Nurses Bring Aid to Iran
An update on the earthquake relief efforts.
The spectacular earthquake that leveled the ancient Iranian city of Bam in the early morning on December 26, 2003 has all but disappeared from the American media radar. But in a city in which more than 42,000 bodies were painstakingly unearthed from the rubble only to be buried again by grieving family members, the tragedy isn't over.
According to the International Federation of Red Cross and Red Crescent Societies and the World Health Organization, in addition to those who perished, some 30,000 people were injured and an estimated 75,000 lost their homes; most survivors lost multiple family members, and some 1,850 children were orphaned. About 80% of the city's roads and buildings were severely damaged, and two hospitals crumbled, killing most of the staff.
In the immediate aftermath of the quake, search-and-rescue teams from 20 countries-including the United States-arrived in Bam to help. More than 50 American physicians, nurses, and paramedics were part of the International Medical Surgical Response Team East, based at Massachusetts General Hospital (MGH) in Boston. Created in 1999 after the attacks on the U.S. embassies in Tanzania and Kenya, it now operates under the National Disaster Medical System, which is part of the Department of Homeland Security. The team left Boston on December 27 and arrived in Bam on December 29; they returned home on January 7.
Barbara Walsh, a surgical nurse at MGH who was a team member, said getting off the plane in Bam was "surreal." "There was hardly anything standing at all," she said. "You could see walls, burning cars, and some fires-and it was cold, going down to 20[degrees]F at night."
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Most of the injuries they treated were fractures, lacerations, and respiratory problems stemming from the dust created when the buildings collapsed. She said that the people being treated were reserved and offered little eye contact but that they were very gracious. "It was a blessing to be given the opportunity to help these people," she said. "There was no politics-just people who needed help and people who could give it." She recalls one 83-year-old woman in particular, who despite leg fractures had pulled nine family members out of the rubble alive.
In late January the International Federation, along with the Iranian Red Crescent Society, set up camps in and around the city, providing clean water, sanitation services, blankets, food, and basic health care. A 200-bed field hospital was also erected and is operated mainly by the Norwegian and the Finnish Red Cross. Sixty percent of the water network has been reestablished, and electricity has been restored in major parts of the city. -Dalia Sofer
Treating Bronchiolitis in Infants
Evidence proves insufficient to support a best practice.
Three percent of all children under one year of age are hospitalized because of bronchiolitis. It's the most common respiratory infection in infants, and the vast majority (70%) of such infections are attributed to the respiratory syncytial virus. Yet there is no agreement on a definitive treatment strategy.
King and colleagues conducted a literature review examining the effectiveness of drugs commonly used to treat bronchiolitis in infants and young children. They reviewed 44 randomized controlled trials, published between 1980 and November 2002, evaluating treatment with epinephrine, [beta]2-agonist bronchodilators, corticosteroids, and ribavirin. In the end, the clinical evidence could not support the use of one medication over another; the majority of studies reviewed were of insufficient size or power and the variables examined were too dissimilar to allow for any firm conclusions to be drawn. The researchers suggest that there needs to be a large clinical trial examining which interventions are most effective in this population.
A clinical trial conducted between 1998 and 2000 of patients treated in the ED of a British children's hospital yielded similar results. Researchers comparing the outcomes of treatment with either nebulized epinephrine or nebulized albuterol in 66 infants moderately ill with bronchiolitis didn't find any significant clinical benefit with either medication. Both treatment groups experienced the same rates of clinical improvement, hospitalization, adverse events, and relapse. The only difference (which the authors say may not be clinically relevant) was that infants treated in the ED with epinephrine were discharged earlier than those who received albuterol.
King VJ, et al. Arch Pediatr Adolesc Med 2004;158(2):127-37; Mull CC, et al. Arch Pediatr Adolesc Med. 2004;158(2):113-8.
Cut Paperwork, Cover All U.S. Uninsured?
A new study makes the case for a national health insurance system.
According to a study by health care policy experts, "bureaucracy" costs in health care in the United States in 2003-including insurance overhead, employers' costs, hospital administration, nursing home administration, practitioners' overhead, and home care agency administration-are estimated to have been around $400 billion, approximately 31% of the total $1.66 trillion spent on health care. The researchers estimate that if the United States were to switch to a single-payer national health insurance system similar to Canada's, administrative costs would decrease by about $286 billion, enough to allocate $6,940 per year for each of the 41.2 million uninsured Americans-which is more than the amount ($5,775) currently spent per person.
But uprooting the mammoth American health system may require more than one optimistic study. According to a new report by Weiss Ratings, a company that evaluates the financial strength of various companies, in 2002 HMOs made a profit of $5.5 billion-an increase of 81% over 2001 figures. In 2003, profits jumped 60% in the first quarter and 73% in the second quarter, with more than 80% of insurance companies showing profits.
Himmelstein DU, et al. Int J Health Serv 2004;34(1):79-86.
FROM THE NATIONAL INSTITUTE OF NURSING RESEARCH
Developing 'Savvy' Caregivers
New support for caregivers of relatives with dementia.
As the proportion of the U.S. population that is elderly continues to grow, the number of patients with dementia is expected to increase. More caregiver support and training programs must be made readily available. Research has shown that offering support and education to those caring for family members with Alzheimer disease or other dementia has a positive impact on the caregiver's well-being; the patient in such cases is also able to receive care at home for longer before requiring institutional care.
University of Minnesota researchers have developed and tested a packaged program designed to help family caregivers of elderly dementia patients understand the effects of the disease, adapt to cognitive changes in the care recipient, establish realistic goals, design appropriate activities, and solve problems as they arise. After an initial field test and extensive revision of the content, a follow-up field test of 140 caregivers taking part in 22 programs showed that the materials helped to increase the care-givers' skill and knowledge and the confidence with which they provided care. In addition, they perceived the burden placed on them to be lighter.
Hepburn KW, et al. Gerontologist 2003;43(6):908-15.
State Supreme Court Rules on Expert Opinion
Says only nurses can testify to nursing standards.
Illinois has established the first state law stipulating that only nurses can provide expert opinion on the standards and scope of nursing practice, thanks to Karen Butler, cochairwoman of the litigation section of the American Association of Nurse Attorneys (TAANA) and Leatrice Schmidt of the Chicago chapter of TAANA.
Butler, an attorney in Albany, New York, wrote an amicus curiae brief on behalf of TAANA in support of an Illinois appellate court's decision that a physician was incompetent to testify to the standard of care for the nursing profession. Schmidt, an attorney in Illinois, reviewed and submitted the brief to the state's highest court.
Butler says that in writing the brief she relied on state nurse practice acts, the ANA Code of Ethics with Interpretive Statements, and reiterating the fact that RNs could never testify to the standard of care for physicians just because they work alongside each other. She notes that, "because this is now in the law, attorneys will have to change an old-fashioned attitude that a nurse is just a physician helper."-Maureen Shawn Kennedy, MA, RN, news director.
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Depression and Cardiovascular Disease in Women
Older women may be at increased risk.
It has long been believed that there is a relationship between cardiovascular disease and depression in post-menopausal women, but whether depression is a precursor of heart disease or vice versa or an independent risk factor isn't known.
Using data from the Women's Health Initiative Observational Study, a nationwide, long-term, prospective study examining the health problems of 94,000 women as they age, researchers found that among women between the ages of 50 and 79, 15.8% (14,764) reported being depressed at the baseline screening.
The researchers found that depression was significantly related to risk factors for the development of cardiovascular disease and was in itself an independent risk factor. Among women without any history of cardiovascular disease, depression was associated with a significantly higher risk of death from cardiac causes, even after adjusting for age, race, established cardiovascular risk factors, socioeconomic factors, and use of hormone replacement therapy. Among women with a history of cardiovascular disease at baseline, depression was significantly associated with the development of stroke. In addition, women who had established cardiovascular disease risk factors, such as obesity, smoking, a low level of physical activity, and diabetes, had a 20% to 50% greater risk, even after adjusting for age, race, education, and income.
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Biological mechanisms involving lipid metabolism and the sympathetic nervous system have been suggested as the link between depression and cardiovascular disease. The authors call for research exploring whether treating depression decreases a woman's risks of developing cardiovascular disease.
Wassertheil-Smoller S, et al. Arch Intern Med 2004; 164(3):289-98.
NewsCAPS
Estrogen study stopped. The National Institutes of Health recently halted the estrogen-only phase of the Women's Health Initiative, an examination of the effects of hormone replacement therapy on heart disease in postmenopausal women. Of the 11,000 women participating in the estrogen-only arm of the study, those taking estrogen appeared to have a greater risk of stroke than those taking a placebo. Moreover, researchers saw no reduction in the risk of heart disease.
In 2002 the estrogen-plus-progestin phase of the study was also halted, when researchers found an increased risk of breast cancer, heart disease, and stroke among women taking the hormones.
Nursing ranks first. Nursing tops the list of the 10 occupations projected to have the most growth between 2002 and 2012, according to a recent report by the U.S. Bureau of Labor Statistics.
Does the flu vaccine prevent exacerbations of asthma, as the conventional wisdom has it? No, according to a study in the February 15 issue of the American Journal of Respiratory and Critical Care Medicine. Dutch researchers didn't find any significant reduction in influenza-induced asthma exacerbations in children with asthma who received influenza vaccine, as compared with those who received placebo. There were also no significant differences among the 700 study subjects in the severity or duration of symptoms.
Combative elders. In one of the first papers to examine the issue, a study published in the February 4 issue of the Journal of the American Medical Association reports that nursing home residents physically assault each other at a high rate and that it appears that the injured person was likely to have provoked the attack. In the study, residents who wandered, were verbally or physically abusive themselves, were socially inappropriate or disruptive, or were cognitively impaired were more likely to be injured than those who were severely dependent.
Thromboembolism risk is high in patients with cancer, according to an article published in the January 26 issue of the Archives of Internal Medicine. A retrospective review of the medical records of 206 patients who had been treated with chemotherapy showed that 7.3% (n = 15) developed venous thromboembolism. And among patients with colorectal cancer being treated with fluorouracil (Adrucil) and leucovorin (Wellcovorin and others), the rate was 15%. Alterations in coagulation factors and damage to blood vessel endothelial cells from the chemotherapy are thought to be contributors. At this time the researchers are not recommending routine anticoagulation prophylaxis for patients with cancer but do recommend additional study to determine its efficacy and safety.
New Magnet Awards
The American Nurses Credentialing Center (ANCC) raises the total number of Magnet facilities to 105.
The Magnet Recog nition Program at the ANCC, which recognizes excellence in nursing services, has designated as Magnet facilities the Children's Hospital of Philadelphia, Mary Imogene Bassett Hospital (Cooperstown, New York); and Atlantic City Medical Center (Atlantic City, New Jersey).
Steps Suggested to Improve Nursing Care
Not everyone is cheering.
The National Quality Forum measures health care quality and recommends steps that can voluntarily be taken to help improve it. As a result of a survey of hospitals, consumer groups, professional nursing and medical organizations, and federal agencies, the organization recently recommended measuring 15 specific nursing outcomes as a way of determining the quality of care delivered, what it terms "standards for nursing-sensitive performance measurement."
But not everyone is rushing to change in-house policies. In a letter to the forum, Rick Pollack, executive vice president of the American Hospital Association, voiced the association's discontent, arguing that three of the measures (the rates of pneumonia and urinary tract infections in hospitals and failure to rescue) must be eliminated from the list because they haven't been proven to be effective predictors of good outcomes in hospitals, and that three others (skill mix, hours of nursing care per patient per day, and practice environment) must be eliminated because they "have not been sufficiently linked" to the quality of patient care or to patient outcomes. For more information, go to http://www.qualityforum.org.
'Nursing-Sensitive Performance'
The 15 aspects and outcomes of nursing to be measured.
* Failure to rescue (death among surgical inpatients with serious but treatable complications)
* Rates of
pressure ulcers
falls
falls with injury
restraint use
urinary tract infection (associated with urinary catheters)
bloodstream infection (associated with central line catheters)
pneumonia (associated with ventilators)
* The existence of smoking cessation counseling for patients with
acute myocardial infarction
heart failure
pneumonia
* The skill mix on the unit
* Hours of nursing care per patient per day
* Practice environment (as evaluated using the Practice Environment Scale of the Nursing Work Index)
* Voluntary turnover