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Telenursing in the Intensive Care Unit: Transforming Nursing Practice Lisa-Mae Williams, Kenneth E. Hubbard, Olive

Telenursing in the Intensive Care Unit: Transforming Nursing Practice

Lisa-Mae Williams, Kenneth E. Hubbard, Olive Daye and Connie Barden

Crit Care Nurse 2012;32:62-69 doi: 10.4037/ccn2012525

© 2012 American Association of Critical-Care Nurses Published online http://www.cconline.org

Personal use only. For copyright permission information:

Tele-ICU Enhancements Telenursing in the Intensive Care Unit: Transforming Nursing Practice Lisa-Mae Williams, RN, MSN

Tele-ICU Enhancements

Telenursing in the Intensive Care Unit: Transforming Nursing Practice

in the Intensive Care Unit: Transforming Nursing Practice Lisa-Mae Williams, RN, MSN Kenneth E. Hubbard, RN,

Lisa-Mae Williams, RN, MSN Kenneth E. Hubbard, RN, AAS, CVRN-BC

Olive Daye, RN, BSN, CVRN-BC Connie Barden, RN/CNS, MSN, CCRN-E, CCNS

In tele–intensive care units, informatics, telecommunication technology, telenursing, and telemedicine are merged to provide expert, evidence-based, and cutting-edge services to critically ill patients. Telenursing is an emerging subspecialty in critical care that is neither well documented in the extant literature nor well understood within the profession. Documentation and quantification of telenurs- ing interventions help to clarify the impact of the telenurse’s role on nursing prac- tice, enhancement of patient care, patient safety, and outcomes. Tele–intensive care unit nursing will continue to transform how critical care nursing is practiced by enhancing/leveraging available resources through the use of technology. (Critical Care Nurse. 2012;32[6]:62-69)

N ursing practice is

constantly evolving

along with the tech-

nology being used to

enhance and deliver

care. Tele–intensive care unit (tele- ICU) nursing, as an outgrowth of the rapidly exploding telemedicine approach to care, has the potential to influence the ongoing transfor- mation of nursing practice and sig- nificantly contribute to care. It is a developing subspecialty of critical care nursing and requires high- level critical thinking and analyti- cal skills.

©2012 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2012525

Telenursing is the use of telecom- munications technology to provide nursing care while using informa- tion and data remotely. 1 Telemedi- cine is defined as “the use of medical information exchanged from one site to another via electronic com- munications to improve patients’ health status.” 2 The tele-ICU is the arena where informatics and telecom- munication technology coupled with telemedicine and telenursing are brought together to affect the care of critically ill patients. Tele-ICU provides expert-driven, evidence- based, cutting-edge services to the monitoring and treatment of criti- cally ill patients. In addition, tele-ICU

62 CriticalCareNurse Vol 32, No. 6, DECEMBER 2012

delivers support to the bedside health care team through collaborations between the tele-ICU nurse and the bedside team. 3 Having had an active tele-ICU in our health system for several years, we felt it important to begin to delineate the role and contributions to care of this developing nursing subspecialty in our health system. During the period of observation, themes emerged that helped to cat- egorize tele-ICU nursing practice at Baptist Health South Florida in Miami. The purpose of this article is to describe these tele-ICU nursing interventions that contributed to patient care within our health sys- tem during the course of 1 year.

The Tele-ICU Environment

Tele-ICU nurses have been an integral part of the tele-ICU since its inception. Examination of the usefulness of the tele-ICU in improv- ing outcomes for critically ill patients has demonstrated reductions in ICU mortality, 4-8 shorter stays in the ICU 5-10 and the hospital, 5-7,9,10

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Table 1 Color-coded acuity system used to categorize patients on the basis of physiological criteria, therapeutic measures currently in use, and safety concerns a

Acuity status

Sample physiological criteria

Sample therapeutic measures

Sample safety concerns

Red

New admission <6 hours earlier Critically unstable condition

Titrating infusions of vasoactive agents Starting mechanical ventilator support Emergency interventions

High acuity level indicates high potential risk from deteriorated disease states

Yellow

Admission in past 6 hours, vital signs have stabilized

Minimal requirement for intravenous infusions of vasoactive agents and little titration needed, weaning off of infusions Improvement in condition allows weaning off of therapies

Moderate acuity level indicates a reduction in potential risk for harm, disease state stabilizing

Green

Physiologically stable Preparing for potential transfer to a reduced level of care

Stable condition with oxygen delivered via nasal cannula, maintenance intra- venous fluids, or saline lock

Prepared for transfer out of unit

a Adapted from Philips VISICU workgroup, 2010.

increased compliance with evidence- based best practices such as screening for sepsis, 11,12 improved outcomes in cardiopulmonary arrest patients, 13 and decreased costs for patient care. 8-10 In the tele-ICU, experienced ICU nurses and intensivist physicians help to monitor and treat critically ill patients and provide an additional layer of safety. Communication occurs via audio and video technol- ogy on demand from either the tele- ICU or the bedside so that nurses and physicians can interact immedi- ately. Often remotely located from the actual hospital facilities, the tele-ICU has the ability to assess and monitor hundreds of patients through any electronic technique in use at the patient’s bedside. Standard monitoring such as electrocardiog- raphy and hemodynamic values are

maintained continually, and access to medical records, diagnostic images, and laboratory results is available at the click of a mouse. A few reports 3,14,15 describe activi- ties and challenges for nurses work- ing in the tele-ICU. One major role of the tele-ICU nurse is making rounds via the camera and assessing all patients. Assessments require the same observation skills and nursing expertise as used at the bedside 16 and include but are not limited to video assessment of patients’ physi- cal appearance; equipment safety check; verification of continuous infusions; and verbal interactions with patients, their families, and staff. The frequency of the rounds is dictated by the acuity of the patient, and tele-ICU nurses use a color-coded system to categorize their patients

Authors

Lisa-Mae Williams is a nurse manager, Kenneth E. Hubbard and Olive Daye are staff nurses, and Connie Barden is a clinical nurse specialist at Baptist Health South Florida in Miami.

Corresponding author: Lisa-Mae Williams, RN, MSN, Baptist Health South Florida, 2100 NW 84th Avenue, Miami, FL 33122 (e-mail: lisamaesw@baptisthealth.net).

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

and prioritize their work (Table 1). Aided by alarms that alert the tele- ICU nurse to physiological trends, subtle changes in patients’ condi- tion can be noted earlier by nurses overseeing the big-picture view of multiple patients. Such surveillance can avoid reintubation of tenuous patients and prevent unplanned extu- bations, critical decreases in blood pressure, dislocation of catheters, and a host of other untoward out- comes that are difficult for bedside nurses to monitor at every moment. The tele-ICU nurse also acts as a resource for the bedside nurse, who finds an experienced colleague with a second set of eyes and ears to observe the patient and with whom to collaborate as they have instant access to the same information as the bedside nurse via print and elec- tronic resources. They can quickly retrieve vital pieces of data for the ICU nurse in order to save them valuable time, provide accurate cur- rent information, and potentially improve patient care and safety. 17 Tele-ICU nurses can also draft a detailed admission note when a

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patient arrives in the unit so that complete information about a patient is available promptly

patient arrives in the unit so that complete information about a patient is available promptly to all care providers in the electronic medical record. Other aspects of the tele-ICU nurse’s role may include ensuring that best practices are adhered to, for example, prophylaxis of venothro- moembolism/stress ulcer, follow-up on new laboratory values, and responding to questions and requests from bedside staff. Unique activities such as watching over a bedside nurse’s second patient while that nurse transports a patient off the unit to diagnostic tests supports the safety of patients and decreases the workload of everyone at the bedside. In this environment, the inten- sivist’s role is described as providing “continuous vigilance, early inter- vention, and ongoing care as dele- gated by the attending physician supporting the patient care plan and decreasing ICU-related morbidity and mortality.” 18 In addition to per- forming tasks related to patient management such as prescribing tests and medications for critically ill patients, teleintensivists intervene in emergency situations when a patient’s condition deteriorates, requiring immediate clinical atten- tion. At times teleintensivists may educate bedside novice physicians and nurses by walking them through unfamiliar procedures such as emer- gent cardioversion of an unstable, symptomatic patient or a host of other urgent interventions. 19 Telein- tensivists also provide consultative comanagement of critically ill patients as well as recognition of changes in patients’ trends, diag- noses, and intervention for patients’ needs often resulting in improved

Leveraging ICU Resources

breadth of their knowledge, their extensive expertise in the care of critically ill patients, and their proven skills in communication and collaboration. From September 1, 2008, through August 31, 2009, nursing interventions made by tele-ICU nurses at Baptist Health were self- reported or documented by nurses who observed colleagues making them. Actions reported were those that, in the opinion of the tele-ICU nurse, resulted in changes in care for patients and/or assisted bedside nurses in their work with patients. Tele-ICU nurses were asked to send accounts of their interventions via e-mail or handwritten notes as they occurred with enough text to describe the event. Reports of these interven- tions were then communicated to and collected by the clinical nurse specialist of the tele-ICU. A small group of tele-ICU nurses then reviewed and categorized the types of interventions described by the staff. Interventions were then sorted into 1 of the following 4 cate- gories: rescue, assist, prevention, or

The application of the sophisti- cated monitoring and intervention capabilities of a fully functional tele- ICU holds promise as 1 method for broadening the reach and enhancing the ability of the bedside care team to meet the needs of sicker patients. According to the Leapfrog Group—

a

national program focused on cre-

ating giant leaps in health care quality and safety—“the quality of care in hospital ICUs is strongly

influenced by whether ‘intensivists’

are providing

.” The Leapfrog

standard for ICU physician staffing 4 calls for the presence of intensivists who provide clinical care exclusively in the ICU during daytime hours. The standard acknowledges that teleintensivist coverage together with some on-site intensivist pres- ence can help to meet this recom- mendation. In our system, in 2007, only 1 hospital had round-the- clock intensivist coverage. The tele- ICU was therefore able to provide access to critical care physicians and nurses, 24/7, to the other hospitals that did not have critical care physi- cian coverage.

Assessing the Tele-ICU Nurses’ Contributions to Care

Baptist Health South Florida is a 5-hospital, 1500-bed health care sys- tem based in Miami, Florida. Baptist Health began using tele-ICU tech- nology in 2005, and since mid-2007

consultation (Figure 1). Working definitions of these categories are described in Table 2.

Tele-ICU Nursing Interventions: The Results

Five hundred ninety-four nurs- ing interventions were documented and categorized during the year of

it

has been part of the standard of

the project. Of the interventions collected and categorized, 477 (80%) were independent nursing interventions where assistance, brainstorming, and overall collabo- ration took place solely between

the bedside nurse and the tele-ICU nurse. The remaining activities

care for critically ill patients in all 5

hospitals. The tele-ICU nurses at Baptist Health have an average of 15 years of critical care nursing experi-

outcomes for patients. 2 0

outcomes for patients. 20

ence and are chosen to work in the tele-ICU because of the depth and

64 CriticalCareNurse Vol 32, No. 6, DECEMBER 2012

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Rescue Assist Prevention Consultation
Rescue
Assist
Prevention
Consultation

Figure 1 Documented tele–intensive care unit (tele-ICU) nurse interventions from September 2008 to August 2009 (N=594). Rescue indicates patient in trouble, immediate action required; assistance indicates that interventions were made that were ini- tiated by the tele-ICU nurse; prevention indicates interventions that most likely prevented occurrences such as falls, unplanned extubation, and allergic reactions; consultation indicates inter- ventions such as troubleshooting equipment, thinking together, educating or coaching bedside staff, and answering questions and requests initiated by the bedside team.

were interde- pendent, usually involving the intensivist physician or telepharmacist in collaboration with the tele- ICU nurse. Thirty-six (6%) interven- tions were coded as rescue interventions. Another 116 interventions (20%) were coded in the prevention cate- gory, and all of these interven- tions—rescue and prevention

(n=152 or 26%) when combined— were described as affecting patient safety. Included in this number were 42 falls, 16 accidental catheter dis- placements, and 11 intubations that were avoided by the direct interven- tion of the tele-ICU nurses (Figure 2). Assists and consultations, when combined, were those interventions described as enhancing nursing practice (Figure 3). A total of 302 assists (51%) and 140 consultations (24%) were reported during the year of this project.

Discussion

In 2008, Stafford and colleagues 3 published an ethnographic study describing the tele-ICU environment and the experiences of those working in that environment. In that report, the experience of the tele-ICU nurse manager in describing the value of

Table 2 Definition and examples of tele–intensive care unit (tele-ICU) nursing interventions that affect safety and nursing practice

Type

Definition

Examples

Safety

Rescue

Patient in trouble who needs immediate action Interventions that helped to avoid imminent deterioration of patient’s condition

Avoid codes Avoid intubation Identify critically low blood pressure Identify rapidly declining oxygen saturation

Prevention

Interventions that most likely prevented occurrences

Avoid falls Avoid unplanned extubation Avoid unplanned removal of catheters Avoid abnormal blood pressures and oxygenation Correct inaccurate information in patient’s electronic medical record Collaborate about results of laboratory tests or radiographic findings that were pertinent to patient’s condition

Nursing practice

Interventions initiated by the tele-ICU nurse

Bring allergy discrepancies to attention of bedside nurses Obtain laboratory and disgnostic test results for bedside nurses Confirm findings from physical examination with bedside nurse Bring arrhythmias to attention of bedside nurses Suggest evidence-based treatment for stress ulcer prevention, deep venous thrombosis, electrolyte replacement, and glucose control

Assist

Consultation

Interventions initiated by the bedside nurse

Troubleshoot equipment Brainstorm with bedside staff Coach/educate bedside staff Answer questions and other requests initiated by bedside team

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50 40 30 20 10 0 Falls Blood pressure, Medication, Catheter Avoid Avoid Avoid Patient
50
40
30
20
10
0
Falls
Blood pressure,
Medication,
Catheter
Avoid
Avoid
Avoid
Patient
oxygen saturation
allergy
displacement
code
deterioration
intubation
identification
No. of interventions
Type of intervention Prevention
Type of intervention
Prevention
Rescue

Rescue

Figure 2 Tele–intensive care unit nursing interventions that affect safety.

140 120 100 80 60 40 20 0 Facilitation Coach/think Expedite Best Documentation of care
140
120
100
80
60
40
20
0
Facilitation
Coach/think
Expedite
Best
Documentation
of care
together
treatment
practices
No. of interventions

Type of intervention

Assist Consultation

Assist

Assist Consultation

Consultation

Figure 3 Tele–intensive care unit nursing interventions that enhance nursing practice.

the service to the organization included, “I quickly evaluated that the true value in this service was all of the interventions that are happen- ing by these fabulous nurses in the [tele]-ICU unit.” 3 The manager went on to explain the power of this infor-

mation in demonstrating the value

of the tele-ICU and in garnering administrative support for its val- ued place as part of the model of care. Similarly, in 2008, Myers and Reed 15 described tele-ICU nurse interventions that prevented errors and complications, thus improving quality and safety. Although the

66 CriticalCareNurse Vol 32, No. 6, DECEMBER 2012

authors pointed out that the tele- ICU nurse is not meant to replace the bedside nurse, they described that the actions of the tele-ICU nurse in monitoring and vigilance improved processes and outcomes produced in their health system. The authors noted not only the tele- ICU nurses’ role in safety and qual- ity, but also their unique position to serve as consultant, collaborator, and colleague to ensure adherence to best practice as major compo- nents of the role that contribute to care improvement. In our system, we similarly found that actions performed by tele-ICU nurses fell into 1 of 2 broad categories: affecting patient safety or enhancing nursing prac- tice. The smallest group of interven- tions we recorded were actions categorized as rescue, where there was imminent danger to patients. Only 6% of our interventions were in this category. It is not known from the literature what an expected benchmark for this type of inter- vention by tele-ICU nurses should

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Sidebar: Preventing a Fall From 30 Miles Away A tele-ICU nurse checks the camera view
Sidebar: Preventing a Fall
From 30 Miles Away
A tele-ICU nurse checks the
camera view in a patient’s room
after noticing a change on the
monitor and sees a patient out
of bed, appearing unsteady. The
tele-ICU nurse calmly speaks to
the patient and quickly realizes
that he is confused and disori-
ented. The tele-ICU nurse calls
the bedside staff to alert them of
the patient’s situation. The bed-
side team quickly arrives at the
patient’s side, reorients him, and
returns him to bed.

be, but it could certainly serve as an indicator used collaboratively between the tele-ICU and ICU teams as a barometer for safety challenges at the bedside. For example, if a given unit had a baseline of 10% of rescue interventions by the tele-ICU and this number suddenly jumped to 30% or 40%, these data might serve as the starting point for fruitful dis- cussions about changes in the care environment that might be contribut- ing to the increase in potentially dangerous situations for patients. Stafford et al 3 discussed the chal- lenges of quantifying cost-avoidance using the tele-ICU. Indeed document- ing the exact value of preventing harm and avoiding complications is fraught with uncertainty. The inter- ventions in this category were those that even though danger may not have been imminent, without inter- vention the situations were very likely to have led to negative out- comes for the patients (see Sidebar). Examples of preventions include a confused patient with his hand pulling the dressing away from the

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entry site of the central venous catheter, a patient with an allergy to aspirin ordered to receive an aspirin- containing analgesic, and patients found climbing out of bed when bedside staff were occupied outside of the room. In our opinion, inter- rupting these potentially dangerous scenes that could otherwise have gone unnoticed in the midst of a busy critical care unit elevates the level of care and safety that is deliv- ered to patients. We found that most of the tele- ICU nurse interventions occurred in the broad category that enhanced nursing practice. Depending on the location from which the interven- tion was initiated, we coded these actions as either assists or consul- tations. The largest group— assists—were initiated by the tele-ICU nurse and then acted on by the bedside team, the tele-ICU team, or both. Goran 17 describes the concept of tele-ICU practice as including a “second set of eyes not to control or intrude, but to sup- port or enhance current care.” Experienced nurses working in the tele-ICU, free from the often unpre- dictable situations and expectations of patients, families, colleagues, and other departments, have the opportunity to assess patients’ findings in an environment that lends itself to careful analysis. Sup- porting colleagues at the bedside who may not have this opportunity creates a team with a built-in dou- ble check on patients’ safety and well-being. To use James Reason’s well-known analogy for preventing harm in complex systems, 21 fewer mishaps are likely to slip through the holes in the Swiss cheese and cause harm in such a system.

The category of interventions labeled as consultation hold particu- lar promise for supporting care and colleagues at the bedside. Consulta- tions, which were initiated by bed- side nurses seeking information or support, represent an opportunity for nurses to gain help from a knowledgeable colleague whose job it is to support their practice. In the tightly staffed and very busy envi- ronment of most critical care units, this opportunity is often not avail- able between bedside nurses. Unique activities such as the tele-ICU watch- ing over a bedside nurse’s patients while that nurse responds to an emergency also support the safety of patients and decrease the work- load of everyone at the bedside. Some tele-ICUs have produced outstanding results by creating for- mal telementoring programs for nurses new to critical care. In these environments, inexperienced nurses who have completed orientation are then paired with an experienced tele-ICU nurse who connects with, coaches, and mentors the newcomer until the nurse feels confident to func- tion totally independently (Wendy Deibert, RN, personal communica- tion, May 2011). Although just in the beginning stages of development, such creative and proactive programs hold promise as a true opportunity to support “our young” and create a humane environment for all. Despite the described advantages of the partnership between the tele- ICU and bedside staff, these rela- tionships do not develop effortlessly, automatically, or perfectly. Using a telecommunication tool is new and challenging, and a level of trust must be developed and sustained between the tele-ICU and the bedside staff in

new and challenging, and a level of trust must be developed and sustained between the tele-ICU
new and challenging, and a level of trust must be developed and sustained between the tele-ICU

CriticalCareNurse Vol 32, No. 6, DECEMBER 2012 67

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the absence of face-to-face commu- nication. With many never having met, bedside and tele-ICU nurses must build relationships in this nication. With many never having met, bedside and tele-ICU nurses must build relationships in this new practice model. In addition, the challenges of technology—overcom- ing inevitable equipment malfunc- tion, network downtimes, or software upgrades—have given staff the opportunity to fine tune their col- laboration and communication skills further. This fine tuning requires a consistent effort to build and strengthen relationships and to be “relentless in pursuing and fostering true collaboration.” 22 The study of tele-ICU nursing and its impact is in its infancy. More information is needed not only to further delineate the contributions that tele-ICU nurses make, but to also outline methods to enhance the acceptance and full utility of this new approach to care. This project was designed to look, from the tele- ICU side of practice, at the interven- tions reported by tele-ICU nurses. It was not our intention to investi- gate tele-ICU contributions to care from the bedside nurse’s perspec- tive. The views of bedside nurses, however, are critical and should be the subject of future studies related to the impact of this model. Using technology for this purpose has inherent challenges, and future studies should be undertaken to delineate these issues and define best practices in implementation. Although both the literature and common sense mandate that an appropriate number of skilled and

sense mandate that an appropriate number of skilled and To learn more about tele-ICU, read “A
sense mandate that an appropriate number of skilled and To learn more about tele-ICU, read “A

To learn more about tele-ICU, read “A Sec- ond Set of Eyes: An Introduction to Tele-ICU” by Goran in Critical Care Nurse, August 2010;

30:46-55. Available at www.ccnonline.org. www.ccnonline.org.

qualified nurses must be present on a unit at any given time, ground- breaking alternatives to how these nurses’ work gets accomplished are just in their infancy of exploration, 23-26 and the tele-ICU is one of those alternatives.

Conclusion

Safety, cost avoidance, and patients’ outcomes are being improved in our health system by these interventions. As technology becomes more integrated into patient care, the significance of tele-ICUs and tele-ICU nursing will most likely become more apparent. Tele- ICU nursing has the potential to add to the tools available to the critical care team by altering how the care of the most critical and vulnerable patients in the system is delivered. Although the role of the bedside care- giver can never be replaced or dimin- ished, it can certainly be augmented, enhanced, and facilitated. The key to the long-term success is the contin- ued consistent collaboration between the bedside team and the tele-ICU nurses, which can transform how critical care nursing is practiced. CCN

transform how critical care nursing is practiced. C C N Now that you’ve read the article,

Now that you’ve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit www.ccnonline.org and click “Submit a response” in either the full-text or PDF view of the article.

Acknowledgments

We thank our colleagues Rosemary Lee, DNP, RN-CNS,

ACNP-BC, CCRN, CCNS, and Donna Lee Wilson, RN, MSN,

CCRN, for their expert review and assistance in the preparation of this article. We also acknowledge the outstanding work of the nurses in the Baptist Health South Florida e-ICU, whose dedication and hard work created the outcomes described.

Financial Disclosures

None reported.

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Correction

In the December 2012 article by Williams et al, “Telenursing in the Intensive Care Unit: Transforming Nursing Practice” (Crit Care Nurse. 2012;32[6]:62-69), there was an error in the color key in Figure 1. The figure, with correct colors represented in the key, is shown here.

36 (6%) 140 (24%) 302 (51%) 116 (19%) Rescue Assist Prevention Consultation
36
(6%)
140
(24%)
302
(51%)
116
(19%)
Rescue
Assist
Prevention
Consultation

Figure 1 Documented tele–intensive care unit (tele-ICU) nurse interventions from September 2008 to August 2009 (N=594). Rescue indicates patient in trouble, immediate action required; assistance indicates that interventions were made that were ini- tiated by the tele-ICU nurse; prevention indicates interventions that most likely prevented occurrences such as falls, unplanned extubation, and allergic reactions; consultation indicates inter- ventions such as troubleshooting equipment, thinking together, educating or coaching bedside staff, and answering questions and requests initiated by the bedside team.

doi: http://dx.doi.org/10.4037/ccn2013707

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