Comparative Effectiveness of Quality Improvement Interventions for Pressure Ulcer Prevention in U.S. Academic Hospitals

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ISBN 13 :
Total Pages : 238 pages
Book Rating : 4.:/5 (955 download)

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Book Synopsis Comparative Effectiveness of Quality Improvement Interventions for Pressure Ulcer Prevention in U.S. Academic Hospitals by : William Vincent Padula (III)

Download or read book Comparative Effectiveness of Quality Improvement Interventions for Pressure Ulcer Prevention in U.S. Academic Hospitals written by William Vincent Padula (III) and published by . This book was released on 2013 with total page 238 pages. Available in PDF, EPUB and Kindle. Book excerpt: OBJECTIVE: To compare the effectiveness of quality improvement (QI) interventions for hospital-acquired pressure ulcer (HAPU) prevention among U.S. academic medical centers of the University HealthSystem Consortium (UHC). METHODS: We surveyed UHC hospitals to longitudinally characterize adoption patterns of QI interventions for HAPU prevention between 2007-2008 in response to CMS nonpayment policy for HAPUs. Characterization was based on the QI best-practice framework for QI strategy which includes 25 QI interventions organized into four domains: Leadership; Staff; Information Technology; and Performance & Improvement. Survey data was merged to quarterly hospital-level HAPU incidence rates to measure the effect of each QI intervention at reducing HAPU incidence. Utilizing an effect size analysis, we calculated derivatives of overall HAPU reduction for each QI intervention. A t-test compared marginal effect size in the first three quarters following adoption to remaining periods of adoption for each hospital. An analysis of covariance (ANCOVA) tested the correlation between of QI interventions and HAPU incidence variability while controlling for Medicare policy, age, gender, length-of-stay, case-mix index, and intensive-care unit (ICU) admission. RESULTS: A representative sample of fifty-five UHC hospitals responded to the survey, of which 53 (96%) indicated use of QI interventions in HAPU prevention. All QI interventions fit within the QI best-practice framework, thereby validating its structure. The effect size analysis identified five QI interventions with clinically meaningful effectiveness by reducing HAPU incidence greater than 1 case per 1,000 patient admissions between 2007-2012, including: Leadership Initiatives; Visual Tools; HAPU Staging; Skin Care; and Patient Nutrition. The t-test returned that the greatest reductions in HAPU incidence occur earlier in the adoption process (p

Patient Safety and Quality

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Publisher : Department of Health and Human Services
ISBN 13 :
Total Pages : 592 pages
Book Rating : 4.:/5 (318 download)

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Book Synopsis Patient Safety and Quality by : Ronda Hughes

Download or read book Patient Safety and Quality written by Ronda Hughes and published by Department of Health and Human Services. This book was released on 2008 with total page 592 pages. Available in PDF, EPUB and Kindle. Book excerpt: "Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/

Pressure Ulcer Treatment Strategies: Comparative Effectiveness

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Publisher : CreateSpace
ISBN 13 : 9781490574592
Total Pages : 490 pages
Book Rating : 4.5/5 (745 download)

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Book Synopsis Pressure Ulcer Treatment Strategies: Comparative Effectiveness by : U. S. Department of Health and Human Services

Download or read book Pressure Ulcer Treatment Strategies: Comparative Effectiveness written by U. S. Department of Health and Human Services and published by CreateSpace. This book was released on 2013-06-29 with total page 490 pages. Available in PDF, EPUB and Kindle. Book excerpt: Uninterrupted pressure exerted on the skin, soft tissue, muscle, and bone can lead to the development of localized ischemia, tissue inflammation, shearing, anoxia, and necrosis. Pressure ulcers affect up to three million adults in the U.S. Pressure ulcer healing rates—which depend on comorbidities, clinical interventions, and ulcer severity—vary considerably. Ulcer severity is assessed using a variety of different staging or grading systems, but the National Pressure Ulcer Advisory Panel (NPUAP) staging system is the most commonly used. Comorbidities predisposing toward pressure ulcer development and affecting ulcer healing include those affecting patient mobility (e.g., spinal cord injury), wound environments (e.g., incontinence), and wound healing (e.g., diabetes and vascular disease). Delayed healing can add to the length of hospitalization and impede return to full functioning. Prevalence of pressure ulcers is used as an indicator of quality for long-term care facilities, and progression of pressure ulcers in hospitalized patients is often considered an avoidable complication representing failure of inpatient management. Given the negative impact pressure ulcers have on health status and patient quality of life, as well as health care costs, treatments are needed that promote healing, shorten healing time, and minimize the risk of complications. Pressure ulcer treatment involves a variety of different approaches, including interventions to treat the conditions that give rise to pressure ulcers (support surfaces and nutritional support); interventions to protect and promote healing of the ulcer (wound dressings, topical applications, and various adjunctive therapies, including vacuum-assisted closure, ultrasound therapy, electrical stimulation, and hyperbaric oxygen therapy); and surgical repair of the ulcer. Most ulcers are treated using a combination of these approaches. The following Key Questions are the focus of our report. KQ1. In adults with pressure ulcers, what is the comparative effectiveness of treatment strategies for improved health outcomes, including but not limited to: complete wound healing, healing time, reduced wound surface area, pain, and prevention of serious complications of infection? KQ1a. Does the comparative effectiveness of treatment strategies differ according to features of the pressure ulcers, such as anatomic site or severity at baseline? KQ1b. Does the comparative effectiveness of treatment strategies differ according to patient characteristics, including but not limited to: age, race/ethnicity, body weight, specific medical comorbidities, and known risk factors for pressure ulcers, such as functional ability, nutritional status, or incontinence? KQ1c. Does the comparative effectiveness of treatment strategies differ according to patient care settings, such as home, nursing facility, or hospital, or according to features of patient care settings, including but not limited to nurse/patient staffing ratio, staff education and training in wound care, the use of wound care teams, and home caregiver support and training? KQ2. What are the harms of treatments for pressure ulcers? KQ2a. Do the harms of treatment strategies differ according to features of the pressure ulcers, such as anatomic site or severity at baseline? KQ2b. Do the harms of treatment strategies differ according to patient characteristics, including age, race/ethnicity, body weight, specific medical comorbidities, and known risk factors for pressure ulcers, such as functional ability, nutritional status, or incontinence? KQ2c. Do the harms of treatment strategies differ according to patient care settings, such as home, nursing facility, or hospital, or according to features of patient care settings, including but not limited to nurse/patient staffing ratio, staff education and training in wound care, the use of wound care teams, and home caregiver support and training?

Pressure Ulcer Risk Assessment and Prevention: Comparative Effectiveness

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Publisher : CreateSpace
ISBN 13 : 9781490574738
Total Pages : 362 pages
Book Rating : 4.5/5 (747 download)

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Book Synopsis Pressure Ulcer Risk Assessment and Prevention: Comparative Effectiveness by : U. S. Department of Health and Human Services

Download or read book Pressure Ulcer Risk Assessment and Prevention: Comparative Effectiveness written by U. S. Department of Health and Human Services and published by CreateSpace. This book was released on 2013-06-29 with total page 362 pages. Available in PDF, EPUB and Kindle. Book excerpt: Pressure ulcers are defined by the National Pressure Ulcer Advisory Panel (NPUAP) as “localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.” A number of risk factors are associated with increased risk of pressure ulcer development, including older age, black race, lower body weight, physical or cognitive impairment, poor nutritional status, incontinence, and specific medical comorbidities that affect circulation such as diabetes or peripheral vascular disease. Pressure ulcers are often associated with pain and can contribute to decreased function or lead to complications such as infection. In some cases, pressure ulcers may be difficult to successfully treat despite surgical and other invasive treatments. In the inpatient setting, pressure ulcers are associated with increased length of hospitalization and delayed return to function. In addition, the presence of pressure ulcers is associated with poorer general prognosis and may contribute to mortality risk. Recommended prevention strategies for pressure ulcers generally involve use of risk assessment tools to identify people at higher risk for developing ulcers in conjunction with interventions for preventing ulcers. A variety of diverse interventions are available for the prevention of pressure ulcers. Categories of preventive interventions include support surfaces (including mattresses, integrated bed systems, overlays, and cushions), repositioning, skin care (including lotions, dressings, and management of incontinence), and nutritional support. Each of these broad categories encompasses a variety of interventions. The purpose of this report is to review the comparative clinical utility and diagnostic accuracy of risk-assessment instruments for evaluating risk of pressure ulcers and to evaluate the benefits and harms of preventive interventions for pressure ulcers in different settings and patient populations. The following Key Questions are the focus of this report: KQ1. For adults in various settings, is the use of any risk-assessment tool effective in reducing the incidence or severity of pressure ulcers compared with other risk-assessment tools, clinical judgment alone, and/or usual care? KQ1a. Do the effectiveness and comparative effectiveness of risk-assessment tools differ according to setting? KeQ1b. Do the effectiveness and comparative effectiveness of risk-assessment tools differ according to patient characteristics and other known risk factors for pressure ulcers, such as nutritional status or incontinence? KQ2. How do various risk-assessment tools compare with one another in their ability to predict the incidence of pressure ulcers? KQ2a. Does the predictive validity of various risk-assessment tools differ according to setting? KQ2b. Does the predictive validity of various risk-assessment tools differ according to patient characteristics? KQ3. In patients at increased risk of developing pressure ulcers, what are the effectiveness and comparative effectiveness of preventive interventions in reducing the incidence or severity of pressure ulcers? KQ3a. Do the effectiveness and comparative effectiveness of preventive interventions differ according to risk level as determined by different risk-assessment methods and/or by particular risk factors? KQ3b. Do the effectiveness and comparative effectiveness of preventive interventions differ according to setting? KQ3c. Do the effectiveness and comparative effectiveness of preventive interventions differ according to patient characteristics? KQ4. What are the harms of interventions for the prevention of pressure ulcers? KQ4a. Do the harms of preventive interventions differ according to the type of intervention? KQ4b. Do the harms of preventive interventions differ according to setting? KQ4c. Do the harms of preventive interventions differ according to patient characteristics?

Fragility Fracture Nursing

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Publisher : Springer
ISBN 13 : 3319766813
Total Pages : 169 pages
Book Rating : 4.3/5 (197 download)

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Book Synopsis Fragility Fracture Nursing by : Karen Hertz

Download or read book Fragility Fracture Nursing written by Karen Hertz and published by Springer. This book was released on 2018-06-15 with total page 169 pages. Available in PDF, EPUB and Kindle. Book excerpt: This open access book aims to provide a comprehensive but practical overview of the knowledge required for the assessment and management of the older adult with or at risk of fragility fracture. It considers this from the perspectives of all of the settings in which this group of patients receive nursing care. Globally, a fragility fracture is estimated to occur every 3 seconds. This amounts to 25 000 fractures per day or 9 million per year. The financial costs are reported to be: 32 billion EUR per year in Europe and 20 billon USD in the United States. As the population of China ages, the cost of hip fracture care there is likely to reach 1.25 billion USD by 2020 and 265 billion by 2050 (International Osteoporosis Foundation 2016). Consequently, the need for nursing for patients with fragility fracture across the world is immense. Fragility fracture is one of the foremost challenges for health care providers, and the impact of each one of those expected 9 million hip fractures is significant pain, disability, reduced quality of life, loss of independence and decreased life expectancy. There is a need for coordinated, multi-disciplinary models of care for secondary fracture prevention based on the increasing evidence that such models make a difference. There is also a need to promote and facilitate high quality, evidence-based effective care to those who suffer a fragility fracture with a focus on the best outcomes for recovery, rehabilitation and secondary prevention of further fracture. The care community has to understand better the experience of fragility fracture from the perspective of the patient so that direct improvements in care can be based on the perspectives of the users. This book supports these needs by providing a comprehensive approach to nursing practice in fragility fracture care.

Advances in Patient Safety

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ISBN 13 :
Total Pages : 526 pages
Book Rating : 4.7/5 (54 download)

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Book Synopsis Advances in Patient Safety by : Kerm Henriksen

Download or read book Advances in Patient Safety written by Kerm Henriksen and published by . This book was released on 2005 with total page 526 pages. Available in PDF, EPUB and Kindle. Book excerpt: v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products.

Pressure Ulcer Treatment Strategies

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ISBN 13 :
Total Pages : 488 pages
Book Rating : 4.:/5 (855 download)

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Book Synopsis Pressure Ulcer Treatment Strategies by : Somnath Saha

Download or read book Pressure Ulcer Treatment Strategies written by Somnath Saha and published by . This book was released on 2013 with total page 488 pages. Available in PDF, EPUB and Kindle. Book excerpt: OBJECTIVES: Pressure ulcers affect up to 3 million Americans and are a major source of morbidity, mortality, and health care cost. This review summarizes evidence comparing the effectiveness and safety of pressure ulcer treatment strategies. DATA SOURCES: Articles published between January 1, 1985, and October 17, 2012, were identified from searches of MEDLINE(r) (Ovid), Embase (Elsevier), CINAHL (EBSCOhost), EBM Reviews (Ovid), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and Health Technology Assessment. Additional studies were identified by searching reference lists from included studies and systematic reviews of pressure ulcer treatments. Gray literature, including unpublished data, abstracts, dissertations, and individual product packets from manufacturers, was also reviewed. REVIEW METHODS: The literature, quality of included studies, and extracted data were dual-reviewed using predefined criteria. Results were summarized in evidence tables. Summary results were derived primarily from qualitative analysis and synthesis. RESULTS: We reviewed 7,274 titles and abstracts and 1,836 full-length articles. We included 174 studies (trials and observational studies) addressing the effectiveness and/or harms of different treatments for pressure ulcers. These studies examined a wide range of interventions, but sample sizes often were small. We found moderate-strength evidence that some interventions were associated with wound improvement, including the use of air-fluidized beds (compared with other support surfaces), protein-containing nutritional supplements (compared with placebos or other routine measures of nutritional support), radiant heat dressings (compared with other dressings), and electrical stimulation (compared with a sham treatment). Several other interventions had limited evidence of effectiveness (strength of evidence rated as low). Only a minority of studies examined complete wound healing as an outcome. In general, the evidence about the harms of any of these treatments was limited. LIMITATIONS: Most studies were of poor quality and had followup periods inadequate to assess complete wound healing. Studies often measured healing outcomes using heterogeneous methods, making it difficult to compare results across studies. CONCLUSIONS: There was limited evidence to draw firm conclusions about the best approaches for treating pressure ulcers, a finding consistent with other recent reviews on this topic. Future research with larger sample sizes, more rigorous adherence to methodological standards for clinical trials, longer followup periods, and more standardized and clinically meaningful outcome measures is needed to inform clinical practice and policy.

Prevention and Treatment of Pressure Ulcers/injuries

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Publisher :
ISBN 13 :
Total Pages : 43 pages
Book Rating : 4.:/5 (125 download)

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Book Synopsis Prevention and Treatment of Pressure Ulcers/injuries by :

Download or read book Prevention and Treatment of Pressure Ulcers/injuries written by and published by . This book was released on 2019 with total page 43 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Prevention and Treatment of Pressure Ulcers

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ISBN 13 : 9780980739657
Total Pages : 308 pages
Book Rating : 4.7/5 (396 download)

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Book Synopsis Prevention and Treatment of Pressure Ulcers by : National Pressure Ulcer Advisory Panel (U.S.)

Download or read book Prevention and Treatment of Pressure Ulcers written by National Pressure Ulcer Advisory Panel (U.S.) and published by . This book was released on 2014-09-30 with total page 308 pages. Available in PDF, EPUB and Kindle. Book excerpt: This Clinical Practice Guideline presents recommendations and summarizes the supporting evidence for pressure ulcer prevention and treatment. The first edition was developed as a four year collaboration between the National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP). In this second edition of the guideline, the Pan Pacific Pressure Injury Alliance (PPPIA) has joined the NPUAP and EPUAP. This edition of the guideline has been developed over a two year period to provide an updated review of the research literature, extend the scope of the guideline and produce recommendations that reflect the most recent evidence. It provides a detailed analysis and discussion of available research, critical evaluation of the assumptions and knowledge in the field, recommendations for clinical practice, a description of the methodology used to develop the guideline and acknowledgements of the 113 experts formally involved in the development process.

Nursing Quality Indicators

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ISBN 13 :
Total Pages : 36 pages
Book Rating : 4.3/5 (91 download)

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Book Synopsis Nursing Quality Indicators by : American Nurses Association

Download or read book Nursing Quality Indicators written by American Nurses Association and published by . This book was released on 1999 with total page 36 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Cost-Effectiveness Analysis in Health

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Publisher : John Wiley & Sons
ISBN 13 : 1119011280
Total Pages : 561 pages
Book Rating : 4.1/5 (19 download)

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Book Synopsis Cost-Effectiveness Analysis in Health by : Peter Muennig

Download or read book Cost-Effectiveness Analysis in Health written by Peter Muennig and published by John Wiley & Sons. This book was released on 2016-02-03 with total page 561 pages. Available in PDF, EPUB and Kindle. Book excerpt: The field's bestselling reference, updated with the latest tools, data, techniques, and the latest recommendations from the Second Panel on Cost-Effectiveness in Health and Medicine Cost-Effectiveness Analysis in Health is a practical introduction to the tools, methods, and procedures used worldwide to perform cost-effective research. Covering every aspect of a complete cost-effectiveness analysis, this book shows you how to find which data you need, where to find it, how to analyze it, and how to prepare a high-quality report for publication. Designed for the classroom or the individual learner, the material is presented in simple and accessible language for those who lack a biostatistics or epidemiology background, and each chapter includes real-world examples and "tips and tricks" that highlight key information. Exercises throughout allow you to test your understanding with practical application, and the companion website features downloadable data sets for students, as well as lecture slides and a test bank for instructors. This new third edition contains new discussion on meta-analysis and advanced modeling techniques, a long worked example using visual modeling software TreeAge Pro, and updated recommendations from the U.S. Public Health Service's Panel on Cost-Effectiveness in Health and Medicine. This is the second printing of the 3rd Edition, which has been corrected and revised for 2018 to reflect the latest standards and methods. Cost-effectiveness analysis is used to evaluate medical interventions worldwide, in both developed and developing countries. This book provides process-specific instruction in a concise, structured format to give you a robust working knowledge of common methods and techniques. Develop a thoroughly fleshed-out research project Work accurately with costs, probabilities, and models Calculate life expectancy and quality-adjusted life years Prepare your study and your data for publication Comprehensive analysis skills are essential for students seeking careers in public health, medicine, biomedical research, health economics, health policy, and more. Cost-Effectiveness Analysis in Health walks you through the process from a real-world perspective to help you build a skillset that's immediately applicable in the field.

Pressure Ulcer Treatment Strategies

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Publisher :
ISBN 13 :
Total Pages : 0 pages
Book Rating : 4.:/5 (19 download)

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Book Synopsis Pressure Ulcer Treatment Strategies by :

Download or read book Pressure Ulcer Treatment Strategies written by and published by . This book was released on 2013 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Measuring Patient Safety

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Publisher : Jones & Bartlett Learning
ISBN 13 : 9780763728410
Total Pages : 172 pages
Book Rating : 4.7/5 (284 download)

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Book Synopsis Measuring Patient Safety by : Robin Purdy Newhouse

Download or read book Measuring Patient Safety written by Robin Purdy Newhouse and published by Jones & Bartlett Learning. This book was released on 2005 with total page 172 pages. Available in PDF, EPUB and Kindle. Book excerpt: The vital nature of improving patient safety requires nurses to assume leadership roles in measuring and improving the structures, processes, and patient outcomes in the clinical setting. This book will enable them to impact patient safety with knowledge and confidence.

Nursing Implementation of Pressure Ulcer Prevention Interventions, a Medical Record Review

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Publisher :
ISBN 13 :
Total Pages : 46 pages
Book Rating : 4.:/5 (126 download)

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Book Synopsis Nursing Implementation of Pressure Ulcer Prevention Interventions, a Medical Record Review by : Rachel S. Carlton

Download or read book Nursing Implementation of Pressure Ulcer Prevention Interventions, a Medical Record Review written by Rachel S. Carlton and published by . This book was released on 2020 with total page 46 pages. Available in PDF, EPUB and Kindle. Book excerpt: "Pressure Ulcers are a prevalent, costly, and complex complication in various specialties and patient populations. Pressure ulcers increase patient mortality. length of stay. and dissatisfaction with their hospital stay. The prevention of pressure ulcers in acute settings falls primarily on the individuals providing day-to-day care for patients, the nurses. Despite the use of pressure ulcer risk assessments there are still a number of pressure ulcers acquired yearly around the world. The purpose of this quality improvement medical record review was to determine if nursing staff at a medical ICU at a mid-Michigan hospital are completing an initial pressure ulcer risk assessment and based on that following hospital protocol for pressure ulcer prevention. This study was a retrospective descriptive quantitative medical record review of those patients with a Braden Score of less than three in any subscale that also spent greater than 24 hours in the medical ICU at this facility. Fifty patient medical records from March 2019 to December 2019 were obtained and reviewed to determine nursing staff compliance with facility pressure ulcer prevention protocol. The compliance rates for each subscale when determined necessary based on risk assessment charted using the Braden Scale were sensory perception (5/5). moisture (0/1 ), activity (20/46), mobility (17/18), nutrition (2/30), and friction and shear ( 19/37). From this data. it is recommended that education be provided to the nursing staff at this facility particularly on interventions and documentation regarding activity. nutrition, and friction and shear. Utilizing these recommendations with nursing staff within this patient care unit may result in the increase in pressure ulcer prevention protocol interventions and decrease the rate at which pressure ulcers are acquired in this facility. " -- From page iv.

Pressure Ulcers Prevention in Health Care Facilities

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ISBN 13 : 9781973235231
Total Pages : 168 pages
Book Rating : 4.2/5 (352 download)

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Book Synopsis Pressure Ulcers Prevention in Health Care Facilities by : R. E. D. Dot RED DOT PUBLICATOINS

Download or read book Pressure Ulcers Prevention in Health Care Facilities written by R. E. D. Dot RED DOT PUBLICATOINS and published by . This book was released on 2017-11-06 with total page 168 pages. Available in PDF, EPUB and Kindle. Book excerpt: Each year, more than 2.5 million people in the United States develop pressure ulcers. These skin lesions bring pain, associated risk for serious infection, and increased health care utilization. Moreover, the Centers for Medicare & Medicaid (CMS) no longer provides additional reimbursement to hospitals to care for a patient who has acquired a pressure ulcer while under the hospital's care. Thus, pressure ulcer prevention presents an important challenge in acute care hospitals. A number of best practices have been shown to be effective in reducing the occurrence of pressure ulcers, but these practices are not used systematically in all hospitals. The aim of this book is to assist hospital staff in implementing effective pressure ulcer prevention practices. The material was developed by the Agency for Healthcare Research and Quality with additional support from the Health Services Research and Development Service of the Department of Veterans Affairs. It was created by a core team with expertise in pressure ulcers and organizational change. An expert advisory panel and quality improvement teams at six participating medical centers provided input.

Pressure Ulcers in Adults

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ISBN 13 :
Total Pages : 22 pages
Book Rating : 4.3/5 (91 download)

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Book Synopsis Pressure Ulcers in Adults by :

Download or read book Pressure Ulcers in Adults written by and published by . This book was released on 1992 with total page 22 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Pressure Ulcer Risk Assessment and Prevention

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ISBN 13 :
Total Pages : 0 pages
Book Rating : 4.:/5 (19 download)

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Book Synopsis Pressure Ulcer Risk Assessment and Prevention by :

Download or read book Pressure Ulcer Risk Assessment and Prevention written by and published by . This book was released on 2013 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: