PhD, University of Cincinnati, 2024, Nursing: Nursing - Doctoral Program

Background: Due to the complexity of medical conditions in the intensive care unit (ICU), mortality rates are typically high in most hospitals. End-of-life care (EOLC) begins when curative treatments are no longer beneficial, shifting the focus to comfort and quality of life for patients and families. Despite EOLC being a standard part of ICU management, healthcare professionals encounter complexities and uncertainties when transitioning from life-saving treatments to comfort-focused care. Additionally, EOLC in the ICU is influenced by the cultural backgrounds of both nurses and patients. The nursing culture in Saudi Arabia reflects a diverse workforce, with a significant reliance on expatriate nurses from various countries, leading to cultural and language differences that can influence EOLC. Objectives: To explore the perceived barriers and facilitators of critical care nurses in providing EOLC in intensive care units, how cultural variations between nurses and patients impact care, and how nurses address and meet the cultural needs of dying patients. Method: The study employed a qualitative descriptive method, utilizing semi-structured interviews that were conducted virtually through Zoom. Purposeful sampling techniques and a homogeneous sampling approach were used to recruit participants. Open-ended questions were used from an interview guide to prompt the critical care nurses to share their viewpoints and experiences. Results: The exploration of the perceived barriers and facilitators of critical care nurses during EOLC for terminally ill patients in the ICU revealed three main themes: (a) EOLC barriers, (b) EOLC facilitators, and (c) suggestions to improve the EOLC and overcome barriers. The exploration of how cultural variations between nurses and patients impact care, and how nurses address and meet the cultural needs of dying patients revealed five main themes: (a) cultural practices and traditions of patients & families, (b) cultural competence during EOLC (open full item for complete abstract)

Committee: Carolyn Smith Ph.D. (Committee Chair); Georgia Anderson M.S.W. (Committee Member); Rebecca Lee Ph.D. (Committee Member) Subjects: Nursing

BS, Kent State University, 2024, College of Nursing

Family Presence During Resuscitation (FPDR) first proposed in 1987, has been recommended by numerous professional nursing organizations. Although studies have been conducted investigating the views of family members and healthcare professionals concerning FPDR, little is known about perceptions of nursing students. Due to this gap in the literature, we investigated the attitudes of nursing students toward FPDR as they will be future members of the largest healthcare profession in the United States. This study was guided by the Relationship Based Care Model, which is a way to provide care for our patients and their families. A descriptive cross-sectional study using Qualtrics was designed to identify the attitudes of nursing students from the largest BSN program in Northeast Ohio toward FPDR. The secondary aim was to investigate if age and work experience in a healthcare setting impacted the attitudes of nursing students towards FPDR. Funding for the project was provided by Kent State University Research Council, and Institutional Review Board approval was obtained prior to data collection which commenced in Summer 2023. By the end of Fall 2023 semester, a total of 96 participants were enrolled in the study which yielded a response rate of 53.6% of 179 eligible students enrolled in a senior-level critical care course. This study did not reach statistical significance in attitudes toward FPDR based on age and work experience in healthcare. However, 67.2% of the participants reported they would support FPDR.

Committee: Amy Petrinec (Advisor); Alison Smith (Committee Member); Daniela Popescu (Committee Member); Jessica Larubina (Advisor); Cindy Wilk (Committee Member) Subjects: Nursing

DNP, Kent State University, 2023, College of Nursing

The purpose of this scholarly quality improvement project was to increase utilization of current evidence-based interventions to improve mobilization with instrumentation of visible goal targets, documented mobility goals, continuous feedback, and nurse education. This project was designed to enhance nursing knowledge of current evidence-based practice and clinical practice guidelines regarding initiation of mobilization in populations of critically ill adult patients receiving extracorporeal membrane oxygenation therapy. Data was collected over three periods of time. During the first data collection period, nurses used a visual confirmation tool to record the number of times per day a patient on extracorporeal membrane oxygenation was mobilized, as defined by any nursing-initiated incidence of mobilization qualifying as a 2 or greater on the Johns Hopkins Highest Level of Mobility Scale. Nurses indicated on the Mobility Tracker the number of mobility events initiated by the nurse, or patient-initiated events with nursing assistance. Physical and occupational therapy providers were responsible for tracking events initiated by physical and occupational therapists. After the first data collection period, an evidence-based educational program for nurses was deployed followed by data period collection 2.and 3. Results: During data collection periods 1, 2, and 3, patients were mobilized to a level 2 on the Johns Hopkins Highest Level of Mobility scale at least three times daily, 40% by physical therapy, 25 % by occupational therapy, and 27% by nurses. Total mobility scores for data collection periods 1, 2, and 3, averaged 3.01, 1.75, and 1.89, respectively. Total mobility between D1 and D3 reported a change of 35.14%. Nurse-led mobilization accounted for at least two of the daily mobility counts during data collection periods 1, 2, and 3, reporting a total of 12, 5, and 2 times, respectively. No patient data was collected on five nonconsecutive days of the three data (open full item for complete abstract)

Committee: Amy Petrinec (Committee Chair); Lisa Cascarelli (Committee Member); Kimberly Cleveland (Committee Member); Lisa Onesko (Committee Member) Subjects: Nursing

Master of Arts, The Ohio State University, 2020, Bioethics

Moral distress is often framed as arising from interpersonal conflict such as moral disagreement. Within the dynamics of disagreement, moral distress becomes linked to power differentials present between the conflicting parties. As such, the understanding of the concept has commonly become dependent on constraints inherent to the nurse's professional role. Within this metanarrative of professional powerlessness, the proposed mitigation strategies have been narrowly focused. Given the widespread nature of moral distress they have also been largely ineffective. While moral distress in nursing remains pervasive, the majority of Americans are not dying well. The institutionalized deathbed in modernity is unlike any that have come before it. This paper traces death's trajectory of change exposing how technology and medicalization have come to authorize and direct the dying process. Spiritual needs of the dying have become obscured if not altogether denied. This has led to new rituals developing at the bedside of the dying. In the critical care environment, the ritualization of futility has become a culturally and institutionally mediated phenomenon. Americans not dying well and moral distress development in nurses may stem from the same healthcare system failures. In this scenario, effective mitigation will require large scale change. The profession of nursing is poised to be an integral partner in the collaboration necessary to affect just such a transformative change.

Committee: Matthew Vest Dr. (Advisor); Courtney Thiele (Committee Member) Subjects: Ethics; Medical Ethics; Nursing; Philosophy

Master of Sciences, Case Western Reserve University, 2014, EECS - Electrical Engineering

In this thesis, an innovative Graphical User Interface (GUI) for the next generation of bedside decision-support systems for the Intensive Care Unit (ICU) is developed. Functions of existing monitors in the ICU are integrated into a single bedside system. The bedside monitor is capable of visualizing real-time data streaming from a patient monitor, performing routine and novel signal analytics and also reading archived patient waveform data in European Data File (EDF) format. Signals such as Electrocardiograph (ECG) waveform, Heart Rate (HR), Oxygen Saturation (SaO2), etc. are available for visualization and analysis. Selection for three different period time data with flexible data length is also created. Novel analytics including Poincare' and histogram plots are available to investigate the variation and connections of different physiological signals.

Committee: Kenneth Loparo (Advisor); Farhad Kaffashi (Committee Member); Frank Jacono (Committee Member) Subjects: Electrical Engineering; Health Care

PHD, Kent State University, 2014, College of Nursing

NURSING CARE PROCEDURES, THERMAL REGULATION AND GROWTH OF THE MODERATELY PREMATURE NEONATE IN THE NEONATAL INTENSIVE CARE UNIT Director of Dissertation: Ann Jacobson Satisfactory weight gain for the moderately premature neonate, defined as a return to birth weight within 10 days after birth, is associated with reduced length of stay, lower health care costs and improved neurological and health outcomes. Despite staggering advances in NICU technology and research over the past five decades recent large-scale studies reveal persistent weight gain failure rates (documented as high as 75 percent). Weight gain of premature neonates depends on the balance of energy intake and expenditure. Interventions should be aimed at promoting a NTE. Yet many routine nursing care activities disrupt the NTE provided by the incubator. The purpose of this study was to identify the effect of nursing care procedure disruptions (NCD) to the neutral thermal environment (NTE) on weight gain of moderately premature neonates in the first 10 days of life in a neonatal intensive care unit (NICU). Aim 2 was to determine the feasibility of using electronic health record (EHR) data. Levine's Conservation Model provided a framework for conceptualizing NCD to the NTE as 26 nursing care procedures that threaten premature neonates' optimal function and wholeness. In this retrospective exploratory descriptive study EHRs of healthy moderately premature neonates (e.g., 32 and 34 weeks gestation) were examined. The dependent variable, weight gain, was calculated from the difference in weight on day 10 from birth weight. The independent variable, NCD to the NTE, was computed by counting the number of entries in the daily care record that represent opening the incubator for care provision. Spearman's rank order correlation coefficient revealed a statistically significant negative correlation rs (164) = -.162, p = .038 between NCD to the NTE and the weight gain of moderately premat (open full item for complete abstract)

Committee: Ann Jacobson PHD (Advisor) Subjects: Nursing

PHD, Kent State University, 2025, College of Nursing

The purpose of this study was to evaluate the ability of moral sensitivity, moral distress, ethical climate, and job satisfaction to predict turnover intent in a cohort of neonatal ICU nurses. This study evaluated job satisfaction and moral distress as mediators and ethical climate as a moderator. These complex interactions were better understood through the guidance of the Moral Habitability Framework which strives to explain the moral-social climate of organizations. A sample of 108 neonatal nurses working in Level II, III, and IV ICUs were recruited. A cross-sectional, correlational research design was used to answer the research questions. Pearson correlation coefficients and multiple regression statistics were conducted to analyze the data. Moral distress was reported as low (M = 115.67, SD = 65.15), job satisfaction moderate (M = 45.97, SD = 9.55), ethical climate moderate (M = 50.22, SD = 10.77), and turnover intent as high (M = 18.53, SD = 5.08) with 38.5% (n = 45) reporting considering leaving their current position. Correlations between variables were supported in the analysis. Moral sensitivity, moral distress, ethical climate, and job satisfaction along with demographic variables were found to explain 39.3% of the variance in turnover intent R2 = .393; F(9, 97) = 6.99, p = <.001 with job satisfaction identified as the only significant predictor of turnover intent R2 = .364; F(1,106) = 60.62, p = <.001 explaining 36.4% of the variance. Moral distress was not found to mediate the relationship between ethical climate and turnover intent. Job satisfaction mediated the relationship between ethical climate and turnover intent β = -.356, 95% BCa CI [-.485, -.232] and the relationship between moral distress and turnover intent β = .317, 95% BCa CI [.189, .455]. Ethical climate was not found to moderate the relationship between moral sensitivity and moral distress. The study findings add knowledge about the complex relationships within the moral social environmen (open full item for complete abstract)

Committee: Amy Petrinec Ph.D., RN (Committee Chair); Jonathan VanGeest Ph.D. (Committee Member); Yafen Wang Ph.D., RN (Committee Member); Pamela Stephenson Ph.D., RN (Committee Member) Subjects: Nursing

MS, University of Cincinnati, 2023, Medicine: Clinical and Translational Research

Objective: To assess the validity of Pediatric Sepsis Biomarker Risk Model (PERSEVERE-II) mortality probability across all body mass indices (BMI) and association of BMI and outcomes in pediatric septic shock. Design: We performed a secondary analysis of a prospective observational study of primarily children with septic shock in whom a PERSEVERE-II baseline mortality risk was assigned. Setting: The PERSEVERE study enrolled patients with septic shock admitted to 14 pediatric intensive care units (PICUs) across the United States from January 2015 to December 2018. Patients (for clinical investigations): Patients from the original study were excluded from these analyses if they were missing height, weight, age, and sex or if calculated BMI was a significant outlier and could not be verified. Interventions: None Measurements and Main Results: This secondary analysis included 434 patients of the original 461 patients, of which 47 (11%) were underweight, 217 (50%) were normal weight, 61 (14%) were overweight, and 109 (25%) were obese. PERSEVERE-II accurately predicted mortality across all BMI: area under receiver operating curve (AUROC) for underweight = 0.78, 95% confidence interval (CI): 0.41-1.00; AUROC for normal weight = 0.79, 95% CI: 0.68-0.89; AUROC for overweight = 0.88, 95% CI: 0.77-0.98; and AUROC for obese = 0.87, 95% CI: 0.80-0.95. Compared to patients with normal weight, patients with obesity were more likely to have multi-organ failure within 7 days of admission (86% vs 74%, P =0.01) and to have a complicated course defined as persistent organ failure at 7 days after sepsis or death within 28 days of sepsis (52 patients [24%]) vs 39 patients [36%], P =0.02). However, on multivariable analysis, BMI was not associated with complicated course. There was no difference in 28-day mortality across BMI. Conclusions: PERSEVERE-II accurately predicted mortality across all BMI classifications. Patients with obesity were more likely to have multi-or (open full item for complete abstract)

Committee: Scott Langevin Ph.D. (Committee Chair); Jennifer Kaplan MD MS (Committee Member); Lin Fei Ph.D. (Committee Member); Matthew Alder (Committee Member) Subjects: Medicine

Doctor of Nursing Practice, Mount St. Joseph University , 2023, Department of Nursing

The use of an indwelling urinary catheter (IUC) in the intensive care unit is a widespread practice in patient care of critically ill patients. Fifteen to twenty-five percent of hospitalized patients will have an IUC as part of their treatment plan during their hospital stay. Catheter-associated urinary tract infections (CAUTI) have a significant impact on patient outcomes including increasing hospital costs, length of stay, readmission rates, and morbidity and mortality. Early discontinuation of an IUC has been shown to decrease the incidence of CAUTI. An external urinary management system or external urinary catheter (EUC) is an alternative device used for the measurement of urinary output and prevention of skin breakdown for incontinent patients. The goal of this Doctor of Nursing Practice (DNP) evidence-based practice quality improvement (EBP-QI) project was to improve patient safety and outcomes by appropriately decreasing the use of IUC and increasing the use of an EUC in the intensive care unit (ICU). The Plan, Do, Study, Act (PDSA) and Lewin's Change Theory were the evidenced-based practice model and theoretical framework used to guide the project in achieving structured and patient outcomes. The project's structured outcome was for nursing staff to achieve a mean test score of ≥90% on the project's post-test, after completing a CAUTI and EUC education. Forty-four staff members completed the education program with a mean test score of 95.45%. The patient outcome was to decrease the post-implementation quarter's CAUTI rate by 50% from the pre-intervention quarter's CAUTI rate, which was met with both quarters resulting in zero CAUTI, demonstrating no significant difference.

Committee: Sandra Curtis Ph.D, MSN, RN, GERO-BC (Advisor) Subjects: Nursing

Master of Science, The Ohio State University, 2023, Genetic Counseling

Background: Approximately 10% of babies admitted to the neonatal intensive care unit (NICU) have a genetic condition or congenital malformation. Despite the high prevalence of genetic disease among NICU patients, there are no guidelines for determining who should receive genetic testing and neonatologists are uncomfortable evaluating patients for genetic diseases. In this study, we aimed to develop and evaluate data-driven models that could predict candidates for genetic testing using electronic health record data from the NICU admission. We also evaluated a previously described, knowledge-driven, prediction model. Methods: This is a retrospective study of Nationwide Children's Hospital (NCH) patients born between January 1, 2010 to December 31, 2021 who were admitted to a NCH Neonatal Network intensive care unit. Phenotypic, demographic, and genetic evaluation data from 33,315 patients was collected. Models were developed for three related classification tasks: 1) Distinguishing patients with a genetic diagnosis from those who never had any involvement with genetic testing or services, 2) Distinguishing patients with any involvement with genetic testing or services from those without, and 3) Identifying those patients undergoing WES/WGS who will receive a diagnosis from those who will not. Univariable analysis for feature selection was conducted on 20% of the sample. The remaining 80% of the sample was used to build and evaluate multivariable models using predictors selected in the univariable analysis and a 75/25 train/test split. Classifiers were built using four different architectures for each of the three classification tasks. The best performing models were selected based on area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve (AUPRC) metrics. In addition to these data-driven approaches, a previous published knowledge-driven approach was computationally represented and replicated in our cohort. Results (open full item for complete abstract)

Committee: Bimal P. Chaudhari MD MPH (Advisor); Sara Conroy PhD (Committee Member); Kristen Suhrie MD (Committee Member); Michael Zinsmeister MS, CGC (Committee Member) Subjects: Genetics

Master of Arts, The Ohio State University, 2021, Educational Studies

The provision of graded supervision affording progressive autonomy is fundamental to the progression of a medical learner towards competency for independent practice; the decision of how much supervision versus trust and autonomy to provide a trainee in the execution of clinical care constitutes an entrustment decision. Despite entrustment decision making occurring both daily in practice and summatively at points of matriculation through stages of medical training, the factors influencing entrustment decisions remain poorly understood across clinical contexts. This study was designed to explore the central research question of: How are entrustment decisions made in the medical intensive care unit? This qualitative case study utilized semi-structured interviews with attending pulmonary and critical care physicians in the medical intensive care unit at a major midwestern medical center to explore the entrustment decision making process as it was enacted in the clinical environment. Five major themes emerged from the data: (1) Task, circumstance, and trainee factors contribute to entrustment decision making, (2) Ad hoc entrustment decisions are enacted by supervisors with a consideration of the care team as a unit, not only an individual, (3) Autonomy does not arise only out of entrustment, but outcomes of prior autonomy inform ongoing intention to entrust, (4) Entrustment decision making includes a social process of back-and-forth akin to negotiation, and (5) Entrustment decision making is a learned skill. The process of entrustment decision making in the ICU is more complex than prior frameworks have captured; a model with more complete incorporation of the factors that influence entrustment in the ICU is presented. Lastly, recommendations for the application of our model of entrustment to improve the quality of entrustment decisions in order to better inform the use of entrustment decisions for assessment are discussed.

Committee: David Stein PhD (Advisor); Daniel Clinchot MD (Committee Member) Subjects: Continuing Education; Education; Educational Psychology; Educational Theory; Health Care; Health Education; Health Sciences; Medicine; Science Education

MS, University of Cincinnati, 2019, Allied Health Sciences: Nutrition

Background: In the United States 10% of all infants are born preterm.1 Preterm birth, low birth weight, and NICU admissions put newborns at increased risk of morbidity and mortality.1,2 Breast milk provides NICU-admitted infants with nutritional and immunologic protections including human milk oligosaccharides, secretory IgA, hormones, growth factors, cytokines, and chemokines.3,4 The AAP states the potent benefits of human milk are such that all premature infants should receive human milk, preferably mother's own milk (MOM).5 Objectives: Our objective was to determine the predictors of the following outcomes for NICU-admitted newborns and their mothers: mother attempting breast milk expression (Attempted Expression), mother initiating breast milk expression within 6 hours of birth (EBM First 6h), newborn receiving MOM as first feeding (MOM First Feeding), newborn receiving colostrum for oral care within the first 36 hours of life (COC First 36h), and newborn receiving any MOM at discharge (DC), or day of life 21 (DOL21) if discharged after DOL21 (MOM DC/DOL 21). Methods: We included all preterm infants born at UCMC June 1, 2018 to May 31, 2019 and examined a comprehensive set of socio-demographic, maternal, obstetric, and infant variables as being potential predictors of MOM outcome variables. We built a database by linking mother's medical record with newborn medical record and hand extraction of additional variables from nursing notes, lactation notes, etc. All data were imported into SAS for data analysis. We used chi square analyses to examine the unadjusted associations between independent variables and MOM outcomes. We used logistic regression models to examine the adjusted associations between the independent variables and MOM outcomes. Results: It was found from our fully adjusted logistic regression model that the independent predictors of mother not attempting breast milk expression were active smoking (P<0.0001), multiparity (P=0.03), maternal (open full item for complete abstract)

Committee: Laurie Nommsen-Rivers Ph.D. (Committee Chair); Laura Ward M.D. (Committee Member) Subjects: Nutrition

MS, University of Cincinnati, 2019, Medicine: Clinical and Translational Research

Background: Healthcare-associated infections (HAIs) are a significant cause of morbidity and mortality in critically ill children. Previous research demonstrates that commensal gut anaerobes provide host resistance against colonization and infection with pathogens, but data is lacking from other potential reservoirs such as the mouth. Methods: A longitudinal cross-sectional study was conducted in PICU patients (0-18 years) receiving antibiotics who were recruited within 72 hours of admission at a quaternary pediatric center 2017-2018. Healthy children without antibiotic exposures in the prior 30 days were enrolled from clinics as age-matched outpatient controls. Metagenomic shotgun sequencing of oral swabs was performed for comparisons of community composition and Shannon diversity between groups using Wilcoxon rank sum and principal coordinate analyses. Results: Comparison of oral samples found a difference in community composition and Shannon diversity of the oral microbiomes with increased abundance of fecal anaerobes and potential pathogens in PICU patients (n=57) compared to age matched controls (n=55). There was no difference in oral microbiome composition or diversity when comparing underlying comorbidities, intubation status, or antibiotic intensity between PICU subgroups. Conclusions: The oral microbiome is impacted by critical illness and hospitalization in the context of antibiotic administration. PICU patients compared to healthy controls demonstrated loss of normal oral flora replaced with increased fecal anaerobes and common HAI organisms, suggesting the mouth is an important reservoir of pathogens. Future studies using metagenomic screening may better identify children at-risk and modify clinical interventions to allow for prevention of HAI in the PICU.

Committee: Patrick Ryan Ph.D. (Committee Chair); David Haslam M.D. (Committee Member); Nicholas Ollberding Ph.D. (Committee Member) Subjects: Surgery

MS, University of Cincinnati, 2018, Medicine: Genetic Counseling

Purpose: To characterize the genetic testing ordered, diagnoses made, and charges acquired for patients admitted to a level IV Neonatal Intensive Care Unit (NICU) in 2013 and 2014. Methods: Retrospective chart review of all patients admitted to a single level IV NICU in 2013 and 2014. Demographic, genetic testing, genetic diagnosis, and charge data were collected from the electronic medical record (EMR). Results: A total of 1327 unique patients were admitted to our level IV NICU during the study period. During the NICU stay and up to two years of age, 478 genetic tests were ordered for 276 (20.8%) patients. Of these, 73.4% (351) were ordered during the initial NICU admission. Most patients had only one test ordered, though this ranged from one to seven tests. The most commonly ordered test in the NICU was a microarray (103, 29.3%), which was the confirmatory test for 12.6% of those patients with a diagnoses. The least commonly ordered test was whole exome sequencing (4, 1.1%). A genetic diagnosis was made in 36.3% of patients who had genetic testing. In total, 128 patients (9.6%) received a genetic diagnosis by two years through genetic testing or other means. These patients were significantly more likely to be either term or late preterm (p = 0.0025), and to have normal birth weights (p = 0.0111). Inpatient clinical genetics evaluation improved the rate of diagnosis as opposed to performing genetic testing without a clinical genetics evaluation (26.5% vs. 44.5% in patients with a consult). However, a majority of the diagnoses (57.6%) were made after discharge. Of the 265 (20.0% of cohort) patients who received a genetics consult, 83 (31.3%) received a diagnosis. Patients receiving a diagnosis had significantly longer and more costly hospital stays. They had higher genetics charges, as expected. These patients were also more labor intensive than patients without a genetic diagnosis. In total $851,982 in charges for genetics services were accrued during the t (open full item for complete abstract)

Committee: Melanie Myers Ph.D. (Committee Chair); D. Brian Dawson Ph.D. (Committee Member); Hua He M.S. (Committee Member); Kristen Suhrie (Committee Member); Daniel Swarr (Committee Member); Leandra Tolusso M.S. (Committee Member) Subjects: Genetics

Master of Science (MS), Ohio University, 2015, Child and Family Studies (Health Sciences and Professions)

Infant's hospitalization soon after birth often causes the family system to adjust to new or different roles while typical routines may change. Medical professionals as well as Certified Child Life Specialists (CCLS) can assist children and their families who are navigating the hospital environment. Through questionnaires completed by CCLS and an interview with a parent who had a child in the Neonatal Intensive Care Unit (NICU), a deeper understanding was reached regarding what CCLS can provide children and their families in the NICU setting.

Committee: Jenny Chabot CCLS (Committee Chair); Joan Jurich (Committee Member) Subjects: Families and Family Life; Health Care; Health Sciences; Medicine

PhD, University of Cincinnati, 2011, Business: Business Administration

Providing equal access to public service resources is a fundamental goal of democratic societies. Growing research interest in public services (e.g., healthcare, humanitarian relief, elections) has increased the importance of considering objective functions related to equity. This research studies discrete-resource allocation problems where the decision maker is concerned with maintaining equity between some dened subgroups of a customer population. In particular, we apply resource-allocation models to improve equity in two specic applications: voting systems and health care. We employ simulation-optimization techniques and Markov-decision-process models to develop rigorous algorithms to allocate resources equitably among these subgroups. The presented solutions are associated with bounds on solution quality, some of which are guaranteed to be optimal. Various numerical tests demonstrate that our algorithms outperform competing heuristics and are robust over various inequity metrics. We apply our algorithms to real case studies using empirical data for a voting-machine-allocation problem in Franklin County, Ohio, and to develop an admission-control policy for a cardiac intensive care unit at Mount Sinai Medical Center in New York.

Committee: Michael Fry PhD (Committee Chair); W. David Kelton PhD (Committee Chair); Theodore Allen PhD (Committee Member); Michael Magazine PhD (Committee Member) Subjects: Operations Research

Doctor of Philosophy, The Ohio State University, 2010, Industrial and Systems Engineering

The emergency medicine system absorbs much of the burden of the chronic problems facing healthcare in the United States today: an increasingly unhealthy populace, variability in access to primary care, and severe resource shortages. This makes emergency medicine, and in particular the emergency department (ED), an excellent natural laboratory in which to study adaptation and cognitive work. The primary objectives of this research are to 1) identify how differing availability of resources influences timeliness of admission for lower-resourced and higher-resourced patient cohorts, and 2) identify strategies for managing margin of maneuver in a complex, socio-technical setting. This research was conducted from a cognitive systems engineering perspective, which has adaptation to complexity as a central conceptual lens. The research was conducted in an ED at one academic hospital; this environment is a complex, socio-technical setting, being characterized by high uncertainty, high consequences for failure, distributed work across specialized roles, and high variation in workload. In particular, this dissertation examines one problem, patient boarding, focusing on the causes and correlates of boarding for two contrasting patient cohorts. A cognitive systems engineering perspective focuses analysis on how boarding exacerbates, and is exacerbated by, challenges to workload capacity, coordination, and ultimately resilience in the ED. Both observations of actual ED work and aggregate chart review are used as inputs to the analysis. The findings have implications for short- and long-term interventions to address boarding and other quality of care-related issues in the ED. Selected findings include that the barriers and facilitators to patient admission are different for patient cohorts that have comparatively more and less resources, and that a variety of solutions, including the creation of a special buffer, are used by the ED to ease the impact of lower-resourced patient coh (open full item for complete abstract)

Committee: Emily Patterson PhD (Advisor); David Woods PhD (Committee Member); Philip Smith PhD (Committee Member) Subjects: Industrial Engineering

Master of Science in Nutrition and Dietetics, University of Akron, 2008, Nutrition and Dietetics

Enteral nutrition is the preferred route of feeding critically ill patients with a functioning gastrointestinal tract. Student's t-tests were used to analyze hypotheses that mechanically ventilated Coronary Intensive Care Unit (CICU) patients who receive early enteral nutrition, will have decreased days on ventilator and decreased length of stay in the CICU when compared to those who do not receive early enteral nutrition. Results include 35 patients, 19 patients (54%) received tube feeding within 72 hours of intubation and 16 (46%) patients received tube feeding after 72 hours of intubation. The average days on mechanical ventilation for patients enterally fed within 72 hours of intubation were 5.3 days, and 9.9 days for patients enterally fed after 72 hours of intubation. The average length of stay in the CICU for patients enterally fed within 72 hours of intubation was 9.6 days, and 16.4 days for patients enterally fed after 72 hours of intubation. In summary, patients fed after 72 hours of intubation averaged 4.6 days longer on mechanical ventilation and 6.7 days longer stay in the CICU compared to patients who received early enteral nutrition within 72 hours of intubation. Results indicated a significant difference between initiation of early enteral nutrition compared to patients who did not receive early enteral nutrition in mechanical ventilation days (p=0.04) and length of CICU stay (p=0.01). Early enteral nutrition contributes to reduced ventilator days and length of stay in CICU. Results encourage dietitians to become engaged in institutional nutrition protocols to favorably influence patient outcomes.

Committee: Sandra Hudak PhD (Advisor) Subjects: Nutrition