MNT: an innovative employee-friendly benefit that saves

In an effort to address the rising cost of health care within employee and retiree populations, many large employers are turning to an innovative health care solution: the registered dietitian and medical nutrition therapy and prevention. Research and case histories show the effectiveness of this approach.

Evidence for a protein related immunologically to the jaagsiekte sheep retrovirus in some human lung tumours

Human bronchioloalveolar carcinoma (BAC) is a lung cancer, morphologically similar to an endemic contagious lung neoplasm of sheep called sheep pulmonary adenomatosis (SPA) or jaagsiekte. SPA is caused by an exogenous type B/D retrovirus (jaagsiekte sheep retrovirus (JSRV)), which prompted the present study to obtain evidence of a retrovirus in BAC. A panel of 249 human lung tumours, 21 nontumour lung lesions, four normal lung tissues, 23 adenocarcinomas from other organs and a cell line expressing a human endogenous retrovirus protein was examined immunohistochemically using a rabbit antiserum directed against the JSRV capsid protein. Specific staining was detected only in the cytoplasm of recognizably neoplastic cells in the pulmonary alveoli of 39 of 129 (30%) BACs, 17 of 65 (26%) lung adenocarcinomas and two of seven large cell carcinomas. The remaining samples were negative. These results support the hypothesis that some human pulmonary tumours may be associated with a jaagsiekte sheep retrovirus-related retrovirus, warranting further studies.

Assessment of alternative hand hygiene regimens to improve skin health among neonatal intensive care unit nurses

OBJECTIVE

The frequent handwashing and gloving required in high-risk, high-volume patient care areas such as critical care units damages skin of the hands. The purpose of this exploratory study was to compare 2 hand care regimens (traditional antiseptic wash with chlorhexidine-containing detergent versus mild soap wash with subsequent alcohol-based rinse for degerming as necessary) in a neonatal intensive care unit (NICU).

DESIGN

Prospective, quasi-experimental, random assignment.

SETTING

One NICU (47 beds) in a New York City children's hospital.

SUBJECTS

Sixteen full-time NICU nurses.

OUTCOME MEASURES

Microbial flora and skin condition of hands.

INTERVENTION

Nurses were randomly assigned to one of the 2 hand care regimens.

RESULTS

No significant differences in microbial counts or types of organisms from hands of staff were found, but after 2 weeks nurses in the mild soap and alcohol group had significant improvements in their skin condition (P =.005).

CONCLUSIONS

Use of a mild soap for cleaning and an alcohol-based product for degerming may offer an acceptable alternative to the traditional antiseptic handwash and may reduce skin damage to health care professionals' hands.

Nurses' job satisfaction and organizational climate in a dynamic work environment

The infrastructure and organization of hospitals are changing rapidly as a result of major transitions in health care. Downsizing in hospitals has caused employees to have to take on new tasks and, often, multiple tasks with a decrease in available resources and an increase in job complexity. Naturally, such organizational changes have a profound effect on the nature and duration of patient hospitalization and on the job responsibilities and roles of inpatient staff. In many hospitals, there is a perception of chaos, sometimes resulting in frustration among the nursing personnel. The purpose of this study was to describe the relationship between nurses' job satisfaction and organizational climate.

Skin hygiene and infection prevention: more of the same or different approaches?

The purpose of this article is to review research indicating a link between hand hygiene and nosocomial infections and the effects of hand care practices on skin integrity and to make recommendations for potential changes in clinical practice and for further research regarding hand hygiene practices. Despite some methodological flaws and data gaps, evidence for a causal relationship between hand hygiene and reduced transmission of infections is convincing, but frequent handwashing causes skin damage, with resultant changes in microbial flora, increased skin shedding, and risk of transmission of microorganisms, suggesting that some traditional hand hygiene practices warrant reexamination. Some recommended changes in practice include use of waterless alcohol-based products rather than detergent-based antiseptics, modifications in lengthy surgical scrub protocols, and incorporation of moisturizers into skin care regimens of health care professionals.

Assessing the need for infection control programs: a diagnostic approach

By using the PRECEDE model, we concluded that the need for standardized infection control programs in long-term care facilities is imminent and believe that the PRECEDE model has wide applicability in infection prevention and control. For example, it could be used to plan continuing education needs for the infection control department in a facility, or to plan a program to improve compliance with universal precautions or handwashing. Its use is limited only by the creativity of the planner.

The impact of physician-nurse interaction on patient care

The perceptions of physicians and nurses vary in a number of respects, including the extent to which collaboration and joint decision making are valued, the definition of what constitutes adequate and appropriate interprofessional communication, the quality of nurse-physician interactions, and the understanding of respective areas of responsibility as well as patient goals. Reasons for these differences have been attributed to gender, historical origins of the two professions, and disparities between physicians and nurses with regard to socioeconomic status, education, and socialization. Failure of physicians and nurses to interact in a coordinated and positive fashion results in unhealthy work environments and poor patient outcomes. Both professions must examine their will to improve interprofessional interactions.

Reframing the meaning of disability to families: the embrace of paradox

In our society, families turn to medical science and health practitioners for assistance when a family member becomes disabled. In the cases of chronic illnesses and developmental disabilities, health professionals may focus interventions on the disease processes, feeling unprepared to deal with the broader issues families struggle with in managing disability. In addition, collaboration between professionals and parents may be strained when family's discourse is viewed as unrealistic, overly emotional, exceedingly optimistic and confusing by professionals. Using in-depth case studies, this qualitative research examined the daily occupations and subjective well-being of six Mexican-origin mothers parenting children with disabilities. Emergent findings demonstrated that these mothers do express apparently contradictory emotions of grief and joy, hope and fear that influenced their subjective well-being. The meaning of the mothers' contrary statements was illuminated in a life metaphor, the embrace of paradox. The embrace of paradox was the management of the internal tension of opposing forces between loving the child as he or she was and wanting to erase the disability, between dealing with the incurability while pursuing solutions and between maintaining hopefulness for the child's future while being given negative information and battling their own fears. The tensions created by the paradox promoted an internal striving to maintain a tenuous hopefulness despite "crashes" in their maternal work, and promoted an extension of maternal skills working toward a hopeful life trajectory for the mother and her child. In the embrace of paradox mothers created a positive bias and regained a sense of control that fueled their optimism in maternal work.

Hospitalk: an exploratory study to assess what is said and what is heard between physicians and nurses

OBJECTIVE

Collaboration and effective communication between healthcare professionals has been demonstrated to improve patient outcomes and job satisfaction. The purpose of this study was to examine physician and nurse communication in a hospital setting during a time of very rapid change.

DATA SOURCES AND STUDY SETTING

Full-time attending internal medicine physicians (n = 5), registered nurses (n = 18), and medical residents (n = 12) working on two adult medical units in a 325-bed tertiary-care hospital in the mid-Atlantic region from fall 1996 to summer 1997.

STUDY DESIGN

Descriptive survey and interview.

DATA COLLECTION METHODS

Each subject completed a written questionnaire, Physician-Nurse Communication Scale, and a structured interview with a trained social linguistics team.

PRINCIPAL FINDINGS

Physicians and nurses shared similar perceptions regarding their roles in communication processes, such as giving orders, asking for information, and asking for and giving opinions. They differed significantly in the perceptions of the physician and nurse roles in giving information, orienting, and providing education. Generally, physicians perceived that nurses initiated certain types of communication significantly less often than did nurses. Both groups expressed an interest in more interaction; nurses particularly expressed the need to be "listened to" or respected more. Nurses were significantly more likely to express the need to change interactions with house staff than with attending physicians (P = .02).

CONCLUSIONS

Interactions between physicians and nurses are perceived differently by the two groups, leading to misunderstanding of motive and meaning. Recommendations are made to improve communication between these two professional groups.

Vancomycin resistant enterococcus in a hospital-based dialysis unit

OBJECTIVE

The emergence of vancomycin resistant enterococcus (VRE) poses a serious threat to the health care community. Reservoirs of VRE are thought to exist in certain high-risk patient groups who reintroduce the organism into the hospital environment. The frequent use of vancomycin in dialysis patients may place this population at higher risk of developing VRE. This article describes the development of VRE and a point prevalence study conducted in a hospital-based dialysis unit.

SETTING/SAMPLE

A dialysis unit of a tertiary care center in the eastern United States was selected as the study site. Patients who agreed to participate in the study after giving informed consent were included. Of the 85 members of this target population 33 (38.8%) agreed to participate in the study. The duration of the study was 30 days.

DESIGN

After the literature was reviewed, a point prevalence study was completed at the study site. Stool samples or rectal swabs were collected from the study participants and analyzed for the presence of VRE. A chart review of patient demographic and prior treatment information was completed in order to help identify factors that correlate to the presence of VRE.

METHODS

Stool or rectal swab samples were cultured on selective media and sensitivity to vancomycin was measured.

RESULTS

A 9.1% prevalence of VRE was detected within the study group. The number of VRE positive subjects (3) did not allow statistically significant correlation with the demographic and prior treatment data collected.

CONCLUSION

Although VRE remains a serious threat to the health care community, the prevalence of VRE within the study group does not vary markedly from rates previously reported.

Quality of diabetes care for non-English-speaking patients. A comparative study

To determine the quality of care provided to non-English-speaking patients with non-insulin-dependent (type 2) diabetes mellitus compared with English-speaking patients, we did a retrospective cohort study of 622 patients with type 2 diabetes, of whom 93 were non-English-speaking and 529 were English-speaking. They were patients at primary and specialty care clinics at a university and a county hospital, and the study was based on clinical and administrative database records with a 12-month follow-up. Professional interpreters were provided to all non-English-speaking patients. Patients were identified using interpreter services records, which reliably included all patients who did not speak English. After adjusting for demographic differences, significantly more non-English-speaking patients received care that met the American Diabetes Association guidelines of 2 or more glycohemoglobin tests per year (odds ratio, 1.9; 95% confidence interval, 1.2-3.0) and 2 or more clinic visits per year (odds ratio, 2.6; 95% confidence interval, 1.2-5.4). More non-English-speaking patients had 1 or more dietary consultations (odds ratio, 2.8; 95% confidence interval, 1.3-6.1). No other significant differences were found in routine laboratory test use or in the number of ophthalmologic examinations. Outcome variables also did not differ, including standardized glycohemoglobin and other laboratory results, complication rates, use of health services, and total charges. At these institutions, the quality of diabetes care for non-English-speaking patients appear to be as good as, if not better than, for English-speaking patients. Physicians may be achieving these results through more frequent visits and laboratory testing.

Effect of several interventions on the frequency of handwashing among elementary public school children

BACKGROUND

The purpose of this educational project was to assess the effect of several interventions on the frequency of handwashing among elementary public school children.

METHODS

Participants in this project were first-graders and fourth-graders from jurisdictions within a mid-Atlantic metropolitan area. Phase I included a baseline assessment of bathroom cleanliness as well as adequacy of supplies for handwashing in each school. During phase 2, the frequency of handwashing before lunch or after bathroom use was monitored and recorded during a 2-month period. The schools were separated into four groups: a peer education group, a hand wipes and instructional poster group, a combination of the education and hand wipes/poster groups, and a (control) comparison school.

RESULTS

Overall, a significant increase occurred in the proportion of handwashing frequency from preintervention to postintervention for each intervention group (wipes: 0.50 vs 0.66, p = 0.03; education only: 0.64 vs 0.72, p = 0.02; and education and wipes: 0.45 vs 0.67, p = 0.03) but not in the control group (0.42 vs 0.46, p = 0.26). When the first 3 weeks and the last 3 weeks after intervention were compared, handwashing frequency remained unchanged in the wipes only group (0.66 vs 0.66, p = 0.96), decreased in the education group (0.77 vs 0.65, p = 0.006), and increased in the education and wipes group (0.58 vs 0.75, p = 0.003), as well as in the control group (0.37 vs 0.52, p = 0.01).

CONCLUSION

Education combined with accessible convenient hand hygiene may result in a sustainable increase in the frequency of handwashing among elementary school children.

Predictors of functional status in patients in a chronic-care facility

OBJECTIVE

To identify those factors correlated with functional status levels (activities of daily living and mobility) in a chronically ill population in long-term care.

METHODS

Retrospective chart reviews were conducted over 3 months for information associated with functional status on all 220 patients in an urban extended-care facility. Independent variables included demographic variables, presence of selected medical conditions, current mental status, and baseline functional status on admission. Mean length of stay was 39 months. Multivariate analysis was performed to identify predictors of functional status.

RESULTS

Factors correlated with functional status levels for 217 patients included total score on admission functional status and total score on current mental status (both P < .0001). There were no significant differences in mean scores of total functional status by medical problem, age, gender, length of stay, condition, level of care, presence of infection, or use of psychotropic drugs.

Prevalence and correlates of skin damage on the hands of nurses

OBJECTIVE

To describe the prevalence and correlates of skin damage on nurses' hands.

DESIGN

Prevalence survey using self-report questionnaire of hand care regimens, problems, and skin condition, and visual examination of the hands at 30X magnification by trained investigators to evaluate degree of skin scaling.

SETTING

Four hospitals: two in the Mid-Atlantic and two in the northern United States.

PARTICIPANTS

Convenience sample of 410 nurses working 30 hours or more per week in acute care units.

OUTCOME MEASURES

Damage to skin of the hands.

RESULTS

Approximately one fourth of subjects (n = 106) met the criteria for currently damaged hands; 85.6% (n = 351) reported ever having skin problems. Damage was not correlated with age (p = 0.43), sex (p = 0.14), or skin type (p = 0.25), type of soap used at home (p = 0.58), reported duration of handwashing (p = 0.12), or glove brand (p = 0.90), but was significantly correlated with the type of soap used at work (p = 0.01), number of hand washes per shift (p = 0.0003), number of times gloves were worn (p = 0.008), and study site (p = 0.009). Variables significantly predictive of skin damage in a logistic regression analysis were type of soap used at work and number of times gloves were worn (p = 0.04). Geographic location was not a factor, because both the highest and lowest prevalence of skin damage occurred in the northern study institutions.

CONCLUSIONS

Damage to skin of the hands is a common and potentially serious problem among nurses, and is associated with gloving and handwashing practices rather than with geographic or demographic factors. Efforts to improve skin condition must focus on improving products and identifying any interactive effects between hand care products and glove materials and brands.

Academic freedom amidst competing demands

Academic freedom means freedom from control in the fulfillment of the faculty roles of teaching and scholarship, but conflicts and misunderstandings regarding this right and responsibility occur, particularly during a time of rapid change. This article discusses the potential conflicts inherent in the academic setting between faculty and administration and differentiates between the role of a faculty member and the academic administrator in three areas: service, scholarship, and support.

Social and economic impact of infectious diseases--United States

Despite major strides in the prevention and control of infectious diseases, they continue to take a significant economic and social toll in the United States. While progress toward meeting the Healthy People (HP) 2000 goals related to infections is generally on target, major disparities among certain groups (e.g., low-income, racial and ethnic minorities) still exist with regard to indicators such as immunization rates and rates of preventable infections. Preventable services for infectious diseases are among the most cost-effective. Progress toward meeting and sustaining the HP 2000 goals would be improved by universal entitlement for certain prevention services; reducing inconvenience as well as economic costs; appropriate utilization of all healthcare professionals and lay experts, as well as physicians; reducing inappropriate and costly use of resources such as antibiotics and specialist time; and engagement of the public and providers in national dialogue about risk benefit decision making, prioritization of use resources, and a focus on prevention rather than cure.

Intravascular site care: are critical care nurses practicing according to written protocols?

OBJECTIVE

To observe and describe site care for intravascular devices, to identify internurse variations in site care, and to compare written protocols for site care with actual practice in one geographic area.

DESIGN

Observational, descriptive study.

SETTING

Adult critical care units in one community, and one university teaching hospital in the Washington, D.C., metropolitan area.

SAMPLE

Direct observation of 86 central and 30 peripheral site care episodes.

RESULTS

A total of 116 site care episodes were observed on five critical care units. There were wide variations between units from the same hospital in gloving practices and use of aseptic technique. Significant differences across both hospitals, as well as between individual units, were noted for a number of other practices including: time since last site care, use of ointment and skin adhesive, type of dressing used, and duration of care. In both hospitals, compliance with all steps of the written protocol was similar-23.2% and 23.3%. Compliance with documentation requirements ranged from 53.3% to 85.7%, and was significantly different between the two hospitals with regard to recording the dressing change and whether the dressing label and chart agreed.

CONCLUSIONS

Intravascular site care varies significantly among critical care units within the same institution, as well as between different hospitals, and varies from written protocol. Standardized, well-defined site care protocols and education of staff, along with quality improvement surveillance systems are needed to ensure consistent quality intravascular site care.

Secreted amyloid beta-protein similar to that in the senile plaques of Alzheimer's disease is increased in vivo by the presenilin 1 and 2 and APP mutations linked to familial Alzheimer's disease

To determine whether the presenilin 1 (PS1), presenilin 2 (PS2) and amyloid beta-protein precursor (APP) mutations linked to familial Alzheimer's disease (FAD) increase the extracellular concentration of amyloid beta-protein (A beta) ending at A beta 42(43) in vivo, we performed a blinded comparison of plasma A beta levels in carriers of these mutations and controls. A beta 1-42(43) was elevated in plasma from subjects with FAD-linked PS1 (P < 0.0001), PS2N1411 (P = 0.009), APPK670N,M671L (P < 0.0001), and APPV7171 (one subject) mutations. A beta ending at A beta 42(43) was also significantly elevated in fibroblast media from subjects with PS1 (P < 0.0001) or PS2 (P = 0.03) mutations. These findings indicate that the FAD-linked mutations may all cause Alzhelmer's disease by increasing the extracellular concentration of A beta 42(43), thereby fostering cerebral deposition of this highly amyloidogenic peptide.