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Nursing Research & Evidence-Based Practice

central line associated bloodstream infections (CLABSIs

Nursing Research & Evidence-Based Practice NUR 561


In researching the topic of central line associated bloodstream infections (CLABSIs), writer completed an online search for relevant articles to the topic. Articles selected were a quantitative and a qualitative article on CLABSI and prevention of CLABSI. This paper is based on the five-peer reviewed article on CLABSIs and CLABSIs prevention. CLABSI is considered a blood stream infection which is confirmed primarily by laboratory work (Sacks et al., 2014). CLABSI is a bloodstream infection that happens to the patient who has central line within 48 hours of insertion and is not related to an infection from another site (CDC, 2016). In general, CLABSI happens when there is a possibility of not correctly inserting the central venous line (CVL) or not monitoring or supervising the site after the insertion and not adhering to CLABSI protocol. It is one of the major blood stream infection with the increased morbidity and mortality rates of 10 to 20 % (Morrison, 2012). It cost a lot of money to the U.S. healthcare system and thousands of deaths in America, yet it is preventable healthcare associated infections just by implementing CLABSI bundle (CDC, 2016).

PICOT Question

The Evidence Based Practice research PICOT Question to be addressed: Does having a CLABSI prevention/elimination team who are dedicated to supervise entire central line insertion in Intensive Care Unit (ICU) and CLABSI bundle protocol as opposed to bedside ICU nurse be responsible to implement the CLABSI-related preventive measures for the purpose of reducing the risk of CLABSI?

P- Patients admitted in ICU

I- Having a CLABSI team to supervise the central line insertion

C- Bedside ICU nurses responsible to maintain and prevent CLABSI

O- Decreased rate of CLABSIs

T- During ICU stay

Keywords: Compliance, CLABSI bundles, Guidelines, CLABSI prevention, CLABSI

Literature Review

According to the article by Furuya et al., (2016), CLABSI is a condition that can be prevented. The intention of this study was to assess the compliance with the central line insertion bundle overall in US. The research method involved cross-sectional design involving National sample of adult ICUs participating in National Healthcare Safety Network (NHSN) surveillance (Furuya et al., 2016). The overall study involved 984 adult ICUs in 632 hospital (Furuya et al., 2016). The results of the study showed that only 69 percent of the US hospitals reported compliance with the set regulations to prevent CLABSI. It is therefore evident that compliance to the stipulated guidelines is not strictly followed. According to Furuya et al., compliance is the most effective method of preventing CLABSI. Most of the healthcare organization and healthcare centers are aware regarding the guidelines recognized by the World Health Organization (WHO) and Center of disease Control to presents the central line associated blood steam infections in ICU’s settings. This article by Furuya et al. (2016), is based on a qualitative study which is focused on the mutli-center research on the prevention and elimination of the CLABSI. This articles also focuses on why some of the hospital are more diligent on preventing the CLABSI than other despite the guidelines provided by national mandates. Research was conducted in 250 hospitals with the mean CLABSI rate of 2.1 per 1000 CVL (Furuya et al., 2016). Among them only 49 % reported to have a written CLABSI bundle policy (Furuya et al., 2016). Even on those who monitored compliance, only 38 % were highly compliant with the CLABSI bundle (Furuya et al., 2016). In this research, first the hospital’s infection preventionist was questioned by phone and then in person interviewed was conducted. On this research there was a use of snowball sampling to conduct the phone interview, in person interviews. The phone interview and in person interview was conducted on the epidemiologists, Physicians, unit managers, nurses in the ICU’s unit. After the interview it was identified that most of the organization had the common challenges to implement the CLABSI protocol in their organizations. There were basically four common challenges which were discussed by all the healthcare organization. The four challenges were the politics, culture, structure, and emotions. Politics meaning the relationship among the employee on the unit, culture as a values and beliefs which were shared by the employee, structure meaning some factors which are affecting the quality improvements projects, and lastly emotions as the level of commitment and passion shared on the unit (Furuya et al., 2016). After analyzing the article, it has been noted that those hospital who had a higher score on the culture and emotion were also the ones who were more committed and passionate about fostering change, improving implementation,  and collaborating more quality improvement projects. On the other hand, those hospital who did not score high on the four challenges were also found to be not having favorable environment for change.  The proposed study will close a gap in knowledge as it identifies that for effective implementation and collaboration of CLABSIs’ prevention plan, plan dissemination was deciphered as a prodigious step. From this article it has been found that the effect of implementing the CLABSI bundle protocol and educating nurses has a significant impact on reducing the CLABSI and associated infection as the p value was 0.015 (P = 0.015), incidence rate ratio [IRR] 0.77, 95% confidence interval and  (β = -1.029, p = 0.015).As we know that the p value less then .05 is significant and that we reject the null hypothesis of stating that there is no difference. The result indicated that there was a significant difference in reduction of CLABSI infection when the CLABSI bundles protocol were implemented and education were provided to the ICU employees on CLABSI. As a plan disseminating for the quality improvement was to meet the guidelines evidence-based practice research and implementing a Vascular Care Team (VCT) to monitor the CLABSI bundle protocol. Normally time frame for these kinds of projects will be three months. On a timely basis meeting were conducted between nurses and CLABSI team to monitor the progress towards prevention of the CLABSI.

The research study by Park et al. (2017) was conducted in a community hospital which was based on the qualitative analysis of midline catheter and central line care that were provided by medical-surgical nurses. Most of the community hospitals are not equipped with the required tools or had experience with preventative measure which are needed to fight central line associated bloodstream infections (CLABSIs). In this research, the researcher has utilized the phenomenological framework and the methods of exploration was the interview process (Park et al., 2017). The study was approved by the Centers for Disease Control and Prevention institutional review board (IRB) and the New Jersey Department of Health’s IRB use in this analysis (Park et al., 2017). Consents were obtained from qualified participants. No human harm was noted on this study as it is an education study and was conducted by interviewing process. The researcher on this research study conducted 45-minute interview with the medical-surgical nurses on the medical-surgical units that has the highest rate of CLABSI. This research studies were basically focused on the nurse’s perspective at central line care. Fifteen medical surgical nurses were interviewed from the medical surgical units who had highest’s incidence of CLABSI who were working as fulltime. After the interview process various challenges emerges out. The biggest challenge was to follow the correct procedure along with CLABSI prevention. Also, nurses did not have high exposure with CLABSI and patient with CLABSI. 15 nurses identified that there is a need for education concentrating on the central line care and CLABIs prevention training. As, a teaching strategy, nurses who were seasoned and experienced related to CLABSI were brought to the community hospital to guide the nurses. As a result, plan was created which was based on the experiences nurses experience and when implemented decreased the CLABSI rate. This article focuses on the prevention of infection from the nurses prospective who were working nurse in a community hospital.  This article explores the interventions that can be implemented to prevent CLABSI. The article highlights that the condition can be prevented if healthcare organizations take the necessary preventive measures. This data collection methods involved exploring the impacts of overall intervention implemented by peer tutoring which involved 1000 days of continuous tutoring. The results of the research showed that CLABSI decreased from 6.9 infections in the pre-intervention period to 2.4 and 1.8 in the intervention (Park et al., 2017). This article focused on the CLABSI rate for 9 months pre-intervention, 6 months during the intervention and 9 months post-intervention. SPSS 22.0 was utilized to conduct the statistical analysis for this article. It has been found from this research that CLABSI rate decreased from 6.9 infections in the pre-intervention phase to 2.4 and 1.8 in the intervention period of 6 months with P value being 0.102 (p= 0.102) per 1000 catheters per 9-month period (Park et al., 2017). The researcher used the regression model to show the significant difference between the pre intervention and post intervention drop rate in CLABSI where the P value was  less than 0.001 (P < 0.001). As mentioned above P value less than 0.05 is considered to be statistically significant and shows the difference preintervention and postintervention of applying the CLABSI bundles and education provided to the nurses and we reject the null hypothesis stating there will be no difference in pre intervention of applying CLABSI bundle and post intervention of CLABSI bundles. Hence, this research showed significant increase in CLABSI when there was no peer tutoring. To close the gap in knowledge, the article highlights that without peer tutoring interventions, the rate of CLABSI infections can increased again. From this article it has been noted that in order to prevent the CLABSI, healthcare organization need to concentrate on clinical reasoning and preventative actions. This article can be used in healthcare organizations to explain the importance of peer tutoring towards the prevention of CLABSI.

The research by Blot et al. (2014) is based on systematic review and meta-analysis of the interventions taken to prevent CLABSI. The article sought to determine whether central line–associated bloodstream infections. The research method involves analysis of the previously done studies from 1995–June 2012 (Blot et al., 2014). CLABSI per 1,000 catheter-days, CLABSI per 1,000 inpatient-days, and catheter utilization rates were identified in this article. Maryland Health Care Commission (MHCC) measured the objectives and difficulties of reporting data publicly and has approved this study (Blot et al., 2014). The research was conducted in a five adult ICUs at a regional teaching hospital, that has 63 ICU beds. The CLABSI bundle was introduced to ICU which has four components: hand hygiene, sterile technique upon insertion, use of chlorohexidine wipes for skin preparations, and avoidance of the femoral vein as the access site (Blot et al., 2014). The research was conducted for 10-month period over 18,656 inpatient-days and 9,388 catheter-days (Blot et al., 2014). In this research 687 CVL insertions on 481 patients were performed (Blot et al., 2014). Consents were obtained from qualified participants and no human harm was noted on this study as it is an education study and was conducted by interviewing process. The results of the study show that CLABSI have decreased significantly over the years due the use of CLABSI bundles and education regarding CLABSI. A ratio of 95% confidence intervals proved that CLABSI can be prevented (Blot et al., 2014). Hence, from the article, quality improvement interventions are crucial in preventing CLABSI. Continuous quality improvement can be used to close the gap in knowledge on how to implement continuous quality improvement in ICU. This article by studied a visual design of information from widely-reported central line-associated blood stream infection (CLABSI) ending data for generating decisions by different target individuals, health care customers and professionals. In deciding on the best way to openly document CLABSI data results Maryland Health Care Commission (MHCC) measured the objectives and difficulties of reporting data publicly and has approved this study (Blot et al., 2014). The visual view of quantitative knowledge explains data for customers and health care professionals for creating decisions. The purpose of visual design, to systematize the information for relaying a message successfully, can be achieved by prioritizing, combining, and arranging the information appropriately. The study used formative methods with several groups to verify the choices that the researchers did to obtain the members, and they employed an extensive cross section of the intended user populations. The researchers confirmed visualizations that were accepted and publicly organized for customers and health care professionals in Maryland. This article recognizes that in order to expedite the CLABSI prevention program, a peer-reviewed research framework which assimilates evidence into practices is really crucial. This article focused on systematic review and meta-analysis examines to find out the impact of quality improvement interventions on central line-associated bloodstream infections in ICU patient. Also, the researcher used the Meta-regression which assessed the impact of CLABSI bundle interventions and high baseline rate on intervention effect. From this article it has been found that the effect of implementing the CLABSI bundle protocol and educating nurses has a significant impact on reducing the CLABSI and associated infection as the p value was .03 (P = .03). As we know that the p value less then .05 is significant and that we reject the null hypothesis of stating that there is no difference. The result indicated that there was a significant difference in reduction of CLABSI infection when the CLABSI bundles protocol were implemented and education were provided to the ICU employees on CLABSI.

According to the article by Chopra et al. the main objective was to research on effective evidence-based care to prevent CLABSI infections among ICU patients. The article notes that Central Venous Catheters (CVC) play a central role in preventing the infections. The method of data collection involved 34 evidence-based studies done previously to identify causes and prevention of CLABSI (Chopra et al., 2013). Moreover, review was conducted in accordance with the protocol proposed by the Federal University of São Paulo. 1,485 studies were initially selected but only 34 studies were considered necessary for this study (Chopra et al., 2013). The results from the study showed that interventions such as hand hygiene and maximal barrier precautions are effective in preventing CLABSI among ICU patients. Therefore, the article concludes that that commitment of stuff plays a crucial role in preventing CLABSI. This article is can be used to seal the gap by teaching members of the staff how to commit themselves in preventing CLABSI. This article by Chopra et al. (2013) is a crossover randomized prospective pilot study of central venous catheter (CVC) team intervention in comparison to standard care. Consents were obtained from qualified participants and no human harm was noted on this study as it is an education study and was conducted by interviewing process. In most cases, treatment for children suffering from cancer includes chemotherapy that is delivered via CVC. Although the CVC is a reliable source for delivering chemotherapy, it increases the risk of bloodstream infections (BSIs). The study takes place in a children’s hospital with the focus on two inpatient oncology units with 41 patients in the experiential unit and 41 in the control unit. The study compares patients who receive CVC blood draw bundle by nurses on the CVC team experimental interventions versus standard care from a bedside nurse. In the six-month study, a significant difference was seen in the CVC team and standard care by the bedside nurse related to risk of BSIs. In determining the effectiveness of the CVC team, a larger cohort group is needed.  While the use of CVC is pervasive, most studies related to CLABSIs are done in the adult population. This article provides data related to CLABSIs in the pediatric population. A vascular team needs to be created to monitor the CLABSI protocol and to calculate the data of CLABSI. The vascular team will be conducting he seminar, meetings, and creation of the EBP bundles for the elimination of CLABSI. A vascular team should be created to monitor the CLABSI protocol and to calculate the data of CLABSI. The vascular team will be conducting he seminar, meetings, and creation of the EBP bundles for the elimination of CLABSI. Vascular team was providing PowerPoint presentation, webinar, websites and handouts regarding the prevention of CLABSI to educate nurses and empower them on CLABSI bundle protocol. In this research the pre intervention and post intervention of education and CLABSI bundles drastically decreased the rate of CLABSI from 3.9 per 1,000 catheter days to 1.0 per 1,000 catheter days. Also, in this research study the P value was 0.000 which is less than 0.5 and is considered to be statistically significant as the (P< 0.001).

According to the article by Sacks et al. (2014), a central line-associated bloodstream infection (CLABSI) develops within 48 hours of the line placement. This article is based on the research done to investigate pathogens associated with CLABSI. The research method involved analysis done from October 2011 to September 2012, with the intention of identifying the infectious causing agents associated with CLABSI. This article investigated the effect of the effect of implementing a checklist for the placement of central venous lines (CVL). Participants were  assigned to the checklist group either control or experimental in a 1:2 ratio (Sacks et al., 2014). In this research the frequency of CLABSI was compared in control and experimental groups. In this study total of 4416 CVL were inserted; 1518 were from checklist group and 2898 participants were in the control group (Sacks et al., 2014).This article explains that the use of checklist during CVL placement has caused lowered incidence of CLABSI frequency. Consents were obtained from qualified participants. There was no human harm noted as the education conducted was online and screenings were performed during routine exams. The results of the study showed that majority of infections were caused by staphylococci 34.1 percent, enterococci16 percent, and Staphylococcus aureus, 9.9 percent (Sacks et al., 2014). The article concludes that the action taken by healthcare organizations to prevent CLABSI like use of antibiotics, echinocandins and parenteral vancomycin which is an antibiotic intervention. The knowledge from the article is useful to medical practitioners working in ICU. The recommendations provided can prevent CLABSI. The study by  (Sacks et al., 2014). was based on a two-year case matched controlled retrospective study of central line associated bloodstream infection (CLABSI) in an urban trauma service. The population consisted of 6014 admissions to the trauma service. The case reviewed 105 case-matched controlled groups who did not suffer from CLABSI. There were 35 CLABSI catheters that were identified, 25 out of 35 documented breaks in sterile technique, and 16 catheters were placed in intensive care unit (ICU). CLABSIs were associated with documented break in sterile technique placed in the ICU setting. Practitioners were encouraged to increase awareness and education to adhere to strict sterile precautions. An emphasis was put on the use of CLABSI bundle and education on CLBASI prevention. Research was approved by the Department of Intensive Care Medicine at the University Medical Center Hamburg–Eppendorf, Hamburg, Germany. Independent variable: Catheterize patients, dependent variables: CLABSI infections (Sacks et al., 2014). The researcher in this article have utilized the SPSS 22.0 has a data analysis method which is mostly used for quantitative data. The researcher noted that the rate of CLABSI per catheter days reduced 19/3,784 to 3/1,870 after implementation and collaboration of the CLABSI protocol Bundle. It was also noted that the p value was 0.02, which is statistically significant value. P value in this research study was less then .05, (p=0.02), p <0.05). With the CLABSI bundle and education intervention, CLABSI rate decreased from 3.9 per 1,000 catheter days to 1.0 per 1,000 catheter days. Also, in this research study the P value was 0.000 which is less than 0.5 and is considered to be statistically significant as the (P= 0.02),and (b = −0.505, χ2 (1) = 4.20) (Sacks et al., 2014). We can conclude that we can reject the null hypothesis and state that there was significant difference noted when CLABSI bundle was applies towards the prevention of the CLABSI. In conclusion, most of the CLABSI identified in the trauma service were related to break in the sterile technique. It is most frequent in the ICU setting. The adherence to proper sterile technique guidelines while placing catheter can help to reduce CLABSI and patient mortality. Also, the CLABSI bundles has been found very effective by various health organizations. As identified in this article, appropriate implementation of the bundle reduces the rate of infections by 38%.


As we all know, there are several comprehensive studies and research done on CLABSI and prevention of CLABSI. The main purpose of this research study is to establish the effect of working as a team on the quest to improve the patient’s safety and prevention of infection in ICU patient. It has been found from different article review that the best way to prevent CLABSI is by developing models, educating bedside nurses, attending seminar, attending continue education based on CLABSI and CLABSI protocol guidelines. The models have to be based on the Evidence Based Research (CDC, 2016).  Knowledge is defined as power (Morrison, 2012). Attending PowerPoint presentation, attending seminar based on the CLABSI and prevention, and keeping communication open on significance of CLABSI prevention was the best way of prevention of CLABSI.  As to test knowledge a competency test should also be conducted on the bedside nurses for competency and knowledge.


Blot, K., Bergs, J., Vogelaers, D., Blot, S., & Vandijck, D. (2014). Prevention of central line–      associated bloodstream infections through quality improvement interventions: a                                  systematic review and meta-analysis. Clinical Infectious Diseases59(1), 96-105.

CDC National and State Healthcare-Associated Infections Progress Report, (March 2014), retrieved from

Chopra, V., Olmsted, R.N., Krein, S.L., Safdar, N., & Saint, S. (2013). Prevention of central line-            associated bloodstream infections: Brief update review in making health care safer II: An             updated critical analysis of the evidence for patient safety practices. Rockville (MD):

 Agency for Healthcare Research and Quality (US), No. 211(10).  doi: 10.1007/s11606-    011-1935-y.

Furuya, E. Y., Dick, A. W., Herzig, C. T., Pogorzelska-Maziarz, M., Larson, E. L., & Stone, P.                W. (2016). Central line–associated bloodstream infection reduction and bundle                                   compliance in intensive care units: a national study. infection control & hospital                                   epidemiology37(7), 805-810.

Morrison, T. (2012). Qualitative analysis of central and midline care in the medical/surgical

setting. Clinical Nurse Specialist, 26(6), 323-328.

Park, S. W., Ko, S., An, H. S., Bang, J. H., & Chung, W. Y. (2017). Implementation of central                 line-associated bloodstream infection prevention bundles in a surgical intensive care unit                     using peer tutoring. Antimicrobial Resistance & Infection Control6(1), 103.

Sacks, G. D., Diggs, B. S., Hadjizacharia, P., Green, D., Salim, A., & Malinoski, D. J. (2014).

Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. The American Journal of Surgery, 207(6), 817-823.


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Opioid Addiction with injured Athletes

Opioid Addiction with injured Athletes

Submitted to South University FNP-S, NSG 69999


The consumption of alcohol, tobacco, and other drugs has become a concern in high-

performance athletes. Professional athletes are more exposed to drugs than the general

population, they have an active social life and encounter various pressures, which may lead to

greater risk of alcohol, marijuana, and cocaine misuse (Millman & Ross, 2003). Although some

drugs are unquestionably detrimental to performance, several studies have nevertheless shown

evidence of increased consumption of these substances within this subpopulation (Brisola dos

Santos et al., 2016). Drug abuse in such individuals may involve doping, in order to obtain a

competitive advantage but can also involve the misuse of substances such as alcohol or cannabis

without the intention of improving performance, thereby developing substance use disorders, just

as any non-athletes. The reasons for athletes using these substances could be the many stressors

to w/hich they are subjected, including the pressure for better (or the best) performance, injuries,

physical pain, and even retirement, which occurs much earlier than in most other careers

(Donohue, Pitts, Gavrilova, Ayarza, & Cintron, 2013). The care of an injured or ill patient may

be the responsibility of only 1 health care provider or a team of many providers. Depending on

where the patient care is given and the patient receiving it, the sports medicine team can include

athletic trainers (ATs), physicians, pharmacists, physical therapists, school nurses, and athletic

training student. Misuse and abuse of prescription opioids in the United States constitute a

public health crisis that has grown to epidemic proportions over the last decade. The Centers for

Disease Control and Prevention (CDC) has identified prescription drug abuse and overdose as

one of the top five health threat. When determining the dose of an opioid for acute pain, it is

critically important for clinicians to take into account whether the patient is opioid naive or

opioid tolerant.




Opioid addiction is a long-lasting (chronic) disease that can cause major health, social, and

economic problems. Opioids are a class of drugs that act in the nervous system to produce

feelings of pleasure and pain relief. Some opioids are legally prescribed by healthcare providers

to manage severe and chronic pain. Commonly prescribed opioids include oxycodone, fentanyl,

buprenorphine, methadone, oxymorphone, hydrocodone, codeine, and morphine. Some other

opioids, such as heroin, are illegal drugs of abuse.  The term opium refers to a mixture of

alkaloids from the poppy seed, and the term opiates refers to naturally occurring alkaloids (e.g.,

morphine, codeine). The term opioid refers to all compounds that bind to opioid receptors.

Opioids have been used for thousands of years for the treatment of moderate-to-severe acute

and chronic pain. Opioids provide their pharmacologic effects by binding to opioid receptors

located both within and outside of the central nervous system.




Reports from CDC, the Drug Abuse Warning Network (DAWN), and the National Poison Data

System have demonstrated an alarming increase in opioid misuse and abuse over the last two

decades. The prescription of opioids is increasingly recognized as one of the most important

current health problems in the sports field. It can lead to physical and/or mental problems, and

even death (NIDA, 2014; Simoni Wastila, Ritter, & Strickler, 2004). Data from the National

Survey on Drug Use and Health (NSDUH) indicate that 12.7% of the population aged 26 and

over have already misused non-prescribed prescription opioids. s. At any one time there are 7.5

million adolescents in the US participating in high-school sports, with an with an anticipated

annual 2 million athletic injuries. A major factor contributing to this crisis is the rate at

which painkillers are being prescribed. The number of prescriptions for opioid painkillers

jumped from 76 million to approximately 207 million between 1991 and 2013. According

to Times Union a startling half-million people have died since 2000 as a result of misusing

painkillers. This issue especially impacts those who play sports. Data shows that 52 percent of

NFL players were exposed to opioids with 71 percent admitting to misuse.




Opioids change the chemistry of the brain and lead to drug tolerance, which means that over time

the dose needs to be increased to achieve the same effect. Taking opioids over a long period of

time produces dependence, such that when people stop taking the drug, they have physical and

psychological symptoms of withdrawal (such as muscle cramping, diarrhea, and anxiety).

Dependence is not the same thing as addiction; although everyone who takes opioids for an

extended period will become dependent, only a small percentage also experience the compulsive,

continuing need for the drug that characterizes addiction. Opioid addiction can cause life-

threatening health problems, including the risk of overdose. Overdose occurs when high

doses of opioids cause breathing to slow or stop, leading to unconsciousness and death

if the overdose is not treated immediately. Both legal and illegal opioids carry a risk of

overdose if a person takes too much of the drug, or if opioids are combined with other

drugs (particularly tranquilizers called benzodiazepines).




Clinical Presentation


Opioid physical dependence develops quickly, and abrupt discontinuation may cause signs and

symptoms such as loss of appetite, anxiety, craving, increased blood pressure and heart rate,

nausea, vomiting, and muscle spasms. sweating, chills, sighs, body pain, diarrhoea, rhinorrhea,

and lacrimation. Opioids include both prescription painkillers Vicodin and OxyContin and the

illicit drug heroin. Signs of opioid abuse include overall sedation, memory issues, inability to

concentrate, slowed reaction times, lethargy and mood swings.





Respiratory depression is the result of opioid toxicity, and supportive care to restore ventilation

and oxygenation is the cornerstone of patient management. Opioid toxicity can be treated with

the competitive m-opioid receptor antagonist naloxone






When patients are being considered for opioid medication, including before surgery, they should

be screened for substance abuse, depression, and other psychiatric disorders. One or more

individuals on the sports medicine team may make decisions pertaining to the management of

OTC and prescription medications in the sports medicine facility. Written policies and

procedures will demonstrate that due diligence was exercised to involve and educate all

concerned parties, and that all personnel have established guidelines to reference when managing

medication in the sports medicine setting. Prescription drug monitoring programs (PDMPs) are

electronic databases created and overseen at the state level to collect data on opioids and other

controlled substances as well as noncontrolled drugs with potential for abuse. Consistent practice

for appropriate screening, assessment, and prescribing for pain can be directed through

computerized prescriber order entry (CPOE), clinical decision support (CDS), pharmacy and

therapeutics committee–approved guidelines, and formulary restriction.






Will healthcare providers (P) That attends educational programs on the assessment and

management of pain in injured athletes (I) lead to an increase of knowledge (O) over a six

month time period (T).



























Brisola Dos Santos, M.B., Mello e Gallinaro, J.G., SampaioJunior, B., Marin, M.C.D., Andrade, A.G., Glick, I.D., … Castaldelli-Maia, J.M. (2016). Prevalence and correlates of cannabis use among athletes: A review. American Journal on Addictions, [Epub ahead of print].


Chang, C. J., Young, C. C., Weston, T., Ohkubo, M., Tedeschi, F., Higgs, J. D., … White, M. (2018). Inter-Association Consensus Statement: The Management of Medications by the Sports Medicine Team. Journal of Athletic Training (Allen Press)53(11), 1103–1112. Retrieved from

Cobaugh, D. J., Gainor, C., Gaston, C. L., Tai, I C. Kwong, Magnani, B., Mc Pherson, M. L.,  Krenelok, E. P. (2014). The opioid abuse and misuse epidemic: Implications for pharmacists in hospitals and health systems. American Journal of Health-System Pharmacy71(18), 1539–1554.

Donohue, B., Pitts, M., Gavrilova, Y., Ayarza, A., & Cintron, K.I. (2013). A culturally sensitive approach to treating substance abuse in athletes using evidence-supported methods. Journal of Clinical Sport Psychology, 7, 98–119

Gil, F., de Andrade, A. G., & Castaldelli-Maia, J. M. (2016). Discussing prevalence, impacts, and treatment of substance use disorders in athletes. International Review of Psychiatry28(6), 572–578.

Millman, R.B. & Ross, E.J. (2003). Steroid and nutritional supplement use in professional athletes. The American Journal on Addictions, 12, S48–S54. doi:10.1111/j.1521- 0391.2003.tb00556.x

Simoni-Wastila, L., Ritter, G., & Strickler, G. (2004). Gender and other factors associated with the nonmedical use of abusable prescription drugs. Substance Use Misuse, 39, 1–23

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Fahrenheit 451

Fahrenheit 451

Fahrenheit 451 is an innovative story that dwells on the life of Guy Montag as the main character and is set in the 24th century. Critically, the novel clarifies how literature and books are illegal, and some firefighters have been hired to destroy the materials. Distinctively, Fahrenheit 451 reveals the disruptive nature of technology where individuals are exposed to digital media that does not help in self-improvement. Additionally, there is the depiction of dependency on technology where some characters foster emotional connections to television presenters at the expense of family members. The story progresses into the life of Guy Montag, who questions the morality of his profession as a firefighter when he sees the community being destroyed and deteriorating. As a result, the protagonist decides to transform where he focuses on the rebuilding of the society through the campaign for literature and culture as a rebel with the aspiration of promoting literacy. Among the compelling literary styles incorporated in Fahrenheit 451 is the depiction of various settings that enable the audience to understand the transformation in culture. Decisively, the change in setting affects symbolism and irony as fiction elements in the plot of the novel.

Change in setting is a literary element in Fahrenheit 451 that affects the development of the plot in the novel. Critically, the change in setting enables the author to establish three distinct sections through the life of Guy Montag in the novel. The first phase represents a time when literature and culture were prioritized in society. Also, the first phase showcased a time when literacy was a virtue in the community and individuals engaged in self-development initiatives. Decisively, the change in setting enables a transformation to the second phase, where there are directives intended to disrupt culture and literacy in society (Hwang 596). Under this context, the change in setting is masterfully used by the author to showcase the role of Guy Montag as a dutiful fireman who contributes to the elimination of literacy and culture.

Furthermore, the last stage is inducted by change in setting by the depiction of rebellion, where the protagonist in Fahrenheit 451 questions the immorality of the directives and decides to campaign for literature and culture. Hence, the integration of change in setting as a literary style enables the audience to appreciate the transformation in the plot as depicted by the characters (Hwang 596). Thus, change in setting becomes an essential literary style that provides a practical platform to support various themes such as symbolism and irony in Fahrenheit 451.

Distinctively, the change in setting has been used in Fahrenheit 451 to present an opportunity for the audience to understand the possibilities in the future. Notably, the conversation between Clarisse and Montag is a reflection of how there has been a significant transformation in the community (Bradbury 18). Similarly, the application of the change in setting reveals how the future is limited through censorship in literature, which makes books less attractive to people. As a result, it is possible for the audience to understand why media and technology have replaced literature in the future (Harrison 56). Additionally, the change in setting enables the reader to reflect on the adverse effects of technology in the community as showcased in Fahrenheit 451. Hence, the change in setting allows the practical description of the literature decline in Fahrenheit 451.

Symbolism is a major theme in Fahrenheit 451 that is supported through the change in setting. Notably, “The Hearth and the Salamander” is a title in the novel, which is a representation of symbolism. Distinctively, the title is a depiction of the life of the character in a changing world. From an analytical perspective, the salamander reveals the personality of Guy Montag, who has the capacity of surviving in a difficult situation without being damaged (Greenwood). Through, extrapolation, it is evident that the change in setting is a useful style used by the author that enables the audience to understand the relationship between the community and Guy Montag. Distinctively, by referring to the hearth and the salamander, the author elucidates the resilience in Guy Montag in a transformative society where culture and literature become forbidden. Hence, the use of changing the setting as a literary style enables the audience to understand the symbolism associated with the hearth and the salamander.

In addition, change in setting enables the definition of symbolism through the Phoenix. Distinctively, the Phoenix is a representation of constructive transformation that has to start with destruction. As in the Phoenix, there has to be destruction through fire to rise from the ashes. Critically, the Phoenix is a reflection of the life of Guy Montag, who had to take a destructive path before being reborn (Khan). The path taken by Guy Montag is a reflection of the fire that consumes the Phoenix before a constructive transformation. Afterward, Guy Montag acknowledges the error in his ways and decides to campaign for the establishment of culture by promoting literacy in society. Moreover, the change in setting presents a familiar background to the audience to correlate the Phoenix as a symbol of the life of Guy Montag. Hence, the incorporation of a change in setting enables the better use of symbolism as a literary style to enhance the understanding of the audience.

Irony is a significant theme in Fahrenheit 451 that is supported by a change in setting. Decisively, the change in setting enables the integration of irony as a literary style used to explain various circumstances in the novel. For example, the change in setting depicts irony associated with the actions of firefighters in the utopian society. Traditionally, firefighters are tasked with the responsibility of putting out fires and protecting property. However, the change in setting depicts irony, where firefighters in the utopian society have the obligation of burning books and starting fires to houses that contain literature (Gomez). The change in setting enables the illustration of irony through the life of firefighters in the story.

Similarly, change in the setting is used to reveal the situational irony encompassing the arrival of firefighters at the house of Montag. During the scene, Beatty explains to Montag that he has to destroy his books, as it was illegal to have them. However, Montag responds by killing Beatty to preserve literature (Lee 144). Critically, the change in setting allows a dynamic flow in the plot where the protagonist transforms from a dutiful servant to a rebel. Distinctively, the use of change in setting provides a platform to alter the plot where the focus is on Guy Montag as a rebel who works to promote the preservation of literature. The inclusion of the change in setting is instrumental in Fahrenheit 451 to support situational irony intended to alter the plot of the novel.

Likewise, change in setting is used to outline verbal irony in Fahrenheit 451 that reflects the harmful effect of technology in the utopian society. Verbal irony refers to a situation where the said words differ in meaning as to what was intended by the speaker. In the novel, Mildred explains that she has a deep affection for television presenters and goes the extra step of identifying them as family. However, through the change in setting, it is possible to outline the verbal irony associated with Mildred remarks, which significantly differ from her interaction with family members (Gomez). In reality, Mildred does not have a close connection with family members and disregards their welfare and well-being. Hence, the change in setting between television and real life is instrumental as it enhances the plot of the novel by displaying the harmful effects of technology on the characters.

In addition, change in setting is a literary style used to showcase dramatic irony in Fahrenheit 451. Dramatic irony refers to a situation where the audience has an understanding of an incident while characters remain oblivious. Critically, change in setting enables the depiction of dramatic irony in the plot where Mildred attempts to commit suicide by ingesting sleeping pills. After the intervention by doctors, Mildred is recuperated. However, Mildred does not remember the suicidal attempt and finds it difficult to accept the incident, as explained by Montag (Gomez). It is from this perspective that change in setting enables dramatic irony in this novel. Consequently, change in setting leads to an omniscient presence of the audience to understand happenings in the story despite ignorance from the characters.

Change in setting enforces irony and makes the plot more believable to the audience. Notably, Fahrenheit 451 is a story written in the 1950s when technology was limited. However, the incorporation of change in setting enables the audience to explore imagination and accept the possibility of big televisions and media (Thompson). Critically, the irony is vital in the novel as it enhances a different mentality where the audience evaluates the impact of technology in their lives. Hence, the incorporation of change in setting enables the establishment of a believable plot based on irony and imagination in Fahrenheit 451.

Conclusively, Fahrenheit 451 is an innovative novel that uses change in setting as a primary style to portray various themes. As discussed above, the novel envisions the transformation of a utopian society where literature and books become illegal. As a result, there is the hiring of firefighters to destroy books and literature houses. Distinctively, the change in setting facilitates the description of the life of Guy Montag as the main character before and after the transformation of the community. Critically, change in setting enables the audience to have a deep understanding of the three phases of transformations through the lives of the characters. Additionally, change in setting is instrumental in enforcing the impact of symbolism in the story. Distinctively the Phoenix and the salamander are symbols used to highlight the life of Guy Montag as he transforms from an antagonist to a protagonist who focuses on the preservation of literacy.. For example, the role of firefighters in the novel is altered, as they are responsible for starting fires rather than stopping them. Additionally, irony outlines the disruptive nature of technology where the characters such as Mildred value television characters more than family members. Hence, the utilization of change in setting allows the dynamic flow of the plot in the story through the transformation up to a point where literature and books become illegal in society.

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Primus Financial Services Case Study

Brad Brooks, the director of communications for Primus, a Boston-based company with a nationwide financial sales distribution system, was busy working on an important speech for Sheila Burke, the company’s newly-appointed president. Burke’s appointment had come on the heels of her predecessor’s abrupt termination two months earlier. The entire organization was feeling uncertain. Would heads roll? What direction would Burke take?
So it was with a sense of foreboding that Brooks, answering the phone, heard the new president’s voice. “Brad, as you know we’re working on the company’s strategic direction and I’m deep into the annual budget. I’m frankly concerned about the millions we’re spending on communication. I’m also concerned that we don’t have any kind of social media presence. Your department is behind the times. Put together a high-level summary of the resource allocation, people, and money, and meet me on Wednesday to discuss. I’m thinking of having consultants come in and do a communication audit.”
Brooks stared out his office window, the Charles River shrouded in fog. Where to begin? It was difficult, he believed, to measure the ROI of communication. Moreover, there never seemed enough time – or the skill set – for his team to focus on measuring and assessing results. Everyone was scrambling to ‘put out fires,’ especially with the change in leadership. And just the thought of outsiders coming in to conduct an audit gave him an anxiety attack. That evening, Brad reviewed the company’s communication portfolio, the annual budget, and how members of the communication team were deployed.
Brooks also knew that the company’s annual sales force survey would be deployed the following week. His plan was to suggest that Burke wait for the survey results before taking any steps to revamp the communications function.
The company’s communication portfolio:
Public Website: Brooks had to admit the company’s public website was a clunker. The platform was outdated and relied heavily on IT support, which was costly. Content changes needed to be passed along to the IT team, which implemented ‘mods’ on a biweekly basis. Discussions were underway to transition the site to a self-publishing platform by Q1 2018 so that the Communication team could publish content with no IT involvement.
Perhaps more seriously, the site’s purpose was unclear. It contained educational content accumulated over several years, some of which was embarrassingly outdated, but there was no focus to the content and no calls to action. Traffic data
showed that customers often used the site to access their online account information, but other sections of the site had little usage. In fact, the number of total visits was steadily falling. At the same time, the site was not generating any sales.
Company Intranet: The prior year, the corporate intranet, PrimusNet, was transitioned to a self-publishing platform, eliminating the need for IT support. That was a good thing. However, maintaining the site was absorbing more and more of the staff’s time. The volume of content provided by other departments was staggering. Brooks had to admit that the site was difficult to navigate and that it was difficult to prioritize content in terms of its importance to the sales process. One person coordinated the daily publication of news, while two others managed content on the site.
One troubling sign was that only 25% of the sales force accessed PrimusNet on a regular basis. Another was the negative feedback given the site in the yearly sales force survey – the major complaints:
• “Information about the advanced markets (business owners, affluent) is almost impossible to find.” • “It’s too difficult to find the information I’m looking for.” • “Much of the information isn’t relevant – I’m inundated with useless information.”

Monthly Magazine: The company’s monthly publication for the sales force had not changed much in recent years. The editorial mix consisted of interviews with senior advisors (who were almost exclusively white males), sales ideas, product descriptions. Anecdotal feedback from opinion leaders in the sales force was that they liked the magazine, but there was no evidence that it increased sales or that the majority of readers really cared about the publication.
Newsletters: Over the years, the number of newsletters published by the group had proliferated. It seemed that every field management constituency “needed” a dedicated communication vehicle: Managing Partners, Sales Managers, Marketing Directors, Brokerage Managers, Operations Managers. Producing these newsletters tied up both staff and resources.
Public Relations: One member of the staff handled public relations, both focusing on industry media and attracting new advisors to the company. Public relations consisted of pitching stories to trade publications, with modest success.
Executive Communication: Brad and another member of the team developed Powerpoint presentations for use by the President at periodic sales office meetings. Sheila Burke had expressed frustration at not being able to get her message out to the entire sales force in a more timely way. Powerpoint presentations and the monthly column in Power Selling just did not, as she commented sarcastically, “cut the mustard.”
Advertising: Primus did not have wide name recognition among consumers, and executives were not interested in spending millions to raise the brand’s profile. National ad spend was directed at recruiting new sales reps in national industry publications. Consumer advertising dollars were allocated to local sales offices, which could decide how and where to spend the money. The team had just begun to investigate digital marketing opportunities.
Primus Sales Force Survey
Survey audience:
Sales Representatives – all levels of experience and tenure with the company. At the time this online survey was conducted, Primus had 2,355 sales representatives in 82 sales offices across the United States.
The response rate for Sales Representatives was 65%.
Sales Managers – people with sales management responsibilities – recruiting, training and supervising sales reps, overseeing sales activity, providing organizational leadership, etc. At the time the survey was conducted, Primus had 344 sales managers in 82 sales offices across the United States.
The response rate for Sales Managers was 91%.
Survey Questions:
Response categories (1-7 scale, with 1 being lowest and 7 being highest in terms of agreement, importance, or satisfaction)
Rate your level of agreement with the following statements on a scale of 1 to 7
1.The monthly sales magazine provides useful information in helping me do my job.
2. The intranet portal provides useful information in helping me do my job.
3. I receive the right amount of communication.
4. The company provides information in a way that allows me to quickly find what I need.
Rate the level of importance on a scale of 1 to 7
5. Importance of communication to sales success
Rate your level of satisfaction with the following on a scale of 1 to 7
6. Satisfaction with communication received.
7. I have a clear sense of company direction.

Survey Results
Response categories (1-7 scale, with 1 being lowest and 7 being highest in terms of agreement, importance, or satisfaction):
• Positive (6, 7) • On the fence (4, 5) • Negative (1-3)

NOTE: Percent change from prior year’s survey is shown in ( ) — two questions were not asked in the prior year survey

Level of Agreement Sales Representatives Sales Managers
The following communication vehicles “provides useful information to my job”:

Monthly sales magazine (NEW QUESTION FROM LAST YEAR – NO YoY %)
32% Positive
38% On the Fence
30% Negative
53% Positive
31% On the Fence
15% Negative
Intranet portal 34% (-15%) Positive
50% (+2%) On the Fence
16% (+13%) Negative
40% (-6%) Positive
50% (+3%) On the Fence
10% (+3%) Negative
I receive the right amount of communication

19% (+4%) Positive
68% (-8%) On the Fence
13% (+4%) Negative
18% (-1%) Positive
73% (+1%) On the Fence
9% (0%) Negative
The company provides information in a way
that allows me to quickly find what I need
10% (-5%) Positive
49% (-2%) On the Fence
41% (+7%) Negative
14% (0%) Positive
52% (-6%) On the Fence
34% (+6%) Negative
Level of importance
Importance of communication to sales success 27% (-3%) Positive
48% (-2%) On the Fence
25% (+5%) Negative
33% (+2%) Positive
52% (0%) On the Fence
15% (-2%) Negative
Level of satisfaction
Satisfaction with communication received 19% (-5%) Positive
52% (-2%) On the Fence
29% (+7%) Negative
21% (-5%) Positive
49% (-5%) On the Fence
30% (+10%) Negative
I have a clear sense of company direction (NEW QUESTION FROM LAST YEAR – NO YoY %)
10% Positive
30% On the Fence
60% Negative
15% Positive
50% On the Fence
35% Negative

Feedback Sales Force Survey Assignment This show how this assignment will be reviewed

Section Comments Key Points of Reference Part 1 (33%) Critique the quality of the survey questions Quality of the survey: • This survey is a prime example of what happens when we don’t relate specific questions to KPIs – how do the questions relate to communication effectiveness? • Several questions include terms that are vague or can be interpreted in multiple ways (e.g., the meaning of the word ‘right,’ satisfaction with what ‘communication,’ etc.). • All of these questions use a seven point scale – could the survey have included other types of questions such as rank order? • The responses to most of these questions are not actionable – they are indications of vague attitudes • How would Hutton critique the survey? “Good questions reveal what’s going on. Bad questions obscure it. Good questions point to solutions, bad questions do not. Good questions resonate with staff. Bad questions bemuse them.” (p. 32)
Part 2 (33%) Analyze the results
Key findings: 1. In general, when reviewing results, focus attention on the largest positive and negative scores. 2. Overall, satisfaction with communication has slipped since last year. 3. Managers tend to be more satisfied, Sales Reps less satisfied – what are the implications of this? Role of sales managers as conduits of information between HQ and sales reps – we would therefore hope to see much more positive responses from sales managers. 4. A large proportion of respondents seems to be ‘on the fence’ 5. Among the communication vehicles, the intranet scores the best, but the large negative scores for allowing “me to quickly find what I need” – a critical finding since we know that sales people have little patience. 6. The new CEO is launching a new strategy – but the sales force seems clueless about company direction – a serious issue! 7. How does material in Chapter 12 of Paine help us understand some of these results?
Part 3 (33%) What issues would you like to explore in more depth
Potential approaches: • The challenge is to identify a few critical areas to assess – where can we “move the needle” in a positive direction with respect to communication effectiveness in two ways: reduce the big negatives, accentuate the big positives • Sending out another, re-worded survey at this stage might not be productive – but we should consider a redesign of the survey with questions tied to KPIs – even though we will lose some benchmarking
• Deploy focus groups especially with sales reps to probe about what’s working and what’s not – we need to dig deeper with this audience • Conduct usability analysis of the intranet to enable quicker and more intuitive navigation and organization of content – we can implement changes with immediate impact • Explore: how the sales force currently receives information and how they would prefer to receive it, where are the gaps? • Big red flag is the strategic understanding results – we have a new leader and a new strategy! This has to be a top priority for further investigation!

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