Implementation of clinical decision support in young children with acute gastroenteritis: a randomized controlled trial at the emergency department.

Acute gastroenteritis (AGE) is one of the most frequent reasons for young children to visit emergency departments (EDs). We aimed to evaluate (1) feasibility of a nurse-guided clinical decision support system for rehydration treatment in children with AGE and (2) the impact on diagnostics, treatment, and costs compared with usual care by attending physician. A randomized controlled trial was performed in 222 children, aged 1 month to 5 years at the ED of the Erasmus MC-Sophia Children's hospital in The Netherlands ( 2010-2012). Outcome included (1) feasibility, measured by compliance of the nurses, and (2) length of stay (LOS) at the ED, the number of diagnostic tests, treatment, follow-up, and costs. Due to failure of post-ED weight measurement, we could not evaluate weight difference as measure for dehydration. Patient characteristics were comparable between the intervention (N = 113) and the usual care group (N = 109). Implementation of the clinical decision support system proved a high compliance rate. The standardized use of oral ORS (oral rehydration solution) significantly increased from 52 to 65%(RR2.2, 95%CI 1.09-4.31 p < 0.05). We observed no differences in other outcome measures. CONCLUSION: Implementation of nurse-guided clinical decision support system on rehydration treatment in children with AGE showed high compliance and increase standardized use of ORS, without differences in other outcome measures. What is Known: • Acute gastroenteritis is one of the most frequently encountered problems in pediatric emergency departments. • Guidelines advocate standardized oral treatment in children with mild to moderate dehydration, but appear to be applied infrequently in clinical practice. What is New: • Implementation of a nurse-guided clinical decision support system on treatment of AGE in young children showed good feasibility, resulting in a more standardized ORS use in children with mild to moderate dehydration, compared to usual care. • Given the challenges to perform research in emergency care setting, the ED should be experienced and adequately equipped, especially during peak times.

ESPEN guideline on ethical aspects of artificial nutrition and hydration.

BACKGROUND: The worldwide debate over the use of artificial nutrition and hydration remains controversial although the scientific and medical facts are unequivocal. Artificial nutrition and hydration are a medical intervention, requiring an indication, a therapeutic goal and the will (consent) of the competent patient. METHODS: The guideline was developed by an international multidisciplinary working group based on the main aspects of the Guideline on "Ethical and Legal Aspects of Artificial Nutrition" published 2013 by the German Society for Nutritional Medicine (DGEM) after conducting a review of specific current literature. The text was extended and introduced a broader view in particular on the impact of culture and religion. The results were discussed at the ESPEN Congress in Lisbon 2015 and accepted in an online survey among ESPEN members. RESULTS: The ESPEN Guideline on Ethical Aspects of Artificial Nutrition and Hydration is focused on the adult patient and provides a critical summary for physicians and caregivers. Special consideration is given to end of life issues and palliative medicine; to dementia and to specific situations like nursing care or the intensive care unit. The respect for autonomy is an important focus of the guideline as well as the careful wording to be used in the communication with patients and families. The other principles of Bioethics like beneficence, non-maleficence and justice are presented in the context of artificial nutrition and hydration. In this respect the withholding and withdrawing of artificial nutrition and/or hydration is discussed. Due to increasingly multicultural societies and the need for awareness of different values and beliefs an elaborated chapter is dedicated to cultural and religious issues and nutrition. Last but not least topics like voluntary refusal of nutrition and fluids, and forced feeding of competent persons (persons on hunger strike) is included in the guideline.

Care and cost-utility indicators for high-flow PICC catheters: a study.

Intravenous therapy teams (IVTT) provide care, education and supervision of the patient with a central line, and his/her family. This article discusses the creation of an IVTT in the Hospital Clínico San Carlos of Madrid, Spain, demonstrating its effectiveness using cost-utility analysis and outcomes indicators. In 2009 the IVTT began using a high-flow peripherally inserted central catheter (PICC) with its target population of chronic patients dependent on central venous catheters or prolonged IV treatment. The team designed activity, welfare, educational and economic indicators. Of the 98 catheters placed, 80% of patients achieved a positive response; 42% of catheters were removed after death and 30% by the end of treatment. Four percent were removed due to infection. The average implantation duration was 45 days. The economic study showed an increasing cost saving compared to peripheral catheters after 90 days of implantation, and after 77 days compared to central venous catheters. This translated into an immediate saving of 161 euros (£133.70) and 303.83 euros (£252.31) per catheter over Hickman lines and ports, as well as reduced risks, length of hospital stays and costs. The study shows PICC to be cost-effective with reported benefits to patients, professionals and organizations. The creation of the IVTT has resulted in improvements to care and the management of resources.

Perioperative fluid management.

Technological advances have changed how traditional surgical procedures are performed. New knowledge and surgical skills are required to effectively monitor the patient and manage fluids administered perioperatively. Today, selective fluids are used in a variety of surgical specialties. Complications of fluid therapy can occur that are intrinsic to each procedure within a specialty. This article provides perioperative nurses with the information needed to evaluate different fluid media and their applications and identify patient care considerations. Possible complications and important postanesthesia care concerns also are discussed.

Traumatic brain injury: an integrated clinical case presentation and literature review. Part I: assessment and initial management.

Holistic nursing care of critically ill patients continues to be a challenge for all levels of critical care clinicians. Patients with multi-system dysfunction in particular, present complicated clinical challenges that demand care based on sound knowledge and understanding of physiological, psychosocial and spiritual needs. Experiential learning through exposure to a range of patient presentations enables incremental development of professional practice and excellence in nursing care. Case study learning enhances understanding through application of theory to practice in complex clinical presentations. This two-part paper outlines the assessment, interventions and outcome of a person who sustained multiple trauma including severe traumatic brain injury (TBI). Part I explores assessment and initial management from pre-hospital care through to the Emergency Department (ED) and operating theatre. Part II describes the intensive care period as an integral component of the continuum of care. Key issues in the case are presented sequentially with relevant literature integrated and applied to clinical progress, focussing on the complex physiological, psychosocial, spiritual and environmental needs of the patient and his family. The purpose of the paper is to therefore provide a comprehensive learning resource for critical care nurses, particularly for those beginning their practice.

Implementing and assessing an evidence-based electrolyte dosing order form in the medical ICU.

UNLABELLED: The purpose of this study was to evaluate the efficacy, safety, and nursing acceptability of a nursing initiated, evidence-based order form to replace potassium, magnesium, and phosphate in the MICU. METHODS: This retrospective study compared patients receiving electrolyte replacement with the order form to matched historical control patients receiving traditional electrolyte replacement (no order form). The primary outcomes were absolute change in serum concentrations and the proportion of doses achieving normal serum concentrations. Other outcomes were adverse events as documented in the medical record and nursing acceptability as assessed by survey. RESULTS: The 2 groups (12 in each group) were similar. The order form and control groups received 36 and 62 potassium doses, 14 and 48 magnesium doses, and 34 and 13 phosphorus doses, respectively. Doses of all three electrolytes were significantly larger with the order form. Absolute changes in potassium, magnesium, and phosphorus serum concentrations for the order form group and control group were 0.36+/-0.42 versus 0.11+/-0.43 mmol/l (p<0.01), 0.56+/-0.69 versus 0.13+/-0.40 mequiv./l (p=0.07), and 0.53+/-0.82 versus 0.66+/-0.83 mg/dl (p=0.63), respectively. Normal serum concentrations achieved for each electrolyte replacement dose in the order form group and control group were 72% versus 18% (p<0.001), 86% versus 21% (p<0.001), and 47% versus 62% (p=0.57), respectively. No adverse events occurred. The nursing survey showed satisfaction and comfort using the order form. CONCLUSIONS: The use of the order form provided greater efficiency for replacing potassium and magnesium but not phosphorus without increasing the occurrence of adverse events. The order form was well received by nursing staff.

Drink to good health.

As part of the Nutrition Now campaign, a toolkit is being launched online to encourage nurses and support staff to increase water consumption among patients in hospital settings.

Patterns of interdialytic weight gain during the first year of hemodialysis.

This retrospective study describes patterns of interdialytic weight gain (IWG) over the first year of hemodialysis in 27 individuals. IWG increased over the first 12 weeks and appeared to reverse after 12 weeks, increasing again after 32 weeks. Interventions may need to occur after the individual has been receiving treatment for 12 weeks; booster interventions may be indicated after 32 weeks. Variability in the two measures used (mean daily interdialytic weight gain and mean daily percent above dry weight) suggests a need for further study.

The use and misuse of electronic patient data.

This article highlights patient privacy rights, briefly discusses a few of the many federal, state, and local regulatory laws protecting patient confidentiality and privacy electronically, and briefly reviews several case decisions in this area. Implications for infusion nurses also are presented.

[Position statement of the National Nursing Assessment Group of Germany: regarding the basic "nutrition and fluid requirements" policy of the elderly by the MDS (Medical Service of the Central Associations of the Health Insurance Companies), July 2003]. / Positionspapier der Nationalen Pflegeassessmentgruppe Deutschland: zur Grundsatzstellungnahme "Ernährung und Flüssigkeitsversorgung älterer Menschen", Abschlussbericht Projektgruppe P 39 des Medizinischen Dienstes der Spitzenverbände der Krankenkassen (MDS), Juli 2003.

Assessing the nutritional state of old and dependent people demands a distinctive consideration of all aspects which might influence the individual's nutritional habits. An isolated consideration of the body mass index (BMI) does not serve the needs of elderly, because the BMI seems not to be a valid indicator for their nutrtional state. In order to prove the risk of malnutrition, also the individual life conditions as well as social, religious, cultural and economic circumstances besides the amount of energy and nu triments are to be taken into account.

Assessment of fluids and electrolytes.

Bedside evaluation of a patient's intravascular volume status is challenging, even for the seasoned practitioner. There is no single diagnostic test to determine whether a patient is hypovolemic, hypervolemic, or euvolemic. Often, underlying or concomitant disease states, medications, and other therapeutics can make available data difficult to interpret. Therefore, a combination of clinical evaluation, laboratory studies, and other diagnostics are required to make a clinical judgment regarding volume status. Patients who demonstrate alterations in their volume status are likely to have electrolyte abnormalities as well, and assessment of serum electrolyte values and potential therapeutic interventions is a vital piece in caring for critically ill patients.

Prehospital and emergency department burn care.

Burn-injured patients have special needs in the prehospital and emergency department settings. This article addresses the nursing priorities in prehospital and emergency department care.

Severe sepsis management are we doing enough?

For the first time in medical history, a drug has been shown to reduce the mortality associated with sepsis, the leading cause of death in many ICUs. Optimal use by appropriate selection of patients and early recognition of sepsis could save thousands of lives. Nurses play a major role in recognizing severe sepsis. By using the concepts introduced here, nurses can play a direct role in saving the lives of patients with sepsis.

Dehydration and hydration in the terminally ill: care considerations.

Debate continues about whether to withhold or withdraw intravenous, subcutaneous, or nasogastric hydration in the terminally ill. Nurses may be confronted with situations where the terminally ill patient or family must make a decision regarding hydration. Therefore, nurses must be knowledgeable about terminal dehydration literature and research. This article is a review of the literature on terminal dehydration. The focus is on the definition of terminal dehydration, physiological benefits and disadvantages of terminal dehydration, rationale for hydrating, review of research in terminal dehydration, physiological basis for comfort in the terminally dehydrated, and suggestions for research and practice.

Fluid resuscitation in the trauma patient.

Fluid management of the trauma patient can be challenging to the nurse anesthetist. Often the Certified Registered Nurse Anesthetist is unaware of the total blood loss of a trauma victim (ie, how much blood loss occurred at the scene). The anesthetist must quickly assess the patient's vital signs and response to fluid replacement to effectively treat the acute blood loss. In today's healthcare market, when cost of care is consistently scrutinized, the nurse anesthetist must weigh the risks and benefits to a patient when selecting fluid therapies. This article outlines current resuscitative theories and fluid types available for use in resuscitating the trauma patient.

IV therapy: a financial feasibility study.

Results of a feasibility study comparing peripheral catheters to midline catheters are summarized. A step-by-step process involving audit studies, cost figures, data collection, calculation parameters, and cost analysis determined the effectiveness of the new technology.