The "CHROME criteria": Tool to optimize and audit prescription quality of psychotropic medications in institutionalized people with dementia.

OBJECTIVE: Describe and validate the CHROME (CHemical Restraints avOidance MEthodology) criteria. DESIGN: Observational prospective longitudinal study. SETTING: Single nursing home in Las Palmas de Gran Canaria, Spain. PARTICIPANTS: 288 residents; mean age: 81.6 (SD 10.6). 77.4% had dementia. INTERVENTION: Multicomponent training and consultancy program to eliminate physical and chemical restraints and promote overall quality care. Clinicians were trained in stringent diagnostic criteria of neuropsychiatric syndromes and adequate psychotropic prescription. MEASUREMENTS: Psychotropic prescription (primary study target), neuropsychiatric syndromes, physical restraints, falls, and emergency room visits were semi-annually collected from December 2015 to December 2017. Results are presented for all residents and for those who had dementia and participated in the five study waves (completer analysis, n=107). RESULTS: For the study completers, atypical neuroleptic prescription dropped from 42.7% to 18.7%, long half-life benzodiazepines dropped from 25.2% to 6.5%, and hypnotic medications from 47.7% to 12.1% (p<0.0005). Any kind of fall evolved from 67.3 to 32.7 (number of falls by 100 residents per year). Physicians' diagnostic confidence increased, while the frequency of diagnoses of neuropsychiatric syndromes decreased (p<0.0005). CONCLUSIONS: Implementing the CHROME criteria reduced the prescription of the most dangerous medications in institutionalized people with dementia. Two independent audits found no physical or chemical restraint and confirmed prescription quality of psychotropic drugs. Adequate diagnosis and independent audits appear to be the keys to help and motivate professionals to optimize and reduce the use of psychotropic medication. The CHROME criteria unify, in a single compendium, neuropsychiatric diagnostic criteria, prescription guidelines, independent audit methodology, and minimum legal standards. These criteria can be easily adapted to other countries.

Predictors of nursing faculty members' organizational commitment in governmental universities.

BACKGROUND: It is essential for all university leaders to develop and maintain an effective programme of total quality management in a climate that promotes work satisfaction and employee support. PURPOSE: The purpose of the study was to investigate the relationship of faculty members' organizational commitment to their job satisfaction, perceived organizational support, job autonomy, workload, and pay. METHODS: A quantitative study, implementing a correlational research design to determine whether relationships existed between organizational commitment and job satisfaction, perceived organizational support, job autonomy, workload and pay. RESULTS: Stepwise linear regression analysis was used to estimate the probability of recorded variables included significant sample characteristics namely, age, experience and other work related attributes. The outcome showed a predictive model of three predictors which were significantly related to faculty members' commitment: job satisfaction, perceived support and age. CONCLUSION: Although the findings were positive toward organizational commitment, continued consideration should be given to the fact that faculty members remain committed as the cost associated with leaving is high. IMPLICATION FOR NURSING MANAGEMENT: A study of this nature increases the compartment in which faculty administrators monitor the work climate, observe and identify factors that may increase or decrease job satisfaction and the work commitment.

Positive experiences in caregivers: an exploratory case series.

BACKGROUND: Recent research into positive experiences in caregivers has begun to redress the traditional focus on negative aspects of caregiving experiences. METHOD: This exploratory study used a cognitive-behavioural approach - namely, the transactional stress model (Lazarus and Folkman, 1984) - to investigate associations between appraisals, coping, and gains over a 6-week period in a small sample (N = 4; case series) design involving stroke caregivers. Analysis involved visual inspection of graphs, supported by descriptive statistics, and co-variation analysis. RESULTS: Participants reported high levels of positive experiences, and these increased over the study period, a previously unreported trend. The study also found individual differences in the interactions between appraisal, coping, and caregiving gain variables, findings explained by the transactional stress model. CONCLUSIONS: Implications for clinical practice and future research are addressed.

Posttraumatic growth and optimism in health-related trauma: a systematic review.

Posttraumatic growth (PTG) research is an emerging area of empirical study, especially within the field of clinical health psychology. Much of the research in this area has thus far focused on determining the correlates and predictors of PTG. This systematic review aimed to evaluate the association between posttraumatic growth and dispositional optimism, specifically in relation to health traumas. Empirical studies that met the inclusion criteria were reviewed according to specific evaluation criteria. Results regarding the relationship between dispositional optimism and posttraumatic growth were found to be equivocal. A number of conceptual and methodological issues were identified and discussed in relation to the field of PTG research. Future directions for research are provided.

The effect of international courses on nursing practice at Jordanian hospitals.

BACKGROUND: Recently, nursing education in Jordan has been radically reformed to fit social and organizational processes of globalization. Jordanian nurses are attending international courses to improve their nursing practice. METHODS: This descriptive, qualitative study was aimed at identifying the impact of Jordanian nurses' participation in international courses on nursing practice in Jordan. Purposive sampling techniques were used. Two focus groups of Jordanian nurses who participated in international courses provided rich data. RESULTS: Findings from the focus groups suggested that participation in international courses makes a significant contribution to nurses' professional and personal development. CONCLUSION: Jordanian nurses are challenged to find ways to actually apply the new skills and knowledge gained from these courses in their work.

[Dialysis and transplant. Spain in 2005]. / Informe de Situación de Diálisis y Trasplante en España, 2005.

In 2005, renal replace treatment (dialysis and transplant) was necessary for about 40,000 people, without being known the number accurate and either their basic characteristics, such as: time in treatment, modality or treatment changes. The presented data cover the 76% of the Spanish population and are the result of the cooperation among technicians of registries, nephrologists and transplant coordinations. 4,125 people started RRT in 2005, the total estimated acceptance rate for renal replacement therapy in adults in Spain was 126 pmp and regarding other European countries it locates us in an intermediate area. The incidence rate seems to keep stable in the last years although there were some differences among communities (from 104 pmp in Castile and Leon to 186 pmp in Canary Islands). Diabetes Mellitus is the most diagnosed cause of renal failure in 2005, more than 20% of patients, followed by vascular diseases. The estimated prevalence of renal replacement therapy in Spain at the end of 2005 was 903 pmp, with important variations among communities (from 806 pmp in Cantabria to 1056 pmp in Valencia Region). The 47% of prevalent RRT patients had a functioning transplant. Mortality on haemodialysis and peritoneal dialysis was 13.7% and 10.8% respectively. Mortality on transplant was 1.3%, one of the lowest values registered so far. Mortality on renal replacement therapy was around 5% among patients from 45 to 64 years, 11% between 65 and 74 years and 19% among the patients older than 75 years.

The medical management and dental implications of long QT syndrome.

Long QT is a disorder of the heart's conduction system. It can be congenital or acquired. The acquired type is caused mainly by medications. The diagnosis of LQT depends on the clinical features, the family history, and the ECG findings. The clinical presentations range from dizziness to syncope and sudden death. The dentist should consult the cardiologist to avoid any complications that may put the LQTS patient at risk. Medications such as erythromycin and antifungals are contra-indicated and should not be prescribed. Local anaesthetics containing adrenaline and bupivacaine should be avoided. Stress can precipitate symptoms and lead to sudden death.

Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. The Spanish Lung Failure Collaborative Group.

Little information exists regarding the proportion of patients treated with mechanical ventilation in intensive care units (ICUs), their underlying disease states, the modes of ventilation used, duration of ventilator support, methods and time required for weaning, and mortality in these patients. We carried out a cross-sectional multicenter study in 47 medical-surgical ICUs in Spain to investigate these issues in 290 patients who required mechanical ventilation for at least 24 hs. Relative frequency of different modes was as follows: assist-control ventilation (AC), 55%; synchronized intermittent mandatory ventilation (SIMV), 26%; pressure support ventilation (PSV), 8%; SIMV plus PSV, 8%; pressure-controlled ventilation (PCV), 1%; and continuous positive airway pressure (CPAP), 2%. Overall duration of mechanical ventilation was 27.1 +/- 1.1 (SE). A variety of techniques were used for weaning: T-tube trials, 24%; SIMV, 18%; PSV, 15%; SIMV plus PSV, 9%; and some combination of two or more methods in succession in 33% of the patients. Time required for weaning using a combination of SIMV and PSV was longer (17.8 days) than with other techniques (about 5 days, p < 0.01). Time between initiation of weaning and removal of mechanical ventilation accounted for 41% of total ventilator time and was particularly high (59%) in patients with chronic obstructive pulmonary disease. Overall mortality rate was 34%, and it was higher in patients who were ventilated for 1 to 10 days than in those ventilated for a longer time. Despite the availability of several new modes of ventilator support, older modes such as AC and SIMV were more commonly used. Weaning constitutes a large portion of total ventilator time, and thus, measures that expedite the weaning process should markedly decrease the duration of mechanical ventilation.

Prospective randomized trial comparing pressure-controlled ventilation and volume-controlled ventilation in ARDS. For the Spanish Lung Failure Collaborative Group.

STUDY OBJECTIVES: To compare in-hospital mortality of patients with ARDS ventilated with either pressure-controlled ventilation (PCV) or volume-controlled ventilation (VCV) with a square-wave inspiratory flow. DESIGN: : Multicenter and randomized trial. SETTING: Twelve medical-surgical ICUs located in tertiary-care hospitals. PATIENTS: Seventy-nine patients having ARDS, as defined by the American-European Consensus Conference. INTERVENTIONS: Patients were randomly assigned to be ventilated with either PCV (n = 37) or VCV (n = 42). In both instances, inspiratory plateau pressure was limited to < or = 35 cm H(2)O. MEASUREMENTS AND RESULTS: There were no significant differences among the studied groups at the moment of randomization, although there was a trend toward greater renal failure in patients assigned to VCV. Ventilatory settings and blood gases did not significantly differ over time between the two groups. Patients in the VCV group had both a significantly higher in-hospital mortality rate than those in the PCV group (78% vs 51%, respectively) and a higher number of extrapulmonary organ failures (median, 4 vs 2, respectively). The development of renal failure during the study period was also significantly more frequent among VCV patients (64% vs 32%, respectively). Multivariate analysis showed that factors independently associated with an increased mortality rate were the presence of two or more extrapulmonary organ failures (odds ratio [OR], 4.61; 95% confidence interval [CI], 1.38 to 15.40) and acute renal failure (OR, 3.96; 95% CI, 1.10 to 14.28) but not the ventilatory mode used. CONCLUSIONS: The increased number of extrapulmonary organ failures developed in patients of the VCV group was strongly associated with a higher mortality rate. The development of organ failures was probably not related to the ventilatory mode.

A randomized and controlled trial of the effect of treatment aimed at maximizing oxygen delivery in patients with severe sepsis or septic shock.

OBJECTIVE: To evaluate the effects of increased oxygen delivery on mortality and morbidity. DESIGN: Randomized, controlled trial. SETTING: Medical-surgical ICU of a tertiary care hospital. PATIENTS: Sixty-three patients classified according to predetermined criteria as having severe sepsis or septic shock. INTERVENTIONS: The patients were randomly assigned to one of two groups: the control group (n = 32) received conventional therapy with a normal targeted value of oxygen delivery, and the treatment group (n = 31) received therapy with a targeted oxygen delivery index (DO2I) value of > 600 mL/min/m2. The therapeutic approach to maintain BP, arterial saturation, hemoglobin concentration, and pulmonary artery occlusion pressure was similar in both groups. MEASUREMENTS AND MAIN RESULTS: The hemodynamic, oxygen transport, and gastric intramucosal pH measurements were recorded at the time of admission to the study and every 6 h for the next 96 h. The outcome measures were the rate of patient mortality and the number of organ dysfunctions occurring during the ICU stay. The study groups were similar with respect to demographics and admission hemodynamic variables, but the percentage of patients with positive blood cultures was significantly higher in the control group than in the treatment group, respectively: 34 vs 13% (p = 0.04). The average cardiac index was significantly higher in the treatment group than in the control group, respectively: 3.96 vs 3.05 L/min/m2 (p = 0.01). This factor did not significantly affect the DO2I. Nine of the 31 treatment group patients reached an average DO2I value of > 600 mL/min/m2. The rate of mortality in the control group patients up to the time of ICU discharge (66%) was similar to that seen in the treatment group (74%), respectively: 21 of 32 vs 23 of 31 (p = 0.46). The number of dysfunctional organs per patient was also similar in the control and treatment groups, respectively: 2.1+/-1.1 vs 2.6+/-1.2 (p = 0.12). CONCLUSION: Treatment aimed at maximizing oxygen delivery in patients with severe sepsis or septic shock does not reduce mortality or morbidity.

Weaning from mechanical ventilation in pediatric intensive care patients.

OBJECTIVE: The development of weaning predictors in mechanically ventilated children has not been sufficiently investigated. The purpose of this study was to evaluate the accuracy of some weaning indices in predicting weaning failure. DESIGN: Prospective, interventional study. SETTING: University-affiliated children's hospital with a 19-bed intensive care unit. PATIENTS: 84 consecutive infants and children requiring mechanical ventilation for at least 48 h and judged ready to wean by their primary physicians. INTERVENTIONS: Patients who met the criteria to start weaning underwent a trial of spontaneous breathing lasting up to 2 h. Bedside measurements of respiratory function were obtained immediately before discontinuation of mechanical ventilation and within the first 5 min of spontaneous breathing. The primary physicians were blinded to those measurements, and the decision to extubate a patient at the end of the spontaneous breathing trial or reinstitute mechanical ventilation was made by them. Failure to wean was defined as the requirement for mechanical ventilation at any time during the trial of spontaneous breathing (trial failure) or needing reintubation within 48 h of extubation (extubation failure). MEASUREMENTS AND MAIN RESULTS: Seventy-five patients had neither signs of respiratory distress nor deterioration in gas exchange during the trial and were extubated. Twelve patients required reintubation within 48 h. In 9 patients, mechanical ventilation was reinstituted after a median duration of the spontaneous breathing trial of 35 min. The only independent predictor of trial failure was tidal volume indexed to body weight [odds ratio 2.60, 95 % confidence interval (CI) 1.40 to 24.9]. The only independent predictor of extubation failure was frequency-to-tidal volume ratio indexed to body weight (odds ratio 1.23, 95 % CI 1.11 to 1.36). The sensitivity, specificity, and positive and negative predictive values to predict weaning failure were calculated for each of the above variables. These values were 0.48, 0.86, 0.53, and 0.83, respectively, for a frequency-to-tidal volume ratio higher than 11 breaths/min per ml per kg and 0.43, 0.94, 0.69, and 0.83, respectively, for a tidal volume lower than 4 ml/kg. CONCLUSIONS: Three-quarters of ventilated children can be successfully weaned after a trial of spontaneous breathing lasting 2 h. Both tidal volume and frequency-to-tidal volume ratio indexed to body weight were poor predictors of weaning failure in the study population.

Comparison of one versus two bronchodilators in ventilated COPD patients.

OBJECTIVE: To compare the bronchodilating effect of a single drug, ipratropium bromide (IBr), with that of its combination with fenoterol (IBr+F). DESIGN: The study was triple blind and randomized. SETTING: Medical-surgical intensive care unit. PATIENTS: 12 patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) requiring mechanical ventilation for severe respiratory failure. INTERVENTIONS: Before administering each drug, peak airway pressure (Ppeak), end inspiratory pressure (Pei), resistive pressure (Pres), and auto positive--end expiratory pressure (auto-PEEP) were measured. Inspiratory system resistance (Rins) and dynamic respiratory system compliance (C) were calculated. Arterial pH and blood gas determinations were made. These measurements were repeated 60 min after administration of each therapeutic regimen. For ipratropium bromide alone the dose was 0.04 mg. When the combination of drugs was used, the doses were 0.04 mg for ipratropium bromide and 0.1 mg for fenoterol. MEASUREMENTS AND RESULTS: With the combination of both drugs, all the pressures in the airway, as well as the auto-PEEP and the Rins were significantly reduced (p < 0.05) with respect to baseline values. With ipratropium bromide alone, no significant changes were observed either in the pressures or in the inspiratory resistance. No significant changes were observed either in the pH or blood gases with any of the treatments. The combination of both drugs produced significantly reduction in Pei and auto-PEEP when compared with ipratropium bromide alone. CONCLUSIONS: The combination of both drugs is more effective than ipratropium bromide alone at the doses used in this study.

What is the daily practice of mechanical ventilation in pediatric intensive care units? A multicenter study.

OBJECTIVE: To describe the daily practice of mechanical ventilation (MV), and secondarily, its outcome in pediatric intensive care units (PICUs). DESIGN: Prospective cohort of infants and children who received MV for at least 12 h. SETTING: Thirty-six medical surgical PICUs. PATIENTS: All consecutive patients admitted to the PICUs during 2-month period. MEASUREMENTS AND MAIN RESULTS: Of the 1893 patients admitted, 659 (35%) received MV for a median time of 4 days (25th percentile, 75%: 2, 6). Median of age was 13 months (25th percentile, 75%: 5, 48). Common indications for MV were acute respiratory failure (ARF) in 72% of the patients, altered mental status in 14% of the patients, and ARF on chronic pulmonary disease in 10% of the patients. Median length of stay in the PICUs was 8 days (25th percentile, 75%: 5, 13). Overall mortality rate in the PICUs was 15% (confidence interval 95%: 13-18) for the entire population, 50% (95% CI: 25-74) in patients who received MV because of acute respiratory distress syndrome, 24% (95% CI: 16-35) in patients who received MV for altered mental status and 16% (95% CI: 9-29) in patients who received MV for ARF on chronic pulmonary disease. CONCLUSION: One in every 3 patients admitted to the PICUs requires ventilatory support. The ARF was the most common reason for MV, and survival of unselected infants and children receiving MV for more than 12 h was 85%.

A comparison of two methods to perform a breathing trial before extubation in pediatric intensive care patients.

OBJECTIVE: To compare the percentage of infants and children successfully extubated after a trial of breathing performed with either pressure support or T-piece. DESIGN: Prospective and randomized study. SETTING: Three medical-surgical pediatric intensive care units (PICUs). PATIENTS: Two hundred fifty-seven consecutive infants and children who received mechanical ventilation for at least 48 h and were deemed ready to undergo a breathing trial by their primary physician. INTERVENTIONS: Patients were randomly assigned to undergo a trial of breathing in one of two ways: pressure support of 10 cmH2O or T-piece. Bedside measurements of respiratory function were obtained immediately before discontinuation of mechanical ventilation and within the first 5 min of breathing through a T-piece. The primary physicians were unaware of those measurements, and the decision to extubate a patient at the end of the breathing trial was made by them. MEASUREMENTS AND MAIN RESULTS: Of the 125 patients in the pressure support group, 99 (79.2%) completed the breathing trial and were extubated, but 15 of them (15.1%) required reintubation within 48 h. Of the 132 patients in the T-piece group, 102 (77.5%) completed the breathing trial and were extubated, but 13 of them (12.7%) required reintubation within 48 h. The percentage of patients who remained extubated for 48 h after the breathing trial did not differ in the pressure support and T-piece groups (67.2% versus 67.4%, p=0.97). CONCLUSIONS: In infants and children mechanically ventilated, successful extubation was achieved equally effectively after a first breathing trial performed with pressure support of 10 cmH2O or a T-piece.

An evaluation of extubation failure predictors in mechanically ventilated infants and children.

OBJECTIVE: To assess the accuracy of traditional weaning indices in predicting extubation failure, and to compare their accuracy when indices are measured at the onset of a breathing trial (SBT) and at the end of the SBT before extubation. DESIGN: Prospective study. SETTING: Medical-surgical intensive care unit at a tertiary care hospital. PATIENTS: Four hundred eighteen consecutive infants and children who received mechanical ventilation for at least 48 h and were deemed ready to undergo a SBT by their primary physician. INTERVENTIONS: Respiratory frequency (RR), tidal volume (V(T)), maximal inspiratory pressure (P(imax)) and frequency-to-tidal volume ratio (f/V(T)) were obtained within the first 5 min of breathing through a T-piece. The primary physicians were unaware of those measurements and the decision to extubate a patient was made by them. RR, V(T), f/V(T) were remeasured before extubation by the respiratory therapists. Extubation failure was defined as needing re intubation within 48 h after extubation. The area under the receiver operating characteristic (ROC) curve was calculated for each index as a measure of the accuracy in predicting extubation outcome. MEASUREMENTS AND MAIN RESULTS: Three hundred twenty-three patients successfully underwent the SBT and were extubated, but 48 of them (14%) required re-intubation. The ROC curve for V(T), RR, P(imax) and f/V(T) measured within the first 5 min of breathing were 0.54, 0.56, 0.57 and 0.57, respectively. The ROC curve did not increase significantly when the above indices were remeasured before extubation. CONCLUSIONS: In a population which had passed SBT, the ability of the traditional weaning indices to discriminate between children successfully extubated and children re-intubated is very poor.

Withdrawing and withholding life support in the intensive care unit: a Spanish prospective multi-centre observational study.

OBJECTIVE: To determine how frequently life support is withheld or withdrawn from adult critically ill patients, and how physicians and patients families agree on the decision regarding the limitation of life support. DESIGN: Prospective multi-centre cohort study. SETTING: Six adult medical-surgical Spanish intensive care units (ICUs). PATIENTS AND PARTICIPANTS: Three thousand four hundred ninety-eight consecutive patients admitted to six ICUs were enrolled. MEASUREMENTS AND RESULTS: Data collected included age, sex, SAPS II score on admission and within 24 h of the decision to limit treatment, length of ICU stay, outcome at ICU discharge, cause and mode of death, time to death after the decision to withhold or withdraw life support, consultation and agreement with patient's family regarding withholding or withdrawal, and the modalities of therapies withdrawn or withheld. Two hundred twenty-six (6.6%) of 3,498 patients had therapy withheld or withdrawn and 221 of them died in the ICU. Age, SAPS II and length of ICU stay were significantly higher in patients dying patients who had therapy withheld or withdrawn than in patients dying despite active treatment. The proposal to withhold or withdraw life support was initiated by physicians in 210 (92.9%) of 226 patients and by the family in the remaining cases. The patient's family was not involved in the decision to withhold or withdraw life support therapy in 64 (28.3%) of 226 cases. Only 21 (9%) patients had expressed their wish to decline life-prolonging therapy prior to ICU admission. CONCLUSIONS: The withholding and withdrawing of treatment was frequent in critically ill patients and was initiated primarily by physicians.

The effects of undergraduate nursing student-faculty interaction outside the classroom on college grade point average.

BACKGROUND: The effects of student-faculty interactions in higher education have received considerable empirical attention. However, there has been no empirical study that has examined the relation between student-faculty interaction and college grade point average. PURPOSE: This is aimed at identifying the effect of nursing student-faculty interaction outside the classroom on students' semester college grade point average at a public university in Jordan. METHODS: The research was cross-sectional study of the effect of student-faculty interaction outside the classroom on the students' semester college grade point average of participating juniors and seniors. RESULTS: Total interaction of the students was crucial as it is extremely significant (t = 16.2, df = 271, P ≤ 0.001) in relation to students' academic scores between those students who had ≥70 and those who had <70 academic scores. However, gender differences between students, and other variables were not significant either to affect students' academic scores or students' interaction. CONCLUSION: This study provides some evidence that student-faculty interactions outside classrooms are significantly associated with student's academically achievements.