Using Simulation to Improve Adherence to Get With the Guidelines Time to First Shock

Background Evidence demonstrates that shocking patients in ventricular fibrillation or pulseless ventricular tachycardia in 2 minutes or less leads to improved outcomes. At our facility in Orlando, Florida, 4 of 7 time to first shock fallouts occurred in the intensive care unit. No standardization for conducting code situations existed in the intensive care unit. Objective To develop nurse simulation education and training to standardize intensive care unit code processes and improve compliance with timely defibrillation. Methods The sample consisted of intensive care unit nurses. Interventions included online education, simulation, and a postintervention survey. Analysis was conducted using the Get With the Guidelines program as well as descriptive statistics. Interventions Online education assigned to all intensive care unit nurses included electrocardiogram recognition and code documentation. Nurses and physicians collaborated to develop a diagram to identify roles needed for successful conduct of a code situation. A code simulation video was created, reflecting these roles, and embedded in the online education. The education was graded and remediated one-on-one with nurses. Intensive care unit nurses completed structured code simulations, allowing them to practice serving as the leader. Three months after the intervention, a survey was distributed to nurses. Results The time to first shock fallouts in the intensive care unit decreased by 100%, and the facility’s fallouts decreased by 71%. The facility’s adherence to the time to first shock metric increased from 42% to 83%. In a postintervention survey, 89% of nurses reported perceived improvement in knowledge, team leadership and communication, and confidence associated with code events. Conclusions Online education and code simulation positively affected time to first shock in code situations and empowered nurses to confidently function in these situations.

Behavior study of EDEU optical code for FE-OCDMA system

The increase in the cardinality of the frequency encoding-optical code division multiple access (OCDMA) system directly affects the length of the optical code, which leads us to find a less expensive solution. In this work, I propose an improved version of the diagonal eigenvalue Unit code (DEU) called Enhanced diagonal eigenvalue Unit code (EDEU) that is much easier in terms of construction and short in code length compared to the DEU code. The results found showed that the performance of the EDEU code exceeds the DEU code in terms of bit error rate (BER), and allowed us to multiplex about 15 more users when using the EDEU code compared to the system using the DEU code. As a result, the EDEU code is very suitable for use in access and OCDMA systems and it can be seen as a strong competitor to existing codes.

Land Pricing Model: Price Re-evaluation Due to the Erosion and Climate Change Effects

The aim of this study is to derive and apply the hedonic approach for determining and updating official land prices with respect to e.g. the impact of climate change that has occurred in the conditions of the Czech Republic in recent years. Pricing using the hedonic method is based on capturing individual factors separately. The evaluated soil ecological unit code consists of a 5-digit numerical code, which expresses the affiliation to the climate region (0-9, see table 1), the main soil unit (0-78), the slope of the land and the orientation to the point of the compass (0-9) and also the depth of the soil profile and skeletality (0-9). The derived hedonic pricing model is estimated using heteroscedasticity corrected estimator. The fitted model shows considerably high explanatory power and together with high parameter significance for majority of dummy variables (soil characteristics) as well as with theoretical and logical consistency represent a tool for new official land price settings in the process of land reevaluation due to the erosion and climate change effects.

Abstract 385: Family Presence During Resuscitation: A Needs Assessment

Introduction: Evidence is mounting that appropriate family presence during resuscitation (FPDR) can be beneficial to patients and their families including lower rates of post-traumatic stress disorder after the event. Despite this, FPDR has not been widely adapted and continues to have legitimate barriers. Therefore, the focus of this quality improvement project was to conduct an organizational needs assessment at Duke University to create a systematic FPDR guideline that can be consistently implemented across the hospital. Methods: A 17-question survey tool was created using Ottowa Decision Making Framework and distributed to all members of a Cardiothoracic Intensive Care Unit code team including physicians, advanced practice providers, nurses, respiratory therapists, chaplains, perfusionists, pharmacists and social workers. The questions addressed FPDR experience, decision making influencers, situational comfort, and demographics. Results: There was a total of 200 responses. 46.6% Registered Nurses, 7.3% were Advanced Practice Providers, 7.8% Attending Physician, 6.2% Resident Physicians, 19.2% Respiratory therapists, 2.5% Chaplains. Four themes emerged - comfort based on experience, support for early chaplain involvement, need of family facilitator role, and absolute resistance. Multiple concerns were raised by the surveyed healthcare providers including logistics, risk for legal retribution, distraction from resuscitation, family suffering, and ill preparedness regarding FPDR. 72% of the respondents endorsed utilizing a family facilitator role to support the practice of FPDR. There was wariness regarding using the term ‘protocol’ for the guideline document. Conclusions: There are varying levels of comfort and support regarding the practice of FPDR amongst the resuscitation team. Many healthcare professionals acknowledge a need for family facilitation with a dedicated staff member, while others respond with a resolute unwillingness to practice FPDR. There is a need for education and publication of guidelines to assist staff in gaining consistency and confidence in the practice of FPDR.

Multispecies and Watershed Approaches to Freshwater Fish Conservation

<em>Abstract</em>.—Native fish conservation areas (NFCAs) are watersheds where management emphasizes proactive conservation and restoration for long-term persistence of native fish assemblages while allowing for compatible uses. Native fish conservation areas are intended to complement traditional fisheries management approaches that are often reactive to population stressors and focused on single-species conservation efforts rather than complete assemblages. We identified potential NFCAs in the upper Snake River basin above Hells Canyon Dam using a process that ranked all subwatersheds (Hydrologic Unit Code 12) and used empirical data on distribution, abundance, and genetics for three native trout species (Bull Trout <em>Salvelinus confluentus</em>, Columbia River Redband Trout <em>Oncorhynchus mykiss gairdneri</em>, and Yellowstone Cutthroat Trout <em>O. clarkii bouvieri</em>, including the fine-spotted form) and both known occurrences and modeled potential distributions of native nongame fishes. Rankings also incorporated drainage network connectivity and land-protection status (e.g., national park, wilderness). Clusters of high-ranking subwatersheds were identified as potential NFCAs that were then classified according to the presence of nongame fishes identified as species of greatest conservation need in state wildlife action plans. The Pacific Creek and Goose Creek watersheds ranked high in the upper basin (above Shoshone Falls), and Little Jacks Creek and Squaw Creek ranked high in the lower basin. We then contrasted characteristics of a select few potential NFCAs, discuss the practical implementation and benefits of NFCAs for both fishes and other aquatic species in the upper Snake River basin, examined how the NFCA approach could enhance existing conservation partnerships, and discuss how designating select watersheds as NFCAs can create higher public awareness of the value of native fishes and other aquatic species and their habitats.

Advances in Understanding Landscape Influences on Freshwater Habitats and Biological Assemblages

<i>Abstract.</i>—Fluvial threat assessments characterize the potential for fluvial habitat conditions to be degraded by differing types and intensities of anthropogenic activities occurring on the landscape, ultimately affecting stream biota. We present a threat assessment for fluvial habitats in Alaska based on six anthropogenic disturbance indices representing urbanization, agriculture/timber harvest, stream fragmentation, point-source pollution, infrastructure, and mines. These indices were combined to develop an overall index of contemporary threat of habitat alteration throughout Alaska using the 12-digit U.S. Geological Survey hydrologic unit code (HUC-12) framework (<i>n </i>= 13,997) and at a finer spatial resolution using local and network catchments for individual stream reaches within Southeast Alaska (<i>n </i>= 207,092). Overall, contemporary threat of habitat alteration indices showed that ~96% of fluvial habitats both statewide and for Southeast Alaska were at low or very low levels; however, anadromous fish habitats were under greater human pressure with nearly double the amount of moderately to severely disturbed habitats when compared to all fluvial habitats. We further evaluated potential future threats to fluvial habitats from mineral mining activities and climate change. More than 86% of existing mine claims statewide and 99% of claims in Southeast Alaska occur in areas of low and very low contemporary threat to fluvial habitats for anadromous fishes. Under climate change, July air temperatures are projected to increase ~1.9°C, on average, by mid-century within HUC-12s containing anadromous fish streams, indicating immense potential to warm streams with anadromous fishes within the state. This fluvial threat assessment demonstrates that overall threats from contemporary anthropogenic disturbance factors are generally low with localized areas of high intensity. However, future threats from mining and climate change have considerable potential to alter fluvial habitats for anadromous fishes in Alaska, particularly those currently unaltered by anthropogenic disturbances.

Past, current, and projected landscape configurational effects on streamflow within the Rocky River HUC-8 watershed of the Charlotte metropolitan region

This study examined past, current, and projected landscape configuration (LC) impacts on streamflow within a 3,553 square kilometer (km2) Hydrologic Unit Code (HUC)-8 Rocky River (RR) watershed of the Charlotte, North Carolina metropolitan region (CMR). Utilizing a monthly model, Thornthwaite Water Balance (TWB) simulations incorporating LC (blended contagion (CON)-adjusted curve numbers (CNs)) derived from two previous (2001, 2006) and one current (2011) US scale land cover/land use (LC/LU) time snapshots outperformed a blended original (ORG) CN watershed model during the 15-year (180-month) period from January 1999 to December 2013. Findings were confirmed using evaluations from several statistically based, hydrologic model performance predictors. Five-year comparisons of the 2001 time snapshot with the 2006 time snapshot and 2011 time snapshot indicated the least underestimation/overestimation of measured streamflow occurred during the 2001 time snapshot. This period had the highest measured runoff and points towards LC influences on streamflow simulation being potentially more quantifiable during periods of greater watershed precipitation. Watershed LC/LU and climatic data were also projected to the 2030 time snapshot under five different scenarios. Streamflow was projected to be about 2.6% higher in volume than what was estimated for the current (2011) time snapshot using a blended CON-adjusted TWB model.

Defining and analyzing the frequency and severity of flood events to improve risk management from a reinsurance standpoint

The National Flood Insurance Program (NFIP) debt has accelerated research into private flood insurance options. Offering this coverage begins with the ability to transfer the risk to the reinsurance market. Within the industry, perils such as hurricanes and earthquakes have standard definitions, but no such definition exists for floods. An event definition must examine the spatial and temporal aspects of the flood as well as the complexities of individual events. In this paper we were able to apply a data-driven methodology to capture and aggregate flood peaks into independent events. To aggregate flood peaks into independent events we needed to define what constituted a basin as our area of aggregation. The USGS utilizes the hydrological unit code (HUC) a 2- to 12-digit code that follows the Pfafsetter Coding System. The HUC code is used to identify varying levels of basin sizes ranging from region (2 digits) to subwatershed (12 digits). We chose to analyze both the HUC8 and HUC6, and a total of 7932 HUC8 events and 8444 HUC6 events were recorded during the 15 water years used in our study. Each event was characterized by duration, magnitude and severity. Focusing on the HUC8, events were unevenly distributed nationally while severity was relatively evenly distributed. The goal for our study was to take a method and be able to apply it to basins of varying characteristics. This framework relied on the ability to analyze the individual processes related to each individual basin.