Change-of-Shift Nursing Handoff Interruptions: Implications for Evidence-Based Practice.

BACKGROUND: The importance of change-of-shift handoffs in maintaining patient safety has been well demonstrated. Change-of-shift handoff is an important source of data used in surveillance, a nursing intervention aimed at identifying and preventing complications. Surveillance requires the nurse to acquire, process, and synthesize information (cues) encountered during patient care. Interruptions in handoff have been observed but there is a gap in the evidence concerning how interruptions during nurse-to-nurse handoff impact the change-of-shift handoff process. AIMS: To describe registered nurses' perceptions of interruptions experienced during change-of-shift handoff at the bedside in critical care units and analyze the number, type, and source of interruptions during change-of-shift handoff at the bedside. METHODS: An exploratory descriptive design was used. One hundred nurse-to-nurse handoffs were observed, and four focus groups were conducted. Observation data were analyzed with descriptive statistics and quantitative content analysis. Focus group data were analyzed with qualitative content analysis. RESULTS AND FINDINGS: Of the 1,196 interruptions observed, 800 occurred in the communication between the two nurses involved in the handoff. Over 80% (645) of these interruptions were from the nurse receiving handoff and included questions or clarification of information received. About half of the nurses reported that interruptions occurred during handoff. Focus group findings revealed that whether or not something is an interruption is determined by the individual nurse's appraisal of value added to their knowledge of the patient and/or plan of care at the time of handoff. LINKING EVIDENCE TO ACTION: Interruptions during handoff are evaluated as useful or disruptive based on the value to the nurse at the time. Strict structuring or mandating of handoff elements may limit nurses' ability to communicate information deemed most relevant to the care of a specific unique patient.

Combined negative pressure wound therapy and ultrasonic MIST therapy for open surgical wounds: a case series.

BACKGROUND: Surgical wounds are at increased risk of infection when left open to heal through secondary intention; they increase length of hospital stay, hospital costs, readmission rates, and patient morbidity. New technologies and methods of treating acute and chronic wounds are emerging. Two recent developments for the treatment of open wounds are noncontact low-frequency ultrasound (NCLFU) treatment and negative pressure wound therapy (NPWT). METHODS: This case series reports findings from 4 hospitalized patients with complex conditions who underwent colorectal surgery resulting in open abdominal wounds. The wounds were treated with NCLFU in combination with NPWT. Data were collected via retrospective review of medical records. RESULTS: After concurrent treatment with NPWT (range, 13-18 days) and NCLFU (range, 5-9 treatments), wound areas in these 4 cases were reduced by 4.5% to 37% and wound volume decreased by 17% to 62%. Granulation tissue increased in the open tissue areas in all patients. In addition, 3 of the cases received a mesh graft. CONCLUSIONS: Combination treatment with NPWT and NCLFU therapy with or without sharp debridement enhanced wound healing in the open abdominal wounds of these 4 patients.

Discharge planning rounds to the bedside: a patient- and family-centered approach.

Discharge planning rounds done at the bedside is an effective patient-centered approach to discharge planning and does not take any longer than traditional rounds apart from the patient and caregiver. Bedside rounds may decrease patient utilization of health care resources after discharge.

Male sling procedures for stress urinary incontinence.

Radical prostatectomy is the most common cause of urinary incontinence in males. Urinary slings are a relatively new treatment option for men. This article describes two urinary sling procedures as possible surgical approaches for incontinence in men.

Effects of urinary catheter education for patients undergoing prostatectomy.

In a nonrandomized prospective study, significant decreases in patient anxiety with home urinary catheter management and in length of stay were reported when patients attended the preoperative prostatectomy class with standard postoperative education versus standard postoperative education.

Bedside nurse-to-nurse handoff promotes patient safety.

UNLABELLED: Nurse-to-nurse beside handoff allows the oncoming nurse to visualize the patient and ask questions of the previous nurse. It encourages pateints to be involved actively in their care and allows standardized communication between nursing shifts. BACKGROUND: Patient handoff between nurses at shift change has been an important process in clinical nursing practice, allowing nurses to exchange necessary patient information to ensure continuity of care and patient safety. Bedside handoff allows the patient the ability to contribute to his or her plan of care. It also allows the oncoming nurse an opportunity to visualize the patient and ask questions. This is critical in meeting the Joint Commission's 2009 National Patient Safety Goals. It encourages patients to be involved actively in their care and it implements standardized handoff communication between nursing shifts. Bedside handoff promotes patient safety and allows an opportunity for patients to correct misconceptions. METHODS: A convenience sample of 60 patients was enrolled, 30 before the practice change and 30 after the change. All nursing staff were invited to participate. Both patients and staff were given self-designed surveys before and after the practice change. RESULTS: Fifteen nurses with a mean of 2 years in the profession completed the pre- and post-survey. A majority of staff were not satisfied with the current shift change report, but statistical improvement was achieved after the practice change. Also, statistical improvement was achieved with patients' satisfaction with involvement in their plan of care. CONCLUSIONS: Use of bedside nursing handoff promotes staff accountability, two-person IV medication reconciliation, and patient satisfaction.

Standardized Change-of-Shift Handoff: Nurses' Perspectives and Implications for Evidence-Based Practice.

BACKGROUND: Nursing handoff is a communication activity with a high risk for loss or omission of information. Efforts to improve handoffs include standardization of the processes and content of handoff communications. OBJECTIVES: To examine nurses' perspectives on the structure and organization of change-of-shift handoffs. METHODS: A qualitative descriptive approach was used to conduct a secondary analysis of focus group data. Thirty-four nurses from 4 critical care units participated in focus groups. RESULTS: Three themes emerged: handoff elements are defined by practice and culture; a clear, consistent, identified structure supports handoff; and personal preferences can disrupt handoff. CONCLUSIONS: A standardized approach to handoff based on unit and organizational needs will be more successful than a broad mandate of content and organization. Individual preference is prevalent and strongly influences the information conveyed and the structure of handoff communication.

Using evidence to enhance the recovery of patients undergoing colorectal surgery: part 3.

This is the third part of a three-part series describing how an enhanced recovery clinical pathway uses a multidisciplinary team to reduce postoperative stress and complications, improve recovery, and decrease hospital length of stay without affecting patient safety for patients undergoing colorectal surgery. Last month, multimodal analgesia and standardized postoperative nausea and vomiting prophylaxis were discussed. This part discusses fluids, diet, tubes and drains, and early mobilization.

Using evidence to enhance the recovery of patients undergoing colorectal surgery: part 2.

This is the second part of a three-part series describing how an enhanced recovery clinical pathway uses a multidisciplinary team to reduce postoperative stress and complications, improve recovery, and decrease hospital length of stay without affecting patient safety for patients undergoing colorectal surgery. Last month, patient education and discharge planning were discussed. This part discusses multimodal analgesia and standardized postoperative nausea and vomiting prophylaxis. Next month, fluids, diet, tubes and drains, and early mobilization will be discussed.

Using evidence to enhance the recovery of patients undergoing colorectal surgery: part 1.

This is the first part of a three-part series describing how an enhanced recovery clinical pathway uses a multidisciplinary team to reduce postoperative stress and complications, improve recovery, and decrease hospital length of stay without affecting patient safety for patients undergoing colorectal surgery. This part discusses patient education and discharge planning. Next month, pain and postoperative nausea and vomiting will be discussed.

Using high-fidelity simulation to develop nurse-physician teams.

BACKGROUND: This study was undertaken to determine whether interdisciplinary high-fidelity simulation training improves group cohesion in nurse-physician teams. In addition, perceptions of collaboration and satisfaction with patient care decisions were measured in nurse-physician participants. METHODS: Clinical scenarios relevant to the general surgical urology inpatient unit were conducted in an interdisciplinary high-fidelity simulation center. Participants included physicians and staff nurses. RESULTS: Participants reported a positive shift in group cohesion over time. In addition, the results suggested a positive shift in perceptions of collaboration and satisfaction with patient care decisions over time. The youngest participants (Millennial Generation, born in the 1980s and 1990s) showed the most significant growth in response to the training. CONCLUSION: This study provides evidence of benefits of high-fidelity simulation that extend beyond the training. Simulation training may be a strategy to build and strengthen relationships across nurse-physician teams. In addition, this type of training may positively affect collaboration and satisfaction with patient care decisions. When data were analyzed by generational grouping, the most significant growth occurred in the Millennial Generation participants. These influences need to be explored further.

Benign Prostatic Hyperplasia Implications for Pharmacologic Treatment and Perioperative Care.

This review provides an update on the treatment of benign prostatic hyperplasia and the pharmacologic considerations for perioperative care. By age 85 years, approximately 90% of men have prostate histologic characteristics consistent with benign prostatic hyperplasia. Pharmacologic treatment with an alpha1 receptor antagonist may reduce symptoms and, when given in combination with a 5-alpha-reductase inhibitor, may decrease the risk of urinary retention and the need for surgical intervention. Transurethral resection of the prostate has been the historical standard when surgical intervention is indicated. However, recent evidence suggests that Holmium laser enucleation of the prostate may have similar efficacy with less risk of complications and with decreased catheterization time. Prostatic urological operations may have perioperative complications, including urethral bleeding, acute urinary retention, urinary tract infection, urge incontinence, and venous thromboembolism. Pharmacist recommendations for the appropriate use of laxatives, antibiotics, anticoagulation, and urinary antispasmodics are key components of perioperative management. Surgical interventions improve symptoms but may have complications, providing the pharmacist an opportunity to improve perioperative care.

Enhancing nurse and physician collaboration in clinical decision making through high-fidelity interdisciplinary simulation training.

OBJECTIVE: To determine whether interdisciplinary simulation team training can positively affect registered nurse and/or physician perceptions of collaboration in clinical decision making. PARTICIPANTS AND METHODS: Between March 1 and April 21, 2009, a convenience sample of volunteer nurses and physicians was recruited to undergo simulation training consisting of a team response to 3 clinical scenarios. Participants completed the Collaboration and Satisfaction About Care Decisions (CSACD) survey before training and at 2 weeks and 2 months after training. Differences in CSACD summary scores between the time points were assessed with paired t tests. RESULTS: Twenty-eight health care professionals (19 nurses, 9 physicians) underwent simulation training. Nurses were of similar age to physicians (27.3 vs 34.5 years; p = .82), were more likely to be women (95.0% vs 12.5%; p < .001), and were less likely to have undergone prior simulation training (0% vs 37.5%; p = .02). The pretest showed that physicians were more likely to perceive that open communication exists between nurses and physicians (p = .04) and that both medical and nursing concerns influence the decision-making process (p = .02). Pretest CSACD analysis revealed that most participants were dissatisfied with the decision-making process. The CSACD summary score showed significant improvement from baseline to 2 weeks (4.2 to 5.1; p < .002), a trend that persisted at 2 months (p < .002). CONCLUSION: Team training using high-fidelity simulation scenarios promoted collaboration between nurses and physicians and enhanced the patient care decision-making process.

Intrathecal anesthesia and recovery from radical prostatectomy: a prospective, randomized, controlled trial.

BACKGROUND: Previous studies suggest that intraoperative anesthetic care may influence postoperative pain and recovery from surgery. The authors tested the hypothesis that the addition of intrathecal analgesia to general anesthesia would improve long-term functional status and decrease pain in patients undergoing radical retropubic prostatectomy. METHODS: One hundred patients received either general anesthesia supplemented with intravenous fentanyl or general anesthesia preceded by intrathecal administration of bupivacaine (15 mg), clonidine (75 microg), and morphine (0.2 mg). Patients and providers were masked to treatment assignment. All patients received multimodal pain management postoperatively. Primary outcomes included pain and functional status over the first 12 postoperative weeks. RESULTS: Patients receiving intrathecal analgesia required more intravenous fluids and vasopressors intraoperatively. Pain was well controlled throughout the study (mean numerical pain scores < 3 in both groups at all times studied). Intrathecal analgesia decreased pain and supplemental intravenous morphine use over the first postoperative day but increased the frequency of pruritus. Pain and functional status after discharge from the hospital did not differ between groups. Intrathecal analgesia significantly decreased the duration of hospital stay (from 2.8 +/- 2.0 to 2.1 +/- 0.5 days; P < 0.01) as a result of five patients in the control group who stayed in the hospital more than 3 days. CONCLUSIONS: The benefits of improved immediate analgesia and decreased morphine requirements resulting from intrathecal analgesia must be weighed against factors such as pruritus, increased intraoperative requirement for fluids and vasopressors, and resources needed to implement this modality. Further studies are needed to determine the significance of the decrease in duration of hospital stay.