Abstract Purpose: The purpose of this project was to evaluate outcomes of an existing inpatient tobacco cessation counseling program with 30-day follow-up among recently admitted tobacco-dependent patients who were tobacco-dependent. Background/Significance: Tobacco use is considered the number one most preventable cause of disease, disability, and death in the United States. Despite associated dangers, approximately 21% Americans currently smoke. This has led to increased hospital admissions and chronic disease management, costing the United States approximately $96 billion per year. Decades of research and evidence-based clinical practice guidelines substantiate that inpatient tobacco cessation counseling has the potential to improve quit rates post-hospital discharge. Method: This quality improvement project utilized existing hospital data containing demographic and medical information about patients and tobacco use behaviors. The goal was to answer the question: Does the provision of a tobacco cessation program initiated during hospitalization for persons who are tobacco-dependent (a) increase quit attempts or (b) reduce tobacco consumption? The electronic medical record was queried for data related to: demographics, insurance type, and diagnosis. Data related to smoking status and the intervention was extracted from a paper chart maintained by the certified tobacco treatment specialist. Results: Out of 176 tobacco-dependent patients admitted to the hospital, 100 (57%) indicated an intention to quit (at admission time) while only 40 (23%) reported having quit within 30 days post discharge (McNemar Test, p=0.000, n=176). The mean number of cigarettes smoked per day dropped from 19 cigarettes on admission to 13 cigarettes post discharge. [t (158)=6.7476, p=0.000]. Conclusions: This quality improvement project showed that although an inpatient smoking cessation program did not improve quit rates, it did significantly improve reduction in tobacco consumption.

The purpose of this evidence-based project was to compare one-year outcomes for newly licensed Registered Nurses (NLRNs) in three organizations within the same healthcare system. All three have lower than nationally reported turnover and strategies for NLRN retention. Only one is using a Nurse Residency Program (NRP). NRPs are recognized as an effective strategy to retain newly licensed registered nurses (NLRNs) in their first year of employment (Institute of Medicine [IOM], 2010; The Advisory Board, 2007; Spector, 2007). The Commission on Collegiate Nursing Education (CCNE) (2008) defines an NRP as a series of learning sessions and work experiences that occur continuously over a 12-month period designed to assist NLRNs as they transition into their first professional nursing role. This cross-sectional, descriptive study utilized the Casey-Fink Graduate Nurse Experience Survey and intent to stay questions to collect data on NLRNs at one year post hire. Results indicated no statistically significant differences between the three sites and the subscales of the survey. There was a trend of a more positive score for professional satisfaction with Site A. Turnover was also similar between sites and lower than the reported 10% average, with Site A at 2%, Site B at 5%, and Site C at 4%. There was a statistically significant difference between Site A and C in the intent to stay in their current position, with Site A longer than Site C. The study supports the literature and evidence that a NRP is an effective strategy to decrease first year turnover. Further study is needed related to the effectiveness of the components of the NRP, length of time for mentorship, and the impact of accumulation of cohorts.

Ongoing evaluation of current practice and incorporation of evidence based research into guidelines and protocols is a requirement for the provision of high quality, cost efficient care. Despite some literature describing observational data, midline catheters (MCs) are not an appropriate vascular access device for Newborn Intensive Care Unit (NICU) patients due to insufficient high level evidence demonstrating safety and efficacy. In addition, national guidelines for MC use in neonatal and infant patients lacks sufficient information for safe and effective use of MCs. The results of this small, online survey indicate that while some neonatal nurses and Nurse Practitioners report the use of MC use in the NICU, there is a wide range of practice pertaining to MC unit-specific protocols, competencies, success with placement, and clinician agreement of appropriate use for this vascular access device (VAD). Multicenter, randomized control trials are needed to evaluate current MC practice in the NICU, and institutions must incorporates current, evidence based practice into policies, procedures, and guidelines.

Submitted by Mariana Dornelles Vargas (marianadv) on 2015-05-28T19:38:08Z No. of bitstreams: 1 analise_processo.pdf: 4833608 bytes, checksum: 44324b393958b01c87ee362f1bf51872 (MD5) / Made available in DSpace on 2015-05-28T19:38:08Z (GMT). No. of bitstreams: 1 analise_processo.pdf: 4833608 bytes, checksum: 44324b393958b01c87ee362f1bf51872 (MD5) Previous issue date: 2011 / Nenhuma / Este trabalho aborda um estudo de caso efetuado em uma empresa multinacional, do ramo metal mecânico, fabricante de equipamentos de bens de capital destinados à construção e à pavimentação de rodovias. A pesquisa consiste em analisar a condução do processo de desenvolvimento de novos produtos - DNP -, identificar as lacunas e propor melhorias para aumentar a sua eficiência e eficácia. O incremento de eficiência e eficácia permite às empresas a busca pela vantagem competitiva no mercado em que atuam por: i) redução de desperdícios, de custos no produto e processo, e de tempo de lançamento do produto, sendo mais rápido do que o da concorrência; e ii) incremento de tecnologia e maturidade no desenvolvimento de novos produtos. Para que fosse possível avaliar o processo de DNP, estabeleceu-se uma estrutura hierárquica que norteia o referencial teórico apresentado, subdividida em projeto e produto. Com relação a projetos, aborda-se a importância do gerenciamento de projetos organizacional, estabelecendo-se a inter-relação entre gerenciamento de projetos, gestão da mudança e aprendizado organizacional. Com relação a produtos, aborda-se o referencial teórico sobre processos de desenvolvimento de produtos, cujas principais características são apresentadas, bem como sua evolução, desde o processo sequencial até os processos contemporâneos. Esse referencial teórico é de suma importância no estudo deste caso para que seja efetuado o diagnóstico do estado atual do processo de DNP, identificar as lacunas e a fragilidade desse processo, além de propor melhorias para o estado futuro. O método de pesquisa utilizado consiste de pesquisa qualitativa, representada pela aplicação de questionários com perguntas objetivas e descritivas, e execução de reuniões de grupo de foco e observação direta. O período de análise do processo ocorreu entre julho de 2007 e dezembro de 2010. A coleta de dados da pesquisa foi realizada entre julho e dezembro de 2010. Como conclusão, foram evidenciadas 18 oportunidades de melhorias de dimensão estratégica, tácita e operacional, e identificadas 8 perdas no fluxo do processo de DNP. Foram apresentadas sugestões de melhorias para aumento de eficiência e eficicácia no processo. / This paper discusses a case study carried out in a multinational company, industry, metal mechanic, a maker of equipment for capital goods for construction and road paving. It is to examine how it is being conducted the process of new product development, NPD, identify gaps and propose improvements to increase efficiency and effectiveness of that. Increased efficiency and effectiveness of this process allows companies to seek competitive advantage in working for 1) reduction, waste, product and process costs, reduced time for product launch, this faster than the competition, and 2) an increase of technology and maturity in developing new products. To enable it to evaluate a NPD process established a hierarchical structure that guides the theoretical framework presented. This is divided into project and product. With regard to projects is discussed the importance of project management organization which establishes the interrelation between project management, change management and organizational learning. With regard to products is discussed on the theoretical development processes of products, which are arepsentadas their main characteristics and evolution from the sequential processes to contemporary. This important theoretical contribution in the case study to make the diagnosis of the current state of the NPD process, this being identified gaps and weaknesses and propose improvements to the future state. The research methodology consists of qualitative research through the application of questionnaires with objective and descriptive exedcução of focus group meetings and direct observation. The period of analysis of the process is considered from July 2007 to December 2010. The implementation of the research was conducted between July 2010 to December 2010 to collect data. As a conclusion were found 18 opportunities for improvement with a strategic dimension, tacit and operational, identified the eight losses in the flow of the companys NPD process and made suggestions for improvements aimed at increasing their efficiency and effectiveness.

Conjunctivitis is the most common cause of red eye and one of the most frequent causes of visits to clinicians. There is significant controversy on the diagnosis and treatment of the disease and the use of ophthalmic antibiotics. The inconvenience of the untimely diagnostic tests led to the trend of treating conjunctivitis empirically with ophthalmic antibiotics. Subsequently, the diagnosis of bacterial conjunctivitis is higher than it should be resulting in overuse of antibiotics. Consequences of inappropriate diagnosis and treatment include increased virulence, increased health care costs, and incorrect use of antibiotics leading to possible adverse reaction and antibiotic resistance. Appropriate diagnosis and treatment will assist to reduce the diagnosis of bacterial conjunctivitis and use of ophthalmic antibiotics resulting in reduced virulence and reduced health care costs. The AdenoPlus test has been shown to be effective in appropriately diagnosing viral conjunctivitis and subsequently decreasing the use of ophthalmic antibiotics however this evidence in limited. A national retail clinic has adopted the use of this tool to assist with proper diagnosis and treatment of viral conjunctivitis. Data has not yet been analyzed to determine if the implementation of this test changes the practice of clinicians at the national retail clinic.

A series of experiments was performed with the Texas A&M University Nuclear Science Center Reactor (NSCR) to verify ²³⁵U delayed neutron emission rates. A custom device was created to accurately measure a sample's pneumatic flight time and the Nuclear Science Center's (NSC's) pneumatic transfer system (PTS) was redesigned to reduce a sample's pneumatic flight time from over 1,600 milliseconds to less than 450 milliseconds. Four saturation irradiations were performed at reactor powers of 100 and 200 kW for 300 seconds and one burst irradiation was performed using a $1.61 pulse producing 19.11 MW-s of energy. Experimental results agreed extremely well with those of Keepin. By comparing the first ten seconds of collected data, the first saturation irradiation deviated ~1.869% with a dead time of 2 microseconds, while the burst irradiation deviated ~0.303% with a dead time of 5 microseconds. Saturation irradiations one, three and four were normalized to the initial count rate of saturation irradiation two to determine the system reproducibility, and deviated ~0.449%, ~0.343% and ~0.389%, respectively.

Helical membrane proteins comprise one third of the expressed proteins encoded in a typical genome. Other membrane proteins are typically beta sheets. Their function varies from pore formation, signaling to antimicrobial activity. They are also capable of transporting large cargo such as proteins or nucleic acids across the cell membrane. Recently, peptides have emerged as promising tools in drug delivery. Membrane proteins can be synthesized chemically or expressed and isotopically labeled in bacteria, isolated, purified and reconstituted into fully hydrated lipid bilayers. The bilayer orientation is kept mechanically by putting them between glass plates. While interacting with these bilayers they exhibit a variety of configurations depending on the lipids composition and thickness. Solid-state Nuclear Magnetic Resonance (NMR) on oriented bilayers is one way to access the topology of peptides associated with phospholipid membranes. Oriented membrane protein are difficult to study with analytical techniques because of their poor solubility outside the lipid membrane, difficulty of expression in bacteria in big quantities, difficulty to crystallize, and they are too large for solution NMR study. The intensity of an NMR signal depends on several factors such as polarization P and magnetic field magnitude B0. One of the major drawbacks of NMR spectroscopy is low sensitivity. This is caused by the small magnetic moment of the nuclear spins which results in a modest Zeeman splitting of the nuclear spin energy levels and therefore in a limited Boltzmann Polarization. The aim of this project is to obtain a better signal from membrane proteins. Thus a Low temperature (LT) solid state NMR with Dynamic Nuclear Polarization (DNP) probe head was created. DNP is an ingenious technique that is used to transfer polarization from highly polarized targets to less polarized nuclei using microwave irradiation. Microwaves will excite selectively the electron spins which will transfer their polarization to the pool of proton nuclei, the proton NMR signal can be enhanced by 660 times. A probe head for DNP enhanced solid state NMR at 100 K and 9.4 T is described. A probe head includes the mechanical piece that holds the sample in the magnetic center of the NMR magnet. It is a tunable antenna that irradiates and detects the rf fields used in NMR. The centerpiece of the probe is the solenoidal or saddle coil surrounding the sample. The feasibility of such a DNP experiment is proven on magic angle oriented sample spinning. These experiments are conducted on oriented samples wrapped into a rotor. Through their orientation with regards to B0 is lost, enhancement values as high as 17 are obtained. [...]

This thesis describes applications of advanced multinuclear solid-state nuclear magnetic resonance (NMR) experiments to the characterisation of industrially-relevant catalyst materials. Experiments on γ-Al₂O₃ introduce the use of solid-state NMR spectroscopy for the investigation of disordered solids. The existence of Al(V) sites on the surface of this material is demonstrated, showing that removal of adsorbed H₂O may facilitate a rearrangement effect in γ-Al₂O₃ that promotes the formation of these Al environments. A range of aluminium oxide-based supported metal catalysts has been investigated. Studies of these systems by ¹H and ²⁷Al solid-state NMR spectroscopy indicate that a metal-support interaction (MSI) exists between surface cobalt oxide crystallites and the γ-Al₂O₃ support, and is strongest for materials containing small, well dispersed Co oxide crystallites. It is shown that the hygroscopic nature of γ-Al₂O₃ allows the extent of the MSI to be visualised by ¹H MAS NMR, by observing the extent of the proton-metal oxide interaction resulting from the presence of adventitious adsorbed H₂O. The surface/bulk chemistry of Co spinel aluminate materials is also investigated. ¹H, ²⁹Si, ²⁷Al and ¹⁷O solid-state NMR techniques are used to gain insight into the structural nature of silicated alumina catalysts. The combination of isotopic enrichment and dynamic nuclear polarisation (DNP) surface-enhanced NMR spectroscopy can provide a definitive and fully quantitative description of the surface structure of Si-γ-Al₂O₃ (1.5 wt% Si), and the role of adventitious surface water is highlighted. Analysis of silicated aluminas prepared by “sequential grafting” and “single shot” approaches shows that silica growth on γ-Al₂O₃ follows two distinct morphologies. ¹⁷O gas exchange enrichment is also shown to be successful in facilitating ¹⁷O solid-state NMR studies of these materials. It is demonstrated that double (²⁹Si and ¹⁷O) enrichment of Si-γ-Al₂O₃ (1.5 wt% Si) can facilitate access to ²⁹Si-¹⁷O 2D correlation experiments, even at low silica loading. An exploratory investigation of Ti-alumina model catalysts has also been carried out using ¹H, ²⁷Al and ¹⁷O solid-state NMR spectroscopy. These studies indicate that Ti-γ-Al₂O₃ and Ti-Al M50 may be structurally distinct materials.

Postoperative pain is of serious concern to patients and anesthesia providers alike. Management of a patients’ pain is a central component of anesthesia care. Ketamine as an anesthetic agent has been available for 50 years. It has been utilized as a general anesthetic and selectively as an anesthetic agent for high-risk patients. Due to dysphoric side effects associated with the dosage required to render general anesthesia, anesthesia providers may be reluctant to utilize this medication to its full potential. Recently there has been a resurgence of interest in ketamine as an analgesic agent. The researcher for this project performed a thorough literature review focusing on intravenous ketamine as an adjunct to standard opioid-based analgesia for postoperative pain. Four systematic reviews published in the last 10 years support the safety and efficacy of ketamine when administered intravenously in sub-anesthetic doses. The purpose of this project was to provide evidence-based education to anesthesia providers regarding the benefits of ketamine and follow-up to evaluate for evidence of changes in practice after the educational At a large community hospital data concerning ketamine utilization by anesthesia providers as a component of multimodal analgesia was collected for a six-month period, including three months pre- and three months post-educational intervention. Despite various methods utilized to present evidence regarding the safety and efficacy of ketamine, the results of this study demonstrated no significant change in practice. Based upon the extensive published literature the evidence is compelling that the addition of a sub-anesthetic (0.5 mg/kg) dose of ketamine to the surgical patient’s operative pain management plan would improve comfort and decrease opioid-related side effects with minimal negative impact.

In an era of value based purchasing and healthcare reform, hospitals face the challenge of delivering high quality care in an environment of diminishing resources. This performance improvement project describes the use of master’s prepared nurses on medical surgical units to improve quality and patient satisfaction. The setting was five medical surgical units in a 200+ bed hospital in the southeastern United States. Declining resources necessitated an increase in the nurse to patient ratios on the units (from 5:1 to 6:1). The project involved the modification of the model of care through the change in nurse/patient ratios and the addition of master’s prepared nurses to coordinate and supplement the care of the staff RNs for complex patients. While inconclusive, the literature review confirmed the impact of master’s prepared nurses on quality metrics and did not conclusively confirm that delivering high quality, safe care was not possible with nurse/patient ratios of 1:6. The goal of the project was to determine if the presence of the master’s prepared nurse could mitigate the changes in ratios and produce high quality and satisfaction outcomes. Measures of success were drawn from archived standardized quality measures in the realms of service (HCAHPS questions), patient safety (CABSI, HAPU) and quality outcomes (core measures and 30 day readmissions). The project design was a retrospective, one-group pre-post design looking at two six-month intervals—before and after project implementation. Results demonstrated sustained or improved quality in six of ten measures. Highest positive impact was in readmissions and nurse sensitive indicators. The most negative results were in patient satisfaction. Modifying the model of care is an iterative process requiring continued evaluation and changes to improve outcomes. Results of this project supported the further evaluation of staffing and expansion of the number of master’s prepared nurses on medical surgical units.