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RESEARCH01-01-2016
Association between self-care and hospital readmissions of patients with heart failure
Revista Brasileira de Enfermagem. 2016;69(3):500-506
Abstract
RESEARCHAssociation between self-care and hospital readmissions of patients with heart failure
Revista Brasileira de Enfermagem. 2016;69(3):500-506
DOI 10.1590/0034-7167.2016690312i
Views0See moreABSTRACT
Objective:
to assess the association between self-care and the number of hospital readmissions of patients with heart failure (ADHF) and test the applicability of two self-care assessment tools. longitudinal study, performed in a cardiology reference hospital in southern Brazil.
Method:
it included 82 patients with a mean age of 61.85±12.33 years, 57.3% male. The mean score of self-care assessment found the scales European Heart Failure Self-care Behavior Scale and Self-care Scale for Patients with Heart Failure was unsatisfactory.
Results:
it was observed an average of 2.57±1.66 rehospitalization last year for decompensated heart failure. There was a correlation between self-care scores with the number of hospital readmissions for decompensated HF. Education and age were associated to self-care of HF patients.
Conclusion:
both scales assess self-care in a relevant way, and correlated their indexes.
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RESEARCH01-01-2016
Knowledge management in Portuguese healthcare institutions
Revista Brasileira de Enfermagem. 2016;69(3):492-499
Abstract
RESEARCHKnowledge management in Portuguese healthcare institutions
Revista Brasileira de Enfermagem. 2016;69(3):492-499
DOI 10.1590/0034-7167.2016690311i
Views0See moreABSTRACT
Objective:
to evaluate the perception of healthcare institution collaborators in relation to knowledge management in the institution where they operate and analyze the existence of differences in this perception, based on the institution’s management model.
Method:
a study conducted in a sample consisting of 671 collaborators from 10 Portuguese healthcare institutions with different models of management. In order to assess the knowledge management perception, we used a score designed from and based on items from the scores available in the literature.
Results:
the perception of moderate knowledge management on the healthcare institutions and the statistically significant differences in knowledge management perception were evidenced in each management model.
Conclusion:
management knowledge takes place in healthcare institutions, and the current management model determines the way staff at these institutions manage their knowledge.
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RESEARCH01-01-2016
Frailty and quality of life in elderly primary health care users
Revista Brasileira de Enfermagem. 2016;69(3):478-483
Abstract
RESEARCHFrailty and quality of life in elderly primary health care users
Revista Brasileira de Enfermagem. 2016;69(3):478-483
DOI 10.1590/0034-7167.2016690309i
Views1See moreABSTRACT
Objective:
to investigate the association between physical frailty and quality of life in elderly users of primary health care in the capital of the state of Paraná.
Method:
a cross-sectional, quantitative study with 203 elders. Data collected included: physical activity questionnaires, weight loss, fatigue/exhaustion, quality of life, performance of gait speed tests, and handgrip strength.
Results:
of the 203 older adults, 115 were pre-frail, 49 were non-frail, and 39 were frail, with a significant association with functional capacity and quality of life in all groups. The dimensions resulting from physical aspects, pain, and vitality were associated with those that were non-frail.
Conclusion:
in this study, frailty syndrome was inversely proportional to the quality of life, and significantly associated with functional capacity of older adults. Physical frailty is a manageable condition which can be targeted through geriatric nursing interventions.
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RESEARCH01-01-2016
Impact of home visits on the functional capacity of patients with venous ulcers
Revista Brasileira de Enfermagem. 2016;69(3):468-477
Abstract
RESEARCHImpact of home visits on the functional capacity of patients with venous ulcers
Revista Brasileira de Enfermagem. 2016;69(3):468-477
DOI 10.1590/0034-7167.2016690308i
Views0See moreABSTRACT
Objective:
to assess the impact of protocol home visits on the functional capacity of adult and elderly patients with venous ulcers, before and after guidance received at home.
Method:
clinical experimental, randomized, nonblinded and controlled study, developed with 32 patients (case and control groups). Fields of research were the Wound Outpatient Care Unit of the Antônio Pedro University Hospital and households of patients treated in the outpatient unit. Data collection occurred from February to June 2014, by means of an assessment tool of the health care unit, the TINETTI index and a script for directions to be provided to study participants who received home visits.
Results:
participants in the case group showed significant and differentiated improvement post-intervention when compared to the control group, which remained stable.
Conclusion:
directions provided in the home context were beneficial to the members of the case group.
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RESEARCH01-01-2016
Pressure ulcers in critically ill patients: incidence and associated factors
Revista Brasileira de Enfermagem. 2016;69(3):460-467
Abstract
RESEARCHPressure ulcers in critically ill patients: incidence and associated factors
Revista Brasileira de Enfermagem. 2016;69(3):460-467
DOI 10.1590/0034-7167.2016690307i
Views0See moreABSTRACT
Objective:
to identify the incidence and describe the associated factors for pressure ulcers in critically ill patients.
Method:
this was a prospective cohort study with 77 patients, using a clinical, metabolic assessment and the associated factors for pressure ulcer, applying the risk scales (Braden and Waterlow) and assigning ulcers to categories.
Results:
an incidence of 22% (95% CI 12.6 – 31.5), with 17 patients with 32 pressure ulcers in the sacral region (47%), and of Class I (72%). The length of stay was greater than ten days (71%), most admissions were surgical (53%) or for congestive heart failure (24%), and were high risk on the Braden Scale (59%).
Conclusion:
the study highlights the high incidence of pressure ulcers, clinical and metabolic characteristics and associated factors, as well as the outcome of death, requiring, therefore, preventive measures.
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RESEARCH01-01-2016
Accreditation in a public hospital: perceptions of a multidisciplinary team
Revista Brasileira de Enfermagem. 2016;69(3):451-459
Abstract
RESEARCHAccreditation in a public hospital: perceptions of a multidisciplinary team
Revista Brasileira de Enfermagem. 2016;69(3):451-459
DOI 10.1590/0034-7167.2016690306i
Views1See moreABSTRACT
Objective:
to analyze the perceptions of the multidisciplinary team on Accreditation in a public hospital.
Method:
descriptive, exploratory, qualitative research, performed in May 2014, using recorded individual interviews. In total, 28 employees of a public hospital, Accredited with Excellence, answered the guiding question: “Tell me about the Accreditation system used in this hospital”. The interviews were transcribed and subjected to content analysis.
Results:
of the speeches, three categories emerged: Advantages offered by the Accreditation; Accredited public hospital resembling a private hospital; Pride/satisfaction for acting in an accredited public hospital.
Conclusion:
participants perceived Accreditation as a favorable system for a quality management in the public service because it promotes the development of professional skills and improves cost management, organizational structure, management of assistance and perception of job pride/satisfaction.
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RESEARCH01-01-2016
Health status and the return to work after traffic accidents
Revista Brasileira de Enfermagem. 2016;69(3):443-450
Abstract
RESEARCHHealth status and the return to work after traffic accidents
Revista Brasileira de Enfermagem. 2016;69(3):443-450
DOI 10.1590/0034-7167.2016690305i
Views0See moreABSTRACT
Objective:
to compare the health status of traffic accident victims, at hospital discharge and after six months, and to analyze the predictive variables of their health status and return to work.
Method:
observational, longitudinal study. Data were collected through interviews and medical records of 102 patients with a mean age of 33 years; with the majority being men and victims of motorcycle accidents. The variables were analyzed by means of validated tools, student’s t-test, multiple linear regression, and logistic regression.
Results:
there was an improvement of perception in the patients’ health status six months after hospital discharge and functional capacity. The individuals who returned to work showed better health-related quality of life evaluation.
Conclusion:
improvement of the perceived health status six months after hospital discharge was found. Factors that influenced the patients’ return to work were not identified.
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RESEARCH01-01-2017
Nursing throughout war times: political propaganda and professional valorization (1942-1945)
Revista Brasileira de Enfermagem. 2017;70(2):407-414
Abstract
RESEARCHNursing throughout war times: political propaganda and professional valorization (1942-1945)
Revista Brasileira de Enfermagem. 2017;70(2):407-414
DOI 10.1590/0034-7167-2016-0440
Views0See moreABSTRACT
Objective:
to discuss the symbolic effects of the publication on written press of institutional rites related to the courses promoted by the Brazilian Federal District’s Schools of Nursing during the Second World War.
Method:
exploratory and documentary study, whose sources were treated by historical method.
Results:
one noticed, in the news reports analyzed, that the Brazilian Estado Novo has used nurses images to divulge within the society the woman’s acting altruistic model in service to the country, through the systematic diffusion by the press of her honorable acting during the war, what assured the amplification of the visibility and acknowledgment of the Nursing profession in that context.
Conclusion:
the diffusion by press of emergency nurses graduations magnified their apparition in public spaces, occasion on which the institutional rite was strategically used to transmit to the society the urgency of the new profession, in order to support the political causes in vigor in the country.
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RESEARCH01-01-2017
Conformity of nurse prescribing to care needs: nurses’ understanding
Revista Brasileira de Enfermagem. 2017;70(2):400-406
Abstract
RESEARCHConformity of nurse prescribing to care needs: nurses’ understanding
Revista Brasileira de Enfermagem. 2017;70(2):400-406
DOI 10.1590/0034-7167-2016-0107
Views0See moreABSTRACT
Objective:
investigate the understanding of nurses on nurse prescribing conformity to the care needs of hospitalized patients and factors associated with that conformity.
Method:
a descriptive study, with a quantitative approach, was conducted at 20 in-patient units of a teaching hospital in the state of São Paulo. The participants (N=139) answered a semi-structured questionnaire.
Results:
For 43 (30.9%) nurses, nurse prescribing is always in line with patients’ care needs. The fields of body care and elimination, skin and mucosa care and investigation and monitoring were the most frequently addressed.
Conclusion:
in the perception of most nurses, nurse prescribing does not conform with patients’ health heeds. The establishment of strategies to improve prescribing quality is recommended, as well as the development of permanent qualification programs and the systematic use of instruments for assessment of patients’ care demands regarding nursing.
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RESEARCH01-01-2017
Religious and spiritual coping in people living with HIV/Aids
Revista Brasileira de Enfermagem. 2017;70(2):392-399
Abstract
RESEARCHReligious and spiritual coping in people living with HIV/Aids
Revista Brasileira de Enfermagem. 2017;70(2):392-399
DOI 10.1590/0034-7167-2015-0170
Views0See moreABSTRACT
Objective:
evaluate the religiosity and the religious/spiritual coping of people living with HIV/Aids.
Method:
descriptive, cross-sectional study with quantitative approach, conducted in a reference HIV/Aids outpatient clinic in a university hospital of Recife-PE, Brazil, from June to November 2015. At total of 52 people living with HIV/Aids (PLWHA) participated in the research, which employed own questionnaire, the Duke University Religion Index (DUREL), and the Religious/Spiritual Coping Scale (RCOPE).
Results:
the sample presented high indices of organizational religiosity (4.23±1.66), non-organizational religiosity (4.63±1.50), and intrinsic religiosity (13.13±2.84). Positive RCOPE was used in high mean scores (3.66±0.88), and negative RCOPE had low use (2.12 ± 0.74). In total, use of RCOPE was high (3.77±0.74), having predominated the positive RCOPE (NegRCOPE/PosRCOPE ratio=0.65±0.46).
Conclusion:
it is evident the importance of encouraging religious activity and RCOPE strategies, seen in the past as inappropriate interventions in clinical practice.
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RESEARCH01-01-2017
Satisfaction and dissatisfaction in the work of recyclable solid waste segregators: convergent-care research
Revista Brasileira de Enfermagem. 2017;70(2):384-391
Abstract
RESEARCHSatisfaction and dissatisfaction in the work of recyclable solid waste segregators: convergent-care research
Revista Brasileira de Enfermagem. 2017;70(2):384-391
DOI 10.1590/0034-7167-2016-0325
Views0See moreABSTRACT
Objectives:
describe elements that promote satisfaction and dissatisfaction in the work of recyclable solid waste segregators and conduct a nursing action focused on these elements.
Method:
qualitative research, convergent-care, conducted with members of the cooperative. Data production occurred during 2015 through participation observation, semi-structured interviews, and a convergence group. Analysis comprised the phases Apprehension, Synthesis, Theorization, and Transference.
Results:
four categories emerged. They showed satisfaction and dissatisfaction related to identification with tasks and work content, material and personal gains obtained from solid waste segregation, prejudice, lack of appreciation, and difficulties in interpersonal relationships. This last item, due to its importance, received a nursing action.
Conclusion:
the study contributed to the advancement of knowledge and the association of possibilities between the research performance and nursing care for workers.
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RESEARCH01-01-2017
The game as strategy for approach to sexuality with adolescents: theoretical-methodological reflections
Revista Brasileira de Enfermagem. 2017;70(2):376-383
Abstract
RESEARCHThe game as strategy for approach to sexuality with adolescents: theoretical-methodological reflections
Revista Brasileira de Enfermagem. 2017;70(2):376-383
DOI 10.1590/0034-7167-2016-0043
Views0ABSTRACT
Objective:
To describe the Papo Reto [Straight Talk] game and reflect on its theoretical-methodological basis.
Method:
Analytical study on the process of elaboration of the Papo Reto online game, destined to adolescents aged 15-18 years, with access to the Game between 2014 and 2015.
Results:
the interactions of 60 adolescents from Belo Horizonte and São Paulo constituted examples of the potentialities of the Game to favor the approach to sexuality with adolescents through simulation of reality, invention and interaction. Based on those potentialities, four thinking categories were discussed: the game as pedagogic device; the game as simulation of realities; the game as device for inventive learning; and the game empowering the interaction.
Conclusion:
By permitting that the adolescents take risks on new ways, the Game allows them to become creative and active in the production of senses, in the creation of their discourses and in the ways of thinking, feeling and acting in the sexuality field.
Keywords:AdolescentsEducation in HealthEducational Technology and Public HealthGames and ToysSexualitySee more -
RESEARCH01-01-2017
Tuberculosis among prison staff in Rio Grande do Sul
Revista Brasileira de Enfermagem. 2017;70(2):370-375
Abstract
RESEARCHTuberculosis among prison staff in Rio Grande do Sul
Revista Brasileira de Enfermagem. 2017;70(2):370-375
DOI 10.1590/0034-7167-2016-0012
Views0See moreABSTRACT
Objective:
to evaluate the risk of infection and illness caused by Mycobacterium tuberculosis among health care and security staff in prisons in two regions of Rio Grande do Sul (RS).
Method:
cross-sectional study involving prison staff. An interview and sputum smear microscopy and culture were performed. Latent infection was evaluated according to the result of the tuberculin test (TT), self-referred.
Results:
among staff who had a TT, 10 (83.3%) in the central region and 2 (16.7%) in the southern region were considered reactors. Length of employment among prison officers who reacted to TT was 15.3 years, and among health care workers, 4.1 years (p = 0.01). No cases of active tuberculosis (TB) were identified.
Conclusion:
prevalence of latent TB was 27.9%. Length of employment between different professional categories and their working regions was considered a risk factor for latent TB.
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RESEARCH01-01-2017
Portable bathtub: technology for bed bath in bedridden patients
Revista Brasileira de Enfermagem. 2017;70(2):364-369
Abstract
RESEARCHPortable bathtub: technology for bed bath in bedridden patients
Revista Brasileira de Enfermagem. 2017;70(2):364-369
DOI 10.1590/0034-7167-2016-0178
Views0See moreABSTRACT
Objective:
determine the benefits of the Portable Bathtub as technology for bed bath in bedridden patients.
Method:
qualitative research of exploratory-descriptive character, whose data were collected by means of 30 interviews with patients, family members and professionals directly involved in bed bath, carried out with Portable Bathtub, in bedridden patients of a medical clinic, from July to December 2015.
Results:
from the data encoded by thematic content analysis resulted two categories: Portable Bathtub: from morphine to the patient’s rekindled eyes; From mechanized practice to unique, transforming care.
Conclusion:
we concluded that the Portable Bathtub constitutes enhancing technology, as it enables clinical improvement of the patient’s general condition and transcends traditional mechanized practices by the reach of advanced nursing care practices.
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RESEARCH01-01-2017
Direct cost of monitoring conventional hemodialysis conducted by nursing professionals
Revista Brasileira de Enfermagem. 2017;70(2):357-363
Abstract
RESEARCHDirect cost of monitoring conventional hemodialysis conducted by nursing professionals
Revista Brasileira de Enfermagem. 2017;70(2):357-363
DOI 10.1590/0034-7167-2016-0447
Views0ABSTRACT
Objective:
to analyze the mean direct cost of conventional hemodialysis monitored by nursing professionals in three public teaching and research hospitals in the state of São Paulo, Brazil.
Method:
this was a quantitative, explorative and descriptive investigation, based on a multiple case study approach. The mean direct cost was calculated by multiplying (clocked) time spent per procedure by the unit cost of direct labor. Values were calculated in Brazilian real (BRL).
Results:
Hospital C presented the highest mean direct cost (BRL 184.52), 5.23 times greater than the value for Hospital A (BRL 35.29) and 3.91 times greater than Hospital B (BRL 47.22).
Conclusion:
the costing method used in this study can be reproduced at other dialysis centers to inform strategies aimed at efficient allocation of necessary human resources to successfully monitor conventional hemodialysis.
Keywords:BenchmarkingCosts and Cost AnalysisDirect Service CostsHospital Hemodialysis UnitsNephrology NursingSee more
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ERRATUM01-13-2024
ERRATUM
Revista Brasileira de Enfermagem. 2024;77(6):e2024n6e08
Abstract
ERRATUMERRATUM
Revista Brasileira de Enfermagem. 2024;77(6):e2024n6e08
DOI 10.1590/0034-7167.20247706e08
Views0In the article “Brazilian nursing specific situation, middle and micro-range theories: a bibliometric study”, with DOI number: , published in Revista Brasileira de Enfermagem, 2024;77(4):e20230520, Chart 1:Where it read:[…]See more -
ERRATUM01-13-2024
ERRATA
Revista Brasileira de Enfermagem. 2024;77(6):e2024n6e07
Abstract
ERRATUMERRATA
Revista Brasileira de Enfermagem. 2024;77(6):e2024n6e07
DOI 10.1590/0034-7167.20247706e06pt
Views0No artigo “Crenças e atitudes de pais ou responsáveis legais sobre a vacinação infantil: revisão de escopo”, com número DOI: , publicado no periódico Revista Brasileira de Enfermagem, 2024;77(4):e20240126, página 5:Onde se lia:[…]See more -
ORIGINAL ARTICLE01-13-2024
Indicators associated with severity and mortality in hospitalized people with HIV: A retrospective cohort
Revista Brasileira de Enfermagem. 2024;77(6):e20240204
Abstract
ORIGINAL ARTICLEIndicators associated with severity and mortality in hospitalized people with HIV: A retrospective cohort
Revista Brasileira de Enfermagem. 2024;77(6):e20240204
DOI 10.1590/0034-7167-2024-0204
Views0See moreABSTRACT
Objectives:
to compare the sociodemographic and clinical severity indicators of hospitalized people with HIV in relation to clinical outcomes and urgent hospital admission.
Methods:
a retrospective cohort study was conducted with 102 medical records of HIV-infected individuals hospitalized in a hospital in southern Brazil. In addition to descriptive analysis, Fisher’s exact test, Pearson’s Chi-square, and logistic regression were used.
Results:
the data showed a significant direct effect on severity indicators in the following variables: male sex (p=0.013), skin color (p=0.023), level of education (p=0.000), urgent admissions (p=0.000), late diagnosis (p=0.001), diabetes mellitus (p=0.001), hypertension (p=0.004), kidney disease (p=0.002), high viral load (p=0.006), CD4+ count below 200 (p=0.005), fever (p=0.016), weight loss (p=0.013), co-infection with hepatitis C (p=0.004), and mortality (p=0.007).
Conclusions:
three sociodemographic and thirteen clinical markers were identified as being associated with the risk of clinical deterioration in hospitalized people with HIV.
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ORIGINAL ARTICLE01-13-2024
Nurses’ perspectives on the use of telemonitoring in the management of people with diabetes and hypertension
Revista Brasileira de Enfermagem. 2024;77(6):e20230481
Abstract
ORIGINAL ARTICLENurses’ perspectives on the use of telemonitoring in the management of people with diabetes and hypertension
Revista Brasileira de Enfermagem. 2024;77(6):e20230481
DOI 10.1590/0034-7167-2023-0481
Views1See moreABSTRACT
Objectives:
to understand the perspective of nurses on the use of telemonitoring in the management of people with type 2 diabetes mellitus and arterial hypertension in primary care.
Methods:
this qualitative research involved sixteen nurses from eight municipalities in Paraná. Data were collected between November 2022 and January 2023 through inperson or remote interviews, which were audio-recorded and subjected to content analysis.
Results:
according to the nurses, telemonitoring enhances users’ knowledge about these conditions, communication and connection with the team, and productivity. However, the lack of electronic resources and equipment, high staff turnover, low user adherence, and the limited availability of professional time present significant challenges.
Final Considerations:
the effective implementation and operation of telemonitoring in the management of people with diabetes and hypertension involve both potential benefits and barriers. It is essential to have the availability of human and technological resources, managerial support, and the commitment of professionals and users.
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ORIGINAL ARTICLE01-13-2024
Knowledge, Attitudes, and Practices of nurses regarding blood culture collection
Revista Brasileira de Enfermagem. 2024;77(6):e20230424
Abstract
ORIGINAL ARTICLEKnowledge, Attitudes, and Practices of nurses regarding blood culture collection
Revista Brasileira de Enfermagem. 2024;77(6):e20230424
DOI 10.1590/0034-7167-2023-0424
Views0ABSTRACT
Objectives:
to investigate the knowledge, attitudes, and practices of nurses regarding blood culture collection.
Methods:
a cross-sectional study was conducted in five Brazilian public hospitals with 112 nurses. Data were collected using an adapted questionnaire and analyzed through descriptive and inferential statistics.
Results:
nurses who did not consider themselves capable of collecting blood cultures had a 72% lower chance of performing the collection at the recommended site and an 83% lower chance of using the same needle for blood inoculation into the vials. Nurses working in the emergency department had a 75% lower chance of knowing the international benchmark for blood culture contamination rates, and those with less than 5 years in the position decreased their chance of accuracy in this matter by 79%.
Conclusions:
there are gaps in the knowledge, attitudes, and practices of nurses regarding blood culture collection. Standardization of the technique, periodic education, supervision and guidance of the collection team, and process auditing are recommended coping strategies.
Keywords:Blood CultureBlood Specimen CollectionHealth Knowledge, Attitudes, PracticeNursing CareQuality of Health CareSee more -
ORIGINAL ARTICLE01-13-2024
Evaluation of care for people with HIV in Primary Health Care: construct validation
Revista Brasileira de Enfermagem. 2024;77(6):e20230190
Abstract
ORIGINAL ARTICLEEvaluation of care for people with HIV in Primary Health Care: construct validation
Revista Brasileira de Enfermagem. 2024;77(6):e20230190
DOI 10.1590/0034-7167-2023-0190
Views0ABSTRACT
Objectives:
to verify the construct validation of an instrument for evaluating care for people living with HIV in Primary Health Care.
Methods:
methodological study carried out in 2021 with 260 health professionals in Recife, PE. Validation based on the internal structure was carried out at this stage using exploratory and confirmatory factor analysis, and validity based on item response theory.
Results:
the validation determined the retention of five factors and 63 items. The instrument’s internal consistency and quality of fit was 0.90, the Tukey-Lewis index was 0.915 and the comparative fit index was 0.918 in the confirmatory factor analysis. The indication for the absolute majority of items is adequate fit.
Conclusions:
the instrument has construct validity, making it possible to use it to evaluate the decentralization process and care for People Living with HIV in Primary Health Care.
Keywords:Acquired Immunodeficiency SyndromeComprehensive Health CareHIVPrimary Health CareProgram EvaluationSee more -
ORIGINAL ARTICLE01-10-2024
Inventory of ethical problems in mobile pre-hospital care
Revista Brasileira de Enfermagem. 2024;77:e20230539
Abstract
ORIGINAL ARTICLEInventory of ethical problems in mobile pre-hospital care
Revista Brasileira de Enfermagem. 2024;77:e20230539
DOI 10.1590/0034-7167-2023-0539
Views0See moreABSTRACT
Objective:
to construct and validate the content of an inventory of ethical problems experienced by nurses in mobile pre-hospital care.
Method:
a psychometric approach study, developed with the following stages: (1) instrument construction through a theoretical matrix based on deliberative bioethics, scoping review and online qualitative research; (2) content validity by judges; (3) pre-testing with Mobile Emergency Care Service nurses in various Brazilian states. For content validity analysis, the Content Validity Ratio was calculated (CVR>0.45 for judges and CVR>0.35 for the target population).
Results:
the instrument had 44 items, distributed across four dimensions.
Final considerations:
the constructed instrument presented sources of evidence of content validity, providing good psychometric measurements and constituting a useful tool for nurses’ practice in the pre-hospital setting.
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