Future of critical care.

Critical care, as a specialty in both nursing and medicine, is well recognized and the number of people requiring hospitalization for critical illnesses continues to increase. The purpose of this paper is to examine the future and the changes that lie ahead in critical care. New and expanding roles for nurses are projected along with a continued refinement and expansion of the critical care medicine subspecialty for physicians. A variety of changes in critical care are anticipated that reflect our increasing abilities in biotechnology, basic and clinical research, and data management. These changes are viewed for their obvious impact on cost, ethical controversies, and patient care and outcome.

Effect of neuromuscular blockers and opiates on the cerebrovascular response to endotracheal suctioning in adults with severe head injuries.

BACKGROUND: Intracranial hypertension occurs in response to routine procedures such as endotracheal suctioning in patients with severe head injuries. In some patients, the intracranial pressure does not immediately return to baseline levels. OBJECTIVES: To examine the effect of drug administration on cerebrovascular response to endotracheal suctioning in adults with severe head injuries. METHODS: Seventy-one subjects were divided into 3 groups: those who received no drugs, those treated with opiates only (morphine sulfate and fentanyl citrate), and those treated with a neuromuscular blocking agent (vecuronium bromide) plus opiates. A controlled protocol involving 2 sequences of endotracheal suctioning that included hyperoxygenation, hyperinflation, and suctioning was used for all subjects. Two-way repeated-measures analyses of variance were done with type of drug as the between-subject factor and phase of suctioning as the within-subject factor. Survival analysis was used to compare the return of intracranial pressure to baseline levels among the 3 groups. RESULTS: Changes in intracranial pressure were significantly smaller in subjects who received a neuromuscular blocking agent plus opiates than in subjects who did not receive any drugs or received opiates only. The greatest increase in intracranial pressure from baseline was in the first and second phases of suctioning. The 3 groups showed no significant difference in the return of intracranial pressure to baseline level. CONCLUSIONS: Neuromuscular blockers attenuate the increases in intracranial pressure that occur with endotracheal suctioning. It is not known whether control of procedurally induced elevations in intracranial pressure affects long-term outcomes in adults with severe head injuries.

Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: a comparison.

BACKGROUND: Little information is available on the practice of acute care nurse practitioners and physician assistants in acute care settings. OBJECTIVES: To compare the care activities performed by acute care nurse practitioners and physician assistants and the outcomes of their patients with the care activities and patients' outcomes of resident physicians. METHODS: Sixteen acute care nurse practitioners and physician assistants and a matched group of resident physicians were studied during a 14-month period. Data on the subjects' daily activities and on patients' outcomes were collected 4 times. RESULTS: Compared with the acute care nurse practitioners and physician assistants, residents cared for patients who were older and sicker, cared for more patients, worked more hours, took a more active role in patient rounds, and spent more time in lectures and conferences. The nurse practitioners and physician assistants were more likely than the residents to discuss patients with bedside nurses and to interact with patients' families. They also spent more time in research and administrative activities. Few of the acute care nurse practitioners and physician assistants performed invasive procedures on a regular basis. Outcomes were assessed for 187 patients treated by the acute care nurse practitioners and physician assistants and for 202 patients treated by the resident physicians. Outcomes did not differ markedly for patients treated by either group. The acute care nurse practitioners and physician assistants were more likely than the residents to include patients' social history in the admission notes. CONCLUSIONS: The tasks and activities performed by acute care nurse practitioners and physician assistants are similar to those performed by resident physicians. However, residents treat patients who are sicker and older than those treated by acute care nurse practitioners and physician assistants. Patients' outcomes are similar for both groups of subjects.

Acute care nurse practitioner curriculum: content and development process.

Curriculum development for preparation of acute care nurse practitioners requires a comprehensive process. To develop a program for their preparation at a large university, the faculty examined needs of the target patient population and care delivery system; scope of acute care nurse practitioner practice; current guidelines for the education of primary care nurse practitioners; evolving guidelines for the didactic and clinical education of acute care nurse practitioners; educational requirements of governing or licensing and certifying bodies; and placement of this new role within the existing healthcare team structure. A curriculum was then developed using a collaborative, multidisciplinary approach.

Unraveling the mystique of power analysis.

Power analysis provides one method for assessing the efficacy of alternative research designs. The purpose of this article is to simplify the methods for calculating power analysis to determine an adequate sample size. Although attention to type I errors (alpha error) is prevalent among nurse researchers, there is less appreciation for research problems resulting from a type II error. Without the a priori examination of the power of the test of significance, there is no assurance that the sample is sufficient to discern significant differences. Formulas for calculating effect size are provided for t tests, correlations, chi-square, analysis of variance, and regression. Examples of calculating the effect size by using four different statistical tests based on research studies are presented: t tests with unequal variance between groups, chi-square, an analysis of variance, and regression. Power analysis is an additional procedure to ensure that the sample size is adequate for the research project about to be undertaken.

Development of a special care unit for chronically critically ill patients.

Intensive care units (ICUs) are recognized as one of the most expensive services provided by hospitals. Within these ICUs are a growing population of patients whose stays are extensively prolonged because of complications or underlying chronic health conditions that are exacerbated by a critical illness. These patients can be described as "chronically critically ill" and are costly to hospitals both in terms of actual dollars and in terms of the burden of care to nurses and physicians. This article describes the creation of a special care unit (SCU) designed specifically to meet the needs of chronically critically ill patients. The SCU environment is composed of a physical design that accommodates limited technology and care aimed at family involvement and rehabilitation, a case management practice model, and a shared governance management model. This structure is in contrast to traditional ICU environments, which include physical layouts that allow for high technology and close monitoring of patients, a primary nursing delivery system, and a bureaucratic management model. A research project to compare the effects of the SCU with the effects of the traditional ICUs on nurse and patient outcomes is described.

Endotracheal suctioning in adults with head injury.

The purpose of this study was to determine the method of endotracheal suctioning (ETS) that resulted in the least compromise to the cerebrovascular status of adult patients with severe head injuries. A two-group (two vs three ETS), two-protocol (100% tidal volume [VT] vs 135% VT) design was used. The dependent variables were mean intracranial pressure (MICP), mean arterial pressure (MAP), cerebral perfusion pressure (CPP), heart rate (HR), and oxygen saturation (SaO2). By random assignment, 14 subjects were in the two-ETS group and 16 subjects were in the three-ETS group. Intracranial pressure response to ETS in these patients with head injury can be characterized as falling into three patterns: (1) a rise in baseline beginning with ETS and continuing throughout the ETS sequences; (2) intracranial pressure spiking during the suctioning component of the protocol; (3) a combination of both a rising baseline and spiking. There was a significant (p less than or equal to 0.001) increase from baseline for both two- and three-ETS groups with both hyperoxygenation protocols (100% VT vs 135% VT) for MICP, MAP, HR, and CPP. No significant difference was found for SaO2 for either of the protocols regardless of number of suction passes. No significant differences were found between two- and three-ETS groups for any of the dependent variables. All groups, however, regardless of number of suction passes, demonstrated a cumulative increase in MICP, MAP, and CPP with each consecutive suction sequence.(ABSTRACT TRUNCATED AT 250 WORDS)

Do-not-resuscitate practices in the chronically critically ill.

OBJECTIVES: To determine the frequency of do-not-resuscitate (DNR) orders in the chronically critically ill; to identify the differences in clinical and demographic characteristics of chronically critically ill patients who have DNR orders and those who do not; to identify the differences in the cost of care between patients with and without DNR orders; and to identify the differences in DNR practices between an experimental special care unit and the traditional intensive care unit (ICU). DESIGN: Randomized, prospective design with a block randomization scheme. SUBJECTS: Two hundred twenty patients who met the following eligibility criteria for enrollment in a parent study of the special care unit: an ICU stay of at least 5 days, an absence of pulmonary artery monitoring, an absence of frequent titration of intravenous vasopressors, an Acute Physiology and Chronic Health Evaluation II score of less than 18, and a Therapeutic Intervention Scoring System score of less than 39. SETTING: A large, urban academic medical center. MEASURES: Clinical and demographic variables describing the study populations, mental status, and timing of DNR orders, mortality rates, and cost of hospitalization. RESULTS: There was no difference in the frequency of DNR orders between the special care unit versus the intensive care unit--although patients in the special care unit had a longer interval between hospital admission and initiation of the DNR order. DNR patients differed from non-DNR in that they were older, less likely to be married, and had a higher Acute Physiology and Chronic Health Evaluation II score on admission to the study. The mortality rate in the DNR group was 71% versus 6% in the non-DNR group. There was no difference in total costs. DNR patients were also more likely to have an impaired mental status on admission, and more likely to have deterioration in mental status by the time of discharge than the non-DNR patients.

Professional and lay interrater reliability of urinary luteinizing hormone surges measured by OvuQuick test.

OBJECTIVE: To determine the reliability of women, unmotivated by fertility problems, to accurately assess and record the urinary luteinizing hormone surge indicated by color changes on OvuQuick test pads. DESIGN: A descriptive, correlational study testing the reliability and validity of an instrument. SETTING: The participants' homes. PARTICIPANTS: 114 college-educated, white women. INTERVENTIONS: An OvuQuick Test Kit and a Menstrual Cycle Diary were mailed to each participant. The monthly diary and test pads of the participants were reassessed by a master's-prepared nurse. MAIN OUTCOME MEASURES: Women without medical or health-care training are reliable in judging the color changes on the OvuQuick test pads and recording these results in a menstrual diary. RESULTS: Investigator and subject assessment and recording of luteinizing hormone surge results agreed 95% (284 of 300 instances) of the time. In addition, the validity of the luteinizing hormone surge for predicting ovulation was accurate in 93% (26 of 28 instances) of the cases. CONCLUSION: OvuQuick is a reliable and valid test for home evaluation of luteinizing hormone surge and prediction of ovulation.

Acquired immunodeficiency syndrome: impact and implication for the neurological system.

Acquired immunodeficiency syndrome (AIDS) has reached epidemic proportions throughout the world. Because at least 40% of AIDS victims are neurologically symptomatic, the neuroscience nurse must be prepared to care for increasing numbers of these patients. This article will define the syndrome, identify risk groups, and discuss the possible etiology. An explanation of the immune system will facilitate understanding of AIDS and its impact on the neurological system. The role of the nurse will be considered, with emphasis on the psychosocial implications of the syndrome for its victims.

The effects of lidocaine on intracranial hypertension.

In head-injured adults sudden increases in intracranial pressure (ICP) frequently occur in response to noxious stimuli, such as endotracheal suctioning (ETS). Transient increased ICP may have potentially harmful effects upon head-injured patients. One intervention clinicians believe to be efficacious in blunting ICP response to ETS is administration of lidocaine hydrochloride. This article critiques studies that examined effects of lidocaine in attenuating the ICP response to suctioning and similar stimuli. The literature to date, while providing conflicting results, does demonstrate tentative support for the use of lidocaine prior to ETS as a means of attenuating a rise in ICP. Support was found for the intratracheal route of administration. Additionally when intratracheal lidocaine was coupled with muscle relaxants or other anesthetic agents administered at appropriate times prior to suctioning, large rises in ICP may be effectively blunted.

Head-injured adults: recommendations for endotracheal suctioning.

Endotracheal suctioning (ETS) is a conventional nursing intervention used to decrease pulmonary complications in the critically ill patient. ETS provides a particular dilemma for the head-injured patient because it increases intracranial pressure and may put the patient at increased risk for intracranial hypertension and cerebral ischemia. Research in endotracheal suctioning targets understanding the ETS response in the severely head-injured patient. This article reviews the major research focused on suctioning the head-injured patient. The guidelines for practice based on this research include preoxygenating patients prior to suctioning, limiting suction duration to 10 seconds, limiting suction passes to 1-2 per procedure, using hyperventilation with caution, not rotating the head, keeping negative suction pressure under 120 mm Hg, and not using suction catheters with outer to inner diameter ratios greater than .50.

Faculty practice: creating a new culture.

This article provides specifics on the development of a clinical track for faculty appointments at the University of Pittsburgh. The criteria to be used for appointment and promotion on the clinical track are discussed along with the practice requirements of 60 hours per term of participation in and responsibility for direct care of patients. The purposes of faculty practice are set forth along with the formation and functioning of a Faculty Practice Council which handles decisions related to faculty practice. Results of the first year after implementation of a clinical track showed that 64 per cent (18) of the faculty had met all of their faculty practice obligations; of the remaining 36 percent (10) who had not, a variety of circumstances were cited. The Income to the School of Nursing for faculty practice, although modest, has helped to highlight that practice is valued and an integral part of the faculty role.

Infection as a complication of liver transplant.

The prognosis for recipients of a liver transplant has been vastly improved by the advent of cyclosporine therapy, and the future holds even more promise with improvements in drug therapy and surgical techniques. The transition from experimental procedure to accepted clinical practice requires nursing to develop standards of care to promote quality care in transplant nursing. With postoperative infection identified as a major cause of mortality for this patient group, nurses will be expected to be skillful in assessing and monitoring for signs and symptoms of infection. Nurses will also need to understand what is involved in the clinical diagnosis of infection, the role of immunosuppressive drug therapy, and the laboratory findings that predispose or herald infection. Infection control standards and methods to manage the risk of infection are appropriate areas of research for critical care nursing and hold the potential for improved patient outcomes for this vulnerable group of transplant patients.

Jogging: cardiovascular benefits and risks.

The cardiovascular benefits and risks of jogging are frequently debated. This article presents information on the effects of jogging and other aerobic exercise on heart rate, cardiac output, tissue oxygen consumption and blood pressure. The indirect effects of jogging on cardiac risk factors, such as serum lipids, blood clotting and glucose metabolism, are discussed. Along with the positive outcomes from jogging, the risks to the cardiovascular system are presented. These risks include a sudden drop in blood pressure at the cessation of intense jogging, cardiac arrhythmias and ischemia. The primary care nurse practitioner can play an important role in prescribing a level of exercise that is safe and will enhance physical fitness, particularly cardiovascular fitness. Guidelines for prescribing an exercise program for a variety of patient populations are reviewed, and the need for exercise monitoring by the individual is stressed.