http://doi.org/10.33698/NRF0183  –  Raj Kumar Kaushal, Surinder Kapoor, Sukhpal Kaur, Hemant Bhagat

Abstract: The current study was carried out to develop a ‘Nursing Checklist’ for receiving patients in ICUs of a tertiary care hospital.Using methodological study design, the study was carried out in total five phases. First, a blue print of the checklist was prepared after identifying the needs and an exhaustive review literature. In 2nd phase, face and content validity of the nursing checklist was established with Delphi technique. Feasibility of the checklist was checked by conducting a pilot study in 3rd phase. In 4th phase, Inter-rater agreement between two raters was checked with Cohen’s Kappa. Then checklist was implemented by 30 subjects in ICUs of a tertiary care hospital and internal consistency reliability of the items was established with Cronbach’s alpha in 5th phase. The data was analyzed by using SPSS version 16.Final draft of the Nursing checklist had 12 main steps with 105 items. The checklist was found feasible after conducting pilot study. The Nursing checklist was homogeneously reliable with a very good inter-rater agreement between raters. Cohen’s Kappa value was 0.98-1.00. The checklist was found internally consistent. Cronbach’s alpha value was 0.97. Results of the nursing checklist indicate that it is valid and reliable and it can be applied in daily practice and in the clinical research context.

Keywords:Checklist, Intensive Care Unit, Nursing checklist.

Correspondence at

Introduction:Intensive care units (ICU), are sections within a hospital that look after patients whose conditions are life-threatening and need constant, close monitoring and support from equipment and medication to keep normal body functions going.1 They have

Raj Kumari Kaushal Public Health Nurse Postgraduate Institute of Medical Education and Research, Chandigarh, India higher levels of staffing, specialist, monitoring and treatment equipment available in these areas.The patient related issues in the Intensive care units (ICUs) are complex. Studies have shown that a patient in an ICU requires 178 interactions (like suctioning, feeding etc.) in his/her care in a whole day.1 All these interactions are prone to human error because of the natural limitations of human memory. In an epidemiological.The present study was undertaken to develop a ‘Nursing checklist’ to receive patients in ICUs as there was no such checklist available in our ICUs.

Material and methods:The study was conducted in five phases as discussed below:finding in United States, it was revealed that 1

Phase I:Preliminary preparation of the million injuries and nearly 100,000 deaths occurred annually as a result of mistakes in medical care.2 A checklist standardizes the process to ensure that all elements or actions are addressed. The structure and predictability of checklists facilitate the careful and systematic delivery of care, which reduces variability and improves performance.1 Many intensive care units (ICUs) operate near full capacity. Maximum ICUs in India do not have 1:1 nurse patient ratio as India is a developing country and has shortage of skilled staff.3 Further, aging population and limited resources place increasing demands on space and personnel, with little capacity to adjust to increased workload.4 For critically ill patients, increasing day- to-day demands on ICU resources could create an environment of increased risk. Pressure of work and tension makes it more prone to commit mistakes. To deter mistakes wherever possible, ‘Checklists’ are must.‘Patient safety’ is a fundamental component of good quality health care and has become a global concern since studies illustrate that between 3-16% of patients admitted to hospital suffer from adverse events that is harm caused to a patient as a result of medical care and not the disease.4 So, ‘checklists’ have been proposed as a Nursing Checklist. It was divided into two steps. The first step dealt with review of relevant literature. An exhaustive literature review was done to collect recent evidences related to receiving patients in ICUs. The review of literature for present study was done for assessment, documentation, and maintenance of records related to admission of patient in the ICU along with identification of various needs of the patient in our hospital. Further, a rigorous review of literature related to instrument construction and standardization of the tool was done. Sources of literature included electronic data bases (Pubmed, Medline, CINHAL) as well as printed material from the Institute library.Second step was the preparation of blue print of nursing checklist. In 2nd step, an item pool was generated to develop a preliminary Checklist. In this draft, there were total 81 items to receive patients in ICUs. These were categorized under 23 steps. Firstly, Permission from ICU consultant or HOD is required and nurses should be informed 15 minutes before. Then there were six steps before receiving a patient to ICU like preparation of article checklist, bed with alpha mattress, equipments, patient bedside trolley, patient records and shifting trolley. Information is also collected from shifting ward or Emergency staff. Patient receiving had eight steps and quick assessment afterwards had nine steps. Then follow state method of improving patient safety orders and medications. Check patient for bed sores, write admission notes and enter to census. Relatives are given orientation and supervisor is informed in case the patient is a VIP/ NRI/ MLC/ Staff member/ Foreign national or prisoner.

Phase II: The face and content validity of the Checklist was done with Delphi technique. It included three steps. Step- 1 Selection of panel of experts:

Phase III: This consisted of testing feasibility of the Nursing Checklist. In order to assess feasibility of the Checklist, a pilot study was conducted on 4 patients in selected ICUsi.e Main ICU, Respirator y ICU and Gastroenterology ICU of Institute. Results of the pilot study revealed that the language of the tool was clear and it was feasible to carry out the final study.

Phase IV:It considered testing inter-rater consisting of 11 members from the field of medical, surgical, nursing and Intensive care staff was formulated. Step- 2 Delphi rounds: The first draft of the tool ‘Nursing checklist’ to receive patient in ICU was circulated among the selected panel of experts. They were requested to validate the content for its relevance, clarity, language, organization, level of understanding, and sequence of items. Delphi rounds were continued until there was common consensus among the panel of experts. Four Delphi rounds were done to obtain the consensus to prepare final draft of the tool.

Step- 3 Modifications as per suggestions: As per the expert’s opinion, the modifications in the checklist were made after every Delphi round. Final draft had 105 items categorized under 12 steps. Nursing Checklist also had separate list for required items so that it is easy for staff to separate it out and give it to the relatives after checking. agreement of the Nursing Checklist. The inter-rater reliability of the checklist was established after making necessary changes based on Delphi technique and pilot study. To test inter-rater agreement, checklist was applied on 5 patients in Liver ICU of the Institute by two raters independently. Inter- rater agreement was calculated at 0.95 C.I. by using Cohen’s Kappa. K value is interpreted as given by Altman 1991.5

Table 1 shows the Kappa value for all the five cases. The agreement values of the ‘Nursing checklist’ vary from 0.98 – 1.00. Kappa value for cases 1,2&5 was 1.00 and for cases 3 & 4 was 0.98. Table 2 depicts the inter-rater agreement interpretation. As the kappa value vary between 0.98 – 1.00. So, according to Altman this shows that all the items had a very good inter-rater agreement5 .This means that modified draft of the checklist was homogeneously reliable with a very good inter-rater agreement between raters.

Table 1: Kappa values for the Inter-rater agreement of the Nursing Checklist  N=5

 

Rater N Kappa value (k)
Case 1 Case 2 Case 3 Case 4 Case 5
R1-R2 5 1.000 1.000 0.981 0.981 1.000

Table 2: Interpretation of k value

 

Value of k Strength of Agreement
<0.20 Poor
0.21-0.40 Fair
0.41-0.60 Moderate
0.61-0.80 Good
0.81-1.00 Very Good

*Source: Altman D G Practical Statistics for Medical Research London: Champman and Halt 1991.5

Phase V: It consist testing internal consistency reliability of developed Nursing Checklist. It included implementation of the tool on patients received in ICUs and checking internal consistency (reliability) of the developed tool.The selected ICUs i.e. Respiratory ICU, Main ICU and Gastroenterology ICU were taken as a research setting for implementation of the tool. Written permission from head of department of all ICUs was taken. Ethical clearance was sought by Institute Ethical Committee.The sister in charge of the respective wards was also informed about the study. Target population was nurses receiving patients in ICUs. Using purposive sampling technique, 30 nurses were selected and given a formal training of 10-15 minutes in a group of 4-5 nurses depending on the availability in all the three ICUs. Subjects were explained about how to use the ‘Nursing checklist’. A set of introduction and instructions regarding how to use the checklist was also written on 1st page of checklist i.e.it is a tool to ensure that all elements are taken care of while receiving a patient in ICU. Instructions included read and follow all the steps and put tick mark in the appropriate yes or no box. First written informed consent was obtained and identification data sheet was filled by the subjects. Then ‘Nursing Checklist’ was given to them to receive patients in ICUs. Non- participatory observation was done in order to observe the application and related nursing activities carried out by nurses while receiving patients in ICUs by using ‘Nursing checklist’. After the procedure was over ‘Nursing checklist’ was taken back. Tool was implemented by 30 nurses while receiving patients in ICUs by using checklist and marked in yes and no boxes in front of steps of checklist. It took near about 25-30 minutes to implement a checklist. Data was collected using identification data sheet and nursing checklist tool. Data collected was coded and analysed by using SPSS version 16.Internal consistency of checklist was calculating Cronbach’s alpha coefficient.

Results:Final Nursing checklist to receive patients in ICUs was prepared.Tables3-7(Part 1 to 5 of Nursing checklist tool) shows reliability analysis of the items of Nursing checklist by using Cronbach’s alpha. The sample size was 30. The overall Cronbach’s alpha coefficient of the developed tool was 0.97, which indicates the reliability and internal consistency of the tool (Ideally Cronbach’s alpha coefficient should be 0.70 or more than 0.70).Corrected item to total correlation was applied on all 105 items of the tool, only 2 items in the scale had an item to total score correlation less than 0.2 showing the incompatibility with the overall tool i.e item 3.6d- intake/ output record and item 10- entry to admission and census register.To check the individual contribution of items, each item was deleted one by one to see the changes in the value of Cronbach alpha coefficient. But none of the items showed any increase, in value of Cronbach alpha coefficient. Rather, the value of Cronbach alpha coefficient remained same or it decreased. This indicates that all the items contributed to the tool. Even on deleting certain items, having item to total correlation less than 0.2, the value of Cronbach alpha did not increase. Hence, these 2 items were also contributing to the reliability of the tool. The average scale mean was 126.68. When scale mean if item deleted was applied on 105 items of the tool, the scale mean if item deleted was in the range of 126.43 to 126.83 and none of the items had shown an increase in the value of average scale mean rather it remained same or it decreased. It means tool is internally consistent by taking all 105 items. Result of Cronbach’s alpha revealed that all items were uniformly contributing for the reliability of the tool.Table 3 (Part1 of tool) shows reliability analysis of first two steps along with sub parts of step 3 of nursing checklist tool i.e consultation with head, prior information and preparation before receiving patient. Cronbach’s alpha varies between 0.969 to 0.970 which is above 0.70 showing reliability of tool. Corrected item to total correlation was also above 0.2 for all the items that all these items were contributing to the reliability of the tool.Table 4 (Part 2 of tool) shows reliability analysis of two sub-steps of step 3 i.e preparation of patient bedside trolley and patients charts of the nursing checklist tool. Cronbach’s alpha varies between 0.969 to 0.970 which is above 0.70 showing very good reliability. Corrected item to total correlation was above 0.2 for all the items except item 3.6d i.e intake/output chart showing incompatibility with the overall tool. To check the individual contribution of this item, it was deleted to see the changes in the value of Cronbach alpha coefficient and scale mean. But value of Cronbach alpha coefficient and scale mean remained same rather than increasing. This indicates that this item was contributing to the reliability and internal consistency of the tool. So it was kept and not deleted from the too

Table – 3 Reliability analysis of the items of ‘Nursing checklist’ to receive patients in ICUs by using Cronbach’s alpha (Part 1)

Items of the tool Scale Mean if Item Deleted Corrected Item – Total Correlation Cronbach’s Alpha If Item Deleted
1.  Consultation with ICU consultant or Head of Department

2.  Nurses and Technicians informed 30 minutes before the admission

3.   Before receiving the patient

3.1)    Carbolization of bed 3.2) Fumigation of room

3.3)    Preparation of bed with air mattress

3.4) Preparation of following equipments and check their working condition:

3.4a) Cardiac monitor with ECG leads and electrodes 3.4b) Pulse oximeter.

3.4c) NIBP/Invasive pressure monitoring. 3.4d) Ambubag

3.4e) Ventilator with circuits.

3.4f) O2 supply and compressed air

3.4g) Suction jar (emptied and disinfected) with tubing connected to suction.

3.4h) I/V fluids and necessary tubings

3.4i) Infusion pumps and syringes as per need. 3.4j) Defibrillator (charged)

126.57 .355 .970
126.43 .714 .969
126.83 .332 .970
126.83 .332 .970
126.47 .300 .970
126.80 .456 .970
126.80 .614 .970
126.80 .625 .970
126.83 .495 .970
126.77 .543 .970
126.80 .690 .969
126.70 .766 .969
126.70 .347 .970
126.73 .467 .970
126.73 .612 .969
126.70 .642 .969
126.63 .473 .970

Table – 4 Reliability analysis of the items of ‘Nursing checklist’ to receive patients in ICUs by using Cronbach’s alpha (Part 2)

Items of the tool Scale Mean if Item Deleted Corrected Item – Total Correlation Cronbach’s Alpha If Item Deleted
3.5) Preparation of patient bedside trolley:

3.5a) Injection tray. 3.5b) Spirit Swabs 3.5c)Handrub

3.5d) Heparinised saline 3.5e) Emergency Drugs 3.5f) Clean glove box 3.5g) Adhesive Plaster

3.5h) Sterile blade/ Pair of scissors 3.5i ) Sterile pair of gloves

3.5j) Sterile Drape sets and Sterile gauze/ sponges 3.5k) Procedure trolley

3.5l) Intubation kit 3.5m) Syringes

3.5n) I/V cannula (different sizes) and Intra arterial cannula

3.5o) Ryles tube and lubricating jelly 3.5p) Foleys catheter, Urobag/ Urometer 3.5q) Betadine lotion

3.6) Preparation of patient records:

3.6a) Vital signs and ventilator settings progress record.

3.6b) TPR Sheet 3.6c) GCS Chart

3.6d) Intake/output record. 3.6e) RBS Chart

3.6f) Abdominal Girth Chart. 3.6g) Medicine prescription sheet. 3.6h) Nursing instructions chart 3.6i) Nurses shift Report.

126.67 .609 .969
126.73 .235 .970
126.73 .414 .970
126.77 .481 .970
126.53 .456 .970
126.73 .705 .969
126.77 .601 .970
126.70 .638 .969
126.63 .592 .969
126.70 .584 .969
126.57 .272 .970
126.57 .617 .969
126.57 .366 .970
126.80 .549 .970
126.60 .363 .970
126.70 .551 .970
126.73 .550 .970
126.70 .367 .970
126.77 .270 .970
126.80 .397 .970
126.77 .328 .970
126.47 .595 .969
126.77 .137* .970
126.73 .292 .970
126.63 .348 .970
126.80 .581 .970
126.70 .396 .970
126.60 .341 .970

Table 5 (Part 3 of tool) shows reliability analysis of two sub-steps i.e preparation of shifting trolley and information collected from emergency staff. Alpha value for all items is above 0.70 showing reliability of tool. Corrected item to total correlation was also above 0.2 for all the items showing that all these items were contributing to the reliability of the tool.

Table – 5 Reliability analysis of the items of ‘Nursing checklist’ to receive patients in ICUs by using Cronbach’s alpha (Part 3)

Items of the tool Scale Mean if Item Deleted Corrected Item – Total Correlation Cronbach’s Alpha If Item Deleted
3.7) Preparation of shifting/ transfer trolley:

3.7a) Bed sheet

3.7b) Diaper sheets/ Diaper

3.7c) O2 Cylinder with breathing circuit 3.7d) Portable monitor/ Ventilator 3.7e) Ambubag

3.7f) Emergency drugs 3.7g) Intubation kit 3.7h) Torch

3.7i) Scissors/ blade

3.8) Information collected from ward or Emergency staff:

3.8a) Identification Data i.e Patients name, age, sex and CR No.

3.8b) Diagnosis.

3.8c) Admitted under which unit/ consultant 3.8d) GCS, Pupillary response

3.8e) Vital parameters

3.8f) Existing ventilator parameters 3.8g) Presence of Invasive lines/ ICD/ RT/

Drains/ Catheters.

3.8h) Date of insertion of lines.

3.8i) Details about ongoing Ionotropic medication 3.8j) Existing medication orders and

administration timings.

3.8k) Details regarding limb/ body, movement/ restriction/ specific position.

3.8l) Presence of bedsores.

3.8m) Any other ongoing therapy i.e Application of TED stockings/ traction/ P.D/H.D.

3.8n) Existing Diet orders. 3.8o) Payment system.

126.77 .717 .969
126.77 .515 .970
126.73 .537 .970
126.63 .618 .969
126.50 .411 .970
126.73 .647 .969
126.70 .396 .970
126.57 .568 .970
126.60 .599 .969
126.57 .648 .969
126.83 .612 .970
126.83 .612 .970
126.73 .318 .970
126.70 .708 .969
126.50 .324 .970
126.67 .438 .970
126.50 .274 .970
126.60 .309 .970
126.50 .337 .970
126.67 .617 .969
126.67 .458 .970
126.53 .293 .970
126.57 .522 .970
126.47 .248 .970
126.50 .454 .970
126.63 .682 .969

Table 6 (Part-4 of tool) shows reliability analysis of remaining sub-steps of step 3 and step 4 i.e preparation of article checklist, giving article checklist and orientation to relative and checking items received. Step 4 is regarding steps performed while receiving the patient.Alpha value for all steps and items is above 0.70 which shows reliability of tool. Corrected item to total correlation for all these was also above 0.2 showing that all these items were contributing to the reliability of the tool.

Table – 6 Reliability analysis of the items of ‘Nursing checklist’ to receive patients in ICUs by using Cronbach’s alpha (Part 4)

Items of the tool Scale Mean if Item Deleted Corrected Item – Total Correlation Cronbach’s Alpha If Item Deleted
3.9)     Preparation of article checklist 126.80 .489 .970
3.10) Give article checklist and Orientation to 126.80 .489 .970
relative about:
3.10a) Contact details 126.63 .314 .970
3.10b) Waiting Room 126.67 .223 .970
3.10c) Visiting timings 126.63 .485 .970
3.10d) Location of pharmacy, reception, chemist 126.60 .452 .970
shop etc.
3.10e) Ward policy of wearing cap, gown, mask 126.63 .626 .969
and hand washing.
3.11) Checking items received from patients 126.73 .454 .970
relative with list
4. While receiving patient 126.80 .489 .970
4.1) Identification of patient. 126.77 .251 .970
4.2) Check airway and breathing. 126.77 .332 .970
4.3) Check Circulation.( Pulse & Heart Rate) 126.70 .282 .970
4.4) Check GCS, pupil reaction 126.60 .506 .970
4.5) Change to ICU clothing 126.70 .658 .969
4.6) Remove ornaments & handover to attendants. 126.57 .652 .969
4.7) Transfer patient to Shifting trolley 126.70 .691 .969
4.8) Take inside ICU and Shift from trolley to ICU bed. 126.73 .700 .969

 Table 7 (Part-5 of tool) shows reliability analysis of step 5 i.e quick assessment soon after admission and further final steps of nursing checklist tool. Cronbach’s alpha for all of them varies between 0.969 to 0.970, which is above 0.70 showing very good reliability of tool. When corrected item to total correlation was applied, it was above 0.2 for all steps and items except on step 10 i.e Entry to admission and census register, showing incompatibility with the overall tool.

Table – 7 Reliability analysis of the items of ‘Nursing checklist’ to receive patients in ICUs by using Cronbach’s alpha (Part 5)

Items of the tool Scale Mean if Item Deleted Corrected Item – Total Correlation Cronbach’s Alpha If Item Deleted
5.   A quick assessment soon after admission

5.1)     Airway and Breathing

5.2)    Check ET / T.T tube placement, tip marking and bilateral air entry

5.3)     Connect Ventilator and adjust settings 5.4) Connect monitor for parameters like ECG,

B.P, H.R, R.R, Temp., arterial B.P, Saturation

and other parameters.

5.5) Check oxygen saturation, B.P, H.R, E.C.G,

R.R & Temp.

5.6)     Check patency/ working of invasive lines.

5.7)    Discard previous I/V lines & change to new lines. 5.8) Connect infusion pumps/ syringe pumps as needed. 5.9) Check chest drainage, Foleys catheter,

Ryle’s tube and other drainage tubes.

6.   Check & Follow stat instructions.

7.  Check for medications and adjust medication frequency timings.

8.  Check for impaired skin integrity & assess for bedsore, document if any.

9.   Once patient stabilized, write Admission notes

10.  Entry to admission & census register

11.  Diet requisition to dietary department.

12.  Inform to the supervisor if the patient is a VIP/ NRI/ MLC/ Staff member/Foreign national/prisoner.

126.77 .645 .969
126.77 .645 .969
126.60 .420 .970
126.63 .377 .970
126.77 .404 .970
 

126.77

 

.332

 

.970

126.73 .344 .970
126.67 .734 .969
126.70 .498 .970
126.70 .646 .969
126.83 .384 .970
126.73 .410 .970
126.70 .654 .969
126.70 .564 .970
126.77 .199* .970
126.67 .442 .970
126.67 .601 .969

Overall scale mean is 126.68, *- Items in the tool which shows item to total correlation < 0.2 Overall reliability of the tool is 0.97 (Cronbach’s alpha)changes in the value of Cronbach alpha coefficient and scale mean. But value of Cronbach alpha coefficient and scale mean remained same rather than increasing. This indicates that this item was contributing to the reliability and internal consistency of the tool. So it was kept and not deleted from the tool.

Discussion:Patient in ICU are admitted with multiple clinical problems related to brain, heart, lungs, liver, kidneys and other body systems. So, the ICU staff needs high level of skills and knowledge. While receiving patients in ICUs, staff nurses have to carry out a number of steps and procedures. Busy environment and critical situations makes them more prone to commit mistakes.So, present methodological study was planned with objective to develop a tool ‘Nursing Checklist’ for receiving patients in ICUs. A Checklist is a comprehensive list of important and relevant actions or steps which are to be carried out in a specific manner. The checklist is meant to assist staff and others in providing adequate, safe, and efficient client care and improvement in communication by reducing the gaps in communication.1Tool was validated with Delphi technique and reliability was assessed with inter-rater agreement and Cronbach’s alpha. In Phase II, content and face validity was undertaken with Delphi Technique. We found that four rounds were needed for all experts to come to a consensus for final draft of the tool. In a similar study, Delphi technique was used by Kirkwood et al., to determine the nursing research priorities in the North Glasgow University hospitals,4 they found that three Delphi rounds were sufficient to reach to a common consensus. receive patient in ICU’ tool is 0.97, which satisfies the criteria for the reliability of the tool. Similarly in a methodological study by Rupinder et al. on development of nursing checklist for cardiac catheterization, value of Cronbach alpha was 0.86.7 Katz et al. reported similar findings on the internal consistency of “The Dynamic Occupational Therapy Cognitive  Assessment for Children”.8 The reported Cronbach’s alpha was 0.77. May-Benson et al. also reported almost similar findings.9 They assessed the internal consistency of the “Gravitational Insecurity” outcome measure. The alpha of the total test score was 0.71.Similar findings were reported by Bandana et al.on the internal consistency of the ‘audit tool’.10 An ‘audit tool’ was developed for auditing the family records. Internal consistency of the tool was checked with Cronbach alpha and the value was 0.73.Ho- Chung et al. also used Cronbach’s alpha to find out the reliability of tool on ‘short form of Chinese version of anxiety state for children’.11 The Cronbach alpha coefficient of their tool was 0.83 which determined the reliability of the tool. Another study by Wood was on development of ‘initial psychometric evaluation of patient perspective of arrhythmiaIn phase IV, inter-rater reliability of the tool questionnaire’.12 In this study also Cronbach was calculated by inter-rater agreement by using Cohen’s kappa, which removes the probability of chance agreement. Cohen’s kappa value for the checklist varied between 0.98-1.00 which shows very good inter-rater agreement. Similar findings were also reported by Ottenbacheretal. and Rupinder et al., who reported inter-rater agreement of functional assessment of elderly in which the Kappa value ranged from 0.90 to 0.99 and of cardiac catheterization checklist with the Kappa value ranging from 0.88-0.97 respectively.6,7 In the present study, the internal consistency (reliability) of the Nursing Checklist was checked in phase V by Cronbach’s alpha by using SPSS version 16. The Cronbach’s alpha coefficient value of the ‘Nursing checklist to alpha coefficient was used which was 0.84 that determined the internal consistency of the tool. Similarly a study on reliability and validity of ‘sexual pressure scale for women’ (Revised), Jones et al. also used Cronbach’s alpha to find out the internal consistency of their tool and value of Cronbach alpha coefficient was 0.88 which suggested the reliability of the tool.13 This study concludes that the developed ‘Nursing checklist’ to receive patients in ICUs is a valid and reliable tool. It consisted of 105 items categorized under 12 steps. It can be applied in daily practice and in the clinical research context in the intensive care settings.In daily routine, it can help in reducing nursing errors and thus will enhance the effectiveness of care and promote safe quality care.

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