Up to 80% of serious medical errors occur due to miscommunication from one provider to another (The Joint Commission, 2012). In order to ensure ongoing safe patient care, it is imperative that anesthesia providers communicate effectively and consistently when transferring patient responsibility to other providers, especially to post-anesthesia care unit (PACU) nurses. Multiple patient transfers occur each day and patients are commonly transferred between multiple providers during the same hospital stay. These opportunities are extremely vulnerable to communication errors. Structured patient handoff checklists or tools increase the consistency of information transferred from anesthesia providers to other providers. The Joint Commission recommended in 2012 that all anesthesia providers utilize a standardized patient handoff checklist to increase and improve the quality of data transferred from anesthesia provider to the PACU nurse. Certified Registered Nurse Anesthetists (CRNA) at a local surgical unit provide the bulk of patient handoffs in this postoperative unit, and currently, there is no mandated use of a standardized handoff checklist. As a result, the CRNAs provide a verbal patient handoff that is unscripted. Verbal patient handoffs differ among providers due to individual provider preference. Without using a standardized handoff checklist, there is a risk of increasing communication errors which increase medical errors and negative patient outcomes. Salzwedel (et al., 2013), in a study when utilizing a handoff checklist, concluded that critical patient data conveyed during patient handoffs increased by 32.4% to 48.7% (Salzwedel et al., 2013). Tscholl et al. (2015) and McElroy et al. (2015) through surveys, determined that data transferred between anesthesia providers was more structured. Handoff checklists increased PACU nurse satisfaction regarding the overall handoff experience (McElroy et al., 2015). No studies, to date, were found that understand the perceptions and thoughts of CRNAs regarding the utilization of patient handoff checklists or tools in clinical practice. This Doctor of Nursing Practice (DNP) project assesses the perceptions and thoughts of utilizing standardized handoff checklists among CRNAs. The hope of this study is to better understand CRNA perceptions in order to identify potential barriers or knowledge gaps regarding the benefit of utilizing a standardized patient handoff checklists. Data from this project may be used to structure future quality improvement projects aimed at decreasing communication errors and improve patient outcomes. The results of this project show the majority of CRNAs (89.5%) surveyed for this project were already familiar with handoff checklists. However, only 26.3% of those same participants agreed they currently use a standardized patient handoff checklist. Of the surveyed participants, only 36.8% were interested in utilizing a standardized patient handoff tool even though nearly 50% agreed that using a handoff checklist would increase the consistency of information transferred from anesthesia provider to nurses. This correlates with the 73.7% of participants who already believe they currently transfer pertinent patient information successfully without utilizing a standardized handoff checklist or tool. Despite studies reporting improved patient outcomes, decreased medical errors, and the Joint Commission’s recommendations to use standardized handoff checklists or tools, the majority of anesthesia providers at this facility do not choose to use handoff checklists. By surveying anesthesia providers' thoughts and perceptions, the researcher attempted to answer why anesthesia providers are not utilizing handoff checklists in their daily routines.

The development of anesthesia has greatly contributed to the safety of surgeries, reduced the level of invasiveness of many procedures, and provided increased comfort for patients. The delivery of anesthetics has been primarily provided by one of two unique health care providers: a trained physician who has specialized in anesthesia, or an advanced practice nurse—the certified registered nurse anesthetist (CRNA). Both providers have a similar scope of practice, are nationally certified, and often work side-by-side. However, in recent years there has been some controversy between the two providers regarding autonomy, safety, and quality of services. The purpose of this study was to utilize current research comparing the two professions to determine if there is a difference in the quality of care and cost effectiveness between these two providers. This research was focused on studies performed in the United States after 1985. Results indicated no significant differences in quality of care between providers; however, a cost difference does exist. CRNA's provide a high quality of care equivalent to their physician counterparts, but at a reduced price. They additionally offer access to care in rural areas that lack anesthesiologists. Limitations include an inability to assess the impact of doctoral level programs for nurse anesthetists (required for entry into practice beginning in 2025) and how this may affect the main components of patient care assessed in this study (quality of care and cost). Future studies should look at ways to improve the relationship between the two providers and to remove barriers to nurse anesthetists’ scope of practice in order to increase overall access to care.

Hospital administrators are being held accountable by patients, insurers, and other stakeholders in evaluating their overall hospital performance to reduce costs and improve efficiency. With the move to alternative payment models and value-based purchasing, hospital administrators must understand the economic viability and value that their specialty services bring to their facility. The purpose of this study was to identify the determinants New England acute care hospital administrators’ utilize in making the choice of anesthesia practice model for their facility. A quantitative, exploratory study of factors hospital administrators use when choosing an anesthesia practice model utilizing a non-experimental, correlational research design was completed. The research was descriptive in nature to determine the factors that influenced a hospital administrator when making decisions about the type of anesthesia practice model that would be the best for their hospital. This research examined seventeen independent variables that were hypothesized to determine hospital administrators’ choice of anesthesia practice model. After the final logistic regression analysis, it was determined that the presence of a hospital being located in a medically underserved area (MUA) alone was a predictor of type of anesthesia practice model utilized. In light of the study limitations and prior literature on the CRNA-only model being present in almost 100% of rural facilities, more exploration is necessary to come to more robust conclusions on predictors of choice of anesthesia practice model determined by hospital administrators. This study showed that there are definitive areas that hospital administrators identify as high importance to the healthy functioning of their facility. By addressing these needs, an anesthesia department could contribute to the overall stability of the hospital, while at the same time, making themselves a more valuable asset overall. Value-driven services offered by anesthesia departments may be the determining factor in choice of anesthesia practice model. By measuring and analyzing anesthesia provider and hospital demographics and hospital administrators’ perceptions of anesthesia services, the objective data collected may assist in defining the most appropriate practice model for a hospital.

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It is widely acknowledged that elevated levels of noise are commonplace in the healthcare environment, particularly in high acuity areas such as the operating room (OR). Excessive ambient noise may pose a threat to patient safety by adversely impacting provider performance and interfering with communication among perioperative care team members. With respect to the certified registered nurse anesthetist (CRNA), increased ambient OR noise may engender distractibility, diminish situation awareness and cause untoward health effects, thereby increasing the possibility for the occurrence of error and patient injury. This research project analytically examines the perceived impact of ambient noise in the operating room by CRNAs. Findings from this study reveal that CRNAs perceive elevated noise to be regularly present in the OR, specifically during the critical emergence phase of the anesthetic. However, CRNAs feel that increased noise only occasionally limits their ability to perform procedures, concentrate and communicate with the perioperative team. OR noise rarely interferes with memory retrieval. CRNAs perceive that noise is sometimes a threat to patient safety but infrequently engenders adverse patient outcomes. CRNAs do not perceive noise in the OR to be detrimental to their health but strongly agree that excessive noise can and should be controlled. Increased ambient OR noise is a veritable reality that may pose a potential threat to patient safety. Further research to identify elevations in noise during critical phases of the anesthetic and delineation of significant contributors to its genesis is warranted.

<p>У овој дисертацији су студиозно сагледане могућности унапређења туристичке понуде северозападне&nbsp; Црне&nbsp; Горе(општине&nbsp; Жабљак,&nbsp; Пљевља,&nbsp; Плужине,&nbsp; Шавник)&nbsp; на&nbsp; бази недовољно&nbsp; искоришћених&nbsp; природних&nbsp; туристичких&nbsp; вредности.&nbsp; Управо&nbsp; разноврстан, хоризонтално&nbsp; и&nbsp; вертикално&nbsp; рашчлањен&nbsp; рељеф&nbsp; и&nbsp; веома&nbsp; сложен&nbsp; геолошки&nbsp; састав, специфичне климатске&nbsp; карактеристике, потом реке и бројна планинска језера, те богат биљни и животињски свет, представљају оне природне вредности које потенцијално чине&nbsp;основу унапређења туристичке понуде овог дела Црне Горе базираног и на заштићеним природним добрима (Национални парк&bdquo;Дурмитор&ldquo;, Регионални парк&bdquo;Пива&ldquo;). Посебан акценат је дат у сагледавању и оцени нивоа искоришћености природних туристичких вредности,&nbsp; као&nbsp; примарних&nbsp; туристичких&nbsp; мотива&nbsp; у&nbsp; границама&nbsp; истраживаног&nbsp; простора. Истовремено су уз процену и вредновање ових ресурса предложене поједине активности за&nbsp; њихово&nbsp; квалитетније&nbsp; уклапање&nbsp; у&nbsp; туристичку&nbsp; понуду&nbsp; северозападне&nbsp; Црне&nbsp; Горе.<br />Реализација таквих активности би требала утицати на унапређење туристичке понуде које се може постићи, генерално само развојем туризма који је у сагласности са еколошким нормама, нарочито ако се имају у виду постојећа заштићена природна добра на територији подручја. Такође је у разматрању наведене проблематике презентовано актуелно стање постојеће укупне туристичке понуде истраживаног подручја која укључује или би требала<br />укључивато поједине антропогене вредности. Оне практично нису укључене у понуду локалних&nbsp; туристичких&nbsp; агенција,&nbsp; с&nbsp; обзиром&nbsp; на&nbsp; то&nbsp; да&nbsp; су&nbsp; агенције&nbsp; готово&nbsp; искључиво&nbsp;&nbsp; усмерене на програме валоризације природних вредности (рафтинг, планинарење и др.). Ове вредности јесу основа унапређења туристичке понуде подручја, али су антропогене вредности&nbsp; њена&nbsp; потенцијално&nbsp; адекватна&nbsp; допуна&nbsp; која&nbsp; уз&nbsp; одговарајуће&nbsp; активности надлежних&nbsp; субјеката&nbsp; може&nbsp; утицати&nbsp; једним&nbsp; делом&nbsp; на&nbsp; садржајну&nbsp; диверзификацију туристичке понуде подручја. SWOT анализом се кроз њене саставне факторе указало на&nbsp;<br />значајне претпоставке у формирању туристичке понуде истраживаног подручја, као што се указало и на прагове ограничења, али и на могућности које могу послужити за умањење или&nbsp; превазилажење&nbsp; неких&nbsp; од&nbsp; њих.&nbsp; За&nbsp; реализацију&nbsp; тих&nbsp; могућности&nbsp; је&nbsp; потребна&nbsp; свест локалне заједнице о томе да се резултати појединих негативних процеса на делу подручја (изразити пример НП&bdquo;Дурмитор&ldquo;) који су мотивисани краткорочним потребама морају са аспекта квалитета природних вредности, одразити на исте кроз дугорочне импликације.<br />Осим&nbsp; овом&nbsp; анализом,&nbsp; значајна&nbsp; сазнања&nbsp; су&nbsp; добијена&nbsp; и&nbsp; из&nbsp; анкетног&nbsp; истраживања спроведеног&nbsp; на&nbsp; узорку&nbsp; од200 случајно&nbsp; изабраних&nbsp; туриста&nbsp; на&nbsp; више&nbsp; локација&nbsp; унутар подручја.&nbsp; Резултати&nbsp; овог&nbsp; истраживања&nbsp; су&nbsp; послужили&nbsp; као&nbsp; веома&nbsp; валидан&nbsp; индикатор предности&nbsp; и&nbsp; недостатака&nbsp; актуелне&nbsp; туристичке&nbsp; понуде,&nbsp; али&nbsp; и&nbsp; нивоа&nbsp; задовољства анкетираних туриста чиме је такође указано на смернице унапређења појединих сегмената туристичке понуде. Наглашеним апликативним карактером овај део истраживања пружа одговарајући&nbsp; информативни&nbsp; допринос&nbsp; надлежним&nbsp; туристичким&nbsp; субјектима&nbsp; којим&nbsp; се<br />указује&nbsp; на&nbsp; анкетним&nbsp; истраживањем&nbsp; утврђен&nbsp; степен&nbsp; афирмативности&nbsp; места,&nbsp; односно подручја&nbsp; у&nbsp; целини.&nbsp; Истовремено,&nbsp; резултати&nbsp; поменутог&nbsp; истраживања&nbsp; пружају,&nbsp; између осталог, и значајне информације које се односе на остварен квалитет, као и на израженије преферирање неких сегмената туристичке понуде при чему исто може послужити делом и као полазна основа у прилагођавању појединих сегмената понуде потребама туриста. Истраживањем&nbsp; у&nbsp; оквиру&nbsp; израде&nbsp; дисертације&nbsp; је&nbsp; констатоватована&nbsp; присутност&nbsp; одређене<br />дискоординације услед различитости у нивоима надлежности и неуједначености у погледу централизације/децентрализације управљања над појединим организационим субјектима. У вези са тим, а на основу резултата проистеклих из целокупно спроведеног истраживања кроз интердисциплинарни приступ дошло се до сагледавања потребе реализације више конкретних мера међу којима је једна од њих потреба формирања Регионалне туристичке организације&nbsp; што&nbsp; је&nbsp; једна&nbsp; од&nbsp; предиспозиција&nbsp; које&nbsp; су&nbsp; од&nbsp; значаја&nbsp; у&nbsp; просецу&nbsp; бољег позиционирања истраживаног подручја као туристичке дестинације.</p> / <p>U ovoj disertaciji su studiozno sagledane mogućnosti unapređenja turističke ponude severozapadne&nbsp; Crne&nbsp; Gore(opštine&nbsp; Žabljak,&nbsp; Pljevlja,&nbsp; Plužine,&nbsp; Šavnik)&nbsp; na&nbsp; bazi nedovoljno&nbsp; iskorišćenih&nbsp; prirodnih&nbsp; turističkih&nbsp; vrednosti.&nbsp; Upravo&nbsp; raznovrstan, horizontalno&nbsp; i&nbsp; vertikalno&nbsp; raščlanjen&nbsp; reljef&nbsp; i&nbsp; veoma&nbsp; složen&nbsp; geološki&nbsp; sastav, specifične klimatske&nbsp; karakteristike, potom reke i brojna planinska jezera, te bogat biljni i životinjski svet, predstavljaju one prirodne vrednosti koje potencijalno čine&nbsp;osnovu unapređenja turističke ponude ovog dela Crne Gore baziranog i na zaštićenim prirodnim dobrima (Nacionalni park&bdquo;Durmitor&ldquo;, Regionalni park&bdquo;Piva&ldquo;). Poseban akcenat je dat u sagledavanju i oceni nivoa iskorišćenosti prirodnih turističkih vrednosti,&nbsp; kao&nbsp; primarnih&nbsp; turističkih&nbsp; motiva&nbsp; u&nbsp; granicama&nbsp; istraživanog&nbsp; prostora. Istovremeno su uz procenu i vrednovanje ovih resursa predložene pojedine aktivnosti za&nbsp; njihovo&nbsp; kvalitetnije&nbsp; uklapanje&nbsp; u&nbsp; turističku&nbsp; ponudu&nbsp; severozapadne&nbsp; Crne&nbsp; Gore.<br />Realizacija takvih aktivnosti bi trebala uticati na unapređenje turističke ponude koje se može postići, generalno samo razvojem turizma koji je u saglasnosti sa ekološkim normama, naročito ako se imaju u vidu postojeća zaštićena prirodna dobra na teritoriji područja. Takođe je u razmatranju navedene problematike prezentovano aktuelno stanje postojeće ukupne turističke ponude istraživanog područja koja uključuje ili bi trebala<br />uključivato pojedine antropogene vrednosti. One praktično nisu uključene u ponudu lokalnih&nbsp; turističkih&nbsp; agencija,&nbsp; s&nbsp; obzirom&nbsp; na&nbsp; to&nbsp; da&nbsp; su&nbsp; agencije&nbsp; gotovo&nbsp; isključivo&nbsp;&nbsp; usmerene na programe valorizacije prirodnih vrednosti (rafting, planinarenje i dr.). Ove vrednosti jesu osnova unapređenja turističke ponude područja, ali su antropogene vrednosti&nbsp; njena&nbsp; potencijalno&nbsp; adekvatna&nbsp; dopuna&nbsp; koja&nbsp; uz&nbsp; odgovarajuće&nbsp; aktivnosti nadležnih&nbsp; subjekata&nbsp; može&nbsp; uticati&nbsp; jednim&nbsp; delom&nbsp; na&nbsp; sadržajnu&nbsp; diverzifikaciju turističke ponude područja. SWOT analizom se kroz njene sastavne faktore ukazalo na&nbsp;<br />značajne pretpostavke u formiranju turističke ponude istraživanog područja, kao što se ukazalo i na pragove ograničenja, ali i na mogućnosti koje mogu poslužiti za umanjenje ili&nbsp; prevazilaženje&nbsp; nekih&nbsp; od&nbsp; njih.&nbsp; Za&nbsp; realizaciju&nbsp; tih&nbsp; mogućnosti&nbsp; je&nbsp; potrebna&nbsp; svest lokalne zajednice o tome da se rezultati pojedinih negativnih procesa na delu područja (izraziti primer NP&bdquo;Durmitor&ldquo;) koji su motivisani kratkoročnim potrebama moraju sa aspekta kvaliteta prirodnih vrednosti, odraziti na iste kroz dugoročne implikacije.<br />Osim&nbsp; ovom&nbsp; analizom,&nbsp; značajna&nbsp; saznanja&nbsp; su&nbsp; dobijena&nbsp; i&nbsp; iz&nbsp; anketnog&nbsp; istraživanja sprovedenog&nbsp; na&nbsp; uzorku&nbsp; od200 slučajno&nbsp; izabranih&nbsp; turista&nbsp; na&nbsp; više&nbsp; lokacija&nbsp; unutar područja.&nbsp; Rezultati&nbsp; ovog&nbsp; istraživanja&nbsp; su&nbsp; poslužili&nbsp; kao&nbsp; veoma&nbsp; validan&nbsp; indikator prednosti&nbsp; i&nbsp; nedostataka&nbsp; aktuelne&nbsp; turističke&nbsp; ponude,&nbsp; ali&nbsp; i&nbsp; nivoa&nbsp; zadovoljstva anketiranih turista čime je takođe ukazano na smernice unapređenja pojedinih segmenata turističke ponude. Naglašenim aplikativnim karakterom ovaj deo istraživanja pruža odgovarajući&nbsp; informativni&nbsp; doprinos&nbsp; nadležnim&nbsp; turističkim&nbsp; subjektima&nbsp; kojim&nbsp; se<br />ukazuje&nbsp; na&nbsp; anketnim&nbsp; istraživanjem&nbsp; utvrđen&nbsp; stepen&nbsp; afirmativnosti&nbsp; mesta,&nbsp; odnosno područja&nbsp; u&nbsp; celini.&nbsp; Istovremeno,&nbsp; rezultati&nbsp; pomenutog&nbsp; istraživanja&nbsp; pružaju,&nbsp; između ostalog, i značajne informacije koje se odnose na ostvaren kvalitet, kao i na izraženije preferiranje nekih segmenata turističke ponude pri čemu isto može poslužiti delom i kao polazna osnova u prilagođavanju pojedinih segmenata ponude potrebama turista. Istraživanjem&nbsp; u&nbsp; okviru&nbsp; izrade&nbsp; disertacije&nbsp; je&nbsp; konstatovatovana&nbsp; prisutnost&nbsp; određene<br />diskoordinacije usled različitosti u nivoima nadležnosti i neujednačenosti u pogledu centralizacije/decentralizacije upravljanja nad pojedinim organizacionim subjektima. U vezi sa tim, a na osnovu rezultata proisteklih iz celokupno sprovedenog istraživanja kroz interdisciplinarni pristup došlo se do sagledavanja potrebe realizacije više konkretnih mera među kojima je jedna od njih potreba formiranja Regionalne turističke organizacije&nbsp; što&nbsp; je&nbsp; jedna&nbsp; od&nbsp; predispozicija&nbsp; koje&nbsp; su&nbsp; od&nbsp; značaja&nbsp; u&nbsp; prosecu&nbsp; boljeg pozicioniranja istraživanog područja kao turističke destinacije.</p> / null / <p>The dissertation deals with the advancement possibilities of tourist offer in north western part of Montenegro (municipalities of Žabljak, Pljevlja, Plužine, &Scaron;avnik) based &nbsp;on insufficiently utilised natural tourism values. Natural tourism values such as diverse, horizontally and vertically segmented relief, extremely complex geological formation, specific climate features, rivers and numerous mountain lakes, bio-diversity &nbsp;of flora and fauna form the prospective ground for tourism offer advancement in this part of Montenegro jointly with protected natural assets (National Park Durmitor and Regional Park Piva). There is special emphasis on comprehension and evaluation of utilization level of natural tourism assets, as primary tourist motives within the boundaries of the researched area. Simultaneous to estimation and evaluation of the resources, certain activities have been proposed for their qualitative integration into the tourist offer of north western part of Montenegro. Realisation of the activities should impact the&nbsp;tourist offer advancement that can be achieved only by means of tourism development that is in concordance with ecology principles, especially related &nbsp;to existing natural assets of this area. Moreover, the study of the issues describes the current condition of the total tourist offer which implies or should imply certain anthropogenic values of the researched area. In practice anthropogenic values were not included into the offer of the local travel agents. Instead, there was exclusive orientation towards the valorisation programmes of natural values (rafting, mountaineering, etc.). Natural values do create the basis for tourist offer advancement in the area, but anthropogenic values create prospective adequate complement to the &nbsp;tourist offer which together with appropriateactivities of the subjects in charge may in return partly impact the content diversification of the tourist offer in the area. SWOT analysis by means of its constituent factors specifies the presuppositions in tourist offer creation of the researched area, identifies&nbsp;restriction factors and also the possibilities that may help to alleviate or surpass some of them. Furthermore, the realisation of the possibilities demands higher awareness of the local community on the issue that the results of certain negative processes in the part of the researched area (prominent example National Park Durmitor) motivated by short-termed needs must have long-termed impact on natural values in terms of quality. Apart from this analysis, important findings have been obtained by the questionnaire conducted on the sample of 200 randomly&nbsp;selected tourists on several locations within the area. The &nbsp;results of the research serve as a valid indicator of strengths and weaknesses of the current tourist offer and the level of satisfaction of the respondents, which also indicates the directions for future improvement of certain segments within the tourist offer. This part of the research offers appropriate informative contribution to the tourism subjects by means of its highlighted applicative potential and defined level of affirmative features of the total area. At the same time the results of the research offer significant information on the achieved quality level and preferred segments of tourist &nbsp;offer that may partly&nbsp;serve as the basisfor adaptation of certain segments within the offer to tourist needs.&nbsp;The research conducted for doctoral thesis highlighted certain discoordination due to differences&nbsp; between the levels of responsibility and unevenly&nbsp; entralised/decentralised management of organisational subjects. Related to this and based on the results of the research based on interdisciplinary approach several measures have been highlighted, among which the need to form Regional tourist organisation as one of the predispositions for the process of better positioning of the researched area as a tourist destination.</p>

No description available.