Electronic access to scientific nursing knowledge: the Virginia Henderson International Nursing Library.

OBJECTIVES: To inform oncology nurses about the electronic knowledge resources offered by the Sigma Theta Tau International Virginia Henderson International Nursing Library. DATA SOURCES: Published articles and research studies. CONCLUSIONS: Clinical nursing research dissemination has been seriously affected by publication bias. The Virginia Henderson International Nursing Library has introduced both a new publishing paradigm for research and a new knowledge indexing strategy for improving electronic access to research knowledge (findings). IMPLICATIONS FOR NURSING PRACTICE: The ability of oncology nursing to evolve, as an evidence-based practice, is largely dependent on access to research findings.

Embedded structures and representation of nursing knowledge.

Nursing Vocabulary Summit participants were challenged to consider whether reference terminology and information models might be a way to move toward better capture of data in electronic medical records. A requirement of such reference models is fidelity to representations of domain knowledge. This article discusses embedded structures in three different approaches to organizing domain knowledge: scientific reasoning, expertise, and standardized nursing languages. The concept of pressure ulcer is presented as an example of the various ways lexical elements used in relation to a specific concept are organized across systems. Different approaches to structuring information-the clinical information system, minimum data sets, and standardized messaging formats-are similarly discussed. Recommendations include identification of the polyhierarchies and categorical structures required within a reference terminology, systematic evaluations of the extent to which structured information accurately and completely represents domain knowledge, and modifications or extensions to existing multidisciplinary efforts.

The content coverage and organizational structure of terminologies: the example of postoperative pain.

Concepts such as symptoms present specific representational challenges in the EMR. This is because concepts without clear boundaries and external referents such as physical objects can only be examined against other terminology-based concept representation systems. The truth and falsity of such concept representation is therefore relative to the terminology-based systems. Using the concept of acute postoperative pain as an example, we examined three terminology based approaches to representing the concept. Widely varying coverage across existing clinical terminologies was evident, although the common clinical approach to reporting attributes of symptoms provided a useful organizational structure and should be examined in relation to developing terminology and information models.

Experience with the use of automated external defibrillators in out of hospital cardiac arrest.

AIM: To describe the sequences of arrhythmias, number of shocks delivered and the number of failures in a consecutive series of patients with out-of-hospital cardiac arrest attended by our emergency medical service (EMS) and in whom cardio-pulmonary resuscitation (CPR) was initiated and in whom automated external defibrillators (AEDs) were used. PATIENTS: All patients with out-of-hospital cardiac arrest attended by the EMS and in whom AEDs were used. Time for inclusion in the study: January 1st, 1987 to December 31st, 1992. RESULTS: In all there were 1781 out of hospital cardiac arrests during the study period. Among them AEDs were used in 383 cases (22%). The total number of interpreted rhythms delivered in these patients was 2719. Among all rhythm sequences coarse ventricular fibrillation (VF) was found on 375 occasions (14%); fine VF on 107 occasions (4%) and ventricular tachycardia (VT) on 12 occasions (0.4%). In ten cases with coarse VF (nine patients) the AED did not advise a shock (2.7%). In five of those nine patients a human error was interpreted as the explanation and in four there was a possible technical error. In these four patients defibrillation was delayed by 33-43 s, respectively. Among the 2225 rhythm sequences not judged as VF/VT the AED advised a shock on one occasion (0.04%). CONCLUSION: Among patients with coarse VF AED gave inaccurate instructions in 2.7%. However, the majority of the failures were judged to be caused by human errors.

Survivors of out of hospital cardiac arrest: their prognosis, longevity and functional status.

This paper reports, consistent with Utstein Style definitions, 13 years experience observing out-of-hospital cardiac arrest survivors' prognosis, longevity and functional status. We report for all patients, available outcome information for out-of-hospital cardiac arrest survivors in Göteborg Sweden between 1980 and 1993. Patients were followed for at least 1 year and some for over 14 years. From 1980 to 1993 Göteborg EMS treated 3754 out-of-hospital cardiac arrests. 9% (n = 324) were discharged from the hospital alive. Survivors' median age was 67 and 21% (n = 67) were women. Mortality rate was: 21% (n = 61) at 1 year; 56% (n = 78) by 5 years; and 82% (n = 32) by 10 years following the arrest. During the first 3 years, 16% (n = 46) experienced another cardiac arrest, 19% (n = 53) had an acute myocardial infraction and a total of 81% (n = 232) were rehospitalized for various conditions. 14% (n = 40) returned to previous employment, and 74% (n = 229) had retired before their arrest occurred. Cerebral performance categories (CPC) scores were: At hospital discharge N = 324; Data available for 320-1 = 53% (n = 171), 2 = 21% (n = 66), 3 = 24% (n = 77), 4 = 2% (n = 6). One year post arrest N = 263; Data available for 212-1 = 73% (n = 156), 2 = 9% (n = 18), 3 = 17% (n = 36), 4 = 1% (n = 2). Overall, 21% (n = 61) of cardiac arrest survivors died during the first year, and an additional 16% (n = 46) experienced another arrest. 73% of those patients who were still alive after 1 year returned to pre-arrest function.

The Virginia Henderson International Nursing Library: resource for nurse administrators.

This article describes the major knowledge resource of the Virginia Henderson International Nursing Library, The Registry of Nursing. The first part of this article examines informatics issues and is accompanied by examples of retrieval from a typical bibliographic database and a retrieval from the Registry of Nursing Research using case mix, both as a subject heading and as a research variable. The second part of the article examines the interaction of informatics and technology used in the Registry and presents some other Library resources.

Out-of-hospital ventricular fibrillation in children and adolescents: causes and outcomes.

STUDY OBJECTIVE: To compare causes and outcomes of patients younger than 20 years with an initial rhythm of ventricular fibrillation versus asystole and pulseless electrical activity. DESIGN: Retrospective cohort study. SETTING: Urban/suburban prehospital system. PARTICIPANTS: Pulseless, nonbreathing patients less than 20 years who underwent out-of-hospital resuscitation. Patients with lividity or rigor mortis or who were less than 6 months old and died of sudden infant death syndrome were excluded. RESULTS: Ventricular fibrillation was the initial rhythm in 19% (29 of 157) of the cardiac arrests. Rhythm assessment was performed by the first responder in only 44% (69 of 157) of patients. All three rhythm groups were similar in age distribution, frequency of intubation (96%), and vascular access (92%); 93% of ventricular fibrillation patients were defibrillated. The causes of ventricular fibrillation were distributed evenly among medical illnesses, overdoses, drownings, and trauma, only two patients had congenital heart defects. Seventeen percent were discharged with no or mild disability, compared with 2% of asystole/pulseless electrical activity patients (P = .003). CONCLUSION: Ventricular fibrillation is not rare in child and adolescent prehospital cardiac arrest, and these patients have a better outcome than those with asystole or pulseless electrical activity. Earlier recognition and treatment of ventricular fibrillation might improve pediatric cardiac arrest survival rates.

CPR and the single rescuer: at what age should you "call first" rather than "call fast"?

STUDY OBJECTIVE: To determine whether the age-related frequency of ventricular fibrillation (VF) in cardiac arrest supports the guideline that single rescuers should "call first" for all victims of sudden collapse older than 8 years. DESIGN: Analysis of data on all nontraumatic cardiac arrests treated by emergency medical service (EMS) personnel in King County, Washington, between 1976 and 1992. MEASUREMENTS: Age, initial cardiac rhythm, witnessed versus unwitnessed status, whether patient was discharged alive. RESULTS: We analyzed 10,992 cardiac arrests. Initial rhythm was VF in 4,252 (40%) and non-VF in 6,740 (60%). VF frequencies were 3% (0 to 8 years old), 17% (8 to 30 years), and 42% (30 years or older). CONCLUSION: Most patients under age 30 were not in VF at the time of EMS evaluation. Our data suggest that a "call fast" strategy may be more effective when a single rescuer is present and the victim is between 8 and 30 years old.

Description of a graduate program in clinical nursing informatics.

This article describes the history and development of the Clinical Nursing Informatics Program at the University of Utah College of Nursing. Program philosophy and curriculum are discussed in the context of the conceptual framework. Courses and student projects are described. The authors reflect on the ensuing stage of program development.

Expected death and unwanted resuscitation in the prehospital setting.

STUDY OBJECTIVE: To determine the outcome, location, preexisting conditions, and resuscitation wishes of prehospital cardiac arrest patients. DESIGN: Retrospective review of paramedic and emergency medical technician run reports. SETTING: Urban area with a two-tiered emergency medical services response system covering an area of 2,128 square miles and serving a population of 1,413,900 (in 1988). PARTICIPANTS: All prehospital cardiac arrest patients to which the King County, Washington, Emergency Medical Services (KCEMS) system responded to during a 12-month period. Unless decapitation, decomposition, or dependent lividity existed, all cardiac arrest patients in the KCEMS system received full resuscitative efforts. MEASUREMENTS: We analyzed run reports from 694 cardiac arrest patients, excluding all cardiac arrests from trauma, overdose, or drowning, or obvious signs of extended downtime such as decomposition or dependent lividity. We defined an unwanted resuscitation as a resuscitation attempt despite written or verbal requests by the patient, family, or private physician. We defined a patient as having severe, chronic disease if the run report listed one or more conditions associated with poor survival rates after inpatient CPR. These included cancer, cerebral vascular accident, dementia, renal failure, dialysis, AIDS, thoracic or abdominal aneurysms, cirrhosis, or if the patient was bedridden or was receiving chronic home nursing care. MAIN RESULTS: Overall 16% (103 of 633) of all cardiac arrest patients survived to hospital discharge. Seven percent (47 of 633) of all cardiac arrest patients fit the unwanted resuscitation definition; 2% (one of 47) survived to hospital discharge. Twenty-five percent (158 of 633) of cardiac arrest patients fit the definition of severe chronic disease; 8% (12 of 158) survived to hospital discharge. CONCLUSION: Severe chronic disease and unwanted resuscitation patients comprised one-third of all resuscitation attempts by KCEMS during a 12-month period. Both groups had lower survival rates compared to cardiac arrest patients who did not have severe chronic disease or indications of unwanted resuscitation.

Translating traditional principles of system development into a process for designing clinical information systems.

Traditional software development methodologies enhanced by a clinical component result in information systems that support the practice of nursing. This paper describes the clinical informatics model used to develop and evaluate a mobile computer assessment tool. Data entry of atomic-level elements, with storage in a relational database, allows the synthesis and analysis by multiple disciplines to aid in real-time decision making. The system is designed to improve the recording and accessibility of patient data and nursing observations on a geriatric unit at the Salt Lake VA Medical Center.

Mapping out the road to quality.

Through the experiences of 12 long-term care organizations, we learn how to successfully create total quality management programs. Commitment, leadership, time, money and ongoing education and training are major components of TQM efforts.

Clinical nursing informatics. Developing tools for knowledge workers.

Current research in clinical nursing informatics is proceeding along three important dimensions: (1) identifying and defining nursing's language and structuring its data; (2) understanding clinical judgment and how computer-based systems can facilitate and not replace it; and (3) discovering how well-designed systems can transform nursing practice. A number of efforts are underway to find and use language that accurately represents nursing and that can be incorporated into computer-based information systems. These efforts add to understanding nursing problems, interventions, and outcomes, and provide the elements for databases from which nursing's costs and effectiveness can be studied. Research on clinical judgment focuses on how nurses (perhaps with different levels of expertise) assess patient needs, set goals, and plan and deliver care, as well as how computer-based systems can be developed to aid these cognitive processes. Finally, investigators are studying not only how computers can help nurses with the mechanics and logistics of processing information but also and more importantly how access to informatics tools changes nursing care.

Out-of-hospital transcutaneous pacing by emergency medical technicians in patients with asystolic cardiac arrest.

BACKGROUND: Transcutaneous cardiac pacemakers generate electrical stimuli that pace the heart through external electrodes that adhere to the chest wall. Transcutaneous pacing has been useful in some patients with bradycardia, but its efficacy in patients with asystole and full cardiac arrest has been limited, possibly because of delays in the initiation of pacing. We studied the efficacy of early transcutaneous pacing in patients with out-of-hospital asystolic cardiac arrest. METHODS: For three years we provided transcutaneous pacemakers to about half the fire districts in a large emergency-medical-services system (the intervention group). In these districts, we authorized emergency medical technicians (EMTs) to begin transcutaneous pacing in patients with cardiac arrest and primary asystole or post-defibrillation asystole. Pacing was done as early as possible, before endotracheal intubation or intravenous medication. EMTs in the other fire districts (the control group) treated similar patients with basic cardiopulmonary resuscitation but without transcutaneous pacing. RESULTS: The EMTs in the intervention group initiated transcutaneous pacing in 112 of the 278 patients with primary asystole. Of these patients, 22 (8 percent) were admitted to the hospital, and 11 (4 percent) were discharged. Among the 259 patients treated by the EMTs in the control group, 21 (8 percent) were admitted to the hospital, and 5 (2 percent) were discharged. The two groups did not differ significantly with respect to the rate of hospital admission or survival. Survival after early pacing for post-defibrillation asystole was no better than survival after pacing for primary asystole. CONCLUSIONS: Transcutaneous pacing appears to offer no benefit in patients with asystolic cardiac arrest, even when it is performed as early as possible by EMTs in the field. Our data suggest that the widespread implementation of early transcutaneous pacing for out-of-hospital asystolic cardiac arrest would be ineffective.