Checking all the boxes: a checklist for when and how to use checklists effectively

Checklists are a type of cognitive aid used to guide task performance; they have been adopted as an important safety intervention throughout many high-risk industries. They have become an ubiquitous tool in many medical settings due to being easily accessible and perceived as easy to design and implement. However, there is a lack of understanding for when to use checklists and how to design them, leading to substandard use and suboptimal effectiveness of this intervention in medical settings. The design of a checklist must consider many factors including what types of errors it is intended to address, the experience and technical competencies of the targeted users, and the specific tools or equipment that will be used. Although several taxonomies have been proposed for classifying checklist types, there is, however, little guidance on selecting the most appropriate checklist type, nor how differences in user expertise can influence the design of the checklist. Therefore, we developed an algorithm to provide guidance on checklist use and design. The algorithm, intended to support conception and content/design decisions, was created based on the synthesis of the literature on checklists and our experience developing and observing the use of checklists in clinical environments. We then refined the algorithm iteratively based on subject matter experts' feedback provided at each iteration. The final algorithm included two parts: the first part provided guidance on the system safety issues for which a checklist is best suited, and the second part provided guidance on which type of checklist should be developed with considerations of the end users' expertise.

Human Factors Integration in Robotic Surgery

OBJECTIVE

Using the example of robotic-assisted surgery (RAS), we explore the methodological and practical challenges of technology integration in surgery, provide examples of evidence-based improvements, and discuss the importance of systems engineering and clinical human factors research and practice.

BACKGROUND

New operating room technologies offer potential benefits for patients and staff, yet also present challenges for physical, procedural, team, and organizational integration. Historically, RAS implementation has focused on establishing the technical skills of the surgeon on the console, and has not systematically addressed the new skills required for other team members, the use of the workspace, or the organizational changes.

RESULTS

Human factors studies of robotic surgery have demonstrated not just the effects of these hidden complexities on people, teams, processes, and proximal outcomes, but also have been able to analyze and explain in detail why they happen and offer methods to address them. We review studies on workload, communication, workflow, workspace, and coordination in robotic surgery, and then discuss the potential for improvement that these studies suggest within the wider healthcare system.

CONCLUSION

There is a growing need to understand and develop approaches to safety and quality improvement through human-systems integration at the frontline of care.Precis: The introduction of robotic surgery has exposed under-acknowledged complexities of introducing complex technology into operating rooms. We explore the methodological and practical challenges, provide examples of evidence-based improvements, and discuss the implications for systems engineering and clinical human factors research and practice.

A Machine Learning Approach with Human-AI Collaboration for Automated Classification of Patient Safety Event Reports: Algorithm Development and Validation Study

BACKGROUND

Adverse events refer to incidents with potential or actual harm to patients in hospitals. These events are typically documented through patient safety event (PSE) reports, which consist of detailed narratives providing contextual information on the occurrences. Accurate classification of PSE reports is crucial for patient safety monitoring. However, this process faces challenges due to inconsistencies in classifications and the sheer volume of reports. Recent advancements in text representation, particularly contextual text representation derived from transformer-based language models, offer a promising solution for more precise PSE report classification. Integrating the machine learning (ML) classifier necessitates a balance between human expertise and artificial intelligence (AI). Central to this integration is the concept of explainability, which is crucial for building trust and ensuring effective human-AI collaboration.

OBJECTIVE

This study aims to investigate the efficacy of ML classifiers trained using contextual text representation in automatically classifying PSE reports. Furthermore, the study presents an interface that integrates the ML classifier with the explainability technique to facilitate human-AI collaboration for PSE report classification.

METHODS

This study used a data set of 861 PSE reports from a large academic hospital's maternity units in the Southeastern United States. Various ML classifiers were trained with both static and contextual text representations of PSE reports. The trained ML classifiers were evaluated with multiclass classification metrics and the confusion matrix. The local interpretable model-agnostic explanations (LIME) technique was used to provide the rationale for the ML classifier's predictions. An interface that integrates the ML classifier with the LIME technique was designed for incident reporting systems.

RESULTS

The top-performing classifier using contextual representation was able to obtain an accuracy of 75.4% (95/126) compared to an accuracy of 66.7% (84/126) by the top-performing classifier trained using static text representation. A PSE reporting interface has been designed to facilitate human-AI collaboration in PSE report classification. In this design, the ML classifier recommends the top 2 most probable event types, along with the explanations for the prediction, enabling PSE reporters and patient safety analysts to choose the most suitable one. The LIME technique showed that the classifier occasionally relies on arbitrary words for classification, emphasizing the necessity of human oversight.

CONCLUSIONS

This study demonstrates that training ML classifiers with contextual text representations can significantly enhance the accuracy of PSE report classification. The interface designed in this study lays the foundation for human-AI collaboration in the classification of PSE reports. The insights gained from this research enhance the decision-making process in PSE report classification, enabling hospitals to more efficiently identify potential risks and hazards and enabling patient safety analysts to take timely actions to prevent patient harm.

Applying an equity lens to hospital safety monitoring: a critical interpretive synthesis protocol

INTRODUCTION

Hospital safety monitoring systems are foundational to how adverse events are identified and addressed. They are well positioned to bring equity-related safety issues to the forefront for action. However, there is uncertainty about how they have been, and can be, used to achieve this goal. We will undertake a critical interpretive synthesis (CIS) to examine how equity is integrated into hospital safety monitoring systems.

METHODS AND ANALYSIS

This review will follow CIS principles. Our initial compass question is: How is equity integrated into safety monitoring systems? We will begin with a structured search strategy of hospital safety monitoring systems in CINAHL, EMBASE, MEDLINE and PsycINFO for up to May 2023 to identify papers on safety monitoring systems generally and those linked to equity (eg, racism, social determinants of health). We will also review reference lists of selected papers, contact experts and draw on team expertise. For subsequent literature searching stages, we will use team expertise and expert contacts to purposively search the social science, humanities and health services research literature to support the development of a theoretical understanding of our topic. Following data extraction, we will use interpretive processes to develop themes and a critique of the literature. The above processes of question formulation, article search and selection, data extraction, and critique and synthesis will be iterative and interactive with the goal to develop a theoretical understanding of equity in hospital monitoring systems that will have practice-based implications.

ETHICS AND DISSEMINATION

This review does not require ethical approval because we are reviewing published literature. We aim to publish findings in a peer-reviewed journal and present at conferences.

Measurement of Direct-Photon Cross Section and Double-Helicity Asymmetry at sqrt[s]=510 GeV in p[over →]+p[over →] Collisions

We present measurements of the cross section and double-helicity asymmetry A_{LL} of direct-photon production in p[over →]+p[over →] collisions at sqrt[s]=510  GeV. The measurements have been performed at midrapidity (|η|<0.25) with the PHENIX detector at the Relativistic Heavy Ion Collider. At relativistic energies, direct photons are dominantly produced from the initial quark-gluon hard scattering and do not interact via the strong force at leading order. Therefore, at sqrt[s]=510  GeV, where leading-order-effects dominate, these measurements provide clean and direct access to the gluon helicity in the polarized proton in the gluon-momentum-fraction range 0.02<x<0.08, with direct sensitivity to the sign of the gluon contribution.

Improving safety in the operating room: Medication icon labels increase visibility and discrimination

Misreading labels, syringes, and ampoules is reported to make up a 54.4% of medication administration errors. The addition of icons to medication labels in an operating room setting could add additional visual cues to the label, allowing for improved discrimination, visibility, and easily processed information that might reduce medication administration errors. A multi-disciplinary team proposed a method of enhancing visual cues and visibility of medication labels applied to vasoactive medication infusions by adding icons to the labels. Participants were 1.12 times more likely to correctly identify medications from farther away (p < 0.001, AOR = 1.12, 95% CI: 1.02, 1.22) with icons. When icons were present, participants were 2.16 times more likely to be more confident in their identifications (p < 0.001, AOR = 2.16, 95%CI: 1.80, 2.57). Carefully designed icons may offer an additional method for identifying medications, and thus reducing medication administration errors.

A better way: training for direct observations in healthcare

Direct observation is valuable for identifying latent threats and elucidating system complexity in clinical environments. This approach facilitates prospective risk assessment and reveals workarounds, near-misses and recurrent safety problems difficult to diagnose retrospectively or via outcome data alone. As observers are an instrument of data collection, developing effective and comprehensive observer training is critical to ensuring the reliability of the data collection and reproducibility of the research. However, methodological rigour for ensuring these data collection properties remains a key challenge in direct observation research in healthcare. Although prior literature has offered key considerations for observational research in healthcare, operationalising these recommendations may pose a challenge and unless guidance is also provided on observer training. In this article, we offer guidelines for training non-clinical observers to conduct direct observations including conducting a training needs analysis, incorporating practice observations and evaluating observers and inter-rater reliability. The operationalisation of these guidelines is described in the context of a 5-year multisite observational study investigating technology integration in the operating room. We also discuss novel tools developed during the course our project to support data collection and examine inter-rater reliability among observers in direct observation studies.

A Smartphone Application for Teamwork and Communication in Trauma: Pilot Evaluation "in the Wild"

OBJECTIVE

To evaluate the potential for a smartphone application to improve trauma care through shared and timely access to patient and contextual information.

BACKGROUND

Disruptions along the trauma pathway that arise from communication, coordination, and handoffs problems can delay progress through initial care, imaging diagnosis, and surgery to intensive care unit (ICU) disposition. Implementing carefully designed and evaluated information distribution and communication technologies may afford opportunities to improve clinical performance.

METHODS

This was a pilot evaluation "in the wild" using a before/after design, 3 month, and pre- post-intervention data collection. Use statistics, usability assessment, and direct observation of trauma care were used to evaluate the app. Ease of use and utility were assessed using the technology acceptance model (TAM) and system usability scale (SUS). Direct observation deployed measures of flow disruptions (defined as "deviations from the natural progression of an procedure"), teamwork scores (T-NOTECHS), and treatment times (total time in emergency department [ED]).

RESULTS

The app was used in 367 (87%) traumas during the trial period. Usability was generally acceptable, with higher scores found by operating room (OR), ICU, and neuro and orthopedic users. Despite positive trends, no significant effects on flow disruptions, teamwork scores, or treatment times were observed.

CONCLUSIONS

Pilot trials of a clinician-centered smartphone app to improve teamwork and communication demonstrate potential value for the safety and efficiency of trauma care delivery as well as benefits and challenges of "in-the-wild" evaluation.

Using flow disruptions to understand healthcare system safety: A systematic review of observational studies

This systematic review provides information on the methodologies, measurements and classification systems used in observational studies of flow disruptions in clinical environments. The PRISMA methodology was applied and authors searched two databases (PubMed and Web of Science) for studies meeting the following inclusion criteria: (a) were conducted in a healthcare setting, (b) explored systems-factors leading to deviations in care processes, (c) were prospective and observational, (d) classified observations, and (e) were original research studies published in peer-reviewed journals. Thirty studies were analyzed and a variety of methods were identified for observer training, data collection and observation classification. Although primarily applied in surgery, comparable research has been successfully conducted in other venues such as trauma care, and delivery rooms. The findings of this review were synthesized into a framework of considerations for conducting rigorous methodological studies aimed at understanding clinical systems.

Probing Gluon Spin-Momentum Correlations in Transversely Polarized Protons through Midrapidity Isolated Direct Photons in p^{↑}+p Collisions at sqrt[s]=200 GeV

Studying spin-momentum correlations in hadronic collisions offers a glimpse into a three-dimensional picture of proton structure. The transverse single-spin asymmetry for midrapidity isolated direct photons in p^{↑}+p collisions at sqrt[s]=200  GeV is measured with the PHENIX detector at the Relativistic Heavy Ion Collider (RHIC). Because direct photons in particular are produced from the hard scattering and do not interact via the strong force, this measurement is a clean probe of initial-state spin-momentum correlations inside the proton and is in particular sensitive to gluon interference effects within the proton. This is the first time direct photons have been used as a probe of spin-momentum correlations at RHIC. The uncertainties on the results are a 50-fold improvement with respect to those of the one prior measurement for the same observable, from the Fermilab E704 experiment. These results constrain gluon spin-momentum correlations in transversely polarized protons.

Room Size Influences Flow in Robotic-Assisted Surgery

The introduction of surgical technology into existing operating rooms (ORs) can place novel demands on staff and infrastructure. Despite the substantial physical size of the devices in robotic-assisted surgery (RAS), the workspace implications are rarely considered. This study aimed to explore the impact of OR size on the environmental causes of surgical flow disruptions (FDs) occurring during RAS. Fifty-six RAS procedures were observed at two academic hospitals between July 2019 and January 2021 across general, urologic, and gynecologic surgical specialties. A multiple regression analysis demonstrated significant effects of room size in the pre-docking phase (t = 2.170, df = 54, β = 0.017, p = 0.035) where the rate of FDs increased as room size increased, and docking phase (t = -2.488, df = 54, β = -0.017, p = 0.016) where the rate of FDs increased as room size decreased. Significant effects of site (pre-docking phase: p = 0.000 and docking phase: p = 0.000) were also demonstrated. Findings from this study demonstrate hitherto unrecognized spatial challenges involved with introducing surgical robots into the operating domain. While new technology may provide benefits towards patient safety, it is important to consider the needs of the technology prior to integration.

Work-system interventions in robotic-assisted surgery: a systematic review exploring the gap between challenges and solutions

BACKGROUND

The introduction of a robot into the surgical suite changes the dynamics of the work-system, creating new opportunities for both success and failure. An extensive amount of research has identified a range of barriers to safety and efficiency in Robotic Assisted Surgery (RAS), such as communication breakdowns, coordination failures, equipment issues, and technological malfunctions. However, there exists very few solutions to these barriers. The purpose of this review was to identify the gap between identified RAS work-system barriers and interventions developed to address those barriers.

METHODS

A search from three databases (PubMed, Web of Science, and Ovid Medline) was conducted for literature discussing system-level interventions for RAS that were published between January 1, 1985 to March 17, 2020. Articles describing interventions for systems-level issues that did not involve technical skills in RAS were eligible for inclusion.

RESULTS

A total of 30 articles were included in the review. Only seven articles (23.33%) implemented and evaluated interventions, while the remaining 23 articles (76.67%) provided suggested interventions for issues in RAS. Major barriers identified included disruptions, ergonomic issues, safety and efficiency, communication, and non-technical skills. Common solutions involved team training, checklist development, and workspace redesign.

CONCLUSION

The review identified a significant gap between issues and solutions in RAS. While it is important to continue identifying how the complexities of RAS affect operating room (OR) and team dynamics, future work will need to address existing issues with interventions that have been tested and evaluated. In particular, improving RAS-associated non-technical skills, task management, and technology management may lead to improved OR dynamics associated with greater efficiency, reduced costs, and better systems-level outcomes.

Work systems analysis of sterile processing: assembly

BACKGROUND

Sterile processing departments (SPDs) play a crucial role in surgical safety and efficiency. SPDs clean instruments to remove contaminants (decontamination), inspect and reorganise instruments into their correct trays (assembly), then sterilise and store instruments for future use (sterilisation and storage). However, broken, missing or inappropriately cleaned instruments are a frequent problem for surgical teams. These issues should be identified and corrected during the assembly phase.

OBJECTIVE

A work systems analysis, framed within the Systems Engineering Initiative for Patient Safety (SEIPS) model, was used to develop a comprehensive understanding of the assembly stage of reprocessing, identify the range of work challenges and uncover the inter-relationship among system components influencing reliable instrument reprocessing.

METHODS

The study was conducted at a 700-bed academic hospital in the Southeastern United States with two reprocessing facilities from October 2017 to October 2018. Fifty-six hours of direct observations, 36 interviews were used to iteratively develop the work systems analysis. This included the process map and task analysis developed to describe the assembly system, the abstraction hierarchy developed to identify the possible performance shaping factors (based on SEIPS) and a variance matrix developed to illustrate the relationship among the tasks, performance shaping factors, failures and outcomes. Operating room (OR) reported tray defect data from July 2016 to December 2017 were analysed to identify the percentage and types of defects across reprocessing phases the most common assembly defects.

RESULTS

The majority of the 3900 tray defects occurred during the assembly phase; impacting 5% of surgical cases (n=41 799). Missing instruments, which could result in OR delays and increased surgical duration, were the most commonly reported assembly defect (17.6%, n=700). High variability was observed in the reassembling of trays with failures including adding incorrect instruments, omitting instruments and failing to remove damaged instrument. These failures were precipitated by technological shortcomings, production pressures, tray composition, unstandardised instrument nomenclature and inadequate SPD staff training.

CONCLUSIONS

Supporting patient safety, minimising tray defects and OR delays and improving overall reliability of instrument reprocessing require a well-designed instrument tracking system, standardised nomenclature, effective coordination of reprocessing tasks between SPD and the OR and well-trained sterile processing technicians.

Train-the-trainer: Pilot trial for ebola virus disease simulation training

BACKGROUND

Highly infectious but rare diseases require rapid dissemination of safety critical skills to health-care workers (HCWs). Simulation is an effective method of education; however, it requires competent instructors. We evaluated the efficacy of an internet-delivered train-the-trainer course to prepare HCWs to care for patients with Ebola virus disease (EVD).

METHODS

Twenty-four individuals without prior EVD training were recruited and divided into two groups. Group A included nine trainees taught by three experienced trainers with previous EVD training. Group B included 15 trainees taught by five novice trainers without previous EVD training who completed the train-the-trainer course. We compared the efficacy of the train-the-trainer course by examining subject performance, measured by time to complete 13 tasks and the proportion of steps per task flagged for critical errors and risky and positive actions. Trainees' confidence in their ability to safely care for EVD patients was compared with a self-reported survey after training.

RESULTS

Overall trainees' confidence in ability to safely care for EVD patients did not differ by group. Participants trained by the novice trainers were statistically significantly faster at waste bagging (P = 0.002), lab specimen bagging (P = 0.004), spill clean-up (P = 0.01), and the body bagging (P = 0.008) scenarios compared to those trained by experienced trainers. There were no significant differences in the completion time in the remaining nine training tasks. Participants trained by novice and experienced trainers did not differ significantly with regard to the proportion of steps in a task flagged for critical errors, risky actions, or positive actions with the exception of the task "Man Down in Gown" (12.5% of steps graded by experienced trainers compared to 0 graded by novice trainers, P = 0.007).

DISCUSSION

The online train-the-trainer EVD course is effective at teaching novices to train HCWs in protective measures and can be accomplished swiftly.

Work systems analysis of sterile processing: decontamination

BACKGROUND

Few studies have explored the work of sterile processing departments (SPD) from a systems perspective. Effective decontamination is critical for removing organic matter and reducing microbial levels from used surgical instruments prior to disinfection or sterilisation and is delivered through a combination of human work and supporting technologies and processes.

OBJECTIVE

In this paper we report the results of a work systems analysis that sought to identify the complex multilevel interdependencies that create performance variation in decontamination and identify potential improvement interventions.

METHODS

The research was conducted at a 700-bed academic hospital with two reprocessing facilities decontaminating approximately 23 000 units each month. Mixed methods, including 56 hours of observations of work as done, formal and informal interviews with relevant stakeholders and analysis of data collected about the system, were used to iteratively develop a process map, task analysis, abstraction hierarchy and a variance matrix.

RESULTS

We identified 21 different performance shaping factors, 30 potential failures, 16 types of process variance, and 10 outcome variances in decontamination. Approximately 2% of trays were returned to decontamination from assembly, while decontamination problems were found in about 1% of surgical cases. Staff knowledge, production pressures, instrument design, tray composition and workstation design contributed to outcomes such as reduced throughput, tray defects, staff injuries, increased inventory and equipment costs, and patient injuries.

CONCLUSIONS

Ensuring patients and technicians' safety and efficient SPD operation requires improved design of instruments and the decontamination area, skilled staff, proper equipment maintenance and effective coordination of reprocessing tasks.

A Work Systems Analysis of Sterile Processing: Sterilization and Case Cart Preparation

Achieving reliable instrument reprocessing requires finding the right balance among cost, productivity, and safety. However, there have been few attempts to comprehensively examine sterile processing department (SPD) work systems. We considered an SPD as an example of a socio-technical system - where people, tools, technologies, the work environment, and the organization mutually interact - and applied work systems analysis (WSA) to provide a framework for future intervention and improvement. The study was conducted at two SPD facilities at a 700-bed academic medical center servicing 56 onsite clinics, 31 operating rooms (ORs), and nine ambulatory centers. Process maps, task analyses, abstraction hierarchies, and variance matrices were developed through direct observations of reprocessing work and staff interviews and iteratively refined based on feedback from an expert group composed of eight staff from SPD, infection control, performance improvement, quality and safety, and perioperative services. Performance sampling conducted focused on specific challenges observed, interruptions during case cart preparation, and analysis of tray defect data from administrative databases. Across five main sterilization tasks (prepare load, perform double-checks, run sterilizers, place trays in cooling, and test the biological indicator), variance analysis identified 16 failures created by 21 performance shaping factors (PSFs), leading to nine different outcome variations. Case cart preparation involved three main tasks: storing trays, picking cases, and prioritizing trays. Variance analysis for case cart preparation identified 11 different failures, 16 different PSFs, and seven different outcomes. Approximately 1% of cases had a tray with a sterilization or case cart preparation defect and 13.5 interruptions per hour were noted during case cart preparation. While highly dependent upon the individual skills of the sterile processing technicians, making the sterilization process less complex and more visible, managing interruptions during case cart preparation, improving communication with the OR, and improving workspace and technology design could enhance performance in instrument reprocessing.

Nuclear Dependence of the Transverse Single-Spin Asymmetry in the Production of Charged Hadrons at Forward Rapidity in Polarized p+p, p+Al, and p+Au Collisions at sqrt[s_{NN}]=200 GeV

We report on the nuclear dependence of transverse single-spin asymmetries (TSSAs) in the production of positively charged hadrons in polarized p^{↑}+p, p^{↑}+Al, and p^{↑}+Au collisions at sqrt[s_{NN}]=200  GeV. The measurements have been performed at forward rapidity (1.4<η<2.4) over the range of transverse momentum (1.8<p_{T}<7.0  GeV/c) and Feynman x (0.1<x_{F}<0.2). We observed positive asymmetries for positively charged hadrons in p^{↑}+p collisions, and significantly reduced asymmetries in p^{↑}+A collisions. These results reveal a nuclear dependence of TSSAs for charged-hadron production in a regime where perturbative techniques are applicable. These results provide new opportunities to use p^{↑}+A collisions as a tool to investigate the rich phenomena behind TSSAs in hadronic collisions and to use TSSAs as a new handle in studying small-system collisions.

Beam Energy and Centrality Dependence of Direct-Photon Emission from Ultrarelativistic Heavy-Ion Collisions

The PHENIX collaboration presents first measurements of low-momentum (0.4<p_{T}<3  GeV/c) direct-photon yields from Au+Au collisions at sqrt[s_{NN}]=39 and 62.4 GeV. For both beam energies the direct-photon yields are substantially enhanced with respect to expectations from prompt processes, similar to the yields observed in Au+Au collisions at sqrt[s_{NN}]=200. Analyzing the photon yield as a function of the experimental observable dN_{ch}/dη reveals that the low-momentum (>1  GeV/c) direct-photon yield dN_{γ}^{dir}/dη is a smooth function of dN_{ch}/dη and can be well described as proportional to (dN_{ch}/dη)^{α} with α≈1.25. This scaling behavior holds for a wide range of beam energies at the Relativistic Heavy Ion Collider and the Large Hadron Collider, for centrality selected samples, as well as for different A+A collision systems. At a given beam energy, the scaling also holds for high p_{T} (>5  GeV/c), but when results from different collision energies are compared, an additional sqrt[s_{NN}]-dependent multiplicative factor is needed to describe the integrated-direct-photon yield.

Pseudorapidity Dependence of Particle Production and Elliptic Flow in Asymmetric Nuclear Collisions of p+Al, p+Au, d+Au, and ^{3}He+Au at sqrt[s_{NN}]=200 GeV

Asymmetric nuclear collisions of p+Al, p+Au, d+Au, and ^{3}He+Au at sqrt[s_{NN}]=200  GeV provide an excellent laboratory for understanding particle production, as well as exploring interactions among these particles after their initial creation in the collision. We present measurements of charged hadron production dN_{ch}/dη in all such collision systems over a broad pseudorapidity range and as a function of collision multiplicity. A simple wounded quark model is remarkably successful at describing the full data set. We also measure the elliptic flow v_{2} over a similarly broad pseudorapidity range. These measurements provide key constraints on models of particle emission and their translation into flow.

A Pilot Trial of Online Simulation Training for Ebola Response Education

This article describes a pilot trial of an internet-distributable online software package that provides course materials and built-in evaluation tools to train healthcare workers in high-risk infectious disease response. It includes (1) an online self-study component, (2) a "hands-on" simulation workshop, and (3) a data-driven performance assessment toolset to support debriefing and course reporting. This study describes a pilot trial of the software package using a course designed to provide education in Ebola response to prepare healthcare workers to safely function as a measurable, high-reliability team in an Ebola simulated environment. Eighteen adult volunteer healthcare workers, including 9 novices and 9 experienced participants, completed an online curriculum with pre- and posttest, 13 programmed simulation training scenarios with a companion assessment tool, and a confidence survey. Both groups increased their knowledge test scores after completing the online curriculum. Simulation scenario outcomes were similar between groups. The confidence survey revealed participants had a high degree of confidence after the course, with a median confidence level of 4.5 out of 5.0 (IQR = 0.5). This study demonstrated the feasibility of using the online software package for the creation and application of an Ebola response course. Future studies could advance knowledge gained from this pilot trial by assessing timely distribution and multi-site effectiveness with standard education.

Measurements of Multiparticle Correlations in d+Au Collisions at 200, 62.4, 39, and 19.6 GeV and p+Au Collisions at 200 GeV and Implications for Collective Behavior

Recently, multiparticle-correlation measurements of relativistic p/d/^{3}He+Au, p+Pb, and even p+p collisions show surprising collective signatures. Here, we present beam-energy-scan measurements of two-, four-, and six-particle angular correlations in d+Au collisions at sqrt[s_{NN}]=200, 62.4, 39, and 19.6 GeV. We also present measurements of two- and four-particle angular correlations in p+Au collisions at sqrt[s_{NN}]=200  GeV. We find the four-particle cumulant to be real valued for d+Au collisions at all four energies. We also find that the four-particle cumulant in p+Au has the opposite sign as that in d+Au. Further, we find that the six-particle cumulant agrees with the four-particle cumulant in d+Au collisions at 200 GeV, indicating that nonflow effects are subdominant. These observations provide strong evidence that the correlations originate from the initial geometric configuration, which is then translated into the momentum distribution for all particles, commonly referred to as collectivity.

Nuclear Dependence of the Transverse-Single-Spin Asymmetry for Forward Neutron Production in Polarized p+A Collisions at sqrt[s_{NN}]=200 GeV

During 2015, the Relativistic Heavy Ion Collider (RHIC) provided collisions of transversely polarized protons with Au and Al nuclei for the first time, enabling the exploration of transverse-single-spin asymmetries with heavy nuclei. Large single-spin asymmetries in very forward neutron production have been previously observed in transversely polarized p+p collisions at RHIC, and the existing theoretical framework that was successful in describing the single-spin asymmetry in p+p collisions predicts only a moderate atomic-mass-number (A) dependence. In contrast, the asymmetries observed at RHIC in p+A collisions showed a surprisingly strong A dependence in inclusive forward neutron production. The observed asymmetry in p+Al collisions is much smaller, while the asymmetry in p+Au collisions is a factor of 3 larger in absolute value and of opposite sign. The interplay of different neutron production mechanisms is discussed as a possible explanation of the observed A dependence.

Centrality-Dependent Modification of Jet-Production Rates in Deuteron-Gold Collisions at √[s(NN)]=200 GeV

Jet production rates are measured in p+p and d+Au collisions at sqrt[s_{NN}]=200  GeV recorded in 2008 with the PHENIX detector at the Relativistic Heavy Ion Collider. Jets are reconstructed using the R=0.3 anti-k_{t} algorithm from energy deposits in the electromagnetic calorimeter and charged tracks in multiwire proportional chambers, and the jet transverse momentum (p_{T}) spectra are corrected for the detector response. Spectra are reported for jets with 12<p_{T}<50  GeV/c, within a pseudorapidity acceptance of |η|<0.3. The nuclear-modification factor (R_{dAu}) values for 0%-100% d+Au events are found to be consistent with unity, constraining the role of initial state effects on jet production. However, the centrality-selected R_{dAu} values and central-to-peripheral ratios (R_{CP}) show large, p_{T}-dependent deviations from unity, challenging the conventional models that relate hard-process rates and soft-particle production in collisions involving nuclei.

Measurements of Elliptic and Triangular Flow in High-Multiplicity 3He+Au Collisions at √(s(NN))=200 GeV

We present the first measurement of elliptic (v(2)) and triangular (v(3)) flow in high-multiplicity (3)He+Au collisions at √(s(NN))=200  GeV. Two-particle correlations, where the particles have a large separation in pseudorapidity, are compared in (3)He+Au and in p+p collisions and indicate that collective effects dominate the second and third Fourier components for the correlations observed in the (3)He+Au system. The collective behavior is quantified in terms of elliptic v(2) and triangular v(3) anisotropy coefficients measured with respect to their corresponding event planes. The v(2) values are comparable to those previously measured in d+Au collisions at the same nucleon-nucleon center-of-mass energy. Comparisons with various theoretical predictions are made, including to models where the hot spots created by the impact of the three (3)He nucleons on the Au nucleus expand hydrodynamically to generate the triangular flow. The agreement of these models with data may indicate the formation of low-viscosity quark-gluon plasma even in these small collision systems.

Basolateral phosphate transport in renal proximal-tubule-like OK cells

It is generally assumed that phosphate (Pi) effluxes from proximal tubule cells by passive diffusion across the basolateral (BL) membrane. We explored the mechanism of BL Pi efflux in proximal tubule-like OK cells grown on permeable filters and then loaded with 32P. BL efflux of 32P was significantly stimulated (P < 0.05) by exposing the BL side of the monolayer to 12.5 mM Pi, to 10 mM citrate, or by acid-loading the cells, and was inhibited by exposure to 0.05 mM Pi or 25 mM HCO3; by contrast, BL exposure to high (8.4) pH, 40 mM K+, 140 mM Na gluconate (replacing NaCl), 10 mM lactate, 10 mM succinate, or 10 mM glutamate did not affect BL 32P efflux. These data are consistent with BL Pi efflux from proximal tubule-like cells occurring, in part, via an electro-neutral sodium-sensitive anion transporter capable of exchanging two moles of intracellular acidic H2PO4- for each mole of extracellular basic HPO4= or for citrate.

Phosphate depletion in opossum kidney cells: apical but not basolateral or transepithelial adaptions of Pi transport

Monolayers of opossum kidney (OK) cells are widely used as models for the renal proximal tubule. OK cells adapt to phosphate (Pi) depletion by increasing their capacity for apical and basolateral Na+-dependent Pi uptake. Because NMR-visible cell Pi was found to be decreased in Pi-deprived kidney cells, we suggested that up-regulation of basolateral Pi efflux also occurs during adaptation to Pi deprivation [American Journal of Physiol 1994;267:C915-919]. In order to test this hypothesis, we measured the cell Pi pool, basolateral Pi efflux and transepithelial Pi fluxes in OK cells grown on permeable plastic filters, exposed overnight to solutions containing either 0.5 mM (deprived) or 2.0 mM (replete) Pi or 32Pi. Following steady state or acute loading with 32Pi, the specific activity (SA) of cell Pi, the cell Pi pool and the basolateral efflux of 32Pi were measured. In the steady state, a 2-fold increase in Pi uptake sustained the intracellular Pi pool at 85% of the control level (30 +/- 5 nmol/mg) in spite of a decrease in extracellular Pi from 2 to 0.5 mM. When the extracellular Pi was acutely (1 h) reduced to 0.1 mM, the cell Pi pool decreased (to 3 +/- 1 nmol/mg) both in cells previously adapted overnight to either 0.5 or to 2 mM Pi (p >0.3). The rates of absolute and fractional basolateral washout of cell 32Pi after 1 h loading with 0.1 mM 32Pi were similar in cells adapted to 0.5 compared to 2 mM Pi. This indicates that Pi depletion did not affect the effective permeability of the basolateral membranes to Pi. Adaptation for 16 h to 0.5 compared to 2 mM Pi did not alter the rate of net transepithelial transport of 0.1 mM Pi from the apical to the basal compartment but reduced (p < 0.05) the unidirectional fluxes of both 32Pi and 14C-mannitol. An insufficient driving force (unchanged or low Pi concentration in the transport pool, low electrical or coupled-anion gradients) and a constant effective basolateral Pi permeability must have limited basolateral Pi efflux in cells exposed to 0.1 mM Pi. Thus, in OK cells grown on plastic support there are no adaptive increases in either basolateral Pi efflux, or in transcellular and paracellular Pi transport, in response to Pi depletion. Adaptations are limited to increases in apical and basolateral sodium-dependent Pi uptakes that can maintain the cell Pi pool as long as apical Pi is not too low (> or =0.5 mM). The OK cells adapt to low Pi concentrations conserving cell Pi but not increasing basolateral Pi efflux nor transepithelial Pi transport.

The effect of a mock trial on nursing students' ability to make clinically sound legal judgments

In an attempt to enhance nursing students' abilities to make legally sound clinical judgments, a mock trial experience was developed and evaluated. Using a quasi-experimental design, students' learning was assessed using scenarios derived from actual cases involving nurses. Satisfaction with a traditional learning approach was compared to learning through attendance at a mock trial. A significant difference was found in learning before and after the trial (t = 2.26, P < 0.05), and students preferred the mock trial experience to traditional classroom presentations.