A randomised controlled feasibility trial of alcohol consumption and the ability to appropriately use a firearm.

OBJECTIVE: To show the feasibility of using a controlled trial to investigate the effect of alcohol on firearm use. METHODS: Randomised, blinded, placebo-controlled trial in the Firearm Usage and Safety Experiments (FUSE) Lab. Treatment subjects (male, 21-40-year-old, non-habitual drinkers, with no professional firearms training) received alcohol; control subjects received placebo alcohol. The AIS PRISim Firearm Simulator, including real pistols retrofitted to discharge compressed air cartridges that simulate firearm recoil and sound, was used to measure firearm performance. Accuracy and speed for target shooting, reaction time scenarios, and scenarios requiring judgement about when to use a gun were measured. RESULTS: 12 subjects enrolled in the trial, completing 160 training scenarios. All subjects in the alcohol arm reached target alcohol level. 33% of placebo subjects reported alcohol consumption. Mechanical malfunction of the simulator occurred in 9 of 160 (5.6%) scenarios. Intoxicated subjects were less accurate, slower to fire in reaction time scenarios, and quicker to fire in scenarios requiring judgement relative to controls. CONCLUSIONS: The feasibility of a randomised, controlled trial exploring the relationship between alcohol consumption and firearm use was shown. The hypothesis that alcohol consumption worsens accuracy and retards judgement about when to use a gun should be tested. Larger trials could inform policies regarding firearm use while intoxicated.

The effect of post-injury depression on return to pre-injury function: a prospective cohort study.

BACKGROUND: Millions of people seek emergency department (ED) care for injuries each year, the majority for minor injuries. Little is known about the effect of psychiatric co-morbid disorders that emerge after minor injury on functional recovery. This study examined the effect of post-injury depression on return to pre-injury levels of function. METHOD: This was a longitudinal cohort study with follow-up at 3, 6 and 12 months post-injury: 275 adults were randomly selected from those presenting to the ED with minor injury; 248 were retained over the post-injury year. Function was measured with the Functional Status Questionnaire (FSQ). Psychiatric disorders were diagnosed using the Structured Clinical Interview for DSM-IV-TR disorders (SCID). RESULTS: During the post-injury year, 18.1% [95% confidence interval (CI) 13.3-22.9] were diagnosed with depression. Adjusting for clinical and demographic covariates, the depressed group was less likely to return to pre-injury levels of activities of daily living [odds ratio (OR) 8.37, 95% CI 3.78-18.53] and instrumental activities of daily living (OR 3.25, 95% CI 1.44-7.31), less likely to return to pre-injury work status (OR 2.37, 95% CI 1.04-5.38), and more likely to spend days in bed because of health (OR 2.41, 95% CI 1.15-5.07). CONCLUSIONS: Depression was the most frequent psychiatric diagnosis in the year after minor injury requiring emergency care. Individuals with depression did not return to pre-injury levels of function during the post-injury year.

The global burden of non-conflict related firearm mortality.

OBJECTIVE: Understanding global firearm mortality is hindered by data availability, quality, and comparability. This study assesses the adequacy of publicly available data, examines populations for whom firearm mortality data are not publicly available, and estimates the global burden of non-conflict related firearm mortality. DESIGN: The design is a secondary analysis of existing data. A dataset of countries, populations, economic development, and geographic regions was created, using United Nations 2000 world population data and World Bank classifications of economic development and global regions. Firearm mortality data were obtained from governmental vital statistics reported by the World Health Organization and published survey data. A qualitative review of literature informed estimates for the 15 most populous countries without firearm death data. For countries without data, estimates of firearm deaths were made using quartiles of observed rates and peer reviewed literature. MAIN OUTCOME MEASURES: Non-conflict related firearm deaths. RESULTS: Global non-conflict related firearm deaths were estimated to fall between 196,000 and 229,000, adjusted to the year 2000. 162,800 firearm deaths adjusted for the year 2000 came from countries reporting data and represent 35% of the world's 186 countries. Public data are not available for 122 of these 186 countries, representing more than three billion (54%) of the world's population, predominately in lower and lower middle income countries. Estimates of firearm death for those countries without data range from 33,200 to 66,200. CONCLUSIONS: This study provides evidence that the burden of firearm related mortality poses a substantial threat to local and global health.

Predictors of psychological distress following serious injury.

Posttraumatic psychological distress was assessed in 109 survivors of serious physical injury during acute hospitalization and at 3 months postdischarge. Participants had an average of 4.4 injuries, with a mean injury severity score of 15.5, denoting moderate to severe injuries. Using the Impact of Event Scale (IES), the mean total IES score in-hospital was 22.5 and at 3 months postdischarge was 30.6. Approximately 32% of individuals experienced high levels of distress in-hospital, and this increased to 49% at 3 months postdischarge. The regression model that best explained the variance in posttraumatic psychological distress at 3 months postdischarge included greater psychological distress during hospitalization, a positive drug/alcohol screen on hospital admission, younger age, and the lack of anticipating problems returning to normal life activities. These findings suggest that factors present during acute hospitalization may be used to identify individuals at risk for increased psychological distress, several months following serious physical injury.

Reimbursement for acute care nurse practitioner services.

Until the passage of the Balanced Budget Act of 1997, acute care nurse practitioners could not be directly reimbursed for inpatient services provided to Medicare patients. With the enactment of this legislation, acute care nurse practitioners may now be directly compensated for care provided. The historical and contextual issues that surround reimbursement for nursing and advanced practice nursing services are reviewed to serve as a foundation for understanding the current Medicare reimbursement regulations. The implications of the Balanced Budget Act of 1997 for acute care nurse practitioners and their professional colleagues are critically examined. The language of the Balanced Budget Act of 1997 and the subsequent rules and regulations issued by the Health Care Financing Administration are reviewed with specific focus on implications for acute care nurse practitioners. The opportunities for reimbursement for services provided by acute care nurse practitioners are more extensive than ever before. Acute care nurse practitioners and their physician colleagues will be wise to become fully conversant with the changes in Medicare reimbursement regulations.

Journey towards recovery following physical trauma.

Journey towards recovery following physical trauma Convalescence and recovery following illness are of central importance to nursing. These themes have been explored increasingly in the literature. The focus, however, has been primarily on the process of integrating chronic illness into one's life. Recovery from physical injury is rarely addressed. A body of work focusing on physical trauma demonstrates that recovery is often not complete after injuries that have not been viewed as disabling. To illuminate understanding of recovery following physical trauma, the purpose of our 1997 study was to describe more thoroughly the nature of recovery. A total of 63 adults, in a convenience sample, who survived serious physical trauma, were interviewed 2.5 years after injury using an open-ended semistructured interview guide. Three themes were identified: event, fallout, and moving-on. These themes provided the organizing structure for exploring the journey to recovery. This journey, as disclosed by the seriously injured, does not necessarily correspond with the views of most trauma clinicians. Traumatic events create a line of demarcation, separating lives into before and after. The event becomes the starting point of a journey to resume one's life. The event itself is more than the trauma; it is the perceptual and contextual experience that needs to be incorporated into a person's essence. Fallout from the injury is multifaceted and includes physical, psychological, social, and spiritual dimensions. Moving-on in this journey is nonlinear as survivors recognize their lives are forever different. The survivors' accounts suggest that nurses should carefully consider the question, 'What is successful recovery?'

A prospective study of predictors of disability at 3 months after non-central nervous system trauma.

OBJECTIVE: To delineate which injury-related, demographic, and psychosocial variables were predictive of severe disability (limitations in the performance of socially defined roles and tasks) at 3 months after discharge from acute hospitalization for non-central nervous system traumatic injury. PATIENTS AND METHODS: The study design was prospective, longitudinal, and correlational. The sample consisted of 109 injured patients at three urban trauma centers. Data were obtained from patient interview using the Sickness Impact Profile, the Impact of Event Scale, and the Social Support Questionnaire; injury-related data were obtained from the medical record and computerized trauma registries. RESULTS: The sample had a mean age of 37.4 +/- 16.8 years, a mean number of injuries per person of 4.4 +/- 2.8, and a mean Injury Severity Score of 15.5 +/- 9.9. Motor vehicle crashes (34.9%) and violent injuries (33%) were the predominant causes of injuries. Patients experienced severe levels of disability (Sickness Impact Profile, mean = 26.1) and moderate levels of psychological distress (Impact of Event Scale, mean = 30.6; intrusion mean = 14.6 and avoidance mean = 16.0). Three variables were predictive of severe disability at 3 months: high levels of intrusive thoughts (odds ratio, 2.9; 95% confidence interval, 1.1-7.7); injury with a maximal Abbreviated Injury Scale score in an extremity (odds ratio, 2.9; 95% confidence interval, 1.2-6.9); and having not graduated from high school (odds ratio, 3.4; 95% confidence interval, 1.2-10). CONCLUSION: Extremity injuries, lack of high school graduation, and high level of posttraumatic psychological distress with intrusive thoughts are risk factors for severe disability at 3 months after discharge from the hospital.

An explanatory model of variables influencing postinjury disability.

This descriptive longitudinal study based on Nagi's theory of the disabling process tested an explanatory model of the relative influence of biologic, environmental, and behavioral/lifestyle risk factors on each other and on postinjury disability after non-central nervous system traumatic injury. Data are reported on the sample of 109 subjects who remained in the study through 3 months post-hospital discharge. Subjects experienced a fairly severe level of injury (mean injury severity of 15.5; mean of number of injuries 4.4) and are representative of an urban trauma population. The trimmed explanatory model demonstrated that 67% of the variance in postinjury disability was accounted for by postinjury functional limitations, post-traumatic psychological distress, pre-injury disability, and age. Age indirectly influenced postinjury disability through its effects on pre-injury functional limitations and pre-injury disability. Social network indirectly influenced disability through its effect on post-traumatic psychological distress. Patients whose maximal injuries involved the extremities and pelvic girdle had significantly higher levels of postinjury functional limitations than those with maximal injuries involving any other body system.

Cerebral resuscitation after global brain ischemia: linking research to practice.

Despite significant advances in resuscitation medicine, neurologic recovery continues to be the major limiting factor in achieving successful resuscitation outcomes. Clinicians must recognize that successful resuscitation outcomes are not limited to the restoration of normal cardiac rhythm and hemodynamics, but rather the restoration of human mentation. It is well recognized that a cascade of injurious events begins within minutes of ischemia and that ischemic and postischemic events cause significant neuronal damage. An increased understanding of the pathophysiology of global brain ischemia provides evidence of a therapeutic window of opportunity during which interventions hold the potential to improve neurologic outcome. The research basis for understanding global brain ischemia, its clinical prognosis, and potential intervention strategies are examined.

An explanatory model of functional status in chronic obstructive pulmonary disease.

The purpose of this study was to test an explanatory model of variables influencing functional status in chronic obstructive pulmonary disease (COPD). The sample consisted of 104 patients with COPD (85 males, 19 females, mean age = 65.5, SD = 7.7). The variables in the initial model were age, length of illness, pulmonary function, oxygen desaturation during exercise, dyspnea, depressed mood, anxiety, self-esteem, exercise capacity, and functional status. Path analysis revealed that exercise capacity (beta = .337, p = .0007), dyspnea (beta = .324, p = .0009), and depressed mood (beta = -.204, p = .011) directly influenced functional status Dyspnea (beta = .488, p < .0001), depression (beta = -.217, p = .003), and pulmonary function (beta = .421, p < .0001) indirectly influenced functional status through exercise capacity. Self-esteem (beta = -.492, p = .004) and anxiety (beta = .696, p < .0001) indirectly influenced functional status through depressed mood. The findings of this study suggest that efforts to improve functional status of individuals with COPD should focus on interventions that influence exercise capacity, dyspnea, anxiety, and depressed mood.

Requirement for nursing care services and associated costs in acute spinal cord injury.

The purpose of this study was to analyze the requirement for professional nursing care and the nursing care costs for patients with acute spinal cord injury. This descriptive study used a convenience sample of 50 consecutively admitted spinal cord-injured (SCI) patients who agreed to participate. Trained data collectors interviewed patients daily, reviewed the chart and spoke with the patient's nurses, after which nursing diagnoses were determined and acuity calculated. The sample consisted of 26 quadriplegic (Q), 5 ventilator-dependent quadriplegic (V) and 19 paraplegic (P) SCI subjects. The median length of stay (LOS) was 16 days with an intensive care unit (ICU) LOS of 4 days. LOS in the intermediate unit was 11 days. Median hours of nursing care was 143 (translating to $2458) for the entire acute care hospitalization. Specific hours of care and consequent costs were determined for all three groups through both phases of care. Significant differences were found in the hours of nursing care required among the three groups (X2 7.18, df = 2, p < .03), even though no difference was found in the LOS. A nursing consumption ratio (hours of nursing care/hours of LOS) demonstrated that ventilator-dependent SCI patients required the greatest number of nursing care hours.

Intracranial pressure monitoring.

Intracranial pressure monitoring (ICP) is a technology that assists critical care nurses in the assessment, planning, intervention, and evaluation of care. The physiologic basis of intracranial hypertension (ICH) and ICP monitoring are reviewed. Types of monitors are described. Advantages, disadvantages, and complications of fluid-filled versus fiberoptic systems are explored. Priorities in nursing care of the patient with an ICP monitor are examined.

Powerlessness in acute spinal cord injury patients: a descriptive study.

The purpose of this study was to describe the frequency and characteristics of the nursing diagnosis, powerlessness, in an acute spinal cord injury (SCI) population. This descriptive study had a sample of 50 SCI patients admitted during the acute phase of injury to a model systems SCI center. Patients with a length of stay of greater than or equal to 15 days experienced a significantly higher (p less than .01) occurrence of powerlessness than did those with hospitalization of less than 15 days. Powerlessness was not found to cluster or occur in any pattern but was random throughout hospitalization. There was a statistically significant relationship (p less than .01) between the occurrence of powerlessness and patient acuity, with the occurrence increasing as acuity increased in severity. Quadriplegics and patients over the age of 60 years had a higher occurrence of powerlessness (p less than .05). This study demonstrated powerlessness was a commonly occurring diagnosis in acute SCI.

Spinal cord injury.

The successful outcome of providing care to the individual with a spinal cord injury is to enable the patient to live as satisfactory and fulfilling a life as possible. How this is achieved will be different with each individual and family depending on the degree of disability, the family and social environment, and preferred life-styles. The nurse, who deals with the human response to the injury, is in an ideal position to help the patient and family realize their life potential.