Quick Reference Card Research Articles

A Bundled Educational Solution to Reduce Incorrect Plaster Splints Applied on Patients Discharged from Emergency Department

Purpose: Plaster splints are routinely performed in the Emergency Department (ED) and avoidable complications such as skin ulcerations and fracture instability arise mainly due to improper techniques. Despite its frequent use, there is often no formal training on the fundamental principles of plaster splint application for a medical officer rotating through ED. We aim to use Quality Improvement (QI) methodology to reduce number of incorrect plaster splint application to improve overall patient care via a bundled educational solution.Methods: We initiated a QI program implementing concepts derived from the Institute for Healthcare Improvement models, including Plan-Do-Study-Act (PDSA) cycles, to decrease the rate of incorrect plaster splint application. A bundled education solution consisting of three sequential interventions (practical teaching session, online video lecture and quick reference cards) were formulated to specifically target critical factors that had been identified as the cause of incorrect plaster splints in ED.Results: With the QI intervention, our overall rate of incorrect plaster splints was reduced from 84.1% to 68.6% over a 6-month period.Conclusion: Following the QI project implementation of the bundled educational solution, there has been a sustained reduction in incorrect plaster splints application. The continuation of the training program also ensures the sustainability of our efforts in ED.

Competent Management of Patients Receiving ECMO and CRRT.

Competent Management of Patients Receiving ECMO and CRRT.

A standardized imaging protocol improves quality and reduces practice variability in echocardiographic assessment of ventricular function by first-year pediatric cardiology fellows.

Echocardiography education for pediatric cardiology fellows has been a recent focus leading to the implementation of "boot camps." Less is described about continuing education through fellowship and improving image quality. We noticed practice variation in echocardiograms assessing ventricular function performed on nights and weekends. Thus, we implemented a standardized protocol and assessed its impact on imaging and reporting completeness. We created an imaging protocol for the assessment of ventricular function in the acute setting. The protocol included demographic information, a list of images to be obtained, and the methods to quantify ventricular function. The protocol was explained to first-year fellows and distributed on an electronic quick reference card. Echocardiograms independently performed by first-year fellows during their first 4months of on-call time were assessed pre- and postintervention using a standard rubric. Compliance with demographic reporting was high pre- and postintervention, but significantly improved after the standardized protocol (P<0.001). Use of the protocol increased the median number of unique images obtained per echocardiogram from 13 to 17 (out of 23 required views, P<0.001). Particularly improved was the performance of quantitative evaluations of function, including Simpson's method for left ventricular ejection fraction (four chamber: 40% vs 67%, P<0.001; two chamber: 33% vs 67%, P<0.001) and tricuspid annular plane systolic excursion (45% vs 80%, P<0.001). The introduction of a standardized imaging protocol and its distribution to first-year fellows resulted in improvements in echocardiographic reporting completeness and increased the quality of information obtained by providing more quantitative assessments of ventricular function.

Parent/guardian knowledge regarding implanted shunt type, setting, and symptoms of malfunction/infection.

OBJECTIVE Patients with shunts often interact with providers distant from their primary hospital, making it important that the parent(s)/guardian(s) is well versed in the type of shunt implanted and symptoms of malfunction/infection. This is particularly important with magnetic-sensitive programmable valves, as the use of MRI becomes more prevalent. METHODS Over a 6-month period, primary caregivers of 148 consecutive patients who received shunts were prospectively administered questionnaires at clinic visits. Caregivers were asked to do the following: 1) identify shunt valve name, type, and setting if applicable; 2) list symptoms of shunt malfunction/infection; and 3) indicate whether they had access to references regarding shunt type/setting, booklets from the Hydrocephalus Association, and quick reference cards with symptoms of shunt malfunction/infection. One cohort of caregivers (n = 75) was asked to carry informational cards with shunt valve/setting information (group I); this cohort was compared with another subgroup of caregivers (n = 73) not carrying cards (group II). RESULTS The mean (± SD) age of patients at implantation/revision was 3.71 ± 4.91 years, and the age at follow-up was 6.12 ± 5.4 years. The average time from surgery to administration of the questionnaire was 2.38 ± 3.22 years. There were 86 new shunt insertions and 62 revisions. One hundred twenty-eight caregivers (87%) could identify the type of valve (programmable vs nonprogrammable). On the other hand, only 72 caregivers (49%) could identify the valve name. Fifty-four of 73 (74%) caregivers of patients who had shunts with programmable valves could correctly identify the valve setting. One hundred caregivers (68%) had a copy of the Hydrocephalus Association booklet, and 103 (70%) had quick reference cards. Eighty caregivers (54%) had references on shunt type/setting. Most caregivers (127 [86%]) could name ≥ 3 signs/symptoms of shunt malfunction, with vomiting (61%), headache (49%), and sleeps more/lethargic (35%) most frequently reported. Caregivers of patients in group I were more likely to have cards with symptoms of shunt infection or malfunction (p = 0.015); have information cards regarding shunt type/setting (p < 0.001); and correctly identify valve type (p = 0.001), name (p < 0.001), and setting if programmable (p = 0.0016). There were no differences in ability to list symptoms of shunt malfunction or infection (p = 0.8812) or in access to Hydrocephalus Association booklets (p = 0.1288). There were no significant demographic differences between the groups, except that group I patients had a shorter time from surgery to last follow-up (1.66 vs 3.17 years; p = 0.0001). CONCLUSIONS Education regarding the care of patients with shunts by providing written cards with shunt type/setting and access to reference materials seems to be effective. Developing plans for guided instruction with assessment in the clinic setting of a caregiver's knowledge is important for patient safety.

Quick reference tidal volume cards reduce the incidence of large tidal volumes during surgery.

Ventilation with large tidal volumes (V T), greater than 10ml/kg of predicted body weight (PBW), is associated with worse outcomes in critically ill and surgical patients. We hypothesized that the availability of quick reference cards with proposed V T ranges specific to gender and different heights would reduce the intraoperative use of large V T during prolonged abdominal surgery. We compared retrospectively the incidence of median V T used during prolonged (≥4-h-long) abdominal surgery before ("before") and after ("after") the quick reference V T cards were made available in all anesthesia machines in operating rooms of a single academic US medical center. We evaluated the effect of the intervention on the primary outcome while adjusting for previously identified risk factors of large V T use: female gender, obesity (body mass index, BMI>30), and short height (<165cm). The frequency of V T>10ml/kg PBW was 15.1% in the before group and 4.3% in the after group (p<0.001). The frequency of large V T used during abdominal surgery was significantly decreased after the intervention even after adjusting for female gender, obesity or short height [adjOR 0.11 (95% CI 0.04-0.30)]. Our quick reference V T cards significantly reduced the frequency of large V T use during abdominal surgery.

Effectiveness of interventions to improve medication use during rapid-sequence intubation in a pediatric emergency department.

Results of a study to determine whether checklist-based interventions improved the selection and administration of rapid-sequence intubation (RSI) medications in a pediatric emergency department (ED) are reported. A retrospective study of data collected during a quality-improvement project was conducted. Data sources included the electronic health record and video review. The central intervention was use of a 21-item RSI checklist, which included guidance for the physician team leader on medication selection and timing. A quick-reference card was developed to guide staff in preparing RSI medications. The main outcomes were (1) standard selection, defined as administration of indicated medications and avoidance of medications not indicated, and (2) efficient administration, defined as an interval of <30 seconds from sedative to neuromuscular blocker (NMB) infusion. A total of 253 consecutive patients underwent RSI during 3 consecutive periods: the historical (preimprovement) period (n = 136), the checklist only period (n = 68), and the checklist/card period (n = 49). The rate of standard selection of 3 RSI medications (atropine, lidocaine, and rocuronium) did not improve. The rate of efficient sedative and NMB administration improved from 56% in the historical period to 88% in the checklist period (p = 0.005). The median duration of RSI medication administration decreased from 28 seconds (interquartile range [IQR], 23-44 seconds) in the historical period to 19 seconds (IQR, 15-25 seconds) in the checklist/card period (p = 0.004). In a quality-improvement project in a pediatric ED, a checklist-based intervention improved RSI medication administration technique but not selection.

G530(P) To give oxygen or not? are we adhering to local guidelines on administering targeted oxygen therapy to our neonatal population?

Context This “spot audit” was carried out in a level 3 neonatal unit. Problem Supplementary oxygen therapy is a vitial to the vulnerable neonate. We know that in excess, oxygen can be toxic, contributing to retinopathy of prematurity (ROP). The recent BOOST 2 study has made clinicians rethink what our oxygen saturation limits should be. However, given the increased mortality in those with lower saturation limits, the exact limit remains controversial. The aim of this “spot audit” was simply to determine whether we were adhering to our local guidelines regarding oxygen saturation targeting. Assessment of problem and analysis of its causes This audit was carried out on a weekly basis. The initial few weeks, before any change, ensured that we obtained baseline numbers. The staff were aware that the audit project was being carried out. We quickly identified that there was a need to intervene and a discussion was had with ward sisters. We identified that nurses were key to ensuring that the limits on the saturation monitors were set correctly. Intervention We realised that verbal communication/education alone would be insufficient to increase our compliance. A visual aid, or quick reference card, was developed. This briefly summarised our protocol, i.e. what the saturation limits should be for neonates, based on their risk of ROP. This was produced in a size which ensured that it could be attached to the saturation monitors. Study design A initial prospective audit was carried out over a period of 8 weeks. information regarding risk of ROP and whether or not stauration limits were achieved was collected on a proforma. When possible, I would then refer to the neonates case notes and/or speak to nursing staff caring for them to determine why the monitors may have been set differently to protocol, i.e. medical decision or in error. 2 years after the initial audit, we’ve reaudited the same thing to determine if compliance has been maintained. Strategy for change Initially discussions were had with the ward sister regarding the audit project, but it became apparent that there was a lack of awareness of our local protocol. The quick reference card was produced on a home computer. Medical physics (who ensure up keep of our saturation monitors) were given additional copies of the visual aid. I presented the inital results at a local quality improvement evening. Measurement of improvement Percentages were used to demonstrate compliance. This ensured that all staff could easily interpret the results obtained. During the initial four weeks of the audit, our compliance with our local guideline, regarding oxygen saturation targets within the neonatal population, ranged from 43–70%. After the introduction of the quick reference card, our compliance was 79–94%. We re-audited this recently and our compliance is sustained at 92%. In the majority of cases, the reasons for non compliance included no quick reference card on the saturation monitor! Effects of changes Our change has increased compliance with local guidelines and ensures that oxygen therapy is being targeted appropriately in the majority of cases. It has also increased staffs awareness of the importance of targeted oxygen therapy. Lessons learnt This simple regular audit process can be applied within any healthcare setting. The simplicity of the concept makes it easily reproducibile. Furthermore, it helped identify a key, often overlooked, problem within our unit, and attempted to address it. Message for others We have demonstrated how simple auditing can result in sustained improvement in neonatal care by targeting our oxygen saturations more effectively in compliance with our local guideline.

A Survey on π-π Stackings and π-Cations in Prion Protein Structures

π-π stackings and π-cations clearly do some contributions to maintain the structural stability of a normal cellular prion protein (PrP). This short article is to do a survey on the π-π stackings and π-cations in all the PrP structures listed in the PDB (www.rcsb.org) Bank. We find the following important π-π stackings: Y218–F175– Y169 (around the β2-α2 loop), Y162–Y128 (linking the two β-strands), F141–Y150– Y157 (in α-helix 1), H187–F198 (linking α-helix 2 and the α2-α3 loop); and we also find the following important π-cations: F141–R208.(N)NH2 (linking the β1-α1 loop and α- helix 3), Y128–R164.(N)NH2–Y169 (linking β-strand 1 and the β2-α2 loop). Thus, for PrPs, there exists a long “π-chain” Y218– F175–Y169–R164–Y128–Y162 covering the β2-α2 loop, and there exists another long “π-chain” R208–Y141–Y150– Y157–F198– H187 covering the α-helix 1. This short article can be acted as a “quick reference card” for PrP protein structure π-interaction studies in laboratories or in theories.

Byzantine Neumes: A New Introduction to the Middle Byzantine Musical Notation (review)

BYZANTIUM Byzantine Neumes: A New Introduction to the Middle Byzantine Musical Notation. By Christian Troelsgard. (Monumenta Musicae Subsidia vol. 9.) Copenhagen: Museum Tusculanum Press, 2011. [142 p. ISBN 9788763531580. $86.] Music examples, tables, illustrations, appendix of manuscript facsimiles, bibliography, indices, reference card. Motivated by the Solesmes reconstructions of Gregorian chant in the late nineteenth century, the Monumenta Musicae Byzantinae (MMB) was inspired to achieve a similar goal. Several of the original members of the MMB realized that there were problems in the original transcription methods of H. J. W. Tillyard, Carsten Hoeg, and Egon Wellesz; later these same problems were mentioned by Oliver Strunk. Some of the more volatile complaints, however, were coming from Greek scholars such as Grigorios Stathis, who had come to work with Jorgen Raasted and ultimately convinced him that there were serious problems with the transcriptions of medieval Byzantine music into Western staffnotation. More precisely, in 1985 Raasted informed this reviewer during a conference in Vienna that he was working on a solution for this project. The following year he wrote an article on this topic offering his ideas on how the transcription process could be revised (Jorgen Raasted, Thoughts on a Revision for the Transcrip - tion Rules of the Monumenta Musicae Byzantinae, Cahiers de l'Institut du Moyenâge grec et latin 54 [1986]: 13-38). Un - fortunately, Raasted was not able to complete his dream, but he leftsketches for his student and successor, Christian Troels - gard, to bring this work to fruition. Consequently, Troelsgard's aim in this volume is to bring up to date Tillyard's Handbook of the Middle Byzantine Musical Notation (Copenhagen: Levin & Munks - gaard, 1935), and, although Troelsgard does not state this explictly, perhaps to bring forth again the MMB Transcripta series, which had been halted since 1958 because of the growing concern of issues surrounding transcriptions into Western staffnotation. Troelsgard covers a wide array of information, beginning with a brief introduction on the history of Middle Byzantine or round notation. This is followed by discussions on the relationships between words and music; chant transmission before neumes; various types of Byzantine musical notations; problems of sizes of intervals and tunings; signs and interpretations of Middle Byzantine notation including rhythm, modes, melody, intervals, and the Hypostaseis or Cheiromomia signs; musical genres; transcriptions of music examples; and twenty-two facsimiles of manuscripts from different locales and periods of notation. Unlike his predecessors, Troelsgard does not provide the text in the original Koine Greek but instead transliterates it into English. He provides an interesting and acceptable transliteration for consonants, diphthongs, and vowel sounds with accents and some underlining to distinguish the omega from the omicron. His pronunciation system obviously makes it easier for a vocalist to chant this music, especially one not familiar with Greek. How - ever, in no way does it guarantee correct pronunciation. The inclusion of the original Greek text with its rough and smooth breath marks and its three different accents of acute, grave, and circumflex could still have served as a visual guide to the non- Greek reader for a more accurate rendering of the pronunciation. A valuable tool in the book is the laminated four-page Quick Reference Card, which can be used as a guide without referring to the book. Included are the signs and starting pitches for the modal signatures, rules for the combination of signs, a combination table, interval signs, rhythmical signs (with the exception of the apoderma which has been interpreted as a fermata but has now been included under the Hypostaseis), and group and phrasing signs. In this last category Troelsgard has included only eleven signs of the more than fifty possible different signs including composites. …

Online Hearing Aid Provider Recruits Physicians

You have accessThe ASHA LeaderASHA News1 Apr 2012Online Hearing Aid Provider Recruits Physicians Matthew Cutter Matthew Cutter Google Scholar More articles by this author https://doi.org/10.1044/leader.AN1.17052012.4 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In Hearing aid provider hi HealthInnovations, a subsidiary of United Healthcare (UHC), has begun sending a “hearing test kit” to physicians—despite concerns voiced by audiologists and professional hearing organizations about specific aspects of its online sales program. The hi HealthInnovations Hearing Test Kit, which is mailed unsolicited to physicians, includes a USB sound card, adapter, ear buds in a range of sizes, instruction manual, quick reference card, and a branded carrying case. According to materials included with the kit, with the oversight of a physician the test can be administered by “a nurse practitioner, physician assistant, or any employee with licensed medical training in a medical and/or health field.” Although the instruction manual notes the types of hearing loss that should be treated by an audiologist (e.g., asymmetrical hearing loss, significant low-frequency loss), it gives minimal guidance in identifying such conditions. One of hi HealthInnovations’ stated purposes in sending the kit to physicians is to “facilitate access by [hi HealthInnovations] members to their covered hearing benefit.” To this end, hi HealthInnovations states that the hearing test is billable to UnitedHealthcare Medicare Advantage Plans under Current Procedural Terminology (CPT, ©American Medical Association) code 92552, the diagnostic code for pure tone audiometry. Opposition to the hi HealthInnovations program is continuing and widespread. Most recently, attorneys representing the International Hearing Society (IHS) sent a letter requesting the Food and Drug Administration (FDA) conduct a review and investigation of hi HealthInnovations’ service and techniques for compliance with FDA requirements. This letter follows another letter from the Hearing Industry Association (HIA) asking the FDA to investigate the program. The HIA letter asserts that the program is illegal and that hi HealthInnovations is: Characterizing its hearing aids as “personal sound amplification products” in an attempt to avoid hearing aid regulations. Using an invalid hearing test. Using a consumer waiver that does not meet FDA requirements. The letter asks the FDA to suspend hi HealthInnovations’ online marketing, and to prohibit the company from shipping hearing aids in the absence of valid audiologic examination results. The letter also includes 21 exhibits to support HIA’s claims. HIA and IHS join several organizations—including ASHA, the American Academy of Audiology, the Academy of Doctors of Audiology, and the American Academy of Otolaryngology–Head and Neck Surgery—that have raised serious concerns about hi Health’s direct-to-consumer online hearing aid sales program. But one notable exception—the Hearing Loss Association of America (HLAA)—has come out in support of the hi HealthInnovations program, with its Executive Director Brenda Battat commenting on the need to lower hurdles to seeking and receiving hearing health care. Audiologists concerned about the hi HealthInnovations program should ensure that local primary care physicians’ offices are aware of them as referral sources. Audiologists also should maintain consistent practice policies and guidelines for hearing aids purchased from other sources—regardless of private pay/insurance types—and should be transparent about the services that are or are not included in their bundled prices. With regard to hi HealthInnovations’ hearing aids, audiologists should inform patients and other health care providers that they are not able to program the devices unless they become a UHC provider, and otherwise cannot offer services to those patients. ASHA remains in conversations with hi HealthInnovations regarding its online hearing aid sales, in the hope it adopts ASHA’s recommended changes. These changes include labeling the hi HealthInnovations online “hearing test” as a screening tool, and expanding its hearing benefit to include diagnostic and rehabilitation services provided by an audiologist. (See “ASHA Questions Online Adult Hearing Aid Program,” The ASHA Leader, March 13, for a complete list of ASHA’s suggested changes.) ASHA also has updated its consumer information for hearing aid buyers. Check out “What You Should Know Before Buying Hearing Aids Online.” Author Notes Matthew Cutter, writer/editor for The ASHA Leader, can be reached at [email protected]. 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Newborn blood spot screening and genetic services: A survey of Minnesota primary care physicians

Purpose:To (1) obtain guidance on the preferred content and format of quick reference newborn blood spot screening information from the Minnesota Department of Health; (2) determine primary care physicians' perceptions of the benefits of genetic services; and (3) determine primary care physicians' satisfaction with genetic counseling services. MethodsA written survey was mailed to family physicians and pediatricians in Minnesota (n = 300). ResultsEighty physicians responded (28% response rate). Whereas 70% of respondents felt previous information received from the newborn screening program was adequate, 83% were interested in quick reference information. The majority of physicians preferred this information as a laminated sheet (63%). Physician procedure for an abnormal screen, newborn screening program protocol for an abnormal screen, and disease treatment and follow-up information were recommended for inclusion on quick reference. Over half of physicians agreed with the following benefits of genetic services: provide testing options (88%); evaluate family members (88%); reduce parental anxiety (87%); provide resources (83%); provide diagnostic information (76%); determine medical needs (67%); and determine emotional needs (51%). Ninety-nine percent of physicians were satisfied with genetic counseling services. ConclusionsPhysicians indicated that reference material for primary care physicians should include a quick reference card with specific categories of information. Newborn screening programs should attempt to increase physician awareness of genetic services, including the subsequent medical and psychosocial benefits for their patients.

Software Reviews : Authority Publisher: Interactive Image Technologies Ltd., 908 Niagara Falls Blvd., North Tonawanda, NY 14120-2060; 416-361-0333; FAX 416-368-5799 ; BBS 416-361-0798 Year of Publication: 1993 Versions Reviewed: 2.0b and 2.0b MM (multimedia) Materials: Five 3.5" floppy disks that include Authority, 14 sample programs, sound collection (20 VOC files), and clip art collection (200 PCX files); User's Guide (235

Software Reviews : Authority Publisher: Interactive Image Technologies Ltd., 908 Niagara Falls Blvd., North Tonawanda, NY 14120-2060; 416-361-0333; FAX 416-368-5799 ; BBS 416-361-0798 Year of Publication: 1993 Versions Reviewed: 2.0b and 2.0b MM (multimedia) Materials: Five 3.5" floppy disks that include Authority, 14 sample programs, sound collection (20 VOC files), and clip art collection (200 PCX files); User's Guide (235

The Whole Internet User's Guide &amp; Catalog

This is the second edition of an introduction to the Internet, the international network that includes virtually every major computer site in the world. The Internet is a resource of almost unimaginable wealth. In addition to electronic mail and news services, thousands of public archives, databases, and other special services are available: everything from space flight announcements to ski reports, remote login, and network news, The Whole Internet pays special attention to some new tools for helping you find information - like the World-Wide Web and its multimedia browser, Mosaic. Aimed at researchers, students, or just people who likes electronic mail, this book should help readers to explore what's possible. It also includes a pull-out quick-reference card.

A Practical Guide to Medical Computer Systems

Decisions, decisions. Whether to operate or observe the patient, to own or rent the office, to participate in Medicare or not to participate in Medicare. And now, whether to automate your practice or stick with your trusty pegboard. To make matters worse, the next generation of computers seems to come faster than the next generation of cephalosporins. If only progress would slow down enough to let our comprehension catch up to it! Yet it would be a mistake to think that choosing a brand of computer will ever be as simple as choosing a brand of rubber glove. The subject is complicated and is likely to stay complicated for some time—this the reason for the glut of computer-oriented books, flash cards, keyboard overlays, quick reference cards, magazines, and videotapes. There are even computer programs to help understand other computer programs. The video under discussion here is designed to assist a

Software Reviews : PROFESSIONAL DYNAMO PLUS Reviewed by Fiona Chen, Florida State University Publisher: Pugh-Roberts Associates, Inc., Five Lee St., Cambridge, MA 02139 (telephone: 617-864-8880) Year of Publication: 1987 Version Reviewed: 3.1c Materials: Three diskettes, one reference manual (281 pages), one introductory guide and tutorial (109 pages), one "PROFESSIONAL DYNAMO PLUS Version 3.1c Additional Information" brochure (2 pages), one quick

PROFESSIONAL DYNAMO PLUS (PD PLUS) is the latest and most advanced DYNAMO PC version published by Pugh-Roberts Associates, Inc. PD PLUS is a simulation language for system dynamics, a technique suitable for modeling social and political systems. Besides keeping the basic features of other DYNAMO versions, PD PLUS is more powerful and speedy. It is a package for serious system dynamics modelers. PD PLUS's potential, however, cannot be fully tapped because of its shortcomings in documentation, file management design, and possible incompatibility with non-IBM machines.

If you write documentation, then try a decision table

A decision table is a powerful documentation tool based on a simple principle: sets of responses for sets of conditions. It is used to present a large quantity of complex information in a simple, straightforward manner. Since the decision table requires no special symbols or shapes, it is understood by nonprogrammers and programmers alike. It can thus serve as a common denominator for a project team, a quick-reference card, and a step-by-step procedural guide. The author argues that if time is invested in explaining how to use a decision table then both the writer and the user will profit from a valuable documentation tool.