bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of a standardized rewarming protocol and acetaminophen on core temperature after coronary artery bypass
Authors: Stevens T , Fitzsimmons L
Published: November 2019

BACKGROUND: Cardiac surgical patients who require hypothermic cardiopulmonary bypass experience hypothermia, normothermia, and hyperthermia during the early postoperative period. Research-based rewarming protocols are needed to manage temperature variations. OBJECTIVE: To describe the effect of a standardized rewarming protocol and acetaminophen on the following outcome variables: core temperature, peak core temperature, rewarming time, and hyperthermia. METHODS: Patients (N = 60) were rewarmed using a standardized rewarming protocol. Electric heating blankets were used for subjects with core temperatures less than 36 degrees C on admission to the intensive care unit; other subjects were covered with cotton bath blankets. Subjects were also assigned to one of three acetaminophen groups (650 mg at 38.1 degrees C, 650 mg at 37 degrees C, 1300 mg at 37 degrees C). RESULTS: Using the protocol, subjects warmed to normothermia in 3.6 to 6 hours. The 16-hour core temperature thermal curves of heating blanket versus cotton bath blanket subjects differed significantly; thermal curves of the acetaminophen groups were similar. Peak core temperature was significantly lower in heating blanket subjects and unaffected by acetaminophen group. The onset of hyperthermia was not significantly affected by the method of rewarming (electric heating blanket versus cotton blankets) or acetaminophen group. Rewarming time was significantly longer for electric heating blanket subjects. CONCLUSIONS: Our results indicate that mildly hypothermic subjects rewarmed with electric heating blankets during the early postoperative period have lower peak core temperatures and longer rewarming times than those rewarmed with cotton bath blankets. Acetaminophen administration at normothermia does not significantly affect peak core temperature or the onset of hyperthermia.
A randomized clinical trial of the effect of bed position after PTCA
Authors: Sulzbach LM , Munro BH , JWJr Hirshfeld
Published: November 2019

BACKGROUND: After percutaneous transluminal coronary angioplasty, prolonged supine bedrest with the bed flat frequently causes back pain. This study was conducted to examine whether percutaneous transluminal coronary angioplasty patients could adjust their bed position to make themselves comfortable without increasing the frequency or severity of bleeding complications. OBJECTIVES: To determine whether the risk of bleeding increased in patients who were allowed to use their bed controls to make themselves comfortable, and if the difference in comfort was significant between patients who controlled and elevated their bed position and patients who remained flat in bed. METHOD: A randomized clinical trial was conducted; 54 patients undergoing percutaneous transluminal coronary angioplasty were randomly assigned to either the control group, in which patients remained flat in bed, or the experimental group, in which they controlled their bed position. Outcome measures included amount of bleeding at the catheter sites and patient comfort. RESULTS: No difference in the amount of bleeding at catheter insertion sites was found between the two groups. Few subjects reported pain at any time. Back pain at dinner and bedtime was higher in the control group, but only the bedtime difference was statistically significant. CONCLUSION: We conclude that patients may be allowed to adjust their bed position to 30 degrees for comfort without incurring increased risk of catheter entry site bleeding and that requiring patients to remain flat in bed has no scientific basis.
Moral distress of critical care nurses
Authors: Corley MC
Published: November 2019

BACKGROUND: Constraint of nurses by healthcare organizations, from actions the nurses believe are appropriate, may lead to moral distress. OBJECTIVE: To present findings on moral distress of critical care nurses, using an investigator-developed instrument. METHODS: An instrument development design using consensus by three expert judges, test-retest reliability, and factor analysis was used. Study participants (N = 111) were members of a chapter of the American Association of Critical-Care Nurses, critical care nurses employed in a large medical center, and critical care nurses from a private hospital. A 32-item instrument included items on prolonging life, performing unnecessary tests and treatments, lying to patients, and incompetent or inadequate treatment by physicians. RESULTS: Three factors were identified using factor analysis after expert consensus on the items: aggressive care, honesty, and action response. Nurses in the private hospital reported significantly greater moral distress on the aggressive care factor than did nurses in the medical center. Nurses not working in intensive care experienced higher levels of moral distress on the aggressive care factor than did nurses working in intensive care. Of the 111 nurses, 12% had left a nursing position primarily because of moral distress. CONCLUSIONS: Although the mean scores showed somewhat low levels of moral distress, the range of responses revealed that some nurses experienced high levels of moral distress with the issues. Research is needed on conditions organizations must provide to support the moral integrity of critical care nurses.
The effect of thoracic surgery on pulmonary function
Authors: Hallfeldt KK , Siebeck M , Thetter O , Schweiberer L
Published: November 2019

BACKGROUND: Pulmonary function is a main factor influencing postoperative morbidity and mortality in thoracic surgery. OBJECTIVE: To determine the significance of surgical trauma on postoperative pulmonary function by comparing the preoperative forced expiratory volume in 1 second with that obtained 14 days after surgery. METHODS: A retrospective study was conducted on 385 consecutive patients undergoing elective thoracic surgery over 3 years. RESULTS: Operative trauma alone effected a reduction of approximately 0.6 L per second in the value of forced expiratory volume in 1 second irrespective of the extent of pulmonary resection. Significant differences in the overall reduction among enucleation, segmental resection, lobectomy, and pneumonectomy were not observed. CONCLUSIONS: The data indicated that the remaining lung tissue was severely compromised throughout the postoperative period and that surgical trauma was the main factor influencing postoperative pulmonary function for at least 2 weeks.
Risk factors of adolescent and young adult trauma victims
Authors: Redeker NS , Smeltzer SC , Kirkpatrick J , Parchment S
Published: November 2019

BACKGROUND: Repeated injury, or recidivism, because of intentional or unintentional injury is a growing chronic health problem among urban adolescents and young adults in the United States. OBJECTIVE: To describe demographic, social, environmental, psychological, and developmental antecedents and risk-taking behaviors, and to examine their relationships to type of trauma and rate of trauma recidivism in adolescent and young adults in an urban trauma center. METHODS: One hundred adolescent and young adult trauma victims in an urban trauma center were interviewed, using the Adolescent Risk-Taking Instrument, the Brief Anger/Aggression Questionnaire, and the Trauma Risk Factor Interview Schedule. Bivariate correlation, multiple regression, and discriminant function analysis were used to examine the data. RESULTS: Of the sample, 89% experienced trauma related to interpersonal violence, including firearm injuries, stab wounds, and blunt trauma. Male gender, unemployment, past arrest, lower levels of spirituality, and higher levels of anger/aggression and thrill-seeking accounted for 25% of the variance in the number of risk-taking behaviors. Factors such as male gender, past arrest, unemployment, having been a crime victim in the past, lower autonomy, use of weapons, fighting, and no psychological counseling distinguished subjects with firearm-related injuries from subjects with other injury sources. Use of alcohol on weekdays, past arrest, and higher education levels were associated with trauma recidivism, explaining 14% of the variance. CONCLUSIONS: Social/environmental and psychological/developmental variables, as well as risk-taking behaviors, are important correlates of trauma and recidivism. These findings suggest the importance of advocacy for social policies conductive to reducing the risks of violence and trauma and risk-reduction interventions as components of posttrauma care.
Presumed consent: the solution to the critical organ donor shortage?
Authors: Futterman LG
Published: November 2019

Extraordinary advances in science and medicine such as transplantation of human tissues not only bring about previously unimaginable societal benefits but also create profound implications that involve autonomy and belonging, opposing moral considerations, and legal concerns. Today, technology is changing faster than our values. The issue of salvaging organs from the dead to meet the escalating need for human organs for lifesaving organ transplantation has evolved into an intricate web of interdisciplinary concerns and value conflicts; right and wrong are opinions and consensus does not seem to exist. This organ supply-demand mismatch, as well as suggestions for its resolution, has become a major challenge to the transplant community and to those in political and bioethical arenas. A methodical transition to presumed consent, or opting-out legislation, which removes the burden of decision from the family and the burden of request from the healthcare professional, may be the only solution to correct the imbalance between human organ need and availability.
Moisture chamber versus lubrication for the prevention of corneal epithelial breakdown
Authors: Cortese D , Capp L , McKinley S
Published: November 2019

BACKGROUND: Patients who are comatose or semicomatose are at risk of corneal dryness and ulceration. OBJECTIVE: To compare and evaluate the effectiveness of two treatments used for the prevention of corneal epithelial breakdown in critically ill patients. METHODS: A randomized clinical trial was used. The sample consisted of critically ill patients (age, 15-84 years) with a limited or absent blink reflex in a 14-bed general intensive care unit in a large metropolitan teaching hospital. Ninety-six eligible patients were studied; of these, 36 were excluded and data from the remaining 60 patients were analyzed. Patients were randomized to receive methylcellulose lubricating drops every 2 hours (n = 30) or to have their eyes covered with a polyethylene film to create a moisture chamber (n = 30). The patients' corneas were tested daily for epithelial breakdown using fluorescein drops. Patients were studied for a minimum of 48 hours and a maximum of 1 week. RESULTS: Eight of the 30 patients in the lubricating drop group had positive fluorescein staining, compared with one in the moisture chamber group. CONCLUSION: Our results suggest that a moisture chamber is more effective than lubricating drops in preventing corneal epithelial breakdown in critically ill patients with limited or absent blink reflex.
Analgesic administration, pain intensity, and patient satisfaction in cardiac surgical patients
Authors: Meehan DA , McRae ME , Rourke DA , Eisenring C , Imperial FA
Published: November 2019

BACKGROUND: Pain can adversely affect a patient's physiological and psychological recovery, yet little is known about the pain experience of cardiac surgical patients. OBJECTIVES: To examine nursing practice regarding analgesic administration and measure pain intensity and patient satisfaction with pain management practices. METHODS: To establish baseline nursing practice regarding analgesic administration, charts were reviewed retrospectively in 50 adult cardiac surgical patients, and the same information was collected concurrently for a prospective sample of 51 patients. The subjects completed visual analogue scales as a measure of pain intensity twice daily while in the cardiothoracic intensive care unit and Pain Relief Satisfaction Questionnaires on the day after transfer from the unit. RESULTS: Patients in the prospective group received significantly more analgesia. Pain intensity was moderate (4 or greater on the Visual Analogue Scale). Women had higher overall visual analogue scale scores than did men, 4.57 versus 3.70. Patients in whom an internal mammary artery had been used as a bypass graft had significantly higher scores compared with patients with vein grafts. The Pain Relief Satisfaction Questionnaire responses indicated that 96% of the patients experienced effective pain management in the cardiothoracic intensive care unit. CONCLUSIONS: Despite receiving analgesic doses twice those reported elsewhere for similar populations, the patients in this study reported moderate pain intensity. This finding was confounded by the fact that 96% expressed satisfaction with their pain management in the cardiothoracic intensive care unit. Frequent assessment and documentation of both pain and pain relief from interventions are necessary if the healthcare team is to implement an individualized analgesic regimen.
The Cardiac Arrhythmia Suppression Trial: Implications for nursing practice
Authors: Kellen JC , Ettinger A , Todd L , Brezsnyak ML , Campion J , McBride R , Thomas S , Corum J , Schron E
Published: November 2019

BACKGROUND: Care of patients with ventricular arrhythmia after myocardial infarction requires careful nursing management, including assisting with arrhythmia monitoring and testing. Because ventricular premature depolarization is a known risk factor for sudden cardiac death, it was hypothesized that the suppression of asymptomatic or mildly symptomatic ventricular premature depolarization would improve survival in these patients. OBJECTIVE: To review the Cardiac Arrhythmia Suppression Trial findings and provide implications for nursing practice for patients after myocardial infarction. METHODS: The Cardiac Arrhythmia Suppression Trial was a multicenter, randomized, placebo-controlled trial designed to determine whether the suppression of ventricular premature depolarizations in postmyocardial infarction patients would improve survival. Three class I antiarrhythmic drugs were used: encainide, flecainide, or moricizine. Patients for whom the drug suppressed their arrhythmia 80% or more were randomly assigned to that drug and dose or its matching placebo and were followed every 4 months (main study). Patients with 1% to 79% suppression were randomly assigned to the drug or its placebo that best treated their arrhythmia and followed every 4 months. RESULTS: Suppression of asymptomatic or mildly symptomatic ventricular premature depolarization in patients using encainide, flecainide, or moricizine failed to improve patient survival and was even harmful in some cases. CONCLUSIONS: Our results showed that in the absence of effective antiarrhythmic drug therapy, supportive nursing care and arrhythmia monitoring is important until appropriate therapy for the management of these arrhythmias in patients who have had a myocardial infarction can be found. Clinical trials are essential to provide an evaluation of therapies and direction for further studies, as well as a basis for practicing clinicians.
Patients' perceptions of environmental factors that disturb sleep after cardiac surgery
Authors: Simpson T , Lee ER , Cameron C
Published: November 2019

BACKGROUND: Effective management of sleep disturbances after cardiac surgery requires insight into patients perceptions of which factors disturb sleep in the intensive care unit and after transfer from the intensive care unit. OBJECTIVE: To describe patients perceptions of environmental factors that disturbed sleep after cardiac surgery. SAMPLE: A convenience sample of 102 patients was surveyed in a 300-bed, acute-care teaching hospital. METHOD: Patients were interviewed several days before discharge from the hospital and rated the extent to which specific factors disturbed their sleep while in the intensive care unit and after transfer. RESULTS: The group mean for the extent of disturbance scores, averaged across all 35 environmental factors studied, was low during and after stay in the intensive care unit. However, selected items such as pain, and inability to get comfortable and perform a familiar nighttime routine, were moderately disturbing to many patients across phases of recovery. Patients varied widely in the number of factors, ranging from 0 to 33 factors, that disturbed sleep at least to some extent. Patients added factors that were not included in the original monitoring instrument. CONCLUSIONS: Patients attribute disturbed sleep to specific factors after cardiac surgery. The number of factors that disturb sleep varies among patients. Nurses can modify many of the factors that disturb sleep to promote an environment that will facilitate improved sleep, thereby enhancing the acute phase of recovery from cardiac surgery.
Intra-aortic balloon counterpulsation timing
Authors: Cadwell CA , Quaal SJ
Published: November 2019

Intra-aortic balloon counterpulsation is a product of an endeavor begun more than 3 decades ago. First the concept, then applications of inflating a nonthrombogenic balloon within the aorta during diastole were explored. The intra-aortic balloon is timed to inflate with aortic valve closure. Two options are available for deflation timing: (1) conventional timing, where deflation is estimated to be completed at some point during isovolumetric contraction, prior to ejection; and (2) R wave deflation, also known as real timing, where deflation is triggered by each QRS complex to occur during isovolumetric contraction or early systole. Although clinical implementation of both conventional and real timing was introduced in 1968, limited information about these methods of deflation is currently available. This article elucidates the differences between these models and suggests implications for clinical practice and further research.
Effect of syringe size on bruising following subcutaneous heparin injection
Authors: Hadley SA , Chang M , Rogers K
Published: November 2019

BACKGROUND: Bruising and induration associated with subcutaneous heparin injection often result in sustained tenderness and severe ecchymosis at the injection site. Research-based practice guidelines for subcutaneous heparin administration are needed to reduce these adverse effects. OBJECTIVES: The purpose of this study was to investigate the effect of syringe size (1-mL vs 3-mL) on postinjection-site bruising and induration following the administration of subcutaneous heparin. METHODS: A convenience sample of 29 subjects receiving 5000 units of subcutaneous heparin at least twice a day was recruited from a large urban hospital. Subjects received their regularly scheduled subcutaneous heparin injections with a 3-mL or a 1-mL syringe in a randomized sequence using a standardized procedure. Injection sites were assessed for bruises and induration at 24, 48, and 72 hours after injection. RESULTS: The incidence of injection site bruising with 1- and 3-mL syringes was 79% and 69%, respectively. The use of a 3-mL vs 1-mL syringe resulted in significantly smaller bruises at 48 and 72 hours after injection. Induration at the injection site occurred in three patients. CONCLUSIONS: Findings suggest that 3-mL syringes are preferable to 1-mL syringes for heparin administration. The effect of other injection-related variables should be studied with the use of the 3-mL syringe, and tested on various populations.
Development and validation of a critical care patient classification system
Authors: Scribante J , Muller ME , Lipman J
Published: November 2019

OBJECTIVE: To describe the research methodology used in development and validation of a scientific patient classification instrument for South African critical care patients. METHOD: This is a contextual, exploratory, and descriptive study. A two-phase validating model was used as a research method. In the development phase a literature review was carried out (domain identification), a provisional instrument developed (item generation), and a peer group discussion conducted (item formation). In the quantification phase 16 experts determined if both the items of the instrument and the entire instrument were content valid. The study was conducted within the framework of South African critical care nursing. RESULTS: In the peer group discussion the instrument was debated until consensus was reached. In the quantification phase, both the items of the instrument and the entire instrument were rated as content valid. CONCLUSIONS: Established patient classification systems can be successfully adapted and validated for local use.
The acute care nurse practitioner and management of common health problems: a proposal
Authors: Piano MR , Kleinpell R , Johnson JA
Published: November 2019

The acute care nurse practitioner, an emerging role in acute healthcare settings, is responsible for managing acutely ill patients with multiple acute and chronic health problems. There are variations in acute care nurse practitioner specialty practices but the complexity and potential progression of the acutely ill patient's status require the use of a multidisciplinary approach to patient care to include knowledge of common health problems. The acute care nurse practitioner curriculum should include course content on common health problems and/or physiological alterations, which should be prerequisites for specialty courses.
Interactions between nurses and patients on ventilators
Authors: Hall DS
Published: November 2019

BACKGROUND: Although the effectiveness of communication between nurses and ventilated patients has been identified by the American Association of Critical-Care Nurses as an area of concern, there are few reports of research in this area. OBJECTIVES: To examine the interactions between nurses and patients on ventilators and the relationship between characteristics of these nurses and their communication with patients. METHODS: An analytical, cross-sectional, experimental design was used to examine the work experience of 30 nurses with ventilated patients, the perceived level of consciousness of their ventilated patients, and the actions and reactions of nurses in relation to these patients. RESULTS: Significant correlations were found between the nurse's perception of the patient's degree of responsiveness and the number of positive and negative interactions with the patient, and between the length of time the nurse cared for the patient and the number of positive nurse reactions. Interaction patterns are also apparent from the data collected. CONCLUSIONS: Findings suggest that nurses' perceptions of patients' responsiveness and length of time nurses care for patients will influence nurse-patient interactions. Patterns of interaction suggest that nurses spend more time providing patients with information that the nurses consider important, rather than assessing or responding to patients' needs.
Survey of current practice patterns for percutaneous transluminal coronary angioplasty. SANDBAG Nursing Coordinators
Authors: Juran NB , Smith DD , Rouse CL , DeLuca SA , Rund M
Published: November 2019

BACKGROUND: The increasing complexity of coronary intervention has led to variations in current patterns of nursing practice for patients undergoing routine percutaneous transluminal coronary angioplasty. In preparation for a large study examining the effects of specific nursing practices on complications at the site of vascular access, we surveyed institutions participating in a randomized phase III trial involving 4010 patients to determine current patterns of practice. OBJECTIVE: The purpose of this study was to determine the current patterns of nursing practice for patients undergoing percutaneous transluminal coronary angioplasty. METHODS: An eight-page questionnaire was completed by 70 hospitals participating in the study titled Integrelin to Manage Platelet Aggregation to Prevent Coronary Thrombosis (IMPACT II). RESULTS: The hospitals participating in this study have an average of 500 beds; 34% of the institutions do 500 to 1000 angioplasty procedures annually. At many sites (39%), heparin is infused for 12 to 18 hours after the intervention, but heparin is not infused at all in 31% of the hospitals studied. At 27% of the hospitals, arterial sheaths are removed 12 to 18 hours after angioplasty, and at 15% of the hospitals, sheaths are removed more than 18 hours after the procedure. Typically after angioplasty (36%), patients are transferred to an ICU, with a nurse-patient ratio of 1:2. Eighty-three percent of the hospitals use CareMAPs or care plans for standardization of care. Most hospitals (83%) require complete bed rest for patients who have had angioplasty, with the affected leg restrained to prevent mobility. Ninety-one percent of the hospitals reported continuing to treat the patient with bed rest for an additional 6 hours after the sheath is removed. CONCLUSION: Comprehensive nursing standards of care based on well-designed clinical trials for patients after angioplasty are not available. In the second phase of our study, we hope to correlate nursing practices with clinical outcome data to improve further the care of patients who have had angioplasty.
Rewarming cardiac surgical patients: warm water vs warm air
Authors: Sanford MM
Published: November 2019

BACKGROUND: Hypothermia is experienced by 60% to 90% of adult patients after surgery. The detrimental physiological consequences of prolonged hypothermia are a significant risk for cardiac surgical patients. OBJECTIVE: To compare the effect of a warmed convective-air blanket with that of a warmed circulating-water blanket on the rates of increase in skin and core temperatures and on total rewarming time in patients with hypothermia after cardiac surgery. METHODS: A quasi-experimental, repeated-measures design was used to study rewarming in 76 adult patients who were hypothermic after cardiac surgery. Subjects were randomized to two groups: 40 were warmed with a convective-air blanket; 36, with a circulating-water blanket. Skin and core temperatures were recorded every 15 minutes until the subject's pulmonary artery temperature reached 37 degrees C. Total time required for rewarming was the period between time of placement of the blanket and time of removal. The effects of 13 other variables on the time required for rewarming were also determined. RESULTS: Both skin and core temperatures increased more rapidly in patients treated with the warm circulating-water blanket than in those treated with the convective-air blanket. The mean time required for rewarming was 45 minutes shorter in the group treated with the circulating-water blanket. The patient's age, volume of i.v. fluids received, length of anesthesia, starting core temperature, and treatment method had significant effects on the time required for rewarming. CONCLUSIONS: The data suggest that rewarming with a circulating-water blanket produces normothermia more rapidly than rewarming with a warm convective-air blanket in adult patients who are hypothermic after cardiac surgery.
Breakdown in the nursing care of families in the ICU
Authors: Chesla CA , Stannard D
Published: November 2019

BACKGROUND: Factors that can lead to breakdown in the care of the families of patients in the ICU include gaps in the healthcare providers' education and skill in working with families, unclear lines of responsibility for various aspects of family care, and insufficient support or supervision for the difficult emotional work of family care. OBJECTIVE: The purpose of this study was to highlight instances in which negative or difficult aspects of nursing care of family members of ICU patients were evident, so that needed changes in caring for the families could be emphasized. METHOD: Interpretive phenomenology was used to analyze transcribed audiotape recordings of interviews with 130 nurse participants and clinical observations of 48 nurse participants. The interpretive account is based on more than 100 narratives of patient care relayed in interviews and on observational notes that focused on care of the family. RESULTS: The five general nursing approaches that constrained family care in ICUs were nurses' efforts to (1) distance the family physically from the patient and the patient's bedside, (2) distance themselves from the patient and the patient's family, (3) characterize the family's perspective as pathological, (4) dissipate responsibility for family care, and (5) take an elemental rather than a systemic perspective. CONCLUSIONS: The breakdowns in family care observed in this study were neither new nor unique. In order to truly realize a patient- and family-focused healthcare system, an infusion of knowledge and skill must occur at the bedside with individual nurses.
Psychological factors and survival in the cardiac arrhythmia suppression trial (CAST): a reexamination
Authors: Thomas SA , Friedmann E , Wimbush F , Schron E
Published: November 2019

BACKGROUND: Evaluating the independent effects of psychosocial and physiological factors on survival of cardiac patients is difficult because it requires obtaining extensive physiological and psychosocial data and long-term follow-up of high-risk patients. OBJECTIVES: To examine the independent contributions of psychosocial and physiological status to survival of patients who had had myocardial infarction. METHODS: The sample consisted of 348 patients in the Cardiac Arrhythmia Suppression Trial who had asymptomatic ventricular arrhythmias after myocardial infarction. Psychosocial status was assessed with the Social Support Questionnaire-6, Social Readjustment Rating Scale, State-Trait Anxiety Inventory, Self-Rating Depression Scale, Jenkins Activity Survey, and Expression of Anger Scale. Physiological data included measurement of left ventricular ejection fraction; history of previous myocardial infarction, congestive heart failure, and diabetes; and results of Holter monitoring. RESULTS: At the first follow-up, after the effect of the physiological predictors was controlled for, psychosocial factors were significant independent predictors of survival. Among men in the nonactive medication group (n = 263), higher state anxiety, lower anger outward, more past life events, and lower expectations of future life events were predictors of mortality. Data suggested that the relationship of anger to mortality might differ for men and women. Increases in past life events and depression from baseline to first follow-up were greater among those who died than among those who lived. CONCLUSION: Among patients who had asymptomatic ventricular arrhythmias after myocardial infarction, psychological status during the period after infarction contributed to mortality beyond the effect of physiological status. The results reaffirm the critical interrelationship between mind and body for cardiovascular health.
Accuracy of detection of clinically important dysrhythmias with and without a dedicated monitor watcher
Authors: Stukshis I , Funk M , Johnson CR , Parkosewich JA
Published: November 2019

BACKGROUND: Although dedicated monitor watchers are used in many progressive care units with telemetry monitors, this costly practice has not been evaluated. OBJECTIVE: To compare the accuracy of detection of clinically important dysrhythmias with and without a dedicated monitor watcher. METHODS: On a 26-bed cardiac progressive care unit, documentation of four categories of dysrhythmias during a 7-week period when a monitor watcher was present was compared with that during a 7-week period when no monitor watcher was present. The Hewlett-Packard CareVue Clinical Event Review, a full-disclosure system, was used as the gold standard. RESULTS: Accuracy of detection of nonsustained ventricular tachycardia, supraventricular tachycardia, and pauses was significantly better with a monitor watcher than without. Although the detection of life-threatening rhythms was correct a higher percentage of the time with a monitor watcher, the difference was not significant. CONCLUSIONS: The efficiency and quality of patient care can be enhanced by using a dedicated monitor watcher. The results of this study raise the question of whether improved accuracy of detection of dysrhythmias results in better outcomes for patients.
Effect of dedicated monitor watchers on patients' outcomes
Authors: Funk M , Parkosewich JA , Johnson CR , Stukshis I
Published: November 2019

BACKGROUND: In 55% of progressive care units, someone is assigned to watch the cardiac monitors at all times, but the effect of this practice on patients' outcomes has not been examined. OBJECTIVE: To evaluate the effect of continual observation of telemetry units by a monitor watcher on mortality, frequency of transfer to a critical care unit, and the occurrence of five life-threatening dysrhythmias. METHODS: Data for this quasi-experimental study were collected on 1185 patients for a 9-month period in 1993 when the cardiac progressive care unit had a monitor watcher and on 1198 patients for a 9-month period in 1994 when the unit had no monitor watcher. RESULTS: We found no significant differences in mortality, frequency of transfer to a critical care unit, or the occurrence of three of the five dysrhythmias examined. The presence of a monitor watcher was associated with significantly fewer episodes of sustained ventricular tachycardia but more bradyarrhythmias. For both sustained ventricular tachycardia and bradyarrhythmias, the monitor watcher variable remained in the final multivariate logistic regression models. CONCLUSIONS: The presence of a monitor watcher was not associated with lower rates of most adverse outcomes evaluated; however, fewer episodes of sustained ventricular tachycardia occurred when a monitor watcher was present. Sustained ventricular tachycardia is life-threatening, disturbing to the patient, and may result in a longer hospital stay while medical therapy is being adjusted. The results of this study support the use of a monitor watcher to prevent sustained ventricular tachycardia.
Nurse-physician collaboration and satisfaction with the decision-making process in three critical care units
Authors: Baggs JG , Schmitt MH , Mushlin AI , Eldredge DH , Oakes D , Hutson AD
Published: November 2019

OBJECTIVE: To assess and compare levels of nurse-physician collaboration and satisfaction with the decision-making process as reported by critical care nurses, resident physicians (residents), and attending physicians (attendings) in making decisions to transfer individual patients out of the critical care unit, and to assess if satisfaction predicts nurse retention. DESIGN: Longitudinal descriptive correlational study using self-reporting instruments. SETTINGS: A university hospital's surgical ICU, a community teaching hospital's medical ICU, and a community hospital's mixed ICU. SUBJECTS: Eighty-one nurses, 23 residents, and 37 attendings from the surgical ICU; 44 nurses and 51 residents from the medical ICU; 25 nurses and 45 attendings from the community hospital's ICU, reporting on the transfers of 473, 465, and 494 patients, respectively. MAIN OUTCOME MEASURES: Healthcare providers' reported levels of collaboration and satisfaction with the decision-making process, the correlations between collaboration and satisfaction, and nurse retention. RESULTS: Nurses and physicians within sites (except attendings from the surgical ICU) reported similarly moderate amounts of collaboration, but nurses reported less satisfaction with decision making than did physicians in all sites. Collaboration was related to satisfaction with decision making for all providers, but more strongly for nurses. The strength of the relationship for nurses was similar in all sites. Nurses' satisfaction with decision making did not predict their retention. CONCLUSIONS: Collaboration between nurses and physicians is a more important component of satisfaction with decision making for nurses than for physicians. Any interventions to change the amount of collaboration in practice must take account of this difference.
Effectiveness of a structured communication program for family members of patients in an ICU
Authors: Medland JJ , Ferrans CE
Published: November 2019

BACKGROUND: In ICUs, an essential component of caring for patients' families is providing information about the patient's status. Nevertheless, interruptions by family members requesting information create an additional burden for nursing staff. OBJECTIVES: To test a structured communications program for family members to determine whether the program would increase family members' satisfaction with care, meet their needs for information better, and decrease disruption for the ICU nursing staff caused by incoming telephone calls from patients' family members. METHODS: The study used a two-group, pretest-posttest quasi-experimental design. The sample consisted of 30 family members of patients in a medical ICU (experimental group, n = 15; control group, n = 15). The intervention consisted of a structured communication program consisting of three components: (1) a discussion with a nurse approximately 24 hours after admission of the patient, (2) an informational pamphlet given at the time of the discussion, and (3) a daily telephone call from the nurse who was caring for the patient that day. RESULTS: The number of incoming calls from family members was significantly lower in the experimental group than in the control group. In the experimental group, satisfaction with care increased significantly from pretest to posttest, as did the members' perception of how well their information needs were being met. CONCLUSIONS: The intervention reduced the number of incoming calls from family members, without compromising family members' satisfaction with care or how well their information needs were met.
Understanding nursing resources in intensive care: a case study
Authors: Diers D , Bozzo J , Blatt L , Roussel M
Published: November 2019

OBJECTIVE: We describe the use of a measurement of nursing acuity in an ICU based on data from an integrated clinical and financial information system to shed light on the problem of a perceived change in the work of the unit. SETTING: A surgical-neurosurgical ICU in a teaching hospital with more than 800 beds. DESIGN: Changes in the work of nursing, defined by nursing acuity and by case mix and use of ancillary services in this unit for an 18-month period, were reviewed. RESULTS: The caseload was unpredictable. The lack of a systematic pattern of use of hospital resources burdened the nurses. CONCLUSION: For the first time at this institution, timely clinical and financial information has been brought together in an understandable format that can be used to explain trends and variances, to plan for the future, and to manage for cost and quality. The model for information management described here might serve other hospitals as well.
Characterization of the precipitants of hospitalization for heart failure decompensation
Authors: Bennett SJ , Huster GA , Baker SL , Milgrom LB , Kirchgassner A , Birt J , Pressler ML
Published: November 2019

BACKGROUND: The model for management of patients with heart failure may be a key determinant of morbidity and quality of life. Development of a better management strategy for these patients requires determination of the reasons for decompensation that leads to hospitalization. OBJECTIVES: To ascertain and rank the principal reasons for hospitalization of patients who have heart failure. METHODS: Retrospective audit of all 1992 admissions (N = 1031; 691 patients) coded for heart failure at a Veterans Affairs medical center and a tertiary care university medical center. RESULTS: The diagnosis of heart failure was verified by preset criteria in 72% of the patients. Of the 496 patients with documented heart failure, worsening heart failure was a main reason for admission in 390 (79%). Despite different socioeconomic backgrounds, excessive sodium retention was the leading factor (55%) associated with decompensation in patients at both institutions. Other factors precipitated admission much less often. CONCLUSIONS: Many hospitalizations for heart failure might be avoided by case management directed at lessening sodium overload. Increased use of medications known to be effective in persons with heart failure (angiotensin-converting enzyme inhibitors, digoxin, and adequate diuretic therapy) might reduce the likelihood of decompensation. Implementation of behavioral interventions to assist patients with self-monitoring signs of sodium retention and to improve compliance with medications and dietary sodium restrictions are strategies for further reducing the risk of decompensation.
Bedside monitoring of the QT interval
Authors: Rimmer LK
Published: November 2019

Cardiac repolarization, represented on the ECG by the QT interval, is of particular clinical interest in critical care. Once it is measured and corrected for changes in heart rate, the QT interval is known as the QTc. Measurement of the QT interval is important because a prolonged QT interval is associated with ventricular tachycardia and sudden cardiac death. Despite the serious complications associated with a prolonged QT interval, the interval is not routinely measured because a standardized method for measuring it has not been established and the length of QT interval critical to the development of ventricular tachycardia has not been determined. Much has been written about the conditions associated with prolonged QT intervals and specific actions to take when complications appear. Guidelines to be used for QT analysis in the clinical area, based on currently available information, include (1) procedures for measuring QT interval and calculating QTc, (2) procedures for QT analysis, (3) warning signs that indicate increased risk of ventricular tachycardia associated with a prolonged QT interval, and (4) actions to consider once increased risk is determined.
Effect of neuromuscular blockers and opiates on the cerebrovascular response to endotracheal suctioning in adults with severe head injuries
Authors: Kerr ME , Sereika SM , Orndoff P , Weber B , Rudy EB , Marion D , Stone K , Turner B
Published: November 2019

BACKGROUND: Intracranial hypertension occurs in response to routine procedures such as endotracheal suctioning in patients with severe head injuries. In some patients, the intracranial pressure does not immediately return to baseline levels. OBJECTIVES: To examine the effect of drug administration on cerebrovascular response to endotracheal suctioning in adults with severe head injuries. METHODS: Seventy-one subjects were divided into 3 groups: those who received no drugs, those treated with opiates only (morphine sulfate and fentanyl citrate), and those treated with a neuromuscular blocking agent (vecuronium bromide) plus opiates. A controlled protocol involving 2 sequences of endotracheal suctioning that included hyperoxygenation, hyperinflation, and suctioning was used for all subjects. Two-way repeated-measures analyses of variance were done with type of drug as the between-subject factor and phase of suctioning as the within-subject factor. Survival analysis was used to compare the return of intracranial pressure to baseline levels among the 3 groups. RESULTS: Changes in intracranial pressure were significantly smaller in subjects who received a neuromuscular blocking agent plus opiates than in subjects who did not receive any drugs or received opiates only. The greatest increase in intracranial pressure from baseline was in the first and second phases of suctioning. The 3 groups showed no significant difference in the return of intracranial pressure to baseline level. CONCLUSIONS: Neuromuscular blockers attenuate the increases in intracranial pressure that occur with endotracheal suctioning. It is not known whether control of procedurally induced elevations in intracranial pressure affects long-term outcomes in adults with severe head injuries.
Nurses' knowledge of advance directives
Authors: Crego PJ , Lipp EJ
Published: November 2019

BACKGROUND: The Patient Self-Determination Act offers persons the opportunity to make their end-of-life choices known by the use of advance directives. Although nurses are designated advocates for patients and are available to communicate patients' concerns and wishes to other healthcare providers, few data on nurses' knowledge of advance directives have been reported. OBJECTIVE: To describe nurses' knowledge of advanced directives. SAMPLE: A volunteer sample of 339 RNs in a 600-bed acute care teaching hospital was surveyed. The sample represents 38% of the approximately 900 nurses employed at this hospital. METHODS: Data obtained from a 44-item questionnaire that tested nurses' knowledge of advance directives were analyzed. In addition, the relationship between nurses' knowledge of advance directives and certain demographic factors was analyzed. RESULTS: The mean score for knowledge of advance directives was 78% correct answers. Fifty-five percent of the respondents indicated that they did not have a good understanding of advance directives. Only 14% had completed these end-of-life documents for themselves, and 92% indicated that further education would increase their understanding of advance directives. An analysis of variance produced only one significant finding: the relationship between ethnicity and knowledge about advance directives. CONCLUSIONS: Nurses must increase their knowledge of advance directives. Results of this survey should stimulate caregivers and hospital policy makers to take a long-range view of their responsibilities to patients regarding advance directives and their responsibilities for educating the persons who convey information about advance directives to patients.
Fifty percent of patients with coronary artery disease do not have any of the conventional risk factors
Authors: Futterman LG , Lemberg L
Published: November 2019

Prinzmetal's variant angina, primarily a vasospastic disease, is a glaring example of the gaps in our knowledge regarding the etiology of coronary heart disease. Half of all patients with coronary heart disease do not have any of the established coronary risk factors. Prinzmetal's variant angina, syndrome X, coronary embolization, and congenital coronary anomalies, are a few examples of conditions that may not be associated with established risk factors. New risk factors that are emerging in an attempt to establish an etiology in this group of patients are homocysteine plasma fibrinogen, estrogen-deficiency lipoprotein (a), C-reactive protein, Chlamydia pneumoniae, factor VII endogenous tissue plasminogen, and endogenous plasminogen activator/inhibitor type I. The battle against cardiovascular disease continues!
Opioid withdrawal in neonates after continuous infusions of morphine or fentanyl during extracorporeal membrane oxygenation
Authors: Franck LS , Vilardi J , Durand D , Powers R
Published: November 2019

BACKGROUND: Complications of opioid analgesia include tolerance and withdrawal. OBJECTIVES: To determine the effects of morphine and fentanyl on the prevalence of withdrawal after extracorporeal membrane oxygenation. METHODS: Two groups of neonates were compared during and after extracorporeal membrane oxygenation: a prospective group receiving a continuous infusion of morphine for analgesia and sedation and a retrospective group who had received a continuous infusion of fentanyl. RESULTS: Neonates receiving morphine required significantly less supplemental analgesia (P < .001) than did neonates who had received fentanyl and had a significantly lower prevalence of withdrawal after the therapy (P = .01). Neonates receiving morphine were discharged from the hospital a mean of 9.6 days sooner (P = .01) than neonates who had received fentanyl. CONCLUSIONS: Morphine may offer marked advantages over fentanyl for providing continuous analgesia and sedation in neonates.