An Observational Study of Decision Making by Medical Intensivists.

OBJECTIVES: The ICU is a place of frequent, high-stakes decision making. However, the number and types of decisions made by intensivists have not been well characterized. We sought to describe intensivist decision making and determine how the number and types of decisions are affected by patient, provider, and systems factors. DESIGN: Direct observation of intensivist decision making during patient rounds. SETTING: Twenty-four-bed academic medical ICU. SUBJECTS: Medical intensivists leading patient care rounds. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: During 920 observed patient rounds on 374 unique patients, intensivists made 8,174 critical care decisions (mean, 8.9 decisions per patient daily, 102.2 total decisions daily) over a mean of 3.7 hours. Patient factors associated with increased numbers of decisions included a shorter time since ICU admission and an earlier slot in rounding order (both p < 0.05). Intensivist identity explained the greatest proportion of variance in number of decisions per patient even when controlling for all other factors significant in bivariable regression. A given intensivist made more decisions per patient during days later in the 14-day rotation (p < 0.05). Female intensivists made significantly more decisions than male intensivists (p < 0.05). CONCLUSIONS: Intensivists made over 100 daily critical care decisions during rounds. The number of decisions was influenced by a variety of patient- and system-related factors and was highly variable among intensivists. Future work is needed to explore effects of the decision-making burden on providers' choices and on patient outcomes.

Watermemories: a swimming club for adults with dementia.

The purpose of this article is to describe the conceptual model and implementation strategies of an evidence-based, aquatic exercise program specifically targeting individuals with dementia-The Watermemories Swimming Club (WSC). Physical exercise not only improves the functional capacity of people with dementia but also has significant effects on other aspects of quality of life such as sleep, appetite, behavioral and psychological symptoms, depression, and falls. Additionally, exercise can improve a person's overall sense of well-being and positively enhance their sociability. The WSC was designed to increase physical exercise while being easy to implement, safe, and pleasurable. Many challenges were faced along the way, and we discuss how these were overcome. Implications for nurses are also provided.

KNOWLEDGE AND SKILLS ENHANCEMENT THROUGH PERIOPERATIVE NURSING SIMULATION LAB TRAINING.

In Edmonton Zone, the attrition rate among new perioperative nursing staff is an issue of concern and many ORs are facing noticeable staffing challenges. In the Edmonton area there are approximately 79 surgical suites. A series of simulation labs were established in 2015 to provide perioperative nurses in order to increase their comfort on the job and to help build confidence levels. The expectations for this simulation are an overall improvement in perioperative nurses' competency, a reduction in OR orientation and training time, and a decrease in the attrition rates among OR nurses.

Default options in advance directives influence how patients set goals for end-of-life care.

Although decisions regarding end-of-life care are personal and important, they may be influenced by the ways in which options are presented. To test this hypothesis, we randomly assigned 132 seriously ill patients to complete one of three types of advance directives. Two types had end-of-life care options already checked-a default choice-but one of these favored comfort-oriented care, and the other, life-extending care. The third type was a standard advance directive with no options checked. We found that most patients preferred comfort-oriented care, but the defaults influenced those choices. For example, 77 percent of patients in the comfort-oriented group retained that choice, while 43 percent of those in the life-extending group rejected the default choice and selected comfort-oriented care instead. Among the standard advance directive group, 61 percent of patients selected comfort-oriented care. Our findings suggest that patients may not hold deep-seated preferences regarding end-of-life care. The findings provide motivation for future research examining whether using default options in advance directives may improve important outcomes, including patients' receipt of wanted and unwanted services, resource use, survival, and quality of life.

Trends in antidepressant overdoses.

BACKGROUND: Debate continues about antidepressants and suicide. However, there are few recent nation-wide data about antidepressant overdoses. The purpose of this study was to describe United States trends from 1983 through 2003 in antidepressant overdoses as well as trends in health care utilization and mortality. METHODS: Data were obtained from the American Association of Poison Control Centers' (AAPPC) Toxic Exposure Surveillance System (TESS), the National Hospital Ambulatory Medical Care Survey (NHAMCS) of emergency departments, and the National Hospital Discharge Survey(NHDS). RESULTS: Antidepressant overdose reports rose dramatically in the United States (from 0.61 per 10,000 population in 1983 to 3.26 per 10,000 population in 2003) chiefly due to the rise in selective serotonin reuptake inhibitor (SSRI) ingestion. However, fatalities per antidepressant overdose report declined from 73 per 10,000 reported ingestions to 32 per 10,000 ingestions. Tricyclic antidepressant (TCA) overdoses had higher rates of hospitalization (78.7 vs. 64.7% hospitalized) and much higher fatality rates than did SSRI overdose reports (0.73 vs. 0.14% mortality). If the 55,977 SSRI overdoses in 2003 had represented TCA overdoses, then (other things being equal) approximately 410 fatalities would have been expected but only 106 people died. Emergency department visits associated with antidepressant overdose increased along with all emergency department visits. Hospitalization associated with antidepressant overdose increased in the early 1980s but then reached a plateau while overall hospitalizations declined. CONCLUSIONS: The dramatic rise in United States antidepressant overdoses has not been reflected in antidepressant overdose fatalities nor in hospitalizations. If the marked increase in antidepressant overdoses in the United States had involved TCAs rather than SSRIs, then there would have been roughly 300 excess deaths annually.