Mt. Ascutney Hospital and Health Center

OBJECTIVE: To determine a just and consistent practice for creating nursing assignments. BACKGROUND: Traditional methods of assigning patients to nurses may lead to unbalanced nursing workload. This article describes the ongoing, hospital-wide effort to evaluate and implement a nursing assignment tool based on electronic health record (EHR) functionality and auto-calculated nursing workload scores. METHODS: EHR records of individual patient workload scores from all hospital units were collected from August 2017 to June 2018. A nurse-specific total workload score was summed for each staff. Then, each hospital unit's mean nurse workload score and standard deviation, along with the unit's nurse-to-patient ratio, were used to calculate levels of high, medium, and low nursing workload measurement (NWM). RESULTS: Mean patient-specific workload scores varied greatly across hospital units. Unit-specific nurse-to-patient ratios were factored into NWM scores to create ranges for assignments that were relatively consistent across the institution. CONCLUSION: The use of objective, electronically generated nursing workload scores, combined with traditional nurse-to-patient ratios, provides accurate real-time nurse staffing needs that can inform best practice in staffing. The confirmation of individual patient workload scores and an appreciation for the complexity of EHR vendor rules are necessary for successful implementation. Automation ensures patient safety, staff satisfaction, and optimal resource allocation.

Description: The base is located along NH Highway 31, 0.5 mile northwest of the intersection of NH Routes 9 and 31 at Hillsboro Lower Village, NH, and 1 mile southeast of Hillsboro Upper Village

William J. Wilgus; Transportation on the Western Front, 1914–1918. Compiled by Colonel A. M. Henniker. With Introduction by Brigadier-General Sir James E. Edmon

Introduction: Rwanda is an East African country of 12 million people that currently has 8 internists regularly performing diagnostic endoscopy. The country has four public referral hospitals with endoscopic capabilities. The Rwandan Society of Endoscopy (RSE) has a goal of expanding its coverage and increasing skills in therapeutic endoscopy. Prior case series of EGDs in Butare and Kigali have revealed major endoscopic diagnoses (i.e. ulceration, stricture and malignancy) in up to 40% of exams. Rwandan endoscopy week was a collaborative effort between a US gastroenterology team and members of the Rwandan Society of Endoscopy (RSE) who have a longstanding working relationship through a series of international physician exchanges. Methods: Six US GI physicians, two nurses, two technicians and a biomedical engineer worked in collaboration with members of the RSE (15 physicians and 18 nurses) for one week. Combined US/Rwandan teams were deployed to the four referral hospitals with endoscopic capabilities. GI consultation was done on the hundreds of patients referred for endoscopy to ensure appropriateness of the procedure. Patient demographic data, procedural indication and results were collected at the four sites with the Google Forms online tool. Results: Completed procedures included 200 EGDs, 39 colonoscopies and 5 ERCPs. 33% of EGDs revealed significant findings including peptic ulcer disease (16%), suspected gastric malignancy (4%), esophageal varices (4.5%), esophageal stenosis (2.5%) and benign-appearing gastric outlet obstruction (2.5%). Interventional procedures included esophageal variceal banding (7), placement of esophageal stents (2), balloon dilation of the esophagus (7), duodenum (1) and pylorus (1). Of those presenting for colonoscopy, the most common indications included hematochezia (41%), abdominal pain (31%) and constipation (28%). Significant findings on colonoscopy included hemorrhoid disease (23%) and suspected colorectal cancer (7.7%). Findings on ERCP included two patients with choledocholithiasis, one with a choledochoduodenal fistula and one with suspected cholangiocarcinoma. Conclusion: Our findings support the presence of a high burden of GI disease in Rwanda. Expanding Rwanda’s current capabilities to address this need is feasible, but will require many more physicians to be trained in diagnostic and therapeutic endoscopy. As the current Rwandan endoscopists are proficient in diagnostic endoscopy, advancement to therapeutic skills is a natural next step.

Abstract A need to improve the transitions of care between a small rural emergency department, a residential care facility and a primary care practice emerged early on in our work to become a level 2 accredited emergency department. One challenge is bringing together 3 partners all with distinct types of health records, unique foci of care and a variety of disciplines and workforce. This paper will focus on our journey of creating an individualized plan of care to help mitigate problems of poor communication with a focus on the 4Ms framework including: What Matters Most, Mobility, Medication and Mentation.

Background: Coronary access following transcatheter aortic valve replacement (TAVR) remains challenging and should be carefully considered when planning re-intervention for patients with structural valve degeneration. Current management options [valve-in-valve (ViV) TAVR or surgical aortic valve replacement and TAVR explant] both carry significant benefits and limitations. Case presentation: A 78-year-old female with a degenerated 23 mm Sapien 3 TAVR presented with severe prosthetic stenosis, moderate paravalvular leak (PVL), and progressive dyspnea. A standard TAVR ViV had a suboptimal risk of not addressing the PVL and worsening prosthesis-patient mismatch, whereas TAVR explantation and SAVR with root enlargement carried an increased surgical risk. Intervention: Open surgical TAVR explantation with direct re-implantation of a 26 mm Sapien Ultra valve, combined with selective metal cells excision facing the left main coronary artery (LMCA) and felt patch repair of the PVL. Outcome: The patient achieved immediate resolution of severe stenosis and elimination of PVL, with sustained clinical improvement at six-month follow-up and a more favorable coronary access. Conclusion: Selective metal cell excision during open TAVR implantation is a technically feasible approach to prophylactically preserve coronary access while maintaining valve integrity and function. This technique may benefit high-risk patients requiring TAVR explants and root enlargement SAVRs.

Read before the Massachusetts chapter of the American Physiotherapy Association, Boston, November 3, 1937.