Effect of a collaborative weaning plan on patient outcome in the critical care setting.

OBJECTIVE: The process of weaning from mechanical ventilation can be complex, requiring collaborative care planning by members of the healthcare team. Improved outcomes have been demonstrated to result from collaborative decision-making processes (e.g., when ventilator teams were utilized). The purpose of this study was to evaluate the effect of a collaborative weaning plan (CWP) on length of time on mechanical ventilation, length of stay in the intensive care unit (ICU), and cost. DESIGN: A new, collaborative weaning plan in the form of a weaning board and flowsheet was introduced into a medical intensive care unit (MICU) setting. A pre- and post-quasi-experimental design using historical controls was used to test the hypotheses. Attempts to control for the effects of history were made by collecting data related to patient, staffing, and organizational variables that could independently effect outcome. SETTING: MICU in a west coast teaching hospital. PATIENTS: Critically ill patients receiving mechanical ventilation for 3 days or greater. INTERVENTION: Implementation of a collaborative weaning plan. MEASUREMENTS: Outcomes studied included length of stay in the MICU, length of time patients were mechanically ventilated in the MICU, cost per MICU stay, and the incidence of complications (e.g., reventilation, readmission to the ICU, and mortality rate). MAIN RESULTS: The CWP decreased length of stay in the MICU by 3.6 days (p =.03) and length of ventilator time by 2.7 days (p =.06). There were no significant differences between groups related to cost or incidence of complications. CONCLUSIONS: These results support the usefulness of collaborative structures (such as weaning boards/flowsheets) in decreasing ICU length of stay.

Randomised controlled study of effect of parathyroid hormone on vertebral-bone mass and fracture incidence among postmenopausal women on oestrogen with osteoporosis.

BACKGROUND: Small increases in bone mass are commonly seen with existing treatments for osteoporosis, which reduce bone remodelling and primarily prevent bone loss. Since these drugs reduce but do not eliminate risk of fractures, an anabolic agent that would increase bone mass and potentially cure the underlying skeletal problem is needed. METHODS: We did a 3-year randomised controlled trial to find out the effects of 1-34 human parathyroid hormone (hPTH [1-34], 400 U/25 micrograms daily subcutaneously) in postmenopausal women with osteoporosis taking hormone-replacement therapy (n = 17). The controls were women taking hormone-replacement therapy only (n = 17). The primary outcome was bone-mineral density of the lumbar vertebrae, with bone-mineral density at other sites and vertebral fractures as secondary endpoints. FINDINGS: Patients taking hormone-replacement therapy and PTH (1-34) had continuous increase in vertebral bone-mineral density during the 3 years, whereas there was no significant change in the control group. The total increase in vertebral bone-mineral density was 13.0% (p < 0.001); 2.7% at the hip (p = 0.05); and 8.0% in total-body bone mineral (p = 0.002). No loss of bone mass was found at any skeletal site. Increased bone mass was associated with a reduction in the rate of vertebral fractures, which was significant when fractures were taken as a 15% reduction in vertebral height (p = 0.04). During the first 6 months of treatment, serum osteocalcin concentration, which reflects bone formation, increased by more than 55%, whereas excretion of crosslinked n-telopeptide, which reflects bone resorption, increased by only 20%, which suggests some uncoupling of bone formation and resorption. By 6 months, there were similar increases in both markers, which gradually returned towards baseline as the study progressed. Vertebral bone-mineral density increased most during the first year of PTH treatment. INTERPRETATION: We found that PTH has a pronouned anabolic effect on the central skeleton in patients on hormone-replacement therapy. PTH also increases total-body bone mineral, with no detrimental effects at any skeletal site. The increased vertebral mass was associated with a reduced rate of vertebral fracture, despite increased bone turnover. Bone-mass changes may be consistent with a reduction in all osteoporotic fractures. If confirmed in larger studies, these data have important implications for the treatment of postmenopausal osteoporosis.

Nurse-physician collaboration: a poststructuralist view.

The impact of various world views on nurse-physician collaboration is discussed in this paper. The poststructuralist perspective, in particular that of Michel Foucault, is presented as a means of advancing collaborative relationships. This approach allows nursing to move beyond the limitations and structure imposed by traditional philosophies. Free of these encumbrances, nursing can achieve its goals as a practice discipline, which includes collaboration with physician colleagues.

Ethical issues in hospital-based nursing practice.

A professional nursing ethic is a living, dynamic set of standards for nurses' professional moral behavior. For a professional ethic to be adequate, it must address the ethical issues perceived as relevant to the profession. The purpose of this descriptive study was to identify the ethical issues hospital-based nurses face in their practice. The authors sought to determine whether there were any differences in these ethical issues over time or according to specialty practice, position, age, educational level, or years in practice. Different groups of nurses (N = 794) were surveyed on five separate occasions over 9 years. Data were analyzed using descriptive and chi 2 statistics. The most frequent ethical issue faced was pain relief and management. Over time, the percentage of nurses who reported being faced with ethical issues related to morphine drips increased. Implications for future research on development of a normative nursing ethic are discussed.

Collaboration: a concept analysis.

Collaboration is a complex phenomenon, yet one that is of significance to nursing. This concept analysis presents definitions and defining characteristics of collaboration so that the concept may be used in the creation of operational definitions, or to develop and evaluate tools for measuring collaboration. Antecedents, consequences and empirical referents of collaboration are explored. Model, contrary and related cases are presented to clarify this concept further.

Evaluating cardiopulmonary instability with continuous monitoring of mixed venous oxygen saturation.

This article presents three cases that demonstrate the clinical application of mixed venous oxygen saturation monitoring. These case studies reflect how the critical care nurse integrates the physiology of oxygen delivery and consumption as well as critical thinking in making decisions regarding the care of patients with cardiopulmonary instability. This information gives the clinician immediate data from which therapeutic decisions are made to achieve positive patient outcomes.

Effect of do-not-resuscitate orders on the nursing care of critically ill patients.

BACKGROUND: The effect of a do-not-resuscitate order on the standard of care of critically ill patients is of concern to practitioners, patients, and their families. Because "do not resuscitate" may be misconstrued to include more than "no cardiopulmonary resuscitation," it may influence the aggressiveness with which some patients are managed. Nurses play a central role in determining standards of care. Hence, confusion on their part as to the meaning of this term can have a significant impact on patient care. OBJECTIVES: To compare nurses' attitudes about standards of care for critically ill patients with and without a do-not-resuscitate order. METHOD: A quasi-experimental design using simulation measurement was used for this study. RESULTS: Nurses reported that they would be significantly less likely to perform a variety of physiologic monitoring modalities and interventions for patients with a do-not-resuscitate order than for patients without such an order. Patients with a do-not-resuscitate order were more likely to receive psychosocial interventions including assessment of their spiritual needs and more flexible visiting practices. CONCLUSIONS: Our findings suggest that "do-not-resuscitate" may be misinterpreted to include more than "no cardiopulmonary resuscitation" even if the patient is receiving aggressive medical management. Misinterpretation of orders not to resuscitate may be related to a variety of factors including lack of understanding about hospital policy and ethical and moral values of the staff. We suggest replacing orders such as "Do not resuscitate" with clearly defined resuscitation plans that are jointly determined by the multidisciplinary team, patient, and family.

Subcutaneous administration of the amino-terminal fragment of human parathyroid hormone-(1-34): kinetics and biochemical response in estrogenized osteoporotic patients.

A standard dose (400 U or 25 micrograms) of human (h) PTH-(1-34) was administered sc in 11 estrogen-treated patients with postmenopausal osteoporosis. Increments in circulating hPTH-(1-34) were brisk, peaking at 30 min, with variable peak levels averaging 10 times normal. Clearance of the peptide from the circulation followed an expontential pattern, with a mean t1/2 of 75 min. Peptide administration was followed by an immediate decline in serum concentrations of PTH-(1-84), which remained suppressed at about 65% of the basal value for the duration of the study (4 h). Serum calcium did not increase until 120 min, thus occurring after the diminution in PTH-(1-84). Serum phosphorus declined promptly as urinary phosphate excretion increased. There were no clear changes in urinary calcium excretion, but urinary cAMP excretion increased within 120 min. In 9 of 11 patients, the serum concentration of 1,25-dihydroxyvitamin D increased, with mean levels increasing progressively after 90 min to approximately 30% above baseline (P < 0.05). In conclusion, sc administration of 25 micrograms hPTH-(1-34) produces significant short term changes in mineral homeostasis that appear to be mediated by the kidney, parathyroid gland, and skeleton, with the latter displaying the most delayed response.

A collaborative practice model for critical care.

Collaborative practice behavior is a concern for healthcare providers and administrators, because it is associated with positive outcomes for both patients and staff in the intensive care unit. Despite the documented benefits derived from collaborative practice, it remains the exception rather than the dominant pattern for nurse-physician interactions. National concern for quality care and rising healthcare costs mandates that collaborative practice behaviors between nurses and physicians replace competition as the means for resolving differences. The purpose of this article is to describe collaborative practice, propose a theoretical framework for collaborative practice and discuss the development, implementation and evaluation of a collaborative practice model.

Need for information. Interventions for practice.

Information is an important need of families of critically ill patients. Meeting this need requires a multidisciplinary approach and an environment that values the delivery of humanistic care. Critical care nurses require special skills in assessment, planning, intervention, and evaluation to effectively meet the information needs of families. Research is available to guide nurses in meeting the family's need for information.

An evaluation of interventions for meeting the information needs of families of critically ill patients.

OBJECTIVE: To evaluate the effectiveness of two methods of meeting the information needs of families of critically ill patients: an open visiting hour policy and a family information booklet. SETTING: Medical intensive care unit of a university medical center. SUBJECTS: Family members (N = 147) of patients admitted to the medical intensive care unit. INTERVENTIONS: Implementation of an open visiting hour policy and information booklet. MEASUREMENTS AND MAIN RESULTS: Questionnaires were distributed to family members 24 to 48 hours after the patient's admission. The questionnaire addressed family satisfaction with having specific information needs met and posed questions that tested their knowledge of unit policies and personnel. The questionnaire was distributed to three groups: families who had restricted visiting hours and no booklet (group 1, n = 48), families who had open visiting hours but no booklet (group 2, n = 50), and families who had open visiting hours and an information booklet (Group 3, n = 49). Implementation of an open visiting hour policy increased family satisfaction. Families exposed to both the open visiting hours and the information booklet were more knowledgeable about specific details than were those exposed to only the open visiting hour policy. CONCLUSIONS: Flexible visiting hours and information booklets were two practical methods of meeting the information needs of families. Open visiting hours, as a singular intervention, significantly improved family satisfaction. The effectiveness of the booklet in assisting families to recall discrete pieces of information supports the further development and use of preprinted materials to assist in meeting family information needs.

Comprehensive patient care and documentation through unit-based nursing rounds.

Unit-based nursing rounds is an advanced practice educational program implemented through collaboration between a unit-based clinical nurse specialist and an education nurse specialist. The purpose of this program is to provide an informal, time efficient means of teaching staff nurses during work hours. The format emphasizes utilization of the nursing process through presentation of selected case studies. The goal is to enhance incorporation of a nursing model into patient care planning to ensure comprehensive patient care and documentation. Each phase of coordinating, implementing, and evaluating this educational program will be reviewed.

Evaluating oxygen delivery and oxygen utilization with mixed venous oxygen saturation monitoring: a case study approach.

Three cases studies are presented to demonstrate clinical application of mixed venous oxygen saturation (SvO2) monitoring in critical care nursing practice. Examples of critically ill patients are used to demonstrate how SvO2 monitoring can be used in clinical practice to reflect an imbalance between oxygen delivery and oxygen utilization. In the first case, the patient had a problem with oxygen delivery. Continuous SvO2 data aided nurses in guiding, adjusting, and assessing therapy. The second case demonstrates how SvO2 monitoring can provide an early sign of a life-threatening complication. The final case is one in which the patient had a problem with oxygen utilization. In all the cases, continuous SvO2 data provided important information about the balance between oxygen delivery and oxygen utilization.

Effect of nursing contact on the stress response of patients being weaned from mechanical ventilation.

A prospective, randomized study was undertaken to determine the effect of direct nursing contact on the stress response of patients being weaned from mechanical ventilation. Twenty-six patients being weaned via T-piece for the first time were randomly assigned to either an experimental or a control group. Patients in the experimental group received touch and verbal interaction during weaning whereas the control group did not. Strict control was maintained over the patient's environment during the data collection period, including restriction of all nonessential medical and nursing interventions. No significant increases were found in heart rate or mean arterial pressure in either the control or experimental group during weaning. Respiratory rate 5 minutes after the ventilator was discontinued increased from baseline in both the control (18.0 to 24.4 breaths/min, p = 0.03) and experimental (18.0 to 22.4 breaths/min, p = 0.04) groups. Because both groups had similar responses to weaning, the differences between the groups was nonsignificant and therefore the hypothesis was not supported.