Testing the Technology Acceptance Model: HIV case managers' intention to use a continuity of care record with context-specific links

OBJECTIVE

To assess the applicability of the Technology Acceptance Model (TAM) constructs in explaining HIV case managers' behavioural intention to use a continuity of care record (CCR) with context-specific links designed to meet their information needs.

DESIGN

Data were collected from 94 case managers who provide care to persons living with HIV (PLWH) using an online survey comprising three components: (1) demographic information: age, gender, ethnicity, race, Internet usage and computer experience; (2) mock-up of CCR with context-specific links; and items related to TAM constructs. Data analysis included: principal components factor analysis (PCA), assessment of internal consistency reliability and univariate and multivariate analysis.

RESULTS

PCA extracted three factors (Perceived Ease of Use, Perceived Usefulness and Perceived Barriers to Use), explained variance = 84.9%, Cronbach's ά = 0.69-0.91. In a linear regression model, Perceived Ease of Use, Perceived Usefulness and Perceived Barriers to Use explained 43.6% (p < 0.001) of the variance in Behavioural Intention to use a CCR with context-specific links.

CONCLUSION

Our study contributes to the evidence base regarding TAM in health care through expanding the type of professional surveyed, study setting and Health Information Technology assessed.

Perceptions of factors influencing use of an electronic record for case management of persons living with HIV

Case managers (CMs) facilitate continuity of care for persons living with HIV (PLWH) by coordination of resources and referrals to social services and medical care. The complexity of the management of HIV drives the need for more coordination, which can be achieved through the use of health information technology (HIT). However, HIT has not been well studied in the context of HIV services. The primary aim of this qualitative study was to assess CMs' perceptions regarding factors that influence acceptance and use of an electronic continuity of care record (CCR) for PLWH. Focus group methodology was used to gather perceptions from 37 CMs. Major themes related to factors for CCR adoption and use included: predisposing (system functionality and confidentiality), enabling (user training and computer access), reinforcing (work efficiency, continuity of care, information quality, and communication). Electronic CCRs have the potential to improve coordination of services and information sharing for PLWH. Careful attention must be paid to factors that predispose, enable, and reinforce use of HIT such as CCRs so that potential benefits in terms of quality and efficiency can be realized.

Information needs of case managers caring for persons living with HIV

OBJECTIVE

The goals of this study were to explore the information needs of case managers who provide services to persons living with HIV (PLWH) and to assess the applicability of the Information Needs Event Taxonomy in a new population.

DESIGN

The study design was observational with data collection via an online survey.

MEASUREMENTS

Responses to open-ended survey questions about the information needs of case managers (n=94) related to PLWH of three levels of care complexity were categorized using the Information Needs Event Taxonomy.

RESULTS

The most frequently identified needs were related to patient education resources (33%), patient data (23%), and referral resources (22%) accounting for 79% of all (N=282) information needs.

LIMITATIONS

Study limitations include selection bias, recall bias, and a relatively narrow focus of the study on case-manager information needs in the context of caring for PLWH.

CONCLUSION

The study findings contribute to the evidence base regarding information needs in the context of patient interactions by: (1) supporting the applicability of the Information Needs Event Taxonomy and extending it through addition of a new generic question; (2) providing a foundation for the addition of context-specific links to external information resources within information systems; (3) applying a new approach for elicitation of information needs; and (4) expanding the literature regarding addressing information needs in community-based settings for HIV services.

Infection control hazards and near misses reported by nursing students

BACKGROUND

Hazard and near-miss reporting has been integrated into the curriculum for postbaccalaureate bachelor of science in nursing/master of science in nursing degree students at our institution through a Web-based reporting system since 2006. The system is used during their 25-week clinical rotations of 2 days per week in community, medical-surgical, obstetrics, pediatrics, and psychiatric settings. The purpose of this article is to describe the frequency and types of hazard and near-miss comments about infection control issues over 3 years of data collection.

METHODS

For each clinical rotation, students were required to complete 2 entries per week into a structured electronic hazard and near-miss reporting system. Three years worth of comments associated with these reports (2006-2009) were extracted and analyzed by 3 independent reviewers (κ statistic = 0.85). Seven categories of infection control problems were identified.

RESULTS

Five hundred nursing students submitted 3492 comments related to hazards and near misses. Of these, 886 responses (25.4%) were related to infection control practices. The most common category was nonadherence to isolation precautions (27.6%), followed by contamination of the environment or equipment (18.5%), breaks in aseptic technique (17.2%), hand hygiene (15.9%) or gloving failures (11.5%), and occupational risks (8.2%).

CONCLUSION

Infection control hazards and near misses were commonly reported across clinical settings by nursing students. Awareness of such problems among clinicians is necessary before work flow process changes can be made, but clinical change require systems-level change. To be effective and sustainable, reporting methods must be easy to use and available in real time.

Predictors of depression screening rates of nurses receiving a personal digital assistant-based reminder to screen

The purpose of this study was to determine if race/ethnicity, payer type, or nursing specialty affected depression screening rates in primary care settings in which nurses received a reminder to screen. The sample comprised 4,160 encounters in which nurses enrolled in advanced practice training were prompted to screen for depression using the Patient Health Questionnaire (PHQ)-2/PHQ-9 integrated into a personal digital assistant-based clinical decision support system for depression screening and management. Nurses chose to screen in response to 52.5% of reminders. Adjusted odds ratios showed that payer type and nurse specialty, but not race/ethnicity, significantly predicted proportion of patients screened.

Impact of a patient safety curriculum for nurse anesthesia students

Patient safety has become an important aspect of national health care initiatives. The purpose of this evaluation was to measure the impact of a patient safety education series for students enrolled in a nurse anesthesia program. Baseline surveys that measured patient safety competencies across three domains, attitudes, skills and knowledge, were administered to the students. A patient safety education series was delivered to the cohort and the survey was then readministered. Mean scores were compared using independent samples t tests. Attitude scores did not change from baseline to posttest. Participants scored higher on posttest means for both the patient safety skills and knowledge domains. Incorporating patient safety content into the nurse anesthesia master's degree curriculum may enhance clinicians' skills and knowledge related to patient safety, and the addition of a patient safety curriculum is important during the formative education process.

Web-based hazard and near-miss reporting as part of a patient safety curriculum

As part of a patient safety curriculum, we developed a Web-based hazard and near-miss reporting system for postbaccalaureate nursing students to use during their clinical experiences in the first year of their combined BS-MS advanced practice nurse program. The 25-week clinical rotations included 2 days per week for 5 weeks each in community, medical-surgical, obstetrics, pediatrics, and psychiatric settings. During a 3-year period, 453 students made 21,276 reports. Of the 10,206 positive (yes) responses to a hazard or near miss, 6,005 hazards (59%) and 4,200 near misses (41%) were reported. The most common reports were related to infection, medication, environmental, fall, and equipment issues. Of the near misses, 1,996 (48%) had planned interceptions and 2,240 (52%) had unplanned interceptions. Types of hazards and near misses varied by rotation. Incorporating hazard and near-miss reporting into the patient safety curriculum was an innovative strategy to promote mindfulness among nursing students.

Barriers to implementation of a Continuity of Care Record (CCR) in HIV/AIDS care

This qualitative study was part of the pre-implementation formative evaluation of SelectHealth's Continuity of Care Record (CCR), an electronic health information network (EHI) for HIV/AIDS care in New York City (NYC). The purpose of the study was to explore case managers' perceptions of the barriers to adoption of the CCR. Focus group methodology was used to gather perceptions from 26 participants who provided direct case management services for persons living with HIV/AIDS (PLWHA) in NYC. Question development was guided by models of technology acceptance. Data about the barriers to implementation of the system were classified into four main themes: client capacity for system adoption, potential breech of confidentiality, information quality concerns, and training needs. The four identified themes can serve as focal points for developers seeking to create EHI networks for the provision of HIV care.

Effect of nurse reminder on depression screening rates in racial/ethnic minorities

We analyzed a set of clinical encounters (n=4,160) in which nurses received a reminder to screen for depression. Patients who were African-American or Hispanic were less likely to be screened as were those with Medicaid or Medicare insurance.

Psychometric evaluation of a handheld decision support attitudes scale

The authors evaluated the psychometrics of a 14-item scale designed to assess attitudes about handheld decision support software. In a sample of 103 nursing students, a principal components factor analysis resulted in three factors that explained 55.1% of the variance. Internal consistency reliability ranged from .71-.83.

Near-miss and hazard reporting: promoting mindfulness in patient safety education

Patient safety efforts advocate for transforming healthcare from a culture of blame to a non-punitive "culture of safety." One of the most challenging hurdles is to encourage healthcare practitioners to be mindful about their activities. To promote mindfulness during clinical education for entry-level nurses, we developed a web-based dangerous situation and near miss reporting system for a cohort of baccalaureate nursing students (N=156). For this curricular innovation project, we provided wireless handheld devices to students who were required to submit one report for each of their clinical days in the medical-surgical, pediatric, psychiatric, obstetrics and community settings. During a ten-week period, students submitted 1487 reports. Of these, 63% were dangerous situations and 37% were near misses. The most frequently occurring dangerous situations were poor infection control practices. The most commonly reported near misses were medication errors. Free text comments from students identified inadequate patient identification and poor documentation as commonly occurring dangerous situations observed.

Airway mechanics and ventilation in response to resistive loading during sleep: influence of gender

The male predominance in obstructive sleep apnea (OSA) is currently poorly understood although differences in pharyngeal airway anatomy and physiology have been proposed. As the response to inspiratory resistive loading (IRL) provides important information on both airway collapsibility (mechanics) and ventilatory control, we compared this respiratory response in eight normal women and eight age and body mass index (BMI)-matched men, during stable nonrapid eye movement (NREM) sleep. Upper airway mechanics, ventilation, plus activation of two dilator muscles (genioglossus [GG] and tensor palatini [TP]) were monitored during basal breathing (BL), followed by four sequentially applied loads (5, 10, 15, 25 cm H(2)O/L/s) for three breaths each. Men developed more severe hypopnea in response to identical applied external loads than did women. At a resistance of 25 cm H(2)O/L/s, VT decreased by 26 +/- 1% in women compared with 44 +/- 1% in men (differences between sexes p < 0.05). Pharyngeal resistance (Rpha) in response to IRL increased significantly more in men than women (37.3 +/- 11.2 cm H(2)O/L/s in men at maximal load, compared with an increase of 6.6 +/- 3.9 cm H(2)O/L/s in women, p < 0.05). Men and women had near identical minute ventilation responses to total load (applied extrinsic plus measured intrinsic), implying no differences in central drive or load response. There were no significant increases in GG or TP activation in response to IRL in either sex. We conclude that normal men are more vulnerable to load-induced hypoventilation than women, due to increased upper airway collapse, which could not be explained by differences in dilator muscle activation. This implies a fundamental difference in the upper airway anatomy and/or tissue characteristics between the two sexes.

Rpn4p acts as a transcription factor by binding to PACE, a nonamer box found upstream of 26S proteasomal and other genes in yeast

We identified a new, unique upstream activating sequence (5'-GGTGGCAAA-3') in the promoters of 26 out of the 32 proteasomal yeast genes characterized to date, which we propose to call proteasome-associated control element. By using the one-hybrid method, we show that the factor binding to the proteasome-associated control element is Rpn4p, a protein containing a C2H2-type finger motif and two acidic domains. Electrophoretic mobility shift assays using proteasome-associated control element sequences from two regulatory proteasomal genes confirmed specific binding of purified Rpn4p to these sequences. The role of Rpn4p to function as a transregulator in yeast is corroborated by its ability of stimulating proteasome-associated control element-driven lacZ expression and by experiments using the RPT4 and RPT6 gene promoters coupled to the bacterial cat gene as a reporter. Additionally, we found the proteasome-associated control element to occur in a number of promoters to genes which are related to the ubiquitin-proteasome pathway in yeast.

Histochemical properties of upper airway muscles: comparison of dilator and nondilator muscles

The upper airway dilator muscles (UADMs) represent a subgroup of muscles in the pharyngeal area which, in addition to their roles in mastication, vocalization, etc., also have an important respiratory function. Failure of these muscles to maintain upper airway patency during sleep is important in the development of the obstructive sleep apnoea syndrome. In the present study, we evaluated the histochemical properties of the UADMs and compared them to those of neighbouring muscles without respiratory functions, and to the diaphragm, to determine whether the UADMs are specifically adapted to their respiratory role. Our results, both in dogs and rats, indicate that the dilator and nondilator upper airway muscles are similar and differ from the diaphragm. In rats, there were significantly less type I fibres (<12% as compared to 42% for the diaphragm) and more type IIb fibres (39-67% as compared to 27% for the diaphragm). A similar pattern was seen in dogs: type I fibres <38% as compared to 46% for the diaphragm, and type IIb fibres, 29-35% as compared to 10% for the diaphragm. These findings suggest that the upper airway dilator muscles are not specifically designed for their respiratory role. They may fail in the presence of increased loads, often encountered in patients with obstructive sleep apnoea, unless appropriate adaptive structural changes take place.

Surgical treatment of sleep apnea syndrome

Several surgical procedures have been developed for the treatment of sleep apnea syndrome. These include nasal, uvulopalatopharyngeal, and head and neck surgery, weight reduction surgery, and tracheostomy. Despite over 15 years of experience with some of these operations, there is still a lack of consensus regarding the indications, success rate, complications, and long-term prognosis associated with these procedures. The current status of these surgical procedures is reviewed.

Dependency of upper airway patency on head position: the effect of muscle contraction

In the present study we examined the effect of flexion and extension of the head on upper airway (UAW) patency in anesthetized dogs, and compared the dilatory and stabilizing effects of electrically stimulated UAW muscles at the different head positions. Flexion of the head increased UAW resistance (Ruaw) and reduced maximal flow (Vmax), but had little effect on the negative pressure at which UAW collapse occurred (Pcrit). Extension of the head, on the other hand, resulted in more negative Pcrit values and increased Vmax without significantly affecting Ruaw. Electrically induced UAW muscle contraction affected the pressure-flow curve and Ruaw, as well as Pcrit. Changing head position had a substantial effect on the dilatory and stabilizing effect of the various UAW muscles. However, independent of head position, genioglossus stimulation was most effective in reducing Ruaw and increasing Pcrit. We conclude that in the anesthetized, supine dog, head position affects the mechanical properties of the UAW and the effects of UAW muscle contraction.

Yta10p, a member of a novel ATPase family in yeast, is essential for mitochondrial function

The yeast gene, YTA10, encodes a member of a novel family of putative ATPases. Yta10p, as deduced from the nucleotide sequence, is 761 amino acids in length (predicted molecular mass 84.5 kDa). The amino acid sequence of Yta10p exhibits high similarity to two other yeast proteins, Yta11 and Yta12, and to E. coli FtsH. Several features of Yta10p are compatible with its localization in mitochondria. We report here that Yta10p is a yeast mitochondrial protein and that import is dependent on a membrane potential and accompanied by processing to a protein of approximately 73 kDa. Disruption of YTA10 leads to a nuclear petite phenotype and to a loss of respiratory competence, as shown by spectrophotometric measurement of the activities of respiratory complexes I-III and IV, respectively. These findings together with the high similarity of Yta10p to several ATP-dependent proteases suggest that Yta10p is a mitochondrial component involved, directly or indirectly, in the correct assembly and/or maintenance of active respiratory complexes.

Identification of a set of yeast genes coding for a novel family of putative ATPases with high similarity to constituents of the 26S protease complex

There is accumulating evidence for a large, highly conserved gene family of putative ATPases. We have identified 12 different members of this novel gene family (the YTA family) in yeast and determined the nucleotide sequences of nine of these genes. All of the putative gene products are characterized by the presence of a highly conserved domain of 300 amino acids containing specialized forms of the A and B boxes of ATPases. YTA1, YTA2, YTA3 and YTA5 exhibit significant similarity to proteins involved in human immunodeficiency virus Tat-mediated gene expression but more significantly to subunits of the human 26S proteasome. YTA1 and YTA2 are essential genes in yeast. Remarkably, the cDNA of human TBP-1 can compensate for the loss of YTA1. Preliminary experiments indicate that YTA1 is a component of the 26S protease complex from yeast. Our findings lead us to propose that YTA1, YTA2, YTA3 and YTA5 function as regulatory subunits of the yeast 26S proteasome. YTA10, YTA11 and YTA12 share significant homology with the Escherichia coli FtsH protein, and together with YTA4 and YTA6 may constitute a separate subclass within this family of putative ATPases.

Effect of upper airway muscle contraction on supraglottic resistance and stability

The activation of upper airway (UAW) muscles is believed to increase UAW patency to air flow. To evaluate the mechanisms by which UAW muscles act to prevent UAW collapse, pressure-flow relationships of the isolated UAW as well as the negative pressure required to cause UAW collapse (Pcrit) were assessed before and during electrical stimulation of four UAW muscle pairs in anesthetized dogs. Stimulation of each of the muscles shifted the pressure-flow curve toward lower pressures for any given flow rate, indicating UAW dilatation. UAW resistance decreased from 7.9 +/- 0.6 to 0.4 +/- 0.1, 2.7 +/- 0.6, 2.3 +/- 0.8 and to 4.8 +/- 1.5 cmH2O.L-1.sec during genioglossus, geniohyoid, sternothyroid and sternohyoid stimulation respectively (P < 0.01 in all cases). However, only genioglossus stimulation significantly increased Pcrit (from -3.4 +/- 0.6 to -12.0 +/- 1.8 cmH2O, P < 0.001). Relaxation of the genioglossus thus appears to produce the main impediment to air flow through the UAW, and contraction of this muscle improves UAW patency both by dilating the supraglottic airway and by stiffening its walls.

Amelioration of sleep apnea by salicylate-induced hyperventilation

It is well documented that upper airway (UAW) muscle activity is augmented in response to increased respiratory drive, the overall effect being an improvement in UAW patency. We have recently shown that salicylate-induced ventilatory stimulation increased UAW muscle electrical activity and decreased UAW resistance and collapsibility in anesthetized dogs. In the present study, we evaluated the effect of respiratory stimulation produced by high therapeutic doses of aspirin on sleep in nine patients with previously diagnosed sleep apnea. A control, all-night, polysomnographic sleep study, including oximetry and ventilatory monitoring by inductive plethysmography, was compared with a second study undertaken after patients ingested 8 to 10 g of aspirin over a period of 4 to 5 h. Aspirin ingestion resulted in high therapeutic salicylate serum levels (33 +/- 2.5 mg/dl, mean +/- SE) the following morning and was associated with marked ventilatory stimulation. Mean sleep duration and the relative partitioning of sleep stages were not affected by aspirin. However, aspirin-induced hyperventilation was associated with a significant non-rapid decrease in periodic breathing and the frequency of both obstructive and mixed apneas in all non-rapid eye movement (REM) sleep stages. The total number of apneas over the whole night was reduced in all subjects and on average fell from a control rate of 42 +/- 7 to 28 +/- 7 apneas/h (p less than 0.01). Similarly, the mean duration of apneas fell from 23 +/- 2 to 20 +/- 1 s (p less than 0.05), and the overall time spent in apneas decreased from 17 +/- 3 to 10 +/- 3 min/h (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Refractoriness to bronchoconstriction following hyperventilation with cold dry air

Fifteen subjects undertook repeated periods of hyperventilation of cold dry air and hyperventilation of warm humidified air followed by cold dry air. Hyperventilation of cold dry air induced a biphasic response with initial bronchodilatation followed by bronchoconstriction. However, exercise produced a greater rise in forced expiratory volume in 1 second (FEV1) than hyperventilation alone. Hyperventilation of cold dry air resulted in a period of refractoriness to a second stress of the same type. Refractoriness induced by exercise or hyperventilation of cold dry air may be the result of refractoriness of the trigger site in the large airways.

The effect of a home exercise programme in children with cystic fibrosis and asthma

Sixty-nine children with asthma and 86 with cystic fibrosis (CF) were assessed for lung function, respiratory muscle function and exercise tolerance. Thirty-seven with asthma and 41 with CF subsequently undertook an at home exercise program and the remainder were matched controls. There was no significant change in pulmonary function after 3 months of the exercise program. Compliance with the program decreased markedly towards the end of the 3 months and this lack of compliance may have contributed to the failure to show any significant training effect. A previously supervised program showed increased fitness and increased peak pressures in children with asthma following intensive exercise. There appears limited value in promoting unsupervised home exercise programs for children with CF and asthma. In those groups of children who will benefit with increased physical activity, supervised programs and more interesting play activities may need to be organized to obtain optimal benefit.