Nurses' Newswire

Complexity and Quality of Care

Seems to me that the more simple the patient’s problems, the more satisfied the patient and family would be with our care.  Not so, according to a recent study!

Dr. Higashi and associates found a direct and linear relationship between the number of medical conditions a patient has and the perceived quality of care.  Each additional condition increased the score by 2.2%.  These findings remained consistent despite difficulty in delivering the care. 

This study raises questions about why quality increases when patients become more complex.  Is it due to the increase in nursing attention that complex patients require?  Or could it be a greater attention to detail that comes with more complex patients?  The study probably raises more questions than it answers.  One take-away could be that we should be more vigilant with less complex patients to assure that quality is maintained and that nothing is “slipping through the cracks” in our care.

From: Higashi, T., et al. (2007). Relationship between Number of Medical Conditions and Quality of Care.  NEJM, 356 (24):2496-2504.

Best wishes,
David W. Woodruff, MSN, RN, CNS, CEN
President, Ed4Nurses, Inc.
www.Ed4Nurses.com
www.dwoodruff.com

Beware of anaphylactic reactions from heparin

Beware of anaphylactic reactions from heparin.  In the last few months you may have heard of several recalls of injectable heparin and heparin flushes.  This is due to a contaminant in the heparin that can cause an allergic-type reaction by stimulating bradykinin and allergic reaction. 

Symptoms include an anaphylactic-type reaction with acute hypotension and acute gastrointestinal distress.  Other signs could be unexplained thrombocytopenia, excessive anticoagulation or hemorrhage, inadequate anticoagulation, and unexplained or premature thrombosis of a heparin-coated device. 

Heparin is not only used as an injectable medication or flush but also is used to coat certain intravascular devices such as IV catheters, oxygenators, pumps, filters, vascular stents and grafts and other devices used for cardiac procedures.  It has been noted that low molecular weight heparin (LMWH) is also affected by this contaminant. 

Many companies have already recalled lots of heparin thought to be contaminated but there may be other lots that are still in circulation.  If you believe your patient is suffering from a heparin induced reaction or you would like to get more information about the heparin recalls please see www.fda.gov/medwatch/report.htm.

From:
U.S. Food and Drug Administration, Center for Drug Evaluation and Research (2008).  Information on Heparin Sodium Injection.  http://www.fda.gov/cder/drug/infopage/heparin/default.htm#recalls.  Last accessed: May 1, 2008. 

Best wishes,
David W. Woodruff, MSN, RN, CNS, CEN
President, Ed4Nurses, Inc.
www.Ed4Nurses.com

Too Much Detail?

In our attempts to define objective markers for evidenced-based practice, additional laboratory studies have been recommended in the literature.  A series of recent articles indicate that additional studies do not provide a significant advantage in predicting the risk of death from cardiovascular (CV) events.  These markers include C-Reactive Protein, B-Type Natriuretic Peptide, D-Dimer, and other markers of inflammation.  These markers may provide additional information that is helpful in the treatment of patients with CV disease.

These data are useful because the practice of obtaining laboratory testing in CV disease is not standardized; and these data may help nurses to better manage their patients by having the right information available to make the right decisions.

Although many of the additional lab tests have been linked to cardiovascular disease, it is important to know what they show and how that affects an individual patient.  Here is a summary of some of the common diagnostic tests that are associated with CV disease and what additional information they provide:

• C-Reactive Protein: elevations may help determine the extent of atherosclerosis.
• B-Type Natriuretic Peptide: elevations indicate increased fluid volume in the ventricle (preload) associated with heart failure.  Higher levels indicate more ventricular failure.
• D-Dimer: elevates with the breakdown of clots; therefore elevations indicate that there are clots present and that the body is trying to break them down.  The clot could be in the coronary vasculature or elsewhere.

Diagnostic testing and other objective information is helpful to validate your assessment; but dependence on diagnostic testing and objective measurements can be misleading as these studies demonstrate.  Take home point?  Look at the patient!

From:
Wang TJ et al. Multiple biomarkers for the prediction of first major cardiovascular events and death. N Engl J Med 2006 Dec 21; 355:2631-9.

Rothenbacher D et al. Comparison of N-terminal pro–B-natriuretic peptide, C-reactive protein, and creatinine clearance for prognosis in patients with known coronary heart disease. Arch Intern Med 2006 Dec 11/25; 166:2455-60.

Ware JH. The limitations of risk factors as prognostic tools. N Engl J Med 2006 Dec 21; 355:2615-7.

Best wishes,
David W. Woodruff, MSN, RN, CNS
President, Ed4Nurses, Inc.
www.Ed4Nurses.com

Google as a Diagnostic Tool

More people are turning to the internet to find answers to their questions, and healthcare workers are no exception.  Investigators entered signs and symptoms into the Google search box to determine whether the search engine could find relevant literature confirming a diagnosis.

They found that Google could come up with the correct diagnosis 58% of the time; and was better in suggesting easy diagnoses then more difficult ones.  Despite the mediocre results, this study validates the importance of using the internet to find information about medical conditions and their treatment.

Healthcare workers should find reliable sources on the internet that are trustworthy and accurate before making treatment decisions.  To evaluate the resources you find, ask yourself:
- Is the source connected with acknowledged experts?
- Is the information peer-reviewed?
- Is the data supported by recent evidence-based research findings?

One great resource for medical information on the internet is www.Medscape.com; it meets the above criteria and has a wealth of free information that can be easily accessed.

From:  Tang H and Ng JHK. Googling for a diagnosis — Use of Google as a diagnostic aid: Internet based study. BMJ 2006 Dec 2; 333:1143-5.

Best wishes,
David W. Woodruff, MSN, RN, CNS, CEN
President, Ed4Nurses, Inc.

Your Patient May be at Risk for VTE and PE

Venous thromboembolism (VTE); this is the thing we used to call deep vein thrombosis (DVT).  It is associated with an increase in morbidity and mortality in hospitalized patients.  Over 150 years ago, Dr. Virchow identified three risk factors that can be assessed to determine if your patient may develop venous thromboembolism.  They are: venous stasis, endothelial injury and alteration in coagulation.  If your patient has these risk factors, they are more likely to develop a VTE and possibly pulmonary embolism (PE) which can be life threatening. 

In recent article by Dr. Cohen, et al, the researchers determined that in only 40 percent of medical patients who were at risk for VTE and only 60 percent of surgical patients at risk for VTE received prophylactic treatment with Heparin or a low molecular weight Heparin (LMWH) injection.  It is surprising that these prophylactic rates are so small; however, they may be the result of a lack of education on the part of our physicians. 

Here’s what you can do to decrease complications in your parents and assure that they don’t develop venous thromboembolism and pulmonary embolism.  When you assess your patient and identify that they have Virchow’s triad of risk factors, check to see if the patient is already on Heparin or low molecular weight Heparin prophylaxis.  If not, make sure that the patient gets sequential calf compression devices, also called SCDs, to compress the calves and decrease the risk of VTE formation. 

From Cohen, A.T. et al. (2008) Venous Thromboembolism Risk and Prophylaxis in the Acute Hospital Care Setting (ENDORSE Study), A Multi National Cross Sectional Study.  Lancet 371:387.

Ageno W. and Dentali, F. (2008) Prevention of In Hospital VTE, Why Can’t We Do Better? Lancet 371:361.

Best wishes,

David W. Woodruff, MSN, RN, CNS, CEN
President, Ed4Nurses, Inc.
www.Ed4Nurses.com

Is it Safe to Monitor Blood Pressure Using the Forearm?

Many patients, due to their size or other physical limitations, require blood pressure readings to be taken from the forearm instead of the upper arm.  But, the standard values that we use for clinical practice come from measurements obtained from the more traditional upper arm approach.  Are forearm measurements accurate?

In a recent study by Schell, et al. a significantly higher blood pressure (as much as 33mmHg) was read from the forearm approach and did not correlate well enough to be used interchangeably with upper arm readings.

A forearm approach may be necessary in some patients, but understand what you’re getting: a higher than standard pressure measurement.  The difference between forearm and upper arm measurements could be significant for clinical care when your patient is hypotensive or in crisis, especially if it is measured with a non-invasive automatic cuff. 

Davis, et al. found that automatic cuffs overestimate systolic blood pressure by as much as 26mmHg in hypotensive patients.  Coupled with the findings of the Schell, et al. study, if your patient is hypotensive and you take the blood pressure using an automatic cuff on the forearm, then the results could be normal while your patient is in shock.

Forearm measurements could be used to watch for trends in your patient’s blood pressure, and to assess stable patients for changes.  If your patient is in crisis, then an upper arm manual blood pressure should be obtained as a baseline, with all other measurements compared to it for accuracy.

From:
Schell, K., et al. (2006). Clinical comparison of automatic, non-invasive measurements of blood pressure in the forearm and upper arm with the patient supine or with the head of bed raised 45 degrees: A follow-up study. American Journal of Critical Care; 15(2): 196-205.

Davis, J.W. et al. (2003). Are automated blood pressure measurements accurate in trauma patients? J Trauma; 55, 860-3.

Best wishes,

David W. Woodruff, MSN, RN, CNS, CEN
President, Ed4Nurses, Inc.
www.Ed4Nurses.com

10 Tips to Improve Patient Safety

1. Survey staff in individual units and throughout the hospital need to assess and improve the culture of patient safety, as noted in the 1999 Institute of Medicine report, To Err is Human. The AHRQ survey and its accompanying toolkit materials are designed to provide hospital officials with the basic knowledge and tools needed to conduct a safety culture assessment, along with ideas for using the data.
 
2.  Limit shifts of more than 24 hours for medical residents and make sure they do not drive home after working extended shifts. Medical residents who work longer than 24 hours are more than twice as likely to have a car crash leaving the hospital and 5 times as likely to have a near-miss incident on the road than medical interns who work shorter shifts.
 
3.  Eliminate the tradition of shifts of more than 30 consecutive hours by interns working in hospital ICUs. The rate of serious medical errors at two Boston hospital intensive care unites (ICUs) committed by first-year interns dropped by 36 percent when 30-hour-in-arow work shifts were eliminated.
 
4.  Adopt interventions to reduce the incidence of ventilator-associated pneumonia in critically ill patients. Putting patients in a semi-recumbent position and using sucralfate rather than H2- antagonists to prevent stress ulcers can prevent ventilator-associated pneumonia in critically ill patients.
 
5.  Count surgical instruments and sponges before and after procedures, and X-ray patients after surgery to reduce the likelihood of objects being left inside patients. These simple techniques can reduce the incidence of these types of medical errors, which occur in more than 1,500 patients each year.
 
6.  Use senior nurses and maintain appropriate round-the-clock staffing levels in ICUs to prevent airway tube complications. A study of adverse events occurring in adult and pediatric ICUs found that more than half were considered preventable. Airway events occurred less frequently during daytime hours (7:00 a.m. to 3:00 p.m.), and their negative impact was limited by skilled assistants, backup, and cross-coverage. ICU managers should take steps to ensure that appropriate staffing and training levels are maintained to limit the impact of adverse events.
 
7.  Ensure that personal digital assistant-based drug information is readily available at the point of care. Epocrates RxPro, Lexi-Drugs, and mobileMicromedex met AHRQ's quality and safety criteria by reducing potential errors associated with insufficient or incomplete drug information.
 
8.  Download a free software tool to identify ways to improve medication safety in the ambulatory care setting. The tool, called the Medication Safety Best Practices Guide, helps hospitals identify ways to create safe practices for medication use, manage medical errors, and contribute to patient safety education in the ambulatory care setting. Go to: http://chrp.creighton.edu/documents/bestpractices.pdf.

  9.  Use computer-based order entry to reduce catheter-related urinary tract infections. A computer-based order entry system prompting catheter removal after 72 hours decreases the duration of urinary catheterization by about one-third, or 3 days.
 
10.  Minimize interruptions and other distractions faced by the nursing staff in their day-to-day routines. Researchers have visually re-created the fast-changing nature of nurses' work, highlighting areas where interruptions can affect patient safety.

From:  10 Patient Safety Tips for Hospitals. AHRQ Publication No. 06-P020, May 2006. Rockville, MD, Agency for Healthcare Research and Quality. http://www.ahrq.gov/qual/10tips.htm

Best wishes,
David W. Woodruff, MSN, RN, CNS, CEN
President, Ed4Nurses, Inc.
www.Ed4Nurses.com

Is it COPD or Heart Failure

Due to physiologic variables such as increased pulmonary vascular pressure and chronic hypoxemia, the patient with chronic obstructive pulmonary disease (COPD) is at risk for heart failure (HF). When this patient presents with dyspnea, it is often difficult to determine the whether it is the COPD or the HF that is causing the respiratory distress.

A recent study examined the predictive value of assessing four clinical variables in diagnosing HF as the cause of dyspnea in these patients: 1) history of ischemic heart disease, 2) laterally displaced apical heart beat (PMI), 3) high body mass index, and 4) increased heart rate. They found that the presence of all four clinical findings had a good clinical correlation with heart failure. And the predictive value increases with the measurement of brain-type natiuretic peptide (BNP) and echocardiogram.

Patients with COPD who complain of dyspnea should be assessed for the four clinical findings to help determine whether their dyspnea is related to COPD or could be a component of HF so that they can be treated appropriately.

From: Rutten FH et al. (2005). Recognizing heart failure in elderly patients with stable chronic obstructive pulmonary disease in primary care: Cross sectional diagnostic study. BMJ, 331:1379-82.

Best wishes,

David W. Woodruff, MSN, RN, CNS, CEN
President, Ed4Nurses, Inc.
www.Ed4Nurses.com

Calcium Causes Contraction

It has been my experience that many nurses have difficulty with understanding electrolytes.  A basic understanding of electrolytes is essential to master in order to understand other concepts of patient care.

The electrolyte calcium is responsible for contraction: of the heart, the vasculature and other smooth muscle in the body.  Calcium-channel blockers inhibit calcium uptake into smooth muscle and thereby slow the heart, cause vasodilation, and may possibly relax the ureters in order to allow the passage of urethral stones.

In a recent study reported in Lancet, spontaneous passage of urethral stones was significantly higher in patients who took calcium-channel blockers or alpha-adrenergic blockers.  It makes sense; calcium-channel blockers cause relaxation of the smooth muscle allowing better passage of stones.

Examples of calcium-channel blockers:
Amlodipine (Norvasc)
Bepridil (Vascor)
Diltiazem (Cardizem)
Felodipine (Lexxel)
Isradipine (DynaCirc)
Nicardipine (Cardene)
Nifedipine (Procardia, Adalat)
Nimodipine (Nimotop)
Verapamil (Calan, Isoptin)

The take-home message is that if you understand how electrolytes work in the body, you will be able to understand how new treatments work and why they might be effective.

From:
Hollingsworth JM et al. Medical therapy to facilitate urinary stone passage: A meta-analysis. Lancet 2006 Sep 30; 368:1171-9.

Best wishes,
David W. Woodruff, MSN, RN, CNS
President, Ed4Nurses, Inc.
www.Ed4Nurses.com
www.Nurses-NewsWire.com

Sit or stand during patient interactions

Factors that influence your patient’s perception of the care you provide go beyond just your knowledge and skill.  Previous research studies have shown that a patient’s perception of the time spent with the nurse had a positive correlation with their satisfaction.  In other words, the more time you spend with your patients, the more satisfied they generally are. 

Whether you sit or stand during your interaction with the patient may also influence her perception of quality care.  In a recent study by Johnson et al, researchers found that when caregivers sat during verbal interactions, patients overestimated the amount of time that the caregiver was with them; and conversely, when the caregiver was standing during the interaction, patients underestimated the amount of time spent together. 

In these times of short staffing, when you are terribly rushed, it is important to make the best use of every minute you have with the patient.  From these studies, it would seem that patient’s satisfaction will be better the longer you spend with the patient.  If your interactions have to be brief, it would be best to sit with the patient since she will perceive that the interaction is longer than it actually is. 

From: Johnson R. L. et al. (2008). To sit or not to sit.  Annuals of Emergency Medicine 51:188.

Best wishes,

David W. Woodruff, MSN, RN, CNS, CEN
President, Ed4Nurses, Inc.

www.Ed4Nurses.com