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  • January 14, 2022

    By Allison Larson, MD

    Whether you’re a winter sports enthusiast or spend the season curled up by the fireplace, the low humidity, bitter winds, and dry indoor heat that accompany cold weather can deplete your skin’s natural moisture. Dry skin is not only painful, uncomfortable, and irritating; it also can lead to skin conditions such as eczema, which results in itchy, red, bumpy skin patches. 

    Follow these six tips to prevent and treat skin damage caused by winter dryness.

    1. Do: Wear sunscreen all year long.

    UV rays can easily penetrate cloudy skies to dry out exposed skin. And when the sun is shining, snow and ice reflect its rays, increasing UV exposure. 

    Getting a sunburn can cause severe dryness, premature aging of the skin, and skin cancer. Snow or shine, apply sunscreen before participating in any outdoor activity during the winter—especially if you take a tropical vacation to escape the cold; your skin is less accustomed to sunlight and more likely to burn quickly.

    The American Academy of Dermatology (AAD) recommends sunscreen that offers protection against both UVA and UVB rays, and offers a sun protection factor (SPF) of at least 30.

    That being said, if you are considering laser skin treatments to reduce wrinkles, hair, blemishes, or acne scars, winter is a better time to receive these procedures. Sun exposure shortly after a treatment increases the risk of hyperpigmentation (darkening of the skin), and people are less likely to spend time outside during the winter.

    Related reading: 7 Simple Ways to Protect Your Skin in the Sun

    2. Do: Skip products with drying ingredients.

    Soaps or facial products you use in warm weather with no issues may irritate your skin during colder seasons. This is because they contain ingredients that can cause dryness, but the effects aren’t noticeable until they’re worsened by the dry winter climate.

    You may need to take a break from:

    • Anti-acne medications containing benzoyl peroxide or salicylic acid
    • Antibacterial and detergent-based soap
    • Anything containing fragrance, from soap to hand sanitizer

    Hand washing and the use of hand sanitizer, which contains a high level of skin-drying alcohol, cannot be avoided; we need to maintain good hand hygiene to stop the spread of germs. If your job or lifestyle requires frequent hand washing or sanitizing, routinely apply hand cream throughout the day as well.

    During the COVID-19 pandemic, I have seen a lot of people develop hand dermatitis—a condition with itchy, burning skin that can swell and blister—due to constant hand washing. Sometimes the fix is as simple as changing the soap they're using. Sensitive-skin soap is the best product for dry skin; it typically foams up less but still cleans the skin efficiently.

    3. Do: Pay closer attention to thick skin.

    Areas of thin skin, such as the face and backs of your hands, are usually exposed to the wind and sun the most. It’s easy to tell when they start drying out. But the thick skin on your palms and bottoms of your feet is also prone to dryness—and tends to receive less attention.

    When thick skin gets dry, fissures form. You’ll see the surface turn white and scaly; then deep, linear cracks will appear. It isn’t as pliable as thin skin. When you’re constantly on your feet or using your hands to work, cook, and everything in between, dry thick skin cracks instead of flexing with your movements. 

    To soften cracked skin, gently massage a heavy-duty moisturizer—such as Vaseline—into the affected area once or twice a day. You can also talk with your doctor about using a skin-safe adhesive to close the fissures and help them heal faster.

    Related reading:  Follow these 5 Tips for Healthy Skin

    4. Don’t believe the myth that drinking more water will fix dry skin.

    Contrary to popular belief, the amount of water or fluids you drink does not play a major role in skin hydration—unless you’re severely dehydrated. In the winter, especially, dry skin is caused by external elements; it should be treated from the outside as well. 

    The best way to keep skin hydrated and healthy is to apply fragrance-free cream or ointment—not lotion—to damp skin after a shower or bath.
    Some people need additional moisturizers for their hands, legs, or other areas prone to dryness.

    While some lotions are made better than others, most are a combination of water and powder that evaporates quickly. Creams and ointments work better because they contain ingredients that can help rebuild your skin barrier. 

    Look for products with ceramide, a fatty acid that helps rebuild the fat and protein barrier that holds your skin cells together. The AAD also recommends moisturizing ingredients such as:

    • Dimethicone
    • Glycerin
    • Jojoba oil
    • Lanolin
    • Mineral oil
    • Petrolatum
    • Shea butter

    For severely dry skin, you can try a “wet wrap” technique:

    1. Rinse a pair of tight-fitting pajamas in warm water and wring them out so they’re damp, not wet.
    2. Apply cream or ointment to your skin.
    3. Put on the damp pajamas, followed by a pair of dry pajamas, and wear the ensemble for several hours.

    Dampness makes your skin more permeable and better able to absorb hydrating products. If the wet wrap or over-the-counter products aren’t working for you, talk with a dermatologist about prescription skin hydration options. 

    Drinking more water isn’t the answer to dry winter skin. The best solution is to apply fragrance-free cream or ointment directly to damp skin. Get more cold weather #SkinCareTips from a dermatologist in this blog:
    Click to Tweet


    5. Don’t confuse skin conditions with dryness.

    Skin conditions are often mistaken for dry skin because peeling or flaking are common symptoms. Redness of the skin or itching in addition to dryness and flaking indicates a skin condition that may need more than an over-the-counter moisturizer.

    Skin cells are anchored together by a lipid and protein layer (like a brick and mortar wall). With very dry skin, the seal on this wall or barrier is not fully intact and water evaporates out of the skin’s surface. The skin will become itchy and red in addition to scaly or flaky. If you experience these symptoms, visit with a dermatologist.

    6. Don’t wait for symptoms to take care of dry skin.

    Be proactive—the best way to maintain moisture is to apply hydrating creams and ointments directly to your skin on a regular basis. Start by applying them as part of your morning routine. Once you get used to that, add a nighttime application. And carry a container of it when you’re on the go or keep it in an easily accessible location at work.


    You can’t avoid dry air, but you can take precautions to reduce its harsh effects on your skin. If over-the-counter products don’t seem to help, our dermatologists can provide an individualized treatment plan. Hydrated skin is healthy skin!

    Does your skin get drier as the air gets colder?

    Our dermatologists can help.

    Call 202-877-DOCS (3627) or Request an Appointment

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  • January 24, 2020

    By MedStar Health

    It’s not unusual for children of physicians to emulate their parents’ career paths. But Stanley J. Pietrak III, MD, insists there was never any pressure to follow in the footsteps of his father, a practicing gastroenterologist in Buffalo, N.Y.

    "I was fascinated by what he did for work,” Dr. Pietrak recalls, “and I always found myself asking him questions about the types of patients he saw, and the disorders he treated.” Gravitating to gastroenterology during his own medical training, he adds, “I was happy to find that the material came naturally to me.”

    Dr. Pietrak was nicknamed “Tripp,” as the third-generation Stanley Pietrak in his family. He received his medical degree from Albany Medical College, then came to MedStar Georgetown University Hospital for his internal medicine residency, which included rotations at MedStar Washington Hospital Center. After a three-year fellowship at Drexel University/Hahnemann University Hospital in Philadelphia, Dr. Pietrak welcomed the opportunity to return to MedStar Georgetown for an additional fellowship in advanced endoscopy, then join the Hospital Center’s gastroenterology staff.

    “I developed many lasting relationships within the MedStar GI division during my residency at MedStar Georgetown, when I had the opportunity to work with some excellent practitioners,” he says. “It’s great to team up with them again, and to apply the training that many of them provided me.”

    Areas of Expertise

    Dr. Pietrak’s clinical focus involves malignant and benign disorders of bile ducts and the pancreas, advanced polyp removal, staging of luminal gastrointestinal cancer, and endoscopic luminal stenting. He notes that advancements in minimally invasive technologies, such as endoscopic ultrasound (EUS), “have broadened the number of medical issues that can be managed endoscopically, and can often help patients avoid surgical procedures that often carry more risk.”

    Dr. Pietrak’s research interests include screening for pancreatic cancer in high-risk populations, as well as endoscopic training proficiency for gastroenterology fellows. With respect to the training provided to fellows, Dr. Pietrak believes that “it is imperative to uncover the teaching techniques that most effectively develop and improve trainee proficiency, as this will allow us to ensure all fellows are graduating with a skill set that allows them to successfully handle even the most challenging of cases.”

    Outside the Hospital

    In his free time, Dr. Pietrak enjoys traveling, following his hometown NFL team the Buffalo Bills, and staying active by running and playing soccer.

  • January 17, 2020

    By MedStar Health

    Whether your pregnancy was long-awaited or sudden, you probably have a few questions about how you and baby can stay healthy. As an OB/GYN, one of the most common questions I get asked is, “How much weight should I gain during pregnancy?”

    There isn’t a one-size-fits-all answer—but it is an important question. Maintaining a healthy weight throughout pregnancy can reduce your risk of health complications involved with having a baby who is too big or too small.

    If you gain too much weight, you may increase your risk of:

    • Preeclampsia
    • Gestational diabetes
    • Baby’s shoulder getting stuck during delivery (shoulder dystocia)
    • Unplanned C-section
    • Hard-to-shed postpartum pounds

    Gaining less than the recommended weight is risky, too. Babies with a lower birth weight (less than five pounds and eight ounces) may struggle to breastfeed, fight infection, and hit developmental milestones.

    So what is a healthy weight during pregnancy? Well, it depends.

    Know how much weight you need to gain during pregnancy.

    The amount of weight that’s healthy for you to gain may be different than other pregnant women you know. That’s because your estimated weight gain is determined based on how much you weigh before getting pregnant. If you weigh less, you may need to gain more than someone with a higher pre-pregnancy weight. If you’re starting pregnancy at a higher weight, you should aim to gain fewer pounds.

    In general, here’s how much you should gain based on your pre-pregnancy body weight.

    If your BMI is... You are considered... And you should gain...
    Less than 18.5 Underweight 28 to 40 pounds
    18.5 - 24.9 Normal weight 25 to 35 pounds
    25 - 29.9 Overweight 15 to 25 pounds
    Over 30 Obese 11 to 20 pounds

    Keep in mind, if you are pregnant with twins or more, your recommended weight gain may be different.

    Your midwife, OB/GYN, or family doctor can help you set a goal for healthy weight gain at your first-trimester appointment. They’ll also help you monitor your weight and baby’s growth throughout pregnancy.

    Eat a well-balanced diet.

    Carb-loaded doughnuts and bagels probably sound appealing when you’re fighting off first trimester morning sickness, but eating a balanced diet is key to maintaining a healthy weight during pregnancy. While a prenatal vitamin will help you pass along the vitamins and minerals that baby—and you—need, it’s also important that you eat nutrient-dense foods.

    A healthy diet includes a variety of foods from the main food groups, as well as key nutrients:

    • Protein: Most pregnant women should eat at least 70 grams of lean protein per day. Lean protein sources include chicken, fish, eggs, beans, or even dairy. Greek yogurt is a great source of protein!
    • Fats: It might sound counter-intuitive but fats won’t actually make you fat (in moderation). During pregnancy, 20 to 35 percent of your total calories should come from healthy fats. Good fat sources include fish, such as salmon or tuna. (Do stay away from fish that is high in mercury, like shark, swordfish, king mackerel, and tilefish.)
    • Carbohydrates: Choose veggies, fruits, and whole grains as your carb sources. Do your best to stay away from junk foods, like chips and ice cream. They offer no nutritional value to you and baby, so you may find yourself still hungry and eating more.

    Hint: You need fewer calories than you think.

    People may encourage you to “eat for two” but the truth is, your body doesn’t actually need many extra calories during pregnancy. In fact, you only need 340 extra calories in the second trimester and 500 extra calories in the third trimester.

    Exercise for 30 minutes on most days.

    In addition to making healthy food choices, staying active can help you maintain a healthy weight. We recommend 30 minutes of exercise on most—or all—days, if you can. If you are just starting to exercise, try walking or swimming. If it’s too hard to find 30 minutes in your day, try breaking up your exercise into three 10-minute blocks.

    Hard to find time to stay active during #pregnancy? Try breaking up exercise into three 10-minute blocks throughout the day. Learn more about maintaining a healthy weight during pregnancy via @MedStarHealth’s #LiveWellHealthy blog.

    Click to Tweet

    If you were already active before pregnancy, continue exercising at a level you and your health provider are comfortable with. As you get further along in your pregnancy, be cautious with activities that put you at risk for falling. Your balance isn’t quite the same during pregnancy!

    Keep an eye on weight gain guidelines by trimester.

    In the first trimester, you don’t actually need extra calories to support the baby’s growth. For women starting out at a healthy weight, we recommend a weight gain of fewer than five pounds. Steady weight gain is more important as your pregnancy progresses in the second and third trimesters.

    If you began pregnancy at a healthy weight, you can expect to gain one to two pounds per week from weeks 12 through 40. But this can add up fast!

    Let’s say you gained the maximum recommended weight of five pounds during the first trimester. Then, you gain two pounds every week through the second trimester. By the beginning of 28 weeks of pregnancy, you would have already gained over 30 pounds—and you still have twelve weeks to go.

    Having regular conversations about your weight during prenatal visits will help you stay on track to gain enough weight at the right speed. Your provider can offer ways to slow down your weight gain while ensuring the baby is getting everything they need.

    Try these tips if you’re gaining weight too quickly.

    If you’ve taken “eating for two” literally and find yourself nearing the high end of your range mid-pregnancy, it’s not too late. Try the following tips to get back on track.

    • Keep a food log. Writing down what you eat really helps keep you accountable in making nutritious food choices. An app like myfitnesspal can simplify tracking.
    • Exercise with other people. Ask your partner, friends, or family to get active with you. Just walking can help you manage your weight and build strength that you’ll need during labor and delivery.
    • Shrink portion sizes. Remember that you don’t need a lot of extra calories. Eating smaller meals every three hours can help you avoid overeating at mealtime.
    • Don’t forget to drink water. It’s important to stay hydrated, and you’ll feel fuller between meals and snacks.

    Start at a healthy weight before getting pregnant, if possible.

    Not yet pregnant? You can set yourself up for healthy pregnancy weight gain by establishing healthy food and exercise habits now. If you’re trying to conceive, healthy weight loss could actually improve your chances of getting pregnant.

    If you’re not sure what your healthy starting weight should be, talk to your healthcare provider. They can help you determine a healthy range for your height, age, and activity level.

    Interested in learning more about women’s health at MedStar Health? View our services here.

    Do you live in St. Mary’s County and need obstetric or gynecology services? Consider making an appointment with Dr. Greenwood.

    Learn More

  • January 14, 2020

    By MedStar Health

    As part of our continued progress toward becoming a world-class academic health system, and advancing health through research and innovation, we are pleased to announce the appointment of Raj Ratwani, PhD, as Vice President of Scientific Affairs for MedStar Health Research Institute (MHRI). In this new position for MedStar, Raj will play a pivotal role in connecting the scientific activities of MHRI, MedStar Institute for Innovation (MI2), and the MedStar Institute for Quality and Safety (MIQS). He will join the MHRI executive leadership team to provide additional scientific perspectives that support research activities and their interaction with clinical operations.

    In his new role on the MHRI executive team, Dr. Ratwani will contribute to the strategy, growth, and administration of research across MedStar, with a focus on working closely with organizational leaders and investigators to translate research results into practice. He will supervise and mentor investigators to support research activities, identify new areas of research funding and enhance MHRI’s reputation as a leading research organization. Furthermore, Dr. Ratwani will lead strategy development for MHRI to support the effective dissemination of research outputs. Dr. Ratwani will remain director of the MedStar Health National Center for Human Factors in Healthcare.

    Please join us in congratulating Dr. Ratwani on his promotion as we continue to advance health for our patients and community.

  • January 10, 2020

    By MedStar Health

    Diabetes is an epidemic in the United States. In fact, 30.3 million Americans have diabetes—an amount that has doubled since 1997. As a result, it’s more important than ever for people to understand ways they can successfully manage their diabetes.

    Appropriately managing diabetes is vital because having too much or too little sugar in your blood can make you feel sick and cause larger health problems down the road, such as damage to the:

    • Eyes
    • Heart
    • Kidneys
    • Nerves

    Through my work with diabetes patients over the years, I’ve come up with a few essential ways to help you manage your diabetes. Read on to learn about them and why they are important.

    Managing #diabetes is important, as it can eventually lead to serious #healthproblems if left untreated. Learn key ways to keep your diabetes in check, via @MedStarHealth.

    Click to Tweet


    1. Know What You Can Eat

    The No.1 type of food we typically recommend people with diabetes eat is nonstarchy vegetables, as they don’t negatively affect your blood sugar and have a lot of fiber, which helps curb your appetite.

    During meals, we recommend that you follow the plate method. This consists of making half of your plate nonstarchy vegetables; a quarter of your plate protein, preferably a lean protein, such as chicken, fish, or turkey; and the other quarter a type of starch or carbohydrate. When you eat carbohydrates, opt for whole grains—such as brown rice or whole-wheat pasta—as they contain more fiber than refined grains.

    Make sure you also drink plenty of water and avoid sugar-sweetened beverages, such as juice, soda, and sweet tea. I’ve seen patients who used to drink beverages high in sugar significantly reduce their blood sugar levels just weeks after cutting it out of their diet in favor of water.


    While adjusting your diet, keep in mind that you don’t have to make your diet overwhelmingly restrictive, as those types of diets don’t often last long. Try to focus more on the foods you can have, rather than the ones you shouldn’t. For example, I usually ask patients during the holidays what one food they most look forward to. Then, we either discuss ways to prepare that food in the healthiest way possible or how they could adjust their diet, such as taking in fewer calories or limiting certain ingredients, for the rest of the day after eating their favorite food. This type of approach can be utilized year-round, not just during the holidays.

    2. Create a Realistic Exercise Routine

    Exercising regularly is one of the best things you can do for your health if you have diabetes, as exercise helps lower your blood sugar and boosts your body’s sensitivity to the hormone insulin (which can help your body counter insulin resistance, a common cause of increased blood sugar levels).

    We recommend that you get about 150 minutes of moderate intensity exercise each week—averaging out to about 30 minutes of exercise five days a week. When it comes to creating your exercise routine, keep in mind that everyone is different. Some people prefer taking a five- or 10-minute walk every few hours, while others enjoy going to the gym multiple days a week and using exercise machines for 30 minutes. Do whatever sounds most convenient, realistic, and fun for you.


    If you haven’t exercised in some time, you should begin by working with your doctor, physical therapist, or trainer to slowly work your way up to moderate-intensity exercise. For people who have difficulty running or walking, low-impact exercises can be a terrific option. These can include doing water aerobics or using an elliptical or a stationary bike.

    3. Take the Right Medication

    Medication is often necessary to successfully manage your diabetes. In fact, one study found that people who took their oral diabetes medications at least 80 percent of the time were 46 percent less likely to have poorly controlled blood sugar, compared to those who took their medications less than 80 percent of the time.

    If you avoid taking your medication due to its side effects, schedule an appointment with your doctor. This way, you can go over your other medication options, as well as any lifestyle modification questions you have, to more successfully manage your diabetes.


    Our Diabetes Bootcamp

    The MedStar Diabetes Bootcamp is a one-year program in which we regularly work with people with type 2 diabetes, helping them reach their diabetes health goals and feel better.

    Participants of the MedStar Diabetes Boot Camp use a blood glucose meter that sends their blood sugar numbers in real time to our team through the Cloud. Our diabetes educators keep track of participants’ numbers Monday through Friday, allowing us to provide them with personalized recommendations that work with their lifestyle. For the first three months, participants are contacted at a minimum of one time per week, and more frequently if needed, such as when their blood sugars are less than 80 or above 350. At the end of the three months, we contact participants weekly to support the changes that they’ve made and assist them in making further changes to their lifestyle and medication plan. We regularly provide updates to patients’ doctors, so that they’re aware of any medication or lifestyle changes that were made, and we also provide their doctors with a report at the end of the program that summarizes the progress the patients made.

    To qualify for our Diabetes Bootcamp, you must have an A1C (a blood test for diabetes that measures your average blood sugar level over the past three months) of 9 percent or above. To learn more about the program, please call 202-877-2383.

    Successfully managing your diabetes is vital to your overall health. Follow these recommendations to help reduce your risk, and make sure to reach out to your doctor or medical team if you have any questions.

    Are you interested in speaking to a doctor about your diabetes? Schedule an appointment with an endocrinologist today.

    Find A Doctor

  • January 02, 2020

    By MedStar Health

    As of January 2018, most non-exempt multi-site human subjects research (HSR) projects funded through NIH agencies require single IRB review. Additionally, in recent years, there has been an increasing trend toward the use of a single IRB (sIRB) review for multi-site HSR projects funded through other sources.  Specifically, many commercial sponsors prefer single IRB review for their multi-site projects.

    Finally, the revised common rule includes a requirement for single IRB review of most federally funded multi-site non-exempt human subjects research projects. Initially, the Office of Human Research Protections (OHRP) indicated only that compliance with this common rule requirement was required starting on January 20, 2020. In a recent communication OHRP clarified that although sIRB review is required for all federally funded multi-site non-exempt HSR projects, the agency has granted an exemption for all projects approved prior to January 20, 2020. This eliminates the need to transition currently approve projects from review by multiple IRBs to sIRB review.

    For all future federally-funded projects, it is strongly suggested that investigators include IRB review fees in the budget for their grant proposals. In most cases it is assumed that sIRB review will be conducted by a commercial IRB (such as WIRB or Advarra) or a larger academic/medical institution IRB. In some limited cases, the MHRI IRB may agree to serve as the IRB of record for a multi-site HSR project but this will not be the norm.

    In all cases (regardless of funding) for which a MedStar investigator intends to request the MHRI IRB serve as the IRB of record, they must submit a request to the ORI office. The request must be submitted before the investigator commits the MHRI IRB to the responsibility of serving as IRB of record for other sites and before discussing reliance with any outside institution. The request should include a copy of the research protocol, an indication of the source of funding (if any), a list of all sites that may be engaged in the project, and the scope of involvement for each site. The ORI Director will evaluate the request and in consultation with the Institutional Official determine if the request will  be approved or should be declined.

    This process is similar to  that for investigators requesting reliance on an external IRB. When an investigator would like to rely on an external IRB for review of their non-exempt HSR project, a request to cede review must be submitted to ORI in advance. In the case of the commercial IRBs for which there is a master reliance agreement (currently WIRB and Advarra), the investigator may simply submit an external IRB application through the Huron system. For other IRBs, a reliance agreement must be executed for each individual project. In the event that MedStar has not previously had an agreement with the intended external IRB, a request should be submitted to the ORI by email. The ORI Director will evaluate the request and in consultation with the Institutional Official determine if the request may be approved or should be declined. If approved the organization will be added to the Huron system and the investigator may submit the external IRB application for the project.

    Please note that in most cases request for reliance involving exempt HSR projects will not be approved. Generally speaking, it is more efficient for these projects to be reviewed individually by each institution and most institutions have not been willing to enter into a reliance agreement for these projects.

    In all cases, requests for reliance (either for the MHRI IRB to serve as the IRB of record or for MedStar to rely on an external IRB) will be considered with regard to the need for reliance, the feasibility of the arraignment and nature of the project. Ultimately the determination of reliance is left to the discretion of the ORI Director and the Institutional Official.

    If you have any questions regarding this process, please contact MHRI’s ORI Director, Jim Boscoe, at

  • January 02, 2020

    By MedStar Health

    Congratulations to all MedStar researchers who had articles published in December 2019. The selected articles and link to PubMed provided below represent the body of work completed by MedStar Health investigators, physicians, and associates and published in peer-reviewed journals last month. The list is compiled from PubMed for any author using “MedStar” in the author affiliation. Congratulations to this month’s authors. We look forward to seeing your future research.

    View the full list of publications on here.

    Selected research:

    1. Combined Vascular Brachytherapy and Stenting for the Treatment of In-Stent Restenosis.
      The American Journal of Cariology, DOI: 10.1016/j.amjcard.2019.11.035
      Chen Y, Buchanan KD, Chan RC, Zhang C, Torguson R, Satler LF, Waksman R.

    2. Frequency of Advanced Cardiac Life Support Medication Use and Association with Survival During In-Hospital Cardiac Arrest.
      Clinical Therapeutics, 2019. DOI: 1016/j.clinthera.2019.11.001
      Benz P, Chong S, Woo S, Brenner N, Wilson M, Dubin J, Heinrichs D, Titus S, Ahn J, Goyal M.

    3. Adherence among post-partum women living with HIV.
      The Lancet HIV, DOI: 10.1016/S2352-3018(19)30403-5
      Scott RK.

    4. Microbiologic Failure Despite Clinical Cure in Pneumonia: Cum Hoc and Post Hoc Ergo Propter Hoc.
      Clinical Infectious Diseases, DOI:10.1093/cid/ciz1191
      Shorr AF, Spellberg B, Zilberberg MD, Kollef MH.

    5. Creating a Care for the Caregiver Program in a Ten-Hospital Health System.
      Critical Care Nursing Clinics of North America, 2019. DOI:10.1177/1078390319878781
      Morales CL, Brown MM.