How sharp is a "sharp scratch"? A mixed methods study of verbal warnings issued before venipuncture.

OBJECTIVES: Health care providers frequently issue a verbal warning before venipuncture. Communications that induce negative expectations in patients can lead to the "nocebo" response, defined as experiencing greater pain. But is this also true for "sharp scratch"? METHODS: The study was conducted across 4 U.K. hospitals. Two separate surveys of health care providers and patients explored the prevalence, phraseology, rationale, and reaction to verbal warnings before venipuncture. Blinded adult patients already attending an outpatient department during a 2-week period were randomized to hearing a "sharp scratch" or the verbal cue "ready?" immediately before venipuncture. They were also asked to rate their pain (the primary outcome). RESULTS: 77% of 117 health care providers surveyed issued a verbal warning before venipuncture; 73% used "sharp scratch". Of 62 patients surveyed, 56% agreed that "sharp scratch" accurately describes venipuncture, and 64% agreed that they prefer "sharp scratch" to no warning. With increasing age, a preference came for an alternative warning to "sharp scratch" (P = 0.039) and to be distracted by conversation (P = 0.002). Of 192 patients in the randomized study, there was no difference in pain between the "sharp scratch" and "ready" groups. The numeric rating scores were 0.74 SD 1.06 vs. 0.88 SD 1.18, respectively. (P = 0.493). CONCLUSIONS: Most health care providers use the verbal warning "sharp scratch" before venipuncture. Most patients find this acceptable and prefer it to no warning. An exception may be elderly patients, who may prefer to be distracted by conversation. "Sharp scratch" makes no difference to the pain experienced compared with a verbal cue.

Relevance of the expression "obs stable" in nursing observations: retrospective study.

OBJECTIVE: To ascertain whether use of the term "obs stable" with respect to the nursing observations is so liberal as to render it meaningless. DESIGN: Retrospective study. SETTING: Three teaching hospitals in London, United Kingdom. METHODS: We searched progress notes for the current admission of 46 inpatients for entries containing the phrases "obs stable" and "observations stable," and reviewed the nursing observations recorded during the 24 hour period preceding each entry containing at least one phrase. We calculated the frequency of abnormalities and of persistent abnormalities (defined as occurring in every observation) observed during these 24 hour periods, and the range of observation values over a 24 hour period if at least two observations had been recorded. RESULTS: We found at least one entry in 36 (78%) progress notes (95% confidence interval 66% to 90%). Observations in the 24 hours preceding an entry included at least one abnormality for 113 (71%) of 159 cases and at least one persistent abnormality for 31 (19%). The most frequently occurring abnormalities were tachypnoea (respiratory rate ≥20 breaths/min) and hypotension (systolic blood pressure <100 mm Hg). An abnormality occurred in the observations immediately preceding an entry in 42% of cases. Mean ranges of observations over 24 hours were within the limits of normal diurnal variation, although we found that some instances of greater than normal variability were described as "stable." CONCLUSIONS: The expression "obs stable" does not reliably indicate normal observations or variations in observations within physiological limits. Doctors should avoid using the expression altogether or clarify it with further information.