CARDIAC ARREST
Oxygen: Too much of a good thing?
Most patients being treated for cardiac arrest receive much too much supplemental oxygen, according to study findings linking higher oxygen concentrations to a greater risk of morbidity and mortality. The large study involved 4,459 nontrauma adult patients resuscitated from cardiac arrest in 120 U.S. hospitals. Patients with hypoxia or severe oxygen impairment were excluded. Researchers focused on the highest partial pressure of arterial oxygen (PaO2) during each patient's first 24 hours in the ICU.
A normal PaO2 ranges from 80 to 100 mm Hg. The median postresuscitation PaO2 was 231 mm Hg (interquartile range 149 to 349 mm Hg). Researchers found that a 100 mm Hg increase in PaO2 was associated with a 24% increase in mortality risk but observed "no evidence supporting a single threshold for harm from supranormal oxygen tension." They concluded that the study showed "a dose-dependent association between supranormal oxygen tension and risk of in-hospital death."
Source: Kilgannon JH, Jones AE, Parrillo JE, et al. Relationship between supranormal oxygen tension and outcome after resuscitation from cardiac arrest. Circulation. 2011;123(23):2717-2722.
PEDIATRICS
Small teams improve RN/MD communication
Organizing healthcare members into unit-based teams may improve both the quality and frequency of their communication and improve patient safety, according to a study conducted in general pediatric units.
Researchers reorganized resident physicians and pediatric nurses into care teams that were based in specific units, with residents admitting and caring only for patients in their assigned unit. They gauged the success of this team approach through anonymous resident physician and nurse self-reports of communication practices and number of pages.
They found that residents were more likely to easily identify the nurse who helped care for patients with the most complex conditions. Residents also reported more frequently contacting and being contacted by that nurse in person and believing their patient care concerns were met. The average number of pages to residents per day decreased by 42%. Nurses reported similar improvements in communication patterns.
Source: Gordon MB, Melvin P, Graham D, et al. Unit-based care teams and the frequency and quality of physician-nurse communications. Arch Pediatr Adolesc Med. 2011;165(5):424-428.
END-OF-LIFE CARE
What drives the DNR decision?
What goes into a patient's decision to choose do-not-resuscitate (DNR) rather than full code (FC) status? Over a 4-month period, researchers conducted interviews with 27 medical inpatients who'd requested DNR and 17 who'd requested FC status. Patients in the DNR group were much older than those in the FC group, but the groups were otherwise similar in admission diagnoses and comorbidities.
Compared with patients who requested FC, those in the DNR group reported having much greater familiarity with the subject and described a more positive experience regarding their discussions with caregivers about resuscitation. The interviews revealed that patients in each group viewed resuscitation and DNR orders differently. For example, those who chose FC described resuscitation as measures that restore life, and associated DNR with substandard care or even euthanasia. Those who chose DNR described resuscitation in "graphic, concrete terms that emphasized suffering and futility" and associated DNR orders with comfort or natural processes.The researchers hope healthcare professionals can use this information to better meet the needs of their patients when discussing resuscitation options.
Source: Downar J, Luk T, Sibbald RW, et al. Why do patients agree to a "do not resuscitate" or "full code" order? Perspectives of medical inpatients. J Gen Intern Med. 2011;26(6):582-587.
CLINICAL PRACTICE
Are you current on these new guidelines?
Check out these two recently released sets of guidelines:
* The Institute for Safe Medication Practices (ISMP) has developed "ISMP Acute Care Guidelines for Timely Administration of Scheduled Medications." These guidelines cover both time-critical and non-time-critical scheduled medications. You can find them at http://www.ismp.org/tools/guidelines/acutecare/tasm.pdf.
* For guidelines addressing perioperative bleeding that requires blood transfusion during cardiac operations, review the "2011 Update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists Blood Conservation Clinical Practice Guidelines," available at http://www.guidelines.gov/content.aspx?id=25744.
CARDIAC SURGERY
Closely monitor older adults for delirium
More than one-third of patients over age 70 experience delirium after cardiac surgery, according to research presented at the American Psychiatric Association Annual Meeting in Honolulu, Hawaii in May. Researchers evaluated 50 patients after cardiac surgery and found the overall incidence of delirium was 20%, with the incidence increasing significantly with age. Delirium affected 38% of patients over age 70 and 43% of those over age 80. No patients under age 70 developed delirium.
Delirium developing after cardiac surgery has been associated with healthcare issues such as increases in intensive care and hospital length of stays.
Source: Delirium following cardiac surgery common in older patients. News release. American Psychiatric Association; May 17, 2011. http://www.psych.org/MainMenu/Newsroom/NewsReleases/2011-News-Releases_1/Delirim.
STAFFING
Nonphysician teams perform well in the ICU
As the number of ICU beds increases nationwide, the demand for physician intensivists exceeds the supply. One proposed solution to the medical staffing shortfall is to staff ICUs with nonphysician provider-based teams for some shifts. A new study comparing nonphysician teams to medical house staff-based teams in a medical ICU (MICU) indicates that patient outcomes are similar with both approaches.
Researchers conducted a retrospective review of 590 daytime admissions to two MICUs in one hospital. One MICU was staffed by nurse practitioners and physician assistants during the day (0700 to 1900) with attending physician coverage at night. The other MICU was staffed with medical residents around the clock.
Comparing patient outcomes in the two units, researchers found no significant differences in hospital mortality, length of stay, or posthospital discharge destination. They conclude that "staffing models including daytime use of nonphysician providers appear to be a safe and effective alternative to the traditional house staff-based team in a high-acuity, adult ICU."
Source: Gershengorn HB, Wunsch H, Wahab R, et al. Impact of nonphysician staffng on outcomes in a medical ICU. Chest. 2011;139(6):1347-1353.
SURVEY RESPONSES
Would you recommend a career in nursing?
Nurses who recently visited our website answered this question: Would you recommend nursing as a career choice?
Answer monthly survey questions and see results from past surveys by visiting http://www.nursingcenter.com/poll, or check out the Quick poll at http://www.nursing2011.com.
CELL PHONE CONTAMINATION
Calling all germs
A study of mobile phones belonging to hospitalized patients and visitors revealed that these phones were significantly more likely to carry pathogens than phones belonging to healthcare workers. Pathogens were found on about 40% of patient and visitor phones, compared with only 21% of phones belonging to healthcare workers. In addition, more patient and visitor phones carried more multidrug-resistant pathogens, such as methicillin-resistant Staphylococcus aureus. Based on their findings, researchers suggest that specific infection control measures may be needed to address this threat.
Source: Tekerekolu MS, Duman Y, Serindag A, et al. Do mobile phones of patients, companions and visitors carry multidrug-resistant hospital pathogens? Am J Infect Control. 2011;39(5):379-381.
ANALGESIA
Cross your arms to relieve pain
In an experiment that may have implications for patients with phantom limb pain, researchers found that crossing the arms across the middle of the body confuses the brain and helps reduce the intensity of pain in the hands. Using a laser, they inflicted a 4-millisecond pinprick of pain on the hands of eight volunteers, first with the volunteers' arms uncrossed, then crossed. Both the volunteers' perception of pain and their electrical brain responses as measured by electroencephalography were weaker when their arms were crossed. The researchers note that "besides studies showing relief of phantom limb pain using mirrors, this is the first evidence that impeding the processes by which the brain localizes a noxious stimulus can reduce pain..."
Sources: Gallace A, Torta DM, Moseley GL, Iannetti GD. The analgesic effect of crossing the arms. Pain. 2011;152(6):1418-1423; In pain? Crossing your arms may help. Reuters Health Information; May 20, 2011. http://www.nlm.nih.gov/medlineplus/news/fullstory_112329.html.
In August, celebrate
* Children's Eye Health and Safety Monthhttp://www.preventblindness.org
* World Breastfeeding Week (August 1-7)http://www.worldbreastfeedingweek.org