Snoring, Trouble Breathing, Un-Refreshed (STBUR) Screening Questionnaire to Reduce Perioperative Respiratory Adverse Events in Pediatric Surgical Patients: A Quality Improvement Project

Children who present for surgery with undiagnosed sleep-disordered breathing are particularly vulnerable to perioperative respiratory adverse events (PRA Es). Preoperative screening can identify children at increased risk who would benefit from evidence-based perioperative management, reducing serious preventable harm or death. The purpose of this quality improvement study was 2-fold: (1) increase identification of pediatric surgical patients who may be at increased risk of PRAE through the introduction of a validated pediatric screening questionnaire (Snoring, Trouble Breathing, Un-Refreshed [STBUR]), and (2) reduce preventable harm by introducing evidence-based perioperative management guidelines. A pre-post intervention design was conducted in 6,216 patients aged 1 to 18 years. The STBUR questionnaire embedded in the electronic medical record was the primary intervention. Data for the primary outcome measure and 3 secondary process measures were analyzed using Yatesχ2 and Fisher exact test to compare proportional change. After STBUR implementation, PRAE risk identification increased from 10.5% to 15% (χ2 (1, N = 12,975) = 57.19, z = -7.59, P < .001, odds ratio =1.49). Results of the secondary process measures were mixed. The STBUR screening questions embedded in the medical record significantly improved identification of patients at risk, allowing modification of perioperative management toward safer practices.

Non-invasive interventions for improving well-being and quality of life in patients with lung cancer

BACKGROUND

This is an updated version of the original review published in Issue 4, 2004 of The Cochrane Library. Lung cancer is one of the leading causes of death globally. Despite advances in treatment, the outlook for the majority of patients remains grim and most face a pessimistic future accompanied by sometimes devastating effects on emotional and psychological health. Although chemotherapy is accepted as an effective treatment for advanced lung cancer, the high prevalence of treatment-related side effects as well the symptoms of disease progression highlight the need for high-quality palliative and supportive care to minimise symptom distress and to promote quality of life.

OBJECTIVES

To assess the effectiveness of non-invasive interventions delivered by healthcare professionals in improving symptoms, psychological functioning and quality of life in patients with lung cancer.

SEARCH STRATEGY

We ran a search in February 2011 to update the original completed review. We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 2), MEDLINE (accessed through PubMed), EMBASE, PsycINFO, AMED, British Nursing Index and Archive (accessed through Ovid) and reference lists of relevant articles; we also contacted authors.

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials assessing the effects of non-invasive interventions in improving well-being and quality of life in patients diagnosed with lung cancer.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed relevant studies for inclusion. Data extraction and risk of bias assessment of relevant studies was performed by one author and checked by a second author.

MAIN RESULTS

Fifteen trials were included, six of which were added in this update. Three trials of a nursing intervention to manage breathlessness showed benefit in terms of symptom experience, performance status and emotional functioning. Four trials assessed structured nursing programmes and found positive effects on delay in clinical deterioration, dependency and symptom distress, and improvements in emotional functioning and satisfaction with care.Three trials assessed the effect of different psychotherapeutic, psychosocial and educational interventions in patients with lung cancer. One trial assessing counselling showed benefit for some emotional components of the illness but findings were not conclusive. One trial examined the effects of coaching sensory self monitoring and reporting on pain-related variables and found that although coaching increases the amount of pain data communicated to providers by patients with lung cancer, the magnitude of the effect is small and does not lead to improved efficacy of analgesics prescribed for each patient's pain level. One trial compared telephone-based sessions of either caregiver-assisted coping skills training (CST) or education/support involving the caregiver and found that patients in both treatment conditions showed improvements in pain, depression, quality of life and self efficacy.Two trials assessed exercise programmes; one found a beneficial effect on self empowerment and the other study showed an increase in quadriceps strength but no significant changes for any measure of quality of life. One trial of nutritional interventions found positive effects for increasing energy intake, but no improvement in quality of life. Two small trials of reflexology showed some positive but short-lasting effects on anxiety and pain intensity.The main limitations of the studies included were the variability of the interventions assessed and the approaches to measuring the considered outcomes, and the lack of data reported in the trials regarding allocation of patients to treatment groups and blinding.

AUTHORS' CONCLUSIONS

Nurse follow-up programmes and interventions to manage breathlessness may produce beneficial effects. Counselling may help patients cope more effectively with emotional symptoms, but the evidence is not conclusive. Other psychotherapeutic, psychosocial and educational interventions can play some role in improving patients' quality of life. Exercise programmes and nutritional interventions have not shown relevant and lasting improvements of quality of life. Reflexology may have some beneficial effects in the short term.

How to ensure patient observations lead to prompt identification of tachypnoea

Tachypnoea is one of the first signs of patient deterioration and accurate measurement of respiratory rate is a fundamental part of assessment. This article aims to describe the assessment and management of tachypnoea.

Oxygen delivery to patients after cardiac surgery: a medical record audit

OBJECTIVE

To describe how intensive care nurses manage the administration of supplemental oxygen to patients during the first 24 hours after cardiac surgery.

METHODS

A retrospective audit was conducted of the medical records of 245 adult patients who underwent cardiac surgery between 1 January 2005 and 31 May 2008 in an Australian metropolitan hospital. Physiological data (oxygen saturation measured by pulse oximetry and respiratory rate) and intensive care unit management data (oxygen delivery device, oxygen flow rate and duration of mechanical ventilation) were collected at hourly intervals over the first 24 hours of ICU care.

RESULTS

Of the 245 patients whose records were audited, 185 were male; mean age was 70 years (SD, 10), and mean APACHE II score was 17.5 (SD, 5.14). Almost half the patients (122, 49.8%) were extubated within 8 hours of ICU admission. The most common oxygen delivery device used immediately after extubation was the simple face mask (214 patients, 87%). Following extubation, patients received supplemental oxygen via, on average, two different delivery devices (range, 1-3), and had the delivery device changed an average of 1.38 times (range, 0-6) during the 24 hours studied. Twenty-two patients (9%) received non-invasive ventilation or high-flow oxygen therapy, and 16 (7%) experienced one or more episode of hypoxaemia during mechanical ventilation. A total of 148 patients (60%) experienced one or more episodes of low oxygenation or abnormal respiratory rate during the first 24 hours of ICU care despite receiving supplemental oxygen.

CONCLUSION

These findings suggest that the ICU environment does not protect cardiac surgical patients from suboptimal oxygen delivery, and highlights the need for strategies to prompt the early initiation of interventions aimed at optimising blood oxygen levels in cardiac surgical patients in the ICU.

Effect of educational outreach to nurses on tuberculosis case detection and primary care of respiratory illness: pragmatic cluster randomised controlled trial

OBJECTIVES

To develop and implement an educational outreach programme for the integrated case management of priority respiratory diseases (practical approach to lung health in South Africa; PALSA) and to evaluate its effects on respiratory care and detection of tuberculosis among adults attending primary care clinics.

DESIGN

Pragmatic cluster randomised controlled trial, with clinics as the unit of randomisation.

SETTING

40 primary care clinics, staffed by nurse practitioners, in the Free State province, South Africa.

PARTICIPANTS

1999 patients aged 15 or over with cough or difficult breathing (1000 in intervention clinics, 999 in control clinics).

INTERVENTION

Between two and six educational outreach sessions delivered to nurse practitioners by usual trainers from the health department. The emphasis was on key messages drawn from the customised clinical practice guideline for the outreach programme, with illustrative support materials.

MAIN OUTCOME MEASURES

Sputum screening for tuberculosis, tuberculosis case detection, inhaled corticosteroid prescriptions for obstructive lung disease, and antibiotic prescriptions for respiratory tract infections.

RESULTS

All clinics and almost all patients (92.8%, 1856/1999) completed the trial. Although sputum testing for tuberculosis was similar between the groups (22.6% in outreach group v 19.3% in control group; odds ratio 1.22, 95% confidence interval 0.83 to 1.80), the case detection of tuberculosis was higher in the outreach group (6.4% v 3.8%; 1.72, 1.04 to 2.85). Prescriptions for inhaled corticosteroids were also higher (13.7% v 7.7%; 1.90, 1.14 to 3.18) but the number of antibiotic prescriptions was similar (39.7% v 39.4%; 1.01, 0.74 to 1.38).

CONCLUSIONS

Combining educational outreach with integrated case management provides a promising model for improving quality of care and control of priority respiratory diseases, without extra staff, in resource poor settings.

TRIAL REGISTRATION

Current controlled trials ISRCTN13438073.

Non-invasive interventions for improving well-being and quality of life in patients with lung cancer

BACKGROUND

Lung cancer is one of the leading causes of death globally. Despite advances in treatment, outlook for the majority of patients remains grim and most face a pessimistic outlook accompanied by sometimes devastating effects on emotional and psychological health. Although chemotherapy is accepted as an effective treatment for advanced lung cancer, the high prevalence of treatment-related side effects as well the symptoms of disease progression highlight the need for high quality palliative and supportive care to minimise symptom distress and to promote quality of life.

OBJECTIVES

To assess the effectiveness of non-invasive interventions delivered by healthcare professionals in improving symptoms, psychological functioning and quality of life in patients with lung cancer.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2003), MEDLINE (1966-March 2003), EMBASE (1974-March 2003), CINAHL (1982-September 2002), CancerLit (1975-October 2002), PsycINFO (1873-March 2003), reference lists of relevant articles and contact with authors.

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials assessing the effects of non-invasive interventions in improving well-being and quality of life in patients diagnosed with lung cancer.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed relevant studies for inclusion. Data extraction and quality assessment of relevant studies was performed by one reviewer and checked by a second reviewer.

MAIN RESULTS

Nine trials were included and categorised into six groups. Two trials of a nursing intervention to manage breathlessness showed benefit on symptom experience, performance status and emotional functioning. Three trials assessed structured nursing programmes and found positive effects on delay in clinical deterioration, dependency and symptom distress, and improvements in emotional functioning and satisfaction with care. One trial assessing counselling showed benefit on some emotional components of the illness but findings were not conclusive. One trial assessing an exercise programme, found a beneficial effect on self-empowerment. One trial of nutritional interventions found positive effects for increasing energy intake, but no improvement in quality of life. One trial of reflexology showed some positive, but short-lasting effects on anxiety.

REVIEWERS' CONCLUSIONS

Nurse follow-up programmes and a nurse intervention to manage breathlessness may produce beneficial effects. Psychotherapeutic study indicates that counselling may help patients cope more effectively with emotional symptoms, but the evidence is not conclusive. Findings from the included studies reinforce the necessity for increased training and education of healthcare professionals giving in these interventions. More research, of higher methodological quality is needed in this area to explore possible underlying explanatory mechanisms.

[Follow-up of children less than five years of age suffering from respiratory diseases: literature review]

Study of a descriptive nature, aiming at identifying publications related to respiratory diseases in children aged less than five years, in national and international periodicals and in some textbooks, from 1990 through 2002, and identifying the ones which describe respiratory diseases over the course of children's growth and development. Twenty-seven works were analyzed. Some features are presented referring to quantity of authors published, language of publication, and methodological as well as thematic aspects: respiratory diseases in children, their determiners and risk factors; use of health services for children suffering from respiratory problems; follow-up and respiratory diseases in childhood.

Respiratory intensive care unit resource use and outcomes in Taiwan

Based on a revision of Donabedian's classic structure, process, and outcome conceptual framework, this study examined the relationship between resource use (length of stay) and outcome (transfer status) in two respiratory intensive care units (ICUs). Medical records of respiratory ICU patients (N = 194) from a medical center in northern Taiwan were reviewed. Data collection focused on patient demographic profile (age, gender, and medical diagnosis), Acute Physiology and Chronic Health Evaluation (APACHE) score, nursing diagnoses, ICU length of stay, and transfer status. The results indicate that patients with lower APACHE scores and more nursing diagnoses had a longer ICU length of stay. In addition, both the number of nursing diagnoses and APACHE scores significantly explained the variance in the length of stay. Nonetheless, a higher APACHE score was correlated with a poor transfer status. These findings indicate that, in addition to the traditional indicators, nursing diagnoses may be a vital variable in predicting ICU length of stay. The results also imply that patients with lower APACHE scores are in better physical condition and are therefore institutionalized longer in ICUs.

Assessing acutely ill patients on general wards

The recent increase in demand for intensive care facilities has resulted in a growing number of patients experiencing periods of critical illness in acute ward areas (Murch and Warren 2001). The authors of this article provide a structured system of assessment for nurses to assess acutely ill patients in the general ward environment.

Cardiorespiratory physical assessment for the acutely ill: 1

This article, the first of two parts, aims to develop core cardiovascular and respiratory knowledge and to enhance practice for the practitioner caring for an acutely ill patient on a general ward setting. The second part will focus on advanced cardiorespiratory assessment. With increasing acuity of illness in general ward settings, patients' needs are becoming more complex in terms of their nursing and medical management. Nurses must be able to respond to subtle clinical signs and symptoms and act appropriately to ensure that a safe, patient-focused environment is maintained and that the care delivered is evidence-based. By increasing knowledge of the theory and practice of nursing physical assessment, and the ensuing management, acutely ill patients nursed in general ward areas may be provided with timely and appropriate care and may avoid further deterioration and an intensive care admission. This article describes core physical assessment skills, the normal physiology of the cardiovascular system, and the management of cardiovascular and respiratory dysfunction.

Clinical implications of respiratory system changes in aging

Nurses must consider the many age-related respiratory system changes when assessing and managing respiratory-related symptoms of older individuals. This article reviews upper and lower respiratory tract changes and provides tips for clinical management of the older person. Pertinent respiratory symptom assessment scales are described. Smoking cessation and other health promotion counseling is discussed.

Implementation and evaluation of Nursing Interventions Classification and Nursing Outcomes Classification in a patient education plan

Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) are recognized examples of standardized nursing languages used to describe the contribution nursing makes to patient care. Columbus Regional Hospital nursing leadership recognized the need to use standardized nursing interventions and nursing-sensitive patient outcomes to describe the unique contribution nursing makes to patient education. In collaboration with the University of Iowa, NIC/NOC languages were implemented in the development of a patient education plan for a clinical pathway population.

An orientation program for nurses in a cardio thoracic intensive care unit

The objective of this qualitative, explorative and descriptive study was to explore and describe the contents and management of an orientation program for a specific cardio thoracic intensive care unit of a specific private hospital. The goals of the study were: Conducting a literature review to explore and describe the concepts identified in the conceptual framework and thereby lending theoretical support to the contents and management of the orientation program. To explore and describe the expectations of the learner with regard to the contents and management of the orientation program. To explore and describe the expectations of the senior professional nursing team with regard to the contents and management of the orientation program.

[Breathing-related nursing care problems--a descriptive study]

Research into nursing problems related to breathing that can occur by pulmonary patients and their relationship with literature on Nursing Diagnoses (further referred to as diagnoses) on this subject has been done on two nursing wards. Interviews have been held with eleven nurses working in direct patient care. From the acquired data twelve problems with their signs and symptoms as well as the possible etiology were found, each showing one or more similarities with diagnoses from the North American Nursing Diagnosis Association (NANDA). Similarities and differences between the NANDA diagnoses and the acquired data have been analysed.

Pediatric emergencies

The care of acutely ill children presents a unique challenge for health care professionals. Nurses often are required to make a quick assessment of the child's condition, even when the child is frightened or uncommunicative. This article addresses the most common of a multitude of illnesses seen in children and organizes them according to organ systems and common final pathways within a system.

The new alternatives to intubation

Noninvasive positive-pressure ventilation devices are brightening prospects for a diverse group of patients--and placing new demands on nurses. Here's how to work with them.

Interventions related to respiratory care

Nursing interventions provide the link between nursing diagnosis and patient outcomes. The validation of nursing interventions is the starting point for a standardized nursing language. This study adapted a method for the validation process for nursing interventions and identified interventions that nursing experts believe are vital to the care of respiratory patients. The study served as the pilot for further surveys by the Iowa classification project. Based on the results of this study, the group made modifications in the survey process. Specifically, national samples of nurses were used, definitions were included in the surveys, and standard deviations were calculated for each activity. The subsequent articles in this issue demonstrate these changes.

Pulmonary complications from enteral nutrition

Complications of enteral nutrition may compromise respiratory function by direct mechanical injury by feeding tubes, aspiration of formula, or alterations in metabolism. Although much of the data reviewed in this paper were published more than 10 years ago, these studies still comprise most of the literature on pulmonary complications of enteral nutrition. Many of the products that are described in these older studies no longer exist or are not widely used. Additional research is needed to determine whether the enteral formulas and delivery devices that have recently been developed are associated with a similar incidence of misplacement, aspiration, or displacement as that previously reported.

A functional classification of respiratory compromise in spinal cord injury

Spinal cord injury (SCI) patients have unique care needs, particularly related to the respiratory system. Respiratory problems now comprise a major cause of death in the acute and chronic phases of SCI, especially among quadriplegics. Previous literature has analyzed respiratory muscle dysfunction in SCI according to neurologic levels of injury (Alvarez, Peterson & Lunsford, 1981; McMichan, Michel & Westbrook, 1980). In general, the higher the level of injury, the greater the respiratory compromise and need for ventilatory assistance. Although level of injury is significant, it cannot be used as the sole determinant of respiratory compromise. For example, a 25 year old C4 quadriplegic with an intact diaphragm might have less respiratory impairment than a 60 year old C6 quadriplegic with CHF and a history of COPD. A new classification of SCI patients according to amount of respiratory compromise was developed by our team at the Spinal Cord Injury Unit at the Palo Alto VA Medical Center. The patient is scored in three categories: 1) level of injury; 2) completeness of injury; and 3) associating factors, i.e. age, preinjury chronic lung disease. The purpose of this grouping is to better predict the amount of ventilatory impairment in SCI patients. Used during the initial assessment, patients at high risk for impairment could be determined and optimal respiratory care initiated. This classification can also be used as a clinical nursing tool. Using this scoring system, the nurse could anticipate the patient's respiratory needs, i.e. suctioning, chest physiotherapy, oxygen, hydration, nutritional support and teaching of patient and family in order to comprehensively plan and implement care.(ABSTRACT TRUNCATED AT 250 WORDS)

Postoperative pulmonary complications

This discussion presented the most common causes of postoperative pulmonary complications. The categories of obstruction, hypoxemia, and hypoventilation were used for structure, with the most common causes of each identified. Problems and patients at risk for these problems have been identified along with treatment priorities. The reader is reminded that the categories of obstruction, hypoxemia, and hypoventilation cannot be taken as absolute. The existence of one usually suggests the presence of another.

Pulmonary problems

Prevention of pulmonary complications continues to be a major goal of therapy in the care of patients in the postoperative period. Numerous factors, including anesthesia and surgery-induced diaphragmatic dysfunction, reductions in lung volumes and capacities, and release of mediators that damage the endothelium, set the stage for the development of complications such as atelectasis, pneumonia, and ARDS. Nursing assessment focuses on the early identification and evaluation of respiratory distress and degree of oxygen supply/demand imbalance. Intervention focuses on restoration of appropriate ventilation/perfusion matching and provision of adequate oxygen to meet tissue metabolic demands.

Pulmonary considerations in the critical care phase

Spinal cord injuries create alterations in ventilatory mechanics that range from complete ventilator dependence in high cervical injuries to the need for an assisted cough to clear secretions in low thoracic injuries. The initial nursing assessment should include the degree of respiratory muscle impairment, the effectiveness of the patient's inspiratory efforts, and the ability to cough. Once the mechanisms responsible for respiratory difficulty have been determined, nursing interventions can be planned to compensate for impaired function. This may involve assisted coughing, frequent chest physiotherapy and suctioning, monitoring vital capacity and ABGs, and use of kinetic beds. Perhaps the greatest challenge for both the nurse and the patient is weaning from mechanical ventilation. Weaning requires a coordinated plan, based on trust between patient and nurse, in order to achieve maximum independence from ventilatory support.