Approach to decreasing emergency department ambulance diversion hours

Analysis between two local Emergency Departments (EDs) suggested an oscillatory phenomenon for ambulance diversion: When one hospital went on diversion it led to a disproportionate flow of ambulance traffic to a neighboring facility that subsequently was forced to go on divert. We hypothesized if one hospital could avoid diversion status, the need for diversion could be averted in the neighboring facility. ED A secured additional resources and made a commitment to no diversion for 1 week. No changes in operations occurred in hospital B. We found no differences in ambulance runs or ED census at either facility comparing the week before, during, and after the trial. There was a dramatic decline in diversion hours from 19.7 to 1.4 and 27.7 to 0 at hospitals A and B, respectively, during the trial period (p < 0.05) compared to the weeks before and after. We conclude that reciprocating effects can be decreased with one institution's commitment to avoid diversion, thus decreasing the need for diversion at a neighboring facility.     

Evolving as nurse educators in problem-based learning through a community of faculty development.

Effective faculty development programs are of paramount importance in this era of profound change in nursing education driven by baccalaureate-degree entry to practice and the concurrent implementation of college/university collaborative partnerships in Ontario, Canada. The overall purpose of this study was to design, disseminate, and evaluate a faculty development program involving nursing faculty from the McMaster University, Mohawk College, and Conestoga College. In keeping with selected conceptual models and responses to a needs assessment, faculty participated in a collaborative faculty development program that included a planned workshop, a mentorship program, and regular faculty development activities. This article presents the qualitative program evaluation component that included focus group discussions and subsequent content analysis to gain an understanding of the experiences and meaning of the faculty who participated in the faculty development program. The overarching theme was that the faculty experienced a sense of evolving as nurse educators in problem-based learning (PBL) through a community of faculty development. The following themes emerged: becoming certain in the midst of uncertainty; developing collegial trust and community; embracing PBL; valuing faculty development; and evolving as a nurse educator in PBL through faculty development. The results attest to the benefits of a collaborative faculty development program, guide future faculty development, and promote mastery in PBL.     

Spiritual caring: end of life in a nursing home

The purpose of this qualitative study was to explore spiritual care for dying nursing home residents from the perspectives of registered nurses, practical nurses, certified nursing assistants, advanced practice nurses, and physicians. Five major themes emerged: honoring the person's dignity, intimate knowing in the nursing home environment, wishing we could do more, personal knowing of self as caregiver, and struggling with end-of-life treatment decisions. Spiritual caring was described within the context of deep personal relationships, holistic care, and support for residents. Spiritual care responses and similarities and differences in the experiences of participants are presented. Education and research about how to assist residents and families as they struggle with difficult end-of-life decisions, adequate time and staff to provide the kind of care they "wished they could," and development of models that honor the close connection and attachment of staff to residents could enhance end-of-life care in this setting.     

Antagonism by chloramphenicol of broad-spectrum beta-lactam antibiotics against Klebsiella pneumoniae.

Chloramphenicol combined with cefotaxime, moxalactam, cefoperazone, aztreonam, or imipenem was tested in vitro against clinical isolates of Klebsiella pneumoniae. By time-kill cultures (killing curves), chloramphenicol interfered with activity of all five beta-lactams. When chloramphenicol was added before the beta-lactams, the action of cefotaxime, moxalactam, or cefoperazone against all isolates was antagonized at all times tested. The action of aztreonam was antagonized against four of six isolates. With imipenem, antagonism occurred against half of the isolates at some time during 24 h when chloramphenicol was added simultaneously, provided that a sufficient inoculum of K. pneumoniae was employed. Generally, less antagonism resulted when chloramphenicol was added after the cephalosporins. Interference of bactericidal activity of three new cephalosporins by chloramphenicol has potential clinical relevance to the therapy of gram-negative bacillary meningitis. The lesser antagonism of aztreonam and imipenem by chloramphenicol is of uncertain clinical relevance but indicates that this in vitro phenomenon may apply to a wide range of beta-lactam antibiotics.     

Differential effects of 19-nor-1,25-dihydroxyvitamin D(2) and 1,25-dihydroxyvitamin D(3) on intestinal calcium and phosphate transport

19-Nor-1,25-dihydroxyvitamin D(2) (19-norD(2)) a less calcemic and phosphatemic analog of 1,25-dihydroxyvitamin D (1,25[OH](2)D(3)), is approved for the treatment of secondary hyperparathyroidism in patients with kidney failure. We have previously demonstrated that 19-norD(2) is less active than 1,25(OH)(2)D(3) in stimulating bone resorption. In this study, we compared the potencies of 19-norD(2) and 1,25(OH)(2)D(3) in stimulating net calcium and phosphate absorption in the intestine. Mineral balance was assessed in normal rats during the last 4 days of a 14-day treatment with various daily doses of 19-norD(2) or 1,25(OH)(2)D(3). Calcium absorption increased from 16.5% +/- 7.8% in vehicle-treated rats to 27.5% +/- 7.2% in rats given 10 ng/day 1,25(OH)(2)D(3) and to 21.6% +/- 3.9%, 26.2% +/- 5.5%, and 27.4% +/- 5.1% in rats treated with 10, 50, and 100 ng/day 19-norD(2), respectively. Thus comparable stimulation of calcium transport was attained with 10 ng 1,25(OH)(2)D(3) and 100 ng 19-norD(2). Similar results were obtained for phosphate absorption, with an increase from 28.2% +/- 5.5% in vehicle-treated rats to 40.2% +/- 4.7% in rats given 10 ng/day 1,25(OH)(2)D(3) and to 32.9% +/- 2.2%, 36.2% +/- 4.5%, and 36.8% +/- 3.8% in rats given 10, 50, and 100 ng/day 19-norD(2), respectively. Vitamin D compounds are believed to increase calcium absorption by inducing a calcium channel (epithelial calcium transporter or calcium transporter-1 [CaT1]) on the luminal membrane, a calcium-binding protein (Calbindin D9k) in the cytosol, and a calcium pump (plasma membrane calcium adenosine triphosphatase-1 [PMCA1]) on the basolateral membrane. Northern-blot analysis of intestinal ribonucleic acid of vitamin D-deficient rats given seven daily injections of vehicle or 100 ng 1,25(OH)(2)D(3) or 19-norD(2) revealed that 19-norD(2) was less potent than 1,25(OH)(2)D(3) in stimulating expression of CaT1, Calbindin D9k and PMCA1. In summary, the reduced calcemic and phosphatemic activities of 19-norD(2) can be attributed to lower potency in stimulating intestinal calcium and phosphate absorption.     

In vitro activity of gemifloxacin against contemporary clinical bacterial isolates from eleven North American medical centers, and assessment of disk diffusion test interpretive criteria

A total of 5499 contemporary clinical bacterial isolates were tested for susceptibility to gemifloxacin and four comparison agents by the broth microdilution method. Gemifloxacin activity against Enterobacteriaceae was generally comparable to that of ciprofloxacin and trovafloxacin, but because the gemifloxacin susceptible MIC breakpoint is lower, the percent susceptible to gemifloxacin was less than that to the other quinolones for some species. All agents were less active against Pseudomonas spp. Gemifloxacin was the most active agent tested against Gram-positive species, though Corynebacterium jeikeium and vancomycin-resistant enterococci were uniformly resistant to all agents tested. With staphylococci, a bimodal distribution of gemifloxacin MICs corresponded with susceptibility or resistance to ciprofloxacin. The significance of ciprofloxacin-resistant staphylococci that have susceptible gemifloxacin MICs is not known at this time. Disk diffusion tests were performed simultaneously with gemifloxacin and trovafloxacin as a control drug. Gemifloxacin MIC-zone diameter scattergrams indicated that interpretive discrepancy rates based on previously proposed criteria when using < or = 0.5 microg/ml as the susceptible MIC breakpoint was within acceptable limits. However, with the currently proposed MIC breakpoint of < or = 0.25 microg/ml, tentative zone diameter breakpoints of > or = 22 mm for susceptible, 19-21 mm for intermediate and < or = 18 mm for resistant are proposed.