Society of Anesthesia and Sleep Medicine Position Paper on Patient Sleep During Hospitalization.

This article addresses the issue of patient sleep during hospitalization, which the Society of Anesthesia and Sleep Medicine believes merits wider consideration by health authorities than it has received to date. Adequate sleep is fundamental to health and well-being, and insufficiencies in its duration, quality, or timing have adverse effects that are acutely evident. These include cardiovascular dysfunction, impaired ventilatory function, cognitive impairment, increased pain perception, psychomotor disturbance (including increased fall risk), psychological disturbance (including anxiety and depression), metabolic dysfunction (including increased insulin resistance and catabolic propensity), and immune dysfunction and proinflammatory effects (increasing infection risk and pain generation). All these changes negatively impact health status and are counterproductive to recovery from illness and operation. Hospitalization challenges sleep in a variety of ways. These challenges include environmental factors such as noise, bright light, and overnight awakenings for observations, interventions, and transfers; physiological factors such as pain, dyspnea, bowel or urinary dysfunction, or discomfort from therapeutic devices; psychological factors such as stress and anxiety; care-related factors including medications or medication withdrawal; and preexisting sleep disorders that may not be recognized or adequately managed. Many of these challenges appear readily addressable. The key to doing so is to give sleep greater priority, with attention directed at ensuring that patients' sleep needs are recognized and met, both within the hospital and beyond. Requirements include staff education, creation of protocols to enhance the prospect of sleep needs being addressed, and improvement in hospital design to mitigate environmental disturbances. Hospitals and health care providers have a duty to provide, to the greatest extent possible, appropriate preconditions for healing. Accumulating evidence suggests that these preconditions include adequate patient sleep duration and quality. The Society of Anesthesia and Sleep Medicine calls for systematic changes in the approach of hospital leadership and staff to this issue. Measures required include incorporation of optimization of patient sleep into the objectives of perioperative and general patient care guidelines. These steps should be complemented by further research into the impact of hospitalization on sleep, the effects of poor sleep on health outcomes after hospitalization, and assessment of interventions to improve it.

The Effectiveness of Capnography Versus Pulse Oximetry in Detecting Respiratory Adverse Events in the Postanesthesia Care Unit (PACU): A Narrative Review and Synthesis.

PURPOSE: The objective of this review was to evaluate the effectiveness of capnography monitoring versus standard monitoring of pulse oximetry in detecting respiratory adverse events in nonintubated pediatric and adult postanesthesia care unit (PACU) patients. DESIGN: Experimental, quasi-experimental, and observational studies examining pulse oximetry and capnography in adult and pediatric patients in the PACU were included in this systematic review. METHODS: An initial search of MEDLINE and CINAHL, PubMed, Web of Science, Prospero, Google Scholar, and Cochrane was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy in July 2019. Reference lists of studies included at critical appraisal stage were hand-searched. Studies published in English from 1978 onward were included. FINDINGS: Meta-analysis was not possible due to variation in outcome measurements; therefore, results are presented in narrative form. Four studies were included in the review: 1 randomized controlled trial (RCT) and 3 observational cross-sectional studies. The RCT was considered of moderate to high quality, and the observational cross-sectional studies were of high quality. The main findings of this review suggest that there is limited high-quality evidence that capnography improves detection of respiratory adverse events in the PACU versus pulse oximetry. CONCLUSIONS: The lack of RCTs and varied outcomes measures in the 4 studies reviewed meant that meta-analysis was not possible. Early detection of respiratory adverse events afforded by the addition of PETCO2 to SpO2 in the PACU was seen in these studies. More research is needed to determine if widespread implementation of capnography in addition to pulse oximetry would reduce severity of respiratory related adverse events in the PACU through more timely identification.

Rapid Response Team-Quality Champion Registered Nurse: Observations and Perceptions.

BACKGROUND: Operationalization of the rapid response team (RRT) and its quality champion (QC) nurses at a community hospital is unique and provides benefits not entirely captured by analysis of mortality data. PURPOSE: The purpose was to determine the perceived benefits of the RRT at the facility and behaviors and activities observed during actual RRT responses. Also examined was the timeliness of the RRT calls. METHODS: This was a mixed-method study including qualitative (interviews, focus groups, and surveys) and quantitative (retrospective chart reviews) data collection. RESULTS: Themes included teaching/education, foster development of critical thinking skills, expertise/resource, communication/facilitation/go-between, safety net/security, validation, and advocate/foster collaboration. RRT calls were made quickly after clinical deterioration. CONCLUSIONS: Benefits of the RRT-QC registered nurse were extensive. Observations showed support, education, and teamwork in an effort to improve outcomes and support clinicians.

Community Hospital Perioperative Services Department Responds to the COVID-19 Pandemic.

Early in 2020, government leaders declared a public health emergency because of the coronavirus disease 2019 (COVID-19) outbreak. After World Health Organization leaders declared that the spread of COVID-19 was a pandemic, it became evident that patients suspected or confirmed to have COVID-19 would present for surgery at our community hospital, the only facility in the county. The Maryland governor charged hospital administrators with expanding bed capacity in anticipation of a surge of critically ill patients. Concurrently, the Maryland secretary of health prohibited all elective procedures. During the early phase of preparation and response, processes, information, and hospital capabilities and capacity changed frequently and rapidly. Effective communication, teamwork, and interprofessional and interdepartmental collaboration helped us prepare to deliver safe surgical care to patients during the pandemic and maintain safety for all involved. This article describes our health care facility's response to the pandemic and lessons learned during the process.

A Tool to Guide Clinical Nurse Specialist Orientation, Professional Development, and Evaluation.

PURPOSE/OBJECTIVES: Currently, orientation for clinical nurse specialists (CNSs) in the Baltimore region is based on past practices: facility-specific or position-specific. A Chesapeake Bay affiliate work group identified a need to develop a theory-driven, competency-based program and tool to guide orientation and ongoing professional development reflecting the scope of CNS practice. DESCRIPTION OF THE PROJECT/PROGRAM: The tool incorporates Benner's concepts of novice-to-expert competence levels, guides progressive development of the CNS, and has relevant assessment metrics that highlight contributions to the patient, nurse, and system. OUTCOME: The group developed a comprehensive orientation tool grounded in the spheres of influence and advanced practice competencies and specific, measurable behavioral statements related to competencies from the 2018 National Association of Clinical Nurse Specialists' draft. This program is adaptable to guide the practice of a CNS in any facility, validate competence, and relate to those with varied experience in the role. CONCLUSION: In a method similar to the process for developing nationally recognized educational standards used to develop the competencies, the program was revised based on an iterative, stepwise process. It was distributed to the membership for evaluation and feedback, which was incorporated into the final version.

Critical Care Performance in a Simulated Military Aircraft Cabin Environment.

BACKGROUND: Critical Care Air Transport Teams care for 5% to 10% of injured patients who are transported on military aircraft to definitive treatment facilities. Little is known about how the aeromedical evacuation environment affects care. OBJECTIVES: To determine the effects of 2 stressors of flight, altitude-induced hypoxia and aircraft noise, and to examine the contributions of fatigue and clinical experience on cognitive and physiological performance of the Critical Care Air Transport Team. METHODS: This repeated measures 2 × 2 × 4 factorial study included 60 military nurses. The participants completed a simulated patient care scenario under aircraft cabin noise and altitude conditions. Differences in cognitive and physiological performance were analyzed using repeated measures analysis of variance. A multiple regression model was developed to determine the independent contributions of fatigue and clinical experience. RESULTS: Critical care scores (P = .02) and errors and omissions (P = .047) were negatively affected by noise. Noise was associated with increased respiratory rate (P = .02). Critical care scores (P < .001) and errors and omissions (P = .002) worsened with altitude-induced hypoxemia. Heart rate and respiratory rate increased with altitude-induced hypoxemia; oxygen saturation decreased (P < .001 for all 3 variables). CONCLUSION: In a simulated military aircraft environment, the care of critically ill patients was significantly affected by noise and altitude-induced hypoxemia. The participants did not report much fatigue and experience did not play a role, contrary to most findings in the literature.

An Occupational Paradox: Why Do We Love Really Tough Jobs?

BACKGROUND: Sometimes we come upon unexpected or counterfactual results during research that make us wonder and lead us into unknown territory. Such was the experience of a team of Air Force researchers exploring aeromedical evacuation crew members' experiences of safety and patient care concerns throughout the en route care system. OBJECTIVE: To explore what it is about the aeromedical evacuation crew members' occupation that generates a strong motivation to the mission despite the demands it places on its workers. METHODS: Eight focus groups were conducted with 69 Air Force aeromedical evacuation and staging facility active duty, Air National Guard, and Air Force Reserve Command nurses and medical technicians between May 2012 and April 2013 at 5 locations in the contiguous and outside the contiguous United States. RESULTS: An unexpected finding was that despite the austere nature of the Air Force en route care mission and the acuity of the patients being transported, nurses and medical technicians were passionate about bringing home the wounded, sick, and injured warriors and were committed to providing the best and safest care possible. CONCLUSIONS: It is plausible that a high level of commitment and mission focus contributes significantly to the safety and well-being of those transported. Still, we must wonder why nurses and technicians voluntarily serve in such a demanding and sometimes dangerous occupation, and yet find such a high degree of satisfaction and contentment with this type of job.

Research in Review: Advancing Critical Care Practice.

Research published in 2016 identified strategies to enhance acute and critical care, initiated discussions on professional roles and responsibilities, clarified complex care issues, and led to robust debate. Some of this important work addressed strategies to prevent delirium and pressure ulcers, considerations for pain management within the context of the opioid abuse crisis, strategies to guide fluid resuscitation in patients with sepsis and heart failure, and ways to enhance care for family members of intensive care patients. The new sepsis definitions highlight the importance of detecting and providing care to patients with sepsis outside of critical care areas. Chimeric antigen receptor T-cell therapy is an example of the advancement of research in genomics and personalized medicine and of the need to understand the care implications of these therapies. Other research topics include interprofessional collaboration and shared decision-making as well as nurses' role in family conferences. Resources such as policies related to medical futility and inappropriate care and the American Association of Critical-Care Nurses' healthy work environment standards may inform conversations and provide strategies to address these complex issues.

Trauma resuscitation and monitoring: military lessons learned.

Over the past 13 years, the military health care system has made improvements that are associated with an unprecedented survival rate for severely injured casualties. Monitoring for indications of deterioration as the critically injured patient moves across the continuum of care is difficult given the limitations of routinely used vital signs. Research by both military and civilian researchers is revolutionizing monitoring, with an increased focus on noninvasive, continuous, dynamic measurements to provide earlier, more sensitive indications of the patient's perfusion status.

Identification and characterisation of an aspartyl protease inhibitor homologue as a major allergen of Trichostrongylus colubriformis.

Allergens were identified from the gastrointestinal nematode of sheep, Trichostrongylus colubriformis, by probing Western blots of infective larvae (third stage) somatic antigen with IgE purified from the serum of sheep grazed on worm contaminated pasture. A 31 kDa allergen was frequently recognised by sera from immune sheep, particularly those deriving from a line that has been genetically selected over 23 years for parasite resistance. Using a proteomic approach, the 31 kDa allergen was identified as an aspartyl protease inhibitor homologue. The entire coding sequence of T. colubriformis aspartyl protease inhibitor (Tco-api-1) was obtained and the mature protein expressed in Escherichia coli. Anti-Tco-API-1 antibodies revealed that a commonly observed 21 kDa T. colubriformis allergen species is a truncated form of Tco-API-1. Specific IgE responses to T. colubriformis aspartyl protease inhibitor were significantly correlated with the degree of resistance to nematode infection as measured by faecal egg count in sheep. Surprisingly, IgE responses to Tco-API-1 were not correlated with breech soiling (dag score), which is thought to be caused, in part, by allergic hypersensitivity to worms. Therefore, a specific IgE response to this allergen may be a suitable marker for identifying lambs at an early age that will develop strong immunity to gastrointestinal nematodes.

En route care patient safety: thoughts from the field.

The purpose of this study was to describe the patient safety culture of en route care in the United States Air Force aeromedical evacuation system. Almost 100,000 patients have been transported since 2001. Safety concerns in this unique environment are complex because of the extraordinary demands of multitasking, time urgency, long duty hours, complex handoffs, and multiple stressors of flight. An internet-based survey explored the perceptions and experiences of safety issues among nursing personnel involved throughout the continuum of aeromedical evacuation care. A convenience sample of 236 nurses and medical technicians from settings representing the continuum was studied. Descriptive and nonparametric statistics were used to analyze the quantitative data, and thematic analysis was applied to the qualitative data. Results indicate that over 90% of respondents agree or strongly agree safety is a priority in their unit and that their unit is responsive to patient safety initiatives. Many respondents described safety incidents or near misses, and these have been categorized as personnel physical capability limitations, environmental threats, medication and equipment issues, and care process problems. Results suggest the care of patients during transport is influenced by the safety culture, human factors, training, experience, and communication. Suggestions to address safety issues emerged from the survey data.

7000 miles and 7 days from the battlefield.

Critically injured combat casualties are rapidly evacuated from the battlefield, and within hours of their injuries they begin a 7000-mile journey home, often arriving in the United States within 7 days. National Naval Medical Center in Bethesda, Maryland, is a major facility for wounded warrior care in the Military Health System. Throughout the facility, the staff from a variety of disciplines and all military services provides care for military personnel with injuries and illnesses, with the goal of optimizing recovery and quality of life. The foundational evidence for select aspects of this care is discussed. Innovations in training and care delivery include the Air Force Nurse Corps' Critical Care Fellowship, the new inpatient Traumatic Brain Injury Unit, and the National Intrepid Center for Excellence for Traumatic Brain Injury and Psychological Health. The future of the Medical Center includes a new name, expanded staff, and newly constructed space by Department of Defense Base Realignment and Closure activities.