Director of Advanced Practice, Stanford Health Care (2013 - Present)
Honors & Awards
Fellow, Academy of Emergency Nursing, Emergency Nurses Association (2008)
Fellow, Palliative Care Nursing, Hospice & Palliative Nurses Association (2010)
Fellow, American Academy of Nursing, American Academy of Nursing (2010)
Fellow, National Academies of Practice, National Academies of Practice (2013)
Community and International Work
Developing the role of nurse practitioners in Japan, Tokyo, Japan
Nurse practitioner role development
Tokyo Healthcare University
Opportunities for Student Involvement
Create the role of nurse practitioner in Switzerland, Bern, Switzerland
Nurse practitioner role development
Opportunities for Student Involvement
Master's Programme in Palliative Care, Molde, Norway
Høgskolen i Molde
Opportunities for Student Involvement
Current Research and Scholarly Interests
Describe your current research interest and activities
Exploring the Relationship Among Moral Distress, Coping, and the Practice Environment in Emergency Department Nurses.
Advanced emergency nursing journal
2016; 38 (2): 133-146
Emergency department (ED) nurses practice in environments that are highly charged and unpredictable in nature and can precipitate conflict between the necessary prescribed actions and the individual's sense of what is morally the right thing to do. As a consequence of multiple moral dilemmas, ED staff nurses are at risk for experiencing distress and how they cope with these challenges may impact their practice. To examine moral distress in ED nurses and its relationship to coping in that specialty group. Using survey methods approach. One hundred ninety-eight ED nurses completed a moral distress, coping, and demographic collection instruments. Advanced statistical analysis was completed to look at relationships between the variables. Data analysis did show that moral distress is present in ED nurses (M = 80.19, SD = 53.27), and when separated into age groups, the greater the age, the less the experience of moral distress. A positive relationship between moral distress and some coping mechanisms and the ED environment was also noted. This study's findings suggest that ED nurses experience moral distress and could receive some benefit from utilization of appropriate coping skills. This study also suggests that the environment in which ED nurses practice has a significant impact on the experience of moral distress. Because health care is continuing to evolve, it is critical that issues such as moral distress and coping be studied in ED nurses to help eliminate human suffering.
View details for DOI 10.1097/TME.0000000000000100
View details for PubMedID 27139135
Pre-participation screening for athletes and the role of advanced practice providers
JOURNAL OF ELECTROCARDIOLOGY
2015; 48 (3): 339-344
Pre-participation screening of athletes for underlying cardiovascular disease is recommended by the AHA/ACC. However, vigorous debate continues as to whether the ECG should be used as part of a broad-based screening program. The AHA/ACC "do not support national mandatory screening ECGs of athletes, because the logistics, manpower, financial and resource considerations make such a program inapplicable to US". In an effort to address these impediments and to increase access for communities, we explore the use of advanced practice providers (Nurse Practitioners and Physician Assistants) in providing pre-participation screening to athletes with ECG interpretation. In the current healthcare environment with limited primary care resources, advanced practice providers are an important new element in improving access to care. Pre-participation screening with ECG interpretation is currently within an advanced practice provider's scope of practice. Emerging data shows that advanced practice providers perform care that is within acceptable patient care standards, safely, and cost effectively, compared to physician counterparts. To further improve pre-participation screening, a national education and certification program on 12-lead ECG interpretation is needed. Standardized screening tools and mass screening protocols that include screening ECGs for targeted athlete populations who are at high risk for SCD are needed. These recommendations are aimed at addressing some of the barriers raised by the AHA/ACC group to pre-participation screening with ECG.
View details for DOI 10.1016/j.jelectrocard.2015.03.003
View details for Web of Science ID 000354343100009
View details for PubMedID 25791248
American Academy of Nursing: Improving health and health care systems with advanced practice registered nurse practice in acute and critical care settings.
2014; 62 (5): 366-370
View details for PubMedID 25353040
INTEGRATION OF PALLIATIVE CARE INTO EMERGENCY MEDICINE: THE IMPROVING PALLIATIVE CARE IN EMERGENCY MEDICINE (IPAL-EM) COLLABORATION
JOURNAL OF EMERGENCY MEDICINE
2014; 46 (2): 264-270
Emergency department (ED) providers commonly care for seriously ill patients who suffer from advanced, chronic, life-limiting illnesses in addition to those that are acutely ill or injured. Both the chronically ill and those who present in extremis may benefit from application of palliative care principles.We present a case highlighting the opportunities and need for better integration of emergency medicine and palliative care.We offer practical guidelines to the ED faculty/administrators who seek to enhance the quality of patient care in their own unique ED setting by starting an initiative that better integrates palliative principles into daily practice. Specifically, we outline four things to do to jumpstart this collaborative effort.The Improving Palliative Care in Emergency Medicine project sponsored by the Center to Advance Palliative Care is a resource that assists ED health care providers with the process and structure needed to integrate palliative care into the ED setting.
View details for DOI 10.1016/j.jemermed.2013.08.087
View details for Web of Science ID 000330578700033
View details for PubMedID 24286714
A Prospective Randomized Blister Prevention Trial Assessing Paper Tape in Endurance Distances (Pre-TAPED)
WILDERNESS & ENVIRONMENTAL MEDICINE
2014; 25 (4): 457-461
Friction foot blisters are a common injury occurring in up to 39% of marathoners, the most common injury in adventure racing, and represent more than 70% of medical visits in multi-stage ultramarathons. The goal of the study was to determine whether paper tape could prevent foot blisters in ultramarathon runners.This prospective randomized trial was undertaken during RacingThePlanet 155-mile (250-km), 7-day self-supported ultramarathons in China, Australia, Egypt, Chile, and Nepal in 2010 and 2011. Paper tape was applied prerace to one randomly selected foot, with the untreated foot acting as the own control. The study end point was development of a hot spot or blister on any location of either foot.One hundred thirty-six participants were enrolled with 90 (66%) having completed data for analysis. There were 36% women, with a mean age of 40 ± 9.4 years (range, 25-40 years) and pack weight of 11 ± 1.8 kg (range, 8-16 kg). All participants developed blisters, with 89% occurring by day 2 and 59% located on the toes. No protective effect was observed by the intervention (47 versus 35; 52% versus 39%; P = .22), with fewer blisters occurring around the tape on the experimental foot than under the tape (23 vs 31; 25.6% versus 34.4%), yet 84% of study participants when queried would choose paper tape for blister prevention in the future.Although paper tape was not found to be significantly protective against blisters, the intervention was well tolerated with high user satisfaction.
View details for Web of Science ID 000346895300013
View details for PubMedID 25443754
A Prospective Cohort Study of Acute Kidney Injury in Multi-stage Ultramarathon Runners: The Biochemistry in Endurance Runner Study (BIERS).
Research in sports medicine
2014; 22 (2): 185-192
The purpose of the study was to evaluate the prevalence of acute kidney injury (AKI) during a multi-stage ultramarathon foot race. A prospective observational study was taken during the Gobi 2008; Sahara 2008; and Namibia 2009 RacingThePlanet 7-day, 6-stage, 150-mile foot ultramarathons. Blood was analyzed before, and immediately after stage 1 (25 miles), 3 (75 miles), and 5 (140 miles). Creatinine (Cr), glomerular filtration rate (GFR), and incidence of AKI were calculated and defined by RIFLE criteria. Thirty participants (76% male, mean age 40 + 11 years) were enrolled. There were significant declines in GFR after each stage compared with the pre-race baseline (p < 0.001), with the majority of participants (55-80%) incurring AKI. The majority of study participants encountered significant renal impairment; however, no apparent cumulative effect was observed, with resolution of renal function to near baseline levels between stages.
View details for DOI 10.1080/15438627.2014.881824
View details for PubMedID 24650338
INTEGRATING PALLIATIVE CARE IN THE OUT-OF-HOSPITAL SETTING: FOUR THINGS TO JUMP-START AN EMS-PALLIATIVE CARE INITIATIVE
PREHOSPITAL EMERGENCY CARE
2013; 17 (4): 511-520
Emergency medical service (EMS) is frequently called to care for a seriously ill patient with a life-threatening or life-limiting illness. The seriously ill include both the acutely injured patients (for example in mass casualty events) and those who suffer from advanced stages of a chronic disease (for example severe malignant pain). EMS therefore plays an important role in delivering realistic, appropriate, and timely care that is consistent with the patient's wishes and in treating distressing symptoms in those who are seriously ill. The purpose of this article is to; 1) review four case scenarios that relate to palliative care and may be commonly encountered in the out-of-hospital setting and 2) provide a road map by suggesting four things to do to start an EMS-palliative care initiative in order to optimize out-of-hospital care of the seriously ill and increase preparedness of EMS providers in these difficult situations.
View details for DOI 10.3109/10903127.2013.811566
View details for Web of Science ID 000323943800012
View details for PubMedID 23968313
An official American Thoracic Society workshop report: assessment and palliative management of dyspnea crisis.
Annals of the American Thoracic Society
2013; 10 (5): S98-106
In 2009, the American Thoracic Society (ATS) funded an assembly project, Palliative Management of Dyspnea Crisis, to focus on identification, management, and optimal resource utilization for effective palliation of acute episodes of dyspnea. We conducted a comprehensive search of the medical literature and evaluated available evidence from systematic evidence-based reviews (SEBRs) using a modified AMSTAR approach and then summarized the palliative management knowledge base for participants to use in discourse at a 2009 ATS workshop. We used an informal consensus process to develop a working definition of this novel entity and established an Ad Hoc Committee on Palliative Management of Dyspnea Crisis to further develop an official ATS document on the topic. The Ad Hoc Committee members defined dyspnea crisis as "sustained and severe resting breathing discomfort that occurs in patients with advanced, often life-limiting illness and overwhelms the patient and caregivers' ability to achieve symptom relief." Dyspnea crisis can occur suddenly and is characteristically without a reversible etiology. The workshop participants focused on dyspnea crisis management for patients in whom the goals of care are focused on palliation and for whom endotracheal intubation and mechanical ventilation are not consistent with articulated preferences. However, approaches to dyspnea crisis may also be appropriate for patients electing life-sustaining treatment. The Ad Hoc Committee developed a Workshop Report concerning assessment of dyspnea crisis; ethical and professional considerations; efficient utilization, communication, and care coordination; clinical management of dyspnea crisis; development of patient education and provider aid products; and enhancing implementation with audit and quality improvement.
View details for DOI 10.1513/AnnalsATS.201306-169ST
View details for PubMedID 24161068
- Palliative Care in Emergency Medicine: Past, Present, and Future JOURNAL OF PALLIATIVE MEDICINE 2012; 15 (10): 1076-1081
- The National Association of Clinical Nurse Specialists Response to the Institute of Medicine's The Future of Nursing Report CLINICAL NURSE SPECIALIST 2012; 26 (4): 222-224
QUASI-EXPERIMENTAL STUDY TO IMPROVE NURSES' QT-INTERVAL MONITORING: RESULTS OF QTIP STUDY
AMERICAN JOURNAL OF CRITICAL CARE
2012; 21 (3): 195-200
A collaboration led by the American Heart Association recently released the scientific statement "Prevention of Torsade de Pointes in Hospital Settings." Patients receiving proarrhythmic drugs, who have electrolyte disturbances, or who have bradyarrhythmias require QT-interval monitoring. Prior studies have demonstrated that physicians have a poor level of proficiency at calculating QT intervals. The ability of nurses at calculating QT intervals remains untested.To evaluate nurses' knowledge and ability to perform QT/QTc interval monitoring.At a single institution, 47 QT-education classes were provided to 480 eligible nurses who regularly perform cardiac monitoring. All nurses completed a researcher-developed knowledge test at baseline and after the QT-related education intervention.Overall 379 nurses participated (mean age 39 [SD, 10] years), 71% had more than 5 years' nursing experience. Total test scores increased after intervention (46% vs 77%, P < .001). Education significantly improved marking of the QT/RR intervals (QT: 65% vs 91%, RR: 83% vs 90%, P ≤ .001 and P = .02) and measurement of the QT/RR intervals (QT: 47% vs 84%, RR: 35% vs 71% P ≤ .001 and P ≤ .001). Calculation of the QTc interval also increased significantly (6% vs 52%, P ≤ .001).Our study results demonstrate that nurses' baseline ability to perform QT interval monitoring is extremely poor. An unacceptable amount of error persists after an educational intervention. Accurate computer-assisted methods are needed to reduce the error associated with manual QT-interval monitoring.
View details for DOI 10.4037/ajcc2012245
View details for Web of Science ID 000310641300014
View details for PubMedID 22549576
High prevalence of corrected QT interval prolongation in acutely ill patients is associated with mortality: Results of the QT in Practice (QTIP) Study
CRITICAL CARE MEDICINE
2012; 40 (2): 394-399
To test the potential value of more frequent QT interval measurement in hospitalized patients.We performed a prospective, observational study.All adult intensive care unit and progressive care unit beds of a university medical center.All patients admitted to one of six critical care units over a 2-month period were included in analyses.All critical care beds (n = 154) were upgraded to a continuous QT monitoring system (Philips Healthcare).QT data were extracted from the bedside monitors for offline analysis. A corrected QT interval >500 msecs was considered prolonged. Episodes of QT prolongation were manually over-read. Electrocardiogram data (67,648 hrs, mean 65 hrs/patient) were obtained. QT prolongation was present in 24%. There were 16 cardiac arrests, with one resulting from Torsade de Pointes (6%). Predictors of QT prolongation were female sex, QT-prolonging drugs, hypokalemia, hypocalcemia, hyperglycemia, high creatinine, history of stroke, and hypothyroidism. Patients with QT prolongation had longer hospitalization (276 hrs vs. 132 hrs, p < .0005) and had three times the odds for all-cause in-hospital mortality compared to patients without QT prolongation (odds ratio 2.99 95% confidence interval 1.1-8.1).We find QT prolongation to be common (24%), with Torsade de Pointes representing 6% of in-hospital cardiac arrests. Predictors of QT prolongation in the acutely ill population are similar to those previously identified in ambulatory populations. Acutely ill patients with QT prolongation have longer lengths of hospitalization and nearly three times the odds for mortality then those without QT prolongation.
View details for DOI 10.1097/CCM.0b013e318232db4a
View details for Web of Science ID 000299313500004
View details for PubMedID 22001585
Trajectories of Approaching Death in the Emergency Department: Clinician Narratives of Patient Transitions to the End of Life
JOURNAL OF PAIN AND SYMPTOM MANAGEMENT
2011; 42 (6): 864-881
Transitions near the end of life have not been well articulated and the end-of-life (EOL) phase is not well understood in the emergency department (ED). The sudden and unforeseen is common in the ED.The purpose of this qualitative research project is to identify different trajectories of approaching death in an effort to describe the EOL experience in the ED.An interpretive phenomenological approach was used to assess the results of interviews with and observations of ED staff who were intimately involved in caring for patients approaching death and dying.Seven trajectories of approaching death in the ED emerged from the data: 1) dead on arrival; 2) prehospital resuscitation with subsequent ED death; 3) prehospital resuscitation with survival until admission; 4) terminally ill and comes to the ED; 5) frail and hovering near death; 6) alive and interactive on arrival, but arrests in the ED; and 7) potentially preventable death by omission or commission.A descriptive articulation of the various trajectories will help clinicians be more astute in their recognition of the clinical situation and react appropriately, will help identify the transitions to the EOL phase, and will help to explore the possibilities open to the patient, family, and clinicians. In addition, understanding the trajectories and discussion of the clinicians' actions and communication strategies can elucidate which of the trajectories could benefit from anticipatory planning.
View details for DOI 10.1016/j.jpainsymman.2011.02.023
View details for Web of Science ID 000298342400009
View details for PubMedID 21624814
Laser Capture Microdissection: Understanding the Techniques and Implications for Molecular Biology in Nursing Research Through Analysis of Breast Cancer Tumor Samples
BIOLOGICAL RESEARCH FOR NURSING
2011; 13 (3): 297-305
The purpose of this paper is to review the techniques and implications of laser capture microdissection (LCM) to isolate tissue and DNA of interest using breast biopsy tissue as an example.Tissues are a heterogeneous mix of different cell types, and molecular alterations are often specific to a single cell type. An accurate correlation of molecular and morphologic pathologies requires the ability to procure pure populations of morphologically similar cells for molecular analysis. LCM is a technique for isolating highly pure cell populations of morphologically similar cells from a heterogeneous tissue section.Nine invasive, paraffin-embedded breast biopsy specimens were obtained and analyzed. Depending on the size of the lesion, 500-1,000 shots using the 7.5- or 15-µm infrared laser beam were utilized to obtain an average of 2,000 cells. DNA was isolated from normal tissue and carcinomas and polymerase chain reaction (PCR) amplification was examined by agarose gel electrophoresis. The HER2/neu gene was amplified by standard PCR. A second round of PCR using nested primers to re-amplify the HER2/neu fragment was performed.Amplification of the HER2/neu gene with DNA isolated from pure cell populations by LCM was performed. The results indicated that 22% of the cases studied were positive for HER2/neu amplifications, which corresponds to the literature regarding HER2/neu amplification/overexpression. HER2/neu amplification could be detected as early as the ductal carcinoma in situ (DCIS) stage.LCM is an accurate and reliable method to acquire nucleic acid and protein profiles from a specific cell population in heterogeneous tissue.
View details for DOI 10.1177/1099800411402054
View details for Web of Science ID 000292052800010
View details for PubMedID 21444330
- Clinical decision making and management of blunt traumatic thoracic aortic injuries. Air medical journal 2008; 27 (3): 139-143