Publications by authors named "Brett Morgan"

29 Publications

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Faculty development workshop on gender-associated incivility in nursing education.

Nurs Forum 2021 May 30. Epub 2021 May 30.

Department of Education and Practice, American Association of Nurse Anesthetists, Park Ridge, Illinois, USA.

Background: Men comprise the minority of entry-level baccalaureate nursing students and are at increased risk of experiencing gender-associated incivility.

Problem: Uncivil peer-to-peer behavior can negatively affect students' mental and physical well-being, and learning experience. Nursing faculty must be able to identify and address gender-associated incivility among students.

Aim: The purpose of this quality improvement program was to train nursing faculty to prevent, identify, and manage gender-associated incivility in the educational environment.

Methods: A day-long interactive workshop utilizing trigger films, small group discussions, and interactive theater was developed to train nursing faculty to implement proactive and reactive techniques to address uncivil behavior which will enhance the learning environment for all students. Utilizing Kirkpatrick's Model of Evaluation, participants were surveyed at the conclusion of the workshop and four months postworkshop to evaluate their learning and its implementation.

Results: Participants gained greater understanding of the impact of gender-associated incivility and felt both empowered and better prepared to manage gender-associated conflict.

Conclusion: Similar approaches may be useful for schools of nursing that wish to empower their nursing faculty to support an equitable nursing education environment free of gender-associated incivility.
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http://dx.doi.org/10.1111/nuf.12615DOI Listing
May 2021

Evolution of adult male horn developmental phenotypes and character displacement in beetles (Scarabaeidae).

Ecol Evol 2021 May 25;11(10):5503-5510. Epub 2021 Mar 25.

Biodiversity Research Center Academia Sinica Taipei Taiwan.

Character displacement that leads to divergent phenotypes between sympatric species has been hypothesized to facilitate coexistence and promote the accumulation of biodiversity. However, there are alternative evolutionary mechanisms that may also lead to the evolution of phenotypic divergence between sympatric species; one of the mechanisms is evolutionary contingency. We studied the evolution of the presence and absence of a major male horn phenotype, which may have ecological implications for promoting coexistence between sympatric beetles, across geographic populations from different beetles. By using a previously published phylogeny with 80 taxa, we estimated the transition rates between the two phenotypic states (i.e., presence vs. absence of a major male phenotype). Based on the estimated transition rates, we then simulated possible phenotypic outcomes between sympatric species. We found that sympatric species were equally likely to evolve the same versus distinct phenotypic states based on the estimated transition rates given the phylogeny. The empirically observed number of sympatric species showing different phenotypic states can be explained by evolutionary contingency alone. We discussed the importance of applying phylogenetic comparative methods when studying phenotypic evolution and more generally to investigate the effect of stochastic processes before making deterministic inferences.
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http://dx.doi.org/10.1002/ece3.7448DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8131760PMC
May 2021

Improving Emergency Cricothyroidotomies: Simulation-Based Training for Critical Care Providers.

Crit Care Nurs Q 2021 Apr-Jun 01;44(2):203-213

Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, North Carolina (Drs Clark, Morgan, and Goode); Department of Evolutionary Anthropology, Duke University, Durham, North Carolina (Dr Schmitt); Department of Anesthesiology, Duke University Hospital, Durham, North Carolina (Dr Harman); and Johns Hopkins University School of Nursing, Baltimore, Maryland (Dr Goode).

This article discusses skill proficiency of providers related to emergency cricothyroidotomies. Various techniques to improve procedural skills were studied. Accurate identification of the cricothyroid membrane via palpation remained consistently inadequate. High-fidelity simulation including the use of human cadavers may be the preferred method of skill training for crisis management. The authors emphasize that additional research is needed regarding a method for rapid cricothyroid membrane identification as well as needle cricothyroidotomy versus surgical airway on cadavers. More consistent training will enable emergency care providers to perform this rare but lifesaving skill.
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http://dx.doi.org/10.1097/CNQ.0000000000000354DOI Listing
February 2021

Using a Retrospective Secondary Data Analysis to Identify Risk Factors for Pulmonary Complications in Trauma Patients in Pietermaritzburg, South Africa.

J Surg Res 2021 Jun 3;262:47-56. Epub 2021 Feb 3.

Department of Surgery, Pietermaritzburg Metropolitan Trauma Service, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

Background: The trauma burden in South Africa is significant. The objective of this project was to investigate the incidence of posttrauma pulmonary complications (PPCs) and to identify patient, health risks, and hospital factors, which predispose trauma patients to develop PPCs hospital in Pietermaritzburg, South Africa.

Methods: The design was a retrospective secondary data analysis of patients who presented as a trauma admission via the health systems' Hybrid Electronic Medical Registry. The final data set included 6382 trauma admissions.

Results: The PPC rate was 9.4% for patients with a surgical intervention versus 1.9% for those without a surgical intervention. Of the total 289 PPCs reported, the most common included pneumonia or atelectasis (46.4%) and prolonged ventilation (36.0%). The risk of developing a PPC was statistically significantly (P < 0.0001) associated with surgical intervention and the number of surgeries.

Conclusions: The trauma burden in South Africa requires complex medical and surgical interventions. The incidence of PPCs is significantly associated with surgical intervention. With the increasing demand to harness data and improve patient care, the Hybrid Electronic Medical Registry proves to be a driver for quality improvement.
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http://dx.doi.org/10.1016/j.jss.2020.12.034DOI Listing
June 2021

Point-of-Care Ultrasound in Anesthesia Care: New AANA Practice Document Adopted by AANA Board of Directors.

AANA J 2021 Feb;89(1):9-11

is the senior director of education and practice for the American Association of Nurse Anesthetists.

The American Association of Nurse Anesthetists recently released a practice considerations document titled, "Point-of-Care Ultrasound in Anesthesia Care," that clinicians, administrators, and other stakeholders are encouraged to download and read in their entirety, available at aana.com/PracticeManual.
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February 2021

Increasing Medication Access by Promoting Appropriate Use of Multi-dose Vials.

Plast Surg Nurs 2020 Oct/Dec;40(4):177-182

William Beauregard Rowe, BSN, RN, is a nursing anesthesia student at Duke University School of Nursing, Durham, NC.

Medication shortage is a problem that affects patients, providers, and institutions of all sizes and scope across the United States. The objective of this quality improvement project was to promote the appropriate use of multi-dose vials (MDVs) by anesthesia providers at an independent plastic surgery office. Multi-dose vials can be used to decrease waste and potentially cost, thus increasing access to necessary medications for the patients at this practice. A focus group was used to obtain an understanding of barriers to the use of MDVs at this practice. A focused E-learning module on safe use based on established guidelines was then created, and a simplified flow sheet was implemented and placed in medication preparation areas as a cognitive aid. The education and flow sheet focused on identification and preparation of the medication area, proper identification of MDVs versus single-use vials, hand hygiene, proper beyond-use labeling, septum cleaning, use of a new sterile syringe and needle, and administration time frames. Provider feedback included high levels of satisfaction with the E-learning module. Our comparison of the use of ketamine from MDVs during the pre- and postimplementation phases showed a 14% increase in the number of doses used per vial. This finding suggests that were similar practices implemented at a larger site with MDVs of medications other than ketamine, resources could be impacted to manage shortages and increase access to medications.
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http://dx.doi.org/10.1097/PSN.0000000000000323DOI Listing
July 2021

Maximizing Use of Social Media to Improve Member Engagement in a Professional Organization.

AANA J 2020 Dec;88(6):473-478

is an assistant clinical professor with the DNP nurse anesthesia program at Duke University.

The North Carolina Association of Nurse Anesthetists recognized concerns surrounding decreased member engagement and communication. Member engagement and communication is the lifeblood of an organization and is directly related to the success of an organization's outcomes and goals. Revamping of social media is a cost-effective method to help increase membership engagement and communication. The purpose of this project was to identify Certified Registered Nurse Anesthestist membership preferences for social media-based communication and engagement through the measurement of activity levels based on Facebook posting content, feature, and time. Therefore, a literature review and retrospective analysis was conducted. Results revealed that posting content of public relations/advocacy, the feature of tagging, and the time of week was influential on audience engagement on the association's Facebook account. The aims of the project were met. Social media allows organizations to employ various features and techniques to increase member engagement and communication. To successfully use social media to engage and communicate with members, organizations will need to continuously analyze and adjust their social media posts.
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December 2020

Considerations for an aging nurse anesthetists workforce.

Geriatr Nurs 2020 Nov - Dec;41(6):1017-1019. Epub 2020 Nov 4.

State Management Affairs, American Association of Nurse Anesthetists, 222 South Prospect Avenue, Park Ridge, IL 60068, United States.

The Certified Registered Nurse Anesthetists (CRNA) workforce is aging. It is estimated that nearly half (49.7%) of the CRNA workforce is age 50 or greater, with those practicing in management positions and as educators having the oldest mean ages. Older CRNAs face workplace challenges that can lead to decreased productivity and overall job satisfaction. Common injuries to older practitioners result from repetitive motion, slips and falls, needle sticks, fatigue, and emotional or mental health related illness. Because of the high acuity environment in which CRNAs practice they are at an elevated risk for these injuries. Creating a healthy and supportive work environment has been shown to improve the retention of aging healthcare workers, and succession planning is essential in preparing for their retirement.
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http://dx.doi.org/10.1016/j.gerinurse.2020.10.010DOI Listing
November 2020

A historical look at men's involvement in nursing and leadership in GAPNA.

Geriatr Nurs 2020 Jan - Feb;41(1):52-53. Epub 2020 Feb 7.

Duke University Medical Center, 40 Duke Medicine Circle, Durham, NC 27710, United States.

The role of men in nursing is not always evident. Men have been care takers in early societies, military health care, and the religious sector. The perception of men in nursing, however, took a shift from one of honor to one of deviance and failure from medical school. As the contributions of historical men in nursing, such as Walt Whitman, are brought to light, so are the contributions of select men within the Gerontological Advanced Practice Nurses Association (GAPNA). Dr. George Peraza-Smith provides an exclusive interview, shares his dedication and contributions to the care of the aging adult, and provides words of wisdom to those wanting to impact the care of geriatric nursing.
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http://dx.doi.org/10.1016/j.gerinurse.2020.01.003DOI Listing
November 2020

Use of Near-Infrared Spectroscopy to Measure Tissue Oxygen Saturation During Total Knee Arthroplasty With Use of a Tourniquet.

AANA J 2019 Jun;87(3):192-198

Duke University School of Nursing, Nurse Anesthesia Program.

The primary purpose of this proof-of-concept quality improvement effort was to evaluate the practicality of using near-infrared spectroscopy (NIRS) to measure tissue oxygen saturation (Sto) during total knee arthroplasty (TKA) with use of a tourniquet. NIRS sensors were applied to the biceps femoris (BF) and gastrocnemius (GS) muscles of both lower extremities of patients undergoing TKA procedures. For a convenience sample of 15 patients, measurement of Sto was attempted at baseline, following subarachnoid block administration, and after tourniquet inflation and deflation. Mean baseline Sto (SD) was 71% (6%) in the BF muscle and 66% (7%) in the GS muscle. Significant changes in Sto values were observed following subarachnoid block, tourniquet inflation, and tourniquet deflation. The Sto returned to or above baseline in the BF muscle but did not return to baseline in the GS muscle following tourniquet deflation. Changes in tissue oxygen saturation resulting from use of a tourniquet can be continuously monitored with the use of an NIRS device. Further evaluation of the use of NIRS should be undertaken to determine if it could be used to guide safe duration and pressure limits for tourniquet inflation.
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June 2019

The importance of the STOP- BANG questionnaire as a preoperative assessment tool for the elderly population.

Geriatr Nurs 2019 Sep - Oct;40(5):536-539. Epub 2019 Aug 31.

Duke University School of Nursing, Nurse Anesthesia Program 307 Trent Dr, Durham, NC 27710. Electronic address:

Undiagnosed obstructive sleep apnea (OSA) may adversely impact surgical patients and can lead to increased morbidity and mortality during the perioperative period, especially among the geriatric patient population (Chung et al. 2008, 2012, 2014; McDonald et al., 2018; Zietlow et al., 2018; Singh et al., 2012). The setting of this quality improvement project was a preoperative anesthesia and geriatric evaluation clinic housed within a 957-bed tertiary academic affiliated hospital. The sample included 45 patients who met the criteria established for surgery and OSA screening preoperatively. Nine patients (20.0%) were assessed as low risk (Stop-bang [SB] score /= 3 indicative of high-risk for OSA. The retrospective utilization of a modified SB screening on charts that did not receive a clinical OSA evaluation (n = 52) detected 23 (44.2%) patients who were considered high-risk for OSA but were not identified prior to surgery. The SB questionnaire is underutilized, and patients' OSA is often unidentified prior to surgery.
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http://dx.doi.org/10.1016/j.gerinurse.2019.08.010DOI Listing
April 2020

Relationship of Patient Self-Administered COPD Assessment Test to Physician Standard Assessment of Chronic Obstructive Pulmonary Disease in a Family Medicine Residency Training Program.

J Patient Cent Res Rev 2019 29;6(3):210-215. Epub 2019 Jul 29.

Department of Family Medicine, Quillen College of Medicine, East Tennessee State University, Johnson City, TN.

Assessing the global impact of chronic obstructive pulmonary disease (COPD) on a patient's life can be difficult to perform in the clinical setting due to time constraints and workflow challenges. The primary objective of this study was to compare disease impact ratings between patient self-administered COPD Assessment Test (CAT) and physician standard office assessment. This prospective study was conducted at a family medicine residency clinic in northeast Tennessee. The study included two study groups: 1) adult patients seen at the clinic during the 3-month study period with an active diagnosis of COPD, and 2) their physicians. Physicians' assessment of the impact of COPD on their patients' daily lives was compared to patients' self-administered CAT assessments. Physician assessment of COPD impact and patient assessment of CAT categories significantly differed (χ=11.0, P=0.012). There was very poor agreement between patient and physician ratings (κ=0.003), with 42.9% of physician ratings underestimating the impact, 28.6% overestimating the impact, and 28.6% correctly estimating the impact COPD had on their patients' lives. These findings support the use of validated assessment tools to help providers understand the symptom burden for patients with COPD.
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http://dx.doi.org/10.17294/2330-0698.1699DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6675137PMC
July 2019

Improving Emergency Airway Knowledge and Self-Efficacy Levels of Outpatient Gastroenterology Staff via Implementation of Online Education and In Situ Simulation.

Gastroenterol Nurs 2019 May/Jun;42(3):242-250

Cameron C. Covington, DNP, CRNA, is Nurse Anesthesia Doctorate of Nursing Practice Graduate, Duke University, Durham, North Carolina. Virginia C. Muckler, DNP, CRNA, CHSE, is Nurse Anesthesia Assistant Program Director, Duke University, Durham, North Carolina. Linda Sheldon, MSN, CRNA, is Nurse Anesthetist, Raleigh, North Carolina. Regina Alexander, RN, is Director of Endoscopy, Wake/Clayton Endoscopy Centers, Raleigh, North Carolina. Brett Morgan, DNP, CRNA, is Nurse Anesthesia Program Director, Duke University, Durham, North Carolina.

Twenty percent of all ambulatory surgery cases utilizing monitored anesthesia care and sedation report at least one perioperative respiratory complication such as bronchospasm, hypoxia, laryngospasm, or aspiration (). However, the national Standards of Practice for both surgical technicians and ambulatory care nurses do not mandate emergency airway education beyond cardiopulmonary resuscitation and Basic Life Support training. A local outpatient gastroenterology clinic noticed the gap in education, and the anesthesia team decided to implement an evidence-based dual-factorial quality improvement project utilizing online education and in situ simulation. First, registered nurses and procedural technologists completed a test to assess their baseline knowledge and airway emergency performance self-efficacy levels. Then an online module was distributed that included information on the 3 most common anesthesia airway emergencies in the outpatient setting: laryngospasm, aspiration, and obstruction with resultant hypoxemia. Next, participants completed an in situ simulation of the 3 airway emergencies using low-fidelity mannequins. A post-education assessment was distributed after completion of the simulation training and again at 6 weeks and 3 months post-implementation. The data collected showed a statistically significant increase in both knowledge scores and levels of self-efficacy at 6 weeks and 3 months posteducation (p < .001).
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http://dx.doi.org/10.1097/SGA.0000000000000437DOI Listing
December 2019

A Quality Improvement Project to Increase Adherence to a Pain, Agitation, and Delirium Protocol in the Intensive Care Unit.

Dimens Crit Care Nurs 2019 May/Jun;38(3):174-181

Wendy Yan, DNP, CRNA, is a Nurse Anesthetist at Duke Regional Hospital. Brett T. Morgan, DNP, CRNA, is Director of the Nurse Anesthesia Program and an assistant professor at Duke University School of Nursing. Peter Berry, MSN, RN, CNL, CCRN, is nurse manager at the intensive care unit of Duke Raleigh Hospital. Mary K. Matthys, BSN, RN, CCRN, is clinical lead at the intensive care unit of Duke Raleigh Hospital. Julie A. Thompson, PhD, is a research associate and a statistical consultant at Duke University School of Nursing. Benjamin A. Smallheer, PhD, RN, ACNP-BC, FNP-BC, CCRN, CNE, is lead faculty of the Adult-Gerontology Acute Care Nurse Practitioner Program at Duke University School of Nursing. He actively practices within the Critical Care Setting at Duke Raleigh Hospital and has expertise in Pulmonary Critical Care. His current areas of research interest are the care of the aging critical care population, the implementation of innovative educational strategies to prepare Nurse Practitioner students for entry to practice, and gender-associated incivility experienced by male nursing students in the academic environment.

Background: In recent years, the incidence of delirium has grown to epidemic proportions in the intensive care setting with up to 80% of mechanically ventilated patients being affected. This can lead to adverse patient outcomes such as increased lengths of hospital stay, increased mortality rates, and increased long-term cognitive impairment.

Objectives: The objective of this project is to determine whether a quality improvement project can increase adherence to an existing pain, agitation, and delirium (PAD) protocol for enhanced patient outcomes.

Methods: Chart audits were conducted to determine baseline compliance, use of the PAD protocol was measured, and the type of medications administered to each mechanically ventilated patient was assessed. Using the Knowledge-to-Action framework, a multidisciplinary, multidimensional educational module was then developed and implemented that included an online tutorial, point-of-care reminders, written materials, and verbal coaching. A 3-month postimplementation chart audit was conducted to determine whether increased protocol competence was achieved.

Results: Protocol use unexpectedly decreased from 74% to 41% (P < .01);however, compliance with medication recommendations did increase despite the decrease in use. Intravenous opioid use increased from 12% to 40% (P ≤ .001), whereas sedative propofol infusions decreased from 82% to 35% (P ≤ .001).

Conclusions: The implementation of a multidimensional, multidisciplinary project was successful in increasing compliance to the clinical practice guidelines for the management of PAD in adult intensive care unit patients, despite a decrease in protocol use. This unanticipated decrease in protocol use indicates the need for additional research in this area. Future recommendations also include a review of the existing PAD protocol to determine whether revisions could be made to better suit the needs of the staff while also improving patient outcomes in the arena of delirium experienced during critical care stays.
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http://dx.doi.org/10.1097/DCC.0000000000000353DOI Listing
December 2019

Multimodal Pain Management for Major Joint Replacement Surgery.

Orthop Nurs 2019 Mar/Apr;38(2):150-156

Victoria M. Goode, PhD, CRNA, Duke University School of Nursing, Durham, NC. Brett Morgan, DNP, CRNA, Duke University School of Nursing, Durham, NC. Virginia C. Muckler, DNP, CRNA, CHSE, Duke University School of Nursing, Durham, NC. Michael P. Cary, Jr., PhD, RN, Duke University School of Nursing, Durham, NC. Christine E. Zdeb, BSN, RN, ONC, Duke University School of Nursing, Durham, NC. Michael Zychowicz, DNP, ANP, ONP, FAAN, FAANP, Duke University School of Nursing, Durham, NC.

Effective pain management for orthopaedic major joint replacement is key to achieving earlier recovery, better functioning, and high rates of patient satisfaction. In an effort to decrease opioid dependency, practitioners are turning to multimodal pain management, which involves the use of multiple analgesic agents and techniques. To utilize this technique, a patient's history of and preoperative consumption of medications to treat pain impacts the success of this regimen. Multimodal pain management involves the use of nonsteroidal anti-inflammatory drugs, acetaminophen, N-methyl-D-aspartate antagonists, gabapentin, serotonin inhibitors, regional techniques, and opioids as needed. It is necessary for the nurse to understand the mechanism of pain and how the multimodal adjuncts target the pain response to benefit the patient's perioperative course as well as his or her postoperative and discharge management.
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http://dx.doi.org/10.1097/NOR.0000000000000525DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6727971PMC
April 2019

Virtual Orientation of Volunteer Short-Term International Health Teams to Increase Self-Confidence and Cultural and Global Health Competence.

J Contin Educ Nurs 2019 Jan;50(1):35-40

International health team volunteers frequently arrive at service sites with considerable lack of confidence and knowledge gaps because of poor preparation. Preservice orientation has been shown to improve knowledge, confidence, and competence, but current practices fall short of meeting most needs. This health care improvement project was aimed to improve self-confidence and cultural and global health competence using a virtual preservice orientation format. The virtual innovation significantly narrowed the difference in confidence between new and experienced team members. Significant increases were observed in knowledge of global health and health equities for new and experienced team members. Following the orientation, a significant difference in global health skills for the entire team also was observed. Many Americans leave the United States annually attempting to help those in need. This effort is hindered by poor preparation and unreal expectations. Improving health team member confidence and competence is one way to address this concern. [J Contin Educ Nurs. 2019;50(1):35-40.].
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http://dx.doi.org/10.3928/00220124-20190102-08DOI Listing
January 2019

Sleep safe in clean hands: Improving hand hygiene compliance in the operating room through education and increased access to hand hygiene products.

Am J Infect Control 2019 05 12;47(5):504-508. Epub 2018 Dec 12.

Duke University School of Nursing, Durham, NC.

Background: Hand hygiene compliance is low among anesthesia providers in the operating room, which places patients at risk of preventable infections. The goal of this project was to improve hand hygiene compliance by educating anesthesia providers on the World Health Organization's 5 indications for hand hygiene, and increasing access to hand hygiene products in the operating room.

Methods: Observations of hand hygiene in the operating room took place in 3 phases: preimplementation, postimplementation, and 60 days postimplementation.

Results: The results showed significant improvements in compliance for each of the 5 indications for hand hygiene as well as overall compliance. Each of the 3 phases of anesthesia demonstrated significant improvement as well. The results also showed a significant decrease in both glove use and use of the portable hand sanitizer device.

Discussion: Education and monitoring of hand hygiene among anesthesia providers in the operating room can improve hand hygiene compliance.

Conclusions: Although the use of the portable device declined, further studies could focus on observing single anesthesia providers instead of a preceptor/student combination, and also examine proximity to hand hygiene products in relation to compliance.
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http://dx.doi.org/10.1016/j.ajic.2018.10.021DOI Listing
May 2019

Treating Chronic Nonmalignant Pain: Evidence and Faith-Based Approaches.

J Christ Nurs 2019 Jan/Mar;36(1):22-30

Sarah Snell, DNP, CRNA, teaches in the Department of Nurse Anesthesia, Adventist University of Health Sciences, Orlando, Florida. Tia Hughes, DrOT, is the program director for the occupational therapy program at Adventist University of Health Sciences. Carolyn Fore, PhD, RN, is a professor in the Department of Nursing at Adventist University of Health Sciences. Roy Lukman, PhD, is the director, Department of Institutional Research at Adventist University of Health Sciences. Brett Morgan, DNP, CRNA, is director of the Nurse Anesthesia Doctor of Nursing Practice Program, Duke University School of Nursing, Durham, North Carolina.

A significant portion of the world's population is impacted by chronic pain; in the United States, chronic pain costs billions annually in treatment and lost productivity. A needs assessment was conducted to evaluate the prevalence of chronic nonmalignant pain (CNMP) at a university occupational therapy clinic over a 3-month period; recommendations were made to improve pain management at the clinic and referring hospital system. Graded Chronic Pain Scale 2.0 results indicated the prevalence of CNMP was a significant problem. Three evidence-based interventions based on the biblically based CREATION Health Model were developed.
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http://dx.doi.org/10.1097/CNJ.0000000000000569DOI Listing
December 2019

Diagnosis and Treatment of Common Pain Syndromes and Disorders.

Nurs Clin North Am 2018 09;53(3):349-360

Department of Anesthesia, Wooden Anesthesia PC, Boone County Medical Center, 406 S 8th Street, Albion, NE 68620, USA.

Management of chronic pain has become a significant challenge for primary care providers, and the population of patients with chronic pain is expected to increase. Common syndromes seen in the primary care setting include myofascial pain syndrome, fibromyalgia, chronic postsurgical pain, complex regional pain syndrome, and painful diabetic neuropathy. This article describes these syndromes and presents current treatment options.
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http://dx.doi.org/10.1016/j.cnur.2018.04.004DOI Listing
September 2018

Using the Electronic Medical Record to Improve Preoperative Identification of Patients at Risk for Obstructive Sleep Apnea.

J Perianesth Nurs 2019 Feb 17;34(1):51-59. Epub 2018 Jul 17.

Purpose: Obstructive sleep apnea (OSA) is a breathing disorder found in surgical patients and associated with complications in the postoperative period. The implementation of a preoperative universal screening process using the STOP-BANG questionnaire to identify patients at high risk for OSA provides opportunities for improved management.

Design: A pre-post design was used to evaluate screening compliance rates.

Methods: This initiative included staff education, which included the process for evaluating and documenting STOP-BANG scores. The data were collected via a chart review of the electronic medical record (EMR).

Findings: The rate of screening for OSA doubled after implementation of this initiative, and compliance with STOP-BANG questionnaire screening was 66.1%. High-risk designation in the EMR was 73.0%. Nearly half of the patients screened were found to be at high risk for OSA.

Conclusions: Implementation of a universal screening initiative for patients and design for the EMR improves compliance with screening and identification of patients at high risk for OSA.
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http://dx.doi.org/10.1016/j.jopan.2018.04.002DOI Listing
February 2019

Administration of Oral Acetaminophen to Reduce Costs for the Hysterectomy Patient at a Community Hospital.

J Perianesth Nurs 2019 Feb 20;34(1):143-150. Epub 2018 Jun 20.

Purpose: This quality improvement project aimed to change the practice of administration route of acetaminophen from intravenous (IV) to oral to patients having a hysterectomy at a community hospital, reduce costs, and maintain postanesthesia care unit pain scores for patients who receive oral acetaminophen comparable to those who receive IV acetaminophen.

Design: There were 46 participants: 23 in the preintervention group and 23 in the postintervention group.

Methods: Data retrieved from the electronic medical record included the route of acetaminophen administered, cost, and pain scores.

Findings: Implementation of this quality improvement project resulted in no difference in the pain scores between the preintervention and postintervention groups (P = .637). In addition, the hospital cost for acetaminophen decreased 95.25% and patients saved $6,683 during the 3-month implementation period.

Conclusions: The administration of oral acetaminophen provided equivalent postoperative analgesia compared with IV acetaminophen and reduced costs for both the hospital and patients.
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http://dx.doi.org/10.1016/j.jopan.2018.03.007DOI Listing
February 2019

Utilization of the STOP-Bang Questionnaire as a Standardized Screening Tool for Obstructive Sleep Apnea in Veteran Administration Surgical Patients.

J Perianesth Nurs 2019 Feb 22;34(1):60-65. Epub 2018 Apr 22.

Purpose: Obstructive sleep apnea (OSA) affects an estimated 20% of the adult surgical population. Veteran patients have many characteristics consistent with OSA, but lack of standardized screening results in decreased detection of patients at risk for OSA.

Design: Pre-post implementation design.

Methods: Preanesthesia clinic providers were educated about OSA and the STOP-Bang questionnaire. Chart reviews evaluating screening and patient demographics were conducted before and after intervention.

Findings: Thirty-one percent of patients had an established diagnosis of OSA. Compliance rates with preoperative STOP-Bang screening were 91.3%. Of patients screened preoperatively, 44% were at risk for OSA with a STOP-Bang score of 4 or greater.

Conclusions: The prevalence of patients among the Veteran population with and at risk for OSA is higher than the general population. Utilization of the STOP-Bang questionnaire as a standardized preoperative screening tool in preanesthesia clinics can increase the identification of patients at risk for OSA.
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http://dx.doi.org/10.1016/j.jopan.2017.11.006DOI Listing
February 2019

Evaluating the Implementation of a Preemptive, Multimodal Analgesia Protocol in a Plastic Surgery Office.

Plast Surg Nurs 2017 Oct/Dec;37(4):137-143

Brandi Tinsbloom, DNP, CRNA, is a graduate of the Duke University Nurse Anesthesia Program. She is a practicing CRNA at a regional medical center in Pinehurst, NC. She has interests in community hospitals and outpatient and office-based practices. Virginia C. Muckler, DNP, CRNA, CHSE, is Assistant Professor in the Duke University Nurse Anesthesia Program in Durham, NC. She serves as a reviewer for multiple journals, is a National League for Nursing Simulation Leader, has served as a simulation consultant nationally and internationally, and serves on national and state associations. William T. Stoeckel, MD, is the owner of Wake Plastic Surgery in Cary, NC. He completed his plastic surgery training at Wake Forest University in 2002 and has been in his solo private practice since. He specializes in body and breast outpatient plastic surgery procedures using MAC anesthesia. Robert L. Whitehurst, MSN, CRNA, is founder and President of Advanced Anesthesia Solutions. He received his BSN from East Carolina University and his MSN (Anesthesia) from Duke University. Robert has practiced as a CRNA in academic institutions, community hospitals, and outpatient and office-based practices since 2004. Robert is an advocate for patients and CRNA practice as Chair of NCANA PAC and his work to expand the availability of anesthesia services to underserved settings. Brett Morgan, DNP, CRNA, is Assistant Professor at the Duke University School of Nursing and the Director of the Nurse Anesthesia Specialty Program. In addition to his faculty role, Dr. Morgan practices clinical anesthesia in office-based settings throughout the research triangle.

Many patients undergoing plastic surgery experience significant pain postoperatively. The use of preemptive, multimodal analgesia techniques to reduce postoperative pain has been widely described in the literature. This quality improvement project evaluated the implementation of a preemptive, multimodal analgesia protocol in an office-based plastic surgery facility to decrease postoperative pain, decrease postoperative opioid consumption, decrease postanesthesia care time, and increase patient satisfaction. The project included adult patients undergoing surgical procedures at an outpatient plastic and cosmetic surgery office, and the protocol consisted of oral acetaminophen 1,000 mg and gabapentin 1,200 mg. Using a pre-/postintervention design, data were collected from patient medical records and telephone interviews of patients receiving the standard preoperative analgesia regimen (preintervention group: n = 24) and the evidence-based preemptive, multimodal analgesia protocol (postintervention group: n = 23). Results indicated no significant differences between the pre- and postintervention groups for any of the outcomes measured. However, results showed that patients in both groups experienced moderate to severe pain postoperatively. In addition, adverse side effects such as dizziness and drowsiness were higher in the postintervention group than in the preintervention group. Although this quality improvement project did not meet the goals it set out to achieve for patients undergoing plastic surgery, it did illustrate the substantial presence of pain after surgical procedures. Thus, clinicians need to continue to focus on identifying targeted treatment plans that use multimodal, non-opioid-based strategies to manage and prevent postoperative pain.
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http://dx.doi.org/10.1097/PSN.0000000000000201DOI Listing
December 2017

Creation of a Low-Cost Simulated Trachea for Deliberate Practice of Cricothyrotomy and Retrograde Wire Use.

AANA J 2017 Aug;85(4):271-275

joined the Duke University School of Nursing faculty in July 2012 as assistant director of the Nurse Anesthesia Program and assistant professor. He is the immediate past president of the North Carolina Association of Nurse Anesthetists.

Simulation is an accepted teaching tool that focuses on active learning and is used to solidify cognitive, motor, critical thinking, and communication skills. This method of experiential learning was introduced and integrated into the distance-based degree completion program for practicing anesthetists at the University for Development Studies (UDS), Tamale, Ghana. Because of scarce resources, a simulated trachea was created for teaching students how to perform a needle cricothyrotomy and use a retrograde wire to secure an airway. Students were oriented to the materials, taught to construct the simulated trachea, and encouraged to consider local, inexpensive resources for equipment substitutions as necessary. Students were guided through the steps of performing a needle cricothyrotomy and retrograde wire intubation using the simulated trachea. Following deliberate practice, the practicing anesthetists were encouraged to instruct fellow anesthesia colleagues on the use of these techniques and create additional simulation equipment that would aid in teaching or refining various skills of Ghanaian anesthetists and training future anesthetists. Appropriate for their initial simulation-based learning, the low-fidelity simulated trachea was a reasonable, low-cost approach that aligned with the established learning objectives. All participants reported satisfaction with and increased confidence levels following the simulation-based learning experience.
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August 2017

The Role of Pharmacogenomics in Anesthesia Pharmacology.

Annu Rev Nurs Res 2017 01;35(1):241-256

The field of pharmacogenomics seeks to identify the impact of genetic variants on drug dosing, response, metabolism, and safety outcomes. The narrow therapeutic indices for anesthesia drugs, variability of patient responses to anesthesia, and the risks associated with surgery make anesthetics and the perioperative period prime targets for pharmacogenetic research. Anesthesia providers strive to optimize anesthesia delivery and patient outcomes and to specifically reduce anesthesia-related risks and negative outcomes. Despite pharmacogenomics emerging from the field of anesthesia, the most significant advances to date in the understanding and application of genetics to pharmacology have occurred outside of anesthesiology. This chapter provides an overview of genetic concepts fundamental to understanding the pharmacogenetics of anesthesia practice and presents the current state of the science with respect to the genetic influence on the response to volatile and intravenous anesthetic agents and opioid receptor agonists commonly used in anesthesia practice. In addition, the chapter delineates U.S. Food and Drug Administration labeling tenets for pharmacogenetics, discusses clinical implications of pharmacogenomics for family members, and highlights the potential for future paradigm shifts in pharmacogenomics of anesthesia practice.
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http://dx.doi.org/10.1891/0739-6686.35.241DOI Listing
January 2017

Framework for Teaching Psychomotor and Procedural Skills in Nursing.

J Contin Educ Nurs 2016 Jun;47(6):278-82

The development of psychomotor and procedural skills requires opportunities for repetitive practice combined with specific, informational feedback from the teacher, another expert, or simulator to correct performance errors. Practice enables learners to refine skills and progress through the phases of motor learning: cognitive, associative, and autonomous. Practice should be spaced over time, can occur in dyads, and can rapidly cycle between practicing and receiving feedback and coaching until skills are mastered. The purpose of this article is to examine psychomotor skill learning in nursing and to suggest strategies for nurse educators in teaching motor and procedural skills in nursing programs, as well as in clinical settings. J Contin Educ Nurs. 2016;47(6):278-282.
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http://dx.doi.org/10.3928/00220124-20160518-10DOI Listing
June 2016

Structured Handover in the Pediatric Postanesthesia Care Unit.

J Perianesth Nurs 2016 Feb 8;31(1):63-72. Epub 2015 Aug 8.

Purpose: To establish a structured handover in the pediatric postanesthesia care unit.

Design: An observational prequality and postquality improvement design was used.

Methods: Convenience samples of 52 preimplementation and 51 postimplementation handover interactions (N = 103) were observed and compared to a 42-item Introductions, Situation, Background, Assessment, Recommendations, & Questions checklist. Patient care team members' satisfaction was assessed using voluntary electronic surveys. Data were analyzed for descriptive measures and differences in the pre- and postchecklist, and satisfaction total scores were compared using a two-sample t test.

Finding: The implementation of the handover checklist resulted in a statistically significant increase in the percentage of items discussed during five of six handover phases (P < .001). Overall, a significant increase in provider satisfaction was demonstrated from preimplementation to postimplementation (P < .01). The average duration of handover (in minutes) was not significantly different from pre (mean = 5.80 ± 3.80) to post (mean = 6.80 ± 2.30), P = .15.

Conclusions: A structured handover checklist is associated with increased communication of handover content information and improved provider satisfaction. No statistically significant effect on handover duration time was found.
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http://dx.doi.org/10.1016/j.jopan.2014.07.015DOI Listing
February 2016

Utilization of a Preemptive, Multimodal Analgesic Regimen in Adult Ambulatory Septoplasty Patients: A Quality Improvement Project.

ORL Head Neck Nurs 2015 ;33(4):6-13

This paper describes a quality improvement project designed to decrease postoperative pain, decrease post-operative nausea and vomiting (PONV), decrease time in the recovery room, and increase patient satisfaction in adult ambulatory septoplasty patients using a multimodal, preemptive analgesic regimen. The project was conducted in a community hospital setting with nine operating rooms, and a twenty one bed recovery room. Project participants included certified registered nurse anesthetists, anesthesiologists, operating room nurses, recovery room nurses, and otolaryngology surgeons. Following a period of departmental education, adult patients scheduled for outpatient septoplasty surgery received a preoperative regimen of medications that included gabapentin, celecoxib, and acetaminophen. Using a pre-post test design, (intervention group n = 17, non-intervention group n = 17) data was collected from patient and analyzed using SPSS version 18.0. The change in practice resulted in a significant decrease in pain scores in the recovery room and on discharge from the recovery room. In addition, patients who received the preemptive regimen also required significantly fewer opioid medications and were ready to be discharged from the recovery room in less time.
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March 2016

Survival outcomes following norwood procedure for hypoplastic left heart.

Pediatr Cardiol 2015 Jan 31;36(1):57-63. Epub 2014 Jul 31.

The Heart Institute, University of Cincinnati and Cincinnati Children Hospital, Cincinnati, OH, USA,

Prior studies evaluating the association of HLHS anatomic variants and mortality report conflicting results. Our objective was to determine if antegrade flow across the mitral within variants of HLHS with aortic atresia is associated with increased mortality compared to ventricular hypoplasia variants without antegrade mitral flow. All patients with HLHS born between 2002 and 2011 year who underwent stage I Norwood palliation with complete history and echocardiograms for patency of the mitral and aortic valves were studied. The cohort was divided into three groups: aortic atresia-mitral atresia (AA-MA), aortic stenosis-mitral stenosis (AS-MS), and aortic atresia-mitral stenosis (AA-MS). Demographic, comorbidities, and operative variables were analyzed. Analysis of variance techniques was applied for continuous variables and categorical variables. Survival analysis was performed using the Kaplan-Meier method with log-rank testing. A total of 70 consecutive patients who underwent Norwood Procedure were analyzed. There were no statistical differences in gender, birth weight, and age at time of Norwood procedure. Thirty patients had AA-MA variant, 23 had AA-MS, and 17 had AS-MS. Long-term Norwood survival was 60% for AA-MA, 65% for AS-MS, and 26% for AA-MS (p = 0.043). Use of extracorporeal membrane oxygenation as well as shunt revisions was more frequent for the AA-MS compared to other variants (p < 0.05). Patient weight at time of Norwood and length of regional perfusion were the highest predictors for hospital death following Norwood procedure. The Norwood procedure for mitral stenosis and aortic atresia is more often associated with use of extracorporeal membrane oxygenation and shunt revision compared to other variants. This HLHS variant has lowest long-term survival.
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http://dx.doi.org/10.1007/s00246-014-0964-9DOI Listing
January 2015
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