Allophone immigrant women's knowledge and perceptions of epidural analgesia for labour pain: a qualitative study.

OBJECTIVES: To explore allophone immigrant women's knowledge and perceptions of epidural analgesia for labour pain, in order to identify their information needs prior to the procedure. DESIGN: We conducted focus groups interviews with allophone women from five different linguistic immigrant communities, with the aid of professional interpreters. Thematic analysis of focus group transcripts was carried out by all authors. SETTING: Women were recruited at two non-profit associations offering French language and cultural integration training to non-French speaking immigrant women in Geneva. PARTICIPANTS: Forty women from 10 countries who spoke either Albanian, Arabic, Farsi/Dari, Tamil or Tigrigna took part in the five focus groups. Four participants were nulliparous, but all others had previous experience of labour and delivery, often in European countries. A single focus group was conducted for each of the five language groups. RESULTS: We identified five main themes: (1) Women's partial knowledge of epidural analgesia procedures; (2) Strong fears of short-term and long-term negative consequences of epidural analgesia during childbirth; (3) Reliance on multiple sources of information regarding epidural analgesia for childbirth; (4) Presentation of salient narratives of labour pain to justify their attitudes toward epidural analgesia; and (5) Complex community positioning of pro-epidural women. CONCLUSIONS: Women in our study had partial knowledge of epidural analgesia for labour pain and held perceptions of a high risk-to-benefits ratio for this procedure. Diverse and sometimes conflicting information about epidural analgesia can interfere with women's decisions regarding this treatment option for labour pain. Our study suggests that women need comprehensive but also tailored information in their own language to support their decision-making regarding epidural labour analgesia.

Neurally adjusted ventilatory assist in patients recovering spontaneous breathing after acute respiratory distress syndrome: physiological evaluation.

OBJECTIVE: Pressure-support ventilation is widely used during the weaning phase in patients with acute respiratory distress syndrome. The pressure-support level is adjusted to prevent ventilator-induced lung injury while limiting the patient's work of breathing. Neurally adjusted ventilatory assist is an assist mode that applies a positive pressure proportional to the integral of the electrical activity of the diaphragm. The objective was to assess the physiologic response to varying pressure-support ventilation and neurally adjusted ventilatory assist levels in selected acute respiratory distress syndrome patients and to evaluate the effect of neural triggering. METHODS: We prospectively assessed 11 consecutive patients with acute respiratory distress syndrome attributable to pulmonary diseases. Pressure-support ventilation and neurally adjusted ventilatory assist were used in random order. Neurally adjusted ventilatory assist was used with a low electrical activity of the diaphragm trigger (neurally adjusted ventilatory assist-electrical activity of the diaphragm) and with a high electrical activity of the diaphragm trigger that led to rescue triggering by inspiratory flow (neurally adjusted ventilatory assist-inspiratory flow). With each ventilation modality, four levels of assistance (100%, 120%, 140%, and 160%) were used in random order. Statistical analysis was performed using analysis of variance for repeated measurements and mixed models. MAIN RESULTS: Contrary to pressure-support ventilation, neurally adjusted ventilatory assist-electrical activity of the diaphragm and neurally adjusted ventilatory assist-inspiratory flow were associated with stable tidal volume levels despite increasing assistance. For the asynchrony index, an interaction was present between ventilation mode and assist level (p = .0076) because asynchrony index increased significantly with the pressure-support ventilation level (p = .004), but not with the neurally adjusted ventilatory assist-electrical activity of the diaphragm or neurally adjusted ventilatory assist-inspiratory flow level. The lowest asynchrony index was obtained with neurally adjusted ventilatory assist-electrical activity of the diaphragm. CONCLUSION: Compared to pressure-support ventilation, neurally adjusted ventilatory assist in acute respiratory distress syndrome patients holds promise for limiting the risk of overassistance, preventing patient-ventilator asynchrony, and improving overall patient-ventilator interactions. Neural triggering (neurally adjusted ventilatory assist-electrical activity of the diaphragm) considerably decreased patient-ventilator asynchrony.

Prehospital and Emergency Care in Adult Patients with Acute Traumatic Brain Injury.

Traumatic brain injury (TBI) is a major healthcare problem and a major burden to society. The identification of a TBI can be challenging in the prehospital setting, particularly in elderly patients with unobserved falls. Errors in triage on scene cannot be ruled out based on limited clinical diagnostics. Potential new mobile diagnostics may decrease these errors. Prehospital care includes decision-making in clinical pathways, means of transport, and the degree of prehospital treatment. Emergency care at hospital admission includes the definitive diagnosis of TBI with, or without extracranial lesions, and triage to the appropriate receiving structure for definitive care. Early risk factors for an unfavorable outcome includes the severity of TBI, pupil reaction and age. These three variables are core variables, included in most predictive models for TBI, to predict short-term mortality. Additional early risk factors of mortality after severe TBI are hypotension and hypothermia. The extent and duration of these two risk factors may be decreased with optimal prehospital and emergency care. Potential new avenues of treatment are the early use of drugs with the capacity to decrease bleeding, and brain edema after TBI. There are still many uncertainties in prehospital and emergency care for TBI patients related to the complexity of TBI patterns.

Impact of organizational culture on preventability assessment of selected adverse events in the ICU: evaluation of morbidity and mortality conferences.

PURPOSE: To determine whether organizational culture is associated with preventability assessment of reported adverse events (AE) in intensive care units (ICU). DESIGN: Blind review of time randomly distributed case notes written in the form of structured abstracts by the nurses who participated in recently implemented morbidity and mortality conferences from December 2006 to June 2010 in a 18-bed ICU in France. Ninety-five abstracts summarizing the discussions of 95 AE involving 95 patients were reviewed by two external blinded pairs (each comprised of one senior intensivist and one psychologist). METHODS: A score for each organizational culture style was determined, with the highest scorer being considered the dominant style present in the abstract. RESULTS: Reliability of the classification and quantification of culture traits between pairs was very good or good for 13 dimensions and moderate for two others. The two pairs deemed 32/95 and 43/95 of AE preventable (κ = 0.59). Concordance was very good (κ = 0.85) between the external pairs for evaluation of the dominant culture style. The Cochran-Armitage trend test indicated an increasing trend for change of the dominant organizational culture style over time: the team-satisfaction-oriented culture took a leading role (p = 0.02), while the people-security-oriented culture decreased dramatically (p < 0.001). The task-security-oriented culture was significantly associated with a preventable judgment, while the people-security-oriented culture was significantly associated with an unpreventable judgment (p < 0.001). CONCLUSIONS: This study demonstrated a strong relationship between preventability assessment of AE reported by caregivers and their organizational culture in the ICU.