Do-not-resuscitate decision making for terminally ill older patients in the emergency department: An explorative, descriptive inquiry of Chinese family members.

Many terminally ill older adults depend on family members to make medical decisions in China. Many family members find it difficult to make do-not-resuscitate (DNR) decisions in emergency departments (ED). Currently, factors that affect DNR decision making by family members for older adults needing emergency care have not been well studied. This qualitative inquiry explores factors influencing DNR decision-making among family members of terminally ill older adults in ED. Semi-structured in-depth interviews were conducted for a 12-family member of terminally ill older adults at ED in China. Results of the conventional content analysis showed that family members made DNR decisions based on a wide of reasons: (a) subjective perception of family members, (b) conditions of the terminally ill older adults, (c) external environmental factors, and (d) internal family factors. The findings of this study expand our knowledge and understanding of factors influencing DNR decision-making by family members of terminally ill older adults in ED.

Poor outcomes of delirium in the intensive care units are amplified by increasing age: A retrospective cohort study.

BACKGROUND: Delirium in patients in intensive care units (ICUs) is an acute disturbance and fluctuation of cognition and consciousness. Though increasing age has been found to be related to ICU delirium, there is limited evidence of the effect of age on delirium outcomes. The aim of this study is to investigate the relationship between age categories and outcomes among ICU delirium patients. METHODS: Data were extracted from the electronic ICU (eICU) Collaborative Research Database with records from 3,931 patients with delirium. Patients were classified into non-aged (<65 years), young-old (65-74 years), middle-old (75-84 years), and very-old (≥85 years) groups. A Cox regression model was built to examine the role of age in death in ICU and in hospital after controlling covariates. RESULTS: The sample included 1,667 (42.4%) non-aged, 891 (22.7%) young-old, 848 (21.6%) middle-old, and 525 (13.3%) very-old patients. The ICU mortality rate was 8.3% and the hospital mortality rate was 15.4%. Compared with the non-aged group, the elderly patients (≥65 yeras) had higher mortality at ICU discharge (χ2 =13.726, P=0.001) and hospital discharge (χ 2=56.347, P<0.001). The Cox regression analysis showed that age was an independent risk factor for death at ICU discharge (hazard ratio [HR]=1.502, 1.675, 1.840, 95% confidence interval [CI] 1.138-1.983, 1.250-2.244, 1.260-2.687; P=0.004, 0.001, 0.002 for the young-, middle- and very-old group, respectively) as well as death at hospital discharge (HR=1.801, 2.036, 2.642, 95% CI 1.454-2.230, 1.638-2.530, 2.047-3.409; all P<0.001). CONCLUSIONS: The risks of death in the ICU and hospital increase with age among delirious patients.

Nursing rounds: A quality improvement project to improve outpatient satisfaction.

AIM: To implement the nursing rounds to improve the quality and patient satisfaction of the outpatient department. BACKGROUND: Patient satisfaction is one of the most critical standards for judging the quality of hospitals. Clinical daily nursing rounds significantly increase patient satisfaction and influence safety. METHOD: SQUIRE guidelines directed the execution of a quality improvement project, which used the Driver Model to improve patient satisfaction in a Chinese outpatient department with 15,000 visits per day (4 million/year). Patient satisfaction based on questionnaires (1,541), pre-intervention and (1,219) post-intervention provided increased satisfaction (p < .05). RESULTS: Improvements validated were satisfaction with outpatient services from patients, effective nurse-patient communications, an increase in the quality of nursing care, doctors' satisfaction with the outpatient department operations, reduced wait time and more efficient management, all impact safety. CONCLUSIONS: The institution of daily nursing rounds made an overall improvement in the operations of the outpatient department, which increased patient satisfaction, quality of care and safety. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing rounds promote patient satisfaction through assessment of operations, addressing patient and staff needs, and appropriate interventions to rectify issues and reduce adverse outcomes. Patient satisfaction impacts quality, outcomes and safety in clinical settings.

Death and do-not-resuscitate order in the emergency department: A single-center three-year retrospective study in the Chinese mainland.

BACKGROUND: Consenting to do-not-resuscitate (DNR) orders is an important and complex medical decision-making process in the treatment of patients at the end-of-life in emergency departments (EDs). The DNR decision in EDs has not been extensively studied, especially in the Chinese mainland. METHODS: This retrospective chart study of all deceased patients in the ED of a university hospital was conducted from January 2017 to December 2019. The patients with out-of-hospital cardiac arrest were excluded. RESULTS: There were 214 patients' deaths in the ED in the three years. Among them, 132 patients were included in this study, whereas 82 with out-of-hospital cardiac arrest were excluded. There were 99 (75.0%) patients' deaths after a DNR order medical decision, 64 (64.6%) patients signed the orders within 24 hours of the ED admission, 68 (68.7%) patients died within 24 hours after signing it, and 97 (98.0%) patients had DNR signed by the family surrogates. Multivariate analysis showed that four independent factors influenced the family surrogates' decisions to sign the DNR orders: lack of referral (odds ratio [OR] 0.157, 95% confidence interval [CI] 0.047-0.529, P=0.003), ED length of stay (ED LOS) ≥72 hours (OR 5.889, 95% CI 1.290-26.885, P=0.022), acute myocardial infarction (AMI) (OR 0.017, 95% CI 0.001-0.279, P=0.004), and tracheal intubation (OR 0.028, 95% CI 0.007-0.120, P<0.001). CONCLUSIONS: In the Chinese mainland, the proportion of patients consenting for DNR order is lower than that of developed countries. The decision to sign DNR orders is mainly affected by referral, ED LOS, AMI, and trachea intubation.

Can a one-on-one mentorship program reduce the turnover rate of new graduate nurses in China? A longitudinal study.

Nursing graduates experience "reality shock" upon entering the workplace as well as face challenges and stress during their transition from nursing student to qualified nurse. The high turnover rate of new graduate nurses not only increases an organization's human resources costs but also results in a shortage of nurses. In particular, a poor experience during the transition from nursing student to qualified nurse can lead to significant turnover. A three-year longitudinal study was conducted to assess the effectiveness of one-on-one mentorship program in reducing the turnover rate of nurses in China. A total of 199 new graduate nurses, recruited in 2013, were considered the control group and received a basic preceptorship, and 239 nurses in 2014 were considered the experimental group, for which a one-on-one mentorship program was implemented. Propensity-score-matching analysis was conducted to adjust the baseline of the two groups, and survival analysis was performed to compare the two groups. The findings showed that the turnover rates for the experimental group were 3.77%, 3.48%, and 8.11% as compared to 14.07%, 9.36%, and 14.19% for the control group at the end of the first three years, respectively. The survival curves of the two groups were significantly different (p < 0.001). The turnover rate for the first year in the experimental group was significantly lower than that for the control group, but the rates in the second and third years were not different. The results indicate that a one-on-one mentorship program is beneficial for the retention of new graduate nurses, particularly during the first year.

Incidence and Related Factors for Hospital-Acquired Pneumonia Among Older Bedridden Patients in China: A Hospital-Based Multicenter Registry Data Based Study.

Objective: To identify the incidence and related factors for hospital-acquired pneumonia (HAP) among older bedridden patients in China. Study design and setting: This multicenter registry data-based study conducted between November 2015 and March 2016 surveyed 7,324 older bedridden patients from 25 hospitals in China (six tertiary, 12 non-tertiary, and seven community hospitals). The occurrence of HAP among all participants was monitored by trained investigators. Demographics, hospitalization information and comorbidity differences were compared between patients with and without HAP. A multilevel regression analysis was used to explore the factors associated with HAP. Results: Among 7,324 older bedridden patients, 566 patients were diagnosed with HAP. The incidence of HAP in this study was 13.9 per 1,000 person-days. There were statistical differences in gender, age, length of bedridden days, BMI, smoking, department, undergoing general anesthesia surgery, ventilator application, Charlson comorbity index (CCI) score, disturbance of consciousness, tranquilizer use, glucocorticosteroid use, and antibiotic use between patients with HAP and patients without HAP (all p < 0.05). Multilevel regression analysis found no significant variance for HAP at the hospital level (0.332, t = 1.875, p > 0.05). There were significant differences for the occurrence of HAP among different departments (0.553, t = 4.320, p < 0.01). The incidence density of HAP was highest in the ICU (30.1‰) among the selected departments, followed by the departments of neurosurgery (18.7‰) and neurology medicine (16.6‰). Individual patient-level factors, including older age, disturbance of consciousness, total CCI score, ICU admission, and glucocorticoid and antibiotic use, were found to be associated with the occurrence of HAP (all p < 0.05). Conclusion: A relatively high incidence density of HAP among older bedridden patients was identified, as well as several factors associated with HAP among the population. This suggests that attention should be paid to the effective management of these related factors of older bedridden patients to reduce the occurrence of HAP.

Prediction of motor recovery after ischemic stroke using diffusion tensor imaging: A meta-analysis.

BACKGROUND: This systematic review aims to investigate the prediction value of diffusion tensor imaging for motor function recovery of ischemic stroke patients. METHODS: Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 9), PubMed, Embase, Clarivate Analytics, Scopus, CINAHL, Chinese Biomedical Literature Database, China National Knowledge Infrastructure and Google Scholar were searched for either motor recovery or corticospinal tract integrity by diffusion tensor imaging in different stroke phase from January 1, 1970, to October 31, 2016. The study design and participants were subjected to metrological analysis. Correlation coefficient (r) was used for evaluating the relationship between fractional anisotropy (FA) and motor function outcome. Correlation coefficient values were extracted from each study, and 95% confidence intervals (CIs) were calculated by Fisher's z transformation. Meta-analysis was conducted by STATA software. RESULTS: Fifteen studies with a total of 414 patients were included. Meta-analysis showed that FA in the subacute phase had the significant correlation with motor function outcome (ES=0.75, 95%CI 0.62-0.87), which showed moderate quality based on GRADE system. The weight correlation coefficient revealed that an effect size (ES) of FA in acute phase and chronic phase was 0.51 (95%CI 0.33-0.68) and 0.62 (95%CI 0.47-0.77) respectively. CONCLUSION: This meta-analysis reveals that FA in the subacute phase after ischemic stroke is a good predictor for functional motor recovery, which shows moderate quality based on the GRADE system.

The optimal choice of medication administration route regarding intravenous, intramuscular, and subcutaneous injection.

BACKGROUND: Intravenous (IV), intramuscular (IM), and subcutaneous (SC) are the three most frequently used injection routes in medication administration. Comparative studies of SC versus IV, IM versus IV, or IM versus SC have been sporadically conducted, and some new findings are completely different from the dosage recommendation as described in prescribing information. However, clinicians may still be ignorant of such new evidence-based findings when choosing treatment methods. METHODS: A literature search was performed using PubMed, MEDLINE, and Web of Sciences™ Core Collection to analyze the advantages and disadvantages of SC, IV, and IM administration in head-to-head comparative studies. RESULTS: "SC better than IV" involves trastuzumab, rituximab, antitumor necrosis factor medications, bortezomib, amifostine, recombinant human granulocyte-macrophage colony-stimulating factor, granulocyte colony-stimulating factor, recombinant interleukin-2, immunoglobulin, epoetin alfa, heparin, and opioids. "IV better than SC" involves ketamine, vitamin K1, and abatacept. With respect to insulin and ketamine, whether IV has advantages over SC is determined by specific clinical circumstances. "IM better than IV" involves epinephrine, hepatitis B immu-noglobulin, pegaspargase, and some antibiotics. "IV better than IM" involves ketamine, morphine, and antivenom. "IM better than SC" involves epinephrine. "SC better than IM" involves interferon-beta-1a, methotrexate, human chorionic gonadotropin, hepatitis B immunoglobulin, hydrocortisone, and morphine. Safety, efficacy, patient preference, and pharmacoeconomics are four principles governing the choice of injection route. Safety and efficacy must be the preferred principles to be considered (eg, epinephrine should be given intramuscularly during an episode of systemic anaphylaxis). If the safety and efficacy of two injection routes are equivalent, clinicians should consider more about patient preference and pharmacoeconomics because patient preference will ensure optimal treatment adherence and ultimately improve patient experience or satisfaction, while pharmacoeconomic concern will help alleviate nurse shortages and reduce overall health care costs. Besides the principles, the following detailed factors might affect the decision: patient characteristics-related factors (body mass index, age, sex, medical status [eg, renal impairment, comorbidities], personal attitudes toward safety and convenience, past experience, perception of current disease status, health literacy, and socioeconomic status), medication administration-related factors (anatomical site of injection, dose, frequency, formulation characteristics, administration time, indication, flexibility in the route of administration), and health care staff/institution-related factors (knowledge, human resources). CONCLUSION: This updated review of findings of comparative studies of different injection routes will enrich the knowledge of safe, efficacious, economic, and patient preference-oriented medication administration as well as catching research opportunities in clinical nursing practice.

Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era.

BACKGROUND: Medication errors may occur during prescribing, transcribing, prescription auditing, preparing, dispensing, administration, and monitoring. Medication administration errors (MAEs) are those that actually reach patients and remain a threat to patient safety. The Joint Commission International (JCI) advocates medication error prevention, but experience in reducing MAEs during the period of before and after JCI accreditation has not been reported. METHODS: An intervention study, aimed at reducing MAEs in hospitalized patients, was performed in the Second Affiliated Hospital of Zhejiang University, Hangzhou, People's Republic of China, during the journey to JCI accreditation and in the post-JCI accreditation era (first half-year of 2011 to first half-year of 2014). Comprehensive interventions included organizational, information technology, educational, and process optimization-based measures. Data mining was performed on MAEs derived from a compulsory electronic reporting system. RESULTS: The number of MAEs continuously decreased from 143 (first half-year of 2012) to 64 (first half-year of 2014), with a decrease in occurrence rate by 60.9% (0.338% versus 0.132%, P<0.05). The number of MAEs related to high-alert medications decreased from 32 (the second half-year of 2011) to 16 (the first half-year of 2014), with a decrease in occurrence rate by 57.9% (0.0787% versus 0.0331%, P<0.05). Omission was the top type of MAE during the first half-year of 2011 to the first half-year of 2014, with a decrease by 50% (40 cases versus 20 cases). Intravenous administration error was the top type of error regarding administration route, but it continuously decreased from 64 (first half-year of 2012) to 27 (first half-year of 2014). More experienced registered nurses made fewer medication errors. The number of MAEs in surgical wards was twice that in medicinal wards. Compared with non-intensive care units, the intensive care units exhibited higher occurrence rates of MAEs (1.81% versus 0.24%, P<0.001). CONCLUSION: A 3-and-a-half-year intervention program on MAEs was confirmed to be effective. MAEs made by nursing staff can be reduced, but cannot be eliminated. The depth, breadth, and efficiency of multidiscipline collaboration among physicians, pharmacists, nurses, information engineers, and hospital administrators are pivotal to safety in medication administration. JCI accreditation may help health systems enhance the awareness and ability to prevent MAEs and achieve successful quality improvements.

Appropriateness of administration of nasogastric medication and preliminary intervention.

A utilization study was performed in a 2200-bed tertiary care teaching hospital. Data mining was performed on all nasogastric medication prescriptions for patients hospitalized in 2011. Nurses were interviewed by questionnaire. A PDCA (Plan-Do-Check-Act) cycle was used for continuous quality improvement. The proportion of patients with nasogastric tubes (NGT) was 3.2%. A large number of medical orders (n = 6261) involved nasogastric medications with a package insert particularly noting that they should not be crushed or opened (group 1) or medications without a specific formulation recommendation in the package insert but having evidence discouraging NGT dosing (group 2). Of the nasogastrically administered sustained-release or controlled-release formulations, a sustained-release sodium valproate tablet formulation was the most prescribed drug and a sustained-release 2.5 mg felodipine tablet was prescribed with the highest proportion of NGT dosing [NGT/(NGT + oral) = 12.3%]. Among the nasogastrically administered enteric-coated formulations, a myrtol-standardized enteric-coated capsule formulation was the most prescribed drug and a pantoprazole tablet formulation was prescribed with the highest proportion of NGT dosing [NGT/(NGT + oral) = 19.3%]. Proportions of NGT dosing for amiodarone and carbamazepine (group 2) were 4.8% and 6.3%, respectively. The percentage of nurses with adequate knowledge about pharmaceutical dosage formulations was 60%. The rate of answering correctly as to whether medications in group 1 could be crushed or opened was only 30%. Awareness of evidence discouraging NGT dosing of medications in group 2 was zero. Most nurses (90%) left physicians and pharmacists with the entire responsibility for knowledge and decision-making concerning route of drug administration. After a 3-month preliminary intervention, irrational medical orders involving nasogastric administration of medications in group 1 were successfully abolished. The rate of answering correctly as to whether medications in group 1 could be crushed or opened increased to 100%. This utilization study indicates poor awareness concerning nasogastric administration of medication on the part of physicians and nurses, and preliminary intervention measures were efficient in improving knowledge through team cooperation and effort.