This document summarizes a study that implemented a nursing assessment-based inpatient pneumococcal vaccination program at a hospital. The program aimed to increase pneumococcal vaccination rates for patients aged 65 and older and those aged 2-64 with risk factors. The study found that after implementing standing orders allowing nurses to assess eligibility and administer vaccines, the vaccination opportunity rate increased from 8.6% to 59.1% and vaccination rates increased from 0% to 15.4%, showing the program significantly improved pneumococcal vaccination in the hospital.
The document summarizes revised standards for adult immunization practices published in 2003. The standards were developed by over 100 experts from more than 60 organizations to encourage best practices for adult vaccination. The revised standards are more comprehensive than the original 1990 standards and focus on accessibility of vaccines, assessing patient vaccination status, patient education, proper administration techniques, strategies to improve rates, and community partnerships. Adoption of the standards aims to increase adult vaccination rates and meet Healthy People 2010 goals, as success rates are much lower for adult versus childhood immunization.
This document provides guidelines for the diagnosis and treatment of community-acquired pneumonia (CAP) in adults. It addresses 16 questions related to diagnostic testing, determining treatment location, selecting initial antibiotic therapy, and ongoing management. While some recommendations remain unchanged from 2007, new evidence has led to revisions for empiric treatment strategies and additional management decisions. The guidelines were developed using the GRADE framework to systematically review evidence and formulate recommendations. Key recommendations include not routinely obtaining sputum cultures for outpatients, but obtaining cultures for hospitalized severe CAP patients or those at risk of drug-resistant pathogens. The guidelines also provide recommendations on initial antibiotic regimens for both outpatients and hospitalized patients with or without risk factors.
This document provides guidelines for the diagnosis and treatment of community-acquired pneumonia (CAP) in adults. It addresses 16 specific questions related to diagnostic testing, determining treatment location, selecting initial antibiotic therapy, and ongoing management. While some recommendations remain unchanged from 2007, new evidence has led to revised guidance for empiric treatment strategies and management decisions. The guidelines were developed using the GRADE framework to systematically review evidence and formulate recommendations.
To Assess the Severity and Mortality among Covid 19 Patients after Having Vac...YogeshIJTSRD
The severity and mortality of COVID 19 cases has been associated with the Three category such as vaccination status, severity of disease and outcome. Objective presently study was aimed to assess the severity and mortality among covid 19 patients. Methods Using simple lottery random method 100 samples were selected. From these 100 patients, 50 patients were randomly assigned to case group and 50 patients in control group after informed consents of relative obtained. Patients in the case group who being died after got COVID 19 whereas 50 patients in the control group participated who were survive after got infected from COVID 19 patients. Result It has three categories such as a Vaccination status For the vaccination status we have seen 59 patients were not vaccinated and 41 patients was vaccinated out of 100. b Incidence There were 41 patients were vaccinated whereas 59 patients were not vaccinated. c Severity In the case of mortality we selected 50 patients who were died from the Corona and I got to know that out of 50 patients there were 12 24 patients were vaccinated whereas 38 76 patients were non vaccinated. Although for the 50 control survival group total 29 58 patients were vaccinated and 21 42 patients was not vaccinated all graph start. Conclusion we have find out that those people who got vaccinated were less infected and mortality rate very low. Prof. (Dr) Binod Kumar Singh | Dr. Saroj Kumar | Ms. Anuradha Sharma "To Assess the Severity and Mortality among Covid-19 Patients after Having Vaccinated: A Retrospective Study" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-5 | Issue-5 , August 2021, URL: https://www.ijtsrd.com/papers/ijtsrd45065.pdf Paper URL: https://www.ijtsrd.com/other-scientific-research-area/other/45065/to-assess-the-severity-and-mortality-among-covid19-patients-after-having-vaccinated-a-retrospective-study/prof-dr-binod-kumar-singh
Asymptomatic Trasmission, the Achilles'Heel of Current Strategies to Control ...Valentina Corona
The editorial discusses an outbreak of COVID-19 at a skilled nursing facility in Washington where asymptomatic transmission played a major role in spreading the virus. Over half of the residents who tested positive were asymptomatic at the time of testing, and live virus was detected in samples from presymptomatic residents days before they developed symptoms. Current strategies relying on symptom screening alone are inadequate for controlling transmission. The authors argue for expanded testing of asymptomatic individuals in high-risk settings like nursing homes to allow for proper isolation and prevent further outbreaks.
The value of real-world evidence for clinicians and clinical researchers in t...Arete-Zoe, LLC
In the midst of a rapidly spreading global pandemic, real-world evidence can offer invaluable insight into the most promising treatments, risk factors, and not only predict but suggest how to improve outcomes. Despite overwhelming news coverage, significant knowledge gaps regarding COVID-19 persist. The current uncertainties regarding incidence and the case fatality rate can only be addressed by widespread testing. But the paucity of testing, and diversity of approaches implemented in different countries, particularly among the general asymptomatic public, perpetuates a lack of understanding about spread and infectivity. The essential indicators that would describe the pandemic more accurately can be obtained using real-world data (RWD). To that purpose, we designed a data collection tool to collect data from hospitals that treat COVID-19 patients. The captured data will enhance our understanding of the COVID-19 pandemic, identify risk factors relevant for triage, relate to other similar seasonal infections and gain insight into the safety and efficacy of experimental and off-label therapies. Knowledge derived from a focused data collection effort will enable clinicians to adjust rapidly clinical protocols and discontinue interventions that turn out to be ineffective or harmful. By deploying our elegantly designed survey to capture routine clinical indicators, we avoid placing an additional burden on practitioners. Systematically generating real-world evidence can decrease the time to insight compared to randomized clinical trials, improving the odds for patients in rapidly changing conditions.
The document discusses guidelines for diagnosing and treating high blood pressure from the National High Blood Pressure Education Program Coordinating Committee. It notes that systolic blood pressure is more important than diastolic pressure for those over 50 years old. It also discusses "prehypertension" between 120-139/80-89 mm Hg and treatment thresholds. The JNC 7 guidelines were issued in 1997 while the JNC 8 guidelines from 2013 include treatment algorithms and comparisons to JNC 7.
The document discusses guidelines for diagnosing and treating high blood pressure from the National High Blood Pressure Education Program Coordinating Committee. It notes that systolic blood pressure is more important than diastolic pressure for those over 50 years old. It also discusses "prehypertension" between 120-139/80-89 mm Hg and treatment thresholds. The JNC 7 guidelines were issued in 1997 while JNC 8 included treatment algorithms and differences from JNC 7.
The document summarizes revised standards for adult immunization practices published in 2003. The standards were developed by over 100 experts from more than 60 organizations to encourage best practices for adult vaccination. The revised standards are more comprehensive than the original 1990 standards and focus on accessibility of vaccines, assessing patient vaccination status, patient education, proper administration techniques, strategies to improve rates, and community partnerships. Adoption of the standards aims to increase adult vaccination rates and meet Healthy People 2010 goals, as success rates are much lower for adult versus childhood immunization.
This document provides guidelines for the diagnosis and treatment of community-acquired pneumonia (CAP) in adults. It addresses 16 questions related to diagnostic testing, determining treatment location, selecting initial antibiotic therapy, and ongoing management. While some recommendations remain unchanged from 2007, new evidence has led to revisions for empiric treatment strategies and additional management decisions. The guidelines were developed using the GRADE framework to systematically review evidence and formulate recommendations. Key recommendations include not routinely obtaining sputum cultures for outpatients, but obtaining cultures for hospitalized severe CAP patients or those at risk of drug-resistant pathogens. The guidelines also provide recommendations on initial antibiotic regimens for both outpatients and hospitalized patients with or without risk factors.
This document provides guidelines for the diagnosis and treatment of community-acquired pneumonia (CAP) in adults. It addresses 16 specific questions related to diagnostic testing, determining treatment location, selecting initial antibiotic therapy, and ongoing management. While some recommendations remain unchanged from 2007, new evidence has led to revised guidance for empiric treatment strategies and management decisions. The guidelines were developed using the GRADE framework to systematically review evidence and formulate recommendations.
To Assess the Severity and Mortality among Covid 19 Patients after Having Vac...YogeshIJTSRD
The severity and mortality of COVID 19 cases has been associated with the Three category such as vaccination status, severity of disease and outcome. Objective presently study was aimed to assess the severity and mortality among covid 19 patients. Methods Using simple lottery random method 100 samples were selected. From these 100 patients, 50 patients were randomly assigned to case group and 50 patients in control group after informed consents of relative obtained. Patients in the case group who being died after got COVID 19 whereas 50 patients in the control group participated who were survive after got infected from COVID 19 patients. Result It has three categories such as a Vaccination status For the vaccination status we have seen 59 patients were not vaccinated and 41 patients was vaccinated out of 100. b Incidence There were 41 patients were vaccinated whereas 59 patients were not vaccinated. c Severity In the case of mortality we selected 50 patients who were died from the Corona and I got to know that out of 50 patients there were 12 24 patients were vaccinated whereas 38 76 patients were non vaccinated. Although for the 50 control survival group total 29 58 patients were vaccinated and 21 42 patients was not vaccinated all graph start. Conclusion we have find out that those people who got vaccinated were less infected and mortality rate very low. Prof. (Dr) Binod Kumar Singh | Dr. Saroj Kumar | Ms. Anuradha Sharma "To Assess the Severity and Mortality among Covid-19 Patients after Having Vaccinated: A Retrospective Study" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-5 | Issue-5 , August 2021, URL: https://www.ijtsrd.com/papers/ijtsrd45065.pdf Paper URL: https://www.ijtsrd.com/other-scientific-research-area/other/45065/to-assess-the-severity-and-mortality-among-covid19-patients-after-having-vaccinated-a-retrospective-study/prof-dr-binod-kumar-singh
Asymptomatic Trasmission, the Achilles'Heel of Current Strategies to Control ...Valentina Corona
The editorial discusses an outbreak of COVID-19 at a skilled nursing facility in Washington where asymptomatic transmission played a major role in spreading the virus. Over half of the residents who tested positive were asymptomatic at the time of testing, and live virus was detected in samples from presymptomatic residents days before they developed symptoms. Current strategies relying on symptom screening alone are inadequate for controlling transmission. The authors argue for expanded testing of asymptomatic individuals in high-risk settings like nursing homes to allow for proper isolation and prevent further outbreaks.
The value of real-world evidence for clinicians and clinical researchers in t...Arete-Zoe, LLC
In the midst of a rapidly spreading global pandemic, real-world evidence can offer invaluable insight into the most promising treatments, risk factors, and not only predict but suggest how to improve outcomes. Despite overwhelming news coverage, significant knowledge gaps regarding COVID-19 persist. The current uncertainties regarding incidence and the case fatality rate can only be addressed by widespread testing. But the paucity of testing, and diversity of approaches implemented in different countries, particularly among the general asymptomatic public, perpetuates a lack of understanding about spread and infectivity. The essential indicators that would describe the pandemic more accurately can be obtained using real-world data (RWD). To that purpose, we designed a data collection tool to collect data from hospitals that treat COVID-19 patients. The captured data will enhance our understanding of the COVID-19 pandemic, identify risk factors relevant for triage, relate to other similar seasonal infections and gain insight into the safety and efficacy of experimental and off-label therapies. Knowledge derived from a focused data collection effort will enable clinicians to adjust rapidly clinical protocols and discontinue interventions that turn out to be ineffective or harmful. By deploying our elegantly designed survey to capture routine clinical indicators, we avoid placing an additional burden on practitioners. Systematically generating real-world evidence can decrease the time to insight compared to randomized clinical trials, improving the odds for patients in rapidly changing conditions.
The document discusses guidelines for diagnosing and treating high blood pressure from the National High Blood Pressure Education Program Coordinating Committee. It notes that systolic blood pressure is more important than diastolic pressure for those over 50 years old. It also discusses "prehypertension" between 120-139/80-89 mm Hg and treatment thresholds. The JNC 7 guidelines were issued in 1997 while the JNC 8 guidelines from 2013 include treatment algorithms and comparisons to JNC 7.
The document discusses guidelines for diagnosing and treating high blood pressure from the National High Blood Pressure Education Program Coordinating Committee. It notes that systolic blood pressure is more important than diastolic pressure for those over 50 years old. It also discusses "prehypertension" between 120-139/80-89 mm Hg and treatment thresholds. The JNC 7 guidelines were issued in 1997 while JNC 8 included treatment algorithms and differences from JNC 7.
The study examined the association between proton pump inhibitor (PPI) prescriptions and the risk of community acquired pneumonia using data from the UK's Clinical Practice Research Datalink. Three analytical methods were used: a cohort study comparing PPI users to non-users adjusted for confounders, a self-controlled case series comparing periods before and after PPI use, and a prior event rate ratio analysis comparing periods before and after the first PPI prescription. All three methods suggested that confounding factors present before PPI use, rather than PPI use itself, best explained the increased rate of community acquired pneumonia seen in PPI patients. The association between PPI use and pneumonia risk observed in previous studies is likely entirely due to
The study examined the association between proton pump inhibitor (PPI) prescriptions and the risk of community acquired pneumonia using data from the UK's Clinical Practice Research Datalink. Three methods were used: a cohort study comparing PPI users to non-users adjusted for confounders, a self-controlled case series comparing periods before and after PPI use, and examining event rates before and after the first PPI prescription. All methods suggested the observed association between PPI use and pneumonia was likely due entirely to underlying confounding factors present before PPI use, rather than being caused by PPI use itself.
This study evaluated the validity of procalcitonin (PCT) for diagnosing bacterial infections in elderly patients aged 75 years or older. 161 patients were included in the study and divided into two groups: 95 patients with probable bacterial infections and 66 patients without infections. PCT levels above 0.5 ng/mL were found in 72% of patients with probable bacterial infections and 8% of patients without infections. The study found that PCT has a sensitivity of 72% and specificity of 92% for diagnosing bacterial infections in elderly patients using a cutoff of 0.5 ng/mL. The researchers concluded that PCT can be reliably used to diagnose bacterial infections in elderly patients due to its good sensitivity and high specificity.
VAP/HAP management guidelines by IDSA/ATS (2016) -: Dr.Tinku JosephDr.Tinku Joseph
This document discusses ventilator-associated pneumonia (VAP) and hospital-acquired pneumonia (HAP). It defines VAP and HAP and outlines their incidence and impact. Guidelines for diagnosing VAP/HAP using microbiologic methods and biomarkers like CPIS are presented. The document reviews controversies around defining healthcare-associated pneumonia (HCAP) and its inclusion in future guidelines. Empiric and pathogen-directed treatment options for VAP/HAP are discussed, along with optimizing antibiotic dosing and the potential role of inhaled antibiotics.
Die britische Regierung räumt ein, dass Impfstoffe das natürliche Immunsystem von Doppelgeimpften geschädigt haben. Die britische Regierung hat zugegeben, dass Sie nach einer Doppelimpfung nie wieder eine vollständige natürliche Immunität gegen Covid-Varianten – oder möglicherweise gegen andere Viren – erlangen können. Sehen wir also zu, wie die „echte“ Pandemie jetzt beginnt! In seinem „COVID-19 Vaccine Surveillance Report“ (Woche 42) räumt das britische Gesundheitsministerium auf Seite 23 ein, dass „die N-Antikörperspiegel bei Menschen, die sich nach zwei Impfdosen infizieren, niedriger zu sein scheinen“. Es heißt weiter, dass dieser Rückgang der Antikörper im Wesentlichen dauerhaft ist. Was bedeutet das? Wir wissen, dass Impfstoffe eine Infektion oder Übertragung des Virus nicht verhindern (tatsächlich zeigt der Bericht an anderer Stelle, dass geimpfte Erwachsene jetzt viel wahrscheinlicher infiziert werden als ungeimpfte). Die Briten stellen nun fest, dass der Impfstoff die Fähigkeit des Körpers beeinträchtigt, nach einer Infektion Antikörper zu bilden, nicht nur gegen das Spike-Protein, sondern auch gegen andere Teile des Virus. Insbesondere scheinen geimpfte Personen keine Antikörper gegen das Nukleokapsid-Protein, die Hülle des Virus, zu bilden, das ein entscheidender Teil der Reaktion bei ungeimpften Personen ist. Langfristig sind die Geimpften deutlich anfälliger für eventuelle Mutationen im Spike-Protein, auch wenn sie bereits einmal oder mehrmals infiziert und geheilt wurden. Die Ungeimpften hingegen werden eine dauerhafte, wenn nicht sogar dauerhafte Immunität gegen alle Stämme des angeblichen Virus erlangen, nachdem sie auch nur einmal auf natürliche Weise damit infiziert wurden. Quelle: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1027511/Vaccine-surveillance-report-week-42.pdf Die
This study aimed to determine the epidemiology of candidemia and evaluate risk factors for mortality in patients with candidemia admitted to an Indian medical ICU. The incidence of candidemia was found to be 17.8 per 1,000 ICU admissions. Non-albican species accounted for 78.6% of candidemia. Previous antifungal use and a Candida score greater than 3 were found to independently predict increased ICU mortality. The Candida score integrates several risk factors and may provide a useful bedside tool for predicting mortality in patients with candidemia.
Role of Personal Protective Measures in Prevention of COVID-19 Spread Among P...NurFathihaTahiatSeeu
1) The study examined the role of personal protective measures in preventing the spread of COVID-19 among physicians in Bangladesh.
2) It found that physicians who were unaware of contact with COVID-19 patients or the status of patients during aerosol-generating procedures had higher odds of testing positive.
3) Wearing an N95 mask during aerosol-generating procedures and face shields/goggles during usual patient care were associated with lower odds of infection, but most associations were not statistically significant due to the small sample size.
This PowerPoint presentation summarizes key information about COVID-19, including its genome structure and receptor, epidemiology, clinical features, diagnosis, treatment, and prognosis. It discusses how the risk of COVID-19 infection was high among study participants and increased with age, gender, and comorbidities. Finally, it outlines common control strategies like social distancing, masks, hand washing, and vaccination to prevent and slow transmission of the virus.
Vaccine safety requires careful monitoring both before and after vaccines are approved. Pre-approval clinical trials evaluate efficacy and safety but are too small to detect rare issues. The Vaccine Adverse Event Reporting System (VAERS) monitors safety after approval by collecting reports from healthcare providers and the public. While VAERS detects potential problems, it cannot determine if a vaccine caused a specific adverse event. Additional studies are needed to evaluate potential safety issues found through VAERS. Ongoing research is also important to improve understanding of vaccine safety and adverse events.
This document discusses the importance of defining the epidemiology of COVID-19 through various studies and surveillance methods. It outlines key questions about the virus that need answers, such as its full disease severity spectrum, transmissibility, most infectious individuals, and risk factors for severe illness. It recommends approaches like syndromic surveillance, household studies, and community studies. Conducting these simultaneously can help characterize the trajectory and severity of the epidemic to inform response efforts. Early investment in such studies will improve understanding and control of the outbreak.
This research article describes a multi-center study that compared 20 different methods for identifying pneumococcal serotypes carried in the nasopharynx. Laboratory-prepared samples containing known serotypes and nasopharyngeal samples from children in six countries were tested. The microarray method, which included a culture amplification step, performed best with high sensitivity and accuracy in detecting both dominant and minor serotypes carried. However, most methods could reliably detect the dominant serotype carried but performed poorly in identifying minor serotypes. This study provides valuable data to help evaluate pneumococcal vaccines and carriage patterns, especially in low-income settings with high disease burden.
A Cross Sectional Study To Assess The Willingness And Hesitancy Regarding COV...Robin Beregovska
This study assessed willingness and hesitancy regarding COVID-19 vaccination among 500 people in India. The majority (60.8%) reported moderate hesitancy and 64.2% reported moderate willingness. Some demographic factors like gender, education, and occupation were associated with hesitancy levels, while age, education, occupation, and family type were associated with willingness levels. The study recommends effective education to address vaccine hesitancy and increase willingness. Other similar studies in other countries also found varying levels of hesitancy influenced by factors like gender, trust in information sources, and safety concerns regarding new vaccines.
The document discusses recommendations from the National Vaccine Advisory Committee regarding adult immunization programs. It provides an overview of adult immunization levels and targets, noting that rates for influenza and pneumococcal vaccines have increased but remain below Healthy People 2010 goals. Burden of vaccine-preventable diseases in adults is significant, with estimates of tens of thousands of influenza-associated deaths annually in the US. Recommendations focus on improving coordination, evaluation, and collaboration across federal agencies to increase adult vaccination uptake.
This document presents the protocol for an observational study examining the predictive value of cell-surface markers in identifying critically ill patients at risk of nosocomial infections. The study aims to validate previously identified markers of immune dysfunction - including low expression of CD88 on neutrophils, low HLA-DR on monocytes, and elevated regulatory T cells - and determine if combining these markers improves prediction of infection risk. It also aims to explore additional cell surface markers and immune cell subsets that may further predict infection risk. The multicenter study will collect blood samples from critically ill patients in the ICU to analyze immune cell markers using flow cytometry and correlate the results with rates of subsequent nosocomial infections.
Assignment on Covid 19 | Tutors India.pptxTutors India
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This document discusses several scoring systems used to assess the severity of community-acquired pneumonia (CAP) and determine the need for hospitalization, including the Pneumonia Severity Index (PSI), CURB-65, SMART-COP, and SCAP. It notes that while PSI and CURB-65 predict mortality risk, they were not designed to identify patients needing intensive care unit (ICU) admission. More recent scores like SMART-COP and SCAP were developed specifically to predict ICU needs. The document concludes that while these scoring systems are useful tools, clinical judgment from experienced doctors considering each patient's full context remains essential for optimal CAP management.
Nejm clinical outcomes of hydroxychlorquine in patients with covid19.pdf.pdfgisa_legal
This study evaluated the effects of hydroxychloroquine treatment in 63 hospitalized patients with COVID-19. Patients were divided into a hydroxychloroquine treatment group (32 patients) and a supportive care only group (31 patients). The primary outcomes measured were need for escalation of respiratory support, change in lymphocyte count, and change in neutrophil-to-lymphocyte ratio. The results showed that hydroxychloroquine treatment was associated with a higher need for escalation of respiratory support compared to the supportive care only group. There were no significant benefits of hydroxychloroquine treatment on lymphocyte counts or neutrophil-to-lymphocyte ratios. The study concludes that hydroxychloroquine did not provide benefits and
Critical care nurses' knowledge and compliance with ventilator associated pne...Alexander Decker
This study assessed critical care nurses' knowledge and compliance with ventilator-associated pneumonia (VAP) bundle practices in Cairo university hospitals. The study found that the majority of nurses had unsatisfactory knowledge about VAP based on a 20-item questionnaire. Direct observation also found that nurses were not compliant with most VAP bundle elements. The study concluded that training programs are needed for nurses on VAP prevention to improve outcomes for mechanically ventilated patients.
Epidemiology treatment and_outcomes_of_sa_nosocomial_pneumonia_chest_2005-1Christian Wilhelm
This study examined outcomes of nosocomial bacteremic Staphylococcus aureus pneumonia (NBSAP) in 60 patients over 5 years. It found that NBSAP commonly developed late in a patient's hospital stay among critically ill patients on mechanical ventilation. NBSAP was associated with high mortality and infection-related mortality rates of 55.5% and 40%, respectively. While delayed appropriate antibiotic therapy did not predict worse outcomes compared to early therapy, the study was limited by small sample size. The findings suggest a need for new antibiotics with better activity against NBSAP.
Barbara Silva is the CIO for Peachtree Community Hospital in Atlanta.docxwilcockiris
Barbara Silva is the CIO for Peachtree Community Hospital in Atlanta, Georgia. As the chief information officer, it has been her duty to assemble a team of healthcare information professionals to prepare for the implementation of HIPAA Privacy Rules.
How did Barbara and her team orchestrate moving forward toward HIPAA Privacy compliance? First, she established a steering committee responsible for HIPAA Privacy planning. The committee focused on three broad areas of development, including:
education;
assessment; and
development of policies and procedures.
The steering committee recognizes that the scope of this project is quite vast and that it encompasses many different areas of the facility. The scope involves not just hospital information systems, but the operations of many departments and manual processes. These varied items are included in the scope of assessment and are found to be the biggest challenge. Developing HIPAA compliant policies and procedures is not a one-time activity as changes are constant. Development and continuous updating will mean that this project is one that will be an ongoing effort.
Part of Peachtree Community Hospital’s key to success has been pulling together the right combination of professionals. The result is a multidisciplinary team which will include the HIM services director and the CCO (chief compliance officer).
Barbara has garnered the following information from experts in the area of HIPAA Privacy Rules who have suggested that healthcare organizations consider the following steps to become compliant:
Inventory the organization’s data as the first step in policy implementation.
Read the Federal Register information on HIPAA.
Focus on HIPAA as a business process issue.
Secure the support of top management and the active involvement and participation of staff in all affected areas.
Thoroughly review outside vendor contracts to ensure compliance with business associate agreements.
Appoint a dedicated staff to the HIPAA privacy initiative.
Preparing for HIPAA compliance will require a complex and thorough evaluation and realignment of business and operational processes.
Your Role/Assignment
You have been consulted by CIO Barbara Silva as the healthcare information systems expert. You will be working directly with the director of HIM services. As a consultant, you have vast experience with HIPAA implementations. Your expertise will be required in several areas.
K E Y P L A Y E R S
Barbara Silva, CIO
As the chief information officer, Barbara will assemble a team of healthcare professionals to prepare for the implementation of HIPAA Privacy Rules. She must ensure that Peachtree is in full compliance with HIPAA regulations for every aspect of the organization
–
not just hospital information systems, but also the operations of related departments and manual processes. Her concerns encompass a large scope of the project, and she will need to identify key people to become involved in this project.
James H.
BARGAIN CITY Your career is moving along faster than you e.docxwilcockiris
The document describes observations of two children, Romee, a 2.5 year old toddler, and Bo, a 4.5 year old preschooler, at a children's center. For Romee, the observations show her developing social awareness as she seeks attention from her caregiver Mandy and plays with dolls. For Bo, the observations depict him engaging in pretend play by pretending to cook and care for teddy bears, and including other children in his play outside using tricycles. The observations provide examples of how the children's social interactions and play differ due to their different cognitive developmental stages.
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The study examined the association between proton pump inhibitor (PPI) prescriptions and the risk of community acquired pneumonia using data from the UK's Clinical Practice Research Datalink. Three analytical methods were used: a cohort study comparing PPI users to non-users adjusted for confounders, a self-controlled case series comparing periods before and after PPI use, and a prior event rate ratio analysis comparing periods before and after the first PPI prescription. All three methods suggested that confounding factors present before PPI use, rather than PPI use itself, best explained the increased rate of community acquired pneumonia seen in PPI patients. The association between PPI use and pneumonia risk observed in previous studies is likely entirely due to
The study examined the association between proton pump inhibitor (PPI) prescriptions and the risk of community acquired pneumonia using data from the UK's Clinical Practice Research Datalink. Three methods were used: a cohort study comparing PPI users to non-users adjusted for confounders, a self-controlled case series comparing periods before and after PPI use, and examining event rates before and after the first PPI prescription. All methods suggested the observed association between PPI use and pneumonia was likely due entirely to underlying confounding factors present before PPI use, rather than being caused by PPI use itself.
This study evaluated the validity of procalcitonin (PCT) for diagnosing bacterial infections in elderly patients aged 75 years or older. 161 patients were included in the study and divided into two groups: 95 patients with probable bacterial infections and 66 patients without infections. PCT levels above 0.5 ng/mL were found in 72% of patients with probable bacterial infections and 8% of patients without infections. The study found that PCT has a sensitivity of 72% and specificity of 92% for diagnosing bacterial infections in elderly patients using a cutoff of 0.5 ng/mL. The researchers concluded that PCT can be reliably used to diagnose bacterial infections in elderly patients due to its good sensitivity and high specificity.
VAP/HAP management guidelines by IDSA/ATS (2016) -: Dr.Tinku JosephDr.Tinku Joseph
This document discusses ventilator-associated pneumonia (VAP) and hospital-acquired pneumonia (HAP). It defines VAP and HAP and outlines their incidence and impact. Guidelines for diagnosing VAP/HAP using microbiologic methods and biomarkers like CPIS are presented. The document reviews controversies around defining healthcare-associated pneumonia (HCAP) and its inclusion in future guidelines. Empiric and pathogen-directed treatment options for VAP/HAP are discussed, along with optimizing antibiotic dosing and the potential role of inhaled antibiotics.
Die britische Regierung räumt ein, dass Impfstoffe das natürliche Immunsystem von Doppelgeimpften geschädigt haben. Die britische Regierung hat zugegeben, dass Sie nach einer Doppelimpfung nie wieder eine vollständige natürliche Immunität gegen Covid-Varianten – oder möglicherweise gegen andere Viren – erlangen können. Sehen wir also zu, wie die „echte“ Pandemie jetzt beginnt! In seinem „COVID-19 Vaccine Surveillance Report“ (Woche 42) räumt das britische Gesundheitsministerium auf Seite 23 ein, dass „die N-Antikörperspiegel bei Menschen, die sich nach zwei Impfdosen infizieren, niedriger zu sein scheinen“. Es heißt weiter, dass dieser Rückgang der Antikörper im Wesentlichen dauerhaft ist. Was bedeutet das? Wir wissen, dass Impfstoffe eine Infektion oder Übertragung des Virus nicht verhindern (tatsächlich zeigt der Bericht an anderer Stelle, dass geimpfte Erwachsene jetzt viel wahrscheinlicher infiziert werden als ungeimpfte). Die Briten stellen nun fest, dass der Impfstoff die Fähigkeit des Körpers beeinträchtigt, nach einer Infektion Antikörper zu bilden, nicht nur gegen das Spike-Protein, sondern auch gegen andere Teile des Virus. Insbesondere scheinen geimpfte Personen keine Antikörper gegen das Nukleokapsid-Protein, die Hülle des Virus, zu bilden, das ein entscheidender Teil der Reaktion bei ungeimpften Personen ist. Langfristig sind die Geimpften deutlich anfälliger für eventuelle Mutationen im Spike-Protein, auch wenn sie bereits einmal oder mehrmals infiziert und geheilt wurden. Die Ungeimpften hingegen werden eine dauerhafte, wenn nicht sogar dauerhafte Immunität gegen alle Stämme des angeblichen Virus erlangen, nachdem sie auch nur einmal auf natürliche Weise damit infiziert wurden. Quelle: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1027511/Vaccine-surveillance-report-week-42.pdf Die
This study aimed to determine the epidemiology of candidemia and evaluate risk factors for mortality in patients with candidemia admitted to an Indian medical ICU. The incidence of candidemia was found to be 17.8 per 1,000 ICU admissions. Non-albican species accounted for 78.6% of candidemia. Previous antifungal use and a Candida score greater than 3 were found to independently predict increased ICU mortality. The Candida score integrates several risk factors and may provide a useful bedside tool for predicting mortality in patients with candidemia.
Role of Personal Protective Measures in Prevention of COVID-19 Spread Among P...NurFathihaTahiatSeeu
1) The study examined the role of personal protective measures in preventing the spread of COVID-19 among physicians in Bangladesh.
2) It found that physicians who were unaware of contact with COVID-19 patients or the status of patients during aerosol-generating procedures had higher odds of testing positive.
3) Wearing an N95 mask during aerosol-generating procedures and face shields/goggles during usual patient care were associated with lower odds of infection, but most associations were not statistically significant due to the small sample size.
This PowerPoint presentation summarizes key information about COVID-19, including its genome structure and receptor, epidemiology, clinical features, diagnosis, treatment, and prognosis. It discusses how the risk of COVID-19 infection was high among study participants and increased with age, gender, and comorbidities. Finally, it outlines common control strategies like social distancing, masks, hand washing, and vaccination to prevent and slow transmission of the virus.
Vaccine safety requires careful monitoring both before and after vaccines are approved. Pre-approval clinical trials evaluate efficacy and safety but are too small to detect rare issues. The Vaccine Adverse Event Reporting System (VAERS) monitors safety after approval by collecting reports from healthcare providers and the public. While VAERS detects potential problems, it cannot determine if a vaccine caused a specific adverse event. Additional studies are needed to evaluate potential safety issues found through VAERS. Ongoing research is also important to improve understanding of vaccine safety and adverse events.
This document discusses the importance of defining the epidemiology of COVID-19 through various studies and surveillance methods. It outlines key questions about the virus that need answers, such as its full disease severity spectrum, transmissibility, most infectious individuals, and risk factors for severe illness. It recommends approaches like syndromic surveillance, household studies, and community studies. Conducting these simultaneously can help characterize the trajectory and severity of the epidemic to inform response efforts. Early investment in such studies will improve understanding and control of the outbreak.
This research article describes a multi-center study that compared 20 different methods for identifying pneumococcal serotypes carried in the nasopharynx. Laboratory-prepared samples containing known serotypes and nasopharyngeal samples from children in six countries were tested. The microarray method, which included a culture amplification step, performed best with high sensitivity and accuracy in detecting both dominant and minor serotypes carried. However, most methods could reliably detect the dominant serotype carried but performed poorly in identifying minor serotypes. This study provides valuable data to help evaluate pneumococcal vaccines and carriage patterns, especially in low-income settings with high disease burden.
A Cross Sectional Study To Assess The Willingness And Hesitancy Regarding COV...Robin Beregovska
This study assessed willingness and hesitancy regarding COVID-19 vaccination among 500 people in India. The majority (60.8%) reported moderate hesitancy and 64.2% reported moderate willingness. Some demographic factors like gender, education, and occupation were associated with hesitancy levels, while age, education, occupation, and family type were associated with willingness levels. The study recommends effective education to address vaccine hesitancy and increase willingness. Other similar studies in other countries also found varying levels of hesitancy influenced by factors like gender, trust in information sources, and safety concerns regarding new vaccines.
The document discusses recommendations from the National Vaccine Advisory Committee regarding adult immunization programs. It provides an overview of adult immunization levels and targets, noting that rates for influenza and pneumococcal vaccines have increased but remain below Healthy People 2010 goals. Burden of vaccine-preventable diseases in adults is significant, with estimates of tens of thousands of influenza-associated deaths annually in the US. Recommendations focus on improving coordination, evaluation, and collaboration across federal agencies to increase adult vaccination uptake.
This document presents the protocol for an observational study examining the predictive value of cell-surface markers in identifying critically ill patients at risk of nosocomial infections. The study aims to validate previously identified markers of immune dysfunction - including low expression of CD88 on neutrophils, low HLA-DR on monocytes, and elevated regulatory T cells - and determine if combining these markers improves prediction of infection risk. It also aims to explore additional cell surface markers and immune cell subsets that may further predict infection risk. The multicenter study will collect blood samples from critically ill patients in the ICU to analyze immune cell markers using flow cytometry and correlate the results with rates of subsequent nosocomial infections.
Assignment on Covid 19 | Tutors India.pptxTutors India
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This document discusses several scoring systems used to assess the severity of community-acquired pneumonia (CAP) and determine the need for hospitalization, including the Pneumonia Severity Index (PSI), CURB-65, SMART-COP, and SCAP. It notes that while PSI and CURB-65 predict mortality risk, they were not designed to identify patients needing intensive care unit (ICU) admission. More recent scores like SMART-COP and SCAP were developed specifically to predict ICU needs. The document concludes that while these scoring systems are useful tools, clinical judgment from experienced doctors considering each patient's full context remains essential for optimal CAP management.
Nejm clinical outcomes of hydroxychlorquine in patients with covid19.pdf.pdfgisa_legal
This study evaluated the effects of hydroxychloroquine treatment in 63 hospitalized patients with COVID-19. Patients were divided into a hydroxychloroquine treatment group (32 patients) and a supportive care only group (31 patients). The primary outcomes measured were need for escalation of respiratory support, change in lymphocyte count, and change in neutrophil-to-lymphocyte ratio. The results showed that hydroxychloroquine treatment was associated with a higher need for escalation of respiratory support compared to the supportive care only group. There were no significant benefits of hydroxychloroquine treatment on lymphocyte counts or neutrophil-to-lymphocyte ratios. The study concludes that hydroxychloroquine did not provide benefits and
Critical care nurses' knowledge and compliance with ventilator associated pne...Alexander Decker
This study assessed critical care nurses' knowledge and compliance with ventilator-associated pneumonia (VAP) bundle practices in Cairo university hospitals. The study found that the majority of nurses had unsatisfactory knowledge about VAP based on a 20-item questionnaire. Direct observation also found that nurses were not compliant with most VAP bundle elements. The study concluded that training programs are needed for nurses on VAP prevention to improve outcomes for mechanically ventilated patients.
Epidemiology treatment and_outcomes_of_sa_nosocomial_pneumonia_chest_2005-1Christian Wilhelm
This study examined outcomes of nosocomial bacteremic Staphylococcus aureus pneumonia (NBSAP) in 60 patients over 5 years. It found that NBSAP commonly developed late in a patient's hospital stay among critically ill patients on mechanical ventilation. NBSAP was associated with high mortality and infection-related mortality rates of 55.5% and 40%, respectively. While delayed appropriate antibiotic therapy did not predict worse outcomes compared to early therapy, the study was limited by small sample size. The findings suggest a need for new antibiotics with better activity against NBSAP.
Similar to Implementation and evaluation of anursing assessmentstandin.docx (20)
Barbara Silva is the CIO for Peachtree Community Hospital in Atlanta.docxwilcockiris
Barbara Silva is the CIO for Peachtree Community Hospital in Atlanta, Georgia. As the chief information officer, it has been her duty to assemble a team of healthcare information professionals to prepare for the implementation of HIPAA Privacy Rules.
How did Barbara and her team orchestrate moving forward toward HIPAA Privacy compliance? First, she established a steering committee responsible for HIPAA Privacy planning. The committee focused on three broad areas of development, including:
education;
assessment; and
development of policies and procedures.
The steering committee recognizes that the scope of this project is quite vast and that it encompasses many different areas of the facility. The scope involves not just hospital information systems, but the operations of many departments and manual processes. These varied items are included in the scope of assessment and are found to be the biggest challenge. Developing HIPAA compliant policies and procedures is not a one-time activity as changes are constant. Development and continuous updating will mean that this project is one that will be an ongoing effort.
Part of Peachtree Community Hospital’s key to success has been pulling together the right combination of professionals. The result is a multidisciplinary team which will include the HIM services director and the CCO (chief compliance officer).
Barbara has garnered the following information from experts in the area of HIPAA Privacy Rules who have suggested that healthcare organizations consider the following steps to become compliant:
Inventory the organization’s data as the first step in policy implementation.
Read the Federal Register information on HIPAA.
Focus on HIPAA as a business process issue.
Secure the support of top management and the active involvement and participation of staff in all affected areas.
Thoroughly review outside vendor contracts to ensure compliance with business associate agreements.
Appoint a dedicated staff to the HIPAA privacy initiative.
Preparing for HIPAA compliance will require a complex and thorough evaluation and realignment of business and operational processes.
Your Role/Assignment
You have been consulted by CIO Barbara Silva as the healthcare information systems expert. You will be working directly with the director of HIM services. As a consultant, you have vast experience with HIPAA implementations. Your expertise will be required in several areas.
K E Y P L A Y E R S
Barbara Silva, CIO
As the chief information officer, Barbara will assemble a team of healthcare professionals to prepare for the implementation of HIPAA Privacy Rules. She must ensure that Peachtree is in full compliance with HIPAA regulations for every aspect of the organization
–
not just hospital information systems, but also the operations of related departments and manual processes. Her concerns encompass a large scope of the project, and she will need to identify key people to become involved in this project.
James H.
BARGAIN CITY Your career is moving along faster than you e.docxwilcockiris
The document describes observations of two children, Romee, a 2.5 year old toddler, and Bo, a 4.5 year old preschooler, at a children's center. For Romee, the observations show her developing social awareness as she seeks attention from her caregiver Mandy and plays with dolls. For Bo, the observations depict him engaging in pretend play by pretending to cook and care for teddy bears, and including other children in his play outside using tricycles. The observations provide examples of how the children's social interactions and play differ due to their different cognitive developmental stages.
Barbara schedules a meeting with a core group of clinic managers. T.docxwilcockiris
Barbara schedules a meeting with a core group of clinic managers. The purpose of the meeting is to review the strategic plan and to gather additional feedback from the managers. Barbara is aware of the importance of diversity within the organization. Diversity and inclusion is particularly important because of the population served by UCCO facilities. However, she realizes during the meeting that there may be some issues with diversity and culture. Furthermore, how diversity and culture impact team performance. Several managers made comments regarding distribution of work and employee perspectives based on stereotypes. She also found out that there are many personality conflicts and issues with subordination. Barbara encountered the conflict and degradation comments, first-hand during the meeting.
Visit the Rasmussen online Library and search for a minimum of 3 articles covering diversity and culture and teamwork.
For this project assignment on UCCO complete a minimum of a 3 page report to address management of change with strategic planning and with the following concepts:
What is the role of executives in the process of change management and strategic planning? How do issues with diversity and culture relate to change management?
Why is diversity inclusion important? What are the benefits? Specifically address UCCO purpose for diversity.
Discuss how working with others can help with respect for diversity and respect for diverse perspectives.
What are the challenges and benefits of employing a diverse workforce?
What should Barbara's plan be for encouraging teamwork among a diverse workforce and ensuring that employees make meaningful and valuable contributions to team projects and tasks. Incorporate Barbara's personal experience with the team of clinic managers.
Remember to integrate citations accurately and appropriately for all resource types; use attribution (credit) as a method to avoid plagiarism. Use NoodleBib to document your sources and to complete your APA formatted reference page and in-text citations.
Transferable Skills for this Project Stage:
Diversity & Teamwork
Communication
.
Barbara schedules a meeting with a core group of clinic managers.docxwilcockiris
Barbara schedules a meeting with a core group of clinic managers. The purpose of the meeting is to review the strategic plan and to gather additional feedback from the managers. Barbara is aware of the importance of diversity within the organization. Diversity and inclusion is particularly important because of the population served by UCCO facilities. However, she realizes during the meeting that there may be some issues with diversity and culture. Furthermore, how diversity and culture impact team performance. Several managers made comments regarding distribution of work and employee perspectives based on stereotypes. She also found out that there are many personality conflicts and issues with subordination. Barbara encountered the conflict and degradation comments, first-hand during the meeting.
Visit the Rasmussen online Library and search for a minimum of 3 articles covering diversity and culture and teamwork.
For this project assignment on UCCO complete a minimum of a 3 page report to address management of change with strategic planning and with the following concepts:
What is the role of executives in the process of change management and strategic planning? How do issues with diversity and culture relate to change management?
Why is diversity inclusion important? What are the benefits? Specifically address UCCO purpose for diversity.
Discuss how working with others can help with respect for diversity and respect for diverse perspectives.
What are the challenges and benefits of employing a diverse workforce?
What should Barbara's plan be for encouraging teamwork among a diverse workforce and ensuring that employees make meaningful and valuable contributions to team projects and tasks. Incorporate Barbara's personal experience with the team of clinic managers.
Remember to integrate citations accurately and appropriately for all resource types; use attribution (credit) as a method to avoid plagiarism. Use NoodleBib to document your sources and to complete your APA formatted reference page and in-text citations.
Transferable Skills for this Project Stage:
Diversity & Teamwork
Communication
.
Barbara schedules a meeting with a core group of clinic managers. Th.docxwilcockiris
Barbara schedules a meeting with a core group of clinic managers. The purpose of the meeting is to review the strategic plan and to gather additional feedback from the managers. Barbara is aware of the importance of diversity within the organization. Diversity and inclusion is particularly important because of the population served by UCCO facilities. However, she realizes during the meeting that there may be some issues with diversity and culture. Furthermore, how diversity and culture impact team performance. Several managers made comments regarding distribution of work and employee perspectives based on stereotypes. She also found out that there are many personality conflicts and issues with subordination. Barbara encountered the conflict and degradation comments, first-hand during the meeting.
Visit the Rasmussen online Library and search for a minimum of 3 articles covering diversity and culture and teamwork.
For this project assignment on UCCO complete a minimum of a 3 page report to address management of change with strategic planning and with the following concepts:
What is the role of executives in the process of change management and strategic planning? How do issues with diversity and culture relate to change management?
Why is diversity inclusion important? What are the benefits? Specifically address UCCO purpose for diversity.
Discuss how working with others can help with respect for diversity and respect for diverse perspectives.
What are the challenges and benefits of employing a diverse workforce?
What should Barbara's plan be for encouraging teamwork among a diverse workforce and ensuring that employees make meaningful and valuable contributions to team projects and tasks. Incorporate Barbara's personal experience with the team of clinic managers.
Remember to integrate citations accurately and appropriately for all resource types; use attribution (credit) as a method to avoid plagiarism. Use NoodleBib to document your sources and to complete your APA formatted reference page and in-text citations.
Discussed the importance of diversity inclusion, benefits, and purpose for diversity at UCCO, with examples and supportive references.
Discussed how working with others can help with respect for diversity and respect for diverse perspectives. Provided supportive examples and references.
Discussed the challenges and benefits of employing a diverse workforce, with examples and supportive references.
Discussed the role of executives in the process of change management and strategic planning, as well as issues with diversity and culture related to change management; with examples and supportive references.
Discussed plan for encouraging teamwork among a diverse workforce and ensuring that employees make meaningful and valuable contributions to team projects and tasks. Incorporated Barbara?s personal experience with the team of clinic managers and provided examples and supportive references.
Transferable Skills fo.
Barbara Rosenwein, A Short History of the Middle Ages 4th edition (U.docxwilcockiris
Barbara Rosenwein, A Short History of the Middle Ages 4th edition (University of Toronto, 2014). If you are unable to obtain the fourth edition, go ahead and get the fifth edition, but let us know. ISBN:9781442608023. Gene Brucker (Editor), Julia Martines (Translator), Two Memoirs of Renaissance Florence: The Diaries of Buonaccorso Pitti and Gregorio Dati.
If the territorial expansion, cultural accomplishments, and administrative innovations of the Frankish Kingdom during the Carolingian period, particularly during Charlemagne's, were ultimately temporary, why was his coronation as Holy Roman Emperor such a significant event? Explain with examples from the lectures and the textbook. No outside research or material is permitted.
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BARBARA NGAM, MPAShoreline, WA 98155 ▪ 801.317.5999 ▪ [email pro.docxwilcockiris
BARBARA NGAM, MPA
Shoreline, WA 98155 ▪ 801.317.5999 ▪ [email protected]
Hi tutor: Here is an example of my current cover letter, which I think it is not applicable or not good enough. Please use below format and build it off from my resume. Please point out my greatest skills and experiences from my resume into the cover letter so that recruiters can capturing or noticing my skills set and capability, thanks.
12/14/2018
Department: VM Foundation
Virginia Mason Medical Center
1100 9th Avenue
Seattle, WA. 98101
Re: Job Number: 182930
Dear Hiring Manager:
Dependable and energetic Accounting Professional with over 9 years of experience in general ledger, reporting, modelling, consolidation, analysis, reconciliations, closing and revenue cycle is seeking to obtain a position that will utilize my potential as a Senior Accountant. It would be privilege to put practice my accounting skills and knowledge gained in private and public accounting for the benefit of the organization.
From analyzing financial reports and overseeing accounts payable and receivable to implementing improved financial processes and providing excellent leadership skills, I excel in strategically directing infinite aspects of accounting activities. My demonstrated expertise in business and financial operations, along with my dedication to increasing productivity and efficiency prepares me to make a significant impact on your organization.
Please consider the following highlights of my experience:
· Accurately and expeditiously facilitated account reconciliations, risk assessments, auditing processes, invoice collection, financial analysis, wire transfer transactions, fixed assets, year-end preparations and month-end closing while providing a superior level of service and support to realize optimal financial performance.
· Successfully cleaned up company accounts by uncovering and writing off old debtors and duplicate creditors, clearing journals, and reclassifying expenses and assets in conjunction with external accountants.
· Collaborated effectively with cross-functional teams and external auditors to drive maximum productivity, efficiency, and accuracy.
· Excelled within time-sensitive, fast-paced atmospheres while resolving issues and ensuring compliance with internal policies and regulatory guidelines.
· In-depth knowledge of various computer applications, including the following: PeopleSoft, Oracle, Concur, Sage Fixed Assets (Sage FAS), Loan Accounting System (LAS) and Microsoft Office applications.,
At your convenience, I welcome an opportunity to meet with you to discuss your goals and objectives and how my experience and abilities can contribute to meeting and exceeding those goals.
Thank you very much for your time and consideration. I am looking forward to hearing from you soon.
Sincerely yours,
Barbara Ngam
BARBARA NGAM, MPA
Shoreline, WA 98155 ▪ 801.317.5999 ▪ [email protected]
SENIOR ACCOUNTANT
Proven success with budgets, financial analys.
Banks 5
Maya Banks
Professor Debra Martin
EN106DLGU1A2018
June 24, 2018
Unmasking the Prevailing Culprits in The Present-Day Education System
In pursuit of a holistic, critically provoking, meaningful, and educational oriented environment where teachers are free to teach, and learners are free to think, and the disappointing reality continues to present itself from every dimension. The faults in the current education system are critically unmasked by Mark Edmundson and Paulo Freire in their two invaluable pieces of articles. A careful analysis of the ideas tabled by the two influential education thinkers illustrates numerous underlying commonalities in their works as well as some overlooked ideas in their arguments. The fact that their central ideas in their respective scholarly works revolve around unmasking the true culprits in the present-day education implies that, if Edmundson and Freire were able to converse with each other, they would both agree on the need to change the current education system and build it around critical thinking. It’s to this end that this paper seeks to synthesize their ideas in an attempt to identify common grounds, differences as well the areas they both overlooked.
Looking at the prevailing schooling system in America as well as the ways through which learners are carrying out their studies, the perception of the two education thinkers is of great heed to the whole education system. Deeply entrenched into the Edmundson and Freire respective pieces of literature is the overarching conspiracy and oppression theme where the established, who is this case is the teacher among other the education leaders seek to contain, manipulate, and control the thoughts of the learners. As acknowledged by Freire, “Teachers either work for the liberation of the people- their humanization- or for their domestication, their dominance” (p.243). As a result of this domination and hierarchical relationship, the only knowledge that the learners in the prevailing education system receive are from the teachers, an aspect that dehumanizes the students as they do not get the chance to develop their own knowledge or even challenge the one received from the teachers. The oppression and domination ideology as presented by Freire cast invaluable light on the need for both teachers and students to embrace an “authentic” approach to education which grants them some chance to be aware of their respective incompleteness and eventually strive to be fully human (Freire 244). In a bid to rethink Freire’s oppression implication, as a college student one ought to act as a co-creator of knowledge at the expense of posing as an empty vessel waiting to be filled by the college professor or instructor.
Similarly, Edmundson acknowledges the presence of oppression in thinking and learning approaches in the contemporary schools, but from a different angle from the one used by Freire. While Freire profoundly argues that students are highly dehumanized a.
Banking industry•Databases that storeocorporate sensiti.docxwilcockiris
Banking industry:
• Databases that store
o corporate sensitive / proprietary information
o employee payroll, health records, etc.
o vendor information
o credit card information
other items as determined by the type of company
• Remote users that must be authenticated
• Security Measures and policies
• What policies need to be in place?
.
BAOL 531 Managerial AccountingWeek Three Article Research Pape.docxwilcockiris
BAOL 531: Managerial Accounting
Week Three: Article Research Paper and Posting Topics
Article Research Papers and Posting: This is a graduate course and students will be expected to research and write papers summarizing in their own words what they have found on current topics from the weekly readings. Research is a theoretical review and application of a topic to a specific industry or field.
The research must be conducted using peer-reviewed trade or academic journals. While Blogs, Wikipedia, encyclopedias, textbooks, popular magazines, newspaper articles, online websites, etc. are helpful for providing background information, these resources are NOT suitable resources for this research assignment.
Assignment Requirements:
i. Choose a research topic from the chapter readings or from the weekly list provided by your professor (See list or potential topics below from Chapter’s 1, 2, 4, 5, and 6).
ii. Research/find a minimum at least one (1), preferably two (2) different peer-reviewed articles on your topic from the University of the Cumberlands Library online business database. The article(s) must be current/published within the last five (5) years.
iii. Write a three (3) to four (4) page double spaced paper in APA format discussing the findings on your specific topic in your own words. Note - paper length does not include cover page or References page.
iv. Structure your paper as follows:
a. Cover page
b. Overview describing the importance of the research topic in your own words
c. Purpose of Research of the article in your own words
d. Review of the Literature summarized in your own words
e. Conclusion in your own words
f. Personal Thoughts
g. References
v. An example paper has been provided for students (attached to email along with this document). Please review this paper for proper structure and APA formatting.
vi. Attach your paper to the Discussion board by the Saturday due date (150 points).
vii. Read and respond to at least four (4) other student postings by the Sunday due date (20 points).
Week Three: Article Research Paper and Posting – List of potential research topics from Chapter’s 1, 2, 4, 5, and 6.
1. Evolution of Management Accounting
2. Decision Management
3. Balanced Scorecard
4. Historical Cost in Accounting
5. Operating Leverage
6. Controllability Principle
7. Lean Accounting Systems
8. Responsibility Accounting
9. Return on Investment as a measurement tool (ROI)
10. Opportunity Costs
11. Performance Measurement System in management
12. Performance Reward System in management
13. Budget Sandbagging
14. Budget Gaming techniques
15. Ratchet Effect of Budgeting
16. Participative Budgeting
17. Strategic Planning and Budgeting
18. Line-item Budgeting
19. Rolling Budget technique
20. Zero-based budgeting
21. Any other managerial accounting topics you wish to pursue from Chapter’s 1, 2, 4, 5, and 6.
Grading Criteria:
· Content & Structure (75 points): All of the requested components are completed as assigned; cont.
bankCustomer1223333SmithJamesbbbbbb12345 Abrams Rd Dallas TX 75043185019123220001000.0005138970142250020101113334LeLiemaaaaaa444 Coit Rd Plano TX 75075137366879810002010111347749515001000.00051212121BellamyKevinbellbell34 GreenVille Richardson TX 75080143233432140020101232123PescadorCharlespescpesc44 Summit Plano TX 750931321668712125020101234432DominguezJohnsondomidomi5551 Monfort Dallas TX 750421543442343240020101234534TranVantrantran1000 Coit Rd Plano TX 7507514325512341801000.00051234567SmithArmandosmithsmith123 Walnut rd Dallas TX 7424311234567892201000.00051313131BluittMarkblutblut222 St. Ann Allen TX 7521316543345671280201011111111113801000.00051455415CoronadoChristcorocoro56 Campbell Rd Richardson TX 750821432331234112020102312435TrinhLaurentrintrin2800 Spring Creek Plano TX 75074143216765436020102323232BurnsJoneburnburn1234 Plano Rd Dallas TX 7524013214432452971000.00052345432NeangWilliamsneannean8109 Scott lane Plano TX 750141234556545180020103214566FanTiffanyfannfann4321 Coit Rd Plano TX 750751765112343220020103344555TorresWannertorrtorr121 Custer Rd Plano TXx 750251543556712321020103456654EsquivelOrlandoesquesqu43 International Rd Dallas TX 752401123554345481020104322344FitzhughLaurenfitzfitz232 Park Rd Plano TX 750931234554345221820104323433RemschelTinaremsrems125 Alma rd Plano TX 75023143211567847101000.0005122222222240020104343434BryantAnnbuyabuya4343 Goerge Prince Plano TX 75075123455432121020105225525CaveStevencavecave154 James St Arlington TX 75042176566543440020105433455KuykendalDevinkuykkuyk25E Parker Rd Plano TX 7507412314454655302010143557722140001000.00055456545NguyenBobnguynguy2323 Floy Rd Richardson TX 750801234665456216520106543123CrowleyMattcrowcrow111 Jose lane Dallas TX 75042112311234321551000.00056543456NguyenMarynguynguy354 Duche Allen TX 7501312341132653202010213321455712001000.00057654321KennedyJohnsonkennkenn43 Buckingham Dallas TX 752401987654321166020107655677MunozJosemunomuno324 Hedgecox Rd Plano TX 7502517651123432882010
Student 1 & 2
Reply to 2 of your classmates' threads. Each reply must be 150 words and comment on their ability to synthesize, not merely summarize, their selected texts. Offer specific examples to encourage them and possible revisions to make it a stronger synthesis.
Student #1 Post
Top of Form
A broad, general problem seen throughout the country is the integration of online course work into the public-school classroom. Technology is integrated into all levels of education: pre-K, elementary, secondary, and higher education (Leggatt, 2016). It began with a modest inclusion of videos or allowing students to research using school-provided laptops or tablets. This was the simple way of using technology. Now that technology is more accessible and affordable, districts are providing students with digital devices to use in and out of schools, allowing them to utilize their phones, and requiring them to complete coursework online outside of the classroom (Hohlfeld, Ritzhaupt, Dawson, & Wilson,.
Barbara and Judi entered into a contract with Linda, which provi.docxwilcockiris
Barbara and Judi entered into a contract with Linda, which provided that they open a jewelry store in Fullerton. Linda is obligated to supply all jewelry in accordance with a specified price list. Linda also agreed that she would not personally compete or supply another retail merchant, either directly or indirectly, within the City of Fullerton.
Linda, in order to give the necessary credit to Barbara and Judi, required that Joanne act as a guarantor. Barbara and Judi have been very successful, making substantial profits each month.
After one year's time, Barbara, who also has an additional job as a legal secretary, requires an extended vacation. Judi is fully in agreement. While Barbara is on her vacation, Linda sells jewelry to three additional retailers, all of whom, in the space of one week, open competitive shops in Fullerton. Linda's agreement with the new retailers is to provide inventory to the new stores at a substantially reduced cost, permitting them to sell retail at rates far below Judi and Barbara's cost. In one month's time, Judi closes the business and, unknown to Barbara, files suit in Federal District Court, alleging breach of contract on Linda's part and further alleging that she only has been damaged. Barbara returns from her extended vacation one month after the suit is filed and files a motion to intervene under Rule 24. Linda files a motion under Rule 19, alleging that Barbara should be joined as a party. Joanne, who lives in Nevada, learns of the lawsuit and asks her attorney to file a motion to intervene under Rule 24. Linda, in the requisite time, files her answer and files a motion under Rule 14 to implead the Rhodesian Diamond Company, her supplier and with whom she has a contract which required that she increase her sales and open new offices or lose her contract.
Assume proper jurisdiction of the subject matter, parties and venue. Discuss all civil procedure issues and give proper argument concerning motions made by Linda, Joanne and Barbara.
Discuss your answers in a very full narrative IRAC essay with much detail.
.
Bank ReservesSuppose that the reserve ratio is .25, and that a b.docxwilcockiris
Bank Reserves
Suppose that the reserve ratio is .25, and that a bank has actual reserves of $15,000, loans of $40,000, and demand deposits of $50,000.
A. Excess reserves are $____________________.
B. This bank, being a single bank in a multibank system, can safely lend $____________________.
C. The multibank system can safely lend $__________________.
D. It is possible for the monetary base to increase by a total of $___________________. Assume now that the Fed lowers the reserve ratio to .20:
E. This bank, being a single bank in a multibank system, can now safely lend $_____________________.
F. The multibank system can safely lend $____________________.
G. It is now possible for the monetary base to increase by a total of $________________________.
H. The increase/decrease in the potential money supply because of the decrease in the required reserve ratio is $_____________________.
.
Baldwin's Kentucky Revised Statutes Annotated
Title XXXV. Domestic Relations
SuperBrowse Chapter 403. Dissolution of Marriage; Child Custody (Refs & Annos)
SuperBrowse Custody
1. Proposed Legislation
Effective: July 14, 2018
KRS § 403.270
403.270 Custodial issues; best interests of child shall determine; rebuttable presumption that joint custody and equally shared parenting time is in child’s best interests; de facto custodian
Currentness
(1) (a) As used in this chapter and KRS 405.020, unless the context requires otherwise, “de facto custodian” means a person who has been shown by clear and convincing evidence to have been the primary caregiver for, and financial supporter of, a child who has resided with the person for a period of six (6) months or more if the child is under three (3) years of age and for a period of one (1) year or more if the child is three (3) years of age or older or has been placed by the Department for Community Based Services. Any period of time after a legal proceeding has been commenced by a parent seeking to regain custody of the child shall not be included in determining whether the child has resided with the person for the required minimum period.
(b) A person shall not be a de facto custodian until a court determines by clear and convincing evidence that the person meets the definition of de facto custodian established in paragraph (a) of this subsection. Once a court determines that a person meets the definition of de facto custodian, the court shall give the person the same standing in custody matters that is given to each parent under this section and KRS 403.280, 403.340, 403.350, 403.822, and 405.020.
(2) The court shall determine custody in accordance with the best interests of the child and equal consideration shall be given to each parent and to any de facto custodian. Subject to KRS 403.315, there shall be a presumption, rebuttable by a preponderance of evidence, that joint custody and equally shared parenting time is in the best interest of the child. If a deviation from equal parenting time is warranted, the court shall construct a parenting time schedule which maximizes the time each parent or de facto custodian has with the child and is consistent with ensuring the child's welfare. The court shall consider all relevant factors including:
(a) The wishes of the child's parent or parents, and any de facto custodian, as to his or her custody;
(b) The wishes of the child as to his or her custodian, with due consideration given to the influence a parent or de facto custodian may have over the child's wishes;
(c) The interaction and interrelationship of the child with his or her parent or parents, his or her siblings, and any other person who may significantly affect the child's best interests;
(d) The motivation of the adults participating in the custody proceeding;
(e) The child's adjustment and continuing proximity to his or her home, school, and community;
(f) The mental and physical health of all in.
Bank confirmations are critical to the cash audit. What information .docxwilcockiris
Bank confirmations are critical to the cash audit. What information does the auditor obtain by sending bank confirmations? Explain the different types of bank confirmations and what assertions each type addresses. How do you determine which is the best bank confirmation type to use ?
.
BalShtBalance SheetBalance SheetBalance SheetBalance SheetThe Frank Beverage GroupThe Frank Beverage GroupThe Frank Beverage GroupThe Frank Beverage GroupFirst QuarterSecond QuarterThird QuarterFourth Quarter2019-20202019-20202019-20202019-2020ASSETSASSETSASSETSASSETSCurrent AssetsCurrent AssetsCurrent AssetsCurrent AssetsCash$110,102Cash$161,052Cash$186,936Cash$219,214Accounts Receivable$35,569Accounts Receivable$37,746Accounts Receivable$40,057Accounts Receivable$42,508Inventory-$1,887Inventory$14,313Inventory$31,504Inventory$50,300Other Current Assets$0Other Current Assets$0Other Current Assets$0Other Current Assets$0Total Current Assets$143,784Total Current Assets$213,111Total Current Assets$258,497Total Current Assets$312,022Fixed AssetsFixed AssetsFixed AssetsFixed AssetsLand$0Land$0Land$0Land$0Facilities$0Facilities$0Facilities$0Facilities$0Equipment$0Equipment$0Equipment$0Equipment$0Computers & Telecommunications$0Computers & Telecommunications$0Computers & Telecommunications$0Computers & Telecommunications$0(Less Accumlated Depreciation)$0(Less Accumlated Depreciation)$0(Less Accumlated Depreciation)$0(Less Accumlated Depreciation)$0Total Fixed Assets$0Total Fixed Assets$0Total Fixed Assets$0Total Fixed Assets$0Other Assets$0Other Assets$0Other Assets$0Other Assets$0TOTAL ASSETS$143,784TOTAL ASSETS$213,111TOTAL ASSETS$258,497TOTAL ASSETS$312,022LIABILITIESLIABILITIESLIABILITIESLIABILITIESCurrent LiabilitiesCurrent LiabilitiesCurrent LiabilitiesCurrent LiabilitiesShort-Term Notes Payable$9,873Short-Term Notes Payable$9,997Short-Term Notes Payable$10,122Short-Term Notes Payable$10,249Income Taxes Due$16,109Income Taxes Due$34,046Income Taxes Due$46,006Income Taxes Due$59,618Other Current Liabilities$0Other Current Liabilities$0Other Current Liabilities$0Other Current Liabilities$0Total Current Liabilities$25,982Total Current Liabilities$44,043Total Current Liabilities$56,128Total Current Liabilities$69,868Long-Term LiabilitiesLong-Term LiabilitiesLong-Term LiabilitiesLong-Term LiabilitiesLong-Term Notes Payable$7,735Long-Term Notes Payable$5,189Long-Term Notes Payable$2,610Long-Term Notes Payable-$0Other Long-Term Liabilities$0Other Long-Term Liabilities$0Other Long-Term Liabilities$0Other Long-Term Liabilities$0Total Long-Term Liabilities$7,735Total Long-Term Liabilities$5,189Total Long-Term Liabilities$2,610Total Long-Term Liabilities-$0NET WORTHNET WORTHNET WORTHNET WORTHPaid-In Capital$61,740Paid-In Capital$61,740Paid-In Capital$61,740Paid-In Capital$61,740Retained Earnings$48,327Retained Earnings$102,139Retained Earnings$138,018Retained Earnings$180,414Total Net Worth$110,067Total Net Worth$163,879Total Net Worth$199,758Total Net Worth$242,154TOTAL LIABILITIES AND NET WORTH$143,784TOTAL LIABILITIES AND NET WORTH$213,111TOTAL LIABILITIES AND NET WORTH$258,497TOTAL LIABILITIES AND NET WORTH$312,022
For information about this worksheet, see "Balance Sheet" in "The Financials" chapter of Successful Business Plan: Secrets & Strategies..
BAM 515 - Organizational Behavior(Enter your answers on th.docxwilcockiris
BAM 515 - Organizational Behavior
(Enter your answers on the enclosed answer sheet)
1) The members of a ________ work together intensively via electronic means, and may never actually meet.
A) cyber group
B) digital team
C) virtual team
D) electronic group
2) The risks associated with planning can be reduced by an understanding of all of the following except
A) decision making.
B) team composition.
C) political science.
D) individual biases.
3) The way managers lead is changing because millions of employees work in
A) downsized organizations.
B) self-managed teams.
C) expanding positions.
D) outsourced functions.
4) Which of the following is not one of the three principal kinds of skills needed by managers?
A) Human
B) Analytical
C) Technical
D) Conceptual
5) An ________ is a rule or routine an employee follows to perform some task in the most effective way.
A) organizational pattern
B) organizational procedure
C) organizational routine
D) organizational schematic
Unit 1 Examination
51
BAM 515 - Organizational Behavior
6) An organization’s workforce consists of workers of different ages, religions, and socioeconomic backgrounds, all of which contribute to its
A) social responsibility.
B) ethics.
C) affirmative action.
D) diversity.
7) The ________ involves responding to the diverse needs of employees and developing employment approaches that promote the well-being of employees.
A) flexibility challenge
B) decision-making challenge
C) fairness and justice challenge
D) performance challenge
8) Organizational behavior is relevant to crisis management because it provides ________ needed to respond to a crisis.
A) guidelines, procedures, and boundaries
B) definitions and contextual perspectives
C) lessons about how to manage and organize the resources
D) an overview of sound management principles
9) ________ consists of computer and communication hardware and software, and the
skills of designers, programmers, technicians, and managers.
A) Strategic capital
B) Knowledge management
C) Corporate knowledge
D) Information technology
10) Standard Textile Company’s Chinese employees are not always comfortable
A) taking the initiative.
B) performing their jobs well.
C) learning new techniques.
D) All of the above
Unit 1 Examination
52
BAM 515 - Organizational Behavior
11) Psychologists have studied identical twins and have
A) attempted to determine to what extent personality is inherited.
B) been unable to determine what impact nature or nurture has on personality development.
C) identified specific genes that are responsible for inherited personality.
D) determined that the personalities of twins are impacted more by nature than are the personalities of non twins.
12) Individuals with an________ tend to believe that outside forces are largely responsible for their fate.
A) extrasensory locus of control
B) external locus of control
C) interdepartmental locus of control
D) internal loc.
BalanchineGeorge Balanchine is an important figure in the histor.docxwilcockiris
Balanchine
George Balanchine is an important figure in the history of ballet as he was a major exponent of ballet in the US. He established the first school of American ballet in NYC with Lincoln Kirstein in 1934. Balanchine’s style has been called Neoclassical and the success of his NYC Ballet has spawned many regional companies in the US, including Miami City Ballet, keeping his repertory alive. Balanchine brought a new aesthetic to ballet, stripping away its sentimentality and bringing attention to the movement rather than the spectacle. He brought quick footwork, precision and musicality to classical ballet technique. He collaborated extensively with the composer Stravinsky. His work with the Ballet Russe in the early 20th century exposed Balanchine to the most prominent musical composers and visual artists of the period (i.e. Picasso, Matisse, etc.) which influenced his experimentation with abstraction in the form.
Ballet continues to evolve today. Traditional classical ballets such as Sleeping Beauty and Swan Lake are still performed today with the addition of more contemporary interpretations of the form. Some examples of contemporary ballet:
Modern Dance
Modern dance began as a departure from the restrictions of ballet and a desire to express a wider palette of the human experience. It emphasized the expression of emotion, the exploration of dynamics in the body and presented narratives in a more abstract manner. Some modern dance pioneers eventually developed their own codification and/or process for working. The postmodern dancers rejected codification of any kind as well as known methods for composition. They valued personal movement, innovative forms of performance and preferred abstraction over story telling.
Pioneers of Modern Dance
Isadora Duncan 1877-1927, believed movement should be drawn from nature and was inspired by Ancient Greece, wearing long toga-like robes in her performances. The Duncan technique was comprised of movements such as hopping, swinging, running, skipping and leaping; her desire was to free the body from the confines of ballet.
Ruth St Denis 1878-1968, was inspired by the dances of Asia, in addition to other culturally based forms. She is well known for her grand spectacles, creating a formal school/company. Her husband Ted Shawn was also a pioneer in modern dance who created an all male dance company in addition to performing with Ruth. Martha Graham was a student Ruth St. Denis and later became a member of her company.
Mary Wigman 1886-1973, was a German dancer/choreographer inspired by Expressionism, an artistic movement that emphasized raw emotions. She was a student of Rudolf Laban. In her famous Witch Dance, she went against traditional norms of female beauty in dance.
https://www.youtube.com/watch?v=AtLSSuFlJ5c
Rudolf Laban 1879-1958, is sometimes referred to as the father of German modern dance; he developed a system for notating dance called Labanotation in addition to developin.
it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
Walmart Business+ and Spark Good for Nonprofits.pdfTechSoup
"Learn about all the ways Walmart supports nonprofit organizations.
You will hear from Liz Willett, the Head of Nonprofits, and hear about what Walmart is doing to help nonprofits, including Walmart Business and Spark Good. Walmart Business+ is a new offer for nonprofits that offers discounts and also streamlines nonprofits order and expense tracking, saving time and money.
The webinar may also give some examples on how nonprofits can best leverage Walmart Business+.
The event will cover the following::
Walmart Business + (https://business.walmart.com/plus) is a new shopping experience for nonprofits, schools, and local business customers that connects an exclusive online shopping experience to stores. Benefits include free delivery and shipping, a 'Spend Analytics” feature, special discounts, deals and tax-exempt shopping.
Special TechSoup offer for a free 180 days membership, and up to $150 in discounts on eligible orders.
Spark Good (walmart.com/sparkgood) is a charitable platform that enables nonprofits to receive donations directly from customers and associates.
Answers about how you can do more with Walmart!"
The simplified electron and muon model, Oscillating Spacetime: The Foundation...RitikBhardwaj56
Discover the Simplified Electron and Muon Model: A New Wave-Based Approach to Understanding Particles delves into a groundbreaking theory that presents electrons and muons as rotating soliton waves within oscillating spacetime. Geared towards students, researchers, and science buffs, this book breaks down complex ideas into simple explanations. It covers topics such as electron waves, temporal dynamics, and the implications of this model on particle physics. With clear illustrations and easy-to-follow explanations, readers will gain a new outlook on the universe's fundamental nature.
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...PECB
Denis is a dynamic and results-driven Chief Information Officer (CIO) with a distinguished career spanning information systems analysis and technical project management. With a proven track record of spearheading the design and delivery of cutting-edge Information Management solutions, he has consistently elevated business operations, streamlined reporting functions, and maximized process efficiency.
Certified as an ISO/IEC 27001: Information Security Management Systems (ISMS) Lead Implementer, Data Protection Officer, and Cyber Risks Analyst, Denis brings a heightened focus on data security, privacy, and cyber resilience to every endeavor.
His expertise extends across a diverse spectrum of reporting, database, and web development applications, underpinned by an exceptional grasp of data storage and virtualization technologies. His proficiency in application testing, database administration, and data cleansing ensures seamless execution of complex projects.
What sets Denis apart is his comprehensive understanding of Business and Systems Analysis technologies, honed through involvement in all phases of the Software Development Lifecycle (SDLC). From meticulous requirements gathering to precise analysis, innovative design, rigorous development, thorough testing, and successful implementation, he has consistently delivered exceptional results.
Throughout his career, he has taken on multifaceted roles, from leading technical project management teams to owning solutions that drive operational excellence. His conscientious and proactive approach is unwavering, whether he is working independently or collaboratively within a team. His ability to connect with colleagues on a personal level underscores his commitment to fostering a harmonious and productive workplace environment.
Date: May 29, 2024
Tags: Information Security, ISO/IEC 27001, ISO/IEC 42001, Artificial Intelligence, GDPR
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Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...
Implementation and evaluation of anursing assessmentstandin.docx
1. Implementation and evaluation of a
nursing assessment/standing orders–
based inpatient pneumococcal
vaccination program
Carl Eckrode, MPH, RRT-NPS,b Nancy Church, RN, MT,a and
Woodruff J. English III, MDa
Portland and Gresham, Oregon
Background: Pneumococcal vaccination is recommended for
patients aged 65 years and greater; inpatient vaccination has
been
suggested as means to increase vaccination rates is this
population. Our hospital implemented an inpatient
pneumococcal vacci-
nation program, and expanded the population of interest to
include patients aged 2 to 64 years with risk factors for
pneumococcal
bacteremia. We studied the outcomes of this program to
determine if the rate of pneumococcal vaccination opportunities
and
pneumococcal vaccination rate could be significantly increased
through the application of an in-hospital pneumococcal vaccina-
tion program, based on standing orders and assessment by
Registered Nurses, when compared to our previous method of
physi-
cian assessment and written vaccination order for each patient.
Methods: Subjects were inpatients admitted to non-intensive
care units of our hospital from August to December of 2004.
Cases
were aged greater than 65 years, or were greater than 2 years of
age with selected risk factors. Patients with previous
2. pneumococcal
vaccination with the past five years, in terminal or comfort care,
those allergic to vaccine components, patients who received
organ
or bone marrow transplants in the year prior to the study, and
those physicians barred them from the vaccination protocol
were
excluded. Program effectiveness was evaluated through
retrospective evaluation of medical records to determine if
subjects had
been evaluated for vaccination eligibility, and if subjects were
eligible, whether or not they had received pneumococcal
vaccination.
Results: Overall vaccination opportunity rate after
implementation of the standing orders-based program increased
form 8.6% to
59.1%, and overall vaccination rates improved form 0% to
15.4%. The study found a statistically significant difference in
the rate
of pneumococcal vaccination opportunities (x2 = 182.46, p =
.00) and the pneumococcal vaccination rate (x2 = 56, p = .00)
between the two methods of assessment and vaccination; these
results are attributable to the study intervention.
Conclusions: The study program contributed to increased
overall vaccination opportunity and vaccination rates, when
compared
to the previous method. The overall rates of vaccination
attained by this program were often lower than those reported in
the ex-
isting literature for other program designs; however, this may
be due to an unusually high rate of vaccination refusal. (Am J
Infect
Control 2007;35:508-15.)
The significance of invasive pneumococcal disease
cannot be understated, because disease caused by
Streptococcus pneumoniae has been reported to be
3. responsible for an estimated 36% of community-
acquired pneumonia, an estimated 50% of nosocomial
pneumonias, 50,000 cases of bacteremia, and an esti-
mated 3000 to 6000 cases of meningitis each year in
the United States.1 Forty thousand deaths have been re-
ported each year from pneumococcal infection,2,3 with
an estimated 175,000 hospitalizations due to the dis-
ease each year in the United States.1 The case-fatality
From the Infection Control Department,a Providence St.
Vincent Hos-
pital and Medical Center, Portland, Oregon; and Respiratory
Care
Program,b Mt. Hood Community College, Gresham, Oregon.
Address correspondence to Carl Eckrode, MPH, RRT-NPS, Mt.
Hood
Community College, 26000 SE Stark Street, Gresham, OR
97222.
0196-6553/$32.00
Copyright ª 2007 by the Association for Professionals in
Infection
Control and Epidemiology, Inc.
doi:10.1016/j.ajic.2006.08.005
508
can range up to 60% for elderly patients who have
pneumococcal bacteremia.1 The comorbid condition
of bacteremic pneumococcal disease, pneumococcal
pneumonia, has a case-fatality of 5% to 7%;1-6 as
one of the leading infectious causes of death in the
United States,7 it has killed more persons annually
than AIDS, tuberculosis, meningitis, and endocarditis
combined.8 This degree of morbidity and mortality
4. from a vaccine-preventable disease is unacceptable;
vaccination has been proven to reduce morbidity and
mortality significantly.9
The current pneumococcal vaccine for adults, the
23-Valent Pneumococcal Polysaccharide Vaccine (23PPV)
(Pneumovax, Pasteur-Merieux MSD, Malvern, PA; Pnu-
Imune, Wyeth-Lederle, Pearl River, NY), is well targeted
against many of the S pneumoniae serotypes that
are responsible for illness. For example, in a study of
pneumococcal disease, 78 isolates were recovered
from patients who had pneumococcal pneumonia.
Seventy-one of those isolates (91%) were remarkable,
in that the serotype of the isolated organism was one
that was included in the 23-valent pneumococcal
Eckrode, Church, and English October 2007 509
vaccine.10 The pneumococcal vaccine has been found
safe, with reports of serious reactions rare,11-13 although
they are more likely on revaccination.14 Reactions that
do occur to the 23PPV typically are local reactions and
low-grade fever, which generally are self-limiting,15
and may be more likely in patients who have coinciden-
tal upper respiratory illness.12 One of the rare systemic
reactions reported was reversible, and may have been
associated with a simultaneous influenza vaccination.16
Although the efficacy of the 23PPV for prevention
of pneumonia is still subject to discussion and study,
an overwhelming amount of evidence and expert
opinion support the contention that it is efficacious
and cost-effective in immunocompetent patients and
those whose diminished immune responses place
5. them at risk for bacteremic pneumococcal dis-
ease.3,4,11,17-26 The body of evidence clearly supports
the vaccine’s efficacy; however, historically the pneu-
mococcal polysaccharide vaccine has been underutil-
ized.11,27-29 In response, the Centers for Disease
Control and Prevention (CDC) Healthy People 2010 ob-
jective for pneumococcal vaccination in people greater
than 65 years of age was set at 90% of elderly ever vac-
cinated, and objectives were set for vaccination targets
of 60% coverage with pneumococcal vaccines among
high-risk adults aged 16 to 64 years.30 Nonetheless,
by 2002, only 62% of adults older than 65 years had
received the pneumococcal vaccine.8 A recent report
shows only slight progress in 2003, to a median of
64.2%, still well below the national health objectives
for 2010 of 90%.31 These low rates may be due to a
lack of formal programs to ensure proper screening
and vaccine administration,32 various beliefs on vacci-
nation held by the targeted populations,33 or a combi-
nation of factors. Whatever the reasons, these low
vaccination rates can have serious negative sequelae.
For instance, two thirds of persons who had serious
pneumococcal disease had been hospitalized within
the previous 4 years before their pneumococcal illness,
yet few had received pneumococcal vaccine.2,7,9,10
Many strategies for increasing pneumococcal vacci-
nation rates have been examined. Among the many
methods for increasing vaccination opportunity, hospi-
tal-based vaccination programs are appealing, given
that inpatients often are within the populations that
are at high risk for invasive pneumococcal disease.26,34
Support for inpatient pneumococcal vaccination dates
back to the early 1990s.11,20 Thus, the Advisory Com-
mittee on Immunization Practices (ACIP)35 and the Task
6. Force on Community Preventive Services have recom-
mended administration of pneumococcal polysaccharide
vaccines to inpatients.11,34,36 Hospital-based vaccination
also may be more cost-effective than a mass vaccination
effort, because of the selective targeting of the at-risk
population. To take advantage of this selective targeting,
a variety of approaches to inpatient pneumococcal vacci-
nation has been attempted, such as the use of nurses,
pharmacists, and other nonphysician providers for
screening and identification of eligible patients.1,26,37,38
Programs also have relied on written physician orders
or patient education to increase vaccination rates,37,38
whereas others attempted to combine pneumococcal
vaccination into a clinical pathway for pneumonia treat-
ment.39 The degree of success of these programs varied
widely.
Because of the clear value of hospital-based pneu-
mococcal vaccination programs, the CDC and ACIP
have promoted proactive approaches, such as the use
of standing orders to simplify the vaccination process
and ensure that every patient who enters the health
care system is immunized.8,40,41 To aid institutions in
implementing a standing orders–based program, the
Centers for Medicare and Medicaid Services (CMS)
promulgated a significant administrative rule change.
Relieving one of the major barriers to implementa-
tion of inpatient vaccination programs, CMS standards
changed to allow the use of standing orders for pneu-
mococcal and influenza vaccination.42 Additionally,
CMS levied the requirement to provide pneumococcal
vaccination to inpatients aged 65 years or greater.
The CMS administrative rule change on standing orders
enabled institutions to devise programs that permitted
7. nonphysician providers to assess patients and adminis-
ter medications, including vaccines, according to an
institution-approved protocol, without a physician’s
examination or individual, patient-specific orders.
Our program was designed in response to an unac-
ceptably low pneumococcal vaccination rate. For the
year prior to program inception (ie, 2003), the inpatient
pneumococcal immunization rate in our hospital was
only 13%. Given the scope of our problem, it was nec-
essary to plan and implement a vaccination program
carefully, but quickly. This was an institutional priority,
facilitated by the new CMS positions on pneumococcal
vaccination and standing orders. Thus, the organization
elected to use Borg and Gall’s Research and Develop-
ment Cycle, as applied to creating a health promotion
program;43 the use of this model allowed for a rapid pro-
gram development. We elected to use the registered
nurse in the role of assessor and for vaccination deliv-
ery. This study assessed the success of this program
for the first 90 days after program implementation.
METHODS
The research method chosen for our study was the
field experiment; the study design chosen was the
Comparison Group Posttest-Only Design.44 The com-
parison group was selected from the population of inpa-
tients who met the program criteria for pneumococcal
510 Vol. 35 No. 8 Eckrode, Church, and English
vaccination during the 90 days prior to program imple-
mentation. The study group was selected from the pop-
ulation who met the program criteria for vaccination
8. during the 90 days after program implementation. Ran-
dom assignment within the groups was performed.
The outcomes of interest—the percentage of eligible
subjects provided with vaccination opportunity and
vaccine delivery—can be measured accurately, despite
variations in and between the sample groups.
Data collection
A computer-generated list of patients who were
admitted to the inpatient units was provided to the
Providence St. Vincent Hospital and Medical Center
Infection Control Department, and medical chart docu-
ments were obtained electronically. These documents
are collected routinely, and these records were used
to obtain the information for evaluation of the pro-
gram. The use of this existing data did not require the
development or implementation of a survey instru-
ment or questionnaire.
The records for the sampled patients were evaluated
to determine if the patient was offered vaccination,
and, if the patient consented, received the pneumococ-
cal vaccination. The records evaluated included the
medication administration record, signed pneumococ-
cal vaccine orders, or signed vaccine consent forms
(a local requirement) with the date, dose, and vaccine
lot number entered. This data was converted to, and
recorded as, categorical (nominal) data (eg, the patient
was offered vaccination or the patient was not offered
vaccination, and the patient received the vaccination
or the patient did not receive the vaccination). The data
were entered into a coding sheet, using the Microsoft
Excel 2002 software package (Microsoft, Redmond,
WA). After conversion and coding, the percentage of
eligible randomly sampled patients who were or
9. were not offered vaccination, and who did or did not
receive the vaccination was calculated and compared
with the number of randomly sampled patients who
were or were not offered vaccination and who did or
did not receive vaccination prior to program
implementation.
Security and confidentiality of data were maintained
throughout the process, through multiple security mea-
sures (eg, use of passwords on computers, ‘‘sanitizing’’
records to remove protected health information, secur-
ing records in locked storage when not in use, and the
use of strong encryption (PGP 7.03, Network Associates,
Dallas, TX) for data stored in portable media). Patient
identifiers, such as name or medical record number,
were not recorded on coding forms or in newly created
databases. Documents containing protected health infor-
mation were destroyed by shredding subsequent to use.
Human/animal subjects
This was a study of a system for ensuring vaccina-
tion opportunity and administration, and no human
or animal experimentation was performed. The pneu-
mococcal polysaccharide vaccine is approved for use
in the study population, and no deviation from the pur-
pose of the approved use (‘‘off-label’’ use) occurred.
Thus, Institutional Review Board approval was not re-
quired. All patients or their representatives were pro-
vided with language-appropriate vaccine information
statements as part of the vaccination protocol. This
reflected local hospital policy.
Study sample
Study subjects included the population of Provi-
dence St. Vincent Hospital and Medical Center inpa-
10. tients during the months of September, October, and
November, aged 65 years or greater, and inpatients be-
tween 2 and 64 years of age with the presence of one
or more risk factors for pneumococcal disease. For this
study, high-risk patients were defined as those with
medical conditions that significantly increase a patient’s
vulnerability to pneumococcal pneumonia or invasive
pneumococcal disease, making them eligible for pneu-
mococcal vaccination if aged between 2 and 64 years.
These factors included cardiovascular disease (IDC-
9-CM 331-336, 340-345, 347, 358, 359, 393-429, 440.9),
cerebrovascular disease (ICD-9-CM 430-438), lower
and chronic respiratory diseases (ICD-9-CM 466, 480-
487, 490-496, 500-505, 506.4, 508, 510-519), renal
disease (ICD-9-CM 580-586), diabetes mellitus (ICD-
9-CM 250), chronic alcoholism and its complications
(ICD-9-CM 291, 303, 571, 577), sickle cell disease (ICD-
9-CM 282.5), asplenia (functional or anatomic) (ICD-9-
CM 45.1), and malignant neoplasms (ICD-9-CM 140-233).
These risk factors were selected by physicians and other
practitioners during design of the Providence St. Vin-
cent program, reflecting ACIP-identified risk factors. Pa-
tients who were excluded from the study were those in
terminal or comfort care; those allergic to vaccine com-
ponents; patients who received organ or bone marrow
transplants in the year prior to the study; anyone who
received pneumococcal vaccination in the 5 years prior
to the study; patients in critical care, short-stay, emer-
gency, and obstetrics units; and those whose physicians
have excluded them from the vaccination protocol.
Statistical analysis
The intervention factor (independent variable) in
this study was the implementation of a program for
administration of the pneumococcal vaccine prior
11. to discharge. Measurements included evaluation of
medical record documentation of assessment for
Eckrode, Church, and English October 2007 511
vaccination eligibility (opportunity), actual vaccina-
tion, patient age, and presence of ACIP-identified risk
factors in the primary diagnosis (by ICD-9-CM code).
The outcome (dependent) variables of interest were as-
sessment for vaccination eligibility (provision of vacci-
nation opportunity) and actual vaccinations given.
All statistical analyses were accomplished using
the SPSS 10.1 for Windows (SPSS, Chicago, IL) software
package. The x2 (goodness of fit/likelihood ratio tests)
statistics were used for analysis of categorical variables,
to determine the strength of association between the
program implementation and rates of opportunity
and vaccination, using the uncorrected x2 statistic for
2 3 2 contingency tables.45,46 Statistical significance
was considered at P , .05.
RESULTS
Data gathered for the first 90 days after program
implementation revealed that, of 5072 inpatients in
the affected units, 1106 (28%) met the program criteria
for pneumococcal vaccination. Data for the 90 days
prior to program implementation revealed that, of
5543 inpatients in the affected units, 2874 (52%) met
the program criteria for pneumococcal vaccination.
Based on these data, a random sample of patients
was drawn for further evaluation. Actual calculation
of sample size was performed by use of the Raosoft
Sample Size Calculator (Raosoft 2004, Seattle, WA).
12. For the population eligible for pneumococcal vaccina-
tion during the 90-day period after program interven-
tion (N = 1106), the sample size was 286 (Table 1).
Two hundred and eighty-six subjects were randomly
selected from the postintervention population, based
on a value obtained from a random number table. For
the population eligible for pneumococcal vaccination
during the comparison period (N = 2874), the sample
Table 1. Demographic characteristics of sampled
patients, first 90 days postintervention (study group)
Characteristics N = 286 (%)
Patients
Male 99 (34.6%)
Age in years (mean) 70.91
Risk factors (n = 137)
Cardiac disease 64 (22.4%)
Cancer 51 (19%)
Pulmonary disease 12 (4.2%)
Renal disease 4 (1.4%)
Cerebrovascular disease 4 (1.4%)
Diabetes 1 (0.3%)
Chronic alcoholism 1 (0.3%)
13. Asplenia 0 (0%)
Sickle cell disease 0 (0%)
size was 338 (Table 2). A sample of 338 subjects from
the population of vaccination-eligible inpatients in
the 90-day period prior to program selection was se-
lected randomly, using the same calculator and in the
same random fashion as the study group. Of note, ex-
amination of the demographics of the samples re-
vealed anomalies, such as only one sampled patient
with a diagnosis of diabetes, and smaller than expected
numbers of patients whose sole risk factor was age
greater than 65 years. These anomalies were noted,
and were not considered significant when analyzing
the data for the outcomes of interest.
For the 90 days prior to program implementation,
29 (8.6%) of the 338 sampled patients (comparison
group) were provided vaccination opportunity. In this
comparison group, none of the 338 vaccination-eligible
patients received the pneumococcal vaccine. Of note,
the demographics of the comparison group did not
match those of the study group exactly. We did not
consider these variations in demographics to be sig-
nificant. Still, seasonal variations in disease patterns
and aperiodic, nonseasonal changes in patient demo-
graphics must be acknowledged.
For the 90 days after implementation of the vaccina-
tion program, where registered nurses assessed the
patients for vaccination eligibility and provided vaccina-
tion under standing orders, 169 (59%) of the 286 sam-
pled patients were provided vaccination opportunity,
and 44 (15%) of the 286 sampled patients received
pneumococcal vaccination. The vaccination rate for
those subjects assessed under the standing order pro-
14. gram was 26% (44 of 169). Again, the demographics of
the comparison group did not match those of the study
group exactly, but the variations were not considered to
be significant. There are several plausible reasons for
missed vaccination opportunities and the low vaccina-
tion rate, and these are addressed in the Discussion.
Table 2. Demographic characteristics of sampled
patients, 90 days preintervention (comparison group)
Characteristics N = 338 (%)
Patients
Male 119 (35.2%)
Age in years (mean) 72.92
Risk factors (n = 148)
Cardiac disease 73 (21.6%)
Cancer 42 (12.4%)
Pulmonary disease 15 (4.4%)
Cerebrovascular disease 13 (3.8%)
Renal disease 4 (1%)
Chronic alcoholism 1 (0.3%)
Diabetes 0 (0%)
Asplenia 0 (0%)
15. Sickle cell disease 0 (0%)
512 Vol. 35 No. 8 Eckrode, Church, and English
Further examination of the data revealed differences
in vaccination opportunity between the population
aged 65 years and older and the population aged be-
tween 2 and 64 years of age. In the comparison group,
vaccination opportunity was provided to 17 (26%) of the
340 patients aged 65 years and older; in the subpopula-
tion aged between 2 and 64 years of age, vaccination op-
portunity was provided to 12 (3.6%) of 334 subjects. In
the study group, vaccination opportunity was provided
to 140 (73.3%) of the 191 patients aged 65 years and
older; in subpopulation aged between 2 and 64 years,
vaccination opportunity was provided to 29 (30.5%) of
95 subjects. Again, the results revealed missed vaccina-
tion opportunities that must be addressed.
Differences in actual vaccination rate also were
identified within the study group, when stratified by
age. The vaccination rate for the subpopulation of pa-
tients aged 65 years and older was 24.3%. In the sub-
population aged between 2 and 64 years, the actual
vaccination rate was 52.6% (Table 3). The study pro-
gram achieved an overall vaccination rate of 15.4%.
Following the descriptive analysis, the study data
were examined and subjected to inferential analysis
to determine whether the rates of opportunity and
vaccination were influenced by the standing orders–
based pneumococcal vaccination program. Using the
x
2 (goodness of fit/likelihood ratio) test, the study
16. found a significant statistical difference in the rate of
pneumococcal vaccination opportunities (x2 = 182.46;
P = .00) and the pneumococcal vaccination rate
(x2 = 56; P = .00).
DISCUSSION
The field experiment method that was chosen for
this study has a high external validity, and is well suited
Table 3. Results of pneumococcal vaccination program
Comparison
group
Study
group
Total number, (%) provided
vaccination opportunity
29 (8.6) 169 (59.1)
Total number, (%) given
pneumococcal vaccination
0 (0) 44 (15.4)
Subset analysis
Number, (%) provided
17. vaccination opportunity,
patients aged $ 65 years
17 (5.0) 140 (73.3)
Number, (%) patients given
pneumococcal vaccination,
aged $ 65 years
0 (0) 34 (24.3)
Number, (%) provided vaccination
opportunity, aged 2-64 years
with risk factors
12 (3.6) 29 (30.5)
Number, (%) patients given
pneumococcal vaccination,
aged 2-64 years with risk factors
0 (0) 10 (52.6)
for applied research that is focused on problem solving.
This design was chosen as the alternative to dividing
the postimplementation population into comparison
and study groups, with one group eligible for evalua-
tion and vaccination by the registered nurse and the
other group reliant on the previous procedure of physi-
cian evaluation and order (which may not have
18. provided an opportunity for vaccination, perhaps be-
cause many physicians and nurses did not actively
encourage pneumococcal polysaccharide vaccination).
There is a weakness associated with this study method,
however. The weakness that directly affects this study
is a result of the sample selection process, which did
not draw sample subjects for the comparison and study
groups from the same population. This was due to
ethical considerations; we believed that patients could
not be denied an efficacious vaccine to determine the
success of a newly designed vaccination program.
Another area of concern was the accuracy of the
existing data. The results of this study could be biased
by errors in the original documents, because docu-
mentation errors could lead to error in measurement.
To avoid counting a study subject erroneously as not
immunized or not provided with the opportunity for
immunization, multiple documents were evaluated to
determine if a lack of opportunity or nonadministra-
tion of vaccine was in appearance only, due to poor
or erroneous documentation. The evaluation of multi-
ple documents was undertaken to avoid a potential
source of bias identified in a previous study. In the pre-
vious study, approximately 18% of vaccines ordered
were not documented on the medication administra-
tion record.32 Thus, multiple documents were evalu-
ated to determine if opportunity for, and delivery of,
the vaccine did, in fact, occur.
A limitation of this study that may impact on its ex-
ternal validity is its timing. This study collected data
that addressed only the 90 days immediately before
and immediately after program implementation. The
first 90 days after program implementation may rep-
resent a period of time when interest in, and training
19. on, the program are high. Thus, the results of this
study may not predict program performance outside
of the initial 90-day period, when the novelty may
have worn off, training is in the past, and supervisory
attention may be directed elsewhere. The Hawthorne
Effect, whereby a new program brings about a short-
term improvement in performance, cannot be dis-
counted as an explanation for the results of this study,
as well. Supporting this premise was an observed de-
cline in assessment rates for the month immediately
following this study, although assessment rates have
improved since. Influenza vaccination was not offered
during this study period, and as such, had no influ-
ence on the results.
Eckrode, Church, and English October 2007 513
Many of the findings of this study are consistent
with previous investigations. For instance, the initial
vaccination rate for this study was 0%, as determined
by analysis of the comparison group data. This is the
same as the preprogram rate reported by Vondracek
and colleagues.26 Scarbrough and Landis38 reported a
vaccination rate of 1.2% when physicians managed
the vaccinations, and a rate of 0.65% was reported un-
der similar circumstances by Bloom and colleagues.2
These low vaccination rates are not surprising, and
they typically provide much of the impetus for pro-
gram design and implementation. An example of a pro-
gram that exhibited these kinds of results was the
previous Providence St. Vincent program, which relied
on physician management of vaccination (without
chart reminders), to little success. Others have had pos-
itive results using chart reminders; one program used
20. simple chart reminders to increase vaccination rates,
and increased pneumococcal vaccination rates from
0% to 53% for patients on a general medical service.26
The outcomes of the study program are comparable
to the outcomes reported for programs that were not
based on standing orders (eg, a program that relied
on family nurse practitioners for assessments, orders,
and vaccinations). That program achieved a vaccina-
tion rate of 16%, compared with the preimplementa-
tion rate of 1.2%.38 As another example, Skledar
et al,32 studying the outcomes of a hospital-based
pneumococcal vaccination program that was depen-
dent on a collaborative effort between physicians and
pharmacists, reported vaccination rates of 11% and
31% for newly admitted patients and high-risk pa-
tients, respectively. The overall rate of vaccination in
the Providence St. Vincent program was higher than
the overall rate reported by Skledar et al, but more sig-
nificant is the report of a difference in vaccination rates
between the total population and the high-risk subpop-
ulation. This difference in vaccination rates between all
patients and the subpopulation of high-risk patients
occurred in the study program as well, with 52.6% of
high-risk patients accepting and receiving pneumococ-
cal vaccination.
When compared with other standing orders–based
programs, whether nursing or pharmacy-driven, the
overall vaccination rates of the Providence St. Vincent
program often were lower than those reported in the
literature. For example, in a pharmacy-based program,
assessment rates of 90% and vaccination rates of
29.3% were achieved.47 Significantly, this program
was based on a standing order that directed pharma-
cists to do the patient assessment. In contrast, also
21. following standing orders, the Providence St. Vincent
registered nurses achieved an assessment rate of
59.1%, yielding 34.33% lower rates of vaccination op-
portunity than did the pharmacy-based program. A
comparison with nursing-driven programs reveals sim-
ilar outcomes. Rhew et al48 reported on a comparison
between patient and provider reminders, a nurse stand-
ing orders system, and a combination of patient and
provider reminders and a nurse standing order system.
The nurse standing order system achieved an opportu-
nity rate (assessment for vaccination) of 39% and a
vaccination rate of 22%. The St. Vincent program com-
pares favorably with its assessment rate of 59.1%, but
not the overall vaccination rate.
In an outpatient program that was reliant on stand-
ing orders for nurses, the pneumococcal vaccination
rate increased from a starting point of 34% to an end
point of 63% overall.37 The outcomes for the outpa-
tient study were for a 10-year period, however; the out-
comes for the Providence St. Vincent study were for the
first 90-day period. It could be argued that 10 years of
program operation may have resulted in the incorpora-
tion of the program into the organizational culture, and
a habit of assessing and vaccinating may have been
gained over this time period. Another result of this study
warrants discussion and comparison. The pneumococ-
cal vaccination rate for the high-risk population in the
outpatient program (52%) was lower than that for
the overall population.37 This is in direct contrast to
the results of our study; the high-risk population was
vaccinated at a higher rate (52.6%) than was the overall
population (15.4%), despite lower rates of vaccination
opportunity (30.5% versus 73.3% for the high-risk
and 65 years and older populations, respectively).
22. Unfortunately, vaccination opportunities were
missed frequently in the study program. Several bar-
riers were identified as obstacles to successful imple-
mentation of standing orders–based programs by
Middleton et al,49 and provide plausible reasons for
the missed opportunities in the study program. Among
the provider-related barriers that were delineated by
Middleton et al, several were identified within the study
program. Concerns for additional workload were ex-
pressed during pilot testing of the program; these con-
cerns may have been carried forward to the program
during the study period. Additionally, some nurses ex-
pressed reluctance to administer a vaccination based
on a standing order; they desired individual physician
orders for each vaccination. Process breakdowns may
have contributed to the missed vaccination opportuni-
ties, as well; simple failure to assess newly admitted
patients and documentation omissions or errors could
account for a portion of the missed opportunities. The
Providence St. Vincent program addressed patients on
multiple services (eg, medical, cardiac, oncology, pul-
monology); however, because the registered nurses
were responsible for performing the assessment under
standing orders that were not service-specific (and no
service exempted its patients from vaccination), this
514 Vol. 35 No. 8 Eckrode, Church, and English
should not have had any influence on the overall
outcome.
For the population of primary interest to most
governmental and nongovernmental agencies (ie, pa-
tients aged 65 years and older), the results of the study
program show that vaccination opportunity increased
23. significantly, from 5% to 73%. Although an increase
of this degree was welcome, it was not as significant
an outcome as it appears. Despite this increase in vac-
cination opportunity, a considerable share of the sam-
pled patients who were provided with that opportunity
(74%) declined vaccination. This is more than twice
the rate that was reported by Scarbrough and Landis,38
who documented a 35% refusal rate. The rate of decli-
nation was slightly more than 2 times higher in the sub-
population that was aged 65 years and older (75.7%)
than it was in the high-risk subpopulation (34.5%).
This negated any advantage that the 65 years and older
group may have gained from increased vaccination op-
portunity. Reasons for vaccination declination in this
study program were documented rarely, which pre-
cluded determination of the underlying factors without
direct patient interview. Although determination of the
factors that drive these declinations are outside the
scope of this study, this characteristic also was identi-
fied during pilot testing of the Providence St. Vincent
program, and has a deleterious effect on vaccination
rates. Internal discussion and further review of the lit-
erature suggest that lack of direct physician recom-
mendation for vaccination, and the fact that some
patients were unclear on, or could not recall, their cur-
rent vaccination status may have been reasons for dec-
lination of the vaccine; however, further study is
needed to support this hypothesis.33 Patient or patient
representative concerns about the vaccine, concerns
that vaccination may not reflect the wishes of the
patient’s physician, and resistance to vaccination
were suggested as patient barriers to vaccination by
Middleton et al.49 It does not seem unreasonable to pro-
pose that these barriers existed in the study program,
as well. Regardless of the reason, the refusal of vaccina-
24. tion by patients after they have been provided with
vaccination opportunity, and in some cases, the appro-
priate vaccine information statement and encourage-
ment by health care practitioners, is of concern. The
reasons for these refusals need examination if vaccina-
tion rates are to increase much beyond current levels.
Our inpatient pneumococcal vaccination program,
targeted to all patients 65 years and older and those
patients ranging from 2 to 64 years with risk factors
for pneumococcal bacteremia, resulted in an overall
increase in vaccination opportunity and vaccination
rates, when compared with our previous method. The
overall rates of vaccination that were attained by this
program often were lower than those reported in the
existing literature for other program designs; however,
this may have been due to an unusually high rate of
vaccination refusal.
The program that was evaluated in this study seems
to generate sustainable gains over time. Examination of
the data 1 year after the end of this study revealed an
overall vaccination rate of 39%, compared with the
overall vaccination rate of 15.4% during the study pe-
riod. Still, this rate was less than our institutional goal
of 80% vaccination, and the program continues to re-
ceive strong support and emphasis.
Based upon the results of this study, we believe that
a standing orders–based, nursing-driven pneumococ-
cal vaccination program can increase vaccination rates
in the inpatient setting. Barriers to program function,
and particularly vaccination receipt, must be examined
and overcome if the program is to generate acceptable
levels of vaccination opportunity and administration.
Given the significance of pneumococcal bacteremia
25. to morbidity and mortality, the increasing prevalence
of drug-resistant strains of S pneumoniae, and the
positive outcomes of our program, we believe that
inpatient pneumococcal vaccination programs have
usefulness and merit and can improve public health.
We strongly encourage their implementation.
References
1. Centers for Disease Control and Prevention. Pneumococcal
disease.
In: Epidemiology and prevention of vaccine-preventable
diseases. 9th
ed. Atlanta (GA): Centers for Disease Control and Prevention;
2006. p. 256-7.
2. Bloom HG, Wheeler DA, Lynn J. A managed care
organization’s attempt
to increase influenza and pneumococcal immunizations for older
adults
in an acute care setting. J Am Geriatr Soc 1999;47(1):106-10.
3. McDaniel LS, Swialto E. Pneumococcal disease:
pathogenesis, treat-
ment, and prevention. Infect Dis Clin Pract 2004;12(2):93-8.
4. Jackson LA, Neuzil KM, Yu O, Benson P, Barlow WE,
Adams AL, et al.
Effectiveness of pneumococcal polysaccharide vaccine in older
26. adults.
N Engl J Med 2003;348:1747-55.
5. Nichol KL, Baken L, Wourenma J, Nelson A. The health and
eco-
nomic benefits associated with pneumococcal vaccination of
elderly
persons with chronic lung disease. Arch Int Med 1999;159(20):
2437-42.
6. Torres JM, Cardenas O, Vasquez A, Schlossberg D.
Streptococcus pneu-
moniae bacteremia in a community hospital. Chest
1998;113(2):387-90.
7. Williams R. Pneumococcal vaccination. Lippincotts Prim
Care Pract
1998;2:625-33.
8. Maki DG. Pneumococcal bacteremia: lessons learned, yet
more to
learn. Mayo Clinic Proc 2004;79(5):599-603.
9. Treanor JJ, Hall CB. Influenza and infections of the trachea,
bronchi, and
bronchioles. In: Betts RF, Chapman SW, Penn RL, editors.
Reese and
27. Betts’ a practical approach to infectious disease. 5th ed.
Philadelphia:
Lippincott Williams and Wilkins; 2003. p. 278-94.
10. Musher DM, Alexandri I, Gravis EA, Yanbeiy N, Eid A,
Inderias L, et al.
Bacteremic and nonbacteremic pneumococcal pneumonia: a
prospec-
tive study. Medicine 2000;79(4):210-21.
11. Bratzler DW, Houck PM, Jang H, Nsa W, Shook C, Moore
L, et al.
Failure to vaccinate Medicare inpatients: a missed opportunity.
Arch
Int Med 2002;162:2349-56.
Eckrode, Church, and English October 2007 515
12. Holdiness MR. Rare systemic dermatologic reaction after
pneumococ-
cal vaccine administration. South Med J 2003;96(1):64-5.
13. Nichol KL, MacDonald R, Hauge M. Side effects associated
with pneu-
mococcal vaccination. Am J Infect Control 1997;25(3):223-8.
14. Jackson LA, Benson P, Sneller VP, Butler JC, Thompson
RS, Holder P,
28. et al. Safety of revaccination with pneumococcal polysaccharide
vac-
cine. JAMA 1999;281(3):243-8.
15. Lackner TL, Hamilton RG, Hill JJ, Davey C, Guay DRP.
Pneumococcal
polysaccharide revaccination: immunoglobulin G
seroconversion, per-
sistence, and safety in frail, chronically ill older subjects. J Am
Geriatr
Soc 2003;51:240-5.
16. Fox BC. Leukocyctoclastic vasculitis after pneumococcal
vaccination
[letter]. AJIC 1998;26(3):365-6.
17. American Public Health Association. Pneumococcal
pneumonia. In:
Chin J, editor. Control of communicable diseases manual. 17th
ed.
Washington, DC: American Public Health Association; 2000. p.
388.
18. Christenson B, Lundbergh P, Hedlund J, Örtqvist Ä. Effects
of a large-scale
intervention with influenza and 23-valent pneumococcal
vaccines in adults
29. aged 65 years or older: a prospective study. Lancet
2001;357:1008-11.
19. Dworkin MS, Ward JW, Hanson DL, Jones JL, Kaplan JE.
Pneumococ-
cal disease among human immunodeficiency virus-infected
persons:
incidence, risk factors, and impact of vaccination. Clin Infect
Dis
2001;32:794-800.
20. Fedson DS, Harward MP, Reid RA, Kaiser DL. Hospital-
based pneumo-
coccal immunization: epidemiological rationale from the
Shenandoah
Study. JAMA 1990;264:1117-22.
21. Harrison LH, Dwyer DM, Billman L, Kolczak MS, Schuchat
A. Invasive
pneumococcal infection in Baltimore, MD: implications for
immunization
policy. Arch Int Med 2000;160:89-94.
22. Lund BC, Ernst EJ, Klepser ME. Strategies in the treatment
of penicillin-
resistant Streptococcus pneumoniae. Am J Health Sys Pharm
1998;55:
30. 1987-94.
23. Penn RL, Betts RF. Lower respiratory tract infections
(including tuber-
culosis). In: Betts RF, Chapman SW, Penn RL, editors. Reese
and Betts’
a practical approach to infectious diseases. 5th ed. Philadelphia:
Lippin-
cott Williams & Wilkins; 2003. p. 295-312.
24. Sisk JE, Whang W, Butler JC, Sneller VP, Whitney G. Cost-
effectiveness
of vaccination against invasive pneumococcal disease among
people
50 through 64 years of age: role of comorbid conditions and
race.
Ann Int Med 2003;138:960-8.
25. Whitney CG, Schaffner W, Butler JC. Rethinking
recommendations for
use of pneumococcal vaccine in adults. Clin Infect Dis
2001;33:662-75.
26. Vondracek TG, Pham TP, Huycke MM. A hospital-based
pharmacy
intervention program for pneumococcal vaccination. Arch Int
Med
31. 1998;158:1543-7.
27. Centers for Disease Control and Prevention. Facilitating
influenza and
pneumococcal vaccination through standing orders programs.
MMWR
Morb Mortal Wkly Rep 2003;52(4):68-9.
28. Nichol KL, Zimmerman R. Generalist and subspecialist
physicians’
knowledge, attitudes, and practices regarding influenza and
pneumo-
coccal vaccinations for elderly and other high-risk patients.
Arch Int
Med 2001;161:2702-8.
29. Peterson RL, Saag K, Wallace RB, Doebbling BN. Influenza
and
pneumococcal vaccine receipt in older persons with chronic
disease:
a population-based study. Med Care 1999;37:502-9.
30. Poland GA, Shefer AM, McCauley M, Webster PS, Whitley-
Williams
PN, Peter G, et al. Standards for adult immunization practices.
Am J
32. Prev Med 2003;25(2):144-50.
31. Centers for Disease Control and Prevention. Influenza and
pneumo-
coccal vaccination coverage among persons aged $65 years and
per-
sons aged 18-64 years with diabetes or asthma-United States,
2003.
MMWR Morb Mortal Wkly Rep 2004;53:1007-12.
32. Skledar SJ, Hess MM, Ervin KA, Gross RR, Nowalk MP,
Carter H,
et al. Designing a hospital-based pneumococcal vaccination
program.
Am J Health System Pharm 2003;60:1471-6.
33. Santibanez TA, Nowalk MP, Zimmerman RK, Jewell IK,
Bardella IJ,
Wislon SA, et al. Knowledge and beliefs about influenza,
pneumo-
coccal disease, and immunizations among older people. J Am
Geriatr
Soc 2002;50:1711-6.
34. Robinson KA, Baughman W, Rothrock G, Barrett NL, Pass
M, Lexau
C, et al. Epidemiology of invasive Streptococcus pneumoniae
infections
33. in the United States, 1995-1998: opportunities for prevention in
the
conjugate vaccine era. JAMA 2001;285:1729-35.
35. Centers for Disease Control and Prevention. Prevention of
pneumo-
coccal disease: Recommendations of the Advisory Committee
on
Immunization Practices (ACIP). MMWR Recomm Rep
1997;46(RR-8):
1-24.
36. Task Force on Community Preventive Services.
Recommendations
regarding interventions to improve vaccination coverage in
children,
adolescents, and adults. Am J Prevent Med 2000;18(15):92-140.
37. Nichol KL. Ten-year durability and success of an organized
program
to increase influenza and pneumococcal vaccination rates
among
high risk adults. Am J Med 1998;105(5):385-92.
38. Scarbrough ML, Landis SE. A pilot study for the
development of a hos-
34. pital-based immunization program. Clin Nurse Spec
1997;11(2):70-5.
39. Metersky ML, Fine JM, Tu GS, Mathur D, Weingarten S,
Petrillo MK,
et al. Lack of effect of a pneumonia clinical pathway on
hospital-based
pneumococcal vaccination rates. Am J Med 2001;110(2):141-3.
40. Centers for Disease Control and Prevention. Advisory
Committee on
Immunization Practices (2004, September 24). Available from:
http://
www.cdc.gov/nip/ACIP/default.htm. Accessed October 24,
2004.
41. Centers for Disease Control and Prevention. Facilitating
influenza and
pneumococcal vaccination through standing orders programs.
MMWR
Morb Mortal Wkly Rep 2003;52(4):68-9.
42. Department of Health and Human Services. Federal Register
61808.
Baltimore, MD. 2002.
43. McKenzie JF, Smeltzer JL. Implementation: strategies and
associated
35. concerns. In: Planning, implementing, and evaluating health
promotion
programs: a primer. 3rd ed. Boston: Allyn and Bacon; 2001. p.
258-9.
44. Shi L. Experimental research. In: Health services research
methods.
Albany (NY): Delmar Publishers; 1997. p. 143-64.
45. Motulksy H. The design of clinical trials. In: Intuitive
biostatistics. New
York: Oxford University Press; 1995. p. 183-91.
46. Rosner B. Hypothesis testing: categorical data. In: Study
guide for
fundamentals of biostatistics. 4th ed. Belmont (CA): Wadsworth
Pub-
lishing; 1995. p. 135-72.
47. Noped JC, Schomberg R. Implementing an inpatient
pharmacy-based
pneumococcal vaccination program. Am J Health System Pharm
2001;
58:1852-5.
48. Rhew DC, Glassman PA, Goetz MB. Improving
pneumococcal vaccine
rates-nurse protocols versus clinical reminders. J Gen Intern
36. Med
1999;14:351-6.
49. Middleton DB, Fox DE, Nowalk MP, Skledar SJ, Sokos DR,
Zimmerman
RK, et al. Overcoming barriers to establishing an inpatient
vaccination
program for pneumococcus using standing orders. Infect Control
Hosp Epidemiol 2005;26:874-81.
http://www.cdc.gov/nip/ACIP/default.htm
http://www.cdc.gov/nip/ACIP/default.htmImplementation and
evaluation of a nursing assessment/standing
orders–based inpatient pneumococcal vaccination
programMethodsData collectionHuman/animal subjectsStudy
sampleStatistical analysisResultsDiscussionReferences