Aproximaciones al espacio turístico en El Tercer Reich de Roberto Bolaño

Background

Methods

Results

Conclusions

Background

Methods

Results

Conclusions

Background: Our primary objective evaluated the perception of emergency medical service (EMS) providers’ review of automated hospital outcome data. Secondarily, we assessed participation in outcome review as a means of microlearning to obtain continuing education (CE).

Methods: From October–December 2023, three high-volume EMS systems participated in a three-part intervention with results evaluated using a mixed-methods approach. First, EMS providers (emergency medical technicians and paramedics) were invited, via their electronic health record (EHR), to complete a presurvey evaluating their perceptions of reviewing outcomes. Then, EMS providers were notified about the opportunity to earn CE via a microlearning intervention, offering Commission on Accreditation for Pre-Hospital Continuing Education (CAPCE)-approved CE hours for completion of outcome reviews and associated learning modules. Finally, EMS providers were invited to complete a post-survey mirroring the pre-survey. Qualitative analyses identified themes among open-ended responses. Quantitative analyses examined perceptions between pre- and post- surveys.

Results: Of 843 providers contacted, 217 responded to the pre-survey (25.7%). The most endorsed rationale for reviewing outcomes included improving clinical knowledge (95%), improving patient care (94%), and knowing whether care made a difference (93%). Nearly all (91%) reported being more likely to review outcomes if CE were awarded. Among the 67 who completed the open-ended items, the three dominant themes included enhance personal confidence and competence (43%); acquire personal knowledge (39%); and operations (21%). Of 211 providers who participated in the intervention, 56 (27%) were awarded CE. A total of 152 providers responded to the post-survey, and the percentage who agreed that reviewing outcomes improves job satisfaction rose from 89% to 95% between pre- and post-surveys (P = 0.05).

Conclusion: EMS providers supported the personal and professional development and patient care improvement of reviewing patients’ outcomes with associated CE. Further study is warranted to evaluate the generalizability of these findings and the best user experience.

This paper could not have been written without the financial and organizational support from Dieter Paulmann and Jo Hastie respectively. Thanks are also due to 2 anonymous reviewers, whose comments on an earlier version of the manuscript greatly improved the paper. The views expressed in this paper are those of the authors alone and do not represent those of Stellwagen Bank National Marine Sanctuary, the U.S. National Marine Sanctuary Program, Southwest Fisheries Science Center, the U.S. National Marine Fisheries Service, NOAA and/or any other institution or agency. Correspondence concerning this article should be addressed to Andrew Wright, Leviathan Sciences, U.S.A. (marinebrit@gmail.com). Consequences of extreme noise exposure are obvious and usually taken into some consideration in the management of many human activities that affect either human or animal populations. However, the more subtle effects such as masking, annoyance and changes in behavior are often overlooked, especially in animals, because these subtleties can be very difficult to detect. To better understand the possible consequences of exposure to noise, this review draws from the available information on human and animal physiology and psychology, and addresses the importance of context (including physiological and psychological state resulting from any previous stressor exposure) in assessing the true meaning of behavioral responses. The current consensus is that the physiological responses to stressors of various natures are fairly stereotyped across the range of species studied. It is thus expected that exposure to noise can also lead to a physiological stress response in other species either directly or indirectly through annoyance, a secondary stressor. In fact many consequences of exposure to noise can result in a cascade of secondary stressors such as increasing the ambiguity in received signals or causing animals to leave a resourceful area, all with potential negative if not disastrous consequences. The context in which stressors are presented was found to be important not only in affecting behavioral responses, but also in affecting the physiological and psychological responses. Young animals may be particularly sensitive to stressors for a number of reasons including the sensitivity of their still-developing brains. Additionally, short exposure to stressors may result in long-term consequences. Furthermore, physiological acclimation to noise exposure cannot be determined from apparent behavioral reactions alone due to contextual influence, and negative impacts may persist or increase as a consequence of such behavioral changes. Despite the lack of information available to managers, uncertainty analysis and modeling tools can be coupled with adaptive management strategies to support decision making and continuous improvements to managing the impacts of noise on free-ranging animals.

This paper could not have been written without the financial and organizational support from Dieter Paulmann and Jo Hastie respectively. Thanks are also due to two anonymous reviewers, whose comments on an earlier version of the manuscript greatly improved the paper. The views expressed in this paper are those of the authors alone and do not represent those of Stellwagen Bank National Marine Sanctuary, the U.S. National Marine Sanctuary Program, Southwest Fisheries Science Center, the U.S. National Marine Fisheries Service, NOAA and/or any other institution or agency. Correspondence concerning this article should be addressed to Andrew Wright, Leviathan Sciences, U.S.A. (marinebrit@gmail.com). Sound travels much further than light in the marine environment. As a result, marine mammals, especially cetaceans, rely heavily on sound for many important life functions, including breeding and foraging. This reliance on sound means it is quite likely that exposure to noise will have some detrimental effects on these life functions. However, there has been little application to marine mammals of the knowledge available in other species of stress responses to noise and other stressors. In this paper we begin to integrate what is known about marine mammals with the current knowledge gained in terrestrial mammals about stress physiology, specifically considering physiological and psychological context and thus also cumulative and synergistic impacts. We determined that it is reasonable to extrapolate information regarding stress responses in other species to marine mammals, because these responses are highly conserved among all species in which they have been examined to date. As a result, we determined that noise acts as a stressor to marine mammals. Furthermore, given that marine mammals will likely respond in a manner consistent with other species studied, repeated and prolonged exposures to stressors (including or induced by noise) will be problematic for marine mammals of all ages. A range of issues may arise from the extended stress response including, but not limited to, suppression of reproduction (physiologically and behaviorally), accelerated aging and sickness-like symptoms. We also determined that interpretation of a reduction in behavioral responses to noise as acclimation will be a mistake in many situations, as alternative reasons for the observed results are much more likely. We recommend that research be conducted on both stress responses and life-history consequences of noise exposure in marine mammals, while emphasizing that very careful study designs will be required. We also recommend that managers incorporate the findings presented here in decisions regarding activities that expose marine mammals to noise. In particular, the effects of cumulative and synergistic responses to stressors can be very important and should not be dismissed lightly.