Prognostic implications of delirium after Left Ventricular Assist Device (LVAD) implantation: A retrospective study

INTRODUCTION

In critically ill patients, delirium is a prognostic indicator of morbidity and mortality. This study investigates the impact of a delirium diagnosis on outcomes after Left Ventricular Assist Device (LVAD) implantation.

METHODS

This retrospective study included all adult patients who received LVADs at our institution between January 2016 and December 2020. We compared pre-implantation characteristics between the two groups, with and without a diagnosis of delirium, and compared their outcomes, including 1-month, 6-month, and in-hospital mortality, as well as re-intubation rate, length of stay (LOS), discharge disposition, and readmission rates.

RESULTS

In total, 361 patients (26.7% women, 75.8% African American) received durable LVADs. Ninety-four patients (26.1%) were diagnosed with delirium during the index admission. Pre-implantation demographic characteristics, past medical and psychiatric conditions, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Profile, and laboratory values did not differ between the two groups with and without a diagnosis of delirium; older age (59 vs 56; P=0.03) was associated with delirium. Delirium diagnosis was associated with higher 1-month (P=0.007), 6-month (P=0.004), and in-hospital mortality (P<0.001), unplanned re-intubations (P<0.001), and a lower likelihood of discharge home (P = 0.03). Total hospital and ICU LOS were higher in patients with a diagnosis of delirium, though these results were not statistically significant. Readmission to hospital after index admission was quicker in patients with a diagnosis of delirium, but this result was not statistically significant.

CONCLUSIONS

In this study, a diagnosis of delirium during the LVAD implantation admission was associated with higher mortality, adverse post-surgical outcomes, and unfavorable discharge dispositions. Future prospective research is needed to validate the prognostic implications of delirium in both the short and long term. Additionally, there is a need to identify modifiable risk factors associated with delirium to promote early diagnosis and implement evidence-based management strategies to enhance outcomes within this population.

School Nurses' Experiences of Organizational Support During the COVID-19 Pandemic

School nurses encountered many workplace struggles while providing care during the COVID-19 pandemic. Several struggles involved organizational support, including having sufficient time, resources, compensation, and school leadership support. The purpose of this mixed methods study was to explore the experiences of school nurses working during the COVID-19 pandemic as they related to sufficient time to complete COVID-related activities, sufficient COVID-19 resources, compensation, and perceived organizational (school leadership) support. We obtained data from 1,564 National Association of School Nurses members regarding respondent characteristics, school characteristics, measures of organizational support, and qualitative perceived organizational support using a 17-question survey. Perceptions of having sufficient time to complete COVID-related tasks and infringement of these tasks on routine activities were worse for those with greater years of experience and education. Compensation for additional COVID-related work was more favorable for LPNs. School leaders should be aware of their role in bolstering organizational support and its impact.

A Retrospective Study: Multimodal Analgesia Quality Measure Implementation and Patient Outcome Assessment

Current research has demonstrated that nonopioid multimodal analgesia decreases perioperative opioid consumption, postoperative nausea and vomiting (PONV), and pain scores. However, no research has been conducted to examine the patient outcomes of Merit-based Incentive Payment System (MIPS) 477. This study evaluates those outcomes following implementation of MIPS 477. The medical records of 400 adult patients who underwent elective and urgent laparoscopic gynecological procedures at a facility in the Mid-Atlantic region were reviewed. Data collection included patient characteristics, analgesics administered, pain scores at postanesthesia care unit (PACU) arrival and discharge, and antiemetic administration in PACU. This study's primary outcomes were postoperative pain scores, total intraoperative and postoperative opioid consumption, and PONV. Twenty-nine patients (7.8%) met the criteria as a control group, and 341 patients (92.2%) met the criteria as a treatment group. Pain scores were higher upon PACU arrival among the control group (P = .001). The total intraoperative morphine milligram equivalents (MMEs) administered was less among the treatment group (P = .04). The treatment group had reduced total intraoperative MMEs and pain scores at PACU arrival. However, there was no statistical significance in PACU discharge pain score, total PACU MMEs, and PONV in both groups.

Assessing CRNA Knowledge of Local Anesthetic Systemic Toxicity Treatment

Local anesthetic systemic toxicity (LAST) is a rare life-threatening adverse event. Due to the potential for devastating patient outcomes, it is crucial for anesthesia providers to understand appropriate LAST management. The primary aim of this study was to assess certified registered nurse anesthetist (CRNA) knowledge of the 2020 American Society of Regional Anesthesia and Pain Medicine (ASRA) LAST treatment guidelines. The secondary aim was to determine whether there was a relationship between the frequency of CRNAs' exposure to perioperative local anesthetic use and their knowledge level. A quantitative descriptive study and national American Association of Nurse Anesthetists electronic survey solicited practicing CRNAs. Survey findings revealed knowledge scores averaging 47.3% among 184 respondents. Almost all (97.8%) recognized the importance of early lipid emulsion administration. Over half (54.3%) were unaware of the recommended epinephrine dosing during LAST. No relationship was found between knowledge level and CRNAs' exposure to local anesthetics. Those who reported having immediate access to written or electronic guidelines in the event of LAST had significantly higher knowledge scores than those without access (P = .049). Implementing cognitive aids may help bridge knowledge gaps identified in this study and ensure critical steps are not missed. Further studies examining the use of cognitive aids to improve CRNA knowledge of LAST management may be beneficial in the future.

Examination of a Nurse Anesthesia Program's Teaching Assistant Model and Its Impact on Increasing Nurse Anesthesia Education Capacity

A nurse anesthesia educator shortage exists that is attributed to factors such as a lack of financial incentive and proper training to be an educator. Due to the faculty shortage, nurse anesthesia programs (NAPs) are forced to defer admission to qualified applicants which reduces the number of certified registered nurse anesthetists (CRNAs) that NAPs can produce. Research regarding students as teaching assistants (TAs) at the university level has shown benefits and challenges to students, professors, and the TAs themselves as well as the impact on the overall faculty capacity. Current research regarding TA programs does not pertain to NAPs, therefore, research regarding the impact of TA programs on increasing nurse anesthesia faculty merits further work. This study was conducted using quantitative surveys and qualitative interviews to bridge the gap in the literature on the potential impact of TA programs on NAP faculty shortages. A survey was sent via email to former TAs (n = 44) of the Georgetown University NAP to assess the impact that the TA program had on their decision to enter a role in academia after graduation. Interviews were then conducted on a voluntary basis via a video conferencing platform to add qualitative data to the survey results. The survey response rate was 45% (n = 20). Following proportional analysis, 80% of the survey respondents indicated that they participated in the education of student registered nurse anesthetists in the clinical or didactic setting as a CRNA. Eighty percent of respondents indicated that being a TA positively influenced their desire to become a faculty member. One hundred percent of CRNAs interviewed reported that the biggest barrier to becoming fulltime faculty was the lack of financial incentives offered by NAPs. Interviewees recalled their TA experience as the foundation for their enjoyment of teaching anesthesia. The results of this study indicate that TA programs in NAPs can be used as a method to increase faculty capacity.

Certified Registered Nurse Anesthetists' occupational exposure to inhalational anesthetic agents: a survey of anesthetic gas safety

BACKGROUND

Anesthetic gases have been known to cause damage when inhaled over long periods of time. Modern safety measures have been put in place to reduce the risk to anesthesia providers, however there is continued lack of information on providers experiencing short term effects (lethargy, fatigue, headache, slowed cognitive ability, nausea, and mucosal irritation) thereby leading to long-term sequalae (sister chromatid exchanges, micronuclei, chromosomal aberrations, and comet assays).

METHOD

A thirteen item, multiple choice survey was sent to 3,000 anesthesia providers, of which 463 completed the survey. A Chi-square test of independence was used to determine the association between gas exposure and participant self-reported symptoms. A Spearman's Correlation test was also utilized to interpret this data since both frequency of smelling gas and frequency of symptoms were ordinal variables for which Spearman's rho correlation was the appropriate measure of association.

RESULTS

The major findings were that as the frequency of smelling anesthetic gas increased, so too did the frequency of self-reported headaches and fatigue. Spearman's rho = .148 and .092. P value = .002 and .049, respectively.

CONCLUSION

There have been many efforts to decrease the risk of exposure of anesthesia providers to anesthetic gases. While there is a decrease in reported exposures, indications of possible long-term effects remain a concern in anesthesia providers. Potential implications of exposure could lead to chromosomal aberrations, sister chromatid exchanges, comet assays, spontaneous abortions, and genotoxic effects.

Exploring Health Demographics of Female Collegiate Rowers

CONTEXT

Limited information exists about health patterns among female rowers at the collegiate level. Furthermore, the element of weight class (lightweights classified as <130 lb [59 kg]) as a factor in the physical and mental health of female collegiate athletes has not been investigated, despite weight requirements in sport being a risk factor for the female athlete triad.

OBJECTIVE

To test the hypotheses that (1) components of the female athlete triad were more prevalent in lightweight than in openweight rowers; (2) perceived stress levels were greater in lightweight than in openweight rowers; and (3) rowers who were unable to row due to injury had greater perceived stress levels than uninjured athletes.

DESIGN

Cross-sectional study.

SETTING

Twelve collegiate women's rowing programs consisting of 6 National Collegiate Athletic Association Division I openweight and 6 Intercollegiate Rowing Association-level lightweight teams.

PATIENTS OR OTHER PARTICIPANTS

A total of 158 female collegiate rowers (78 lightweight, 80 openweight).

MAIN OUTCOME MEASURE(S)

An electronic survey addressing injury history, diet and eating habits and body image (according to the triad screening questionnaire), stress levels (Perceived Stress Scale), and athlete identity (Athlete Identity Measurement Scale) was administered.

RESULTS

Lightweight rowers reported limiting or carefully controlling foods more frequently than openweight rowers (41.9% to 29.9%, P = .013). A history of an eating disorder was more prevalent among lightweight than openweight rowers (25.7% to 13.0%, P = .048). Prevalences of stress fractures and menstrual irregularities did not differ between weight classes. Lightweight and openweight rowers' scores on the Perceived Stress Scale (16.0 ± 9.9 and 17.3 ± 6.4, respectively) were not different. Injured rowers scored higher on the Perceived Stress Scale (19.4 ± 7.2) than did uninjured rowers (16.6 ± 5.72).

CONCLUSIONS

Weight class did not contribute to differences in the prevalence of female athlete triad components or perceived stress, although lightweight rowers were more likely to have a history of eating disorder. Injury may be a risk factor for increased stress in this population.

Healthcare seeking for chronic illness among adult slum dwellers in Bangladesh: A descriptive cross-sectional study in two urban settings

Introduction

Accompanying rapid urbanization in Bangladesh are inequities in health and healthcare which are most visibly manifested in slums or low-income settlements. This study examines socioeconomic, demographic and geographic patterns of self-reported chronic illness and healthcare seeking among adult slum dwellers in Bangladesh. Understanding these patterns is critical in designing more equitable urban health systems and in enabling the country’s goal of Universal Health Coverage by 2030.

Methods

This descriptive cross-sectional study compares survey data from slum settlements located in two urban sites in Bangladesh, Tongi and Sylhet. Reported chronic illness symptoms and associated healthcare-seeking strategies are compared, and the catastrophic impact of household healthcare expenditures are assessed.

Results

Significant differences in healthcare-seeking for chronic illness were apparent both within and between slum settlements related to sex, wealth score (PPI), and location. Women were more likely to use private clinics than men. Compared to poorer residents, those from wealthier households sought care to a greater extent in private clinics, while poorer households relied more on drug shops and public hospitals. Chronic symptoms also differed. A greater prevalence of musculoskeletal, respiratory, digestive and neurological symptoms was reported among those with lower PPIs. In both slum sites, reliance on the private healthcare market was widespread, but greater in industrialized Tongi. Tongi also experienced a higher probability of catastrophic expenditure than Sylhet.

Conclusions

Study results point to the value of understanding context-specific health-seeking patterns for chronic illness when designing delivery strategies to address the growing burden of NCDs in slum environments. Slums are complex social and geographic entities and cannot be generalized. Priority attention should be focused on developing chronic care services that meet the needs of the working poor in terms of proximity, opening hours, quality, and cost.

Preventing hepatocellular carcinoma in Egypt: results of a Pilot Health Education Intervention Study

BACKGROUND

Hepatocellular carcinoma (HCC), one of the most fatal malignancies, is particularly prevalent in Egypt, where we previously found deficiencies in knowledge concerning HCC and its risk factors. Hepatitis B and C viral infections are highly prevalent in Egypt, pesticides are very commonly used, and diets are often contaminated by aflatoxin, especially in rural areas.

METHODS

We conducted a study to pilot test a health education intervention addressing HCC, its risk factors, and its main modes of prevention. It included four health education modules: HCC, hepatitis viruses, pesticides and aflatoxin. We used a pre- and post-intervention set of questionnaires to assess knowledge gained by the participants.

RESULTS

A total of 25 participants from a village in the Nile Delta area attended the health education session and completed the questionnaires. The education intervention significantly increased the participants' knowledge on HCC and its risk factors, particularly regarding the use of pesticides at home and aflatoxin contaminated foods (both p < 0.05). Overall, there was a 12% increase in the number of participants who believed that HCC could be prevented, and they reported their intention to practice prevention for HCC risk factors.

CONCLUSIONS

We found that the education intervention we pilot tested was feasible and proved effective in increasing participants' knowledge. Future efforts should focus on implementing targeted education programs in high-risk populations in Egypt.

Evaluation of a Tobacco Cessation Curricular Intervention Among Acute Care Nurse Practitioner Faculty Members

Background In 2002, a report indicated that tobacco-related curricular content in educational programs for acute care nurse practitioners was insufficient. To provide healthcare professionals with the necessary knowledge and skills to intervene with patients who smoke tobacco, the Summer Institute for Tobacco Control Practices in Nursing Education was implemented at Georgetown University in Washington, DC.

Objective To evaluate the impact of a train-the-trainer program in which the Rx for Change: Clinician-Assisted Tobacco Cessation curriculum was used among faculty members of acute care nurse practitioner programs.

Methods Thirty faculty members participated in the 2-day train-the-trainer program. Surveys were administered at baseline and 12 months after training to examine perceived effectiveness for teaching tobacco content, the value of using an evidence-based national guideline, and the number of hours of tobacco content integrated in curricula.

Results The percentage of faculty members who devoted at least 3 hours to tobacco education increased from 22.2% to 74.1% (P&lt;.001). Perceived effectiveness in teaching tobacco cessation also increased (P &lt; .001), as did mean scores for the perceived value of using an evidence-based national guideline (P&lt;.001).

Conclusions Use of the Rx for Change train-the-trainer program can enhance the level of tobacco education provided in acute care nurse practitioner programs. Widespread adoption of an evidence-based tobacco education in nursing curricula is recommended to help decrease tobacco-related morbidity and mortality.

Evaluation of a tobacco cessation curricular intervention among acute care nurse practitioner faculty members

BACKGROUND

In 2002, a report indicated that tobacco-related curricular content in educational programs for acute care nurse practitioners was insufficient. To provide healthcare professionals with the necessary knowledge and skills to intervene with patients who smoke tobacco, the Summer Institute for Tobacco Control Practices in Nursing Education was implemented at Georgetown University in Washington, DC.

OBJECTIVE

To evaluate the impact of a train-the-trainer program in which the Rx for Change: Clinician-Assisted Tobacco Cessation curriculum was used among faculty members of acute care nurse practitioner programs.

METHODS

Thirty faculty members participated in the 2-day train-the-trainer program. Surveys were administered at baseline and 12 months after training to examine perceived effectiveness for teaching tobacco content, the value of using an evidence-based national guideline, and the number of hours of tobacco content integrated in curricula.

RESULTS

The percentage of faculty members who devoted at least 3 hours to tobacco education increased from 22.2% to 74.1% (P<.001). Perceived effectiveness in teaching tobacco cessation also increased (P < .001), as did mean scores for the perceived value of using an evidence-based national guideline (P<.001).

CONCLUSIONS

Use of the Rx for Change train-the-trainer program can enhance the level of tobacco education provided in acute care nurse practitioner programs. Widespread adoption of an evidence-based tobacco education in nursing curricula is recommended to help decrease tobacco-related morbidity and mortality.

Using the Rx for Change tobacco curriculum in advanced practice nursing education

In today's health care system driven by quality outcome indicators and performance care measures, it is essential for nurses to know how to intervene with tobacco-dependent patients. This article discusses pilot results from the "Rx for Change: Clinician Assisted Tobacco Cessation Curriculum" intervention conducted at Georgetown University School of Nursing and Health Studies using advanced practice students. The results reveal that 6 hours of tobacco-cessation training can increase knowledge and self-efficiency scores.