Clinical intervention trials: the ACE unit

The loss of independent self-care by older patients during hospitalization for an acute illness can be modified by specific interventions. Acute care geriatric units appear to be the most effective intervention, but geriatric consultation on specific units, comprehensive discharge planning, and nutritional support also appear to have beneficial effects on clinical outcomes of hospitalization. These studies highlight the potential of geriatricians, in the setting of interdisciplinary care, to improve the process of patient care and to serve as directors of medical units that focus on management of acutely ill older patients.     

Preferences for chemotherapy in patients with advanced non-small cell lung cancer: descriptive study based on scripted interviews

OBJECTIVE: To determine how patients with lung cancer value the trade off between the survival benefit of chemotherapy and its toxicities. DESIGN: Scripted interviews that included three hypothetical scenarios. Each scenario described the same patient with metastatic non-small cell lung cancer with an expected survival of 4 months without treatment. Subjects were asked to indicate the minimum survival benefit required to accept the side effects of chemotherapy in the first two scenarios (mild toxicity and severe toxicity). In the third scenario, subjects were asked to choose between chemotherapy and supportive care when the benefit of chemotherapy was either to prolong life by 3 months or to palliate symptoms. SUBJECTS: 81 patients previously treated with cis-platinum based chemotherapy for advanced non-small cell lung cancer. MAIN OUTCOME MEASURE: Survival threshold for accepting chemotherapy. RESULTS: The minimum survival threshold for accepting the toxicity of chemotherapy varied widely in patients. Several patients would accept chemotherapy for a survival benefit of 1 week, while others would not choose chemotherapy even for a survival benefit of 24 months. The median survival threshold for accepting chemotherapy was 4.5 months for mild toxicity and 9 months for severe toxicity. When given the choice between supportive care and chemotherapy only 18 (22%) patients chose chemotherapy for a survival benefit of 3 months; 55 (68%) patients chose chemotherapy if it substantially reduced symptoms without prolonging life. CONCLUSIONS: Patients' willingness to accept chemotherapy for the treatment of metastatic lung cancer varies widely. Many would not choose chemotherapy for its likely survival benefit of 3 months but would if it improved quality of life. The conflict between these patients' preferences and the care they previously received has several explanations, one being that some patients had not received the treatment they would have chosen had they been fully informed.     

Euthanasia among US critical care nurses. Practices, attitudes, and social and professional correlates

OBJECTIVES: The authors sought to identify associations between critical care nurses' self-reported participation in euthanasia, their social and professional characteristics, and their attitudes toward end-of-life care. METHODS: Data were collected through an anonymous mail survey of 1,560 US critical care nurses, of whom 1,139 (73%) responded. Nurses were asked to report whether they had received requests to engage in euthanasia and whether they had engaged in euthanasia. In addition, nurses were asked to respond to items assessing their attitudes toward end-of-life care. RESULTS: Of 852 nurses who identified themselves as practicing exclusively in adult intensive care units, 164 (19%) reported that they had engaged in euthanasia, 650 (76%) reported that they had not engaged in euthanasia, and 38 (4%) could not be classified. Only 30% of respondents believed that euthanasia is unethical. Logistic regression indicated that older nurses, more religious nurses, nurses practicing in cardiac care units, and nurses with less favorable attitudes toward euthanasia were significantly less likely to report having engaged in euthanasia, although the effects of age and religious beliefs appear to have been mediated by attitudes. CONCLUSIONS: These results help explain why some US critical care nurses engaged in euthanasia despite legal and professional prohibitions against it. Because critical care nurses may have a special understanding of the needs of critically ill patients, these results may indicate that current guidelines for end-of-life care are inadequate.     

Mucin secretion in papillary (chromophil) renal cell carcinoma

BACKGROUND: In Canada, primary care physicians manage most musculoskeletal problems. However, their training in this area is limited, and some aspects of management may be suboptimal. This study was conducted to examine primary care physicians' management of 3 common musculoskeletal problems, ascertain the determinants of management and compare management with that recommended by a current practice panel. METHODS: A stratified computer-generated random sample of 798 Ontario members of the College of Family Physicians of Canada received a self-administered questionnaire by mail. Respondents selected various items in the management of 3 hypothetical patients: a 77-year-old woman with a shoulder problem, a 64-year-old man with osteoarthritis of the knee and a 30-year-old man with an acutely hot, swollen knee. Scores reflecting the proportion of recommended investigations, interventions and referrals selected for each scenario were calculated and examined for their association with physician and practice characteristics and physician attitudes. RESULTS: The response rate was 68.3% (529/775 eligible physicians). For the shoulder problem, all of the recommended items were chosen by the majority of respondents. However, of the items not recommended, ordering blood tests was selected by almost half (242 [45.7%]) as was prescribing an NSAID (236 [44.7%]). For the knee osteoarthritis the majority of respondents chose the recommended items except exercise (selected by only 175 [33.1%]). Of the items not recommended, tests were chosen by about half of the respondents and inappropriate referrals (chiefly for orthopedic surgery) were chosen by a quarter. For the acutely hot knee, the majority of physicians chose all of the recommended items except use of ice or heat (selected by only 188 [35.6%]). Although most (415 [78.5%]) of the respondents selected the recommended joint aspiration for this scenario, 84 (15.9%) omitted this investigation or referral to a specialist. The selection of recommended items was strongly associated with training in musculoskeletal specialties during medical school and residency. INTERPRETATION: Primary care physicians' management of 3 common musculoskeletal problems was for the most part in accord with panel recommendations. However, the unnecessary use of diagnostic tests, inappropriate prescribing of NSAIDs, low use of patient-centred options such as exercise, and lack of diagnostic suspicion of infectious arthritis are cause for concern. The results point to the need for increased exposure to musculoskeletal problems during undergraduate and residency training and in continuing medical education.     

Is there paradoxical arousal reaction in the EEG subdelta range in patients during anesthesia?

The human oral microflora is diverse and is usually predominately composed of Gram-positive bacteria. It is uncommon to find Gram-negative bacilli (GNB) in healthy mouths. The incidence of infection with GNB rises in institutionalised, frail elderly subjects. There is also evidence of an association between intra-oral GNB presence and denture wearing. There have been few studies which have investigated intra-oral GNB carriage in acutely ill elderly patients. The aim of this study was to evaluate the oral flora of a group of elderly patients during an acute medical admission and to investigate any associations between the oral microflora and existing medical or oral factors. A total of 28 patients (17 females and 11 males; age: 74-93 years) on a care for the elderly ward were studied. Epidemiological data, detailed medical histories and oral examinations were undertaken. In addition, oral swabs of the palate area were taken to determine their oral flora. Twelve (43%) of the patients had GNB in their oral cavities. These patients were suffering from a variety of medical conditions and were on various drug regimes. There was a correlation between oral GNB presence and denture use. There was no association between GNB presence and denture hygiene. As oropharyngeal GNB colonisation can be associated with infections such as aspiration pneumonia, it is important in patients at risk that intra-oral organisms are identified and managed.     

Colposcopic evaluation of patients with abnormal cytologic smears during pregnancy

A new tube test for pregnancy, having a sensitivity of 0.5 I.U. of human chorionic gonadotropin per milliliter, was evaluated, along with two other commercially available kits, in a hospital patient population. Of 586 patients in the study, 302 were in nonobstetric services and many were acutely ill. Approximately one fourth of the women were age 40 or older. The medical records of 66% of the patients were retrieved to obtain information on the drugs administered prior to pregnancy testing. A small number of problems did occur in the pregnancy test procedures. Inconclusive results were recorded for both pregnant and nonpregnant patients and could not be correlated with disease states and/or medications. The importance of a reagent control for tube test procedures is discussed.     

11C]beta-CIT-FE, a radioligand for quantitation of the dopamine transporter in the living brain using positron emission tomography

Patients with gastrointestinal hemorrhage are frequently admitted to critical care units, in large part to be observed for signs of hemodynamic instability. All patients admitted with gastrointestinal bleeding to our medical intensive care unit over a 1-year period (n=108) were retrospectively reviewed to determine the incidence of hemodynamic instability. In an elderly patient population with predominantly nonvariceal bleeding, only 13% of those admitted had documented hypotension that led to an intervention. Only 7% had clinically significant hypotension after the first 5 hours of admission. Admission clinical criteria were analyzed by multivariate analysis but could not reliably predict patients at increased risk for hemodynamic instability. However, patients without significant comorbid illness who have been endoscopically shown to have a low-risk lesion can be considered for early transfer to a regular bed after a short period of close observation. This could lead to better resource utilization and cost savings without jeopardizing patient care.     

Clinical decision making in the prediction of falls.

Objective: Examine rehabilitation professionals' capacity to identify risk factors for patient falls. Design: Survey study. Setting: Three academic medical center rehabilitation departments. Participants: Fifty-six rehabilitation specialists representing disciplines typically involved in patient care, including physiatry and occupational, physical, recreation, and speech therapy. Measures: A 2-part, self-report questionnaire with spontaneous and cued rank-order listing of factors related to fall risk. Results: Clinicians did not consider advanced age and history of falling when spontaneously delineating risks for falls. The importance of fall history, but not of advanced age, was recognized through cueing. Conclusions: Clinicians appear aware of strong predictors of fall risk but require cueing to consistently use them. Cueing increased hypothetical predictive accuracy, although clinicians still downplayed some of the most salient predictive factors. Staff education regarding validated fall risk factors and potential errors in clinical decision making can improve patient care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Current nursing practice of point-of-care laboratory diagnostic testing in critical care units

BACKGROUND: The development of user-friendly laboratory analyzers, combined with the need for rapid assessment of critically ill patients, has led to the performance of in vitro diagnostic testing at the point of care by personnel without formal laboratory training. OBJECTIVES: To determine the range of laboratory testing performed by critical care nurses and their attitudes toward this role. METHODS: A survey of critical care nursing consultants was conducted, using a modified Likert scale, to assess objective measures of point-of-care testing practice in critical care units and to determine nurses' attitudes toward the practice of point-of-care testing. Statistical analysis was performed to determine significant trends in responses. RESULTS: Of the units responding to the survey, 35% used critical care nurses exclusively to perform point-of-care testing, 32.5% used laboratory technicians and critical care nurses, and 25% used other personnel. Of critical care nurses performing laboratory testing, 95.5% performed blood glucose analysis; 18.7%, arterial blood gas analysis; 4.5%, electrolyte analysis; 4.5%, hematology profiles; and 22.7%, other testing. Most agreed that stat tests were not reported promptly, thereby necessitating bedside testing. Respondents indicated that they would prefer that laboratory personnel operate in vitro diagnostic equipment and that requirements for critical care nurses to perform laboratory testing detracted from other patient care duties. CONCLUSIONS: Most nurses who perform point-of-care testing responded that it was necessary and helpful in patient management. However, they would prefer, because of their other patient care responsibilities, that laboratory personnel take this responsibility.     

Bilateral total hip prosthesis in osteopetrosis. Apropos of a case. Review of the literature

BACKGROUND: After our first known patient with vancomycin-resistant enterococci (VRE) infection was admitted in 1993, we observed a gradual increase in infections and colonization caused by this organism. Thus we initiated a prospective study to quantitate the incidence of VRE infection versus colonization, to identify risk factors for VRE, and to define the natural history of VRE colonization among our patients. METHODS: Stool/rectal cultures were performed for patients admitted to the intensive care units at the time of admission and weekly thereafter. Patients found to be carrying VRE were followed with cultures every 2 weeks, and this protocol was continued after transfer to the medical-surgical wards. A surveillance form was initiated on each VRE patient and included demographics, underlying diseases, and risk factors. Environmental cultures in the intensive care units were randomly performed. Patients with positive cultures were isolated. RESULTS: During a 27-month period, 210 patients were found to be colonized or infected with VRE. Ages ranged from 35 to 97 years; the mean age was 65 years. Fourteen percent (29 of 210) of the patients were VRE positive on admission. Nosocomial colonization or infection occurred at an average of 28 days after admission. Seventeen percent (25 of 216) of patients cleared VRE during their hospital stay; 19% (40 of 210) developed 47 infections. One third of infections involved the urinary tract. Liver transplantation, chemotherapy, and total parenteral nutrition were each associated with infection. CONCLUSION: Routine measures as advocated by the Centers for Disease Control and Prevention were not effective in controlling VRE in our patient population.     

Sleep Disturbances and Fatigue in Critically Ill Patients

Sleep disturbances and fatigue are significant problems for critically ill patients. Existing sleep disorders, underlying medical/surgical conditions, environmental factors, stress, medications, and other treatments all contribute to a patient's inability to sleep. Sleep disturbance and debilitating fatigue that originate during acute illness may continue months after discharge from intensive care units (ICUs). If these issues are unrecognized, lack of treatment may contribute to chronic sleep problems, impaired quality of life, and incomplete rehabilitation. A multidisciplinary approach that incorporates assessment of sleep disturbances and fatigue, environmental controls, appropriate pharmacologic management, and educational and behavioral interventions is necessary to reduce the impact of sleep disturbances and fatigue in ICU patients. Nurses are well positioned to identify issues in their own units that prevent effective patient sleep. This article will discuss the literature related to the occurrence, etiology, and risk factors of sleep disturbance and fatigue and describe assessment and management options in critically ill adults.

     

Satisfaction with inpatient acquired immunodeficiency syndrome care. A national comparison of dedicated and scattered-bed units

OBJECTIVES: This study sought to determine whether there were differences in acquired immunodeficiency syndrome (AIDS) patients' satisfaction with inpatient nursing care on dedicated AIDS units compared with conventional, multidiagnosis medical units. METHODS: Interview data were collected from more than 600 consecutive AIDS admissions in 40 patient care units in 20 hospitals in 11 high AIDS incidence cities. Ten hospitals with dedicated AIDS units were matched with comparable hospitals treating AIDS patients on multidiagnosis medical units. AIDS patients' satisfaction with nursing care on dedicated AIDS units was compared with AIDS patients' satisfaction with care on scattered-bed units in the same hospital and with AIDS patients' satisfaction on scattered-bed units in different, matched hospitals without dedicated units. Interhospital differences that were not controlled by design were controlled statistically, as were differences in patient characteristics and illness severity. RESULTS: Acquired immunodeficiency syndrome patients receiving care on dedicated AIDS units were significantly more satisfied with their nursing care. In hospitals with units of both types, dedicated AIDS units had a higher proportion of white patients, men, and homosexuals, whereas scattered-bed units had more minority patients and intravenous drug users. Controlling for these factors as well as for differences in illness severity and interhospital differences in patient satisfaction did not diminish the positive AIDS unit effect on patient satisfaction. CONCLUSIONS: Dedicated AIDS units achieve higher levels of satisfaction among patients with AIDS than general medical units. There is no evidence that patients feel isolated or stigmatized on dedicated AIDS units compared with patients on general units, and many patients have a clear preference for dedicated units.     

Life values, resuscitation preferences, and the applicability of living wills in an older population

OBJECTIVES: To determine whether life values are related to resuscitation preferences and living will completion in an older population and to assess beliefs about the applicability of living wills. DESIGN: Individual structured interviews. SETTING: An independent retirement community. PARTICIPANTS: One hundred thirty-two subjects older than 63 years of age. MEASUREMENTS: Resuscitation preferences were elicited in five hypothetical scenarios. Subjects with living wills were asked whether their living will would play a role in the scenarios. Subjects rated the importance of 13 life value statements. RESULTS: The percentage of subjects desiring CPR in each scenario was as follows: current condition (66%); acute illness (33%); terminal disease (8%); functional impairment (8%); and dementia (7%). The percentage of those with a living will who thought their living wills would play a role in the scenarios was as follows: acute illness (84%); terminal disease (93%); functional impairment with intact cognition (66%); and dementia (91%). Factor analysis of the life value statements revealed five meaningful factors: quality of life; capacity/autonomy; family relations; physical comfort; and treatment philosophy. Multiple correlations were found between four of five life value factors and hypothetical resuscitation preferences or the presence of a living will. CONCLUSION: Subjects misinterpreted the applicability of living wills in nonterminal illness scenarios. A relationship between life values and resuscitation preferences was noted, which emphasizes the importance of eliciting and including life values when discussing advance directives.     

Results of the consensus conference on fostering more humane critical care: creating a healing environment. Society of Critical Care Medicine

The Society of Critical Care Medicine (SCCM) sponsored the Consensus Conference on Fostering More Human Care Creating a Healing Environment in October 1990 at Snowbird, Utah. The purpose of this conference was to address the challenges of providing sensitive, humane critical care in an increasingly technological and cost-conscious environment. The long-term objective was to develop this document (initially published by SCCM in 1992) as a resource for critical care professionals who are seeking methods by which to foster more humane care of their acutely ill patients.     

Telemetry outside critical care units: patterns of utilization and influence on management decisions

BACKGROUND: Guidelines for the use of telemetry in hospitalized patients have been proposed by the American College of Cardiology (ACC). However, there have been only a few studies which have investigated the usefulness of these guidelines in clinical practice. HYPOTHESIS: This study assessed the role of telemetry in the decision making process outside the critical care units. METHODS: The observational study, lasting 4 weeks, was conducted in the telemetry unit of a tertiary care teaching hospital and included 61 male patients (age range 40-61 years). They had been directly admitted to the telemetry unit or transferred from a critical care unit and were followed for as long as telemetry was active. Indication for telemetry and the contribution of telemetry to management decisions were assessed by a physician not involved in the care of the patient. RESULTS: Cumulative number of telemetry days was 379 with a mean of 6.2 days per patient. Total number of telemetry events was 297. According to the ACC classification, 14 patients (22.9%) had class I indication, 21 patients (34.4%) had class II indication, and 26 patients (42.6%) had class III indication. Telemetry events were seen in 18.2% of class I patients, in 39.7% of class II patients, and in 42.1% of class III patients. Only 12 telemetry events (4%) resulted in patient management, with none belonging to class III. CONCLUSION: Telemetry findings in patients outside the critical care units are not usually responsible for major therapeutic changes. The value of telemetry in such patients may be overrated.     

Prolonged surgery increases the likelihood of admission of scheduled ambulatory surgery patients

STUDY OBJECTIVE: To identify variables influencing the likelihood of unanticipated admission following scheduled ambulatory surgery. DESIGN: Retrospective case-controlled chart review study. SETTING: A large academic tertiary care hospital. PATIENTS: 8,549 ASA physical status I, II, III, and IV patients who underwent scheduled ambulatory surgery in 1991. MEASUREMENTS AND MAIN RESULTS: Of the 8,549 patients, 216 were admitted, with complete medical record information available for 167 of the admitted patients. The most common reasons for admission among the 167 were surgical (43%), anesthetic (28%), and medical (17%) complications. Odds for admission following long surgery (of at least 60 minutes) were 7.5 times (p < 0.001) greater than following short surgery (under 60 minutes). Among long cases, independent variables influencing admission were: general anesthesia [odds ratio 20.8; 95% confidence interval (CI) 4.4 to 45.6], and monitored anesthesia care or regional anesthesia (combined odds ratio 8.3; 95% CI 1.7 to 40.8). ASA physical status and patient age did not significantly influence admission rate for long cases. For short cases, patients over 65 years (odds ratio 5.6; 95% CI 2.6 to 12.0), ASA physical status III or IV (odds ratio 4.8; 95% CI 2.0 to 11.6), use of general anesthesia (odds ratio 4.7; 95% CI 1.5 to 14.2), and monitored anesthesia care or regional anesthesia (odds ratio 3.1; 95% CI 1.0 to 10.1) independently influenced the likelihood of admission. Type of surgery and gender had no detectable effect on admission. CONCLUSIONS: Surgery duration of 60 minutes or longer was the most important predictor of unanticipated admission following scheduled ambulatory surgery.     

Management of Nausea, Vomiting, and Diarrhea During Critical Illness

Symptoms are subjective patient experiences that may negatively impact the patient's hospitalization, treatment plan, and quality of life. Critically ill patients frequently experience nausea, vomiting, and diarrhea related to underlying disease, procedures, and medical interventions (eg, medication, enteral feeding, surgery). Optimally, the nurse performs a subjective assessment that explores the patient's perception and impact of these symptoms to develop a comprehensive plan of care. Unfortunately, little evidence is available to guide assessment of nausea, vomiting, and diarrhea in critically ill nonverbal patients. Understanding the disease processes, medical treatments, and pathophysioglogy of these symptoms will assist the critical care nurse in the anticipation of symptoms and development of a proactive plan to alleviate the symptom-associated discomfort.

     

The mechanism of red cell (dis)aggregation investigated by means of direct cell manipulation using multiple optical trapping

Red cell exchange is important in the care of acutely ill sickle-cell patients, and may be life-saving. An automated red cell exchange technique has been developed using a Baxter blood cell separator, enabling an isovolaemic exchange to be performed within 2.5 h. A total of 20 procedures have been performed in 15 patients, including one woman in the third trimester of pregnancy, with a mean decrease of 72% in the circulating sickle haemoglobin (HbS) level. This method enables almost all adult patients with sickle cell anaemia to have their HbS reduced to safe levels by only one procedure. The procedure was well tolerated by all patients, including those who were acutely ill. This technique provides an effective procedure for reducing the percentage of circulating HbS rapidly in acutely ill patients with complications of sickle cell anaemia.