A B S T R A C TConceptual Framework: The Academic Center for Evidence-based Practice (ACE) Star Model was used to implement an evidence-based clinical practice guideline (CPG) in order to decrease ventilator-associated pneumonia (VAP) incidence rates and ventilator days. The goal was to interrupt person-to-person transmission of bacteria and bacterial colonization using low-cost, evidence-based strategies to prevent VAP.Discovery: Two geographically proximate medical centers, inclusive of five intensive care units located in the southwestern region of the United States had significant variations in their VAP rates.Evidence summary: Using the U.S. Preventive Services Task Force grading criteria, the results of 69 studies were used to establish a clinical practice guideline to prevent ventilator-associated pneumonia.Translation: A clinical practice guideline was developed for the prevention of VAP and included five nursing activities: (a) head-of-bed elevation; (b) oral care; (c) ventilator tubing condensate removal; (d) hand hygiene; and (e) glove use. The effect of the CPG, inclusive of an educational intervention, was measured using an observational, prospective, quasi-experimental design.Integration: A multidisciplinary education team developed a self-learning packet, educational materials, and storyboards for the staff as dissemination strategies. Strategies also included e-mail, one-on-one teaching with clinicians, and feedback on guideline adoption and VAP rate reports.Evaluation: Observation data were collected to evaluate adoption of the CPG while caring for 106 ventilated patients. VAP rates changed at both hospitals although the change was not statistically significant. Additionally, the ICU length of stay declined at both facilities, causing cost savings.Discussion: These results support the idea that adoption of evidence-based practices contributes to decreased VAP rates. For a successful program, ICU leaders should emphasize strategies that routinize adoption of evidence-based CPGs.

Hearing rehabilitation with an intracochlear prosthesis is well documented in patients who have an intact otic capsule prior to implantation. However, the suitability for implantation of patients who have undergone extensive procedures involving the otic capsule such as labyrinthectomy has not been directly addressed. This report documents a case of a patient deafened by a transmastoid labyrinthectomy who subsequently received a cochlear implant. Postimplantation performance of this patient was compared with the performance of three other postlingual implant recipients. The results suggest that labyrinthectomy is not a contraindication to auditory rehabilitation by a cochlear implant. The implications of implantation in a surgically manipulated otic capsule are discussed.

Until recently, the U.S. Army Combat Medic School used a traditional teaching model with heavy emphasis on large group lectures. Skills were taught separately with minimal links to didactics. Objectives: To evaluate whether the adult learning model improves student learning in terms of cognitive performance and perception of proficiency in military medic training. Methods: The study population was two sequential groups of randomly selected junior, enlisted, active duty soldiers with no prior formal emergency medical training who were enrolled in an experimental model of a U.S. Army Combat Medic School. The control population was a similar group of students enrolled in the traditional curriculum. Instructors were drawn from the same pool, with experimental group instructors receiving two weeks of training in adult-learning strategies. The study population was enrolled in the experimental program that emphasized the principles of adult learning, including small-group interactive approach, self-directed study, multimedia didactics, and intensive integrated practice of psychomotor skills. Instructors and students were also surveyed at the end of the course as to their confidence in performing four critical skills. The survey instrument used a five-point scale ranging from ''strongly disagree'' through ''undecided'' to ''strongly agree.'' Proficiency for this survey was defined as the sum of the top two ratings of ''agree'' or ''strongly agree'' to questions regarding the particular skill. Both experimental and control programs lasted ten weeks and covered the same academic content and nonacademic (e.g., physical fitness) requirements, and the two groups of students had similar duty days. Evaluations included performance on internal and National Registry of Emergency Medical Technicians (NREMT) written examinations and other measures of academic and nonacademic performance. Results: One hundred fifty students (experimental n ¼ 81, control n ¼ 69) were enrolled in 1999-2000. The scores for internal course grade, NREMT written score, and NREMT written pass rate were, respectively, 86.3, 71.6, and 63% for the experimental group; and 85.8, 69.6, and 49% for the control group. The p-value was # 0.05 for the comparison between internal course grade and NREMT written score, but p > 0.05 for the comparison between NREMT written pass rates. Students in both the adult-learning and traditional groups rated themselves high in proficiency, whereas instructors in the traditional group were generally much more modest in their rating of student proficiency than instructors of the adultlearning program. Conclusions: In this study setting, an adult-learning model offers only a modest improvement in cognitive evaluation scores over traditional teaching when measured at the end of the course. Additionally, students in the traditional teaching model assess themselves as proficient more frequently than instructors, whereas instructor and student perception of proficiency more closely matched in the adult-learning model.

In the presence of an intact cochlear nerve, hearing loss has been attributed to either transection or spasm of the internal auditory artery or direct mechanical trauma to the cochlear nerve during tumor manipulation. Such events have been correlated with changes in intraoperative auditory evoked potentials. The possibility of a reversible conduction block in the cochlear nerve, however, has not been investigated. Review of four cases of delayed spontaneous recovery of hearing several months after acoustic tumor resection suggests that a conduction block phenomenon may exist. By comparing recent pertinent animal data with clinical intraoperative electrophysiologic data obtained during posterior fossa surgery in human subjects, we attempt to elucidate further the pathophysiology and intraoperative predisposing factors to cochlear nerve injury during hearing preservation procedures.