A comparison of labor and delivery management activities in two settings

Similarities and differences in management activities and patient health outcomes between a traditional physician staffed labor and delivery setting and a certified nurse-midwife staffed Birth Center within the same hospital were described. The 950 study subjects, low income, minority women, were classified as low obstetrical risk by a POPRAS score of 25 points or less at time of admission for labor and delivery. The study subjects were similar in demographic, antepartum and intrapartum characteristics; the labor course was problem free for the majority in both settings. There were no remarkable differences in health outcomes between the groups. Management activities varied between settings; these variations were policy related rather than health related. The POPRAS rating system was an accurate predictor for 93% of BC subjects and 85% of LDU subjects. Charge for service was approximately $600 less for BC women; length of stay did not contribute to the difference in charge. Overall, BC respondents to the attitude survey were more satisfied with their labor and delivery experience than L\&DU women. ^

Assessing the impact of electronic health record technology adoption on hospital labor efficiency

Information technology (IT) in the hospital organization is fast becoming a key asset, particularly in light of recent reform legislation in the United States calling for expanding the role of IT in our health care system. Future payment reductions to hospitals included in current health reform are based on expected improvements in hospital operating efficiency. Since over half of hospital expenses are for labor, improved efficiency in use of labor resources can be critical in meeting this challenge. Policy makers have touted the value of IT investments to improve efficiency in response to payment reductions. ^ This study was the first to directly examine the relationship between electronic health record (EHR) technology and staffing efficiency in hospitals. As the hospital has a myriad of outputs for inpatient and outpatient care, efficiency was measured using an industry standard performance metric – full time equivalent employees per adjusted occupied bed (FTE/AOB). Three hypotheses were tested in this study.^ To operationalize EHR technology adoption, we developed three constructs to model adoption, each of which was tested by separate hypotheses. The first hypothesis that a larger number of EHR applications used by a hospital would be associated with greater staffing efficiency (or lower values of FTE/AOB) was not accepted. Association between staffing efficiency and specific EHR applications was the second hypothesis tested and accepted with some applications showing significant impacts on observed values for FTE/AOB. Finally, the hypothesis that the longer an EHR application was used in a hospital would be associated with greater labor efficiency was not accepted as the model showed few statistically significant relationships to FTE/AOB performance. Generally, there does not appear a strong relationship between EHR usage and improved labor efficiency in hospitals.^ While returns on investment from EHR usage may not come from labor efficiencies, they may be better sought using measures of quality, contribution to an efficient and effective local health care system, and improved customer satisfaction through greater patient throughput.^

A Time-Motion Study of Registered Nurses’ Workflow in Intensive Care Unit Remote Monitoring

Utilizing advanced information technology, Intensive Care Unit (ICU) remote monitoring allows highly trained specialists to oversee a large number of patients at multiple sites on a continuous basis. In the current research, we conducted a time-motion study of registered nurses’ work in an ICU remote monitoring facility. Data were collected on seven nurses through 40 hours of observation. The results showed that nurses’ essential tasks were centered on three themes: monitoring patients, maintaining patients’ health records, and managing technology use. In monitoring patients, nurses spent 52% of the time assimilating information embedded in a clinical information system and 15% on monitoring live vitals. System-generated alerts frequently interrupted nurses in their task performance and redirected them to manage suddenly appearing events. These findings provide insight into nurses’ workflow in a new, technology-driven critical care setting and have important implications for system design, work engineering, and personnel selection and training.

Use of instructional video to prepare parents for learning infant cardiopulmonary resuscitation.

Parents of premature infants often receive infant cardiopulmonary resuscitation (CPR) training prior to discharge from the hospital, but one study showed that 27.5% of parents could not demonstrate adequate CPR skills after completing an instructor-led class. We hypothesized that parents who viewed an instructional video on infant CPR before attending the class would perform better on a standardized skills test than parents who attended the class with no preparation. Parents randomized to the intervention (video) group viewed the video within 48 hours of the CPR class. Parents in the control group attended the class with no special preparation. All parents completed the CPR skills checklist test, usually within 7 days after class and before the infant's hospital discharge. The test rated subjects' skills in the areas of assessment, ventilation, and chest compressions; each section was rated as good, fair, or fail. In this pass/fail test, students had to be rated good or fair on all three sections to pass. All 10 subjects in the video group passed the test versus only 9 of 13 in the control group, but this difference was not significant (P = 0.08). However, 8 of 10 (80%) subjects in the video group were rated as good on all three sections, versus only 3 of 13 (18.7%) in the control group, and this was a significant difference (P = 0.012). We conclude that preparation of students using an instructional video prior to infant CPR class is associated with improvement in skills performance as measured by a standardized skills test. Video preparation is relatively inexpensive, eliminates the barrier of reading ability for preparation, and can be done at the convenience of the parent.

Maternal and neonatal outcomes by labor onset type and gestational age.

OBJECTIVE: We sought to determine maternal and neonatal outcomes by labor onset type and gestational age. STUDY DESIGN: We used electronic medical records data from 10 US institutions in the Consortium on Safe Labor on 115,528 deliveries from 2002 through 2008. Deliveries were divided by labor onset type (spontaneous, elective induction, indicated induction, unlabored cesarean). Neonatal and maternal outcomes were calculated by labor onset type and gestational age. RESULTS: Neonatal intensive care unit admissions and sepsis improved with each week of gestational age until 39 weeks (P < .001). After adjusting for complications, elective induction of labor was associated with a lower risk of ventilator use (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.28-0.53), sepsis (OR, 0.36; 95% CI, 0.26-0.49), and neonatal intensive care unit admissions (OR, 0.52; 95% CI, 0.48-0.57) compared to spontaneous labor. The relative risk of hysterectomy at term was 3.21 (95% CI, 1.08-9.54) with elective induction, 1.16 (95% CI, 0.24-5.58) with indicated induction, and 6.57 (95% CI, 1.78-24.30) with cesarean without labor compared to spontaneous labor. CONCLUSION: Some neonatal outcomes improved until 39 weeks. Babies born with elective induction are associated with better neonatal outcomes compared to spontaneous labor. Elective induction may be associated with an increased hysterectomy risk.

Expression and Regulation of Human Cytochrome P450 4F Isoforms in Tissue Samples and Under TNF-Alpha Challenges

CYP4F (Cytochrome P4504F) enzymes metabolize endogenous molecules including leukotrienes, prostaglandins and arachidonic acid. The involvement of these endogenous compounds in inflammation has led to the hypothesis that changes in the inflamed tissue environment may affect the expression of CYP4Fs during the pro-inflammatory state, which in turn may modulate inflammatory conditions during the anti-inflammatory state. We demonstrated that inflamed tissues have different levels of CYP4F isoform expression profiles in a number of human samples when compared to the average population. The CYP4F isoform expression levels change with the degree of inflammation present in tissue. Further investigation in cell culture studies revealed that inflammatory cytokines, in particular TNF-α, play a role in regulating the expression of the CYP4F family. One of the isoforms, CYP4F11, had different characteristics than that of the other five CYP4F family members. CYP4F11 metabolizes xenobiotics while the other isoforms metabolize endogenous compounds with higher affinity. CYP4F11 also was expressed at high quantities in the brain, and was up-regulated by TNF-α, while the other isoforms were not expressed at high quantities in the brain and were down-regulated by TNF-α. We identified the AP-1 protein of the JNK pathway as the signaling protein that causes significant increase in CYP4F11 expression. Since TNF-α stimulation causes a simultaneous activation of both JNK pathway and NF-κB signaling, we investigated further the role that NF-κB plays on expression of the CYP4F11 gene. We concluded that although there is a significant increase in CYP4F11 expression in the presence of TNF-α, the activation of NF-κB signaling inhibits CYP4F11 expression in a time dependent manner. The expression of CYP4F11 is only significantly increased after 24 hours of treatment with TNF-α; at shorter time points NF-κB signaling overpowers the JNK pathway activation. We believe that these findings may in the future lead to improved drug design for modulating inflammation.

Addressing Obesity: Fear of Crime, Perceptions of Disorder and Disaparities in Child and Adolescent Use of Public Parks

Abstract The objectives of this study were: 1) To determine factors which inhibit and facilitate child and adolescent use of outdoor spaces for healthy physical activity by race and ethnicity in four Houston communities and 2) To propose guidelines for encouraging and maintaining child and adolescent outdoor physical activity. Using local health data and Houston Police Department crime statistics, four communities were identified for the study that had the highest concentration of crime and the racial/ ethnic groups of interest. The researchers then identified public parks in the communities. At least two parks were observed in each of the four communities from 2010 to 2011 during spring, summer, fall and winter. The parks were observed for use by children and adolescents and to describe the condition of the park spaces. The communities were Alief (Asian), Sunnyside (Black), Eldridge- West Oaks (White) and Northside- Northline (Hispanic). Observations were made at varying hours of both day and night, weekdays and weekends. Photographs were taken and the condition of the spaces noted in detail. One hundred and twenty persons, 18 years and over, using the spaces or otherwise in these communities were conveniently sampled and interviewed about their health and the extent to which they, or any children or adolescents under their care, used the outdoor spaces of interest. Data were analyzed qualitatively and with basic descriptive statistics. The photographs, journal notes and observation notes of all investigators and key personnel were analyzed. Interview data were also coded to identify patterns and themes in the responses. The findings indicate disparities in the quality and quantity of park equipment and the maintenance of the areas. Where perceptions of disorder were described, there was often visible evidence to support the perceptions. In many cases, residents' perceptions of crime were corroborated by police data. While interview reports did not seem to support the expectation that the condition of the parks was a significant deterrent to their use by children and adolescents, the condition of the parks might be said to limit the extent of that use. Specific reports of disorder that inhibited use included hearing gunfire, seeing drug dependent homeless persons and/or suspected prostitutes in an area.

A study in nursing home effectiveness in Texas

This exploratory study was conducted to examine the relationship between nursing home organizational variables and variations in financial efficiency and effectiveness in Texas nursing homes. Efficiency was defined in terms of nursing home profit, contribution margin, and administrative costs. Effectiveness was defined as the level of the quality of care measured by Texas Department of Health annual surveys of Medicaid certified facilities.^ A sample of 318 intermediate care facilities was selected from a population of 1,026 Texas nursing homes operating in 1987. Location was not found to be related to nursing home effectiveness. Nursing home ownership was positively related to financial efficiency. A moderate amount of quality of care variation was explained by examining nursing home size, employee turnover rate, labor hours per patient day and occupancy rate.^ The number of labor hours per patient day and employee turnover rate were significantly related negatively to both measures of profitability and quality of care. ^

A COMPARISON OF TWO METHODS FOR THE DETECTION OF FECAL POLLUTION IN DRINKING WATER (HYDROGEN SULFIDE, INDICATOR, MODIFICATION)

A new technique for the detection of microbiological fecal pollution in drinking and in raw surface water has been modified and tested against the standard multiple-tube fermentation technique (most-probable-number, MPN). The performance of the new test in detecting fecal pollution in drinking water has been tested at different incubation temperatures. The basis for the new test was the detection of hydrogen sulfide produced by the hydrogen sulfide producing bacteria which are usually associated with the coliform group. The positive results are indicated by the appearance of a brown to black color in the contents of the fermentation tube within 18 to 24 hours of incubation at 35 (+OR-) .5(DEGREES)C. For this study 158 water samples of different sources have been used. The results were analyzed statistically with the paired t-test and the one-way analysis of variance. No statistically significant difference was noticed between the two methods, when tested 35 (+OR-) .5(DEGREES)C, in detecting fecal pollution in drinking water. The new test showed more positive results with raw surface water, which could be due to the presence of hydrogen sulfide producing bacteria of non-fecal origin like Desulfovibrio and Desulfomaculum. The survival of the hydrogen sulfide producing bacteria and the coliforms was also tested over a 7-day period, and the results showed no significant difference. The two methods showed no significant difference when used to detect fecal pollution at a very low coliform density. The results showed that the new test is mostly effective, in detecting fecal pollution in drinking water, when used at 35 (+OR-) .5(DEGREES)C. The new test is effective, simple, and less expensive when used to detect fecal pollution in drinking water and raw surface water at 35 (+OR-) .5(DEGREES)C. The method can be used for qualitative and/or quantitative analysis of water in the field and in the laboratory. ^