Nurse experts jump-start clinical simulation in rehabilitation nursing: supporting new graduate transition to competence.

This article outlines a high-fidelity simulation project developed and implemented by expert staff nurses at a specialty rehabilitation hospital. The project is designed to educate new graduate nurses on appropriate care for patients after a rare spinal cord surgical procedure. Due to the complicated nature of the surgery, patients are highly acute and may present with specific complications that need to be addressed for positive patient outcomes. Expert staff nurses imparted their knowledge in developing a scenario emphasizing common and unusual postsurgery patient presentations. The scenario was implemented as a teaching exercise for new graduate nurses, with experienced staff nurses as facilitators of learning in a safe, nonthreatening environment. New graduate nurses were overwhelmingly positive in the postsimulation debriefing, reporting increased confidence and knowledge necessary to care for these patients. Future endeavors include expanding involvement of staff nurses in simulation education and researching new graduate transition through simulation.

Selective dorsal rhizotomy in children: comparison of outcomes after single-level versus multi-level laminectomy technique.

Children with cerebral palsy may experience spasticity, which may negatively impact their quality of life. One proven treatment for such spasticity is selective dorsal rhizotomy (SDR), whereby a partial sectioning of the dorsal roots from L2 to S1 is performed. SDR can be performed where the nerve root exits the intervertebral foramina via multi-level laminectomies, or at the level of the conus via a single-level laminectomy. At British Columbia Children's Hospital (BCCH), SDRs were performed via multi-level laminectomies until 2005, when the single-level technique was adopted. The single-level procedure is technically more challenging and takes longer, but requires a smaller incision and involves less muscle dissection. Functional outcomes at one-year follow-up are similar for the two methods of surgery. It was hypothesized that post-operative pain would be less, mobilization faster and hospital stay shorter using the single-level technique. Using a retrospective case series analysis, we compared nine patients who had had single-level SDR to 18 matched controls who had undergone SDR using the multi-level technique. There were no significant differences in post-operative pain, duration of opioid infusion, or time to mobilization. Length of hospital stay was significantly decreased after the single level procedure: 3.4 versus 5.2 days (p = 0.01).

Laminectomy and fusion after spinal cord injury: national inpatient complications and outcomes.

There is little information about national in-hospital complication rates, adverse outcomes, and mortality after spinal fusion for spinal cord injury (SCI). The National Inpatient Sample (NIS) was utilized to identify 31,381 admissions of acute spinal cord injured patients who underwent spinal decompression with laminectomy and/or fusion (lam/fusion) in the United States from 1993 to 2002. Multivariate analysis was performed to analyze the effects of patient and hospital characteristics on outcomes such as mortality, complications, and discharge disposition, which were then stratified by age, level, and type of injury. The overall mortality was 3.0%, with a complication rate of 26.3% and mean length of stay (LOS) of 17 days. Pulmonary complications (14.4%) and postoperative hemorrhages or hematomas (3.8%) were the most common complications reported. One postoperative complication doubled the length of stay, increased the mortality rate by fivefold and added over $50,000 to hospital charges. Age and comorbidities were the main significant predictors of mortality on multivariate analysis. Patients aged >85 or 65-84 had a 44- and 14-fold greater risk of dying compared with patients in the 18-44 age group respectively. Patients with >3 comorbidities also had an increased risk of mortality (odds ratio [OR] = 1.8). Alcohol abuse was the most common medical comorbidity (present in 12% of patients treated). This study represents the first major national estimate of in-hospital mortality and complication rates after nonoperative and operative treatment for SCI.

Development of a same day laminectomy program.

Historically, patients undergoing a lumbar laminectomy for discectomy (LLD) have been admitted to the hospital for 1 to 3 days. Because a patient undergoing a surgical procedure is not necessarily medically ill, many surgical procedures are now performed on an outpatient basis. A multidisciplinary nursing team proposed that some patients scheduled to undergo an LLD would be able to have this surgery as an outpatient. A 6-month research project was developed to study outcomes of patients undergoing LLD who were discharged after 4 to 6 hours of postoperative care in the PACU. Guidelines were established to define the candidates for enrollment in the same day LLD. A patient clinical pathway was established, and outcome monitors were selected. Twenty-seven patients were enrolled in this study. This article describes the process of development, application, and future implications of this study.

Continuity of care for short-stay neurosurgery patients: a quality improvement initiative.

Decreases in the length of hospital stay for patients undergoing spinal surgery prompted this evaluation of the post-discharge needs of patients and the strategies that patients and their families employ to meet these needs. The nature and extent of post-discharge problems experienced by newly discharged patients was required as a baseline for the evaluation and improvement of discharge planning. Forty patients were interviewed following discharge, 20 patients within the first week of discharge, and 20 different patients between three and four weeks after discharge. Most patients reported that they had been well-informed about pain management and the majority of patients reported that pain was well-controlled. There was a subset of patients, however, who continued to report high levels of pain, even at one month after discharge. Less than one in three patients stated that they had received information about wound care and the information received was not consistent among health professionals. Given the limited time to prepare patients for discharge, this project highlights the need for written materials and for systematic follow-up after discharge.

Laminectomía / Laminectomy

El caso del paciente con una afección de la columna proporciona las bases para esbozar un plan de cuidados de enfermería centrado en el operado de laminectomía

Impact of patient-controlled analgesia on required nursing time and duration of postoperative recovery.

BACKGROUND AND OBJECTIVES: Patient-controlled analgesia (PCA) offers effective postoperative pain management. However, the evidence of economic benefits associated with its use is lacking. Although suggestive, the potential economic advantages of PCA in saving nursing time and shortening hospital stay need objective documentation. METHODS: This study compared the effects of morphine administered by PCA systems with intramuscular (i.m.) morphine injection on patient analgesic response, satisfaction, nursing time requirements, and postoperative recovery in 23 patients undergoing "open" cholecystectomy and 44 patients undergoing lumbar laminectomy and bony fusion. After the operation, patients in the PCA group received 1.5-2 mg morphine with a lockout of 5-10 minutes on demand, whereas those in the i.m. group received 0.15-0.2 mg/kg every 4 hours on demand. Visual analog scale (VAS) pain scores and satisfaction scores were evaluated at 4-hour intervals while nursing time spent on both analgesia-related and non-analgesia-related activities was recorded continuously by a team of independent observers on the ward. Recovery time profile for the return of bowel function, activities of daily living, ambulation without support, and length of hospital stay was also recorded. RESULTS: It was found that morphine consumption, VAS, and satisfaction scores were similar in both PCA and i.m. treatment groups following both types of surgery. However, the delay in nurse response to i.m. morphine request ranged from 27.2 +/- to 42.1 +/- 11.8 minutes. The demand of nursing time on analgesia administration was less with PCA. The magnitude of time saving was 10 min/patient/d in cholecystectomy patients and 13 min/patient/d in laminectomy patients. The speed of postoperative patient recovery was similar between the two analgesia groups. Length of hospital stay following cholecystectomy was shorter--92.0 +/- 5.9 hours with PCA versus 128.6 +/- 22.2 hours with i.m. (not statistically significant)--whereas that following laminectomy was not different. CONCLUSIONS: Data in this study have demonstrated some beneficial effects of PCA on nursing time requirements when it was used following cholecystectomy and lumbar laminectomy at the University of Toronto: however, the magnitude of these benefits was less than previously reported. The effects of PCA on postoperative recovery and hospital stay, however, were not significantly different from i.m. therapy.

Dedicated short-stay spinal unit.

Prolonged waiting periods for patients with benign spinal surgical lesions led to the creation of a Dedicated Short Stay Spinal Surgical Unit. This unit was implemented in November, 1992, on a 29 bed Neuroscience Unit in a 1200 bed Acute Care Teaching Hospital. Considerations for implementation were many, including psychological impact of chronic pain for patients on prolonged waiting lists, the increased probability of permanent waiting lists, the increased probability of permanent neurological deficits, and the economic impact to patient, societal and hospital budgets. This paper will focus on explanation of the design of the unit, define the benefits and provide study results of the first 85 patients admitted to the unit.

Body image in preoperative and postoperative lumbar laminectomy patients.

Many patients each year undergo a lumbar laminectomy for removal of a herniated disc. This study was conducted to determine if the patient had a change in body image from the preoperative to postoperative period. Body image was measured using the Body-Cathexis Scale. Twenty-four (24) patients were included in the study. Results indicated that there was a significantly higher difference in the total Body-Cathexis score postoperatively as compared to preoperatively. In addition, there was a significantly higher difference in the patients' ratings of back, knee, posture, energy level and sexual activity in the postoperative period. Further research is needed with a larger sample and over time to see whether these effects hold true.

Nursing case management: application to neuroscience nursing.

The changing health care environment has challenged nurses to develop creative care delivery systems that provide for quality, comprehensive, cost-effective care in a time of restricted reimbursement and diminishing human and material resources. Nursing case management has been identified as one such approach to health care delivery that has resulted in quality, patient-centered care and improved resource utilization. The case management plan, critical path and discharge planning sheet are primary tools in this care delivery model. Because of the diverse case types and variety of patient care settings, neuroscience nursing is an ideal arena for implementing a nursing case management model of care.

Intramedullary spinal cord abscesses.

Intramedullary spinal cord abscesses are rare lesions that cause a variety of neurologic problems. This article reviews pathogenesis and symptoms associated with these lesions. In addition, specific nursing interventions for care of patients with intramedullary spinal cord abscesses are presented. These interventions focus on diagnostic testing, treatment options and a plan of care for patients diagnosed with this disease entity.

Factors determining length of hospitalization for patients having laminectomy surgery.

The purpose of this study was to determine factors associated with length of stay for patients undergoing lumbar laminectomy. Significant differences were identified related to method of payment for hospitalization, number of doses of analgesic medications, and presence of muscle spasms. Other factors studied were sex, pre- or postoperative administration of steroids, presence of complications, age, length of surgical procedure and types of antispasmodic medications administered. The study was conducted in an urban north Texas hospital, using a retrospective review of 30 charts selected randomly. Further study of factors related to length of hospitalization is necessary in this, as well as other patient populations, especially since the advent of prospective payment.

Thoracic disc disease: diagnosis and surgical treatment.

Symptomatic thoracic disc disease is uncommon. Unlike cervical or lumbar disc disease, this disorder frequently is not associated with pain. Often, diagnosis is delayed until signs of myelopathy develop. Surgical intervention is the treatment of choice. Because of the unique characteristics of the thoracic spinal canal, the vascular supply to the spinal cord, and the fact that many of these disc extrusions are anterior to the cord, different surgical techniques are needed. Few patients experience intraoperative complications; however, some approaches predispose patients to the risks of both thoracotomy and exploration of the spinal canal. Postoperative complications are similar to those associated with thoracotomy. Most patients have an improvement in neurologic function after therapy.