periods was assessed by the McNemar χ(2) test. Successful performance of all 10 tasks in the prechecklist period was not observed for any ESS case at any of the four study sites. As might be expected, performance of any individual task was highly variable, ranging from 14% to 95%. After implementation of the ESS Checklist, successful performance of all 10 tasks during an individual surgery increased from 0% to 87% across all institutions, a change that was highly significant (P < .001). Significant increases in the performance of individual tasks was observed for nine of 10 items across all institutions (P ≤ .031 for all). Significant heterogeneity exists with regard to performance of specific tasks aimed at minimizing error during ESS. Utilization of the ESS Checklist standardized practice across four institutions and significantly increased the likelihood that individual safety tasks were performed during the course of sinus surgery.

Evaluation of occupational injuries in an urban emergency medical services system before and after implementation of electrically powered stretchers

Musculoskeletal injuries are frequently reported among Emergency Medical Services (EMS) professionals. The objective of this study was to evaluate occupational injuries in an urban EMS system before and after implementation of hydraulic stretchers. Data for this analysis were obtained from Austin Travis County EMS (A/TCEMS). In December 2006, A/TCEMS placed into service electrically powered patient stretchers. The pre-intervention period was between 01/01/1999 and 12/31/2006, and the post-intervention period was between 01/01/2007 and 4/30/2008. Incidence rate calculations were performed for four injury sub-groups and rate ratios (RRs) and corresponding 95% confidence interval (CI) were presented. There were 2087 and 706 person-years of observation pre- and post-intervention, respectively. The incidence rates for overall injury pre-intervention and post-intervention were 61.1 and 28.8 per 100 FTE, with a corresponding RR of 0.47 (95% CI 0.41–0.55) indicating a significant decrease in the rate of injury. The subcategory of stretcher-related injuries had the lowest RR (0.30; 95% CI 0.17–0.52) when comparing pre- and post-intervention time periods.

Immediate effects of a tibiofibular joint manipulation on lower extremity H-reflex measurements in individuals with chronic ankle instability

Persistent muscle inhibition of the fibularis longus and soleus muscles and altered joint arthrokinematics may play a role in chronic ankle instability (CAI). Joint mobilization has been shown to improve ankle joint motion, but effects on surrounding musculature is unknown. The purpose of this study was to determine the change in fibularis longus and soleus activation following tibiofibular joint manipulation in individuals with CAI. Forty-three subjects were randomized to one of three groups (proximal tibiofibular manipulation, distal tibiofibular manipulation, or control). A two-way mixed model ANOVA was used to compare changes in the ratio of the maximum H-reflex and maximum M-wave measurements (H/M ratio) of the fibularis longus and soleus between groups over time (pre, post 0, 10, 20, 30 min). The distal tibiofibular joint manipulation group demonstrated a significant increase ( P < .05) in soleus H/M ratio at all post-intervention time periods except 20 min post-intervention ( P = .48). The proximal tibiofibular joint manipulation and control groups did not demonstrate a change in soleus H/M ratios. All groups demonstrated a decrease ( P < .05) from baseline values in fibularis longus (10–30 min post-intervention) and soleus (30 min post-intervention) H/M ratios. Interventions directed at the distal tibiofibular joint acutely increase soleus muscle activation.

An impact evaluation of a federal mine safety training regulation on injury rates among US stone, sand, and gravel mine workers: an interrupted time-series analysis.

We evaluated the impact of a safety training regulation, implemented by the US Department of Labor's Mine Safety and Health Administration (MSHA) in 1999, on injury rates at stone, sand, and gravel mining operations. We applied a time-series design and analyses with quarterly counts of nonfatal injuries and employment hours from 7998 surface aggregate mines from 1995 through 2006. Covariates included standard industrial classification codes, ownership, and injury severity. Overall crude rates of injuries declined over the 12-year period. Reductions in incident rates for medical treatment only, restricted duty, and lost-time injuries were consistent with temporal trends and provided no evidence of an intervention effect attributable to the MSHA regulation. Rates of permanently disabling injuries (PDIs) declined markedly. Regression analyses documented a statistically significant reduction in the risk rate in the postintervention time period (risk rate = 0.591; 95% confidence interval = 0.529, 0.661). Although a causal relationship between the regulatory intervention and the decline in the rate of PDIs is plausible, inconsistency in the results with the other injury-severity categories preclude attributing the observed outcome to the MSHA regulation. Further analyses of these data are needed.