Nursing record systems: effects on nursing practice and healthcare outcomes

BACKGROUND

A nursing record system is the record of care that was planned or given to individual patients and clients by qualified nurses or other caregivers under the direction of a qualified nurse. Nursing record systems may be an effective way of influencing nurse practice.

OBJECTIVES

To assess the effects of nursing record systems on nursing practice and patient outcomes.

SEARCH STRATEGY

For the original version of this review in 2000, and updates in 2003 and 2008, we searched: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; MEDLINE, EMBASE, CINAHL, BNI, ISI Web of Knowledge, and ASLIB Index of Theses. We also handsearched: Computers, Informatics, Nursing (Computers in Nursing); Information Technology in Nursing; and the Journal of Nursing Administration. For this update, searches can be considered complete until the end of 2007. We checked reference lists of retrieved articles and other related reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs), controlled before and after studies, and interrupted time series comparing one kind of nursing record system with another in hospital, community or primary care settings. The participants were qualified nurses, students or healthcare assistants working under the direction of a qualified nurse, and patients receiving care recorded or planned using nursing record systems.

DATA COLLECTION AND ANALYSIS

Two review authors (in two pairs) independently assessed trial quality and extracted data.

MAIN RESULTS

We included nine trials (eight RCTs, one controlled before and after study) involving 1846 people. The studies that evaluated nursing record systems focusing on relatively discrete and focused problems, for example effective pain management in children, empowering pregnant women and parents, reducing loss of notes, reducing time spent on data entry of test results, reducing transcription errors, and reducing the number of pieces of paper in a record, all demonstrated some degree of success in achieving the desired results. Studies of nursing care planning systems and total nurse records demonstrated uncertain or equivocal results.

AUTHORS' CONCLUSIONS

We found some limited evidence of effects on practice attributable to changes in record systems. It is clear from the literature that it is possible to set up the randomised trials or other quasi-experimental designs needed to produce evidence for practice. Qualitative nursing research to explore the relationship between practice and information use could be used as a precursor to the design and testing of nursing information systems.

[Relatives' opinions of the nursing discharge summary in infants who have undergone surgery]

OBJECTIVES

To determine the utility of the nursing discharge summary and the degree of satisfaction with the information received by the relatives of infants' after surgery.

METHOD

We conducted an observational, descriptive, cross-sectional study in the infants unit at the Juan Canalejo University Hospital Complex in La Coruña (Spain). A total of 110 patients were included, all aged between 1 month and 2 years, who were hospitalized between January and December 2006. A telephone survey was performed among the relatives of selected infants, using an adapted questionnaire consisting of eleven questions related to the aim of this study.

RESULTS

Eighty-five families were surveyed. The nursing discharge summary was given to 98.8% of the families. During hospitalization, 91.8% of the parents received information about the care to be continued at home. The relatives surveyed gave nursing explanations a mean score of 4.6 points (SD = 0.61) (1 "bad", 5 "excellent"); 96.5% considered the contents of the nursing discharge summary to be adequate, and 97.6% found the information easy to understand. A total of 17.6% resorted to the primary health care center to continue with care and 7.1% to clarify doubts. The mean score for overall satisfaction with the summary was 4.67 points (SD = 0.54) out of a possible maximum of 5 points.

CONCLUSIONS

The nursing discharge summary used in the infants' unit provides the relatives and guardians of infants with sufficient information that is easy to understand and matches their needs. We highlight the high degree of satisfaction with the summary.

Public health law for the collection and reporting of health care-associated infections

BACKGROUND

State-based laws for reporting of health care-associated infections (HAI) have developed and changed dramatically in recent years, affecting the costs of reporting and impact on infection rates. It is necessary for practitioners of infection control to understand these changing legal frameworks and their application to practice.

METHODS

Employing systematic state-based research, the researchers have documented legislation and administrative regulations for institution-specific HAI reporting, using this information to create a comprehensive resource on state-based laws for mandatory HAI reporting.

RESULTS

As of August 27, 2007, 24 states have adopted laws requiring reporting of HAI rates, with an additional 7 states currently considering legislation that would require HAI reporting and 19 states employing detailed regulation in the absence of any current legislative authorization specific to HAI. This study documents (1) which states require reporting of HAI and, if so, whether this is done by legislation or administrative regulation; (2) whether the specific HAIs to be reported are identified in state law or codified generally as "diseases of public health importance," with reporting specified by administrative regulation; and (3) what reporting policies and procedures are detailed in law.

CONCLUSION

Through analysis of the collected information, the researchers have examined the degree to which states have modernized their respective public health laws to approach mandatory reporting by way of general legislation regarding "matters of public health importance" and subsequent detailed administrative regulation to specify those matters.

Frequent and rare complications of resuscitation attempts

INTRODUCTION

Resuscitation attempts require invasive iatrogenic manipulations on the patient. On the one hand, these measures are essential for survival, but on the other hand can damage the patient and thus contain a significant violation risk of both medical and forensic relevance for the patient and the physician. We differentiate between frequent and rare resuscitation-related injuries. Factors of influence are duration and intensity of the resuscitation attempts, sex and age of the patient as well as an anticoagulant medication.

MATERIALS AND METHODS

Review of current literature and report on autopsy cases from our institute (approximately 1,000 autopsies per year).

RESULTS

Frequent findings are lesions of tracheal structures and bony chest fractures. Rare injuries are lesions of pleura, pericardium, myocardium and other internal organs as well as vessels, intubation-related damages of neural and cartilaginous structures in the larynx and perforations of abdominal organs such as liver, stomach and spleen.

CONCLUSION

We differentiate between frequent and rare complications. The risk of iatrogenic CPR-related trauma is even present with adequate execution of CPR measures and should not question the employment of proven medical techniques.

[Comparative study of burnout in Intensive Care and Emergency Care nursing staff]

OBJECTIVE

To assess and compare the burnout level between Intensive Care Unit and Emergency Unit, and study its association with the sociodemographic and work characteristics of the professionals surveyed.

DESCRIPTION

Cross-sectional, descriptive study. Emplacement. Intensive Care Unit of the university hospital Morales Meseguer, Murcia-Spain. STUDIED SAMPLE: 97 nursing professionals: 55 professionals belong to the Emergency Department, and 42 professionals belong to the Intensive Care Department.

METHOD

Two evaluation tools were used: a sociodemographic and work survey, and the Maslach Burnout Inventory, 1986. Quantitative variables expressed as mean +/- SD compared with the Student's T test and qualitative variables compared with the chi2 test.

STATISTICAL ANALYSIS

SPSS 12.0(c).

RESULTS

The comparative analysis of the burnout dimensions shows that emotional exhaustion level is significantly higher in the intensive care service than in the emergency one (25.45 +/- 11.15 vs 22.09 +/- 10.99) p < 0.05. The rest of burnout dimensions do not show significant differences between both departments. The masculine gender obtains a higher score in the depersonalization dimension of burnout (10.12 +/- 5.38) than female one (6.7 +/- 5.21) p < 0.01. There is greater vulnerability to emotional exhaustion among the professional group with more than 15 years of work experience (F = 3.592; p = 0.031).

CONCLUSIONS

The burnout levels are moderate to high among the nursing professionals studied. A total of 5.15% of the sample studied achieves a high score in the three dimensions of the burnout syndrome. The intensive care professionals are the most vulnerable to suffering high levels of emotional exhaustion, and the masculine gender is more susceptible to depersonalization attitudes.

[Effect of the do-not-resuscitate orders on the critical patient care plan]

BACKGROUND

Do-not-resuscitate (DNR) orders are physician orders that refer to not initiating cardiopulmonary resuscitation in a patient who is in cardiac or respiratory arrest. However, these orders often imply other treatment modifications.

AIMS

To analyze the effect that do-not-resuscitate orders have on the care plan of the critically ill patient; and to analyze if differences exist in the nursing workload (NEMS), before and after DNR prescription.

METHOD

This descriptive study analyzed the care plan of 50 critically ill adult patients, before and after an electronic DNR order.

RESULTS

After the DNR order was written the following variations were found: treatment was withdrawn in 30 patients; initiated in 6; both withdrawn and initiated in 12 patients; and there were no changes in their treatment in 2 patients. Specific modifications were: respiratory support: invasive mechanical ventilation was withdrawn in 7 patients, and non-invasive ventilation in 3, and the FiO(2) of the ventilator was reduced in 15 patients on the day of death; circulatory support: in 10 patients vasoconstrictor drugs were withdrawn and in one patient this therapy was initiated; inotropic drugs were withdrawn in 3 patients and initiated in 2 patients; extrarenal depuration hemofiltration was withdrawn in 4 patients and initiated in 2. The NEMS scores decreased on the patients after the order was written (36.20-34.62; p = 0.03).

CONCLUSIONS

Do-not-resuscitate orders have an effect on the care plan of the critically ill adult patient. Also, although the NEMS scores decrease after the order, the nursing workload remains the same due to an increase in the psychosocial intervention with patient and family.

[Stressful environmental events in the Intensive Care Unit]

The high standard of specialization of the Intensive Care Units (ICU) creates a stressful setting that generates anxiety and stress for the patients. This has been related to delirium or acute confusional syndrome.

OBJECTIVES

To describe the stressful environmental events as perceived by patients an, to establish the differences between patients who suffered from delirium in ICU and those who did not suffer from it.

MATERIAL AND METHODS

Descriptive crosssectional study that includes a qualitative part. A total of 91 patients were interviewed, 33 patients diagnosed of delirium in the ICU and 58 patients without this diagnosis. Ballard's Environmental stressful events scale with 43 items was used to determine the most stressful events. In addition, an open interview was carried out in which the patients could narrate their experiences in the ICU. Descriptive statistic was used to show the characteristics of patients selected and to determine the frequency distributions for each item inthe questionnaire.

RESULTS

The factors perceived as the most stressful were: thirst(62.6%), sleep deprivation (42.9%), tubes in mouth or nose (35.2)and not knowing what time it was (34.1). Patients who suffered from delirium perceive disorientation or hallucinations as stressants

CONCLUSIONS

As in previous investigations, ICU patiens, who did not suffered from delirium, perceived phisycal needs as most streesfull events.

Modeling the distribution of Nursing Effort using structured Labor and Delivery documentation

Our study objectives included the development and evaluation of models for representing the distribution of shared unit-wide nursing care resources among individual Labor and Delivery patients using quantified measurements of nursing care, referred to as Nursing Effort. The models were intended to enable discrimination between the amounts of care delivered to patient subsets defined by attributes such as patient acuity. For each of five proposed models, scores were generated using an analysis set of 686,402 computerized nurse-documented events associated with 1093 patients at three hospitals during January and February 2006. Significant differences were detected in Nursing Effort scores according to patient acuity, care facility, and in scores generated during shift change versus non-shift change hours. The development of nursing care quantification strategies proposed in this study supports outcomes analysis by establishing a foundation for measuring the effect of patient-level nursing care on individual patient outcomes.

[What is important for the family of patients in the intensive care unit?]

The abundant bibliography shows us that the family plays a fundamental paper in the recovery of the hospitalized patients, and the patients in the intensive care units (ICU) are no exception. Several authors have demonstrated that a stress-free and calm setting helps in the care process. Thus, the family needs must be considered to improve their well-being. In this way, their attitude will help in the patient's recovery. Health care personnel must be aware of these needs and make up for their deficit as far as possible. The first study that evaluated this question used the CCFNI questionnaire (Critical Care Family Needs Inventory) that measures the degree of importance given by the relatives to the needs of safety, support, information, comfort and proximity. This study has aimed to detect the degree of importance given by the relatives of the patients in the ICU of the Hospital Dr. Josep Trueta of Girona, using the CCFNI questionnaire. All the relatives of the patients in said unit during the autumn of the year 2003 were interviewed and the needs considered to be most important were compared with the sociodemographic variables of the relatives. The total sample was made up of the 132 people interviewed. The need considered to be most important was safety with 50.3% followed by need for support with 47.2%. In the results, some differences were observed depending according to age and studies of those surveyed and according to the diagnosis and the origin of the hospitalization. The collected data did not differ with the reviewed bibliography. All the study was very valuable for the health care professionals of the unit and was taken into account to improve the deficiencies of the ICU of the hospital of Girona.

[AURORA 2003: Intensive care nursing discharge report manager]

Since December 2003, the Intensive Care Unit (ICU) of the Hospital General Universitario of Alicante has a new nursing discharge report and the Aurora 2003 program to be filled out and filed.

OBJECTIVES

Evaluate the Aurora 2003 program and determine the degree of its use, in addition of evaluate user satisfaction with this program.

MATERIAL AND METHODS

Having initiated the program, anonymous surveys were given to the nurses of the ICU. The percentage of reports filled out with the program, the professionals who had become to fill out the report by computer instead of in writing and their satisfaction with the program were obtained.

RESULTS

A nursing discharge report was issued for 563 (85%) of the patients who were discharged: 473 (84%) with the Aurora 2003 program and 92 (16%) manually. A total of 43 nurses (86%) used the program, 30 (71%) felt it was easy to use and 22 (52%) felt that is did not add any greater workload. The new report is better according to 35 (73%) professionals.

CONCLUSIONS

1) The Aurora 2003 program is used by most of the nurses of the ICU of the Hospital General Universitario of Alicante. They classify it as easy or very easy to learn and use. 2) The Aurora 2003 is a good tool for the management of nursing discharge reports.

[Is the NEMS scale useful to describe homogeneously a population of patients in Intensive Care?]

The use of scales that quantify therapeutic effort and severity level is a common practice in Intensive Care Units (ICU). The NEMS and APACHE II scales allow us to objectively determine the therapeutic effort and severity level of the patients admitted to the unit. With the use of both scales, we aimed to control our work quality, comparing the results obtained with various measurements. In this way, we will discover what type of patients require a greater workload, and we will also be able to distribute them according to care levels. We designed a prospective study of 458 patients hospitalized in a 6-bed ICU of a community hospital. The obtained results demonstrate that there is a correlation in our unit between the NEMS and APACHE II scales. Due to the characteristics of our hospital, most of the patients we admit are classified into care level 2 (NEMS 18-30). Surgical patients have a greater NEMS than medical patients (p = 0.02). If we divide our patients according to diseases, it stands out that the highest score corresponds to cardiovascular surgery postoperative patients in a sub-acute period (NEMS 39.13 +/- 13) and the lowest one to traumatologic surgery postoperative patients (NEMS 20.66 +/- 3.72). It is concluded that the NEMS scale is easily applied and can reflect the effort of nursing care staff. With the data obtained through the application of the NEMS and APACHE II scales, we could objectively define our work and classify the patients we treated according to care levels.

Closed tracheal suction systems versus open tracheal suction systems for mechanically ventilated adult patients

BACKGROUND

Ventilator-associated pneumonia is a common complication in ventilated patients. Endotracheal suctioning is a procedure that may constitute a risk factor for ventilator-associated pneumonia. It can be performed with an open system or with a closed system. In view of suggested advantages being reported for the closed system, a systematic review comparing both techniques was warranted.

OBJECTIVES

To compare the closed tracheal suction system and the open tracheal suction system in adults receiving mechanical ventilation for more than 24 hours.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2006, Issue 1) MEDLINE, CINAHL, EMBASE and LILACS from their inception to July 2006. We handsearched the bibliographies of relevant identified studies, and contacted authors and manufacturers.

SELECTION CRITERIA

The review included randomized controlled trials comparing closed and open tracheal suction systems in adult patients who were ventilated for more than 24 hours.

DATA COLLECTION AND ANALYSIS

We included the relevant trials fitting the selection criteria. We assessed methodological quality using method of randomization, concealment of allocation, blinding of outcome assessment and completeness of follow up. Effect measures used for pooled analyses were relative risk (RR) for dichotomous data and weighted mean differences (WMD) for continuous data. We assessed heterogeneity prior to meta-analysis.

MAIN RESULTS

Of the 51 potentially eligible references, the review included 16 trials (1684 patients), many with methodological weaknesses. The two tracheal suction systems showed no differences in risk of ventilator-associated pneumonia (11 trials; RR 0.88; 95% CI 0.70 to 1.12), mortality (five trials; RR 1.02; 95% CI 0.84 to 1.23) or length of stay in intensive care units (two trials; WMD 0.44; 95% CI -0.92 to 1.80). The closed tracheal suction system produced higher bacterial colonization rates (five trials; RR 1.49; 95% CI 1.09 to 2.03).

AUTHORS' CONCLUSIONS

Results from 16 trials showed that suctioning with either closed or open tracheal suction systems did not have an effect on the risk of ventilator-associated pneumonia or mortality. More studies of high methodological quality are required, particularly to clarify the benefits and hazards of the closed tracheal suction system for different modes of ventilation and in different types of patients.

Alteraciones emocionales y necesidades psicológicas de pacientes en una Unidad de Cuidados Intensivos

From the time when a disease whose treatment is going to require hospitalization for a surgical intervention is diagnosed, both the patient and his/her family members or primary caretakers are involved in a process that may involve the experience of several emotional alterations. This work focuses on the description of the different psychological problems and needs manifested by the patients who require, as part of the treatment process and recovery control, admission to an Intensive Care Unit (ICU). During the patient's stay in the ICU, the emotional alterations mentioned most frequently by them are anxiety, stress, depression or the so-called intensive care syndrome, during which factors such as excessive noise that may make sleeping and rest difficult, pain, the methods used for ventilation that prevent the patients from communicating adequately, etc. Furthermore, the patients generally develop a feeling of loss of self-control, the main needs described being the sensation of safety and "knowing what is happening". The experiences lived may continue to produce emotional alterations even months after hospital discharge, with the development of a Posttraumatic Stress Disorder. This justifies a follow-up in order to detect them and treat them adequately. It seems to be appropriate for the treatment of these patients to be multidisciplinary, attending to both the physical needs related with the disease as well as the psychological ones.

Propuesta de una nueva escala de valoración de cargas de trabajo y tiempos de enfermería (VACTE©)

The scale Nine Equivalents of nursing Manpower use Score (NEMS) for the evaluation of the nursing care loads is the most well known and applied worldwide. Nevertheless, we have found a series of limitations: it does not reflect the "proper nursing activity" but only the cares related to the medical intervention. Furthermore, it is directly related to severity while integral attention to the patient implies an infinity of cares, which are not necessarily related to the severity. In addition, we understand that the planned personnel ratios may be unsuitable, with the consequent repercussions for the patient, nurses and the sanitary institution. The primary targets were: elaboration of a representative scale of all the cares and tasks made by the nurses (VACTE) in our unit, to determine if it is more precise and objective than NEMS for the measurement of the service loads and to calculate the operative ratio patient-nurse based on the new proposed scale. We made a descriptive and retrospective study on 91 patients admitted to the Intermediate Care Unit of the Fundación Hospital de Jove during the first three months of 2004. Previously we created scale VACTE, making real measurements of the time inverted in the execution of each one of the cares in 50 patients. Later, a comparison was made between the APACHE II, NEMS and VACTE scales, taking as reference the scores obtained in the same ones during the first 24 hours of the stay. The statistical analysis was made by SPSS 11.0, assuming a confidence level of 95% (p < 0.05): lineal analysis of simple regression to compare the different scales; the force of its correlation with Spearman's coefficient and we compared the independent dichotomize variables with the Mann-Whitney test. The main results determined after the study were the following: regarding the scale to evaluate seriousness applied to the patients, an average APACHE II score of 12.1 +/- 5.9 was obtained. The average value with the NEMS was 19.5 +/- 5.7 and the average one with VACTE was 365 +/- 91.2. Significant differences were found between APACHE II and the NEMS (p = 0.008) and VACTE (p < 0.001) scales. This relationship presented more force with VACTE (r = 0.43; p < 0.001) than with NEMS (r = 0.23; p = 0.002). The operative patient-nurse ratio calculated with VACTE was 2.01. Scale VACTE is representative of nursing activity and seems to be more effective than NEMS to determine service loads. The ratio planned in the unit duplicated the calculated operative ratio.

[Intermediate Care Units dependent on Internal Medicine in a hospital without an Intensive Care Unit]

Intermediate care units are considered a solution for care of patients who require superior care than those in a normal hospitalization ward but are not amenable to intensive therapy. We present our experience with an open model, with a responsible person of the ward appointed to the Internal Medicine Department, that could be assumed in other hospitals without Intensive Care Unit in which these units would also avoid unnecessary transfers or make it possible to optimize them so that these are done under better conditions.

[Comparative study of maintenance of patency of triple lumen central venous catheter]

OBJECTIVE

Establish an action protocol for the maintenance of patency of the three lumen central venous catheters (CVC) when any of them are not used. The main variable of interest was evaluate it 24 hours.

MATERIAL AND METHOD

This is a blind, randomized clinical trial. Phase 1: Comparison of efficacy, for maintenance of patency of the lumen at 24 hours and on discharge of the patient, of sodium heparin 500 IU (control 1), versus sodium heparin 100 IU (study 1). Phase 2: Once efficacy of sodium heparin 100 IU (control 2) was confirmed, we compared it with saline solution (SS) (study 2).

POPULATION

multiple diseased patients admitted to eight critical care unit who were carriers of 3 lumen CVC without previous coagulation disorders.

ANALYSIS

quantitative variables with mean (SD) analyzed with Student's t test and qualitative ones with -2.

ANALYSIS

SPSS 12.0 program.

RESULTS

Phase 1: 128 catheters (control 1: 49, study 1: 79). Mean days of permanency with CVC: 5.4 (SD 6). At 24h, 100% of the CVC of both groups were patent. On discharge of the patient (n = 107) were not patent and 4.9% of the control group and 4.5% of the study group 1. Phase 2: 95 catheters (control 2: 38, study 2: 57) Mean days of permanency: 4.87 (SD 5). At 24h (n = 95), at 72 h (n = 66) and on discharge (n = 43), 100% of the CVC of both groups were patent. No significant difference was established in the two study phases between the groups studied with days of permanence, laboratory values and anticoagulant treatment.

CONCLUSIONS

SS is as effective as 100 or 500 IU of heparin for maintenance of patency of CVC.

Open and closed endotracheal suction systems in mechanically ventilated intensive care patients: a meta-analysis

BACKGROUND

Closed suction systems (CSS) are increasingly replacing open suction systems (OSS) to perform endotracheal toilet in mechanically ventilated intensive care unit patients. Yet effectiveness regarding patient safety and costs of these systems has not been carefully analyzed.

OBJECTIVE

To review effectiveness of CSS and OSS, with respect to patient outcome, bacterial contamination, and costs in adult intensive care unit patients.

DATA SOURCE

Search of MEDLINE, CINAHL, EMBASE, and Cochrane databases and a manual review of article bibliographies.

STUDY SELECTION

Randomized controlled trials comparing CSS and OSS in adult intensive care unit patients were retrieved.

DATA EXTRACTION/SYNTHESIS

Assessment of abstracts and study quality was performed by two reviewers. Data were combined in meta-analyses by random effect models. Fifteen trials were identified. No significant differences were found in incidences of ventilator-associated pneumonia (eight studies, 1,272 patients) and mortality (four studies, 1,062 patients). No conclusions could be drawn with respect to arterial oxygen saturation (five studies, 109 patients), arterial oxygen tension (two studies, 19 patients), and secretion removal (two studies, 37 patients). Compared with OSS, endotracheal suctioning with CSS significantly reduced changes in heart rate (four studies, 85 patients; weighted mean difference, -6.33; 95% confidence interval, -10.80 to -1.87) and changes in mean arterial pressure (three studies, 59 patients; standardized mean difference, -0.43; 95% confidence interval, -0.87 to 0.00) but increased colonization (two studies, 126 patients; relative risk, 1.51; 95% confidence interval, 1.12-2.04). CSS seems to be more expensive than OSS.

CONCLUSIONS

Based on the results of this meta-analysis, there is no evidence to prefer CSS more than OSS.

Fluid replacement via the rectum for treatment of hypovolaemic shock in an animal model

BACKGROUND

The importance of early and effective fluid resuscitation in hypovolaemic shock treatment is indisputable.

AIM

To examine the effects of fluid replacement via the rectum in an animal model of hypovolaemic shock as a possible life-saving method in situations where veins cannot be accessed quickly.

METHODS

Rabbits were randomly divided into two groups: a control group of 7 animals and a second group of 10, the fluid replacement via the rectum (FRVR) group. The femoral artery of each subject was catheterised and 15 ml blood was withdrawn over 1 min at 5-min intervals. After reaching a mean arterial pressure (MAP) of 30 mm Hg, additional blood was withdrawn until the MAP dropped to <25 mm Hg, at which time blood withdrawal ceased. At this point, control animals were given no treatment and were monitored for 30 min. The FRVR group, however, was given 0.9% sodium chloride solution (amount equal to three times the amount of blood withdrawn) via the rectum over a 15-min period. The MAPs of both groups were then measured, every 5 min after the start of resuscitation, for 30 min.

RESULTS

In the FRVR group, the MAP began to rise significantly after 15 min of receiving fluid per rectum (p = 0.035) and continued to be significantly greater than the control group at 20, 25 and 30 min (p = 0.035, 0.002 and 0.001, respectively).

CONCLUSION

FRVR is a viable alternative for fluid resuscitation in this animal model of hypovolaemic shock. This easy and non-invasive method of fluid replacement may be useful when standard intravenous access is unobtainable, and should be compared with other access routes using varying types and amounts of fluids in future animal studies.

[Care work load in critical patients. Comparative study NEMS versus NAS]

INTRODUCTION

The systems of calculating care load have not yet reached the levels of generalized use which the systems of prognostic estimation of survival have. The reason for this is their potential defects of design (medical and not nursing conceptualization) and the sometimes confusing completion (TISS 76). The simplest ("nine equivalents of nurse manpower use score" [NEMS], care levels) add the difficulty of not being useful for the calculation of staff, because the design is not oriented towards nursing. The development of NAS (nursing activity score) by FRICE tries to solve all these problems. Our objective has been to verify to what degree the NEMS and NAS are correlated as systems of expression and calculation of care load.

PATIENTS AND METHOD

During the last quarter of 2004, NEMS and NAS have been used simultaneously by the nursing staff. During this period, 150 pairs of daily calculation values of NEMS-NAS and 150 pairs of calculation values by shift of NEMS-NAS have been collected. Comparison of means and linear correlation of values obtained and the analysis of the histograms of values of each series, their value ranges and analysis of their bias coefficients have been done. The analysis was done with the SPSS/PC 11.

RESULTS

During the period indicated, it has been verified that NEMS has a much narrower value range than NAS, both in regards to daily values (18-45 versus 29.70-84.50) and in regards to values by shift (18-45 versus 22.40-84.50). The bias analysis shows a deviation to the left of both series of values. Linear correlation between NEMS-NAS by shift shows a R2 of 0.1634 and becomes even poorer in the NEMS-NAS correlation per day with R2 of 0.2012. It should also be stressed that NEMS expresses its results in points while NAS does so in percentage of time occupied in the attention and care of the patient.

CONCLUSIONS

In this preliminary study, the better adaptation of NAS versus NEMS to real work loads of patients hospitalized in the ICU and the non-possible correlation between the values of both systems is affirmed.

Consensus forum: worldwide guidelines on the critical care nursing workforce and education standards

This article explores the key themes, evidence, and arguments that inform the current position statements. It is acknowledged that future research, evidence, and practice experience may create the need to review and change these guidelines. Reform and refinement of the guidelines are inevitable; however, the current guidelines represent the best attempt yet to reach international consensus on what are appropriate standards to guide critical care nursing education and workforce requirements.

Epidemiology, risk and prevention of pressure ulcers in critically ill patients: a literature review

New nursing interventions and pressure-redistributing devices in intensive care units, and specific risk factors affecting critically ill patients, mean that different factors must be taken into consideration in preventing pressure ulcers.

Quality of life after acute respiratory distress syndrome: a meta-analysis

OBJECTIVE

To summarize long-term quality of life (QOL) and the degree of variation in QOL estimates across studies of acute respiratory distress (ARDS) survivors.

DESIGN

A systematic review of studies evaluating QOL in ARDS survivors was conducted. Medline, EMBASE, CINAHL, pre-CINAHL, and the Cochrane Library were searched, and reference lists from relevant articles were evaluated. Two authors independently selected studies reporting QOL in adult survivors of ARDS or acute lung injury at least 30 days after intensive care unit discharge and extracted data on study design, patient characteristics, methods, and results.

MEASUREMENTS AND RESULTS

Thirteen independent observational studies (557 patients) met inclusion criteria. Eight of these studies used eight different QOL instruments, allowing only qualitative synthesis of results. The five remaining studies (330 patients) measured QOL using the Medical Outcomes Study 36-Item Short Form survey (SF-36). Mean QOL scores were similar across these studies, falling within a range of 20 points for all domains. Pooled domain-specific QOL scores in ARDS survivors 6 months or later after discharge ranged from 45 (role physical) to 66 (social functioning), or 15-26 points lower than population norms, in all domains except mental health (11 points) and role physical (39 points). Corresponding confidence intervals were no wider than +/-9 points. Six studies all found stable or improved QOL over time, but only one found significant improvement beyond 6 months after discharge.

CONCLUSIONS

ARDS survivors in different clinical settings experience similar decrements in QOL. The precise magnitude of these decrements helps clarify the long-term prognosis for ARDS survivors.

Tracheal suction by closed system without daily change versus open system

BACKGROUND

Tracheal suctioning costs are higher with a closed tracheal suction system (CTSS) than with an open system (OTSS), due to the need for complete daily change as recommended by the manufacturer. However, is it necessary to change the closed system daily?

OBJECTIVE

To evaluate the tracheal suctioning costs and incidence of ventilator-associated pneumonia (VAP) using closed system without daily change vs OTSS.

DESIGN

Prospective and randomised study.

SETTING

An Intensive Care Unit in a university hospital.

PATIENTS

Patients requiring mechanical ventilation.

INTERVENTIONS

Patients were randomly assigned to CTSS without daily change or OTSS. We used a CTSS that allowed partial or complete change.

MEASUREMENTS AND RESULTS

There were no significant differences between both groups of patients (236 with CTSS and 221 with OTSS) in gender, age, diagnosis, APACHE-II score, mortality, number of aspirations per day, percentage of patients who developed VAP (13.9 vs 14.1%) or the number of ventilator-associated pneumonia per 1000 days of mechanical ventilation (14.1 vs 14.6). There were not significant differences in tracheal suctioning costs per patient/day between CTSS vs OTSS (2.3+/-3.7 vs 2.4+/-0.5 Euros; p=0.96); however, when length of mechanical ventilation was lower than 4 days, the cost was higher with CTSS than with OTSS (7.2+/-4.7 vs 1.9+/-0.6 Euros; p<0.001); and when length of mechanical ventilation was higher than 4days, the cost was lower with CTSS than with OTSS (1.6+/-2.8 vs 2.5+/-0.5 Euros; p<0.001).

CONCLUSION

CTSS without daily change is the optimal option for patients needing tracheal suction longer than 4 days.

Evaluating the reliability of recorded fluid balance to approximate body weight change in patients undergoing cardiac surgery

OBJECTIVES

The objective of this study was to investigate body weight change in adult patients undergoing cardiac surgery and to assess the accuracy of conventional recorded fluid balance charting methods to reflect this change in body weight.

DESIGN

This was a descriptive study.

SETTING

This study was conducted at the cardiac care unit and medical-surgical intensive care unit (ICU) of a private hospital in Melbourne, Australia.

SUBJECTS

The subjects were 32 adult patients who underwent cardiac surgical procedures. Twenty-six were male, and the mean age was 67 years (range 36-84 years). Twenty-three patients underwent coronary artery bypass graft surgery, and nine patients underwent heart valve repair or replacement+/-coronary artery bypass graft surgery between December 2003 and May 2004.

OUTCOME MEASURES

The measures were recorded fluid balance for the perioperative period together with body weight measurements from the night before surgery and immediately on discharge from the ICU. An additional body weight measurement on the seventh postoperative day provided a trajectory of body weight gain or loss for the period of hospitalization after surgery. A retrospective medical history audit and an HV-CS digital chair scale (A&D Mercury Pty Ltd, Victoria, Australia) were used to collect the data.

RESULTS

Analysis revealed that 30 patients increased their body weight from the night before surgery until discharge from the ICU. The mean weight gain was 3.34 kg (standard deviation [SD] 1.17, 95% confidence interval 2.70-3.98, P<.001). The average preoperative body weight was 80.97 kg (SD 16.79), whereas the average ICU postoperative weight was 83.94 kg (SD 16.15). Twenty-six patients (81.25%) had returned to, or were below, their preoperative weight by their seventh postoperative day (M 2.96 kg, SD 2.24 kg, P<.05). The average recorded fluid balance during the perioperative period was +1.56 L (SD 2.59 L, P<.001) with a difference of 1.39 kg between the recorded fluid balance and measured body weight change. Three patients (9.75%) met the criteria for accurate recorded fluid balance, and eight patients (25%) experienced a net difference in the opposite direction between recorded fluid balance and body weight change during the perioperative period.

CONCLUSION

Body weight in patients who undergo cardiac surgery was found to fluctuate over the perioperative period. Use of recorded fluid balance to reflect change in body weight for patients undergoing cardiac surgery was deemed unreliable. Further investigation of body weight change and scrutiny of conventional recorded fluid balance charting methods for patients who undergo cardiac surgery is needed.

[Intracranial pressure response during secretion aspiration after administration of a muscle relaxant]

Aspiration of secretions is a usual nursing technique in patients undergoing mechanical ventilation that may be the cause of increased Intracranial Pressure (ICP).

OBJECTIVE

This study aims to evaluate the repercussion of a muscle relaxant on ICP with secretion aspiration.

METHOD

Clinical trial using the same patient as case and control, performing two endotracheal aspirations in each patients, on of them after administration of a muscle relaxant (Cis-Atracurium) and another no. The bolus administration of the relaxant in the first or second aspiration was done randomly. Thirteen patients with intraparenchymatous ICP measurement catheter were studied within the first 36 hours post-placement and with sedoanalgesia for a score of 6 on the Ramsay scale. ICP and CPP were measured before, during and after each aspiration.

STATISTICAL METHOD

SPSS 11.0 program was used. Data analysis by Student's t test for paired data. Statistical significance level accepted was 95%.

RESULTS

On comparing the cases in which muscle relaxant was administered with those in which it was not administered, statistically significant differences were found in the ICP and CCP values during secretion aspiration.

CONCLUSIONS

According to the data obtained in the study, a lower increase of ICP was observed during secretion aspiration in those cases in which muscle relaxant was administered prior to the aspiration.

Nursing Activity Score (NAS). Nuestra experiencia con un sistema de cómputo de cargas de enfermería basado en tiempos

INTRODUCTION

The load calculation systems of nursing work in the ICU has not had the same success in its introduction as the prognostic survival estimation systems. It causes may be: a medical design not oriented towards nursing (Therapeutic Intervention Scoring System--TISS in all its versions), lack of adaptation to the calculating of staff (Nursing Manpower Use Score--NEMS, care levels) and demand for permanent technological up-dating. In 2003, NAS was published in an attempt to obviate all the problems expressed. Its result expresses the percentage of nursing work time required for attention to each patient. Our objective has been to apply the method in our ICU and evaluate its results.

PATIENTS AND METHODS

During the last quarter of 2004, NAS was systematically applied to all the patients admitted to our ICU, regardless of the reason for admission and stay time in the Unit. The analysis of this application was done by SPSS/PC 11.

RESULTS

NAS calculations of 350 patients, which represents 1880 total registers, were collected during the mentioned period. The NAS result of the first day was analyzed, 40.8 +/- 14.1, comparing it with its evolution during all the stay days of each patient, until reaching the ICU discharge date (39.3 +/- 12.7). The mean stay of our series has been 4.3 +/- 5.4 days during this period and the total accumulated NAS per patient was 196.2 +/- 279.8. There was no good correlation (R2: 0.273) between the NAS score on the first day of stay in the ICU but there was between total NAS and total stay of each case (R2: 0.958). Translated into times, this implies that one nurse can care for (by shift and average) 2.5 patients in our ICU.

CONCLUSIONS

This system adapts, without demands of periodic up-dating, to the real nursing work in the ICU. Its design is oriented to nursing work, regardless of the disease that justifies admission to the ICU. It is useful to adequately evaluate the nursing staff in the conventional ICU.

Úlceras por presión en cuidados intensivos: valoración del riesgo y medidas de prevención

Pressure ulcers (PU) are associated to greater patient morbidity and mortality. Thus, all prevention measures are very important. In order to establish the appropriate care early, the first measure is the identification of patients at risk of developing PU, using specific scales.

OBJECTIVES

1) to assess the risk of developing PU in the patients admitted in an Intensive Care Unit (ICU), using the Waterlow scale; 2) to identify patients with PU and to analyse the possible relationship between them and the measured risk; 3) to analyse the preventive care received by patients for its prevention.

METHOD

This descriptive study analysed the risk of developing PU in 91 critical patients with a stay greater than 3 days. To measure the risk the Waterlow scale (modified by Weststrate in 1998), that included 14 risk factors, was used. Sociodemographic data, cause of admission, patients with PU, its location and grade and care applied were also collected.

RESULTS

Risk grade obtained on the Waterlow scale was: without risk (< 10 points) in 8 patients, 23 with risk (10-14 points), 29 with high risk (15-19 points) and 31 had very high risk (20 points). Thirteen patients had ulcer, in 10 of them it was present on admission. Their score obtained on the scale was risk in 2 patients, high risk in 5 and very high risk in the remaining 6. A statistically significant difference was found between the mean score of risk of the 13 patients who had ulcer and the remaining sample (21.85-16.83; p = 0.005). When the risk factors included in the scale and its relationship with the presence of ulcer were analysed, statistically significant difference was only found in the "heart failure" factor (vasoconstrictor treatment), p = 0.045. No association was found between age, gender, diagnosis and presence of ulcer. Regarding the daily care applied to patients, the following results were obtained: skin hydration and hygiene were done in 100% of the patients, patient repositioning were done every 2 hours or more frequently in 80% of the patients, every 3 hours in 10% and in the remaining 10%, with a frequency greater than 4 hours. Heel protection was applied in 57% of the patients and special mattress was used in 54%.

CONCLUSIONS

Most of the studied patients had high risk of developing PU. The patients who had an ulcer were at risk of developing it. The low incidence of ulcers obtained in this study allows us to consider appropriate the protocol of care.

[Liver transplantation: teaching strategies used with patients waiting for surgery]

This study aims to describe the learning results of the implementation of teaching strategies involving patients who will be submitted to liver transplantation. One of these strategies is to give the patients a manual with orientations and the subsequent application of a questionnaire related to the content of the manual. Authors analyzed 13 patients who were waiting for liver transplantation. With respect to the answers regarding the questionnaire, an average of 83.8% of correct responses was given and only one patient got all the questions right. During the correction and the time to clarify their doubts, authors concluded that the opportunity of reading the manual and applying the questionnaire allowed patients and families to get a better understanding about the surgery's most important aspects.

[Organization of visits in Spanish ICU]

It is a fact that visits in the intensive care units (ICU) have always been very restrictive due to diverse criteria. Nowadays, some of them have been progressively liberalized, giving to the relatives more satisfaction and a better cover to their necessities. In our country there are no surveys about the organization of these visits at the present time, apart from some exceptional cases which commentate the situation in a particular center.

OBJECTIVE

Know how are visits organized in the intensive cares units in Spain.

MATERIAL AND METHOD

DESIGN

cross-sectional study; scope: 98 ICU of different Spanish hospitals; studied variables: the number of visits, their duration, the number of relatives in each visit, the number of relatives visiting the patients at the same time, the amount of information each day, the professional that informs, the use of written information and information by telephone, preventive measures taken before the entry in the unit, how relatives take part in the cares, location of the waiting room and use or not of a protocol of attention to relatives.

INSTRUMENTATION

The information has been obtained by a questionnaire placed in a web site of the Internet and directed to professionals of different Intensive cares units.

RESULTS

The ninety and eight evaluated units represent 37 Spanish provinces from all the autonomous communities. The most frequently noticed pattern for the organization of visits shows a restrictive character of the visits in Spain.

CONCLUSIONS

There are clear differences in the organization of visits between the studied ICU and no connection between the most common practice and what the survey, after evaluating the necessities of the relatives, recommends. These recommendations are: more visits, more flexibility of schedules, more integration of the relatives in the patients cares, broach the information from diverse disciplines, washing hands as the only necessary measure to be taken by the relatives.

[Repercussion on the hemodynamic measurements across a Swan-Ganz catheter with the postural changes]

AIM

Usually hemodynamic measures are done with the patient in dorsal decubitus and the bedside at 0 degrees. Our aim has been to evaluate the influence that postural changes has in the hemodynamic measures which were carried out with a pulmonary artery catheter, so as called Swan-Ganz.

MATERIAL AND METHOD

It's a prospective study. The same patient is control group and study group. There were done tree consecutive measures in each patient. Firstly in dorsal decubitus, then right lateral decubitus and finally in left lateral decubitus. Before doing the measures after change of posture a thirty minutes period was left in order to stabilise the hemodynamical flow. The items of study were, a part of demographic ones, cardiac index, pulmonary artery systolic pressure, pulmonary artery diastolic pressure, pulmonary artery mean pressure, pulmonary artery occlusion pressure, right atrial pressure, systolic arterial pressure, diastolic arterial pressure, mean arterial pressure and heart rate. 28 patients were included in the study.

RESULTS

The age average was 62.5 years (27.05-67.05); a 78.6% were male. Who had a NEMS average of 42.4 (39.9-44.9). No difference was found between hemodynamic measures in the different postures.

CONCLUSIONS

Postural changes in stable patients have no influence in pressures and other hemodynamic variables measures.

A preventative health education programme for osteoporosis

BACKGROUND

Osteoporosis is a preventable disease that is usually not managed until the disease becomes evident, although it places huge economic and social burdens on societies worldwide. It is predicted that this burden will grow if left unchecked. Despite this, evidence suggests that osteoporosis prevention activity is given a low priority, and services often only provide biomedically-based programmes, in which resources are predominantly allocated to screening and pharmacological treatments. Referral to these services mostly occurs when a client is already known to have osteoporosis or to be at risk, rather than as an early preventative intervention.

AIM

This paper reports an action research project with one hospital osteoporosis service. The aim of the project was to assess the current service, identify areas where change was needed, and evaluate the implementation of such changes.

METHOD

Participatory action research was used, with group meetings and reflective journals to collect data for analysis. The process involved assessment of a preventative osteoporosis service, and determination of clinical issues and problems, and it aided decisions on an appropriate course of organizational reform and evaluated any change processes as they occurred. It also encouraged participants to reflect on and evaluate their experiences of using a participatory framework.

CONCLUSION

A change programme was implemented that focused on preventative health education activity in a range of clinical settings. Over the two and a half years of the project, the osteoporosis service expanded its programme to include a wide range of preventative activities, running alongside other organizational reforms.

¿Qué perspectiva tienen las enfermeras de unidades de cuidados intensivos de su relación con los familiares del paciente crítico?

Introduction and aim. Nursing professionals in intensive care units (ICU) face situations of uncertainty and anxiety, above all in patients' relatives. In the literature, we find that the way in which the family and their needs are valued by professionals in the unit is not very systematical, even though there are instruments that have been validated for this purpose. Therefore, we decided to value what perspective ICU nurses have of the relationship they establish with patients' relatives, in order to find possible explanations for this situation. Material and methods. A qualitative study with a critical-social orientation. This was carred out in three ICUs in three state hospitals in Mallorca. Research techniques: 8 observations of the visit of relatives to the unit and 6 semi-structured interviews with nurses from the three hospitals. The transcripts of the interviews were analysed and codified in significance units. Sources and methods were triangulated.Results. Categories of the relationship process: 1) who the social actors are; 2) what the actions of the nurses with respect to the relatives are; 3) what the relationships are like between both; and 4) expectations of the nurses regarding this relationship.Conclusions. a) It is necessary to establish quality standards for attending the relatives of critical patients. b) Continuous nursing training is necessary in order to provide emotional support to families and to protect nurses from the added stress involved in providing this emotional support.

[Frecuency of adverse events during the hygiene of the critical care patient]

The hygiene of the patient in critical condition is a common nursing technique in the intensive care unit, which does not mean that doing it is exempt of risk for the patient's state. We carry out a study to measure the frequency of the appearance of certain adverse events during the hygiene care and their clinical repercussion.Hygiene of the critical patients was monitored, measuring the appearance of certain events at the time of hygiene and until one hour after to assess if the complications were at the moment or had a greater repercussion on the state of the patient.During the study period, some adverse event appeared in 48% (CI 95%: 43-52) of the hygiene performed while none appeared in 52% (CI 95%: 48-56) of it. The events that appeared most frequently were: desaturation in 18% (CI 95%: 15-21) of the hygiene performed, the deadaptation of the mechanical ventilation in 11% (CI 95%: 9-14), arterial hypertension in 21% (CI 95%: 18-25) and arterial hypotension in 11% (CI 95%: 9-14). The intracranial hypertension appeared in 42% (CI 95%: 26-61) of the hygiene performed to patients who were carriers of intraventricular catheter, 9% (CI 95%: 2-25) continued with elevated values 1 hour after concluding the hygiene. The rest of the events monitored presented a lower frequency, although the appearance of one episode of cardiorespiratory arrest and two of auricular fibrillation with rapid ventricular response, one of which required cardioversion, stand out. We conclude that it is an essential job of the nursing staff to correctly assess the risks that the performance of hygiene means for the critical patient, so that the technique should be applied rationally and under strict monitoring and control.